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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 25, Issue 10, 2019

Review

Melasma pathogenesis: a review of the latest research, pathological findings, and investigational therapies

Melasma is an acquired hyperpigmentation disorder most commonly affecting females with darker skin types. It is triggered by several factors including sun exposure, genetic influences, and female sex hormones. The pathology of melasma extends beyond melanocytes and recent literature points to interactions between keratinocytes, mast cells, gene regulation abnormalities, neovascularization, and disruption of basement membrane. This complex pathogenesis makes melasma difficult to target and likely to recur post treatment. A better understanding of the latest pathological findings is key to developing novel and successful treatment options. This review aims to provide a summary of the more novel pathological findings and latest investigational therapies.

Original

Critical analysis of features and quality of applications for clinical management of acne

Background: Mobile medical applications (apps) for clinical management of medical conditions are increasing in prevalence. Our aim was to identify features and overall quality of acne apps that could facilitate clinical management. Methods: We established 10 pertinent features (6 essential and 4 desirable) for an acne app through literature search and nominal group discussion. Searches were then conducted in the Apple App Store and Google Play Store. Apps which assisted with clinical management of acne were assessed for functionality and quality. Overall quality was evaluated by grading against pre-established criteria for medical apps. Results: A total of 358 Apple apps and 256 Google apps were found. After removing apps which did not assist with the clinical management of acne, 12 Apple and 13 Google apps remained. Apps were classified as interactive, informational, or teledermatology apps. Mean Masud scores were 12.8±3.7 for the Apple apps and 12.2±3.7 for the Google apps. Conclusions: Mobile acne apps can be effective in the self-management and collaborative management of acne. The current acne apps are of variable quality and none contained all 10 features crucial for effective clinical management. The shortcomings identified in this paper can guide future acne app development.

Commentary

A new somatic-type delusional disorder subtype: delusion inversus

The interplay between psychiatric and dermatologic conditions has been recognized for decades as evidenced by the widely accepted classification system of psychocutaneous disorders: (1) primary dermatologic disorder with psychiatric sequelae, (2) primary dermatologic disorder exacerbated by stress, (3) primary psychiatric disorder with dermatologic sequelae, and (4) miscellaneous. However, there is minimal literature regarding dermatologic patients who demonstrate a preoccupation with a more severe cutaneous disorder despite evidence confirming a diagnosis of a minor, treatable skin condition. These patients are a hybrid of the first and fourth categories and should be classified under a new entity known as delusion inversus. These patients have a primary dermatologic condition; however, they believe their condition to be more severe and malignant than it is, despite evidence to the contrary. Their beliefs are pathological and analogous to delusion disorder somatic type. Given the scarcity of data concerning delusion inversus, the epidemiology, diagnosis, and management of the disorder as described in this review is extrapolated from reported cases of delusion disorder and delusion disorder somatic-type. Often these patients will present to a non-psychiatric, outpatient clinic for medical care. Thus, it is imperative that dermatologists are able to identify the condition and manage the patient appropriately.

Impact of medical scribes on dermatology trainee and attending experience

Background: Medical scribe integration into academic dermatology practices results in decreased attending documentation time, improved physician efficiency, and positive patient satisfaction. However, scribes' impact on dermatology education has not been explored. Methods: We conducted a cross-sectional survey at the Brigham and Women's Hospital Dermatology Department and its associated residency program assessing trainee and attending perceptions of scribe impact on documentation time, teaching time, and quality of teaching. Results: Thirty-nine surveys (67% of eligible population) were analyzed. The majority of faculty and trainees perceived that scribes decreased documentation time (92% attendings, 88% trainees), increased attendings' direct teaching time (57% attendings, 76% trainees), increased attending availability to answer questions (57% attendings, 68% trainees), and improved overall education (57% attendings, 80% trainees). Trainees generally perceived educational benefits of scribes more strongly than attendings. Trainees and attendings had discordant views regarding number of patients that the trainee sees (29% attendings, 72% trainees, P<0.05) and the amount of supervision provided for procedures (43% attendings, 56% trainees). Conclusions: The positive impact of scribes on dermatology education is consistent with results in other disciplines. Although hospitals typically invest in scribes to increase physician efficiency, this study suggests that scribes can also improve the educational experience.

