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Open Access Publications from the University of California

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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 20, Issue 2, 2014

Articles

A slowly enlarging mass on the finger

An otherwise healthy 71-year-old woman presented with an asymptomatic mass on her right 4th finger that had been slowly enlarging over the past 2 years. On physical examination, there was a tan-pink, freely mobile, rubbery, 9-mm papule with a central keratotic plug located over the extensor aspect of the proximal interphalangeal joint of the right 4th finger. A 3-mm punch biopsy of the lesion was performed. Histopathologic findings were consistent with a diagnosis of aggressive digital papillary adenocarcinoma (ADPAca), an adnexal tumor with high metastatic potential that is unfortunately initially misdiagnosed secondary to its rarity and nondescript appearance. Aggressive surgical treatment including radical excision or digital amputation with or without sentinel lymph node biopsy is advocated in the treatment of ADPAca.

Original

Patient satisfaction in dermatology: a qualitative assessment

Patient satisfaction is of growing interest to the medical field. Qualities essential to patient satisfaction with primary care providers have been characterized, but little work has been done to assess factors that affect patient satisfaction in dermatology.  The objective of this study was to determine factors essential to patient satisfaction in dermatology. Qualitative data from an online survey were collected and organized thematically relying on a previously established coding scheme for patient satisfaction comments. Themes studied include the character of the physician, communication, time, care, and qualities of the office staff.   Doctors with good character who communicated effectively and spent sufficient time with patients received high satisfaction. An efficient and friendly office staff also contributed to high satisfaction. Poor patient satisfaction was mainly linked to flaws in physician demeanor, lack of communication, and rushed appointments.  A limitation to the study included potential bias of an online survey sample, although the widespread use of the tool to capture more respondents in dermatology may mitigate this limitation. To achieve high patient satisfaction, it is vital that a physician is cognizant of the profound effects of how his or her character, communication style, time investment, and office staff appear to patients because patients consider these factors in addition to clinical outcomes when evaluating physicians.

Patient Satisfaction in Dermatology: A Qualitative Assessment

Abstract

Patient satisfaction is of growing interest to the medical field. Qualities essential to patient satisfaction with primary care providers have been characterized, but little work has been done to assess factors that affect patient satisfaction in dermatology.  The objective of this study was to determine factors essential to patient satisfaction in dermatology. Qualitative data from an online survey were collected and organized thematically. Themes studied include the character of the physician, communication, time, care, and qualities of the office staff.   Doctors with good character who communicated effectively and spent sufficient time with patients received high satisfaction. An efficient and friendly office staff also contributed to high satisfaction. Poor patient satisfaction was mainly linked to flaws in physician demeanor, lack of communication, and rushed appointments.  A limitation to the study included potential bias of an online survey sample, although the widespread use of the tool to capture more respondents in dermatology may mitigate this limitation. To achieve high patient satisfaction, it is vital that a physician is cognizant of the profound effects of how his or her character, communication style, time investment and office staff appear to patients, as patients consider these factors in addition to clinical outcomes when evaluating physicians.

  • 4 supplemental files

Case Report

Subcutaneous panniculitis-like T-cell lymphoma with unusual eschar-like crusting

Subcutaneous panniculitis-like T-cell lymphoma (SPTCL) is a rare subtype of non-Hodgkin's lymphoma of the skin. Clinically, SPTCL presents as subcutaneous tumors located on the extremities or trunk, often associated with systemic symptoms like fever or fatigue. The therapeutic regimen for SPTCL is at present not standardized. We describe herein a case of a young woman who presented with intermittent fever and skin rash and was diagnosed later with SPTCL. The case is reported here for its rarity and rapidly changing unusual clinical manifestations. This case also highlights that monotherapy with systemic steroid can be a valuable treatment option for the management of SPTCL, especially in those without hemophagocytic syndrome.

Commentary

Why sulfonamides are contraindicated in Rocky Mountain spotted fever

Sulfonamide antibiotics are not effective for the treatment of Rocky Mountain spotted fever (RMSF). Patients suspected of having RMSF based on history and physical exam should be treated with doxycycline and not a sulfonamide to avoid increased morbidity and mortality.

Compliance with follow-up among patients with melanoma and non-melanoma skin cancers

Background: A history of cutaneous malignancies puts patients at an increased risk of developing additional skin cancers, but there is little data available regarding compliance with any recommended follow-up regimens.

