Consideration of the Aerosol Transmission for COVID-19 and Public Health.

This article analyzes the available evidence to address airborne, aerosol transmission of the SARS-CoV-2. We review and present three lines of evidence: case reports of transmission for asymptomatic individuals in association with studies that show that normal breathing and talking produce predominantly small droplets of the size that are subject to aerosol transport; limited empirical data that have recorded aerosolized SARS-CoV-2 particles that remain suspended in the air for hours and are subject to transport over distances including outside of rooms and intrabuilding, and the broader literature that further supports the importance of aerosol transmission of infectious diseases. The weight of the available evidence warrants immediate attention to address the significance of aerosols and implications for public health protection.

Initial skin cancer screening for solid organ transplant recipients in the United States: Delphi method development of expert consensus guidelines.

Skin cancer is the most common malignancy affecting solid organ transplant recipients (SOTR), and SOTR experience increased skin cancer-associated morbidity and mortality. There are no formal multidisciplinary guidelines for skin cancer screening after transplant, and current practices are widely variable. We conducted three rounds of Delphi method surveys with a panel of 84 U.S. dermatologists and transplant physicians to establish skin cancer screening recommendations for SOTR. The transplant team should risk stratify SOTR for screening, and dermatologists should perform skin cancer screening by full-body skin examination. SOTR with a history of skin cancer should continue regular follow-up with dermatology for skin cancer surveillance. High-risk transplant patients include thoracic organ recipients, SOTR age 50 and above, and male SOTR. High-risk Caucasian patients should be screened within 2 years after transplant, all Caucasian, Asian, Hispanic, and high-risk African American patients should be screened within 5 years after transplant. No consensus was reached regarding screening for low-risk African American SOTR. We propose a standardized approach to skin cancer screening in SOTR based on multidisciplinary expert consensus. These guidelines prioritize and emphasize the need for screening for SOTR at greatest risk for skin cancer.

Surgical site identification with personal digital device: A prospective pilot study.

BACKGROUND: Various means to facilit ate accurate biopsy site identification have been proposed. OBJECTIVE: To determine the accuracy of biopsy site identification by using photographs taken with a patient's digital device by a dermatologist versus professional medical photography. METHODS: Photographs of circled biopsy sites were taken with personal digital devices by the principal investigator (PI). Another set of photographs was taken by a professional photographer. Secondary photographs were taken of the biopsy site location pointed to by the staff and PI on the basis of the personal digital device image and professional medical photography, respectively. On the basis of secondary photographs, 2 independent dermatologists determined whether the skin biopsy locations pointed out by the staff were consistent with the ones pointed out by PI. RESULTS: Per dermatologist A, the staff correctly identified all 53 biopsy sites. Per dermatologist B, the staff were correct on 51 of 53 observations. Dermatologist C, the final arbiter, concurred with dermatologist A on the 2 cases in which dermatologist B was not certain of the location of the biopsy site. LIMITATIONS: The mean interval from initial biopsy to reidentification of the site was 36.2 days. CONCLUSION: Utilizing patients' personal digital devices is a cost-effective, Health Insurance Portability and Accountability Act-compliant, and readily available means to identify skin biopsy sites.

Pseudo-Bullous Dermatosis Induced by Topical Anesthetic Agent-Clues to This Localized Toxic Reaction.

Eutectic mixture of 2.5% lidocaine and 2.5% prilocaine (EMLA AstraZeneca, DE) is a widely used topical anesthetic cream for preprocedural cutaneous analgesia. In addition to potential clinical cutaneous and systemic adverse effects, EMLA may also induce microscopic changes detectable by light and electron microscopy leading to difficulty in accurate diagnosis. We report the case of a biopsy demonstrating EMLA-induced histopathologic changes. The biopsy was taken from the back of a 5-month-old infant and submitted to rule out psoriasis. Hematoxylin and eosin (H&E) staining of the biopsy demonstrated spongiosis and a noninflammatory subepidermal bulla, raising the histopathologic possibility of epidermolysis bullosa. Further investigation confirmed that EMLA was applied under occlusion before biopsy. A second biopsy without topical anesthetic did not demonstrate a bulla and supported the clinical diagnosis of psoriasiform dermatitis. Our case highlights the importance of awareness of EMLA-induced histopathologic changes to avoid potential misdiagnosis. The histopathologic findings of this case in conjunction with other previously reported cases of EMLA-induced bullae were analyzed. Vacuolization of the basal and suprabasilar layer, pallor and swelling of upper layer epidermal keratinocytes, a pauci-inflammatory cleavage beneath or within the basal layer, basophilic granular karyorrhectic debris in the subepidermal cleft, and congestion of papillary dermal vessels characterized the biopsy findings of this localized adverse reaction.

