Mar / April 2012

March/April 2012 • Volume 10 • Issue 2

EDITORIALScabies Then and NowLavery, Parish, and Wolf

ORIGINAL CONTRIBUTIONSErlotinib-Induced Scalp Perifolliculitis

Rallis, Petronic-Rosic, and Korfitis

New Findings in Delusions of ParasitosisFellner

REVIEWWound Care in Short-Term Rehabilitation

Facilities and Long-Term Care: Special Needs for a Special Population

White-Chu and Reddy

CORE CURRICULUMCutaneous Tuberculosis: A Diagnostic

Dilemma—Laboratory InputsSehgal, Verma, Bhattacharya, Sharma, Singh, and Verma

DEPARTMENTSPERILS OF DERMATOPATHOLOGY

Sometimes It Takes Darkness to See the Light: Pitfalls in the Interpretation of Cell Proliferation

Markers (Ki-67 and PCNA)Castilla, McDonough, Tumer, Lambert, and Lambert

INFECTIOUS DISEASE CAPSULESThe Lion Is NOT Sleeping Tonight

Carr, Bernstein, and Trevino

PHOTO CAPSULESActinomycetomaDlova and Mosam

CASE STUDIESMalignant Melanoma Arising Within Nevus Spilus

Karam and Jackson

Pseudocyst of the Auricle: An Uncommon Entity of the Ear

Sheaffer, Sahu, and Lee

Necrotic Ulcer: A Manifestation of Leukemia CutisAksu, Saracoglu, Sabuncu, Ciftci, Gulbas, and Isiksoy

Inflammatory Linear Verrucous Epidermal Nevus With Genital Involvement

Balci, Yenin, Çelik, Sarikaya, and Atik

Oral Frictional Hyperkeratosis (Morsicatio Buccarum): An Entity to Be Considered in the Differential

Diagnosis of White Oral Mucosal LesionsCam, Santoro, and Lee

Vesicular Palmoplantar Pityriasis RoseaSingh, Sharma, Narang, and Madan

BOOK REVIEWHall’s Manual of Skin as a Marker of Underlying Disease

Reviewed by Scheinfeld

Now patients can spend less time thinking about their scars and more time seeing results.

NEWDaily Scar Gel 1X

1Data on fi le. Dec. 2011. 2IMS Health. NDTI. December 2010. *Statistical significance reached on all measurements observed (P<0.01). ©/®/™ 2012 Merz Pharmaceuticals, LLC

New Mederma® Advanced Scar Gel—the fi rst and only 1X daily scar therapy.

• From the #1 doctor recommended brand in scar care2

• More convenient application, better patient compliance, better results

• Clinically shown to improve scar softness, redness, texture and overall appearance

• Subjects saw a 36% greater improvement in the overall appearance of their scar

after 8 weeks vs. untreated scars (P<0.01)1

More information at mederma.com

Wear your skin proudly.™

Post Baseline: Subject Assessment for Treated vs. Untreated Scar at Week 81

Softness*0.0

1.0

2.0

3.0

Redness* Texture* Overall*

treateduntreated

0 = no change, 1 = mild improvement, 2 = moderate improvement, 3 = significant improvement

Mean

Scar

Rati

ng

61

TABLE OF CONTENTS

EDITORIAL

Scabies Then and Now .................................................................................................................................. 67 Michael Joseph Lavery, MB BCh BAO; Lawrence Charles Parish, MD, MD (Hon); Ronni Wolf, MD

ORIGINAL CONTRIBUTIONS

Erlotinib-Induced Scalp Perifolliculitis ............................................................................................................ 70 Efstathios Rallis, MD, PhD; Vesna Petronic-Rosic, MD, MSc; Chrysovalantis Korfitis, MD

New Findings in Delusions of Parasitosis ........................................................................................................ 72 Michael J. Fellner, MD

REVIEW

Wound Care in Short-Term Rehabilitation Facilities and Long-Term Care: Special Needs for a Special Population ..................................................................................................................................... 75

E. Foy White-Chu, MD; Madhuri Reddy, MD, MSc

Self-Test Review Questions (p. 81)

CORE CURRICULUMVirendra N. Sehgal, MD, Section Editor

Cutaneous Tuberculosis: A Diagnostic Dilemma— Laboratory Inputs ................................................................ 82 Virendra N. Sehgal, MD; Prashant Verma, MD; Sambit N. Bhattacharya, MD; Sonal Sharma, MD; Navjeevan Singh, MD; Nishant Verma, MD

DEPARTMENTS

PERILS OF DERMATOPATHOLOGY

W. Clark Lambert, MD, PhD, Section Editor

Sometimes It Takes Darkness to See the Light: Pitfalls in the Interpretation of Cell Proliferation Markers (Ki-67 and PCNA) ............................................................................................................................ 90 Carmen Castilla, BS; Patrick McDonough, BA; Gizem Tumer, MD; Peter C. Lambert, BA, MS; W. Clark Lambert, MD, PhD

INFECTIOUS DISEASE CAPSULES

Jack M. Bernstein, MD, Section Editor

The Lion Is NOT Sleeping Tonight ................................................................................................................... 94 David R. Carr, MD; Jack M. Bernstein, MD; Julian Trevino, MD

PHOTO CAPSULES

Ncoza C. Dlova, MBChB, FCDerm, Section Editor

Actinomycetoma ........................................................................................................................................... 98 Ncoza C. Dlova, MBChB, FCDerm; Anisa Mosam, MBChB, FCDerm

CASE STUDIESVesna Petronic-Rosic, MD, MSc, Section Editor

Malignant Melanoma Arising Within Nevus Spilus ......................................................................................... 100 Susan L. Karam, BS; Scott M. Jackson, MD

Pseudocyst of the Auricle: An Uncommon Entity of the Ear ........................................................................... 104 Alexis Sheaffer, BS; Joya Sahu, MD; Jason B. Lee, MD

Necrotic Ulcer: A Manifestation of Leukemia Cutis ....................................................................................... 108 Ayse Esra Koku Aksu, MD; Zeynep Nurhan Saracoglu, MD; Ilham Sabuncu, MD; Evrim Ciftci, MD; Zafer Gulbas, MD; Serap Isiksoy, MD

Inflammatory Linear Verrucous Epidermal Nevus With Genital Involvement ................................................... 112 Didem Didar Balci, MD; Jülide Zehra Yenin, MD; Ebru Çelik, MD; Gökhan Sarikaya, MD; Esin Atik, MD

62

TABLE OF CONTENTS

EDITORIAL DIRECTOR

COPYEDITOR

MEDIA WEB DIRECTOR

PUBLISHER ASSOCIATE PUBLISHER

PRESIDENT

CHIEF EXECUTIVE OFFICER

ABOUT OUR JOURNAL

SKINmed: Dermatology for the Clinician®

©

Corporate

Publishing

Editorial

GENERAL COUNSEL

Oral Frictional Hyperkeratosis (Morsicatio Buccarum): An Entity to Be Considered in the Differential Diagnosis of White Oral Mucosal Lesions .......................................................................... 114

Kristin Cam, MD; Anthony Santoro, MD; Jason B. Lee, MD

Vesicular Palmoplantar Pityriasis Rosea....................................................................................................... 116 Varinder Singh, MD; Meghna Sharma, MD; Tarun Narang, MD; Manas Madan, MD

BOOK REVIEWNoah S. Scheinfeld, MD, JD, Section Editor

Hall’s Manual of Skin as a Marker of Underlying Disease .............................................................................. 120 Edited by John C. Hall and Brian J. Hall. 300 pages. Shelton, CT; People’s Medical Publishing House–USA; 2011. $89.95. ISBN 1607951029

THE Aesthetic Show of the Year

World-Class FacultyPre-Show Educational SessionsAdvanced Hands-On Training

Patient Tx Workshops

To register visit www.aestheticshow.com or call + 1 (949) 830-5409

Register with Promo Code TAS3AD:

Aesthetic TV

THE Aesthetic Awards TM

March/April 2012 EDITORIAL BOARD

65

Mohamed Amer, MD

Cairo, Egypt

Robert L. Baran, MD

Cannes, France

Anthony V. Benedetto, DO

Philadelphia, PA

Brian Berman, MD, PhD

Miami, FL

Jack M. Bernstein, MD

Dayton, OH

Sarah Brenner, MD

Tel Aviv, Israel

Joaquin Calap Calatayud, MD

Cadiz, Spain

Henry H.L. Chan, MB, MD, PhD, FRCP

Hong Kong, China

Noah Craft, MD, PhD, DTMH

Torrance, CA

Ncoza C. Dlova, MBChB, FCDerm

Durban, South Africa

Richard L. Dobson, MD

Mt Pleasant, SC

William H. Eaglstein, MD

Palo Alto, CA

Boni E. Elewski, MD

Birmingham, AL

Charles N. Ellis, MD

Ann Arbor, MI

Howard A. Epstein, PhD

Philadelphia, PA

Ibrahim Hassan Galadari, MD, PhD, FRCP

Dubai, United Arab Emirates

Anthony A. Gaspari, MD

Baltimore, MD

Michael Geiges, MD

Zurich, Switzerland

Michael H. Gold, MD

Nashville, TN

Lowell A. Goldsmith, MD, MPH

Chapel Hill, NC

Aditya K. Gupta, MD, PhD, FRCP(C)

London, Ontario, Canada

Seung-Kyung Hann, MD, PhD

Seoul, Korea

Roderick J. Hay, BCh, DM, FRCP, FRCPath

London, UK

Tanya R. Humphreys, MD

Philadelphia, PA

Camila K. Janniger, MD

Englewood, NJ

Abdul-Ghani Kibbi, MD

Beirut, Lebanon

Andrew P. Lazar, MD

Highland Park, IL

Jasna Lipozencic, MD, PhD

Zagreb, Croatia

Eve J. Lowenstein, MD, PhD

New York, NY

George M. Martin, MD

Kihei, HI

Marc S. Micozzi, MD, PhD

Bethesda, MD

George F. Murphy, MD

Boston, MA

Oumeish Youssef Oumeish, MD, FRCP

Amman, Jordan

Joseph L. Pace, MD, FRCP

Naxxar, Malta

Art Papier, MD

Rochester, NY

Johannes Ring, MD, DPhil

Munich, Germany

Roy S. Rogers III, MD

Rochester, MN

Donald Rudikoff, MD

New York, NY

Robert I. Rudolph, MD

Wyomissing, PA

Vincenzo Ruocco, MD

Naples, Italy

Noah S. Scheinfeld, MD, JD

New York, NY

Virendra N. Sehgal, MD

Delhi, India

Charles Steffen, MD

Oceanside, CA

Alexander J. Stratigos, MD

Athens, Greece

James S. Studdiford III, MD

Philadelphia, PA

Robert J. Thomsen, MD

Los Alamos, NM

Julian Trevino, MD

Dayton, OH

Snejina Vassileva, MD, PhD

Sofia, Bulgaria

Daniel Wallach, MD

Paris, France

Michael A. Waugh, MB, FRCP

Leeds, UK

Wm. Philip Werschler, MD

Spokane, WA

Joseph A. Witkowski, MD

Philadelphia, PA

Ronni Wolf, MD

Rechovot, Israel

EDITOR IN CHIEF

EDITORIAL BOARD

DEPUTY EDITORS

William Abramovits, MD

Dallas, TX

W. Clark Lambert, MD, PhD

Newark, NJ

Larry E. Millikan, MD

Meridian, MS

Jennifer L. Parish, MD

Philadelphia, PA

Lawrence Charles Parish, MD, MD (Hon)Philadelphia, PA

Vesna Petronic-Rosic, MD, MSc

Chicago, IL

Marcia Ramos-e-Silva, MD, PhD

Rio de Janeiro, Brazil

March/April 2012

67SKINmed. 2012;10:67–69

There’s a squeak of pure delight from a matey little mite,

As it tortuously tunnels in the skin,

Singing furrow, folly furrow, come and join me in my burrow,

And we’ll view the epidermis from within1

-

2

The cheese-mites asked how the cheese got there,

And warmly debated the matter;

The Orthodox said that it came from the air,

And the Heretics said from the platter.

