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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 22, Issue 4, 2016

Original

Speckle-variance optical coherence tomography: a novel approach to skin cancer characterization using vascular patterns

Non-invasive imaging devices are currently being utilized in research and clinical settings to help visualize, characterize, anddiagnose cancers of the skin. Speckle-variance optical coherence tomography (svOCT) is one such technology that offers considerable promise for non-invasive, real time detection of skin cancers given its added ability to show changes in microvasculature. We present four early lesions of the face namely sebaceous hyperplasia, basal cell skin cancer, pigmented actinic keratosis, and malignant melanoma in situ that each display different important identification markers on svOCT. Up until now, svOCT has mainly been evaluated for lesion diagnosis using transversal (vertical) sections. Our preliminary svOCT findings use dynamic en face (horizontal) visualization to differentiate lesions based on their specific vascular organizations. These observed patterns further elucidate the potential of this imaging device to become a powerful tool in patient disease assessment.

A gender-based comparison of promotion and research productivity in academic dermatology

Purpose: Gender disparities within academic promotion have been reported in several medical specialties. Female representationin association with research productivity has not been reported among academic dermatologists. As research productivity is a heavily weighted factor in determining promotion, we sought to determine whether gender disparities in academic rank and scholarly impact, measured by the h-index, exist in academic dermatology.Methods: In 2015, the authors determined gender and academic rank using academic dermatology department websites. H- index and publication range were determined using the Scopus database. Rank, h-index, and publication range were compared between male and female academic dermatologists.Results: The h-index of academic dermatologists increased with successive academic rank from Assistant Professor through Professor (p<0.001), although no significant difference existed between Chairs and Professors. Publication range also increased with each successive rank from Assistant Professor through Professor (p<0.001), with no statistical significant difference between publication range of Chairs and Professors. Overall, men had higher h-indices than female colleagues (p<0.001). This difference was maintained when controlling for academic rank among Assistant Professors, Professors, and Chairs and when controlling for publication range in years.Conclusion: Women in academic dermatology are underrepresented among senior academic ranks. The difference in scholarly productivity between male and female academic dermatologists may contribute to this disparity. Recommendation for earlyinvolvement in research activities may help minimize this gap.

Case Report

Congenital cutaneous Langerhans cell histiocytosis and cutaneous mastocytoma in a child

Langerhans cell histiocytosis and mastocytoma are clonal disorders of bone-marrow-derived cells, most commonly seen in the pediatric age. Infiltration of mast cells and Langerhans cells in the same lesion has been published before, but, to our knowledge, this is the first time that the occurrence of two mastocytomas and Langerhans cell histiocytosis is reported. It could be hypothesized that both clonal disorders of bone-marrow-derived cells could have a common origin.

Vancomycin-induced linear IgA bullous dermatosis: associations

Linear IgA bullous dermatosis (LABD) is a rare autoimmune blistering disease. LABD is considered mostly idiopathic, butsome cases have been reported to be drug-induced, mainly associated with vancomycin (VCM).We present two cases of LABD possibly associated with VCM used for cardiac surgery prophylaxis; in the presented cases, the eruptions occurred only after VCM withdrawal, therefore leaving a question about the relationship between VCM and LABD in these cases.We reviewed previous reports of VCM-induced LABD and analyzed the following parameters: gender, age, recent medical history, concurrent medication, latency period, progression after withdrawal, time to resolution, treatment, and rechallenge.Results: The causal relationship between VCM and LABD was often unclear; patients frequently had concurrent medication and symptoms frequently began and/or progressed after VCM withdrawal. Among the 46 reviewed patients in addition to our two cases (n=48), 20 (42%) had recent history of cardiac procedure, cardiac infection, congestive heart failure, or aortic aneurism.Conclusion: Further investigation is needed to ascertain the association between LABD, VCM, and heart disease.

Commentary

Phototherapy for the treatment of prurigo nodularis: a review

Background/Purpose: Review the available literature on phototherapy for treatment of prurigo nodularis (PN).

Methods: Literature search was conducted on MEDLINE.

Results:  6 prospective trials, 2 retrospective studies, and 3 case series were found investigating efficacy and safety of phototherapy for treatment of PN.

Conclusion: Although large randomized clinical trials are necessary, phototherapy appears to be a safe and efficacious treatment for PN, alone and in combination with other common treatment modalities for PN.

