Rápida implementación de teledermatología durante la pandemia por COVID-19: lecciones aprendidas de un departamento académico de Dermatología / Rapid implementation of tele-dermatology during COVID-19 pandemic in an academic dermatology department

BACKGROUND: The day after COVID-19 quarantine started, we initiated patient care through Tele-dermatology. AIM: To report the experience of the implementation of Telemedicine in dermatology and to assess its impact on the number of dermatological visits compared with the pre-pandemic period. MATERIAL AND METHODS: The study was conducted between March 27th, 2020, and April 30th, 2020. All patients submitted clinical images of their skin condition via secure email before the telemedicine visit. All telemedicine visits were conducted using the Zoom video conferencing platform. Patient demographics and medical history were recorded. If the dermatologist was unable to reach a diagnosis, the patient was sent for an in-person visit, skin biopsy, or additional laboratory workup. RESULTS: We recorded 1,357 Tele dermatology visits from 1,222 patients aged 29 ± 18 years (38% males). Visits increased from 104 to 298 from the first to the last week, corresponding to 17% of the patient volume seen before the pandemic (1,709 in-person patients/week). A preliminary diagnosis was made in 95% of cases. Ninety percent of patients sent photos. Fifty eight percent of cases were chronic diseases, and were classified as inflammatory in 68%, infectious in 15%, neoplastic/tumoral in 7%, or other conditions in 11%. Less than 1% of these visits were COVID-19 related. CONCLUSIONS: In this prospective study of Tele-dermatology lasting five weeks, a preliminary diagnosis could be made in approximately 95% of cases and in the first five weeks of implementation, a volume of consultations equivalent to 17% of those made in the pre-pandemic period was carried out. Therefore, Tele-dermatology can be implemented quickly and successfully in practices when healthcare access is limited.

Cutaneous Metastasis From Parotid Tumors: A Report of 2 Cases and Literature Review.

ABSTRACT: Cutaneous metastases from parotid tumors are uncommon and imply a poor prognosis. In this article, we report 2 new cutaneous metastasis cases from 2 different parotid malignancies and 42 additional cases from a literature review. Clinical manifestations, localization, and outcomes of skin metastasis from parotid tumors are described. Although infrequent, parotid neoplasms may develop skin metastasis many years after the initial diagnosis, mostly in the head and neck region. Therefore, long-term follow-up and periodic skin examination of these patients is mandatory. Dermatologists and surgeons must have a high index of suspicion when evaluating any skin lesion arising on these patients because cutaneous metastasis from parotid neoplasms generally implies a poor prognosis.

[Rapid implementation of tele-dermatology during COVID-19 pandemic in an academic dermatology department]. / Rápida implementación de teledermatología durante la pandemia por COVID-19: lecciones aprendidas de un departamento académico de Dermatología.

BACKGROUND: The day after COVID-19 quarantine started, we initiated patient care through Tele-dermatology. AIM: To report the experience of the implementation of Telemedicine in dermatology and to assess its impact on the number of dermatological visits compared with the pre-pandemic period. MATERIAL AND METHODS: The study was conducted between March 27th, 2020, and April 30th, 2020. All patients submitted clinical images of their skin condition via secure email before the telemedicine visit. All telemedicine visits were conducted using the Zoom video conferencing platform. Patient demographics and medical history were recorded. If the dermatologist was unable to reach a diagnosis, the patient was sent for an in-person visit, skin biopsy, or additional laboratory workup. RESULTS: We recorded 1,357 Tele dermatology visits from 1,222 patients aged 29 ± 18 years (38% males). Visits increased from 104 to 298 from the first to the last week, corresponding to 17% of the patient volume seen before the pandemic (1,709 in-person patients/week). A preliminary diagnosis was made in 95% of cases. Ninety percent of patients sent photos. Fifty eight percent of cases were chronic diseases, and were classified as inflammatory in 68%, infectious in 15%, neoplastic/tumoral in 7%, or other conditions in 11%. Less than 1% of these visits were COVID-19 related. CONCLUSIONS: In this prospective study of Tele-dermatology lasting five weeks, a preliminary diagnosis could be made in approximately 95% of cases and in the first five weeks of implementation, a volume of consultations equivalent to 17% of those made in the pre-pandemic period was carried out. Therefore, Tele-dermatology can be implemented quickly and successfully in practices when healthcare access is limited.

Influence of the phenotype on mycosis fungoides prognosis, a retrospective cohort study of 160 patients.

