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Although immunocompromised patients have a higher risk of developing cutaneous squamous cell carcinomas, it is unknown whether immune status is an independent risk factor for poor outcomes.To compare cutaneous squamous cell carcinoma outcomes in immunocompromised and immunocompetent patients when controlling for T-stage.We performed a retrospective cohort study at 2 tertiary care centers, examining 989 primary tumors from 814 immunocompromised patients (solid organ transplant: 259 [31.7%], chronic lymphocytic leukemia: 113 [13.9%]) and 6608 tumors from 4198 immunocompetent patients. Our primary outcome was the composite of disease-specific death or tumor metastasis ("poor outcomes").Immunocompromised patients had 50% more high T-stage tumors (ie, Brigham and Women's Hospital stage T2b and T3), than immunocompetent patients (3.3% vs 4.9%, respectively; P .001). Significant predictors of poor outcomes included tumor stage (sub hazards ratio [SHR], 14.8 for high T-stage tumors; 95% confidence interval [CI], 8.0-27.6; P .001) and male sex (SHR, 2.3; 95% CI, 1.4-3.8; P = .002). Immune status was not a significant predictor (SHR, 1.04; 95% CI, 0.69-1.6; P = .85).This study is retrospective.Although immunocompromised patients had 50% more high T-stage tumors than immunocompetent patients, immunocompromised patients had a similar chance of metastasis and disease-specific death when adjusting for T-stage in our cohort of primary tumors.

Background Calciphylaxis is a rare disorder characterized by skin necrosis caused by calcium deposition within vessels, thrombosis, and subsequent tissue ischemia. Penile involvement may rarely occur. Objective To identify risk factors, diagnosis, management, and mortality of patients with penile calciphylaxis. Methods A retrospective medical record review was conducted of 16 patients with penile calciphylaxis treated at 2 large urban tertiary care centers between January 2001 and December 2019. A control group of 44 male patients with nonpenile calciphylaxis at the same institution was included. Results The median survival of patients with penile calciphylaxis was 3.8 months (interquartile range, 27.0 months). Mortality was 50% at 3 months and 62.5% at 6 months for penile calciphylaxis, and 13.6% at 3 months and 29.5% at 6 months for controls (P = .008). Patients with penile calciphylaxis were less likely to be obese (P = .04) but more likely to have hyperparathyroidism (P = .0003) and end-stage renal disease (P = .049). Limitations Retrospective study design and small sample size. Conclusions This study further defines the disease course of penile calciphylaxis, which has high mortality. Imaging may be used to aid diagnosis. Risk factors include end-stage renal disease, hyperparathyroidism, and normal body mass index.

Background The National Comprehensive Cancer Network (NCCN) has established guidelines for the treatment of keratinocyte carcinomas (KCs). Complete circumferential peripheral and deep margin assessment (CCPDMA) is recommended for "high-risk" tumors that cannot be closed primarily. If flap or grafts are needed and CCPDMA was not used, it is recommended that reconstruction be delayed until achieving clear margins. Objective To measure provider utilization rates of the NCCN guidelines for high-risk KCs and assess barriers that are limiting adherence. Materials and methods A ten-item questionnaire was distributed to NCCN nonmelanoma skin cancer panel members and physicians participating in KC treatment at academic institutions. Results Response rate was 49% (57/116). Responses were categorized by practice area: Mohs surgery, pathology, and other specialties: General Dermatology, Otolaryngology, Plastic Surgery, Surgical Oncology, Radiation Oncology, and Oral and Maxillofacial Surgery. Mohs surgeons were most likely to use CCPDMA for tumors meeting NCCN criteria with 14/15 using this technique in a majority of their cases, versus 2/6 pathologists and 10/16 specialists from other fields. Reasons cited for not using CCPDMA included deference to pathologists to determine the appropriate method for margin assessment and logistical difficulty. Conclusion Further efforts are needed to increase adherence to NCCN's guidelines regarding CCPDMA in KCs.

