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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 25, Issue 12, 2019

Commentary

Survey of resident physician and attending physician feedback perceptions: There is still work to be done

Feedback is essential for resident physician (RP) personal and professional growth. The goal of this study was to explore RP and attending physician (AP) perceptions of feedback. Two online surveys (one for RPs and one for APs) were distributed. One hundred twenty two responses were received, of which 67 were RPs and 55 were APs. Although the majority of RP and AP agree that feedback is essential for resident formation, there was a statistical difference between these groups, P=0.04 (RPs 91% versus APs 80%) with residents more likely to agree and strongly agree with this sentiment. Thirty one percent of APs report giving daily feedback, while only 9% of RPs report receiving daily feedback. Resident physicians are more dissatisfied with the quality of the feedback (40%) rather than the amount of feedback (34%). When providing feedback to their AP only 33% of RP versus 83% of APs provide honest and balanced feedback (P?0.001). RPs desire feedback that is specific, prompt, private, personalized and face-to-face. This knowledge and skills gap presents an important opportunity to incorporate feedback training into residencies to ensure that the dermatologists of the future are not only medically competent, but also competent in providing feedback to future generations.

Case Report

Characteristics of patients hospitalized for Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) at a Level 1 trauma center

The purpose of this study is to further characterize the population that is hospitalized for a severe cutaneous drug reaction or that developed once during their hospitalization. We conducted a chart review of patients seen by a dermatologist at the University of California Davis Medical Center for the diagnosis of Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS). Between January 2000 and July 2018, 25 cases of DRESS were diagnosed using RegiSCAR criteria. Twenty-two patients recovered, two were deceased, and one was transferred to another hospital. The most commonly implicated drugs in the development of DRESS were nafcillin (N=3) and carbamazepine (N=3). Of the 25 patients in our care, 88% developed eosinophilia, 50% developed renal involvement, and 44% had liver involvement. There was a positive correlation between age and creatine (P=0.01) and age and eosinophils (P=0.02). There was a negative correlation between age and liver enzyme abnormalities (AST P=0.01; ALT P=0.0003). Carbamazepine and nafcillin were commonly implicated drugs in DRESS. There was no significant difference between treatment group and patient outcome. Those who develop DRESS at an older age were more likely to have elevated creatinine and more profound eosinophilia, but were less likely to develop liver involvement.

Case Presentation

Drug-induced anti-Ro positive subacute cutaneous lupus in a man treated with olmesartan

A 66-year-old man presented to the outpatient dermatology clinic with a chief complaint of a pruritic rash on his upper trunk and proximal upper extremities, which had been present for three weeks. Upon examination, he was found to have an erythematous, annular, and polycyclic eruption on the chest, upper back, and proximal extremities. A clinical diagnosis of subacute cutaneous lupus erythematosus (SCLE) was made. The patient was found to have a positive anti-nuclear antibody (ANA) in a speckled pattern and a positive anti-Ro antibody. A biopsy revealed an interface and lichenoid dermatitis with dermal mucin deposition, consistent with subacute cutaneous lupus erythematosus. The patient reported that he had recently been diagnosed with hypertension and began treatment with olmesartan, a potassium-sparing diuretic that blocks the angiotensin II receptor, commonly used as an antihypertensive or in patients with heart failure. Cutaneous reactions to olmesartan are rare and reported in <1% of patients in post-marketing surveillance. The patient discontinued use of olmesartan and the rash completely resolved within three weeks. To date, there are no other reported cases of drug induced SCLE in patients taking olmesartan to our knowledge.