They argued it long and they argued it strong,

And I hear they are arguing now;

But of all the choice spirits who lived in the cheese,

Not one of them thought of a cow.3

-

4

INCIDENCE

5 -6

7

9

CONTRIBUTING FACTORS

-

ENTOMOLOGY

Sarcoptes scabiei var. Hominis

10

11; 5 Sarcoptes

scabiei 10

11

CLINICAL FEATURES

9 12

From the Department of Dermatology, Altnagelvin Area Hospital, Derry, North Ireland;1 the Department of Dermatology and Cutaneous Biology, Jefferson Center for International Dermatology, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA;2 and the Dermatology Unit, Kaplan Medical Center, Rechovet, Israel3

Address for Correspondence: Michael Joseph Lavery, MB BCh BAO, Altnagelvin Area Hospital, Department of Dermatology, Glenshane Road, Derry BT47 6SB, North Ireland E-mail: [email protected]

EDITORIAL

Scabies Then and Now Michael Joseph Lavery, MB BCh BAO;1 Lawrence Charles Parish, MD, MD (Hon);2 Ronni Wolf, MD3

March/April 2012

SKINmed. 2012;10:67–69

1 5

14 There 10

15

TREATMENT

-

16

Figure 1. The scabies mite, showing 8 legs.

Figure 2. The characteristic red papules on the finger webs.

Figure 3. Red papules on the penile corona indicating sca-bies, until proven otherwise.

Figure 4. Crusted scabies in an older man who had neglected himself.

March/April 2012

69SKINmed. 2012;10:67–69

17

CONCLUSIONS

5

7

Poor Giovanni Bonomo,

Would be filled with such woe,

To have this tiny little mite,

Still causing affliction by its bite.

REFERENCES

1 Graham-Brown RAC, Burns T. Lecture notes. Dermatology. 9th ed. Malden, MA: Blackwell Publishing; 2007:41–45.

2 Cheese mites and other wonders. BBC News Online. http://news.bbc.co.uk/1/hi/magazine/7423847.stm. Accessed July 30, 2011.

3 Arthur Conan Doyle. A Parable 1916. http://rpo.library.utoronto.ca/poem/3284.html. Accessed July 30, 2011.

4 Ramos-e-Silva M. Giovan Cosimo Bonomo (1663-1696): discoverer of the etiology of scabies. Int J Dermatol. 1998;37;625–630.

5 Vandergriff T, Harting M, Rosen T. Venereal diseases. In: Hall JC, Hall BJ. Skin Infections: Diagnosis and Treatment. Cambridge, England; Cambridge University Press; 2009; Part VI, Ch 24; 317–318.

6 Scabies Homepage. (American incidence) http://www.stanford.edu/group/parasites/ParaSites2005/Scabies/SCABIES.html. Accessed July 30, 2011.

7 Lassa S, Campbell MJ, Bennett CE. Epidemiology of scabies prevalence in the UK from general practice records. Br J Dermatol. 2011;164;1329–1334.

8 Downs AMR, Harvey I, Kennedy CTC. The epidemiology of head lice and scabies in the UK. Epidemiol Infect. 1999;3;471–477.

9 Johnston G, Sladden M. Scabies: diagnosis and treatment. Clinical review. BMJ. 2005;331:619

10 Parasites and Health. Scabies. www.cdc.gov/scabies/risk.html. Accessed July 30, 2011.

11 Harrison S, Knott H, Bergfeld WF. Infections of the Scalp. In: Hall JC, Hall BJ. Skin Infections: Diagnosis and Treatment. Cambridge, England; Cambridge University Press: 2009; Part V, Ch 20; 260.

12 Currie BJ, McCarthy JS. Permethrin and ivermectin for scabies. New Engl J Med. 2010;362;717–725.

13 Cestari TF, Martignago BF. Scabies, pediculosis, bedbugs and stinkbugs: uncommon presentations. Clin Dermatol. 2005;23;545–554.

14 Wolf R, Davidovici B. Treatment of scabies and pediculosis: facts and controversies. Clin Dermatol. 2010;28;511–518.

15 Currie BJ, Harumal P, McKinnon M, et al. First documentation of in vivo and in vitro ivermectin resistance in sarcoptes scabiei. Clin Infect Dis. 2004;39;e8–e12.

16 Wolf R, Davidovici B, Parish LC. Can the scabies mite be tamed? SKINmed. 2006;5:214–216.

17 Cox NH. Permethrin treatment in scabies infestation: importance of the correct formulation. Clinical Review. BMJ. 2000;320:37.

Candidiasis, Infection with Candida albicans. Moulage No 238–239, made by Lotte Volger in the Dermatology Clinic in Zurich in 1923. Museum of Wax Moulages Zurich, www.moulagen.ch

Courtesy of Michael Geiges, MD

WAX MOULAGE

March/April 2012

70SKINmed. 2012;10:70–71

E-

1

2

CASE 1

-

-

Staphylococcus aureus

-

-

CASE 2

-

-

DISCUSSION

-

-

-

3

ORIGINAL CONTRIBUTION

Erlotinib-Induced Scalp PerifolliculitisEfstathios Rallis, MD, PhD;1 Vesna Petronic-Rosic, MD, MSc;2 Chrysovalantis Korfitis, MD1

ABSTRACT

From the Department of Dermatology, Veterans Administration Hospital (NIMTS), Athens, Greece;1 and the Section of Dermatology, University of Chicago Pritzker School of Medicine, Chicago, IL2

-

SKINmed

March/April 2012

71SKINmed. 2012;10:70–71

-

2

-

-

-2

-

-2

-

REFERENCES

1 Cyto-

kine Growth Factor Rev

2 Pathogenesis, clinical significance and management in pancreatic can-

J Pancreas (Online)

3

J Clin Oncol

4 Hautarzt

5 J Drugs Dermatol

Figure 2.

Figure 3.

Figure 4.

Figure 1.

March/April 2012

72SKINmed. 2012;10:72–74

From the Metropolitan Hospital, New York Medical College, New York, NY

Address for Correspondence: Michael J. Fellner, MD, Metropolitan Hospital, New York Medical College, 50 East 89th Street, New York,

T -

-

-

1

CASE 1

-

-

-

-

-

ORIGINAL CONTRIBUTION

New Findings in Delusions of ParasitosisMichael J. Fellner, MD

SKINmed.

ABSTRACT

Delusions of Parasitosis

ORIGINAL CONTRIBUTIONMarch/April 2012

73SKINmed. 2012;10:72–74

CASE 2

A 90-year-old woman was referred from a major medical der-

matology center with a diagnosis of delusions of parasitosis. On

the first visit she described worms and strings coming out of

her body including the skin, eyes, and mouth. She reported the

onset as September 2009 following a bout of diarrhea during

the summer that lasted for 2 months. She was treated with

albendazole by a noted parasitologist for trichuris infection. The

diarrhea abated with the treatment.

By September 2009, she had described worms and strings com-

ing out of her body, causing her great discomfort. She first went

to her primary care physician at the medical school center. He

examined the material she brought and told her there were no

parasites or strings but only mucous. This angered her and she

refused to return to the physician. She brought a drawing of the

worms and strings on her first dermatology visit (Figure 1).

Examination revealed a thin elderly woman in no acute dis-

tress whose stream of thought was verbose and rambling. The

skin showed a reddened and ulcerated area on the right thigh

(Figure 2). The remainder of the physical examination was

within normal limits. Results from laboratory tests were within

normal limits. The patient was given mupirocin ointment for

the ulcer and ammonium lactate 12% lotion for the skin on

the body and was reassured there was some possibility that the

disturbance might abate.

On follow-up 2 weeks later, she claimed the parasites had started

in June 2009, contradicting her previous statement that they had

started in September 2009. She now claimed slight improve-

ment with the treatment. There were, however, new lesions on

the right thigh (Figure 3). Once again she was unclear about

whether these resulted from the parasites. She indicated that the

strings and worms were coming out of her ears, eyes, nose, and

skin on the face.

She was encouraged to take doxepin 25 mg at night and con-

tinue with ammonium lactate 12% lotion and mupirocin oint-

ment. She was also encouraged to ventilate about her multiple

social problems, including her family, her will, and her eating

problems. She said she weighed 87 pounds because she was

unable to eat any carbohydrates since she believed the parasites

lived on sugars. She said she was in the process of getting assis-

tance in daily-living activities at home.

Figure 3. The patient’s thigh lesions on second visit.

Figure 1. The patient’s drawing of string and parasite coming out of her skin.

Figure 2. The patient’s thigh lesion on first visit.

Delusions of Parasitosis

ORIGINAL CONTRIBUTIONMarch/April 2012

74SKINmed. 2012;10:72–74

On third follow-up, she said she felt considerably better

(2 weeks after second visit) using emollients. She did not men-

tion parasites, but said the problem was improving. She was

encouraged to seek psychologic or psychiatric counseling but was

not accepting of this suggestion. She said she was going to make

an appointment for a visit at a nearby medical center geriatric

unit to help her with nutrition and memory problems. She was

encouraged to take doxepin at bedtime and to use emollients.

