March/April 2012 • Volume 10 • Issue 2 EDITORIAL Scabies Then and Now Lavery, Parish, and Wolf ORIGINAL CONTRIBUTIONS Erlotinib-Induced Scalp Perifolliculitis Rallis, Petronic-Rosic, and Korfitis New Findings in Delusions of Parasitosis Fellner REVIEW Wound Care in Short-Term Rehabilitation Facilities and Long-Term Care: Special Needs for a Special Population White-Chu and Reddy CASE STUDIES Malignant Melanoma Arising Within Nevus Spilus Karam and Jackson Pseudocyst of the Auricle: An Uncommon Entity of the Ear Sheaffer, Sahu, and Lee Necrotic Ulcer: A Manifestation of Leukemia Cutis Aksu, Saracoglu, Sabuncu, Ciftci, Gulbas, and Isiksoy Inflammatory Linear Verrucous Epidermal Nevus With Genital Involvement Balci, Yenin, Çelik, Sarikaya, and Atik Oral Frictional Hyperkeratosis (Morsicatio Buccarum): An Entity to Be Considered in the Differential Diagnosis of White Oral Mucosal Lesions Cam, Santoro, and Lee CORE CURRICULUM Cutaneous Tuberculosis: A Diagnostic Dilemma—Laboratory Inputs Vesicular Palmoplantar Pityriasis Rosea Singh, Sharma, Narang, and Madan Sehgal, Verma, Bhattacharya, Sharma, Singh, and Verma DEPARTMENTS PERILS OF DERMATOPATHOLOGY Sometimes It Takes Darkness to See the Light: Pitfalls in the Interpretation of Cell Proliferation Markers (Ki-67 and PCNA) Castilla, McDonough, Tumer, Lambert, and Lambert INFECTIOUS DISEASE CAPSULES The Lion Is NOT Sleeping Tonight Carr, Bernstein, and Trevino PHOTO CAPSULES Actinomycetoma Dlova and Mosam BOOK REVIEW Hall’s Manual of Skin as a Marker of Underlying Disease Reviewed by Scheinfeld NEW 1X Daily Scar Gel Now patients can spend less time thinking about their scars and more time seeing results. Mean Scar Rating Post Baseline: Subject Assessment for Treated vs. Untreated Scar at Week 81 3.0 2.0 1.0 0.0 Softness* Redness* untreated Texture* Overall* treated 0 = no change, 1 = mild improvement, 2 = moderate improvement, 3 = significant improvement New Mederma® Advanced Scar Gel—the first and only 1X daily scar therapy. • From the #1 doctor recommended brand in scar care2 • More convenient application, better patient compliance, better results • Clinically shown to improve scar softness, redness, texture and overall appearance • Subjects saw a 36% greater improvement in the overall appearance of their scar after 8 weeks vs. untreated scars (P<0.01)1 Wear your skin proudly.™ More information at mederma.com 1 2 Data on file. Dec. 2011. IMS Health. NDTI. December 2010. *Statistical significance reached on all measurements observed (P<0.01). ©/®/™ 2012 Merz Pharmaceuticals, LLC TABLE OF CONTENTS .BSDI"QSJMt7PMVNFt*TTVF EDITORIAL Scabies Then and Now .................................................................................................................................. 67 Michael Joseph Lavery, MB BCh BAO; Lawrence Charles Parish, MD, MD (Hon); Ronni Wolf, MD ORIGINAL CONTRIBUTIONS Erlotinib-Induced Scalp Perifolliculitis ............................................................................................................ 70 Efstathios Rallis, MD, PhD; Vesna Petronic-Rosic, MD, MSc; Chrysovalantis Korfitis, MD New Findings in Delusions of Parasitosis ........................................................................................................ 72 Michael J. Fellner, MD REVIEW Wound Care in Short-Term Rehabilitation Facilities and Long-Term Care: Special Needs for a Special Population ..................................................................................................................................... 75 E. Foy White-Chu, MD; Madhuri Reddy, MD, MSc Self-Test Review Questions (p. 81) CORE CURRICULUM Virendra N. Sehgal, MD, Section Editor Cutaneous Tuberculosis: A Diagnostic Dilemma—Laboratory Inputs ................................................................ 82 Virendra N. Sehgal, MD; Prashant Verma, MD; Sambit N. Bhattacharya, MD; Sonal Sharma, MD; Navjeevan Singh, MD; Nishant Verma, MD DEPARTMENTS PERILS OF DERMATOPATHOLOGY W. Clark Lambert, MD, PhD, Section Editor Sometimes It Takes Darkness to See the Light: Pitfalls in the Interpretation of Cell Proliferation Markers (Ki-67 and PCNA) ............................................................................................................................ 90 Carmen Castilla, BS; Patrick McDonough, BA; Gizem Tumer, MD; Peter C. Lambert, BA, MS; W. Clark Lambert, MD, PhD INFECTIOUS DISEASE CAPSULES Jack M. Bernstein, MD, Section Editor The Lion Is NOT Sleeping Tonight................................................................................................................... 94 David R. Carr, MD; Jack M. Bernstein, MD; Julian Trevino, MD PHOTO CAPSULES Ncoza C. Dlova, MBChB, FCDerm, Section Editor Actinomycetoma ........................................................................................................................................... 98 Ncoza C. Dlova, MBChB, FCDerm; Anisa Mosam, MBChB, FCDerm CASE STUDIES Vesna Petronic-Rosic, MD, MSc, Section Editor Malignant Melanoma Arising Within Nevus Spilus ......................................................................................... 100 Susan L. Karam, BS; Scott M. Jackson, MD Pseudocyst of the Auricle: An Uncommon Entity of the Ear ........................................................................... 104 Alexis Sheaffer, BS; Joya Sahu, MD; Jason B. Lee, MD Necrotic Ulcer: A Manifestation of Leukemia Cutis ....................................................................................... 108 Ayse Esra Koku Aksu, MD; Zeynep Nurhan Saracoglu, MD; Ilham Sabuncu, MD; Evrim Ciftci, MD; Zafer Gulbas, MD; Serap Isiksoy, MD Inflammatory Linear Verrucous Epidermal Nevus With Genital Involvement ................................................... 112 Didem Didar Balci, MD; Jülide Zehra Yenin, MD; Ebru Çelik, MD; Gökhan Sarikaya, MD; Esin Atik, MD 61 TABLE OF CONTENTS .BSDI"QSJMt7PMVNFt*TTVF Oral Frictional Hyperkeratosis (Morsicatio Buccarum): An Entity to Be Considered in the Differential Diagnosis of White Oral Mucosal Lesions .......................................................................... 114 Kristin Cam, MD; Anthony Santoro, MD; Jason B. Lee, MD Vesicular Palmoplantar Pityriasis Rosea....................................................................................................... 116 Varinder Singh, MD; Meghna Sharma, MD; Tarun Narang, MD; Manas Madan, MD BOOK REVIEW Noah S. Scheinfeld, MD, JD, Section Editor Hall’s Manual of Skin as a Marker of Underlying Disease .............................................................................. 120 Edited by John C. Hall and Brian J. Hall. 300 pages. Shelton, CT; People’s Medical Publishing House–USA; 2011. $89.95. ISBN 1607951029 ABOUT OUR JOURNAL SKINmed: Dermatology for the Clinician®QSJOU*44/POMJOF *44/JTQVCMJTIFECJNPOUIMZCZ1VMTF.BSLFUJOH$PN NVOJDBUJPOT--$MPDBUFEBU1FOJOTVMB"WFOVF4FB#SJHIU/+ Editorial EDITORIAL DIRECTOR 4BSBI%4UBBUT TTUBBUT!TLJONFEKPVSOBMDPN 1SJOUFEJOUIF64" %JTDMBJNFSɨF1VCMJTIFS&EJUPSTBOE&EJUPSJBM#PBSEDBOOPUCFIFME SFTQPOTJCMFGPSFSSPSTPSBOZDPOTFRVFODFTBSJTJOHGSPNUIFVTFPGJOGPS NBUJPODPOUBJOFEJOUIJTKPVSOBMUIFWJFXTBOEPQJOJPOTFYQSFTTFEIFSFJO EPOPUOFDFTTBSJMZSFìFDUUIPTFPGUIF1VCMJTIFS&EJUPSTBOE&EJUPSJBM #PBSEOFJUIFSEPFTUIFQVCMJDBUJPOPGBEWFSUJTFNFOUTDPOTUJUVUFBOZFO EPSTFNFOUCZUIF1VCMJTIFS&EJUPSTBOE&EJUPSJBM#PBSEPGUIFQSPEVDUT PSTFSWJDFTBEWFSUJTFEɨF1VCMJTIFS&EJUPST&EJUPSJBM#PBSE3FWJFXFST "VUIPSTBOE"ïMJBUFE"HFOUTTIBMMOPUCFIFMESFTQPOTJCMFPSJOBOZXBZ MJBCMFGPSUIFDPOUJOVFEBDDVSBDZPGUIFJOGPSNBUJPOPSGPSBOZFSSPST JOBDDVSBDJFTPSPNJTTJPOTPGBOZLJOEJOUIJTQVCMJDBUJPOXIFUIFSBSJTJOH GSPNOFHMJHFODFPSPUIFSXJTFPSGPSBOZDPOTFRVFODFTBSJTJOHUIFSFBGUFS COPYEDITOR &MJ[BCFUI)PMDPNC FIPMDPNC!TLJONFEKPVSOBMDPN MEDIA WEB DIRECTOR +PBO0THPPECZ KPBO!TLJONFEKPVSOBMDPN Publishing PUBLISHER "SU,BMBLB $PQZSJHIU©1VMTF.BSLFUJOH$PNNVOJDBUJPOT--$"MMSJHIUT SFTFSWFE/PQBSUPGUIJTQVCMJDBUJPONBZCFSFQSPEVDFETUPSFEPSUSBOT NJUUFEJOBOZGPSNPSCZBOZNFBOTXJUIPVUUIFQSJPSQFSNJTTJPOJOXSJU JOHGSPNUIF1VCMJTIFS3FRVFTUTTIPVMECFBEESFTTFEUPUIF1FSNJTTJPOT &EJUPSBU1VMTF.BSLFUJOH$PNNVOJDBUJPOT--$1FOJOTVMB"W FOVF4FB#SJHIU/+ ASSOCIATE PUBLISHER +BNFT3"EBNT KBEBNT!TLJONFEKPVSOBMDPN Corporate PRESIDENT "SUIVS,BMBLB BLBMBLB!TLJONFEKPVSOBMDPN CHIEF EXECUTIVE OFFICER +P"OO,BMBLB"EBNT KBEBNT!TLJONFEKPVSOBMDPN "CTUSBDUJOH*OEFYJOHɨFKPVSOBMJTJOEFYFEJO*OEFY.FEJDVT .&%-*/& GENERAL COUNSEL .BSJBOOF.DLFO[JF NNDLFO[JF!TLJONFEKPVSOBMDPN 5PTVCNJUBNBOVTDSJQUGPSQFFSSFWJFXTFOEBTBOFNBJMBUUBDI NFOUUPUIF&EJUPSJO$IJFGBUMQBSJTI!TLJONFEKPVSOBMDPN1MFBTF WJTJUXXXTLJONFEKPVSOBMDPNGPS*OGPSNBUJPOGPS"VUIPST 1VMTF.BSLFUJOH$PNNVOJDBUJPOT--$ 1FOJOTVMB"WFOVFt4VJUFt4FB#SJHIU/+ 5FM t'BY 62 rday Satu 12 Sun day BER TEM P E S ay Mond SE CONGRESS OF THE TEM BRO Tu esday 34 CENTENNIAL CELEBRATION R EMBE SEPT SEPTE MBER OF OUR SOCIETY In this so importan t year of the 100 years celebrati on of the Brazilian Society of Derma tology, w e would invite yo like to u to join us in the th Brazilian 6 7 Congress of Derma tology. Marcia Ra m o s -e -Silva Presiden t of the Cong ress September 1 - 4 | Rio de Janeiro | Brazil www.dermato2012.com.br Organized by Executive Secretariat Venue Travel Agency Tel.: (55 21) 2286-2846 [email protected] www.riocentro.com.br www.blumar.com.br Media Partner THE Aesthetic Show of the Year Register with Promo Code TAS3AD: World-Class Faculty Pre-Show Educational Sessions Advanced Hands-On Training THE Aesthetic Awards Patient Tx Workshops TM UÊ,iViÛiÊfÓääÊvvÊÀi}ÃÌÀ>ÌÊviià UÊ,iViÛiÊV«iÌ>ÀÞÊÕ«}À>`iÊÌÊ6*ÊiLiÀÊÃÌ>ÌÕà UÊ-Ì>ÀÊÊ>ÊÛiÊw}ÊvÊAesthetic TV To register visit www.aestheticshow.com or call + 1 (949) 830-5409 March/April 2012 EDITORIAL BOARD EDITOR IN CHIEF Lawrence Charles Parish, MD, MD (Hon) Philadelphia, PA DEPUTY EDITORS William Abramovits, MD Dallas, TX W. Clark Lambert, MD, PhD Newark, NJ Larry E. Millikan, MD Meridian, MS Vesna Petronic-Rosic, MD, MSc Chicago, IL Marcia Ramos-e-Silva, MD, PhD Rio de Janeiro, Brazil Jennifer L. Parish, MD Philadelphia, PA EDITORIAL BOARD Mohamed Amer, MD Cairo, Egypt Howard A. Epstein, PhD Philadelphia, PA Jasna Lipozencic, MD, PhD Zagreb, Croatia Noah S. Scheinfeld, MD, JD New York, NY Robert L. Baran, MD Cannes, France Ibrahim Hassan Galadari, MD, PhD, FRCP Dubai, United Arab Emirates Eve J. Lowenstein, MD, PhD New York, NY Virendra N. Sehgal, MD Delhi, India Anthony V. Benedetto, DO Philadelphia, PA Anthony A. Gaspari, MD Baltimore, MD George M. Martin, MD Kihei, HI Charles Steffen, MD Oceanside, CA Brian Berman, MD, PhD Miami, FL Michael Geiges, MD Zurich, Switzerland Marc S. Micozzi, MD, PhD Bethesda, MD Alexander J. Stratigos, MD Athens, Greece Jack M. Bernstein, MD Dayton, OH Michael H. Gold, MD Nashville, TN George F. Murphy, MD Boston, MA James S. Studdiford III, MD Philadelphia, PA Sarah Brenner, MD Tel Aviv, Israel Lowell A. Goldsmith, MD, MPH Chapel Hill, NC Oumeish Youssef Oumeish, MD, FRCP Amman, Jordan Robert J. Thomsen, MD Los Alamos, NM Joaquin Calap Calatayud, MD Cadiz, Spain Aditya K. Gupta, MD, PhD, FRCP(C) London, Ontario, Canada Joseph L. Pace, MD, FRCP Naxxar, Malta Julian Trevino, MD Dayton, OH Henry H.L. Chan, MB, MD, PhD, FRCP Hong Kong, China Seung-Kyung Hann, MD, PhD Seoul, Korea Art Papier, MD Rochester, NY Snejina Vassileva, MD, PhD Sofia, Bulgaria Noah Craft, MD, PhD, DTMH Torrance, CA Roderick J. Hay, BCh, DM, FRCP, FRCPath London, UK Johannes Ring, MD, DPhil Munich, Germany Daniel Wallach, MD Paris, France Ncoza C. Dlova, MBChB, FCDerm Durban, South Africa Tanya R. Humphreys, MD Philadelphia, PA Roy S. Rogers III, MD Rochester, MN Michael A. Waugh, MB, FRCP Leeds, UK Richard L. Dobson, MD Mt Pleasant, SC Camila K. Janniger, MD Englewood, NJ Donald Rudikoff, MD New York, NY Wm. Philip Werschler, MD Spokane, WA William H. Eaglstein, MD Palo Alto, CA Abdul-Ghani Kibbi, MD Beirut, Lebanon Robert I. Rudolph, MD Wyomissing, PA Joseph A. Witkowski, MD Philadelphia, PA Boni E. Elewski, MD Birmingham, AL Andrew P. Lazar, MD Highland Park, IL Vincenzo Ruocco, MD Naples, Italy Ronni Wolf, MD Rechovot, Israel Charles N. Ellis, MD Ann Arbor, MI 65 2XUWK<HDUDW WKH 3DOD]]R+RWHO LQ/DV9HJDV 5HJLVWHU1RZIRU6SHFLDO5DWHV +RWHO5RRPV$YDLODEOHDW*UHDW5DWHV ')+56'419^ 7KXUVGD\1RYHPEHUWKDW$0±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t*TTVF March/April 2012 EDITORIAL Scabies Then and Now Michael Joseph Lavery, MB BCh BAO;1 Lawrence Charles Parish, MD, MD (Hon);2 Ronni Wolf, MD3 CONTRIBUTING FACTORS There’s a squeak of pure delight from a matey little mite, As it tortuously tunnels in the skin, Singing furrow, folly furrow, come and join me in my burrow, And we’ll view the epidermis from within1 8IZTIPVMETDBCJFTSFNBJOBQSPCMFNBGUFSDFOUVSJFTPGLOPXJOH BCPVUJUTFYJTUFODF &WFO"SJTUPUMFSFDPHOJ[FEUIJTFDUPQBSBTJUJD EJTFBTF#ZUIFUJNFPGUIFTDBOEBMJO"MJCFSUTDMJOJDJOUIFFBSMZ UIDFOUVSZXJUIUIFDIFFTFNJUFCFJOHTVCTUJUVUFEGPSUIFTDBCJFTNJUFTPNFMBZQFPQMFPGUFOLOFXTPNFUIJOHPGUIFJOTBOE PVUT PG UIF EJTFBTF CVU QIZTJDJBOT XFSF SFMVDUBOU UP NBLF UIF DPSSFMBUJPOPGUIFNJUFXJUIUIFBð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iNBUFZMJUUMF NJUFwBTDPOëSNFECZUIFBVEJFODFMBVHIJOHCVUCFJOHFRVBMMZ ENTOMOLOGY EJTHVTUFECZUIFDIFFTFNJUFJOBëMNEPDVNFOUBSZJO2 Sarcoptes scabiei var. HominisJTBOFDUPQBSBTJUFUIBUCFMPOHTUP The cheese-mites asked how the cheese got there, UIF"SBDIOJEBDMBTTBOEIBTMFHT'JHVSF *UJTNJDSPTDPQJD And warmly debated the matter; XJUIBTUBHFXFFLMJGFDZDMF"GUFSGFSUJMJ[BUJPOUIFGFNBMF The Orthodox said that it came from the air, NJUFXIJDISFBDIFTVQUPNNSFNBJOTGFSUJMFGPSMJGF10*U And the Heretics said from the platter. CVSSPXTJOUPUIFFQJEFSNBMMBZFSSFMFBTFTQSPUFBTFTXIJDICSFBL They argued it long and they argued it strong, EPXOUIFTUSBUVNDPSOFVNVQPOXIJDIJUTVCTFRVFOUMZGFFET11; And I hear they are arguing now; BOE UIFO QMBOUT JUT FHHT JO UIF TUSBUVN HSBOVMPTVN5 Sarcoptes But of all the choice spirits who lived in the cheese, scabieiMJWFGPSBSPVOEUPXFFLTJOUIFIPTUTTLJO10XJUIUIF Not one of them thought of a cow.3 GFNBMFTCVSSPXJOHUIFJSFHHT0OMZBNBYJNVNPGPGUIFTF ɨJTXJUUZQPFNNJSSPSTNBOTJOBCJMJUZUPFSBEJDBUFUIFTDBCJFT FHHTXJMMTVSWJWFUPBEVMUIPPE$POUSBSZUPDPNNPOUIPVHIU NJUFXIJDIIBTTVSWJWFEGPSUIPVTBOETPGZFBSTEFTQJUF#POP- UIF TDBCJFT NJUF DBO MJWF GPS VQ UP IPVST XJUI OP IVNBO 11 NPT DPODMVTJWF QSPPG JO PG UIF DBVTBUJWF PSHBOJTN IPX DPOUBDU TDBCJFTDPVMECFTQSFBEBOEJUTFêFDUJWFUSFBUNFOU4 CLINICAL FEATURES INCIDENCE $MJOJDBMGFBUVSFTUZQJDBMMZBQQFBSBGUFSIPVSTJGUIFQBUJFOUIBT 4DBCJFTJTOPUBTNBMMHMPCBMQSPCMFNCFDBVTFNJMMJPODBTFT IBETDBCJFTJOUIFQBTUBOECFUXFFOBOEXFFLTGPSBëSTU BOOVBMMZBSFTVTQFDUFEXPSMEXJEF5XJUI64JODJEFODFBQQSPYJNBU- FYQPTVSF912 JOHNJMMJPO6ɨF6,NFBOQSFWBMFODFJTQFSJOCPZT ɨF DMBTTJDBM QJDUVSF JOWPMWFT SFE QBQVMFT JO UIF ëOHFS XFCT BOENFOBOEJOJOHJSMTBOEXPNFO7XIFSFJO 'JHVSF PO UIF QFOJT 'JHVSF BOEPS UIF CSFBTU PS XJUI QFPQMFDPOTVMUUIFJSGBNJMZQIZTJDJBOBCPVUUIFJOUFOTFJUDIJOH TDBUUFSFEMFTJPOTPOUIFCPEZFBDIDBVTJOHOPDUVSOBMQSVSJUVT ɨJTQPMJUJDBMMZDPSSFDUPSHBOJTNJTOPOEJTDSJNJOBUPSZBêFDUJOH ɨFGBDFJTTQBSFEFYDFQUGPSJOJNNVOPDPNQSPNJTFEQBUJFOUT CPUITFYFTFWFSZTPDJBMDMBTTBOEBMMBHFTBOESBDFTBMUIPVHI DIJMESFOBOEUIFFMEFSMZ&YQMBOBUJPOTGPSUIJTEJTUSJCVUJPOBSF "GSJDBO"NFSJDBOTIBWFCFFOTIPXOUPIBWFBMPXFSQSFWBMFODF9 JODPODMVTJWF"NPSFJOUFOTFJOGFTUBUJPOJTTFFOJOQBUJFOUTXIP From the Department of Dermatology, Altnagelvin Area Hospital, Derry, North Ireland;1 the Department of Dermatology and Cutaneous Biology, Jefferson Center for International Dermatology, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA;2 and the Dermatology Unit, Kaplan Medical Center, Rechovet, Israel3 Address for Correspondence: Michael Joseph Lavery, MB BCh BAO, Altnagelvin Area Hospital, Department of Dermatology, Glenshane Road, Derry BT47 6SB, North Ireland t E-mail: [email protected] SKINmed. 2012;10:67–69 67 ª1VMTF.BSLFUJOH$PNNVOJDBUJPOT--$ &%*503*"- March/April 2012 Figure 3. Red papules on the penile corona indicating scabies, until proven otherwise. 6TVBMMZUPGFNBMFTDBOCFPCTFSWFEJOUIFCVSSPXTIPXFWFS JUIBTCFFOSFQPSUFEUIBUUIJTOVNCFSDBOCFNVDIIJHIFS14 There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¡'PSLFQUJOTUPSBHFGPSVQUPXFFLT16 Figure 1. The scabies mite, showing 8 legs. ɨFSF JT BMXBZT DPODFSO SFHBSEJOH SFTJTUBODF IPXFWFS UIJT IBT OPU CFFO EPDVNFOUFE XJUI UIF DVSSFOU SFHJNFOT .PSF Figure 2. The characteristic red papules on the finger webs. BSFJNNVOPDPNQSPNJTFENBMOPVSJTIFEPSTFOTPSZJNQBJSFE QSPEVDJOHDSVTUFEMFTJPOT15IFODFDSVTUFETDBCJFTBMTPLOPXO BT/PSXFHJBOTDBCJFT 'JHVSF SKINmed. 2012;10:67–69 Figure 4. Crusted scabies in an older man who had neglected himself. 4DBCJFTɨFOBOE/PX &%*503*"- March/April 2012 5 Vandergriff T, Harting M, Rosen T. Venereal diseases. In: Hall JC, Hall BJ. Skin Infections: Diagnosis and Treatment. Cambridge, England; Cambridge University Press; 2009; Part VI, Ch 24; 317–318. 6 Scabies Homepage. (American incidence) http://www.stanford.edu/ group/parasites/ParaSites2005/Scabies/SCABIES.html. Accessed July 30, 2011. 4DBCJFT JT B TJHOJëDBOU XPSMEXJEF JOGFDUJPO BêFDUJOH PG UIF HMPCBM QPQVMBUJPO5 &êFDUJWF UPQJDBM BOE PSBM UIFSBQJFT BSF BWBJMBCMFCVUUIFNJUFIBTOPUCFFOFMJNJOBUFE0WFSDSPXEJOH VOTBOJUBSZDPOEJUJPOTBOETFYVBMQSPNJTDVJUZNBZJODSFBTFUIF SJTLPGJOGFDUJPO75PNBOBHFTDBCJFTTVDDFTTGVMMZUIFHPBMTIPVME CFUPBEESFTTUIFTFSJTLGBDUPSTBOEBEFRVBUFMZUSFBUBMMQBUJFOUT BOEUIFJSDPOUBDUT 7 Lassa S, Campbell MJ, Bennett CE. Epidemiology of scabies prevalence in the UK from general practice records. Br J Dermatol. 2011;164; 1329–1334. 8 Downs AMR, Harvey I, Kennedy CTC. The epidemiology of head lice and scabies in the UK. Epidemiol Infect. 1999;3;471–477. 9 Johnston G, Sladden M. Scabies: diagnosis and treatment. Clinical review. BMJ. 2005;331:619 Poor Giovanni Bonomo, Would be filled with such woe, To have this tiny little mite, Still causing affliction by its bite. 11 Harrison S, Knott H, Bergfeld WF. Infections of the Scalp. In: Hall JC, Hall BJ. Skin Infections: Diagnosis and Treatment. Cambridge, England; Cambridge University Press: 2009; Part V, Ch 20; 260. PGUFO UIBO OPU MBDL PG DPNQMJBODF PS SFJOGFTUBUJPO IBT CFFO DPOTJEFSFESFTJTUBODFXIJDIJUJTOPU17 CONCLUSIONS 10 Parasites and Health. Accessed July 30, 2011. Scabies. www.cdc.gov/scabies/risk.html. 12 Currie BJ, McCarthy JS. Permethrin and ivermectin for scabies. New Engl J Med. 2010;362;717–725. 13 Cestari TF, Martignago BF. Scabies, pediculosis, bedbugs and stinkbugs: uncommon presentations. Clin Dermatol. 2005;23;545–554. REFERENCES 14 Wolf R, Davidovici B. Treatment of scabies and pediculosis: facts and controversies. Clin Dermatol. 2010;28;511–518. 1 Graham-Brown RAC, Burns T. Lecture notes. Dermatology. 9th ed. Malden, MA: Blackwell Publishing; 2007:41–45. 2 Cheese mites and other wonders. BBC News Online. http://news.bbc. co.uk/1/hi/magazine/7423847.stm. Accessed July 30, 2011. 