Acute generalized exanthematous pustulosis (AGEP) is an uncommon cutaneous eruption characterized by acute, extensive, nonfollicular, sterile pustules accompanied by widespread erythema, fever, and leukocytosis. The clinical hallmark is superficial, sterile, subcorneal pustular dermatosis, which typically starts on the face, axilla, and groin and then progresses to most of the body. Approximately 90% of AGEP cases are due to drug hypersensitivity to a newly initiated medication, while the other 10% are thought to be viral in origin.¹ Discontinuation of the offending agent may allow for complete resolution within 15 days. Agents commonly implicated in causing AGEP are antibiotics such as aminopenicillins, macrolides, and cephalosporins.² Hydroxychloroquine (HCQ) also has been reported to cause AGEP,^3-7 with resolution shortly after discontinuation of the drug,^4,6 close to the characteristic 15 days of AGEP due to alternate medications.We report an unusual case of HCQ-induced AGEP that lasted far beyond the typical 15 days. We also review other cases of HCQ-induced AGEP and possible mechanisms to explain our patient’s symptoms.

Figure 1. Acute generalized exanthematous pustulosis extending to the chest and upper extremities (A) as well as the shoulders and back (B).

Case Report

A 50-year-old woman who was previously diagnosed with rheumatoid factor seronegative, nonerosive rheumatoid arthritis, which was only moderately controlled with low-dose prednisone (5 mg once daily) after 2 months of treatment, was started on oral HCQ 200 mg twice daily by her rheumatologist. Two weeks after starting HCQ treatment, she developed a pustular exanthem that gradually spread on the back over the next 24 to 48 hours. She described the eruption initially as pruritic, but she then developed painful stinging sensations as the eruption spread. She visited her primary care physician the next day and stopped the HCQ after 14 days following a discussion with the physician. Her prednisone dosage was increased to 50 mg daily for 5 days, but by the fifth day the lesions had spread to the face, full back, shoulders, and upper chest (Figure 1). Morphologically, she presented to the dermatology clinic with innumerable 1- to 2-mm pustules with confluent erythema on the back, extending to the forearms (Figure 2). She also had scattered erythematous macules and papules on the buttocks, legs, and plantar surfaces of the feet. A biopsy taken from the right forearm demonstrated subcorneal pustular dermatosis consistent with AGEP. Prednisone 50 mg once daily was continued. She was scheduled for a follow-up in 3 days but instead went to the emergency department 1 day later due to worsening of the eruption, fever, and malaise. On examination there were multiple discrete and confluent erythematous plaques on the face that extended to the lower extremities. Pustules and scales were noted on the back. New pustules had developed on the hands and feet with intense pruritus.

On admission, her vitals were stable with mild tachycardia. Aggressive intravenous hydration was administered. Her white blood cell count was elevated at 28.3×10⁹/L (reference range, 4.5–10×10⁹/L). She was started on intravenous methylprednisolone 100 mg once daily; topical steroid wet wraps with triamcinolone 0.1% were applied to the trunk, arms, legs, and abdomen twice daily; and hydrocortisone cream 2.5% was applied to the face and intertriginous areas 3 times daily. Over the next 2 days, eruptions continued to persist and the patient reported worsening of pain despite treatment. On day 3, intravenous methylprednisolone 100 mg was switched to oral prednisone 80 mg once daily.

Over the ensuing 5 days, recurrent episodes of erythema on the back had spread to the extremities. After 1 week in the hospital, the diffuse erythema had improved and she had widespread desquamation. She was discharged and prescribed oral prednisone 80 mg once daily and topical therapy twice daily. The patient followed up in the dermatology clinic 4 days after discharge with a mildly pruritic eruption on the trunk and proximal lower extremities but otherwise was doing well. She was instructed to taper the prednisone by 10 mg every 4 days.

At a follow-up 3 weeks later, she had persistent stinging and tingling sensations, widespread xerosis, and diffuse patchy erythema primarily on the back and proximal extremities, which flared over the last week. The patient reported waxing and waning of the erythema and pruritus since being discharged from the hospital. Despite the recent flare, which was her fourth flare of cutaneous eruption, she showed marked improvement since her initial examination and 40 days after discontinuation of HCQ. She was taking prednisone 40 mg once daily and was advised to continue tapering the dose by 2 mg every 6 to 8 days as tolerated. At 81 days after AGEP onset, the eruption had resolved and the patient was back to her baseline prednisone dosage of 5 mg once daily.

Comment

Acute generalized exanthematous pustulosis is characterized by the sudden appearance of erythema and hundreds of sterile nonfollicular pustules, fever, and leukocytosis. Histologically, AGEP is composed of subcorneal and intraepidermal pustules, edema of the papillary dermis, and perivascular infiltrates of neutrophils and possible eosinophils. The pathogenesis of AGEP is thought to be due to the release of increased amounts of IL-8 by T cells, which attract and activate polymorphonuclear neutrophils.¹ Psoriasiform changes are uncommon. Clinically, AGEP is similar to pustular psoriasis but has shown to be its own distinct entity. Unlike patients with pustular psoriasis, patients with AGEP lack a personal or family history of psoriasis or arthritis, have a shorter duration of pustules and fever, and have a history of new medication administration. Other conditions to consider in the differential diagnosis include pustular psoriasis, subcorneal pustulosis, IgA pemphigus, drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome, Stevens-Johnson syndrome, and acute febrile neutrophilic dermatosis.

In AGEP, the average duration of medication exposure prior to onset varies depending on the causative agent. Antibiotics consistently have been shown to trigger symptoms after 1 day, whereas other medications, including HCQ, averaged closer to 11 days. Hydroxychloroquine is widely used to treat rheumatic and dermatologic diseases and has previously been reported to be a less common cause of AGEP³; however, a EuroSCAR study found that patients treated with HCQ were at a greater risk for AGEP.² Acute generalized exanthematous pustulosis usually follows a benign self-limiting course. Within days the eruption gradually evolves into superficial desquamation. Characteristically, removal of the offending agent typically leads to spontaneous resolution in less than 15 days. Resolution is generally without complications and, therefore, treatment is not always necessary. Death has been reported in up to 2% of cases.⁸ There are no known therapies that prevent the spread of lesions or further decline of the patient’s condition. Systemic corticosteroids often are used to treat AGEP with variable results.^1,5

Unique to our patient were recurring exacerbations of the cutaneous lesions beyond the typical 15 days for complete resolution. Even up to 40 days after discontinuation of medication, our patient continued to experience cutaneous symptoms. Other reported cases have not described patients with symptoms flaring or continuing for this extended period of time. A review of 7 external AGEP cases caused by HCQ (identified through a PubMed search of articles indexed for MEDLINE using the search terms acute generalized exanthematous pustulosis or eruption with hydroxychloroquine or plaquenil) showed resolution within 8 days to 3 weeks (Table).^3-6,8 One case report documented disease exacerbation on day 18 after tapering the methylprednisolone dose. This patient was then treated with cyclosporine and had a prompt recovery.⁵ One case of AGEP due to terbinafine reported continual symptoms for approximately 4 weeks after terbinafine discontinuation.⁹ Our patient’s continual symptoms beyond the typical 15 days may be due to the long half-life of HCQ, which is approximately 40 to 50 days. Systemic corticosteroids often are used to control severe eruptions in AGEP and were administered to our patient; however, their utility in shortening the duration or reducing the severity of the eruption has not been proven.

Conclusion

Hydroxychloroquine is a commonly used agent for dermatologic and rheumatologic conditions. The rare but severe acute adverse event of AGEP warrants caution in HCQ use. Correct diagnosis of AGEP with HCQ cessation generally is effective as therapy. Our patient demonstrated that not all cases of AGEP show rapid resolution of cutaneous symptoms after cessation of the drug. Hydroxychloroquine’s extended half-life of 40 to 50 days surpasses that of other medications known to cause AGEP and may explain our patient’s symptoms beyond the usual course.

Acute generalized exanthematous pustulosis (AGEP) is an uncommon cutaneous eruption characterized by acute, extensive, nonfollicular, sterile pustules accompanied by widespread erythema, fever, and leukocytosis. The clinical hallmark is superficial, sterile, subcorneal pustular dermatosis, which typically starts on the face, axilla, and groin and then progresses to most of the body. Approximately 90% of AGEP cases are due to drug hypersensitivity to a newly initiated medication, while the other 10% are thought to be viral in origin.¹ Discontinuation of the offending agent may allow for complete resolution within 15 days. Agents commonly implicated in causing AGEP are antibiotics such as aminopenicillins, macrolides, and cephalosporins.² Hydroxychloroquine (HCQ) also has been reported to cause AGEP,^3-7 with resolution shortly after discontinuation of the drug,^4,6 close to the characteristic 15 days of AGEP due to alternate medications.We report an unusual case of HCQ-induced AGEP that lasted far beyond the typical 15 days. We also review other cases of HCQ-induced AGEP and possible mechanisms to explain our patient’s symptoms.

Figure 1. Acute generalized exanthematous pustulosis extending to the chest and upper extremities (A) as well as the shoulders and back (B).

Case Report

A 50-year-old woman who was previously diagnosed with rheumatoid factor seronegative, nonerosive rheumatoid arthritis, which was only moderately controlled with low-dose prednisone (5 mg once daily) after 2 months of treatment, was started on oral HCQ 200 mg twice daily by her rheumatologist. Two weeks after starting HCQ treatment, she developed a pustular exanthem that gradually spread on the back over the next 24 to 48 hours. She described the eruption initially as pruritic, but she then developed painful stinging sensations as the eruption spread. She visited her primary care physician the next day and stopped the HCQ after 14 days following a discussion with the physician. Her prednisone dosage was increased to 50 mg daily for 5 days, but by the fifth day the lesions had spread to the face, full back, shoulders, and upper chest (Figure 1). Morphologically, she presented to the dermatology clinic with innumerable 1- to 2-mm pustules with confluent erythema on the back, extending to the forearms (Figure 2). She also had scattered erythematous macules and papules on the buttocks, legs, and plantar surfaces of the feet. A biopsy taken from the right forearm demonstrated subcorneal pustular dermatosis consistent with AGEP. Prednisone 50 mg once daily was continued. She was scheduled for a follow-up in 3 days but instead went to the emergency department 1 day later due to worsening of the eruption, fever, and malaise. On examination there were multiple discrete and confluent erythematous plaques on the face that extended to the lower extremities. Pustules and scales were noted on the back. New pustules had developed on the hands and feet with intense pruritus.

On admission, her vitals were stable with mild tachycardia. Aggressive intravenous hydration was administered. Her white blood cell count was elevated at 28.3×10⁹/L (reference range, 4.5–10×10⁹/L). She was started on intravenous methylprednisolone 100 mg once daily; topical steroid wet wraps with triamcinolone 0.1% were applied to the trunk, arms, legs, and abdomen twice daily; and hydrocortisone cream 2.5% was applied to the face and intertriginous areas 3 times daily. Over the next 2 days, eruptions continued to persist and the patient reported worsening of pain despite treatment. On day 3, intravenous methylprednisolone 100 mg was switched to oral prednisone 80 mg once daily.

Over the ensuing 5 days, recurrent episodes of erythema on the back had spread to the extremities. After 1 week in the hospital, the diffuse erythema had improved and she had widespread desquamation. She was discharged and prescribed oral prednisone 80 mg once daily and topical therapy twice daily. The patient followed up in the dermatology clinic 4 days after discharge with a mildly pruritic eruption on the trunk and proximal lower extremities but otherwise was doing well. She was instructed to taper the prednisone by 10 mg every 4 days.

At a follow-up 3 weeks later, she had persistent stinging and tingling sensations, widespread xerosis, and diffuse patchy erythema primarily on the back and proximal extremities, which flared over the last week. The patient reported waxing and waning of the erythema and pruritus since being discharged from the hospital. Despite the recent flare, which was her fourth flare of cutaneous eruption, she showed marked improvement since her initial examination and 40 days after discontinuation of HCQ. She was taking prednisone 40 mg once daily and was advised to continue tapering the dose by 2 mg every 6 to 8 days as tolerated. At 81 days after AGEP onset, the eruption had resolved and the patient was back to her baseline prednisone dosage of 5 mg once daily.

