Design  Retrospective cohort of patients exposed to gadolinium-based contrast agents (GBCAs) at a single institution during an 8-year period (January 1, 1999, to December 31, 2006), and a case series study of patients with biopsy-proven NSF.

Setting  A primary, secondary, and tertiary health care center that treated more than 2.2 million outpatients and had 135 000 hospital admissions in 2007.

Patients  A total of 94 917 patients exposed to GBCAs; patients at risk for NSF (3779 patients on hemodialysis, 1694 patients with renal transplants, and 717 patients with liver transplants, a well-defined subgroup that includes patients at risk for reduced renal function); and 61 patients with a clinical diagnosis of NSF.

Main Outcome Measure  Risk estimate for NSF.

Results  The risk of development of NSF is 1.0% for patients who undergo hemodialysis (8 of 827), 0.8% for patients with renal transplantation (4 of 527), and 0% for patients with liver transplantation at our institution (0 of 327).

Conclusions  Despite the limitations, this study, which reviewed a large number of patients who underwent intravascular GBCA injections, demonstrates a 77-fold higher risk of NSF among patients who undergo hemodialysis and a 69-fold higher risk in patients with renal transplantation. This increased risk is thought to be associated with poor clearance of most GBCAs.

Design  Prognostic study of an inception cohort.

Setting  Academic research.

Patients  Between July 1, 1999, and July 31, 2002, all patients who had primary cutaneous or mucosal melanomas that have a Breslow depth of 1.5 mm or greater, ulceration, or Clark level IV or V, or had SLN biopsies.

Main Outcome Measures  By the use of quantitative reverse transcription–polymerase chain reaction, the expression of the following was analyzed in SLNs: 2 melanocytic differentiation antigens (tyrosinase [P17646] and melanoma antigen recognized by T cells [MART-1; Q16655]) and genes involved in angiogenesis (VEGF [NM_001025366] and VEGFR2 [AF035121]), lymphangiogenesis (VEGFC [NM_005429], VEGFR3 [X68203], LYVE1 [NM_016164], and PROX1 [002763]), and invasion (uPA [NM_002658], PAI1 [NM_00602], and EMMPRIN [L10240]). Outcome measures were the association of these melanocytic differentiation antigens and angiogenesis biomarkers with clinicopathologic characteristics of patients, and an evaluation of the prognostic value for relapse-free survival and overall survival.

Results  Ninety-one patients were included, with a median follow-up period of 41 months. Micrometastases were present in 15% (14 of 91) of patients. Tyrosinase (P < .001), MART-1 (P < .001), vascular endothelial growth factor 121 (VEGF₁₂₁) (P = .007), and PAI1 (P = .02) expression was significantly associated with micrometastasis. In univariate analysis, histologic findings and tyrosinase and MART-1 expression were significantly associated with relapse-free survival. Tyrosinase and MART-1 expression was associated with overall survival. A multiple Cox proportional hazards regression model identified negative histologic findings and tyrosinase expression that exceeded 27 copies/copy of TATA box-binding protein (third quartile) as significantly associated with an increased risk of relapse or death.

Conclusions  Quantitative assessment of melanocytic differentiation antigens in SLNs, which has prognostic value, is more specific than qualitative assessment. Prognosis may be more effectively predicted by the combination of quantitative assessment of melanocytic differentiation antigens in SLNs with histologic assessment. A significant association was found between the presence of micrometastases and the expression of angiogenesis biomarkers.

Design  Biochemical analyses of human skin biopsy specimens following microdermabrasion treatment in vivo.

Setting  Academic referral center.

Participants  Volunteer sample of 40 adults, aged 50 to 83 years, with clinically photodamaged forearms.

Intervention  Focal microdermabrasion treatment with diamond-studded handpieces of varying abrasiveness on photodamaged forearms and serial biopsies at baseline and various times after treatment.

Main Outcome Measures  Quantitative polymerase chain reaction, immunohistochemistry, and enzyme-linked immunosorbent assay were used to quantify changes in inflammatory, proliferative, and remodeling effectors of normal wound healing. Type I and type III procollagen served as the main outcome marker of dermal remodeling.

Results  Coarse-grit microdermabrasion induces a wound healing response characterized by rapid increase in induction of cytokeratin 16 and activation of the AP-1 transcription factor in the epidermis. Early inflammation was demonstrated by induction of inflammatory cytokines, antimicrobial peptides, and neutrophil infiltration in the dermis. AP-1 activation was followed by matrix metalloproteinase–mediated degradation of extracellular matrix. Consistent with this wound-healing response, we observed significant remodeling of the dermal component of the skin, highlighted by induction of type I and type III procollagen and by induction of collagen production enhancers heat shock protein 47 and prolyl 4-hydroxylase. Dermal remodeling was not achieved when microdermabrasion was performed using a medium-grit handpiece.

Conclusions  Microdermabrasion using a coarse diamond-studded handpiece induces a dermal remodeling cascade similar to that seen in incisional wound healing. Optimization of these molecular effects is likely the result of more aggressive treatment with a more abrasive handpiece.

Trial Registration  clinicaltrials.gov Identifier: NCT00111254

Design  Retrospective survey.

Setting  Academic pediatric dermatology practice.

Patients  Three hundred seventy-four patients with alopecia referred from July 1, 1997, to June 31, 2007.

Main Outcome Measures  Epidemiologic data for all forms of alopecia were ascertained, such as sex, age at onset, age at the time of evaluation, and clinical diagnosis. Patients with LAHS were further studied by the recording of family history, disease associations, hair-pull test or biopsy results, hair color, laboratory test result abnormalities, initial treatment, and involvement of eyelashes, eyebrows, and nails.