Bullous hemorrhagic lichen sclerosus of the breast: a report of two cases and review of the literature

Lichen sclerosus (LS) is a chronic dermatologic condition characterized by atrophic porcelain-appearing plaques that can cause intense discomfort and eventually lead to destruction of local architecture. Lichen sclerosus most commonly arises in the anogenital area, but up to 20% of cases can present on extragenital skin. Rarely, LS can also present with hemorrhage and bullae; the mechanism by which this occurs is unknown. We report two cases of bullous hemorrhagic LS of the breast arising in 66-year-old and 77-year-old women. Bullous hemorrhagic LS of the breast is exceedingly rare, with few reported cases, and presents a diagnostic challenge to clinicians.

Cutaneous angiosarcoma of the leg

Angiosarcomas are malignant neoplasms arising from endothelial cells. Cutaneous angiosarcoma is the most common form, typically occurring in the setting of chronic lymphedema or previous radiation. The head and neck are the most common locations for cutaneous angiosarcoma, with rare occurrence on the trunk and extremities. Herein, we present a case of angiosarcoma on the lower extremity in an elderly man. This 71-year-old man presented with a two-year history of red-yellow discoloration of the left lower leg with subsequent development of black nodules over the past several months prior to presentation. He denied any itching, bleeding, or ulceration. Past medical history included diabetes, hypertension, and non-melanoma skin cancer. Physical examination showed erythematous, violaceous, non-blanchable papules with yellow atrophic regions and overlying black crusted nodules and plaques. Biopsies were taken and the patient was diagnosed with angiosarcoma and referred to a tertiary care center for further evaluation.

Photo Vignette

Elephantiasis nostras verrucosa: an atypical presentation following intrapelvic lymphoma

Elephantiasis nostras verrucosa is a progressively debilitating and disfiguring disease commonly presenting with verrucous, cobblestone-like papules, nodules, or plaques with nonpitting edema in the lower extremities. Histopathology is marked by hyperkeratosis and dermal or subcutaneous fibrosis as a result of chronic lymphedema. Risk factors include obesity, recurrent cellulitis, chronic venous insufficiency, congestive heart failure, scleroderma, radiation, trauma, and tumors. We report a 72-year-old man who presented to the dermatology clinic for an 11-year history of edematous legs, occasionally associated with ulcerations. The findings developed within a year of intrapelvic non-Hodgkin lymphoma and progressed gradually over 10 years after lymphoma remission. Physical examination revealed atypical features including compressible cysts and pitting edema extending from the lower legs to the thighs bilaterally. The patient was noncompliant for the recommended compressive devices and the condition progressively worsened over the course of 7 months of follow-up. Early interdisciplinary management using compressive devices and a lymphatic pump are recommended. Underlying causative factors should be assessed with regular follow-up to optimize treatment outcomes.

Onset of disseminated cutaneous nodules following toe amputation in heart transplant patient

Alternaria spp. infections are rare, but organ transplant recipients and immunosuppressed patients are particularly at risk of developing cutaneous alternariosis. Although cutaneous alternariosis is well-defined, instances of disseminated infection are exceedingly rare. We report a case of disseminated Alternaria infection in an immunocompromised patient from a primary focus of ungual phaeohyphomycosis.

Verrucous venous malformation

Verrucous venous malformation, also known as verrucous hemangioma, is a superficial vascular malformation with a variable degree of hyperkeratosis that is composed of capillaries and veins in the dermis and sometimes subcutaneous tissue. We describe a 53-year-old man who presented with a large hyperkeratotic plaque of the left dorsal and plantar foot. Biopsy revealed verrucous acanthosis of the epidermis and a proliferation of thin-walled vessels in the dermis. We provide a brief review of the clinical and histopathologic presentation, differential diagnosis, and management of this rare entity.