Mycosis fungoides, the most common cutaneous T-cell lymphoma, is known to exhibit varied clinical presentations and mimic many other dermatoses. This morphological heterogeneity can often lead to initial misdiagnoses resulting in significant delays from symptom onset to diagnosis. We report a case of mycosis fungoides imitating clinical and histopathological features of erythema annulare centrifugum.

Cutaneous reactions are among the most prevalent immune-related adverse events in patients treated with immunotherapy. Given that immunotherapies often act through blocking inhibitory signals on T cells, these treatments also have the potential to generate a host of immune toxicities. We report the case of a 73-year-old woman with a history of non-small cell lung cancer treated with nivolumab 10 months prior to presentation who developed painful nodules, bullae, and a scaly rash on her extremities. Four months after discontinuation of nivolumab, she noted an acute eruption of painful nodules on her extremities, followed by pink papules and tense bullae on her palms and soles. Biopsies were performed of three lesions in sites of varying morphologies. These findings were felt to be consistent with a nivolumab-induced lichenoid reaction. She was initially treated with intralesional steroid injections, topical steroid ointment, and liquid nitrogen cryotherapy with minimal improvement. As the lesions continued to progress, the patient was admitted to the hospital and started on intravenous methylprednisolone. She eventually transitioned to daily oral prednisone with a slow taper with good effect and no recurrence of lesions.

Immune checkpoint inhibitors (ICIs) are widely used for various malignancies. However, their safety and efficacy in patients with a kidney transplant have not been defined. To delineate this, we conducted a multicenter retrospective study of 69 patients with a kidney transplant receiving ICIs between January 2010 and May 2020. For safety, we assessed the incidence, timing, and risk factors of acute graft rejection. For efficacy, objective response rate and overall survival were assessed in cutaneous squamous cell carcinoma and melanoma, the most common cancers in our cohort, and compared with stage-matched 23 patients with squamous cell carcinoma and 14 with melanoma with a kidney transplant not receiving ICIs. Following ICI treatment, 29 out of 69 (42%) patients developed acute rejection, 19 of whom lost their allograft, compared with an acute rejection rate of 5.4% in the non-ICI cohort. Median time from ICI initiation to rejection was 24 days. Factors associated with a lower risk of rejection were mTOR inhibitor use (odds ratio 0.26; 95% confidence interval, 0.09-0.72) and triple-agent immunosuppression (0.67, 0.48-0.92). The objective response ratio was 36.4% and 40% in the squamous cell carcinoma and melanoma subgroups, respectively. In the squamous cell carcinoma subgroup, overall survival was significantly longer in patients treated with ICIs (median overall survival 19.8 months vs. 10.6 months), whereas in the melanoma subgroup, overall survival did not differ between groups. Thus, ICIs were associated with a high risk of rejection in patients with kidney transplants but may lead to improved cancer outcomes. Prospective studies are needed to determine optimal immunosuppression strategies to improve patient outcomes. ispartof: KIDNEY INTERNATIONAL vol:100 issue:1 pages:196-205 ispartof: location:United States status: published

Introduction Psoriasis patients demonstrate high interest in the role of diet on their skin condition. However, data are lacking to describe dietary interventions among psoriasis patients and associated outcomes. This study aims to identify common dietary habits, interventions and perceptions among patients with psoriasis, and to examine patient-reported skin outcomes in response to these interventions. Methods We administered a 61-question survey to the National Psoriasis Foundation membership asking psoriasis patients about dietary habits, modifications, skin responses, and perceptions. Results A total of 1206 psoriasis patients responded to the survey. Compared to age- and sex-matched controls, psoriasis patients consumed significantly less sugar, whole grain fiber, dairy, and calcium (p

