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Long-term immunosuppression in the organ transplant recipient (OTR) population places these individuals at higher risk of developing skin malignancies. Oral retinoids have become a useful tool for pharmacologic prophylaxis in the OTR population. Immunosuppressants that inhibit mTOR, such as sirolimus, may be used in combination with a systemic retinoid for chemoprophylaxis of cutaneous malignancies. We present the case of a male patient status post second renal transplant who developed an abrupt and unexpected rise in sirolimus levels to supra-therapeutic levels after initiation of prophylactic acitretin for innumerable squamous cell carcinomas (SCC). The sirolimus levels returned to baseline after cessation of acitretin. Systemic drug-drug interactions are an important phenomenon, especially in the solid OTR population. It is postulated that this interaction was mediated by acitretin inhibition of CYP3A4, the primary enzyme responsible for sirolimus metabolism. The Drug Interaction Probability Scale (DIPS) indicates this was a "probable" drug-drug interaction. To date, this interaction has not been reported in the literature. This case accentuates the importance of close monitoring of solid OTRs for adverse medication interactions when multiple medications are taken.

Radiation therapy (RT) is a noninvasive treatment for a variety of skin cancers. Although surgery is often preferred for basal cell carcinoma (BCC) and lentigo maligna (LM), these conditions often affect patients that are medically inoperable, who decline surgery, or have lesions in challenging anatomic locations. Although nonsurgical treatments can be employed, close monitoring for disease recurrence and progression is of utmost importance. Typically, this is carried out by clinical examination, without adjunctive imaging. Reflectance confocal microscopy (RCM) is an emerging imaging technology that is proving useful to aid in the assessment of treatment response and disease recurrence (Fig 1). RCM has a high

Importance Extramammary Paget disease (EMPD) is commonly refractory to surgical and nonsurgical therapies. Identifying recurrent or persistent EMPD is challenging because the disease is multifocal, and multiple blind scouting biopsies are usually performed in this setting. Handheld reflectance confocal microscopy (HRCM) has been used to diagnose and map primary EMPD and therefore may be used to identify EMPD recurrences. Objective To evaluate HRCM’s diagnostic accuracy in the setting of recurrent or persistent EMPD as well as its potential diagnostic pitfalls. Design, Setting, and Participants This prospective case series study included patients referred to the Dermatology Service at Memorial Sloan Kettering Cancer Center between January 1, 2014, and December 31, 2016, with biopsy-proven EMPD in whom HRCM was used to monitor treatment response. Five patients were included, and 22 sites clinically concerning for recurrent or persistent disease were evaluated using HRCM and histopathologic examination. In 2 patients, video mosaics were created to evaluate large areas. Main Outcomes and Measures Sensitivity and specificity of HRCM in identifying recurrent or persistent EMPD; causes for false-negative results according to their location, histopathologic findings, and previous treatments. Results Of the 22 clinically suspicious sites evaluated in 5 patients (4 men, 1 woman; median [range] age, 70 [56-77] years), 9 (40.9%) were positive for recurrent disease on HRCM and histopathologically confirmed, and 13 (59.1%) sites were negative on HRCM, but 3 of the 13 were positive for EMPD on histopathological examination. In general, HRCM had a sensitivity of 75% and a specificity of 100% in identifying recurrent or persistent EMPD. False-negative results were found in 2 patients and occurred at the margins of EMPD, close to previous biopsy sites. Creating video mosaics (or video mosaicking) seemed to improve the detection of EMPD. Conclusions and Relevance Handheld reflectance confocal microscopy is a useful auxiliary tool for diagnosing EMPD recurrences and can be used to guide scouting biopsies, thus reducing the number of biopsies needed to render a correct diagnosis.

It is estimated that nearly a quarter of all persons aged 18 to 50 in the United States have a tattoo.1 Demand for tattoo removal has increased, with an estimated 1 in 5 persons considering tattoo removal.1 American Society for Dermatologic Surgery physicians reported about 100,000 laser tattoo removal procedures in 2013, up more than 50% from 2012.2 Motives for removal include aesthetic reasons, poor tattoo result, and professional or social stigma. Laser-assisted tattoo removal remains the gold standard treatment. With increasing demand for tattoo removal, it is important to be cognizant of adverse events that may occur. We report the novel case of a woman who had an allergic cutaneous reaction at a distant, untreated tattoo site, and subsequently had a delayed anaphylactic reaction after laser tattoo removal.