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Generalized pustular psoriasis (GPP) is a subtype of pustular psoriasis characterized by painful and occasionally disfiguring cutaneous manifestations with sepsis-like systemic symptoms. Affecting any age and race, GPP can occur with other forms of psoriasis or by itself. Stimuli for flares include medications, infections and environmental triggers. The interleukin family and caspase recruitment domain family have been implicated in its pathogenesis. Other forms of pustular psoriasis include impetigo herpetiformis, palmoplantar pustular psoriasis, annular pustular psoriasis and acrodermatitis continua of Hallopeau. Treatment is not well established, but includes the use of retinoids, methotrexate, cyclosporine, corticosteroids, TNF-alpha inhibitors, topical therapy and phototherapy. The use of TNF-alpha inhibitors may result in the formation of antidrug antibodies and should be administered with methotrexate.

Milker's nodule virus, also called paravaccinia virus is a DNA virus of the parapoxvirus genus transmitted from infected cows to humans. It results from contact with cattle, cattle byproducts, or fomites. Classified as an occupational disorder, those at risk of exposure include farmers, butchers, and agricultural tourists. The viral infection begins 5-15 days after inoculation as an erythematous-purple, round nodule with a clear depressed center, and a surrounding erythematous ring. While familiar to those in farming communities, the presence of the nodule may be concerning to others, particularly the immunosuppressed. Milker's nodules are self-limited in immunocompetent individuals and heal without scarring within 8 weeks. Another member of the Parapoxvirus genus, the orf virus, is also transmitted from animals to humans by direct-contact. While complications are rare, hematopoietic stem cell transplant recipients are at risk of graft-versus-host disease, as the parapoxvirus may trigger these complications in immunocompromised individuals. In addition, paravaccinia may serve as the antigen source for the development of erythema multiforme. The unique structure and replication process of viruses in the Poxvirus family, while includes the Parapoxvirus genus, have been a focus for treatment of infections and cancer. Manipulation of these viruses has demonstrated promising therapeutic possibilities as vectors for vaccines and oncologic therapy. This article is protected by copyright. All rights reserved.

Men are interested in reducing signs of aging, while maintaining a masculine appearance. A chief concern among men is maintenance of scalp hair. Men are also concerned with reducing under eye bags and dark circles. The concern of feminization is of significant importance. Neuromodulators remain the most common cosmetic procedure performed in men. Men often prefer a reduction in facial rhytids, as opposed to elimination of the lines. Softening facial lines in men is meant to maintain an appearance of wisdom, without appearing fragile. Men also wish to maintain a taut jawline and a slim waist and reduce breast tissue.

SummaryBackground Lasers and noncoherent intense pulse light sources effectively treat vascular lesions. Intense pulsed light (IPL), a nonablative treatment for photorejuvenation, uses a flashlamp which emits noncoherent light between 400 and 1400 nm. The light may be filtered to target a specific chromophore. The pulsed dye laser (PDL), at 595 nm, has been the historical standard of care in the treatment of facial erythema. We sought to determine whether IPL may be used in lieu of PDL in reducing facial erythema. Objectives To determine whether IPL may be used to treat facial erythema with equal efficacy as PDL used at nonpurpuric settings. Methods Prospective investigation of a cohort of 15 subjects with unwanted bilateral facial erythema. Subjects presented for two treatments with an IPL (BBL™ BroadBand Light; Sciton, Palo Alto, CA) to one half of the face and PDL (Cynergy™; Cynosure, Westford, MA) to the other half. Results Patients with facial erythema may be successfully treated with IPL or PDL. Conclusions Intense pulsed light and pulsed dye laser with nonpurpuric settings were equally effective in reducing facial erythema.

