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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 4, 2018


Restrictions on blood donations relevant to dermatology

Over 36,000 units of blood are transfused every day in the US. With nearly 40% of the population eligible to donate, we may frequently treat potential blood donors. We reviewed the American Red Cross and World Health Organization’s restrictions on blood donation. Multiple drugs used, and diseases treated in dermatology, are associated with blood donation restrictions. Understanding these restrictions may help us better educate our patients.


Gender differences in melanoma prognostic factors

Background: Although previous studies identify gender differences in melanoma, limited research on the phenomenon exists.Methods: In this retrospective chart review, 1,156 adults diagnosed with melanoma, between 2006-2016, at the University of Colorado were included. Breslow depth, mitotic rate, ulceration status, and location were extracted from charts between March and August 2016. Cochran-Armitage trend tests and cumulative logistic regression were used to examine the association between gender and Breslow depth, univariately and after adjusting for potential confounders.

Results: In univariate analysis, males were significantly more likely to present with lesions with higher Breslow depths (p for trend=0.005). In models adjusted for age, melanoma subtype, and location, males were marginally more likely to present with lesions with higher Breslow depths (cumulative OR: 1.261, 95% CI: 0.988-1.611, p=0.060). Males were also marginally more likely to present with lesions with higher mitotic rates, after further adjustments for all other prognostic factors (cumulative OR: 1.244, 95% CI: 0.979-1.580, p=0.074).

Limitations: This was a retrospective single-institution study.

Conclusion: Differences in mitotic rates among melanomas in males versus females, even after adjustments for all other prognostic factors, suggests that biological differences may contribute to the female prognosis advantage.

Nickel release from surgical instruments and operating room equipment

Background There has been no systematic study assessing nickel release from surgical instruments and equipment used within the operating suite. This equipment represents important potential sources of exposure for nickel-sensitive patients and hospital staff.

Objective: To investigate nickel release from commonly used surgical instruments and operating room equipment.

Methods and Materials: Using the dimethylglyoxime nickel spot test, a variety of surgical instruments and operating room equipment were tested for nickel release at our institution.

Results: Of the 128 surgical instruments tested, only 1 was positive for nickel release. Of the 43 operating room items tested, 19 were positive for nickel release, 7 of which have the potential for direct contact with patients and/or hospital staff.

Conclusion: Hospital systems should be aware of surgical instruments and operating room equipment as potential sources of nickel exposure.

Do looks matter? The role of the Electronic Residency Application Service photograph in dermatology residency selection

Background: There is a lack of research on the impact of the Electronic Residency Application Service (ERAS) photograph on the residency selection process.

Objective: We sought to elucidate the role of the ERAS photograph in the dermatology residency selection outcome and to determine if photographs submitted by matched applicants differ from those of unmatched applicants.

Methods: We analyzed ERAS photographs submitted by dermatology residency applicants based on photograph characteristics related to composition, attire, facial expression, hairstyle, and accessories.

Results: Candidates who smiled, wore glasses, and wore jackets in their photographs were more likely to match. There was no difference in the rate of matching among applicants depending on whether their photograph was of professional quality or whether they wore formal attire in their pictures. Gender specific characteristics were not found to be influential in the match outcome for male applicants. Among female applicants, having hair to the shoulders or longer was associated with a positive match outcome.

Conclusion: Certain characteristics of the ERAS photographs were found to be associated with a more favorable match outcome. Further biases inferred from these photographs might be present in the dermatology selection process. We suggest blinding the selection committees to ERAS application photographs prior to granting residency interviews.


Moonlighting in residency: a dermatology perspective

Background: Moonlighting refers to the practice of medicine outside one’s training institution in exchange for financial compensation. High medical debt-to-income ratios drive residents to seek additional compensation during residency.

Objective: To gather information to establish the current practices of moonlighting and to better understand the thoughts and experiences of dermatology residency program directors regarding moonlighting.

Methods: All allopathic and osteopathic dermatology residency program directors in the United States and Puerto Rico received a blinded survey between February 1, 2017 and April 1, 2017 through an email link.

Results: Response rate was 47.0%. Of the programs that responded, 63.16% allowed moonlighting. In three regions, 100% of programs allowed moonlighting. The geographic area with the lowest percentage of programs permitting moonlighting was New England with 25%.

Limitations: This survey only reflects the field of dermatology and beliefs/policies of program directors.

Conclusion: This survey highlighted that training programs allowing moonlighting tend to have a more positive outlook on the practice than programs who do not. Results revealed trends that suggest that states in regions with less access to dermatologic care were more inclined to allow moonlighting.

Layout and flow of dermatology clinics: principles from operations management

Dermatology is a medical specialty that experiences high patient demand and long patient wait times. Dermatology clinics should look for ways to improve efficiency through the incorporation of principles from operations management. Addressing the layout and flow of a clinic can lead to operational efficiency. An ideal layout may lead to increased patient volume, satisfaction, and retention.

