Cutis

Practice Gap

Tuberous sclerosis complex (TSC) is an autosomal-dominant genetic disorder resulting in loss-of-function mutations in the TSC1 and TSC2 genes. These mutations lead to constitutive activation of the mitogenic mTOR pathway and release of lymphangiogenic growth factors, causing the formation of hamartomatous tumors throughout multiple organ systems.¹ Facial angiofibromas (FAs) are a common cutaneous manifestation of TSC, affecting up to 80% of patients worldwide.² Aesthetic disfigurement, vision obstruction, and breathing impairment often are associated with FAs. They frequently arise in children with TSC and impose a psychosocial burden that can affect the patient’s overall quality of life.

Cutaneous stigmata of TSC pose a significant therapeutic challenge. Topical sirolimus has become a first-line treatment of FAs by inhibiting the mitogenic mTOR pathway¹; however, thicker, more extensive lesions are less responsive to topical therapy. The entire dermis is involved in TSC, and topical sirolimus alone often is ineffective for large fibrous FAs.³ Likewise, oral mTOR inhibition has shown only 25% to 50% improvement in FAs and has potential side effects that can limit patients’ tolerance and compliance.⁴

The Technique

A 46-year-old man with TSC was referred to dermatology for treatment of numerous facial papules and plaques that had been present since childhood and were consistent with FAs (Figure 1A). The lesions were tender, impaired the patient’s breathing, and caused emotional distress. Dermabrasion was attempted 20 years prior with minimal improvement and subsequent progression of the FAs. Other stigmata of TSC were present, including cutaneous hypopigmented macules and shagreen patches as well as seizures and renal angiomyolipomas. Due to multiorgan involvement, the patient was started on once-daily oral everolimus 2.5 mg; however, the FAs were progressive despite the systemic mTOR inhibition. Furthermore, it was presumed that topical sirolimus monotherapy would be ineffective due to thickness and extent of FAs; therefore, we proposed a novel treatment approach combining initial surgical debulking with subsequent longitudinal use of topical sirolimus to reduce the risk of recurrence.

Local anesthesia with lidocaine 1% and epinephrine 1:100,000 was administered. Larger FAs were removed at the base with a sterile surgical blade. Nasal recontouring subsequently was performed using a combination of shave biopsy and curettage. Extensive electrocautery was performed for hemostasis and destruction of residual FAs. Figure 1B shows the immediate postoperative result.

One month postoperatively, the patient stopped the oral everolimus at his oncologist’s recommendation due to abdominal pain and peripheral edema. Once the abraded skin showed evidence of wound healing, the patient was instructed to initiate sirolimus ointment 1% twice daily to reduce the risk of recurrence.^1,5,6 At 8-week follow-up, the patient was noted to have cosmetic improvement and resolution of breathing impairment (Figure 2A). He continued to show excellent cosmetic results at 1-year follow-up using topical sirolimus monotherapy (Figure 2B).

Practical Implications

Surgical debulking combined with longitudinal use of sirolimus ointment 1% can achieve an optimal therapeutic response for disfiguring phymatous presentation of FAs in the setting of TSC. We believe it is an effective approach for thick disfiguring FAs that are unlikely to respond to mTOR inhibition alone.

Practice Gap

Tuberous sclerosis complex (TSC) is an autosomal-dominant genetic disorder resulting in loss-of-function mutations in the TSC1 and TSC2 genes. These mutations lead to constitutive activation of the mitogenic mTOR pathway and release of lymphangiogenic growth factors, causing the formation of hamartomatous tumors throughout multiple organ systems.¹ Facial angiofibromas (FAs) are a common cutaneous manifestation of TSC, affecting up to 80% of patients worldwide.² Aesthetic disfigurement, vision obstruction, and breathing impairment often are associated with FAs. They frequently arise in children with TSC and impose a psychosocial burden that can affect the patient’s overall quality of life.

Cutaneous stigmata of TSC pose a significant therapeutic challenge. Topical sirolimus has become a first-line treatment of FAs by inhibiting the mitogenic mTOR pathway¹; however, thicker, more extensive lesions are less responsive to topical therapy. The entire dermis is involved in TSC, and topical sirolimus alone often is ineffective for large fibrous FAs.³ Likewise, oral mTOR inhibition has shown only 25% to 50% improvement in FAs and has potential side effects that can limit patients’ tolerance and compliance.⁴

The Technique

A 46-year-old man with TSC was referred to dermatology for treatment of numerous facial papules and plaques that had been present since childhood and were consistent with FAs (Figure 1A). The lesions were tender, impaired the patient’s breathing, and caused emotional distress. Dermabrasion was attempted 20 years prior with minimal improvement and subsequent progression of the FAs. Other stigmata of TSC were present, including cutaneous hypopigmented macules and shagreen patches as well as seizures and renal angiomyolipomas. Due to multiorgan involvement, the patient was started on once-daily oral everolimus 2.5 mg; however, the FAs were progressive despite the systemic mTOR inhibition. Furthermore, it was presumed that topical sirolimus monotherapy would be ineffective due to thickness and extent of FAs; therefore, we proposed a novel treatment approach combining initial surgical debulking with subsequent longitudinal use of topical sirolimus to reduce the risk of recurrence.

Local anesthesia with lidocaine 1% and epinephrine 1:100,000 was administered. Larger FAs were removed at the base with a sterile surgical blade. Nasal recontouring subsequently was performed using a combination of shave biopsy and curettage. Extensive electrocautery was performed for hemostasis and destruction of residual FAs. Figure 1B shows the immediate postoperative result.

One month postoperatively, the patient stopped the oral everolimus at his oncologist’s recommendation due to abdominal pain and peripheral edema. Once the abraded skin showed evidence of wound healing, the patient was instructed to initiate sirolimus ointment 1% twice daily to reduce the risk of recurrence.^1,5,6 At 8-week follow-up, the patient was noted to have cosmetic improvement and resolution of breathing impairment (Figure 2A). He continued to show excellent cosmetic results at 1-year follow-up using topical sirolimus monotherapy (Figure 2B).

Practical Implications

Surgical debulking combined with longitudinal use of sirolimus ointment 1% can achieve an optimal therapeutic response for disfiguring phymatous presentation of FAs in the setting of TSC. We believe it is an effective approach for thick disfiguring FAs that are unlikely to respond to mTOR inhibition alone.

Practice Gap

Tuberous sclerosis complex (TSC) is an autosomal-dominant genetic disorder resulting in loss-of-function mutations in the TSC1 and TSC2 genes. These mutations lead to constitutive activation of the mitogenic mTOR pathway and release of lymphangiogenic growth factors, causing the formation of hamartomatous tumors throughout multiple organ systems.¹ Facial angiofibromas (FAs) are a common cutaneous manifestation of TSC, affecting up to 80% of patients worldwide.² Aesthetic disfigurement, vision obstruction, and breathing impairment often are associated with FAs. They frequently arise in children with TSC and impose a psychosocial burden that can affect the patient’s overall quality of life.

Cutaneous stigmata of TSC pose a significant therapeutic challenge. Topical sirolimus has become a first-line treatment of FAs by inhibiting the mitogenic mTOR pathway¹; however, thicker, more extensive lesions are less responsive to topical therapy. The entire dermis is involved in TSC, and topical sirolimus alone often is ineffective for large fibrous FAs.³ Likewise, oral mTOR inhibition has shown only 25% to 50% improvement in FAs and has potential side effects that can limit patients’ tolerance and compliance.⁴

The Technique

A 46-year-old man with TSC was referred to dermatology for treatment of numerous facial papules and plaques that had been present since childhood and were consistent with FAs (Figure 1A). The lesions were tender, impaired the patient’s breathing, and caused emotional distress. Dermabrasion was attempted 20 years prior with minimal improvement and subsequent progression of the FAs. Other stigmata of TSC were present, including cutaneous hypopigmented macules and shagreen patches as well as seizures and renal angiomyolipomas. Due to multiorgan involvement, the patient was started on once-daily oral everolimus 2.5 mg; however, the FAs were progressive despite the systemic mTOR inhibition. Furthermore, it was presumed that topical sirolimus monotherapy would be ineffective due to thickness and extent of FAs; therefore, we proposed a novel treatment approach combining initial surgical debulking with subsequent longitudinal use of topical sirolimus to reduce the risk of recurrence.

Local anesthesia with lidocaine 1% and epinephrine 1:100,000 was administered. Larger FAs were removed at the base with a sterile surgical blade. Nasal recontouring subsequently was performed using a combination of shave biopsy and curettage. Extensive electrocautery was performed for hemostasis and destruction of residual FAs. Figure 1B shows the immediate postoperative result.

One month postoperatively, the patient stopped the oral everolimus at his oncologist’s recommendation due to abdominal pain and peripheral edema. Once the abraded skin showed evidence of wound healing, the patient was instructed to initiate sirolimus ointment 1% twice daily to reduce the risk of recurrence.^1,5,6 At 8-week follow-up, the patient was noted to have cosmetic improvement and resolution of breathing impairment (Figure 2A). He continued to show excellent cosmetic results at 1-year follow-up using topical sirolimus monotherapy (Figure 2B).

Practical Implications

Surgical debulking combined with longitudinal use of sirolimus ointment 1% can achieve an optimal therapeutic response for disfiguring phymatous presentation of FAs in the setting of TSC. We believe it is an effective approach for thick disfiguring FAs that are unlikely to respond to mTOR inhibition alone.

What Are Essential Oils?

Essential oils are aromatic volatile oils produced by medicinal plants that give them their distinct flavors and aromas. They are extracted using a variety of different techniques, such as microwave-assisted extraction, headspace extraction, and the most commonly employed hydrodistillation.¹ Different parts of the plant are used for the specific oils; the shoots and leaves of Origanum vulgare are used for oregano oil, whereas the skins of Citrus limonum are used for lemon oil.² Historically, essential oils have been used for cooking, food preservation, perfume, and medicine.^3,4

Historical Uses for Essential Oils

Essential oils and their intact medicinal plants were among the first medicines widely available to the ancient world. The Ancient Greeks used topical and oral oregano as a cure-all for ailments including wounds, sore muscles, and diarrhea. Because of its use as a cure-all medicine, it remains a popular folk remedy in parts of Europe today.³ Lavender also has a long history of being a cure-all plant and oil. Some of the many claims behind this flower include treatment of burns, insect bites, parasites, muscle spasms, nausea, and anxiety/depression.⁵ With an extensive list of historical uses, many essential oils are being researched to determine if their acclaimed qualities have quantifiable properties.

Science Behind the Belief

In vitro experiments with oregano (O vulgare) have demonstrated notable antifungal and antimicrobial effects.⁶ Gas chromatographic analysis of the oil shows much of it is composed of phenolic monoterpenes, such as thymol and carvacrol. They exhibit strong antifungal effects with a slightly stronger effect on the dermatophyte Trichophyton rubrum over other yeast species such as Candida.^7,8 The full effect of the monoterpenes on fungi is not completely understood, but early data show it has a strong affinity for the ergosterol used in the cell-wall synthesis. Other effects demonstrated in in vitro studies include the ability to block drug efflux pumps, biofilm formation, cellular communication among bacteria, and mycotoxin production.⁹

A double-blind, randomized trial by Akhondzadeh et al¹⁰ demonstrated lavender (Lavandula officinalis) to have a mild antidepressant quality but a noticeably more potent effect when combined with imipramine. The effects of the lavender with imipramine were stronger and provided earlier improvement than imipramine alone for treatment of mild to moderate depression. The team concluded that lavender may be an effective adjunct therapy in treating depression.¹⁰

In a study by Mori et al,¹¹ full-thickness circular wounds were made in rats and treated with either lavender oil (L officinalis), nothing, or a control oil. With the lavender oil being at only 1% solution, the wounds treated with lavender oil demonstrated earlier closure than the other 2 groups of wounds, where no major difference was noted. On cellular analysis, it was seen that the lavender had increased the rate of granulation as well as expression of types I and III collagen. The most striking result was the large expression of transforming growth factor β seen in the lavender group compared to the others. The final thoughts on this experiment were that lavender may provide new approaches to wound care in the future.¹¹

Potential Problems With Purity

One major concern raised about essential oils is their purity and the fidelity of their chemical composition. The specific aromatic chemicals in each essential oil are maintained for each species, but the proportions of each change even with the time of year.¹² Gas chromatograph analysis of the same oil distilled with different techniques showed that the proportions of aromatic chemicals varied with technique. However, the major constituents of the oil remained present in large quantities, just at different percentages.¹ Even using the same distillation technique for different time periods can greatly affect the yield and composition of the oil. Although the percentage of each aromatic compound can be affected by distillation times, the antioxidant and antimicrobial effects of the oil remain constant regardless of these variables.² There is clearly a lack in standardization in essential oil production, which may not be an issue for its use in complementary medicine if its properties are maintained regardless.

Safety Concerns and Regulations

With essential oils being a natural cure for everyday ailments, some people are turning first to oils for every cut and bruise. The danger in these natural cures is that essential oils can cause several types of dermatitis and allergic reactions. The development of allergies to essential oils is at an even higher risk, considering people frequently put them on wounds and rashes where the skin barrier is already weakened. Many essential oils fall into the fragrance category in patch tests, negating the widely circulating blogger and online reports that essential oils cannot cause allergies.

Some of the oils, although regarded safe by the US Food and Drug Administration for consumption, can cause dermatitis from simple contact or with sun exposure.¹³ Members of the citrus family are notorious for the phytophotodermatitis reaction, which can leave hyperpigmented scarring after exposure of the oils to sunlight.¹⁴ Most companies that sell essential oils are aware of this reaction and include it in the warning labels.

The legal problem with selling and classifying essential oils is that the US Food and Drug Administration requires products intended for treatment to be labeled as drugs, which hinders their sales on the open market.¹³ It all boils down to intended use, so some companies sell the oils under a food or fragrance classification with vague instructions on how to use said oil for medicinal purposes, which leads to lack of supervision, anecdotal cures, and false health claims. One company claims in their safety guide for topical applications of their oils that “[i]f a rash occurs, this may be a sign of detoxification.”¹⁵ If essential oils had only minimal absorption topically, their safety would be less concerning, but this does not appear to be the case.

Absorption and Systemics

The effects of essential oils on the skin is one aspect of their use to be studied; another is the more systemic effects from absorption through the skin. Most essential oils used in small quantities for fragrance in over-the-counter lotions prove only to be an issue for allergens in sensitive patient groups. However, topical applications of essential oils in their pure concentrated form get absorbed into the skin faster than if used with a carrier oil, emulsion, or solvent.¹⁶ For most minor uses of essential oils, the body can detoxify absorbed chemicals the same way it does when a person eats the plants the oils came from (eg, basil essential oils leaching from the leaves into a tomato sauce). A possible danger of the oils’ systemic properties lies in the pregnant patient population who use essential oils thinking that natural is safe.

Many essential oils, such as lavender (L officinalis), exhibit hormonal mimicry with phytoestrogens and can produce emmenagogue (increasing menstrual flow) effects in women. Other oils, such as those of nutmeg (Myristica fragrans) and myrrh (Commiphora myrrha), can have abortifacient effects. These natural essential oils can lead to unintended health risks for mother and baby.¹⁷ With implications this serious, many essential oil companies put pregnancy warnings on most if not all of their products, but pregnant patients may not always note the risk.

Conclusion

Essential oils are not the newest medical fad. They outdate every drug on the market and were used by some of the first physicians in history. It is important to continue research into the antimicrobial effects of essential oils, as they may hold the secret to treatment options with the continued rise of multidrug-resistant organisms. The danger of these oils lies not in their hidden potential but in the belief that natural things are safe. A few animal studies have been performed, but little is known about the full effects of essential oils in humans. Patients need to be educated that these are not panaceas with freedom from side effects and that treatment options backed by the scientific method should be their first choice under the supervision of trained physicians. The Table outlines the uses and side effects of the essential oils discussed here.

What Are Essential Oils?

Essential oils are aromatic volatile oils produced by medicinal plants that give them their distinct flavors and aromas. They are extracted using a variety of different techniques, such as microwave-assisted extraction, headspace extraction, and the most commonly employed hydrodistillation.¹ Different parts of the plant are used for the specific oils; the shoots and leaves of Origanum vulgare are used for oregano oil, whereas the skins of Citrus limonum are used for lemon oil.² Historically, essential oils have been used for cooking, food preservation, perfume, and medicine.^3,4

Historical Uses for Essential Oils

Essential oils and their intact medicinal plants were among the first medicines widely available to the ancient world. The Ancient Greeks used topical and oral oregano as a cure-all for ailments including wounds, sore muscles, and diarrhea. Because of its use as a cure-all medicine, it remains a popular folk remedy in parts of Europe today.³ Lavender also has a long history of being a cure-all plant and oil. Some of the many claims behind this flower include treatment of burns, insect bites, parasites, muscle spasms, nausea, and anxiety/depression.⁵ With an extensive list of historical uses, many essential oils are being researched to determine if their acclaimed qualities have quantifiable properties.

