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Ethylene urea/melamine formaldehyde resin (permanent press) is a common fabric finishing agent added to Army Combat Uniforms for a wrinkle-free appearance and to strengthen the fabric. We describe the case of an active duty U.S. Army soldier with a diffuse eczematous dermatitis in whom patch testing was used to identify an allergy to permanent press, a ubiquitous fabric finishing agent in the Army combat uniform. To our knowledge, this is the first case report of a soldier with an allergic contact dermatitis to ethylene urea/melamine formaldehyde resin. This case highlights the importance of considering the diagnosis of allergic contact dermatitis in patients with a recurrent eczematous dermatitis that does not respond appropriately to therapy and the unique occupational impact of diagnosing an Army soldier with permanent press allergy. [ABSTRACT FROM AUTHOR]

Cyanoacrylates are widely used as topical skin adhesives in emergency departments, clinics, and operating rooms. We report 4 patients who developed allergic contact dermatitis (ACD) following postsurgical closure with 2-octyl cyanoacrylate. These patients were challenged with a novel method of use testing to confirm sensitivity to 2-octyl cyanoacrylate. The popularity of skin adhesives makes this emerging allergen worthy of examination. It is possible that cyanoacrylate allergy currently is underrecognized.

Background: Toxic epidermal necrolysis (TEN) is a serious drug eruption that results in death in approximately 25% to 50% of patients. There is controversy over whether SCORTEN accurately predicts mortality or if treatment interventions such as intravenous immunoglobulin (IVIg) can alter mortality., Objectives: We sought to determine whether SCORTEN accurately predicts mortality in this cohort, whether IVIg improved survival, and which drugs and medical comorbidities impacted mortality., Methods: We summarize our experience prospectively over 5 years and 82 patients. Patients either received supportive care, intravenous immunoglobulin, or cyclosporine as treatment. All patients had a SCORTEN on admission, an offending drug on record, and a list of medical comorbidities., Results: Of the 82 patients, 29% died from TEN. SCORTEN accurately predicted mortality in this cohort with an area under the curve (AUC) of 0.83 in a receiver operator curve (ROC) analysis. A Kaplan-Meier curve did not show improved mortality if patients received IVIg versus supportive care (P = .9). Medications most often responsible for TEN were trimethoprim/sulfamethoxazole, followed by anticonvulsants, nonsteroidal anti-inflammatories, and allopurinol., Limitations: This prospective cohort study design is not as ideal as patients presenting for a randomized controlled trial., Conclusions: SCORTEN was an accurate predictor of mortality in this cohort. Age older than 40 years, the presence of metabolic syndrome and/or gout, higher body surface area involvement, higher SCORTEN, and higher number of medical comorbidities statistically significantly increased risk of death. IVIg did not significantly alter mortality. Although the highest number of cases was due to trimethoprim/sulfamethoxazole, the greatest proportion of deaths was due to allopurinol., (Copyright © 2012 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.)

Pasteurella multocida is a bacterial organism that commonly causes cellulitis after animal bites, especially cat bites. We report an unusual vesiculopustular infection of the hand following a domestic cat bite. Pasteurella multocida and Staphylococcus aureus were cultured from the wound and the patient was treated with amoxicillin-clavulanate potassium. Further history revealed that the patient's cat had nibbled on her hand. Pasteurella usually is resistant to many of the typical empiric antibiotics used to treat skin infections. Amoxicillin-clavulanate potassium (500 mg 3 times daily) is the treatment of choice for patients who have an infected cat or dog bite with no known bacterial cause. A thorough patient history is needed to promptly arrive at a proper diagnosis for an atypical presentation of a common disease.

Background: Azathioprine (AZA) hypersensitivity syndrome is a rare side effect that typically occurs early in the initiation of therapy and may include a cutaneous eruption. It is often under-recognized because it mimics infection or disease exacerbation. Until recently, the cutaneous findings associated with AZA hypersensitivity have been reported using nonspecific, descriptive terms without a supportive diagnostic biopsy., Objective: To characterize the cutaneous and histologic findings associated with AZA hypersensitivity syndrome., Methods: We conducted a retrospective analysis of two cases of AZA hypersensitivity syndrome and describe the cutaneous manifestations and histological findings of each case. A review of the English literature for cases of AZA hypersensitivity or allergic or adverse reactions associated with AZA was performed., Results: Sixty-seven cases of AZA hypersensitivity were reviewed; 49% (33/67) had cutaneous manifestations. Of those cases presenting with cutaneous findings, 76% (25/33) had biopsy results or clinical features consistent with a neutrophilic dermatosis, whereas the other 24% (8/33) were reported as a nonspecific cutaneous eruption., Limitations: Only case reports in which the skin findings could be classified were reviewed., Conclusions: The predominant cutaneous reaction reported in the literature and observed in the present case series is a neutrophilic dermatosis. Hypersensitivity to AZA can manifest along a wide clinical spectrum from local neutrophilic disease to a systemic syndrome. Skin findings may be an important early clue to the diagnosis of AZA hypersensitivity and aid in prompt recognition and treatment of this potentially life-threatening adverse drug effect., (Copyright © 2010 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.)

