Faculty Bibliography

The authors present a case of erythema multiforme-like drug reaction to the multikinase inhibitor sorafenib. While considered targeted therapy, multikinase inhibitors have been demonstrated to have various cutaneous effects. It is important to distinguish allergic reactions from adverse side effects as the latter may permit cautious re-challenge with medications that can potentially prolong survival in patients with advanced or metastatic disease

A 36-year-old man with a prior diagnosis of primary cutaneous marginal-zone B cell lymphoma presented with newly-developed, small, erythematous papules and nodules on his upper left arm and pink-to-skin-colored, clustered papules on his left forearm. A biopsy specimen and immunohistochemical analysis of the left arm lesions showed a lymphocytic infiltrate which stained positively for CD20 and Bcl-2 and negatively for CD10. A PET-CT scan was negative for any extra-cutaneous manifestations of disease. These clinicopathologic findings are indicative of recurrent localized primary cutaneous marginal-zone B cell lymphoma.

Acquired brachial cutaneous dyschromatosis (ABCD) is a newly described disorder of pigmentary change that occurs on the dorsal aspects of the forearms in post-menopausal women. We report a case of a 62-year-old woman who developed an asymptomatic, reticulated, gray-brown eruption on the dorsal aspects of the forearms of gradual onset that is clinically and histopathologically consistent with ABCD. Whereas the original report found an association between hypertension and/or the use of anti-hypertensive medications in the original cohort, we propose that this entity may, in fact, be associated more closely with cumulative sun damage and may be related to such acquired disorders of the skin as poikiloderma of Civatte. Treatment of these lesions may prove to be a challenge, with an emphasis on rigorous sun protection and adjunctive measures with depigmentating agents, chemical peels, and lasers.

A 49-year-old man with advanced HIV/AIDS on anti-retroviral therapy (HAART) and trimethoprim-sulfamethoxazole (TMP-SMX) presented with a several-month history of pruritic, erythematous, lichenified papules that coalesced into hyperkeratotic plaques on the trunk and extremities in a sun-exposed distribution. He shortly thereafter developed a progressive depigmentation over more than 80 percent of his body surface area. A biopsy specimen of an erythematous plaque on the trunk showed a superficial and mid-dermal infiltrate of lymphocytes with eosinophils, most consistent with either chronic lichenoid drug eruption or atypical lymphoproliferative disorder (ACLD) of HIV. The patient's lichenoid skin disease has persisted despite discontinuation of TMP-SMX, although it has improved partially with administration of topical glucocorticoids and acitretin. His depigmentation has continued to progress. We discuss the overlapping diagnostic entities which may be comprised by this patient's clinical disease, and highlight a unique presentation of the complex interaction between HIV infection and the skin.

Like all organ systems, the skin undergoes significant changes during pregnancy. The majority of physiologic skin conditions related to gestation resolve after childbirth. However, they may cause significant concern or cosmetic distress or be mistaken for one of the specific dermatoses of pregnancy. Dermatoses unique to pregnancy are rare but important to recognize because they may be intensely pruritic or painful to the mother, and they may pose significant risks to the patient, her fetus, or both. Clinicians familiar with the cutaneous manifestations of pregnancy can most effectively treat and counsel patients, guide expectations, and avoid unnecessary diagnostic tests and therapies. This review summarizes physiologic skin changes in the gravid patient and the specific dermatoses of pregnancy

A 69-year-old woman presented with a 30-year history of lower back and large joint pain of the hips and shoulders. On examination blue-grey, pigmented macules were present over the cartilaginous portions of the ears and on the sclera. Past medical history included aortic stenosis. Urine homogentisic acid level was elevated, which is diagnostic for alkaptonuria. Alkaptonuria is an autosomal recessive disorder that results in deficiency of homogentisic acid oxidase and in the accumulation of homogentisic acid in connective tissue. Disease can result in blue-grey pigmentation of the cartilage, sclerae, face, and hands as well as severe arthropathy and cardiac valve disease. Treatment is limited at this time. Promising early reports of the use of nitisinone have prompted ongoing trials of this therapeutic agent

A 72-year-old man with a history of metastatic melanoma presented with a two-day history of erythematous and edematous plaques, with scattered bullae on the neck, chest, axillae, and inguinal and gluteal folds, which began five days after infusion of an experimental drug. The clinical and histopathologic findings were consistent with systemic drug-related intertriginous and flexural exanthema (SDRIFE), which is an uncommon drug reaction that results in symmetric erythema that affects the buttocks, groin, and/or thighs as well other flexural folds. The clinical manifestations of SDRIFE are highly characteristic and include distinctive primary cutaneous lesions with a specific distribution and course; however, heterogeneity exists with respect to histopathologic features, skin test results, and in vitro investigations. The exact mechanism of SDRIFE remains unknown but is thought to result from a type IV delayed hypersensitivity immune response. Treatment is symptomatic and includes topical or oral glucocorticoids