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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 25, Issue 2, 2019

Review

Diet and psoriasis

Background: Patients with psoriasis have a growing interest in managing their disease through diet.

Objective: This review paper aims to analyze dietary interventions for psoriasis and their outcome.

Methods: Terms "psoriasis AND diet" were used to search PubMed database and 63 articles describing dietary changes influencing psoriasis were selected.

Results: Low calorie diet (LCD) improves Psoriasis Area and Severity Index (PASI) and Dermatology Life Quality Index (DLQI) in conjunction with topical or systemic therapy, although LCD was unsuccessful in maintaining disease remission when patients discontinued concomitant cyclosporine or methotrexate therapy. A fish oil diet improved baseline PASI of 7.7 to 5.3 at three months and 2.6 at 6 months compared to control (PASI: 8.9, 7.8, and 7.8, respectively). A randomized, double-blind, placebo-controlled study investigating selenium supplementation in psoriasis provided no PASI improvement. Zinc supplementation with concomitant betamethasone valerate 0.0025% ointment in a randomized, double-blind, placebo-controlled study provided a mean PASI of 11.2 in the intervention group and 8.0 in the control group with no significant difference between both arms. Gluten free diet and vitamin D supplementation were also efficacious dietary changes although results were mixed.

Conclusions: Dietary changes alone do not cause a large effect in psoriasis but may become an important adjunct to current first line treatments.

Original

Merkel cell carcinoma: long-term follow-up of a single institution series and clinical outcomes by immunological status

Merkel cell carcinoma (MCC) usually arises in sun-exposed areas of older patients and might be more aggressive in the immunocompromised. We performed a retrospective chart review of 40 consecutive MCC patients treated at our institution between the years 2006-2017. Clinical and epidemiologic data were utilized and therapy and survival were analyzed. Compared to Surveillance, Epidemiology, and End Results (SEER) data, our population was entirely Caucasian (100% versus 95%; P=0.11) and male predominant (75% versus 63%; P=0.11). The median age was 76. The patients more often had Tumor-Node-Metastasis (TNM) stage I disease (50% versus 39%; P=0.00003) and a primary tumor size<2cm (57.5% versus 34%; P<0.01). They received more frequently lymph node dissection (70% versus 63%, P=0.002) compared with the SEER findings. We identified a subset of immunocompromised patients (n=10) who presented with more stage III disease (40% versus 33%; P=0.021). Time to death averaged 290.1 days in this subset versus 618.2 days (P<0.001) in immunocompetent patients and their likelihood of death was 5 times higher. As clinical outcomes in MCC patients vary by immunological status, a multidisciplinary tumor-board approach may better optimize individual patient management.

Commentary

Laser-assisted drug delivery for the treatment of androgenetic alopecia: ablative laser fractional photothermolysis to enhance cutaneous topical delivery of platelet-rich plasma — with or without concurrent bimatoprost and/or minoxidil

Platelet-rich plasma, which contains numerous growth factors that promote hair growth, is a nonsurgical treatment available for patients with androgenetic alopecia. However, neither the quantity nor the location and depth of platelet-rich plasma placement in the scalp is uniform; in addition, multiple painful injections are required. Vertical uniform channels from the skin surface into the dermis, created by ablative laser fractional photothermolysis, can be used to enhance the cutaneous delivery of medications. This technique — referred to as laser assisted drug delivery — may provide an efficacious means for the administration of platelet-rich plasma to the scalp. It would not only enable the uniform placement of platelet-rich plasma in the dermis (instead of inadvertently in the subcutaneous fat) of androgenetic alopecia patients' scalps, but also eliminate the injection-associated pain. In addition, the topical application of either bimatoprost or minoxidil or both could also be enhanced with laser assisted drug delivery. In conclusion, to potentially maximize the stimulation of hair growth, laser assisted drug delivery of platelet-rich plasma — with or without bimatoprost and/or minoxidil — should be considered in patients with androgenetic alopecia in order to effectively deliver the agents to the dermis where the bulge area of the hair follicles is located.

A novel ultraviolet B home phototherapy system: Efficacy, tolerability, adherence, and satisfaction

Background: Phototherapy is effective in treating psoriasis and other skin conditions. However, clinic-based phototherapy can be time-consuming, expensive, and inconvenient. Conventional home phototherapy addresses many hurdles, but has other limitations.

Objective: Assess the treatment efficacy, adherence, and satisfaction of a novel ultraviolet B home phototherapy system.

Methods: Eight patients with stable plaque psoriasis completed a multicenter, prospective, open label, interventional study using a home phototherapy device designed to improve treatment control and adherence. Matched control and study lesions were assessed on each subject. A dosing protocol based on American Academy of Dermatology guidelines for narrowband UVB phototherapy was managed by the phototherapy system. Responsiveness to the treatment was measured using the Psoriasis Severity Index (PSI) at 10 weeks versus control. Patient satisfaction was graded on a five-star Likert scale.

