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Open Access Publications from the University of California

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Dermatology Online Journal is an open-access, refereed publication intended to meet reference and education needs of the international dermatology community since 1995. Dermatology Online Journal is supported by the Department of Dermatology UC Davis, and by the Northern California Veterans Administration.

Volume 25, Issue 1, 2019

Review

Bioidentical hormone therapy in menopause: relevance in dermatology

Hormone replacement therapy has been shown to be effective in alleviating menopausal symptoms. However, its use is controversial owing to potential health risks, such as thromboembolism and cancer. Bioidentical hormone therapy has recently become popular as an alternative to conventional hormone replacement therapy. These bioidentical hormones have a molecular structure identical to endogenous hormones found in a woman's body. A claimed advantage of bioidentical hormone therapy is the compounding practice in order to individualize therapy depending on patient's own hormone levels and symptoms. However, there is no scientific evidence to assess the validity of these claims. Bioidentical hormone therapy has also been used by dermatologists for its anti-aging effects on the skin, but little is known about efficacy and side effects of bioidentical hormones in this field. This review illustrates the main purpose of bioidentical hormone therapy for dermatological uses and its potential side effects, serving as a tool for dermatologists when facing these patients.

Cutaneous cytomegalovirus manifestations, diagnosis, and treatment: a review

The possible presentations of cytomegalovirus (CMV) are vast not only in its systemic manifestations, but also in the various cutaneous lesions that may result. Cutaneous cytomegalovirus is rarely reported in the literature because the clinical and pathologic features can be difficult to identify. Its identification, however, is vital as cutaneous human CMV infection can signal systemic disease and an unfavorable prognosis. The objective of this study is to aid in recognition, diagnosis, and treatment of CMV according to dermatological evidence. A complete literature search was performed within PubMed, resulting in the inclusion of 58 patient cases. The most common dermatologic manifestation was perianal or oral ulcers, but the locations and types of lesions noted throughout the review were numerous. Treatment is often simple, yet incorrect diagnoses along with concurrent illnesses can often complicate management. It is imperative for CMV to be detected early in its course to prevent mortality, especially in the immunocompromised. Dermatological presentations are often the first sign of this deadly virus' activity and it is essential that these diagnoses are made more efficient and accurate.

Original

Movement artifacts in pediatric cutaneous ultrasonography

Background: Cutaneous ultrasonography can be challenging in children. We aim to identify the most complicated cases and the best timing for assessment.

Methods: We retrospectively reviewed sonographic exams in pediatric patients from our cutaneous ultrasonography clinic over a two-year period. Movement artifacts were classified according to their consequences and their frequency was studied in relation to the age of the patient, location of the lesion, and underlying pathology.

Results: The overall frequency of exams affected by movement artifacts was 16.76% (91/543) and all belonged to children younger than 4 years of age. The frequency of impaired sonographies was particularly low in patients aged 0 to 4 months (12.77%; 6/47) and particularly high in children aged from 4 to 12 months (56.60%; 60/106). Regarding location, exams were more frequently disadvantaged when assessing the head and neck area (44.53%; 61/137). In relation to pathology, developmental anomalies showed a significantly higher frequency of exams damaged by movement artifacts (41.82%; 23/55).

Conclusions: Cutaneous ultrasonography without sedation can be particularly difficult in children aged between 4 and 12 months, especially when lesions are located on the head and neck and a Doppler exam is required. When assessing congenital lesions, the first four months of life are ideal for a first examination.

Commentary

The doctor's office is the best setting for most cutaneous procedures

Although most dermatologic procedures are done in an office setting, some providers are performing them instead in ambulatory surgery centers (ASCs). This relocation of care comes with significantly higher expenses for patients and insurers. Compounding the issue of increased costs is the paucity of evidence demonstrating better outcomes associated with the use of ASCs. The most common cutaneous procedures have low complication rates when performed in an office setting and regular use of ASCs for these procedures is not justified.

An assessment of social media usage by dermatology residency programs

Despite the increasing popularity of social media, the activity of dermatology residency programs on top social media platforms has never been investigated to our knowledge. We investigated a total of 126 dermatology residency programs to assess their presence and popularity on social media. Searches were conducted to identify dermatology residency departments' accounts on Facebook, Twitter, and Instagram. The number of Facebook likes, Twitter followers, and Instagram followers were recorded. Of the 126 dermatology residency programs, 29 (23%) were active on Facebook, 14 (11%) on Twitter, and 9 (7%) on Instagram. There was a wide range in the number of Facebook likes, Twitter followers, and Instagram followers. The top ten dermatology residency programs with the highest Facebook likes, Twitter followers, and Instagram followers were charted. Our results demonstrate the sparse usage of social media by dermatology residency programs. Although social media continues to increase in prevalence, dermatology residency programs are underutilizing these valuable resources.

