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Dermatologic Adverse Events of Cancer Therapy

Key Points Dermatologic adverse events (AEs) of cancer therapies can cause patient discomfort and impair their quality of life, increase the cost of medical care, and even result in dose modifications, all of which can negatively impact clinical outcomes. The traditional cytotoxic chemotherapies are commonly associated with dermatologic AEs such as alopecia, hypersensitivity reactions, xerosis, skin hyperpigmentation, nail changes, and hand-foot syndrome (HFS). Targeted therapies encompass…

Skin Signs of Internal Malignancy

Key Points Curth’s postulates provide a group of criteria that are helpful to determine whether a skin condition is likely to be related to an internal malignancy. Individual paraneoplastic skin conditions tend to be associated more frequently with certain types of cancer (e.g., Bazex syndrome and upper aerodigestive cancer). The pathogenesis of many paraneoplastic skin conditions remains unclear. Tumor-secreting hormones, paracrine factors, and the immune response…

Bullous Diseases

Key Points Immunobullous diseases are a complicated multisystem management challenge requiring advanced immunosuppressive regimens. Pathogenesis has been linked to disease-specific autoantibodies to structural antigens within the epidermis and basement membrane zone. The location of blistering, risk of subsequent scarring, and degree of systemic involvement depend upon the type and distribution of antigen targeted. Clinical presentation, histologic findings, and immunofluorescence studies (both indirect and direct) are the…

Purpura

Key Points Purpura has an extended and complex differential diagnosis, but can be sorted into three main pathophysiologies: simple hemorrhage, inflammatory (vessel-directed) hemorrhage, and microvascular occlusion. Recognition of patterns of morphology, number and distribution can rapidly narrow the diagnostic possibilities enabling a focused and efficient work-up to confirm the diagnosis. The differential diagnosis of cutaneous microvascular occlusion only minimally overlaps with traditional differential diagnosis of deep…

Erythroderma

Key Points Erythroderma is erythema, with or without scaling, involving more than 90% of the cutaneous surface. Many cases of erythroderma are idiopathic, but the most common causes are exacerbation of an underlying skin disease, a drug hypersensitivity reaction, and cutaneous T-cell lymphoma. Although pathology can be nonspecific, a biopsy should typically be performed because it may give clues to the underlying diagnosis. Hospitalization may be…

Pruritus

Key Points Chronic itch can occur without primary skin rash associated with underlying systemic diseases. Itch can be the presenting symptom of lymphoma and hepatic diseases. Chronic systemic itch is associated with imbalance of μ versus κ opioids. Topical antipruritic treatments include local anesthetics, coolants, emollients, and topical immunomodulators. Systemic antipruritic treatments include drugs that are used for neuropathic pain, such as gabapentin, pregabalin, selective serotonin…

Panniculitis

Key Points The panniculitides comprise a heterogeneous group of inflammatory diseases that involve the subcutaneous fat. Various panniculitides may show the same clinical appearance, consisting of erythematous nodules, which frequently makes histopathologic study necessary in order to obtain the specific diagnosis. In patients presenting with panniculitis, performing an excisional biopsy that incorporates at least a fat lobule and its surrounding connective tissue septa is crucial in…

Erythema Multiforme, Stevens–Johnson Syndrome, and Toxic Epidermal Necrolysis

Key Points Herpes simplex virus infection is a frequent cause of erythema multiforme, while drugs most often cause Stevens–Johnson syndrome and toxic epidermal necrolysis. Erythema multiforme is often self-limited, skin lesions often target-appearing, and mucosal lesions can occur in the absence of skin lesions. Stevens–Johnson syndrome patients have systemic illness with prominent mucosal involvement and may have skin sloughing. Toxic epidermal necrolysis patients have systemic illness…

Urticaria

Key Points Urticaria is characterized by development of wheals and/or angioedema of the skin or mucosa. Individual lesions have a transient nature lasting less than 24 hours. Infection, drugs, chemicals, foods, inhalants, contactants, and physical stimuli are several recognizable triggers of urticaria. Urticaria can also be associated with endocrinopathies, autoimmune connective tissue diseases, and malignancies. However, in many cases, the cause of urticaria can remain unexplained…

Eosinophil-Associated Diseases with Dermatologic Manifestations

Key Points Peripheral blood eosinophilia provides clues to diagnosis, but it is not a diagnostic marker except when levels of peripheral blood eosinophils are in the “hypereosinophilic” range as found in the hypereosinophilic syndromes. Many diseases with increased peripheral blood eosinophils have accompanying tissue eosinophil infiltration, including skin, often with degranulation and loss of morphological identity of infiltrating eosinophils. Eosinophils are observed in biopsy specimens of…

