The rate of surgical site infections in colectomy patients decreased as hospitals implemented three specific care measures promoted by the Michigan Surgical Quality Collaborative, according to a study funded by the Blue Cross Blue Shield of Michigan.

With surgical site infections (SSIs) after colectomy associated with high morbidity as the second leading hospital acquired infection, and costing the health care system approximately $315 million annually, investment in this quality improvement program could ease a tremendous burden, according to Joceline V. Vu, MD, general surgery resident at the University of Michigan, Ann Arbor, and fellow investigators. The study was published in the Journal of the American College of Surgeons (2018 Jan;226[1]:91-99).

The study cohort included 5,742 colectomy patients at 1 of 52 hospitals associated with the Michigan Surgical Quality Collaborative (MSQC) between 2012 and 2016. Investigators assessed the use of the MSQC-recommended care bundle – cefazolin/metronidazole, oral antibiotics with mechanical bowel preparation, and postoperative day-1 glucose less than or equal to 140 mg/dL – and the impact of the bundle components on surgical site infection (SSI).

Patients were also split into groups based on the use of perioperative treatments previously found to be associated with SSI improvement, which included the three treatments in the care bundle as well as postoperative normothermia, minimally invasive surgery, and operative duration defined as either less than or greater than 100 minutes.

Those who had received these perioperative measures were given one point for each measure received.

Of the total, 8.1% of patients received 0-1 point, 22.2% received 2 points, 31.7% received 3 points, 27.2% received 4 points, and 10.7% received 5-6 points.

Patients were split relatively evenly between male and female, and the majority of patients were white across all six SSI perioperative groups.

Patients with 0-1 point were more likely to be older than 65 years (56.4%), while those who received 5-6 points were more likely to be between 45 and 64 years old (45.6% [P less than .001]).

Hospitals increased the use of three of the promoted processes (cefazolin/metronidazole, oral antibiotics with mechanical bowel preparation, and normoglycemia) during 2012-2016, and average use scores for patients went from 1.1 to 1.5 (P less than .001), according to investigators. As the rate of cefazolin/metronidazole and oral antibiotics with mechanical bowel preparation use rose from 18.6% and 42.9%, respectively, to 32.3% and 62.0% (P less than .001), SSI rates fell from 6.7% to 3.9% (P = .012) during the same period. The change in the normoglycemia rate (48.9% to 57.7%) was not significant (P = .112).

Hospitals that used all six recommended items saw a slightly decreased rate of SSI (r = –.39) between 2012 and 2016, according to Dr. Vu and her colleagues. Patients who received more measures had lower rates of complications, with SSI rates at 5.7% for those with 0-1 point, compared with 1.1% in those with 5-6 (P less than .001).

Rates of sepsis, pneumonia, emergency department visits, readmission, reoperation, and morbidity were also significantly lower.

“The MSQC and other collaborative quality improvement organizations represent a step toward this vision [of a learning health care system],” according to Dr. Vu and her colleagues. “Collaborating organizations can identify problems in care, adopt practice changes, and analyze the effect of those changes in a timely fashion.”

The findings of this study may be limited by a selection bias of how many bundle procedures a patient received based on comorbidities such as chronic obstructive pulmonary disease, hypertension, and obesity, which were all higher among those with fewer points. Investigators were also unable to discern causality of certain results because of the observational nature of the study. Hospitals included in the cohort volunteered to use the MSQC infrastructure, which may have limited the generalizability of the study,

Investigators reported no relevant financial disclosures. The study was funded by the Blue Cross Blue Shield of Michigan.

[email protected]

SOURCE: Vu, J V et al. J Am Coll Surg. 2018 Jan;226(1):91-9.

The rate of surgical site infections in colectomy patients decreased as hospitals implemented three specific care measures promoted by the Michigan Surgical Quality Collaborative, according to a study funded by the Blue Cross Blue Shield of Michigan.

With surgical site infections (SSIs) after colectomy associated with high morbidity as the second leading hospital acquired infection, and costing the health care system approximately $315 million annually, investment in this quality improvement program could ease a tremendous burden, according to Joceline V. Vu, MD, general surgery resident at the University of Michigan, Ann Arbor, and fellow investigators. The study was published in the Journal of the American College of Surgeons (2018 Jan;226[1]:91-99).

The study cohort included 5,742 colectomy patients at 1 of 52 hospitals associated with the Michigan Surgical Quality Collaborative (MSQC) between 2012 and 2016. Investigators assessed the use of the MSQC-recommended care bundle – cefazolin/metronidazole, oral antibiotics with mechanical bowel preparation, and postoperative day-1 glucose less than or equal to 140 mg/dL – and the impact of the bundle components on surgical site infection (SSI).

Patients were also split into groups based on the use of perioperative treatments previously found to be associated with SSI improvement, which included the three treatments in the care bundle as well as postoperative normothermia, minimally invasive surgery, and operative duration defined as either less than or greater than 100 minutes.

Those who had received these perioperative measures were given one point for each measure received.

Of the total, 8.1% of patients received 0-1 point, 22.2% received 2 points, 31.7% received 3 points, 27.2% received 4 points, and 10.7% received 5-6 points.

Patients were split relatively evenly between male and female, and the majority of patients were white across all six SSI perioperative groups.

Patients with 0-1 point were more likely to be older than 65 years (56.4%), while those who received 5-6 points were more likely to be between 45 and 64 years old (45.6% [P less than .001]).

Hospitals increased the use of three of the promoted processes (cefazolin/metronidazole, oral antibiotics with mechanical bowel preparation, and normoglycemia) during 2012-2016, and average use scores for patients went from 1.1 to 1.5 (P less than .001), according to investigators. As the rate of cefazolin/metronidazole and oral antibiotics with mechanical bowel preparation use rose from 18.6% and 42.9%, respectively, to 32.3% and 62.0% (P less than .001), SSI rates fell from 6.7% to 3.9% (P = .012) during the same period. The change in the normoglycemia rate (48.9% to 57.7%) was not significant (P = .112).

Hospitals that used all six recommended items saw a slightly decreased rate of SSI (r = –.39) between 2012 and 2016, according to Dr. Vu and her colleagues. Patients who received more measures had lower rates of complications, with SSI rates at 5.7% for those with 0-1 point, compared with 1.1% in those with 5-6 (P less than .001).

Rates of sepsis, pneumonia, emergency department visits, readmission, reoperation, and morbidity were also significantly lower.

“The MSQC and other collaborative quality improvement organizations represent a step toward this vision [of a learning health care system],” according to Dr. Vu and her colleagues. “Collaborating organizations can identify problems in care, adopt practice changes, and analyze the effect of those changes in a timely fashion.”

The findings of this study may be limited by a selection bias of how many bundle procedures a patient received based on comorbidities such as chronic obstructive pulmonary disease, hypertension, and obesity, which were all higher among those with fewer points. Investigators were also unable to discern causality of certain results because of the observational nature of the study. Hospitals included in the cohort volunteered to use the MSQC infrastructure, which may have limited the generalizability of the study,

Investigators reported no relevant financial disclosures. The study was funded by the Blue Cross Blue Shield of Michigan.

[email protected]

SOURCE: Vu, J V et al. J Am Coll Surg. 2018 Jan;226(1):91-9.

The rate of surgical site infections in colectomy patients decreased as hospitals implemented three specific care measures promoted by the Michigan Surgical Quality Collaborative, according to a study funded by the Blue Cross Blue Shield of Michigan.

With surgical site infections (SSIs) after colectomy associated with high morbidity as the second leading hospital acquired infection, and costing the health care system approximately $315 million annually, investment in this quality improvement program could ease a tremendous burden, according to Joceline V. Vu, MD, general surgery resident at the University of Michigan, Ann Arbor, and fellow investigators. The study was published in the Journal of the American College of Surgeons (2018 Jan;226[1]:91-99).

The study cohort included 5,742 colectomy patients at 1 of 52 hospitals associated with the Michigan Surgical Quality Collaborative (MSQC) between 2012 and 2016. Investigators assessed the use of the MSQC-recommended care bundle – cefazolin/metronidazole, oral antibiotics with mechanical bowel preparation, and postoperative day-1 glucose less than or equal to 140 mg/dL – and the impact of the bundle components on surgical site infection (SSI).

Patients were also split into groups based on the use of perioperative treatments previously found to be associated with SSI improvement, which included the three treatments in the care bundle as well as postoperative normothermia, minimally invasive surgery, and operative duration defined as either less than or greater than 100 minutes.

Those who had received these perioperative measures were given one point for each measure received.

Of the total, 8.1% of patients received 0-1 point, 22.2% received 2 points, 31.7% received 3 points, 27.2% received 4 points, and 10.7% received 5-6 points.

Patients were split relatively evenly between male and female, and the majority of patients were white across all six SSI perioperative groups.

Patients with 0-1 point were more likely to be older than 65 years (56.4%), while those who received 5-6 points were more likely to be between 45 and 64 years old (45.6% [P less than .001]).

Hospitals increased the use of three of the promoted processes (cefazolin/metronidazole, oral antibiotics with mechanical bowel preparation, and normoglycemia) during 2012-2016, and average use scores for patients went from 1.1 to 1.5 (P less than .001), according to investigators. As the rate of cefazolin/metronidazole and oral antibiotics with mechanical bowel preparation use rose from 18.6% and 42.9%, respectively, to 32.3% and 62.0% (P less than .001), SSI rates fell from 6.7% to 3.9% (P = .012) during the same period. The change in the normoglycemia rate (48.9% to 57.7%) was not significant (P = .112).

Hospitals that used all six recommended items saw a slightly decreased rate of SSI (r = –.39) between 2012 and 2016, according to Dr. Vu and her colleagues. Patients who received more measures had lower rates of complications, with SSI rates at 5.7% for those with 0-1 point, compared with 1.1% in those with 5-6 (P less than .001).

Rates of sepsis, pneumonia, emergency department visits, readmission, reoperation, and morbidity were also significantly lower.

