Inpatient dermatology consultations during COVID 19 pandemic in a tertiary referral center.

Since the COVID-19 infection first appeared in December 2019, patient profile of outpatient and inpatient clinics has changed. Various cutaneous findings associated with COVID-19 have been reported in the literature. The main objective of this study was to describe and analyze the profile of the consultations requested from dermatology department during the COVID pandemic. Retrospective, cohort study. In this study, we observed the dermatology consultations of the hospitalized patients over a period of 2 months, corresponding to the peak of COVID outbreak in a tertiary care hospital in Turkey. We reviewed the inpatient dermatology consult database retrospectively. Both pediatric and adult dermatology inpatient consultations were evaluated. A total of 166 inpatient dermatology consultations were requested from dermatology department during March-May, 2020. The mean age of the patients was 53.12 (1-89) years. Almost 32.5% (n = 54) of dermatology consultations were requested from the COVID wards and the COVID intensive care unit. The second most common consultations were requested from internal medicine departments (n = 46, 27.7%). The most common indications for the consultations were cutaneous infections (36%), followed by inflammatory disorders (32%), and urticaria (11%). Dermatology consultations have an essential role on the management of hospitalized patients, especially at that pandemic time. Careful dermatological examination improves diagnostic accuracy in skin disorders and skin manifestations of COVID-19 infection that provides an early diagnosis and treatment, helps to improve the quality of the patient care and management.

Histopathological Study of a Broad Spectrum of Skin Dermatoses in Patients Affected or Highly Suspected of Infection by COVID-19 in the Northern Part of Italy: Analysis of the Many Faces of the Viral-Induced Skin Diseases in Previous and New Reported Cases.

Skin manifestations of COVID-19 infections are diverse and are new to the dermatology community. We had the opportunity to examine the clinical and histopathological features of several patients who were divided into 3 groups. The first group included 8 COVID-19-positive patients who were hospitalized and quarantined at home. The second group included children and young adults who presented with chilblain erythema, erythema multiforme, and urticaria-like lesions. This group of patients was negative for the COVID-19 gene sequences by polymerase chain reaction but had a high risk of COVID-19 infection. The third group included clinically heterogeneous and challenging lesions. These patients were not subject to either polymerase chain reaction tests or serological analyses because they sought dermatological attention only for a dermatosis. The histopathological analysis of these cases showed a wide spectrum of histopathological patterns. What appears to be constant in all skin biopsies was the presence of prominent dilated blood vessels with a swollen endothelial layer, vessels engulfed with red blood cells, and perivascular infiltrates, consisting mainly of cytotoxic CD8+ lymphocytes and eosinophils. In 2 cases, there was diffuse coagulopathy in the cutaneous vascular plexus. In the early phases of the disease, there were numerous collections of Langerhans cells in the epidermis after being activated by the virus. The presence of urticarial lesions, chilblains, targetoid lesions (erythema multiforme-like lesions), exanthema, maculohemorrhagic rash, or chickenpox-like lesions associated with the histopathological features mentioned previously should cause clinical dermatologists to suspect the possibility of COVID-19 infection, especially in patients with fever and cough.

Polyomaviruses of the skin: integrating molecular and clinical advances in an emerging class of viruses.

BACKGROUND: Human polyomaviruses (HPyVs) are small, nonenveloped, double-stranded DNA viruses that express tumour antigen proteins. Fourteen species of polyomaviruses have been discovered in humans, and since the 2008 discovery of the first cutaneous polyomavirus - Merkel cell polyomavirus (MCPyV) - six more species have been detected in the skin: trichodysplasia spinulosa-associated polyomavirus (TSPyV), HPyV6, HPyV7, HPyV9, HPyV10 and HPyV13. Of these cutaneous species, only MCPyV, TSPyV, HPyV6 and HPyV7 have been definitively associated with diseases of the skin, most commonly in immunocompromised individuals. MCPyV is a predominant aetiology in Merkel cell carcinomas. TSPyV is one of the aetiological factors of trichodysplasia spinulosa. HPyV6 and HPyV7 have been recently linked to pruritic skin eruptions. The roles of HPyV9, HPyV10 and HPyV13 in pathogenesis, if any, are still unknown, but their molecular features have provided some insight into their functional biology. RESULTS: In this review, we summarize the known molecular mechanisms, clinical presentation and targeted therapies of each of the eight cutaneous HPyVs. CONCLUSIONS: We hope that heightened awareness and clinical recognition of HPyVs will lead to increased reports of HPyV-associated diseases and, consequently, a more robust understanding of how to diagnose and treat these conditions.