Clear guidelines for the treatment of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are lacking due to its infrequency and the absence of large controlled studies. Systemic corticosteroids and intravenous immunoglobulin (IVIG) have received considerable attention, though reports of the use of these agents have demonstrated mixed success rates in improving morbidity and mortality from SJS/TEN. We present a case series of 4 patients with SJS/TEN who rapidly responded to treatment with cyclosporin A (CsA). We discuss the proposed mechanism of action and the rationale for the use of cyclosporin based on the currently understood pathophysiologic mechanism of TEN.

Histoplasmosis is recognized to occur in the Ohio and Mississippi River Valleys of the United States, but less widely appreciated is its worldwide distribution. We report a case of disseminated histoplasmosis with disease involving skin, lungs, and epiglottis in a renal transplant patient 6 months after a trip to Bangladesh, to highlight the potential risk of acquisition of this infection in the Indian subcontinent.

Background: Since July 2004, the United States (U.S.) Army has operated a forward-deployed dermatology clinic in Baghdad, Iraq. This paper outlines the prevalence of skin disease among deployed service men and women in Operation Iraqi Freedom., Methods: A cross-sectional study was performed for all dermatology visits presenting to the Combat Dermatology Clinic, Ibn Sina, Iraq, between January 15, 2008 and July 15, 2008., Results: In the six-month period reviewed, 2,696 total patients were evaluated. The most prevalent diagnoses included eczematous dermatitis [17%, n=462] and benign neoplasms [14%, n=375]. Eight percent (n=205) of the total visits were for skin cancer. This included: basal cell carcinoma, squamous cell carcinoma both in-situ and invasive, mycosis fungoides and melanoma. Actinic keratosis comprised 5% of the total visits (n=129). Bacterial infections comprised 6% (n=158) of the total visits and 31 of these cases were community acquired methicillin resistant Staphylococcus aureus (MRSA)., Limitations: Cross-sectional study with referral bias., Conclusion: This is the largest publication of the prevalence of skin disease in an exclusively dermatologic clinic in a combat setting. For the first time the presence of skin cancer is noted in a combat setting. The prevalence of MRSA is noted and was exclusively seen in U.S. soldiers. There was a statistically significant rise in the prevalence of eczematous dermatitides when compared with previous conflicts. Dermatologists can have a significant and strategic impact on deployed military medicine.

Background: Despite the large contribution by dermatology to military readiness, there have been no published reports regarding dermatologic surgery or skin cancer in the combat environment., Objective: To outline the contribution of dermatologic surgery, including skin cancer and benign tumors, to deployed service men and women in Operation Iraqi Freedom., Methods: A retrospective chart review was performed of all dermatology visits at the 86th Combat Support Hospital, Ibn Sina, Iraq, between January 15, 2008 and July 15, 2008., Results: Two thousand six hundred ninety-six patients were seen in the combat dermatology clinic during the 6-month period reviewed; 8% (205/2,696) of the total visits were for skin cancer, and another 129 patients were treated for actinic keratosis. The specific diagnoses were basal cell carcinoma (n=70), in situ and invasive squamous cell carcinoma (n=68), mycosis fungoides (n=1), bowenoid papulosis (n=1), and in situ and invasive melanoma (n=9). Benign lesions and tumors accounted for 14% (357/2,696) of total patient visits. Three hundred seven surgeries were performed during the 6-month period (178 skin cancers and 129 benign lesions), and 20 patients were referred for Mohs micrographic surgery. The surgical complications included five postoperative wound infections (1 methicillin-resistant Staphylococcus aureus), one wound dehiscence, and seven allergic contact dermatitis., Conclusions: To the authors' knowledge, this is the first publication regarding skin cancer and dermatologic surgery in the combat setting. This report outlines the important contribution of dermatologic surgery in the combat environment.

