Background  Painful lobular panniculitis appears to be a novel cutaneous adverse effect of selective BRAF inhibitors.

Observation  We report the clinical course and management in 2 women with metastatic melanomas harboring the BRAF^V600E mutation, who developed panniculitis with arthralgia during therapy with selective oral BRAF inhibitors. Panniculitis with arthralgia was the acute presenting adverse effect in both patients. Painful, red, nodular lesions were located on the upper and lower extremities. Biopsy specimens of the nodules showed a mild, predominantly lobular neutrophilic panniculitis. Analgesic and anti-inflammatory treatment improved panniculitis and arthralgia in both cases. It was also necessary to reduce the BRAF inhibitor dose in 1 patient.

Conclusions  During therapy with selective BRAF inhibitors, panniculitis with arthralgia represents a new adverse effect that can require dose reduction. In case of this adverse effect, treatment with nonsteroidal anti-inflammatory drugs, such as etoricoxib, should be initiated early to keep patients on treatment and to avoid drug discontinuation and tumor progression.

Objectives  To evaluate the toxic effects and maximum tolerated dose of topical carmustine [1,3-bis (2-chloroethyl)-1-nitrosourea] following intravenous O6-benzylguanine in the treatment of cutaneous T-cell lymphoma (CTCL), and to determine pharmacodynamics of O6-alkylguanine DNA alkyltransferase activity in treated CTCL lesions.

Design  Open-label, dose-escalation, phase I trial.

Setting  Dermatology outpatient clinic and clinical research unit at a university teaching hospital.

Patients  A total of 21 adult patients (11 male, 10 female) with early-stage (IA-IIA) refractory CTCL, mycosis fungoides type, treated with topical carmustine following intravenous O6-benzylguanine.

Intervention  Treatment once every 2 weeks with 120 mg/m² intravenous O6-benzylguanine followed 1 hour later by whole-body, low-dose topical carmustine starting at 10 mg, with 10-mg incremental dose-escalation in 3 patient cohorts. Cutaneous T-cell lymphoma lesional skin biopsy specimens were taken at baseline and 6 hours, 24 hours, and 1 week after the first O6-benzylguanine infusion for analysis of O6-alkylguanine-DNA alkyltransferase activity.

Main Outcome Measures  Clinical response measured by physical examination and severity-weighted assessment tool measurements, safety data acquired by review of adverse events at study visits, and O6-alkylguanine-DNA alkyltransferase activity in treated lesion skin biopsy specimens.

Results  A minimal toxic effect was observed through the 40-mg carmustine dose level with 76% of adverse events being grade 1 based on the National Cancer Institute Common Terminology Criteria for Adverse Events. Mean baseline O6-alkylguanine-DNA alkyltransferase activity in CTCL lesions was 3 times greater than in normal controls and was diminished by a median of 100% at 6 and 24 hours following O6-benzylguanine with recovery at 1 week. Clinical disease reduction correlated positively with O6-alkylguanine-DNA alkyltransferase activity at 168 hours (P = .02) and inversely with area under the curve of O6-alkylguanine-DNA alkyltransferase over 1 week (P = .01). Twelve partial responses and 4 complete responses were observed (overall response, 76% [95% CI, 0.55-0.89]). Five patients discontinued therapy owing to adverse events with a possible, probable, or definite relationship to the study drug.

Conclusion  O6-benzylguanine significantly depletes O6-alkylguanine-DNA alkyltransferase in CTCL lesions and in combination with topical carmustine is well tolerated and shows meaningful clinical responses in CTCL at markedly reduced total carmustine treatment doses.

Trial Registration  clinicaltrials.gov Identifier: NCT00003613

Objective  To evaluate overall trends in melanoma mortality rates among non-Hispanic whites by educational level.

Design  Descriptive study.

Setting  Death certificate records from 26 states, representing approximately 45% of the US population as reported by the National Center for Health Statistics, with recorded educational level information and population data from the US Bureau of Census Current Population Survey.

Patients  Recorded deaths from malignant melanoma in non-Hispanic whites reported from 1993 through 2007.

Main Outcome Measures  Age-standardized mortality rates for melanoma were evaluated by educational attainment (a marker of socioeconomic status) among non-Hispanic whites (aged 25-64 years) from 1993 through 2007. Rate ratios assessed the time trend in age-adjusted death rates by sex and educational level. Mortality differentials in educational level were measured using the regression-based Relative Index of Inequality. All statistical tests were 2-sided.

