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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 24, Issue 10, 2018


Incidence rates of comorbidities among patients with psoriasis in the United States

Psoriasis is associated with a substantial burden of comorbidities; however, incidence rates (IRs) of these comorbidities following psoriasis diagnosis are not well characterized. Using administrative claims data from the Truven Health Analytics MarketScan Commercial and Medicare Supplemental Databases between January 1, 2002 and September 30, 2015, we compared the incidence of newly diagnosed comorbidities among patients with psoriasis versus demographically matched (birth year, gender, and geographic region) control patients without psoriasis in the United States. Comorbidities of interest were identified using ICD-9-CM codes. A total of 114,824 matched pairs of patients with psoriasis and control patients were included. IRs of all selected comorbidities were significantly higher among patients with psoriasis compared with controls (P<0.05). The most common newly diagnosed comorbidities in both groups were hyperlipidemia (psoriasis versus control, IR per 1,000 patient-years, 127.5 versus 102.8) and hypertension (94.3 versus 80.6). The greatest differences in IRs between patients with psoriasis and controls were observed for rheumatoid arthritis (9.7 versus 3.1; IR ratio [IRR], 3.15) and psoriatic arthritis (24.0 versus 0.2; IRR, 151.57). In this real-world study, patients with psoriasis were more likely to develop new selected comorbidities after diagnosis compared with demographically matched patients without psoriasis.


Dermatology on Flickr

Flickr, which was launched in 2004, is one of the oldest photo-sharing services online. The company, which was once at the forefront of the internet social media explosion, lost users and received criticism as its repeated acquisitions by other companies forced users to adapt to new owners. Now facing another acquisition by the online photo-sharing service SmugMug, the future is uncertain again for the once popular internet and mobile application service. Flickr, with its rapid rise in popularity, sudden halt in growth, and its gradual loss of users and popularity, has been repeatedly looked to as a lesson for other internet startups on the necessity of adapting quickly in the current internet age. Given the rise of social media use in the healthcare field, and the long-standing presence of Flickr on the internet, this study investigated the presence of dermatology-related content on Flickr and how the photo-sharing platform has applied to the visual field of dermatology, its dermatologists, and its professional associations.

Case Report

Recurrent retroauricular cystic nodules: lichen planus follicularis tumidus

Lichen planus follicularis tumidus (LPFT) is a rare subtype of lichen planus (LP) that has been most commonly described in middle-aged women. LPFT clinically manifests as recurrent cystic follicular nodules that preferentially involve the retroauricular area; concurrent classic LP lesions on the extremities and mucosal surfaces may also be present. Histologically, LPFT demonstrates epithelial-lined follicular cysts filled with orthokeratotic keratin surrounded by a dense lichenoid infiltrate. We present a case of a 67-year-old man with clinical and histopathologic findings consistent with LPFT and discuss differential diagnostic considerations for entities resembling LPFT. Lastly, treatment options for LPFT are reviewed.

Case Presentation

Cutaneous mucinosis of infancy: report of a rare case and review of the literature.

Cutaneous mucinosis of infancy (CMI) is a rare dermatologic condition, first reported in 1980 and currently classified within the complex group of papular mucinoses. We report a case of CMI and review the prior 13 cases in the literature. The patient was a 5-year-old girl who presented with asymptomatic dermal papules and plaques on her leg and back with no overlying color change. These lesions were first noticed during infancy and had become slightly more evident over time. The patient had a history of birthmarks and eczema. Her family history included eczema, allergies, photosensitivity, and Graves disease. Pre-biopsy clinical differential diagnosis included connective tissue nevus, granuloma annulare, myofibroma, lipofibroma, and lymphangioma. Biopsies revealed significant increase in interstitial mucin within the reticular and mid dermis, without significant sclerosis or fibroblastic proliferation. The relatively quiescent pattern of interstitial mucinosis with slight fibrocyte hyperplasia presenting as dermal papules-plaques on the trunk and extremities was most consistent with a diagnosis of CMI. We report another case of CMI in an otherwise healthy patient. Our patient is unique as she is the first CMI patient with a family history of Graves disease, although our patient appeared euthyroid. We will also review the literature on this rare entity.

A case report of adult-onset multiple angiokeratomas with zosteriform distribution

Angiokeratomas are benign vascular ectasias in the papillary dermis associated with epidermal changes in the form of hyperkeratosis and/or acanthosis. Clinically, angiokeratomas appear as solitary or multiple dark red to purple-black macules and/or papules, mostly with a verrucous surface. Five subtypes of angiokeratoma have been proposed - angiokeratoma corporis diffusum, angiokeratoma of Mibelli, angiokeratoma of Fordyce, angiokeratoma circumscriptum, and "solitary and multiple" angiokeratomas. We report an unusual case of multiple angiokeratomas in a zosteriform distribution with onset at age 74.

Polycyclic annular presentation of pemphigus vulgaris with an eosinophil predominance in two pregnant patients

Pemphigus during pregnancy has a more complicated course owing to the limitations in treatment options and alterations in the severity and presentation of the clinical features. We would like to present two pemphigus vulgaris (PV) cases associated with pregnancy with an unusual clinical appearance exhibiting polycyclic, annular, vesiculobullous plaques with marked eosinophil infiltration in histopathology. To the best of our knowledge pregnancy-associated pemphigus cases with this particular clinical presentation have not been reported in the literature. Changes in the immunologic and hormonal state during pregnancy may play a role in altering the classic clinical presentation and treatment response of PV.

