Comparative effectiveness of ice packs versus topical lidocaine-prilocaine mixture for pain control in laser hair removal of the axilla: A rater-blinded randomized controlled trial.

BACKGROUND: Laser hair removal is associated with moderate acute pain. OBJECTIVE: To compare effectiveness of ice pack to topical lidocaine-prilocaine for pain reduction during axillary laser hair removal. METHODS: Participants were randomly assigned to receive topical anesthetic to one axilla and ice packs to the other before each of 3, monthly 810 nm diode laser sessions. The primary endpoint was participant-reported pain on the visual analog scale (VAS) immediately following and 5 minutes after laser session. Posttreatment erythema, overall edema, and perifollicular edema were assessed by 2 blinded photoraters. Skin temperatures, patient preferences, and adverse events were recorded. RESULTS: Eighty-eight of 90 (98%) planned laser treatments were delivered and randomized. Participants reported higher VAS scores immediately after laser treatment with lidocaine-prilocaine compared to ice (P = .03). Five minutes after, participants reported higher VAS scores with ice (P = .03). After 53 of the 88 treatments (60.2%), participants reported preferring ice (P = .055). No serious adverse events were reported. LIMITATIONS: All participants were Caucasian or Asian with Fitzpatrick skin type I to III and coarse dark axillary hair, which may limit generalizability. CONCLUSIONS: While pain control with ice and topical anesthesia is associated with time after treatment, the 2 modalities do not differ in terms of degree of pain reduction associated with axillary laser hair removal.

Pain of local anesthetic injection of lidocaine during subsequent stages of Mohs micrographic surgery: A multicenter prospective cohort study.

BACKGROUND: Patients awake during staged cutaneous surgery procedures may experience procedure-related pain. OBJECTIVE: To determine whether the level of pain associated with local anesthetic injections prior to each Mohs stage increases with subsequent Mohs stages. METHODS: Multicenter longitudinal cohort study. Patients rated pain (visual analog scale: 1-10) after anesthetic injection preceding each Mohs stage. RESULTS: Two hundred fifty-nine adult patients presenting for Mohs who required multiple Mohs stages at 2 academic medical centers were enrolled; 330 stages were excluded due to complete anesthesia from prior stages, and 511 stages were analyzed. Mean visual analog scale pain ratings were nominally but not significantly different for subsequent stages of Mohs surgery (stage 1: 2.5; stage 2: 2.5; stage 3: 2.7: stage 4:2.8: stage 5: 3.2; P = .770). Between 37% and 44% experienced moderate pain, and 9.5% and 12.5% severe pain, during first as versus subsequent stages (P > .05) LIMITATIONS: Both academic centers were in urban areas. Pain rating is inherently subjective. CONCLUSIONS: Patients did not report significantly increased anesthetic injection pain level during subsequent stages of Mohs.

Dermatopathologic features of cutaneous squamous cell carcinoma and actinic keratosis: Consensus criteria and proposed reporting guidelines.

BACKGROUND: There is considerable variation in the literature regarding the dermatopathologic diagnostic features of and reporting guidelines for actinic keratosis (AK) and cutaneous squamous cell carcinoma (cSCC). OBJECTIVE: To develop consensus recommendations regarding diagnostic criteria, nomenclature, and reporting of AK and cSCC. METHODS: Literature review and cross-sectional multiround Delphi process including an international group of expert dermatopathologists followed by a consensus meeting. RESULTS: Consensus was achieved regarding the key dermatopathologic features necessary for diagnosing cSCC, AK, and associated variants; grading of degree of cellular differentiation in cSCC; utility of immunohistochemistry for diagnosis of cSCC; and pathologic features that should be reported for cSCC and AK. LIMITATIONS: Consensus was not achieved on all questions considered. CONCLUSION: Despite the lack of clarity in the literature, there is consensus among expert dermatopathologists regarding diagnostic criteria and appropriate reporting of AK and cSCC. Widespread implementation of these consensus recommendations may improve communication between dermatopathologists and clinicians, facilitating appropriate treatment of AK and cSCC.

Utility of high-resolution ultrasound in measuring subcutaneous fat thickness.