Purpose: To report on compliance with physician recommended follow-up regimens among patients diagnosed with melanoma and non-melanoma skin cancers.

Methods: 105 patients with cutaneous melanoma and 1151 patients with non-melanoma skin cancers diagnosed between December 1996 and December 2001 were identified through biopsy records.  The records of all identified patients were then retrospectively reviewed for compliance with physician recommended follow-up regimens over a 60-month period.

Results: At 60 months following initial diagnosis, 22.6% of melanoma patients and 19.3% of non-melanoma patients were still continuing follow-up examinations.  However, only 10.5% of melanoma patients and 7.2% of non-melanoma patients were compliant with the recommended follow-up schedule.  Among melanoma patients, Breslow thickness correlated positively with duration of follow-up (P = 0.03).  The frequency of additional primary non-melanoma and melanoma skin cancers was positively correlated with duration of follow-up among patients with non-melanoma skin cancers (P ≤ 0.001).

Conclusions: Patient compliance with physician recommended follow-up regimens is generally poor; further research and intervention is necessary to identify and address the underlying causes.

Case Presentation

A slowly enlarging mass on the finger

An otherwise healthy 71-year-old woman presented with an asymptomatic mass on her right 4th finger that had been slowly enlarging over the past 2 years.  On physical examination, there was a tan-pink, freely mobile, rubbery 9-mm papule with a central keratotic plug located over the extensor aspect of the proximal interphalangeal joint of the right 4th finger.  A 3-mm punch biopsy of the lesion was performed.  Histopathologic findings were consistent with a diagnosis of aggressive digital papillary adenocarcinoma (ADPAca), an adnexal tumor with high metastatic potential that is unfortunately commonly misdiagnosed owing to its rarity and nondescript appearance.  Aggressive surgical treatment including radical excision or digital amputation with or without sentinel lymph node biopsy is advocated in the treatment of ADPAca.

Erlotinib induced target-like purpura

Erlotinib is an epidermal growth factor receptor (EGFR) inhibitor, used as a treatment for advanced stage cancer.  The most common side effect is cutaneous toxicity including the already known papulopustular reaction.  We herein report a case of erlotinib induced target-like purpura, a peculiar cutaneous adverse event.

A 57-year-old patient with advanced non-small cell lung cancer was treated by erolotinib 150 mg daily. After taking the drug for three days, an unusual target-like purpura developed on her lower legs. Skin biopsy specimen taken from the lesion revealed an extravasation of erythrocytes in the upper dermis without destruction of blood vessel walls. This skin eruption cleared after the drug was withdrawn and recurred after erlotinib was re-challenged.

The mechanism underlying this cutaneous adverse event remains to be elucidated. Physicians should be aware of the rare side effect of this increasingly used drug.

A case of harlequin ichthyosis treated with isotretinoin

Harlequin ichthyosis is a rare congenital ichthyosis classified under the category of Autosomal Recessive Congenital Ichthyoses, which also include lamellar ichthyosis and congenital ichthyosiform erythroderma. It is caused by functional null mutations in the ABCA12 gene, a keratinocyte lipid transporter associated with lamellar granule formation. Patients have a classic clinical presentation at delivery and need neonatal intensive care treatment to maximize their chances of survival. Early oral retinoid therapy has been shown to increase survival in patients with harlequin ichthyosis[1], and we present a case of a 9-month-old male with this condition who has been treated with isotretinoin since day 7 of life.

Cutaneous metastasis of a transitional cell carcinoma

Cutaneous metastases are infrequently encountered in dermatology. We describe a rare case of a urolethial carcinoma metastatic to the skin in an elderly female. The metastasis expanded rapidly and was thought to possibly be infectious on her initial evaluation by her primary team. We were called in as consultants and biopsied this mass to confirm our concern for metastatic disease. In this case there was an unknown primary tumor. Histologic staining patterns were used to suggest that the tumor may have originated from her urinary bladder.

Oral compound nevus

The melanocytic nevus is a benign and focal proliferation of nevus cells that can be congenital or acquired. Intraoral lesions are uncommon, and the etiology and pathogenesis are poorly understood. The occurrence rate of oral compound nevus is about 5.9% to 16.5% of all oral melanocytic nevi. A 22-year-old male patient presented with a dark brown macule on the buccal mucosa of the maxilla in the region of tooth 26. The lesion was elliptical, 0.7 x 0.5 cm, well circumscribed, asymptomatic, and the evolution time was unknown. An excisional biopsy was performed and microscopic analysis revealed nests of nevus cells in the epithelium and underlying connective tissue that were compatible with melanocytic compound nevus. Owing to the clinical similarity between oral melanocytic nevus and oral melanoma, a histopathological analysis is mandatory for definitive diagnosis.

