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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 21, Issue 1, 2015

Review

The use of photodynamic therapy to treat hidradenitis suppurativa a review and critical analysis

Hidradenitis Suppurativa (HS) is an inflammatory disease that results in abscesses, keloids, and fistulas.   Acne inversa is likely to result from aberrant cellular immunity and dysfunction of the hair follicle in which coagulase negative staphylococcus (CONS) and perhaps other bacteria appear e.g Corynebacterium sp.to play a role by creating biofilms and stimulating the immune system.  One treatment that has been proposed for HS is photodynamic therapy.  The cases series reported are small and not double blinded. As of October of 2104, 8 articles with 64 patients report success with photodynamic therapy using 5-aminolevulinic acid (PDT-ALA) or its methyl ester (PDT-MAL).  One of these 8 reports noted superiority of the free methylene blue gel over niosomal methylene blue gel.  Another report described success in a 27-patient trial using intralesional 5-aminolevulinic acid (ALA) in saline at a concentration of 1%.  This was administered at a dose of 0.2 ml per cm3 and an HS fistula was irradiated by a continuous 630-nm laser diode through a 1-mm thick optical fiber to 1 Watt per cm3 for 3 minutes (180 Joules).  However, 3 articles reported failure with PDT-ALA or pulse dye laser-mediated photodynamic therapy (PDL-PDT) and one article note 1 failure and 1 success.  We suggest that it is the ability of PDT-ALA or PDT-MAL to break up the bio-film produced by CONS and other antibacterial effects that account for its success in treating HS in patients in whom bio-film plays a pivotal part of their pathogenesis.  Other effects are also possible as well.  Other mechanisms by which PDT may improve HS include cytotoxic effects, which cause selective cell necrosis, and immunomodulatory effects.  The data suggests that if PDT is to be used, it should be with MAL or intralesional ALA.

Note that there are a variety of causes of HS. These include hyperkeratosis of in the follicular infundibulum, aberrant cellular immunity, down regulations of defensins in stage III HS, and the infiltration of neutrophils, mast cells, plasma cells, and lymphocytes into the affected follicle, among others.  However, it is likely that in individual cases one cause is primary and others secondary.  In conclusion, PDT is not a first line treatment for HS but in some cases could be added as an adjuvant to therapies such as clindamycin and rifampin.

Case Report

Multifocal tuberculosis verrucosa cutis

Tuberculosis Verrucosa Cutis (TBVC), a verrucous form of cutaneous tuberculosis, occurs from inoculation of tubercle bacilli into the skin of a previously sensitized patient with moderate to high degree of immunity. This disease is now rare in western countries and in India; the incidence of cutaneous tuberculosis has fallen from 2% to 0.15%. However two recent studies from the Indian subcontinent have reported the prevalence of cutaneous tuebrculosis as 0.7% (Varshney et al) and 0.26% (Patra et al)

This case is reported to demonstrate the indolent and extensive nature of tuberculosis verrucosa cutis in an immunocompetent individual and to highlight the importance of histopathology and empirical antitubercular therapy as an adjunct diagnostic tool.

Idiopathic perniosis of the buttocks and thighs – clinical report

Perniosis manifests as inflammatory cutaneous lesions mostly located on acral skin in association with cold and damp conditions. Perniosis of the thighs is quite uncommon and has been associated in the literature with horse riding (equestrian perniosis) or with other recreational activities with long time exposure to cold and humidity. We report a rare case of perniosis of the buttocks and thighs in a 34-year-old healthy woman without a previous history of horse riding or other high-risk activities. In this case, the use of thin and tight clothes is believed to have been enough for the development of perniosis in this susceptible subject.

Case Presentation

Severe cutaneous adverse reaction to telaprevir

A 50-year-old woman presented with diffuse, intensely pruritic pink-red papules on her trunk and extremities three weeks after starting combination therapy with ribavirin, telaprevir, and interferon. She also had cervical lymphadenopathy, fever, eosinophilia, and transaminitis consistent with a severe drug reaction to telaprevir. She was started on high potency topical steroids under inpatient observation and recovered within two weeks.  Severe cutaneous eruptions secondary to telaprevir have resulted in black-box warnings for potentially fatal skin reactions, including Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) and Stevens-Johnson Syndrome (SJS), and Toxic Epidermal Necrolysis (TEN). Because these reactions carry acute mortality rates of 10%, prompt detection and treatment with steroids are important. As such, physicians should be aware of these potentially lethal side effects.

