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Archives of Dermatology recent issuesArchives of Dermatology is a monthly journal that enhances the understanding of skin and its diseases by publishing practical, peer-reviewed original articles. Characterized as an investigative journal for clinicians, the Archives is recognized as one of the most influential publications in its field and is the oldest US dermatology journal. Objective To examine the association between nonsteroidal anti-inflammatory drug (NSAID) use and cutaneous squamous cell carcinoma (SCC). Design Retrospective case-control study. Setting Kaiser Permanente Northern California (KPNC), a large population based-health maintenance organization. Patients Random sample of 415 KPNC members diagnosed as having a pathologically verified SCC in 2004 and 415 age-, sex-, and race-matched controls with no history of skin cancer. Main Exposure Measure Self-reported NSAID use in the 10 years prior to baseline. Use of NSAIDs was categorized based on type (any NSAIDs, aspirin, ibuprofen, and nonaspirin NSAIDs). Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using conditional logistic regression to estimate the association of SCC with regular use, dose, and duration of exposure to the different NSAID types. Information on pharmacy-dispensed NSAIDs was also examined to assess its association with SCC risk. Models were adjusted for all ascertained SCC risk factors (fully adjusted model) and only those variables associated with both SCC risk and NSAID use (parsimonious model). Results Fully adjusted analyses showed no statistically significant reduction in SCC risk with self-reported regular use of any NSAID (OR, 1.32; 95% CI, 0.92-1.89), aspirin (OR, 1.38; 95% CI, 0.96-1.97), ibuprofen (OR, 0.74; 95% CI, 0.46-1.19), or nonaspirin NSAIDs (OR, 0.84; 95% CI, 0.56-1.26). Analyses examining duration, dose, and variables combining duration and dose of NSAID exposure did not appreciably change results. An analysis using the parsimonious model showed similar results. The data on pharmacy-dispensed NSAIDs also showed no association with SCC risk. Conclusion Neither self-reported nor pharmacy-dispensed NSAID exposure was associated with cutaneous SCC risk. Published online February 15, 2010 (doi:10.1001/archdermatol.2009.374). Background Voriconazole is a triazole antifungal agent approved by the US Food and Drug Administration for serious fungal infections, including with Aspergillus, Fusarium, Pseudallescheria, and Scedosporium species. In initial clinical trials, approximately 2% of patients developed cutaneous reactions, including photosensitivity, cheilitis, and xerosis. Subsequent reports have implicated voriconazole as a cause of severe photosensitivity and accelerated photoaging, pseudoporphyria cutanea tarda, and aggressive squamous cell carcinoma. Observation We report 5 melanoma in situ lesions in the setting of extreme photosensitivity associated with long-term voriconazole therapy. Conclusions We recommend surveillance for skin cancer formation in all patients who require long-term voriconazole treatment, particularly those who manifest signs or symptoms of photosensitivity or chronic photodamage. Further study of the mechanism underlying voriconazole photosensitivity and oncogenesis is warranted. Published online January 18, 2010 (doi:10.1001 /archdermatol.2009.362). About This Journal [About This Journal] This Month in Archives of Dermatology [This Month in Archives of Dermatology] Objectives To investigate the extent antibodies to adalimumab are formed in patients with plaque psoriasis and whether these antibodies have clinical consequences. Also, to examine the relationship between antibodies to adalimumab and adalimumab trough titers. Design Prospective observational cohort study. Setting Two Dutch dermatology departments in university hospitals. Patients All consecutive patients starting a regimen of adalimumab for chronic plaque psoriasis. Patients were screened and fulfilled the Dutch reimbursement criteria for adalimumab to treat psoriasis. Intervention Adalimumab treatment (per label). Main Outcome Measures The titer of antibodies to adalimumab, the adalimumab trough concentration, and the Psoriasis Area and Severity Index at weeks 12 and 24. Results Antibodies to adalimumab were detected in 13 of 29 patients (45%) during 24 weeks of treatment. Differences in response rates among patients with low, high, and no titers of antibodies to adalimumab were significant at weeks 12 and 24 (P = .04 and P < .001, respectively). The median adalimumab trough concentrations varied significantly among patients with low, high, and no titers of antibodies to adalimumab (1.30 [range, 0.01-5.50], 0.0 [range, 0.0-0.0], and 9.6 [range, 0.0-22.6] mg/L, respectively; P < .001). At week 24, the median adalimumab trough concentrations also differed significantly among good responders, moderate responders, and nonresponders (9.7 [range, 0.0-22.6], 8.9 [range, 3.2-12.6], and 0.0 [range, 0.0-13.3] mg/L, respectively; P = .01). Conclusion Antibodies to adalimumab are associated with lower serum adalimumab trough concentrations and with nonresponse or loss of response to adalimumab in patients with plaque psoriasis. Objective To assess the safety and efficacy of ablative fractional resurfacing (AFR) for nonacne atrophic scarring. Design In this before-and-after trial, each scar received 3 AFR treatments and 6 months of follow-up. Setting Private academic practice. Patients Fifteen women with Fitzpatrick skin types I to IV, aged 21 to 66 years, presented with 22 nonacne atrophic scars between June 1 and November 30, 2007. Three patients (3 scars) were excluded from the study after receiving 1 AFR treatment and not returning for follow-up visits. The remaining 12 patients (19 scars) completed all 3 treatments and 6 months of follow-up. Interventions Each scar received 3 AFR treatments at 1- to 4-month intervals. Main Outcome Measures Erythema, edema, petechiae, scarring, crusting, and dyschromia were graded after treatment and through 6 months of follow-up. Skin texture, pigmentation, atrophy, and overall appearance were evaluated after treatment and through 6 months of follow-up by the patient and a nonblinded investigator. A 3-dimensional optical profiling system generated high-resolution topographic representations of atrophic scars for objective measurement of changes in scar volume and depth. Results Adverse effects of treatment were mild to moderate, and no scarring or delayed-onset hypopigmentation was observed. At the 6-month follow-up visit, patient and investigator scores demonstrated improvements in skin texture for all scars (patient range, 1-4 [mean, 2.79]; investigator range, 2-4 [mean, 2.95]), pigmentation for all scars (patient range, 1-4 [mean, 2.32]; investigator range, 1-4 [mean, 2.21]), atrophy for all scars (patient range, 1-4 [mean, 2.26]; investigator range, 2-4 [mean, 2.95]), and overall scar appearance for all scars (patient range, 2-4 [mean, 2.89]; investigator range, 2-4 [mean, 3.05]). Image analysis revealed a 38.0% mean reduction of volume and 35.6% mean reduction of maximum scar depth. Conclusion The AFR treatments represent a safe, effective treatment modality for improving atrophic scarring due to surgery or trauma. Objectives To evaluate the effectiveness of a teaching method that uses 3-dimensional (3D) silicone-based prosthetic mimics of common serious lesions and eruptions and to compare learning outcomes with those achieved through the conventional method of lectures with 2-dimensional (2D) images. Design Prospective and comparative. Setting University of Massachusetts Medical School. Participants Ninety second-year medical students. Intervention A 1-hour teaching intervention using a lecture with 2D images (2D group) or using 3D prosthetic mimics of lesions and eruptions (3D group). Main Outcome Measures Mean scores in the domains of morphology, lesion and rash recognition, lesion and rash management, and overall performance assessed at baseline, immediately after, and 3 months after each group's respective teaching intervention. Results Immediately after the teaching intervention, the 3D group had significantly higher mean percentage scores than did the 2D group for overall performance (71 vs 65, P = .03), lesion recognition (65 vs 56, P = .02), and rash management (80 vs 67, P = .01). Three months later, the 3D group still had significantly higher mean percentage scores than did the 2D group for lesion recognition (47 vs 40, P = .03). The 3D group better recognized lesions at 3 months compared with at baseline, whereas the 2D group was no better at recognizing lesions at 3 months compared with at baseline. Conclusions Despite limited curricular time, the novel teaching method using 3D prosthetic mimics of lesions and eruptions improves immediate and long-term learning outcomes, in particular, lesion recognition. It is also a preferred teaching format among second-year medical students. Objectives To describe clinical and immunohistochemical findings in patients with cutaneous Langerhans cell histiocytosis (LCH) beginning in the first 3 months of life and to define predictors of disease evolution. Design Observational