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The recent coronavirus disease 19 (COVID-19) crisis has resulted in an economic downturn and the implementation of policies such as social distancing and shelter-in-place.1 In light of these events, the US government has passed the Coronavirus Preparedness and Response Supplemental Appropriations Act. This act relaxed Health Insurance Portability and Accountability Act regulations and instituted new avenues of revenue for telehealth, including (1) real-time audio-video technology communication; (2) store-and-forward technology, which collects data to be later transmitted via virtual check-ins, email, or other digital applications; and (3) verbal/audio-only communication without images or prerecorded videos.2 Moreover, latest polls have found that around two-thirds of patients are willing to try telehealth because of the pandemic.3 These factors have allowed physicians to provide virtual care for patients who are receptive to such technology while adhering to newly instituted policies. The various treatment options for keratinocyte carcinomas (KCs)—surgery, radiation, lasers, curettage and electrodesiccation, photodynamic therapy, intralesional chemotherapy, and cryotherapy—require in-person office visits for implementation.4 Currently, effective treatment options for KCs that allow for entirely no in-person visits are unknown or limited. The combination of topical antitumor agents (imiquimod 5% cream [IMI], 5-fluorouracil 2% solution [5-FU], and tretinoin 0.1% cream [TRET]) with limited cryotherapy was found to be efficacious in the treatment of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC).5 With the recent institution of social distancing, we evaluated the use of store-and-forward technology with this combination (IMI/5-FU/TRET) for the treatment of KCs that required no in-office patient visits.

Background Bullous pemphigoid (BP) is an autoimmune blistering disorder occurring mostly in the elderly that lacks adequate treatments. Objective To describe our experience using dupilumab in a series of patients with BP. Methods This is a case series of patients from 5 academic centers receiving dupilumab for BP. Patients were eligible if they had a clinical diagnosis of BP confirmed by lesional skin biopsy evaluated by one of more of the following: hematoxylin and eosin staining, direct immunofluorescence, or enzyme-linked immunosorbent assay for BP180 or BP230, or both. Results We identified 13 patients. Patients were an average age of 76.8 years, and the average duration of BP before dupilumab initiation was 28.8 months (range, 1-60 months). Disease clearance or satisfactory response was achieved in 92.3% (12 of 13) of the patients. Satisfactory response was defined as clinician documentation of disease improvement and patient desire to stay on the medication without documentation of disease clearance. Total clearance of the BP was achieved in 53.8% (7of 13) of patients No adverse events were reported. Limitations Include small sample size, lack of a control group, lack of a standardized assessment tool, and lack of standardized safety monitoring. Conclusion Dupilumab may be an additional treatment for BP, leading to disease clearance or satisfactory response in 92.3% of patients, including in those in whom previous conventional therapy had failed.

BACKGROUND Dermatology consultations in the inpatient hospital setting can improve diagnostic accuracy and management. OBJECTIVE Characterize dermatologic diagnostic and treatment trends in the hospital setting and identify variables that may affect patient care. METHODS Retrospective chart review from 1 January 2012 to 31 December 2017 at Jackson Memorial Hospital (JMH) (Miami, Florida, USA), an academic non-profit tertiary care centre affiliated with University of Miami Miller School of Medicine, was performed. Patients who received dermatology consultations in the emergency department (ED) or inpatient settings were included. Patient demographics, admission information, provisional diagnosis and management plans by primary teams, final diagnosis, management plans and testing recommendations by the dermatology consults team, and follow-up information were collected. Analysis using Microsoft Excel of how time to consultation, admission length, inpatient versus ED setting and primary team affected diagnostic accuracy was also performed. RESULTS The 1004 consultations for 812 patients (n = 812) were reviewed (359 women, 453 men). Most patients were Hispanic (n = 359; 44.2%) or African American (n = 273; 33.6%). Mean admission length was 20.6 days (range 0-439; median 6). The most common consulting service was internal medicine (n = 452). In 387 cases (47.6%), primary teams did not give a provisional diagnosis. The most common provisional diagnoses were bacterial infection (n = 93), viral infection (n = 49) and drug reaction (n = 44). The most common diagnoses by dermatology were viral infection (n = 93), bacterial infection (n = 90) and drug reaction (n = 80). Dermatology consultation changed the provisional diagnosis in 55.7% of cases, more often in cases where consultation took place ≥2 days after admission (P

