Cutaneous metastases from urothelial carcinoma are rare and, when present, are associated with a poor prognosis. We report the case of a 70-year-old male with advanced urothelial carcinoma who developed biopsy-proven cutaneous metastases to the groin. The patient initially presented with hypoxia, worsening cancer-related pain, and a left groin rash. Before hospitalization, he had been treated with chemotherapy, radical cystectomy with ileal conduit, and pembrolizumab. Following discontinuation of immunotherapy because of immune-related toxicity, he later presented with hypoxia, worsening cancer-related pain, and a new groin rash that was ultimately confirmed to represent cutaneous metastasis. Imaging obtained during hospitalization revealed progression of metastatic disease involving the mediastinal lymph nodes, lungs, and bone. The patient ultimately died of disease progression. This case highlights the importance of recognizing atypical metastatic presentations, managing immunotherapy-related toxicities, and incorporating early palliative care discussions.

We present a case of a 2-month-old female with an acute onset and rapidly progressing diffuse erythroderma involving the scalp, face, neck folds, torso, and groin. She had a history of seborrheic and diaper dermatitis and developed a worsening rash that initially appeared as a "blister-like" lesion on the cheek. Examination revealed greasy yellow scaling and intertriginous erythema. Workup ruled out herpes simplex virus/varicella-zoster virus, and blood cultures grew presumed contaminant Staphylococcus epidermidis. She was treated empirically with antibiotics, antivirals, anti-fungals, and topical steroids. Dermatology suspected inverse psoriasis. The patient improved within 48 h of treatment. Diagnoses included inverse psoriasis, fungal diaper dermatitis with secondary bacterial infection, and possible early staphylococcal scalded skin syndrome. This case emphasizes the diagnostic complexity of infantile erythroderma and the importance of a broad differential and multidisciplinary approach. Recognition of inverse psoriasis in this age group is crucial, especially in the setting of superimposed fungal and bacterial infections.

Trichostasis spinulosa (TS) is a follicular disorder involving the retention of numerous hairs in a dilated follicle, primarily reported in adults. Drug-induced TS and pediatric TS are rarely described in the literature. We report a four-year-old female with an unusual presentation of TS localized in the groin and vulva. Interestingly, the patient's TS seemed to worsen with the introduction of clonidine for her autism spectrum disorder (ASD). The rash improved significantly once clonidine was held, and recurred when clonidine was re-started. This case highlights that TS should be considered in pediatric patients, even in atypical locations, and clonidine may exacerbate TS.

