Phytophotodermatitis due to a Citrus-Based Hand Sanitizer: A Case Report

Phytophotodermatitis, a cutaneous reaction caused by direct contact with photosensitive substances in plants and subsequent exposure to ultraviolet light, is commonly caused by psoralens in plants, including citrus fruits. We describe a case of phytophotodermatitis caused by a hand sanitizer containing a blood orange (Citrus sinensis) extract. To our knowledge, this is the first reported case of phytophotodermatitis caused by a hand sanitizer. A 41-year-old woman presented with a 2-week history of pruritic cutaneous eruptions on her right thigh. Approximately 24 hours prior to the onset of her symptoms, she applied a new citrus-based hand sanitizer. Immediately after applying the hand sanitizer, her right thigh was exposed to sunlight for approximately 5 hours. Extracts from oranges are used in many cosmetics, including perfumes and fragrances. With the increased use of hand sanitizers during the coronavirus disease 2019 pandemic, physicians should note that phytophotodermatitis due to scented hand sanitizers may occur more frequently.

Cutaneous adverse events in 155 patients with metastatic melanoma consecutively treated with anti-CTLA4 and anti-PD1 combination immunotherapy: Incidence, management, and clinical benefit

BACKGROUND

In response to the increased use of combination checkpoint inhibitors (CPIs) and the resulting increased cutaneous adverse events (CAEs), this study reviewed patients with melanoma treated with combination CPIs to characterize CAE features and their clinical impact, correlation to adverse events in other organs, and correlation to tumor response.

METHODS

Patients from the authors' institutional database who received at least 1 dose of ipilimumab in combination with either nivolumab or pembrolizumab between January 1, 2012, and December 31, 2017, for stage IV or unresectable stage III melanoma were identified. The time to next treatment (TTNT) was calculated from the start of CPI therapy to the start of the next treatment or death, and the development of CAEs was tested in a time-dependent Cox regression to identify associations with TTNT.

RESULTS

Eighty-one patients (52.3%) experienced a total of 92 CAEs, including eczematous dermatitis (25.0%), morbilliform eruption (22.8%), vitiligo (12.0%), and pruritus without rash (8.7%). The median times to the onset and resolution of CAEs were 21 days (range, 0-341 days) and 50 days (range, 1-352 days), respectively. Most CAEs resolved after patients entered the CPI maintenance phase and treatment with oral antihistamines with or without topical steroids. CPI discontinuation occurred in 4 patients (2.6%) because of CAEs, in 49 (31.6%) because of other immune-related adverse events, and in 20 (12.9%) because of melanoma progression or death. For patients definitively treated with CPIs (n = 134; 86.5%), TTNT was significantly longer with CAEs than without CAEs (hazard ratio, 0.567; 95% CI, 0.331-0.972; P = .039).

CONCLUSIONS

CAEs were mostly reversible and rarely required therapy discontinuation. The development of CAEs was associated with a longer TTNT, and this suggested a possible clinical benefit.

Cutaneous Toxicities in the Setting of Immune Checkpoint Blockade:: The Era of Oncodermatopathology

Advancements in cancer therapy with monoclonal immune checkpoint antibody blockade have impacted the practice of all medical specialties. Cutaneous immune-related adverse events (irAEs) are a frequent, unintended, off-target consequence of immune checkpoint inhibitor (ICI) therapy that have ushered in the era of oncodermatopathology. Knowledge of the diverse morphologic types of cutaneous irAEs from ICI therapy allows further classification of cutaneous irAEs according to major histopathologic reaction patterns. Early studies suggest that immune mechanisms of lichenoid dermatitis irAE, psoriasiform dermatitis irAE, and bullous pemphigoid irAE show some similarities and differences from their histopathologic counterparts not associated with ICI therapy.

