Publications by authors named "Scott Worswick"

61 Publications

Pityriasis rubra pilaris: a bibliometric analysis.

Int J Dermatol 2021 Feb 20. Epub 2021 Feb 20.

Division of Dermatology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.

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http://dx.doi.org/10.1111/ijd.15434DOI Listing
February 2021

Cutaneous manifestations of COVID-19.

Dermatol Online J 2021 Jan 15;27(1). Epub 2021 Jan 15.

Department of Dermatology, Keck School of Medicine, University of Southern California, Los Angeles, CA.

The severe acute respiratory syndrome coronavirus two (SARS-CoV-2), which causes the 2019 coronavirus disease (COVID-19), has infected patients worldwide. Physicians have increasingly identified cutaneous findings as a significant clinical manifestation of COVID-19. In this review, we describe the clinical presentation, onset, duration, associated symptoms, treatment, and outcome of cutaneous manifestations thus far reported to be related to COVID-19. We have included data from 63 studies and subdivided reported cutaneous manifestations into the categories of viral exanthem, urticarial, vesicular, chilblains/chilblains-like, non-chilblains vasculopathy-related, pityriasis rosea-like, erythema multiforme-like, Kawasaki/Kawasaki-like disease, and others. Physicians should be aware of the known common cutaneous manifestations of COVID-19 and future research is required to better understand the pathophysiology and prognosis of each COVID-19-related skin manifestation.
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January 2021

Sweet syndrome as an adverse reaction to tyrosine kinase inhibitors: A review.

Dermatol Ther 2021 Jan 5;34(1):e14461. Epub 2020 Nov 5.

Division of Dermatology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.

Tyrosine kinase inhibitors are a class of targeted anticancer drugs that inhibit cancer cell proliferation by inactivating proteins involved in signal transduction cascades. Various cutaneous adverse events have been observed after tyrosine kinase inhibitor administration, including Sweet syndrome. We queried the PubMed database to identify 14 cases of Sweet syndrome thought to be secondary to tyrosine kinase inhibitors. Tyrosine kinase inhibitor-induced Sweet syndrome had a median of 2 months latency following drug administration. All cases but one had morphologic features classic for Sweet syndrome (erythematous and tender papules, plaques, or nodules). All cases also had classic histopathologic findings (dermal neutrophilic infiltrate without vasculitis or necrosis). Using diagnostic criteria for drug-induced Sweet syndrome and the Naranjo Drug Reaction Probability Scale for a drug-induced cutaneous eruption, we found that six cases favored a drug-induced etiology over malignancy, two cases favored a malignancy-associated Sweet syndrome, and the remaining eight met drug-induced Sweet syndrome criteria but had low Naranjo scores. Nine cases resulted in medication discontinuation, while five cases continued anticancer therapy and were treated only with corticosteroids with quick resolution of skin lesions. Dermatologists should be aware of this adverse cutaneous reaction to tyrosine kinase inhibitors and should treat on a case-by-case basis, though limited evidence in this review suggests that oncologic therapy may safely be continued with prompt corticosteroid treatment.
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http://dx.doi.org/10.1111/dth.14461DOI Listing
January 2021

Stevens-Johnson syndrome and toxic epidermal necrolysis in pregnant patients: A systematic review.

Int J Womens Dermatol 2020 Sep 13;6(4):239-247. Epub 2020 Apr 13.

Department of Dermatology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States.

Background: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are two of the most severe dermatologic emergencies. Although pregnant women comprise a subset of individuals at risk for SJS and TEN development, little is known with regard to outcomes and treatment.

Objective: This study aimed to conduct a systematic review to characterize the risk factors, outcomes, and treatment of SJS and TEN in pregnant patients and newborns.

Methods: A primary literature search was conducted using PubMed in September 2019, using the following search terms entered in separate pairs: or and or or Reviews, studies in a language other than English, and articles not including pregnant patients were excluded.

