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Open Access Publications from the University of California

Dermatology Online Journal

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Dermatology Online Journal is an open-access, refereed publication intended to meet reference and education needs of the international dermatology community since 1995. Dermatology Online Journal is supported by the Department of Dermatology UC Davis, and by the Northern California Veterans Administration.

Volume 21, Issue 11, 2015


The use of botanical products and vitamins in sunscreens

The use of botanical products and vitamins in skin care creams and sunscreens is prevalent. Herein we conduct an evaluation of sunscreens to quantitatively assess how often sunscreens incorporate botanically derived products and vitamins. The most commonly used botanicals products and vitamins are identified and stratified based on the sunscreen sun protection factor (SPF). The overall prevalence for the use of botanical agents and vitamins was 62% and 79%, respectively. Aloe vera and licorice root extracts were the most common botanical agents used in sunscreens. Retinyl palmitate was the most common vitamin derivative utilized in sunscreens. The prices of sunscreens significantly increased when more than one botanical product was added. Botanical products and vitamins are widely utilized in sunscreens and more research is needed to assess how their inclusion may enhance or alter the function of sunscreens.

Skin simulators for dermatological procedures

Background: A variety of skin simulators are available on which to practice procedures; however, choice of a suboptimal substitute compromises realism and productive practice.

Objective: Skin simulators for basic dermatological procedures are reviewed.

Methods: The authors’ anecdotal experience with various skin simulators for different procedures is shared.

Results: The following simulators are suggested:  an unripe banana for elliptical excision, pork belly for undermining, pork belly for simple interrupted and buried suture, capped needle on a human shoulder for intramuscular injection, ripe tomato or hotdog with skin for intradermal injection, eggplant for shave biopsy, pork belly for punch biopsy, plastic tape over a dark surface for cryosurgery, and beef liver for electrosurgery.  Flaps are best practiced with foam sandwiched between foam tape or artificial anatomical models created specifically for this purpose.

Limitations: The utility of one simulator over another was not compared in a controlled study.

Conclusion: Efficient, realistic skin simulators are readily available for practice, which should enhance the safety of the practitioner and improve outcomes of novices.

Surgical Pearl

Usefulness of a “puzzle” flap; more than an advancement flap for surgical reconstruction of nasal ala defects: Review of 10 cases.

Reconstructive surgery in nasal pyramid can be a challenge for surgeons. Moreover this anatomic area is one the most common sites for non-melanoma skin cancer.

The “puzzle” flap was described to repair surgical defects located just on the nasal ala affecting melolabial sulcus. We have seen this flap can be also very useful to repair defects located on nasal sidewall and cheek without dysfunctional effects and with a good cosmetic result.

Case Report

Treatment of metastatic cutaneous Crohn disease with certolizumab

Metastatic Crohn disease is a rare cutaneous manifestation of Crohn disease characterized by granulomatous lesions discontinuous with the diseased areas of the gastrointestinal tract. We report a case of a 32-year-old woman with history of Crohn disease who was admitted for treatment of cellulitis after presenting with a tender erythematous plaque of the left calf. Microbiological tests including tissue cultures were negative. A skin biopsy revealed granulomatous dermatitis consistent with metastatic cutaneous Crohn disease. Owing to concomitant perianal fistulas and abscesses and prior infusion reaction to infliximab, the patient was treated with certolizumab, a pegylated tumor necrosis factor (TNF) inhibitor combined with methotrexate resulting in complete resolution of the skin lesion. This case emphasizes the importance of recognizing this rare skin manifestation of Crohn disease and adds certolizumab as one of TNF inhibitors useful in the treatment of metastatic cutaneous Crohn disease.

Case Presentation

Unilateral nevoid trichoepitheliomas on the neck: an unfamiliar presentation

Trichoepitheliomas are epidermal appendageal hamartomas, which usually present as solitary lesions; rarely multiple lesions may be present, mainly involving the centrofacial skin symmetrically. We report herein an adolescent male patient with multiple trichoepitheliomas, linearly arranged and dermatomal, present since birth, along the left side of the neck.

Adalimumab-induced psoriatic alopecia/alopecia areata-like reaction in a patient with Crohn's disease

Anti-tumor necrosis factor (anti-TNF) agents have been successfully used to treat both chronic idiopathic inflammatory bowel disease and other immune-mediated chronic diseases, but they can also induce a wide array of cutaneous reactions, including new-onset psoriasis and alopecia. We report a case of alopecia associated with psoriasiform skin lesions in a patient on adalimumab treatment for Crohn's disease.

Persistent blaschkitis responsive to high potency topical steroids

Blaschkitis is an acquired, rare dermatosis distributed along the lines of Blaschko. The papulovesicular eruption generally resolves in weeks and shows minimal response to topical steroids. Herein, we present a case of blaschkitis in an adult male who had lesions present for one year, which showed significant improvement after two weeks of topical clobetasol ointment.