Extragenital cutaneous warts - clinical presentation, diagnosis and treatment.

Extragenital cutaneous warts are benign epidermal tumors caused by human papillomaviruses (HPVs) and a frequent reason for patients to consult a dermatologist. Depending on wart type and site involved, the clinical presentation is highly varied. Given that warts represent a self-limiting condition, a wait-and-see approach may be justified. However, treatment is always indicated if the lesions become painful or give rise to psychological discomfort. Factors to be considered in this context include subjective disease burden, patient age, site affected, as well as the number and duration of lesions. Destructive treatment methods involve chemical or physical removal of diseased tissue. Nondestructive methods consist of antimitotic and antiviral agents aimed at inhibiting viral proliferation in keratinocytes. Some of the various immunotherapies available not only have localized but also systemic effects and are thus able to induce remission of warts located at any distance from the injection site. Especially patients with warts at multiple sites benefit from this form of treatment. Intralesional immunotherapy using the mumps-measles-rubella (MMR) vaccine is a particularly promising option for the treatment of recalcitrant warts in adult patients. For children, on the other hand, HPV vaccination is a novel and promising approach, even though it has not been approved for the treatment of cutaneous warts. At present, there is no universally effective treatment available. Moreover, many frequently employed therapies are currently not supported by conclusive clinical trials.

Morphological characteristics and human papillomavirus genotype predict the treatment response in cutaneous warts.

BACKGROUND: Cutaneous warts have a cure rate after therapy of no more than approximately 50%. Recently, we developed and validated a standard assessment tool for warts (Cutaneous WARTS diagnostic tool, CWARTS) based on phenotypical characteristics. OBJECTIVES: To assess whether patient and morphological wart characteristics predict the human papillomavirus (HPV) type in a specific wart and whether these characteristics as well as the HPV type predict a favourable treatment response. METHODS: Photographs were used to score nine morphological wart characteristics using the newly developed CWARTS tool. Genotyping of 23 wart-associated HPV types was performed using the hyperkeratotic skin lesion-polymerase chain reaction/multiplex genotyping assay. The results were correlated with a favourable response to treatment with monochloroacetic acid, cryotherapy or a combination of cryotherapy and salicylic acid. Odds ratios were calculated using logistic regression in a generalized estimating equations model. RESULTS: Black dots (capillary thrombosis) strongly predicted the presence of any HPV type in a wart. From all characteristics tested, the HPV type most strongly predicted the treatment response when the warts were treated with monochloroacetic acid or a combination of cryotherapy and salicylic acid with a significantly decreased treatment response if the warts contained HPVs of the alpha genus (HPV2, HPV27 or HPV57). When cryotherapy alone was used for common warts, HPV type did not play a role, but cryotherapy was less effective in the presence of callus and when the wart was located deeper in the skin. CONCLUSIONS: Morphological characteristics of the warts and the HPV genotype influence treatment outcome and thus potentially influence future treatment decisions for common and plantar warts.

[The alpha-herpesviridae in dermatology : Varicella zoster virus. German version]. / Alpha-Herpesviridae in der Dermatologie : Varicella-Zoster-Virus.