Results  Approximately 10% of all children with alopecia had LAHS. The mean age (95% confidence interval) at onset differed between patients with LAHS (2.8 [1.2-4.3] years) vs patients without LAHS (7.1 [6.6-7.7] years) (P < .001), with 3 years being the most common age at onset for patients with LAHS. All but 1 of 37 patients with LAHS were female. The most common symptom reported was thin, sparse hair. Family histories were significant for LAHS (n = 1) and for alopecia areata (n = 3). In 32 of 33 patients, trichograms showed typical loose anagen hairs. Two children had underlying genetic syndromes. No associated laboratory test result abnormalities were noted among patients who underwent testing.

Conclusions  Loose anagen hair syndrome is a common nonscarring alopecia in young girls with a history of sparse or fine hair. Before ordering extensive blood testing in young girls with diffusely thin hair, it is important to perform a hair-pull test, as a trichogram can be instrumental in the confirmation of a diagnosis of LAHS.

Design  Survey of residents in November 2003.

Setting  Four US residency programs.

Participants  Medical residents in family medicine, pediatrics, obstetrics and gynecology, and internal medicine and specialists.

Main Outcome Measure  Proportion of residents reporting their current skill level for the performance of the SCE.

Results  Of 454 surveys distributed, 342 residents completed the survey (75.3% response rate). Clinical training for the SCE during residency was infrequent. During residency, 75.8% were never trained in the SCE, 55.3% never observed an SCE, and 57.4% never practiced the examination. Only 15.9% of residents reported being skilled in the SCE. However, the conduct of 4 SCEs (or slightly more than 1 per each year of residency) was associated with manifold increases in self-reported skill levels.

Conclusions  Information now collected from 7 medical schools and 4 residency programs underscores the need for more supervised opportunities to enable physicians in training to perform an SCE during routine patient examinations.

Design  A dedicated Web platform was developed to train the participants and to allow independent distant evaluations of confocal images via the Internet.

Setting  Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy.

Participants  The study population was composed of 15 melanomas, 30 nevi, and 5 Spitz/Reed nevi. Six expert centers were invited to participate at the study.

Intervention  Evaluation of 36 features in 345 confocal microscopic images from melanocytic lesions.

Main Outcome Measure  Interobserved and intraobserved agreement, by calculating the Cohen statistics measure for each descriptor.

Results  High overall levels of reproducibility were shown for most of the evaluated features. In both the training and test sets there was a parallel trend of decreasing values as deeper anatomic skin levels were evaluated. All of the features, except 1, used for melanoma diagnosis, including roundish pagetoid cells, nonedged papillae, atypical cells in basal layer, cerebriform clusters, and nucleated cells infiltrating dermal papillae, showed high overall levels of reproducibility. However, less-than-ideal reproducibility was obtained for some descriptors, such as grainy appearance of the epidermis, junctional thickening, mild atypia in basal layer, plump bright cells, small bright cells, and reticulated fibers in the dermis.

Conclusion  The standard consensus confocal terminology useful for the evaluation of melanocytic lesions was reproducibly recognized by independent observers.

Observation  In this particular case, MDCT venography demonstrated the origin, course, and relationship to adjacent anatomical structures of aberrant vessels that configure the superficial venous system with an anatomically normal and patent deep venous system. At the end of the treatment, which consisted of 8 sessions of microfoam sclerotherapy within 12 months, a considerable reduction in the number and size of the percutaneously treated aberrant veins was observed. The obvious clinical improvement was objectively demonstrated with MDCT venography, which showed clear reduction in the number and size of treated veins. Further clinical investigation performed because of isolated migraine episodes related to the sclerotherapy session revealed that the patient had a patent foramen ovale. A transcranial Doppler examination during the procedure showed middle cerebral artery bubbles, which indicated right-to-left shunt. No cerebral damage was observed in a subsequent diffusion-weighted magnetic resonance examination.

Conclusions  Microfoam sclerotherapy is an effective treatment option in patients with Klippel-Trenaunay syndrome. MDCT venography allows diagnosis of the disease, planning of therapy, and assessment of response to treatment. Although foam-induced microembolism is a common phenomenon during sclerotherapy, in this report we demonstrate that polidocanol microfoam prepared with a low-nitrogen gas mixture is safe in a patient with a patent foramen ovale.

Observations  Of 27 patients diagnosed as having adenosquamous carcinoma, 19 were men and 5 were immunosuppressed. The mean age was 74 years. The majority of tumors were located on the face and scalp (19 of 27 [70%]) or upper extremity (4 of 27 [15%]). Squamous and glandular differentiation was characteristic. Thickness of the primary lesion ranged from 1.2 to 9.2 mm, with all tumors extensively invading the reticular dermis. Perineural invasion was seen in 4 of 27 primary cases (15%). Although 3 of 6 patients treated with Mohs micrographic surgery had subsequent locoregional recurrences, there was no evidence of distant metastasis after a mean of 2.3 years of patient follow-up.

Conclusions  Adenosquamous carcinoma is best considered as a locally aggressive high-risk subtype of cutaneous squamous cell carcinoma. Tumor thickness and perineural invasion are high-risk histopathological attributes, and immunosuppression is an important clinical risk factor. Although Mohs micrographic surgery may be the best initial treatment, locoregional recurrence is common.

