Background: In the 2022 mpox (monkeypox) outbreak, 79,000 global cases have been reported. Yet, limited dermatologic data have been published regarding lesion morphology and progression.Objective: The objective of this study was to characterize skin lesion morphology, symptomatology, and outcomes of mpox infection over time.Methods: The American Academy of Dermatology/International League of Dermatological Societies Dermatology COVID-19, Mpox, and Emerging Infections Registry captured deidentified patient cases of mpox entered by health care professionals.Results: From August 4 to November 13, 2022, 101 cases from 13 countries were entered, primarily by dermatologists (92%). Thirty-nine percent had fewer than 5 lesions. In 54% of cases, skin lesions were the first sign of infection. In the first 1-5 days of infection, papules (36%), vesicles (17%), and pustules (20%) predominated. By days 6-10, pustules (36%) were most common, followed by erosions/ulcers (27%) and crusts/scabs (24%). Crusts/scabs were the predominant morphology after day 11. Ten cases of morbilliform rash were reported. Scarring occurred in 13% of the cases.Limitations: Registry-reported data cannot address incidence. There is a potential reporting bias from the predilection to report cases with greater clinical severity.Discussion: These findings highlight differences in skin findings compared to historical outbreaks, notably the presence of skin lesions prior to systemic symptoms and low overall lesion counts. Scarring emerged as a major possible sequela. ( J Am Acad Dermatol 2023;88:1066-73.)

Emerging infectious diseases are of great importance to public health and clinical practice. This review aims to characterize the clinical and histopathologic features of emerging infectious diseases with cutaneous manifestations in order to increase awareness of these entities among dermatologists, pathologists, and dermatopathologists.

To the Editor: Since the onset of the COVID-19 pandemic, >612 million cases of SARS-CoV-2 and over 6.5 million deaths have been reported. 12.6 billion vaccine doses have been administered worldwide, but we have not yet reached vaccine equity.1Mathieu E. Ritchie H. Rodés-Guirao L. et al.Coronavirus pandemic (COVID-19).https://ourworldindata.org/coronavirusDate: 2020Date accessed: November 1, 2022Google Scholar The spectrum of cutaneous findings of SARS-CoV-2 are associated with different COVID-19 severities, and in some cases can be the presenting, or only sign of infection. Characterizing cutaneous reactions to COVID-19 vaccination remains important, as booster doses are a key component to limiting COVID-19 related morbidity and mortality. In April 2020, in response to growing reports of SARS-CoV-2 cutaneous findings, the American Academy of Dermatology and the International League of Dermatological Societies COVID-19 Dermatology Registry was generated to rapidly collate SARS-CoV-2 associated dermatologic manifestations. In December 2020, the registry expanded to include COVID-19 vaccine-related reactions. Over 500 cases of SARS-CoV-2 cutaneous findings were submitted within 25 days of launch. As of September 2022, the registry has amassed 1436 reports of COVID-related and 1086 reports of vaccine–related dermatologic manifestations spanning 72 countries (Fig 1). The registry was designed in collaboration with a panel of experts in dermatology and infectious disease and hosted via REDCap's (Vanderbilt University) secure online survey platform. Data entry was restricted to healthcare providers for more accurate clinical and morphological data. Respondents were asked for case follow-up and biopsy results as available. Data requests are available for outside investigations via a data request application and reviewed by an appointed data governance group. The American Academy of Dermatology/International League of Dermatological Societies COVID-19 Dermatology Registry exemplifies collaborative efforts of the dermatologic community during the SARS-CoV-2 outbreak. Case entry led to 24 publications, including 111 authors across 19 different countries (Fig 2), and served as a training platform for 13 trainees. Registry publications led to >190 million media impressions, allowing for rapid dissemination of information to the medical field and the lay public. COVID–related dermatologic registries across the globe amassed over 8000 cases in total and contributed to data sharing across a spectrum of COVID-19 related dermatologic subjects.2Freeman E.E. Chamberlin G.C. McMahon D.E. et al.Dermatology COVID-19 registries: updates and future directions.Dermatol Clin. 2021; 39: 575-585Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Registry data are useful specifically for hypothesis generation, not as a replacement for epidemiologic data, but as an initial method of rapid collation and harmonization of disparate real-world observations in times of novel disease outbreak when resources are low, but the need for data is high. Efficient data collection and dissemination functions as means of combatting misinformation and facilitating diagnosis in times of novel disease outbreaks. The registry will continue to gather information, particularly as the medical community continues to investigate Long COVID — its origins and impacts on the estimated millions it affects—and as vaccination and booster campaigns remain a key component in infection control.3Statistics NCfHLong COVID household pulse survey.https://www.cdc.gov/nchs/covid19/pulse/long-covid.htmDate: 2022Date accessed: November 3, 2022Google Scholar In response to World Health Organization's declaration of the spread of monkeypox (mpox) as a public health emergency, the registry expanded in August 2022, becoming the American Academy of Dermatology/International League of Dermatological Societies Dermatology COVID-19, Monkeypox (mpox), and Emerging Infections Registry.4Freeman E.E. Galvan Casas C. Prasad S. et al.The American Academy of Dermatology and International League of Dermatological Societies monkeypox registry: expanding the COVID-19 registry to emerging infections.J Am Acad Dermatol. 2022; 87: 1278-1280Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Reports of COVID-19, as well as mpox cases and cutaneous reactions to mpox/smallpox vaccines, are being accepted from healthcare providers worldwide (https://www.aad.org/monkeypoxregistry). Dr Freeman is the Principal Investigator of the AAD/ILDS Dermatology Registry for COVID-19, Monkeypox, and Emerging Infections. Dr Fox is a Board member of the AAD. Dr Lim is a Board member of the ILDS. Dr French is the President of the ILDS. Authors Strahan, Lubov, and Prasad; Dr McMahon; Author Singh; Drs Rosenbach, Desai, Thiers, and Hruza have no conflicts of interest to declare.

