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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 7, 2021


Treatment of rosacea during pregnancy

Background: Exacerbation of rosacea may occur during pregnancy and there are multiple associated cases of rosacea fulminans (RF). Treatment during pregnancy poses a significant challenge as many rosacea treatments are contraindicated or have limited evidence regarding potential adverse fetal effects. Objective: Review the pregnancy categories of various treatments and develop algorithms for treating pregnant patients with rosacea and RF. Methods: Rosacea treatments showing efficacy in randomized controlled trials were searched through DailyMed to review pregnancy labelling. Searching the PubMed/MEDLINE database for English articles using keywords "rosacea fulminans AND pregnancy" without publishing-time restrictions yielded 8 articles. We summarized treatments used in cases of RF during pregnancy. Results: Topical ivermectin was more effective than metronidazole, but has a more concerning pregnancy category. Three pregnant women with RF were treated successfully with topical metronidazole in combination with other therapies. Azithromycin is the only oral rosacea therapy that is considered safe for pregnant patients and it has been used to treat RF. Conclusions: This review highlights the challenging aspects of treating pregnant patients with rosacea, as there is limited pregnancy-related treatment efficacy and safety data. The pregnancy categories of therapeutic options are summarized. Further studies are needed to learn which therapies are effective and safe for use during pregnancy.


Social media (SoMe) enhances exposure of dermatology articles

Social media (SoMe) refers to a variety of virtual platforms used to enhance sharing of information. To evaluate the influence of SoMe with regards to views and downloads of published dermatology articles, we conducted a retrospective study from July 2020-March 2021 examining articles published on Instagram and Twitter under Dermatology Online Journal (DOJ) accounts and compared these with type-matched and issue-matched articles that were not posted on social media. During this time period, 163 total articles of the three types used for social media (Case Report, Case Presentation, and Photo Vignette) were published in DOJ and 15 were promoted via SoMe. Utilization of SoMe demonstrated a significant (P<0.0001) positive effect with regards to both views (175.5±16.4) and downloads (31.5±4.0) over matched articles not published on SoMe. Similar trends illustrating the positive effect of SoMe on readership have been previously observed in the field of dermatology as well as other medical specialties. Most direct accessions to articles arrived via Instagram rather than Twitter, diverging from previous studies on SoMe use in medical journals. Social media, in particular Instagram, can be a successful platform to enhance the exposure of peer-reviewed medical information.

Case Report

Adult colloid milium is clinically distinguishable from its histopathologic mimic cutaneous amyloidosis

Colloid milium, also known as colloid degeneration of the skin or dermal hyalinosis, is a cutaneous deposition disease that presents as three subtypes: juvenile, nodular, and adult. Adult colloid milium is characterized by amyloid-like depositions in the dermis, mimicking cutaneous amyloidosis histologically. A 70-year-old man presented with lesions on the sun-exposed skin of the face, dorsal hands, and dorsal forearms resembling adult colloid milium. A punch biopsy was performed on the left zygoma and histopathological features were consistent with this diagnosis, though cutaneous amyloidosis was considered. A case of adult colloid milium is presented to emphasize the clinical and histopathologic differentiation from cutaneous amyloidosis.

Pediatric necrobiosis lipoidica: case report and review of the literature

Necrobiosis lipoidica (NL) is a rare, granulomatous disease considered to be associated with diabetes. It is frequently seen in female and middle-aged patients and is rarely observed in children. We present a 14-year-old boy with poorly controlled type 1 diabetes who developed biopsy-proven NL. He had improvement, but not resolution of the plaque with improved glycemic control. Pediatric NL may be associated with diabetes and could be related to poor glycemic control. However, further investigation is warranted in this young population.

