Cutis

Bellafill

Suneva Medical, Inc, announces US Food and Drug Administration approval of the polymethylmethacrylate collagen filler Bellafill for the correction of moderate to severe, atrophic, distensible facial acne scars on the cheek in patients older than 21 years. Bellafill adds volume to the skin to lift and smooth out pitted acne scars to the level of the surrounding skin. Bellafill also is indicated for correction of nasolabial folds. For more information, visit www.bellafill.com.

Benzac

Galderma Laboratories, LP, launches Benzac Acne Solutions, an over-the-counter 3-step acne regimen consisting of a skin balancing foaming cleanser, intensive spot treatment, and blemish clearing hydrator. In addition to salicylic acid, Benzac also contains Kakadu plum (an antioxidant) to brighten the skin, lemon myrtle (an astringent) to reduce excess oil, and zinc to act as a barrier against skin moisture loss. Benzac contains pharmaceutical-grade East Indian sandalwood oil to calm and soothe the skin. For more information, visit www.benzac.com.

The Promius Promise App

Promius Pharma, LLC, marketers of Zenatane (isotretinoin capsules), launches The Promius Promise App designed to help educate and guide patients through the iPLEDGE program from the first visit to the last visit. The app is free for patients who have received a Zenatane prescription through The Promius Promise program. Patients can easily find important information, which may help with treatment compliance. The app will be useful for young adults and teenagers as well as their parents. For more information, visit www.zenatane.com/toolkit/Promius-Promise-Enrollment-Form.php.

Soolantra

Galderma Laboratories, LP, announces US Food and Drug Administration approval of Soolantra Cream 1% for the once-daily treatment of inflammatory lesions of rosacea. Ivermectin, the active ingredient in Soolantra, has both anti-inflammatory and antiparasitic activity. The basis for the cream formulation is Cetaphil Moisturizing Cream. Soolantra offers patients improvement as early as week 2 of treatment. For more information, visit www.soolantra.com/hcp.

If you would like your product included in Product News, please e-mail a press release to the Editorial Office at cutis@frontlinemedcom.com.

Bellafill

Suneva Medical, Inc, announces US Food and Drug Administration approval of the polymethylmethacrylate collagen filler Bellafill for the correction of moderate to severe, atrophic, distensible facial acne scars on the cheek in patients older than 21 years. Bellafill adds volume to the skin to lift and smooth out pitted acne scars to the level of the surrounding skin. Bellafill also is indicated for correction of nasolabial folds. For more information, visit www.bellafill.com.

Benzac

Galderma Laboratories, LP, launches Benzac Acne Solutions, an over-the-counter 3-step acne regimen consisting of a skin balancing foaming cleanser, intensive spot treatment, and blemish clearing hydrator. In addition to salicylic acid, Benzac also contains Kakadu plum (an antioxidant) to brighten the skin, lemon myrtle (an astringent) to reduce excess oil, and zinc to act as a barrier against skin moisture loss. Benzac contains pharmaceutical-grade East Indian sandalwood oil to calm and soothe the skin. For more information, visit www.benzac.com.

The Promius Promise App

Promius Pharma, LLC, marketers of Zenatane (isotretinoin capsules), launches The Promius Promise App designed to help educate and guide patients through the iPLEDGE program from the first visit to the last visit. The app is free for patients who have received a Zenatane prescription through The Promius Promise program. Patients can easily find important information, which may help with treatment compliance. The app will be useful for young adults and teenagers as well as their parents. For more information, visit www.zenatane.com/toolkit/Promius-Promise-Enrollment-Form.php.

Soolantra

Galderma Laboratories, LP, announces US Food and Drug Administration approval of Soolantra Cream 1% for the once-daily treatment of inflammatory lesions of rosacea. Ivermectin, the active ingredient in Soolantra, has both anti-inflammatory and antiparasitic activity. The basis for the cream formulation is Cetaphil Moisturizing Cream. Soolantra offers patients improvement as early as week 2 of treatment. For more information, visit www.soolantra.com/hcp.

If you would like your product included in Product News, please e-mail a press release to the Editorial Office at cutis@frontlinemedcom.com.

Bellafill

Suneva Medical, Inc, announces US Food and Drug Administration approval of the polymethylmethacrylate collagen filler Bellafill for the correction of moderate to severe, atrophic, distensible facial acne scars on the cheek in patients older than 21 years. Bellafill adds volume to the skin to lift and smooth out pitted acne scars to the level of the surrounding skin. Bellafill also is indicated for correction of nasolabial folds. For more information, visit www.bellafill.com.

