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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 23, Issue 1, 2017

Original

YouTube as a source of health information: Analysis of sun protection and skin cancer prevention related issues

Although social media ubiquitously supplementstraditional information sources such as newspapers,magazines, radio, and television, investigation of onlinehealth information related to sun protection and skincancer prevention has been scarce and largely limitedto English language sources. Using the search terms“sun protection,” “sunscreen,” “skin cancer prevention,”“tanning bed” and “vitamin D,” we investigated 281YouTube videos presented in 6 languages: English,German, French, Spanish, Swedish, and Danish. Foreach video, we used a four-sectioned checklist toassess general information, popularity, expert drivenmeasures, and heuristic driven measures. Differencesbetween languages were detected: English languagevideos were most frequently viewed (median numberof views: 5488 compared to 248 -1591 in otherlanguages). Approximately 60% of videos revealednegative effects of solar ultraviolet (UV)-exposure.The majority of videos (75%) targeted adults. Videoson tanning beds and sunscreen contained false ormisleading information 40% and 20% of the time,respectively. We confirm observations made withrespect to other medical disciplines that the generalquality of YouTube contributions is often inferiorand does not deliver sustainable information. Othersources of information should be included whensearching for health information online.

Healthcare reform literacy among academic dermatologists: What we know and don’t know about the Affordable Care Act

Importance: There have been no attempts to determinethe understanding of the Affordable Care Act (ACA)among dermatologists. Objective: Assess knowledgeof the ACA among academic dermatologists. Design:A 21-item survey was administered to membersof the Association of Professors of Dermatology(APD). The items assessed knowledge and opinionsof the ACA, and demographics of the participants.Multivariate regressions were conducted todetermine associations between variables.Participants: Members of the Association of Professorsof Dermatology. Main Measure: Knowledge of theACA. Results: One hundred and eight out of 368 APDmembers completed the survey (29.3%). Ninetysixpercent of responders practice in an academicsetting. Only 36 (33.3%) rated their knowledge of theACA as good/great, whereas 67 (62%) believed thatthe ACA will change their practice. The mean numberof knowledge questions correctly answered was 4.5out of 7 (64.3%). Dermatologists who reported thattheir knowledge of the bill was good/great (p=0.04)and procedural dermatologists (p= 0.04) answeredmore questions correctly. Compared to proceduraldermatologists, general dermatologists were morelikely to support the ACA (p=0.003) but less likely toanswer questions correctly. Conclusion: There appearsto be knowledge gaps among dermatologists aboutthe ACA and discordance between support for andknowledge about the ACA. The need for educatingdermatologists on health care policies may warrantfurther investigation.

Case Report

Unna boot central gauze technique for chronic venous leg ulcers

Background: Venous leg ulcers generally take manyweeks to heal. Novel therapies that shorten healingtime and require less complex care are needed.Purpose: The purpose of this report is to presenta pilot study for a new method that can result ina faster healing time for venous leg ulcers usinginexpensive materials. Methods: A central-gauzeprotocol was developed as described here. A three-ply gauze sponge was placed in the center of theulcer, allowing a peripheral 3-5 mm rim of ulcer toremain exposed. Saline solution was applied to thegauze sponge. A 3-layer Unna boot was applied overthe ulcer with short-stretch compression. This noveltechnique exposed only a peripheral rim of the ulcerto the zinc oxide paste, allowing the central portionof the ulcer to drain through the saline-soaked gauze.The ulcer was photographed at each clinic visit andthe wound area was estimated by finding the bestfitellipse for the ulcer area and computing the areaof the ellipse by a standard formula. Results: Threepatients with small venous leg ulcers treated with thezinc rim technique showed an average healing rate of46.1% per week (range 27.8% - 50.7%). All ulcers werenearly healed by three weeks. After the ulcer size wasreduced sufficiently, patients were discharged withinstructions to apply pieces of Unna dressing to theulcer, under a conventional self-adhesive bandage,maintaining compression, without any saline-gauzein the center. Conclusions: The three patients in thispilot study showed rapid healing for venous leg ulcerswith the central gauze modification of Unna boottherapy.

