Vascular cutaneous manifestations of COVID-19 and RNA viral pathogens: a systematic review.

BACKGROUND: COVID-19, the widely recognized and highly contagious respiratory tract infection, has had a substantial impact on the field of dermatology since its emergence in 2019. SARS-CoV-2, the causative virus of COVID-19, is classified as an RNA virus. Various skin-related symptoms have been reported in patients with COVID-19, most notably the distinctive purple-red acral rash resembling chilblain lesions, commonly referred to as 'COVID toe'; similarly, skin-related symptoms have been observed in connection with other RNA viruses. OBJECTIVES: To explore the relationship between RNA viruses and their associated vascular cutaneous manifestations vs. those observed in patients infected with SARS-CoV-2. METHODS: A systematic literature review was conducted using PubMed and medical subject heading terms related to RNA viruses and related skin manifestations. RESULTS: In total, 3994 patients diagnosed with COVID-19 presenting with skin rashes were included. Chilblain-like lesions were most frequently observed (30.2%), followed by erythematous maculopapular/morbilliform rashes (9.1%) and urticarial rashes (4.7%). Of 8362 patients diagnosed with RNA viruses, more than half of the skin findings reported were erythematous/maculopapular/morbilliform rashes (52.3%), followed by unspecified (11.3%) and purpuric rashes (10.6%). CONCLUSIONS: When comparing RNA viral infections with COVID-19 infection, we observed similarities in the reported skin manifestations and their presumed pathways, with many implicated in the proinflammatory response. Owing to the wide range of cutaneous symptoms associated with RNA viruses and our currently limited understanding of the underlying mechanisms, additional research is warranted to investigate the pathology behind viral-induced skin lesions.

Part II: Cutaneous manifestations of peripheral vascular disease.

In this Part 2 of a 2-part continuing medical education series, we review the epidemiology of peripheral vascular disease, its association with cutaneous symptoms, and the diagnosis and evaluation of cutaneous features of vascular disorders. As peripheral vascular disease becomes more prevalent globally, it is essential for dermatologists to become competent at accurately recognizing and diagnosing cutaneous manifestations and directing individuals to receive appropriate care and treatment.

Part I: Cutaneous manifestations of cardiovascular disease.

In this part 1 of a 2-part continuing medical education series, we review the epidemiology and pathophysiology of cardiovascular disease, its association with cutaneous symptoms, and the diagnosis and evaluation of cutaneous features of cardiovascular syndromes, including infective endocarditis, acute rheumatic fever, Kawasaki disease, cholesterol embolization syndrome, lipid disorders, cardiac amyloidosis, and cardiac myxomas. As the incidence and prevalence of cardiovascular diseases increase, dermatologists play an essential role in recognizing the cutaneous manifestations of cardiovascular diseases in order to appropriately connect patients with follow-up care.

Holistic dermatology: An evidence-based review of modifiable lifestyle factor associations with dermatologic disorders.

BACKGROUND: Holistic dermatology focuses on treating the human body as a whole and implementing lifestyle changes to enhance the treatment and prognosis of skin disease. Understanding the interplay between modifiable lifestyle factors and patients' dermatologic health will help physicians better inform patients on self-care methods to mitigate the burden of their skin disease(s). OBJECTIVE: To review the current scientific literature on the relationship between modifiable lifestyle factors and the dermatologic outcome of skin disorders. METHODS: A systematic literature search on PubMed, Cochrane, and Web of Science was conducted to identify research articles examining the relationship between dermatology and 6 major categories of modifiable lifestyle factors: diet, sleep, exercise, stress, alcohol, and smoking. RESULTS: A substantial amount of evidence supports the relationship between modifiable lifestyle factors and dermatologic outcomes. There were the most studies on diet, stress, alcohol, and smoking, but all lifestyle factors were supported by some degree of scientific evidence. CONCLUSION: All modifiable lifestyle factors explored in this review play a critical role in modulating the onset and progression of skin disease. We anticipate more research studies in the future and an increasing integration of holistic dermatology into patient care.

Impact of Direct-to-Consumer Advertising of Cosmetic Procedures on Consumers.