Optimizing visiting clerkships in dermatology: a dual perspective approach

Matching into a dermatology residency program has become increasingly more challenging for medical students. As students continue to explore various methods to help them standout to programs, recent medical literature has continued to show evidence of the important role that visiting clerkships play. Visiting clerkships offer several benefits to both students and programs. In order to optimize visiting clerkships, the perspectives of both students and programs are each examined with recommendations provided to help maximize its benefits.

Teledermatology leading to an important diagnosis in an underserved clinic

Cutaneous signs can be the first manifestation of important medical diagnoses, including inherited cancer syndromes, but access to dermatologic evaluation is especially challenging for uninsured patients. Herein, we present a case in which a volunteer academic teledermatology triage program was used by a community health clinic to make a diagnosis of multiple cutaneous leiomyomas, which confer a high likelihood of hereditary leiomyomatosis and renal cell cancer syndrome, also known as Reed syndrome; this prompted malignancy screening for the patient. Importantly, this case underscores the potential for teledermatology to improve access to dermatologist evaluation and make crucial diagnoses in patients with barriers to care.

Case Report

Adult-onset papular purpuric gloves and socks syndrome

Papular purpuric gloves and socks syndrome (PPGSS) is a self-limited exanthem that presents as painful or pruritic edema, erythema, petechiae, and purpura of the palms and soles with occasional extension to the dorsal hands and feet. The majority of PPGSS cases reported in the literature are associated with parvovirus B19 and occur in children and young adults. In a recent literature search, there were 11 PPGSS cases in adults with none reporting Epstein-Barr virus (EBV) as a viral etiology. However, there have been PPGSS cases related to EBV in children. We report the case of a 72-year-old man with PPGSS associated with Epstein-Barr virus. This case report serves as a reminder that PPGSS can present not only in the setting of pediatric and young adult parvovirus B19 infection, but also in immunocompetent adults with other viral infections.

Topical application of 5-fluorouracil 5 percent cream associated with severe neutropenia: discussion of a case and review of systemic reactions after topical treatment with 5-fluorouracil

5-fluorouracil, a fluoropyrimidine antineoplastic drug, is used to topically treat actinic keratoses. Local skin reactions to the medication are common and anticipated. However, severe adverse events from topical 5-fluorouracil are rare and unexpected. A 69-year-old man with a lower lip actinic keratosis developed severe neutropenia on day 11 of topical 5-fluorouracil treatment — after 14 applications. After receiving a subcutaneous injection of filgrastim, his neutrophil count normalized. The PubMed database was used to search the following terms: agranulocytosis, cream, 5-fluorouracil, granulocytopenia, neutropenia, severe, systemic, topical, and toxicity. The papers, and relevant cited references, generated were reviewed. Systemic reactions to topical 5-fluorouracil included angioedema, melanonychia, neurologic conditions (such as acute cerebellar syndrome, headaches, and peripheral neuropathy exacerbation), taste alteration, and systemic toxicity requiring hospitalization (including severe neutropenia). One of the individuals (a man with severe neutropenia and other symptoms) also had a deficiency of dihydropyrimidine dehydrogenase, the enzyme that catalyzes the rate-limiting step in 5-fluorouracil metabolism. Evaluation for dihydropyrimidine dehydrogenase deficiency is not routinely performed in patients receiving systemic or topical 5-fluorouracil. Also, the incidence of potentially severe 5-fluorouracil-induced toxicity associated with topical application of the drug may be greater than documented.

Case Presentation

Myopericytoma in an unusual location

Myopericytoma is a soft-tissue tumor of perivascular cells (pericytes). It is slow-growing, usually asymptomatic, and generally benign, although a malignant variant has been described. The etiology is unknown, but it has been associated with local trauma. The most common location is on the distal extremities. Histologically, it is characterized by a well-circumscribed, non-encapsulated proliferation of spindle shaped cells similar to myofibroblasts with oval nuclei and eosinophilic cytoplasm, arranged in perivascular concentric rings. There are few mitoses and no necrosis is reported. The immunohistochemical analysis is positive for smooth muscle actin and negative or weakly positive for desmin. A low Ki-67 proliferation index is typical. Treatment is surgical excision with free margins. Recurrences after adequate excision are uncommon. We describe a 48-year-old woman with a myopericytoma in an unusual location (next to the inner corner of her left eye) who was treated with surgical excision; there has been no recurrence after 5 years of follow up.

Squamous cell carcinoma of the perineum masquerading as necrotizing hidradenitis suppurativa

Many cases of superinfected hidradenitis suppurativa (HS) involve multiple species of bacteria, but gas-producing infections are rare and can complicate the clinical picture. Additionally, recognizing squamous cell carcinoma (SCC) as a complication of longstanding HS is imperative. Herein, we present a unique case of a severe emphysematous HS that was initially mistaken for Fournier gangrene and eventually diagnosed as superinfected SCC.