Science Behind the Belief

In vitro experiments with oregano (O vulgare) have demonstrated notable antifungal and antimicrobial effects.⁶ Gas chromatographic analysis of the oil shows much of it is composed of phenolic monoterpenes, such as thymol and carvacrol. They exhibit strong antifungal effects with a slightly stronger effect on the dermatophyte Trichophyton rubrum over other yeast species such as Candida.^7,8 The full effect of the monoterpenes on fungi is not completely understood, but early data show it has a strong affinity for the ergosterol used in the cell-wall synthesis. Other effects demonstrated in in vitro studies include the ability to block drug efflux pumps, biofilm formation, cellular communication among bacteria, and mycotoxin production.⁹

A double-blind, randomized trial by Akhondzadeh et al¹⁰ demonstrated lavender (Lavandula officinalis) to have a mild antidepressant quality but a noticeably more potent effect when combined with imipramine. The effects of the lavender with imipramine were stronger and provided earlier improvement than imipramine alone for treatment of mild to moderate depression. The team concluded that lavender may be an effective adjunct therapy in treating depression.¹⁰

In a study by Mori et al,¹¹ full-thickness circular wounds were made in rats and treated with either lavender oil (L officinalis), nothing, or a control oil. With the lavender oil being at only 1% solution, the wounds treated with lavender oil demonstrated earlier closure than the other 2 groups of wounds, where no major difference was noted. On cellular analysis, it was seen that the lavender had increased the rate of granulation as well as expression of types I and III collagen. The most striking result was the large expression of transforming growth factor β seen in the lavender group compared to the others. The final thoughts on this experiment were that lavender may provide new approaches to wound care in the future.¹¹

Potential Problems With Purity

One major concern raised about essential oils is their purity and the fidelity of their chemical composition. The specific aromatic chemicals in each essential oil are maintained for each species, but the proportions of each change even with the time of year.¹² Gas chromatograph analysis of the same oil distilled with different techniques showed that the proportions of aromatic chemicals varied with technique. However, the major constituents of the oil remained present in large quantities, just at different percentages.¹ Even using the same distillation technique for different time periods can greatly affect the yield and composition of the oil. Although the percentage of each aromatic compound can be affected by distillation times, the antioxidant and antimicrobial effects of the oil remain constant regardless of these variables.² There is clearly a lack in standardization in essential oil production, which may not be an issue for its use in complementary medicine if its properties are maintained regardless.

Safety Concerns and Regulations

With essential oils being a natural cure for everyday ailments, some people are turning first to oils for every cut and bruise. The danger in these natural cures is that essential oils can cause several types of dermatitis and allergic reactions. The development of allergies to essential oils is at an even higher risk, considering people frequently put them on wounds and rashes where the skin barrier is already weakened. Many essential oils fall into the fragrance category in patch tests, negating the widely circulating blogger and online reports that essential oils cannot cause allergies.

Some of the oils, although regarded safe by the US Food and Drug Administration for consumption, can cause dermatitis from simple contact or with sun exposure.¹³ Members of the citrus family are notorious for the phytophotodermatitis reaction, which can leave hyperpigmented scarring after exposure of the oils to sunlight.¹⁴ Most companies that sell essential oils are aware of this reaction and include it in the warning labels.

The legal problem with selling and classifying essential oils is that the US Food and Drug Administration requires products intended for treatment to be labeled as drugs, which hinders their sales on the open market.¹³ It all boils down to intended use, so some companies sell the oils under a food or fragrance classification with vague instructions on how to use said oil for medicinal purposes, which leads to lack of supervision, anecdotal cures, and false health claims. One company claims in their safety guide for topical applications of their oils that “[i]f a rash occurs, this may be a sign of detoxification.”¹⁵ If essential oils had only minimal absorption topically, their safety would be less concerning, but this does not appear to be the case.

Absorption and Systemics

The effects of essential oils on the skin is one aspect of their use to be studied; another is the more systemic effects from absorption through the skin. Most essential oils used in small quantities for fragrance in over-the-counter lotions prove only to be an issue for allergens in sensitive patient groups. However, topical applications of essential oils in their pure concentrated form get absorbed into the skin faster than if used with a carrier oil, emulsion, or solvent.¹⁶ For most minor uses of essential oils, the body can detoxify absorbed chemicals the same way it does when a person eats the plants the oils came from (eg, basil essential oils leaching from the leaves into a tomato sauce). A possible danger of the oils’ systemic properties lies in the pregnant patient population who use essential oils thinking that natural is safe.

Many essential oils, such as lavender (L officinalis), exhibit hormonal mimicry with phytoestrogens and can produce emmenagogue (increasing menstrual flow) effects in women. Other oils, such as those of nutmeg (Myristica fragrans) and myrrh (Commiphora myrrha), can have abortifacient effects. These natural essential oils can lead to unintended health risks for mother and baby.¹⁷ With implications this serious, many essential oil companies put pregnancy warnings on most if not all of their products, but pregnant patients may not always note the risk.

Conclusion

Essential oils are not the newest medical fad. They outdate every drug on the market and were used by some of the first physicians in history. It is important to continue research into the antimicrobial effects of essential oils, as they may hold the secret to treatment options with the continued rise of multidrug-resistant organisms. The danger of these oils lies not in their hidden potential but in the belief that natural things are safe. A few animal studies have been performed, but little is known about the full effects of essential oils in humans. Patients need to be educated that these are not panaceas with freedom from side effects and that treatment options backed by the scientific method should be their first choice under the supervision of trained physicians. The Table outlines the uses and side effects of the essential oils discussed here.

What Are Essential Oils?

Essential oils are aromatic volatile oils produced by medicinal plants that give them their distinct flavors and aromas. They are extracted using a variety of different techniques, such as microwave-assisted extraction, headspace extraction, and the most commonly employed hydrodistillation.¹ Different parts of the plant are used for the specific oils; the shoots and leaves of Origanum vulgare are used for oregano oil, whereas the skins of Citrus limonum are used for lemon oil.² Historically, essential oils have been used for cooking, food preservation, perfume, and medicine.^3,4

Historical Uses for Essential Oils

Essential oils and their intact medicinal plants were among the first medicines widely available to the ancient world. The Ancient Greeks used topical and oral oregano as a cure-all for ailments including wounds, sore muscles, and diarrhea. Because of its use as a cure-all medicine, it remains a popular folk remedy in parts of Europe today.³ Lavender also has a long history of being a cure-all plant and oil. Some of the many claims behind this flower include treatment of burns, insect bites, parasites, muscle spasms, nausea, and anxiety/depression.⁵ With an extensive list of historical uses, many essential oils are being researched to determine if their acclaimed qualities have quantifiable properties.

Science Behind the Belief

In vitro experiments with oregano (O vulgare) have demonstrated notable antifungal and antimicrobial effects.⁶ Gas chromatographic analysis of the oil shows much of it is composed of phenolic monoterpenes, such as thymol and carvacrol. They exhibit strong antifungal effects with a slightly stronger effect on the dermatophyte Trichophyton rubrum over other yeast species such as Candida.^7,8 The full effect of the monoterpenes on fungi is not completely understood, but early data show it has a strong affinity for the ergosterol used in the cell-wall synthesis. Other effects demonstrated in in vitro studies include the ability to block drug efflux pumps, biofilm formation, cellular communication among bacteria, and mycotoxin production.⁹

A double-blind, randomized trial by Akhondzadeh et al¹⁰ demonstrated lavender (Lavandula officinalis) to have a mild antidepressant quality but a noticeably more potent effect when combined with imipramine. The effects of the lavender with imipramine were stronger and provided earlier improvement than imipramine alone for treatment of mild to moderate depression. The team concluded that lavender may be an effective adjunct therapy in treating depression.¹⁰

In a study by Mori et al,¹¹ full-thickness circular wounds were made in rats and treated with either lavender oil (L officinalis), nothing, or a control oil. With the lavender oil being at only 1% solution, the wounds treated with lavender oil demonstrated earlier closure than the other 2 groups of wounds, where no major difference was noted. On cellular analysis, it was seen that the lavender had increased the rate of granulation as well as expression of types I and III collagen. The most striking result was the large expression of transforming growth factor β seen in the lavender group compared to the others. The final thoughts on this experiment were that lavender may provide new approaches to wound care in the future.¹¹

Potential Problems With Purity

One major concern raised about essential oils is their purity and the fidelity of their chemical composition. The specific aromatic chemicals in each essential oil are maintained for each species, but the proportions of each change even with the time of year.¹² Gas chromatograph analysis of the same oil distilled with different techniques showed that the proportions of aromatic chemicals varied with technique. However, the major constituents of the oil remained present in large quantities, just at different percentages.¹ Even using the same distillation technique for different time periods can greatly affect the yield and composition of the oil. Although the percentage of each aromatic compound can be affected by distillation times, the antioxidant and antimicrobial effects of the oil remain constant regardless of these variables.² There is clearly a lack in standardization in essential oil production, which may not be an issue for its use in complementary medicine if its properties are maintained regardless.

Safety Concerns and Regulations

With essential oils being a natural cure for everyday ailments, some people are turning first to oils for every cut and bruise. The danger in these natural cures is that essential oils can cause several types of dermatitis and allergic reactions. The development of allergies to essential oils is at an even higher risk, considering people frequently put them on wounds and rashes where the skin barrier is already weakened. Many essential oils fall into the fragrance category in patch tests, negating the widely circulating blogger and online reports that essential oils cannot cause allergies.

Some of the oils, although regarded safe by the US Food and Drug Administration for consumption, can cause dermatitis from simple contact or with sun exposure.¹³ Members of the citrus family are notorious for the phytophotodermatitis reaction, which can leave hyperpigmented scarring after exposure of the oils to sunlight.¹⁴ Most companies that sell essential oils are aware of this reaction and include it in the warning labels.

The legal problem with selling and classifying essential oils is that the US Food and Drug Administration requires products intended for treatment to be labeled as drugs, which hinders their sales on the open market.¹³ It all boils down to intended use, so some companies sell the oils under a food or fragrance classification with vague instructions on how to use said oil for medicinal purposes, which leads to lack of supervision, anecdotal cures, and false health claims. One company claims in their safety guide for topical applications of their oils that “[i]f a rash occurs, this may be a sign of detoxification.”¹⁵ If essential oils had only minimal absorption topically, their safety would be less concerning, but this does not appear to be the case.

Absorption and Systemics

The effects of essential oils on the skin is one aspect of their use to be studied; another is the more systemic effects from absorption through the skin. Most essential oils used in small quantities for fragrance in over-the-counter lotions prove only to be an issue for allergens in sensitive patient groups. However, topical applications of essential oils in their pure concentrated form get absorbed into the skin faster than if used with a carrier oil, emulsion, or solvent.¹⁶ For most minor uses of essential oils, the body can detoxify absorbed chemicals the same way it does when a person eats the plants the oils came from (eg, basil essential oils leaching from the leaves into a tomato sauce). A possible danger of the oils’ systemic properties lies in the pregnant patient population who use essential oils thinking that natural is safe.

Many essential oils, such as lavender (L officinalis), exhibit hormonal mimicry with phytoestrogens and can produce emmenagogue (increasing menstrual flow) effects in women. Other oils, such as those of nutmeg (Myristica fragrans) and myrrh (Commiphora myrrha), can have abortifacient effects. These natural essential oils can lead to unintended health risks for mother and baby.¹⁷ With implications this serious, many essential oil companies put pregnancy warnings on most if not all of their products, but pregnant patients may not always note the risk.

Conclusion

Essential oils are not the newest medical fad. They outdate every drug on the market and were used by some of the first physicians in history. It is important to continue research into the antimicrobial effects of essential oils, as they may hold the secret to treatment options with the continued rise of multidrug-resistant organisms. The danger of these oils lies not in their hidden potential but in the belief that natural things are safe. A few animal studies have been performed, but little is known about the full effects of essential oils in humans. Patients need to be educated that these are not panaceas with freedom from side effects and that treatment options backed by the scientific method should be their first choice under the supervision of trained physicians. The Table outlines the uses and side effects of the essential oils discussed here.

With today’s technology, it is easier than ever to access web-based tools that enrich traditional dermatology education. The literature supports the use of these innovative platforms to enhance learning at the student and trainee levels. A controlled study of pediatric residents showed that online modules effectively supplemented clinical experience with atopic dermatitis.¹ In a randomized diagnostic study of medical students, practice with an image-based web application (app) that teaches rapid recognition of melanoma proved more effective than learning a rule-based algorithm.² Given the visual nature of dermatology, pattern recognition is an essential skill that is fostered through experience and is only made more accessible with technology.

With the added benefit of convenience and accessibility, mobile apps can supplement experiential learning. Mirroring the overall growth of mobile apps, the number of available dermatology apps has increased.³ Dermatology mobile apps serve purposes ranging from quick reference tools to comprehensive modules, journals, and question banks. At an academic hospital in Taiwan, both nondermatology and dermatology trainees’ examination performance improved after 3 weeks of using a smartphone-based wallpaper learning module displaying morphologic characteristics of fungi.⁴ With the expansion of virtual microscopy, mobile apps also have been created as a learning tool for dermatopathology, giving trainees the flexibility and autonomy to view slides on their own time.⁵ Nevertheless, the literature on dermatology mobile apps designed for the education of medical students and trainees is limited, demonstrating a need for further investigation.

Prior studies have reviewed dermatology apps for patients and practicing dermatologists.^6-8 Herein, we focus on mobile apps targeting students and residents learning dermatology. General dermatology reference apps and educational aid apps have grown by 33% and 32%, respectively, from 2014 to 2017.³ As with any resource meant to educate future and current medical providers, there must be an objective review process in place to ensure accurate, unbiased, evidence-based teaching.

Well-organized, comprehensive information and a user-friendly interface are additional factors of importance when selecting an educational mobile app. When discussing supplemental resources, accessibility and affordability also are priorities given the high cost of a medical education at baseline. Overall, there is a need for a standardized method to evaluate the key factors of an educational mobile app that make it appropriate for this demographic. We conducted a search of mobile apps relating to dermatology education for students and residents.

Methods

We searched for publicly available mobile apps relating to dermatology education in the App Store (Apple Inc) from September to November 2019 using the search terms dermatology education, dermoscopy education, melanoma education, skin cancer education, psoriasis education, rosacea education, acne education, eczema education, dermal fillers education, and Mohs surgery education. We excluded apps that were not in English, were created for a conference, cost more than $5 to download, or did not include a specific dermatology education section. In this way, we hoped to evaluate apps that were relevant, accessible, and affordable.

We modeled our study after a review of patient education apps performed by Masud et al⁶ and utilized their quantified grading rubric (scale of 1 to 4). We found their established criteria—educational objectives, content, accuracy, design, and conflict of interest—to be equally applicable for evaluating apps designed for professional education.⁶ Each app earned a minimum of 1 point and a maximum of 4 points per criterion. One point was given if the app did not fulfill the criterion, 2 points for minimally fulfilling the criterion, 3 points for mostly fulfilling the criterion, and 4 points if the criterion was completely fulfilled. Two medical students (E.H. and N.C.)—one at the preclinical stage and the other at the clinical stage of medical education—reviewed the apps using the given rubric, then discussed and resolved any discrepancies in points assigned. A dermatology resident (M.A.) independently reviewed the apps using the given rubric.

The mean of the student score and the resident score was calculated for each category. The sum of the averages for each category was considered the final score for an app, determining its overall quality. Apps with a total score of 5 to 10 were considered poor and inadequate for education. A total score of 10.5 to 15 indicated that an app was somewhat adequate (ie, useful for education in some aspects but falling short in others). Apps that were considered adequate for education, across all or most criteria, received a total score ranging from 15.5 to 20.

Results

Our search generated 130 apps. After applying exclusion criteria, 42 apps were eligible for review. At the time of publication, 36 of these apps were still available. The possible range of scores based on the rubric was 5 to 20. The actual range of scores was 7 to 20. Of the 36 apps, 2 (5.6%) were poor, 16 (44.4%) were somewhat adequate, and 18 (50%) were adequate. Formats included primary resources, such as clinical decision support tools, journals, references, and a podcast (Table 1). Additionally, interactive learning tools included games, learning modules, and apps for self-evaluation (Table 2). Thirty apps covered general dermatology; others focused on skin cancer (n=5) and cosmetic dermatology (n=1). Regarding cost, 29 apps were free to download, whereas 7 charged a fee (mean price, $2.56).

Comment

In addition to the convenience of having an educational tool in their white-coat pocket, learners of dermatology have been shown to benefit from supplementing their curriculum with mobile apps, which sets the stage for formal integration of mobile apps into dermatology teaching in the future.⁸ Prior to widespread adoption, mobile apps must be evaluated for content and utility, starting with an objective rubric.

Without official scientific standards in place, it was unsurprising that only half of the dermatology education applications were classified as adequate in this study. Among the types of apps offered—clinical decision support tools, journals, references, podcast, games, learning modules, and self-evaluation—certain categories scored higher than others. App formats with the highest average score (16.5 out of 20) were journals and podcast.

One barrier to utilization of these apps was that a subscription to the journals and podcast was required to obtain access to all available content. Students and trainees can seek out library resources at their academic institutions to take advantage of journal subscriptions available to them at no additional cost. Dermatology residents can take advantage of their complimentary membership in the American Academy of Dermatology for a free subscription to AAD Dialogues in Dermatology (otherwise $179 annually for nonresident members and $320 annually for nonmembers).

On the other hand, learning module was the lowest-rated format (average score, 11.3 out of 20), with only Medical Student: Dermatology qualifying as adequate (total score, 16). This finding is worrisome given that students and residents might look to learning modules for quick targeted lessons on specific topics.

The lowest-scoring app, a clinical decision support tool called Naturelize, received a total score of 7. Although it listed the indications and contraindications for dermal filler types to be used in different locations on the face, there was a clear conflict of interest, oversimplified design, and little evidence-based education, mirroring the current state of cosmetic dermatology training in residency, in which trainees think they are inadequately prepared for aesthetic procedures and comparative effectiveness research is lacking.^9-11

At the opposite end of the spectrum, MyDermPath+ was a reference app with a total score of 20. The app cited credible authors with a medical degree (MD) and had an easy-to-use, well-designed interface, including a reference guide, differential builder, and quiz for a range of topics within dermatology. As a free download without in-app purchases or advertisements, there was no evidence of conflict of interest. The position of a dermatopathology app as the top dermatology education mobile app might reflect an increased emphasis on dermatopathology education in residency as well as a transition to digitization of slides.⁵

The second-highest scoring apps (total score of 19 points) were Dermatology Database and VisualDx. Both were references covering a wide range of dermatology topics. Dermatology Database was a comprehensive search tool for diseases, drugs, procedures, and terms that was simple and entirely free to use but did not cite references. VisualDx, as its name suggests, offered quality clinical images, complete guides with references, and a unique differential builder. An annual subscription is $399.99, but the process to gain free access through a participating academic institution was simple.

