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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 27, Issue 1, 2021

Review

Cutaneous manifestations of COVID-19

The severe acute respiratory syndrome coronavirus two (SARS-CoV-2), which causes the 2019 coronavirus disease (COVID-19), has infected patients worldwide. Physicians have increasingly identified cutaneous findings as a significant clinical manifestation of COVID-19. In this review, we describe the clinical presentation, onset, duration, associated symptoms, treatment, and outcome of cutaneous manifestations thus far reported to be related to COVID-19. We have included data from 63 studies and subdivided reported cutaneous manifestations into the categories of viral exanthem, urticarial, vesicular, chilblains/chilblains-like, non-chilblains vasculopathy-related, pityriasis rosea-like, erythema multiforme-like, Kawasaki/Kawasaki-like disease, and others. Physicians should be aware of the known common cutaneous manifestations of COVID-19 and future research is required to better understand the pathophysiology and prognosis of each COVID-19-related skin manifestation.

Original

Real-world biologic and apremilast treatment patterns and healthcare costs in moderate-to-severe plaque psoriasis

Plaque psoriasis is a chronic disease requiring long-term therapy. However, long-term real-world treatment patterns and costs are not well characterized. This study examined treatment patterns and healthcare costs among patients newly initiating a biologic or apremilast for moderate-to-severe plaque psoriasis. Included patients had ?1 prescription for secukinumab, ixekizumab, adalimumab, ustekinumab, etanercept, or apremilast between 01/01/2015 and 08/31/2018, no prior use of the index medication, and continuous enrolment 12 months pre-index and 24 months post-index. Treatment adherence, non-persistence, discontinuation, switching, use of combination therapy, and re-initiation were assessed at 12, 18, and 24 -months post-index. In addition, total and psoriasis-related healthcare costs were evaluated at 24 months. A total of 7,773 patients with 24-month follow-up were included. Overall, adherence was low (21.3%-33.5%) and non-persistence was high (58.4%-86.5%) over 24 months. Discontinuation (38.4%-51.3%), switching (29.7%-52.6%), combination therapy (27.6%-42.9%), and re-initiation of the index medication (19.3%-44.5%) were common. Healthcare costs were high and mostly contributed by psoriasis treatment. Therefore, maintaining disease control on long-term therapy is still challenging for many patients.

Demographic and medical school characteristics associated with urban versus rural dermatology practice: A national cross-sectional study

There are significant disparities in access to dermatologists in rural areas relative to urban areas. We examined the associations between demographic and medical school characteristics and entry into dermatology practice in urban versus rural counties. All dermatologists who graduated from U.S. allopathic or osteopathic medical schools in the 2020 Centers for Medicare & Medicaid Services Physician Compare Database were assessed. Dermatology practice locations were coded as metropolitan or non-metropolitan according to the Rural-Urban Continuum Codes. Of 10,076 dermatologists, 543 (5.4%) practiced in non-metropolitan counties. Male gender (odds ratio [OR] 1.48, 95% CI 1.23-1.77), public medical school attendance (OR 1.94, 95% CI 1.61-2.34), DO degree (OR 1.84, 95% CI 1.32-2.51), medical school location in a non-metropolitan county (OR 5.41, 95% CI 3.66-7.84), and medical school rural track program (OR 1.57, 95% CI 1.07-2.26) were associated with higher odds of non-metropolitan dermatology practice. Our findings highlight that male gender, graduation from a non-metropolitan or public medical school, DO degree, and rural tracks are associated with higher likelihood of non-metropolitan dermatology practice. These results can inform efforts within the field of dermatology to strengthen the rural dermatologist workforce and suggest that rural educational experiences during medical school may increase recruitment of rural dermatologists.

Patient perceptions about nutrition and skin health: a survey study characterizing patient opinions and information resources

Background: Numerous studies in the clinical literature have explored the link between nutrition and skin physiology. However, it is unclear whether patients visit their dermatologists with knowledge of these studies, and unknown where they obtain their skin health information. We characterized patient perceptions surrounding nutrition and skin, including what patients identified as aggravating and alleviating foods and their information sources. Methods: We administered a questionnaire to 409 participants attending University of California (UC) Davis Dermatology and Pacific Skin Institute in Sacramento. This survey assessed their perception on the influence of nutrition. We stratified responses by diseases. Results: Of the 409 respondents, 83% believed that nutrition affects skin health. Respondents with healthy skin were not more likely to agree than those with skin conditions in general (P=0.34). Those with skin conditions also more likely received their information from reputable sources, defined as physicians and scientific journals (P=0.02). Additionally, respondents who disagreed were more likely informed by reputable sources (P=0.002), but when online blogs were included as reputable, this relationship was less significant (P=0.046). Conclusions: As online resources become more accessible, it is important for providers to know about changing patient perspectives. Our findings may help improve how dermatologists counsel patients about nutrition.