Results: At 10 weeks, all patients experienced improvement in the treated lesions, with a mean improvement of 57% in PSI (P<0.0001 compared to baseline and P<0.0002 compared to the control lesions). Patient treatment adherence was 96% and treatment satisfaction was 100% five-star rated. Control lesions did not significantly change in PSI over the 10-week period (P=0.1411).

Conclusions: The home phototherapy system provided a safe and effective means to manage plaque psoriasis.

Case Report

Non-uremic calciphylaxis in a patient with multiple rheumatologic diseases

Non-uremic calciphylaxis is a rare, life-threatening condition characterized clinically by cutaneous necrosis and histologically by calcium deposition in small vessel walls. The etiology of non-uremic calciphylaxis remains the subject of ongoing speculation and debate. Herein we present a patient with calciphylaxis who had normal kidney function and numerous rheumatologic diseases, namely systemic lupus erythematosus (SLE), Sjogren syndrome (SS), and myasthenia gravis (MG). We review the pathophysiology, possible mechanisms, and management for non-uremic calciphylaxis.

Case Presentation

Cutaneous toxicity associated with enfortumab vedotin treatment of metastatic urothelial carcinoma

Enfortumab vedotin is an antibody-drug conjugate targeting nectin-4 and is being studied in the treatment of various epithelial carcinomas including urothelial carcinoma; early data suggests efficacy and tolerability. Rash has been described as an adverse event associated with treatment with enfortumab vedotin, but has not been characterized to date. We report a patient with metastatic urothelial carcinoma treated with enfortumab vedotin who developed erythematous, scaly papules and plaques on his torso and extremities with corresponding histologic features of vacuolar interface dermatitis and maturation disarray of keratinocytes. He was successfully treated with topical corticosteroids. Cutaneous toxicity appears to be a common adverse reaction in this growing class of antibody-drug conjugates.

Glans penis necrosis caused by calcific uremic arteriolopathy

Calcific uremic arteriolopathy (CUA) or calciphylaxis is a syndrome characterized by calcification of vessels located in the dermis and adipose tissue. It commonly occurs in patients with diabetes mellitus, hypertension, and end-stage renal disease. Clinical presentation generally begins with severe pain, followed by the presence of liveloid or purpuric plaques. Later the formation necrotic ulcers occur. This condition is associated with a poor prognosis, with a high rate of mortality within months of the diagnosis. Penile involvement is an uncommon but severe manifestation. We present an 81-year-old man with a history of diabetes mellitus, hypertension, and end-stage renal disease with a one-month evolution of painful necrotic ulcers on his glans penis. He was diagnosed with CUA. Owing to infection complicated by sepsis; penectomy was performed. Unfortunately, the patient died of myocardial infarction during his hospitalization.

Solitary noninfiltrating angiolipoma on the finger, an unusual localization.

Angiolipoma, a subtype of lipoma, is a benign adypocytic soft tissue tumor composed of mature adipose tissue and small vascular proliferations. This entity makes up 5–17% of all lipomas. The diagnosis is made by clinical and pathological examination, ultrasonography, and/or magnetic resonance imaging (MRI). It is generally an encapsulated tumor (noninfiltrative), but rarely has an infiltrative form. Angiolipoma mostly occurs on the trunk and extremities with male predominance. The forearm is the most frequent location for angiolipomas. It is very rarely seen on the fingers. Herein, we report a patient with solitary noninfiltrating angiolipoma on a finger. The patient was treated with surgical excision and no recurrence has been noted over one year of observation.

Blastic plasmacytoid dendritic cell neoplasm: an early presentation

A blastic plasmacytoid dendritic cell neoplasm (BPDCN) is a cutaneous lymphoma derived from a plasmacytoid dendritic precursor cell that exhibits aggressive clinical behavior. Herein, we report a 46-year-old woman with a complaint of a painless nodule on the back, associated with pruritus. The nodule grew and new growths appeared over six months of evolution. The histopathological examination of one of the left upper limb lesions showed a dense lymphoid cell infiltrate with atypia in the superficial and deep dermis. Immunohistochemistry showed positivity for CD45, S-100 protein, CD123, and TCL 1. About two months after the initial evaluation, the patient was admitted to the Emergency Hospital of Marituba-PA with dyspnea. She progressed to cardiorespiratory arrest and death within 12 hours of admission. There is still no consensus for the treatment of BPDCN. Intensive therapy for acute leukemia can be useful, but allogeneic bone marrow transplantation has a greater chance of long-term survival.

