Dermatology

Figure 1

The FP suspected that this was a nodular basal cell carcinoma (BCC) with pigmentation. The physical exam was suspicious because of the pearly appearance, superficial ulcerations, and presence of telangiectasias with a loss of the normal pore pattern. Dermoscopy gave further evidence for a nodular BCC by revealing arborizing “tree-like” telangiectasias, ulcerations, shiny white areas, and gray-blue globules. Skin cancers often produce their own vascular supply and also ulcerate. The shiny white areas (which are the result of collagen deposition and occur in many skin cancers) are best seen with polarized dermoscopy.

The FP recommended a shave biopsy and performed one immediately after obtaining patient consent. (See the Watch & Learn video on “Shave biopsy.”) Knowing that the BCC would be vascular, the FP injected 1% lidocaine with epinephrine and waited 15 minutes for the epinephrine to work.

After seeing another patient, he performed the shave biopsy with a Dermablade, and used a cotton-tipped applicator to vigorously apply the aluminum chloride to the site. He used a twisting motion and pressure to stop most of the bleeding and then used his electrosurgical instrument—with a sharp tipped electrode—to stop recalcitrant bleeders.

The patient was given a diagnosis of BCC on the follow-up visit. The FP referred the patient for Mohs surgery because of the large size and location of the tumor.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Basal cell carcinoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:989-998.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

Figure 1

The FP suspected that this was a nodular basal cell carcinoma (BCC) with pigmentation. The physical exam was suspicious because of the pearly appearance, superficial ulcerations, and presence of telangiectasias with a loss of the normal pore pattern. Dermoscopy gave further evidence for a nodular BCC by revealing arborizing “tree-like” telangiectasias, ulcerations, shiny white areas, and gray-blue globules. Skin cancers often produce their own vascular supply and also ulcerate. The shiny white areas (which are the result of collagen deposition and occur in many skin cancers) are best seen with polarized dermoscopy.

The FP recommended a shave biopsy and performed one immediately after obtaining patient consent. (See the Watch & Learn video on “Shave biopsy.”) Knowing that the BCC would be vascular, the FP injected 1% lidocaine with epinephrine and waited 15 minutes for the epinephrine to work.

After seeing another patient, he performed the shave biopsy with a Dermablade, and used a cotton-tipped applicator to vigorously apply the aluminum chloride to the site. He used a twisting motion and pressure to stop most of the bleeding and then used his electrosurgical instrument—with a sharp tipped electrode—to stop recalcitrant bleeders.

The patient was given a diagnosis of BCC on the follow-up visit. The FP referred the patient for Mohs surgery because of the large size and location of the tumor.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Basal cell carcinoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:989-998.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

Figure 1

The FP suspected that this was a nodular basal cell carcinoma (BCC) with pigmentation. The physical exam was suspicious because of the pearly appearance, superficial ulcerations, and presence of telangiectasias with a loss of the normal pore pattern. Dermoscopy gave further evidence for a nodular BCC by revealing arborizing “tree-like” telangiectasias, ulcerations, shiny white areas, and gray-blue globules. Skin cancers often produce their own vascular supply and also ulcerate. The shiny white areas (which are the result of collagen deposition and occur in many skin cancers) are best seen with polarized dermoscopy.

The FP recommended a shave biopsy and performed one immediately after obtaining patient consent. (See the Watch & Learn video on “Shave biopsy.”) Knowing that the BCC would be vascular, the FP injected 1% lidocaine with epinephrine and waited 15 minutes for the epinephrine to work.

After seeing another patient, he performed the shave biopsy with a Dermablade, and used a cotton-tipped applicator to vigorously apply the aluminum chloride to the site. He used a twisting motion and pressure to stop most of the bleeding and then used his electrosurgical instrument—with a sharp tipped electrode—to stop recalcitrant bleeders.

The patient was given a diagnosis of BCC on the follow-up visit. The FP referred the patient for Mohs surgery because of the large size and location of the tumor.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Basal cell carcinoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:989-998.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

An 80-year-old white woman presented to our dermatology clinic with a rash across her abdomen that had been there for more than a year. While not itchy or painful, the rash was slowly expanding. The patient had tried treatments including topical antifungals and topical corticosteroids, but none had helped.

Her medical history was significant for dementia and stage III triple-negative breast cancer in the left breast (diagnosed 8 years prior), which was treated with a simple left mastectomy, chemotherapy, and radiation. She reported no history of skin cancer. She was not taking any medications and had no known drug allergies. A physical examination revealed an erythematous, papulonodular rash with diffuse induration in a band-like pattern across her entire upper abdomen and left flank (FIGURE).

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

Based on our patient’s history, we gave a presumptive diagnosis of cutaneous breast cancer metastasis. A punch biopsy was performed. The pathology report showed nests of neoplastic cells within the dermis, which was consistent with this diagnosis. Immunohistochemical stains and fluorescence in-situ hybridization confirmed triple-negative breast markers for estrogen receptor, progesterone receptor, and human epidermal growth factor receptor-2.

An uncommon phenomenonseen mostly with breast cancer

Cutaneous metastatic carcinoma is relatively uncommon; one meta-analysis reported the overall incidence to be 5.3%.¹ While it is unusual, any internal malignancy can metastasize to the skin. In women, the most common malignancy to do so is breast cancer. One study found breast cancer to be associated with 26.5% of cutaneous metastatic cases.² These metastases often occur well after the patient has been treated for the primary malignancy.

Identifying features. Most cutaneous metastases occur near the site of the primary tumor, initially in the form of a firm, mobile, nonpainful nodule.³ This nodule is typically skin-colored or red, but in the case of cutaneous metastases of melanomas, it can appear blue or black. In the case of breast cancer, the lesions most often arise on the chest and abdomen.⁴ Occasionally, metastases can ulcerate through the skin.

Although cutaneous metastasis is uncommon, it should always be considered when asymptomatic skin lesions resist treatment—even when there is no known history of malignancy.

Some forms of cutaneous metastasis, such as carcinoma erysipeloides, can appear in specific patterns. Carcinoma erysipeloides has a similar appearance to cellulitis; it manifests as a sharply demarcated, red, inflammatory patch in the skin adjacent to the primary tumor.

Consider the clinical picture

Cutaneous metastatic lesions have a wide range of differential diagnoses due to their varied appearances. It is important to view the overall clinical picture when distinguishing such lesions. Although cutaneous metastasis is uncommon, it should always be considered when asymptomatic skin lesions resist treatment—even in someone without a known history of malignancy.

Perform a biopsy. The diagnosis can be confirmed with a skin biopsy. A punch biopsy is preferable, as visualization of the dermis is crucial, and histology often reveals nests of pleomorphic cells. Further cellular cytology can elicit the primary malignancy of origin.

Making our diagnosis

We ruled out several possibilities before arriving at our diagnosis. An infectious etiology (eg, cutaneous candidiasis) was considered, as was a cutaneous change due to radiation therapy. We also considered shingles, the early stages of which would have been similar in appearance to our patient’s lesions, and urticaria, which can manifest as erythematous papules and wheals across various parts of the body. A lack of specific symptoms (eg, pruritis, pain, fever) made these alternative diagnoses less likely. The fact that our patient’s lesions persisted for more than a year without any response to treatment—and that they continued to grow—alerted us of a more sinister etiology.

Continue to: Treating the tumor is often not possible

Treating the tumor is often not possible

Treatment first involves treating the underlying tumor. For cases in which cutaneous lesions are the first manifestation of an internal malignancy, investigation as to the source should be performed. The lesions can then be treated with a combination of chemotherapy, radiation, and surgery.^5,6

Unfortunately, in most cases of cutaneous metastases, the primary malignancy is already widespread and possibly untreatable. In such instances, palliative care is offered. Lesions are managed symptomatically, and prevention of skin irritation becomes the primary focus. Keeping the skin clean and dry helps to prevent ulceration and secondary infection.

In cases where the lesions ulcerate or crust, debridement can help. Excision of lesions, as well as pairing laser therapy with electrochemotherapy, may be helpful to improve the patient’s quality of life when lesions cause discomfort.

The prognosis for cutaneous metastasis due to breast cancer is often hard to predict because it is determined by other factors, such as the presence of internal metastases, which indicates a worse prognosis (on the scale of months). Some case reports have demonstrated that patients with metastases limited to the skin may have prolonged survival (on the scale of years).⁷

Our patient was offered an initial trial of radiation therapy, but she refused all treatment because the lesions did not cause discomfort, and she preferred to not go through further aggressive cancer treatment that could potentially cause complications and pain. We respected the patient’s wishes and counseled her on follow-up if the lesions became symptomatic or she decided she wanted to try treatment.

CORRESPONDENCE
Araya Zaesim, 1550 College St, Macon, GA, 31207; [email protected]

An 80-year-old white woman presented to our dermatology clinic with a rash across her abdomen that had been there for more than a year. While not itchy or painful, the rash was slowly expanding. The patient had tried treatments including topical antifungals and topical corticosteroids, but none had helped.

Her medical history was significant for dementia and stage III triple-negative breast cancer in the left breast (diagnosed 8 years prior), which was treated with a simple left mastectomy, chemotherapy, and radiation. She reported no history of skin cancer. She was not taking any medications and had no known drug allergies. A physical examination revealed an erythematous, papulonodular rash with diffuse induration in a band-like pattern across her entire upper abdomen and left flank (FIGURE).

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

Based on our patient’s history, we gave a presumptive diagnosis of cutaneous breast cancer metastasis. A punch biopsy was performed. The pathology report showed nests of neoplastic cells within the dermis, which was consistent with this diagnosis. Immunohistochemical stains and fluorescence in-situ hybridization confirmed triple-negative breast markers for estrogen receptor, progesterone receptor, and human epidermal growth factor receptor-2.

An uncommon phenomenonseen mostly with breast cancer

Cutaneous metastatic carcinoma is relatively uncommon; one meta-analysis reported the overall incidence to be 5.3%.¹ While it is unusual, any internal malignancy can metastasize to the skin. In women, the most common malignancy to do so is breast cancer. One study found breast cancer to be associated with 26.5% of cutaneous metastatic cases.² These metastases often occur well after the patient has been treated for the primary malignancy.

Identifying features. Most cutaneous metastases occur near the site of the primary tumor, initially in the form of a firm, mobile, nonpainful nodule.³ This nodule is typically skin-colored or red, but in the case of cutaneous metastases of melanomas, it can appear blue or black. In the case of breast cancer, the lesions most often arise on the chest and abdomen.⁴ Occasionally, metastases can ulcerate through the skin.

Although cutaneous metastasis is uncommon, it should always be considered when asymptomatic skin lesions resist treatment—even when there is no known history of malignancy.

Some forms of cutaneous metastasis, such as carcinoma erysipeloides, can appear in specific patterns. Carcinoma erysipeloides has a similar appearance to cellulitis; it manifests as a sharply demarcated, red, inflammatory patch in the skin adjacent to the primary tumor.

Consider the clinical picture

Cutaneous metastatic lesions have a wide range of differential diagnoses due to their varied appearances. It is important to view the overall clinical picture when distinguishing such lesions. Although cutaneous metastasis is uncommon, it should always be considered when asymptomatic skin lesions resist treatment—even in someone without a known history of malignancy.