Benzac

Galderma Laboratories, LP, launches Benzac Acne Solutions, an over-the-counter 3-step acne regimen consisting of a skin balancing foaming cleanser, intensive spot treatment, and blemish clearing hydrator. In addition to salicylic acid, Benzac also contains Kakadu plum (an antioxidant) to brighten the skin, lemon myrtle (an astringent) to reduce excess oil, and zinc to act as a barrier against skin moisture loss. Benzac contains pharmaceutical-grade East Indian sandalwood oil to calm and soothe the skin. For more information, visit www.benzac.com.

The Promius Promise App

Promius Pharma, LLC, marketers of Zenatane (isotretinoin capsules), launches The Promius Promise App designed to help educate and guide patients through the iPLEDGE program from the first visit to the last visit. The app is free for patients who have received a Zenatane prescription through The Promius Promise program. Patients can easily find important information, which may help with treatment compliance. The app will be useful for young adults and teenagers as well as their parents. For more information, visit www.zenatane.com/toolkit/Promius-Promise-Enrollment-Form.php.

Soolantra

Galderma Laboratories, LP, announces US Food and Drug Administration approval of Soolantra Cream 1% for the once-daily treatment of inflammatory lesions of rosacea. Ivermectin, the active ingredient in Soolantra, has both anti-inflammatory and antiparasitic activity. The basis for the cream formulation is Cetaphil Moisturizing Cream. Soolantra offers patients improvement as early as week 2 of treatment. For more information, visit www.soolantra.com/hcp.

If you would like your product included in Product News, please e-mail a press release to the Editorial Office at cutis@frontlinemedcom.com.

The phenomenon of natural (nonchemically treated) hair in individuals of African and Afro-Caribbean descent is sweeping across the United States. The ideals of beauty among this patient population have shifted from a relaxed, straightened, noncurly look to a more natural curly and/or kinky appearance. The discussion on natural hair versus straight hair has been brought to the mainstream by films such as Good Hair (2009). Furthermore, major hair care companies have increased their marketing of natural hair products to address the needs of these patients.

Popular traumatic hair care practices such as chemical relaxation and thermal straightening may lead to hair damage. Although the role of hair care practices in various scalp and hair disorders is ambiguous, traumatic practices commonly are performed by patients who are diagnosed with dermatologic conditions such as scarring alopecia.¹ Alopecia is the fourth most common dermatologic diagnosis in black patients.² Central centrifugal cicatricial alopecia is the most common form of scarring alopecia in this patient population³ and has been associated with traumatic hair care practices. As a result, many patients have switched to natural hairstyles that are less traumatic and damaging, often due to recommendations by dermatologists.

As the US population continues to become more diverse, dermatologists will be faced with many questions regarding hair disease and natural hair care in patients with skin of color. A basic understanding of hair care practices among black individuals is important to aid in the diagnosis and treatment of hair shaft and scalp disorders.⁴ When patients switch to natural hairstyles, are dermatologists prepared to answer questions that may arise during this process? This article will familiarize dermatologists with basic hair care terminology and general recommendations they can make to black patients who are transitioning to natural hairstyles.

Characteristics of Hair in the Skin of Color Population

A basic understanding of the structural properties of hair is fundamental. Human hair is categorized into 3 groups: Asian, Caucasian, and African.⁵ African hair typically is curly and, depending on the degree of the curl, is more susceptible to damage due to increased mechanical fragility. It also has a tendency to form knots and fissures along the hair shaft, which causes additional fracturing with simple manipulation. African hair grows more slowly than Asian and Caucasian hair, which can be discouraging to patients. It also has a lower water concentration and does not become coated with sebum as naturally as straightened hair.⁵ A simplified explanation of these characteristics can help patients understand how to proceed in managing and styling their natural hair.

As physicians, it is important for us to treat any underlying conditions related to the hair and scalp in black patients. Common dermatologic conditions such as seborrheic dermatitis, lupus, folliculitis, and alopecia can affect patients’ hair health. In addition to traumatic hair care practices, inflammation secondary to bacterial infections can contribute to the onset of central centrifugal cicatricial alopecia.⁶ Therefore, a detailed history and physical examination are needed to evaluate the etiology of associated symptoms. Treatment of these associated symptoms will aid in the overall care of patients.

