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Archives of Dermatology is a monthly journal that enhances the understanding of skin and its diseases by publishing practical, peer-reviewed original articles. Characterized as an investigative journal for clinicians, the Archives is recognized as one of the most influential publications in its field and is the oldest US dermatology journal.

Atypical Fibroxanthoma With Regional Lymph Node Metastasis: Report of a Case and Review of the Literature [Observation] 16 Aug 2010

Background Atypical fibroxanthoma (AFX) is a low-grade sarcoma usually occurring on sun-damaged skin of the head and neck in elderly patients. Metastatic disease has been reported very rarely. The potential aggressiveness of AFX is controversial.

Observations We describe herein a patient who developed metastatic disease in cervical lymph nodes. Our patient was an 87-year-old man with a 7-week history of a rapidly growing AFX presenting as a 1.5-cm sessile nodule on his right mandible. Two months following excision, the patient developed cervical lymphadenopathy. Histopathologic analysis of the cervical lymph nodes revealed spindle-cell tumors with histologic characteristics identical to those of the primary AFX, and the tumors were immunonegative for cytokeratin MNF-116 and S-100. In addition, we review and analyze cases from the literature and articles related to immunohistochemical stains used to diagnose AFX.

Conclusions Atypical fibroxanthoma is a diagnosis of exclusion, and only a small number of metastatic AFX cases have been reported. A review of the literature pertaining to immunohistochemical stains suggests the potential benefit of use of CD10, procollagen I, CD99, CD117, p63, and LN-2 in differentiating AFX from other spindle-cell tumors. The metastatic potential of AFX may not be fully appreciated, and clinicians should be reminded of its potential aggressive behavior.

Alcohol Intake and Risk of Incident Psoriasis in US Women: A Prospective Study [Study] 16 Aug 2010

Objectives To evaluate the independent association between alcohol consumption and risk of developing psoriasis and to determine if this risk is associated with different types of alcoholic beverages.

Design A prospective study of female nurses who were followed up from 1991 to 2005.

Setting Nurses' Health Study II, a cohort of 116 671 US women aged 27 to 44 years in 1991.

Participants The study population included 82 869 women who reported amount and type of alcohol intake on biennial questionnaires. We excluded participants with a history of psoriasis prior to 1991.

Main Outcome Measure Self-report of incident physician-diagnosed psoriasis. For a sensitivity analysis, we had a subset of confirmed psoriasis cases.

Results There were 1150 cases of incident psoriasis, 1069 of which were used for analysis. Compared with women who did not drink alcohol, the multivariate relative risk (RR) of psoriasis was 1.72 (95% confidence interval [CI], 1.15-2.57) for an alcohol consumption of 2.3 drinks/wk or more. When examined by type of alcoholic beverage, there was an association between psoriasis and nonlight beer intake (multivariate RR for ≥5 drinks/wk, 1.76; 95% CI, 1.15-2.69); light beer, red wine, white wine, and liquor were not significantly associated with psoriasis risk. The association with nonlight beer intake became stronger in a subset of confirmed psoriasis cases (multivariate RR for ≥5 drinks/wk, 2.29; 95% CI, 1.36-3.85).

Conclusions Nonlight beer intake is associated with an increased risk of developing psoriasis among women. Other alcoholic beverages did not increase the risk of psoriasis in this study.

Association of Hearing Loss With PHACE Syndrome [Observation] 16 Aug 2010

Background PHACE syndrome describes a spectrum of anomalies associated with large facial infantile hemangiomas and characterized by posterior fossa malformations, hemangiomas, arterial anomalies, coarctation of the aorta and cardiac defects, and eye abnormalities. With improved recognition and imaging practices of infants with PHACE syndrome, additional associations have been identified. To our knowledge, the potential association of ipsilateral hearing loss and PHACE syndrome has not been previously emphasized.

Observations We describe 6 patients, 4 with definite and 2 with probable PHACE syndrome, according to the new diagnostic criteria, and associated auditory deficiencies. One patient had isolated conductive hearing loss; 2 patients had isolated sensorineural hearing loss; 1 patient had mixed hearing loss (both conductive and sensorineural components); and 1 patient had hearing loss that was inconclusive at the time. Also, 1 patient had conductive loss and auditory neuropathy and auditory dyssynchrony. Four of the 6 patients had magnetic resonance imaging features of lesions consistent with intracranial hemangiomas involving auditory structures. All 6 patients had facial hemangiomas in a nearly identical distribution ipsilateral to the ear with the hearing loss, with involvement of the proposed facial segments S1 and S3, the affected ear, the periauricular region, and the midoccipital area of the scalp.

