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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 2, 2015

Original

Participant satisfaction with appearance-based versus health-based educational videos promoting sunscreen use: a randomized controlled trial

Background: Increasing participant satisfaction with health interventions can improve compliance with recommended health behaviors and lead to better health outcomes. However, factors that influence participant satisfaction have not been well studied in dermatology-specific behavioral health interventions. We sought to assess participant satisfaction of either an appearance-based educational video or a health-based educational video promoting sunscreen use along dimensions of usefulness of educational content, message appeal, and presentation quality.

Methods: In a randomized controlled trial, participants were randomized 1:1 to view an appearance-based video or a health-based video. After six weeks, participant satisfaction with the educational videos was assessed.

Results: Fifty high school students were enrolled and completed the study. Participant satisfaction ratings were assessed using a pre-tested 10-point assessment scale. The participants rated the usefulness of the appearance-based video (8.1 ± 1.2) significantly higher than the health-based video (6.4 ± 1.4, p<0.001). The message appeal of the appearance-based video (8.3 ± 1.0) was also significantly higher than the health-based video (6.6 ± 1.6, p<0.001). The presentation quality rating was similar between the appearance-based video (7.8 ± 1.3) and the health-based video (8.1 ± 1.3), p=0.676.

Conclusions: Adolescents rated the appearance-based video higher than the health-based video in terms of usefulness of educational content and message appeal.

Review

Topical treatment of melanoma skin metastases with Imiquimod: a review

Background: At present, case studies are the only source of results on imiquimod (IMQ) as monotherapy in cutaneous metastases from melanoma. We analyzed these studies in the literature with the aim to review the efficacy of IMQ as topical treatment for melanoma skin metastases. Objective: The aim of our review was to critically assess the studies evaluating the monotherapy with IMQ cream in the treatment of cutaneous metastases from melanoma.  Methods: A PubMed search was conducted using the term "melanoma" combined with "metastases" and "imiquimod". Results: 57 studies were identified. 46 did not meet inclusion criteria, leaving 11 case studies. Overall, 17 patients were treated in these 11 studies. Main treatment choice was 5% IMQ cream applied once daily (for 6-8 hours), five days per week under occlusive conditions, in 8/17 patients (47,1%). IMQ was applied 3 times weekly in 4/17 patients (23,53%), daily in 2/17 patients (11,76%) and twice daily in 2/17 patients (11,76%).

Treatment length was variable, with a mean duration of 22 weeks (range from 8 weeks to 72 weeks).

The majority of studies showed that IMQ is an effective and safe treatment for metastases of melanoma. Even if this treatment doesn't stop the disease progression, it is mainly useful in clearing cutaneous metastases spreading from melanoma primary tumor.

 

Case Report

TNF-inhibitor induced Lupus in a patient treated with adalimumab for rheumatoid arthritis

Anti-tumor necrosis factor induced lupus (ATIL) is a rare side effect reported in patients treated with anti-tumor necrosis factor medications such as infliximab, etanercept and adalimumab. Of the three, this condition has been least commonly reported secondary to adalimumab. In this report, we present a case of ATIL in a patient treated for rheumatoid arthritis (RA) with adalimumab. This report will increase physician awareness of the warning signs, diagnostic options and potential complications of ATIL. In this patient, adalimumab was discontinued and treatment was started, leading to improvement in the patient’s status.

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Granulomatous pigmented purpuric dermatosis: an unusual variant associated with hyperlipidemia

Granulomatous pigmented purpuric dermatosis (PPD) is a rare subtype of pigmented purpuric dermatosis that is typically seen in women of Far East Asian descent on the distal lower extremities and feet. Granulomatous PPD is a benign condition that does not typically require treatment. Hyperlipidemia has been seen in over half of the eighteen cases reported in the literature. We report an unusual presentation of granulomatous PPD seen in a 71 year-old Caucasian female with hyperlipidemia.

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  • 1 supplemental file

Case Presentation

Paraneoplastic plaque-like cutaneous mucinosis: a case report

Plaque-like cutaneous mucinosis (PCM) is a rare disorder of dermal mucin deposition.  Some patients with PCM will be found to have an associated malignancy. We report the case of a 72-year-old man presenting with new onset pruritic, waxy-appearing erythematous and skin-colored papules and nodules coalescing into plaques on his shoulder, scalp, and forehead. Skin biopsy revealed cutaneous mucinosis. Despite conservative treatment, his skin lesions progressed, and he was found to have an occult malignancy of pancreatobiliary origin. After several months of chemotherapy, his skin lesions showed progressive improvement. To our knowledge, this is the third reported case of paraneoplastic PCM and the first reported to occur in association with underlying adenocarcinoma of pancreatobiliary origin. PCM may occasionally represent a paraneoplastic dermatosis. This case highlights the importance of a search for occult malignancy in such patients.