Dermoscopy in Merkel cell carcinoma: a case report

Merkel cell carcinoma (MCC) is a rare malignant and primary neuroendocrine carcinoma with several known risk factors. Early diagnosis and aggressive treatment are critical. We report the case of an 82-year old woman with a Merkel cell carcinoma on the face. Clinical and histopathological features are presented. In addition, dermoscopic features and the differential diagnosis of this rare tumor are discussed. Although nodules with atypical dermoscopic vascular pattern and milky-red areas will end up being excised, this report adds more clues to the rarely described dermoscopic morphologic presentation of MCC.

Eruptive nodules of the head and neck: a case report of metastatic prostate cancer

Cutaneous metastasis is an uncommon but well recognized phenomenon occurring as a result of internal malignancy. Cancers most often associated with cutaneous metastasis are melanoma and primary malignancies of the breast and head and neck. Cutaneous metastatic prostate cancer is rare, representing only 1% of cases. Herein we report a case of advanced prostate cancer with multiple cutaneous metastases and briefly review the literature highlighting the clinical and histopathological features as well as a management approach to the patient with metastatic prostate cancer involving the skin.

Localized acne induced by radiation therapy

The appearance of localized acne or comedo reaction during or shortly after radiotherapy is an unusual adverse event, but one that is probably underestimated. It can manifest as an inflammatory (papules, pustules, nodules), comedonal (open and closed comedones, Favre-Racouchot-like syndrome), or mixed presentation. We report two new cases of radiation-induced acne with different clinical aspects and discuss the main known features of this adverse event.

Localized acneiform eruption following radiotherapy in a patient with breast carcinoma

The vast majority of patients treated with radiotherapy develop dermatological side effects. Acute radiation dermatitis or chronic skin fibrosis are well known sequels of radiation, but there are also other infrequent skin toxicities following external radiotherapy we should be aware of. We present a case of a rare form of delayed radiation dermatitis consisting of a localized acneiform eruption, confirmed by skin biopsy, in the irradiated fields in a woman with breast cancer. We review the clinical characteristics and risk factors available in the literature about this unusual adverse effect of radiotherapy. It is important for dermatologists to recognize this rare adverse effect, owing to the important impact on physical and psychosocial health of the patients and because it may delay the surgical reconstruction.

Photo Vignette

Transient symptomatic zinc deficiency in a preterm exclusively breast-fed infant

A 5-month-old female infant, preterm, exclusively breast-fed, presented with a 2-month history of erythematous, erosive, and crusted patches and plaques in a peri-oral, scalp, genital, and peri-anal distribution. A clinical diagnosis of zinc deficiency was confirmed by a low serum zinc level in the infant and decreased maternal breast milk zinc. Complete resolution occurred within two weeks of oral zinc supplementation. Acquired zinc deficiency is a rare nutritional disorder of infants. Early diagnosis and adequate treatment will prevent associated morbidity and complications.

Firm papules on the penis and scrotum

An 18-year-old man presented with a 6-year history of penile and scrotal papules. Biopsy of one of the 1-3mm papules revealed calcinosis cutis.

Angioedema-like allergic contact dermatitis related to black henna

Allergic contact dermatitis related to para-phenylendiamine (PPD) from temporary black henna tattoos and hair dyes has become an epidemic in recent years. Several cases of adverse skin reactions to PPD have been reported in the literature. Herein, we present a case of angioedema-like allergic contact dermatitis related to hair coloring with henna.

Fibromatosis digital infantil de presentación atípica

Infantile digital fibromatosis is a rare benign fibro/myofibroblastic proliferation that almost only occurs on the fingers and toes. It is characterized by bright, round, intracytoplasmic, eosinophilic inclusions. We present a case of infantile digital fibromatosis in a 6-years-old child.

Changing pigmentation in a solitary scalp lesion

A healthy 66 year-old man presented with a complaint of changes within a nodule on the scalp, which had first appeared over 10 years prior. He had no previous history of skin cancer.  On physical examination a solitary, asymmetric, purple-black nodule with irregular borders was identified on the right vertex of his scalp. The remainder of his examination did not reveal any additional lesions.