Conclusions There is an underrecognized risk of hearing loss in patients with PHACE syndrome, although the exact nature of such deficiencies can vary. Patients with PHACE syndrome who have cutaneous hemangiomas involving the ear should be evaluated for intracranial hemangiomas and monitored for hearing loss. Early detection and therapy of intracranial hemangiomas may slow or stop tumor growth, resultant hearing loss, and structural damage.

Increased Programmed Death-1 Expression on CD4+ T Cells in Cutaneous T-Cell Lymphoma: Implications for Immune Suppression [Study] 16 Aug 2010

Objectives To investigate the expression profile of programmed death-1 (PD-1) on T cells derived from patients with cutaneous T-cell lymphoma (CTCL), analyze a potential mechanism responsible for upregulation of PD-1, and assess the correlation between blockade of its signaling pathway and improvement in immunological function.

Design Translation research study.

Setting University medical center.

Participants Patients with Sézary syndrome, patients with mycosis fungoides, and healthy volunteers.

Main Outcome Measures Programmed death-1 expression on T cells by flow cytometry and interferon (IFN-) production by enzyme-linked immunosorbent assay.

Results We report significantly increased PD-1 expression on CD4⁺ T cells from patients with Sézary syndrome compared with CD4⁺ T cells from patients with mycosis fungoides and healthy volunteers. Both CD26^– and CD26⁺ populations of CD4⁺ T cells demonstrated increased expression of PD-1, which was upregulated by the engagement of the T-cell receptor with anti-CD3/CD28 antibodies. In addition, blockade of the signaling pathway with blocking antibodies to PD-1 or its ligand PD-L1 led to an increase in the capacity to produce IFN- among some patients. Finally, longitudinal studies of 1 patient revealed a progressive decrease in PD-1 expression on CD4⁺ T cells with improvement of clinical disease.

Conclusion Our data imply that increased PD-1 expression in Sézary syndrome may play a role in attenuating the immune response and provide further insight into the immunosuppressive nature of CD4⁺ T cells in Sézary syndrome and suggest another potential means of targeted therapy for these patients.

Drug Reaction With Eosinophilia and Systemic Symptoms: A Retrospective Study of 60 Cases [Study] 16 Aug 2010

Objective To investigate the clinical and pathologic features of patients with drug reaction with eosinophilia and systemic symptoms (DRESS) in Taiwan.

Design Case series and retrospective analysis.

Setting A medical referral center in Northern Taiwan.

Patients Sixty cases of DRESS occurring from June 1998 to May 2008.

Main Outcome Measures Clinical characteristics for specific drugs and important prognostic factors in DRESS.

Results Patients ranged in age from 6 to 90 years (mean age, 51 years). The female to male ratio was 1.3 to 1. The most common culprit drugs were allopurinol, phenytoin, and dapsone. Exanthematous eruption was the most common skin manifestation, but purpurae and blisters were also observed. Hepatic (80%), renal (40%), and pulmonary (33%) involvement were also common. The overall mortality rate was 10%. Allopurinol-induced DRESS was characterized by preceding chronic renal insufficiency and frequent renal involvement. Pancytopenia indicated a poor prognosis.

Conclusions Drug reaction with eosinophilia and systemic symptoms has a variable clinical presentation, and its definition requires clarification. It may be a heterogeneous syndrome with some particular patterns related to different drugs. Early diagnosis and prompt discontinuation of offending drug regimens are essential.

Variation in the Depth of Excision of Melanoma: A Survey of US Physicians [Study] 19 Jul 2010

Objective To assess current practices and recommendations of US physicians regarding depth of excision for melanomas of varying histologic thicknesses.

Design A 2-page, 13-question survey of depth of excision practices for the treatment of melanoma was developed and distributed.

Setting Both private and academic settings.

Participants A total of 1184 US physicians (1000 dermatologists and 184 melanoma specialists) were sent the survey. The 184 melanoma specialists included dermatologists, oncologists, and surgeons working in pigmented lesion clinics.

Main Outcome Measures Depth of excision practices reported for melanomas of varying histologic thicknesses and comparison of treating physician groups. Results were tabulated, and descriptive frequencies were used to describe demographics and survey responses.

