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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


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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

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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"WFOVF 4FB#SJHIU /+

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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


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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

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SKINmed. 2012;10:67â&#x20AC;&#x201C;69

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March/April 2012

Figure 3. Red papules on the penile corona indicating scabies, until proven otherwise.

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Figure 1. The scabies mite, showing 8 legs.

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Figure 2. The characteristic red papules on the finger webs.

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Figure 4. Crusted scabies in an older man who had neglected himself.

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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; 317â&#x20AC;&#x201C;318.

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Scabies Homepage. (American incidence) http://www.stanford.edu/ group/parasites/ParaSites2005/Scabies/SCABIES.html. Accessed July 30, 2011.

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Lassa S, Campbell MJ, Bennett CE. Epidemiology of scabies prevalence in the UK from general practice records. Br J Dermatol. 2011;164; 1329â&#x20AC;&#x201C;1334.

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Downs AMR, Harvey I, Kennedy CTC. The epidemiology of head lice and scabies in the UK. Epidemiol Infect. 1999;3;471â&#x20AC;&#x201C;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 DPOTJEFSFESFTJTUBODF XIJDIJUJTOPU17 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;717â&#x20AC;&#x201C;725. 13 Cestari TF, Martignago BF. Scabies, pediculosis, bedbugs and stinkbugs: uncommon presentations. Clin Dermatol. 2005;23;545â&#x20AC;&#x201C;554.

REFERENCES

14 Wolf R, Davidovici B. Treatment of scabies and pediculosis: facts and controversies. Clin Dermatol. 2010;28;511â&#x20AC;&#x201C;518.

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Graham-Brown RAC, Burns T. Lecture notes. Dermatology. 9th ed. Malden, MA: Blackwell Publishing; 2007:41â&#x20AC;&#x201C;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;e8â&#x20AC;&#x201C;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;5:214â&#x20AC;&#x201C;216.

4

Ramos-e-Silva M. Giovan Cosimo Bonomo (1663-1696): discoverer of the etiology of scabies. Int J Dermatol. 1998;37;625â&#x20AC;&#x201C;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 238â&#x20AC;&#x201C;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

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ORIGINAL CONTRIBUTION

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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/FXFSQTZDIPUSPQJDT TVDIBTSJTQFSEBMBOEMFYBQSP  TIPXQSPNJTFJOIFMQJOHUIFTFQBUJFOUTBOEBEEUPUIFUIFSBQFVUJDBSNBNFOUBSJVNPGQJNP[JEF SKINmed. o

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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.

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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


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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 PGDBSFOFFETɨJTBSUJDMFGPMMPXTDBTFTBTLJOUFBSDPNQMJDBUFECZWFOPVTVMDFSBUJPO BQSFTTVSFVMDFSXJUIGFWFS BOEBSUFSJBMVMDFSTJOB QBUJFOUXIPPQUTGPSDPNGPSUDBSFɨFDBTFTJMMVTUSBUFUIFIJHIFSOFFETPGUIJTQPQVMBUJPOBOEFNQIBTJ[FUIFBUUFOUJPOUIBUNVTUCFQBJE UPSFTQFDUOVSTJOHUJNFJOUFOTJWFOFTT JODPSQPSBUFSFBMJTUJDHPBMTPGDBSFGPSXPVOEIFBMJOH BOEFOTVSFFYDFMMFOUDPNNVOJDBUJPOXJUIUIF UFBNNFNCFST QBUJFOUT BOEGBNJMZ SKINmed. o

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CASE 1: SKIN TEAR THAT IS SLOW TO HEAL

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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

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Figure 1. Venous ulcer status post-debridement. Photo courtesy of E. Foy White-Chu, MD.

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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.

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76

Table I. Prevention of Skin Tears

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77

CASE 2: STAGE IV PRESSURE ULCER AND FEVER ɨF XPVOE DBSF UFBN XBT BTLFE UP TFF B ZFBSPME XPNBO SFHBSEJOHBTUBHF*7QSFTTVSFVMDFSBOEGFWFS4IFIBEBTJHOJë DBOUNFEJDBMIJTUPSZPGEJBCFUFTNFMMJUVTBOEFOETUBHFSFOBMEJT FBTF POIFNPEJBMZTJT ɨFXPVOEEFWFMPQFEBUIPNFXIFOTIF SFGVTFEUPQBSUJDJQBUFJOSFIBCJMJUBUJWFUIFSBQZBGUFSIFSGFNPSBM GSBDUVSF XIJDIPDDVSSFEBUMFBTUNPOUITQSJPSUPIFSBENJTTJPO UPUIFTIPSUUFSNSFIBCJMJUBUJWFGBDJMJUZɨFQBUJFOUXBTOPUBEIFS FOU UP IFS SFIBCJMJUBUJWF SFHJNFO  TUBUJOH TIF XBT UPP UJSFE5P BEESFTTUIJT IFSTFEBUJOHNFEJDBUJPOTXFSFSFEVDFECZUIFHFSJ BUSJDJBO BOEIFSEJBMZTJTSFHJNFOXBTPQUJNJ[FECZUIFOFQISPMP HJTUUPDVSUBJMMPXCMPPEQSFTTVSFT4IFDPOUJOVFEOPUUPFOHBHFJO UIFSBQZ BOEUIFQBUJFOUJOTJTUFEPOTJUUJOHVQJOCFEPSJOBDIBJS

Table II. Venous Ulcer Challenges and Treatments

PROBLEM

APPROACH

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Belowitz DR, Brandeis GH, Anderson J, Du W, Brand H. Effect of presTVSFVMDFSTPOUIFTVSWJWBMPGMPOHUFSNDBSFSFTJEFOUTJ Gerontol A Biol Sci Med Sci. 1997;52:M106â&#x20AC;&#x201C;M110.

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3PCFSUT .+ 1SFWFOUJOH BOE NBOBHJOH TLJO UFBST B SFWJFX J Wound Ostomy Continence Nurs. 2007;34:256â&#x20AC;&#x201C;259.

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,BO., %FMJT,5)FNPEZOBNJDFGGFDUTPGTVQFSWJTFEDBMGNVTDMFFYFSDJTF JO QBUJFOUT XJUI WFOPVT MFH VMDFSBUJPO B QSPTQFDUJWF DPOUSPMMFE study. Arch Surg. 2001;136:1364â&#x20AC;&#x201C;1369.

