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 25, Issue 8, 2019
Artifacts and landmarks: pearls and pitfalls for in vivo reflectance confocal microscopy of the skin using the tissue-coupled device
Reflectance confocal microscopy (RCM) is a non-invasive imaging tool for cellular-level examination of skin lesions, typically from the epidermis to the superficial dermis. Clinical studies show RCM imaging is highly sensitive and specific in the diagnosis of skin diseases. RCM is disseminating from academic tertiary care centers with early adopter "experts" into diverse clinical settings, with image acquisition performed by technicians and image interpretation by physicians. In the hands of trained users, RCM serves an aid to accurately diagnose and monitor skin tumors and inflammatory processes. However, exogenous and endogenous artifacts introduced during imaging can obscure RCM images, limiting or prohibiting interpretation. Herein we review the types of artifacts that may occur and techniques for mitigating them during image acquisition, to assist technicians with qualitative image assessment and provide physicians guidance on identifying artifacts that may confound interpretation. Finally, we discuss normal skin "landmarks" and how they can (i) obscure images, (ii) be exploited for additional diagnostic information, and (iii) simulate pathological structures. A deeper understanding of the principles and methods behind RCM imaging and the varying appearance of normal skin structures in the acquired images aids technicians in capturing higher quality image sets and enables physicians to increase interpretation accuracy.
Fall risk assessment and injury prevention in the Mohs surgery clinic: a review of the literature and recommendations for improving patient safety
Patient falls remain a major cause of adverse events in the medical setting. Many patients receiving Mohs micrographic surgery are at high risk, both for falling and resultant injuries. Although the incidence of patient falls in dermatologic surgery is low, falls can have significant consequences for both patient and provider. Therefore, effective interventions to improve organizational safety are critical. Though there is a considerable amount of research pertaining to fall prevention strategies, the majority of studies have been confined to the inpatient setting and long-term care facilities. Implementation of fall prevention initiatives in the outpatient setting has rarely been evaluated and no studies have focused on the Mohs patient population to date. Methods: We reviewed the literature pertaining to fall risk and prevention guidelines in the inpatient and outpatient settings as it applies to the dermatologic surgery environment. Results: Herein we will discuss patient risk factors for falling relevant to the Mohs setting and review existing validated fall risk assessment tools and strategies for fall prevention. Conclusion: Identifying fall risk factors can improve patient safety and reduce falls in the dermatologic surgery clinic.
Background: Topical corticosteroids are available in many vehicles. However, patients' preference for vehicles are variable and could be tailored to maximize patient adherence. Spray vehicles may offer, convenience, and strong efficacy. Methods: A literature review was conducted using keywords: clobetasol, desoximetasone, betamethasone, triamcinolone, corticosteroid, topical, spray, vehicles, treatment, and clinical trial. Results: For moderate-to-severe plaque psoriasis, 87% of subjects achieved an Overall Disease Severity (ODS) Score ≤2 at week two and 78% achieved an ODS ≤1 after four weeks with clobetasol propionate (CP) 0.05% spray compared to 17% and 3% in the control group, respectively (P<0.001). For desoximetasone 0.25% spray, 31%-53% with moderate-to-severe psoriasis achieve Physician's Global Assessment (PGA) score ≤1 at day 28 versus 5%-18% in the vehicle spray group (P<0.01). For betamethasone dipropionate 0.05% spray, 19% with mild-to-moderate plaque psoriasis achieved an Investigator's Global Assessment (IGA) score ≤1 or a 2-grade reduction in IGA versus 2.3% in vehicle group (P≤0.001). For mild-to-severe steroid responsive inflammatory dermatoses, 64% using triamcinolone acetonide 0.2% spray achieved clear or almost clear skin at day 14 (no P value reported). Adverse events including burning, irritation, and dryness were similar across all corticosteroids.
Atopic dermatitis (AD) is a common multifactorial skin disease occurring primarily in young children. AD has increased in prevalence over the past decades, but little knowledge exists on the prevalence of AD in adults. Herein, published estimates of the point-prevalence and one-year prevalence of AD in adults are reviewed in the context of various study characteristics such as the age and gender distribution of the populations, sampling methods, study design, and geographical area of origin. In total, 14 different population studies reporting the prevalence of AD in adults in 17 countries were identified. There was a substantial between-country variation in both the point-prevalence (1.6 to 11.5%) and one-year prevalence (2.2 to 17.6%) of AD with heterogeneity explained partly by gender, age, geography, study design, and diagnostic criteria.
In medical practice, physicians are sometimes faced with patients who reject the gold-standard treatment for a condition. In this hypothetical clinical scenario, we present the case of a patient who refuses Mohs micrographic surgery for management of infiltrative basal cell carcinoma and instead requests off-label therapy with imiquimod. We discuss the treating dermatologist's options in response to this patient's request and the ethical considerations surrounding the case. We conclude that the physician has the right to refuse to provide treatment that deviates from standard clinical practice but that the physician should counsel the patient on all options, provide thorough informed consent, offer contact information for the patient to pursue a second opinion or a radiation oncology referral, and ensure safe transfer of care should the patient desire treatment with a different provider.