DISCUSSION

These cases are the first to exhibit findings of Morgellons dis-

ease and delusions of parasitosis at the same time. Morgellons is

a pattern of dermatologic symptoms very similar, if not identi-

cal, to those of delusions of parasitosis, and many patients with

Morgellons are diagnosed with another psychosomatic illness.2 In

delusional parasitosis, patients hold a delusional belief that they

are infested with parasites. They may experience formication, the

sensation that insects are crawling under the skin. It is a common

symptom in cocaine abusers as well. Individuals who experience

this condition may develop elaborate rituals of inspection and

cleansing to locate and remove parasites and fibers, resulting in

a form of self-mutilation; they injure themselves in attempts to

be rid of the “parasites” by picking at the skin, causing second-

ary lesions. Continuous picking of the lesions prevents healing.

Patients with delusional parasitosis often present at the doctor’s

office with what physician’s term the matchbox sign, a medical sign

characterized by the patient making collections of fibers and other

foreign objects supposedly retrieved from the skin, and, because of

“unshakeable delusional ideation,” strongly reject diagnoses that

do not involve parasites. The Morgellons Research Foundation, a

nonprofit organization, considers Morgellons to be a newly emerg-

ing infectious disease, but the medical community disagrees, not-

ing that the described symptoms of Morgellons are associated with

the psychotic disorder known as delusional parasitosis.2

Due to the second patient’s age, it was deemed inappropriate

to give pimozide or treatment with an SSRI medication since

sudden death in the elderly has been reported.3 The treatment

plan was to gain the patient’s confidence before attempting to

refer her for psychologic or psychiatric care, since there did not

appear to be any insight on her part at the first 2 visits.

Therapy is often unsuccessful because many patients, such as

those reported here, refuse consultation with a psychiatrist either

because they believe the problem is organic or because they fear

mental illness and the stigma of psychiatry. In extremely severe

cases, suicide has been reported, illustrating the urgency of cor-

rective medication and prompt psychiatric referral.4 Standard

treatment with pimozide risks substantial side effects.3 This has

led to trial with additional psychotropic agents. Recent success

has been reported with the use of risperdal5 and olanzapine.6

Nowhere have these diseases been more graphically illustrated

than in the Oscar-nominated 2010 film “Black Swan” wherein

the heroine played by Natalie Portman suffers from the delusion

that parasites and strings are coming out of her skin. This is a

must-see film for dermatologists and psychiatrists alike.

REFERENCES

1 Fellner MJ, Majeed MH. Tales of bugs, delusions of parasitosis, and what to do. Clin Dermatol. 2009;27:135–138.

2 Savely VR, Leitao MM, Stricker RB. The mystery of Morgellon’s disease: infection or delusion? Am J Clin Dermatol. 2006;7:1–5.

3 van Vloten WA. Pimozide use in dermatology. Dermatol Online J. 2003;9:3.

4 Monk BE, Rao YJ. Delusions of parasitosis with fatal outcome. Clin Exp Dermatol. 1994;19:341–342.

5 Friedmann AC, Ekeowa-Anderson A, Taylor R, Bewley A. Delusional para-sitosis presenting as folie a trois: successful treatment with risperidone. Br J Dermatol. 2006;155:841–842.

6 Atilganoglu U, Ugurad I, Arikan M, Ergun SS. Monosymptomatic hypo-chondriacal psychosis presenting with recurrent oral mucosal ulcers and multiple skin lesions responding to olanzapine treatment. Int J Dermatol. 2006;45:1189–1192.

VINTAGE LABEL

Courtesy of BuyEnlarge, Philadelphia, PA

March/April 2012

75SKINmed. 2012;10:75–81

March/April 2012

From the Wound Healing Center, Hebrew Senior Life Department of Medicine, Boston, MA

Address for Correspondence: E. Foy White-Chu, MD, Director of Wound Healing Center, Hebrew Senior Life Department of Medicine, 1200

1 2

3

4

CASE 1: SKIN TEAR THAT IS SLOW TO HEAL

REVIEW

Wound Care in Short-Term Rehabilitation Facilities and Long-Term Care: Special

Needs for a Special PopulationE. Foy White-Chu, MD; Madhuri Reddy, MD, MSc

SKINmed.

ABSTRACT

March/April 2012

76SKINmed. 2012;10:75–81

SKIN TEARS

5–7

6

VENOUS ULCERS

8

10

11 12

10

Figure 1. Venous ulcer status post-debridement. Photo courtesy of E. Foy White-Chu, MD.

Figure 2. Proper wrapping technique on the right leg. Note the inclusion of the heel from toes to knee. Photo courtesy of E. Foy White-Chu, MD.

Table I. Prevention of Skin Tears

DO DON ’ T

March/April 2012

77SKINmed. 2012;10:75–81

13 14

15

stocking

16

17

16

18

17

CASE 2: STAGE IV PRESSURE ULCER AND FEVER

Table II. Venous Ulcer Challenges and Treatments

PROBLEM APPROACH

March/April 2012

78SKINmed. 2012;10:75–81

PRESSURE ULCERS

20

21 22

23

24

22

24 25

Figure 3. -

courtesy of E. Foy White-Chu, MD.

Figure 4. Healing stage IV pressure ulcer. Photo courtesy of E. Foy White-Chu, MD.

March/April 2012

SKINmed. 2012;10:75–81

26 27

28

30

24 25 31 32

Staphylococcus aureus33–35

CASE 3: TOE ULCERS AND REFRACTORY PAIN

PALLIATIVE WOUND CARE

Figure 5: Worsening arterial ulcers. Photo courtesy of E. Foy White-Chu, MD.

March/April 2012

80SKINmed. 2012;10:75–81

36

37 38

CONCLUSIONS

Disclosure: The authors declare no financial interests. There was no

funding source provided for this contribution.

REFERENCES

1 hospital stay. Infect Control Hosp Epidemiol. 2005;26:293–297.

2 Belowitz DR, Brandeis GH, Anderson J, Du W, Brand H. Effect of pres-J Gerontol A Biol

Sci Med Sci. 1997;52:M106–M110.

3

4

5 Cough-Csarny J, Kopac CA. Skin tears in institutionalized elder-ly: an epidemiological study. Ostomy Wound Manage. 1998;44(3A suppl):14S–24S.

6 Ostomy Wound Manage. 2007;53:32–34, 36,

38–40.

7 J Wound Ostomy Continence Nurs. 2007;34:256–259.

8 --

tion using MDS. Adv Skin Wound Care. 2000;13:218–224.

9 -

study. Arch Surg. 2001;136:1364–1369.

10 Br J Surg.

1999;86:338–341.

11 quality of life. Ostomy Wound Manage. 1998;44:38–49.

12 their impact on daily life. J Clin Nurs. 2004;13:341–354.

13

ulceration. Wound Repair Regen. 2003;11:166–171.

14 BMJ. 1997;315:576–580.

15 Chronic

Wound Care: A Clinical Source Book for Healthcare Professionals. 4th ed. Wayne, PA: Health Management Publications, Inc; 2007:481–488.

16 Romanelli M, Dini V, Willliamson D, et al. Measurement: lower

Chronic Wound Care: A Clinical Source Book for Healthcare Professionals, Fourth Edition. Wayne, PA: Health Manage-ment Publications, Inc; 2007:463–480.

17 Palfreyman SSJ, Nelson EA, Lochiel R, Michaels JA. Dressings for healing Cochrane Database Syst Rev. 2006;(3):CD001103.

18 Second European Consensus Document on chronic critical leg ischemia. Circulation. 1991;84(4 suppl):IV1–IV26.

19

20 Langemo DK, Brown G. Skin fails too: acute, chronic, and end-stage skin failure. Adv Skin Wound Care. 2006;19:206–211.

21 -

sory Panel monograph. Adv Skin Wound Care. 2001;14:208–215.

22 Allman RM, Goode PS, Patrick MM, et al. Pressure ulcer risk fac-JAMA.

1995;273:865–870.

23 -J Am Geriatr

Soc. 2000;48:73–81.

24 debridement, bacterial balance and moisture balance. Ostomy Wound Manage. 2000;46:14–22, 24–28, 30–35.

25 Schultz GS, Sibbald RG, Falanga V, et al. Wound bed preparation: a sys-temic approach to wound management. Wound Rep Reg. 2003;11:1–28.

26 West J Med. 1991;154:219–223.

March/April 2012

81SKINmed. 2012;10:75–81

27 Allen C, Glasziou P, Del Mar C. Bed rest: a potentially harmful treatment Lancet. 1999;354:1229–1233.

28 Treatment of Pressure Ulcers: Quick Reference Guide.

29 JAMA. 2008;300:2647–2662.

30 Cullum N, McInnes E, Bell-Syer SEM, Legood R. Support surfaces

31 Sibbald RG, Woo K, Ayello EA. Increased bacterial burden and infection: the Adv Skin Wound Care. 2006;19:447–461.

32 Drosou A, Falabella A, Kirsner RS. Antiseptics on wounds: an area of Wounds. 2003;15:149–166.

33 Am J Surg. 1986;151:400–406.

34 -

J Clin Pathol. 1976;29:752–755.

35 -

Postgrad Med J.

1993;69 suppl 3:S78–S83.

36 -

Chronic Wound

Care: A Clinical Source Book for Healthcare Professionals, Fourth Edi-

tion. Wayne, PA: Health Management Publications, Inc; 2007:443–449.

37 neuropathy with isosorbide dinitrate spray: a double-blind placebo-

Diabetes Care. 2002; 25:1699.

38 ulcers with nitroglycerin ointment. J Dermatol Surg Oncol. 1983;9:548.

SELF-TEST REVIEW QUESTIONSW. Clark Lambert, MD, PhD, Section EditorInstructions: For each of the following numbered questions, choose the appropriate lettered response(s). Unless directed to choose only one lettered response, all, some, or none of the responses may be correct.

1) skin tears in elderly patients are: (Choose the single best

response.)

a. facilities.

b.

c.

d. and waiting rooms.

e. bedroom.

2) (Choose the single best response.)

a. b. fourteen days.

c. d. e. three months.

3) Which of the following statements regarding treatment of

(Answer as many as apply.)

a. Compression is the most important aspect for

b. c. Arterial disease is not a contraindication for treatment

with compression.

d. -

cation for treatment with compression.

e. f.

compression treatment.

4) blood flow in: (Choose the single best response.)

a. elderly patients.

b. patients with diabetes mellitus.

c. d. e. all of these are correct.

5) Nitroglycerin patches should be applied: (Answer as many

as apply.)

a. early in management of all symptomatic ulcers in

b. early in management of all symptomatic ulcers in

patients who smoke more than one pack of cigarettes

per day.

c. for pain management only.

d. e.

potential to heal.

