Janus kinase inhibitors are immunomodulatory drugs increasingly used to treat a broad range of inflammatory dermatologic conditions. Although effective, they carry a risk of serious adverse effects, including opportunist...Janus kinase inhibitors are immunomodulatory drugs increasingly used to treat a broad range of inflammatory dermatologic conditions. Although effective, they carry a risk of serious adverse effects, including opportunistic infections. We present a patient who developed an atypical mycobacterial infection while on the Janus kinase 1 and Janus kinase 3 inhibitors, tofacitinib. A 76-year-old man was started on tofacitinib for a severe ulcerative colitis flare. Six weeks after starting therapy, he developed an erythematous papule on his right forearm that progressed into an ulcerating nodule. Initial biopsies suggested subcutaneous pyoderma gangrenosum. However, after failing multiple treatments, repeat biopsies and cultures were performed. An acid-fast bacilli stain was positive and specialized tissue cultures identified Mycobacterium chelonae. The lesions resolved after 6 weeks of clarithromycin therapy. This case highlights the immunosuppressive effects of Janus kinase inhibitors, which can lead to atypical infections including nontuberculous mycobacteria. Additionally, this case highlights the diagnostic challenges associated with these infections, which often require multiple biopsies and specialized microbiological techniques to diagnose. As the use of Janus kinase inhibitors expands, clinicians must maintain a high suspicion for atypical infections, particularly in patients with unusual dermatologic symptoms. Prompt diagnosis and intervention are essential to prevent complications.
Skin tension lines are fundamental guidelines in surgical procedures for determining optimal incision placement to enhance healing and minimize visible scarring. This paper delves into the historical development and prac...Skin tension lines are fundamental guidelines in surgical procedures for determining optimal incision placement to enhance healing and minimize visible scarring. This paper delves into the historical development and practical implications of Langer lines and relaxed skin tension lines. Utilization of relaxed skin tension lines enhances the precision of incisions and closures by considering facial muscle tension, an aspect not addressed by Langer cleavage lines. Relaxed skin tension lines more accurately reflect skin dynamics, underscoring the importance of patient positioning. Additionally, Cornelius Kraissl played a significant role in highlighting the alignment of scars with wrinkle lines. The interchangeable use of relaxed skin tension lines and Langer lines often leads to confusion within the field. Clarifying their distinct origins and criteria is crucial for the optimization of surgical outcomes.
Richmond A, Ray L, Truong-Balderas K
… +13 more, Almukhtar R, Minkis K, Eshaq M, Kuemmet T, Joo JS, Desai S, Lucas R, Wambier C, Boucher A, Kang B, Levin Y, Wyles S, Alam M
Comprehensive education in cosmetic and laser procedures is fundamental during dermatology residency to meet the demand for cosmetic medical procedures and effectively treat a myriad of complex dermatological conditions....Comprehensive education in cosmetic and laser procedures is fundamental during dermatology residency to meet the demand for cosmetic medical procedures and effectively treat a myriad of complex dermatological conditions. This article highlights the importance of structured learning to provide step-wise opportunities for proficiency throughout residency. Although reading assignments and didactic sessions create a solid foundation, focused workshops, resident cosmetic clinics, and offsite electives serve as important experiences for residents to practice hands-on skills. This article provides guidance for curriculum development and establishing hands-on procedural learning. Additionally, the importance of joining professional societies to receive unique training as well as mentorship is highlighted. Having a structured and comprehensive cosmetic curriculum will equip dermatology residents with the toolkit to successfully care for diverse patient needs effectively and safely.
