Visual perception, cognition, and error in dermatologic diagnosis: Key cognitive principles.

Dermatologic diagnosis relies on vision primarily and auditory and verbal input secondarily. Accurate dermatologic diagnosis is predicated on seeing and perceiving a skin finding, categorizing and naming the finding correctly, and comparing the visual data and data obtained from the totality of the clinical encounter (ie, from other sensory modalities) with one's working mental database of dermatologic diagnoses. The baseline assumption-which is false-is that a dermatologist is an expert at each of the aforementioned steps and transitions sequentially between them seamlessly in an error-free fashion. Each of these steps has inherent challenges, and the transitions between steps can also be problematic. In part 1 of this 2-part report, we describe the pitfalls associated with visual recognition. In part 2, we discuss cognitive heuristics as they relate to the dermatologic diagnostic process and prevention of diagnostic error.

Visual perception, cognition, and error in dermatologic diagnosis: Diagnosis and error.

Diagnostic error in dermatology is a large practice gap that has received little attention. Diagnosis in dermatology relies heavily on a heuristic approach that is responsible for our perception of clinical findings. To improve our diagnostic accuracy, a better understanding of the strengths and limitations of heuristics (cognitive shortcuts) used in dermatology is essential. Numerous methods have been proposed to improve diagnostic accuracy, including brain training, reducing cognitive load, and getting feedback and second opinions. Becoming comfortable with the uncertainty intrinsic to medicine is essential. Ultimately, the practice of metacognition, or thinking about how we think, can offer corrective insights to improve accuracy in diagnosis.

The Largest Mass Poisoning in History: Arsenic Contamination of Well Water in Bangladesh.

Arsenic is a naturally occurring compound that is widely distributed in trace quantities in the environment. Levels toxic to humans have been found contaminating certain regions of the world and their groundwater, leading to deleterious effects. In fact, an estimated 150 million people are affected by arsenic contamination worldwide.1 Arsenic poisoning leads to several adverse health effects, including cancer of the lung, bladder, and kidney, neurologic disorders, cardiovascular disease, peripheral vascular disease, hypertension, pulmonary disease, and diabetes mellitus.2 Skin lesions are a common manifestation of arsenic poisoning. Early findings include diffuse or spotted melanosis, leukomelanosis, and depigmentation. Years of chronic arsenic poisoning can lead to acral keratoses and squamous cell carcinoma of the skin.3.

Recurrent Palisaded Neutrophilic and Granulomatous Dermatitis in the Setting of Systemic Lupus Erythematosus.

We present the case of a 66-year-old woman with a history of systemic lupus erythematosus, who presented with tender nodules on the forearms. The patient reported an 8-year history of pink bumps on the extensor surfaces of the forearms bilaterally that would arise episodically for a few weeks and subsequently resolve with no intervention. Her systemic lupus erythematosus was under good control with oral prednisone 10 mg daily, and the development of these lesions was not associated with concomitant flares of the systemic lupus erythematosus.

Acquired elastoma in a subungual location.

Elastomas are connective tissue nevi or hamartomas. They may occur in isolation or can be associated with familial syndromes such as Buschke-Ollendorff syndrome. Elastomas typically present in childhood as small ivory papules or firm skin-colored nodules that can coalesce into larger yellow plaques. These lesions are typically distributed over the extremities, abdomen, and back. Herein, we report an unusual case of a renal transplant recipient who presented with an acquired subungual papule with associated koilonychia and distal nail plate dystrophy. Histopathologic findings were consistent with subungual elastoma.

Fowler's Solution and the Evolution of the Use of Arsenic in Modern Medicine.

While arsenic has been used medicinally and as a poison for thousands of years, Fowler's solution, an arsenic compound, has had a fascinating history in medicine during the past 200 years. The use of Fowler's solution was first described and published as a treatment for malaria and syphilis in the late 1700s. Many clinical applications for Fowler's solutions have been studied and utilized over the years, but toxicities have limited its utility. Even so, arsenic trioxide, chemically related to Fowler's solution, was approved by the US Food and Drug Administration for treating acute promyelocytic leukemia. The history of Fowler's solution, its applications and uses, and benefits and risks are discussed.