To the Editor: In July 2022, the World Health Organization declared "mpox" a public health emergency. Since outbreak onset, >91,000 cases have been reported. 1 CDC. 2022 Monkeypox Outbreak Global Map. 2022. https://www.cdc.gov/poxvirus/monkeypox/response/2022/world-map.htmlDate accessed: November 6, 2022 Google Scholar During the 2022 mpox outbreak, most disease courses were mild. 2 Yon H. Shin H. Shin J.I. et al. Clinical manifestations of human Mpox infection: a systematic review and meta-analysis. Rev Med Virol. 2023; 33e2446https://doi.org/10.1002/rmv.2446 Crossref Scopus (12) Google Scholar In some cases, however, severe outcomes were reported and included hospitalization and death. People living with HIV/AIDS (PLWH) have been disproportionally affected, and all immunocompromised individuals are at a higher risk of severe outcomes. 3 Mitjà O. Alemany A. Marks M. et al. Mpox in people with advanced HIV infection: a global case series. Lancet. 2023; 401: 939-949https://doi.org/10.1016/s0140-6736(23)00273-85 Crossref PubMed Scopus (0) Google Scholar ,4 Benites-Zapata V.A. Ulloque-Badaracco J.R. Alarcon-Braga E.A. et al. Clinical features, hospitalisation and deaths associated with monkeypox: a systematic review and meta-analysis. Ann Clin Microbiol Antimicrob. 2022; 21: 36https://doi.org/10.1186/s12941-022-00527-1 Crossref PubMed Scopus (86) Google Scholar Hospitalization in those diagnosed with mpox ranges from 14% to 59%. 4 Benites-Zapata V.A. Ulloque-Badaracco J.R. Alarcon-Braga E.A. et al. Clinical features, hospitalisation and deaths associated with monkeypox: a systematic review and meta-analysis. Ann Clin Microbiol Antimicrob. 2022; 21: 36https://doi.org/10.1186/s12941-022-00527-1 Crossref PubMed Scopus (86) Google Scholar In cases requiring hospitalization, death was reported in 4% of the cases, but it is as high as 25% in PLWH. 3 Mitjà O. Alemany A. Marks M. et al. Mpox in people with advanced HIV infection: a global case series. Lancet. 2023; 401: 939-949https://doi.org/10.1016/s0140-6736(23)00273-85 Crossref PubMed Scopus (0) Google Scholar ,4 Benites-Zapata V.A. Ulloque-Badaracco J.R. Alarcon-Braga E.A. et al. Clinical features, hospitalisation and deaths associated with monkeypox: a systematic review and meta-analysis. Ann Clin Microbiol Antimicrob. 2022; 21: 36https://doi.org/10.1186/s12941-022-00527-1 Crossref PubMed Scopus (86) Google Scholar Reports of dermatologic findings and associated clinical outcomes in PLWH are limited.

By Sigrid Collier, Rhea Sing & 13 more. In this study we show that addressing HIV stigma to the diagnosis and treatment of KS could improve engagement with cancer care among people with HIV-associated cancers in Sub-Saharan Africa.

M, et al. Advanced chemical peels: phenol-croton oil peel. J Am Acad Dermatol. 2019;81(2):327–36. https://doi.org/10.1016/j. jaad.2018.11.060 5 Hetter GP. An examination of the phenol-croton oil peel: part IV. Face peel results with different concentrations of phenol and croton oil. Plast Reconstr Surg. 2000;105(3):1061–83; discussion 1084-7. https://doi.org/10.1097/00006534200003000-00035 6 Justo AS, Lemes BM, Nunes B, Antunes KA, Capote ACMO, Lipinski LC, et al. Characterization of the activity of Croton tiglium oil in Hetter’s very heavy phenol-croton oil chemical peels. Dermatol Surg. 2021;47:944–6. https://doi.org/10.1097/ DSS.0000000000002990 7 da Silva JA, Lemes BM, Nunes B, Antunes KA, Carletto B, Koga AY, et al. Depth of injury of Hetter’s phenol-croton oil chemical peel formula using two different emulsifying agents. J Am Acad Dermatol. 2020;82:1544–6. https://doi.org/10.1016/j. jaad.2020.02.064 8 Larson DL, Karmo F, Hetter GP. Phenol-croton oil peel: establishing an animal model for scientific investigation. Aesthetic Surg J. 2009;29(1):47–53. https://doi.org/10.1016/j.asj. 2008.11.008 9 Takei H, Araki A, Watanabe H, Ichinose A, Sendo F. Rapid killing of human neutrophils by the potent activator phorbol 12myristate 13-acetate (PMA) accompanied by changes different from typical apoptosis or necrosis. J Leukoc Biol. 1996;59 (2):229–40. https://doi.org/10.1002/jlb.59.2.229 10 Kim M, Jung Y, Kim J, Jeong SW, Woo YR, Park HJ. Antiaging effects of ingenol mebutate for patients with actinic keratosis. J Am Acad Dermatol. 2018;79:1148–50. https://doi. org/10.1016/j.jaad.2018.05.1244

By Rhea Sing, Sigrid Collier & 13 more. In this study we show that assessing financial barriers for people with HIV-associated Kaposi’s Sarcoma is crucial in creating interventions necessary to promote early diagnosis and efficient treatment.

