Dermatologic care in the homeless and underserved populations: observations from the Venice Family Clinic.

Dermatologic care in the homeless and impoverished urban underserved populations is rarely described despite the wide prevalence of skin concerns in this population. Because the homeless population may be subject to increased sun exposure compared to the nonhomeless population, they also may be at increased risk for skin cancer. We sought to describe the spectrum of dermatologic diseases seen in a free clinic in Venice, California--the Venice Family Clinic (VFC)--as well as the differences in diagnoses between the homeless and nonhomeless patients seen at this clinic. A retrospective chart review was performed of dermatology patients (N = 82) seen at VFC throughout the 2006 calendar year. The homeless population (n = 22) was found to have more diagnoses of malignant/premalignant growths (25% [16/64] of all homeless diagnoses) compared to their nonhomeless (n = 60) counterparts (6.1% [8/132] of all nonhomeless diagnoses; P < .0001). This difference was sustained when ethnicity was controlled, with 29.6% [16/54] of diagnoses in the homeless white group consisting of malignant/ premalignant growths compared to 8.9% [4/45] of diagnoses in the nonhomeless white cohort (P < .005). Homeless patients may have a higher incidence of skin cancers and precancerous skin lesions due to increased sun exposure and/or limited access to dermatologic care.

Comparison of treatment of melomental fold rhytides with cross-linked hyaluronic acid combined with onabotulinumtoxina and cross-linked hyaluronic acid alone.

BACKGROUND: Hyaluronic acid and onabotulinumtoxinA combination therapy has been shown to have greater clinical effectiveness than hyaluronic acid alone for glabellar furrowing, but this is not well documented for melomental fold rhytides. OBJECTIVE: To compare the efficacy of intradermal cross-linked hyaluronic acid (HA) and onabotulinumtoxinA combination therapy with the efficacy of cross-linked HA monotherapy in patients with melomental fold rhytides. METHODS AND MATERIALS: Twenty-two patients received combination therapy to a melomental fold area while also receiving cross-linked HA and a placebo saline injection to the contralateral side. Blinded physician evaluators and patient self-evaluators clinically and photographically assessed responses during standard intervals over 12 months. RESULTS: The melomental folds treated with combination therapy had significantly greater aesthetic improvement than the monotherapy-treated side at 2 weeks and 1 month upon physician photographic review. Furthermore, the median time for return to pretreatment rhytides was 6.5 weeks longer in the combination therapy side. Patient assessment also revealed improvement over baseline for the combination therapy at 1 month. CONCLUSION: Cross-linked HA and onabotulinumtoxinA combination therapy to melomental fold rhytides may provide better overall aesthetic results and longer duration of aesthetic improvement than cross-linked HA monotherapy.

Where is it? The utility of biopsy-site photography.

BACKGROUND: With wrong-site surgery being one of the major causes of medical lawsuits in the United States, tools to confirm location are essential. A previous survey of 300 Mohs surgeons revealed that 14% of malpractice cases were due to wrong-site surgery. In dermatologic surgery, photography is helpful in precisely locating biopsy sites. OBJECTIVES: We present a case series of 34 biopsy-proven cutaneous head and neck malignancies performed in our university-based dermatology clinic, comparing the reliability of patient and blinded dermatologist identification with that of biopsy-site photography. RESULTS: Of 34 biopsy sites, the patient and the blinded dermatologist incorrectly identified four (12%). The patient alone incorrectly identified an additional six biopsy sites, resulting in a total of 10 (29%) cases incorrectly identified by the patient. There were no instances in which the patient correctly identified the biopsy site and the blinded dermatologist incorrectly identified it. CONCLUSION: In our current medical environment, in which more than 90% of health care is delivered in a clinic setting, wrong-site surgery is certainly underreported. In adopting a zero-tolerance policy for wrong-site surgeries, biopsy-site photography saves time, money, and potential frustration, hopefully eliminating the number of excisions performed on the wrong site.

Successful treatment of metastatic Crohn's disease with cyclosporine.

Metastatic Crohn's disease refers to cutaneous granulomatous lesions that are noncontiguous to the gastrointestinal tract. The treatment of cutaneous Crohn's disease is challenging. A patient with metastatic Crohn's disease whose lesions cleared after a 3-month course of cyclosporine is reported.

Facial porokeratosis.

A 34-year-old man from El Salvador was referred to our clinic with a 10-year history of a pruritic erythematous facial eruption. He reported increased pruritus and scaling of lesions when exposed to the sun. He worked as a construction worker and admitted to frequent sun exposure. Physical examination revealed well-circumscribed erythematous to violaceous papules with raised borders and atrophic centers localized to the nose (Figure 1). He did not have lesions on the arms or legs. He did not report a family history of similar lesions. A biopsy specimen was obtained from the edge of a lesion on the right ala. Histologic examination of the biopsy specimen showed acanthosis of the epidermis with focal invagination of the corneal layer and a homogeneous column of parakeratosis in the center of that layer consistent with a cornoid lamella (Figure 2). Furthermore, the granular layer was absent at the cornoid lamella base. The superficial dermis contained a sparse, perivascular lymphocytic infiltrate. No evidence of dysplasia or malignancy was seen. These findings supported a diagnosis of porokeratosis. The patient underwent a trial of cryotherapy with moderate improvement of the facial lesions.

Isoprenylation is necessary for the full invasive potential of RhoA overexpression in human melanoma cells.

Rho GTPases are signaling molecules known to control cell motility. Several recent studies have suggested a role for Rho proteins in mediating tumor metastasis independent of their affects on cell proliferation. As Rho proteins require post-translational modification with a geranlygeranyl moiety for full activity, we tested the affect of blocking geranylation on localization, downstream signaling, and stimulation of invasion. Expression of a constitutively active Rho construct in A375 melanoma cells dramatically stimulated invasion through Matrigel membranes; however, a constitutively active RhoA mutated so that it cannot be geranylated, failed to stimulate invasion. Moreover, expression of epitope or GFP tagged modifications of this nongeranylatable constitutively active Rho demonstrated that geranylation is necessary for correct cellular localization of Rho. Geranylation was also found to be necessary for full downstream activation of serum response factor mediated transcription. Pharmacologic inhibition of Rho geranylation produced similar inhibition of Rho localization, signaling, and invasion. Our results suggest that inhibition of Rho geranylation may be an attractive pharmacologic target for inhibiting melanoma metastasis.

Evaluation of procollagen I deposition after intense pulsed light treatments at varying parameters in a porcine model.

Several lasers and light sources have been reported to induce dermal collagen remodeling without damaging the epidermis. The intense pulsed light (IPL) system, which emits polychromatic light of wavelengths between 560 and 1200 nm belongs to this group of increasingly popular non-ablative skin rejuvenation devices. Various IPL treatment parameters can be adjusted to achieve optimal dermal remodeling and clinical improvement. The aim of this study was to evaluate variations in IPL treatment parameters and the effect on procollagen I deposition. Marked areas of a live Yorkshire pig's flank skin were irradiated with a single or double pass of an IPL source using a fluence of 30 or 40 J/cm2 and a cut-off wavelength filter of 590 nm. Skin biopsies were performed on postoperative days 1, 7, 14, 21, and 42. A statistically significant increase in procollagen I in treated versus untreated sites was found on postoperative days 21 and 42, but not earlier. There was a uniformly significant increase in procollagen I on day 42 using the 590 nm filter at both 30 and 40 J/cm2 with either a single or double pass. The increase in procollagen was greater with a fluence of 40 J/cm2 compared with 30 J/cm2.