Observations  We describe a 94-year-old woman with IgA pemphigus with a unique immunopathologic pattern. Direct immunofluorescence microscopy revealed IgA deposits throughout the entire epidermis, with stronger staining in the upper epidermis. The autoantibodies from this patient did not show IgA or IgG reactivity with desmogleins via immunoblotting or enzyme-linked immunosorbent assay. By indirect immunofluorescence by the use of COS7 cells transfected with desmocollin 1, 2, or 3, IgA autoantibodies in a serum sample from our patient clearly reacted with all of them.

Conclusions  The pathophysiology and autoantigen profile of bullous autoimmune diseases, especially pemphigus and its subforms, are more complex than previously believed. Because pemphigus seems to be a heterogeneous disorder, further studies are needed to evaluate the complexity of the disease.

Observations  Findings from polymerase chain reaction and high-resolution capillary electrophoresis for T-cell receptor gene rearrangement analysis showed that all 6 prospectively evaluated patients (100%) with nephrogenic systemic fibrosis had detectable clonal T cells in their peripheral blood. In contrast, only 4 of the 15 control patients (27%) with chronic renal failure and none of the 12 healthy individuals analyzed in this study had evidence for T-cell clonality using the same type of examination. Clonal T-cell–positive patients with systemic sclerosis have previously been reported to better respond to extracorporeal photopheresis. However, this was not the case in 2 of our patients with nephrogenic systemic fibrosis.

Conclusion  As in systemic sclerosis, clonally expanded T-cell populations could play a critical role in the pathogenesis of nephrogenic systemic fibrosis, probably as an in vivo–activated inflammatory response to gadolinium exposure.

Observations  Four patients with NSF were treated with UV-A1 phototherapy at a tertiary medical center from 2005 through 2007. To our knowledge, it is unique to this series that all patients were receiving hemodialysis before, during, and after therapy with UV-A1. All experienced improvement in the degree of induration, and 2 experienced improvement in mobility of the hands and legs. Total treatments ranged from 22 treatments (with a cumulative dose of 1855 J/cm²) to 50 treatments (total UV-A1 exposure, 3850 J/cm²). No adverse events were observed.

Conclusions  Although no patient had complete resolution of indurated plaques, the improvement was substantial. For 2 patients, it resulted in a resumption of hand and leg mobility. As a result, UV-A1 therapy may represent a treatment for NSF when kidney transplantation is not an option or is delayed. Limitations of this study include the lack of a controlled trial, lack of quantification of gadolinium levels within tissue, and the lack of a defined grading scale for NSF severity.

Design  Prospective cohort nested within a randomized controlled trial. Skin examinations in 3 consecutive years (2004, 2005, and 2006) included full-body counts of nevi, skin color and tanning measurement using colorimetry, and hair and eye color evaluation by comparison with charts. Telephone interviews of parents provided sun exposure, sun protection, and sunburn history.

Setting  Large managed-care organization and private pediatric offices in the Denver, Colorado, metropolitan area.

Participants  A total of 131 very-light-skinned white children without red hair and 444 darker-skinned white children without red hair born in Colorado in 1998.

Main Outcome Measures  Full-body nevus counts at ages 6 to 8 years.

Results  Among very-light-skinned white children, geometric mean numbers of nevi for minimally tanned children were 14.8 at age 6 years; 18.8 at age 7 years; and 22.3 at age 8 years. Mean numbers of nevi for tanned children were 21.2 at age 6 years; 27.9 at age 7 years; and 31.9 at age 8 years. Differences in nevus counts between untanned and tanned children were statistically significant at all ages (P < .05 for all comparisons). The relationship between tanning and number of nevi was independent of the child's hair and eye color, parent-reported sun exposure, and skin phototype. Among darker-skinned white children, there was no relationship between tanning and nevi.

Conclusions  Very-light-skinned children who tan (based on objective measurement) develop more nevi than children who do not tan. These results suggest that light-skinned children who develop tans may be increasing their risk for developing melanoma later in life.

Design  Cross-sectional study.

Setting  United States.

Participants  Employees of 3647 indoor tanning facilities were contacted by telephone. Data collectors (ie, confederates) posed as prospective, fair-skinned, 15-year-old female customers who had never tanned before.

Main Outcome Measures  Confederates asked respondents about their facility's practices related to parental consent, parental accompaniment, and allowable tanning session frequency.

Results  Approximately 87% of the facilities required parental consent, 14% required parental accompaniment, 5% said they would not allow the confederate to tan owing to her age, and 71% would allow tanning every day the first week of indoor tanning. In Wisconsin, which bans indoor tanning among those younger than 16 years, 70% of facilities would not allow the confederate to tan. Multivariate analyses indicated that facilities in states with a youth access law were significantly more likely to require parental consent (P <.001) and parental accompaniment (P <.001) than those in states without a youth access law. Law was not significantly related to allowable tanning frequency (P = .81).

Conclusion  We recommend that additional states pass youth access legislation, preferably in the form of bans.

Design  Retrospective population-based analysis.

Setting  Mortality records from the Centers for Disease Control and Prevention mortality database.

Participants  Mortality records from 1979 through 2002 for persons who died of bullous disease.

Main Outcome Measures  Age-adjusted mortality rates and trends for 4 bullous disease subgroups: toxic epidermal necrolysis, pemphigoid, pemphigus, and epidermolysis bullosa.

Results  The overall age-adjusted (to the 2000 US standard population) annual mortality rate from bullous diseases of the skin was 0.103 death per 100 000. The average mortality from bullous disorders was 0.098 per 100 000 in 1979 through 1982 and remained stable at 0.099 per 100 000 during the final 4 years of the study, 1999 through 2002. Pemphigoid had a significant increase in mortality from 1979 through 2002, while pemphigus demonstrated a significant decrease in mortality. The mortality rate for toxic epidermal necrolysis was much higher among blacks (0.192 death per 100 000) than whites (0.025 per 100 000) (P < .001), with a mortality rate ratio of 7.57 (95% confidence interval, 6.97-8.21).