Cutaneous T-cell lymphoma-associated Leser-Trélat sign: report and world literature review

Background: The sign of Leser-Trélat is characterizedby the sudden appearance of seborrheic keratosesassociated with an underlying malignancy. Objectives:An elderly man who developed multiple new-onsetseborrheic keratoses temporally associated witha diagnosis of mycosis fungoides is described andlymphoma-associated Leser-Trélat sign is reviewed.Methods: Pubmed was used to search the followingterms: cutaneous T-cell lymphoma, Leser-Trélat,leukemia, lymphoma, mycosis fungoides, and Sézarysyndrome. Papers with these terms and referencescited within these papers were reviewed. Results:An 84-year-old man developed multiple seborrheickeratoses temporally associated with a diagnosisof mycosis fungoides is presented. He was treatedwith bexarotene and achieved clinical remission;the number of seborrheic keratoses also decreased.Lymphoma-associated Leser-Trélat sign has beenobserved not only with mycosis fungoides but alsoother lymphomas and leukemias. Conclusions: Thesign of Leser-Trélat is predominantly associated withsolid organ adenocarcinomas. Albeit less common, aneruptive onset of seborrheic keratoses can also occurin association with hematopoietic malignancies.

Case Presentation

Malignant syphilis: ostraceous, ulceronecrotic lesions in a patient with human immunodeficiency virus

We present a 36-year-old HIV-positive man with a sixweek history of spreading, ulcerative, and necroticcutaneous lesions. Laboratory and histopathologicexamination revealed syphilis. This case of malignantsyphilis, also known as lues maligna, is an uncommonvariant of this sexually transmitted infection. This casehighlights the importance of including malignantsyphilis in the differential diagnosis of patientspresenting with a disseminated ulcerative andnecrotic rash, especially in individuals with HIV.

Cutaneous manifestations of disseminated gonococcemia

Background: Sexually transmitted infections, includingurogenital gonorrheal infection, are a growing healthconcern in the United States. Nearly 50% of cervicalinfections are asymptomatic. If left undiagnosedand untreated, there is a risk of disseminatedinfection. Purpose: To describe an 18-year-old womanpresenting with disseminated gonococcal infectionconfirmed by blood cultures, skin biopsy, and urinegonococcal probe. We also describe the presentation,diagnosis, and treatment of disseminated gonococcalinfection, including discussion of the variousmorphologies of cutaneous lesions that have beenreported in the literature. Materials and Methods: Thefeatures of a woman with disseminated gonococcalinfection are presented. Using PubMed, the termscutaneous, disseminated, gonococcal, gonorrhea,infection, lesions, manifestations, pustules, skin, andsystemic were searched. Relevant citations wereutilized and discussed. Results: Hemorrhagic pustules,petechiae, and purpuric lesions developed in a youngwoman with fever and joint pain. Blood cultures grewbeta lactamase negative Neisseria gonorrhoeae andthe Neisseria gonorrhoeae/Chlamydia trachomatisprobe was positive for both N. gonorrhoeae and C.trachomatis. Biopsy revealed bulla with neutrophils,extravasated erythrocytes, fibrin deposits in the vesselwalls, and leukocytoclasia. Conclusion: Cutaneouslesions of disseminated gonococcal infection caninclude abscesses, cellulitis, petechiae, purpuricmacules, necrotizing fasciitis, and vasculitis. It isimportant for the clinician to recognize the clinicalsigns and symptoms of disseminated gonococcalinfection, particularly the various cutaneousmanifestations.

First report of mesalamine (5-aminosalicylic acid) as the causative agent in a case of acute generalized exanthamous pustulosis

