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Updating rosacea diagnosis to improve treatment strategy: Recommendations from the Global ROSacea COnsensus (ROSCO) panel
5006
5711
Unusual presentations of cutaneous cytomegalovirus: A case series Rasnik Singh, BS, David Geffen School of Medicine; Suzanne Sachsman, MD, UCLA Division of Dermatology; Swati Kannan, MD, UCLA Division of Dermatology; Scott Worswick, MD, UCLA Division of Dermatology Although cytomegalovirus (CMV) is a common opportunistic pathogen affecting multiple organ systems, cutaneous manifestations are relatively rare and portend an ominous prognosis. The following case series reports on three atypical presentations of cutaneous CMV. A 22-year-old woman with acute myeloid leukemia treated with stem cell transplant (SCT) complicated by graft versus host disease (GVHD) of the liver, was evaluated for a 3-week history of desquamating rash. Exam was remarkable for gray exudative macerated plaques on her tongue and hard palate, petechiae on her extremities, rare intact scattered bullae and desquamating erosions and ulcers affecting 30% body surface area (BSA). Biopsies showed interface dermatitis with lymphocytic infiltrate and epidermal atrophy. Despite concern for cutaneous GVHD or toxic epidermal necrolysis (TEN), further work up revealed positive oral CMV culture and serum CMV PCR. A 62 year-old woman with B-cell lymphoma treated with SCT and prior history of TEN presented with 4 days of worsening fever, rash, and skin and oral pain. Exam revealed dusky reticulate plaques with desquamative scale, occasional intact bullae, and erosions involving 40% BSA, and oral and genital erosions. Clinically there was concern for recurrent TEN versus paraneoplastic pemphigus (PNP). Biopsies showed interface dermatitis, necrotic keratinocytes, bullae, and acantholysis favoring PNP, however, immunofluorescence studies and malignancy work up were negative. Further testing revealed positive serum and tissue CMV PCR studies. The patient was treated with Ganciclovir with improvement of her skin lesions. A 45-year-old HIV positive male not on antiretroviral therapy was evaluated for worsening nodular rash accompanied by fever and tachycardia. He reported a 6-month history of dark spots on his extremities that gradually became palpable. He was previously treated with multiple systemic antibiotics without significant improvement and serologic studies for Bartonella and Coccidioides were negative. Exam revealed multiple hyperpigmented subcutaneous nodules and a few scattered pink erosions on his extremities and back. Biopsy showed numerous CMV inclusion bodies and serum CMV PCR was also positive. This case series illustrates the variation of clinical presentations seen with cutaneous CMV ranging from skin denudation to subcutaneous nodules. A high degree of clinical suspicion is important for timely diagnosis, especially in immunocompromised patients.
Updates on novel research in laser and photodynamic therapy for treatment of acne vulgaris Marjon Vatanchi, MD, SUNY Downstate Medical Center; Georgina Ferzli, MD, SUNY Downstate Medical Center; Daniel Siegel, MD, SUNY Downstate Medical Center Purpose: For decades, mainstay therapy for acne vulgaris has included topical/oral retinoids and antibiotics. Due to advancements in energy-based technologies and the exorbitant increase in cost of prescription medications, laser therapy is slowly becoming a favored modality. We attempt to identify a consensus on safety, efficacy, and practicality of lasers for acne vulgaris based on cutting-edge research. Design: Novel publications from January 2015 to March 2016 were reviewed regarding acne vulgaris and laser therapy/photodynamic therapy (PDT). Articles on acne scarring were excluded. Summary: Targeted mechanisms of laser and PDT include sebaceous gland activity, inflammatory mediators, and porphyrins endogenous to P acnes. A review of 36 clinical trials on PDT for acne vulgaris identified 24 trials that evaluated efficacy. The studies proved PDT to be efficacious for both comedonal and inflammatory acneiform lesions irrelevant of severity. Improvement was visible within three weeks and persisted for 20 weeks. Two independent randomized controlled clinical trials (RCT) evaluated photothermolysis of sebaceous follicles with topical gold microspheres that absorb light. Each trial showed clinical and statistically significant improvement in inflammatory lesions at 6, 12, and 16 weeks. A comparative splitface study evaluating pulsed-dye laser (PDL) at different fluence levels demonstrated positive efficacy measured by improvements in the severity scale. The fluence level did not have a statistical effect on lesion count. A RCT evaluating salicylic acid chemical peel alone versus a chemical peel combined with PDL found that there was significant efficacy in the PDL group recognized by evaluators who were blinded to the treatment arm. Two clinical trials on erbium:glass lasers demonstrated moderate to significant improvement in short-term (1-3 months) and long-term (1-2 years) studies. Conclusion: Numerous clinical trials have proved positive for both safety and efficacy of laser therapy and PDT for acne vulgaris. These modalities can provide options for patients who have disease refractory to current medical therapies, are prone to medication side effects, or have difficulty with compliance. In such patients, energy-based therapies demonstrate a practical option or can be included as adjuvant therapy. More research is necessary to address laser parameters, modality comparisons, and guidelines for optimal treatment based on acne severity.