A strategic evidence-based framework for international medical graduates (IMGs) applying to dermatology residence in the United States: a literature review
Dermatology is one of the least diverse medical fields, partly owing to the low number of international medical graduates that apply and match to dermatology residency programs in the United States each year. Our objective was to determine and outline the factors that can increase competitiveness of international applicants interested in applying to dermatology residency in the U.S. Higher match rates for IMGs were associated with several applicant-dependent characteristics, including higher USMLE scores, higher research participation and numbers of publications, strong recommendation letters, and dermatology rotations. Although states with a greater number of dermatology residency positions (New York, Massachusetts, and California) had more IMGs matched from 2013 to 2018, certain states with a smaller number of residency positions, namely Colorado and Georgia, had the highest dermatology match rates for IMGs when adjusted for the total number of matched applicants. Evidenced-based application guidance for international applicants, as outlined in this literature review, may improve the competitiveness of IMGs and increase diversity within the field of dermatology. Rotating and applying to dermatology residency programs in states that have historically accepted a higher number of IMGs may further improve the applicants' chances of matching into a dermatology residency.
Discrete cutaneous lesions in a critically ill patient treated only for AIDS and miliary tuberculosis: a case report of disseminated histoplasmosis
Histoplasmosis is a systemic mycosis caused by the dimorphic fungus Histoplasma capsulatum, with disseminated histoplasmosis (HD) being one of its clinical forms. As a consequence of the HIV-AIDS pandemic, HD has become prevalent not only in regions that are recognized as endemic but also in areas not considered endemic, such as Europe and Asia. Its clinical manifestations are varied and mimic several infectious diseases, mainly tuberculosis. In endemic areas, it is the first manifestation of AIDS in 50 to 70% of patients. The diagnosis of histoplasmosis is difficult and HD can lead to death if not diagnosed early and if proper treatment is not instituted. The present report presents a patient with a recent diagnosis of HIV-AIDS, in treatment for miliary tuberculosis, who was diagnosed with disseminated histoplasmosis because of his dermatological manifestations.
Cutaneous collagenous vasculopathy is a rare clinicopathological entity, first described in 2000. Cutaneous collagenous vasculopathy has been considered a form of microangiopathy of superficial dermal vessels and produce lesions that appear as telangiectasia. We present a patient with histopathologic features of cutaneous collagenous vasculopathy and scattered erythematous papules on the trunk with a striking dermatoscopic finding. We propose the term of 'cutaneous papular collagenous vasculopathy' as a new clinical manifestation of this disease.
Langerhans cell histiocytosis (LCH) is a rare, clinically heterogeneous disease that most commonly occurs in pediatric populations. Congenital self-limited LCH is a benign variant of LCH. It most commonly presents as a diffuse eruption and reports of single lesion cases are infrequent in the literature. Even in the case of congenital self-limited LCH, there is potential for future multisystem relapse, making long-term follow-up important. We present a case of single lesion self-limited LCH in a full-term male infant with interesting morphology. Physical examination revealed a painless, 6 millimeter, well-demarcated, papule encircled by erythema with central hemorrhage. An infectious workup was negative and a punch biopsy was obtained, which showed a dermal infiltrate of histiocytes consistent with a diagnosis of LCH. The lesion healed without intervention within three weeks. Our case highlights the need for dermatologists to consider LCH in the differential diagnosis for lesions of varying morphology in children, as proper identification is necessary to monitor for multisystem recurrence.
Eosinophilic fasciitis is a rare connective tissue disorder characterized by inflammation of the fascia that leads to painful, indurated skin. Because of its variable clinical presentation and overlap with conditions, such as morphea, the diagnosis of eosinophilic fasciitis can be challenging and relies on clinical presentation, histopathologic and laboratory analysis, and response to therapy. Herein, we present an unusual, solitary, isolated plaque with pathologic features and response to therapy most consistent with eosinophilic fasciitis.
Treatment-resistant ulcerative necrobiosis lipoidica in a diabetic patient responsive to ustekinumab
Necrobiosis lipoidica is a chronic granulomatous disease of unknown etiopathogenesis, which is often difficult to treat. While data from randomized controlled trials for the treatment of necrobiosis lipoidica is lacking, several treatments of varying efficacy for necrobiosis lipoidica have been reported in the scientific literature. We present a case of a 29-year-old female with uncontrolled diabetes and treatment-resistant necrobiosis lipoidica which was responsive to ustekinumab.