OBJECTIVE: Previous studies conclude that high-resolution ultrasound (HRUS) enables noninvasive and accurate measurements of subcutaneous fat thickness. The primary objective of this cross-sectional study was to better characterize subcutaneous fat thickness measurements in a diverse patient population using HRUS. Secondarily, we sought to correlate these measurements with patients' body image. METHODS: A cross-sectional study to measure subcutaneous fat measurements at seven distinct anatomic sites, including upper and lower extremities, submental, and torso regions, in 40 men and women of different ages and races using HRUS. Independent t-tests and analysis of variance were performed to analyze findings. RESULTS: In our patient population, on average, women had thicker subcutaneous fat than men at all anatomic sites. Asian patients had significantly reduced fat thickness at peripheral anatomic sites, such as arms when compared to patients who identified as Black and Other (p = 0.05 and p = 0.008, respectively). Lastly, women reported decreased total body satisfaction at all anatomic sites when compared to men. CONCLUSION: The information obtained and methods developed in this study may be utilized clinically during patient selection for fat reduction procedures, including for estimating the degree of likely benefit; for managing pathologies involving subcutaneous fat thickness alteration; and to monitor the progression of lipodystrophy secondary to disease or drugs.

Primary Dermal Melanoma: A Case Report.

ABSTRACT: Primary dermal melanoma (PDM) is defined as a primary melanoma tumor confined to the dermis, subcutis, or both, without epidermal involvement. The significant overlap of histopathological features in PDM and cutaneous metastatic melanoma makes diagnostic accuracy of PDM challenging. We present a case of a 48-year-old man with a nontender 1.5 × 1.5 cm subcutaneous nodule on the left leg, which had been present for years. Biopsy revealed a dermal tumor with melanocytic differentiation noted to be positive for SOX-10. Additional pathology findings included a high Ki-67 proliferation index and a loss of p16 expression. Pathology reports were consistent with primary tumor stage 4a, and the patient was referred to surgical oncology where examination and workup demonstrated no evidence of the residual lesion representing a metastasis from a primary site. As PDM is histologically indistinguishable from melanoma metastasis to the skin, clues including a history of an evolving subepidermal nodule and exclusion of previous or concurrent melanomas can assist in its accurate diagnosis. Currently, a consensus on the criteria, staging, and management of PDM does not exist. Poorly defined diagnostic criteria and general lack of awareness of PDM result in high rates of incorrect and late-stage diagnoses. This case report highlights the importance of physician familiarity with PDM to ensure accurate recognition, evidence-based management, and improved patient outcomes.

The Development of Disgust and Its Relationship to Adolescent Psychosocial Functioning.

Experiences of excessive disgust have been implicated in several psychopathologies. Research, however, has rarely examined disgust and its role in psychosocial functioning from a developmental standpoint. This study examines the relationship between disgust expression in early life and subsequent adolescent psychosocial functioning. Data from 165 children were collected as part of a longitudinal study. Disgust propensity in infancy and childhood was assessed using a facial expressivity task and food aversion task, respectively. Adolescent psychosocial functioning was measured through several self-report measures. Results suggest that there exists a degree of consistency in disgust expression within the first year of life, and that childhood disgust propensity may be related to impairment in early adolescent psychosocial functioning. These findings highlight the potential importance of identifying early disgust expression as a marker for later psychopathology.

Cognitive performance of youth with primary generalized anxiety disorder versus primary obsessive-compulsive disorder.

BACKGROUND: Despite gains made in the study of childhood anxiety, differential diagnosis remains challenging because of indistinct boundaries between disorders and high comorbidity. This is certainly true for generalized anxiety disorder (GAD) and obsessive-compulsive disorder (OCD) as they share multiple cognitive processes (e.g., rumination, intolerance of uncertainty, and increased attention to threat). Disentangling such cognitive characteristics and, subsequently, underlying mechanisms could serve to inform assessment and treatment practices, and improve prognoses. METHODS: The current study sought to compare the cognitive performance (working memory, visuospatial memory, planning ability/efficiency, and cognitive flexibility), indexed by the Cambridge Neuropsychological Automated Battery (CANTAB) among three nonoverlapping groups of youth: (1) those diagnosed with OCD (n = 28), (2) those diagnosed with GAD, not OCD (n = 34), and (3) typically-developing controls (TDC) (n = 65). RESULTS: Results showed that OCD and GAD youth demonstrated neurocognitive deficits in planning ability/efficiency, cognitive flexibility, and visual processing when compared to TDC, with potential diagnostic specificity such that youth with GAD or OCD had unique deficits compared to TDC and to one another. Specifically, youth with OCD demonstrated significantly impaired planning ability compared to youth in the GAD and TDS groups, whereas youth with GAD demonstrated greater cognitive inflexibility and delayed visual processing compared to youth in the OCD and TDC groups. CONCLUSIONS: Future studies should expand upon these findings with more comprehensive assessment of cognitive functioning by including self- and parent-report forms, and neuroimaging to link behavioral findings with subjective ratings and neurocircuitry. Altogether, data can then inform future assessment and treatment targets.

