Dermatology Online Journal

Fingernails and toenails can be an important source of trace evidence at a crime scene investigation. Arsenic, gold, lead, mercury, selenium, silver, and thallium are heavy metals; exposure to these metals can result not only in dyschromia of the nail, but also dystrophy of the nail plate. Mees lines, either single or multiple transverse white bands on the nail, were originally described in association with arsenic exposure. Similar white horizontal bands of transverse leukonychia have also been observed in patients following exposure to selenium and thallium. A diagnostic clue for persons who investigate forensic crime scenes to the possibility of heavy metal toxicity in the victim can be changes in the fingernails and toenails. The nails can be photographed and subsequently analyzed for the presence of the causative metal when the possibility of heavy metal exposure is entertained by crime scene investigators and/or medical examiners or coroners.

Personal lubricants vary appreciably in ingredient composition. Although some products are labeled hypoallergenic, these claims are seldom evidence-based. The objective was to determine the potential allergenicity of popular lubricants and elucidate the validity of hypoallergenic product claims. This cross-sectional study involved publicly available data on Amazon's 50 best-selling lubricants as of July 2023. Product ingredient lists were cross-referenced with the North American Contact Dermatitis Group and American Contact Dermatitis Society allergen series. Associations were explored between lubricant price per ounce, average customer rating, number of customer reviews, hypoallergenic claim, lubricant base, and allergen quantity using descriptive statistics, Kruskal-Wallis tests, Wilcoxon tests, ?2 tests, and Spearman correlation analyses. Of all studied, 30% (n=15) of products were allergen-free. Nine personal lubricants (18%) were advertised as hypoallergenic, 5 of which were among the 15 products without allergens. Hypoallergenic products were less likely to contain allergens than lubricants without this claim (P=0.03). Silicone-based lubricants contained fewer allergens than water-based lubricants (P<0.01) but were more expensive (P=0.01). Understanding potential allergenicity of personal lubricants should inform clinicians' product recommendations and differential diagnosis of anogenital contact dermatitis. Silicone-based lubricants labeled as hypoallergenic may be the safest option for sensitive skin but are not guaranteed to be allergen-free.

Melanoma, an invasive and potentially fatal form of skin cancer, is projected to comprise 5% of new cancer cases and 1.4% of cancer-related deaths in 2024 alone [1]. Survival rates are closely linked to the stage at detection, with thicker tumors at initial diagnosis associated with reduced overall survival rate [2,3]. Increased distance to healthcare providers creates barriers to early detection; disparities in sun exposure and healthcare access between rural and urban populations underscore the need for targeted interventions. This review explores the relationship between rurality and distance to providers with melanoma staging at detection. A search was conducted of the PubMed and Embase databases, following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines [4]. The included studies examined melanoma staging and Breslow thickness in rural versus urban areas and the impact of distance to healthcare provider. Greater distance to healthcare providers was associated with more advanced tumor stages at diagnosis, while rurality status had largely insignificant effects. This review investigates the impact of rurality status and distance to a healthcare provider on melanoma detection. Ensuring equitable access is crucial for better melanoma management across different regions.

Comprehensive education in cosmetic and laser procedures is fundamental during dermatology residency to meet the demand for cosmetic medical procedures and effectively treat a myriad of complex dermatological conditions. This article highlights the importance of structured learning to provide step-wise opportunities for proficiency throughout residency. Although reading assignments and didactic sessions create a solid foundation, focused workshops, resident cosmetic clinics, and offsite electives serve as important experiences for residents to practice hands-on skills. This article provides guidance for curriculum development and establishing hands-on procedural learning. Additionally, the importance of joining professional societies to receive unique training as well as mentorship is highlighted. Having a structured and comprehensive cosmetic curriculum will equip dermatology residents with the toolkit to successfully care for diverse patient needs effectively and safely.

Skin tension lines are fundamental guidelines in surgical procedures for determining optimal incision placement to enhance healing and minimize visible scarring. This paper delves into the historical development and practical implications of Langer lines and relaxed skin tension lines. Utilization of relaxed skin tension lines enhances the precision of incisions and closures by considering facial muscle tension, an aspect not addressed by Langer cleavage lines. Relaxed skin tension lines more accurately reflect skin dynamics, underscoring the importance of patient positioning. Additionally, Cornelius Kraissl played a significant role in highlighting the alignment of scars with wrinkle lines. The interchangeable use of relaxed skin tension lines and Langer lines often leads to confusion within the field. Clarifying their distinct origins and criteria is crucial for the optimization of surgical outcomes.

