Necrolytic acral erythema: a review of the literature

Necrolytic acral erythema (NAE) has been described as an early cutaneous marker for hepatitis C virus (HCV) infection. It most commonly presents as a well-defined, dusky, erythematous eruption with marked hyperkeratosis and a dark red rim associated with pruritus or burning. Necrolytic acral erythema bears microscopic and clinical resemblance to other necrolytic erythemas, including necrolytic migratory erythema (NME) and several nutrient-deficient syndromes. It is distinct, however, in its predominantly acral distribution and strong association with HCV infection. The pathogenesis is unknown, but a relationship to metabolic alterations has been hypothesized. Optimal therapy appears to be treatment of the underlying HCV infection using a combination of ribavirin and interferon alfa; oral zinc therapy may be an alternative but useful therapy. Cases of NAE without HCV infection suggest that more work needs to be done defining NAE and its relationship to HCV.

Pazopanib, a VEGF receptor tyrosine kinase inhibitor for cancer therapy

Pazopanib, which is being developed by GlaxoSmithKline plc, is an oral, second-generation multi-targeted tyrosine kinase inhibitor that targets VEGFR, platelet-derived growth factor receptor and c-kit, key proteins responsible for tumor growth and survival. Pazopanib exhibited good potency against all of the human VEGFRs and closely related tyrosine receptor kinases in vitro, and demonstrated antitumor activity in several human tumor xenografts, including renal cell carcinoma (RCC), and breast and lung cancer. In phase I and II clinical trials, pazopanib was generally well tolerated with the main side effects being hypertension, fatigue or gastrointestinal disorders. Pazopanib alone caused a decrease in tumor size and stable disease in a significant number of patients, including those with RCC, NSCLC and gynecological tumors. The combination of pazopanib with lapatinib was effective in patients with breast cancer. At the time of publication, pazopanib monotherapy was being evaluated in phase III trials in patients with RCC and as combination therapy with lapatinib in patients with breast cancer. In addition, phase I and II trials were being conducted to assess pazopanib alone or in combination with a range of chemotherapeutics in patients with solid tumors or multiple myeloma.

Talarozole, a selective inhibitor of P450-mediated all-trans retinoic acid for the treatment of psoriasis and acne

Talarozole, being developed by Barrier Therapeutics Inc under license from Johnson & Johnson, is a potent and selective inhibitor of cytochrome P450 26-mediated breakdown of endogenous all-trans retinoic acid for the treatment of psoriasis and acne. Phase II clinical trials of an oral formulation of talarozole in patients with psoriasis and with acne, and a phase I clinical trial of a topical formulation have been completed. At the time of publication, Barrier Therapeutics had suspended the development of talarozole as part of a series of cost-cutting initiatives; the company had also been acquired by Stiefel Laboratories Inc. No formal announcement had been made regarding the further development of talarozole.

Pramiconazole, a triazole compound for the treatment of fungal infections

Pramiconazole from Barrier Therapeutics Inc is a new addition to the family of triazole antifungal agents that act by inhibiting fungal cell membrane ergosterol synthesis, thereby leading to increased cell permeability and destruction. Barrier Therapeutics was developing an oral formulation of pramiconazole for the potential treatment of seborrheic dermatitis (erythematosquamous skin disease), onychomycosis and dermatomycosis (including tinea versicolor, tinea pedis and tinea cruris/corporis). In preclinical studies, pramiconazole exhibited similar or superior antifungal activity to ketoconazole and itraconazole, and selectively inhibited ergosterol synthesis with a broad spectrum activity. Pramiconazole was absorbed rapidly and had a long half-life, allowing for once-daily dosing. In phase I and II clinical trials, pramiconazole reduced the growth of Candida albicans, Malassezia globosa, Microsporum canis, Trichophyton mentagrophytes and Trichophyton rubrum, and was generally well tolerated. At the time of publication, Barrier Therapeutics had suspended the development of pramiconazole as part of a series of cost-cutting initiatives; the company had also been acquired by Stiefel Laboratories Inc. No formal announcement had been made regarding the further development of pramiconazole. The results of studies performed to date suggest that pramiconazole may be useful in the treatment of dermatomycoses when oral treatment is mandated. Promising preclinical and early phase II clinical data warrant the further development of the drug in larger clinical trials.

