Abstract: Imiquimod (1-[2-methylpropyl]-1H-imidazo[4,5-c]quinolin-4-amine) is a widely used topical immune response modifier. This drug was initially developed as an antiviral agent and was found to have potent effects on the immune system. Because imiquimod causes the activation of antigen-presenting cells (APCs), it acts as an immunologic adjuvant. By triggering cytokine production, imiquimod enhances the ability of APC to present viral or tumor antigens to reactive T lymphocytes, and amplifies type 1 helper T cell (T(H) 1)-mediated immune responses (interferon [IFN] gamma production as well as other related cytokines). The cellular receptors for imiquimod and its analogues are toll-like receptors (TLR) 7 and 8. These 2 receptors are part of a larger family of TLRs that are critical components of innate immunity, which has evolved to detect dangerous bacterial, viral, fungal, and parasitic infections. Topical imiquimod is a U.S. Food and Drug Administration (FDA)-approved treatment for external genital warts, actinic keratoses (AKs), and superficial basal cell carcinomas (sBCCs). Because there are a number of cell types that express either TLR7 or receptors for cytokines induced by imiquimod, this agent has broad-reaching direct and indirect effects in the skin as well as the related skin immune system. Thus, imiquimod has been demonstrated to be useful in the treatment of a number of conditions beyond the FDA-approved indications (mostly neoplastic and infectious but also fibrotic and some degenerative conditions).

Abstract: Many dermatologic diseases, including vitiligo and other pigmentary disorders, vascular malformations, acne, and disfiguring scars from surgery or trauma, can be distressing to pediatric patients and can cause psychological alterations such as depression, loss of self-esteem, deterioration of quality of life, emotional distress, and, in some cases, body dysmorphic disorder. Corrective camouflage can help cover cutaneous unaesthetic disorders using a variety of water-resistant and light to very opaque products that provide effective and natural coverage. These products also can serve as concealers during medical treatment or after surgical procedures before healing is complete. Between May 2001 and July 2003. corrective camouflage was used on 15 children and adolescents (age range, 7-16 years; mean age, 14 years). The majority of patients were girls. Six patients had acne vulgaris; 4 had vitiligo; 2 had Becker nevus; and 1 each had striae distensae, allergic contact dermatitis. and postsurgical scarring. Parents of all patients were satisfied with the cosmetic cover results. We consider corrective makeup to be a well-received and valid adjunctive therapy for use during traditional long-term treatment and as a therapeutic alternative in patients in whom conventional therapy is ineffective.

Abstract: A 68-year-old healthy man presented with papulopustular rosacea (PPR) recalcitrant to multiple therapies, including permethrin cream 5%. Histologic examination detected the presence of chronic folliculitis and numerous Demodex organisms. A diagnosis of rosacealike demodicidosis was rendered, and the patient was treated with oral ivermectin and permethrin cream 5%, resulting in resolution of the folliculitis. Demodex infestation should be considered in any patient with rosacealike dermatitis resistant to conventional rosacea therapies. If infestation is demonstrated in these patients, oral ivermectin in combination with topical permethrin is a safe and effective therapeutic option.

Abstract: A phase 4, open-label, multicenter, community-based study was conducted in subjects with mild to moderately severe papulopustular rosacea of various etiologies and locations to identify subgroups particularly responsive to twice-daily application of metronidazole topical gel 0.75% to the affected areas of the face. A total of 582 subjects were randomized. Evaluations were conducted at baseline and at weeks 4, 8, and 12. At each evaluation, investigator global assessment (IGA) scores, mean papule and pustule counts, erythema scores, and telangiectasia scores improved significantly (P < .0001), with consistent results across sex and age subgroups. The mean erythema severity score decreased significantly (P < .0001) from baseline by week 4 and continued to decline at all study visits, with a nearly 50% reduction by week 12. At study end, subjects indicated a 25% improvement in itching, pain, soreness, or stinging; a 53% improvement in embarrassment or self-consciousness; and a 31% improvement in rosacea's effect on social or leisure activities. Metronidazole topical gel 0.75% was associated with a very low incidence of side effects in this trial, similar to previous clinical trials. The most common treatment-related adverse event (AE) reported in this study was mild application-site discomfort. The gel formulation was well-tolerated and effective in all subject subgroups and in a variety of climates. The findings of this study expand the collected data on the efficacy and safety of metronidazole topical gel 0.75% beyond that demonstrated in controlled clinical trials and confirm the utility of this therapy in the community setting.