The rise in subscription skin care services

Subscription skin care services are a rising niche of direct-to-consumer telehealth models. The explosion of such services may be a reflection of the increasing demand by patients to have accessible, affordable dermatological care. These models come with both benefits and risks to patients. A thorough understanding of how subscription skin care services work may benefit dermatologists in addressing patients' questions regarding alternative care options.

Case Report

Bullous dermatoses secondary to anti-PD-L1 agents: a case report and review of the literature

Immune checkpoint inhibitors are used to treat numerous malignancies but may be associated with severe adverse events. Bullous dermatoses, chiefly bullous pemphigoid (BP), are potentially progressive adverse events that cause blistering skin lesions and may involve a significant body surface area. Herein, we report an 87-year-old man with urothelial cell carcinoma undergoing atezolizumab treatment who presented with an acute-onset blistering eruption. Biopsy revealed a subepidermal bulla, direct immunofluorescence revealed linear IgG and C3 deposits at the dermal-epidermal junction, and serum studies revealed elevated levels of antibodies to BP180 and BP230. Anti-PD-L1-induced BP was diagnosed, immunotherapy was withheld, and he was treated with oral doxycycline with niacinamide and clobetasol ointment. He restarted atezolizumab and has successfully received four cycles (every 3 weeks) while continuing this BP treatment regimen. A literature review revealed eight other cases of anti-PD-L1-induced bullous disorders. The incidence of bullous dermatoses with anti-PD-1/anti-PD-L1 agents combined is 1%, whereas the reported incidence for anti-PD-L1 agents alone ranges from 1.3-5%, raising concerns for a higher overall risk. In addition to our case, only one other case reported successful resumption of immunotherapy. Early control and management of immunotherapy-induced BP may reduce complications and prevent treatment discontinuation.

Case Presentation

A challenging diagnosis of penile sarcomatoid squamous cell carcinoma

We report a patient with penile sarcomatoid squamous cell carcinoma (SCC) initially misdiagnosed as condyloma acuminatum. Sarcomatoid SCC is a rare, aggressive, biphasic cancer that often presents a diagnostic challenge and carries a poor prognosis, especially after a delay in diagnosis. Although sarcomatoid SCC may exhibit a broad range of clinical features, the expression of p63 and keratin 34?E12 is a common finding. Our case highlights the importance of accurate clinicopathologic correlation to facilitate a timely diagnosis and management of this rare and highly aggressive malignancy.

Keratoacanthoma-like nodules as first manifestation of metastatic epithelioid trophoblastic tumor

Cutaneous metastases are rarely the initial manifestation of a previously undiagnosed malignancy and keratoacanthoma-like lesions are a notoriously unusual presentation pattern of cutaneous dissemination of a primary tumor. Herein, we report a 40-year-old woman presenting to our dermatology department with multiple keratoacanthoma-like scalp nodules. Subsequent investigation determined it to be the first manifestation of a disseminated endometrial epithelioid trophoblastic tumor, eventually causing the patient's death. Epithelioid trophoblastic tumor, a rare form of gestational trophoblastic disease, is a recently described neoplasm whose cutaneous metastasis has not been previously reported in the literature.

Hydroxyurea-induced hyperpigmentation with iron deposition

Hydroxyurea is a chemotherapeutic agent that is used in the treatment of various hematological diseases including chronic myelogenous leukemia, polycythemia vera, and sickle cell anemia. Hydroxyurea is also used to treat psoriasis. Drug-induced hyperpigmentation is a known cutaneous side effect of hydroxyurea along with xerosis, dermal ulcers, and dermatomyositis-like eruptions. Hyperpigmentation has been observed in the oral mucosa, nails, and in a generalized or a diffuse pattern. The mechanism of hyperpigmentation related to hydroxyurea is believed to be correlated with increased melanin. Classically, clinical types of diffuse hyperpigmentation owing to iron deposition in the dermis have been associated with minocycline and not with hydroxyurea. We report a novel case in which hydroxyurea hyperpigmentation is associated with iron deposition.

