Diversifying the dermatology workforce: Physician characteristics vary by race/ethnicity.

BACKGROUND: In the United States (US), dermatology remains one of the least diverse specialties in medicine. Increasing the diversity of the dermatology workforce is essential for reducing health disparities. OBJECTIVE: To describe the experiences of racially and ethnically diverse physicians in the US who successfully matched into dermatology. METHODS: Board-certified dermatologists and dermatology residents were recruited to participate in an anonymous, online survey in which self-reported demographic, socioeconomic, pre-residency, and post-residency career data were obtained. RESULTS: Of the 100 participants included in the study, 30% were dermatology residents and 25% belonged to a group underrepresented in medicine (UIM). Black physicians were 3.69 times more likely to select dermatology prior to medical school (odds ratio [OR], 3.69; 95% confidence interval [CI], 1.04 - 13.0) compared to non-Black physicians. UIM dermatologists and trainees were more likely to receive a need-based scholarship in medical school (OR, 4.37; 95% CI, 1.30 - 14.7), graduate from a private medical institution (OR, 6.49; 95% CI, 1.95 - 21.6), and have at least one UIM dermatology mentor during medical school (adjusted OR, 13.1; 95% CI, 2.77 - 61.5) compared to non-UIM physicians. CONCLUSIONS: A holistic review of dermatology applicants by residency programs may reduce racial/ethnic disparities in the admission process. Our data provide further evidence in support of pre-medical outreach programs, mentorship, and institutional funding to promote diversity in dermatology.

Multimodal single-cell analysis of cutaneous T-cell lymphoma reveals distinct subclonal tissue-dependent signatures.

Cutaneous T-cell lymphoma (CTCL) is a heterogeneous group of mature T-cell neoplasms characterized by the accumulation of clonal malignant CD4+ T cells in the skin. The most common variant of CTCL, mycosis fungoides (MF ), is confined to the skin in early stages but can be accompanied by extracutaneous dissemination of malignant T cells to the blood and lymph nodes in advanced stages of disease. Sézary syndrome (SS), a leukemic form of disease, is characterized by significant blood involvement. Little is known about the transcriptional and genomic relationship between skin- and blood-residing malignant T cells in CTCL. To identify and interrogate malignant clones in matched skin and blood from patients with leukemic MF and SS, we combine T-cell receptor clonotyping with quantification of gene expression and cell surface markers at the single cell level. Our data reveal clonal evolution at a transcriptional and genetic level within the malignant populations of individual patients. We highlight highly consistent transcriptional signatures delineating skin- and blood-derived malignant T cells. Analysis of these 2 populations suggests that environmental cues, along with genetic aberrations, contribute to transcriptional profiles of malignant T cells. Our findings indicate that the skin microenvironment in CTCL promotes a transcriptional response supporting rapid malignant expansion, as opposed to the quiescent state observed in the blood, potentially influencing efficacy of therapies. These results provide insight into tissue-specific characteristics of cancerous cells and underscore the need to address the patients' individual malignant profiles at the time of therapy to eliminate all subclones.

Cutaneous T Cell Lymphoma: A Difficult Diagnosis Demystified.

Cutaneous T cell lymphoma (CTCL) represents a heterogeneous group of extranodal non-Hodgkin lymphomas in which monoclonal T lymphocytes infiltrate the skin. The mechanism of CTCL development is not fully understood, but likely involves dysregulation of various genes and signaling pathways. A variety of treatment modalities are available, and although they can induce remission in most patients, the disease may recur after treatment cessation. Owing to relatively low incidence and significant chronicity of disease, and the high morbidity of some therapeutic regimens, further clinical trials are warranted to better define the ideal treatment option for each subtype of CTCL.

Lymphomatoid papulosis.

Lymphomatoid papulosis is often regarded as a low-grade variant of cutaneous T cell lymphoma (CTCL). Given the excellent long-term prognosis, recent consensus guidelines indicate that patients can be monitored off therapy. We report a case of a 67-year-old man who presented with lymphomatoid papulosis, with necrotic papules that have been intermittently present for over forty years.

Role of Dysregulated Cytokine Signaling and Bacterial Triggers in the Pathogenesis of Cutaneous T-Cell Lymphoma.

Cutaneous T-cell lymphoma is a heterogeneous group of lymphomas characterized by the accumulation of malignant T cells in the skin. The molecular and cellular etiology of this malignancy remains enigmatic, and what role antigenic stimulation plays in the initiation and/or progression of the disease remains to be elucidated. Deep sequencing of the tumor genome showed a highly heterogeneous landscape of genetic perturbations, and transcriptome analysis of transformed T cells further highlighted the heterogeneity of this disease. Nonetheless, using data harvested from high-throughput transcriptional profiling allowed us to develop a reliable signature of this malignancy. Focusing on a key cytokine signaling pathway previously implicated in cutaneous T-cell lymphoma pathogenesis, JAK/STAT signaling, we used conditional gene targeting to develop a fully penetrant small animal model of this disease that recapitulates many key features of mycosis fungoides, a common variant of cutaneous T-cell lymphoma. Using this mouse model, we show that T-cell receptor engagement is critical for malignant transformation of the T lymphocytes and that progression of the disease is dependent on microbiota.

