Background: Positive allergic patch-test results are generally described as erythematous papules, vesicles, or a spreading reaction with crust and ulceration. This description excludes milder reactions, including macular erythema.Objective Our aim was to investigate the prevalence and relevance of reactions graded as macular erythema at Mayo Clinic.Methods: Between January 2001 and June 2004, patients suspected of having allergic contact dermatitis were patch-tested with our institution's standard patch test, a screening series of 68 to 72 allergens. In total, 2,823 patients were patch-tested with 193,530 allergen applications. Reactions were interpreted with the North American Contact Dermatitis Group scale, including and excluding reactions graded as macular erythema. Irritant reactions were excluded from calculations. For this study, scores for current, questionable, and past relevance were combined.Results: On day 5, with the exclusion of reactions graded as irritant, 7,274 allergen applications were associated with reactions, including 3,082 (42.4%) that were graded as macular erythema. Of the macular erythema reactions, 2,430 (78.8%) were graded as relevant. The rate of reaction in our patients was 2.2% if macular erythema was excluded, 3.8% if all macular erythema reactions were included, and 3.4% if only those macular reactions deemed relevant were included.Conclusion: Patch-test reactions rated as macular erythema are common and may be of clinical relevance. For the purposes of patient education, they should not be disregarded. Consideration should be given to including these reactions when reporting patch-test results.

A 17-year-old white woman presented with a 2-year history of increasingly frequent episodes of erythromelalgia involving her hands, feet, and lower legs (Figure). She described the discomfort as “throbbing, burning, stinging.” Her symptoms occurred daily. The episodes involved her feet about 10 to 15 times during the day and involved her hands slightly less frequently. Whenever her feet got warm at night, erythromelalgia developed. These episodes were extremely painful. Generally, the erythema and pain occurred independently in the hands and feet. The symptoms were precipitated in her hands and feet by exercise; for example, walking precipitated the symptoms in her feet and legs, and writing precipitated them in her hands. Occasionally, the symptoms occurred when she was at rest, and they occasionally were worse at night. The symptoms lasted from minutes to up to 2 hours. She relieved the symptoms by cooling the affected area with ice and by raising the symptomatic limbs above the level of her heart. At night, she would stick her feet out of bed to relieve the symptoms and, during warm weather, used a fan.

BACKGROUND:Confluent and reticulate papillomatosis (CRP) (Gougerot-Carteaud syndrome) is a disorder that has been characterized in only small cohorts of patients.OBJECTIVES:Better to characterize the clinical and pathological findings of the disorder.METHODS:We retrospectively reviewed the clinical presentation, response to treatment and histological findings of patients presenting to Mayo Clinic (Rochester, MN, U.S.A.) with CRP.RESULTS:The disorder was diagnosed in 39 patients between 1972 and 2003. Mean age at onset of the skin eruption was 15 years (range 8-32); 21 patients (54%) were male; most were white; most (33) presented for reasons of cosmesis; and eight described the rash as mildly pruritic. At presentation, the skin eruption had been present for a mean of 3.1 years (range 3 months-20 years) and had been recalcitrant to treatment, including antifungal treatment. Typical objective findings were scaling brown macules and patches and velvety papules and plaques, reticulated and papillomatous at least in part, involving the upper trunk, axillae and neck. The most frequent initial diagnostic impressions were tinea versicolor, acanthosis nigricans and CRP. Scales in 32 cases were examined with potassium hydroxide: eight (25%) showed hyphae, and 24 (75%) did not. Skin biopsy specimens from 21 patients showed variable degrees of hyperkeratosis, acanthosis and papillomatosis. Minocycline was prescribed for 22 patients, of whom 14 of 18 (78%) had complete clearing of the skin eruption and four (22%) a partial response. The skin eruptions recurred after stopping treatment in six patients.CONCLUSIONS:CRP occurs predominantly in young adults and teenagers, with cosmetically displeasing brown scaling patches and plaques affecting the neck, upper trunk and axillae. Frequently, the diagnosis is delayed and the disorder not recognized by physicians, including dermatologists. Clinically, the eruption is most often confused with tinea versicolor. Potassium hydroxide staining of the scale is negative in the majority of cases, implying that fungi are not involved in the pathogenesis of this condition, as has been previously proposed. It is important to recognize this disorder, because minocycline therapy is highly effective in most patients. Criteria for the diagnosis are proposed.