15 Currie BJ, Harumal P, McKinnon M, et al. First documentation of in vivo and in vitro ivermectin resistance in sarcoptes scabiei. Clin Infect Dis. 2004;39;e8–e12. 3 Arthur Conan Doyle. A Parable 1916. http://rpo.library.utoronto.ca/ poem/3284.html. Accessed July 30, 2011. 16 Wolf R, Davidovici B, Parish LC. Can the scabies mite be tamed? SKINmed. 2006;5:214–216. 4 Ramos-e-Silva M. Giovan Cosimo Bonomo (1663-1696): discoverer of the etiology of scabies. Int J Dermatol. 1998;37;625–630. 17 Cox NH. Permethrin treatment in scabies infestation: importance of the correct formulation. Clinical Review. BMJ. 2000;320:37. WAX MOULAGE Candidiasis, Infection with Candida albicans. Moulage No 238–239, made by Lotte Volger in the Dermatology Clinic in Zurich in 1923. Museum of Wax Moulages Zurich, www.moulagen.ch Courtesy of Michael Geiges, MD SKINmed. 2012;10:67–69 69 4DBCJFTɨFOBOE/PX 7PMVNFt*TTVF March/April 2012 ORIGINAL CONTRIBUTION Erlotinib-Induced Scalp Perifolliculitis Efstathios Rallis, MD, PhD;1 Vesna Petronic-Rosic, MD, MSc;2 Chrysovalantis Korfitis, MD1 ABSTRACT &SMPUJOJCJTBIJHIMZTQFDJëDFQJEFSNBMHSPXUIGBDUPSSFDFQUPSUZSPTJOFLJOBTFJOIJCJUPSVTFEUPUSFBUWBSJPVTNFUBTUBUJDDBODFSTɨFNPTU DPNNPOMZ SFQPSUFE TJEF FêFDUT JO QBUJFOUT SFDFJWJOH FSMPUJOJC BSF EFSNBUJUJT BOE EJBSSIFB ɨF BVUIPST QSFTFOU UXP DBTFT PG FSMPUJOJC JOEVDFETFWFSFTDBMQQFSJGPMMJDVMJUJTXIJDIJTBOBEWFSTFSFBDUJPOUIBUIBTOPUCFFOSFQPSUFEUPEBUF#PUIQBUJFOUTEFWFMPQFEQVTUVMFTBOE UIJDLZFMMPXHSFFODSVTUFEQMBRVFTPOUIFTDBMQXJUIJOXFFLTPGTUBSUJOHUSFBUNFOUXJUIFSMPUJOJCGPSNFUBTUBUJDOPOoTNBMMDFMMMVOHDBSDJOPNB4LJOCJPQTJFTSFWFBMFEBQFSJGPMMJDVMBSBDDVNVMBUJPOPGJOìBNNBUPSZDFMMTMZNQIPDZUFTBOEOFVUSPQIJMT#PUIQBUJFOUTXFSFUSFBUFE 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SVQUJPOPSEJTDPOUJOVBUJPO"TJNJMBSFSVQUJPOJTTFFOPO B TVOTDSFFO PG TVOCVSO QSPUFDUJPO GBDUPS PS IJHIFS XBT UP PG QBUJFOUT USFBUFE XJUI FSMPUJOJC3 *UT QBUIPHFOFTJT From the Department of Dermatology, Veterans Administration Hospital (NIMTS), Athens, Greece;1 and the Section of Dermatology, University of Chicago Pritzker School of Medicine, Chicago, IL2 "EESFTTGPS$PSSFTQPOEFODF>UBUIJPT3BMMJT.%1I%1BGTBOJPV4USFFU"UIFOT(SFFDF(3t&NBJMFGSBMM!PUFOFUHS SKINmed. 2012;10:70–71 70 ª1VMTF.BSLFUJOH$PNNVOJDBUJPOT--$ 03*(*/"-$0/53*#65*0/ March/April 2012 Figure 1. $BTF5IJDLNBMPEPSPVTHSFFOJTIBOEZFMMPXJTI DSVTUFEMFTJPOTPOUIFTDBMQ Figure 4. $BTF4BNFQBUJFOUBGUFSXFFLTPGUIFSBQZXJUI PSBMEPYZDZDMJOF SFQPSUBiCVSOJOHwTFOTBUJPOXIJDIJTFYBDFSCBUFECZUIFVTFPG TPNF BDOF UIFSBQJFT TVDI BT SFUJOPJET PS BMQIBIZESPYZ BDJET )JTUPMPHJDBMMZUIFTFCBDFPVTHMBOETBSFOPUBêFDUFEBOEDPNFEPOFTBSFOPUPCTFSWFEIPXFWFSUPQJDBMBOEPSPSBMBOUJJOìBNNBUPSZBDOFUSFBUNFOUTNBZCFCFOFëDJBM2 *OEJTUJOHVJTIJOHUIJTUZQFPGFSVQUJPOGSPNUIFUZQJDBMBDOFJGPSN 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Clin Oncolo 4 (VU[NFS38FSGFM5,BQQ"&MTOFS+$VUBOFPVTTJEFFGGFDUTPG&(' SFDFQUPSJOIJCJUJPOBOEUIFJSNBOBHFNFOUHautarzto 5 $BNQCFMM5.#SPXO$8+S%JNPSQIJDDVUBOFPVTNBOJGFTUBUJPOPGBUPYJD FSVQUJPOEVFUPFSMPUJOJCUIFSBQZJ Drugs Dermatolo &SMPUJOJC*OEVDFE4DBMQ1FSJGPMMJDVMJUJT 7PMVNFt*TTVF March/April 2012 ORIGINAL CONTRIBUTION New Findings in Delusions of Parasitosis Michael J. Fellner, MD ABSTRACT 5XP OFX DBTFT BSF QSFTFOUFE XJUI EFMVTJPOT PG QBSBTJUPTJT #PUI XFSF XPNFO POF NJEEMFBHFE BOE POF FMEFSMZ BOE FYIJCJUFE DMBTTJD TZNQUPNT PG QBSBTJUFT BOE iTUSJOHTw JO UIF TLJO JOEJDBUJWF PG .PSHFMMPOT EJTFBTF &BDI IBE BO BEEJUJPOBM QTZDIJBUSJD EJTPSEFS ESVH BEEJDUJPOUPDPDBJOFBOETFOJMFEFNFOUJBɨFZBMTPJMMVTUSBUFUIFEJïDVMUZFODPVOUFSFECZUIFEFSNBUPMPHJTUJOQSPWJEJOHBEFRVBUFUIFSBQZ CFDBVTFPGSFTJTUBODFUPQTZDIJBUSJDSFGFSSBMBTXFMMBTUPTUBOEBSEBDDFQUFENFEJDBUJPO/FXFSQTZDIPUSPQJDTTVDIBTSJTQFSEBMBOEMFYBQSP TIPXQSPNJTFJOIFMQJOHUIFTFQBUJFOUTBOEBEEUPUIFUIFSBQFVUJDBSNBNFOUBSJVNPGQJNP[JEFSKINmed. o T IJTJTUIFëSTUSFQPSUPGUXPQBUJFOUTXJUICPUIUIFDMBTTJD GFBUVSFTPG.PSHFMMPOTEJTFBTFBOEEFMVTJPOTPGQBSBTJUPTJTBUUIFTBNFUJNF%FMVTJPOTPGQBSBTJUPTJTBSFBEJTFBTFDIBSBDUFSJ[FECZBOFODBQTVMBUFEEFMVTJPOUIBUUIFCPEZJT JOGFTUFEXJUIQBSBTJUFTVTVBMMZJOTFDUTPSCVHTJOPSPOUIFTLJO 1BUJFOUT XJUI .PSHFMMPOT EJTFBTF SFQPSU TUSJOHT DPNJOH PVU PG UIFTLJO*UJTUIPVHIUUPCFBTVCTFUPGEFMVTJPOTPGQBSBTJUPTJT 0OFPGUIFUXPQBUJFOUTFYIJCJUFEUIFQSFWJPVTMZSFQPSUFEëOEJOHCZUIJTBVUIPSPGUIFQSFDJQJUBUJOHMJGFGBDUPSUIBUJODJUFEUIF EJTFBTFXIJDIXBTBCBOEPONFOUCZIFSMPWFS1 CASE 1 " ZFBSPME "GSJDBO "NFSJDBO XPNBO QSFTFOUFE XJUI UIF DPNQMBJOUPGiTUVêDSBXMJOHPOUIFTLJOw4IFEFTDSJCFEJOHSFBU EFUBJMUIBUTUSJOHTXFSFDPNJOHPVUPGIFSFZFMJETBOEFZFMBTIFT DBVTJOHIFSHSFBUEJTUSFTT4IFGFMUUIFOFFEUPDPOTUBOUMZCSVTIPê UIFTUSJOHTGSPNUIFFZFTXJUIIFSIBOETXIJDIDBVTFEIFSIBOET UPGFFMJSSJUBUFEBTXFMMBTIFSGBDF*OBEEJUJPOTIFEFTDSJCFEUIBU iQBSBTJUFTDPNFPVUPGNZFBSTw4IFTBJEUIFQBSBTJUFTNBEFB ë[[JOHOPJTFJOIFSFBSTXIJDITIFEFTDSJCFEBTSFTFNCMJOHUIF ë[[TPVOEPGTPEBQPVSFEJOUPBHMBTT 4IF JOEJDBUFE UIBU UIF POTFU PG UIF TZNQUPNT CFHBO BQQSPYJNBUFMZZFBSQSFWJPVTMZXIJDIDPJODJEFEXJUIBCBOEPONFOUCZ IFSMPWFSPGZFBSTBTXFMMBTUIFMPTTPGIFSKPCBTBTPDJBMXPSLFS )FSNFEJDBMIJTUPSZSFWFBMFEUIBUTIFIBECFFOBEEJDUFEUPDSBDL DPDBJOFBTXFMMBTIFSPJOJOUIFQBTU4IFBENJUUFEUPTNPLJOH DSBDLBTSFDFOUMZBTXFFLTCFGPSFUIFJOJUJBMWJTJU*OBEEJUJPO TIFXBTUBLJOHNFUIBEPOFXIJDIXBTQSFTDSJCFECZUIFIPTQJUBMTNFOUBMIFBMUIDMJOJD GPSEFQSFTTJPOXJUIBOBOUJEFQSFTTBOUCZBNFOUBMIFBMUIDMJOJD 4IF SFGVTFE UP SFUVSO UP UIF NFOUBM IFBMUI GBDJMJUZ EVF UP IFS QFSDFQUJPOPGTUJHNBPWFSNFOUBMJMMOFTT 1IZTJDBMFYBNJOBUJPOSFWFBMFENJMETDBMJOHPGUIFTDBMQDPOTJTUFOUXJUINJMETFCPSSIFJDEFSNBUJUJTTDBMJOHPGQBMNTBOETPMFT BOEEZTUSPQIJDUPFOBJMTɨFSFNBJOEFSPGUIFQIZTJDBMFYBNJOBUJPOJODMVEJOHUIFGBDFCBDLUSVOLBSNTBOEMFHTXFSFXJUIJO OPSNBMMJNJUT 3FTVMUTGSPNBMMMBCPSBUPSZUFTUTJODMVEJOHDPNQMFUFCMPPEDFMM DPVOUBOEDPNQMFUFNFUBCPMJDQBOFMXFSFXJUIJOOPSNBMMJNJUT ɨFQBUJFOUSFGVTFEUPIBWFBVSJOFUPYJDPMPHZFYBNJOBUJPO 5SFBUNFOUXBTJOJUJBUFEXJUIìVPDJOPMPOFTPMVUJPOUPUIFTDBMQ BTXFMMBTUIFIFBEBOETIPVMEFSTDJDMPQJSPYDSFBNUXJDFBEBZ UP UIF GFFU GPS UJOFB QFEJT BOE QFSNFUISJO DSFBN UP UIF CPEZ GPSJUDI 4IF IBE QSFWJPVTMZ VTFE 4BSOB MPUJPO BOE IZESPYZ[JOF NH FWFSZOJHIUBUCFEUJNFBOEIBEIFSBQBSUNFOUFYUFSNJOBUFEΉXJUI OPSFMJFG"UUIFëSTUWJTJUTIFXBTTUBSUFEPOFTDJUBMPQSBNNH FWFSZOJHIUBUCFEUJNF4IFSFGVTFEBQTZDIJBUSJDDPOTVMUBUJPO "UUIFTFDPOEGPMMPXVQWJTJUXFFLTMBUFSUIFQBUJFOUSFQPSUFE OP JNQSPWFNFOU JO TZNQUPNT BOE JG BOZUIJOH SFQPSUFE UIBU UIFiTUSJOHTwXFSFXPSTFUIBOFWFSBOEUIFQBSBTJUFTXFSFDSBXMJOHPVUPGIFSFBSTBOEPOUPIFSGBDF4IFXBTWFSZBOHSZUIBUTIF XBT QSFTDSJCFE B TFMFDUJWF TFSPUPOJO SFVQUBLF JOIJCJUPS 443* &YBNJOBUJPOSFWFBMFEOPDIBOHFDPNQBSFEXJUIUIFëSTUWJTJU ɨF QBUJFOU XBT FODPVSBHFE UP WFOUJMBUF BCPVU IFS QSPCMFNT -JEPDBJOFQSJMPDBJOFDSFBNXBTQSFTDSJCFEGPSEZTFTUIFTJBTBOE 4IFSFQPSUFEUPCFJOPUIFSXJTFHPPEIFBMUIFYQFDUGPSBOBMMFSHZ GFFMJOHTPGGPSNJDBUJPOBOETIFXBTFODPVSBHFEUPJODSFBTFUIF UPJPEJOF"GUFSUIFSFMBUJPOTIJQCSFBLVQTIFXBTCSJFìZUSFBUFE EPTFPGFTDJUBMPQSBNUPNHBUOJHIU From the Metropolitan Hospital, New York Medical College, New York, NY Address for Correspondence: Michael J. Fellner, MD, Metropolitan Hospital, New York Medical College, 50 East 89th Street, New York, /:ùt&NBJMGSFEEBHG!BPMDPN SKINmed. 2012;10:72–74 72 ª1VMTF.BSLFUJOH$PNNVOJDBUJPOT--$ March/April 2012 ORIGINAL CONTRIBUTION CASE 2 A 90-year-old woman was referred from a major medical dermatology center with a diagnosis of delusions of parasitosis. On the first visit she described worms and strings coming out of her body including the skin, eyes, and mouth. She reported the onset as September 2009 following a bout of diarrhea during the summer that lasted for 2 months. She was treated with albendazole by a noted parasitologist for trichuris infection. The diarrhea abated with the treatment. By September 2009, she had described worms and strings coming out of her body, causing her great discomfort. She first went to her primary care physician at the medical school center. He examined the material she brought and told her there were no parasites or strings but only mucous. This angered her and she refused to return to the physician. She brought a drawing of the worms and strings on her first dermatology visit (Figure 1). Examination revealed a thin elderly woman in no acute distress whose stream of thought was verbose and rambling. The skin showed a reddened and ulcerated area on the right thigh (Figure 2). The remainder of the physical examination was within normal limits. Results from laboratory tests were within normal limits. The patient was given mupirocin ointment for the ulcer and ammonium lactate 12% lotion for the skin on the body and was reassured there was some possibility that the disturbance might abate. Figure 2. The patient’s thigh lesion on first visit. On follow-up 2 weeks later, she claimed the parasites had started in June 2009, contradicting her previous statement that they had started in September 2009. She now claimed slight improvement with the treatment. There were, however, new lesions on the right thigh (Figure 3). Once again she was unclear about Figure 3. The patient’s thigh lesions on second visit. whether these resulted from the parasites. She indicated that the strings and worms were coming out of her ears, eyes, nose, and skin on the face. Figure 1. The patient’s drawing of string and parasite coming out of her skin. SKINmed. 2012;10:72–74 She was encouraged to take doxepin 25 mg at night and continue with ammonium lactate 12% lotion and mupirocin ointment. She was also encouraged to ventilate about her multiple social problems, including her family, her will, and her eating problems. She said she weighed 87 pounds because she was unable to eat any carbohydrates since she believed the parasites lived on sugars. She said she was in the process of getting assistance in daily-living activities at home. 73 Delusions of Parasitosis March/April 2012 ORIGINAL CONTRIBUTION On third follow-up, she said she felt considerably better (2 weeks after second visit) using emollients. She did not mention parasites, but said the problem was improving. She was encouraged to seek psychologic or psychiatric counseling but was not accepting of this suggestion. She said she was going to make an appointment for a visit at a nearby medical center geriatric unit to help her with nutrition and memory problems. She was encouraged to take doxepin at bedtime and to use emollients. DISCUSSION These cases are the first to exhibit findings of Morgellons disease and delusions of parasitosis at the same time. Morgellons is a pattern of dermatologic symptoms very similar, if not identical, to those of delusions of parasitosis, and many patients with Morgellons are diagnosed with another psychosomatic illness.2 In delusional parasitosis, patients hold a delusional belief that they are infested with parasites. They may experience formication, the sensation that insects are crawling under the skin. It is a common symptom in cocaine abusers as well. Individuals who experience this condition may develop elaborate rituals of inspection and cleansing to locate and remove parasites and fibers, resulting in a form of self-mutilation; they injure themselves in attempts to be rid of the “parasites” by picking at the skin, causing secondary lesions. Continuous picking of the lesions prevents healing. Patients with delusional parasitosis often present at the doctor’s office with what physician’s term the matchbox sign, a medical sign characterized by the patient making collections of fibers and other foreign objects supposedly retrieved from the skin, and, because of “unshakeable delusional ideation,” strongly reject diagnoses that do not involve parasites. The Morgellons Research Foundation, a nonprofit organization, considers Morgellons to be a newly emerging infectious disease, but the medical community disagrees, noting that the described symptoms of Morgellons are associated with the psychotic disorder known as delusional parasitosis.2 Due to the second patient’s age, it was deemed inappropriate to give pimozide or treatment with an SSRI medication since sudden death in the elderly has been reported.3 The treatment plan was to gain the patient’s confidence before attempting to refer her for psychologic or psychiatric care, since there did not appear to be any insight on her part at the first 2 visits. Therapy is often unsuccessful because many patients, such as those reported here, refuse consultation with a psychiatrist either because they believe the problem is organic or because they fear mental illness and the stigma of psychiatry. In extremely severe cases, suicide has been reported, illustrating the urgency of corrective medication and prompt psychiatric referral.4 Standard treatment with pimozide risks substantial side effects.3 This has led to trial with additional psychotropic agents. Recent success has been reported with the use of risperdal5 and olanzapine.6 Nowhere have these diseases been more graphically illustrated than in the Oscar-nominated 2010 film “Black Swan” wherein the heroine played by Natalie Portman suffers from the delusion that parasites and strings are coming out of her skin. This is a must-see film for dermatologists and psychiatrists alike. REFERENCES 1 Fellner MJ, Majeed MH. Tales of bugs, delusions of parasitosis, and what to do. Clin Dermatol. 2009;27:135–138. 2 Savely VR, Leitao MM, Stricker RB. The mystery of Morgellon’s disease: infection or delusion? Am J Clin Dermatol. 2006;7:1–5. 3 van Vloten WA. Pimozide use in dermatology. Dermatol Online J. 2003;9:3. 4 Monk BE, Rao YJ. Delusions of parasitosis with fatal outcome. Clin Exp Dermatol. 1994;19:341–342. 5 Friedmann AC, Ekeowa-Anderson A, Taylor R, Bewley A. Delusional parasitosis presenting as folie a trois: successful treatment with risperidone. Br J Dermatol. 2006;155:841–842. 6 Atilganoglu U, Ugurad I, Arikan M, Ergun SS. Monosymptomatic hypochondriacal psychosis presenting with recurrent oral mucosal ulcers and multiple skin lesions responding to olanzapine treatment. Int J Dermatol. 2006;45:1189–1192. VINTAGE LABEL Courtesy of BuyEnlarge, Philadelphia, PA SKINmed. 2012;10:72–74 74 Delusions of Parasitosis 7PMVNFt*TTVF March/April 2012 REVIEW Wound Care in Short-Term Rehabilitation Facilities and Long-Term Care: Special Needs for a Special Population E. Foy White-Chu, MD; Madhuri Reddy, MD, MSc ABSTRACT $ISPOJDXPVOETDBOQPTFBDIBMMFOHJOHEJBHOPTUJDBOEUSFBUNFOUEJMFNNBJOUIFPMEFSGSBJMBEVMUQPQVMBUJPOɨFCFOFëUTPGTIPSUUFSN SFIBCJMJUBUJPO BOE MPOHUFSN DBSF TFUUJOHT BSF UIF BDDFTT UP JOUFSEJTDJQMJOBSZ SFTPVSDFT 3FIBCJMJUBUJWF TQFDJBMJTUT EJFUJDJBOT BOE TLJMMFE OVSTFTBSFSFBEJMZBWBJMBCMFUPNFFUUIFQBUJFOUTOFFETBTUIFZUSBOTJUJPOUPIPNFPSSFNBJOJOBMPOHUFSNDBSFTFUUJOHGPSUIFJSIJHIFSMFWFM PGDBSFOFFETɨJTBSUJDMFGPMMPXTDBTFTBTLJOUFBSDPNQMJDBUFECZWFOPVTVMDFSBUJPOBQSFTTVSFVMDFSXJUIGFWFSBOEBSUFSJBMVMDFSTJOB QBUJFOUXIPPQUTGPSDPNGPSUDBSFɨFDBTFTJMMVTUSBUFUIFIJHIFSOFFETPGUIJTQPQVMBUJPOBOEFNQIBTJ[FUIFBUUFOUJPOUIBUNVTUCFQBJE UPSFTQFDUOVSTJOHUJNFJOUFOTJWFOFTTJODPSQPSBUFSFBMJTUJDHPBMTPGDBSFGPSXPVOEIFBMJOHBOEFOTVSFFYDFMMFOUDPNNVOJDBUJPOXJUIUIF UFBNNFNCFSTQBUJFOUTBOEGBNJMZSKINmed. o $ ISPOJD XPVOET DBO QPTF B DIBMMFOHJOH EJBHOPTUJD BOE USFBUNFOUEJMFNNBJOUIFGSBJMPMEFSBEVMUQPQVMBUJPO "T UIF CPEZ BHFT XPVOE IFBMJOH TMPXT BT B SFTVMU PG UIFOBUVSBMBHJOHQSPDFTTBOETFRVFMBFGSPNDISPOJDVOEFSMZJOH EJTFBTFT1SFTTVSFVMDFSTJOQBSUJDVMBSDBOMFOHUIFOIPTQJUBMTUBZ BOEMFBEUPQSFNBUVSFNPSUBMJUZ125PPQUJNJ[FBOPMEFSQBUJFOUT QPUFOUJBMUPSFUVSOUPIPNFUIFZBSFPGUFOEJTDIBSHFEUPBTIPSU UFSNSFIBCJMJUBUJWFDFOUFSɨ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ɨFXPVOEDBSFUFBNXBTBTLFEUPFYBNJOFBOZFBSPMEXPNBO GPSBTLJOUFBSUIBUXBTTMPXUPIFBMɨFTLJOUFBSPDDVSSFEXJUI BMFHTDSBUDIXIJMFEPOOJOHDPNQSFTTJPOTUPDLJOHTɨFXPVOE CFDBNFJOGFDUFEMFBEJOHUPIFSIPTQJUBMJ[BUJPOBOETVCTFRVFOU TIPSUUFSNSFIBCJMJUBUJWFTUBZ)FSXPVOEJOGFDUJPOSFTPMWFECVU UIFXPVOESFNBJOFE4IFSFQPSUFEBTJHOJëDBOUNFEJDBMIJTUPSZ PGDISPOJDNZFMPNPOPDZUJDMFVLFNJBBOENZFMPEZTQMBTUJDEJTPS EFSGPSXIJDITIFUPPLIZESPYZVSFBBOEQSFEOJTPOF)FSFYBN JOBUJPO SFWFBMFE WFOPVT TUBTJT DIBOHFT QJUUJOH FEFNB BOE QBMQBCMFQVMTFTCJMBUFSBMMZ)FSXPVOEXBTUFOEFSUPBOZUPVDI "MJEPDBJOFQSJMPDBJOFNJYUVSFDSFBNXBTBQQMJFEXJUIBOPDDMV TJWFESFTTJOHIPVSQSJPSUPCFETJEFEFCSJEFNFOU4IFUPMFSBUFE UIFEFCSJEFNFOUXFMMBOEUIFSFTVMUTBSFTFFOJO'JHVSF"MPDBM ESFTTJOHPGBUIJOëMNPGTJMWFSTVMGBEJB[JOFXJUIBOPOBEIFSFOU GPBNESFTTJOHXBTBQQMJFEUPUIFXPVOEɨFMFHXBTXSBQQFE XJUIBNVMUJMBZFSDPNQSFTTJPOXSBQQJOH'JHVSF ɨFQBUJFOU BOEOVSTJOHTUBêXFSFFEVDBUFEPOQSPQFSXSBQQJOHUFDIOJRVF ɨFQIZTJDBMUIFSBQZUFBNDPPSEJOBUFEBOJOUFOTFXBMLJOHQSP HSBNXJUIUIFQBUJFOUXIJMFUIFEJFUJDJBOPQUJNJ[FEIFSOVUSJ UJPO8PVOEIFBMJOHFYQFDUBUJPOTXFSFQSFTFOUFEUPUIFQBUJFOU FYQMBJOJOHUIBUIFSIFNBUPMPHJDEJTFBTFTBOEOFFEGPSJNNVOP TVQQSFTTJWFNFEJDBUJPOTXJMMTMPXXPVOEIFBMJOHCVUUIBUUIF XPVOEEJEIBWFUIFQPUFOUJBMUPIFBM From the Wound Healing Center, Hebrew Senior Life Department of Medicine, Boston, MA Address for Correspondence: E. Foy White-Chu, MD, Director of Wound Healing Center, Hebrew Senior Life Department of Medicine, 1200 $FOUSF4USFFU#PTUPO."t&NBJMGPZXIJUFDIV!ISDBIBSWBSEFEV SKINmed. 2012;10:75–81 75 ª1VMTF.BSLFUJOH$PNNVOJDBUJPOT--$ 3&7*&8 March/April 2012 OPUDBVTFQSFTTVSFVMDFSTɨFJOUFSWFOUJPOUPQSPNPUFIFBMJOHJO BTLJOUFBSJOUIJTMPDBUJPOJTEJêFSFOUGSPNUIFBQQSPBDIGPSQSFT TVSFVMDFST%VFUPUIFIJHIMJUJHJPVTGBDUPSTVSSPVOEJOHQSFTTVSF VMDFSTJOMPOHUFSNDBSFTFUUJOHTJUJTJNQPSUBOUUIBUUIFDMJOJDJBO EPDVNFOUDMFBSMZXIFUIFSBXPVOEJTBQSFTTVSFVMDFSPSOPU ɨ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igure 1. Venous ulcer status post-debridement. Photo courtesy of E. Foy White-Chu, MD. $PNQSFTTJPO JT UIF NPTU JNQPSUBOU BTQFDU GPS UIF QSFWFOUJPO BOE USFBUNFOU PG WFOPVT MFH VMDFST10 0êFSJOH WBSJPVT MFWFMT PGDPNQSFTTJPOCBTFEPOUIFQBUJFOUTUPMFSBODFTBOEDPFYJTUJOH QFSJQIFSBMBSUFSJBMEJTFBTFJTSFDPNNFOEFE$PNQSFTTJPODBOCF TBGFMZBQQMJFEBTMPOHBTUIFSFJTOPUTJHOJëDBOUBSUFSJBMEJTFBTF BOEUIFQBUJFOUEPFTOPUIBWFVODPNQFOTBUFEDPOHFTUJWFIFBSU GBJMVSF " HSFBUFS OVNCFS PG MBZFST BMMPX GPS UJHIUFS DPNQSFT TJPO BOE UJHIUFS DPNQSFTTJPO MFBET UP BO JODSFBTFE MJLFMJIPPE PG WFOPVT VMDFS IFBMJOH -PXFS DPNQSFTTJPO NBZ CF JOEJDBUFE Figure 2. Proper wrapping technique on the right leg. Note the inclusion of the heel from toes to knee. Photo courtesy of E. Foy White-Chu, MD. SKIN TEARS ɨF HSFBUFTU OVNCFS PG TLJO UFBST JO PMEFS BEVMUT PDDVS JO UIF QBUJFOUTCFESPPNBOEUIFNPTUDPNNPOPCKFDUTUPDBVTFTLJO UFBSTBSFXIFFMDIBJSTGPMMPXFECZCFESBJMTBOEHFSJBUSJDSFDMJOFST .PCJMFQBUJFOUTUFOEUPIBWFUFBSTPOUIFMFHTXIJMFOPONPCJMF QBUJFOUT IBWF TLJO UFBST PO UIF FMCPXT BSNT BOE MFHT 8IFO QBUJFOUTBSFJNNPCJMFUSBOTGFSTBOESFQPTJUJPOJOHQMBZHSFBUFS SPMFT JO DBVTJOH TLJO UFBST ɨF MPXFS CBDL BOE TBDSBM BSFB BSF FTQFDJBMMZBUSJTLPGTLJOUFBSTDBVTFECZTIFBSJOHGSPNUSBOTGFST 3JTLGBDUPSTGPSTLJOUFBSTJODMVEFJODSFBTFEBHFVTFPGBOBTTJTU EFWJDFDPHOJUJWFJNQBJSNFOUBOETFOTPSZJNQBJSNFOU5–74LJO UFBSTPGUFODBOCFNJTUBLFOGPSTUBHF**QSFTTVSFVMDFSTFTQFDJBMMZ JGUIFZPDDVSPOUIFCBDLBOECVUUPDLTIPXFWFSTLJOUFBSTEP SKINmed. 