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This Month in Archives of Dermatology
Oct 2011

This Month in Archives of Dermatology

Arch Dermatol. 2011;147(10):1142. doi:10.1001/archdermatol.2011.276

Ustekinumab is a fully human immunoglobulin that binds to important cytokines in the pathogenesis of psoriasis. In this case report, Gratton et al describe a single case of reversible posterior leukoencephalopathy syndrome (RPLS) observed in a ustekinumab clinical trial for psoriasis. A reversible neurologic syndrome, RPLS is characterized by acute headache, visual disturbances, altered mental status, seizures, transient cerebral edema, and infarction in the posterior brain. The syndrome is often associated with hypertension, autoimmune diseases, and treatment with immunosuppressive agents. The clinical features of this case were atypical of drug-associated RPLS. Although the relationship between ustekinumab and RPLS remains unclear, this case emphasizes the need for dermatologists to recognize the syndrome and refer patients for appropriate evaluation and treatment.

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Several studies have attempted to demonstrate that chronic pruritus has a significant effect on health-related quality of life (QoL). Chronic pain and chronic pruritus share many similarities, and in this cross-sectional study, Kini et al determine the QoL impact of these 2 conditions by measuring health utility scores. Chronic pruritus was found to have a substantial impact on QoL, comparable to that of pain. The severity of symptoms and use of support networks are factors that determine the degree to which patients are affected by their symptoms.

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Spitz tumors have long drawn interest because a reasonable subset of these lesions appears to metastasize and yet not prove fatal. In this case series drawn from a pathology database, Sepehr et al demonstrate that the long-term clinical outcome of patients with Spitz tumors is good, with a highly favorable prognosis. An increased risk of melanoma was seen among patients with classic Spitz nevus as well as those with atypical Spitz tumors. The authors suggest that minimizing aggressive treatment for localized lesions and offering continued surveillance for rare relapse and subsequent melanomas is warranted.

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Twelve case series have reported a variable response rate of lentigo maligna (LM) to imiquimod, but these studies varied widely in methodology. In this open-label before-and-after interventional study, Ly et al use imiquimod cream, 5%, 5 days a week for 12 weeks to treat 43 patients with LM, and then the original lesion was then excised. A total of 53% of patients demonstrated histopathologic clearance of LM, and the positive predictive value of visible inflammation at the treatment site was low. Imiquimod cream, 5%, as monotherapy has lower efficacy in treating LM than does surgical excision, but its efficacy may be comparable to that of other nonsurgical options, and close follow-up of patients treated with this technique is warranted.

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Interleukin 23 (IL-23) is involved in the pathogenesis of Crohn disease, with which pyoderma gangrenosum (PG) may be associated. Because IL-23 plays a critical role in driving inflammation and neutrophil production in inflammatory bowel diseases and psoriasis, PG may be driven by similar mechanisms. In this case report, Guenova et al demonstrate an IL-23 –dominated inflammatory infiltrate in a case of PG, as well as complete resolution of the ulcer at week 14 of treatment. Six months after the last ustekinumab dose, no relapse was observed.

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