Squamous cell carcinoma (SCC) of the lower lip is a deadly nonmelanoma skin cancer. Its precursor, a distinctive cutaneous neoplasia analogous to cervical dysplasia, is known by the confusing term actinic cheilitis. Solar cheilosis (SC) is a more appropriate designation. It represents incipient SCC in situ. SC is widely recognized as an ultraviolet light–induced precancer of the lower lip that is typically seen in light-skinned individuals and others with poorly pigmented lower lips. Lip SCC is one of the most common malignancies of the oral cavity. SCC is much more likely to metastasize from the lip than cutaneous surfaces, with a 5-year overall survival rate of less than 75%. SC results from long-term exposure to ultraviolet radiation. The occurrence of SC is dose-dependent and is influenced by the patient’s solar exposure, age, genetic predisposition, geographic latitude of residence, occupation, leisure activities, and use of lip protective agents. Molecular abnormalities of SC are similar to those of actinic keratosis and facilitate the evolution to SCC. A high degree of clinical suspicion should be maintained, given the malignant nature of this condition. Ulceration and nodularity often indicate progression to SCC. We performed a Medline and Google Scholar search for all articles related to actinic cheilitis, actinic cheilosis, SC, actinic keratosis, solar keratosis, premalignant oral disease, and lip SCC, and have also evaluated many other articles and book chapters. One hundred forty-two peer-reviewed articles were identified as being of particular value. Pertinent facts were selected and analyzed.

The differential diagnosis of SC includes malignant, premalignant, metastatic, inflammatory, and eczematoid disorders, along with photodermatoses and a few rare but important disorders of the lower lip. Current treatment options include topical, ablative, and surgical therapies. Several clinical challenges are also addressed, including the issue of obtaining a high-yield diagnostic biopsy specimen while minimizing patient morbidity, field-directed treatment for SC, and strategies for combination therapy.

The entry of biosimilar forms of biopharmaceutical therapies for the treatment of psoriasis and other immune-mediated disorders has provoked considerable interest. Although dermatologists are accustomed to the use of a wide range of generic topical agents, recognition of key differences between original agent (ie, the name brand) and the generic or biosimilar agent is necessary to support optimal therapy management and patient care. In this review we have summarized the current state of the art related to the impending introduction of biosimilars into dermatology. Biosimilars represent important interventions that are less expensive and hence offer the potential to deliver benefit to large numbers of patients who may not currently be able to access these therapies. But the development of biosimilars is not equivalent to that of small molecule generic therapies because of differences in molecular structure and processes of manufacture. The planned regulatory guidelines and path to approval may not encompass all of these potentially important differences and this may have clinical relevance to the prescriber and patient. Consequently, we have identified a series of key issues that should be considered to support the full potential of biosimilars for the treatment of psoriasis; ie, that of increased access to appropriate therapy for the psoriasis population worldwide.

To the Editor: We read with great interest the recent article by Gaudy-Marqueste et al entitled “The ‘‘spaghetti technique’’: An alternative to Mohs surgery or staged surgery for problematic lentiginous melanoma (lentigo maligna and acral lentiginous melanoma)” in the January 2011 edition of the Journal. The authors introduced a two-phase procedure (spaghetti technique), which seems to be a modification of the “square technique” described in 1997 by Johnson et al. We agree with the authors that the spaghetti technique provides a comprehensive longitudinal en face dermatopathologic control of the periphery. However, in our opinion, the technique has some disadvantages. The major drawback of the spaghetti technique is that the central tumor is not excised until the time of closure, so an unsuspected invasive melanoma would not be identified until after closure is complete. In a recent review of 10 studies on histologically proven lentigo maligna and melanoma in-situ lesions, Dawn, Dawn, and Miller determined that 23% have an invasive melanoma upon re-excision. When an invasive melanoma is found, the surgical margin is generally determined according to the National Comprehensive Cancer Network (NCCN) guidelines on the basis of the tumor depth, regardless of the histology of the “spaghetti” sections. This may lead to a second surgical procedure if the margins of the spaghetti technique are less than the depth-appropriate margins. In addition, some surgical oncologists prefer to perform wide excision at the same time as nodal evaluation.

