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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 24, Issue 12, 2018

Commentary

Dermatology and anatomy laboratory: comparing three formats of integration

Background: Medical schools rarely offer exposure to clinical dermatology in the first-year curriculum.

Objective: We describe and report student satisfaction results of three novel teaching methods for integrating basic dermatology concepts into gross anatomy laboratory.

Methods: During the first year of the intervention, 180 students attended an hour-long anatomy laboratory session during which skin lesions were examined. One attending and three resident dermatologists spent time at all tables of students, then circulated to answer questions. During the second year, 189 students participated in the same teaching session preceded by a 30-minute in-class lecture. During the third year, 172 students were given the option to view a supplemental online video module before or after the teaching session. Each year following the teaching session, students were sent an optional online survey regarding the impact of the teaching session on their understanding of skin lesions and their cadaver experience.

Results: Overall, students felt the intervention helped them develop a better understanding and appreciation for dermatology. Preceding the laboratory session with a lecture or educational video yielded higher satisfaction scores.

Conclusions: This brief teaching intervention illustrates an approach to introducing dermatologic entities within the foundational science curriculum of the first year of medical school.

Dermatology on YouTube - an update and analysis of new trends

Because YouTube is one of the most popular search engines, it is an instrumental tool to stay up to date on the most relevant dermatology trends and content in order to better direct patients and improve health outcomes. Twelve select terms (i.e. Dermatology, Sun protection, Skin cancer awareness, Skin cancer, Skin condition, Sun safety, Tanning, Melanoma, Basal cell carcinoma, Squamous cell carcinoma, Skin cancer treatment, Skin cancer prevention) were searched on YouTube. Overall, the results included 240 videos with over 160 million views. Educational content was most prevalent at 35% of the total search results. Of the total videos, 42% were uploaded by or featured a medical health professional (MD, DO, PhD, RN, ND), with 28% involving a board-certified dermatologist. Trends in content type have changed: educational and personal videos have increased, while advocacy and advertising have decreased. Most search terms are moving in a positive, informative direction, specifically the term "tanning." Other search terms such as "skin condition" and "skin cancer treatment" should be more closely monitored for misleading and perhaps harmful information. Therefore, dermatologists and other medical personnel should keep pace with relevant and popular dermatology content on YouTube in order to understand, advise, market, educate, and address patients' questions and concerns.

Case Report

Erythema nodosum and sarcoid granulomas — letting the cat out of the bag

A 41-year-old woman presented with a violaceous papule on the dorsum of the hand, large ipsilateral axillary lymphadenopathy, and tender, erythematous, subcutaneous nodules on the legs. Accompanying signs included fever, ankle swelling, and bilateral red eye. She recalled having a previous exposure to kittens one month before and had a positive family history for sarcoidosis. Histological examination of the hand lesion showed sarcoidal granulomas with positive Bartonella henselae DNA, whereas a biopsy done on the leg nodules was compatible with erythema nodosum. Cat scratch disease (CSD) typically presents as a tender regional lymphadenopathy preceded by an inoculation papule with spontaneous resolution occurring between 8-16 weeks. Cutaneous manifestations of CSD are rare, with erythema nodosum accompanying only 0.6% of cases. Although speculative, the background of a positive family history for sarcoidosis may explain the atypical presentation of this case, with red eye, persistent arthralgia, and associated sarcoidal granulomas.

NYU Grand Rounds

Folliculotropic mycosis fungoides

Folliculotropic mycosis fungoides (MF) is a distinct subset of cutaneous T cell lymphoma (CTCL). The disease is typically marked by an aggressive course and is often recalcitrant to skin-direct therapy. We report a case of an 83-year-old woman with folliculotropic MF characterized by erythematous, scaly plaques on the forehead along with poliosis and alopecia of the right medial eyebrow.

Generalized essential telangiectasia

The pathophysiology of generalized essential telangiectasia is not well understood. Generalized essential telangiectasia is an uncommon disorder in which widespread telangiectasias of unknown cause develop without associated systemic or antecedent dermatologic disease. We report a case of generalized essential telangiectasia in an otherwise healthy 49-year-old man.

Lichen planus pigmentosus

Lichen planus pigmentosus (LPP) is an uncommon variant of lichen planus of unclear etiology that predominantly affects patients of skin types III to VI. We report a case of LPP of two years duration in a 67-year-old man involving upper extremities, chest, abdomen, and upper back.

Acquired immune deficiency syndrome-related epidemic Kaposi sarcoma

Kaposi sarcoma (KS) is a vascular neoplasm that is one of the most common human immunodeficiency virus (HIV)-related malignancies. We present the case of a 42-year-old man with a new diagnosis of HIV and acquired immune deficiency syndrome (AIDS)-related epidemic KS.

Necrobiosis lipoidica

We present a case of necrobiosis lipoidica (NL) of the right abdomen in a 75-year-old man. A skin biopsy performed showed a layered infiltrate of mono and multinucleated histiocytes palisaded around degenerated collagen bundles. Laboratory workup was unremarkable. The patient was treated with topical corticosteroids with cessation of progression of his disease, although the eruption did not resolve. There are a number of treatments for NL reported in the literature, all with varying efficacy. Although NL lesions are usually asymptomatic, patients with NL must be monitored closely for signs of ulceration or malignant transformation, in which case more aggressive treatment options may be warranted.

Lymphomatoid papulosis

Lymphomatoid papulosis is often regarded as a low-grade variant of cutaneous T cell lymphoma (CTCL). Given the excellent long-term prognosis, recent consensus guidelines indicate that patients can be monitored off therapy. We report a case of a 67-year-old man who presented with lymphomatoid papulosis, with necrotic papules that have been intermittently present for over forty years.

