A review of bubble hair deformity.

Bubble hair deformity is an acquired abnormality characterized by air-filled cavity formations within the hair shaft, usually because of heat damage. Traditionally, bubble hair is diagnosed by visualization of characteristic bubbles under light microscopy. The increased utilization of trichoscopy (scalp dermoscopy) has led to its adoption in the diagnosis of many hair and scalp conditions, including bubble hair deformity. We sought to review clinical reports evaluating the patient profile, use of diagnostic imaging, and treatment options for bubble hair deformity. A systematic search of PubMed was performed in February 2021 using various keywords. Titles and abstracts were screened, leading to the selection of 11 case reports or series. The majority of patients were middle-aged Caucasian women who had used a heated tool to dry or style wet hair. Treatment consisted of cessation of heated tool usage. Light microscopy visualization of characteristic hair shaft cavities was used for diagnosis of bubble hair deformity in reports published prior to 2012. Diagnosis by trichoscopy was used in more recent reports. Our findings support the use of trichoscopy as a convenient and noninvasive method of diagnosing bubble hair deformity. More clinical studies are needed to evaluate the development of bubble hair deformity in ethnic hair.

Mycobacterium abscessus infection in a patient with ornithine transcarbamylase deficiency and liver transplant.

Rapidly growing mycobacteria, including Mycobacterium abscessus, have become a common cause of post-procedural infections and are notoriously difficult to diagnose and treat. Here, we report a 10-month-old male status post-orthotopic liver transplantation due to ornithine transcarbamylase deficiency who presented with a 4-month history of hypertrophic and friable granulation tissue of surgical wounds refractory to treatment with broad spectrum antibiotics and surgical debridement. Skin biopsy and tissue culture yielded a diagnosis of M abscessus infection that demonstrated excellent clinical response to appropriate antibiotic and surgical treatment.

Dermatomyositis and malignancy: should all patients with dermatomyositis undergo malignancy screening?

Dermatomyositis is an autoimmune disease that occurs in association with underlying malignancy in a subset of patients. Given this association, diagnosis of dermatomyositis typically triggers malignancy screening. Although various malignancy screening protocols have been proposed, none have been extensively studied or taken into account prevalence of dermatomyositis-associated malignancies. We utilized peer-reviewed manuscripts identified by a Medline search from May 2000 to April 2020 to present a focused review concerning the association between dermatomyositis and malignancy, and controversies related to screening for malignancies most commonly occurring in dermatomyositis patients. This information was then synthesized to propose a rational strategy for approaching malignancy screening in dermatomyositis patients. Our review supports that risk of malignancy in dermatomyositis patients is well-established. However, the subset of dermatomyositis patients in whom the benefits of malignancy screening outweigh the risks of harm is unknown. Additionally, an evidence-based malignancy screening protocol for dermatomyositis patients that optimizes the risk:benefit ratio does not exist. Given the clear harms that can result, we propose that shared decision-making strategies be implemented to determine whether pursuit of malignancy screening conforms with dermatomyositis patients' desires and values. Physicians should be clear about potential risks and benefits of malignancy screening, and discuss clinical and serologic features present that may suggest/refute underlying malignancy during conversations aimed at shared decision-making. Research is greatly needed to determine which dermatomyositis patients warrant malignancy screening, which tests should be performed, and the intensity with which they should be ordered. Only after such work is done can malignancy screening in dermatomyositis patients be considered to have high value.

Case of Bullous Grover Disease.

ABSTRACT: Grover disease is an acquired acantholytic dermatosis affecting middle-aged men, with pruritus being the most commonly associated symptom. Grover disease tends to wax and wane and can last between several months to several years. Although Grover disease is usually papular, we report here a patient who presented with mainly vesicular and bullous lesions on his back originally concerning for folliculitis, contact dermatitis, or disseminated herpes simplex viral infection. Skin biopsy demonstrated acantholysis, suprabasal blisters, and a predominantly lymphocytic dermal infiltrate. Tzanck preparation for giant cells, immunohistochemistry for viral markers, and direct immunofluorescence staining were all negative. A diagnosis of bullous Grover disease was made based on clinicopathological correlation. Minocycline was recommended based on report of its efficacy. However, patient declined treatment and his rash self-resolved within a couple of months. This case brings awareness to this atypical variant of Grover disease and encourages physician to include Grover disease in their differential of vesiculobullous disorders.

