Combining Nd:YAG laser with optical coherence tomography for nonsurgical treatment of basal cell carcinoma.

BACKGROUND: Effective and aesthetically appealing management options are needed for basal cell carcinoma (BCC), the most common skin cancer. The Nd:YAG laser shows promise, but most studies use biopsy to demonstrate tumor clearance. Optical coherence tomography (OCT) could allow good tumor margin control while enabling recurrence monitoring. OBJECTIVE: Determine the efficacy of the Nd:YAG laser to treat BCCs while controlling for tumor margin with OCT. METHODS: A 1064-nm Nd:YAG laser was applied to treat 119 BCCs in 102 patients, where tumor margins were approximated using OCT. Lesions were treated every 2 months until no residual tumor remained; patients were monitored for 1 year after treatment completion for clinical and subclinical recurrences. Outcomes were analyzed retrospectively. RESULTS: Most BCCs cleared after one treatment (85/119, 70.4%). Several factors were significantly associated with a suboptimal response, that is, those with recurrence or requiring ≥2 treatments: lesion size >5 mm (p = 0.03), focal sclerosing subtype (p = 0.018), and immunosuppression (p = 0.039). Midface location, patient compliance, and diagnosis method were codependent variables (r2 = 0.2011, p = 0.0008). All BCCs (119/119) demonstrated complete clinical and subclinical tumor clearance 2 months after final laser treatment. By 1 year, overall clinical recurrence rate (RR) was 1.7% (2/119) and cumulative subclinical RR was 4.2% (5/119). Upon excluding immunosuppressed patients, clinical RR and combined subclinical RR for primary BCC were 1% (1/98) and 2% (2/98), respectively, and 0% (0/17) and 11.8% (2/17), respectively, for recurrent BCC. CONCLUSIONS: The Nd:YAG nonablative laser can offer an effective treatment for BCCs when used with noninvasive diagnostic tools such as OCT.

Transforming the treatment of psoriasis to the 21st century: Detecting subclinical therapeutic response to secukinumab using optical coherence tomography as a prognostic indicator.

BACKGROUND: Optical coherence tomography (OCT) is a noninvasive imaging device that scans the skin up to 2 mm in depth. OCT can capture real-time epidermal thickness (ET) measurements and detect subclinical changes in inflammatory skin diseases like eczema and psoriasis. © 2022 Wiley Periodicals LLC. OBJECTIVE: To determine if measuring ET with OCT can detect a subclinical therapeutic response in psoriasis treated with the biological therapy, secukinumab (an IL-17A antagonist). DESIGN: Phase IV, single-center, open-label, and single-arm study. PARTICIPANTS: Twenty-six consecutive patients with moderate to severe plaque psoriasis. MEASUREMENTS: Clinical, dermoscopic, and OCT images were obtained at each visit. The clinician measured disease severity with the Investigator's Global Assessment (IGA) and Psoriasis Area And Severity Index (PASI). OCT was used to scan the ET at the center of lesional skin (ET-L), along the border, and normal skin (ET-N) on the same body plane; their difference was noted as ΔET. RESULTS: Initially, ET-L was greater than ET-N (p < 0.0001), their differences decreased throughout the study, and there were no significant differences at Week 16 (p = 0.48). Twenty-four (92%) patients achieved a 50% reduction in PASI score (PASI50); they had lower ΔET at Weeks 0, 1, 3, 4, and 8 compared to those who did not clear (p < 0.04). Having a lower ΔET at Week 4 was associated with a shorter time to reach PASI50 (p = 0.02). CONCLUSION: ET measurements using OCT can detect an early subclinical response to secukinumab compared to clinical scoring and identify nonresponders as early as 4 weeks.

Combining Reflective Confocal Microscopy and Dynamic Optical Coherence Tomography to Diagnose Melanoacanthoma: Case Report.

ABSTRACT: Few reported cases discuss distinguishing between melanoma and melanoacanthoma, a seborrheic keratosis (SK) variant, using noninvasive imaging devices. We present a case of a 38-year-old man with Fitzpatrick skin type IV with an asymmetric black papule showing clinical and dermoscopic features of both melanoma and SK. Reflectance confocal microscopy (RCM) and dynamic optical coherence tomography (d-OCT) were used for further evaluation. RCM revealed acanthotic epidermis with a mixed honeycomb and cobblestone pattern, polycyclic bulbous rete ridges, and bright plump cells within entrapped, edged, dermal papillae, compatible with pigmented SK. Also noted were a population of fairly uniform bright dendritic cells scattered quite evenly at all levels of the epidermis and the notable absence of concomitant features of a melanocytic neoplasm (roundish Pagetoid cells, sheets of roundish or dendritic cells at the dermal-epidermal junction, junctional thickenings, and melanocytic nests), suggesting melanoacanthoma. d-OCT showed well-circumscribed, regular, epidermal acanthosis, superficial rounded hypodense structures, normal vascular flow, and notable absence of wiry or contoured vessels, features typically seen in SKs and benign lesions, respectively. Similarly, histologic examination revealed characteristics of pigmented SK containing a population of evenly dispersed dendritic melanocytes (decorated using Melan-A stain) confirming a diagnosis of melanoacanthoma. This case highlights the advantages of incorporating both RCM and d-OCT into clinical practice to noninvasively differentiate melanoma from its clinical mimickers.