Perform a biopsy. The diagnosis can be confirmed with a skin biopsy. A punch biopsy is preferable, as visualization of the dermis is crucial, and histology often reveals nests of pleomorphic cells. Further cellular cytology can elicit the primary malignancy of origin.

Making our diagnosis

We ruled out several possibilities before arriving at our diagnosis. An infectious etiology (eg, cutaneous candidiasis) was considered, as was a cutaneous change due to radiation therapy. We also considered shingles, the early stages of which would have been similar in appearance to our patient’s lesions, and urticaria, which can manifest as erythematous papules and wheals across various parts of the body. A lack of specific symptoms (eg, pruritis, pain, fever) made these alternative diagnoses less likely. The fact that our patient’s lesions persisted for more than a year without any response to treatment—and that they continued to grow—alerted us of a more sinister etiology.

Continue to: Treating the tumor is often not possible

Treating the tumor is often not possible

Treatment first involves treating the underlying tumor. For cases in which cutaneous lesions are the first manifestation of an internal malignancy, investigation as to the source should be performed. The lesions can then be treated with a combination of chemotherapy, radiation, and surgery.^5,6

Unfortunately, in most cases of cutaneous metastases, the primary malignancy is already widespread and possibly untreatable. In such instances, palliative care is offered. Lesions are managed symptomatically, and prevention of skin irritation becomes the primary focus. Keeping the skin clean and dry helps to prevent ulceration and secondary infection.

In cases where the lesions ulcerate or crust, debridement can help. Excision of lesions, as well as pairing laser therapy with electrochemotherapy, may be helpful to improve the patient’s quality of life when lesions cause discomfort.

The prognosis for cutaneous metastasis due to breast cancer is often hard to predict because it is determined by other factors, such as the presence of internal metastases, which indicates a worse prognosis (on the scale of months). Some case reports have demonstrated that patients with metastases limited to the skin may have prolonged survival (on the scale of years).⁷

Our patient was offered an initial trial of radiation therapy, but she refused all treatment because the lesions did not cause discomfort, and she preferred to not go through further aggressive cancer treatment that could potentially cause complications and pain. We respected the patient’s wishes and counseled her on follow-up if the lesions became symptomatic or she decided she wanted to try treatment.

CORRESPONDENCE
Araya Zaesim, 1550 College St, Macon, GA, 31207; [email protected]

An 80-year-old white woman presented to our dermatology clinic with a rash across her abdomen that had been there for more than a year. While not itchy or painful, the rash was slowly expanding. The patient had tried treatments including topical antifungals and topical corticosteroids, but none had helped.

Her medical history was significant for dementia and stage III triple-negative breast cancer in the left breast (diagnosed 8 years prior), which was treated with a simple left mastectomy, chemotherapy, and radiation. She reported no history of skin cancer. She was not taking any medications and had no known drug allergies. A physical examination revealed an erythematous, papulonodular rash with diffuse induration in a band-like pattern across her entire upper abdomen and left flank (FIGURE).

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

Based on our patient’s history, we gave a presumptive diagnosis of cutaneous breast cancer metastasis. A punch biopsy was performed. The pathology report showed nests of neoplastic cells within the dermis, which was consistent with this diagnosis. Immunohistochemical stains and fluorescence in-situ hybridization confirmed triple-negative breast markers for estrogen receptor, progesterone receptor, and human epidermal growth factor receptor-2.

An uncommon phenomenonseen mostly with breast cancer

Cutaneous metastatic carcinoma is relatively uncommon; one meta-analysis reported the overall incidence to be 5.3%.¹ While it is unusual, any internal malignancy can metastasize to the skin. In women, the most common malignancy to do so is breast cancer. One study found breast cancer to be associated with 26.5% of cutaneous metastatic cases.² These metastases often occur well after the patient has been treated for the primary malignancy.

Identifying features. Most cutaneous metastases occur near the site of the primary tumor, initially in the form of a firm, mobile, nonpainful nodule.³ This nodule is typically skin-colored or red, but in the case of cutaneous metastases of melanomas, it can appear blue or black. In the case of breast cancer, the lesions most often arise on the chest and abdomen.⁴ Occasionally, metastases can ulcerate through the skin.

Although cutaneous metastasis is uncommon, it should always be considered when asymptomatic skin lesions resist treatment—even when there is no known history of malignancy.

Some forms of cutaneous metastasis, such as carcinoma erysipeloides, can appear in specific patterns. Carcinoma erysipeloides has a similar appearance to cellulitis; it manifests as a sharply demarcated, red, inflammatory patch in the skin adjacent to the primary tumor.

Consider the clinical picture

Cutaneous metastatic lesions have a wide range of differential diagnoses due to their varied appearances. It is important to view the overall clinical picture when distinguishing such lesions. Although cutaneous metastasis is uncommon, it should always be considered when asymptomatic skin lesions resist treatment—even in someone without a known history of malignancy.

Perform a biopsy. The diagnosis can be confirmed with a skin biopsy. A punch biopsy is preferable, as visualization of the dermis is crucial, and histology often reveals nests of pleomorphic cells. Further cellular cytology can elicit the primary malignancy of origin.

Making our diagnosis

We ruled out several possibilities before arriving at our diagnosis. An infectious etiology (eg, cutaneous candidiasis) was considered, as was a cutaneous change due to radiation therapy. We also considered shingles, the early stages of which would have been similar in appearance to our patient’s lesions, and urticaria, which can manifest as erythematous papules and wheals across various parts of the body. A lack of specific symptoms (eg, pruritis, pain, fever) made these alternative diagnoses less likely. The fact that our patient’s lesions persisted for more than a year without any response to treatment—and that they continued to grow—alerted us of a more sinister etiology.

Continue to: Treating the tumor is often not possible

Treating the tumor is often not possible

Treatment first involves treating the underlying tumor. For cases in which cutaneous lesions are the first manifestation of an internal malignancy, investigation as to the source should be performed. The lesions can then be treated with a combination of chemotherapy, radiation, and surgery.^5,6

Unfortunately, in most cases of cutaneous metastases, the primary malignancy is already widespread and possibly untreatable. In such instances, palliative care is offered. Lesions are managed symptomatically, and prevention of skin irritation becomes the primary focus. Keeping the skin clean and dry helps to prevent ulceration and secondary infection.

In cases where the lesions ulcerate or crust, debridement can help. Excision of lesions, as well as pairing laser therapy with electrochemotherapy, may be helpful to improve the patient’s quality of life when lesions cause discomfort.

The prognosis for cutaneous metastasis due to breast cancer is often hard to predict because it is determined by other factors, such as the presence of internal metastases, which indicates a worse prognosis (on the scale of months). Some case reports have demonstrated that patients with metastases limited to the skin may have prolonged survival (on the scale of years).⁷

Our patient was offered an initial trial of radiation therapy, but she refused all treatment because the lesions did not cause discomfort, and she preferred to not go through further aggressive cancer treatment that could potentially cause complications and pain. We respected the patient’s wishes and counseled her on follow-up if the lesions became symptomatic or she decided she wanted to try treatment.

CORRESPONDENCE
Araya Zaesim, 1550 College St, Macon, GA, 31207; [email protected]

A 15-year-old Caucasian boy presented for evaluation of an asymptomatic brown patch on his right shoulder. While the patient’s mother first noticed the patch when he was 5 years old, the discolored area had recently been expanding in size and had developed hypertrichosis. The patient was otherwise healthy; he took no medications and denied any symptoms or history of trauma to the area. None of his siblings were similarly affected.

A physical examination revealed a well-demarcated hyperpigmented patch with an irregularly shaped border and an increased number of terminal hairs (FIGURE 1). The affected area was not indurated, and there were no muscular or skeletal abnormalities on inspection. Examination of the patch under a dermatoscope revealed islands of reticular (lattice-like) hyperpigmentation, focal hypopigmentation, and prominent follicles (FIGURE 2).

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

Becker melanosis (also called Becker’s nevus or Becker’s pigmentary hamartoma) is an organoid hamartoma that is most common among males.¹ This benign area of hyperpigmentation typically manifests as a circumscribed patch with an irregular border on the upper trunk, shoulders, or upper arms of young men. Becker melanosis is usually acquired and typically comes to medical attention around the time of puberty, although there may be a history of discoloration (as was true in this case).

A diagnosis that’s usually made clinically

Androgenic origin. Because of the male predominance and association with hypertrichosis (and for that matter, acne), androgens have been thought to play a role in the development of Becker melanosis.² The condition affects about 1 in 200 young men.¹ To date, no specific gene defect has been identified.

Becker melanosis is a benign condition marked by hyperpigmentation and hypertrichosis.

Underlying hypoplasia of the breast or musculoskeletal abnormalities are uncommonly associated with Becker melanosis. When these abnormalities are present, the condition is known as Becker’s nevus syndrome.³

Look for the pattern. Becker melanosis is associated with homogenous brown patches with perifollicular hypopigmentation, sometimes with a faint reticular pattern.^4,5 The diagnosis can usually be made clinically, but a skin biopsy can be helpful to confirm questionable cases. Dermoscopy can also assist in diagnosis. In this case, our patient’s presentation was typical, and additional studies were not needed.

Other causes of hyperpigmentation

The differential diagnosis includes other localized disorders associated with hyperpigmentation (TABLE^1,3,4).

Continue to: Morphea

Morphea represents a thickening of collagen bundles in the skin. Although morphea can affect the shoulder and trunk, as Becker melanosis does, lesions of morphea feel firm to the touch and are not associated with hypertrichosis.

Localized post-inflammatory hyperpigmentation occurs following a traumatic event, such as a burn, or a prior dermatosis, such as zoster. Careful history-taking can uncover an antecedent inflammatory condition. Post-inflammatory pigment changes do not typically result in hypertrichosis.

Café-au-lait macules can manifest as isolated areas of discoloration. These macules can be an important indicator of neurofibromatosis, a genetic disorder in which tumors grow in the nervous system. Melanocytic hamartomas of the iris (Lisch nodules), axillary freckling (Crowe’s sign), or multiple cutaneous neurofibromas serve as additional clues to neurofibromatosis. In ambiguous cases, a skin biopsy can help differentiate a café au lait macule from Becker melanosis.

To treat or not to treat?

No treatment other than reassurance is needed in most cases of Becker melanosis, as it is a benign condition. Protecting the area from sunlight can minimize darkening and contrast with the surrounding skin. Electrolysis and laser therapy can be used to treat the associated hypertrichosis; laser therapy can also reduce the hyperpigmentation. Nonablative fractional resurfacing accompanied by laser hair removal is also reported to be of value.⁶

Our patient was satisfied with reassurance of the benign nature of the condition and did not elect treatment.

CORRESPONDENCE
Matthew F. Helm, MD, 500 University Drive, Suite 4300, Department of Dermatology, HU14, UPC II, Hershey, PA 17033-2360; [email protected]

A 15-year-old Caucasian boy presented for evaluation of an asymptomatic brown patch on his right shoulder. While the patient’s mother first noticed the patch when he was 5 years old, the discolored area had recently been expanding in size and had developed hypertrichosis. The patient was otherwise healthy; he took no medications and denied any symptoms or history of trauma to the area. None of his siblings were similarly affected.

