Clinical presentation and management of atypical and recalcitrant acute generalized exanthematous pustulosis.

Acute generalized exanthematous pustulosis (AGEP) is a severe cutaneous adverse reaction (SCAR) characterized by sterile nonfollicular pustules on an erythematous base that form rapidly after drug exposure. AGEP is mediated by numerous cytokines produced by drug-specific T cells that mediate neutrophilic intracorneal, subcorneal, or intraepidermal pustule development. Though genetic susceptibility is not fully understood, individuals with mutations in IL-36RN may be at increased risk of AGEP development. AGEP commonly presents with leukocytosis and fever in the acute pustular phase and follows a self-limited desquamative recovery phase upon removal of offending drug. Severe cases of AGEP may have multisystem organ involvement. Atypical presentations of AGEP include localized eruptions and cases with overlapping clinical and histopathologic features associated with Stevens-Johnson syndrome/toxic epidermal necrolysis, drug reaction with eosinophilia and systemic symptoms, and generalized pustular psoriasis. Most cases of AGEP clear rapidly with systemic corticosteroids, but severe or recalcitrant cases may require other systemic therapies, such as cyclosporine, and intravenous immunoglobulin.

Beyond Mohs surgery and excisions: A focused review of treatment options for subtypes of basal cell carcinoma.

Basal cell carcinoma (BCC) is the most common nonmelanoma skin cancer. It originates from undifferentiated cells in the basal cell layer of the epidermis or from the outer root sheath of the hair follicle. The most important factor in development of BCC is ultraviolet radiation. Surgery is considered the gold standard of treatment for BCC. However, nonsurgical options are available for individuals who are unsuitable for surgery. The purpose of this review is to summarize the efficacy and indications of alternative, nonsurgical treatments that can be used in the management of BCC. An extensive literature review was performed for the nonsurgical options for the treatment of BCC. Resources searched included PubMed and Google Scholars, limited to the years 1995 to 2020. Key words searched included BCC, destructive methods, photodynamic therapy (PDT), radiotherapy, topical medication, laser, hedgehog pathway inhibitors (HPIs). The most relevant results such as systematic reviews, randomized controlled trials, or comparative studies were selected to provide a summary for the most common nonsurgical methods used for treating BCC. Effective nonsurgical treatments for BCC include destructive methods (eg, curettage alone, cryosurgery, or electrodessication), PDT, topical medications, radiotherapy, laser, and HPIs. Nonsurgical therapeutic alternatives are safe and effective for the treatment of BCC. Factors such as tumor location, size, and histopathological subtype should be taken into consideration when selecting optimal treatment. In addition to clinical factors, cosmetic results and patient preference should be considered.

Dermatologists' Perceptions and Confidence in Cosmetic Care for Male Patients.

BACKGROUND: Despite a growing interest in nonsurgical cosmetic procedures in men, the utilization of aesthetic treatments remains comparatively low, suggesting the presence of barriers to care. OBJECTIVE: To describe barriers to cosmetic intervention for male patients from the perspective of dermatologists. MATERIALS AND METHODS: An anonymous, online survey was distributed through a listserv made available by the American Academy of Dermatology. RESULTS: Dermatologist respondents perceived a low utilization of cosmetic services in male patients (5%) and a lack of opportunity (72.3%) to provide such services. Respondents also perceived a lack of sufficient education/training (40.9%), experience (20.5%), and a lack of evidence in the field (20.5%) for dermatologists as potential barriers to cosmetic care for male patients. Presence of targeted messaging and in-office educational materials for male patients was found to be associated with increased utilization of cosmetic treatments by male patients (p = .012, p = .012, respectively). Dermatologists reported strong confidence in delivering various noninvasive cosmetic treatments to male patients. CONCLUSION: Despite dermatologists' reported confidence in performing cosmetic procedures in men, many perceive insufficient education/training and experience with this population which may create barriers to cosmetic care for male patients. Increasing educational materials and targeted messaging to male patients may decrease barriers for patients to receive desired cosmetic care.

Pediatric teledermatology: A review of the literature.

Skin complaints are common among pediatric patients, yet as of 2020, fewer than 400 board-certified pediatric dermatologists currently practice in the United States. Pediatric teledermatology may address barriers to dermatologic care in children, assisting with distant geographic locations and long wait times. A review of the literature was conducted to synthesize important features of teledermatology for pediatric dermatologists. We summarize types of telemedicine platforms, common dermatologic conditions seen by pediatric teledermatologists, diagnostic accuracy and concordance, and guidelines from the American Academy of Dermatology and the American Telemedicine Association regarding teledermatology. This report highlights the utility of pediatric telemedicine in both the outpatient and inpatient dermatology setting to increase access to high-quality dermatologic care.