Drug-induced photoallergic and phototoxic reactions

Drug-induced photosensitivity involves reactions to medication triggered by exposure of the skin to ultraviolet light. Medications that trigger reactions can be topical or oral. Following interaction of ultraviolet radiation with a chemical present in sufficient amounts in the skin, one of the several reactions may occur in susceptible patients, most commonly photoallergy or phototoxicity. These reactions can be diagnosed separately based on pathogenesis, clinical characteristics and histopathology. Phototoxic disorders have a higher incidence than photoallergic disorders. The action spectra for most photoallergens and phototoxins lie in the ultraviolet A range. Subtypes of drug-induced photosensitivity include dyschromia, pseudoporphyria, photo onycholysis, and lichenoid and telangiectatic reactions.

Is blistering distal dactylitis a variant of bullous impetigo?

Blistering distal dactylitis (BDD) manifests as acral oval bullae 10-30 mm in diameter, and is caused by infection with Gram-positive bacteria. BDD was first linked to infection with group A beta-haemolytic streptococcus in children, but has more recently linked to Staphylococcus aureus and noted in adults. BDD most commonly occurs as bullae on the volar fat pads of the fingers but can occur on the proximal phalangeal and palmar areas of the hands and can manifest as multiple bullae. The bullae can evolve into erosions over the course of several days. BDD can coexist with and may be secondary to clinically imperceptible infections of the nasopharynx, conjunctiva or anus, which underlines the need for systemic antibiotic therapy. Multiple bullae appear to be a predictor that S. aureus is the causative agent of a case of BDD. When BDD is suspected, treatment involves: (i) incision and drainage of bullae, (ii) wet to dry compresses to dry the eroded areas, and (iii) a course of a beta-lactamase-resistant antibiotics, necessary because S. aureus, now found to be a common cause of BDD, is usually resistant to penicillin. No treatment failures have been reported.

Ulcerative paraneoplastic dermatomyositis secondary to metastatic breast cancer

A 40-year-old Chinese-American woman with breast carcinoma metastatic to her lungs presented with a 3-month history of erosions on her inner thighs (Figure 1) and medial left shoulder. Faint livedo reticularis was evident on her legs as well. She had difficulty in walking and raising her shoulders. Her cutaneous examination was also notable for cuticular erythema (Figure 2) and mild periorbital erythema and edema. She had no systemic or rheumatologic complaints other than some difficulty in swallowing. Her blood chemistry values were notable for a creatinine kinase of 564 IU/L (5-200 IU/L), alanine aminotransferase 161 U/L (0-40 U/L) and aspartate aminotransferase 93 U/L (0-40 U/L), and an antinuclear antibody titer of 1:2560. Other blood chemistries and antibody serologies (anti-Jo-1, anti-Mi-2 and other anti-tRNA synthetase, anti-Ro/SSA, anti-U1RNP, anti-PM/Scl, and anti-Ku) were within normal limits. A biopsy specimen was obtained from an area of intact skin close to a right thigh ulceration that showed subtle vacuolar alteration at the dermo-epidermal junction with occasional necrotic keratinocyte (Figure 3). Melanophages and telangiectases were present. Within the subcutis there was fibrin deposition and neutrophils. A diagnosis of dermatomyositis was made. The patient received oral prednisone 20 mg three times a day, and her ulcerations resolved. Her creatinine kinase, alanine aminotransferase, and aspartate aminotransferase values returned to normal over the course of 3 weeks, but her antinuclear antibody was unchanged. Radiographic studies concurrently noted that her breast cancer had recurred in her lungs; plans were made to treat her with chemotherapy. The patient was lost to close follow-up, but it was learned that her erosions had reoccurred while her prednisone was tapered and resolved when her dosage of prednisone was increased.

