Cantwell, Hafsa M.

ABSTRACTBackgroundDrug‐induced hypersensitivity syndrome (DiHS), or drug reaction with eosinophilia and systemic symptoms (DRESS), is a delayed and severe immune response to certain medications. We investigated vancomycin‐induced DiHS/DRESS, notable for frequent and severe organ involvement, to describe its specific histopathology and the correlations between histopathologic and clinical findings.MethodsA retrospective review was conducted to identify patients between 2006 and 2022 who received vancomycin, had archived skin biopsy specimens, and were scored as having probable or definite DiHS/DRESS. Clinical features were retrospectively collected, and biopsy specimens were reviewed by a board‐certified dermatopathologist. A subset of histopathologic and clinical features was analyzed for statistical correlation.ResultsTwenty‐three patients met the inclusion criteria. Most biopsy specimens (87%) showed an eczematous reaction pattern; 17 (74%) showed a secondary reaction pattern. Spongiosis (87%) and neutrophilic infiltration (91%) were common epidermal characteristics. The dermal inflammatory infiltrate was frequently superficial (87%) and consistently included plasma cells (96%). Eosinophils were present in the dermis in 70% of cases. Parakeratosis negatively correlated with liver involvement and positively correlated with desquamative rash. Epidermal lymphocytes were negatively correlated with the RegiSCAR score.ConclusionsVancomycin‐associated DiHS/DRESS histopathology was characterized by a frequent eczematous reaction pattern, multiple coexisting reaction patterns, and epidermal neutrophilic infiltration.

Abstract: Background: Allergic contact Dermatitis (ACD) is a common condition within the pediatric population. Patch testing is an important way to identify relevant allergens. Objective: To provide an update of the common contact allergens seen in children based on patch testing data at our institution from 2016 to 2020. Methods: We performed a retrospective analysis of patch test data from children aged 1–18 years from 2016 to 2020 at Mayo Clinic. Reaction rates were compared to the rates reported by the Pediatric Contact Dermatitis Registry (PCDR). Results: One hundred ninety-two children aged 1–18 were patch tested to various allergens. A total of 15,457 allergens were tested, with 291 positive tests. The top 5 allergens with highest positive reaction rates were hydroperoxides of linalool, hydroperoxides of limonene, methylisothiazolinone, nickel, and cobalt. Seven of the top 38 allergens with the highest reaction rates are not currently included in the Mayo Clinic Pediatric Patch Test Series, and 11 are not currently included in the Pediatric Baseline Series (as developed by the Pediatric Contact Dermatitis Workgroup). Conclusions: Patch testing is a useful tool to diagnose children with ACD. With new products and exposures, there is an opportunity to expand current pediatric patch testing series.

AbstractBackgroundDermatology grand rounds are popular educational activities among dermatologists and trainees, contributing to improved knowledge and skills. Dermatology hospital conferences at Mayo Clinic Dermatology are separate from dermatology grand rounds in that they focus on inpatient consultations and dermatology admissions.ObjectivesThis study aimed to determine the types of cases presented during dermatology hospital grand rounds and evaluate the educational value of this continuing medical education (CME)‐accredited activity.MethodsThis retrospective study reviewed all inpatient dermatology cases presented during hospital grand rounds at Mayo Clinic Dermatology in Rochester, MN from 2019 to 2022; this study also reviewed the compiled surveys of faculty participants at our institution from 2019 to 2022.ResultsA total of 389 cases met the inclusion criteria for analysis. The most common diagnostic category was inflammatory/autoimmune diseases (157 cases, 40%), followed by infection or infestation (73 cases, 19%), drug‐induced eruptions (49 cases, 13%), neoplastic or metastatic diseases (41 cases, 11%), genetic/congenital disorders (21 cases, 5%), depositional/nutritional/metabolic conditions (15 cases, 4%) and wound/traumatic/iatrogenic dermatoses (12 cases, 3%), which were the least common. Most cases were presented for discussion of diagnosis and management (246 cases, 63%), but others focused on the arrival of diagnosis (119 cases, 31%) or management alone (24 cases, 6%). The compiled surveys of faculty participants (n = 50) indicated high satisfaction with dermatology hospital grand rounds, with the majority expressing that evidence‐based research was incorporated and positively impacted their practice. Most respondents indicated that hospital conference participation improved knowledge (97%), competence (64%), clinician performance (54%), patient outcomes (52%) and team performance (50%).ConclusionsThe cases presented during these conferences spanned from challenging inflammatory diseases to simple dermatoses, with over 800 literature references reviewed. Dermatology hospital grand rounds provide high value as a CME‐accredited activity for dermatology faculty, even for those without a specific interest in hospital/inpatient dermatology.

