Faculty Bibliography

Ultraviolet filters are the most common topical photoallergens. Although currently not available on the US market, methylene bis-benzotriazolyl tetramethylbutylphenol (referred to as bisoctrizole on product labels) represents a new class of UV filters that have both organic and inorganic properties and are widely available in different preparations in Europe, South America, and Asia. We report two patients with atopic dermatitis and chronic actinic dermatitis who had positive patch- and photopatch-test reactions, which suggested both an allergic contact and a photoallergic contact dermatitis from bisoctrizole. Neither patient could identify previous or current contact with the chemical; nonetheless, it is possible that either the allergic contact or photoallergic contact dermatitis from bisoctrizole led to their chronic actinic dermatitis

BACKGROUND: Retrospective chart reviews are periodically needed to update allergen series to detect changes in photoallergic contact dermatitis (PACD) over time. OBJECTIVE: We sought to evaluate photopatch test results during a 13-year period and extend the observations to 20 years. METHODS: A retrospective chart review was conducted in patients who were photopatch tested. RESULTS: In all, 76 patients were evaluated. A total of 69 positive photopatch and 45 positive patch test reactions were detected in 30 and 23 patients, respectively. The frequencies of the positive photopatch test reactions were sunscreens 23.2%, antimicrobial agents 23.2%, medications 20.3%, fragrances 13%, plants and plant derivatives 11.6%, and pesticides 8.7%. Of the positive photopatch reactions to antimicrobial agents, 60% were caused by Fentichlor. LIMITATIONS: This study was a retrospective chart analysis, and the number of patients was small. CONCLUSIONS: Sunscreens and antimicrobial agents were the most frequent allergens eliciting PACD, and there was a decrease in PACD caused by fragrances. The number of reactions to medications increased. This study also demonstrated that pesticides can be a cause of PACD. The detection of reactions to Fentichlor was unexpected and, although they have been attributed in some studies to cross-reactions to sulfanilamides and bithionol, such a robust association was not observed in this study. This study extends our experience of the changes in the allergens that elicit PACD to 20 years

A 54-year-old woman with a history of arthritis presented for a long-standing history of symmetric, indurated plaques on her thighs and lateral aspects of the trunk. Histopathologic examination of skin biopsy specimens was consistent with interstitial granulomatous dermatitis, and a diagnosis of interstitial granulomatous dermatitis with arthritis was made. Administration of topical potent glucocorticoids, intralesional glucocorticoids, and narrow-band ultraviolet B phototherapy, in addition to continuation of systemic glucocorticoids and methotrexate, resulted in improvement of her cutaneous and musculoskeletal disease

A 78-year-old man presented with an eight-month history of folliculocentric, pink, hyperkeratotic papules and plaques with thick white scale that involved the entire body, with confluence on the buttocks and genitalia. A biopsy specimen demonstrated superficial and focal, mild perivascular and perifollicular, band-like lymphocytic infiltrate and eosinophils. There were lymphocytes extending to the dermo-epidermal junction with vacuolar changes. A diagnosis of lichenoid drug eruption secondary to a proton-pump inhibitor was made. To the best of our knowledge, only one other case of lichenoid drug eruption secondary to a proton-pump inhibitor has been reported

A 71-year-old man presented with a six-year history of a pruritic, erythematous, blistering eruption of the face, chest, and arms. Clinical findings, histopathologic features, and phototests were consistent with a diagnosis of chronic actinic dermatitis. The patient also had contact allergy and photocontact allergy to multiple allergens. A discussion of chronic actinic dermatitis is presented

A 79-year-old woman presented with a history of peeling of the palms and soles that began in young adulthood, with exacerbation after exposure to water. Her mother, 2 sisters, and a female maternal cousin have similar symptoms. Physical examination showed scale and hyperlinearity of the palms. Brief exposure to water initiated the development of 1-to 2-mm, translucent, white papules that were distributed diffusely on the palmar surface, with a concentration at the palmar margins and pressure points. Histopathologic examination showed an acanthotic epidermis with a central depression that was filled with compact orthokeratosis. The physical examination and histopathologic findings are consistent with a diagnosis of hereditary papulotranslucent acrokeratoderma

A 32-year-old woman and her 35-year-old sister presented with plaques of scleroderma en coup de sabre. The younger sister's disease was more severe and preceded the older sister's by 10 years. This is the second reported case of familial en coup de sabre, and the first case of horizontal transmission. Treatment of the younger sister with antimalarials and narrow-band ultraviolet B (NB-UVB) phototherapy slowed disease progression and reversed hair loss. The observation that NB-UVB was effective in this case of linear scleroderma suggests that it may be indicated as a therapy for cutaneous scleroderma

The bioterrorism-related anthrax outbreak generated unanticipated demand for dermatologic services. In this study we sought to perform rapid, efficient, cost-effective evaluation of patients suspected of having cutaneous anthrax. During the outbreak, we developed an anthrax evaluation system featuring clinical field examination by nondermatologist physicians, followed by rapid referral of selected high-risk patients to a centralized dermatology center. We excluded anthrax in 29 previously screened high-risk patients. All were examined within 24 hours, costing $272.07 per patient. Diagnoses were established quickly (median, same day; range, 0-15 days). Among 2259 at-risk postal workers, 144 (6.4%) self-identified new (< or =14 days) skin lesions and were examined in the field; 8 (5.6%) were referred to our system. Our system was not the only local dermatologic resource available during the outbreak. A system featuring initial nondermatologist examination with minimal laboratory evaluation, followed by rapid centralized referral of high-risk patients, functioned efficiently in this outbreak

OBJECTIVE: To define comprehensive criteria for the classification and differential diagnosis of tumid lupus erythematosus (LE). METHODS: A prospective study of patients fulfilling the classical description of tumid LE was performed. Clinical evaluation, histopathologic and direct immunofluorescence analyses of skin specimens, and serologic evaluation were conducted. The inflammatory cell infiltrate was quantitatively investigated by immunohistochemical analysis of fresh frozen skin specimens using multiple lymphocytic markers. RESULTS: Fifteen patients were followed for a mean of 7 years. Smooth, indurated, nonscarring, pink to violaceous papules, plaques, or nodules, devoid of surface changes were distributed on sun exposed sites. The mean lesion duration was 2 years, female:male ratio was 8:7, and racial distribution was 11 white, 2 Hispanic, and 2 African American patients. Histopathologic findings included a superficial and deep, perivascular, and frequently periadnexal infiltrate of lymphocytes, mucin deposition throughout the dermis, and absent to focal dermal-epidermal junctional involvement. Direct immunofluorescence immunoreactants and low titer antinuclear antibodies were variably present. Immunohistochemical findings included a predominance of pan-T cell marker CD3-expressing (78.0% +/- 6.3%) T lymphocytes. Most were CD4 expressing (82.7% +/- 8.0%) helper T cells; a minority were CD8 expressing (31.3% +/- 14.0%) cytotoxic T cells. The CD4:CD8 ratio was 3.1 (+/-1.3):1. One patient developed systemic LE and one a discoid LE lesion. CONCLUSION: Comprehensive clinical, histopathologic, and immunohistochemical criteria for the classification of tumid LE are proposed that differentiate tumid LE from other cutaneous disorders that may be clinically and histologically indistinguishable. The chronic, benign course indicates that tumid LE be classified as a form of chronic cutaneous LE, although it may be a cutaneous feature of systemic LE