Cutaneous Complications Research Articles

Disease characteristics and treatment attributes of patients admitted to the oncology ward of a tertiary care government hospital.

The burden of oncology patients in the most developing countries including India has witnessed a steady, progressive, and significant upward trend attributed mainly to increased life span, availability of better imaging modalities, increased awareness, and lifestyle and environmental changes. The management of such patients in government setup often presents lots of challenges such as advanced stage of presentation, existence of medical comorbid conditions, scarcity of beds, and long multimodal treatment often complicated with therapy-induced toxicities. A prospective study was undertaken in a Radiation Oncology ward catering to male patients over 6-month duration in a superspecialty hospital of defense services. The clinical, pathological, and treatment-related attributes were recorded. Wherever possible, the clinical course of stay, complications during admission, and the response to primary management were studied. A total of 570 patients were admitted for 6-month duration. Of these patients, 240 were transferred in from other peripheral service hospitals while the remaining were admitted directly from this hospital or transferred from various wards of this hospital. The mean age of the patients was 46.5 years. Most common histology was squamous cell carcinoma. The most common site of primary was head and neck, followed closely by central nervous system tumors and gastrointestinal tract. A total of 185 patients were fresh cases admitted for workup and complete duration of definitive management (of which 82 received concurrent chemoradiation), 280 patients were for follow-up, 70 patients were admitted briefly for supportive care during a while on chemoradiation, and 15 patients were admitted for administrative reasons. Fifty-eight patients developed Grade II and onward therapy-induced hematological, gastrointestinal, cutaneous complications, and 14 patients suffered from febrile neutropenia. Thirty patients developed other significant complications warranting cross-referrals to other specialists. One hundred and thirty patients underwent more than one imaging modalities (contrast-enhanced computed tomography, magnetic resonance imaging, bone scan, and positron emission tomography-computed tomography). The duration of stay varied from 3 to 64 days, with an average duration of 38 days. There were 18 deaths during the study period. The course of hospitalization for oncology cases is often prolonged and complicated by significant complications, warranting aggressive supportive care by various concerned specialists. These patients often require multiple imaging for primary and metastatic workup. There is a need for judicious selection of patients meriting admission for optimum utilization of existing resources.

Immune-related adverse events by immune checkpoint inhibitors.

Recent introduction of immune checkpoint inhibitors represented by anti-PD-1 antibodies such as nivolumab and pembrolizumab, and anti-CTLA-4 antibody such as ipilimumab had a great impact on cancer immunotherapy especially for melanoma, non-small cell lung cancer, renal cell carcinoma, and Hodgkin's lymphoma. On the other hand, immune checkpoint inhibitors have their own distinctive adverse events, which are collectively named as "immune-related adverse events". Although immune-related adverse events may occur at any part of the body, interstitial pneumonia, colitis, hypothyroidism, liver dysfunction, skin rash, vitiligo, hypophysitis, type 1 diabetes, renal dysfunction, myasthenia gravis, neuropathy, myositis, and uveitis are representative. The onset of these immune-related adverse events varies. As for ipilimumab, cutaneous and mucous complications appear relatively early, and subsequently digestive symptoms emerge. As for nivolumab, most immune-related adverse events start around a few months after its administration. These immune-related adverse events are basically managed according to the algorism. Prompt consultation to the experts are of great importance and the grade of immune-related adverse events and patients' disease conditions need to be carefully evaluated to decide the optimal measures. As immune-related adverse events could affect various organs, cooperation with many experts from various fields is critical and it is important to organize a cooperative system within a hospital.

Should lower limb fractures be treated surgically in patients with chronic spinal injuries? Experience in a reference centre

ObjectiveTo report the outcomes of surgical treatment of lower limb fractures in patients with chronic spinal cord injuries. Material and methodA total of 37 lower limb fractures were treated from 2003 to 2010, of which 25 fractures were treated surgically and 12 orthopaedically. ResultsPatients of the surgical group had better clinical results, range of motion, bone consolidation, and less pressure ulcers and radiological misalignment. No differences were detected between groups in terms of pain, hospital stay, and medical complications. DiscussionThere is no currently consensus regarding the management of lower limb fractures in patients with chronic spinal cord injuries, but the trend has been conservative treatment due to the high rate of complications in surgical treatment. ConclusionsChronic spinal cord injuries patients with lower limb fractures who are treated surgically achieved a more reliable consolidation, practically a free range of motion, low rate of cutaneous complications, and pain associated with the fracture. This allows a quick return to the previous standard of living, and should be considered as an alternative to orthopaedic treatment in these patients.

