Dermpedia

Sharing dermatology and dermatopathology knowledge

Acute urticaria is self-limiting, and a cause can be identified in many patients. Chronic urticaria is a long lasting disease, and patients are commonly examined for an autoimmune origin and for associated diseases. Although the diagnosis of urticaria is straightforward in most patients, it may pose some difficulties at times and it may require a careful differential diagnosis with a number of conditions. Urticarial syndromes comprise both cutaneous and systemic disorders. Part I of this two-part series focuses on the clinical and histologic features that characterize common urticaria and on the cutaneous diseases that may manifest with urticarial lesions and must be considered in the differential diagnosis.Learning objectives: After completing the learning activity, participants should be able to distinguish between the typical wheals of urticaria and urticarial lesions suggesting other diagnoses and to assess patients with urticarial lesions in order to exclude or confirm other cutaneous diseases.

There are a number of systemic disorders that can manifest with urticarial skin lesions, including urticarial vasculitis, connective tissue diseases, hematologic diseases, and autoinflammatory syndromes. All of these conditions may enter into the differential diagnosis of ordinary urticaria. In contrast to urticaria, urticarial syndromes may manifest with skin lesions other than wheals, such as papules, necrosis, vesicles, and hemorrhages. Lesions may have a bilateral and symmetrical distribution; individual lesions have a long duration, and their resolution frequently leaves marks, such as hyperpigmentation or bruising. Moreover, systemic symptoms, such as fever, asthenia, and arthralgia, may be present. The most important differential diagnosis in this group is urticarial vasculitis, which is a small-vessel vasculitis with predominant cutaneous involvement. Systemic involvement in urticarial vasculitis affects multiple organs (mainly joints, the lungs, and the kidneys) and is more frequent and more severe in patients with hypocomplementemia. Clinicopathologic correlation is essential to establishing a correct diagnosis.Learning objectives: After completing the learning activity, participants should be able to distinguish urticarial lesions suggesting diagnoses other than common urticaria; assess patients with urticarial lesions, and suspect systemic diseases presenting with urticarial skin lesions.

Background: Surgical evaluation of longitudinal melanonychia requires biopsy of the nail matrix. Previous publications have presented detailed surgical approaches to this problem. However, discussion of longitudinal excision with local matrix flap reconstruction is documented sparsely in the literature.Objective: To describe the indications for and technique of performing a longitudinal, full-thickness excision for longitudinal melanonychia; as this surgery poses a high risk of postoperative split nail, reconstruction is essential. Three local matrix flaps are detailed to maximize functional and cosmetic results.Methods: The authors detail the different procedures, with several illustrations and clinical photographs highlighting the techniques.Results: These techniques provide the surgeon with additional approaches to excise lesions of longitudinal melanonychia and reconstruct the surgical defects.Limitations: All surgeries of the nail matrix pose a risk of postoperative nail dystrophy and/or split nail.Conclusion: The different flaps provide elegant local alternatives to second-intention healing and maximize cosmetic and functional results after matrix excision with narrow margins for longitudinal melanonychia.

Background: Hidradenitis suppurativa (HS) is a chronic inflammatory disease involving the intertriginous areas.Objective: We sought to conduct clinical and histopathologic evaluation of the efficacy of long-pulsed neodymium:yttrium-aluminium-garnet laser treatment for HS.Methods: We conducted a prospective, randomized, right-left within-patient controlled trial for HS (n = 22). Four monthly laser sessions were performed. Disease activity was measured at baseline, and treatment response was assessed before each laser session and monthly for 2 months after the completion of laser treatment, using a modified scoring system based on Sartorius score. Histologic examination was performed at baseline, immediately after laser treatment, and at 1 and 4 weeks after treatment. A patient questionnaire was circulated on the last visit to assess patients' level of satisfaction.Results: There was progressive improvement in disease activity, most significantly during the 4 months of treatment, which was maintained during the 2-month posttreatment follow-up period. Averaged over all anatomic sites, the percent improvement was 72.7% on the laser treated side, and 22.9% on the control side (P < .05). Histologic examination showed an initial acute neutrophilic infiltrate. Granulomatous inflammation was present on follow-up biopsy specimens 4 weeks later. An inflammatory infiltrate surrounded the hair shaft remnants, denoting destruction of hair follicles.Limitations: Small sample size was a limitation.Conclusions: Long-pulsed neodymium:yttrium-aluminium-garnet laser, together with topical benzoyl peroxide and clindamycin, is significantly more effective than topical benzoyl peroxide and clindamycin alone for the treatment of HS. Preliminary review of histopathology suggests the mechanism of action is destruction of the hair follicle. The overall success of the treatment in both clearing pre-existing lesions and preventing new eruptions, coupled with high patient satisfaction, makes the neodymium:yttrium-aluminium-garnet laser a promising treatment advance for this highly disabling condition.