Anti-CTLA-4 therapy-associated granuloma annulare in chronic myelomonocytic leukemia

Immune checkpoint inhibitor (ICI) therapies activate the immune system to unmask cancer cells that the body might otherwise not detect. These cancer therapies alter the immune system at different "checkpoint" proteins such as PD-1, PD-L1, or CTLA-4 to better target tumor cells, but also have the potential to affect normal tissues. In patients receiving ICI therapy, cutaneous reactions have been frequently documented, ranging from mild urticarial rashes to widespread cutaneous necrosis. Proper identification and management of ICI therapy side effects is essential to the care of these patients. Here, we present an unusual granulomatous cutaneous reaction in a patient receiving anti-CTLA-4 therapy for chronic myelomonocytic leukemia.

Dermatomyositis, pembrolizumab, and squamous cell carcinoma of the lung

Cancer immunotherapy has impacted the treatment of numerous tumor types, including skin, lung, and colon cancers. Immune checkpoint inhibitors (ICI) activate the immune system to attack cancer cells, but this mechanism can also impact healthy cells. Dermatomyositis, an autoimmune syndrome affecting multiple organ systems, is often associated with cancer as a paraneoplastic syndrome, but this syndrome can also be induced by ICI. Here, we describe a case of dermatomyositis in a patient receiving pembrolizumab for treatment of squamous cell carcinoma of the lung and discuss the importance of recognizing complications of ICI.

Leukocytoclastic vasculitis with late-onset Henoch-Schönlein purpura after trifluridine/tipiracil treatment

Trifluridine/tipiracil has been approved for the treatment of refractory metastatic colorectal cancer. Adverse effects of this drug combination include leukopenia, neutropenia, fatigue, diarrhea, and vomiting. We present a case of trifluridine/tipiracil-induced leukocytoclastic vasculitis (LCV) with late-onset Henoch-Schönlein purpura (HSP) in a 42-year-old man with metastatic appendiceal cancer. The patient's biopsy-proven LCV developed one month after he began trifluridine/tipiracil treatment and resolved after discontinuation of the drug. He presented to the emergency department two months after the appearance of his LCV with shortness of breath, elevated blood pressure, elevated creatinine, hematuria, and proteinuria. A kidney biopsy was performed and the presence of IgA deposits and cellular crescents indicated rapidly progressive glomerulonephritis secondary to Henoch-Schönlein purpura (HSP). Neither LCV nor HSP have been reported as adverse effects of trifluridine/tipiracil treatment. Malignancy as a cause of our patient's HSP is another possibility. The delay between our patient's skin findings and acute renal failure indicates that suspected HSP should be monitored by urinalysis for a period of time owing to the risk of life-threatening renal disease.

Pyoderma gangrenosum-like ulceration of the lower extremity secondary to sunitinib therapy: a case report

Sunitinib is a multi-targeted receptor tyrosine kinase inhibitor used for the treatment of multiple different types of malignancies. Serious grade 3–4 adverse events occur in <10% of the patient population and usually improve with dose reduction. One of the more rarely reported side effects of sunitinib therapy is the development of pyoderma gangrenosum–like ulcerations in the lower extremities. These pyoderma gangrenosum–like ulcerations are difficult to treat and distinguish from similar-appearing dermatological diagnoses. We present a patient with refractory lung carcinoma and a past medical history of squamous cell carcinoma of the lower extremity, who developed a non-healing ulceration at the previous site of her skin cancer while undergoing therapy with sunitinib. At the time of the initial evaluation, the ulceration mimicked recurrent squamous cell carcinoma, posing a diagnostic challenge. Histopathological findings showed epidermal hyperplasia, ulceration, and dense acute inflammation. Despite meticulous wound care and treatment of infection, the ulcer only improved with cessation of sunitinib.

Vemurafenib-related cutaneous side effects ameliorated by acitretin

BACKGROUND

Vemurafenib is a BRAF kinase inhibitor that improves the survival of patients with metastatic melanoma, who have the V600E BRAF mutation. The development of cutaneous neoplasms, including squamous cell carcinomas (SCCs), keratoacanthomas (KAs), and hyperkeratotic papules is one of the most common adverse effects of this therapy. Systemic retinoids, such as isotretinoin and acitretin, have been used for chemoprophylaxis in individuals at high risk of developing many non-melanoma skin cancers, such as immunosuppressed solid organ transplant recipients. These agents may reduce and delay the growth of skin cancers by exerting their effects during the promotion and progression stages of carcinogenesis.