Widespread subacute cutaneous lupus erythematosus in a patient receiving checkpoint inhibitor immunotherapy with ipilimumab and nivolumab

Checkpoint inhibitor immunotherapy, including ipilimumab and nivolumab, is associated with numerous immune-related adverse events including dermatitis, pruritus, hepatitis, diarrhea, and hypophysitis. As the number of patients undergoing immunotherapy treatment increases, however, rare and unusual immune-related adverse events are observed. Many of these resemble known autoimmune phenomenon, such as subacute lupus erythematosus and myositis. Herein, we report a patient with metastatic serous ovarian carcinoma undergoing treatment with combination ipilimumab and nivolumab who developed subacute cutaneous lupus erythematosus (SCLE). Recent case reports have documented SCLE as a novel immune-related adverse event. In our case, she was able to successfully restart immunotherapy after a course of oral corticosteroids and maintenance oral hydroxychloroquine and topical corticosteroid therapy.

Photo Vignette

Follicular spicules of multiple myeloma

Follicular spicules are a very rare but highly characteristic cutaneous manifestation of multiple myeloma. The spicules typically appear as hyperkeratotic horns in the follicular openings of the face, most commonly on or around the nose and forehead. The pathophysiology of this condition has not been fully elucidated and remains an active area of research and debate. Herein we describe a patient who presented with follicular spicules in the context of unintentional weight loss, anemia, and elevated inflammatory markers. We discuss the diagnostic work-up for such a presentation, review the classification of follicular spicules of multiple myeloma, and describe approaches to manage this uncommon skin condition.

Pink verrucous plaque in a man with systemic mastocytosis

Porokeratosis ptychotropica is a rare and commonly misdiagnosed subtype of porokeratosis involving the body folds. We present a 53-year-old man with systemic mastocytosis who presented with a pruritic, verrucous plaque in the gluteal fold that showed multiple cornoid lamellae on histopathologic evaluation, diagnostic of porokeratosis ptychotropica. Various treatments have been reported, including topical corticosteroids, retinoids, vitamin D analogs, calcineurin inhibitors, imiquimod, phototherapy, cryotherapy, or ablative laser therapy, but recurrences are common.

Persistent dermatomal eruption on a leg

Unilateral linear capillaritis (ULC) is a rare variant of pigmented purpuric dermatoses (PPD) that is characterized by a linear or pseudo-dermatomal eruption on a single extremity. Although clinically distinct from the other PPD, it shares histopathologic features with this group. Herein, we present a man in his 50s who presented with asymptomatic macules and scaly papules on the left lower extremity in a linear distribution. The eruption persisted despite treatment with topical triamcinolone 0.1% and oral rutocide.

Apocrine hidrocystoma on the nipple: the first report in this unusual location

Apocrine hidrocystoma is a rare, benign, cystic tumor of the apocrine sweat glands. They are most commonly located around the eyes and may also be found on the scalp and neck. However, despite the fact that the nipple and areola contain numerous apocrine sweet glands, apocrine hydrocystomas have not been described previously in this area to the best of our knowledge. We report the first case of this cyst in this unsual location.

Palmoplantar epidermoid cysts: two cases and brief review of the literature

Palmoplantar epidermoid cysts can range in clinical presentation from an asymptomatic slowly enlarging mass to a painful nodule. We report two cases: an epidermoid cyst on the sole and another on the palm. This article reviews the possible etiology, diagnosis, and prognosis of palmoplantar epidermoid cysts.

Letter

Safety of guselkumab in hepatitis B virus infection

Reactivation of hepatitis B virus (HBV) following the use of TNF antagonists has been reported and is a contraindication to use of these medications. Although the risk of reactivation of HBV during use of ustekinumab and secukinumab is low in patients with only HBV core antibody positivity, the risk is substantial in patients with chronic HBV infection. Less information is available regarding the use of pure IL-23 antagonists. Herein we discuss the successful treatment with guselkumab of a patient with HBV core antibody positivity, without evidence of HBV reactivation or other liver complications.

Unilateral contact dermatitis of the chest

Unusual distributions of contact dermatitis often lead to identification of the offending agent. We present a case of unilateral dermatitis of the chest developing in a patient with a history of allergy to metal. A name tag attached magnetically to his work uniform was identified as the cause of the eruption. Unilateral eruption of the chest can be a manifestation of allergic contact dermatitis to metal objects in breast pockets or attached to clothing.