A fixed drug eruption (FDE) is a relatively common reaction associated with more than 100 medications. It is defined as a same-site recurrence with exposure to a particular medication. The primary approach and treatment for all types of FDEs are to identify and remove the causative agent, often accomplished by a thorough history of medication and other chemical exposures, and possibly prior episodes. The most common category of FDE, localized FDE, whether bullous or non-bullous, is self-limited. Although one can confirm the causative agent using oral challenge testing, it is not recommended due to the risk of severe exacerbation or possible generalization; patch testing is now preferred. Bullous FDE may resemble erythema multiforme. Treatment of localized FDE includes medication removal, patient counseling, and symptomatic relief. Failure to remove the causative agent in localized FDE can lead to recurrence, which is associated with increased inflammation, hyperpigmentation, and risk of a potentially lethal generalized bullous FDE (GBFDE), which may resemble Stevens–Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN). Distinguishing GBFDE from SJS and TEN is salient and will be stressed: GBFDE has more rapid onset in 1–24 h rather than in weeks, less or no mucosal involvement, less or no systemic involvement, and a tendency for a more favorable prognosis; however, recent experience suggests it may be just as life-threatening. This review will provide a comprehensive update and approach to diagnosis and management.

Shiitake mushroom dermatitis is a cutaneous reaction caused by the consumption of raw or undercooked shiitake mushrooms. Symptoms include linear erythematous eruptions with papules, papulovesicles or plaques, and severe pruritus. It is likely caused by lentinan, a heat-inactivated beta-glucan polysaccharide. Cases were initially reported in Japan but have now been documented in other Asian countries, North America, South America, and Europe, as this mushroom is now cultivated and consumed worldwide. Shiitake mushroom dermatitis may result from mushroom ingestion or from handling, which can result in an allergic contact dermatitis.

Acne vulgaris is a chronic dermatologic complaint with a multifactorial cause. Traditionally, antibiotics and retinoids have been used to manage the condition; patient compliance has been an ongoing issue. A variety of energy-based devices have been reported to be effective in the treatment of acne vulgaris.To review and summarize the current literature specific to treatment of acne vulgaris with energy-based devices.A review of the current literature of energy-based devices used for the treatment of acne vulgaris.Although limited randomized controlled trials for the treatment of acne have been performed, significant clinical improvement of acne vulgaris, especially of inflammatory lesions, has been demonstrated with a variety of energy-based devices. Newer approaches may lead to even better results.

Patients with skin conditions may apply or consume a wide variety of "remedies" with a similarly wide range of effects that may alter the clinical and/or dermatologic presentations of the lesion. Dermatologists or other clinicians should probe for this and carefully document such treatment, as well as any treatment administered by a health care professional or any other person. The dermatopathologist, however, cannot assume that this has been done or done successfully, and therefore must be on constant alert to recognize the effects of such "remedies."

The diagnosis of leishmaniasis can be challenging because it mimics both infectious and malignant conditions. A misdiagnosis may lead to an unfavorable outcome. Using culture, histologic, and/or polymerase chain reaction study results, a diagnosis of leishmaniasis can be established and treatment initiated. Appropriate management requires an accurate diagnosis, which often includes identification of the specific etiologic species. Different endemic areas have varying sensitivities to the same medication, even within individual species. Species identification may be of practical value, because infections with select species have a substantial risk of visceral involvement. In addition, HIV and otherwise immunocompromised patients with leishmaniasis have a propensity for diffuse cutaneous leishmaniasis. For most New World Leishmania species, parenteral antimonial drugs remain the first line of therapy, while Old World species are easily treated with physical modalities. Historically, live organism vaccination has been used and is effective in preventing leishmaniasis, but results in an inoculation scar and an incubation period that may last for years. A more effective method of vaccination would be welcome.

Human papillomavirus (HPV) affects hundreds of millions of people worldwide and is associated with both benign and malignant neoplasms in men and women. It is a double-stranded DNA virus with an icosahedral capsid. Forty HPV types are known to infect mucosal keratinocytes. If not cured by the immune system, the infection can lead to genital warts, mucosal dysplasia, or cancer. The most common oncogenic types are 16 and 18. The vaccine to prevent HPV and its associated morbidity and mortality has existed since 2006. Several variations protect against an increasing number of HPV types. The recommended vaccination age is before sexual exposure; administration of the vaccine to children has been controversial. This continuing medical education review evaluates the current HPV vaccines available to clinicians. Part I focuses on the debate over who should be vaccinated, at what age, and in which populations.