BACKGROUND: Mycosis fungoides (MF) typically has a CD4+ CD8- T-cell phenotype. Rare cases of CD4- CD8+ , CD4- CD8- , or CD4+ CD8+ immunophenotypes have been described. Little is known about the impact of MF immunophenotypes on disease behavior. METHODS: We conducted a retrospective cohort study to review all cases of MF from 2007 to 2017 from Sunnybrook Health Sciences Centre, Toronto, Canada. CD4+ CD8- (Group 1) was compared to the three less common subtypes (Group 2) with respect to stage at diagnosis, progression, and transformation. Potential confounding factors (demographic, clinical, and laboratory parameters) were assessed. RESULTS: A total of 160 patients with confirmed MF were analyzed, including 126 CD4+ CD8- MF (79%), 26 CD4- CD8+ MF (16%), six CD4+ CD8+ MF (4%), and two CD4- CD8- MF (1%). Both groups were similar with respect to demographics and laboratory parameters at the time of diagnosis. There was no difference between patients with late stage disease (10% vs. 9%) for groups 1 and 2, respectively (P = 0.901). There was no statistically significant difference either in 5-year progression (27.7% vs. 23.5%, P = 0.283) or transformation (16.2% vs. 17.3%, P = 0.350) estimates. We did find that atypical immunophenotypes presented with different clinical morphologies and were less likely to require systemic therapy. CONCLUSION: Our large cohort study indicates that atypical MF immunophenotypes do not seem to influence prognosis. Hypopigmented MF was more frequent in the CD4- CD8+ group while folliculotropic MF was exclusively seen in the CD4+ CD8- group. We believe that cases of CD8+ MF with aggressive behavior described in the literature represent misclassified primary cutaneous aggressive epidermotropic CD8+ T-cell lymphoma. The small number of patients included in the study is a limiting factor.

Eosinophils in the skin-a red herring masking lymphoma: a case series.

Eosinophilia, both peripheral and in cutaneous tissue, is not a typical finding in mycosis fungoides; in fact, when faced with a lymphoeosinophilic infiltrate, mycosis fungoides is often not part of initial differential considerations. However, eosinophilia has been described in certain subtypes of mycosis fungoides, namely, in folliculotropic mycosis fungoides. We describe three challenging cases of folliculotropic mycosis fungoides presenting with varied clinical morphologies and a dense lymphoeosinophilic infiltrate and/or severe hypereosinophilia that obscured the final diagnosis for years. Only after treatment of the eosinophilia were the underlying atypical lymphocytes more apparent on histology and a correct diagnosis made. Thus, when characteristic features of mycosis fungoides are subtle, eosinophils can act as a red herring in terms of clinico-pathologic correlation and may prevent early and accurate diagnosis of mycosis fungoides. We suggest that further studies are needed to evaluate whether treatments to reduce eosinophilia, once other causes have been excluded, may help clear the confounding reactive inflammatory infiltrate and facilitate the diagnosis of mycosis fungoides.

Toxic Epidermal Necrolysis Spectrum Management at Sunnybrook Health Sciences Centre: Our Multidisciplinary Approach After Review of the Current Evidence.

Toxic epidermal necrolysis spectrum (TENS) is a rare yet severe adverse drug reaction associated with a high mortality rate. Beyond supportive care, there is still no established therapy for TENS, although recent meta-analyses and UK guideline recommendations have attempted to offer a review of relevant literature on this difficult topic. As most directed treatments lack clear consensual evidence, care centres often resort to establishing their own strategies. As Canada's largest adult burn centre and the provincial reference centre for most burn patients in Ontario, our team at the Ross Tilley Burn Centre, in collaboration with the Department of Dermatology at Sunnybrook Health Sciences Centre, Toronto, Canada, has managed over 60 confirmed cases of TENS over the past 2 decades. We would like to share our management, experience, and present our treatment protocol that we recently established by a collaborative multidisciplinary team approach to help guide treatment of these complex patients not only in Canada but worldwide.

[Ecthyma gangrenosum caused by Staphylococcus aureus]. / Ectima gangrenoso secundario a Staphylococcus aureus.

Ecthyma gangrenosum is an uncommon necrotizing vasculitis, in most cases secondary to sepsis by Pseudo-mona aeruginosa in immunocompromised patients. However, there have been several reports of ecthyma gangre-nosum caused by other infectious etiologies. We report an unusual case of ecthyma gangrenosum associated with methicillin-resistant Staphylococcus aureus infection in a patient without the classic immunological risk factors described in the literature.

Ectima gangrenoso secundario a Staphylococcus aureus / Ecthyma gangrenosum caused by Staphylococcus aureus

El ectima gangrenoso es una vasculitis necrosante poco frecuente, en la mayoría de los casos secundaria a sepsis por Pseudomonas aeruginosa en pacientes inmunocomprometidos. Sin embargo, existen reportes de ectima gangrenoso secundarios a otras etiologías infecciosas. Presentamos un caso de ectima gangrenoso asociado a una infección por Staphylococcus aureus resistente a meticilina en una paciente sin los factores de riesgo clásicos de inmunosupresión que se describen en la literatura médica.