ANSWERS TO SELF-TEST REVIEW QUESTIONS:

1) e 2) c; 3) a, d, e; 4) e; 5) c, e

March/April 2012

82SKINmed. 2012;10:82–89

CORE CURRICULUMVirendra N. Sehgal, MD, Section Editor

Cutaneous Tuberculosis: A Diagnostic Dilemma— Laboratory Inputs

Virendra N. Sehgal, MD; Prashant Verma, MD; Sambit N. Bhattacharya, MD; Sonal Sharma, MD; Navjeevan Singh, MD; Nishant Verma, MD

-

-

DIAGNOSTIC MODALITIES

SKIN TESTS

TUBERCULIN TEST

-

-

proviso

-

-1

-2

-

6

7

6

MYCOBACTERIAL ANTIGEN, MPB64 TRANSDERMAL PATCH TEST

-8

9

INTERFERON-γ RELEASE ASSAYS

QUANTIFERON-TB GOLD TEST

Mycobacterium tuberculosis

Bacterial cultures are the gold standard for diagnosing cutaneous tuberculosis, but there are limitations, despite the advances embracing the innovative technologies, including interferon γ release assays, enzyme-linked immunoabsorbant assay, and molecular diagnostics, in addition to conventional skin tests and microscopic pathology. The results and their interpretation of cultures are reviewed for use in day-to-day practice.

From the Dermato-Venereology (Skin/VD) Center, Sehgal Nursing Home, Panchwati, Delhi; Department of Dermatology and STD, Department of Pathology, University College of Medical Sciences and Associated Guru Teg Bahadur Hospital, Delhi; Department of Microbiology, Maulana Azad Medical College and Associated Chacha Nehru Bal Chikitsalaya, Delhi, India

E-mail: [email protected]

March/April 2012

SKINmed. 2012;10:82–89

γ γ-

-

10

-11 -

γ

γγ

-

M tuber-

culosis 12

T-SPOT.TB TEST

M tuberculosis γ -

γ

-

γ -

-

γ -

-

-

12

MICROSCOPIC PATHOLOGY

FINE-NEEDLE ASPIRATION CYTOLOGY

-

16

-

-

-

17

HISTOPATHOLOGIC UNDERTONES

-18 19

SCROFULODERMA

-

-20 21

March/April 2012

SKINmed. 2012;10:82–89

TB CUTIS ORIFICIALIS

-

20

TUBERCULOUS GUMMA

-

Figure 1. (A) Cohesive epithelioid cell granuloma in an aspirate from a cervical lymph node (May-Grunwald-Giemsa stain, magnification ×400). (B) Single acid-fast bacillus in a fine-needle aspirate smear from a lymph node (Ziehl-Neelsen stain, magnification ×400).

A

B

Figure 2. Tuberculosis verrucosa cutis: Section show-ing marked hyperkeratosis and acanthosis. Epithelioid cell granulomas mixed with neutrophilic abscesses is prominent in the upper dermis (hematoxylin-eosin stain, original magnification ×40). Inset: hematoxylin-eosin stain, original magnification ×400.

DISSEMINATED MILIARY TB

TB VERRUCOSA CUTIS

22

LUPUS VULGARIS

LICHEN SCROFULOSORUM

-

March/April 2012

SKINmed. 2012;10:82–89

ERYTHEMA INDURATUM OF BAZIN

-

-

PAPULONECROTIC TUBERCULIDS

-

IMMUNOHISTOCHEMISTRY

M tuberculosis

M tuber-

culosis

-

-

-

26

Figure 4. Lichen scrofulosorum: Section showing perifollicular epithelioid cell granulomas with relative sparing of arrector pili muscle (hematoxylin-eosin stain, original magnification ×100).

Figure 5. Erythema induratum: Section showing septal pannicultis, vascular damage, neutrophil and macrophage infiltrate in the vessel wall, and thrombosis (hematoxylin-eosin stain, original magnification ×40). Inset: hematoxylin-eosin stain, original magnification ×400.

Figure 3. Lupus vulgaris: Section showing epithelioid cell granulomas with conspicuous prominent giant cells extending to mid-dermis along with hyperplastic epithelium depicting hyperkeratosis and acanthosis (hematoxylin-eosin stain, original magnification ×40). Inset: hematoxylin-eosin stain, original magnification ×100.

March/April 2012

86SKINmed. 2012;10:82–89

ISOLATION AND IDENTIFICATION OF M TUBERCULOSIS, IN VITRO CULTURE AND GUINEA PIG INOCULATION

IN VITRO RECOVERY OF M uberculosis

-

27–29

29

BACTEC SYSTEM

-

-

BACTEC MGIT 960 SYSTEM

-

MB-REDOX

-

MB CHEK (BIPHASIC MEDIUM)M tuberculosis

M tuberculosis

GUINEA PIG INOCULATION

-

IMMUNOCHROMATOGRAPHY

M tuberculosis

-

-

-

M

tuberculosis

HIGH-PERFORMANCE LIQUID CHROMATOGRAPHY

M tuberculosis

ENZYME-LINKED IMMUNOSORBENT ASSAY

-

-

-

March/April 2012

87SKINmed. 2012;10:82–89

MOLECULAR DIAGNOSIS

M tuberculosis -

-

M tuberculosis

M tuberculosis

-

-

M tuberculosis -

M tuberculo-

sis

M

tuberculosis

M tuberculosis

M tuberculosis

-

M tuberculosis

REAL-TIME PCR TECHNIQUE

-

M tuberculosis

DNA PROBES

–20

M tuberculo-

sis Mycobacterium avium

-

RIBOSOMAL RRNA-BASED PROBES

-

M tuberculosis,

Mycobacterium leprae M avium.

-

GENE AMPLIFICATION METHODS FOR IDENTIFICATION

March/April 2012

88SKINmed. 2012;10:82–89

-

-

kat

M tuberculosis -

ANTITUBERCULAR THERAPY AS A DIAGNOSTIC ADJUNCT

-

-

-

CONCLUSIONS

REFERENCES

1 World Health Organization: The WHO standard tuberculin test 1963.WHO/TB/Tech guide/3, Chahda VK. Tuberculin test. Ind J Paed. 2001;68:53–58.

2 Frankel A, Penrose C, Emer J. Cutaneous tuberculosis: a practical case report and review for the dermatologist. J Clin Aesthet Dermatol. 2009;2:19–27.

3 Brown FS, Anderson RH, Burnett JW. Cutaneous tuberculosis. J Am Acad Dermatol. 1982;6:101–106.

4 MacGregor RR. Cutaneous tuberculosis. Clin Dermatol. 1995;13:245–255.

5 Frankel A, Penrose C, Emer J. Cutaneous tuberculosis: a practical case report and review for the dermatologist. J Clin Aesthet Dermatol. 2009;2:19–27.

6 Pereira J. Tuberculids. Rev Port Pneumol. 2004;10:97–105.

7 Marcoval J, Servitje O, Moreno A, et al. Lupus vulgaris. Clinical, histo-pathologic, and bacteriologic study of 10 cases. J Am Acad Dermatol. 1992;26:404–407.

8 Nakamura RM, Einck L, Velmonte MA, et al. Detection of active tubercu-losis by an MPB-64 transdermal patch: a field study. Scand J Infect Dis. 2001;33:405–407.

9 Nakamura RM, Velmonte MA, Kawajiri K, et al. MPB64 mycobacterial an-tigen: a new skin-test reagent through patch method for rapid diagnosis of active tuberculosis. Int J Tuberc Lung Dis. 1998;2:541–546.

10 National Tuberculosis Controllers Association; Centers for Disease Con-trol and Prevention (CDC) Guidelines for the investigation of contacts of persons with infectious tuberculosis. Recommendations from the National Tuberculosis Controllers Association and CDC. MMWR Recomm Rep. 2005;54(RR-15).

11 Bocchino M, Chairadonna P, Matarese A, et al. Limited usefulness of QuantiFERON-TB Gold In-Tube for monitoring antituberculosis therapy. Respir Med. 2010;104:1551–1556.

12 Centers for Disease Control and Prevention. Updated Guidelines for Using Interferon Gamma Release Assays to Detect Mycobacterium Tu-berculosis Infection, United States. MMWR. 2010;59(No.RR-5).

13 Ribeiro S, Dooley K, Hackman J, et al. T-SPOT.TB responses during treat-ment of pulmonary tuberculosis. BMC Infect Dis. 2009;9:23.

14 Huo FF, Zhang LF, Liu XQ. Sensitivity of interferon-gamma release assay T-SPOT.TB in diagnosing extrapulmonary tuberculosis. Zhongguo Yi Xue Ke Xue Yuan Xue Bao. 2009;31:449–452.

15 Domínguez J, De Souza-Galvão M, Ruiz-Manzano J, et al. T-cell responses to the Mycobacterium tuberculosis-specific antigens in active tuberculo-sis patients at the beginning, during, and after antituberculosis treat-ment. Diagn Microbiol Infect Dis. 2009;63:43–51.

16 Kathuria P, Agarwal K, Koranne RV. The role of fine-needle aspiration cytology and Ziehl Neelsen staining in the diagnosis of cutaneous tuber-culosis. Diagn Cytopathol. 2006;34:826–829.

17 Bezabih M, Mariam DW, Selassie SG. Fine needle aspiration cytology of suspected tuberculous lymphadenitis. Cytopathology. 2002;13:284–290.

18 Elder DE, Elenitsas R, Ioffreda MD, et al. Atlas and Synopsis of Lever’s Histopathology of the Skin. 2nd ed. Philadelphia, PA: Lipincott Willams & Wolters Kluwer; 2007:230.

19 Bravo FG, Gotuzzo E. Cutaneous tuberculosis. Clin Dermatol. 2007;25:173–180.

20 Baek SE, Kang WH, Lee KH. Tuberculosis cutis orificialis. Korean J Der-matol. 1985;23:667–671.

21 Singal A, Bhattacharya SN. Lichen scrofulosorum: a prospective study of 39 patients. Int J Dermatol. 2005;44:489–493.

22 Sehgal VN, Sardana K, Bajaj P, Bhattacharya SN. Tuberculosis verrucosa cutis: antitubercular therapy, a well-conceived diagnostic criterion. Int J Dermatol. 2005;44:230–232.

23 Sehgal VN. Lichen scrofulosorum: current status. Int J Dermatol. 2005;44:521–523.

24 Padmavathyi L, Rao LL, Ramanadhan, et al. Mycobacterial antigen in tissues in diagnosis of cutaneous tuberculosis. Indian J Tuberc. 2005;52:31–35.