Commercial support: None identified. Commercial support: None identified.
5322
5051
Updating rosacea diagnosis to improve treatment strategy: Recommendations from the Global ROSacea COnsensus (ROSCO) panel Jerry Tan, MD, University of Western Ontario; Luiz Mauricio Costa Almeida, MD, Faculdade de Ci^encias Medicas de Minas Gerais; Anthony Bewley, MD, Whipps Cross University Hospital and the Royal London Hospital; Bernard Cribier, MD, Dermatology University Uospital Strasbourg; Ncoza Dlova, MD, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal; Gerd Kautz, MD, Haut- und Laserklinik; Hazel H. Oon, MD, National Skin Centre; Martin Schaller, MD, Department of Dermatology, T€ ubingen University Hospital Introduction: Rosacea is currently diagnosed/classified by subtype, but features can span multiple subtypes. This can confound epidemiology studies and clinical trials, limiting disease management and treatment development. Clinicians and scientists have proposed a phenotype-led approach (presenting feature based) that may benefit clinical practice by better representing all rosacea features. The ROSacea COnsensus (ROSCO) project aims to support this transition and align global consensus on phenotype-led rosacea diagnosis, classification and management.
Updated view on epidemiology and clinical aspects about pilomatricoma in adults Geo Han, MD, Department of Dermatology, Guro Hospital, Korea University College of Medicine; Seung Hwi Kwon, MD, Department of Dermatology, Guro Hospital, Korea University College of Medicine; Ae-Ree Kim, MD, Department of Pathology, Guro Hospital, Korea University College of Medicine; Hae Jun Song, MD, Department of Dermatology, Guro Hospital, Korea University College of Medicine; Chil Hwan Oh, MD, Department of Dermatology, Guro Hospital, Korea University College of Medicine; Jiehyun Jeon, MD, Department of Dermatology, Guro Hospital, Korea University College of Medicine Background: Clinically, pilomatricoma offers a wide spectrum of differential diagnoses. It is known to occur typically in pediatric patients with most common location being the head. Epidemiologically it has been regarded that pilomatricoma is a rather uncommon neoplasm in middle aged and old patients. Objective: To investigate the clinical and epidemiological features of pilomatricoma, as it is a common and frequently misdiagnosed tumor, also in adults over 20 years old. Methods: This was a retrospective study of pilomatricomas surgically removed at a tertiary hospital between January 1994 and December 2014. A search of the allpathological database of patients aged over 20 years old with a pathological diagnosis of pilomatricoma, was carried out. 145 surgically removed pilomatricomas from 137 patients were identified. Results: The clinical preoperative diagnosis of pilomatricoma was made in 34.01% of cases. Clinically, the most common misdiagnosis was epidermal cyst. Tumors were slightly more common in female patients. Tumor location showed predilection to the head and neck. 19 of the 137 patients had reported concomitant neoplasm. The most common concomitant neoplasm was epidermal cyst. 3 patients had concomitant malignant neoplasm such as basal cell carcinoma and endometrioid carcinoma. Conclusion: The frequency of occurrence and distribution of pilomatricoma seems to match the distribution, density and depth of vellus hair follicles in skin as a whole. It should be emphasized that the clinical features of pilomatricoma including incidence in adults are similar as those in children. However, the results of the present study outline the overall clinical presentations of pilomatricoma in adults and help to guide differential diagnoses of subcutaneous tumors in elderly individuals.
