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Open Access Publications from the University of California

Dermatology Online Journal

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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 24, Issue 11, 2018


Morgellons disease: insights into treatment

Morgellons disease is a disfiguring and distressing condition. Patients commonly present with multiple, non-healing, cutaneous wounds. Patients report protruding fibers or other objects as the source and often provide samples to the clinician. Originally the etiology of this condition was broad and debated ranging from infectious to psychiatric. This article reviews current treatments and details our approach to treatment, aiming to aid clinicians with useful pharmacotherapy and adherence techniques when treating patients with Morgellons disease. Although current opinions have consolidated to the psychiatric spectrum, Morgellons treatment remains difficult and unstandardized with most evidence from retrospective reviews and a handful of case reports. Having considerable overlap with delusions of parasitosis, treatments have consisted of various antipsychotics and antibacterial wound care. Many antipsychotics have been selected owing to additional antipruritic or analgesic benefits. Generally, low-doses are used to minimize the risk of side effects. Risperidone or trifluoperazine can provide relief to patients especially when paired with adjuvant therapies, strong doctor-patient relationships, and a multidisciplinary approach.

Current biological therapies for use in HIV-positive patients with psoriasis: case report of guselkumab used and review

Background: Psoriasis in human immunodeficiency virus (HIV)-positive patients may be severe. Physicians may be tentative to use biologics in HIV-infected patients.

Objective: We present an HIV-positive patient with psoriasis who was treated with guselkumab. This paper aims to investigate the safety, efficacy, and tolerability of biologic therapies for HIV-positive patients with psoriasis.

Methods: A systematic PubMed review of articles dating between 2000-2018 containing key words psoriasis AND HIV, and psoriatic AND HIV combined with several approved biologic therapies. The review generated 15 articles containing 27 cases of HIV-positive patients treated with etanercept, infliximab, adalimumab, or ustekinumab for their psoriasis.

Results: The majority of cases reported excellent clinical responses, limited adverse events, and well tolerated treatment. CD4 count and viral loads were stable throughout treatment. Similar safety and efficacy were seen in the illustrative case report. Available literature is limited to case reports or case series and could be subject to publication bias of successful cases. Many reports lack quantifiable data and report results based on clinical judgement. No randomized, controlled trials evaluate biologic treatment for psoriasis in HIV-positive patients.

Conclusions: The findings suggest that biologic therapy is an efficacious, safe, and tolerable treatment for most patients with moderate-to-severe psoriasis in HIV-positive patients.

A systematic review on the use of cryotherapy versus other treatments for basal cell carcinoma

Background: Cryotherapy is a commonly discussed method for treatment of basal cell carcinoma skin cancer. Some uncertainty remains about its efficacy relative to other modalities.

Objective: To determine the efficacy and adverse events profile of cryotherapy for the treatment of basal cell carcinoma compared to other therapeutic options or non-intervention.

Methods: We systematically searched PubMed, OVID, Cochrane Library, EMBASE, CINHAL, and CANCERLIT databases for the following terms: "cryotherapy", AND "basal cell carcinoma", OR "cryosurgery" OR "cryoablation" up to April 2018. Two independent reviewers screened the results and extracted the data. Study endpoints included basal cell carcinoma recurrence, cosmetic outcome, and healing time. Study quality was assessed using the Jadad scale.

Results: Six clinical studies met our inclusion criteria. The efficacy and safety of cryotherapy alone or with curettage in the treatment of primary superficial and nodular basal cell carcinoma was comparable to photodynamic therapy and surgery, respectively. Cryotherapy was inferior to radiation in terms of recurrence rate. Most patients had better cosmetic outcomes with photodynamic therapy and surgery compared to cryotherapy alone, and cryotherapy with curettage.

Conclusion: Current available data suggests equivalent efficacy of cryotherapy alone compared to photodynamic therapy or surgery, but inferior to radiotherapy. More studies are necessary to draw definitive conclusions.