2012;10:75–81 76 Table I. Prevention of Skin Tears DO DON ’ T "EWJTFNPJTUVSJ[FST 8FBSWFSZUJHIUDMPUIJOH 3FWJFXNFEJDBUJPOMJTUUP NJOJNJ[FGBMMT 'PSHFUUPDIFDLGSJDUJPOQSPOF BSFBTJODIBJSCFECPVOEQBUJFOU FHPDDJQVUFMCPXTLOFFTBOE IFFMT 6TFQBQFSUBQFPSTPGUTJMJDPOF GPSXPVOET 6TFSFHVMBSUBQFGPSPDDMVTJWF ESFTTJOHT $POTJEFSTIJOQBETQBEEJOH GVSOJUVSF )FTJUBUFUPGPSNBOJOUFSEJTDJ QMJOBSZDBSFQMBOXJUIOVSTJOH TUBêPOUSBOTGFST 8PVOE$BSFJOB4QFDJBM1PQVMBUJPO 3&7*&8 March/April 2012 CFDBVTFPGQBUJFOUQSFGFSFODFFTQFDJBMMZXJUIPMEFSBEVMUT4PNF GPSFEFNBNBOBHFNFOUXJUIPVUEFDPNQSFTTJPOPGUIFMFHXJUI DPNQSFTTJPOJTCFUUFSUIBOOPOFBUBMM1314 GSFRVFOUVOXSBQQJOH$POTJEFSJOHIPXOVSTJOHJOUFOTJWFUIFTF XSBQQJOHT DBO CF DIBOHJOH FWFSZ EBZT MPXFST UIF OVSTJOH 'PS QBUJFOUT XIP IBWF TPNF QFSJQIFSBM BSUFSJBM EJTFBTF CVU CVSEFOBOEFOTVSFTCFUUFSXSBQQJOHUFDIOJRVF'PSIJHIMZFYV TJHOJëDBOUFEFNBUIFFEFNBNBZDBVTFGVSUIFSDPNQSPNJTFPG EBUJOHXPVOETBOJODPOUJOFODFHBSNFOUDBOCFVTFEPWFSUIF BSUFSJBMìPXɨFTFQBUJFOUTTUJMMCFOFëUGSPNTPNFGPSNPGDPN XPVOEQSPEVDUGPMMPXFECZUIFDPNQSFTTJPOXSBQQJOHɨFTF QSFTTJPO15 "TTFTT UIF QBUJFOUT BSUFSJBM ìPX CZ QBMQBUJOH QFEBM ESFTTJOHTBSFDIBOHFEEBJMZVOUJMUIFESBJOBHFIBTEFDSFBTFEUP QVMTFT*GOPQVMTFTBSFQBMQBUFECVUUIFSFJTTJHOJëDBOUFEFNB XIFSFJUDBOCFDIBOHFEMFTTGSFRVFOUMZ"$PDISBOFSFWJFXPG JOUIFGFFUUIFOBUUFNQUNJMEDPNQSFTTJPOXJUIBDPNQSFTTJPO ESFTTJOHTGPSWFOPVTMFHVMDFSTGPVOEUIBUUIFSFXBTJOBEFRVBUF stockingJFFMBTUJDBUFEUVCVMBSCBOEBHF SBUIFSUIBOXSBQQJOH EBUB UP TVQQPSU POF GPSN PG ESFTTJOH PWFS BOPUIFS UIFSFGPSF ɨSPNCPFNCPMJD TUPDLJOHT BSF VTFE POMZ GPS CFEGBTU QBUJFOUT UIFZSFDPNNFOEFEDIPPTJOHBESFTTJOHCBTFEPOMPDBMDPTUTBOE 16 BOEBSFOPUDPOTJEFSFEBGPSNPGDPNQSFTTJPOTUPDLJOHT $PPS QSPWJEFSPSQBUJFOUQSFGFSFODFT17ɨFDIBMMFOHFTBOEUSFBUNFOUT EJOBUFXJUIOVSTFTUPGPMMPXQBJOMFWFMTBOEEJTDPMPSBUJPOPGUIF PGWFOPVTVMDFSTBSFNFOUJPOFEJO5BCMF** UPFTBOEUPSFNPWFUIFTUPDLJOHJGBOZDPNQMJDBUJPOTBSJTF 'PSQBUJFOUTXIPIBWFQBMQBCMFQVMTFTPêFSFMBTUJDDPNQSFTTJPO XSBQQJOHɨJTJTNBEFVQPGUPMBZFSTPGDPNQSFTTJPOXSBQ QJOHDPUUPOBCTPSCFOU HBV[F MBZFS GPMMPXFE CZ BO FMBTUJD XSBQ GPMMPXFE CZ BO FMBTUJD TFMGBEIFSFOU CBOEBHF &BDI MBZFS JTMBJEEPXOBUTUSFUDIXJUIPWFSMBQ*GUIFQBUJFOUT BOLMF JT DN JO DJSDVNGFSFODF PS JG UIF QBUJFOU ëOET UIF MBZFSTUPCFVODPNGPSUBCMFPNJUUIFTFDPOEMBZFS$BSFNVTU CFUBLFOUPOPUPWFSTUSFUDIFBDIMBZFSBTUIJTDBODBVTFOFXBSFBT PGCSFBLEPXO*GCBMMPPOJOHPGUIFGPPUPDDVSTUIJTJTCFDBVTFPG UPPNVDIDPNQSFTTJPOBUUIFBOLMF"WPJEUIFVTFPGBOPOFMBTUJD TZTUFNFH6OOBCPPU CFDBVTFUIJTJTBGPSNPGTVQQPSUUIBU FYFSUTIJHIQSFTTVSFXJUIXBMLJOHPOMZ17.BOZQBUJFOUTXIPBSF FJUIFSKVTUPVUPGUIFIPTQJUBMPSMJWFJOMPOHUFSNDBSFBSFOPU BNCVMBUPSZBOEUIVTXPVMEOPUCFOFëUGSPNBOPOFMBTUJDTZT UFNGPSFEFNBNBOBHFNFOU 5PEFUFSNJOFUIFWBTDVMBSJUZPGUIFGPPUXPVOEJOPSEFSUPEFUFS NJOFUIFXPVOETBCJMJUZUPIFBMDPOTJEFSDPMMBCPSBUJPOXJUIB WBTDVMBS TVSHFPO XIP EPFT UPF QIPUPQMFUIZTNPHSBQIZ "OLMF CSBDIJBMJOEJDFT"#*T NBZOPUCFTQFDJëDJOPMEFSQBUJFOUTPS QBUJFOUT XJUI EJBCFUFT CFDBVTF PG WFTTFM DBMDJëDBUJPO BOE OPO DPNQSFTTJCMF WFTTFMT JF UIFZ NBZ PWFSFTUJNBUF UIF BNPVOU PG CMPPE ì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ɨJTBMMPXT SKINmed. 2012;10:75–81 77 CASE 2: STAGE IV PRESSURE ULCER AND FEVER ɨF XPVOE DBSF UFBN XBT BTLFE UP TFF B ZFBSPME XPNBO SFHBSEJOHBTUBHF*7QSFTTVSFVMDFSBOEGFWFS4IFIBEBTJHOJë DBOUNFEJDBMIJTUPSZPGEJBCFUFTNFMMJUVTBOEFOETUBHFSFOBMEJT FBTFPOIFNPEJBMZTJT ɨFXPVOEEFWFMPQFEBUIPNFXIFOTIF SFGVTFEUPQBSUJDJQBUFJOSFIBCJMJUBUJWFUIFSBQZBGUFSIFSGFNPSBM GSBDUVSFXIJDIPDDVSSFEBUMFBTUNPOUITQSJPSUPIFSBENJTTJPO UPUIFTIPSUUFSNSFIBCJMJUBUJWFGBDJMJUZɨFQBUJFOUXBTOPUBEIFS FOU UP IFS SFIBCJMJUBUJWF SFHJNFO TUBUJOH TIF XBT UPP UJSFE5P BEESFTTUIJTIFSTFEBUJOHNFEJDBUJPOTXFSFSFEVDFECZUIFHFSJ BUSJDJBOBOEIFSEJBMZTJTSFHJNFOXBTPQUJNJ[FECZUIFOFQISPMP HJTUUPDVSUBJMMPXCMPPEQSFTTVSFT4IFDPOUJOVFEOPUUPFOHBHFJO UIFSBQZBOEUIFQBUJFOUJOTJTUFEPOTJUUJOHVQJOCFEPSJOBDIBJS Table II. Venous Ulcer Challenges and Treatments PROBLEM APPROACH &EFNB $PNQSFTTJPOCBOEBHJOHBTNVDIBTQBUJFOU DBOUPMFSBUFPSJTNFEJDBMMZBDDFQUBCMF VOUJMBOE GPSXFFLTBGUFSXPVOEIBTDPNQMFUFMZIFBMFE UIFOMJGFMPOHDPNQSFTTJPOTUPDLJOHT.FEJDBM DPOUSBJOEJDBUJPOTUPDPNQSFTTJPOJODMVEF TFWFSFQFSJQIFSBMBSUFSJBMEJTFBTFBOEVOTUBCMF DPOHFTUJWFIFBSUGBJMVSF *NQBJSFEDBMG NVTDMFQVNQ GVODUJPO 8BMLJOHSBOHFPGNPUJPOFYFSDJTFTGPSUIFBOLMF 1BJO "TOFFEFEBDFUBNJOPQIFOPSMPXEPTFPQJPJET NBZCFOFDFTTBSZUPGBDJMJUBUFQBUJFOUTBCJMJUZUP FYFSDJTFBOEPSUPMFSBUFDPNQSFTTJPO*OBDVUF MJQPEFSNBUPTDMFSPTJTOPOTUFSPJEBMBOUJJOìBN NBUPSJFTNBZCFIFMQGVMTIPSUUFSN %POOJOH DPNQSFTTJPO TUPDLJOHTBGUFS IFBMJOH 6UJMJ[FTUPDLJOHBJEFT$POTJEFSDVTUPN TUPDLJOHTXJUI[JQQFSTPS7FMDSPBMUIPVHI NPSFFYQFOTJWFUIFZXJMMCFFBTJFSUPBQQMZ 8PVOE$BSFJOB4QFDJBM1PQVMBUJPO 3&7*&8 March/April 2012 GPSNPTUPGUIFEBZ1FSTUBOEBSEPGDBSFBUUIJTGBDJMJUZTIFIBEB TQFDJBMJ[FEXIFFMDIBJSDVTIJPOBOEQPXFSFENBUUSFTTQVUJOQMBDF BMPOHXJUIGSJDUJPOSFEVDJOHEFWJDFTGPSUSBOTGFSTJOIFSCFE ɨFJOJUJBMTUBUFPGUIJTJODSFBTJOHMZQBJOGVMXPVOEJTQJDUVSFEJO 'JHVSFɨFSFXBTBGPVMPEPSQSFTFOUBOEUIFHSBOVMBUJPOUJTTVF XBTGSJBCMFBOECMFEFBTJMZ*OUSBWFOPVTBOUJCJPUJDTXFSFTUBSUFE TJODF NPTU MJLFMZ UIF GFWFS XBT DBVTFE CZ UIJT XPVOE #FDBVTF UIFXPVOEDPVMEOPUCFBEFRVBUFMZPðPBEFEBTBSFTVMUPGUIF QBUJFOUTOPOBEIFSFODFUPSFIBCJMJUBUJWFUIFSBQJFTUIFXPVOEXBT UFNQPSBSJMZUSFBUFEBTBXPVOEXJUIPVUUIFQPUFOUJBMUPIFBMɨF XPVOEXBTQBDLFEXJUIQPWJEPOFJPEJOFoTPBLFEHBV[FUISPVHI PVUUIFXPVOE.JSSPSTXFSFTFUVQJOUIFQBUJFOUTSPPNTPTIF DPVMETFFUIFXPVOEEVSJOHPVSFYBNJOBUJPO*UXBTTIPSUMZBGUFS UIJTJOUFSWFOUJPOUIBUUIFQBUJFOUCFHBOUPBDUJWFMZQBSUJDJQBUFJO SFIBCJMJUBUJWFUIFSBQJFT)FSQMBTUJDTVSHFPOXBTDPOUBDUFEGPSGVS UIFSPQFSBUJWFEFCSJEFNFOUPGUIFXPVOECFDBVTFIFSCMPPEDVM UVSFTDPOUJOVFEUPEFNPOTUSBUFCBDUFSFNJB0ODFTIFSFUVSOFEUP UIFTIPSUUFSNSFIBCJMJUBUJWFVOJUUIFQBUJFOUTXPVOEDBSFPSEFST XFSFDIBOHFEUPSFìFDUBXPVOEUIBUIBEUIFQPUFOUJBMUPIFBM BOENPJTUXPVOEIFBMJOHXBTJNQMFNFOUFEɨFQBUJFOUFOHBHFE JO UIFSBQZ BOE NBJOUBJOFE HPPE EJBCFUJD OVUSJUJPO VOEFS UIF HVJEBODF PG B EJFUJDJBO ɨF QBUJFOU XBT FWFOUVBMMZ EJTDIBSHFE UPBOPUIFSGBDJMJUZQSJPSUPIFSUSBOTJUJPOUPIPNFɨFQBUJFOU XBT GPMMPXFE CZ UIF XPVOE DBSF UFBN JO UIF PVUQBUJFOU DMJOJD BOENPOUITBGUFSJOJUJBMDPOTVMUBUJPOUIFXPVOEDPOUJOVFEUP JNQSPWFBTTIPXOJO'JHVSFΉɨJTQBUJFOUTXPVOEFWFOUVBMMZ IFBMFEFOUJSFMZXJUIPVUBOZOFFEGPSTVSHJDBMSFQBJS Figure 4. Healing stage IV pressure ulcer. Photo courtesy of E. Foy White-Chu, MD. GPSUSFBUNFOUPGQSFTTVSFVMDFSTUIBUIBWFEFWFMPQFEJOIPVTFɨ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ɨFZ DBO BMTP PDDVS BOZXIFSFUIBUTLJOJTEBNBHFECZFYDFTTJWFQSFTTVSFGSJDUJPOPS TIFBS PS FYDFTT NPJTUVSF24 ɨJT JT JMMVTUSBUFE CZ UIF TUSJBUJPOT GSPNUIFOFHBUJWFQSFTTVSFEFWJDFUVCJOHPOUIFQPTUFSJPSUIJHIT BT TFFO JO 'JHVSF 3JTL GBDUPST BSF OVNFSPVT CVU QSJNBSJMZ JODMVEFJNNPCJMJUZ.BMOVUSJUJPOBMTPQMBZTBOJNQPSUBOUSPMF22 %FUFSNJOJOHUIFFYBDUDBVTFPGUIFQSFTTVSFVMDFSJTFTTFOUJBMUP FOIBODFIFBMJOH2425 $POëSN XJUI UIF GBDJMJUZ XIFUIFS UIFZ VTF B OPOQPXFSFE TQFDJBMJ[FE NBUUSFTT 'PS QSFTTVSF VMDFST UIBU BSF JO TUBHF *** PS *7 B QPXFSFE PWFSMBZ PS NBUUSFTT NBZ CF PSEFSFE 3FIBCJMJUBUJWFUIFSBQJTUTDBOFWBMVBUFXIFFMDIBJSTBOEDVTIJPOT FWFSZ ZFBST GPS QBUJFOUT XIP BSF QSJNBSJMZ XIFFMDIBJS VTFST "OZ TLJO CSFBLEPXO UIBU DBO CF BUUSJCVUFE UP TJUUJOH TIPVME BMTPQSPNQUBOFWBMVBUJPOPGUIFDIBJSBOEDVTIJPO4QFDJBMJ[FE XIFFMDIBJSDVTIJPOTHFMHFMGPBNPSBJSëMMFEDBOCFJNQMF NFOUFE BGUFS UIF UIFSBQJTU IBT FWBMVBUFE UIF XIFFMDIBJS 4USJDU Figure 3. 4UBHF*7QSFTTVSFVMDFS/PUFUIBUUIFOFHBUJWFQSFTTVSFEFWJDFUVCJOHDBVTFEQSFTTVSFNBSLTPOUIFUIJHI1IPUP courtesy of E. Foy White-Chu, MD. SKINmed. 2012;10:75–81 78 8PVOE$BSFJOB4QFDJBM1PQVMBUJPO 3&7*&8 March/April 2012 CFE SFTU JT OPU SFDPNNFOEFE BT UIJT NBZ MFBE UP XPSTFOJOH GBJMVSFUPUISJWFEFQSFTTJPOEFDPOEJUJPOJOHQOFVNPOJBEFFQ WFOPVTUISPNCPTJTBOENPSFQSFTTVSFVMDFST2627ɨFTFSFDPN NFOEBUJPOTSFHBSEJOHCFESFTUQPXFSFEEFWJDFTBOETQFDJBMJ[FE XIFFMDIBJS DVTIJPOT BSF CBTFE PO UIF /BUJPOBM BOE &VSPQFBO 1SFTTVSF 6MDFS "EWJTPSZ 1BOFM (VJEFMJOFT28 ɨF FWJEFODF BT SFWJFXFECZUIFQBOFMBOEBMTPJOSFDFOUTZTUFNBUJDSFWJFXTEJE OPUëOEUIBUQPXFSFENBUUSFTTFTXFSFTVQFSJPSUPOPOQPXFSFE NBUUSFTTFT FJUIFS GPS QSFWFOUJPO PS USFBUNFOU30 3BUIFS UIF HVJEFMJOFT XFSF CBTFE PO FYQFSU PQJOJPO 4VQQPSU TVSGBDFT BSF JNQPSUBOUGPSPðPBEJOHPGQSFTTVSFCVUUIFZEPOPUBEESFTTUIF PUIFSVMDFSDBVTFTTVDIBTGSJDUJPOTIFBSBOENPJTUVSF*OTIPSU OPUIJOHDBOSFQMBDFHPPEQFSTPOBMBUUFOEBOUDBSFXJUIGSFRVFOU UVSOJOHJODPOUJOFODFDBSFBOEMJGUJOHBOEUSBOTGFSTUIBUNJOJ NJ[FGSJDUJPOBOETIFBS TUVEJFTSFWFBMFETFWFSFMPXFSFYUSFNJUZBSUFSJBMEJTFBTFUIBUNBZ POMZCFBNFOBCMFUPBCZQBTTQSPDFEVSF#PUIUIFQBUJFOUBOE IFSGBNJMZEFDMJOFETVSHFSZBHBJOPQUJOHGPSDPNGPSUDBSFBOE UIFQBUJFOUSFUVSOFEUPUIFMPOHUFSNDBSFGBDJMJUZXJUIBQBMMJB UJWFDBSFDPOTVMUBUJPO .PEBMJUJFT UP IFMQ UIF QBJO JODMVEJOH PSBM PQJBUFT OJUSPHMZD FSJO QBUDI PO UIF EPSTVN PG IFS GPPU BOE BMMPXJOH IFS UP IBOH IFS MFHT EFQFOEFOUMZ XFSF BMM PêFSFE UP UIF QBUJFOU 4IF EFWFMPQFE B DPDDZY QSFTTVSF VMDFS GSPN UIF QSPMPOHFE TJUUJOH EFTQJUFBTQFDJBMJ[FEDVTIJPOBOEXIFFMDIBJSUPPðPBEUIFBSFB ɨFQBUJFOUTGBNJMZXBTJOGPSNFEPGUIFTLJOCSFBLEPXOUIFZ SFRVFTUFEUPGPMMPXUIFQBUJFOUTXJTIFTUPTUBZTJUUJOHGPSNPTUPG UIFEBZBTBQBJOSFMJFGNPEBMJUZBOEBMTPRVBMJUZPGMJGFFOIBODFS "TUIFQBUJFOUTQBJOXPSTFOFEXJUIQSPHSFTTJPOPGUIFQFSJQIFSBM BSUFSJBMEJTFBTFJODMVEJOHQBJOXJUIBOZQBTTJWFNPWFNFOUGPS .PJTUXPVOEIFBMJOHJTXJEFMZFNQMPZFEJOVMDFSNBOBHFNFOU IZHJFOFTPEJEIFSXPVOET'JHVSF ɨFQBMMJBUJWFDBSFUFBN IPXFWFSJOTPNFDMJOJDBMTJUVBUJPOTNPJTUXPVOEIFBMJOHNBZ BEWJTFE JODSFBTJOH QBJO BOE BOYJFUZ NFEJDBUJPOT BOE UP UJNF JODSFBTF CBDUFSJBM CVSEFO BOE JOGFDUJPO SJTLT24253132 *O UIFTF UIFTFXJUIIZHJFOFDBSFɨFQBUJFOUEJFEXJUIJONPOUIPGUIF TJUVBUJPOTBOUJTFQUJDTNBZCFOFDFTTBSZUPQSFWFOUXPVOEXPST JOJUJBMDPOTVMUBUJPO FOJOH1PWJEPOFJPEJOFJTBWFSZCSPBETQFDUSVNBOUJNJDSPCJBM XJUI JO WJUSP BDUJWJUZ BHBJOTU HSBNQPTJUJWF BOE HSBNOFHBUJWF PALLIATIVE WOUND CARE CBDUFSJB JODMVEJOH NFUIJDJMMJOSFTJTUBOU Staphylococcus aureus %VFUPUIFGSBJMUZPGPMEFSQBUJFOUTTPNFNBZPQUUPOPUIBWF GVOHJ BOE QSPUP[PB33–35 #FDBVTF BOUJTFQUJDT IBWF GBMMFO PVU PG BHHSFTTJWFNFBTVSFTɨFJSFYQFSJFODFTXJUISFQFBUFEIPTQJUBMJ[B GBWPS CZ NBOZ XPVOE QSBDUJUJPOFST BOE IBWF CFFO QSPIJCJUFE UJPOTBOEJOUFSWFOUJPOTQSPWFUPCFUSBVNBUJDBOEUIFQBUJFOUT BMUPHFUIFS JO TPNF GBDJMJUJFT JU JT JNQPSUBOU UP EPDVNFOU UIF NBZëOEUIFNTFMWFTXPSTFPêBGUFSBIPTQJUBMJ[BUJPO"TQBSUPG QPUFOUJBMIFBMBCJMJUZPGUIFXPVOE*GBXPVOEEPFTOPUIBWFUIF UIFQSPWJEFSTBTTFTTNFOUUIFHPBMTPGDBSFTIPVMECFBEESFTTFE QPUFOUJBM UP IFBM UIFO UIJT TIPVME CF DMFBSMZ TUBUFE JODMVEJOH XJUI UIF QBUJFOU BOEPS GBNJMZ ɨF QSPWJEFS TIPVME EJTDVTT UIFSFBTPOTGPSQPPSIFBMBCJMJUZɨJTEPDVNFOUBUJPOXJMMTVQQPSU BOEEPDVNFOUUIFQPUFOUJBMIFBMBCJMJUZPGBXPVOEBOEXIBU UIFVTFPGBOBOUJTFQUJDBOEXJMMBMMPXUIFGBDJMJUZUPVUJMJ[FUIF NFBTVSFTNVTUCFUBLFOUPJODSFBTFIFBMBCJMJUZ BOUJTFQUJDXJUIPVUHFUUJOHDJUFECZTUBUFTVSWFZPST 1BJONBOBHFNFOUGPSBSUFSJBMVMDFSTJTDIBMMFOHJOH"QBMMJBUJWF DBSFTQFDJBMJTUDBOGBDJMJUBUFDPNNVOJDBUJPOXJUIUIFGBNJMZPO CASE 3: TOE ULCERS AND REFRACTORY PAIN "ZFBSPMEXPNBOXJUIBTJHOJëDBOUNFEJDBMIJTUPSZPGMZNQI FEFNBDPSPOBSZBSUFSZEJTFBTFBOEBUSJBMëCSJMMBUJPOXIPIBEMJWFE BUUIFMPOHUFSNDBSFGBDJMJUZGPSZFBSTXBTTFFOGPSQSFTTVSFVMDFST POIFSIFFMTɨFQBUJFOUSFQPSUFETJHOJë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ɨF XPVOE DBSF UFBN DPOUBDUFE UIF WBTDVMBS TVSHFPO QSJPS UP IPTQJUBMSFGFSSBMUPDMBSJGZUIFQBUJFOUTHPBMTPGDBSFBOEPCKFD UJWFTPGJOUFSWFOUJPOJGBOZUPIFMQXJUIUIFQBJO/POJOWBTJWF SKINmed. 2012;10:75–81 Figure 5: Worsening arterial ulcers. Photo courtesy of E. Foy White-Chu, MD. 8PVOE$BSFJOB4QFDJBM1PQVMBUJPO 3&7*&8 March/April 2012 UIF OBUVSBM QSPHSFTTJPO PG EJTFBTF BTTFTT OPOQIBSNBDPMPHJD NPEBMJUJFT GPS DPNGPSU BOE PêFS BEWJDF PO PSBM NFEJDBUJPOT TVDIBTPQJBUFTPSHBNNBBNJOPCVUZSJDBDJEBOBMPHTFHHBCB QFOUJO 5PQJDBMMPDBMMZBQQMJFEOJUSPHMZDFSJOQBUDIBQQMJDBUJPO DBO TPNFUJNFT CF VTFGVM GPS QBJO NBOBHFNFOU /JUSPHMZDFSJO QBUDIFT TIPVME POMZ CF VTFE JO VMDFST UIBU EP OPU IBWF UIF QPUFOUJBMUPIFBM*TDIFNJBJTBWFSZQPUFOUWBTPEJMBUPSBOEUIFSF JTTPNFDPODFSOUIBUUIFDBMGNVTDMFCMPPETVQQMZXJMMEJMBUFGVS UIFSBOEiTUFBMwUIFCMPPEGSPNUIFGPPU36ɨFSFBSFTPNFTUVEJFT UIBUTVHHFTUUPQJDBMOJUSPHMZDFSJOUPBNFMJPSBUFQBJOJOQBUJFOUT XJUI EJBCFUJD OFVSPQBUIZ BOE PUIFS JTDIFNJD QSPDFTTFT3738 " XFFL USJBM PG B MPDBMMZ BQQMJFE EPSTVN PG GPPU MPXEPTF OJUSPHMZDFSJO QBUDI NHI UP NHI NBZ CF BUUFNQUFE ɨFQBUJFOUGBNJMZBOEMPOHUFSNDBSFTUBêTIPVMECFFEVDBUFE UIBUUIJTNFEJDBUJPOJTGPSQBJONBOBHFNFOUPOMZBOEOPUGPS XPVOEIFBMJOH*GUIFSFJTOPJNQSPWFNFOUJOQBJOBGUFSXFFLT UIFOUIFNFEJDBUJPOTIPVMECFEJTDPOUJOVFE ,FFQJOH UIF JTDIFNJD FYUSFNJUJFT EFQFOEFOU DBO BMTP JNQSPWF QBJO"TJOUIJTQBUJFOUQSPMPOHFETJUUJOHDBOQVUBQBUJFOUBU SJTL GPS QSFTTVSF VMDFST TQFDJëDBMMZ JO UIF DPDDZY BOE JTDIJBM SFHJPOT 3FIBCJMJUBUJWF TQFDJBMJTUT JO DPMMBCPSBUJPO XJUI OVSTFT BOEQFSTPOBMDBSFBUUFOEBOUTDBOSFDPNNFOETQFDJBMJ[FEXIFFM DIBJSTBOEDVTIJPOTUIBUPðPBEUIFQSFTTVSFQPJOUTCVUNBJOUBJO UIFQBUJFOUTQBJODPOUSPMPGUIFJTDIFNJDFYUSFNJUJFT CONCLUSIONS ɨF TIPSUUFSN SFIBCJMJUBUJWF BOE MPOHUFSN DBSF TFUUJOHT BSF VOJRVF PQQPSUVOJUJFT GPS XPVOE DBSF ɨF QBUJFOUT IBWF UIF BEWBOUBHFTPGBOJOUFSEJTDJQMJOBSZUFBNUIBUDBOBQQSPBDIXPVOE IFBMJOH GSPN NVMUJQMF BOHMFT PQUJNJ[JOH OVUSJUJPO PðPBE JOHXJUISFIBCJMJUBUJWFUIFSBQJFTBTTJTUBODFJOQFSTPOBMDBSFBOE UVSOJOHBOEUJUSBUJPOPGNFEJDBUJPOTBTBQQSPQSJBUFɨFPVUTJEF QSPWJEFSXIPJTTFFJOHUIFTFQBUJFOUTJOUIFJSDMJOJDTIPVMEQBZ TQFDJBMBUUFOUJPOUPUIFQBUJFOUTHPBMTPGDBSFUIFPQUJNJ[BUJPOPG XPVOEIFBMJOHXJUIPVUDPOìJDUJOHXJUIUIFQBUJFOUTEBJMZBDUJWJ UJFTBOESFIBCJMJUBUJWFTFTTJPOTBOEUIFOVSTJOHJOUFOTJWFOFTTPG ESFTTJOHDIBOHFT.PTUJNQPSUBOUMZUIFQSPWJEFSNVTUCFBWBJM BCMFUPUIFQSJNBSZUFBN"GUFSFBDIQBUJFOUWJTJUBCSJFGQIPOF DBMMUPUIFDIBSHFOVSTFPSQSJNBSZDBSFQSPWJEFSDBOHPBMPOHXBZ JOGBDJMJUBUJOHFYDFMMFOUDPNNVOJDBUJPOBOEDBSFGPSUIFQBUJFOU Disclosure: The authors declare no financial interests. There was no funding source provided for this contribution. REFERENCES 1 (SBWFT / #JSSFMM ' 8IJUFCZ . &GGFDU PG QSFTTVSF VMDFST PO MFOHUI PG hospital stay. Infect Control Hosp Epidemiol. 2005;26:293–297. 2 Belowitz DR, Brandeis GH, Anderson J, Du W, Brand H. Effect of presTVSFVMDFSTPOUIFTVSWJWBMPGMPOHUFSNDBSFSFTJEFOUTJ Gerontol A Biol Sci Med Sci. 1997;52:M106–M110. SKINmed. 2012;10:75–81 80 3 $FOUFST GPS .FEJDBSF .FEJDBJE 4FSWJDFT IUUQXXXDNTHPW%BUB $PNQFOEJVN@@%BUB@$PNQFOEJVNBTQ5PQ0G1BHF76UJMJ[BUJPO ;JQ%SJWF6UJMJ[BUJPO5BCMF7åOBMQEG"DDFTTFE+VMZ 4 $FOTVT #VSFBV BOE *OTUJUVUF GPS 3FTFBSDI PO 1PWFSUZ 'JHVSFT IUUQDFOTVTHPW"DDFTTFE%FDFNCFS 5 Cough-Csarny J, Kopac CA. Skin tears in institutionalized elderly: an epidemiological study. 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Dressings for healing WFOPVTMFHVMDFSTCochrane Database Syst Rev. 2006;(3):CD001103. 18 Second European Consensus Document on chronic critical leg ischemia. Circulation. 1991;84(4 suppl):IV1–IV26. 19 /BUJPOBM1SFTTVSF6MDFS"EWJTPSZ1BOFMIUUQOQVBQPSH"@6" 1SFTT3FMFBTFQEG"DDFTTFE+VMZ 20 Langemo DK, Brown G. Skin fails too: acute, chronic, and end-stage skin failure. Adv Skin Wound Care. 2006;19:206–211. 21 1SFTTVSFVMDFSTJO"NFSJDBQSFWBMFODFJODJEFODFBOEJNQMJDBUJPOTGPS UIFGVUVSF"OFYFDVUJWFTVNNBSZPGUIF/BUJPOBM1SFTTVSF6MDFS"EWJsory Panel monograph. Adv Skin Wound Care. 2001;14:208–215. 22 Allman RM, Goode PS, Patrick MM, et al. Pressure ulcer risk facUPST BNPOH IPTQJUBMJ[FE QBUJFOUT XJUI BDUJWJUZ MJNJUBUJPO JAMA. 1995;273:865–870. 23 #FOOFUU3(04VMMJWBO+%F7JUP&.FUBM5IFJODSFBTJOHNFEJDBMNBMQSBDUJDFSJTLSFMBUFEUPQSFTTVSFVMDFSTJOUIF6OJUFE4UBUFTJ Am Geriatr Soc. 2000;48:73–81. 24 4JCCBME3(8JMMJBNTPO%0STUFE)-FUBM1SFQBSJOHUIFXPVOECFE debridement, bacterial balance and moisture balance. Ostomy Wound Manage. 2000;46:14–22, 24–28, 30–35. 25 Schultz GS, Sibbald RG, Falanga V, et al. Wound bed preparation: a systemic approach to wound management. Wound Rep Reg. 2003;11:1–28. 26 $PSDPSBO 1+ 6TF JU PS MPTF JUUIF IB[BSET PG CFE SFTU BOE JOBDUJWJUZ West J Med. 1991;154:219–223. 8PVOE$BSFJOB4QFDJBM1PQVMBUJPO 3&7*&8 March/April 2012 27 Allen C, Glasziou P, Del Mar C. Bed rest: a potentially harmful treatment OFFEJOHNPSFDBSFGVMFWBMVBUJPOLancet. 1999;354:1229–1233. 34 )PVBOH&5(JMNPSF0+3FJE$4IBX&+"CTFODFPGCBDUFSJBMSFTJTUBODFUPQPWJEPOFJPEJOFJ Clin Pathol. 1976;29:752–755. 28 &VSPQFBO 1SFTTVSF 6MDFS "EWJTPSZ 1BOFM BOE /BUJPOBM 1SFTTVSF 6MDFS "EWJTPSZ1BOFMTreatment of Pressure Ulcers: Quick Reference Guide. 8BTIJOHUPO%$/BUJPOBM1SFTTVSF6MDFS"EWJTPSZ1BOFM 35 -BDFZ 38 $BUUP " "DUJPO PG QPWJEPOFJPEJOF BHBJOTU NFUIJDJMMJOTFOTJUJWFBOESFTJTUBOUDVMUVSFTPG4UBQIZMPDPDDVTBVSFVTPostgrad Med J. 1993;69 suppl 3:S78–S83. 29 3FEEZ.(JMM44,BMLBS435SFBUNFOUPGQSFTTVSFVMDFSTBTZTUFNBUJD SFWJFXJAMA. 2008;300:2647–2662. 36 )PMMPXBZ (" "SUFSJBM VMDFST BTTFTTNFOU DMBTTJåDBUJPO BOE NBOBHFNFOU*O,SBTOFS%-3PEFIFBWFS(54JCCBME3(FETChronic Wound Care: A Clinical Source Book for Healthcare Professionals, Fourth Edition. Wayne, PA: Health Management Publications, Inc; 2007:443–449. 30 Cullum N, McInnes E, Bell-Syer SEM, Legood R. Support surfaces GPSQSFTTVSFVMDFSQSFWFOUJPO$PDISBOF%BUBCBTF4ZTU3FW $%%0*$%QVC 31 Sibbald RG, Woo K, Ayello EA. Increased bacterial burden and infection: the TUPSZPG/&3%4BOE450/&4Adv Skin Wound Care. 2006;19:447–461. 32 Drosou A, Falabella A, Kirsner RS. Antiseptics on wounds: an area of DPOUSPWFSTZWounds. 2003;15:149–166. 37 :VFO,$+#BLFS/33BZNBO(5SFBUNFOUPGDISPOJDQBJOGVMEJBCFUJD neuropathy with isosorbide dinitrate spray: a double-blind placeboDPOUSPMMFEDSPTTPWFSTUVEZDiabetes Care. 2002; 25:1699. 33 ;BNPSB +- $IFNJDBM BOE NJDSPCJPMPHJD DIBSBDUFSJTUJDT BOE UPYJDJUZ PG QPWJEPOFJPEJOFTPMVUJPOTAm J Surg. 1986;151:400–406. 38 8IFFMBOE3((JMDISJTU38+S:PVOH$++S5SFBUNFOUPGJTDIFNJDEJHJUBM ulcers with nitroglycerin ointment. J Dermatol Surg Oncol. 1983;9:548. SELF-TEST REVIEW QUESTIONS W. Clark Lambert, MD, PhD, Section Editor Instructions: For each of the following numbered questions, choose the appropriate lettered response(s). Unless directed to choose only one lettered response, all, some, or none of the responses may be correct. a. b. c. d. e. 2) e. f. CFESBJMTXJUIJOKVSJFTTVTUBJOFEJOIPTQJUBMJOUFOTJWFDBSF facilities. HFSJBUSJD SFDMJOFST XJUI JOKVSJFT TVTUBJOFE JO EPDUPST PGåDFTBOEXBJUJOHSPPNT HFSJBUSJD SFDMJOFST XJUI JOKVSJFT TVTUBJOFE JO IPTQJUBM JOUFOTJWFDBSFGBDJMJUJFT XIFFMDIBJST XJUI JOKVSJFT TVTUBJOFE JO EPDUPST PGåDFT and waiting rooms. XIFFMDIBJSTXJUIJOKVSJFTTVTUBJOFEJOUIFQBUJFOUT bedroom. 4) 5) b. c. d. e. Which of the following statements regarding treatment of WFOPVTMFHVMDFSTJTBSF DPSSFDU (Answer as many as apply.) a. b. c. Compression is the most important aspect for QSFWFOUJPO &MFWBUJPOJTUIFNPTUJNQPSUBOUBTQFDUGPSUSFBUNFOU Arterial disease is not a contraindication for treatment with compression. elderly patients. patients with diabetes mellitus. QBUJFOUTXJUIOPODPNQSFTTJCMFWFTTFMT QBUJFOUTXJUIWBTDVMBSDBMDJåDBUJPOT all of these are correct. Nitroglycerin patches should be applied: (Answer as many as apply.) a. TFWFOEBZT fourteen days. TFWFOUPUXFOUZPOFEBZT POFNPOUIUPTJYXFFLT three months. 