Bexarotene is a retinoid drug that is approved for the treatment of cutaneous T-cell lymphoma. We report 6 cases in which the initiation of bexarotene therapy for cutaneous T-cell lymphoma was temporally associated with the progression of internal disease despite improvement in cutaneous signs and symptoms. It is possible that bexarotene contributed to this progression. Although bexarotene therapy may alleviate symptoms and signs of cutaneous T-cell lymphoma, careful surveillance of lymph nodes and solid organs during treatment is advised.

Disabling pansclerotic morphea involves all layers of the skin, extending through the dermis and subcutaneous tissues to involve muscle, tendon, and bone. It is distinguished from generalized scleroderma by its lack of systemic involvement. Onset usually occurs before the age of 14 years. We describe adulton-set disabling pansclerotic morphea in two previously healthy young men. In both cases, the onset of disease was explosive, with rapid progression, widespread cutaneous involvement, and severe disablement caused by mutilating contracture deformities. Increased susceptibility of sclerodermatous tissue to recalcitrant ulceration and malignant transformation with development of nonmelanoma skin cancers was also observed. Treatment of this disease continues to present a therapeutic dilemma with only sporadic remission despite multimodality therapy.

Department of Dermatology Mayo Clinic and Mayo Foundation Rochester, MN The authors thank Sara A. Farmer, Division of Biostatistics, Mayo Clinic, for assistance with the statistics in this article. Reprints not available.

OBJECTIVE To examine retrospectively the use and effectiveness of intravenous immunoglobulin (IVIg) treatment of various skin diseases, primarily immunobullous disease. PATIENTS AND METHODS We identified patients who had received IVIg therapy for skin disease between 1996 and 2003 at the Mayo Clinic in Rochester, Minn, Scottsdale, Ariz, and Jacksonville, Fla, and retrospectively reviewed their medical records. RESULTS Eighteen patients were treated with IVIg for various skin diseases: immunobullous disease in 11 adults (pemphigus vulgaris [7 patients], bullous pemphigoid [3], and cicatricial pemphigoid [1]); dermatomyositis (2); mixed connective tissue disease (1); chronic urticaria (1); scleromyxedema (1); leukocytoclastic vasculitis (1); and linear IgA bullous disease (1). Responses of patients by type of disease were as follows: pemphigus vulgaris, 1 partial response (PR) and 6 no response (NR); bullous pemphigoid, 1 complete response (CR) and 2 NR; cicatricial pemphigoid, 1 NR; dermatomyositis, 1 CR and 1 PR; mixed connective tissue disease, 1 CR; chronic urticaria, 1 CR; scleromyxedema, 1 CR; leukocytoclastic vasculitis, 1 PR; and linear IgA bullous disease, 1 CR. Six patients (33%) experienced CR, 3 (17%) had PR, and 9 (50%) had NR to IVIg therapy. All 9 nonresponders were adult patients with immunobullous disease. CONCLUSION Although this was a retrospective study of a small cohort of a mixture of patients, the findings emphasize that our experience with IVIg treatment for skin disease, particularly immunobullous disease, is less favorable than that reported previously. Further studies are needed to verify the efficacy of IVIg for skin disease. To examine retrospectively the use and effectiveness of intravenous immunoglobulin (IVIg) treatment of various skin diseases, primarily immunobullous disease. We identified patients who had received IVIg therapy for skin disease between 1996 and 2003 at the Mayo Clinic in Rochester, Minn, Scottsdale, Ariz, and Jacksonville, Fla, and retrospectively reviewed their medical records. Eighteen patients were treated with IVIg for various skin diseases: immunobullous disease in 11 adults (pemphigus vulgaris [7 patients], bullous pemphigoid [3], and cicatricial pemphigoid [1]); dermatomyositis (2); mixed connective tissue disease (1); chronic urticaria (1); scleromyxedema (1); leukocytoclastic vasculitis (1); and linear IgA bullous disease (1). Responses of patients by type of disease were as follows: pemphigus vulgaris, 1 partial response (PR) and 6 no response (NR); bullous pemphigoid, 1 complete response (CR) and 2 NR; cicatricial pemphigoid, 1 NR; dermatomyositis, 1 CR and 1 PR; mixed connective tissue disease, 1 CR; chronic urticaria, 1 CR; scleromyxedema, 1 CR; leukocytoclastic vasculitis, 1 PR; and linear IgA bullous disease, 1 CR. Six patients (33%) experienced CR, 3 (17%) had PR, and 9 (50%) had NR to IVIg therapy. All 9 nonresponders were adult patients with immunobullous disease. Although this was a retrospective study of a small cohort of a mixture of patients, the findings emphasize that our experience with IVIg treatment for skin disease, particularly immunobullous disease, is less favorable than that reported previously. Further studies are needed to verify the efficacy of IVIg for skin disease.