Aman inhis 20swithwell controlledCrohn’s disease on infliximab (treated for four years) presented with a two year history of painful, crusted, and ulcerated nodules ina sporotrichoid (lymphangitic) distribution on the dorsum of his left hand and distal arm (fig 1). While working on a marsh prior to symptom onset, he noticed a splinter in his left second finger. A few weeks after the splinter was removed, he developed redness of the area and multiple skin lesions. At the time, the patient was diagnosed with cellulitis, and treated with vancomycin without improvement. As the redness spreadandnodules developed, therewas clinical suspicion for sporotrichosis (fungal infection from Sporothrix schenckii). The patient was empirically treated with oral itraconazole for six months, followed by posaconazole, with minimal improvement. Two previous punch biopsy samples had shown granulomatous inflammation without micro-organisms. In our dermatology clinic, tissue cultures, blood count, and metabolic panel were unremarkable. The patient had not travelled outside the northeastern region of the United States. He denied fever, chills, or weight loss. A deep wedge biopsywas sent for culture anduniversal polymerase chain reaction (PCR) sequencing at a referral centre, revealing the diagnosis.

Background: Cutaneous reactions after COV1D-19 vaccination have been commonly reported; however, histopathologic features and clinical correlations have not been well characterized. Methods: We evaluated for a history of skin biopsy all reports of reactions associated with COVID-19 vaccination identified in an international registry. When histopathology reports were available, we categorized them by reaction patterns. Results: Of 803 vaccine reactions reported, 58 (7%) cases had biopsy reports available for review. The most common histopathologic reaction pattern was spongiotic dermatitis, which clinically ranged from robust papules with overlying crust, to pityriasis rosea-like eruptions, to pink papules with fine scale. We propose the acronym "V-REPP" (vaccine-related eruption of papules and plaques) for this spectrum. Other clinical patterns included bullous pemphigoid-like (n = 12), dermal hypersensitivity (n = 4), herpes zoster (n = 4), lichen planus-like (n = 4), pernio (n = 3), urticarial (n = 2), neutrophilic dermatosis (n = 2), leukocytoclastic vasculitis (n = 2), morbilliform (n = 2), delayed large local reactions (n = 2), erythromelalgia (n = 1), and other (n = 5). Limitations: Cases in which histopathology was available represented a minority of registry entries. Analysis of registry data cannot measure incidence. Conclusion: Clinical and histopathologic correlation allowed for categorization of cutaneous reactions to the COVID-19 vaccine. We propose defining a subset of vaccine-related eruption of papules and plaques, as well as 12 other patterns, following COVID-19 vaccination.

