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Open Access Publications from the University of California

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Dermatology Online Journal is an open-access, refereed publication intended to meet reference and education needs of the international dermatology community since 1995. Dermatology Online Journal is supported by the Department of Dermatology UC Davis, and by the Northern California Veterans Administration.

Volume 19, Issue 9, 2013

Review

Lasers and photodynamic therapy in the treatment of onychomycosis: a review of the literature.

Onychomycosis is a widespread problem. Oral antifungal medications are currently the gold standard of care, but treatment failure is common and oral therapy is contraindicated in many cases. There is a need for effective treatment without the systemic complications posed by oral therapy. Laser and photodynamic therapy may have the potential to treat onychomycosis locally without adverse systemic effects; some small studies have even reported achieving clinical and mycologic cure. However, there is reason for restraint; these therapies are expensive and time-consuming. Furthermore, they may not be covered by insurance and have not been proven effective with randomized, controlled clinical trials. This paper will review current literature regarding the use of laser and photodynamic therapy as potential treatments for onychomycosis.

Case Presentation

Mycobacterium porferae infection in a psoriasis patient on anti-tnf-a therapy

Psoriasis is a chronic, auto-inflammatory disease affecting millions of individuals worldwide.  In addition to classic cutaneous manifestations, the condition is linked to significant co-morbidities including cardiovascular disease, metabolic syndrome, melanoma and non-melanoma skin cancer, and psychiatric disease [1,2].  Therefore, more aggressive treatment and multi-disciplinary care is critical.   Measures of disease burden (quantified by anatomic location, body surface area (BSA) of involvement, and impact on daily life) assist in determining the severity of disease and have been integral in objective assessment of treatment regimens and new drug therapies [1].  Biologic agents have entered the clinical armamentarium as treatment options for patients with moderate-to-severe psoriasis who have failed traditional systemic therapies.  Three of the four FDA-approved biologic agents for psoriasis suppress TNFa mediated pathways [2], which are essential for granuloma formation and maintenance, key components of host defenses against intracellular pathogens [3].  Subsequently, the increased use of these agents is accompanied by increased reporting of granulomatous infectious diseases such as tuberculosis, histoplasmosis, nocardia, and nontuberculous mycobacteria [4].  Report of any unusual infection is therefore vitally important in the care of this immune suppressed patient population.

Malignant combined squamomelanocytic tumor: a clinical case

A combined squamomelanocytic tumor is an exceedingly rare occurrence; little is known about its pathogenesis. A definitive diagnosis can only be made via histological examination. We describe herein an 83 year-old man who was discovered to have this combined tumor and recommend the appropriate management for such a lesion.

A bruise-like patch in a 4-year-old girl

Dermatofibrosarcoma protuberans (DFSP), a rare medium grade sarcoma, occasionally occurs in childhood and is even more rarely present at birth. In children, the clinical appearance may be mistaken for a vascular malformation and so delayed diagnosis is not uncommon. Dermatofibrosarcoma protuberans is locally invasive and notorious for its high recurrence rate even after attempted wide local excision owing to extensive subclinical and asymmetrical extensions. In adult DFSP, Mohs Micrographic Surgery (MMS) is the treatment of choice because it offers a higher clearance rate compared to wide local excision. However, MMS may result in extended operating times owing to tissue processing and multiple stages. In children, this means a prolonged period under general anesthetic, which may be undesirable.  We describe an interesting case of a 4- year-old girl diagnosed with DFSP. She underwent a modified MMS procedure in which she had two short general anesthetics.  The advantage of MMS technique in which the full peripheral and deep margin of the specimen was examined.

Generalized acanthosis nigricans without systemic disease associated

Acanthosis nigricans (OMIM ID % 100600) is a dermatosis characterized by velvety hyperpigmentation, skin thickening, and papillomatosis. It mainly affects flexural areas. In most cases, the generalized form is related to malignancy in adults; it is rarely reported in the absence of systemic disease in children and adolescents. The present report is aimed at describing an unusual case of generalized acanthosis nigricans in a 17 year-old patient, in which, after extensive investigation (clinical, laboratorial and by imaging methods) no association with systemic disease was found.