Mycobacterium marinum lymphocutaneous infection

Mycobacterium marinum is a nontuberculous mycobacteria with worldwide distribution that lives in fresh or salt water and is responsible for infections in fish, and sometimes in humans. Human disease consists mainly of cutaneous nodules, but deep structure involvement may also occur. Diagnosis of M. marinum infection remains a challenge, with a considerable time delay between onset of symptoms and diagnosis. We present a 33-year-old man with no immunosuppressive history who was seen in our department with skin nodules over his hand and forearm, distributed in a sporotrichoid pattern. His hobbies included maintaining an aquarium of tropical fish. Histological examination of the patient's skin biopsy was compatible with the diagnosis of mycobacterial infection, and the Ziehl-Neelsen staining revealed acid-fast bacilli. Molecular techniques confirmed the suspicion of M. marinum infection. A necropsy was performed on one of the patient's fish, more specifically, a Poecilia reticulata, and resulted in identification of M. marinum from its gut. The patient was treated with clarithromycin, ethambutol, and rifampicin for 9 months, with clearance of infection.

Neurosis and true dermatosis: a case of ossified pilomatricoma developing within a self-inflicted ulcer

Clinicians have a tendency to dismiss patients with psychiatric illness like skin picking disorder without assessing completely for organic disease. Patients with psychocutaneous disease have the potential to develop true dermatopathology and should always be examined thoroughly. We describe a case of skin picking disorder with underlying pilomatricoma. The patient met criteria for skin picking disorder and had been prescribed numerous topical treatments without efficacy by countless physicians over 18 years. In addition, a pilomatricoma was discovered within a self-inflicted ulcer. Pilomatricomas can rarely result from trauma and develop ossification, both of which were true of this lesion. The prevalence of skin picking disorder proves more pervasive than previously realized and it has only recently been recognized by the DSM-5 as an independent diagnosis. Therefore, it is necessary to clarify the diagnosis as well as remind clinicians not to discount underlying dermatologic disease. In addition to the risk of bleeding and infection, these patients are at risk for masking neoplasms, which should be removed. Our case emphasizes the need for thorough examination of patients with psychocutaneous disease and further work-up when necessary to prevent permanent disfigurement.

Photo Vignette

Umbilical condyloma lata

Condyloma lata, a cutaneous manifestation of secondary syphilis, usually appear as verrucous papules and plaques in the anogenital area. Involvement of the umbilicus is very uncommon. Thus, awareness of this presentation, along with appropriate history, physical exam, and laboratory testing may aid clinicians in prompt and accurate diagnosis. We describe a patient with an unusual presentation of condyloma lata on the umbilicus.

Verrucous melanoma masquerading as a seborrheic keratosis

Seborrheic keratosis is a benign condition that can mimic many different non-melanoma and melanoma neoplasms. There have been several case reports of underlying squamous cell carcinomas or intraepidermal carcinomas appearing within lesions that look analogous to seborrheic keratoses. We present a patient with a verrucous melanoma that could be mistaken for a benign skin tumor like an inflamed seborrheic keratosis. In our patient's case, her verrucous plaque was initially clinically suggestive of a benign seborrheic keratosis. However, given the patient's complaint of pain associated with the lesion, a biopsy was performed and revealed a verrucous-keratotic malignant melanoma, which was subsequently removed through surgical excision. It is important to remain vigilant of this diagnosis, as treatment for inflamed seborrheic keratosis often includes a trial of cryotherapy, which potentially could lead to a delayed diagnosis of an underlying malignant lesion.

Large peri-punctal eccrine hidrocystoma

Eccrine hidrocystoma is a benign cystic tumor. Such benign cystic lesions may be a cosmetic concern, or when large, can cause eyelid malpositions. We report a patient with a peri-punctal hidrocystoma of the eyelid.

Surgical Pearl

Electrosurgical debulking of pretibial myxedema of the foot

Pretibial myxedema or thyroid dermopathy constitutes dermal deposition of mucin, primarily hyaluronic acid and chondroitin sulfate. It is a manifestation of autoimmune thyroiditis, seen more in Graves disease than in Hashimoto thyroiditis. The time delay from treatment of hyperthyroidism to appearance of localized myxedema varies from one month to 16 years (mean 5.13 years). Despite a variety of therapeutic options, failure and relapse rates are high. Therapeutic options reported in the literature include compression, topical and intralesional corticosteroids, oral pentoxifylline, octreotide, rituximab, plasmapheresis, and high-dose intravenous immunoglobulin. We share our experience in two patients who were treated with electrosurgical debulking of selected longstanding myxedematous lesions, with one positive result and one negative result.

Letter

Acrodermatitis continua of Hallopeau response to optimized biological therapy

Acrodermatitis continua of Hallopeau, first described in 1890, is an uncommon variant of pustular psoriasis. It presents as a sterile pustular eruption of the tips of fingers and toes. The condition has a chronic, relapsing course and is often resistant to many anti-psoriatic therapies. In the following case, we present our experience of etanercept use in a 61-year-old man. Although initial therapy with high-dose etanercept achieved a rapid, sustained response and remission, the lesions relapsed a few months into a lower, maintenance dosage. This result prompted the use a second biotherapeutic agent ustekinumab, which resulted in complete remission, but required a higher dosage than recommended with reduced dosing intervals.