A novel case of NKX3.1-positive metastatic cutaneous prostate cancer

Prostate carcinoma is the most common non-dermatological malignancy in men and only second to lung cancer as the leading cause of cancer related deaths in America. Moreover, metastasis to the skin is even more uncommon following apparently successful treatment of a preexisting prostate cancer. We present an 87-year-old man previously diagnosed with prostate cancer treated with brachytherapy, who presented with a metastatic prostate adenocarcinoma of the scalp mimicking a basal cell carcinoma. Herein, we present a patient with an NKX 3.1 positive cutaneous metastatic prostate carcinoma identified through NKX3.1 stain rather than the typical PSA/PSAP stain.

Basal cell carcinoma with intravascular invasion: A case report and review of the literature

The significance of basal cell carcinoma (BCC) invading the intravascular space is unknown. We report a case of an infiltrative BCC on the scalp that showed evidence of both intravascular and perineural invasion. The tumor locally recurred in the bone marrow space 4.5 years following the initial procedure. Since recurrence and metastasis of BCC can be delayed for many years, we recommend long term follow-up for tumors showing aggressive features.

Leukocytoclastic vasculitis with late-onset Henoch-Schönlein purpura after trifluridine/tipiracil treatment

Trifluridine/tipiracil has been approved for the treatment of refractory metastatic colorectal cancer. Adverse effects of this drug combination include leukopenia, neutropenia, fatigue, diarrhea, and vomiting. We present a case of trifluridine/tipiracil-induced leukocytoclastic vasculitis (LCV) with late-onset Henoch-Schönlein purpura (HSP) in a 42-year-old man with metastatic appendiceal cancer. The patient's biopsy-proven LCV developed one month after he began trifluridine/tipiracil treatment and resolved after discontinuation of the drug. He presented to the emergency department two months after the appearance of his LCV with shortness of breath, elevated blood pressure, elevated creatinine, hematuria, and proteinuria. A kidney biopsy was performed and the presence of IgA deposits and cellular crescents indicated rapidly progressive glomerulonephritis secondary to Henoch-Schönlein purpura (HSP). Neither LCV nor HSP have been reported as adverse effects of trifluridine/tipiracil treatment. Malignancy as a cause of our patient's HSP is another possibility. The delay between our patient's skin findings and acute renal failure indicates that suspected HSP should be monitored by urinalysis for a period of time owing to the risk of life-threatening renal disease.

Erythema annulare centrifugum-type eruption in a patient undergoing cancer vaccine immunotherapy

Sipuleucel-T is a cellular immunotherapy approved for the treatment of metastatic castration-resistant prostate cancer. We report a patient developing an immune related adverse effect from sipuleucel-T drug-induced erythema annulare centrifugum-like eruption. A brief review of the mechanism and implications of this eruption are also included.

Photo Vignette

Glomuvenous malformations in a young man

A young man presented with blue nodules on the trunk, face, and extremities that gradually increased in number and size. His mother had similar lesions. Initially, blue rubber bleb nevus syndrome was suspected, but histological findings confirmed the diagnosis of hereditary glomuvenous malformations. Making the correct diagnosis spares the patient unnecessary evaluation for the arteriovenous malformations of the gastrointestinal tract associated with the former diagnosis.

Eosinophilic pustular folliculitis with labial and oral involvement: report of a rare presentation

Eosinophilic pustular folliculitis (EPF) is a recurrent inflammatory dermatosis primarily involving hair follicles. Several subtypes of EPF have been described: Classic EPF, infantile EPF, and immunosuppression-associated EPF. Although classic EPF has a predilection for face, involvement of hairless areas such as palms and soles has been reported frequently. There are rare case reports of mucosal EPF. Herein, we report a woman who presented with classic EPF involving the lip and oral mucosa.


Acneiform eruption induced by vedolizumab

The development of new biological drugs for the treatment of advanced oncological processes or severe inflammatory diseases brings with it the appearance of new adverse effects. Vedolizumab, an α4β7 integrin inhibitor antibody, is approved for induction and maintenance therapy in both Crohn disease and ulcerative colitis. We report a case of severe acneiform eruption induced by vedolizumab in a 17-year-old woman with ulcerative colitis.

Role of family history in patchy alopecia areata

Background: Family history of alopecia areata has been associated with more severe clinical presentations, but its specific prognostic implications in patchy alopecia remains unclear.

Objective: To evaluate the relationship of family history of alopecia areata with demographics, triggers, comorbidities, disease course, and relapse rate in patchy alopecia.

Methods: The medical records of 256 patients seen over a 17-year period was examined. Data collected included demographics, comorbidities, disease severity, and response to treatment. Comparisons were drawn using Pearson chi-square tests, Fisher exact tests, Wilcoxon rank sum tests, and t-tests as appropriate.

Results: Family history of alopecia areata was associated with reduced hair regrowth after relapses, more severe symptoms, and earlier age of onset. Stress/fatigue, illnesses, thyroid disorders, and season changes were the most common relapse triggers. Dermatologic disorders were the most common comorbidities, followed by atopy and autoimmune disease.

Limitations: Given the retrospective nature of data collection, most measures have some missing data, which may impact findings.

Conclusion: Patchy alopecia patients with a family history of alopecia areata experienced worse outcomes. Concomitant autoimmunity may also adversely affect alopecia areata disease course. Identification of a positive family history of alopecia areata and control of autoimmune comorbidities may aid alopecia areata management.

Augmenting the scope of dermatologic care and training via student-run health clinics

Skin cancer is a major public health problem. Unfortunately, individuals who lack health insurance have lower skin cancer screening rates compared to insured individual and, therefore, have a higher risk of more advanced cancer diagnoses. Student-run health clinics may be the answer to this dilemma. Student-run health clinics can not only help by providing essential dermatologic services to the general population, both insured and uninsured, but also provide early exposure to dermatology education for medical students.