Commentary

Prior authorizations in dermatology and impact on patient care: An updated survey of US dermatology providers and staff by the American Academy of Dermatology

Background: Completing prior authorizations (PAs) can be a lengthy process, which can delay access to appropriate care. A 2017 American Academy of Dermatology survey highlighted that PAs are common across many dermatologic medication classes. However, little is known regarding the impact of PAs on patient care and resource use. Methods: To better characterize the burden of PAs on dermatology practices and their effects on patient care, a survey was conducted in February 2020 among U.S.-based dermatologists (N=3,000) and the Association of Dermatology Administrators/Managers (ADAM) members (N=718). Results: Respondents reported 24% of patients require PAs. Dermatologists and staff spend a mean of 3.3 hours/day on PAs. Sixty percent of dermatologists reported interrupting patient visits for PAs. Sixty-five percent respondents reported PAs were required for clobetasol, 76% for tretinoin, and 42% for 5-fluorouracil. Respondents noted 45% of PA determinations took beyond one week and 17% took beyond two weeks. Respondents reported 12% of PAs resulted in delaying or abandoning treatment and 17% resulted in less appropriate treatment. Conclusions: Prior authorization burden remains high and consumes substantial clinical resources, which may negatively impact patient care. Additionally, they result in prolonged treatment delays and are associated with delaying treatment, abandoning treatment, or using lesser treatment.

Case Report

BRAF L597K mutation: an opportunity to treat

The outcomes of patients with metastatic melanoma (MM) have significantly improved after the introduction of BRAF-specific inhibitors. Herein is reported a patient with MM and non-V600-BRAF mutation who responded to iBRAF/iMEK therapy. In July 2014, a 63-year-old man presented with a 4.1mm-thick V600E-BRAF wild type melanoma on the back. Metastases were identified in one sentinel node and two of 11 subsequently excised lymph nodes, with no signs of distant metastatic disease. In September 2017, lung metastasis was observed and pembrolizumab was started. Progressive disease was apparent at cycle 10 and therapy was switched to ipilimumab. After four cycles, an asymmetric response was observed. In November 2017, next generation sequencing genomic profiling disclosed a rare L597K-BRAF mutation and vemurafenib plus cobimetinib therapy was initiated in January 2018. Seven days after treatment start, a remarkable clinical improvement was observed. In April 2018, the patient achieved partial response, which was sustained until October 2018. Cases of patients with non-V600-BRAF mutations responding to iBRAF/iMEK therapy have been reported over the last years. To the best of our knowledge, this is the first case reporting response to combined iBRAF/iMEK therapy in a patient with metastatic melanoma harboring L597K mutation.

Orf progressiva: giant progressive and destructive infections in the immunocompromised

Orf virus causes a self-limited infection in humans that resolves without scarring within 6-12 weeks. However, lesions in the immunocompromised can be progressive and disfiguring. The lesions frequently recur after treatment. To our knowledge, there are eleven published cases of these infections. We propose the name orf progressiva to call attention to this progressive, treatment-resistant entity. We present a 43-year-old male ranch owner with a history of renal transplantation who contracted an orf infection from his lamb. The infection recurred despite attempts at debridement, but achieved near complete resolution after treatment with imiquimod and valacyclovir. The histologic findings of orf progressiva are identical to the early stages of classic orf infection and are characterized by epithelial hyperplasia, intracytoplasmic eosinophilic inclusions, and an edematous, vascular dermis. There is no standard treatment for orf progressiva. Surgical excision has frequently resulted in rapid reoccurrence. Topical therapies such as imiquimod and cidofovir cream in combination with excision have been successful in some cases. Acyclovir or valacyclovir with imiquimod has been reported to be effective. Two patients achieved cure with imiquimod alone. We summarize these cases to prompt recognition of orf progressiva as a distinct clinical entity that requires treatment.

Case Presentation

Blastic plasmacytoid dendritic cell neoplasm in a young patient

Blastic plasmacytoid dendritic cell neoplasm is a rare hematologic neoplasm originating from plasmacytoid dendritic cell precursors that has an aggressive disease course with typically poor prognosis. Herein, we report a man in his early twenties who presented with rapid onset of violaceous nodules and purpuric papules and macules that began on his chest before spreading to his arms, back, face, scalp, and legs. He also exhibited systemic symptoms including weight loss and night sweats. He was diagnosed with blastic plasmacytoid dendritic cell neoplasm and began treatment with aggressive multidrug therapy. Thus far his treatment has resulted in complete resolution of his cutaneous manifestations.

Lupus miliaris disseminatus faciei with complete response to isotretinoin

Lupus miliaris disseminatus faciei is an uncommon type of granulomatous rosacea characterized by a papular eruption in the central regions of the face. A 43-year-old woman presented with an asymptomatic papular eruption on the face that had developed over a period of five months. Physical examination revealed multiple, small, reddish-brown papules, distributed symmetrically on the central area of the face. A biopsy was taken, showing dermal epithelioid cell granulomas with central necrosis and surrounding lymphocytic infiltrate with multinucleate giant cells. No foreign bodies were found in granulomas and no mycobacterial or fungal components were detected. On the basis of these findings, the diagnosis of lupus miliaris disseminatus faciei was made. The patient was given oral isotretinoin 20mg/day with initial slow response. After 6 months' treatment the lesions completely disappeared. Many authors consider this entity to be a variant of granulomatous rosacea. It is a chronic condition that primarily affects young adults. Treatment is usually unsatisfactory. Therapies with corticosterois, tetracyclines, retinoids, clofazimine or topical tacrolimus have been described but there is a lack of controlled studies and convincing results. Our success with a 6-month course of low dose isotretinoin suggests consideration of a longer trial prior to abandoning this as treatment.