Melanoma, an invasive and potentially fatal form of skin cancer, is projected to comprise 5% of new cancer cases and 1.4% of cancer-related deaths in 2024 alone [1]. Survival rates are closely linked to the stage at dete...Melanoma, an invasive and potentially fatal form of skin cancer, is projected to comprise 5% of new cancer cases and 1.4% of cancer-related deaths in 2024 alone [1]. Survival rates are closely linked to the stage at detection, with thicker tumors at initial diagnosis associated with reduced overall survival rate [2,3]. Increased distance to healthcare providers creates barriers to early detection; disparities in sun exposure and healthcare access between rural and urban populations underscore the need for targeted interventions. This review explores the relationship between rurality and distance to providers with melanoma staging at detection. A search was conducted of the PubMed and Embase databases, following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines [4]. The included studies examined melanoma staging and Breslow thickness in rural versus urban areas and the impact of distance to healthcare provider. Greater distance to healthcare providers was associated with more advanced tumor stages at diagnosis, while rurality status had largely insignificant effects. This review investigates the impact of rurality status and distance to a healthcare provider on melanoma detection. Ensuring equitable access is crucial for better melanoma management across different regions.
Personal lubricants vary appreciably in ingredient composition. Although some products are labeled hypoallergenic, these claims are seldom evidence-based. The objective was to determine the potential allergenicity of pop...Personal lubricants vary appreciably in ingredient composition. Although some products are labeled hypoallergenic, these claims are seldom evidence-based. The objective was to determine the potential allergenicity of popular lubricants and elucidate the validity of hypoallergenic product claims. This cross-sectional study involved publicly available data on Amazon's 50 best-selling lubricants as of July 2023. Product ingredient lists were cross-referenced with the North American Contact Dermatitis Group and American Contact Dermatitis Society allergen series. Associations were explored between lubricant price per ounce, average customer rating, number of customer reviews, hypoallergenic claim, lubricant base, and allergen quantity using descriptive statistics, Kruskal-Wallis tests, Wilcoxon tests, ?2 tests, and Spearman correlation analyses. Of all studied, 30% (n=15) of products were allergen-free. Nine personal lubricants (18%) were advertised as hypoallergenic, 5 of which were among the 15 products without allergens. Hypoallergenic products were less likely to contain allergens than lubricants without this claim (P=0.03). Silicone-based lubricants contained fewer allergens than water-based lubricants (P<0.01) but were more expensive (P=0.01). Understanding potential allergenicity of personal lubricants should inform clinicians' product recommendations and differential diagnosis of anogenital contact dermatitis. Silicone-based lubricants labeled as hypoallergenic may be the safest option for sensitive skin but are not guaranteed to be allergen-free.
Fingernails and toenails can be an important source of trace evidence at a crime scene investigation. Arsenic, gold, lead, mercury, selenium, silver, and thallium are heavy metals; exposure to these metals can result not...Fingernails and toenails can be an important source of trace evidence at a crime scene investigation. Arsenic, gold, lead, mercury, selenium, silver, and thallium are heavy metals; exposure to these metals can result not only in dyschromia of the nail, but also dystrophy of the nail plate. Mees lines, either single or multiple transverse white bands on the nail, were originally described in association with arsenic exposure. Similar white horizontal bands of transverse leukonychia have also been observed in patients following exposure to selenium and thallium. A diagnostic clue for persons who investigate forensic crime scenes to the possibility of heavy metal toxicity in the victim can be changes in the fingernails and toenails. The nails can be photographed and subsequently analyzed for the presence of the causative metal when the possibility of heavy metal exposure is entertained by crime scene investigators and/or medical examiners or coroners.
Cutaneous collagenous vasculopathy is a rare microangiopathy that presents with asymptomatic telangiectasias and distinct histopathological features, including hyaline material deposition in vessel walls. Diagnosis requi...Cutaneous collagenous vasculopathy is a rare microangiopathy that presents with asymptomatic telangiectasias and distinct histopathological features, including hyaline material deposition in vessel walls. Diagnosis requires biopsy and differentiation from other telangiectatic disorders. Current treatment options are limited, but increased awareness may improve recognition and management of this rare condition. Herein, we describe an unusual presentation of cutaneous collagenous vasculopathy as asymptomatic, pink, mat-like telangiectatic macules on the trunk and proximal extremities of a 62-year-old woman. Histopathologic evaluation revealed dilated superficial dermal vessels with hyaline thickening of the vessel walls, consistent with a diagnosis of cutaneous collagenous vasculopathy.
