Distinct patterns of chromonychia, Beau's lines, and melanoderma seen with vincristine, adriamycin, dexamethasone therapy for multiple myeloma

Nail and skin alterations associated with the use of chemotherapy have been described in the last decade involving various combinations of two different types of nail changes. They are entirely reversible within a few months after withdrawal of the offending agent. We describe a 52-year-old male diagnosed with stage III multiple myeloma, who was treated with 5-monthly cycles of VAD (vincristine, adriamycin and dexamathasone). During administration of chemotherapy, the patient progressively developed a complex association of Beau's lines, transverse melanonychia, Muehrcke's lines, and diffuse hyperpigmentation of the skin. No metabolic or endocrine changes were present to explain the observed pigmentation and structural alterations. This complex pattern of nail and skin changes is accounted by synergy or an additive effect of chemotherapy agents on cellular proliferation of nail compartments. All changes disappeared 4 months after the discontinuation of VAD chemotherapy, which further pointed out towards adriamycin and vincristine as possible etiologic agents.     

Severe Hypoglycemia During Successful Treatment of Diffuse Hemangiomatosis with Propranolol

Abstract: A 27‐day‐old male infant with diffuse hemangiomatosis of the skin and liver was treated with oral propranolol at a dosage of 2 mg/kg per day. Five months later skin and liver hemangiomas regressed almost completely. After 160 days of onset of propranolol, the patient presented with seizures on waking up. Laboratory examinations showed blood glucose of 15 mmol (n.v. 50–110) and increased ketone bodies. Propranolol was recommenced at a lower dosage the day after the crisis and then withdrawn when the baby was aged ten months. Hypoglycemia is the most frequent and insidious side effect of propranolol, mainly occurring in circumstances with diminished oral intake. Although the risk appears small, increased vigilance for hypoglycemia in children on chronic propranolol treatment who have decreased caloric intake for any reason seems prudent.     

Accelerated reduction of post‐skin‐resurfacing erythema and discomfort with a combination of non‐thermal blue and near infrared light

The prolonged crusting and erythematic phases following chemical and laser skin resurfacing create discomfort and aggravate patients. Depending on the aggressiveness of the procedure, post‐procedure erythema may last from three weeks to several months. iClearXL (CureLight Ltd) is a non‐contact, non‐thermal blue (405–420?nm)/near infrared (850–900?nm) dual‐band light source emitting up to 60?J/cm² on a 30?cm by 30?cm treatment area. The blue component of the light source has been proven to have a significant anti‐inflammatory effect, whereas the near infrared component enhances vascular circulation as well as lymphatic drainage in the thin, necrotized papillary layer.

Facial skin laser resurfacing was performed on twelve patients. Starting one day after resurfacing, six patients received a daily 20‐minute treatment of blue (405–420?nm)/near infrared (850–900?nm) light for six consecutive days, and six control patients were treated with the usual topical care protocol. Twelve days after the procedure, the treated group had a weighted average erythema score of 0.33 as compared to 1.33 in the control group. Two months after the procedure, the treated group had a weighted average erythema score of 0.16 as compared to 0.83 in the control group. Twelve days after the procedure, the treated group had a weighted average discomfort score of 0.33 as compared to 0.83 in the control group.

The tested combination of non‐thermal blue (405–420?nm)/near infrared (850–900?nm) dual‐band light was found to significantly shorten the duration of post‐laser‐resurfacing erythema and discomfort with no side effects.     

Laser‐assisted depigmentation for resistant vitiligo: a retrospective case series with long‐term follow‐up