Dermatologic manifestations in spaceflight: a review

With manned missions to Mars on the horizon, understanding and preparing for the medical conditions these astronauts might face becomes vital. According to the literature, the most commonly reported medical events in space are dermatological in nature. Dermatologic conditions rarely threaten an astronaut's life or the mission. However, manifestations and management of dermatologic events become an important consideration in anticipation of spaceflights to Mars and beyond. Given the limited number of articles written about dermatological conditions in this specific population, this review summarizes current knowledge related to dermatology in space. Overall, common dermatologic conditions found during spaceflight include viral reactivations, contact dermatitis or eczematous patches, and skin infections. Diagnosis and treatment can be difficult given the lack of resources in space as well as the hazards and side effects of certain treatments. In this review article we aim to summarize common skin changes induced by spaceflight, describe previously reported skin conditions including current treatment options, explore the risk of skin cancer in this unique population, and address the challenge of remote diagnosis.

Case Report

Desmoplastic intradermal spitz nevi arising within red tattoo ink

Tattoos present a diagnostic challenge for dermatologists. Various reactions to tattoo have been identified in the literature ranging from allergic, to infectious, to neoplastic. Of the neoplastic cases identified, it is unclear whether the tattoo ink was directly causative, or if the cases were merely coincidence, as the number of cutaneous malignancies has also been on the rise. We present a novel case of two desmoplastic intradermal Spitz nevi arising within red tattoo ink.

Case Presentation

Disseminated cutaneous sporotrichosis: an unusual case

Sporotrichosis is a subcutaneous mycosis caused by Sporothrix schenckii with endemic regions in the American continent. Clinical features depend on the immunological patient state and some characteristics of the fungus. Disseminated cutaneous sporotrichosis is a rare variant usually described in immunocompromised patients. A 42-year-old man was admitted with multiple verrucous and erythematous papules and plaques of the face and limbs. Many lesions showed an ulcerated and crusted component, some papules displayed linear arrangement, and some verrucous plaques exhibited black spots. Skin biopsy revealed pseudoepitheliomatous hyperplasia and granulomas in the papillary dermis. Culture of a skin sample grew Sporothrix schenkii. We report an unusual presentation of disseminated cutaneous sporotrichosis, which was a diagnostic challenge owing to polymorphism and spread of the lesions in a patient without an immunosuppressive state.

Acquired progressive kinking of the hair in an elderly woman: a case report

Acquired progressive kinking of the hair (APK) is a rare disorder that presents at any age and is infrequently presented in the literature. This diagnosis has been used to describe similar hair changes, though there are significant differences in presentation, population, and individual clinical features. Histologic analysis of hair shafts aids in diagnosis owing to commonly reported features such as irregular twisting, bending, and grooving of hair shafts with polygonal shapes on cross-section. We present a case with classic histologic features in an unusual patient to highlight this rare condition. Additional cases and studies are necessary to evaluate etiology, differentiate subsets of APK, and develop both treatment and prevention strategies.

Metastatic calcinosis cutis in a patient with Hodgkin's lymphoma

Calcinosis cutis results from the deposition of insoluble calcium salts in the skin and subcutaneous tissue. Herein, we report a case of extensive metastatic calcinosis cutis in an 18-year-old woman with stage IV Hodgkin lymphoma with skeletal involvement. With combination therapy including radiation directed at her lymphoma and diltiazem, her lesions improved dramatically. This case demonstrates the previously unreported association between calcinosis cutis and Hodgkin lymphoma.

CK7 negative anaplastic thyroid carcinoma presenting as cutaneous metastases to the scalp

Anaplastic thyroid carcinoma (ATC) is an extremely rare but aggressive form of thyroid cancer. Although local tissue invasion is characteristic of this disease, systemic metastases are a common clinical finding. Our case discusses an unusual presentation of cutaneous metastases to the scalp in a patient with a remote history of ATC. It also highlights the utility of immunohistochemical staining in determining the origin of a tumor when the source of primary malignancy is not readily identifiable.

