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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 4, 2015

Commentary

The use of an imagery mnemonic to teach the porphyrin biochemical pathway

We designed an imagery mnemonic to help medical students and residents learn the porphyrin pathway and associated diseases. Fourth year medical students at the Icahn School of Medicine at Mount Sinai in the spring of 2014 participated. One group (n=11) received the porphyrin pathway in a lecture explaining a mnemonic, whereas a second group (n=11) was simply taught the steps of the pathway. A pre-intervention assessment before the lectures was given to assess baseline differences in knowledge of the porphyrin pathway between the groups. Immediately following the lecture, 1 week after the lecture, and 3 weeks after the lecture, the students were given quizzes to assess their knowledge. Students were aware of the week 1 quiz and were asked not to study for it. The week 3 quiz was a surprise. There were no statistically significant differences in knowledge of the pathway at baseline (p=.45), at the immediate post-intervention (p=.22), or one week post-intervention (p=.40). Three weeks after the lecture, students in the mnemonic group scored 20% higher than controls (p=.02). Students who had learned the mnemonic demonstrated better long-term retention of information than students learning by the control method. This mnemonic minimizes study time while improving long-term retention.

Case Presentation

An usual elastophagocytic granuloma with involvement of the back: a possible variant of an annular elastolytic giant cell granuloma

Annular elastolytic giant cell granuloma (AEGCG) is a very infrequent granulomatous dermatitis characterized by elastolysis and elastophagocytosis. It usually appears in middle-aged Caucasian women and is normally located in sun-exposed areas.

We present a case of a 73-year-old woman with hypertension and type II diabetes, who was admitted to the hospital for an ischemic cerebrovascular accident. She presented with annular and serpiginous skin lesions on her back and arms that had appeared seven months earlier;  a clinical and histological diagnosis of elastophagocytic granuloma was made. Our patient exhibited a florid presentation and a self-limiting course.

Cutaneous sarcoidosis masquerading as psoriatic plaques

Sarcoidosis is a multisystem disease characterized by non-caseating granulomas present in the involved organ systems. The disease is believed to result from an interaction among genetic factors, antigens, and the immune response. Environmental exposures and infectious agents have been implicated as potential causes [1]. Cutaneous sarcoidosis presents clinically in many forms and the lesions are classified as either specific or non-specific. Non-specific lesions show a nondescript inflammatory process [2] whereas specific lesions display typical, non-caseating granulomas. There are many different forms of specific lesions with some being more common than others. Psoriasiform lesions are uncommon [1].  The literature suggests that as few as 0.9% of patients display this type of cutaneous sarcoidosis [3]. Some of these patients present solely with cutaneous sarcoidosis, but others have systemic involvement with pulmonary involvement being the most common concomitant presentation [4-8]. Plaques appear as round or oval, brownish, red infiltrated lesions [9], frequently involving the extensor surface of the extremities, face, scalp, back, and buttocks [9, 10]. Multiple configurations, including discrete, confluent, annular, and polycyclic, have been reported [5 11]. Despite the clinical resemblance to psoriasis, on histological examination, only non-caseating granulomas are seen in the dermis. In rare cases both psoriasiform sarcoidosis and psoriasis were present [4].

A misdiagnosed melanoma: a case of cutaneous epithelioid malignant peripheral nerve sheath tumor

Malignant Peripheral Nerve Sheath Tumor (MPNST) is a rare soft tissue sarcoma that can occur in superficial locations. Histologically it is categorized into two variants: a conventional/spindled and an epithelioid variant. The latter one is very rare and can be confused histologically with malignant melanoma as it is diffusely positive for S100-protein. Herein we present a case that was initially misdiagnosed as malignant melanoma and discuss morphological and immunohistochemical clues to reach a correct diagnosis.

Morphea-like complications to illicit gluteal silicone injections

We present a case of a 39-year-old Hispanic woman who was referred to our clinic for treatment of several indurated plaques on her buttocks that developed one year prior to presentation, after she received injections of an unknown substance for augmentation. Biopsy of one nodule revealed silicone in the dermis.

