Neutrophilic Panniculitides.

Neutrophilic panniculitides are a heterogeneous group of inflammatory disorders encompassing many different entities. This review article focuses on the epidemiology, pathogenesis, clinicopathological features, diagnosis, and treatment of selected diseases. Patients often seek care due to systemic involvement, but the variable presentation of panniculitides can present a diagnostic challenge. Most therapeutic modalities for neutrophilic disorders are anecdotal at best with a notable lack of standardization of the responses to medications. There is an urgent need for a larger multi-institutional collaboration to address the unmet needs of these challenging, yet rare conditions.

Skin cancer discovery during total body skin examinations.

BACKGROUND: Patients presenting with a site-specific skin complaint may receive a total body skin examination (TBSE) or a more focused examination. A TBSE may be time-consuming but can potentially detect unsuspected or early stage skin cancers. The purpose of this study was to assess the detection of skin cancers associated with dermatologist-initiated TBSE performed immediately after a focused skin examination on the same patients. METHODS: The dermatology records of patients with biopsy-proven melanoma, basal cell carcinoma (BCC), or squamous cell carcinoma (SCC) during a 2-year period were reviewed. Generalized linear mixed-effects models were used to estimate the odds of a lesion being identified by a dermatologist (rather than the patient or the patient's primary health care provider). RESULTS: A total 1563 biopsy-proven cutaneous malignancies were found on 1010 patients. Of these, 797 cancers (51%) were first identified by a dermatologist on TBSE and 764 (48.9%) by the patient or the referring provider. Among tumors first identified by dermatologists (n = 797), 553 (69%) were BCCs, 220 (28%) were SCCs, and 24 (3%) were melanomas. The mean Breslow depth was 0.53 mm (standard deviation: 0.31 mm) for melanomas found on TBSE versus 1.04 mm (standard deviation: 1.68 mm) if identified by patients or referring providers. BCCs were more likely to be identified by a dermatologist during a TBSE (n = 553 [56%] vs. n = 434 [44%]; odds ratio: 1.79; p < .001). Tumors ultimately diagnosed as SCCs were more often identified by patients or patients' primary care providers (n = 302 [58%]; odds ratio: 0.56; p < .001). However, 220 otherwise undetected SCCs were found during dermatologist-performed TBSE. CONCLUSION: Dermatologist-performed TBSEs identified numerous cutaneous malignancies that might otherwise have remained undiagnosed. Early detection of melanoma or nonmelanoma skin cancer by TBSEs may spare patients significant morbidity and mortality.

Video education to improve clinical skills in the prevention of and response to vasovagal syncopal episodes.

BACKGROUND: Vasovagal syncope is a common clinical occurrence during routine outpatient dermatology procedures, such as injections and biopsies. Despite its prevalence, many medical students and health care professionals do not know how to respond appropriately to a syncopal episode. OBJECTIVE: The aim of this study was to determine the efficacy of a health education video in teaching medical students and health care professionals the appropriate management steps for vasovagal syncope and its prodromal symptoms in a clinical setting. METHODS: With input from dermatologists and an anesthesiologist, an instructional video was developed to demonstrate basic management for a presyncopal and syncopal patient. A pre- and post-video quiz was used to assess comprehension. A total of 124 medical students and health care professionals were enrolled in this study. RESULTS: After viewing the video, the proportion of respondents who were able to correctly identify how long to monitor a patient after a syncopal episode increased from pre- to post-intervention (44% vs. 71%; p < .001). Participants expressed higher levels of agreement with the statement "I am aware of the appropriate steps in managing a patient during an episode of vasovagal syncope" after the intervention (p < .001). Respondents reported increased confidence in managing a patient during a syncopal episode after this intervention (p < .001). CONCLUSION: These results suggest that this health education video is a useful tool for educating medical students and nursing professionals about the management of vasovagal syncope in a clinical setting. We propose the use of video education as an efficient means of increasing recognition and standardizing therapeutic response to the prodromal symptoms of syncope and syncopal episodes.

A comparison of imaging software and conventional cell counting in determining melanocyte density in photodamaged control sample and melanoma in situ biopsies.

BACKGROUND: Objective methods for distinguishing melanoma in situ (MIS) from photodamaged skin (PS) are needed to guide treatment in patients with melanocytic proliferations. Melanocyte density (MD) could serve as an objective histopathological criterion in difficult cases. Calculating MD via manual cell counts (MCC) with immunohistochemical (IHC)-stained slides has been previously published. However, the clinical application of this method is questionable, as quantification of MD via MCC on difficult cases is time consuming, especially in high volume practices. METHODS: ImageJ is an image processing software that uses scanned slide images to determine cell count. In this study, we compared MCC to ImageJ calculated MD in microphthalmia transcription factor-IHC stained MIS biopsies and control PS acquired from the same patients. RESULTS: We found a statistically significant difference in MD between PS and MIS as measured by both MCC and ImageJ software (P < 0.01). Additionally, no statistically significant difference was found when comparing MD measurements recorded by ImageJ vs those determined by the MCC method. CONCLUSION: MD as determined by ImageJ strongly correlates with the MD calculated by MCC. We propose the use of ImageJ as a time-efficient, objective, and reproducible tool to assess MD.

A Comparison of Ferric Subsulfate Solution, Silver Nitrate, and Aluminum Chloride for Pain Assessment, Time to Hemostasis, and Cosmesis in Acrochordon Snip Excision.

BACKGROUND: Acrochordon (skin tag) removal by snip excision is a routine dermatologic procedure. Bleeding is a common sequelae of snip excision that requires hemostatic control. Chemical cautery is a common means of achieving hemostasis in this procedure. OBJECTIVE: The aim of this study was to evaluate three different chemical cautery solutions for their time to hemostasis, pain upon application, and associated pigmentary changes. METHODS: Twelve patients with six or more skin tags on the bilateral neck and/or axilla were enrolled. Two skin tags were cauterized with ferric subsulfate solution, two with silver nitrate, and two with aluminum chloride hexahydrate solution. Time to hemostasis and pain with application of each cautery solution to the skin tag was recorded. At a two-week follow-up appointment, patient satisfaction was assessed with a survey, and pigmentary changes were documented with digital photography. RESULTS: There was no significant variability in the time to hemostasis among the three chemical cautery solutions (p=0.57). Pain response was significantly different among the three solutions (p=0.003). Compared to silver nitrate (median=6.00, interquartile range [IQR]: 4.50-6.50), aluminum chloride hexahydrate (median=1.00, IQR: 0.50 to 6.00; Sidak p=0.02) and ferric subsulfate (median=1.50, IQR: 0.00-3.50; Sidak p=0.01) had a significantly lower pain response. Among participants, three (25%) experienced a pigmentary change with ferric subsulfate, two (17%) with aluminum chloride, and six (50%) with silver nitrate (overall p= 0.14). CONCLUSION: These results indicate that the three standard chemical cautery solutions for skin tag snip excision have significant differences in pain upon application and pigmentary changes. This might be a relevant consideration when selecting a chemical cautery solution.