Results The final study analysis included 498 completed surveys. The overall response rate was 45% (498 of 1097 [1184 total respondents – 87 ineligibles]). The response rate for the specialists was 63% (115 of 183 [184 total respondents – 1 ineligible]), and for nonspecialist dermatologists it was 43% (383 of 892 [1000 total respondents – 108 ineligibles]). Specialists were more likely to practice in an urban setting than were nonspecialist dermatologists (78% vs 46%) (P < .001). Fifty-eight percent of nonspecialist dermatologists reported more than 400 patient visits per month compared with only 16% of specialists (P < .001). While specialists reported fewer patient visits per month, 51% reported diagnosing over 20 invasive melanomas in the previous year compared with 11% of nonspecialist dermatologists. There was no significant difference in excision depth reported among the specialties for melanoma in situ (P = .15). For invasive melanoma, significant differences were observed among treating groups, with the greatest incongruence reported for thin invasive melanoma (<0.50 mm, P = .02; 0.50-0.75 mm, P < .001; and 0.76-1.00 mm, P < .001). Specialist nondermatologists consistently reported excising more deeply than specialist dermatologists and nonspecialist dermatologists. More specialist nondermatologists report excising to the fascia for thin invasive melanoma than do both specialist and nonspecialist dermatologists. For thicker melanomas (>1.00 mm), differences in excision depths among treating physician groups decreased: most physicians in each group reported excising to the fascia.

Conclusions There is considerable variation among physician groups with regard to depth of excision practices for the treatment of melanoma. Given the current lack of clinical data available, studies assessing depth of excision and patient outcomes are needed to better define our surgical management of melanoma.

Published online July 19, 2010 (doi:10.1001/archdermatol.2010.156).

About This Journal [About This Journal] 16 Aug 2010

This Month in Archives of Dermatology [This Month in Archives of Dermatology] 16 Aug 2010

Diseases of the Genito-Urinary Organs. [Archives a Century Ago] 16 Aug 2010

In Situ Photoimmunotherapy: A Surgery- and Limb-Sparing Approach to the Treatment of Cutaneous Metastases in Advanced Melanoma [The Cutting Edge] 16 Aug 2010

Extending the Sun Safety Recommendations: Emphasizing Eye Protection for Patients Taking Sun-Sensitizing Medications [From the Archives] 16 Aug 2010

The Effect of Narrowband UV-B Treatment for Psoriasis on Vitamin D Status During Wintertime in Ireland [Study] 16 Aug 2010

Objectives To determine whether narrowband UV-B (NB–UV-B) may mediate its beneficial effect on psoriasis by increasing vitamin D levels, and to assess the effect of NB–UV-B on vitamin D status in patients with psoriasis in wintertime.

Design A prospective controlled study from October 2008 to February 2009.

Setting A dermatology outpatient department at a university teaching hospital.

Patients Thirty consecutive patients with psoriasis treated with NB–UV-B and 30 control patients with psoriasis were recruited. Control patients were recruited within 1 week of treated patients to control for seasonal variation of serum 25-hydroxyvitamin D [25(OH)D] levels. One patient with photoaggravated psoriasis was withdrawn from the study.

Intervention Narrowband UV-B was administered 3 times per week.

Main Outcome Measure Serum 25(OH)D was measured at baseline, after 4 weeks and at completion of treatment.

Results Levels of serum 25(OH)D increased significantly (P < .001) from a median (range) of 23 (9-46) ng/mL at baseline to 59 (32-112) ng/mL at the end of NB–UV-B treatment compared with no change in the control group. The change in serum 25(OH)D level correlated with the number of exposures of NB–UV-B (r = 0.61; P < .001) and cumulative UV-B dose (r = 0.47; P = .01) but not with treatment response. At the end of the study, all patients in the treatment group were vitamin D sufficient, but 75% of the control group had vitamin D insufficiency [serum 25(OH)D level <20 ng/mL]. In a multiple regression model, prior phototherapy was the sole predictor of baseline serum 25(OH)D level (r² = 0.13; P = .006), whereas the number of exposures of NB–UV-B predicted change in serum 25(OH)D level (r² = 0.38; P = .001).

Conclusions Narrowband UV-B effectively increases serum 25(OH)D level while clearing psoriasis. Up to 75% of Irish patients with psoriasis were shown to be vitamin D insufficient during wintertime.

