A Girl with Cutaneous Lesions, Polyarthritis, and Antinuclear Antibodies Positivity

On October 1996, a 14-year-old girl was admitted to the hospital because cutaneous lesions, asthenia, and arthralgias. On examination, there was nonscarring hair thinning with a widened part over the frontal hairline, polymorphic papulosquamous rash on her face, neck, arms, and trunk, and livedo reticularis in her legs. Multiple aphtous ulcers were present on the buccal and nasal mucosa. There was polyarthritis involving the wrist, metacarpophalangeal joints, proximal interphalangeal joints, and metatarsophalangeal joints of both hands and feet. Skin biopsy of the face was compatible with subacute cutaneous lupus erythematosus. She started on prednisone 60 mg/d without improvement, and later hdroxhchloroquine (HCQ) 6 mg/kg/d was added for one year. Cutaneous lesions were almost healed, with just a hypopigmented macules left. Over the last 14 years, she has not shown any cutaneous or systemic manifestations

Pediatric Dermatologist UC Davis School of Medicine Department of Dermatology

The University of California, Davis, School of Medicine, Department of Dermatology, is recruiting for a PediatricDermatologist in the Clinical X series or Health Sciences Clinical Professor (HSCP) series at the Assistant/Associate/FullProfessor level based on experience and qualifications. The appointment may be made up to 100%.Basic Qualifications: Candidates must possess an MD or MD/PhD, can be board eligible, but must be board-certified in dermatology at the time ofstarting employment and must be eligible for medical licensure in the State of California. Candidates must also be board eligible in pediatric dermatology at the time of starting employment and board certified within2 years of starting employment. Successful completion of an approved dermatology residency training program (ACGME accredited) and successful completionof an approved pediatric dermatology fellowship program (ACGME accredited). Demonstrated proficiency in the teaching of students and housestaff. Service including committees, leadership ability, and community outreach. Ability to work cooperatively and collegially within a diverse environment. Ability to adhere to policies and procedures, and leadership experience and abilities. Selected candidates will be expected to participate in clinical care, teaching, research and university service.Preferred Qualifications: Experience and interest in clinical research.For first consideration, applications should be received by October 15, 2019; however, the position will be open until filled throughSeptember 30, 2020. The following information is required: Cover Letter, Curriculum Vitae, contact information for 3-5 referencesand Statement of Contributions to Diversity. Please visit http://academicaffairs.ucdavis.edu/diversity/equity_inclusion/index.htmlfor information about why diversity statements are requested and guidelines for writing a diversity statement. Please upload thisinformation and apply online at https://recruit.ucdavis.edu/apply/JPF03038.The position is in Sacramento, California. The Department of Dermatology (http://www.ucdmc.ucdavis.edu/dermatology) is a majorclinical care, research, and teaching department in the School of Medicine. Our faculty are engaged in multiple collaborations withother Schools and UC Davis campus departments, research centers, clinical centers, and primary care networks, and thus allpositions require flexibility in local job locations in addition to the Department of Dermatology. This includes the Veteran'sAdministration, UCD Medical Center Campus, and other community centers.UC Davis commits to inclusion excellence by advancing equity, diversity and inclusion in all that we do. We are an AffirmativeAction/Equal Opportunity employer, and particularly encourage applications from members of historically underrepresentedracial/ethnic groups, women, individuals with disabilities, veterans, LGBTQ community members, and others who demonstrate theability to help us achieve our vision of a diverse and inclusive community. For the complete University of Californianondiscrimination and affirmative action policy, see: http://policy.ucop.edu/doc/4000376/NondiscrimAffirmAct. If you needaccommodation due to a disability, please contact the recruiting department.Under Federal law, the University of California may employ only individuals who are legally able to work in the United States asestablished by providing documents as specified in the Immigration Reform and Control Act of 1986. Certain UC Davis positionsfunded by federal contracts or sub-contracts require the selected candidates to pass an E-Verify check. More information is availableat http://www.uscis.gov/e-verify.UC Davis is a smoke & tobacco-free campus (http://breathefree.ucdavis.edu)

Psoriasis vulgaris flare during efalizumab therapy does not preclude future use: a case series

BACKGROUND: Severe psoriasis vulgaris can be extremely difficult to treat in some patients, even with the newer biological therapies available today. CASE PRESENTATIONS: We present two patients with severe chronic plaque psoriasis who received numerous systemic anti-psoriatic therapies with varied results. Both responded well to initial treatment with efalizumab (anti-CD11a), but then experienced a flare of their disease after missing a dose. However, after disease stablization, both patients responded well to re-introduction of efalizumab, one patient requiring concurrent treatment with infliximab (anti-TNF-α). CONCLUSION: These cases are presented to characterize this "flare" reaction, and to inform health care providers that efalizumab can still be administered after disease flare, and again may be a successful therapy