Abstract: The most common skin infections are caused by Staphylococcus aureus, group A streptococci (Streptococcus pyogenes), or the normal skin flora. An antistaphylococcal oral antibiotic is the preferred treatment for nonbullous and bullous impetigo, and a therapeutic agent that is effective against both S aureus and streptococci is appropriate for most cases of cellulitis. For furuncles, carbuncles, cutaneous abscesses, and inflamed epidermal cysts, the most important therapy is incision and drainage, and in most cases there is no need for antimicrobial therapy. Patients with venous ulcers and atopic eczema do not benefit from systemic antimicrobial therapy unless obvious infection is present, as indicated by clinical features such as fever, cellulitis, and lymphangitis.

Abstract: Immunomodulatory therapy, which functions to upregulate immune response, may be directed against a variety of disease states, including viral infections and skin malignancies. Examples of immune response modifiers include injectable interferon (IFN) and topical imiquimod. Topical imiquimod has been studied for a variety of different disorders including human papillomavirus infection, molluscum contagiosum, actinic keratosis (AK), squamous cell carcinoma (SCC) in situ, superficial basal cell carcinoma (sBCC), nodular basal cell carcinoma (nBCC), and lentigo maligna. Case reports also have demonstrated use for select cases of extramammary Paget disease. This article focuses on therapies designed to augment immune response to treat viral infections and nonmelanoma skin cancers and reviews clinical applications, efficacy, recommended treatment regimens, monitoring of response, and avoidance of pitfalls associated with the use of topical imiquimod.

Abstract: Lentigo maligna (LM) is an in situ variant of melanoma. Although LM has the potential for invasion, it often has a greatly protracted radial growth phase and may remain indolent for years. The current standard of care is surgical excision, but this often results in substantial morbidity; thus, nonsurgical approaches continue to be investigated. Imiquimod cream 5% is an immunomodulatory agent that previously has been reported to successfully eradicate LM. We evaluated the treatment course of topical imiquimod in 12 patients with LM. Data from patients with biopsy-proven LM were collected retrospectively, reviewed, and summarized. Patients ranged in age from 54 to 83 years. Most patients chose imiquimod cream as their initial form of treatment; however, other patients had a history of LM recurrence after excision or had positive histologic margins at the time of excision. Initial application regimens varied from 2 to 7 times weekly. The average duration of treatment was 15.7 weeks but ranged from 7 to 44 weeks. Results of posttreatment biopsies of the most clinically suspicious areas in 6 patients showed histologic clearance; 2 patients demonstrated single atypical melanocytes and 4 patients demonstrated clinical clearance without histologic confirmation. These findings suggest that imiquimod cream 5% may be an effective alternative treatment for LM.

Abstract: When topical therapy and tap water iontophoresis (TWI) fail, are unavailable, or are deemed unsatisfactory by patients with palmar or plantar hyperhidrosis (HH), the next logical treatment option is botulinum toxin type A (BTX-A). Skill and precision are required to treat palmar and plantar HH because of the dense innervation in the palms and soles. This article describes best practice techniques for BTX-A (Botox), including suggested dilution and syringe selection, injection technique, dose and injection grids, and anesthesia recommendations. In addition, general BTX-A background and special considerations for treating palmar and plantar HH are provided. Insurance reimbursement for treating HH with BTX-A can be challenging; navigating the insurance reimbursement process will be discussed.