A physical examination revealed a well-demarcated hyperpigmented patch with an irregularly shaped border and an increased number of terminal hairs (FIGURE 1). The affected area was not indurated, and there were no muscular or skeletal abnormalities on inspection. Examination of the patch under a dermatoscope revealed islands of reticular (lattice-like) hyperpigmentation, focal hypopigmentation, and prominent follicles (FIGURE 2).

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

Becker melanosis (also called Becker’s nevus or Becker’s pigmentary hamartoma) is an organoid hamartoma that is most common among males.¹ This benign area of hyperpigmentation typically manifests as a circumscribed patch with an irregular border on the upper trunk, shoulders, or upper arms of young men. Becker melanosis is usually acquired and typically comes to medical attention around the time of puberty, although there may be a history of discoloration (as was true in this case).

A diagnosis that’s usually made clinically

Androgenic origin. Because of the male predominance and association with hypertrichosis (and for that matter, acne), androgens have been thought to play a role in the development of Becker melanosis.² The condition affects about 1 in 200 young men.¹ To date, no specific gene defect has been identified.

Becker melanosis is a benign condition marked by hyperpigmentation and hypertrichosis.

Underlying hypoplasia of the breast or musculoskeletal abnormalities are uncommonly associated with Becker melanosis. When these abnormalities are present, the condition is known as Becker’s nevus syndrome.³

Look for the pattern. Becker melanosis is associated with homogenous brown patches with perifollicular hypopigmentation, sometimes with a faint reticular pattern.^4,5 The diagnosis can usually be made clinically, but a skin biopsy can be helpful to confirm questionable cases. Dermoscopy can also assist in diagnosis. In this case, our patient’s presentation was typical, and additional studies were not needed.

Other causes of hyperpigmentation

The differential diagnosis includes other localized disorders associated with hyperpigmentation (TABLE^1,3,4).

Continue to: Morphea

Morphea represents a thickening of collagen bundles in the skin. Although morphea can affect the shoulder and trunk, as Becker melanosis does, lesions of morphea feel firm to the touch and are not associated with hypertrichosis.

Localized post-inflammatory hyperpigmentation occurs following a traumatic event, such as a burn, or a prior dermatosis, such as zoster. Careful history-taking can uncover an antecedent inflammatory condition. Post-inflammatory pigment changes do not typically result in hypertrichosis.

Café-au-lait macules can manifest as isolated areas of discoloration. These macules can be an important indicator of neurofibromatosis, a genetic disorder in which tumors grow in the nervous system. Melanocytic hamartomas of the iris (Lisch nodules), axillary freckling (Crowe’s sign), or multiple cutaneous neurofibromas serve as additional clues to neurofibromatosis. In ambiguous cases, a skin biopsy can help differentiate a café au lait macule from Becker melanosis.

To treat or not to treat?

No treatment other than reassurance is needed in most cases of Becker melanosis, as it is a benign condition. Protecting the area from sunlight can minimize darkening and contrast with the surrounding skin. Electrolysis and laser therapy can be used to treat the associated hypertrichosis; laser therapy can also reduce the hyperpigmentation. Nonablative fractional resurfacing accompanied by laser hair removal is also reported to be of value.⁶

Our patient was satisfied with reassurance of the benign nature of the condition and did not elect treatment.

CORRESPONDENCE
Matthew F. Helm, MD, 500 University Drive, Suite 4300, Department of Dermatology, HU14, UPC II, Hershey, PA 17033-2360; [email protected]

A 15-year-old Caucasian boy presented for evaluation of an asymptomatic brown patch on his right shoulder. While the patient’s mother first noticed the patch when he was 5 years old, the discolored area had recently been expanding in size and had developed hypertrichosis. The patient was otherwise healthy; he took no medications and denied any symptoms or history of trauma to the area. None of his siblings were similarly affected.

A physical examination revealed a well-demarcated hyperpigmented patch with an irregularly shaped border and an increased number of terminal hairs (FIGURE 1). The affected area was not indurated, and there were no muscular or skeletal abnormalities on inspection. Examination of the patch under a dermatoscope revealed islands of reticular (lattice-like) hyperpigmentation, focal hypopigmentation, and prominent follicles (FIGURE 2).

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

Becker melanosis (also called Becker’s nevus or Becker’s pigmentary hamartoma) is an organoid hamartoma that is most common among males.¹ This benign area of hyperpigmentation typically manifests as a circumscribed patch with an irregular border on the upper trunk, shoulders, or upper arms of young men. Becker melanosis is usually acquired and typically comes to medical attention around the time of puberty, although there may be a history of discoloration (as was true in this case).

A diagnosis that’s usually made clinically

Androgenic origin. Because of the male predominance and association with hypertrichosis (and for that matter, acne), androgens have been thought to play a role in the development of Becker melanosis.² The condition affects about 1 in 200 young men.¹ To date, no specific gene defect has been identified.

Becker melanosis is a benign condition marked by hyperpigmentation and hypertrichosis.

Underlying hypoplasia of the breast or musculoskeletal abnormalities are uncommonly associated with Becker melanosis. When these abnormalities are present, the condition is known as Becker’s nevus syndrome.³

Look for the pattern. Becker melanosis is associated with homogenous brown patches with perifollicular hypopigmentation, sometimes with a faint reticular pattern.^4,5 The diagnosis can usually be made clinically, but a skin biopsy can be helpful to confirm questionable cases. Dermoscopy can also assist in diagnosis. In this case, our patient’s presentation was typical, and additional studies were not needed.

Other causes of hyperpigmentation

The differential diagnosis includes other localized disorders associated with hyperpigmentation (TABLE^1,3,4).

Continue to: Morphea

Morphea represents a thickening of collagen bundles in the skin. Although morphea can affect the shoulder and trunk, as Becker melanosis does, lesions of morphea feel firm to the touch and are not associated with hypertrichosis.

Localized post-inflammatory hyperpigmentation occurs following a traumatic event, such as a burn, or a prior dermatosis, such as zoster. Careful history-taking can uncover an antecedent inflammatory condition. Post-inflammatory pigment changes do not typically result in hypertrichosis.

Café-au-lait macules can manifest as isolated areas of discoloration. These macules can be an important indicator of neurofibromatosis, a genetic disorder in which tumors grow in the nervous system. Melanocytic hamartomas of the iris (Lisch nodules), axillary freckling (Crowe’s sign), or multiple cutaneous neurofibromas serve as additional clues to neurofibromatosis. In ambiguous cases, a skin biopsy can help differentiate a café au lait macule from Becker melanosis.

To treat or not to treat?

No treatment other than reassurance is needed in most cases of Becker melanosis, as it is a benign condition. Protecting the area from sunlight can minimize darkening and contrast with the surrounding skin. Electrolysis and laser therapy can be used to treat the associated hypertrichosis; laser therapy can also reduce the hyperpigmentation. Nonablative fractional resurfacing accompanied by laser hair removal is also reported to be of value.⁶

Our patient was satisfied with reassurance of the benign nature of the condition and did not elect treatment.

CORRESPONDENCE
Matthew F. Helm, MD, 500 University Drive, Suite 4300, Department of Dermatology, HU14, UPC II, Hershey, PA 17033-2360; [email protected]

THE CASE

A 40-year-old white woman presented to clinic with multiple pruritic skin lesions on her abdomen, arms, and legs that had developed over a 2-month period. The patient reported that she’d been feeling tired and had been experiencing psychological stressors in her personal life. Her medical history was significant for psoriasis (which was controlled), and her family history was significant for breast and bone cancer (mother) and asbestos-related lung cancer (maternal grandfather).

A physical examination, which included breast and pelvic exams, was unremarkable apart from the lesions located on her abdomen, arms, and legs. On skin examination, we noted multiple polygonal, planar papules and plaques of varying size with an overlying scale (FIGURE).

THE DIAGNOSIS

The physician obtained a biopsy of one of the skin lesions, and it was sent to a dermatopathologist to evaluate. Unfortunately, though, the patient’s history and a description of the lesion were not included with the initial biopsy requisition form. Based on the biopsy sample alone, the dermatopathologist’s report indicated a diagnosis of seborrheic keratosis.

A search for malignancy. Any case of sudden, extensive seborrheic keratosis is suspected to be a Leser-Trélat sign, which is known to be associated with human immunodeficiency virus or underlying malignancy—especially in the gastrointestinal system. The physician talked to the patient about the possibility of malignancy, and an extensive work-up was performed, including multiple laboratory tests, computed tomography (CT) imaging, an esophagogastroduodenoscopy, a colonoscopy, and mammography. None of the test results showed signs of an underlying malignancy.

In light of the negative findings, the physician reached out to the dermatopathologist to further discuss the case. It was determined that the dermatopathologist did not receive any clinical information (prior to this discussion) from the primary care office. This was surprising to the primary care physician, who was under the assumption that the clinical chart would be sent along with the biopsy sample. With this new information, the dermatopathologist reexamined the slides and diagnosed the lesion as lichen planus, a rather common skin disease not associated with cancer.

[polldaddy:10153197]

DISCUSSION

A root-cause analysis of this case identified multiple system failures, focused mainly on a lack of communication between providers:

1. The description of the lesion and of the patient’s history were not included with the initial biopsy requisition form due to a lack of communication between the nurse and the physician performing the procedure.
2. The dermatopathologist did not seek additional clinical information from the referring physician after receiving the sample.
3. When the various providers did communicate, an accurate diagnosis was reached—but only after extensive investigation (and worry).

Communication is key to an accurate diagnosis

In 2000, it was estimated that health care costs due to preventable adverse events represent more than half of the $37.6 billion spent on health care.¹ Since then, considerable effort has been made to address patient safety, misdiagnosis, and cost-effectiveness. Root cause analysis is one of the most popular methods used to evaluate and prevent future serious adverse events.²

Continue to: Diagnostic errors are often unreported...

Diagnostic errors are often unreported or unrecognized, especially in the outpatient setting.³ Studies focused on reducing diagnostic error show that a second review of pathology slides reduces error, controls costs, and improves quality of health care.⁴

Don’t rely (exclusively) on the health record. Gaps in effective communication between providers are a leading cause of preventable adverse events.^5,6 The incorporation of electronic health records has allowed for more streamlined communication between providers. However, the mere presence of patient records in a common system does not guarantee the receipt or communication of information. The next step after entering the information into the record is to communicate it.

Our patient underwent a battery of costly and unnecessary tests and procedures, many of which were unwarranted at her age. In addition to being exposed to harmful radiation, she also experienced significant stress secondary to the tests and anticipation of the results. However, a root cause analysis of the case led to an improved protocol for communication between providers at the outpatient clinic. We now emphasize the necessity of including a clinical history and corresponding physical findings with all biopsies. We also encourage more direct communication between nursing staff, primary care physicians, and specialists.

THE TAKEAWAY

As medical professionals become increasingly reliant on the many emerging studies available to them, we sometimes forget that communication is key to optimal medical care, an accurate diagnosis, and patient safety.

Continue to: In addition, a second review...