Chondrodermatitis nodularis helicis in a teenager caused by frequent headphone use

Chondrodermatitis nodularis helicis is a benign condition that presents as a painful ear nodule and is commonly seen in older adults. Herein, we highlight a pediatric case of chondrodermatitis nodularis helicis caused by an increasingly common age-related behavior of frequent headphone use.

Pyoderma gangrenosum associated with levamisole-adulterated cocaine in a c-ANCA positive patient

Pyoderma gangrenosum (PG) is an inflammatory, ulcerative condition that is characterized by painful ulcers that commonly present on the lower extremities. Up to half of PG cases are associated with underlying systemic disease, including inflammatory bowel disease, various autoimmune conditions, and malignancy. Another well-known association is the manifestation of PG with recreational cocaine use, especially cocaine contaminated with the adulterant agent levamisole. Once utilized for its immunomodulatory capabilities, levamisole was withdrawn from the market in 2002. It has since been repurposed to potentiate the amphetamine-like effects and duration of cocaine and has reduced preparation cost. We present a 52-year-old woman with chronic maxillary sinusitis and cocaine use disorder presenting with a two-week history of painful ulcers on bilateral lower extremities, each with a purulent base and undermined, violaceous borders. Urine toxicology was positive for cocaine and serologic studies were positive for cytoplasmic antineutrophil cytoplasmic antibodies (c-ANCA) and lupus anticoagulant. Underlying conditions, especially that of granulomatosis with polyangiitis, were considered and ultimately ruled out. The patient's lesions exhibited a marked response with a short course of oral corticosteroids, typical of PG associated with levamisole. This case highlights the crucial role that drug abstinence plays in the prevention of recurrence.

An unusual case of pyogenic granuloma-like Kaposi sarcoma

Kaposi sarcoma (KS) is not typically included in the differential diagnosis of lesions with clinical characteristics of pyogenic granuloma. However, cases of pyogenic granuloma-like Kaposi sarcoma have been reported in the literature. This variant is extremely rare and possesses clinical and histological findings consistent with both conditions. We report an elderly, immunocompetent man with pyogenic granuloma-like Kaposi sarcoma, which was clinically consistent with a pyogenic granuloma and possessed histological findings consistent with Kaposi sarcoma and pyogenic granuloma.

Photo Vignette

Erythematous papules on the penis as first manifestation of metastatic prostate adenocarcinoma

We report a 70-year-old man with asymptomatic reddish papules on the glans penis that histologically showed metastases of prostate adenocarcinoma. He had a medical history of a stage IV undifferentiated prostate adenocarcinoma that was currently being treated with chemotherapy. The medical history of advanced stage prostate adenocarcinoma associated with the clinical and pathological findings confirmed the diagnosis of penile metastatic prostate adenocarcinoma. This is an example of the relevance of a thorough history combined with histopathological and immunohistochemical correlation which allowed the diagnosis of a penile lesion that may be the first manifestation of prostate metastatic progression and should therefore be included among the differential diagnoses of penile tumors.

Lichen planopilaris with significant post-inflammatory pigmentary alteration

Lichen planopilaris is an uncommon dermatological manifestation of lichen planus of the scalp and results in cicatricial alopecia. We present a patient with lichen planopilaris and significant post-inflammatory pigmentary alteration, confirmed by histopathology. The patient's case represents a clinically important variation from an expected typical pattern of dyschromia at periphery of alopecic zones in lichen planopilaris.

Epidermolytic hyperkeratosis of the vulva

Vulvar epidermolytic hyperkeratosis is a benign entity that mimics other malignant and inflammatory vulvar dermatoses clinically and histologically requiring careful clinical pathologic correlation for diagnosis.

Apocrine hidrocystoma: a slowly growing postauricular translucent nodule

Apocrine hidrocystoma is a benign, cystic proliferation of the apocrine sweat gland that may present commonly on sun-exposed areas of the head and neck. However, given its location and features, apocrine hidrocystomas may often be confused with malignant tumors such as basal cell carcinomas or primary cutaneous mucinous carcinomas. Herein, we present an unusual case of an apocrine hidrocystoma presenting in the postauricular region and highlight the importance of histopathological examination of cystic tumors on the periauricular area.

Atypical paronychia: don't forget herpesvirus

Paronychia is usually caused by bacterial infections. Herpetic whitlow is an acute infection of the fingers or toes caused by herpes simplex viruses and it typically presents with vesicles. We report the case of a 78-year-old woman with gingivostomatitis and atypical paronychia in several fingers without blisters.