To the Editor: We thank the authors for their reply to our article and would like to clarify the concerns described.1McMahon D.E. Amerson E. Rosenbach M. et al.Cutaneous reactions reported after Moderna and Pfizer COVID-19 vaccination: a registry-based study of 414 cases.J Am Acad Dermatol. 2021; 85: 46-55Abstract Full Text Full Text PDF PubMed Scopus (603) Google Scholar The letter noted that the distribution of COVID-19 vaccine skin reactions was unclear and suggested we delineate each reaction pattern as local, distant, or generalized.1McMahon D.E. Amerson E. Rosenbach M. et al.Cutaneous reactions reported after Moderna and Pfizer COVID-19 vaccination: a registry-based study of 414 cases.J Am Acad Dermatol. 2021; 85: 46-55Abstract Full Text Full Text PDF PubMed Scopus (603) Google Scholar While we did not specify the body part affected by each reaction, we would also like to highlight the challenges with adopting the proposed local/distant/generalized approach. Patients often experienced multiple reactions simultaneously, including reactions both local and distant to the injection site. For instance, patients can exhibit concurrent, delayed large local reactions at the injection site and papulovesicles of the elbow/hand.2Blumenthal K.G. Freeman E.E. Saff R.R. et al.Delayed large rocal Reactions to mRNA-1273 vaccine against SARS-CoV-2.N Engl J Med. 2021; 384: 1273-1277Crossref PubMed Scopus (208) Google Scholar Others had local reactions combined with generalized morbilliform eruptions.1McMahon D.E. Amerson E. Rosenbach M. et al.Cutaneous reactions reported after Moderna and Pfizer COVID-19 vaccination: a registry-based study of 414 cases.J Am Acad Dermatol. 2021; 85: 46-55Abstract Full Text Full Text PDF PubMed Scopus (603) Google Scholar We do agree that at the level of the reaction pattern, certain eruptions were typically more generalized (such as morbilliform, urticaria, or vaccine-related eruption of papules and plaques3McMahon D.E. Kovarik C.L. Damsky W. et al.Clinical and pathologic correlation of cutaneous COVID-19 vaccine reactions including V-REPP: a registry-based study.J Am Acad Dermatol. September 10, 2021; https://doi.org/10.1016/j.jaad.2021.09.002Abstract Full Text Full Text PDF Scopus (102) Google Scholar), while others usually occurred at/near the injection site (local injection site reactions and delayed large local reactions). Others are harder to classify with regard to location: erythema multiforme and vasculitis, for example, could be either distal, in one location (for example, hands/feet only) or generalized. Our study also captured an extensive vaccine reactogenicity profile. Reactogenicity is defined as a subset of reactions occurring shortly after vaccination, including local signs and symptoms, such as pain, redness, swelling and induration, and systemic manifestations, such as fever, myalgia, headache, and rash.4Hervé C. Laupèze B. Del Giudice G. Didierlaurent A.M. Tavares Da Silva F. The how's and what's of vaccine reactogenicity.NPJ Vaccines. 2019; 4: 1-11PubMed Google Scholar We described reactogenicity for each dose of the Moderna/Pfizer vaccines, including fatigue, myalgia, headache, fever, arthralgia, nausea, chills, lymphadenopathy, diarrhea, vomiting, nasal congestion, and others.1McMahon D.E. Amerson E. Rosenbach M. et al.Cutaneous reactions reported after Moderna and Pfizer COVID-19 vaccination: a registry-based study of 414 cases.J Am Acad Dermatol. 2021; 85: 46-55Abstract Full Text Full Text PDF PubMed Scopus (603) Google Scholar We would also like to highlight new data on skin reactions to other COVID-19 vaccines, including AZD1222, Johnson & Johnson's Ad26.COV2.S, Sputnik V, and Sinovac-Coronavac (Table I). As of August 16, 2021, the American Academy of Dermatology/International League of Dermatological Societies registry included 2063 cutaneous vaccine reactions from 870 patients. We identified 24 reactions after AZD1222 vaccination, most commonly local erythema and pain. Johnson & Johnson's Ad26.COV2.S, another adenovirus vector vaccine, generated 15 reactions, including pityriasis rosea and alopecia. One individual developed urticaria and pruritus to the Sputnik V vaccine. Our data on skin reactions to other vaccine classes, such as the inactivated virus-based vaccine, Sinovac's CoronaVac, are limited. Four cases of reactions have been reported to the registry, including pityriasis rosea and zoster. Clinical trials frequently lump skin reactions into a nonspecific "rash" category, but real-world data better characterizing these cutaneous manifestations can provide mechanistic clues.Table ICharacteristics of dermatologic vaccine reactions reported after COVID-19 vaccination to the AAD/ILDS COVID-19 Dermatology Registry∗December 24, 2020—August 16, 2021.Moderna dose 1Moderna dose 2Pfizer dose 1Pfizer dose 2Astrazeneca dose 1Astrazeneca dose 2Johnson & JohnsonSputnik V dose 1Sputnik V dose 2Sinovac-Coronavac dose 1Sinovac-Coronavac dose 2Unknown dose 1Unknown dose 2TotalNumber of individuals427214114140921101311921870Patient age (Median, IQR)49 (37-66)47 (37-61)46 (35-56)51 (37-64)49 (44.5-55.5)39.5 (37-42)51 (28-60)-3842 (19-85)4261 (45-75)60 (49-75)-Patient sex (F)366 (85.7%)181 (84.5%)77 (67.5)103 (73.6%)5 (55.5%)1 (50%)10 (90.9%)-0 (0)3 (100%)1 (100%)16 (84.2%)13 (61.9%)776 (89.2%)Number of vaccine reactions99852620822822215023127312063Local reactions Local swelling151971214201000022281 Local erythema1691011315301000032307 Local pain116811414300000012231 Delayed local hypersensitivity reaction230501217200000012314Distal and/or generalized reactions Pruritus138642325202010053263 Urticaria28222421102010002101 Morbilliform2617161510100003281 Zoster195111301100104459 Vesicular148111400000000047 Pityriasis rosea1063520100112031 Pernio/chilblains735700000004026 Erythema multiforme1331410000001124 Bullous disease715900100000023 Erythromelalgia772400000000020 Filler reaction771200000000017 Angioedema653020000000016 Contact dermatitis530500000000114 Vasculitis315100000000111 Alopecia12110020000029 Petechiae13310000000008 Reaction in breast-fed infant01210000000004 Livedo reticularis00300000000014 New dermatologic condition7†Moderna first dose: lichen planus (4); psoriasis (1); possible leukocytoclastic vasculitis (1); Acne vulgaris (1).3‡Moderna second dose: granuloma annulare (1); lichen planus (1); psoriasis (1).1§Pfizer first dose: herpes zoster (1).8‖Pfizer second dose: lichen planus (2), granuloma annulare (1), morphea (1), Raynaud (1), pityriasis lichenoides (1); "lichen striatus versus inflammatory linear verrucous epidermal nevus versus Wolf isotopic response" (1); unspecified toe rash (1).000000002¶Unknown second dose: granuloma annulare (1); sarcoidosis (1).21 Flare of existing dermatologic condition91315910000000249 Other24232023213001012100F, Female; IQR, interquartile range.∗ December 24, 2020—August 16, 2021.† Moderna first dose: lichen planus (4); psoriasis (1); possible leukocytoclastic vasculitis (1); Acne vulgaris (1).‡ Moderna second dose: granuloma annulare (1); lichen planus (1); psoriasis (1).§ Pfizer first dose: herpes zoster (1).‖ Pfizer second dose: lichen planus (2), granuloma annulare (1), morphea (1), Raynaud (1), pityriasis lichenoides (1); "lichen striatus versus inflammatory linear verrucous epidermal nevus versus Wolf isotopic response" (1); unspecified toe rash (1).¶ Unknown second dose: granuloma annulare (1); sarcoidosis (1). Open table in a new tab F, Female; IQR, interquartile range. Poulas and Farsalinos3McMahon D.E. Kovarik C.L. Damsky W. et al.Clinical and pathologic correlation of cutaneous COVID-19 vaccine reactions including V-REPP: a registry-based study.J Am Acad Dermatol. September 10, 2021; https://doi.org/10.1016/j.jaad.2021.09.002Abstract Full Text Full Text PDF Scopus (102) Google Scholar hypothesized the spike glycoprotein from vaccination drives these skin phenomena, but the underlying mechanism is likely multifaceted and may vary by vaccine reaction. For instance, delayed large local reactions suggest a delayed hypersensitivity response to vaccination or a T-cell-mediated response resulting from molecular mimicry to viral epitopes. Other manifestations, such as viral reactivation, bullous pemphigoid, and leukocytoclastic vasculitis, may be explained by off-target immune activation postvaccination.3McMahon D.E. Kovarik C.L. Damsky W. et al.Clinical and pathologic correlation of cutaneous COVID-19 vaccine reactions including V-REPP: a registry-based study.J Am Acad Dermatol. September 10, 2021; https://doi.org/10.1016/j.jaad.2021.09.002Abstract Full Text Full Text PDF Scopus (102) Google Scholar RNA-mediated activation of innate immunity via Toll- and RIG-like receptors could also result in type I interferon release. Analysis of the underlying mechanisms for each pattern of skin reaction and systematic characterization of these cutaneous manifestations are paramount to understanding how these side effects influence vaccine adoption, particularly as additional doses, boosters, and vaccine mixing become increasingly common. Drs Freeman, Hruza, and Fox are part of the American Academy of Dermatology (AAD) COVID-19 Ad Hoc Task Force. Dr French is the President of the ILDS. Dr Freeman is an author of COVID-19 dermatology for UpToDate. Drs Sun, McMahon, and Blumenthal have no conflicts of interest to declare. Authors Singh, Fathy, and Tyagi have no conflicts of interest to declare. Response to McMahon et al's "Cutaneous reactions reported after Moderna and Pfizer COVID-19 vaccination: A registry-based study of four hundred fourteen cases"Journal of the American Academy of DermatologyVol. 86Issue 4PreviewTo the Editor: McMahon et al1 reported cutaneous reactions that occurred after the administration of messenger RNA (mRNA) COVID-19 vaccines. The authors recorded 414 unique patients and observed a broad spectrum of reactions after vaccination, from local injection site reactions and delayed large local reactions to urticaria and morbilliform eruptions. Several unusual reactions (erythromelalgia, pernio/chilblains, filler reactions, and pityriasis rosea-like eruptions) were also observed. All these lesions were characterized as local (near the injection site), according to the authors. Full-Text PDF

