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BACKGROUND AND OBJECTIVE Epidermal preservation is essential during laser treatment for vascular, hair, and benign pigment dyschromias. Epidermal tolerance is determined by epidermal melanin content, fluence, pulse width, wavelength, skin cooling, and spot size. The authors' objective was to determine the maximum epidermal tolerance for the long-pulse alexandrite 755 nm and the long-pulse neodymium-doped yttrium aluminum garnet (Nd:YAG) 1064-nm lasers for varying epidermal melanin content. MATERIALS AND METHODS Skin melanin measurements were performed at the test sites with a melanin reader, and 0.5 to 1 second of refrigerated air precooled the skin. Then, alexandrite and Nd:YAG laser test spots of 5 to 18 mm were delivered in a series of ascending fluences using 5-, 20-, and 50-ms pulse widths. Skin response at 24 to 48 and 96 hours was scored from 0 to 15 varying from "no reaction" to "severe scabbing." RESULTS Alexandrite laser, mean threshold fluences increased by a factor of 1.2 increasing from 5 to 20 ms, and by a factor of 1.4 increasing from 5 to 50 ms, among subjects with a melanin index (MI) from 9 to 25 (Fitzpatrick skin phototype I-III). The Nd:YAG fluence to reach epidermal tolerance was 6X the fluence with the alexandrite laser for the same MI in subjects with MI 26 to 35. CONCLUSION Epidermal melanin measurements are quantitative and objective, therefore, improving treatment setting determination by decreasing the risk of overtreatment or undertreatment.

Background Non-melanoma skin cancer is the most common malignancy in transplant patients. However, routine skin cancer evaluation is currently not the standard of care. Objective To investigate the current barriers among transplant physicians to skin cancer screening in their patients. To provide recommendations for appropriate routine skin surveillance. Methods A web-based survey was conducted among Baylor, Dallas transplant physicians. Thirty-seven of 46 responses were received, and 13 physicians (28%) were classified as “high screeners.” Results The univariate analysis revealed three main barriers including the perception of difficulty in seeing a dermatologist (p = 0.017), skin cancer evaluation is not an important aspect of transplant care (p = 0.038), and thirdly, the belief that there is insufficient evidence to warrant universal skin cancer screening in transplant patients (p = 0.013). The fully adjusted multivariable analysis resulted in two significant conclusions; the most important predictor was the perceived lack of medical evidence for skin cancer screening. Limitations The small sample size and all responses being from the same institution in Texas. Conclusion The dermatologic evidence for regular skin cancer screening in transplant patients needs dissemination to our transplant colleagues. This is a significant practice gap which can be appropriately closed by integrating dermatologists into the transplant team.

To determine the outcome of tangential shave removal (TS) of basal cell carcinoma (BCC) on the trunk and extremities.Cohort study of patients with multiple truncal BCC treated using TS in an academic dermatologic surgery practice.Academic institution referral practice.Individuals with BCC referred to the dermatologic surgery unit for ongoing therapy of multiple lesions.TS of amenable superficial and nodular BCCs with twice-annual follow-up. Lesions were removed using a scalpel as a uniform-depth mid-to-upper dermal shave and sent for routine pathology. Basic wound care was applied.Apparent cure rate and outcome of scars.One hundred eighty-two BCCs were treated in 19 individuals. Patients were followed for an average of 5.2 years. One lesion recurred. Three specimens had positive margins requiring further surgery. Scarring was acceptable and similar to what is observed with curettage and electrocoagulation.TS is a reasonable treatment for primary superficial and nodular BCC on the trunk and extremities.

The advent of biologic therapies has revolutionized the treatment of psoriasis. Increased understanding of immunogenetic pathways has allowed for the development of more selective targeted biologic therapies. Multiple new treatments are currently in development for the treatment of psoriasis. Preliminary data for many of these agents, particularly with regard to agents targeting the IL-23/Th17 pathway, are promising. Proven long-term safety, however, is an absolute necessity with newly developed drugs, and should, therefore, still be considered second-line agents to current established treatments with long-term safety data.This review details the mechanisms of action of drugs currently in development or in clinical trials for the treatment of psoriasis, using clinical trial registries and associated publications. Readers will gain a comprehensive overview about the mechanism of action of emerging treatments targeting various immune pathways deeply involved in psoriasis. Pathogenesis, clinical efficacy and safety data for these treatments are discussed where available.Psoriasis remains a heavily undertreated systemic immune-mediated disease despite increased understanding of immunopathogenesis of the disease and advent of a multitude of novel therapeutic agents with potentially improved bioavailability and safety profiles. Limitations, however, remain in the realm of topical agents for treatment of mild to moderate psoriasis, which has seen little progress over the years. A concerted effort will need to be made among researchers, clinicians and patient advocacy groups to ensure new therapeutic agents are developed and gain proper exposure.