10 :BOH% 7BOEPOHFO:, 4UBDFZ.$&GGFDUPGFYFSDJTFPODBMGNVTDMF QVNQ GVODUJPO JO QBUJFOUT XJUI DISPOJD WFOPVT EJTFBTF Br J Surg. 1999;86:338â&#x20AC;&#x201C;341. 11 ,SBTOFS%1BJOGVMWFOPVTVMDFSTUIFNFTBOETUPSJFTBCPVUUIFJSJNQBDUPO quality of life. Ostomy Wound Manage. 1998;44:38â&#x20AC;&#x201C;49. 12 1FSTPPO" )FJOFO.. WBEFS7MFVUFO$+ FUBM-FHVMDFSTBSFWJFXPG their impact on daily life. J Clin Nurs. 2004;13:341â&#x20AC;&#x201C;354. 13 .PGGBUU$+ .D$VMMBHI- 0$POOPS5 FUBM3BOEPNJ[FEUSJBMPGGPVSMBZFS BOEUXPMBZFSCBOEBHFTZTUFNTJOUIFNBOBHFNFOUPGDISPOJDWFOPVT ulceration. Wound Repair Regen. 2003;11:166â&#x20AC;&#x201C;171. 14 'MFUDIFS" $VMMVN/ 4IFMEPO5""TZTUFNBUJDSFWJFXPGDPNQSFTTJPO USFBUNFOUGPSWFOPVTMFHVMDFSTBMJ. 1997;315:576â&#x20AC;&#x201C;580. 15 4JCCBME 3(  "MBWJ "  /PSUPO -  #SPXOF "$  $PVUUT 1 $PNQSFTTJPO UIFSBQJFT *O ,SBTOFS  %-  3PEFIFBWFS (5  4JCCBME 3(  FET Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. 4th ed. Wayne, PA: Health Management Publications, Inc; 2007:481â&#x20AC;&#x201C;488. 16 Romanelli M, Dini V, Willliamson D, et al. Measurement: lower MFHVMDFSWBTDVMBSBOEXPVOEBTTFTTNFOU*O,SBTOFS %- 3PEFIFBWFS (5  4JCCBME 3(  FET Chronic Wound Care: A Clinical Source Book for Healthcare Professionals, Fourth Edition. Wayne, PA: Health Management Publications, Inc; 2007:463â&#x20AC;&#x201C;480. 17 Palfreyman SSJ, Nelson EA, Lochiel R, Michaels JA. 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):IV1â&#x20AC;&#x201C;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;19:206â&#x20AC;&#x201C;211. 21 1SFTTVSFVMDFSTJO"NFSJDBQSFWBMFODF JODJEFODF BOEJNQMJDBUJPOTGPS UIFGVUVSF"OFYFDVUJWFTVNNBSZPGUIF/BUJPOBM1SFTTVSF6MDFS"EWJsory Panel monograph. Adv Skin Wound Care. 2001;14:208â&#x20AC;&#x201C;215. 22 Allman RM, Goode PS, Patrick MM, et al. Pressure ulcer risk facUPST BNPOH IPTQJUBMJ[FE QBUJFOUT XJUI BDUJWJUZ MJNJUBUJPO JAMA. 1995;273:865â&#x20AC;&#x201C;870. 23 #FOOFUU3( 04VMMJWBO+ %F7JUP&. FUBM5IFJODSFBTJOHNFEJDBMNBMQSBDUJDFSJTLSFMBUFEUPQSFTTVSFVMDFSTJOUIF6OJUFE4UBUFTJ Am Geriatr Soc. 2000;48:73â&#x20AC;&#x201C;81. 24 4JCCBME3( 8JMMJBNTPO% 0STUFE)- FUBM1SFQBSJOHUIFXPVOECFEÂ&#x2030; debridement, bacterial balance and moisture balance. Ostomy Wound Manage. 2000;46:14â&#x20AC;&#x201C;22, 24â&#x20AC;&#x201C;28, 30â&#x20AC;&#x201C;35. 25 Schultz GS, Sibbald RG, Falanga V, et al. Wound bed preparation: a systemic approach to wound management. Wound Rep Reg. 2003;11:1â&#x20AC;&#x201C;28. 26 $PSDPSBO 1+ 6TF JU PS MPTF JUÂ&#x2030;UIF IB[BSET PG CFE SFTU BOE JOBDUJWJUZ West J Med. 1991;154:219â&#x20AC;&#x201C;223.

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March/April 2012 27 Allen C, Glasziou P, Del Mar C. Bed rest: a potentially harmful treatment OFFEJOHNPSFDBSFGVMFWBMVBUJPOLancet. 1999;354:1229â&#x20AC;&#x201C;1233.

34 )PVBOH&5 (JMNPSF0+ 3FJE$ 4IBX&+"CTFODFPGCBDUFSJBMSFTJTUBODFUPQPWJEPOFJPEJOFJ Clin Pathol. 1976;29:752â&#x20AC;&#x201C;755.

28 &VSPQFBO 1SFTTVSF 6MDFS "EWJTPSZ 1BOFM BOE /BUJPOBM 1SFTTVSF 6MDFS "EWJTPSZ1BOFMTreatment of Pressure Ulcers: Quick Reference Guide. 8BTIJOHUPO%$/BUJPOBM1SFTTVSF6MDFS"EWJTPSZ1BOFM

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29 3FEEZ. (JMM44 ,BMLBS435SFBUNFOUPGQSFTTVSFVMDFSTBTZTUFNBUJD SFWJFXJAMA. 2008;300:2647â&#x20AC;&#x201C;2662.

36 )PMMPXBZ (" "SUFSJBM VMDFST BTTFTTNFOU  DMBTTJÃ¥DBUJPO  BOE NBOBHFNFOU*O,SBTOFS %- 3PEFIFBWFS(5 4JCCBME3( FETChronic Wound Care: A Clinical Source Book for Healthcare Professionals, Fourth Edition. Wayne, PA: Health Management Publications, Inc; 2007:443â&#x20AC;&#x201C;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;19:447â&#x20AC;&#x201C;461. 32 Drosou A, Falabella A, Kirsner RS. Antiseptics on wounds: an area of DPOUSPWFSTZWounds. 2003;15:149â&#x20AC;&#x201C;166.

37 :VFO,$+ #BLFS/3 3BZNBO(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;151:400â&#x20AC;&#x201C;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.

CFESBJMT XJUIJOKVSJFTTVTUBJOFEJOIPTQJUBMJOUFOTJWFDBSF facilities. HFSJBUSJD SFDMJOFST  XJUI JOKVSJFT TVTUBJOFE JO EPDUPST PGÃ¥DFTBOEXBJUJOHSPPNT HFSJBUSJD SFDMJOFST  XJUI JOKVSJFT TVTUBJOFE JO IPTQJUBM JOUFOTJWFDBSFGBDJMJUJFT XIFFMDIBJST  XJUI JOKVSJFT TVTUBJOFE JO EPDUPST PGÃ¥DFT and waiting rooms. XIFFMDIBJST XJUIJOKVSJFTTVTUBJOFEJOUIFQBUJFOUT bedroom.

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d.

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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.

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1)

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CORE CURRICULUM Virendra N. Sehgal, MD, Section Editor

Cutaneous Tuberculosis: A Diagnostic Dilemmaâ&#x20AC;&#x201D;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 Îł 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.

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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 Ã&#x2014;40). Inset: hematoxylin-eosin stain, original magnification Ã&#x2014;400.

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B Figure 1. (A) Cohesive epithelioid cell granuloma in an aspirate from a cervical lymph node (May-Grunwald-Giemsa stain, magnification Ã&#x2014;400). (B) Single acid-fast bacillus in a fine-needle aspirate smear from a lymph node (Ziehl-Neelsen stain, magnification Ã&#x2014;400).

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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 Ã&#x2014;40). Inset: hematoxylin-eosin stain, original magnification Ã&#x2014;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 Ã&#x2014;40). Inset: hematoxylin-eosin stain, original magnification Ã&#x2014;100.

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DNA PROBES

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REAL-TIME PCR TECHNIQUE

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GENE AMPLIFICATION METHODS FOR IDENTIFICATION

87

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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.

