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A case of Hansen Disease presenting as tinea versicolor

Thu, 04/20/2017 - 12:39pm

Hansen Disease (leprosy) is an infectious disease that targets macrophages and Schwann cells, caused by the acid fast intracellular organism, Mycobacterium leprae. Clinically, it presents with a spectrum of findings that may include hypopigmented macules, erythematous plaques and nodules, and thickened or tender peripheral nerves. The most feared complication is mutilating damage to facial structures or digits resulting from loss of sensation in affected skin. In non-endemic areas, the diagnosis of leprosy is frequently delayed because it may mimic other more common skin conditions. We present a case of borderline/lepromatous leprosy in an otherwise healthy young Brazilian man that was initially diagnosed as tinea versicolor, but did not respond to appropriate treatment. This case highlights the importance of having a high index of suspicion for leprosy in patients from endemic areas who present with lesions that could be consistent with this disease.

Clinical manifestations of pediatric psoriasis: results of a multicenter study in the United States

Thu, 04/20/2017 - 12:39pm

The clinical features of pediatric psoriasis warrant further attention. A national study was conducted to determine the prevalence of scalp and nail involvement and a history of guttate psoriasis at onset according to age, sex, and disease severity. One hundred eighty-one children ages 5 to 17 years with plaque psoriasis were enrolled in a multicenter, cross-sectional study. Subjects and guardians were asked about a history of scalp and nail involvement and whether the initial presentation was guttate. Peak psoriasis severity was assessed and defined historically as mild psoriasis (MP) or severe psoriasis (SP) according to the Physician's Global Assessment and body surface area measures. One hundred forty-three (79.0%) subjects reported a history of scalp involvement, and 71 (39.2%) described a history of nail involvement. Boys were less likely than girls to report a history of scalp involvement (odds ratio [OR] = 0.40, 95% confidence interval [CI] = 0.19-0.84) but more likely to have had nail involvement (OR = 3.01, 95% CI = 1.62-5.60). Scalp and nail involvement was not related to psoriasis severity. In contrast, subjects with SP (35.9%) more often reported a history of guttate lesions than did those with MP (21.8%) (p = .02). Antecedent streptococcal infection was more common in children with guttate than those with plaque psoriasis at onset (p = .02) but did not correlate with severity. Sex-related differences in scalp and nail involvement suggest koebnerization. Preceding streptococcal infection predicts guttate morphology but not severity, and initial guttate morphology is associated with eventual greater severity of disease. More aggressive monitoring and management should be considered for guttate psoriasis, given its later association with more severe disease.

Vitiligo and alopecia areata: apples and oranges

Thu, 04/20/2017 - 12:39pm

Vitiligo and alopecia areata are common autoimmune diseases of the skin. Vitiligo is caused by the destruction of melanocytes and results in the appearance of white patches on any part of the body, while alopecia areata is characterized by patchy hair loss primarily on the scalp, but may also involve other areas as well. At first glance, the two diseases appear to be quite different, targeting different cell types and managed using different treatment approaches. However, the immune cell populations and cytokines that drive each disease are similar, they are closely associated within patients and their family members, and vitiligo and alopecia areata have common genetic risk factors, suggesting that they share a similar pathogenesis. Like apples and oranges, vitiligo and alopecia areata have some obvious differences, but similarities abound. Recognizing both similarities and differences will promote research into the pathogenesis of each disease, as well as the development of new treatments.

CXCL10 is critical for the progression and maintenance of depigmentation in a mouse model of vitiligo

Thu, 04/20/2017 - 12:39pm

Vitiligo is an autoimmune disease of the skin that results in disfiguring white spots. There are no U.S. Food and Drug Administration-approved treatments for vitiligo, and most off-label treatments yield unsatisfactory results. Vitiligo patients have increased numbers of autoreactive, melanocyte-specific CD8(+) T cells in the skin and blood, which are directly responsible for melanocyte destruction. We report that gene expression in lesional skin from vitiligo patients revealed an interferon-gamma (IFN-gamma)-specific signature, including the chemokine CXCL10. CXCL10 was elevated in both vitiligo patient skin and serum, and CXCR3, its receptor, was expressed on pathogenic T cells. To address the function of CXCL10 in vitiligo, we used a mouse model of disease that also exhibited an IFN-gamma-specific gene signature, expression of CXCL10 in the skin, and up-regulation of CXCR3 on antigen-specific T cells. Mice that received Cxcr3(-/-) T cells developed minimal depigmentation, as did mice lacking Cxcl10 or treated with CXCL10-neutralizing antibody. CXCL9 promoted autoreactive T cell global recruitment to the skin but not effector function, whereas CXCL10 was required for effector function and localization within the skin. Surprisingly, CXCL10 neutralization in mice with established, widespread depigmentation induces reversal of disease, evidenced by repigmentation. These data identify a critical role for CXCL10 in both the progression and maintenance of vitiligo and thereby support inhibiting CXCL10 as a targeted treatment strategy.