The authors reviewed 22 patients who received living skin equivalent (LSE) (Apligraf(R), Organogenesis, Inc., Canton, Massachusetts) over 20 months in whom conventional therapy had failed. Ten patients had chronic venous insufficiency, and six patients had ulcers caused by venous stasis, diabetes mellitus, and arterial insufficiency. The remaining ulcers were attributed to connective tissue disease, trauma, radiation, cryoglobulinemia, and necrobiotic xanthogranuloma. Eight patients were diabetic. The mean duration of ulceration before LSE placement was 15 months. The mean ulcer size was 48mm. Patients were followed up weekly for eight weeks and then monthly for at least 22 months. Fourteen patients healed completely; treatment failed in eight.

Becaplermin (Regranex; McNeil Pharmaceuticals, Raritan, NJ) may be a new treatment option for patients with chronic wounds. The goal of this study was to review our experience with becaplermin gel and to determine if becaplermin gel has utility in the treatment of chronic lower extremity ulcers, including diabetic neuropathic ulcers,1Steed D.L. Clinical evaluation of recombinant human platelet-derived growth factor for the treatment of lower extremity diabetic ulcers Diabetic Ulcer Study Group.J Vasc Surg. 1995; 21: 71-78Abstract Full Text Full Text PDF PubMed Scopus (506) Google Scholar, 2Steed D.L. Donohoe D. Webster M.W. Lindsley L. Effect of extensive débridement and treatment on the healing of diabetic foot ulcers Diabetic Ulcer Study Group.J Am Coll Surg. 1996; 183: 61-64PubMed Google Scholar the only labeled indication approved by the US Food and Drug Administration.With Mayo Foundation Institutional Review Board approval, we retrospectively analyzed our initial results of becaplermin use to treat refractory lower extremity ulcers present for longer than 3 months. We compared the characteristics of ulcers that healed with those that did not. We paid particular attention to the etiology, duration, and size of the wound before becaplermin gel applications and the time needed for healing. Although some patients had multiple ulcers, a single target ulcer was selected for follow-up on each patient.All patients received ulcer care consisting of initial complete sharp débridement, a non-weight-bearing regimen, systemic treatment of wound-related infection if present, application of saline-moistened dressings, and additional debridement as necessary. All patients had been treated at the wound care center at Mayo Clinic for their ulcerations before initiation of becaplermin gel. In addition, numerous other approaches to healing their wounds had been tried as appropriate to each ulceration, including antiseptic solutions, topical collagen, gauze dressings, antibiotics, silver dressings, circulator boots, absorbent antimicrobial dressings, whirlpool baths, and foam dressings.Becaplermin gel 0.01% was applied once a day and covered with a saline-moistened dressing. After approximately 12 hours, the gel was rinsed off, and a saline-moistened dressing was applied for the remainder of the day. Patients were treated until complete healing occurred or for up to 20 weeks.Twenty-one patients (14 women) with 21 target chronic lower extremity ulcers received becaplermin gel. The mean patient age was 60 years (range, 39-92 years). Patients had wounds attributable to various causes (Table I), and the ulcers were on the foot or ankle (16) or leg (5). Of the neuropathic ulcerations, 5 of 6 were ascribed to diabetes. All ulcers had been present for at least 3 months before initiation of becaplermin gel treatment (mean, 7.4 months), were refractory to previous treatment (18 ulcers had between 1 and 6 different types of treatment without healing), and were large (mean ± standard deviation [SD] diameter, 336.23 ± 311.05 mm).Table I%Causes and response of ulcers treated with becaplerminPathogenic factorNo. of patientsNo. of ulcers 100% healedNo. of ulcers healed >50%No. of ulcers healed >30%Venous1000Lipodermatosclerosis1111Neurotrophic6355Multifactorial (mixed arterial and venous)13101213 Open table in a new tab Fourteen ulcers healed completely. The mean ± SD time to complete healing was 111.1 ± 81.5 days. Of the 7 ulcers that did not heal, the area of ulceration was reduced by more than 50% in 4 (mean ± SD time, 126.0 ± 40.2 days) and by 37% in 1; in 2 the area of the ulcers enlarged during treatment. No adverse effects of the treatment were noted.Our results suggest that becaplermin may be used as adjunctive therapy for patients who have refractory, atypical lower extremity ulcers of varying pathogenesis. The ulcers were large and of long duration, generally poor prognostic factors for healing.3Margolis D.J. Berlin J.A. Strom B.L. Which venous leg ulcers will heal with limb compression bandages?.Am J Med. 2000; 109: 15-19Abstract Full Text Full Text PDF PubMed Scopus (177) Google Scholar Could