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14 Huo 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;31:449â&#x20AC;&#x201C;452.

CONCLUSIONS

21 Singal A, Bhattacharya SN. Lichen scrofulosorum: a prospective study of 39 patients. Int J Dermatol. 2005;44:489â&#x20AC;&#x201C;493.

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22 Sehgal VN, Sardana K, Bajaj P, Bhattacharya SN. Tuberculosis verrucosa cutis: antitubercular therapy, a well-conceived diagnostic criterion. Int J Dermatol. 2005;44:230â&#x20AC;&#x201C;232.

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World Health Organization: The WHO standard tuberculin test 1963. WHO/TB/Tech guide/3, Chahda VK. Tuberculin test. Ind J   Paed. 2001;68:53â&#x20AC;&#x201C;58.

2

Frankel A, Penrose C, Emer J. Cutaneous tuberculosis: a practical case report and review for the dermatologist. J Clin Aesthet Dermatol. 2009;2:19â&#x20AC;&#x201C;27.

3

Brown FS, Anderson RH, Burnett JW. Cutaneous tuberculosis. J Am Acad Dermatol. 1982;6:101â&#x20AC;&#x201C;106.

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MacGregor RR. Cutaneous tuberculosis. Clin Dermatol. 1995;13:245â&#x20AC;&#x201C;255.

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Frankel A, Penrose C, Emer J. Cutaneous tuberculosis: a practical case report and review for the dermatologist. J Clin Aesthet Dermatol. 2009;2:19â&#x20AC;&#x201C;27.

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Pereira J. Tuberculids. Rev Port Pneumol. 2004;10:97â&#x20AC;&#x201C;105.

7

Marcoval J, Servitje O, Moreno A, et al. Lupus vulgaris. Clinical, histopathologic, and bacteriologic study of 10 cases. J Am Acad Dermatol. 1992;26:404â&#x20AC;&#x201C;407.

8

Nakamura RM, Einck L, Velmonte MA, et al. Detection of active tuberculosis by an MPB-64 transdermal patch: a field study. Scand J Infect Dis. 2001;33:405â&#x20AC;&#x201C;407.

9

Nakamura RM, Velmonte MA, Kawajiri K, et al. MPB64 mycobacterial antigen: a new skin-test reagent through patch method for rapid diagnosis of active tuberculosis. Int J Tuberc Lung Dis. 1998;2:541â&#x20AC;&#x201C;546.

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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;104:1551â&#x20AC;&#x201C;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 DomĂ­nguez J, De Souza-GalvĂŁo 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;63:43â&#x20AC;&#x201C;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;34:826â&#x20AC;&#x201C;829. 17 Bezabih M, Mariam DW, Selassie SG. Fine needle aspiration cytology of suspected tuberculous lymphadenitis. Cytopathology. 2002;13:284â&#x20AC;&#x201C; 290. 18 Elder DE, Elenitsas R, Ioffreda MD, et al. Atlas and Synopsis of Leverâ&#x20AC;&#x2122;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;25:173â&#x20AC;&#x201C;180. 20 Baek SE, Kang WH, Lee KH. Tuberculosis cutis orificialis. Korean J Dermatol. 1985;23:667â&#x20AC;&#x201C;671.

23 Sehgal VN. Lichen scrofulosorum: current status. Int J Dermatol. 2005;44:521â&#x20AC;&#x201C;523. 24 Padmavathyi L, Rao LL, Ramanadhan, et al. Mycobacterial antigen in tissues in diagnosis of cutaneous tuberculosis. Indian J  Tuberc. 2005;52:31â&#x20AC;&#x201C;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;19:1606â&#x20AC;&#x201C; 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;38:56â&#x20AC;&#x201C;60.

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27 FariĂąa MC, Gegundez MI, PiquĂŠ E, et al. Cutaneous tuberculosis: a clinical, histopathologic, and bacteriologic study. J Am Acad Dermatol. 1995;33:433â&#x20AC;&#x201C;440. 28 Brown FS, Anderson RH, Burnett JW. Cutaneous tuberculosis. J Am Acad Dermatol. 1982;6:101â&#x20AC;&#x201C;106. 29 API TB Consensus Guidelines 2006: Management of pulmonary tuberculosis, extra-pulmonary tuberculosis and tuberculosis in special situations. J Assoc Physicians India. 2006;54:219â&#x20AC;&#x201C;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;161:1376â&#x20AC;&#x201C;1395.

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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.

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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 â&#x20AC;&#x153;[Clarity], like a photograph, develops in the dark.Â&#x2030;:PVTVG,BSTI

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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. Georgeâ&#x20AC;&#x2122;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

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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.

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carcinoma, extracutaneous small cell carcinoma, and cutaneous squamous cell carcinoma. Histopathology. 2005;46:614â&#x20AC;&#x201C;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;17:408â&#x20AC;&#x201C;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;297:249â&#x20AC;&#x201C;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: 263â&#x20AC;&#x201C;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;27:225â&#x20AC;&#x201C;231.

CONCLUSIONS %FSNBUPQBUIPMPHJTUTNVTUCFBXBSFPGUIFQPTTJCJMJUZPGVQSFHVMBUJPOPG,JBOE1$/"GPMMPXJOH67FYQPTVSFɨJTFMFWBUJPO DBOMFBEUPJODPSSFDUUVNPSHSBEJOHPSQTPSJBTJTSBUJOHBOETVCTFRVFOUQSPKFDUFEQSPHOPTJT*OBOJEFBMTFUUJOH QBUJFOUTTIPVMEBWPJE 67 FYQPTVSF CFGPSF UIF CJPQTZ PG B TVTQFDUFE DVUBOFPVT NBMJHOBODZIPXFWFS UIJTJTOPUBMXBZTQSBDUJDBM8FSFDPNNFOEUIBU DMJOJDJBOT SPVUJOFMZ BTL QBUJFOUT BCPVU UIFJS SFDFOU 67 FYQPTVSF CFGPSFBTLJOCJPQTZBOESFQPSUUIJTJOGPSNBUJPOUPUIFEFSNBUPQBUIPMPHJTUUPBWPJENJTJOUFSQSFUBUJPOPG,JBOEPS1$/"MFWFMT REFERENCES 1

Scholzen T, Gerdes J. The Ki-67 protein: from the known and the unknown. J Cell Physiol. 2000;182:311â&#x20AC;&#x201C;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;29:1â&#x20AC;&#x201C;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;87:334â&#x20AC;&#x201C;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;29:1480â&#x20AC;&#x201C;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: 4828â&#x20AC;&#x201C;4839. 12 .PPS+0 1BMFQ43 4BMBEJ3/ FUBM&GGFDUTPGVMUSBWJPMFU#FYQPTVSF on the expression of proliferating cell nuclear antigen in murine skin. Photochem Photobiol. 2004;80:587â&#x20AC;&#x201C;595. 13 #BVN)1 .FVSFS* 6OUFSFHHFS(&YQSFTTJPOPGQSPMJGFSBUJPOBTTPDJBUFE proteins (proliferating cell nuclear antigen and Ki-67 antigen) in Bowenâ&#x20AC;&#x2122;s disease. Br J Dermatol. 1994;131:231â&#x20AC;&#x201C;236.

