Folliculitis decalvans is a rare scarring alopecia that presents with indurated, tender pustules and papules on the vertex and occipital scalp. Although systemic antibiotics with activity against Staphylococcus species provide some symptomatic improvement, folliculitis decalvans remains a significant management challenge and often exhibits a relapsing-and-remitting course. In this report, we posit the potential utility of medical grade honey as a safe and cost-effective adjuvant therapy in the treatment of folliculitis decalvans. We describe a patient with painful, boggy scalp pustules who achieved clearance of his scalp lesions with the addition of Manuka honey. To our knowledge, this report is the first to demonstrate the clinical use of honey in the management of folliculitis decalvans and may lend support to the role of Staphylococcus in the pathogenesis of this disease.

Nodular lymphangitis, also known as lymphocutaneous syndrome or sporotrichoid lymphangitis, presents with inflammatory nodules along the lymphatic vessels, typically involving the upper or lower extremities. Although the most common cause of nodular lymphangitis is infection due to Sporothrix schenckii, Nocardia brasiliensis, Mycobacterium marinum, or Leishmania braziliensis, it is important for clinicians to be aware of methicillin-resistant Staphylococcus aureus as a rare cause of nodular lymphangitis and perform gram stain, bacterial culture, and antibiotic sensitivity profiles when appropriate. History of recent travel or exposures, incubation time, presence of systemic symptoms, and presence of ulceration, suppuration, or drainage can serve as diagnostic clues, but microbiological tissue cultures and histopathologic studies confirm the diagnosis. Herein, we present a case of nodular lymphangitis caused by methicillin-resistant Staphylococcus aureus (MRSA); tissue culture and antibiotic sensitivities were used to guide treatment.

Importance

Use of prognostic gene expression profile (GEP) testing in cutaneous melanoma (CM) is rising despite a lack of endorsement as standard of care.

Objective

To develop guidelines within the national Melanoma Prevention Working Group (MPWG) on integration of GEP testing into the management of patients with CM, including (1) review of published data using GEP tests, (2) definition of acceptable performance criteria, (3) current recommendations for use of GEP testing in clinical practice, and (4) considerations for future studies.

Evidence review

The MPWG members and other international melanoma specialists participated in 2 online surveys and then convened a summit meeting. Published data and meeting abstracts from 2015 to 2019 were reviewed.

Findings

The MPWG members are optimistic about the future use of prognostic GEP testing to improve risk stratification and enhance clinical decision-making but acknowledge that current utility is limited by test performance in patients with stage I disease. Published studies of GEP testing have not evaluated results in the context of all relevant clinicopathologic factors or as predictors of regional nodal metastasis to replace sentinel lymph node biopsy (SLNB). The performance of GEP tests has generally been reported for small groups of patients representing particular tumor stages or in aggregate form, such that stage-specific performance cannot be ascertained, and without survival outcomes compared with data from the American Joint Committee on Cancer 8th edition melanoma staging system international database. There are significant challenges to performing clinical trials incorporating GEP testing with SLNB and adjuvant therapy. The MPWG members favor conducting retrospective studies that evaluate multiple GEP testing platforms on fully annotated archived samples before embarking on costly prospective studies and recommend avoiding routine use of GEP testing to direct patient management until prospective studies support their clinical utility.

Conclusions and relevance

More evidence is needed to support using GEP testing to inform recommendations regarding SLNB, intensity of follow-up or imaging surveillance, and postoperative adjuvant therapy. The MPWG recommends further research to assess the validity and clinical applicability of existing and emerging GEP tests. Decisions on performing GEP testing and patient management based on these results should only be made in the context of discussion of testing limitations with the patient or within a multidisciplinary group.

Importance

Therapy for advanced melanoma has transformed during the past decade, but early detection and prognostic assessment of cutaneous melanoma (CM) remain paramount goals. Best practices for screening and use of pigmented lesion evaluation tools and gene expression profile (GEP) testing in CM remain to be defined.

Objective

To provide consensus recommendations on optimal screening practices and prebiopsy diagnostic, postbiopsy diagnostic, and prognostic assessment of CM.

Evidence review

Case scenarios were interrogated using a modified Delphi consensus method. Melanoma panelists (n = 60) were invited to vote on hypothetical scenarios via an emailed survey (n = 42), which was followed by a consensus conference (n = 51) that reviewed the literature and the rationale for survey answers. Panelists participated in a follow-up survey for final recommendations on the scenarios (n = 45).

Findings

The panelists reached consensus (≥70% agreement) in supporting a risk-stratified approach to melanoma screening in clinical settings and public screening events, screening personnel recommendations (self/partner, primary care provider, general dermatologist, and pigmented lesion expert), screening intervals, and acceptable appointment wait times. Participants also reached consensus that visual and dermoscopic examination are sufficient for evaluation and follow-up of melanocytic skin lesions deemed innocuous. The panelists reached consensus on interpreting reflectance confocal microscopy and some but not all results from epidermal tape stripping, but they did not reach consensus on use of certain pigmented lesion evaluation tools, such as electrical impedance spectroscopy. Regarding GEP scores, the panelists reached consensus that a low-risk prognostic GEP score should not outweigh concerning histologic features when selecting patients to undergo sentinel lymph node biopsy but did not reach consensus on imaging recommendations in the setting of a high-risk prognostic GEP score and low-risk histology and/or negative nodal status.

Conclusions and relevance

For this consensus statement, panelists reached consensus on aspects of a risk-stratified approach to melanoma screening and follow-up as well as use of visual examination and dermoscopy. These findings support a practical approach to diagnosing and evaluating CM. Panelists did not reach consensus on a clearly defined role for GEP testing in clinical decision-making, citing the need for additional studies to establish the clinical use of existing GEP assays.