Bullous acrodermatitis enteropathica: case report of a unique clinical presentation and review of the literature

Acrodermatitis enteropathica is a rare autosomal recessive disease characterized by pink scaly plaques and erosions in the periorificial and acral regions. A mutation in a gene responsible for zinc transport results in significant zinc deficiency in individuals lacking oral supplementation. We present a female infant with acrodermatitis enteropathica with crusting of the periorificial regions along with perineal plaques. A delay in diagnosis and treatment led to the development of pronounced painful acral bullae. Although plaques and erosions in the periorificial and acral regions are most commonly observed, bullae should also be considered in the spectrum of clinical manifestations of acrodermatitis enteropathica. The rare bullous variant of acrodermatitis enteropathica can be distinguished histologically.

Erythema multiforme like allergic contact dermatitis associated with laurel oil: a rare presentation

Allergic contact dermatitis is a common skin disease, which affects approximately 20% of the population. This reaction may present with several clinical manifestations. Erythema multiforme-like allergic contact dermatitis is a rare type of non-eczematous contact dermatitis, which may lead to difficulty in diagnosis.Essential oil of Laurus nobilis is widely used in massage therapy for antiinflammatory and analgesic effects. Laurus nobilis induced contact dermatitis has been reported in the literature but an erythema multiforme-like presentation is rare.

Photo Vignette

Coral contact dermatitis

Corals can elicit both toxic and allergic reactions upon contact with the skin. Clinical presentations vary depending on whether the reaction is acute, delayed, or chronic. Literature concerning cutaneous reactions to corals and other Cnidarians is scarce. Herein we report a case of delayed contact hypersensitivity reaction to coral and review the clinical and histopathological features of coral contact dermatitis.

Harlequin syndrome: a mask of rare dysautonomic syndromes

Harlequin syndrome (HS) is a rare disorder of the sympathetic nervous system which presents with unilateral decreased sweating and flushing of the face, neck, and chest in response to heat, exercise, or emotional factors. The contralateral side displays a compensatory overreaction to provide normal heat regulation of the face as a whole. In the literature, most of the cases are primary in nature and no underlying cause could be identified. Harlequin sign is used to denote these symptoms in patients who also exhibit associated oculosympathetic paresis, such as Horner syndrome, Adie syndrome, and Ross syndrome.We report a rare case of a 13-year-old boy who presented with complaints of flushing and sweating of the left side of the face after exertion, while the right side remained dry and maintained its normal color. No structural abnormality was identified on detailed work up. Thus, diagnosis of classic idiopathic HS was made. Despite the rarity of this syndrome, dermatologists should be acquainted with this distinctive entity and should refer the patient for complete ophthalmological and neurological examination.

Pedunculated polypoid melanoma. A case report of a rare spindle-cell variant of melanoma

We report an 89-year-old man who presented with a slowly growing pigmented pedunculated tumor. The nodule was diagnosed as a spindle cell pedunculated malignant melanoma (PMM), a rare variant of spindle-cell malignant melanoma. The clinical presentation of this tumor and its histological and immunohistological features are discussed.

Utilidad de la ecografía cutánea en el diagnóstico diferencial de las lesiones azules, hidrocistoma

Numerosas enfermedades cutáneas pueden presentarse como lesiones azules, el diagnóstico diferencial incluye entidades tan diferentes como las metástasis de melanoma, los angiomas, los lipomas, los quistes epidermoides, los pilomatrixoma, los nevus azules, los tumores glómicos o los hidrocistomas, como el que presentamos. La ecografía cutánea será una técnica diagnóstica complementaria de gran valor para hacer un correcto diagnostico diferencia pues cada una de estas lesiones tienen hallazgos ecográficos diferentes que orientaran el diagnóstico.

Squamous cell carcinoma in the setting of chronic hidradenitis suppurativa; report of a patient and update of the literature.