Comment

Acute generalized exanthematous pustulosis is characterized by the sudden appearance of erythema and hundreds of sterile nonfollicular pustules, fever, and leukocytosis. Histologically, AGEP is composed of subcorneal and intraepidermal pustules, edema of the papillary dermis, and perivascular infiltrates of neutrophils and possible eosinophils. The pathogenesis of AGEP is thought to be due to the release of increased amounts of IL-8 by T cells, which attract and activate polymorphonuclear neutrophils.¹ Psoriasiform changes are uncommon. Clinically, AGEP is similar to pustular psoriasis but has shown to be its own distinct entity. Unlike patients with pustular psoriasis, patients with AGEP lack a personal or family history of psoriasis or arthritis, have a shorter duration of pustules and fever, and have a history of new medication administration. Other conditions to consider in the differential diagnosis include pustular psoriasis, subcorneal pustulosis, IgA pemphigus, drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome, Stevens-Johnson syndrome, and acute febrile neutrophilic dermatosis.

In AGEP, the average duration of medication exposure prior to onset varies depending on the causative agent. Antibiotics consistently have been shown to trigger symptoms after 1 day, whereas other medications, including HCQ, averaged closer to 11 days. Hydroxychloroquine is widely used to treat rheumatic and dermatologic diseases and has previously been reported to be a less common cause of AGEP³; however, a EuroSCAR study found that patients treated with HCQ were at a greater risk for AGEP.² Acute generalized exanthematous pustulosis usually follows a benign self-limiting course. Within days the eruption gradually evolves into superficial desquamation. Characteristically, removal of the offending agent typically leads to spontaneous resolution in less than 15 days. Resolution is generally without complications and, therefore, treatment is not always necessary. Death has been reported in up to 2% of cases.⁸ There are no known therapies that prevent the spread of lesions or further decline of the patient’s condition. Systemic corticosteroids often are used to treat AGEP with variable results.^1,5

Unique to our patient were recurring exacerbations of the cutaneous lesions beyond the typical 15 days for complete resolution. Even up to 40 days after discontinuation of medication, our patient continued to experience cutaneous symptoms. Other reported cases have not described patients with symptoms flaring or continuing for this extended period of time. A review of 7 external AGEP cases caused by HCQ (identified through a PubMed search of articles indexed for MEDLINE using the search terms acute generalized exanthematous pustulosis or eruption with hydroxychloroquine or plaquenil) showed resolution within 8 days to 3 weeks (Table).^3-6,8 One case report documented disease exacerbation on day 18 after tapering the methylprednisolone dose. This patient was then treated with cyclosporine and had a prompt recovery.⁵ One case of AGEP due to terbinafine reported continual symptoms for approximately 4 weeks after terbinafine discontinuation.⁹ Our patient’s continual symptoms beyond the typical 15 days may be due to the long half-life of HCQ, which is approximately 40 to 50 days. Systemic corticosteroids often are used to control severe eruptions in AGEP and were administered to our patient; however, their utility in shortening the duration or reducing the severity of the eruption has not been proven.

Conclusion

Hydroxychloroquine is a commonly used agent for dermatologic and rheumatologic conditions. The rare but severe acute adverse event of AGEP warrants caution in HCQ use. Correct diagnosis of AGEP with HCQ cessation generally is effective as therapy. Our patient demonstrated that not all cases of AGEP show rapid resolution of cutaneous symptoms after cessation of the drug. Hydroxychloroquine’s extended half-life of 40 to 50 days surpasses that of other medications known to cause AGEP and may explain our patient’s symptoms beyond the usual course.

Acute generalized exanthematous pustulosis (AGEP) is an uncommon cutaneous eruption characterized by acute, extensive, nonfollicular, sterile pustules accompanied by widespread erythema, fever, and leukocytosis. The clinical hallmark is superficial, sterile, subcorneal pustular dermatosis, which typically starts on the face, axilla, and groin and then progresses to most of the body. Approximately 90% of AGEP cases are due to drug hypersensitivity to a newly initiated medication, while the other 10% are thought to be viral in origin.¹ Discontinuation of the offending agent may allow for complete resolution within 15 days. Agents commonly implicated in causing AGEP are antibiotics such as aminopenicillins, macrolides, and cephalosporins.² Hydroxychloroquine (HCQ) also has been reported to cause AGEP,^3-7 with resolution shortly after discontinuation of the drug,^4,6 close to the characteristic 15 days of AGEP due to alternate medications.We report an unusual case of HCQ-induced AGEP that lasted far beyond the typical 15 days. We also review other cases of HCQ-induced AGEP and possible mechanisms to explain our patient’s symptoms.

Figure 1. Acute generalized exanthematous pustulosis extending to the chest and upper extremities (A) as well as the shoulders and back (B).

Case Report

A 50-year-old woman who was previously diagnosed with rheumatoid factor seronegative, nonerosive rheumatoid arthritis, which was only moderately controlled with low-dose prednisone (5 mg once daily) after 2 months of treatment, was started on oral HCQ 200 mg twice daily by her rheumatologist. Two weeks after starting HCQ treatment, she developed a pustular exanthem that gradually spread on the back over the next 24 to 48 hours. She described the eruption initially as pruritic, but she then developed painful stinging sensations as the eruption spread. She visited her primary care physician the next day and stopped the HCQ after 14 days following a discussion with the physician. Her prednisone dosage was increased to 50 mg daily for 5 days, but by the fifth day the lesions had spread to the face, full back, shoulders, and upper chest (Figure 1). Morphologically, she presented to the dermatology clinic with innumerable 1- to 2-mm pustules with confluent erythema on the back, extending to the forearms (Figure 2). She also had scattered erythematous macules and papules on the buttocks, legs, and plantar surfaces of the feet. A biopsy taken from the right forearm demonstrated subcorneal pustular dermatosis consistent with AGEP. Prednisone 50 mg once daily was continued. She was scheduled for a follow-up in 3 days but instead went to the emergency department 1 day later due to worsening of the eruption, fever, and malaise. On examination there were multiple discrete and confluent erythematous plaques on the face that extended to the lower extremities. Pustules and scales were noted on the back. New pustules had developed on the hands and feet with intense pruritus.

On admission, her vitals were stable with mild tachycardia. Aggressive intravenous hydration was administered. Her white blood cell count was elevated at 28.3×10⁹/L (reference range, 4.5–10×10⁹/L). She was started on intravenous methylprednisolone 100 mg once daily; topical steroid wet wraps with triamcinolone 0.1% were applied to the trunk, arms, legs, and abdomen twice daily; and hydrocortisone cream 2.5% was applied to the face and intertriginous areas 3 times daily. Over the next 2 days, eruptions continued to persist and the patient reported worsening of pain despite treatment. On day 3, intravenous methylprednisolone 100 mg was switched to oral prednisone 80 mg once daily.

Over the ensuing 5 days, recurrent episodes of erythema on the back had spread to the extremities. After 1 week in the hospital, the diffuse erythema had improved and she had widespread desquamation. She was discharged and prescribed oral prednisone 80 mg once daily and topical therapy twice daily. The patient followed up in the dermatology clinic 4 days after discharge with a mildly pruritic eruption on the trunk and proximal lower extremities but otherwise was doing well. She was instructed to taper the prednisone by 10 mg every 4 days.

At a follow-up 3 weeks later, she had persistent stinging and tingling sensations, widespread xerosis, and diffuse patchy erythema primarily on the back and proximal extremities, which flared over the last week. The patient reported waxing and waning of the erythema and pruritus since being discharged from the hospital. Despite the recent flare, which was her fourth flare of cutaneous eruption, she showed marked improvement since her initial examination and 40 days after discontinuation of HCQ. She was taking prednisone 40 mg once daily and was advised to continue tapering the dose by 2 mg every 6 to 8 days as tolerated. At 81 days after AGEP onset, the eruption had resolved and the patient was back to her baseline prednisone dosage of 5 mg once daily.

Comment

Acute generalized exanthematous pustulosis is characterized by the sudden appearance of erythema and hundreds of sterile nonfollicular pustules, fever, and leukocytosis. Histologically, AGEP is composed of subcorneal and intraepidermal pustules, edema of the papillary dermis, and perivascular infiltrates of neutrophils and possible eosinophils. The pathogenesis of AGEP is thought to be due to the release of increased amounts of IL-8 by T cells, which attract and activate polymorphonuclear neutrophils.¹ Psoriasiform changes are uncommon. Clinically, AGEP is similar to pustular psoriasis but has shown to be its own distinct entity. Unlike patients with pustular psoriasis, patients with AGEP lack a personal or family history of psoriasis or arthritis, have a shorter duration of pustules and fever, and have a history of new medication administration. Other conditions to consider in the differential diagnosis include pustular psoriasis, subcorneal pustulosis, IgA pemphigus, drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome, Stevens-Johnson syndrome, and acute febrile neutrophilic dermatosis.

In AGEP, the average duration of medication exposure prior to onset varies depending on the causative agent. Antibiotics consistently have been shown to trigger symptoms after 1 day, whereas other medications, including HCQ, averaged closer to 11 days. Hydroxychloroquine is widely used to treat rheumatic and dermatologic diseases and has previously been reported to be a less common cause of AGEP³; however, a EuroSCAR study found that patients treated with HCQ were at a greater risk for AGEP.² Acute generalized exanthematous pustulosis usually follows a benign self-limiting course. Within days the eruption gradually evolves into superficial desquamation. Characteristically, removal of the offending agent typically leads to spontaneous resolution in less than 15 days. Resolution is generally without complications and, therefore, treatment is not always necessary. Death has been reported in up to 2% of cases.⁸ There are no known therapies that prevent the spread of lesions or further decline of the patient’s condition. Systemic corticosteroids often are used to treat AGEP with variable results.^1,5

Unique to our patient were recurring exacerbations of the cutaneous lesions beyond the typical 15 days for complete resolution. Even up to 40 days after discontinuation of medication, our patient continued to experience cutaneous symptoms. Other reported cases have not described patients with symptoms flaring or continuing for this extended period of time. A review of 7 external AGEP cases caused by HCQ (identified through a PubMed search of articles indexed for MEDLINE using the search terms acute generalized exanthematous pustulosis or eruption with hydroxychloroquine or plaquenil) showed resolution within 8 days to 3 weeks (Table).^3-6,8 One case report documented disease exacerbation on day 18 after tapering the methylprednisolone dose. This patient was then treated with cyclosporine and had a prompt recovery.⁵ One case of AGEP due to terbinafine reported continual symptoms for approximately 4 weeks after terbinafine discontinuation.⁹ Our patient’s continual symptoms beyond the typical 15 days may be due to the long half-life of HCQ, which is approximately 40 to 50 days. Systemic corticosteroids often are used to control severe eruptions in AGEP and were administered to our patient; however, their utility in shortening the duration or reducing the severity of the eruption has not been proven.

Conclusion

Hydroxychloroquine is a commonly used agent for dermatologic and rheumatologic conditions. The rare but severe acute adverse event of AGEP warrants caution in HCQ use. Correct diagnosis of AGEP with HCQ cessation generally is effective as therapy. Our patient demonstrated that not all cases of AGEP show rapid resolution of cutaneous symptoms after cessation of the drug. Hydroxychloroquine’s extended half-life of 40 to 50 days surpasses that of other medications known to cause AGEP and may explain our patient’s symptoms beyond the usual course.

Practice Gap

Warts may negatively impact a patient's quality of life, as they may cause not only discomfort and pain but also embarrassment and low self-esteem.¹ Moreover, Ciconte et al¹ demonstrated that study participants with warts on their feet were more likely to report physical discomfort than those with warts on their hands. Therefore, plantar warts should be diagnosed promptly to allow for proper treatment.