The pernicious effects of lead on child health are well documented. The Vermont Department of Health (VDH) recommends screening all 12- and 24-month-old children for elevated blood lead levels (BLL). In 2006, only 41.4% of 24-month-old Vermont children were screened. To identify barriers preventing pediatricians from performing blood lead screening, a survey was distributed to Vermont primary care pediatricians—divided in higher and lower screening groups. Vermont pediatricians were more likely to be lower screeners if they reported negative health outcomes began at BLL >" xbd="641" xhg="618" ybd="1456" yhg="1421"/> 10 µg/dL (odds ratio [OR] = 3.64, 95% confidence interval [CI] = 1.12-11.99), practiced in Chittenden County (OR = 3.34, 95% CI = 1.14-9.78), or disagreed with the VDH’s recommendation (OR = 4.90, 95% CI = 1.66-15.50). Adjusted analysis indicated the most significant determinants of lower screening rates were male gender, a perceived dangerous BLL as >10 µg/dL and low self-reported Medicaid population. The VDH may have an opportunity to increase BLL screening emphasizing the significant health risks associated with BLL ≤ 10 µg/dL.

Using a large consortium of undergraduate students in an organized program at the University of California, Los Angeles (UCLA), we have undertaken a functional genomic screen in the Drosophila eye. In addition to the educational value of discovery-based learning, this article presents the first comprehensive genomewide analysis of essential genes involved in eye development. The data reveal the surprising result that the X chromosome has almost twice the frequency of essential genes involved in eye development as that found on the autosomes.

Importance Skin cancer is the most common malignancy occurring after organ transplantation. Although previous research has reported an increased risk of skin cancer in solid organ transplant recipients (OTRs), no study has estimated the posttransplant population–based incidence in the United States. Objective To determine the incidence and evaluate the risk factors for posttransplant skin cancer, including squamous cell carcinoma (SCC), melanoma (MM), and Merkel cell carcinoma (MCC) in a cohort of US OTRs receiving a primary organ transplant in 2003 or 2008. Design, Setting, and Participants This multicenter retrospective cohort study examined 10 649 adult recipients of a primary transplant performed at 26 centers across the United States in the Transplant Skin Cancer Network during 1 of 2 calendar years (either 2003 or 2008) identified through the Organ Procurement and Transplantation Network (OPTN) database. Recipients of all organs except intestine were included, and the follow-up periods were 5 and 10 years. Main Outcomes and Measures Incident skin cancer was determined through detailed medical record review. Data on predictors were obtained from the OPTN database. The incidence rates for posttransplant skin cancer overall and for SCC, MM, and MCC were calculated per 100 000 person-years. Potential risk factors for posttransplant skin cancer were tested using multivariate Cox regression analysis to yield adjusted hazard ratios (HR). Results Overall, 10 649 organ transplant recipients (mean [SD] age, 51 [12] years; 3873 women [36%] and 6776 men [64%]) contributed 59 923 years of follow-up. The incidence rates for posttransplant skin cancer was 1437 per 100 000 person-years. Specific subtype rates for SCC, MM, and MCC were 812, 75, and 2 per 100 000 person-years, respectively. Statistically significant risk factors for posttransplant skin cancer included pretransplant skin cancer (HR, 4.69; 95% CI, 3.26-6.73), male sex (HR, 1.56; 95% CI, 1.34-1.81), white race (HR, 9.04; 95% CI, 6.20-13.18), age at transplant 50 years or older (HR, 2.77; 95% CI, 2.20-3.48), and being transplanted in 2008 vs 2003 (HR, 1.53; 95% CI, 1.22-1.94). Conclusions and Relevance Posttransplant skin cancer is common, with elevated risk imparted by increased age, white race, male sex, and thoracic organ transplantation. A temporal cohort effect was present. Understanding the risk factors and trends in posttransplant skin cancer is fundamental to targeted screening and prevention in this population.