Results  Melanoma mortality declined significantly between 1993-1997 and 2003-2007 in men (RR [rate ratio], 0.916; 95% CI, 0.878-0.954; P < .001) and women (RR, 0.907; 95% CI, 0.857-0.957; P < .001). However, these declines occurred only among the most educated persons (≥13 years of education irrespective of sex), and nonsignificant increases were found among the least-educated individuals, specifically men (P = .17). As a result, the Relative Index of Inequality by education in melanoma mortality in 2003-2007 relative to 1993-1997 (baseline) widened by 51.7% in men and by 35.7% in women.

Conclusions  Recent declines in melanoma mortality rates among non-Hispanic whites in the United States mainly reflect declines among the most-educated individuals. The widening disparities in melanoma mortality rates by education calls for early detection strategies to effectively target high-risk, less-educated, non-Hispanic white individuals.

Objectives  To measure the thickness at which primary schoolchildren apply sunscreen on school day mornings and to compare it with the thickness (2.00 mg/cm²) at which sunscreen is tested during product development, as well as to investigate how application thickness was influenced by age of the child (school grades 1-7) and by dispenser type (500-mL pump, 125-mL squeeze bottle, or 50-mL roll-on).

Design  A crossover quasiexperimental study design comparing 3 sunscreen dispenser types.

Setting  Children aged 5 to 12 years from public primary schools (grades 1-7) in Queensland, Australia.

Participants  Children (n = 87) and their parents randomly recruited from the enrollment lists of 7 primary schools. Each child provided up to 3 observations (n = 258).

Intervention  Children applied sunscreen during 3 consecutive school weeks (Monday through Friday) for the first application of the day using a different dispenser each week.

Main Outcome Measure  Thickness of sunscreen application (in milligrams per square centimeter). The dispensers were weighed before and after use to calculate the weight of sunscreen applied. This was divided by the coverage area of application (in square centimeters), which was calculated by multiplying the children's body surface area by the percentage of the body covered with sunscreen.

Results  Children applied their sunscreen at a median thickness of 0.48 mg/cm². Children applied significantly more sunscreen when using the pump (0.75 mg/cm²) and the squeeze bottle (0.57 mg/cm²) compared with the roll-on (0.22 mg/cm²) (P < .001 for both).

Conclusions  Regardless of age, primary schoolchildren apply sunscreen at substantially less than 1.00 mg/cm², similar to what has been observed among adults. Some sunscreen dispensers seem to facilitate thicker application than others.

Objective  To determine whether growth rate (GR) of cutaneous melanoma predicts the histological sentinel lymph node (SLN) positivity.

Design  Retrospective cohort study.

Setting  Two tertiary melanoma referral centers.

Patients  A total of 698 patients with invasive primary cutaneous melanoma in whom the SLN was identified between January 1, 2000, and June 30, 2010.

Main Outcome Measure  Based on previous studies, a surrogate measure for GR in primary invasive melanoma was calculated as the ratio of Breslow thickness to time to melanoma development.

Results  The SLN was positive in 20.2% of patients. Multivariate logistic regression analysis revealed that GR, Breslow thickness, and the presence of microscopic satellitosis were independently associated with SLN positivity. The probability of SLN positivity was 8.2% for slow-growth melanomas (<0.10 mm/mo) compared with 19.8% for intermediate-growth melanomas (0.10-0.50 mm/mo) and 37.7% for fast-growth melanomas (>0.50 mm/mo). Growth rate was not an independent predictive factor for survival.

Conclusion  Growth rate of primary cutaneous melanoma, together with Breslow thickness and the presence of microscopic satellitosis, predicts the histological SLN positivity.

Objectives  To assess current self-reported communication and screening practices of dermatologists to their patients with melanoma about family members' risk of melanoma at the time of diagnosis and to understand the barriers that dermatologists encounter in communicating risk to patients.

Design  Descriptive survey study.

Setting  Office-based practicing physicians in the United States.

Participants  One thousand dermatologists.

Main Outcome Measure  Melanoma risk communication practices.

Results  Of 974 eligible dermatologists, 406 completed the survey (response rate, 41.7%). Almost 85% of dermatologists reported that they often or always communicate risk to patients with melanoma about their first-degree relatives, and almost 80% reported that they often or always advise their patients with melanoma that their older children (≥18 years) may be at greater risk of skin cancer. However, less than 50% of dermatologists routinely offered to screen first-degree relatives who live nearby, while only 19.7% used medical record reminders to note communication of melanoma risk to family members. Most dermatologists reported no major barriers to melanoma risk communication. However, the presence of "any risk communication barrier" (time constraints, absence of guidelines, or lack of written material) was associated with reduced melanoma risk communication practices by dermatologists.

