Gout Affecting the Nail Unit: Report of Two Cases and Literature Review.

Background: Gout is a depositional, inflammatory disorder that is rarely reported to affect the nail unit. Cases of gout involving the nail unit are likely under-recognized and therefore underreported. We present two cases of tophaceous gout affecting the nail unit and a literature review of the various presentations. Summary: Five cases of gout were identified to affect the nail unit. In all cases, these presented as white hyperkeratotic papulonodules with associated nail dystrophy. Chalky discharge was seen in three of the five cases. Nine cases were identified to have demonstrated pseudocarcinomatous changes that histopathologically mimic squamous cell carcinoma (SCC). Literature review highlights a range of findings including subclinical deposits of uric acid in the nail, onychoschizia, onychorrhexis, and Beau's line. Key Messages: Physicians should be aware of the subtle and nonspecific clinical findings of gout, which may be easily misconstrued for other pathological entities.

Leprosy in the Upper Midwest.

INTRODUCTION: Leprosy is a life-threatening infection caused by Mycobacterium leprae with an average 5-year long incubation period. It is curable when treated early. Early diagnosis requires knowledge of its myriad clinical features as risk factors may not be readily apparent. CASE PRESENTATION: We report the case of a male patient from Wisconsin who tested positive for leprosy without a known exposure or recent travel to endemic areas. DISCUSSION: The clinical presentation of leprosy exists on a spectrum and correlates with cell immunity levels. The Ridley-Jopling and World Health Organization classifications are used to define leprosy subtypes and guide treatment. Histopathologic examination may aid in diagnosis of suspicious presentations. CONCLUSIONS: Leprosy may present with nonspecific clinical features and elevated inflammatory markers leading to a misdiagnosis. It should be considered on the differential diagnosis for suspicious presentations and appropriately worked up with various diagnostic modalities. A multidisciplinary approach to treatment may prevent spread and permanent damage.

Onychodystrophy as the Presenting Sign of Steal Syndrome.

A man in his 70s presented to the dermatology nail clinic with a 1-month history of worsening onychodystrophy, leukonychia, and pain in his left fifth finger. Physical examination revealed a cool hand and absent radial pulse. Ischemia was suspected, and the patient was sent to the emergency department where the diagnosis of steal syndrome was made and his previously required arteriovenous fistula was ligated. This case highlights the clinical features of steal syndrome, that nail changes should be recognized as clinical features, and that urgent triage of these patients to vascular surgery is of critical importance.

Deferring Nail Mycological Sampling during the COVID-19 Pandemic: Recommendations from a Multidisciplinary Panel of Nail Specialists.

Onychomycosis is the most common nail condition seen in clinical practice, with significant impact on quality of life. Clinical examination alone is insufficient for accurate diagnosis, but mycological confirmation can be challenging during the COVID-19 pandemic. In this letter, a multidisciplinary panel of dermatologists, a podiatrist, dermatopathologists, and a mycologist, discuss considerations for mycological sampling during the pandemic.

The challenge of change: Resilience traits in Women's Dermatological Society Forum participants by generation.