Assessment of Health Risk from Historical Use of Cosmetic Talcum Powder.

This study's objective is to assess the risk of asbestos-related disease being contracted by past users of cosmetic talcum powder.  To our knowledge, no risk assessment studies using exposure data from historical exposures or chamber simulations have been published. We conducted activity-based sampling with cosmetic talcum powder samples from five opened and previously used containers that are believed to have been first manufactured and sold in the 1960s and 1970s.  These samples had been subject to conflicting claims of asbestos content; samples with the highest claimed asbestos content were tested.  The tests were conducted in simulated-bathroom controlled chambers with volunteers who were talc users.  Air sampling filters were prepared by direct preparation techniques and analyzed by phase contrast microscopy (PCM), transmission electron microscopy (TEM) with energy-dispersive x-ray (EDX) spectra, and selective area diffraction (SAED).  TEM analysis for asbestos resulted in no confirmed asbestos fibers and only a single fiber classified as "ambiguous."  Hypothetical treatment of this fiber as if it were asbestos yields a risk of 9.6 × 10-7 (under one in one million) for a lifetime user of this cosmetic talcum powder.  The exposure levels associated with these results range from zero to levels far below those identified in the epidemiology literature as posing a risk for asbestos-related disease, and substantially below published historical environmental background levels.  The approaches used for this study have potential application to exposure evaluations of other talc or asbestos-containing materials and consumer products.

Radiation-induced localized bullous pemphigoid in a patient with breast carcinoma.

Bullous pemphigoid (BP) is a common pemphigoid disorder, which is localized in approximately 16-29% of cases. A small subset of localized BP cases is associated with prior radiation therapy, most commonly for breast carcinoma. We present a patient with an unusual presentation of localized BP after receiving partial accelerated breast irradiation (a type of brachytherapy that has a decreased amount of radiation to the skin as compared to the more common external beam radiation therapy).

Umbilical and periumbilical dermatoses.

The umbilicus may be the site of congenital and acquired malformations and may harbor clinical clues to the diagnosis of potentially fatal inherited disorders, primary skin conditions, and a variety of infectious diseases. Both benign and malignant tumors may involve the umbilicus, and some are unique to this site. Finally, cutaneous signs localized to this anatomic location may be found in diverse systemic diseases.

Cutaneous microemboli from hydrophilic polymer after endovascular procedures.

BACKGROUND: Multiple devices and coatings assist with endovascular insertion of sheaths, catheters, and guide wires. Hydrophilic polymer coatings, a common component of endovascular surgical devices, reportedly cause microvascular obstruction and embolization, with various sequelae in organs and soft tissue. OBJECTIVE: We sought to describe clinical and histopathologic features of cutaneous manifestations of hydrophilic polymer gel emboli. METHODS: We evaluated the clinical and histopathologic characteristics of 8 patients with cutaneous complications of hydrophilic polymer gel emboli who presented in May 2013 through February 2015. RESULTS: Sudden onset of lower extremity livedo racemosa, purpuric patches, or both, occurred hours to days after endovascular procedures involving the aorta. Histopathologic evaluation showed basophilic lamellated material, consistent with hydrophilic polymer gel emboli, within small dermal vessels. LIMITATIONS: This was a retrospective study with small sample size and not controlled for all similar procedures in this population. CONCLUSION: Hydrophilic polymer gel coatings in endovascular devices can embolize to skin and cause microvascular occlusion, presenting as livedo racemosa, purpura, or both. Given the number of patients observed over a short period, this phenomenon may be underappreciated. Hydrophilic polymer gel emboli should be considered in differential diagnosis of livedo racemosa and purpura after endovascular procedure.

Amitriptyline/Ketamine as therapy for neuropathic pruritus and pain secondary to herpes zoster.

Frequent causes of morbidity secondary to herpes zoster include acute pain, secondary infection, and postherpetic neuralgia. A less documented complication is pruritus, which can be either acute or postinfectious when it persists more than 3 months after the rash has healed. We discuss a case of severe, acute neuropathic pruritus and pain secondary to active herpes zoster that was unresponsive to standard medical therapy, including oral antihistamines, topical lidocaine, oral gabapentin, and local wound care. Modest control of the pruritus and pain was achieved with continued multimodal therapy and the addition of topical 2% amitriptyline/0.5% ketamine gel.