Patients with atopic dermatitis (AD) commonly turn to dietary modifications to manage their skin condition.To investigate patient-reported outcomes and perceptions regarding the role of diet in AD.One hundred and sixty nine AD patients were surveyed in this cross-sectional study. The 61-question survey asked about dietary modifications, perceptions and outcomes.Eighty seven percent of participants reported a trial of dietary exclusion. The most common were junk foods (68%), dairy (49.7%) and gluten (49%). The best improvement in skin was reported when removing white flour products (37 of 69, 53.6%), gluten (37 of 72, 51.4%) and nightshades (18 of 35, 51.4%). 79.9% of participants reported adding items to their diet. The most common were vegetables (62.2%), fish oil (59.3%) and fruits (57.8%). The best improvement in skin was noted when adding vegetables (40 of 84, 47.6%), organic foods (17 of 43, 39.5%) and fish oil (28 of 80, 35%). Although 93.5% of patients believed it was important that physicians discuss with them the role of diet in managing skin disease, only 32.5% had consulted their dermatologist.Since dietary modifications are extremely common, the role of diet in AD and potential nutritional benefits and risks need to be properly discussed with patients.

Introduction Chronic skin conditions have been well reported to affect a patient’s quality of life on multiple dimensions, including the psychosocial domain. Psychosocial is defined as the interrelation of social factors with an individual’s thoughts and behavior. The assessment of the psychosocial impact of skin disease on a patient can help direct the dermatologists’ treatment goals. To evaluate the psychosocial impact of skin disease, we conducted a review of the literature on three skin conditions with onsets at various stages of life: acne, vitiligo, and psoriasis. Methods A PubMed search was conducted in March 2015 using the terms “psychosocial” AND “acne”, “psychosocial” AND “vitiligo”, and “psychosocial” AND “psoriasis”. The results were limited to articles published in English in the past 5 years studying patients of all ages. Results and their references were evaluated for relevance according to their discussion of psychosocial qualities in their patients and the validity of psychosocial assessments. The search for acne yielded 51 results, and eleven were found to be relevant; vitiligo yielded 30 results with ten found to be relevant; and psoriasis yielded 70 results with seven found to be relevant. Results According to the articles evaluated, 19.2% of adolescent patients with acne were affected in their personal and social lives. Social phobia was present in 45% of patients with acne compared to 18% of control subjects. Race and sex played a role in self-consciousness and social perceptions of the disease. Vitiligo negatively affected marriage potential and caused relationship problems in >50% of patients. Psoriasis negatively affected multiple domains of life, including work, relationships, and social activities. Anxiety and depression affected not only psoriasis patients but also their cohabitants; up to 88% of cohabitants had an impaired quality of life. Conclusion Though all three skin conditions resulted in an increase in anxiety and depression among their patient populations, the psychosocial focus varied slightly for each disease. Overall, acne, vitiligo, and psoriasis can have negative psychosocial impact in different stages of life development.

The most recent reclassification of dermatoses of pregnancy includes polymorphic eruption of pregnancy, atopic eruption of pregnancy, and pemphigoid gestationis; intrahepatic cholestasis of pregnancy, strictly not a dermatosis, was included in specific dermatoses of pregnancy for working purposes. Another dermatosis, pustular psoriasis of pregnancy, could be included for similar reasons. The nomenclature of these pregnancy-specific eruptions has been revised several times, generating potential confusion among practitioners. Clouding the picture further are misnomers that have been used to describe dermatoses of pregnancy. In addition, several cutaneous conditions that are associated with, but not specific to, pregnancy, have been misunderstood, which has resulted in certain myths among patients and physicians. In this contribution, we describe how the nomenclature of each dermatosis of pregnancy has evolved to fit the current classification scheme. We then identify several misnomers that have generated confusion within the scheme. Finally, we debunk several myths that have developed around cutaneous conditions outside of this scheme, in both mother and newborn.

The Psoriasis Area and Severity Index (PASI) and Physician Global Assessment (PGA) are the most commonly used tools for the evaluation of psoriasis disease severity in clinical trials. Based on U.S. Food and Drug Administration requirements, many recent trials concerning measurement of psoriasis disease severity have included the PGA as a primary endpoint alongside the PASI. In this commentary, we review the advantages and disadvantages of the PASI and PGA scales, and discuss an example of a psoriasis patient in whom PGA fails to capture clinically significant disease improvement. We argue that despite its limitations, the PASI is a more accurate and descriptive instrument than the PGA for the assessment of psoriasis severity.

