Inter- and intra-observer variability in the selection of therapy for infantile hemangiomas among pediatric dermatologists in Spain.

BACKGROUND: Guidelines and expert recommendations on infantile hemangiomas (IH) are aimed at increasing homogeneity in clinical decisions based on the risk of sequelae. OBJECTIVE: The objective was to analyze the inter- and intra-observer agreement among pediatric dermatologists in the choice of treatment for IH. METHODS: We performed a cross-sectional inter-rater and intra-rater agreement study within the Spanish infantile hemangioma registry. Twenty-seven pediatric dermatologists were invited to participate in a survey with 50 clinical vignettes randomly selected within the registry. Each vignette contained a picture of an infantile hemangioma with a clinical description. Raters chose therapy among observation, topical timolol, or oral propranolol. The same survey reordered was completed 1 month later to assess intra-rater agreement. Vignettes were stratified into hemangioma risk categories following the Spanish consensus on IH. The agreement was measured using kappa statistics appropriate for the type of data (Gwet's AC1 coefficient and Gwet's paired t test). RESULTS: Twenty-four dermatologists completed the survey. Vignettes represented 7.8% of the Spanish hemangioma registry. The inter-rater agreement on the treatment decision was fair (AC1  = 0.39, 95% confidence interval [CI]: 0.30-0.47). When stratified by risk category, good agreement was reached for high-risk hemangiomas (AC1  = 0.77, 95% CI: 0.51-1.00), whereas for intermediate- and low-risk categories, the agreement was only fair (AC1 0.31, 95% CI: 0.16-0.46 and AC1  = 0.38, 95% CI: 0.27-0.48, respectively). Propranolol was the main option for high-risk hemangiomas (86.4%), timolol for intermediate-risk (36.8%), and observation for low-risk ones (55.9%). The intra-rater agreement was good. The inter-rater agreement between pediatric dermatologists on the treatment of IH is only fair. Variability was most significant with intermediate- and low-risk hemangiomas.

"Nails Only" Phenotype and Partial Dominance of p.Glu170Lys Mutation in a Family with Epidermolysis Bullosa Simplex.

Epidermolysis bullosa (EB) is a heterogeneous group of rare, chronic, inherited skin disorders characterized by marked mechanical fragility of epithelial tissues, with blistering and erosions after minor trauma. We present the first report of a nails-only phenotype in two patients with epidermolysis bullosa simplex (EBS) and a heterozygous pGlu170Lys mutation and the second reported case of EBS associated with a homozygous p.Glu170Lys mutation in the KRT5 gene. Our findings may be relevant for genetic counseling and for understanding the inheritance pattern of EBS.

Primary cutaneous adenoid cystic carcinoma: an unusual case.

Primary cutaneous adenoid cystic carcinoma (PCACC) is an uncommon adnexal skin tumor. It is usually located on the head or neck of people over 50 years of age, affecting men and women equally. The etiology is unclear; the source used to be considered the eccrine glands, but more recent hypotheses defend this carcinoma as originating in the apocrine glands or modified apocrine glands. The tumor may clinically appear as a normal skin-colored nodule with ill-defined edges and slow growth. Histologically, a proliferation of neoplastic cells appears, which could present in a tubular, cribriform, or solid pattern. Perineural invasion is characteristic for this tumor. For diagnosis of PCACC it is essential to exclude metastasis, especially in the salivary glands. Treatment involves surgical excision. We present a case of primary adenoid cystic carcinoma in a young woman located on the skin of the upper limb, which is an unusual place.

[Shiitake dermatitis in a Spanish patient]. / Letter: Dermatitis shiitake en una paciente española.

Shiitake dermatitis is a toxicodermia that occurs after ingestion of raw or half-cooked shiitake. We present a Spanish patient who was referred to the emergency room after developing a pruritic, dermatographic, eruption that affected the trunk and neck region. The eruption occurred a few days after eating shiitake mushrooms.

Subcutaneous midline suprasternal mass in a ten-month-old girl.

A ten-month-old girl presented to our clinic with a progressively enlarging congenital mass at the midline suprasternal location. Histopathologic examination revealed a benign cyst with stratified squamous keratinized epithelium with numerous eccrine glands in the sinus wall. The diagnosis was compatible with dermoid cyst. Dermoid cysts of the trunk are rare lesions, but a midline location is characteristic for these congenital masses. A dermoid cyst should be high on the list of differential diagnoses given a unilocular midline cyst in a neonate.

Subclinical atherosclerosis in psoriasis. Usefulness of femoral artery ultrasound for the diagnosis, and analysis of its relationship with insulin resistance.

BACKGROUND: Psoriasis is associated with an increased risk of cardiovascular disease (CVD) at younger ages that is not identifiable by traditional risk factors. Screening for subclinical atherosclerosis with ultrasound has only been investigated in carotid arteries. Femoral artery ultrasound has never been considered for this purpose. The link between psoriasis and accelerated atherosclerosis has not yet been established. OBJECTIVE: To study the usefulness of femoral artery ultrasound for the detection of subclinical atherosclerosis in psoriasis. We also investigated its possible relationship with changes in insulin resistance. METHODS: We conducted a cross-sectional study in 140 participants, 70 patients with moderate-to-severe psoriasis and 70 healthy controls, matched 1:1 for age, sex, and BMI. Femoral and carotid atherosclerotic plaques were evaluated by ultrasonography. Insulin resistance was assessed by the homeostasis model assessment method (HOMA-IR). RESULTS: Femoral atherosclerotic plaque prevalence was significantly higher in patients with psoriasis (44.64%) than in controls (19.07%) (p<0.005), but no significant difference was found in carotid plaque prevalence (p<0.3). Femoral plaques were significantly more prevalent than carotid plaques (21.42%) among patients with psoriasis (p<0.001). In the regression analysis, insulin resistance was the most influential determinant of atherosclerosis in psoriasis and C-reactive protein the most significant predictor of insulin resistance. CONCLUSIONS: Ultrasound screening for femoral atherosclerotic plaques improves the detection of subclinical atherosclerosis in patients with psoriasis, whereas the study of carotid arteries is not sufficiently accurate. Insulin resistance appears to play a greater role in the development of atherosclerosis in these patients in comparison to other classical CVD risk factors.