Journal of Cutaneous Medicine and Surgery

Radiation-induced angiosarcoma after conservative treatment of breast cancer affects a small percentage of patients but has a significant impact on survival. Early detection requires a high index of suspicion and is important for optimal management of this aggressive disease.

The patient reported here presented with radiation-induced angiosarcoma of the left breast 14 years after radiation therapy. Histopathology was positive for anti-CD31, anti-CD34, D2-40, and anti–factor VIII (von Willebrand). She underwent a total mastectomy and is still in remission 20 months later. The authors present a review of the clinical presentation, diagnostic methods, and treatment options.

This case report demonstrates the importance of long-term follow-up and investigation of even the subtlest cutaneous changes in the breast after radiation treatment, because radiation-induced angiosarcoma is a very aggressive disease that could benefit from early diagnosis and management.

Chronic spontaneous urticaria (CSU) is a skin disorder that is said to be “frustrating” and “difficult to treat.” It is characterized by recurrent hives for more than 6 weeks, and is further divided into spontaneous or inducible by physical stimuli.¹ To better understand dermatologists’ perspective of this disorder, a survey was conducted with Canadian dermatologists.

A detailed online practice survey was sent to all currently practicing Canadian dermatologists.

In all, 80 responses were received (response rate of 20%). Most respondents in Canada had treated patients with CSU (98.4%), with many of the patients having the disease last over 6 months (86.6%). A majority of the patients were female, with 84.1% of the respondents having over 50% of their patients as female. Most patients were over the age of 30 (74.2%). Of dermatologists, 85.7% felt that investigations were unhelpful in diagnosing CSU in a patient. Of respondents, 37.1% were not satisfied with current treatment methods of CSU, and 43.6% somewhat satisfied. Popular therapies included H1 and H2 antihistamines, oral corticosteroids, and montelukast. There were 16.1% of dermatologists who had over 50% of their patients refractory to treatment.

There was a clear demographic preponderance for CSU patients with a majority as female over age 30. Investigations ordered for CSU patients do not seem to be helpful among dermatologists. Satisfaction with current therapies and investigations was quite low among Canadian dermatologists, suggesting new therapies are indicated.

Apremilast is an oral phosphodiesterase 4 inhibitor that has been approved as monotherapy for the treatment of moderate to severe chronic plaque psoriasis. No data exist on the safety or efficacy of apremilast as a component of combination therapy with either phototherapy or conventional systemic or biological therapies.

To evaluate the short term-efficacy and safety of apremilast in combination with at least one form of photo-, systemic, or biologic therapy in the treatment of chronic plaque psoriasis.

A retrospective chart review was conducted for patients who received apremilast in addition to systemic, biologic, or phototherapy. The primary outcome was the proportion of patients achieving at least 75% improvement in Psoriasis Area and Severity Index score (PASI-75).

A total of 81 patients with plaque psoriasis were treated with apremilast in combination with at least 1 other therapy (NB-UVB, methotrexate, acitretin, cyclosporin, etanercept, adalimumab, infliximab, or ustekinumab). Fourteen patients (17%) discontinued treatment before completion of 12 weeks of apremilast therapy. Sixty-seven patients continued on drug past 12 weeks. Of these patients, 81% achieved PASI-75 at week 12 after apremilast was added to an existing therapy. Nausea and/or diarrhea were reported in 25% of these patients, and weight loss was observed in 15%.

Apremilast can be safely and effectively combined with phototherapy, systemic, and/or biological agents in patients with plaque psoriasis not responding adequately to these agents alone. Gastrointestinal side effects were manageable in the majority of patients.

There are no current instruments to facilitate population screening for rosacea.

To develop and evaluate a screening instrument for rosacea applicable for population surveys.

A rosacea-specific screening instrument (Rosascreen), consisting of a subject-completed questionnaire and screening algorithm, was developed based on current diagnostic criteria for rosacea. Three iterations were pilot tested and refined for clarity and sensitivity in adult outpatients with and without rosacea.