Case Presentation

Primary cutaneous angioplasmocellular hyperplasia

Angioplasmocellular hyperplasia is a rare clinical condition with blood vessel proliferation and a reactive plasma cell infiltrate. To the best of our knowledge fewer than 20 cases of cutaneous angioplasmocellular hyperplasia have been published in English literature. We report a case of a 65-year-old man who presented with a long standing asymptomatic flesh colored ulcerated nodule on the back. Histopathological examination revealed a dermal vascular proliferation with polyclonal plasma cell infiltration. A diagnosis of angioplasmocellular hyperplasia was established. This entity is rare and we would like to emphasize the importance of clinico-pathological correlation to differentiate it from various other conditions of cutaneous plasma cell infiltration.

Bullous impetigo and pregnancy: Case report and review of blistering conditions in pregnancy

Background:  Bullous impetigo results from Staphylococcus aureus (S. aureus) release of exfoliative toxins type A and type B thatresults in flaccid, easily ruptured, bullae in the upper layers of the epidermis.  Physiologic, gestation-associated, and incidental skin changes can occur in pregnancy.  Blisters in pregnant women can occur secondary to either common skin disorders orspecific dermatoses of pregnancy.Purpose:  To describe a pregnant woman with bullous impetigo and review bullous conditions in pregnant women.Methods:  PubMed was used to search the following terms, separately and in combination:  blister, blistering, bullous, gestationis, herpes, herpetiformis, impetigo, pemphigoid, pregnancy, pregnant, psoriasis, pustular, virus. All papers were reviewed and relevant manuscripts, along with their reference citations, were evaluated.

Results:  Flaccid, easily rupturing, pustules, which developed into superficial annular erosions with peripheral scale and central healing appeared in a woman of 7-weeks gestation and allergy to penicillin on her lower abdomen, suprapubic region, perineum, buttocks, and proximal legs.  A bacterial culture subsequently isolated methicillin-susceptible S. aureus.  All of the lesions resolved after treatment with clindamycin.

Conclusions:  Bullous impetigo should be considered in the differential diagnosis of common skin diseases presenting as blistersin pregnant women.

Leser-Trélat Sign in Tumor-Stage Mycosis Fungoides

A 71-year-old man presented with numerous pruritic seborrheic keratoses, with an eruptive onset over the course of 3 months. At presentation, he was also found to have hypopigmented tumors diffusely scattered throughout his body that were found to be mycosis fungoides on histologic examination. A theory regarding the pathophysiology of the development of eruptive seborrheic keratoses in the presence of mycosis fungoides is briefly discussed and 10 previous case reports of the Leser-Trélat sign in the setting of mycosis fungoides are reviewed.

Treatment of refractory pyoderma gangrenosum with infliximab in a 17-month-old boy

This report details the case of a 17-month old boy with refractory multifocal pyoderma gangrenosum responsive to anti-TNF therapy.

Granuloma inguinale in a 51-year-old man

Granuloma inguinale, or Donovanosis, is a rare, sexually transmitted ulcerative disease primarily affecting the genital area. In this report, we present a case of a 50-year-old man that was diagnosed with granuloma inguinale after a 2-month history of a penile ulcer. Histological analysis demonstrated the presence of Donovan bodies within macrophages, confirming the diagnosis. He was subsequently treated with trimethoprim/sulfamethoxazole with improvement in the ulcer. This case serves as a reminder to clinicians that although granuloma inguinale is rarely encountered in the US, it should still be suspected in patients with non-healing penile ulcers.

Papular angiolymphoid hyperplasia and lymphoplasmacytic plaque: a clinical and histological spectrum

Acral pseudolymphomatous angiokeratoma of children (APACHE) is a rare form of cutaneous pseudolymphoma characterized byangiomatous papules with a predilection for the acral regions of children. Classically, a dense dermal lymphocytic infiltrate composed of both T and B cells is seen in histological specimens, together with prominent vessels lined by plump endothelial cells. Increasing evidence suggests that this condition is neither necessarily acral, pseudolymphomatous, nor angiokeratomatous. It may not always be a pediatric disease. Therefore, the correctness of its nomenclature has been questioned. Herein, we report threecases whose clinical and histological features were consistent with the diagnosis of APACHE. To our knowledge, this is the first report of APACHE from Southeast Asia. We also discuss why we believe “APACHE” to be a misnomer and support “papular angiolymphoid hyperplasia” as a more accurate and encompassing term. In addition, we illustrate a case with significant overlapping features with lymphoplasmacytic plaque in children, suggesting that both entities may exist on a clinical andhistological spectrum.