Background: Hidradenitis suppurativa (HS) and psoriasis are inflammatory skin diseases associated with obesity. Each disease is likely to impact the quality of life of patients, but the relative impact of each disease is unknown. Objectives: This study aimed to determine whether skin disease or obesity is more distressing to obese patients who have either psoriasis or HS. Methods: A cohort of obese patients with psoriasis and HS was surveyed using a time-trade-off utility. T-tests and regression analysis were used to compare differences in impact on quality of life between skin disease and obesity for patients with HS and psoriasis. Further analyses were adjusted for degree of obesity and severity of disease. Results: A total of 79 subjects completed the survey. Obese patients with HS were heavier than patients with psoriasis (mean body mass index 38.1 kg/m2 vs. 34.9 kg/m2). Obese patients with either HS or psoriasis were both willing to trade a significantly higher proportion of their life to live without skin disease than to live at a normal weight (p = .01). This effect persisted after controlling for disease severity and weight. Patients with HS were willing to trade significantly more years of life to live at a normal weight than obese patients with psoriasis (14 vs. 7; p < .04). Limitations: This was a small study conducted at an academic institution. Conclusion: In this study population, obesity was more severe in patients with HS than in those with psoriasis. Even after controlling for relative severity, HS was more problematic for subjects in this study than weight when these conditions existed concomitantly. Keywords: Hidradenitis suppurativa, obesity, psoriasis, quality of life

Background Psoriasis patients experience a significant decrease in quality of life (QoL). Objectives This study was conducted to prospectively measure changes in QoL of patients with moderate-to-severe psoriasis who are treated with ustekinumab. We performed a review of the literature, and discussed the significance of our results in the context of the controversy regarding the correlation between the Dermatology Life Quality Index (DLQI) and Psoriasis Area Severity Index (PASI). Methods Seventeen patients with moderate-to-severe plaque psoriasis received 36 weeks of ustekinumab and were followed every 4 weeks. Results All patients demonstrated significant improvement, both in terms of QoL and physical assessments. The data suggest a strong linear correlation between mean percent reduction in PASI and mean reduction in DLQI (R2=0.94). Conclusion Psoriasis patients treated with ustekinumab achieved significant improvement of QoL, which correlated with physical improvement. This study demonstrates a strong correlation between mean percent reduction in PASI and mean reduction in DLQI.

Major developments in topical therapy for psoriasis have taken place since 1500 B.C. Older methods such as coal tar and anthralin therapy are effective but less popular given difficulty of use. Topical steroids were a revolutionary development for psoriasis. However, they are limited in use due to local and systemic side effects. Non-steroidal topical agents are less efficacious than super-potent topical steroids but have a more favorable side effect profile. Combination medications, such as betamethasone/calcipotriene agents, allow the agents to act synergistically for psoriasis management, while maintaining a safe side effect profile. We recommend a sequential strategy when using a newer combination agent to maximize efficacy and safety, and increase patient compliance.

A common therapeutic modality for psoriasis includes the combination of phototherapy with topical treatments. The recent development of targeted phototherapy with the excimer laser and spray formulations for topical treatments has increased the efficacy and convenience of these combinational therapies. Herein, we aim to assess the efficacy of a novel combination of therapies using the 308 nm excimer laser, clobetasol propionate spray and calcitriol ointment for the treatment of moderate to severe generalized psoriasis. In this 12-week study, patients with moderate to severe psoriasis received twice weekly treatments with a 308-nm excimer laser combined with clobetasol proprionate twice daily for a month followed by calcitriol ointment twice daily for the next month. Of the 30 patients enrolled, 83% of patients (25/30) achieved PASI-75 [65-94%, 95% confidence interval (CI)] at week 12. For PGA, there was an estimated decrease of 3.6 points (3.1-4.1, 95% CI, p