The second part of this publication deals with varicella zoster virus (VZV) and presents an overview of new, rare, and atypical clinical manifestations, including photolocalized varicella, hemorrhagic bullae during varicella, the implication of VZV in immunoglobulin A vasculitis, VZV-related alopecia, ulcerative varicella skin lesions, childhood herpes zoster (HZ), prolonged prodromal pains, recurrent HZ, VZV implication in burning mouth syndrome, verruciform VZV lesions, the significance of satellite lesions during HZ, and late HZ complications, either neurological or internal. Furthermore, certain associations between the occurrence of HZ and subsequent internal pathologies, as well as risk factors for HZ and new developments in vaccination against HZ will be addressed.

Carbon dioxide laser treatment of extensive pigmented viral plaque lesions in a golden retriever dog.

BACKGROUND: Canine pigmented viral plaque (PVP) is an uncommon skin disease, associated with papillomavirus infection. Lesions are usually small (<1 cm diameter), pigmented macules to plaques on the ventral abdomen and medial thigh. ANIMALS: An 8-year-old male, neutered golden retriever dog presented with numerous dark plaques forming cohesive plaques on the ventrum extending down the medial aspect of both hind legs. The plaques were associated with significant pruritus. RESULTS: Histology confirmed a diagnosis of PVP and PCR amplified Canis familiaris papillomavirus 4 from a formalin fixed plaque sample. The PVPs were completely resolved by two courses of CO2 laser treatment. There was very minimal postoperative discomfort and no relapse or new lesion development within a 12 months follow-up period. CONCLUSIONS AND CLINICAL IMPORTANCE: Extensive PVPs have not previously been described in a golden retriever dog or previously reported to cause pruritus in dogs. Due to the large skin area involved, surgical excision was not feasible in this case. However, two rounds of treatment using laser were completely curative for both focal pedunculated and plaque-like PVP lesions. Additionally, compared to surgical excision, laser treatment is expected to result in less postoperative discomfort, reduced surgery time and fewer postoperative infections. This is the first report of successful treatment of canine PVPs using a CO2 laser. The success of this treatment in this case suggests that laser provides an excellent treatment option for extensive PVPs in dogs.

Cutaneous viral infections in organ transplant patients.

Cutaneous infections might occur in up to 80% of organ transplant recipients (OTR) and viral infections are the most common them. The risk of different skin infection is among related to the intensity of immunosuppression. During the first post-transplant period, herpes viruses are most common. After some months following transplantation, human papilloma viruses represent the most significant infections among OTR. Reactivation of herpes simplex virus in OTR can become more invasive, takes longer to heal, and shows greater potential for dissemination to visceral organs compared to the general population. Specific immunosuppressive drugs (namely muromonab and mycophenolate mofetil) have been associated with an increased risk of herpes virus reactivation after transplantation. On the other hand, there is evidence that the mTOR inhibitors, such as everolimus, may be associated with a decreased incidence of herpesvirus infections in transplant recipients. The incidence of herpes zoster in OTR is 10 to 100 fold higher than the general population, ranging from 1% to 12%. The chronic immunosuppression performed in OTR may lead to persistent replication of herpesviruses, dissemination of the virus with multivisceral involvement (hepatitis, pneumonitis, myocarditis, encephalitis and disseminated intravascular coagulation) and eventually, the emergence of antiviral-drug resistance. Viral warts are the most common cutaneous infection occurring in OTR. The number of warts increases with the duration of immunosuppressive therapy. Since warts in organ recipients are frequently multiple and only rarely undergo spontaneous regression, the therapeutic management of warts in patients treated with immunosuppressive drugs might be challenging. Imiquimod, 1% cidofovir ointment, acitretin proved to be useful off-label strategies for recalcitrant cutaneous viral warts in OTR. Extensive and atypical presentation of molluscum contagiosum has been also reported in OTR, with a prevalence between 3% to 6.9%. Giant molluscum contagiosum is a clinical variant in which large nodule greater than 0.5-1 cm in diameter are observed.

Viral infections of the skin: clinical features and treatment options.

Viral infections of the skin can cause significant distress and embarrassment for people who are affected. This article explores four specific viral infections that manifest on the skin: herpes simplex, herpes zoster, viral warts and molluscum contagiosum. It describes the presentation and appearance of the virus as it affects the skin and what can be done to minimise the spread of the virus. Management options are considered, although many of these conditions are self-limiting.