retrospective survey from July 15, 1989, to April 30, 2007. Setting Referral center in pediatric dermatology. Patients Thirty-one patients with a diagnosis of cutaneous LCH in the first 3 months of life and no previous visceral LCH. Main Outcome Measures Cutaneous lesion characteristics, regulatory T-lymphocyte density, and E-cadherin expression were assessed. Data were compared between the patient groups with self-regressive vs non–self-regressive forms of cutaneous LCH. Pathologic analysis was performed blinded to patient group. Results Self-regressive cutaneous LCH was found in 21 patients and non–self-regressive cutaneous LCH in 10 patients. Monolesional forms, necrotic lesions, hypopigmented macules at presentation, and distal topography of limb lesions were seen only in patients with self-regressive cutaneous LCH. Regulatory T-lymphocyte density correlated with interleukin 10 expression in lesions (r = 0.77, P = .003) but was not predictive of disease evolution. E-cadherin expression by Langerhans cells was found in 7 patients with disease limited to the skin whether self-regressive or not. One patient with secondary disseminated disease showed loss of E-cadherin expression in Langerhans cells. Conclusions Some morphologic traits of skin lesions can orient the diagnosis to a self-regressive form of cutaneous LCH. Regulatory T-lymphocyte density does not seem to be predictive of disease evolution. E-cadherin expression seems to be an indicator of limited skin disease but not of disease regression. Additional immunohistochemical study is required to confirm these data. Predicting Migraine Responsiveness to Botulinum Toxin Type A Injections [Observation] Background Botulinum toxin type A (BTX) is used prophylactically to reduce the frequency of migraine headaches, with inconsistent responses reported in the literature. The purpose of our study was to determine whether BTX injections at doses used for upper-face cosmetic purposes, which differ from doses typically used by headache specialists, could prevent imploding and ocular but not exploding migraines. Observations Study participants were recruited among patients who had received or were planning to receive BTX injections for upper-face cosmetic purposes but also reported having migraines. Among the 18 patients who completed the study, most with imploding and ocular migraines experienced a significant reduction in their headache frequency, whereas those with exploding migraines generally did not. Conclusions Our study supports the hypothesis that patients with imploding and ocular migraines are more responsive to BTX than those with exploding migraines. Injections of BTX at doses appropriate for cosmetic purposes may be sufficient to prevent migraine attacks. Cutaneous Macroglobulinosis: A Report of 2 Cases [Observation] Background Specific cutaneous lesions of Waldenström macroglobulinemia are rare and include neoplastic cell infiltrates, IgM bullous disease, and so-called IgM-storage papules, which characterize cutaneous macroglobulinosis (CM). Observations We report 2 patients with CM. In patient 1, CM started as small papules, as reported in most of the previously published case studies of CM. In patient 2, lesion evolution was remarkable by its severity, with large ulcerated nodules, and the disease progressed rapidly. As mentioned for half the previously described patients, peripheral neuropathy was suspected in patient 2 and demonstrated in patient 1, with production of antibodies to myelin-associated glycoprotein. Conclusions To the best of our knowledge, rituximab treatment of Waldenström macroglobulinemia associated with CM has not been described previously. Rituximab caused complete remission of the lesions in patient 1, whereas disease rapidly progressed in patient 2, and the patient died. These observations suggest that evolution of the cutaneous IgM-storage lesions reflects that of the underlying Waldenström macroglobulinemia, and CM is not a prognostic marker. Cystic Fibrosis Presenting With Dermatitis [Observation] Background Patients with cystic fibrosis classically present with evidence of pulmonary disease, exocrine pancreatic insufficiency, and high sweat chloride concentrations. Dermatitis as an initial manifestation of the disease is uncommon and has been attributed to multiple nutritional deficiencies. Observation We describe the case of a 3-month-old female infant with cystic fibrosis presenting with dermatitis in the setting of protein-energy malnutrition. A review of the laboratory study results in this case and others showed that a deficiency in zinc, essential fatty acids, and protein likely contributes to the development of the rash seen in cystic fibrosis. Conclusions Given the frequent delay in diagnosis, as well as the increased morbidity and mortality associated with protein-energy malnutrition in these patients, it is important to consider cystic fibrosis as a possible diagnosis in any infant presenting with a rash and other signs of malnutrition. The relative contribution of specific nutritional deficiencies and the degree to which they influence and interact with each other in producing the dermatitis remain unclear, although they may all affect a common underlying metabolic pathway. Background Primary cutaneous B-cell lymphoma manifested by anetoderma has been reported in 7 cases. In all, the secondary anetoderma developed in lesions of marginal-zone lymphoma or posttransplant lymphoproliferative disorder resembling marginal-zone lymphoma. The mechanisms underlying the destruction of elastic tissue in anetoderma are unclear. However, there is growing evidence linking primary anetoderma with a wide range of immunologic abnormalities, the most common being the presence of antiphospholipid antibodies. Observations We analyzed data from 5 patients (3 male, 2 female) with clinical and histopathological features of anetodermic primary cutaneous B-cell lymphoma. Three had marginal-zone lymphoma and 2 had follicle-center cell lymphoma. In all, secondary anetoderma developed in self-regressing nodules/plaques of the lymphoma. Two patients also had lesions clinically and histopathologically compatible with primary anetoderma. Associated immunologic diseases were systemic lupus erythematosus–like disease and rheumatoid arthritis (1 patient each; not in patients with primary anetoderma). Antiphospholipid antibodies were found in 4 patients. Conclusions Anetodermic primary cutaneous B-cell lymphoma is a rare and unique clinicopathological manifestation not only of marginal-zone lymphoma, as previously described, but also of follicle-center cell lymphoma. This type of secondary anetoderma, like primary anetoderma, might be associated with immunologic disorders, particularly antiphospholipid antibodies. Them's the Breaks: Creature of Broken Habits [Notable Notes] Purpuric Eruption in a Patient Treated With Systemic Steroids--Quiz Case [Off-Center Fold] Purpuric Eruption in a Patient Treated With Systemic Steroids--Diagnosis [Off-Center Fold] Infantile Erythroderma--Quiz Case [Off-Center Fold] Infantile Erythroderma--Diagnosis [Off-Center Fold] Superficial Flaccid Bullae in a Female Neonate--Quiz Case [Off-Center Fold] Superficial Flaccid Bullae in a Female Neonate--Diagnosis [Off-Center Fold] A Nontender Nodule on the Tip of the Left Index Finger--Quiz Case [Off-Center Fold] A Nontender Nodule on the Tip of the Left Index Finger--Diagnosis [Off-Center Fold] Pilot Study Using Teledermatology to Manage High-Need Patients With Psoriasis [Research Letters] Risk of Hepatic Hemangiomas in Infants With Large Hemangiomas [Research Letters] The Problem With "Pruritis" [Research Letters] Speckled Lentiginous Nevi: No Longer One Single Disorder [Correspondence] Rare Cutaneous Manifestation of Prostate Cancer [Correspondence] Rare Cutaneous Manifestation of Hyperbilirubinemia [Correspondence] Cutaneous Larva Migrans Complicated by Loffler Syndrome [Correspondence] November 2009 Archives Web Quiz Winner [Archives Web Quiz Winner] Dermoscopy of White Fibrous Papulosis of the Neck [skINsight] Publishing Online Ahead of Print [Announcement] About This Journal [About This Journal] This Month in Archives of Dermatology [This Month in Archives of Dermatology] Memorial to Dr. Ernest Besnier from the New York Dermatological Society [Archives a Century Ago] Basal Cell Nevus Syndrome: A Brave New World [The Cutting Edge] Anti-Bullous Pemphigoid 180 and 230 Antibodies in a Sample of Unaffected Subjects [Study] Objective To evaluate the prevalence of autoantibodies against 2 hemidesmosomal proteins typically found in patients with bullous pemphigoid (BP), BP antigen II (BP180) and BP antigen I (BP230), in persons without BP. Design Cross-sectional study. Setting Academic medical center. Patients An age- and sex-stratified, random, population-based sample of local county patients seen during 2007: 20 men and 20 women per decade of age (from age 20 to 89 years) and 57 patients (33 women and 24 men) aged 90 to 99 years. Intervention Stored serum samples were retrieved for analysis by enzyme-linked immunosorbent assay and indirect immunofluorescence. Main Outcome Measure Presence of circulating autoantibodies to BP180 and BP230. Results Of the 337 study