In addition, a second review of dermatopathologic slides may be warranted if the pathologic diagnosis is inconsistent with the clinical picture or if the diagnosed condition is resistant to the usual therapies of choice. Incorrect diagnoses are more likely to occur when tests are interpreted in a vacuum without the corresponding clinical correlation. The weight of these mistakes is felt not only by the health care system, but by the patients themselves.

CORRESPONDENCE
Magdalena Pasarica, MD, PhD, University of Central Florida College of Medicine, 6850 Lake Nona Boulevard, Orlando, FL 32827; [email protected]

THE CASE

A 40-year-old white woman presented to clinic with multiple pruritic skin lesions on her abdomen, arms, and legs that had developed over a 2-month period. The patient reported that she’d been feeling tired and had been experiencing psychological stressors in her personal life. Her medical history was significant for psoriasis (which was controlled), and her family history was significant for breast and bone cancer (mother) and asbestos-related lung cancer (maternal grandfather).

A physical examination, which included breast and pelvic exams, was unremarkable apart from the lesions located on her abdomen, arms, and legs. On skin examination, we noted multiple polygonal, planar papules and plaques of varying size with an overlying scale (FIGURE).

THE DIAGNOSIS

The physician obtained a biopsy of one of the skin lesions, and it was sent to a dermatopathologist to evaluate. Unfortunately, though, the patient’s history and a description of the lesion were not included with the initial biopsy requisition form. Based on the biopsy sample alone, the dermatopathologist’s report indicated a diagnosis of seborrheic keratosis.

A search for malignancy. Any case of sudden, extensive seborrheic keratosis is suspected to be a Leser-Trélat sign, which is known to be associated with human immunodeficiency virus or underlying malignancy—especially in the gastrointestinal system. The physician talked to the patient about the possibility of malignancy, and an extensive work-up was performed, including multiple laboratory tests, computed tomography (CT) imaging, an esophagogastroduodenoscopy, a colonoscopy, and mammography. None of the test results showed signs of an underlying malignancy.

In light of the negative findings, the physician reached out to the dermatopathologist to further discuss the case. It was determined that the dermatopathologist did not receive any clinical information (prior to this discussion) from the primary care office. This was surprising to the primary care physician, who was under the assumption that the clinical chart would be sent along with the biopsy sample. With this new information, the dermatopathologist reexamined the slides and diagnosed the lesion as lichen planus, a rather common skin disease not associated with cancer.

[polldaddy:10153197]

DISCUSSION

A root-cause analysis of this case identified multiple system failures, focused mainly on a lack of communication between providers:

1. The description of the lesion and of the patient’s history were not included with the initial biopsy requisition form due to a lack of communication between the nurse and the physician performing the procedure.
2. The dermatopathologist did not seek additional clinical information from the referring physician after receiving the sample.
3. When the various providers did communicate, an accurate diagnosis was reached—but only after extensive investigation (and worry).

Communication is key to an accurate diagnosis

In 2000, it was estimated that health care costs due to preventable adverse events represent more than half of the $37.6 billion spent on health care.¹ Since then, considerable effort has been made to address patient safety, misdiagnosis, and cost-effectiveness. Root cause analysis is one of the most popular methods used to evaluate and prevent future serious adverse events.²

Continue to: Diagnostic errors are often unreported...

Diagnostic errors are often unreported or unrecognized, especially in the outpatient setting.³ Studies focused on reducing diagnostic error show that a second review of pathology slides reduces error, controls costs, and improves quality of health care.⁴

Don’t rely (exclusively) on the health record. Gaps in effective communication between providers are a leading cause of preventable adverse events.^5,6 The incorporation of electronic health records has allowed for more streamlined communication between providers. However, the mere presence of patient records in a common system does not guarantee the receipt or communication of information. The next step after entering the information into the record is to communicate it.

Our patient underwent a battery of costly and unnecessary tests and procedures, many of which were unwarranted at her age. In addition to being exposed to harmful radiation, she also experienced significant stress secondary to the tests and anticipation of the results. However, a root cause analysis of the case led to an improved protocol for communication between providers at the outpatient clinic. We now emphasize the necessity of including a clinical history and corresponding physical findings with all biopsies. We also encourage more direct communication between nursing staff, primary care physicians, and specialists.

THE TAKEAWAY

As medical professionals become increasingly reliant on the many emerging studies available to them, we sometimes forget that communication is key to optimal medical care, an accurate diagnosis, and patient safety.

Continue to: In addition, a second review...

In addition, a second review of dermatopathologic slides may be warranted if the pathologic diagnosis is inconsistent with the clinical picture or if the diagnosed condition is resistant to the usual therapies of choice. Incorrect diagnoses are more likely to occur when tests are interpreted in a vacuum without the corresponding clinical correlation. The weight of these mistakes is felt not only by the health care system, but by the patients themselves.

CORRESPONDENCE
Magdalena Pasarica, MD, PhD, University of Central Florida College of Medicine, 6850 Lake Nona Boulevard, Orlando, FL 32827; [email protected]

THE CASE

A 40-year-old white woman presented to clinic with multiple pruritic skin lesions on her abdomen, arms, and legs that had developed over a 2-month period. The patient reported that she’d been feeling tired and had been experiencing psychological stressors in her personal life. Her medical history was significant for psoriasis (which was controlled), and her family history was significant for breast and bone cancer (mother) and asbestos-related lung cancer (maternal grandfather).

A physical examination, which included breast and pelvic exams, was unremarkable apart from the lesions located on her abdomen, arms, and legs. On skin examination, we noted multiple polygonal, planar papules and plaques of varying size with an overlying scale (FIGURE).

THE DIAGNOSIS

The physician obtained a biopsy of one of the skin lesions, and it was sent to a dermatopathologist to evaluate. Unfortunately, though, the patient’s history and a description of the lesion were not included with the initial biopsy requisition form. Based on the biopsy sample alone, the dermatopathologist’s report indicated a diagnosis of seborrheic keratosis.

A search for malignancy. Any case of sudden, extensive seborrheic keratosis is suspected to be a Leser-Trélat sign, which is known to be associated with human immunodeficiency virus or underlying malignancy—especially in the gastrointestinal system. The physician talked to the patient about the possibility of malignancy, and an extensive work-up was performed, including multiple laboratory tests, computed tomography (CT) imaging, an esophagogastroduodenoscopy, a colonoscopy, and mammography. None of the test results showed signs of an underlying malignancy.

In light of the negative findings, the physician reached out to the dermatopathologist to further discuss the case. It was determined that the dermatopathologist did not receive any clinical information (prior to this discussion) from the primary care office. This was surprising to the primary care physician, who was under the assumption that the clinical chart would be sent along with the biopsy sample. With this new information, the dermatopathologist reexamined the slides and diagnosed the lesion as lichen planus, a rather common skin disease not associated with cancer.

[polldaddy:10153197]

DISCUSSION

A root-cause analysis of this case identified multiple system failures, focused mainly on a lack of communication between providers:

1. The description of the lesion and of the patient’s history were not included with the initial biopsy requisition form due to a lack of communication between the nurse and the physician performing the procedure.
2. The dermatopathologist did not seek additional clinical information from the referring physician after receiving the sample.
3. When the various providers did communicate, an accurate diagnosis was reached—but only after extensive investigation (and worry).

Communication is key to an accurate diagnosis

In 2000, it was estimated that health care costs due to preventable adverse events represent more than half of the $37.6 billion spent on health care.¹ Since then, considerable effort has been made to address patient safety, misdiagnosis, and cost-effectiveness. Root cause analysis is one of the most popular methods used to evaluate and prevent future serious adverse events.²

Continue to: Diagnostic errors are often unreported...

Diagnostic errors are often unreported or unrecognized, especially in the outpatient setting.³ Studies focused on reducing diagnostic error show that a second review of pathology slides reduces error, controls costs, and improves quality of health care.⁴

Don’t rely (exclusively) on the health record. Gaps in effective communication between providers are a leading cause of preventable adverse events.^5,6 The incorporation of electronic health records has allowed for more streamlined communication between providers. However, the mere presence of patient records in a common system does not guarantee the receipt or communication of information. The next step after entering the information into the record is to communicate it.

Our patient underwent a battery of costly and unnecessary tests and procedures, many of which were unwarranted at her age. In addition to being exposed to harmful radiation, she also experienced significant stress secondary to the tests and anticipation of the results. However, a root cause analysis of the case led to an improved protocol for communication between providers at the outpatient clinic. We now emphasize the necessity of including a clinical history and corresponding physical findings with all biopsies. We also encourage more direct communication between nursing staff, primary care physicians, and specialists.

THE TAKEAWAY

As medical professionals become increasingly reliant on the many emerging studies available to them, we sometimes forget that communication is key to optimal medical care, an accurate diagnosis, and patient safety.

Continue to: In addition, a second review...

In addition, a second review of dermatopathologic slides may be warranted if the pathologic diagnosis is inconsistent with the clinical picture or if the diagnosed condition is resistant to the usual therapies of choice. Incorrect diagnoses are more likely to occur when tests are interpreted in a vacuum without the corresponding clinical correlation. The weight of these mistakes is felt not only by the health care system, but by the patients themselves.

CORRESPONDENCE
Magdalena Pasarica, MD, PhD, University of Central Florida College of Medicine, 6850 Lake Nona Boulevard, Orlando, FL 32827; [email protected]

The Food and Drug Administration has approved the adalimumab biosimilar Hyrimoz (adalimumab-adaz) for a variety of conditions, according to Sandoz, the drug’s manufacturer and a division of Novartis.

Wikimedia Commons/FitzColinGerald/Creative Commons License

FDA approval for Hyrimoz is based on a randomized, double-blind, three-arm, parallel biosimilarity study that demonstrated equivalence for all primary pharmacokinetic parameters, according to the press release. A second study confirmed these results in patients with moderate to severe plaque psoriasis, with Hyrimoz having a safety profile similar to that of adalimumab. Hyrimoz was approved in Europe in July 2018.

Hyrimoz has been approved to treat rheumatoid arthritis, juvenile idiopathic arthritis in patients aged 4 years and older, psoriatic arthritis, ankylosing spondylitis, adult Crohn’s disease, ulcerative colitis, and plaque psoriasis. The most common adverse events associated with the drug, according to the label, are infections, injection site reactions, headache, and rash.

Hyrimoz is the third adalimumab biosimilar approved by the FDA.

“Biosimilars can help people suffering from chronic, debilitating conditions gain expanded access to important medicines that may change the outcome of their disease. With the FDA approval of Hyrimoz, Sandoz is one step closer to offering U.S. patients with autoimmune diseases the same critical access already available in Europe,” Stefan Hendriks, global head of biopharmaceuticals at Sandoz, said in the press release.

Find the full press release on the Novartis website.

[email protected]

The Food and Drug Administration has approved the adalimumab biosimilar Hyrimoz (adalimumab-adaz) for a variety of conditions, according to Sandoz, the drug’s manufacturer and a division of Novartis.

