Novel Education Modules Addressing the Underrepresentation of Skin of Color in Dermatology Training.

BACKGROUND: Representative images of pathology in patients with skin of color are lacking in most medical education resources. This particularly affects training in dermatology, which relies heavily on the use of images to teach pattern recognition. The presentation of skin pathology can vary greatly among different skin tones, and this lack of representation of dark skin phototypes challenges providers' abilities to provide quality care to patients of color.In Botswana and other countries in sub-Saharan Africa, this challenge is further compounded by limited resources and access to dermatologists. There is a need for improved and accessible educational resources to train medical students and local medical providers in basic skin lesion description and diagnosis. OBJECTIVES: We examined whether online Perceptual and Adaptive Learning Modules (PALMs) composed of representative dark skin images could efficiently train University of Botswana medical students to more accurately describe and diagnose common skin conditions in their community. METHODS: Year 4 and 5 medical students voluntarily completed PALMs that teach skin morphology, configuration, and distribution terminology and diagnosis of the most common dermatologic conditions in their community. Pre-tests, post-tests and delayed-tests assessed knowledge acquisition and retention. RESULTS: PALMs training produced statistically significant (P < .0001) improvements in accuracy and fluency with large effect sizes (1.5, 3.7) and good retention after a 12.5-21-week median delay. Limitations were a self-selected group of students, a single institution, slow internet connections, and high drop-out rates. CONCLUSIONS: Overall, population-specific PALMs are a useful tool for efficient development of pattern recognition in skin disease description and diagnosis.

A case of pleomorphic dermal sarcoma with perineural invasion treated with Mohs micrographic surgery and adjuvant radiation therapy.

Pleomorphic dermal sarcoma (PDS) was recognized in the 2013 World Health Organization Classification of Tumors of Soft Tissue and Bone as a clinical entity with adverse histopathologic features compared to the more superficial and less aggressive atypical fibroxanthoma (AFX). Although the gold standard treatment of AFX is Mohs micrographic surgery (MMS), the optimal treatment for PDS has yet to be determined. We report the case of a 71-year-old man with a PDS with perineural invasion on the scalp, with no recurrence one-year post-treatment with MMS and adjuvant radiation therapy. In contrast to wide local excision, MMS offers complete margin control and tissue preservation, which helps minimize scarring and morbidity. The comparative efficacy of MMS versus wide local excision in the treatment of PDS with and without radiation remains unknown and warrants further investigation.

Teledermatology as a Means to Provide Multispecialty Care: A Case of Global Specialty Collaboration.

Telemedicine can serve as a platform for specialty collaboration and potentially address the lack of specialized and subspecialized care globally. In this article we present a case in which the use of teledermatology facilitated global collaboration between multiple specialists and subspecialists, resulting in high-quality care of a child from a remote area of Botswana. We present the lessons learned and factors that should be considered when engaging in global specialty collaboration, especially between developed and developing countries. We also discuss the potential limitations of telemedicine when used within a global context. With these considerations in mind, global specialty collaboration facilitated by telemedicine can provide a potential solution to the lack of access to specialized and subspecialized care.

Polymorphous Cutaneous Sarcoidosis With Excellent Response to Minocycline.

Sarcoidosis is notorious for producing a wide variety of skin lesions, which are categorized as either specific or nonspecific. The specific lesions include primary morphologies ranging from micropapules to subcutaneous nodules. Nonspecific skin lesions include associated conditions like erythema nodosum, calcinosis cutis, and prurigo. It is not uncommon for a patient to have a combination of specific and nonspecific lesions. In contrast, it is exceedingly rare for one patient to have multiple specific sarcoidal lesions. When present, the term "polymorphous cutaneous sarcoidosis" has been used. We present the case of a patient who presented with three specific cutaneous morphologies of sarcoidosis: papular sarcoid, Darier-Roussy subcutaneous sarcoidosis, and lupus pernio. After only two months of oral minocycline, our patient demonstrated remarkable improvement with near-complete resolution of the cutaneous lesions. In addition to describing the rare polymorphous presentation, this case also highlights the challenge of relating lesion type to overall prognosis when multiple morphologies are present.