Games were a unique mobile app format; however, 2 of 3 games scored in the somewhat adequate range. The game DiagnosUs, which tested users’ ability to differentiate skin cancer and psoriasis from dermatitis on clinical images, would benefit from more comprehensive content as well as professional verification of true diagnoses, which earned the app 2 points in both the content and accuracy categories. The Unusual Suspects tested the ABCDE algorithm in a short learning module, followed by a simple game that involved identification of melanoma in a timed setting. Although the design was novel and interactive, the game was limited to the same 5 melanoma tumors overlaid on pictures of normal skin. The narrow scope earned 1 point for content, the redundancy in the game earned 3 points for design, and the lack of real clinical images earned 2 points for educational objectives. Although game-format mobile apps have the capability to challenge the user’s knowledge with a built-in feedback or reward system, improvements should be made to ensure that apps are equally educational as they are engaging.

AAD Dialogues in Dermatology was the only app in the form of a podcast and provided expert interviews along with disclosures, transcripts, commentary, and references. More than half the content in the app could not be accessed without a subscription, earning 2.5 points in the conflict of interest category. Additionally, several flaws resulted in a design score of 2.5, including inconsistent availability of transcripts, poor quality of sound on some episodes, difficulty distinguishing new episodes from those already played, and a glitch that removed the episode duration. Still, the app was a valuable and comprehensive resource, with clear objectives and cited references. With improvements in content, affordability, and user experience, apps in unique formats such as games and podcasts might appeal to kinesthetic and auditory learners.

An important factor to consider when discussing mobile apps for students and residents is cost. With rising prices of board examinations and preparation materials, supplementary study tools should not come with an exorbitant price tag. Therefore, we limited our evaluation to apps that were free or cost less than $5 to download. Even so, subscriptions and other in-app purchases were an obstacle in one-third of apps, ranging from $4.99 to unlock additional content in Rash Decisions to $69.99 to access most topics in Fitzpatrick’s Color Atlas. The highest-rated app in our study, MyDermPath+, historically cost $19.99 to download but became free with a grant from the Sulzberger Foundation.¹² An initial investment to develop quality apps for the purpose of dermatology education might pay off in the end.

To evaluate the apps from the perspective of the target demographic of this study, 2 medical students—one in the preclinical stage and the other in the clinical stage of medical education—and a dermatology resident graded the apps. Certain limitations exist in this type of study, including differing learning styles, which might influence the types of apps that evaluators found most impactful to their education. Interestingly, some apps earned a higher resident score than student score. In particular, RightSite (a reference that helps with anatomically correct labeling) and Mohs Surgery Appropriate Use Criteria (a clinical decision support tool to determine whether to perform Mohs surgery) each had a 3-point discrepancy (data not shown). A resident might benefit from these practical apps in day-to-day practice, but a student would be less likely to find them useful as a learning tool.

Still, by defining adequate teaching value using specific categories of educational objectives, content, accuracy, design, and conflict of interest, we attempted to minimize the effect of personal preference on the grading process. Although we acknowledge a degree of subjectivity, we found that utilizing a previously published rubric with defined criteria was crucial in remaining unbiased.

Conclusion

Further studies should evaluate additional apps available on Apple’s iPad (tablet), as well as those on other operating systems, including Google’s Android. To ensure the existence of mobile apps as adequate education tools, they should be peer reviewed prior to publication or before widespread use by future and current providers at the minimum. To maximize free access to highly valuable resources available in the palm of their hand, students and trainees should contact the library at their academic institution.

With today’s technology, it is easier than ever to access web-based tools that enrich traditional dermatology education. The literature supports the use of these innovative platforms to enhance learning at the student and trainee levels. A controlled study of pediatric residents showed that online modules effectively supplemented clinical experience with atopic dermatitis.¹ In a randomized diagnostic study of medical students, practice with an image-based web application (app) that teaches rapid recognition of melanoma proved more effective than learning a rule-based algorithm.² Given the visual nature of dermatology, pattern recognition is an essential skill that is fostered through experience and is only made more accessible with technology.

With the added benefit of convenience and accessibility, mobile apps can supplement experiential learning. Mirroring the overall growth of mobile apps, the number of available dermatology apps has increased.³ Dermatology mobile apps serve purposes ranging from quick reference tools to comprehensive modules, journals, and question banks. At an academic hospital in Taiwan, both nondermatology and dermatology trainees’ examination performance improved after 3 weeks of using a smartphone-based wallpaper learning module displaying morphologic characteristics of fungi.⁴ With the expansion of virtual microscopy, mobile apps also have been created as a learning tool for dermatopathology, giving trainees the flexibility and autonomy to view slides on their own time.⁵ Nevertheless, the literature on dermatology mobile apps designed for the education of medical students and trainees is limited, demonstrating a need for further investigation.

Prior studies have reviewed dermatology apps for patients and practicing dermatologists.^6-8 Herein, we focus on mobile apps targeting students and residents learning dermatology. General dermatology reference apps and educational aid apps have grown by 33% and 32%, respectively, from 2014 to 2017.³ As with any resource meant to educate future and current medical providers, there must be an objective review process in place to ensure accurate, unbiased, evidence-based teaching.

Well-organized, comprehensive information and a user-friendly interface are additional factors of importance when selecting an educational mobile app. When discussing supplemental resources, accessibility and affordability also are priorities given the high cost of a medical education at baseline. Overall, there is a need for a standardized method to evaluate the key factors of an educational mobile app that make it appropriate for this demographic. We conducted a search of mobile apps relating to dermatology education for students and residents.

Methods

We searched for publicly available mobile apps relating to dermatology education in the App Store (Apple Inc) from September to November 2019 using the search terms dermatology education, dermoscopy education, melanoma education, skin cancer education, psoriasis education, rosacea education, acne education, eczema education, dermal fillers education, and Mohs surgery education. We excluded apps that were not in English, were created for a conference, cost more than $5 to download, or did not include a specific dermatology education section. In this way, we hoped to evaluate apps that were relevant, accessible, and affordable.

We modeled our study after a review of patient education apps performed by Masud et al⁶ and utilized their quantified grading rubric (scale of 1 to 4). We found their established criteria—educational objectives, content, accuracy, design, and conflict of interest—to be equally applicable for evaluating apps designed for professional education.⁶ Each app earned a minimum of 1 point and a maximum of 4 points per criterion. One point was given if the app did not fulfill the criterion, 2 points for minimally fulfilling the criterion, 3 points for mostly fulfilling the criterion, and 4 points if the criterion was completely fulfilled. Two medical students (E.H. and N.C.)—one at the preclinical stage and the other at the clinical stage of medical education—reviewed the apps using the given rubric, then discussed and resolved any discrepancies in points assigned. A dermatology resident (M.A.) independently reviewed the apps using the given rubric.

The mean of the student score and the resident score was calculated for each category. The sum of the averages for each category was considered the final score for an app, determining its overall quality. Apps with a total score of 5 to 10 were considered poor and inadequate for education. A total score of 10.5 to 15 indicated that an app was somewhat adequate (ie, useful for education in some aspects but falling short in others). Apps that were considered adequate for education, across all or most criteria, received a total score ranging from 15.5 to 20.

Results

Our search generated 130 apps. After applying exclusion criteria, 42 apps were eligible for review. At the time of publication, 36 of these apps were still available. The possible range of scores based on the rubric was 5 to 20. The actual range of scores was 7 to 20. Of the 36 apps, 2 (5.6%) were poor, 16 (44.4%) were somewhat adequate, and 18 (50%) were adequate. Formats included primary resources, such as clinical decision support tools, journals, references, and a podcast (Table 1). Additionally, interactive learning tools included games, learning modules, and apps for self-evaluation (Table 2). Thirty apps covered general dermatology; others focused on skin cancer (n=5) and cosmetic dermatology (n=1). Regarding cost, 29 apps were free to download, whereas 7 charged a fee (mean price, $2.56).

Comment

In addition to the convenience of having an educational tool in their white-coat pocket, learners of dermatology have been shown to benefit from supplementing their curriculum with mobile apps, which sets the stage for formal integration of mobile apps into dermatology teaching in the future.⁸ Prior to widespread adoption, mobile apps must be evaluated for content and utility, starting with an objective rubric.

Without official scientific standards in place, it was unsurprising that only half of the dermatology education applications were classified as adequate in this study. Among the types of apps offered—clinical decision support tools, journals, references, podcast, games, learning modules, and self-evaluation—certain categories scored higher than others. App formats with the highest average score (16.5 out of 20) were journals and podcast.

One barrier to utilization of these apps was that a subscription to the journals and podcast was required to obtain access to all available content. Students and trainees can seek out library resources at their academic institutions to take advantage of journal subscriptions available to them at no additional cost. Dermatology residents can take advantage of their complimentary membership in the American Academy of Dermatology for a free subscription to AAD Dialogues in Dermatology (otherwise $179 annually for nonresident members and $320 annually for nonmembers).

On the other hand, learning module was the lowest-rated format (average score, 11.3 out of 20), with only Medical Student: Dermatology qualifying as adequate (total score, 16). This finding is worrisome given that students and residents might look to learning modules for quick targeted lessons on specific topics.

The lowest-scoring app, a clinical decision support tool called Naturelize, received a total score of 7. Although it listed the indications and contraindications for dermal filler types to be used in different locations on the face, there was a clear conflict of interest, oversimplified design, and little evidence-based education, mirroring the current state of cosmetic dermatology training in residency, in which trainees think they are inadequately prepared for aesthetic procedures and comparative effectiveness research is lacking.^9-11

At the opposite end of the spectrum, MyDermPath+ was a reference app with a total score of 20. The app cited credible authors with a medical degree (MD) and had an easy-to-use, well-designed interface, including a reference guide, differential builder, and quiz for a range of topics within dermatology. As a free download without in-app purchases or advertisements, there was no evidence of conflict of interest. The position of a dermatopathology app as the top dermatology education mobile app might reflect an increased emphasis on dermatopathology education in residency as well as a transition to digitization of slides.⁵

The second-highest scoring apps (total score of 19 points) were Dermatology Database and VisualDx. Both were references covering a wide range of dermatology topics. Dermatology Database was a comprehensive search tool for diseases, drugs, procedures, and terms that was simple and entirely free to use but did not cite references. VisualDx, as its name suggests, offered quality clinical images, complete guides with references, and a unique differential builder. An annual subscription is $399.99, but the process to gain free access through a participating academic institution was simple.

Games were a unique mobile app format; however, 2 of 3 games scored in the somewhat adequate range. The game DiagnosUs, which tested users’ ability to differentiate skin cancer and psoriasis from dermatitis on clinical images, would benefit from more comprehensive content as well as professional verification of true diagnoses, which earned the app 2 points in both the content and accuracy categories. The Unusual Suspects tested the ABCDE algorithm in a short learning module, followed by a simple game that involved identification of melanoma in a timed setting. Although the design was novel and interactive, the game was limited to the same 5 melanoma tumors overlaid on pictures of normal skin. The narrow scope earned 1 point for content, the redundancy in the game earned 3 points for design, and the lack of real clinical images earned 2 points for educational objectives. Although game-format mobile apps have the capability to challenge the user’s knowledge with a built-in feedback or reward system, improvements should be made to ensure that apps are equally educational as they are engaging.

AAD Dialogues in Dermatology was the only app in the form of a podcast and provided expert interviews along with disclosures, transcripts, commentary, and references. More than half the content in the app could not be accessed without a subscription, earning 2.5 points in the conflict of interest category. Additionally, several flaws resulted in a design score of 2.5, including inconsistent availability of transcripts, poor quality of sound on some episodes, difficulty distinguishing new episodes from those already played, and a glitch that removed the episode duration. Still, the app was a valuable and comprehensive resource, with clear objectives and cited references. With improvements in content, affordability, and user experience, apps in unique formats such as games and podcasts might appeal to kinesthetic and auditory learners.

An important factor to consider when discussing mobile apps for students and residents is cost. With rising prices of board examinations and preparation materials, supplementary study tools should not come with an exorbitant price tag. Therefore, we limited our evaluation to apps that were free or cost less than $5 to download. Even so, subscriptions and other in-app purchases were an obstacle in one-third of apps, ranging from $4.99 to unlock additional content in Rash Decisions to $69.99 to access most topics in Fitzpatrick’s Color Atlas. The highest-rated app in our study, MyDermPath+, historically cost $19.99 to download but became free with a grant from the Sulzberger Foundation.¹² An initial investment to develop quality apps for the purpose of dermatology education might pay off in the end.

To evaluate the apps from the perspective of the target demographic of this study, 2 medical students—one in the preclinical stage and the other in the clinical stage of medical education—and a dermatology resident graded the apps. Certain limitations exist in this type of study, including differing learning styles, which might influence the types of apps that evaluators found most impactful to their education. Interestingly, some apps earned a higher resident score than student score. In particular, RightSite (a reference that helps with anatomically correct labeling) and Mohs Surgery Appropriate Use Criteria (a clinical decision support tool to determine whether to perform Mohs surgery) each had a 3-point discrepancy (data not shown). A resident might benefit from these practical apps in day-to-day practice, but a student would be less likely to find them useful as a learning tool.

Still, by defining adequate teaching value using specific categories of educational objectives, content, accuracy, design, and conflict of interest, we attempted to minimize the effect of personal preference on the grading process. Although we acknowledge a degree of subjectivity, we found that utilizing a previously published rubric with defined criteria was crucial in remaining unbiased.

Conclusion

Further studies should evaluate additional apps available on Apple’s iPad (tablet), as well as those on other operating systems, including Google’s Android. To ensure the existence of mobile apps as adequate education tools, they should be peer reviewed prior to publication or before widespread use by future and current providers at the minimum. To maximize free access to highly valuable resources available in the palm of their hand, students and trainees should contact the library at their academic institution.

With today’s technology, it is easier than ever to access web-based tools that enrich traditional dermatology education. The literature supports the use of these innovative platforms to enhance learning at the student and trainee levels. A controlled study of pediatric residents showed that online modules effectively supplemented clinical experience with atopic dermatitis.¹ In a randomized diagnostic study of medical students, practice with an image-based web application (app) that teaches rapid recognition of melanoma proved more effective than learning a rule-based algorithm.² Given the visual nature of dermatology, pattern recognition is an essential skill that is fostered through experience and is only made more accessible with technology.

With the added benefit of convenience and accessibility, mobile apps can supplement experiential learning. Mirroring the overall growth of mobile apps, the number of available dermatology apps has increased.³ Dermatology mobile apps serve purposes ranging from quick reference tools to comprehensive modules, journals, and question banks. At an academic hospital in Taiwan, both nondermatology and dermatology trainees’ examination performance improved after 3 weeks of using a smartphone-based wallpaper learning module displaying morphologic characteristics of fungi.⁴ With the expansion of virtual microscopy, mobile apps also have been created as a learning tool for dermatopathology, giving trainees the flexibility and autonomy to view slides on their own time.⁵ Nevertheless, the literature on dermatology mobile apps designed for the education of medical students and trainees is limited, demonstrating a need for further investigation.

Prior studies have reviewed dermatology apps for patients and practicing dermatologists.^6-8 Herein, we focus on mobile apps targeting students and residents learning dermatology. General dermatology reference apps and educational aid apps have grown by 33% and 32%, respectively, from 2014 to 2017.³ As with any resource meant to educate future and current medical providers, there must be an objective review process in place to ensure accurate, unbiased, evidence-based teaching.

Well-organized, comprehensive information and a user-friendly interface are additional factors of importance when selecting an educational mobile app. When discussing supplemental resources, accessibility and affordability also are priorities given the high cost of a medical education at baseline. Overall, there is a need for a standardized method to evaluate the key factors of an educational mobile app that make it appropriate for this demographic. We conducted a search of mobile apps relating to dermatology education for students and residents.

Methods

We searched for publicly available mobile apps relating to dermatology education in the App Store (Apple Inc) from September to November 2019 using the search terms dermatology education, dermoscopy education, melanoma education, skin cancer education, psoriasis education, rosacea education, acne education, eczema education, dermal fillers education, and Mohs surgery education. We excluded apps that were not in English, were created for a conference, cost more than $5 to download, or did not include a specific dermatology education section. In this way, we hoped to evaluate apps that were relevant, accessible, and affordable.

We modeled our study after a review of patient education apps performed by Masud et al⁶ and utilized their quantified grading rubric (scale of 1 to 4). We found their established criteria—educational objectives, content, accuracy, design, and conflict of interest—to be equally applicable for evaluating apps designed for professional education.⁶ Each app earned a minimum of 1 point and a maximum of 4 points per criterion. One point was given if the app did not fulfill the criterion, 2 points for minimally fulfilling the criterion, 3 points for mostly fulfilling the criterion, and 4 points if the criterion was completely fulfilled. Two medical students (E.H. and N.C.)—one at the preclinical stage and the other at the clinical stage of medical education—reviewed the apps using the given rubric, then discussed and resolved any discrepancies in points assigned. A dermatology resident (M.A.) independently reviewed the apps using the given rubric.

The mean of the student score and the resident score was calculated for each category. The sum of the averages for each category was considered the final score for an app, determining its overall quality. Apps with a total score of 5 to 10 were considered poor and inadequate for education. A total score of 10.5 to 15 indicated that an app was somewhat adequate (ie, useful for education in some aspects but falling short in others). Apps that were considered adequate for education, across all or most criteria, received a total score ranging from 15.5 to 20.

Results

Our search generated 130 apps. After applying exclusion criteria, 42 apps were eligible for review. At the time of publication, 36 of these apps were still available. The possible range of scores based on the rubric was 5 to 20. The actual range of scores was 7 to 20. Of the 36 apps, 2 (5.6%) were poor, 16 (44.4%) were somewhat adequate, and 18 (50%) were adequate. Formats included primary resources, such as clinical decision support tools, journals, references, and a podcast (Table 1). Additionally, interactive learning tools included games, learning modules, and apps for self-evaluation (Table 2). Thirty apps covered general dermatology; others focused on skin cancer (n=5) and cosmetic dermatology (n=1). Regarding cost, 29 apps were free to download, whereas 7 charged a fee (mean price, $2.56).

Comment

In addition to the convenience of having an educational tool in their white-coat pocket, learners of dermatology have been shown to benefit from supplementing their curriculum with mobile apps, which sets the stage for formal integration of mobile apps into dermatology teaching in the future.⁸ Prior to widespread adoption, mobile apps must be evaluated for content and utility, starting with an objective rubric.