Warts may be identified by viewing the dilated capillaries that lie on their surface, which appear as small black dots to the naked eye.¹ The formation of a plantar wart obliterates the normal plantar creases, thereby flattening the skin’s natural markings. However, a plantar wart may appear clinically similar to a callus and both lesions typically form in pressure point areas, warranting the use of a tool that aids in its diagnostic evaluation.^1,2

Diagnostic Tools

Dermoscopy, a noninvasive tool that creates a microscopic visualization of lesions, is commonly used to distinguish dermatologic pathology if the clinical presentation overlaps with a similar lesion, such as a callus, corn, or plantar wart.^1,3 However, there is another way of differentiating plantar warts from calluses using a simple 2-step clinical maneuver that we learned from Dr. Lewis Kaplan at the University of Miami.

Using the thumb or index finger, apply pressure at a perpendicular angle to the lesion on the sole of the patient’s foot, which will not create substantial discomfort or pain in a patient who has a plantar wart (Figure) but will be painful in a patient who has a callus due to the underlying bony spur. The next step involves applying pressure to the left and right sides of the lesion by squeezing toward the center with the thumb and index finger at a 45° angle. This maneuver will create substantial discomfort and pain in patients with plantar warts, thus helping to confirm the diagnosis.

A plantar wart before (A) and after undergoing the squeeze maneuver (B). The patient denied feelings of discomfort or pain.

Practice Implications

Rarely, a plantar wart can progress to form a verrucous carcinoma if left untreated.² Thus, it is important to diagnose and treat plantar warts to avoid pain and potential complications. The technique discussed here, which we are coining as the “squeeze maneuver,” allows for easy diagnosis and negates the need for an expensive diagnostic tool.To submit a clinical pearl, contact our Editorial Office.

Practice Gap

Warts may negatively impact a patient's quality of life, as they may cause not only discomfort and pain but also embarrassment and low self-esteem.¹ Moreover, Ciconte et al¹ demonstrated that study participants with warts on their feet were more likely to report physical discomfort than those with warts on their hands. Therefore, plantar warts should be diagnosed promptly to allow for proper treatment.

Warts may be identified by viewing the dilated capillaries that lie on their surface, which appear as small black dots to the naked eye.¹ The formation of a plantar wart obliterates the normal plantar creases, thereby flattening the skin’s natural markings. However, a plantar wart may appear clinically similar to a callus and both lesions typically form in pressure point areas, warranting the use of a tool that aids in its diagnostic evaluation.^1,2

Diagnostic Tools

Dermoscopy, a noninvasive tool that creates a microscopic visualization of lesions, is commonly used to distinguish dermatologic pathology if the clinical presentation overlaps with a similar lesion, such as a callus, corn, or plantar wart.^1,3 However, there is another way of differentiating plantar warts from calluses using a simple 2-step clinical maneuver that we learned from Dr. Lewis Kaplan at the University of Miami.

Using the thumb or index finger, apply pressure at a perpendicular angle to the lesion on the sole of the patient’s foot, which will not create substantial discomfort or pain in a patient who has a plantar wart (Figure) but will be painful in a patient who has a callus due to the underlying bony spur. The next step involves applying pressure to the left and right sides of the lesion by squeezing toward the center with the thumb and index finger at a 45° angle. This maneuver will create substantial discomfort and pain in patients with plantar warts, thus helping to confirm the diagnosis.

A plantar wart before (A) and after undergoing the squeeze maneuver (B). The patient denied feelings of discomfort or pain.

Practice Implications

Rarely, a plantar wart can progress to form a verrucous carcinoma if left untreated.² Thus, it is important to diagnose and treat plantar warts to avoid pain and potential complications. The technique discussed here, which we are coining as the “squeeze maneuver,” allows for easy diagnosis and negates the need for an expensive diagnostic tool.To submit a clinical pearl, contact our Editorial Office.

Practice Gap

Warts may negatively impact a patient's quality of life, as they may cause not only discomfort and pain but also embarrassment and low self-esteem.¹ Moreover, Ciconte et al¹ demonstrated that study participants with warts on their feet were more likely to report physical discomfort than those with warts on their hands. Therefore, plantar warts should be diagnosed promptly to allow for proper treatment.

Warts may be identified by viewing the dilated capillaries that lie on their surface, which appear as small black dots to the naked eye.¹ The formation of a plantar wart obliterates the normal plantar creases, thereby flattening the skin’s natural markings. However, a plantar wart may appear clinically similar to a callus and both lesions typically form in pressure point areas, warranting the use of a tool that aids in its diagnostic evaluation.^1,2

Diagnostic Tools

Dermoscopy, a noninvasive tool that creates a microscopic visualization of lesions, is commonly used to distinguish dermatologic pathology if the clinical presentation overlaps with a similar lesion, such as a callus, corn, or plantar wart.^1,3 However, there is another way of differentiating plantar warts from calluses using a simple 2-step clinical maneuver that we learned from Dr. Lewis Kaplan at the University of Miami.

Using the thumb or index finger, apply pressure at a perpendicular angle to the lesion on the sole of the patient’s foot, which will not create substantial discomfort or pain in a patient who has a plantar wart (Figure) but will be painful in a patient who has a callus due to the underlying bony spur. The next step involves applying pressure to the left and right sides of the lesion by squeezing toward the center with the thumb and index finger at a 45° angle. This maneuver will create substantial discomfort and pain in patients with plantar warts, thus helping to confirm the diagnosis.

A plantar wart before (A) and after undergoing the squeeze maneuver (B). The patient denied feelings of discomfort or pain.

Practice Implications

Rarely, a plantar wart can progress to form a verrucous carcinoma if left untreated.² Thus, it is important to diagnose and treat plantar warts to avoid pain and potential complications. The technique discussed here, which we are coining as the “squeeze maneuver,” allows for easy diagnosis and negates the need for an expensive diagnostic tool.To submit a clinical pearl, contact our Editorial Office.

Fishing is one of the world’s most beloved activities, enjoyed as a sport or a leisure activity. However, a common injury from fishing is embedment of the fishhook in the cutaneous tissue. Barbed fishhooks are used for their effectiveness in maintaining the fish on the hook once it is caught, but when implanted in the hand of a fisherman or fisherwoman, barbs can pose problems for removal without exacerbating internal tissue injury. Nevertheless, dermatologists should not shy away from removal of barbed fishhooks, as there are several simple methods that can be easily utilized in the outpatient setting.

Case Report

A 68-year-old man presented to an outpatient dermatology clinic after sustaining a barbed fishhook injury while fishing. The fishhook was firmly inserted into the ventral side of the third digit of the right hand (Figure 1).

Prior to presenting to dermatology, the patient went to 2 urgent care clinics the same day seeking treatment. He reported that practitioners at the first clinic were not able to remove the fishhook because they did not have pliers in stock. At the second clinic he was told the fishhook might be embedded in deeper tissues and was advised to go to the emergency department at the local hospital. When he arrived at the emergency department, a 6-hour wait time prompted him to see a local dermatologist instead.

To remove the fishhook, the area was cleaned and prepared first; lidocaine 2% was administered for local anesthesia. An 18-gauge needle was then advanced through the puncture site parallel to the fishhook’s inner shaft on the same side as the barb, which could be successfully palpated using the tip of the 18-gauge needle. The tip of the needle was then used to cap the barb beneath the skin. This technique allowed for the hook to be easily extracted in a retrograde manner without causing further destruction to the surrounding tissue. The patient then was started on prophylaxis cephalexin 500 mg 3 times daily for 3 days.

Comment

The hand is the most common site of fishhook injury, followed closely by the head and eyes.¹ Barbless fishhooks usually can be removed by pushing the hook in a retrograde manner along the path of insertion. This method is simple and rarely results in complications. However, there are no guidelines for removal of barbed fishhooks. Furthermore, removing a barbed fishhook in the same retrograde manner would result in extensive internal tissue destruction and increased complications. Due to the popularity of the sport of fishing, fishhook injuries, depending on geographical location, are not uncommon.² For this reason, trauma and emergency practitioners have become well versed in safe methods for barbed fishhook removal. However, patients are not always able or willing to seek medical care in emergency departments and may opt to seek treatment in outpatient settings, such as in our case. As a result, dermatologists should familiarize themselves with safe and effective fishhook removal methods, as they are not time consuming and do not require complex equipment. Failure to treat the patient may lead to further patient discomfort and increased risk for complications. Additionally, many of the techniques for removal may be useful with other foreign bodies embedded in cutaneous tissue (eg, splinters).

There are a number of safe and effective techniques for removing barbed fishhooks from cutaneous tissue, including the advance-and-cut method, the cut-it-out technique, the string-pull method, and the needle cover technique.^1-3 The method chosen to remove the fishhook is dependent on a variety of factors, such as anatomic location, tissue depth, and provider comfort.

With the advance-and-cut method (Figure 2), the affected area is anesthetized and a small incision in the skin is created to expose the barb. The fishhook is then advanced through the incision, providing visibility of the barb and thus allowing the practitioner to cut the barbed tip without creating further damage to the surrounding tissue. The shaft of the fishhook can subsequently be removed in a retrograde fashion. The advantages of this technique include that it may be successfully used in all types of barbed fishhooks and it provides the practitioner with direct visibility of the barb, thus minimizing risk for neurovascular injury during removal.¹ However, the primary disadvantage is that a second cutaneous wound is created in exposing the barb.

Figure 2. The advance-and-cut method for fishhook removal.		Figure 3. The cut-it-out method for fishhook removal.

The cut-it-out technique (Figure 3) is similar to the advance-and-cut method in that they both require anesthesia along with creating an incision. With this method, a scalpel is used to create a small linear incision originating at the fishhook entrance site and ending at the approximated location of the fishhook’s tip. The fishhook then is simply lifted superiorly in a retrograde fashion.

The string-pull method (Figure 4) has been credited to fishermen in South Australia and was first described by Cooke² in 1961. This method is relatively painless, does not require anesthesia, and has a high success rate when properly administered. However, it does require rapid and confident motions (ie, without hesitation) by the practitioner and should not be performed on free-moving areas of the body (eg, earlobe).³ With this technique, a sturdy piece of suture (eg, 2/0 or 3/0 strength silk) is looped around the hook and is extended away from the practitioner at a 30° angle. The free end of the suture is then securely fastened around the index finger of the practitioner’s dominant hand. The index finger of the nondominant hand should apply a downward pressure to the hook shaft to disengage the barb from the tissue. Simultaneously and rather quickly and forcefully the practitioner must pull the dominant index finger with the string attached in a superior and lateral direction, as depicted by the long arrow in Figure 4. If successful, the barbed hook will pull out of the entrance site. The use of string in pulling the fishhook parallel to the site of injury is helpful for smaller fishhooks that may be difficult to grab with fingers alone. However, with larger fishhooks, the string may not be required so long as the practitioner is able to obtain a secure grasp on the fishhook shaft. The string-pull method becomes particularly useful when anesthesia is unavailable or when the barb of the hook is embedded too deeply for safe advancement through tissue to visualize and cut the barb.

Lastly, the needle cover technique (Figure 5) is another simple method that does not require the creation of a secondary wound. An 18-gauge needle is simply inserted parallel to the fishhook curvature into the site of entry. By using the needle to slide along the fishhook’s curve, the practitioner is able to follow its pathway while in the tissue. The tip of the 18-gauge needle is then used to cap or cover the barb, thus allowing the fishhook to be removed in a retrograde fashion from the wound. In an outpatient setting, this technique does not require the creation of additional tissue damage and practitioners who are inexperienced with fishhook removal may proceed through the motions more slowly and methodically than the string-pull method permits.

Wound care following fishhook removal should involve adequate flushing of the wound with normal saline along with the application of topical antibiotics and a simple dressing and adhesive bandage. Oral prophylactic antibiotics typically are not required for shallow cutaneous injuries unless the fishhook is dirty, the patient is immunocompromised, or the patient has a condition lending to poor wound healing (eg, diabetes mellitus, peripheral vascular disease).³ When deciding on antibiotics, it is important to note that fishhook injuries while saltwater fishing are associated with Vibrio infection, while injuries sustained during freshwater fishing are associated with gram-negative bacteria (eg, Pseudomonas and Aeromonas species).³ Lastly, it is essential to find out the immunization status of the patient, and tetanus immune globulin should be provided if necessary.