Abdominal Elephantiasis Nostras Verrucosa: An Underrecognized Disorder.

Case 1 A 60-year-old African American man presented with a medical history of morbid obesity (weighing more than 550 lb), benign prostatic hyperplasia, hyperlipidemia, gynecomastia, atrial fibrillation, hypertension, chronic obstructive pulmonary disease, psoriasis, sleep apnea, and cardiomegaly. His size has limited his ability to clean himself properly. He experiences chronic and recurrent skin irritation and cellulitis possibly secondary to intertriginous superinfection, lymphedema, and venous stasis. On examination, his abdomen showed heavy skinfolding with hyperpigmentation, cobblestone and velvety changes, thickening and fibrotic induration of the skin, focal areas of redness, and tenderness on palpation (Figure 1A and 1B). These findings are consistent with a clinical picture of chronic elephantiasis nostras verrucosa (ENV) and lipodermatosclerosis (LDS). He has had numerous hospitalizations for recurrent cellulitis in the abdomen and lower limbs during the past 8 years. He is currently residing in a weight-loss facility and is managing skin care using topical nystatin powder and periodic topical triamcinolone ointment.

Eucerin: A Revolutionary Formulation Still Going Strong for Over a Century.

Eucerit, now more commonly known as Eucerin, was a revolutionary emulsion developed more than 100 years ago that is still popular and in common use today. The initial formulation is still the basis for a relevant global product line that holds significant market share today. The concept for Eucerin was originally developed in Germany by Dr Isaac Lifschütz, who helped develop Eucerin, meaning "beautiful wax," in 1898. The ointment was very smooth, allowing Eucerin to develop as a stable emulsion. Eucerin was revolutionary and outperformed all of its predecessors in emulsion stability, moisturizing ability, its ability to resist degradation, and its cost-effectiveness.1.

Dermatologic manifestation of hyperandrogenism: a retrospective chart review.

Several studies have described a wide spectrum of hyperandrogenism diseases, many of which are difficult to distinguish from each other. In order to better understand diseases of hyperandrogenism, the authors performed a retrospective study of the cutaneous features and metabolic findings in women with hyperandrogenism. A retrospective chart analysis compiled by three dermatologists in both academic and private settings was performed, including patients presenting with > or = 2 manifestations of hyperandrogenism. Relevant dermatologic and associated manifestations and laboratory and imaging study findings were reviewed. Moderate to severe acne was the most common manifestation. Other common manifestations that patients first presented with include hirsutism, acanthosis nigricans, androgenic alopecia, and skin tags. Oligomenorrhea was the most common systemic presenting sign. Statistical analysis of various clinical markers revealed correlations with hyperandrogenemia. Acanthosis nigricans and hirsutism were found to be useful clinical markers for hyperandrogenism, whereas androgenic alopecia was not. This study provides some insights into the presentation and diverse manifestations seen in hyperandrogenism.

Occam's razor and Hickam's dictum: a dermatologic perspective.

Diagnostic heuristics help ease the cognitive load in our day-to-day work. Occam's razor or the rule of diagnostic parsimony is a diagnostic heuristic often applied in dermatology. Occam's razor dictates that all things being equal, one diagnosis (as opposed to several diagnoses) should be sought to explain a patient's presentation. While this can often be helpful, it can also obscure the full picture. Hickam's dictum is an aphorism expressing the opposite opinion: "patients can have as many diseases as they damn (or darn) well please." This acknowledges that multiple simultaneous processes can be at play. This article delves into the implications of use of these approaches and offers tips through cases illustrating the limitations of Occam's razor and when Hickam's Dictum should be invoked.

Development of a Skin-Directed Scoring System for Stevens-Johnson Syndrome and Epidermal Necrolysis: A Delphi Consensus Exercise.