Autoinflammatory Syndromes

Key Points Autoinflammatory syndromes are characterized by excessive multisystem inflammation from activation of innate pathways rather than the acquired immune system. Autoinflammatory syndromes are mostly rare monogenic disorders that generally first present in childhood. Most of these diseases are, at least in part, modulated by the interleukin-1 pathway, which has provided targeted treatment strategies. Tumor necrosis factor-alpha antagonists have also proved useful agents for these diseases.…

Other Rheumatologic–Dermatologic Conditions

Key Points Rheumatoid arthritis (RA) is a multisystem disorder with many extra-articular manifestations that may affect the skin, including rheumatoid nodules and rheumatoid vasculitis. Rheumatoid nodules are the most characteristic cutaneous manifestation of RA. They, along with other extra-articular manifestations, are most common among seropositive RA patients. Systemic-onset juvenile idiopathic arthritis and adult-onset Still’s disease are diagnoses of exclusion that are characterized by intermittent fevers with…

Psoriasis and Systemic Disease

Key Points Psoriasis is common, affecting over 125 million worldwide. Comorbidities include diabetes, hypertension, dyslipidemia, obesity, myocardial infarction, stroke, cardiovascular death, lymphoma, autoimmune disorders, and renal disease. TNF signaling and the IL-23/Th17 pathways are critical in the pathogenesis of psoriasis, and effective therapies interfere with these pathways. Treatment with systemic therapy may improve risk for cardiovascular disease. About one-third of psoriasis patients may develop psoriatic arthritis,…

Neutrophilic Dermatoses

Key Points Neutrophilic dermatoses encompass a spectrum of diseases marked by cutaneous lesions that on histopathologic examination show intense inflammation composed primarily of mature neutrophils. Behçet’s disease is a neutrophilic dermatosis characterized by an immune-mediated occlusive vasculitis of small, medium, and large blood vessels that is associated with a wide range of cutaneous and systemic findings. Sweet’s syndrome is typified by a cutaneous infiltrate of dermal…

Vasculitis

Key Points Vasculitic processes may be idiopathic or associated with infections, drugs, malignancies, or connective tissue diseases. Drugs and infections are the most common underlying etiologies in adults with cutaneous vasculitis (CV). IgA vasculitis (Henoch-Schönlein purpura) is the most frequent vasculitic condition associated with CV in children. Clinical manifestations depend on the localization and size of the involved vessel. Although the Chapel Hill Consensus Conference has…

Scleroderma, Raynaud’s Phenomenon, and Related Conditions

Key Points The range of conditions presenting as “hard skin” is broad, including those diseases that cause cutaneous sclerosis (increased connective tissue with normal or decreased fibroblasts) and those that cause cutaneous fibrosis (increased connective tissue and increased fibroblasts). The clinical differential diagnosis of “hard skin” can be divided into two main categories: morphea and morphea-like conditions and systemic sclerosis and sclerodermoid conditions. Patients with morphea…

Dermatomyositis

Key Points Classic dermatomyositis involves a proximal inflammatory myopathy with a characteristic cutaneous eruption. In patients with clinically amyopathic dermatomyositis, skin disease is the prominent feature. Pathognomonic cutaneous findings of dermatomyositis include the heliotrope eruption and Gottron’s papules. In dermatomyositis, cutaneous disease is photoexacerbated. All adult patients with dermatomyositis require screening for malignancy and pulmonary disease, regardless of whether they have muscle involvement. Juvenile dermatomyositis is…

Lupus Erythematosus

Key Points Lupus erythematosus is a multisystem disorder that frequently has cutaneous involvement Lupus-specific skin disease can be characterized as acute, subacute, or chronic based on clinical and laboratory features Other nonspecific cutaneous changes such as cutaneous vasculitis and Raynaud’s phenomenon occur more commonly in lupus patients Prevention involves protection from ultraviolet radiation and smoking cessation Topical and intralesional corticosteroids and other topical immunomodulators may be…

Future Cosmeceuticals of Dermatologic Importance

Summary and Key Features Cosmeceuticals that inhibit tyrosinase activity, including polyphenols and genistein reduce pigmentation. Combinations of multiple growth factors and cytokines in single products have the most beneficial effect. More research is needed on the systemic effects of nanoparticles. Key therapies in cosmeceuticals aim to replace what the skin loses with age meanwhile attempting to enhance the body’s endogenous production of these materials. Many cosmeceuticals…