Scalp sarcoidosis: a sign of systemic sarcoidosis

Thu, 04/20/2017 - 12:39pm

Sarcoidosis is a systemic disease often with cutaneous manifestations. Scarring alopecia of the scalp is a rare form of cutaneous sarcoidosis. Herein, we describe a case of sarcoidosis of the scalp mimicking discoid lupus.

Dystrophic epidermolysis bullosa associated with amniotic band syndrome

Thu, 04/20/2017 - 12:39pm

Amniotic band syndrome (ABS) is a term used to describe congenital anomalies that result from the entrapment of a fetus in fibrous bands. We describe two male infants born with features of dystrophic epidermolysis bullosa (DEB) and ABS. These cases add to the few previous reports of simultaneous DEB and ABS. Abnormal type VII collagen in anchoring structures of the amniotic epithelium is a proposed mechanism for loose amniotic bands that entangle the fetus, with an abnormality in the gene that encodes for type VII collagen.

Contact allergens in oral antihistamines

Thu, 04/20/2017 - 12:39pm

BACKGROUND: Excipients in various formulations of active drugs occasionally include known contact allergens. Their ingestion may trigger dermatitis or cause it to become widespread or refractory to therapy.

OBJECTIVE: The aim of this study was to investigate the prevalence of common contact allergens among the excipients of oral antihistamines available in this country.

METHODS: We gathered the complete ingredient lists of 2119 different preparations of 12 oral antihistamines from the National Library of Medicine data bank and entered them into an electronic database for analysis.

RESULTS: More than half the formulations (55.0%) contained at least 1 member of the 10 allergen families assessed. Most brompheniramine and doxepin preparations included potentially allergenic excipients, whereas fexofenadine was most often free of them. Sorbitan group members, azo dyes, and propylene glycol were the allergens found most frequently in the antihistamines, each present in over 25% of the products. Elixirs, liquids, solutions, suspensions, and syrups were more likely than nonchewable caplets, capsules, and tablets to contain the allergens tabulated (100% vs 39.3%, respectively). Chewable pills frequently contained azo dyes.

CONCLUSIONS: Ingestion of antihistamines could precipitate a systemic contact dermatitis in a patient sensitized to an allergen present as an excipient in the medicine.

Sinus pericranii with a hair collar sign

Thu, 04/20/2017 - 12:39pm

Sinus pericranii is a rare vascular malformation in which the extracranial veins are connected to the intracranial venous circulation. It typically appears as a soft mass with a blue hue on the scalp. We describe a patient with sinus pericranii and associated hair collar sign.

Multifocal cutaneous alternariosis in a 70-year-old Kenyan renal transplant patient

Thu, 04/20/2017 - 12:39pm

Alternaria species are a group of dematiaceous fungi that are ubiquitous in nature and are becoming an increasingly important cause of disease in immunocompromised patients. We present a case of a 70 year old renal transplant recipient with multiple areas of cutaneous Alternaria infections likely introduced during local trauma. Treatment has required a combination of systemic therapy and surgical excision. This case illustrates the importance of recognizing fungal infections with cutaneous manifestations, such as alternariosis, in immunosuppressed patients.

An update on diaper dermatitis

Thu, 04/20/2017 - 12:39pm

Diaper dermatitis leads to approximately 20% of all childhood dermatology visits. There have been several technologic advances in diaper design the last several years; however, due to the unique environment of the diaper area, many children continue to suffer from a variety of dermatologic conditions of this region. Common causes include allergic contact dermatitis, irritant contact dermatitis, infection, and psoriasis. Treatments include allergen avoidance, barrier protection, parent education, and topical therapies.

Child abuse masquerading as a soft tissue sarcoma

Thu, 04/20/2017 - 12:39pm

Pediatric fasciitides are rare benign lesions that may clinically mimic a malignant sarcoma. Nodular fasciitis, the most common of these fasciitides, rarely occurs in children younger than 5 years of age. Often there is a history of preceding trauma. Herein, we report the case of a 5-month-old boy diagnosed with nodular fasciitis in the setting of nonaccidental trauma.

Immunology and skin in health and disease

Thu, 04/20/2017 - 12:38pm

The skin is a complex organ that, in addition to providing a strong barrier against external insults, serves as an arena for a wide variety of inflammatory processes, including immunity against infections, tumor immunity, autoimmunity, and allergy. A variety of cells collaborate to mount functional immune responses, which are initiated by resident populations and evolve through the recruitment of additional cell populations to the skin. Inflammatory responses are quite diverse, resulting in a wide range of signs and symptoms that depend on the initiating signals, characteristics of the infiltrating cell populations, and cytokines that are produced (cytokines are secreted protein that allows for cell-cell communication; usually refers to communication between immune-immune cells or stromal-immune cells). In this work, we will review the skin architecture and resident and recruited cell populations and discuss how these populations contribute to inflammation using human diseases and treatments when possible to illustrate their importance within a clinical context.