Without official scientific standards in place, it was unsurprising that only half of the dermatology education applications were classified as adequate in this study. Among the types of apps offered—clinical decision support tools, journals, references, podcast, games, learning modules, and self-evaluation—certain categories scored higher than others. App formats with the highest average score (16.5 out of 20) were journals and podcast.

One barrier to utilization of these apps was that a subscription to the journals and podcast was required to obtain access to all available content. Students and trainees can seek out library resources at their academic institutions to take advantage of journal subscriptions available to them at no additional cost. Dermatology residents can take advantage of their complimentary membership in the American Academy of Dermatology for a free subscription to AAD Dialogues in Dermatology (otherwise $179 annually for nonresident members and $320 annually for nonmembers).

On the other hand, learning module was the lowest-rated format (average score, 11.3 out of 20), with only Medical Student: Dermatology qualifying as adequate (total score, 16). This finding is worrisome given that students and residents might look to learning modules for quick targeted lessons on specific topics.

The lowest-scoring app, a clinical decision support tool called Naturelize, received a total score of 7. Although it listed the indications and contraindications for dermal filler types to be used in different locations on the face, there was a clear conflict of interest, oversimplified design, and little evidence-based education, mirroring the current state of cosmetic dermatology training in residency, in which trainees think they are inadequately prepared for aesthetic procedures and comparative effectiveness research is lacking.^9-11

At the opposite end of the spectrum, MyDermPath+ was a reference app with a total score of 20. The app cited credible authors with a medical degree (MD) and had an easy-to-use, well-designed interface, including a reference guide, differential builder, and quiz for a range of topics within dermatology. As a free download without in-app purchases or advertisements, there was no evidence of conflict of interest. The position of a dermatopathology app as the top dermatology education mobile app might reflect an increased emphasis on dermatopathology education in residency as well as a transition to digitization of slides.⁵

The second-highest scoring apps (total score of 19 points) were Dermatology Database and VisualDx. Both were references covering a wide range of dermatology topics. Dermatology Database was a comprehensive search tool for diseases, drugs, procedures, and terms that was simple and entirely free to use but did not cite references. VisualDx, as its name suggests, offered quality clinical images, complete guides with references, and a unique differential builder. An annual subscription is $399.99, but the process to gain free access through a participating academic institution was simple.

Games were a unique mobile app format; however, 2 of 3 games scored in the somewhat adequate range. The game DiagnosUs, which tested users’ ability to differentiate skin cancer and psoriasis from dermatitis on clinical images, would benefit from more comprehensive content as well as professional verification of true diagnoses, which earned the app 2 points in both the content and accuracy categories. The Unusual Suspects tested the ABCDE algorithm in a short learning module, followed by a simple game that involved identification of melanoma in a timed setting. Although the design was novel and interactive, the game was limited to the same 5 melanoma tumors overlaid on pictures of normal skin. The narrow scope earned 1 point for content, the redundancy in the game earned 3 points for design, and the lack of real clinical images earned 2 points for educational objectives. Although game-format mobile apps have the capability to challenge the user’s knowledge with a built-in feedback or reward system, improvements should be made to ensure that apps are equally educational as they are engaging.

AAD Dialogues in Dermatology was the only app in the form of a podcast and provided expert interviews along with disclosures, transcripts, commentary, and references. More than half the content in the app could not be accessed without a subscription, earning 2.5 points in the conflict of interest category. Additionally, several flaws resulted in a design score of 2.5, including inconsistent availability of transcripts, poor quality of sound on some episodes, difficulty distinguishing new episodes from those already played, and a glitch that removed the episode duration. Still, the app was a valuable and comprehensive resource, with clear objectives and cited references. With improvements in content, affordability, and user experience, apps in unique formats such as games and podcasts might appeal to kinesthetic and auditory learners.

An important factor to consider when discussing mobile apps for students and residents is cost. With rising prices of board examinations and preparation materials, supplementary study tools should not come with an exorbitant price tag. Therefore, we limited our evaluation to apps that were free or cost less than $5 to download. Even so, subscriptions and other in-app purchases were an obstacle in one-third of apps, ranging from $4.99 to unlock additional content in Rash Decisions to $69.99 to access most topics in Fitzpatrick’s Color Atlas. The highest-rated app in our study, MyDermPath+, historically cost $19.99 to download but became free with a grant from the Sulzberger Foundation.¹² An initial investment to develop quality apps for the purpose of dermatology education might pay off in the end.

To evaluate the apps from the perspective of the target demographic of this study, 2 medical students—one in the preclinical stage and the other in the clinical stage of medical education—and a dermatology resident graded the apps. Certain limitations exist in this type of study, including differing learning styles, which might influence the types of apps that evaluators found most impactful to their education. Interestingly, some apps earned a higher resident score than student score. In particular, RightSite (a reference that helps with anatomically correct labeling) and Mohs Surgery Appropriate Use Criteria (a clinical decision support tool to determine whether to perform Mohs surgery) each had a 3-point discrepancy (data not shown). A resident might benefit from these practical apps in day-to-day practice, but a student would be less likely to find them useful as a learning tool.

Still, by defining adequate teaching value using specific categories of educational objectives, content, accuracy, design, and conflict of interest, we attempted to minimize the effect of personal preference on the grading process. Although we acknowledge a degree of subjectivity, we found that utilizing a previously published rubric with defined criteria was crucial in remaining unbiased.

Conclusion

Further studies should evaluate additional apps available on Apple’s iPad (tablet), as well as those on other operating systems, including Google’s Android. To ensure the existence of mobile apps as adequate education tools, they should be peer reviewed prior to publication or before widespread use by future and current providers at the minimum. To maximize free access to highly valuable resources available in the palm of their hand, students and trainees should contact the library at their academic institution.

Basal cell carcinoma (BCC) is the most common type of skin cancer frequently encountered in both dermatology and primary care settings.¹ When biopsies of these neoplasms are performed to confirm the diagnosis, pathology reports may indicate positive or negative margin status. No guidelines exist for reporting biopsy margin status for BCC, resulting in varied reporting practices among dermatopathologists. Furthermore, the terminology used to describe margin status can be ambiguous and differs among pathologists; language such as “approaches the margin” or “margins appear free” may be used, with nonuniform interpretation between pathologists and providers, leading to variability in patient management.²

When interpreting a negative margin status on a pathology report, one must question if the BCC extends beyond the margin in unexamined sections of the specimen, which could be the result of an irregular tumor growth pattern or tissue processing. It has been estimated that less than 2% of the peripheral surgical margin is ultimately examined when serial cross-sections are prepared histologically (the bread loaf technique). However, this estimation would depend on several variables, including the number and thickness of sections and the amount of tissue discarded during processing.³ Importantly, reports of a false-negative margin could lead both the clinician and patient to believe that the neoplasm has been completely removed, which could have serious consequences.

Our study sought to determine the reliability of negative biopsy margin status for BCC. We examined BCC biopsy specimens initially determined to have uninvolved margins on routine tissue processing and determined the proportion with truly negative margins after complete tissue block sectioning of the initial biopsy specimen. We felt this technique was a more accurate measurement of true margin status than examination of a re-excision specimen. We also identified any factors that were predictive of positive true margins.

Methods

We conducted a retrospective study evaluating tissue samples collected at Geisinger Health System (Danville, Pennsylvania) from January to December 2016. Specimens were queried via the electronic database system at our institution (CoPath). We included BCC biopsy specimens with negative histologic margins on initial assessment that subsequently had block exhaust levels routinely ordered. These levels are cut every 100 to 150 µm, generating approximately 8 glass slides. We excluded all tumors that did not fit these criteria as well as those in patients younger than 18 years. Data collection was performed utilizing specimen pathology reports in addition to the note from the corresponding clinician office visit from the institution’s electronic medical record (Epic). Appropriate statistical calculations were performed. This study was approved by an institutional review board at our institution, which is required for all research involving human participants. This served to ensure the proper review and storage of patients’ protected health information.

Results

The search yielded a total of 122 specimens from 104 patients after appropriate exclusions. We examined a total of 122 BCC biopsy specimens with negative initial margins: 121 (99.2%) shave biopsies and 1 (0.8%) punch biopsy. Of 122 specimens with negative initial margins, 53 (43.4%) were found to have a truly positive margin based on the presence of either tumor or stroma at the lateral or deep tissue edge after complete tissue block sectioning. Sixty-nine (56.6%) specimens had clear margins and were categorized as truly negative after complete tissue block sectioning. Specimens with positive and negative final margin status did not differ significantly with respect to patient age; gender; biopsy technique; number of gross specimen sections; or tumor characteristics, including location, size, and subtype (Table)(P>.05).

We also examined the type of treatment performed, which varied and included curettage, electrodesiccation and curettage, excision, and Mohs micrographic surgery. Clinicians, who were not made aware of the exhaust level protocol, chose not to pursue further treatment in 6 (4.9%) of the cases because of negative biopsy margins. Four (66.7%) of the 6 providers were physicians, and 2 (33.3%) were advanced practitioners. All of the providers practiced within the Department of Dermatology.

Comment

Our findings support prior smaller studies investigating this topic. A prospective study by Schnebelen et al⁴ examined 27 BCC biopsy specimens and found that 8 (30%) were erroneously classified as negative on routine examination. This study similarly determined true margin status by assessing the margins at complete tissue block exhaustion.⁴ Willardson et al⁵ also demonstrated the poor predictive value of margin status based on the presence of residual BCC in subsequent excisions. They found that 34 (24%) of 143 cases with negative biopsy margins contained residual tumor in the corresponding excision.⁵

Our study revealed that almost half of BCC biopsy specimens that had negative histologic margins with routine sectioning had truly positive margins on complete block exhaustion. This finding was independent of multiple factors, including tumor subtype, indicating that even nonaggressive tumors are prone to false-negative margin reports. We also found that reports of negative margins persuaded some clinicians to forgo definitive treatment. This study serves to remind clinicians of the limitations of margin assessment and provides impetus for dermatopathologists to consider modifying how margin status is reported.

Limitations of this study include a small number of cases and limited generalizability. Institutions that routinely examine more levels of each biopsy specimen may be less likely to erroneously categorize a positive margin as negative. Furthermore, despite exhausting the tissue block, we still may have underestimated the number of cases with truly positive margins, as this method inherently does not allow for complete margin examination.

Acknowledgments
We thank the Geisinger Department of Dermatopathology and the Geisinger Biostatistics & Research Data Core (Danville, Pennsylvania) for their assistance with our project.

Basal cell carcinoma (BCC) is the most common type of skin cancer frequently encountered in both dermatology and primary care settings.¹ When biopsies of these neoplasms are performed to confirm the diagnosis, pathology reports may indicate positive or negative margin status. No guidelines exist for reporting biopsy margin status for BCC, resulting in varied reporting practices among dermatopathologists. Furthermore, the terminology used to describe margin status can be ambiguous and differs among pathologists; language such as “approaches the margin” or “margins appear free” may be used, with nonuniform interpretation between pathologists and providers, leading to variability in patient management.²

When interpreting a negative margin status on a pathology report, one must question if the BCC extends beyond the margin in unexamined sections of the specimen, which could be the result of an irregular tumor growth pattern or tissue processing. It has been estimated that less than 2% of the peripheral surgical margin is ultimately examined when serial cross-sections are prepared histologically (the bread loaf technique). However, this estimation would depend on several variables, including the number and thickness of sections and the amount of tissue discarded during processing.³ Importantly, reports of a false-negative margin could lead both the clinician and patient to believe that the neoplasm has been completely removed, which could have serious consequences.

Our study sought to determine the reliability of negative biopsy margin status for BCC. We examined BCC biopsy specimens initially determined to have uninvolved margins on routine tissue processing and determined the proportion with truly negative margins after complete tissue block sectioning of the initial biopsy specimen. We felt this technique was a more accurate measurement of true margin status than examination of a re-excision specimen. We also identified any factors that were predictive of positive true margins.

Methods

We conducted a retrospective study evaluating tissue samples collected at Geisinger Health System (Danville, Pennsylvania) from January to December 2016. Specimens were queried via the electronic database system at our institution (CoPath). We included BCC biopsy specimens with negative histologic margins on initial assessment that subsequently had block exhaust levels routinely ordered. These levels are cut every 100 to 150 µm, generating approximately 8 glass slides. We excluded all tumors that did not fit these criteria as well as those in patients younger than 18 years. Data collection was performed utilizing specimen pathology reports in addition to the note from the corresponding clinician office visit from the institution’s electronic medical record (Epic). Appropriate statistical calculations were performed. This study was approved by an institutional review board at our institution, which is required for all research involving human participants. This served to ensure the proper review and storage of patients’ protected health information.

Results

The search yielded a total of 122 specimens from 104 patients after appropriate exclusions. We examined a total of 122 BCC biopsy specimens with negative initial margins: 121 (99.2%) shave biopsies and 1 (0.8%) punch biopsy. Of 122 specimens with negative initial margins, 53 (43.4%) were found to have a truly positive margin based on the presence of either tumor or stroma at the lateral or deep tissue edge after complete tissue block sectioning. Sixty-nine (56.6%) specimens had clear margins and were categorized as truly negative after complete tissue block sectioning. Specimens with positive and negative final margin status did not differ significantly with respect to patient age; gender; biopsy technique; number of gross specimen sections; or tumor characteristics, including location, size, and subtype (Table)(P>.05).

We also examined the type of treatment performed, which varied and included curettage, electrodesiccation and curettage, excision, and Mohs micrographic surgery. Clinicians, who were not made aware of the exhaust level protocol, chose not to pursue further treatment in 6 (4.9%) of the cases because of negative biopsy margins. Four (66.7%) of the 6 providers were physicians, and 2 (33.3%) were advanced practitioners. All of the providers practiced within the Department of Dermatology.

Comment

Our findings support prior smaller studies investigating this topic. A prospective study by Schnebelen et al⁴ examined 27 BCC biopsy specimens and found that 8 (30%) were erroneously classified as negative on routine examination. This study similarly determined true margin status by assessing the margins at complete tissue block exhaustion.⁴ Willardson et al⁵ also demonstrated the poor predictive value of margin status based on the presence of residual BCC in subsequent excisions. They found that 34 (24%) of 143 cases with negative biopsy margins contained residual tumor in the corresponding excision.⁵

Our study revealed that almost half of BCC biopsy specimens that had negative histologic margins with routine sectioning had truly positive margins on complete block exhaustion. This finding was independent of multiple factors, including tumor subtype, indicating that even nonaggressive tumors are prone to false-negative margin reports. We also found that reports of negative margins persuaded some clinicians to forgo definitive treatment. This study serves to remind clinicians of the limitations of margin assessment and provides impetus for dermatopathologists to consider modifying how margin status is reported.

Limitations of this study include a small number of cases and limited generalizability. Institutions that routinely examine more levels of each biopsy specimen may be less likely to erroneously categorize a positive margin as negative. Furthermore, despite exhausting the tissue block, we still may have underestimated the number of cases with truly positive margins, as this method inherently does not allow for complete margin examination.

Acknowledgments
We thank the Geisinger Department of Dermatopathology and the Geisinger Biostatistics & Research Data Core (Danville, Pennsylvania) for their assistance with our project.

Basal cell carcinoma (BCC) is the most common type of skin cancer frequently encountered in both dermatology and primary care settings.¹ When biopsies of these neoplasms are performed to confirm the diagnosis, pathology reports may indicate positive or negative margin status. No guidelines exist for reporting biopsy margin status for BCC, resulting in varied reporting practices among dermatopathologists. Furthermore, the terminology used to describe margin status can be ambiguous and differs among pathologists; language such as “approaches the margin” or “margins appear free” may be used, with nonuniform interpretation between pathologists and providers, leading to variability in patient management.²

When interpreting a negative margin status on a pathology report, one must question if the BCC extends beyond the margin in unexamined sections of the specimen, which could be the result of an irregular tumor growth pattern or tissue processing. It has been estimated that less than 2% of the peripheral surgical margin is ultimately examined when serial cross-sections are prepared histologically (the bread loaf technique). However, this estimation would depend on several variables, including the number and thickness of sections and the amount of tissue discarded during processing.³ Importantly, reports of a false-negative margin could lead both the clinician and patient to believe that the neoplasm has been completely removed, which could have serious consequences.

Our study sought to determine the reliability of negative biopsy margin status for BCC. We examined BCC biopsy specimens initially determined to have uninvolved margins on routine tissue processing and determined the proportion with truly negative margins after complete tissue block sectioning of the initial biopsy specimen. We felt this technique was a more accurate measurement of true margin status than examination of a re-excision specimen. We also identified any factors that were predictive of positive true margins.

Methods

We conducted a retrospective study evaluating tissue samples collected at Geisinger Health System (Danville, Pennsylvania) from January to December 2016. Specimens were queried via the electronic database system at our institution (CoPath). We included BCC biopsy specimens with negative histologic margins on initial assessment that subsequently had block exhaust levels routinely ordered. These levels are cut every 100 to 150 µm, generating approximately 8 glass slides. We excluded all tumors that did not fit these criteria as well as those in patients younger than 18 years. Data collection was performed utilizing specimen pathology reports in addition to the note from the corresponding clinician office visit from the institution’s electronic medical record (Epic). Appropriate statistical calculations were performed. This study was approved by an institutional review board at our institution, which is required for all research involving human participants. This served to ensure the proper review and storage of patients’ protected health information.

Results

The search yielded a total of 122 specimens from 104 patients after appropriate exclusions. We examined a total of 122 BCC biopsy specimens with negative initial margins: 121 (99.2%) shave biopsies and 1 (0.8%) punch biopsy. Of 122 specimens with negative initial margins, 53 (43.4%) were found to have a truly positive margin based on the presence of either tumor or stroma at the lateral or deep tissue edge after complete tissue block sectioning. Sixty-nine (56.6%) specimens had clear margins and were categorized as truly negative after complete tissue block sectioning. Specimens with positive and negative final margin status did not differ significantly with respect to patient age; gender; biopsy technique; number of gross specimen sections; or tumor characteristics, including location, size, and subtype (Table)(P>.05).

