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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 5, 2017

Original

Dermatology discharge continuity clinic enhances resident autonomy and insight into transitions-of-care competencies: a cross-sectional survey study

Dermatology residents perform consults onhospitalized patients, but are often limited intheir ability to follow-up with these patients afterdischarge, leading to inadequate follow-up andunderstanding of post-discharge transitions of care.In 2013, a discharge continuity clinic (DCC) staffedby the inpatient consult dermatology resident andattending dermatologist was established at one ofthe four adult hospital sites residents rotate throughin the Harvard Combined Dermatology ResidencyProgram. Resident perceptions about the DCC andtheir educational experience on inpatient consultrotations with a DCC and without a DCC were obtainedusing a cross-sectional survey instrument in June2016. Self-reported data from a multi-year cohort ofdermatology residents (n = 14 of 20, 70% responserate) reveals that the DCC enabled resident autonomyand resident satisfaction in care of their patients,insight into the disease-related challenges and thebroader social context during transitions of care frominpatient to outpatient settings, and more enrichinglearning experiences than inpatient consult rotationswithout a DCC. Dermatology residents self-reportparticipation in an inpatient consult rotation with aDCC supports their autonomy and achievement ofpost-discharge transitions-of-care competencies

Continuity of care in dermatology residency programs in the United States

Purpose: As established by the AccreditationCouncil for Graduate Medical Education (ACGME),dermatology residents in the United States mustparticipate in continuity clinic. This requirementmay be achieved through multiple means, allowingfor program variation. To better assess continuityclinic’s role in resident learning, more data onthis component of graduate medical education isneeded. Methods: An anonymous online survey wasdistributed via the American Board of Dermatologylistserv to all U.S. dermatology residents. Continuityclinic organization, setting, frequency, and patientand preceptor characteristics were assessed; residentsatisfaction and learning were compared. Results:Of 231 responses, 7.8% reported continuity clinicdaily, 77.1% weekly, 9.1% every other week, 3.0%monthly, 0.4% once every several months, and 2.2%only during certain blocks. Of the clinics reported,80.1% were “resident-run with attending” and 11.3%were attending-run. The rest were “resident-run withno attending” (0.9%), both resident and attendingrun(3.0%), or “other” (4.8%). Trainees in resident-runclinics (with attendings) reported greater continuityof care than those in attending-run clinics (p<0.001).Residents reported better teaching with attendingpresence during patient encounters than whenattendings were present only if concerns were raised(p<0.01).

Case Report

Multifocal primary cutaneous nodular amyloidosis

Nodular cutaneous amyloidosis (NCA), the leastcommon form of primary cutaneous amyloidosis, ischaracterized clinically by waxy, purpuric plaques andnodules and histologically by amyloid deposits in thedermis and subcutaneous tissue. We present a patientwho developed multiple, non-contiguous NCA lesionsover a three year period without evidence of systemicdisease. We reviewed the literature and found fewother cases of this unusual presentation.

Superficial morphea: case report, look-alikes, pathogenesis, and treatment

Superficial morphea, a rare variant of morphea, ischaracterized by hypopigmented to hyperpigmentedskin lesions located predominantly in a symmetricfashion at intertriginous sites. These patches andplaques typically lack the significant induration,contractures, and atrophy seen in other subtypesof morphea. Histologic examination is key foraccurate diagnosis considering the number of similarconditions which may clinically mimic superficialmorphea. Herein, we present a case of a 25-year-oldwoman who re-presented for consultation in ourclinic after gradual progression of her skin lesions. Inaddition, we review dermatologic look-alikes, as wellas the pathophysiology and treatment options forsuperficial morphea.

Commentary

Cost-effectiveness analysis of using dermatologists versus pediatricians to treat mild to moderate acne

Objective: To assess the cost-effectiveness from thepayer perspective of using dermatologists versuspediatricians to treat acne in adolescents ages 10-18. Methods: A Markov model was constructed toexplore outcomes over a 2-year period from the USprivate payer perspective. Patients ages 10-18 withacne entered the model under the “dermatologist”and “pediatrician” conditions. In each 3-month cycle,each modeled patient received topical retinoids,benzoyl peroxide (BP), antibiotics, or no treatment,and could progress to an acne-free state or remainin an acne state. Results: The average patient spent42.3% of the time in acne-free states under thedermatologist condition and 28.0% of the time inacne-free states under the pediatrician condition.The cohort of 1000 patients experienced 1900 totalquality-adjusted life years (QALYs) at a cost of $2.33million in the dermatologist condition and 1883 totalQALYs at a cost of $1.62 million in the pediatriciancondition, yielding an ICER of $40,000/QALY. Mostsensitivity analyses confirmed the base case results.Conclusion: Dermatologist treatment appears costeffectiverelated to producing additional QALYs at acost of less than $100,000 per QALY gained. Healthplans should consider creating incentives to directenrollees to dermatologists for acne treatment.