4

Soyer HP. Ki 67 immunostaining in melanocytic skin tumors. Correlation with histological parameters. J Cutan Pathol. 1991;18:264â&#x20AC;&#x201C;272.

5

'FSOBOEF['JHVFSBT.5 1VJH- .VTVMFO& FUBM1SPHOPTUJDTJHOJĂĽDBODF 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;8:203â&#x20AC;&#x201C;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.]

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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

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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 EPSTBMTVSGBDFPGUIFIBOET FYUFOTPSTVSGBDFPGUIF GPSFBSNT EJTUBMBTQFDUTPGUIFMPXFSFYUSFNJUJFT BOEEPSTBMTVSGBDFPGUIFGFFU 'JHVSF *OBEEJUJPO UIFQBUJFOUIBEJOEVSBUFE 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 QPTJUJWF BOEBQSFTVNQUJWFEJBHOPTJTPGMFQSPTZXBTNBEF6QPO DPOTVMUBUJPOXJUIUIF/BUJPOBM)BOTFOT%JTFBTF$MJOJDBM$FOUFS UIFQBUJFOUXBTTUBSUFEPOBNVMUJESVHSFHJNFO DMPGB[JNJOF  EBQTPOF BOESJGBNQJO GPSBUPUBMPGNPOUIT

DVUBOFPVT TJUFT 4PMJUBSZ TIPSUUFSN DPOUBDU XJUI BO JOGFDUFE QBUJFOUJTVTVBMMZJOTVïDJFOUGPSUSBOTGFSPGUIFCBDJMMVTɨFSJTL PG JOGFDUJPO JO UIF HFOFSBM QPQVMBUJPO IBT CFFO BQQSPYJNBUFE BU XIFSFBTJUJODSFBTFTUPJOJOEJWJEVBMTXIPIBWF MPOHUFSNDMPTFDPOUBDUXJUIJOGFDUFEQFSTPOT4 5

"MUIPVHIMFQSPTZIBTBXPSMEXJEFEJTUSJCVUJPO JUJTNPTUQSFWBMFOUJO*OEJB #SB[JM UIF%FNPDSBUJD3FQVCMJDPG$POHP 5BO[BOJB  /FQBM .P[BNCJRVF .BEBHBTDBS "OHPMB BOEUIF$FOUSBM"GSJDBO 3FQVCMJD1 2*OUIF6OJUFE4UBUFT DBTFTPGMFQSPTZBSFQSJNBSJMZTFFO JOJNNJHSBOUT BTJOUIFDBTFQSFTFOUFE BMUIPVHINVMUJQMFDBTFTBSF SFQPSUFEJOJOEJWJEVBMTOBUJWFUPUIF6OJUFE4UBUFTɨF/BUJPOBM )BOTFOT%JTFBTF3FHJTUSZSFQPSUFEDBTFTJOUIF6OJUFE4UBUFT JO PGXIJDIXFSFJEFOUJëFEBTJNNJHSBOUT

NBUPVTMFQSPTZ -- BTTFFOJOUIJTDBTF JTUIFDMJOJDBMQSFTFOUBUJPOɨFCPSEFSMJOFGPSNTPGUIFEJTFBTFEFOPUFUIFTQFDUSVNPG 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[BUJPO 8)0 IBT DSFBUFEBNPSFQSBHNBUJDTZTUFNUIBUEJWJEFTMFQSPTZJOUPUISFF -FQSPTZ )BOTFOTJTFBTF JTBDISPOJDJOGFDUJPVTEJTFBTFDBVTFE HSPVQT   QBVDJCBDJMMBSZ  TJOHMFMFTJPO   QBVDJCBDJMMBSZ MFQCZUIFCBDJMMVTMycobacterium leprae*UJTSBSFMZGBUBM CVUJUJT SPTZ oMFTJPOT BOE  NVMUJCBDJMMBSZMFQSPTZ MFTJPOT  BTTPDJBUFEXJUIEJTBCMJOHTFRVFMBFɨFDISPOJDHSBOVMPNBUPVT ɨFDMJOJDBMNBOJGFTUBUJPOTBSFEFQFOEFOUPOUIFIPTUTJNNVOF JOGFDUJPO QSFGFSFOUJBMMZ BêFDUT UIF TLJO BOE QFSJQIFSBM OFSWFT SFTQPOTFUPUIFCBDJMMVT5VCFSDVMPJEMFQSPTZ 55 PDDVSTXIFO ɨF LFZT UP FêFDUJWF USFBUNFOU BSF FBSMZ EJBHOPTJT BOE SBQJE DFMMNFEJBUFE JNNVOJUZ QSFWBJMT ɨ DZUPLJOFT  IPXFWFS  JOTUJUVUJPOPGNVMUJESVHUIFSBQZ JGÎ&#x2030;UIFSFJTQSJNBSJMZBOBOUJCPEZSFTQPOTF ɨDZUPLJOFT MFQSP-

M leprae QSJNBSJMZ BêFDUT UIF TLJO BOE QFSJQIFSBM OFSWFT *O -- POFDBOTFFOVNFSPVTQPPSMZEFëOFENBDVMFT QBQVMFT PS QMBRVFTQSJNBSJMZPWFSUIFGBDF EJTUBMFYUSFNJUJFT BOEUIFCVUUPDLT*GUIFSFJTEJêVTFJOëMUSBUJPO MFPOJOFGBDJFTDBOCFBQQSF5SBOTNJTTJPOPGUIFEJTFBTFJTQSFEPNJOBOUMZWJBOBTBMBOEPSBM DJBUFE "EEJUJPOBM DMJOJDBM TJHOT DBO JODMVEF UIJDLFOJOH PG UIF ESPQMFUTGSPNBOJOGFDUFEJOEJWJEVBMBOE MFTTGSFRVFOUMZ GSPN FBSMPCFT MPTTPGUIFFZFMBTIFTBOEFZFCSPXT NBEBSPTJT 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[BCFUI1MBDF 4VJUF %BZUPO 0)t&NBJMKVMJBOUSFWJOP!XSJHIUFEV

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March/April 2012

Figure 2. Multiple, 2â&#x20AC;&#x201C;8 mm dermal papules over the dorsal surface of the feet.

Figure 1. Multiple, 2â&#x20AC;&#x201C;8 mm dermal papules over the ears.

