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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 5, 2021


Mental health outcomes in White patients versus patients with skin of color with psoriasis

Objective: To evaluate the relationship between psoriasis and mental health in patients from different racial backgrounds. Methods: We performed a nationwide, cross-sectional study evaluating 7,519,662 (weighted) patients, comparing White patients versus patients with skin of color (SOC), using the 2004-2017 Medical Expenditure Panel Survey (MEPS). Results: Psychological distress (measured by Kessler 6-Item Psychological Distress Scale) was similar between White and SOC patients (4.132 [95% CI,3.679-4.586] and 3.710 [95% CI,2.932-4.488], P=0.407). Depression (measured by Patient Health Questionnaire 2) was similar between White and SOC patients (0.886 [95% CI,0.744-1.027] and 0.748 [95% CI,0.506-0.989], P=0.385). Overall mental health (measured by Mental Component Summary) was similar between White and SOC patients (49.959 [95% CI,48.979-50.939] and 50.257 [95% CI,48.449-52.065], P=0.789). Perceived mental health state (measured by Perceived Mental Health Status) was similar between White and SOC patients (2.159 [95% CI,2.065-2.253] and 2.103 [95% CI,1.911-2.294], P=0.603). Conclusion: There were no significant differences in mental health outcome scores between White and SOC patients with psoriasis. Clinicians should screen for and manage mental health comorbidities in psoriasis patients of all racial backgrounds.

Rural melanoma patients in Maryland do not present with more advanced disease than urban patients

Purpose: Rural populations have higher poverty rates, lower educational attainment, higher smoking rates, lower rates of health insurance, higher proportions of elderly individuals, decreased access to health services including dermatology, higher all-cause mortality, and higher mortality from melanoma. Despite these disparities, rural patients have not been adequately studied within the dermatologic literature, particularly at geographic units smaller than the county level. Methods: We used zip codes and Rural Urban Commuting Area (RUCA) codes to conduct a cross-sectional study on the prevalence and severity of melanoma among 31,750 rural versus urban patients treated by the Johns Hopkins Department of Dermatology from January, 2016 to June, 2017. Results: Compared to urban patients, rural patients had a 2.6 times higher melanoma prevalence (P<0.0001), travelled much greater distances for treatment (101.8 miles versus 17.7 miles, P<0.0001), and lived in zip codes with median household incomes $18,188 lower ($58,718 versus $76,906; P=0.0040). However, there were no significant differences in Breslow depth or clinical stage between rural and urban patients. Conclusions: Despite having a higher prevalence of melanoma and travelling much greater distances to receive care, rural patients did not present with more advanced disease than their urban counterparts.


Practitioner assessment of mental health in dermatologic disease

Patients with certain dermatologic skin diseases have been found to be at increased risk for depression and suicidal ideation. As there is not much information available on mental health interventions taken in dermatologic practices, we conducted a survey to assess the extent to which dermatologists monitor and follow up with the mental health of their patients. We discovered that dermatologists are aware of mental health issues associated with these dermatologic diseases but have no standard of care for their assessment. By obtaining this information, we can enable ourselves to fill in these deficiencies to help improve patient care.

Sun protection behaviors among people living with HIV

People living with HIV (PLWH) are at increased risk for both melanoma and nonmelanoma skin cancers, but there is currently no data on sun protection behaviors among PLWH. We created a 28-question paper survey to collect information on patient demographics and sun protection behaviors among PLWH. We found that although 71.6% of respondents reported spending at least 30 minutes to two hours in the sun daily, only 29.7% reported consistent use of sunscreen. In addition, 41.9% rarely or never received sunscreen counseling by their healthcare providers. There is therefore a need for increased training for healthcare providers in sun protection behavior counseling for PLWH.

The effect of physician appearance on patient perceptions of treatment plans

The presentation of a physician's clothing and themselves is an important part of the physician-patient interaction. Physician attire can impact patient satisfaction and trust in their physician. We sought to discover the influence physician attire may have on patients' comfort level with proposed treatment plans, which could influence treatment adherence. We surveyed 495 subjects to better understand the relationship between physician attire and patients' perceptions of treatment plans. We found subjects' comfort level in proposed treatment plans was not significantly affected by physician attire. This finding suggests physician attire may not be as important when considering the potential effect on treatment adherence.

