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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 26, Issue 3, 2020


Reflectance confocal microscopy for the diagnosis of skin infections and infestations

Reflectance confocal microscopy (RCM) is a noninvasive real-time imaging technique that has been widely used for the diagnosis of skin cancer. More recently, it has been reported as a useful tool for the diagnosis and management of several inflammatory and infectious skin disorders. This article provides an overview of the current available applications of RCM use in cutaneous infections and infestations. PubMed was used to search the following terms in various combinations: reflectance confocal microscopy, skin, hair, nail, infection, parasitosis, mycosis, virus, bacteria. All papers were accordingly reviewed. In most cutaneous infections or infestations, the main alterations are found in the epidermis and upper dermis, where the accuracy of confocal microscopy is nearly similar to that of histopathology. The high resolution of this technique allows the visualization of most skin parasites, fungi, and a few bacteria. Although viruses cannot be identified because of their small size, viral cytopathic effects can be observed on keratinocytes. In addition, RCM can be used to monitor the response to treatment, thereby reducing unnecessary treatments.

A review of intralesional wart therapy

Background: New treatment options for warts include intralesional wart injection with agents such as vitamin D, measles, mumps, and rubella (MMR) vaccine antigen, Bacillus Calmette-Guerin (BCG) antigen, and candida antigen but there have been limited studies to compare their efficacies. Objective: The purpose of this systematic review is to compare the efficacy and safety of injectable agents used for the treatment of warts.Methods: A PubMed search included terms “intralesional wart therapy,” “wart injection” and “verruca injection.” Articles reviewed were published over 10 years.Results: A total of 43 articles were reviewed; 30 covered studies with more than 10 participants and 13 were case reports, case series, and reviews. In comparison studies intralesional agents have equal or superior efficacy (66%-94.9%) compared to first-line salicylic acid or cryotherapy (65.5-76.5%). One advantage of intralesional injections is the rate of complete resolution of distant warts.Limitations: Each study varied in their agents, treatment interval, and treatment dose, making comparisons difficult.Conclusions: Intralesional wart injections are safe, affordable, and efficacious treatments for warts. Physicians should consider intralesional injections for patients with refractory warts, multiple warts, or warts in sensitive areas.

A review of non-pharmacologic approaches to enhance the patient experience in dermatologic surgery

Efforts to increase patient comfort by minimizing pain and anxiety have been shown to improve clinical outcomes, reduce pain thresholds, decrease analgesic requirements and complication risk, strengthen the physician-patient relationship, and increase overall patient satisfaction. Patients also have a strong preference for patient-centered communication and educational discussion with physicians. In recent years, the increasing emphasis on patient experience scores as a metric for quality care has had significant implications for physician practice and has reinforced attempts to provide more patient-centered care. Though different pharmacologic agents and techniques have been extensively reviewed in the dermatologic literature, there have been few studies of non-pharmacologic strategies for improving patient-centered care. This evidence-based review describes alternative techniques that have been suggested for use in dermatologic surgery. Mechanoanesthesia, cold therapy, verbal and audiovisual distraction, music, optimal needle insertion methods, hypnosis and guided-imagery, perioperative communication, and educational strategies have been reported to improve the patient experience in dermatologic surgery. These interventions are often cost-effective and easy to implement, avoid medication side effects, and serve as adjunct approaches to enhance patient comfort. This review examines the corresponding evidence for these nonpharmacologic strategies to provide a clinical resource for the dermatologic surgeon seeking to optimize the patient experience.


Utilization of Facebook for support and education by patients with skin cancer

The expanding role of social media in medical care has resulted in dermatology patients seeking support online regarding personal experience with diagnosis and treatment of skin cancer. Owing to increased privacy settings in closed Facebook groups, the current study analyzed themes of keratinocyte carcinoma patients’ posts within a relatively private social media network. Although the majority of messages included sharing personal experience and provided psychosocial support (50%), there were a significant number of posts offering medical advice (35%), with the majority of such replies being unsupported by evidence-based medicine (87%). The level of medical misinformation and potential harm to patients seeking advice online is important for medical practitioners treating skin cancer and provides impetus for possible further research into online support and education groups that are moderated for misinformation.