Hyperkeratotic variant of porokeratosis in a patient with Hepatitis C virus infection and a concomitant immunosuppressed state

Porokeratoses are acquired and hereditary disorders of keratinization that share a distinctive lesion characterized by raised keratotic borders corresponding histologically to an angled column of parakeratotic cells, called a cornoid lamella. Although a precise mechanistic explanation is lacking, ultraviolet radiation and immunosuppressed states are considered causally-associated with most cases of acquired porokeratosis. Hepatitis C virus (HCV) infection has been proposed as a link between the immunosuppressed states and development of acquired porokeratosis. Among the various recognized clinical entities that constitute this group, rare cases of hyperkeratotic variants have been described that may pose a diagnostic challenge. Herein we describe a remarkable case of the hyperkeratotic variant of porokeratosis that occurred in a patient with known HIV and HCV infections and a coexisting therapy-related immunosuppressed state. We also provide a review of the relevant literature.

A curious case of blue-green discoloration in a middle-aged indian man: Chromhidrosis

Introduction: Chromhidrosis is a rare sweat gland disorder charac­terized by the excretion of colored sweat. It can be classified as apocrine, true eccrine, and pseudochromhidrosis. Amongst the different types of chromhidrosis, green chromhidrosis is extremely rare. We describe herein a case of blue green chromhidrosis induced by ingestion of homeopathic medicine.

Case report: A middle aged man presented to us with blue green discoloration of hands and feet. There was a preceding history of ingestion of homeopathic medication. Histopathology from the involved skin showed greenish particles within eccrine glands. Initial blood copper level was high which returned to normal level after discontinuation of the homeopathic medicine. Spectrophotometry revealed high copper content of the green sweat.

Conclusion: Our case emphasizes the importance of considering any type of ingested medicine, including homeopathic medicine, as a probable cause of chromhidrosis.

Pressure-induced isomorphic sclerodermoid graft-versus-host disease from brassiere underwire and tight-fitting watch

Sclerodermoid chronic graft-versus-host disease (scGVHD) is a rare form of cGVHD with an estimated prevalence of 3% to 11% in patients receiving allogeneic bone marrow transplants. scGVHD is believed to be an immune-mediated response characterized by aberrant T-cell function and dysregulation of tyrosine kinase cascades. Published literature on scGVHD is still limited and the mechanisms are yet to be fully understood. Thus, successful treatment of scGVHD remains largely unknown and many current options are hindered by potential side effects. This case provides an example of scGVHD localizing to areas of trauma and friction as a potential mechanism behind scGVHD and provides several case reports that document similar findings.

Folliculocentric cutaneous presentation of disseminated Candida krusei infection in a patient with acute myeloid leukemia

Candida krusei (C. krusei) is a multidrug-resistant opportunistic fungal pathogen that may cause disseminated infections in immunocompromised hosts. However, its clinical and histologic features are not well-characterized. We present a unique case to contribute to the growing knowledge base associated with this organism. During hospitalization for neutropenic fever, a 19-year-old man with acute myeloid leukemia, who underwent hematopoietic stem cell transplantation, developed a generalized folliculocentric eruption following initiation of antifungal therapy for newly diagnosed C. krusei fungemia. Despite adequate antifungal coverage and negative blood cultures, the follicular-based erythematous papules persisted. Biopsies demonstrated yeast within ruptured follicles, without angiotropism or involvement of the interfollicular dermis, subcutaneous tissue, or stratum corneum. Concurrent skin tissue cultures confirmed C. krusei. The patient remained febrile despite aggressive antifungal therapy, with relapse of leukemia and subsequent death. Our case is unusual given the development of cutaneous lesions following clearance of fungemia, with yeast limited to ruptured follicular lumina, possibly indicating a primary cutaneous source or early transfollicular/transepidermal elimination. Given the limited available descriptions of cutaneous histopathology for C. krusei, we seek to add to the understanding of its pathophysiology and aid in the diagnosis and treatment of this often fatal infection.

Photo Vignette

Ungual squamous cell carcinoma mimicking a chronic paronychia: clinical, pathological and radiological correlation

Squamous cell carcinoma is a malignant skin tumor that is rarely located in the nails. Its presentation, can sometimes be confused with an inflammatory process as onychomycosis or psoriatic onychopathy or other tumors as viral warts. We report the case of a 73-year-old woman with a locally invasive squamous cell carcinoma reaching the bone, simulating a chronic paronychia.

Painful nodule in the caesarean section scar of a young woman

Endometriosis is the presence of ectopic endometrial tissue outside the uterus and cutaneous endometriosis is a rare manifestation of this disease that may be found at the sites of surgical scars as a result of iatrogenic implantation. Herein we present a case of scar endometriosis in a 35-year-old woman. The scar was sustained following a remote caesarean section.


Impact of the Pregnancy and Lactation Labeling Rule (PLLR) on Practicing Dermatologists

On June 30th 2015, the FDA instituted a new system for the categorization of drug safety during pregnancy and lactation, known as the Pregnancy and Lactation Labeling Rule (PLLR), which replaces the “A, B, C, D, X” pregnancy labeling categories. The new rule will apply to all newly approved prescription medications, with a staggered phase-in for prescription drugs approved prior to the effective date. In this article, we provide a brief description of the major changes introduced by the PLLR and discuss the major implication of this new categorization system for clinical dermatologists.