Methods: The panel (17 dermatologists, 3 ophthalmologists) reached consensus by a modified Delphi approach (e-surveys, direct meetings). Panelists voted on each statement: strongly disagree, disagree, agree/strongly agree (consensus defined as $75% agree/strongly agree). Statements without consensus were refined via nominal group discussion and re-voted on. Voting was electronic and blinded. The project was funded by Galderma. Recommendations: Panelists recommended transition to a phenotype-led rosacea management approach based on individual features rather than subtypes. Table 1 shows the recommended diagnostic criteria. Independently diagnostic Diagnostic in combination ($2) Persistent centrofacial erythema Flushing/transient erythema Phymatous changes Inflammatory papules/pustules Telangiectasia (excl. perinasal) Ocular manifestations Table 1. Recommended diagnostic criteria for rosacea. Minimum diagnostic criteria for ocular rosacea are either lid margin telangiectasia + interpalpebral injection, or corneal findings + scleral inflammation. Validated categorical severity scales are needed to assess individual features. Ideal treatment should use optimized therapeutic combinations targeted to individual presentations, including baseline general skincare (trigger avoidance, SPF 30+, frequent moisturizer use). Medications and physical procedures for specific features can be used in parallel. As a global project, ROSCO assumes availability of all rosacea treatments. Local accessibility and costs will vary and should be defined in local or regional guidelines. Conclusion A phenotype-led approach to rosacea management aids combination treatment, and targeted parallel treatment of individual features (including patients with cutaneous, multiple cutaneous, and ocular manifestations). A phenotype-led approach may improve treatment outcomes by personalizing treatment and addressing the disease aspects most troubling to the patient.
Commercial support: None identified.
Commercial support: Galderma R&D funded this study.
JUNE 2017
J AM ACAD DERMATOL
AB275
5711
Unusual presentations of cutaneous cytomegalovirus: A case series Rasnik Singh, BS, David Geffen School of Medicine; Suzanne Sachsman, MD, UCLA Division of Dermatology; Swati Kannan, MD, UCLA Division of Dermatology; Scott Worswick, MD, UCLA Division of Dermatology Although cytomegalovirus (CMV) is a common opportunistic pathogen affecting multiple organ systems, cutaneous manifestations are relatively rare and portend an ominous prognosis. The following case series reports on three atypical presentations of cutaneous CMV. A 22-year-old woman with acute myeloid leukemia treated with stem cell transplant (SCT) complicated by graft versus host disease (GVHD) of the liver, was evaluated for a 3-week history of desquamating rash. Exam was remarkable for gray exudative macerated plaques on her tongue and hard palate, petechiae on her extremities, rare intact scattered bullae and desquamating erosions and ulcers affecting 30% body surface area (BSA). Biopsies showed interface dermatitis with lymphocytic infiltrate and epidermal atrophy. Despite concern for cutaneous GVHD or toxic epidermal necrolysis (TEN), further work up revealed positive oral CMV culture and serum CMV PCR. A 62 year-old woman with B-cell lymphoma treated with SCT and prior history of TEN presented with 4 days of worsening fever, rash, and skin and oral pain. Exam revealed dusky reticulate plaques with desquamative scale, occasional intact bullae, and erosions involving 40% BSA, and oral and genital erosions. Clinically there was concern for recurrent TEN versus paraneoplastic pemphigus (PNP). Biopsies showed interface dermatitis, necrotic keratinocytes, bullae, and acantholysis favoring PNP, however, immunofluorescence studies and malignancy work up were negative. Further testing revealed positive serum and tissue CMV PCR studies. The patient was treated with Ganciclovir with improvement of her skin lesions. A 45-year-old HIV positive male not on antiretroviral therapy was evaluated for worsening nodular rash accompanied by fever and tachycardia. He reported a 6-month history of dark spots on his extremities that gradually became palpable. He was previously treated with multiple systemic antibiotics without significant improvement and serologic studies for Bartonella and Coccidioides were negative. Exam revealed multiple hyperpigmented subcutaneous nodules and a few scattered pink erosions on his extremities and back. Biopsy showed numerous CMV inclusion bodies and serum CMV PCR was also positive. This case series illustrates the variation of clinical presentations seen with cutaneous CMV ranging from skin denudation to subcutaneous nodules. A high degree of clinical suspicion is important for timely diagnosis, especially in immunocompromised patients.