BACKGROUND: Physician burnout is a common problem that can have negative ramifications for both physicians and patients. Lack of effective coping mechanisms decreases resilience, which can lead to burnout, and women may be particularly vulnerable. OBJECTIVE: We aimed to evaluate resilience by generation among professionals in dermatology. We hope to gain a better understanding of the plasticity of resilience traits to identify modifiable resilience components. METHODS: Attendees of the 2020 Women's Dermatological Society Forum were asked to complete an 80-item questionnaire evaluating eight characteristics of resilience. Each participant received scores electronically, and attendees were invited to anonymously submit scores, job category (physician or industry), and birth year and/or generation category. Participants who provided scores and were part of the millennial generation (born 1980-1994; ages 26-40 years at the time of survey completion), Generation X (born 1965-1979; ages 41-55 years), or baby boomer generation (born 1944-1964; ages 56-76 years) were included. RESULTS: Of the 67 participants meeting the inclusion criteria, 96.7% were women and 3.3% were men, 69.4% were physicians and 30.6% were industry representatives. Millennials accounted for 43.3%, Generation X for 35.8%, and baby boomers for 20.9% of the study participants. There was a significant difference among the three generations for mean scores on rumination (p = .0071) and flexibility (p = .0005), with scores becoming more ideal for older generations. There was no significant difference among generations for other resilience or burnout indicators, including emotional inhibition, toxic achieving, avoidance coping, perfect control, detached coping, and sensitivity. CONCLUSION: Resilience traits such as rumination and flexibility differed by generation, with the most favorable scores occurring in the oldest cohort, suggesting that some resilience traits may be malleable and improve with age or be inherently affected by environment during development. Health care professionals may benefit from engaging in activities that enhance malleable resilience traits and improve the ability to manage work-related stressors.

Nail health in women.

Healthy nails are functionally and cosmetically important to the daily work of women. The globally increasing market for nail cosmetics reflects the importance of the appearance of nails. This article details the composition of a healthy nail, diagnosis and treatment of nail disorders, use of nail cosmetics and their risks, the impact of the aging process on nails, and the relative risks to nail salon workers. Knowledge of these issues will prepare health care providers and patients to maintain healthy nails throughout their lives.

Lipoatrophic panniculitis in an adolescent.

Lipoatrophic panniculitis (LP) is a rare childhood panniculitis characterized by sclerotic, atrophic plaques on the extremities. We present a case of LP diagnosed during the inflammatory phase that was difficult to distinguish clinically from eosinophilic fasciitis. This report adds to the limited phenotypic spectrum of LP by differentiating the clinical features of disease activity from disease damage and highlighting the importance of biopsy in establishing a diagnosis.

Clinical, Imaging, and Pathologic Features of Conditions with Combined Esophageal and Cutaneous Manifestations.

A variety of clinically significant conditions can affect both the esophagus and the skin. Esophageal and cutaneous manifestations may directly reflect the underlying disease process, as in infections such as herpes simplex virus, bullous diseases such as epidermolysis bullosa and mucous membrane pemphigoid, connective tissue diseases such as systemic sclerosis, and inflammatory diseases such as lichen planus. Alternatively, esophageal and cutaneous findings may result from conditions that are closely associated with and potentially pathognomonic for but distinct from the underlying disease process, as in genetic diseases such as Cowden syndrome or paraneoplastic syndromes such as acrokeratosis paraneoplastica. Other diseases such as Crohn disease may have cutaneous manifestations that directly reflect the same underlying inflammatory process that affects the gastrointestinal tract or cutaneous manifestations that represent reactive or associated conditions distinct from the underlying inflammatory process. The cutaneous manifestations of disease may precede, coincide with, or follow the esophageal manifestations of disease. The authors present the characteristic clinical features and imaging findings associated with common and uncommon conditions that have esophageal and cutaneous manifestations. Each condition is presented with a brief overview, discussion of salient clinical and cutaneous manifestations, and description of the typical esophageal imaging findings, with particular attention to implications for diagnosis, prognosis, and treatment. Recognition of potential associations between cutaneous lesions and esophageal imaging findings is important for establishing a specific diagnosis or generating a meaningful differential diagnosis.

Palisaded Neutrophilic Granulomatous Dermatitis Leading to Diagnosis of Hodgkin Lymphoma: Report of Rare Case and Literature Review of Paraneoplastic Granulomatous Dermatitides.