“The MSQC and other collaborative quality improvement organizations represent a step toward this vision [of a learning health care system],” according to Dr. Vu and her colleagues. “Collaborating organizations can identify problems in care, adopt practice changes, and analyze the effect of those changes in a timely fashion.”

The findings of this study may be limited by a selection bias of how many bundle procedures a patient received based on comorbidities such as chronic obstructive pulmonary disease, hypertension, and obesity, which were all higher among those with fewer points. Investigators were also unable to discern causality of certain results because of the observational nature of the study. Hospitals included in the cohort volunteered to use the MSQC infrastructure, which may have limited the generalizability of the study,

Investigators reported no relevant financial disclosures. The study was funded by the Blue Cross Blue Shield of Michigan.

[email protected]

SOURCE: Vu, J V et al. J Am Coll Surg. 2018 Jan;226(1):91-9.

Some states are facing a mid-January loss of funding for their Children’s Health Insurance Program (CHIP) despite spending approved by Congress in late December that was expected to keep the program running for 3 months, federal health officials said Jan. 5.

The $2.85 billion was supposed to fund states’ CHIP programs through March 31. But some states will start running out of money after Jan. 19, according to the Centers for Medicare & Medicaid Services. The CMS did not say which states are likely to be affected first.

The latest estimates for when federal funding runs out could cause states to soon freeze enrollment and alert parents that the program could soon shut down.

The CHIP program provides health coverage to 9 million children from lower-income households that make too much money to qualify for Medicaid. Its federal authorization ended Oct. 1, and states were then forced to use unspent funds to carry them over while the House and Senate try to agree on a way to continue funding.

Congress extended funding on Dec. 21 and touted that states would have money to last while Congress worked on a long-term funding solution. But the CMS said on Jan. 5 it could only guarantee that the appropriation will be enough to fund all states through Jan. 19.

The CMS said the agency is in discussions with states to help deal with the funding shortfall.

“The funding … should carry all the states through January 19th based upon best estimates of state expenditures to date,” said CMS spokesman Johnathan Monroe. “However, due to a number of variables relating to state expenditure rates and reporting, we are unable to say with certainty whether there is enough funding for every state to continue its CHIP program through March 31, 2018.”

“States need to know whether they will need to find additional funding for children covered under the Medicaid CHIP program at a much lower federal matching rate, send letters to families, and re-program their eligibility systems,” said Lisa Dubay, a senior fellow at the Urban Institute. “Of course, the implications for families with CHIP-eligible children cannot be understated: Parents are worried that their children will lose coverage. And they should be.”

Although the program enjoys bipartisan support on Capitol Hill, the Republican-controlled House and Senate have for months been unable to agree on how to continue funding CHIP, which began in 1997.

The House plan includes a controversial funding provision – opposed by Democrats -– that takes millions of dollars from the Affordable Care Act’s Prevention and Public Health Fund and increases Medicare premiums for some higher-earning beneficiaries.

The Senate Finance Committee reached an agreement to extend the program for 5 years but did not unite around a plan on funding.

Before the CHIP funding extension on Dec. 21, Alabama said it would freeze enrollment Jan. 1 and shut down the program Jan. 31. Colorado, Connecticut, and Virginia sent letters to CHIP families warning that the program could soon end.

After the funding extension, Alabama put a hold on shutting down CHIP.

“Some states will begin exhausting all available funding earlier than others,” a CMS official said Jan. 5. “But the exact timing of when states will exhaust their funding is a moving target.”

Bruce Lesley, president of First Focus, a child advocacy group, said Congress should have known its short-term funding plan was not enough.

“The math never worked on the patch, as it only bought a few weeks,” he said. “Congress must get this finalized before Jan. 19.”
 

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente. KHN’s coverage of children’s health care issues is supported in part by the Heising-Simons Foundation.

Some states are facing a mid-January loss of funding for their Children’s Health Insurance Program (CHIP) despite spending approved by Congress in late December that was expected to keep the program running for 3 months, federal health officials said Jan. 5.

The $2.85 billion was supposed to fund states’ CHIP programs through March 31. But some states will start running out of money after Jan. 19, according to the Centers for Medicare & Medicaid Services. The CMS did not say which states are likely to be affected first.

The latest estimates for when federal funding runs out could cause states to soon freeze enrollment and alert parents that the program could soon shut down.

The CHIP program provides health coverage to 9 million children from lower-income households that make too much money to qualify for Medicaid. Its federal authorization ended Oct. 1, and states were then forced to use unspent funds to carry them over while the House and Senate try to agree on a way to continue funding.

Congress extended funding on Dec. 21 and touted that states would have money to last while Congress worked on a long-term funding solution. But the CMS said on Jan. 5 it could only guarantee that the appropriation will be enough to fund all states through Jan. 19.

The CMS said the agency is in discussions with states to help deal with the funding shortfall.

“The funding … should carry all the states through January 19th based upon best estimates of state expenditures to date,” said CMS spokesman Johnathan Monroe. “However, due to a number of variables relating to state expenditure rates and reporting, we are unable to say with certainty whether there is enough funding for every state to continue its CHIP program through March 31, 2018.”

“States need to know whether they will need to find additional funding for children covered under the Medicaid CHIP program at a much lower federal matching rate, send letters to families, and re-program their eligibility systems,” said Lisa Dubay, a senior fellow at the Urban Institute. “Of course, the implications for families with CHIP-eligible children cannot be understated: Parents are worried that their children will lose coverage. And they should be.”

Although the program enjoys bipartisan support on Capitol Hill, the Republican-controlled House and Senate have for months been unable to agree on how to continue funding CHIP, which began in 1997.

The House plan includes a controversial funding provision – opposed by Democrats -– that takes millions of dollars from the Affordable Care Act’s Prevention and Public Health Fund and increases Medicare premiums for some higher-earning beneficiaries.

The Senate Finance Committee reached an agreement to extend the program for 5 years but did not unite around a plan on funding.

Before the CHIP funding extension on Dec. 21, Alabama said it would freeze enrollment Jan. 1 and shut down the program Jan. 31. Colorado, Connecticut, and Virginia sent letters to CHIP families warning that the program could soon end.

After the funding extension, Alabama put a hold on shutting down CHIP.

“Some states will begin exhausting all available funding earlier than others,” a CMS official said Jan. 5. “But the exact timing of when states will exhaust their funding is a moving target.”

Bruce Lesley, president of First Focus, a child advocacy group, said Congress should have known its short-term funding plan was not enough.

“The math never worked on the patch, as it only bought a few weeks,” he said. “Congress must get this finalized before Jan. 19.”
 

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente. KHN’s coverage of children’s health care issues is supported in part by the Heising-Simons Foundation.

Some states are facing a mid-January loss of funding for their Children’s Health Insurance Program (CHIP) despite spending approved by Congress in late December that was expected to keep the program running for 3 months, federal health officials said Jan. 5.

The $2.85 billion was supposed to fund states’ CHIP programs through March 31. But some states will start running out of money after Jan. 19, according to the Centers for Medicare & Medicaid Services. The CMS did not say which states are likely to be affected first.

The latest estimates for when federal funding runs out could cause states to soon freeze enrollment and alert parents that the program could soon shut down.

The CHIP program provides health coverage to 9 million children from lower-income households that make too much money to qualify for Medicaid. Its federal authorization ended Oct. 1, and states were then forced to use unspent funds to carry them over while the House and Senate try to agree on a way to continue funding.

Congress extended funding on Dec. 21 and touted that states would have money to last while Congress worked on a long-term funding solution. But the CMS said on Jan. 5 it could only guarantee that the appropriation will be enough to fund all states through Jan. 19.

The CMS said the agency is in discussions with states to help deal with the funding shortfall.

“The funding … should carry all the states through January 19th based upon best estimates of state expenditures to date,” said CMS spokesman Johnathan Monroe. “However, due to a number of variables relating to state expenditure rates and reporting, we are unable to say with certainty whether there is enough funding for every state to continue its CHIP program through March 31, 2018.”

“States need to know whether they will need to find additional funding for children covered under the Medicaid CHIP program at a much lower federal matching rate, send letters to families, and re-program their eligibility systems,” said Lisa Dubay, a senior fellow at the Urban Institute. “Of course, the implications for families with CHIP-eligible children cannot be understated: Parents are worried that their children will lose coverage. And they should be.”

Although the program enjoys bipartisan support on Capitol Hill, the Republican-controlled House and Senate have for months been unable to agree on how to continue funding CHIP, which began in 1997.

The House plan includes a controversial funding provision – opposed by Democrats -– that takes millions of dollars from the Affordable Care Act’s Prevention and Public Health Fund and increases Medicare premiums for some higher-earning beneficiaries.

The Senate Finance Committee reached an agreement to extend the program for 5 years but did not unite around a plan on funding.

Before the CHIP funding extension on Dec. 21, Alabama said it would freeze enrollment Jan. 1 and shut down the program Jan. 31. Colorado, Connecticut, and Virginia sent letters to CHIP families warning that the program could soon end.

After the funding extension, Alabama put a hold on shutting down CHIP.

“Some states will begin exhausting all available funding earlier than others,” a CMS official said Jan. 5. “But the exact timing of when states will exhaust their funding is a moving target.”

Bruce Lesley, president of First Focus, a child advocacy group, said Congress should have known its short-term funding plan was not enough.

“The math never worked on the patch, as it only bought a few weeks,” he said. “Congress must get this finalized before Jan. 19.”
 

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente. KHN’s coverage of children’s health care issues is supported in part by the Heising-Simons Foundation.