FYUSFNJUZFEFNB BOEBDRVJSFEJDIUIZPTJTPGUIFMPXFSFYUSFNJUJFT*O55 UIFSFJTBTJOHMFPSWFSZGFXMFTJPOTɨFZBSFXFMM 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 QBMQBCMFUIJDLFOJOHPGUIFOFSWFT NPTUDPNNPOMZUIFQPTUFSJPS UJCJBMOFSWF7ɨFTFQBMQBCMFOFSWFTDBOCFQBJOGVMBOEBSFBUBO JODSFBTFESJTLPGCFDPNJOHEBNBHFE4FRVFMBFPGOFSWFJOWPMWFNFOU BSF TJNJMBS UP UIPTF TFFO JO BOZ QFSJQIFSBM OFVSPQBUIZ  JODMVEJOHUSBVNBUJDVMDFSBUJPOBOEJOGFDUJPO "OPUIFSNBOJGFTUBUJPOPGMFQSPTZJTUZQF*BOEUZQF**SFBDUJPOT .PTUDPNNPOMZTFFOBGUFSCFHJOOJOHBOUJNJDSPCJBMUIFSBQZ UIFZ BSFBMTPTFFOXJUITUSFTTPSTTVDIBTJOGFDUJPOTBOEQSFHOBODZ5ZQF Figure 3. *OEVSBUFEQMBRVFTPWFSUIFGPSFIFBEXJUINPEFSBUF *SFBDUJPOT PSSFWFSTBMSFBDUJPOT PDDVSXIFOUIFJNNVOPMPHJD MPTTPGUIFFZFCSPXT SFTQPOTFUPM lepraeDIBOHFT JF GSPNBDFMMNFEJBUFE ɨ UP BIVNPSBM ɨ SFTQPOTF PSWJDFWFSTB.PTUDPNNPOMZ UIJT NBUPVT QBUJFOUT*UJTQSJODJQBMMZBDVUBOFPVTTNBMMWFTTFMWBTDVMJQSFTFOUT BT BDVUF JOìBNNBUJPO JO TLJO MFTJPOT BOEPS OFSWFT UJTDBVTFECZBOFYVCFSBOUIVNPSBMSFTQPOTFɨFNPTUDPNNPO 5ZQF**SFBDUJPOTBSFQSJNBSJMZTFFOJO-- BOECPSEFSMJOFMFQSP- NBOJGFTUBUJPO JT FSZUIFNB OPEPTVN MFQSPTVN ɨFTF QBUJFOUT SKINmed. 2012;10:94â&#x20AC;&#x201C;97

95

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March/April 2012

Table I. Ridley-Jopling Leprosy Classification

CATEGORIES

CLINICAL FINDINGS

NERVE INVOLVEMENT

BACILLI PRESENCE

-FQSPNBUPVT MFQSPTZ

/VNFSPVTQPPSMZEFëOFETZNNFUSJD NBDVMFT QBQVMFT OPEVMFT BOEPSEJêVTF JOëMUSBUJPO$BOMFBEUPMFPOJOFGBDJFT MPTT PGFZFMBTIFT TBEEMFOPTF BOEPSBDRVJSFE JDIUIZPTJT

â&#x2C6;&#x2019;-FTJPOBOFTUIFTJB.BZIBWFTZNNFUSJDOFSWF UIJDLFOJOHBOEBTUPDLJOHBOEHMPWFBOFTUIFTJB

.BOZ

#PSEFSMJOF MFQSPNBUPVT

4JNJMBSUPMFQSPNBUPVTMFQSPTZ

+/â&#x2C6;&#x2019;-FTJPOBOFTUIFTJB.BZIBWFTZNNFUSJDOFSWF .BOZ UIJDLFOJOH

.JECPSEFSMJOF

.BOZQPPSMZEFëOFEQMBRVFT

+/â&#x2C6;&#x2019;-FTJPOBOFTUIFTJB/FSWFNBZCFUIJDLFOFE UFOEFS

.BOZ

#PSEFSMJOFUVCFSculoid

*OëMUSBUFEQMBRVFXJUIOVNFSPVTTBUFMMJUF MFTJPOT

+-FTJPOBOFTUIFTJB/FSWFJTVTVBMMZUIJDLFOFE UFOEFS

'FX

5VCFSDVMPJE MFQSPTZ

0OFPSTFWFSBMXFMMEFëOFE JOëMUSBUFE  IBJSMFTTQBQVMFTPSQMBRVFT0GUFOIZQPQJHNFOUFE

+-FTJPOBOFTUIFTJB/FSWFJTVTVBMMZUIJDLFOFE UFOEFS

/POF

*OEFUFSNJOBUF

0OFPSTFWFSBMIZQPQJHNFOUFENBDVMFTXJUI WBSJBCMFEFëOJUJPOGSPNTVSSPVOEJOHTLJO

+/â&#x2C6;&#x2019;-FTJPOBOFTUIFTJB/FSWFNBZCFUIJDLFOFE UFOEFS

/POF

IBWFUFOEFS SFEQBQVMFTPSOPEVMFTPWFSUIFGBDFBOEFYUFOTPS DMJOJDBM QSBDUJDF JT NJOJNBM ɨF NBJO EFUSBDUPS JT UIBU JO UIF FYUSFNJUJFT"TFWFSFWBSJBOUPGUIFUZQF**SFBDUJPOJT-VDJPTQIF- NPTUEJïDVMUUPEJBHOPTFGPSNTPGMFQSPTZ JF 55BOECPSEFSMJOF OPNFOPO EFTDSJCFEBTBOFDSPUJ[JOHWBTDVMJUJTBTTPDJBUFEXJUI UVCFSDVMPJE UIFTFUFTUTEPOPUSFMJBCMZEFUFDUM leprae. WBTDVMBSUISPNCPTJTBOETVCTFRVFOUJTDIFNJDOFDSPTJT9 'JOBMMZ UIFMFQSPNJO PS.JUTVEB UFTUJTQFSGPSNFECZJOKFDUJOH IFBULJMMFEM lepraeJOUSBEFSNBMMZ"UFTUSFTVMUJTEFFNFEQPTJDIAGNOSTIC TOOLS ɨFEJBHOPTJTPGMFQSPTZJTQSJNBSJMZDMJOJDBM BMUIPVHINVMUJQMF UJWFXIFOBOPEVMFGPSNTBUUIFJOKFDUJPOTJUFBQQSPYJNBUFMZ UPXFFLTMBUFS JOEJDBUJOHBDFMMNFEJBUFESFTQPOTFɨJTUFTUJT JOWFTUJHBUJPOTBSFBWBJMBCMF QPTJUJWFJO55BOECPSEFSMJOFUVCFSDVMPJEMFQSPTZ"MUIPVHIJU *GQPTTJCMF BTLJOCJPQTZTIPVMEBMXBZTCFQFSGPSNFE QSFGFSFOIBTTPNFQSPHOPTUJDWBMVF JUIBTOPEJBHOPTUJDWBMVFBOEJTOPU UJBMMZ GSPNUIFBDUJWFFEHF 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-- PGCPSEFSMJOFMFQSPTZ BOEPG554 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  CFSPGTLJOMFTJPOTBOECBDJMMJOPUFEPOFYBNJOBUJPO 5BCMF** 14 " SFDFOU SFQPSU QSPQPTFE GPMMPXJOH BOUJ1(* BOUJCPEZ USFOET ɨFTF HVJEFMJOFT BSF DPOUSPWFSTJBM  BOE NBOZ TUJMM SFDPNNFOE BOENBZCFVTFGVMJONPOJUPSJOHSFTQPOTFUPUSFBUNFOUJO-- NPOUITPGUSFBUNFOUGPSNVMUJCBDJMMBSZEJTFBTF XIFSFBTDVSQBUJFOUT11 "EEJUJPOBMMZ  TFWFSBM NPMFDVMBS CJPMPHJD UFDIOJRVFT SFOU8)0HVJEFMJOFTSFDPNNFOENPOUIT .VMUJESVHUIFSIBWFCFFOEFWFMPQFE JODMVEJOHNPMFDVMBSQSPCFTUBSHFUJOHCPUI BQZXBTTUBSUFEJOBGUFSESVHUIFSBQZXJUIBTJOHMFBHFOU %/"BOE3/"PGM lepraeBOEQPMZNFSBTFDIBJOSFBDUJPOUFDI- XBT BTTPDJBUFE XJUI EBQTPOF SFTJTUBODF1 15 "MUIPVHI SFTJTUBODF OJRVFTS3/"BOES%/"QSPCFTNBZCFIFMQGVMJOFWBMVBUJOH DPOUJOVFTUPCFBDPODFSO NVMUJESVHUIFSBQZMFBETUPPOMZSBSF TNFBSOFHBUJWF FWPMWJOHNVMUJCBDJMMBSZEJTFBTFBOESFTQPOTFUP USFBUNFOU GBJMVSFT 3FMBQTF SBUFT IBWF CFFO BQQSPYJNBUFE UP USFBUNFOU126OGPSUVOBUFMZ UIFVUJMJUZPGUIFTFJOWFTUJHBUJPOTJO SBOHFGSPNUPPGQFSTPOZFBST"EEJUJPOBMBHFOUT SKINmed. 2012;10:94â&#x20AC;&#x201C;97