INTRODUCTION:The experience of stigma can be multifaceted for people with HIV and cancer. Kaposi's sarcoma (KS), one of the most common HIV-associated cancers in sub-Saharan Africa, often presents with visible skin lesions that may put people at risk for stigmatization. In this way, HIV-associated KS is unique, as people with KS can experience stigma associated with HIV, cancer, and skin disease simultaneously. The aim of this study is to characterize the intersectionality of HIV-related, cancer-related and skin disease-related stigma in people living with HIV and KS. METHODS:We used a convergent mixed-methods approach nested within a longitudinal study of people with HIV-associated KS in western Kenya. Between February 2019 and December 2020, we collected quantitative surveys among all participants and conducted semi-structured interviews among a purposive sample of participants. Quantitative surveys were adapted from the abridged Berger HIV Stigma Scale to assess overall stigma, HIV-related stigma, cancer-related stigma, and skin disease-related stigma. Qualitative data were coded using stigma constructs from the Health Stigma and Discrimination Framework. RESULTS:In 88 semi-structured interviews, stigma was a major barrier to KS diagnosis and treatment among people with HIV-associated KS. Participant's stories of stigma were dominated by HIV-related stigma, more than cancer-related or skin disease-related stigma. However, quantitative stigma scores among the 117 participants were similar for HIV-related (Median: 28.00; IQR: 28.0, 34.0), cancer-related (Median: 28.0; IQR: 28.0, 34.8), and skin disease-related stigma (Median: 28.0; IQR: 27.0, 34.0). In semi-structured interviews, cancer-related and skin disease-related stigma were more subtle contributors; cancer-related stigma was linked to fatalism and skin-related stigma was linked to visible disease. Participants reported resolution of skin lesions contributed to lessening stigma over time; there was a significant decline in quantitative scores of overall stigma in time since KS diagnosis (adjusted β = -0.15, p <0.001). CONCLUSIONS:This study highlights the role mixed-method approaches can play in better understanding stigma in people living with both HIV and cancer. While HIV-related stigma may dominate perceptions of stigma among people with KS in Kenya, intersectional experiences of stigma may be subtle, and quantitative evaluation alone may be insufficient to understand intersectional stigma in certain contexts.

The World Health Organization declared the global monkeypox outbreak a public health emergency of international concern in July 2022. In response, the American Academy of Dermatology and International League of Dermatological Societies expanded the existing COVID-19 Dermatology Registry to become the “AAD/ILDS Dermatology COVID-19, Monkeypox, and Emerging Infections Registry.” The goal of the registry is to rapidly collate cases of monkeypox and other emerging infections and enable prompt dissemination of findings to front-line healthcare workers and other members of the medical community. The registry is now accepting reports of monkeypox cases and cutaneous reactions to monkeypox/smallpox vaccines. The success of this collaborative effort will depend on active case entry by the global dermatology community.

To the Editor: Booster doses for COVID-19 messenger RNA (mRNA) vaccines ≥6 months after the completion of a patient’s primary vaccine series are now in use across the globe.1,2 Although cutaneous reactions have been widely reported in response to the original series of mRNA vaccines,3-5 little is known about adverse cutaneous reactions to the administration of booster doses. We sought to evaluate cutaneous side effects after mRNA COVID-19 booster to (1) describe reaction sequences after first, second and booster doses, and (2) characterize cutaneous reaction morphology following vaccine booster administration.