Wikimedia Commons/FitzColinGerald/Creative Commons License

FDA approval for Hyrimoz is based on a randomized, double-blind, three-arm, parallel biosimilarity study that demonstrated equivalence for all primary pharmacokinetic parameters, according to the press release. A second study confirmed these results in patients with moderate to severe plaque psoriasis, with Hyrimoz having a safety profile similar to that of adalimumab. Hyrimoz was approved in Europe in July 2018.

Hyrimoz has been approved to treat rheumatoid arthritis, juvenile idiopathic arthritis in patients aged 4 years and older, psoriatic arthritis, ankylosing spondylitis, adult Crohn’s disease, ulcerative colitis, and plaque psoriasis. The most common adverse events associated with the drug, according to the label, are infections, injection site reactions, headache, and rash.

Hyrimoz is the third adalimumab biosimilar approved by the FDA.

“Biosimilars can help people suffering from chronic, debilitating conditions gain expanded access to important medicines that may change the outcome of their disease. With the FDA approval of Hyrimoz, Sandoz is one step closer to offering U.S. patients with autoimmune diseases the same critical access already available in Europe,” Stefan Hendriks, global head of biopharmaceuticals at Sandoz, said in the press release.

Find the full press release on the Novartis website.

[email protected]

The Food and Drug Administration has approved the adalimumab biosimilar Hyrimoz (adalimumab-adaz) for a variety of conditions, according to Sandoz, the drug’s manufacturer and a division of Novartis.

Wikimedia Commons/FitzColinGerald/Creative Commons License

FDA approval for Hyrimoz is based on a randomized, double-blind, three-arm, parallel biosimilarity study that demonstrated equivalence for all primary pharmacokinetic parameters, according to the press release. A second study confirmed these results in patients with moderate to severe plaque psoriasis, with Hyrimoz having a safety profile similar to that of adalimumab. Hyrimoz was approved in Europe in July 2018.

Hyrimoz has been approved to treat rheumatoid arthritis, juvenile idiopathic arthritis in patients aged 4 years and older, psoriatic arthritis, ankylosing spondylitis, adult Crohn’s disease, ulcerative colitis, and plaque psoriasis. The most common adverse events associated with the drug, according to the label, are infections, injection site reactions, headache, and rash.

Hyrimoz is the third adalimumab biosimilar approved by the FDA.

“Biosimilars can help people suffering from chronic, debilitating conditions gain expanded access to important medicines that may change the outcome of their disease. With the FDA approval of Hyrimoz, Sandoz is one step closer to offering U.S. patients with autoimmune diseases the same critical access already available in Europe,” Stefan Hendriks, global head of biopharmaceuticals at Sandoz, said in the press release.

Find the full press release on the Novartis website.

[email protected]

Patients with psoriasis and hypertension are at a higher risk of having to undergo cardiovascular procedures and surgery, compared with patients with hypertension alone.

“The results suggested that hypertensive patients with concurrent psoriasis experienced an earlier and more aggressive disease progression of hypertension, compared with general hypertensive patients,” Hsien-Yi Chiu, MD, PhD, from the department of dermatology at the National Taiwan University Hospital in Hsinchu, Taiwan, and his colleagues wrote in the Journal of Dermatology. “Thus, patients with hypertension and psoriasis should be considered for more aggressive strategies for prevention of primary [cardiovascular disease] and more intense assessments for cardiovascular interventions needed to improve [cardiovascular disease] outcome in these patients.”

They performed a nationwide cohort study of patients in the Taiwan National Health Insurance Research Database with new onset hypertension from 2005 to 2006. Those with psoriasis (4,039 patients) were matched by age and sex to patients in the database who were diagnosed with hypertension but not psoriasis; the mean follow-up was 5.62 years. Their mean age was 58 years and about 31% of the psoriasis cohort were female. They were divided into groups based on psoriasis severity (mild and severe psoriasis) and type (psoriasis with and without arthritis). Researchers noted patients with both psoriasis and hypertension also had higher rates of cerebrovascular disease, coronary heart disease, hyperlipidemia, and diabetes mellitus during the year prior to the study.

The outcome measured was having a cardiovascular procedure (percutaneous coronary intervention with/without stenting or percutaneous transluminal coronary angioplasty and transcatheter radiofrequency ablation for arrhythmia) and cardiovascular surgery (coronary artery bypass grafting and other surgery for heart valves, arrhythmia, cerebrovascular disease, peripheral vessels, and the aorta).

Patients with both psoriasis and hypertension were at an increased risk for having a cardiovascular procedure and surgery (adjusted hazard ratio, 1.28; 95% confidence interval, 1.07-1.53), compared with patients with only hypertension. The risk of this outcome was also increased among patients with severe psoriasis or psoriatic arthritis, compared with patients who had mild psoriasis (aHR, 1.22; 95% CI, 0.98-1.51) and with patients with psoriasis but not arthritis (aHR, 1.15; 95% CI, 0.84-1.58); however, the results did not reach statistical significance after adjustment, which the researchers attributed to the small subgroup size.


“Another possible explanation was that the observed increased requirement for cardiovascular procedure and surgery in patients with severe psoriasis was mediated by a complex interplay among inflammation, traditional risk factors for [cardiovascular disease], and antirheumatic drugs, which probably attenuate the effects conferred by psoriasis,” the authors wrote.

Limitations in the study included reliance on administrative claims data for psoriasis diagnosis, unavailability of some details of the cardiovascular procedures and surgery, lack of blood pressure data to identify hypertension severity, as well as unmeasured factors and confounders. Further, “comparative occurrence of a requirement for cardiovascular procedure and surgery in the two groups may be influenced by a competing risk for death,” the researchers noted.


This study was supported in part through grants by the National Taiwan University Hospital, Asia-Pacific La Roche–Posay Foundation 2014, and the Ministry of Science and Technology. Dr. Chiu is on the speaker’s bureau for AbbVie, Janssen Pharmaceuticals, Novartis, Eli Lilly and Pfizer. Another author has conducted clinical trials for or received fees for being a consultant or speaker for companies that include Abbvie, Boehringer Ingelheim, and Celgene. The remaining authors reported no relevant conflicts of interest.

SOURCE: Chiu H-Y et al. J Dermatol. 2018 Oct 16. doi: 10.1111/1346-8138.14654.

Patients with psoriasis and hypertension are at a higher risk of having to undergo cardiovascular procedures and surgery, compared with patients with hypertension alone.

“The results suggested that hypertensive patients with concurrent psoriasis experienced an earlier and more aggressive disease progression of hypertension, compared with general hypertensive patients,” Hsien-Yi Chiu, MD, PhD, from the department of dermatology at the National Taiwan University Hospital in Hsinchu, Taiwan, and his colleagues wrote in the Journal of Dermatology. “Thus, patients with hypertension and psoriasis should be considered for more aggressive strategies for prevention of primary [cardiovascular disease] and more intense assessments for cardiovascular interventions needed to improve [cardiovascular disease] outcome in these patients.”

They performed a nationwide cohort study of patients in the Taiwan National Health Insurance Research Database with new onset hypertension from 2005 to 2006. Those with psoriasis (4,039 patients) were matched by age and sex to patients in the database who were diagnosed with hypertension but not psoriasis; the mean follow-up was 5.62 years. Their mean age was 58 years and about 31% of the psoriasis cohort were female. They were divided into groups based on psoriasis severity (mild and severe psoriasis) and type (psoriasis with and without arthritis). Researchers noted patients with both psoriasis and hypertension also had higher rates of cerebrovascular disease, coronary heart disease, hyperlipidemia, and diabetes mellitus during the year prior to the study.

The outcome measured was having a cardiovascular procedure (percutaneous coronary intervention with/without stenting or percutaneous transluminal coronary angioplasty and transcatheter radiofrequency ablation for arrhythmia) and cardiovascular surgery (coronary artery bypass grafting and other surgery for heart valves, arrhythmia, cerebrovascular disease, peripheral vessels, and the aorta).

Patients with both psoriasis and hypertension were at an increased risk for having a cardiovascular procedure and surgery (adjusted hazard ratio, 1.28; 95% confidence interval, 1.07-1.53), compared with patients with only hypertension. The risk of this outcome was also increased among patients with severe psoriasis or psoriatic arthritis, compared with patients who had mild psoriasis (aHR, 1.22; 95% CI, 0.98-1.51) and with patients with psoriasis but not arthritis (aHR, 1.15; 95% CI, 0.84-1.58); however, the results did not reach statistical significance after adjustment, which the researchers attributed to the small subgroup size.


“Another possible explanation was that the observed increased requirement for cardiovascular procedure and surgery in patients with severe psoriasis was mediated by a complex interplay among inflammation, traditional risk factors for [cardiovascular disease], and antirheumatic drugs, which probably attenuate the effects conferred by psoriasis,” the authors wrote.

Limitations in the study included reliance on administrative claims data for psoriasis diagnosis, unavailability of some details of the cardiovascular procedures and surgery, lack of blood pressure data to identify hypertension severity, as well as unmeasured factors and confounders. Further, “comparative occurrence of a requirement for cardiovascular procedure and surgery in the two groups may be influenced by a competing risk for death,” the researchers noted.


This study was supported in part through grants by the National Taiwan University Hospital, Asia-Pacific La Roche–Posay Foundation 2014, and the Ministry of Science and Technology. Dr. Chiu is on the speaker’s bureau for AbbVie, Janssen Pharmaceuticals, Novartis, Eli Lilly and Pfizer. Another author has conducted clinical trials for or received fees for being a consultant or speaker for companies that include Abbvie, Boehringer Ingelheim, and Celgene. The remaining authors reported no relevant conflicts of interest.

SOURCE: Chiu H-Y et al. J Dermatol. 2018 Oct 16. doi: 10.1111/1346-8138.14654.

Patients with psoriasis and hypertension are at a higher risk of having to undergo cardiovascular procedures and surgery, compared with patients with hypertension alone.

“The results suggested that hypertensive patients with concurrent psoriasis experienced an earlier and more aggressive disease progression of hypertension, compared with general hypertensive patients,” Hsien-Yi Chiu, MD, PhD, from the department of dermatology at the National Taiwan University Hospital in Hsinchu, Taiwan, and his colleagues wrote in the Journal of Dermatology. “Thus, patients with hypertension and psoriasis should be considered for more aggressive strategies for prevention of primary [cardiovascular disease] and more intense assessments for cardiovascular interventions needed to improve [cardiovascular disease] outcome in these patients.”

They performed a nationwide cohort study of patients in the Taiwan National Health Insurance Research Database with new onset hypertension from 2005 to 2006. Those with psoriasis (4,039 patients) were matched by age and sex to patients in the database who were diagnosed with hypertension but not psoriasis; the mean follow-up was 5.62 years. Their mean age was 58 years and about 31% of the psoriasis cohort were female. They were divided into groups based on psoriasis severity (mild and severe psoriasis) and type (psoriasis with and without arthritis). Researchers noted patients with both psoriasis and hypertension also had higher rates of cerebrovascular disease, coronary heart disease, hyperlipidemia, and diabetes mellitus during the year prior to the study.

The outcome measured was having a cardiovascular procedure (percutaneous coronary intervention with/without stenting or percutaneous transluminal coronary angioplasty and transcatheter radiofrequency ablation for arrhythmia) and cardiovascular surgery (coronary artery bypass grafting and other surgery for heart valves, arrhythmia, cerebrovascular disease, peripheral vessels, and the aorta).

