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 6, 2021
Burnout in dermatology is on the rise, with 36% of U.S. dermatologists experiencing burnout in 2020. The coronavirus disease 2019 (COVID-19) pandemic may exacerbate this problem with healthcare workers reporting increased anxiety, depression, and insomnia. To assess the rate, severity, and causes of burnout before and during the pandemic, a survey was sent to academic dermatologists through the Association of Professors of Dermatology (APD) listserv and compared to a similar survey administered to the same population prior to the pandemic. Burnout rates have increased from 2018, with 53% of participants experiencing burnout once a week or more and 17% experiencing burnout daily during the pandemic. The most common COVID-related burnout factors involve uncertainty about the future, teledermatology, fear of exposing loved ones to COVID-19, and compensation reduction. The challenges posed by the COVID-19 pandemic compound existing burnout within dermatology, warranting consideration by academic institutions.
Cost-effectiveness of skin biopsies performed by non-physician clinicians for Medicare beneficiaries
An increasing number of non-physician clinicians (NPCs) are providing dermatologic care. We compared the cost-effectiveness of skin biopsies performed by dermatologists and dermatology NPCs using publicly-available Medicare claims data and numbers needed to biopsy (NNBs) published in the literature. We estimated that dermatology NPCs performed slightly greater mean numbers of skin biopsies per beneficiary (0.51 versus 0.47) at a lower payment per biopsy ($44.93 versus $55.10) as compared to dermatologists. However, we estimated a higher mean cost per malignancy diagnosed by dermatology NPCs relative to dermatologists (range based on literature NNB values, $39.08 to $190.23). This translated to a $16.7M-$43.3M aggregate cost of additional, benign biopsies performed by NPCs on Medicare beneficiaries. Although this preliminary analysis has several limitations, including the reliance on NNB values for calculations, it likely highlights the importance of training, education, and supervision to promote diagnostic accuracy. Further investigation is needed so that the potential cost of additional skin biopsies performed by NPCs can be appropriately weighed against the improvement in dermatologic access by including NPCs in the dermatology workforce.
Skin diseases are commonly encountered in medical practice, yet medical students often receive little dermatology training. There is little research on what self-study materials best prepare students. We aim to identify which resources dermatology residents have found to be most useful in preparing for clinical dermatology rotations and dermatology residency. Forty current dermatology residents and fellows responded to our REDCap-generated survey. Data was analyzed using descriptive statistics. Most respondents (N=36, 90%) reported using outside resources to prepare for clinical dermatology rotations and dermatology residency. American Academy of Dermatology (AAD) modules and other online resources were most used (N=31, 77.5%) and most recommended (N=32, 80%). However, 67.5% of all respondents also used printed textbooks in some capacity, but low-to-no cost, usefulness, and easy accessibility of online resources made them more favorable among study participants. Multiple clinical dermatology rotations were recommended for preparing for dermatology residency (N= 34, 85%), as were other rotations, including internal medicine (N=22, 55%) and rheumatology (N=17, 42.5%). Overall, the AAD modules and online resources are most useful when preparing for clinical dermatology rotations because of favorable cost and accessibility. Compared to clinical rotations in other specialties, multiple rotations in dermatology may be most helpful for dermatology residency.
To investigate the extent to which dermatology programs use social media to connect with applicants, we conducted a search of all 140 residency programs on Instagram, Facebook, Twitter, and YouTube. Our search revealed 74 (53%) Instagram, 21 (15%) Facebook, 20 (14%) Twitter, and four (3%) YouTube accounts for dermatology programs, with the number of Instagram accounts increasing five-fold from the end of 2019 to present. Our results demonstrate that conditions created during the coronavirus disease 2019 (COVID-19) pandemic accelerated dermatology residency programs' acceptance of social media, particularly Instagram, as a means to communicate and share information with applicants.
Epidermolytic ichthyosis (EI) is a rare inherited ichthyosis related to heterozygous mutations in the Keratin 1 or Keratin 10 genes. Because of the broad phenotypic spectrum, it is sometimes difficult to differentiate it from other keratinopathic ichthyoses (KI) in clinical practice. We report an intriguing case of KI presenting as generalized ichthyosis in a reticulate pattern surrounding islands of normal skin, epidermolytic hyperkeratosis and binucleate cells on histopathology, and heterozygous mutation in KRT10. Through this case, we would like to demonstrate the importance of genetic studies and genotype-phenotype correlation in diagnosing such challenging cases.
Focal epithelial hyperplasia is a rare, benign, and asymptomatic disorder, characterized by soft papules on the oral cavity. It is primarily associated with human papillomavirus genotypes 13 and 32. It most commonly affects children and young adults. When it affects young adults, it is important to differentiate it from oral condyloma acuminata. Its diagnosis may be made clinically, but histologic examination and PCR genotyping are often useful. Treatment is not always mandatory.
Syphilis has many atypical morphologies which can present a diagnostic challenge, especially in patients with HIV/AIDS who may have multiple concurrent conditions. We describe a 41-year-old man with recently diagnosed HIV who was admitted for acute right vision loss and a diffuse rash with involvement of the palms and soles. He received diagnoses of secondary syphilis and Kaposi sarcoma in the setting of AIDS. Examination revealed an unusual dark brown-to-purple umbilicated papule with a necrotic center on the abdomen, raising a diagnostic dilemma. Skin biopsy showed secondary syphilis, despite the concurrent diagnosis of Kaposi sarcoma. The patient was treated with antibiotic and antiretroviral therapy and symptoms resolved. This case aims to share the clinical reasoning behind diagnosing a patient with HIV/AIDS with multiple concurrent conditions and to raise awareness of the many atypical cutaneous manifestations of secondary syphilis.