Conclusions  Overall mortality from bullous diseases remained stable from 1979 through 2002, although an increasing mortality from pemphigoid and a decreasing mortality from pemphigus occurred during this period. A very large racial disparity in mortality from toxic epidermal necrolysis was observed.

Design  Prospective multicenter case-control study.

Setting  Three French university hospitals.

Patients  One hundred eight patients with LE and 216 control subjects.

Intervention  Standardized questionnaire evaluating cigarette smoking and alcohol consumption.

Main Outcome Measures  The statistical significance of smoking history and alcohol consumption as associated risk factors for LE by estimating matched case-control odds ratios and their 95% confidence intervals, using multiple conditional logistic regression and the Breslow-Day test to investigate differences in quantities of cigarette and alcohol consumption.

Results  Of the LE patients, 73.1% smoked compared with 49.5% of controls, (odds ratio, 2.77; 95% confidence interval, 1.63-4.76). There was no significant difference in alcohol consumption between LE patients and controls. Among the 79 LE patients who smoked, 72 (91.1%) had started smoking before the first manifestation of LE (mean delay between initiation of smoking and first signs of LE, 14.1 years). The LE patients smoked significantly more than controls did (11.7 vs 7.0 pack-years; P = .002). The prevalence of smoking among patients who met more than 4 American College of Rheumatology (ACR) criteria and/or with antinuclear DNA antibodies was lower than the prevalence in patients who met fewer than 4 ACR criteria or than the prevalence in controls (P < .001).

Conclusions  Cigarette smoking is associated with LE, but alcohol consumption is not. The risk conferred by cigarette smoking seems highest in patients who meet fewer than 4 ACR criteria and/or who do not have antinuclear DNA antibodies.

Design  Cross-sectional study.

Setting  Dermatology outpatient clinic of a university hospital.

Participants  Of 120 patients with morphea or eosinophilic fasciitis diagnosed between December 1, 1994, and July 15, 2007, who were enrolled in the study, only 74 completed questionnaires were suitable for data analysis.

Main Outcome Measures  Self-reported responses on the Impact of Chronic Skin Diseases on Daily Life scale measure psychological distress, specifically anxiety and depressed mood.

Results  Psychological functioning was generally impaired in patients with skin disease, particularly among patients with generalized morphea and eosinophilic fasciitis. Twenty-eight patients (38%) were at risk of depression or anxiety. Higher levels of psychological distress were significantly related to greater severity of skin disease; more pain and fatigue; impact of disease on daily life; more perceived stigmatization; illness cognitions of greater helplessness; and less acceptance and less perceived social support.

Conclusions  Physical and psychosocial aspects play a substantial role in the quality of life for patients with morphea. Physicians should be encouraged to assess the physical and psychosocial factors when treating patients with sclerotic skin diseases. This approach could improve quality of life and ultimately lead to improved dermatological treatment outcomes.

Observation  We describe a 17-year-old Afghani girl who had lived in the United States for 4 years and who presented with a 6-month history of pretibial ulcerations, 9.1-kg weight loss, abdominal pain, splenomegaly, and extreme fatigue. Histopathologic examination and culture with isoenzyme electrophoresis speciation of her skin lesions confirmed the presence of L tropica. In addition, results of serum laboratory and serological studies were highly suggestive of concomitant visceral involvement. The patient was treated with a 28-day course of intravenous pentavalent antimonial compound sodium stibogluconate with complete resolution of her systemic signs and symptoms and improvement of her pretibial ulcerations.

Conclusions  This is an exceptional case in that our patient presented with disease after an incubation period of years rather than the more typical weeks to months. In addition, this patient had confirmed cutaneous involvement, as well as strong evidence of viscerotropic disease caused by L tropica, a species that characteristically displays dermotropism, not viscerotropism.

Observations  Products containing benzoyl peroxide produced an orange-brown discoloration when mixed with either sulfacetamide or dapsone.

Conclusions  Knowledge of the chemical reaction between benzoyl peroxide and sulfacetamide and dapsone will help minimize the occurrence of this interaction on our patients' skin.

Observations  We describe 2 patients with drug-induced hypersensitivity syndrome (one end of a spectrum of severe drug eruptions) who subsequently developed cutaneous CMV ulcers at unusual sites, such as the trunk; this occurrence was immediately followed by gastrointestinal manifestations, which were fatal in 1 patient. To identify factors predictive of CMV disease, we retrospectively investigated the prevalence of CMV reactivation during drug-induced hypersensitivity syndrome in 18 patients. In this analysis, patients were divided into 2 groups depending on the positivity of CMV DNA in the blood.

Conclusions  Older and male patients with antecedent high human herpesvirus 6 DNA loads are at risk for CMV disease irrespective of corticosteroid administration. A rapid reduction in white blood cell numbers is also predictive of the onset of CMV disease.

Data Sources  Bibliographical searches were conducted in the MEDLINE, EMBASE, and China National Knowledge Infrastructure (CNKI) databases without any language limitations.

Study Selection  Studies were selected when the following criteria were met: the coexistence of a study group and a control group, the reliable and nonselective use of the reference standards for the diagnosis of LP and HCV, and the proportion of events (the prevalence of HCV in patients with LP or the prevalence of LP in patients with HCV).