Results: Twenty-six articles were included for review, including a total of 177 patients. The average maternal age for a reaction was 29.9 years, gestational age was 24.9 weeks, and time to reaction after drug initiation was 27.5 days. Approximately 85% of pregnant women in this review were infected with HIV. The most common causative medications were antiretroviral therapy (90% of all cases), antibiotics (3%), and gestational drugs (2%). Of the 94 cases in which outcome data were available, the survival rates of pregnant women and newborns after delivery were 98% and 96%, respectively. Withdrawal of the offending agent and supportive care was often sufficient for treatment, but antibiotics, steroids, and intravenous immunoglobulin were implemented in some cases. Complications included preterm labor, vaginal stenosis, and vaginal adhesions.

Conclusion: Given the predominance of studies focusing on the subset of pregnant patients who are infected with HIV, SJS and TEN is most commonly reported in young patients after antiretroviral therapy, primarily nevirapine. Overall mortality is lower than that of the general population, but similar to the expected mortality rates of younger adults. Early recognition and withdrawal of the offending agent is essential to mitigate the distinct consequences of these conditions in the pregnant population.
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http://dx.doi.org/10.1016/j.ijwd.2020.04.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7522894PMC
September 2020

Overlap between hemophagocytic lymphohistiocytosis and drug reaction and eosinophilia with systemic symptoms: a review.

Int J Dermatol 2020 Sep 21. Epub 2020 Sep 21.

Department of Dermatology, Keck School of Medicine at the University of Southern California, Los Angeles, CA, USA.

Drug reaction and eosinophilia with systemic symptoms (DRESS), also known as drug-induced hypersensitivity syndrome (DIHS), shares features with hemophagocytic lymphohistiocytosis (HLH), most notably fever, rash, and internal organ involvement. However, there is increasing recognition of drug-induced (secondary) HLH and biopsy-proven hemophagocytosis in DRESS, suggesting that HLH and DRESS not only overlap but also may be diseases on the same spectrum of immune dysfunction. To characterize existing literature on HLH/DRESS overlap, we queried the PubMed/MEDLINE database for 23 cases of HLH-DRESS codiagnosis. Average time-to-onset of rash after exposure to inciting drug was 2.7 weeks. Fourteen cases (61%) clinically worsened despite initial therapy, prompting a workup with diagnosis of HLH on average 2.3 weeks after diagnosing DRESS. Nine cases met HLH diagnostic criteria and had a RegiSCAR score ≥4. Nine cases met one set of criteria with a presentation suggestive of the other. Five cases met neither criteria. A patient presenting with fever, generalized rash, bicytopenia, and internal organ involvement after drug exposure was most predictive of meeting diagnostic criteria for both HLH and DRESS. Treatment was highly variable, although most initiated systemic corticosteroids with/without IVIG, plasmapheresis, or etoposide. Patients with poor outcomes in this review were treated using steroid monotherapy and had viral reactivation. Dermatologists should consider the possibility of HLH in any patient presenting with fever, rash, internal organ involvement, and cytopenia. Additional studies will be necessary to further characterize HLH and DRESS overlap and determine optimal management.
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http://dx.doi.org/10.1111/ijd.15196DOI Listing
September 2020

Purpuric plaques with hemorrhagic bullae on both arms.

JAAD Case Rep 2020 Aug 24;6(8):796. Epub 2020 Apr 24.

University of Chicago Pritzker School of Medicine, Chicago, Illinois.

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http://dx.doi.org/10.1016/j.jdcr.2020.04.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7426217PMC
August 2020

Nodular secondary syphilis in three HIV-positive patients: a case series.

Int J STD AIDS 2020 Sep 21;31(10):1004-1007. Epub 2020 Jul 21.

Department of Dermatology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.

Nodular secondary syphilis is an uncommon variant of secondary syphilis. We identified three cases of nodular secondary syphilis at our institution. The first patient presented with a diffuse nodular rash that included his scrotum and penis. The second patient had disseminated skin-colored nodules with serosanguinous crust on his face, trunk, and extremities. The third patient had a pruritic papular and nodular rash with overlying crust. All three patients had a reactive rapid plasma reagin and tested positive for fluorescent treponemal antibody absorption. All were eventually confirmed to be human immunodeficiency virus-positive. Histopathological examination demonstrated inflammatory infiltrate in the dermis composed of lymphocytes, histiocytes, and plasma cells, and treponemal staining highlighted spirochetes in the dermis. The patients were successfully treated with intramuscular penicillin benzathine G. Physicians should be aware of nodular syphilis as a less common cutaneous manifestation of secondary syphilis. Prompt diagnosis of secondary syphilis can expedite resolution of the infection and avoid progression to tertiary syphilis.
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http://dx.doi.org/10.1177/0956462420933787DOI Listing
September 2020

Corrigendum: Thiotepa hyperpigmentation preceding epidermal necrosis: malignant intertrigo misdiagnosed as Stevens-Johnson syndrome-toxic epidermal necrolysis overlap.