Skin cancer is the most commonly diagnosed cancer worldwide. Understanding the natural history of skin cancer will provide a framework for the creation of prevention and control strategies that aim to reduce skin cancer burden. The strategies include health promotion, primary prevention, secondary prevention, and tertiary prevention. Health promotion and primary prevention were covered in the first part of this 2-part review. The second part covers the secondary and tertiary prevention of skin cancer. In particular, preventive strategies centered on the early detection of skin cancer, the prevention of disease progression, clinical surveillance, and educational and behavioral interventions are highlighted. The summaries of existing recommendations, challenges, opportunities, and future directions are discussed.

Background Minimally invasive alternative approaches to treat non-melanoma skin cancers remain limited and unproven. Objective We aim to assess the efficacy of varying combinations of anti-tumor agentsmimiquimod 5% cream, 5-fluorouracil 2% solution, and tretinoin 0.1% creammwith brief cryotherapy in treating non-melanoma skin cancers. Methods This retrospective study included 690 cases of non-melanoma skin cancers in 480 patients who received a diagnosis of a basal cell carcinoma or squamous cell carcinoma during a ten-year period. During treatment period, patients applied 30 applications of one of three combinations (imiquimod/tretinoin, 5-fluorouracil/tretinoin, or imiquimod/5-fluorouracil/tretinoin) and had cryotherapy every 2 weeks. Each patient had a clinical examination at least three years post-treatment or documented treatment failure. Clearance was defined by a lack of persistence or recurrence for 3 years following the completion of treatment. The likelihood of lesion clearance was evaluated using multivariable logistic regression analysis. Results A total of 186 cases (97; basal cell carcinoma and 89; squamous cell carcinoma) in 133 patients [37% women and 63% men; median (interquartile range) age, 77 (69, 83) years] met the inclusion criteria. Multivariable logistic regression analysis adjusting for clinical and lesion variables demonstrated that, relative to the imiquimod/5-fluorouracil/tretinoin treatment approach, imiquimod/ tretinoin (odds ratio, 0.05; 95% confidence interval, 0.00-0.99) and 5-fluorouracil/tretinoin (0.02; 0.00n0.45) were associated with lower likelihoods of lesion clearance. Likewise, morpheaform basal cell carcinoma had a lower probability of clearance (0.05; 0.00n0.72). Conclusions The combination of imiquimod/5-fluorouracil/tretinoin with cryotherapy had high clearance rates and was the most effective treatment regimen. J Drugs Dermatol. 2021;20(3):260-267. doi:10.36849/JDD.5427.

The recent coronavirus disease 2019 (COVID-19) pandemic has created a quandary for the physician in terms of evaluating and treating cutaneous skin cancers, particularly melanomas. At the onset of the pandemic, many planned medical and surgical visits for skin cancers were postponed. Physicians and patients have had to balance the risk of exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) with that of worsening morbidity and mortality due to delays in skin cancer treatments. We present a male patient who had two melanoma-in-situs (MISs) that were treated during the COVID-19 pandemic with a combination of topical imiquimod 5% cream, 5-fluorouracil 2% solution, and tretinoin 0.1% cream. The successful treatments occurred without in-person visits and with the aid of telemedicine. Although surgery is the standard for the treatment of melanoma in situ, this case demonstrates an effective viable treatment modality for MIS during a pandemic situation.

Acne and rosacea are inflammatory skin conditions that can be frustrating for patients and challenging for physicians to treat. As a result, many patients seek alternative therapies. Complementary and alternative medicine (CAM) is a group of treatment used as a complement to or, in some instances, as a substitution for Western medical therapies. Traditional Chinese medicine (TCM) has been practiced for thousands of years and has been used in the management of multiple dermatologic conditions, including acne and rosacea. In small studies, herbal remedies, acupuncture, and cupping have shown favorable outcomes in acne and rosacea, with few reported side effects.