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Linear syringocystadenoma papilliferum on female breast: a rare appendageal tumour on an uncommon location

Syringocystadenoma papilliferum is a rare benign adnexal tumor commonly located on the head and neck region and is usually associated with a nevus sebaceous. Linear lesions are uncommon and lesions on the breast are extremely rare. We report here a case of linear SCAP occurring de novo on the left breast of a 35-year-old healthy woman. Histopathology showed the characteristic papillary projections lined by double layer of cells inside epidermal invaginations.

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Extensive hidradenitis suppurativa (HS) Hurly stage III disease treated with intravenous (IV) linezolid and meropenem with rapid remission

A 57-year-old woman with Hurley Stage 3 hidradenitis suppurativa (HS) and multiple co-morbidities is presented. She had failed multiple antibiotic therapies and etanercept. She had end stage renal disease and was on dialysis. Her HS was put into remission with one month of daily IV treatment with 1.2 grams linezolid and 1 gram of meropenem, administered daily through her dialysis shunt. Unfortunately, her disease flared again two weeks after the cessation of the IV treatment. Nevertheless, more conventional therapy was then able to maintain her disease at a level that was significantly improved over baseline prior to the IV treatment. This case highlights above all a primary etiology of HS is stimulus of immune system's over-reaction in HS to the bacterial microbiome. If antibiotics are administered to a patient with stage 3 HS powerful enough to wipe out the bacterial biome, the immune system having no target retreats, permanent scarring in its wake and retreats to a certain but hardly permanent normalcy.

Cutaneous metastasis of Papillary thyroid carcinoma to the neck: a case report and review of the literature

Papillary thyroid carcinoma, the most common subtype of thyroid malignancy, rarely presents with cutaneous metastatic spread.  Despite metastatic cutaneous lesions presenting as slow and indolent growing nodules of the head and neck, such lesions most frequently appear in the setting of diffuse and dramatic metastatic disease and a bleak prognosis.  Given the rarity of these metastatic lesions, the diagnosis may be delayed, and often the initial diagnosis is incorrect.  Several case reports have been published in the literature noting unusual or interesting presentations of thyroid carcinoma with cutaneous metastasis.  Here we present a classic case of a patient with a prior diagnosis of thyroid carcinoma presenting with a slowly growing ulcerated lesion on the neck nine years after partial thyroidectomy and characteristic histopathology on microscopic examination.  Furthermore we review the literature regarding papillary thyroid carcinoma with cutaneous metastasis and the diagnostic challenge these lesions present to practitioners.

Cryotherapy-induced milia en plaque: case report and literature review

Background: Cryotherapy-induced milia is a rarely described cutaneous reaction that may occur in patients who have received cryotherapy with liquid nitrogen. Cryotherapy-induced milia is characterized by 1-2 millimeter white dermal cysts that develop at the healed cryotherapy site. Milia en plaque, an erythematous plaque containing numerous milia, has not previously been described following treatment of a skin lesion with liquid nitrogen cryotherapy.

Purpose:  We describe a man who developed cryotherapy-induced milia en plaque after receiving cryotherapy to his dorsal hand for the treatment of an actinic keratosis. We also summarize the potential complications of cryotherapy, the differential diagnosis of milia en plaque, and therapeutic interventions for this lesion.

Materials and methods:  The features of a man with cryotherapy-induced milia en plaque are presented. Using PubMed, the following terms were searched and relevant citations assessed: cryosurgery, cryotherapy, hypothermia, milia, milia en plaque, and Wolf's isotopic response. In addition, the literature on cryotherapy-induced milia and cryotherapy-induced milia en plaque is reviewed.

Results:  Our patient developed cryotherapy-induced milia en plaque shortly after his cryotherapy site had healed. Some of the asymptomatic cystic dermal lesions had spontaneously resolved when a lesional biopsy was performed to confirm the diagnosis. The diagnosis, natural course, and potential treatments were discussed with the patient. Subsequent management was to observe the area; at follow-up examination, the remainder of the milia had also spontaneously resolved.

Conclusion:  Cryotherapy-induced milia is a benign condition characterized by the development of small white dermal cystic lesions that develop at a healed liquid nitrogen cryotherapy site. The lesions may appear individually or as milia en plaque. While the mechanism of pathogenesis is unknown, we postulate that the condition is an example of Wolf's isotopic response, in which a new, unrelated skin disease develops at the site of a previously healed dermatosis - in this circumstance, following cryotherapy which created an immune compromised zone. The diagnosis of milia en plaque can usually be established by clinical presentation; if necessary, a biopsy can be performed to provide pathologic confirmation of the suspected diagnosis. Treatment options include manual extraction, topical retinoids, or observation. Similar to our patient, the milia may resolve spontaneously.