Case Presentation

Dermatologic ultrasound in the management of childhood linear morphea

Linear morphea is the most common subtype of localized scleroderma in the pediatric population. This condition can be quite disabling, with complications such as growth defects and painful flexion contractures. Assessment of disease progression and early intervention are key to minimize morbidity. We report linear morphea in a previously healthy 12-year-old girl. The patient presented with a one-year history of a linear plaque crossing her left antecubital fossa, measuring 7x3cm. The diagnosis was confirmed by biopsy, in which deep tissue involvement was noted. Subsequent management and evaluation of the disease activity was done by ultrasound, which allowed precise guidance of pharmacotherapy. The patient improved both clinically and sonographically with a methotrexate course. Sonographic changes accurately described the disease activity on follow up assessments. Features suggestive of an active phase include a thickened and hypoechoic dermis contrasting hyperechoic subcutaneous tissue. The atrophic stage is characterized by a thinned-out dermis and subcutaneous area. Typical vascular traits of each disease phase can also contribute to the assessment. Ultrasound is a grossly underused tool in the field of dermatology. It can provide accurate and sensitive information about disease activity in linear morphea, allowing for more timely intervention and optimal patient management.

Significant improvement of dermatitis herpetiformis with tofacitinib

Dermatitis herpetiformis (DH) is a rare autoimmune blistering disorder in which patients with celiac disease, a gluten-sensitive enteropathy, present with a severely pruritic papulovesicular eruption over extensor surfaces such as the knees, elbows, lower back, buttocks, and neck. Patients are instructed to adhere to a gluten-free diet for purposes of improving their skin disease and gluten-sensitive enteropathy; this is the only treatment that lowers risk of enteropathy-associated T cell lymphoma. Patients who adhere to a strict gluten-free diet often have remission of their skin disease over months to years. Dapsone is a rapid and extremely effective first-line treatment option and often used while transitioning to a gluten-free diet. Aside from gluten-free diet and dapsone, second-line treatment options include sulfapyridine, sulfasalazine, and colchicine. Some patients have difficulty adhering to a gluten-free diet or develop intolerable side effects to systemic therapies. Furthermore, there is limited data on the use of the second-line treatments. Recent studies have shed light on the role of JAK-STAT-dependent pathways in the pathogenesis of dermatitis herpetiformis. We present a patient treated with tofacitinib, 5mg twice daily, an oral JAK1/3 inhibitor, who demonstrated clinical improvement of DH and control of new lesion development.

Severe EGFR inhibitor-induced acneiform eruption responding to dapsone

Epidermal growth factor receptor (EFGR) inhibitors are targeted chemotherapeutic agents that are effective in treating various epithelial cancers. Cutaneous adverse effects, most commonly acneiform/papulopustular eruption, can occur with these medications and limit their tolerability. In severe cases, patients may refuse treatment with EGFR inhibitors because of the significant impact on the quality of life and aesthetic discomfort. We present a 72-year-old-man with a history of EGFR+ non-small-cell lung carcinoma who developed a severe acneiform eruption secondary to afatinib that failed to improve with various traditional treatment modalities. The patient was treated with dapsone and his acneiform eruption resolved within two months of initiating therapy. Patient tolerated dapsone with no reported adverse effects and continues on low dose dapsone, as he will remain on afatinib indefinitely. Dapsone can be an effective therapy for refractory or severe cases of EGFR-induced acneiform eruptions. As in this case, dapsone may improve patient adherence to EGFR inhibitors, thereby allowing for effective therapy of underlying malignancy.

Cervicofacial actinomycosis: a unique diagnostic challenge

Actinomycosis is a rare, chronic bacterial infection caused by Actinomcyes israelii. This anaerobic filamentous gram-positive bacterium frequently colonizes the human mouth, digestive, and genital tracts. Cervicofacial actinomycosis infections have a proclivity for affecting the upper and lower mandibles and occur in 50% of cases. Most cases present in immunocompetent individuals and almost always involve some degree of pre-existing mucosal trauma through either recent dental procedures or poor dental hygiene. Herein, we present a 54-year-old man diagnosed with cervicofacial actinomyces infection in the absence of periodontal disease or recent dental procedures. The purpose of this testimony is to discuss the pathogenesis and clinical and histologic findings of actinomycosis. In addition, we review diagnostic techniques and the current breadth of treatment options. It is our hope that this manuscript will serve as a guide for physicians of all specialties in accurately recognizing and promptly treating actinomycosis.