25 Mustafa T, Wiker HG, Mfinanga SG, et al. Immunohistochemistry using a Mycobacterium tuberculosis complex specific antibody for improved diagnosis of tuberculous lymphadenitis. Mod Pathol. 2006;19:1606–1614.

26 Kutzner H, Argenyi ZB, Requena L, et al. A new application of BCG anti-body for rapid screening of various tissue microorganisms. J Am Acad Dermatol. 1998;38:56–60.

27 Fariña MC, Gegundez MI, Piqué E, et al. Cutaneous tuberculosis: a clinical, histopathologic, and bacteriologic study. J Am Acad Dermatol. 1995;33:433–440.

28 Brown FS, Anderson RH, Burnett JW. Cutaneous tuberculosis. J Am Acad Dermatol. 1982;6:101–106.

29 API TB Consensus Guidelines 2006: Management of pulmonary tuber-culosis, extra-pulmonary tuberculosis and tuberculosis in special situa-tions. J Assoc Physicians India. 2006;54:219–234.

30 Diagnostic Standards and Classification of Tuberculosis in Adults and Children. This official statement of the American Thoracic Society and the Centers for Disease Control and Prevention was adopted by the ATS Board of Directors, July 1999. This statement was endorsed by the Council of the Infectious Disease Society of America, September 1999. Am J Respir Crit Care Med. 2000;161:1376–1395.

March/April 2012

89SKINmed. 2012;10:82–89

31 Aggarwal P, Singal A, Bhattacharya SN, et al. Comparison of the radio-metric BACTEC 460 TB culture system and Löwenstein-Jensen medium for the isolation of mycobacteria in cutaneous tuberculosis and their drug susceptibility pattern. Int J Dermatol. 2008;47:681–687.

32 Tortoli E, Cichero P, Piersimoni C, et al. Use of BACTEC MGIT 960 for recovery of mycobacteria from clinical specimens: multicenter study. J Clin Microbiol. 1999;37:3578–3582.

33 Piersimoni C, Scarparo C, Cichero P, et al. Multicenter evaluation of the MB-Redox medium compared with radiometric BACTEC system, myco-bacteria growth indicator tube (MGIT), and Löwenstein-Jensen medium for detection and recovery of acid-fast bacilli. Diagn Microbiol Infect Dis. 1999;34:293–299.

34 Luquin M, Gamboa F, Barcelo MG, et al. Comparison of a biphasic non radiometric system with Lowenstein Jensen and BACTEC 460 system for recovery of mycobacteria from clinical samples. Tuber Lung Dis. 1996;77:449–453.

35 Piersimoni C, Morbiducci V, De Sio G, et al. Comparative evaluation of the MB-check system for recovery of mycobacteria from clinical speci-mens. Eur J Clin Microbiol Infect Dis. 1992;11:1174–1177.

36 Abe C, Hosojima S, Fukasawa Y, et al. Comparison of MB chek, BACTEC and egg-based media for recovery of mycobacteria. J Clin Microbiol. 1992;30:878–881.

37 Pallen MJ. The inoculation of tissue specimens into guinea-pigs in sus-pected cases of mycobacterial infection does it aid diagnosis and treat-ment? Tubercle. 1987;68:51–57.

38 Peluffo G, de Kantor IN. Bacteriologic diagnosis of extrapulmonary tuberculosis in a general hospital. Rev Argent Microbiol. 1982;14:91–96.

39 Schneider JW, Jordaan HF, Geiger DH, et al. Erythema induratum of Bazin. A clinicopathological study of 20 cases and detection of Mycobacterium tuberculosis DNA in skin lesions by polymerase chain reaction. Am J Dermatopathol. 1995;17:350–356.

40 Hasegawa N, Miura T, Ishii K, et al. New simple and rapid test for cul-ture confirmation of Mycobacterium tuberculosis complex: a multicenter study. J Clin Microbiol. 2002;40:908–912.

41 Jost KC, Chiu SH, Kenney TM, et al. American Society for Microbiology. General Meeting. Identification and quantitation of Mycobacterium tuber-culosis directly from clinical specimens by fluorescence detection high-performance liquid chromatography. Abstr Gen Meet Am Soc Microbiol. 1997;97:568.

42 Charpin D, Herbault H, Gevaudan MJ, et al. Value of ELISA using A 60 antigen in the diagnosis of active pulmonary tuberculosis. Am Rev Respir Dis. 1990;142:380–384.

43 Arya L, Koranne RV, Deb M. Cutaneous tuberculosis in children a clinico-microbiological study. Indian J Dermatol Venereol Leprol. 1999;65:137–139.

44 Rao L, Padmavathy L. Utility of MycoDot test in the diagnosis of cutane-ous tuberculosis. Indian J Dermatol Venereol Leprol. 2003;69:428–429.

45 Balasingham SV, Davidsen T, Szpinda I, et al. Molecular diagnostics in tuberculosis: basis and implications for therapy. Mol Diagn Ther. 2009;13:137–151.

46 Honoré-Bouakline S, Vincensini JP, Giacuzzo V, et al. Rapid diagnosis of

extrapulmonary tuberculosis by PCR: impact of sample preparation and

DNA extraction. J Clin Microbiol. 2003;41:2323–2329.

47 Cheng VC, Yew WW, Yuen KY. Molecular diagnostics in tuberculosis. Eur

J Clin Microbiol Infect Dis. 2005;24:711–720.

48 Abdalla CM, de Oliveira ZN, Sotto MN, et al. Polymerase chain reac-

tion compared to other laboratory findings and to clinical evaluation in

the diagnosis of cutaneous tuberculosis and atypical mycobacteria skin

infection. Int J Dermatol. 2009;48:27–35.

49 Padmavathy L, Rao L, Veliath A. Utility of polymerase chain reaction as

a diagnostic tool in cutaneous tuberculosis. Indian J Dermatol Venereol

Leprol. 2003;69:214–216.

50 Salian NV, Rish JA, Eisenach KD, et al. Polymerase chain reaction to

detect Mycobacterium tuberculosis in histologic specimens. Am J Respir

Crit Care Med. 1998;158:1150–1155.

51 Ortu S, Molicotti P, Sechi LA, et al. Rapid detection and identification of

Mycobacterium tuberculosis by Real Time PCR and Bactec 960 MIGT.

New Microbiol. 2006;29:75–80.

52 Katoch VM. Newer diagnostic techniques for tuberculosis. Indian J Med

Res. 2004;120:418-428.

53 Katoch VM, Kanaujia GV, Shivannavar CT, et al. Progress in developing

ribosomal RNA and rRNA gene(s) based probes for diagnosis and epi-

demiology of infections diseases specially leprosy. In: Sushil Kumar, Sen

AK, Dutta GP, Sharma RN, eds. Tropical Diseases—Molecular Biology and

Control Strategies. 1st ed. New Delhi, India: Council for Scientific and

Industrial Research; 1994:581–587.

54 Roth A, Reischl U, Streubel A, Naumann L, et al. Novel diagnostic algo-

rithm for identification of mycobacteria using genus specific amplifica-

tion of 16S-23S rRNA gene spacer and restriction endonucleases. J Clin

Microbiol. 2000;38:1094–1104.

55 Sehgal VN, Sardana K, Bajaj P, et al. Tuberculosis verrucosa cutis: anti-

tubercular therapy, a well-conceived diagnostic criterion. Int J Dermatol.

2005;44:230–232.

56 Sehgal VN, Sardana K, Sehgal R, et al. The use of anti-tubercular therapy

(ATT) as a diagnostic tool in pediatric cutaneous tuberculosis. Int J Der-

matol. 2005;44:961–963.

57 Ramam M, Mittal R, Ramesh V. How soon does cutaneous tuberculosis

respond to treatment? Implications for a therapeutic test of diagnosis. Int

J Dermatol. 2005;44:121–124.

58 Sehgal VN, Sardana K, Sharma S. Inadequacy of clinical and/or laboratory

criteria for the diagnosis of lupus vulgaris, re-infection cutaneous tuberculo-

sis: fallout/implication of 6 weeks of anti-tubular therapy (ATT) as a precise

diagnostic supplement to complete the scheduled regimen. J Dermatolog

Treat. 2008;19:164–167.

FORMULARY OF DR GEORGE C. ANDREWS

LIQUID ROUGE

Carmine gr.v

Aq. Ammon mx.v

Alcohol 3 i ss

Ol. Rose gtt.1

Aq. Rosae 3 i

Mix and filter

Submitted by Douglas D. Altchek, MD, New York, NY.

March/April 2012

90SKINmed. 2012;10:90–92

From the Class of 2012, New Jersey Medical School, Newark, NJ;1 the Departments of Pathology and Dermatology, UMDNJ-New Jersey Medical School, Newark, NJ;2 and the Class of 2015, St. George’s University School of Medicine, Grenada, West Indies3

Address for Correspondence: W. Clark Lambert, MD, PhD, Room C520 MSB, UMDNJ-NJMS, 185 South Orange Avenue, Newark, NJ 07103

K -1 -

2

-

3

-

-4 5

6

7 8

-9 10

-

CHARACTERISTICS

-

-

-

11

12

12 13

PERILS OF DERMATOPATHOLOGYW. Clark Lambert, MD, PhD, Section Editor

Sometimes It Takes Darkness to See the Light: Pitfalls in the Interpretation of Cell Proliferation

Markers (Ki-67 and PCNA) Carmen Castilla, BS;1 Patrick McDonough, BA;1 Gizem Tumer, MD;2 Peter C. Lambert, BA, MS;3

W. Clark Lambert, MD, PhD2

“[Clarity], like a photograph, develops in the dark.

March/April 2012

91SKINmed. 2012;10:90–92

Figure 1. (A) Multiple nests of melanocytes are shown in malignant melanoma. (B) Ki-67 immunostain showing increased reactivity. Black arrowhead indicates a melanin pigment. Red arrowheads indicate increased Ki-67 labeling in or above the basal layer, indica-tive of cell proliferation or of ultraviolet exposure within the previous 24 hours. Full black arrows indicate a hypocellular dermis, indicative of long term ultraviolet exposure.

Figure 2. showing increased Ki-67 proliferation index above the basal layer (arrowheads) due to ultraviolet exposure.

Figure 3. DNA replication fork illustrating DNA synthesis along the leading and lagging strand. Proliferating cell nuclear antigen (PCNA) is shown in pink acting as a clamp to secure polymerase delta (shown in green) and polymerase epsilon (shown in teal) to the DNA strand, allowing for greater efficiency of nucleotide addition.