Background Immunological changes in pregnancy are associated with improvements in some pre-existing immune-mediated skin diseases. Estrogen has been hypothesized to contribute to these changes by creating a shift from Th1 and Th17 to Th2 immunity. As this hypothesis would predict, psoriasis (a primarily Th17 mediated immune disease) tends to improve during pregnancy. However, the precise mechanism by which estrogen induces immunological change in psoriasis remains poorly understood. Objective To summarize the immunologic effects of estrogen as they relate to psoriasis during pregnancy. Methods We performed an English-language PubMed search of articles from September 2004 to September 2014 combining the key terms "psoriasis," "estrogen," "autoimmune disease," and "pregnancy." Results Estrogen appears to up-regulate Th2 cytokines and down-regulate Th1 and Th17 cytokines. This shift was initially observed in murine systems, which showed decreased mixed lymphocyte reactions of splenocytes and increased antibody production during pregnancy. Antigen stimulated splenocytes produced fewer Th1 cytokines and more Th2 cytokines in pregnant mice. IL17 producing T cells were significantly decreased in healthy pregnancies compared to non-pregnant controls. Limitations This review is limited by the paucity of studies evaluating immunological changes of psoriasis in pregnancy among human subjects. Conclusions Increased estrogen production in pregnancy is associated with decreased Th1 and Th17 cytokine production. While estrogen may be responsible for some of these immune shifts resulting in disease improvement, there remains no definitive evidence to prove the hypothesis that estrogen is responsible for such improvement., Capsule Summary • Psoriasis is a cutaneous immune-mediated disease which tends to improve during pregnancy • This article reviews the immunologic mechanisms that may contribute to this improvement. • We hope to encourage the development of new and inexpensive topical or oral treatment for psoriasis in women of childbearing age.

Brodalumab is a human monoclonal antibody developed by Amgen, Inc. to treat inflammatory diseases. In May 2015, Amgen announced that it was ending its participation in co-development of the compound because of reports of patients having "events of suicidal ideation and behavior"... Language: en

Psoriasis is a chronic immune disorder that affects 2–3% of the US population. Ustekinumab, a monoclonal antibody against IL-23/12, has shown great efficacy in treating psoriasis. Here we present a rare finding of a patient with plaque-type psoriasis who was diagnosed with congestive heart failure after initiating treatment with ustekinumab. The patient experienced full recovery of cardiac function upon discontinuation of ustekinumab.

The specific dermatoses of pregnancy are defined as a group of pruritic inflammatory dermatoses associated exclusively with pregnancy and/or the immediate postpartum period [1]. Classification of this disease entity remains a topic of debate. The three generally accepted dermatoses include pemphigoid gestationis (PG), polymorphic eruption of pregnancy (PEP), and intrahepatic cholestasis of pregnancy (ICP) [2]. Apart from these three, a series of clinical entities in pregnancy have been previously documented including prurigo of pregnancy, pruritic folliculitis of pregnancy, and atopic dermatitis. However, recent literature has illustrated significant overlaps in clinical presentation and histopathology between these three presentations and, therefore, they will all be categorized together under the term “atopic eruption of pregnancy” (AEP) [3]. It is important to note that two of these four dermatoses (PG and ICP) may pose significant risk for the fetus, and that early recognition and appropriate diagnostic testing are imperative. This chapter will focus on diagnosis, pathogenesis, and management of the four aforementioned dermatoses of pregnancy.

The negative impact of psoriasis on quality of life is well documented. Psoriasis is also associated with impairments in work productivity and daily activities.This study was conducted to prospectively measure the impact of ustekinumab treatment on work productivity and daily activity impairments due to psoriasis, using the Work Productivity and Activity Index: Psoriasis instrument.Thirty-two patients with moderate-to-severe plaque psoriasis received 36 weeks of ustekinumab and were followed every 4 weeks. During each visit, patients were evaluated using the Psoriasis Area Severity Index and Work Productivity and Activity Index: Psoriasis instrument.Thirty-two patients completed the study. There was no change in unemployment rate after treatment. Twenty-two patients who were employed at both baseline and week 36 experienced a significant decrease in total work productivity impairment, presenteeism and a non-significant decrease in absenteeism. All patients demonstrated significant reduction in total activity impairment.This study was limited by the lack of a placebo group and a small sample size.This study demonstrates the benefits of ustekinumab treatment in terms of reducing psoriasis-related work productivity and activity impairments among patients with moderate-to-severe psoriasis.

