The Association of Academic Cosmetic Dermatology: improving cosmetic dermatology education through collaboration, research, and advocacy.

Cosmetic and laser procedures are increasingly popular among patients and are skills in which dermatologists are regarded as well trained. Most dermatology residents intend to incorporate cosmetic procedures into their practice and prefer to learn such procedures during residency through direct patient care. However, there are notable challenges in optimizing how residents are trained in cosmetic and laser dermatology. To address these barriers and elevate the practice of cosmetic dermatology in academic medicine, the Association of Academic Cosmetic Dermatology (AACD) was founded in 2021 as the lead professional society for dermatologists who direct the education of resident trainees in cosmetic and laser dermatology. The AACD, a group of board-certified dermatologists who teach cosmetic and laser dermatology to residents, aims to improve cosmetic dermatology education through collaboration, research, and advocacy.

Needs and Gaps in Resident Trainee Education, Clinical Patient Care, and Clinical Research in Cosmetic Dermatology: Position Statement of the Association of Academic Cosmetic Dermatology.

Cosmetic dermatology is a key subspecialty of academic dermatology. As such, academic centers are expected to demonstrate excellence in the teaching of cosmetic dermatology skills to trainees, the clinical delivery of cosmetic dermatology services to patients, and the performance of clinical research that advances knowledge and uncovers new therapies in cosmetic dermatology. The Association of Academic Cosmetic Dermatology (AACD), a newly formed medical professional society, includes as its principal aims the support of all of these areas. AACD is comprised of group of board-certified dermatologists who teach cosmetic and laser dermatology at US dermatology residency programs. An expert panel constituted by the AACD recently convened a workshop to review gaps pertaining to academic cosmetic dermatology. This panel considered needs and potential corrective initiatives in three domains: resident education, patient experience, and clinical research. The work of the panel was used to develop a roadmap, which was adopted by consensus, and which will serve to guide the AACD moving forward.

Severe acne and its variants: Exploring its natural history and heritability.

BACKGROUND: Acne vulgaris varies in clinical severity, from minimal comedonal disease to severe hemorrhagic and ulcerative lesions with scarring. While a family history confers a higher risk for developing acne, the correlation between heritability and clinical severity remains unclear. OBJECTIVE: To examine the natural history and heritability of severe acne with scarring in patients undergoing isotretinoin therapy. METHODS: A total of 101 subjects with severe acne with scarring and its variants, including acne conglobata and acne fulminans, were enrolled. All subjects and adult family members underwent an interview regarding their acne, and a corresponding "historical" Investigator's Global Assessment (hIGA) score (0 = clear, 1 = almost clear, 2 = mild, 3 = moderate, 4 = severe, 5 = very severe) was assigned. Study assessors performed an "examination" Investigator's Global Assessment (eIGA) based on the clinical examination of each subject (0 = clear, 1 = almost clear, 2 = mild, 3 = moderate, 4 = severe, 5 = very severe). A detailed family history and pedigree were documented. RESULTS: Most subjects were Caucasian (44.5%) and male (79.2%) who had previously used doxycycline and/or minocycline (86.1%). The mean eIGA and hIGA scores were 2.7 and 4.4, respectively. 37.2% of subjects had one first-degree relative with a history of moderate or severe acne with scarring; of note, of the patients with hemorrhagic disease, 30% had at least one parent with moderate or severe acne. CONCLUSIONS: Severe forms of acne often "cluster" in families, underscoring the heritable nature of acne and the prognostic value of a family history of moderate or severe disease.

Treating melasma with the 1064 nm Nd:YAG laser with a 650-microsecond pulse duration: A clinical evaluation.