Case Presentation

Alopecia areata in a patient with WNT10A heterozygous ectodermal dysplasia

We report a case of a patient with ectodermal dysplasia attributed to a heterozygous 321C>A mutation in WNT10A who developed overlying autoimmune mediated hair loss. To the best of our knowledge this is the first reported case of alopecia areata in a patient with WNT10A heterozygous ectodermal dysplasia. This case highlights the importance of considering multiple pathways of hair loss in patients with underlying genetic defects and raises the possibility of a shared genetic predisposition.

Subcutaneous metastasis from an atypical pulmonary carcinoid tumor

Pulmonary carcinoid tumors are uncommon neuroendocrine tumors that rarely metastasize to the skin. We report the case of a 71-year-old woman with a longstanding history of primary atypical pulmonary carcinoid tumor who presented with a new tender cutaneous nodule. Immunostaining of the nodule was consistent with metastatic atypical carcinoid tumor of the skin including positive staining for neuroendocrine markers chromogranin and synaptophysin. Dermatologists should consider cutaneous neuroendocrine metastasis when evaluating new nodules in patients with stable pulmonary carcinoid tumors or in those with concomitant concerning respiratory symptoms.

An unusual case of multiple grouped non-familial trichoepitheliomas

Trichoepitheliomas (TEs) are benign and rare adnexal hamartomas of the pilosebaceous units. Trichoepitheliomas could occur in the setting of an underlying genetic disorder with multiple TEs or as solitary non-hereditary TEs. We report a healthy 32-year-old woman with sporadic multiple clustered and non-segmental TEs without positive family history. There have been two other cases reported in the literature that had non-familial multiple TEs, one was facially disfiguring and the other was in a segmental pattern. Our case has been the only one reported in the English literature which has sporadic, multiple TEs clustered unilaterally and non-segmentally on the trunk.

Gefitinib-associated lichen planus pigmentosus-like eruption

The epidermal growth factor receptor (EGFR) signaling pathway is one of the oncogenic pathways in non-small cell lung cancer. Gefitinib is classified as a first-generation EGFR-tyrosine kinase inhibitor (TKI). A variety of cutaneous adverse effects related to the drug has been reported. Cutaneous hyperpigmentation is a rare side effect of EGFR inhibitor (EGFRi). Herein, we report a 62-year-old woman with non-small cell lung carcinoma who presented with symmetrical, slate-gray-to-brownish-black macular pigmentation on sun-exposed and non-sun-exposed areas after eight months of gefitinib administration. The clinical features were consistent with lichen planus pigmentosus. This case highlights the unusual hyperpigmented condition occurring in patients taking EGFR-TKIs.

Granular cell tumor: importance of histopathology in determining malignant potential

Granular cell tumors (GCTs), sometimes called Abrikossoff tumors, are rare and typically benign soft tissue tumors. Malignant GCTs, which are even rarer than benign GCTs, can occur and must be detected early given their high mortality rate. Distinguishing between benign and malignant GCTs is difficult clinically; however, histologic evaluation plays an essential role in this endeavor.

Interstitial granuloma annulare triggered by Lyme disease

Granuloma annulare is a non-infectious granulomatous skin condition with multiple different associations. We present a case of a man in his 60s with a three-week history of progressive targetoid plaques on his arms, legs, and trunk. Skin biopsy demonstrated interstitial granuloma annulare. Additional testing revealed IgM antibodies to Borrelia burgdorferi on western blot suggesting interstitial granuloma annulare was precipitated by the recent infection. Lyme disease is an uncommonly reported association with interstitial granuloma annulare.

Combined carvedilol and gabapentin treatment induces a rapid response in red scrotum syndrome

Red scrotum syndrome (RSS) is a rare dermatologic condition characterized by persistent erythema and analgesia of the male genitalia that cannot be attributed to contact or atopic dermatitis or acute or chronic infections. Treatment of RSS is challenging since it often fails to respond to corticosteroids, antifungals, antivirals, and antibiotics. Several reports described RSS patients who responded to gabapentin, pregabalin, and ?-adrenergic receptor blockers, suggesting a neuropathic etiology. Here we present a refractory RSS case with rapid clinical improvement on a combined carvedilol plus gabapentin therapy. We suggest that RSS manifestations are driven by neurogenic inflammation and that the efficacy of gabapentin/carvedilol relates to the suppression of the neuro-immuno-epidermal axis.