Abstract: A major issue in treating acne in individuals of color is the need to treat and prevent postinflammatory hyperpigmentation (PIH), which is common in this population. This subset analysis reports the pigmentary changes in subjects of color with acne who were enrolled in a community-based trial comparing 3 different topical therapeutic regimens. All subjects received combination clindamycin 1%-benzoyl peroxide (BPO) 5% topical gel containing glycerin and dimethicone. Subjects were randomized to receive this combination therapy in addition to either a tretinoin microsphere (RAM) gel at concentrations of either 0.04% or 0.1% or adapalene (AP) gel 0.1%. There was a trend toward better resolution of hyperpigmentation in the subjects receiving the clindamycin-BPO topical gel in combination with RAM gel 0.04%.

Abstract: Some sun safety activities have included only non-Hispanic white individuals, even though individuals in other ethnoracial groups may be at risk for skin cancer. The objectives of this study were to investigate distributions of self-reported Fitzpatrick skin type within 5 ethnoracial groups and substantiate each group's self-report with an objective measure. The study used a cross-sectional design. The research was conducted at 70 postal stations in Southern California. Participants were US Postal Service letter carriers and included 115 Pacific Islanders, 222 black individuals, 329 Asians, 513 Hispanics, and 1364 non-Hispanic white individuals. Participants self-reported skin type and had skin color measurements taken with colorimeters. Some individuals in each ethnoracial group reported having sun-sensitive skin. Correlation tests assessing the relationship between skin type and colorimeter data showed substantial associations for each group except Asians. Future sun safety research and educational messages should include all potentially high-risk individuals, irrespective of ethnoracial identity.

Abstract: Erythema ab igne is a condition characterized by reticulated telangiectasia and hyperpigmentation caused by repeated long-term exposure to infrared radiation insufficient to produce a burn. We report a case of laptop computer-induced erythema ab igne.

Abstract: The Lichtenberg figure (LF) is a recognizable skin pattern that is only seen in individuals struck by lightning. LF, also known as a ferning pattern, is a transient finding. It is not a burn, and biopsies of the skin reveal no pathologic changes. We present 3 case reports of patients who presented with LF after being struck by lightning. The explanation of what LF represents remains unknown. Many researchers believe that LFs are fractal patterns and do not correspond to known vascular or neuroanatomic patterns. We present our ideas on possible mechanisms of the pathophysiology of LFs.

Abstract: This double-blinded, randomized, vehicle-controlled, multicenter, parallel-group, 12-week, phase 4 study was conducted in adults with mild to moderate acne vulgaris. Of 178 subjects randomized to be treated, 88 subjects (49%) were treated with tretinoin gel microsphere 0.04% and 90 subjects (51%) were treated with vehicle. Inflammatory lesion counts were statistically significantly reduced at 2 weeks in tretinoin-treated subjects (P = .0110), and reductions in total lesion counts also were noted. The reduction in total lesion counts reached statistical significance at week 4 (P = .0305); at week 12, mean total, inflammatory, and noninflammatory lesion counts were statistically significantly lower in the tretinoin treatment group versus vehicle group (P < .05), and mean percentage reductions in lesion counts were significantly greater in the subjects with noninflammatory lesions treated with tretinoin compared with vehicle (P < .05). Mean percentage reductions in total, inflammatory, and noninflammatory lesion counts were 35.5%, 38.2%, and 33.6%, respectively, at week 12 for the tretinoin treatment group compared with 20.9%, 19.2%, and 20.4%, respectively, for the vehicle group (all P < .05). All adverse events were of mild or moderate intensity with the exception of severe skin irritation in one tretinoin-treated subject. At week 12, there were no statistically significant differences between treatment groups for any measured tolerability parameter.

Abstract: Localized cutaneous argyria presenting as an asymptomatic blue-gray macule has been rarely reported from diverse etiologies including occupational exposures, topical medications, alternative medical therapies, body jewelry, and dental procedures (amalgam tattoos). The lesions often are clinically indistinguishable from blue nevi and malignant melanoma. We present a case of localized cutaneous argyria from an acupuncture needle in a patient with a history of malignant melanoma. Fine granules of nonbleachable dark particles coating collagen and elastin fibers, altered yellow-brown collagen bundles similar to ochronosis, and involvement of eccrine structures were histologically consistent with the pseudo-ochronosis pattern of localized cutaneous argyria, demonstrating that clinicopathologic correlation is of crucial importance.