Acute generalized exanthamous pustulosis (AGEP)is a rare eruption of non-follicular sterile pustuleson a diffuse background of erythema and edema,commonly associated with fever and leukocytosis.Antibiotics are implicated in most cases; however,other drugs have been reported to cause AGEP. Wereport a case of a 73-year-old man with a historyof ulcerative colitis who presented with a diffusepustular rash, renal failure, elevated liver functiontests, and leukocytosis with neutrophilia. A week priorto admission, the patient was started on mesalamineto treat colitis. Upon admission, a workup includinga skin biopsy was performed and was consistentwith AGEP. Mesalamine was discontinued, and thepatient’s skin eruption, renal function, liver functiontests, and leukocytosis subsequently improved.Mesalamine has an unknown mechanism of action.However, it is thought to be an anti-inflammatoryagent that blocks the production of leukotrienesand prostaglandins and is an immunosuppressantthat increases the release of adenosine, whichinterferes with leukocyte function. The decrease inprostaglandin synthesis or deregulation of leukocytefunction caused by mesalamine may be the etiologyin this case. Discontinuation of the offending agentleads to resolution of AGEP, as it did in this patient.

Metastatic neuroendocrine carcinoma in the skin

Cutaneous metastases secondary to neuroendocrinetumors are rare. Herein we report a case of a 75-yearoldwoman who presented with a rare cutaneousmetastatic disease. She was previously diagnosed withmetastatic neuroendocrine carcinoma of unknownprimary, with metastases to liver, lung, and bone.Biopsy of the skin lesion demonstrated archetypicalpathology and positive immunohistochemicalstaining for chromogranin A and synaptophysin. Thepatient started palliative chemo-radiation therapyand passed away soon after.

Successful treatment of recalcitrant discoid lupus erythematosus with ustekinumab

We report a 52-year old woman with a 28-year historyof disfiguring facial discoid lupus erythematosus(DLE), persistent despite both classical therapiesand rituximab. Ustekinumab 45 mg was started incombination with methotrexate and intralesionalcorticosteroids. Methotrexate and intralesionalcorticosteroids were withdrawn 30 months later andustekinumab maintained as monotherapy. Fortyeight months later stable improvement was achievedwithout side effects. Only nine patients with cutaneouslupus erythematosus (CLE) treated with ustekinumabhave been reported to date. Ustekinumab could be apromising alternative in severe and recalcitrant casesof CLE. Possibly, the Th17-inflammation pathway isplaying a role in these patients.

Certolizumab-induced guttate psoriasiform dermatitis

Certolizumab is a TNF inhibitor that has showngreat efficacy in chronic inflammatory diseases. Wereport a patient exhibiting a novel adverse effect ofcertolizumab: drug-induced guttate psoriasiformeruption. A review of the mechanism of psoriasiformdrug eruptions is also included.

Classic Kaposi sarcoma in an HIV-negative Han Chinese man: a case report

Kaposi sarcoma (KS) is a multifocal angioproliferativetumor of endothelial origin. Despite nearly identicalclinical and histopathologic presentations, KS isclassified into four distinct varieties: classic/sporadic,AIDS-associated, African/endemic, and iatrogenic. Allsubtypes are invariably linked to human herpesvirus-8(HHV-8) and show a male predilection. Classic Kaposisarcoma is exceedingly rare in the Asian populationand its incidence varies by region and ethnic grouppredominance. A study in the Xinjiang region of Chinafound that only 1% of classic KS cases occurred inpatients belonging to the Han Chinese ethnic group,which formulates 84% of the Taiwanese population.Therefore, classic KS is extremely rare in Taiwan, withvery few reports describing the manifestations ofdisease in this population. We report a case of animmunocompetent 68-year-old HIV-negative HanChinese man born and raised in Taiwan with classicKaposi sarcoma on his trunk and extremities.

Pregnancy-associated morphea: a case report and literature review

Morphea, also known as localized scleroderma, is arare fibrosing disorder of the skin, the pathogenesisof which is incompletely understood. It is thought,however, to involve interplay of genetic dispositionand triggering environmental factors, such asinfections and autoimmunity. Pregnancy as a potentialtrigger has only been reported in four cases. Herein,we present a patient who developed morphea of thebreasts during pregnancy, which rapidly resolvedwith a normal delivery. Our patient was distinct fromsome of the reported patients because her conditionwas tightly correlated with her pregnancy, as judgingby rapid resolution after delivery. In addition, therewas no apparent infection, history of autoimmunity,or development of autoimmunity during or afterpregnancy. Although the pathogenesis of pregnancyassociatedmorphea is largely unknown, we exploredpotential mechanisms of this condition, which mayinvolve mechanical injury, “microchimerism,” andshifts in intrapartum hormones, such as TGF-β.