Dermatologic findings in individuals with genetically confirmed Proteus syndrome.

BACKGROUND/OBJECTIVE: Proteus syndrome, caused by a mosaic activating AKT1 variant, typically presents in toddlers with progressive, asymmetric overgrowth of the skin and bones. We aimed to define the spectrum of dermatologic disease in individuals with genetically confirmed Proteus syndrome. METHODS: We conducted a retrospective review of records from dermatologic examinations of individuals evaluated at the NIH with a molecular diagnosis of Proteus syndrome. The types, prevalence, and localization of dermatologic findings were assessed. RESULTS: Fifty-one individuals (29 males, 22 females, mean age: 9 years) with clinical features of Proteus syndrome had the mosaic c.49G>A, p.Glu17Lys AKT1 variant. Fifty (98%) had at least one cutaneous feature constituting current clinical diagnostic criteria, including vascular malformations in 42 (82%), epidermal nevus in 41 (80%), volar cerebriform connective tissue nevi in 34 (67%), and adipose dysregulation in 30 (59%). Forty-nine (96%) had at least one dermatologic finding not included within the diagnostic criteria, including confluent volar skin-colored to hypopigmented papules or nodules (n = 33, 65%), papules or nodules on the digits or face (n = 27, 53%), and nonlinear epidermal nevi (n = 15, 29%). Other frequently observed features include nail changes (n = 28, 55%), hyperpigmented macules (n = 27, 53%), patchy dermal hypoplasia (n = 18, 35%), gingival/oral mucosal overgrowth (n = 17, 33%), hypopigmented macules (n = 16, 31%), dental enamel changes (n = 9, 18%), acrochordons (n = 6, 12%), and lingual overgrowth (n = 4, 8%). CONCLUSIONS: The range of mucocutaneous features occurring in Proteus syndrome is broader than previously considered. These observations may assist in earlier diagnosis and management and provide novel insights regarding the pathogenesis of the condition.

Combination therapy with 5-fluorouracil and salicylic acid in a treatment-resistant case of filiform facial warts.

Filiform warts are commonly treated with surgical removal or cryotherapy, yet such treatment modalities may result in complications for darker skin types. We report a man successfully treated for more than 50 filiform facial warts using a combination of 5-fluorouracil 5% and salicylic acid 20%.

Culturally Competent Care for LGBT Patients in Dermatology Clinics.

Lesbian, gay, bisexual, and transgender (LGBT) patients face unique health disparities.1 Routine collection of sexual orientation and gender identity (SOGI) data can optimize patient-provider interactions.2 Gender-neutral bathrooms promote inclusivity for LGBT patients.3 There is limited data on the extent to which dermatology practices make use of such features to deliver culturally competent care to LGBT patients.

Umbilicated papules on the bilateral upper and lower extremities.

Cryptococcosis is a rare opportunistic infection with morphologically diverse cutaneous presentations. Primary infection typically occurs in the lungs with subsequent hematogenous dissemination to other organ systems, especially in immunocompromised patients. Herein, we report a woman in her 70's who presented with pruritic, umbilicated papulonodules of the bilateral upper and lower extremities present for many weeks. She was diagnosed with disseminated Cryptococcus and subsequently evaluated for potential pulmonary and meningeal disease involvement. She died as a result of multiple medical comorbidities.

Crusted scabies in an elderly woman.

Crusted scabies is a highly contagious variant of classic scabies. Affected individuals are often elderly or immunocompromised and disease is associated with significant morbidity and mortality. Herein, we report an elderly woman residing in an assisted living facility who presented with diffuse sand-on-skin scale on her trunk, proximal extremities, scalp, hands, and feet. She was diagnosed with crusted scabies, isolated from other patients, and subsequently treated with permethrin 5% lotion and ivermectin. She died two weeks after initial presentation owing to sepsis.

Nuclear matrix protein 2 antibody-positive adult dermatomyositis: a case report and review of the literature.

Dermatomyositis is a clinically heterogenous inflammatory myopathy with unique cutaneous features. Myositis-specific antibodies can aid in diagnosis and anticipation of patient prognosis. Herein, we report a 22-year-old man who presented with multifocal erythematous plaques with violaceous papules on his bilateral elbows, neck, and face. He was diagnosed with biopsy-proven dermatomyositis and determined to be seropositive for nuclear matrix protein 2 antibody (NXP-2). He was treated with systemic corticosteroids, then intravenous methylprednisolone and azathioprine, and ultimately achieved greatest treatment response with intravenous immune globulin therapy.

Fluid Overload and Cumulative Thoracostomy Output Are Associated With Surgical Site Infection After Pediatric Cardiothoracic Surgery.