patients, 25 (7.4%) were positive for 1 or both autoantibodies; these 25 samples all tested negative with indirect immunofluorescence. Autoantibody levels did not vary by age or sex. Conclusions Bullous pemphigoid has a higher incidence in the elderly population, but the prevalence of antibodies to BP180 and BP230 did not increase significantly with age or vary by sex in this population-based sample. Other exogenous factors may affect the development of these autoantibodies in a population without clinically evident immunobullous disease, including limitations inherent to the test (false-positive rate). Objectives To identify new and existing cases of dermatomyositis and its subtypes in Olmsted County, Minnesota, from 1976 through 2007, and to establish a population-based estimate of the incidence and prevalence of dermatomyositis and amyopathic dermatomyositis. Design Retrospective population-based study. Setting Community-based epidemiology project. Patients Patients with a diagnosis of dermatomyositis were identified from the Rochester Epidemiology Project. Main Outcome Measures Incidence of dermatomyositis and clinically amyopathic dermatomyositis and risk of malignancy in clinically amyopathic dermatomyositis. Results Of the 29 patients identified, 6 (21%) had the clinically amyopathic subtype of dermatomyositis and 22 (76%) were female. Overall age- and sex-adjusted incidence of dermatomyositis including all subtypes was 9.63 (95% confidence interval [CI], 6.09-13.17) per 1 million persons and 2.08 (95% CI, 0.39-3.77) per 1 million persons for clinically amyopathic dermatomyositis. Age- and sex-adjusted prevalence for all subtypes of dermatomyositis was 21.42 (95% CI, 13.07-29.77) per 100 000 persons. Eight patients (28%) had a malignant condition during the study period; the risk of malignancy (odds ratio) for classic dermatomyositis compared with clinically amyopathic dermatomyositis was 4.61 but was not statistically significant (95% CI, 0.22-96.09) (P = .44). Conclusions Dermatomyositis is a rare disease, and clinically amyopathic dermatomyositis represents an estimated 20% of all dermatomyositis cases. Larger population-based studies are needed to estimate the risk of malignancy associated with subtypes of dermatomyositis, particularly clinically amyopathic dermatomyositis. Objective To assess the comparative efficacy of energy treatments in resolving cherry angiomata. Design Rater-blinded randomized controlled trial. Setting Outpatient dermatology clinic in an urban referral academic medical center. Participants Fifteen healthy adults aged 21 to 65 years were enrolled. Two eligible individuals who were approached declined to participate, and no one enrolled was withdrawn for adverse effects. Interventions For each participant, 3 areas on the torso were demarcated such that each area contained 4 cherry angiomata. Each area was then randomly assigned to receive 1 of the 3 treatments: pulsed-dye laser (PDL) (595 nm), potassium titanyl phosphate (KTP) laser (532 nm), or electrodesiccation. Two treatments spaced 2 weeks apart were delivered to each area. Main Outcome Measures Standardized photographs from before treatment and 3 months after the last treatment were evaluated for color and texture on visual analog scales. Results Mean change in color was a significant improvement of 7.77 (P < .001), but there was no significant difference across treatment arms (P = .19). Mean change in texture was a significant improvement of 6.23 (P < .001), and the degree of textural change also differed across treatments (P < .001). In pairwise comparisons, cherry angiomata treated with electrodesiccation were significantly less improved than were those receiving KTP laser (P = .003) and those treated with PDL (P = .001). The effects of KTP laser and PDL on texture were not different (P = .50). Conclusions Cherry angiomata can be effectively treated with electrodesiccation and with laser. Laser, especially PDL, may minimize the likelihood of treatment-associated textural change. Trial Registration clinicaltrials.gov Identifier: October 2009 Archives Web Quiz Winner [Archives Web Quiz Winner] In Vitro and In Vivo Laser Treatments of Tattoos: High Efficiency and Low Fluences [Study] Objective To analyze the absorption of tattoo inks related to their in vivo and in vitro behavior under laser irradiation to improve laser-assisted tattoo removal. Design The absorption of 21 tattoo inks in a wavelength range from 300 to 800 nm was characterized by reflection spectroscopy from samples consisting of inks mixed in gelatin. Tattoo inks were removed in vitro using pulsed laser radiation with different variables, and morphologic analysis of the irradiated areas was performed. Setting An interdisciplinary laser laboratory with a common industrial project with the Spanish company Milesman S.A. Participant One person was voluntarily tattooed with 2 of the studied inks. Main Outcome Measures (1) First approach to the optimum dose for pigment removal in in vitro models. (2) Correlation between the in vitro and in vivo situations at the optimum dose. Results Reflection spectroscopy facilitated selection of the most adequate laser wavelengths for tattoo removal. Red, orange, and rose inks were successfully lightened at 532 nm with 0.6 J/cm2; brown at 1064 nm with 0.3 J/cm2; yellow and green at 448 nm with 2.6 J/cm2; and blue at 600 nm with 0.9 J/cm2. Similar colors in in vitro and in vivo tattoos responded with the same efficiency to the laser variables. Conclusions High efficiency is reached in the removal of in vivo tattoos by using an irradiation wavelength at which the percentage of reflection from the pigment is minimal. Under this condition, laser pulses can be used with a low fluence, minimizing adverse effects and clinical time. Volunteering With Health Volunteers Overseas [Announcement] Recent Trends in Systemic Psoriasis Treatment Costs [Study] Objectives To analyze the current total cost of systemic therapy for psoriasis and to compare annual trends in the cost of both generic and brand-name therapies with trends in the Consumer Price Index–Urban since 2000. Design A cost model was developed that includes costs for prescription drugs, office visits, and suggested laboratory tests and monitoring procedures. Annual trends in psoriasis drug costs from 2000 through 2008 were analyzed by calculating the percentage change in the average wholesale price from the previous year; these values were compared with changes in the yearly Consumer Price Index–Urban values. Setting The United States. Main Outcome Measures Total annual costs for systemic psoriasis therapies and trends in cost compared with the trends in Consumer Price Index–Urban values (equivalent to inflation). Results Current total annual costs for systemic psoriasis therapies ranged from $1197 (methotrexate) to $27 577 (alefacept, two 12-week courses). Trends in the average wholesale price of brand-name psoriasis therapies from 2000 through 2008 demonstrate an average increase of 66% (range, –24% to +316%); thus, costs of several brand-name psoriasis drugs greatly outpaced the rates of inflation for all items and all prescription drugs. Conclusions Despite the higher monitoring costs associated with traditional systemic therapies, annual costs of biologics exceed those of other available therapies. Current trends demonstrate that systemic psoriasis therapy costs are increasing at a much higher rate compared with general inflation. Background Impaired skin integrity in patients with Netherton syndrome (NS) results in significant systemic absorption of topically applied medications. Some have advocated the administration of pimecrolimus, 1%, topical cream for the treatment of patients with NS. Insufficient data exist with regard to its safety, systemic absorption, and efficacy. Observations An exploratory study was conducted involving 3 children with NS who received twice-daily application of pimecrolimus, 1%, cream over 18 months. There were no notable abnormalities in hematologic or chemistry profiles. Blood levels of pimecrolimus ranged from 0.625 to 7.08 ng/mL, with peak levels reached during the first month in all 3 patients. Dramatic reductions were observed in the Netherton Area and Severity Assessment, Eczema Area and Severity Index, Investigator Global Evaluation of Disease, and pruritus scores compared with baseline levels. Conclusions Use of pimecrolimus, 1%, cream was well tolerated and demonstrated marked improvements in nearly all of the parameters evaluated. Patients treated with pimecrolimus responded rapidly, within the first month of treatment, and improvement persisted throughout the study period. In adult patients receiving oral pimecrolimus, blood levels as high as 54 ng/mL for 3 months have not shown clinically significant immunosuppression. Absorption of pimecrolimus, 1%, cream was detectable, but levels were much lower than expected even when applied to 50% of total body surface area. Larger studies are warranted to determine the safety and efficacy of pimecrolimus, 1%, cream in the treatment of NS. Trial Registration clinicaltrials.gov Identifier: Buschke-Ollendorff Syndrome: Absence of LEMD3 Mutation in an Affected Family [Observation] Background