Introduction: Standard of care for squamous cell carcinoma (SCC) is usually surgical, with either excision or Mohs micrographic surgery. However, surgery may not be ideal for elderly patients with numerous lesions, who are poor surgical candidates or who refuse surgery. Topical 5-fluorouracil (5-FU) and imiquimod have been studied off-label as monotherapies in the treatment of SCC in situ with promising results. However, long-term tumor-free survival rates are still less than with surgical management. Methods: We report a case of biopsy-proven invasive SCC in an 86-year-old Caucasian male with history of multiple actinic keratoses and no previous skin cancers. The patient declined surgical treatment due to concerns about cosmetic outcomes. A combination of topical 5% imiquimod cream, 2% 5-FU solution, and 0.1% tretinoin cream was used five nights per week under occlusion for a treatment goal of 30 total applications. The patient was evaluated in clinic every 2 weeks during which the site was treated with cryotherapy. The patient reported burning pain associated with treatment and only completed 24 of the 30 applications. Results: Follow-up biopsy 15 months after completing topical treatment revealed dermal scar with no evidence of residual carcinoma. Conclusion: Topical combination therapy with imiquimod, 5-FU, and tretinoin with intermittent, brief cryotherapy effectively treated a small, invasive SCC in this select patient who deferred surgery. Prospective randomized-controlled clinical trials to assess the role of combination topical treatment for invasive SCCs are warranted. J Drugs Dermatol. 2020;19(2)202-204. doi:10.36849/JDD.2020.2228

Introduction: Disseminated histoplasmosis is often seen in immunocompromised individuals, such those with acquired immunodeficiency syndrome (AIDS). The initial infection mainly involves the lungs but it may develop into a disseminated form especially in immunocompromised patients. Since it can be a systemic disease with cutaneous manifestations, dermatologists must be able to recognize its clinical presentation to ensure prompt management.Case: We present a man in his 50s with past medical history of AIDS who developed disseminated histoplasmosis with skin and gastrointestinal involvement over a one-month period of time. Despite receiving induction therapy with intravenous amphotericin B followed by oral itraconazole, the patient expired. His death was attributed to his persistently low CD4 T-cell count and secondary bacteremia.Discussion: This condition should be recognized early and treated aggressively. However, patients with multiple comorbidities are at increased risk of mortality even despite adequate treatment. This case highlights the significant mortality risk of disseminated histoplasmosis in patients with AIDS.

Tinea capitis is one of the most prevalent infections in young children. Non-inflammatory, black dot tinea capitis may be difficult to distinguish between other hair disorders in children such as seborrheic dermatitis, alopecia areata, trichotillomania, or Langerhan histiocytosis. This case highlights the salient trichoscopic features of non-inflammatory black dot tinea capitis. Trichoscopy is a fast, noninvasive technique that helps distinguish this common diagnosis and spares the need for scalp biopsies in children. Under magnification, the presence of comma hairs is specific to tinea capitis in all skin types whereas corkscrew hairs have been reported specifically in African American children. Awareness and recognition of this type of hair would exclude the most common differential diagnoses of patchy alopecia in this age and spare the need for biopsy in young children.

A 51-year-old female with a history of rheumatoid arthritis was admitted for progressive fevers, chills and malaise. Five weeks prior, she started minocycline for an RA exacerbation. Two weeks after starting minocycline she developed an abscess on her right ankle that was treated at an urgent care facility with ceftriaxone and trimethoprim-sulfamethoxazole. She had minimal improvement so was switched to clindamycin. She developed additional abscesses on her right ankle and right axilla and spiking fevers so she was treated with incision and drainage under general anesthesia. Routine blood work obtained prior to surgery revealed severe neutropenia (0.74 103/ul) and the patient was urgently referred to the emergency department. Skin biopsy was obtained on admission and revealed ulceration, necrosis, acute and chronic inflammation, vasculitis with vascular thrombosis and rod-shaped bacteria in blood vessel walls and lumina consistent with ecthyma gangrenosum. The following day tissue and blood cultures confirmed the growth of Pseudomonas aureginosa. Bone-marrow biopsy showed decreased granulopoiesis and hematopoiesis, and a diagnosis of minocycline-induced agranulocytosis presenting as ecthyma gangrenosum was made. The patient had dramatic improvement with appropriate antibiotic therapy, discontinuation of minocycline and initiation of filgrastrim. She has remained healthy without recurrence for 17 months.