Conclusions  The observed high rates of self-reported risk communication by dermatologists to patients with melanoma about their first-degree family members are encouraging. However, the reported low rates of actual screening of first-degree relatives warrant easy-to-administer office-based medical record reminders to facilitate and optimize screening of at-risk relatives.

Objectives  To establish the effect of sunless tanning products on tanning behaviors and to determine characteristics of sunless tanning product users.

Design  A cross-sectional survey study conducted between May 30, 2007, and December 4, 2007.

Setting  The Emory University campus and surrounding locations in Atlanta, Georgia.

Participants  Four hundred fifteen community and university-affiliated women.

Main Outcome Measures  Self-reported use of sunless tanning products and UV radiation tanning methods.

Results  Forty-eight percent of participants had used sunless tanning products, 70.6% had tanned in the sun, and 26.0% had used tanning beds at least once in the past year. Most participants (92.7%) believed that tanned skin is more attractive than untanned skin, and 79.2% reported feeling better about themselves when tan. Many sunless tanning product users reported decreased frequency of tanning in the sun (36.8%) or in tanning beds (38%) because of product use. Frequent users were more likely to have decreased their UV radiation exposure. Lighter complexion, frequent use of UV radiation tanning methods, feeling better about oneself when tan, and having a history of skin cancer were independently associated with sunless tanning product use.

Conclusions  The desire for tanned skin remains strong despite growing awareness of the dangers of UV radiation exposure. In some women, sunless tanning product use is associated with decreased UV radiation tanning frequency, especially in women who use them repeatedly. Improvements in the appearance of sunless tanning product tans may allow wider acceptance by the public and further decreases in UV radiation tanning practices.

Objective  To describe characteristics and treatment of patients with calcinosis cutis in the clinical setting of autoimmune connective tissue disease (ACTD).

Design  Retrospective study.

Setting  Tertiary referral center.

Patients  Seventy-eight patients with calcinosis cutis and ACTD between 1996 and 2009.

Main Outcome Measures  Clinical features, treatments, and outcomes of patients with calcinosis cutis in the clinical setting of ACTD.

Results  Of 78 patients (mean age at onset of calcinosis cutis, 40.1 years), 64 (82%) were female. The following diseases were associated with calcinosis cutis: dermatomyositis (n = 30) with classic (n = 15), juvenile (n = 14), and amyopathic (n = 1) subtypes; systemic sclerosis with limited cutaneous scleroderma (n = 24); lupus panniculitis (n = 4); systemic lupus erythematosus (n = 2); mixed connective tissue disease (n = 4); overlap connective tissue disease (n = 6); undifferentiated connective tissue disease (n = 6); polymyositis (n = 1); and rheumatoid arthritis (n = 1). Therapy for calcinosis cutis consisted of medical treatment alone (n = 19), surgical therapy alone (n = 11), combined medical and surgical treatment (n = 17), no treatment (n = 30), and unknown (n = 1). Diltiazem hydrochloride was the most commonly used medical therapy, with 9 of 17 patients having a partial response. Twenty-eight patients had surgical excision of 1 or more lesions of calcinosis cutis: 22 had a complete response, 5 had a partial response, and 1 had no response.

Conclusions  Dermatomyositis and systemic sclerosis were the most common ACTDs associated with calcinosis cutis. Although no treatment was uniformly effective, surgical excision of symptomatic lesions and medical treatment with diltiazem provided benefit for some patients.

Objectives  To conduct a systematic review of the effectiveness of various modalities to treat hidradenitis suppurativa (HS) and to establish recommendations on its appropriate management.

Data Sources  MEDLINE, Cochrane, and PubMed databases.

Study Selection  English-language prospective, retrospective, and case studies describing at least 4 patients with HS.

Data Extraction  Data quality and validity were addressed by multiple reviewers using independent extraction.

Data Synthesis  Studies were categorized as treatments using antibiotics, biological agents, laser surgery, excisional surgery, or miscellaneous modalities. Of 62 publications included in the review, 4 studies met criteria to be assigned the highest grade for quality of evidence.

Conclusions  Shown to be effective treatments for HS were a clindamycin-rifampin combination regimen, a course of infliximab, monthly Nd:YAG laser sessions, and surgical excision and primary closure with a gentamicin sulfate–collagen sponge. Most therapies used to treat HS were supported by limited or weak scientific evidence. A treatment approach is presented based on the evidence and on clinical experience at the Follicular Disorders Clinic, Department of Dermatology, Henry Ford Hospital, Detroit, Michigan. This review emphasizes the need for large randomized controlled trials to evaluate treatment options for HS.