Debilitating erosive lichenoid interface dermatitis from checkpoint inhibitor therapy

As the list of anti-tumor immunotherapy agents and the list of cancers treated by these novel agents grow, a subset of patients are experiencing immune-related adverse events as a result of prolonged stimulation of the immune system. Many different immune related adverse events including colitis, hepatitis, pneumonitis, thyroiditis, hypophysitis, and cutaneous reactions can result from blocking these inhibitory pathways. The full spectrum of cutaneous immune related adverse events secondary to checkpoint inhibitor therapy is still being defined. The reported varied presentations include lichenoid reactions and bullous pemphigoid, amongst others. We present a severe cutaneous reaction, a case of debilitating erosive lichenoid dermatitis. This case emphasizes both the wide range of possible cutaneous reactions and the potential severity of these reactions.

Generalized fixed drug eruption to piperacillin/tazobactam and review of literature

Fixed drug eruption (FDE) is an adverse drug reaction characterized by the development of well-circumscribed, round, dusky erythematous macules and plaques on cutaneous or mucosal surfaces. The reaction occurs on the same mucosal or cutaneous site with subsequent exposures to the offending drug. Although FDE usually manifests as a single lesion, in rare instances, more than one lesion may arise and this is referred to as a generalized eruption. Herein, we present a 31year-old man with history of cystic fibrosis who developed a generalized fixed drug eruption to piperacillin/tazobactam (Zosyn, Pfizer). We discuss our patient’s course and review causes and outcomes of generalized fixed drug eruptions in the literature.

Annular and arcuate syphilis: an uncommon presentation of disseminated secondary syphilis

Physicians should be aware of unusual presentations of syphilis. For dermatologists, the visual recognition of lesional morphology and distribution is a fundamental part of clinical evaluation, which dictates the workup and diagnosis. Secondary syphilis has a variety of presentations, the most common being a diffuse symmetrical papulosquamous eruption. It continues to be a diagnostic challenge as the myriad manifestations of secondary syphilis can mimic many dermatological disorders. Herein we report a case of secondary syphilis with an uncommon presentation characterized by disseminated annular and arcuate lesions.

Photo Vignette

Tender finger nodule

A male in his twenties presented with a tender finger nodule that had been present for 3 months. Histopathological examination revealed a dermis with nodules of necrotic, athypical epithelaia cells with high nuclear to cytoplasmic ratios. Glandular formation was present with lumens lined by columnar epithelium, consistent with digital papillary adenocarcinoma. Digital papilary adenocarcinoma is a rare malignant adnexal tumor arising from sweat glands and requires further work-up.

Syringocystadenoma papilliferum on the mons pubis

It is relatively rare to find syringocystadenoma papilliferum (SCAP) outside the head and neck region and extremely rare in the anogenital area. Characteristic histological features such as cystic invaginations, glandular epithelium showing decapitation secretion, and stroma with plasma cells are important for making the diagnosis. We present a rare case of SCAP on the mons pubis of a 13-year-old girl and compare cases of SCAP from other rare locations.


Industry payments to dermatologists: updates from the 2016 open payment data

Payments made to dermatologists by pharmaceutical and medical device manufacturing companies have become better understood following the advent of the Open Payments program. The purpose of this study was to analyze payments made to dermatologists in 2016 and evaluate trends in the payments from the previously published 2014 data.

Randomized and controlled pilot study of the pragmatic use of mobile phone based follow up of actinic keratoses treated with topical 5-fluorouracil

Store-and-forward teledermatology involves transmission of a patient’s images to a healthcare provider and subsequent response from the provider about the diagnosis or management. Furthermore, teledermatology in which mobile phones (e.g. smartphones) are utilized for communication between the patient and their provider is referred to as mobile-teledermatology. In this study, we investigate the use of mobile-teledermatology in the management of actinic keratoses. We demonstrate that mobile-teledermatology may enhance communication between the patient and their provider when managing cutaneous disease and that even individuals in older age groups are highly satisfied with this type of follow up.

Dermatology on Google+

Google+ sets itself apart from other social media platforms through a number of unique features, including search engine optimization services and high user satisfaction. The purpose of this study was to evaluate the presence of dermatological entities on Google+. Searches were conducted to locate any Google+ accounts associated with the most popular dermatology journals, dermatological patient-centered organizations, and professional dermatology-related organizations on social media. Additionally, “dermatology Google+” was searched via Google, and Google+ profiles retrieved in the first page of results were assessed. Four of the five active Google+ profiles identified in the first page of Google search results were run by private dermatology practices. Only one of the 13 searched journals was active on Google+. Twenty-six of the 34 patient-centered and professional organizations had Google+ accounts, but only seven of these accounts were active in the last year. Therefore, unlike some private practices, the majority of dermatology journals and organizations have yet to take advantage of the exclusive opportunities offered by Google+ to expand their audiences and bolster their overall online presence.