ABSTRACT
BACKGROUND: Dermatology consultations in the inpatient hospital setting can improve diagnostic accuracy and management. OBJECTIVE: Characterize dermatologic diagnostic and treatment trends in the hospital setting and identify variables that may affect patient care. METHODS: Retrospective chart review from 1 January 2012 to 31 December 2017 at Jackson Memorial Hospital (JMH) (Miami, Florida, USA), an academic non-profit tertiary care centre affiliated with University of Miami Miller School of Medicine, was performed. Patients who received dermatology consultations in the emergency department (ED) or inpatient settings were included. Patient demographics, admission information, provisional diagnosis and management plans by primary teams, final diagnosis, management plans and testing recommendations by the dermatology consults team, and follow-up information were collected. Analysis using Microsoft Excel of how time to consultation, admission length, inpatient versus ED setting and primary team affected diagnostic accuracy was also performed. RESULTS: The 1004 consultations for 812 patients (n = 812) were reviewed (359 women, 453 men). Most patients were Hispanic (n = 359; 44.2%) or African American (n = 273; 33.6%). Mean admission length was 20.6 days (range 0-439; median 6). The most common consulting service was internal medicine (n = 452). In 387 cases (47.6%), primary teams did not give a provisional diagnosis. The most common provisional diagnoses were bacterial infection (n = 93), viral infection (n = 49) and drug reaction (n = 44). The most common diagnoses by dermatology were viral infection (n = 93), bacterial infection (n = 90) and drug reaction (n = 80). Dermatology consultation changed the provisional diagnosis in 55.7% of cases, more often in cases where consultation took place ≥2 days after admission (P < 0.05). Primary teams followed dermatology treatment recommendations in 85.2% of cases. CONCLUSION: Dermatology consultation improves diagnostic accuracy in skin disorders in the hospital setting and serves as a valuable resource for inpatient care. A notable aspect of data from this study is the unique patient population, predominantly comprised of underrepresented racial and ethnic minorities including Hispanics and African Americans.
Subject(s)
Dermatology , Skin Diseases , Female , Hospitals, Urban , Humans , Male , Referral and Consultation , Retrospective Studies , Skin Diseases/diagnosis , Skin Diseases/therapySubject(s)
Buttocks , Mycobacterium chelonae , Anti-Bacterial Agents , Humans , Mycobacterium InfectionsABSTRACT
OBJECTIVE: Epidermolysis bullosa (EB) describes a number of genetically inherited conditions which cause skin fragility and minor trauma leading to skin damage, skin loss and wounding. Owing to the fragility of the skin and requirement for frequent dressing changes, at present, the optimal dressing(s) is not clear. Our objective was to assess the use of a keratin gel in the management of wounds in patients with different forms of EB. METHOD: We treated patients with different types of EB and a range of wounds with a novel keratin gel. In a convenience sample of consecutive patients, we introduced the keratin gel into their treatment regimen maintaining other aspects of their care. RESULTS: Patients reported faster healing and more resilient healed skin. Of the ten patients treated in this pilot study, six found the gel effective; two found it ineffective; and in two patients, it caused itching leading to discontinuation of the treatment. CONCLUSION: The results of this case study series suggest that keratin gel can be useful in the management of EB and are consistent with previous published experiences.
Subject(s)
Bandages , Epidermolysis Bullosa/drug therapy , Keratins/therapeutic use , Skin Abnormalities/drug therapy , Wound Healing/drug effects , Adolescent , Child , Child, Preschool , Disease Management , Epidermolysis Bullosa/complications , Female , Gels/therapeutic use , Humans , Infant , Male , Pilot Projects , Skin Abnormalities/etiology , Treatment OutcomeABSTRACT
Chronic wounds of the lower extremities are occurring with increasing prevalence. They affect millions of individuals annually, representing both a significant health risk and a large economic burden. Chronic wounds are associated with increased mortality and substantial morbidity due to infection, pain, limitation of daily activities, and psychosocial consequences. To manage these wounds effectively, clinicians must be able to diagnose and manage their aetiology. Diagnosis starts with determining whether the wound is one of the four most common chronic wounds: venous leg ulcers, diabetic foot ulcers, pressure ulcers and arterial ulcers. Moreover, despite many recent advances in wound care, the challenge of managing chronic wounds is complicated by the lack of consistently accepted diagnostic methods and wound-care standards. We present a comprehensive yet condensed approach to managing lower-extremity ulcers, from diagnosis to basic management.