A 39-year-old man with an unrecognized facial sinus tract under his chin initially presented with an innocuous lesion resembling an acne pimple. The patient's journey began with dermatologic intervention, involving syste...A 39-year-old man with an unrecognized facial sinus tract under his chin initially presented with an innocuous lesion resembling an acne pimple. The patient's journey began with dermatologic intervention, involving systemic and topical antibiotics. Upon treatment failure, referral to a general dentist revealed a carious lesion on the lower right lateral incisor, prompting further investigation. A subsequent referral to an endodontic specialist led to the diagnosis of a chronic periapical abscess, and an endodontic intervention was initiated. Despite the persistence of intracanal purulent exudate, a strategic application of pure calcium hydroxide was implemented, followed by a temporary seal. A two-year follow-up demonstrated complete healing of the periapical lesion and resolution of the extraoral cutaneous sinus tract. The report showcases the intricate diagnostic journey, meticulous endodontic intervention, and successful management of an extraoral cutaneous sinus tract mimicking scar or cyst, emphasizing the importance of a correct diagnosis to avoid ineffective treatment.
Enfortumab vedotin is a first-in-class antibody-drug conjugate used in the treatment of locally advanced or metastatic urothelial carcinoma. A range of cutaneous adverse events has been reported with enfortumab vedotin u...Enfortumab vedotin is a first-in-class antibody-drug conjugate used in the treatment of locally advanced or metastatic urothelial carcinoma. A range of cutaneous adverse events has been reported with enfortumab vedotin use. Nectin-4, a transmembrane protein overexpressed by urothelial carcinoma cells, is the intended target of enfortumab vedotin. However, as nectin-4 is also expressed by epidermal keratinocytes, sweat glands, and hair follicles, it is believed that cutaneous toxicity is mediated though off-target delivery of enfortumab vedotin. We present a patient with metastatic urothelial carcinoma who developed a grade 3 bullous dermatitis after his second treatment cycle of enfortumab vedotin and pembrolizumab therapy. Histopathologic findings showed intraepidermal blisters with prominent dyskeratotic and necrotic keratinocytes. Temporary withholding of enfortumab vedotin and pembrolizumab and treatment with potent topical corticosteroids led to significant improvement and enfortumab vedotin (with pembrolizumab) was resumed at a reduced dosage of enfortumab vedotin without recurrence. We present this case to highlight the clinical manifestations, histopathologic findings, and management of enfortumab vedotin-induced cutaneous toxicity.
Osteoma cutis miliaris is a rare condition of bone formation in the dermis, often misdiagnosed. We present a 52-year-old woman with asymptomatic, hard papules on the forehead, initially treated as acne. Biopsy confirmed...Osteoma cutis miliaris is a rare condition of bone formation in the dermis, often misdiagnosed. We present a 52-year-old woman with asymptomatic, hard papules on the forehead, initially treated as acne. Biopsy confirmed osteoma cutis, and surgical removal via microincisions successfully extracted the lesions with no recurrence. This case emphasizes the importance of accurate diagnosis and highlights a minimally invasive approach as an effective, low-risk treatment option.
Purpura fulminans is a rare life-threatening presentation of disseminated intravascular congestion that presents with widespread purpura and skin necrosis secondary to considerable tissue thrombosis. It usually occurs in...Purpura fulminans is a rare life-threatening presentation of disseminated intravascular congestion that presents with widespread purpura and skin necrosis secondary to considerable tissue thrombosis. It usually occurs in pediatric patients and can have various causes with acute infection being the most common. Common infectious triggers include Neisseria and Streptococcus pneumoniae as well as varicella. Our report describes a generally healthy adult patient who developed purpura fulminans in the setting of Group A Streptococcus bacteremia. Group A Streptococcus is a rare cause of purpura fulminans in adult patients with only a few documented cases reported in the literature.