Dermatol Online J 2020 Mar 15;26(3). Epub 2020 Mar 15.

Cedars Dermatology, Cedars Sinai Medical Group, CA.

The original article was published on February 15, 2020 and corrected on March 15, 2020.The revised version of the article corrects the contact information of the Corresponding Author. The changes appear in the revised online PDF copy of this article.
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March 2020

Herpes associated erythema multiforme: A retrospective study.

Am J Emerg Med 2020 12 29;38(12):2761.e1-2761.e3. Epub 2020 May 29.

University of Southern California Keck School of Medicine, Department of Dermatology, United States of America.

Background: Erythema multiforme (EM), an acute dermatologic condition frequently encountered in the Emergency Department, classically presents with a targetoid rash. We reviewed all recent EM cases seen at the LAC-USC County Hospital in order to ascertain the proportion of Herpes associated EM (HAEM) cases and to inform the diagnostic workup of these patients.

Methods: ICD-9 and ICD-10 codes were used to extract a list of EM cases at our institution from 2013 to 2019. Two non-blinded abstractors screened records to confirm an EM diagnosis and entered patient data utilizing a standardized data abstraction form. Cohen's kappa statistic was used to measure inter-rater reliability on various variables. Kappa (κ) values ranged from 0.803 to 1.0.

Results: 70 pediatric and 56 adult EM patients were included in the study. A likely etiology was ascribed to 63% of pediatric and adult EM cases. Pediatric EM was most commonly attributed to upper respiratory infection (URI) (n = 23; 33%), Mycoplasma pneumoniae infection (n = 5; 7%), and medications (n = 4; 6%). Adult EM was most commonly attributed to HSV infection (n = 11; 20%), medications (n = 5; 9%), URIs (n = 4; 7%), and other infections (n = 4; 7%).

Conclusion: HSV-1/2 serologic testing should be considered in most EM patients to potentially prevent repeated ED visits. In EM cases not clearly attributable to herpes or drug exposure, physicians can consider further workup: Mycoplasma serology, nasal PCR, and a respiratory viral panel in pediatric patients. Identification of an etiologic cause may suggest a different treatment approach and prevent mislabeling of medication allergies in patient charts.
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http://dx.doi.org/10.1016/j.ajem.2020.05.084DOI Listing
December 2020

Use of teledermatology by dermatology hospitalists is effective in the diagnosis and management of inpatient disease.

J Am Acad Dermatol 2020 May 7. Epub 2020 May 7.

Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts. Electronic address:

Background: Patient outcomes are improved when dermatologists provide inpatient consultations. Inpatient access to dermatologists is limited, illustrating an opportunity to use teledermatology. Little is known about the ability of dermatologists to accurately diagnose disease and manage inpatients with teledermatology, particularly when using nondermatologist-generated clinical data.

Methods: This prospective study assessed the ability of teledermatology to diagnose disease and manage 41 dermatology consultations from a large urban tertiary care center, using internal medicine referral documentation and photographs. Twenty-seven dermatology hospitalists were surveyed. Interrater agreement was assessed by the κ statistic.

Results: There was substantial agreement between in-person and teledermatology assessment of the diagnosis with differential diagnosis (median κ = 0.83), substantial agreement in laboratory evaluation decisions (median κ = 0.67), almost perfect agreement in imaging decisions (median κ = 1.0), and moderate agreement in biopsy decisions (median κ = 0.43). There was almost perfect agreement in treatment (median κ = 1.0), but no agreement in follow-up planning (median κ = 0.0). There was no association between raw photograph quality and the primary plus differential diagnosis or primary diagnosis alone.

Limitations: Selection bias and single-center nature.