Socio-epidemiologic aspects and cutaneous side effects of permanent tattoos in Germany - Tattoos are not restricted to a specific social phenotype.

ABSTRACTBackground: More and more people of all age classes have a tattoo. Intriguingly, there are multiple prejudices in the general population and published data that concern tattooed persons, such as being criminals, having a low education, being alcohol or drug abusers, or more risky in their life style. Objective: To obtain and to evaluate sociodemographic data on tattooed persons, to investigate the incidence of tattoo-related cutaneous complications and to define personal risk factors and course of the persons after being tattooed concerning behavior of personal environment. Patients and Methods: We interviewed 426 participants with already existing tattoos and 20 participants just before getting a new tattoo by using an online questionnaire. The participators were asked about socio-epidemiologic aspects of tattoos in general and special aspects of their own tattoo(s) in particular. There were no exclusion criteria. Results: Tattoos are interesting for people seeking popular body art, esp. university graduates and financially-secure individuals. 446 persons participated in this study. Most of the persons were female with a mean age of 35. Local pruritus around the tattooed area was the most common cutaneous side effect among the participants. 93.5% of the participants did not want a tattoo removal. Intriguingly, most of the participants experienced no career problems related to the tattoo(s). Limitations: The study population is not representative as we included only persons being tattooed prior to or getting newly tattooed. Furthermore, there is a potential selection bias as the participation in this study was voluntary. Only persons that felt involved by the flyer did answer the questionnaire. Conclusion: The present data shows that common tattooed persons are not low educated criminals with any drug or alcohol abuse or with risky life style. Nowadays being tattooed encompasses a kind of body art and displays a certain kind of lifestyle habit.

Olive Leaf: From Tradition to Clinic

The olive (Olea europaea from the Oleaceae family) leaves have had a lot of medicinal usages in traditional and modern medicine. In traditional Iranian medicine (TIM), it has special indications for wound healing and skin applications such as antiperspirant applications, and also its ash is used in ophthalmic traditional remedies. Literature survey was performed via electronic search on Pubmed, Scopus and Siencedirect. We found 270 articles related to the topic. Conventional pharmacy texts including Martindale, British pharmacopoeia and Lexi natural products as well as TIM texts were reviewed. Our results showed that Olive leaf has responsible effects such as antioxidant, antitoxic and anticancer properties. Also it has antimicrobial and antiviral effects as well as effects on nervous system, endocrine system, gastrointestinal system and cardiovascular system. It has therapeutic effects on some metabolic disorders and cutaneous complications and some miscellaneous effects such as anti-arthritis and anti-bone loss effects. Despite the large amount of studies on the possible effects of olive leaf has been done, the number of available products and their therapeutic targets are limited. It is expected that more extensive studies done on the olive leaf in clinical trials and according to its dose adjustment and special cautions, it becomes more popular herbal medicine in markets and clinics.

A rapid and intelligent designing technique for patient-specific and 3D-printed orthopedic cast.

BackgroundTwo point four out of 100 people suffer from one or more fractures in the course of average lifetimes. Traditional casts are featured as cumbersome structures that result in high risk of cutaneous complications. Clinical demands for developing a hygienic cast have gotten more and more attention. 3D printing technique is rapidly growing in the fabrication of custom-made rehabilitation tools. The objective of this study is to develop a rapid and intelligent modeling technique for developing patient-specific and hygienic orthopedic casts produced by 3D printing technologies.ResultsA cast model is firstly created from a patient’s image to develop patient-specific features. A unique technique to creating geometric reference has been developed to perform detail modeling cast. The cast is modeled as funnel-shaped geometry to create smooth edges to prevent bruises from mild movements of injured limbs. Surface pattern includes ventilation structure and opening gap for hygienic purpose and wearing comfort. The cast can be adjusted to accommodate swelling from injured limbs during treatment. Finite element analysis (FEA) is employed to validate the mechanical performance of the cast structure and identify potential risk of the structural collapse due to concentrated stresses. The cast is fabricated by 3D printing technology using approval material.ConclusionsThe 3D-printed prototype is featured as super lightweight with 1/10 of weight in compared with traditional alternatives. Medical technicians with few experiences can design cast within 20 min using the proposed technique. The image-based design minimizes the distortion during healing process because of the best fit geometry. The highly ventilated structure develops hygienic benefits on reducing the risk of cutaneous complications and potentially improve treatment efficacy and increase patients’ satisfactions.