Figure 4. The string-pull method for fishhook removal.		Figure 5. The needle cover technique for fishhook removal.

Conclusion

Although guidelines for barbed fishhook removal are not available, outpatient physicians, including dermatologists, should not fear removal procedures. There are many safe and effective fishhook removal methods that are not time consuming and do not require complex equipment. Furthermore, familiarization with these same techniques may be useful for removal of other foreign bodies embedded in cutaneous tissue.

Fishing is one of the world’s most beloved activities, enjoyed as a sport or a leisure activity. However, a common injury from fishing is embedment of the fishhook in the cutaneous tissue. Barbed fishhooks are used for their effectiveness in maintaining the fish on the hook once it is caught, but when implanted in the hand of a fisherman or fisherwoman, barbs can pose problems for removal without exacerbating internal tissue injury. Nevertheless, dermatologists should not shy away from removal of barbed fishhooks, as there are several simple methods that can be easily utilized in the outpatient setting.

Case Report

A 68-year-old man presented to an outpatient dermatology clinic after sustaining a barbed fishhook injury while fishing. The fishhook was firmly inserted into the ventral side of the third digit of the right hand (Figure 1).

Prior to presenting to dermatology, the patient went to 2 urgent care clinics the same day seeking treatment. He reported that practitioners at the first clinic were not able to remove the fishhook because they did not have pliers in stock. At the second clinic he was told the fishhook might be embedded in deeper tissues and was advised to go to the emergency department at the local hospital. When he arrived at the emergency department, a 6-hour wait time prompted him to see a local dermatologist instead.

To remove the fishhook, the area was cleaned and prepared first; lidocaine 2% was administered for local anesthesia. An 18-gauge needle was then advanced through the puncture site parallel to the fishhook’s inner shaft on the same side as the barb, which could be successfully palpated using the tip of the 18-gauge needle. The tip of the needle was then used to cap the barb beneath the skin. This technique allowed for the hook to be easily extracted in a retrograde manner without causing further destruction to the surrounding tissue. The patient then was started on prophylaxis cephalexin 500 mg 3 times daily for 3 days.

Comment

The hand is the most common site of fishhook injury, followed closely by the head and eyes.¹ Barbless fishhooks usually can be removed by pushing the hook in a retrograde manner along the path of insertion. This method is simple and rarely results in complications. However, there are no guidelines for removal of barbed fishhooks. Furthermore, removing a barbed fishhook in the same retrograde manner would result in extensive internal tissue destruction and increased complications. Due to the popularity of the sport of fishing, fishhook injuries, depending on geographical location, are not uncommon.² For this reason, trauma and emergency practitioners have become well versed in safe methods for barbed fishhook removal. However, patients are not always able or willing to seek medical care in emergency departments and may opt to seek treatment in outpatient settings, such as in our case. As a result, dermatologists should familiarize themselves with safe and effective fishhook removal methods, as they are not time consuming and do not require complex equipment. Failure to treat the patient may lead to further patient discomfort and increased risk for complications. Additionally, many of the techniques for removal may be useful with other foreign bodies embedded in cutaneous tissue (eg, splinters).

There are a number of safe and effective techniques for removing barbed fishhooks from cutaneous tissue, including the advance-and-cut method, the cut-it-out technique, the string-pull method, and the needle cover technique.^1-3 The method chosen to remove the fishhook is dependent on a variety of factors, such as anatomic location, tissue depth, and provider comfort.

With the advance-and-cut method (Figure 2), the affected area is anesthetized and a small incision in the skin is created to expose the barb. The fishhook is then advanced through the incision, providing visibility of the barb and thus allowing the practitioner to cut the barbed tip without creating further damage to the surrounding tissue. The shaft of the fishhook can subsequently be removed in a retrograde fashion. The advantages of this technique include that it may be successfully used in all types of barbed fishhooks and it provides the practitioner with direct visibility of the barb, thus minimizing risk for neurovascular injury during removal.¹ However, the primary disadvantage is that a second cutaneous wound is created in exposing the barb.

Figure 2. The advance-and-cut method for fishhook removal.		Figure 3. The cut-it-out method for fishhook removal.

The cut-it-out technique (Figure 3) is similar to the advance-and-cut method in that they both require anesthesia along with creating an incision. With this method, a scalpel is used to create a small linear incision originating at the fishhook entrance site and ending at the approximated location of the fishhook’s tip. The fishhook then is simply lifted superiorly in a retrograde fashion.

The string-pull method (Figure 4) has been credited to fishermen in South Australia and was first described by Cooke² in 1961. This method is relatively painless, does not require anesthesia, and has a high success rate when properly administered. However, it does require rapid and confident motions (ie, without hesitation) by the practitioner and should not be performed on free-moving areas of the body (eg, earlobe).³ With this technique, a sturdy piece of suture (eg, 2/0 or 3/0 strength silk) is looped around the hook and is extended away from the practitioner at a 30° angle. The free end of the suture is then securely fastened around the index finger of the practitioner’s dominant hand. The index finger of the nondominant hand should apply a downward pressure to the hook shaft to disengage the barb from the tissue. Simultaneously and rather quickly and forcefully the practitioner must pull the dominant index finger with the string attached in a superior and lateral direction, as depicted by the long arrow in Figure 4. If successful, the barbed hook will pull out of the entrance site. The use of string in pulling the fishhook parallel to the site of injury is helpful for smaller fishhooks that may be difficult to grab with fingers alone. However, with larger fishhooks, the string may not be required so long as the practitioner is able to obtain a secure grasp on the fishhook shaft. The string-pull method becomes particularly useful when anesthesia is unavailable or when the barb of the hook is embedded too deeply for safe advancement through tissue to visualize and cut the barb.

Lastly, the needle cover technique (Figure 5) is another simple method that does not require the creation of a secondary wound. An 18-gauge needle is simply inserted parallel to the fishhook curvature into the site of entry. By using the needle to slide along the fishhook’s curve, the practitioner is able to follow its pathway while in the tissue. The tip of the 18-gauge needle is then used to cap or cover the barb, thus allowing the fishhook to be removed in a retrograde fashion from the wound. In an outpatient setting, this technique does not require the creation of additional tissue damage and practitioners who are inexperienced with fishhook removal may proceed through the motions more slowly and methodically than the string-pull method permits.

Wound care following fishhook removal should involve adequate flushing of the wound with normal saline along with the application of topical antibiotics and a simple dressing and adhesive bandage. Oral prophylactic antibiotics typically are not required for shallow cutaneous injuries unless the fishhook is dirty, the patient is immunocompromised, or the patient has a condition lending to poor wound healing (eg, diabetes mellitus, peripheral vascular disease).³ When deciding on antibiotics, it is important to note that fishhook injuries while saltwater fishing are associated with Vibrio infection, while injuries sustained during freshwater fishing are associated with gram-negative bacteria (eg, Pseudomonas and Aeromonas species).³ Lastly, it is essential to find out the immunization status of the patient, and tetanus immune globulin should be provided if necessary.

Figure 4. The string-pull method for fishhook removal.		Figure 5. The needle cover technique for fishhook removal.

Conclusion

Although guidelines for barbed fishhook removal are not available, outpatient physicians, including dermatologists, should not fear removal procedures. There are many safe and effective fishhook removal methods that are not time consuming and do not require complex equipment. Furthermore, familiarization with these same techniques may be useful for removal of other foreign bodies embedded in cutaneous tissue.

Fishing is one of the world’s most beloved activities, enjoyed as a sport or a leisure activity. However, a common injury from fishing is embedment of the fishhook in the cutaneous tissue. Barbed fishhooks are used for their effectiveness in maintaining the fish on the hook once it is caught, but when implanted in the hand of a fisherman or fisherwoman, barbs can pose problems for removal without exacerbating internal tissue injury. Nevertheless, dermatologists should not shy away from removal of barbed fishhooks, as there are several simple methods that can be easily utilized in the outpatient setting.

Case Report

A 68-year-old man presented to an outpatient dermatology clinic after sustaining a barbed fishhook injury while fishing. The fishhook was firmly inserted into the ventral side of the third digit of the right hand (Figure 1).

Prior to presenting to dermatology, the patient went to 2 urgent care clinics the same day seeking treatment. He reported that practitioners at the first clinic were not able to remove the fishhook because they did not have pliers in stock. At the second clinic he was told the fishhook might be embedded in deeper tissues and was advised to go to the emergency department at the local hospital. When he arrived at the emergency department, a 6-hour wait time prompted him to see a local dermatologist instead.

To remove the fishhook, the area was cleaned and prepared first; lidocaine 2% was administered for local anesthesia. An 18-gauge needle was then advanced through the puncture site parallel to the fishhook’s inner shaft on the same side as the barb, which could be successfully palpated using the tip of the 18-gauge needle. The tip of the needle was then used to cap the barb beneath the skin. This technique allowed for the hook to be easily extracted in a retrograde manner without causing further destruction to the surrounding tissue. The patient then was started on prophylaxis cephalexin 500 mg 3 times daily for 3 days.

Comment

The hand is the most common site of fishhook injury, followed closely by the head and eyes.¹ Barbless fishhooks usually can be removed by pushing the hook in a retrograde manner along the path of insertion. This method is simple and rarely results in complications. However, there are no guidelines for removal of barbed fishhooks. Furthermore, removing a barbed fishhook in the same retrograde manner would result in extensive internal tissue destruction and increased complications. Due to the popularity of the sport of fishing, fishhook injuries, depending on geographical location, are not uncommon.² For this reason, trauma and emergency practitioners have become well versed in safe methods for barbed fishhook removal. However, patients are not always able or willing to seek medical care in emergency departments and may opt to seek treatment in outpatient settings, such as in our case. As a result, dermatologists should familiarize themselves with safe and effective fishhook removal methods, as they are not time consuming and do not require complex equipment. Failure to treat the patient may lead to further patient discomfort and increased risk for complications. Additionally, many of the techniques for removal may be useful with other foreign bodies embedded in cutaneous tissue (eg, splinters).

There are a number of safe and effective techniques for removing barbed fishhooks from cutaneous tissue, including the advance-and-cut method, the cut-it-out technique, the string-pull method, and the needle cover technique.^1-3 The method chosen to remove the fishhook is dependent on a variety of factors, such as anatomic location, tissue depth, and provider comfort.

With the advance-and-cut method (Figure 2), the affected area is anesthetized and a small incision in the skin is created to expose the barb. The fishhook is then advanced through the incision, providing visibility of the barb and thus allowing the practitioner to cut the barbed tip without creating further damage to the surrounding tissue. The shaft of the fishhook can subsequently be removed in a retrograde fashion. The advantages of this technique include that it may be successfully used in all types of barbed fishhooks and it provides the practitioner with direct visibility of the barb, thus minimizing risk for neurovascular injury during removal.¹ However, the primary disadvantage is that a second cutaneous wound is created in exposing the barb.

Figure 2. The advance-and-cut method for fishhook removal.		Figure 3. The cut-it-out method for fishhook removal.

The cut-it-out technique (Figure 3) is similar to the advance-and-cut method in that they both require anesthesia along with creating an incision. With this method, a scalpel is used to create a small linear incision originating at the fishhook entrance site and ending at the approximated location of the fishhook’s tip. The fishhook then is simply lifted superiorly in a retrograde fashion.

The string-pull method (Figure 4) has been credited to fishermen in South Australia and was first described by Cooke² in 1961. This method is relatively painless, does not require anesthesia, and has a high success rate when properly administered. However, it does require rapid and confident motions (ie, without hesitation) by the practitioner and should not be performed on free-moving areas of the body (eg, earlobe).³ With this technique, a sturdy piece of suture (eg, 2/0 or 3/0 strength silk) is looped around the hook and is extended away from the practitioner at a 30° angle. The free end of the suture is then securely fastened around the index finger of the practitioner’s dominant hand. The index finger of the nondominant hand should apply a downward pressure to the hook shaft to disengage the barb from the tissue. Simultaneously and rather quickly and forcefully the practitioner must pull the dominant index finger with the string attached in a superior and lateral direction, as depicted by the long arrow in Figure 4. If successful, the barbed hook will pull out of the entrance site. The use of string in pulling the fishhook parallel to the site of injury is helpful for smaller fishhooks that may be difficult to grab with fingers alone. However, with larger fishhooks, the string may not be required so long as the practitioner is able to obtain a secure grasp on the fishhook shaft. The string-pull method becomes particularly useful when anesthesia is unavailable or when the barb of the hook is embedded too deeply for safe advancement through tissue to visualize and cut the barb.