March/April 2012

92SKINmed. 2012;10:90–92

14

-

15 -

16

CONCLUSIONS

-

-

-

-

REFERENCES

1 Scholzen T, Gerdes J. The Ki-67 protein: from the known and the unknown. J Cell Physiol. 2000;182:311–322.

2 Duchrow M, Schluter C, Wholenberg C, Flad HD, Gerdes J. Molecular characterization of the gene locus of the human cell proliferation- associated nuclear protein defined by monoclononal antibody Ki-67. Cell Prolif. 1996;29:1–12.

3 Schmidt M, Broll R, Bruch H, Duchrow M. Proliferation marker pKi-67 affects the cell cycle in a self regulated manner. J Cell Biochem. 2002;87:334–341.

4 Soyer HP. Ki 67 immunostaining in melanocytic skin tumors. Correlation with histological parameters. J Cutan Pathol. 1991;18:264–272.

5 of p27kip1, p45skp2 and Ki67 expression profiles in Merkel cell

carcinoma, extracutaneous small cell carcinoma, and cutaneous squamous cell carcinoma. Histopathology. 2005;46:614–621.

6 Chen GS, Wu TM, Yang SA, Yu HS. Quantitative assessments of physiological and biological parameters in psoriatic lesions and its correlations to the clinical severity of psoriasis. Kaohsiung J Med Sci. 2001;17:408–418.

7 Yazici AC, Tursen U, Apa DD, et al. The changes in expression of icam-3, ki-67, pcna, and cd31 in psoriatic lesions before and after methotrexate treatment. Arch Dermatol Res. 2005;297:249–255.

8 -noic acid metabolism blocking agent rambazole for plaque pso-riasis: an immunohistochemical study. Br J Dermatol. 2005;156:263–270.

9 keratinocyte proliferation and epidermal hyperplasia through the activation of the epidermal growth factor receptor. Carcinogenesis. 2006;27:225–231.

10 expression of Ki-67, topoisomerase IIalpha, PCNA, p53 and p21WAF1/Cip1 reflecting proliferation and repair activity in UV-irradiated melano-cytic nevi. Hum Pathol. 1998;29:1480–1487.

11 Overmeer RM, Gourdin AM, Giglia-Mari A, et al. Replication factor C recruits DNA polymerase delta to sites of nucleotide excision repair but is not required for PCNA recruitment. Mol Cell Biol. 2010;30:4828–4839.

12 on the expression of proliferating cell nuclear antigen in murine skin. Photochem Photobiol. 2004;80:587–595.

13 proteins (proliferating cell nuclear antigen and Ki-67 antigen) in Bowen’s disease. Br J Dermatol. 1994;131:231–236.

14 Hall PA, McKee PH, Menage HD, Dover R, Lane DP. High levels of p53 pro-tein in UV-irradiated normal human skin. Oncogene. 1993;8:203–207.

15 Freudenthal BD. Studies of proliferating cell nuclear antigen and its role in translesion synthesis [PhD dissertation]. Iowa City: University of Iowa; 2010.

16 McDonough P, Castilla C, Tumer G, Lambert WC. Interpretation of Ki-67 stain confounded by patient exposure to ultraviolet radiation prior to skin biopsy. J Euro Acad Venereol Dermatol. [In press.]

VINTAGE LABEL

Soothing and alcohol-free — part of a complete approach to acne treatment

TM C A L M I N G

WIPES(30 WIPES)

Complementary T3 Calming Wipes

A dual approach to acne care

ONE PRESCRIPTION.TWO POWERFUL EFFECTS.

The power to eradicate P acnesSignificant reduction in P acnes—even up to 3 weeks after discontinuation2

A decrease in P acnes can lead to a drop in pro-inflammatory cytokines and reduced inflammation1

Minimal resistance in an in vitro study

—The majority of tetracycline-resistant P acneswere cross-resistant to doxycycline—but sensitive to minocycline*3

The power to calm inflammatory acneInflammation is an important aspect in the pathophysiology of acne1

Both laboratory and clinical studies document the anti-inflammatory effects of minocycline1

+

The most common adverse events associated with MINOCIN are nausea, vomiting, and diarrhea. CNS adverse effects may includedizziness, vertigo, and headache.

References: 1. SapadinAN,Fleischmajer R.Tetracyclines:nonantibiotic properties and their clinical implications.JAmAcad Dermatol. 2006;54(2):258-265. 2. Leyden JJ,McGinley KJ,KligmanAM.Tetracycline and minocyclinetreatment.Arch Dermatol. 1982;118(1):19-22. 3. Hubbell CG,Hobbs ER,RistT,White JW Jr.Efficacy of minocycline compared with tetracycline in treatment of acne vulgaris.Arch Dermatol.1982;118(12):989-992.

*In vitro activity does not necessarily correlate to in vivo activity.

©2010 Triax Pharmaceuticals, LLC All rights reserved. Printed in USA. MN-0810-280

Important InformationThe most common adverse events associated with MINOCIN are nausea, vomiting, and diarrhea. Central nervous system adverse events includinglight-headedness, dizziness, or vertigo have been reported with minocycline therapy, but are generally transient in nature. Other adverse eventsinclude tinnitus, headache, sedation, and skin pigmentation, particularly on the face and mucous membranes. MINOCIN is contraindicated in personswho have shown hypersensitivity to any of the tetracyclines or to any of the components of the product formulation. WARNING: MINOCIN Pellet-Filled Capsules, like other tetracycline-class antibiotics, can cause fetal harm when administered to a pregnant woman. The use of drugs of thetetracycline class during tooth development (last half of pregnancy, infancy, and childhood to the age of 8 years) may cause permanent discoloration of teeth (yellow-gray-brown). Concurrent use of tetracyclines may render oral contraceptives less effective.

For more information, go to www.minocin-kit.com

The only pelletized form of Minocycline available...

March/April 2012

94SKINmed. 2012;10:94–97

A

-

-

-

Mycobacterium leprae

-

1 2

4 5

DIAGNOSIS

CLINICAL PRESENTATION

-

-

-

-

M leprae

-

-

INFECTIOUS DISEASE CAPSULESJack M. Bernstein, MD, Section Editor

The Lion Is NOT Sleeping Tonight David R. Carr, MD;1,4 Jack M. Bernstein, MD;2,3 Julian Trevino, MD1,4

From Medical1 and Research2 Services, VA Medical Center, Dayton, OH; and the Department of Medicine3 and the Department of Dermatology,4 Boonshoft School of Medicine, Wright State University, Dayton, OH

March/April 2012

95SKINmed. 2012;10:94–97

-

-

7

-

M leprae

-

Figure 3.

Figure 2. Multiple, 2–8 mm dermal papules over the dorsal surface of the feet.Figure 1. Multiple, 2–8 mm dermal papules over the ears.

-

March/April 2012

SKINmed. 2012;10:94–97

-

9

DIAGNOSTIC TOOLS

-

M leprae -10

4

M leprae

11

M leprae -

12

M leprae.

M leprae -

TREATMENT

-14

-

-

1 15

Table I. Ridley-Jopling Leprosy Classification

CATEGORIES CLINICAL FINDINGS NERVE INVOLVEMENT BACILLI PRESENCE

−

+/−

+/−

-

culoid+

-+

+/−

March/April 2012

97SKINmed. 2012;10:94–97

M leprae

-

CONCLUSIONS

-

REFERENCES

1 Clin Dermatol. 2007;25:165–172.

2 Global leprosy situation. Wkly Epidemiol Rec. 2005;80:289–295. 25:165–172.

3 Global leprosy situation. Wkly Epidemiol Rec. 2005;80:289–295.

4 nia J, Jorizzo JL, Rapini RP. Dermatology1145–1152.

5 Canizares O, Harman R, Adriaans B. Leprosy. In: Clinical Tropi-cal Dermatology165–200.

6 Int J Lepr. 1966;34:255–273.

7 impairment in leprosy: design, methodology, and intake status of a

Lepr Rev. 1999;70:140–159.

8 Quismorio FP, Rea T, Chandors, et al. Lucio’s phenomenon: an immune complex deposition syndrome in lepromatous leprosy. Clin Immunol Immunopathol. 1978;9:184–193.

9 Kaur C, Thami GP, Mohan H. Lucio phenomenon and Lucio leprosy. Clin Exp Dermatol. 2005;30:525–527.

10 Job CKreference to early diagnosis and leprous neuropathy. Indian J Lepr. 2007;79:75–83.

11 Silva EA, Iyer A, Ura S, et al. Utility of measuring serum levels of

Trop Med Int Health. 2007;12:1450–1458.

12 Kamal R, Dayal R, Katoch VM, Katoch K. Analysis of gene probes and

in childhood leprosy. Lepr Rev. 2006;77:141–146.

13 Scollard DM, Adams LB, Gillis TP, et al. The continuing challenges of leprosy. Clin Microbiol Rev. 2006;19:338–381.

14

15 World Health Organization. Chemotherapy of leprosy for control programmes. Tech Rep Ser Geneva. 1982:675.

Table II. Multidrug Therapy: World Health Organization Guidelines14

TYPE OF LEPROSY TREATMENT REGIMEN

TREATMENT DURATION

March/April 2012

98SKINmed. 2012;10:98

From the Department of Dermatology, Nelson R. Mandela School of Medicine, Durban, South Africa

PHOTO CAPSULESNcoza C. Dlova, MBChB, FCDerm, Section Editor

ActinomycetomaNcoza C. Dlova, MBChB, FCDerm; Anisa Mosam, MBChB, FCDerm

A Norcadia brasiliensis

Figure 1. Actinomycetoma of the right foot. Figure 2. Actinomycetoma of the groin.

VINTAGE LABEL

[email protected]

University of AthensMedical School,Athens, Greece

DERMATOLOGYOF COSMETICWORLD CONGRESS

BY THE INTERNATIONAL ACADEMYOF COSMETIC DERMATOLOGY

ATHENS, GREECEJUNE 27-30, 2013

C o n g r e s s O r g a n i s i n g B u r e a uERASMUS CONFERENCES TOURS & TRAVEL S.A.E-mail: [email protected]: www.erasmus.gr

March/April 2012

100SKINmed. 2012;10:100–102

From the Department of Dermatology, Louisiana State University Health Science Center, New Orleans, LA

Address for Correspondence: Scott M. Jackson, MD, LSUHSC, New Orleans, Department of Dermatology, 1542 Tulane Avenue, 6th Floor,

CASE STUDYVesna Petronic-Rosic, MD, MSc, Section Editor

Malignant Melanoma Arising Within Nevus SpilusSusan L. Karam, BS; Scott M. Jackson, MD

-

-

-

N 1

2–

7

8

-8–22

2

7

11

12

-6

-

12

-

-

10

12

March/April 2012

101SKINmed. 2012;10:100–102

26

2

-

-

1

Figure 1. Oval tan patch studded with hyperpigmented macules and melanoma at the margin of lesion.