Squamous cell carcinoma (SCC) developing in chronic hidradenitis suppurativa (HS) is rare, but failing to recognize the condition may have significant consequences. Dermatologists must be aware of the potential for malignant transformation and should have a low threshold for biopsy when clinical presentation is atypical. Herein we describe a 64-year-old woman with metastatic vulvar SCC that developed within an area of chronic HS. Like SCC associated with other chronic inflammatory disorders (Marjolin’s ulcers), mortality is significant. Past reviews have reported death rates above 40% and our most recent update continues to support poor prognoses for these patients.

Dermatology and Social Media

Patient use of social media to evaluate cosmetic treatments and procedures

Background: With a growing sphere of influence in the modern world, online social media serves as a readily accessible interface for communication of information. Aesthetic medicine is one of many industries increasingly influenced by social media, as evidenced by the popular website, “RealSelf,” an online community founded in 2006 that compiles ratings, reviews, photographs, and expert physician commentary for nearly 300 cosmetic treatments.

Objective: To investigate the current preferences of patients regarding cosmetic non-surgical, surgical, and dental treatments on RealSelf and in the documented medical literature.Methods: On a single day of data collection, all cosmetic treatments or procedures reviewed on the RealSelf website were tabulated, including name, percent “worth it” rating, total number of reviews, and average cost. Patient satisfaction rates documented in the current medical literature for each cosmetic treatment or procedure were also recorded. Statistical t-testingcomparing RealSelf ratings and satisfaction rates in the literature was performed for each category—non-surgical, surgical, and dental.Results: The top ten most-commonly reviewed non-surgical treatments, top ten most-commonly reviewed surgical procedures, and top 5 most-commonly reviewed dental treatments, along with documented satisfaction rates in the medical literature for each treatment or procedure were recorded in table format and ranked by RealSelf “worth it” rating. Paired t-testing revealed that satisfaction rates documented in the literature were significantly higher than RealSelf “worth it” ratings for both non-surgical cosmetic treatments (p=0.00076) and surgical cosmetic procedures (p=0.00056), with no statistically significant difference for dental treatments.Conclusions: For prospective patients interested in cosmetic treatments or procedures, social media sites such as RealSelf may offer information helpful to decision-making as well enable cosmetic treatment providers to build reputations and expand practices. “Worth it” ratings on RealSelf may, in fact, represent a more transparent view of cosmetic treatment or procedural outcomes relative to the high satisfaction rates documented in medical literature. Massive online communication of patient experiences made possible through social media will continue to influence the practice of medicine, both aesthetic and otherwise.

Letter

Nd:YAG laser offers promising treatment option for familial glomuvenous malformation

Although an uncommon entity, familial glomangiomatosis is often a source of significant discomfort to affected patients and impacts quality of life. Patients develop numerous painful vascular lesions, beginning in childhood. Because management strategies for this entity are sparsely reported in the literature, additional study is needed to establish best practice. We report positive results with the use of Nd:YAG laser in treating symptomatic lesions of familial glomuvenous malformation

European trends in the frequency of original research in acne vulgaris, rosacea, dermatitis, psoriasis, skin cancer, and skin infections, 1970-2010

We analyzed trends in the frequency of original publications into common dermatologic topics in two premier European journals, the British Journal of Dermatology and the Journal of the European Academy of Dermatology and Venereology. Most notably, we found that psoriasis publications peaked around the mid-to-late 1980’s as well as demonstrated an upward trend since the 21st century. Skin cancer research witnessed a gradual increase in the frequency of publications since 1970. These findings were consistent with a prior study analyzing trends in two American dermatology journals. We attempted to analyze these results from a historical perspective as well as provide an outlook on the future of research into these common dermatologic topics.

Tonsillar chancre as unusual manifestation of primary syphilis

Primary syphilis with oropharyngeal manifestations should be kept in mind, though. Lips and tongue ulcers are the most frequently reported lesions and tonsillar ulcers are much more rare. We report the case of a 24-year-old woman with a syphilitic ulcer localized in her left tonsil.