The Diagnosis: Atypical Vascular Lesion

Atypical vascular lesion (AVL)(quiz image), named by Fineberg and Rosen,¹ is a vascular lesion that arises on mammary skin with a history of radiation exposure. Clinically, AVL can present as a papule or erythematous patch that manifests 3 to 7 years after radiation therapy.^2,3 There are 2 histologic subtypes of AVL: lymphatic and vascular.^2,4 Lymphatic-type AVL is comprised of a symmetric distribution of thin, dilated, and anastomosing vessels usually found in the superficial and mid dermis. The vessels are lined by flat or hobnail protuberant endothelial cells that lack nuclear irregularity or pleomorphism; however, hyperchromatism of endothelial cell nuclei is a common finding. Vascular-type AVL is morphologically similar to a capillary hemangioma, and histologic features include irregular growth of capillary-sized vessels that extend to the dermis and subcutis.^2,4 Atypical vascular lesions are benign lesions but may be a precursor to angiosarcoma. Along with vascular markers, D2-40 typically is positive. Surgical excision with clear margins is recommended when the lesion is small.^4,5 Observation is more appropriate for extensive lesions.

Angiosarcoma can arise spontaneously or in association with radiation or chronic lymphedema. Given the shared risk factors and presentation with AVL, it is essential to differentiate angiosarcoma from AVL. Primary cutaneous angiosarcoma usually presents on the head of elderly patients as an ecchymotic patch or plaque with ulceration.⁴ Secondary angiosarcoma may arise following radiation or chronic lymphedema (Stewart-Treves syndrome); however, some authors now prefer to consider lymphangiosarcoma arising in chronic lymphedematous limbs a distinct entity.⁶ Surgical excision with wide margins is the mainstay of therapy, but angiosarcoma has high recurrence rates, and the 5-year survival rate has been reported to be as low as 35%.⁷ Histologic overlap with AVL includes dissecting anastomosing vessels lined by hyperchromatic nuclei; however, angiosarcoma is distinguished by endothelial cell layering, nuclear pleomorphism, and prominent nucleoli (Figure 1).^4,8 Increased positivity for Ki-67 immunostain, which indicates cell proliferation, may be used to distinguish angiosarcoma from an AVL (Figure 1 [inset]).⁹ Further, in contrast to AVL, radiation-induced angiosarcoma is characterized by amplification of C-MYC, a regulator gene, and FLT4 (FMS-related tyrosine kinase 4), a gene encoding vascular endothelial growth factor receptor 3. Gene amplification may be detected through immunohistochemistry or fluorescence in situ hybridization.¹⁰ Ki-67 labeling showed less than 10% staining in endothelial cells in our case (quiz image [inset]), and fluorescence in situ hybridization was negative for C-MYC amplification, supporting the diagnosis of AVL.

Lymphangioma circumscriptum, the most common superficial lymphangioma, is a hamartomatous malformation that usually occurs at the axillary folds, neck, and trunk. It clinically presents as small agminated vesicles with a characteristic frog spawn appearance.¹¹ Dermoscopic features include yellow lacunae that may alternate with a dark red color secondary to extravasation of erythrocytes.¹² These clinical features often lead to a differential diagnosis of verrucae, angiokeratoma, and angiosarcoma. Lymphangioma circumscriptum histologically is characterized by an overgrowth of dilated lymphatic vessels that fill the papillary dermis. The vessels are composed of flat endothelial cells typically filled with acellular proteinaceous debris and occasional erythrocytes (Figure 2). As the lesion traverses deeper into the dermis, the caliber of the lymphatic channel becomes narrower. The presence of deep lymphatic cisterns with surrounding smooth muscle is helpful to differentiate lymphangioma circumscriptum from other lymphatic malformations such as acquired lymphangiectasia. Treatment options include surgical excision, sclerosing agents, and destructive modalities such as cryotherapy.

Hobnail hemangioma, originally termed targetoid hemosiderotic hemangioma by Santa Cruz and Aronberg,¹³ presents as a violaceous papule or nodule surrounded by a characteristic brown halo on the leg. Trauma has been proposed as the inciting factor for the clinical appearance of hobnail hemangioma.¹⁴ Microscopically, the lesion shows vessels in a wedge shape. The superficial component has telangiectatic vessels with focal areas of papillary projections lined by endothelial cells. Although the endothelial nuclei typically project into the lumen, the nuclei are small, bland, and without mitotic activity.¹⁵ Deeper components show slit-shaped vasculature with dermal collagen dissection. Hemosiderin, extravasated red blood cells, and inflammation are found adjacent to the vessels (Figure 3). Given the benign nature, hobnail hemangiomas may be monitored.

Kaposi sarcoma (KS) is a low-grade vascular neoplasm associated with human herpesvirus 8 that arises in multiple clinical settings, especially in immunosuppression secondary to human immunodeficiency virus. There are 3 distinct clinical stages: patch, plaque, and tumor. The patch stage appears as red macules that blend into larger plaques; the tumor stage is defined as larger nodules developing from plaques. Histologic features differ by stage. Similar to angiosarcoma, KS is comprised of anastomosing vessels that dissect collagen bundles; endothelial cell atypia is minimal. A useful feature of KS is its propensity to involve adnexa and display the promontory sign, which involves the tumor growing into normal vasculature (Figure 4).¹⁶ Positive immunohistochemistry for human herpesvirus 8 aids in confirmation of the diagnosis. Treatment options for KS are numerous but include destructive modalities, chemotherapeutic agents such as doxorubicin, or highly active antiretroviral therapy for AIDS-related KS.¹⁷

The Diagnosis: Atypical Vascular Lesion

Atypical vascular lesion (AVL)(quiz image), named by Fineberg and Rosen,¹ is a vascular lesion that arises on mammary skin with a history of radiation exposure. Clinically, AVL can present as a papule or erythematous patch that manifests 3 to 7 years after radiation therapy.^2,3 There are 2 histologic subtypes of AVL: lymphatic and vascular.^2,4 Lymphatic-type AVL is comprised of a symmetric distribution of thin, dilated, and anastomosing vessels usually found in the superficial and mid dermis. The vessels are lined by flat or hobnail protuberant endothelial cells that lack nuclear irregularity or pleomorphism; however, hyperchromatism of endothelial cell nuclei is a common finding. Vascular-type AVL is morphologically similar to a capillary hemangioma, and histologic features include irregular growth of capillary-sized vessels that extend to the dermis and subcutis.^2,4 Atypical vascular lesions are benign lesions but may be a precursor to angiosarcoma. Along with vascular markers, D2-40 typically is positive. Surgical excision with clear margins is recommended when the lesion is small.^4,5 Observation is more appropriate for extensive lesions.

Angiosarcoma can arise spontaneously or in association with radiation or chronic lymphedema. Given the shared risk factors and presentation with AVL, it is essential to differentiate angiosarcoma from AVL. Primary cutaneous angiosarcoma usually presents on the head of elderly patients as an ecchymotic patch or plaque with ulceration.⁴ Secondary angiosarcoma may arise following radiation or chronic lymphedema (Stewart-Treves syndrome); however, some authors now prefer to consider lymphangiosarcoma arising in chronic lymphedematous limbs a distinct entity.⁶ Surgical excision with wide margins is the mainstay of therapy, but angiosarcoma has high recurrence rates, and the 5-year survival rate has been reported to be as low as 35%.⁷ Histologic overlap with AVL includes dissecting anastomosing vessels lined by hyperchromatic nuclei; however, angiosarcoma is distinguished by endothelial cell layering, nuclear pleomorphism, and prominent nucleoli (Figure 1).^4,8 Increased positivity for Ki-67 immunostain, which indicates cell proliferation, may be used to distinguish angiosarcoma from an AVL (Figure 1 [inset]).⁹ Further, in contrast to AVL, radiation-induced angiosarcoma is characterized by amplification of C-MYC, a regulator gene, and FLT4 (FMS-related tyrosine kinase 4), a gene encoding vascular endothelial growth factor receptor 3. Gene amplification may be detected through immunohistochemistry or fluorescence in situ hybridization.¹⁰ Ki-67 labeling showed less than 10% staining in endothelial cells in our case (quiz image [inset]), and fluorescence in situ hybridization was negative for C-MYC amplification, supporting the diagnosis of AVL.

Lymphangioma circumscriptum, the most common superficial lymphangioma, is a hamartomatous malformation that usually occurs at the axillary folds, neck, and trunk. It clinically presents as small agminated vesicles with a characteristic frog spawn appearance.¹¹ Dermoscopic features include yellow lacunae that may alternate with a dark red color secondary to extravasation of erythrocytes.¹² These clinical features often lead to a differential diagnosis of verrucae, angiokeratoma, and angiosarcoma. Lymphangioma circumscriptum histologically is characterized by an overgrowth of dilated lymphatic vessels that fill the papillary dermis. The vessels are composed of flat endothelial cells typically filled with acellular proteinaceous debris and occasional erythrocytes (Figure 2). As the lesion traverses deeper into the dermis, the caliber of the lymphatic channel becomes narrower. The presence of deep lymphatic cisterns with surrounding smooth muscle is helpful to differentiate lymphangioma circumscriptum from other lymphatic malformations such as acquired lymphangiectasia. Treatment options include surgical excision, sclerosing agents, and destructive modalities such as cryotherapy.

Hobnail hemangioma, originally termed targetoid hemosiderotic hemangioma by Santa Cruz and Aronberg,¹³ presents as a violaceous papule or nodule surrounded by a characteristic brown halo on the leg. Trauma has been proposed as the inciting factor for the clinical appearance of hobnail hemangioma.¹⁴ Microscopically, the lesion shows vessels in a wedge shape. The superficial component has telangiectatic vessels with focal areas of papillary projections lined by endothelial cells. Although the endothelial nuclei typically project into the lumen, the nuclei are small, bland, and without mitotic activity.¹⁵ Deeper components show slit-shaped vasculature with dermal collagen dissection. Hemosiderin, extravasated red blood cells, and inflammation are found adjacent to the vessels (Figure 3). Given the benign nature, hobnail hemangiomas may be monitored.