Confocal Laser Scanning Microscopy vs 3-Dimensional Histologic Imaging in Basal Cell Carcinoma [Study] 16 Aug 2010

Objective To compare ex vivo confocal laser scanning microscopy (CLSM), which offers rapid images without the need for tissue processing, vs 3-dimensional histologic imaging, the criterion standard treatment for basal cell carcinomas in high-risk areas of the face.

Design Single-center prospective trial.

Setting Dermatosurgical unit of a university hospital.

Patients Seventy-two consecutive surgically removed basal cell carcinomas were examined using CLSM vs standard paraffin-embedded 3-dimensional histologic imaging.

Interventions A total of 312 images, including 73 midsections, 196 lateral margins, 23 "muffins," and 20 "bread loaf sections," were obtained using CLSM. Immediately after surgery, the CLSM images were evaluated by the surgeon. The following day, the 3-dimensional histologic slides were evaluated and compared with the CLSM images.

Main Outcome Measures Diagnostic accuracy of ex vivo CLSM to detect tumor strands of basal cell carcinomas and the practicality of using CLSM vs 3-dimensional histologic slides in micrographic surgery.

Results The sensitivity of CLSM reached 94.0% in midsections, 73.7% in lateral margins, 80.0% in muffins, and 80.0% in bread loaf sections. The CLSM images were evaluated by the surgeon within 7.5 minutes.

Conclusions Confocal laser scanning microscopy lacks high sensitivity to detect small tumor strands of basal cell carcinomas. In the future, CLSM may represent a time-saving and less expensive alternative to cryostat histopathologic examination.

Risk Factors for Single and Multiple Basal Cell Carcinomas [Study] 16 Aug 2010

Objective To investigate the incidence of single and multiple basal cell carcinoma (BCC) lesions and associated risk factors.

Design A prospective, population-based cohort study (from January 1, 1990, through December 31, 2007).

Setting Two cohorts of 10 994 Dutch people, 55 years or older, were studied in 1990 (first cohort) and 1999 (second cohort).

Patients Patients with BCC lesions were identified from the Dutch national pathology laboratories network, hospitals, and general practices.

Main Outcome Measures The associations between determinants and single and multiple BCC lesions were studied by estimating odds ratios (ORs) and hazards ratios, using multivariate logistic regression and Andersen-Gill models, respectively.

Results Of the eligible 10 820 cohort members, 524 (4.8%) had BCC, of whom 361 had single and 163 (31.1%) had multiple lesions. Age and red hair were significant risk factors for a first BCC lesion in a multivariate model. In the Andersen-Gill model, people who developed a first BCC lesion after 75.0 years of age were significantly less likely to develop multiple lesions (≥75.0 years adjusted OR, 0.58; 95% confidence interval [CI], 0.47-0.71). Red hair (adjusted OR, 1.43; 95% CI, 1.05-1.94), high educational level (1.42; 1.12-1.81), and a first BCC lesion located on the upper extremities (1.49; 1.02-2.15) were associated with a significantly increased risk of developing multiple lesions.

Conclusion Patients who are relatively young at their first BCC diagnosis, those with red hair, those with higher socioeconomic status, and/or those with a BCC lesion on their upper extremities have a higher risk of developing multiple lesions and require closer follow-up over time.

Advanced Biological Therapies for Diabetic Foot Ulcers [Study] 16 Aug 2010

Objective To assess the clinical use of advanced biological therapies in treating diabetic foot ulcers in practice and the effect of these therapies on time to healing.

Design A retrospective cohort study.

Setting A validated wound care database from January 1, 2001, through December 31, 2004.

Participants Two thousand five hundred seventeen patients with diabetic neuropathic foot ulcers.

Intervention Patients who received advanced biological therapy (ie, Apligraf, Regranex, or Procuren).

Main Outcome Measure Time to healing after initial use of advanced biological therapy. This was derived using Kaplan-Meier estimates and the Ederer least squares method after adjusting for covariates, which were assessed using generalized estimating equations and Cox proportional hazards regression modeling.

Results Advanced biological therapy was used, on average, within 28 days from the first wound clinic visit and associated with a median time to healing of 100 days. Regardless of the advanced biological therapy used, wounds with larger wound area, more severe wound grades, longer duration of wound prior to the first visit, and prolonged time to treatment with advanced biological therapies were significantly associated with longer time to healing. Wounds treated with engineered skin as the first advanced biological therapy were 31.2% more likely to heal than wounds first treated with topical recombinant growth factor (P < .001), and 40.0% more likely to heal than those first treated with platelet releasate (P = .01). Wound size, wound grade, duration of wound, and time to initiation of advanced biological therapy affected the time to healing.