OBJECTIVES: To determine the impact of cumulative, postoperative thoracostomy output, amount of bolus IV fluids and peak fluid overload on the incidence and odds of developing a deep surgical site infection following pediatric cardiothoracic surgery. DESIGN: A single-center, nested, retrospective, matched case-control study. SETTING: A 26-bed cardiac ICU in a 303-bed tertiary care pediatric hospital. PATIENTS: Cases with deep surgical site infection following cardiothoracic surgery were identified retrospectively from January 2010 through December 2013 and individually matched to controls at a ratio of 1:2 by age, gender, Risk Adjustment for Congenital Heart Surgery score, Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery category, primary cardiac diagnosis, and procedure. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Twelve cases with deep surgical site infection were identified and matched to 24 controls without detectable differences in perioperative clinical characteristics. Deep surgical site infection cases had larger thoracostomy output and bolus IV fluid volumes at 6, 24, and 48 hours postoperatively compared with controls. For every 1 mL/kg of thoracostomy output, the odds of developing a deep surgical site infection increase by 13%. By receiver operative characteristic curve analysis, a cutoff of 49 mL/kg of thoracostomy output at 48 hours best discriminates the development of deep surgical site infection (sensitivity 83%, specificity 83%). Peak fluid overload was greater in cases than matched controls (12.5% vs 6%; p < 0.01). On receiver operative characteristic curve analysis, a threshold value of 10% peak fluid overload was observed to identify deep surgical site infection (sensitivity 67%, specificity 79%). Conditional logistic regression of peak fluid overload greater than 10% on the development of deep surgical site infection yielded an odds ratio of 9.4 (95% CI, 2-46.2). CONCLUSIONS: Increased postoperative peak fluid overload and cumulative thoracostomy output were associated with deep surgical site infection after pediatric cardiothoracic surgery. We suspect the observed increased thoracostomy output, fluid overload, and IV fluid boluses may have altered antimicrobial prophylaxis. Although analysis of additional pharmacokinetic data is warranted, providers may consider modification of antimicrobial prophylaxis dosing or alterations in fluid management and diuresis in response to assessment of peak fluid overload and fluid volume shifts in the immediate postoperative period.

Review and reappraisal of assessment parameters of second intention healing after Mohs micrographic surgery.

Mohs micrographic surgery (MMS) is used to remove cutaneous tumors in cosmetically sensitive anatomic areas. Surgeons can provide several reconstructive options to patients following tumor removal, including primary closure, skin grafts, local, regional or free flaps, and secondary intention healing (SIH). Notably, with the advancement of surgical and reconstructive techniques, the use of second intention healing has declined and may be underutilized. This review aims to critically evaluate the literature regarding indications, anatomical considerations, advantages, and complications of second intention wound healing following Mohs surgery. We also offer reappraisal of SIH following MMS to promote evidence-based postoperative care.

Reappraising Diabetic Foot Ulcers: A Focus on Mechanisms of Ulceration and Clinical Evaluation.

Diabetic foot ulcers (DFU) are one of the most devastating complications of diabetes as they have significant effects on patient morbidity and mortality. Since their first description in the 19th century, our understanding of DFU has evolved as we uncover the mechanisms that mediate ulceration. In this review, we aim to summarize the various pathways that lead to the development of DFU in order to reappraise physicians' understanding of these complex wounds. Relevant pathways include the following: (1) neuropathy (motor neuropathy, loss of protective sensation, and autonomic sympathetic dysfunction), (2) vascular disease (arterial ischemia, venous insufficiency, and microvascular changes), and (3) metabolism (signaling and immunological effects of hyperglycemia). We also discuss the clinical presentation of DFU and an evidence-based evaluation to assist clinicians in early identification and classification of these wounds to inform management of DFU. Finally, we summarize complications of DFU caused by the various pathways mediating ulceration and briefly overview DFU management in order to educate physicians about the potential risks if left untreated. A better understanding of the synergistic pathways leading to DFU is essential for clinicians to improve DFU diagnosis, tailor intervention, and mitigate significant patient morbidity and mortality.

A review of Nigella sativa plant-based therapy in dermatology.

Nigella sativa (N. sativa) is a widely used medicinal herb with a rich cultural and religious history in Unani, Ayurveda, Chinese, and Arabic medicine. N. sativa contains many natural bioactive agents including alkaloids, saponins, alpha-hederin, and thymoquinone that contribute to its broad range of benefits as a diuretic, bronchodilator, antihypertensive, antidiabetic, and analgesic. In addition, N. sativa possesses antimicrobial, anti-inflammatory, and antineoplastic effects, making it an interesting potential therapy for the treatment of dermatological conditions. This article reviews the current literature surrounding the pharmacological effects of N. sativa for the treatment of acne vulgaris, melanoma, vitiligo, atopic dermatitis, plaque psoriasis, and wound healing.