Creating and utilizing a multimedia dermatology medical record for a PocketPC personal digital assistant

Personal digital assistants are lightweight computers that capture and display data via tapping on their screens with a stylus and are easily linked to desktop and network computers. They have been used in medicine for a variety of purposes, and many believe personal digital assistant use can improve the provision of medical care. The author created a multimedia dermatology electronic medical record for a PocketPC (Microsoft Corp., Redmond, WA) personal digital assistant that contains patient images, tables of phototherapy, laboratory and systemic medication data, and typed chart notes. Such a record can be created and utilized but requires more time to assemble than a handwritten note, mostly due to capturing and organizing images. Future challenges involve streamlining record assembly, integrating multimedia records with hospital and office medical records, and assessing how having multimedia data available might affect care.

Condyloma with lichen nitidus

A 32-year-old black man presented with two separate eruptions on his penis (Figure). He has had a 10-year history of asymptomatic 1-3 mm shiny papules on the shaft of his penis. He also has had one asymptomatic verrucous brown plaque 1.5 cm in diameter on his penis. A small shave biopsy was performed for each process. The former showed lymphocytes and histocytes in the papillary dermis in a "ball-in-claw" relation to the rete ridges of the epidermis. The latter showed an acanthotic epidermis with papillomatosis. Diagnoses of lichen nitidus and condyloma acuminata were respectively made. As the shiny papules did not bother the patient, but he wanted to be rid of the verrucous plaque, only the latter was treated. Liquid nitrogen was applied to the plaque. The patient was also given podofilox 0.5% gel to apply to the condyloma overnight on Monday, Tuesday, and Wednesday, with a 4-day respite. This cycle was to be repeated for 3 more weeks. He was examined several more times and treated with cryotherapy and podofilox gel with the near disappearance of the condyloma over 4 months.

Granular parakeratosis: Pathologic and clinical correlation of 18 cases of granular parakeratosis

BACKGROUND

Granular parakeratosis (originally termed axillary granular parakeratosis) is an idiopathic, benign, nondisabling cutaneous disease that manifests with intertriginous erythematous, brown or red, scaly or keratotic papules and plaques. It presents in all age groups and has no established clinical associations.

OBJECTIVES

We wanted to assess the following: (1) the incidence of granular parakeratosis in biopsy specimens; (2) the differential diagnosis submitted with specimens requisition of granular parakeratosis; and (3) variations in its histopathology.

METHODS

Between July 1, 1999 and December 31, 2003, 363,343 specimens were submitted to The Ackerman Institute of Dermatopathology in New York. A computer search was done of these specimen records and cases diagnosed with granular parakeratosis were reviewed. A thickened stratum corneum with retention of keratohyalin granules was considered diagnostic of granular parakeratosis.

RESULTS

Eighteen of 363,343 specimens (0.005%) were diagnosed with granular parakeratosis. The diagnosis was confirmed by re-review of specimens. All lesions were located in the axillae. All patients were adults; most were women. In only one instance was the correct clinical diagnosis of granular parakeratosis submitted with a biopsy requisition of it. Granular parakeratosis is rare, if its incidence among biopsy specimens is representative of its true prevalence. The failure to include granular parakeratosis on biopsy requisition forms of granular parakeratosis specimens indicates that dermatologists are not familiar with it. Variations of the histopathology of the 18 cases occurred but did not correlate with the clinical impressions included on biopsy requisition forms.

A case of systemic malignant atrophic papulosis (Köhlmeier-Degos' disease)

Malignant atrophic papulosis (MAP) is a rare and clinically distinctive vasculopathy. It is characterized by narrowing and occlusion of the lumen by intimal proliferation and thrombosis, which leads to ischemia and infarction in the involved organ systems. Its rarity and rapidly fatal course make the disease a difficult diagnostic and therapeutic challenge.