Herpes zoster presenting as unilateral vasculitis

Vasculitis can be a primary disorder or a cutaneous manifestation of a viral infection. The present case describes an atypical localized cutaneous varicella-zoster virus infection inducing a small vessel vasculitis in a patient with multisystem sarcoidosis. Additionally, we discuss the differential diagnoses and treatment options. Varicella-Zoster infection occurs more frequently in immunosuppressed populations and can present with uncharacteristic clinical manifestations complicating the diagnosis as in the present case.

Photo Vignette

Rapidly progressing ulcer and a urine drainage bag

Primary cutaneous mucormycosis is an opportunistic fungal infection caused by the order Mucorales, most frequently by the Rhizopus species. Both systemic factors, such as diabetes mellitus or malignancies and local factors disrupting the skin barrier are implicated in development of this entity. The initial manifestation is a red-to-black papule rapidly progressing to a necrotic and painful ulcer. Diagnosis is obtained by identification of fungal forms in a skin biopsy, typically showing branching and non-septate hyphae. The clinical course is highly variable and depends mostly on the fungal invasion of deep tissues. However, an early diagnosis is essential for implementation of prompt and optimal treatment, based upon antifungal therapy and aggressive surgical debridement.

Escherichia coli-infected cephalohematoma in an infant

We report a case of Escherichia coli infection of a cephalohematoma in an infant delivered by vacuum extraction. After excluding potential complications, the patient was treated with intravenous ceftriaxone while hospitalized followed by oral cephalexin after discharge. Infection is a rare but serious complication of cephalohematomas in the newborn period. Escherichia coli is the most common pathogen responsible for infected cephalohematomas. Clinicians should be aware that infected cephalohematomas may be complicated by sepsis, meningitis, or osteomyelitis.

Hypo-pigmented mycosis fungoides is a rare malignancy in pediatrics

Hypopigmented mycosis fungoides (HMF) is an uncommon form of cutaneous T-cell lymphoma. It can be seen in children and is usually mistaken for eczema, vitiligo, or progressive macular hypomelanosis, clinically and histopathologically. We present a boy with HMF confirmed by histopathology. The patient had a course with slow clinical progression without Sezary syndrome.

Trichoscopic features of tinea capitis in a straight-haired Hispanic woman

Comma and corkscrew hairs are trichoscopic markers of tinea capitis. Although comma hairs have been reported in both black and white patients with tinea capitis, corkscrew hairs were previously hypothesized to manifest exclusively in patients with curly or African hair types. However, we report a significant number of comma and corkscrew hairs in a Hispanic female patient with naturally straight hair and Trichophyton tonsurans tinea capitis. Thus, dermoscopy is a rapid, noninvasive, and cost-effective tool for evaluating tinea capitis and should be used in combination with culture in all patients regardless of hair texture or race.

Acquired trichorrhexis nodosa: how to diagnose it?

Acquired trichorrhexis nodosa is an uncommon hair disorder, defined as a cuticle response to extrinsic or environmental insults, such as certain chemical agents. In the following report, we present a clinical case of acquired trichorrhexis nodosa and make a critical comparison by trichoscopy, optical microscopy, and scanning electron microscopy. Some diagnostic tools can provide high quality information, but their high cost and low access make them an inconvenient option. When comparing the cost-benefit ratio of each one, we conclude that acquired trichorrhexis nodosa can be easily diagnosed with a careful clinical history and examination using a dermatoscope with non-polarized light.


Trypophobia, skin, and media

Trypophobia is the fear of patterns of clustered holes, bumps, or nodules. Trypophobia has a special relationship with dermatology because of its effects on individuals with skin disease, its relationship with disease avoiding behavior, and its utilization in many online skin disease hoaxes. Trypophobic patterns on skin and characters can be found in movies, TV shows, and videogames. Several popular horror villains take advantage of trypophobic patterns like Freddy Kreuger, Jason Vorhees, and Pinhead. Most recently, another blockbuster villain has joined their ranks - Killmonger. Public health messaging about these biases and the often noncontagious nature of skin disease is warranted to attenuate public stigma of skin disease perpetuated by media.

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