As of December 2014, there were 3 approved vaccines for human papillomavirus (HPV): bivalent Cervarix (GlaxoSmithKline, New York, NY), quadrivalent Gardasil (Merck and Co, Kenilworth, NJ), and 9-valent Gardasil-9 (Merck and Co). The average cost per dose is $120, with a recommended 3-dose course. The quadrivalent vaccine is the most widely administered worldwide. As with the bivalent and 9-valent vaccines, the vaccine is considered safe, although concerns have been raised. In addition to immunization against the targeted HPV types, there is evidence that there is cross protection against other types of HPV. This continuing medical education review evaluates the differences in vaccines that are currently on the market; part II focuses on the cost-effectiveness of vaccination, the HPV vaccination programs currently instituted around the globe, efficacy, and safety.

Neonatal leukaemia cutis is a significant neoplasm that may represent a cutaneous manifestation of systemic leukaemia, usually of myeloblastic type. Rarely, it may be or appear to be limited to skin, in which case it is called neonatal aleukaemic leukaemia cutis. By definition, it presents within the first 4 weeks of life and often has a 'blueberry muffin baby' appearance of magenta coloured nodules affecting almost any area of the skin, usually sparing mucous membranes, palms and soles. This clinical pattern is more commonly associated with neonatal infections such rubella and toxoplasmosis, and may be evident with other neonatal neoplasms such as neuroblastoma. Due to the morbidity associated with chemotherapy and reported cases of spontaneous remission without systemic progression in those with neonatal aleukaemic leukaemia cutis without 11q23 translocation, the authors not treating the child with chemotherapy, but to simply monitor for fading of the violaceous nodules, and watch for possible signs of systemic leukaemia.

No studies have examined the use of topical ingenol mebutate for improvement of photoaged skin.To evaluate clinical results of ingenol mebutate gel applied to photoaged skin and to quantify improvement at 7, 30, and 60 days after application.Twenty-five subjects were enrolled in the study. Picato (ingenol mebutate) (LEO Pharma, Parsippany, NJ) gel was applied to an area with a known actinic keratosis daily for 3 days. Subjects self-evaluated and were investigator evaluated on 6 characteristics on Days 7, 30, and 60 using an objective scale. The scale evaluated actinic keratosis, overall skin appearance, wrinkling, dyschromia, erythema, and texture. The subjects were also evaluated using the Griffiths' Photonumeric Photoaging Scale for overall improvement.Twenty-two subjects completed the clinical study and demonstrated statistically significant improvement by Day 60 in actinic keratosis, overall skin appearance, wrinkling, dyschromia, erythema, and texture (p.05).Topical ingenol mebutate 0.015% gel produces cosmetic improvement of photoaged skin within 60 days of application.

Squamous cell carcinoma (SCC) of the scalp has increased prevalence in older patients and often presents later in life. Mohs micrographic surgery remains the most effective treatment in most cases. Delayed presentation may result in localized bony invasion or distant metastases. We present a case of an elderly woman presenting with extension of SCC into the parietal bone of the skull.

Onychomadesis is the proximal separation of the nail plate from the nail matrix due to a temporary cessation of nail growth. It can occur in children of all ages including neonates. Diagnosis is made clinically through palpation and inspection of the nail plate. Physicians should consider underlying associations. A review of the patient's history for any viral illnesses 1 to 2 months prior to nail changes often will help identify the causative disease. Onychomadesis typically is mild and self-limited. There is no specific treatment, but a conservative approach to management is recommended with treatment of any underlying causes and supportive care. Spontaneous nail regrowth usually occurs within 12 weeks and may occur faster in children. In this article, causes of onychomadesis are described, including the connection between hand-foot-and-mouth disease (HFMD) and onychomadesis. We also explore several theories of possible mechanisms for onychomadesis; however, the precise mechanism remains unclear and further investigation is needed.