Botulinum toxin for treatment of Raynaud phenomenon in CREST syndrome

Calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia (CREST) syndrome is a form of a rare, clinical subtype of systemic sclerosis, known as limited systemic sclerosis. Limited systemic sclerosis, including CREST syndrome, manifests as fibrotic skin changes restricted to the hands and face, with vascular, musculoskeletal, and visceral involvement. We present a case of a 75-year-old woman with a longstanding history of CREST syndrome complicated by a digital ulceration and persistent pain associated with recalcitrant Raynaud phenomenon. After failing a number of first-line pharmacologic therapies such as diltiazem, sildenafil, and topical nitropaste, the patient was started on a trial of botulinum toxin for the left second digit, with 10 unit injections into both webspaces for a total of 20 units. Following injection, the patient reported no further baseline pain in the affected finger and an over fifty-percent improvement in discomfort with manipulation of the digit at a follow-up time of one week. The ulceration started healing within the following three weeks. This result was maintained at a follow-up time of six weeks.

Unusual eruption in association with sorafenib: a case of acquired perforating dermatosis, reactive perforating collagenosis type

The term, acquired perforating dermatoses (APD), represents a group of skin conditions that develop in adulthood and are characterized by transepidermal elimination of dermal connective tissue. This appears clinically as a papulonodule with a keratotic core. Although APD is typically associated with diabetes mellitus, chronic renal failure, and several other conditions causing generalized pruritus, there have been reports in the literature describing an association of APD with select drugs including sorafenib. We present a case of acquired perforating dermatosis in a patient with HIV and hepatocellular carcinoma undergoing treatment with sorafenib.

Photo Vignette

Whitish vulvar tumors associated with macular symmetrical rash

We present a woman with an unusual case of secondary syphilis after an unnoticed primary infection. She initially presented with multiple grayish plaques and nodules on the vulva associated with an erythematous macular symmetrical rash affecting the trunk and extremities. Despite the increasing incidence of sexually transmitted diseases such as syphilis, presentation with unusual manifestations can lead to a delayed diagnosis.

Majocchi granuloma on a child's face

Majocchi granuloma (MG) is a rare dermal and subcutaneous fungal infection. We report a rare case of MG on the face of a six-year-old child caused by Trichophyton mentagrophytes after long term use of topical corticosteroids and other inadequate topical medications. He was treated with griseofulvin 25 mg/kg/day for 35 days unsuccessfully and successful treatment was obtained with terbinafine.

PD-1 inhibitor induced alopecia areata

Immune checkpoint modulators are becoming more prevalent in clinical use for the treatment of metastatic melanoma and other malignancies. These drugs, including programmed death 1 (PD-1) inhibitors, have a high incidence of immune adverse events, including cutaneous manifestations. Alopecia is a known side effect with these drugs, but previous reports describe chemotherapy-induced alopecia. We report a case of alopecia areata in a patient on monotherapy with pembrolizumab (PD-1 inhibitor). It is important for the dermatologist to recognize and appropriately treat to decrease morbidity for these patients.

Letter

Acrodermatitis enteropathica: the need for sustained high dose zinc supplementation

Acrodermatitis enteropathica (AE) is a rare congenital disorder owing to an abnormality with intestinal absorption and/or transportation of zinc. We describe two male siblings, who presented with evidence of both acute and chronic zinc deficiency, despite being diagnosed with AE very early in life. We wish to highlight the importance of sustained high-dose zinc supplementation and regular monitoring in AE cases. Proper counselling of parents about the need for life long supplementation and increasing requirements with age is essential.

Local and distal involution of recalcitrant warts after a single intralesional dose of measles, mumps, and rubella vaccine

Verruca vulgaris is a prevalent childhood condition, but treatments are often poorly tolerated. Early treatment is preferable because delays increase the probability of pain, disfigurement, and failed eradication. However, typical treatments require multiple sessions without promising cure. We describe the use of a single intralesional treatment with the measles, mumps, and rubella (MMR) vaccine to successfully eliminate both local and distant recalcitrant warts as well as the proposed mechanism of this method. There are no other known reports of complete wart regression at distant untreated sites after a single intralesional MMR treatment.

Laptop computer-induced hyperpigmentation

A 25-year-old afebrile man presented with one year of worsening non-pruritic hyperpigmented non-blanchable reticulated patches and one erosion on his abdomen. He denied trauma, contact with new detergents, and recent travel. He was not taking medications and denied ever having similar skin findings. Further questioning revealed that he positioned his laptop computer directly on his abdomen for several hours every night. His progressive skin findings characterize erythema ab igne, which occurs after repetitive prolonged exposure to temperatures between 43 to 47 degrees Celsius. The hyperpigmentation can occur anywhere on unprotected skin and is an ongoing clinical problem in all demographics as heat sources evolve. Guided questioning of an unsuspecting patient can expedite diagnosis and prevent the development of erosions and ulcers, permanent skin discoloration, and even skin cancers.

The smartphone: an effective tool in transitioning patients from mole mapping to mole excision

We describe a useful strategy to accurately identify the correct 'atypical' nevus for excision in patients with multiple nevi. We believe this is an effective strategy and eliminates risk of any incorrect procedures being performed, and have used this technique on over 50 patients to date. As the patient stores the images on their own phone, there is no breach of data protection. We find patients prefer this method as opposed to giving others permission to store their sensitive information.