Familial benign chronic pemphigus, also known as Hailey-Hailey disease, was first described by the Hailey brothers in 1939 (1). It represents a chronic autosomal-dominant genetic skin disorder with incomplete penetrance, usually diagnosed in children and young adults. As a result, family history of this disorder can be elicited in only about 66% of patients. We describe herein a patient with Hailey-Hailey disease who received treatment with hydroxyurea for a new diagnosis of polycythemia vera, with a surprising outcome. A 54-year-old man was diagnosed with Hailey-Hailey disease at age ten when he presented with several erythematous and blistering skin lesions involving the neck, wrist flexure surfaces, and the forearms. The patient underwent regular dermatology follow-up for this condition. His disease followed a relapsing-remitting pattern, with short disease-free intervals. It predominantly involved the neck, torso, and upper extremities (Figure 1), and only rarely buttocks and groin areas. Initially, mild-moderate potency topical steroid creams were tried, with only modest success. Topical antibiotics were required on several occasions due to secondary infections. Photodynamic therapy was only minimally helpful, as the disease continued to worsen. In his 40s, the disease became more difficult to manage, and several systemic options were tried, with very little if any success. Thus, the patient failed oral steroids, dapsone and azathioprine. He became anxious, depressed, and socially isolated. Other past medical history was significant for hypertension. The patient was a never-smoker, and denied alcohol or drug abuse. There was no family history of skin disorders of cancers in his immediate family members. In May 2019, the patient presented with elevated hemoglobin/hematocrit and moderate thrombocytosis. Further work-up identified JAK-2 V617F kinase mutated polycythemia vera, for which he was started on periodic phlebotomies and low-dose aspirin. Four months later, hydroxyurea was prescribed due to increased phlebotomy needs and worsening thrombocytosis. The hydroxyurea dose was subsequently titrated to 1000 mg orally per day, alternating with 1500 mg orally per day. The patient tolerated this agent well, without significant side-effects. He also achieved excellent control of hematocrit and normalization of platelet count. Pleasantly surprised, the patient also realized that he had not experienced any more relapsing Hailey-Hailey skin lesions 8 weeks after the commencement of hydroxyurea. Four years later, his polycythemia remains in excellent control. He also remains without any further evidence of skin lesions. The hallmark of Hailey-Hailey disease is believed to be the haploinsufficiency of the enzyme ATP2C1 (2). The ATP2C1 gene is located on chromosome 3 and encodes a Ca2+ ATPase protein. A mutation in one copy of the gene causes only half of this necessary protein to be synthesized. Consequently, impaired keratinocyte adhesion ensues, leading to acantholysis, blisters, and rash (2). The initial lesion may be an erythematous area or a fluid-filled blister which subsequently ruptures, leading to a macerated or crusted lesion. The lesions more commonly affect the sides of the neck, armpits, forearms, buttocks and groins, but may expand to a generalized skin eruption. Patients may complain of itching in the affected areas, potentially leading to social distress and isolation (3). Affected areas undergo repeated blistering and inflammation, and may be tender to touch. A pattern of multiple relapses and remissions is characteristic of Hailey-Hailey disease. Nonetheless, most lesions are transient and leave little or no scars (Figure 2). The differential diagnosis includes intertrigo, contact dermatitis, pemphigus, psoriasis, and cutaneous candidiasis. Skin biopsy and/or family history can confirm the diagnosis of Hailey-Hayley disease. The lack of both mucosal lesions and intercellular antibodies on immunohistochemistry distinguishes this entity from other forms of pemphigus. Hailey-Hayley disease is currently believed to be incurable, and its complications include secondary bacterial, viral, or fungal infections, which may require antimicrobial agents (4). The patients are advised to avoid friction and sweating by wearing light cotton clothes. Sun avoidance as much as possible and using SPF 50 sunscreen while in the sun are advised. Applying soothing compresses followed by topical corticosteroid cream can offer symptom relief (3,4). Topical antibiotics can be used for localized lesions. Generalized lesions may require systemic steroids and antibiotics. Topical tacrolimus, laser, and photodynamic therapy have been used with varying degrees of success in the second line (4). Oral dapsone, cyclosporine, azathioprine, thalidomide, etretinate, and intramuscular alefacept were shown to control the mild-moderate disease but not severe chronic or relapsing forms (4). Surgical skin grafting usually represents the last resort in resistant localized disease. Mestre et al. (5) described a case of chronic Hailey-Hailey disease in a Caucasian woman, whose skin lesions were refractory to topical and oral steroids, tetracyclines, antifungals, and azathioprine. After introduction of weekly oral methotrexate for rheumatoid arthritis treatment, the skin lesions regressed, with significant impact on the patient's quality of life. Similarly, Hailey-Hailey disease in our patient responded completely to hydroxyurea, without any relapses over a 4-year interval. Hydroxyurea has been used for many decades in hematology and oncology, has a favorable side-effect profile, and is cost-effective. Our case report supports the clinical evidence of hydroxyurea's potential role in Hailey-Hailey disease treatment. There is hope that our findings will be confirmed by larger studies and shift the treatment paradigm in severe chronic or relapsing-remitting forms of Hailey-Hailey disease.

A Caucasian female in her 80s with a past history of hypothyroidism, chronic kidney disease, lichen sclerosus, and intertrigo presented originally with a pustular rash to an outpatient dermatology office. The patient was treated for intertrigo with nystatin and oral fluconazole before re-presenting four months later with new erythematous plaques and overlying small pustules in the groin, axilla, and inframammary folds. A shave biopsy was taken, and the patient was treated with triamcinolone for plaques on the abdomen and nystatin and hydrocortisone for intertriginous areas. After two weeks, the patient was admitted to the hospital with expressive aphasia and a presumed stroke, and an EEG consistent with metabolic encephalopathy. Her thyroid-stimulating hormone (TSH) level was found to be 29 mlU/L (reference: 0.27-4.20 mlU/L) and T4 level of 0.42 ng/dL (reference: 0.93-1.70 ng/dL), reflective of severe hypothyroidism. The patient was started on IV levothyroxine and methylprednisolone, with improvement in mental status and rash within six days of admission to the hospital. A review of initial biopsy histology showed subcorneal accumulation of neutrophils with spongiosis, consistent with Sneddon-Wilkinson disease (SWD). SWD commonly manifests as painless superficial pustular lesions arising within erythematous plaques. It is found to often be associated with multiple comorbidities, including thyroid disorders. Given this unique presentation of SWD prior to the onset of severe hypothyroidism and myxedema coma, clinicians should consider examining thyroid hormone levels in such patients to rule out hyperthyroidism and hypothyroidism.

This case reports highlights a 37-year-old woman who was transferred to Mayo Clinic Arizona for care after development of seizures, altered mental status, and a diffuse petechial rash, along with vesicular lesions near the groin. She received broad-spectrum antimicrobial therapy. CSF testing showed lymphocytic pleocytosis and elevated protein levels, and PCR testing confirmed varicella zoster virus (VZV) infection. MRI of the brain demonstrated chronic microhemorrhages, indicative of vasculitis secondary to disseminated VZV. Dermatology consultation and subsequent biopsy of the skin lesions revealed leukocytoclastic vasculitis with IgA deposition, consistent with Henoch-Schonlein Purpura (HSP). A VZV-positive PCR from the rash further corroborated the diagnosis. This case highlights the first reported instance of VZV induced HSP in an adult. Although this patient had no complications from HSP, early recognition and targeted treatment are necessary in some cases to prevent severe conditions. This case underscores the importance of maintaining a broad differential diagnosis and the importance of biopsy lesions for prompt recognition of uncommon conditions in high-risk patients.