Lastly, the needle cover technique (Figure 5) is another simple method that does not require the creation of a secondary wound. An 18-gauge needle is simply inserted parallel to the fishhook curvature into the site of entry. By using the needle to slide along the fishhook’s curve, the practitioner is able to follow its pathway while in the tissue. The tip of the 18-gauge needle is then used to cap or cover the barb, thus allowing the fishhook to be removed in a retrograde fashion from the wound. In an outpatient setting, this technique does not require the creation of additional tissue damage and practitioners who are inexperienced with fishhook removal may proceed through the motions more slowly and methodically than the string-pull method permits.

Wound care following fishhook removal should involve adequate flushing of the wound with normal saline along with the application of topical antibiotics and a simple dressing and adhesive bandage. Oral prophylactic antibiotics typically are not required for shallow cutaneous injuries unless the fishhook is dirty, the patient is immunocompromised, or the patient has a condition lending to poor wound healing (eg, diabetes mellitus, peripheral vascular disease).³ When deciding on antibiotics, it is important to note that fishhook injuries while saltwater fishing are associated with Vibrio infection, while injuries sustained during freshwater fishing are associated with gram-negative bacteria (eg, Pseudomonas and Aeromonas species).³ Lastly, it is essential to find out the immunization status of the patient, and tetanus immune globulin should be provided if necessary.

Figure 4. The string-pull method for fishhook removal.		Figure 5. The needle cover technique for fishhook removal.

Conclusion

Although guidelines for barbed fishhook removal are not available, outpatient physicians, including dermatologists, should not fear removal procedures. There are many safe and effective fishhook removal methods that are not time consuming and do not require complex equipment. Furthermore, familiarization with these same techniques may be useful for removal of other foreign bodies embedded in cutaneous tissue.

Porokeratosis of Mibelli (PM) is a lesion characterized by a surrounding cornoid lamella with variable nonspecific findings (eg, atrophy, acanthosis, verrucous hyperplasia) in the center of the lesion that typically presents in infancy to early childhood.¹ We report a case of PM in which a prior biopsy from the center of the lesion demonstrated papulosquamous dermatitis. We propose a 3-step technique to ensure proper orientation of a punch biopsy in cases of suspected PM.

Case Report

A 3-year-old girl presented with an erythematous, hypopigmented, scaling plaque on the posterior aspect of the left ankle surrounded by a hard rim. The plaque was first noted at 12 months of age and had slowly enlarged as the patient grew. Six months prior, a biopsy from the center of the lesion performed at another facility demonstrated a papulosquamous dermatitis.

Physical examination revealed a lesion that was 4.2-cm long, 2.2-cm wide at the superior pole, and 3.5-cm wide at the inferior pole (Figure 1). A line was drawn with a skin marker perpendicular to the rim of the lesion (Figure 2A) and a 6-mm punch biopsy was performed, centered at the intersection of the drawn line and the cornoid lamella (Figure 2B). The tissue was then bisected at the bedside along the skin marker line with a #15 blade (Figure 2C) and submitted in formalin for histologic processing. Histologic examination revealed an invagination of the epidermis producing a tier of parakeratotic cells with its apex pointed away from the center of the lesion. Dyskeratotic cells were noted at the base of the parakeratosis (Figure 3). Verrucous hyperplasia was present in the central portion of the specimen adjacent to the cornoid lamella. Based on these histopathologic findings, the correct diagnosis of PM was made.

Comment

Porokeratosis of Mibelli is a rare condition that typically presents in infancy to early childhood.¹ It may appear as small keratotic papules or larger plaques that reach several centimeters in diameter.² There is a 7.5% risk for malignant transformation (eg, basal cell carcinoma, squamous cell carcinoma, Bowen disease).³ Variable nonspecific findings (eg, atrophy, acanthosis, verrucous hyperplasia) typically are present in the center of the lesion. In our case, a biopsy from the center of the plaque demonstrated verrucous hyperplasia. The incorrect diagnosis of PM as psoriasis also has been reported.⁴

We propose a 3-step technique to ensure proper orientation of a punch biopsy in cases of suspected PM. First, draw a line perpendicular to the rim of the lesion to mark the biopsy site (Figure 2A). Second, perform a punch biopsy centered at the intersection of the drawn line and the cornoid lamella (Figure 2B). Third, section the biopsied tissue with a #15 blade along the perpendicular line at the bedside (Figure 2C). The surgical pathology requisition should mention that the specimen has been transected and the cut edges should be placed down in the cassette, ensuring that the cornoid lamella will be present in cross-section on the slides.

If the punch biopsy specimen is not bisected, it can be difficult to orient it in the pathology laboratory, especially if the cornoid lamellae are not prominent. Furthermore, the technician processing the tissue may not be aware of the importance of sectioning the specimen perpendicular to the cornoid lamella. Following this procedure, diagnosis can be confirmed in virtually every case of PM.

Porokeratosis of Mibelli (PM) is a lesion characterized by a surrounding cornoid lamella with variable nonspecific findings (eg, atrophy, acanthosis, verrucous hyperplasia) in the center of the lesion that typically presents in infancy to early childhood.¹ We report a case of PM in which a prior biopsy from the center of the lesion demonstrated papulosquamous dermatitis. We propose a 3-step technique to ensure proper orientation of a punch biopsy in cases of suspected PM.

Case Report

A 3-year-old girl presented with an erythematous, hypopigmented, scaling plaque on the posterior aspect of the left ankle surrounded by a hard rim. The plaque was first noted at 12 months of age and had slowly enlarged as the patient grew. Six months prior, a biopsy from the center of the lesion performed at another facility demonstrated a papulosquamous dermatitis.

Physical examination revealed a lesion that was 4.2-cm long, 2.2-cm wide at the superior pole, and 3.5-cm wide at the inferior pole (Figure 1). A line was drawn with a skin marker perpendicular to the rim of the lesion (Figure 2A) and a 6-mm punch biopsy was performed, centered at the intersection of the drawn line and the cornoid lamella (Figure 2B). The tissue was then bisected at the bedside along the skin marker line with a #15 blade (Figure 2C) and submitted in formalin for histologic processing. Histologic examination revealed an invagination of the epidermis producing a tier of parakeratotic cells with its apex pointed away from the center of the lesion. Dyskeratotic cells were noted at the base of the parakeratosis (Figure 3). Verrucous hyperplasia was present in the central portion of the specimen adjacent to the cornoid lamella. Based on these histopathologic findings, the correct diagnosis of PM was made.

Comment

Porokeratosis of Mibelli is a rare condition that typically presents in infancy to early childhood.¹ It may appear as small keratotic papules or larger plaques that reach several centimeters in diameter.² There is a 7.5% risk for malignant transformation (eg, basal cell carcinoma, squamous cell carcinoma, Bowen disease).³ Variable nonspecific findings (eg, atrophy, acanthosis, verrucous hyperplasia) typically are present in the center of the lesion. In our case, a biopsy from the center of the plaque demonstrated verrucous hyperplasia. The incorrect diagnosis of PM as psoriasis also has been reported.⁴

We propose a 3-step technique to ensure proper orientation of a punch biopsy in cases of suspected PM. First, draw a line perpendicular to the rim of the lesion to mark the biopsy site (Figure 2A). Second, perform a punch biopsy centered at the intersection of the drawn line and the cornoid lamella (Figure 2B). Third, section the biopsied tissue with a #15 blade along the perpendicular line at the bedside (Figure 2C). The surgical pathology requisition should mention that the specimen has been transected and the cut edges should be placed down in the cassette, ensuring that the cornoid lamella will be present in cross-section on the slides.

If the punch biopsy specimen is not bisected, it can be difficult to orient it in the pathology laboratory, especially if the cornoid lamellae are not prominent. Furthermore, the technician processing the tissue may not be aware of the importance of sectioning the specimen perpendicular to the cornoid lamella. Following this procedure, diagnosis can be confirmed in virtually every case of PM.

Porokeratosis of Mibelli (PM) is a lesion characterized by a surrounding cornoid lamella with variable nonspecific findings (eg, atrophy, acanthosis, verrucous hyperplasia) in the center of the lesion that typically presents in infancy to early childhood.¹ We report a case of PM in which a prior biopsy from the center of the lesion demonstrated papulosquamous dermatitis. We propose a 3-step technique to ensure proper orientation of a punch biopsy in cases of suspected PM.

Case Report

A 3-year-old girl presented with an erythematous, hypopigmented, scaling plaque on the posterior aspect of the left ankle surrounded by a hard rim. The plaque was first noted at 12 months of age and had slowly enlarged as the patient grew. Six months prior, a biopsy from the center of the lesion performed at another facility demonstrated a papulosquamous dermatitis.

Physical examination revealed a lesion that was 4.2-cm long, 2.2-cm wide at the superior pole, and 3.5-cm wide at the inferior pole (Figure 1). A line was drawn with a skin marker perpendicular to the rim of the lesion (Figure 2A) and a 6-mm punch biopsy was performed, centered at the intersection of the drawn line and the cornoid lamella (Figure 2B). The tissue was then bisected at the bedside along the skin marker line with a #15 blade (Figure 2C) and submitted in formalin for histologic processing. Histologic examination revealed an invagination of the epidermis producing a tier of parakeratotic cells with its apex pointed away from the center of the lesion. Dyskeratotic cells were noted at the base of the parakeratosis (Figure 3). Verrucous hyperplasia was present in the central portion of the specimen adjacent to the cornoid lamella. Based on these histopathologic findings, the correct diagnosis of PM was made.

Comment

Porokeratosis of Mibelli is a rare condition that typically presents in infancy to early childhood.¹ It may appear as small keratotic papules or larger plaques that reach several centimeters in diameter.² There is a 7.5% risk for malignant transformation (eg, basal cell carcinoma, squamous cell carcinoma, Bowen disease).³ Variable nonspecific findings (eg, atrophy, acanthosis, verrucous hyperplasia) typically are present in the center of the lesion. In our case, a biopsy from the center of the plaque demonstrated verrucous hyperplasia. The incorrect diagnosis of PM as psoriasis also has been reported.⁴

We propose a 3-step technique to ensure proper orientation of a punch biopsy in cases of suspected PM. First, draw a line perpendicular to the rim of the lesion to mark the biopsy site (Figure 2A). Second, perform a punch biopsy centered at the intersection of the drawn line and the cornoid lamella (Figure 2B). Third, section the biopsied tissue with a #15 blade along the perpendicular line at the bedside (Figure 2C). The surgical pathology requisition should mention that the specimen has been transected and the cut edges should be placed down in the cassette, ensuring that the cornoid lamella will be present in cross-section on the slides.

If the punch biopsy specimen is not bisected, it can be difficult to orient it in the pathology laboratory, especially if the cornoid lamellae are not prominent. Furthermore, the technician processing the tissue may not be aware of the importance of sectioning the specimen perpendicular to the cornoid lamella. Following this procedure, diagnosis can be confirmed in virtually every case of PM.

Physicians Nasim Afsar, MD, SFHM, and Eric Howell, MD, SFHM, presented key leadership lessons to a standing-room-only audience at Hospital Medicine 2016, the “Year of the Hospitalist.” The value of leadership and management skills is important in every day decisions from co-management of patients to motivating your teams.