the high rate of healing—67% in less than 4 months—be attributable wholly to use of becaplermin? A number of obstacles limit such a conclusion. The number of ulcers studied was small, and the study was retrospective. Also, the patients received intensive instruction and care at the wound care center; this factor alone may increase the rate of healing. Comparing characteristics of wounds that healed with those of wounds that did not heal after becaplermin use, we found no particular factors that predicted healing. Becaplermin (Regranex; McNeil Pharmaceuticals, Raritan, NJ) may be a new treatment option for patients with chronic wounds. The goal of this study was to review our experience with becaplermin gel and to determine if becaplermin gel has utility in the treatment of chronic lower extremity ulcers, including diabetic neuropathic ulcers,1Steed D.L. Clinical evaluation of recombinant human platelet-derived growth factor for the treatment of lower extremity diabetic ulcers Diabetic Ulcer Study Group.J Vasc Surg. 1995; 21: 71-78Abstract Full Text Full Text PDF PubMed Scopus (506) Google Scholar, 2Steed D.L. Donohoe D. Webster M.W. Lindsley L. Effect of extensive débridement and treatment on the healing of diabetic foot ulcers Diabetic Ulcer Study Group.J Am Coll Surg. 1996; 183: 61-64PubMed Google Scholar the only labeled indication approved by the US Food and Drug Administration. With Mayo Foundation Institutional Review Board approval, we retrospectively analyzed our initial results of becaplermin use to treat refractory lower extremity ulcers present for longer than 3 months. We compared the characteristics of ulcers that healed with those that did not. We paid particular attention to the etiology, duration, and size of the wound before becaplermin gel applications and the time needed for healing. Although some patients had multiple ulcers, a single target ulcer was selected for follow-up on each patient. All patients received ulcer care consisting of initial complete sharp débridement, a non-weight-bearing regimen, systemic treatment of wound-related infection if present, application of saline-moistened dressings, and additional debridement as necessary. All patients had been treated at the wound care center at Mayo Clinic for their ulcerations before initiation of becaplermin gel. In addition, numerous other approaches to healing their wounds had been tried as appropriate to each ulceration, including antiseptic solutions, topical collagen, gauze dressings, antibiotics, silver dressings, circulator boots, absorbent antimicrobial dressings, whirlpool baths, and foam dressings. Becaplermin gel 0.01% was applied once a day and covered with a saline-moistened dressing. After approximately 12 hours, the gel was rinsed off, and a saline-moistened dressing was applied for the remainder of the day. Patients were treated until complete healing occurred or for up to 20 weeks. Twenty-one patients (14 women) with 21 target chronic lower extremity ulcers received becaplermin gel. The mean patient age was 60 years (range, 39-92 years). Patients had wounds attributable to various causes (Table I), and the ulcers were on the foot or ankle (16) or leg (5). Of the neuropathic ulcerations, 5 of 6 were ascribed to diabetes. All ulcers had been present for at least 3 months before initiation of becaplermin gel treatment (mean, 7.4 months), were refractory to previous treatment (18 ulcers had between 1 and 6 different types of treatment without healing), and were large (mean ± standard deviation [SD] diameter, 336.23 ± 311.05 mm). Fourteen ulcers healed completely. The mean ± SD time to complete healing was 111.1 ± 81.5 days. Of the 7 ulcers that did not heal, the area of ulceration was reduced by more than 50% in 4 (mean ± SD time, 126.0 ± 40.2 days) and by 37% in 1; in 2 the area of the ulcers enlarged during treatment. No adverse effects of the treatment were noted. Our results suggest that becaplermin may be used as adjunctive therapy for patients who have refractory, atypical lower extremity ulcers of varying pathogenesis. The ulcers were large and of long duration, generally poor prognostic factors for healing.3Margolis D.J. Berlin J.A. Strom B.L. Which venous leg ulcers will heal with limb compression bandages?.Am J Med. 2000; 109: 15-19Abstract Full Text Full Text PDF PubMed Scopus (177) Google Scholar Could the high rate of healing—67% in less than 4 months—be attributable wholly to use of becaplermin? A number of obstacles limit such a conclusion. The number of ulcers studied was small, and the study was retrospective. Also, the patients received intensive instruction and care at the wound care center; this factor alone may increase the rate of healing. Comparing characteristics of wounds that healed with those of wounds that did not heal after becaplermin use, we found no particular factors that predicted healing.