Bowel-associated dermatosis-arthritis syndrome (BADAS) is an uncommon neutrophilic dermatosis characterized by arthralgias, fever, myalgias, and malaise as well as cutaneous eruptions on the extremities and trunk. The characteristic skin lesions are erythematous macules that evolve into purpuric papules, papulopustules, or tender subcutaneous nodules within a few days.1 First described as a consequence of bowel bypass surgery, BADAS has also been associated with diverticulitis, inflammatory bowel disease (IBD), and peptic ulcers.1 The pathophysiology of BADAS is thought to involve immune complex formation and deposition in response to antigens from intestinal bacterial overgrowth. We present the first reported case of BADAS in a patient with cystic fibrosis (CF).

Introduction: Non-melanoma skin cancers (NMSCs) are the most common malignancies in humans. When treating NMSC, quality-of-life (QOL) is an important consideration. The purpose of this study was to measure and compare QOL outcomes of two common therapies for NMSC: Mohs micrographic surgery and excision, using a disease-specific QOL instrument, the Skin Cancer Index (SCI).Methods: The University of Miami Institutional Review Board approved this retrospective chart review of patients diagnosed with NMSC from 2016 through 2019 at a private dermatology clinic (Deerfield Beach, FL, USA). Disease-specific QOL before and after surgery was measured with the SCI.Results: Pre- and post-surgery surveys were completed by 208 patients undergoing Mohs surgery and 30 patients undergoing excisional surgery. All patients were similar in age, gender, and race, and most patients undergoing either procedure had a history of additional prior skin cancers. For the Mohs cohort, the total SCI scores and each of the subscales were significantly higher post-surgery when compared with the baseline scores. In contrast, in the excision cohort, the social subscale was significantly lower post-surgery when compared with the baseline scores.Conclusion: There is limited data in the literature describing the specific effects of Mohs or excision for NMSC on QOL using a disease-specific QOL instrument. Our data supports increased QOL at 2-week follow up for patients with NMSC treated with Mohs, but no improvement in QOL was noted for patients treated with excision. This data is limited by the fact there were far more patients that underwent Mohs as opposed to excision, which gave the Mohs cohort greater statistical power when analyzing the difference in SCI.

Psoriasis is an immune-mediated disease associated with many comorbidities, including obesity, metabolic syndrome and cardiovascular disease. Many patients seek alternatives to standard treatments. In this case report, we present a non-obese patient who was able to completely clear her psoriatic plaques by following a plant-based, anti-inflammatory diet, focusing on the consumption of nutrient-dense foods. The efficacy of this anti-inflammatory diet may lie in the overall reduction of the systemic inflammatory state associated with psoriasis. Possible mechanisms of action are explored.

Hidradenitis suppurativa is a chronic skin disease with a significant genetic component and prevalence from 0.5% to 4%. Adalimumab is the only treatment approved by either the European Medicines Agency or the U.S. Food and Drug Administration for the management of moderate to severe hidradenitis suppurativa. To identify genetic variants associated with adalimumab response, we performed a genome-wide association study (GWAS) from the most extensive two phase 3 hidradenitis suppurativa clinical trials (PIONEER I and II) to date. Through direct genotyping and imputation, we tested almost 7 million genetic variants with minor allele frequency > 5% and identified one single linkage disequilibrium block, located in the intron of the BCL2 gene, which reached genome-wide significance (lead single-nucleotide polymorphism, rs59532114; P = 2.35E–08). Bioinformatic analysis and functional genomics experiments suggested a correlation of the most strongly associated single-nucleotide polymorphism minor allele with increased BCL2 gene and protein expressions in hair follicle tissues. In reciprocal knockdown experiments, we found that BCL2 is down-regulated by TNF inhibition. These results highlight a pathway that involves BCL2 in response to adalimumab. Further work is required to determine how this pathway influences adalimumab effectiveness in patients with hidradenitis suppurativa.

