Eruptive nevi in a patient with constitutional mismatch repair deficiency (CMMRD).

Biallelic mutations in the DNA mismatch repair genes MLH1, MSH2, MSH6, or PMS2 result in one of the most aggressive genetic cancer conditions, constitutional mismatch repair syndrome (CMMRD). We present a case of a 10-year-old boy with biallelic MSH6 mutation and systemic lupus erythematosus with eruptive melanocytic nevi after receiving chemotherapy for mediastinal T-cell lymphoblastic lymphoma.

Art of prevention: The importance of measles recognition and vaccination.

Measles is a viral infection that has a characteristic pattern of prodromal symptoms followed by a rash. Previously considered an inevitable childhood condition, measles is known as the "first" classic childhood exanthem. For most children, measles was a one-time, short-term illness; however, some children developed complications that led to severe sequelae and death. The introduction of the measles vaccine dramatically decreased the number of cases, but the current trend against vaccination has caused outbreaks of the condition. We propose the implementation of the AAA approach (assume, advise, and answer) as a way for providers to directly encourage the administration of the vaccine and prevent future cases of measles.

Contact dermatitis and atopic dermatitis: two tales, an interwoven story.

Atopic dermatitis is a multifactorial disease that can concomitantly occur with irritant or allergic contact dermatitis. The colloquial use of atopic dermatitis and eczema interchangeably has created confusion among patients and providers alike. Atopic skin is a complex entity that involves a defective barrier and biome, an aberrant immune response, and abnormal neural activation, while eczema is a generalized term denoting a particular appearance common to multiple diagnoses including atopic dermatitis and contact dermatitis. The conventional paradigm that simplifies atopic dermatitis and allergic contact dermatitis into distinct Th2 and Th1 processes, respectively, fails to acknowledge potential immunologic intersection points and contributes to impaired disease management. This article will review the complex interplay of atopic dermatitis and contact dermatitis and discuss treatment strategies for recalcitrant cases.

Clinical pearl: Mohs cantaloupe analogy for the dermatology resident.

Mohs micrographic surgery (MMS) is a challenging procedure to conceptualize, yet it is an integral component of dermatology residency. The cantaloupe analogy is a tool that can be used to assist in visualizing MMS specimen processing, which transitions the 3-dimensional multilayered skin to a 2-dimensional histologic slide.

Using Dermoscopy to Identify Melanoma and Improve Diagnostic Discrimination.

Use of dermoscopy and detection algorithms by primary care physicians can enhance assessment of clinically suspicious lesions compared with that of naked eye examinations.

Renal Pelvic Pressure in Percutaneous Nephrolithotomy: The Effect of Multiple Tracts.

INTRODUCTION: During percutaneous nephrolithotomy (PCNL), elevated renal pelvic pressures (RPPs) may spread infection through pyelovenous backflow whereas decreased pressures can hinder observation and increase bleeding. The purpose of this study was to evaluate the effects of multiple access tracts and different sized endoscopic equipment on RPP in a porcine model. MATERIALS AND METHODS: RPP was measured in one- vs two-tract access, rigid vs flexible nephroscopy, and suction vs no suction. Twenty trials were performed for each condition. An independent samples Mann-Whitney U-test was used to compare parameters, with p < 0.05 considered significant. RESULTS: With one tract, rigid nephroscopy resulted in higher mean pressures (31.35 mm Hg) than flexible nephroscopy (11.1 mm Hg; p < 0.001). The RPP was higher with rigid nephroscopy in one tract (31.35 mm Hg) than when two tracts were present (9.35 mm Hg; p < 0.001). In contrast, there was no difference in pressure during the use of a flexible nephroscope in one (11.1 mm Hg) vs two tracts (10.7 mm Hg; p = 0.63). Use of suction with the rigid nephroscope resulted in significantly lower pressures with one (-1.3 mm Hg) than with two tracts (1.8 mm Hg; p = 0.004). CONCLUSION: In PCNL, RPP is significantly affected by an additional tract during rigid nephroscopy and suctioning but not when using a flexible nephroscope. Understanding the effects of multiple tracts and equipment type on RPP may improve the safety of PCNL.

Comparison of Phototherapy Guidelines for Psoriasis: A Critical Appraisal and Comprehensive Review.