Buschke-Ollendorff syndrome (BOS), an autosomal dominant disorder, features small, acquired, asymptomatic, symmetrical foci of osteosclerosis detected radiographically in epimetaphyseal bone (osteopoikilosis) (OPK) together with connective tissue nevi or juvenile elastomas. Heterozygous, loss-of-function, germline mutation in the LEMD3 gene (which encodes an inner nuclear membrane protein called LEMD3, or MAN1) has been repeatedly documented in patients with BOS or OPK. Observations We describe a father and son with multiple yellowish papules and nodules coalescing into cobblestone nevoid plaques consistent with nevus elasticus. Radiographs of the father show multiple, small, bone islands within the hands, wrists, distal femurs, proximal tibias, and left distal fibula consistent with OPK. Although the clinical findings are diagnostic of Buschke-Ollendorf syndrome, analysis of the LEMD3 gene showed no exonic mutations. Conclusion Absence of LEMD3 mutation in the exons and splice sites of a family with BOS suggests that there is genetic heterogeneity for this disorder. Cock's Peculiar Tumor [Notable Notes] Background Human papillomavirus (HPV) infections cause a spectrum of clinical disease states, depending on the causative HPV and the characteristics of the infected host, especially the status of cell-mediated immunity. Generalized verrucosis is an unusual clinical presentation of a disseminated HPV infection associated with severe immunodeficiency status. Observations We present a case of extreme disfigurement associated with an HPV-2 (common wart virus) infection. Virologic studies, immune status of the patient, and treatment(s) are summarized. Conclusions The severe disfigurement of this patient was a result of an underlying severe immunodeficiency, permissive for a disseminated HPV-2 infection that was allowed to progress for many years before the initiation of therapy. Such a rare case illustrates the natural history of generalized verrucosis in the setting of severe immunodeficiency in the absence of sustained medical interventions. Medical and surgical treatments resulted in marked improvement in the general health of this patient, as well as improvement of the disfigurement that resulted from the generalized verrucosis. Prevalence of Autoantibodies to Bullous Pemphigoid Antigens Within the Normal Population [Editorial] Clinically Amyopathic Dermatomyositis: What Can We Now Tell Our Patients? [Editorial] Ulcerated Facial Nodules in a Renal Transplant Recipient--Quiz Case [Off-Center Fold] Ulcerated Facial Nodules in a Renal Transplant Recipient--Diagnosis [Off-Center Fold] Pruritic Reticular Eruption on the Chest of a 24-Year-Old Woman--Quiz Case [Off-Center Fold] Pruritic Reticular Eruption on the Chest of a 24-Year-Old Woman--Diagnosis [Off-Center Fold] Erythematous Erosive Patch on the Left Nipple--Quiz Case [Off-Center Fold] Erythematous Erosive Patch on the Left Nipple--Diagnosis [Off-Center Fold] Hemochromatosis and Bilateral Yellow Papules of the Neck--Quiz Case [Off-Center Fold] Hemochromatosis and Bilateral Yellow Papules of the Neck--Diagnosis [Off-Center Fold] Lack of Wnt5A Expression in Merkel Cell Carcinoma [Research Letters] A Simple Solution to the Common Problem of Ecchymosis [Research Letters] Pretibial Lymphoplasmacytic Plaque in Children [Correspondence] Therapeutic Effect of Clopidogrel on Cutaneous Polyarteritis Nodosa [Correspondence] The Dermatologic Manifestation of Novel Influenza A(H1N1) [Correspondence] Reversal of Canities [Correspondence] Dermoscopic Subpatterns of Ashy Dermatosis Related to Lichen Planus [skINsight] Our Thanks to ARCHIVES Peer Reviewers [Annual Reviewers List] About This Journal [About This Journal] This Month in Archives of Dermatology [This Month in Archives of Dermatology] Wassermann Test in Scleroderma [Archives a Century Ago] Objective To examine and compare the temporal trends in melanoma incidence and stage at diagnosis among whites, Hispanics, and blacks in Florida from 1990 to 2004. Design Cross-sectional and retrospective analysis. Setting Florida Cancer Data System. Patients Melanoma cases with known stage and race/ethnicity reported from 1990 to 2004. Main Outcome Measures Age-adjusted melanoma incidence and stage at diagnosis. Results Of 41 072 cases of melanoma, 39 670 cases were reported for white non-Hispanics (WNHs), 1148 for white Hispanics (WHs), and 254 for blacks. Melanoma incidence rates increased by 3.0% per year among WNH men (P < .001), 3.6% among WNH women (P < .001), 3.4% among WH women (P = .01), and 0.9% among WH men (P = .52), while remaining relatively stable among black men and women. Both WHs and blacks had significantly more advanced melanoma at presentation: 18% of WH and 26% of black patients had either regional or distant-stage melanoma at diagnosis compared with 12% of WNH patients. The proportion of distant-stage melanoma diagnosed among WHs and blacks changed little from 1990 to 2004, compared with a steady decrease in the percentage of melanoma cases diagnosed at distant stage among WNHs (P < .001). Such differences in the time trends of the proportion of distant-stage melanoma remained after excluding in situ cases. Conclusions The rising melanoma incidence among WNHs and WHs emphasizes the need for primary prevention. The persistence of disparity in melanoma stage at diagnosis among WHs, blacks, and WNHs warrants closer examination of secondary prevention efforts in minority groups. Factors That Affect Skin Aging: A Cohort-Based Survey on Twins [Study] Objective To identify environmental factors that correlate with skin photoaging, controlling for genetic susceptibility by using a questionnaire administered to twins. Design The survey collected information about each participant's Fitzpatrick type, history of skin cancer, smoking and drinking habits, and weight from a cohort of twins. Clinicians then assigned a clinical photodamage score to each participant. Setting The annual Twins Days Festival in Twinsburg, Ohio. Participants A voluntary cohort of twins from the general community, mostly from Ohio, Pennsylvania, and the northeastern United States. The survey was completed on a voluntary basis by sets of monozygotic (MZ) and dizygotic (DZ) twins. A total of 130 surveys taken by 65 complete twin pairs were analyzed. Main Outcome Measure Skin aging was assessed using a validated photographic scale of photodamage, graded by such characteristics as wrinkling and pigmentation change. Results Photodamage scores among twins of a pair, whether MZ or DZ, were highly correlated (P = .92). Factors found to predict higher photodamage include history of skin cancer (P < .001), zygosity status (MZ vs DZ) (P = .001), weight (P = .02), and cigarette smoking (P = .046). Alcohol consumption was significantly associated with lower photodamage scores (P = .003). Conclusions The study of twins provides a unique opportunity to control for genetic susceptibility in order to elucidate environmental influences on skin aging. The relationships found between smoking, weight, sunscreen use, skin cancer, and photodamage in these twin pairs may help to motivate the reduction of risky behaviors. Objective To evaluate the relationship between frequency of pruritic symptoms experienced over a 1-month period and psychological stress. Design Cohort study. Setting Population-based study in Japan. Participants A total of 2224 participants at least 18 years old and without psychiatric disorders participated in the Japan Health Diary Study (October 2003), a cohort study comprising a representative sample in Japan. Main Outcome Measures Frequency of pruritic symptoms assessed by self-reported health diaries over the 1-month period and subsequent psychological stress measured using the Japanese version of the Perceived Stress Scale. Results The 2224 participants had a mean age of 44.6 years, 1212 (54.5%) were women, and 70 (3.1%) presented with pruritic symptoms. Multivariable analysis showed that patients with pruritic symptoms had significantly higher psychological stress than those without pruritic symptoms (β coefficient, 2.33; 95% confidence interval [CI], 0.53-4.14; P = .01). Furthermore, a linear trend was observed between increased psychological stress and increased severity of pruritic symptoms, with β coefficients for the first, second, and third tertiles for symptoms of 0.81 (95% CI, –1.97 to 3.59), 1.77 (95% CI, –0.82 to 4.37), and 4.86 (95% CI, 1.29 to 8.43), respectively (P value for trend, .004). Conclusion Our results suggest that frequency of pruritic symptoms is associated with psychological stress in the general population. Incidence of and Risk Factors for Skin Cancer After Heart Transplant [Study] Objective To examine the incidence, tumor burden, and risk factors for nonmelanoma and other skin cancer types in this heart transplant cohort. Design Retrospective review of patient medical records. Setting Tertiary care center. Patients All heart transplant recipients at Mayo Clinic from 1988 to 2006. Main Outcome Measures Cumulative incidence of skin cancer and tumor burden, with Cox proportional hazards regression models used to evaluate risk factors for posttransplant primary and secondary nonmelanoma skin cancer. Results