Transitioning to Natural Hairstyles

Following evaluation and treatment of any hair or scalp conditions, how can dermatologists help black patients transition to natural hairstyles? The term transition refers to the process of switching from a chemically relaxed or thermally straightened hairstyle to a natural hairstyle. Dermatologists must understand the common terminology used to describe natural hair practices in this patient population.

There are several methods patients can use to transition from chemically treated hairstyles to natural hairstyles. Patients may consider the option of the “big chop,” or cutting off all chemically treated hair. This option typically leaves women with very short hairstyles down to the new growth, or hair that has grown since the last chemical relaxer. Other commonly used methods during the transition phase include protective styling (eg, braids, weaves, extensions) or simply growing out the chemically treated hair.

Protective styling methods such as braids, weaves, and extensions allow hair to be easily styled while the chemically treated hair grows out over time.⁷ Typically, protective styles may be worn for weeks to months, allowing hair growth without hair breakage and shedding. Hair weaving is a practice that incorporates artificial (synthetic) or human hair into one’s natural scalp hair.⁸ There are various techniques to extend hair including clip-in extensions, hair bonding and fusion with adhesives, sewing hair into braided hair, or the application of single strands of hair into a cap made of nylon mesh known as a lace front. Braided styles, weaves, and hair extensions cannot be washed as often as natural hair, but it is important to remind patients to replenish moisture as often as possible. Moisturizing or greasing the exposed scalp and proximal hair shafts can assist with water retention. It is imperative to inform patients that overuse of tight braids and glues for weaves and extensions may further damage the hair and scalp. Some of the natural ingredients commonly used in moisturizers include olive oil, jojoba oil, coconut oil, castor oil, and glycerin. These products can commonly cause pomade acne, which should be recognized and treated by dermatologists. Furthermore, long weaves and extensions can put excess weight on natural hair causing breakage. To prevent breakage, wearing an updo (a hairstyle in which the hair is pulled upward) can reduce the heavy strain on the hair.

Dermatologists should remind patients who wish to grow out chemically treated hair to frequently moisturize the hair and scalp as well as to avoid trauma to prevent hair breakage. As the natural hair grows out, the patient will experience varying hair textures from the natural curly hair to the previously processed straightened hair; as a result, the hair may tangle and become damaged. Manual detangling and detangling conditioners can help prevent damage. Patients should be advised to detangle the hair in sections first with the fingers, then with a wide-tooth comb working retrograde from the hair end to the roots.

Frequent hair trimming, ranging from every 4 to 6 weeks to every 2 to 4 months, should be recommended to patients who are experiencing breakage or wish to prevent damage. Trimming damaged hair can relieve excess weight on the natural hair and remove split ends, which promotes hair growth. Braiding and other lengthening techniques can prevent the hair from curling upon itself or tangling, causing less kinking and thereby decreasing the need for trimming.⁷ Wearing bonnets, using satin pillowcases, and wearing protective hairstyles while sleeping also can decrease hair breakage and hair loss. A commonly used hairstyle to protect the hair while sleeping is called “pineappling,” which is used to preserve and protect curls. This technique is described as gathering the hair in a high but loose ponytail at the top of the head. For patients with straightened hair, wrapping the hair underneath a bonnet or satin scarf while sleeping can prevent damage.

Managing Natural Hairstyles

An important factor in the management of natural hairstyles is the retention of hair moisture, as there is less water content in African hair compared to other hair types.⁵ Overuse of heat and harsh shampoos can strip moisture from the hair. Similar to patients with atopic dermatitis who should restore and maintain the skin barrier to prevent transepidermal water loss, it is important to remind patients with natural hairstyles to avoid using products and styling practices that may further deplete water content in the hair. Moisture is crucial to healthy hair.

A common culprit in shampoos that leads to hair dryness is sodium lauryl sulfate/sodium laureth sulfate, a detergent/surfactant used as a foaming agent. Sodium lauryl sulfate is a potent degreaser that binds dirt and excess product on the hair and scalp. It also dissolves oil in the hair, causing additional dryness and breakage.

Patients with natural hairstyles commonly use sulfate-free shampoos to prevent stripping the hair of its moisture and natural oils. Another method used to prevent hair dryness is co-washing, or washing the hair with a conditioner. Co-washing can effectively cleanse the hair while maintaining moisture. The use of cationic ingredients in conditioners aids in sealing moisture within the hair shaft. Hair consists of the negatively charged protein keratin, which binds to cationic surfactants in conditioners.⁹ The hydrophobic ends of the surfactant prevent the substance from being rinsed out and act to restore the hair barrier.