Pancreatic Panniculitis

We describe a rare case of a patient with pancreatic adenocarcinoma who presented initially with a rash on her lower legs. Skin biopsy showed lobular panniculitis and characteristic “ghost” adipocytes consistent with pancreatitic panniculitis.  This clinical case is an interesting example where a seemingly innocuous skin condition heralds an underlying malignant disease process.

Diffuse lichenplanopilaris and multiple squamous neoplasms

Lichen planus is an inflammatory process that can affect the skin, mucosa, and hair follicles. An increased risk of squamous cell carcinoma has been noted in lichen planus of the mucosa. Rarely, in chronic, hypertrophic lichen planus of the skin, squamous cell neoplasms have been reported. We report a case of new onset lichen planopilaris with multiple squamous cell neoplasms.

Unusual manifestations of ectodermal dysplasia-syndactyly syndrome type I in two Yemeni siblings

Ectodermal dysplasias (EDs) are a group of genodermatoses characterized by malformations of tissues derived from the ectoderm, including the skin, its appendages (hair, nails, sweat glands), teeth, and the breasts. Ectodermal dysplasia syndactyly syndrome (EDSS) is a rare, newly described type of ED involving syndactyly. We report 2 Yemeni siblings with typical EDSS manifestations, including bilateral, partial cutaneous syndactyly of the fingers and toes; sparse, coarse, brittle scalp hair, eyebrows, and eyelashes; and conical, widely spaced teeth with enamel notches. In addition, the siblings presented with other features hitherto not described for this syndrome, such as adermatoglyphia, onychogryphosis, hypoplastic widely spaced nipples, hypoplastic thumbs, and red scalp hair.

Gout nodulosis: report of a rare case and brief review

The development of tophi in the absence of prior episodes of gouty arthritis is unusual. We hereby present a case of a non-alcoholic, normoglycemic, and normotensive middle-aged man, who presented with multiple nodules distributed bilaterally over the dorsum of hands, feet, and elbow joints without any prior history of arthritis. Serum uric acid level was found to be normal. Histology was consistent with features of tophi. On the basis of clinical and histological findings, the nodules were diagnosed as gouty tophi and the patient was diagnosed with gouty nodulosis. Gouty nodulosis is a very rare presentation of gout and only a few reports exist in the medical literature.

Commentary

Comparing burden of dermatologic disease to search interest on google trends

Google Trends is a publicly available resource for comparing Internet search query frequency and trends interest in queries over time. The tool provides country, region, and city-specific data for term search volume on Google Search. Our study sought to compare the relative search interest to the burden of disease for the fifteen skin conditions studied by the Global Burden of Disease (GBD) 2010 project. Searches on Google Trends were conducted by using the most inclusive terms and true ICD code definitions as possible for the skin conditions studied. We report that relative interest on Google Trends did largely correlate to burden of disease reported by the GBD 2010 study, though some conditions were either underrepresented or overrepresented. Acne and herpes were the most Googled skin disease terms. This study provides further insight into what may be the most burdensome skin diseases because those with more burdensome diseases likely sought out information on their condition.

Impact of a dermatology wiki website on dermatology education

Background: The Dermatology Education Wiki (dermwiki) website serves as a resource platform for medical students and residents. The readily accessible interface provides dermatology articles, survival guides, didactic lectures, and links to faculty talks as well as research opportunities.Objective: To assess medical student and resident satisfaction with the dermwiki website.Methods: Fourth-year medical students taking a dermatology elective were provided with a temporary password to access relevant dermwiki information. A satisfaction survey was created to assess whether medical students found the website helpful. Second- and third-year dermatology residents were also surveyed to compare satisfaction scores prior to and after the introduction of the dermwiki website. End-of-rotation medical student exam scores were tabulated and compared to the average scores from years prior to the development of the dermwiki website.Results: Medical students rated the dermatology elective with the dermwiki website higher than rotations without a wiki (8.12 vs 7.31). Students planning to go into dermatology were more satisfied with the dermwiki website, reported accessing the website more frequently (11 times vs 9.5 times), and reported more time spent studying (12.2 hours vs 6.7 hours) than students not going into dermatology. End-of-rotation medical student exam scores did not differ from those prior to the development of the demwiki website. Ten second- and third-year dermatology residents unanimously stated that they were more satisfied with the program after the institution of the dermwiki website.Conclusions: Overall, addition of the dermwiki website to the dermatology elective curriculum has improved medical student and resident satisfaction scores. The improvement is greater among students planning to enter the field of dermatology. This study serves as a model for the incorporation of internet-based interactive tools to transform and supplement the learning environment.