BACKGROUND: The effective treatment of melasma remains a challenge that necessitates a multifaceted approach that includes strict sun protection, bleaching creams, chemical peels, and laser therapy. The 1064 nm Nd:YAG laser with a 650-microsecond pulse duration provides a safe option for all skin types. METHODS: We treated 10 patients with the 1064 nm Nd:YAG laser with a 650-microsecond pulse duration. Treatments were performed every 2-4 weeks. RESULTS: Using a conservative treatment protocol, lightening of melasma occurred as early as 3 weeks post-treatment, with all subjects requiring several treatment sessions to achieve adequate resolution of their melasma. The majority of subjects experienced up to 25% improvement after two treatments, and an even more noticeable improvement after the 3rd treatment session. None reported any associated pain or discomfort. CONCLUSIONS: Advantages of this laser modality include essentially no pain or downtime, lower risk of rebound, and the ability to safely treat all skin types with melasma. Therefore, the 1064 nm Nd:YAG laser with a 650-microsecond pulse duration serves as a treatment option for melasma.

The perception bias of aesthetic providers.

Since there is no universal standard of beauty, each aesthetic provider's definition may shape his/her practice of aesthetic procedures. Beauty and attractiveness are commonly defined by both mathematical and cultural influences and are shaped by our surroundings and what is most familiar to us. Therefore, we thoroughly explored the literature to better elucidate these variables and biases that affect the perception of beauty, in order to better provide appropriate and customized aesthetic procedures that preserve each individuals' own unique beauty. Understanding how each provider's own bias and aesthetic preferences differs from that of his/her patients may go a long way to improving communication in the consultation process and patient satisfaction with the outcomes achieved. We know that clinicians many times superimpose their biases onto their patients, so it is important that each practitioner accounts for bias in aesthetic medicine when consulting with patients and colleagues.

A Rare Presentation of Basal Cell Carcinoma Arising within Trichoepithelioma: A Diagnostic Challenge.

Differentiating between trichoepithelioma and basal cell carcinoma (BCC) is sometimes diagnostically challenging. We present a case of a 61-year-old male with a BCC arising within a trichoepithelioma, which is rarely reported in the literature. Clinical and histological diagnosis of trichoepithelioma is sometimes complicated by its many similarities to BCC. Therefore, immunohistochemical analysis and adequate tissue sampling are essential in suspicious lesions. In addition, as represented by our patient's presentation, it is important for clinicians to remember that the presence of a concurrent malignant neoplasm may be masked by the benign nature of a trichoepithelioma and that a superficial shave biopsy may not be sufficient for accurately diagnosing such suspicious lesions.

The perception of procedural vascular laser pain and discrepancies amongst patients, physicians, and industry.

BACKGROUND: The inherent subjectivity of pain perception makes pre-procedural pain counseling especially challenging. Setting the wrong pain expectations will negatively impact the patient's experience and affect their physiologic and emotional state. Best practices for sourcing pain related information about a given procedure, however, remains understudied. This retrospective study explores the accuracy of industry materials for describing procedural pain in a clinical trial when compared to subject reported pain scores from the same clinical trial. METHODS: Median and mode pain scores were collected from the data of a past clinical trial investigating a dual wavelength laser used for 4 different types of treatments. Industry provided materials were reviewed to ascertain language regarding procedural pain. The principal investigator was interviewed about setting pain expectations during the trial. Subject-reported pain scores and verbal pain descriptors were transferred to validated pain scales, the Numerical Rating Scale and the Verbal Rating Scale, for comparison. RESULTS: A total of 85 procedural pain scores were collected from 22 subject charts. The average procedural pain scores for 3 of 4 treatment types reported by subjects were translated to entirely different verbal and numerical categories of pain than that described by industry materials. CONCLUSIONS: Industry materials failed to capture the range of procedural pain scores reported by subjects for 3 of 4 treatment types in a clinical trial setting. When counseling patients on procedural pain, physicians should take extra care to not mislead patients and cause undue physiological or emotional stress.

Speckled lentiginous nevus: A rare presentation associated with motor neuropathy and muscular atrophy in a child.

Speckled lentiginous nevus syndrome has been described in individuals with a speckled lentiginous nevus with rare associated neurologic deficits. Because speckled lentiginous nevus syndrome almost always affects adults, it is not typically considered when evaluating children. We present the first reported case of speckled lentiginous nevus syndrome presenting in a young child with muscle atrophy and motor deficits affecting muscles along the same distribution as the speckled lentiginous nevus.

Pediatric dermatology procedures and pearls: Multimodal revision of earlobe keloids.