Conclusions: Teledermatology may be effective in the inpatient setting, with concordant diagnosis, evaluation, and management decisions.
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http://dx.doi.org/10.1016/j.jaad.2020.04.171DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7204758PMC
May 2020

Residency training during the #MeToo movement.

Cutis 2020 Mar;105(3):111-112

Department of Dermatology, Keck School of Medicine, University of Southern California, Los Angeles, USA.

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March 2020

Thiotepa hyperpigmentation preceding epidermal necrosis: malignant intertrigo misdiagnosed as Stevens-Johnson syndrome-toxic epidermal necrolysis overlap.

Dermatol Online J 2020 Feb 15;26(2). Epub 2020 Feb 15.

Cedars Dermatology, Cedars Sinai Medical Group, CA.

Thiotepa is a common alkylating agent known to precipitate cutaneous reactions consistent with toxic erythema of chemotherapy, including erythema and hyperpigmentation. Herein, we describe an atypical case of malignant intertrigo involving preferential erythema and desquamation not only of skin folds but also of occluded areas after thiotepa-based conditioning. The diagnosis was complicated by concurrent stomatitis and oral petechiae in the setting of autologous stem cell transplant 11 days prior for diffuse large B-cell lymphoma. Histopathological examination from two cutaneous sites demonstrated epidermal dysmaturation and eccrine gland necrosis consistent with thiotepa-induced desquamation and not Stevens-Johnson syndrome or graft-versus-host-disease. Malignant intertrigo can present with extensive cutaneous involvement, as evidenced by our patient who had 25% body surface area affected. Mucosal involvement is common with most chemotherapeutic regimens and its presence should not deter the astute clinician from consideration of a diagnosis of toxic erythema of chemotherapy. No further interventions were needed and the patient healed spontaneously.
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February 2020

Bullous Pemphigoid and Malignancy in Two Different Hospital Populations: A Retrospective Cohort Review.

Oncology 2020 17;98(5):318-320. Epub 2020 Mar 17.

Keck-USC Department of Dermatology, Los Angeles, California, USA.

Background: Bullous pemphigoid (BP) is a rare autoimmune blistering condition characterized by antibodies to the structural proteins BP1 and BP2 at the dermal-epidermal junction. The link between BP and malignancy remains unclear. Due to the rarity of the disease, there have been few studies with small sample sizes characterizing the association between BP and malignancy.

Objectives: There were two main goals of this retrospective cohort study: (1) to look at the associated risk of malignancy in patients with BP compared to controls and (2) to compare the rates of malignancy in two separate hospitals with differing patient populations.

Method: We reviewed the medical records of 99 patients diagnosed with BP observed between 2014 and 2019. 66 patients were from Keck Hospital and 33 were from Los Angeles County/University of Southern California (LAC/USC) Hospital. Each patient was age- and sex-matched to a control from the same hospital.

Results: Malignancies occurred in 26 BP patients and 29 controls. 7 of the BP patients from LAC/USC Hospital (21.2%) and 19 patients from Keck Hospital (28.8%) had malignancies.

Conclusions: Overall, we did not find an increased risk of malignancy in BP patients compared to controls, nor did we find a statistically differing rate of malignancy in BP patients from various socioeconomic and ethnic backgrounds.
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http://dx.doi.org/10.1159/000506055DOI Listing
May 2020

Society of Dermatology Hospitalists supportive care guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in adults.

J Am Acad Dermatol 2020 Jun 7;82(6):1553-1567. Epub 2020 Mar 7.

Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania.

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are life-threatening conditions with high morbidity and mortality. Supportive care management of SJS/TEN is highly variable. A systematic review of the literature was performed by dermatologists, ophthalmologists, intensivists, and gynecologists with expertise in SJS/TEN to generate statements for supportive care guideline development. Members of the Society of Dermatology Hospitalists with expertise in SJS/TEN were invited to participate in a modified, online Delphi-consensus. Participants were administered 9-point Likert scale questionnaires regarding 135 statements. The RAND/UCLA Appropriateness Method was used to evaluate and select proposed statements for guideline inclusion; statements with median ratings of 6.5 to 9 and a disagreement index of ≤1 were included in the guideline. For the final round, the guidelines were appraised by all of the participants. Included are an evidence-based discussion and recommendations for hospital setting and care team, wound care, ocular care, oral care, urogenital care, pain management, infection surveillance, fluid and electrolyte management, nutrition and stress ulcer prophylaxis, airway management, and anticoagulation in adult patients with SJS/TEN.
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http://dx.doi.org/10.1016/j.jaad.2020.02.066DOI Listing
June 2020

Stevens-Johnson syndrome and toxic epidermal necrolysis-like reactions to checkpoint inhibitors: a systematic review.

