Perineal cutaneous basal cell carcinomas in patients with familial seronegative celiac disease: Report of three cases

The etiopathogenesis of basal cell carcinoma (BCC) arising in the perineum is unclear. We report BCC arising in the perineum of three longstanding untreated celiac disease (CD) patients. CD is an autoimmune enteropathy due to hypersensitivity to consumed gluten. Patients can present with gastrointestinal symptoms including diarrhea and weight loss, as well as fatigue, iron-deficiency anemia, vitamin D deficiency, depression, and unexplained hypocalcemia. As a result, CD often goes undiagnosed for many years before a diagnosis is made.

Treatment options for leishmaniasis

Leishmaniasis is broadly classified into three types: cutaneous, mucocutaneous and visceral. The visceral form is most dangerous and can result in death. Although leishmaniasis is an ancient disease, its treatment is still challenging. Several drugs, differing in their cost, toxicity, treatment duration and emergence of drug resistance, are used for different types of leishmaniasis. To overcome these limitations, the search for newer drugs and other treatments continues. In this article, we discuss conventional drugs, other treatments, including newer options such as immunotherapy and immunochemotherapy, and future prospects for leishmaniasis treatment.

Interdigital syphilis: a rare form of secondary syphilis

A 39-year-old man with bilateral painful erosions in his toe web spaces and on the penile shaft was misdiagnosed as having Gram-negative toe web infection, and treated with broad-spectrum oral antibiotics. Further evaluation revealed positive serological tests for syphilis. Pedal interdigital syphilis is a rare manifestation of secondary syphilis.

Topical antiviral and antifungal medications in pregnancy: a review of safety profiles

Medications should be employed with caution in women of childbearing age who are pregnant or considering pregnancy. Compared to oral or parenteral agents, topical medications have limited systemic absorption and are deemed safer. However, their safety profile must be assessed cautiously due to the limited available data. In this article, we aggregate human and animal studies to provide recommendations on utilizing topical antiviral and antifungal medications in pregnancy. For antiviral medications, acyclovir and trichloroacetic acid are safe to use in pregnancy. Docosanol, imiquimod and penciclovir are likely safe, but should be utilized as second-line agents. Podofilox and podophyllin resin should be avoided. For antifungal medications, clotrimazole, miconazole and nystatin are considered first-line agents. Butenafine, ciclopirox, naftifine, oxiconazole and terbinafine may be utilized after the above agents. Econazole should be avoided during the first trimester and used sparingly during 2nd and 3rd trimester. Ketoconazole and selenium sulphide are likely safe, but should be employed in limited areas for brief periods.

Vitiligo and depression: a systematic review and meta-analysis of observational studies

Vitiligo is a common depigmenting disorder with profound psychosocial impacts. Previous observational studies have suggested a link between vitiligo and psychiatric morbidity, such as depression. However, variability in study design makes it difficult to quantify accurately the relationship between vitiligo and depression. We aimed to investigate the underlying prevalence and risk of depression among patients with vitiligo. A comprehensive search of MEDLINE, Embase and the Cochrane Library was conducted. Cross-sectional, case-control or cohort studies that assessed the prevalence of depression among patients with vitiligo or the relationship between vitiligo and depression were included. DerSimonian and Laird random-effects models were utilized to calculate the pooled prevalence and relative risks. Publication bias was evaluated by funnel plots and Egger's tests. Twenty-five studies with 2708 cases of vitiligo were included. Based on diagnostic codes, the pooled prevalence of depression among patients with vitiligo was 0·253 [95% confidence interval (CI) 0·16-0·34; P < 0·001)]. Using self-reported questionnaires, the pooled prevalence of depressive symptoms was 0·336 (95% CI 0·25-0·42; P < 0·001). The pooled odds ratio of depression among patients with vitiligo was 5·05 vs. controls (95% CI 2·21-11·51; P < 0·001). Moderate-to-high heterogeneity was observed between the studies. Patients with vitiligo were significantly more likely to suffer from depression. Clinical depression or depressive symptoms can be prevalent, with the actual prevalence differing depending on screening instruments or, possibly, geographical regions. Clinicians should actively evaluate patients with vitiligo for signs/symptoms of depression and provide appropriate referrals to manage their psychiatric symptoms accordingly.

Basal cell naevus syndrome: an update on genetics and treatment

Basal cell naevus syndrome is an autosomal dominant disorder that stems from mutations in multiple genes, most commonly patched 1 (PTCH1). The classic triad of symptoms consists of basal cell carcinomas, jaw keratocysts and cerebral calcifications, although there are many other systemic manifestations. Because of the broad range of symptoms and development of several types of tumours, early diagnosis and close monitoring are essential to preserve quality of life. Targeting treatment is often difficult because of tumour prevalence. Newer inhibitors of the hedgehog signalling pathway and proteins involved in proliferative growth have shown therapeutic promise. In addition, preventive medications are being devised. We propose a method for determining appropriate treatment for cutaneous tumours.

