MULTI-CENTER CLINICAL TRIALS: Genentech Janssen Pharmaceuticals Corrona Psoriasis Registry Novartis Glaxo-Smith-Kline

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1 Robert T. Brodell, MD Professor and Chair Department of Dermatology University of Mississippi Medical Center Jackson, Mississippi 1 MULTI-CENTER CLINICAL TRIALS: Genentech Janssen Pharmaceuticals Corrona Psoriasis Registry Novartis Glaxo-Smith-Kline 2 1

2 3 Country doctor 27 years in solo private practice Ohio I like to teach 4 2

3 Procedural pearls ClinPath Correlation pearls New diseases New Concept Rare Diseases 5 6 3

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5 Saucerization Punch Elliptical Excision

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8 15 Fountain pen ink Rub across the interdigital webs Remove ink with alcohol after waiting seconds Apply thin layer of mineral oil Scrape across ends of burrows ( firmly ) 16 8

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11 21 Jacks SK, EA Lewis and PM Witman. TECHNIQUES FOR TOTS. Pediatric Dermatology Vol. 29 No ,

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14 57-year-old African American man PMH: hypertension, dyslipidemia and congestive heart Failure Pin-point papules with spines (spinulosism) appeared in the central face and spread to the ears, arms and legs. Began 12 months after heart transplant Immunosuppression with mycophenolic acid and tacrolimus (FK-506) Alopecia affecting eyebrows

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17 33 Trichodysplasia spinulosa Follicular spines of multiple myeloma (FSMM): Usually Ig in follicles, but one case demonstrated a low copy number of Merkel cell polyomavirus (MCV) in a patient with FSMM Keratosis pilaris 34 17

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21 H&E: Dilatation of anagen hair follicles with a proliferation of haphazard inner root-sheath cells filling the follicular lumen Hair shafts were absent and infundibula were plugged Inner root-sheath keratinocytes were enlarged and dystrophic with deeply eosinophilic trichohyaline granules

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27 Transmission EM: intranuclear viral inclusions within affected inner root-sheath keratinocytes composed of nonenveloped, icosahedral viral particles measuring 33 to 38 nm in diameter PCR: negative for polyomavirus perhaps due to sampling error : Haycox described trichodysplasia spinulosa (TS) in an immunocompromised patient 2009: van der Meijden isolated TSassociated polyomavirus (TSPyV) in a patient with TS 54 27

28 The Research Driven Treatment: 1. Lessen immunosuppression without jeopardizing transplant if possible 2. Custom-compounded cidofovir 1% gel applied twice daily to face and ears for four weeks

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31 Understanding an underlying infection causing a condition in an immune compromised patient can lead to effective treatment

32 Tip #2: A 77 year-old man with a widespread blistering process. Path Report: Intraepidermal blister with necrotic roof. Is this an intraepidermal process? Answer: Re-epitheliization of a chronic D-E blister can result in the appearance of an intraepidermal blister with a necrotic roof in a sub-epidermal pathophysiologic process unrelated to keratinocyte necrosis Hodge B, J Roach, J Reserva, T Patel, A Googe, J Schulmeier, and RT Brodell. The Spectrum of Histopathologic Findings in Pemphigoid: Avoiding Diagnostic Pitfalls. Journal of Cutaneous Pathology. Electronic publication 9/18. DOI: /cup

33 65 66 Kidney Disease Gadolinium exposure from radiology contrast media Widespread dermal fibrosis Histopathology: Sclerotic bodies (pink, finely-laminated globules surrounded by concentrically arranged spindled cells with loose fibrotic stroma) Field emission scanning EM (electron backscatter mode) gadolinium by energy dispersive spectroscopy in sclerotic bodies Each patient with sclerotic bodies ever described received the same type of gadolinium (gadodiamide contrast: OmniScan, GE Healthcare, USA) NSF occurs with all 5 types 33

34 Kidney Disease Incidental finding in tails of nmsc excision

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39 77 Gathings R, R Reddy, D Santa Cruz, RT Brodell. Gadolinium-Associated Plaques: A New, Distinctive Clinical Entity. JAMA Dermatol, Accepted 8/1/

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49 T tonsurans 3 weeks after Rx with terbinifine

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53 Microsporun sp

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56 EAGLES: HOTEL CALIFORNIA 111 Procedural Pearls Oval Lesion/round punch Inked Scabies Prep DermPath Pearls Trichodysplasia spinulosa Old Bullous Pemphigoid Lesions New disease Gadolinium Associated Plaques-GAP Rare Diseases Marginal Inflammatory Vitiligo Tinea Capitis in Adults