Treatment options: herpes simplex viruses

A 35-year-old woman presented with a 1-week history of vesiculopustules on erythematous bases on and in proximity to her lips (Figure 1). The patient had noted burning and itching in the area of these vesiculo-pustules before they developed. She had no systematic symptoms and had not noted similar vesiculopustules in this location in the past. A Tzanck smear was done that revealed multinucleated giant cells. A viral culture was performed. The patient was diagnosed with herpes labialis and received valacyclovir 500 mg b.i.d. for 5 days. One week later, the eruption was noted to have resolved, at which time the results of the viral culture showed growth of Herpes Simplex Virus-1. Thereafter, the patient was lost to follow-up.

Obesity and dermatology

Obesity is associated with a number of dermatoses. It affects cutaneous sensation, temperature regulation, foot shape, and vasculature. Acanthosis nigricans is the most common dermatological manifestation of obesity. Skin tags are more commonly associated with diabetes than with obesity. Obesity increases the incidence of cutaneous infections that include: candidiasis, intertigo, candida folliculitis, furunculosis, erythrasma, tinea cruris, and folliculitis. Less common infections include cellulitis, necrotizing fasciitis, and gas gangrene. Leg ulcerations, lymphedema, plantar hyperkeratosis, and striae are more common with obesity. Hormonal abnormalities and genetic syndromes (Prader-Willi) are related to obesity and its dermatoses; however, cellulite is not related to obesity.

Common diseases/treatment options: treatment options for psoriasis part 1: topical treatments

A 40-year-old Hispanic man presented for treatment of dermatitis on his elbows and knees that had been evident for 5 years (Figure 1). He also had scaling plaques on his scalp. He had not been treated previously. He did not have any other medical problems and did not complain of arthritis. A clinical diagnosis was made of psoriasis and he was prescribed clobetasol propionate ointment with salicylic acid 6% in petrolatum that should be applied in the evening to his elbows and knees and calcipotriene ointment with clobetasol that should be applied in the morning. For his scalp, he was prescribed betamethasone valerate foam 0.12% to be applied directly to the scalp once a day and told to use a tar shampoo contain-ing 4% neutar solubilized coal tar extract (1.0% coal tar) three times a week. He followed this regimen for 2 weeks and the plaques became much less keratotic. He continued his scalp regimen. He then started using calcipotriene ointment and clobetasol propionate ointment together twice a day. Three weeks later the plaques were much flatter and less erythematous. The patient was instructed to apply clobetasol propionate to the affected areas twice a day on Saturday and Sunday and calcipotriene twice a day Monday through Friday. At this point, his scalp was almost clear and the patient was told touse the foam as necessary and to continue the shampoo.

The preauricular sinus: a review of its clinical presentation, treatment, and associations

Preauricular sinuses (ear pits) are common congenital abnormalities. Usually asymptomatic, they manifest as small dells adjacent to the external ear near the anterior margin of the ascending limb of the helix, most frequently on the right side. Preauricular sinuses can be either inherited or sporadic. When inherited, they show an incomplete autosomal dominant pattern with reduced penetrance and variable expression. They may be bilateral, increasing the likelihood of being inherited, in 25-50% of cases. Preauricular sinuses are features of other conditions or syndromes in 3-10% of cases, primarily in association with deafness and branchio-oto-renal (BOR) syndrome. When other congenital anomalies coexist with these sinuses, auditory testing and renal ultrasound should be considered. Sinuses may become infected, most commonly with gram-positive bacteria, in which case their exudates should be cultured and appropriate antibiotics administered. Recurrent infection is a clear indication for complete excision and provides the only definitive cure. Recurrence rates after surgery range from 9% to 42%. Meticulous excision by an experienced head and neck surgeon minimizes the risk of recurrence.