Background Blanching creams are used to depigment and to achieve uniform skin tone in widespread vitiligo. Length of the treatment and side‐effects strongly limit their use in common practice. Objectives To assess the long‐term efficacy and tolerance of Q‐Switched (QS) lasers for depigmenting the remaining unaffected skin in vitiligo. Methods Retrospective study of vitiligo patients treated with QS lasers in the Department of Dermatology of the University Hospital of Nice, France, from 2002 to 2011. Localizations and the percentage of body surface area of treated lesions, the total number of sessions and the possible relapses and side‐effects, were analysed. Global satisfaction of the patients was evaluated on a visual analogical scale. Results Sixteen areas of normally pigmented skin were treated in six patients. The median number of sessions to achieve a complete depigmentation was 2 (1–6). The mean duration of follow‐up was 36 months (19–120). One third of the patients had no relapse. A complete repigmentation was observed after 21 months in one patient; a 50% repigmentation was noted in one patient, 7 months after the end of the treatment. Two patients showed a minimal repigmentation (<25%), 18 months and 9 years after the first laser treatments. The repigmentations were effectively treated with a maintenance session. The mean total number of sessions performed during this period was 3 (1–20). Side‐effects were limited to transient purpura and crusts. The satisfaction of the patients was excellent (mean 9/10). Conclusions QS lasers appear as an efficient and safe modality for depigmenting normal skin in vitiligo.     

Pulsed dye laser treatment of capillary malformations in infants at 2‐weekly versus 3‐monthly intervals,reducing the need for general anaesthesia

Capillary malformations (CM) cause significant psychosocial complications. Pulsed dye laser (PDL) treatment at 6–12‐weekly intervals under general anaesthesia (GA) commencing in infants at 6 months of age remains the standard of care in order to achieve maximal improvement prior to school age. The safety of repeated GA in children is controversial. Shortening the time between treatments increases the number that can be delivered prior to 6 months of age, thus reducing the number of subsequent treatments needed under GA. We investigated the safety and effectiveness of more frequent PDL treatment of CM in infancy via a pilot, prospective patient‐controlled study of 10 patients. Using 595 nm (Vbeam) PDL, the entire CM was treated initially, then half the CM randomly allocated to 2‐weekly and half to 3‐monthly intervals for two further treatments. Photographs of the CM taken 3 months after treatment completion were evaluated by an independent, blinded dermatologist. Nine infants completed the study. Three infants (33%) had more improvement on the 2‐weekly treated side and four (44%) had more improvement on the 3‐monthly treated side. Two patients (22%) showed no difference between sides. Treatments were well tolerated without complications. We conclude that 2‐weekly PDL treatments of CM in infants aged under 6 months is effective and well tolerated without adverse effects. Our preliminary data suggest a possible superior efficacy with 3‐monthly treatment intervals; however, larger studies are warranted for stronger evidence. More frequent non‐GA treatment of CM in infants should be further investigated to decrease the risk of repeated GA exposure in young children.     

Basal cell carcinoma in a series of renal transplant recipients: epidemiology and clinicopathologic features

Background Basal cell carcinoma (BCC) is the most common malignancy among Caucasians worldwide. The risk of BCC is 10–16 times higher among immunosuppressed transplant recipients compared with the general population. Objective To analyze the incidence, clinical presentation, histologic features, treatment and recurrence rate of BCC in a cohort of 69 renal transplant recipients (RTRs; 53 male). Methods Retrospective population‐based cohort study of immunosuppressed RTRs. Results Ten of 69 patients (14.5%, five male) developed a total of 17 BCCs, mostly on the head. Mean age at first diagnosis of BCC was 65.5 ± 8.5 years, and latency between kidney transplantation and diagnosis of the first BCC was 11.1 ± 6.3 years (mean ± SD). The risk of female RTRs to develop BCCs appeared to be three times higher than the risk of male RTRs, and female RTRs developed BCCs earlier after transplantation. Nodular BCC was the most common histologic subtype. Most BCCs in these RTRs were treated by complete surgical excision. Recurrence after surgical excision was observed in one of the 10 patients (10%). Conclusion Our results suggest female RTRs to be at higher risk to develop cutaneous BCCs than male RTRs. There are no differences in localization and clinicopathologic presentation of BCCs developing in RTRs compared with immunocompetent patients. Therefore, BCCs in RTRs do not require different treatment than in other patient groups. As patients tend to develop a second BCC, close follow‐up is mandatory.     