Second degree burn to mustard powder

Mustard seeds and powder are commonly used inhomeopathic and traditional medicines, in whichthey are believed to have both anti-microbial andanti-inflammatory properties. They are thereforeutilized in the treatment of conditions ranging fromarthritis to respiratory congestion. Herein, we presenta patient with a second degree burn who usedmustard powder in the form of a mustard plasterto treat chest congestion. She experienced seconddegree burn wounds to the lower neck and chest, andrecovery with complete re-epithelialization followingtopical silver sulfadiazine, liberal emollient therapy,and triamcinolone ointment. This case highlightsthe potential danger of inappropriate use of topicalhomeopathic remedies such as mustard powder anddetails a successful treatment regimen.

Photo Vignette

Eruptive collagenoma in a child

Eruptive collagenoma is a rare entity, with unknownetiology, considered to be a type of connective tissuenevus composed of collagen. It is usually reported inyoung adults occurring predominantly on the trunkand extremities. Systemic findings and family historyof a similar condition are not typically associated andthe prognosis is excellent. There are few pediatric casesreported in literature. Herein we report an uncommoncase of eruptive collagenoma in a 12-year-old childand present a brief review of the literature.

Apremilast for treatment of recurrent erythema multiforme

Recurrent erythema multiforme with oralinvolvement is therapeutically challenging.Apremilast has been used with success in resolvingthe oral aphthae of Behçet disease, prompting theuse of the drug in patients with oral erosions fromerythema multiforme. Three patients with oralerythema multiforme were given apremilast at dosesof 30-60mg daily. Complete clearance of the lesionswere observed in all three patients, including thoserefractory to other standard therapies. Apremilast maypresent an effective option for recurrent erythemamultiforme for patients who have failed trials antiviraland immunosuppressive therapies.

Linear atrophy and vascular fragility following ultrasoundguided triamcinolone injection for DeQuervain tendonitis

A 64 year-old woman presented with a one-yearhistory of purpuric, atrophic, linear patches alongthe left lateral forearm. The patient had receivedtwo ultrasound-guided triamcinolone injectionsone year earlier into her left extensor pollicis brevisand abductor pollicis longus tendon sheathsfor DeQuervain tendonitis. In the seven monthsfollowing the second injection, the patient developedatrophy, purpura, and telangiectasias starting at thesite of injection and extending proximally, followingthe course of her left cephalic vein. The patient wastreated initially with amlactin and moisturizing creamcontaining alpha-hydroxy acid cream to aid in dermalrepair. Despite treatment, she continued to haveproximal progression of the atrophy and purpura.A 4mm punch biopsy revealed a normal-appearingepidermis overlying horizontal dermal fibrosis, alongwith atrophic-appearing adipocytes with accentuatedcapillaries in the subcutaneous fat, consistent witha diagnosis of corticosteroid atrophy. These grossand microscopic changes presumably resulted fromlymphatic uptake and spread of the corticosteroidfollowing the injections for tendonitis. Although localatrophy and vascular fragility are well-documentedside effects of corticosteroid injections, linear spreadof these symptoms is rarely reported, and to this pointhas not been demonstrated in the literature followingultrasound-guided steroid injection for DeQuervaintendonitis.

Letter

Cutaneous leishmaniasis mimicking squamous cell carcinoma

A 41-year-old man from Cuero, Texas with a nonhealinglesion on his left cheek was referred to ourclinic for removal of a squamous cell carcinoma. Thepatient first noticed a “pimple” on his left cheek 3-4months prior to presentation. When the lesion beganto grow he presented to his primary care physician anda biopsy was taken, showing “atypical squamous cellproliferation.” Mohs surgery was performed and thenodule was removed with no evidence of malignancyseen on histopathology. Upon review of the surgicalbiopsies by consulting pathologists, the diagnosis ofleishmaniasis was established and later confirmed bythe Center for Disease Control and Prevention (CDC)as Leishmania mexicana. The patient was referred toinfectious disease specialists for further management.