Subject(s)
Leg Ulcer/therapy , Humans , Ischemia/diagnosis , Ischemia/etiology , Ischemia/therapy , Leg/blood supply , Leg Ulcer/diagnosis , Leg Ulcer/etiology , Physical Examination/methods , Pressure Ulcer/diagnosis , Pressure Ulcer/etiology , Pressure Ulcer/therapy , Prognosis , Risk Factors , Wound Infection/diagnosis , Wound Infection/therapyABSTRACT
Biofilms are diverse communities of microorganisms embedded within a self-produced matrix of extracellular polymeric substance which are firmly attached to biotic or abiotic surfaces. Approximately 80% of all human infections are associated with biofilms and evidence for their role in an ever-growing number of cutaneous disorders is constantly unfolding. Biofilms present a difficult challenge to clinicians due to their persistent nature, inability to be cultured with standard techniques, and resistance to conventional antimicrobial therapy. Although limited treatment options are presently available, better understanding of the molecular biology of biofilms and their pathogenicity will likely lead to the development of novel anti-biofilm agents for clinical use.
Subject(s)
Biofilms/growth & development , Skin Diseases, Bacterial/microbiology , Wounds and Injuries/microbiology , Anti-Infective Agents/therapeutic use , Biofilms/drug effects , Humans , Skin Diseases, Bacterial/drug therapyABSTRACT
Angiolymphoid hyperplasia with eosinophilia (ALHE) is a benign, uncommon idiopathic condition, characterized by cutaneous papules or nodules, whose etiopathogenesis is still unclear. It has been considered an angioproliferating lesion (epithelioid hemangioma) since histologically it is marked by a proliferation of blood vessels, accompanied by an inflammatory infiltrate, consisting mainly of lymphocytes and eosinophils. We present a case of ALHE assessed immunohistochemically for D2-40-a new marker for lymphatic endothelial cells. A biopsy specimen obtained from the same anatomical area of a healthy individual served as a normal control. The ALHE specimen showed increased number of lymphatic vessels when stained for D2-40, whereas the endothelial cells lining blood vessels were negative. The specificity of D2-40 for lymphatic vessels was further substantiated by studying Factor VIII-related antigen expression in consecutive sections of both ALHE and the control specimen. A reverse pattern was appreciated-blood vessels showed Factor VIII positive labeling, whereas lymphatic endothelial cells remained unlabeled. We therefore assume that apart from the lymphocytic infiltrate in the lesion, the recognized lymphoid component in ALHE is due to lymphatic vessel proliferation as well. Hence, this condition may be considered as possibly derived from lymphatic endothelium.
Subject(s)
Antibodies, Monoclonal , Endothelial Cells/pathology , Lip Diseases/pathology , Lymphatic Vessels/pathology , Aged , Angiolymphoid Hyperplasia with Eosinophilia/metabolism , Angiolymphoid Hyperplasia with Eosinophilia/pathology , Antibodies, Monoclonal, Murine-Derived , Endothelial Cells/metabolism , Female , Humans , Lip Diseases/metabolism , Lymphatic Vessels/metabolismABSTRACT
Psoriasis is highly prevalent and is associated with skin-associated complaints as well as arthritis, depression and a lower quality of life. Recently, it has been demonstrated that not only do patients with psoriasis have an increased prevalence of cardiovascular risk factors, but an increased risk of myocardial infarction, and for those with severe disease, increased mortality. Dermatologists and other health professionals need to be cognizant of this association and ensure that cardiovascular risk factors are evaluated and treated appropriately in those patients with psoriasis. We review the association between psoriasis, atherosclerosis and inflammation, as well as some treatable cardiovascular risk factors that may prove beneficial in reducing a patient's cardiovascular risk.