Eccrine squamous syringometaplasia (ESS) is a histological term describing a mature squamous metaplasia of the eccrine ducts. Eccrine squamous syringometaplasia is not an infrequent histological finding and may be associated with chemotherapy or with a variety of non-specific conditions including infections, neoplastic conditions, and inflammatory skin diseases. We report a 75-year-old man who developed ESS within lesions of leukemia cutis (LC). The patient had an inaugural diagnosis of acute myeloid leukemia (AML) and he was not on chemotherapy when the biopsy was performed.
Ulcerative sarcoidosis is a rare variant of cutaneous sarcoidosis that may present as ulceration with necrotic yellow plaques on the lower extremities, face, arms, trunk, or genital area. Adalimumab, a human monoclonal anti-TNF antibody, is an emerging treatment for recalcitrant cutaneous sarcoidosis. We describe severe ulcerative sarcoidosis in a 60-year-old woman with chronic ulcerative necrobiosis lipoidica-like plaques on her left arm for over 20 years. Her condition had not responded to previous treatments with hydroxychloroquine, methotrexate, and sulfasalazine. After a four-month course of adalimumab therapy in addition to pentoxifylline and prednisone with taper, the patient had significant improvement in her skin disease.
Nontuberculous mycobacteria are pathogens with diverse manifestations in immunocompromised hosts. The lesser-known Mycobacterium haemophilum usually causes cutaneous infection. Diagnosis is challenging but is aided by molecular testing and multidisciplinary communication. We present an immunocompromised patient with disseminated cutaneous mycobacterial infection with digital tenosynovitis.
5-Fluorouracil (5-FU) is an antineoplastic agent that is used topically to treat actinic keratoses. Although topical 5-FU frequently causes irritant contact dermatitis at the site of application, distant skin reactions are rare and could relate to accidental transfer or systemic absorption of the drug. We present a patient who developed a painful scrotal dermatitis after applying the topical cream to actinic keratoses on his chest. Upon discontinuation of topical 5-FU, the reaction resolved over a four-week period with oral prednisone and topical betamethasone ointment. The patient was re-challenged with topical 5-FU one year later and again developed scrotal pain and erythema similar to the initial reaction. Scrotal dermatitis is a rare adverse effect of topical 5-FU therapy that can be associated with significant distress and disruption of daily activities.
Acquired dermal melanocytoses include pigmented lesions with a clear late onset, histologically characterized by the presence of melanocytes in the dermis. In this report, we describe a rare case of acquired unilateral facial melanocytosis, also called nevus of Sun, in a Caucasian woman.
Endocrine mucin-producing sweat gland carcinoma (EMPSGC) is a low-grade adnexal malignant neoplasm. We report a 90-year-old man who had a hard, dome-shaped tumor approximately 9 mm in diameter on the left cheek. Dermoscopy showed an overall, non-uniformly light-pink tumor with crust. The diagnosis of EMPSGC is made histologically from excisional biopsy. No signs of recurrent disease were evident at 42 months postoperatively.
We present a patient with a painful, mobile nodule on the elbow. The nodule was skin-colored and had no punctum or discharge. It was excised and histopathology showed that the lesion was a glomangioma, or glomuvenous malformation. This is a neoplasm that arises from the glomus body, a thermoregulatory neurovascular structure. The glomus body is composed of glomus cells, vascular cells, and smooth muscle cells. Three subtypes of neoplasms may arise from the glomus body, depending on the extent to which they involve the three types of cells. They include glomus tumors, glomangiomas/glomuvenous malformations, and glomangiomyomas. This case was unusual in that it did not present with surface color change to indicate a vascular component.
Pilomatrix carcinoma is a rare tumor that is generally not diagnosed clinically. An 80-year-old man presented with a 5-month history of rapidly growing nodule of the submandibular area. Histological examination revealed a pilomatrix carcinoma, an aggressive malignancy with metastatic potential
Basaloid follicular hamartoma (BFH) is a rare follicular hamartoma of benign nature, which should be part of the differential diagnoses of basal cell carcinoma. Familial multiple BFH (FMBFH) is a hereditary subtype which typically presents early in life with multiple small, skin-colored papules primarily on the central face. Although these lesions are usually asymptomatic, they can be cosmetically disfiguring. Treatment options include surgery, cryotherapy, CO2 laser and imiquimod; no standard of care has been determined. We present a case of FMBFH presenting in adulthood, which was treated with CO2 laser with satisfactory results.
Exfoliative cheilitis related to psychologic factors uncovered during primary immunodeficiency evaluation
A 40-year-old previously healthy, non-atopic woman was referred for evaluation of a possible immunodeficiency disorder in the setting of an unusual erosive cheilitis and history of recurrent methicillin-resistant Staphylococcus aureus (MRSA) infection. Extensive work-up was non-diagnostic, including screening for immunologic disorders. She had failed multiple therapeutic modalities, including corticosteroid and immunosuppressive therapy. Tissue biopsy from the lip proved pivotal in demonstrating changes suggestive of factitial disease. This led to further detailed history-taking, yielding evidence of considerable psychologic distress. The patient was diagnosed with exfoliative cheilitis related to factitial disease in association with underlying untreated anxiety and psychologic trauma.