Patients with both psoriasis and hypertension were at an increased risk for having a cardiovascular procedure and surgery (adjusted hazard ratio, 1.28; 95% confidence interval, 1.07-1.53), compared with patients with only hypertension. The risk of this outcome was also increased among patients with severe psoriasis or psoriatic arthritis, compared with patients who had mild psoriasis (aHR, 1.22; 95% CI, 0.98-1.51) and with patients with psoriasis but not arthritis (aHR, 1.15; 95% CI, 0.84-1.58); however, the results did not reach statistical significance after adjustment, which the researchers attributed to the small subgroup size.


“Another possible explanation was that the observed increased requirement for cardiovascular procedure and surgery in patients with severe psoriasis was mediated by a complex interplay among inflammation, traditional risk factors for [cardiovascular disease], and antirheumatic drugs, which probably attenuate the effects conferred by psoriasis,” the authors wrote.

Limitations in the study included reliance on administrative claims data for psoriasis diagnosis, unavailability of some details of the cardiovascular procedures and surgery, lack of blood pressure data to identify hypertension severity, as well as unmeasured factors and confounders. Further, “comparative occurrence of a requirement for cardiovascular procedure and surgery in the two groups may be influenced by a competing risk for death,” the researchers noted.


This study was supported in part through grants by the National Taiwan University Hospital, Asia-Pacific La Roche–Posay Foundation 2014, and the Ministry of Science and Technology. Dr. Chiu is on the speaker’s bureau for AbbVie, Janssen Pharmaceuticals, Novartis, Eli Lilly and Pfizer. Another author has conducted clinical trials for or received fees for being a consultant or speaker for companies that include Abbvie, Boehringer Ingelheim, and Celgene. The remaining authors reported no relevant conflicts of interest.

SOURCE: Chiu H-Y et al. J Dermatol. 2018 Oct 16. doi: 10.1111/1346-8138.14654.

MONTEREY, CALIF. – “Consort dermatitis” – when a patient is allergic to his or her partner. “Lime dermatitis” – when gin and tonics are the culprit. And “sample dermatitis” – when an unprescribed drug sample turns out to be the cause of a mysterious reaction.

Pcholik/getty images

Dermatologist Vincent DeLeo, MD, of the University of Southern California, Los Angeles, has seen them all. He provided insight about how to diagnose these unusual conditions at the Coastal Dermatology Symposium.

The following are a few unusual causes of dermatitis that he discussed:

• Romantic partners. A patient’s partner can be the cause of a reaction, as in the case of a 25-year-old woman who turned out to be allergic to her boyfriend’s cologne. In another case, a 50-year-old man had a 3-year history of recurrent dermatitis on his left arm and the left side of his chest. The cause was a mystery until it became clear that it was caused by exposure to hair dye, but not his. “He didn’t color his hair, but his wife did, and she always slept on that side of him,” Dr. DeLeo recalled. “When she stopped coloring her hair, his disease cleared.”
• Black henna. The dye known as “black henna,” or just “henna,” can cause reactions in adults (who use it as a hair dye or to decorate the skin) and children (who can be exposed to it with temporary tattoos). “Because henna typically produces a brown, orange-brown, or reddish-brown tint, other ingredients must be added to produce other colors, such as those marketed as ‘black henna’ and ‘blue henna,’ ” according to a Food and Drug Administration statement. “Even brown shades of products marketed as henna may contain other ingredients intended to make them darker or make the stain last longer on the skin. The problem? “The extra ingredient used to blacken henna is often a coal-tar hair dye containing p-Phenylenediamine, an ingredient that can cause dangerous skin reactions in some people,” the statement says. Dr. DeLeo said that one good rule of thumb is to consider a reaction to black henna if a patient acknowledges using a henna dye and their hair is any color but red. That’s a sign, he said, that they’re actually using black henna.
• Makeup applicators. Dr. DeLeo has seen two cases of patients with facial dermatitis who turned out to be allergic to thiuram, a component of rubber. Their skin was reacting to the rubber in some sponges used to apply makeup.
• Lime and sun exposure. Patients are impressed when Dr. DeLeo correctly guesses what they were drinking the previous weekend, because of their telltale blisters indicating a lime allergy. Noninflammatory blisters on the fingers or hyperpigmentation can be caused by touching the skin of a lime and then having subsequent exposure to ultraviolet light. It may take days for the blisters to appear, he noted. A weekend after mixing gin and tonics with lime, for example, a patient “may show up on Tuesday of the following week. The patient doesn’t always think of what they did over the weekend.”
• Liquid detergents. As a general rule, laundry detergents do not cause dermatitis, Dr. DeLeo said. “By the time that clothing is rinsed in your washer, there’s not enough left of anything on the clothing to cause a problem.” But there’s an exception: When people hand wash clothing with liquid detergents, such as Woolite. “It’s not the fragrance,” he said. “It’s the preservative in the detergent.”
• Unexpected nickel. Skin allergy to nickel is common, and the metal can lurk in unexpected places, as he discovered when he treated a Columbia University student who was “allergic to his tuba.” The tuba was made of brass, not nickel. But “the little things connecting the tubes to each other are alloy metals,” he said, including nickel.
• Drug samples. Dr. DeLeo recalled the case of a dermatology office administrator with a recurrent neck rash. Dermatologist after dermatologist failed to find the cause. Patch and photopatch testing turned up nothing. Then Dr. DeLeo asked her to bring in every skin product she was using. She returned with a large bag full of dermatologic samples, including Drithocreme (anthralin), which can be an irritant. None of the drugs were prescribed. “This is case of sample dermatitis,” which may occur among employees and family members of dermatologists, he said. “Always think of having patients bring in what they’re using,” he added, “because you can be surprised.”

The Coastal Dermatology Symposium is jointly presented by the University of Louisville and Global Academy for Medical Education. This publication and Global Academy for Medical Education are both owned by Frontline Medical Communications.

Dr. DeLeo disclosed consulting work for Estée Lauder.

MONTEREY, CALIF. – “Consort dermatitis” – when a patient is allergic to his or her partner. “Lime dermatitis” – when gin and tonics are the culprit. And “sample dermatitis” – when an unprescribed drug sample turns out to be the cause of a mysterious reaction.

Pcholik/getty images

Dermatologist Vincent DeLeo, MD, of the University of Southern California, Los Angeles, has seen them all. He provided insight about how to diagnose these unusual conditions at the Coastal Dermatology Symposium.

The following are a few unusual causes of dermatitis that he discussed:

• Romantic partners. A patient’s partner can be the cause of a reaction, as in the case of a 25-year-old woman who turned out to be allergic to her boyfriend’s cologne. In another case, a 50-year-old man had a 3-year history of recurrent dermatitis on his left arm and the left side of his chest. The cause was a mystery until it became clear that it was caused by exposure to hair dye, but not his. “He didn’t color his hair, but his wife did, and she always slept on that side of him,” Dr. DeLeo recalled. “When she stopped coloring her hair, his disease cleared.”
• Black henna. The dye known as “black henna,” or just “henna,” can cause reactions in adults (who use it as a hair dye or to decorate the skin) and children (who can be exposed to it with temporary tattoos). “Because henna typically produces a brown, orange-brown, or reddish-brown tint, other ingredients must be added to produce other colors, such as those marketed as ‘black henna’ and ‘blue henna,’ ” according to a Food and Drug Administration statement. “Even brown shades of products marketed as henna may contain other ingredients intended to make them darker or make the stain last longer on the skin. The problem? “The extra ingredient used to blacken henna is often a coal-tar hair dye containing p-Phenylenediamine, an ingredient that can cause dangerous skin reactions in some people,” the statement says. Dr. DeLeo said that one good rule of thumb is to consider a reaction to black henna if a patient acknowledges using a henna dye and their hair is any color but red. That’s a sign, he said, that they’re actually using black henna.
• Makeup applicators. Dr. DeLeo has seen two cases of patients with facial dermatitis who turned out to be allergic to thiuram, a component of rubber. Their skin was reacting to the rubber in some sponges used to apply makeup.
• Lime and sun exposure. Patients are impressed when Dr. DeLeo correctly guesses what they were drinking the previous weekend, because of their telltale blisters indicating a lime allergy. Noninflammatory blisters on the fingers or hyperpigmentation can be caused by touching the skin of a lime and then having subsequent exposure to ultraviolet light. It may take days for the blisters to appear, he noted. A weekend after mixing gin and tonics with lime, for example, a patient “may show up on Tuesday of the following week. The patient doesn’t always think of what they did over the weekend.”
• Liquid detergents. As a general rule, laundry detergents do not cause dermatitis, Dr. DeLeo said. “By the time that clothing is rinsed in your washer, there’s not enough left of anything on the clothing to cause a problem.” But there’s an exception: When people hand wash clothing with liquid detergents, such as Woolite. “It’s not the fragrance,” he said. “It’s the preservative in the detergent.”
• Unexpected nickel. Skin allergy to nickel is common, and the metal can lurk in unexpected places, as he discovered when he treated a Columbia University student who was “allergic to his tuba.” The tuba was made of brass, not nickel. But “the little things connecting the tubes to each other are alloy metals,” he said, including nickel.
• Drug samples. Dr. DeLeo recalled the case of a dermatology office administrator with a recurrent neck rash. Dermatologist after dermatologist failed to find the cause. Patch and photopatch testing turned up nothing. Then Dr. DeLeo asked her to bring in every skin product she was using. She returned with a large bag full of dermatologic samples, including Drithocreme (anthralin), which can be an irritant. None of the drugs were prescribed. “This is case of sample dermatitis,” which may occur among employees and family members of dermatologists, he said. “Always think of having patients bring in what they’re using,” he added, “because you can be surprised.”

The Coastal Dermatology Symposium is jointly presented by the University of Louisville and Global Academy for Medical Education. This publication and Global Academy for Medical Education are both owned by Frontline Medical Communications.

Dr. DeLeo disclosed consulting work for Estée Lauder.

MONTEREY, CALIF. – “Consort dermatitis” – when a patient is allergic to his or her partner. “Lime dermatitis” – when gin and tonics are the culprit. And “sample dermatitis” – when an unprescribed drug sample turns out to be the cause of a mysterious reaction.

Pcholik/getty images

Dermatologist Vincent DeLeo, MD, of the University of Southern California, Los Angeles, has seen them all. He provided insight about how to diagnose these unusual conditions at the Coastal Dermatology Symposium.