Immunohistochemical Study of Cytokeratin Related Protein Expression in Patients with Trichilemmal Tumors and Squamous Cell Carcinoma of the Skin

Trichilemmal tumors can be either benign and malignant skin tumors arising from the outer root sheath of the hair follicle. It remains unknown whether malignant trichilemmal tumors can be differentiated from squamous cell carcinoma (SCC). In order to differentiate malignant trichilemmal tumors from SCC, we studied cytokeratin-related protein and involucrin expression immunohistochemically. Twenty-three trichilemmal carcinomas (TLC), 4 malignant proliferating tricholemmal tumors (MPTT) and 25 SCCs were studied. All the skin biopsy specimens were subjected to staining with anti-cytokeratin and anti-involucrin antibodies immunohistochemically, and the expression of cytokeratins and involucrin were investigated. The occurrence rate of cytoketatin 1 positive staining in TLC was significantly less than that in SCC (P<0.05), while that of cytokeratin 19 positivity in SCC was significantly less than that in TLC (P<0.01). These results demonstrate that immunohistochemical staining with anti-cytokeratin 1 and anti-cytokeratin 19 antibodies is useful for the differential diagnosis of TLC and SCC

Celebrating 20 years of the UK Dermatology Clinical Trials Network: Part 2 – education, training and capacity building

In part 1 of this 2-part review of the 20th anniversary of the UK Dermatology Clinical Trials Network (UK DCTN), we described its role in developing and supporting clinical trial proposals, elaborating on structure, process and clinical trials activity. This review describes the diverse educational and training activities that the UK DCTN supports. Although not primarily set up as an educational organisation, an education and training function emerged organically as the network grew. Education and training also embodies the democratisation principle that drove the formation of the UK DCTN, allowing participation from a much wider group of individuals than just senior academics. Far from being a side-line, education and training has now become a major component of the UK DCTN that evolves constantly through changing training curricula and trial methodology developments. Formal UK DCTN training opportunities started in 2007 with competitively awarded annual fellowships for dermatology trainees, followed by similar schemes for general practitioners, Staff and Associate Specialist clinicians, and dermatology nurses. These were followed in 2013 by larger groups of trainees who work up specific trial proposals with senior mentors. Finally, a virtual journal club emerged during the pandemic in 2020 in order to reach trainees with little access to academic training. Focused activities with dermatological nurses and patients/carers also take place. Such activities require considerable organisation and volunteerism from the co-ordinating centre and former fellows. Education and training has become an essential component for capacity building to develop clinical trials and succession planning for the UK DCTN

ヒフ ノ メンエキ アレルギー トクシュウ アレルギー メンエキ チリョウ ノ サイシンノ シンポ

アトピー性皮膚炎の病態理解の歴史を振り返り,最新の知見と対比させて紹介した.皮膚の乾燥,湿疹,強い掻痒,高IgE 値などを特徴とし,喘息やアレルギー性鼻炎などを合併しやすい疾患であるとの古典的な理解は現在も変わらない.最も大きく変化したのは「皮膚の乾燥」の意義である.フィラグリンの異常などに伴う皮膚バリア異常が蛋白抗原による経皮感作を容易にし,食物アレルギー,ダニアレルギー等が誘導される.皮膚バリア障害によって誘導されるthymic stromal lymphopoietin( TSLP)がIgE産生や抗原特異的,非特異的なTh2 サイトカイン産生リンパ球を誘導し,掻痒にも関連する.つまり,表皮の異常により一元的にアトピー性皮膚炎の病態が説明できるようになったと言える.誘導されたTh2 タイプの炎症は皮膚バリア異常を誘導し,線維芽細胞にペリオスチンの産生を促し,さらに表皮細胞にTSLP の産生を誘導する.また,末梢神経や神経ペプチドによる神経原性炎症は炎症の増幅,掻痒閾値の低下,皮膚バリア異常を誘導する.この様に主要な病態が相互に影響し合うこともアトピー性皮膚炎の特徴的な病態といえる.Pathogenesis of atopic dermatitis( AD) has been complex and difficult to understand for many years, because not only allergic and immune response but also the function of residual cells:keratinocytes, fibroblasts and peripheral nerve, are involved in inflammation and itch of atopic dermatitis. Discover of frequent filaggrin gene loss-of-function mutations in patients with AD in 2006 have changed the concept of pathogenesis of AD. Disruption of cutaneous permeability barrier function due to loss-of-function of filaggrin gene or other induces not only Th2 type immune response in the skin but also in lung as asthma and food allergy by induction of thymic stromal lymphopoietin (TSLP). TSLP also directly induces itch, and induces type 2 innate lymphoid cells in corporate with IL-33 and IL-25 produced by keratinocytes as well as TSLP without specific antigens. Thus excessive production of TSLP following barrier dysfunction is considered to play a central role for AD. In addition to permeability barrier dysfunction, pruritus and Th2-dominant conditions are the most important characteristics of AD. Pruritus may be caused by IL-31 produced by Th2 or induced by penetrating peripheral nerve into epidermis following barrier disruption. Th2-dominant environments induce barrier dysfunction, reduced levels of anti-microbial peptides, and increased synthesis of periostin by fibroblasts followed by TSLP production by keratinocytes, which maintains and exacerbates AD. Neurogenic inflammation induced by neuropeptides such as substance P enhances inflammation, weakens permeability barrier function functionally and mechanically, and lowers threshold of itch. Thus barrier dysfunction, pruritus, and Th2 condition are established as major three characteristics of AD and their mutual effects make AD complicated. Based on the pathogenesis of AD, new therapeutic approaches have started: proactive therapy to stop a vicious itch-scratch spiral and intensive treatment with moisturizer for infant to prevent from development of AD