¿Se deben tratar quirúrgicamente las fracturas de extremidad inferior en pacientes con lesiones medulares crónicas? Experiencia en un centro de referencia

ObjectiveTo report the outcomes of surgical treatment of lower limb fractures in patients with chronic spinal cord injuries. Material and methodA total of 37 lower limb fractures were treated from 2003 to 2010, of which 25 fractures were treated surgically and 12 orthopaedically. ResultsPatients of the surgical group had better clinical results, range of motion, bone consolidation, and less pressure ulcers and radiological misalignment. No differences were detected between groups in terms of pain, hospital stay, and medical complications. DiscussionThere is no currently consensus regarding the management of lower limb fractures in patients with chronic spinal cord injuries, but the trend has been conservative treatment due to the high rate of complications in surgical treatment. ConclusionsChronic spinal cord injuries patients with lower limb fractures who are treated surgically achieved a more reliable consolidation, practically a free range of motion, low rate of cutaneous complications, and pain associated with the fracture. This allows a quick return to the previous standard of living, and should be considered as an alternative to orthopaedic treatment in these patients.

Erratum to: Cutaneous Complications of Targeted Melanoma Therapy

Erratum to: Cutaneous Complications of Targeted Melanoma Therapy

Severe Skin Complications After Small Bowel Transplantation: Graft-Versus-Host Disease, DRESS, Virus, or Drug Toxicity?

Severe skin problems are uncommon after small bowel transplantation. Differential diagnosis includes drug reactions, infections, graft-versus-host disease (GVHD), and mixed diseases. Early diagnosis and treatment are determinant for prognosis. We describe 6 patients with severe cutaneous complications after small bowel transplantation, the work-up, final diagnosis, and evolution. Two patients died from chronic GVHD or unrecognized drug rash with eosinophilia and systemic symptoms, the others recovered completely. In 2 patients, drugs and viruses could be implicated, and in 1 patient may have hidden or triggered chronic GVHD. Viruses (human herpesvirus 6, Epstein-Barr virus, and cytomegalovirus) were suspected to trigger drug rash with eosinophilia and systemic symptoms or GVHD. The 2 cases of acute GVHD were reversed completely by increased immunosuppression and anti-interleukin-2 receptor antibody. In these severe cases, diagnosis is urgent and should include a careful evaluation of drug history, clinical presentation, biological investigations, infections, and toxic screening. A skin biopsy and chimerism study should be performed whenever possible. An early treatment is key to a positive outcome.

Cutaneous Complications of Targeted Melanoma Therapy.

The landscape of advanced and metastatic melanoma therapy has shifted dramatically in recent years. Since 2011, eight drugs (ipilimumab, vemurafenib, dabrafenib, trametinib, cometinib, pembrolizumab, nivolumab, and talimogene laherparepvec) have received FDA approval for the treatment of advanced or metastatic melanoma, including combination regimens of both small molecule kinase and immune checkpoint inhibitors. These therapies have revolutionized the management of unresectable regional nodal and distant melanoma, providing hope of extended survival to patients. As the use of novel agents has increased, so have the cutaneous toxicities associated with these medications. While most skin reactions are low-grade and can be managed conservatively with topical therapies, malignant lesions and more serious or life-threatening drug reactions can arise during therapy, requiring prompt dermatologic recognition and treatment in order to improve patient outcome. Given the survival benefit attributed to these new agents, treating skin toxicity and maintaining patient quality of life is of paramount importance. Oncologists should be aware of the common cutaneous toxicities associated with these medications and should be encouraged to involve dermatologists in the collaborative care of advanced melanoma patients. Close communication between oncologists and dermatologists can help to avoid unnecessary dose reduction or treatment discontinuation and identify situations when treatment cessation is truly warranted.