Dr. Afsar and Dr. Howell went into detailed tips for these leadership lessons:

1. Decision-making bias. It is important to be aware of bias in decisions. A technique to evaluate a decision and “de-bias” is the WRAP process: Widen your options, Reality-test your assumptions, Attain distance before deciding, and Prepare to be wrong.
2. Performance management. Feedback and 360 evaluations are helpful tools in appraising performance.
3. Motivation can be intrinsic or extrinsic. Intrinsic motivation is essential for non-routine high level work in medicine. Understanding the motivation of a team member is very useful to the team leader.
4. Groups versus teams. The composition of a team is crucial to success. It is also important to be aware of team limitations and plan for these potential limitations.
5. Persuasion and influence. Six principles of persuasion are:

1. Demonstrate trustworthiness and expertise.
2. Social proof. Highlight existing norms or set new norms.
3. Highlight similarities.
4. A win-win situation with concessions shows willingness to participate.
5. Reach agreement.
6. An option that appears to be a rare offer is more desirable.

Key Takeaways

• Consistently using a standard decision-making process, such as WRAP, can ensure better decision making.
• Financial compensation can be detrimental to intrinsic motivation and worsen performance.
• Make a conscious decision about when you need a group to help make decisions versus a team to work towards a common goal.
• Set specific goals for performance during feedback: include timeline, particular actions, and results that are expected.
• Social proof can be a powerful tool in persuasion.
• The SHM Leadership Academy is available to hospitalists interested in expanding leadership skills. TH

Dr. Hale is a pediatric hospitalist at Floating Hospital for Children at Tufts University Medical Center in Boston, and a former member of Team Hospitalist.

Physicians Nasim Afsar, MD, SFHM, and Eric Howell, MD, SFHM, presented key leadership lessons to a standing-room-only audience at Hospital Medicine 2016, the “Year of the Hospitalist.” The value of leadership and management skills is important in every day decisions from co-management of patients to motivating your teams.

Dr. Afsar and Dr. Howell went into detailed tips for these leadership lessons:

1. Decision-making bias. It is important to be aware of bias in decisions. A technique to evaluate a decision and “de-bias” is the WRAP process: Widen your options, Reality-test your assumptions, Attain distance before deciding, and Prepare to be wrong.
2. Performance management. Feedback and 360 evaluations are helpful tools in appraising performance.
3. Motivation can be intrinsic or extrinsic. Intrinsic motivation is essential for non-routine high level work in medicine. Understanding the motivation of a team member is very useful to the team leader.
4. Groups versus teams. The composition of a team is crucial to success. It is also important to be aware of team limitations and plan for these potential limitations.
5. Persuasion and influence. Six principles of persuasion are:

1. Demonstrate trustworthiness and expertise.
2. Social proof. Highlight existing norms or set new norms.
3. Highlight similarities.
4. A win-win situation with concessions shows willingness to participate.
5. Reach agreement.
6. An option that appears to be a rare offer is more desirable.

Key Takeaways

• Consistently using a standard decision-making process, such as WRAP, can ensure better decision making.
• Financial compensation can be detrimental to intrinsic motivation and worsen performance.
• Make a conscious decision about when you need a group to help make decisions versus a team to work towards a common goal.
• Set specific goals for performance during feedback: include timeline, particular actions, and results that are expected.
• Social proof can be a powerful tool in persuasion.
• The SHM Leadership Academy is available to hospitalists interested in expanding leadership skills. TH

Dr. Hale is a pediatric hospitalist at Floating Hospital for Children at Tufts University Medical Center in Boston, and a former member of Team Hospitalist.

Physicians Nasim Afsar, MD, SFHM, and Eric Howell, MD, SFHM, presented key leadership lessons to a standing-room-only audience at Hospital Medicine 2016, the “Year of the Hospitalist.” The value of leadership and management skills is important in every day decisions from co-management of patients to motivating your teams.

Dr. Afsar and Dr. Howell went into detailed tips for these leadership lessons:

1. Decision-making bias. It is important to be aware of bias in decisions. A technique to evaluate a decision and “de-bias” is the WRAP process: Widen your options, Reality-test your assumptions, Attain distance before deciding, and Prepare to be wrong.
2. Performance management. Feedback and 360 evaluations are helpful tools in appraising performance.
3. Motivation can be intrinsic or extrinsic. Intrinsic motivation is essential for non-routine high level work in medicine. Understanding the motivation of a team member is very useful to the team leader.
4. Groups versus teams. The composition of a team is crucial to success. It is also important to be aware of team limitations and plan for these potential limitations.
5. Persuasion and influence. Six principles of persuasion are:

1. Demonstrate trustworthiness and expertise.
2. Social proof. Highlight existing norms or set new norms.
3. Highlight similarities.
4. A win-win situation with concessions shows willingness to participate.
5. Reach agreement.
6. An option that appears to be a rare offer is more desirable.

Key Takeaways

• Consistently using a standard decision-making process, such as WRAP, can ensure better decision making.
• Financial compensation can be detrimental to intrinsic motivation and worsen performance.
• Make a conscious decision about when you need a group to help make decisions versus a team to work towards a common goal.
• Set specific goals for performance during feedback: include timeline, particular actions, and results that are expected.
• Social proof can be a powerful tool in persuasion.
• The SHM Leadership Academy is available to hospitalists interested in expanding leadership skills. TH

Dr. Hale is a pediatric hospitalist at Floating Hospital for Children at Tufts University Medical Center in Boston, and a former member of Team Hospitalist.

Dr. Vivek Murthy delivered an excellent opening address to Hospital Medicine 2016, the “Year of the Hospitalist.” He presented a key message that hospitalists can be major supporters of public health and disease prevention. He described the clean water crisis in Flint, Michigan as a tragedy that should not be occurring in the United States in the year 2016.

We need to renew our commitment to a strong foundation of public health. “Health is the key to opportunity,” Dr. Murthy stated. He reviewed four pillars for the foundation of good public health:

1. Make healthy choices a desired choice. We should try to establish exercise and good eating as a part of a normal lifestyle, not something onerous or difficult. Healthy choices can be a source of pleasure.
2. Change the environment to make healthy changes sustainable. The environment includes advertising and marketing of good choices, access to healthy foods, and access to increased activity. An example was local government commitments to increased walkable routes and parks will increase activity in a population.
3. Focus on the mind and spirit, not just the body.
4. Cultivate the ability to give and receive kindness.

Dr. Murthy left the hospitalist with three take-home questions:

1. Can a hospitalist leverage leadership to create a culture of healing?
2. Can a hospitalist be a force for change outside the hospital setting? Can you assist with nutrition wellness or safety projects outside of the hospital?
3. Can we inspire the next generation of physicians to work on public health and preventing illness?

Key Takeaways

1. Hospitalists can be major supporters of public health and disease prevention; and
2. The foundation of good public health includes the changes to make healthy choices a desired choice, change the environment to make healthy changes sustainable, focus on the mind and spirit, and cultivate the ability to give and receive kindness.

Dr. Vivek Murthy delivered an excellent opening address to Hospital Medicine 2016, the “Year of the Hospitalist.” He presented a key message that hospitalists can be major supporters of public health and disease prevention. He described the clean water crisis in Flint, Michigan as a tragedy that should not be occurring in the United States in the year 2016.

We need to renew our commitment to a strong foundation of public health. “Health is the key to opportunity,” Dr. Murthy stated. He reviewed four pillars for the foundation of good public health:

1. Make healthy choices a desired choice. We should try to establish exercise and good eating as a part of a normal lifestyle, not something onerous or difficult. Healthy choices can be a source of pleasure.
2. Change the environment to make healthy changes sustainable. The environment includes advertising and marketing of good choices, access to healthy foods, and access to increased activity. An example was local government commitments to increased walkable routes and parks will increase activity in a population.
3. Focus on the mind and spirit, not just the body.
4. Cultivate the ability to give and receive kindness.

Dr. Murthy left the hospitalist with three take-home questions:

1. Can a hospitalist leverage leadership to create a culture of healing?
2. Can a hospitalist be a force for change outside the hospital setting? Can you assist with nutrition wellness or safety projects outside of the hospital?
3. Can we inspire the next generation of physicians to work on public health and preventing illness?

Key Takeaways

1. Hospitalists can be major supporters of public health and disease prevention; and
2. The foundation of good public health includes the changes to make healthy choices a desired choice, change the environment to make healthy changes sustainable, focus on the mind and spirit, and cultivate the ability to give and receive kindness.

Dr. Vivek Murthy delivered an excellent opening address to Hospital Medicine 2016, the “Year of the Hospitalist.” He presented a key message that hospitalists can be major supporters of public health and disease prevention. He described the clean water crisis in Flint, Michigan as a tragedy that should not be occurring in the United States in the year 2016.

We need to renew our commitment to a strong foundation of public health. “Health is the key to opportunity,” Dr. Murthy stated. He reviewed four pillars for the foundation of good public health:

1. Make healthy choices a desired choice. We should try to establish exercise and good eating as a part of a normal lifestyle, not something onerous or difficult. Healthy choices can be a source of pleasure.
2. Change the environment to make healthy changes sustainable. The environment includes advertising and marketing of good choices, access to healthy foods, and access to increased activity. An example was local government commitments to increased walkable routes and parks will increase activity in a population.
3. Focus on the mind and spirit, not just the body.
4. Cultivate the ability to give and receive kindness.

Dr. Murthy left the hospitalist with three take-home questions:

1. Can a hospitalist leverage leadership to create a culture of healing?
2. Can a hospitalist be a force for change outside the hospital setting? Can you assist with nutrition wellness or safety projects outside of the hospital?
3. Can we inspire the next generation of physicians to work on public health and preventing illness?

Key Takeaways

1. Hospitalists can be major supporters of public health and disease prevention; and
2. The foundation of good public health includes the changes to make healthy choices a desired choice, change the environment to make healthy changes sustainable, focus on the mind and spirit, and cultivate the ability to give and receive kindness.

Presenter: Aziz Ansari, DO, FHM

Summary: With the implementation of ICD-10, correct and specific documentation to ensure proper patient diagnosis categorization has become increasingly important. Hospitalists are urged to understand the impact CDI has on quality and reimbursement.

Quality Impact: Documentation has a direct impact on quality reporting for mortality and complication rates, risk of mortality, as well as severity of illness. Documenting present on admission (POA) also directly impacts the hospital-acquired condition (HAC) classifications.

Reimbursement Impact: Documentation has a direct impact on expected length of stay, case mix index (CMI), cost reporting, and appropriate hospital reimbursement.

HM Takeaways:

• Be clear and specific.
• Document principle diagnosis and secondary diagnoses, and their associated interactions, are critically important.
• Ensure all diagnoses are a part of the discharge summary.
• Avoid saying “History of.”
• It’s OK to document “possible,” “probably,” “likely,” or “suspected.”
• Document “why” the patient has the diagnosis.
• List all differentials, and identify if ruled in or ruled out.
• Indicate acuity, even if obvious.

This presenter also reviewed common CDI opportunities in hospital medicine.

Note: This discussion was specific to the needs of the hospital patient diagnosis and billing, and not related to physician billing and CPT codes.

Presenter: Aziz Ansari, DO, FHM

Summary: With the implementation of ICD-10, correct and specific documentation to ensure proper patient diagnosis categorization has become increasingly important. Hospitalists are urged to understand the impact CDI has on quality and reimbursement.

Quality Impact: Documentation has a direct impact on quality reporting for mortality and complication rates, risk of mortality, as well as severity of illness. Documenting present on admission (POA) also directly impacts the hospital-acquired condition (HAC) classifications.

Reimbursement Impact: Documentation has a direct impact on expected length of stay, case mix index (CMI), cost reporting, and appropriate hospital reimbursement.

HM Takeaways:

• Be clear and specific.
• Document principle diagnosis and secondary diagnoses, and their associated interactions, are critically important.
• Ensure all diagnoses are a part of the discharge summary.
• Avoid saying “History of.”
• It’s OK to document “possible,” “probably,” “likely,” or “suspected.”
• Document “why” the patient has the diagnosis.
• List all differentials, and identify if ruled in or ruled out.
• Indicate acuity, even if obvious.

This presenter also reviewed common CDI opportunities in hospital medicine.