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Commentary

Home ultraviolet light therapy for psoriasis: Why patients choose other options

Background: Psoriasis is a common inflammatory skin condition for which office-based and home phototherapy are safe and effective treatments. However, patients who are prescribed home phototherapy devices often choose other treatment options.

Objective: To determine the reasons why patients do not purchase a home phototherapy device after it has been recommended and prescribed by their physician.

Methods:  Patients who were written a prescription for a home phototherapy device but did not fill the prescription were identified and contacted by the National Biological Corporation to participate in a telephone survey consisting of 4 questions regarding why they did not pursue a prescribed home ultraviolet device and how they were currently treating their psoriasis.

Results: The most common reason for not obtaining the prescribed home phototherapy device was using a biologic agent (31%). The second and third most frequently reported reasons were “cost share too high” and “insurance will not cover” (18% and 17%, respectively), together accounting for 35%.

Limitations: The reason why patients were prescribed biologics while having an unfilled home phototherapy device prescription was not obtained.

Conclusions: Out of pocket cost is a significant barrier to home phototherapy, even to patients who are well insured.

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Update on mobile applications in dermatology

Background: As the use of mobile devices surpasses that of personal computers, medical applications increasingly provide easy access to a diverse range of health care resources.

Purpose: To analyze changes in the number of dermatologic mobile applications since 2012.

Methods: We examined five mobile platforms (Apple, Android, Windows, Nokia, and Blackberry) for dermatology-related diagnoses applications. The apps were categorized by purpose, cost, and target audience.

Results: A total of 365 dermatologic mobile applications were analyzed with 225 new mobile applications found since 2012. Since the last query, there was a decrease in market share of reference materials (26.6% in 2012 to 15.9% in 2014) and self-surveillance/diagnosis applications (17.9% in 2012 to 12.9% in 2014) while teledermatology apps increased from 3.5% of total apps in 2012 to 9% in 2014.

Conclusions: Dermatology apps continue to proliferate with minimal regulation. As technology continues to advance and physicians have greater access to mobile- health information, novel advancements in diagnosis may lead to more time-and-location-flexible patient care.

Is the duration of skin disease visits decreasing in the united states?

Background: Changes in the practice of medicine may be affecting how much time physicians spend with their patients.  Economic pressures in some health systems may limit how much time patients spend with doctors.  Inefficiencies associated with the use of EMR potentially could lengthen the duration of office visits.

Objective: To assess trends in the duration of skin disease visits over the last two decades.

Methods: Skin disease visits were selected from the 1993-2010 National Ambulatory Medical Care Survey. Changes in overall number of visits per dermatologist, variation in visit duration, and differences by specialty in visit duration were assessed.

Results: The mean duration of skin disease visits increased over time for both dermatologists (β=0.24 minutes) and nondermatologists (β=0.19, both P<0.0001). For visits with a sole diagnosis of skin disease, dermatologist visits were shorter (14.7 minutes) than nondermatologist visits (16.4 minutes, P<0.0001). Visits for unspecified warts, atopic dermatitis, unspecified dermatitis, and acne grew significantly longer over time. In a multivariate analysis, older age, later year, nondermatology specialty, new patient status, procedure performed, private insurance, no physician extender involvement, and electronic medical records were associated with longer visit duration.

Limitations: The data are not informative about the quality of the time physicians spend with patients.

Conclusions: Economic pressures have, so far, not reduced the average time physicians spend in direct contact with patients.

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Photo Vignette

Whitish oral lesions in a heavy pipe smoker

Classically known as the "Great Imitator", the diagnosis of syphilis continues to be an enormous challenge. We describe a case of isolated oral lesions as the sole presentation of secondary syphilis and only clinical clue to previously undiagnosed human immunodeficiency virus infection. The current increase in new cases of syphilis is leading to reemergence of forgotten old scenarios, which physicians should bear in mind within the differential diagnosis of their daily practice.

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Dermoscopy of acral angioma serpiginosum

Angioma serpiginosum (AS) is an unusual vascular disorder that typically affects female patients, begins in childhood and stabilizes in adulthood and not frequently involve acral skin. We herein present a 13 year-old girl with an asymptomatic erythematous punctuate first noticed on the right palm three years ago, with a proximal serpiginous progression up to the forearm. On examination there was a nonblanching erythematous punctuate on the palm and the inner aspect of right hand and forearm. Dermoscopy showed an erythematous parallel ridge pattern with some red globules and dots spreading on a linear arrangement, and the acrosyringia openings were not affected. Histopathological study showed dilated capillaries in the dermal papillae. This feature is consistent with angioma serpiginosum (AS). To the best of our knowledge, this is the first report that shows a dermoscopic image of a palmar AS. The dermoscopic pattern described in this case could aid in the diagnosis of AS and could add a value in the differential diagnosis with vascular lesions on acral skin.