Psoriasis is a common, chronic immune-mediated inflammatory skin disorder that significantly impacts quality of life and has potential systemic complications. The majority of psoriatic patients have mild to moderate disease and are adequately controlled with topical medications. However, approximately 20% of patients have moderate-to-severe disease. Phototherapy has remained a mainstay option for patients with moderate-to-severe psoriasis resistant to topical treatments due to its efficacy, cost-effectiveness, and relative lack of side effects, in particular a lack of systemic immunosuppression seen with traditional and biologic systemic therapies. There are several well-established guidelines for phototherapy treatment of psoriasis proposed in the United States by the American Academy of Dermatology (AAD), in Europe by the European S3, and in the United Kingdom by the National Institute for Health and Care Excellence (NICE). The guidelines set by these groups are largely based on current evidence or expert panel consensus where evidence is lacking. This article reviews and compares the current recommendations of these guidelines for psoriasis phototherapy in regards to the initial clinical encounter, dosage, adverse reactions, and special considerations.

J Drugs Dermatol. 2016;15(8):995-1000.

Comparison of Guidelines for the Use of Cyclosporine for Psoriasis: A Critical Appraisal and Comprehensive Review.

There are several well-established guidelines for the treatment of psoriasis. Guidelines have been proposed in the United States by the American Academy of Dermatology (AAD), in Europe by the European S3, in the United Kingdom by the National Institute for Health and Care Excellence (NICE), and in Canada by the Canadian Dermatology Association. These guidelines are predominantly evidence-based, supported by expert panel consensus where evidence is lacking. Cyclosporine, a potent calcineurin inhibitor that acts selectively on T-cells, revolutionized the world of immunosuppression upon its discovery in 1970. Since its approval in 1997 by the U.S. Food and Drug Administration for the treatment of psoriasis, cyclosporine has been used with great efficacy in the treatment of not only psoriasis but also a wide consortium of dermatological diseases. However, in the past decade or so, many dermatologists have become increasingly hesitant to use this important drug because of its potent toxicity profile. The purpose of this article is to review and compare the current evidence-based guideline recommendations for the use of cyclosporine in the treatment of psoriasis. Although the various guidelines are similar in their initial treatment recommendations, significant differences exist in recommendations on maximal treatment duration (1 year versus 2 years), intermittent short-term versus continuous therapy, use in erythrodermic and palmoplantar psoriasis, as well as recommendations on managing cyclosporine-associated side effects. By following guideline recommendations, cyclosporine remains an excellent and indispensable tool for the dermatologist treating moderate-to-severe psoriasis.

Recurrent lumbosacral herpes simplex virus infection.

We present the case of a 54-year-old white woman with episodic lumbosacral lesions that she had been treating as psoriasis. Evaluation revealed classic herpes simplex virus (HSV) infection. The discussion reviews the significance and potential complications of recurrent lumbosacral HSV infection.

Laser fiber cleaving techniques: effects on tip morphology and power output.

BACKGROUND AND PURPOSE: Proper cleaving of reusable laser fibers is needed to maintain optimal functionality. This study quantifies the effect of different cleaving tools on power output of the holmium laser fiber and demonstrates morphologic changes using microscopy. MATERIALS AND METHODS: The uncleaved tips of new 272 µm reusable laser fibers were used to obtain baseline power transmission values at 3 W (0.6 J, 5 Hz). Power output for each of four cleaving techniques-11-blade scalpel, scribe pen cleaving tool, diamond cleaving wheel, and suture scissors-was measured in a single-blinded fashion. Dispersion of light from the fibers was compared with manufacturer specifications and rated as "ideal," "acceptable," or "unacceptable" by blinded reviewers. The fiber tips were also imaged using confocal and scanning electron microscopy. Independent samples Kruskal-Wallis test and chi square were used for statistical analysis (α<0.05). RESULTS: New uncleaved fiber tips transmitted 3.04 W of power and were used as a reference (100%). The scribe pen cleaving tool produced the next highest output (97.1%), followed by the scalpel (83.4%), diamond cleaving wheel (77.1%), and suture scissors (61.7%), a trend that was highly significant (P<0.001). On pairwise comparison, no difference in power output was seen between the uncleaved fiber tips and those cleaved with the scribe pen (P=1.0). The rating of the light dispersion patterns from the different cleaving methods followed the same trend as the power output results (P<0.001). Microscopy showed that the scribe pen produced small defects along the fiber cladding but maintained a smooth, flat core surface. The other cleaving techniques produced defects on both the core and cladding. CONCLUSION: Cleaving techniques produce a significant effect on the initial power transmitted by reusable laser fibers. The scribe pen cleaving tool produced the most consistent and highest average power output.