OBSERVATIONS

We report a series of two patients with stage IV metastatic melanoma who presented to our Dermatology clinic for evaluation of a florid eruption of hyperkeratotic neoplasms (verrucae, actinic keratoses, and SCCs) within one month of initiating vemurafenib. After one month of acitretin, substantially fewer new neoplasms were observed in both patients.

CONCLUSIONS

Although not definitive, these cases suggest that acitretin may have a role in chemoprevention of a subset of patients with rapidly developing vemurafenib-associated neoplasms and slowing the progression of more aggressive SCCs and KAs. Future studies to evaluate acitretin may substantially improve the morbidity associated with vemurafenib.

Antibiotic overuse and resistance in dermatology

Antibiotics have a significant role in dermatology, treating a wide range of diseases, including acne, rosacea, inflammatory skin conditions and skin structure infections, such as cellulitis, folliculitis, carbuncles, and furuncles. Because of their consistent use, utility, and availability, antibiotics are susceptible to overuse within the medical practice, and, specific to this discussion, in the dermatologic setting. The issue of continuously increasing risk of antibiotic resistance remains an important concern to the dermatologist. The scope of this review will be to provide an overview of the common antibiotics used in the dermatologic setting with an emphasis on identifying areas of overuse, reported bacterial resistance, and discussion of clinical management aimed at decreasing antibiotic resistance.

A case of bupropion-induced Stevens-Johnson syndrome with acute psoriatic exacerbation

Bupropion is a very popular medication prescribed to millions of patients globally for depression (Wellbutrin, GlaxoSmithKline, Research Triangle Park, NC) as well as an aid in smoking cessation (Zyban, GlaxoSmithKline, Research Triangle Park, NC). It has been reported to have some common dermatologic side effects, such as pruritus, urticaria and serum-sickness like reaction. The authors report a case of bupropion-induced Stevens-Johnson syndrome (SJS) with a concomitant acute psoriatic exacerbation in a 56-year-old woman, who began taking bupropion for treatment of depression. While the United States (U.S.) prescribing information for bupropion does include SJS as a rare potential side effect, it does not mention worsening of psoriasis. Physicians should be aware of the potential life-threatening adverse effects of this commonly prescribed medication as well as the risk in patients with known psoriasis.

Generalized necrobiotic xanthogranuloma successfully treated with lenalidomide

Necrobiotic xanthogranuloma (NXG) presents a therapeutic challenge to clinicians. Generalized NXG has limited treatment options. A patient presented to the authors with generalized NXG associated with monoclonal gammopathy of unknown significance (MGUS), a plasma cell dyscrasia considered to be a precursor to multiple myeloma. The patient was treated with lenalidomide, a derivative of thalidomide with efficacy in treatment of multiple myeloma. Resolution of paraproteinemia was associated with resolution of NXG.

Sorafenib-induced psoriasiform eruption in a patient with metastatic thyroid carcinoma

Sorafenib is a multikinase inhibitor that blocks tumor cell proliferation and angiogenesis and is used for the treatment of advanced renal cell carcinoma, unresectable hepatocellular carcinoma, and other solid tumors. Various dermatologic side effects have been reported, most notably a hand-foot-skin reaction (HFSR). This is a case of a sorafenib-induced psoriasiform eruption in a patient with metastatic thyroid carcinoma. This patient also developed cutaneous squamous cell carcinoma and HFSR in association with sorafenib. To the authors' knowledge, a psoriasiform eruption due to sorafenib has not been reported in the literature and has important therapeutic implications.

A pilot quality-of-life instrument for acne rosacea

BACKGROUND

No rosacea-specific quality-of-life (QOL) instrument exists.

OBJECTIVE

We sought to develop a validated, reliable rosacea-specific instrument.

METHODS

From 6 in-depth interviews, we composed 21 rosacea-specific items. These items and Skindex-29 were administered in a validation cohort (n = 59). Internal consistency reliability and reproducibility were measured with Cronbach's coefficient alpha and intraclass correlation coefficient, respectively. Responsiveness was assessed comparing baseline with 4- to 6-month responses. Construct validity was assessed with principal axes factor analyses. Discriminant validity was examined with an additional 38 patients comparing differences in responsiveness between the rosacea-specific QOL instrument and Skindex.

