Development of a Skin-Directed Scoring System for Stevens-Johnson Syndrome and Epidermal Necrolysis: A Delphi Consensus Exercise.

Importance: Scoring systems for Stevens-Johnson syndrome and epidermal necrolysis (EN) only estimate patient prognosis and are weighted toward comorbidities and systemic features; morphologic terminology for EN lesions is inconsistent. Objectives: To establish consensus among expert dermatologists on EN terminology, morphologic progression, and most-affected sites, and to build a framework for developing a skin-directed scoring system for EN. Evidence Review: A Delphi consensus using the RAND/UCLA appropriateness criteria was initiated with a core group from the Society of Dermatology Hospitalists to establish agreement on the optimal design for an EN cutaneous scoring instrument, terminology, morphologic traits, and sites of involvement. Findings: In round 1, the 54 participating dermatology hospitalists reached consensus on all 49 statements (30 appropriate, 3 inappropriate, 16 uncertain). In round 2, they agreed on another 15 statements (8 appropriate, 7 uncertain). There was consistent agreement on the need for a skin-specific instrument; on the most-often affected skin sites (head and neck, chest, upper back, ocular mucosa, oral mucosa); and that blanching erythema, dusky erythema, targetoid erythema, vesicles/bullae, desquamation, and erosions comprise the morphologic traits of EN and can be consistently differentiated. Conclusions and Relevance: This consensus exercise confirmed the need for an EN skin-directed scoring system, nomenclature, and differentiation of specific morphologic traits, and identified the sites most affected. It also established a baseline consensus for a standardized EN instrument with consistent terminology.

Occam's razor and Hickam's dictum: a dermatologic perspective.

Diagnostic heuristics help ease the cognitive load in our day-to-day work. Occam's razor or the rule of diagnostic parsimony is a diagnostic heuristic often applied in dermatology. Occam's razor dictates that all things being equal, one diagnosis (as opposed to several diagnoses) should be sought to explain a patient's presentation. While this can often be helpful, it can also obscure the full picture. Hickam's dictum is an aphorism expressing the opposite opinion: "patients can have as many diseases as they damn (or darn) well please." This acknowledges that multiple simultaneous processes can be at play. This article delves into the implications of use of these approaches and offers tips through cases illustrating the limitations of Occam's razor and when Hickam's Dictum should be invoked.

Senile Gluteal Dermatosis: An Underreported Condition in Elderly Patients.

Case 1: An 89-year-old obese Caucasian man with a history of coronary artery disease, hypothyroidism, and hyperlipidemia presented with herpes zoster on the lower back, and postherpetic neuralgia. The patient complained of significant pain and reported that he had been spending most of his day over the past few weeks in a seated position. (SKINmed. 2022;20:149-151).

The darker side of head lice infestations.

Head lice (Pediculus humanus capitis) infestations are prevalent among young children and generally not considered a health hazard. Although massive chronic head lice infestations have been documented in paleo medical literature, their association with severe iron deficiency anemia has been rarely discussed in modern medicine. A recently published case implicating a head lice infestation as the cause of death of a 12-year-old girl brings this topic to the fore. This contribution discusses the available information concerning the circumstances under which this girl died and the ongoing criminal investigation as a springboard for discussion of how head lice infestations may serve as forensic and legal evidence and as a warning sign of mental illness, abuse, neglect, and rape.

Domestic violence in the coronavirus disease 2019 era: Insights from a survivor.

Amid the coronavirus disease 2019 (COVID-19) pandemic, there has been an alarming rise in domestic violence worldwide. Factors believed to be fueling this escalation in domestic violence include increasing social confinement at home during lockdowns and mounting stress levels from unemployment that have resulted from the economic uncertainties of these times. This contribution explores some of the challenges faced by physicians in clinically assessing victims of domestic violence during the COVID-19 era. One such challenge is the increased reliance on telemedicine during the pandemic, a medium of communication that offers a narrower clinical view of patients than is what is usually provided by an in-person examination. In this contribution, we offer suggestions on how best to screen for domestic violence, whether through telemedicine or during an in-person encounter. The history and physical findings that suggest domestic violence are reviewed along with recommendations on how to make the clinical examination more sensitive and compassionate to the needs of the victims. One of the authors of this contribution (L.C.H.) is herself a survivor of domestic violence and has courageously shared, in these pages, details of her harrowing near murder by an abusing husband. From this case history, it is hoped that readers will gain wider insights into what domestic violence means from the perspective of a victim and how we can better help save victims from this widespread and devastating social problem.

Visual perception, cognition, and error in dermatologic diagnosis: Key cognitive principles.

Dermatologic diagnosis relies on vision primarily and auditory and verbal input secondarily. Accurate dermatologic diagnosis is predicated on seeing and perceiving a skin finding, categorizing and naming the finding correctly, and comparing the visual data and data obtained from the totality of the clinical encounter (ie, from other sensory modalities) with one's working mental database of dermatologic diagnoses. The baseline assumption-which is false-is that a dermatologist is an expert at each of the aforementioned steps and transitions sequentially between them seamlessly in an error-free fashion. Each of these steps has inherent challenges, and the transitions between steps can also be problematic. In part 1 of this 2-part report, we describe the pitfalls associated with visual recognition. In part 2, we discuss cognitive heuristics as they relate to the dermatologic diagnostic process and prevention of diagnostic error.

Visual perception, cognition, and error in dermatologic diagnosis: Diagnosis and error.

Diagnostic error in dermatology is a large practice gap that has received little attention. Diagnosis in dermatology relies heavily on a heuristic approach that is responsible for our perception of clinical findings. To improve our diagnostic accuracy, a better understanding of the strengths and limitations of heuristics (cognitive shortcuts) used in dermatology is essential. Numerous methods have been proposed to improve diagnostic accuracy, including brain training, reducing cognitive load, and getting feedback and second opinions. Becoming comfortable with the uncertainty intrinsic to medicine is essential. Ultimately, the practice of metacognition, or thinking about how we think, can offer corrective insights to improve accuracy in diagnosis.

The Largest Mass Poisoning in History: Arsenic Contamination of Well Water in Bangladesh.

Arsenic is a naturally occurring compound that is widely distributed in trace quantities in the environment. Levels toxic to humans have been found contaminating certain regions of the world and their groundwater, leading to deleterious effects. In fact, an estimated 150 million people are affected by arsenic contamination worldwide.1 Arsenic poisoning leads to several adverse health effects, including cancer of the lung, bladder, and kidney, neurologic disorders, cardiovascular disease, peripheral vascular disease, hypertension, pulmonary disease, and diabetes mellitus.2 Skin lesions are a common manifestation of arsenic poisoning. Early findings include diffuse or spotted melanosis, leukomelanosis, and depigmentation. Years of chronic arsenic poisoning can lead to acral keratoses and squamous cell carcinoma of the skin.3.

Recurrent Palisaded Neutrophilic and Granulomatous Dermatitis in the Setting of Systemic Lupus Erythematosus.

We present the case of a 66-year-old woman with a history of systemic lupus erythematosus, who presented with tender nodules on the forearms. The patient reported an 8-year history of pink bumps on the extensor surfaces of the forearms bilaterally that would arise episodically for a few weeks and subsequently resolve with no intervention. Her systemic lupus erythematosus was under good control with oral prednisone 10 mg daily, and the development of these lesions was not associated with concomitant flares of the systemic lupus erythematosus.