BACKGROUND: Direct-to-consumer (DTC) advertising is a prominent type of health care communication. OBJECTIVE: This study aims to determine the impact of DTC advertisements on consumer opinion. METHODS: A total of 203 participants were recruited from dermatology clinics at an urban academic center. Participants viewed 2 cosmetically oriented DTC advertisements, and prequestionnaires and postquestionnaires were administered to assess consumer opinion. RESULTS: Postquestionnaire data highlight a 18.8% and 24.6% increase in participants reporting using commercials as an information source (p < .001) and seeking out additional medical knowledge (p < .001), respectively. After watching the advertisements, there was a 14.4% increase in participants who believed advertisements facilitate better discussions between patients and physicians (p < .001) and a 33% increase in patients reporting they would discuss the procedures with their doctors (p < .001). Of the participants, 60% believed the advertisements did not provide enough information about the possible risks of the product and 39.4% believed a physician was not required to perform cosmetic procedures. CONCLUSION: Direct-to-consumer advertisements instill meaningful information to patients and promote patient-physician communication. They also seem to exaggerate the benefits while making the procedures seem simple and without risks, suggesting trained medical professionals are not needed for administration.

Cosmetic treatment in patients with autoimmune connective tissue diseases: Best practices for patients with lupus erythematosus.

The cutaneous manifestations of lupus, especially chronic cutaneous lupus erythematosus, are a source of significant morbidity and can negatively impact patient quality of life. While the active inflammatory component of the disease may be adequately treated, patients are frequently left with residual skin damage and disfiguring aesthetic deficits. Dermatologists lack guidelines regarding the use and safety of various reconstructive and cosmetic interventions in this patient population. Laser treatments are largely avoided in the lupus population because of the possible photodamaging effects of ultraviolet and visible light. Similarly, given the autoimmune nature of this disease, some physicians avoid injectable treatment and grafts because of the concern for disease reactivation via antigenic stimulation. In the second article in this continuing medical education series we compile available data on this topic with the goal of providing evidence-based guidance on the cosmetic treatment of patients with lupus erythematosus with a focus on chronic cutaneous lupus erythematosus.

Cosmetic treatment in patients with autoimmune connective tissue diseases: Best practices for patients with morphea/systemic sclerosis.

Morphea and systemic sclerosis are inflammatory, sclerosing disorders. Morphea primarily affects the dermis and subcutaneous fat, while systemic sclerosis typically involves the skin and internal organs. Functional impairment and cosmetic disfigurement are common in both diseases. Treatment options to mitigate disease progression remain limited. Both functional impairment and cosmetic deficits negatively impact quality of life and psychological well-being in this patient population. While the number of cosmetic procedures performed in the United States continues to rise each year, limited data exist regarding best practices for correcting aesthetic deficits caused by autoimmune conditions. There is scarce information to guide safety decisions regarding laser parameters, soft tissue augmentation, treatment intervals, and the concurrent use of immune-modifying or immune-suppressing medications. Given the fears of disease reactivation and exacerbation from postprocedural inflammation along with limited data, it is difficult for clinicians to provide evidence-based cosmetic treatment with realistic expectations with regard to short- and long-term outcomes. In the first article in this continuing medical education series, we attempt to address this practice gap.

Racial and ethnic disparities in melanoma awareness: A cross-sectional survey.

BACKGROUND: Hispanics are among the fastest growing population in the United States and are predicted to account for one third of the nation by 2060. Although melanoma is more common among white patients, Hispanic individuals are at greater risk of late-stage diagnosis, increased tumor thickness, and poorer survival. OBJECTIVE: To better understand public awareness of melanoma and evaluate change over the last 21 years, particularly among high-risk minority populations. METHODS: A cross-sectional survey collecting information on knowledge and awareness of melanoma was conducted on 285 participants from May through November 2017. RESULTS: Approximately 39% of participants were unaware of melanoma. Sixty-five percent successfully identified early signs of disease. Approximately 86% of Fitzpatrick skin types (FST) I and II identified melanoma as a cancer, compared to 46.3% of FST III and IV and 57.6% of FST V and VI. Hispanic particiapnts were less likely to know what melanoma was compared to white participants (odds ratio [OR], 0.27; 95% confidence interval [CI], 0.65-0.11; P = .0037). US natives (OR, 2.38; 95% CI, 5.56-1.04; P = .0403) and patients with any college education (OR, 2.86; 95% CI, 5.26-1.54; P = .0007) were more likely to know the meaning of melanoma. CONCLUSION: White participants and those with any college education were more likely to know the meaning of melanoma. Individuals of racial and ethnic minorities would benefit from educational programs geared toward early detection.