Hypergranulation is the extension of granulation tissue beyond the required amount to close a tissue defect. We report our experience using aluminum chloride to treat a series of two patients with hypergranulation tissue. Both patients had lengthy treatment courses after Mohs surgery with growth of hypergranulation tissue that resolved once aluminum chloride was placed on the wound. Aluminum chloride is a useful hemostatic agent frequently employed in dermatology. It is a readily available and low-cost option for management of hypergranulation after dermatologic procedures. Chronic wounds are a common treatment challenge for clinicians. Due to its affordability and availability, clinicians may consider topical aluminum chloride when managing post-surgical hypergranulation tissue.

Focal dermal hypoplasia (FDH), or Goltz syndrome, is a rare multisystem disorder affecting mesodermal and ectodermal structures, with the skin, eyes, teeth, and musculoskeletal systems most commonly affected. FDH results from mutations in the PORCN gene. Ninety-five percent of cases arise from novo mutations, whereas 5% are hereditary with an X-linked dominant inheritance pattern. Here, we describe an uncommon presentation of FDH in three consecutive generations. Patient 1 is an 8-month-old female born of non-consanguineous marriage who presented with diffuse alopecia of the scalp, linear hypopigmented, atrophic papules, and plaques with peripheral hyperpigmentation on the left hemiabdomen and right lateral leg along Blaschko's lines as well as syndactyly of the right second and third toes. Skin biopsy from the abdomen showed a thin epidermis with flattened rete ridges and massive dermal edema within collagen fibers and reactive capillaries. Family history was significant for similar skin lesions and bone deformities in her mother and similar skin lesions in her grandmother. Patient 2 (patient 1’s mother) is a 17-year-old female with similar linear hypopigmented, atrophic plaques with peripheral hyperpigmentation on the abdomen and right axilla, syndactyly of the right hand, patchy alopecia of the scalp, microdontia, teeth fusion, enamel defects, verrucous papillomas in the axillae and onycholysis. Patient 3 (patient 1’s grandmother), presented with similar hypopigmented, atrophic plaques on the abdomen and left arm.

Not available.

Background: Psoriasis is a chronic remitting and relapsing skin disease. For many patients, improved quality of life (QoL) is as important as clinical improvement of lesions. Objective: To review reporting of Dermatology Life Quality Index (DLQI) in randomized controlled trials (RCTs) of biologics for adult patients with plaque psoriasis. Methods: A systematic review was conducted in 4 databases for RCTs that measured DLQI at baseline and endpoint. A data collection form was created for collecting study variables. Risk of bias was assessed using the Cochrane risk of bias tool. Results: Thirty-four RCTs enrolling 16,784 patients were included. Complete baseline and final mean DLQI data was retrieved for 24 studies (70.6%). The mean DLQI at baseline was reported in 79.4% of RCTs. The median at baseline was reported in 14.7% of RCTs. The mean DLQI at endpoint was reported in 23.5% of RCTs and the median DLQI at endpoint was reported in 5.9% of RCTs. The mean change in DLQI was reported in 64.7% of RCTs. Conclusions: DLQI was measured in most clinical trials assessing the efficacy of biologics for psoriasis. Studies did not adhere to uniform standards in publishing results, making analysis of the impact on DLQI challenging. Key Words: plaque psoriasis, quality of life, Dermatology Life Quality Index, Systematic Review, biologic therapy

Complementary and alternative medicine (CAM) therapies are increasing in popularity in the field of dermatology. Natural products and holistic approaches are in high demand among patients and research has begun to support their roles in acne and rosacea pathophysiology. In this article, commonly utilized biologically based complementary and alternative therapies for acne and rosacea are reviewed from an evidence-based perspective. Therapies discussed include vitamin C, nicotinamide, zinc, tea tree oil, green tea, resveratrol, curcumin, feverfew, licorice, chamomile, polypodium leucotomos, and nutrition-based approaches. J Drugs Dermatol. 2018;17(6):611-617.