Naltrexone is a competitive antagonist of μ, κ and γ opioid receptors, used for treatment of alcoholism and opioid addiction. Low-dose naltrexone (LDN) is defined as daily doses ranging from 1mg to 5mg. This is purported to have a paradoxical effect that leads to an increase in endogenous opioids, including beta-endorphins, which have anti-inflammatory properties. Theses mechanisms may also justify their possible role in the treatment of inflammatory conditions. The aim of this article is to discuss the use of LDN as an adjuvant therapeutic option in symptomatic alopecias presenting with trichodynia. Trichodynia is defined as scalp discomfort of variable intensity presenting as diffuse or localized dysesthesia and may be described by patients as pain, pruritus, or burning. These are common symptoms in patients with hair loss that negatively impacts quality of life. Scalp discomfort may be refractory to conventional therapies and does not yet have a specific therapeutic guideline. For these cases, LDN would be a possible alternative to be added to the therapeutic arsenal owing to its anti-inflammatory properties, analgesic potential, low cost, and few adverse effects described. Further studies are needed to standardize dosing, better understand its mechanism of action, and evaluate its potential therapeutic indications.
Injections of botulinum toxin type A represent the most common nonsurgical cosmetic treatment worldwide. The authors report a case of dynamic horizontal wrinkling in the upper lip that appeared after botulinum toxin type A injections to treat gummy smile associated with nasal alar base reduction, in a 28-year-old woman. The anatomic features and pathogenic mechanism underlying this unusual complication are analyzed and discussed.
Folliculitis decalvans is a rare scarring alopecia that presents with indurated, tender pustules and papules on the vertex and occipital scalp. Although systemic antibiotics with activity against Staphylococcus species provide some symptomatic improvement, folliculitis decalvans remains a significant management challenge and often exhibits a relapsing-and-remitting course. In this report, we posit the potential utility of medical grade honey as a safe and cost-effective adjuvant therapy in the treatment of folliculitis decalvans. We describe a patient with painful, boggy scalp pustules who achieved clearance of his scalp lesions with the addition of Manuka honey. To our knowledge, this report is the first to demonstrate the clinical use of honey in the management of folliculitis decalvans and may lend support to the role of Staphylococcus in the pathogenesis of this disease.
Advertisement for Assistant/Associate/Full ClinX/HSCP (4 Positions) UC Davis School of Medicine, Department of Dermatology
The University of California, Davis, School of Medicine, Department of Dermatology, is recruiting for four academic dermatologists in the Clinical X series or Health Sciences Clinical Professor (HSCP) series at the Assistant/Associate/Full Professor level based on experience and qualifications. These positions are for general medical dermatologists. The appointments may be made up to 100%.
Candidates must possess an MD or MD/PhD, can be board eligible, but must be board-certified in dermatology at the time of starting employment and must be eligible for medical licensure in the State of California.
• Successful completion of an approved dermatology residency training program (ACGME accredited)
• Demonstrated proficiency in the teaching of students and housestaff
• Service including committees, leadership ability, and community outreach
• Ability to work cooperatively and collegially within a diverse environment
• Ability to adhere to policies and procedures, and leadership experience and abilities
• Selected candidates will be expected to participate in clinical care, teaching, research and university service
Subspecialty expertise or experience in the following areas of dermatology are not required but would be preferred: hidradenitis suppurativa, cosmetic dermatology, melanoma and atopic dermatitis.
For first consideration, applications should be received by September 15, 2019; however, the positions will be open until filled through December 17, 2019. The following information is required: Cover Letter, Curriculum Vitae, contact information for at least 3 references and Statement of Contributions to Diversity. Please visit http://academicaffairs.ucdavis.edu/diversity/equity_inclusion/index.html for information about why diversity statements are requested and guidelines for writing a diversity statement. Please upload this information and apply online at https://recruit.ucdavis.edu/apply/JPF02549.
The positions are located in Sacramento, California. The Department of Dermatology (http://www.ucdmc.ucdavis.edu/dermatology) is a major clinical care, research, and teaching department in the School of Medicine. Our faculty are engaged in multiple collaborations with other Schools and UC Davis campus departments, research centers, clinical centers, and primary care networks, and thus all positions require flexibility in local job locations in addition to the Department of Dermatology. This includes the Veteran's Administration, UCD Medical Center Campus, and other community centers.
UC Davis commits to inclusion excellence by advancing equity, diversity and inclusion in all that we do. We are an Affirmative Action/Equal Opportunity employer, and particularly encourage applications from members of historically underrepresented racial/ethnic groups, women, individuals with disabilities, veterans, LGBTQ community members, and others who demonstrate the ability to help us achieve our vision of a diverse and inclusive community. For the complete University of California nondiscrimination and affirmative action policy, see: http://policy.ucop.edu/doc/4000376/NondiscrimAffirmAct. If you need accommodation due to a disability, please contact the recruiting department.
Under Federal law, the University of California may employ only individuals who are legally able to work in the United States as established by providing documents as specified in the Immigration Reform and Control Act of 1986. Certain UCSC positions funded by federal contracts or sub-contracts require the selected candidates to pass an E-Verify check. More information is available at http://www.uscis.gov/e-verify.
UC Davis is a smoke & tobacco-free campus (http://breathefree.ucdavis.edu).