Keloid scars are benign proliferations of fibrous tissue and collagen that usually occur in response to cutaneous injury. Many treatment modalities have been described in the literature, with variable rates of recurrence and no clear consensus. Keloids remain a therapeutic challenge to patients and physicians alike. Herein we describe a novel technique for treating recurrent earlobe keloids in an outpatient setting with multimodal therapy including shave removal followed immediately by ablative fractional laser resurfacing (AFR) and laser-assisted delivery (LAD) of corticosteroids.

Evidence-based recommendations for the management of acne fulminans and its variants.

BACKGROUND: Acne fulminans (AF) is a severe variant of inflammatory acne. It typically manifests as an explosive worsening and ulceration of skin lesions, and can be associated with systemic symptoms. However, there is a paucity of evidence-based information and no clear guidelines concerning the classification and treatment of AF. OBJECTIVE: To better define the spectrum of AF and its variants, devise optimal therapeutic approaches, and identify areas of future research. METHODS: A panel of physicians with expertise in severe acne vulgaris was convened after a comprehensive literature review of severe acne variants. Priority topics were reviewed and presented by each panelist at a 5-hour conference. Following review of the audiotape and scribed notes from the conference, surveys were utilized to address points of controversy and to clarify consensus recommendations. RESULTS: Appropriate clinical case presentations and consensus survey questions were utilized to create final recommendations based on both the literature and the expert consensus. LIMITATIONS: Limited evidenced-based data and prospective studies in the literature concerning the treatment of AF is available. CONCLUSION: These guidelines better characterize AF and provide health care practitioners approaches to the classification, treatment, and prevention of AF and its variants.

Erythrasma: A report of nine men successfully managed with mupirocin 2% ointment monotherapy.

BACKGROUND: Erythrasma is a benign dermatosis that typically occurs on intertriginous skin. PURPOSE: We describe a series of nine men with erythrasma that were successfully treated with mupirocin 2% ointment monotherapy. METHODS AND MATERIALS: We reviewed PubMed for the following terms: erythrasma, mupirocin, ointment, treatment. We also reviewed papers containing these terms and their references. RESULTS: Complete resolution of erythrasma occurred following monotherapy with twice daily application of mupirocin 2% ointment. CONCLUSIONS: Several topical and oral treatments are available to successfully manage erythrasma. Our series of patients with erythrasma experienced resolution with mupirocin 2% ointment treatment within 2 to 4 weeks of therapy. Monotherapy with mupirocin 2% ointment should be considered as a primary treatment alternative for erythrasma.

Squamous Cell Carcinoma In Situ Upstaged to Invasive Squamous Cell Carcinoma: A 5-Year, Single Institution Retrospective Review.

BACKGROUND: Shave biopsy may not be able to accurately distinguish squamous cell carcinoma in situ (SCCIS) from invasive squamous cell carcinoma (SCC). Information on the incidence of biopsy-proven SCCIS upstaged to SCC after a more complete histologic examination is limited. OBJECTIVE: To determine the incidence and clinical risk factors associated with upstaging the biopsy diagnosis of SCCIS into invasive SCC based on findings during Mohs micrographic surgery (MMS). METHODS: All MMS cases of SCCIS performed between March 2007 and February 2012 were identified, MMS operative notes were examined, and invasive dermal components were confirmed by the MMS slide review. Upstaged SCCIS was defined as biopsy-diagnosed SCCIS subsequently found to be an invasive SCC during MMS. RESULTS: From 566 cases with the preoperative diagnosis of SCCIS, 92 (16.3%) cases were SCCIS upstaged to SCC. Location of ears, nose, lips, and eyelids, preoperative diameter >10 mm, and biopsy report mentioning a transected base were significant predictors of upstaged SCCIS. CONCLUSION: Considering the possibility that over 16% of SCCIS may be truly invasive SCC, biopsy-proven SCCIS should be treated adequately with margin-assessed treatment modalities such as surgical excision or Mohs surgery when indicated.

Non-invasive methods to establish the diagnosis of terra firma-forme dermatosis: The SMART (Skin Modified by Alcohol Rubbing Test) evaluation and dermoscopy.