Kaposi sarcoma (KS) is a low-grade vascular neoplasm associated with human herpesvirus 8 that arises in multiple clinical settings, especially in immunosuppression secondary to human immunodeficiency virus. There are 3 distinct clinical stages: patch, plaque, and tumor. The patch stage appears as red macules that blend into larger plaques; the tumor stage is defined as larger nodules developing from plaques. Histologic features differ by stage. Similar to angiosarcoma, KS is comprised of anastomosing vessels that dissect collagen bundles; endothelial cell atypia is minimal. A useful feature of KS is its propensity to involve adnexa and display the promontory sign, which involves the tumor growing into normal vasculature (Figure 4).¹⁶ Positive immunohistochemistry for human herpesvirus 8 aids in confirmation of the diagnosis. Treatment options for KS are numerous but include destructive modalities, chemotherapeutic agents such as doxorubicin, or highly active antiretroviral therapy for AIDS-related KS.¹⁷

The Diagnosis: Atypical Vascular Lesion

Atypical vascular lesion (AVL)(quiz image), named by Fineberg and Rosen,¹ is a vascular lesion that arises on mammary skin with a history of radiation exposure. Clinically, AVL can present as a papule or erythematous patch that manifests 3 to 7 years after radiation therapy.^2,3 There are 2 histologic subtypes of AVL: lymphatic and vascular.^2,4 Lymphatic-type AVL is comprised of a symmetric distribution of thin, dilated, and anastomosing vessels usually found in the superficial and mid dermis. The vessels are lined by flat or hobnail protuberant endothelial cells that lack nuclear irregularity or pleomorphism; however, hyperchromatism of endothelial cell nuclei is a common finding. Vascular-type AVL is morphologically similar to a capillary hemangioma, and histologic features include irregular growth of capillary-sized vessels that extend to the dermis and subcutis.^2,4 Atypical vascular lesions are benign lesions but may be a precursor to angiosarcoma. Along with vascular markers, D2-40 typically is positive. Surgical excision with clear margins is recommended when the lesion is small.^4,5 Observation is more appropriate for extensive lesions.

Angiosarcoma can arise spontaneously or in association with radiation or chronic lymphedema. Given the shared risk factors and presentation with AVL, it is essential to differentiate angiosarcoma from AVL. Primary cutaneous angiosarcoma usually presents on the head of elderly patients as an ecchymotic patch or plaque with ulceration.⁴ Secondary angiosarcoma may arise following radiation or chronic lymphedema (Stewart-Treves syndrome); however, some authors now prefer to consider lymphangiosarcoma arising in chronic lymphedematous limbs a distinct entity.⁶ Surgical excision with wide margins is the mainstay of therapy, but angiosarcoma has high recurrence rates, and the 5-year survival rate has been reported to be as low as 35%.⁷ Histologic overlap with AVL includes dissecting anastomosing vessels lined by hyperchromatic nuclei; however, angiosarcoma is distinguished by endothelial cell layering, nuclear pleomorphism, and prominent nucleoli (Figure 1).^4,8 Increased positivity for Ki-67 immunostain, which indicates cell proliferation, may be used to distinguish angiosarcoma from an AVL (Figure 1 [inset]).⁹ Further, in contrast to AVL, radiation-induced angiosarcoma is characterized by amplification of C-MYC, a regulator gene, and FLT4 (FMS-related tyrosine kinase 4), a gene encoding vascular endothelial growth factor receptor 3. Gene amplification may be detected through immunohistochemistry or fluorescence in situ hybridization.¹⁰ Ki-67 labeling showed less than 10% staining in endothelial cells in our case (quiz image [inset]), and fluorescence in situ hybridization was negative for C-MYC amplification, supporting the diagnosis of AVL.

Lymphangioma circumscriptum, the most common superficial lymphangioma, is a hamartomatous malformation that usually occurs at the axillary folds, neck, and trunk. It clinically presents as small agminated vesicles with a characteristic frog spawn appearance.¹¹ Dermoscopic features include yellow lacunae that may alternate with a dark red color secondary to extravasation of erythrocytes.¹² These clinical features often lead to a differential diagnosis of verrucae, angiokeratoma, and angiosarcoma. Lymphangioma circumscriptum histologically is characterized by an overgrowth of dilated lymphatic vessels that fill the papillary dermis. The vessels are composed of flat endothelial cells typically filled with acellular proteinaceous debris and occasional erythrocytes (Figure 2). As the lesion traverses deeper into the dermis, the caliber of the lymphatic channel becomes narrower. The presence of deep lymphatic cisterns with surrounding smooth muscle is helpful to differentiate lymphangioma circumscriptum from other lymphatic malformations such as acquired lymphangiectasia. Treatment options include surgical excision, sclerosing agents, and destructive modalities such as cryotherapy.

Hobnail hemangioma, originally termed targetoid hemosiderotic hemangioma by Santa Cruz and Aronberg,¹³ presents as a violaceous papule or nodule surrounded by a characteristic brown halo on the leg. Trauma has been proposed as the inciting factor for the clinical appearance of hobnail hemangioma.¹⁴ Microscopically, the lesion shows vessels in a wedge shape. The superficial component has telangiectatic vessels with focal areas of papillary projections lined by endothelial cells. Although the endothelial nuclei typically project into the lumen, the nuclei are small, bland, and without mitotic activity.¹⁵ Deeper components show slit-shaped vasculature with dermal collagen dissection. Hemosiderin, extravasated red blood cells, and inflammation are found adjacent to the vessels (Figure 3). Given the benign nature, hobnail hemangiomas may be monitored.

Kaposi sarcoma (KS) is a low-grade vascular neoplasm associated with human herpesvirus 8 that arises in multiple clinical settings, especially in immunosuppression secondary to human immunodeficiency virus. There are 3 distinct clinical stages: patch, plaque, and tumor. The patch stage appears as red macules that blend into larger plaques; the tumor stage is defined as larger nodules developing from plaques. Histologic features differ by stage. Similar to angiosarcoma, KS is comprised of anastomosing vessels that dissect collagen bundles; endothelial cell atypia is minimal. A useful feature of KS is its propensity to involve adnexa and display the promontory sign, which involves the tumor growing into normal vasculature (Figure 4).¹⁶ Positive immunohistochemistry for human herpesvirus 8 aids in confirmation of the diagnosis. Treatment options for KS are numerous but include destructive modalities, chemotherapeutic agents such as doxorubicin, or highly active antiretroviral therapy for AIDS-related KS.¹⁷

While James Kim, MD, did not originally begin medical school with a plan to become a hospitalist, he has embraced his current role wholeheartedly.

Since becoming board certified in both internal medicine and infectious diseases, Dr. Kim has welcomed the opportunity to be part of hospital medicine, which gives him the opportunity to pursue his other passion: teaching and mentoring.

QUESTION: How did you find your career path in medicine?

ANSWER: I originally went into medical school thinking I was going to do pediatrics, but then I realized that I really enjoy talking to people and that I like the process of thinking through diagnoses, managing patients, and learning about what makes their circumstances unique.

Q: How did you get into hospital medicine?

A: When I finished my internal medicine residency, I thought I was going to do medical missions. However, I realized along the way that the care you need to provide in order to really make a difference in other countries requires a constant presence there – not just a week or two. So after my fellowship, I was searching for jobs and found a hospitalist position at the University of California, Los Angeles. When I saw it, I thought ‘Wow, I really miss doing inpatient medicine.’

Q: Since you started, what have been some of your favorite parts of hospital medicine?

A: When people come to you in the hospital setting, they are usually pretty sick. It is very satisfying when, through the course of a person’s hospital stay, we are able to come up with a plan that can get them acutely better.

Q: What do you think is the hardest part of hospital medicine?

A: I think one of the things that is most frustrating is when we are placed into a situation in which we are not necessarily doing medical work for a patient but are doing something more like social work. For instance, there are cases in which patients can not be on their own in the community, and there’s no family to take them in, so the hospital, on behalf of the state, has to take them in.

Q: What else do you do outside of hospitalist work?

A: Since I’ve finished medical school, I’ve always been in some kind of academia, which is not something I would have expected. But as time has gone by, I have really come to appreciate being in academia. I really enjoy teaching, and I also think that an academic institution kind of keeps me on my toes. I’m involved with interprofessional education at Emory, with teaching medical students, interns, and residents when I’m on teaching service, and obviously now I’m on The Hospitalist editorial board. I’m looking forward to keeping abreast of what’s hot in the world of hospital medicine.

Q: What are you excited about bringing to The Hospitalist editorial board?

A: I want to try to contribute ideas. I feel that even in my short time at Emory, I’ve gotten to know a few people who might be good resources for reporters to interview or even who might write articles themselves. I also think that seeing what is trending in the world of hospital medicine is a nice way of understanding the future direction of hospital medicine.

Q: What have you seen as being the biggest change in hospital medicine since you started?

A: I feel as though I’ve kept my head down and plowed forward through the first part of my career, but I think that, more than anything else, what I’ve noticed is bigger shifts within health care itself. I know that there’s a lot of consolidation going on. I think that there are many questions that are going to come up about how do we manage a health care system as complicated as America’s and how do we deliver optimal care to people especially when sometimes we end up in situations in which we don’t have all the resources that we would want to have because of circumstances.

Q: Do you see anything in particular on the horizon for hospital medicine?

A: I’ve noticed that there’s been more “hospitalist-ization” – if that’s even a term – of other medical services. At our institution, we already have an acute care service that is basically hospital medicine for general surgery. I think another thing that’s been kind of a hot topic recently is a point-of-care testing, including ultrasounds for line placements.

Q: Where do you see yourself in 10 years?

A: I really enjoy my work at Emory. I want to find more opportunities to teach. For example, I’ve already gotten involved in teaching physician assistant students about how to perform interviews and deliver presentations for attendings. A lot of serendipitous things have happened to me over time, so I think I will continue to teach, but I’m open to those opportunities that present themselves in the future.

Q: What’s the best book you’ve read recently and why?

A: “The Hero with a Thousand Faces,” by Joseph Campbell. This is a very well-known book – I think George Lucas made reference to it when he was writing Star Wars – but I think it was a great literary way to examine the hero’s journey. Once you read the book, and you then watch any kind of movie or read any other kind of adventure narrative, you can’t miss the pattern.