Figure 3. and eosin, original magnification ×40).

Figure 2. and eosin, original magnification ×10).

March/April 2012

102SKINmed. 2012;10:100–102

-

-

CONCLUSIONS

10

-

-

REFERENCES

1 Dermatol-

ogy

2 Cohen JH, Minkin W, Frank SB. Nevus spilus. Arch Dermatol. 1970;

3 spilus. Int J Dermatol

4 nous melanomas: case report and literature review. J Cutan Med Surg.

5 Sigg C, Pelloni F, Schnyder UW. Frequency of congenital nevi, nevi spili

Dermatologica

6 other pigmented lesions of schoolchildren: the Vancouver Mole Study. J Am Acad Dermatol

7 like nevi, nevi spili, and café au lait spots. Arch Dermatol

8 noma developing in a speckled lentiginous nevus. Int J Dermatol.

9 case report and review of the literature. J Cutan Med Surg. 2010;14:

10 within the spectrum of congenital melanocytic nevi. Arch Dermatol.

11 teriform lentiginous nevus. Int J Dermatol

12 dysplastic nevus spilus. Arch Dermatol

13

J Cutan Pathol

14 spilus. Cutis

15 nous nevus. Arch Dermatol

16 Haenssle HA, Kaune KM, Buhl T, et al. Melanoma arising in segmental J Am Acad

Dermatol



19 acquired dermal melanocytosis on congenital nevus spilus. J Dermatol.

20 cursor of cutaneous melanoma: report of a case and literature review. Clin Exp Dermatol

21 Arch Dermatol

22 lentiginous nevus. J Am Acad Dermatol

23 Kaur TD, Kanwar AJ. Giant nevus spilus and centrofacial lentiginosis. Pediatr Dermatol

24 Br J Dermatol

25 Arch Dermatol

26 Cohen LM. Nevus spilus: congenital or acquired? Arch Dermatol.

March/April 2012

104SKINmed. 2012;10:104–106

From the Department of Dermatology and Cutaneous Biology, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA

Address for Correspondence: Alexis Sheaffer, BS, 1000 Walnut Street, Orlowitz Apartment 609, Philadelphia, PA 19107

CASE STUDY

Pseudocyst of the Auricle: An Uncommon Entity of the Ear

P 1–5

5

HISTOLOGY

8–10 -

9 -10

10

11

-

8

-10

THEORIES

-

4

12

-

-11

1

-

-10

March/April 2012

105SKINmed. 2012;10:104–106

-

12 -14

15

16

-16

β1

18 -

1

TREATMENTS

-

-

10

19

-

-

-10

Figure 1. Pseudocyst at the junction of the scaphoid fossa and superior

Figure 2. surface of an intracartilagenous cystic cavity at the base of the specimen (hematoxy

Figure 3.

flanked by degenerative cartilage at

March/April 2012

106SKINmed. 2012;10:104–106

-10

-

-

-10

-

6

1

-

1

10

-

-

-19

1

CONCLUSIONS

-

-

REFERENCES

1 Am J Otolaryngol

2 Lever’s Histopathology of the Skin

3 Arch Otolaryngol Head Neck Surg

4 Arch Otolaryngol

5 Arch Otolaryngol

6 Cutis

7 J Am Acad Dermatol

8 Laryngoscope

9 Weedon’s Skin Pathology

10 J Am Acad Dermatol

11 Laryngoscope

12 J Dermatol Surg Oncol

13 J Laryngol Otol

14 J Clin Pathol

15 Ann Plast Surg

16 in and intralesional steroid injection therapy for pseudocyst of the au

Inter J Dermatol

17

Am J Reprod Immunol

18

Ann Rheum Dis

19 J Otolaryngol

March/April 2012

108SKINmed. 2012;10:108–110

From the Department of Dermatology, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey

Address for Correspondence: Ayse Esra Koku Aksu, MD, Eskisehir Osmangazi University Faculty of Medicine, Department of Dermatology,

CASE STUDY

Necrotic Ulcer: A Manifestation of Leukemia CutisAyse Esra Koku Aksu, MD; Zeynep Nurhan Saracoglu, MD; Ilham Sabuncu, MD; Evrim Ciftci, MD;

Zafer Gulbas, MD; Serap Isiksoy, MD

-

-

2 -

-

-

-

7– -

10–12

12

-

March/April 2012

SKINmed. 2012;10:108–110

-

-

-

-17

-

18

8

CONCLUSIONS

12

-

-

REFERENCES

1 Br J Haema-

tol

2

WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues

3 Hypertension: Pathophysiology, Diagnosis and Man-

agement.

4 Cutis

5 J Cutan Pathol

6

Fitzpatrick’s Dermatology Treatment in General Medicine

7 tion, treatment and prognosis in a series of eight patients with leukaemia

Clin Exp Dermatol

8 trates in patients with myelogenous leukemia: a clinicopathologic study

J Am Acad Derma-tol

9 Arch Dermatol

10 Cancer

11

Cutis

Figure 2.

Figure 1.

March/April 2012

110SKINmed. 2012;10:108–110

12 mographic, hematological, and cytogenetic findings and prognosis in

Ann Hematol

13 following allogeneic bone marrow transplantation for acute myeloge

Bone Marrow Transplant

14 J Cutan Pathol

15 Br J Derma-

tol

16 Haematologica

17 Pathology of the Skin With Clinical

Correlations

18 Lever’s Histopathology of the Skin

Diagnosis and treatments have advanced over the past century. This feature depicts conditions from a collection of steroptic cards published in 1910 by by Dr. S. I. Rainforth.

HISTORICAL DIAGNOSIS & TREATMENT

SYPHILIS PRIMARIA:

A few days after the appearance of the chancre it is not uncommon to palpate a few hard painless cords which vary in thick

They are lymphatic vessels which have become specifically indurated, plugged with agglutinated leucocytes or compressed by

inflammatory edema however, in that it is very firm and elastic, like caoutchouc, and does not pit on pressure, its border is rather abrupt in its substance the hard lymphatic cords can often be felt, the skin over the affected area is nearly always dusky

Although a comparatively rare accompaniment of the primary sore this peculiar form of edema, when it is well marked, is a

Arnika Forte®

SPEED THE HEALING

Arnika Forte®

The New Gold Standardfor treating bruising,swelling, pain

1st and only combination of Arnica Montana 30x and Bromelain

One convenient capsuletwice a day

All natural, safe,physician - formulated

Speed the healing timefrom bruising, swelling andpain after surgery or dermalfiller injections

To Order Call 484-568-0306

�

�

�

March/April 2012

112SKINmed. 2012;10:112–113

CASE STUDY

Inflammatory Linear Verrucous Epidermal Nevus With Genital Involvement

Didem Didar Balci, MD;1 Jülide Zehra Yenin, MD;1 Ebru Çelik, MD;1 Gökhan Sarikaya, MD;1 Esin Atik, MD2

From the Departments of Dermatology,1 and Pathology,2 Mustafa Kemal University, Hatay, Turkey

Address for Correspondence: Didem Didar Balci, MD, Associate Professor, Mustafa Kemal University, Faculty of Medicine, Department of

E -

1–3 Ver-

-

1 -

-

3

-

-4

2

5 -2

-1– 5

1–3

-

2

5–

-

5

-

-

March/April 2012

113SKINmed. 2012;10:112–113

-

-1–3

-

CONCLUSIONS

-

10

11

-

-

REFERENCES

1

Fitzpatrick’s Dermatology in General Medicine

2 Pediatrik Dermatoloji

3 Dermatology

4 Arch Dermatol

5 Australas J Dermatol

6 Australas J Dermatol

7 Pediatr Dermatol

8

Aesthetic Plast Surg

9 Acta Derm Venereol

10 Arch Derma-

tol

11

Ann Plast Surg

Figure. Linear erythematous, lichenified, verrucous papules

CASE STUDY

Chronic Lymphocytic Leukemia Revealed by a Granulomatous Zosteriform EruptionSondes Trojjet, MD; Houda Hammami, MD; Inès Zaraa, MD; Alia Bouzguarrou, MD; Meriem Joens, MD; Slim Haouet, MD;

Amel Ben Osman, MD; Mourad Mokni, MD

March/April 2012

114SKINmed. 2012;10:114–115

O1

2

3

CASE STUDY

Oral Frictional Hyperkeratosis (Morsicatio Buccarum): An Entity to Be Considered in the Differential

Diagnosis of White Oral Mucosal LesionsKristin Cam, MD;1 Anthony Santoro, MD;2 Jason B. Lee, MD1

From the Department of Dermatology and Cutaneous Biology, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA;1 and Doylestown Dermatology, Doylestown, PA2

Address for Correspondence: Jason B. Lee, MD, Department of Dermatology and Cutaneous Biology, Jefferson Medical College of Thomas

Figure 1. Whitish plaque with an irregular surface on the left mucosa near the line of dental occlusion.

March/April 2012

115SKINmed. 2012;10:114–115

4

4

CONCLUSIONS

Figure 2. A biopsy of the lesion showing psoriasiform hyperplasia, surface epithelium with ballooning degeneration,* and parakeratosis colonized by numerous bacteria** (hematoxylin and eosin stain, magnification ×100).

Figure 3. Swabbed specimen from the buccal mucosa show

(hematoxylin and eosin stain, original magnification ×100).

keratosis (hematoxylin and eosin stain, magnification ×400).

REFERENCES

1 Obermayer M. Cheekbiting (morsicatio buccarum). Arch Dermatol. 1964;90:185–190.

2 tal patients. Ann Saudi Med. 2009;29:365–368.

3 Krahl D, Altenburg A, Zouboulis CC. Reactive hyperplasias, precancerous and malignant lesions of the oral mucosa. J Dtsch Dermatol Ges. 2008;6:217–232.

4 Woo S and Lin D. Moriscatio mucosae oris—a chronic oral frictional keratosis, not a leukoplakia. J Oral Maxillofac Surg. 2009;67:140–146.