The following are a few unusual causes of dermatitis that he discussed:

• Romantic partners. A patient’s partner can be the cause of a reaction, as in the case of a 25-year-old woman who turned out to be allergic to her boyfriend’s cologne. In another case, a 50-year-old man had a 3-year history of recurrent dermatitis on his left arm and the left side of his chest. The cause was a mystery until it became clear that it was caused by exposure to hair dye, but not his. “He didn’t color his hair, but his wife did, and she always slept on that side of him,” Dr. DeLeo recalled. “When she stopped coloring her hair, his disease cleared.”
• Black henna. The dye known as “black henna,” or just “henna,” can cause reactions in adults (who use it as a hair dye or to decorate the skin) and children (who can be exposed to it with temporary tattoos). “Because henna typically produces a brown, orange-brown, or reddish-brown tint, other ingredients must be added to produce other colors, such as those marketed as ‘black henna’ and ‘blue henna,’ ” according to a Food and Drug Administration statement. “Even brown shades of products marketed as henna may contain other ingredients intended to make them darker or make the stain last longer on the skin. The problem? “The extra ingredient used to blacken henna is often a coal-tar hair dye containing p-Phenylenediamine, an ingredient that can cause dangerous skin reactions in some people,” the statement says. Dr. DeLeo said that one good rule of thumb is to consider a reaction to black henna if a patient acknowledges using a henna dye and their hair is any color but red. That’s a sign, he said, that they’re actually using black henna.
• Makeup applicators. Dr. DeLeo has seen two cases of patients with facial dermatitis who turned out to be allergic to thiuram, a component of rubber. Their skin was reacting to the rubber in some sponges used to apply makeup.
• Lime and sun exposure. Patients are impressed when Dr. DeLeo correctly guesses what they were drinking the previous weekend, because of their telltale blisters indicating a lime allergy. Noninflammatory blisters on the fingers or hyperpigmentation can be caused by touching the skin of a lime and then having subsequent exposure to ultraviolet light. It may take days for the blisters to appear, he noted. A weekend after mixing gin and tonics with lime, for example, a patient “may show up on Tuesday of the following week. The patient doesn’t always think of what they did over the weekend.”
• Liquid detergents. As a general rule, laundry detergents do not cause dermatitis, Dr. DeLeo said. “By the time that clothing is rinsed in your washer, there’s not enough left of anything on the clothing to cause a problem.” But there’s an exception: When people hand wash clothing with liquid detergents, such as Woolite. “It’s not the fragrance,” he said. “It’s the preservative in the detergent.”
• Unexpected nickel. Skin allergy to nickel is common, and the metal can lurk in unexpected places, as he discovered when he treated a Columbia University student who was “allergic to his tuba.” The tuba was made of brass, not nickel. But “the little things connecting the tubes to each other are alloy metals,” he said, including nickel.
• Drug samples. Dr. DeLeo recalled the case of a dermatology office administrator with a recurrent neck rash. Dermatologist after dermatologist failed to find the cause. Patch and photopatch testing turned up nothing. Then Dr. DeLeo asked her to bring in every skin product she was using. She returned with a large bag full of dermatologic samples, including Drithocreme (anthralin), which can be an irritant. None of the drugs were prescribed. “This is case of sample dermatitis,” which may occur among employees and family members of dermatologists, he said. “Always think of having patients bring in what they’re using,” he added, “because you can be surprised.”

The Coastal Dermatology Symposium is jointly presented by the University of Louisville and Global Academy for Medical Education. This publication and Global Academy for Medical Education are both owned by Frontline Medical Communications.

Dr. DeLeo disclosed consulting work for Estée Lauder.

PARIS – Treatment with the fixed combination adapalene 0.3%/benzoyl peroxide 2.5% gel not only reduced facial acne lesions, it also decreased the atrophic acne scar count in a multicenter, randomized trial, Brigitte Dreno, MD, reported at the annual congress of the European Academy of Dermatology and Venereology.

Bruce Jancin/MDedge News

“To my knowledge, this is the first time that we have seen a topical therapy showing a reduction in atrophic acne scars,” said Dr. Dreno, professor and chair of the department of dermatology at Nantes (France) University Hospital.

She reported on 67 adolescents and adults with mainly moderate facial acne randomized to treat half their face with adapalene 0.3%/benzoyl peroxide 2.5% gel (Epiduo Forte) and the other half with the product’s vehicle daily for 6 months. Investigators were blinded as to which side was which. At baseline, patients averaged 40 acne lesions and 12 scars per half face.

The primary efficacy endpoint was the atrophic acne scar count per half face at week 24. At that point, the mean total was 9.5 scars on the active treatment side, compared with 13.3 on the control side. This translated to a statistically significant and clinically meaningful 15.5% decrease in scars with active treatment versus a 14.4% increase with vehicle. The between-side difference achieved statistical significance at week 1 and remained so at all follow-up visits through week 24.

By Scar Global Assessment at week 24, 32.9% of half faces treated with the combination product were rated clear or almost clear, compared with 16.4% with vehicle.

At 24 weeks, 24.1% of participants reported having moderately or very visible holes or indents on the active treatment side of their face, compared with 51.8% on the control side. The number of inflammatory acne lesions fell by 86.7% with the active treatment and 57.9% with vehicle over the course of 24 weeks. Again, the difference became statistically significant starting at week 1. By the Investigator’s Global Assessment at week 24, 64.2% of adapalene/benzoyl peroxide gel–treated faces were rated clear or almost clear, as were 19.4% with vehicle. In addition, 32% of patients reported a marked improvement in skin texture on their active treatment side at 24 weeks, as did 14% on the control side.

The salutary effect on acne scars documented with a topical therapy in this study represents a real advance in clinical care.

“Facial acne scars are a very important and difficult problem for our patients and also for dermatologists,” Dr. Dreno observed, adding that the evidence base for procedural interventions for acne scars, such as dermabrasion and laser resurfacing, is not top quality.

Not surprisingly with a topical retinoid, skin irritation was the most common treatment-emergent adverse event, reported by 14.9% of patients on their active treatment side and 6% with vehicle. This side effect was typically mild and resolved within the first 2-3 weeks.

The improvement in preexisting acne scars documented in this trial was probably caused by drug-induced remodeling of the dermal matrix, according to Dr. Dreno.

The study was funded by Galderma. Dr. Dreno reported receiving research grants from and/or serving as a consultant to Galderma, Bioderma, Pierre Fabre, and La Roche–Posay.

[email protected]

PARIS – Treatment with the fixed combination adapalene 0.3%/benzoyl peroxide 2.5% gel not only reduced facial acne lesions, it also decreased the atrophic acne scar count in a multicenter, randomized trial, Brigitte Dreno, MD, reported at the annual congress of the European Academy of Dermatology and Venereology.

Bruce Jancin/MDedge News

“To my knowledge, this is the first time that we have seen a topical therapy showing a reduction in atrophic acne scars,” said Dr. Dreno, professor and chair of the department of dermatology at Nantes (France) University Hospital.

She reported on 67 adolescents and adults with mainly moderate facial acne randomized to treat half their face with adapalene 0.3%/benzoyl peroxide 2.5% gel (Epiduo Forte) and the other half with the product’s vehicle daily for 6 months. Investigators were blinded as to which side was which. At baseline, patients averaged 40 acne lesions and 12 scars per half face.

The primary efficacy endpoint was the atrophic acne scar count per half face at week 24. At that point, the mean total was 9.5 scars on the active treatment side, compared with 13.3 on the control side. This translated to a statistically significant and clinically meaningful 15.5% decrease in scars with active treatment versus a 14.4% increase with vehicle. The between-side difference achieved statistical significance at week 1 and remained so at all follow-up visits through week 24.

By Scar Global Assessment at week 24, 32.9% of half faces treated with the combination product were rated clear or almost clear, compared with 16.4% with vehicle.

At 24 weeks, 24.1% of participants reported having moderately or very visible holes or indents on the active treatment side of their face, compared with 51.8% on the control side. The number of inflammatory acne lesions fell by 86.7% with the active treatment and 57.9% with vehicle over the course of 24 weeks. Again, the difference became statistically significant starting at week 1. By the Investigator’s Global Assessment at week 24, 64.2% of adapalene/benzoyl peroxide gel–treated faces were rated clear or almost clear, as were 19.4% with vehicle. In addition, 32% of patients reported a marked improvement in skin texture on their active treatment side at 24 weeks, as did 14% on the control side.

The salutary effect on acne scars documented with a topical therapy in this study represents a real advance in clinical care.

“Facial acne scars are a very important and difficult problem for our patients and also for dermatologists,” Dr. Dreno observed, adding that the evidence base for procedural interventions for acne scars, such as dermabrasion and laser resurfacing, is not top quality.

Not surprisingly with a topical retinoid, skin irritation was the most common treatment-emergent adverse event, reported by 14.9% of patients on their active treatment side and 6% with vehicle. This side effect was typically mild and resolved within the first 2-3 weeks.

The improvement in preexisting acne scars documented in this trial was probably caused by drug-induced remodeling of the dermal matrix, according to Dr. Dreno.

The study was funded by Galderma. Dr. Dreno reported receiving research grants from and/or serving as a consultant to Galderma, Bioderma, Pierre Fabre, and La Roche–Posay.

[email protected]

PARIS – Treatment with the fixed combination adapalene 0.3%/benzoyl peroxide 2.5% gel not only reduced facial acne lesions, it also decreased the atrophic acne scar count in a multicenter, randomized trial, Brigitte Dreno, MD, reported at the annual congress of the European Academy of Dermatology and Venereology.

Bruce Jancin/MDedge News

“To my knowledge, this is the first time that we have seen a topical therapy showing a reduction in atrophic acne scars,” said Dr. Dreno, professor and chair of the department of dermatology at Nantes (France) University Hospital.

She reported on 67 adolescents and adults with mainly moderate facial acne randomized to treat half their face with adapalene 0.3%/benzoyl peroxide 2.5% gel (Epiduo Forte) and the other half with the product’s vehicle daily for 6 months. Investigators were blinded as to which side was which. At baseline, patients averaged 40 acne lesions and 12 scars per half face.

The primary efficacy endpoint was the atrophic acne scar count per half face at week 24. At that point, the mean total was 9.5 scars on the active treatment side, compared with 13.3 on the control side. This translated to a statistically significant and clinically meaningful 15.5% decrease in scars with active treatment versus a 14.4% increase with vehicle. The between-side difference achieved statistical significance at week 1 and remained so at all follow-up visits through week 24.

By Scar Global Assessment at week 24, 32.9% of half faces treated with the combination product were rated clear or almost clear, compared with 16.4% with vehicle.

At 24 weeks, 24.1% of participants reported having moderately or very visible holes or indents on the active treatment side of their face, compared with 51.8% on the control side. The number of inflammatory acne lesions fell by 86.7% with the active treatment and 57.9% with vehicle over the course of 24 weeks. Again, the difference became statistically significant starting at week 1. By the Investigator’s Global Assessment at week 24, 64.2% of adapalene/benzoyl peroxide gel–treated faces were rated clear or almost clear, as were 19.4% with vehicle. In addition, 32% of patients reported a marked improvement in skin texture on their active treatment side at 24 weeks, as did 14% on the control side.

The salutary effect on acne scars documented with a topical therapy in this study represents a real advance in clinical care.

“Facial acne scars are a very important and difficult problem for our patients and also for dermatologists,” Dr. Dreno observed, adding that the evidence base for procedural interventions for acne scars, such as dermabrasion and laser resurfacing, is not top quality.

Not surprisingly with a topical retinoid, skin irritation was the most common treatment-emergent adverse event, reported by 14.9% of patients on their active treatment side and 6% with vehicle. This side effect was typically mild and resolved within the first 2-3 weeks.