Extensive keloid formation after pemphigus vulgaris

Pemphigus vulgaris is an immunobullous disease characterized by intraepidermal blister formation. These blisters eventually rupture, leaving erosions that are slow to heal, often leaving hyperpigmented patches, but no scars. We describe a case of a 67- year-old man with pemphigus vulgaris who suffered severe keloidal scarring after the pemphigus lesions became infected. His keloids were treated with intralesional corticosteroids with some improvement. Pemphigus vulgaris, a process confined to the epidermis, may lead to scarring in predisposed individuals, particularly if infection occurs.

Paronychia-like cutaneous leishmaniasis

Chronic paronychia is an inflammatory recalcitrant disorder affecting the nail folds. We report one patient with paronychia  revealing ungueal leishmaniasis.

A 34-year-old man, resident in the north of Morocco, presented with a 6-month history of an inflamed proximal nail fold of  the left thumb, resistant to antibiotics and anti-fungal treatments.

En bloc excision of the proximal nail fold was done. The histopathological exam showed epithelioid  granulomas  with giant  cells and the presence of  leshmania  amastigotes, leading to the diagnosis of ungueal leishmaniasis.

Clinical aspects of cutaneous leishmaniasis can be very misleading. The paronychial form is rarely described. In endemic areas  it is necessary for the physician to be aware of atypical skin presentations of  leishmaniasis.

Failure of lichen planopilaris to respond to ustekinumab

Lichen planopilaris failed to respond to ustekinumab after 10 months of treatment.

Professional dermatology societies in the USA: an overview

This is a concise overview in a table format for the current membership-based dermatology societies in the USA. The primary objective of these societies is to provide continuous medical education. These societies serve all health care providers in dermatology care, including physician assistants and nurses. There is a clear need for establishing more societies which focus on different aspect of dermatology. There is always a potential for improving the educational activities of these societies.

Cutaneous myiasis of scalp in a young girl related to Musca domestica

Cutaneous myiasis is a parasitic disease secondary to the presence of the larvae of certain insects, particularly diptera, in the skin of man or vertebrates [1]. Human myiasis is a rare clinical condition, but more frequently seen in tropical and subtropical areas. Hot humid climate with inadequate sanitary conditions favor the development of this condition.  Dermatitis, psychiatric illnesses, leprosy, and diabetes are some contributory factors [2]. Treatment of myiasis, once diagnosed, is simple and rapid recovery is anticipated.


Dermatologic health literacy in underserved communities: a case report of south Los Angeles middle schools

Background: The incidence of melanoma and other skin cancers has risen drastically in the United States.  As with most types of cancer, the prognosis and survival rates are significantly improved with early diagnosis, but dismal for patients who present with advanced disease.  It remains a fact that although melanoma is most common in Caucasian populations, ethnic minorities have a worse prognosis. Our hypothesis in this dermatologic health literacy study was that before necessary education, the required fund of knowledge with respect to skin cancer risk is lacking in several ethnic communities, but that intended compliance occurs when educational intervention occurs.

Methods: Three middle schools in South Los Angeles with predominantly Latino and African American youth were surveyed. Permission was obtained from the principals of the middle schools for the multi-day educational initiative. A total of 150 students were ultimately recruited and a pre-intervention survey administered. After preliminary review of the pre-intervention dermatologic health literacy results, a set of “core” learning concepts about sun safety were summarized and solidified for incorporation into the adolescent-appropriate sun safety protection pamphlet that was designed by designers at UCLA/Johnson & Johnson Health Care Institute. A full day of education on skin disease and the importance of sun protection from an early age was executed, followed three months later by a post-intervention visit that assessed compliance with the sun protection products and intended future use.

Results:  Results from the pre- and post-intervention surveys/questionnaires were analyzed and interpreted. Of 150 pre-intervention surveys that were distributed, 54 identified as African American and 96 of whom identified as Latino. Of these, 75% of Latino students reported having a sunburn in the last year, whereas only 38.9% of African American students reported a sunburn.  A total of 80% of the students reported as least some use of sunscreen in the 3 months prior to the post-intervention survey.  Only 8% of African American students reported “everyday” use, whereas 24% of Latino students reported “everyday” use (P < 0.05).  A total of 94% of the students intend to wear sunscreen in the future (89% of African American students and 97% of Latino students, with a P < 0.05 calculated using a two-sample t test).  However, it should be noted that more than half (54%) of the total students reported that although they planned to apply the sunscreen daily, they deemed it too expensive, which might prevent consistent future use.

Conclusions: Our hypothesis in this dermatologic health literacy study was that before necessary education, the required fund of knowledge with respect to skin cancer risk is lacking in several ethnic communities, but that intended compliance occurs when educational intervention occurs.  The data, both quantitative and qualitative, demonstrate that our hypothesis is substantiated.