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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 5, 2019

Review

Ashy dermatosis: a review

Ashy dermatosis is characterized by asymptomatic, symmetrically-distributed, gray-colored macules located on the trunk, neck, face, and upper extremities. The condition occurs most commonly in patients with Fitzpatrick phototype III-V skin. The etiology is unknown, but drug ingestion, infection, and genetic factors have been suggested to elicit ashy dermatosis. No gold standard treatments have been established yet. The most successful treatment to date has been clofazimine, although topical tacrolimus, oral dapsone, narrowband ultraviolet light B phototherapy, and isotretinoin have shown treatment success. Ashy dermatosis is primarily a cosmetic concern, but can be a very distressing condition, especially for dark skinned individuals. Therefore, an increase in clinician awareness and more studies are needed to further understand the etiology and treatment options for this disease. This review serves as a single source for clinicians to stay up-to-date regarding the history, clinical presentation, histology, pathogenesis, differential diagnosis, and management options for ashy dermatosis. It also suggests an alternative name that more appropriately encompasses the clinical and histopathologic features, while acknowledging our lack of understanding of its etiology: macular hyperpigmentation of indeterminate etiology.

Original

Impact on clinical practice of a non-invasive gene expression melanoma rule-out test: 12-month follow-up of negative test results and utility data from a large US registry study

The Pigmented Lesion Assay (PLA, sensitivity 91-95%, specificity 69-91%, negative predictive value ?99%) is a commercially available, non-invasive gene expression test that helps dermatologists guide pigmented lesion management decisions and rule out melanoma. Earlier studies have demonstrated high clinical utility and no missed melanomas in a 3-6-month follow-up period. We undertook the current investigations to provide 12-month follow-up data on PLA(-) tests, and to further confirm utility. A 12-month chart review follow-up of 734 pigmented lesions that had negative PLA results from 5 US dermatology centers was performed. Thirteen of these lesions (1.8%) were biopsied in the follow-up period and submitted for histopathologic review. None of the lesions biopsied had a histopathologic diagnosis of melanoma. The test's utility was studied further in a registry (N=1575, 40 US dermatology offices, 62 participating providers), which demonstrated that 99.9% of PLA(-) lesions were clinically monitored, thereby avoiding a surgical procedure, and 96.5% of all PLA(+) lesions were appropriately biopsied, most commonly with a tangential shave. This long-term follow-up study confirms the PLA's high negative predictive value and high utility in helping guide the management of pigmented lesions to avoid unnecessary surgical procedures.

Comparison of quality of life and illness perception among patients with acne, eczema, and psoriasis

Dermatologic diseases have a similar influence on quality of life (QoL) and disability as other chronic medical conditions. Although QoL has been studied in relation to acne, eczema, and psoriasis, there is little information on how patients conceptualize their diseases - the illness experience. More information about illness perception (IP) and the impact of these perceptions on QoL, will help clinicians identify and address patients' conceptions, with the potential to positively impact patients' wellbeing. We sought to examine the effect of IP on QoL and make comparisons across acne, psoriasis, and eczema among a diverse population. A cross-sectional survey-based study was completed anonymously by patients presenting to an urban university hospital-based dermatology clinic. In our final model, we showed that IP was independently associated with overall QoL. A secondary finding showed that overall QoL was significantly worse for nonwhite patients compared to white patients. Our results are based on patient survey data, without correlation with objective clinical information. Taken together, our data demonstrate a direct relationship between IP and QoL in three common dermatologic conditions in a clinic-based setting and suggest that this relationship may be influenced by group differences, such as race/ethnicity.

Interview date trends for dermatology residency from 2012-2017

Data regarding dermatology residency interview patterns can better inform applicants regarding the application process as well as encourage further coordination among programs. Our objective was to describe dermatology residency interview date patterns over the past five applications cycles from 2012 to 2017. A retrospective review of dermatology online forums (the Dermatology Interest Group Association and Student Doctor Network) was performed from 2012 to 2017; these web-based public databases were reviewed for interview dates and interview offer dates. Data from 117 programs per year were obtained. The majority of interview offers arrived in early November (41.5%), followed by late November (40%). Interviews were conducted predominantly in December (25.7%) and January (66.3%). On average, programs scheduled 2.26 (range 1-13) interview dates. Most interviews were held on Thursday (23.9%) and Friday (28.7%). Our results suggest that there is an increasing trend of overlapping interview dates among programs. Being cognizant of dermatology residency interview date patterns can help prepare applicants for interview scheduling while avoiding scheduling conflicts.