Background:In summer 2021, several countries including the U.S. authorized COVID-19 mRNA vaccine booster doses ≥6 months after completion of a patient's primary vaccine series. The aim of this study was to characterize vaccine cutaneous reactions following a booster dose of mRNA vaccine reported to the American Academy of Dermatology (AAD) & International League of Dermatologic Societies (ILDS) COVID-19 Dermatology registry. Methods:In December 2020, the AAD/ILDS registry was adapted to include COVID-19 vaccine skin reactions. In September 2021 the registry also solicited COVID-19 vaccine booster reactions either as new cases or updates to existing entries. Results:From Dec 2020-Jan 2022, 994 cases of vaccine skin reactions were entered in the registry, of which 44 records indicated the presence or absence of cutaneous reactions following a booster dose. Of 44 records, 31(71%) developed a cutaneous reaction to the booster dose and 29% developed a reaction to the 1st and/or 2nd dose but not the booster. Of the 31 patients who developed a reaction to the booster dose, 22 reacted to the booster alone, 1 reacted to the 1st & booster, 3 reacted to the 2nd & booster, and 5 reacted to all three doses. The most common morphologies among all booster reactions were local injection site reactions (n=31), delayed large local reaction (n=7), erythromelalgia (n=3), and vesicular reactions (n=3). Conclusion:Booster reactions represent a small portion of COVID vaccine reactions in the registry. Infrequent reporting could be due slow booster uptake, reporter fatigue, and/or booster reactions may truly be less frequent than reactions to the initial series. Dermatologists should be aware that cutaneous reactions to boosters are possible, even when reactions to dose 1 & 2 did not occur;none of the reactions were life-threatening.

BACKGROUND:Although HIV-associated Kaposi sarcoma (KS) is frequently diagnosed at an advanced stage in sub-Saharan Africa, reasons for diagnostic delays have not been well described.METHODS:We enrolled patients >18 years with newly diagnosed KS between 2016 and 2019 into the parent study, based in western Kenya. We then purposively selected 30 participants with diversity of disease severity and geographic locations to participate in semistructured interviews. We used 2 behavioral models in developing the codebook for this analysis: situated Information, Motivation, and Behavior framework and Andersen model of total patient delay. We then analyzed the interviews using framework analysis.RESULTS:The most common patient factors that delayed diagnosis were lack of KS awareness, seeking traditional treatments, lack of personal efficacy, lack of social support, and fear of cancer, skin biopsy, amputation, and HIV diagnosis. Health system factors that delayed diagnosis included previous negative health care interactions, incorrect diagnoses, lack of physical examination, delayed referral, and lack of tissue biopsy availability. Financial constraints were prominent barriers for patients to access and receive care. Facilitators for diagnosis included being part of an HIV care network, living near health facilities, trust in the health care system, desire to treat painful or disfiguring lesions, and social support.CONCLUSIONS:Lack of KS awareness among patients and providers, stigma surrounding diagnoses, and health system referral delays were barriers in reaching KS diagnosis. Improved public health campaigns, increased availability of biopsy and pathology facilities, and health provider training about KS are needed to improve early diagnosis of KS.

Abstract Background Kaposi sarcoma is one of the most prevalent HIV-associated malignancies in sub-Saharan Africa and is often diagnosed at advanced stage of disease. Only 50% of KS patients who qualify for chemotherapy receive it and adherence is sub-optimal. Methods 57 patients > 18 years with newly diagnosed KS within the AMPATH clinic network in Western Kenya were purposively selected to participate in semi-structured interviews stratified by whether they had completed, partially completed, or not completed chemotherapy for advanced stage KS. We based the interview guide and coding framework on the situated Information, Motivation, Behavioral Skills (sIMB) framework, in which the core patient centered IMB constructs are situated into the socioecological context of receiving care. Results Of the 57 participants, the median age was 37 (IQR 32–41) and the majority were male (68%). Notable barriers to chemotherapy initiation and adherence included lack of financial means, difficulty with convenience of appointments such as distance to facility, appointment times, long lines, limited appointments, intrapersonal barriers such as fear or hopelessness, and lack of proper or sufficient information about chemotherapy. Factors that facilitated chemotherapy initiation and adherence included health literacy, motivation to treat symptoms, improvement on chemotherapy, prioritization of self-care, resilience while experiencing side effects, ability to carry out behavioral skills, obtaining national health insurance, and free chemotherapy. Conclusion Our findings about the barriers and facilitators to chemotherapy initiation and adherence for KS in Western Kenya support further work that promotes public health campaigns with reliable cancer and chemotherapy information, improves education about the chemotherapy process and side effects, increases oncology service ability, supports enrollment in national health insurance, and increases incorporation of chronic disease care into existing HIV treatment networks.