We also examined the type of treatment performed, which varied and included curettage, electrodesiccation and curettage, excision, and Mohs micrographic surgery. Clinicians, who were not made aware of the exhaust level protocol, chose not to pursue further treatment in 6 (4.9%) of the cases because of negative biopsy margins. Four (66.7%) of the 6 providers were physicians, and 2 (33.3%) were advanced practitioners. All of the providers practiced within the Department of Dermatology.

Comment

Our findings support prior smaller studies investigating this topic. A prospective study by Schnebelen et al⁴ examined 27 BCC biopsy specimens and found that 8 (30%) were erroneously classified as negative on routine examination. This study similarly determined true margin status by assessing the margins at complete tissue block exhaustion.⁴ Willardson et al⁵ also demonstrated the poor predictive value of margin status based on the presence of residual BCC in subsequent excisions. They found that 34 (24%) of 143 cases with negative biopsy margins contained residual tumor in the corresponding excision.⁵

Our study revealed that almost half of BCC biopsy specimens that had negative histologic margins with routine sectioning had truly positive margins on complete block exhaustion. This finding was independent of multiple factors, including tumor subtype, indicating that even nonaggressive tumors are prone to false-negative margin reports. We also found that reports of negative margins persuaded some clinicians to forgo definitive treatment. This study serves to remind clinicians of the limitations of margin assessment and provides impetus for dermatopathologists to consider modifying how margin status is reported.

Limitations of this study include a small number of cases and limited generalizability. Institutions that routinely examine more levels of each biopsy specimen may be less likely to erroneously categorize a positive margin as negative. Furthermore, despite exhausting the tissue block, we still may have underestimated the number of cases with truly positive margins, as this method inherently does not allow for complete margin examination.

Acknowledgments
We thank the Geisinger Department of Dermatopathology and the Geisinger Biostatistics & Research Data Core (Danville, Pennsylvania) for their assistance with our project.

The first part of this 2-part series addressed the basics of patch testing, including patch test systems, allergens, and patch test readings. In the second part of this series, we examine the incredibly important and absolutely vital steps that come after the patch test: determining relevance, patient counseling, and identifying allergen-free products for patient use. Let’s dive in!

Determining Relevance

The purpose of determining relevance is to assess whether the positive patch test explains the patient’s dermatitis. It is important to consider all of the patient’s exposures, including at home, at work, and during recreational activities. Several relevance grading scales exist. The North American Contact Dermatitis Group grades relevance as current, past, or unknown. Current relevance is further divided into definite, probable, and possible.¹ Table 1 includes explanations and clinical examples of each relevance type.

True relevance is only known weeks or months after patch testing is complete. If the patient avoids allergens and is subsequently free of dermatitis, the allergens identified through patch testing were relevant. However, if the patient avoids allergens and sees no improvement in dermatitis, the allergens were not relevant. Gipson et al² analyzed relevance as documented by the physician at final patch test reading vs patient opinion of relevance 30 days to 3 years after the final reading and found that there was variable agreement between the 2 groups; percentage agreement for formaldehyde-releasing preservatives was 88%, neomycin was 78%, nickel was 71%, fragrances was 65%, and gold was 56%. These differences underscore the need for ongoing research on patch test methods, determination of relevance, and standards for patient follow-up.²

Patient Counseling

Patient counseling is one of the most important and complex parts of patch testing. We have consulted with patients who had already completed patch testing with other providers but did not receive comprehensive allergen counseling and therefore did not improve. It is up to you to explain positive allergens to your patients in a way that they understand, can retain long-term, and can use to their advantage to keep their skin free of dermatitis, which is an incredibly difficult feat to accomplish. The resources that we describe next are the very basic requirements for proficient patch testing.

There are several tools that can be utilized to develop patch test counseling skills (Table 2). Membership with the American Contact Dermatitis Society (ACDS) includes opportunities for virtual and in-person (post–coronavirus disease 2019) lectures and conferences, videos, patch test support information, and patient resources. The European Society of Contact Dermatitis is similar, with a focus on European-based patch testers. Both societies are affiliated with academic journals—Dermatitis and Contact Dermatitis, respectively—which are phenomenal educational resources. Dermatitis Academy (https://www.dermatitisacademy.com) and Contact Dermatitis Institute (https://www.contactdermatitisinstitute.com) are websites that are privately designed and managed by US-based patch test experts.

Allergen Information Handouts

Allergen information should be presented in both verbal and written formats as well as in the patient’s preferred language and education level. Patch test counseling is detailed and complex. Patients rarely remember everything that is discussed; written information allows them to review again when necessary. Allergen information sheets typically include the name of the allergen, alternative names, types of products that might contain the allergen, and other pertinent facts. They also can be helpful for the physician who does not patch test full time; in this case, they can be used as a quick reference to guide patient counseling. It is helpful to highlight or underline important points and make notes when relevant. Importantly, reviewing information sheets with the patient allows time for questions.

Allergen information sheets are provided by manufacturers of patch test materials, including SmartPractice (allergEAZE, T.R.U.E. Test) and Chemotechnique (Dormer)(Table 2). The ACDS also provides a selection of allergen information sheets for members to share with their patients. The ACDS allergen handouts are designed for patient use, are vetted by practicing patch test dermatologists, and contain up-to-date information for patients. We recommend that you choose the handout(s) that are most appropriate for your patient; this decision can be made based on patient education or reading level, the region of the world where you are patch testing or where the patient lives, the patient’s primary language, and the specific allergen. Information on rare or new allergens may not be available on every website resource.

Identification of Allergen-Free Products

We ask patients to bring their personal care products to their patch test reading visit, and once positive allergens are known, we search for the presence of that allergen in their products. It is helpful for patients if products that are “safe” and “not safe” are sorted for them. We frequently emphasize that just one exposure to an allergen in a personal care product can be the source of the dermatitis. If a product label does not include ingredients, they often can be identified with a quick web search (use your favorite search engine or see Table 2 for websites); however, caution is advised, as lists found online may not match those found on in-store products.³ Reviewing the patient’s own products in the clinic is preferred over searching for ingredient lists online. If the product’s ingredients cannot be found (eg, ingredients that are found on external packaging), the patient has several choices: do not use, complete repeat open application testing if it is a leave-on product, or check to see if it is on a product database safe list.

We explain to patients that once they have confirmed that they are using only “safe” allergen-free products, it can take up to 6 to 8 weeks for dermatitis to improve, and at that point, the skin may only be about 75% to 80% clear. A clear description of what to expect and when is needed for a strong patient-physician partnership. For example, if the patient expects to be clear in 2 days but is not and stops avoiding their allergens because they think the process has failed, their dermatitis will not improve.

Product Databases

Because allergens sometimes have multiple different chemical names and cross-reactivity is abundant, avoidance of both the allergen and cross-reactors can be daunting for many patients (and dermatologists!). The use of a product database to aid in product selection is an invaluable resource. Product databases help patients avoid not only their allergens but also common cross-reactors by relying on complex cross-reactor programming. The ACDS owns and maintains the Contact Allergy Management Program (CAMP). Another resource is SkinSafe, which is powered by HER Inc and developed with the Mayo Clinic. Both CAMP and SkinSafe have mobile apps and update product lists frequently; they allow for much easier shopping and identification of safe products.

We typically use CAMP for generation of patient safe lists. We enter the patient’s allergens into the database, and a safe list is generated and shared with the patient. Next, we educate the patient on how to use the safe list. It is vital that the concept of exact product matching be explained to patients, as not all products from one brand or type of product is necessarily safe for a given individual. We also share information on how to download the CAMP app onto mobile devices and tablets.

Product safe lists are important resources for patients to be successful in avoiding allergens but are not a substitute for reading labels. Both CAMP and SkinSafe can potentially contain ingredient list errors due to companies frequently changing their product formulations.³ Although safe lists are an important part in selecting safe skin care products, they are not a substitute for label reading.

Counseling Pitfalls and Pearls

Language
Chemotechnique handouts are available in English, Swedish, French, and Spanish, and ACDS handouts are available in English and Spanish. If language interpretation is needed, inform the interpreter before the visit begins that you will be discussing patch test information and products so they can carefully interpret the details of the discussion.

Barriers to Allergen Avoidance
There are several barriers to long-term avoidance of contact allergy. In a European-based study of methylisothiazolinone (MI) contact allergy 2 to 5 years after patch testing, challenges described by patients included label reading, verifying products, difficulty obtaining ingredients of industrial products, the need to have their “safe” products always available for use, remembering allergen name, avoiding workplace allergens, finding acceptable MI-free products, and navigating the cost of MI-free products.⁴

Patient allergen recall is a well-documented long-term concern. In the previously mentioned European study (N=139), 11% of patients identified remembering the allergen name as a contributor to difficulty with avoidance.⁴ A Swedish study evaluated patient allergen recall at 1, 5, and 10 years after patch testing was completed; 96% of 252 patients remembered that they had completed patch testing, 79% (111/141) remembered that they had positive results, and only 29% (41/141) correctly recalled their allergens.⁵ Patients who had completed patch testing 10 years prior were less likely to correctly recall their allergens (P=.0045). Recall also was less likely if there was more than 1 allergen as well as in males.⁵ Korkmaz and Boyvat⁶ analyzed outcomes 6 months after patch testing in Turkey and found that 38 of 51 (74.5%) correctly recalled their allergens. Patients with more than 1 positive allergen were less likely to recall their allergens (P=.046), and patients with higher baseline investigator global assessment (P=.036) and dermatology life quality index (P=.041) scores were more likely to recall their allergens.⁶ A US-based study (N=757) noted that 34.1% of patients correctly recalled all of their allergens.⁷ Patients were less likely to remember if they had 3 or more positives but were more likely to remember if they were aged 50 to 59 years (compared to other age groups) or female as well as if their occupation was nursing (as compared to other occupations).

Additional barriers include hidden sources of allergens, as has been reported in the cases of undeclared MI⁸ and formaldehyde⁹ in personal care products. Although this phenomenon is thought to be the exception and not the rule, possible reasons for the presence of these undeclared allergens include their use as preservatives in raw materials,^8,9 or in the case of formaldehyde, theorized release from product packaging or auto-oxidation and degradation of other chemicals present within the product.⁹

Readers may recall that we mentioned the option of identifying product ingredients with online search engines or databases, but it is not a perfect system. Comstock and Reeder³ reviewed and compared online ingredient lists from Amazon and several product databases to products taken off shelves at Target and Walgreens and found that 27.7% of online ingredient lists did not match the in-store labels.³ These differences likely are due to changes in product formulations, ingredient variability based on production site, outdated product on store shelves, or data entry error and may not be entirely avoidable. Regardless, patch test experts should be aware of this possibility. When in doubt, always check the product’s original packaging.

Finally, the elephant in the room: We challenge you, as dermatologists and patch test enthusiasts, to name all of the formaldehyde releasers or perhaps declare whether linalool and hydroxycitronellol are fragrances, preservatives, or surfactants. How about naming the relationship between cocamidopropyl betaine, amidoamine, and dimethylaminopropylamine? Difficult stuff, right? And we are medical specialists. It is downright impossible for many of our patients to memorize the names of these chemicals, let alone know their cross-reactors or other important chemical relationships. We mention that providing a safe list is part of patient counseling, but we bring up this knowledge gap to illustrate that patch testing without providing resources to select safe care products is almost as bad as not patch testing at all because in many cases patients may be left without the tools they need to be successful. Do not let this be your downfall!

Final Interpretation

The most challenging and nuanced part of patch testing happens after the actual patch test: assessment of relevance, allergen counseling, and identification of appropriate products for patient use. You now have the tools to successfully counsel your patients after patch testing; get to it!

The first part of this 2-part series addressed the basics of patch testing, including patch test systems, allergens, and patch test readings. In the second part of this series, we examine the incredibly important and absolutely vital steps that come after the patch test: determining relevance, patient counseling, and identifying allergen-free products for patient use. Let’s dive in!

Determining Relevance

The purpose of determining relevance is to assess whether the positive patch test explains the patient’s dermatitis. It is important to consider all of the patient’s exposures, including at home, at work, and during recreational activities. Several relevance grading scales exist. The North American Contact Dermatitis Group grades relevance as current, past, or unknown. Current relevance is further divided into definite, probable, and possible.¹ Table 1 includes explanations and clinical examples of each relevance type.

True relevance is only known weeks or months after patch testing is complete. If the patient avoids allergens and is subsequently free of dermatitis, the allergens identified through patch testing were relevant. However, if the patient avoids allergens and sees no improvement in dermatitis, the allergens were not relevant. Gipson et al² analyzed relevance as documented by the physician at final patch test reading vs patient opinion of relevance 30 days to 3 years after the final reading and found that there was variable agreement between the 2 groups; percentage agreement for formaldehyde-releasing preservatives was 88%, neomycin was 78%, nickel was 71%, fragrances was 65%, and gold was 56%. These differences underscore the need for ongoing research on patch test methods, determination of relevance, and standards for patient follow-up.²

Patient Counseling

Patient counseling is one of the most important and complex parts of patch testing. We have consulted with patients who had already completed patch testing with other providers but did not receive comprehensive allergen counseling and therefore did not improve. It is up to you to explain positive allergens to your patients in a way that they understand, can retain long-term, and can use to their advantage to keep their skin free of dermatitis, which is an incredibly difficult feat to accomplish. The resources that we describe next are the very basic requirements for proficient patch testing.

There are several tools that can be utilized to develop patch test counseling skills (Table 2). Membership with the American Contact Dermatitis Society (ACDS) includes opportunities for virtual and in-person (post–coronavirus disease 2019) lectures and conferences, videos, patch test support information, and patient resources. The European Society of Contact Dermatitis is similar, with a focus on European-based patch testers. Both societies are affiliated with academic journals—Dermatitis and Contact Dermatitis, respectively—which are phenomenal educational resources. Dermatitis Academy (https://www.dermatitisacademy.com) and Contact Dermatitis Institute (https://www.contactdermatitisinstitute.com) are websites that are privately designed and managed by US-based patch test experts.

Allergen Information Handouts

Allergen information should be presented in both verbal and written formats as well as in the patient’s preferred language and education level. Patch test counseling is detailed and complex. Patients rarely remember everything that is discussed; written information allows them to review again when necessary. Allergen information sheets typically include the name of the allergen, alternative names, types of products that might contain the allergen, and other pertinent facts. They also can be helpful for the physician who does not patch test full time; in this case, they can be used as a quick reference to guide patient counseling. It is helpful to highlight or underline important points and make notes when relevant. Importantly, reviewing information sheets with the patient allows time for questions.

Allergen information sheets are provided by manufacturers of patch test materials, including SmartPractice (allergEAZE, T.R.U.E. Test) and Chemotechnique (Dormer)(Table 2). The ACDS also provides a selection of allergen information sheets for members to share with their patients. The ACDS allergen handouts are designed for patient use, are vetted by practicing patch test dermatologists, and contain up-to-date information for patients. We recommend that you choose the handout(s) that are most appropriate for your patient; this decision can be made based on patient education or reading level, the region of the world where you are patch testing or where the patient lives, the patient’s primary language, and the specific allergen. Information on rare or new allergens may not be available on every website resource.

Identification of Allergen-Free Products

We ask patients to bring their personal care products to their patch test reading visit, and once positive allergens are known, we search for the presence of that allergen in their products. It is helpful for patients if products that are “safe” and “not safe” are sorted for them. We frequently emphasize that just one exposure to an allergen in a personal care product can be the source of the dermatitis. If a product label does not include ingredients, they often can be identified with a quick web search (use your favorite search engine or see Table 2 for websites); however, caution is advised, as lists found online may not match those found on in-store products.³ Reviewing the patient’s own products in the clinic is preferred over searching for ingredient lists online. If the product’s ingredients cannot be found (eg, ingredients that are found on external packaging), the patient has several choices: do not use, complete repeat open application testing if it is a leave-on product, or check to see if it is on a product database safe list.

We explain to patients that once they have confirmed that they are using only “safe” allergen-free products, it can take up to 6 to 8 weeks for dermatitis to improve, and at that point, the skin may only be about 75% to 80% clear. A clear description of what to expect and when is needed for a strong patient-physician partnership. For example, if the patient expects to be clear in 2 days but is not and stops avoiding their allergens because they think the process has failed, their dermatitis will not improve.

Product Databases

Because allergens sometimes have multiple different chemical names and cross-reactivity is abundant, avoidance of both the allergen and cross-reactors can be daunting for many patients (and dermatologists!). The use of a product database to aid in product selection is an invaluable resource. Product databases help patients avoid not only their allergens but also common cross-reactors by relying on complex cross-reactor programming. The ACDS owns and maintains the Contact Allergy Management Program (CAMP). Another resource is SkinSafe, which is powered by HER Inc and developed with the Mayo Clinic. Both CAMP and SkinSafe have mobile apps and update product lists frequently; they allow for much easier shopping and identification of safe products.

We typically use CAMP for generation of patient safe lists. We enter the patient’s allergens into the database, and a safe list is generated and shared with the patient. Next, we educate the patient on how to use the safe list. It is vital that the concept of exact product matching be explained to patients, as not all products from one brand or type of product is necessarily safe for a given individual. We also share information on how to download the CAMP app onto mobile devices and tablets.

Product safe lists are important resources for patients to be successful in avoiding allergens but are not a substitute for reading labels. Both CAMP and SkinSafe can potentially contain ingredient list errors due to companies frequently changing their product formulations.³ Although safe lists are an important part in selecting safe skin care products, they are not a substitute for label reading.

Counseling Pitfalls and Pearls

Language
Chemotechnique handouts are available in English, Swedish, French, and Spanish, and ACDS handouts are available in English and Spanish. If language interpretation is needed, inform the interpreter before the visit begins that you will be discussing patch test information and products so they can carefully interpret the details of the discussion.