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Digitial endochondroma

A case of Ollier`s disease presenting with onycholysis and nail dystrophy

Letter

Gluteal silicone injections leading to extensive filler migration with induration and arthralgia

Silicone injections have been used for cosmetic soft tissue augmentation for over five decades with documented consequences both systemic and dermatologic. We present a case of extensive filler migration causing bilateral lower extremity woody induration in a 53 year old Hispanic woman. She presented with a multi-year history of progressive joint stiffening at the knees, accompanied by induration and pain of the bilateral lower extremities. The patient had received two injections of an unknown substance placed into her bilateral gluteals 11 years prior.  MRI indicated an infiltrative process of both lower extremities and pathology was consistent with migration of injected tissue augmentation material, most likely silicone. Due to the extent of involvement the patient was started on a trial of doxycycline 100 mg PO BID.

News reports: update on buying indoor uv tanning with university debit cards

Background & Objective: Indoor tanning by adults under 35 years of age increases the risk of developing melanoma 59% to 75%. Cost is a major barrier limiting young adults from purchasing indoor tanning services. Our recent study by Boyers et al determined that 18 of 96 major universities, all in the eastern and southern United States, had university-sponsored debit cards with indoor tanning affiliations. These debit cards, which conveniently link with student identification (ID) cards, help with student living expenses and are often loaded with money by parents. By creating agreements with indoor tanning salon vendors, universities are endorsing a World Health Organization class I carcinogen. To expand the results of our previous study, we broadened our search to further assess universities in the western United States as well as Australia, New Zealand, Ireland, Canada, and the United Kingdom.

Methods: Using www.collegeboard.edu, we identified the 4 largest residential colleges in Arizona, California, Colorado, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming. Additionally, we investigated the top international universities, utilizing www.topuniversities.com. Internet searches, phone calls, and email correspondence were used to determine if an institution had a student ID-linked debit card. Universities with affiliations to bank debit cards and cards that could only be used on campus were excluded.

Results: In the western United States, indoor tanning merchants were affiliated with University of Arizona, Embry-Riddle Aeronautical University: Prescott Campus, and the University of Denver student debit cards. Of the original 18 schools with affiliations according to the Boyers et al study, 2 universities no longer have agreements and 5 created agreements with additional tanning salons.

Of 45 universities examined in our international search, no debit cards were discovered for off-campus purchases. Therefore, the concerning issue of university associations with tanning salons appears to be solely a domestic problem.

Conclusions: Our findings indicate that the formation of financial agreements between universities and tanning salons is an ever-present and growing problem in the United States. Since Boyers et al, we have engaged in outreach efforts with alumni, faculty, administration, and local university cancer centers to terminate university ties with tanning salon vendors.  Further advocacy efforts are critical to combat this dangerous association, reduce the frequency of skin cancer, and protect the health of young adults.

Sweet syndrome associated with interferon

Although still very rare, drug-related cases of Sweet’s syndrome have been reported. The more frequent associated medications with drug induced Sweet´s syndrome was: tetracyclines, trimethoprim-sulphamethaxazol, azatioprine, all trans retinoic acid, nitrofurantoin, granulocyte colony-stimulating factor, hydralazine, tripharil, lithium, oral contraceptives, furosemide, celecoxib and azathioprine.

We only found one case of drug-induced Sweet´s syndrome secondary to pegylated interferon-alpha in combination with ribavirin  reported in literature. To our knowledge, this one is the first reported case of Sweet’s syndrome in association with interferon beta 1-b therapy.Also, we would like to remark the atypical localization of the lesions in our patient, with a unilateral predominance on the left lower extremity and a very severe pain.

Patient perspectives on low level light therapy and laser therapies for rosacea-associated persistent facial redness

Introduction: There are no definitive treatments of facial redness for rosacea. All treatments aim to alleviate symptoms. Patients’ perspectives of two emerging modalities, Low level light therapy and laser treatments are not well characterized.

The purpose is to further understand rosacea patients unmet needs about these modalities,

 

Methods: The publicly accessible, online rosacea forum was accessed at august 2013. Stratified random sampling method has done to identify a 10% sample of total 27,051 posts. The Posts were published in the “Laser and IPL therapy” and “Low level light therapy” forums were qualitatively analyzed.

Results: Patients discussed a variety of topics, but most commonly discussed effectiveness (34.2%), treatment education (19.3%), and adverse effects (18%). Relationship with the health care provider (9.9%), cost (8.1%), execution of treatments (8.1%) and convenience of treatments (2.5%) were less commonly discussed, but contributed to patients’ decisions about utilizing laser and light therapies.

Conclusions: Online forums are utilized to fulfill patients’ desire for educational, empathic and collaborative relationship. Patients’ adherence to laser and light therapies will likely increase if costs are reduced, reduction in redness is consistent with their expectations, and if physicians empower them through education on device choices and managing adverse effects.