Health Insurance Coverage for Asymptomatic Seborrheic Keratoses Treatment.

Seborrheic keratosis is one of the most common benign cutaneous neoplasms encountered in dermatology practice. However, treatment of asymptomatic seborrheic keratosis is not covered by health insurance. Patients frequently report being bothered by the lesions but decline treatment to avoid incurring "out of pocket" expenses. In this commentary, the authors explore the various conundrums associated with this and the implications for health equity and ethical medical financing.

When a Biopsy Is Inadequate in Diagnosing Calciphylaxis.

Calciphylaxis is a rare disease that typically presents in patients with end-stage renal disease and can be a diagnostic challenge. Calcium deposition with fibrin thrombi and necrosis of the overlying epidermis may support the diagnosis; however, depending on the stage of the disease, skin biopsy can have low sensitivity and specificity, and may be contraindicated in some situations. We discuss the utility of imaging studies in supporting the diagnosis of calciphylaxis. (SKINmed. 2022;20:450-451).

Pseudocarcinomatous Hyperplasia Masquerading as a Well-Differentiated Squamous Cell Carcinoma Associated With Primary Cutaneous Anaplastic Large-Cell Lymphoma.

ABSTRACT: Pseudocarcinomatous hyperplasia (PCH) is a reactive proliferation of the epidermis associated with CD30 + lymphoproliferative disorders. In this article, we report the case of a 42-year-old man who presented with a 10-year history of a solitary erythematous patch on the right thigh that progressed to an ulcerated, crusted plaque. Histologic examination revealed an infiltrate of atypical CD30 + lymphocytes consistent with primary cutaneous anaplastic large-cell lymphoma with overlying well differentiated keratinocyte hyperplasia akin to a well-differentiated invasive squamous cell carcinoma. This case demonstrates the phenomenon of pseudocarcinomatous hyperplasia mimicking features of invasive squamous cell carcinoma. It highlights the necessity of careful clinical correlation when diagnosing squamous cell carcinomas in younger patients on non-sun-exposed areas and the exclusion of accompanying known causes of pseudocarcinomatous hyperplasia.

Updates in the Diagnosis and Management of Linear IgA Disease: A Systematic Review.

Background and Objectives: Linear IgA disease (LAD) is a rare autoimmune blistering disease with linear IgA deposits along the basement membrane zone. Direct immunofluorescence remains the gold standard for diagnosis, but other diagnostic measures reported in recent literature have proven useful in the setting of inconclusive preliminary results. Dapsone is a commonly used treatment, but many therapeutic agents have emerged in recent years. The objective of this study is to provide a comprehensive overview of updates on the diagnosis and management of LAD. Materials and Methods: A literature search was conducted from May to June of 2021 for articles published in the last 5 years that were related to the diagnosis and management of LAD. Results: False-negative results in cases of drug-induced LAD and the presence of IgG and IgM antibodies on immunofluorescence studies were reported. Serration pattern analysis has been reported to be useful in distinguishing LAD from sublamina densa-type LAD. Rituximab, omalizumab, etanercept, IVIg, sulfonamides, topical corticosteroids, and others have been used successfully in adult and pediatric patients with varying disease severity. Topical corticosteroids were preferred for pediatric patients while rituximab and IVIg were used in adults with recalcitrant LAD. Sulfonamides were utilized in places without access to dapsone. Conclusion: In cases where preliminary biopsy results are negative and clinical suspicion is high, repeat biopsy and additional diagnostic studies should be used. Patient factors such as age, medical comorbidities, and disease severity play a role in therapeutic selection.

Skin cancer risk and tanning in pageant contestants.

Since tanned skin may be perceived as a marker of beauty in American pageant culture, we evaluated pageant contestants regarding motivations for tanning, skin care behaviors, and possible tanning addiction. Responses were analyzed via summary statistics and compared across Fitzpatrick skin types. Statistically significant differences were found between skin types regarding tanning frequency, feelings of attractiveness after tanning, and perceptions of elevated mood after tanning. Contestants also demonstrated limited skin care behaviors; nearly 70% of respondents examined their skin for moles less than monthly. Of all respondents, 34% met tanning-modified Cut-Annoyed-Guilty-Eye-opener (CAGE) criteria, suggesting possible tanning addiction. This study raises several considerations regarding the possible addictive nature of tanning and the importance of skin safety in the pageant population.

Dermatology Resident Training on Depression Screening: A Cross-Sectional Survey.