Terra firma-forme dermatosis may mimic a variety of hyper pigmented dermatoses.  The diagnosis can be characterized using dermoscopy and confirmed with the SMART (Skin Modified by Alcohol Rubbing Test) evaluation.  When terra firma-forme dermatosis (Duncan's dirty dermatosis) is clinically suspected, clearance of the dermatosis follows rubbing the affected skin with 70% isopropyl alcohol.

Cosmetic tattoo pigment reaction.

BackgroundCutaneous reactions to tattoos are most commonly granulomatous or lichenoid.PurposeWe describe a woman who developed a lymphocytic reaction following a cosmetic tattoo procedure with black dye. The reaction occurred not only at the site of the tattoos (eyebrows and eyelash lines), but also in non-tattooed skin (bilateral malar cheeks).Methods and MaterialsWe reviewed PubMed for the following terms: cosmetic, dye, granuloma, granulomatous, lichenoid, lymphocytic, perivascular, pigment, pseudolymphoma, reaction, and tattoo. We also reviewed papers containing these terms and their references.ResultsHistopathologic examination of the left eyebrow and left cheek punch biopsies showed predominantly a perivascular lymphocytic reaction secondary to exogenous tattoo pigment.ConclusionsPerivascular lymphocytic reaction is an uncommonly described complication of tattooing. Our patient had an atypical presentation since she had no prior tattoos, became symptomatic only a few days after the procedure, reacted to black dye, and involved skin both within and outside the confines of the tattoos. Her symptoms and lesions resolved after treatment with systemic and topical corticosteroids and oral antihistamines.

Onychoheterotopia Due to a Traumatically Transplanted Nail in a Child.

Onychoheterotopia is a rare condition characterized by ectopic nail tissue growth. It is a digital mass that is commonly misdiagnosed. We describe a 6-year-old girl who presented with onychoheterotopia after trauma to the digit. Her onychoheterotopia was incorrectly diagnosed as a common wart. It is important to include onychoheterotopia in the differential diagnosis of digital masses, especially in the setting of previous traumatic injury.

Pitted keratolysis: successful management with mupirocin 2% ointment monotherapy.

BACKGROUND: Pitted keratolysis is a benign dermatosis that occurs on plantar skin. PURPOSE: We describe a man with pitted keratolysis that was successfully treated with mupirocin 2% ointment monotherapy. METHODS AND MATERIALS: We reviewed PubMed for the following terms: mupirocin, ointment, pitted keratolysis, treatment. We also reviewed papers containing these terms and their references. RESULTS: Complete resolution of pitted keratolysis occurred following monotherapy with twice daily application of mupirocin 2% ointment for a duration of three weeks. There was no recurrence at a follow-up visit eight weeks later. CONCLUSIONS: Several topical and oral treatments are available to successfully manage pitted keratolysis. Our patient confirms previous reports of pitted keratolysis resolving with mupirocin 2% ointment treatment. Monotherapy with mupirocin 2% ointment should be considered as a primary treatment alternative for pitted keratolysis.

Terra firma-forme dermatosis: A report of ten individuals with Duncan's dirty dermatosis and literature review.

BACKGROUND: Terra-firma forme dermatosis, also known as Duncan's dirty dermatosis, is a benign skin condition that presents as dirt-like plaques in patients of all ages. PURPOSE: We describe a series of ten patients that presented with terra-firma forme dermatosis. METHODS AND MATERIALS: We reviewed PubMed for the following terms: dermatosis, Duncan's dirty dermatosis, isopropyl alcohol, terra firma, and terra firma-forme dermatosis. We also reviewed papers containing these terms and their references. RESULTS: The diagnosis of terra firma-forme dermatosis was confirmed in all patients who had complete resolution of each lesion after the application of 70% isopropyl alcohol. CONCLUSIONS: Terra-firma forme dermatosis is easily diagnosed and treated with 70% isopropyl alcohol. It is important to recognize this benign dermatologic condition since it can be confused with other cutaneous disorders. Therefore, in order to avoid unnecessary referrals, biopsies, blood tests, and medications, we suggest a trial of wiping the skin lesion with 70% isopropyl alcohol pads when the diagnosis of terra-firma forme dermatosis is considered.