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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 27, Issue 4, 2021


The effect of gluten on skin and hair: a systematic review

Non-celiac gluten sensitivity is often clinically indistinguishable from celiac disease, and patients show improvement or resolution of their symptoms with a gluten-free diet. In contrast to celiac disease, the effects of gluten on the skin and hair in the context of non-celiac gluten sensitivity are not as clear. This review aims to describe the impact of gluten on the skin and hair in patients with non-celiac gluten sensitivity and those without a definitive celiac disease diagnosis. A literature search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) reporting guidelines for systematic reviews. Forty-two publications met inclusion criteria with five studies describing the skin manifestations of non-celiac gluten sensitivity. Trials identifying the impact of a gluten-free diet on skin disease, as well as dermatologic conditions and their associations with antigliadin antibodies were also identified. Dermatologic manifestations in patients with non-celiac gluten sensitivity vary and may be non-specific. It may be appropriate for some of these patients with skin manifestations to trial a gluten-free diet. Dermatologic conditions that may respond positively to a gluten-free diet include psoriasis, atopic dermatitis, vitiligo, and palmoplantar pustulosis, while linear IgA disease does not appear to improve with this dietary change.


Semi-automated total body photography supports robust delivery of skin cancer monitoring services during the SARS-COV2/COVID-19 pandemic

Background: The SARS-CoV-2/COVID-19 pandemic dramatically impacted the delivery of healthcare, including dermatological services. In the initial stages of the pandemic, reduced patient flow produced a dramatic drop in the volume of skin cancer screening. Consistent with COVID-19 precautions, our practice conducted visual skin examinations (VSE) utilizing semi-automated total body photography (TBP). Methods: A cross-sectional study of patient characteristics and self-reported melanoma risk factors associated with TBP usage was conducted on all patients from May to November 2020 in a single practitioner private dermatology setting. The process and histopathology-confirmed outcomes were compared to those in the same 6-month period in 2019. Results: For the May-November 2020 timeframe, those who opted for the home TBP (35%) compared to clinic TBP were younger, had higher self-reported skin cancer risk, and were more likely to have had previous TBP sessions. Overall, the number of TBP sessions increased, while dermoscopy usage and biopsy number decreased. There was no change in the number and distribution of skin cancer diagnoses compared to the same period in 2019. The Melanoma-In-Situ:Invasive Melanoma (MIS:INV) ratio was above the U.S. ratio reported for 2020 of 0.95:1 (95,710 MIS:100,350 INV). Conclusion: Semi-automated TBP was successfully implemented during the pandemic without affecting skin cancer detection.

Sunburn frequency and risk and protective factors: a cross-sectional survey

Skin cancer prevention is at the forefront of public health as morbidity increases. Limited data exists on effective interventions to reduce sunburn frequency and modifiable risk factors. This research aims to determine an association between 1) demographic characteristics and outdoor sunburn frequency, and 2) sunburn frequency and sun-related risk and protective factors in a nationally representative, cross-sectional household survey. Of 23,430 surveys sent, 4,883 respondents reported sunburn-related data. Association between sunburns and demographic, risk, and protective factors were examined. When assessing demographic factors, potential confounding was addressed using multivariable analysis. In multivariable models, younger, non-Hispanic White respondents were more likely to report sunburn. Those with higher income were more likely to report any sunburn, but less likely to sunburn frequently. Females were less likely to report frequent sunburns. Engagement in sporting events, outdoor events, and day-to-day activities during the most recent sunburn was more commonly reported by those with frequent sunburns as compared with those with infrequent sunburns. Sun-protection interventions targeting higher-risk demographics during time spent outdoors, at sporting events, and during other day-to-day activities may be beneficial. Further insight into risk and protective behaviors for those who did not burn could be useful to guide public health interventions.


Teledermatology after COVID-19: key challenges ahead

Teledermatology has been leveraged during the COVID-19 pandemic as a means of adopting novel ways to treat patients while reducing the risk of viral transmission. Although teledermatology offers benefits related to patient convenience and improved access to care, key challenges in the areas of reimbursement, licensure, and diagnostic accuracy remain. In this commentary, we discuss these three obstacles and potential solutions.

Case Report

Subcorneal pustular dermatosis associated with IgG monoclonal gammopathy of undetermined significance

Subcorneal pustular dermatosis is a rare chronic relapsing bullous neutrophilic dermatosis. Because it can be associated with monoclonal gammopathy of undetermined significance and multiple myeloma, screening for these conditions is necessary. Herein, we present a case of subcorneal pustular dermatosis, with concurrent monoclonal gammopathy of undetermined significance, successfully treated with acitretin.