To the Editor: In the June 2011 issue of the JAAD, Ly et al reported a 4-case series on malignant melanoma (MM) arising on speckled lentiginous nevus (SLN). It is my opinion that none of those cases can be classified as SLN because by definition SLN, either of the macular or papular type, is characterized by a homogeneous hyperpigmented background which defines the size of the lesion and is virtually indistinguishable from café-au-lait spots (CALs) as of color and histologic features. Instead, in all 4 cases, lentigines (and often CALs) were present in a block-like segmental pattern, and a hyperpigmented background was evidently absent as it would have made invisible the lentigines and, mostly, CALs. Taken all together, these features are instead pathognomonic for partial unilateral lentiginosis (or, more appropriately, segmental lentiginosis [SL]). The presence of papular melanocytic nevi within the lesions is not surprising and can be reasonably attributed to evolution of lentigines. An increasing number of lentigines over time is a well-described phenomenon in SL as well.

To the Editor: We would disagree with the primary argument put forward by Torchia in response to our article “Melanoma(s) arising in large segmental speckled lentiginous nevi (SLN): A case series,” which disputes the diagnosis of SLN in all 4 cases described.

To the Editor: We read with interest the CME article on vitiligo that mentioned the paucity of long-term follow-up data of narrowband ultraviolet B (NB-UVB) therapy in vitiligo. Although there are no established treatment caps for NB-UVB, the suggested limit for skin types I-III is arbitrarily set at 200 treatments. While there is no set limit for skin types IV-VI, the recommendation for number of treatments should be based on clinician discretion and patient consent. We have observed that long-term NB-UVB in vitiligo patients is safe. This is important because these patients often require more than 12 to 24 months of treatment for repigmentation.

To the Editor: Pruritus ani (PA) is a common and embarrassing proctologic condition, which can be difficult to treat if there are no obvious predisposing factors. There is little scientific evidence concerning the treatment of idiopathic PA. Randomized controlled studies have been published for both 1% hydrocortisone ointment (symptom reduction in 68% of patients after 2 weeks’ treatment compared with placebo) and capsaicin 0.006% (70% with relieved itching compared with 2% with placebo after 4 weeks 3 times daily). Intradermal injection of methylene blue is frequently reported, but no randomized studies have been done. Prolonged topical steroid use may provoke skin atrophy. Topical tacrolimus is proposed as an alternative treatment for inflammatory skin diseases in thin skin areas.

To the Editor: Therapeutic options for cutaneous sarcoidosis are limited. Several reports of successful treatment of cutaneous sarcoidosis with anti-tumor necrosis factor have been published. We aimed to evaluate our experience with the use of infliximab in refractory cutaneous sarcoidosis.

To the Editor: Grover disease is an eruption of intraepidermal acantholysis presenting as crusted reddened papules; it is usually found on the trunk of middle aged patients, with a male to female ratio of 2:1. The disease may be transient or persistent. Although the onset of Grover disease often appears to be spontaneous, the expression of Grover disease has been associated with a multitude of factors, including sun exposure, winter time, interleukin-4 administration, heat or sweat, ionizing radiation, psoralen plus ultraviolet A light phototherapy, chemotherapy, and chronic renal failure. Causation has not been established.

To the Editor: We report a 74-year-old man with a history of severe rheumatoid arthritis treated with infliximab who presented with a slowly enlarging nodule on his posterior left leg. The lesion began as a small red bump approximately 1 month after being stuck with a thorn of a pyracantha bush. The bump grew in size over 4 months and was unresponsive to multiple oral antibiotics. Bacterial cultures were negative. The patient did not complain of any systemic symptoms. Physical examination showed a 1.5- × 4-cm violaceous scaling and crusted nodule on the posterior aspect of his left leg (). No lymphadenopathy was present.

To the Editor: When repairing surgical defects in patients with thin, fragile skin, it can sometimes be difficult to suture wounds without tearing through cutaneous layers, particularly for distal extremity defects in elderly patients with extreme photodamage. Additional comorbidities, such as prolonged systemic steroid use, can further complicate closures in these patients. In these extreme cases the dermis is too thin to anchor deep sutures, and attempts with full-thickness superficial sutures result in skin tearing if the wound is under tension. This necessitates the use of other techniques or devices to aid in the closure of these surgical defects.

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A 40-year-old Hispanic man presented with thickened, fissured, and peeling palms and soles that had been present since childhood (). He was seen for a refill of his medication (acitretin 25 mg/day), which improved the symptoms.