US Dermatology Resident Responses about the COVID-19 Pandemic: Results from a Nationwide Survey.

OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic has drastically changed resident training in the United States. Here, we explore the early perceived effects of COVID-19 on dermatology residents through an electronic sample survey and identify possible areas for targeted improvement in lieu of a possible second wave of COVID-19 cases. METHODS: On April 3, 2020, a survey of link with 25 questions was sent to dermatology program coordinators to be disseminated among dermatology residents in the United States. The survey was closed on April 13, 2020. All of the questions were optional and no personal identifiers were collected. RESULTS: A total of 140 dermatology residents from 50 different residency programs across 26 states responded to the survey. The majority of respondents (85%) reported negative effects of COVID-19 on their overall wellness. Despite the majority of residents (92%) speculating that COVID-19 will have negative long-term effects on the US economy, only 33% agreed or strongly agreed that it will affect their job prospects. Teledermatology was widely implemented following the declaration of a national emergency (96% of represented residencies compared with only 30% before the pandemic), with heavy resident involvement. The majority of residents (99%) reported having virtual didactics and that they found them to be beneficial. Most residents were uncomfortable with the prospect of being reassigned to a nondermatology specialty during the pandemic. In addition, 22% of residents believed that their leadership were not transparent and prompt in addressing changes relating to COVID-19. CONCLUSIONS: Dermatology residents were affected negatively by COVID-19 in regard to their well-being, clinical training, and education. Several areas of improvement were identified that could improve our preparedness for a second wave of the virus.

Evidence-based best practice advice for patients treated with systemic immunosuppressants in relation to COVID-19.

The emergence of the COVID-19 pandemic has led to significant uncertainty among physicians and patients about the safety of immunosuppressive medications used for the management of dermatologic conditions. We review available data on commonly used immunosuppressants and their effect on viral infections beyond COVID-19. Notably, the effect of some immunosuppressants on viruses related to SARS-CoV2, including SARS and MERS, has been previously investigated. In the absence of data on the effect of immunosuppressants on COVID-19, these data could be used to make clinical decisions on initiation and continuation of immunosuppressive medications during this pandemic. In summary, we recommend considering the discontinuation of oral Janus kinase (JAK) inhibitors and prednisone; considering the delay of rituximab infusion; and suggesting the careful continuation of cyclosporine, mycophenolate, azathioprine, methotrexate, and biologics in patients currently benefitting from such treatments.

Polymyxin B-induced skin hyperpigmentation.

Polymyxin B (PMB) is a potent antibiotic targeting gram-negative bacteria and is associated with serious side effects including nephrotoxicity, neurotoxicity, and hypersensitivity reactions. PMB is a therapeutic option for the management of infections caused by multi-drug-resistant (MDR) bacteria and used in combination with other antibiotics when options are limited. We describe the case of a 30-year-old female patient with a complex medical history who underwent a multi-visceral transplantation complicated by intra-abdominal infections. Subsequently, patient developed diffuse skin darkening after initiation of intravenous PMB for treatment of MDR Pseudomonas aeruginosa. Her skin hyperpigmentation was most prominent on her face and forearms. Hyperpigmentation peaked at around 2 weeks following PMB initiation and was discontinued after 3 weeks when the possibility of PMB hyperpigmentation was raised and other causes were ruled out. Skin biopsy showed hypermelanosis of the basal layer and melanin deposition in the dermis. Overall clinical picture was consistent with PMB-induced hyperpigmentation. The patient demonstrated some improvement in discoloration within 4 weeks of PMB discontinuation.

The influence of the menstrual cycle on acute and persistent pain after laparoscopic cholecystectomy / A influência do ciclo menstrual na dor aguda e persistente após colecistectomia laparoscópica

