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 27, Issue 10, 2021
Innovations in translational research in dermatology: minimally invasive methods for biosample acquisition
Translational research has improved patient care over the last decade. In dermatology, this research often requires human tissue for laboratory analysis. The skin biopsy remains the gold standard for tissue acquisition, but the procedure comes with a small risk of bleeding and infection. It also causes scarring and anxiety in certain populations. These risks and concerns may affect participation rates in translational studies, which can require multiple biopsies. Minimally invasive procedures may mitigate these risks and concerns. We queried the PubMed database for all minimally invasive technologies studied as of May 2021. Of the 53 articles reviewed, we identified 13 unique, minimally invasive methods for tissue biosample acquisition. Herein, we describe each sampling method, biosample type analyzed, disease target, molecular application, procedure, quantity of obtained biosample, purpose, and required equipment. We organize this information into a comprehensive chart. We then synthesize this information into another table that compares the pros and cons of each intervention. We found that tape stripping, suction blistering, hair plucking, microbiopsy, and microneedle patching provide a variety of useful biosample types for laboratory analysis. In translational research, these technologies have the potential to replace more invasive methods like the punch biopsy, likely improving participation in studies.
Dermatologists are more likely than oncologists to prescribe skin-directed therapies for early-stage cutaneous T-cell lymphoma: a retrospective review
Early-stage cutaneous T-cell lymphoma (CTCL) is managed effectively with skin-directed therapies such as topical medications, phototherapy, and local ionizing radiation. Patients with CTCL often seek care from both dermatologists and oncologists. Our study aimed to compare the frequency that skin-directed treatments were prescribed to patients managed by each of these specialties. Overall, we found there was a statistically detectable relationship between the presence or absence of oncologist involvement and the likelihood that a patient would be prescribed skin-directed therapies (P=0.0003). Of the oncologists included in the study, 66% opted for management revolving around systemic rather than skin-directed therapies. However, when a dermatologist and oncologist worked together in a patient's care, the number of patients receiving skin-directed therapies increased to 100%. Our study suggests that patients with early stage CTCL may benefit from having a dermatologist involved in their care.
Evaluation of clinical characteristics and pre-biopsy impressions of primary Merkel cell carcinoma of the skin
Merkel cell carcinoma is an aggressive carcinoma of the skin notable for protean presentation on physical exam. A retrospective cohort of 232 patients with primary cutaneous Merkel cell carcinoma was reviewed for availability of data on pre-biopsy clinical differential diagnosis based on clinical exam. Data was available for 192 patients (83%). The three most common impressions were cyst (33.3%), basal cell carcinoma (31.8%), and squamous cell carcinoma (19.8%). Merkel cell carcinoma was correctly suspected in only 13 cases (6.8%). A greater proportion of lesions that were less than or equal to 2 cm in diameter (10.2%) or carried BCC as a co-diagnosis (11.5%) were correctly suspected as Merkel cell carcinoma prior to biopsy, versus lesions greater than 2 cm in diameter (1.6%) or carrying SCC as a co-diagnosis (2.6%), suggesting that clinicians may be anchoring on the well-publicized concept of Merkel cell carcinoma as a small, pearly papule in real-world practice.
Teledermatology has been widely adopted during the COVID-19 pandemic as virtual patient care promotes social distancing and decreases viral exposure risk. As teledermatology has become more prominent during this period, it is essential to assess whether virtual visits allow for adequate patient care. To assess perceptions of advantages and disadvantages of teledermatology, a survey was sent to academic dermatologists through the Association of Professors of Dermatology (APD) listserv. Of the physicians surveyed, 94% reported their departments had implemented teledermatology during the COVID-19 pandemic. The majority (64%) described teledermatology as an effective tool for patient care because of improved access to care, decreased risk of COVID-19 exposure, and convenience. Frequently cited limitations of teledermatology were image quality, technical difficulties, and inability to perform a comprehensive skin examination. Thirty-seven percent of respondents reported teledermatology as a contributor to their professional burnout. Although teledermatology has become more prevalent as a result of the pandemic, its role moving forward is uncertain given its limitations.