Erythema ab igne (EAI) is a persistent, chronic skin condition resulting from prolonged exposure to infrared radiation, experienced as heat. Once associated with traditional warming sources like wood burning stoves or open fires, modern, infrared exposure originates also from newer sources like laptops and heating pads and may be creating a rebound of EAI. The epidemiology may be different too, with younger patients than previously seen. Localized EAI over an area of pain in the abdomen or lower back can be a sign of an underlying disorder, including cancer. Prognosis of EAI is good, with removal of the heat source resulting in complete remission. In chronic cases in which premalignant cutaneous dysplasia has resulted, additional treatments may be necessary including topical retinoids, 5-fluorouracil cream, and laser treatments. Rarely, cancers such as squamous cell carcinoma, Merkel cell carcinoma, and cutaneous marginal zone B cell lymphoma have been associated with longstanding EAI.

Hereditary leiomyomatosis and renal cell cancer (HLRCC) syndrome is a rare genetic disorder that predisposes individuals to multiple cutaneous leiomyomas, renal cell carcinomas, and in women, uterine leiomyomas. Also known as Reed syndrome, it is caused by a germline heterozygous mutation of the fumarate hydratase tumor suppressor gene. HLRCC is associated with significant morbidity because of pain from cutaneous and uterine leiomyomas, the cutaneous pain often of unique character. Although genetic testing is currently considered the criterion standard to diagnose HLRCC, newer immunohistochemistry markers may provide rapid and cost effective alternatives to genetic testing. Because of the potentially aggressive nature of renal cell carcinomas that develop as early as in childhood, close annual cancer surveillance is desirable in individuals with HLRCC. In this review, we offer an update and an approach to the diagnosis, management, and renal cancer surveillance in HLRCC.

Porphyrias are a group of intriguing genetic diseases of the heme pathway, of which porphyria cutanea tarda (PCT) is the most common. Resulting from a defect in enzymes in the porphyria pathway, PCT has been linked to several conditions. Recent studies have demonstrated a change in thinking regarding the human immunodeficiency virus (HIV) and development of PCT. The exacerbation of PCT with contraction of HIV is now believed to result from coinfection from the hepatitis C virus (HCV). Blistering of sun-exposed skin, a classic presenting sign of PCT, is not exclusive to the condition. Cutaneous findings must also trigger physicians to consider additional types of porphyrias, such as variegate porphyria. The diagnosis of pseudoporphyria, which does not result from enzymatic absence, must be considered in patients with photosensitivity and cutaneous bullae. Recent health food trends, such as chlorophyll, have been linked to pseudoporphyria. PCT is a serious condition in which accurate diagnosis is necessary for appropriate management.

Xanthoma is a highly prevalent disorder of lipid deposition that manifests as cutaneous papules, nodules, or plaques. Microscopically, lipid-laden macrophages, known as foam cells, are seen. The different types of xanthoma include eruptive xanthoma, plane xanthoma, xanthoma tuberosum, tendon xanthoma, and xanthelasma palpebrarum. The most commonly used therapeutic method for all forms of xanthoma is surgical excision, although dietary modification to lower serum lipid levels, particularly for tendinous xanthoma, has been attempted. Therapeutic alternatives for xanthelsma palpebrarum include electrocautery, trichloroacetic acid, and carbon dioxide laser vaporization. Tuberous xanthoma and xanthelasma palpebrarum have been successfully treated with cryosurgery, with low recurrence rates. Cryosurgery should be considered due to its ease of use, cost-effectiveness, comparable outcomes and superior cosmetic outcome.