Int J Dermatol 2020 Jun 13;59(6):e183-e188. Epub 2020 Feb 13.

Department of Dermatology, Keck School of Medicine at the University of Southern California, Los Angeles, CA, USA.

The use of checkpoint inhibitors for treatment of advanced malignancies is increasing. Rashes, pruritus, and more rarely, reactions resembling Stevens-Johnsons syndrome (SJS) or toxic epidermal necrolysis (TEN) may occur secondary to checkpoint inhibitors. To characterize existing literature on these reports, we queried the PubMed/MEDLINE database for cases of SJS or TEN associated with checkpoint inhibitors. We identified 18 cases of SJS or TEN-like reactions to checkpoint inhibitors in the literature. There were 12 cases of SJS-like rashes with median time to onset of 5.6 weeks (average of 8.9 weeks), of which five were delayed to week 8 or later from checkpoint inhibitor initiation. The five TEN-like reactions had a median time to onset of 4 weeks (average of 5.38 weeks), of which two were delayed to week 6 or later. SJS/TEN-like reactions to nivolumab (seven cases) had median onset time of 3 weeks, whereas five cases secondary to pembrolizumab had median onset time of 11 weeks. Seven cases in this study described prodromal rashes, which varied from localized papular rashes to generalized morbilliform rashes, prior to evolution into SJS or TEN-like patterns. SJS-like patterns generally improved well on systemic treatment/supportive care and no cases of death were identified, but mortality occurred in three of five patients with TEN-like reactions. Dermatologists should consider the possibility for unique features of SJS/TEN in response to checkpoint inhibitors. Additional studies will be necessary to further characterize SJS/TEN-like eruptions on checkpoint inhibitors and determine the optimal management of these cases.
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http://dx.doi.org/10.1111/ijd.14811DOI Listing
June 2020

Verrucous venous malformation.

Dermatol Online J 2019 Dec 15;25(12). Epub 2019 Dec 15.

Department of Dermatology, Keck School of Medicine, University of Southern California, Los Angeles, CA.

Verrucous venous malformation, also known as verrucous hemangioma, is a superficial vascular malformation with a variable degree of hyperkeratosis that is composed of capillaries and veins in the dermis and sometimes subcutaneous tissue. We describe a 53-year-old man who presented with a large hyperkeratotic plaque of the left dorsal and plantar foot. Biopsy revealed verrucous acanthosis of the epidermis and a proliferation of thin-walled vessels in the dermis. We provide a brief review of the clinical and histopathologic presentation, differential diagnosis, and management of this rare entity.
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December 2019

Dupilumab in Dermatology: Potential for Uses Beyond Atopic Dermatitis

J Drugs Dermatol 2019 Oct;18(10)

Dupilumab inhibits the interleukin-4 receptor subunit α and is FDA approved for treatment of moderate-to-severe atopic dermatitis. It is a relatively new drug, and whether it is efficacious for other diseases in dermatology is an area of increasing interest. We searched the literature and ClinicalTrials.gov database for uses of dupilumab beyond atopic dermatitis in dermatology and for ongoing studies on new uses for dupilumab. Off-label reports identified described use of dupilumab for several different dermatologic conditions, including allergic contact dermatitis, hand dermatitis, chronic spontaneous urticaria, prurigo nodularis, and alopecia areata. Overall, there is limited but promising data for dupilumab use beyond atopic dermatitis in dermatology. The relatively safe adverse effect profile of dupilumab may make it an option for certain recalcitrant diseases in dermatology, but further studies will be needed to assess its efficacy and determine its best possible use. J Drugs Dermatol. 2019;18(10):1053-1055.
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October 2019

Cutaneous Metastasis of Internal Tumors.