Case Presentation

Anti-MDA-5 negative, anti-Ku positive clinically amyopathic dermatomyositis

We present a patient with anti-MDA5 negative, anti-Ku positive clinically amyopathic dermatomyositis (CADM). A 61-year-old woman presented with a chief complaint of a 20-year history of a pruritic rash that was active on her face, chest, hands, legs, and back. A mildly scaly, erythematous, photo-distributed eruption along with slightly violaceous, scaly papules accentuated on the wrist, metacarpophalangeal joints, proximal interphalangeal and distal interphalangeal joints. Antibody profile was significant for positive ANA and anti-dsDNA, elevated anti-TIF-1gamma (RDL)/p155, and weakly positive anti Ku. Biopsy was consistent with dermatomyositis. Melanoma differentiation-associated gene 5 antibody (anti-MDA-5) has been identified as the most commonly associated autoantibody found in CADM and is associated with poor prognosis and a biomarker for the diagnosis of rapidly progressive interstitial lung disease. To our knowledge, our patient is the first case of negative anti-MDA-5 and anti-Ku positive CADM.

Successful treatment of bullous pemphigoid with dupilumab: a case and brief review of the literature

Bullous pemphigoid is an autoimmune skin disease that results in formation of pruritic blisters. Most cases are treated with a combination of systemic and topical corticosteroids as well as other immunomodulatory drugs. Dupilumab is a fully human monoclonal antibody that acts as an antagonist against IL4Ra traditionally used in the treatment of atopic dermatitis. We present an 80-year-old man with moderate to severe bullous pemphigoid successfully treated with dupilumab.

Recurrent episodes of palpable migratory arciform erythema associated with IVIg infusions

Palpable migratory arciform erythema (PMAE) is an uncommon T cell pseudolymphoma characterized by erythematous, annular-to-arciform papules and plaques. Although the eruption is self-limited in most cases, recurrences are routine. Diagnosis requires attention to clinical history as well as histopathologic analysis, which allow for differentiation from other T cell pseudolymphomas and gyrate erythemas. A common triggering factor has not been identified. We report a 60-year-old man who developed PMAE after IVIg infusion. Interestingly, although the individual eruptions were self-limited and resolved after several weeks, subsequent infusions predictably resulted in recurrence of PMAE, confirming the association. To our knowledge, this is the first reported case of recurrent PMAE in association with IVIg infusions.

Pembrolizumab-associated pyoderma gangrenosum in a patient with metastatic squamous cell carcinoma

Pyoderma gangrenosum (PG) is a rare, ulcerative neutrophilic dermatosis that has been reported in association with certain medications. Recognition of medications that trigger PG may help to better understand the pathogenesis of the condition and to provide earlier diagnosis and treatment for affected patients. Herein, we report a case of new-onset PG following initiation of the checkpoint inhibitor pembrolizumab for the treatment of metastatic cutaneous squamous cell carcinoma. Our case was resistant to intralesional corticosteroid therapy, but ultimately improved with systemic corticosteroids and cessation of pembrolizumab.

Linear lichen planus pigmentosus of the face with histological findings of lichen planopilaris - an uncommon variant of lichen planus

Lichen planus pigmentosus and lichen planopilaris are two clinically and histologically distinct forms of lichen planus. Lichen planus pigmentosus presents with sudden onset hyperpigmented macules and patches, predominantly in darker skin phototypes. On the other hand, lichen planopilaris is a scarring follicular variant of lichen planus that presents with progressive, permanent patches of alopecia. It is not uncommon for different variants of lichen planus to clinically coexist with each other. However, to our knowledge, there has been no previous reporting of linear lichen planus pigmentosus of the face with histological features of lichen planopilaris. We herein present a hybrid case of these two entities.

Photo Vignette

Metastatic malignant melanoma in an endometrial polyp

Melanocytic metastasis to gynecologic organs is rare with most metastases to the ovaries. Metastases to the uterus, or in this case report, a uterine polyp, is exceedingly rare with only 17 cases reported in the literature. Post-menopausal bleeding is the most common presentation of metastatic melanoma in the endometrium, followed by uterine bleeding or abnormal postnatal bleeding in the premenopausal population. We present an 81-year-old woman with metastatic melanoma confined to an endometrial polyp leading to the diagnosis of widespread dissemination of the patient's acral melanoma resected 6 years prior. Although rare, metastatic melanoma should be considered as a cause for abnormal bleeding, especially in the post-menopausal patient with a history of melanoma.

Can cats cause colossal contagious cutaneous carbuncles?

Sporothrix spp. cause the most common deep fungal skin infections in Brazil and this is related to infected cats. Transmission is traditionally from organic material/plants but can also be zoonotic. Culture of a skin biopsy is the golden standard for determination. Treatment with oral itraconazole approaches up to 95% efficacy in patients with cutaneous sporotrichosis.

Granuloma annulare on the palms

We present the case of a 72-year-old man with a one-week history of a red rash on the palms of both hands. A 4mm punch biopsy revealed interstitial granulomatous inflammation within the dermis and a colloidal iron stain showed increased dermal acid mucin. Immunohistochemical staining for CD68 confirmed the presence of abundant histiocytes within the dermis. The clinical and pathological correlation was consistent with the diagnosis of interstitial granuloma annulare. Exclusive involvement of the palms is a rare presentation and serves as a reminder for practitioners to keep granuloma annulare in their differential diagnosis when observing palmar plaques.