Verruca palmaris is a common presentation resulting from HPV infection of keratinocytes of the palms. If the virus is not suppressed, replication of the epithelium occurs, creating a keratotic papilloma of the palm. Cryosurgery is the first line treatment for verruca palmaris, resulting in destruction of the verruca’s vascular supply and stimulation of the immune system. Optimal technique involves targeted destruction of the wart with no greater than 2–3 mm of collateral destruction of healthy adjacent tissue.

Since the beginning of the twenty-first century, there has been a rapid rise in the number of cases of chikungunya. Initially limited to islands of the southwestern Indian Ocean, the virus has spread across Africa and into the islands of the Caribbean. Cutaneous symptoms include a morbilliform eruption, hyperpigmented macules, and aphthae-like ulcers. Patients often also experience fever and joint pain. We review the methods for diagnosis, treatment, and prevention of this increasingly prevalent virus now emerging more commonly in Europe and North America.

A 15-year-old Colombian boy with a 10-year history of linear morphea presented to a pediatric orthopedic clinic with a leg length discrepancy. The morphea had been previously treated with methotrexate, oral and topical steroids, and topical vitamin D, but the lesion persisted, extending down the entire medial aspect of the left leg across the popliteal fossa. The patient had atrophy and growth retardation of the left leg, resulting in lower extremity bone and joint pain and a 3-cm limb length disparity at maturity. The patient preferred left tibial lengthening to improve the limb length disparity.

As of December 2014, there were 3 approved vaccines for human papillomavirus (HPV): bivalent Cervarix (GlaxoSmithKline, New York, NY), quadrivalent Gardasil (Merck and Co, Kenilworth, NJ), and 9-valent Gardasil-9 (Merck and Co). The average cost per dose is $120, with a recommended 3-dose course. The quadrivalent vaccine is the most widely administered worldwide. As with the bivalent and 9-valent vaccines, the vaccine is considered safe, although concerns have been raised. In addition to immunization against the targeted HPV types, there is evidence that there is cross protection against other types of HPV. This continuing medical education review evaluates the differences in vaccines that are currently on the market; part II focuses on the cost-effectiveness of vaccination, the HPV vaccination programs currently instituted around the globe, efficacy, and safety.

Human papillomavirus (HPV) affects hundreds of millions of people worldwide and is associated with both benign and malignant neoplasms in men and women. It is a double-stranded DNA virus with an icosahedral capsid. Forty HPV types are known to infect mucosal keratinocytes. If not cured by the immune system, the infection can lead to genital warts, mucosal dysplasia, or cancer. The most common oncogenic types are 16 and 18. The vaccine to prevent HPV and its associated morbidity and mortality has existed since 2006. Several variations protect against an increasing number of HPV types. The recommended vaccination age is before sexual exposure; administration of the vaccine to children has been controversial. This continuing medical education review evaluates the current HPV vaccines available to clinicians. Part I focuses on the debate over who should be vaccinated, at what age, and in which populations.

Hemifacial microsomia is a well known yet rare collection of developmental facial defects. Almost half of all known cases exhibit additional anomalies beyond the classic malformations of the first and second brachial arches. This case is unique in that it describes a child with hemifacial microsomia and an associated oropharyngeal stenosis, nasal stenosis and a v-shaped mandibular deformity.

Hemimaxillary enlargement, asymmetry of the face, tooth abnormalities, and skin findings (HATS syndrome) is a rare developmental disorder involving the first and second branchial arches. Physical manifestations may present at birth or during early childhood. Characteristic findings include unilateral abnormalities of the face involving the bones, teeth, gums, and skin. Among the characteristic cutaneous manifestations of HATS syndrome, Becker nevus is the most common. A variety of modalities have been utilized in the treatment of HATS syndrome, but no standardized therapy has been established. We report a case of this rare condition in a 14-year-old adolescent boy.

not available

Leishmaniasis is endemic in 98 countries and territories, with 1.2 million new cases per year, making it a worldwide concern. The deadly visceral form is a leading cause of death from tropical parasitic infections, second only to malaria. Leishmaniasis appears to be increasing in many countries because of extended urbanization. The disease reservoir includes small mammals; parasite transmission occurs via bite of the female phlebotomine sandfly. Disease manifestations vary and largely depend upon the Leishmania species acquired. It may be first evident with a range of findings-from a localized cutaneous ulcer to diffuse painless dermal nodules-or, in the mucocutaneous form, ulceration of the oropharynx. In the potentially deadly visceral form, the internal organs and bone marrow are affected.