While James Kim, MD, did not originally begin medical school with a plan to become a hospitalist, he has embraced his current role wholeheartedly.

Since becoming board certified in both internal medicine and infectious diseases, Dr. Kim has welcomed the opportunity to be part of hospital medicine, which gives him the opportunity to pursue his other passion: teaching and mentoring.

QUESTION: How did you find your career path in medicine?

ANSWER: I originally went into medical school thinking I was going to do pediatrics, but then I realized that I really enjoy talking to people and that I like the process of thinking through diagnoses, managing patients, and learning about what makes their circumstances unique.

Q: How did you get into hospital medicine?

A: When I finished my internal medicine residency, I thought I was going to do medical missions. However, I realized along the way that the care you need to provide in order to really make a difference in other countries requires a constant presence there – not just a week or two. So after my fellowship, I was searching for jobs and found a hospitalist position at the University of California, Los Angeles. When I saw it, I thought ‘Wow, I really miss doing inpatient medicine.’

Q: Since you started, what have been some of your favorite parts of hospital medicine?

A: When people come to you in the hospital setting, they are usually pretty sick. It is very satisfying when, through the course of a person’s hospital stay, we are able to come up with a plan that can get them acutely better.

Q: What do you think is the hardest part of hospital medicine?

A: I think one of the things that is most frustrating is when we are placed into a situation in which we are not necessarily doing medical work for a patient but are doing something more like social work. For instance, there are cases in which patients can not be on their own in the community, and there’s no family to take them in, so the hospital, on behalf of the state, has to take them in.

Q: What else do you do outside of hospitalist work?

A: Since I’ve finished medical school, I’ve always been in some kind of academia, which is not something I would have expected. But as time has gone by, I have really come to appreciate being in academia. I really enjoy teaching, and I also think that an academic institution kind of keeps me on my toes. I’m involved with interprofessional education at Emory, with teaching medical students, interns, and residents when I’m on teaching service, and obviously now I’m on The Hospitalist editorial board. I’m looking forward to keeping abreast of what’s hot in the world of hospital medicine.

Q: What are you excited about bringing to The Hospitalist editorial board?

A: I want to try to contribute ideas. I feel that even in my short time at Emory, I’ve gotten to know a few people who might be good resources for reporters to interview or even who might write articles themselves. I also think that seeing what is trending in the world of hospital medicine is a nice way of understanding the future direction of hospital medicine.

Q: What have you seen as being the biggest change in hospital medicine since you started?

A: I feel as though I’ve kept my head down and plowed forward through the first part of my career, but I think that, more than anything else, what I’ve noticed is bigger shifts within health care itself. I know that there’s a lot of consolidation going on. I think that there are many questions that are going to come up about how do we manage a health care system as complicated as America’s and how do we deliver optimal care to people especially when sometimes we end up in situations in which we don’t have all the resources that we would want to have because of circumstances.

Q: Do you see anything in particular on the horizon for hospital medicine?

A: I’ve noticed that there’s been more “hospitalist-ization” – if that’s even a term – of other medical services. At our institution, we already have an acute care service that is basically hospital medicine for general surgery. I think another thing that’s been kind of a hot topic recently is a point-of-care testing, including ultrasounds for line placements.

Q: Where do you see yourself in 10 years?

A: I really enjoy my work at Emory. I want to find more opportunities to teach. For example, I’ve already gotten involved in teaching physician assistant students about how to perform interviews and deliver presentations for attendings. A lot of serendipitous things have happened to me over time, so I think I will continue to teach, but I’m open to those opportunities that present themselves in the future.

Q: What’s the best book you’ve read recently and why?

A: “The Hero with a Thousand Faces,” by Joseph Campbell. This is a very well-known book – I think George Lucas made reference to it when he was writing Star Wars – but I think it was a great literary way to examine the hero’s journey. Once you read the book, and you then watch any kind of movie or read any other kind of adventure narrative, you can’t miss the pattern.

While James Kim, MD, did not originally begin medical school with a plan to become a hospitalist, he has embraced his current role wholeheartedly.

Since becoming board certified in both internal medicine and infectious diseases, Dr. Kim has welcomed the opportunity to be part of hospital medicine, which gives him the opportunity to pursue his other passion: teaching and mentoring.

QUESTION: How did you find your career path in medicine?

ANSWER: I originally went into medical school thinking I was going to do pediatrics, but then I realized that I really enjoy talking to people and that I like the process of thinking through diagnoses, managing patients, and learning about what makes their circumstances unique.

Q: How did you get into hospital medicine?

A: When I finished my internal medicine residency, I thought I was going to do medical missions. However, I realized along the way that the care you need to provide in order to really make a difference in other countries requires a constant presence there – not just a week or two. So after my fellowship, I was searching for jobs and found a hospitalist position at the University of California, Los Angeles. When I saw it, I thought ‘Wow, I really miss doing inpatient medicine.’

Q: Since you started, what have been some of your favorite parts of hospital medicine?

A: When people come to you in the hospital setting, they are usually pretty sick. It is very satisfying when, through the course of a person’s hospital stay, we are able to come up with a plan that can get them acutely better.

Q: What do you think is the hardest part of hospital medicine?

A: I think one of the things that is most frustrating is when we are placed into a situation in which we are not necessarily doing medical work for a patient but are doing something more like social work. For instance, there are cases in which patients can not be on their own in the community, and there’s no family to take them in, so the hospital, on behalf of the state, has to take them in.

Q: What else do you do outside of hospitalist work?

A: Since I’ve finished medical school, I’ve always been in some kind of academia, which is not something I would have expected. But as time has gone by, I have really come to appreciate being in academia. I really enjoy teaching, and I also think that an academic institution kind of keeps me on my toes. I’m involved with interprofessional education at Emory, with teaching medical students, interns, and residents when I’m on teaching service, and obviously now I’m on The Hospitalist editorial board. I’m looking forward to keeping abreast of what’s hot in the world of hospital medicine.

Q: What are you excited about bringing to The Hospitalist editorial board?

A: I want to try to contribute ideas. I feel that even in my short time at Emory, I’ve gotten to know a few people who might be good resources for reporters to interview or even who might write articles themselves. I also think that seeing what is trending in the world of hospital medicine is a nice way of understanding the future direction of hospital medicine.

Q: What have you seen as being the biggest change in hospital medicine since you started?

A: I feel as though I’ve kept my head down and plowed forward through the first part of my career, but I think that, more than anything else, what I’ve noticed is bigger shifts within health care itself. I know that there’s a lot of consolidation going on. I think that there are many questions that are going to come up about how do we manage a health care system as complicated as America’s and how do we deliver optimal care to people especially when sometimes we end up in situations in which we don’t have all the resources that we would want to have because of circumstances.

Q: Do you see anything in particular on the horizon for hospital medicine?

A: I’ve noticed that there’s been more “hospitalist-ization” – if that’s even a term – of other medical services. At our institution, we already have an acute care service that is basically hospital medicine for general surgery. I think another thing that’s been kind of a hot topic recently is a point-of-care testing, including ultrasounds for line placements.

Q: Where do you see yourself in 10 years?

A: I really enjoy my work at Emory. I want to find more opportunities to teach. For example, I’ve already gotten involved in teaching physician assistant students about how to perform interviews and deliver presentations for attendings. A lot of serendipitous things have happened to me over time, so I think I will continue to teach, but I’m open to those opportunities that present themselves in the future.

Q: What’s the best book you’ve read recently and why?

A: “The Hero with a Thousand Faces,” by Joseph Campbell. This is a very well-known book – I think George Lucas made reference to it when he was writing Star Wars – but I think it was a great literary way to examine the hero’s journey. Once you read the book, and you then watch any kind of movie or read any other kind of adventure narrative, you can’t miss the pattern.

REPORTING FROM THE EADV CONGRESS

GENEVA – Psoriasis patients switched to ixekizumab after previous exposure to another interleukin-17 inhibitor respond as well as those who are IL-17 antagonist naive, Kim A. Papp, MD, PhD, reported at the annual congress of the European Academy of Dermatology and Venereology.

This finding is of importance in real-world clinical practice because it’s not at all uncommon for psoriasis patients on one biologic to have to switch to another because of insufficient efficacy, side effects, or a change in insurance coverage. Physicians would like to know what sort of responses can be expected to whatever agent they prescribe next.

[email protected]

REPORTING FROM THE EADV CONGRESS

GENEVA – Psoriasis patients switched to ixekizumab after previous exposure to another interleukin-17 inhibitor respond as well as those who are IL-17 antagonist naive, Kim A. Papp, MD, PhD, reported at the annual congress of the European Academy of Dermatology and Venereology.

This finding is of importance in real-world clinical practice because it’s not at all uncommon for psoriasis patients on one biologic to have to switch to another because of insufficient efficacy, side effects, or a change in insurance coverage. Physicians would like to know what sort of responses can be expected to whatever agent they prescribe next.

[email protected]

REPORTING FROM THE EADV CONGRESS

GENEVA – Psoriasis patients switched to ixekizumab after previous exposure to another interleukin-17 inhibitor respond as well as those who are IL-17 antagonist naive, Kim A. Papp, MD, PhD, reported at the annual congress of the European Academy of Dermatology and Venereology.

This finding is of importance in real-world clinical practice because it’s not at all uncommon for psoriasis patients on one biologic to have to switch to another because of insufficient efficacy, side effects, or a change in insurance coverage. Physicians would like to know what sort of responses can be expected to whatever agent they prescribe next.

[email protected]

GENEVA – In real-world clinical practice, roughly two-thirds of patients with chronic spontaneous urticaria treated with the approved dose of omalizumab will achieve good disease control – and for those who don’t, three-quarters will respond upon updosing to 450 or 600 mg every 4 weeks.