Commentary

Topical probiotics: the unknowns behind their rising popularity

Objective: Topical probiotics have been used for skin care and treatment since the early 20th century. Over the past decade, there has been a dramatic surge of commercially-available topical probiotic products. We conducted a systematic search of clinical data relating to the use of topical probiotics and identified relevant clinical and regulatory gaps. Methods: PubMed and Google Scholar searches were conducted for trials and reviews of probiotics. FDA definitions of cosmetics, drugs, and regulation of topical probiotics were reviewed. Results: Topical probiotics have shown efficacy in a number of limited trials, particularly those involving the treatment of acne, atopic dermatitis, and rosacea. However, there is a paucity of literature on the safety profiles, mechanistic action, and therapeutic potential of topical probiotic products. Several regulatory gaps exist, including approval and classification of topical probiotic products by the FDA; currently there are no topical probiotic products the FDA has approved as drugs. Conclusion: With increasing popularity among the general public, but insufficient clinical data to demonstrate large-scale effectiveness and a thorough understanding of side effects, there is a need for further mechanistic and clinical investigation, as well as improved regulation and standardization of topical probiotic products.

Case Report

Treatment of warts with topical cidofovir in a pediatric patient

Cidofovir is an antiviral nucleotide analogue with relatively new treatment capacities for dermatological conditions, specifically verruca vulgaris caused by human papilloma virus infection. In a 10-year old boy with severe verruca vulgaris recalcitrant to multiple therapies, topical 1% cidofovir applied daily for eight weeks proved to be an effective treatment with no adverse side effects. This case report, in conjunction with multiple published reports, suggests that topical 1% cidofovir is a safe and effective treatment for viral warts in pediatric patients.

Apocrine adenocarcinoma of the eyelid: case report and literature review on management

Apocrine adenocarcinoma of the eyelid is a rare sweat gland cancer. It is predominant in older adults and has increased prevalence in males. Management is based on recommendations from reported cases and their outcomes. Surgical excision is considered effective in apocrine adenocarcinoma of the eyelid. We report the case of a 58-year-old woman with apocrine adenocarcinoma located on her left upper eyelid. Excisional biopsy demonstrated focal apocrine secretion in a basaloid nest proliferation. The patient had no recurrence at four months. Our case provides insight into the workup and management of eyelid apocrine adenocarcinoma. Furthermore, we discuss key management recommendations according to previous authors' experiences with eyelid apocrine adenocarcinoma.

Case Presentation

Prurigo pigmentosa following laparoscopic gastric sleeve

Prurigo pigmentosa is an uncommon inflammatory skin disease predominately affecting young women. Clinically the disease presents with erythematous and urticarial papules arranged in a reticular pattern. Lesions heal with reticulated hyperpigmentation. Strict ketogenic diet is one of many factors that might trigger the disease. In this article, we present a case of prurigo pigmentosa following a complicated laparoscopic gastric sleeve with the resolution of the rash after improvement of the patient's diet.

Factitial panniculitis as a manifestation of self-imposed factitious disorder

Factitious disorder imposed on self is characterized by self-induction. Dermatitis artefacta, the cutaneous subtype of factitious disorder imposed on self, can have a variety of atypical presentations. A 36-year-old woman with an extensive past medical history presented with painful nodules on her abdomen, thighs, and arms. Histologic evaluation identified panniculitis with foreign body material seen under polarization. Chart review from previous hospital visits established a history of factitious disorder imposed on self and upon subsequent search of the hospital room, syringes with an unknown substance were found. Factitial panniculitis should be considered in cases with atypical lesions or locations that do not conform to the presentation of organic causes of panniculitis. Management should include a multidisciplinary approach that prioritizes patient safety and establishes a therapeutic patient-provider relationship.