A 17-month-old girl was brought by her parents and grandparents for a further opinion regarding her 3-month history of an itching skin eruption, thinning of scalp hair with hair “falling out in clumps,” swelling of her extremities, and lack of weight gain. One year earlier, her rate of growth slowed and reached progressively lower percentiles on a normal growth curve. Although she had started walking at 10 months of age, she stopped in the previous 3 months and was unsteady on her feet. She had a history of chronic atopic dermatitis managed with topical corticosteroids, emollients, and topical 0.1% tacrolimus, previously with reasonable control. Four months earlier, her dermatologist had performed radioallergosorbent testing (RAST), which showed positive results for multiple foods including green beans, strawberries, wheat, green peas, milk, eggs, beef, chicken, potatoes, barley, corn, rice, oranges, and soybeans. On physical examination her height was 70.5 cm and her weight 7.5 kg. These values were less than the third percentile for her age group. She had widespread discrete and confluent patches and plaques with mild flaking paintlike scaling most prominent on the extensor surfaces (Figure 1). Follicular papules were present on the upper and lower extremities and there was mild pitting edema of the lower extremities. The scalp showed diffuse sparse thinned hairs and diffuse yellow scaling. (Figure 2A). The scalp hairs had hypopigmented roots suggestive of an early flag sign (Figure 2B). Laboratory studies demonstrated marked anemia, protein deficiency, and abnormal liver test results. The child’s hemoglobin concentration was 7.8 g/dL (reference range, 10.5-13.5 g/dL), with a hematocrit of 23% (reference range, 33%-40%). Her total serum protein was 3.5 g/dL (reference range, 6.3-7.9 g/dL), with an albumin value of 1.2 g/dL (reference range, 3.5-5.0 g/dL) and a prealbumin value of 10 mg/dL (reference range, 19-38 mg/dL). Her serum levels of alkaline phosphatase and biotinidase were normal at 469 U/L (reference range, 368809 U/L) and 6.8 U/L (reference range, 3.5-13.8 U/L), respectively, but her levels of aspartate aminotransferase and alanine aminotransferase were 54 U/L (reference range, 26-48 U/L) and 54 U/L (reference range, 9-29 U/L), respectively. Serum amino acid screening revealed low levels of virtually all amino acids and her zinc level was low, at 0.27 μg/mL (reference range, 0.66-1.10 μg/mL). Her bone age was estimated to be 71⁄2 months, which represented a considerable delay in maturation. A genetics consultation suggested that the likelihood of B A

