Sjogren's Syndrome Presenting with Solely Cutaneous Features.

Sjogren's syndrome is classically characterized by symptoms of keratoconjunctivitis sicca and xerostomia, secondary to lymphocytic infiltration of the salivary and lacrimal glands. Cutaneous findings of this disease are infrequently discussed and thus rarely considered among patients without the typical symptomatology. However, these patients can develop xerosis, alopecia, vitiligo, papular or nodular lesions, or cutaneous vasculitis. A 56-year-old Asian female presented with intermittent cutaneous erythematous lesions of her bilateral pinna and preauricular areas. Despite initial symptom presentation causing concern for tumid lupus versus cutaneous T cell lymphoma versus relapsing polychondritis, extensive serologic and histopathologic workup eventually indicated a likely diagnosis of Sjogren's syndrome. This case brings to light that Sjogren's syndrome is truly a multi-systemic disease and can present with primarily extra glandular cutaneous symptoms. When approaching the workup of a new patient, it is absolutely vital to maintain a broad differential and keep in mind that overlap syndromes among multiple autoimmune diseases do exist as well.

Increasing a Dermatologist's Footprint on Instagram: An Analysis of Top Influencers Performing Nonsurgical Cosmetic Procedures.

BACKGROUND: Patients use social media to find information about cosmetic procedures, yet dermatologists historically lack a social media presence. Misleading information from nonexperts is potentially harmful. OBJECTIVE: To identify the top influencers posting about nonsurgical cosmetic procedures on Instagram, verify their credentials, and analyze their content to empower dermatologists to effectively join the online conversation, combat harmful misinformation, and preserve the expertise and influence of board-certified dermatologists. METHODS AND MATERIALS: Using the Klear marketing platform, Instagram influencers with more than 50,000 followers were identified. Influence rating, top posts, and other metrics were extracted using proprietary algorithms. RESULTS: Ninety nine influencers were identified. Of the top 10, 70% were board-certified plastic surgeons. Physicians not board-certified in a core cosmetic specialty had the highest influencer rating and number of followers. The most popular posts were of before and after photographs and personal posts. CONCLUSION: Dermatologists may be able to increase their Instagram footprint by posting frequently, especially of before and after and personal photographs, using hashtags, Instagram live and Instagram television, and Instagram stories. It is important for the dermatology community to find a way to ethically navigate social media to have a seat at the table and meet patients where they are.

THINKING LEAN: Improving Vitreoretinal Clinic Efficiency by Decentralizing Optical Coherence Tomography.

PURPOSE: Patients in vitreoretinal clinic have long wait times that could be reduced by improving the efficiency of patient flow. The objective of this study was to determine whether decentralizing optical coherence tomography (OCT) into the technicians' room would reduce patient wait times and improve clinic efficiency. METHODS: Randomized, single-center, clinical trial for 1 month without follow-up at Byers Eye Institute at Stanford. Subjects were return patients of three vitreoretinal specialists in March 2013. The intervention consisted of decentralizing OCT devices from the central photography suite into the technician screening rooms. Total clinic times and total wait times throughout subject appointments were recorded and compared with the control group (centralized photography suite). Secondary outcomes included frequency of injections, procedures, and primary diagnosis codes. RESULTS: Decentralized OCT reduced patient wait times by 74% and reduced total clinic appointment time by 36%. Subjects in the intervention arm experienced significantly reduced total wait time (mean difference = 15.9 minutes, P < 0.0001) and total time in clinic (mean difference = 22.9 minutes, P < 0.0001). CONCLUSION: Decentralized OCT represents the application of lean process concepts to improve vitreoretinal clinic efficiency. Decentralized OCT reduced both the total wait time and total time in clinic for return patients in a vitreoretinal clinic.

Acral verruca-like presentation of chronic graft-vs.-host disease.

BACKGROUND: Chronic graft-vs.-host disease (GVHD) is a severe and potentially fatal complication in patients after undergoing allogeneic stem cell transplant. This disease may be hard to diagnose as it has numerous cutaneous presentations. METHODS: We report four cases of patients seen at Stanford Hospital between January 2013 to December 2014 with hematologic malignancy who developed hyperkeratotic papules and plaques on the palms and soles after allogeneic hematopoietic stem cell transplant. RESULTS: In all four cases, standard treatments for verruca vulgaris failed. Histopathology uniformly showed basal vacuolar alteration at the dermal-epidermal junction and necrotic keratinocytes around the eccrine glands, consistent with GVHD. Interestingly, all four patients responded to topical immunosuppression. CONCLUSIONS: Acral verrucous lesions represent an underrecognized presentation of chronic GVHD. We describe four patients with verruca-like lesions on the palms and soles following allogeneic HSCT. Histopathology confirmed GVHD, and lesions improved with immunosuppression. It is important for dermatologists and dermatopathologists to recognize this rare presentation of cutaneous GVHD.

Multiple pilomatricomas in the setting of myotonic dystrophy.

The association between multiple pilomatricomasand the autosomal dominant neurodegenerativedisorder myotonic dystrophy has been described inthe literature. Although the mechanism is unknown,it is hypothesized that the dystrophia myotonicaprotein kinase mutation in myotonic dystrophyaffects intracellular calcium levels, which alterproliferation and terminal differentiation that leads tocells that are observed in pilomatricomas. We presenta patient with multiple, symptomatic pilomatricomasand myotonic dystrophy, with a strong family historyof both of these rare disorders.