Determinants of patient and physician treatment satisfaction in moderate-to-severe psoriasis: a multinational survey of psoriasis patients
There is a lack of validated information of both physician and patient-reported treatment satisfaction, and association with outcomes in psoriasis. Data from the 2015 Adelphi Psoriasis Disease Specific Programme were used to compare self-reported satisfaction with biologic and non-biologic therapy for psoriasis in physicians and their consulting patients in the United States (USA) and five European countries (EU5). Disease severity and health-related quality of life (HRQoL) were assessed using Body Surface Area (BSA) affected by psoriasis and the Dermatology Life Quality Index (DLQI), respectively. Patients satisfied with biologic therapy reported better HRQoL than unsatisfied patients, whereas a greater proportion of unsatisfied patients on biologic therapy had moderate-to-severe psoriasis (USA: 95.1% versus 52.4%, EU5; 86.4% versus 43.1%, P<0.0001). Multivariate logistic regression indicated that having a BSA affected by psoriasis of >10% was associated with lower likelihoods of physician and patient treatment satisfaction versus <3% (P<0.0001). A one-unit increase in the DLQI score lowered the likelihood of a patient being satisfied by approximately 20% (P<0.0001). Patients were ~60% more likely to be satisfied on biologic therapy than non-biologic therapy (P=0.0012). Physician and patient-reported treatment satisfaction was associated with greater HRQoL and lesser disease severity.
The prevalence of telogen effluvium (TE) has increased during COVID-19. In this study we describe the clinical characteristics of patients with COVID-19-related TE and review the current literature on COVID-19-associated TE. We conducted a retrospective chart review of 66 patients, all of which had COVID-19 infection (confirmed by PCR or antibodies) and had either non-scarring hair loss or TE in Elmhurst, Queens. Our data suggest that this form of TE is similar to other forms of TE, after which many patients experience regrowth within several months.
How to improve the interface between dermatology and psychiatry: a review and expert suggestion regarding the management of delusional patients
Psychodermatological problems are prevalent in dermatology practices. Among those, delusional infestation (DI) is the subject of one of the most challenging patient encounters practicing dermatologists may experience. This difficulty arises, at least partly, from the unavailability of psychiatric knowledge and skillset necessary to properly manage these patients, reflecting that most dermatology residency programs are unable to provide training in psychodermatology. This relates to the lack of faculty available with such expertise. This article reviews various suggestions made in the medical literature to try to improve this current unfortunate situation. However, the more common suggestion regarding organizing a multidisciplinary psychodermatologic clinic may be difficult to achieve as reflected by the scarcity of such clinics in the U.S. The authors offer alternative suggestions beyond the idea of organizing a multidisciplinary clinic.
Social distancing requirements associated with the COVID-19 pandemic have allowed for the expansion of different healthcare delivery modalities. Namely, there has been an increase in the utilization of remote diagnostic services for both primary and specialist care. Dermatology care has traditionally been inaccessible to many pediatric patients; this is due in part to a limited number of practicing pediatric dermatologists, as well as a maldistribution of the pediatric dermatology workforce with the majority of providers located in large metropolitan areas. There is therefore a need for an accessible alternative for care to reach underserved patient populations. This commentary highlights evidence from recent studies on remote dermatology care (teledermatology) and how it has not only improved access to dermatologic care but also quality of care. Although teledermatology does not completely replace traditional in-person visits and is limited by poor broadband access in traditionally underserved areas, teledermatology can, in some instances, be a cost-effective and efficient alternative for pediatric patients otherwise lacking dermatologic care.