That’s the key message of an open-label study of 286 patients with chronic spontaneous urticaria (CSU) conducted at 15 hospitals by the Catalan and Balearic Chronic Urticaria Network (XUrCB), Jorge Spertino, MD, reported at the annual congress of the European Academy of Dermatology and Venereology.

Bruce Jancin/Frontline Medical News

[email protected]

SOURCE: Spertino J et al. EADV Congress

GENEVA – In real-world clinical practice, roughly two-thirds of patients with chronic spontaneous urticaria treated with the approved dose of omalizumab will achieve good disease control – and for those who don’t, three-quarters will respond upon updosing to 450 or 600 mg every 4 weeks.

That’s the key message of an open-label study of 286 patients with chronic spontaneous urticaria (CSU) conducted at 15 hospitals by the Catalan and Balearic Chronic Urticaria Network (XUrCB), Jorge Spertino, MD, reported at the annual congress of the European Academy of Dermatology and Venereology.

Bruce Jancin/Frontline Medical News

[email protected]

SOURCE: Spertino J et al. EADV Congress

GENEVA – In real-world clinical practice, roughly two-thirds of patients with chronic spontaneous urticaria treated with the approved dose of omalizumab will achieve good disease control – and for those who don’t, three-quarters will respond upon updosing to 450 or 600 mg every 4 weeks.

That’s the key message of an open-label study of 286 patients with chronic spontaneous urticaria (CSU) conducted at 15 hospitals by the Catalan and Balearic Chronic Urticaria Network (XUrCB), Jorge Spertino, MD, reported at the annual congress of the European Academy of Dermatology and Venereology.

Bruce Jancin/Frontline Medical News

[email protected]

SOURCE: Spertino J et al. EADV Congress

The 2016 Magnetic Resonance Imaging in Multiple Sclerosis (MAGNIMS) criteria showed accuracy similar to that of the 2010 McDonald criteria in predicting the development of clinically definite multiple sclerosis, a retrospective study found.

“Among the different modifications proposed, our results support removal of the distinction between symptomatic and asymptomatic lesions, which simplifies the clinical use of MRI criteria, and suggest that further consideration is given to increasing the number of lesions needed to define periventricular involvement from one to three, because this might slightly increase specificity,” wrote researchers led by Massimo Filippi, MD. The report was published Dec. 21, 2017, in The Lancet Neurology. “Further effort is still needed to improve cortical lesion assessment and more studies should be done to evaluate the effect of including optic nerve assessment as an additional DIS [dissemination in space] criterion.”

solitude72/iStockphoto

[email protected]

SOURCE: Filippi M et al., Lancet Neurol. 2017 Dec 21. doi: 10.1016/S1474-4422(17)30469-6.

The 2016 Magnetic Resonance Imaging in Multiple Sclerosis (MAGNIMS) criteria showed accuracy similar to that of the 2010 McDonald criteria in predicting the development of clinically definite multiple sclerosis, a retrospective study found.

“Among the different modifications proposed, our results support removal of the distinction between symptomatic and asymptomatic lesions, which simplifies the clinical use of MRI criteria, and suggest that further consideration is given to increasing the number of lesions needed to define periventricular involvement from one to three, because this might slightly increase specificity,” wrote researchers led by Massimo Filippi, MD. The report was published Dec. 21, 2017, in The Lancet Neurology. “Further effort is still needed to improve cortical lesion assessment and more studies should be done to evaluate the effect of including optic nerve assessment as an additional DIS [dissemination in space] criterion.”

solitude72/iStockphoto

[email protected]

SOURCE: Filippi M et al., Lancet Neurol. 2017 Dec 21. doi: 10.1016/S1474-4422(17)30469-6.

The 2016 Magnetic Resonance Imaging in Multiple Sclerosis (MAGNIMS) criteria showed accuracy similar to that of the 2010 McDonald criteria in predicting the development of clinically definite multiple sclerosis, a retrospective study found.

“Among the different modifications proposed, our results support removal of the distinction between symptomatic and asymptomatic lesions, which simplifies the clinical use of MRI criteria, and suggest that further consideration is given to increasing the number of lesions needed to define periventricular involvement from one to three, because this might slightly increase specificity,” wrote researchers led by Massimo Filippi, MD. The report was published Dec. 21, 2017, in The Lancet Neurology. “Further effort is still needed to improve cortical lesion assessment and more studies should be done to evaluate the effect of including optic nerve assessment as an additional DIS [dissemination in space] criterion.”

solitude72/iStockphoto

[email protected]

SOURCE: Filippi M et al., Lancet Neurol. 2017 Dec 21. doi: 10.1016/S1474-4422(17)30469-6.

Dermoscopy increases diagnostic accuracy in the analysis of skin growths.^1,2 Recently the use of dermoscopy has broadened to include inflammatory dermatoses and skin infections.³ To substantiate the value of dermoscopy in assessing psoriasis, we performed a systematic review of the literature and briefly reviewed 31 articles. We also report a case that highlights the differences between psoriasis and basal cell carcinoma (BCC) under dermoscopic examination, and we discuss the literature on the dermoscopic findings of psoriasis with an emphasis on the relative sensitivities and specificities of dermoscopic findings for psoriasis and for BCC.

Case Report

A 63-year-old man with psoriasis and a history of BCC presented for follow-up of psoriasis, which was well-controlled on etanercept. The physical examination was remarkable for scaly pink papules scattered on the trunk and extremities. A new larger red-pink patch was located on the left lower back (Figure 1). Dermoscopic evaluation of the new patch revealed shiny white lines and branching blood vessels (Figure 2). Pathology results of a shave biopsy revealed superficial BCC. The skin cancer was treated with electrodesiccation and curettage.

Comment

The clinical morphology of psoriasis and BCC can be similar, and dermoscopy can help in differentiating between the 2 conditions.

Literature Search on Dermoscopy and Psoriasis
We performed a PubMed search of articles indexed for MEDLINE to review the published literature on dermoscopy and psoriasis. Two reviewers (C.H. and L.C.) searched for psoriasis paired with the terms dermoscopy or dermatoscopy or epiluminescence microscopy. Only English-language articles published between 1996 and 2016 were included in the search. Articles that focused solely on confocal microscopy were excluded. Article titles and abstracts were evaluated and articles that omitted mention of dermoscopy and psoriasis were excluded, yielding a total of 31 articles. Of these articles, only 2 discussed the specificity or sensitivity of the dermoscopic findings of psoriasis.^4,5 Most of the articles were case reports and descriptive cross-sectional studies. The reports addressed multiple subtypes of psoriasis, but reports on psoriasis vulgaris and scalp psoriasis were most common (Table). Lallas et al⁶ provided a comprehensive descriptive review of the main findings on dermoscopy for psoriasis and other inflammatory skin conditions, but it lacked a comparison between psoriasis and BCC or data on the sensitivity and specificity of the findings. Two studies reported sensitivity and specificity values for the dermoscopic findings of psoriasis.^4,5 Pan et al⁵ reported a 98% diagnostic probability of psoriasis if red dots, homogeneous vascular pattern, and a light red background are all present. Additionally, they reported that the presence of 4 of 6 criteria for BCC—scattered vascular pattern, arborizing microvessels, telangiectatic or atypical vessels, milky-pink background, and brown dots⁄globules—yielded a diagnostic probability of 99%.⁵ Similarly, Lallas et al⁶ demonstrated that the presence of dotted vessels alone is not sufficient to presume a diagnosis of psoriasis, as this finding can be seen in other inflammatory skin conditions. However, “the combination of regularly distributed dotted vessels over a light red background associated with diffuse white scales was highly predictive of [plaque psoriasis] and allowed a correct diagnosis with 88.0% specificity and 84.9% sensitivity.”⁴ Figure 3 shows a dermoscopic image of plaque psoriasis that demonstrates these findings. The remaining literature corroborated this evidence, with the most commonly reported dermoscopic findings of psoriasis being red dots, red globules, glomerular vessels (also known as twisted capillary loops), red globular rings, and white scale.^7-12

Dermoscopy and BCC
Much has been published on the dermoscopic findings of BCC.^5,13-15 The dermoscopic findings of BCC include large blue-gray ovoid nests, leaflike areas, spoke-wheel–like areas, arborizing vessels (telangiectasia), and ulceration.¹⁵ Superficial BCC is characterized by short fine or arborizing telangiectasia, shallow erosions, and shiny white areas.¹⁵ The positive predictive value of dermoscopy in BCC is as high as 97%.¹⁶ Additionally, multiple studies report a sensitivity of 95% to 99%^5,13,14 and a specificity of 79% to 99% in the use of dermoscopy for identifying BCC. According to Pan et al,⁵ the most sensitive finding for BCC is a scattered vascular pattern (97%), while the most specific finding is arborizing microvessels (99%).

Utility of Dermoscopy
Our case of a 63-year-old man with a history of psoriasis and BCC highlights the usefulness of dermoscopy in accurately determining the features of each condition. Additionally, dermoscopy aids in differentiating between psoriasis and squamous cell carcinoma. In contrast to the dotted vessels seen in psoriasis, squamous cell carcinomas often have peripheral hairpin (glomerular) vessels.¹⁷

If future reports confirm dermoscopy’s utility in accurately diagnosing psoriasis, fewer biopsies may be needed when evaluating patients with new rashes. Furthermore, dermoscopy may expedite treatment of psoriasis (as it can for malignant conditions) by obviating the wait for pathology results currently needed to initiate systemic treatment. For patients with psoriasis who also have sun-damaged skin, dermoscopy may assist in differentiating pink patches and plaques of psoriasis from skin cancer, such as superficial BCCs, which often have shiny white lines not seen in psoriasis.¹⁵

Dermoscopy increases diagnostic accuracy in the analysis of skin growths.^1,2 Recently the use of dermoscopy has broadened to include inflammatory dermatoses and skin infections.³ To substantiate the value of dermoscopy in assessing psoriasis, we performed a systematic review of the literature and briefly reviewed 31 articles. We also report a case that highlights the differences between psoriasis and basal cell carcinoma (BCC) under dermoscopic examination, and we discuss the literature on the dermoscopic findings of psoriasis with an emphasis on the relative sensitivities and specificities of dermoscopic findings for psoriasis and for BCC.