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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[JNJOFNHEBJMZ BOE NHFWFSZNPOUI

NPOUIT

1BVDJCBDJMMBSZ 3JGBNQJDJONHFWFSZ oMFTJPOT NPOUI %BQTPOFNHEBJMZ

NPOUIT

1BVDJCBDJMMBSZ 3JGBNQJDJONHPODF TJOHMFMFTJPO 0ìPYBDJONHPODF .JOPDZDMJOFNHPODF

0OFEPTF

UIBUBSFBDUJWFBHBJOTUM leprae PUIFSUIBOUIPTFNFOUJPOFEJO 5BCMFÎ&#x2030; **  BSF DMBSJUISPNZDJO BOE ìVPSPRVJOPMPOF BOUJCJPUJDT  FTQFDJBMMZQFìPYBDJO OPUBWBJMBCMFJOUIF6OJUFE4UBUFT  5SFBUNFOUPGUZQF*SFBDUJPOTJTXJUIPSBMQSFEOJTPOFɨFBJNJT UPEFDSFBTFUIFJOìBNNBUJPOBOEFZFOFSWFEBNBHFɨFUSFBUNFOU GPS UZQF ** SFBDUJPOT FSZUIFNB OPEPTVN MFQSPTVN  JT JNNVOPTVQQSFTTJPOɨFNPTUDPNNPOUIFSBQZJTUIBMJEPNJEF UPNHEBJMZ *OTFWFSFSFBDUJPOT QSFEOJTPOFNBZCF OFFEFE

8BMLFS 4-  -PDLXPPE %/+ -FQSPTZ Clin Dermatol. 2007;25: 165â&#x20AC;&#x201C;172.

2

Global leprosy situation. Wkly Epidemiol Rec. 2005;80:289â&#x20AC;&#x201C;295. 25:165â&#x20AC;&#x201C;172.

3

Global leprosy situation. Wkly Epidemiol Rec. 2005;80:289â&#x20AC;&#x201C;295.

4

3BNPTF4JMWB .  EF $BTUSP .$3 .ZDPCBDUFSJBM JOGFDUJPOT *O #PMPH nia J, Jorizzo JL, Rapini RP. Dermatology/FX:PSL /:.PTCZ 1145â&#x20AC;&#x201C;1152.

5

Canizares O, Harman R, Adriaans B. Leprosy. In: Clinical Tropical Dermatology OE FE #PTUPO  ." #MBDLXFMM 4DJFOUJÃ¥D  165â&#x20AC;&#x201C;200.

6

3JEMFZ%4 +PQMJOH8)$MBTTJÃ¥DBUJPOPGMFQSPTZBDDPSEJOHUPJNNVOJUZ Int J Lepr. 1966;34:255â&#x20AC;&#x201C;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;70:140â&#x20AC;&#x201C;159.

8

Quismorio FP, Rea T, Chandors, et al. Lucioâ&#x20AC;&#x2122;s phenomenon: an immune complex deposition syndrome in lepromatous leprosy. Clin Immunol Immunopathol. 1978;9:184â&#x20AC;&#x201C;193.

9

Kaur C, Thami GP, Mohan H. Lucio phenomenon and Lucio leprosy. Clin Exp Dermatol. 2005;30:525â&#x20AC;&#x201C;527.

10 Job CK 3FDFOU IJTUPQBUIPMPHJDBM TUVEJFT JO MFQSPTZ  XJUI QBSUJDVMBS reference to early diagnosis and leprous neuropathy. Indian J Lepr. 2007;79:75â&#x20AC;&#x201C;83. 11 Silva EA, Iyer A, Ura S, et al. Utility of measuring serum levels of BOUJ1(-*BOUJCPEZ OFPQUFSJOBOE$SFBDUJWFQSPUFJOJONPOJUPSJOHMFQSPTZ QBUJFOUTEVSJOHNVMUJESVHUSFBUNFOUBOESFBDUJPOTTrop Med Int Health. 2007;12:1450â&#x20AC;&#x201C;1458. 12 Kamal R, Dayal R, Katoch VM, Katoch K. Analysis of gene probes and HFOFBNQMJÃ¥DBUJPOUFDIOJRVFTGPSEJBHOPTJTBOENPOJUPSJOHPGUSFBUNFOU in childhood leprosy. Lepr Rev. 2006;77:141â&#x20AC;&#x201C;146.

CONCLUSIONS -FQSPTZJTBDISPOJDJOGFDUJPOUIBUIBTCFDPNFRVJUFSBSFJO UIF6OJUFE4UBUFTUIFSFGPSF UIFQSBDUJUJPOFSNVTUIBWFBIJHI JOEFYPGTVTQJDJPOJOPSEFSUPNBLFUIFBQQSPQSJBUFEJBHOPTJT8JUIFBSMJFSEFUFDUJPOBOESBQJEJOEVDUJPOPGNVMUJESVH UIFSBQZ UIFFYUSFNFNPSCJEJUJFTBTTPDJBUFEXJUIMPOHTUBOEJOH JOGFDUJPODBOCFBWPJEFE

SKINmed. 2012;10:94â&#x20AC;&#x201C;97

1

13 Scollard DM, Adams LB, Gillis TP, et al. The continuing challenges of leprosy. Clin Microbiol Rev. 2006;19:338â&#x20AC;&#x201C;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

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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

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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 info@wcocd2013.com Congress Organising Bureau ERASMUS CONFERENCES TOURS & TRAVEL S.A. E-mail: info@wcocd2013.com Website: www.erasmus.gr


7PMVNFt*TTVF

March/April 2012

CASE STUDY Vesna Petronic-Rosic, MD, MSc, Section Editor

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Figure 1. Oval tan patch studded with hyperpigmented macules and melanoma at the margin of lesion.