The diagnosis of leishmaniasis can be challenging because it mimics both infectious and malignant conditions. A misdiagnosis may lead to an unfavorable outcome. Using culture, histologic, and/or polymerase chain reaction study results, a diagnosis of leishmaniasis can be established and treatment initiated. Appropriate management requires an accurate diagnosis, which often includes identification of the specific etiologic species. Different endemic areas have varying sensitivities to the same medication, even within individual species. Species identification may be of practical value, because infections with select species have a substantial risk of visceral involvement. In addition, HIV and otherwise immunocompromised patients with leishmaniasis have a propensity for diffuse cutaneous leishmaniasis. For most New World Leishmania species, parenteral antimonial drugs remain the first line of therapy, while Old World species are easily treated with physical modalities. Historically, live organism vaccination has been used and is effective in preventing leishmaniasis, but results in an inoculation scar and an incubation period that may last for years. A more effective method of vaccination would be welcome.

Staphylococcal scalded skin syndrome is a potentially life-threatening disorder caused most often by a phage group II Staphylococcus aureus infection. Staphylococcal scalded skin syndrome is more common in newborns than in adults. Staphylococcal scalded skin syndrome tends to appear abruptly with diffuse erythema and fever. The diagnosis can be confirmed by a skin biopsy specimen, which can be expedited by frozen section processing, as staphylococcal scalded skin syndrome should be distinguished from life threatening toxic epidermal necrolysis. Histologically, the superficial epidermis is detached, the separation level being at the granular layer. The diffuse skin loss is due to a circulating bacterial exotoxin. The aetiological exfoliating toxin is a serine protease that splits only desmoglein 1. The exfoliative toxins are spread haematogenously from a localized source of infection, causing widespread epidermal damage at distant sites. Sepsis and pneumonia are the most feared complications. The purpose of this review is to summarize advances in understanding of this serious disorder and provide therapeutic options for both paediatric and adult patients. Recent epidemiological studies have demonstrated that paediatric patients have an increased incidence of Staphylococcal scalded skin syndrome during the summer and autumn. Mortality is less than 10% in children, but is between 40% and 63% in adults, despite antibacterial therapy. Previously, intravenous immunoglobulin had been recommended to combat Staphylococcal scalded skin syndrome, but a recent study associates its use with prolonged hospitalization.

Importance The absence of data on the prevalence of pilomatricoma among patients with Turner syndrome served as the catalyst for this multicenter investigation. Objectives To ascertain the prevalence of pilomatricoma among patients with Turner syndrome and to determine any association between the development of pilomatricomas and the use of exogenous hormones in patients with Turner syndrome. Design A retrospective medical record review from January 1, 2000, through January 1, 2010, was performed of all patients with Turner syndrome. Data on pilomatricomas and the use of hormone therapy were collected. Setting University of California–Davis Medical Center, University of Nebraska Medical Center, and The University of North Carolina at Chapel Hill. Participants Patients with a diagnosis of Turner syndrome. Main Outcome Measures Prevalence of concomitant pilomatricoma and diagnosis of Turner syndrome. Secondary outcome measures included the use of the exogenous hormones estrogen or recombinant human growth hormone (rhGH). Results In total, 311 patients with Turner syndrome were identified from these 3 institutions. Among them, 8 patients (2.6%) were diagnosed as having pilomatricomas. Before the development of pilomatricomas, 5 patients had been treated with rhGH but not estrogen, 1 patient had received estrogen but not rhGH, and 2 patients did not receive either therapy. Conclusions and Relevance Although the prevalence of pilomatricoma among the general population is unknown, this study demonstrates a high prevalence (2.6%) of pilomatricomas among patients with Turner syndrome. No apparent relationship was noted among our patients or in the literature between the use of rhGH and the development of pilomatricomas.

