Davis, Mark D.P.

Background Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis characterized by painful and ulcerating lesions on the skin. It rarely involves the face and is often difficult to diagnose. There are few cases reported in the literature of PG involving the face. Aim To share our experience with 5 patients in whom the final diagnosis was PG involving the face, and to review the literature. Methods We report a series of 5 patients with a final diagnosis of PG involving the face and reviewed relevant literature. We searched through PubMed and EMBASE using keywords such as “face” and “pyoderma gangrenosum,” “blastomycosis-like pyoderma gangrenosum, vegetative pyoderma gangrenosum and granulomatous pyoderma gangrenosum.” Results We report 5 patients (4 females) with pyoderma gangrenosum involving the face. All 5 had a final diagnosis of superficial granulomatous PG. All cases presented with nonhealing facial ulcer most commonly on cheeks and a common histopathology of mixed inflammatory infiltrates, multinucleated giant cells, and plasma cells with some granulomatous inflammation. Conclusions PG can involve the face, and all 5 of our patients had the superficial granulomatous as the most common form.

AbstractBackgroundFew large studies have assessed spironolactone treatment of adult female acne.ObjectivesTo explore the role of spironolactone in the treatment of adult female acne.MethodsWe performed a retrospective case series assessing the efficacy of spironolactone treatment of a cohort of women evaluated at Mayo Clinic in Rochester, Minnesota, from 2007 through 2017.ResultsIn total, 395 patients (median age, 32 years) received a median spironolactone dose of 100 mg daily. Approximately two‐thirds of patients (66.1%) had a complete response; 85.1% had a complete response or a partial response greater than 50%. Median times to initial response and maximum response were 3 and 5 months. Efficacy was observed across all severity subtypes of acne, including those with papulopustular and nodulocystic acne. Patients received long‐term treatment with spironolactone (median duration, 13 months) and had few adverse effects.ConclusionsSpironolactone is a safe and effective treatment of acne for women.

Background A major question in patch testing is when to perform the final reading. Our current standard practice is to place patches on day 1, remove them on day 3, and perform readings on days 3 and 5. For certain allergens, another reading is performed sometime from days 7 to 14≥. Objectives The aim of the study was to identify allergens with positive reactions on day 5 that were negative on day 7 or later and allergens with negative reactions on day 5 that were subsequently positive on day 7 or later. Methods We reviewed records of patients who underwent patch testing from January 2007 to December 2016 at Mayo Clinic with readings on day 5 and day 7 or later. Conclusions In total, 131 allergens had positive reactions on day 5 that were negative on day 7 or later, and 58 allergens had negative reactions on day 5 that were positive on day 7 or later. Twenty-five allergens had significantly higher reaction rates on day 5 than day 7 or later. Our standard practice is to perform readings on days 3 and 5 and on days 3, 5, and 7 or later for series containing metals. Readings on days 3, 5, and 7 or later should also be considered for acrylates.

When the final patch test reading is barely discernable, it is termed a doubtful, macular erythema , “?+,” or “+/−” reaction (hereby referred to as doubtful reaction ). Information is conflicting about how to interpret doubtful reactions. Many guidelines do not comment on how to approach doubtful reactions; others state that further evaluation can (not should) be performed. In clinical reports, some investigators regard them as positive allergic reactions; some, as positive under certain circumstances; and many, as negative. Indeed, 16 (84%) of 19 recent reports of patch test reactions to standard/baseline series considered doubtful reactions negative for purposes of the report and did not include the number of these reactions. The problem is that these reactions are common and are not infrequently relevant. We recommend that researchers include frequency of doubtful reactions in reports and that doubtful reactions be assessed with the same scrutiny as stronger allergic reactions in the clinical setting.

AbstractAimEosinophilic fasciitis (EF) is a rare, fibrosing disorder of skin and subcutaneous tissue. This study was undertaken to describe its clinical and laboratory features and identify prognostic factors associated with outcome.MethodsWe conducted a retrospective review of all EF patients evaluated at our institution from 1 January1997 to 30 December 2016. Kaplan‐Meier methods were used to determine treatment response rates over time. Potential associations between baseline characteristics and complete response were examined using Cox models adjusted for age and sex. Time‐dependent covariates were used to examine treatment effects.ResultsWe identified 89 EF patients, with a female‐to‐male ratio of 1:1. Clinical features included groove sign in 26 (29%), peau d'orange/dimpling in 22 (25%), inflammatory arthritis in 9 (10%) and muscle weakness in 9 (10%). Aldolase was elevated in 11/36 (31%). Complete response rate was 60% (95% confidence interval [CI]: 35‐75) at 3 years. Diagnostic delay was inversely associated with treatment response (hazards ratio: 0.84 per 1 month increase; 95% CI: 0.73‐0.98). No baseline characteristics correlated with treatment response, but a trend toward positive association of elevated aldolase, hypergammaglobulinemia and presence of hematologic disorders was noted. Methotrexate was the most commonly used immunosuppressant in 79%, hydroxychloroquine in 45%, mycophenolate mofetil in 18% and azathioprine in 8%. No single immunosuppressant agent was associated with a superior response during treatment.ConclusionsEF is characterized by relatively high response rates. Consensus diagnostic criteria, standardized management algorithms, and large prospective multi‐center cohorts are needed to develop an evidence‐directed approach to this challenging condition.