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.D-FBO%* (BMMBHIFS31i4VOCVSOwGSFDLMFT DBGĂ?BVMBJUNBDVMFT BOE other pigmented lesions of schoolchildren: the Vancouver Mole Study. J Am Acad Dermatolo

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$PSSBEJO.5 ;BUUSB& 'JPSFOUJOP3 FUBM/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 "ZEJO0 FUBM.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[0 FUBM/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? Arch Dermatol. o

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March/April 2012

CASE STUDY

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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, &TLJTFIJS 5VSLFZt&NBJMFTSBBLTV!HNBJMDPN

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March/April 2012

CASE STUDY

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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)BUBZ 5VSLFZt&NBJMEJEFNBMUJOFS!ZBIPPDPN

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REFERENCES

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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

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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 UJPOJOUFYUVSFXJUIJOIJTNPVUIDSFBUFEBOVODPNGPSUBCMFTFOTBUJPOBOE BUUJNFT UIFMFTJPOTTQPOUBOFPVTMZQFFMFEBXBZSFRVJSJOHIJNUP TQJUSFQFBUFEMZɨFQBUJFOUEFOJFEBOZIJTUPSZPGUSBVNB DIFFLCJUJOH PSVTFPGUPCBDDPQSPEVDUT0OJOJUJBMFYBNJOBUJPO UIFQBUJFOUXBT BTZNQUPNBUJDBOEUIFPSBMNVDPTBIBEOPBCOPSNBMëOEJOHT CVUPOSFQFBUFYBNJOBUJPOXIFOTZNQUPNTXFSFQSFTFOU UIFQBUJFOUIBE TIBHHZXIJUFQMBRVFTPOUIFCJMBUFSBMCVDDBMNVDPTBMJNJUFEUPUIFMJOFPGEFOUBMPDDMVTJPO 'JHVSF ɨFQMBRVFTDPVMECFFBTJMZQFFMFE BXBZGSPNUIFVOEFSMZJOHTLJOXJUIBDPUUPOTXBCXJUIPVUBOZQBJO MFBWJOHCFIJOEOPSNBMVOEFSMZJOHNVDPTB"SFWJFXPGUIFQSJPS CJPQTZPGUIFBêFDUFENVDPTBSFWFBMFEBOJSSFHVMBSMZIZQFSQMBTUJDFQJUIFMJVNXJUIGPDJPGCBMMPPOFEFQJUIFMJBMDFMMTXJUIJOUIFVQQFSMBZFS  QBSBLFSBUPTJT BOECBDUFSJBMPWFSHSPXUI 'JHVSF .JDSPTDPQJDFYBNJOBUJPOPGGSBHNFOUTPGNVDPTBQFFMFEBXBZGSPNUIFBêFDUFEBSFB SFWFBMFEGSBHNFOUTPGQBSBLFSBUPUJDDPSOJëFENBUFSJBMDPMPOJ[FECZOVNFSPVTCBDUFSJB 'JHVSF 3FTVMUTGSPNQFSJPEJDBDJE4DIJêTUBJOSF WFBMFEOPGVOHBMFMFNFOUTɨFEJBHOPTJTPGPSBMGSJDUJPOBMIZQFSLFSBUPTJTXBTFTUBCMJTIFECBTFEPOUIFDMJOJDBMBOENJDSPTDPQJDëOEJOHT*U XBTDPODMVEFEUIBUUIFIZQFSLFSBUPTJTXBTMJLFMZDBVTFECZCJUFUSBVNBPSHSJOEJOHPGUIFUFFUIXIJMFUIFQBUJFOUXBTBTMFFQ5SJBNDJOPMPOF PJOUNFOUJO0SBCBTFBOEUSFUJOPJOHFMXFSFJOFêFDUJWFɨFQBUJFOUGPVOEUIBUSJOTJOHXJUIIZESPHFOQFSPYJEFTPMVUJPOXBT NPTUIFMQGVMJOSFEVDJOHUIFMFTJPOT"CJUFHVBSEXBTSFDPNNFOEFECZBOPSBMBOENBYJMMPGBDJBMTVSHFPO CVUUIFQBUJFOUIBTZFUUPVTFJU

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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 +FGGFSTPO6OJWFSTJUZ ù$IFTUOVU4USFFU 4VJUF 1IJMBEFMQIJB 1"t&NBJMKBTPOMFF!KFGGFSTPOFEV

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Figure 3. Swabbed specimen from the buccal mucosa show JOHCBDUFSJBMBEFOJSSFHVMBSMZTVSGBDFETIBHHZQBSBLFSBUPTJT (hematoxylin and eosin stain, original magnification Ã&#x2014;100). *OTFUIJHIQPXFSWJFXIJHIMJHIUJOHUIFCBDUFSJBMBEFOQBSB keratosis (hematoxylin and eosin stain, magnification Ã&#x2014;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 Ã&#x2014;100).

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"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;90:185â&#x20AC;&#x201C;190.

2

"M.PCFFSJFL" "M%PTBSJ"1SFWBMFODFPGPSBMMFTJPOTBNPOH4BVEJEFO tal patients. Ann Saudi Med. 2009;29:365â&#x20AC;&#x201C;368.

3

Krahl D, Altenburg A, Zouboulis CC. Reactive hyperplasias, precancer ous and malignant lesions of the oral mucosa. J Dtsch Dermatol Ges. 2008;6:217â&#x20AC;&#x201C;232.

4

Woo S and Lin D. Moriscatio mucosae orisâ&#x20AC;&#x201D;a chronic oral frictional keratosis, not a leukoplakia. J Oral Maxillofac Surg. 2009;67:140â&#x20AC;&#x201C;146.

CONCLUSIONS %FQFOEJOHPOUIFDBVTBUJWFGBDUPST USFBUNFOUNBZJODMVEFUIF VTFPGBCJUFHVBSEEVSJOHTMFFQUPQSFWFOUUIFHSJOEJOHPGUFFUI EFOUBMFWBMVBUJPOGPSUIFUSFBUNFOUPGSPVHI TIBSQ PSNBMQP TJUJPOFEUFFUIPSPUIFSQTZDIPMPHJDBMUIFSBQZUPIFMQCSFBLUIF IBCJUPGCJUJOH