Case Report

Pyoderma gangrenosum: a presenting sign of myelodysplastic syndrome in undiagnosed Fanconi anemia

A 26-year-old man with a history of congenital bilateral microtia, unilateral renal agenesis, left aural atresia, and right external auditory canal occlusion admitted for right rib cartilage graft harvest and left ear re-construction. Following surgery, an ulceration with violaceous borders and a yellow fibrinous base unresponsive to broad-spectrum antibiotics developed at the harvest site. The wound was expanding and not responsive to systemic broad-spectrum antibiotics. Biopsy revealed a dense dermal infiltrate of neutrophils with negative tissue cultures consistent with pyoderma gangrenosum (PG). He was treated with systemic, intralesional, and topical steroids, as well as doxycycline. Three weeks after the diagnosis of PG, he was found to have persistent anemia and leukopenia. Bone marrow aspiration analysis was consistent with hypocellular myelodysplastic syndrome and genetic testing was consistent with Fanconi anemia. There is a well-known association of PG with hematological disorders. Fanconi anemia is a rare genetic hematologic disorder with congenital defects leading to bone marrow failure and malignancy in long-standing disease. In our patient, we consider his development of PG a paraneoplastic sign associated with the onset of his hypocellular myelodysplastic syndrome.

Case Presentation

Bullous lupus erythematosus with an erythema gyratum repens-like pattern

Bullous lupus erythematosus is a rare clinical form of lupus. The diagnosis is challenging and involves the exclusion of other subepidermal bullous dermatoses. We present a 21-year-old woman with erythematosus, polycyclic plaques with vesiculobullae along the periphery, creating an erythema gyratum repens-like pattern on acral regions. The cutaneous biopsy, analytical, and autoimmune studies support the diagnosis of systemic lupus erythematosus. Dapsone and glucocorticosteroids were given with prompt resolution of the lesions within two weeks. To our knowledge this is the first case of bullous lupus erythematosus with this atypical acral presentation.

Fibro-osseous pseudotumor on the hyponychium of the great toe

Fibro-osseous pseudotumor of the toe is a benign soft tissue tumor that is predominant in the young adult population. Although the etiology is unknown, a history of trauma has been reported to precede tumor development. The differential diagnosis includes myositis ossificans, extraskeletal osteosarcoma, and pyogenic granuloma. Once removed, the tumor typically has no recurrence. Surgical excision is the treatment of choice. We present a patient with fibro-osseous pseudotumor of the great toe, which had no recurrence following excision.

Koebner phenomenon: pemphigus vulgaris following Mohs micrographic surgery

Koebnerization of pemphigus vulgaris (PV) is an infrequently reported reaction. We present a 65-year-old man with Koebnerized pemphigus vulgaris after Mohs microscopic surgery for a basal cell carcinoma. We present this case to heighten awareness of the phenomenon in the dermatological community.

Rapid progression of immune dysregulation in an HIV-infected patient with Sézary syndrome

A 44-year-old man known to have human immunodeficiency virus (HIV) infection presented to our clinic with erythroderma, generalized lymphadenopathy, and cutaneous nodules and tumors. After a series of investigations, we confirmed that he had Sézary syndrome. In this paper we describe the immune alterations that occur in both Sézary Syndrome and HIV infection and how these changes together resulted in rapid and overwhelming immune dysregulation in our patient.

Photo Vignette

A pink enlarging plaque on the plantar foot: amelanotic acral lentiginous melanoma

Acral lentiginous melanomas account for less than 5% of all melanomas, whereas amelanotic melanomas account for around 2-8% of all melanomas. Amelanotic acral lentiginous melanomas are even less common and can often be mistaken for other clinical entities, including pyogenic granulomas, non-melanoma skin cancers, and warts. We describe a man in his 50s with a twenty-year history of a skin-colored plaque on the right plantar foot; after enlargement and failure of wart treatment, a shave biopsy revealed an amelanotic melanoma. A subsequent wide local excision and sentinel lymph node biopsy revealed melanoma in 4 lymph nodes and the patient underwent an abbreviated course of interferon-alpha therapy. The patient remained stable until 2 ? years after diagnosis, at which time he presented with in-transit metastases on the foot and right thigh; he has since been stable on nivolumab. This case represents the challenge of diagnosing amelanotic melanomas on acral surfaces and highlights the importance of considering a skin biopsy for diagnosis of any changing, atypical amelanotic lesions on the feet or hands.