Usefulness of docetaxel as first‐line chemotherapy for metastatic extramammary Paget's disease

In invasive extramammary Paget's disease (EMPD), distant metastases may develop and the condition may become fatal; however, no standardized treatment has been established. Although based on only a few cases, several chemotherapy regimens were reported to be promising. We conducted a multicenter, retrospective study to evaluate the efficacy of docetaxel for metastatic EMPD. We retrospectively collected data on 18 metastatic EMPD patients treated using docetaxel from 1998 to 2012 in 12 institutes in Japan. The following clinical data were collected: tumor response, time to progression, overall survival and adverse effects. Of those, three patients treated combined with S‐1, one patient treated with weekly schedule and one patient treated combined with radiotherapy were excluded from the further analysis. All 13 patients received monthly docetaxel as the first‐line treatment. The average number of treatment cycles was 9.1. Among the 12 patients with a confirmed response, seven (58%) showed a partial response, three (25%) stable disease and two (17%) progressive disease. The disease control rate (partial response + stable disease) was as high as 83%. The time to progression and median overall survival were 7.1 and 16.6 months, respectively. The 1‐year overall survival rate determined by the Kaplan–Meier method was 75.0%. All adverse effects were manageable and no treatment‐related deaths were observed. The high disease control rate and overall survival shown by this study suggest that first‐line use of docetaxel may be a promising treatment for metastatic EMPD. A prospective clinical trial is required to confirm our results.     

Antiretroviral‐induced toxic epidermal necrolysis in a patient positive for human immunodeficiency virus

Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are two variants on a spectrum of severe systemic hypersensitivity characterized by blistering maculopapular lesions and desquamation of the skin and mucus membranes. Although several causative agents, including infections, have been reported for SJS/TEN, medications remain the most common cause. We report the case of a 42‐year‐old man with human immunodeficiency virus (HIV) who developed TEN 4 months after starting treatment with darunavir and abacavir. The patient presented with upper body lesions, oral mucosal ulcerations, and impending airway compromise. He was intubated and admitted to the burns unit. Score for Toxic Epidermal Necrolysis (SCORTEN) was 5, with > 90% predicted mortality. However, after intravenous immunoglobulin and supportive treatment, the patient made a remarkable recovery. Abacavir and darunavir may be associated with SJS/TEN. TEN should be considered a risk for patients with HIV and should be monitored for cutaneous eruptions for several months after changes in treatment regimen.     

Low-dose total skin electron beam therapy as a debulking agent for cutaneous T-cell lymphoma: an open-label prospective phase II study

Background Total skin electron beam therapy (TSEBT) is a powerful treatment for cutaneous T‐cell lymphoma (CTCL). Based on the occurrence of relapses with low radiation doses, doses of 30–36 Gy are commonly used but most patients still eventually relapse and repeat treatment courses are limited due to the cumulative toxicity. Complete response (CR) rates are about 60–90% for T2–4 stages with a 5‐year relapse‐free survival of 10–25% for stages IB–III. Objectives To evaluate prospectively the efficacy of low‐dose TSEBT (10 Gy) in terms of complete cutaneous response rate, overall response rate and response duration in CTCL. Methods Ten patients with stage IB–IV mycosis fungoides (MF) were treated in an open‐label manner with four fractions of TSEBT 1 Gy weekly to a total skin dose of 10 Gy. Treatment responses were assessed at 1 and 3 months after treatment and subsequently at least every 6 months for a total period of 2 years or to disease relapse or progression. Results Patients achieved an overall response rate of 90%. The rate of CR or very good partial response (VGPR; < 1% skin affected with patches/plaques) was 70%. The median response duration was 5·2 months (range 83–469 days) for CR and VGPR. Adverse effects were generally mild to moderate in severity. Conclusions Low‐dose TSEBT (10 Gy) gave a satisfactory response rate and was well tolerated in patients with MF stage IB–IV. Future studies should determine if the combination of low‐dose TSEBT with other agents could increase the rate of CR and response duration.     

Permanent makeup removal using Q‐switched Nd:YAG laser

Red‐brown tattoos are usually treated with a frequency‐doubled Q‐switched (QS) neodymium : yttrium–aluminum–garnet Nd:YAG laser (532 nm), because red and pink pigments show maximum absorption between 500 and 570 nm. Using a QS laser for red‐brown tattoo removal has sometimes led to paradoxical darkening of the tattoo pigments, and this darkened grey‐black colour may be difficult to remove. A woman with red‐brown cosmetic tattoos on her eyebrows was treated using a QS Nd:YAG laser (1064 nm) initially with low fluence and subsequently with increasing fluences at 6‐weekly intervals. After the first treatment, a slight darkening of the tattoo pigments was seen, but this faded and complete clearance was achieved after five treatments. There was no downtime during every treatment and there were no scars, pigmentary alterations or textural changes.     