Uncorrectable Ptosis: Primary Cutaneous Signet-ring Cell Carcinoma

Primary cutaneous signet-ring cell carcinoma (PCSRCC) is a rare but aggressive tumor. Our case highlights a 60-year-old man who presented with eyelid ptosis, for which he underwent multiple surgical procedures over a 3-year period prior to referral to our clinic. These procedures were complicated by scarring, delayed healing, and poor cosmetic outcome.  In addition, the patient was noted to develop progressive enophthalmos.  These concerning signs led to a CT scan and subsequent eyelid biopsy, which revealed a diagnosis of PCSRCC.  Further management has involved an MRI and orbitotomy with biopsy revealing widespread extension of the carcinoma.  Exenteration was performed to reduce the likelihood of metastasis.

There are few documented case reports of PCSRCC of the eyelid in the literature.  Of the 33 published cases of PCSRCC, 27 cases involve the eyelids and the other 6 cases involve the axilla. The unique clinical features of this case will be discussed, in particular the presentation as ptosis, an otherwise commonplace complaint in the oculoplastics clinic.  The surgical course and histopathologic findings will be presented.  The literature regarding PCSRCC will be reviewed including demographics, management, and prognosis. Although rare, PCSRCC follows an aggressive course with characteristically delayed diagnosis.  Early identification and treatment likely offer a better prognosis.  Thus, description of the clinical presentation of this rare tumor may aid in recognition and earlier treatment.

Calciphylaxis treated with sodium thiosulfate: report of two cases

Although traditionally observed in patients with end-stage renal disease and secondary hyperparathyroidism, calciphylaxis has been reported in patients with normal renal and parathyroid function. There is no evidence-based therapy available. The use of sodium thiosulfate (STS) has been increasingly described. Herein we describe two patients who responded well to this treatment.

Solitary erythematous, tender plaque of the heel in a young infant

Calcinosis cutis is a rare disorder resulting from the precipitation and deposition of insoluble calcium and phosphate salts (hydroxyapatite crystals) in the dermis and subcutaneous tissue. It is generally divided into four main groups on the basis of etiology and pathogenesis. Clinical presentation of cutaneous calcinosis cutis varies according to the diagnosis and the underlying process. We report a case of calcinosis cutis of the heel in which both the extravasation of a calcium gluconate infusion and renal failure could have promoted the development of calcinosis cutis

Preterm infant with a late presentation of blueberry muffin lesions secondary to recombinant erythropoietin

Our patient is a 26-week-old preterm female infant delivered by caesarean section secondary to severe maternal preeclampsia who had been receiving subcutaneous recombinant erythropoietin (r-EPO) for anemia of prematurity. At 8 weeks of age after 8 doses of r-EPO, the infant developed numerous non-blanching erythematous macules and patches located on the back, posterior shoulder, and posterior arms, concerning for late-onset blueberry muffin lesions. Biopsy of the lesions confirmed dermal hematopoiesis. After r-EPO was discontinued all skin lesions gradually resolved over a period of 2 weeks and never recurred. 

A case of glyburide-induced leukocytoclastic vasculitis

Introduction: Medication-induced leukocytoclastic vasculitis is a small-vessel vasculitis that most commonly manifests with palpable purpuric lesions on gravity dependent areas. Development of the vasculitis occurs within weeks after the initial administration of the medication, with clearance upon withdrawal of the medication. Glyburide, a sulfonylurea medication, is used to treat non-insulin dependent diabetes mellitus. We report a rare case of glyburide-associated leukocytoclastic vasculitis.

Observation: We report a 71-year-old man with type 2 diabetes mellitus who presented with palpable purpura on the lower extremities. Cutaneous biopsy revealed superficial small vessel vasculitis with IgA perivascular deposits.  Further questioning revealed three prior episodes of palpable purpura after restarting the glyburide medication, with clearance upon discontinuation. We diagnosed drug-induced vasculitis related to the glyburide.