Insulin pump-associated adverse events are common, but not associated with glycemic control, socio-economic status, or pump/infusion set type.

While there have been many outcome-focussed studies examining insulin pump therapy, only a few have looked at potential adverse events (AEs), with none examining the relationship between AEs and pump/infusion set type, ethnicity or socio-economic status. In addition, current data on the incidence and characteristics of pump-associated AEs are confined to one paediatric centre. We aimed to describe the incidence, characteristics and potential predictors of insulin pump-associated AEs in New Zealand adults and children with T1DM. We approached adults and families of children with T1DM on insulin pumps in four main New Zealand centres. Participants completed a questionnaire examining pump-related issues they had experienced in the preceding 12 months. Response rate was 64% with 174 of 270 eligible people participating in the study. 84% of subjects reported one or more AEs, with an overall AE incidence of 3.42 per person/year (95% CI 3.14, 3.73). An event serious enough to require a hospital presentation occurred in 9.8%, all but one reporting high ketones or diabetic ketoacidosis (DKA). Set/site problems were the AE most commonly reported (by 53% of respondents), followed by cutaneous complications (43%) and pump malfunction (38%). Few predictors of AEs (of any type) were found; however, a negative binomial regression model found that a longer duration of pumping (p=0.018) and age <18years (p=0.043) were both associated with fewer AEs (all types combined). Insulin pump-associated AEs are very common. However, few variables are predictive of them with no relationships seen with glycaemic control, socio-economic status, pump manufacturer or infusion set type. Based on these findings, AEs should be anticipated in both adults and children, with anticipatory patient education and training recommended for their successful and safe use.

Evaluation of the pharmacoeconomics of drugs used for the treatment of long-term complications of sulfur mustard

Sulfur mustard (SM), a cytotoxic vesicant chemical warfare agent, has powerful irritant and blistering effects on the skin, eyes and respiratory tract. Since during the Iraq-Iran war, many Iranian soldiers and civilians were exposed to SM, there are several victims still suffering from long-term cutaneous, ocular and pulmonary complications. Currently, there is no definite treatment for long-term complications of SM, and only supportive medical care is being taken to minimize the symptoms. In this study, we compared the cost-effectiveness of common drugs that are used against long-term SM-induced complications in Iranian patients. In this review article, electronic databases were checked using the following key words: sulfur mustard, lung, skin, eye, cost-effectiveness, pharmacoeconomics and treatment. Abstracts of non-English papers and proceedings of congresses on SM were also assessed. Among the studied drugs, high-dose oral N-acetyl cysteine and long-acting inhaled corticosteroids against respiratory complications, topical corticosteroids and oral antihistamines against cutaneous complications and NSAIDS and corticosteroids ophthalmic drops against ocular complications were found to be cost-effective. Usage of different drugs in the treatment of SM injuries in Iran, have imposed a significant economic burden to patients and their families because many drugs that are effective against chemical injuries are not covered by insurance. In addition, development of more effective drugs in this field is considered as an urgent demand that should be noticed by the pharmaceutical industry.

Cutaneous and systemic complications associated with tattooing

Tattooing can result in a wide variety of complications, whose prevalence and incidence remain still unclear. Hypersensitivity reactions (or allergies) to tattoo pigments are currently the most common complication on a tattoo, however they are not predictable. Infections are nowadays directly related to the lack of asepsis and hygiene during the tattooing procedure or during the healing phase. Patients with a known cutaneous disease should be warned of a potential risk of localization of their disease to the tattoo. A skin eruption restricted to a tattoo may reveal sarcoidosis. Patients with chronic conditions and/or impaired immunity should discuss with their physician about the possibility and when to have a tattoo.