Recurrent Merkel cell carcinoma of the gluteal region: A case report

Merkel cell carcinoma (MCC) is a rare malignant tumor of the skin. The development of MCC on non‐sun‐exposed skin is extremely rare, with few cases reported in the literature. The present authors aimed to highlight the characteristic features and treatment options of this tumor. The present authors present a 50‐year‐old man who developed MCC on the left gluteal region (non‐sun‐exposed skin). After surgery with clear margins, adjuvant radiotherapy was given. Three months after radiotherapy, lymphatic recurrence was observed and he was treated with chemotherapy. On follow‐up, systemic metastases were found and palliative treatment was planned.     

Remission of extensive intrahepatic metastasis by C‐arm computed tomography guided chemoembolization in uveal melanoma

As soon as uveal melanoma has metastasized to the liver, response rates to systemic chemotherapy are low. It can be improved by development of special locoregional procedures. A 24‐year‐old woman suffered from inoperable hepatic metastases which grew to life‐endangering size despite both systemic chemotherapy with gemc‐itabine/treosulfan and conventional intrahepatic chemoembolization with fotemustine and starch particles. We subsequently performed two angiographic C‐arm CT‐guided, superselective chemoembolizations of the hepatic arteries feeding the tumor, using cisplatin, starch microspheres and ethiodized oil. Following this treatment, no vital tumor tissue was detectable by MRI. This remission lasted for more than 6 months and the patient's quality of life was good. A subsequent local relapse could not be treated with chemoembolization because of thrombosis of the portal vein due to tumor compression. And the patient died 20 months after first detection of metastases. However, the selective angiographic C‐arm CT‐guided chemoembolization resulted in prolongation of life with good quality despite the advanced stage of the disease.     

A novel rat model for chemotherapy-induced alopecia

Background. More than half of all people diagnosed with cancer receive chemotherapy, and approximately 65% of these develop chemotherapy‐induced alopecia (CIA), a side‐effect that can have considerable negative psychological repercussions. Currently, there are very few animal models available to study the mechanism and prevention of CIA. Aim. To develop a clinically relevant adult rat model for CIA. Methods. We first tested whether neonatal pigmented Long–Evans (LE) rats developed alopecia in response to the chemotherapeutic agents etoposide and cyclophosphamide. We then determined whether the rats developed CIA as adults. In the latter experiment, rat dorsal hair was clipped during the early telogen stage to synchronize the hair cycle, and starting 15 days later, the rats were treated with etoposide for 3 days. Results. Neonatal LE pups developed CIA in response to etoposide and cyclophosphamide, similar to other murine models for CIA. Clipping of the hair shaft during early telogen resulted in synchronized anagen induction and subsequent alopecia after etoposide treatment in the clipped areas only. Hair follicles in the clipped areas had the typical chemotherapy‐induced follicular dystrophy (dystrophic catagen). When the hair in the pigmented alopecic areas regrew, it had normal pigmentation. Conclusions. A novel, pigmented adult rat model has been established for CIA. By hair‐shaft clipping during early telogen, synchronized anagen entry was induced, which resulted in alopecia in response to chemotherapy. This is the first clinically relevant adult rat model for CIA, and will be a useful tool to test agents for the prevention and treatment of CIA.     

Aggressive T cytotoxic CD8+ epidermotropic cutaneous lymphoma: a case in a patient with Steinert's myotonic dystrophy