Note: This discussion was specific to the needs of the hospital patient diagnosis and billing, and not related to physician billing and CPT codes.

Presenter: Aziz Ansari, DO, FHM

Summary: With the implementation of ICD-10, correct and specific documentation to ensure proper patient diagnosis categorization has become increasingly important. Hospitalists are urged to understand the impact CDI has on quality and reimbursement.

Quality Impact: Documentation has a direct impact on quality reporting for mortality and complication rates, risk of mortality, as well as severity of illness. Documenting present on admission (POA) also directly impacts the hospital-acquired condition (HAC) classifications.

Reimbursement Impact: Documentation has a direct impact on expected length of stay, case mix index (CMI), cost reporting, and appropriate hospital reimbursement.

HM Takeaways:

• Be clear and specific.
• Document principle diagnosis and secondary diagnoses, and their associated interactions, are critically important.
• Ensure all diagnoses are a part of the discharge summary.
• Avoid saying “History of.”
• It’s OK to document “possible,” “probably,” “likely,” or “suspected.”
• Document “why” the patient has the diagnosis.
• List all differentials, and identify if ruled in or ruled out.
• Indicate acuity, even if obvious.

This presenter also reviewed common CDI opportunities in hospital medicine.

Note: This discussion was specific to the needs of the hospital patient diagnosis and billing, and not related to physician billing and CPT codes.

[WpProQuiz 5]

[WpProQuiz_toplist 5]

[WpProQuiz 5]

[WpProQuiz_toplist 5]

[WpProQuiz 5]

[WpProQuiz_toplist 5]

The recipient of the first uterus transplant performed in the United States is recovering well and looking forward to the next phase of the research project: pregnancy, according to the team of Cleveland Clinic surgeons who performed the groundbreaking Feb. 24 transplant.

“I’m pleased to report to you that our patient is doing very well,” lead surgeon Dr. Andreas G. Tzakis said during a press conference on March 7.

The transplant recipient, known only as “Lindsey” to protect her privacy, is a 26-year-old woman with uterine factor infertility (UFI). She was selected from among more than 250 applicants to undergo the 9-hour procedure involving transplantation of a uterus from a deceased organ donor of reproductive age. She is the first of 10 women set to undergo the procedure as part of the Cleveland Clinic study.

Courtesy of the Cleveland Clinic

“Lindsey” made an appearance at the press conference and expressed, first and foremost, her “immense gratitude” to the donor’s family.

“They have provided me with a gift that I will never be able to repay,” she said in an emotional statement in which she shared about learning at age 16 that she would never be able to have children.

“From that moment on I prayed that God would allow me the opportunity to experience pregnancy, and here we are today at the beginning of that journey,” she said.

Lindsey will undergo a year of anti-rejection treatment prior to undergoing in vitro fertilization; her eggs were previously fertilized using her husband’s sperm, and the embryos are in cryogenic storage, according to Dr. Rebecca Flyckt, another member of the surgical team.

The embryos will be transferred one by one until the goal of a healthy pregnancy and healthy baby delivered by cesarean section is achieved, Dr. Flyckt said.

After one or two successful pregnancies and births, the uterus will be removed. Although substantial evidence suggests that anti-rejection medications are relatively safe in pregnancy, minimizing and ultimately eliminating the need for them is advisable, thus uterus transplants, at least under the Cleveland Clinic research protocol, are meant to be temporary.

Uterus transplants are performed to enable patients – who have either lost their uterus to disease or who were born without a uterus or a functioning uterus – to experience pregnancy and childbirth.

Prior to the Cleveland Clinic transplant, nine had been performed successfully with healthy outcomes (the first post-transplant baby was born healthy in 2014). All were performed at the University of Gothenburg in Sweden. Dr. Tzakis traveled there to work with surgeons prior to performing the procedure at the Cleveland Clinic, where he is the Transplant Center program director.

Ethical issues

Addressing the bioethical issues surrounding uterine transplant was an important part of this project, according to team member Dr. Ruth Farrell, a bioethicist and ob.gyn. surgeon at the Cleveland Clinic.

“Despite the name uterine transplant, the focus of this procedure is not on the uterus. It’s on women and children and families,” she said, adding that to understand the ethical issues of uterine transplant, it’s important to consider the perspectives of women with UFI.

“For instance, women born without a uterus have a medical condition that affects every aspect of their lives, from the time they are diagnosed in adolescence, to when they are adults looking for relationships and trying to decide if and how to have a family,” she said, adding that “these women face the real possibility of never having children.”

But this advance in reproductive medicine and science also requires a close look at how the potential risks and benefits of uterine transplant weigh against existing options of adoption and surrogacy. While there are many successful stories involving surrogacy and adoption, these options are not available to all women because of “legal, cultural, religious, and other very personal reasons,” Dr. Farrell said.

“Our research on uterine transplant, we hope, may give women another option which may work better for them and their families,” she said, also noting that while living donor transplants have been performed, these come with some risk, thus deceased donors are being used for the current study.

Insurance coverage

As for the feasibility of uterine transplant, many questions remain to be answered, according to Dr. Tommaso Falcone, chair of the department of obstetrics and gynecology at the Cleveland Clinic, who said that the procedures done as part of the current study will be paid for by an institutional grant.

While the American Society for Reproductive Medicine contends that infertility is a disease worthy of insurance coverage, that is “outside of our hands,” he said.

Indeed, while this first uterine transplant in the United States is a “huge and exciting breakthrough,” and while “the folks at Cleveland Clinic should be congratulated,” the possibility of this procedure ever being covered by insurance and being available to women outside of the research protocol is questionable, especially given the available alternatives, such as gestational carriers and surrogacy, Dr. David A. Forstein, a reproductive endocrinologist at the University of South Carolina, Greenville, said in an interview.

In a patient-centered model, this “tremendous, wonderful gift from science” would give patients – like the 1 in 5,000 women in the United States who are born without a uterus – a very viable alternative, but the question is whether having one’s own children is a right, and whether extensive financial resources should be committed to helping women achieve that, he said.

Dr. Charles E. Miller, a reproductive endocrinologist in Chicago, and head of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital in Park Ridge, Ill., agreed that this transplant is to be celebrated.

“It’s a big moment, to say the least,” he said in an interview.

But Dr. Miller also questioned the feasibility of the procedure and whether society will “look favorably upon donation,” given the availability of alternatives for which there is now great success.

“I salute the pioneering effort,” he said, “But at the end of the day, can society take on this burden of a procedure performed not to sustain life, but to help create life? That’s a tough one.”

sworcester@frontlinemedcom.com

The recipient of the first uterus transplant performed in the United States is recovering well and looking forward to the next phase of the research project: pregnancy, according to the team of Cleveland Clinic surgeons who performed the groundbreaking Feb. 24 transplant.

“I’m pleased to report to you that our patient is doing very well,” lead surgeon Dr. Andreas G. Tzakis said during a press conference on March 7.

The transplant recipient, known only as “Lindsey” to protect her privacy, is a 26-year-old woman with uterine factor infertility (UFI). She was selected from among more than 250 applicants to undergo the 9-hour procedure involving transplantation of a uterus from a deceased organ donor of reproductive age. She is the first of 10 women set to undergo the procedure as part of the Cleveland Clinic study.

Courtesy of the Cleveland Clinic

“Lindsey” made an appearance at the press conference and expressed, first and foremost, her “immense gratitude” to the donor’s family.

“They have provided me with a gift that I will never be able to repay,” she said in an emotional statement in which she shared about learning at age 16 that she would never be able to have children.

“From that moment on I prayed that God would allow me the opportunity to experience pregnancy, and here we are today at the beginning of that journey,” she said.

Lindsey will undergo a year of anti-rejection treatment prior to undergoing in vitro fertilization; her eggs were previously fertilized using her husband’s sperm, and the embryos are in cryogenic storage, according to Dr. Rebecca Flyckt, another member of the surgical team.

The embryos will be transferred one by one until the goal of a healthy pregnancy and healthy baby delivered by cesarean section is achieved, Dr. Flyckt said.

After one or two successful pregnancies and births, the uterus will be removed. Although substantial evidence suggests that anti-rejection medications are relatively safe in pregnancy, minimizing and ultimately eliminating the need for them is advisable, thus uterus transplants, at least under the Cleveland Clinic research protocol, are meant to be temporary.

Uterus transplants are performed to enable patients – who have either lost their uterus to disease or who were born without a uterus or a functioning uterus – to experience pregnancy and childbirth.

Prior to the Cleveland Clinic transplant, nine had been performed successfully with healthy outcomes (the first post-transplant baby was born healthy in 2014). All were performed at the University of Gothenburg in Sweden. Dr. Tzakis traveled there to work with surgeons prior to performing the procedure at the Cleveland Clinic, where he is the Transplant Center program director.

Ethical issues

Addressing the bioethical issues surrounding uterine transplant was an important part of this project, according to team member Dr. Ruth Farrell, a bioethicist and ob.gyn. surgeon at the Cleveland Clinic.

“Despite the name uterine transplant, the focus of this procedure is not on the uterus. It’s on women and children and families,” she said, adding that to understand the ethical issues of uterine transplant, it’s important to consider the perspectives of women with UFI.

“For instance, women born without a uterus have a medical condition that affects every aspect of their lives, from the time they are diagnosed in adolescence, to when they are adults looking for relationships and trying to decide if and how to have a family,” she said, adding that “these women face the real possibility of never having children.”

But this advance in reproductive medicine and science also requires a close look at how the potential risks and benefits of uterine transplant weigh against existing options of adoption and surrogacy. While there are many successful stories involving surrogacy and adoption, these options are not available to all women because of “legal, cultural, religious, and other very personal reasons,” Dr. Farrell said.

“Our research on uterine transplant, we hope, may give women another option which may work better for them and their families,” she said, also noting that while living donor transplants have been performed, these come with some risk, thus deceased donors are being used for the current study.

Insurance coverage

As for the feasibility of uterine transplant, many questions remain to be answered, according to Dr. Tommaso Falcone, chair of the department of obstetrics and gynecology at the Cleveland Clinic, who said that the procedures done as part of the current study will be paid for by an institutional grant.

While the American Society for Reproductive Medicine contends that infertility is a disease worthy of insurance coverage, that is “outside of our hands,” he said.

Indeed, while this first uterine transplant in the United States is a “huge and exciting breakthrough,” and while “the folks at Cleveland Clinic should be congratulated,” the possibility of this procedure ever being covered by insurance and being available to women outside of the research protocol is questionable, especially given the available alternatives, such as gestational carriers and surrogacy, Dr. David A. Forstein, a reproductive endocrinologist at the University of South Carolina, Greenville, said in an interview.

In a patient-centered model, this “tremendous, wonderful gift from science” would give patients – like the 1 in 5,000 women in the United States who are born without a uterus – a very viable alternative, but the question is whether having one’s own children is a right, and whether extensive financial resources should be committed to helping women achieve that, he said.

Dr. Charles E. Miller, a reproductive endocrinologist in Chicago, and head of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital in Park Ridge, Ill., agreed that this transplant is to be celebrated.

“It’s a big moment, to say the least,” he said in an interview.

But Dr. Miller also questioned the feasibility of the procedure and whether society will “look favorably upon donation,” given the availability of alternatives for which there is now great success.

“I salute the pioneering effort,” he said, “But at the end of the day, can society take on this burden of a procedure performed not to sustain life, but to help create life? That’s a tough one.”

sworcester@frontlinemedcom.com

The recipient of the first uterus transplant performed in the United States is recovering well and looking forward to the next phase of the research project: pregnancy, according to the team of Cleveland Clinic surgeons who performed the groundbreaking Feb. 24 transplant.

“I’m pleased to report to you that our patient is doing very well,” lead surgeon Dr. Andreas G. Tzakis said during a press conference on March 7.

The transplant recipient, known only as “Lindsey” to protect her privacy, is a 26-year-old woman with uterine factor infertility (UFI). She was selected from among more than 250 applicants to undergo the 9-hour procedure involving transplantation of a uterus from a deceased organ donor of reproductive age. She is the first of 10 women set to undergo the procedure as part of the Cleveland Clinic study.