Cicatricial pemphigoid (mucous membrane pemphigoid) is a group of chronic disorders characterized by recurrent subepithelial blisters and scarring, predominantly of the mucous membranes. The authors report the case of a 63-year-old female with a 20-year history of cicatricial pemphigoid who had failed treatment with cytoxan, dapsone, systemic steroids and minocycline. She achieved complete clinical remission with the addition of etanercept 50 mg twice a week with azathioprine 150 mg daily. This patient has remained clear for two years with this combination and has tolerated a tapering of the azathioprine from the initial dose of 250 mg. Etanercept is a recombinant human dimeric fusion protein which acts as a competitive inhibitor of TNF-alpha by binding to both soluble and receptor-bound molecules of TNF-alpha. There have been a few reports of successful use of TNF-alpha inhibitors in cicatricial pemphigoid. This report will discuss the possible mechanism of action of the addition of TNF-alpha inhibitors as a steroid-sparing agent in these patients.

Background: Refractory dermatitis can frequently cause loss of personnel and poses an economic drain on the military due to the evacuation of civilians and soldiers out of theater., Objective: Proof-of-concept retrospective analysis to review the utility of the T.R.U.E. Test in the combat environment., Methods: Thirty T.R.U.E. Tests were performed by the dermatology clinic in Baghdad, Iraq, between January 15, 2008, and July 15, 2008. Thirty active-duty and civilian contractors referred to the dermatology clinic for dermatitis were tested and four others were clinically rechallenged for suspected bacitracin contact allergy., Results: Of the 30 patients tested, 14 (46.7%) had a positive test reaction to at least one antigen. In these positive tests, nickel, neomycin, and thimersol each comprised 17% followed by neomycin, thimerosal, budesonide, epoxy resin, potassium dichromate, p-phenylenediamine, formaldehyde, quaternium-15, fragrance, and balsam of Peru. All four clinical rechallenges for bacitracin allergy were also positive., Conclusions: The use of the T.R.U.E. Test in the combat desert environment is an efficient, easy, and clinically relevant method of testing for allergic contact dermatitis. Continued study of the prevalence of allergic contact dermatitis at Ibn Sina Hospital, Baghdad, Iraq, is recommended.

We present a case of cutaneous and systemic infection with Scedosporium apiospermum occurring in a patient with systemic lupus erythematosus. Scedosporium apiospermum is a rare cause of systemic mycosis but is associated with a high rate of mortality in immunocompromised hosts. Because the patient presented in an advanced state of infection, supportive measures were unsuccessful and definitive diagnosis could not be made until postmortem examination. We discuss the presentation, pathology, diagnosis, and treatment strategies for Scedosporium infection.

Background: Mycobacterium marinum is an atypical mycobacterium found worldwide and associated with swimming pools and aquariums. Infections typically present with subcutaneous nodules and lymphangitis., Case Report: A 61-year-old female presented with a two-month history of subcutaneous nodules. The patient had a significant recent history that included rose gardening and cleaning her aquarium at home. Biopsy for histology and tissue culture proved the presence of infection with Mycobacterium marinum and the patient was treated with minocycline. The nodules eventually healed and no new lesions appeared after initiation of treatment., Conclusion: Mycobacterium marinum is one of many entities that must be considered in a patient with ascending nodules along the lymphatic drainage of an extremity.

Burn patients with extensive involvement of body surface area (BSA >30%) represent a challenge in wound treatment. Multiple topical agents may be used for cleansing, barrier protection, and antimicrobial control leading to complications of contact and/or irritant dermatitis, which may further complicate re-epithelization and eventual wound healing. We present 4 patients who sustained extensive burns during Operation Iraqi Freedom/Operation Enduring Freedom and later developed contact dermatitis to mafenide acetate, a common topical antimicrobial used in burn care treatment, also known as Sulfamylon (alpha-amino-p-toluenesulfonamide monoacetate). All patients who were patch tested to mafenide acetate 7% solution were positive. A rechallenge with mafenide acetate resulted in recrudescence of the eruption in 2 out of the 4 patients. Though cutaneous reactions to mafenide acetate were reported by Yaffe and Dressler in 1969, the most recent case reports are from 1995. This paper presents more recent examples of cutaneous reactions to mafenide acetate, while also reviewing the literature.