Unmet Needs in Psychodermatology: A Narrative Review.

Psychodermatology, the multidisciplinary field that explores the intricate interplay between the mind and the skin, has gained increasing recognition over the past decade. However, several knowledge gaps and unmet needs persist in the field. The objective of this narrative review was to investigate the unmet needs in the field of psychodermatology as they pertain to medical training, treatment, research, and care access. PubMed was searched from inception through December 2023 to identify articles related to psychodermatology. Findings revealed several unmet needs within the field of psychodermatology. First, there is a need for further investigation into the pathophysiology that links psychological stress to cutaneous disease including the development of novel therapies targeting key neuropeptides. Second, the existing literature focuses primarily on the pharmacologic treatment of body dysmorphic disorder and body-focused repetitive behaviors, as well as delusional parasitosis, for which the first-line agents are selective serotonin reuptake inhibitors and atypical antipsychotics, respectively. However, additional research into the efficacy and safety of the remaining psychotropic medications and the treatment of other common psychocutaneous diseases is required. Finally, there exists a significant gap in knowledge amongst clinicians tasked with treating psychocutaneous diseases. Dermatologists report low rates of training in psychodermatology and discomfort with prescribing psychotropic medications. In conclusion, increasing resources for dermatologist education on psychotropic agent use, development of new drugs targeting stress-induced skin conditions, and research on the psychocutaneous applications of current medications may greatly improve the quality and access of psychodermatology care.

Non-invasive Skin Imaging in Cutaneous Lymphomas.

The diagnosis of cutaneous lymphomas is challenging and requires skin tissue for histology and immunophenotyping using immunohistochemistry and molecular studies. In recent years, the role of non-invasive imaging techniques has been described as part of the clinical assessment of cutaneous lymphoma lesions. Imaging modalities such as dermoscopy, reflectance confocal microscopy (RCM), and high frequency ultrasound (HFUS) have been shown to be very valuable in raising the clinical suspicion for lymphomas of the skin, and in distinguishing cutaneous lymphomas from inflammatory dermatoses such as lupus, psoriasis, or eczema. These non-invasive methods can be used to direct the clinician to the optimal biopsy site to maximize the histopathological results and minimize false negatives. These methods also have a potential place in monitoring treatment response. In this review we present a concise summary of the dermoscopic imaging, RCM, and HFUS features seen in cutaneous T-cell lymphomas (CTCL) and B-cell lymphomas (CBCL).

Subcision with and without suction for acne scars: a split-faced, rater-blinded randomized control trial.

Therapeutic options for acne scars include subcision and suction with microdermabrasion, but these treatment modalities have not been studied in conjunction. To compare effectiveness of subcision alone versus subcision with suction for the treatment of facial acne scars. Randomized, split-faced, evaluator-blinded control trial. Participants underwent one subcision treatment on both sides of the face followed by 10 sessions of suction to one side. Photographs at baseline, 1-month, and 4-months were assessed. Primary outcome measures were the validated Acne Scar Severity Scale (ASSS) (0 = no acne scarring, 4 = severe), Acne Scar Improvement Grading Scale (ASIGS) (-100 to 100%), and modified Quantitative Global Scarring Grades (QGSG) (point-based questionnaire instrument), as well as subject preference. Twenty-eight treatment areas and 154 treatments were analyzed. Dermatologist raters found no differences between subcision alone and subcision-suction at 1-month or 4-months. Mean subject-assessed percent improvement for subcision-suction was higher than that for subcision alone at 1-month (37% versus 24%, p = 0.04) but not at 4-months (p = 0.37). Subjects preferred combination therapy to monotherapy at 1-month (50% vs. 21%) and 4-months (43% vs. 21%). While blinded raters did not detect significant differences, subjects perceived combination treatment as working more quickly than monotherapy, and preferred combination treatment at all time points.Clinical trial registration NCT01696513 on Clinicaltrials.gov.