Simvastatin prevents and reverses depigmentation in a mouse model of vitiligo

Thu, 04/20/2017 - 12:38pm

Vitiligo is a common autoimmune disease of the skin that results in disfiguring white spots. There are no Food and Drug Administration (FDA)-approved treatments, and current treatments are time-consuming, expensive, and of low efficacy. We sought to identify new treatments for vitiligo, and first considered repurposed medications because of the availability of safety data and expedited regulatory approval. We previously reported that the IFN-gamma-induced chemokine CXCL10 is expressed in lesional skin from vitiligo patients, and that it is critical for the progression and maintenance of depigmentation in our mouse model of vitiligo. We hypothesized that targeting IFN-gamma signaling might be an effective new treatment strategy. Activation of signal transducer and activator of transcription 1 (STAT1) is required for IFN-gamma signaling and recent studies revealed that simvastatin, an FDA-approved cholesterol-lowering medication, inhibited STAT1 activation in vitro. Therefore, we hypothesized that simvastatin may be an effective treatment for vitiligo. We found that simvastatin both prevented and reversed depigmentation in our mouse model of vitiligo, and reduced the number of infiltrating autoreactive CD8(+) T cells in the skin. Treatment of melanocyte-specific, CD8(+) T cells in vitro decreased proliferation and IFN-gamma production, suggesting additional effects of simvastatin directly on T cells. Based on these data, simvastatin may be a safe, targeted treatment option for patients with vitiligo.

The deep penetrating nevus

Thu, 04/20/2017 - 12:38pm

The deep penetrating nevus (DPN), also known as the plexiform spindle cell nevus, is a pigmented lesion that commonly arises on the head and neck in the first few decades of life. Histopathologically, the DPN is wedge-shaped and contains melanocytes that exhibit deep infiltration into the dermis. Given these features, DPN may clinically and histopathologically mimic malignant melanoma, sparking confusion about the appropriate evaluation and management of these lesions. The goal of this review is to summarize the clinical and histopathological features of DPN and to discuss diagnostic and treatment strategies for dermatologists.

Child abuse masquerading as a soft tissue sarcoma

Thu, 04/20/2017 - 12:38pm

Pediatric fasciitides are rare benign lesions that may clinically mimic a malignant sarcoma. Nodular fasciitis, the most common of these fasciitides, rarely occurs in children younger than 5 years of age. Often there is a history of preceding trauma. Herein, we report the case of a 5-month-old boy diagnosed with nodular fasciitis in the setting of nonaccidental trauma.

Excipients in Oral Antihistamines Can Perpetuate Allergic Contact Dermatitis

Thu, 04/20/2017 - 12:38pm

Propylene glycol is a well-documented causative agent of allergic contact dermatitis (ACD). It is also reported to cause systemic dermatitis after ingestion of foods or medicines containing it and after intravenous injection of a medicine with propylene glycol in its base. We describe two adolescents with sensitivity to propylene glycol confirmed by patch testing whose dermatitis improved dramatically after cessation of oral antihistamines containing propylene glycol. We report these cases to alert providers to the potential for worsening of ACD due to systemic exposure to propylene glycol in patients with a cutaneous sensitivity to the allergen.

Gene expression profiling of skeletal muscles treated with a soluble activin type IIB receptor

Tue, 04/18/2017 - 9:01pm

Inhibition of the myostatin signaling pathway is emerging as a promising therapeutic means to treat muscle wasting and degenerative disorders. Activin type IIB receptor (ActRIIB) is the putative myostatin receptor, and a soluble activin receptor (ActRIIB-Fc) has been demonstrated to potently inhibit a subset of transforming growth factor (TGF)-beta family members including myostatin. To determine reliable and valid biomarkers for ActRIIB-Fc treatment, we assessed gene expression profiles for quadriceps muscles from mice treated with ActRIIB-Fc compared with mice genetically lacking myostatin and control mice. Expression of 134 genes was significantly altered in mice treated with ActRIIB-Fc over a 2-wk period relative to control mice (fold change > 1.5, P < 0.001), whereas the number of significantly altered genes in mice treated for 2 days was 38, demonstrating a time-dependent response to ActRIIB-Fc in overall muscle gene expression. The number of significantly altered genes in Mstn(-/-) mice relative to control mice was substantially higher (360), but for most of these genes the expression levels in the 2-wk treated mice were closer to the levels in the Mstn(-/-) mice than in control mice (P < 10(-)(3)(0)). Expression levels of 30 selected genes were further validated with quantitative real-time polymerase chain reaction (qPCR), and a correlation of > /= 0.89 was observed between the fold changes from the microarray analysis and the qPCR analysis. These data suggest that treatment with ActRIIB-Fc results in overlapping but distinct gene expression signatures compared with myostatin genetic mutation. Differentially expressed genes identified in this study can be used as potential biomarkers for ActRIIB-Fc treatment, which is currently in clinical trials as a therapeutic agent for muscle wasting and degenerative disorders.