Subject(s)
Cardiovascular Diseases/etiology , Psoriasis/complications , Aspirin/therapeutic use , Cardiovascular Diseases/immunology , Diabetes Mellitus, Type 2/complications , Diabetic Angiopathies/complications , Dyslipidemias/complications , Female , Humans , Interleukin-2/metabolism , Male , Obesity/metabolism , Psoriasis/immunology , Risk Factors , Smoking/adverse effects , Smoking/metabolism , Th1 Cells/metabolism , Vascular Endothelial Growth Factor A/metabolismABSTRACT
AIM: Toxic epidermal necrolysis (TEN) is a severe drug reaction characterized by massive epidermal cell death. The authors of the current study and others have noted improved outcomes in TEN patients treated with human intravenous immunoglobulin (IVIG), purportedly due to its ability to inhibit the fas/fas-ligand (Fas-L) apoptotic pathway, but published case series evaluating TEN through the use of immunohistochemical antibody stains for Fas and Fas-L before and after IVIG treatment are lacking. The authors hypothesized that due to IVIG's ability to arrest the evolution of TEN, expression of Fas/Fas-L on keratinocytes would be decreased or absent following IVIG treatment. METHODS: Ten patients diagnosed with TEN underwent biopsies of their lesions prior to and five days after treatment with IVIG. Seven post-treatment biopsies were of sufficient quality to undergo evaluation. RESULTS: All ten pretreatment biopsies had Fas and Fas-L expression by immunohistochemistry, while six out of seven (85.7%) post-treatment biopsies failed to demonstrate Fas or Fas-L expression. One of seven post-treatment biopsies stained positive for Fas and Fas-L. CONCLUSION: This reduced immunohistochemical expression of apoptotic markers may represent IVIG inhibition of the pathogenic mechanism of TEN. Alternatively reduced Fas and Fas-L may be a feature of reepithelialization in TEN, or characteristic of rapidly proliferating epidermis.
Subject(s)
Fas Ligand Protein/drug effects , Immunoglobulins, Intravenous/therapeutic use , Immunologic Factors/therapeutic use , Stevens-Johnson Syndrome/pathology , Stevens-Johnson Syndrome/therapy , fas Receptor/drug effects , Adult , Apoptosis/drug effects , Biopsy , Female , Humans , Immunohistochemistry , Male , Middle Aged , Signal Transduction/drug effects , Stevens-Johnson Syndrome/immunology , Treatment OutcomeABSTRACT
BACKGROUND: Hidradenitis suppurativa (HS) is a chronic disease characterized by significant morbidity. Current medical therapies are only minimally effective at treating the disease. Infliximab is a chimeric monoclonal antibody with high affinity for tumour necrosis factor (TNF)-alpha. TNF-alpha is known to induce proinflammatory cytokines and may play an important role in the therapy of a number of disparate inflammatory disorders. Infliximab has shown promise for the therapy of rheumatoid arthritis and psoriasis. OBJECTIVES: Retrospectively to evaluate the effectiveness of infliximab for the treatment of HS. METHODS: A retrospective chart review was performed for patients who received infliximab at the University of Miami Department of Dermatology. Patients were contacted and asked retrospectively to rate their disease activity immediately prior to and after therapy. RESULTS: Patients' self-reported disease activity scores were significantly decreased (P = 0.0001, paired t-test) following infliximab infusion. This correlated with physician-observed clinical improvement. CONCLUSIONS: Infliximab is a promising agent for the treatment of HS. These initial results suggest that infliximab is associated with objective and subjective improvement in HS. Further controlled studies of the efficacy of infliximab and its effect on the course of the disease are warranted.