Skin infections in the elderly

The diagnosis and management of viral diseases of the skin are significant issues in the elderly population. With advances in these areas, there are new tools to combat these diseases and limit morbidity. It is important for clinicians to monitor and treat these diseases aggressively in the elderly because of the potential for immunosuppression in this population. Further advances in antiviral therapy and the potential for the development of antiviral vaccines will aid in the therapy of these diseases. Onychomycosis is found more frequently in the elderly. In this population, the most common clinical presentations are distal and lateral subungual onychomycosis (which usually affects the great or first toe) and white superficial onychomycosis (which generally involves the third or fourth toes). Over the past several years, new treatments for this disorder have emerged that offer shorter courses of therapy and greater efficacy than previous therapies. The treatment of bacterial skin and skin structure infections in the elderly is an important issue. There has been an alarming increase in the incidence of gram-positive infections, including resistant bacteria, such as MRSA and drug-resistant pneumococci. Although vancomycin has been considered the drug of last defense against gram-positive multidrug-resistant bacteria, the late 1980s saw a rise in vancomycin-resistant bacteria, including VRE. With treatment options limited, it has become critical to identify antibiotics with novel mechanisms of activity. Several new drugs have emerged as possible therapeutic alternatives, including linezolid and quinupristin-dalfopristin.

Cutaneous infections in the elderly: diagnosis and management

Over the past several years there have been many advances in the diagnosis and treatment of cutaneous infectious diseases. This review focuses on the three major topics of interest in the geriatric population: herpes zoster and postherpetic neuralgia (PHN), onychomycosis, and recent advances in antibacterial therapy. Herpes zoster in adults is caused by reactivation of the varicella-zoster virus (VZV) that causes chickenpox in children. For many years acyclovir was the gold standard of antiviral therapy for the treatment of patients with herpes zoster. Famciclovir and valacyclovir, newer antivirals for herpes zoster, offer less frequent dosing. PHN refers to pain lasting > or = 2 months after an acute attack of herpes zoster. The pain may be constant or intermittent and may occur spontaneously or be caused by seemingly innocuous stimuli such as a light touch. Treatment of established PHN through pharmacologic and nonpharmacologic therapy will be discussed. In addition, therapeutic strategies to prevent PHN will be reviewed. These include the use of oral corticosteroids, nerve blocks, and treatment with standard antiviral therapy. Onychomycosis, or tinea unguium, is caused by dermatophytes in the majority of cases, but can also be caused by Candida and nondermatophyte molds. Onychomycosis is found more frequently in the elderly and in more males than females. There are four types of onychomycosis: distal subungual onychomycosis, proximal subungual onychomycosis, white superficial onychomycosis, and candidal onychomycosis. Over the past several years, new treatments for this disorder have emerged which offer shorter courses of therapy and greater efficacy than previous therapies. The treatment of bacterial skin and skin structure infections in the elderly is an important issue. There has been an alarming increase in the incidence of gram-positive infections, including resistant bacteria such as methicillin-resistant Staphylococcus aureus (MRSA) and drug-resistant pneumococci. While vancomycin has been considered the drug of last defense against gram-positive multidrug-resistant bacteria, the late 1980s saw an increase in vancomycin-resistant bacteria, including vancomycin-resistant enterococci (VRE). More recently, strains of vancomycin-intermediate resistant S. aureus (VISA) have been isolated. Gram-positive bacteria, such as S. aureus and Streptococcus pyogenes are often the cause of skin and skin structure infections, ranging from mild pyodermas to complicated infections including postsurgical wound infections, severe carbunculosis, and erysipelas. With limited treatment options, it has become critical to identify antibiotics with novel mechanisms of activity. Several new drugs have emerged as possible therapeutic alternatives, including linezolid and quinupristin/dalfopristin.

