Cutaneous Mycobacterium avium-intracellulare infection masquerading as sarcoidosis.

Mycobacterium avium-intracellulare (MAC) infection may have different skin manifestations, including cutaneous granulomas. Granulomatous skin reactions have distinct morphologic and histopathologic appearances. We present the case of an adolescent male with cutaneous MAC, misdiagnosed as sarcoidosis after initial biopsy results, demonstrated preservation of reticulin fibers and absence of organisms within granulomas. Sarcoidal granulomas often stain positive for reticulin fibers, which could be used to distinguish them from the infectious kind. This case should alert clinicians to the fact that the presence or quantity of intact reticular fibers may not be a reliable tool to differentiate between a sarcoidal and an infectious granuloma. Our case also highlights the diagnostic challenge of cutaneous MAC infection.

The use of virtual reality in non-burn dermatological care - a review of the literature.

AIM: Virtual Reality (VR) is the artificial depiction of a three-dimensional (3D) environment using computer-generated technology which allows users to interact with a simulated setting. VR has been used in a variety of clinical scenarios due to its efficacy as a distraction intervention, reducing anxiety and pain associated with medical procedures. The aim of this review is to provide clinicians with an overview of VR use in clinical dermatology. METHODS: A search on VR use in clinical dermatology was conducted using PubMed Medline, Embase, Cochrane, Google Scholar and ClinicalTrials.Gov in July 2019. Results related to burn care were excluded. RESULTS: This review identifies studies that utilized VR in the management of skin diseases and discusses considerations for its future use. CONCLUSION: The findings of these studies indicate that VR has beneficial effects as a complementary tool in the treatment of dermatological conditions.

Evidence-Based Review of Antibiofilm Agents for Wound Care.

Significance: Biofilms in vivo are small densely packed aggregations of microbes that are highly resistant to host immune responses and treatment. They attach to each other and to nearby surfaces. Biofilms are difficult to study and identify in a clinical setting as their quantification necessitates the use of advanced microscopy techniques such as confocal laser scanning microscopy. Nonetheless, it is likely that biofilms contribute to the pathophysiology of chronic skin wounds. Reducing, removing, or preventing biofilms is thus a logical approach to help clinicians heal chronic wounds. Recent Advances: Wound care products have demonstrated varying degrees of efficacy in destroying biofilms in in vitro and preclinical models, as well as in some clinical studies. Critical Issues: Controlled studies exploring the beneficial role of biofilm eradication and its relationship to healing in patients with chronic wounds are limited. This review aims to discuss the mode of action and clinical significance of currently available antibiofilm products, including surfactants, dressings, and others, with a focus on levels of evidence for efficacy in disrupting biofilms and ability to improve wound healing outcomes. Future Directions: Few available products have good evidence to support antibiofilm activity and wound healing benefits. Novel therapeutic strategies are on the horizon. More high-quality clinical studies are needed. The development of noninvasive techniques to quantify biofilms will facilitate increased ease of research about biofilms in wounds and how to combat them.

Non-pharmacologic approaches for hidradenitis suppurativa - a systematic review.

Importance: Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition presenting with painful nodules and sinus tracts primarily in intertriginous regions. The persistent nature of HS and challenges in symptom management lead many patients to seek non-pharmacologic approaches due to the paucity and limited efficacy of conventional HS therapeutic options.Objective: To evaluate the existing evidence for non-pharmacologic modalities in treatment of HS.Findings: Discussed in this review are non-pharmacologic modalities with evidence of efficacy in HS treatment, including weight loss, vitamin B12, vitamin D and zinc supplementation, and dietary avoidance of brewer's yeast. Limitations of the available data on non-pharmacologic therapies in HS include the predominance of pilot and single-armed studies, as well as heterogeneity in study design, subject disease severity, concomitant treatment and comorbid conditions.Conclusions and relevance: HS patients are becoming increasingly interested in the use of non-pharmacologic approaches to augment conventional treatments. Strength of evidence for non-pharmacologic therapies in HS is limited by small study size and lack of randomized controlled trials. Future large-scale investigations should be pursued to better establish efficacy and dosing regimens for the use of non-pharmacologic treatments in HS.

Use of Topical Timolol Maleate as Re-Epithelialization Agent for Treatment of Recalcitrant Wounds of Varying Etiologies.