Background Cutaneous siderosis is accumulation of iron in the dermis and the subcutaneous tissue secondary to extravasation of an intramuscular or intravascular iron injection. It presents as varying shades of brown macules with no distinct contours. The hyperpigmentation is permanent without treatment. Objective Q-switched lasers have been used effectively to treat lentigines and tattoos however, there is little data on the treatment of cutaneous siderosis with lasers. Our objective was to effectively treat cutaneous siderosis with a Q-switched alexandrite laser. Results A 50-year-old female had received nine injections of intramuscular iron dextran, one injection every 2 weeks alternating right buttock and left buttock over the course of 5 months. A couple of weeks after her 9th injection which was on the left, she noted brown hyperpigmentation in the injection area with the left worse than the right. She waited 3 months for the hyperpigmentation to self-resolve before presenting in our clinic. We utilized the Q-switched alexandrite laser to treat the patient with a test spot. One week later, there was nice partial clearance from the test spot so we commenced full treatment of the hyperpigmentation. There was significant improvement after the first treatment and she has been treated 4 times with continued improvement over the past 2 months. Conclusion The Q-switched alexandrite laser is a useful tool in the treatment of cutaneous siderosis secondary to iron injection. Lasers Surg. Med. 47:386–387, 2015. © 2015 Wiley Periodicals, Inc.

Background and Objectives Acral persistent papular mucinosis (APPM) is a rare condition with persistent flesh colored papules on the hands and extensor wrists. The authors aim to present a novel treatment option for this condition. Patients and Methods A female with APPM was treated using a 2940 nm Erbium-YAG laser with a 1 mm spotsize defocused to 2-3 mm with settings of 200-300 mJ until the lesion was flush with the surrounding skin. Results Healing of the wounds with resolution of the individually treated papules. Conclusions Erbium-YAG lasers should be considered a treatment option for APPM. Lasers Surg. Med. 47:467–468, 2015. © 2015 Wiley Periodicals, Inc.

Background Tumor necrosis factor inhibitory agents are currently considered to be contraindicated in psoriatic patients with hepatitis B. Objective We aim to provide guidance to dermatologists on the use of tumor necrosis factor inhibitor therapy in these patients. Methods The current literature was reviewed regarding the use of tumor necrosis factor-alpha inhibitory agents (etanercept, adalimumab, and infliximab) in psoriatic patients with particular reference to hepatitis B infection. Results Tumor necrosis factor-alpha inhibitor therapy may result in reactivated hepatitis B in hepatitis B surface antigen-positive patients with psoriasis. This also occurs, although less frequently in patients with an isolated positive hepatitis B core antibody. Thus, all psoriasis patients should be screened for hepatitis B surface antigen plus hepatitis B core antibody prior to the initiation of tumor necrosis factor-alpha inhibitor therapy. Infliximab has been associated with more reactivation cases than the other 2 agents and fatalities have been reported with this agent. Evidence is presented that the risk of reactivation can be greatly minimized or eliminated by early or pre-emptive antiviral therapy. Limitations The data is largely based on small case series that are retrospective in nature. Conclusions Hepatitis B screening is essential prior to the initiation of tumor necrosis factor-alpha inhibitor therapy. Psoriatic patients found to be hepatitis B surface antigen or hepatitis B core antibody-positive should be referred to an appropriate specialist for evaluation and therapy. This would allow for the safe use of tumor necrosis factor-alpha inhibitors in psoriatic patients despite recently published guidelines to the contrary.