Dermatitis Herpetiformis (DH) is a rare, blistering skin disease described by Duhring in 1884.[1] DH is strongly associated with the HLA-DQ2 phenotype, a gateway in which dietary gluten reaches inflammatory cells and stimulates an autoimmune process. The etiopathogenesis involves IgA anti-endomysial antibodies directed against tissue transglutaminase (TG); the presumed skin autoantigen is epidermal TG. IgA/TG immune complexes form locally within the papillary dermis leading to neutrophil chemotaxis and degranulation (which forms neutrophilic abscesses), proteolytic cleavage disrupting the lamina lucida, and blister subepidermal blister formation.[2] Current standard-of-care for DH is oral dapsone and a gluten-free diet. We describe a teenage patient in whom resolution of lesions was achieved with adjuvant use of topical dapsone 5% gel (aczone), the first case in the literature. A 14-year-old male had been suffering recurrent eruptions of blisters on his chest and arms for 16 months. He had been diagnosed with direct immunofluorescent proven DH based on granular IgA deposition in the upper papillary dermis. Though distinguishing LABD (linear IgA bullous dermatosis) from DH is often clinically impossible, the finding of IgA in a granular pattern at the dermoepidermal junction with accentuation in the dermal papillae was specific for DH in our patient. Upon an exacerbated eruption of blisters on the chest and shoulders, the patient presented to our clinic. On physical examination he presented with multiple, welldefined, pink keratotic papules, plaques and diffuse, hypopigmented macules and patches on the chest and shoulders, equally distributed on the left and right side. Primary lesions were counted before treatment and numbered 33 on the left side and 34 on the right side of the chest, respectively. The patient did not maintain a gluten-free diet and was receiving daily oral dapsone (25 mg). Twice daily application of topical dapsone (Aczone gel, 5%) was initiated on the right side of the patient’s chest and Aquaphor ointment to the left. Two physicians were blinded to which side received the medication. The patient was asked to follow up in four weeks. Over the following three days the patient’s skin lesions did not improve on either side of the chest. The oral dosage of dapsone was modified to 25 mg and 50 mg on alternating days. The patient continued to apply the topical products unilaterally as originally prescribed. On a follow-up visit four weeks later, the blinded physicians observed improvement of the lesions on the right side of his chest in comparison to the left. Physical exam demonstrated two remaining ulcerated vesicles on the right chest and five on the left without signs of erosion. It was also noted that relative to the left side, the skin on the right side was significantly smoother. The patient was then allowed to expand usage of topical dapsone to all affected areas and had similar improvements. There have been no reports on treating dermatitis herpetiformis using topical dapsone and the current standard-ofcare remains oral dapsone. Most clinical remissions are related to dietary gluten restriction, however, the gluten-free diet is inconvenient and unacceptable to some patients. Oral dapsone (diaminodiphenylsulfone) is the current treatment and the most effective sulfone but many physicians would prefer a non-systemic treatment choice. Though patients intolerant to dapsone may consider therapy with sulfapyridines, there is significant risk for nephrolithiasis and some patients may not respond at any dose. Although this patient had received oral and topical dapsone simultaneously, he only applied topical dapsone 5% gel to the right side, the same side which demonstrated significant improvement of the lesions. The left side where aquaphor was applied did not show the same level of improvement at four-week follow-up. High doses of oral dapsone simply increase toxicity while providing minimal benefit. The main side effects associated with oral dapsone may be classified as toxic/pharmacologic or idiosyncratic/allergic; these range from hemolytic anemia, the most common complication within 2 weeks after starting therapy, to nephritis and renal failure, precluding the need for strict monitoring of renal function tests.[3] Hemolytic anemia occurs in virtually every patient on oral therapy and may even occur in breastfed infants since dapsone is secreted in breast milk. A notable complication, especially in patients with glucose-6-phophate dehydrogenase (G6PD) deficiency, is hemolysis and methemoglobinemia due to oxidative stress from the hydroxylamine metabolite.[4] Adverse effects of dapsone are generally dose-dependent and are more commonly observed in patients with comorbid conditions such as anemia and cardiopulmonary disease.[3] Other rare complications include agranulocytosis early on, as well as a systemic drug hypersensitivity syndrome, a serious complication that requires medication withdrawal and systemic corticosteroid administration.[5] Regular follow-up visits and routine laboratory monitoring of blood counts are needed for patients receiving treatment with oral dapsone, especially during the first 3 months.[5] Dapsone is clinically useful in diseases containing neutrophilic infiltrates. Dapsone inhibits neutrophil myeloperoxidase, decreasing the damage from the neutrophil respiratory burst pathway mediated by this enzyme. The anti-inflammatory properties of topical dapsone benefit patients with acne and could also hinder the immunologic cascade and accompanying inflammatory process that occurs in DH. We attribute the efficacy of topical dapsone to a local inhibition of neutrophil chemotaxis to N-formyl-methionyl-leucyl-phenylalanine and interference of the CD11b/CD18-mediated neutrophil binding that induces chemoattractant signal transduction and inhibits leukotrienes. IgA adherence may also be inhibited though it remains to be proven.[5] Concerning our review of the literature, we conclude that there is therapeutic explanation for the moderate therapeutic effects seen from use of topical dapsone in DH. Using topical dapsone alone or in combination with a lower dose of oral dapsone is preferable to high doses of oral dapsone. Additionally, facial disease may prove refractory to oral dapsone therapy; topical dapsone gel may provide a more tolerable alternative than breaking facial vesicles and applying a potent corticosteroid gel. In order to further study the utility of topical dapsone in DH, a more extensive trial of topical dapsone is warranted. In summary, aczone appears to be a promising therapeutic agent for patients with dermatitis herpetiformis who are refractory to oral therapy and noncompliant with a gluten-free diet.