Background: Chronic wounds remain a challenge for the clinician and healthcare system. It is therefore vital for additional therapies that target steps involved in wound recalcitrance. Recently, topical timolol has shown promising results for use in wound healing. Objective: The goal of this study was to assess timolol's effectiveness in healing wounds of varying etiologies. Methods: This multi-center series took place from 2016¬­2019 at the wound healing centers at the University of Miami Health System and the Veterans Affairs Northern California Healthcare. We identified all wound patients who received treatment with topical timolol maleate 0.5% for at least 4 weeks after failing previous treatments. Timolol drops at a dose of 1 drop per cm2 of wound area were instilled with dressing changes twice a day, once a day, every other day, or continuous application. Once they began the study, they stopped all concurrent therapies aside from standard of care. Healing outcomes were classified into 3 categories: healed, defined as complete re-epithelialization of the wound and closure, improved, defined as decreasing wound size area (WSA), and worsening, defined as increasing WSA. Results: We identified 39 patients, 32 males and 7 females that had a total of 55 chronic wounds of varying etiologies. Thirty-four of the wounds had completely healed, 15 wounds improved in WSA, 4 wounds were unchanged in WSA, and 2 wounds worsened in WSA. Conclusions: In line with our previous experience, we found topical timolol to be a safe, cost-effective, and efficacious treatment for recalcitrant wounds of varying etiologies.

Traditional and advanced therapeutic modalities for wounds in the paediatric population: an evidence-based review.

OBJECTIVE: Children can have non-healing wounds due to a wide range of pathologies, including epidermolysis bullosa (EB), pilonidal disease and Stevens-Johnson syndrome, with some causes being iatrogenic, including extravasation injuries and medical device-related hospital-acquired pressure ulcers. Furthermore, paediatric wounds are vastly different from adult wounds and therefore require a different treatment approach. While there are numerous types of dressings, topical remedies, and matrices with high-tier evidence to support their use in adults, evidence is scarce in the neonatal and paediatric age groups. The purpose of this review is to discuss the basic principles in paediatric wound management, as well as to present new treatment findings published in the literature to date. The benefits and risks of using different types of debridement are discussed in this review. Various topical formulations are also described, including the need to use antibiotics judiciously. METHOD: Databases were searched for relevant sources including Pubmed, Embase, Web of Science and DynaMed. Search terms used included 'wound care', 'wound management', 'paediatrics', 'children', 'skin substitutes', and 'grafts'. Additionally, each treatment and disease entity was searched for relevant sources, including, for example: 'Apligraf', 'dermagraft', 'Manuka honey', 'antibiotic', 'timolol', and 'negative pressure wound therapy' (NPWT). RESULTS: Amniotic membrane living skin equivalent is a cellular matrix that has been reportedly successful in treating paediatrics wounds and is currently under investigation in randomised clinical trials. Helicoll is an acellular matrix, which shows promise in children with recessive dystrophic EB. NPWT may be used as a tool to accelerate wound closure in children; however, caution must be taken due to limited evidence to support its safety and efficacy in the paediatric patient population. Integra has been reported as a useful adjunctive treatment to NPWT as both may act synergistically. Hospitalised children and neonates frequently have pressure ulcers, which is why prevention in this type of wound is paramount. CONCLUSION: Advancements in wound care are rapidly expanding. Various treatments for non-healing wounds in paediatric and neonatal patients have been reported, but high tier evidence in these populations is scarce. We hope to shed light on existing evidence regarding the different therapeutic modalities, from debridement techniques and dressing types to tissue substitutes and topical remedies. There have been promising results in many studies to date, but RCTs involving larger sample sizes are necessary, in order to determine the specific role these innovative agents play in paediatric wounds and to identify true safety and efficacy.

Increased Preauricular Wrinkles in Frontal Fibrosing Alopecia Compared to Age-Matched Controls: A Prospective Study of 64 Patients.