Angiolymphoid hyperplasia with eosinophilia treated with Mohs micrographic surgery

A 60-year-old healthy man presented with several enlarging, tender, spontaneously bleeding, and episodically pruritic nodules on his ear. Five agminated pink-red papulonodules of the superior postauricular sulcus were noted on examination. Pathological examination revealed a lobular dermal vascular proliferation with plump endothelial cells protruding into the lumen in a hobnail pattern, along with a dense perivascular inflammatory infiltrate composed of plasma cells, lymphocytes, and numerous eosinophils. The diagnosis of angiolymphoid hyperplasia with eosinophilia was confirmed. After discussing treatment modalities, the patient opted for Mohs micrographic surgery (MMS). Three stages of MMS were able to remove all large vessel involvement and clear the peripheral margins, but the tumor had a complex branching pattern of growth in the deep bed of the wound with numerous tiny foci remaining. Owing to risk of disfigurement, no further excision was undertaken. The area was reconstructed with a temporalis fascia flap and a full-thickness skin graft. Despite remaining microscopic disease, the patient remained without recurrence or symptoms at one year of follow up.

NYU Grand Rounds

Erythroderma with circulating atypical T-cells, likely Sézary syndrome

The erythrodermic patient is often challenging and requires careful evaluation. Work-up should include an extensive and careful medication history, histological and laboratory testing, and if necessary, molecular studies for the evaluation of underlying malignancy. Herein, we present an erythrodermic patient with repeated biopsies demonstrating a spongiotic process who was found to have circulating atypical T-cells concerning for an underlying erythrodermic T-cell leukemia, most closely related to Sézary syndrome.

A case of porphyria cutanea tarda in the setting of hepatitis C infection and tobacco usage

Porphyria cutanea tarda (PCT) is the most common type of porphyria, presenting in middle-aged patients with a photodistributed vesiculobullous eruption, milia, and scars. Porphyria cutanea tarda occurs in relation to inhibition of uroporphyrinogen decarboxylase, a key enzyme in the heme biosynthesis pathway. A number of genetic and acquired factors increase susceptibility to PCT by reducing uroporphyrinogen decarboxylase activity. A handful of other vesiculobullous conditions may mimic PCT both clinically and histologically; therefore, both skin biopsy and laboratory evaluation are helpful in confirming the diagnosis. We report a case of PCT in the setting of cigarette usage and untreated hepatitis C infection.

Letter

Vitiligo-like lesions located over In-transit metastases of malignant melanoma as a clinical marker of complete response to pembrolizumab.

Anti-programmed cell death (PD)-1 therapies in metastatic tumors have a high incidence of immune adverse events, including cutaneous manifestations such as vitiligo-like lesions. This side effect is associated with increased survival and it is a clinical marker of response to treatment. This case report is a graphic representation of the appearance of vitiligo-like lesions over in-transit metastases of malignant melanoma linked to a complete response to treatment with pembrolizumab.

Unbearable wearables

As wearable devices play an increasing role in the management of health and disease, adverse skin reactions to wearables have become more common. However, the management of allergic contact dermatitis is challenging and new treatment options more compatible with wearable devices are needed. In a 40-year-old woman with contact dermatitis to a continuous glucose monitoring device, topical clobetasol propionate 0.05% spray proved to be an effective treatment that was compatible with the application of adhesive wearables. This case demonstrates that spray formulations of topical steroids are a good option for the treatment of dermatitis under wearable devices such as continuous glucose monitors or ostomy appliance.

The tangential punch biopsy

Dermatologists around the world widely utilize skin biopsies, which can be performed using shave, punch, incisional, or excisional techniques [1]. The punch biopsy allows a dermatologist to obtain a full-thickness skin sample. The post-biopsy wound heals by primary closure or second intention [2]. Some suspicious lesions may be located at the body parts that are difficult to access.

A fluorescing spot on the temple: a helpful reminder for a detailed history and physical exam

We discuss a woman with a history of non-melanoma skin cancer who presented with a new erythematous macule on her right temple. On examination with Wood lamp the well-demarcated macule fluoresced pink making neoplasm unlikely. Further history and physical examination suggested an inadvertent ink stain and the patient was spared a biopsy highlighting the importance of eliciting a good history and performing a detailed physical examination with additional tools such as a Wood lamp when necessary.