Leprosy: Treatment and management of complications.

In the second article in this continuing medical education series, we review the treatment of leprosy, its immunologic reactions, and important concepts, including disease relapse and drug resistance. A fundamental understanding of the treatment options and management of neuropathic sequelae are essential to reduce disease burden and improve patients' quality of life.

Leprosy: Clinical aspects and diagnostic techniques.

Leprosy, also known as Hansen's disease, is a curable infectious disease that remains endemic in >140 countries around the world. Despite being declared "eliminated" as a global public health problem by the World Health Organization in the year 2000, approximately 200,000 new cases were reported worldwide in 2017. Widespread migration may bring leprosy to nonendemic areas, such as North America. In addition, there are areas in the United States where autochthonous (person-to-person) transmission of leprosy is being reported among Americans without a history of foreign exposure. In the first article in this continuing medical education series, we review leprosy epidemiology, transmission, classification, clinical features, and diagnostic challenges.

Characteristics of keratinocyte carcinomas in Hispanics compared to non-Hispanic whites: A retrospective 5-year study.

BACKGROUND: Hispanics are one of the fastest growing populations in the United States. Few studies have characterized the patterns of keratinocyte carcinoma presentation in Hispanics. OBJECTIVE: The study aimed to compare the clinical and histologic characteristics of keratinocyte carcinomas in Hispanics and non-Hispanic whites. MATERIALS AND METHODS: A five-year retrospective chart review was conducted at a single academic center to identify all histologically-confirmed cases of keratinocyte carcinomas. Tumor characteristics were then compared between Hispanics and non-Hispanic whites. RESULTS: A total of 197 tumors were identified of which 76% occurred in non-Hispanic whites and 24% in Hispanics. Tumor diameter was not larger and histologic subtype was not more aggressive in Hispanics compared to non-Hispanic whites. Age of diagnosis of basal cell carcinoma was younger among Hispanics compared to non-Hispanic whites (P < .05). CONCLUSION: Hispanics were not more likely to present with more high-risk keratinocyte carcinomas compared to non-Hispanic whites in terms of tumor diameter, differentiation and subtype.

Microneedling as a Treatment for Acne Scarring: A Systematic Review.

BACKGROUND: Microneedling is a popular, minimally invasive skin rejuvenation modality for acne scarring. Recent reports have evaluated the efficacy and safety of microneedling monotherapy and combination treatment for scarring. OBJECTIVE: This review aims to systematically analyze the current literature on microneedling techniques used for acne scarring. METHODS: A PubMed search (2009-current) was used to identify literature on microneedling treatment for acne. All randomized and nonrandomized clinical trials, case cohorts, case reports, and case series were included with the exception of 2 studies, which were excluded due to unavailability. RESULTS: All 33 articles evaluated showed improvement of acne scar appearance after microneedling treatment. Evidence was inconsistent when comparing microneedling monotherapy to dual therapy or to fractional laser treatment. CONCLUSION: Microneedling improves acne scarring, and further studies are needed to compare microneedling with other minimally invasive treatments.

Benign oral mucosal lesions: Clinical and pathological findings.

A diverse spectrum of benign oral mucosal lesions exists, presenting as either isolated oral findings or in association with dermatologic conditions. Oral lesions can closely resemble one another; therefore, it is important for clinicians to be able to recognize their distinctive features, to be able to recognize benign versus malignant disease, and to recognize when obtaining a biopsy specimen is warranted. The first article in this continuing medical education series reviews oral anatomy, the clinical attributes of several benign lesions of the oral cavity, and appropriate management and therapeutic modalities.

Premalignant and malignant oral mucosal lesions: Clinical and pathological findings.