INTRODUCTION: Primary cutaneous "aggressive" CD8-positive epidermotropic cytotoxic T-cell lymphoma is a rare subset of cutaneous cytotoxic T/NK lymphomas that clearly differs from mycosis fungoides, whether CD4+ or CD8+, by the presence of rapidly evolving tumoral cutaneous lesions, foci of keratinocytes necrosis, a cytotoxic T phenotype and a poor prognosis. CASE REPORT: A 33-year-old man with Steinert's myotonic dystrophy was referred for evaluation of rapidly worsening cutaneous tumors along with marked deterioration of general status. Clinical, histological and immunohistological data led to the diagnosis of primary cutaneous CD8+ epidermotropic cytotoxic T-cell lymphoma. CHOP chemotherapy was effective despite cardiac toxicity in the setting of Steinert's dystrophy, but the patient relapsed and died of pulmonary sepsis after chemotherapy was resumed. DISCUSSION: The treatment of primary cutaneous epidermotropic CD8+ cytotoxic T-cell lymphoma is not codified. CHOP chemotherapy is usually the first-line therapy but relapses are frequent with median survival of no more than 34 months. In our patient, an additional difficulty was the cardiac toxicity of cytostatic drugs linked to the myopathy which prevented the use of high dosages, requiring a change of therapeutic regimen.     

Radiotherapy in the management of classic Kaposi's sarcoma: A single institution experience from Northeast Turkey

Kaposi sarcoma is a rare adult neoplasm and there has been no certain consensus on standard treatment, either local or systemic. Radiotherapy is an effective, suitable treatment modality. Between 1996 and 2016, patients who were diagnosed with Kaposi sarcoma and referred to our clinic for radiotherapy were included in this retrospective study. Ninety‐two patients were examined in total and it was diagnosed that all the patients had non‐HIV associated Kaposi's sarcoma. There were 36 (39%) females and 56 (61%) males and female to male ratio was 2/3. Median age at presentation was 72 (30–93) years. Sixty‐eight patients (77%) were treated with 8 Gy (1 fraction), 15 patients (16%) were treated with 20 Gy (2 Gy/fraction), four patients (4%) were treated 25 Gy (2.5 Gy/fraction), and five patients (6%) were treated 30 Gy (3 Gy/fraction). The median follow‐up time was 72 (5–192) months. The complete response at 5 years was 91.6% with >20 Gy and 89.6% with 8 Gy. Radiotherapy is an effective, suitable treatment modality of Classic Kaposi sarcoma and usually, radiotherapy is well tolerated with minimal side effects.     

NB‐UVB (311–312 nm)‐induced lentigines in patients with mycosis fungoides: a new adverse effect of phototherapy

Background Lentigines are a common pigmentary disorder in adults and in patients treated by psoralen and ultraviolet A (PUVA) radiation. Their appearance following treatment with narrow‐band ultraviolet B (NB‐UVB) radiation has been reported in only two patients. Objective To describe the clinical and histological features of NB‐UVB‐induced lentigines their relation to dosimetry and the course of the eruption in patients with mycosis fungoides (MF). Methods The files of all patients with MF treated in our department in 2003–2010 were searched to identify those in whom lentigines appeared following monotherapy with NB‐UVB radiation. Results Of the 73 patients with early stage MF identified, 10 met the study criteria. Lentigines were detected in skin previously involved by MF in seven patients, and in both involved and uninvolved skin in three patients. They appeared during therapy in three patients, after a mean of 56 exposures (range 50–61), and several months (mean 7.8) following completion of treatment in seven patients, after a mean of 69 exposures (range 32–157). Histopathological study of lesions from five patients revealed basal hyperpigmentation relative to adjacent normal‐looking skin. Two lesions had a slight increased number of normal‐looking melanocytes on immunohistochemical staining with melanoma cocktail. One lesion had elongated rete ridges. The lesions persisted throughout follow‐up (mean 26.7 months) in 8 patients. Conclusions Patients with MF treated with NB‐UVB may acquire lentigines. As opposed to PUVA‐induced lentigines which are a known common side‐effect of long‐term treatment, NB‐UVB‐induced lentigines are uncommon but appear earlier, even after a few months of treatment.     

Omalizumab in children and adolescents with chronic spontaneous urticaria: Case series and review of the literature

The recent EAACI/GA²LEN/EDF/WAO guidelines recommend omalizumab (anti–IgE) for the management of patients aged ≥12 years with chronic urticaria unresponsive to high–doses second–generation H₁–antihistamines (antiH₁). However, there is little published information on the success of omalizumab for such a treatment in children. We reported our experience of six patients with chronic spontaneous urticaria (CSU) treated with omalizumab. Mean age of our case series was 14.7 years (range 11–16 years) with a prevalence of male gender (66.7%). All six patients were treated with at least one 6–months course of omalizumab. The average follow–up period was 13 ± 6 months. Only one patient was no responder to omalizumab therapy. Thus far, two patients have experienced a complete CSU regression over 12 months after the final omalizumab administration. The remaining three patients needed a second course of treatment. Our experience demonstrates that omalizumab is effective and safe as treatment option for CSU unresponsive to antiH₁, even in adolescent age.     