Effect of topical imiquimod as primary treatment for lentigo maligna: the LIMIT-1 study

Background: Topical imiquimod is sometimes used for lentigo maligna (LM) in situ melanoma instead of surgery, but frequency of cure is uncertain. Pathological complete regression (pCR) is a logical surrogate marker for cure after imiquimod, although residual LM and atypical melanocytic hyperplasia may not be reliably distinguished. A trial comparing imiquimod vs. surgery might be justified by a high imiquimod pCR rate.  Objectives: Primary: to estimate the pCR rate for LM following imiquimod. Secondary: to assess the accuracy of prediction of pCR, using clinical complete regression (cCR) plus negative post-treatment biopsies, tolerability, resource use, patients' preferences and induced melanoma immunity.  Methods: This was a single-arm phase II trial of 60 imiquimod applications over 12 weeks for LM then radical resection. A pCR rate ≥ 25 out of 33 would reliably discriminate between pCR rates < 60% and ≥ 85%. Clinical response was assessed and biopsies taken after imiquimod. Patients recorded adverse events in diaries. Patient preference was measured after surgery using a standard gamble tool.  Results: The pCR rate was 10 of 27 (37%, 95% confidence interval 19-58%). The rate of cCR plus negative biopsies was 12 of 28, of whom seven of 11 had pCR on subsequent surgery. The median dose intensity was 86·7%. Of the 16 surveyed patients, eight preferred primary imiquimod over surgery if the cure rate for imiquimod was 80%, and four of 16 if it was ≤ 40%.  Conclusions: The pCR rate was insufficient to justify phase III investigation of imiquimod vs.  Surgery: Clinical complete response and negative targeted biopsies left uncertainty regarding pathological clearance. Some patients would trade less aggressive treatment of LM against efficacy

Comparison of the two most commonly used treatments for pyoderma gangrenosum: results of the STOP GAP randomised controlled trial

Objective To determine whether ciclosporin is superior to prednisolone for the treatment of pyoderma gangrenosum, a painful, ulcerating skin disease with a poor evidence base for management. Design Multicentre, parallel group, observer blind, randomised controlled trial. Setting 39 UK hospitals, recruiting from June 2009 to November 2012. Participants 121 patients (73 women, mean age 54 years) with clinician diagnosed pyoderma gangrenosum. Clinical diagnosis was revised in nine participants after randomisation, leaving 112 participants in the analysis set (59 ciclosporin; 53 rednisolone). Intervention Oral prednisolone 0.75 mg/kg/day compared with ciclosporin 4 mg/kg/day, to a maximum dose of 75 and 400 mg/day, respectively. Main outcome measures The primary outcome was speed of healing over six weeks, captured using digital images and assessed by blinded investigators. Secondary outcomes were time to healing, global treatment response, resolution of inflammation, self reported pain, quality of life, number of treatment failures, adverse reactions, and time to recurrence. Outcomes were assessed at baseline and six weeks and when the ulcer had healed (to a maximum of six months). Results Of the 112 participants, 108 had complete primary outcome data at baseline and six weeks (57 ciclosporin; 51 rednisolone). Groups were balanced at baseline. The mean (SD) speed of healing at six weeks was −0.21 (1.00) cm2/day in the ciclosporin group compared with −0.14 (0.42) cm2/day in the prednisolone group. The adjusted mean difference showed no between group difference (0.003 cm2/day, 95% confidence interval −0.20 to 0.21; P=0.97). By six months, ulcers had healed in 28/59 (47%) participants in the ciclosporin group compared with 25/53 (47%) in the prednisolone group. In those with healed ulcers, eight (30%) receiving ciclosporin and seven (28%) receiving prednisolone had a recurrence. Adverse reactions were similar for the two groups (68% ciclosporin and 66% prednisolone), but serious adverse reactions, especially infections, were more common in the prednisolone group. Conclusion Prednisolone and ciclosporin did not differ across a range of objective and patient reported outcomes. Treatment decisions for individual patients may be guided by the different side effect profiles of the two drugs and patient preference. Trial registration Current Controlled Trials ISRCTN35898459

