Faculty Bibliography

The erythrodermic patient is often challenging and requires careful evaluation. Work-up should include an extensive and careful medication history, histological and laboratory testing, and if necessary, molecular studies for the evaluation of underlying malignancy. Herein, we present an erythrodermic patient with repeated biopsies demonstrating a spongiotic process who was found to have circulating atypical T-cells concerning for an underlying erythrodermic T-cell leukemia, most closely related to Sézary syndrome.

Psoriasis prevalence has long been considered to be 2-4% in the United States (US). Recently, prevalence rates of 0.5-0.6% were reported in Medicare patients and 0.128% in commercially insured children. We investigated psoriasis prevalence among commercially insured individuals younger than 65 years. The Truven Health Analytics MarketScan Commercial Claims and Encounters databases, which includes beneficiaries of employer-based commercial insurance in the US, was interrogated for continuously enrolled beneficiaries from 2011-2017. Psoriasis cases were identified using >=1 or >=2 inpatient or outpatient claims by any physician (ICD-9-CM code 696.1; ICD-10-CM codes L40.0-L40.4, L40.8, L40.9). Annual prevalence and 95% confidence intervals (CI) were calculated for each year separately. Information on gender and age range was also collected. Defining psoriasis as >=1 claim yielded a prevalence of 0.529% (95% CI 0.526-0.531) in 2011 and 0.718% (95% CI 0.714-0.721) in 2017. Women (51.7-53%) were slightly more represented than men (48.3-47%). Prevalence rose in the 18-34 years and 45-54 years age groups, reflecting a bimodal distribution of onset of psoriasis. When using >=2 claims of psoriasis as the definition, the prevalence fell to 0.220% (95% CI 0.219-0.222) to 0.329% (95% CI 0.326-0.331) during the study period. This study suggests that psoriasis is possibly up to 4-fold less prevalent than previously believed with a prevalence of 0.5-0.7% using >=1 claim of psoriasis as our criterion. When using 2 claims for psoriasis, a more clinically vigorous case definition, prevalence dropped to 0.2-0.3%. This replicates observations of previous studies and reflects the greater positive predictive value of using multiple claims for psoriasis as compared to one claim. Limitations of our study include diagnosis misclassification and the restriction to commercial insurance beneficiaries. Given the effects of psoriasis on quality of life, comorbid conditions, and health care utilization, a re-appraisal of the prevalence of psoriasis in the US is a necessary consideration.
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Background/UNASSIGNED:Two primary histologic subtypes, superficial spreading melanoma (SSM) and nodular melanoma (NM), comprise the majority of all cutaneous melanomas. NM is associated with worse outcomes, which have been attributed to increased thickness at presentation, and it is widely expected that NM and SSM would exhibit similar behavior once metastasized. Herein, we tested the hypothesis that primary histologic subtype is an independent predictor of survival and may impact response to treatment in the metastatic setting. Methods/UNASSIGNED:We examined the most recent Surveillance, Epidemiology, and End Results (SEER) cohort (n = 118 508) and the New York University (NYU) cohort (n = 1621) with available protocol-driven follow-up. Outcomes specified by primary histology were studied in both the primary and metastatic settings with respect to BRAF-targeted therapy and immunotherapy. We characterized known driver mutations and examined a 140-gene panel in a subset of NM and SSM cases using next-generation sequencing. All statistical tests were two-sided. Results/UNASSIGNED:NM was an independent risk factor for death in both the SEER (hazard ratio [HR] = 1.55, 95% confidence interval [CI] = 1.41 to 1.70, P < .001) and NYU (HR = 1.47, 95% CI = 1.05, 2.07, P = .03) cohorts, controlling for thickness, ulceration, stage, and other variables. In the metastatic setting, NM remained an independent risk factor for death upon treatment with BRAF-targeted therapy (HR = 3.33, 95% CI = 1.06 to 10.47, P = .04) but showed no statistically significant difference with immune checkpoint inhibition. NM was associated with a higher rate of NRAS mutation (P < .001), and high-throughput sequencing revealed NM-specific genomic alterations in NOTCH4, ANK3, and ZNF560, which were independently validated. Conclusions/UNASSIGNED:Our data reveal distinct clinical and biological differences between NM and SSM that support revisiting the prognostic and predictive impact of primary histology subtype in the management of cutaneous melanoma.

We present a case of necrobiosis lipoidica (NL) of the right abdomen in a 75-year-old man. A skin biopsy performed showed a layered infiltrate of mono and multinucleated histiocytes palisaded around degenerated collagen bundles. Laboratory workup was unremarkable. The patient was treated with topical corticosteroids with cessation of progression of his disease, although the eruption did not resolve. There are a number of treatments for NL reported in the literature, all with varying efficacy. Although NL lesions are usually asymptomatic, patients with NL must be monitored closely for signs of ulceration or malignant transformation, in which case more aggressive treatment options may be warranted.