Janus kinase inhibitors are immunomodulatory drugs increasingly used to treat a broad range of inflammatory dermatologic conditions. Although effective, they carry a risk of serious adverse effects, including opportunistic infections. We present a patient who developed an atypical mycobacterial infection while on the Janus kinase 1 and Janus kinase 3 inhibitors, tofacitinib. A 76-year-old man was started on tofacitinib for a severe ulcerative colitis flare. Six weeks after starting therapy, he developed an erythematous papule on his right forearm that progressed into an ulcerating nodule. Initial biopsies suggested subcutaneous pyoderma gangrenosum. However, after failing multiple treatments, repeat biopsies and cultures were performed. An acid-fast bacilli stain was positive and specialized tissue cultures identified Mycobacterium chelonae. The lesions resolved after 6 weeks of clarithromycin therapy. This case highlights the immunosuppressive effects of Janus kinase inhibitors, which can lead to atypical infections including nontuberculous mycobacteria. Additionally, this case highlights the diagnostic challenges associated with these infections, which often require multiple biopsies and specialized microbiological techniques to diagnose. As the use of Janus kinase inhibitors expands, clinicians must maintain a high suspicion for atypical infections, particularly in patients with unusual dermatologic symptoms. Prompt diagnosis and intervention are essential to prevent complications.

Angiomatoid melanoma is a rare variant of malignant melanoma not currently recognized by the World Health Organization classification system. In this study, we present a case of primary angiomatoid melanoma in a 57-year-old man who presented to clinic with a complaint of a growing lesion on the frontal scalp for four months. Microscopic examination of the lesion revealed cavernous spaces filled with extravasated red blood cells. Immunohistochemical markers were positive for melanoma and negative for vascular endothelium. We also review the literature on angiomatoid melanoma, finding distinct morphological differences in previously reported cases. Owing to these differences, we propose new diagnostic criteria and offer a mechanism for formation of blood-filled cavernous spaces while cautioning against misinterpretation of CD31 expression by macrophages in zones of immune regression. Angiomatoid melanoma is a diagnostic challenge because of its rarity, signaling a need for further histopathological evaluation and more complete awareness of its features.

Given the rise of radiation based medical procedures, cutaneous radiation reactions are increasing in frequency. Diagnosis of fluoroscopic radiation-related cutaneous injuries are challenging, as patients are often unaware of or cannot recall radiation exposure. It is important to maintain clinical suspicion of radiation induced skin injuries in patients with persistent morpheaform areas and localized areas of dermatitis or ulceration. Several cutaneous radiation induced injuries have overlapping clinical presentations. Histopathology may be required to help differentiate between these distinct disorders. Treatment of cutaneous radiation reactions may vary, dictated by a variety of factors, including the disease process, the severity of the lesions, and the presence of comorbidities. Herein, we present two cases to highlight the spectrum of fluoroscopic radiation induced cutaneous injuries.

Erlotinib is one of the epithelial growth factor receptor tyrosine kinase inhibitors that have been developed and extensively employed in the treatment of non-small cell lung cancer, particularly in individuals with activating epithelial growth factor receptor mutations. This report presents a case of erlotinib induced eyelash trichomegaly and irritation, a rare side effect in a woman who received erlotinib for lung adenocarcinoma. Following the detection of an epithelial growth factor receptor mutation in tumor tissue from a non-small cell lung cancer in a nonsmoking woman, the patient was initiated on erlotinib therapy. After several months, she experienced significant overgrowth of both eyelashes, leading to vision problems. Dermoscopy findings revealed an increase in the length and thickness of the eyelashes associated with inflammation of the eyelid's edges. It has been hypothesized that the inhibition of epithelial growth factor receptor signaling by epithelial growth factor receptor tyrosine kinase inhibitors could alter the growth pattern of hair, potentially leading to the induction of abnormal hair growth, such as trichomegaly, which has been reported only in a small number of case reports.

Ovarian carcinoma ranks among the top causes of cancer-related fatalities among women in the United States [1]. In the spectrum of ovarian carcinomas, low-grade serous ovarian carcinoma (LGSOC) is a relatively rare form, constituting only 2-5% of all ovarian carcinomas [2]. Although metastasis to the peritoneum and other organs is frequently observed, cutaneous metastasis of ovarian carcinoma is uncommon, occurring in less than 4% of cases and occurring even less often in the serous subtype [3]. Owing to its rare and variable presentation, cutaneous involvement in ovarian carcinoma is particularly challenging to recognize. Patients presenting with skin lesions in the setting of a history of ovarian carcinoma should raise suspicion for cutaneous metastasis. We present a rare case of LGSOC with non-nodular cutaneous involvement presenting as asymptomatic erythematous papules and hyperpigmented patches on the upper chest, abdomen, and lower back.

Drug-induced subacute cutaneous lupus erythematosus (DI-SCLE) is an erythematous, photodistributed, scaly, and annular cutaneous eruption that is clinically similar to subacute cutaneous lupus erythematosus. However, DI-SCLE is associated with medication use and generally resolves or greatly improves following discontinuation. Chemotherapeutic agents are common triggers of DI-SCLE. We report a patient with breast cancer who experienced multiple episodes of DI-SCLE associated with the use of different chemotherapeutic agents for treatment-resistant cancer. Notably, to the best of our knowledge, this case highlights the first reported association of DI-SCLE with trastuzumab deruxtecan. Additionally, this case is unique owing to a component of radiation recall dermatitis, as the rash was prominent in areas that had prior ionizing radiation. A prior history of DI-SCLE in oncology patients who continue to undergo treatment should prompt clinicians to consider DI-SCLE when faced with a new photodistributed, erythematous, annular, and scaly eruption. Early initiation of immunomodulating agents like hydroxychloroquine in patients with a history of moderate to severe DI-SCLE to chemotherapy who continue to undergo anti-cancer treatment may provide benefit and warrants further investigation.