6ODPNQFOTBUFEDPOHFTUJWFIFBSUGBJMVSFJTBDPOUSBJOEJcation for treatment with compression. "O6OOBCPPUFYFSUTIJHIQSFTTVSFXJUIXBMLJOHPOMZ 5ISPNCPFNCPMJDTUPDLJOHTBSFBOFYDFMMFOUDIPJDFGPS compression treatment. "OLMFCSBDIJBMJOEJDFT"#*T NBZPWFSFTUJNBUFUIFBNPVOUPG blood flow in: (Choose the single best response.) a. b. c. d. e. "TLJOUFBSJOBOFMEFSMZQBUJFOUTIPVMECFFYQFDUFEUPIFBMJO BQQSPYJNBUFMZ(Choose the single best response.) a. b. c. d. e. 3) d. 5IF NPTU DPNNPO PCKFDU BOE MPDBUJPO BTTPDJBUFE XJUI skin tears in elderly patients are: (Choose the single best response.) early in management of all symptomatic ulcers in QBUJFOUTPWFSZFBSTPGBHF early in management of all symptomatic ulcers in patients who smoke more than one pack of cigarettes per day. for pain management only. POMZJOVMDFSTDBVTFECZOFHBUJWFQSFTTVSFEFWJDFT POMZ JO VMDFST UIBU IBWF CFFO KVEHFE OPU UP IBWF UIF potential to heal. ANSWERS TO SELF-TEST REVIEW QUESTIONS: 1) e 2) c; 3) a, d, e; 4) e; 5) c, e 1) 'SPNUIF%FQBSUNFOUTPG1BUIPMPHZBOE%FSNBUPMPHZ6.%/+/FX+FSTFZ.FEJDBM4DIPPM/FXBSL/+ "EESFTTGPS$PSSFTQPOEFODF8$MBSL-BNCFSU.%1I%3PPN$.4#6.%/+/+.44PVUI0SBOHF"WFOVF/FXBSL/+ t&NBJMMBNCFSXD!VNEOKFEV SKINmed. 2012;10:75–81 81 8PVOE$BSFJOB4QFDJBM1PQVMBUJPO 7PMVNFt*TTVF March/April 2012 CORE CURRICULUM Virendra N. Sehgal, MD, Section Editor Cutaneous Tuberculosis: A Diagnostic Dilemma—Laboratory Inputs Virendra N. Sehgal, MD; Prashant Verma, MD; Sambit N. Bhattacharya, MD; Sonal Sharma, MD; Navjeevan Singh, MD; Nishant Verma, MD Bacterial cultures are the gold standard for diagnosing cutaneous tuberculosis, but there are limitations, despite the advances embracing the innovative technologies, including interferon γ release assays, enzyme-linked immunoabsorbant assay, and molecular diagnostics, in addition to conventional skin tests and microscopic pathology. The results and their interpretation of cultures are reviewed for use in day-to-day practice. $ VUBOFPVT UVCFSDVMPTJT 5# JT B DIBMMFOHF UP D MJOJDBM EJBHOPTJT*UNBZXBSSBOUUIFBQQMJDBUJPOPGTFWFSBMOPWFM UFDIOJRVFTXIJDIBSFOPXBWBJMBCMFGPSVTFEFTQJUFUIF FYPSCJUBOUDPTUCPUIJOEFWFMPQJOHBOEEFWFMPQFEOBUJPOT0DDBTJPOBMMZMJNJUFESFTPVSDFTNBZQSPWFBOJNQFEJNFOUOFWFSUIFMFTTUIFBQQSBJTBMPGOFXFSNPEBMJUJFTJTTJHOJëDBOUBOETIPVMECF VTFEXIFSFWFSBQQSPQSJBUF UJPO5PDPOGVTFUIFJTTVFFWFONPSFUIFTJ[FPGJOEVSBUJPOJOBO JOGFDUFEJOEJWJEVBMNBZCFEJNJOJTIFEJOUIFQSFTFODFPGJNNVOPTVQQSFTTJWFDPOEJUJPOT1 "QBUJFOUXJUIBUVCFSDVMPVTDIBODSFVTVBMMZCFDPNFTUVCFSDVMJO UFTUoQPTJUJWFBSPVOEUIFUJNFXIFOMZNQIBEFOPQBUIZJTBQQBSFOUXIJDIDPSSFMBUFTXJUI5DFMMTFOTJUJ[BUJPO2"QBUJFOUXJUI TDSPGVMPEFSNBNPTUPGUFOTIPXTBQPTJUJWFUVCFSDVMJOTLJOUFTU 545 XIFSFBTUIFUFTUNBZPSNBZOPUCFQPTJUJWFJOBQBUJFOU DIAGNOSTIC MODALITIES XJUI5#DVUJTPSJëDJBMJTɨF545JTUZQJDBMMZOFHBUJWFJOBEJTTFNJOBUFENJMJBSZ5#QBUJFOUEVFUPBOFSHZXIJMFJUJTWBSJBCMF SKIN TESTS JOBQBUJFOUXJUIBNFUBTUBUJD5#HVNNB6"OJOEJWJEVBMT545 TUBERCULIN TEST JTVTVBMMZQPTJUJWFJOMVQVTWVMHBSJT71BUJFOUTXJUIUVCFSDVMJET ɨFUVCFSDVMJOUFTUJTCBTFEPOUIFQSJODJQMFUIBUJOEJWJEVBMTXIP BSFVTVBMMZJOHPPEIFBMUICVUTIPXBQPTJUJWF5456 IBWFCFFOJOGFDUFEXJUIUIFUVCFSDMFCBDJMMJSFTQPOEUPBEFMBZFE UZQFIZQFSTFOTJUJWJUZSFBDUJPOBUUIFUFTUTJUFɨFJOUFSQSFUBUJPO MYCOBACTERIAL ANTIGEN, MPB64 TRANSDERMAL PG UIF UFTU NBZ CF DPNQMJDBUFE CZ DSPTTTFOTJUJWJUZ JOEVDFE CZ PATCH TEST FOWJSPONFOUBM NZDPCBDUFSJB BOEPS #BDJMMF $BMNFUUF(VÏSJO ɨJTBOUJHFOIBTCFFOGPSNVMBUFEGPSEFMJWFSZJOBUSBOTEFSNBM #$( WBDDJOBUJPO4UBOEBSEUVCFSDVMJOQVSJëFEQSPUFJOEFSJWBQBUDI GPS VTF BT B EJBHOPTUJD TLJO UFTU SFBHFOU UP EFUFDU BDUJWF UJWF11% UFTUJTDPOTJEFSFEVTFGVMJOUIFEFWFMPQJOHXPSME*U 5# ɨF UFTU NBZ CF VTFGVM UP EJTUJOHVJTI QBUJFOUT XJUI BDUJWF JOWPMWFTUIFJOUSBEFSNBMJOKFDUJPOPGUVCFSDVMJOVOJU11%35 5#GSPNQBUJFOUTXIPBSF5#JOGFDUFECVUBTZNQUPNBUJDɨF XJUI5XFFOPOUIFNJEWPMBSBTQFDUPGUIFGPSFBSNBOENFB.1#USBOTEFSNBMQBUDINBZCFVTFGVMJONPOJUPSJOHTVDDFTTTVSFNFOUPGUIFNBYJNVNUSBOTWFSTFEJBNFUFSPGJOEVSBUJPOBGUFS GVMDIFNPUIFSBQZ86OGPSUVOBUFMZUIFSFJTIBSEMZBSFQPSUPOJUT EBZTXJUIBprovisoUIBUUIFMBSHFSUIFTJ[FPGUIFJOEVSBUJPOUIF VTFJODVUBOFPVT5#UIVTGBS9 IJHIFSUIFQSPCBCJMJUZPGJUTCFJOHBUVCFSDVMPVTJOGFDUJPO"TJ[F ǚNNNBZCFEVFUPJOGFDUJPOXJUIUVCFSDMFCBDJMMJJSSFTQFDUJWF INTERFERON-γ RELEASE ASSAYS PG#$(WBDDJOBUJPOTUBUVTIPXFWFSJOEVSBUJPONNJOEJDBUFT BCTFODFPGUVCFSDVMJOTFOTJUJWJUZ*OEVSBUJPOJOUIFSBOHFPGNN QUANTIFERON-TB GOLD TEST UPNNJTVTVBMMZPGBOPOUVCFSDVMPVTOBUVSFXIJMFJOEVSBUJPO *U JT BO JO WJUSP EJBHOPTUJD BJE UIBU NFBTVSFT B DPNQPOFOU PG PGNNUPNNJTFRVJWPDBMSFRVJSJOHBDBSFGVMJOUFSQSFUB- DFMMNFEJBUFE JNNVOJUZ UP Mycobacterium tuberculosis BOE JT From the Dermato-Venereology (Skin/VD) Center, Sehgal Nursing Home, Panchwati, Delhi; Department of Dermatology and STD, Department of Pathology, University College of Medical Sciences and Associated Guru Teg Bahadur Hospital, Delhi; Department of Microbiology, Maulana Azad Medical College and Associated Chacha Nehru Bal Chikitsalaya, Delhi, India "EESFTTGPS$PSSFTQPOEFODF7JSFOESB/4FIHBM.%%FSNBUP7FOFSPMPHZ4LJO7% $FOUFS4FIHBM/VSTJOH)PNF"1BODIXBUJ%FMIJ*OEJBt E-mail: [email protected] SKINmed. 2012;10:82–89 82 ª1VMTF.BSLFUJOH$PNNVOJDBUJPOT--$ $03&$633*$6-6. 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March/April 2012 A Figure 2. Tuberculosis verrucosa cutis: Section showing marked hyperkeratosis and acanthosis. Epithelioid cell granulomas mixed with neutrophilic abscesses is prominent in the upper dermis (hematoxylin-eosin stain, original magnification ×40). Inset: hematoxylin-eosin stain, original magnification ×400. DISSEMINATED MILIARY TB ɨFIJTUPQBUIPMPHZPGEJTTFNJOBUFENJMJBSZ5#JTVOVTVBM*UJT JEFOUJëFECZUIFQSFTFODFPGNJDSPBCDFTTFTGPSNFECZNBTTJWF OFVUSPQIJMJDJOëMUSBUFTDPOUBJOJOH"'# TB VERRUCOSA CUTIS *UT NJDSPTPQJD QBUIPMPHZ JT DIBSBDUFSJ[FE CZ NBSLFE QTFVEP FQJUIFMJPNBUPVT IZQFSQMBTJB PG UIF FQJEFSNJT XJUI IZQFSLFSBUPTJT BOEBEFOTFJOìBNNBUPSZDFMMJOëMUSBUFDPOTJTUJOHPGOFVUSPQIJMT MZNQIPDZUFTBOEHJBOUDFMMT(SBOVMPNBUPVTJOëMUSBUFTBSFLFZUPJUT EJBHOPTJT'JHVSF 5ZQJDBMUVCFSDVMPVTGPDJXJUIDBTFBUJOHOFDSPTJT BSFVODPNNPO22 B Figure 1. (A) Cohesive epithelioid cell granuloma in an aspirate from a cervical lymph node (May-Grunwald-Giemsa stain, magnification ×400). (B) Single acid-fast bacillus in a fine-needle aspirate smear from a lymph node (Ziehl-Neelsen stain, magnification ×400). LUPUS VULGARIS *UTIJTUPQBUIPMPHZJTDPOTQJDVPVTBOEJTGPSNFECZBHSBOVMPNB DPOUBJOJOH QSPNJOFOU FQJUIFMJPJE DFMMT -BOHIBOT HJBOU DFMMT 6MDFSBUJPO TVSSPVOEFE CZ B OPOTQFDJëD JOìBNNBUPSZ JOëM- BOE B NPOPOVDMFBS JOëMUSBUF 'JHVSF $BTFBUJPO OFDSPTJT JT USBUF BOE FYUFOTJWF DBTFBUJPO OFDSPTJT JT UIF QSFFNJOFOU NJOJNBMBCTFOU"'#BSFBMTPBSFSBSFɨFWBSJBUJPOTJOUJTTVF NJDSPTDPQJD GFBUVSF PG 5# DVUJT PSJëDJBMJT ɨF QSFTFODF PG IJTUPMPHZNBZCFFYQFDUFEEVFUPTFDPOEBSZDIBOHFTPGBCTDFTT HSBOVMPNBT DPOUBJOJOH FQJUIFMJPJE BOE -BOHIBOTUZQF HJBOU GPSNBUJPOVMDFSBUJPOBUSPQIZBOETDBSSJOH DFMM JO UIF EFSNJT NBZ CF QSFTFOU 6TVBMMZ ;JFIM/FFMTFOo LICHEN SCROFULOSORUM TUBJOFE"'#BSFEFUFDUFE20 *U JT OFDFTTBSZ UP FTUBCMJTI JUT NJDSPTDPQJD QBUIPMPHZ XIJDI JT TUBERCULOUS GUMMA QSJNBSJMZDIBSBDUFSJ[FECZBDPMMFDUJPOPGFQJUIFMJPJEDFMMTJOUIF ɨJTJTNBSLFECZNBTTJWFEFSNBMOFDSPTJTDPOUBJOJOHTFWFSBMUVCFS- VQQFSQBSUPGUIFEFSNJTBOEPSBSPVOEUIFIBJSGPMMJDMF"OPDDBDVMFTDPNQSJTFEPGMZNQIPDZUFTIJTUJPDZUFTBOE-BOHIBOTUZQF TJPOBMHJBOUDFMMNBZCFJEFOUJëFEJOUIFHSBOVMPNB$BTFBUJPO OFDSPTJTIPXFWFSJTDPOTQJDVPVTCZJUTBCTFODF'JHVSF HJBOUDFMMTTUVEEFEXJUIOVNFSPVT"'# TB CUTIS ORIFICIALIS SKINmed. 2012;10:82–89 $VUBOFPVT5VCFSDVMPTJT $03&$633*$6-6. March/April 2012 Figure 5. Erythema induratum: Section showing septal pannicultis, vascular damage, neutrophil and macrophage infiltrate in the vessel wall, and thrombosis (hematoxylin-eosin stain, original magnification ×40). Inset: hematoxylin-eosin stain, original magnification ×400. Figure 3. Lupus vulgaris: Section showing epithelioid cell granulomas with conspicuous prominent giant cells extending to mid-dermis along with hyperplastic epithelium depicting hyperkeratosis and acanthosis (hematoxylin-eosin stain, original magnification ×40). Inset: hematoxylin-eosin stain, original magnification ×100. 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March/April 2012 NJOEEJêFSFOUTUSBUFHJFTUPJEFOUJGZUIFJTPMBUFTGSPNDVMUVSFTBOE EJSFDUMZGSPNUIFDMJOJDBMTQFDJNFOTJODMVEFBNQMJëDBUJPOPGTQFDJëDHFOFSFHJPOTGPMMPXFECZIZCSJEJ[BUJPOXJUITQFDJFTTQFDJëD QSPCFT TFRVFODJOH BOE SFTUSJDUJPO GSBHNFOU MFOHUI QPMZNPSQIJTN3'-1 BOBMZTJTTVDIBTITQL%BHFOFkat(BOES3/" HFOFTɨFTF1$33'-1BTTBZTIFMQJOUIFRVJDLJEFOUJëDBUJPO PGQBUIPHFOJDNZDPCBDUFSJBJODMVEJOHM tuberculosisGSPNUIFDVMUVSFJTPMBUFTBTXFMMBTEJSFDUMZGSPNUIFDMJOJDBMTQFDJNFO 10 National Tuberculosis Controllers Association; Centers for Disease Control and Prevention (CDC) Guidelines for the investigation of contacts of persons with infectious tuberculosis. Recommendations from the National Tuberculosis Controllers Association and CDC. MMWR Recomm Rep. 2005;54(RR-15). ANTITUBERCULAR THERAPY AS A DIAGNOSTIC ADJUNCT 13 Ribeiro S, Dooley K, Hackman J, et al. T-SPOT.TB responses during treatment of pulmonary tuberculosis. BMC Infect Dis. 2009;9:23. ɨ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uo FF, Zhang LF, Liu XQ. Sensitivity of interferon-gamma release assay T-SPOT.TB in diagnosing extrapulmonary tuberculosis. Zhongguo Yi Xue Ke Xue Yuan Xue Bao. 2009;31:449–452. 11 Bocchino M, Chairadonna P, Matarese A, et al. Limited usefulness of QuantiFERON-TB Gold In-Tube for monitoring anti-tuberculosis therapy. Respir Med. 2010;104:1551–1556. 12 Centers for Disease Control and Prevention. Updated Guidelines for Using Interferon Gamma Release Assays to Detect Mycobacterium Tuberculosis Infection, United States. MMWR. 2010;59(No.RR-5). 15 Domínguez J, De Souza-Galvão M, Ruiz-Manzano J, et al. T-cell responses to the Mycobacterium tuberculosis-specific antigens in active tuberculosis patients at the beginning, during, and after antituberculosis treatment. Diagn Microbiol Infect Dis. 2009;63:43–51. 16 Kathuria P, Agarwal K, Koranne RV. The role of fine-needle aspiration cytology and Ziehl Neelsen staining in the diagnosis of cutaneous tuberculosis. Diagn Cytopathol. 2006;34:826–829. 17 Bezabih M, Mariam DW, Selassie SG. Fine needle aspiration cytology of suspected tuberculous lymphadenitis. Cytopathology. 2002;13:284– 290. 18 Elder DE, Elenitsas R, Ioffreda MD, et al. Atlas and Synopsis of Lever’s Histopathology of the Skin. 2nd ed. Philadelphia, PA: Lipincott Willams & Wolters Kluwer; 2007:230. 19 Bravo FG, Gotuzzo E. Cutaneous tuberculosis. Clin Dermatol. 2007;25:173–180. 20 Baek SE, Kang WH, Lee KH. Tuberculosis cutis orificialis. Korean J Dermatol. 1985;23:667–671. CONCLUSIONS 21 Singal A, Bhattacharya SN. Lichen scrofulosorum: a prospective study of 39 patients. Int J Dermatol. 2005;44:489–493. %JBHOPTUJDEJMFNNBDPOUJOVFTUPMPPNMBSHFJODVUBOFPVT5# MFBEJOH UP SFRVJTJUJPO PG TFWFSBM MBCPSBUPSZ JOOPWBUJPOT XIJDI BSFSFRVJSFEUPCFNBEFVTFPGEVSJOHJUTEJTDPVSTF 22 Sehgal VN, Sardana K, Bajaj P, Bhattacharya SN. Tuberculosis verrucosa cutis: antitubercular therapy, a well-conceived diagnostic criterion. Int J Dermatol. 2005;44:230–232. REFERENCES 1 World Health Organization: The WHO standard tuberculin test 1963. WHO/TB/Tech guide/3, Chahda VK. Tuberculin test. 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MPB64 mycobacterial antigen: a new skin-test reagent through patch method for rapid diagnosis of active tuberculosis. Int J Tuberc Lung Dis. 1998;2:541–546. SKINmed. 2012;10:82–89 88 23 Sehgal VN. Lichen scrofulosorum: current status. Int J Dermatol. 2005;44:521–523. 24 Padmavathyi L, Rao LL, Ramanadhan, et al. Mycobacterial antigen in tissues in diagnosis of cutaneous tuberculosis. Indian J Tuberc. 2005;52:31–35. 25 Mustafa T, Wiker HG, Mfinanga SG, et al. Immunohistochemistry using a Mycobacterium tuberculosis complex specific antibody for improved diagnosis of tuberculous lymphadenitis. Mod Pathol. 2006;19:1606– 1614. 26 Kutzner H, Argenyi ZB, Requena L, et al. A new application of BCG antibody for rapid screening of various tissue microorganisms. J Am Acad Dermatol. 1998;38:56–60. 27 Fariña MC, Gegundez MI, Piqué E, et al. Cutaneous tuberculosis: a clinical, histopathologic, and bacteriologic study. J Am Acad Dermatol. 1995;33:433–440. 28 Brown FS, Anderson RH, Burnett JW. Cutaneous tuberculosis. J Am Acad Dermatol. 1982;6:101–106. 29 API TB Consensus Guidelines 2006: Management of pulmonary tuberculosis, extra-pulmonary tuberculosis and tuberculosis in special situations. J Assoc Physicians India. 2006;54:219–234. 30 Diagnostic Standards and Classification of Tuberculosis in Adults and Children. This official statement of the American Thoracic Society and the Centers for Disease Control and Prevention was adopted by the ATS Board of Directors, July 1999. This statement was endorsed by the Council of the Infectious Disease Society of America, September 1999. Am J Respir Crit Care Med. 2000;161:1376–1395. $VUBOFPVT5VCFSDVMPTJT $03&$633*$6-6. March/April 2012 31 Aggarwal P, Singal A, Bhattacharya SN, et al. Comparison of the radiometric BACTEC 460 TB culture system and Löwenstein-Jensen medium for the isolation of mycobacteria in cutaneous tuberculosis and their drug susceptibility pattern. Int J Dermatol. 2008;47:681–687. 32 Tortoli E, Cichero P, Piersimoni C, et al. Use of BACTEC MGIT 960 for recovery of mycobacteria from clinical specimens: multicenter study. J Clin Microbiol. 1999;37:3578–3582. 33 Piersimoni C, Scarparo C, Cichero P, et al. Multicenter evaluation of the MB-Redox medium compared with radiometric BACTEC system, mycobacteria growth indicator tube (MGIT), and Löwenstein-Jensen medium for detection and recovery of acid-fast bacilli. Diagn Microbiol Infect Dis. 1999;34:293–299. 34 Luquin M, Gamboa F, Barcelo MG, et al. Comparison of a biphasic non radiometric system with Lowenstein Jensen and BACTEC 460 system for recovery of mycobacteria from clinical samples. Tuber Lung Dis. 1996;77:449–453. 35 Piersimoni C, Morbiducci V, De Sio G, et al. Comparative evaluation of the MB-check system for recovery of mycobacteria from clinical specimens. Eur J Clin Microbiol Infect Dis. 1992;11:1174–1177. 36 Abe C, Hosojima S, Fukasawa Y, et al. Comparison of MB chek, BACTEC and egg-based media for recovery of mycobacteria. J Clin Microbiol. 1992;30:878–881. 37 Pallen MJ. The inoculation of tissue specimens into guinea-pigs in suspected cases of mycobacterial infection does it aid diagnosis and treatment? Tubercle. 1987;68:51–57. 38 Peluffo G, de Kantor IN. Bacteriologic diagnosis of extrapulmonary tuberculosis in a general hospital. Rev Argent Microbiol. 1982;14:91–96. 39 Schneider JW, Jordaan HF, Geiger DH, et al. Erythema induratum of Bazin. A clinicopathological study of 20 cases and detection of Mycobacterium tuberculosis DNA in skin lesions by polymerase chain reaction. Am J Dermatopathol. 1995;17:350–356. 40 Hasegawa N, Miura T, Ishii K, et al. New simple and rapid test for culture confirmation of Mycobacterium tuberculosis complex: a multicenter study. J Clin Microbiol. 2002;40:908–912. 41 Jost KC, Chiu SH, Kenney TM, et al. American Society for Microbiology. General Meeting. Identification and quantitation of Mycobacterium tuberculosis directly from clinical specimens by fluorescence detection highperformance liquid chromatography. Abstr Gen Meet Am Soc Microbiol. 1997;97:568. 42 Charpin D, Herbault H, Gevaudan MJ, et al. Value of ELISA using A 60 antigen in the diagnosis of active pulmonary tuberculosis. Am Rev Respir Dis. 1990;142:380–384. 43 Arya L, Koranne RV, Deb M. Cutaneous tuberculosis in children a clinicomicrobiological study. Indian J Dermatol Venereol Leprol. 1999;65:137– 139. 44 Rao L, Padmavathy L. Utility of MycoDot test in the diagnosis of cutaneous tuberculosis. Indian J Dermatol Venereol Leprol. 2003;69:428–429. 45 Balasingham SV, Davidsen T, Szpinda I, et al. Molecular diagnostics in tuberculosis: basis and implications for therapy. Mol Diagn Ther. 2009;13:137–151. 46 Honoré-Bouakline S, Vincensini JP, Giacuzzo V, et al. Rapid diagnosis of extrapulmonary tuberculosis by PCR: impact of sample preparation and DNA extraction. J Clin Microbiol. 2003;41:2323–2329. 47 Cheng VC, Yew WW, Yuen KY. Molecular diagnostics in tuberculosis. Eur J Clin Microbiol Infect Dis. 2005;24:711–720. 48 Abdalla CM, de Oliveira ZN, Sotto MN, et al. Polymerase chain reaction compared to other laboratory findings and to clinical evaluation in the diagnosis of cutaneous tuberculosis and atypical mycobacteria skin infection. Int J Dermatol. 2009;48:27–35. 49 Padmavathy L, Rao L, Veliath A. Utility of polymerase chain reaction as a diagnostic tool in cutaneous tuberculosis. Indian J Dermatol Venereol Leprol. 2003;69:214–216. 50 Salian NV, Rish JA, Eisenach KD, et al. Polymerase chain reaction to detect Mycobacterium tuberculosis in histologic specimens. Am J Respir Crit Care Med. 1998;158:1150–1155. 51 Ortu S, Molicotti P, Sechi LA, et al. Rapid detection and identification of Mycobacterium tuberculosis by Real Time PCR and Bactec 960 MIGT. New Microbiol. 2006;29:75–80. 52 Katoch VM. Newer diagnostic techniques for tuberculosis. Indian J Med Res. 2004;120:418-428. 53 Katoch VM, Kanaujia GV, Shivannavar CT, et al. Progress in developing ribosomal RNA and rRNA gene(s) based probes for diagnosis and epidemiology of infections diseases specially leprosy. In: Sushil Kumar, Sen AK, Dutta GP, Sharma RN, eds. Tropical Diseases—Molecular Biology and Control Strategies. 1st ed. New Delhi, India: Council for Scientific and Industrial Research; 1994:581–587. 54 Roth A, Reischl U, Streubel A, Naumann L, et al. Novel diagnostic algorithm for identification of mycobacteria using genus specific amplification of 16S-23S rRNA gene spacer and restriction endonucleases. J Clin Microbiol. 2000;38:1094–1104. 55 Sehgal VN, Sardana K, Bajaj P, et al. Tuberculosis verrucosa cutis: antitubercular therapy, a well-conceived diagnostic criterion. Int J Dermatol. 2005;44:230–232. 56 Sehgal VN, Sardana K, Sehgal R, et al. The use of anti-tubercular therapy (ATT) as a diagnostic tool in pediatric cutaneous tuberculosis. Int J Dermatol. 2005;44:961–963. 57 Ramam M, Mittal R, Ramesh V. How soon does cutaneous tuberculosis respond to treatment? Implications for a therapeutic test of diagnosis. Int J Dermatol. 2005;44:121–124. 58 Sehgal VN, Sardana K, Sharma S. Inadequacy of clinical and/or laboratory criteria for the diagnosis of lupus vulgaris, re-infection cutaneous tuberculosis: fallout/implication of 6 weeks of anti-tubular therapy (ATT) as a precise diagnostic supplement to complete the scheduled regimen. J Dermatolog Treat. 2008;19:164–167. FORMULARY OF DR GEORGE C. ANDREWS LIQUID ROUGE Carmine gr.v Aq. Ammon mx.v Alcohol 3 i ss Ol. Rose gtt.1 Aq. Rosae 3i Mix and filter Submitted by Douglas D. Altchek, MD, New York, NY. SKINmed. 