Cutaneous histoplasmosis in patients with acquired immunodeficiency syndrome

Since 1987, the US Centers for Disease Control and Prevention has considered disseminated histoplasmosis an acquired immunodeficiency syndrome (AIDS)-defining illness. Cutaneous manifestations of disseminated disease are diverse and often present as a nondescript rash with systemic complaints. Diagnosis is best established by histopathologic examination with appropriate stains for fungal organisms. Skin lesions often resolve within weeks of initiating treatment. We detail a case of cutaneous histoplasmosis and review its epidemiology, common presentations, diagnosis, and treatment options.

Reticulate and stellate acral pigmentation associated with systemic lupus erythematosus and high titers of circulating anticardiolipin antibodies: a possible association with acral microlivedo

A Hispanic man with a twenty-eight year history of systemic lupus erythematosus (SLE) and a high titer of anticardiolipin IgG antibodies was noted to have reticulate and stellate acral pigmentation. The patient reported that hand swelling and erythema developed soon after the diagnosis of SLE was established. This episode resolved quickly without recurrence or immediate sequelae. We postulate that this eruption was related to SLE and anticardiolipin antibodies. Reticulate and stellate acral pigmentation should be considered a possible manifestation of SLE and high titers of anticardiolipin antibodies, or a consequence of therapy.

Syndromic albinism: a review of genetics and phenotypes

There are several syndromes of albinism associated with systemic pathology. These include Chediak-Higashi Syndrome (CHS), Hermansky-Pudlack Syndrome (HPS), Griscelli Syndrome (GS), Elejalde Syndrome (ES) and Cross-McKusick-Breen Syndrome (CMBS). In the last several years the genetic defects underlying some of these syndromes have been described. HPS is related to 7 genes in humans. GS is related to 3 genes: MYOVA, Rab-27A, and melanophilin (Mlph). CHS is related to one gene: LYST. The genetic defects in ES and CMBS are yet to be defined. Syndromic forms of albinism are associated with defects in the packaging of melanin and other cellular proteins. As such they are distinct from oculocutaneous albinism, which is associated with defects in the production of melanin (e.g., TRP1, P gene, and tyrosinase).

Trends in the use of cameras and computer technology among dermatologists in New York City 2001-2002

BACKGROUND

Photography and computers can enhance dermatologic visit documentation and care.

OBJECTIVE

To determine dermatologists' use of cameras and computers.

METHODS

We surveyed computer and camera use during the Dermatologic Society of Greater New York's meetings in January 2001 and 2002.

RESULTS

Approximately 75% of dermatologists can use computers. Between 2001 and 2002, 35-mm film camera use by attending and resident dermatologists fell from 60% to 47% and 43% to 32%, respectively, and digital camera increased from 25% to 38% and 35% to 59%, respectively. Approximately 50% of dermatologists use instant cameras. Approximately 15% of dermatologists use no camera. Most find images useful; however, medical dermatologists usually image only interesting patients, and dermatologic surgeons image almost all patients. Approximately 15% of dermatologist used electronic medical records (EMRs).

CONCLUSION

Computers and cameras are widely used but have not changed dermatologic practice. Images are not used to track skin disease or integrated with EMRs nor are EMRs widely used, probably because of difficulty of use and limited computer literacy. Where images appear to add value, for example, for preoperative and postoperative documentation among dermatologic surgeons, camera use is common, suggesting that utility drives technology adoption.

Linezolid and quinupristin/dalfopristin: novel antibiotics for gram-positive infections of the skin

With the continuing development of clinical drug resistance among bacteria, the need for new, effective agents to treat multi-drug-resistant Gram-positive infections remains important. With treatment options limited, it has become critical to identify antibiotics with novel mechanisms of activity. Several new drugs have emerged as possible therapeutic alternatives. This review focuses on agents newly introduced and FDA-approved for the treatment of skin and skin structure infections: linezolid and quinupristin/dalfopristin.