Rosacea Core Domain Set for Clinical Trials and Practice: A Consensus Statement.

Importance: Inconsistent reporting of outcomes in clinical trials of rosacea is impeding and likely preventing accurate data pooling and meta-analyses. There is a need for standardization of outcomes assessed during intervention trials of rosacea. Objective: To develop a rosacea core outcome set (COS) based on key domains that are globally relevant and applicable to all demographic groups to be used as a minimum list of outcomes for reporting by rosacea clinical trials, and when appropriate, in clinical practice. Evidence Review: A systematic literature review of rosacea clinical trials was conducted. Discrete outcomes were extracted and augmented through discussions and focus groups with key stakeholders. The initial list of 192 outcomes was refined to identify 50 unique outcomes that were rated through the Delphi process Round 1 by 88 panelists (63 physicians from 17 countries and 25 patients with rosacea in the US) on 9-point Likert scale. Based on feedback, an additional 11 outcomes were added in Round 2. Outcomes deemed to be critical for inclusion (rated 7-9 by ≥70% of both groups) were discussed in consensus meetings. The outcomes deemed to be most important for inclusion by at least 85% of the participants were incorporated into the final core domain set. Findings: The Delphi process and consensus-building meetings identified a final core set of 8 domains for rosacea clinical trials: ocular signs and symptoms; skin signs of disease; skin symptoms; overall severity; patient satisfaction; quality of life; degree of improvement; and presence and severity of treatment-related adverse events. Recommendations were also made for application in the clinical setting. Conclusions and Relevance: This core domain set for rosacea research is now available; its adoption by researchers may improve the usefulness of future trials of rosacea therapies by enabling meta-analyses and other comparisons across studies. This core domain set may also be useful in clinical practice.

Psychiatric and psychologic aspects of chronic skin diseases.

Chronic skin diseases can substantially affect a patient's physical, psychologic, and social well-being. Physicians may play a critical role in identifying and managing the psychologic sequelae of the most common chronic skin conditions. Acne, atopic dermatitis, psoriasis, vitiligo, alopecia areata, and hidradenitis suppurativa are chronic dermatologic diseases that put patients at high risk for symptoms of depression, anxiety, and decreased quality of life. Both general and disease-specific scales exist to assess the quality of life in patients with chronic skin disease, the most common being the Dermatology Life Quality Index. The general management approach to the patient with chronic skin disease should incorporate acknowledgment and validation of the patient's struggles; patient education on the potential effect of disease and prognosis; medical management of the dermatologic lesions; coaching on stress management; and psychotherapy. Psychotherapies include talk therapy (eg, cognitive behavioral therapy), arousal-reducing therapies (eg, meditation, relaxation), and behavioral therapies (eg, habit reversal therapy). Improved understanding, identification, and management of the psychiatric and psychologic aspects of the most common chronic skin conditions by dermatologists and other health care providers may positively affect patient outcomes.

VEXAS syndrome in dermatology.

Vacuoles, E1 enzyme, x-linked, autoinflammatory, and somatic mutation (VEXAS) syndrome is a recently described disease associated with high morbidity and mortality. VEXAS syndrome results from a somatic mutation affecting UBA1, a gene that codes for the E1 ubiquitin activating protein. Loss of UBA1 leads to a broad range of inflammatory conditions and a clinical course often refractive to therapy. We present the cases of two patients who demonstrated a rapid decline in overall health, decreased energy, arthralgias, anemia, fever, increased inflammatory markers, and characteristic bone marrow. Importantly, dermatologic assessment revealed skin biopsy findings of medium-vessel vasculitis and neutrophilic infiltration. Following blood analysis, both patients were diagnosed with VEXAS syndrome resulting from a mutation in the UBA1 gene. Our report highlights the pivotal role dermatologists have in early diagnosis of patients with VEXAS syndrome.