Complications and manifestations of diabetic patients skin in Aden-Yemen

Diabetes Mellitus is a chronic disease that affects multiple systems of the body, including the skin. Cutaneous manifestations of diabetes mellitus generally appear subsequent to the development of the disease, but they may be the first presenting signs and, in some cases, they may precede the primary disease manifestation by many years. The purpose of this study was to calculate the frequency of cutaneous manifestations and complications in patients with diabetes mellitus. This study is a prospective study for one hundred patients with diagnose and un diagnose cases of DM and having skin lesions that either attending the Diabetic Center, or Dermatology Outpatient at Al-Gamhoria Teaching Hospital, during the period April - December 2014.Pre-designed and pretested Performa was filled after taking informed consent .Among one hundred diabetic patients, there were 39% males and 61% females. The age of the patients ranges from 13-75 years, with a mean age were 49.6± 13.37 years .Among cutaneous disorders, commonly associated with diabetes, infections (51%) were the most prevalent and among this group the fungal infectious diseases topped the list (65.4%) followed by pruritus (18%) .Various associated complications has been noted, in which neuropathy was the most commonly found (35%) followed by hypertension (27%) then retinopathy (17%).One should be vigilant enough for the cutaneous manifestations as they are the window to the systemic illness.

Xeroderma Pigmentosum.

Xeroderma pigmentosum (XP) is a rare disorder of defective UV-radiation induced damage repair that is characterized by photosensitivity with easy skin burning following minimal sun exposure, early freckling and development of lentiginous pigmentation along with other features of poikiloderma and a propensity for developing skin cancer at an early age. In this short review, the clinical, pathological, genetic and molecular aspects of XP are reviewed in the current literature. XP encompasses a spectrum of disease that overlaps with other diseases of DNA repair systems. In addition to cutaneous complications, patients are susceptible to eye conditions, neurodegenerative processes, central nervous system tumors and other tumors as a result of UV radiation exposure and its byproducts. Patients with XP frequently experience a shorter life span due to skin cancer and neurodegenerative sequelae, but aggressive preventative measures to minimize UV radiation exposure and damage can improve the course of disease and prolong life. The disease has served as a model for photoaging and UV radiation-induced cancer and has led to a better understanding of cell processes that prevent development of these disease features in normal individuals.

Incongruent Phenotypic Expression of Autosomal Dominant Hyper IgE Syndrome (AD-HIES) in a Mother and Son

AD-HIES has multifarious effects on multiple systems. Although variable expressivity has been described, no reports detail the course of immediate family members with the AD type. Reviewed documented clinical course and studies conducted at WRNMMC and NIH. Mother and son shared the 1909 G-A mutation in the SH2 domain of STAT3. They had near identical clinical courses from birth through infancy, including classic AD-HIES manifestations such as eczema and pulmonary infections; however, their courses subsequently diverged. The mother developed pneumatoceles and bronchiectasis and required a partial lobectomy by three years of age. Diagnosed with AD-HIES at 8 years old, she started SCIG. In early adulthood, her large pneumatoceles became chronically infected with aspergillus, mycobacterium abscesses, and stenotrophomonas. She underwent bilateral lung transplant at age 27 and developed a diaphragmatic aspergilloma resistant to standard antifungal therapies. Two years later, aspergilloma was identified involving her right pulmonary artery causing hypoxia. Isovuconazole led to improvement, but her lung function diminished requiring continuous oxygen. The patient’s son started replacement SCIG and prophylactic antibiotics by the first year of life. His pulmonary and cutaneous complications were mild after infancy. Although, he has small stature and characteristic AD-HIES facies, his course has been relatively benign on treatment. This is the first reported case highlighting marked variable expressivity in AD-HIES of affected immediate family members. The divergent clinical courses may have been influenced by early diagnosis, initiation of SCIG and prophylaxis, and suggests that providers should consider early testing of AD-HIES patients’ offspring.

Cutaneous manifestations of patients with relapsing polychondritis: an association with extracutaneous complications.

The aim of this study was to determine the prognostic characteristics of patients with relapsing polychondritis (RP) accompanying cutaneous manifestations in Japan. We analyzed a cohort of 239 patients with RP in view of cutaneous and extracutaneous complications. Thirty three cases (14%) developed cutaneous manifestations and 23 cases had both cutaneous and extracutaneous manifestations. Five RP patients developed myelodysplastic syndrome (MDS) and all of the five patients had cutaneous manifestations, including Sweet's syndrome. Only one patient died of MDS among the five patients, suggesting rather better prognosis as compared with ordinary MDS. Five RP patients developed Behcet's disease and all the five patients had cutaneous manifestations. Death rate of the RP patients with cutaneous manifestations (15%) was slightly higher than that of whole Japanese RP patient cohort (9.2%). RP patients with cutaneous manifestations had a slightly higher death rate, than those without cutaneous manifestations. MDS of RP patients had a rather better prognostic impact in Japan. Further studies are needed to elucidate the pathophysiology of RP, which brings about development of extracutaneous manifestations, especially MDS and Behcet's disease.