Prevention of poison ivy dermatitis with oral homeopathic Rhus toxicodendron

Acute allergic contact dermatitis to poison ivy is acommon and miserable dermatosis which affectsmillions of Americans each year. Preventativemeasures, such as avoidance, protective clothing,barrier creams, soaps, and solvents often fail despiteour patients’ best attempts. Severe allergic reactionsto poison ivy are a significant source of decreasedemployee productivity owing to inability to work anda major health care expenditure. Patients may haveto leave their jobs and discontinue favorite outdoorrecreational activities as a result of severe urushiolsensitivity. Thus, a simple and effective method ofpreventing poison ivy dermatitis would be of greatbenefit to clinical dermatologists and their patients.Complementary and alternative medical practitionerscommonly prescribe homeopathic poison ivyproducts by mouth for the prevention of poisonivy dermatitis. Yet, conventional dermatologists aremostly unaware of this little known clinical pearl. Theauthor discusses two open studies and anecdotalexperience with administration of homeopathicpoison ivy in the prevention of acute allergic contactdermatitis related to poison ivy exposure. Potentialadvantages could include patient acceptability,ease of administration, affordability, and availability.Randomized clinical trials are needed to furtherevaluate the safety and efficacy of this interesting andpromising clinical tip.

The use of a sunscreen containing DNA-photolyase in the treatment of patients with field cancerization and multiple actinic keratoses: a case-series

Cutaneous field cancerization (CFC) is associated witha high-risk of developing cutaneous squamous cellcarcinoma (cSCC). It manifests as actinic keratoses(AK) as one of the few macroscopic alterations in CFCpatients. A prospective, single-arm, case-series wasperformed to evaluate the utility of a novel sunscreencontaining DNA-photolyase for treatment of CFCin nine subjects (mean age 70.6 years, male: femaleratio 5:4). The cream was applied topically twicedaily on CFC/AK areas and patients were followedup for three months, with no other treatments. Theprimary outcome was the overall response rate (ORR),categorized as complete response (CR, completeresolution of AKs), partial response (PR, reduction inthe number of AKs), and no-response (NR, similar/increase in number of AKs). A 100% PR was observed.All subjects displayed at minimum, a 50% reductionin their lesion number and most patients experiencedalmost CR. Evaluation of AK numbers revealed anabsolute count reduction of 76.6% in the number oflesions, with the mean number of lesions reducedfrom 13.4 to 3.1 (p < 0.0001). No adverse events werereported. Patients with CFC may benefit from noveltopical applications containing DNA-photolyase,at minimum, as complementary therapy for themanagement of CFC disease. We propose a newconcept called “active photoprotection” because of itsdual mechanism involving therapy and protection.

Gabapentin-induced aquagenic wrinkling of the palms

Aquagenic keratoderma (AK) or aquagenic wrinklingis a rare palmoplantar skin disease. It is sporadic orhereditary condition. It appears in childhood or youngadulthood and it is seen as multiple asymptomaticsmall shiny papules on the peripheral margin ofpalms and/or soles after submersion in water. Thepathogenesis and etiology of ASA remains unclear.Drugs sometimes trigger AK. Herein, we present thecase of a 29-year-old man who had begun treatmentwith gabapentin three weeks before the onset of hiscutaneous symptoms.

Recruitment Advertisement

Job Recruitment - Dermatologists & Mohs Surgeon

The University of California, Davis, School of Medicine, Department of Dermatology, is recruiting for four academic dermatologists in the Clinical X series or Health Sciences Clinical Professor (HSCP) series at the Assistant/Associate/Professor level based on experience and qualifications. Three of these positions are for general medical dermatologists, and one is for a fellowship-trained Mohs surgeon/procedural dermatologist. The appointments may be made up to 100%.

Job Recruitment - Novy

The University of California Davis, School of Medicine, Department of Dermatology is recruiting for a full-time position at the Associate or Full Professor level in the Clinical X Series or Health Sciences Clinical Professor (HSCP) Series. The successful candidate is nominated to be the holder of the Frederick G. Novy, Jr. M.D Endowed Professorship. Appointees to the ClinX series are expected to conduct independent research. Both series require significant participation in teaching and University/public service.