Data Extraction  Three investigators independently assessed abstracts for relevant studies, and 2 investigators independently reviewed all eligible studies.

Data Synthesis  Sixty-three articles entailing 7 studies were included in the meta-analysis. For the primary outcome of prevalence of events, the meta-analysis showed that there existed an important association between HCV and LP. In the comparison of the prevalence of HCV exposure among patients with LP with that of control participants, the odds ratio (OR) was 5.4 (95% confidence interval [CI], 3.5-8.3); in the prevalence of LP among patients with HCV compared with the prevalence among control participants, the OR was 2.5 (95% CI, 2.0-3.1). The subgroup analyses with geographical stratification did not show a significant association in studies from South Asia (P = .21), Africa (P = .15), and North America (P = .09), and the subgroup analyses from stratification by LP type also did not show a significant association in the isolated cutaneous type (P = .17). When strict criteria were applied, the results of sensitivity analysis remained robust.

Conclusion  Hepatitis C virus infection is associated with a statistically significant risk for development of LP, suggesting that the presence of either HCV or certain types of LP may be used as a predictive marker of the other in certain geographical regions.

Design  Retrospective analytical case series.

Setting  Private dermatology practice in Florida, from July 2005 through October 2008.

Patients  Patients with 126 melanomas, of which 51 were invasive and 75 were melanomas in situ.

Main Outcome Measures  Proportion of melanomas detected as a result of patient complaint vs proportion determined by dermatologist-conducted full-body skin examination (FBSE). As a secondary analysis, we used logistic regression odds ratios (ORs) of association to examine whether dermatologist detection rather than patient complaint was associated with detecting thinner melanomas. A post hoc analysis was performed using a thickness cutoff of 1.0 mm to define a deep melanoma.

Results  Overall, 56.3% (95% confidence interval [CI], 47.6%-65.1%) of melanomas were found by the dermatologist and were not part of the presenting complaint. Of melanomas in situ, 60.0% (95% CI, 48.7%-71.3%) were dermatologist detected. Dermatologist detection was significantly associated with thinner melanomas, with an OR of 0.42 (P = .04). We found a significant association between thinner melanomas as a group (thickness <1 mm) and dermatologist detection, with a logistic regression OR of 5.0 (95% CI, 1.0-25.3).

Conclusions  Most melanomas detected in a general-practice dermatology setting were found as a result of dermatologist-initiated FBSE, not patient complaint. We found that dermatologist detection was associated with thinner melanomas and an increasing likelihood of the melanoma being in situ.

Design  Population-based prospective study (Vitamins and Lifestyle [VITAL] cohort).

Setting  Western Washington State.

Participants  A total of 69 671 men and women who self-reported (1) intake of multivitamins and supplemental antioxidants, including selenium and beta carotene, during the past 10 years and (2) melanoma risk factors on a baseline questionnaire.

Main Outcome Measure  Incident melanoma identified through linkage to the Surveillance, Epidemiology, and End Results (SEER) cancer registry.

Results  Cox proportional hazards regression models were used to estimate multivariable relative risks (RRs) and 95% confidence intervals (CIs) for multivitamin, supplemental selenium, and supplemental beta carotene use. After adjusting for melanoma risk factors, we did not detect a significant association between multivitamin use and melanoma risk in women (RR, 1.14; 95% CI, 0.78-1.66) or in men (RR, 1.09; 95% CI, 0.83-1.43). Moreover, we did not observe increased melanoma risk with the use of supplemental beta carotene (RR, 0.87; 95% CI, 0.48-1.56) or selenium (RR, 0.98; 95% CI, 0.69-1.41) at doses comparable with those of the SUVIMAX study.

Conclusion  Antioxidants taken in nutritional doses do not seem to increase melanoma risk.

Design  Retrospective study of patients seen between the years 2004 and 2007.

Setting  Tertiary care neurofibromatosis referral clinic at St Louis Children's Hospital.

Patients  The study population comprised 110 patients who presented with CALMs and no other diagnostic features of NF1. The median number of CALMs at initial presentation was 6, while the median age of the patients was 33 months. The median age at the last follow-up examination was 76.5 months.

Main Outcome Measures  Number and morphologic appearance of CALMs and diagnosis of NF1.

Results  Thirty-four of the children met diagnostic criteria for NF1 during the study period. Thirty-two children met criteria prior to age 72 months, and 2 children met criteria after 72 months. The mean number of CALMs at presentation in children eventually diagnosed as having NF1 (11.8 CALMs) was significantly higher than the mean number of CALMs in children not diagnosed as having NF1 (4.6 CALMs). Of the 44 children who had 6 or more typical CALMs at presentation, 34 children met criteria for NF1. Sixty-eight patients had CALMs described as "typical," while 42 patients had "atypical" CALMs. Only 2 patients with atypical CALMs met criteria for NF1.

Conclusion  The majority of patients with 6 or more CALMs will eventually meet diagnostic criteria for NF1, typically by age 6 years, and this likelihood increases with increasing number and typical morphologic appearance of CALMs.

Design  Retrospective inception cohort study.

Setting  Two departments in tertiary teaching hospitals.

Patients  All patients diagnosed as having dermatomyositis (DM) according to the criteria of Bohan and Peter seen during a 13-year period.

Main Outcome Measures  Cumulative incidence rates of herpesvirus infections using the Kaplan-Meier method and risk factors for herpesvirus infections during the first year of DM using Cox proportional hazards models.