2012;10:82–89 89 $VUBOFPVT5VCFSDVMPTJT 7PMVNFt*TTVF March/April 2012 PERILS OF DERMATOPATHOLOGY W. Clark Lambert, MD, PhD, Section Editor Sometimes It Takes Darkness to See the Light: Pitfalls in the Interpretation of Cell Proliferation Markers (Ki-67 and PCNA) Carmen Castilla, BS;1 Patrick McDonough, BA;1 Gizem Tumer, MD;2 Peter C. Lambert, BA, MS;3 W. Clark Lambert, MD, PhD2 “[Clarity], like a photograph, develops in the dark.:PVTVG,BSTI ɨFEFHSFFPGDFMMQSPMJGFSBUJPOJOBUVNPSJTPGUFOBTTPDJBUFEXJUINFUBTUBUJDSJTLBOENPSUBMJUZ1SPMJGFSBUJOHDFMMOVDMFBSBOUJHFO1$/" BOE,JBSFQSPMJGFSBUJPONBSLFSTUIBUDBOCFVTFEUPBTTFTTNBMJHOBOUQPUFOUJBMJODVUBOFPVTMFTJPOTBOEQBUIPMPHJDBMDFMMQSPMJGFSBUJPO JOQTPSJBTJTɨFTFNBSLFSTBSFFMFWBUFEEVSJOHQFSJPETPGDFMMQSPMJGFSBUJPOIPXFWFSUIFZBSFBMTPVQSFHVMBUFEGPMMPXJOH67JSSBEJBUJPO ɨJTVQSFHVMBUJPONBZCFQSPCMFNBUJDBTNBOZTLJOMFTJPOTBSFTVCKFDUUPTVOFYQPTVSFJOBOFWFSZEBZTFUUJOH K JUIFOBNFPGXIJDIXBTEFSJWFEGSPNUIFUPXOJO XIJDIJUXBTEJTDPWFSFE,JFM(FSNBOZBOEUIFOVNCFSPGUIFPSJHJOBMDMPOFJOXFMMQMBUF 1JTBMBSHFQSPUFJOXJUIUXPJTPGPSNTHFOFSBUFECZBMUFSOBUJWFN3/"TQMJDJOH2 *UΉ JTΉ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ΉBEEJUJPOBOJODSFBTFJO,JQPTJUJWFDFMMT IBTCFFOTIPXOUPDPSSFMBUFXJUIBOJODSFBTFJOUIFQTPSJBTJTBSFB BOETFWFSJUZJOEFYXJUIIJHIFSTDPSFTJOEJDBUJOHXPSTFEJTFBTF6 ɨJT DPSSFMBUJPO IBT QSPNQUFE TPNF SFTFBSDIFST UP VTF ,J UPFWBMVBUFUIFFêFDUJWFOFTTPGNFEJDBUJPOTJOUIFUSFBUNFOUPG QTPSJBTJT78 67SBEJBUJPOIBTCFFOTIPXOUPBêFDUFQJEFSNBMDFMMTPOBNPMFDVMBSMFWFMCZBDUJWBUJOHQBUIXBZTUIBUJOEVDFDFMMQSPMJGFSBUJPO910 'JHVSF #FDBVTF,JJTDMPTFMZBTTPDJBUFEXJUIDFMMQSPMJGFSBUJPOJUJTBMTPVQSFHVMBUFEGPMMPXJOH67JSSBEJBUJPO1PTTJCMZJU NBZBMTPQMBZBSPMFJO%/"SFQBJSGPMMPXJOH67JSSBEJBUJPO"T BSFTVMUQBUJFOUTDBOIBWFB67SBEJBUJPOoJOEVDFEJODSFBTFJO ,JXIJDIDBOCFNJTUBLFOMZJOUFSQSFUFEUPJOEJDBUFBIJHIFS HSBEFOFPQMBTNPSJOUIFDBTFPGQTPSJBTJTTVCPQUJNBMUSFBUNFOU CHARACTERISTICS 1SPMJGFSBUJOHDFMMOVDMFBSBOUJHFO1$/" JTBDJSDVMBSIPNPUSJNFSJDQSPUFJOUIBUBTTPDJBUFTXJUI%/"QPMZNFSBTFTEFMUBBOE FQTJMPOXIJDIBSFJOWPMWFEJO%/"TZOUIFTJTBOESFQBJS1$/" GVODUJPOT BT B TMJEJOH DMBNQ IPMEJOH UIF %/" QPMZNFSBTF BSPVOEUIF%/"TUSBOEBOEJODSFBTJOHUIFFïDJFODZPGOVDMFPUJEF BEEJUJPO 'JHVSF 8IFO 67 SBEJBUJPO JOEVDFT QZSJNJEJOFEJNFST1$/"BOE%/"QPMZNFSBTFEFMUBBSFVQSFHVMBUFE QFSGPSNJOHOVDMFPUJEFFYDJTJPOSFQBJSUPSFTUPSFUIFJOUFHSJUZPG UIF%/"11.VDIMJLF,J1$/"IBTCFFOVTFEBTBNBSLFS PGDFMMQSPMJGFSBUJPOJOBTTFTTJOHDVUBOFPVTOFPQMBTNT*OOPSNBM TLJO1$/"QPTJUJWFDFMMTBSFPOMZMPDBUFEBSPVOEIBJSGPMMJDMFT BOE JO UIF CBTBM MBZFS PG UIF FQJEFSNJT12 XIJMF JO OFPQMBTNT 1$/"QPTJUJWF DFMMT DBO CF GPVOE BOZXIFSF JO UIF UVNPS1213 *OIVNBOTLJO67FYQPTVSFIBTCFFOTIPXOUPJOEVDF1$/" From the Class of 2012, New Jersey Medical School, Newark, NJ;1 the Departments of Pathology and Dermatology, UMDNJ-New Jersey Medical School, Newark, NJ;2 and the Class of 2015, St. George’s University School of Medicine, Grenada, West Indies3 Address for Correspondence: W. Clark Lambert, MD, PhD, Room C520 MSB, UMDNJ-NJMS, 185 South Orange Avenue, Newark, NJ 07103 t&NBJMMBNCFSXD!VNEOKFEV SKINmed. 2012;10:90–92 90 ª1VMTF.BSLFUJOH$PNNVOJDBUJPOT--$ 1&3*-40'%&3."501"5)0-0(: March/April 2012 Figure 1. (A) Multiple nests of melanocytes are shown in malignant melanoma. (B) Ki-67 immunostain showing increased reactivity. Black arrowhead indicates a melanin pigment. Red arrowheads indicate increased Ki-67 labeling in or above the basal layer, indicative of cell proliferation or of ultraviolet exposure within the previous 24 hours. Full black arrows indicate a hypocellular dermis, indicative of long term ultraviolet exposure. Figure 3. DNA replication fork illustrating DNA synthesis along the leading and lagging strand. Proliferating cell nuclear antigen (PCNA) is shown in pink acting as a clamp to secure polymerase delta (shown in green) and polymerase epsilon (shown in teal) to the DNA strand, allowing for greater efficiency of nucleotide addition. Figure 2. /PSNBMTLJOBEKBDFOUUPUIFNFMBOPDZUJDMFTJPO showing increased Ki-67 proliferation index above the basal layer (arrowheads) due to ultraviolet exposure. SKINmed. 2012;10:90–92 91 *OUFSQSFUBUJPOPG$FMM1SPMJGFSBUJPO.BSLFST 1&3*-40'%&3."501"5)0-0(: March/April 2012 FYQSFTTJPOJOTVQSBCBTBMDFMMT14"TBSFTVMUTLJOCJPQTJFTUBLFO GSPN QBUJFOUT XIP XFSF SFDFOUMZ FYQPTFE UP UIF TVO PS PUIFS TPVSDFTPG67SBEJBUJPODBOBQQFBSUPDPOUBJOSBQJEMZQSPMJGFSBUJOHDFMMTXIFOJOGBDUUIFDFMMTBSFPOMZSFQBJSJOH67JOEVDFE EBNBHF158JUIPVUBHPPEIJTUPSZGSPNUIFDMJOJDBMEFSNBUPMPHJTU UIF EFSNBUPQBUIPMPHJTU NBZ NJTJOUFSQSFU UIFTF 1$/" QPTJUJWFDFMMTBTJOEJDBUJWFPGBIJHIFSHSBEFNBMJHOBODZ16 carcinoma, extracutaneous small cell carcinoma, and cutaneous squamous cell carcinoma. Histopathology. 2005;46:614–621. 6 Chen GS, Wu TM, Yang SA, Yu HS. Quantitative assessments of physiological and biological parameters in psoriatic lesions and its correlations to the clinical severity of psoriasis. Kaohsiung J Med Sci. 2001;17:408–418. 7 Yazici AC, Tursen U, Apa DD, et al. The changes in expression of icam-3, ki-67, pcna, and cd31 in psoriatic lesions before and after methotrexate treatment. Arch Dermatol Res. 2005;297:249–255. 8 #PWFOTDIFO )+ 0UFSP .& -BOHFXPVUFST ". FU BM 0SBM SFUJnoic acid metabolism blocking agent rambazole for plaque psoriasis: an immunohistochemical study. Br J Dermatol. 2005;156: 263–270. 9 &M"CFTFSJ 5# 1VUUB 4 )BOTFO -" 6MUSBWJPMFU JSSBEJBUJPO JOEVDFT keratinocyte proliferation and epidermal hyperplasia through the activation of the epidermal growth factor receptor. Carcinogenesis. 2006;27:225–231. CONCLUSIONS %FSNBUPQBUIPMPHJTUTNVTUCFBXBSFPGUIFQPTTJCJMJUZPGVQSFHVMBUJPOPG,JBOE1$/"GPMMPXJOH67FYQPTVSFɨJTFMFWBUJPO DBOMFBEUPJODPSSFDUUVNPSHSBEJOHPSQTPSJBTJTSBUJOHBOETVCTFRVFOUQSPKFDUFEQSPHOPTJT*OBOJEFBMTFUUJOHQBUJFOUTTIPVMEBWPJE 67 FYQPTVSF CFGPSF UIF CJPQTZ PG B TVTQFDUFE DVUBOFPVT NBMJHOBODZIPXFWFSUIJTJTOPUBMXBZTQSBDUJDBM8FSFDPNNFOEUIBU DMJOJDJBOT SPVUJOFMZ BTL QBUJFOUT BCPVU UIFJS SFDFOU 67 FYQPTVSF CFGPSFBTLJOCJPQTZBOESFQPSUUIJTJOGPSNBUJPOUPUIFEFSNBUPQBUIPMPHJTUUPBWPJENJTJOUFSQSFUBUJPOPG,JBOEPS1$/"MFWFMT REFERENCES 1 Scholzen T, Gerdes J. The Ki-67 protein: from the known and the unknown. J Cell Physiol. 2000;182:311–322. 2 Duchrow M, Schluter C, Wholenberg C, Flad HD, Gerdes J. Molecular characterization of the gene locus of the human cell proliferationassociated nuclear protein defined by monoclononal antibody Ki-67. Cell Prolif. 1996;29:1–12. 3 Schmidt M, Broll R, Bruch H, Duchrow M. Proliferation marker pKi-67 affects the cell cycle in a self regulated manner. J Cell Biochem. 2002;87:334–341. 10 3VEPMQI 1 5SPOOJFS . .FO[FM 3 .PMMFS . 1BSXBSFTDI 3 &OIBODFE expression of Ki-67, topoisomerase IIalpha, PCNA, p53 and p21WAF1/ Cip1 reflecting proliferation and repair activity in UV-irradiated melanocytic nevi. Hum Pathol. 1998;29:1480–1487. 11 Overmeer RM, Gourdin AM, Giglia-Mari A, et al. Replication factor C recruits DNA polymerase delta to sites of nucleotide excision repair but is not required for PCNA recruitment. Mol Cell Biol. 2010;30: 4828–4839. 12 .PPS+01BMFQ434BMBEJ3/FUBM&GGFDUTPGVMUSBWJPMFU#FYQPTVSF on the expression of proliferating cell nuclear antigen in murine skin. Photochem Photobiol. 2004;80:587–595. 13 #BVN)1.FVSFS*6OUFSFHHFS(&YQSFTTJPOPGQSPMJGFSBUJPOBTTPDJBUFE proteins (proliferating cell nuclear antigen and Ki-67 antigen) in Bowen’s disease. Br J Dermatol. 1994;131:231–236. 4 Soyer HP. Ki 67 immunostaining in melanocytic skin tumors. Correlation with histological parameters. J Cutan Pathol. 1991;18:264–272. 5 'FSOBOEF['JHVFSBT.51VJH-.VTVMFO&FUBM1SPHOPTUJDTJHOJåDBODF of p27kip1, p45skp2 and Ki67 expression profiles in Merkel cell 14 Hall PA, McKee PH, Menage HD, Dover R, Lane DP. High levels of p53 protein in UV-irradiated normal human skin. Oncogene. 1993;8:203–207. 15 Freudenthal BD. Studies of proliferating cell nuclear antigen and its role in translesion synthesis [PhD dissertation]. Iowa City: University of Iowa; 2010. 16 McDonough P, Castilla C, Tumer G, Lambert WC. Interpretation of Ki-67 stain confounded by patient exposure to ultraviolet radiation prior to skin biopsy. J Euro Acad Venereol Dermatol. [In press.] VINTAGE LABEL $PVSUFTZPG#VZ&OMBSHF1IJMBEFMQIJB1" SKINmed. 2012;10:90–92 92 *OUFSQSFUBUJPOPG$FMM1SPMJGFSBUJPO.BSLFST ONE PRESCRIPTION. TWO POWERFUL EFFECTS. The power to calm inflammatory acne Inflammation is an important aspect in the pathophysiology of acne1 Both laboratory and clinical studies document the anti-inflammatory effects of minocycline1 + Complementary T 3 Calming Wipes Soothing and alcohol-free — part of a complete approach to acne treatment TM The power to eradicate P acnes Significant reduction in P acnes —even up to 3 weeks after discontinuation2 A decrease in P acnes can lead to a drop in pro-inflammatory cytokines and reduced inflammation1 Minimal resistance in an in vitro study —The majority of tetracycline-resistant P acnes were cross-resistant to doxycycline—but sensitive to minocycline*3 C ALM I NG WI P ES (30 WIPES) The only pelletized form of Minocycline available... A dual approach to acne care For more information, go to www.minocin-kit.com The most common adverse events associated with MINOCIN are nausea, vomiting, and diarrhea. CNS adverse effects may include dizziness, vertigo, and headache. Important Information The most common adverse events associated with MINOCIN are nausea, vomiting, and diarrhea. Central nervous system adverse events including light-headedness, dizziness, or vertigo have been reported with minocycline therapy, but are generally transient in nature. Other adverse events include tinnitus, headache, sedation, and skin pigmentation, particularly on the face and mucous membranes. MINOCIN is contraindicated in persons who have shown hypersensitivity to any of the tetracyclines or to any of the components of the product formulation. WARNING: MINOCIN PelletFilled Capsules, like other tetracycline-class antibiotics, can cause fetal harm when administered to a pregnant woman. The use of drugs of the tetracycline class during tooth development (last half of pregnancy, infancy, and childhood to the age of 8 years) may cause permanent discoloration of teeth (yellow-gray-brown). Concurrent use of tetracyclines may render oral contraceptives less effective. References: 1. SapadinAN,Fleischmajer R.Tetracyclines:nonantibiotic properties and their clinical implications. JAmAcad Dermatol. 2006;54(2):258-265. 2. Leyden JJ,McGinley KJ,KligmanAM.Tetracycline and minocycline treatment. Arch Dermatol. 1982;118(1):19-22. 3. Hubbell CG,Hobbs ER,RistT,White JW Jr.Efficacy of minocycline compared with tetracycline in treatment of acne vulgaris. Arch Dermatol.1982;118(12):989-992. *In vitro activity does not necessarily correlate to in vivo activity. ©2010 Triax Pharmaceuticals, LLC All rights reserved. Printed in USA. MN-0810-280 7PMVNFt*TTVF March/April 2012 INFECTIOUS DISEASE CAPSULES Jack M. Bernstein, MD, Section Editor The Lion Is NOT Sleeping Tonight David R. Carr, MD;1,4 Jack M. Bernstein, MD;2,3 Julian Trevino, MD1,4 A ZFBSPME "GSJDBO XPNBO QSFTFOUFE XJUI NVMUJQMF NNUPNNEFSNBMQBQVMFTUIBUIBECFFOFWPMWJOH PWFS TFWFSBM XFFLT ɨFZ XFSF QSJNBSJMZ PWFS UIF FBST 'JHVSF EPSTBMTVSGBDFPGUIFIBOETFYUFOTPSTVSGBDFPGUIF GPSFBSNTEJTUBMBTQFDUTPGUIFMPXFSFYUSFNJUJFTBOEEPSTBMTVSGBDFPGUIFGFFU'JHVSF *OBEEJUJPOUIFQBUJFOUIBEJOEVSBUFE QMBRVFTPWFSUIFFBSMPCFTBOEGPSFIFBE'JHVSF XJUINPEFSBUF MPTTPGUIFFZFCSPXTɨFSFXBTBNJMETFOTPSZEFëDJUPWFSUIF MFGUEJTUBMBTQFDUTPGUIFBSNTBOESJHIUEJTUBMBTQFDUTPGUIFMPXFS FYUSFNJUZPONPOPëMBNFOUUFTUJOH"EFSNBMOPEVMFXBTOPUFE PWFS&SCTQPJOUPOUIFMFGUTJEFPGUIFOFDLɨFQBUJFOUEFOJFE QSPCMFNTXJUIIFSWJTJPOPSBIJTUPSZPGQSFWJPVTHFOJUBMVMDFST 4IFIBESFDFOUMZJNNJHSBUFEUPUIF6OJUFE4UBUFTGSPN5BO[BOJB 4IFIBEOPTJHOJëDBOUNFEJDBMIJTUPSZBOEXBTOPUUBLJOHBOZ NFEJDBUJPO4FWFSBMGVMMUIJDLOFTTQVODICJPQTJFTXFSFPCUBJOFE BOE DIBOHFT XFSF TFFO DPOTJTUFOU XJUI B NZDPCBDUFSJBM JOGFDUJPO 3FTVMUT GSPN B 'JUF'BSBDPoNPEJëFE BDJEGBTU TUBJO XFSF QPTJUJWFBOEBQSFTVNQUJWFEJBHOPTJTPGMFQSPTZXBTNBEF6QPO DPOTVMUBUJPOXJUIUIF/BUJPOBM)BOTFOT%JTFBTF$MJOJDBM$FOUFSUIFQBUJFOUXBTTUBSUFEPOBNVMUJESVHSFHJNFODMPGB[JNJOF EBQTPOFBOESJGBNQJO GPSBUPUBMPGNPOUIT DVUBOFPVT TJUFT 4PMJUBSZ TIPSUUFSN DPOUBDU XJUI BO JOGFDUFE QBUJFOUJTVTVBMMZJOTVïDJFOUGPSUSBOTGFSPGUIFCBDJMMVTɨFSJTL PG JOGFDUJPO JO UIF HFOFSBM QPQVMBUJPO IBT CFFO BQQSPYJNBUFE BUXIFSFBTJUJODSFBTFTUPJOJOEJWJEVBMTXIPIBWF MPOHUFSNDMPTFDPOUBDUXJUIJOGFDUFEQFSTPOT45 "MUIPVHIMFQSPTZIBTBXPSMEXJEFEJTUSJCVUJPOJUJTNPTUQSFWBMFOUJO*OEJB#SB[JMUIF%FNPDSBUJD3FQVCMJDPG$POHP5BO[BOJB /FQBM.P[BNCJRVF.BEBHBTDBS"OHPMBBOEUIF$FOUSBM"GSJDBO 3FQVCMJD12*OUIF6OJUFE4UBUFTDBTFTPGMFQSPTZBSFQSJNBSJMZTFFO JOJNNJHSBOUTBTJOUIFDBTFQSFTFOUFE BMUIPVHINVMUJQMFDBTFTBSF SFQPSUFEJOJOEJWJEVBMTOBUJWFUPUIF6OJUFE4UBUFTɨF/BUJPOBM )BOTFOT%JTFBTF3FHJTUSZSFQPSUFEDBTFTJOUIF6OJUFE4UBUFT JOPGXIJDIXFSFJEFOUJëFEBTJNNJHSBOUT NBUPVTMFQSPTZ-- BTTFFOJOUIJTDBTFJTUIFDMJOJDBMQSFTFOUBUJPOɨFCPSEFSMJOFGPSNTPGUIFEJTFBTFEFOPUFUIFTQFDUSVNPG JNNVOPMPHJD SFTQPOTFT CFUXFFO UIF QVSFMZ DFMMNFEJBUFE BOE BOUJCPEZNFEJBUFESFTQPOTFTTFFOJO55BOE--SFTQFDUJWFMZ DIAGNOSIS -FQSPTZ JT B EJïDVMU EJBHOPTJT UP NBLF QSJNBSJMZ EVF UP UIF SBSJUZ PG UIJT EJTFBTF JO UIF 6OJUFE 4UBUFT ɨJT TVHHFTUT UIBU B IJHI JOEFY PG TVTQJDJPO JT SFRVJSFE GPS NBLJOH UIF DPSSFDU EJBHOPTJT*UJTJNQPSUBOUGPSUIFQSBDUJUJPOFSUPVOEFSTUBOEUIF SBOHF PG DMJOJDBM NBOJGFTUBUJPOT BOE BWBJMBCMF EJBHOPTUJD UPPMT 8JUI FBSMJFS EFUFDUJPO BQQSPQSJBUF NVMUJESVH UIFSBQZ NBZ CF JOTUJUVUFEBOENPSCJEJUZSFEVDFE CLINICAL PRESENTATION -FQSPTZIBTUXPDMBTTJëDBUJPOTZTUFNTɨF3JEMFZ+PQMJOH4ZTUFNEJWJEFTMFQSPTZJOUPDBUFHPSJFTBDDPSEJOHUPDMJOJDBMBOE IJTUPQBUIPMPHJDëOEJOHTBOEOVNCFSPGCBDUFSJBJOUIFMFTJPOT 5BCMF* XIFSFBTUIF8PSME)FBMUI0SHBOJ[BUJPO8)0 IBT DSFBUFEBNPSFQSBHNBUJDTZTUFNUIBUEJWJEFTMFQSPTZJOUPUISFF -FQSPTZ)BOTFOTJTFBTF JTBDISPOJDJOGFDUJPVTEJTFBTFDBVTFE HSPVQT QBVDJCBDJMMBSZ TJOHMFMFTJPO QBVDJCBDJMMBSZ MFQCZUIFCBDJMMVTMycobacterium leprae*UJTSBSFMZGBUBMCVUJUJT SPTZoMFTJPOT BOE NVMUJCBDJMMBSZMFQSPTZMFTJPOT BTTPDJBUFEXJUIEJTBCMJOHTFRVFMBFɨFDISPOJDHSBOVMPNBUPVT ɨFDMJOJDBMNBOJGFTUBUJPOTBSFEFQFOEFOUPOUIFIPTUTJNNVOF JOGFDUJPO QSFGFSFOUJBMMZ BêFDUT UIF TLJO BOE QFSJQIFSBM OFSWFT SFTQPOTFUPUIFCBDJMMVT5VCFSDVMPJEMFQSPTZ55 PDDVSTXIFO ɨF LFZT UP FêFDUJWF USFBUNFOU BSF FBSMZ EJBHOPTJT BOE SBQJE DFMMNFEJBUFE JNNVOJUZ QSFWBJMT ɨ DZUPLJOFT IPXFWFS JOTUJUVUJPOPGNVMUJESVHUIFSBQZ JGΉUIFSFJTQSJNBSJMZBOBOUJCPEZSFTQPOTFɨDZUPLJOFT MFQSP- M leprae QSJNBSJMZ BêFDUT UIF TLJO BOE QFSJQIFSBM OFSWFT *O --POFDBOTFFOVNFSPVTQPPSMZEFëOFENBDVMFTQBQVMFTPS QMBRVFTQSJNBSJMZPWFSUIFGBDFEJTUBMFYUSFNJUJFTBOEUIFCVUUPDLT*GUIFSFJTEJêVTFJOëMUSBUJPOMFPOJOFGBDJFTDBOCFBQQSF5SBOTNJTTJPOPGUIFEJTFBTFJTQSFEPNJOBOUMZWJBOBTBMBOEPSBM DJBUFE "EEJUJPOBM DMJOJDBM TJHOT DBO JODMVEF UIJDLFOJOH PG UIF ESPQMFUTGSPNBOJOGFDUFEJOEJWJEVBMBOEMFTTGSFRVFOUMZGSPN FBSMPCFTMPTTPGUIFFZFMBTIFTBOEFZFCSPXTNBEBSPTJT MPXFS From Medical1 and Research2 Services, VA Medical Center, Dayton, OH; and the Department of Medicine3 and the Department of Dermatology,4 Boonshoft School of Medicine, Wright State University, Dayton, OH "EESFTTGPS$PSSFTQPOEFODF+VMJBO5SFWJOP.%0OF&MJ[BCFUI1MBDF4VJUF%BZUPO0)t&NBJMKVMJBOUSFWJOP!XSJHIUFEV SKINmed. 2012;10:94–97 94 ª1VMTF.BSLFUJOH$PNNVOJDBUJPOT--$ */'&$5*064%*4&"4&$"146-&4 March/April 2012 Figure 2. Multiple, 2–8 mm dermal papules over the dorsal surface of the feet. Figure 1. Multiple, 2–8 mm dermal papules over the ears. FYUSFNJUZFEFNBBOEBDRVJSFEJDIUIZPTJTPGUIFMPXFSFYUSFNJUJFT*O55UIFSFJTBTJOHMFPSWFSZGFXMFTJPOTɨFZBSFXFMM EFëOFE FSZUIFNBUPVT UP IZQPQJHNFOUFE NBDVMFT PS QMBRVFT XJUI B SBJTFE FEHF UIF QSFGFSSFE TJUF GPS CJPQTZ 0GUFO UIF MFTJPOTBSFIBJSMFTTXJUIIZQFTUIFTJBPSBOFTUIFTJB /FVSBM JOWPMWFNFOU DBO SFTVMU JO TFOTPSZ NPUPS BOE BVUPOPNJD JNQBJSNFOU (SBOVMPNBUPVT JOìBNNBUJPO DBO MFBE UP QBMQBCMFUIJDLFOJOHPGUIFOFSWFTNPTUDPNNPOMZUIFQPTUFSJPS UJCJBMOFSWF7ɨFTFQBMQBCMFOFSWFTDBOCFQBJOGVMBOEBSFBUBO JODSFBTFESJTLPGCFDPNJOHEBNBHFE4FRVFMBFPGOFSWFJOWPMWFNFOU BSF TJNJMBS UP UIPTF TFFO JO BOZ QFSJQIFSBM OFVSPQBUIZ JODMVEJOHUSBVNBUJDVMDFSBUJPOBOEJOGFDUJPO "OPUIFSNBOJGFTUBUJPOPGMFQSPTZJTUZQF*BOEUZQF**SFBDUJPOT .PTUDPNNPOMZTFFOBGUFSCFHJOOJOHBOUJNJDSPCJBMUIFSBQZUIFZ BSFBMTPTFFOXJUITUSFTTPSTTVDIBTJOGFDUJPOTBOEQSFHOBODZ5ZQF Figure 3. *OEVSBUFEQMBRVFTPWFSUIFGPSFIFBEXJUINPEFSBUF *SFBDUJPOTPSSFWFSTBMSFBDUJPOT PDDVSXIFOUIFJNNVOPMPHJD MPTTPGUIFFZFCSPXT SFTQPOTFUPM lepraeDIBOHFTJFGSPNBDFMMNFEJBUFEɨ UP BIVNPSBMɨ SFTQPOTFPSWJDFWFSTB.PTUDPNNPOMZUIJT NBUPVT QBUJFOUT*UJTQSJODJQBMMZBDVUBOFPVTTNBMMWFTTFMWBTDVMJQSFTFOUT BT BDVUF JOìBNNBUJPO JO TLJO MFTJPOT BOEPS OFSWFT UJTDBVTFECZBOFYVCFSBOUIVNPSBMSFTQPOTFɨFNPTUDPNNPO 5ZQF**SFBDUJPOTBSFQSJNBSJMZTFFOJO--BOECPSEFSMJOFMFQSP- NBOJGFTUBUJPO JT FSZUIFNB OPEPTVN MFQSPTVN ɨFTF QBUJFOUT SKINmed. 2012;10:94–97 95 ɨF-JPO*T/054MFFQJOH5POJHIU */'&$5*064%*4&"4&$"146-&4 March/April 2012 Table I. Ridley-Jopling Leprosy Classification CATEGORIES CLINICAL FINDINGS NERVE INVOLVEMENT BACILLI PRESENCE -FQSPNBUPVT MFQSPTZ /VNFSPVTQPPSMZEFëOFETZNNFUSJD NBDVMFTQBQVMFTOPEVMFTBOEPSEJêVTF JOëMUSBUJPO$BOMFBEUPMFPOJOFGBDJFTMPTT PGFZFMBTIFTTBEEMFOPTFBOEPSBDRVJSFE JDIUIZPTJT −-FTJPOBOFTUIFTJB.BZIBWFTZNNFUSJDOFSWF UIJDLFOJOHBOEBTUPDLJOHBOEHMPWFBOFTUIFTJB .BOZ #PSEFSMJOF MFQSPNBUPVT 4JNJMBSUPMFQSPNBUPVTMFQSPTZ +/−-FTJPOBOFTUIFTJB.BZIBWFTZNNFUSJDOFSWF .BOZ UIJDLFOJOH .JECPSEFSMJOF .BOZQPPSMZEFëOFEQMBRVFT +/−-FTJPOBOFTUIFTJB/FSWFNBZCFUIJDLFOFE UFOEFS .BOZ #PSEFSMJOFUVCFSculoid *OëMUSBUFEQMBRVFXJUIOVNFSPVTTBUFMMJUF MFTJPOT +-FTJPOBOFTUIFTJB/FSWFJTVTVBMMZUIJDLFOFE UFOEFS 'FX 5VCFSDVMPJE MFQSPTZ 0OFPSTFWFSBMXFMMEFëOFEJOëMUSBUFE IBJSMFTTQBQVMFTPSQMBRVFT0GUFOIZQPQJHNFOUFE +-FTJPOBOFTUIFTJB/FSWFJTVTVBMMZUIJDLFOFE UFOEFS /POF *OEFUFSNJOBUF 0OFPSTFWFSBMIZQPQJHNFOUFENBDVMFTXJUI WBSJBCMFEFëOJUJPOGSPNTVSSPVOEJOHTLJO +/−-FTJPOBOFTUIFTJB/FSWFNBZCFUIJDLFOFE UFOEFS /POF IBWFUFOEFSSFEQBQVMFTPSOPEVMFTPWFSUIFGBDFBOEFYUFOTPS DMJOJDBM QSBDUJDF JT NJOJNBM ɨF NBJO EFUSBDUPS JT UIBU JO UIF FYUSFNJUJFT"TFWFSFWBSJBOUPGUIFUZQF**SFBDUJPOJT-VDJPTQIF- NPTUEJïDVMUUPEJBHOPTFGPSNTPGMFQSPTZJF55BOECPSEFSMJOF OPNFOPOEFTDSJCFEBTBOFDSPUJ[JOHWBTDVMJUJTBTTPDJBUFEXJUI UVCFSDVMPJEUIFTFUFTUTEPOPUSFMJBCMZEFUFDUM leprae. WBTDVMBSUISPNCPTJTBOETVCTFRVFOUJTDIFNJDOFDSPTJT9 'JOBMMZUIFMFQSPNJOPS.JUTVEB UFTUJTQFSGPSNFECZJOKFDUJOH IFBULJMMFEM lepraeJOUSBEFSNBMMZ"UFTUSFTVMUJTEFFNFEQPTJDIAGNOSTIC TOOLS ɨFEJBHOPTJTPGMFQSPTZJTQSJNBSJMZDMJOJDBMBMUIPVHINVMUJQMF UJWFXIFOBOPEVMFGPSNTBUUIFJOKFDUJPOTJUFBQQSPYJNBUFMZ UPXFFLTMBUFSJOEJDBUJOHBDFMMNFEJBUFESFTQPOTFɨJTUFTUJT JOWFTUJHBUJPOTBSFBWBJMBCMF QPTJUJWFJO55BOECPSEFSMJOFUVCFSDVMPJEMFQSPTZ"MUIPVHIJU *GQPTTJCMFBTLJOCJPQTZTIPVMEBMXBZTCFQFSGPSNFEQSFGFSFOIBTTPNFQSPHOPTUJDWBMVFJUIBTOPEJBHOPTUJDWBMVFBOEJTOPU UJBMMZGSPNUIFBDUJWFFEHF ɨFUXPNPTUJNQPSUBOUëOEJOHT SPVUJOFMZQFSGPSNFE POIJTUPQBUIPMPHJDTUVEZBSFM lepraeJOUIFUJTTVFBOEHSBOVMPNBUPVTJOìBNNBUJPOBSPVOEUIFOFSWFT10ɨFCBDJMMJBSFNPTU DPNNPOMZ TUBJOFE XJUI UIF 'JUF'BSBDP UFDIOJRVF BMUIPVHI TREATMENT ;JFIM/FFMTFO BOE8BEF DBO BMTP CF VTFE "OPUIFS NFBOT GPS ɨFDVSSFOUUSFBUNFOUPGMFQSPTZJTDFOUFSFEPONVMUJESVHUIFSBQZ JEFOUJGZJOHCBDJMMJJTTMJUTLJOTNFBST"TNBMMTMJUJTNBEFJOBO *O UIF 6OJUFE 4UBUFT UIF /BUJPOBM )BOTFOT %JTFBTF $MJOJDBM JOWPMWFEBSFBBOETNFBSFEPOBHMBTTTMJEFɨFTMJEFJTTUBJOFE $FOUFS JO #BUPO 3PVHF -PVJTJBOB JT BO JNQPSUBOU SFTPVSDF BOEFYBNJOFEGPSCBDJMMJɨFTMJUTLJOJTQPTJUJWFJOOFBSMZ IUUQXXXISTBHPWIBOTFOTDMJOJDBMDFOUFSIUN *U TFSWFT BT B TPVSDF PG JOGPSNBUJPO BOE NFEJDBUJPOT *O FOEFNJD DPVOUSJFT PGDBTFTPG--PGCPSEFSMJOFMFQSPTZBOEPG554 UIF 8)0 TQFBSIFBET UIF FêPSU JO EFMJWFSJOH GSFF NVMUJESVH 4FSPMPHJDUFTUJOHGPSM lepraeJODMVEFTBOUJQIFOPMJDHMZDPMJQJE* UIFSBQZUPQBUJFOUT BOUJ1(* BOUJCPEZ OFPQUFSJO BOE MJQPBSBCJOPNBOOBO "T POF NJHIU FYQFDU UIF MFWFMT PG BOUJ1(* BOUJCPEJFT BSF IJHIFS ɨF8)0SFDPNNFOEBUJPOTPOMFQSPTZBSFCBTFEPOUIFOVNJO UIF NVMUJCBDJMMBSZ QBUJFOU DPNQBSFE XJUI QBVDJCBDJMMBSZ CFSPGTLJOMFTJPOTBOECBDJMMJOPUFEPOFYBNJOBUJPO5BCMF** 14 " SFDFOU SFQPSU QSPQPTFE GPMMPXJOH BOUJ1(* BOUJCPEZ USFOET ɨFTF HVJEFMJOFT BSF DPOUSPWFSTJBM BOE NBOZ TUJMM SFDPNNFOE BOENBZCFVTFGVMJONPOJUPSJOHSFTQPOTFUPUSFBUNFOUJO-- NPOUITPGUSFBUNFOUGPSNVMUJCBDJMMBSZEJTFBTFXIFSFBTDVSQBUJFOUT11 "EEJUJPOBMMZ TFWFSBM NPMFDVMBS CJPMPHJD UFDIOJRVFT SFOU8)0HVJEFMJOFTSFDPNNFOENPOUIT .VMUJESVHUIFSIBWFCFFOEFWFMPQFEJODMVEJOHNPMFDVMBSQSPCFTUBSHFUJOHCPUI BQZXBTTUBSUFEJOBGUFSESVHUIFSBQZXJUIBTJOHMFBHFOU %/"BOE3/"PGM lepraeBOEQPMZNFSBTFDIBJOSFBDUJPOUFDI- XBT BTTPDJBUFE XJUI EBQTPOF SFTJTUBODF115 "MUIPVHI SFTJTUBODF OJRVFTS3/"BOES%/"QSPCFTNBZCFIFMQGVMJOFWBMVBUJOH DPOUJOVFTUPCFBDPODFSONVMUJESVHUIFSBQZMFBETUPPOMZSBSF TNFBSOFHBUJWFFWPMWJOHNVMUJCBDJMMBSZEJTFBTFBOESFTQPOTFUP USFBUNFOU GBJMVSFT 3FMBQTF SBUFT IBWF CFFO BQQSPYJNBUFE UP USFBUNFOU126OGPSUVOBUFMZUIFVUJMJUZPGUIFTFJOWFTUJHBUJPOTJO SBOHFGSPNUPPGQFSTPOZFBST"EEJUJPOBMBHFOUT SKINmed. 