Abstract: Until recently, with the exception of oral isotretinoin for the treatment of severe recalcitrant nodular acne, systemic therapy for acne vulgaris and rosacea has been based on anecdotal support, clinical experience, and small clinical trials. Tetracycline derivatives are the predominant systemic agents that have been used for both disease states, prescribed in dose ranges that produce antibiotic activity. Anti-inflammatory dose doxycycline, a controlled-release (CR) 40-mg capsule formulation of doxycycline that is devoid of antibiotic activity when administered once daily, was US Food and Drug Administration (FDA)-approved for the treatment of inflammatory lesions (papules and pustules) of rosacea, based on large-scale phase 3 pivotal trials and long-term microbiologic and safety data. Also, an extended-release (ER) tablet formulation of minocycline was approved by the FDA for the treatment of inflammatory lesions of moderate to severe acne vulgaris in patients 12 years and older based on large-scale phase 3 clinical trials that evaluated efficacy and safety, dose-response analysis, and long-term data. This article discusses the studies and clinical applications related to the use of these agents.

Abstract: A 40-year-old woman presented with an asymptomatic reticulated eruption on the thighs. After an extensive workup, she was diagnosed with erythema ab igne caused by laptop computer use. The eruption ultimately cleared several months after discontinuation of direct placement of the laptop computer on her thighs. Erythema ab igne is becoming increasingly associated with exposure to modern heat sources. A thorough history of patients with suspicious lesions should include questioning for contact with alternative heat sources to avoid an unnecessary workup for this condition.

Abstract: Oral trimethoprim/sulfamethoxazole (TMP-SMX) is approved by the US Food and Drug Administration for the treatment of urinary tract infections, shigellosis, acute otitis media in pediatric patients, and Pneumocystis carinii pneumonia. TMP-SMX has been used off label in dermatology to treat various skin conditions, including acne vulgaris and other skin and soft tissue infections, especially those infections caused by methicillin-resistant Staphylococcus aureus.

Abstract: Infliximab is a chimeric immunoglobulin G1kappa monoclonal antibody against tumor necrosis factor alpha (TNF-alpha), a proinflammatory cytokine that participates in both normal immune function and the pathogenesis of many autoimmune disorders. Treatment with infliximab reduces the biologic activities of TNF-alpha and thus is indicated in the treatment of rheumatoid arthritis, Crohn disease, ankylosing spondylitis, psoriatic arthritis, plaque psoriasis, and ulcerative colitis. To our knowledge, there have been 13 case reports of new-onset psoriasis, psoriasiform dermatitis, and palmoplantar pustular psoriasis that developed during treatment with infliximab. We report 3 additional cases of biopsy-proven new-onset psoriasis that developed while the patients underwent treatment with infliximab for inflammatory bowel disease. Although the mechanism for the development of psoriasis in these patients is unclear, several possible explanations are proposed. With increasing use of infliximab and other TNF-alpha inhibitors in clinical practice, more cases of similar reactions to these drugs probably will be reported and are necessary to determine the importance of this eruption.

Abstract: Microcystic adnexal carcinoma (MAC) is a relatively uncommon adnexal neoplasm that can demonstrate locally aggressive behavior; rare instances of metastatic lesions have been reported. We report a case of a 34-year-old black man with multiple primary MACs.

Abstract: Juvenile pemphigus vulgaris (PV) is a rare and often misdiagnosed condition. Although PV frequently is severe in children, a substantial portion of the morbidity and mortality associated with juvenile PV has been attributed to treatment. This report demonstrates the efficacy of rituximab therapy in juvenile PV. We report 2 cases and review the literature. Rituximab treatment was effective in helping to control 2 recalcitrant cases of juvenile PV without inducing the adverse effects associated with other adjuvant therapies. Rituximab should be considered when treating resistant cases of PV in pediatric populations to avoid the long-term side effects of other immunosuppressive treatments.