Glitter Effects of Nail Art on Optical Coherence Tomography.

Optical coherence tomography (OCT) is a noninvasive imaging technology that can visualize nail morphology in diseases such as psoriatic arthritis or onychomycosis. We recommend removal of glitter nail art to properly assess nail pathology and decrease diagnostic delay.

Distributive Shock in Erythrodermic Psoriasis Treated With Norepinephrine and Vasopressin: A Case Report.

Distributive shock and hypothermia are two unusual and potentially fatal complications of erythroderma, a rare complication of psoriasis. Very few cases of erythrodermic psoriasis have been reported, particularly in the United States, which may pose a diagnostic challenge for internists. We present a case report of distributive hemodynamic instability and hypothermia in a 61-year-old female who initially presented with acute altered mental status thought to be related to an infectious etiology.

Acute HIV Infection Presenting With Diffuse Plaque Psoriasis Treated With Highly Active Antiretroviral Therapy.

Cutaneous diseases such as psoriasis are often the first disease manifestations in HIV+ patients, with greater severity corresponding to a weaker immune system. Despite its prevalence, literature and placebo-controlled studies on the recognition of HIV as a cause of psoriasis are lacking, causing challenges to arise in its treatment. In this article, we illustrate a case of an HIV+ patient whose psoriasis drastically improved after the initiation of highly active antiretroviral therapy (HAART) consisting of bictegravir, emtricitabine, and tenofovir alafenamide. While it is unclear which combination of antiretrovirals is optimal for controlling psoriasis in HIV+ patients, prompt initiation of HAART can significantly improve immune status and psoriasis in HIV+ patients.

New Onset Granulomatosis with Polyangiitis Associated with COVID-19.

The coronavirus disease 2019 (COVID-19) has recently been found to cause cutaneous vasculitis in patients. Granulomatosis with polyangiitis (GPA) is a type of small and medium vessel vasculitis that is often associated with pulmonary issues and has been shown to raise diagnostic complications in COVID-19 infection. In this report, we discuss the first case of new-onset GPA in the setting of active COVID-19 infection. Symptoms often overlap between the two diseases, and while there is no current cure for COVID-19, rapid immunosuppressive initiation can be lifesaving for patients with GPA. Thus, this case is essential in expanding our current knowledge of COVID-19 and its many skin manifestations.

Risks and Benefits of Using Social Media in Dermatology: Cross-sectional Questionnaire Study.

BACKGROUND: Dermatological information on social media is often presented by nondermatologists. Increasing the online engagement of trained dermatologists may improve information quality, patient education, and care. OBJECTIVE: Our study assesses dermatologists' perceptions of social media and patterns of use to identify barriers limiting engagement. METHODS: In our cohort study, a 36-item online survey was distributed to dermatologists in the United States; responses were captured on a 1-100 sliding scale. RESULTS: Of 166 initiated surveys, 128 valid responses were submitted. Dermatologists showed greater concern for social media risk-related issues (mean 77.9, SD 15.1) than potential benefits (mean 61.8, SD 16.4; P<.001). Leading concerns were poor patient care, nonevidence-based information, and breaching patient privacy. Benefits included interphysician collaboration, patient education, and public health awareness. The most avid and enthusiastic social media users were millennials (mean total optimism score 67.5, SD 14.9) and baby boomers (mean total optimism score 63.1, SD 11.2) compared with Generation X dermatologists (mean total optimism score 52.2, SD 16.3, P<.001). Of 128 dermatologists, 103 (82.4%) plan on increasing their social media use (P=.003). Predictors showing an intent to increase future social media use were younger age, integration into professional use, and an optimistic view (r2=.39; P<.001). CONCLUSIONS: Dermatologists perceive the risk of social media to be considerable but still intend to increase its use, likely recognizing the value and importance of social media to the field.

A Case of Late Diagnosis of Acute Aortic Dissection Involving the Carotid Arteries in a Patient Presenting with Signs of Acute Ischemic Stroke.