Skin cancer screening and melanoma detection: a life saved

Rural America spans about two-thirds of the land that composes the United States. There are major health disparities in this population including a lack of screening, a shortage in education, and limited access to health care providers. These health disparities combined with a lack of health insurance led our patient to ignore the asymptomatic melanoma on her right foot for 10 years. Although the most recent update from the US Preventive Service Task Force found insufficient evidence to recommend for or against routine melanoma and non-melanoma skin cancer screening, our patient insists that the screening she attended that day saved her life.

Biopsy rates vary with patient profile across different physicians in an academic dermatology practice

Current healthcare trends promote data-driven “benchmarking” to decrease cost and increase quality. Dermatologists perform 79% of skin biopsies and biopsy rate is an easily measured benchmark. To reduce the risk of a misguided “one size fits all” benchmark for biopsies, it will help to document the factors driving divergent biopsy rates.

This letter compares biopsy rates and high-risk patient ratios for 1000 sequential patients from two academic dermatologists. Elevated biopsy rates (0.55 vs 0.42, p < 0.001) were associated with elevated ratios of high-risk patients (.52 versus .30, p< 0.001). Although limited by small sample size, this research takes a first step toward future efforts to improve accuracy of biopsy benchmarking.

Topical AC-11 abates actinic keratoses and early squamous cell cancers in hairless mice exposed to Ultraviolet A (UVA) radiation

AC-11 is an aqueous extract of the botanical, Uncaria tomentosa, which has a variety of effects that enhance DNA repair and down regulate inflammation. AC-11 is essentially free of oxindole alkaloids (< 0.05%, w/w) but contains more than 8% carboxy alkyl esters (CAEs) as their active ingredients. Three groups of 10 outbred SK-1 hairless or SK-II hairless strains of mice each were treated with AC-11 at 0.5%, 1.5%, and 3.0% in a non-irritating, dye-free, perfume-free, and fragrance-free vanishing cream vehicle. Ten mice used vehicle only and 10 were untreated. Each concentration of AC-11 and was applied daily to the backs of the mice prior to exposure to a 1,600-watt solar simulator used in this work (Solar Light Co. Philadelphia, PA) emitting (mainly Ultraviolet A (UVA) and B (UVB) radiation) duration of the experimental period with UVB wavelengths was filtered out with a 1.0 cm Schott WG 345 filter. AC-11 with a peak absorption at 200nm does act as a sun block. We tested for and focused on clinical appearance of mice and histological appearance of tumors in mice rather than metrics of radiation generated inflammation. Tumor progression scores were assigned as follows: 4+ = extensive tumor development; 3+ = early malignancies (raised palpable plaques)(early squamous cell cancers) 2+ = firm scaling, palpable keratosis (actinic keratoses); 1+ = light scaling with erythema. Following a total cumulative dose of 738 J/cm2, 85.7% all of the irradiated control animals, which did not receive AC–11 had precancerous actinic keratosis (AK)-type lesions (2+) (64.3% versus 42.9%) or early squamous cell carcinoma (SCC) (3+) (21.4% vs. 4.8%), in comparison with 47.7 % of AC-11-treated animals. There were no significant differences between the AC–11 groups. Three months after cessation of exposure to UVA radiation, the lesions in all but three of the 14 animals which were treated with AC-11 that were still evaluable irradiated with UVA radiation progressed to papillomas and frank squamous cell carcinomas (+4 responses). AC-11 retarded, but did not stop, carcinogenesis progression. It is possible that if AC-11 was continuously applied tumors would not have in mice treated with AC-11 for a limited period. While we do not know how AC-11 exerts its DNA repair and anti-inflammatory effects, AC-11 is therapeutic for the treatment at the time of development of actinic keratoses and squamous cell carcinomas in mice and by extension humans. Without the constant presence of AC-11 these protective effects do not occur.