Subject(s)
Antibodies, Monoclonal/therapeutic use , Dermatologic Agents/therapeutic use , Hidradenitis Suppurativa/drug therapy , Adult , Female , Humans , Infliximab , Male , Middle Aged , Patient Satisfaction , Retrospective Studies , Severity of Illness Index , Treatment OutcomeABSTRACT
BACKGROUND: Mucocutaneous depositions of various metals such as silver, lead, gold, arsenic, mercury, iron, and bismuth have been previously published. Heavy metal deposition typically occurs in the setting of either prolonged topical application to intact skin, topical application to eroded or ulcerated skin, as a result of either parenteral administration, or due to penetrating traumatic exposure. METHOD: We report a unique case of mucocutaneous pigmentation occurring in a snow skier after topical application of a zinc-containing sunblock. Formalin-fixed paraffin-embedded tissue was utilized for electron microscopy. RESULT: Backscatter electron imaging and energy dispersive spectroscopy revealed that the dominant metal present was zinc. CONCLUSIONS: Mucocutaneous deposition of metals is enhanced by damage to the surface epithelium. Metal-containing topical agents, although commonly used, may rarely result in a permanent pigmentary alteration. We believe similar cases of mucocutaneous deposition of zinc exist; however, as these may be currently misdiagnosed as amalgam tattoos, the true incidence of this disorder is presently undefined.
Subject(s)
Dermis/drug effects , Hyperpigmentation/chemically induced , Mucous Membrane/drug effects , Zinc/adverse effects , Adult , Dermis/metabolism , Dermis/ultrastructure , Electron Probe Microanalysis , Female , Humans , Hyperpigmentation/metabolism , Hyperpigmentation/pathology , Microscopy, Electron, Scanning , Mucous Membrane/metabolism , Mucous Membrane/ultrastructure , Zinc/analysis , Zinc/metabolismABSTRACT
Venous thrombosis is a cause of considerable morbidity and mortality. Over the past several years, several new causes of thrombophilia have been identified and have dramatically altered the approach to patients presenting with thrombosis. Newly described abnormalities associated with thrombophilia include the syndrome of activated Protein C resistance (APCR), the prothrombin 20210A mutation, hyperhomocysteinemia, and elevated levels of coagulation factors VIII and XI. Clinicians can now frequently determine causes of thromboses that have previously been deemed idiopathic. Though the risk factors for VTE are becoming better defined, the cost-effective approach to diagnosis and therapeutic implications are not entirely clear at this point.
Subject(s)
Venous Thrombosis/etiology , Activated Protein C Resistance/complications , Activated Protein C Resistance/genetics , Anticoagulants/therapeutic use , Contraceptives, Oral/adverse effects , Factor V/genetics , Factor VIII/metabolism , Factor XI/metabolism , Female , Humans , Hyperhomocysteinemia/complications , Mutation , Pregnancy , Prothrombin/genetics , Risk Factors , Thromboembolism/etiology , Thrombophilia/etiology , Venous Thrombosis/drug therapySubject(s)
Collagen , Leg Ulcer/surgery , Skin Transplantation , Skin, Artificial , Adult , Aged , Aged, 80 and over , Chronic Disease , Female , Humans , Male , Middle Aged , Treatment Outcome , Wound HealingABSTRACT
Currently, only a minority of dermatologists participate in the primary hospital care of patients with severe skin disease. However, an opportunity exists to alter this course. We believe the current course is a detriment to our specialty, and as a specialists we should provide the care for the full spectrum of dermatologic diseases. Moreover, by not delivering complete dermatology care, our specialty also stands to lose respect from both our patients and peers. Our experience at UM suggests that the creation of a cadre of dermatology hospitalists at selected academic medical centers would allow improved patient hospital care, education, and research.