Abstract Background and objectives: Fluctuations of female sex hormones during menstrual cycle influence pain perception. Endogenous pain inhibition is impaired in follicular phase of menstrual cycle. We tested the primary hypothesis that the women having surgery during their follicular phase have more acute pain and require higher opioids than those in the luteal phase, and secondarily we tested that women who have surgery during their follicular phase have more incisional pain at 3 month postoperatively. Methods: 127 adult females having laparoscopic cholecystectomy were randomized to have surgery during the luteal or follicular phase of their menstrual cycle. Standardized anesthesia and pain management regimen was given to all patients. Pain and analgesic consumption were evaluated in post-anesthesia care unit and every 4 h in the first 24 h. Adverse effects were questioned every 4 h. Time to oral intake and ambulation were recorded. Post-surgical pain, hospital anxiety, depression scale, SF-12 questionnaire were evaluated at 1 and 3 month visits. Results: There was no difference in acute pain scores and analgesic consumption through the 24 h period, Visual Analog Scale at 24 h was 1.5 ± 1.5 cm for follicular group 1.4 ± 1.7 cm for luteal group (p = 0.57). Persistent postoperative pain was significantly more common one and at three month, with an incidence was 33% and 32% in the patients at follicular phase versus 16% and 12% at luteal phase, respectively. The Visual Analog Scale at one and at three month was 1.6 ± 0.7 cm and 1.8 ± 0.8 cm for follicular group and 2.7 ± 1.3 cm and 2.9 ± 1.7 cm in the luteal group (p = 0.02), respectively. There were no significant differences between the groups with respect to anxiety and depression, SF-12 scores at either time. Nausea was more common in follicular-phase group (p = 0.01) and oral feeding time was shorter in follicular phase (5.9 ± 0.9 h) than in luteal phase (6.8 ± 1.9 h, p = 0.02). Conclusions: Although persistent postoperative pain was significantly more common one and three months after surgery the magnitude of the pain was low. Our results do not support scheduling operations to target particular phases of the menstrual cycle.

Resumo Justificativa e objetivos: As flutuações dos hormônios sexuais femininos durante o ciclo menstrual influenciam a percepção da dor. A inibição endógena da dor é prejudicada na fase folicular do ciclo menstrual. Testamos a hipótese primária de que cirurgias em mulheres durante a fase folicular têm mais dor aguda e precisam de mais opioide do que aquelas na fase lútea e a hipótese secundária testada foi que as cirurgias em mulheres durante a fase folicular têm mais dor incisional aos três meses de pós-operatório. Métodos: No total, 127 mulheres adultas submetidas à colecistectomia laparoscópica foram randomizadas para serem operadas durante a fase lútea ou folicular de seus ciclos menstruais. Um regime padronizado para anestesia e tratamento da dor foi administrado a todas as pacientes. A dor e o consumo de analgésico foram avaliados na sala de recuperação pós-anestésica e a cada quatro horas nas primeiras 24 horas. Efeitos adversos foram avaliados a cada quatro horas. Os tempo para ingestão oral e deambulação foram registrados. Dor pós-cirúrgica, ansiedade hospitalar, escala de depressão e questionário SF-12 foram avaliados em visitas feitas no primeiro e terceiro meses. Resultados: Não houve diferença nos escores de dor aguda e no consumo de analgésicos durante o período de 24 horas, Escala Visual Analógica em 24 horas foi de 1,5 ± 1,5 cm para o grupo folicular e 1,4 ± 1,7 cm para o grupo lúteo (p = 0,57). A dor persistente no pós-operatório foi significativamente mais prevalente no primeiro e terceiro mês, com incidência de 33% e 32% nas pacientes em fase folicular versus 16% e 12% na fase lútea, respectivamente. A Escala Visual Analógica no primeiro e terceiro mês foi 1,6 ± 0,7 cm e 1,8 ± 0,8 cm no grupo folicular e 2,7 ± 1,3 cm e 2,9 ± 1,7 cm no grupo lúteo (p = 0,02), respectivamente. Não houve diferença significativa entre os grupos em relação à ansiedade e à depressão, escore SF-12 em ambos os tempos. Náusea foi mais comum no grupo na fase folicular (p = 0,01) e o tempo para alimentação oral foi menor na fase folicular (5,9 ± 0,9 horas) do que na fase lútea (6,8 ± 1,9 horas, p = 0,02). Conclusões: Embora a dor persistente no pós-operatório tenha sido significativamente mais prevalente no primeiro e no terceiro mês após a cirurgia, a magnitude da dor foi baixa. Nossos resultados não apoiam o agendamento de cirurgias tendo como alvo fases específicas do ciclo menstrual.

[The influence of the menstrual cycle on acute and persistent pain after laparoscopic cholecystectomy]. / A influência do ciclo menstrual na dor aguda e persistente após colecistectomia laparoscópica.