A 69-year-old Caucasian man presented with a lesion on his forehead which “grew overnight” (Figure ​(Figure11). It was located at the edge of a scar of a previously removed squamous cell carcinoma. The patient has had numerous squamous cell carcinomas and mild hyperlipidemia. What is your diagnosis? Figure 1 Right frontolateral forehead. A 5-mm well-circumscribed superficial ulcer with a rolled pink border and surrounding telangiectasias at the medial edge of a scar. Superolateral to the lesion, there is a second scar from a previously treated nonmelanoma ... Over the ensuing week, the patient developed two fresh ulcers on his forehead “overnight” (Figure ​(Figure22). There was no erythema, flaking, pain, numbness, or tingling in the areas prior to the development of the ulcers. The two new lesions were tender. There was no known trauma. Now, what is your diagnosis? Figure 2 The blue circle (A) is a superficial ulcer with an overlying hemorrhagic crust along the scalp fringe to the right of the midline. The red circle (B) is a superficial ulcer with a rolled border within the right eyebrow. The yellow circle indicates the ... DIAGNOSIS: Herpes zoster. Herpes zoster is the reactivation of varicella zoster virus. It typically presents with a prodrome of pain, tingling, or tenderness, and then an eruption of grouped vesicles on an erythematous base occurs within a sensory dermatome. The most common complication is postherpetic neuralgia, which is a neuropathic pain syndrome that develops after the rash has resolved (1–3). It is typically described as burning, stabbing, or shocklike pain in the area where the rash was located (1, 4). Postherpetic neuralgia occurs in 14% to 20% of patients with herpes zoster (2). A vaccine for the prevention of herpes zoster and postherpetic neuralgia, Zostavax, was approved by the Food and Drug Administration in 2006 (5). It is a live virus vaccine composed of at least 19,400 plaque-forming units of the Oka/Merck strain of the varicella zoster virus. The potency of this vaccine is 14-fold higher than that used in children (2). Zostavax reduces the risk of developing herpes zoster by 51% and decreases the incidence of postherpetic neuralgia by 67% (3, 4); further, it decreases the burden of illness of herpes zoster by 61% and decreases the duration of postherpetic neuralgia by 57% (3, 4). Therefore, disease severity is decreased in patients who experience a herpes zoster outbreak despite vaccination (3, 4). Most recently, Zostavax was shown to decrease the risk of ophthalmic involvement, therefore decreasing the risk of serious vision-threatening sequelae (4). Zostavax is recommended by the Centers for Disease Control and Prevention for use in patients >60 years of age who are not immunocompromised (3, 4). Our patient had received the Zostavax vaccine 2 weeks prior to his initial presentation. The patient is otherwise healthy and is not immunocompromised. To date, there are no reports of the Zostavax Oka/Merck varicella virus strain causing herpes zoster itself. However, there are reports of a herpes zoster–like reaction occurring at an average of 16 days after vaccination (4, 6). Wild-type varicella zoster virus DNA was isolated by polymerase chain reaction from the active lesions of the vaccinated patients with a herpes zoster–like reaction, confirming the reactions were likely not due to the vaccine (6). Thus, our patient experienced a herpes zoster–like reaction from the vaccine given 2 weeks prior to the onset of his facial lesions. The case highlights the importance of conducting a thorough history, including a vaccination history. It exemplifies how a vaccine-dampened outbreak of herpes zoster can clinically mimic nonmelanoma skin cancer. Therefore, truncated herpes zoster should be included in the differential diagnosis for nonmelanoma skin cancer for recently vaccinated individuals; a biopsy of the lesion is necessary for confirmation of disease.

There are a multitude of diseases that commonly affect both the skin and the eye. Part II of this 2-part series reviews the oculocutaneous manifestations of neoplasms, both benign and malignant, and adverse drug reactions affecting the skin and the eye. Though rare, a number of neoplasms that primarily involve the skin, such as melanoma and basal cell carcinoma, can metastasize to the eye, leading to permanent damage if not properly treated. In addition, periocular neoplasms can irritate the conjunctiva and lid, reducing a patient's ability to see clearly. Neoplastic diseases, such as xeroderma pigmentosum, Sturge–Weber syndrome, and multiple myeloma, can also lead to permanent changes in the eye if not discovered and managed promptly. Furthermore, there are a multitude of drugs, including those commonly used by dermatologists, which can result in permanent damage to the eye. With proper knowledge of the ocular manifestations and treatment recommendations described in this 2-part series, dermatologists with the assistance of their ophthalmology colleagues can help avoid the complications, including permanent blindness, associated with infectious, inflammatory, genetic, neoplastic, and drug-related conditions.

The excitement of scientific research and discovery cannot be fully conveyed by didactic lectures alone. Several recent initiatives and proposals, therefore, have supported a more participatory, discovery-based instruction for undergraduate science education [1,2]. In functional genomics, we have found an ideal platform to simultaneously benefit students and contribute to scientific discovery. The sequencing of eukaryotic genomes has facilitated the identification of complete sets of genes in humans and model genetic organisms. This has allowed many forms of high-throughput analyses of transcriptional profiles, protein interactions, structural motifs, and even genome-wide knock-downs in cell lines or in selected organisms. However, one of the best tools to provide functional information about gene action— obtaining in vivo evidence about the phenotype resulting from heritable loss of function—is difficult and less amenable to high-throughput research. We were able to achieve a large-scale in vivo analysis with a significant number of undergraduate students at UCLA, called the UCLA Undergraduate Consortium for Functional Genomics. This work, a practical manifestation of policy positions proposing discoverybased education, is described in summary form here (and in Box 1) and in detail online at http://www.bruinfly.ucla.edu. This effort combines professional-quality research with a strategy for research-based undergraduate education.