Squamous cell carcinoma of the dorsal hands and feet after repeated exposure to ultraviolet nail lamps

Gel nails are a common artificial nail option. Ultraviolet (UV) nail lamps are commonly used to cure gel nails. Ultraviolet A radiation is a known mutagen that penetrates into the nail bed. Although previously reported, the role of UV nail lamps in the carcinogenesis of both keratinocyte carcinoma and melanoma remains controversial. Herein, we report a patient taking the photosensitizing agent hydrochlorothiazide who developed numerous squamous cell carcinomas on the dorsal hands and feet with a 10-year history of UV nail light exposure every 2-3 weeks.

Public social media consultations for dermatologic conditions: an online survey

The use of social media in medicine has been increasingly studied in recent years, especially concerning its role in patient outreach, education, diagnosis, and management. Dermatology is a unique field in that patients can post photographs of their skin ailments when seeking online medical advice and information. This study examines the role of public social media consultations for dermatologic conditions. A large portion of patients utilize social media for dermatologic consultations and many do not seek care from a dermatologist afterward. Future studies should trend this phenomenon, especially as the use of social media continues to expand.

Publication rates on the topic of racial and ethnic diversity in dermatology versus other specialties

Background: The population of the U.S. is becoming more diverse every year. The field of dermatology is not following the same trend. Objective: To assess the promotion of diversity in the field of dermatology by analyzing publications focused on diversity, compared to other specialties. Methods: The PubMed database was systematically searched to identify publications focused on diversity from January 2008 to July 2019. The search criteria were as follows: dermatology/radiology/ophthalmology/ anesthesiology/orthopedic surgery/family medicine/ internal medicine/general surgery AND diversity/ diverse/racial/race/ethnic/ethnicity/cultural/culture/competency/competence. Comparisons were made using single-factor ANOVA and two-group t-tests. A qualitative analysis was performed for publications in the field of dermatology. Results: From January 2016 to July 2019, there were 25 publications focused on diversity in dermatology (Mean=6.25, SD=2.06), compared to 6 in radiology (Mean=1.50, SD=1.29, P=0.01), two in ophthalmology (Mean=0.50, SD=0.58, P=0.01), two in anesthesiology (Mean=0.50, SD=1.00, P=0.01), 12 in orthopedic surgery (Mean=3.00, SD=1.41, P=0.04), 23 in family medicine (Mean=5.75, SD=2.22, P=0.75), 9 in internal medicine (Mean=2.25, SD=1.71, P=0.02), and 7 in general surgery (Mean=1.75, SD=0.50, P=0.02). Conclusions: Although the field of dermatology has suffered from a lack of racial/ethnic diversity, efforts to promote diversity via increased publications in the last four years have been stronger in dermatology compared to many other fields.

Analyzing China’s contributions to major dermatologic journals from the past 20 years

Background: Over the past 20 years, China has experienced an increased popularity of Western medicine. The impact of Western medicine in China on the field of dermatology is not well characterized. Objective: To assess the impact China has had on the field of dermatology by analyzing the total publications to six dermatological journals, compared to two other Asian countries: Japan and Korea. Methods: PubMed was utilized to search for publications from China, Japan, and Korea within the past 20 years. Descriptive statistics were used to determine the average percentage change in publications during this 20-year period, and the average annual increase in total number of publications from each country. Comparisons were made using one-way ANOVA and two-group t-tests. Results: From 1998 to 2019, there was a 24% average annual increase in publications from China (M=24.4, SD=24.5), compared to a 6% increase from Japan (M=5.6, SD=25.4, P=0.02) and 8% increase from Korea (M=7.8, SD=23.4, P=0.03). Conclusion: For the past 20 years, there has been a strong positive trend regarding the total number of publications from China. This finding might be related in part to an increased acceptance of Western medicine, which follows a similar trend during the time period we analyzed.

