Learning to surf is a rite of passage for teens in seaside communities around the world. But in recent years children with disabilities ranging from near-blindness to autism have been joining the fun.

While some educators prohibit aggressive play, other educators and researchers claim that banishing violent play from classrooms can be harmful to boys.

A stunning number of teens have lost a little bit of their hearing — nearly one in five — and the problem has increased substantially in recent years, a new national study has found.

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.

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.

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.

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.

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.

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).

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.

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.

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.

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.