Differentiating hidradenitis suppurativa flare from infection in the emergency department and recommendations for transitioning care to the outpatient setting.

Hidradenitis suppurativa is a painful and often progressive inflammatory skin condition that presents with papules, nodules, abscesses, and tunnels in the axillary, inframammary and anogenital regions. HS can be difficult to differentiate from a skin infection, such as a bacterial abscess. However, differentiation between the two is important as management of hidradenitis suppurativa often requires long-term follow-up and specialist care. Emergency physicians should be aware of how to differentiate acute hidradenitis suppurativa flares from similarly presenting conditions, particularly skin and soft tissue infection, when encountered in the emergency department and what steps should be taken to adequately bridge care to the outpatient setting.

Cystic fibrosis dermatitis arthritis syndrome: A series of four cases.

Dermatologic manifestations of cystic fibrosis (CF) include nutrient deficiency dermatoses, vasculitis, transient reactive papulotranslucent acrokeratodema, digital clubbing, and increased rates of atopy and drug reactions. Few cases of a characteristic eruption in patients with episodic arthritis of CF have been described with prior reports primarily occurring outside of the dermatology literature. We report four cases consistent with this presentation to add to the literature and propose a new and unifying name to recognize this entity as cystic fibrosis dermatitis arthritis syndrome (CF-DAS). Clinical suspicion should remain high in young female patients with cystic fibrosis presenting with episodic joint pain and rash, independent of pulmonary exacerbations.

Concordance in Distinguishing Actinic Keratosis from Squamous Cell Carcinoma in Situ on Mohs Histological Frozen Sections.

BACKGROUND: Mohs surgeons routinely encounter squamous cell carcinoma at surgical margins and often base the decision to take another layer on the severity of atypia observed. Currently, no criteria exists for distinguishing borderline histological patterns that could be interpreted differently as actinic keratosis (AK), squamous cell carcinoma in situ (SCCIS), or AK with focal SCCIS. OBJECTIVE: To assess interrater concordance amongst Mohs surgeons in distinguishing AK from SCCIS when evaluating Mohs frozen sections. METHODS: Seventeen slides were selected and converted into digitally formatted cases. They were compiled into an electronic survey and distributed to the American College of Mohs Surgery. RESULTS: Overall κ was 0.26 corresponding to weak agreement between raters compared to the standard, with κ of 0.34 for AK and 0.37 for SCCIS. CONCLUSION: There exists notable variability among Mohs surgeons who interpret the spectrum of in situ carcinoma differently. Ongoing learning and consensus building among Mohs surgeons and trainees can aid in quality patient care, even if there may not be agreement on every case. J Drugs Dermatol. 2023;22(2):199-194. doi:10.36849/JDD.7084.

Surgical delays of less than 1 year in Mohs surgery associated with tumor growth in moderately- and poorly-differentiated squamous cell carcinomas but not lower-grade squamous cell carcinomas or basal cell carcinomas: A retrospective analysis.

BACKGROUND: Evidence is controversial and limited concerning whether surgical delays are associated with tumor growth for cutaneous squamous cell carcinomas (SCCs) and basal cell carcinomas. OBJECTIVE: Identify tumor subpopulations that may demonstrate an association between tumor growth and surgical delay. METHODS: We retrospectively analyzed 299 SCCs and 802 basal cell carcinomas treated with Mohs surgery at a single institution. Time interval from biopsy to surgery represented surgical delay. Change in major diameter (ΔMD) from size at biopsy to postoperative defect represented tumor growth. Independent predictors of ΔMD were identified by multivariate analysis. Linear regression was then utilized to assess for whether the ΔMD from these independent predictors trended with surgical delay. RESULTS: Surgical delays ranged from 0 to 331 days. Among SCCs, histologic subtype and prior treatment were identified as independent predictors of ΔMD. Significant associations between ΔMD and surgical delay were found for poorly- and moderately-differentiated SCCs, demonstrating growth rates of 0.28 cm and 0.24 cm per month of delay, respectively. The ΔMD for SCCs with prior treatment and basal cell carcinoma subgroups did not vary with surgical delay. LIMITATIONS: Retrospective design, single center. CONCLUSION: Surgical delays of less than a year were associated with tumor growth for higher-grade SCCs, with effect sizes bearing potential for clinical significance.

Doubly Misdiagnosed: Exophiala Masquerading as Squamous Cell Carcinoma and Chromoblastomycosis.

ABSTRACT: Deep cutaneous fungal infections (DCFI) can arise in the setting of skin trauma and immunosuppression. DCFI may be secondary to chromoblastomycosis, which is typically characterized by pseudoepitheliomatous hyperplasia histologically and can be mistaken for squamous cell carcinoma. In addition, "copper penny" spore-like pigmented yeast forms on Grocott's methenamine silver stain can suggest chromoblastomycosis, but this finding is not specific. By contrast, phaeohyphomycosis characteristically exhibits circumscribed pseudocyst or abscess on histopathology, and both yeast and hyphae can be seen. Our case reports a DCFI with pseudoepitheliomatous hyperplasia and "copper penny" yeast forms, ultimately diagnosed as phaeohyphomycosis after isolating Exophiala spinifera on fungal culture.