Dermatol Clin 2019 Oct 10;37(4):545-554. Epub 2019 Jul 10.

Department of Dermatology, Keck School of Medicine, University of Southern California, 1441 Eastlake Avenue, Ezralow Tower, Suite 5301, Los Angeles, CA 90033-9174, USA. Electronic address:

Cutaneous metastasis portends a poor prognosis. Therefore, a high clinical index of suspicion is necessary so that a clinician knows how to recognize the presentation of a cutaneous metastasis, while the pathologist must know the appropriate stains to order. In this review, the authors summarize the common and uncommon ways that these tumors will present. Frequently a metastatic cancer will present as a firm red nodule or as a plaque, ulcer, or papule. Less commonly they will present with a clinical clue that can alert a clinician to a likely diagnosis; these manifestations include alopecic, vesicular, blue color, sclerodermoid, acrochordon-, or pellagra-like.
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http://dx.doi.org/10.1016/j.det.2019.05.012DOI Listing
October 2019

Twenty-year-old woman presenting with typical Kawasaki disease.

Dermatol Online J 2019 Jul 15;25(7). Epub 2019 Jul 15.

Division of Dermatology, Department of Medicine, University of California at Los Angeles, CA Department of Dermatology, University of California at San Francisco, CA.

We describe adult-onset Kawasaki disease (KD) and review clinical manifestations and treatment guidelines. Our patient is a 20-year-old female who initially presented to an outside hospital for fever, cervical lymphadenopathy, malaise, exudative tonsillitis, and skin eruption. She received antibiotics for suspected exudative pharyngitis, but experienced continued fevers and presented to the UCLA emergency room one week later. She had diffuse petechial macules coalescing into reticulated patches, fingertip peeling, conjunctival injection, oral erosions, and tongue swelling. Despite her age, given her constellation of symptoms, a diagnosis of typical KD was favored. She was started on high dose aspirin and IVIG, with improvement of rash and conjunctivitis. She was discharged on 325mg of aspirin daily with close follow-up. This case highlights the challenge of diagnosing KD in adults. Although this patient had classic symptoms, she was likely misdiagnosed because KD is rare in adults and without validated criteria. Our patient met the pediatric criteria, suggesting these should be considered when clinical suspicion for adult-onset KD is high. Adult-onset KD is most commonly misdiagnosed as toxic shock syndrome or drug-induced hypersensitivity syndrome and these are important to rule-out. Treatment with high-dose aspirin and IVIG is well established and should be initiated promptly.
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July 2019

Neutrophilic dermatoses as adverse effects of checkpoint inhibitors: A review.

Dermatol Ther 2019 09 4;32(5):e13074. Epub 2019 Sep 4.

Department of Dermatology, Keck School of Medicine at the University of Southern California, Los Angeles, California.

Checkpoint inhibitors are a new class of drugs that enhance the immune system's intrinsic ability to destroy tumor cells by blocking signaling through the programmed cell death (PD-1) receptor, its ligand (PD-L1), and the cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4). The resulting increase in immunologic activity is responsible for a variety of adverse cutaneous reactions, which sometimes include neutrophilic dermatoses. We queried the PubMed database for existing cases of checkpoint inhibitors causing neutrophilic dermatoses. The literature search identified four cases of Sweet syndrome, four cases of pustular eruptions, two cases of pyoderma gangrenosum, and one case of bullous lupus erythematosus secondary to checkpoint inhibitors. All neutrophilic dermatoses were treated with topical or systemic steroids and most (9 of 11) completely resolved. Dermatologists should be aware of these rare, adverse cutaneous reactions to checkpoint inhibitors and how to approach their treatment, especially as their use increases.
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http://dx.doi.org/10.1111/dth.13074DOI Listing
September 2019

Patient experiences with biologics and apremilast in pityriasis rubra pilaris: A patient survey.

Dermatol Ther 2019 09 18;32(5):e13060. Epub 2019 Aug 18.

Department of Dermatology, University of Southern California, Los Angeles, California.

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http://dx.doi.org/10.1111/dth.13060DOI Listing
September 2019

Development and Validation of a Risk Prediction Model for In-Hospital Mortality Among Patients With Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis-ABCD-10.

