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Options to prevent facial insect bites while sleeping are limited. Patients may prefer to avoid facial application of potentially neurotoxic insect repellants. Non-toxicldquo;naturalrdquo; repellants have limited efficacy, and netting may not be well-tolerated. Nightly facial application of 1% topical ivermectin (IVM) cream completely prevented overnight bites in 2 patients, both of whom reported recurrent bites after discontinuation, and a return to complete bite prevention after IVM resumption. Topical IVM may be an alternative facial mosquito bite prevention modality. J Drugs Dermatol. 2022;21(8):906-907. doi:10.36849/JDD.6432.

Dermatologists often recommend vitamin D for sun-protected patients. Most patients are not aware of the key role vitamin K2 plays in vitamin D metabolism and do not receive sufficient dietary vitamin K2. A survey of 50 sun-protecting patients shows 4/50 understood the role of vitamin K2 and 1/50 was supplementing vitamin K2. Therefore, counseling on vitamin K2 supplementation may be of benefit to sun-protected dermatology patients. J Drugs Dermatol. 2021;20(2):228-229. doi:10.36849/JDD.5829.

Paring is useful for both diagnosis and treatment of plantar warts. Paring techniques generally involve scalpel blades, abrasive tools, or curettes. However, these tools do not permit the use of an “awl-like” carving technique of the wart afforded by using a punch biopsy tool. We have found this technique to be associated with greater precision and safety, as well as potentially increased efficacy compared to traditional methods.

Erythema Gyratum Repens Associated with Anal Cancer A 73-year-old woman presented with an evolving pruritic, erythematous rash and was found to have anal cancer. A diagnosis of erythema gyratum repens was made.

Hyperhidrosis, or abnormally increased sweating, is a condition that may have a primary or secondary cause. Usually medication- induced secondary hyperhidrosis manifests with generalized, rather than focal sweating. We report a 32-year-old woman with a history of palmoplantar hyperhidrosis for 15 years who presented for treatment and was prescribed oral glycopyrrolate. One month later, the palmoplantar hyperhidrosis had resolved, but she developed new persistent craniofacial sweating. After an unsuccessful trial of clonidine, oxybutynin resolved the craniofacial hyperhidrosis. To our knowledge, this is the first case of compensatory hyperhidrosis secondary to glycopyrrolate reported in the literature. The case highlights the importance of reviewing medication changes that correlate with new onset or changing hyperhidrosis. It also demonstrates a rare drug adverse effect with successful treatment.

Current healthcare trends promote data-driven “benchmarking” to decrease cost and increase quality. Dermatologists perform 79% of skin biopsies and biopsy rate is an easily measured benchmark. To reduce the risk of a misguided “one size fits all” benchmark for biopsies, it will help to document the factors driving divergent biopsy rates. This letter compares biopsy rates and high-risk patient ratios for 1000 sequential patients from two academic dermatologists. Elevated biopsy rates (0.55 vs 0.42, p < 0.001) were associated with elevated ratios of high-risk patients (.52 versus .30, p< 0.001). Although limited by small sample size, this research takes a first step toward future efforts to improve accuracy of biopsy benchmarking.

Syphilis is commonly known as "the great imitator" owing to its varied clinical manifestations. Secondary syphilis has a variety of presentations, with the most common manifesting as a diffuse papulosquamous eruption on the palms and soles. Lues maligna praecox is a rare form of secondary syphilis, with severe constitutional symptoms, seen primarily in HIV-positive individuals. We report an atypical case of suspected lues maligna in a 45-year-old male. The patient was HIV-positive with a CD4 count of 441. He presented to our clinic with large painful gummatous ulcers in the groin and lower back. He also reported daily fevers, night sweats, and weight loss consistent with secondary syphilis. Prior to this episode the patient had a history of acute active syphilis (RPR 1:128) in 2012 treated at that time with a single dose of 2.4 million units intramuscular benzathine penicillin; he had no reported exposures since that time. The patient was treated with three weekly doses of benzathine penicillin, 2.4 million units, given intramuscularly. This case demonstrates the importance of recognizing the varied clinical presentation of secondary syphilis and keeping lues maligna in consideration for ulceronodular skin lesions in patients who are HIV-positive.

Skin cancer in organ transplant recipients (OTRs) and other immunosuppressed populations is a significant health care concern. The more than two million American OTRs have a dramatically increased risk for developing squamous cell cancer, as well as a variety of other skin cancers, including basal cell cancer, melanoma, Merkel cell carcinoma, and Kaposi sarcoma. Skin cancer risk is also increased among patients receiving immunosuppressive treatment for various autoimmune diseases such as rheumatoid arthritis, inflammatory bowel disease, and psoriasis, and also patients infected with the human immunodeficiency virus. Management of cutaneous neoplasia in these at-risk populations includes topical therapies, photodynamic therapy, systemic retinoids, surgical excision, as well as multidisciplinary care involving patient education and frequent dermatological examinations. In OTRs and autoimmune patients the revision of immunosuppression is also a key treatment consideration for aggressive skin cancers.

Acute generalized exanthematous pustulosis (AGEP) is a clinical reaction pattern characterized by the rapid appearance of widespread sterile, nonfollicular pustules arising within edematous erythematous skin. This aseptic pustular eruption is commonly accompanied by leukocytosis and fever and usually follows recent administration of oral or parenteral drugs. We report two cases of terbinafine-induced AGEP in male patients. Both patients developed a generalized erythroderma with scaling and pruritic pustules 7 and 14 days following initiation of oral terbinafine. With immediate discontinuation of terbinafine and various treatment protocols, both patients demonstrated recovery followed by skin desquamation during the subsequent weeks. Terbinafine is the most frequently used systemic antimycotic and antifungal medication, reflecting its superior efficacy for dermatophyte infections. Despite the appealing drug profile, an awareness of terbinafine-induced AGEP is important given the 5 percent mortality associated with AGEP. Additionally, distinguishing the characteristics of AGEP from those associated with toxic epidermal necrolysis, Stevens-Johnson syndrome, and generalized pustular psoriasis allows for prompt dermatologic evaluation, accurate diagnosis, and appropriate treatment.