Portable equipment for taking dramatic sun-damagerevealing photos at skin cancer prevention outreach events

In recent years, appearance-based interventionshave gained popularity as a means to improve publicawareness about skin cancer and sun protectivebehaviors. Although numerous reports discuss theuse of ultraviolet (UV) camera devices for this purpose,studies on the use of portable imaging devicesin community outreach events do not presentlyexist. In this report, we discuss how we successfullyutilize portable imaging devices at communityoutreach events. We also discuss the advantages anddisadvantages of our portable devices in comparisonto traditional UV cameras. Portable imaging devicesare easy to use and have allowed us to increase ourinvolvement in community outreach events targetinga wide range of participants.

Combined closures in reconstructive surgery

It is common for dermatology surgery patients topresent on the day of surgery with more than one skincancer needing Mohs micrographic surgery. Whenthese carcinomas are located near one another, itmay be more practical to treat both at the same timeas the reconstruction for one defect may involve orotherwise affect the treatment or reconstruction forthe other carcinoma. Treating both cancers on thesame day creates an opportunity for efficient repairswhere a creative single reconstruction may minimizethe amount of tissue wasted during reconstruction,and minimize morbidity for the patient. Further,combining multiple defects into one closure mayreduce cost as it has been shown that reconstructivechoice affects the cost-effectiveness of Mohs surgeryrelative to a traditional excision and Mohs surgeonsmore commonly select less costly options for woundmanagement. We present a case series of two-in-oneclosures - repairing two defects with one closure.

Global skin diseases on Instagram hashtags

Recently named one of the most influential phoneapplications, Instagram continues to grow inpopularity [1]. Instagram consists of images andvideo posts, making it ideal for education andcommunication within the visual field of dermatology.In this study, we seek to determine the presenceof dermatology-related content with regard to themost common cutaneous diseases of the world. Wesearched the account types and hashtags associatedwith the eight most common skin diseases globallyas identified by the Global Burden of Disease (GBD)study by Hollenstein et al.: eczema, psoriasis, acne,pruritus, alopecia, decubitus ulcer, urticaria, andscabies [9]. The majority of Instagram accountsincluded patient experiences (n=73), private accounts(n=52), and disease advocacy and awareness groups(n=20), (total n=221). We further investigated over 2million skin disease hashtags. The greatest numbersof hashtags were the following: #acne (n = 1,622,626),#alopecia (n = 317,566), and #eczema (n = 196,115).Our results demonstrate that patients interact withone another through Instagram. As social networkingplatforms become more frequently used as a sourceof information for patients and patient support,medical professionals must gain awareness ofcontent available through Instagram and consider itas a means to educate the public.

Case Presentation

Use of an oral phosphodiesterase-4 inhibitor (apremilast) for the treatment of chronic, severe atopic dermatitis: a case report

Atopic dermatitis (AD) is a common inflammatorydermatosis characterized by pruritus, erythema,induration, and lichenification. Current treatmentoptions for generalized atopic dermatitis arelimited and have potentially serious adverse effects,especially in patients with severe, chronic AD whofrequently require systemic anti-inflammatory agents.Apremilast, an oral phosphodiesterase-4 inhibitor, wasFDA approved in September 2014 for the treatmentof moderate-to-severe plaque psoriasis. However, itsupstream anti-inflammatory effects, ease of use asan oral agent, and mild side-effect profile make it aninteresting treatment option for AD as well. Herein,we present a patient with a life-long history of ADrecalcitrant to topical steroids and cyclosporine whoattained subjective and objective improvement inpruritus and erythema after 10-week treatment withapremilast.

Erythrasma: A report of nine men successfully managed with mupirocin 2% ointment monotherapy

Background: Erythrasma is a benign dermatosis thattypically occurs on intertriginous skin. Purpose: Wedescribe a series of nine men with erythrasmathat were successfully treated with mupirocin 2%ointment monotherapy. Methods and Materials:We reviewed PubMed for the following terms:erythrasma, mupirocin, ointment, treatment. Wealso reviewed papers containing these terms andtheir references. Results: Complete resolution oferythrasma occurred following monotherapywith twice daily application of mupirocin 2%ointment. Conclusions: Several topical andoral treatments are available to successfullymanage erythrasma. Our series of patientswith erythrasma experienced resolution withmupirocin 2% ointment treatment within 2 to 4weeks of therapy. Monotherapy with mupirocin2% ointment should be considered as a primarytreatment alternative for erythrasma.