Abstract: Methicillin-resistant Staphylococcus aureus (MRSA) is a common bacterial pathogen that has long been considered a hospital-acquired pathogen. However, newer community-acquired strains have appeared that differ from nosocomial strains in their susceptibility to different antibiotics. Because these community isolates harbor a novel methicillin-resistance cassette gene element that has not been associated with hospital-acquired strains, they can encode virulence factors, such as Panton-Valentine leukocidin (PVL), which has been linked to skin and soft tissue infections and necrotizing pneumonia. A variety of antibiotics are available for the treatment of hospital-acquired MRSA (HAMRSA) and community-acquired MRSA (CAMRSA). Incision and drainage is of paramount importance in the treatment of cutaneous abscesses and is sufficient treatment in most uncomplicated skin and soft tissue infections.

Abstract: Short-term corticosteroids (CSs), most commonly defined as short-term prednisone (STP) 40 to 60 mg or its equivalent, either tapered or level, prescribed over a few days to 3 weeks (total dose, 400-600 mg), often are used to treat acute and self-limiting diseases. Serious side effects, though uncommon, can occur; however, they receive little attention. The literature contains scattered case reports and legal cases that highlight the relationship between STP and avascular necrosis (AVN). The orthopedic literature finds that CSs are one of the most common causes of AVN. An Internet search of AVN identifies several commercial pages prepared for lawyers that describe references and supplies relevant to initiating lawsuits. Court cases consistently find that patients must be informed of treatment risks and options. Informed consent and thorough documentation are required when prescribing STP.

Abstract: Epidermodysplasia verruciformis (EV) is an uncommon dermatosis associated with human papillomavirus (HPV) infection in association with defects in cell-mediated immunity. Malignant transformation to squamous cell carcinoma has been associated with lesions caused by HPV-5, HPV-8, and HPV-14. Clinically, the disease may be confused with verruca plana, seborrheic keratosis, and pityriasis versicolor. We present an unusual case of EV occurring in a human immunodeficiency virus (HIV)-positive man and discuss the clinical and histologic findings. Clinically, the patient had 1- to 3-mm hypopigmented smooth macules covering the entire body. Histopathologic examination of the skin biopsy results demonstrated enlarged keratinocytes with prominent blue-gray cytoplasm and clumping of keratohyalin granules within the granular layer of the epidermis. Although EV typically is viewed as a disease of childhood, sometimes presenting in patients with a family history of the disease, it rarely may be seen in immunocompromised adults.

Abstract: Acne rosacea is a chronic skin disorder that requires long-term therapy. Oral azithromycin has been used successfully to treat acne vulgaris. an observation that suggested an infectious agent may play an active role in the etiology of this disorder. Ten adults (not previously reported) with acne rosacea were selected to be treated with oral azithromycin. Nine of the 10 subjects received 250 mg 3 times weekly for periods ranging from 5 to 19 weeks, at which time follow-up examinations were performed on 8 of the 9 treated subjects: 1 subject was lost to follow-up. Prior to therapy. C pneumoniae antigen was detected in malar biopsy specimens in 4 of 10 subjects by immunoperoxidase technique (using monoclonal antibody to C pneumoniae). Serum antibodies against C pneumoniae were detected in 8 of 10 intent-to-treat subjects. Using polymerase chain reaction, C pneumoniae was not detected in peripheral blood mononuclear cells. The inflammatory response in tissues was characterized by a widespread infiltration of polymorphonuclear neutrophil cells, lymphocytes, and plasma cells, which support the clinical diagnosis of acne rosacea. Nine of 10 subjects treated with azithromycin showed moderate to marked improvement of their acne rosacea. No adverse reactions to azithromycin occurred. and the drug appeared to be safe and effective. These preliminary data suggest the need for further investigation with clinical trials to study long-term tolerability and efficacy and also strongly implicate C pneumoniae in the pathogenesis of acne rosacea.

Abstract: Both classic and atypical Spitz nevi are uncommon melanocytic lesions usually presenting in children and adolescents. The classic Spitz nevus typically is benign and has characteristic clinical and histologic features. In contrast, the atypical Spitz nevus has an unknown clinical prognosis, and its clinical and histologic traits are loosely defined. Melanoma can have similar features to both classic and atypical Spitz nevi and must be ruled out in all cases. We review the literature on classic and atypical Spitz nevi, advances in differentiating both types of nevi from melanoma, and treatment options.