Background The infant mortality rate is higher in sub-Saharan Africa than in other developing regions. The purpose of this study was to evaluate the association of sexually transmitted diseases (STDs) and socioeconomic and obstetric factors with perinatal mortality in rural Ghana.Methods Perinatal mortality data were collected from 154 patient records of the outpatient and inpatient gynecology department of a rural Ghanaian setting in 1997. All women attended the antenatal care unit of the hospital at least once before delivery, where they were screened for common STDs, including syphilis, gonorrhea, and trichomoniasis. Patients' socioeconomic characteristics and previous obstetric complications were recorded.Results The rate of perinatal mortality at the Holy Family Hospital in the Berekum district of Ghana was 13.7% in 1997 (154 of 1123 documented births). Characteristics of mothers whose infants died in the perinatal period and who had attended antenatal care at least once were as follows: prior obstetric complications, 108 patients (70.1%); average age, 25 years (range: 16-42 years); average number of previous sexual partners, three; prevalence of STDs, including gonorrhea, trichomoniasis, or syphilis, 83 patients (53.8%); history of other chronic diseases, 13 patients (8.5%); and illiteracy, 66 patients (42.8%). The number of previous sexual partners and illiteracy were higher in the STD-positive women.Conclusions Sexually transmitted diseases and previous obstetric complications seemed to contribute considerably to perinatal mortality in rural Ghana.

Urticarial vasculitis is a clinicopathologic entity in which episodes of urticaria are accompanied by histopathologic features of cutaneous vasculitis. The histopathologic definition of vasculitis varies from report to report. In this article, vasculitis is defined as histopathologic features of blood vessel damage: There should be evidence of leukocytoclasis and vessel wall destruction, which may or may not be accompanied by fibrinoid deposits. Red blood cell extravasation and perivascular inflammatory cell infiltrate also may be present. The extent to which each of these elements must be present has been debated.

BACKGROUND:Topical tacrolimus has been reported to be an effective treatment for genital lichen planus in small case series. We retrospectively reviewed the medical records of 16 patients with symptomatic vulvar lichen planus who received treatment with tacrolimus ointment.OBSERVATIONS:All patients had symptomatic vulvar lichen planus recalcitrant to other treatments. Of 16 patients, 15 (94%) experienced a symptomatic response to tacrolimus treatment within 3 months (mean, 4.2 weeks) and had a partial or complete resolution of the lesions. Six patients (38%) reported mild adverse effects, including irritation, burning, and tingling. With continued use of the medication, these adverse effects resolved. When patients stopped treatment, lichen planus returned in 10 (83%) of 12 patients within 6 months after discontinuation of therapy (median, 1 week; range, 0.3-24 weeks), but in 6 patients the lesions were less severe than the lesions before treatment; all 10 patients resumed use of topical tacrolimus.CONCLUSIONS:In this retrospective series of 16 women with vulvar lichen planus, topical tacrolimus therapy effectively controlled symptoms and improved lesions in all but 1 patient. The effect may be temporary, requiring continued use of tacrolimus, which appears to be safe and effective in controlling disease activity.

Cutaneous infection with Paecilomyces lilacinus is encountered worldwide, with most infections occurring either iatrogenically or in immunocompromised hosts. We report three cases of cutaneous hyalohyphomycosis caused by P. lilacinus, one of which occurred in an immunocompetent individual. In addition, we review the 17 cases previously reported in the literature. Although this infection can be difficult to treat, most cases are not fatal. Most cases responded well to systemic azole antifungal agents, either alone or in association with surgical excision of the lesion. Paecilomyces species are saprophytic fungi found in soil and decaying organic matter. Infection in humans is rare, but when it occurs treatment is often difficult. We report three cases of cutaneous hyalohyphomycosis caused by P. lilacinus and review the 17 previously reported cases in which the clinical history and response to therapy were described.