Barriers to Allergen Avoidance
There are several barriers to long-term avoidance of contact allergy. In a European-based study of methylisothiazolinone (MI) contact allergy 2 to 5 years after patch testing, challenges described by patients included label reading, verifying products, difficulty obtaining ingredients of industrial products, the need to have their “safe” products always available for use, remembering allergen name, avoiding workplace allergens, finding acceptable MI-free products, and navigating the cost of MI-free products.⁴

Patient allergen recall is a well-documented long-term concern. In the previously mentioned European study (N=139), 11% of patients identified remembering the allergen name as a contributor to difficulty with avoidance.⁴ A Swedish study evaluated patient allergen recall at 1, 5, and 10 years after patch testing was completed; 96% of 252 patients remembered that they had completed patch testing, 79% (111/141) remembered that they had positive results, and only 29% (41/141) correctly recalled their allergens.⁵ Patients who had completed patch testing 10 years prior were less likely to correctly recall their allergens (P=.0045). Recall also was less likely if there was more than 1 allergen as well as in males.⁵ Korkmaz and Boyvat⁶ analyzed outcomes 6 months after patch testing in Turkey and found that 38 of 51 (74.5%) correctly recalled their allergens. Patients with more than 1 positive allergen were less likely to recall their allergens (P=.046), and patients with higher baseline investigator global assessment (P=.036) and dermatology life quality index (P=.041) scores were more likely to recall their allergens.⁶ A US-based study (N=757) noted that 34.1% of patients correctly recalled all of their allergens.⁷ Patients were less likely to remember if they had 3 or more positives but were more likely to remember if they were aged 50 to 59 years (compared to other age groups) or female as well as if their occupation was nursing (as compared to other occupations).

Additional barriers include hidden sources of allergens, as has been reported in the cases of undeclared MI⁸ and formaldehyde⁹ in personal care products. Although this phenomenon is thought to be the exception and not the rule, possible reasons for the presence of these undeclared allergens include their use as preservatives in raw materials,^8,9 or in the case of formaldehyde, theorized release from product packaging or auto-oxidation and degradation of other chemicals present within the product.⁹

Readers may recall that we mentioned the option of identifying product ingredients with online search engines or databases, but it is not a perfect system. Comstock and Reeder³ reviewed and compared online ingredient lists from Amazon and several product databases to products taken off shelves at Target and Walgreens and found that 27.7% of online ingredient lists did not match the in-store labels.³ These differences likely are due to changes in product formulations, ingredient variability based on production site, outdated product on store shelves, or data entry error and may not be entirely avoidable. Regardless, patch test experts should be aware of this possibility. When in doubt, always check the product’s original packaging.

Finally, the elephant in the room: We challenge you, as dermatologists and patch test enthusiasts, to name all of the formaldehyde releasers or perhaps declare whether linalool and hydroxycitronellol are fragrances, preservatives, or surfactants. How about naming the relationship between cocamidopropyl betaine, amidoamine, and dimethylaminopropylamine? Difficult stuff, right? And we are medical specialists. It is downright impossible for many of our patients to memorize the names of these chemicals, let alone know their cross-reactors or other important chemical relationships. We mention that providing a safe list is part of patient counseling, but we bring up this knowledge gap to illustrate that patch testing without providing resources to select safe care products is almost as bad as not patch testing at all because in many cases patients may be left without the tools they need to be successful. Do not let this be your downfall!

Final Interpretation

The most challenging and nuanced part of patch testing happens after the actual patch test: assessment of relevance, allergen counseling, and identification of appropriate products for patient use. You now have the tools to successfully counsel your patients after patch testing; get to it!

The first part of this 2-part series addressed the basics of patch testing, including patch test systems, allergens, and patch test readings. In the second part of this series, we examine the incredibly important and absolutely vital steps that come after the patch test: determining relevance, patient counseling, and identifying allergen-free products for patient use. Let’s dive in!

Determining Relevance

The purpose of determining relevance is to assess whether the positive patch test explains the patient’s dermatitis. It is important to consider all of the patient’s exposures, including at home, at work, and during recreational activities. Several relevance grading scales exist. The North American Contact Dermatitis Group grades relevance as current, past, or unknown. Current relevance is further divided into definite, probable, and possible.¹ Table 1 includes explanations and clinical examples of each relevance type.

True relevance is only known weeks or months after patch testing is complete. If the patient avoids allergens and is subsequently free of dermatitis, the allergens identified through patch testing were relevant. However, if the patient avoids allergens and sees no improvement in dermatitis, the allergens were not relevant. Gipson et al² analyzed relevance as documented by the physician at final patch test reading vs patient opinion of relevance 30 days to 3 years after the final reading and found that there was variable agreement between the 2 groups; percentage agreement for formaldehyde-releasing preservatives was 88%, neomycin was 78%, nickel was 71%, fragrances was 65%, and gold was 56%. These differences underscore the need for ongoing research on patch test methods, determination of relevance, and standards for patient follow-up.²

Patient Counseling

Patient counseling is one of the most important and complex parts of patch testing. We have consulted with patients who had already completed patch testing with other providers but did not receive comprehensive allergen counseling and therefore did not improve. It is up to you to explain positive allergens to your patients in a way that they understand, can retain long-term, and can use to their advantage to keep their skin free of dermatitis, which is an incredibly difficult feat to accomplish. The resources that we describe next are the very basic requirements for proficient patch testing.

There are several tools that can be utilized to develop patch test counseling skills (Table 2). Membership with the American Contact Dermatitis Society (ACDS) includes opportunities for virtual and in-person (post–coronavirus disease 2019) lectures and conferences, videos, patch test support information, and patient resources. The European Society of Contact Dermatitis is similar, with a focus on European-based patch testers. Both societies are affiliated with academic journals—Dermatitis and Contact Dermatitis, respectively—which are phenomenal educational resources. Dermatitis Academy (https://www.dermatitisacademy.com) and Contact Dermatitis Institute (https://www.contactdermatitisinstitute.com) are websites that are privately designed and managed by US-based patch test experts.

Allergen Information Handouts

Allergen information should be presented in both verbal and written formats as well as in the patient’s preferred language and education level. Patch test counseling is detailed and complex. Patients rarely remember everything that is discussed; written information allows them to review again when necessary. Allergen information sheets typically include the name of the allergen, alternative names, types of products that might contain the allergen, and other pertinent facts. They also can be helpful for the physician who does not patch test full time; in this case, they can be used as a quick reference to guide patient counseling. It is helpful to highlight or underline important points and make notes when relevant. Importantly, reviewing information sheets with the patient allows time for questions.

Allergen information sheets are provided by manufacturers of patch test materials, including SmartPractice (allergEAZE, T.R.U.E. Test) and Chemotechnique (Dormer)(Table 2). The ACDS also provides a selection of allergen information sheets for members to share with their patients. The ACDS allergen handouts are designed for patient use, are vetted by practicing patch test dermatologists, and contain up-to-date information for patients. We recommend that you choose the handout(s) that are most appropriate for your patient; this decision can be made based on patient education or reading level, the region of the world where you are patch testing or where the patient lives, the patient’s primary language, and the specific allergen. Information on rare or new allergens may not be available on every website resource.

Identification of Allergen-Free Products

We ask patients to bring their personal care products to their patch test reading visit, and once positive allergens are known, we search for the presence of that allergen in their products. It is helpful for patients if products that are “safe” and “not safe” are sorted for them. We frequently emphasize that just one exposure to an allergen in a personal care product can be the source of the dermatitis. If a product label does not include ingredients, they often can be identified with a quick web search (use your favorite search engine or see Table 2 for websites); however, caution is advised, as lists found online may not match those found on in-store products.³ Reviewing the patient’s own products in the clinic is preferred over searching for ingredient lists online. If the product’s ingredients cannot be found (eg, ingredients that are found on external packaging), the patient has several choices: do not use, complete repeat open application testing if it is a leave-on product, or check to see if it is on a product database safe list.

We explain to patients that once they have confirmed that they are using only “safe” allergen-free products, it can take up to 6 to 8 weeks for dermatitis to improve, and at that point, the skin may only be about 75% to 80% clear. A clear description of what to expect and when is needed for a strong patient-physician partnership. For example, if the patient expects to be clear in 2 days but is not and stops avoiding their allergens because they think the process has failed, their dermatitis will not improve.

Product Databases

Because allergens sometimes have multiple different chemical names and cross-reactivity is abundant, avoidance of both the allergen and cross-reactors can be daunting for many patients (and dermatologists!). The use of a product database to aid in product selection is an invaluable resource. Product databases help patients avoid not only their allergens but also common cross-reactors by relying on complex cross-reactor programming. The ACDS owns and maintains the Contact Allergy Management Program (CAMP). Another resource is SkinSafe, which is powered by HER Inc and developed with the Mayo Clinic. Both CAMP and SkinSafe have mobile apps and update product lists frequently; they allow for much easier shopping and identification of safe products.

We typically use CAMP for generation of patient safe lists. We enter the patient’s allergens into the database, and a safe list is generated and shared with the patient. Next, we educate the patient on how to use the safe list. It is vital that the concept of exact product matching be explained to patients, as not all products from one brand or type of product is necessarily safe for a given individual. We also share information on how to download the CAMP app onto mobile devices and tablets.

Product safe lists are important resources for patients to be successful in avoiding allergens but are not a substitute for reading labels. Both CAMP and SkinSafe can potentially contain ingredient list errors due to companies frequently changing their product formulations.³ Although safe lists are an important part in selecting safe skin care products, they are not a substitute for label reading.

Counseling Pitfalls and Pearls

Language
Chemotechnique handouts are available in English, Swedish, French, and Spanish, and ACDS handouts are available in English and Spanish. If language interpretation is needed, inform the interpreter before the visit begins that you will be discussing patch test information and products so they can carefully interpret the details of the discussion.

Barriers to Allergen Avoidance
There are several barriers to long-term avoidance of contact allergy. In a European-based study of methylisothiazolinone (MI) contact allergy 2 to 5 years after patch testing, challenges described by patients included label reading, verifying products, difficulty obtaining ingredients of industrial products, the need to have their “safe” products always available for use, remembering allergen name, avoiding workplace allergens, finding acceptable MI-free products, and navigating the cost of MI-free products.⁴

Patient allergen recall is a well-documented long-term concern. In the previously mentioned European study (N=139), 11% of patients identified remembering the allergen name as a contributor to difficulty with avoidance.⁴ A Swedish study evaluated patient allergen recall at 1, 5, and 10 years after patch testing was completed; 96% of 252 patients remembered that they had completed patch testing, 79% (111/141) remembered that they had positive results, and only 29% (41/141) correctly recalled their allergens.⁵ Patients who had completed patch testing 10 years prior were less likely to correctly recall their allergens (P=.0045). Recall also was less likely if there was more than 1 allergen as well as in males.⁵ Korkmaz and Boyvat⁶ analyzed outcomes 6 months after patch testing in Turkey and found that 38 of 51 (74.5%) correctly recalled their allergens. Patients with more than 1 positive allergen were less likely to recall their allergens (P=.046), and patients with higher baseline investigator global assessment (P=.036) and dermatology life quality index (P=.041) scores were more likely to recall their allergens.⁶ A US-based study (N=757) noted that 34.1% of patients correctly recalled all of their allergens.⁷ Patients were less likely to remember if they had 3 or more positives but were more likely to remember if they were aged 50 to 59 years (compared to other age groups) or female as well as if their occupation was nursing (as compared to other occupations).

Additional barriers include hidden sources of allergens, as has been reported in the cases of undeclared MI⁸ and formaldehyde⁹ in personal care products. Although this phenomenon is thought to be the exception and not the rule, possible reasons for the presence of these undeclared allergens include their use as preservatives in raw materials,^8,9 or in the case of formaldehyde, theorized release from product packaging or auto-oxidation and degradation of other chemicals present within the product.⁹

Readers may recall that we mentioned the option of identifying product ingredients with online search engines or databases, but it is not a perfect system. Comstock and Reeder³ reviewed and compared online ingredient lists from Amazon and several product databases to products taken off shelves at Target and Walgreens and found that 27.7% of online ingredient lists did not match the in-store labels.³ These differences likely are due to changes in product formulations, ingredient variability based on production site, outdated product on store shelves, or data entry error and may not be entirely avoidable. Regardless, patch test experts should be aware of this possibility. When in doubt, always check the product’s original packaging.

Finally, the elephant in the room: We challenge you, as dermatologists and patch test enthusiasts, to name all of the formaldehyde releasers or perhaps declare whether linalool and hydroxycitronellol are fragrances, preservatives, or surfactants. How about naming the relationship between cocamidopropyl betaine, amidoamine, and dimethylaminopropylamine? Difficult stuff, right? And we are medical specialists. It is downright impossible for many of our patients to memorize the names of these chemicals, let alone know their cross-reactors or other important chemical relationships. We mention that providing a safe list is part of patient counseling, but we bring up this knowledge gap to illustrate that patch testing without providing resources to select safe care products is almost as bad as not patch testing at all because in many cases patients may be left without the tools they need to be successful. Do not let this be your downfall!

Final Interpretation

The most challenging and nuanced part of patch testing happens after the actual patch test: assessment of relevance, allergen counseling, and identification of appropriate products for patient use. You now have the tools to successfully counsel your patients after patch testing; get to it!

Vaccines work. They are powerful tools that have saved millions of lives worldwide; however, a robust antivaccine movement has taken hold in the United States and worldwide despite overwhelming data in support of vaccination. In fact, vaccine hesitancy—the reluctance or refusal to vaccinate despite the availability of vaccines—was listed by the World Health Organization as one of the top 10 global health threats in 2019.¹

Several vaccines have a role in dermatology, including the human papillomavirus (HPV) vaccine (Gardasil 9 [Merck Sharp & Dohme Corp]), the herpes zoster vaccines (Zostavax [Merck Sharp & Dohme Corp] and Shingrix [GlaxoSmithKline Biologicals]), and the measles-mumps-rubella vaccine, among others. These vaccinations are necessary for children and many adults alike, and they play a critical role in protecting both healthy and immunosuppressed patients.

Vaccine hesitancy is a growing threat to individual and public health that requires a response from all physicians. In our experience, dermatologists have been somewhat passive in advocating for vaccinations, possibly due to knowledge barriers or time constraints; however, this stance must change. Dermatologists must join the front lines in advocating for vaccinations, which are a proven and effective modality in promoting public health.

Dermatologists can employ the following practical tips to improve vaccination compliance among patients:

• Familiarize yourself with the Centers for Disease Control and Prevention immunization schedules and vaccination information sheets (https://www.cdc.gov/vaccines/hcp/vis/current-vis.html). Printed copies of informational handouts should be readily available to provide to patients in the office. The Centers for Disease Control and Prevention also offers tip sheets to guide conversations with patients (https://www.cdc.gov/vaccines/hcp/conversations/index.html).

• Prior to starting an immunosuppressive medication, confirm the patient’s immunization status. You should know which vaccines are live (containing an attenuated pathogen) and which are inactivated. Live vaccines typically are not administered to immunosuppressed patients.

• Use electronic medical records to help provide reminders to prompt administration of any necessary vaccines.

• Know the facts, especially regarding purported vaccine controversies, and be able to cite data on vaccine safety and efficacy. For example, when having a conversation with a patient you could state that vaccination against HPV, which can cause genital warts and certain cancers, has decreased the number of HPV infections by more than 70% in young women and 80% in teenaged girls.² Cervical precancers were reduced by 40% in women vaccinated against HPV. Twelve years of monitoring data validates the safety and efficacy of the HPV vaccine—it is safe and effective, with benefits that outweigh any potential risks.²

• Tailor counseling based on the patient’s age and focus on benefits that directly impact the patient. For example, consider showing young adults photographs of genital warts while educating them that the HPV vaccine can help prevent this kind of infection in the future.

• Emphasize that vaccines are a routine part of comprehensive patient care and support this point by providing data and specific reasons for recommending vaccines.³ Avoid phrases such as, “Do you want the vaccine?” or “You could consider receiving the vaccine today,” which can imply that the vaccine is not necessary.

• Offer vaccines in your office or provide clear printed informational sheets directing patients to nearby primary care clinics, infectious disease clinics, or pharmacies where vaccinations are offered.

• Consider using social media to promote the benefits of vaccination among patients.

The recent coronavirus disease 2019 pandemic has brought the topic of vaccination into the limelight while highlighting that rampant misinformation can lead to distrust of health care workers. Dermatologists, along with all physicians, should be trusted advisors and advocates for public health. In addition to being knowledgeable, dermatologists must remain open-minded in having conversations with skeptical patients. Physicians must take the time and effort to promote vaccinations—the health of patients and the general public depends on it.

Vaccines work. They are powerful tools that have saved millions of lives worldwide; however, a robust antivaccine movement has taken hold in the United States and worldwide despite overwhelming data in support of vaccination. In fact, vaccine hesitancy—the reluctance or refusal to vaccinate despite the availability of vaccines—was listed by the World Health Organization as one of the top 10 global health threats in 2019.¹

Several vaccines have a role in dermatology, including the human papillomavirus (HPV) vaccine (Gardasil 9 [Merck Sharp & Dohme Corp]), the herpes zoster vaccines (Zostavax [Merck Sharp & Dohme Corp] and Shingrix [GlaxoSmithKline Biologicals]), and the measles-mumps-rubella vaccine, among others. These vaccinations are necessary for children and many adults alike, and they play a critical role in protecting both healthy and immunosuppressed patients.

Vaccine hesitancy is a growing threat to individual and public health that requires a response from all physicians. In our experience, dermatologists have been somewhat passive in advocating for vaccinations, possibly due to knowledge barriers or time constraints; however, this stance must change. Dermatologists must join the front lines in advocating for vaccinations, which are a proven and effective modality in promoting public health.

Dermatologists can employ the following practical tips to improve vaccination compliance among patients:

• Familiarize yourself with the Centers for Disease Control and Prevention immunization schedules and vaccination information sheets (https://www.cdc.gov/vaccines/hcp/vis/current-vis.html). Printed copies of informational handouts should be readily available to provide to patients in the office. The Centers for Disease Control and Prevention also offers tip sheets to guide conversations with patients (https://www.cdc.gov/vaccines/hcp/conversations/index.html).

• Prior to starting an immunosuppressive medication, confirm the patient’s immunization status. You should know which vaccines are live (containing an attenuated pathogen) and which are inactivated. Live vaccines typically are not administered to immunosuppressed patients.

