Horse flies are common dipteran insects that can be found in most parts of the world. They feed on the blood of their hosts, including humans. Female horse flies pierce the skin of the host, inject anticoagulant saliva, and suck the blood, which can result in minor cutaneous reactions (eg, urticaria, papules localized to the bite site). In severe cases, bites also can result in anaphylaxis. Horse flies can transmit tularemia, which typically manifests as cutaneous ulcers and lymphadenopathy but also can result in severe systemic reactions such as septic shock. Minor cutaneous reactions can be treated with symptomatic management and oral antihistamines, while anaphylaxis and tularemia require systemic therapy with intramuscular epinephrine and intravenous gentamicin, respectively. Exposure to horse flies can be minimized via use of protective clothing, topical repellants, and traps.
Recent updates to evaluation and management coding emphasize medical decision-making (MDM) as the primary determinant of visit level, though clinicians still face challenges in application. Medical decision-making is established by meeting criteria in 2 of 3 domains: problem complexity, data, and risk. In this article, key clarifications are discussed, including inadequately controlled conditions as moderate complexity; distinction between prescription drug management and simple refills; inclusion of relevant social determinants of health; and classification of independent test interpretation under data. Additional nuances in procedural decision-making and common clinical scenarios also are reviewed to support accurate coding and documentation.
Immune checkpoint inhibitors (ICIs), including the programmed cell death protein-1 (PD-1) inhibitor pembrolizumab, have revolutionized metastatic urothelial carcinoma management but are frequently associated with cutaneous immune-related adverse events, including drug-induced bullous pemphigoid (DIBP). We present the case of an 81-year-old man with PD-L1-negative metastatic high-grade papillary urothelial carcinoma with a generalized, pruritic, bullous eruption following treatment with pembrolizumab. Histopathology and direct immunofluorescence confirmed bullous pemphigoid (BP). This case underscores the diagnostic challenges of DIBP. Clinicians must maintain a high index of suspicion and consider early transition to steroid-sparing agents such as rituximab in refractory cases. Timely dermatologic referral and close multidisciplinary coordination are essential.
Triatomine bugs are widely distributed globally and are important vectors of trypanosomiasis in the New World. The Romaña sign, characterized by unilateral swelling of the eyelid, is common in triatomine and bedbug bites. The range of Trypanosoma cruzi, the cause of Chagas disease has expanded with the organism detected in triatomine reduviids in suburban areas of the southwestern United States.
The aim of this study was to evaluate outcomes of treatment with cemiplimab in patients with metastatic or locally advanced cutaneous squamous cell carcinoma (cSCC) not amenable to surgery or radiotherapy in a single tertiary center. Demographic, histologic, and clinical data were retrospectively collected for patients treated with cemiplimab between November 2018 and March 2023. The primary objective was overall response rate (ORR), with secondary objectives including progression-free survival (PFS), overall survival (OS), and adverse events (AEs). Among 31 patients, 20 (64.5%) achieved a complete response, 6 (19.4%) achieved a partial response, and 2 (6.5%) experienced disease progression. Our findings yielded an ORR of 83.9%, which exceeded the 46.1% reported in the EMPOWER-CSCC 1 trial. The 2-year OS was 73.5%, comparable to the 73.3% reported in EMPOWER-CSCC 1. Adverse events occurred in 24 patients (77.4%). These findings provide additional real-world evidence supporting the efficacy of cemiplimab in advanced cSCC, with a substantial proportion of patients achieving complete response, including after limited treatment exposure; further studies are needed to better define optimal treatment duration and dosing strategies.
Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition with metabolic and hormonal comorbidities. This study analyzed the association between HS and polycystic ovary syndrome (PCOS) using data from the National Institute of Health's All of Us Research Program database. In a cross-sectional analysis of 78,742 females, 5.64% of those with HS had PCOS compared with 0.93% of those without HS. After adjusting for age, race/ethnicity, smoking status, type 2 diabetes, and obesity, females with HS were found to be 2.06 times more likely to have PCOS (95% CI, 1.41-3.02; P<.001). In unadjusted analyses stratified by race/ethnicity, HS was associated with increased odds of PCOS within each group. Non-Hispanic Black and Hispanic patients were less likely to have PCOS compared with White patients, possibly reflecting disparities in diagnosis. Obesity and type 2 diabetes also were strongly associated with PCOS, conferring 11.14-and 10.43-fold increased odds, respectively. These findings underscore the importance of PCOS screening among patients with HS, particularly for minority populations. Shared hormonal and metabolic pathways may contribute to the observed associations, supporting the use of antiandrogen therapies and oral contraceptives for treatment. Further research is warranted to explore the shared pathophysiology and improve targeted care for patients with both conditions.
Occupational hand dermatitis (HD) is a chronic refractory hand eczema that is caused or exacerbated by workplace exposures. The hands are uniquely vulnerable to dermatitis from exposure to allergens and irritants in the workplace, including metals, preservatives, acrylates, rubber accelerators, food, water, plants, and fragrances. In occupational allergic contact dermatitis (ACD), patch testing plays a critical role in identifying contact allergens to help guide avoidance strategies that are key for clinical improvement. A coordinated return-to-work plan is essential for managing patients with occupational HD. In this article, we review practical considerations for evaluation and management of occupational HD, highlighting relevant exposures and pearls on workup and management.
Pyogenic granulomas (PGs) are rapidly growing benign vascular lesions that often become ulcerated, bleed, and recur after standard surgical or laser treatments. This article highlights a simple noninvasive technique for treating recurrent PGs using cryotherapy followed by daily application of table salt under occlusion for 2 weeks. Topical application of table salt is an inexpensive and largely pain-free option for patients who are not candidates for or opt out of surgery.
Chromoblastomycosis is a neglected tropical skin disease acquired through traumatic inoculation of dematiaceous fungi. It is characterized clinically by a chronic granulomatous infection of the skin and subcutaneous tissue. Delays in diagnosis and limited access to anti-fungal therapy contribute to prolonged disease, recurrent inflammation, and debilitating sequelae. A rare but devastating complication is squamous cell carcinoma (SCC) associated with long-standing lesions, which may necessitate extensive surgery or amputation and can be fatal. In this review, we summarize reported epidemiology and clinical risk factors for SCC complicating chromoblastomycosis. We also discuss plausible inflammatory mechanisms of malignant transformation and propose pragmatic clinical and public health interventions, including decentralized microscopy-based diagnosis, timely antifungal access, and biopsy-triggered surveillance of chronically inflamed lesions, to reduce preventable morbidity.