Colloid milium is a rare and clinically underdiagnosed dermatosis, characterized by deposition of amorphous material in the dermis. Definitive diagnosis is established by histopathology which reveals the presence of coll...Colloid milium is a rare and clinically underdiagnosed dermatosis, characterized by deposition of amorphous material in the dermis. Definitive diagnosis is established by histopathology which reveals the presence of colloid in dermal papillae. Photo-exposed areas are the most frequently involved sites and include dorsa of hands, neck, and ears. We present an adult man with an outdoor occupation who had longstanding chronic actinic dermatitis. For one and a half years he had been developing skin colored to slightly erythematous papules and nodules on his face, anterior neck, and dorsal aspect of the hands, symmetrically. These discrete lesions arose on the background of his eczematous sun exposed skin. Skin biopsy for histopathology of these papules showed deposition of amorphous colloid material in the dermal papillae with an uninvolved Grenz zone along with dermal solar elastoses. The coexistence of colloid milium with chronic actinic dermatitis in the same patient has not been previously reported in the medical literature even though both conditions are precipitated by chronic sun exposure. Similarly, such extensive lesions of colloid milium have rarely been reported and we ascribe this to his profession, compelling him to spend numerous hours in the sun every day.
Inflammatory linear verrucous epidermal nevus is a rare benign epidermal nevus that classically presents in childhood with pruritic, linear, erythematous, scaly coalescing papules and plaques distributed along the lines...Inflammatory linear verrucous epidermal nevus is a rare benign epidermal nevus that classically presents in childhood with pruritic, linear, erythematous, scaly coalescing papules and plaques distributed along the lines of Blaschko. We report a 28-year-old woman with a long-standing history of photosensitive pruritic dermatosis, exhibiting minimal improvement with topical therapies, including clobetasol, cholesterol/lovastatin cream, and ruxolitinib. Histologic evaluation revealed psoriasiform epidermal hyperplasia with focal cornoid lamella. The combination of clinical and histologic features led to the diagnosis of porokeratotic inflammatory linear verrucous epidermal nevus, a proposed variant of inflammatory linear verrucous epidermal nevus with overlapping features of linear porokeratosis. The patient demonstrated substantial improvement following CO2 laser therapy, highlighting its potential as an effective treatment option for this variant of inflammatory linear verrucous epidermal nevus.
An 82-year-old man with a history of hypertension, thyroid nodule, and parkinsonism on carbidopa/levodopa was referred for a sudden eruption of scattered purpuric macules. He noted fatigue, weakness, ankle swelling, abdo...An 82-year-old man with a history of hypertension, thyroid nodule, and parkinsonism on carbidopa/levodopa was referred for a sudden eruption of scattered purpuric macules. He noted fatigue, weakness, ankle swelling, abdominal fullness, headaches, lapses in memory, and dysphasia. On physical examination, he had thin and atrophied upper extremities and central obesity, as well as nonblanching red to purple macules on the lower abdomen and ecchymosis on bilateral arms. The patient denied the use of any corticosteroids. Lab workup showed an abnormally high post-dexamethasone cortisol level, which raised suspicion for Cushing syndrome. Further inquiry into the patient's medication and supplement history revealed that he was consuming Artri King, a supplement marketed for the treatment of joint pain and arthritis. Artri King can lead to numerous dermatological manifestations akin to endogenous Cushing syndrome such as thin skin, easy bruising, and purple striae. This case illustrates the potential risks of over-the-counter dietary supplements, which often circumvent the strict Food and Drug Administration regulations applied to prescription medications, posing significant health hazards to users. There is critical need for transparency and regulation of supplements.