Number of Nevi at a Specific Anatomical Site and Its Relation to Cutaneous Malignant Melanoma

The risk of cutaneous malignant melanoma (CMM) is strongly associated with total number of nevi. Scanty information is available on the association between CMM at a specific anatomical site and number of nevi at the same site. We analyzed data from a case–control study conducted in Italy between 1992 and 1994, on 542 cases of CMM and 538 hospital controls. Cases and controls were examined by trained dermatologists who counted the number of melanocytic nevi. We derived multivariate odds ratios (ORs) and 95% confidence intervals (95% CIs) of site-specific risk of CMM for high versus low number of nevi at the corresponding site. The ORs of CMM for the highest versus the lowest tertile of number of nevi at the corresponding site was 1.4 (95% CIs: 0.7–2.8) at face and neck, 2.3 (95% CIs: 1.1–4.9) at anterior trunk, 4.9 (95% CIs: 2.9–8.4) at posterior trunk, 2.9 (95% CIs: 1.2–6.6) at upper limbs and 5.0 (95% CIs: 2.9–8.5) at lower limbs. In a case–case analysis, comparing CMM cases at a specific site and CMM cases at all other sites, the only excess risk was found for the posterior trunk, the ORs being 2.1 (95% CIs: 1.2–3.6) for the highest versus the lowest tertile of number of nevi. Our data do not support the hypothesis of a specific effect of nevi at each single anatomical site

A prescription for resistance: Management of staphylococcal skin abscesses by general practitioners in Australia

Objectives: We investigated the management of staphylococcal abscesses (boils) by general practitioners (GPs) in the context of rising antibiotic resistance in community strains of Staphylococcus aureus. Design, Setting, Participants: We analyzed patient-reported management of 66 cases of uncomplicated skin abscesses from the frequency matched methicillin-resistant S. aureus (MRSA) and methicillin-sensitive S. aureus (MSSA) Community-Onset Staphylococcus aureus Household Cohort (COSAHC) study (Melbourne, Australia, 2008-2012). Susceptibilities in all cases were known: 50/66 abscesses were caused by MRSA. In order to investigate GP-reported management of staphylococcal abscesses, we surveyed a random subset of GPs, from the COSAHC study (41), and of GPs (39) who used the same community-based pathology service (December 2011-May 2012). Main outcome measures: Patient outcomes, antibiotics prescribed, antibiotic resistance profiles of infecting strains, rates of incision and drainage (I & D), and attitudes to ordering microbiological cultures. Results: MRSA was three times more likely to be cultured from an abscess than MSSA. Patient-reported management revealed 100% were prescribed antibiotics and only 60.6% had I & D. Of those 85% who remembered their prescription(s), 81% of MRSA cases and 23% of MSSA cases initially received inactive antibiotics. Repeat GP visits where antibiotics were changed occurred in 45 MRSA and 7 MSSA cases, although at least 33% of subsequent prescriptions were inactive for the MRSA infections. Patients treated with I & D and antibiotics did no better than those treated with only I & D, regardless of the antibiotic activity. In the GP surveys, 89% reported I & D, with or without antibiotics, to be their preferred management. Only 29.9% of GPs would routinely swab abscesses. Conclusion: The recommended management of uncomplicated Staphylococcus abscesses is I & D without antibiotics to reduce exposure to unnecessary antibiotics. In our study, I & D was performed in only 60.6% of 66 patients, and antibiotics were always prescribed. The prescribed antibiotics were frequently inactive and often changed, and did not appear to affect patient recovery. Our results show that community GPs can confidently reduce their use of antibiotics for patients with skin abscesses and should be aware that MRSA is a much more common in this type of infection