Journal of the European Academy of Dermatology and VenereologyVolume 36, Issue 1 p. e6-e9 Letter to the Editor Varicella-zoster and herpes simplex virus reactivation post-COVID-19 vaccination: a review of 40 cases in an International Dermatology Registry R.A. Fathy, R.A. Fathy Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USASearch for more papers by this authorD.E. McMahon, D.E. McMahon orcid.org/0000-0002-3649-9208 Harvard Medical School, Massachusetts General Hospital, Boston, MA, USASearch for more papers by this authorC. Lee, C. Lee Department of Dermatology, Las Vegas School of Medicine, University of Nevada, Las Vegas, NV, USASearch for more papers by this authorG.C. Chamberlin, G.C. Chamberlin Medical Practice Evaluation Center, Mongan Institute, Massachusetts General Hospital, Boston, MA, USASearch for more papers by this authorM. Rosenbach, M. Rosenbach Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USASearch for more papers by this authorJ.B. Lipoff, J.B. Lipoff Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USASearch for more papers by this authorA. Tyagi, A. Tyagi Medical Practice Evaluation Center, Mongan Institute, Massachusetts General Hospital, Boston, MA, USASearch for more papers by this authorS.R. Desai, S.R. Desai The University of Texas Southwestern Medical Center, Dallas, TX, USA Innovative Dermatology, Plano, TX, USASearch for more papers by this authorL.E. French, L.E. French Department of Dermatology, University Hospital, Munich University of Ludwig Maximilian, Munich, Germany Dr. Philip Frost, Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, USASearch for more papers by this authorH.W. Lim, H.W. Lim Department of Dermatology, Henry Ford Health System, Detroit, MI, USASearch for more papers by this authorB.H. Thiers, B.H. Thiers Department of Dermatology and Dermatologic Surgery, Medical University of SC, Charleston, SC, USASearch for more papers by this authorG.J. Hruza, G.J. Hruza Department of Dermatology, St. Louis University, St. Louis, MO, USASearch for more papers by this authorM. Fassett, M. Fassett Department of Dermatology, University of California San Francisco, San Francisco, CA, USASearch for more papers by this authorL.P. Fox, L.P. Fox Department of Dermatology, University of California San Francisco, San Francisco, CA, USASearch for more papers by this authorH.L. Greenberg, H.L. Greenberg Las Vegas Dermatology, Las Vegas, NV, USASearch for more papers by this authorK. Blumenthal, K. Blumenthal Harvard Medical School, Massachusetts General Hospital, Boston, MA, USASearch for more papers by this authorE.E. Freeman, Corresponding Author E.E. Freeman [email protected] orcid.org/0000-0001-7751-9466 Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA Medical Practice Evaluation Center, Mongan Institute, Massachusetts General Hospital, Boston, MA, USA *Correspondence: E. Freeman. E-mail: [email protected]Search for more papers by this author R.A. Fathy, R.A. Fathy Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USASearch for more papers by this authorD.E. McMahon, D.E. McMahon orcid.org/0000-0002-3649-9208 Harvard Medical School, Massachusetts General Hospital, Boston, MA, USASearch for more papers by this authorC. Lee, C. Lee Department of Dermatology, Las Vegas School of Medicine, University of Nevada, Las Vegas, NV, USASearch for more papers by this authorG.C. Chamberlin, G.C. Chamberlin Medical Practice Evaluation Center, Mongan Institute, Massachusetts General Hospital, Boston, MA, USASearch for more papers by this authorM. Rosenbach, M. Rosenbach Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USASearch for more papers by this authorJ.B. Lipoff, J.B. Lipoff Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USASearch for more papers by this authorA. Tyagi, A. Tyagi Medical Practice Evaluation Center, Mongan Institute, Massachusetts General Hospital, Boston, MA, USASearch for more papers by this authorS.R. Desai, S.R. Desai The University of Texas Southwestern Medical Center, Dallas, TX, USA Innovative Dermatology, Plano, TX, USASearch for more papers by this authorL.E. French, L.E. French Department of Dermatology, University Hospital, Munich University of Ludwig Maximilian, Munich, Germany Dr. Philip Frost, Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, USASearch for more papers by this authorH.W. Lim, H.W. Lim Department of Dermatology, Henry Ford Health System, Detroit, MI, USASearch for more papers by this authorB.H. Thiers, B.H. Thiers Department of Dermatology and Dermatologic Surgery, Medical University of SC, Charleston, SC, USASearch for more papers by this authorG.J. Hruza, G.J. Hruza Department of Dermatology, St. Louis University, St. Louis, MO, USASearch for more papers by this authorM. Fassett, M. Fassett Department of Dermatology, University of California San Francisco, San Francisco, CA, USASearch for more papers by this authorL.P. Fox, L.P. Fox Department of Dermatology, University of California San Francisco, San Francisco, CA, USASearch for more papers by this authorH.L. Greenberg, H.L. Greenberg Las Vegas Dermatology, Las Vegas, NV, USASearch for more papers by this authorK. Blumenthal, K. Blumenthal Harvard Medical School, Massachusetts General Hospital, Boston, MA, USASearch for more papers by this authorE.E. Freeman, Corresponding Author E.E. Freeman [email protected] orcid.org/0000-0001-7751-9466 Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA Medical Practice Evaluation Center, Mongan Institute, Massachusetts General Hospital, Boston, MA, USA *Correspondence: E. Freeman. E-mail: [email protected]Search for more papers by this author First published: 06 September 2021 https://doi.org/10.1111/jdv.17646Citations: 37Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat References 1McMahon DE, Amerson E, Rosenbach M et al. Cutaneous reactions reported after moderna and pfizer COVID-19 vaccination: A Registry-Based Study of 414 Cases. J Am Acad Dermatol 2021. 10.1016/j.jaad.2021.03.092 Web of Science®Google Scholar 2Dooling K, Harpaz R, Radford K et al. The clinical and laboratory diagnosis of Herpes Zoster: how good is it? Open Forum Infectious Diseases. 2016; 3( suppl_1). Oxford University Press, p. 243. 10.1093/ofid/ofw172.110 Google Scholar 3Harbecke R, Oxman MN, Arnold BA et al. A real-time PCR assay to identify and discriminate among wild-type and vaccine strains of varicella-zoster virus and herpes simplex virus in clinical specimens, and comparison with the clinical diagnoses. J Med Virol 2009; 81(7): 1310–1322. 10.1002/jmv.21506 CASPubMedWeb of Science®Google Scholar 4Rodríguez-Jiménez P, Chicharro P, Cabrera LM et al. Varicella-zoster virus reactivation after SARS-CoV-2 BNT162b2 mRNA vaccination: Report of 5 cases. J Am Acad Dermatol Case Rep 2021; 12: 58–59. Google Scholar 5Lee C, Cotter D, Basa J, Greenberg HL. Post COVID-19 vaccine related shingles cases seen at the Las Vegas dermatology clinic and sent to us via social media. J Cosmet Dermatol 2021; 20, 1960–1964. 10.1111/jocd.14210 PubMedWeb of Science®Google Scholar 6Furer V, Zisman D, Kibari A, Rimar D, Paran Y, Elkayam O. Herpes zoster following BNT162b2 mRNA COVID-19 vaccination in patients with autoimmune inflammatory rheumatic diseases: a case series. Rheumatology 2021. doi: 10.1093/rheumatology/keab345 10.1093/rheumatology/keab345 Web of Science®Google Scholar 7Alpalhão M, Filipe P. Herpes Zoster following SARS-CoV-2 vaccination–a series of 4 cases. J Eur Acad Dermatol Venereol 2021. 10.1111/jdv.17555 PubMedWeb of Science®Google Scholar 8Walter R, Hartmann K, Fleisch F, Reinhart WH, Kuhn M. Reactivation of herpesvirus infections after vaccinations? Lancet 1999; 353(9155): 810. 10.1016/S0140-6736(99)00623-6 CASPubMedWeb of Science®Google Scholar 9Blumenthal KG, Saff RR, Freeman EE. Delayed large local reactions to mRNA Vaccines. Reply. N Engl J Med 2021; 384(24): e98. 10.1056/NEJMc2104751 PubMedWeb of Science®Google Scholar 10Siddiqui MS, Hasnain N. Varicella-Zoster Virus Reactivation amid the COVID-19 pandemic-Do we need to be vigilant? A mini review. J Clin Med Kaz 2020; 6(60): 40–43. 10.23950/jcmk/9267 Google Scholar Citing Literature Volume36, Issue1January 2022Pages e6-e9 This article also appears in:JEADV COVID-19 articles ReferencesRelatedInformation