Secondary organizing pneumonia (bronchiolitis obliterans with organizing pneumonia) associated with adalimumab for treatment of chronic plaque psoriasis

Organizing pneumonia is defined histopathologically by intra-alveolar buds of granulation tissue, consisting of intermixed myofibroblasts and connective tissue. The pathological pattern of organizing pneumonia may be idiopathic or related to a determined cause, termed secondary organizing pneumonia. We report a 68-year-old woman with a longstanding history of chronic plaque psoriasis, treated with the tumor necrosis factor (TNF) inhibitor, adalimumab. After 8 years of treatment, she developed a gradual-onset, non-productive cough with associated generalized fatigue and mild dyspnea. Radiological investigations demonstrated ground-glass opacities in the left lower lobe and bronchoscopy revealed a fibroinflammatory process consistent with organizing pneumonia. Her biologic treatment was ceased and corticosteroid treatment commenced, with resolution of both her symptoms and the radiological findings. Given the increasing incidence of biologic treatment in the management of dermatological conditions, clinicians should be aware of secondary organizing pneumonia as a possible side effect of TNF inhibitor therapy.

Pediatric Dermatologist UC Davis School of Medicine Department of Dermatology

The University of California, Davis, School of Medicine, Department of Dermatology, is recruiting for a PediatricDermatologist in the Clinical X series or Health Sciences Clinical Professor (HSCP) series at the Assistant/Associate/FullProfessor level based on experience and qualifications. The appointment may be made up to 100%.Basic Qualifications: Candidates must possess an MD or MD/PhD, can be board eligible, but must be board-certified in dermatology at the time ofstarting employment and must be eligible for medical licensure in the State of California. Candidates must also be board eligible in pediatric dermatology at the time of starting employment and board certified within2 years of starting employment. Successful completion of an approved dermatology residency training program (ACGME accredited) and successful completionof an approved pediatric dermatology fellowship program (ACGME accredited). Demonstrated proficiency in the teaching of students and housestaff. Service including committees, leadership ability, and community outreach. Ability to work cooperatively and collegially within a diverse environment. Ability to adhere to policies and procedures, and leadership experience and abilities. Selected candidates will be expected to participate in clinical care, teaching, research and university service.Preferred Qualifications: Experience and interest in clinical research.For first consideration, applications should be received by October 15, 2019; however, the position will be open until filled throughSeptember 30, 2020. The following information is required: Cover Letter, Curriculum Vitae, contact information for 3-5 referencesand Statement of Contributions to Diversity. Please visit http://academicaffairs.ucdavis.edu/diversity/equity_inclusion/index.htmlfor information about why diversity statements are requested and guidelines for writing a diversity statement. Please upload thisinformation and apply online at https://recruit.ucdavis.edu/apply/JPF03038.The position is in Sacramento, California. The Department of Dermatology (http://www.ucdmc.ucdavis.edu/dermatology) is a majorclinical care, research, and teaching department in the School of Medicine. Our faculty are engaged in multiple collaborations withother Schools and UC Davis campus departments, research centers, clinical centers, and primary care networks, and thus allpositions require flexibility in local job locations in addition to the Department of Dermatology. This includes the Veteran'sAdministration, UCD Medical Center Campus, and other community centers.UC Davis commits to inclusion excellence by advancing equity, diversity and inclusion in all that we do. We are an AffirmativeAction/Equal Opportunity employer, and particularly encourage applications from members of historically underrepresentedracial/ethnic groups, women, individuals with disabilities, veterans, LGBTQ community members, and others who demonstrate theability to help us achieve our vision of a diverse and inclusive community. For the complete University of Californianondiscrimination and affirmative action policy, see: http://policy.ucop.edu/doc/4000376/NondiscrimAffirmAct. If you needaccommodation due to a disability, please contact the recruiting department.Under Federal law, the University of California may employ only individuals who are legally able to work in the United States asestablished by providing documents as specified in the Immigration Reform and Control Act of 1986. Certain UC Davis positionsfunded by federal contracts or sub-contracts require the selected candidates to pass an E-Verify check. More information is availableat http://www.uscis.gov/e-verify.UC Davis is a smoke & tobacco-free campus (http://breathefree.ucdavis.edu).