In total, 312 heart transplant patients had 1395 new skin cancers in 2097 person-years (mean, 0.43 per year per patient) with a range of 0 to 306 for squamous cell carcinoma (SCC) and 0 to 17 for basal cell carcinoma (BCC). The cumulative incidence rates of any skin cancer were 20.4%, 37.5%, and 46.4% at 5, 10, and 15 years after heart transplant, respectively. Cumulative incidence of SCC after the first BCC was 98.1% within 7 years. Multivariate analysis showed that posttransplant nonskin cancer, increased age, and heart failure etiologic factors other than idiopathic disease were associated with increased risk of SCC. Posttransplant herpes simplex viral infection, increased age, and use of mycophenolate mofetil for immunosuppression were associated with increased risk of BCC. Conclusions With prolonged survival, many heart transplant patients have numerous skin cancers. Vigilant sun protection practices, skin cancer education, and regular skin examination are appropriate interventions in these high-risk patients. September 2009 Archives Web Quiz Winner [Archives Web Quiz Winner] Objectives To test the applicability and prognostic value of the new TNM classification system for primary cutaneous lymphomas other than mycosis fungoides and Sézary syndrome in patients with primary cutaneous anaplastic large cell lymphoma (C-ALCL) and to evaluate the prognostic significance of other clinical variables, in particular the site of presentation. Design Retrospective cohort analysis. Setting Dutch Cutaneous Lymphoma Group database. Patients One hundred thirty-five patients with C-ALCL. Main Outcome Measures Clinical variables, including T category and site of presentation. Results Eighty patients (59.3%) presented with T1 disease, 37 (27.4%) with T2 disease, and 18 (13.3%) with T3 disease. Median follow-up was 56 months (range, 11-288 months). Five-year disease-specific survival (DSS) was 93% for T1 disease, 93% for T2 disease, and 77% for T3 disease (P = .19). Patients with skin lesions on a leg had reduced 5-year DSS compared with lesions on other sites (82% for leg vs 95% for head and neck, 96% for trunk, and 95% for arm; P = .23). Patients with leg involvement (n = 32) had significantly worse 5-year DSS than did patients without leg involvement (n = 103; 76% vs 96%; P = .03 after adjustment for T category). Conclusions The new TNM system can be applied well to patients with C-ALCL and may provide prognostic information, in particular when combined with site of presentation. Patients with T2 or T3 disease with skin lesions on the leg may have reduced survival and require close surveillance during follow-up. SunSmart Sprint 5K Run/Walk for Melanoma Awareness: A Student Initiative [Notable Notes] Background Scalp dermoscopy plays an important role in the diagnosis of hair and scalp disorders, and specific dermoscopic patterns have recently been associated with several disorders causing noncicatricial alopecia, such as androgenetic alopecia, alopecia areata, trichotillomania, and tinea capitis. Observations We describe the morphologic and pathologic features of a new dermoscopic pattern, referred to as "follicular red dots," that was found in scalp lesions of 5 patients with active discoid lupus erythematosus (DLE). Follicular red dots appear as erythematous polycyclic, concentric structures, with a diameter ranging from 0.16 to 0.47 mm, regularly distributed in and around the follicular ostia. In the pathologic findings, red dots correspond to widened infundibula plugged by keratin and surrounded by dilated vessels and extravasated erythrocytes. Retrospective blinded evaluation of the dermoscopic images of 155 patients with cicatricial alopecia suggests that follicular red dots are a specific feature of DLE because the pattern was not identified in the images of cicatricial alopecia resulting from other diseases. Conclusions The follicular red dot pattern is a specific feature of scalp lesions of active lupus erythematosus of the scalp. Recognition of this distinctive dermoscopic pattern may help the clinician to differentiate DLE from other diseases causing cicatricial alopecia. A Rectangular Dermatosis of the Left Back [Observation] Background Cardioversion and defibrillation have become widely used techniques aimed at restoring normal sinus rhythm in patients with cardiac arrhythmias. Following the procedure, cutaneous lesions are often seen at the site of the electrodes, but little has been reported regarding the evolution of such lesions over time. Observations Two patients presented with unusual, well-defined rectangular eruptions on the left back, and both reported a history of having undergone electrical cardioversion or defibrillation several years previously. The histologic characteristics of each lesion were distinct, and the management was symptomatic, with most of the relief coming from the recognition that the eruption was actually a self-limited manifestation of cardioversion and defibrillation. Conclusions The clinical cases and corresponding histologic findings represent possible long-term sequelae of electrical cardioversion or defibrillation. They are presented in order to enhance the diagnostic acumen of dermatologists and to avoid potential misdiagnosis. Objective To conduct a systematic review of the literature to identify the prevalence of, and demonstrated risk factors for, psychological distress among individuals affected by, or at high risk of developing, melanoma. For a substantial subset of patients, the diagnosis and/or treatment of cutaneous malignant melanoma may cause significant psychological distress. Data Sources Using the MEDLINE, PsycINFO, and CINAHL databases, published studies (1988 to March 2008) of individuals affected by melanoma were included if they examined the demographic, clinical, psychological, and/or social correlates of emotional distress. Study Selection Searches were restricted to publications in English and were supplemented by citation lists in retrieved articles and contact with researchers. Data Extraction A total of 356 articles were critically appraised by 2 reviewers to assess eligibility and clinical evidence level. A total of 44 studies met the inclusion criteria. Data Synthesis Approximately 30% of patients with melanoma reported clinically relevant levels of psychological distress, as measured by a range of validated scales, with symptoms of anxiety more prevalent than depression. A number of empirically demonstrated risk factors for distress were identified, including female sex, younger age, lower education, visibility of affected body site, lack of social support, and negative appraisal of melanoma. Conclusions Routine psychological screening of patients with melanoma is widely recommended as standard practice; however, standard screening measures may have limited sensitivity and specificity as demonstrated by the wide range of results reported in this review. Development of a brief screening tool that incorporates empirically supported risk factors is recommended to improve the timely identification and support of those patients most susceptible to adverse psychological outcomes. Objectives To conduct a systematic review to determine clearance rates and adverse effects of topical imiquimod or fluorouracil therapy in the treatment of nonmelanoma skin cancers such as basal (BCC) and squamous cell carcinoma (SCC), and to develop recommendations for the use of topical imiquimod or fluorouracil to treat BCC and SCC. Data Sources MEDLINE, CANCERLIT, and Cochrane databases. Study Selection Prospective, retrospective, and case studies in English containing a minimum of 4 subjects and a 6-month follow-up or posttreatment histologic evaluation. Data Extraction We calculated the rate of clearance and adverse effects for BCC subtypes and invasive and in situ SCC treated with topical imiquimod or fluorouracil. Data Synthesis Clearance rates varied by drug regimen, and most of the studies lacked long-term follow-up. Imiquimod use produced the following clearance rates: 43% to 100% for superficial BCC, 42% to 100% for nodular BCC, 56% to 63% for infiltrative BCC, 73% to 88% for SCC in situ, and 71% for invasive SCC. Fluorouracil use produced the following clearance rates: 90% for superficial BCC and 27% to 85% for SCC in situ. Up to 100% and 97% of patients applying imiquimod and fluorouracil, respectively, experienced at least 1 adverse event. Adverse event intensity ranged from mild to severe; erythema, pruritus, and pain were common. Conclusions Evidence supports the use of topical imiquimod as monotherapy for superficial BCC and topical fluorouracil as monotherapy for superficial BCC and SCC in situ. Based on the available evidence, the strength of any recommendations for the use of these 2 agents in the primary treatment of these tumors is weak. We recommend that their use be limited to patients with small tumors in low-risk locations who will not or cannot undergo treatment with better-established therapies for which long-term clearance rates have been determined. Long-term clinical follow-up is essential for patients treated with topical imiquimod or fluorouracil. Limitations of therapy include high rates of adverse effects, lower clearance rates