Background: The standard allergen series used in patch testing contains metals that most commonly cause allergic contact dermatitis, but testing with additional metal allergens is warranted for select patients. Objective: To report our experience with patch testing of metals. Methods: We retrospectively analyzed outcomes of 1,112 patients suspected of having metal allergies. Patients were seen from January 1, 2000, through December 31, 2009. Patch testing was performed with 42 metal preparations (6 in the standard series, 36 in the metal series). Results: Patch testing most commonly was performed for patients with oral disease (almost half the patients), hand dermatitis, generalized dermatitis, and dermatitis affecting the lips, legs, arms, trunk, or face. At least one positive reaction was reported for 633 patients (57%). Metals with the highest allergic patch-test reaction rates were nickel, gold, manganese, palladium, cobalt, Ticonium, mercury, beryllium, chromium, and silver. Metals causing no allergic patch-test reactions were titanium, Vitallium, and aluminum powder. Metals with extremely low rates of allergic patch-test reactions included zinc, ferric chloride, and tin. Reaction rates varied depending on metal salt, concentration, and timing of readings. Conclusion: Many metals not in the standard series were associated with allergic patch-test reactions. The many questions raised by these findings, concerning patch testing with individual metals, will be the subject of future studies.

Background: Hairdressing chemicals may be associated with allergic contact dermatitis. Objective: To review our experience of patch-testing with hairdressing chemicals. Methods: We reviewed results from patients who underwent patch testing with our standard allergen series (including 15 hairdressing chemicals) and a supplementary “hairdresser series” (18 additional hairdressing chemicals) at Mayo Clinic (Rochester, MN; Scottsdale, AZ; and Jacksonville, FL) from January 1, 2000, through December 31, 2008. Results: Two hundred ten patients (mean age, 53.8 years [SD, 16.9 yr]; female, 94.8%) were patch-tested. The most common sites of dermatitis were the scalp, face, and hands. Patients had widely varying occupations. The most common occupations were cosmetologist (10.5%), housewife (9.5%), and beautician (5.2%); 14.3% were retired. The hairdresser series detected 13 additional patients with allergies (6.4%; 204 patients tested with both series) who would not have been detected with the standard allergen series alone. The highest allergic patch-test rates in the supplemental hairdresser series were with ammonium persulfate (14.4%), 4-aminoazobenzene (13.4%), and pyrogallol (9.1%). Conclusions: Patch-testing with hairdressing-specific chemicals (standard series plus supplemental hairdresser series) was appropriate for numerous clinical situations and was not limited to patients in hair care occupations. The supplemental hairdresser series helped identify more patients than would have been identified with the standard series alone.

Background: Few US studies have reported results of patch testing with plastics and glues. Objective: To report our institution's results of testing patients suspected of allergy to plastics and glues with a comprehensive plastics and glues series and to compare these results with previously published data. Methods: Retrospective review of results of patch-testing with plastics and glues allergens at our institution between 2000 and 2007. In total, 444 patients were patch-tested with up to 56 plastics and glues allergens in the specialized series and up to five plastics and glues allergens in a baseline series. Positive-reaction rates were compared to other patch testing reports. Results: Of patients, 97 (22%) had irritant reactions, and 201 (45%) had at least one allergic reaction. Bis(2-dimethylaminoethyl) ether 1%, benzoyl peroxide 1%, epoxy resin, bisphenol F 0.25%, 2-hydroxyethyl methacrylate 2%, and 2-hydroxyethyl acrylate 0.1% had the highest allergy reaction rates. Testing with specialized series identified 193 patients with plastics and glues allergy, of whom 162 were not identified by testing with baseline series alone. Conclusion: For patients suspected of allergy to plastics and glues, patch-testing with specialized series of plastics and glues allergens is an important adjunct to patch-testing with baseline series.