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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 22, Issue 8, 2016


Comparing the efficacies of alginate, foam, hydrocolloid, hydrofiber, and hydrogel dressings in the management of diabetic foot ulcers and venous leg ulcers: a systematic review and meta-analysis examining how to dress for success

Diabetic foot ulcers and venous leg ulcers are chronic wounds frequently encountered by dermatologists. Choosing appropriate wound dressings can effectively promote wound healing and potentially reduce morbidity and financial burden experienced by patients. The objective of our systematic review and meta-analysis was to evaluate wound healing efficacies of synthetic active dressings in diabetic foot ulcer and venous leg ulcer management. For data collection, PubMed, Embase, Cochrane Library, CINAHL, and online databases were searched from database inception to 10 May 2015. Fixed and random effects modeling were used to calculate pooled risk ratios for complete ulcer healing from pairwise dressing comparisons. The results of our review showed moderate-quality level evidence that hydrogels were more effective in healing diabetic foot ulcers than basic wound contact dressings (RR 1.80 [95% CI, 1.27-2.56]). The other dressing comparisons showed no statistically significant differences between the interventions examined in terms of achieving complete diabetic foot ulcer healing. Non-adherent dressings were more cost-effective than hydrofiber dressings for diabetic foot ulcers in terms of mean total cost per patient of the dressings themselves. All venous leg ulcer pairwise dressing comparisons showed equivalent dressing efficacies in terms of promoting complete ulcer healing. Overall, most synthetic active dressings and traditional wound dressings are equally efficacious in treating diabetic foot ulcers and venous leg ulcers. For treating diabetic foot ulcers, hydrogels are more efficacious than basic wound contact dressings, and non-adherent dressings are more cost-effective than hydrofiber dressings. Ultimately, dressing choice should be tailored to the wound and the patient


Do non-melanoma skin cancer survivors use tanning beds less often than the general public?

Purpose Indoor tanning is associated with an increased risk of non-melanoma skin cancers (NMSC), yet little is known about indoor tanning habits of individuals with a history of NMSC. Methods We examined self-reported history of NMSC and tanning bed use among non-Hispanic white respondents in the 2010 National Health Interview Survey (NHIS), a cross-sectional population-based survey designed to be representative of the civilian US population. We computed weighted population estimates and standard errors using the Taylor series linearization method. We then evaluated chi-square tests of independence and conducted weighted logistic regression analyses to evaluate if NMSC status was a predictor of indoor tanning. Results In our analytic sample of 14,400 non-Hispanic white participants, representing 145,287,995 in the population, 543 participants (weighted proportion = 3.45%) self-reported a history of NMSC or “skin cancer type not known.” In multivariate analyses, non-melanoma skin cancer survivors were no less likely to use tanning beds in the last 12 months than skin cancer free controls (OR = 0.70, 95% CI: 0.34-1.43, p = 0.33). Conclusions Non-melanoma skin cancer survivors should be educated on their increased risk of recurrence and other skin cancers and in particular the role of indoor tanning in skin tumorigenesis.

Case Report

Generalized eruptive histiocytosis associated with a novel fusion in LMNA-NTRK1

Non-Langerhans cell histiocytosis (NLCH) is a histiocyte disorder comprised of dermal dendritic histiocytes with a characteristic staining pattern. Erdheim-Chester disease (ECD) is a subset of NLCH in which patients experience bone pain with corresponding changes on imaging. In addition, these patients show other evidence of systemic involvement, which can also be identified with imaging. This disease can occasionally present with cutaneous findings. We present a case of generalized eruptive histiocytosis (GEH), misdiagnosed as ECD, found to have an NTRK1 gene rearrangement. This is the first report of an NTRK1 kinase fusion with NLCH. The implication is unclear and further studies are warranted.

Recurrent adult onset Henoch-Schonlein Purpura: a case report

Henoch-Schonlein purpura is an immunoglobulin A (IgA)-immune complex mediated leukocytoclastic vasculitis that classically manifests with palpable purpura, abdominal pain, arthritis, and hematuria or proteinuria. The condition is much more predominant in children (90% of cases) and commonly follows an upper respiratory infection. We present a case of recurrent Henoch-Schonlein purpura (HSP) complicated by nephritis in an adult female initially categorized as IgA nephropathy (IgAN). We review the pathophysiologic basis of HSP nephritis as the variant of HSP accompanied by renal involvement and its pathogenetic commonality with IgA nephropathy.