Results  A total of 121 patients met the inclusion criteria (mean [SD] age, 52 [15] years; 85 were women [70%]). Seventy-six percent had primary dermatomyositis, and 24% had dermatomyositis associated with a malignant neoplasm. The mean (SD) duration of follow-up was 42 (33) months. During follow-up, 20 patients developed a total of 22 herpesvirus infections (16 developed herpes zoster infections). The incidence rates for herpesvirus and for herpes zoster infections were 49 and 33 episodes per 1000 patient-years, respectively. In multivariate analysis, a positive association was noted between the risk of herpesvirus infection and use of systemic corticosteroid therapy (hazard ratio [HR], 3.71 [95% confidence interval {CI}, 1.02-13.41]; P = .04), lymphocyte count lower than 6000/µL (HR, 3.55 [95% CI, 1.00-12.65]; P = .05), and creatine phosphokinase level higher than 300 U/L (HR, 4.81 [95% CI, 1.28-18.06]; P = .02). Dermatomyositis associated with a malignant neoplasm tended to be negatively associated with the risk of herpesvirus infection (HR, 0.16 [95% CI, 0.02-1.29]; P = .08).

Conclusions  The risk of serious herpesvirus infections in patients with DM is high. Educational strategies and studies evaluating the risk-to-benefit and the cost-to-benefit balances of a prophylaxis with valacyclovir hydrochloride in selected patients with DM are warranted.

Design  The Australian Longitudinal Study on Women's Health was designed to investigate multiple factors affecting the health and well-being of women over a 20-year period. Data from 3 surveys (conducted in 2000, 2003, and 2006) were analyzed. Multivariate longitudinal generalized estimating equation models, with and without time lag, were used to determine significant factors associated with skin disease (including anxiety, depressive symptoms, and stress).

Setting  An Australian community-based study.

Participants  Women, aged 22 to 27 years at the time of the first survey, were randomly selected from the Australian National Medicare database. Participant numbers for the surveys from the years 2000, 2003, and 2006 were 9688, 9081, and 8910, respectively.

Main Outcome Measures  Outcome measures were the scores from the Center for Epidemiologic Studies Depression Scale, the Perceived Stress Questionnaire for Young Women, and an item to elicit reporting of anxiety symptoms.

Results  Of 6630 women providing data on skin diseases on all 3 surveys, 8.0% (n = 523) reported having skin problems on all 3 occasions; 12.1% (n = 803) on 2 occasions; and 23.9% (n = 1582) on 1 occasion. On the 2000, 2003, and 2006 surveys, prevalence of skin problems was 24.2%, 23.9%, and 24.3%, respectively. In the generalized estimating equation models, depression symptoms and stress (but not anxiety) were significantly associated with skin problems (P < .005).

Conclusion  The findings of this relationship of depression and stress to skin disease may have considerable clinical implications, including implications for adjunctive psychological interventions in the management of patients with skin disease.

Observations  A 41-year-old man sought treatment for cutaneous and bone marrow sarcoidosis resulting in fatigue, anemia, and leukopenia refractory to conventional therapies and mycophenolate mofetil. We initiated combination immunosuppressive therapy with methotrexate sodium and mycophenolate mofetil, which resulted in a safe and prolonged quiescence of cutaneous disease and resolution of anemia and leukopenia throughout a 34-month follow-up period.

Conclusions  We present this case to highlight the growing body of evidence supporting combination immunosuppressive therapy to treat refractory sarcoidosis. In our patient, sarcoidal bone marrow involvement responded dramatically to a combined regimen of methotrexate and mycophenolate mofetil with no significant adverse effects, despite previously having been refractory to conventional agents and mycophenolate mofetil alone. This report provides evidence that combination immunosuppressive therapy is a potential treatment of refractory bone marrow sarcoidosis and highlights important issues about combined immunosuppressive therapy.

Observations  We describe a 39-year-old woman with XP who developed 38 primary melanomas along with 6 squamous cell carcinomas and 70 basal cell carcinomas over a 23-year period. During this time, a 3-fold management approach of total-body cutaneous examination, total-body photography, and dermoscopy was used in the care of the patient. The thickest melanoma had a Breslow thickness of 1.07 mm, and the mean Breslow thickness of her detected melanomas was 0.18 mm. The ratio of benign to malignant biopsied suspicious melanocytic lesions during 23 years of follow-up was 0.9:1. All melanomas were treated using wide local excision, and she had no evidence of local or in-transit metastases of any of her malignant neoplasms at the most recent follow-up examination.

Conclusion  Monthly follow-up using total-body cutaneous examinations, total-body photography, and dermoscopy is an important 3-fold secondary management technique for this unique patient, allowing early detection of her melanomas.

Observations  A 43-year-old woman with multiple sclerosis treated with subcutaneous interferon beta presented with right lower abdominal quadrant pain, fever, and an indurated McBurney point. An abdominal computed tomographic scan showed an inflammatory subcutaneous fat infiltration reaching the surface of the right lateral rectus muscle. The patient was brought to the operating room, where a laparoscopic appendectomy was performed. She returned a week later unimproved. The infiltration near a site of subcutaneous injection progressed with areas of liquefaction. Histologic examination of a deep cutaneous biopsy specimen revealed a septal panniculitis without vasculitis.

Conclusions  Panniculitides encompass various clinical syndromes characterized by inflammation of the fibrous septae, fatty lobules, or both components of the subcutaneous tissue. Interferon beta-1b should be considered among the list of putative agents.