Dermatology on Pinterest

Background: Pinterest is a social media internet service utilized by individuals, organizations, and businesses to collect and share ideas related to projects or interests.Objective: The literature related to dermatology-related content on Pinterest is scarce. This study aims to investigate the presence of dermatology related content available on Pinterest.Methods: Investigators searched five terms related to dermatology in the "pins" and "boards" search categories of pinterest. The first 20 results were evaluated for content and assigned to a content group of "advocacy," "informative," or "home remedies." Boards were also categorized as being posted by an MD or professional society versus others. The top ten dermatology journals were also searched for under the boards category.Results: Informative pins were the most common (49%) followed by advocacy (37%) and home remedies (14%). Informative boards were the most common (53%) followed by home remedies (31%) and advocacy (16%).We identified that only 24% of boards were created by either M.D.s or advocacy organizations. The top ten dermatology journals identified by prior studies had little presence, with only one board posted by JAMA Dermatology.Conclusions: Our study contributes to a growing body of data that dermatology organizations are relatively absent from new social media sites, and Pinterest represents a potential outlet for targeted intervention in high-risk groups for skin disease.

Photo Vignette

A case of primary cutaneous mucormycosis caused by minor trauma

We present the case of a 66-year-old neutropenic man with mantle-cell lymphoma who presented for evaluation of a rapidly expanding necrotic eschar after a minor cutaneous injury. Histopathology revealed infection with Rhizopus indicating primary cutaneous mucormycosis. Our case reviews the presentation and management of this condition as well highlights the potential for minor cutaneous injuries in the hospital to lead to this dangerous infection.

Recurrent, pruritic papules on the legs

We present a patient with recurrent, pruritic, erythematous papules to the legs.

A case of cutaneous larva migrans presenting in a pregnant patient

Cutaneous larva migrans (CLM) is a pruritic dermatitis caused by migration of animal hookworm larvae into the skin. We present a case of CLM in a 31-year-old pregnant woman. The treatment of CLM relies on antihelminthic agents, such as thiabendazole, albendazole, and ivermectin. This case was interesting in that the standard treatment options previously mentioned were contraindicated owing to the patient’s pregnancy. Cryotherapy with liquid nitrogen resulted in complete resolution of her lesion and symptoms.

Worn down nails after acrylic nail removal

Worn-down nail syndrome is a nail disorder characterized by thinning of the distal nail plate caused by repetitive chemical or mechanical trauma. We present a previously undescribed source of worn-down nail syndrome caused by trauma from nail filing after acrylic nail removal.

Letter

Pulmonary sarcoidosis and latent tuberculosis in a patient with psoriasis treated with adalimumab

Tumor necrosis factor (TNF) inhibitors are powerful biologic medications that have been used successfully in the treatment of a variety of inflammatory conditions, including psoriasis. Although TNF inhibitors are generally well tolerated, their use increases the risk of infections such as tuberculosis (TB), and paradoxically, they have been associated with development of sarcoidosis. We report the case of a 54-year old man with plaque psoriasis who developed a positive TB test and pulmonary sarcoidosis after 12 months of adalimumab treatment. After stopping adalimumab, his psoriasis worsened and he was started on ustekinumab and narrowband UVB, with improvement in symptoms. We provide a review of the literature and discuss treatment challenges.

A large hyperplastic nodule on the abdomen

A 65-year-old man presented with a slowly enlarging, hyperplastic cutaneous nodule on the abdomen that developed over a period of 20 years. Based on the clinical manifestation and typical histopathology, the patient received a diagnosis of giant basal cell carcinoma.