A 50-year-old diabetic woman developed multiple abscesses after daily injections of subcutaneous regular human insulin. Initial cultures from the draining fluid revealed no organisms, and the patient was unresponsive to multiple courses of antibiotics including doxycycline, amoxicillin/clavulanic acid, and intravenous vancomycin and piperacillin/tazobactam. After consulting dermatology, the patient underwent punch biopsy and tissue culture. The tissue culture grew mycobacterium fortuitum after 22 days of incubation. The patient was diagnosed with non-tuberculous mycobacterial infection and began to improve after treatment with ciprofloxacin. Non-tuberculous mycobacteria are common in the environment, although systemic manifestations of infection are rare in healthy individuals. In this paper, we discuss the risk factors, diagnostic methods, and treatment recommendations for these types of infections.

This case report and literature review underscores the cutaneous presentations of phaeohyphomycosis in the solid organ transplant population. Increased cognizance with prompt identification is critical. The therapy and clinical outcomes of phaeohyphomycosis, caused by the Exophiala genus, in the solid organ transplant population, is analyzed to examine optimal care. This review highlights the inherent difficulties in providing the appropriate duration of antifungal therapy to avoid relapsing infections in immunosuppressed patients.

Importance Up to 51% of patients with psoriasis report the use of complementary and alternative medicine (CAM) in their treatment regimen, although it is unclear which CAM therapies are effective for treatment of psoriasis. Objective This review compiles the evidence on the efficacy of the most studied CAM modalities for treatment of patients with plaque psoriasis and discusses those therapies with the most robust available evidence. Evidence Review PubMed, Embase, and ClinicalTrials.gov searches (1950-2017) were used to identify all documented CAM psoriasis interventions in the literature. The criteria were further refined to focus on those treatments identified in the first step that had the highest level of evidence for plaque psoriasis with more than 1 randomized clinical trial supporting their use. This excluded therapies lacking randomized clinical trial (RCT) data or showing consistent inefficacy. Findings Primary CAM therapy searches identified 457 articles, of which 107 articles were retrieved for closer examination. Of those articles, 54 were excluded because the CAM therapy did not have more than 1 RCT on the subject or showed consistent lack of efficacy. An additional 7 articles were found using references of the included studies, resulting in a total of 44 RCTs (17 double-blind, 13 single-blind, and 14 nonblind), 10 uncontrolled trials, 2 open-label nonrandomized controlled trials, 1 prospective controlled trial, and 3 meta-analyses. Compared with placebo, application of topical indigo naturalis, studied in 5 RCTs with 215 participants, showed significant improvements in the treatment of psoriasis. Treatment with curcumin, examined in 3 RCTs (with a total of 118 participants), 1 nonrandomized controlled study, and 1 uncontrolled study, conferred statistically and clinically significant improvements in psoriasis plaques. Fish oil treatment was evaluated in 20 studies (12 RCTs, 1 open-label nonrandomized controlled trial, and 7 uncontrolled studies); most of the RCTs showed no significant improvement in psoriasis, whereas most of the uncontrolled studies showed benefit when fish oil was used daily. Meditation and guided imagery therapies were studied in 3 single-blind RCTs (with a total of 112 patients) and showed modest efficacy in treatment of psoriasis. One meta-analysis of 13 RCTs examined the association of acupuncture with improvement in psoriasis and showed significant improvement with acupuncture compared with placebo. Conclusions and Relevance The CAM therapies with the most robust evidence of efficacy for treatment of psoriasis are indigo naturalis, curcumin, dietary modification, fish oil, meditation, and acupuncture. This review will aid practitioners in advising patients seeking unconventional approaches for treatment of psoriasis.