Updates on novel research in laser and photodynamic therapy for treatment of acne vulgaris Marjon Vatanchi, MD, SUNY Downstate Medical Center; Georgina Ferzli, MD, SUNY Downstate Medical Center; Daniel Siegel, MD, SUNY Downstate Medical Center Purpose: For decades, mainstay therapy for acne vulgaris has included topical/oral retinoids and antibiotics. Due to advancements in energy-based technologies and the exorbitant increase in cost of prescription medications, laser therapy is slowly becoming a favored modality. We attempt to identify a consensus on safety, efficacy, and practicality of lasers for acne vulgaris based on cutting-edge research. Design: Novel publications from January 2015 to March 2016 were reviewed regarding acne vulgaris and laser therapy/photodynamic therapy (PDT). Articles on acne scarring were excluded. Summary: Targeted mechanisms of laser and PDT include sebaceous gland activity, inflammatory mediators, and porphyrins endogenous to P acnes. A review of 36 clinical trials on PDT for acne vulgaris identified 24 trials that evaluated efficacy. The studies proved PDT to be efficacious for both comedonal and inflammatory acneiform lesions irrelevant of severity. Improvement was visible within three weeks and persisted for 20 weeks. Two independent randomized controlled clinical trials (RCT) evaluated photothermolysis of sebaceous follicles with topical gold microspheres that absorb light. Each trial showed clinical and statistically significant improvement in inflammatory lesions at 6, 12, and 16 weeks. A comparative splitface study evaluating pulsed-dye laser (PDL) at different fluence levels demonstrated positive efficacy measured by improvements in the severity scale. The fluence level did not have a statistical effect on lesion count. A RCT evaluating salicylic acid chemical peel alone versus a chemical peel combined with PDL found that there was significant efficacy in the PDL group recognized by evaluators who were blinded to the treatment arm. Two clinical trials on erbium:glass lasers demonstrated moderate to significant improvement in short-term (1-3 months) and long-term (1-2 years) studies. Conclusion: Numerous clinical trials have proved positive for both safety and efficacy of laser therapy and PDT for acne vulgaris. These modalities can provide options for patients who have disease refractory to current medical therapies, are prone to medication side effects, or have difficulty with compliance. In such patients, energy-based therapies demonstrate a practical option or can be included as adjuvant therapy. More research is necessary to address laser parameters, modality comparisons, and guidelines for optimal treatment based on acne severity.
Commercial support: None identified. Commercial support: None identified.
5322
5051
Updating rosacea diagnosis to improve treatment strategy: Recommendations from the Global ROSacea COnsensus (ROSCO) panel Jerry Tan, MD, University of Western Ontario; Luiz Mauricio Costa Almeida, MD, Faculdade de Ci^encias Medicas de Minas Gerais; Anthony Bewley, MD, Whipps Cross University Hospital and the Royal London Hospital; Bernard Cribier, MD, Dermatology University Uospital Strasbourg; Ncoza Dlova, MD, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal; Gerd Kautz, MD, Haut- und Laserklinik; Hazel H. Oon, MD, National Skin Centre; Martin Schaller, MD, Department of Dermatology, T€ ubingen University Hospital Introduction: Rosacea is currently diagnosed/classified by subtype, but features can span multiple subtypes. This can confound epidemiology studies and clinical trials, limiting disease management and treatment development. Clinicians and scientists have proposed a phenotype-led approach (presenting feature based) that may benefit clinical practice by better representing all rosacea features. The ROSacea COnsensus (ROSCO) project aims to support this transition and align global consensus on phenotype-led rosacea diagnosis, classification and management.