Neonatal leukaemia cutis

Neonatal leukaemia cutis is a significant neoplasm that may represent a cutaneous manifestation of systemic leukaemia, usually of myeloblastic type. Rarely, it may be or appear to be limited to skin, in which case it is called neonatal aleukaemic leukaemia cutis. By definition, it presents within the first 4 weeks of life and often has a 'blueberry muffin baby' appearance of magenta coloured nodules affecting almost any area of the skin, usually sparing mucous membranes, palms and soles. This clinical pattern is more commonly associated with neonatal infections such rubella and toxoplasmosis, and may be evident with other neonatal neoplasms such as neuroblastoma. Due to the morbidity associated with chemotherapy and reported cases of spontaneous remission without systemic progression in those with neonatal aleukaemic leukaemia cutis without 11q23 translocation, the authors not treating the child with chemotherapy, but to simply monitor for fading of the violaceous nodules, and watch for possible signs of systemic leukaemia.

Infectious eczematoid dermatitis: a comprehensive review

Infectious eczematoid dermatitis (IED) is characterized by an acute eczematous eruption triggered by purulent discharge from a primary infected site. Alcohol consumption, cigarette smoking and occupations with higher incidences of contact dermatitis portend increased risk for IED. Staphylococcus aureus is the most commonly cultured microbe from affected skin, with Streptococcus species the second most. Patients are first evident with peripherally spreading vesicles and pustules radiating from an infected site. Older areas of involvement become crusty, scaly and erythematous. Diagnosis is clinical. Other eczematous rashes, including autoeczemitization and contact dermatitis, should be on the differential diagnosis list. The treatment centres on topical antibiotics and soaks. Prognosis has improved since the advent of antibiotics. However, cases with multiple relapses and poor response to therapy are still observed.

Body dysmorphic disorder: beyond skin deep

Body dysmorphic disorder (BDD) is a psychiatric illness that primarily affects adolescents and young adults of both sexes. Patients have a distorted self-image, which manifests as a preoccupation with slight or imagined defects in the face, nose, skin, hair or any part of the body that ultimately interferes with daily functioning. It is a relatively common yet long unrecognized problem. Patients often seek multiple physician assessments for their perceived defects and request cosmetic procedures. Early intervention can prevent a cycle of multiple surgeries, as the outcome is usually poor and may lead to exacerbation of symptoms, anger and litigation. BDD is a disabling, and even life-threatening, condition; it can lead to major depression and suicidal ideation. Selective serotonin reuptake inhibitors and cognitive behavioral therapy are the mainstay of treatment and are beneficial in most patients. A multidisciplinary approach is strongly recommended.

Staphylococcal scalded skin syndrome: diagnosis and management in children and adults

Staphylococcal scalded skin syndrome is a potentially life-threatening disorder caused most often by a phage group II Staphylococcus aureus infection. Staphylococcal scalded skin syndrome is more common in newborns than in adults. Staphylococcal scalded skin syndrome tends to appear abruptly with diffuse erythema and fever. The diagnosis can be confirmed by a skin biopsy specimen, which can be expedited by frozen section processing, as staphylococcal scalded skin syndrome should be distinguished from life threatening toxic epidermal necrolysis. Histologically, the superficial epidermis is detached, the separation level being at the granular layer. The diffuse skin loss is due to a circulating bacterial exotoxin. The aetiological exfoliating toxin is a serine protease that splits only desmoglein 1. The exfoliative toxins are spread haematogenously from a localized source of infection, causing widespread epidermal damage at distant sites. Sepsis and pneumonia are the most feared complications. The purpose of this review is to summarize advances in understanding of this serious disorder and provide therapeutic options for both paediatric and adult patients. Recent epidemiological studies have demonstrated that paediatric patients have an increased incidence of Staphylococcal scalded skin syndrome during the summer and autumn. Mortality is less than 10% in children, but is between 40% and 63% in adults, despite antibacterial therapy. Previously, intravenous immunoglobulin had been recommended to combat Staphylococcal scalded skin syndrome, but a recent study associates its use with prolonged hospitalization.