Intraoperative Diagnosis of Histologic Change in Irradiated Skeletal Muscle.

ABSTRACT: Adjuvant radiation may be used to reduce the recurrence of high-risk cutaneous squamous cell carcinoma after resection. Adjuvant radiation can produce histologic changes in the skeletal muscle that mimic keratinocyte atypia, presenting a diagnostic challenge during subsequent resections. We present a case of cutaneous squamous cell carcinoma and histologic changes observed in a fresh frozen section that were consistent with degenerative changes of irradiated skeletal muscle that had a muscle-specific actin+, Melan-A-, and cytokeratin- immunophenotype on paraffin-embedded permanent sections. We also reviewed the literature of other similar reported findings on irradiated skeletal muscle.

Topical timolol for treatment of persistent granulation tissue in the setting of severe hidradenitis suppurativa.

Hidradenitis suppurativa (HS) is a potentially debilitating dermatological disease that negatively impacts patients' quality of life. Severe cases can be further complicated by persistent granulation tissue at the ostia of sinus tracts, which may prove recalcitrant to standard interventions. Herein we report such a case in which a patient experienced significant improvement from severe HS but was left with persistent granulation tissue that complicated his course of recovery. When standard interventions failed, we elected to begin treatment with topical timolol. After three months, the majority of the granulation tissue had regressed and has remained quiescent after 12 months of follow up. The patient has tolerated the treatment well and continues to use topical timolol daily as needed for flares. We believe that topical timolol can provide a practical and painless alternative to current invasive and expensive therapies for persistent granulation tissue associated with severe HS.

Hyperpigmented Plaques of the Alar Crease: An Unusual Presentation of Acanthosis Nigricans.

Although acanthosis nigricans of the posterior neck and intertriginous areas is common, acanthosis nigricans of the supra-alar creases is rare. We present the case of an obese 16-year-old African American boy with hyperpigmented plaques along the supra-alar creases of his nose. Clinicians should be aware of this rare manifestation, because newly diagnosed acanthosis nigricans should prompt examination for insulin resistance.

What are the most important factors that determine the overall quality of dermatology residency training: A resident survey.

Currently no broadly accepted and standardized objective ranking system for dermatology residency programs exist. A new ranking system was recently developed in an attempt to address this issue. However, it remains unclear if the algorithm employed is based on factors that have a tangible impact on the quality of training provided by dermatology residency programs [1]. Our authors surveyed all current dermatology residents in order to investigate the factors that they feel are most important in determining the strength of training provided by a residency program.

Cutaneous mucormycosis with suspected dissemination in a patient with metastatic adrenocortical carcinoma.

Mucormycosis is a frequently lethal fungal infection that most commonly affects patients with poorly controlled diabetes or other immunosuppressed states. We report the case of a suspected disseminated Rhizopus infection in a patient who was pursuing naturopathic treatment including mud baths for metastatic adrenocortical carcinoma. He was empirically treated with liposomal amphotericin B but opted to stop treatment following multiorgan failure. The patient passed away on the tenth day of his hospital admission.

Estimating electromyographic and heart rate fatigue thresholds from a single treadmill test.

INTRODUCTION: The purposes of this study were to (1) develop a fatigue threshold based on electromyography (EMG) and heart rate (HR) responses for treadmill running from a single incremental test; and (2) propose a new fatigue threshold called the RV(EMGFT) and RV(HRFT). METHODS: Eleven men performed incremental treadmill exercise to exhaustion on a single occasion. The RV(EMGFT) and RV(HRFT) were defined as the average of the highest velocity that resulted in a nonsignificant slope coefficient for the EMG amplitude versus time relationship and the lowest velocity that resulted in a significant positive slope coefficient. RESULTS: There was a significant (P < 0.05) difference between the 2 thresholds [RV(EMGFT) = 11.7 ± 0.6 km/h and RV(HRFT) = 8.3 ± 0.8 km/h]. CONCLUSIONS: The fatigue threshold for EMG amplitude and heart rate can be determined from a single incremental treadmill test, but there are differences between cardiac and neuromuscular factors of fatigue.

Reverse-Grip Technique of Scissors in Dermatologic Surgery: Tips to Improve Undermining Efficiency.

Undermining in difficult-to-reach positions often requires a shift in body position or stretching over the surgical field to obtain adequate reach. We propose a technique of reversing the grip on undermining scissors that improves efficiency without sacrificing technique.

Herpes zoster following varicella vaccination in children.

Herpes zoster (HZ), or shingles, is commonly seen in older adults but does occur in children. Routine administration of the varicella vaccine started in 1995 in the United States; since then, the incidence of varicella and HZ has declined. We report a case of HZ in an otherwise healthy 19-month-old boy who had been vaccinated at 13 months of age and recovered fully after acyclovir treatment. We review previously reported cases of HZ in healthy vaccinated children.