Background: Patch testing to a standard series is used to identify culprit allergens in patients with contact dermatitis. The reaction rates evolve over time based on trends in cutaneous exposures by the general population. Objective: The aim of this study was to analyze the patch test results of the Mayo Clinic standard series in patients tested from 2017 to 2021. Methods: The patch test reactions of standard series allergens tested from 2017 to 2021 were retrospectively reviewed and compared with the results of our prior report from 2011 to 2015 as well as the North American Contact Dermatitis Group (NACDG) report from 2017 to 2018. Results: Of 2667 patients tested, 1683 (63.1%) had at least 1 positive reaction. The 15 allergens with the highest reaction rates were hydroperoxides of linalool 1%, nickel (II) sulfate hexahydrate, methylisothiazolinone, Myroxylon pereirae resin, hydroperoxides of linalool 0.5%, methyldibromo glutaronitrile, neomycin sulfate, cobalt (II) chloride hexahydrate, fragrance mix I, benzalkonium chloride, bacitracin, hydroperoxides of limonene, methylchloroisothiazolinone/methylisothiazolinone, p-phenylenediamine, and textile dye mix. Twelve (80%) of these allergens were also in the top 15 of the most recent NACDG report. Conclusions: Hydroperoxides of linalool and hydroperoxides of limonene are new allergens that have been added to our standard series. These are associated with high reaction rates.

AbstractBackgroundVEXAS (vacuoles, E1 enzyme, X‐linked, autoinflammatory, somatic) syndrome is an autoinflammatory disease with frequent cutaneous manifestations.MethodsWe conducted a retrospective study of all patients with genetically confirmed VEXAS syndrome seen at our institution. Available clinical photographs and skin biopsy slides were reviewed.ResultsCutaneous manifestations developed in 22/25 (88%) patients with VEXAS syndrome. From this group, 10/22 (45%) developed skin involvement before or at the time of other clinical features of VEXAS. Twenty distinct dermatologic presentations of VEXAS from 14 patients were reviewed, and histopathologic patterns were classified as follows: neutrophilic urticarial dermatosis (n = 5, 25%), leukocytoclastic/urticarial vasculitis (n = 4, 20%), urticarial tissue reaction (n = 4, 20%), neutrophilic dermatosis (n = 3, 15%), neutrophilic panniculitis (n = 2, 10%), and nonspecific chronic septal panniculitis (n = 2, 10%). Common systemic findings included macrocytic anemia (96%), fever (88%), thrombocytopenia (76%), weight loss (76%), ocular inflammation (64%), pulmonary infiltrates (56%), deep venous thrombosis or pulmonary embolism (52%), and inflammatory arthritis (52%).ConclusionsCutaneous involvement is a common feature of VEXAS syndrome, and histopathologic findings exist on a spectrum of neutrophilic inflammatory dermatoses.