March/April 2012

116SKINmed. 2011;10:116–118

From the Department of Dermatology, Venereology & Leprology,1 and the Department of Pathology,2 Gian Sagar Medical College & Hospital, Ram Nagar, Banur, Patiala, India

Address for Correspondence: Varinder Singh, MD, Associate Professor, Department of Dermatology, Venereology & Leprology, Gian Sagar

CASE STUDY

Vesicular Palmoplantar Pityriasis RoseaVarinder Singh, MD;1 Meghna Sharma, MD;1 Tarun Narang, MD;1 Manas Madan, MD2

-

-

P 1

-

2

2

-

-

-

-

6

6 -

-

9

March/April 2012

SKINmed. 2012;10:116–118

10

11

chlamydia12

CONCLUSIONS

Figure 3. Focal spongiosis and slight exocytosis in the

Figure 4.

Figure 1.

Figure 2.

A

B

March/April 2012

118SKINmed. 2012;10:116–118

REFERENCES

1 Textbook of Dermatology

2 J Am Acad Dermatol.

3 Dermatologica.

4

Dermatology.

5 Arch Dermatol Syph.

6 J Eur Acad Dermatol Venereol.

7 Arch Dermatol.

8 Cochrane Database Syst Rev.

9 J Drugs Dermatol.

10 J Drugs Dermatol.

11 potential? J Antimicrob Chemother.

12 Eur J

Dermatol.

VINTAGE LABELS

March/April 2012

120SKINmed. 2012;10:120

nosocological mobius

-

-

-

-

review Hall’s Manual of Skin as a Marker of Underlying Disease

1 2 3 -

-

-

-

-

REFERENCES

1 Braverman IM. Skin Signs of Systemic Disease. 3rd ed. Philadelphia, PA: W.B. Saunders Co; 1998.

2 Callen, JP, Jorizzo, JL, Bolognia, JL, Piette, W, Zone JJ. Dermatological Signs of Internal Disease. 4th ed. Philadelphia, PA: W.B. Saunders Co; 2009.

3 Provost TT, Flynn JA. Cutaneous Medicine: Cutaneous Manifestations of Systemic Disease. Hamilton, Ontario: BC Decker Inc; 2001.

BOOK REVIEWNoah S. Scheinfeld, MD, JD, Section Editor

Hall’s Manual of Skin as a Marker of Underlying Disease

Edited by John C. Hall and Brian J. Hall. 300 pages. Shelton, CT; People’s Medical Publishing House–USA; 2011. $89.95. ISBN 1607951029

Reviewed by Noah S. Scheinfeld, MD, JD

From the Department of Dermatology, Columbia University, College of Physicians and Surgeons, New York, NY

Address for Correspondence: Noah S. Scheinfeld, MD, JD, Department of Dermatology, Columbia University, College of Physicians and Surgeons, 150 West

Locoid Lipocream® Cream, 0.1% Rx Only(hydrocortisone butyrate 0.1% cream)For Topical Use Only

BRIEF SUMMARY

INDICATIONS AND USAGELocoid Lipocream is a topical corticosteroid indicated for: relief of the inflammatoryand pruritic manifestations of corticosteroid-responsive dermatoses in adults andthe treatment of mild to moderate atopic dermatitis in patients 3 months to 18 yearsof age.

WARNINGS AND PRECAUTIONSReversible hypothalamic-pituitary-adrenal (HPA) axis suppression may occur, withthe potential for glucocorticosteroid insufficiency. Consider periodic evaluations forHPA axis suppression if Locoid Lipocream is applied to large surface areas or usedunder occlusion. If HPA axis suppression is noted, reduce the application frequency,discontinue use, or switch to a lower potency corticosteroid. Systemic effects of topical corticosteroids may also include manifestations ofCushing’s syndrome, hyperglycemia, and glucosuria. Pediatric patients may be more susceptible to systemic toxicity due to their largerskin surface-to-body-mass ratios. Initiate appropriate therapy if concomitant skin infections develop. Discontinue use if irritation develops.

ADVERSE REACTIONSThe most common adverse reactions (>1%) are HPA axis suppression andapplication site reactions.The following additional local adverse reactions have been reported infrequentlywith topical corticosteroids, and they may occur more frequently with the use ofocclusive dressings and higher potency corticosteroids. These reactions included:irritation, folliculitis, acneiform eruptions, hypopigmentation, perioral dermatitis,allergic contact dermatitis, secondary infection, skin atrophy, striae, miliaria andtelangiectasia.

USE IN SPECIFIC POPULATIONSPregnancyPregnancy Category C. Corticosteroids have been shown to be teratogenic inlaboratory animals when administered systemically at relatively low dosage levels.Some corticosteroids have been shown to be teratogenic after dermal applicationin laboratory animals.There are no adequate and well-controlled studies inpregnant women. Therefore, Locoid Lipocream should be used during pregnancyonly if the potential benefit justifies the potential risk to the fetus.Please refer to full prescribing information for detailed information regardingsystemic embryofetal development studies.Nursing MothersSystemically administered corticosteroids appear in human milk and couldsuppress growth, interfere with endogenous corticosteroid production, or causeother untoward effects. It is not known whether topical administration ofcorticosteroids could result in sufficient systemic absorption to produce detectablequantities in human milk. Because many drugs are excreted in human milk, cautionshould be exercised when Locoid Lipocream is administered to a nursing woman.Pediatric UseSafety and efficacy in pediatric patients below 3 months of age have not beenestablished. Because of higher skin surface-to-body-mass ratios, pediatric patients are at agreater risk than adults of HPA axis suppression when they are treated with topicalcorticosteroids. They are therefore also at a greater risk of glucocorticosteroidinsufficiency after withdrawal of treatment and of Cushing’s syndrome while ontreatment. Eighty-six (86) pediatric subjects (5 months to less than 18 years of age) withmoderate to severe atopic dermatitis affecting at least 25% of body surface area(BSA) treated with Locoid Lipocream three times daily for up to 4 weeks wereassessed for HPA axis suppression. The disease severity (moderate to severeatopic dermatitis) and the dosing regimen (three times daily) in this HPA axis studywere different from the subject population (mild to moderate atopic dermatitis) andthe dosing regimen (two times daily) for which Locoid Lipocream is indicated. Five of the 82 evaluable subjects (6.1%) demonstrated laboratory evidence ofsuppression, where the sole criterion for defining HPA axis suppression was aserum cortisol level of less than or equal to 18 micrograms per deciliter aftercosyntropin stimulation. Suppressed subjects ranged in age from 5 months to 16 years and, at the time of enrollment, had 25% to 95% BSA involvement. Thesesubjects did not develop any other signs or symptoms of HPA axis suppression. At the first follow up visit, approximately one month after the conclusion oftreatment, cosyntropin stimulation results of all subjects had returned to normal,with the exception of one subject. This last subject recovered adrenal function bythe second post treatment visit, 65 days post-treatment. Cushing’s syndrome, linear growth retardation, delayed weight gain, andintracranial hypertension have also been reported in pediatric patients receivingtopical corticosteroids. Manifestations of adrenal suppression in pediatric patientsinclude low plasma cortisol levels to an absence of response to ACTH stimulation.Manifestations of intracranial hypertension include bulging fontanelles, headaches,and bilateral papilledema.

Geriatric UseClinical studies of Locoid Lipocream did not include sufficient numbers of subjectsaged 65 and over to determine whether they respond differently from youngersubjects.Carcinogenesis, Mutagenesis, Impairment of FertilityNo studies were conducted to determine the photococarcinogenic or dermalcarcinogenic potential of Locoid Lipocream.Hydrocortisone butyrate revealed no evidence of mutagenic or clastogenicpotential based on the results of two in vitro genotoxicity tests (Ames test andL5178Y/TK+ mouse lymphoma assay) and one in vivo genotoxicity test (mousemicronucleus assay).No evidence of impairment of fertility or effect on mating performance wasobserved in a fertility and general reproductive performance study conducted inmale and female rats at subcutaneous doses up to and including 1.8 mg/kg/day(0.7X maximum topical human dose [MTHD]). Mild effects on maternal animals,such as reduced food consumption and a subsequent reduction in body weight gain,were seen at doses ≥0.6 mg/kg/day (0.2X MTHD).

PATIENT COUNSELING INFORMATIONPatients using Locoid Lipocream should receive the following information and instructions:Apply a thin layer to the affected skin two or three times daily for corticosteroid-responsive dermatoses in adults. Consult with your physician to determine iftreatment is needed beyond 2 weeks. Apply a thin film to the affected skin areastwo times daily for atopic dermatitis in patients 3 months of age and older. Safety of Locoid Lipocream in pediatric patients has not been established beyond 4weeks of use.Rub in gently.Avoid contact with the eyes. Do not bandage, otherwise cover, or wrap the affected skin area so as to beocclusive unless directed by your physician.Do not use Locoid Lipocream in the diaper area, as diapers or plastic pants mayconstitute occlusive dressings.Do not use Locoid Lipocream on the face, underarms, or groin areas unlessdirected by your physician.If no improvement is seen within 2 weeks, contact your physician.Do not use other corticosteroid-containing products while using Locoid Lipocreamwithout first consulting your physician.

Store at 25°C (77°F); excursions permitted to 15-30°C (59-86°F) [see USP ControlledRoom Temperature]. Protect from freezing. Keep out of the reach of children.

Marketed and Distributed By:Triax Pharmaceuticals, LLCCranford NJ 07016www.Locoid.com

Manufactured for: Triax Pharmaceuticals, LLCCranford NJ 07016By: Ferndale Laboratories, Inc.Ferndale MI 48220

131B301Rev 11/09

Locoid Lipocream is a registered trademark of Astellas Pharma Europe BV licensed to Triax Pharmaceuticals, LLC.

Now younger eczema patients have something

to smile about

Now approved for use in children down to 3 months of age

(hydrocortisone butyrate 0.1%) Cream

Locoid Lipocream is indicated for the relief of the inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses, including the treatment of mild to moderate atopic dermatitis in patients 3 months of age and older.Safety and effectiveness in pediatric patients below 3 months of age have not been established.Reversible HPA axis suppression may occur, with the potential for corticosteroid insufficiency. Consider periodic evaluations for HPA axis suppression if applied to large surface areas or used under occlusion . Systemic effects of topical corticosteroids may also includemanifestations of Cushing’s syndrome, hyperglycemia, and glucosuria. Pediatric patients may be more susceptible to systemic toxicity due to their large skin surface-to-body-mass ratios. Initiate appropriate therapy if concomitant skin infection develops. Discontinue use if irritation develops. Please see full Prescribing Information on adjacent page. Visit us at www.locoid.com

©2010 Triax Pharmaceuticals, LLC. All rights reserved. Locoid is a registered trademark of Astellas Pharma Europe B.V. licensed to Triax Pharmaceuticals, LLC. LOC-0410-01

The power of an ointment with the elegance of a cream

Mar / April 2012

Documents

Transcript of Mar / April 2012