Biopsy diagnoses of clinically atypical pigmented lesions of the head and neck in adults.

A subset of facial melanoma in situ has histological features that overlap with those of "dysplastic" nevi. The authors evaluated this important diagnostic pitfall by assessing the frequency of melanoma as the final diagnosis in skin biopsies submitted over a 1-year period with a clinical impression of "atypical" or dysplastic nevus from the head or neck of adults. A total of 1998 biopsies met inclusion criteria. Final diagnoses included both melanocytic and nonmelanocytic processes. Clear trends were noted based on the age of the patient with benign nevi encompassing nearly 70% of specimens in patients aged 21-29 years and <10% in patients aged 70 years and above. The incidence of atypical nevi decreased with age (16% in 21-29 years, 3% in age 70+ years). Nineteen of the 180 (10%) atypical nevi in our series were located on the face (7, cheek; 6, forehead; 3, jawline; and 3, temple), a location not traditionally associated with atypical nevi. Facial atypical nevi were found in all age groups. Malignant melanoma accounted for 1.8% of all specimens increasing from 0% in the patients aged 21-29 years to 5% in patients aged 70 years and above. Caution is warranted when evaluating skin biopsies from sun-damaged skin of the head or neck of an older adult submitted with a clinical diagnosis of atypical nevus. However, the authors' findings suggest that atypical nevi with histological features of dysplastic nevi occur on the head and neck of adults, including elderly adults. The incidence of such lesions decreases with age as the incidence of melanoma increases, and careful clinicopathologic correlation is vital.

Defining the role of mirtazapine in the treatment of refractory pruritus.

BACKGROUND/OBJECTIVE: Mirtazapine has traditionally been used for the treatment of major depressive disorder, with an added benefit in patients who have comorbid insomnia or anxiety. Recent studies describe its usefulness in treating refractory pruritus of various causes as well. Our goal is to better define the use of mirtazapine in the treatment of refractory pruritus. METHOD: Through a thorough literature review of PubMed, we identified all reports of the use of mirtazapine for pruritus. RESULTS: Upon examination of 8 supporting articles, we found mirtazapine has quality evidence for the treatment of intra-thecal morphine-induced pruritus. Mirtazapine may also be effective in treating pruritus related to various other conditions, including psoriasis, atopic dermatitis, cutaneous malignancies (primary or metastatic), hematologic malignancies (lymphomas and leukemias), liver failure, renal failure, cholestasis, as well as pruritus of unknown origin. CONCLUSIONS: Mirtazapine plays a role in treatment for intra-thecel morphine-induced pruritis yet high-quality trials are needed to confirm its efficacy in other dermatologic conditions.

Basal cell carcinoma in childhood: case report and literature review.

Childhood onset basal cell carcinoma is uncommon. In addition to occurring in children with albinism, Bazex syndrome, basal cell carcinoma nevus syndrome, nevus sebaceus, radiotherapy-treated cancers, solid organ transplants, and xeroderma pigmentosum, childhood onset basal cell carcinoma has also occurred, albeit less commonly, de novo. We describe a boy with idiopathic childhood onset basal cell carcinoma. Previously published children with de novo basal cell carcinoma were collected from computerized medical literature search (PubMed) and citations from earlier reports. To our knowledge, childhood onset idiopathic basal cell carcinoma has been observed in a total of 107 children, including our patient. Tumors were most commonly located on the head (90%). The tumors are most frequently nodular in appearance (52%) and in histology (at least 17%); however, aggressive histologic variants were observed in 20% of tumors. Basal cell carcinoma in children may be associated with prior sun exposure. The most common treatment is excision, with or without using the Mohs technique. However, 15 of 85 children, nearly 20%, developed recurrent tumors during a follow-up period ranging from 4 months to 20 years.

Incidence of and Risk Factors for Skin Cancer in Organ Transplant Recipients in the United States.