INTRODUCTION: Frontal fibrosing alopecia (FFA) is a scarring alopecia affecting mainly postmenopausal females. Associated clinical signs include facial papules, glabellar red dots, depression of frontal veins, and lichen planus pigmentosus. Our objective was to establish the validity of increased preauricular lines as another clinical marker of FFA. MATERIALS AND METHODS: Thirty-two females with FFA were compared to 32 age-matched females with either androgenetic alopecia or chronic telogen effluvium. Bilateral images of the preauricular area were taken, and disease severity was calculated in all FFA patients using the FFA severity scale (FFASS). The average number of preauricular lines were determined and compared based on group, age, and severity. RESULTS: Patients with FFA had a significantly higher mean number of preauricular lines than controls (p = 0.002). Intergroup analysis among the FFA patients revealed no significant difference between FFASS and the number of wrinkles or the number of wrinkles in patients ≥60 years old. DISCUSSION AND CONCLUSION: Females with FFA have increased preauricular lines compared to age-matched controls regardless of age, and disease severity was not correlated to increased lines. Although the cause is unknown, atrophy and loss of elastic fibers in biopsies of the preauricular area in diseased patients may contribute. These findings reveal another potential clinical marker of FFA.

Stasis Mucinosis: Insights Into Euthyroid Localized Mucinosis.

INTRODUCTION: Stasis mucinosis and obesity-associated lymphedematous mucinosis (OALM) have been described as 2 discrete diagnostic entities. CASE REPORT: A morbidly obese African American man in his late 60s presented to the emergency room with a 3-month history of swelling of both lower extremities and secondary changes suggestive of lymphedema and venous dermatitis. On physical examination, the patient had severe edema with multiple raised areas of verruciform skin changes and varicosities, diffuse induration, erythema, and scaling. He also had an open wound in his left hallux. The skin biopsy found mucinosis. A diagnosis of stasis mucinosis was rendered. He had normal thyroid function test laboratory results. CONCLUSIONS: The authors suggest stasis mucinosis and OALM represent the spectrum of euthyroid mucin depositional disease in varying clinical settings.

Skin changes in the obese patient.

Obesity is a worldwide major public health problem with an alarmingly increasing prevalence over the past 2 decades. The consequences of obesity in the skin are underestimated. In this paper, we review the effect of obesity on the skin, including how increased body mass index affects skin physiology, skin barrier, collagen structure, and wound healing. Obesity also affects sebaceous and sweat glands and causes circulatory and lymphatic changes. Common skin manifestations related to obesity include acanthosis nigricans, acrochordons, keratosis pilaris, striae distensae, cellulite, and plantar hyperkeratosis. Obesity has metabolic effects, such as causing hyperandrogenism and gout, which in turn are associated with cutaneous manifestations. Furthermore, obesity is associated with an increased incidence of bacterial and Candida skin infections, as well as onychomycosis, inflammatory skin diseases, and chronic dermatoses like hidradenitis suppurativa, psoriasis, and rosacea. The association between atopic dermatitis and obesity and the increased risk of skin cancer among obese patients is debatable. Obesity is also related to rare skin conditions and to premature hair graying. As physicians, understanding these clinical signs and the underlying systemic disorders will facilitate earlier diagnoses for better treatment and avoidance of sequelae.

Comparison of 3-dimensional Wound Measurement With Laser-assisted and Hand Measurements: A Retrospective Chart Review.

Wound area measurements provide an objective assessment of wound healing; however, most commonly used measurement techniques are imprecise. PURPOSE: A new portable 3-dimensional (3D) wound measurement device was tested against laser- and hand-measurement methods. METHODS: A retrospective comparative analysis was conducted to analyze the difference in wound measurements using records of patients seen at the University of Miami Hospital (Miami, FL) outpatient wound healing clinic between November 2017 and February 2018 who had wounds of various etiologies measured using 3 different techniques during a single visit: the 3D device, a laser-assisted wound measurement device (laser), and standard hand measurements. Patients with circumferential wounds were excluded (the laser and 3D devices are incapable of assessing these wounds). Differences were compared using paired t tests. RESULTS: The wounds ranged in area from 0.8 cm² (hand measurements) and 0.2 cm² (3D and laser devices) to 100.94 cm², 61.9 cm², and 65 cm² by hand measurement, 3D, and laser device, respectively. Among the 23 wounds measured, the majority (16) were venous ulcers. No statistically significant difference was noted between the 3D measurements compared with the laser (P = .340). Statistically significant differences in the measurements between the 3D device and hand measurements (P = .008) and the laser device and hand measurements (P = .006) were found. CONCLUSION: Measurements of the 3D device appear analogous to laser devices, making it an alternative tool for clinicians interested in monitoring wound progression. Because the 3D device has the capacity to examine wound volume, prospective comparative trials should be used to examine the accuracy and precision of the device to measure volume.

Evaluation of Donor Site Pain After Fractional Autologous Full-Thickness Skin Grafting.