One of the most important immunologic phenomena in pregnancy is a shift from T-helper 1 (Th1) to T-helper 2 (Th2) immunity. As a result, pregnancy is associated with an exacerbation of Th2 mediated diseases such as systemic lupus erythematosis, atopic dermatitis, and forms of pemphigus such as pemphigus vulgaris. To summarize the clinical and immunologic effects of estrogen as they relate to atopic dermatitis, we performed an English-language PubMed search of articles combining key terms including "atopic dermatitis," "atopic eruption of pregnancy," "estrogen," and "pregnancy." Estrogen appears to cause Th2 polarization and subsequent increase in Th2 cytokines. Pregnant women with atopic disease have greater numbers of Th2 cells producing IL-4 and IFN-gamma cytokines, and a decrease in the Th1 chemokine ratio. Effects of estrogen on Th17 cells vary depending on cell type. Estrogen stimulates mast cell proliferation and promotes allergic sensitization. Overall, atopic dermatitis tends to worsen during pregnancy, at least in part due to the effects of estrogen on the immune system. New advances in therapies will require an increased understanding of the immunopathology of AD, some of which may be learned by studying its unique course in pregnancy.

The National Research Council of the National Academies defines elder mistreatment as: (1) intentional actions that cause harm or create serious risk of harm (whether or not harm is intended) to a vulnerable elder by a caregiver or other person who stands in a trust relationship to the elder; or (2) failure by a caregiver to satisfy the elder's basic needs or to protect the elder from harm. Estimates of the prevalence of elder abuse have ranged from 2.2% to 18.4%. Dermatologists are uniquely positioned to identify and manage suspected cases of elder abuse given their expertise in distinguishing skin lesions of abuse from organic medical disease and their patient populations with strong elderly representation. This article discusses aspects of both the screening and management of elder abuse with particular relevance to dermatologists. Like physicians across medical specialties, dermatologists must be familiar with those aspects of elder abuse in screening, diagnosis, management, and reporting that are unique to their field and to those aspects that are applicable to all health care providers.

Over the previous decade, several innovative teaching methods have been introduced to overcome the decreasing allotment of time dedicated to dermatology in U.S. medical school curricula. We report our experience of increasing medical student exposure to clinical dermatology thorough involvement in an extracurricular, volunteer-driven dermatology clinic. The clinic was well received by students and faculty. Our experience demonstrates that volunteer-driven dermatology clinics may be an effective method of teaching and engendering a culture of community outreach among medical students and faculty.

Psoriasis is a chronic immune-mediated inflammatory condition that affects 2-3% of the population. Apremilast was FDA-approved in March 2014 for the treatment of psoriatic arthritis and in September 2014 for the treatment of moderate to severe plaque psoriasis. Apremilast appears to have lower efficacy than some biologic agents such as adalimumab and ustekinumab, which achieve a PASI-75 in approximately 70% of patients after 12-16 weeks of therapy. However, its ease of administration as an oral agent coupled with a mild side effect profile make it an attractive option for psoriasis treatment. Herein, we present a patient with a 17-year history of plaque type psoriasis recalcitrant to topical, oral, and biologic mediations who attained near-complete remission after therapy with a combination of adalimumab and apremilast.

Tripe palms [(TP); acral acanthosis nigricans (AN)], is a rare cutaneous syndrome in which the palms develop velvety thickening and rugosity that creates an exaggeration or distortion of dermatoglyphics, resembling boiled tripe. In more than 90% of patients, TP is associated with malignancy, predominantly pulmonary and gastric carcinomas.1 However, in approximately 6% to 10% of patients with TP, no associated malignancy is found.1 We report a case of TP associated only with interstitial lung disease (ILD), specifically idiopathic nonspecific interstitial pneumonia (NSIP), and no associated malignancy.