Acute generalised exanthematous pustulosis (AGEP) is a rare cutaneous adverse reaction which is caused due to drugs or other triggers in children. We report a very rare case of AGEP after introduction of oral cefixime for a female child who presented with complaints of fever, cough and cold for 6 days. It was noted that she developed a rash over the face within 24 hours and within the following few hours, it spread over the neck, in the axilla and over the groin. The patient has no history of allergy and had no history of similar reaction in the past. On examination, the patient was vitally stable with no sign of shock or any other significant systemic findings. The rash was characterised by erythematous base with multiple pinpoint pustules and culture of those was sterile. Haemogram was suggestive of mild leucocytosis with normal liver and renal functions. Treatment included stopping the triggering medication, that is, syrup cefixime and starting the child on oral corticosteroids along with antihistamines. The child started improving within 48 hours of medication, and rashes recovered with desquamation. AGEP is an adverse reaction which is rarely noted in children. It is treated with oral corticosteroids and supportive care of the local lesions.

Symmetrical drug-related intertriginous and flexural exanthema (SDRIFE) is a rare, symmetrical skin eruption triggered by various medications, predominantly beta-lactam antibiotics. We report the case of a 69-year-old male with moderate-to-severe ulcerative colitis who developed SDRIFE following the seventh intravenous administration of infliximab. The patient presented with symmetrical, pruritic erythema in the cubital and popliteal fossae, groins, gluteal and retroauricular regions without systemic involvement. Skin biopsy showed mild exocytosis of T lymphocytes in the epidermis and dense superficial perivascular CD3+ and CD4+ infiltration, consistent with a type IVa hypersensitivity reaction. The patient responded well to a regimen of systemic antihistamines, topical corticosteroids and tacrolimus ointment, with complete regression of lesions within one week. Despite mild recurrences of SDRIFE after each infliximab administration, the therapy was not discontinued due to the mild nature of the reaction and favourable prognosis. The authors are not aware of previously published cases of type IVa SDRIFE induced by infliximab. Unlike previous reports of severe type IVc SDRIFE reactions requiring discontinuation of infliximab, our case highlights the predominance of CD4+ cells, which may explain the mild clinical course. Understanding the underlying immunologic mechanisms of infliximab-induced SDRIFE could affect treatment decisions and prevent unnecessary discontinuation of effective therapies.

Psoriasis (PsO) is a chronic, systemic, and autoimmune dermatologic condition characterized by dry, scaly, and erythematous plaques on the skin. PsO can present in various forms, including guttate (small, round lesions commonly over the upper trunk and extremities that can be raised and scaly), inverse (smooth plaques of inflamed skin within skin folds of the groin, buttock, and breasts), pustular (white painful pustules within red inflamed blotches widespread over the body), and erythrodermic (red rash present over most of the body). Individuals with PsO can present differently, with unique symptoms and patterns on the skin. These diverse manifestations make PsO a complex condition with mild to severe symptoms affecting different body areas. Researchers have identified intrinsic risk factors (and comorbidities) tied to PsO, including genetics, obesity, metabolic syndrome, infection, cardiovascular disease, stress, and type 2 diabetes mellitus (T2DM). In addition, several extrinsic risk factors have also been shown to be tied to PsO onset and progression, such as ultraviolet (UV) light, air pollution, and various pharmacological treatments. While these intrinsic and extrinsic factors have been tied to disease pathophysiology, the underlying mechanisms of disease activity have yet to be elucidated fully, making diagnosis and treatment cumbersome. Currently, PsO is diagnosed clinically with no definitive test. Noninvasive tools such as dermoscopy aid in diagnosis, while the biopsy is reserved for difficult-to-characterize psoriatic-like lesions. The reliance on clinical presentation and the lack of diagnostic testing available have led to the underdiagnosis of PsO, particularly in minority communities. The goal of this study is to utilize data from the National Health and Nutrition Examination Survey (NHANES) to improve the diagnosis of PsO and target treatment more effectively, and biometric measurements associated with PsO should be studied to aid clinical practitioners in better understanding the disease pathophysiology and improve patient diagnosis, management, and prognosis. Using the dataset, we conducted a retrospective cohort study to find which variables are significantly associated with PsO. These objective measurements can complement clinical assessments by providing quantifiable data that could improve accuracy by detecting PsO in its early stages or distinguishing it from other skin conditions with similar presentations. This enables healthcare providers to adjust management strategies based on measurable changes in disease markers, rather than relying solely on subjective clinical observations.