Effects of anti‐TNF‐α agents on circulating endothelial‐derived and platelet‐derived microparticles in psoriasis

Psoriasis involves TNF‐α secretion leading to release of microparticles into the bloodstream. We investigated the effect of TNF blockers on microparticles levels before and after treatment in patients (twenty treated by anti‐TNF‐α agents and 6 by methotrexate) with severe psoriasis. Plasmatic microparticles were labelled using fluorescent monoclonal antibodies and were analysed using cytometry. Three months later, 70% of patients treated with anti‐TNF‐α agents achieved a reduction in PASI score of at least 75%. The clinical improvement in patients treated with anti‐TNF‐α agents was associated with a significant reduction of the mean number of platelet microparticles (2837/μl vs 1849/μl, P = 0.02) and of endothelial microparticles (64/μl vs 22/μl, P = 0.001). Microparticles are significantly decreased in psoriatic patients successfully treated by anti‐TNF‐α. Microparticles levels as circulating endothelial cells represent signs of endothelial dysfunction and are elevated in psoriasis. Then, TNF blockade may be effective to reduce cardiovascular risk through the reduction of circulating microparticles.     

Clinical comparison of four hair removal lasers and light sources

Background and objective: There are few clinical studies directly comparing the efficacy of multiple hair removal systems in the same individual. This study evaluates the efficacy of four highly popular systems for laser hair removal. Methods: In this prospective comparison study, 10 subjects underwent treatment of unwanted hair on the back or thigh. Subjects were skin types I–III, aged 18–55 years. All were treated twice with (1) an intense pulsed light with a red filter; (2) an intense pulsed light with a yellow filter; (3) an 810?nm diode laser; and (4) a 755?nm alexandrite laser. Four treatment areas, using commonly accepted parameters for permanent hair reduction, as well as a control non‐treated area were selected. Each treatment area was evaluated with a camera system specifically designed for hair counts at 1, 3, and 6 months after the second treatment by a blinded non‐treating physician. Clinical results and adverse events were also noted. Results: Evaluation of photographs at 1, 3, and 6 months revealed a significant decrease in hair counts (～50%) and hair coverage (～55%). In the hairs that remained after two treatments, no statistical difference was noted in hair length or diameter. There was no statistical difference in efficacy between the four different light devices. Minimal transient adverse effects were noted from all systems. The cryogen spray‐based alexandrite laser showed the highest pain scores. Conclusion: Although hair removal with commonly used systems is, as expected, highly effective, treatment with light‐based devices can cause less pain, yet show efficacy similar to laser systems.     

The risk of malignancy or progression of existing malignancy in patients with psoriasis treated with biologics: case report and review of the literature

There is some debate regarding the risk of developing malignancy and progression of malignancy in patients with psoriasis treated with biologics. The lack of extensive, long‐term, and large studies, including patients with psoriasis, to assess these aforementioned risks makes it difficult to ascertain the safety profile of biologic therapy in these patients. Several studies do support the favorability of the safety profile of biologics in patients with psoriasis in terms of the risk of developing malignancy. A few studies include patients with a previous history of cancer that were thereafter treated with biologics and show no increased risk of recurrence in those treated with biologics compared to non‐biologic therapy. Although recent studies do not show an increased risk of new or recurrent malignancy in patients with psoriasis treated with biologic agents, there is still hesitancy in the widespread use of biologic agents in these patients. Considering all of the current data and opinions, the benefits of biologic therapy to improve quality of life often outweigh the negligible risk of solid organ malignancy associated with biologics in patients with existing or previous malignancies. Coordinating the management of patients that develop or have a history of previous malignancy with an oncology team is crucial for patient‐centered care until clear evidence‐based guidelines are developed.