Courtesy of the Cleveland Clinic

“Lindsey” made an appearance at the press conference and expressed, first and foremost, her “immense gratitude” to the donor’s family.

“They have provided me with a gift that I will never be able to repay,” she said in an emotional statement in which she shared about learning at age 16 that she would never be able to have children.

“From that moment on I prayed that God would allow me the opportunity to experience pregnancy, and here we are today at the beginning of that journey,” she said.

Lindsey will undergo a year of anti-rejection treatment prior to undergoing in vitro fertilization; her eggs were previously fertilized using her husband’s sperm, and the embryos are in cryogenic storage, according to Dr. Rebecca Flyckt, another member of the surgical team.

The embryos will be transferred one by one until the goal of a healthy pregnancy and healthy baby delivered by cesarean section is achieved, Dr. Flyckt said.

After one or two successful pregnancies and births, the uterus will be removed. Although substantial evidence suggests that anti-rejection medications are relatively safe in pregnancy, minimizing and ultimately eliminating the need for them is advisable, thus uterus transplants, at least under the Cleveland Clinic research protocol, are meant to be temporary.

Uterus transplants are performed to enable patients – who have either lost their uterus to disease or who were born without a uterus or a functioning uterus – to experience pregnancy and childbirth.

Prior to the Cleveland Clinic transplant, nine had been performed successfully with healthy outcomes (the first post-transplant baby was born healthy in 2014). All were performed at the University of Gothenburg in Sweden. Dr. Tzakis traveled there to work with surgeons prior to performing the procedure at the Cleveland Clinic, where he is the Transplant Center program director.

Ethical issues

Addressing the bioethical issues surrounding uterine transplant was an important part of this project, according to team member Dr. Ruth Farrell, a bioethicist and ob.gyn. surgeon at the Cleveland Clinic.

“Despite the name uterine transplant, the focus of this procedure is not on the uterus. It’s on women and children and families,” she said, adding that to understand the ethical issues of uterine transplant, it’s important to consider the perspectives of women with UFI.

“For instance, women born without a uterus have a medical condition that affects every aspect of their lives, from the time they are diagnosed in adolescence, to when they are adults looking for relationships and trying to decide if and how to have a family,” she said, adding that “these women face the real possibility of never having children.”

But this advance in reproductive medicine and science also requires a close look at how the potential risks and benefits of uterine transplant weigh against existing options of adoption and surrogacy. While there are many successful stories involving surrogacy and adoption, these options are not available to all women because of “legal, cultural, religious, and other very personal reasons,” Dr. Farrell said.

“Our research on uterine transplant, we hope, may give women another option which may work better for them and their families,” she said, also noting that while living donor transplants have been performed, these come with some risk, thus deceased donors are being used for the current study.

Insurance coverage

As for the feasibility of uterine transplant, many questions remain to be answered, according to Dr. Tommaso Falcone, chair of the department of obstetrics and gynecology at the Cleveland Clinic, who said that the procedures done as part of the current study will be paid for by an institutional grant.

While the American Society for Reproductive Medicine contends that infertility is a disease worthy of insurance coverage, that is “outside of our hands,” he said.

Indeed, while this first uterine transplant in the United States is a “huge and exciting breakthrough,” and while “the folks at Cleveland Clinic should be congratulated,” the possibility of this procedure ever being covered by insurance and being available to women outside of the research protocol is questionable, especially given the available alternatives, such as gestational carriers and surrogacy, Dr. David A. Forstein, a reproductive endocrinologist at the University of South Carolina, Greenville, said in an interview.

In a patient-centered model, this “tremendous, wonderful gift from science” would give patients – like the 1 in 5,000 women in the United States who are born without a uterus – a very viable alternative, but the question is whether having one’s own children is a right, and whether extensive financial resources should be committed to helping women achieve that, he said.

Dr. Charles E. Miller, a reproductive endocrinologist in Chicago, and head of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital in Park Ridge, Ill., agreed that this transplant is to be celebrated.

“It’s a big moment, to say the least,” he said in an interview.

But Dr. Miller also questioned the feasibility of the procedure and whether society will “look favorably upon donation,” given the availability of alternatives for which there is now great success.

“I salute the pioneering effort,” he said, “But at the end of the day, can society take on this burden of a procedure performed not to sustain life, but to help create life? That’s a tough one.”

sworcester@frontlinemedcom.com

The use of progression-free survival and response rate as surrogates for overall survival were supported by significant correlations between the endpoints, in randomized trials of advanced soft tissue sarcoma.

However, 3-month progression-free survival (PFS) and 6-month PFS were not significantly correlated with overall survival (OS) and were not recommended as surrogates for OS, according to the researchers.

Significant correlations were observed between overall survival and PFS (correlation coefficient, 0.61) and overall survival and response rate (0.51). Correlations between 3-month PFS and 6-month PFS with overall survival (0.27 and 0.31, respectively) were not significant.

“In soft tissue sarcoma, trial design is particularly challenging, owing to the rarity and heterogeneity of this disease. Time-based endpoints including PFS, 3-month PFS, and 6-month PFS are gaining popularity as primary endpoints in phase III RCTs [randomized controlled trials], despite the fact that current data support their use only to screen for effective drugs in phase II trials,” wrote Dr. Alona Zer of Princess Margaret Cancer Centre and the University of Toronto and colleagues (J Clin Oncol. 2016 March 7. Doi: 10.1200/JCO.2016.66.4581).

“Data show that the assessment of outcomes as a single point in time … only rarely mirrors the hazards of the same endpoint. … As such, the odds ratio for 3-month PFS or 6-month PFS likely do not approximate the hazard ratio for PFS, making it difficult to justify the use of these endpoints in definitive phase III trials.”

PFS and overall survival have shown poor correlation in other cancer types, and evidence suggests that survival post progression may influence the association, with weaker correlations at longer survival post progression. The majority of soft tissue sarcoma reports had survival post progression of less than 12 months, likely explaining the high correlation between PFS and overall survival.

The investigators performed a systematic review of 52 randomized controlled trials, published from 1974 to 2014, that included 9,762 patients who received systemic therapy for advanced/metastatic soft tissue sarcoma.

Comprehensive toxicity assessment was included in just 20 studies (47%) and poorly reported in 6 studies (14%). Few studies included quality of life as a secondary endpoint. The authors noted that in the soft tissue sarcoma setting in which the purpose of systemic treatment may be palliation of symptoms, this is a concern.

Over the 4 decades represented by the systematic review, several trends appeared. Overall, a low proportion of studies included intent-to-treat analyses and clearly defined primary endpoints, but these characteristics improved over time. Endpoint selection has shifted away from response rate in favor of time-based events, including PFS, 3-month PFS, and 6-month PFS. Overall survival was the primary endpoint in just 4% of studies. Studies published in the last 2 decades were more likely to be supported by industry (5% vs. 35%).

Dr. Zer and coauthors reported having no relevant financial disclosures.

The use of progression-free survival and response rate as surrogates for overall survival were supported by significant correlations between the endpoints, in randomized trials of advanced soft tissue sarcoma.

However, 3-month progression-free survival (PFS) and 6-month PFS were not significantly correlated with overall survival (OS) and were not recommended as surrogates for OS, according to the researchers.

Significant correlations were observed between overall survival and PFS (correlation coefficient, 0.61) and overall survival and response rate (0.51). Correlations between 3-month PFS and 6-month PFS with overall survival (0.27 and 0.31, respectively) were not significant.

“In soft tissue sarcoma, trial design is particularly challenging, owing to the rarity and heterogeneity of this disease. Time-based endpoints including PFS, 3-month PFS, and 6-month PFS are gaining popularity as primary endpoints in phase III RCTs [randomized controlled trials], despite the fact that current data support their use only to screen for effective drugs in phase II trials,” wrote Dr. Alona Zer of Princess Margaret Cancer Centre and the University of Toronto and colleagues (J Clin Oncol. 2016 March 7. Doi: 10.1200/JCO.2016.66.4581).

“Data show that the assessment of outcomes as a single point in time … only rarely mirrors the hazards of the same endpoint. … As such, the odds ratio for 3-month PFS or 6-month PFS likely do not approximate the hazard ratio for PFS, making it difficult to justify the use of these endpoints in definitive phase III trials.”

PFS and overall survival have shown poor correlation in other cancer types, and evidence suggests that survival post progression may influence the association, with weaker correlations at longer survival post progression. The majority of soft tissue sarcoma reports had survival post progression of less than 12 months, likely explaining the high correlation between PFS and overall survival.

The investigators performed a systematic review of 52 randomized controlled trials, published from 1974 to 2014, that included 9,762 patients who received systemic therapy for advanced/metastatic soft tissue sarcoma.

Comprehensive toxicity assessment was included in just 20 studies (47%) and poorly reported in 6 studies (14%). Few studies included quality of life as a secondary endpoint. The authors noted that in the soft tissue sarcoma setting in which the purpose of systemic treatment may be palliation of symptoms, this is a concern.

Over the 4 decades represented by the systematic review, several trends appeared. Overall, a low proportion of studies included intent-to-treat analyses and clearly defined primary endpoints, but these characteristics improved over time. Endpoint selection has shifted away from response rate in favor of time-based events, including PFS, 3-month PFS, and 6-month PFS. Overall survival was the primary endpoint in just 4% of studies. Studies published in the last 2 decades were more likely to be supported by industry (5% vs. 35%).

Dr. Zer and coauthors reported having no relevant financial disclosures.

The use of progression-free survival and response rate as surrogates for overall survival were supported by significant correlations between the endpoints, in randomized trials of advanced soft tissue sarcoma.

However, 3-month progression-free survival (PFS) and 6-month PFS were not significantly correlated with overall survival (OS) and were not recommended as surrogates for OS, according to the researchers.

Significant correlations were observed between overall survival and PFS (correlation coefficient, 0.61) and overall survival and response rate (0.51). Correlations between 3-month PFS and 6-month PFS with overall survival (0.27 and 0.31, respectively) were not significant.

“In soft tissue sarcoma, trial design is particularly challenging, owing to the rarity and heterogeneity of this disease. Time-based endpoints including PFS, 3-month PFS, and 6-month PFS are gaining popularity as primary endpoints in phase III RCTs [randomized controlled trials], despite the fact that current data support their use only to screen for effective drugs in phase II trials,” wrote Dr. Alona Zer of Princess Margaret Cancer Centre and the University of Toronto and colleagues (J Clin Oncol. 2016 March 7. Doi: 10.1200/JCO.2016.66.4581).

“Data show that the assessment of outcomes as a single point in time … only rarely mirrors the hazards of the same endpoint. … As such, the odds ratio for 3-month PFS or 6-month PFS likely do not approximate the hazard ratio for PFS, making it difficult to justify the use of these endpoints in definitive phase III trials.”

PFS and overall survival have shown poor correlation in other cancer types, and evidence suggests that survival post progression may influence the association, with weaker correlations at longer survival post progression. The majority of soft tissue sarcoma reports had survival post progression of less than 12 months, likely explaining the high correlation between PFS and overall survival.

The investigators performed a systematic review of 52 randomized controlled trials, published from 1974 to 2014, that included 9,762 patients who received systemic therapy for advanced/metastatic soft tissue sarcoma.

Comprehensive toxicity assessment was included in just 20 studies (47%) and poorly reported in 6 studies (14%). Few studies included quality of life as a secondary endpoint. The authors noted that in the soft tissue sarcoma setting in which the purpose of systemic treatment may be palliation of symptoms, this is a concern.

Over the 4 decades represented by the systematic review, several trends appeared. Overall, a low proportion of studies included intent-to-treat analyses and clearly defined primary endpoints, but these characteristics improved over time. Endpoint selection has shifted away from response rate in favor of time-based events, including PFS, 3-month PFS, and 6-month PFS. Overall survival was the primary endpoint in just 4% of studies. Studies published in the last 2 decades were more likely to be supported by industry (5% vs. 35%).

Dr. Zer and coauthors reported having no relevant financial disclosures.