Updated view on epidemiology and clinical aspects about pilomatricoma in adults Geo Han, MD, Department of Dermatology, Guro Hospital, Korea University College of Medicine; Seung Hwi Kwon, MD, Department of Dermatology, Guro Hospital, Korea University College of Medicine; Ae-Ree Kim, MD, Department of Pathology, Guro Hospital, Korea University College of Medicine; Hae Jun Song, MD, Department of Dermatology, Guro Hospital, Korea University College of Medicine; Chil Hwan Oh, MD, Department of Dermatology, Guro Hospital, Korea University College of Medicine; Jiehyun Jeon, MD, Department of Dermatology, Guro Hospital, Korea University College of Medicine Background: Clinically, pilomatricoma offers a wide spectrum of differential diagnoses. It is known to occur typically in pediatric patients with most common location being the head. Epidemiologically it has been regarded that pilomatricoma is a rather uncommon neoplasm in middle aged and old patients. Objective: To investigate the clinical and epidemiological features of pilomatricoma, as it is a common and frequently misdiagnosed tumor, also in adults over 20 years old. Methods: This was a retrospective study of pilomatricomas surgically removed at a tertiary hospital between January 1994 and December 2014. A search of the allpathological database of patients aged over 20 years old with a pathological diagnosis of pilomatricoma, was carried out. 145 surgically removed pilomatricomas from 137 patients were identified. Results: The clinical preoperative diagnosis of pilomatricoma was made in 34.01% of cases. Clinically, the most common misdiagnosis was epidermal cyst. Tumors were slightly more common in female patients. Tumor location showed predilection to the head and neck. 19 of the 137 patients had reported concomitant neoplasm. The most common concomitant neoplasm was epidermal cyst. 3 patients had concomitant malignant neoplasm such as basal cell carcinoma and endometrioid carcinoma. Conclusion: The frequency of occurrence and distribution of pilomatricoma seems to match the distribution, density and depth of vellus hair follicles in skin as a whole. It should be emphasized that the clinical features of pilomatricoma including incidence in adults are similar as those in children. However, the results of the present study outline the overall clinical presentations of pilomatricoma in adults and help to guide differential diagnoses of subcutaneous tumors in elderly individuals.
Methods: The panel (17 dermatologists, 3 ophthalmologists) reached consensus by a modified Delphi approach (e-surveys, direct meetings). Panelists voted on each statement: strongly disagree, disagree, agree/strongly agree (consensus defined as $75% agree/strongly agree). Statements without consensus were refined via nominal group discussion and re-voted on. Voting was electronic and blinded. The project was funded by Galderma. Recommendations: Panelists recommended transition to a phenotype-led rosacea management approach based on individual features rather than subtypes. Table 1 shows the recommended diagnostic criteria. Independently diagnostic Diagnostic in combination ($2) Persistent centrofacial erythema Flushing/transient erythema Phymatous changes Inflammatory papules/pustules Telangiectasia (excl. perinasal) Ocular manifestations Table 1. Recommended diagnostic criteria for rosacea. Minimum diagnostic criteria for ocular rosacea are either lid margin telangiectasia + interpalpebral injection, or corneal findings + scleral inflammation. Validated categorical severity scales are needed to assess individual features. Ideal treatment should use optimized therapeutic combinations targeted to individual presentations, including baseline general skincare (trigger avoidance, SPF 30+, frequent moisturizer use). Medications and physical procedures for specific features can be used in parallel. As a global project, ROSCO assumes availability of all rosacea treatments. Local accessibility and costs will vary and should be defined in local or regional guidelines. Conclusion A phenotype-led approach to rosacea management aids combination treatment, and targeted parallel treatment of individual features (including patients with cutaneous, multiple cutaneous, and ocular manifestations). A phenotype-led approach may improve treatment outcomes by personalizing treatment and addressing the disease aspects most troubling to the patient.
Commercial support: None identified.
Commercial support: Galderma R&D funded this study.
JUNE 2017
J AM ACAD DERMATOL
AB275