A 9-year-old girl presented with a congenital, blue-purple, partially compressible plaque with a cobblestone surface on the left lateral foot and ankle. Similar, solitary, blue nodules later appeared elsewhere on the extremities. The lesions were tender to palpation and were associated with spontaneous paroxysms of pain and paresthesias. Histopathologic evaluation of a skin biopsy specimen showed rows of glomus cells that surrounded thin-walled vascular channels, which confirmed the diagnosis of glomuvenous malformations. This autosomal dominant condition, which is due to mutations in the GLMN gene, presents with clinical findings that are distinct from those of familial, multiple, cutaneous and mucosal venous malformations. Treatment options include excision, sclerotherapy, and laser therapy (ablative or pulsed dye).

Background: The color, architecture, symmetry, and homogeneity (CASH) algorithm for dermoscopy includes a feature not used in prior algorithms, namely, architecture. Architectural order/disorder is derived from current concepts regarding the biology of benign versus malignant melanocytic neoplasms., Objective: We sought to evaluate the accuracy of the CASH algorithm., Methods: A total CASH score (TCS) was calculated for dermoscopic images of 325 melanocytic neoplasms. Sensitivity, specificity, diagnostic accuracy, and receiver operating characteristic curve analyses were performed by comparing the TCS with the histopathologic diagnoses for all lesions., Results: The mean TCS was 12.28 for melanoma, 7.62 for dysplastic nevi, and 5.24 for nondysplastic nevi. These differences were statistically significant (P < .001). A TCS of 8 or more yielded a sensitivity of 98% and specificity of 68% for the diagnosis of melanoma., Limitations: This is a single-evaluator pilot study. Additional studies are needed to verify the CASH algorithm., Conclusions: The CASH algorithm can distinguish melanoma from melanocytic nevi with sensitivity and specificity comparable with other algorithms. Further study is warranted to determine its intraobserver and interobserver correlations.

A 64-year-old Chinese man presented to the Bellevue Hospital Center Department of Dermatology with a 2-year history of an enlarging mass in his suprapubic region, which measured 7 cm x 9 cm and involved the penis and scrotum. A biopsy specimen showed extramammary Paget's disease. Twenty years earlier, while living in China in 1983, this patient had a suprapubic skin cancer which was excised, and he received radiation to the region. Extramammary Paget's disease is a rare cutaneous adenocarcinoma of epidermal origin, which is frequently associated with adnexal carcinoma and internal malignant conditions. Clinically, extramammary Paget's disease is characterized by a red, moist, eroded plaque in the anogenital region. Extramammary Paget's disease usually behaves as a slow-growing intraepithelial adenocarcinoma; however, it may become invasive and may metastasize through dermal lymphatics. The treatment of choice is wide excision.

A 3-year-old girl presented with a 6-month history of multiple, light-pink, flat-topped papules over the dorsal aspects of the metacarpophalangeal and interphalangeal joints of the hands and feet. Nailfold telangiectases, ragged cuticles, and a heliotrope color of the upper eyelids were also evident, but there was no clinical evidence of muscle weakness and levels of muscle enzymes were normal. A biopsy specimen from one of the papules showed a vacuolar interface dermatitis consistent with a diagnosis of dermatomyositis. This report draws attention to juvenile amyopathic dermatomyositis, which is an uncommon subtype of dermatomyositis with an excellent prognosis.

A 19-year-old woman presented with a five-year history of guttate macules and yellow to skin-colored papules with collarette of fine scale on the trunk and the upper and lower extremities. Guttate pityriasis lichenoides chronica is an uncommon presentation of this T-cell-mediated disease. It is of unknown etiology; however, an infectious agent has been suspected. It is considered in a spectrum with pityriasis lichenoides et varioloformis acuta and rarely mycosis fungoides and CD30 lymphomas. Improvement has been shown after treatment with oral tetracyclines, ultraviolet B and UVA1 phototherapy, and PUVA photochemotherapy.

This is a case report of a highly trained, heat-acclimatized infantry soldier who suffered from exertional heatstroke during a 12-mile road march shortly after taking an ephedra-based supplement. Heatstroke is associated with systemic complications and a high mortality rate if not recognized early. Control of risk factors is key to the prevention of heatstroke. Since there are no clear ergogenic benefits in using ephedra alone, clinicians and military commanders should strongly discourage the use of ephedra-containing substances in active duty soldiers undergoing strenuous exercise.

Snoek was implicated in the food poisoning of 2 people in Bloemfontein. The patients' symptoms and culture of snoek samples suggested Staphylococcus aureus as the causative agent. Enumeration of S. aureus by selective procedures gave counts of 200 000 per gram in snoek obtained from the patients and from the butchery supplying the snoek. Investigations indicated that the snoek was heavily contaminated with S. aureus before arrival at the butchery and that the organisms grew as a result of mishandling after processing.