Treatment of rosacea with topical ivermectin cream: a series of 34 cases

Rosacea is a highly prevalent, chronic inflammatory disease. The use of topical ivermectin cream has recently been described in the treatment of rosacea in three clinical trials. We report our experience in a series of 34 patients treated with topical ivermectin cream. The results are a reflection of the reality of clinical practice and the perception of patients of the treatment. We also evaluate the efficacy in cases of mild rosacea and erythematotelangiectatic rosacea which have not been studied in trials.

Case Presentation

Fluoroscopy-induced radionecrosis

Complications from radiation exposure during fluoroscopic guidance of cardiac catheterization may occur. With repeated procedures, the risk for cutaneous injuries increases. Herein, we describe a 59-year-old man with extensive coronary artery disease, who had undergone multiple revascularization procedures and developed a non-healing ulcer on his left inferior scapula. The patient’s medical history, physical exam findings, and histopathology gave clues to a case of radiation-induced dermatitis and necrosis.

Nilontinib induced keratosis pilaris atrophicans

Keratosis pilaris (KP) is a disorder of follicular keratinization that is characterized by keratin plugs in the hair follicles with surrounding erythema. A 46-year-old man with chronic myelogenous leukemia (CML) was started on nilotinib, a second generation tyrosine kinase inhibitor (TKI). Two months later the patient noticed red bumps on the skin and patchy hair loss on the arms, chest, shoulders, back, and legs. Cutaneous reactions to nilotinib are the most frequent non-hematologic adverse effects reported. However, it is important to distinguish KP-like eruptions from more severe drug hypersensitivity eruptions, which can necessitate discontinuing the medication. Also, it is important to classify the cutaneous eruptions in patients on TKI according to the morphology instead of labeling them all as “chemotherapy eruption” to be able to better manage these adverse effects.

Epithelioid angiosarcoma of the skin. A malignant tumor mimicking many different neoplasms

Epithelioid angiosarcomas are rare malignant mesenchymal tumors. The main problem of these tumors is the complicate clinical and histological diagnosis. We report a case with an immunohistochemical panel. We propose the use of CD31 in the immunohistochemical panel of an undifferenciated tumor with epithelioid features, because it appears to be the only endothelial marker these tumors constantly express.

Mucin in the dermis: a case of tender tumors

We present an original case report of a 45-year-old woman with a five-month history of sporadic, tender, nodules present on the right upper abdomen, bilateral dorsal wrists, right upper arm, and left flank. Biopsy revealed a mild perivascular infiltrate, increased dermal mucin, and no significant increase in fibroblasts. Presentation and histology were most consistent with nodular lichen myxedematosus (NLM), a rare primary mucinosis. Only four previous cases are reported in the literature to our knowledge. Management of NLM and other subtypes of lichen myxedematosus is not well described. Our patient failed systemic steroids and was unable to tolerate hydroxychloroquine, but subsequently improved with oral methotrexate. This suggests that methotrexate may be of benefit for NLM.

Photo Vignette

Frictional alopecia of the distal legs: case series and review

BackgroundAcquired alopecia of the lower legs may occur secondary to friction due to socks, footwear, or both on the lower extremities. There is scant literature that reports on this phenomenon.

Methods and MaterialsWe describe 5 patients who presented with alopecia of their lower legs induced by socks, footwear, or both.

Methods and Materials: We reviewed PubMed for the following terms: ankle alopecia, friction alopecia, frictional alopecia, lower extremity alopecia, non-scarring leg alopecia, and sock alopecia. We also reviewed papers containing these terms and their references.

ResultsAcquired frictional alopecia of the lower extremities is often an asymptomatic condition found incidentally on physical examination. The condition can persist for many years despite removal of the source of friction.

ConclusionThe incidence of acquired frictional alopecia of the lower extremities may be greater than reflected in previously published reports. It is a non-scarring subtype of alopecia that was noted as an incidental finding during the patient’s dermatology appointment.

Primary periungual leiyomyosarcoma

Primary superficial leiomyosarcoma is a very uncommon malignant tumor which occurs most commonly the lower limbs. We report one case of unusual topography of this tumor. An 81-year-old female patient presented with a 2 year history of a periungual tumor of the left index finger. The histopathological and immunohistochemical examination of a biopsy specimen was compatible with the diagnosis of leiomyosarcoma. There was no evidence of metastatic disease. An amputation of the index was performed.