Conclusions: This case highlights a rarely reported cutaneous adverse reaction to the commonly used diabetic medication, glyburide. Physicians should consider cutaneous vasculitis as a potential side effect of glyburide.

Abbreviations: LCV (Leukocytoclastic vasculitis), c-ANCA (centrally accentuated anti-neutrophilic cytoplasmic antibody), p-ANCA (Perinuclear anti-neutrophilic cytoplasmic antibody), anti-TNF-alpha (anti-tumor necrosis factor alpha)

Syringocystadenocarcinoma papilliferum: a rare tumor with a favorable prognosis

Syringocystadenocarcinoma papilliferum (SCACP) is a rare adenexal carcinoma with only 21 cases reported in the literature. Most patients describe a long-standing mass with recent change, supporting the idea that SCACP arises from malignant transformation of pre-existing syringocystadenoma papilliferum (SCAP). Syringocystadenocarcinoma papilliferum is generally treated with wide surgical excision of the lesion and patients do exceeding well and require no systemic therapy.

Photo Vignette

Umbilicated nodule over eyebrow

Trichofolliculoma is a pilosebaceous follicle hamartoma in which several hairs are formed within single pilosebaceous unit and protrude out of single orifice. Herein we report a 45-year-old woman with a trichofolliculoma of the eyebrow.

Letter

Clinical Characteristics and Awareness of Skin Cancer in Hispanic Patients

Skin cancer in darker skin is associated with considerable morbidity and mortality. We sought to assess the clinical characteristics of cutaneous malignancy amongst Hispanic skin cancer patients and compare them to age-matched non-Hispanic Caucasians.  In this retrospective study, 150 Hispanic skin cancer patients were identified from electronic medical records and age-matched to 150 non-Hispanic Caucasian controls with skin cancer.  The incidence of actinic keratoses (AKs) in Hispanic skin cancer patients (34.0%) was statistically lower than age-matched non-Hispanic Caucasian skin cancer controls (61.3%, P <0.001; odds ratio, 3.08; 95% confidence interval, 1.92 - 4.93).  Moreover, non-Hispanic Caucasian SCC (squamous cell cancer) controls were much more likely to report AKs (36.1%, P = 0.003) than Hispanic SCC patients (25.0%, P = 0.19).  This study illustrates a lower incidence of AKs in Hispanic skin cancer patients as compared to their age-matched non-Hispanic Caucasians.  The Hispanic skin malignancies present at a more advanced state and there is usually a lack of awareness in such cases.  Therefore, patient knowledge and education is crucial for early detection and prevention of skin cancer in the Hispanic population.      

A case of microscopic polyangiitis with skin manifestations in a seven-year-old girl

A case of a 7-year-old girl with microscopic polyangiitis (MPA) with a skin eruption characterized by maculopapular, erythematous and purpuric lesions on the face, elbows, and knees is presented. Anti-neutrophil cytoplasmic autoantibodies (ANCA) with myeloperoxidase specificity (MPO-ANCA) were identified. Chest X-ray and computed tomography scan revealed diffuse infiltrates in both lung fields, suggesting alveolar hemorrhage. Microscopic hematuria was detected but a renal biopsy showed no abnormalities. Histological  examination  of a skin biopsy from a  purpuric papule showed leukocytoclastic vasculitis of the small vessels in the entire dermis. The patient was treated with prednisolone and mizoribine, resulting in an improvement in the skin lesions except for those on the knee.

Bilateral and symmetrical tinea mammae

Tinea corporis has rarely been reported in some locations such as on the breast skin as unilaterally. Herein, we present a case of bilateral tinea mammae, which has not been reported before in English language literature to our knowledge.

Congenital agminated segmental nevi of the chest

Grouped patterns of pigmented lesions are infrequent. Of the several reports of agminated nevi, most have been Spitz nevi or blue nevi. The distribution of these nevi is often segmental, following a dermatome or the lines of Blaschko. Most segmental nevi are not agminated and develop early in childhood [1]. We describe a rare case of congenital agminated segmental nevi on the chest.