2012;10:94–97 ɨF-JPO*T/054MFFQJOH5POJHIU */'&$5*064%*4&"4&$"146-&4 March/April 2012 REFERENCES Table II. Multidrug Therapy: World Health Organization Guidelines14 TYPE OF LEPROSY TREATMENT REGIMEN TREATMENT DURATION .VMUJCBDJMMBSZ 3JGBNQJDJONHFWFSZ MFTJPOT NPOUI %BQTPOFNHEBJMZ $MPGB[JNJOFNHEBJMZBOE NHFWFSZNPOUI NPOUIT 1BVDJCBDJMMBSZ 3JGBNQJDJONHFWFSZ oMFTJPOT NPOUI %BQTPOFNHEBJMZ NPOUIT 1BVDJCBDJMMBSZ 3JGBNQJDJONHPODF TJOHMFMFTJPO 0ìPYBDJONHPODF .JOPDZDMJOFNHPODF 0OFEPTF UIBUBSFBDUJWFBHBJOTUM lepraePUIFSUIBOUIPTFNFOUJPOFEJO 5BCMFΉ ** BSF DMBSJUISPNZDJO BOE ìVPSPRVJOPMPOF BOUJCJPUJDT FTQFDJBMMZQFìPYBDJOOPUBWBJMBCMFJOUIF6OJUFE4UBUFT 5SFBUNFOUPGUZQF*SFBDUJPOTJTXJUIPSBMQSFEOJTPOFɨFBJNJT UPEFDSFBTFUIFJOìBNNBUJPOBOEFZFOFSWFEBNBHFɨFUSFBUNFOU GPS UZQF ** SFBDUJPOT FSZUIFNB OPEPTVN MFQSPTVN JT JNNVOPTVQQSFTTJPOɨFNPTUDPNNPOUIFSBQZJTUIBMJEPNJEF UPNHEBJMZ *OTFWFSFSFBDUJPOTQSFEOJTPOFNBZCF OFFEFE 8BMLFS 4- -PDLXPPE %/+ -FQSPTZ Clin Dermatol. 2007;25: 165–172. 2 Global leprosy situation. Wkly Epidemiol Rec. 2005;80:289–295. 25:165–172. 3 Global leprosy situation. Wkly Epidemiol Rec. 2005;80:289–295. 4 3BNPTF4JMWB . EF $BTUSP .$3 .ZDPCBDUFSJBM JOGFDUJPOT *O #PMPH nia J, Jorizzo JL, Rapini RP. Dermatology/FX:PSL/:.PTCZ 1145–1152. 5 Canizares O, Harman R, Adriaans B. Leprosy. In: Clinical Tropical Dermatology OE FE #PTUPO ." #MBDLXFMM 4DJFOUJåD 165–200. 6 3JEMFZ%4+PQMJOH8)$MBTTJåDBUJPOPGMFQSPTZBDDPSEJOHUPJNNVOJUZ Int J Lepr. 1966;34:255–273. 7 $SPGU 31 3JDIBSEVT +) /PDIPMMT 1( 4NJUI 8$ /FSWF GVODUJPO impairment in leprosy: design, methodology, and intake status of a QSPTQFDUJWF DPIPSU TUVEZ PG OFX MFQSPTZ DBTFT JO #BOHMBEFTI Lepr Rev. 1999;70:140–159. 8 Quismorio FP, Rea T, Chandors, et al. Lucio’s phenomenon: an immune complex deposition syndrome in lepromatous leprosy. Clin Immunol Immunopathol. 1978;9:184–193. 9 Kaur C, Thami GP, Mohan H. Lucio phenomenon and Lucio leprosy. Clin Exp Dermatol. 2005;30:525–527. 10 Job CK 3FDFOU IJTUPQBUIPMPHJDBM TUVEJFT JO MFQSPTZ XJUI QBSUJDVMBS reference to early diagnosis and leprous neuropathy. Indian J Lepr. 2007;79:75–83. 11 Silva EA, Iyer A, Ura S, et al. Utility of measuring serum levels of BOUJ1(-*BOUJCPEZOFPQUFSJOBOE$SFBDUJWFQSPUFJOJONPOJUPSJOHMFQSPTZ QBUJFOUTEVSJOHNVMUJESVHUSFBUNFOUBOESFBDUJPOTTrop Med Int Health. 2007;12:1450–1458. 12 Kamal R, Dayal R, Katoch VM, Katoch K. Analysis of gene probes and HFOFBNQMJåDBUJPOUFDIOJRVFTGPSEJBHOPTJTBOENPOJUPSJOHPGUSFBUNFOU in childhood leprosy. Lepr Rev. 2006;77:141–146. CONCLUSIONS -FQSPTZJTBDISPOJDJOGFDUJPOUIBUIBTCFDPNFRVJUFSBSFJO UIF6OJUFE4UBUFTUIFSFGPSFUIFQSBDUJUJPOFSNVTUIBWFBIJHI JOEFYPGTVTQJDJPOJOPSEFSUPNBLFUIFBQQSPQSJBUFEJBHOPTJT8JUIFBSMJFSEFUFDUJPOBOESBQJEJOEVDUJPOPGNVMUJESVH UIFSBQZUIFFYUSFNFNPSCJEJUJFTBTTPDJBUFEXJUIMPOHTUBOEJOH JOGFDUJPODBOCFBWPJEFE SKINmed. 2012;10:94–97 1 13 Scollard DM, Adams LB, Gillis TP, et al. The continuing challenges of leprosy. Clin Microbiol Rev. 2006;19:338–381. 14 8PSME )FBMUI 0SHBOJ[BUJPO SFDPNNFOEFE .%5 SFHJNFOT IUUQXXX XIPJOUMFQNEUSFHJNFOTFOJOEFYIUNM"DDFTTFEPO+BOVBSZ 15 World Health Organization. Chemotherapy of leprosy for control programmes. Tech Rep Ser Geneva. 1982:675. 97 ɨF-JPO*T/054MFFQJOH5POJHIU 7PMVNFt*TTVF March/April 2012 PHOTO CAPSULES Ncoza C. Dlova, MBChB, FCDerm, Section Editor Actinomycetoma Ncoza C. Dlova, MBChB, FCDerm; Anisa Mosam, MBChB, FCDerm A O ZFBSPME CPZ QSFTFOUFE XJUI B NPOUI IJTUPSZ PG 0DDBTJPOBMESBJOJOHTJOVTFTXFSFPCTFSWFEɨFQBUJFOUXBTIVNBO BTZNQUPNBUJD NVMUJQMF OPEVMFT QBQVMFT BOE TPNF JNNVOPEFëDJFODZWJSVTOFHBUJWF4LJOCJPQTZBOEGVOHBMDVMUVSF VMDFSBUFE QMBRVFT JOWPMWJOH UIF HSPJO BOE SJHIU GPPU DPOëSNFEBDUJOPNZDFUPNBDBVTFECZNorcadia brasiliensis Figure 2. Actinomycetoma of the groin. Figure 1. Actinomycetoma of the right foot. From the Department of Dermatology, Nelson R. Mandela School of Medicine, Durban, South Africa "EESFTTGPS$PSSFTQPOEFODF/DP[B$%MPWB.#$I#'$%FSNt&NBJMEMPWBO!VL[OBD[B VINTAGE LABEL $PVSUFTZPG#VZ&OMBSHF1IJMBEFMQIJB1" SKINmed. 2012;10:98 98 ª1VMTF.BSLFUJOH$PNNVOJDBUJPOT--$ University of Athens Medical School, Athens, Greece WORLD CONGRESS OF COSMETIC DERMATOLOGY BY THE INTERNATIONAL ACADEMY OF COSMETIC DERMATOLOGY ATHENS, GREECE JUNE 27-30, 2013 www.wcocd2013.com [email protected] Congress Organising Bureau ERASMUS CONFERENCES TOURS & TRAVEL S.A. E-mail: [email protected] Website: www.erasmus.gr 7PMVNFt*TTVF March/April 2012 CASE STUDY Vesna Petronic-Rosic, MD, MSc, Section Editor Malignant Melanoma Arising Within Nevus Spilus Susan L. Karam, BS; Scott M. Jackson, MD "ZFBSPME$BVDBTJBONBOQSFTFOUFEXJUIBTVTQJDJPVTMFTJPOOFBSUIFMFGUBYJMMBEVSJOHBGVMMTLJOFYBNJOBUJPOUIBUXBTQFSGPSNFEGPSB QSFTFOUBUJPOGPSEFSNBUJUJTɨFQBUJFOUTUBUFEUIBUIFIBEUIFMFTJPOGPSTFWFSBMEFDBEFTCVUUIBUJUNBZIBWFCFDPNFNPSFSBJTFEPWFSUIF QBTUGFXNPOUIT)FEJEOPUUIJOLNVDIPGUIFDIBOHFTIPXFWFSCFDBVTFJUXBTUPIJNiKVTUBCJSUINBSLwɨ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ɨFTFOUJOFMMZNQIOPEFCJPQTJFTBTXFMMBTBDPNQVUFEUPNPHSBQIJDTDBOQFSGPSNFECZPODPMPHZTIPXFEOPFWJEFODFPGNFUBTUBUJDEJTFBTF4JODFUIFQSPDFEVSFUIFQBUJFOUIBTTIPXOOPTJHOTPGEJTFBTFSFDVSSFODF N FWVTTQJMVT/4 BMTPDPNNPOMZSFGFSSFEUPBTTQFDLMFE MFOUJHJOPVTOFWVT1JTBTLJOMFTJPODPNQPTFEPGBUBO UPCSPXOQJHNFOUFEQBUDITQPUUFECZTFWFSBMTNBMMFS EBSLFSNFMBOJDNBDVMFTPSQBQVMFT2–ɨFTFMFTJPOTBSFGPVOEJO UPPGUIFPWFSBMMQPQVMBUJPOo7&WFOUIPVHI/4JT DMBTTJDBMMZSFHBSEFEBTBCFOJHOMFTJPO8UIFSFIBWFCFFOTFWFSBM DBTFTSFQPSUFEJOUIFMJUFSBUVSFPGNBMJHOBOUNFMBOPNBEFWFMPQJOH XJUIJO UIJT FOUJUZ8–22 "U UIJT UJNF IPXFWFS UIF QSFDJTF SJTLGPSNBMJHOBODZXJUIJO/4IBTZFUUPCFEFUFSNJOFEɨF/4 MFTJPOJTUZQJDBMMZBTJOHMFOPOIBJSZMFTJPO2XJUIBCBDLHSPVOE QJHNFOUFEQBUDIBGFXDFOUJNFUFSTJOEJBNFUFSBOEUIBUJTEPUUFE CZNVMUJQMFTNBMMFSEBSLFSNBDVMFTPSQBQVMFTVTVBMMZNFBTVSJOH UPNNJOEJBNFUFS"MUIPVHINPTU/4MFTJPOTBSFEFTDSJCFE BTTNBMMDN PSNFEJVNoDN 7UIFSFIBWFBMTP CFFOSFQPSUTPGHJBOUMFTJPOTBTXFMMBTUIPTFJOB[PTUFSJGPSN EJTUSJCVUJPO11/4DBOCFGPVOEBOZXIFSFPOUIFCPEZCVUNPTU SFQPSUFEMFTJPOTBSFGPVOEPOUIFUSVOLPSFYUSFNJUJFT12ɨFTF MFTJPOTPDDVSGBJSMZFRVBMMZJONFOBOEXPNFO"MUIPVHITUVEJFT IBWFGPVOEUIBU/4PDDVSTXJUIFRVBMQSFWBMFODFXJUIJOEJêFSFOUSBDFT6DBTFSFQPSUTUFOEUPGFBUVSF$BVDBTJBOQBUJFOUT /4 JO B HSPVQ PG OFXCPSOT12 ɨF CBDLHSPVOE /4 MFTJPO JTNPTUDPNNPOMZGPVOEEVSJOHUIFëSTUZFBSPGMJGFJGOPUMBUFS BOEUIFTQPUUFENBDVMFTPSQBQVMFTIBWFCFFOPCTFSWFEUPEFWFMPQ FWFOMBUFSCFUXFFOUIFBHFTPGBOEZFBST%FTQJUFUIFTFë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iNFMBOPDZUJDHBSEFOwUIBUDBOHJWFSJTFUPBWBSJFUZPGEJêFSFOU MFTJPOTCBTFEPOUIFXBZJOXIJDINFMBOPDZUFTEJêFSFOUJBUF100OF FYQFSU TVQQPSUT /4 BT UIF iSPPUT PG UIF NFMBOPDZUJD HBSEFOw *U JT UIPVHIU UIBU /4 BSJTFT GSPN B MPDBMJ[FE EFGFDU JO OFVSBM DSFTU NFMBOPCMBTUT XIJDI NBZ CF JOìVFODFE CZ CPUI HFOFUJD BOE FOWJSPONFOUBMGBDUPST12ɨFNFMBOPDZUJDTUFNDFMMTEFWFMPQJOUP NFMBOPDZUFT JO UIF FNCSZPOJD EFSNJT BOE UIFJS QSPHFOZ UIFO ɨFSFIBTCFFOTPNFEFCBUFBTUPXIFUIFS/4JTBOBDRVJSFEPSDPO- NJHSBUFJOUPUIFFQJEFSNJTɨFTFNFMBOPDZUFTDBOEJêFSFOUJBUFJOUP HFOJUBMMFTJPO4VQQPSUGPSUIFUIFPSZUIBUUIFTFMFTJPOTBSFBDRVJSFE BWBSJFUZPGSFEVOEBOUMFTJPOTCFMPXUIFFQJEFSNJTXIJDIDPVME DPNFT GSPN B TUVEZ UIBU GPVOE OP FWJEFODF PG UIFTF MFTJPOT JO FYQMBJOUIFHSFBUWBSJBUJPOJODIBSBDUFSGPVOEBNPOHTU/4MFTJPOT OFXCPSOTBOEBOPUIFSTUVEZUIBUGPVOEPOMZUXPDBTFTPG ɨJTJOWFTUJHBUPSTVQQPSUTUIFJEFBPGPUIFSTUIBUBDPOHFOJUBMMFTJPO From the Department of Dermatology, Louisiana State University Health Science Center, New Orleans, LA Address for Correspondence: Scott M. Jackson, MD, LSUHSC, New Orleans, Department of Dermatology, 1542 Tulane Avenue, 6th Floor, /FX0SMFBOT-"t&NBJMTKBDLTPO!DPYOFU SKINmed. 2012;10:100–102 100 ª1VMTF.BSLFUJOH$PNNVOJDBUJPOT--$ $"4&456%: March/April 2012 JTPOFXIJDIEFWFMPQTXJUIJOUIFë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ɨF TQPUT IBWF CFFO GPVOE UP CF FJUIFS KVODUJPOBM DPNQPVOE PS EZTQMBTUJD OFWJ *OWFTUJHBUPST QSPQPTF UIF UIFPSZ UIBU /4 MFTJPOT DBO CF GVSUIFS EJWJEFE CBTFE PO XIFUIFS UIFZ IBWF NBDVMBS PS QBQVMBS TQPUT .BDVMBS /4 JT DPNQPTFE PG MFTJPOT XJUI VOJGPSNMZ ìBU EPUTJOBDIFDLFSCPBSEQBUUFSO)JTUPMPHJDBMMZUIFNBDVMBSUZQF TQPUT TIPX BO FMPOHBUJPO PG UIF JOUFSQBQJMMBSZ SJEHFT XJUI BO JODSFBTFE OVNCFS PG NFMBOPDZUFT BT XFMM BT JODSFBTFE NFMBOJO QJHNFOUJOUIFCBTBMMBZFSPGUIFFQJEFSNJT/FTUTPGNFMBOPDZUFT DBOBMTPCFGPVOEBUUIFEFSNPFQJEFSNBMKVODUJPOPGUIFUJQTPG UIFQBQJMMBFɨFCBDLHSPVOEQJHNFOUBUJPOIBTJODSFBTFENFMBOPDZUFTPOMZJOUIFCBTBMFQJEFSNBMMBZFSBOEJODSFBTFENFMBOJO EFQPTJUTJOUIFLFSBUJOPDZUFT1BQVMBS/4JTDIBSBDUFSJ[FECZB CBDLHSPVOE NBDVMF UIBU JT TVQFSJNQPTFE CZ NVMUJQMF QBQVMFT PS OPEVMFT BMTP JO B DIFDLFSCPBSE QBUUFSO ɨF QBQVMFT IBWF NFMBOPDZUJDOFTUTJOUIFQBQJMMBSBOESFUJDVMBSEFSNJTSFTVMUJOH JOFJUIFSBEFSNBMPSDPNQPVOENFMBOPDZUJDOFWJQBUUFSOɨF CBDLHSPVOE NBDVMF DPOTJTUT PG FMPOHBUFE JOUFSQBQJMMBSZ SJEHFT BTXFMMBTFMFWBUFEBNPVOUTPGNFMBOJOBOENFMBOPDZUFTJOUIF CBTBMMBZFSPGUIFFQJEFSNJT1"MUIPVHIUIFNBDVMBSGPSNPG/4 JTNPSFMJLFMZUPEFHFOFSBUFJOUPNFMBOPNBCPUIGPSNTIBWFUIF BCJMJUZUPVOEFSHPNBMJHOBOUUSBOTGPSNBUJPO Figure 1. Oval tan patch studded with hyperpigmented macules and melanoma at the margin of lesion. .PSFUIBODBTFTPG/4EFHFOFSBUJOHUPNBMJHOBOUNFMBOPNB JODMVEJOH B GFX GBUBM DBTFT IBWF CFFO SFQPSUFE IPXFWFS UIFFYBDUSJTLGPSNBMJHOBOUEFHFOFSBUJPOJTDVSSFOUMZVOLOPXO *OWFTUJHBUPST IBWF GPVOE UIBU UIFSF JT OP TJHOJëDBOUMZ FMFWBUFE JODJEFODF PG NBMJHOBOU NFMBOPNB JO B QPQVMBUJPO XJUI /4 Figure 3. 4VQFSåDJBMTQSFBEJOHNFMBOPNBIFNBUPYZMJO and eosin, original magnification ×40). Figure 2. 4VQFSåDJBMTQSFBEJOHNFMBOPNBIFNBUPYZMJO and eosin, original magnification ×10). SKINmed. 2012;10:100–102 101 .BMJHOBOU.FMBOPNB"SJTJOH8JUIJO/FWVT4QJMVT $"4&456%: March/April 2012 MFTJPOTBTDPNQBSFEXJUIBDPOUSPMHSPVQPGHFOFSBMEFSNBUPMPHZ PVUQBUJFOUT JNQMZJOH UIBU /4 EPFT OPU QPTTFTT B QBSUJDVMBSMZ IJHI SJTL PG NBMJHOBOU QPUFOUJBM ɨF SJTL PG /4 EFHFOFSBUJOH JOUP NBMJHOBODZ EPFT OPU TFFN UP CF BTTPDJBUFE XJUI TFY BHF PSSBDFIPXFWFSNPTUSFQPSUFEDBTFTPGNBMJHOBOUUSBOTGPSNBUJPOIBWFCFFOGPVOEJO$BVDBTJBOPSCMBDLQBUJFOUT0OFSJTL GBDUPSGPSNBMJHOBODZJTUIFTJ[FPGUIF/4MFTJPOɨFNBKPSJUZ PGNFMBOPNBTSFQPSUFEJOUIFMJUFSBUVSFBSFGPVOEPONFEJVN o DN PS MBSHF /4 MFTJPOT *OWFTUJHBUPST SFDFOUMZ SFQPSUFEUIBUPGNFMBOPNBTEFWFMPQFEPO[PTUFSJGPSN/4 BOE EFWFMPQFE PO HJBOU MFTJPOT #FDBVTF UIFTF UZQFT PG MFTJPOT BSF NVDI MFTT DPNNPO UIBO UIF TNBMM PS NFEJVN /4 MFTJPOTUIFHJBOUBOE[PTUFSJGPSNMFTJPOTIBWFBIJHIFSSFMBUJWF SJTLPGNBMJHOBOUUSBOTGPSNBUJPO "OPUIFS GBDUPS TVHHFTUFE BT B QPTTJCMF QSFDVSTPS UP NBMJHOBOU NFMBOPNB JT EZTQMBTJB XJUIJO UIF OFWVT 3FTFBSDIFST EFTDSJCF JOUSBFQJEFSNBMNFMBOPDZUJDEZTQMBTJBBTBDPNNPOGFBUVSFJOQSFDVSTPSMFTJPOTPGNFMBOPNB6TJOHìPXDZUPNFUSZPUIFSTUVEJFT TIPXOVDMFBSBOFVQMPJEZJOUIFNFMBOPNBBTXFMMBTJOΉUIFEBSLFS TQPUT PG UIF /4 MFTJPO 4UVEJFT PG UIFTF EZTQMBTUJD /4 MFTJPOT TIPXBMUFSBUJPOTUPUIFTUSPNBBTXFMMBTJODSFBTFEWBTDVMBSJ[BUJPO BOEMJHIUJOìBNNBUPSZJOëMUSBUJPOPGUIFEFSNJT CONCLUSIONS #FDBVTF NBOZ RVFTUJPOT SFNBJO TVSSPVOEJOH UIF NBMJHOBOU QPUFOUJBMPG/4UIFNBOBHFNFOUPGUIFTFMFTJPOTIBTOPUCFFO QSFDJTFMZ EFëOFE $BSFGVM PCTFSWBUJPO GPS DIBOHFT UIBU DPVME JOEJDBUF UIF EFWFMPQNFOU PG NFMBOPNB JT SFDPNNFOEFE10 1BUJFOU FEVDBUJPO BCPVU TFMGFYBNJOBUJPO JT PG VUNPTU JNQPSUBODF JO UIF NBOBHFNFOU PG QBUJFOUT BêFDUFE XJUI UIJT TLJO MFTJPO0ODFBNFMBOPNBEFWFMPQTJUIBTBTJNJMBSQSPHOPTJTBOE NBOBHFNFOUBTDPNQBSFEXJUIPUIFSNFMBOPNBT0WFSBMMJOEJWJEVBMJ[FENBOBHFNFOUPGFBDIDBTFJTSFDPNNFOEFEEVFUPUIF MBDL PG FTUBCMJTIFE HVJEFMJOFT GPS UIFTF DBTFT 8F SFDPNNFOE PVSQBUJFOUTUPIBWFUIFMFTJPOFYBNJOFECZBEFSNBUPMPHJTUFWFSZ UPZFBST/4JTBOFOUJUZUIBUSFRVJSFTGVSUIFSTUVEZHJWFOJUT XFMMEFëOFENBMJHOBOUQPUFOUJBM8JUIPVSDBTFXFBEEUPUIF LOPXOJOGPSNBUJPOSFHBSEJOHUIJTMFTJPOXJUIUIFIPQFUIBUXJUI UJNF JU XJMM DPNF UP CF NPSF DPNQMFUFMZ VOEFSTUPPE8F BMTP SFNJOEUIFDMJOJDJBOUIBUBMUIPVHISBSFNBMJHOBOUEFHFOFSBUJPO PG /4 JT QPTTJCMF BOE DMJOJDJBOT TIPVME DPOTJEFS UIJT GBDU JO FWBMVBUJOHQBUJFOUTXJUIUIJTVOVTVBMTLJOMFTJPO REFERENCES 1 2 7JEBVSSJEFMB$SV[))BQQMF35XPEJTUJODUUZQFTPGTQFDLMFEMFOUJHJ OPVTOFWJDIBSBDUFSJ[FECZNBDVMBSWFSTVTQBQVMBSTQFDLMFTDermatologyo Cohen JH, Minkin W, Frank SB. Nevus spilus. Arch Dermatol. 1970; o SKINmed. 2012;10:100–102 102 3 (SJOTQBO%$BTBMB""CVMBåB+FUBM.FMBOPNBPOEZTQMBTUJDOFWVT spilus. Int J Dermatolo 4 .FHVFSEJUDIJBO"/$IFOFZ35,BOF+.SE/FWVTTQJMVTXJUITZODISP nous melanomas: case report and literature review. J Cutan Med Surg. o 5 Sigg C, Pelloni F, Schnyder UW. Frequency of congenital nevi, nevi spili BOEDBGÏBVMBJUTQPUTBOEUIFJSSFMBUJPOUPOFWVTDPVOUBOETLJODPNQMFY JPOJODIJMESFODermatologicao 6 .D-FBO%*(BMMBHIFS31i4VOCVSOwGSFDLMFTDBGÏBVMBJUNBDVMFTBOE other pigmented lesions of schoolchildren: the Vancouver Mole Study. J Am Acad Dermatolo 7 ,PQG "8 -FWJOF -+ 3JHFM %4 FU BM 1SFWBMFODF PG DPOHFOJUBMOFWVT like nevi, nevi spili, and café au lait spots. Arch Dermatol o 8 7BTRVF[%VWBM + 4PMB ." $POUSFSBT.FKVUP ' FU BM .BMJHOBOU NFMB noma developing in a speckled lentiginous nevus. Int J Dermatol. o 9 $PSSBEJO.5;BUUSB&'JPSFOUJOP3FUBM/FWVTTQJMVTBOENFMBOPNB case report and review of the literature. J Cutan Med Surg. 2010;14: o 10 4DIBGGFS +7 0SMPX 4+ -B[PWB 3 FU BM 4QFDLMFE MFOUJHJOPVT OFWVT within the spectrum of congenital melanocytic nevi. Arch Dermatol. o 11 4UFSO+#)BVQU)"BSPOTPO$.BMJHOBOUNFMBOPNBJOBTQFDLMFE[PT teriform lentiginous nevus. Int J Dermatolo 12 3IPEFT"3.JIN.$+S0SJHJOPGDVUBOFPVTNFMBOPNBJOBDPOHFOJUBM dysplastic nevus spilus. Arch Dermatolo 13 ,VSCBO 3' 1SFGGFS '* 4PCFS "+ FU BM 0DDVSSFODF PG NFMBOPNB JO iEZTQMBTUJDwOFWVTTQJMVTSFQPSUPGDBTFBOEBOBMZTJTCZýPXDZUPNFUSZ J Cutan Patholo 14 8FJOCFSH+.4DIVU[FS1+)BSSJT3.FUBM.FMBOPNBBSJTJOHJOOFWVT spilus. Cutiso 15 #PMPHOJB +- 'BUBM NFMBOPNB BSJTJOH JO B [PTUFSJGPSN TQFDLMFE MFOUJHJ nous nevus. Arch Dermatolo 16 Haenssle HA, Kaune KM, Buhl T, et al. Melanoma arising in segmental OFWVTTQJMVTEFUFDUJPOCZTFRVFOUJBMEJHJUBMEFSNBUPTDPQZJ Am Acad Dermatolo 17 1JBOB4(FMMJ.$(SFO[J-FUBM.VMUJGPDBMNFMBOPNBBSJTJOHPOOFWVT spilus. Int J Dermatolo 18 ;FSFO#JMHJO*(àS4"ZEJO0FUBM.FMBOPNBBSJTJOHJOBIBJSZOFWVT spilus. Int J Dermatolo 19 :POFZBNB,,BNBEB/.J[PHVDIJ.FUBM.BMJHOBOUNFMBOPNBBOE acquired dermal melanocytosis on congenital nevus spilus. J Dermatol. o 20 #PSSFHP-)FSOBOEF[4BOUBOB+#BF[0FUBM/BFWVTTQJMVTBTBQSF cursor of cutaneous melanoma: report of a case and literature review. Clin Exp Dermatolo 21 3àUUFO"(PPT./FWVTTQJMVTXJUINBMJHOBOUNFMBOPNBJOBQBUJFOUXJUI OFVSPåCSPNBUPTJTArch Dermatolo 22 8BHOFS3'+S$PUUFM8**OTJUVNBMJHOBOUNFMBOPNBBSJTJOHJOBTQFDLMFE lentiginous nevus. J Am Acad Dermatolo 23 Kaur TD, Kanwar AJ. Giant nevus spilus and centrofacial lentiginosis. Pediatr Dermatolo 24 8BMUPO3(+BDPCT")$PY"+1JHNFOUFEMFTJPOTJOOFXCPSOJOGBOUT Br J Dermatolo 25 $SBNFS 4' 4QFDLMFE MFOUJHJOPVT OFWVT OFWVT TQJMVT UIF iSPPUTw PG UIFiNFMBOPDZUJDHBSEFOwArch Dermatolo 26 Cohen LM. Nevus spilus: congenital or acquired? 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JODSFBTFE MZTPTPNFT PO CPUI FMFDUSPO NJDSPTDPQZ BOEQTFVEPDZTUìVJEBOBMZTJTEJTQSPWJOHUIJTFBSMZIZQPUIFTJT12 "TVCTFRVFOUUIFPSZTVHHFTUFEUIBUBOFNCSZPMPHJDBMEFGFDUMFGU SFTJEVBMQMBOFTPGUJTTVFJOUIFBVSJDMFQSFEJTQPTJOHJOEJWJEVBMTUP QTFVEPDZTUGPSNBUJPOɨJTEFGFDUNBEFUIFBVSJDMFJOIFSFOUMZTVTDFQUJCMFUPTIFBSJOHGPSDFTPGNJOPSUSBVNBMFBEJOHUPFYQBOTJPO PGSFTJEVBMUJTTVFQMBOFTXJUITVCTFRVFOUìVJEBDDVNVMBUJPO "GUFSOPUJOHMZNQIPDZUJDQFSJWBTDVMBSJOëMUSBUJPOPOIJTUPMPHJD FYBNJOBUJPOFYQFSUTQSPQPTFEBOVOEFSMZJOHJOìBNNBUPSZDBTDBEFBTUIFFUJPMPHZPGQTFVEPDZTUGPSNBUJPO11"MZNQIPDZUJD JOëMUSBUFJOFYDJTFEQTFVEPDZTUTQFDJNFOTXBTTJNJMBSMZSFQPSUFE1 ɨJTIPXFWFSIBTCFFOSFGVUFECZPUIFSTXIPEFTDSJCFQTFVEPDZTUT BT OPOJOìBNNBUPSZ OPUJOH TQBSTF QFSJWBTDVMBS MZNQIPDZUJDJOëMUSBUFPOIJTUPMPHJDFYBNJOBUJPO10 From the Department of Dermatology and Cutaneous Biology, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA Address for Correspondence: Alexis Sheaffer, BS, 1000 Walnut Street, Orlowitz Apartment 609, Philadelphia, PA 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BOE . -$ JT SBSF JO ".-.5P PVS LOPXMFEHF POMZ GPVS DBTFT PG -$ XJUI ".-. IBT CFFO SFQPSUFE *OWFTUJHBUPST EFëOFE POF DBTF PG -$ BNPOH ".-. QBUJFOUT12 0UIFS FYQFSUT EFëOFE BOPUIFS DBTF PG -$ BNPOH ".-. QBUJFOUT "OPUIFS SFQPSUPGBQBUJFOUXJUI-$IBEBDVUBOFPVTOPEVMBSFSVQUJPO "TJOPVSDBTF-$SFQSFTFOUFEUIFëSTUDMJOJDBMNBOJGFTUBUJPOPG ".-.*OWFTUJHBUPSTSFQPSUFEBZFBSPMEXPNBOEJBHOPTFEXJUI".-.4IFIBEPOFOPEVMFBTUIFNBOJGFTUBUJPO PG-$ From the Department of Dermatology, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey Address for Correspondence: Ayse Esra Koku Aksu, MD, Eskisehir Osmangazi University Faculty of Medicine, Department of Dermatology, &TLJTFIJS5VSLFZt&NBJMFTSBBLTV!HNBJMDPN SKINmed. 2012;10:108–110 108 ª1VMTF.BSLFUJOH$PNNVOJDBUJPOT--$ $"4&456%: March/April 2012 JTVTFGVMCVUJNNVOPTUBJOTGPS$%BOE$%BSFJOTVïDJFOUMZ TFOTJUJWF *O BOPUIFS TUVEZ MZTP[ZNF BOE NZFMPQFSPYJEBTF XFSF GPVOEUPCFTFOTJUJWFNBSLFSTPGNZFMPJEMJOFBHF8 CONCLUSIONS -$ JT BDDFQUFE BT B TJHO PG QPPS QSPHOPTJT ɨF USFBUNFOU JT EJSFDUFEBUUIFMFVLFNJBJUTFMG 5SFBUNFOUSFTQPOTFPG-$JTJOMJOFXJUIUIFUSFBUNFOUSFTQPOTF PGUIFIFNBUPMPHJDEJTFBTF12 ɨJT DBTF XBT VOJRVF CFDBVTF UIF QBUJFOU DPOTVMUFE PVS DMJOJD XJUIBOFDSPUJDVMDFSXJUIPVUQSJPSIJTUPSZPGNZFMPJEMFVLFNJB PSPUIFSIFNBUPMPHJDEJTPSEFS/FDSPTJTJTBOVOVTVBMQSFTFOUBUJPOPG-$BOEJUJTFWFOIBSEFSUPEJBHOPTFXJUIPVUBIFNBUPMPHJDEJTPSEFS Figure 1. /FDSPUJDMFTJPOPOUIFMFH 8F BMTP XBOU UP FNQIBTJ[F UIF JNQPSUBODF PG FYBNJOJOH UIF IJTUPQBUIPMPHZ PG MPOHTUBOEJOH MFH VMDFST BOE CMPPE UFTUJOH IFNPHSBQIZQFSJQIFSBMCMPPETNFBS PGQBUJFOUTXIPDPNQMBJO PGXFBLOFTTPSXFJHIUMPTT REFERENCES Figure 2. 