Erythematous papules over the neck: a diagnostic conundrum

Syringomas are common appendageal neoplasms, manifested as skin-colored papules, most commonly distributed over the periorbital region. We describe a patient with syringoma localized over the neck and upper chest.


A case of pachydermodactyly in a seventeen year old associated with repetitive minor trauma

A boy presented initially to a Rheumatology clinic with a three year history of asymptomatic swelling of the third to fourth proximal interphalangeal (PIP) joints bilaterally. A presumptive diagnosis of seronegative arthritis was made. Sulfasalazine was commenced without improvement and resulted in mood disturbance. Blood tests including ESR, lupus anticoagulant, rheumatoid factor and CCP antibodies were unremarkable. Hand radiographs were normal. MRI showed oedema within soft tissues around PIP joints. His care was transferred to the Rheumatology unit in our hospital and the rheumatological diagnosis was revised; sulfasalazine was stopped and skin biopsy organised. Onward referral to Dermatology was made. Examination revealed symmetrical swelling and thickening of soft tissues on PIP joints with no evidence of joint synovitis. He denied habitual behaviour but was noted to rub his fingers subconsciously. With this as a cause of repetitive minor trauma, a clinical diagnosis of pachydermodactyly was made. Skin biopsy was supportive showing a dermis with coarse collagen. Pachydermodactyly is rare. This case highlights the importance of prompt recognition to avoid invasive and excessive diagnostic procedures as well as unnecessary immunosuppression.

External ear nodule revealing a disseminated Kaposi disease

Kaposi disease (KD) is an angiogenetic tumor process, characterized by its various clinical aspects. Its pathogenesis is multifactorial and it was attributed to HHV-8 infection. We report an original case of disseminated KD revealed by solitary lesion of external ear in a patient treated by corticosteroids for bullous pemphigoid.

Top-cited psoriasis authors in 4 high-impact dermatology journals: 2000-2012

Psoriasis is a largely researched topic with abundant potential for publication in dermatologic journals. We used the Thomson Reuters’ Web of Science citation database using the search term “psoriasis” in the titles of any literature published in 4 high-impact dermatology journals. We compiled a ranking of the top 25 cited first authors and top 25 cited authors overall on the subject of psoriasis between 2000-2012. We hope our analysis highlights the achievements of our colleagues and predecessors

Active tuberculosis in a psoriasis patient treated with tumor necrosis factor inhibitors despite an initial negative tuberculin skin test and no known risk factors

Tumor necrosis factor (TNF) inhibitors are becoming more common in the treatment of moderate-to-severe chronic plaque psoriasis. These medications have a low incidence of serious adverse events and are generally considered safe; however, they do make patients more susceptible to tuberculosis (TB) infection both through latent reactivation and primary infection. We describe a case of a patient who had an initial negative tuberculin skin test (TST), began TNF inhibitor therapy, and then 11 years later was diagnosed with active TB. After the initial screening, the patient did not have any subsequent screenings for TB and no apparent change to his TB risk status. TB is still common in many areas of the United States and travel is not necessary to be exposed. Patients on TNF inhibitors that develop active TB have increased morbidity and mortality than those who are not. It is necessary that dermatologists limit the risk of TB to patients by screening them before initiation and annually when they are on the TNF inhibitor.

Uremic pruritus treated successfully with the Goeckerman Program

Uremic pruritus (UP) is a common condition among patients with chronic kidney disease (CKD) on hemodialysis (HD). We report 19 a case of severe UP recalcitrant to conventional therapy including topical corticosteroids, anti-histamines, and phototherapy, 20 which was treated successfully with the Goeckerman regimen consisting of topical coal tar, topical corticosteroids, and broadband 21 UVB (BB-UVB). Little is known about the pathophysiology of UP, and there is currently no consensus or evidence-based 22 treatments for UP. Although further studies are necessary, Goeckerman therapy may be a promising treatment option when 23 available for severe UP intractable to conventional therapies.

Special Review

Zebrafish for modeling skin disorders

The experimental advantages of zebrafish make this model system highly amenable to the field of dermatology. Zebrafish skin development is similar to humans and its genome is ~70% orthologous to the human genome. Its external developmental process allows for genetic manipulation and analysis of embryogenesis within a short time frame with all important internal organs and skin compartments formed within 6 days. Zebrafish models of cutaneous human diseases offer insight into pathogenesis and a unique platform for testing of potential therapies. This review details the specific advantages of zebrafish and highlights its use in dermatological research.