BACKGROUND AND OBJECTIVES: Fluctuations of female sex hormones during menstrual cycle influence pain perception. Endogenous pain inhibition is impaired in follicular phase of menstrual cycle. We tested the primary hypothesis that the women having surgery during their follicular phase have more acute pain and require higher opioids than those in the luteal phase, and secondarily we tested that women who have surgery during their follicular phase have more incisional pain at 3 month postoperatively. METHODS: 127 adult females having laparoscopic cholecystectomy were randomized to have surgery during the luteal or follicular phase of their menstrual cycle. Standardized anesthesia and pain management regimen was given to all patients. Pain and analgesic consumption were evaluated in post-anesthesia care unit and every 4h in the first 24h. Adverse effects were questioned every 4h. Time to oral intake and ambulation were recorded. Post-surgical pain, hospital anxiety, depression scale, SF-12 questionnaire were evaluated at 1 and 3 month visits. RESULTS: There was no difference in acute pain scores and analgesic consumption through the 24h period, Visual Analog Scale at 24h was 1.5±1.5cm for follicular group 1.4±1.7cm for luteal group (p=0.57). Persistent postoperative pain was significantly more common one and at three month, with an incidence was 33% and 32% in the patients at follicular phase versus 16% and 12% at luteal phase, respectively. The Visual Analog Scale at one and at three month was 1.6±0.7cm and 1.8±0.8cm for follicular group and 2.7±1.3cm and 2.9±1.7cm in the luteal group (p=0.02), respectively. There were no significant differences between the groups with respect to anxiety and depression, SF-12 scores at either time. Nausea was more common in follicular-phase group (p=0.01) and oral feeding time was shorter in follicular phase (5.9±0.9h) than in luteal phase (6.8±1.9h, p=0.02). CONCLUSIONS: Although persistent postoperative pain was significantly more common one and three months after surgery the magnitude of the pain was low. Our results do not support scheduling operations to target particular phases of the menstrual cycle.

Skin findings associated with nutritional deficiencies.

Certain vitamin and mineral deficiencies may be recognized by their cutaneous signs. This case-based article reviews deficiencies of zinc and vitamins A, B2, B3, B6, and C, discussing their consequences and skin findings.

Dermatology consultations significantly contribute quality to care of hospitalized patients: a prospective study of dermatology inpatient consults at a tertiary care center.

BACKGROUND: Cutaneous abnormalities are common in hospitalized patients but are frequently missed or misdiagnosed by admitting teams. Inpatient dermatology consultations provide important information to help diagnose and manage these patients. However, few studies have analyzed dermatology inpatient consultations and their effect. METHODS: We prospectively collected information for 691 consecutive dermatology consultations from November 2013 to November 2014. RESULTS: Patients ranged in age from newborns to 97 years old. The internal medicine service requested the most consultations (45%). Only 6.5% of consultations were requested within 24 hours of appearance of cutaneous findings. Before consultation, 70.3% of patients did not receive treatment for or based on their cutaneous findings. Dermatology consultation resulted in treatment change in 81.9% of patients. The most common diagnoses were drug rash and contact dermatitis. Biopsies confirmed 71.7% of the initial bedside diagnoses by the dermatology consultation team. CONCLUSIONS: Common skin diseases were responsible for the majority of dermatology consultations. Most patients were not treated for their cutaneous conditions before the dermatology consultation. Dermatology consultations resulted in treatment changes in the majority of cases.

Effect of statin use on pain relief by transforaminal epidural steroid injection.

AIM: To investigate the impact of statin use on response to fluoroscopy-assisted transforaminal anterior epidural steroid injection (TAESI). METHODS: Patients undergoing TAESI for low back pain were recruited and stratified according to statin use. Pain was evaluated with a visual analogue scale (VAS) before and at 1, 3, and 6 months after TAESI. Health-related quality-of-life was evaluated using the Short Form 36 (SF-36) questionnaire 6 months after TAESI. RESULTS: There were no significant differences in VAS scores after TAESI between statin users (n = 40) and statin nonusers (n = 253). The SF-36 subgroup: role limitations due to emotional problems score was significantly lower in statin users than statin nonusers. There were no significant between-group differences in any other SF-36 parameter. CONCLUSION: Statin use had no effect on pain scores after TAESI.