Vitiligo: recent insights and new therapeutic approaches

Vitiligo represents a selective destruction of the melanocytes. It is a relatively common, probably autoimmune disorder that affects people of all backgrounds and both genders. No particular group seems to be preferentially affected. Half of vitiligo patients have an onset before the age of 18 years. In regions where leprosy is endemic, individuals with vitiligo are often stigmatized due to similarities in appearance between the two diseases. We will review this important subject, emphasizing the latest therapeutic advances.

Melasma

Melasma is a common disorder of hyperpigmentation that is present most commonly in reproductive age women with brown or black skin colors. The lesions of melasma are characteristically distributed in a symmetric manner on the sun-exposed areas of the face and neck. The precise pathogenesis of the disorder is unknown, but a number of etiologic agents have been implicated as its cause. These include ultraviolet radiation, hormonal alterations such as those evident during pregnancy, thyroid dysfunction, and phototoxic and anti-seizure drugs. The pathophysiology of melasma is believed to involve excess production of melanin or an increase in the number of melanocytes in the skin. This is confirmed by histological analysis of melasma, which shows an increased number of melanocytes along with an enhanced capability of these cells to produce melanin. Lack of an understanding of the precise pathogenesis of the condition has led to a large number of treatments for melasma. These therapies include hypopigmenting agents, chemical peels, lasers, and dermabrasion. Further investigations into this disorder may lead to more specific and effective treatments in the future.

Infantile haemangiomas: a challenge in paediatric dermatology

Infantile haemangiomas, common benign vascular tumours of childhood, are characterized by rapid growth during the first year of life and a slow regression that is usually completed at 7-10 years of age. These tumours are composed of endothelial cells with high mitotic rates and stromal components such as fibroblasts, mast cells and pericytes. Haemangiomas become a challenge when they are part of a syndrome, are located in certain areas of the body or when complications develop. The above-mentioned factors also influence the treatment modality used. However, although there remain many uncertainties regarding management, the beta-adrenergic receptor blocker propranolol is a promising new candidate for first-line systemic therapy. It produces such a dramatic and rapid response that the appearance of an infantile haemangioma should impart expeditious consideration of the risks and benefits of its use.

Graham-Little syndrome

Graham-Little syndrome, also know as Graham-Little-Piccardi-Lassueur syndrome, is an unusual form of lichen planopilaris, characterized by the presence of cicatricial alopecia on the scalp, keratosis pilaris of the trunk and extremities, and non-cicatricial hair loss of the pubis and axillae. We present the case of a 47-year-old woman whose condition was unusual in that there was a prominence of scalp findings. Her treatment included a topical steroid plus systemic prednisone beginning at 30 mg every morning, which rendered her skin smooth, but did not alter her scalp lopecia.

Hereditary keratosis palmoplantaris varians of Wachters (keratosis palmoplantaris striata et areata)

Keratosis palmoplantaris varians of Wachters is a rare autosomal dominant disorder. A 17-year-old boy with characteristic clinical and histopathologic findings of 10 years' duration is described. He displayed yellowish patchy and linear hyperkeratoses of the palms and nummular keratoses on the soles that were symmetrical and often confluent, specifically on the pressure points. Because there was no family history of a similar pattern, he probably represented an isolated case in his family. The typical clinical presentation, differential diagnosis, and classification of hereditary palmoplantar keratoses are discussed.

Sweet's syndrome: an update and review

Sweet's syndrome, or acute neutrophilic dermatosis, is an unusual dermatologic disorder that may serve as a marker of leukemia or lymphoma, other malignancy or another serious systemic disorder. It is characterized by the sudden eruption of tender discrete erythematous nodules or plaques which are sometimes associated with fever, neutrophilic leukocytosis, and a dense dermal infiltrate of mature neutrophils. It may occur as a hypersensitivity reaction with cytokines playing a pivotal role. It may remit after the treatment of an underlying cancer or discontinuation of an offending pharmacologic agent, although it con also resolve spontaneously without therapeutic intervention. The gold standard of treatment is with systemic corticosteroids; however, potassium iodide, colchicine and other therapeutic agents have been utilized successfully.

Erythroderma: review of a potentially life-threatening dermatosis

Erythroderma, or generalized exfoliative dermatitis, is a disease characterized by erythema and scaling of greater than 90% of the body's surface. The resultant dysmetabolism is potentially life threatening. A detailed history is to identify and treat the underlying cause of this dermatitis. We present two cases of erythroderma in African patients and review this important disease.