Severe pellagra masked by concurrent plaque psoriasis: a case report of a hidden diagnosis

Despite characteristic features, psoriasis can mimicother dermatologic conditions, such as seborrheicdermatitis, lichen simplex chronicus, and certainnutritional deficiencies such as pellagra. We present apatient with a longstanding history of severe plaquepsoriasis who presented with disfiguring scaly plaquesinvolving greater than 80% body surface area. Thepatient’s disease was minimally responsive to multipletherapies. Repeat punch biopsies demonstratedparakeratosis, psoriasiform hyperplasia, and dilatedblood vessels consistent with psoriasis. Given atypicalclinical features and overall poor treatment responseadditional work up was obtained. A serum nutritionalpanel was consistent with niacin deficiency andthe patient later revealed extensive alcohol intake.A diagnosis of concurrent pellagra was made andthe patient was started on niacin supplementationand instructed to reduce alcohol intake, whilecontinuing adalimumab and high potency topicalsteroids. Within two weeks, his disease had markedlyimproved. Pellagra presents characteristically with aphotosensitivity dermatitis that may appear clinicallyand histologically similar to psoriasis. It is importantto maintain an index suspicion for a secondarypathology in treatment-resistant psoriasis.

Laboratory tests in patients treated with isotretinoin: occurrence of liver and muscle abnormalities and failure of AST and ALT to predict liver abnormality

Current laboratory monitoring may not be optimal.A retrospective chart review was performed on thelaboratory results of 246 patients who were treatedwith isotretinoin for acne over a 9-year period. Testsobtained were CBC, lipid panel, AST, ALT, CK, GGT,and C-reactive protein. Thirty-five patients had anelevated AST and 35 of these had an elevated CK; 32had an elevated ALT and 11 of these had an elevatedCK. Thirteen patients had an elevated GGT; in 5 thiswas the only abnormality, whereas 8 had a GGTelevation accompanied by an elevated AST or ALT.Two had an elevated GGT and an elevated CK withnormal AST and ALT. Fifty-two patients had a singleepisode of elevated CK, of which 22 were female.However, 57 had multiple CK elevations and only onewas female. Thirty-five patients had CK elevations <2 times normal; 38 had levels between 2 and 3 timesnormal, 18 had levels between 3 and 4 times normal,and 18 had levels greater than 4 times normal. Wesuggest that ALT and AST are not useful for monitoringisotretinoin therapy and that GGT and CK may be ofgreater value in managing patients.

A nodule on the scalp as the first sign of extranodal disease in medullary thyroid carcinoma

Medullary carcinoma of the thyroid gland accounts foronly 5-10% of thyroid carcinomas. Also, metastases tothe skin of malignant tumors are infrequently (2-9%of patients). In the case herein reported in a 64-yearoldwoman, a metastatic nodule on the scalp wasthe presenting clinical manifestation of a medullarythyroid carcinoma. A comprehensive review of theliterature was conducted for similar cases usingPubMed. Only 18 cases of cutaneous metastases ofmedullary thyroid carcinoma have been previouslyreported in the literature, but skin lesions were thepresenting complaint of the thyroid neoplasm in onlythree.

Eruptive sebaceous hyperplasia as a side effect of oral tacrolimus in a renal transplant recipient

Sebaceous hyperplasia, a benign proliferation ofsebaceous glands, has been well documented inorgan transplant recipients treated with cyclosporine.Sebaceous hyperplasia has not been stronglyassociated with any other immunosuppressivemedications. We report a case of eruptive sebaceoushyperplasia in a renal transplant recipient with noprevious exposure to cyclosporine that was recentlystarted on tacrolimus, mycophenolate mofetil, andprednisone. To our knowledge, this is the first report oferuptive sebaceous hyperplasia in a renal transplantrecipient who was immunosuppressed withtacrolimus and had no prior exposure to cyclosporine

Basaloid follicular hamartoma: clinical, dermoscopic, and histopathological characteristics of case

Basaloid follicular hamartoma (BFH) is a rare benignadnexal tumor with variable clinical presentation.We report a case of a 64-year-old man, whopresented with an incidental finding of a 3mmhyperpigmented macule on his cheek. Dermoscopyrevealed a structureless blue lesion. Histopathologyexamination showed interconnecting lobules andcords of bland pigmented epithelial cells within thedermal stroma, with the presence of pseudohorncysts. The lesional cells were faintly positive for Bcl2on immunohistochemical staining. These findingswere consistent with basaloid follicular hamartoma.Histological differential diagnoses include benignlesions such as trichoepithelioma, and malignantlesions such as basal cell carcinoma (BCC).