RESULTS

Reliability was high (Cronbach's alpha: 0.82-0.97, intraclass correlation coefficient: 0.70-0.95). The rosacea-specific QOL instrument showed preliminary responsiveness for patients with improved disease (P <or= .05). Principal axes factor analyses correlated to hypothesized scales (r = 0.57-0.82). Discriminant validity was illustrated with greater differences in responsiveness using the rosacea-specific QOL instrument (P = .008).

LIMITATIONS

Potential selection bias and lack of generalizability was a limitation.

CONCLUSIONS

The rosacea-specific QOL instrument, RosaQoL, appears to be a reliable and valid QOL instrument and shows preliminary responsiveness for patients with improving rosacea.

The response of skin disease to stress: changes in the severity of acne vulgaris as affected by examination stress

BACKGROUND

Although emotional stress has long been suspected to exacerbate acne vulgaris, previous reports addressing its influence on acne severity have been mainly anecdotal.

OBJECTIVES

To elucidate the possible relationship between stress and acne exacerbation by evaluating changes in acne severity during nonexamination and examination periods and to assess the possible relationship of these changes in severity with perceived examination stress by using previously validated scales measuring acne severity and perceived stress.

DESIGN

Prospective cohort study.

SETTING

General university community.

PARTICIPANTS

A volunteer sample of 22 university students (15 women and 7 men) with a minimum acne vulgaris severity of 0.5 on the photonumeric Leeds acne scale (baseline scores, 0.50-1.75).

MAIN OUTCOME MEASURES

Participants were graded on their acne severity using the Leeds acne scale, and had their subjective stress levels assessed with the Perceived Stress Scale questionnaire during both nonexamination and examination periods.

RESULTS

Subjects had a higher mean grade of acne severity and mean perceived stress score (P<.01 for both) during examinations. Using regression analysis and adjusting for the effects of confounding variables, such as changes in sleep hours, sleep quality, diet quality, and number of meals per day, increased acne severity was significantly associated with increased stress levels (r = 0.61, P<.01), while self-assessed change in diet quality was the only other significant association (P =.02).

CONCLUSIONS

Patients with acne may experience worsening of the disease during examinations. Furthermore, changes in acne severity correlate highly with increasing stress, suggesting that emotional stress from external sources may have a significant influence on acne.

Cooperative role of interferon regulatory factor 1 and p91 (STAT1) response elements in interferon-gamma-inducible expression of human indoleamine 2,3-dioxygenase gene

Interferon (IFN)-gamma induces the expression of the indoleamine 2, 3-dioxygenase (INDO) gene in human cells, which plays a role in the inhibitory effect of IFN-gamma on intracellular pathogens and on cell proliferation. Earlier studies established that the IFN-gamma-inducible expression of the INDO gene was dependent on two upstream elements: (i) a 14-base pair sequence homologous to an interferon-stimulated response element (ISRE) sequence found in IFN-alpha-inducible genes and (ii) a 9-base pair palindromic sequence (palindromic element (PE) II) homologous to an interferon-gamma-activated site (GAS) element found in IFN-gamma-inducible genes. A second GAS element (PE I), between ISRE and PE II, was ineffective in supporting a response to IFN-gamma. Studies were carried out to determine the distinction between the two GAS elements and the relative role of the two elements (ISRE and PE II) required for a response to IFN-gamma. The PE I element was able to form a complex with IFN-gamma-activated p91 (STAT1) factor but with lower efficiency than the complex formed with PE II sequence. However, switching the positions of PE I and II sequences in reporter plasmid constructs (containing chloramphenicol acetyltransferase gene) showed that both PE I and PE II were able to support a response to IFN-gamma if located at the position of PE II but not at the position of PE I. Increasing the distance between the ISRE and PE II also affected the level of response, suggesting that the relative position of the two elements is important for optimal stimulus. To explore whether an interaction between the IFN-gamma-regulated factors (IRF-1 and p91) binding to the ISRE and PE II might be important, we tested whether the ISRE sequence could be replaced by another response element, NF-kappaB. The plasmid construct with NF-kappaB element in place of the ISRE was responsive to IFN-gamma, indicating that an interaction between the IRF-1 and p91 factors was not required. The results indicate that the response of INDO gene to IFN-gamma depends on a cooperative role of IFN-gamma-responsive factors binding to the ISRE and GAS elements.