JAMA Dermatol 2019 04;155(4):448-454

Department of Dermatology, University of Pennsylvania, Philadelphia.

Importance: Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a spectrum of severe mucocutaneous drug reaction associated with significant morbidity and mortality. A previously developed SJS/TEN-specific severity-of-illness model (Score of Toxic Epidermal Necrolysis [SCORTEN]) has been reported to overestimate and underestimate SJS/TEN-related in-hospital mortality in various populations.

Objective: To derive a risk prediction model for in-hospital mortality among patients with SJS/TEN and to compare prognostic accuracy with the SCORTEN model in a multi-institutional cohort of patients in the United States.

Design, Setting, And Participants: Data from a multicenter cohort of patients 18 years and older treated for SJS/TEN between January 1, 2000, and June 1, 2015, were obtained from inpatient consult databases and electronic medical record systems at 18 medical centers in the United States as part of the Society for Dermatology Hospitalists. A risk model was derived based on data from 370 of these patients. Model discrimination (calculated as area under the receiver operating characteristic curve [AUC]) and calibration (calculated as predicted vs observed mortality, and examined using the Hosmer-Lemeshow goodness-of-fit statistic) were assessed, and the predictive accuracy was compared with that of SCORTEN. All analysis took place between December 2016 and April 2018.

Main Outcomes And Measures: In-hospital mortality.

Results: Among 370 patients (mean [SD] age 49.0 [19.1] years; 195 [52.7%] women), 54 (15.14%) did not survive to hospital discharge. Five covariates, measured at the time of admission, were independent predictors of in-hospital mortality: age in years (odds ratio [OR], 1.05; 95% CI, 1.02-1.07), body surface area (BSA) in percentage of epidermal detachment (OR, 1.02; 95% CI, 1.01-1.04), serum bicarbonate level below 20 mmol/L (OR, 2.90; 95% CI, 1.43-5.88), active cancer (OR, 4.40; 95% CI, 1.82-10.61), and dialysis prior to admission (OR, 15.94; 95% CI, 3.38-66.30). A severity-of-illness score was calculated by taking the sum of 1 point each for age 50 years or older, epidermal detachment greater than 10% of BSA, and serum bicarbonate level below 20 mmol/L; 2 points for the presence of active cancer; and 3 points for dialysis prior to admission. The score was named ABCD-10 (age, bicarbonate, cancer, dialysis, 10% BSA). The ABCD-10 model showed good discrimination (AUC, 0.816; 95% CI, 0.759-0.872) and calibration (Hosmer-Lemeshow goodness of fit test, P = .30). For SCORTEN, on admission, the AUC was 0.827 (95% CI, 0.774-0.879) and was not significantly different from that of the ABCD-10 model (P = .72).

Conclusions And Relevance: In this cohort of patients with SJS/TEN, ABCD-10 accurately predicted in-hospital mortality, with discrimination that was not significantly different from SCORTEN. Additional research is needed to validate ABCD-10 in other populations. Future use of a new mortality prediction model may provide improved prognostic information for contemporary patients, including those enrolled in observational studies and therapeutic trials.
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http://dx.doi.org/10.1001/jamadermatol.2018.5605DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6459085PMC
April 2019

Development of alopecia in patients treated with dupilumab.

Dermatol Ther 2019 05 18;32(3):e12869. Epub 2019 Mar 18.

Division of Dermatology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California.

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http://dx.doi.org/10.1111/dth.12869DOI Listing
May 2019

Paraneoplastic dermatomyositis presenting with interesting cutaneous findings.

Cutis 2019 Jan;103(1):E17-E19

Keck School of Medicine of the University of Southern California, Los Angeles, USA.

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January 2019

The role of biologics in the treatment of chronic granuloma annulare.

Int J Dermatol 2019 May 7;58(5):622-626. Epub 2019 Jan 7.

David Geffen School of Medicine at University of California, Los Angeles, CA, USA.

Background: Granuloma annulare (GA), a benign inflammatory skin disease, is considered a Th1-type delayed hypersensitivity reaction. Localized GA is likely to resolve spontaneously, whereas disseminated GA (DGA) may persist for decades and can be resistant to treatment. Biologics including TNF-α inhibitors have been proposed and utilized as salvage therapy for GA and other related diseases, interstitial granulomatous dermatitis (IGD), and actinic granuloma (AG).