e14523 Background: Cutaneous immune-related adverse events (cirAE) may disrupt immune-checkpoint inhibitor (ICI) therapy. Current guidelines recommend systemic corticosteroids (SCS) for moderate to severe cirAE, but SCS-associated complications and their impact on survival remain poorly understood. We therefore investigated the impact of SCS exposures on infectious complications and survival outcomes among patients with cirAE. Methods: We retrospectively reviewed the medical records of patients who initiated anti-programmed death-1/ligand-1 (PD-1/PDL-1) and/or anti-cytotoxic-T-lymphocyte-4 (CTLA-4) ICI therapy between 1/1/16-3/8/19 with confirmed cirAE, obtaining oncologic history, clinical features, SCS exposures, infection rates, and survival outcomes. SCS exposures were categorized by indication (cirAE, other immune-related adverse event, other medical reason) and dosage in prednisone equivalents (low, ≤7.5mg/day for ≥2 months; moderate, > 7.5mg/day for ≥2 months; high, ≥1mg/kg/day for ≥1 week). Infection rates were compared among patients treated with SCS for initial cirAE and those with no SCS exposures for any indication. Cox proportional hazards (CPH) models adjusted for age, sex, and covariates with P <0.05 were used to assess relationships between SCS for first cirAE episode, progression-free survival (PFS) and overall survival (OS). Results: 358 patients developed cirAE (median age 64 years, 40.5% female, 41.9% melanoma). 50 (14.0%) patients received SCS for initial cirAE, 192 (53.6%) received SCS for another indication, and 116 (32.4%) had no SCS exposures. Patients who received SCS for initial cirAE had higher median rash severity (Common Terminology Criteria for Adverse Events grade 3 vs. 1, P< 0.001) and were more likely to be hospitalized for cirAE management (20.0% vs. 1.9%, P< 0.001) than those who did not receive SCS. SCS delivery for initial cirAE was predominantly at low doses (n = 42, 84.0%). Infection rates were higher in patients who received SCS for initial cirAE than those with no SCS exposures for any indication (34.0% vs. 19.8%). Most infections in both groups required systemic therapy (88.2% vs. 95.7%). In multivariate models adjusted for age, sex, and SCS exposures by indication and dosage, patients who received SCS for initial cirAE and those who did not had similar PFS (HR 0.7, CI 0.4-1.3, P= 0.287) and OS (HR 3.0, CI 0.3-35.3, P =0.380). Conclusions: We observed higher rates of infection than previously reported among both patients who did and did not receive SCS for initial cirAE. Despite the theoretical risk of SCS impeding the anti-tumor response, we found no relationship between SCS for initial cirAE and PFS/OS. Collectively, these findings suggest that with appropriate management, low-dose SCS may be safely administered for cirAE without significant impact on survival outcomes.

BACKGROUND:Cutaneous reactions after messenger RNA (mRNA)-based COVID-19 vaccines have been reported but are not well characterized. OBJECTIVE:To evaluate the morphology and timing of cutaneous reactions after mRNA COVID-19 vaccines. METHODS:A provider-facing registry-based study collected cases of cutaneous manifestations after COVID-19 vaccination. RESULTS:From December 2020 to February 2021, we recorded 414 cutaneous reactions to mRNA COVID-19 vaccines from Moderna (83%) and Pfizer (17%). Delayed large local reactions were most common, followed by local injection site reactions, urticarial eruptions, and morbilliform eruptions. Forty-three percent of patients with first-dose reactions experienced second-dose recurrence. Additional less common reactions included pernio/chilblains, cosmetic filler reactions, zoster, herpes simplex flares, and pityriasis rosea-like reactions. LIMITATIONS:Registry analysis does not measure incidence. Morphologic misclassification is possible. CONCLUSIONS:We report a spectrum of cutaneous reactions after mRNA COVID-19 vaccines. We observed some dermatologic reactions to Moderna and Pfizer vaccines that mimicked SARS-CoV-2 infection itself, such as pernio/chilblains. Most patients with first-dose reactions did not have a second-dose reaction and serious adverse events did not develop in any of the patients in the registry after the first or second dose. Our data support that cutaneous reactions to COVID-19 vaccination are generally minor and self-limited, and should not discourage vaccination.

During the COVID-19 pandemic, rapid, real-world evidence is essential for the development of knowledge and subsequent public health response. In dermatology, provider-facing and patient-facing registries focused on COVID-19 have been important sources of research and new information aimed at guiding optimal patient care. The 7 dermatology registries included in this update now include more than 8000 case reports sourced from physicians and patients from countries all over the world.