Video endoscopic inguinal lymphadenectomy for radical management of inguinal nodes in patients with penile squamous cell carcinoma.

Background:Inguinal lymph node involvement is an important prognostic factor in penile cancer. Inguinal lymph node dissection allows staging and treatment of inguinal nodal disease. However, it causes morbidity and is associated with complications such as lymphocele, skin loss, and infection.Aims:To report our institutional experience with video endoscopic inguinal lymphadenectomy (VEIL) for radical management of inguinal nodes in patients with penile squamous cell carcinoma.Materials and Methods:It is a prospective analysis of data of patients that underwent VEIL, by a single surgeon, from 2008 to 2015. 14 patients of penile carcinoma were suitable for VEIL technique were included in this study and followed. Data analyzed included mean operative time, mean lymph node yield, intraoperative complications, cutaneous complication, lymph-related complications, and surgical emphysema.Results:The mean age of patients was 57.8 years (range: 45–70 years). Mean operative time for VEIL was 194.86 min (178–210 min). Mean lymph node yield was 7.68 (range: 5–11 nodes). No intraoperative complication was experienced during series. We noted no cutaneous complications, localized lymphocele were seen in total 6 units out of 22 units (27.2%). Surgical emphysema is seen in 3 limbs (13.63%). There was significantly decreased overall morbidity in our study. Follow-up of 10 out of 14 patients with median of 48 months shows no recurrence.Conclusions:In our early experience, VEIL is a safe and feasible technique in patients with penile carcinoma who require radical inguinal lymphadenectomy. It allows the removal of inguinal lymph nodes within the same limits as in conventional surgical dissection and reduces surgical morbidity substantially.

Cardiac stroke following total knee replacement in an ochronotic arthropathy: Case report and literature review

Alkaptonuria is a rare autosomal recessive disorder caused by defective metabolism of homogentisic acid (HGA) which on accumulation in the connective tissues causes arthritis, darkening of urine and connective tissue pigmentation. Knee is most commonly affected joint whereas pigment deposition is seen in entire body causing cardiovascular, genitourinary, ocular, cutaneous, and musculoskeletal complications. We here report such a case of bilateral ochronotic arthropathy, who was diagnosed to be alkaptonuric only during joint exploration. He sustained a cardiac catastrophic stroke on 3 rd post operative day of the left knee replacement which was done one week after the right knee replacement. With prompt treatment and good hospital care, the patient was revived successfully, without valvulotomy or valvular replacement. The spectrum of clinical manifestations are discussed in the report with emphasis on thorough history and clinical examination of the patient, before taking the patient to the total knee replacement to make accurate diagnosis before hand and be prepared for the complications or catastrophic by a multidisciplinary approach.

Comparison of cutaneous nerve injury and vessel disruption complications following saphenous vein stripping using big or small olive heads.

Objective:To compare the nerve injury and vessel disruption complicaitons in patients undergoing saphenous vein stripping using olive heads of different sizes.Methods:Big olive heads were used in group A (n=50) and small olive heads were used in group B (n=50) from the ankle to the groin; in group C (n=50), the vein was stripped in two sections; in an upward fashion by stripping the distal portion from the ankle to the level of the knee using small olive heads and by stripping the proximal portion from the knee to the level of the groin using big olive heads.Results:Six months after the operation, nerve injury symptoms were identified in 26%, 4%, 6% of patients in groups A, B, and C respectively. Vessel disruption occurred 2% in group A, 32% in group B, and 4% in group C. Both vessel disruption and nerve injury complications of group C were significantly lower than group A and B (p<0.001).Conclusion:Saphenous stripping using big olive heads for the proximal portion from the groin down to the level of the knee and using small olive heads for the distal portion from the knee to the level of the ankle is the alternative method which results in minimal nerve injury and vessel disruption.