Abstract: Background: Trends in patch testing for allergic contact dermatitis (ACD) have not been well characterized in Black patients. Despite similar incidence of ACD in Black and White patients, there are differences in allergen profiles. Understanding patch testing trends in Black patients furthers knowledge that has considerable impact on the management of ACD in the Black population. Objective: The purpose of this study was to review the results of patch testing in Black patients at Mayo Clinic over a decade. Methods: We retrospectively reviewed the results of patch testing to the standard, extended standard, or hairdresser series in 149 Black patients seen at Mayo Clinic (Rochester, MN; Scottsdale, AZ; and Jacksonville, FL) from January 1, 2011, to December 31, 2020. Results: During the 10-year period, 149 Black patients (mean age, 49.2 years [SD, 17.1 years]; female 67.1%) were patch tested at Mayo Clinic to the standard, extended standard, or hairdresser series. Most common sites of dermatitis were generalized (30.9%), hands (18.8%), leg (16.8%), trunk (16.1%), and arm (14.8%). Overall, 109 patients (73.2%) had at least 1 positive reaction and 74 patients (50%) had 2 or more positive reactions. Overall, the 10 allergens with the highest reaction rates (from highest to lowest) identified in our study population were 4-amino-2-hyroxytoluene (33.3%), thimerosal (20.4%), nickel sulfate (18.9%), methylisothiazolinone (16.5%), methyldibromo glutaronitrile (13.4%), methyldibromo glutaronitrile/phenoxyethanol (12.5%), captan (12.5%), carmine (12.5%), methylchloroisothiazolinone/methylisothiazolinone (11.5%), and hydroperoxide of linalool 1% (11.3%). Conclusions: We describe patch test results in Black patients over a decade at Mayo Clinic. The top 10 allergens were preservatives, hair dyes, and fragrances. Differing patterns of allergens may occur in Black patients due to different patterns of exposures related to cultural practices.

Abstract Background Reactive granulomatous dermatitis (RGD) is an umbrella term used to describe interstitial granulomatous dermatitis (IGD), palisaded neutrophilic and granulomatous dermatitis (PNGD), and interstitial granulomatous drug eruption (IGDR). Objective The aim of this study was to describe systemic associations of RGD, explore possible associations between histopathologic findings and systemic RGD associations and determine clinical relevance of RGD subtypes. Methods We retrospectively studied clinical and histopathologic characteristics of patients with RGD from 1990 through 2020. Results Of 65 patients with RGD (41 women, 24 men; median age at diagnosis, 62 years), 37 had IGD, 26 had PNGD, and 2 had IGDR. Fifty patients (76.9%) had an associated systemic condition; rheumatologic conditions were identified for 34 (52.3%) patients. The associated systemic condition occurred before RGD in approximately 75% of patients. Statistical analyses did not show significant associations between specific subtypes of RGD and systemic diseases or treatment response, and specific histopathologic findings were not predictive of an associated systemic disease. Conclusions Although most patients with RGD had an associated systemic condition, subtypes of RGD did not correlate with systemic associations, lending support to the use of the umbrella term RGD .

AbstractBackground/ObjectiveThere are few studies examining pediatric scarring alopecia. The objective of this study is to characterize the clinicopathologic findings, comorbidities, and treatment outcomes of pediatric patients with scarring alopecia.MethodsRetrospective review of patients under age 18 diagnosed with scarring alopecia at Mayo Clinic from 01/01/1992 through 02/05/2019.Results27 patients met inclusion criteria with a mean age of 11.2 years and a racial breakdown of 85.2% (23) White, 11.1% (3) Black, and 3.7% (1) Multiracial. Clinical scarring was noted in most (23, 85.2%). Biopsy confirmed the diagnosis in most (24, 88.9%). The most common diagnoses were folliculitis decalvans (6, 22.2%), lichen planopilaris (6, 22.2%), aplasia cutis congenita (4, 14.8%), tinea capitis (4, 14.8%), and morphea (3, 11.1%). Comorbid depression (6, 22.2%) and anxiety (6, 22.2%) were prevalent. Of the patients who received follow‐up, most who pursued treatment achieved stabilization (55.5%) or slowing of progression (27.8%), with 44.4% of those treated experiencing regrowth. Mean time to stabilization in the treated population was 19.6 months. Two patients did not pursue treatment, but received follow‐up and these untreated patients did not experience hair regrowth.ConclusionsMost patients presented with clinically evident primary scarring alopecia. Biopsy may confirm the diagnosis. Active treatment should be pursued, and successful treatment often requires combination therapies. Time to stabilization often takes years. Screening for depression and anxiety should be pursued.