Methods: A systematic review was conducted using the combination of search terms "granuloma annulare," "interstitial granulomatous dermatitis," or "actinic granuloma" and either "biologics," "etanercept," "adalimumab," "infliximab," "ustekinumab," "ixekizumab," "secukinumab," "guselkumab," "golimumab," "brodalumab," "tildrakizumab," or "certolizumab" from the years 1970-2017.

Results: Review of the literature revealed that 79.3% of the patients with GA, IGD, or AG who had been treated with demonstrated TNF-α inhibitor therapy a clinical response.

Conclusions: TNF-α inhibitor therapy has been used to treat chronic GA, IGD, and AG that involved extensive body surface areas. However, the literature is limited to case series lacking control groups. Randomized, controlled trials are required to establish evidence-based treatment of GA and related cutaneous, granulomatous conditions.
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http://dx.doi.org/10.1111/ijd.14350DOI Listing
May 2019

Successful treatment of dermatomyositis with low-dose naltrexone.

Dermatol Ther 2018 11 24;31(6):e12720. Epub 2018 Sep 24.

Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, California.

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http://dx.doi.org/10.1111/dth.12720DOI Listing
November 2018

The use of etanercept for treatment of toxic epidermal necrolysis when toxic shock syndrome is in the differential.

Dermatol Ther 2018 09 2;31(5):e12684. Epub 2018 Sep 2.

Department of Medicine, Division of Dermatology, University of California Los Angeles, Los Angeles, California.

Toxic shock syndrome (TSS) can sometimes mimic Steven Johnsons syndrome/toxic epidermal necrolysis (SJS/TEN). Tumor necrosis factor (TNF) alpha is thought to play a role in the pathogenesis of both TSS and SJS/TEN. Etanercept, a TNF-alpha inhibitor has been recently shown to treat and decrease mortality of SJS/TEN. We report a 51-year-old female with history of SJS presenting with painful skin and bullae 2 days following cystoscopy with botulinum toxin injection into the bladder. Due to initial concern for SJS/TEN, the patient was treated with 50 mg of subcutaneous etanercept. Punch biopsies were not consistent with SJS, and the patient fulfilled five out of five criteria for a confirmed case of TSS. The patient ultimately had a favorable outcome despite etanercept treatment. Ultimately, TNF-alpha antagonists are an emerging therapy to treat SJS/TEN, and are unlikely to worsen TSS prognosis. Given that etanercept can be used to successfully treat SJS/TEN and TNF-alpha levels are elevated in TSS, if a dermatologist chooses to treat TEN with etanercept, consideration of TSS on the differential should not necessarily exclude etanercept as a reasonable treatment option.
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http://dx.doi.org/10.1111/dth.12684DOI Listing
September 2018

Successful Treatment of Severe Alopecia Areata With Oral or Topical Tofacitinib.

J Drugs Dermatol 2018 Jul;17(7):800-803

Alopecia areata is an autoimmune disease involving the hair follicle with a chronic, relapsing course. Tofacitinib is Janus kinase inhibitor approved for treatment of rheumatoid arthritis that has been shown to be effective in treatment of alopecia areata. We present a case series of 11 patients with severe alopecia areata on longstanding, regular to high dose oral tofacitinib with marked hair regrowth. Additionally, we present a case of moderate to severe alopecia areata successfully treated with topical tofacitinib cream. J Drugs Dermatol. 2018;17(7):800-803.
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July 2018

Squamous cell carcinoma of the perineum masquerading as necrotizing hidradenitis suppurativa.

Dermatol Online J 2018 Apr 15;24(4). Epub 2018 Apr 15.

Division of Dermatology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.

Many cases of superinfected hidradenitis suppurativa (HS) involve multiple species of bacteria, but gas-producing infections are rare and can complicate the clinical picture. Additionally, recognizing squamous cell carcinoma (SCC) as a complication of longstanding HS is imperative. Herein, we present a unique case of a severe emphysematous HS that was initially mistaken for Fournier gangrene and eventually diagnosed as superinfected SCC.
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April 2018