Subject(s)
Dermatology , Hospitalists , Hospitalization , Skin Diseases/therapy , Clinical Protocols , Dermatology/organization & administration , Dermatology/statistics & numerical data , Diagnosis-Related Groups , Hospital Departments/organization & administration , Hospitalization/statistics & numerical data , Humans , Patient Admission/standardsABSTRACT
BACKGROUND: Cutaneous disease is commonly encountered in primary care. The frequency of patients presenting to primary care physicians with skin disease and their eventual disposition is not well studied. OBJECTIVE: The purpose of this study was to determine the prevalence of patients seen with skin disease in a primary care setting and the likelihood of their referral to a dermatologist. The impact the primary care provider had on the quality of skin care was also examined. METHODS: A retrospective chart review was performed of patients seen during a 2-year period at a general medicine clinic within the University of Miami and upon referral to a University of Miami dermatology office. Data were obtained on the prevalence of skin disease, dispositions of referral, diagnoses made, and procedures performed. RESULTS: During a 2-year period, 36.5% of patients who presented to their primary care physician had at least one skin problem. Of 208 patients with skin disease, in 58.7% (122/208) it was their chief complaint. A wide range of diagnoses were made by the primary care physician, with a limited number of diagnostic procedures performed. Of the 37.5% of patients referred to a dermatologist, 68% were referred on initial evaluation. Diagnoses made by the primary care physician were concordant with that made by the dermatologists 57% of the time. CONCLUSION: Patients frequently see their primary care physician for skin disease. A large percentage are referred to dermatologists, often for a biopsy of a suspect lesion, to confirm a suspected diagnosis, or to establish a diagnosis of lesions of unknown origin.
Subject(s)
Primary Health Care/statistics & numerical data , Skin Diseases/diagnosis , Skin Diseases/therapy , Adult , Dermatology , Female , Humans , Male , Referral and Consultation , Retrospective StudiesABSTRACT
BACKGROUND: Primary care providers (PCPs) have limited training in recognizing common skin disorders, and additional emphasis may be placed on laboratory evaluation, including skin biopsies. METHODS: Primary care providers in Miami, Fla, were surveyed regarding skin biopsy and excision practices and histologic interpretation. They then participated in an examination, using 20 high-quality color photographs of common dermatologic disorders. RESULTS: Of the 80 PCPs who participated, 42% currently do skin biopsies and consult general pathologists for interpretation. Another 20% of PCPs intend to do biopsies within the next 5 years. Only 33% prefer to have a dermatopathologist interpret histopathology. We found no correlation between PCPs' scores on diagnostic testing and whether they do skin biopsies. CONCLUSION: Nearly all PCPs doing skin biopsies in our study sample use general pathologists to interpret histopathology. The limited training in clinical dermatology of both PCPs and general pathologists may result in compromised clinical-pathologic correlation.
Subject(s)
Clinical Competence , Family Practice , Internal Medicine , Referral and Consultation , Skin Diseases/pathology , Biopsy , Dermatology , Female , Florida , Humans , Male , Pathology , Practice Patterns, Physicians' , Statistics, NonparametricABSTRACT
Venous thrombosis is a cause of considerable morbidity and is often responsible for chronic venous disorders that frequently lead to visits to dermatologists and others involved in wound healing. Over the past several years, many new causes of thrombophilia have been identified and have dramatically altered the approach to patients presenting with thrombosis. Newly described abnormalities associated with thrombophilia include the syndrome of activated protein C resistance, the prothrombin 20210A mutation, hyperhomocysteinemia, and elevated levels of coagulation factors VIII and XI. Clinicians can now frequently determine causes of thromboses that have previously been deemed idiopathic.