than other treatment modalities, dependence on patient adherence to treatment, and higher costs than other therapies. Thank You to Our Reviewers [Announcement] Psychoneuro-oncology: Its Time Has Arrived [Editorial] A Conceptual Framework for Advancing Melanoma Health Disparities Research [Editorial] Widespread Crusted Lesions in a Patient With HIV--Quiz Case [Off-Center Fold] Widespread Crusted Lesions in a Patient With HIV--Diagnosis [Off-Center Fold] Sharply Demarcated, Erythematous Plaques on an Amputation Stump--Quiz Case [Off-Center Fold] Sharply Demarcated, Erythematous Plaques on an Amputation Stump--Diagnosis [Off-Center Fold] A Cherry-Red Umbilical Papule in an Infant--Quiz Case [Off-Center Fold] A Cherry-Red Umbilical Papule in an Infant--Diagnosis [Off-Center Fold] Multiple Comedonelike Lesions Encircling the Anal Orifice--Quiz Case [Off-Center Fold] Multiple Comedonelike Lesions Encircling the Anal Orifice--Diagnosis [Off-Center Fold] The Fascial Plication Suture: An Adjunct to Layered Wound Closure [Research Letters] Lack of Lower Extremity Hair Not a Predictor for Peripheral Arterial Disease [Research Letters] Onychomatricoma: Clinical and Sonographic Findings [Correspondence] Dermoscopy of Extragenital Lichen Sclerosus [skINsight] About This Journal [About This Journal] This Month in Archives of Dermatology [This Month in Archives of Dermatology] Leflunomide in the Treatment of Palmoplantar Pustulosis [The Cutting Edge] Objective To evaluate the effectiveness of cellular telephone text messaging as a reminder tool for improving adherence to sunscreen application. Design We conducted a randomized, controlled trial of the effect of an electronic text-message reminder system on adherence to sunscreen application. Adherence to daily sunscreen use was evaluated using a novel electronic monitoring device. Setting Participants were recruited from the general community. Participants Seventy participants constituted a volunteer sample from the general community. The inclusion criteria required participants to be 18 years or older, to own a cellular telephone with text-message features, and to know how to retrieve text messages. Intervention Half of the participants received daily text-message reminders via cellular telephone for 6 weeks, and the other half did not receive reminders. The text-message reminders consisted of 2 components: a "hook" text detailing daily local weather information and a "prompt" text reminding users to apply sunscreen. Main Outcome Measure The primary end point of the study was adherence to sunscreen application measured by the number of days participants applied sunscreen during the 6-week study period. Results All 70 participants completed the 6-week study. There were no statistically significant differences in baseline characteristics between the 2 study groups. At the end of the study period, the 35 participants who did not receive reminders had a mean daily adherence rate of 30.0% (95% confidence interval, 23.1%-36.9%). In comparison, the 35 participants who received daily text-message reminders had a mean daily adherence rate of 56.1% (95% confidence interval, 48.1%-64.1%) (P < .001). Among the participants in the reminder group, 24 (69%) reported that they would keep using the text-message reminders after the study, and 31 (89%) reported that they would recommend the text-message reminder system to others. Subgroup analysis did not reveal any significant demographic factors that predicted adherence. Conclusions Despite awareness of the benefits of sunscreen, adherence is low, even in this population, for whom adherence was knowingly monitored. Short-term data demonstrate that using existing cellular telephone text-message technology offers an innovative, low-cost, and effective method of improving adherence to sunscreen application. The use of ubiquitous communications technology, such as text messaging, may have implications for large-scale public health initiatives. Trial Registration clinicaltrials.gov Identifier: Elevated D-dimer Level in the Differential Diagnosis of Venous Malformations [Study] Objective To evaluate if elevated D-dimer level is specific for venous malformations (VMs) and thus useful for differential diagnosis, which can be problematic even in specialized interdisciplinary centers. Localized intravascular coagulopathy, characterized by elevated D-dimer levels, has been observed in approximately 40% of patients with VMs. Design Prospective convenience sample accrued from 2 interdisciplinary sites. Setting Two interdisciplinary centers for vascular anomalies in Brussels, Belgium, and Caen, France Participants The study population comprised 280 patients with clinical data, Doppler ultrasonograms (for 251 patients), and coagulation parameter measurements. Main Outcome Measure Measurement of D-dimer levels. Results A VM was diagnosed in 195 of 280 patients (69.6%), and 83 of them had elevated D-dimer levels; the sensitivity of D-dimer dosage was 42.6% (95% confidence interval, 35.6%-49.5%). Among the 85 patients without VM, D-dimer levels were elevated only in 3 patients; the specificity of the dosage was 96.5% (95% confidence interval, 92.5%-100%). Conclusions Elevated D-dimer level is highly specific for VMs (pure, combined, or syndromic), and therefore this easy and inexpensive biomarker test should become part of the clinical evaluation of vascular anomalies. It can detect hidden VMs and help differentiate glomuvenous malformation (normal D-dimer levels) from other multifocal venous lesions. Elevated D-dimer level also differentiates a VM from a lymphatic malformation. Moreover, slow-flow Klippel-Trenaunay syndrome (capillaro-lymphatico-venous malformation with limb hypertrophy) can be distinguished from fast-flow Parkes Weber syndrome (capillary malformation with underlying multiple microfistulas and limb hypertrophy). For these reasons, D-dimer level measurement is a useful complementary tool for diagnosing vascular anomalies in everyday practice. Analysis of Globule Types in Malignant Melanoma [Study] Objective To identify and analyze subtypes of globules based on size, shape, network connectedness, pigmentation, and distribution to determine which globule types and globule distributions are most frequently associated with a diagnosis of malignant melanoma. Design Retrospective case series of dermoscopy images with globules. Setting Private dermatology practices. Participants Patients in dermatology practices. Intervention Observation only. Main Outcome Measure Association of globule types with malignant melanoma. Results The presence of large globules (odds ratio [OR], 5.25) and globules varying in size (4.72) or shape (5.37) had the highest ORs for malignant melanoma among all globule types and combinations studied. Classical globules (dark, discrete, convex, and 0.10-0.20 mm) had a higher risk (OR, 4.20) than irregularly shaped globules (dark, discrete, and not generally convex) (2.89). Globules connected to other structures were not significant in the diagnosis of malignant melanoma. Of the different configurations studied, asymmetric clusters have the highest risk (OR, 3.02). Conclusions The presence of globules of varying size or shape seems to be more associated with a diagnosis of malignant melanoma than any other globule type or distribution in this study. Large globules are of particular importance in the diagnosis of malignant melanoma. August 2009 Archives Web Quiz Winner [Archives Web Quiz Winner] Objective To study rates of incomplete excision of basal (BCC) and squamous (SCC) cell cancer by Australian general practitioners with a special interest. Design Records review. Setting A network of 15 primary care skin cancer clinics across Australia. Participants Fifty-seven physicians performing excisions of 9417 BCCs and SCCs in a single network of 15 primary care skin cancer clinics across Australia between 2005 and 2007. Main Outcome Measures Rates of incomplete excision according to physician, clinic, anatomic location of the lesion, and whether a previous biopsy had been performed. Results Four hundred forty-three of 6881 BCCs (6.4%) and 159 of 2536 SCCs (6.3%) were excised incompletely. Incomplete BCC and SCC excisions were more frequent on the head and neck (282 of 2872 excisions [9.8%] and 97 of 861 [11.3%], respectively) than elsewhere. Ears (74 of 388 excisions [19.1%]) and nose (78 of 546 [14.3%]) had the highest rates of incompletely excised BCCs, and ears (26 of 144 excisions [18.1%]) and forehead (20 of 157 [12.7%]) had the highest rates of incompletely excised SCCs. Of all BCC excisions, 67.3% were once-off excisions with no previous biopsy, and these excisions were more likely to be incomplete (odds ratio, 1.73; 95% confidence interval, 1.36-2.20) than those with a previous biopsy. There was, however, substantial variation in frequency of incomplete excision between clinics for BCC (ranging from 3.3% to 24.7%) and SCC (ranging from 0% to 17.2%) and between physicians within clinics (BCC ranging from 0% to 31.1%, and SCC ranging from 0% to 23.5%). Conclusions Overall frequency of incomplete excision is low and similar to that in other reports. However, high frequency in high-risk sites, low rates of previous biopsy, and