Case Report

A 63-year-old man with psoriasis and a history of BCC presented for follow-up of psoriasis, which was well-controlled on etanercept. The physical examination was remarkable for scaly pink papules scattered on the trunk and extremities. A new larger red-pink patch was located on the left lower back (Figure 1). Dermoscopic evaluation of the new patch revealed shiny white lines and branching blood vessels (Figure 2). Pathology results of a shave biopsy revealed superficial BCC. The skin cancer was treated with electrodesiccation and curettage.

Comment

The clinical morphology of psoriasis and BCC can be similar, and dermoscopy can help in differentiating between the 2 conditions.

Literature Search on Dermoscopy and Psoriasis
We performed a PubMed search of articles indexed for MEDLINE to review the published literature on dermoscopy and psoriasis. Two reviewers (C.H. and L.C.) searched for psoriasis paired with the terms dermoscopy or dermatoscopy or epiluminescence microscopy. Only English-language articles published between 1996 and 2016 were included in the search. Articles that focused solely on confocal microscopy were excluded. Article titles and abstracts were evaluated and articles that omitted mention of dermoscopy and psoriasis were excluded, yielding a total of 31 articles. Of these articles, only 2 discussed the specificity or sensitivity of the dermoscopic findings of psoriasis.^4,5 Most of the articles were case reports and descriptive cross-sectional studies. The reports addressed multiple subtypes of psoriasis, but reports on psoriasis vulgaris and scalp psoriasis were most common (Table). Lallas et al⁶ provided a comprehensive descriptive review of the main findings on dermoscopy for psoriasis and other inflammatory skin conditions, but it lacked a comparison between psoriasis and BCC or data on the sensitivity and specificity of the findings. Two studies reported sensitivity and specificity values for the dermoscopic findings of psoriasis.^4,5 Pan et al⁵ reported a 98% diagnostic probability of psoriasis if red dots, homogeneous vascular pattern, and a light red background are all present. Additionally, they reported that the presence of 4 of 6 criteria for BCC—scattered vascular pattern, arborizing microvessels, telangiectatic or atypical vessels, milky-pink background, and brown dots⁄globules—yielded a diagnostic probability of 99%.⁵ Similarly, Lallas et al⁶ demonstrated that the presence of dotted vessels alone is not sufficient to presume a diagnosis of psoriasis, as this finding can be seen in other inflammatory skin conditions. However, “the combination of regularly distributed dotted vessels over a light red background associated with diffuse white scales was highly predictive of [plaque psoriasis] and allowed a correct diagnosis with 88.0% specificity and 84.9% sensitivity.”⁴ Figure 3 shows a dermoscopic image of plaque psoriasis that demonstrates these findings. The remaining literature corroborated this evidence, with the most commonly reported dermoscopic findings of psoriasis being red dots, red globules, glomerular vessels (also known as twisted capillary loops), red globular rings, and white scale.^7-12

Dermoscopy and BCC
Much has been published on the dermoscopic findings of BCC.^5,13-15 The dermoscopic findings of BCC include large blue-gray ovoid nests, leaflike areas, spoke-wheel–like areas, arborizing vessels (telangiectasia), and ulceration.¹⁵ Superficial BCC is characterized by short fine or arborizing telangiectasia, shallow erosions, and shiny white areas.¹⁵ The positive predictive value of dermoscopy in BCC is as high as 97%.¹⁶ Additionally, multiple studies report a sensitivity of 95% to 99%^5,13,14 and a specificity of 79% to 99% in the use of dermoscopy for identifying BCC. According to Pan et al,⁵ the most sensitive finding for BCC is a scattered vascular pattern (97%), while the most specific finding is arborizing microvessels (99%).

Utility of Dermoscopy
Our case of a 63-year-old man with a history of psoriasis and BCC highlights the usefulness of dermoscopy in accurately determining the features of each condition. Additionally, dermoscopy aids in differentiating between psoriasis and squamous cell carcinoma. In contrast to the dotted vessels seen in psoriasis, squamous cell carcinomas often have peripheral hairpin (glomerular) vessels.¹⁷

If future reports confirm dermoscopy’s utility in accurately diagnosing psoriasis, fewer biopsies may be needed when evaluating patients with new rashes. Furthermore, dermoscopy may expedite treatment of psoriasis (as it can for malignant conditions) by obviating the wait for pathology results currently needed to initiate systemic treatment. For patients with psoriasis who also have sun-damaged skin, dermoscopy may assist in differentiating pink patches and plaques of psoriasis from skin cancer, such as superficial BCCs, which often have shiny white lines not seen in psoriasis.¹⁵

Dermoscopy increases diagnostic accuracy in the analysis of skin growths.^1,2 Recently the use of dermoscopy has broadened to include inflammatory dermatoses and skin infections.³ To substantiate the value of dermoscopy in assessing psoriasis, we performed a systematic review of the literature and briefly reviewed 31 articles. We also report a case that highlights the differences between psoriasis and basal cell carcinoma (BCC) under dermoscopic examination, and we discuss the literature on the dermoscopic findings of psoriasis with an emphasis on the relative sensitivities and specificities of dermoscopic findings for psoriasis and for BCC.

Case Report

A 63-year-old man with psoriasis and a history of BCC presented for follow-up of psoriasis, which was well-controlled on etanercept. The physical examination was remarkable for scaly pink papules scattered on the trunk and extremities. A new larger red-pink patch was located on the left lower back (Figure 1). Dermoscopic evaluation of the new patch revealed shiny white lines and branching blood vessels (Figure 2). Pathology results of a shave biopsy revealed superficial BCC. The skin cancer was treated with electrodesiccation and curettage.

Comment

The clinical morphology of psoriasis and BCC can be similar, and dermoscopy can help in differentiating between the 2 conditions.

Literature Search on Dermoscopy and Psoriasis
We performed a PubMed search of articles indexed for MEDLINE to review the published literature on dermoscopy and psoriasis. Two reviewers (C.H. and L.C.) searched for psoriasis paired with the terms dermoscopy or dermatoscopy or epiluminescence microscopy. Only English-language articles published between 1996 and 2016 were included in the search. Articles that focused solely on confocal microscopy were excluded. Article titles and abstracts were evaluated and articles that omitted mention of dermoscopy and psoriasis were excluded, yielding a total of 31 articles. Of these articles, only 2 discussed the specificity or sensitivity of the dermoscopic findings of psoriasis.^4,5 Most of the articles were case reports and descriptive cross-sectional studies. The reports addressed multiple subtypes of psoriasis, but reports on psoriasis vulgaris and scalp psoriasis were most common (Table). Lallas et al⁶ provided a comprehensive descriptive review of the main findings on dermoscopy for psoriasis and other inflammatory skin conditions, but it lacked a comparison between psoriasis and BCC or data on the sensitivity and specificity of the findings. Two studies reported sensitivity and specificity values for the dermoscopic findings of psoriasis.^4,5 Pan et al⁵ reported a 98% diagnostic probability of psoriasis if red dots, homogeneous vascular pattern, and a light red background are all present. Additionally, they reported that the presence of 4 of 6 criteria for BCC—scattered vascular pattern, arborizing microvessels, telangiectatic or atypical vessels, milky-pink background, and brown dots⁄globules—yielded a diagnostic probability of 99%.⁵ Similarly, Lallas et al⁶ demonstrated that the presence of dotted vessels alone is not sufficient to presume a diagnosis of psoriasis, as this finding can be seen in other inflammatory skin conditions. However, “the combination of regularly distributed dotted vessels over a light red background associated with diffuse white scales was highly predictive of [plaque psoriasis] and allowed a correct diagnosis with 88.0% specificity and 84.9% sensitivity.”⁴ Figure 3 shows a dermoscopic image of plaque psoriasis that demonstrates these findings. The remaining literature corroborated this evidence, with the most commonly reported dermoscopic findings of psoriasis being red dots, red globules, glomerular vessels (also known as twisted capillary loops), red globular rings, and white scale.^7-12

Dermoscopy and BCC
Much has been published on the dermoscopic findings of BCC.^5,13-15 The dermoscopic findings of BCC include large blue-gray ovoid nests, leaflike areas, spoke-wheel–like areas, arborizing vessels (telangiectasia), and ulceration.¹⁵ Superficial BCC is characterized by short fine or arborizing telangiectasia, shallow erosions, and shiny white areas.¹⁵ The positive predictive value of dermoscopy in BCC is as high as 97%.¹⁶ Additionally, multiple studies report a sensitivity of 95% to 99%^5,13,14 and a specificity of 79% to 99% in the use of dermoscopy for identifying BCC. According to Pan et al,⁵ the most sensitive finding for BCC is a scattered vascular pattern (97%), while the most specific finding is arborizing microvessels (99%).

Utility of Dermoscopy
Our case of a 63-year-old man with a history of psoriasis and BCC highlights the usefulness of dermoscopy in accurately determining the features of each condition. Additionally, dermoscopy aids in differentiating between psoriasis and squamous cell carcinoma. In contrast to the dotted vessels seen in psoriasis, squamous cell carcinomas often have peripheral hairpin (glomerular) vessels.¹⁷

If future reports confirm dermoscopy’s utility in accurately diagnosing psoriasis, fewer biopsies may be needed when evaluating patients with new rashes. Furthermore, dermoscopy may expedite treatment of psoriasis (as it can for malignant conditions) by obviating the wait for pathology results currently needed to initiate systemic treatment. For patients with psoriasis who also have sun-damaged skin, dermoscopy may assist in differentiating pink patches and plaques of psoriasis from skin cancer, such as superficial BCCs, which often have shiny white lines not seen in psoriasis.¹⁵

The Diagnosis: Necrobiotic Xanthogranuloma

A 4-mm punch biopsy was performed for routine stain with hematoxylin and eosin. The differential diagnosis included sarcoidosis, necrobiosis lipoidica, xanthoma disseminatum, and multicentric reticulohistiocytosis. Histopathologic examination demonstrated a dermal infiltrate of foamy histiocytes and neutrophils (Figure). There were surrounding areas of degenerated collagen containing numerous cholesterol clefts. After clinical pathologic correlation, a diagnosis of necrobiotic xanthogranuloma (NXG) was elucidated.