Pyoderma gangrenosum is a rare and often painful skin disease that can be unpredictable in its response to treatment. There is currently no gold standard of treatment or published algorithm for choice of therapy. The majority of data comes from case studies that lack a standard protocol not only for treatment administration but also for the objective assessment of lesion response to a specific therapy. This review provides an update to the treatment of pyoderma gangrenosum with a particular focus on new systemic therapies.

Dialogues in Dermatology, a monthly audio program from the American Academy of Dermatology, contains discussions between dermatologists on timely topics. Commentaries from Dialogues Editor-in-Chief Jacqueline M. Junkins-Hopkins, MD, are provided after each discussion as a topic summary and are provided here as a special service to readers of the Journal of the American Academy of Dermatology.

Hossler EW. Caterpillars and moths. Part I. Dermatologic manifestations of encounters with Lepidoptera. J Am Acad Dermatol 2010;62:1-10. Hossler EW. Caterpillars and moths. Part II. Dermatologic manifestations of encounters with Lepidoptera. J Am Acad Dermatol 2010;62:13-28.

We present a report of a 63-year-old man with AIDS who was diagnosed with coexistent Kaposi sarcoma (KS), Cryptococcus neoformans, and Mycobacterium avium intracellulare in a single, solitary lesion. A literature review identified 11 cases of patients with AIDS and cutaneous lesions with co-existent KS and other infectious organisms. To our knowledge, this is the first report of coexistent KS, C neoformans, and M avium intracellulare in the same cutaneous lesion in a patient with AIDS.

Lymphoepithelioma-like carcinoma of the skin (LELCS) is a rare cutaneous neoplasm with histopathologic similarities to nasopharyngeal carcinoma. The association of nasopharyngeal carcinoma with Epstein–Barr virus (EBV) is well documented. EBV has also been reported to be associated with LELC in only four sites (the stomach, salivary glands, lung, and thymus), but not in the skin. We report herein a case of EBV-positive LELCS. An 82-year-old female presented with a red nodule on the right cheek. Histologically, the entire dermis was occupied by atypical tumor cell nests with dense lymphocytic infiltration. Neoplastic cells were strongly positive for cytokeratin 14 but were negative for cytokeratins 19 and 20. EBV genomes in neoplastic cells were detected by polymerase chain reaction analysis and in situ hybridization for EBV-encoded RNA, suggesting an association with EBV.

To the Editor: Choosing appropriate, safe treatment for pregnant patients with psoriasis can be challenging. Although tumor necrosis factor–alfa (TNFα) antagonists are considered category B drugs according to the US Food and Drug Administration (FDA), Carter et al reported a disturbing association of infliximab and etanercept with congenital anomalies associated with the vertebral, anal, cardiovascular, tracheoesophageal, renal, limb (VACTERL) syndrome. In their review of more than 120000 adverse events of patients on TNFα antagonist therapy, they found 61 congenital anomalies occurring at higher than expected frequencies. No reports of congenital anomalies were reported in patients taking adalimumab; however, the database included entries only through 2005, which was relatively soon after adalimumab received approval by the FDA. This suggests that caution should be exercised in prescribing TNFα antagonists in pregnancy despite their category B status.

To the Editor: We read with great interest the comprehensive review by Alikhan et al in the April 2009 issue of the Journal and would like to comment on our own recent findings regarding hidradenitis suppurativa (HS) and the Dermatology Life Quality Index (DLQI).

To the Editor: I read with interest the article by Nijsten et al in the January 2009 issue of the Journal that describes three minimally invasive techniques in the treatment of saphenous varicose veins: foam sclerotherapy, endovenous laser therapy, and radiofrequency ablation. Another procedure—the 3S saphenectomy (the 3S technique)—should be added to theses techniques. The 3S technique associates the surgical sectioning and sclerotherapy of saphenous veins under local anesthesia. It has been developed in France mainly by Vin et al. Many angiophlebologists learned this technique during the educational program of the European School of Phlebology in Paris. It is useful in the following instances: (1) when surgery is not recommended because of an advanced age and/or in case of a leg ulcer or other complication; (2) when surgery is refused for a personal reason; and (3) when the varicose veins are too large to be treated with classical sclerotherapy. In selected cases, the 3S technique gives good results and should be completed by sclerotherapy in the distal portion of the saphenous veins. Moreover, in a study conducted in Spain, this technique decreased the overall rate of recurrence when compared to classical surgery (stripping).