substantial variation in performance between physicians and clinics suggests there is significant opportunity to further improve health outcomes. Alefacept for Severe Alopecia Areata: A Randomized, Double-blind, Placebo-Controlled Study [Study] Objective To assess the efficacy of alefacept for the treatment of severe alopecia areata (AA). Design Multicenter, double-blind, randomized, placebo-controlled clinical trial. Setting Academic departments of dermatology in the United States. Participants Forty-five individuals with chronic and severe AA affecting 50% to 95% of the scalp hair and resistant to previous therapies. Intervention Alefacept, a US Food and Drug Administration–approved T-cell biologic inhibitor for the treatment of moderate to severe plaque psoriasis. Main Outcome Measure Improved Severity of Alopecia Tool (SALT) score over 24 weeks. Results Participants receiving alefacept for 12 consecutive weeks demonstrated no statistically significant improvement in AA when compared with a well-matched placebo-receiving group (P = .70). Conclusion Alefacept is ineffective for the treatment of severe AA. Objectives To evaluate the efficacy of topical application of calcipotriol to healing wounds in preventing or reducing hypertrophic scar formation and to investigate the biochemical properties of the epidermis associated with hypertrophic scar formation. Design Randomized, double-blind, placebo-controlled trial using the reduction mammoplasty wound-healing model. Setting University Medical Center Groningen. Patients Thirty women who underwent bilateral reduction mammoplasty. Interventions For 3 months, scar segments were treated with either topical calcipotriol or placebo. Main Outcome Measures Three weeks, 3 months, and 12 months postoperatively, the scars were evaluated and punch biopsy samples were collected for immunohistochemical analysis. Results No significant difference in the prevalence of hypertrophic scars was observed between the placebo- and calcipotriol-treated scars. Only scars with activated keratinocytes 3 weeks postoperatively became hypertrophic (P = .001). Conclusions Topical application of calcipotriol during the first 3 months of wound healing does not affect the incidence of hypertrophic scar formation. We observed a strong association between keratinocyte activation and hypertrophic scar formation. Trial Registration trialregister.nl Identifier: Objectives To comprehensively ascertain the extent and severity of clinical features in affected individuals from 2 large families with proven heterozygous mutations in the CYLD locus and to correlate these findings with the 3 appendageal tumor predisposition syndromes (familial cylindromatosis, Brooke-Spiegler syndrome, and multiple familial trichoepitheliomas) known to be associated with such germline mutations. Design Interfamilial and intrafamilial observational study. Setting Tertiary genetic and dermatology referral center. Participants Thirty-four individuals recruited from 2 large multigenerational families with CYLD mutations. Clinical details, history, and tumor maps were obtained from all participants; in 18, the information was corroborated by detailed clinical examination. Main Outcome Measures Tumor density, distribution and histologic findings, associated medical conditions, patient symptoms, and impact of disease on quality of life. Results The severity of penetrance and phenotype varied within families. Although an approximately equal female to male predisposition was noted, 5 women and 1 man (of 26 patients surveyed [23%]) had undergone total scalp removal. The average age at onset was 16 years (range, 8-30 years). Symptoms reported by affected patients included painful tumors (in 12 of 23 patients [52%] who answered the question), conductive deafness, and sexual dysfunction. Of the 26 surveyed patients, tumors were noted on the scalp in 21 (81%), on the trunk in 18 (69%), and in the pubic area in 11 (42%). Tumor mapping provided clinical evidence that correlated with hormonally stimulated hair follicles being particularly vulnerable to loss of heterozygosity and tumor induction. Conclusions The burden of disease at sites other than the head and neck appears to be underreported in the literature and greatly affects quality of life. Differentiation between the clinical diagnoses has little prognostic or clinical utility in genetic counseling, even within individuals from the same family. Thus, we suggest an encompassing diagnosis of "CYLD cutaneous syndrome." Finally, the clinical distribution of tumors suggests that hormonal factors may play an important role in tumor induction in these patients. Unexpected Occurrence of Xeroderma Pigmentosum in an Uncle and Nephew [Observation] Background Xeroderma pigmentosum (XP) is a rare autosomal recessive disorder characterized by a decreased ability to repair DNA damaged by UV radiation and the early development of cutaneous and ocular malignant neoplasms. Approximately 20% of patients with XP also develop progressive neurologic degeneration. Observations We describe a boy who was found to have XP after a severe burn following minimal sun exposure. His maternal uncle, now age 20 years, had been diagnosed with XP after a similar sunburn in infancy. The uncle has the typical skin pigmentary findings of XP along with severe progressive neurologic involvement. Although the infant's parents were not known to be blood relatives, the infant and his affected uncle proved to be compound heterozygotes for the same 2 frameshift mutations in the XPA DNA repair gene (c.288delT and c.349_353del). After the diagnosis of XP in the infant, genealogic investigation identified a common Dutch ancestor for both of his grandfathers 5 generations back. Conclusions Counseling families at risk for a rare inherited disease is not always straightforward. The sociocultural and demographic backgrounds of the families must be considered for evaluation of risk assessment. Background There is scant literature that documents pseudoxanthoma elasticum (PXE)–like histologic changes in the setting of inflammatory skin diseases. This article documents granulomatous dermatitis with PXE-like changes in a patient with cystic fibrosis. This is the first report of its kind, to our knowledge. Observations A 33-year-old woman with cystic fibrosis developed a papular eruption on the flexural surfaces of the upper and lower extremities, which was initially treated with prednisone. A punch biopsy showed granulomatous inflammation and associated PXE-like changes. The combined histologic and clinical findings were most consistent with granuloma annulare. There was no family history of PXE or clinical manifestations of PXE. The rash gradually resolved itself over the next several months. Conclusions There are few publications that document PXE-like changes in association with various inflammatory skin conditions. Thus, the clinical significance of this finding remains uncertain. This case and previous reports are discussed in the context of current molecular and genetic knowledge. It is hoped that greater awareness of this phenomenon will promote further investigation and elucidation of the clinical and biologic significance of PXE-like changes observed in biopsies of inflammatory skin disorders. July 2009 Archives Web Quiz Winner [Archives Web Quiz Winner] Objective To determine the prevalence of aquagenic wrinkling of the palms (AWP) in patients with cystic fibrosis (CF) compared with control patients, and evaluate for genotype-phenotype correlations. Since its first description over 30 years ago, AWP has frequently been anecdotally associated with CF, but this association has not been confirmed in a rigorous prospective case-control study. Design Blinded comparison. Setting The CF and dermatology clinics at St Louis Children's Hospital. Participants Forty-four individuals with CF from a CF clinic and 26 controls from a dermatology clinic. Intervention Participants were tested for AWP using 3 minutes of water immersion with room-temperature tap water. Main Outcome Measure The degree of AWP was scored from 0 (no wrinkling) to 4 (severe wrinkling) by 3 blinded physicians. For genotype-phenotype correlations, patients with CF were divided into those homozygous for the F508 mutation and those with other genotypes. Results The mean AWP score of the CF group was significantly higher than the mean score of the control group (1.5 vs 0.6; P < .001). Patients with CF who were homozygous for the F508 mutation (n = 27) had significantly higher scores than patients with CF who were not homozygous for the F508 mutation (n = 17) (1.7 vs 1.1; P = .02). The 17 patients with CF who were not homozygous for the F508 mutation still had higher scores than the control group (1.1 vs 0.6; P = .03). There was no correlation between sweat chloride concentrations measured at the time of diagnosis and AWP score. Conclusions Our results confirm the association between AWP and CF. Among patients with CF, greater AWP occurs in those who are homozygous for the F508 mutation. Background Lichen sclerosus (LS) is a rare, chronic inflammatory skin disease that predominantly affects the anogenital area. A few patients exhibit widespread extragenital disease