The patient was referred to general surgery for elective excision of 1 or more of the lesions. Excision of an abdominal lesion was performed without complication. After several months, a new lesion reformed within the excisional scar that also was consistent with NXG. At further dermatologic visits, a trial of intralesional corticosteroids was attempted to the largest lesions with modest improvement. In addition, follow-up with hematology and oncology was recommended for routine surveillance of the known blood dyscrasia.

Necrobiotic xanthogranuloma is a multisystem non-Langerhans cell histiocytic disease. Clinically, NXG is characterized by infiltrative plaques and ulcerative nodules. Lesions may appear red, brown, or yellow with associated atrophy and telangiectasia.¹ Koch et al² described a predilection for granuloma formation within preexisting scars. Periorbital location is the most common cutaneous site of involvement of NXG, seen in 80% of cases, but the trunk and extremities also may be involved.^1,3 Approximately half of those with periocular involvement experience ocular symptoms including prop- tosis, blepharoptosis, and restricted eye movements.⁴ The onset of NXG most commonly is seen in middle age.

Characteristic systemic associations have been reported in the setting of NXG. More than 20% of patients may exhibit hepatomegaly. Hematologic abnormalities, hyperlipidemia, and cryoglobulinemia also may be seen.¹ In addition, a monoclonal gammopathy of uncertain significance is found in more than 80% of NXG cases. The IgG κ light chain is most commonly identified.² A foreign body reaction is incited by the immunoglobulin-lipid complex, which is thought to contribute to the formation of cutaneous lesions. There may be associated plasma cell dyscrasia such as multiple myeloma or B-cell lymphoma in approximately 13% of cases.² Evaluation for underlying plasma cell dyscrasia or lymphoproliferative disorder should be performed regularly with serum protein electrophoresis or immunofixation electrophoresis, and in some cases full-body imaging with computed tomography or magnetic resonance imaging may be warranted.¹

Treatment of NXG often is unsuccessful. Surgical excision, systemic immunosuppressive agents, electron beam radiation, and destructive therapies such as cryotherapy may be trialed, often with little success.¹ Cutaneous regression has been reported with combination treatment of high-dose dexamethasone and high-dose lenalidomide.⁵

The Diagnosis: Necrobiotic Xanthogranuloma

A 4-mm punch biopsy was performed for routine stain with hematoxylin and eosin. The differential diagnosis included sarcoidosis, necrobiosis lipoidica, xanthoma disseminatum, and multicentric reticulohistiocytosis. Histopathologic examination demonstrated a dermal infiltrate of foamy histiocytes and neutrophils (Figure). There were surrounding areas of degenerated collagen containing numerous cholesterol clefts. After clinical pathologic correlation, a diagnosis of necrobiotic xanthogranuloma (NXG) was elucidated.

The patient was referred to general surgery for elective excision of 1 or more of the lesions. Excision of an abdominal lesion was performed without complication. After several months, a new lesion reformed within the excisional scar that also was consistent with NXG. At further dermatologic visits, a trial of intralesional corticosteroids was attempted to the largest lesions with modest improvement. In addition, follow-up with hematology and oncology was recommended for routine surveillance of the known blood dyscrasia.

Necrobiotic xanthogranuloma is a multisystem non-Langerhans cell histiocytic disease. Clinically, NXG is characterized by infiltrative plaques and ulcerative nodules. Lesions may appear red, brown, or yellow with associated atrophy and telangiectasia.¹ Koch et al² described a predilection for granuloma formation within preexisting scars. Periorbital location is the most common cutaneous site of involvement of NXG, seen in 80% of cases, but the trunk and extremities also may be involved.^1,3 Approximately half of those with periocular involvement experience ocular symptoms including prop- tosis, blepharoptosis, and restricted eye movements.⁴ The onset of NXG most commonly is seen in middle age.

Characteristic systemic associations have been reported in the setting of NXG. More than 20% of patients may exhibit hepatomegaly. Hematologic abnormalities, hyperlipidemia, and cryoglobulinemia also may be seen.¹ In addition, a monoclonal gammopathy of uncertain significance is found in more than 80% of NXG cases. The IgG κ light chain is most commonly identified.² A foreign body reaction is incited by the immunoglobulin-lipid complex, which is thought to contribute to the formation of cutaneous lesions. There may be associated plasma cell dyscrasia such as multiple myeloma or B-cell lymphoma in approximately 13% of cases.² Evaluation for underlying plasma cell dyscrasia or lymphoproliferative disorder should be performed regularly with serum protein electrophoresis or immunofixation electrophoresis, and in some cases full-body imaging with computed tomography or magnetic resonance imaging may be warranted.¹

Treatment of NXG often is unsuccessful. Surgical excision, systemic immunosuppressive agents, electron beam radiation, and destructive therapies such as cryotherapy may be trialed, often with little success.¹ Cutaneous regression has been reported with combination treatment of high-dose dexamethasone and high-dose lenalidomide.⁵

The Diagnosis: Necrobiotic Xanthogranuloma

A 4-mm punch biopsy was performed for routine stain with hematoxylin and eosin. The differential diagnosis included sarcoidosis, necrobiosis lipoidica, xanthoma disseminatum, and multicentric reticulohistiocytosis. Histopathologic examination demonstrated a dermal infiltrate of foamy histiocytes and neutrophils (Figure). There were surrounding areas of degenerated collagen containing numerous cholesterol clefts. After clinical pathologic correlation, a diagnosis of necrobiotic xanthogranuloma (NXG) was elucidated.

The patient was referred to general surgery for elective excision of 1 or more of the lesions. Excision of an abdominal lesion was performed without complication. After several months, a new lesion reformed within the excisional scar that also was consistent with NXG. At further dermatologic visits, a trial of intralesional corticosteroids was attempted to the largest lesions with modest improvement. In addition, follow-up with hematology and oncology was recommended for routine surveillance of the known blood dyscrasia.

Necrobiotic xanthogranuloma is a multisystem non-Langerhans cell histiocytic disease. Clinically, NXG is characterized by infiltrative plaques and ulcerative nodules. Lesions may appear red, brown, or yellow with associated atrophy and telangiectasia.¹ Koch et al² described a predilection for granuloma formation within preexisting scars. Periorbital location is the most common cutaneous site of involvement of NXG, seen in 80% of cases, but the trunk and extremities also may be involved.^1,3 Approximately half of those with periocular involvement experience ocular symptoms including prop- tosis, blepharoptosis, and restricted eye movements.⁴ The onset of NXG most commonly is seen in middle age.

Characteristic systemic associations have been reported in the setting of NXG. More than 20% of patients may exhibit hepatomegaly. Hematologic abnormalities, hyperlipidemia, and cryoglobulinemia also may be seen.¹ In addition, a monoclonal gammopathy of uncertain significance is found in more than 80% of NXG cases. The IgG κ light chain is most commonly identified.² A foreign body reaction is incited by the immunoglobulin-lipid complex, which is thought to contribute to the formation of cutaneous lesions. There may be associated plasma cell dyscrasia such as multiple myeloma or B-cell lymphoma in approximately 13% of cases.² Evaluation for underlying plasma cell dyscrasia or lymphoproliferative disorder should be performed regularly with serum protein electrophoresis or immunofixation electrophoresis, and in some cases full-body imaging with computed tomography or magnetic resonance imaging may be warranted.¹

Treatment of NXG often is unsuccessful. Surgical excision, systemic immunosuppressive agents, electron beam radiation, and destructive therapies such as cryotherapy may be trialed, often with little success.¹ Cutaneous regression has been reported with combination treatment of high-dose dexamethasone and high-dose lenalidomide.⁵

Rituximab was associated with a lower drug discontinuation rate versus all other commonly prescribed disease-modifying treatments (DMTs) used as initial therapy for relapsing-remitting multiple sclerosis (RRMS) in a retrospective study of patient data from a Swedish multiple sclerosis registry.

In addition, relapse rates were lower with rituximab (Rituxan) than they were with injectable DMTs and dimethyl fumarate (Tecfidera), according to results of the study, which appeared online Jan. 8 in JAMA Neurology.

designer491/Thinkstock

[email protected]

SOURCE: Granqvist M et al. JAMA Neurol. 2018 Jan 8. doi: 10.1001/jamaneurol.2017.4011

Rituximab was associated with a lower drug discontinuation rate versus all other commonly prescribed disease-modifying treatments (DMTs) used as initial therapy for relapsing-remitting multiple sclerosis (RRMS) in a retrospective study of patient data from a Swedish multiple sclerosis registry.

In addition, relapse rates were lower with rituximab (Rituxan) than they were with injectable DMTs and dimethyl fumarate (Tecfidera), according to results of the study, which appeared online Jan. 8 in JAMA Neurology.

designer491/Thinkstock

[email protected]

SOURCE: Granqvist M et al. JAMA Neurol. 2018 Jan 8. doi: 10.1001/jamaneurol.2017.4011

Rituximab was associated with a lower drug discontinuation rate versus all other commonly prescribed disease-modifying treatments (DMTs) used as initial therapy for relapsing-remitting multiple sclerosis (RRMS) in a retrospective study of patient data from a Swedish multiple sclerosis registry.

In addition, relapse rates were lower with rituximab (Rituxan) than they were with injectable DMTs and dimethyl fumarate (Tecfidera), according to results of the study, which appeared online Jan. 8 in JAMA Neurology.

designer491/Thinkstock

[email protected]

SOURCE: Granqvist M et al. JAMA Neurol. 2018 Jan 8. doi: 10.1001/jamaneurol.2017.4011