Anetoderma is commonly characterized by well-circumscribed areas of slack or baggy skin related to the loss of elastic fibers in the dermis. It has associations with some well-defined skin lesions, such as acne vulgaris and varicella. We report a 67-year-old woman with clinical and pathologically confirmed anetoderma at sites of previously documented lichen planus.

Blue rubber bleb nevus syndrome (BRBNS) and familial multiple glomuvenous malformations (GVM) are genetic disorders characterized by multiple cutaneous vascular malformations. Unlike multiple GVM, BRBNS comprises a risk of systemic involvement with vascular malformations in other organs, potentially causing life-threatening bleeding. The correct distinction between these two conditions is challenging due to their clinical similarity, but it is crucial in light of the pivotal differences in prognosis and follow-up. We report a case of multiple glomuvenous malformations in a child with lower gastrointestinal bleeding that posed a thought-provoking diagnosis.

Enchondromas are frequently occurring cartilaginous tumors, accounting for 10-25% of all benign bone neoplasms. We present a distinctive case involving distal clubbing of the right third toenail with a painless, 5mm-wide red longitudinal streak. Clinical examination, nail matrix biopsy, and imaging confirmed the presence of an enchondroma in the distal phalanx. Although solitary enchondromas often present with pain or pathological fractures, asymptomatic cases like this one are quite rare. Given the low risk of malignant transformation, the patient chose regular magnetic resonance imaging (MRI) monitoring. This case highlights the need to consider enchondromas in the differential diagnosis of painless longitudinal erythronychia, an infrequent manifestation. Proper diagnosis is essential to differentiate these lesions from malignant chondrosarcomas, which have a different management approach.

A 76-year-old woman with a significant cardiac surgery and breast cancer history presented to the dermatology clinic with a three-year history of an enlarging, tender, nonhealing cutaneous nodule on her upper abdomen. A shave biopsy was attempted given concern for nonmelanoma skin cancer or cutaneous metastasis. The biopsy was halted after a white wire was visualized. Retrospective computed tomography (CT) imaging review revealed a hyperdense linear structure becoming superficial at the location of the nodule seen on examination. Discussion with a cardiothoracic surgeon revealed this wire was likely a retained temporary epicardial pacing wire that was placed at the time of the patient's cardiac surgery three years prior. The decision was made to excise the lesion to fully remove the wire. Given intraoperative resistance with traction, the wire was partially removed by cutting it flush to the skin's surface. The patient healed appropriately with complete resolution of her symptoms. This case is unique because the wire was fully visualized on the CT scan, and it was unable to be fully removed.

Traumatic tattoos result from the forceful implantation of foreign material into the skin and may present a significant cosmetic burden to patients. Long-lasting or permanent skin pigmentation in traumatic tattoo may arise from particles of numerous materials such as fireworks, metals, gunpowder, asphalt, and dust embedded within injured skin. Our aim was to demonstrate the appropriate and beneficial use of the Q-switched alexandrite laser to treat traumatic tattoos. The patient's pigmented scars were biopsied and processed using standard histological methods to demonstrate foreign material within the scars. Following patient consent and laser tolerance testing, pigmented scars on the face were treated on two occasions with the Q-switched alexandrite laser. Progress photos were obtained before and after each treatment. The pigmented lesions responded well to treatment with the Q-switched alexandrite laser and exhibited almost complete resolution of foreign body pigmentation after just two treatments. The Q-switched alexandrite laser was used safely and effectively to treat traumatic tattoos.

eclare that the contents of this article are their own original unpublished findings. Title: Changes in public interest for Mohs micrographic surgery: a Google Trends analysis Authors: Joshua Burshtein1 MD, Milaan Shah2 MD, Danny Zakria3 MD MBA, Lauren DeBusk4 MD, Angela Rosenberg4 DO, Darrell Rigel5 MD MS Affiliations: 1Department of Dermatology, University of Illinois Chicago, Chicago, Illinois, USA, 2Department of Dermatology, Medical University of South Carolina, Charleston, South Carolina, USA, 3Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York, USA, 4Department of Dermatology, UT Southwestern Medical Center, Dallas, Texas, USA, 5Department of Dermatology, NYU Grossman School of Medicine, New York, New York, USA Corresponding Author: Joshua Burshtein MD, 808 South Wood Street, Chicago, IL 60612, Tel: 845-596-9482, Email: jburshtein13@gmail.com