Three subject groups were consecutively evaluated with iterations of the questionnaire at each centre (overall N = 121). The final version had a sensitivity of 93% to 100% for key diagnostic criteria, and use of the algorithm had a sensitivity of 100% for detection of rosacea and specificity of 63% to 71%. Most subjects found the questionnaire easy to understand and complete.

Rosascreen, a subject-completed questionnaire and diagnostic algorithm, is a highly sensitive screening instrument that may facilitate estimation of rosacea prevalence in general populations.

Contact dermatitis to personal sporting equipment in youth is poorly studied.

To review the results of patch testing 6 youth to their sporting equipment in a dermatology general private practice from 2006 to 2011.

A retrospective analysis of 6 youth aged 11 to 14 who were evaluated for chronic and persistent dermatitis occurring in relation to sports equipment was conducted. All patients were subjected to epicutaneous (patch) testing, which included some or all of the following: North American Contact Dermatitis Group (NACGD) series, textile series, rubber series, corticosteroid series, and raw material from the patients’ own personal equipment.

All cases had 1 or more positive patch test reactions to an allergen within the aforementioned series, and 3 subjects tested positive to their personal equipment in raw form.

Allergic contact dermatitis, not irritant, was deemed the relevant cause of chronic dermatitis in 4 of the 6 patients due to positive reactions to epicutaneous tests and/or personal equipment. The utility of testing to patients’ own sporting equipment was shown to be of additional value and should be considered when patch testing for contact allergy to sporting equipment.

Psoriasis is known to be associated with metabolic syndrome, a well-established risk factor for ischemic heart disease and stroke. Emerging evidence indicates that psoriasis is an independent risk factor for cardiovascular disease and stroke.

To evaluate whether psoriasis is independently associated with myocardial infarction (MI), ischemic heart disease (MI, angina pectoris, or coronary heart disease), and stroke, we conducted a cross-sectional study using the US National Health and Nutrition Examination Survey (NHANES) database.

Data on clinical history of psoriasis, MI, angina pectoris, coronary heart disease, and stroke from the questionnaire as well as laboratory parameters on serum lipid and uric acid levels in the cycle years 2003-2006 and 2009-2012 were analyzed. Multivariate analysis with logistic regression modelling was performed with the aforementioned cardiovascular events or stroke as the dependent variables and with risk factors such as age, gender, ethnic group, current smoking status, alcohol consumption, metabolic syndrome, hyperuricemia, and psoriasis as independent variables.

There were 520 cases of psoriasis, and 108 of them had metabolic syndrome (20.8%). Well-established cardiovascular risk factors such as age, gender, ethnic group, smoking, alcohol consumption, metabolic syndrome, and hyperuricemia were also found to have significant associations with MI and ischemic heart disease (all P values <.001). Psoriatic patients were at significantly higher risks of developing MI (odds ratio [OR] 2.24; 95% CI: 1.27-3.95; P = .005) and ischemic heart disease (OR 1.90; 95% CI: 1.18-3.05; P = .008), but not stroke (OR 1.01; 95% CI: 0.48-2.16; P = .744), after adjustment was made for major cardiovascular risk factors.

This study provides epidemiological evidence that psoriasis may be independently associated with the development of MI and ischemic heart disease. Physicians should be cognizant of any underlying cardiovascular risk factors, especially among psoriatic patients with metabolic syndrome, and manage them according to national guidelines.

Reed’s syndrome, also known as hereditary leiomyomatosis and renal cell cancer (HLRCC) syndrome, is an autosomal dominant condition in which affected individuals may develop cutaneous leiomyomas, uterine fibroids, and renal cell carcinoma.

This report describes a unique case of HLRCC because it presented in pregnancy with development of cutaneous pilar leiomyomas.

Review of the literature for previous cases of Reed’s syndrome during pregnancy including PubMed and Medline search.

Genetic testing of this patient demonstrated a mutation in the fumarate hydratase (FH) gene. Review of the literature showed only 1 previous case series that described the onset of cutaneous lesions during pregnancy.

This case serves as a reminder that there may exist a correlation between pregnancy and the first manifestation of cutaneous lesions in patients with HLRCC, and thus an increased clinical suspicion is warranted during this period.