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115

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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-FTJPOTPOUIFQBMNTBOETPMFTXFSFBDDPNQBOJFECZTFWFSFCVSOJOHBOEJUDIJOHɨFQBUJFOUHBWFBIJTUPSZPGTPSFUISPBUBOEGFWFS XFFLQSJPSUPUIFPOTFUPGMFTJPOT"HFOFSBMQIZTJDBMFYBNJOBUJPOXBTOPSNBM BOEDVUBOFPVTFYBNJOBUJPO SFWFBMFENVMUJQMF XFMMEFëOFEFSZUIFNBUPVTTDBMZQMBRVFTXJUIDPMMBSFUTDBMJOHPOUIFUSVOLBOEFYUSFNJUJFT 'JHVSF 7FTJDVMBSMFTJPOT XFSFTFFOPOUIFQBMNTBOETPMFT 'JHVSF ɨFEJêFSFOUJBMEJBHOPTFTXFDPOTJEFSFEXFSFQJUZSJBTJTSPTFBBOETFDPOEBSZTZQIJMJTɨFQPTTJCJMJUZPGEFSNBUPQIZUJE WFTJDVMBSQJUZSJBTJTSPTFB BOEQPNQIPMZYXBTMJNJUFEUPUIFQBMNTBOETPMFMFTJPOT$PNQMFUFCMPPEDFMMDPVOU XBTXJUIJOOPSNBMMJNJUT3FTVMUTGSPNBOUJTUSFQUPMZTJO0UJUFS QPUBTTJVNIZESPYJEFNPVOU BOEWFOFSFBMEJTFBTFSFTFBSDIMBCPSBUPSZXFSF OFHBUJWF4LJOCJPQTJFTXFSFUBLFOGSPNUIFCBDLBOEMFGUQBMNɨFCJPQTZTQFDJNFOGSPNUIFCBDLSFWFBMFEGPDBMTQPOHJPTJT MZNQIPDZUF FYPDZUPTJT WBDVPMBSDIBOHFTJOUIFCBTBMMBZFS BOEQFSJWBTDVMBSMZNQIPDZUJDJOëMUSBUFJOUIFEFSNJT 'JHVSF ɨFCJPQTZPCUBJOFEGSPN UIFWFTJDVMBSMFTJPOPOUIFMFGUQBMNSFWFBMFEBOJOUSBFQJEFSNBMWFTJDMFXJUIOPFWJEFODFPGBDBOUPMZUJDQSPDFTT 'JHVSF "EJBHOPTJTPG QJUZSJBTJTSPTFBXBTNBEFBOEUIFQBUJFOUXBTTUBSUFEPODMBSJUISPNZDJONHPODFBEBZGPSEBZT BMPOHXJUIBOUJIJTUBNJOFTBOE FNPMMJFOUTɨFMFTJPOTGBEFEESBNBUJDBMMZJOBWFSZTIPSUQFSJPE BOEUIFSFXBTTJHOJëDBOUJOWPMVUJPOPGBMNPTUBMMPGUIFMFTJPOTBGUFS EBZTPGDMBSJUISPNZDJO%VSJOHUIFNPOUITPGGPMMPXVQ OPSFDVSSFODFXBTPCTFSWFE

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Figure 3. Focal spongiosis and slight exocytosis in the FQJEFSNJTBTXFMMBTPWFSMZJOHQBSBLFSBUPTJT BNPOPOVDMFBS DFMMJOåMUSBUFJOUIFVQQFSEFSNJT IFNBUPYZMJOFPTJOTUBJO  PSJHJOBMNBHOJåDBUJPO¨ 

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6

.JSBOEB4# -VQJ0 -VDBT&7FTJDVMBSQJUZSJBTJTSPTFBSFTQPOTFUPFSZUI SPNZDJOUSFBUNFOUJ Eur Acad Dermatol Venereol.o

7

(SJGåUIT"7FTJDVMBSQJUZSJBTJTSPTFBArch Dermatol.ù

8

$IVI"" %PÃ¥UBT#- $PNJTFM(( FUBM*OUFSWFOUJPOTGPSQJUZSJBTJTSPTFB Cochrane Database Syst Rev.$%

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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))1SPTQFDUJWFDBTFDPOUSPMTUVEZPGDIMBNZEJB MFHJP OFMMBBOENZDPQMBTNBJOGFDUJPOTJOQBUJFOUTXJUIQJUZSJBTJTSPTFBEur J Dermatol.o

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BOOK REVIEW Noah S. Scheinfeld, MD, JD, Section Editor

Hallâ&#x20AC;&#x2122;s Manual of Skin as a Marker of Underlying Disease Edited by John C. Hall and Brian J. Hall. 300 pages. Shelton, CT; Peopleâ&#x20AC;&#x2122;s Medical Publishing Houseâ&#x20AC;&#x201C;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 %/" $BODFS XJMM CF WJFXFE BT B QIFOPNFOPMPHJDBM 7FOO EJBHSBN PG NVUBUJPOT  WJSBM JOUFSQPMBUJPOT  BOE JNNVOPMPHJDBM VOEFSBDIJFWFNFOUÎ&#x2030;%JTFBTFTPGJNNVOJUZXJMMCFVOEFSTUPPEBTBDPMMFDUJPO PG JOGFDUJPOT BOE OFPQMBTUJD TJOT UIBU DBOOPUCFVOEPOF6OUJMUIBUUJNFBOE QFSIBQT FWFO JO UIBU UJNF  UIF QIZTJDJBOXJMMCFXFMMBEWJTFEUPDBSSZBOE review Hallâ&#x20AC;&#x2122;s Manual of Skin as a Marker of Underlying Disease BTLJMMGVMMZ FEJUFECPPLXJUIBOJOUFSOBUJPOBMUBMFOUTIPXPGDPOUSJCVUPST ɨJTEFSNBUPMPHJDUFYU XIJDISFBETMJLFBSPNBOÃ&#x2039;DMFG UBLFTJUTQMBDFXJUIUIF PUIFSOFDFTTBSZXPSLTUIBUIBWFBEESFTTFEEFSNBUPMPHZBOETZTUFNJDEJTFBTF CZ#SBWFSNBO 1$BMMFO 2BOE1SPWPTU3*OPOFJNQPSUBOUXBZ )BMMTCPPLTVSQBTTFTUIFN)BMMTQSJDFQPJOUJTVOEFS XIJDINFBOTUIBU)BMMTCPPL DBOCFQSFTFOUFECZUIFQIBSNBDFVUJDBMDPNQBOJFTBTBOFEVDBUJPOBMBJE +VTUBTB+FXJTITDIPMBSLFFQTB.JTIOBI5PSBIBVUIPSFECZUIF3BNCBNPOIJT EFTL UIF5VS "SCBBI5VSJN CZ+BDPCCFO"TIFSJOIJTBSDIJWF 3BCCJ:JU[DIBL "MGBTJTUIFJOUFMMJHFOUEJHFTUiUIF3JGwJOUIFBQQFOEJYTFDUJPOTPGIJT5BMNVEBOEUIF 4IVMDBO"SVDICZ:PTFG,BSPPOIJTXBMMXJUIUIFIBOEZHMPTTFTPGUIF3FNB .PTFT *TTFSMFTPO,BSPTQBHFT UIFTDIPMBSJTBEWJTFEJGIFDBOUPLFFQBMMUIFTFCPPLTPO TZTUFNJDEJTFBTFXJUIJOBSNTMFOHUI)BMMTCPPLDPWFSTUIFUPQJDTPGJOUFSOBMEJTFBTFT BOETLJOJOBCSJFGCVUFêFDUJWFGBTIJPO XJUITFDUJPOTPOOFVSPMPHJDBM JOGFDUJPVT  QFEJBUSJD HFOFUJD BOEPUIFSUPQJDTEJWJEFEJOUPDIBQUFSTPOUIFNBOJGFTUBUJPOPGUIF TQFDJëDEJTFBTFTUBUFT&BDIDIBQUFSJTVOJRVFBOESFQMFUFXJUIFYDFMMFOUJOGPSNBUJPO *QBSUJDVMBSMZFOKPZFEUIFTFDUJPOPOOFVSPMPHJDBMEJTFBTFTBOEUIFTLJOÎ&#x2030;*Î&#x2030;GPVOE UIFEJTDVTTJPOPOSFìFYTZNQBUIFUJDEZTUSPQIZ 34% FOMJHIUFOJOHÎ&#x2030;*Î&#x2030;DPOGFTT UIBU*IBEOFWFSQBSTFE34%JOUPJUTTUBHFTVOUJM*SFBEUIFDIBQUFSJO)BMMT CPPLɨFTFTUBHFTBSF

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REFERENCES

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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

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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 Cushingâ&#x20AC;&#x2122;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 Š2010 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


Mar / April 2012