that may lead to blister formation and superficial erosions. We evaluated the efficacy of pulsed high-dose corticosteroids combined with low-dose methotrexate treatment in patients with refractory generalized LS that had failed to respond to standard topical corticosteroid therapy. Observation Seven patients were included in this retrospective study, all of whom were treated with pulsed high-dose corticosteroids combined with low-dose methotrexate for at least 6 months. The outcome measure was an individual, nonvalidated clinical score. Overall, a significant decrease in the clinical score was observed, from a median score of 8 (range, 5 to 24) before treatment to 2 (range, 1 to 4) after treatment. Adverse effects observed during therapy were moderate and disappeared after the end of treatment. During the follow-up period of at least 3 months (mean, 4.7 [range, 3-8] months), none of the patients experienced a relapse of extragenital LS. Conclusions Patients with severe extragenital LS benefit from pulsed high-dose corticosteroids combined with low-dose methotrexate therapy. This combination therapy should be considered in generalized disease, especially disease that is refractory to conventional treatment. The Balm of Gilead [Notable Notes] Background Given the recent boom of the cosmetic industry, there is a wealth of new products available to patients and physicians, including soft-tissue fillers. Bio-Alcamid polyacrylamide gel (Polymekon, Milan, Italy) is a filler that has potential to cause adverse reactions. Observations Two patients who had previously been treated with Bio-Alcamid outside of the United States presented with different manifestations of inflammatory responses to the product. These reactions were challenging to treat. Conclusions Despite claims of safety, Bio-Alcamid and possibly other soft-tissue fillers available worldwide have the potential to cause adverse reactions. Physicians should be aware of the various presentations and treatment options for these reactions. Background Gastrointestinal stromal tumors (GISTs) harbor gain-of-function mutations of the c-kit tyrosine kinase receptor. Imatinib mesylate is an inhibitor of c-kit and is indicated in the treatment of chronic myeloid leukemia and GISTs. Reported adverse effects of imatinib include hypopigmentation, depigmentation, and hyperpigmentation. Although the exact mechanism by which these occur is unclear, it is likely that inhibition of c-kit leads to downstream inhibition of the tyrosinase gene promoter and thus to inhibition of pigment production. Observations A 45-year-old woman with a history of multiple dysplastic nevi and lentigines was diagnosed as having familial GIST syndrome. Treatment with imatinib mesylate was started in an attempt to decrease the tumor load. Three months after treatment initiation, the patient noted a decrease in the number of pigmented lesions, lightening of the skin in her genital area, and graying of her terminal hair. Conclusions The potential association between a specific genetic mutation and pigmentation changes secondary to imatinib therapy may account for the variety in presentation of this potential side effect. Further genetic studies paired with melanocyte-specific or c-kit–specific stains of affected tissue are warranted to better understand the relationship between the genetic mutation and the effect of imatinib on pigmentation. Adherence, the Fourth Dimension in the Geometry of Dermatological Treatment [Editorial] Relevance of D-dimer Testing in Patients with Venous Malformations [Editorial] A Rapidly Growing Lesion on the Lip--Quiz Case [Off-Center Fold] A Rapidly Growing Lesion on the Lip--Diagnosis [Off-Center Fold] Fleshy Facial Lesion on an 80-Year-Old Dayak Woman--Quiz Case [Off-Center Fold] Fleshy Facial Lesion on an 80-Year-Old Dayak Woman--Diagnosis [Off-Center Fold] Asymptomatic Nodules on the Foot--Quiz Case [Off-Center Fold] Asymptomatic Nodules on the Foot--Diagnosis [Off-Center Fold] Confluent Scaly Erythematous Plaques on the Trunk of a 16-Year-Old Boy--Quiz Case [Off-Center Fold] Confluent Scaly Erythematous Plaques on the Trunk of a 16-Year-Old Boy--Diagnosis [Off-Center Fold] The Whiteboard Marker as a Useful Tool for the Dermoscopic "Furrow Ink Test" [Research Letters] No Biopsy Needed for Eclipse and Cockade Nevi Found on the Scalps of Children [Research Letters] Linking Publication About Efalizumab Effectiveness With Safety Concerns [Correspondence] Leukonychia Related to Vorinostat [Correspondence] Cutaneous Epidermal Cysts as a Presentation of Gorlin Syndrome [Correspondence] Volunteering With Health Volunteers Overseas [Announcement]
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Health Insurance
Your health insurance policy lists a package of medical benefits such as tests, drugs and treatment services. The insurance company agrees to cover the cost of certain benefits listed in your policy.
Everyone’s different. That's why Online-Insurance-Advisor has a huge range of health cover options – you’ll find the right level of hospital, extras or package cover for you, your partner and family here. Worlds Best PharmacyThe name says it all. This is the best online pharmacy on the web. The index page is set to show the most polular ED products, while the menu and quicksearch allow to find products in other categories. Indian MedsA most recent indian-themed, ethnic site. Includes generic and original (brand) products. al our standard navigational tools and support options are available. This site converts nicely on general pharmaceutical traffic as it has products for vurtually any need. Health Insurance Quote health insurance quote california health insurance quote free health insurance quote health insurance online quote individual health insurance quote health insurance quote texas florida health insurance quote instant online health insurance quote family health insurance quote health care insurance quote instant health insurance quote arizona health insurance quote cheap health insurance quote small business health insurance quote affordable health insurance quote illinois health insurance quote arizona free health insurance quote health and medical insurance quote california health insurance online quote affordable individual health insurance quote private health insurance quote health insurance quote wisconsin california group health insurance quote california individual health insurance quote health insurance quote georgia missouri health insurance quote individual health insurance quote online self employed health insurance quote health insurance ohio quote free health insurance quote texas california life and health insurance quote health and life insurance quote online health insurance quote for child colorado health insurance quote affordable family health insurance quote health insurance life quote health insurance low cost health insurance family health insurance health insurance quote affordable health insurance texas health insurance california health insurance individual health insurance health insurance company florida health insurance short term health insurance health and dental insurance health insurance illinois health insurance houston cheap health insurance health insurance coverage student health insurance health insurance dallas temporary health insurance child health insurance health insurance chicago health insurance lead private health insurance free health insurance arizona health insurance health insurance indianapolis health insurance las vegas health insurance jacksonville health insurance in california health insurance nashville health insurance miami health insurance philadelphia affordable california health insurance health insurance new york long term care health insurance health insurance provider health insurance cincinnati medical health insurance california individual health insurance north carolina health insurance health insurance atlanta health insurance pittsburgh health insurance dayton health insurance greenville health insurance orlando oxford health insurance health insurance new orleans health insurance online health insurance denver michigan health insurance ohio health insurance personal health insurance health insurance indiana free health insurance quote online health individual insurance quote texas california family health insurance quote affordable health insurance quote online florida health insurance instant quote indiana health insurance quote free instant health insurance quote california free health insurance quote student health insurance quote health insurance quote short term michigan health insurance quote minnesota health insurance quote dental health insurance quote health insurance quote virginia best health insurance quote california cheap health insurance quote north carolina health insurance quote california care health insurance quote southern california individual health insurance quote health insurance quote new jersey personal health insurance quote low cost health insurance quote illinois affordable health insurance quote oregon health insurance quote instant health insurance quote california health insurance quote tennessee |
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