• Use electronic medical records to help provide reminders to prompt administration of any necessary vaccines.

• Know the facts, especially regarding purported vaccine controversies, and be able to cite data on vaccine safety and efficacy. For example, when having a conversation with a patient you could state that vaccination against HPV, which can cause genital warts and certain cancers, has decreased the number of HPV infections by more than 70% in young women and 80% in teenaged girls.² Cervical precancers were reduced by 40% in women vaccinated against HPV. Twelve years of monitoring data validates the safety and efficacy of the HPV vaccine—it is safe and effective, with benefits that outweigh any potential risks.²

• Tailor counseling based on the patient’s age and focus on benefits that directly impact the patient. For example, consider showing young adults photographs of genital warts while educating them that the HPV vaccine can help prevent this kind of infection in the future.

• Emphasize that vaccines are a routine part of comprehensive patient care and support this point by providing data and specific reasons for recommending vaccines.³ Avoid phrases such as, “Do you want the vaccine?” or “You could consider receiving the vaccine today,” which can imply that the vaccine is not necessary.

• Offer vaccines in your office or provide clear printed informational sheets directing patients to nearby primary care clinics, infectious disease clinics, or pharmacies where vaccinations are offered.

• Consider using social media to promote the benefits of vaccination among patients.

The recent coronavirus disease 2019 pandemic has brought the topic of vaccination into the limelight while highlighting that rampant misinformation can lead to distrust of health care workers. Dermatologists, along with all physicians, should be trusted advisors and advocates for public health. In addition to being knowledgeable, dermatologists must remain open-minded in having conversations with skeptical patients. Physicians must take the time and effort to promote vaccinations—the health of patients and the general public depends on it.

Vaccines work. They are powerful tools that have saved millions of lives worldwide; however, a robust antivaccine movement has taken hold in the United States and worldwide despite overwhelming data in support of vaccination. In fact, vaccine hesitancy—the reluctance or refusal to vaccinate despite the availability of vaccines—was listed by the World Health Organization as one of the top 10 global health threats in 2019.¹

Several vaccines have a role in dermatology, including the human papillomavirus (HPV) vaccine (Gardasil 9 [Merck Sharp & Dohme Corp]), the herpes zoster vaccines (Zostavax [Merck Sharp & Dohme Corp] and Shingrix [GlaxoSmithKline Biologicals]), and the measles-mumps-rubella vaccine, among others. These vaccinations are necessary for children and many adults alike, and they play a critical role in protecting both healthy and immunosuppressed patients.

Vaccine hesitancy is a growing threat to individual and public health that requires a response from all physicians. In our experience, dermatologists have been somewhat passive in advocating for vaccinations, possibly due to knowledge barriers or time constraints; however, this stance must change. Dermatologists must join the front lines in advocating for vaccinations, which are a proven and effective modality in promoting public health.

Dermatologists can employ the following practical tips to improve vaccination compliance among patients:

• Familiarize yourself with the Centers for Disease Control and Prevention immunization schedules and vaccination information sheets (https://www.cdc.gov/vaccines/hcp/vis/current-vis.html). Printed copies of informational handouts should be readily available to provide to patients in the office. The Centers for Disease Control and Prevention also offers tip sheets to guide conversations with patients (https://www.cdc.gov/vaccines/hcp/conversations/index.html).

• Prior to starting an immunosuppressive medication, confirm the patient’s immunization status. You should know which vaccines are live (containing an attenuated pathogen) and which are inactivated. Live vaccines typically are not administered to immunosuppressed patients.

• Use electronic medical records to help provide reminders to prompt administration of any necessary vaccines.

• Know the facts, especially regarding purported vaccine controversies, and be able to cite data on vaccine safety and efficacy. For example, when having a conversation with a patient you could state that vaccination against HPV, which can cause genital warts and certain cancers, has decreased the number of HPV infections by more than 70% in young women and 80% in teenaged girls.² Cervical precancers were reduced by 40% in women vaccinated against HPV. Twelve years of monitoring data validates the safety and efficacy of the HPV vaccine—it is safe and effective, with benefits that outweigh any potential risks.²

• Tailor counseling based on the patient’s age and focus on benefits that directly impact the patient. For example, consider showing young adults photographs of genital warts while educating them that the HPV vaccine can help prevent this kind of infection in the future.

• Emphasize that vaccines are a routine part of comprehensive patient care and support this point by providing data and specific reasons for recommending vaccines.³ Avoid phrases such as, “Do you want the vaccine?” or “You could consider receiving the vaccine today,” which can imply that the vaccine is not necessary.

• Offer vaccines in your office or provide clear printed informational sheets directing patients to nearby primary care clinics, infectious disease clinics, or pharmacies where vaccinations are offered.

• Consider using social media to promote the benefits of vaccination among patients.

The recent coronavirus disease 2019 pandemic has brought the topic of vaccination into the limelight while highlighting that rampant misinformation can lead to distrust of health care workers. Dermatologists, along with all physicians, should be trusted advisors and advocates for public health. In addition to being knowledgeable, dermatologists must remain open-minded in having conversations with skeptical patients. Physicians must take the time and effort to promote vaccinations—the health of patients and the general public depends on it.

To the Editor:

Symmetric drug-related intertriginous and flexural exanthema (SDRIFE) is a curious disorder that has undergone many clinical transformations since first being described by Andersen et al¹ in 1984 using the term baboon syndrome. Initially described as a mercury hypersensitivity reaction resulting in an eruption resembling the red-bottomed baboon, this exanthema has expanded in definition with inciting agents, clinical features, and diagnostic criteria. Its prognosis, however, has remained stable and favorable throughout the decades. The condition is almost universally benign and self-limited.^1-3 As new cases are reported in the literature and the paradigm of SDRIFE continues to shift, its prognosis also may warrant reconsideration and respect as a potentially destructive reaction.

A 39-year-old woman who was otherwise healthy presented to the emergency department after developing a rapidly evolving and blistering rash on the left flank. Hours later, the rash had progressed to a sharply demarcated, confluent, erythematous plaque with central ulceration and large flaccid bullae peripherally, encompassing 18% of total body surface area and extending from the gluteal cleft to the tip of the scapula along the left flank (Figure 1) with no vaginal or mucosal involvement. The patient recently had completed a 10-day course of amoxicillin–clavulanic acid 2 days prior for a cat bite on the right dorsal wrist. Additional history confirmed the absence of prodromal fever, fatigue, or chills. Inciting trauma, including chemical and thermal burns, was denied. Potential underlying psychosocial cofounders were explored and were unrevealing.

In the undifferentiated patient, categorization of the clinical syndrome proves helpful in prognostication and therapeutic approach. The complexities and commonalities intrinsic to these syndromes, however, may simultaneously preclude certain cases from neatly following the predefined rules. These atypical presentations, while diagnostically challenging, can in turn offer a unique opportunity to reexamine the current state of disease understanding to better allow for appropriate classification.

Despite its rarity, SDRIFE should be considered in the differential of undiagnosed drug eruptions, particularly as new clinical presentations emerge. Careful documentation and timely declaration of future cases will prove invaluable for diagnostic and therapeutic advancements should this once-benign condition develop a more destructive potential.

To the Editor:

Symmetric drug-related intertriginous and flexural exanthema (SDRIFE) is a curious disorder that has undergone many clinical transformations since first being described by Andersen et al¹ in 1984 using the term baboon syndrome. Initially described as a mercury hypersensitivity reaction resulting in an eruption resembling the red-bottomed baboon, this exanthema has expanded in definition with inciting agents, clinical features, and diagnostic criteria. Its prognosis, however, has remained stable and favorable throughout the decades. The condition is almost universally benign and self-limited.^1-3 As new cases are reported in the literature and the paradigm of SDRIFE continues to shift, its prognosis also may warrant reconsideration and respect as a potentially destructive reaction.

A 39-year-old woman who was otherwise healthy presented to the emergency department after developing a rapidly evolving and blistering rash on the left flank. Hours later, the rash had progressed to a sharply demarcated, confluent, erythematous plaque with central ulceration and large flaccid bullae peripherally, encompassing 18% of total body surface area and extending from the gluteal cleft to the tip of the scapula along the left flank (Figure 1) with no vaginal or mucosal involvement. The patient recently had completed a 10-day course of amoxicillin–clavulanic acid 2 days prior for a cat bite on the right dorsal wrist. Additional history confirmed the absence of prodromal fever, fatigue, or chills. Inciting trauma, including chemical and thermal burns, was denied. Potential underlying psychosocial cofounders were explored and were unrevealing.

In the undifferentiated patient, categorization of the clinical syndrome proves helpful in prognostication and therapeutic approach. The complexities and commonalities intrinsic to these syndromes, however, may simultaneously preclude certain cases from neatly following the predefined rules. These atypical presentations, while diagnostically challenging, can in turn offer a unique opportunity to reexamine the current state of disease understanding to better allow for appropriate classification.

Despite its rarity, SDRIFE should be considered in the differential of undiagnosed drug eruptions, particularly as new clinical presentations emerge. Careful documentation and timely declaration of future cases will prove invaluable for diagnostic and therapeutic advancements should this once-benign condition develop a more destructive potential.

To the Editor:

Symmetric drug-related intertriginous and flexural exanthema (SDRIFE) is a curious disorder that has undergone many clinical transformations since first being described by Andersen et al¹ in 1984 using the term baboon syndrome. Initially described as a mercury hypersensitivity reaction resulting in an eruption resembling the red-bottomed baboon, this exanthema has expanded in definition with inciting agents, clinical features, and diagnostic criteria. Its prognosis, however, has remained stable and favorable throughout the decades. The condition is almost universally benign and self-limited.^1-3 As new cases are reported in the literature and the paradigm of SDRIFE continues to shift, its prognosis also may warrant reconsideration and respect as a potentially destructive reaction.

A 39-year-old woman who was otherwise healthy presented to the emergency department after developing a rapidly evolving and blistering rash on the left flank. Hours later, the rash had progressed to a sharply demarcated, confluent, erythematous plaque with central ulceration and large flaccid bullae peripherally, encompassing 18% of total body surface area and extending from the gluteal cleft to the tip of the scapula along the left flank (Figure 1) with no vaginal or mucosal involvement. The patient recently had completed a 10-day course of amoxicillin–clavulanic acid 2 days prior for a cat bite on the right dorsal wrist. Additional history confirmed the absence of prodromal fever, fatigue, or chills. Inciting trauma, including chemical and thermal burns, was denied. Potential underlying psychosocial cofounders were explored and were unrevealing.

In the undifferentiated patient, categorization of the clinical syndrome proves helpful in prognostication and therapeutic approach. The complexities and commonalities intrinsic to these syndromes, however, may simultaneously preclude certain cases from neatly following the predefined rules. These atypical presentations, while diagnostically challenging, can in turn offer a unique opportunity to reexamine the current state of disease understanding to better allow for appropriate classification.

Despite its rarity, SDRIFE should be considered in the differential of undiagnosed drug eruptions, particularly as new clinical presentations emerge. Careful documentation and timely declaration of future cases will prove invaluable for diagnostic and therapeutic advancements should this once-benign condition develop a more destructive potential.

To the Editor:

A 32-year-old man presented to the dermatology clinic with multiple asymptomatic blue lesions on the arms and upper torso of 15 years’ duration. His medical history was notable for a recent diagnosis of malignant melanoma following excision of a mole on the upper back 4 months prior. He reported that the mole had been present since childhood, but his sister noticed that it increased in size and changed in color over the course of a year. Physical examination showed multiple blue subcutaneous nodules on the bilateral arms and lower back. The nodules were soft and nontender, and some had telangiectasia on the overlying skin.

Given the atypical distribution of nodules and the patient’s recent history of melanoma, there was concern for cutaneous metastases. A punch biopsy of one of the nodules on the right upper arm was performed. Microscopic examination of the biopsy specimen revealed a proliferation of multiple cavernous vessels surrounded by several rows of monotonous round cells with moderate eosinophilic cytoplasm and monomorphic nuclei, which was consistent with a diagnosis of glomangioma (Figure 1). Immunohistochemical analysis showed diffuse positive staining for smooth muscle actin (Figure 2); CD34 immunostain was positive in endothelial cells and negative in tumor cells (Figure 3).

Glomus tumors arise from modified smooth muscle cells located in glomus bodies. The glomus body is a component of the dermis involved in regulation of body temperature that is composed of an afferent arteriole and an efferent venule. The arterial end of this apparatus, known as the Sucquet-Hoyer canal, is surrounded by glomus cells that have a contractile capability similar to smooth muscle cells. Glomus tumors usually present as painful masses on the fingers with a typical subungual location and almost always are solitary.¹ Glomangiomas, sometimes known as glomuvenous malformations, tend to be larger and usually are painless. They mostly are found on the trunk and extremities and can appear in groups.^2,3 Histopathologically, glomus tumors are circumscribed lesions that show a predominance of glomus cells surrounding inconspicuous blood vessels. Glomangiomas are less well-circumscribed and show a more vascular architecture with prominent dilated vessels and a smaller number of glomus cells.⁴

We present a case of a patient with multiple glomangiomas. There are few reports of multiple glomangiomas in the literature. This case is particularly interesting in that our patient had a history of malignant melanoma, and there was a concern for skin metastases. Despite the patient’s personal history of blue lesions that predated the diagnosis of melanoma for many years, we could not exclude the possibility of cutaneous metastases without performing biopsies.

Tumors of glomus cell origin usually are benign. It has been suggested to replace the term glomangioma with glomuvenous malformations to emphasize the hamartomatous nature of these lesions.⁵ Glomuvenous malformations, or glomangiomas, can occur sporadically or can be inherited as a familial disorder. Inheritable glomangioma has been linked to the chromosome 1p21-22 locus and mutations in the glomulin gene, GLMN, with variable penetrance.⁶ Our patient did not report a family history of such lesions.

Glomangiomas typically are solitary but rarely can present as multiple lesions in fewer than 10% of cases.⁷ Multiple glomangiomas are classified into 3 subtypes: localized, disseminated, and congenital plaque type. Localized multiple glomangiomas present as blue nodules confined to 1 anatomic location such as the hand or arm. Disseminated glomangiomas are more widely distributed and involve more than 1 anatomic location.⁸ Plaque-type glomangiomas consist of numerous confluent lesions occurring either as solitary or multiple plaques.² Clinically, glomangiomas manifest as painless to mildly painful cutaneous nodules. Compared to venous malformations, glomangiomas are less compressible under external pressure.

Histopathologically, glomangiomas appear as nonencapsulated tumors with large, irregular, prominent vessels lined by glomus cells. Glomus cells may be so sparse that the distinction from venous malformations and hemangiomas becomes difficult. Immunohistochemistry can play an important role in diagnosis. As modified smooth muscle cells, glomus cells stain positive with a-smooth muscle actin, while CD34 highlights the vascular endothelium.¹The clinical differential diagnosis of multiple blue or violaceous subcutaneous nodules includes blue rubber bleb nevus syndrome, Maffucci syndrome, glomus tumor, pyogenic granuloma, hemangioma, spiradenoma, angiolipoma, leiomyoma, or hemangiopericytoma.^9-12

Different treatment modalities are available for solitary glomangiomas, including surgical excision, sclerotherapy, and laser application. Treatment of multiple glomangiomas may not be feasible, and excision of isolated symptomatic lesions may be the only option; however, it is crucial to reach the correct diagnosis in these patients to avoid improper treatments and interventions.

To the Editor:

A 32-year-old man presented to the dermatology clinic with multiple asymptomatic blue lesions on the arms and upper torso of 15 years’ duration. His medical history was notable for a recent diagnosis of malignant melanoma following excision of a mole on the upper back 4 months prior. He reported that the mole had been present since childhood, but his sister noticed that it increased in size and changed in color over the course of a year. Physical examination showed multiple blue subcutaneous nodules on the bilateral arms and lower back. The nodules were soft and nontender, and some had telangiectasia on the overlying skin.

Given the atypical distribution of nodules and the patient’s recent history of melanoma, there was concern for cutaneous metastases. A punch biopsy of one of the nodules on the right upper arm was performed. Microscopic examination of the biopsy specimen revealed a proliferation of multiple cavernous vessels surrounded by several rows of monotonous round cells with moderate eosinophilic cytoplasm and monomorphic nuclei, which was consistent with a diagnosis of glomangioma (Figure 1). Immunohistochemical analysis showed diffuse positive staining for smooth muscle actin (Figure 2); CD34 immunostain was positive in endothelial cells and negative in tumor cells (Figure 3).

Glomus tumors arise from modified smooth muscle cells located in glomus bodies. The glomus body is a component of the dermis involved in regulation of body temperature that is composed of an afferent arteriole and an efferent venule. The arterial end of this apparatus, known as the Sucquet-Hoyer canal, is surrounded by glomus cells that have a contractile capability similar to smooth muscle cells. Glomus tumors usually present as painful masses on the fingers with a typical subungual location and almost always are solitary.¹ Glomangiomas, sometimes known as glomuvenous malformations, tend to be larger and usually are painless. They mostly are found on the trunk and extremities and can appear in groups.^2,3 Histopathologically, glomus tumors are circumscribed lesions that show a predominance of glomus cells surrounding inconspicuous blood vessels. Glomangiomas are less well-circumscribed and show a more vascular architecture with prominent dilated vessels and a smaller number of glomus cells.⁴

We present a case of a patient with multiple glomangiomas. There are few reports of multiple glomangiomas in the literature. This case is particularly interesting in that our patient had a history of malignant melanoma, and there was a concern for skin metastases. Despite the patient’s personal history of blue lesions that predated the diagnosis of melanoma for many years, we could not exclude the possibility of cutaneous metastases without performing biopsies.

Tumors of glomus cell origin usually are benign. It has been suggested to replace the term glomangioma with glomuvenous malformations to emphasize the hamartomatous nature of these lesions.⁵ Glomuvenous malformations, or glomangiomas, can occur sporadically or can be inherited as a familial disorder. Inheritable glomangioma has been linked to the chromosome 1p21-22 locus and mutations in the glomulin gene, GLMN, with variable penetrance.⁶ Our patient did not report a family history of such lesions.