Case Report

A case of new-onset vitiligo in a patient on tofacitinib and brief review of paradoxical presentations with other novel targeted therapies

With recent advancements in the understanding of vitiligo pathogenesis, Janus kinase (JAK) inhibitors have emerged as a promising new treatment modality, but their effects remain incompletely elucidated. Tofacitinib, an oral JAK 1/3 inhibitor approved for the treatment of rheumatoid arthritis, has previously been shown to induce significant re-pigmentation in vitiligo. However, as with other novel targeted therapies, cutaneous adverse effects have been observed. We report a 36-year-old woman with a history of rheumatoid arthritis, refractory to multiple pharmacotherapies, who was initiated on tofacitinib and subsequently developed progressive depigmented patches consistent with new-onset vitiligo. Although definitive causation cannot be established in this case without additional studies, it is important to note that many targeted therapies have the potential to induce paradoxical effects, that is, the occurrence or exacerbation of pathologic conditions that have been shown to respond to these medications. Paradoxical findings with other targeted therapies include the occurrence of melanoma during treatment with BRAF inhibitors, keratoacanthomas with PD-1 inhibitors, vitiligo and psoriasis with TNF-alpha inhibitors, and hidradenitis suppurativa with various biologic agents. Although JAK inhibitors hold therapeutic promise in the treatment of inflammatory skin disorders, further research is warranted to more fully comprehend their effects.

A lumpy back: extensive cutaneous collagenomas

A widespread form of eruptive collagenomas in a 12-year-old man is presented for the impressive iconography, challenging differential diagnosis, and histopathological considerations associated with such rare connective tissue disorders. Syndromic forms should be carefully investigated for the different course and prognosis. Treatment is a major unsolved issue as aesthetic concerns are significant, especially in young adults.

Case Presentation

Nuclear matrix protein 2 antibody-positive adult dermatomyositis: a case report and review of the literature

Dermatomyositis is a clinically heterogenous inflammatory myopathy with unique cutaneous features. Myositis-specific antibodies can aid in diagnosis and anticipation of patient prognosis. Herein, we report a 22-year-old man who presented with multifocal erythematous plaques with violaceous papules on his bilateral elbows, neck, and face. He was diagnosed with biopsy-proven dermatomyositis and determined to be seropositive for nuclear matrix protein 2 antibody (NXP-2). He was treated with systemic corticosteroids, then intravenous methylprednisolone and azathioprine, and ultimately achieved greatest treatment response with intravenous immune globulin therapy.

Lichenoid inflammation of DSAP lesions following treatment with durvalumab, olaparib and paclitaxel: A potential diagnostic pitfall mimicking lichenoid drug eruptions associated with PDL-1 inhibitors

Disseminated superficial actinic porokeratosis (DSAP) is an uncommon skin condition that can be inherited or may occur sporadically with multiple red-brown, thin plaques in a photodistribution. The condition more often affects middle-aged women and is often recalcitrant to therapy. In rare literature reports, systemic medications can trigger exacerbation or promote inflammation in pre-existing lesions of DSAP. We present a novel case of chemotherapy-associated DSAP inflammation in a 66-year-old woman after triple therapy with durvalumab (PD-L1 inhibitor), olaparib (PARP inhibitor) and paclitaxel, showing similarities to primary lichen planus-like eruption from immune checkpoint inhibitors.

Sweet syndrome with pulmonary involvement in a patient with myelodysplastic syndrome

We report a patient with Sweet syndrome involving the pulmonary system in the context of myelodysplastic syndrome. Although Sweet syndrome may involve a variety of organ systems, the pulmonary system is rarely affected and can result in poor clinical outcomes, including acute respiratory distress syndrome. Both cutaneous and pulmonary symptoms respond well to systemic corticosteroid therapy and early diagnosis and treatment can improve the prognosis. Our case highlights the importance of collaboration between hematologists, dermatologists, and pulmonologists to facilitate effective diagnosis, triage, and treatment of these patients.

Photo Vignette

Eosinophilic dermatosis of hematologic malignancy: a case report

Eosinophilic dermatosis of hematologic malignancy (EDHM) is a dermatosis characterized by tissue eosinophilia that has been previously reported as insect bite-like reaction. It is a rare condition with a wide variety of clinical presentations ranging from papules, nodules, or blisters that simulate arthropod bites, to the formation of plaques of differing sizes. We report a case of eosinophilic dermatosis of hematologic malignancy in a patient with a hematoproliferative disorder.