Conclusions Advanced biological therapies were used, on average, within 1 month, and improved healing of refractory diabetic foot ulcers. Differences on outcomes among advanced biological therapies were noted.

Development and Validation of Skindex-Teen, a Quality-of-Life Instrument for Adolescents With Skin Disease [Study] 16 Aug 2010

Objective To develop and validate a quality-of-life index for adolescents with skin disease.

Design Prospective, longitudinal cohort study taking place from July 15, 2005, through February 29, 2008.

Setting Academic pediatric dermatology practice.

Patients A total of 205 patients between the ages of 12 and 17 years with a skin condition.

Main Outcome Measures Participants completed the Skindex-Teen questionnaire, reported sociodemographic data, and answered clinical questions at enrollment. Four weeks later, they completed Skindex-Teen and responded to clinical questions again. Forty patients also completed Skindex-Teen 48 hours after baseline.

Results Of 205 patients, 200 (97.6%) completed all enrollment materials; 125 (62.5%) of these returned follow-up materials, of which 115 (57.5%) were complete. Twenty-three of 40 participants (57.5%) completed the 48-hour-after-initial-answers materials. The mean (SD) age of the patients was 15.3 (1.4) years (range, 12.9-18.0 years). Approximately half reported their skin condition as poor (26 [13.0%]) or fair (67 [33.5%]); most rated their general health as very good (62 [31.0%]) or excellent (80 [40.0%]). The dimensionality of the items was evaluated using factor analysis; results suggested 2 factors, termed physical symptoms (5 items) and psychosocial functioning (16 items). Both scales demonstrated excellent internal consistency. All item-scale reliabilities were greater than 0.4. Fit of items to the measurement model was supported by Rasch analysis. Test-retest reliability was supported by intraclass correlation coefficients (0.82-0.94) for total scores, physical symptoms, and psychosocial functioning scales. At 4 weeks, 16 (13.9%) reported worsening of their skin condition, 57 (19.6%) reported it had remained unchanged, and 42 (36.5%) reported improvement. Significant mean differences were present between the improved and worsened groups for the psychosocial functioning scale and total scores.

Conclusions These data provide evidence of construct, content, and face validity for Skindex-Teen, a new quality-of-life instrument for adolescents with skin disease. Test-retest reliability was verified, and responsiveness at 4 weeks was shown for total scores and the psychosocial functioning scale scores.

The Dermatopathology Ward Round: A Tribute to the Multiheaded Microscope [Notable Notes] 16 Aug 2010

Viral-Associated Trichodysplasia of Immunosuppression: Report of a Pediatric Patient With Response to Oral Valganciclovir [Observation] 16 Aug 2010

Background Viral-associated trichodysplasia of immunosuppression is an increasingly recognized entity characterized by follicular-based papules, primarily in the central part of the face, that produce variable degrees of alopecia and dysmorphic features. It has been primarily described in transplant recipients but has recently been recognized in patients receiving chemotherapy for leukemia and lymphoma. It is associated with distinctive histologic features such as dilated anagen hair follicles, absent hair papillae, and abrupt cornification of the inner root sheath.

Observations A 5-year-old boy presented with spiny follicular papules that caused thickening of the skin of the face 1 year after cardiac transplantation. He had been exposed to several immunosuppressive agents, including mycophenolate mofetil, tacrolimus, intravenous immunoglobulin, rituximab, cylcophosphamide, and prednisone. Despite the failure of multiple topical treatments, our patient's eruption improved with systemic valganciclovir therapy.

Conclusions We describe the youngest patient (to our knowledge) with viral-associated trichodysplasia of immunosuppression and discuss the characteristic clinicopathologic features. Our report supports the theory that immunosuppression is the predisposing factor to a folliculotropic papovavirus that alters follicular maturation.

Lipoatrophic Panniculitis: Case Report and Review of the Literature [Observation] 16 Aug 2010

Background Lipoatrophic panniculitis (LP) is a rare disease of childhood characterized by eruption of tender erythematous nodules and plaques followed by circumferential bands of lipoatrophy often seen on the arms and legs. This condition has also been known as lipophagic panniculitis of childhood, annular atrophy of the ankles, and partial lipodystrophy.