Background Many dermatologic diseases are implicated in the development of depression. Currently, there is no literature addressing the extent of dermatology residency training on depression screening. Objective Our study aimed to determine the extent of dermatology residency training on depression screening to potentially improve education in this area. Methods We designed a 12-question survey to assess the level of resident training and comfort in depression screening for patients with acne vulgaris, atopic dermatitis, psoriasis, hidradenitis suppurativa, and skin cancer. Fifty-six residents completed the survey, and data for each question was analysed in aggregate. Results Participants found depression screening most important for patients with acne vulgaris, psoriasis, and hidradenitis suppurativa (p<0.0001, 95% CI). Ratings of confidence in screening were similar across all conditions. Most residents reported only occasional screening in the setting of these diseases. Sixty-four percent of participants stated that education on depression screening is not included as part of their curriculum or clinical practice, while 23% were uncertain. Conclusions Our results suggest a lack in relevant training during residency, warranting the inclusion of education on depression screening into the dermatology residency curriculum to facilitate better recognition of the mental health comorbidities of dermatologic diseases.

What are the ethical and legal considerations when your patient refuses the standard of care?

In medical practice, physicians are sometimes faced with patients who reject the gold-standard treatment for a condition. In this hypothetical clinical scenario, we present the case of a patient who refuses Mohs micrographic surgery for management of infiltrative basal cell carcinoma and instead requests off-label therapy with imiquimod. We discuss the treating dermatologist's options in response to this patient's request and the ethical considerations surrounding the case. We conclude that the physician has the right to refuse to provide treatment that deviates from standard clinical practice but that the physician should counsel the patient on all options, provide thorough informed consent, offer contact information for the patient to pursue a second opinion or a radiation oncology referral, and ensure safe transfer of care should the patient desire treatment with a different provider.

Primary cutaneous Hodgkin-like polymorphic post-transplant lymphoproliferative disorder.

Post-transplant lymphoproliferative disorder (PTLD) is an uncommon complication after solid-organ transplants and hematopoietic stem cell transplants. Isolated involvement of the skin without systemic involvement in PTLD is extremely rare. Primary cutaneous PTLD is generally categorized as either cutaneous T-cell lymphoma or cutaneous B-cell lymphoma, with variable Epstein-Barr virus (EBV) positivity. Herein, we describe an exceedingly uncommon case of a primary cutaneous Hodgkin-like polymorphic PTLD. A man in his 60s, with a history of kidney transplant, presented with a 5-week history of two indurated plaques. Clinical, histologic and immunohistochemical findings were consistent with primary cutaneous Hodgkin-like polymorphic PTLD. Reduction in immunosuppression led to resolution of his lesions. This case highlights a rare case of primary cutaneous Hodgkin-like PTLD and increases awareness of this uncommon post-transplant complication. It also underscores the importance of collaboration between dermatology, hematology, dermatopathology and hematopathology in order to diagnose challenging cases.

Failed Treatment of Classic Kaposi's Sarcoma with Topical Timolol: Case Report and Review of the Literature.

Classic Kaposi's sarcoma (CKS) is an angioproliferative cutaneous neoplasm which currently lacks a well-defined treatment regimen. Because the disease is often localized, topical therapies offer therapeutic potential without the morbidity of systemic or surgical treatment. Timolol, a topical ß-adrenergic receptor antagonist, has shown promise in the treatment of CKS in individual cases. Here we report a patient with classic Kaposi's sarcoma who failed treatment with 0.5% topical timolol three times daily for 12 weeks. Topical timolol use has been previously reported in eight patients with CKS who all responded to treatment with no adverse effects. Our divergent experience from the literature implies that while topical timolol may be an effective and safe treatment alternative to traditional therapies for patients with CKS, further prospective studies are needed.

Atypical disseminated herpes zoster: management guidelines in immunocompromised patients.

Reactivation of the varicella-zoster virus (VZV) causes dermatomal herpes zoster (HZ) and more rarely severe disseminated HZ including diffuse rash, encephalitis, hepatitis, and pneumonitis. An atypical form of VZV infection, disseminated HZ has been described primarily in immunocompromised hosts. We report 2 cases of atypical disseminated HZ in immunocompromised patients presenting with diffuse, nondermatomal, vesicular eruptions. We also provide a review of the literature and summarize the current guidelines for the treatment and prophylaxis of HZ in patients with human immunodeficiency virus (HIV) infection, solid organ transplantation (SOT), and hematopoietic stem cell transplantation (HSCT). Given the atypical presentation of VZV infection among some immunocompromised patients, this case series emphasizes the need for clinical suspicion for disseminated HZ to facilitate timely diagnosis and initiation of antiviral therapy. Clinician awareness of methods for prevention and treatment of VZV infection in immunocompromised individuals also is critical to minimize the risk for disease and associated morbidity in these patients.