Calciphylaxis: how specific are the pathological features: avoiding false-positives and false-negatives
Calciphylaxis is considered a critical inflammatory dermatosis with potentially devastating clinical consequences. Skin biopsies are expedited for evaluation and are often considered as a gold standard for diagnostic confirmation and exclusion of other conditions. The key histopathological features include a combination of vascular and extra-vascular calcifications, intravascular microthrombi, and changes related to resulting ischemia. The pathological diagnosis of calciphylaxis is not always a straightforward process as it can be influenced by a number of factors. The specificity of pathological diagnosis of calciphylaxis has been questioned and a systematic approach with multidisciplinary collaboration is required to avoid potential errors.
Report _Case Presentation _Photo Vignette _Letter Authors declare that the contents of this article are their own original unpublished findings. Title: Primary cutaneous perivascular epithelioid cell tumors: two cases and a review of the literature Authors: Jennifer Wong1 DO, Jason Mammino2 DO, Jennifer Seyffert3 DO, Kristen Schmits4 MD, Etan Marks4 MD, Daniel Rivlin3 MD Affiliations: 1Department of Dermatology, LECOM- Larkin Community Hospital, Miami, Florida, USA, 2Department of Dermatology, KCUMB - Advanced Dermatology and Cosmetic Surgery, Orlando, Florida, USA, 3Department of Dermatology, LECOM- Skin and Cancer Associates, Miami Beach, Florida, USA, 4Department of Dermatopathology Advanced Dermatology and Cosmetic Surgery Pathology Laboratory, Delray Beach, Florida, USA Corresponding Author: Jennifer Seyffert DO, 4308 Alton Road, Suite 510, Miami Beach, FL 33140, Tel: 305-674-8865, Fax: 305-674-1459, Email: firstname.lastname@example.org Abstract: Perivascular epithelioid cell tumors, also known as PEComas, are mesenchymal neoplasms which uncommonly originate within the skin, with only 23 cases documented within the literature. These rare neoplasms classically display epithelioid cells composed of granular or clear cytoplasm arranged in sheets, nests, or cords. Their immunoreactivity for melanocytic and smooth muscle markers makes these tumors distinct and unique. We herein present two cases of primary cutaneous PEComas that clinically mimic other common cutaneous neoplasms and illustrate the necessity for clinical-pathologic correlation. A literature review is also presented to compare the different clinical and histological presentations of cutaneous PEComas.
Diffuse dermal angiomatosis (DDA) is a cutaneous reactive angiomatosis. Typically presenting as ulcerated, erythematous, violaceous, or purpuric plaques on the breast or lower extremities, DDA is believed to be a reaction to tissue ischemia. Granuloma inframammary adultorum (GIA) is a type of irritant dermatitis of multifactorial etiology, clinically presenting as papules and nodules. Herein, we report an interesting rash presenting as fungiform papulonodules overlying a large violaceous plaque on the left breast. Biopsy revealed an exuberant epidermal proliferation and a diffuse and deep dermal proliferation, consisting of small slit-like blood vessels in between collagen bundles. In light of these clinical and histopathologic findings in the setting of an indurated plaque on a pendulous breast of a woman with multiple risk factors for local tissue ischemia, a diagnosis of concurrent diffuse angiomatosis of the breast (DDAB) and GIA was rendered. This case highlights the critical importance of clinicopathologic correlation in the diagnosis of multiple diagnostic entities.
Folliculosebaceous cystic hamartoma (FSCH) is a benign lesion that presents as a solitary papule or nodule that typically affects the face and scalp of adults. A few reports have observed a congenital presentation. We present an infant boy exhibiting a tumor with overlap features between an FSCH and fibrofolliculoma in the perianal region that was first noticed at 6 months of age. The histological examination showed a hamartomatous benign proliferation of hair follicles and disordered sebaceous glands, which is consistent with the infundibular structures and radiating sebaceous glands that are typically observed in previously reported cases of FSCH. Sebaceous differentiation is a hallmark feature of FSCH. Folliculosebaceous cystic hamartoma is believed to be a late-stage form of trichofolliculoma (TF). Another consideration is that FSCH and TF are two distinct entities set apart by their degree of sebaceous or follicular differentiation and development of the mesenchymal stroma.