1FSJBEOFYBMJOåMSBUFPGOFPQMBTUJDDFMMT IFNBUPYZMJOFPTJOTUBJOPSJHJOBMNBHOJåDBUJPO¨ -$JTNPSFDPNNPOJOQBUJFOUTXJUILOPXOIFNBUPMPHJDEJTFBTF -FTT GSFRVFOUMZ IPXFWFS -$ NJHIU BQQFBS BT UIF ëSTU TZNQUPNPGMFVLFNJB*OUIFMBUUFSDBTFJUCFDPNFTIBSEFSUP EJBHOPTF-$IFODFNBLJOHUIFIJTUPQBUIPMPHZBOEJNNVOQIFOPUZQJOHNPSFJNQPSUBOUJOBDDVSBUFEJBHOPTJT 0O IJTUPQBUIPMPHJDBM FWBMVBUJPO UIF EFHSFF PG JOëMUSBUJPO WBSJFT GSPN TNBMM QFSJWBTDVMBS EFQPTJUT UP EFOTF EJêVTF JOëMUSBUFT DPNQMFUFMZëMMJOHUIFEFSNJTBOEPGUFOFYUFOEJOHJOUPUIFTVCDVUBOFPVT GBU17 .BMJHOBOU NZFMPJE DFMMT UFOE UP BQQFBS DZUPMPHJDBMMZ NPOPUPOPVT/VDMFJBSFSPVOEUPPWBMBOEDISPNBUJONBZCFFWFOMZ EJTQFSTFE*NNVOPIJTUPDIFNJTUSZJTHFOFSBMMZSFRVJSFEGPSDPOëSNBUJPOBTXFMMBTFYBNJOBUJPOPGQFSJQIFSBMCMPPEBOECPOFNBSSPX $FMMTBSFQPTJUJWFGPSNZFMPQFSPYJEBTF.ZFMPJEDFMMTEPOPUFYQSFTT #MJOFBHFPS5MJOFBHFNBSLFST184PNFFYQFSUTDMBJNUIBU$%BOE MZTP[ZNFJNNVOPTUBJOTBSFUIFNPTUTFOTJUJWFJNNVOPTUBJOTJOUIF EFUFDUJPOPGNZFMPJEMFVLFNJBDVUJT.ZFMPQFSPYJEBTFJNNVOPTUBJO SKINmed. 2012;10:108–110 1 #FOOFUU+.$BUPWTLZ%%BOJFM.5FUBM1SPQPTBMGPSUIFSFDPHOJUJPOPG NJOJNBMMZEJGGFSFOUJBUFEBDVUFNZFMPJEMFVLBFNJB".-.0 Br J Haematolo 2 "SCFS %" #SVOOJOH 3% 0SB[J " FU BM "DVUF NZFMPJE MFVLBFNJB OPU PUIFSXJTF TQFDJåFE BOE SFMBUFE QSFDVSTFS OFPQMBTN *Où4XFSEMPX4) $BNQP&)BSSJT/-+BGGF&41JMFSJ4"4UFJO)5IJFMF+7BSEJNBO+8 FET WHO Classification of Tumours of Haematopoietic and Lymphoid TissuesUIFE(FOFWB4XJU[FSMBOE8)01SFTTo 3 1IJMMJQT 4+ 8IJTOBOU +1 )ZQFSUFOTJPO BOE TUSPLF *O -BSBHI +) #SFOOFS #. FET Hypertension: Pathophysiology, Diagnosis and Management.OEFE/FX:PSL/:3BWFO1SFTTo 4 4UBXJTLJ ." 4LJO NBOJGFTUBUJPOT PG MFVLFNJBT BOE MZNQIPNBT Cutis o 5 %FTDI+,4NPMMFS#35IFTQFDUSVNPGDVUBOFPVTEJTFBTFJOMFVLFNJBT J Cutan Patholo 6 3BTIJE #" )PVTINBOE # )FGGFSOBO .1 )FNBUPMPHJD EJTFBTFT *O 8PMG , (PMETNJUI -" ,BU[ 4* (JMDISFTU #" 1BMMFS "4 -FGGFMM %+ FETFitzpatrick’s Dermatology Treatment in General MedicineUIFE /FX:PSL/:.D(SBX)JMMo 7 8BUTPO,..VGUJ(4BMJTCVSZ+3FUBM4QFDUSVNPGDMJOJDBMQSFTFOUB tion, treatment and prognosis in a series of eight patients with leukaemia DVUJTClin Exp Dermatolo 8 ,BEEV 4 ;FOBIMJL 1 #FIBN4DINJE $ FU BM 4QFDJåD DVUBOFPVT JOåM trates in patients with myelogenous leukemia: a clinicopathologic study PGQBUJFOUTXJUIBTTFTTNFOUPGEJBHOPTUJDDSJUFSJBJ Am Acad Dermatolo 9 .BSLPXTLJ53.BSUJO%#,BP('FUBM-FVLFNJBDVUJTBQSFTFOUJOH TJHOJOBDVUFQSPNZFMPDZUJDMFVLFNJBArch Dermatolo 10 #BFS.3#BSDPT.'BSSFMM)FUBM"DVUFNZFMPHFOPVTMFVLFNJBXJUI MFVLFNJBDVUJT&JHIUFFODBTFTTFFOCFUXFFOBOECancer o 11 4IBJLI #4 'SBOU[ & -PPLJOHCJMM %1 )JTUPMPHJDBMMZ QSPWFO MFVLFNJB DVUJT DBSSJFT B QPPS QSPHOPTJT JO BDVUF OPOMZNQIPDZUJD MFVLFNJB Cutiso /FDSPUJD6MDFS".BOJGFTUBUJPOPG-FVLFNJB$VUJT $"4&456%: March/April 2012 12 "HJT ) 8FMUFSNBOO " 'POBUTDI $ FU BM " DPNQBSBUJWF TUVEZ PO EF mographic, hematological, and cytogenetic findings and prognosis in BDVUFNZFMPJEMFVLFNJBXJUIBOEXJUIPVUMFVLFNJBDVUJTAnn Hematol o 15 #FOVDDJ3"OOFTTJ(4JHOPSFUUJ4FUBM.JOJNBMMZEJGGFSFOUJBUFEBDVUF NZFMPJEMFVLBFNJBSFWFBMFECZTQFDJåDDVUBOFPVTMFTJPOTBr J Dermatolo 16 .BSUJOP34VSFEB"4JUKBT%FUBM-FVLFNJDEFSNBMJOåMUSBUFBUUIFFYJU TJUFPGBDFOUSBMWFOPVTDBUIFUFSHaematologicao 13 .JDIFM ( #PVMBE ' 4NBMM 5/ FU BM 3JTL PG FYUSBNFEVMMBSZ SFMBQTF following allogeneic bone marrow transplantation for acute myeloge OPVTMFVLFNJBXJUIMFVLFNJBDVUJTBone Marrow Transplant o 17 .DLFF 1) $BMPOKF & (SBOUFS 43 $VUBOFPVT MZNQIPQSPMJGFSBUJWF EJTFBTFT BOE SFMBUFE EJTPSEFST Pathology of the Skin With Clinical CorrelationsSEFE/FX:PSL/:&MTFWJFS.PTCZo 14 $JCVMM 5- 5IPNBT "# 0.BMMFZ %1 FU BM .ZFMPJE MFVLFNJB D VUJT B IJTUPMPHJD BOE JNNVOPIJTUPDIFNJDBM SFWJFX J Cutan Pathol o 18 .VSQIZ('4DIXBSUJOH3&MFOJUTBT3+PIOTPO#-$VUBOFPVTMZNQIP NBTBOEMFVLFNJBT*O&MEFS%&FELever’s Histopathology of the Skin UIFE1IJMBEFMQIJB1"-JQQJODPUU8JMMJBNTo HISTORICAL DIAGNOSIS & TREATMENT Diagnosis and treatments have advanced over the past century. This feature depicts conditions from a collection of steroptic cards published in 1910 by 5IF4UFSFPTDPQJD4LJO$MJOJD by Dr. S. I. Rainforth. SYPHILIS PRIMARIA: 4DMFSPTJTTZQIJMJUJDBFUPFEFNBJOEVSBUJWVN A few days after the appearance of the chancre it is not uncommon to palpate a few hard painless cords which vary in thick OFTTGSPNUIBUPGBQJOUPUIBUPGBNBUDIBOEFYUFOEGSPNUIFOFJHICPSIPPEPGUIFDIBODSFUPXBSEUIFCBTFPGUIFQFOJT They are lymphatic vessels which have become specifically indurated, plugged with agglutinated leucocytes or compressed by QFSJMZNQIBOHJUJDJOGJMUSBUJPO5IFZEJTBQQFBSVTVBMMZXJUIUIFJOEVSBUJPOPGUIFDIBODSFUIBUJTJOGPVSUPTJYXFFLT0DDBTJPOBMMZ UIFMZNQIBUJDJOWPMWFNFOUJTTPFYUFOTJWFUIBUJUDBVTFTDPOTJEFSBCMFFEFNBPGUIFQSFQVDFXIJDIEJGGFSTGSPNBOPSEJOBSZ inflammatory edema however, in that it is very firm and elastic, like caoutchouc, and does not pit on pressure, its border is rather abrupt in its substance the hard lymphatic cords can often be felt, the skin over the affected area is nearly always dusky SFEBOEUIFTXPMMFOUJTTVFTBSFQBJOMFTTBOEOPUBUBMMPSPOMZTMJHIUMZUFOEFS5IFGPSNTXFMMJOHVTVBMMZDBVTFTQIJNPTJTBOE UIVTDPNQMFUFMZDPODFBMTBOZDIBODSFMPDBUFEPOUIFJOOFSGPMEPGUIFQSFQVDFPSJOUIFDPSPOBSZTVMDVT5IFTBNFMFTJPOJT NPSFDPNNPOJOXPNFOBTTPDJBUFEXJUIBDIBODSFPOBMBCJVNNBKVT*UEPFTOPUEJGGFSGSPNUIFJOEVSBUFEFEFNBPGUIFQFOJT FYDFQUUIBUUIFUIJDLFOFEMZNQIBUJDTDBOSBSFMZCFQBMQBUFEPXJOHUPUIFJSMFTTBDDFTTJCMFQPTJUJPO5IFTXFMMJOHJTVTVBMMZRVJUF TMVHHJTIQFSTJTUTGPSXFFLTPSNPOUITBOEFWFOVOEFSUSFBUNFOUEJTBQQFBSTWFSZHSBEVBMMZCVUXJUIPVUMFBWJOHBOZUSBDFT Although a comparatively rare accompaniment of the primary sore this peculiar form of edema, when it is well marked, is a EJTUJODUJWFBTQFDJGJDMFTJPOBTUIFDIBODSFJUTFMG/FWFSUIFMFTTJUJTOPUBEWJTBCMFUPCFHJODPOTUJUVUJPOBMUSFBUNFOUXJUINFSDVSZ VOUJMUIFEJBHOPTJTIBTCFFODPOGJSNFECZUIFGJOEJOHPG4QJSPDIBFUBQBMMJEBPSUIFBQQFBSBODFPGTFDPOEBSZNBOJGFTUBUJPOT SKINmed. 2012;10:108–110 110 /FDSPUJD6MDFS".BOJGFTUBUJPOPG-FVLFNJB$VUJT Arnika Forte ® The New Gold Standard for treating bruising, swelling, pain 1st and only combination of Arnica Montana 30x and Bromelain Arnika Forte® SPEED THE HEALING One convenient capsule twice a day All natural, safe, physician - formulated Speed the healing time from bruising, swelling and pain after surgery or dermal filler injections To Order Call 484-568-0306 7PMVNFt*TTVF March/April 2012 CASE STUDY Inflammatory Linear Verrucous Epidermal Nevus With Genital Involvement Didem Didar Balci, MD;1 Jülide Zehra Yenin, MD;1 Ebru Çelik, MD;1 Gökhan Sarikaya, MD;1 Esin Atik, MD2 "OZFBSPMEXPNBOXBTBENJUUFEUPPVSDMJOJDDPNQMBJOJOHPGQSVSJUJDMFTJPOTPOIFSJOHVJOBMBOEHFOJUBMBSFBTUIBUIBECFFOQSFTFOU TJODFCJSUI4IFIBEQSFWJPVTMZVTFEUPQJDBMTUFSPJETBOEBDPNCJOBUJPOPGUPQJDBMTUFSPJETBOEDBMDJQPUSJPMGPSBQQSPYJNBUFMZNPOUIT IPXFWFS UIF USFBUNFOU XBT VOTVDDFTTGVM )FS NFEJDBM IJTUPSZ XBT VOSFNBSLBCMF 0O EFSNBUPMPHJD FYBNJOBUJPO NJME FSZUIFNBUPVT MJDIFOJëFEBOEWFSSVDPVTQBQVMFTPDDVSSJOHJOBMJOFBSQBUUFSOPOUIFSJHIUJOHVJOBMBSFBBOEPOUIFSFHJPOFYUFOEJOHGSPNUIFSJHIUMBCJVNNBKVTUPUIFQFSJBOBMBSFBXFSFOPUFE'JHVSF "EEJUJPOBMMZBOFSZUIFNBUPVTBSFBXJUIDFOUSBMFSPTJPOTVSSPVOEFECZNBDFSBUJPOXBT 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BEPMFTDFODFBOENBOJGFTUTBTMPDBMJ[FEPSXJEFTQSFBEMFTJPOT2 *OBDBTFTFSJFTFYQFSUTSFQPSUFEUIBUUIFMFTJPOXBTQSFTFOU BUCJSUIJOPGUIFQBUJFOUTBOEUIBUUIFBHFPGPOTFUSBOHFE GSPNNPOUITUPZFBST5*-7&/JTVTVBMMZTQPSBEJDBOEGBNJMJBMDBTFTBSFSBSF2*OPVSQBUJFOUBTXFMMUIFMFTJPOXBTQSFTFOUBU CJSUIBOEUIFSFXBTOPGBNJMZIJTUPSZɨFNPTUQSPNJOFOUDPNQMBJOUJTJUDIJOH1–5%FTQJUFUIFGBDUUIBUJUDIJOHXBTUIFNBJO DPNQMBJOU JO UIF QSFTFOU DBTF UIF QBUJFOU XBT BMTP DPODFSOFE XJUIUIFDPTNFUJDBQQFBSBODF *-7&/ VTVBMMZ DPOTJTUT PG JOìBNNBUPSZ QBQVMFT UIBU DPBMFTDF JOUP VOJMBUFSBM QSVSJUJD FSZUIFNBUPVT BOE WFSSVDPVT QMBRVFT PDDVSSJOH JO B MJOFBS QBUUFSO BMPOH UIF MJOFT PG #MBTDILP1–3 *-7&/JTVTVBMMZVOJMBUFSBMBOEMPDBMJ[FEUPUIFMPXFSFYUSFNJUJFTBOEHMVUFBMBSFBIPXFWFSUIFBSNTHFOJUBMBSFBBOEPUIFS QBSUT PG UIF CPEZ NBZ BMTP CF JOWPMWFE2 *-7&/ XJUI HFOJUBM JOWPMWFNFOUIBTSBSFMZCFFOSFQPSUFEJOUIFMJUFSBUVSF5–"UPUBM PG*-7&/DBTFTXFSFEJBHOPTFEBNPOHBDBTFTFSJFTPG FQJEFSNBMOFWVTBOEPGUIFTFJOWPMWFNFOUPGUIFJOHVJOPHFOJUBM BSFB XBT OPUFE JO POMZ DBTFT *O B TUVEZ DPOEVDUFE PO DBTFTPG*-7&/JOHVJOBMJOWPMWFNFOUXBTOPUFEJODBTFT XIJMF*-7&/XBTMPDBUFEPOUIFQFOJTTDSPUVNMBCJVNNBKPS BOEWVMWBFJODBTFT5*OUIFQSFTFOUDBTFUIF*-7&/MFTJPOT From the Departments of Dermatology,1 and Pathology,2 Mustafa Kemal University, Hatay, Turkey Address for Correspondence: Didem Didar Balci, MD, Associate Professor, Mustafa Kemal University, Faculty of Medicine, Department of %FSNBUPMPHZ"OUBLZB)BUBZ5VSLFZt&NBJMEJEFNBMUJOFS!ZBIPPDPN SKINmed. 2012;10:112–113 112 ª1VMTF.BSLFUJOH$PNNVOJDBUJPOT--$ $"4&456%: March/April 2012 IBWFCFFOBDIJFWFECZDBSCPOEJPYJEFMBTFS0OΉUIFPUIFSIBOE TVDDFTTGVM SFTVMUT XJUI UIF VTF PG TZTUFNJD SFUJOPJET IBWF CFFO SFQPSUFE CVU MJGFMPOH USFBUNFOU JT SFRVJSFE *O BOPUIFS SFQPSU BQBUJFOUXJUIDPNQMFUFSFDPWFSZGPMMPXJOHNPOUITPGTZTUFNJD FUBOFSDFQU UIFSBQZ XBT SFQPSUFE10 4VSHJDBM FYDJTJPO JT UIF NPTU EFëOJUJWF USFBUNFOU GPS *-7&/11 0VS QBUJFOU IBE QSFWJPVTMZ SFDFJWFEUPQJDBMQPUFOUTUFSPJETBOEDBMDJQPUSJPMUIFSBQZBMUIPVHI UIFUSFBUNFOUXBTPGOPCFOFëU$SZPUIFSBQZXBTJOJUJBUFEBOE BQQMJFE GPS 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Linear erythematous, lichenified, verrucous papules POUIFSJHIUJOHVJOBMBSFBBOESJHIUMBCJVNNBKVT REFERENCES XFSFMPDBUFEPOUIFSJHIUJOHVJOBMBSFBSJHIUMBCJVNNBKVTBOE QFSJBOBMBSFB 1 5IPNBT 7% 4XBOTPO /" -FF ,, #FOJHO FQJUIFMJBM UVNPST IBNBSUP NBTBOEIZQFSQMBTJBT*O8PMGG,(PMETNJUI-",BU[4*(JMDISFTU#" 1BMMFS"4-FGGFMM%+FETFitzpatrick’s Dermatology in General Medicine /FX:PSL/:.D(SBX)JMMo 2 1BSMBL ") &QJEFSNBM OFWVTMBS *O 5V[VO : ,PUPHZBO " 4FSEBSPHMV 4$PLVHSBT)5V[VO#.BU.$FETPediatrik Dermatoloji*TUBOCVM /PCFM5JQ,JUBCFWMFSJo 3 $PDLFSFMM$+-BSTFO'#FOJHOFQJEFSNBMUVNPSTBOEQSPMJGFSBUJPOT*O #PMPHOJB+-+PSJ[[P+-3BQJOJ31FETDermatology&EJOCVSHI&MTFWJFS o 4 "MUNBO+.FISFHBO")*OýBNNBUPSZMJOFBSWFSSVDPTFFQJEFSNBMOFWVT Arch Dermatolo 5 -FF 4) 3PHFST . *OýBNNBUPSZ MJOFBS WFSSVDPVT FQJEFSNBM O BFWJ B SFWJFXPGDBTFTAustralas J Dermatolo ɨFIJTUPQBUIPMPHJDBMBQQFBSBODFPG*-7&/JODMVEFTBMUFSOBUJOH QBSBLFSBUPUJD BOE PSUIPLFSBUPUJD BSFBT 1TPSJBTJGPSN FQJEFSNBM IZQFSQMBTJBXJUIFMPOHBUJPOPGSFUFSJEHFTTQPOHJPTJTBOEFYPDZUPTJTBSFQSFTFOUUPHFUIFSXJUIIZQFSLFSBUPTJTBDBOUIPTJTBOE QBQJMMPNBUPTJTNPSFPWFSQFSJWBTDVMBSMZNQIPIJTUJPDZUJDJOìBNNBUPSZJOëMUSBUFJTOPUFEJOUIFVQQFSQBSUPGUIFEFSNJT1–3*O UIFQSFTFOUDBTFIJTUPQBUIPMPHJDBMFYBNJOBUJPOSFWFBMFEPSUIPLFSBUPTJT QBSBLFSBUPTJT QBQJMMPNBUPTJT BOE BDBOUIPTJT XIJDI XBTDPOTJTUFOUXJUIUIFUZQJDBMIJTUPQBUIPMPHZPG*-7&/ 6 -F,8POH-$'JTDIFS(7VMWBMBOEQFSJBOBMJOýBNNBUPSZMJOFBSWFS SVDPVTFQJEFSNBMOBFWVTAustralas J Dermatolo 7 3PHFST.&QJEFSNBMOFWJBOEUIFFQJEFSNBMOFWVTTZOESPNFTBSFWJFX PGDBTFTPediatr Dermatolo CONCLUSIONS 8 6MLVS&$FMJLP[#:VLTFM',BSBHP[)$BSCPOEJPYJEFMBTFSUIFSBQZ GPS BO JOýBNNBUPSZ MJOFBS WFSSVDPVT FQJEFSNBM OFWVT Bù DBTF SFQPSU Aesthetic Plast Surgo 9 3FOOFS33ZUUFS.4UJDIFSMJOH."DJUSFUJOUSFBUNFOUPGBTZTUFNBUJ[FE JOýBNNBUPSZ MJOFBS WFSSVDPVT FQJEFSNBM OBFWVT Acta Derm Venereol o ɨF USFBUNFOU PG *-7&/ JT EJï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ýBNNBUPSZWFSSVDPVTFQJEFSNBMOFWVTXJUIFUBOFSDFQUArch Dermatolo 11 -FF # .BODJOJ " 3FOVDDJ + 1BMMFS " #BVFS # 'VMMUIJDLOFTT TVSHJDBM FYDJTJPO GPS UIF USFBUNFOU PG JOýBNNBUPSZ MJOFBS WFSSVDPVT FQJEFSNBM OFWVTAnn Plast Surgo &33"56.+BOVBSZ'FCSVBSZt7PMVNFt*TTVFt1BHFTBOE CASE STUDY Chronic Lymphocytic Leukemia Revealed by a Granulomatous Zosteriform Eruption Sondes Trojjet, MD; Houda Hammami, MD; Inès Zaraa, MD; Alia Bouzguarrou, MD; Meriem Joens, MD; Slim Haouet, MD; Amel Ben Osman, MD; Mourad Mokni, MD "XPSE(SBOVMPNBUPVT JOUIFUJUMFPGUIJT$BTF4UVEZXBTJODPSSFDUMZQSFTFOUFEPOUIFDPWFS SKINmed. 2012;10:112–113 113 *OìBNNBUPSZ-JOFBS7FSSVDPVT&QJEFSNBM/FWVT 7PMVNFt*TTVF March/April 2012 CASE STUDY Oral Frictional Hyperkeratosis (Morsicatio Buccarum): An Entity to Be Considered in the Differential Diagnosis of White Oral Mucosal Lesions Kristin Cam, MD;1 Anthony Santoro, MD;2 Jason B. Lee, MD1 "ZFBSPMENBOQSFTFOUFEXJUIEFTRVBNBUJOHMFTJPOTPOIJTCJMBUFSBMCVDDBMNVDPTBJOUFSNJUUFOUMZGPSBQQSPYJNBUFMZZFBSTɨFBMUFSB UJPOJOUFYUVSFXJUIJOIJTNPVUIDSFBUFEBOVODPNGPSUBCMFTFOTBUJPOBOEBUUJNFTUIFMFTJPOTTQPOUBOFPVTMZQFFMFEBXBZSFRVJSJOHIJNUP TQJUSFQFBUFEMZɨFQBUJFOUEFOJFEBOZIJTUPSZPGUSBVNBDIFFLCJUJOHPSVTFPGUPCBDDPQSPEVDUT0OJOJUJBMFYBNJOBUJPOUIFQBUJFOUXBT BTZNQUPNBUJDBOEUIFPSBMNVDPTBIBEOPBCOPSNBMëOEJOHTCVUPOSFQFBUFYBNJOBUJPOXIFOTZNQUPNTXFSFQSFTFOUUIFQBUJFOUIBE TIBHHZXIJUFQMBRVFTPOUIFCJMBUFSBMCVDDBMNVDPTBMJNJUFEUPUIFMJOFPGEFOUBMPDDMVTJPO'JHVSF ɨFQMBRVFTDPVMECFFBTJMZQFFMFE BXBZGSPNUIFVOEFSMZJOHTLJOXJUIBDPUUPOTXBCXJUIPVUBOZQBJOMFBWJOHCFIJOEOPSNBMVOEFSMZJOHNVDPTB"SFWJFXPGUIFQSJPS CJPQTZPGUIFBêFDUFENVDPTBSFWFBMFEBOJSSFHVMBSMZIZQFSQMBTUJDFQJUIFMJVNXJUIGPDJPGCBMMPPOFEFQJUIFMJBMDFMMTXJUIJOUIFVQQFSMBZFS QBSBLFSBUPTJTBOECBDUFSJBMPWFSHSPXUI'JHVSF .JDSPTDPQJDFYBNJOBUJPOPGGSBHNFOUTPGNVDPTBQFFMFEBXBZGSPNUIFBêFDUFEBSFB SFWFBMFEGSBHNFOUTPGQBSBLFSBUPUJDDPSOJëFENBUFSJBMDPMPOJ[FECZOVNFSPVTCBDUFSJB'JHVSF 3FTVMUTGSPNQFSJPEJDBDJE4DIJêTUBJOSF WFBMFEOPGVOHBMFMFNFOUTɨFEJBHOPTJTPGPSBMGSJDUJPOBMIZQFSLFSBUPTJTXBTFTUBCMJTIFECBTFEPOUIFDMJOJDBMBOENJDSPTDPQJDëOEJOHT*U XBTDPODMVEFEUIBUUIFIZQFSLFSBUPTJTXBTMJLFMZDBVTFECZCJUFUSBVNBPSHSJOEJOHPGUIFUFFUIXIJMFUIFQBUJFOUXBTBTMFFQ5SJBNDJOPMPOF PJOUNFOUJO0SBCBTFBOEUSFUJOPJOHFMXFSFJOFêFDUJWFɨFQBUJFOUGPVOEUIBUSJOTJOHXJUIIZESPHFOQFSPYJEFTPMVUJPOXBT NPTUIFMQGVMJOSFEVDJOHUIFMFTJPOT"CJUFHVBSEXBTSFDPNNFOEFECZBOPSBMBOENBYJMMPGBDJBMTVSHFPOCVUUIFQBUJFOUIBTZFUUPVTFJU O SBM GSJDUJPOBM IZQFSLFSBUPTJT 0') BMTP SFGFSSFE NBUJUJT XIJUF TQPOHF OFWVT MJDIFO QMBOVT DBOEJEJBTJT BOE UP BT NPSTJDBUJP CVDDBSVN PS NPSTJDBUJP NVDPTBF PSBM MFVLPQMBLJB FTQFDJBMMZ XIFO MFTJPOT BSF QSFTFOU PO UIF PSJTJTBXIJUFMFTJPOJOUIFNPVUIUIBUSFTVMUTGSPN DISPOJD USBVNB BT B SFTVMU PG MPOHTUBOEJOH SVCCJOH PS CJU JOH CZ UIF UFFUI1 ɨJT FOUJUZ JT XFMMSFDPHOJ[FE BNPOH PSBM BOENBYJMMPGBDJBMTQFDJBMJTUTBOEEFOUJTUTCVUJTMFTTGSFRVFOUMZ FODPVOUFSFE BOE QPTTJCMZ VOEFSSFDPHOJ[FE CZ EFSNBUPMP HJTUT 1BUJFOUT PGUFO TFFL IFMQ PO EJTDPWFSJOH BO JSSFHVMBSJUZ PG UIF PSBM NVDPTB TPNFUJNFT DPNQMBJOJOH PG BSFBT PG QFFM JOHPSTISFEEJOHPGUJTTVF"MUIPVHIUIJTDPOEJUJPOJTVTVBMMZ TFMGJOEVDFEUIFQBUJFOUNBZOPUCFBXBSFPGIJTPSIFSIBCJU XIJDIJTPGUFOUIFSFTVMUPGHSJOEJOHPGUIFUFFUIEVSJOHTMFFQ "Ή TUVEZ PG EFOUBM PVUQBUJFOUT SFWFBMFE PG QBUJFOUT XJUI GSJDUJPOBM IZQFSLFSBUPTJT2 4JUFT PG JOWPMWFNFOU JODMVEF UIF CVDDBM NVDPTB BOE MFTT DPNNPOMZ UIF MBCJBM Figure 1. Whitish plaque with an irregular surface on the left NVDPTBBOEUIFUPOHVFBMMBSFBTXJUIJOSFBDIPGUIFUFFUI3 mucosa near the line of dental occlusion. ɨFEJêFSFOUJBMEJBHOPTJTPGUIFTFMFTJPOTJODMVEFTDPOUBDUTUP From the Department of Dermatology and Cutaneous Biology, Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA;1 and Doylestown Dermatology, Doylestown, PA2 Address for Correspondence: Jason B. Lee, MD, Department of Dermatology and Cutaneous Biology, Jefferson Medical College of Thomas +FGGFSTPO6OJWFSTJUZù$IFTUOVU4USFFU4VJUF1IJMBEFMQIJB1"t&NBJMKBTPOMFF!KFGGFSTPOFEV SKINmed. 2012;10:114–115 114 ª1VMTF.BSLFUJOH$PNNVOJDBUJPOT--$ $"4&456%: March/April 2012 Figure 3. Swabbed specimen from the buccal mucosa show JOHCBDUFSJBMBEFOJSSFHVMBSMZTVSGBDFETIBHHZQBSBLFSBUPTJT (hematoxylin and eosin stain, original magnification ×100). *OTFUIJHIQPXFSWJFXIJHIMJHIUJOHUIFCBDUFSJBMBEFOQBSB keratosis (hematoxylin and eosin stain, magnification ×400). Figure 2. A biopsy of the lesion showing psoriasiform hyper plasia, surface epithelium with ballooning degeneration,* and parakeratosis colonized by numerous bacteria** (hematoxylin and eosin stain, magnification ×100). TJEFTPGUIFUPOHVF0')IPXFWFSIBTBDIBSBDUFSJTUJDBQQFBS BODFTFUUJOHJUBQBSUGSPNPUIFSPSBMMFTJPOTOBNFMZ SPVHI TIBHHZTVSGBDFFQJUIFMJVNUIBUFBTJMZQFFMTPê CJMBUFSBMJUZ BOE MPDBUJPOPONPWBCMFOPOLFSBUJOJ[FENVDPTBUIBUDBO CFSFBDIFECZUIFUFFUI4)JTUPQBUIPMPHJDBMMZ0')JTDIBSBD UFSJ[FECZ BOJSSFHVMBSTIBHHZIZQFSQBSBLFSBUPUJDFQJUIF MJVNUIBUJTDPMPOJ[FEPOUIFTVSGBDFCZCBDUFSJB JOUSBDFM MVMBSFEFNBPSCBMMPPOJOHOFBSUIFTVSGBDFBOE BWBSJBCMF EFHSFFPGBDBOUIPTJT4 "XBSFOFTT PG UIJT SFMBUJWFMZ DPNNPO BOE CFOJHO DPOEJUJPO PG UIFPSBMNVDPTBXJMMBMMPXGPSHSFBUFSSFDPHOJUJPOPG0')CBTFE PO DMJOJDBM GFBUVSFT PCWJBUJOH UIF OFFE GPS BO JOWBTJWF CJPQTZ ɨFDMJOJDBMEJBHOPTJTDBOCFDPOëSNFECZFYBNJOBUJPOPGEFT RVBNBUJOHUJTTVFPCUBJOFEQBJOMFTTMZGSPNUIFQBUJFOUXJUIUIF VTFPGBDPUUPOTXBC"CJPQTZNBZCFJOEJDBUFEJODBTFTPG0') XJUIBUZQJDBMDMJOJDBMGFBUVSFT REFERENCES 1 Obermayer M. Cheekbiting (morsicatio buccarum). Arch Dermatol. 1964;90:185–190. 2 "M.PCFFSJFL""M%PTBSJ"1SFWBMFODFPGPSBMMFTJPOTBNPOH4BVEJEFO tal patients. Ann Saudi Med. 2009;29:365–368. 3 Krahl D, Altenburg A, Zouboulis CC. Reactive hyperplasias, precancer ous and malignant lesions of the oral mucosa. J Dtsch Dermatol Ges. 2008;6:217–232. 4 Woo S and Lin D. Moriscatio mucosae oris—a chronic oral frictional keratosis, not a leukoplakia. J Oral Maxillofac Surg. 2009;67:140–146. CONCLUSIONS %FQFOEJOHPOUIFDBVTBUJWFGBDUPSTUSFBUNFOUNBZJODMVEFUIF VTFPGBCJUFHVBSEEVSJOHTMFFQUPQSFWFOUUIFHSJOEJOHPGUFFUI EFOUBMFWBMVBUJPOGPSUIFUSFBUNFOUPGSPVHITIBSQPSNBMQP TJUJPOFEUFFUIPSPUIFSQTZDIPMPHJDBMUIFSBQZUPIFMQCSFBLUIF IBCJUPGCJUJOH SKINmed. 