Ecthyma gangrenosum is an uncommon necrotizing vasculitis, in most cases secondary to sepsis by Pseudo-mona aeruginosa in immunocompromised patients. However, there have been several reports of ecthyma gangre-nosum caused by other infectious etiologies. We report an unusual case of ecthyma gangrenosum associated with methicillin-resistant Staphylococcus aureus infection in a patient without the classic immunological risk factors described in the literature.

Fotoféresis en el tratamiento de Síndrome de Sézary: Caso clínico / Sézary syndrome treated with extracorporeal photopheresis: Report of one case

Sézary syndrome (SS) is an unusually aggressive T- cell lymphoma characterized by the triad of erythroderma, the presence of more than 1,000 Sézary cells in peripheral blood and lymphadenopathies. It is accompanied by generalized pruritus and poor quality of life. The management of SS depends on its stage, patient comorbidities, and treatment availability. Extracorporeal photopheresis (ECP) is the first line of treatment for patients with T-cell lymphomas in stage IVA1, IVA2 or SS. This treatment comprises three phases: leukapheresis, photoactivation and subsequent reinfusion of lymphocytes. As it is an immunomodulatory therapy it does not produce generalized immunosuppression. We report a 76 year-old male with SS stage IIIb initially treated with 12 sessions of ultraviolet phototherapy without response. After 10 well-tolerated sessions of ECP, itching and skin lesions eventually disappeared.

[Sézary syndrome treated with extracorporeal photopheresis: Report of one case]. / Fotoféresis en el tratamiento de Síndrome de Sézary: Caso clínico.

Sézary syndrome (SS) is an unusually aggressive T- cell lymphoma characterized by the triad of erythroderma, the presence of more than 1,000 Sézary cells in peripheral blood and lymphadenopathies. It is accompanied by generalized pruritus and poor quality of life. The management of SS depends on its stage, patient comorbidities, and treatment availability. Extracorporeal photopheresis (ECP) is the first line of treatment for patients with T-cell lymphomas in stage IVA1, IVA2 or SS. This treatment comprises three phases: leukapheresis, photoactivation and subsequent reinfusion of lymphocytes. As it is an immunomodulatory therapy it does not produce generalized immunosuppression. We report a 76 year-old male with SS stage IIIb initially treated with 12 sessions of ultraviolet phototherapy without response. After 10 well-tolerated sessions of ECP, itching and skin lesions eventually disappeared.

Melanoma dérmico hiperpigmentado de bajo grado de malignidad (melanoma de tipo animal): reporte de cuatro casos / Hyperpigmented dermal melanoma of low-grade of malignancy (animal-type melanoma): report of four cases

El melanoma animal o hiperpigmentado es un subtipo infrecuente de melanoma con células melanocíticas epitelioideas y fusadas muy pigmentadas. Esta entidad sería similar al llamado “melanoma de tipo equino”, una forma de melanoma de bajo grado de malignidad que afecta a los caballos grises. Se reportan cuatro casos, tres hombres y una mujer, cuyas edades variaron de 22 a 84 años; el estudio histopatológico confirmó melanoma dérmico hiperpigmentado; dos casos mostraron ganglio centinela positivo y un caso evolucionó con metástasis múltiples. Tres casos están en control o tratamiento sin evidencias de recidiva o metástasis. El melanoma animal es considerado un subtipo de melanoma de conducta poco agresiva y de mejor pronóstico, pese a su tendencia a las metástasis ganglionares. Los casos presentados mostraron una conducta menos agresiva que la esperada para el espesor de Breslow y estadio clínico en estos casos. Se requieren más estudios para poder identificar variables que permitan predecir el comportamiento biológico y así protocolizar el tratamiento de esta entidad, considerada por algunos como diferente del melanoma.

Animal type or hyperpigmented melanoma is an infrequent subtype of melanoma with heavily pigmented epithelioid and spindle melanocytes. This entity is similar to the so-called “equine-type melanoma”, an indolent variant of melanoma affecting gray horses. We report four cases, three males and one female, whose ages varied from 22 to 84 years; the histopathological study confirmed the diagnosis of hyperpigmented dermal melanoma; two cases showed positive sentinel lymph nodes and one case evolved with multiple metastases. Three cases are in control or under therapy without evidence of recurrences and/or metastases. Animal-type melanoma is considered a subtype of melanoma with indolent behavior and better prognosis, despite its tendence to develop lymph node metastases. The present cases showed a less aggressive behavior than expected for the Breslow’s thickness and clinical stage. More studies are needed to identify variables to predict its behavior and propose therapy protocols for this tumor, considered by some authors a different type of melanoma.