Subject(s)
Blood Coagulation Disorders , Activated Protein C Resistance/blood , Activated Protein C Resistance/etiology , Anticoagulants/therapeutic use , Blood Coagulation Disorders/blood , Blood Coagulation Disorders/drug therapy , Blood Coagulation Disorders/etiology , Contraceptives, Oral/adverse effects , Factor V/metabolism , Female , Humans , Hyperhomocysteinemia/complications , Mutation , Pregnancy , Pregnancy Complications, Cardiovascular/etiology , Prothrombin/genetics , Recurrence , Risk Factors , Warfarin/therapeutic useABSTRACT
UNLABELLED: Venous ulcers are the most common form of leg ulcers. Venous disease has a significant impact on quality of life and work productivity. In addition, the costs associated with the long-term care of these chronic wounds are substantial. Although the exact pathogenic steps leading from venous hypertension to venous ulceration remain unclear, several hypotheses have been developed to explain the development of venous ulceration. A better understanding of the current pathophysiology of venous ulceration has led to the development of new approaches in its management. New types of wound dressings, topical and systemic therapeutic agents, surgical modalities, bioengineered tissue, matrix materials, and growth factors are all novel therapeutic options that may be used in addition to the "gold standard," compression therapy, for venous ulcers. This review discusses current aspects of the epidemiology, pathophysiology, clinical presentation, diagnostic assessment, and current therapeutic options for chronic venous insufficiency and venous ulceration. (J Am Acad Dermatol 2001;44:401-21.) LEARNING OBJECTIVE: At the conclusion of this learning activity, participants should be familiar with the 3 main types of lower extremity ulcers and should improve their understanding of the epidemiology, pathogenesis, risk factors, clinical presentation, diagnostic assessment, and current therapies for chronic venous insufficiency and venous ulcers.
Subject(s)
Bandages , Varicose Ulcer/physiopathology , Varicose Ulcer/therapy , Vascular Surgical Procedures/methods , Anti-Bacterial Agents/therapeutic use , Debridement , Growth Substances/therapeutic use , Humans , Leg/blood supply , Risk FactorsABSTRACT
OBJECTIVE: To ascertain the patient's perspective on dermatologic care provided by primary care providers (PCPs) or dermatologists. DESIGN: Cross-sectional survey of patients drawn from primary care and dermatology clinics. SETTING: Academic Veterans Affairs medical center. PATIENTS: Convenience sample of patients in either a primary care or a dermatology clinic. INTERVENTION: Survey questionnaire. MAIN OUTCOME MEASURES: Patients' confidence in having their skin problems cared for by PCPs and dermatologists and satisfaction with previous care rendered. RESULTS: A total of 137 patients in the primary care clinic (group 1) and 100 patients in the dermatology clinic (group 2) participated. Patients (N = 237) expressed confidence in their PCP's ability to treat rashes (62%), diagnose skin cancer (65%), perform skin biopsies (60%), "freeze" lesions with liquid nitrogen (50%), and perform cutaneous surgery (46%). Group 2 patients were significantly less likely to have confidence in their PCP than group 1 patients for all measures other than the use of liquid nitrogen. High levels of confidence were expressed in a dermatologist's ability for all 5 measures: 92%, 91%, 92%, 83%, and 85%, respectively. Patients were more confident in dermatologists' abilities to perform these procedures compared with PCPs (P<.001 for all comparisons). Of patients previously treated for skin disorders, there was a high rate of satisfaction with the treatment rendered by PCPs (81% for group 1 and 75% for group 2) and by dermatologists (92% for group 1 and 90% for group 2). However, patient satisfaction was higher for dermatology vs primary care for the treatment of skin disease (P<.001). Direct access to dermatologists was preferred. CONCLUSIONS: Although patients have confidence in their PCP to care for their skin disease, they have greater confidence in the care provided by dermatologists. Among patients previously treated for skin disease, satisfaction was higher with care rendered by dermatologists vs PCPs. Most patients prefer direct access to dermatologists should they develop a skin problem.