The Department of Defense: pioneers of early teledermatology.

The United States (US) Department of Defense(DoD) has been a leader in using telecommunicationstechnology to provide remote medical care. The DoDhas been using telemedicine for more than twentyyears to provide medical services to military personneldeployed throughout the world, and has largelyinfluenced the development of teledermatology. Theexperiences of early military teledermatology serviceshave yielded valuable lessons that have been essentialto the creation of successful civilian programs.

Kaposi's sarcoma in an HIV-negative patient.

We report an HIV-negative, 55-year-old manwith recurrent Kaposi's sarcoma (KS) of the lowerextremities, who does not fit into any of thefour previously described variants of KS: classicKS, AIDS-related KS, iatrogenic KS, and AfricanendemicKS. There are reports in the literature ofchildhood-onset KS, which is thought to be dueto an inherited immune deficiency that confers ahigher susceptibility to human Herpesvirus-8 (HHV-8), which is the virus that is known to cause KS. Ourpatient may be affected with an inherited immunedeficiency that has predisposed him to KS, and thismutation also may account for his prostate andbladder cancer.

Primary cutaneous marginal-zone lymphoma.

Primary cutaneous B cell lymphomas (PCBCL) are thesecond most common type of primary cutaneouslymphoma. The three main types of PCBCL areprimary cutaneous marginal-zone lymphoma(PCMZL), primary cutaneous follicle-centerlymphoma, and primary cutaneous diffuse largeB-cell lymphoma, leg type. PCMZL has an indolentcourse with a five-year survival rate approaching99%. Lesions most often present on the trunk or armas erythematous-to-violaceous papules, plaques, ornodules. Approximately one-half of patients havesolitary skin lesions. Treatment options includesurgery, radiation, and topical, intralesional orsystemic therapy. We present the case of a 33-yearoldHispanic woman with firm, pruritic, pink papuleson the forehead and cheeks, who was diagnosedwith PCMZL.

Mycosis fungoides with epidermal mucinosis: a variant of mycosis fungoides with a spongiosis-like pattern.

BACKGROUND: The histopathologic diagnosis of mycosis fungoides (MF) has classically relied on the presence of atypical epidermotropic T-lymphocytes predominating over spongiosis. However, in some cases of MF, prominent epidermal mucinosis in a spongiosis-like pattern mimics a spongiotic dermatitis. To our knowledge, only one series in the literature has thus far recognized the presence of epidermal mucinosis in MF. METHODS: We evaluated 30 skin biopsies from 18 patients with the clinical diagnosis of MF, which fulfilled all histopathologic criteria for patch- or plaque-stage MF, but also showed epidermal mucinosis in a spongiosis-like pattern. A total of 15 specimens were studied by immunohistochemistry, and seven were tested for T-cell receptor (TCR) gene rearrangements. Twenty biopsies of spongiotic dermatitides were included as controls. RESULTS: We confirmed the presence of epidermal mucinosis in all 30 cases of MF with a spongiosis-like pattern based on histopathologic criteria and the colloidal iron stain for mucin. Immunohistochemistry in 15 specimens showed significant loss of pan-T-cell antigens CD5 (10/15) and CD7 (14/15); and TCR clonality was detected in 7 specimens from 6 patients, supporting the diagnosis of MF. CONCLUSIONS: We report helpful histopathologic criteria for distinguishing MF with epidermal mucinosis in a spongiosis-like pattern from spongiotic dermatitis.

Primary cutaneous follicle-center lymphoma.

We present a 64-year-old man with a three-year history of pruritic, pink papules and nodules of the face who was found to have a clonal lymphoproliferative B-cell disease that was characterized by a clonal IGH rearrangement. Although morphologic features present in the biopsy specimen were consistent with a reactive process, additional clinicopathologic correlation (anatomic presentation of lesions on the face, the absence of t(14:18) translocation, and bcl-2 and MUM1 expression) reinforced suspicion of a cutaneous B-cell lymphoma. Systemic work-up with CT/PET and a bone marrow biopsy ultimately excluded systemic disease and primary cutaneous follicle-center lymphoma (PCFCL) was a strong diagnostic consideration. The patient was treated with systemic rituximab with a partial resolution of the facial lesions. The case demonstrates both clinical and pathologic challenges to the diagnosis of primary cutaneous B-cell lymphoma (PCBCL). Furthermore, despite a newly refined classification system, the case also specifically highlights the persistent requirement for flexible clinical reasoning and pathologic correlation. Such reasoning is necessary to generate individualized strategies for diagnosis and treatment when cutaneous B-cell lymphoma is suspected.