Observations A previously healthy 8-year-old boy was evaluated for tender, raised plaques on the ankles, which progressed to circumferential atrophy of the distal lower extremities. Biopsy specimen analysis revealed a dense mixed infiltrate extending into the subcutaneous tissue as well as lipophages within the fatty lobules. A diagnosis of LP was made, and the patient began treatment with prednisone and hydroxychloroquine. Methotrexate was added later to the regimen as a steroid-sparing agent, and the dose was increased over the course of 3 months, by which time the cutaneous disease progression was nearly halted. However, the patient continued to have lower leg pain with bone changes demonstrated on magnetic resonance imaging.

Conclusions We report this case and review of the literature to call attention to the clinical features of LP and its association with skeletal changes. Our patient's response to combination therapy is of interest and contributes to the limited literature about management of this disease.

Subcutaneous Fat Necrosis as a Complication of Whole-Body Cooling for Birth Asphyxia [Observation] 16 Aug 2010

Background Subcutaneous fat necrosis (SCFN) of the newborn is a form of panniculitis that affects full-term neonates who often have suffered either birth asphyxia or hypothermia. The induction of hypothermia in newborns is becoming frequently used to reduce the neurologic sequelae associated with birth asphyxia. The risk of SCFN in neonates undergoing this therapy is unknown.

Observation We describe a neonate who developed an abscesslike presentation of SCFN and subsequent asymptomatic hypercalcemia after undergoing whole-body cooling for hypoxic-ischemic encephalopathy.

Conclusions Hypothermia protocols may be placing newborns at increased risk for the development of SCFN. Clinicians should recognize this association, and newborns who undergo therapeutic cooling should have frequent dermatologic assessments.

Top-Accessed Article: Dermoscopy of Amelanotic and Hypomelanotic Melanoma [The Best of the Best] 16 Aug 2010

The Hazards of Moist Toilet Paper: Allergy to the Preservative Methylchloroisothiazolinone/Methylisothiazolinone [Observation] 16 Aug 2010

Background Methylchloroisothiazolinone/methylisothiazolinone (MCI/MI), a common preservative in some brands of moist toilet paper (baby wipes and moist towelettes), has been reported to be a cause of allergic contact dermatitis. However, few cases have been reported in the United States.

Observations We report the cases of 4 adult patients with severe perianal and perineal allergic contact dermatitis seen at our institution during a 6-month period. With patch testing, we identified allergy to MCI/MI, and we determined that all 4 patients were using moist toilet paper. The dermatitis resolved after use of the moist toilet paper was discontinued.

Conclusion This study highlights that the MCI/MI in moist toilet paper can be a cause of perianal and perineal allergic contact dermatitis.

May 2010 Archives Web Quiz Winner [Archives Web Quiz Winner] 16 Aug 2010

The Risk of Depression, Anxiety, and Suicidality in Patients With Psoriasis: A Population-Based Cohort Study [Evidence-Based Dermatology: Study] 16 Aug 2010

Objective To determine the incidence of depression, anxiety, and suicidality in patients with psoriasis compared with the general population.

Design A population-based cohort study using data collected as part of patient's electronic medical record from 1987 to 2002.

Setting General Practice Research Database.

Patients Analyses included 146 042 patients with mild psoriasis, 3956 patients with severe psoriasis, and 766 950 patients without psoriasis. Five controls without psoriasis were selected from the same practices and similar cohort entry dates as patients with psoriasis.

Main Outcome Measure Clinical diagnoses of depression, anxiety, and suicidality among patients.

Results The adjusted hazard ratios (HRs) for receiving a diagnosis of depression, anxiety, and suicidality in patients with psoriasis compared with controls were 1.39 (95% confidence interval [CI], 1.37-1.41), 1.31 (95% CI, 1.29-1.34), and 1.44 (95% CI, 1.32-1.57), respectively. The adjusted HR of depression was higher in severe (HR, 1.72; 95% CI, 1.57-1.88) compared with mild psoriasis (HR, 1.38; 95% CI, 1.35-1.40). Younger patients with psoriasis had elevated HRs of outcomes compared with older patients with psoriasis.