BACKGROUND Acute aortic dissection (AAD) is a rare but life-threatening condition with high mortality. The Stanford classification of aortic dissection includes type A, which originates in the ascending aorta, and type B, which originates in the descending aorta. The diagnosis may be missed due to its ability to mimic other more common cardiovascular conditions. A case is presented of late diagnosis of AAD involving the right carotid arteries in a 55-year-old man who presented with acute ischemic stroke. CASE REPORT A 55-year-old man presented with sudden onset of left-sided facial weakness and aphasia. He was diagnosed with acute ischemic stroke and treated with tissue plasminogen activator. Further imaging showed an AAD involving the entire length of the aorta. Treatment with tissue plasminogen activator was discontinued, and the patient underwent surgical repair of the aorta. His hospital stay was complicated by acute kidney injury (AKI), pneumonia, and sepsis, and he died three weeks later from renal failure. CONCLUSIONS This case demonstrated that AAD can be challenging to diagnose, and may present atypically with ischemic stroke when it involves the carotid arteries. In such cases, imaging studies of the chest, abdomen, and head and neck may identify AAD and prevent inappropriate treatment with anticoagulants.

Rectal foreign body of a shattered glass bottle; Case report of unexpected late post-operative hemorrhage managed transanally.

INTRODUCTION: Retained rectal foreign bodies are commonly implicated in patients engaging in erotic behavior. The foreign bodies vary widely, however, penetrating rectal wounds are uncommon and often complicate the retrieval of the object. The rich vascular bed of the rectal mucosa provides additional bleeding complications. PRESENTATION OF CASE: A 55-year-old male presented with active bleeding after intentional insertion of a glass bottle into the rectum which shattered. Partial retrieval via proctoscopy was followed by an exploratory laparotomy with a diverting colostomy, mucous fistula, and presacral drainage. Postoperative course was complicated by severe hematochezia. Colonoscopy was performed in the operating room found actively bleeding ulcers at sites of previously lacerated mucosa; one pulsating, protruding, vessel was visible. Clips were placed over the vessel with cessation of bleeding. Barium enema at three months follow revealed no leaks allowing for reversal of the colostomy. DISCUSSION: This case of operative retrieval of a rectal foreign body is unique because it displays deviation from commonly used algorithms are periodically needed to optimize patient recover. CONCLUSION: The utilization of minimally-invasive colonoscopy prior to additional surgical intervention in post-operative rectal bleeding following a rectal foreign body retrieval may improvie patient recovery time, functionality, and long-term outcomes.

Acute Generalized Exanthematous Pustulosis in an African American Male Caused by Trimethoprim-Sulfamethoxazole.

Acute generalized exanthematous pustulosis (AGEP) is a rare drug-induced autoimmune disease that presents with hundreds of sterile pustules and systemic symptoms. Genetic predisposition, race, and medications prescribed are all factors in AGEP's frequency, which occurs most commonly in Caucasians and with the use of macrolides and aminopenicillins. Cases of AGEP with sulfonamides or in African American patients are rare. To our knowledge, this is the first documented example of trimethoprim-sulfamethoxazole-induced AGEP in an African American male. In this article, we will further discuss our case and review the literature.

Infliximab-induced Depression and Suicidal Behavior in Adolescent with Crohn's Disease: Case Report and Review of Literature.

Infliximab, an anti-inflammatory agent, is used to treat various autoimmune disorders. There are at least 3 reports of severe psychiatric adverse effects of the drug, including suicidal behaviors in adults and psychosis in adult and adolescent patients. We report a case of an adolescent who developed depression and suicidal behaviors shortly after beginning infliximab. Although there have been reports of adolescents developing acute psychosis shortly after starting infliximab, this is, to our knowledge, the first report of adolescent suicidal behavior in the setting of infliximab treatment. METHODS: We describe a patient's presentation and clinical course, as well as existing reports of adverse psychiatric effects of infliximab. RESULTS: A 16-year-old male with a 2-year history of disabling symptoms and complications of Crohn's disease was initiated on a trial of infliximab. Within days of the first infliximab infusion, he experienced symptoms of depression, which intensified over weeks and resulted in a serious suicide attempt. The patient was treated with fluoxetine, melatonin, and psychotherapy, which effectively managed his infliximab-induced depressive disorder with suicidal thoughts and behaviors. Posttreatment, he tolerated additional infliximab infusions without the recurrence of psychiatric symptoms. CONCLUSIONS: Treatment with infliximab may rarely and suddenly cause severe and potentially life-threatening psychiatric symptoms. Therefore, youth with chronic illnesses considered for infliximab treatment should be screened for preexisting, as well as for a family history of, psychiatric disorders and suicidal behavior.