The second article in this continuing medical education series discusses the clinical and histopathologic features of common premalignant and malignant lesions of the oral cavity. It is imperative for dermatologists to be able to appropriately recognize suspicious lesions, determine the need to obtain a biopsy specimen, counsel, and refer patients presenting with premalignant or malignant conditions. Given the higher rates of mortality and morbidity of oral mucosal malignancies because of late diagnosis, appropriate treatment with multidisciplinary care in a timely manner is essential to patients with these neoplasms.

Effect of stimuli on sun protective habits: A randomized double-blind controlled study.

BACKGROUND: Visual imagery has been shown to improve adherence to health messages but has scarcely been investigated in sun protection campaigns. OBJECTIVE: To determine the effectiveness of pictorial- and textual-based sun protective messages in a largely Hispanic population. METHODS: One hundred and forty-five participants received standard of care (SOC) as defined as sun protective counseling and were then randomized to receive either (a) images of sun damage, (b) a textual pamphlet about sun damage, or (c) no further messages. Analysis-of-variance tests for repeated measures were used to estimate the effects of the different stimuli on participants' knowledge and intention to sun protect. RESULTS: All stimulus groups demonstrated an improvement in perceived effectiveness of sun protective habits (p < 0.05). However, pictorial and textual stimuli were both more effective than SOC in improving intentions to sun protect (p < 0.05), but there was no differential effect between the two. CONCLUSIONS: Both pictorial and textual stimuli were more effective than SOC in improving intentions to sun protect, but there was no differential effect between the two.

Dermatoses caused by cultural practices: Cosmetic cultural practices.

The second article in this continuing medical education series discusses cosmetic practices associated with cultural dermatoses, including hair care, traditional clothing, and skin decorations. Often, the steps individuals take to enhance their physical appearance are determined by cultural perceptions of beauty. Without awareness of cultural practices, a multitude of cutaneous dermatoses may be missed by the dermatologist. Recognition and understanding of patients' cultural backgrounds and habits will allow the practicing dermatologist to offer better counseling and treatment options while providing a more meaningful and understanding physician-patient relationship.

Assessing the safety of superficial chemical peels in darker skin: A retrospective study.

BACKGROUND: Chemical peels have shown efficacy in the treatment of acne, photoaging, and pigmentary dyschromias; however, studies evaluating side effects, particularly in patients with skin of color, are limited. OBJECTIVE: We sought to determine the frequency of side effects and complications associated with superficial chemical peels in patients with skin types III-VI. METHODS: A 5-year single center retrospective analysis was performed. RESULTS: Of 473 chemical peel treatments included in this study, 18 (3.8%) were associated with short-term (≤2 weeks) or long-term (>2 weeks) complications. The most frequent complications were crusting (2.3%), postinflammatory hyperpigmentation (1.9%), and erythema (1.9%). All side effects resolved within 8 months of treatment and were located on the face. When stratified by season, side effects were noted to be less common during the winter. In the adjusted model, Fitzpatrick skin type VI was associated with a higher odds of side effects (odds ratio 5.14, 95% confidence interval 1.21-21.8; P = .0118). LIMITATIONS: Single center retrospective design. CONCLUSION: In this study, superficial chemical peels performed on patients with skin types III-VI had a relatively low complication rate, and skin type VI had higher odds of experiencing an adverse event. Side effects were noted to be less frequent during the winter months.

Dermatoses caused by cultural practices: Therapeutic cultural practices.

With globalization and widespread immigration, physicians increasingly encounter patients from varying backgrounds and diverse customs. Although certain cultural practices are widely performed, there is limited medical literature describing their dermatologic and systemic effects and complications. Population diversity and sharing of traditions make it increasingly important for dermatologists to understand the role of cultural practices and recognize physiologic and pathologic sequelae. In addition, dermatologists are often adjured to assess skin findings that may be mistaken for abuse. Child abuse misdiagnosis can be traumatizing to all those involved, and immigrant families with limited English proficiency may have difficulty explaining their traditional practices. The first article of this 2-part continuing medical education series begins with a review of therapeutic cultural practices, including traditional Chinese medicine, Ayurveda, acupuncture, cupping, moxibustion, and coining, and the clinically relevant complications that may occur. Therapeutic practices can cause a range of complications, including contact dermatitis, heavy metal toxicity, and severe cutaneous adverse reactions.