Observations  Sixty-two consecutive patients with cGVHD following allogeneic hematopoietic stem cell transplantation were evaluated for sclerotic skin disease. Forty-four patients (71%) had cutaneous cGVHD, and 28 patients (45%) had evidence of sclerotic involvement based on physical examination findings. Fifteen patients agreed to undergo research magnetic resonance imaging to evaluate quantifiable changes in the dermis, subcutaneous tissue, and muscle. Among 15 patients, magnetic resonance imaging identified abnormalities in the skin in 7 (47%), subcutaneous fibrous septa in 13 (87%), deep fascia in 12 (80%), epimysium in 9 (60%), and muscle in 3 (20%).

Conclusions  Magnetic resonance imaging should be considered in the evaluation of patients with cGVHD suspected of having subcutaneous or fascial involvement. Additional studies are needed to validate this noninvasive modality for serial monitoring of disease activity and response to therapy.

Trial Registration  clinicaltrials.gov Identifier: NCT00331968

Observations  We describe the occurrence of cutaneous hyperpigmentation after photosensitivity in 2 patients who were treated with vandetanib. The pigmentation patterns were variable within and between patients. Biopsy specimens from different sites revealed variability in Perls and Fontana staining patterns.

Conclusions  These 2 cases highlight the unusual occurrence of cutaneous hyperpigmentation after vandetanib-associated photosensitivity, a reaction that demonstrates that medications are important causes of acquired photosensitivity and hyperpigmentation. Aggressive photoprotection may facilitate the resolution of diffuse hyperpigmentation. Dermatologists should endeavor to identify and report novel cutaneous adverse effects as new targeted therapies are developed.

Design  A prospective study in patients with sonographically proven SVT.

Setting  Outpatient department of the Department of Dermatology, Medical University of Graz.

Patients  Forty-six consecutive patients with superficial vein thrombosis were enrolled.

Intervention  Every patient underwent color-coded duplex sonography of both lower extremities at the beginning of the study.

Main Outcome Measures  Important risk factors (eg, history of thromboembolic events, recent immobilization, active malignant disease, and the use of oral contraceptives) were investigated.

Results  In 24% of our patients, a concomitant, mostly asymptomatic DVT was found. In 73% of these patients, the DVT occurred in the affected leg, in 9% in the contralateral leg, and in 18% in both legs. The calf muscle veins were most commonly involved. In all patients with DVT, the SVT was located on the lower leg and the D-dimer findings were positive.

Conclusions  Superficial vein thrombosis is not a life-threatening disease, but the risk of concomitant DVT cannot be ignored. Color-coded duplex sonography should be performed in patients with SVT to rule out DVT.

Design  Retrospective study.

Setting  Tokyo Kousei-Nenkin Hospital, Tokyo, Japan.

Patients  The study included 183 patients with subcutaneous benign lesions who underwent ultrasonography and then received a pathologic diagnosis after surgery.

Main Outcome Measures  The study evaluated the number of cases in which the preoperative diagnosis after ultrasonography or just after palpation agreed with the pathologic diagnosis.

Results  Ultrasonography significantly increased the preoperative diagnostic yield of subcutaneous benign lesions (after palpation, 29%; after ultrasonography, 46%; P < .001). The sensitivity for the diagnosis of lipoma (after palpation, 54.8%; after ultrasonography, 88.1%; P < .01) and the specificity for the diagnosis of epidermal cyst (after palpation, 93.5%; after ultrasonography, 99.3%; P < .05) significantly increased after ultrasonography. The sensitivity for the diagnosis of epidermal cyst and ganglion also tended to increase after ultrasonography.

Conclusion  The study results suggest that ultrasonography is useful for the preoperative examination of subcutaneous benign lesions.

Design  Prospective RCM imaging of lesions suspected clinically and/or dermoscopically to be SCC or AK, followed by RCM assessment of the biopsy-proven SCCs and AKs.

Setting  Private skin cancer clinic, Plantation, Florida.

Patients  A total of 38 lesions in 24 patients were assessed, including 7 AKs, 25 SCCs in situ, 3 invasive SCCs, and 3 keratoacanthomas.

Interventions  Prior to undergoing biopsy, all lesions were assessed by RCM.

Results  Mosaic RCM images at the stratum corneum level revealed scale in 29 SCCs (95%) and in all 7 AKs. Polygonal nucleated cells at the stratum corneum were seen in 3 SCCs (10%) and 1 AK (14%). All 38 cases displayed an atypical honeycomb and/or a disarranged pattern of the spinous-granular layer of the epidermis; round nucleated cells were seen in the spinous-granular layer in 20 SCCs (65%) and 1 AK (14%). Round blood vessels in the superficial dermis were seen in 28 SCCs (90%) and 5 AKs (72%).

Conclusions  An increasing frequency of abnormal RCM features can be observed across the spectrum of keratinocytic neoplasias. The presence of an atypical honeycomb or a disarranged pattern of the spinous-granular layer, round nucleated cells at the spinous-granular layer, and round blood vessels traversing through the dermal papilla are the key RCM features of SCC.

Design  In an open longitudinal study, PRISM and Skindex-29 and DLQI questionnaires were completed and HRQOL measurements compared.

Setting  Academic dermatological inpatient ward.

Participants  The study population comprised 227 sequential dermatological inpatients on admission.

Intervention  Patients completed the PRISM tool and the Skindex-29 and DLQI questionnaires at admission and discharge.

Main Outcome Measures  PRISM Self-Illness Separation (SIS) score; Skindex-29 and DLQI scores; and qualitative PRISM information by Mayring inductive qualitative context analysis.