Importance Squamous cell carcinoma (SCC) is the second most common form of skin cancer, and its incidence is increasing. When surgical management is not an option, finding a safe and efficacious treatment is a challenge. Mounting evidence suggests that the human papillomavirus (HPV) is involved in the pathogenesis of some SCCs. Objective To assess whether the 9-valent HPV vaccine could be an effective treatment strategy for cutaneous SCC. Design, Setting, and Participants A woman in her 90s with multiple, inoperable cutaneous basaloid SCCs was successfully treated at a university-based outpatient dermatology clinic with a combination of systemic and intratumoral delivery of the 9-valent HPV vaccine from March 17, 2016, through February 27, 2017, and then followed up through May 21, 2018. Main Outcomes and Measures Reduction in tumor size and number after a combination of systemic and intratumoral administration of the HPV vaccine. Results All tumors resolved 11 months after the first intratumoral injection of the vaccine. The patient remained free of tumors at the end of follow-up. Conclusions and Relevance This is the first report, to our knowledge, of complete regression of a cutaneous malignant tumor after combined systemic and direct intratumoral injection of the 9-valent HPV vaccine. This report suggests that the HPV vaccine may have therapeutic utility for SCCs in patients who are poor surgical candidates, have multiple lesions, or defer surgery.

Importance Keratinocyte carcinomas (KCs), consisting of squamous cell carcinomas (SCCs) and basal cell carcinomas (BCCs), are the most common human malignant neoplasms. Several risk factors have been implicated in KC development. For some SCCs, particularly those in immunocompromised patients, human papillomavirus (HPV) may be an important factor. Objective To determine whether quadrivalent HPV vaccination would affect the development of KCs in immunocompetent patients with a history of multiple KCs. Design, Setting, and Participants Two patients with a history of multiple KCs—a man in his 70s (patient 1) and a woman in her 80s (patient 2)—were treated in a private dermatology practice. Each patient received 3 doses of the quadrivalent HPV vaccine at 0, 2, and 6 months in 2013, and both patients underwent full-body skin examinations at least every 3 months. Biopsy-proven skin cancers were recorded for 16 months (for patient 1) or 13 months (for patient 2) after the first dose of vaccine and then compared with the number of biopsy-proven skin cancers recorded over a similar period before the first dose of vaccine. The period of observation was from October 18, 2011, to June 21, 2014. Main Outcomes and Measures The numbers of new SCCs and BCCs after the first dose of the quadrivalent HPV vaccine. Results Patient 1 had a mean of 12 new SCCs and 2.25 new BCCs per year before vaccination. After vaccination, he developed 4.44 SCCs and 0 BCCs per year, a 62.5% reduction in SCCs and a 100% reduction in BCCs. Patient 2 had a mean of 5.5 new SCCs and 0.92 new BCCs per year before vaccination. After vaccination, she developed 1.84 SCCs and 0 BCCs per year, a 66.5% reduction in SCCs and a 100% reduction in BCCs. The quadrivalent HPV vaccine was well tolerated by both patients and had no adverse effects. Conclusions and Relevance A reduction of SCCs and BCCs was observed in 2 patients after administration of the quadrivalent HPV vaccine. These findings highlight the possibility that cutaneous SCC development, and perhaps BCC development, may be driven in part by HPV in immunocompetent patients. Human papillomavirus vaccination may represent an efficacious, cost-effective, readily available, and well-tolerated strategy for preventing KCs.

Leigh A. Nattkemper1,2, Zhong-Qiu Zhao5, Anna J. Nichols6, Alexandru D.P. Papoiu1, Carol A. Shively4, Zhou-Feng Chen5, and Gil Yosipovitch1,2,3,* 1Department of Dermatology, Wake Forest University School of Medicine, Winston Salem, NC, USA 2Department of Neurobiology & Anatomy, University Wake Forest School of Medicine, Winston Salem, NC, USA 3Department of Regenerative Medicine, Wake Forest University School of Medicine, Winston Salem, NC, USA 4Department of Comparative Medicine, Wake Forest University School of Medicine, Winston Salem, NC, USA 5Center for the Study of Itch, Washington University School of Medicine, St. Louis, MO, USA 6Department of Neuroscience and Physiology, SUNY Upstate Medical University, Syracuse, NY, USA