Postinflammatory hypopigmentation: a comprehensive review of treatments.

Postinflammatory hypopigmentation is an acquired form of hypopigmentation that occurs secondary to an exogenous or endogenous insult to the skin. It can occur in all skin phototypes but is more visually apparent in skin of color. Due in part to greater attention given to its counterpart, postinflammatory hyperpigmentation, there is a dearth of literature describing this entity and treatment options remain limited. This review provides a comprehensive update on the pathogenesis, diagnostic evaluation and treatment of postinflammatory hypopigmentation, with a focus on newly reported treatment modalities.

Autoimmune skin disease among dermatology outpatients in Botswana: a retrospective review.

BACKGROUND: There is a paucity of data describing autoimmune skin diseases in sub-Saharan Africa and in HIV positive cohorts. We describe the incidence of autoimmune skin diseases in public dermatology clinics in Botswana. METHODS: New patient records from public dermatology clinics were reviewed retrospectively for the period of September 2008 to December 2015. New diagnoses of cutaneous lupus erythematosus, systemic lupus erythematosus (SLE) with cutaneous involvement, dermatomyositis, systemic sclerosis, lichen sclerosus, bullous pemphigoid, pemphigus foliaceus, pemphigus vulgaris, and pemphigus vegetans were identified. Demographic data were recorded, and incidence was determined. RESULTS: A total of 262 patients were diagnosed with autoimmune skin disease (4% of all new patients) with an incidence rate of 28.8 (per 1,000,000). Cutaneous lupus was the most common diagnosis with discoid lupus occurring most frequently (12.6). The incidence of systemic sclerosis (2.2), morphea (1.6), lichen sclerosus (1.5), SLE with cutaneous involvement (1.3) and dermatomyositis (1.2) was relatively lower. Bullous pemphigoid was the most common bullous disease (3.8). Pemphigus foliaceus (0.9), pemphigus vulgaris (0.6), and pemphigus vegetans (0.2) were observed at a lower rate. At least 19.8% of these patients were also HIV positive. CONCLUSIONS: The incidence of autoimmune skin diseases in Botswana is lower compared to other published studies in other geographic areas, which may be reflective of a younger population, barriers to access, genetic differences, and a lack of comparative studies in sub-Saharan Africa. The hygiene hypothesis and helminth infections may also contribute to these differences. Further studies are needed to understand these disorders in this region.

Follicular and scarring disorders in skin of color: presentation and management.

Skin of color, also known as ethnic skin, is described as skin of individuals of African, Asian, Hispanic, Native-American, Middle Eastern, and Pacific Island backgrounds. Differences in hair morphology, hair grooming, cultural practices, and susceptibility to keloid scarring exist within these populations and have been implicated in hair, scalp, and skin disorders. Acne keloidalis (AK), central centrifugal cicatricial alopecia (CCCA), dissecting cellulitis of the scalp (DCS), pseudofolliculitis barbae (PFB), traction alopecia (TA), and keloids are the most prevalent follicular and scarring disorders in skin of color. They have been associated with disfigurement, permanent hair loss, emotional distress, and decreased quality of life. Hair grooming practices, such as the use of chemical relaxers, heat straightening, and tight braiding and weaving can cause scalp irritation and follicular damage and are linked to the pathogenesis of some of these conditions. Consequently, patient education and behavior modifications are integral to the prevention and management of these disorders. Scarring disorders are also of concern in ethnic populations. Keloid scarring is more prevalent in individuals of African, Asian, and Hispanic descent. The scarring alopecia CCCA is almost exclusively seen in patients of African descent. Therapeutic regimens such as intralesional corticosteroids, surgical excision, and laser therapy can be effective for these follicular and scarring disorders, but carry a risk of dyspigmentation and keloid scarring. Ethnic skin and hair may present unique challenges to the clinician, and knowledge of these differences is essential to providing quality care.