Results  The PRISM scores correlated well with those from the Skindex-29 ( = 0.426; P < .001) and DLQI ( = 0.304; P < .001) questionnaires. Between PRISM and Skindex-29 scores, the highest correlations were for dermatitis ( = 0.614) and leg ulcer ( = 0.554), and between PRISM and DLQI scores, the highest correlations were for psoriasis ( = 0.418) and tumor ( = 0.399). The PRISM tool showed comparable or higher sensitivity than quality of life questionnaires to assess changes in the burden of suffering during hospitalization. Inductive qualitative context analysis revealed impairment of adjustment and self-image as major aspects. Patients overall expected symptomatic and functional improvement. In patients with psoriasis and leg ulcers, many expected no treatment benefit.

Conclusions  The PRISM tool proved to be convenient and reliable for health-related quality of life assessment, applicable for a wide range of skin diseases, and correlated with DLQI and Skindex-29 scores. With the PRISM tool, free-text answers allow for the assessment of individual information and potentially customized therapeutic approaches.

Observations  We retrospectively analyzed 7 patients with pyoderma gangrenosum who were treated with mycophenolate mofetil. Patients were included if they had a diagnosis of pyoderma gangrenosum and were treated with mycophenolate mofetil for at least 2 uninterrupted months. Improvement was based on reduction in lesion size or decrease in concomitant therapy. Overall, 6 of 7 patients had some reduction in ulcer size while receiving mycophenolate mofetil therapy, and 4 of 7 completely healed. However, responsiveness was inadequate in 3 patients. Two discontinued mycophenolate mofetil for alternate therapy, and the third required the addition of dapsone and infliximab for complete healing. The only adverse event observed in our analysis attributed to mycophenolate mofetil therapy was transient anemia.

Conclusions  Mycophenolate mofetil may be beneficial as an immunomodulatory agent in selected patients with pyoderma gangrenosum. Further controlled trials are warranted to define its place among the therapeutic options for this rare disease.

Observations  We report 6 cases with biopsy-proved GA, resistant to the standard modalities of treatment that resolved after 3 months with monthly rifampin (600 mg), ofloxacin (400 mg), and minocycline hydrochloride (100 mg) combination therapy. Rifampin, ofloxacin, and minocycline combination therapy has been successfully used to treat patients with paucibacillary leprosy. Given reports that prolonged antibiotic agents are a useful treatment for GA, rifampin (600 mg), ofloxacin (400 mg), and minocycline hydrochloride (100 mg) combination therapy was initiated in these patients. Complete clearance of the plaques was achieved 3 to 5 months after the initiation of treatment. Some patients experienced postinflammatory hyperpigmentation.

Conclusion  Although our treatment was effective, further studies may be needed to confirm the success of this therapeutic option for patients with recalcitrant lesions of GA.

Observations  Patients treated with neoadjuvant imatinib therapy had an average tumor size reduction of 36.9%. This clinical response was paralleled by histopathologic changes, including decreased cellularity in 100% of the total area as well as significant hyalinization. Imatinib therapy for DFSP before Mohs micrographic surgery was associated with 100% local control at a maximum follow-up of 4 years.

Conclusions  Neoadjuvant imatinib therapy is a well-tolerated, novel approach to DFSP that reduces tumor burden and facilitates resection. Larger prospective studies are needed to confirm and expand on these results.

Observations  A 9-month-old boy presented with cysts and nodules on his face after he began cyclosporine therapy after a heart transplantation. We describe successful treatment with cessation of cyclosporine therapy and administration of isotretinoin.

Conclusions  Nodulocystic acne may be induced by the use of cyclosporine in children as well as adults. When it occurs, it can be managed with cessation of cyclosporine therapy and treatment with isotretinoin. Because this management approach may influence other outcomes in children with transplants, it is best to treat these patients using a multidisciplinary approach.

Observations  We describe 3 men recently referred to our institution for evaluation and treatment of severe, ulcerative psoriasis that ultimately was determined to be aggressive, cytotoxic, cutaneous lymphoma. Each had a history of relatively indolent, nonulcerative patches and plaques (duration, 2-45 years) that changed to ulcerated lesions; these rapidly progressed and eventuated in death.

Conclusions  The clinical characteristics of the skin lesions and the histopathologic findings form a distinct and rare presentation of cutaneous lymphoma. The initial course is similar to that of mycosis fungoides but eventuates in a highly aggressive disease with fatal outcome.

Data Sources  Data for this article were identified by searching the English and German literature by Medline and Journals@Ovid search for the period 1950 to January 2009.

Study Selection  The following relevant terms were used: dermoscopy, dermatoscopy, epiluminescence microscopy (ELM), surface microscopy, digital dermoscopy, digital dermatoscopy, digital epiluminescence microscopy, digital surface microscopy, melanocytic skin lesion, nevi, and pigmented skin lesions. There were no exclusion criteria.

Data Synthesis  The dermoscopic diagnosis of nevi relies on the following 4 criteria (each of which is characterized by 4 variables): (1) color (black, brown, gray, and blue); (2) pattern (globular, reticular, starburst, and homogeneous blue pattern); (3) pigment distribution (multifocal, central, eccentric, and uniform); and (4) special sites (face, acral areas, nail, and mucosa). In addition, the following 6 factors related to the patient might influence the pattern of pigmentation of the individual nevi: age, skin type, history of melanoma, UV exposure, pregnancy, and growth dynamics.

Conclusions  The 4 x 4 x 6 "rule" may help clinicians remember the basic dermoscopic criteria of nevi and the patient-related factors influencing their patterns. Dermoscopy is a useful technique for diagnosing melanocytic nevi, but the clinician should take additional factors into consideration to optimize the management of cases of pigmented lesions.