Pediculus humanus capitis: an update

Head lice infestation, or pediculosis capitis, caused by Pediculus humanus capitis, is a common health concern. In the US, where pediculosis capitis is the most prevalent parasitic infestation of children, 6 to 12 million people are affected every year. Pediculosis capitis remains confined to the scalp. Scalp pruritus is the cardinal symptom, although patients with lice can be asymptomatic. Pruritus with impetiginization should prompt the physician to look for lice or viable nits. All close contacts should be examined. Treatment directed at killing the lice and the ova should be considered only if active lice or viable eggs are observed. The three fundamental effective treatment options for head lice are topical pediculicides, wet combing, and oral therapy. Spraying or fogging a home with insecticides or pediculicides is not recommended.

Plasma-cell-predominant B-cell pseudolymphoma

A 46-year-old woman with no history of foreign travel presented to the New Jersey Medical School Dermatology Clinic in July, 2007, with pruritic ulcerating facial masses that had been present since October, 2006. Clinical and histopathologic findings were most consistent with a diagnosis of cutaneous plasma cell predominant B cell pseudolymphoma. An extensive search using special stains for an etiologic organism was negative. The term cutaneous pseudolymphoma has been coined to describe the accumulation of either T or B cell lymphocytes in the skin that is caused by a nonmalignant stimulus and encompasses several different terms depending on etiology. In cases of cutaneous pseudolymphoma where a cause is identified, treatment entails removing the underlying causative agent. Idiopathic cases tend to be recalcitrant to treatment.

Human herpes simplex labialis

Humans are the natural host for eight of more than 80 known herpes viruses. Infections with herpes simplex virus type 1 (HSV-1) are ubiquitous worldwide and highly transmissible. Herpes simplex labialis (HSL) is the best-recognized recrudescent infection of the lips and perioral tissues caused by HSV-1. Facial lesions of HSL may be unsightly, frequent outbreaks unpleasant, and the infection itself more severe locally and systemically in immunocompromised people. This article highlights the pathogenesis, clinical presentation, diagnostic features and management issues for HSL.

Erysipelas: a common potentially dangerous infection

Erysipelas is an acute superficial cutaneous cellulitis that commonly occurs not only in elderly and immunocompromised persons, but also in neonates and small children subsequent to bacterial inoculation through a break in the skin barrier. Group A Beta-hemolytic streptococcus (GABHS, Streptoccocus pyogenes) is the usual etiologic agent. Factors that predispose pediatric patients to the development of erysipelas include very young age, diabetes mellitus, an immunocompromised state, and nephrotic syndrome. Patients typically have a well-demarcated, erythematous, indurated, rapidly spreading patch with a palpable advancing border on the face or extremities. Fever with chills and general malaise may be prominent symptoms. Antibiotics are usually effective. Patients handled in a timely manner tend to recover without problems. However, potential complications include abscess formation, necrotizing fasciitis, septicemia, recurrent infection, and lymphedema.

Atopic dermatitis. A clinical challenge

Atopic dermatitis has a significant impact on both the pediatric and adult population worldwide, which has triggered extensive research on the topic. However, various limitations have created difficulties both in making accurate diagnoses and effectively managing atopic dermatitis patients. This review summarizes the current knowledge in the field, providing an overview of the pathophysiology, disease progression, clinical presentation, and diagnosis and treatment of atopic dermatitis.

Necrotizing fasciitis: a deadly infection

Necrotizing fasciitis (NF) is a life-threatening condition, consisting of a soft-tissue infection with rapidly progressive, widespread fascial necrosis. NF may be caused by a wide variety of microbes. Indeed, NF may be an infection of one species of bacteria or may be polymicrobial. Prompt diagnosis and treatment are essential. Surgical debridement and antibiotic therapy are the primary treatment options.

Rocky Mountain spotted fever

Rocky Mountain spotted fever (RMSF) is an unusual but important dermatological condition to identify without hesitation. The classic triad of headache, fever, and a rash that begins on the extremities and travels proximally to involve the trunk is found in a majority of patients. The cutaneous centripetal pattern is a result of cell to cell migration by the causative organism Rickettsia rickettsii. Such individuals should receive prompt antimicrobial therapy and supportive care to avoid serious and potentially fatal complications.

Keratosis lichenoides chronica: a diagnostic and therapeutic challenge

A 45-year-old man presented with a 7-year history of keratosis lichenoides chronica (KLC), a mucocutaneous lichenoid disorder of keratinization with no known aetiology, without significant systemic associations. Our patient also had type I diabetes mellitus, mild hypertension and lipid abnormalities. The diagnosis and treatment of KLC is often challenging.

Vitiligo

Vitiligo represents a selective destruction of the melanocytes. It is a relatively common, probably autoimmune disorder that affects people of all backgrounds and both genders. No particular group seems to be preferentially affected. Half of vitiligo patients have an onset before the age of 18 years. In regions where leprosy is endemic, individuals with vitiligo are often stigmatized due to similarities in appearance between the two diseases. We will review this important subject, emphasizing the latest therapeutic advances.