Unusual case of Paget disease of the nipple diagnosed by nipple scraping cytology

Paget disease of the nipple is a rare presentation of breast cancer. It is sometimes mistaken for a benign skin condition of the nipple and surrounding areola, which can significantly delay the diagnosis and treatment. In over 90% of cases there is an underlying carcinoma, either ductal carcinoma in situ (DCIS) or invasive breast cancer. We present a rare case of Paget disease of the nipple without the typical characteristics, detected by simple nipple scraping technique. A 62-year-old woman presented with a small fissure on the left nipple with scant clear nipple discharge. There were no other changes to the nipple-areola complex. The mammography and ultrasound were unremarkable. However, nipple scraping provided the immediate cytological diagnosis of Paget disease. Breast MRI with core biopsy showed high grade ductal carcinoma in situ with suggestion of microinvasion, confirmed histologically after mastectomy. Nipple scraping is a simple and inexpensive technique, which can be used in the office without anesthesia and with minimal discomfort to the patient. It could allow for significantly earlier cancer detection and treatment at the earliest stage of breast cancer. However, if the results are negative, full thickness biopsy may be needed if clinically indicated.


A case of resistant pityriasis ribra pilaris responsive to combination acitrentin and ustekinumab

Pityriasis rubra pilaris is a rare psoriasiform dermatitis. Treatment has been adopted from psoriasis protocols, with topical corticosteroids and systemic retinoids as first-line agents, followed by escalation to biologics for recalcitrant disease. We report a patient with resistant pityriasis rubra pilaris who dramatically improved with acitretin and ustekinumab, a combination not well documented in the literature. The purpose of this letter is to emphasize the potential benefit of dual therapy in patients who fail traditional pityriasis rubra pilaris treatment regimens.

Women’s representation at an academic dermatology conference: trending upwards, but not equal yet

Although women make up a significant portion of the workforce in dermatology, they remain underrepresented in academia. This study investigates the number of male and female symposium speakers at the American Academy of Dermatology annual meetings over a three-year period and compares research productivity and academic rank between the men and women invited to speak. The results demonstrate a steady increase in the representation of female symposium speakers at the conference from 2016 to 2018, although a higher proportion of invited male speakers hold professorships and leadership positions. This upward trend in women's representation may translate to more opportunities for female engagement in academic dermatology. Although women make up over 60% of residents in dermatology, they are not proportionally represented in this conference sample. This imbalance in representation demonstrates that further interventions to increase the representation of female professors and chairs may be necessary.

Successful non-operative treatment of eruptive keratoacanthomas refractory to excision

Keratoacanthomas are rapidly growing neoplasms of squamous epithelium. Despite their benign nature, they are often difficult to distinguish from squamous cell carcinoma and require excision. In cases in which excision is not successful or not desired, intralesional treatments may be considered. However, limited research exists on individual therapeutic efficacy. We present a 68-year-old man who developed multiple eruptive keratoacanthomas around the wound edge of a previous keratoacanthoma excision. Considering previous excisional failure, intralesional 5-fluorouracil was used as a treatment modality. Injections every 3-4 weeks over a course of 12 weeks induced clinical keratoacanthoma clearance with excellent cosmetic results. This case showcases that weekly intralesional 5-fluorouracil injections, as was the standard mode of treatment in previous case reports, may not be necessary. This less frequent injection strategy is more convenient for the patient and may lead to fewer treatments and less medication necessary. Although a case-by-case basis is needed for any alternative approach to keratoacanthoma treatment, this report is useful for the practicing clinician in showing that 5-fluorouracil may be efficacious in these difficult-to-treat patients.


Corrigendum: Thiotepa hyperpigmentation preceding epidermal necrosis: malignant intertrigo misdiagnosed as Stevens-Johnson syndrome-toxic epidermal necrolysis overlap

The original article was published on February 15, 2020 and corrected on March 15, 2020.The revised version of the article corrects the contact information of the Corresponding Author. The changes appear in the revised online PDF copy of this article.