Late-onset pseudoepitheliomatous hyperplasia developing within a red ink tattoo

The popularity of tattoos has increased dramatically worldwide particularly in the last three decades, giving rise to the frequent occurrence of a wide spectrum of secondary cutaneous and systemic complications. Pseudoepitheliomatous hyperplasia (PEH) is a benign irregular hyperplasia of the epidermis occurring in response to various stimuli, that clinically and histopathologically resembles cutaneous neoplasms such as squamous cell carcinoma and keratoacanthoma. In an attempt to improve the awareness of the possible occurrence of PEH in tattoos and of its diagnostic and therapeutic aspects, we present herein the case of a 30-year-old woman with histologically confirmed PEH related to a red-ink tattoo. She revealed two important features: the longest interval reported so far between tattooing and onset of PEH (two years) and the lack of the otherwise very common lichenoid tissue reaction to red ink. In view of the serious toxicological potential of tattoo inks, implementation of updated and standardized regulations worldwide regarding their use in the tattooing process is now urgently warranted and continuous efforts should be undertaken in order to enhance the awareness among tattoo artists and the public with regard to the possible serious health risks associated with the use of tattoo ink pigments.

Keratosis lichenoides chronica: First case reported in Chile

We present a woman with a history of years of evolution of confluent hyperkeratotic papules and plaques with a generalized linear and reticulate pattern. Histopathological characteristics concordant with keratosis lichenoides chronica were finally evidenced after several non-specific biopsies. The cutaneous manifestations, chronicity. histopathology findings, and refractoriness to therapies are typical of this rare dermatosis.

Multiple eruptive dermatofibromas associated with pregnancy- a case and literature review

Dermatofibromas are common and asymptomatic benign histiocytic tumors. The occurrence in a small number (up to 5 lesions) is frequent. However, the expression "multiple eruptive dermatofibromas" is reserved for the appearance of more than 5 lesions in less than four months. Multiple eruptive dermatofibromas are rare and usually associated with an underlying systemic condition, the most common being autoimmune diseases or HIV infection. Herein we report multiple eruptive dermatofibromas developing in an otherwise healthy pregnant woman. Although the pathogenesis of this condition remains unknown, it is believed to be related to immunological alterations, given the strong association with states of immunosuppression or, in the case of pregnancy, with a state of immunotolerance.

Photo Vignette

Indurated purple plaques on the scalp

Cutaneous epithelioid angiosarcoma is a rare neoplasm of vascular endothelial cell origin that can mimic a cutaneous lymphoma, metastatic carcinoma, or Kaposi sarcoma. It is one of the most malignant cutaneous tumors and early diagnosis is essential, as the tumor metastasizes quickly. We describe a 75-year-old man who presented with three tender, indurated violaceous plaques on his scalp. Biopsy revealed a poorly circumscribed infiltrate extending into the subcutaneous fat, composed of atypical epithelioid cells lining vascular spaces. We provide a brief review of the clinical presentation, histopathologic features, differential diagnosis, and management of this rare tumor.

Novel PTEN mutation in Cowden syndrome: case report with late diagnosis and non-malignant course

Cowden syndrome (CS) is an infrequent genodermatosis caused by mutations in the phosphatase and tensin homolog (PTEN) gene in the majority of cases. As such, it belongs to the PTEN hamartoma tumor syndrome spectrum. This disease has a variable clinical expression characterized by the development of multiple hamartomatous tumors in different organs, usually during the second and third decades of life, and a high cumulative risk of several malignancies. We present a case of Cowden syndrome with late diagnosis presenting with a florid dermatological expression and multiple benign tumors, but no malignancies. A novel PTEN mutation was identified.

A fleshy papule on the eyelid

Angiolymphoid hyperplasia with eosinophilia is an uncommon tumor affecting the head and neck region. It usually presents as solitary or multiple erythematous or brownish papules and nodules. It is considered a reactive angioproliferative disorder by some, whereas others believe it to be a neoplastic growth. Involvement of the eyelid is a rare occurrence. We report an instance of angiolymphoid hyperplasia with eosinophilia involving the eyelid in a 19-year-old woman with review of literature.

Letter

Wound healing elective: an opportunity to improve medical education curriculum to better manage the increasing burden of chronic wounds

Chronic wounds are highly prevalent and have become a public health crisis. Successful treatment of chronic wounds requires that healthcare providers study both the pathophysiology of wound healing and maintain knowledge of the most current wound care guidelines set forth by the Agency for Healthcare Research and Quality. Unfortunately, medical students currently receive limited wound care training. A focused and well-organized course integrating a diverse group of medical and surgical faculty, residents, and medical students in the clinical years has been created to address this growing medical issue. The goal of such curricular innovations is to help future physicians gain exposure to chronic wounds and develop crucial clinical skills so they enter residency prepared to offer basic treatments and prevent rapid deterioration of the many wounds they will encounter.