The improvement in preexisting acne scars documented in this trial was probably caused by drug-induced remodeling of the dermal matrix, according to Dr. Dreno.

The study was funded by Galderma. Dr. Dreno reported receiving research grants from and/or serving as a consultant to Galderma, Bioderma, Pierre Fabre, and La Roche–Posay.

[email protected]

Since birth, this now–13-year-old boy has had redness on his face— the intensity of which has slowly increased with time. Various providers have offered a plethora of diagnoses, but no treatment attempts thus far have helped. The condition is asymptomatic but nonetheless distressing to the patient.

More history-taking reveals that, when he was about 6, crops of tiny papules developed on both triceps, his buttocks, and his upper back. These, too, have resisted treatment with OTC creams.

Neither of the boy’s two siblings have had any similar lesions, and no one in the family has any related health problems (eg, atopic diatheses).

EXAMINATION
The posterior 2/3 of both sides of the patient’s face are strikingly red. His nasolabial folds are spared, but the redness extends posteriorly to the immediate preauricular areas and vertically from the zygoma to the jawline. The erythema is highly blanchable with digital pressure and has a uniformly rough, papular feel. There is no tenderness or increased warmth on palpation.

The papules on the triceps, anterior thighs, and upper back are uniform in size (pinpoint, measuring ≤ 1 mm) and distribution, obviously originating from follicles. Unlike the face, these areas are not erythematous.

What’s the diagnosis?

DISCUSSION
There are several types of keratosis pilaris (KP), including rubra faceii, the form affecting this patient (distinguished in part by involvement of the facial skin). KP is utterly common, affecting 30% to 50% of the white population worldwide, with no gender preference. This autosomal dominant disorder involves follicular keratinization—normal keratin (produced in the hair follicle) builds up and creates a “plug” that manifests as a firm, dry papule. Obstruction of the follicular orifice may be significant enough to prevent hair from exiting, in which case, the hair continues to grow but simply curls in on itself and accentuates the appearance of the papule.

Although KP is a condition and not a disease, it is often considered part of the atopic diatheses, which include the major diagnostic criteria of eczema, urticaria, and seasonal allergies. KP is often mistaken for acne, especially when it affects the face, but its lack of comedones and pustules is a distinguishing characteristic.

Keratosis follicularis (Darier disease) also features follicular papules, but the distribution and morphology differ significantly. Darier is a more serious problem in terms of extent and symptomatology.

Treatment of KP is unsatisfactory at best, but emollients can make it less bumpy. Salicylic acid and lactic acid–containing preparations can also help, but only temporarily. Gentle exfoliation followed by the application of heavy oils is considered the most effective treatment method. The most encouraging thing we can tell our patients: The problem tends to lessen with age.

TAKE-HOME LEARNING POINTS

• Keratosis pilaris (KP) is a common inherited defect of follicular keratinization that affects 30% to 50% of the white population worldwide.
• KP results in a distribution of follicular rough papules across the face, triceps, thighs, buttocks, and upper back, beginning in early childhood.
• A significant percentage of affected patients exhibit the variant termed rubra faceii, which involves the posterior 2/3 of the bilateral face.
• Treatment is problematic, but the application of emollients after gentle exfoliation can help; most cases improve as the patient ages.

Since birth, this now–13-year-old boy has had redness on his face— the intensity of which has slowly increased with time. Various providers have offered a plethora of diagnoses, but no treatment attempts thus far have helped. The condition is asymptomatic but nonetheless distressing to the patient.

More history-taking reveals that, when he was about 6, crops of tiny papules developed on both triceps, his buttocks, and his upper back. These, too, have resisted treatment with OTC creams.

Neither of the boy’s two siblings have had any similar lesions, and no one in the family has any related health problems (eg, atopic diatheses).

EXAMINATION
The posterior 2/3 of both sides of the patient’s face are strikingly red. His nasolabial folds are spared, but the redness extends posteriorly to the immediate preauricular areas and vertically from the zygoma to the jawline. The erythema is highly blanchable with digital pressure and has a uniformly rough, papular feel. There is no tenderness or increased warmth on palpation.

The papules on the triceps, anterior thighs, and upper back are uniform in size (pinpoint, measuring ≤ 1 mm) and distribution, obviously originating from follicles. Unlike the face, these areas are not erythematous.

What’s the diagnosis?

DISCUSSION
There are several types of keratosis pilaris (KP), including rubra faceii, the form affecting this patient (distinguished in part by involvement of the facial skin). KP is utterly common, affecting 30% to 50% of the white population worldwide, with no gender preference. This autosomal dominant disorder involves follicular keratinization—normal keratin (produced in the hair follicle) builds up and creates a “plug” that manifests as a firm, dry papule. Obstruction of the follicular orifice may be significant enough to prevent hair from exiting, in which case, the hair continues to grow but simply curls in on itself and accentuates the appearance of the papule.

Although KP is a condition and not a disease, it is often considered part of the atopic diatheses, which include the major diagnostic criteria of eczema, urticaria, and seasonal allergies. KP is often mistaken for acne, especially when it affects the face, but its lack of comedones and pustules is a distinguishing characteristic.

Keratosis follicularis (Darier disease) also features follicular papules, but the distribution and morphology differ significantly. Darier is a more serious problem in terms of extent and symptomatology.

Treatment of KP is unsatisfactory at best, but emollients can make it less bumpy. Salicylic acid and lactic acid–containing preparations can also help, but only temporarily. Gentle exfoliation followed by the application of heavy oils is considered the most effective treatment method. The most encouraging thing we can tell our patients: The problem tends to lessen with age.

TAKE-HOME LEARNING POINTS

• Keratosis pilaris (KP) is a common inherited defect of follicular keratinization that affects 30% to 50% of the white population worldwide.
• KP results in a distribution of follicular rough papules across the face, triceps, thighs, buttocks, and upper back, beginning in early childhood.
• A significant percentage of affected patients exhibit the variant termed rubra faceii, which involves the posterior 2/3 of the bilateral face.
• Treatment is problematic, but the application of emollients after gentle exfoliation can help; most cases improve as the patient ages.

Since birth, this now–13-year-old boy has had redness on his face— the intensity of which has slowly increased with time. Various providers have offered a plethora of diagnoses, but no treatment attempts thus far have helped. The condition is asymptomatic but nonetheless distressing to the patient.

More history-taking reveals that, when he was about 6, crops of tiny papules developed on both triceps, his buttocks, and his upper back. These, too, have resisted treatment with OTC creams.

Neither of the boy’s two siblings have had any similar lesions, and no one in the family has any related health problems (eg, atopic diatheses).

EXAMINATION
The posterior 2/3 of both sides of the patient’s face are strikingly red. His nasolabial folds are spared, but the redness extends posteriorly to the immediate preauricular areas and vertically from the zygoma to the jawline. The erythema is highly blanchable with digital pressure and has a uniformly rough, papular feel. There is no tenderness or increased warmth on palpation.

The papules on the triceps, anterior thighs, and upper back are uniform in size (pinpoint, measuring ≤ 1 mm) and distribution, obviously originating from follicles. Unlike the face, these areas are not erythematous.

What’s the diagnosis?

DISCUSSION
There are several types of keratosis pilaris (KP), including rubra faceii, the form affecting this patient (distinguished in part by involvement of the facial skin). KP is utterly common, affecting 30% to 50% of the white population worldwide, with no gender preference. This autosomal dominant disorder involves follicular keratinization—normal keratin (produced in the hair follicle) builds up and creates a “plug” that manifests as a firm, dry papule. Obstruction of the follicular orifice may be significant enough to prevent hair from exiting, in which case, the hair continues to grow but simply curls in on itself and accentuates the appearance of the papule.

Although KP is a condition and not a disease, it is often considered part of the atopic diatheses, which include the major diagnostic criteria of eczema, urticaria, and seasonal allergies. KP is often mistaken for acne, especially when it affects the face, but its lack of comedones and pustules is a distinguishing characteristic.

Keratosis follicularis (Darier disease) also features follicular papules, but the distribution and morphology differ significantly. Darier is a more serious problem in terms of extent and symptomatology.

Treatment of KP is unsatisfactory at best, but emollients can make it less bumpy. Salicylic acid and lactic acid–containing preparations can also help, but only temporarily. Gentle exfoliation followed by the application of heavy oils is considered the most effective treatment method. The most encouraging thing we can tell our patients: The problem tends to lessen with age.

TAKE-HOME LEARNING POINTS

• Keratosis pilaris (KP) is a common inherited defect of follicular keratinization that affects 30% to 50% of the white population worldwide.
• KP results in a distribution of follicular rough papules across the face, triceps, thighs, buttocks, and upper back, beginning in early childhood.
• A significant percentage of affected patients exhibit the variant termed rubra faceii, which involves the posterior 2/3 of the bilateral face.
• Treatment is problematic, but the application of emollients after gentle exfoliation can help; most cases improve as the patient ages.

The FP suspected a basal cell carcinoma (BCC) or squamous cell carcinoma.

Informed consent was obtained, and the FP numbed the area with 1% lidocaine and epinephrine using a 30 gauge needle. The area was exquisitely tender, so a small needle was used and the anesthesia was injected slowly. (It is safe and recommended to use epinephrine for biopsy on or around the nose.) The physician performed a shave biopsy. (See the Watch & Learn video on “Shave biopsy.”)

The biopsy results confirmed an infiltrative BCC. The physician recognized this as a more aggressive BCC and its location at the nasolabial fold suggested that the patient was at an increased risk for recurrence. He communicated these risk factors to the patient, and she accepted a referral for Mohs surgery.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Basal cell carcinoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:989-998.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

The FP suspected a basal cell carcinoma (BCC) or squamous cell carcinoma.

Informed consent was obtained, and the FP numbed the area with 1% lidocaine and epinephrine using a 30 gauge needle. The area was exquisitely tender, so a small needle was used and the anesthesia was injected slowly. (It is safe and recommended to use epinephrine for biopsy on or around the nose.) The physician performed a shave biopsy. (See the Watch & Learn video on “Shave biopsy.”)

The biopsy results confirmed an infiltrative BCC. The physician recognized this as a more aggressive BCC and its location at the nasolabial fold suggested that the patient was at an increased risk for recurrence. He communicated these risk factors to the patient, and she accepted a referral for Mohs surgery.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Basal cell carcinoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:989-998.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.

The FP suspected a basal cell carcinoma (BCC) or squamous cell carcinoma.

Informed consent was obtained, and the FP numbed the area with 1% lidocaine and epinephrine using a 30 gauge needle. The area was exquisitely tender, so a small needle was used and the anesthesia was injected slowly. (It is safe and recommended to use epinephrine for biopsy on or around the nose.) The physician performed a shave biopsy. (See the Watch & Learn video on “Shave biopsy.”)

The biopsy results confirmed an infiltrative BCC. The physician recognized this as a more aggressive BCC and its location at the nasolabial fold suggested that the patient was at an increased risk for recurrence. He communicated these risk factors to the patient, and she accepted a referral for Mohs surgery.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Karnes J, Usatine R. Basal cell carcinoma. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:989-998.

To learn more about the Color Atlas of Family Medicine, see: www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/.

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking on this link: usatinemedia.com.