2012;10:114–115 115 0SBM'SJDUJPOBM)ZQFSLFSBUPTJT.PSTJDBUJP#VDDBSVN 7PMVNFt*TTVF March/April 2012 CASE STUDY Vesicular Palmoplantar Pityriasis Rosea Varinder Singh, MD;1 Meghna Sharma, MD;1 Tarun Narang, MD;1 Manas Madan, MD2 "ZFBSPMEZPVOHNBOQSFTFOUFEXJUIJOUFOTFMZJUDIZFSZUIFNBUPVTEFSNBUJUJTPOUIFCPEZGPSXFFLBOEWFTJDVMBSMFTJPOTPOUIF QBMNTBOETPMFTGPSUPEBZT-FTJPOTPOUIFQBMNTBOETPMFTXFSFBDDPNQBOJFECZTFWFSFCVSOJOHBOEJUDIJOHɨFQBUJFOUHBWFBIJTUPSZPGTPSFUISPBUBOEGFWFSXFFLQSJPSUPUIFPOTFUPGMFTJPOT"HFOFSBMQIZTJDBMFYBNJOBUJPOXBTOPSNBMBOEDVUBOFPVTFYBNJOBUJPO SFWFBMFENVMUJQMFXFMMEFëOFEFSZUIFNBUPVTTDBMZQMBRVFTXJUIDPMMBSFUTDBMJOHPOUIFUSVOLBOEFYUSFNJUJFT'JHVSF 7FTJDVMBSMFTJPOT XFSFTFFOPOUIFQBMNTBOETPMFT'JHVSF ɨFEJêFSFOUJBMEJBHOPTFTXFDPOTJEFSFEXFSFQJUZSJBTJTSPTFBBOETFDPOEBSZTZQIJMJTɨFQPTTJCJMJUZPGEFSNBUPQIZUJEWFTJDVMBSQJUZSJBTJTSPTFBBOEQPNQIPMZYXBTMJNJUFEUPUIFQBMNTBOETPMFMFTJPOT$PNQMFUFCMPPEDFMMDPVOU XBTXJUIJOOPSNBMMJNJUT3FTVMUTGSPNBOUJTUSFQUPMZTJO0UJUFSQPUBTTJVNIZESPYJEFNPVOUBOEWFOFSFBMEJTFBTFSFTFBSDIMBCPSBUPSZXFSF OFHBUJWF4LJOCJPQTJFTXFSFUBLFOGSPNUIFCBDLBOEMFGUQBMNɨFCJPQTZTQFDJNFOGSPNUIFCBDLSFWFBMFEGPDBMTQPOHJPTJTMZNQIPDZUF FYPDZUPTJTWBDVPMBSDIBOHFTJOUIFCBTBMMBZFSBOEQFSJWBTDVMBSMZNQIPDZUJDJOëMUSBUFJOUIFEFSNJT'JHVSF ɨFCJPQTZPCUBJOFEGSPN UIFWFTJDVMBSMFTJPOPOUIFMFGUQBMNSFWFBMFEBOJOUSBFQJEFSNBMWFTJDMFXJUIOPFWJEFODFPGBDBOUPMZUJDQSPDFTT'JHVSF "EJBHOPTJTPG QJUZSJBTJTSPTFBXBTNBEFBOEUIFQBUJFOUXBTTUBSUFEPODMBSJUISPNZDJONHPODFBEBZGPSEBZTBMPOHXJUIBOUJIJTUBNJOFTBOE FNPMMJFOUTɨFMFTJPOTGBEFEESBNBUJDBMMZJOBWFSZTIPSUQFSJPEBOEUIFSFXBTTJHOJëDBOUJOWPMVUJPOPGBMNPTUBMMPGUIFMFTJPOTBGUFS EBZTPGDMBSJUISPNZDJO%VSJOHUIFNPOUITPGGPMMPXVQOPSFDVSSFODFXBTPCTFSWFE P JUZSJBTJTSPTFB13 JTBOBDVUFTFMGMJNJUJOHEFSNBUJUJTXJUI BOBUVSBMDPVSTFUIBUMBTUTGSPNUPXFFLT1"MUIPVHIOP FUJPMPHZ IBT CFFO QSPWFO JOGFDUJPVT BHFOUT BVUPJNNVOJUZESVHTBOETUSFTTIBWFCFFOQSPQPTFEBTQPTTJCMFFUJPMPHJDBM GBDUPST23FDFOUTUVEJFTIBWFTIPXOBQSPCBCMFFUJPMPHJDBMSPMF GPSIVNBOIFSQFTWJSVT))7 BOE))7PSCPUIJO13ɨ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ɨF MFTJPOTNBZFJUIFSQSFDFEFUIFDMBTTJDFSVQUJPOPG13PSBQQFBS 5ZQJDBM13JTBDMJOJDBMEJBHOPTJTGPSBUZQJDBMFSVQUJPOTXJUIPVUB TJNVMUBOFPVTMZ 7FTJDVMBS 13 NBZ CF NJTUBLFOMZ EJBHOPTFE BT EFëOJUFEJBHOPTJTIPXFWFSJUJTTBGFSUPDPOTJEFSTLJOCJPQTZBOE EJTIJESPTJTEFSNBUPQIZUJETDBCJFTESVHFSVQUJPOPSWBSJDFMMB PUIFSJOWFTUJHBUJPOTUPSVMFPVUPUIFSEJêFSFOUJBMEJBHOPTFT)JT- (FOFSBMMZOPUSFBUNFOUJTSFRVJSFEJOBTZNQUPNBUJDDBTFTCFDBVTF UPQBUIPMPHJDBMDIBSBDUFSJ[BUJPOPG13JTOPUTQFDJëDCVUDBOIFMQ PGUIFTFMGMJNJUJOHOBUVSFPGUIFEJTFBTF6"SFDFOU$PDISBOFDPMUP EJBHOPTF BUZQJDBM WBSJBOUT )JTUPQBUIPMPHJDBM ëOEJOHT PG 13 MBCPSBUJPOQBQFSTVHHFTUFEUIBUUIFSFJTJOBEFRVBUFFWJEFODFGPS JODMVEFBCTFODFPSEFDSFBTFPGUIFHSBOVMBSDFMMMBZFSFYUSBWBTBUJPO UIFFïDBDZPGBMMUPQJDBMNFEJDBUJPOTBOEBHFOUTUIBUIBWFOPU PGSFECMPPEDFMMTJOUIFQBQJMMBSZEFSNJTBOEQBSUMZJOUPUIFFQJ- CFFOGPVOEUPCFTJHOJëDBOUMZCFOFëDJBMJODMVEFTVOMJHIUBSUJEFSNJT EZTLFSBUPTJT MJRVFGBDUJPO PG CBTBM DFMMT IPNPHFOJ[BUJPO ëDJBM 67 UIFSBQZ TZTUFNJD BOUJIJTUBNJOFT BOE DPSUJDPTUFSPJET PGQBQJMMBSZDPMMBHFOBOEJOUSBFQJEFSNBMWFTJDMFTJOBQQBSFOUMZESZ BOUJWJSBM BHFOUT BOE JOUSBWFOPVT HMZDZSSIJ[JO "MUIPVHI UIFSF TLJOɨFWFTJDVMBSMFTJPOTBSFDBVTFECZTFWFSFTQPOHJPTJTFYPDZ- BSFSFQPSUTPGIJHIEPTFTPGBDZDMPWJSCFJOHVTFGVMJO13UIFSFJT UPTJTBOEJOUSBFQJEFSNBMWFTJDMFT4PNFTUVEJFTIBWFBMTPPCTFSWFE TPNFFWJEFODFUIBUPSBMFSZUISPNZDJONBZTIPSUFOUIFDPVSTFPG NVMUJOVDMFBUFEHJBOUDFMMTBOEBDBOUIPMZTJTJOUIFFQJEFSNJT&MFD- UIFSBTIBOEBMMFWJBUFQSVSJUVT9$MBSJUISPNZDJOIBTBMTPCFFO From the Department of Dermatology, Venereology & Leprology,1 and the Department of Pathology,2 Gian Sagar Medical College & Hospital, Ram Nagar, Banur, Patiala, India Address for Correspondence: Varinder Singh, MD, Associate Professor, Department of Dermatology, Venereology & Leprology, Gian Sagar .FEJDBM$PMMFHF)PTQJUBM3BN/BHBS#BOVS1BUJBMB*OEJBt&NBJMESWBSJOEFSTJOHI!HNBJMDPN SKINmed. 2011;10:116–118 116 ª1VMTF.BSLFUJOH$PNNVOJDBUJPOT--$ $"4&456%: March/April 2012 Figure 3. Focal spongiosis and slight exocytosis in the FQJEFSNJTBTXFMMBTPWFSMZJOHQBSBLFSBUPTJTBNPOPOVDMFBS DFMMJOåMUSBUFJOUIFVQQFSEFSNJTIFNBUPYZMJOFPTJOTUBJO PSJHJOBMNBHOJåDBUJPO¨ Figure 1. 5ZQJDBMMFTJPOTPGQJUZSJBTJTSPTFBPOUIFUSVOL A B Figure 4.*OUSBFQJEFSNBMWFTJDMFXJUIFEFNBBOENPOPOVDMFBS JOåMUSBUFJOTVQFSåDJBMEFSNJTIFNBUPYZMJOFPTJOTUBJOPSJHJOBM NBHOJåDBUJPO¨ ɨFFYDFMMFOUSFTQPOTFJOPVSDBTFXJUIDMBSJUISPNZDJONBZCF DBVTFECZUIFBOUJJOìBNNBUPSZBOEJNNVOPNPEVMBUPSZFêFDUT PG DMBSJUISPNZDJO11 PS JU DPVME JOEJSFDUMZ TVHHFTU JOWPMWFNFOU PGQBUIPHFOTTVDIBTTUSFQUPDPDDJNZDPQMBTNBMFHJPOFMMBBOE chlamydia12 JO DBVTJOH PS USJHHFSJOH 13 JO PVS QBUJFOU XIJDI SFTQPOEXFMMUPDMBSJUISPNZDJO CONCLUSIONS $MJOJDJBOTTIPVMECFBXBSFPGUIFXJEFTQFDUSVNPG13WBSJBOUT TPUIBUBQQSPQSJBUFNBOBHFNFOUBOESFBTTVSBODFDBOCFPêFSFE Figure 2. 7FTJDVMBSMFTJPOTPOUIFQBMNT" BOETPMFT# %FTQJUF UIF SBSJUZ PG WFTJDVMBS 13 QIZTJDJBOT TIPVME JODMVEF VTFETVDDFTTGVMMZJOPOFTUVEZ100VSQBUJFOUSFTQPOEFEXFMMUP UIJTFOUJUZJOUIFEJêFSFOUJBMEJBHOPTJTPGTVEEFOPOTFUWFTJDVMBS DMBSJUISPNZDJOXIFSFJOMFTJPOTTUBSUFESFHSFTTJOHXJUIJOEBZT FSVQUJPOT.PSFBOBMZUJDBMTUVEJFTPOWJSBMBOECBDUFSJBMFUJPMPHZ BSFOFFEFEUPTFUUMFUIFJTTVFPGFUJPQBUIPHFOFTJT BOEIFIBEOPSFMBQTFVOUJMNPOUIGPMMPXVQ SKINmed. 2012;10:116–118 7FTJDVMBS1BMNPQMBOUBS1JUZSJBTJT3PTFB $"4&456%: March/April 2012 REFERENCES 1 2 3 4 5 4UFSMJOH+$7JSVTJOGFDUJPOT*O#VSOT5#SFBUIOBDI4$PY/(SJGåUIT $ FET Textbook of Dermatology UI FE 0YGPSE &OHMBOE #MBDLXFMM 4DJFODF$Po %SBHP'#SPDDPMP'3FCPSB"1JUZSJBTJTSPTFBBOVQEBUFXJUIBDSJUJ DBMBQQSBJTBMPGJUTQPTTJCMFIFSQFTWJSBMFUJPMPHZJ Am Acad Dermatol. o *NBNVSB40[BLJ.0HVDIJ.0LBNPUP))PSJHVDIJ:"UZQJDBMQJUZSJB TJTSPTFBDermatologica.o %SBHP ' 3BOJFSJ & .BMBHVUJ ' FU BM )VNBO IFSQFTWJSVT JO QBUJFOUT XJUIQJUZSJBTJTSPTFB&MFDUSPONJDSPTDPQZJOWFTUJHBUJPOTBOEQPMZNFSBTF DIBJO SFBDUJPO JO NPOPOVDMFBS DFMMT QMBTNB BOE TLJO Dermatology. o 8FJTT3--BDF$84IPXNBO8"1JUZSJBTJTSPTFB Arch Dermatol Syph. o 6 .JSBOEB4#-VQJ0-VDBT&7FTJDVMBSQJUZSJBTJTSPTFBSFTQPOTFUPFSZUI SPNZDJOUSFBUNFOUJ Eur Acad Dermatol Venereol.o 7 (SJGåUIT"7FTJDVMBSQJUZSJBTJTSPTFBArch Dermatol.ù 8 $IVI""%PåUBT#-$PNJTFM((FUBM*OUFSWFOUJPOTGPSQJUZSJBTJTSPTFB Cochrane Database Syst Rev.$% 9 3BTJ " 5BK[JFIDIJ - 4BWBCJ/BTBC 4 0SBM FSZUISPNZDJO JT JOFGGFDUJWF JOUIFUSFBUNFOUPGQJUZSJBTJTSPTFB J Drugs Dermatol.o 10 #VLIBSJ*"0SBMFSZUISPNZDJOJTJOFGGFDUJWFJOUIFUSFBUNFOUPGQJUZSJBTJT SPTFBJ Drugs Dermatol. 11 -BCSP .5 "OUJJOýBNNBUPSZ BDUJWJUZ PG NBDSPMJEFT B OFX UIFSBQFVUJD potential? J Antimicrob Chemother.o 12 $IVI""$IBO))1SPTQFDUJWFDBTFDPOUSPMTUVEZPGDIMBNZEJBMFHJP OFMMBBOENZDPQMBTNBJOGFDUJPOTJOQBUJFOUTXJUIQJUZSJBTJTSPTFBEur J Dermatol.o VINTAGE LABELS $PVSUFTZPG#VZ&OMBSHF1IJMBEFMQIJB1" SKINmed. 2012;10:116–118 118 7FTJDVMBS1BMNPQMBOUBS1JUZSJBTJT3PTFB 7PMVNFt*TTVF March/April 2012 BOOK REVIEW Noah S. Scheinfeld, MD, JD, Section Editor Hall’s Manual of Skin as a Marker of Underlying Disease Edited by John C. Hall and Brian J. Hall. 300 pages. Shelton, CT; People’s Medical Publishing House–USA; 2011. $89.95. ISBN 1607951029 4PNF EBZ BMM TLJO EJTFBTFT * UIJOL XJMM CF VOEFSTUPPE CZ QIZTJDJBOT BT nosocological mobius TUSJQT ɨBU JT JOGFDUJPVT EJTFBTFT XJMM CF TFFO BT BCFSSBUJPOT PG JNNVOJUZ BOE SFJëDBUJPOT PG NVUBUFE %/" $BODFS XJMM CF WJFXFE BT B QIFOPNFOPMPHJDBM 7FOO EJBHSBN PG NVUBUJPOT WJSBM JOUFSQPMBUJPOT BOE JNNVOPMPHJDBM VOEFSBDIJFWFNFOUΉ%JTFBTFTPGJNNVOJUZXJMMCFVOEFSTUPPEBTBDPMMFDUJPO PG JOGFDUJPOT BOE OFPQMBTUJD TJOT UIBU DBOOPUCFVOEPOF6OUJMUIBUUJNFBOE QFSIBQT FWFO JO UIBU UJNF UIF QIZTJDJBOXJMMCFXFMMBEWJTFEUPDBSSZBOE review Hall’s Manual of Skin as a Marker of Underlying DiseaseBTLJMMGVMMZ FEJUFECPPLXJUIBOJOUFSOBUJPOBMUBMFOUTIPXPGDPOUSJCVUPST ɨJTEFSNBUPMPHJDUFYUXIJDISFBETMJLFBSPNBOËDMFGUBLFTJUTQMBDFXJUIUIF PUIFSOFDFTTBSZXPSLTUIBUIBWFBEESFTTFEEFSNBUPMPHZBOETZTUFNJDEJTFBTF CZ#SBWFSNBO1$BMMFO2BOE1SPWPTU3*OPOFJNQPSUBOUXBZ)BMMTCPPLTVSQBTTFTUIFN)BMMTQSJDFQPJOUJTVOEFSXIJDINFBOTUIBU)BMMTCPPL DBOCFQSFTFOUFECZUIFQIBSNBDFVUJDBMDPNQBOJFTBTBOFEVDBUJPOBMBJE +VTUBTB+FXJTITDIPMBSLFFQTB.JTIOBI5PSBIBVUIPSFECZUIF3BNCBNPOIJT EFTLUIF5VS"SCBBI5VSJN CZ+BDPCCFO"TIFSJOIJTBSDIJWF3BCCJ:JU[DIBL "MGBTJTUIFJOUFMMJHFOUEJHFTUiUIF3JGwJOUIFBQQFOEJYTFDUJPOTPGIJT5BMNVEBOEUIF 4IVMDBO"SVDICZ:PTFG,BSPPOIJTXBMMXJUIUIFIBOEZHMPTTFTPGUIF3FNB.PTFT *TTFSMFTPO,BSPTQBHFTUIFTDIPMBSJTBEWJTFEJGIFDBOUPLFFQBMMUIFTFCPPLTPO TZTUFNJDEJTFBTFXJUIJOBSNTMFOHUI)BMMTCPPLDPWFSTUIFUPQJDTPGJOUFSOBMEJTFBTFT BOETLJOJOBCSJFGCVUFêFDUJWFGBTIJPOXJUITFDUJPOTPOOFVSPMPHJDBMJOGFDUJPVT QFEJBUSJDHFOFUJDBOEPUIFSUPQJDTEJWJEFEJOUPDIBQUFSTPOUIFNBOJGFTUBUJPOPGUIF TQFDJëDEJTFBTFTUBUFT&BDIDIBQUFSJTVOJRVFBOESFQMFUFXJUIFYDFMMFOUJOGPSNBUJPO *QBSUJDVMBSMZFOKPZFEUIFTFDUJPOPOOFVSPMPHJDBMEJTFBTFTBOEUIFTLJOΉ*ΉGPVOE UIFEJTDVTTJPOPOSFìFYTZNQBUIFUJDEZTUSPQIZ34% FOMJHIUFOJOHΉ*ΉDPOGFTT UIBU*IBEOFWFSQBSTFE34%JOUPJUTTUBHFTVOUJM*SFBEUIFDIBQUFSJO)BMMT CPPLɨFTFTUBHFTBSF t 4UBHF UXP 34% DIBSBDUFSJ[FE CZ NPSF JOUFOTF QBJO ɨF TXFMMJOH TQSFBET IBJS HSPXUI EJNJOJTIFT OBJMT CFDPNF DSBDLFE CSJUUMF HSPPWFEBOETQPUUZPTUFPQPSPTJTCFDPNFTTFWFSFBOEEJêVTFKPJOUT UIJDLFOCMJTUFSTGPSNBOENVTDMFBUSPQIZPDDVST t 4UBHFUISFF34%DIBSBDUFSJ[FECZJSSFWFSTJCMFDIBOHFTJOUIFTLJOBOE CPOFTXIJMFUIFQBJOCFDPNFTVOZJFMEJOHBOENBZJOWPMWFUIFFOUJSF FYUSFNJUZɨFSFJTNBSLFENVTDMFBUSPQIZ *WJWJEMZSFDBMMXIJMF*XBTBSFTJEFOUTFFJOHBQBUJFOUJOUIFQBMMJBUJWFDBSF VOJU PG #FUI *TSBFM )PTQJUBM OFBS 4UVZWFTBOU 1BSL .BOIBUUBO XIP IBE DISPOJD QBJO BOE CMJTUFST PO IJT GFFU * DPVME OPU NBLF UIF EJBHOPTJT BU UIFCFETJEF8JUIUIFIFMQPG1VC.FE*FWFOUVBMMZXBTBCMFUPNBLFUIJT EJBHOPTJT/PUVOUJM*IBESFBE)BMMTCPPLEJE*LOPXIPXUPTUBHF34% ɨFQJDUVSFTBSFDPNNFOEBCMFBOEBEEFEUPNZWJTVBMNFNPSZ*OQBSUJDVMBSUIF DIBQUFSPOFZFEJTFBTFTIBTHSFBUJNBHFT*OUIFTFDUJPOTPOFOEPDSJOFEJTFBTFT* MFBSOFEBCJUIPXFWFSTPNFPGUIFJOGPSNBUJPOJOUIFDIBQUFSPOEJBCFUFT*DBNF UPCFMJFWFXBTNPSFGPVOEFEJOUIFBVUIPSTPQJOJPOTSBUIFSUIBOJOSFDPHOJ[FE GBDU*OQBSUJDVMBS*UIJOLUIFBVUIPSTTVHHFTUJPOUIBUMJDIFOQMBOVTBOEHSBOVMPNBBOOVMBSFDPVMECFBTTPDJBUFEXJUIEJBCFUFTJTPOFTVDIFYBNQMF*FOKPZFE UIFEJTDVTTJPOBOEQJDUVSFTJOWPMWFEXJUIOVUSJUJPOBMEJTPSEFSTBOEUIPVHIUUIF DPMPSQMBUFTNFNPSBCMFɨFEJTDVTTJPOPGMVQVTXBTBCJUNVEEMFEBTFWJEFODFE CZBDIBSUQBSTJOHMVQVTJOUPNBOZDBUFHPSJFTBOETVCDBUFHPSJFTCVUUIFOUIFDVSSFOUVOEFSTUBOEJOHPGMVQVTJTNVEEMFEBOESFTFNCMFT1UPMNFZTDPNQMFYTZTUFN VUJMJ[JOHBQIZTJDBMSFBMJ[BUJPOPGUIFVOJWFSTFBTBTFUPGOFTUFETQIFSFTSBUIFSUIBO 3FMBUJWJUZTBVTUFSFUSVUIɨFEJTDVTTJPOPGHSBGUWTIPTUEJTFBTFXPVMECFOFëU GSPNBEJTDVTTJPOPGUIFVTFPG67"BOEJNBUJOJCBTUSFBUNFOUTXIJDI*NFOUJPOCFDBVTFEFSNBUPMPHJTUTTIPVMENPSFDBSFGVMMZVOEFSTUBOEUIFTFUIFSBQJFT ɨJTCPPLëMMTUIFSFBEFSXJUIXPOEFSNFOUBOEJTFBTZUPSFBEɨFBVEJFODF XJMMCFBUPODFUIFTFBTPOFEEFSNBUPMPHJTUBTXFMMBTUIFSFTJEFOUJOOFFEPG MFBWFOJOHFBDIPGXIPNXJMMCFOFëUGSPNSFBEJOHUIJTCPPLBOESFGFSSJOHUP JUGSFRVFOUMZɨFSFBTPOBCMFQSJDFNFBOTUIBUJUXJMMBDUVBMMZHFUJOUPIBOET BOEJOGSPOUPGUIFFZFTPGEFSNBUPMPHJTUTIPQFGVMMZFWFSZXIFSF REFERENCES t 4UBHFPOF34%DIBSBDUFSJ[FECZTFWFSFCVSOJOHQBJOBUUIFTJUFPGUIF JOKVSZ XJUI NVTDMF TQBTN KPJOU TUJêOFTT SFTUSJDUFE NPCJMJUZ SBQJE IBJSBOEOBJMHSPXUIBOEWBTPTQBTN 1 Braverman IM. Skin Signs of Systemic Disease. 3rd ed. Philadelphia, PA: W.B. Saunders Co; 1998. 2 Callen, JP, Jorizzo, JL, Bolognia, JL, Piette, W, Zone JJ. Dermatological Signs of Internal Disease. 4th ed. Philadelphia, PA: W.B. Saunders Co; 2009. 3 Provost TT, Flynn JA. Cutaneous Medicine: Cutaneous Manifestations of Systemic Disease. Hamilton, Ontario: BC Decker Inc; 2001. Reviewed by Noah S. Scheinfeld, MD, JD From the Department of Dermatology, Columbia University, College of Physicians and Surgeons, New York, NY Address for Correspondence: Noah S. Scheinfeld, MD, JD, Department of Dermatology, Columbia University, College of Physicians and Surgeons, 150 West UI4USFFU/FX:PSL/:t&NBJMTDIFJOGFME!FBSUIMJOLOFU SKINmed. 2012;10:120 120 ª1VMTF.BSLFUJOH$PNNVOJDBUJPOT--$ Locoid Lipocream® Cream, 0.1% (hydrocortisone butyrate 0.1% cream) For Topical Use Only Rx Only BRIEF SUMMARY INDICATIONS AND USAGE Locoid Lipocream is a topical corticosteroid indicated for: relief of the inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses in adults and the treatment of mild to moderate atopic dermatitis in patients 3 months to 18 years of age. WARNINGS AND PRECAUTIONS Reversible hypothalamic-pituitary-adrenal (HPA) axis suppression may occur, with the potential for glucocorticosteroid insufficiency. Consider periodic evaluations for HPA axis suppression if Locoid Lipocream is applied to large surface areas or used under occlusion. If HPA axis suppression is noted, reduce the application frequency, discontinue use, or switch to a lower potency corticosteroid. Systemic effects of topical corticosteroids may also include manifestations of Cushing’s syndrome, hyperglycemia, and glucosuria. Pediatric patients may be more susceptible to systemic toxicity due to their larger skin surface-to-body-mass ratios. Initiate appropriate therapy if concomitant skin infections develop. Discontinue use if irritation develops. ADVERSE REACTIONS The most common adverse reactions (>1%) are HPA axis suppression and application site reactions. The following additional local adverse reactions have been reported infrequently with topical corticosteroids, and they may occur more frequently with the use of occlusive dressings and higher potency corticosteroids. These reactions included: irritation, folliculitis, acneiform eruptions, hypopigmentation, perioral dermatitis, allergic contact dermatitis, secondary infection, skin atrophy, striae, miliaria and telangiectasia. USE IN SPECIFIC POPULATIONS Pregnancy Pregnancy Category C. Corticosteroids have been shown to be teratogenic in laboratory animals when administered systemically at relatively low dosage levels. Some corticosteroids have been shown to be teratogenic after dermal application in laboratory animals.There are no adequate and well-controlled studies in pregnant women. Therefore, Locoid Lipocream should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Please refer to full prescribing information for detailed information regarding systemic embryofetal development studies. Nursing Mothers Systemically administered corticosteroids appear in human milk and could suppress growth, interfere with endogenous corticosteroid production, or cause other untoward effects. It is not known whether topical administration of corticosteroids could result in sufficient systemic absorption to produce detectable quantities in human milk. Because many drugs are excreted in human milk, caution should be exercised when Locoid Lipocream is administered to a nursing woman. Pediatric Use Safety and efficacy in pediatric patients below 3 months of age have not been established. Because of higher skin surface-to-body-mass ratios, pediatric patients are at a greater risk than adults of HPA axis suppression when they are treated with topical corticosteroids. They are therefore also at a greater risk of glucocorticosteroid insufficiency after withdrawal of treatment and of Cushing’s syndrome while on treatment. Eighty-six (86) pediatric subjects (5 months to less than 18 years of age) with moderate to severe atopic dermatitis affecting at least 25% of body surface area (BSA) treated with Locoid Lipocream three times daily for up to 4 weeks were assessed for HPA axis suppression. The disease severity (moderate to severe atopic dermatitis) and the dosing regimen (three times daily) in this HPA axis study were different from the subject population (mild to moderate atopic dermatitis) and the dosing regimen (two times daily) for which Locoid Lipocream is indicated. Five of the 82 evaluable subjects (6.1%) demonstrated laboratory evidence of suppression, where the sole criterion for defining HPA axis suppression was a serum cortisol level of less than or equal to 18 micrograms per deciliter after cosyntropin stimulation. Suppressed subjects ranged in age from 5 months to 16 years and, at the time of enrollment, had 25% to 95% BSA involvement. These subjects did not develop any other signs or symptoms of HPA axis suppression. At the first follow up visit, approximately one month after the conclusion of treatment, cosyntropin stimulation results of all subjects had returned to normal, with the exception of one subject. This last subject recovered adrenal function by the second post treatment visit, 65 days post-treatment. Cushing’s syndrome, linear growth retardation, delayed weight gain, and intracranial hypertension have also been reported in pediatric patients receiving topical corticosteroids. Manifestations of adrenal suppression in pediatric patients include low plasma cortisol levels to an absence of response to ACTH stimulation. Manifestations of intracranial hypertension include bulging fontanelles, headaches, and bilateral papilledema. Geriatric Use Clinical studies of Locoid Lipocream did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Carcinogenesis, Mutagenesis, Impairment of Fertility No studies were conducted to determine the photococarcinogenic or dermal carcinogenic potential of Locoid Lipocream. Hydrocortisone butyrate revealed no evidence of mutagenic or clastogenic potential based on the results of two in vitro genotoxicity tests (Ames test and L5178Y/TK+ mouse lymphoma assay) and one in vivo genotoxicity test (mouse micronucleus assay). No evidence of impairment of fertility or effect on mating performance was observed in a fertility and general reproductive performance study conducted in male and female rats at subcutaneous doses up to and including 1.8 mg/kg/day (0.7X maximum topical human dose [MTHD]). Mild effects on maternal animals, such as reduced food consumption and a subsequent reduction in body weight gain, were seen at doses ≥0.6 mg/kg/day (0.2X MTHD). PATIENT COUNSELING INFORMATION Patients using Locoid Lipocream should receive the following information and instructions: Apply a thin layer to the affected skin two or three times daily for corticosteroidresponsive dermatoses in adults. Consult with your physician to determine if treatment is needed beyond 2 weeks. Apply a thin film to the affected skin areas two times daily for atopic dermatitis in patients 3 months of age and older. Safety of Locoid Lipocream in pediatric patients has not been established beyond 4 weeks of use. Rub in gently. Avoid contact with the eyes. Do not bandage, otherwise cover, or wrap the affected skin area so as to be occlusive unless directed by your physician. Do not use Locoid Lipocream in the diaper area, as diapers or plastic pants may constitute occlusive dressings. Do not use Locoid Lipocream on the face, underarms, or groin areas unless directed by your physician. If no improvement is seen within 2 weeks, contact your physician. Do not use other corticosteroid-containing products while using Locoid Lipocream without first consulting your physician. Store at 25°C (77°F); excursions permitted to 15-30°C (59-86°F) [see USP Controlled Room Temperature]. Protect from freezing. Keep out of the reach of children. Manufactured for: Triax Pharmaceuticals, LLC Cranford NJ 07016 By: Ferndale Laboratories, Inc. Ferndale MI 48220 Locoid Lipocream is a registered trademark of Astellas Pharma Europe BV licensed to Triax Pharmaceuticals, LLC. Marketed and Distributed By: Triax Pharmaceuticals, LLC Cranford NJ 07016 www.Locoid.com 131B301 Rev 11/09 Now younger eczema patients have something to smile about Now approved for use in children down to 3 months of age The power of an ointment with the elegance of a cream Locoid Lipocream is indicated for the relief of the inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses, including the treatment of mild to moderate atopic dermatitis in patients 3 months of age and older. Safety and effectiveness in pediatric patients below 3 months of age have not been established. Reversible HPA axis suppression may occur, with the potential for corticosteroid insufficiency. Consider periodic evaluations for HPA axis suppression if applied to large surface areas or used under occlusion. Systemic effects of topical corticosteroids may also include manifestations of Cushing’s syndrome, hyperglycemia, and glucosuria. Pediatric patients may be more susceptible to systemic toxicity due to their large skin surface-to-body-mass ratios. Initiate appropriate therapy if concomitant skin infection develops. Discontinue use if irritation develops. Please see full Prescribing Information on adjacent page. Visit us at www.locoid.com (hydrocortisone butyrate 0.1%) Cream ©2010 Triax Pharmaceuticals, LLC. All rights reserved. Locoid is a registered trademark of Astellas Pharma Europe B.V. licensed to Triax Pharmaceuticals, LLC. LOC-0410-01
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