Acitretin-induced periungual pyogenic granulomas and review

Periungual pyogenic granulomas are benign vascular tumors that present as painful, round, spontaneously bleeding lesions composed of rapidly proliferating capillaries and excess tissue. The vast majority of pyogenic granulomas are caused by physical trauma or infectious agents and they may resolve spontaneously. Herein, we highlight a very rare case of periungual pyogenic granulomas induced by the regularly prescribed oral retinoid acitretin during treatment for congenital palmoplantar keratoderma. This unique case showed that it is feasible to continue acitretin therapy in the presence of pyogenic granuloma development if proper dose reduction and topical therapies are utilized. The patient's lesions resolved within two weeks of this protocol's initiation and the pyogenic granulomas did not recur over the course of a six-month follow-up observation period. In addition, we performed a systematic review of the literature using PubMed databases for the clinical features and treatments in other reported acitretin-induced pyogenic granuloma cases; we compiled a comprehensive list of other prescription drugs known to cause pyogenic granulomas up-to-date.

Intramuscular lipoma of the scapular region

Intramuscular lipomas are rare, benign soft tissue neoplasms characterized by infiltrative growth into muscle tissue or between muscle fibers. These benign tumors can present similarly to malignant soft tissue neoplasms, such as liposarcomas. Unlike subcutaneous lipomas, intramuscular lipomas require diagnostic imaging to better distinguish the tumor and rule out alternative, malignant etiologies. It is imperative that dermatologists are able to identify this rare lipoma variant and have a thorough understanding of the diagnosis, imaging, and treatment options for this uncommon soft tissue tumor. Our case serves as a reminder for dermatologists to be cognizant of this rare tumor and aware of the importance of diagnostic testing in ruling out similarly-presenting, soft tissue malignancies.

Photo Vignette

Reactive arthritis: images

Reactive arthritis is an extremely rare spondyloarthritis that affects the peripheral joints and spine, resulting in common symptoms such as arthritis, urethritis, conjunctivitis, and mucocutaneous lesions. On rare occasions, oral lesions such as circinate erosions on the hard and soft palate, gums, tongue, and cheeks may occur. Reactive arthritis may develop during or after genitourinary or gastrointestinal bacterial infections such as Shigella, Salmonella, Yersinia, and Chlamydia. A 36-year-old man presented with circinate balanitis, urethral discharge, oligoarthralgia, conjunctivitis, lymphadenopathy, pharyngitis, and erythematous lesions on the palate. Culture examination showed presence of Neisseria gonorrhoeae and antibiotic treatment resulted in improvement of conjunctivitis and the lesions on the penis. However, severe oligoarthralgia, palatal erosions that increased in severity and size, and depilated areas on the tongue were observed. The definitive diagnosis was reactive arthritis. The prevalence of sexually transmitted infections is increasing, highlighting the need to increase awareness of associated risks such as reactive arthritis. Moreover, consideration of non-specific oral manifestations in a systemic context may aid in effective diagnosis and treatment, suggesting the need for multidisciplinary teams.

Anogenital giant condyloma in an infant with liver transplantation

Human papillomavirus (HPV) types 6 and 11 were detected in a 3-year-old girl with extensive anogenital condylomata. Although sexual abuse must be considered, non-sexual transmission is evident in at least 57% of children with anogenital warts. Perinatal transmission may occur in approximately 24.5% of infants born to HPV-positive mothers. We present an immunosuppressed child with giant condylomata and discuss transmission, work up, and treatment.

Histopathological features of iatrogenic occlusive vasculopathy caused by intra-articular hyaluronic acid injection for osteoarthritis

Occlusive vasculopathy may rarely occur after intra-articular injection with hyaluronic acid. The associated histological changes are not well described. Herein, we would like to present representative histology of this phenomenon.