The Canadian Dermatology Association's Top Five Choosing Wisely Canada Recommendations.

INTRODUCTION: In this article, we present the Canadian Dermatology Association's (CDA) Choosing Wisely Canada (CWC) list of top "Five Things Physicians and Patients Should Question in Dermatology" and the evidence in support of each recommendation. METHODS: Using a nominal technique, the CDA Working Group and Task Force generated an initial list based on literature review and expert consultation. After several rounds of list refinement via a modified Delphi process, a final list of recommendations was generated. These were approved by the CDA Board of Directors, presented at the CDA 93rd Annual Conference in 2018, and published by CWC in 2019. RESULTS: The top five recommendations are as follows: (1) Don't routinely prescribe antibiotics for bilateral lower leg redness and swelling; (2) Don't routinely prescribe topical combination corticosteroid/antifungal products; (3) Don't routinely use topical antibiotics on a surgical wound; (4) Don't prescribe systemic antifungals without mycological confirmation of dermatophyte infection; and (5) Don't use oral antibiotics for acne vulgaris for more than 3 months without assessing efficacy. DISCUSSION: This list of recommendations aims to encourage both physicians and patients to reevaluate ineffective, yet common, practices in treating dermatologic conditions. These recommendations represent actionable changes in practice, and therefore have considerable potential to enhance value-based care in dermatology. CONCLUSIONS: This list was developed to identify tangible changes in practice within dermatology that may reduce inefficiencies, prevent potential patient harm, and improve care. Future advocacy work may include updates, feedback obtainment, and patient care handouts, to continue to promote value-based healthcare and best practices.

Lichen planus pigmentosus inversus in children: Case report and updated review of the literature.

Lichen planus pigmentosus inversus (LPPI) is a rare variant of lichen planus characterized by slate grey to dark black-brown macules, papules, or patches occurring in the skin folds. We present a case of LPPI in an 11-year-old girl, the second-youngest case and only the third pediatric case. This article also reviews the differential diagnosis and treatment of LPPI.

Resident intimal dendritic cells accumulate lipid and contribute to the initiation of atherosclerosis.

RATIONALE: Atherosclerosis is an inflammatory disease in which leukocytes and oxidatively modified lipids accumulate in the arterial intima. Previously, we showed that dendritic cells (DCs) accumulate preferentially in regions predisposed to atherosclerosis in the normal murine aortic intima. The function of these cells in atherogenesis is unknown. OBJECTIVE: Our goal was to determine the role of resident intimal DCs in the initiation of atherosclerosis. METHODS AND RESULTS: En face immunostaining of nascent atherosclerotic lesions in low-density lipoprotein receptor-deficient (Ldlr(-/-)) mice fed a cholesterol-rich diet for 5 or 10 days demonstrated that foam cells expressed DC markers CD11c, 33D1, and major histocompatibility complex class II. Transmission electron microscopy revealed that the majority of intimal lipid was intracellular. The role of resident intimal DCs in lesion formation was verified by their conditional depletion using transgenic mice expressing the simian diphtheria toxin receptor in CD11c(+) cells. A single injection of diphtheria toxin depleted intimal CD11c(+) DCs by >98% within 24 hours, with 25% and 75% recovery at 1 and 3 weeks, respectively. When bred onto the Ldlr(-/-) background, intimal DC depletion with diphtheria toxin during 5 days of lesion formation reduced the intimal lipid area by 55% relative to undepleted controls. Transmission electron microscopy revealed few foam cells in DC-depleted mice and abundant accumulation of subendothelial extracellular lipid. CONCLUSIONS: Induction of hypercholesterolemia in mice triggers rapid ingestion of lipid by resident intimal DCs, which initiate nascent foam cell lesion formation.

The dark side of skin lightening: An international collaboration and review of a public health issue affecting dermatology.

Skin lightening (SL) for cosmetic reasons is associated with profound negative impacts on well-being and adverse effects on the skin, resulting in immense challenges for dermatologists. Despite current regulations, lightening agents continue to dominate the cosmetic industry. In this review, our international team of dermatologists tackles the topic of SL as a global public health issue, one of great concern for both women's health and racial implications. We have examined SL in Africa, Asia, the Middle East, and the Americas. We aim to inspire a global discourse on how modern dermatologists can utilize scientific evidence and cultural competency to serve and protect patients of diverse skin types and backgrounds. In doing so, we hope to promote healthy skin and inclusive concepts of beauty in our patients and society.

Koebner phenomenon in leukocytoclastic vasculitis: A case report and an updated review of the literature.

Leukocytoclastic vasculitis is the most common form of cutaneous vasculitis. It is a neutrophilic small vessel vasculitis resulting from the deposition of circulating immune complexes. Henoch-Schonlein purpura is a systemic type of leukocytoclastic vasculitis, characterized by immunoglobulin A-mediated blood vessel injury. We present a case of Henoch-Schonlein purpura in an adult female manifesting with a vasculitic rash with Koebner phenomenon.

Health care utilization characteristics in patch test patients.

BACKGROUND: The length of time between onset of symptoms and definitive diagnosis is associated with outcomes in contact dermatitis (CD). Understanding the health care experience of patients with CD could identify areas for improvement. OBJECTIVE: The objective of the study was to describe the health care experience of individuals being patch tested and the barriers and facilitators to their seeking care. METHODS: One hundred forty-nine patients completed a survey containing information on types of health care providers seen, length of wait times, and barriers and facilitators to seeking care. RESULTS: Sixty-six percent were first assessed by their family physicians. Forty-five percent waited more than 3 months before seeing a health care provider. Common reasons for delay included thinking their symptoms (1) would get better, (2) were not serious enough, or (3) were not limiting their ability to work or carry out other activities. Most patients waited less than 3 months for dermatological assessment and for patch test consultation after referral. CONCLUSIONS: Patients with possible CD spend considerable time in the health care system before they undergo definitive assessment. Understanding the reasons for not seeking care may be useful for promoting earlier evaluation and intervention to result in better outcomes.