Involvement of two regulatory elements in interferon-gamma-regulated expression of human indoleamine 2,3-dioxygenase gene

Interferon (IFN)-gamma-induced expression of indoleamine 2,3-dioxygenase (IDO) gene is implicated in the antimicrobial and antiproliferative effects of IFN-gamma in cell cultures. Earlier studies identified a 96 base pair (bp) regulatory region upstream of the IDO gene that conferred IFN-gamma response to the chloroamphenicol acetyltransferase (CAT) gene linked to herpesvirus thymidine kinase promoter. The IFN-gamma-responsive region was further narrowed to a 67 bp fragment by 3' deletion. This 67 bp fragment contains several sequence elements of potential interest, including a 14 bp sequence homologous to the ISRE sequence found in IFN-alpha-inducible genes and two palindromic sequences (PE I and PE II) homologous to the GAS sequence identified in IFN-gamma-inducible genes. Site-directed mutagenesis studies showed that IFN-gamma-induced expression of IDO-CAT constructs involved cooperation between two elements: the ISRE homolog and the PE II (but not PE I). Either element alone with its flanking sequence was inadequate in conferring an IFN-gamma response to CAT reporter gene. Two IFN-gamma-regulated protein factors interacting with these two elements were identified. The factor binding to the ISRE region was induced with a slower kinetics, required new protein synthesis, and reacted with antibodies to IRF-1. The factor interacting with the PE II region appeared rapidly after treatment with IFN-gamma independently of new protein synthesis, and its binding to DNA probe was blocked by antibodies to p91 factor, reported to bind to GAS element.(ABSTRACT TRUNCATED AT 250 WORDS)

Differential regulation of human indoleamine 2,3-dioxygenase gene expression by interferons-gamma and -alpha. Analysis of the regulatory region of the gene and identification of an interferon-gamma-inducible DNA-binding factor

The induction of indoleamine 2,3-dioxygenase (IDO) activity has been implicated in the antiproliferative action of interferon (IFN)-gamma on tumor cells and the inhibition of intracellular pathogens. Earlier studies have demonstrated that the expression of the IDO gene is induced strongly by IFN-gamma, but very poorly by IFN-alpha despite the presence of a sequence highly homologous to the IFN-alpha-responsive sequence element (interferon-stimulated response element (ISRE)) in its IFN-gamma-responsive control region. In addition, a sequence with a partial homology to the IFN-gamma-responsive sequence (GAS) identified by Lew et al. (Lew, D.J., Decker, T., Strehlow, I., and Darnell, J.E., Jr. (1991) Mol. Cell. Biol. 11, 182-191) in a human gene for a guanylate-binding protein and to the X box sequence found in all major histocompatibility complex class II genes was found. Deletion experiments have indicated that the ISRE homolog (but not the GAS-related or the X box-related sequence) was essential for an inducibility by IFN-gamma. To investigate the lack of inducibility by IFN-alpha despite the presence of an ISRE homolog, the binding of this ISRE homolog to the IFN-alpha-stimulated gene factor 3 (ISGF3) was examined. Gel mobility shift experiments and competition experiments indicated that this ISRE homolog did not form a stable complex with ISGF3. This may account for a poor inducibility by IFN-alpha. This inability to bind ISGF3 appears to be (at least in part) due to minor differences between the nucleotide sequence of the ISRE homolog present in the IDO gene promoter and the ISRE consensus sequence found in IFN-alpha-inducible genes. An IFN-gamma-inducible DNA-binding factor was identified with characteristics different from ISGF3: (i) the IFN-gamma-inducible factor was detected in the nuclear extracts, but not in the cytoplasmic extracts; and (ii) the appearance of this DNA-binding factor required new protein synthesis, which could explain the dependence on new protein synthesis for the induction of IDO by IFN-gamma.