Abstract: The present study examined the impact of once-daily fexofenadine hydrochloride (HCl) 180 mg on health-related quality of life (HRQL) in subjects with chronic idiopathic urticaria (CIU). This was a multicenter, randomized, double-blind. parallel-group, placebo-controlled study. Subjects completed the Dermatology Life Quality Index (DLQI) and the Work Productivity and Activity Impairment (WPAI) questionnaire at baseline and at weeks 2 and 4. The primary HRQL end point was mean change from baseline to week 4 in total DLQI score. Subjects in the fexofenadine HCl treatment group (n = 163) experienced significantly greater improvements in mean total DLQI score (P = .0219) and in the individual domains of symptoms and feelings (P = .0119) and personal relationships (P = .0091) compared with those in the placebo group (n = 91). Subjects who received fexofenadine HCl experienced less work productivity impairment, overall work impairment, and activity impairment than those who received placebo. The results indicated that once-daily fexofenadine HCl 180 mg improved the HRQL of subjects with CIU, as assessed by change in total DLQI score.

Abstract: Protothecosis is a rare cause of systemic and/or cutaneous infection Because approximately 100 cases of human infection with Prototheca wickerhamii have been reported, little is known about the pathogenesis of this infection Cases include both immunocompetent and immunocompromised patients However, most cases contain an element of immune compromise, either local or systemic We present a case of an 81-year-old white woman with a history of multiple nonmelanoma skin cancers, including squamous and basal cell carcinomas and actinic keratoses, throughout her legs and thighs bilaterally She presented to a central Florida dermatology clinic with complaints of persistent bumps on her right lower leg despite therapy with diclofenac sodium gel 3% and 5-fluorouracil cream 5% Biopsies of skin specimens from the right lower leg revealed a dermal abscess that contained spherical funguslike organisms, with periodic acid-Schiff staining revealing 6- to 10-microm organisms with internal septations, which are characteristic of P wickerhamii

Abstract: Desmoplastic malignant melanoma (DMM) is a rare variant of melanoma with distinct histopathologic and clinical features. Compared with other melanomas, the desmoplastic variant demonstrates a greater frequency of local recurrence and a proclivity for tracking along nerves, but it poses a lower risk of distant metastases. Elective lymph node dissection and sentinel lymph node biopsy (SLNB) are commonly used tools for determining prognosis in thick melanomas. The role of these procedures for DMM remains unclear. This study was designed to characterize DMM and determine the frequency of histologically positive lymph nodes in patients with DMM. This retrospective chart review included patients with DMM treated by Johns Hopkins Hospital (JHH) physicians between 1998 and 2003. Among the 28 patients included in the study, 18 patients had biopsies performed on lymph nodes (15 SLNBs and 3 radical neck dissections). One patient had a sentinel lymph node with histology positive for DMM. All others had negative results from histology and S100 stains. This study suggests that the frequency of positive SLNBs in DMM may be substantially lower than that of other melanomas.

Abstract: Microdermabrasion and superficial glycolic acid peels are common aesthetic procedures. Microdermabrasion alone provides the benefits of exfoliation but may provide faster results and increased patient satisfaction when combined with superficial glycolic acid (alpha-hydroxy acid) peels because of the significant antiaging effects of glycolic acid peels. A roundtable discussion was held with dermatologists to review methods of combining these procedures. The first method included alternating glycolic acid peels and microdermabrasion treatments every 2 weeks, enabling the patient to receive both a peel and microdermabrasion in the same month. With the second method, microdermabrasion may be used prior to the superficial glycolic acid peel to increase the exfoliation and antiaging effects of both treatments within the same visit. This second method is considered to be a more aggressive approach and usually is reserved for patients with a history of procedures. Lastly, combining treatments can be used to maintain a patient's skin after the initial treatment stage, usually performed every other month or seasonally, depending on the patient. As with all combination treatments, safety precautions and monitoring the patient's skin throughout treatment are crucial to success.