Glomangiomas typically are solitary but rarely can present as multiple lesions in fewer than 10% of cases.⁷ Multiple glomangiomas are classified into 3 subtypes: localized, disseminated, and congenital plaque type. Localized multiple glomangiomas present as blue nodules confined to 1 anatomic location such as the hand or arm. Disseminated glomangiomas are more widely distributed and involve more than 1 anatomic location.⁸ Plaque-type glomangiomas consist of numerous confluent lesions occurring either as solitary or multiple plaques.² Clinically, glomangiomas manifest as painless to mildly painful cutaneous nodules. Compared to venous malformations, glomangiomas are less compressible under external pressure.

Histopathologically, glomangiomas appear as nonencapsulated tumors with large, irregular, prominent vessels lined by glomus cells. Glomus cells may be so sparse that the distinction from venous malformations and hemangiomas becomes difficult. Immunohistochemistry can play an important role in diagnosis. As modified smooth muscle cells, glomus cells stain positive with a-smooth muscle actin, while CD34 highlights the vascular endothelium.¹The clinical differential diagnosis of multiple blue or violaceous subcutaneous nodules includes blue rubber bleb nevus syndrome, Maffucci syndrome, glomus tumor, pyogenic granuloma, hemangioma, spiradenoma, angiolipoma, leiomyoma, or hemangiopericytoma.^9-12

Different treatment modalities are available for solitary glomangiomas, including surgical excision, sclerotherapy, and laser application. Treatment of multiple glomangiomas may not be feasible, and excision of isolated symptomatic lesions may be the only option; however, it is crucial to reach the correct diagnosis in these patients to avoid improper treatments and interventions.

To the Editor:

A 32-year-old man presented to the dermatology clinic with multiple asymptomatic blue lesions on the arms and upper torso of 15 years’ duration. His medical history was notable for a recent diagnosis of malignant melanoma following excision of a mole on the upper back 4 months prior. He reported that the mole had been present since childhood, but his sister noticed that it increased in size and changed in color over the course of a year. Physical examination showed multiple blue subcutaneous nodules on the bilateral arms and lower back. The nodules were soft and nontender, and some had telangiectasia on the overlying skin.

Given the atypical distribution of nodules and the patient’s recent history of melanoma, there was concern for cutaneous metastases. A punch biopsy of one of the nodules on the right upper arm was performed. Microscopic examination of the biopsy specimen revealed a proliferation of multiple cavernous vessels surrounded by several rows of monotonous round cells with moderate eosinophilic cytoplasm and monomorphic nuclei, which was consistent with a diagnosis of glomangioma (Figure 1). Immunohistochemical analysis showed diffuse positive staining for smooth muscle actin (Figure 2); CD34 immunostain was positive in endothelial cells and negative in tumor cells (Figure 3).

Glomus tumors arise from modified smooth muscle cells located in glomus bodies. The glomus body is a component of the dermis involved in regulation of body temperature that is composed of an afferent arteriole and an efferent venule. The arterial end of this apparatus, known as the Sucquet-Hoyer canal, is surrounded by glomus cells that have a contractile capability similar to smooth muscle cells. Glomus tumors usually present as painful masses on the fingers with a typical subungual location and almost always are solitary.¹ Glomangiomas, sometimes known as glomuvenous malformations, tend to be larger and usually are painless. They mostly are found on the trunk and extremities and can appear in groups.^2,3 Histopathologically, glomus tumors are circumscribed lesions that show a predominance of glomus cells surrounding inconspicuous blood vessels. Glomangiomas are less well-circumscribed and show a more vascular architecture with prominent dilated vessels and a smaller number of glomus cells.⁴

We present a case of a patient with multiple glomangiomas. There are few reports of multiple glomangiomas in the literature. This case is particularly interesting in that our patient had a history of malignant melanoma, and there was a concern for skin metastases. Despite the patient’s personal history of blue lesions that predated the diagnosis of melanoma for many years, we could not exclude the possibility of cutaneous metastases without performing biopsies.

Tumors of glomus cell origin usually are benign. It has been suggested to replace the term glomangioma with glomuvenous malformations to emphasize the hamartomatous nature of these lesions.⁵ Glomuvenous malformations, or glomangiomas, can occur sporadically or can be inherited as a familial disorder. Inheritable glomangioma has been linked to the chromosome 1p21-22 locus and mutations in the glomulin gene, GLMN, with variable penetrance.⁶ Our patient did not report a family history of such lesions.

Glomangiomas typically are solitary but rarely can present as multiple lesions in fewer than 10% of cases.⁷ Multiple glomangiomas are classified into 3 subtypes: localized, disseminated, and congenital plaque type. Localized multiple glomangiomas present as blue nodules confined to 1 anatomic location such as the hand or arm. Disseminated glomangiomas are more widely distributed and involve more than 1 anatomic location.⁸ Plaque-type glomangiomas consist of numerous confluent lesions occurring either as solitary or multiple plaques.² Clinically, glomangiomas manifest as painless to mildly painful cutaneous nodules. Compared to venous malformations, glomangiomas are less compressible under external pressure.

Histopathologically, glomangiomas appear as nonencapsulated tumors with large, irregular, prominent vessels lined by glomus cells. Glomus cells may be so sparse that the distinction from venous malformations and hemangiomas becomes difficult. Immunohistochemistry can play an important role in diagnosis. As modified smooth muscle cells, glomus cells stain positive with a-smooth muscle actin, while CD34 highlights the vascular endothelium.¹The clinical differential diagnosis of multiple blue or violaceous subcutaneous nodules includes blue rubber bleb nevus syndrome, Maffucci syndrome, glomus tumor, pyogenic granuloma, hemangioma, spiradenoma, angiolipoma, leiomyoma, or hemangiopericytoma.^9-12

Different treatment modalities are available for solitary glomangiomas, including surgical excision, sclerotherapy, and laser application. Treatment of multiple glomangiomas may not be feasible, and excision of isolated symptomatic lesions may be the only option; however, it is crucial to reach the correct diagnosis in these patients to avoid improper treatments and interventions.

Punch biopsies from the right axilla (Figure) and right abdomen as well as a tangential biopsy from the left volar wrist papule showed an interstitial histiocytic infiltrate with focal palisading of histiocytes around central regions with collagen alteration and increased mucin. Grocott-Gomori methenamine-silver stain and acid-fast bacilli smear both were negative for organisms; these findings were consistent with a diagnosis of granuloma annulare (GA).

Granuloma annulare is a noninfectious granulomatous disease of unknown etiology. It most commonly appears as asymptomatic, flesh-colored, pink or violaceous annular patches or thin plaques favoring the trunk and extremities. Granuloma annulare has many documented presentations including generalized, patch, subcutaneous, and perforating forms. It can present as macules, papules, nodules, patches, or plaques. Reported associations include diabetes mellitus, hyperlipidemia, solid organ tumors, systemic infection, and thyroid disease.¹ Granuloma annulare can occur in any age group but is most common between the ages of 20 and 40 years.²

Diagnosis most often is made clinically and can be confirmed by histopathology. Histologic examination most commonly shows histiocytes within the dermis that palisade around a central area of mucin deposition between degenerating collagen fibers. The histiocytes of GA stain positive with vimentin, lysozyme, and CD68. The increased mucin stains with colloidal iron and Alcian blue. Multinucleated giant cells and perivascular lymphocytic infiltrate also are commonly seen.³

Cutaneous B-cell lymphoma has a wide range of presentations but usually occurs as hyperpigmented plaques and patches with dermal atrophy. Psoriasis can present in an inverse distribution but will show epidermal changes including scale. Sarcoidosis presents as multiple erythematous plaques and papules and also can be accompanied by erythema nodosum. Tinea corporis likely would have resolved with antifungal treatment.

Many different treatments have been described as effective, including cryosurgery, topical and intralesional corticosteroids, antibiotics, immune modulators, phototherapy, and oral corticosteroids.¹ We started our patient on triple-antibiotic therapy with rifampin 600 mg, minocycline 100 mg, and ofloxacin 400 mg all once monthly for 6 months, which has been shown to be efficacious in treating GA.⁴ The patient returned for follow-up 1 year after the initial presentation. At that time, she had faint pink patches on the waist and medial upper thighs, and the axillary lesions had cleared. In the interim, she developed more classic GA lesions—pink to violaceous smooth papules with no overlying epidermal changes—on the volar wrists and dorsal feet. These lesions were asymptomatic, and she currently is not undergoing any further treatment.

Punch biopsies from the right axilla (Figure) and right abdomen as well as a tangential biopsy from the left volar wrist papule showed an interstitial histiocytic infiltrate with focal palisading of histiocytes around central regions with collagen alteration and increased mucin. Grocott-Gomori methenamine-silver stain and acid-fast bacilli smear both were negative for organisms; these findings were consistent with a diagnosis of granuloma annulare (GA).

Granuloma annulare is a noninfectious granulomatous disease of unknown etiology. It most commonly appears as asymptomatic, flesh-colored, pink or violaceous annular patches or thin plaques favoring the trunk and extremities. Granuloma annulare has many documented presentations including generalized, patch, subcutaneous, and perforating forms. It can present as macules, papules, nodules, patches, or plaques. Reported associations include diabetes mellitus, hyperlipidemia, solid organ tumors, systemic infection, and thyroid disease.¹ Granuloma annulare can occur in any age group but is most common between the ages of 20 and 40 years.²

Diagnosis most often is made clinically and can be confirmed by histopathology. Histologic examination most commonly shows histiocytes within the dermis that palisade around a central area of mucin deposition between degenerating collagen fibers. The histiocytes of GA stain positive with vimentin, lysozyme, and CD68. The increased mucin stains with colloidal iron and Alcian blue. Multinucleated giant cells and perivascular lymphocytic infiltrate also are commonly seen.³

Cutaneous B-cell lymphoma has a wide range of presentations but usually occurs as hyperpigmented plaques and patches with dermal atrophy. Psoriasis can present in an inverse distribution but will show epidermal changes including scale. Sarcoidosis presents as multiple erythematous plaques and papules and also can be accompanied by erythema nodosum. Tinea corporis likely would have resolved with antifungal treatment.

Many different treatments have been described as effective, including cryosurgery, topical and intralesional corticosteroids, antibiotics, immune modulators, phototherapy, and oral corticosteroids.¹ We started our patient on triple-antibiotic therapy with rifampin 600 mg, minocycline 100 mg, and ofloxacin 400 mg all once monthly for 6 months, which has been shown to be efficacious in treating GA.⁴ The patient returned for follow-up 1 year after the initial presentation. At that time, she had faint pink patches on the waist and medial upper thighs, and the axillary lesions had cleared. In the interim, she developed more classic GA lesions—pink to violaceous smooth papules with no overlying epidermal changes—on the volar wrists and dorsal feet. These lesions were asymptomatic, and she currently is not undergoing any further treatment.

Punch biopsies from the right axilla (Figure) and right abdomen as well as a tangential biopsy from the left volar wrist papule showed an interstitial histiocytic infiltrate with focal palisading of histiocytes around central regions with collagen alteration and increased mucin. Grocott-Gomori methenamine-silver stain and acid-fast bacilli smear both were negative for organisms; these findings were consistent with a diagnosis of granuloma annulare (GA).

Granuloma annulare is a noninfectious granulomatous disease of unknown etiology. It most commonly appears as asymptomatic, flesh-colored, pink or violaceous annular patches or thin plaques favoring the trunk and extremities. Granuloma annulare has many documented presentations including generalized, patch, subcutaneous, and perforating forms. It can present as macules, papules, nodules, patches, or plaques. Reported associations include diabetes mellitus, hyperlipidemia, solid organ tumors, systemic infection, and thyroid disease.¹ Granuloma annulare can occur in any age group but is most common between the ages of 20 and 40 years.²

Diagnosis most often is made clinically and can be confirmed by histopathology. Histologic examination most commonly shows histiocytes within the dermis that palisade around a central area of mucin deposition between degenerating collagen fibers. The histiocytes of GA stain positive with vimentin, lysozyme, and CD68. The increased mucin stains with colloidal iron and Alcian blue. Multinucleated giant cells and perivascular lymphocytic infiltrate also are commonly seen.³

Cutaneous B-cell lymphoma has a wide range of presentations but usually occurs as hyperpigmented plaques and patches with dermal atrophy. Psoriasis can present in an inverse distribution but will show epidermal changes including scale. Sarcoidosis presents as multiple erythematous plaques and papules and also can be accompanied by erythema nodosum. Tinea corporis likely would have resolved with antifungal treatment.

Many different treatments have been described as effective, including cryosurgery, topical and intralesional corticosteroids, antibiotics, immune modulators, phototherapy, and oral corticosteroids.¹ We started our patient on triple-antibiotic therapy with rifampin 600 mg, minocycline 100 mg, and ofloxacin 400 mg all once monthly for 6 months, which has been shown to be efficacious in treating GA.⁴ The patient returned for follow-up 1 year after the initial presentation. At that time, she had faint pink patches on the waist and medial upper thighs, and the axillary lesions had cleared. In the interim, she developed more classic GA lesions—pink to violaceous smooth papules with no overlying epidermal changes—on the volar wrists and dorsal feet. These lesions were asymptomatic, and she currently is not undergoing any further treatment.

To the Editor:

Cutaneous reactions to implantable devices, such as dental implants, intracoronary stents, prosthetic valves, endovascular prostheses, gynecologic devices, and spinal cord stimulator devices, occur with varying frequency and include infectious, hypersensitivity, allergic, and foreign-body reactions. Manifestations have included contact dermatitis; urticarial, vasculitic, and bullous eruptions; extrusion; and granuloma formation.^1,2 Immune complex reactions around implants causing pain, inflammation, and loosening of hardwarealso have been reported.^3,4 Most reported cutaneous reactions typically occur within the first weeks or months after implantation; a reaction rarely presents several years after implantation. We report a cutaneous reaction to an orthopedic appliance almost 10 years after implantation.

A 67-year-old man presented with 2 painful nodules on the right clavicle that were present for several months. The patient denied fever, chills, weight loss, enlarged lymph nodes, or night sweats. Approximately 10 years prior to the appearance of the nodules, the patient fractured the right clavicle and underwent placement of a metal plate. His medical history included resection of the right tonsil and soft-palate carcinoma with radical neck dissection and postoperative radiation, which was completed approximately 4 years prior to placement of the metal plate. The patient recently completed 4 to 6 weeks of fluorouracil for shave biopsy–proven actinic keratosis overlying the entire irradiated area.

Physical examination revealed 2 pink friable nodules measuring 1.5 to 2.5 cm in diameter and leaking serous fluid within the irradiated area (Figure 1). The differential diagnosis included pyogenic granuloma, cutaneous recurrent metastasis, and atypical basal cell carcinoma. A skin biopsy specimen showed hemorrhagic ulcerated skin with acute and chronic inflammation and abscess.

To the Editor:

Cutaneous reactions to implantable devices, such as dental implants, intracoronary stents, prosthetic valves, endovascular prostheses, gynecologic devices, and spinal cord stimulator devices, occur with varying frequency and include infectious, hypersensitivity, allergic, and foreign-body reactions. Manifestations have included contact dermatitis; urticarial, vasculitic, and bullous eruptions; extrusion; and granuloma formation.^1,2 Immune complex reactions around implants causing pain, inflammation, and loosening of hardwarealso have been reported.^3,4 Most reported cutaneous reactions typically occur within the first weeks or months after implantation; a reaction rarely presents several years after implantation. We report a cutaneous reaction to an orthopedic appliance almost 10 years after implantation.

A 67-year-old man presented with 2 painful nodules on the right clavicle that were present for several months. The patient denied fever, chills, weight loss, enlarged lymph nodes, or night sweats. Approximately 10 years prior to the appearance of the nodules, the patient fractured the right clavicle and underwent placement of a metal plate. His medical history included resection of the right tonsil and soft-palate carcinoma with radical neck dissection and postoperative radiation, which was completed approximately 4 years prior to placement of the metal plate. The patient recently completed 4 to 6 weeks of fluorouracil for shave biopsy–proven actinic keratosis overlying the entire irradiated area.

Physical examination revealed 2 pink friable nodules measuring 1.5 to 2.5 cm in diameter and leaking serous fluid within the irradiated area (Figure 1). The differential diagnosis included pyogenic granuloma, cutaneous recurrent metastasis, and atypical basal cell carcinoma. A skin biopsy specimen showed hemorrhagic ulcerated skin with acute and chronic inflammation and abscess.

To the Editor:

Cutaneous reactions to implantable devices, such as dental implants, intracoronary stents, prosthetic valves, endovascular prostheses, gynecologic devices, and spinal cord stimulator devices, occur with varying frequency and include infectious, hypersensitivity, allergic, and foreign-body reactions. Manifestations have included contact dermatitis; urticarial, vasculitic, and bullous eruptions; extrusion; and granuloma formation.^1,2 Immune complex reactions around implants causing pain, inflammation, and loosening of hardwarealso have been reported.^3,4 Most reported cutaneous reactions typically occur within the first weeks or months after implantation; a reaction rarely presents several years after implantation. We report a cutaneous reaction to an orthopedic appliance almost 10 years after implantation.

A 67-year-old man presented with 2 painful nodules on the right clavicle that were present for several months. The patient denied fever, chills, weight loss, enlarged lymph nodes, or night sweats. Approximately 10 years prior to the appearance of the nodules, the patient fractured the right clavicle and underwent placement of a metal plate. His medical history included resection of the right tonsil and soft-palate carcinoma with radical neck dissection and postoperative radiation, which was completed approximately 4 years prior to placement of the metal plate. The patient recently completed 4 to 6 weeks of fluorouracil for shave biopsy–proven actinic keratosis overlying the entire irradiated area.

Physical examination revealed 2 pink friable nodules measuring 1.5 to 2.5 cm in diameter and leaking serous fluid within the irradiated area (Figure 1). The differential diagnosis included pyogenic granuloma, cutaneous recurrent metastasis, and atypical basal cell carcinoma. A skin biopsy specimen showed hemorrhagic ulcerated skin with acute and chronic inflammation and abscess.