While clinical symptoms of strongyloidiasis are often nonspecific, larva currens (with erythematous, serpiginous, and pruritic papules and plaques) should prompt investigation including stool microscopy, serology, and skin biopsy of the lesion. Appropriate diagnosis and treatment with ivermectin is necessary, especially in the immunocompromised patient who is at increased risk for hyperinfection syndrome and disseminated disease.

We present a 61-year-old immunocompromised man with presentation of larva currens of cutaneous strongyloides infection without symptoms of hyperinfection or disseminated disease.

Hyper–immunoglobulin E syndrome (HIES) is a rare primary immunodeficiency disorder that affects multiple systems. One of the early findings is a papulopustular rash, which has a wide differential diagnosis.

The authors report the case of a male newborn diagnosed with HIES. He presented with papulopustular dermatitis on the scalp. The authors also present a review of current theory on the pathophysiology, clinical presentation, and management of HIES.

Although HIES is a multisystem disorder, many of the manifestations of HIES may present after the neonatal period. The cutaneous manifestations of HIES are usually present shortly after birth, and the presentation of pustules in a newborn may be one of the reasons a dermatologist would be asked to assess a patient in the neonatal period.

Optimal aesthetic results are achieved when nasal defects after Mohs micrographic surgery (MMS) are reconstructed as entire nasal subunits.

To illustrate the importance of reconstructing the nose in entire subunits and explore the possibilities of expanding the principles of subunit reconstruction to the concept of subunit Mohs excision.

An 83-year-old man presented for MMS to excise 3 lesions on the nasal ala. The surgeons elected to excise and reconstruct the entire subunit.

Excellent aesthetic and functional results were obtained.

When a defect greater than 50% of a nasal subunit is encountered during MMS, immediate marginal control excision of the entire subunit can be performed with subsequent reconstruction. This technique ultimately has the potential to deliver a more aesthetically pleasing outcome and should be, at the very least, considered by all Mohs surgeons.

Pruritus is a frequent occurrence in dermatology, and investigation is often unrevealing. The authors report the case of a 65-year-old man presenting with generalized recalcitrant pruritus as the presenting manifestation of hypereosinophilic syndrome.

A 65-year-old man developed intractable pruritus. Results of polymerase chain reaction clonal rearrangement were positive and led to the diagnosis and treatment. The patient also developed massive pulmonary embolism, which can be caused by chronic eosinophilia.

This case highlights the importance of investigating patients with pruritus and unexplained persistent eosinophilia. Hypereosinophilic syndrome must be included in the differential diagnosis, which in this case presented initially as intractable pruritus. Polymerase chain reaction clonal rearrangement was key in reinforcing the diagnosis.

Lipodystrophia centrifugalis abdominalis infantilis (LCAI) is an uncommon dermatological condition characterized by a centrifugally expanding area of lipoatrophy involving the lower abdominal area and is frequently associated with inguinal lymphadenopathy. The average age of onset is 4 years and female individuals from Japan, China, and Korea are affected more often.

To report the first case of LCAI in a Vietnamese patient.

A complete clinical assessment was done and a biopsy from the affected area was performed.

There was an atrophic, slightly hyperpigmented patch at the lower abdomen with prominent underlying vasculature. Inguinal lymphadenopathy was noted on the ipsilateral side. A biopsy showed a lobular panniculitis with fat necrosis and lymphohistiocytic infiltrate with scattered plasma cells and multinucleated giant cells.

To our knowledge, this is the first reported case of LCAI in a Vietnamese patient.

Previous reports have shown inconsistent findings with regard to the relationship between biologic therapy and risk for major adverse cardiovascular events (MACEs).

The aim of this study was to determine the overall rate of MACEs in a cohort of 398 patients.

All patients treated with biologics for psoriasis at 2 academic centers in Toronto, Ontario, between September 2005 and September 2014 were considered for inclusion. Medical records were reviewed to identify MACEs.

A total of 398 patients were included. The median duration of disease was 19.8 years. Median time to biologic therapy withdrawal because of an adverse event was 23.5 months. In this cohort, no MACEs were identified in patients treated with biologic therapy.

Biologic treatment for psoriasis was not associated with increased cardiovascular risk in this cohort. These results require validation in larger studies.