Characteristics, treatment, and survival of invasive malignant melanoma (MM) in giant pigmented nevi (GPN) in adults: 976 cases from the National Cancer Data Base (NCDB).

BACKGROUND: Malignant melanoma (MM) arising in a giant pigmented nevus (GPN) is a rare disease in adults with no large series published to our knowledge. OBJECTIVE: We sought to describe the characteristics, treatment, and survival of MM in GPN for adults. METHODS: Adults with invasive MM in GPN (n = 976) reported to the National Cancer Data Base from 1998 to 2012 were evaluated for patient and tumor characteristics, treatment, and survival. For comparison, data from adults with invasive superficial spreading melanoma (SSM) (n = 111,870) and nodular melanoma (n = 35,962) were used. RESULTS: Compared with patients with SSM, patients with MM in GPN had a thicker Breslow depth, more positive lymph nodes, and distant metastasis more frequently. Multivariate analysis identified age older than 65 years, Breslow thickness greater than 2 mm, presence of ulceration, presence of distant metastasis, and positive margins as independent predictors of survival in patients with MM in GPN. At all stages, having MM in GPN has similar overall survival compared with SSM. LIMITATIONS: The study is retrospective and registry-based. CONCLUSIONS: Invasive MM in GPN occurs in adults, with overall survival similar to SSM. Clinicians should be aware of the continued risk of MM in adults with GPN with low threshold for biopsy.

UVB-protective properties of contact lenses with intended use in photoresponsive eyelid dermatoses.

BACKGROUND: UV-blocking contact lenses were evaluated to determine if they could provide adequate ocular protection during narrowband UVB phototherapy treatment. Theoretical safe exposure durations for the crystalline lens, cornea and conjunctiva were determined. METHODS: A Cary 500 spectrophometer generated transmittance data for six UV-blocking and two non-UV-blocking contact lenses. An IL-1700 radiometer measured the lenses' radiation transmittance within the NB-UVB phototherapy unit. The lenses were exposed to a 1500-mJ/cm(2) dose of radiation from a 308-nm excimer laser to determine if the radiation would alter their protective properties. Theoretical safe exposure durations for eye structures were calculated using previous human and animal study data. RESULTS: All UV-blocking contact lenses showed less than 1E-7 W/cm(2) of radiation transmittance within the narrowband phototherapy unit. The excimer laser did not significantly alter the lenses' UV-blocking capabilities. The safe exposure durations for the cornea and crystalline lens were greater than 11 min with UV-blocking lenses, and that for the unprotected conjunctiva was approximately 11 s. CONCLUSION: Some UV-blocking contact lenses potentially provide sufficient ocular protection during narrowband UVB phototherapy treatment, as the crystalline lens and cornea are adequately protected should a patient open his or her eyes for a short time.

Factors influencing survival in patients undergoing palliative bypass for pancreatic adenocarcinoma.

PURPOSE: The purpose of this study is to identify factors predictive of early mortality following palliative bypass in patients with previously unsuspected advanced pancreatic adenocarcinoma to provide a basis for the selection of appropriate therapies. METHODS: All patients with pancreatic adenocarcinoma who underwent a bypass procedure at our institution between 9/30/1994 and 1/31/2006 were reviewed. Patients with peri-operative mortality were excluded from the analysis. Univariate analysis was performed on peri-operative data to identify factors associated with early mortality (death within 6 months of surgery). Patients having multiple risk factors were assigned an overall prognostic score based on the sum of these factors. RESULTS: Of the 397 patients with pancreatic adenocarcinoma analyzed, four factors were found to predict early mortality following palliative bypass: Presence of distant metastatic disease (HR 2.59, P < 0.0001), poor tumor differentiation (HR 1.71, P = 0.009), severe pre-operative nausea and vomiting (HR 1.48, P = 0.013), and lack of previous placement of a biliary stent (HR 1.36, P = 0.048). Patients with a prognostic score of 0 were significantly more likely to survive past 6 months than patients with a prognostic score of 1 (HR 2.71, P < 0.0001), 2 (HR 3.70, P < 0.0001), or ≥3 (HR 5.63, P < 0.0001). CONCLUSIONS: In a cohort of patients undergoing a palliative bypass procedure, specific peri-operative factors can be used to identify patients who are at risk of early mortality. These factors may be helpful in selecting appropriate interventions for this group of patients.