Common skin infections in children.

There are many common skin infections that may affect children at any time. Certain conditions may be recurrent, while others tend to result in the child developing immunity and do not recur. Skin infections may be bacterial, fungal or viral in origin, and the article outlines some of the most common of these and the management options available.

Cutaneous lumbosacral Herpes simplex virus among patients hospitalized for an advanced disease.

BACKGROUND: Cutaneous Herpes simplex virus (HSV) infections are regularly observed in lumbosacral areas, and many are refractory to appropriate initial diagnosis and management. OBJECTIVE: We aimed to evaluate the incidence of lumbosacral HSV among advanced disease patients, to estimate their survival index from HSV onset, and to describe their clinical and virological characteristics. METHODS: A prospective, descriptive study was conducted in a palliative and continuous care centre, collecting patients with suspected cutaneous HSV lesions in the lumbosacral area. RESULTS: From 2008 to 2010, 24 patients were included: 19 had HSV-2 confirmed by at least one laboratory test. Incidence of HSV-2 was 2.67% (1.73-4.33%, 95% CI). No age, gender or survival differences were observed compared to the global population in the centre. Most lesions were detected early as vesicles (14/24) or small ulcers. Sensitivity was good for all diagnostic methods (62.5% for immunofluorescence and 79.2% for culture and/or PCR). Outcome was favourable under classical antiherpetic drugs and topical antiseptic dressing. CONCLUSIONS: Cutaneous lumbosacral HSV remains uncommon in patients hospitalized with advanced diseases. Most of these patients suffer from pressure ulcers or other dermatitis; we advocate increased attention of this diagnosis to avoid skin complications and added pain.

Phototherapy in the treatment of cutaneous herpesvirus manifestations.

There is a considerable need for effective and safe treatment of cutaneous herpesvirus lesions. Current common approaches are limited to expensive or multidose oral pills. This systematic review of evidence-based approaches to phototherapy for the various manifestations of the herpesvirus discusses original publications of controlled clinical trials and case reports that were identified through searches in PubMed, MEDLINE, and Ovid. Interventions included photodynamic therapy (PDT), UV light, and near-infrared lasers. Nearly all studies (10 of 11) saw reduction of most or all lesions and extended time before reactivation of the virus. Side effects often were minimal to nonexistent, usually mild erythema at sites of phototreatment. Serious side effects included first-degree burns and linear IgA dermatosis, which were not common. Evidence from the reviewed literature indicates that short-term efficacy from treatment with phototherapy is the most likely outcome. However, long-term effects and follow-up of this treatment modality are lacking but appear promising. We recommend future studies to include more patients, determine the most effective type of phototherapy, and assess long-term follow-up. Furthermore, light-based therapies can be considered a reasonable alternative in situations that preclude traditional drug-based therapies.

The impact of the COVID-19 pandemic on dermatologic practice: an Italian survey.

BACKGROUND: Since December 2019, the global population has been experiencing an unprecedented challenge due to Corona virus disease (COVID-19). A pandemic was declared by the World Health Organization on March 11th 2020, with an escalation of new cases worldwide. Dermatology units experienced a reorganization of regular activity, also providing clinical diagnosis and medical assistance to COVID-19-positive patients who developed cutaneous manifestations. OBJECTIVE: To evaluate the impact of the COVID-19 pandemic on Italian dermatologic clinical practice. MATERIALS & METHODS: This was a prospective online survey, consisting of a questionnaire with 35 multiple-choice questions uploaded on the website of the Italian Society of Dermatology and Venereology - SIDeMaST. RESULTS: A total of 136 dermatologists, 78 women (57%) and 58 men (43%), participated in the survey. The mean age was 58 ± 14 years. In total, 60% of participants reported an impact of the pandemic on their practice, in most cases consisting of a remarkable reduction in routine clinical activity (58%). Concern regarding possible infection was evaluated with a score ranging from 0 (no concern) to 5 (extremely concerned): the fear of becoming infected was high (≥3 in 40%), as was the fear of infecting families, colleagues or patients (≥3 points in 45%). CONCLUSION: The COVID-19 pandemic is having a strong impact on dermatology practice in Italy. The identification of critical points may help scientific societies to improve the clinical scenario and create specific strategies to overcome the emergency.