Psoriasis mimicking mycosis fungoides clinically

Psoriasis is a complex, chronic immune-mediatedinflammatory disease that most commonly presentsas well-demarcated erythematous plaques withmicaceous scale, affecting roughly 3-4% of the USpopulation [1-4]. Clinically, lesions are often welldemarcatedthick, scaly, erythematous plaques,characteristically located on the extensor surfaces,such as elbows and knees [1]. In most cases, clinicalimpression is sufficient to diagnose psoriasis. However,sometimes psoriasis can mimic other cutaneousdisorders and biopsy may be warranted to discoverthe diagnosis. We report an unusual presentation ofpsoriasis clinically mimicking mycosis fungoides.

Letter

A child with kwashiorkor misdiagnosed as atopic dermatitis

Although uncommon, kwashiorkor continues to occurin developed, but mainly in developing nations. It is atype of protein-calorie malnutrition that occurs in thesetting of insufficient protein intake in the presence ofsufficient caloric intake. Skin and hair changes shouldprompt a thorough dietary history and appropriatedietary intervention. We report a case of a 12-montholdgirl in Belo Horizonte, Minas Gerais, Brazil, whopresented with diffuse edema, desquamation, andirritability misdiagnosed as atopic dermatitis. Thediagnosis was consistent with kwashiorkor as a resultof severe dietary restriction. The mother had placedthe child on a severely restrictive diet, consisting onlyof potatoes, gelatin, and juice as a consequence of theinability to breastfeed. Kwashiorkor is often underdiagnosedor misdiagnosed and if unrecognizedor untreated, may be devastating. This makes itimperative that physicians consider this diagnosis,recognize potential risk factors, and be prepared toaccurately assess overall nutritional status of patients.

Public perception of dermatologic surgery in Saudi Arabia: an online survey

Background: Dermatologic surgery is a wellestablishedsubspecialty in dermatology, butobservations suggest that the public may not beaware of this field.Objective: To explore the public perception of thenature and scope of dermatologic surgeryMethods: A cross-sectional online-based surveyconsisting of two parts was used. The first part recordeddemographic data. The second part presented aseries of clinical scenarios in common surgical andcosmetic procedures performed by dermatologicsurgeons to determine respondents’ choice amongthree specialties: general surgery, plastic surgery, anddermatologic surgery.Results: A total of 1,248 responses were recorded.Seventy-four percent of respondents were female,with 80.29% between the ages of 18 and 34 years.Forty-nine percent considered dermatologic surgeonsto be specialized skin surgeons and 71.63% said theywould consult dermatologic surgeons for skin tumorexcisions. However, plastic surgeons emerged morefavorably for cosmetic procedures. For office-basedprocedures, 80.85% and 87.18% of respondentschose plastic surgeons for fillers and Botox® injections,respectively, compared to 15.79% and 12.02% ofrespondents who chose dermatologic surgeons.Conclusions: Although the majority of participantsshowed no doubt about the surgical skills ofdermatologic surgeons, the responses demonstratethat the public is not aware of the full scope andpractice of dermatologic surgery, especially as itpertains to cosmetic procedures. Therefore, we musteducate the public about the field and branches ofdermatologic surgery.

Anxiety levels of patients undergoing common dermatologic procedures versus those seeking general dermatologic care

Patients undergoing Mohs micrographic surgeryfrequently experience anxiety as a result of multiplepotential factors. There is currently no data regardinghow this anxiety compares to other commonprocedures performed in dermatology offices, suchas shave biopsy and excision, relative to a generaldermatology visit. Herein, we conducted a survey of471 dermatology patients at an academic medicalcenter, using a validated tool (Visual Analogue Scalefrom 1 “no anxiety at all” to 10 “extremely anxious”).

Painful erythematous, infiltrated papulonodules in a middle aged man

Cutaneous leiomyomas (CL) often present as painfultumors in the skin. Herein we report an adultman who presented with multiple, erythematouspapulonodules in both segmental and non-segmentaldistribution.

Leishmanial dactylitis: an unusual clinical presentation

Cutaneous leishmaniasis (CL) is one of the mostcommon endemic diseases in Iran. It has a diversespectrum of clinical manifestations. Herein we presenta woman with leishmanial dactylitis, which is a veryrare clinical form of CL. Successful treatment consistedof parenteral pentavalent antimonials for two months.Leishmanial dactylitis can be easily misdiagnosedas bacterial or fungal infections, psoriasis, or evenmalignancies. Accordingly, it should be consideredin the differential diagnosis of dactylitis in endemicareas and in travelers from endemic countries.

The residency interview is still paramount: results of a retrospective cohort study on concordance of dermatology residency applicant evaluators and influence of the applicant interview

Application to dermatology residency is a highlycompetitive process. Although factors associatedwith successfully matching have been studied,less is known regarding the ability of admissionscommittees to screen applicants in a uniformmanner or the importance of the interview in rankingapplicants. Our goal was to retrospectively measureour admission committee evaluators’ concordanceregarding residency application credentials andinterview performance, and ultimately the effects onfinal applicant ranking.