Background: Despite the development of numerous wound treatment alternatives, 25% to 50% of leg ulcers and >30% of foot ulcers are not fully healed after 6 months of treatment. Autologous skin grafting is a time-tested therapy for these wounds; however, the creation of a new wound in the donor area yields a considerable limitation to this procedure. Innovation: Fractional autologous full-thickness skin grafting (FFTSG) is a technique wherein multiple small full-thickness skin grafts (FTSGs) are harvested with possibly minor donor-site comorbidities. The first device used to harvest FFTSG (ART™ system, Medline, Northfield, IL) is a device capable of harvesting >300 small FTSGs and transferring them to a target wound. Objective: To better evaluate patients' clinical experience, we sought to evaluate pain at the donor site associated with this procedure. Approach: Pain was assessed with numeric visual analog pain scales at days 1, 2, 4, and 7. Nine subjects underwent this procedure with only six of them reporting any level of pain on day 1, and none disclosing pain after day 2. Conclusion: In this study, we evidenced that this device manages to harvest FTSGs with minimal associated pain. Future research will need to evaluate other aspects of the procedure as well as long-term outcomes at the donor and recipient areas.

Alopecia Areata: Review of Epidemiology, Clinical Features, Pathogenesis, and New Treatment Options.

Alopecia areata (AA) is a complex autoimmune condition that causes nonscarring hair loss. It typically presents with sharply demarcated round patches of hair loss and may present at any age. In this article, we review the epidemiology, clinical features, pathogenesis, and new treatment options of AA, with a focus on the immunologic mechanism underlying the treatment. While traditional treatment options such as corticosteroids are moderately effective, a better understanding of the disease pathogenesis may lead to the development of new treatments that are more directed and effective against AA. Sources were gathered from PubMed, Embase, and the Cochrane database using the keywords: alopecia, alopecia areata, hair loss, trichoscopy, treatments, pathogenesis, and epidemiology.

Low-level laser therapy for the treatment of androgenic alopecia: a review.

There are many new low-level laser technologies that have been released commercially that claim to support hair regrowth. In this paper, we will examine the clinical trials to determine whether the body of evidence supports the use of low-level laser therapy (LLLT) to treat androgenic alopecia (AGA). A literature search was conducted through Pubmed, Embase, and Clinicaltrials.gov for clinical trials using LLLT to treat AGA. Thirteen clinical trials were assessed. Review articles were not included. Ten of 11 trials demonstrated significant improvement of androgenic alopecia in comparison to baseline or controls when treated with LLLT. In the remaining study, improvement in hair counts and hair diameter was recorded, but did not reach statistical significance. Two trials did not include statistical analysis, but showed marked improvement by hair count or by photographic evidence. Two trials showed efficacy for LLLT in combination with topical minoxidil. One trial showed efficacy when accompanying finasteride treatment. LLLT appears to be a safe, alternative treatment for patients with androgenic alopecia. Clinical trials have indicated efficacy for androgenic alopecia in both men and women. It may be used independently or as an adjuvant of minoxidil or finasteride. More research needs to be undertaken to determine the optimal power and wavelength to use in LLLT as well as LLLT's mechanism of action.

A review of monochromatic light devices for the treatment of alopecia areata.

There are many laser technologies that are being tested that claim to support hair regrowth for patients with alopecia areata (AA). In this paper, we will determine whether the body of evidence supports the use of devices using monochromatic light sources to treat AA. Articles were gathered from PubMed, Embase, and the Cochrane database using these keywords: lasers, excimer laser, low-level laser therapy (LLLT), low-level light therapy, alopecia, alopecia areata, and hair loss with a category modifier of English. Ten clinical trials and seven case reports/abstracts were assessed. Eight clinical trials and two case reports demonstrated hair regrowth with the 308-nm excimer laser/light in men, women, and children. One case report demonstrated hair regrowth with the ALBA 355® laser. One clinical trial and two case reports demonstrated hair regrowth with LLLT. While two case reports demonstrated hair regrowth with fractional laser therapy, one clinical trial showed no improvement. The 308-nm excimer laser is a safe and effective treatment for men, women, and children with refractory AA of the scalp and beard. Larger, double-blinded clinical trials should be conducted to compare excimer laser therapy to standard treatments. More data is needed to determine the efficacy of LLLT and fractional laser therapy in the treatment of AA.