Conclusions Patients with psoriasis have an increased risk of depression, anxiety, and suicidality. We estimate that in the United Kingdom, in excess of 10 400 diagnoses of depression, 7100 diagnoses of anxiety, and 350 diagnoses of suicidality are attributable to psoriasis annually. It is important for clinicians to evaluate patients with psoriasis for these conditions to improve outcomes. Future investigation should determine the mechanisms by which psoriasis is associated with psychiatric outcomes as well as approaches for prevention.

Retrospective Analysis of the Association Between Demodex Infestation and Rosacea [Evidence-Based Dermatology: Review] 16 Aug 2010

Objectives To explore the association between Demodex infestation and rosacea and the pathogenesis of demodicosis rosacea by means of a meta-analysis.

Data Sources Electronic searches of the ISI Web of Knowledge (Science Citation Index, ISTP [Index to Scientific & Technical Proceedings], Journal Citation Reports, BP [BIOSIS Preview], INSPEC [Ination Service in Physics, Electronics Technology, and Computer and Control], and DII [Derwent Innovation Index]), MEDLINE, and CNKI (China National Knowledge Infrastructure) databases (January 1, 1950, to December 31, 2009). We also performed hand searches of reference lists and conference proceedings.

Study Selection Predefined selection criteria were applied to all published case-control studies that analyzed the association between Demodex infestation and rosacea.

Data Extraction Two of us independently extracted data from the included studies. For disputed articles, a third party mediated whether to include the study.

Data Synthesis Forty-eight English- and Chinese-language articles, which covered 10 different countries and 28 527 participants, were eligible. The pooled odds ratio in random-effects models is 7.57 (95% confidence interval, 5.39-10.62). Stability is good according to sensitivity analysis. The fail-safe number is 18 456 in the quantitative analysis of publication bias.

Conclusions A significant association exists between Demodex infestation and the development of rosacea. Demodex infestation is a vital risk factor for rosacea according to the time-to-event relationship, and the degree of infestation played a more important role than did the mite infestation rate in the development of rosacea.

What Is the Evidence for Effective Treatments of Acquired Epidermodysplasia Verruciformis in HIV-Infected Patients? [Evidence-Based Dermatology: Critically Appraised Topic] 16 Aug 2010

Phototherapy and Vitamin D [Editorial] 16 Aug 2010

Optical Biopsy at the Bedside [Editorial] 16 Aug 2010

Pruritic Natal Cleft Plaque--Quiz Case [Off-Center Fold] 16 Aug 2010

Pruritic Natal Cleft Plaque--Diagnosis [Off-Center Fold] 16 Aug 2010

Subungual Tumor in a 66-Year-Old Woman--Quiz Case [Off-Center Fold] 16 Aug 2010

Subungual Tumor in a 66-Year-Old Woman--Diagnosis [Off-Center Fold] 16 Aug 2010

Increased IL-23 Expression in Palmoplantar Psoriasis and Hyperkeratotic Hand Dermatitis [Research Letters] 16 Aug 2010

A Cost-effectiveness Comparison of Liquor Carbonis Distillate Solution and Calcipotriol Cream in the Treatment of Moderate Chronic Plaque Psoriasis [Research Letters] 16 Aug 2010

An Internet-Delivered Video Intervention for Skin Self-examination by Patients With Melanoma [Research Letters] 16 Aug 2010

Actinic Keratosis on a Continuum With Squamous Cell Carcinoma [Correspondence] 16 Aug 2010

"Pruritis" Redux [Correspondence] 16 Aug 2010

Livedoid Vasculopathy in a Pediatric Patient With Elevated Lipoprotein(a) Levels: Prompt Response to Continuous Low-Molecular-Weight Heparin [Correspondence] 16 Aug 2010

Bacillary Angiomatosis After Skin Autografting in a Patient Without Human Immunodeficiency Virus Who Was Treated With Interferon Alfa [Correspondence] 16 Aug 2010

Traction Alopecia in a Ballerina: Clinicopathologic Features [Correspondence] 16 Aug 2010

Human Papillomavirus Typing of Verrucae in a Patient With WHIM Syndrome [Correspondence] 16 Aug 2010

Perforated Ischiogluteal Bursitis Mimicking a Gluteal Decubitus Ulcer in Patients With Spinal Cord Injury: Report of 2 Cases [Correspondence] 16 Aug 2010

Lymphomatoid Contact Dermatitis to Baby Wipes [Correspondence] 16 Aug 2010

Dermoscopic Patterns of Purpuric Lesions [skINsight] 16 Aug 2010

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