Perianal purpuric plaques revealing an amyloid light-chain amyloidosis: case report and review of the literature

Systemic immunoglobulin light chain amyloidosis is the most common and severe type of amyloidosis. There is an abnormal fibrillary protein deposition in tissues that leads to progressive and irreversible organ dysfunction. The most commonly affected organs are kidney and heart. Although rare, cutaneous manifestations may be the first clinical sign of the disease and usually present as hemorrhagic lesions, such as purpura, petechiae, and ecchymosis. We present a 71-year-old man that presented to our department because of exuberant purpuric plaques in the anogenital area as the first manifestation of an amyloid light-chain (AL) amyloidosis. The multi-organ involvement in addition to rapid clinical deterioration precipitated the patient's death four months later.

Letter

Appearance of lentigines in psoriasis patient treated with guselkumab

Development of lentigines in areas of resolving psoriatic plaques is a rare phenomenon that has been reported following various treatment modalities including phototherapy, topical therapies, and biologics. Although the exact mechanism is unknown, evidence suggests that the cause may be multifactorial, with factors such as skin type, sun exposure, inflammation, and immunologic cytokines all playing a potential role. Herein, we present the first reported case of a patient developing multiple lentigines following treatment of psoriasis with the IL-23 inhibitor guselkumab.

CELLULITIS: A mnemonic to increase accuracy of cellulitis diagnosis

Cellulitis, a bacterial infection of the skin and subcutaneous tissue, is often misdiagnosed. Cellulitis accounts for a large number of all infectious disease-related hospitalizations in the U.S. Cellulitis can be challenging to diagnose since it lacks pathognomonic findings. We reviewed all articles on cellulitis within the last 20 years that included a statistical analysis, with odds ratios (OR), of specific clinical features of cellulitis. We then constructed a mnemonic encompassing the features with the highest odds ratios. Our mnemonic is CELLULITIS for cellulitis history, edema, local warmth, lymphangitis, unilateral, leukocytosis, injury, tender, instant onset, and systemic signs. The first characteristic has the highest OR and may be the easiest to recall: past episode(s) of cellulitis.

Over-the-counter light therapy for acne: a cross-sectional retrospective analysis

Acne vulgaris affects a large portion of the population and drives many patients to seek over-the-counter (OTC) treatments. Light-emitting diode (LED) therapy has recently emerged as a potential therapeutic option for inflammatory acne. We used the U.S. Food and Drug Administration (FDA) 510(k) premarket submission database to assess the growth in OTC LED therapy devices for treatment of acne. We also used Google Trends data in searches for "acne light therapy mask" to characterize growth in consumer interest in these devices. Overall, 35 LED devices received pre-market approval from 2000 to 2018, with a peak in approvals in 2016. Similarly, there was a dramatic increase in public interest in these devices in 2016. Only two devices were associated with company-approved trials. The current regulatory process requires little evidence to substantiate specified uses and a better understanding of practice guidelines and the efficacy of this treatment modality is required.

Photodamage spares the distal digits owing to primate-like hand flexion

Sun-exposed areas of the body - including the face, neck, and extensor forearms - are chronically exposed to UV light and display signs of photoaging. The skin distal to the proximal interphalangeal (PIP) joint is, however, typically spared owing to the natural rest position of the hand. The inward curvature of the fingers, termed the finger flexion cascade, orients the skin distal to the PIP joint toward the ground as in knuckle-walking primates. The near constant protection of this area of skin from sun may reflect our primate ancestry, the daily activities of which included swinging through trees and knuckle-walking. Primates have elongated, inward curved fingers that were once advantageous for gripping branches during arboreal locomotion. Although natural selection has favored shorter, straighter fingers, the human hand continues to assume a natural shape of flexion at rest. The UV untouched, healthy skin at the ends of the fingers is a reminder of our primate heritage. This finding may provide a colorful, memorable means to reinforce to patients how photoaging is a manifestation of sun exposure rather than age.