Background Human growth hormone (HGH) and insulin-like growth factor-1 (IGF-1) have been shown to play a role in the malignant transformation and progression of a variety of cancers. HGH is also known to upregulate molecular signaling pathways implicated in the pathogenesis of melanoma. Although HGH has previously been implicated in promoting the clinical growth of both benign and malignant melanocytic neoplasms, to our knowledge there are no conclusive studies demonstrating an increased risk of melanoma following HGH therapy. Nevertheless, there are reports of melanoma developing subsequent to HGH coadministered with either other hormones or following irradiation. Observation A 49-year-old white man presented with a new pigmented papule that was diagnosed as melanoma. The patient reported using HGH for 3 months prior to the diagnosis. His 51-year-old wife, who also was white, had also been using exogenous HGH for 3 months and had been diagnosed as having a melanoma 2 weeks prior. Conclusions Given the unlikelihood of 2 unrelated people developing melanoma within a short time span, it is reasonable to assume that a common environmental component (HGH or other shared exposure) contributed to the development of both melanomas. Because of the increased use of exogenous HGH as an antiaging agent, it is important to be aware of the growth-promoting effects of this hormone. Until better data are available that determines the true risk of exogenous HGH, its use as an antiaging agent merits increased surveillance.

Idiopathic atrophoderma of Pasini and Pierini is a disorder of dermal atrophy. There is a female predominance and almost never does the condition present at birth. Histopathological examination reveals attenuated dermis. We report a case of a healthy male born with a plaque of idiopathic atrophoderma of Pasini and Pierini.

A 27-year-old male with a history of Crohn's disease was treated for chronic pyoderma gangrenosum at his stoma site. Treatment with topical application of crushed dapsone resulted in improvement of his pyoderma gangrenosum. Crushed dapsone may be an efficacious treatment with minimal systemic side effects. This appears to be the first case of pyoderma gangrenosum treated with crushed dapsone.