Importance: Skin cancer is the most common malignancy occurring after organ transplantation. Although previous research has reported an increased risk of skin cancer in solid organ transplant recipients (OTRs), no study has estimated the posttransplant population-based incidence in the United States. Objective: To determine the incidence and evaluate the risk factors for posttransplant skin cancer, including squamous cell carcinoma (SCC), melanoma (MM), and Merkel cell carcinoma (MCC) in a cohort of US OTRs receiving a primary organ transplant in 2003 or 2008. Design, Setting, and Participants: This multicenter retrospective cohort study examined 10 649 adult recipients of a primary transplant performed at 26 centers across the United States in the Transplant Skin Cancer Network during 1 of 2 calendar years (either 2003 or 2008) identified through the Organ Procurement and Transplantation Network (OPTN) database. Recipients of all organs except intestine were included, and the follow-up periods were 5 and 10 years. Main Outcomes and Measures: Incident skin cancer was determined through detailed medical record review. Data on predictors were obtained from the OPTN database. The incidence rates for posttransplant skin cancer overall and for SCC, MM, and MCC were calculated per 100 000 person-years. Potential risk factors for posttransplant skin cancer were tested using multivariate Cox regression analysis to yield adjusted hazard ratios (HR). Results: Overall, 10 649 organ transplant recipients (mean [SD] age, 51 [12] years; 3873 women [36%] and 6776 men [64%]) contributed 59 923 years of follow-up. The incidence rates for posttransplant skin cancer was 1437 per 100 000 person-years. Specific subtype rates for SCC, MM, and MCC were 812, 75, and 2 per 100 000 person-years, respectively. Statistically significant risk factors for posttransplant skin cancer included pretransplant skin cancer (HR, 4.69; 95% CI, 3.26-6.73), male sex (HR, 1.56; 95% CI, 1.34-1.81), white race (HR, 9.04; 95% CI, 6.20-13.18), age at transplant 50 years or older (HR, 2.77; 95% CI, 2.20-3.48), and being transplanted in 2008 vs 2003 (HR, 1.53; 95% CI, 1.22-1.94). Conclusions and Relevance: Posttransplant skin cancer is common, with elevated risk imparted by increased age, white race, male sex, and thoracic organ transplantation. A temporal cohort effect was present. Understanding the risk factors and trends in posttransplant skin cancer is fundamental to targeted screening and prevention in this population.

Use of Candida antigen injections for the treatment of verruca vulgaris: A two-year mayo clinic experience.

Common warts (verruca vulgaris) are one of the most common problems encountered in dermatology and may present a difficult treatment dilemma, as no particular therapy has demonstrated complete efficacy. Intralesional injection of purified Candida antigen has produced impressive treatment results in small prospective and retrospective studies and is thought to produce its effect through stimulation of a cell-mediated immune response. We report a retrospective study of adult and pediatric patients treated with Candida antigen therapy in clinical practice. Of the 100 patients treated, 80% responded to therapy: 39% demonstrated a complete response and 41% demonstrated a partial response. In addition, 6 out of 7 immunocompromised patients who were treated demonstrated a partial or complete response. Injections were generally well-tolerated and adverse events were minimal and short-lived. Our data indicate that intralesional Candida antigen therapy for cutaneous warts is an efficacious option in a clinical practice setting. The treatment may also be effective in immunosuppressed patients with cutaneous warts. Our results add to the literature one of the largest retrospective series reported to date and treatment outcomes are similar to previously reported studies evaluating this therapeutic modality.

Acral vesicles and bullae in a patient with severe rheumatoid arthritis.

We present the case of a 56-year-old black woman with rheumatoid arthritis who developed worsening fatigue, fever, weight loss, and a vesiculobullous skin eruption while being treated with certolizumab pegol for her arthritis. Microscopic findings confirmed the diagnosis of a neutrophilic dermatosis.

Correction of intrinsic nasal tip asymmetries in primary rhinoplasty.

Preoperative nasal analysis for the rhinoplasty patient is not complete without recognition and characterization of asymmetries. A simplified classification of columellar and intrinsic nasal tip asymmetries has evolved from 15 years' experience with rhinoplasty. Nasal tip asymmetries have vertical and horizontal dimensions. The vertical, or cephalocaudal, causes of tip asymmetry are primarily extrinsic factors. Elements that contribute to tip asymmetry and are extrinsic to the lower lateral cartilages are the bony and cartilaginous septum, the nasal bones, the upper lateral cartilages, and the maxilla. Horizontal or side-to-side asymmetries can be the result of intrinsic lower lateral cartilage abnormalities. The importance of this distinction is to differentiate the patient with a deviated nose and concomitant tip asymmetry from the patient with an isolated, intrinsic deformity of the nasal tip cartilages. A simplified classification system for nasal tip asymmetries is presented along with proposed methods for surgical correction. Case examples are analyzed also. A description of nondestructive suturing techniques and cartilage grafts to restore nasal tip symmetry is provided for each deformity. An open rhinoplasty approach is advocated in all cases.