Importance: Scoring systems for Stevens-Johnson syndrome and epidermal necrolysis (EN) only estimate patient prognosis and are weighted toward comorbidities and systemic features; morphologic terminology for EN lesions is inconsistent. Objectives: To establish consensus among expert dermatologists on EN terminology, morphologic progression, and most-affected sites, and to build a framework for developing a skin-directed scoring system for EN. Evidence Review: A Delphi consensus using the RAND/UCLA appropriateness criteria was initiated with a core group from the Society of Dermatology Hospitalists to establish agreement on the optimal design for an EN cutaneous scoring instrument, terminology, morphologic traits, and sites of involvement. Findings: In round 1, the 54 participating dermatology hospitalists reached consensus on all 49 statements (30 appropriate, 3 inappropriate, 16 uncertain). In round 2, they agreed on another 15 statements (8 appropriate, 7 uncertain). There was consistent agreement on the need for a skin-specific instrument; on the most-often affected skin sites (head and neck, chest, upper back, ocular mucosa, oral mucosa); and that blanching erythema, dusky erythema, targetoid erythema, vesicles/bullae, desquamation, and erosions comprise the morphologic traits of EN and can be consistently differentiated. Conclusions and Relevance: This consensus exercise confirmed the need for an EN skin-directed scoring system, nomenclature, and differentiation of specific morphologic traits, and identified the sites most affected. It also established a baseline consensus for a standardized EN instrument with consistent terminology.

Senile Gluteal Dermatosis: An Underreported Condition in Elderly Patients.

Case 1: An 89-year-old obese Caucasian man with a history of coronary artery disease, hypothyroidism, and hyperlipidemia presented with herpes zoster on the lower back, and postherpetic neuralgia. The patient complained of significant pain and reported that he had been spending most of his day over the past few weeks in a seated position. (SKINmed. 2022;20:149-151).

The darker side of head lice infestations.

Head lice (Pediculus humanus capitis) infestations are prevalent among young children and generally not considered a health hazard. Although massive chronic head lice infestations have been documented in paleo medical literature, their association with severe iron deficiency anemia has been rarely discussed in modern medicine. A recently published case implicating a head lice infestation as the cause of death of a 12-year-old girl brings this topic to the fore. This contribution discusses the available information concerning the circumstances under which this girl died and the ongoing criminal investigation as a springboard for discussion of how head lice infestations may serve as forensic and legal evidence and as a warning sign of mental illness, abuse, neglect, and rape.

Forensics in dermatology: part I.

Examination of the skin and adnexae is a critical part of the forensic examination. Little information on forensic sciences has been published in the dermatologic literature. Correct forensic terminology and documentation of dermatologic findings is of critical importance in forensic investigations. The skin may reveal clues to the identity of an individual and the time and method of death or injury. Normal postmortem changes in the skin are described along with pseudopathology and damage from postmortem animal activity. The forensic classification of types of injuries is introduced in this first of a two-part paper on forensics in dermatology.

Forensics in dermatology: part II.

The evaluation of skin findings is critical in identifying many types of injury, whether self- inflicted or accidentally or intentionally inflicted. Specific causes of injury include homicide, abuse, neglect, assault, self-inflicted injury, suicide, torture, poisoning, and bioterrorism. Forensic findings in hair and nails are also discussed. This overview of dermatologic findings in forensic pathology highlights the significance of the cutaneous manifestations of injury.

The role of nutrition in acne pathogenesis: YouTube as a reflection of current popular thought.

Although studies have yet to prove definitively a causal relationship between diet and acne, the lay public has traditionally held that such causality exists. The authors' study aims to determine which nutritional elements are thought to be related to acne, both positively and negatively. YouTube, a popular video-sharing Web site, was used to survey the views of the lay public. The keywords "acne," "acne diet," and "acne food" were searched in YouTube in July and August of 2009, and 87 videos were included in the study. More than 85% of videos suggest at least a moderate correlation between diet and acne. Dairy products and oily and greasy foods were viewed as aggravating factors, while fruits, vegetables, and supplements were regarded as alleviating factors. Generally regarded "truths" can affect patient compliance with treatment regimens, and a knowledgeable physician is better able to address these issues with his or her patients.