Photo Vignette

Infantile epidermolytic ichthyosis with prominent maternal palmoplantar keratoderma

Epidermolytic Ichthyosis (EI) is a rare autosomal dominant genodermatosis. Although an inherited disorder, 50% of cases represent novel mutations. This disorder presents as a bullous disease in newborns progressing to a lifelong ichthyotic skin disorder.  Other manifestations include palmoplantar keratoderma (PPK).  EI results from mutations in the keratin 1 and keratin 10 genes. Phenotypic variability is seen in affected individuals based on the genotypic mutation.  We present a mother and her newborn son with EI and prominent PPK in the mother, which also developed in the child at a few months of age.  Genotype analysis was performed on the newborn child who was found to harbor a mutation in the keratin 1 gene. This family demonstrates the phenotypic expression of PPK associated with keratin 1 gene mutations and illustrates the importance of genotype-phenotypecorrelation in this disorder.

Familial benign pemphigus atypical localization

We present an atypical case of familial benign pemphigus (Hailey-Hailey disease), which presented as crusted, annular plaques limited to the back without intertriginous involvement. We could not find in the literature another patient with plaques located solely on the back without a prior history of classical disease.

Idiopathic eruptive macular pigmentation with papillomatosis (IEMPP): A controversial entity

A 19-year-old man with a 6-month history of progressive development of hyperpigmented, velvety plaques on the face and body. A diagnosis of idiopathic eruptive macular pigmentation with papillomatosis (IEMPP) was determined. This entity is discussed.

 

Letter

Resident perspectives on a dermatology Quality Improvement curriculum: the University of Colorado experience

The Centers for Medicare and Medicaid Services (CMS) have prioritized the objective of optimizing quality healthcare though quality improvement initiatives, yet research on dermatology-specific QI programs and their perceptions among dermatology residents remains limited. We explore residents’ opinions of a dermatology-specific QI scholarly project curriculum implemented at University of Colorado Denver (UCD) in 2010 and also evaluate residents’ attitudes regarding the value of this curriculum in aiding them to meet ACGME core competencies.

Angiomatosis dérmica difusa de la mama: aportación de un nuevo caso en paciente no fumadora

Diffuse cutaneous angiomatosis is one of the reactive angiomatoses. Historically, it is associated with lesions located in the lower extremities. Breast localization is uncommon, but may be under-reported. We report a non-smoking woman who exhibited this vascular condition of both breasts.

Diclofenac sodium 3% gel for darier's disease treatment

Background: Darier’s disease (DD) is an autosomal dominant skin disorder which causative gene, ATP2A2, is located atchromosome 12q23–24. The lesions of DD are skin-coloured to brown, hyperkeratotic, greasy papules that coalesce into warty plaques commonly involving the seborrhoeic areas of the trunk and face, especially the scalp margins, temples, ears, and scalp. The most common complaint associated with the disease is itching, with exacerbations attributed to heat, sweating, sunlight, lithium, steroid therapy, stress, and menstruationObjectives: We report a patient with DD treated with topical diclofenac sodium 3%.Methods: We report a 33-year-old patient with Darier's Disease. He was followed in our department since 2009, and we had tried to control several flares of lesions during follow-up, but oral isotretinoin was not tolerated because of adverse effects; and oral doxycycline showed lack of efficacy.At April 2014, patient presented with new lesions, involving anterior chest wall, abdomen, back and shoulders areas. We started with diclofenac sodium 3% in hyaluronic acid 2.5% once daily, only applied at abdomen and anterior chest wall.Results: After six-month therapy, hyperkeratotic papules were flattened and less harshness of them was noticed, even some of them disappeared.Conclusions: We consider topical diclofenac therapy as a useful alternative treatment for DD patients, in which previous therapies have not shown efficacy. We did not observed topical adverse effects, neither systemic absorption symptoms, but werecognized further and larger studies are needed to asses the efficacy and safety of this treatment in DD.

Fixed drug eruption related to fluconazole

Fixed drug eruption (FDE) is a type of cutaneous drug reaction that occurs at the same sites upon re-exposure to specific medications. Herein we discuss the case of a 23-year-old man with a FDE to fluconazole.

Treatment of pediatric pyogenic granuloma in a functionally and cosmetically sensitive area with the 1064nm ND:Yag laser

There has been increasing interest in minimally invasive approaches to treat pyogenic granulomas. We report successful treatment of a pyogenic granuloma in a pediatric patient on a functionally and cosmetically sensitive area using the 1064nm Nd:YAG laser

Hereditary angioedema: 44 years of diagnostic delay

We report a 64-year-old man who suffered from recurrent visible swelling attacks since the age of 20 as well as episodes with severe upper airway edema, resulting in 4 emergency tracheotomies. Eventually after 44 years he was diagnosed with hereditary angioedema (HAE) type II. The aims of this report is to emphasize the importance of awareness concerning HAE, which does not respond to traditional anti-allergic therapy, and remind physicians to test for functional C1-INH deficiency.