A case of COVID-19 with papulovesicular rash that progressed to retiform purpura, accompanied by cherry angiomas.

CONTEXT: Various skin manifestations have been reported in coronavirus disease. It may be difficult to determine the etiology of these lesions in view of the increased frequency of handwashing during the pandemic, along with occurrences of irritant contact dermatitis and allergic contact dermatitis due to disinfectant use; usage of herbal medicine and supplements to strengthen the immune system; and urticarial or maculopapular drug eruptions due to COVID-19 treatment. The variety of associated skin manifestations seen with COVID-19 makes it challenging to identify virus-specific skin manifestations. Petechiae, purpura, acrocyanosis and necrotic and non-necrotic purpura, which can be considered as manifestations of vascular involvement on the skin, have been reported. CASE REPORT: Here, we report a case of eruptive cherry angiomas, which was thought to have developed due to COVID-19, with a papulovesicular rash on distal extremities that progressed over time to reticular purpura. CONCLUSION: The case presented had a papulovesicular rash at the onset, which evolved to retiform purpura, and eruptive cherry angiomas were observed. It should be kept in mind that dermatological signs may vary in patients with COVID-19.

Viral Venereal Diseases of the Skin.

Viral venereal diseases remain difficult to treat. Human papilloma virus (HPV) and herpes simplex virus (HSV) are two common viral venereal diseases. HPV infections are characterized by anogenital warts and less commonly by premalignant or malignant lesions. HSV infections classically present as grouped vesicles on an erythematous base with associated burning or pain; however, immunosuppressed patients may have atypical presentations with nodular or ulcerative lesions. This review discusses the epidemiology, diagnosis, and management of anogenital HPV and HSV infections with an emphasis on treatment modalities for the practicing dermatologist. Diagnosis of these diseases typically relies on clinical assessment, although multiple diagnostic techniques can be utilized and are recommended when diagnosis is uncertain or evaluating an individual with increased risk of malignancy. Management of HPV and HSV infections involves appropriate counseling, screening, and multiple treatment techniques. Particularly for HPV infections, a practitioner may need to use a combination of techniques to achieve the desired outcome.

Thermotherapy in dermatologic infections.

The use of local induced hyperthermia or thermotherapy for dermatologic infections has not been fully explored in the more recent medical literature. Herein, we discuss the rationale behind the use of thermotherapy and review reported clinical experience with its use in the management of cutaneous infections.

Cutaneous warts in children before and after renal transplantation.

Cutaneous warts occur in 3.9-4.9% of children in the UK. The incidence is increased in organ transplant recipients and may be increased in patients with chronic kidney disease (CKD), since uraemia reduces the immune system's function. We surveyed the records from our CKD and renal transplant clinic to ensure patients with warts were identified and appropriately treated. Data were collected by questionnaire. The presence of warts, location, treatment, levels of pain and emotional upset were recorded. Nine of 49 (18.4%) pre-transplantation patients (33 male, median age 12.1 years) were currently suffering from warts compared with 17 of 60 (28.3%) post-transplantation patients (34 male, median age 13.9 years). A further 14 pre-transplantation and 16 post-transplantation patients had previously suffered from warts which had resolved. Forty-one patients had sought treatment for warts, mainly from primary care. Five patients, all having received transplants, were seen by a dermatologist. Self-rated levels of pain and emotional upset were generally low, apart from those of four adolescent patients who expressed significant emotional upset. We concluded that cutaneous warts are more common among CKD patients. Appropriate information and treatment are required before and after transplantation. The majority of warts can be treated in primary care, but selected patients with extensive warts that cause distress need early referral for dermatology opinion.