Palisaded neutrophilic granulomatous dermatitis (PNGD) presents as skin-colored to erythematous papules symmetrically distributed on extensor extremities. Histologically, interstitial and/or palisaded granulomatous infiltrates are present with neutrophils and leukocytoclasis. Together with interstitial granulomatous dermatitis (IGD), PNGD is considered a reactive granulomatous dermatitis to a systemic trigger including connective tissue disease, infection, medication reaction, and less commonly malignancy. We present the second case of PNGD leading to diagnosis of Hodgkin lymphoma. A 47-year-old woman presented with a new asymptomatic eruption of erythematous, nonscaly papules and thin plaques with variable annular configuration, symmetrically distributed on extremities. Biopsies revealed mid-dermal focal degeneration of collagen and leukocytoclasis in association with a palisaded mixed inflammatory infiltrate of neutrophils, lymphocytes, and histiocytes, some forming small granulomas. She had associated fevers, night sweats, weight loss, arthralgias and malaise. Imaging revealed retroperitoneal adenopathy. Excisional lymph node biopsy led to diagnosis of Hodgkin lymphoma. Paraneoplastic PNGD is rare with only 9 reported cases. In all cases, PNGD presented concurrently or before presentation of clinical signs/symptoms of underlying neoplasm. We reviewed a total of 37 cases of paraneoplastic PNGD/IGD, summarizing clinical presentation, histology, associated neoplasm, and response of the skin lesions to treatment. The most commonly associated neoplasia is hematologic, with myelodysplastic syndrome (9 of the 37 cases or 24%) being the most frequent. Seven cases of solid tumor malignancies (prostate, esophageal, hypopharyngeal, breast, endometrial, and lung cancers) have been reported. Recognition of paraneoplastic PNGD/IGD may allow dermatopathologists, pathologists, and dermatologists to direct further workup that reveals underlying malignancy.

Tender finger nodule.

A male in his twenties presented with a tender finger nodule that had been present for 3 months. Histopathological examination revealed a dermis with nodules of necrotic, athypical epithelaia cells with high nuclear to cytoplasmic ratios. Glandular formation was present with lumens lined by columnar epithelium, consistent with digital papillary adenocarcinoma. Digital papilary adenocarcinoma is a rare malignant adnexal tumor arising from sweat glands and requires further work-up.

Inflammatory diseases of the nail unit.

inflammatory disorders of the nail unit are frequently encountered in clinical medicine and are a cause of significant morbidity. Psoriasis, lichen planus, chronic paronychia, and trachyonychia will be discussed. An approach to diagnosis and management of these disorders requires knowledge of nail unit anatomy, consideration of associated systemic manifestations, and patient education with respect to prognosis and management of factors that will maximize disease improvement. The nail unit responds with a limited number of signs to disparate clinical entities such that there is some overlap in clinical presentation between inflammatory conditions. Nail unit biopsy may therefore be useful in establishing a specific diagnosis.

Eccrine Porocarcinoma Treated by Mohs Micrographic Surgery: Over 6-Year Follow-up of 12 Cases and Literature Review.

BACKGROUND: Eccrine porocarcinoma (EPC) has a poor prognosis after standard wide local excision (WLE), with 20% local recurrence, 20% regional and 12% distant metastatic rates. Mohs micrographic surgery (MMS) has been used as a promising treatment. OBJECTIVE: To review the use of MMS for EPC and assess treatment outcomes. MATERIALS AND METHODS: This was a retrospective case series of 12 EPC patients treated by MMS between 1984 and 2013 in the institution. Furthermore, a literature review revealed an additional 17 cases of EPC managed by MMS. RESULTS: Of 29 cases of EPC treated by MMS, outcome was established in 27 cases. The patients had a significantly longer mean follow-up period of 6 years (range, 4-206 months), as compared with 19 months (range, 2-48 months) in reported cases. Two patients had regional lymph node metastasis after MMS. The regional metastatic rates to lymph nodes were 7% (2/27). There was no local recurrence, distant metastasis, or disease-specific death in the 27 cases studied. CONCLUSION: To the best of the authors' knowledge, this is the single largest case series of EPCs treated by MMS and the authors' data demonstrated that MMS may be superior to the standard WLE.