Morpheaform extra-ocular sebaceous carcinoma

BACKGROUND

Sebaceous carcinoma is an unusual, aggressive, malignant tumor derived from the epithelium of sebaceous glands. It may arise in ocular or extra-ocular sites and is often evident as an ulcerated or non-ulcerated cystic nodule measuring up to 8 cm in diameter. A significant number of extra-ocular sebaceous carcinomas have been associated with metastases and high mortality rate.

METHODS AND RESULTS

We reviewed the literature in the context of our report of a 68-year-old woman who had a morpheaform plaque of the upper lip of 15 years duration, extending into the left naso-genal groove, which histologically also showed marked stromal fibrosis. Three years after excision, there were no signs of recurrence or metastases.

CONCLUSIONS

This patient is unusual in clinical and histologic pattern, as a morpheaform appearance has only been described previously in only one sebaceous carcinoma. In addition, no metastatic disease 15 years after tumor onset is a fortunate and remarkable feature.

Oculocutaneous albinism

Oculocutaneous albinism represents a group of inherited skin disorders characterized by a generalized reduction of cutaneous, ocular and pilar pigmentation from the time of birth. Oculocutaneous albinism types 1 and 2 are the most common, but several other types have been described. A defect in the melanin synthesis pathway, resulting in reduced formation of melanin, is responsible for oculocutaneous albinism. Aetiology, clinical manifestations, diagnosis and management are discussed.

Cutaneous manifestations of systemic cryptococcosis in immunosupressed patients

Since its discovery 100 years ago, the encapsulated yeast Cryptococcus neoformans has been implicated in systemic infections of many immunocompromised patients and has been a leading cause of morbidity and mortality in AIDS patients. Clinical symptoms are often initially subtle or lacking. Cutaneous involvement often carries a dismal prognosis as it is usually a sign of dissemination. However, lesions may develop before any systemic or constitutional symptomatology, and despite their non specific appearance, are easily accessible for scrapings, biopsies and cultures. A high index of suspicion is of utmost importance in high risk individuals to avoid delaying the diagnosis and treatment.

Pseudoporphyria: an atypical variant resembling toxic epidermal necrolysis

BACKGROUND

Pseudoporphyria has been attributed to both medication usage and chronic hemodialysis. Histologically, it is identical to porphyria cutanea tarda. It is most commonly seen as localized bullae on sun-exposed skin, often on the dorsum of the hands and fingers.

OBJECTIVES

We describe a 31-year-old man with rapidly evolving bullae which became denuded, clinically suggestive of toxic epidermal necrolysis. Pseudoporphyria was proven histologically. However, our patient's eruption was not localized as small bullae but was widespread, with large bullae evolving into large, cutaneous, denuded erosions.

CONCLUSIONS

We describe a previously unreported, generalized variant of pseudoporphyria that resembles toxic epidermal necrolysis. We provide a review of pseudoporphyria and compare our variant to toxic epidermal necrolysis and mimicking disorders.

Inflammatory linear verrucous epidermal nevus

Inflammatory linear verrucous epidermal nevus (ILVEN) is an unusual unilateral eruption with onset usually in infancy or childhood, female predominance, frequent left leg involvement, pruritus, refractoriness to therapy, and a psoriasiform histologic pattern. We review this disorder in describing a 5-year-old girl who also had melanodontia, an association not previously observed to our knowledge.

Papular urticaria

Papular urticaria is a common and often distressing childhood disorder manifested by chronic or recurrent papules caused by a hypersensitivity reaction to the bites of mosquitoes, fleas, bedbugs, and other insects. Individual papules may surround a wheal and often have a central punctum. The histopathology of papular urticaria consists of mild subepidermal edema, extravasation of erythrocytes, interstitial eosinophils, and exocytosis of lymphocytes. Papular urticaria may represent a clinical challenge, particularly during spring and summer months.

Insect bite reactions: an update

Contact with insects may induce cutaneous or systemic reactions, ranging from little more than annoying to life threatening. The diagnosis depends on maintaining a high index of suspicion and being familiar with the insect fauna of the patient's environment and area of travel.

Childhood herpes zoster

Herpes zoster (HZ) in childhood is rather unusual. This reactivation of chickenpox, the primary varicella-zoster virus (VZV) infection that lies dormant within sensory ganglia, is seen with increased frequency in otherwise healthy children who acquire chickenpox either in utero or within the first year of life. Our patient is a good example of this; he was exposed to chickenpox at the age of 3 months (by his 2 siblings) and developed HZ at 6 years of age.