A solitary lesion of idiopathic calcinosis cutis in an infant: subepidermal nodular calcinosis or milia-like idiopathic calcinosis cutis?

Milia-like idiopathic calcinosis cutis (MICC) and subepidermal calcified nodule (SCN) are described as different entities under the heading of idiopathic calcinosis cutis. Although there are some clinical differences, they share many features. Whereas MICC lesions are located mostly on the extremities and rarely on the face, SCN manifests itself mostly on the face, rarely on the extremities. Milia-like idiopathic calcinosis cutis almost always presents with multiple lesions, whereas SCN shows mainly solitary and rarely multiple lesions. Association with Down syndrome (DS) has been reported in up to two-third of the cases with MICC, but not in SCN. We herein present a 5-months-old girl without DS, manifesting a 2mm solitary, white hard papule surrounded by erythema, located on the finger. Histopathologic findings revealed the presence of dermal calcium deposits. When a solitary papular lesion of idiopathic calcinosis is seen in a child, especially if not associated with DS, it is difficult to differentiate MICC from SCN. We believe that these entities may represent variants of the same pathology and it may be more appropriate to designate a solitary lesion as SCN, regardless of its location.

Photo Vignette

Adenoma of the nipple: a mimic of breast malignancy

Adenoma of the nipple is a very uncommon benign neoplasm of lactiferous ducts. Its clinical presentation is variable and it can be easily misdiagnosed as a malignancy such as mammary Paget disease or breast intraductal carcinoma. Although dermoscopy and imaging tests such as ultrasonography or mammography can be of help, histological examination is mandatory to confirm the diagnosis. We describe the clinical, dermoscopic, and histopathological findings in a patient with nipple adenoma and discuss the clinical and histological differential diagnosis as well as the different treatment options.

Giant chondroid syringoma on the upper lip: a case report

Chondroid syringoma is a benign, rare, asymptomatic, slow-growing mixed tumor. Tumors larger than 3cm are considered giant and may be malignant. We present a 65-year-old man with a chronic, indolent, subcutaneous tumor with upper lip deformity. An excisional biopsy was performed under local anesthesia. Based on histopathological analysis, the resected lesion was identified as a chondroid syringoma of the apocrine type. There was no recurrence during the one-year follow-up after surgery. The occurrence of a large chondroid syringoma in the upper lip is rare.

Bullous eosinophilic annular erythema

Eosinophilic annular erythema is an idiopathic acute eosinophilic dermatosis. It is a rare condition, with approximately 30 cases reported in the English literature. It features annular, figurate urticarial edematous plaques primarily affecting the trunk and proximal limbs. During evaluation of a patient, secondary causes of eosinophilic inflammation such as allergy-related conditions (eczema, drug, urticaria, contact dermatitis), parasitic infestations, and autoimmune dermatoses will need to be excluded. We present an unusual case of a 47-year-old patient who developed this condition.

Plica neuropathica in severe reactive depression: clinical and trichoscopic features

Plica neuropathica (PN), also known as plica polonica, felting, matting or bird's nest hair, is an acquired hair condition in which hair becomes twisted, leading to the formation of a compact mass. Psychiatric disorders are an important etiologic factor for PN. We report a case of PN in a woman with severe reactive depression and present the trichoscopic findings.

Perniosis in the COVID-19 era

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) and the most common symptoms include fever, dry cough, dyspnea, fatigue, anorexia, ageusia, and anosmia. Cutaneous manifestations are less common and we share our experience with an otherwise healthy and asymptomatic young man. The patient presented with painless acrocynosis of the left toes which progressed to desquamation by day 16 of disease onset. Disease progression is documented via multiple photographs that portray progression of disease and subsequent resolution over approximately six weeks. Symptomatic treatment included non-steroidal anti-inflammatory medications, leg elevation, and warm compresses.