Silicone is another important ingredient in hair care products. In patients with natural hair, there are varying views on the use of products containing silicone. Silicones are added to products designed to coat the hair, adding shine, retaining moisture, and providing thermal protection. Silicones are used to provide “slip.” Slip is a term that is commonly used among patients with natural hair to describe how slippery a product is and how easily the product will help comb or detangle the hair. There are 2 basic types of silicones: water insoluble and water soluble. Water-insoluble silicones traditionally build up on the hair and require surfactant-containing shampoos to becompletely removed. Residue buildup on the hair weighs the hair down and causes damage. In contrast, water-soluble silicones do not build up and typically do not cause damage.

Silicones with the prefixes PEG- or PPG- typically are water soluble and will not build up on the hair. Dimethicone copolyol and lauryl methicone copolyol are other water-soluble silicones. In general, water-soluble silicones provide moisturizing properties without leaving residue. Other silicones such as amodimethicone and cyclomethicone are not water soluble but have properties that prevent buildup.

It is common practice for patients with natural hairstyles to avoid using water-insoluble silicones. As dermatologists, we can recommend silicone-free conditioners or conditioners containing water-soluble silicones to prevent hair dehydration and subsequent breakage. It may be advantageous to have patients try various products to determine which ones work best for their hair.

More Resources for Patients

Dermatologists have extensive knowledge of the pathophysiology of skin, hair, and nail diseases; however, despite our vast knowledge, we also need to recognize our limits. In addition to increasing your own knowledge of natural hair care practices to help your patients, it is important to recommend that your patients search for additional resources to aid in their transition to natural hairstyles. Natural hairstylists can be great resources for patients to help with hair management. In the current digital age, there also are thousands of blogs and social media forums dedicated to the topic of natural hair care. Advising patients to consult natural hair care resources can be beneficial, but as hair specialists, it also is important for us to dispel any false information that our patients may receive. As physicians, it is essential not only to manage patients who present to our offices with conditions resulting from damaging hair practices but also to help prevent such conditions from occurring. Although there may not be an overwhelming amount of evidence-based medical research to guide our decisions, we also can learn from the thousands of patients who have articulated their stories and experiences. Through observing and listening to our patients, we can incorporate this new knowledge in the management of our patients.

The phenomenon of natural (nonchemically treated) hair in individuals of African and Afro-Caribbean descent is sweeping across the United States. The ideals of beauty among this patient population have shifted from a relaxed, straightened, noncurly look to a more natural curly and/or kinky appearance. The discussion on natural hair versus straight hair has been brought to the mainstream by films such as Good Hair (2009). Furthermore, major hair care companies have increased their marketing of natural hair products to address the needs of these patients.

Popular traumatic hair care practices such as chemical relaxation and thermal straightening may lead to hair damage. Although the role of hair care practices in various scalp and hair disorders is ambiguous, traumatic practices commonly are performed by patients who are diagnosed with dermatologic conditions such as scarring alopecia.¹ Alopecia is the fourth most common dermatologic diagnosis in black patients.² Central centrifugal cicatricial alopecia is the most common form of scarring alopecia in this patient population³ and has been associated with traumatic hair care practices. As a result, many patients have switched to natural hairstyles that are less traumatic and damaging, often due to recommendations by dermatologists.

As the US population continues to become more diverse, dermatologists will be faced with many questions regarding hair disease and natural hair care in patients with skin of color. A basic understanding of hair care practices among black individuals is important to aid in the diagnosis and treatment of hair shaft and scalp disorders.⁴ When patients switch to natural hairstyles, are dermatologists prepared to answer questions that may arise during this process? This article will familiarize dermatologists with basic hair care terminology and general recommendations they can make to black patients who are transitioning to natural hairstyles.

Characteristics of Hair in the Skin of Color Population

A basic understanding of the structural properties of hair is fundamental. Human hair is categorized into 3 groups: Asian, Caucasian, and African.⁵ African hair typically is curly and, depending on the degree of the curl, is more susceptible to damage due to increased mechanical fragility. It also has a tendency to form knots and fissures along the hair shaft, which causes additional fracturing with simple manipulation. African hair grows more slowly than Asian and Caucasian hair, which can be discouraging to patients. It also has a lower water concentration and does not become coated with sebum as naturally as straightened hair.⁵ A simplified explanation of these characteristics can help patients understand how to proceed in managing and styling their natural hair.

As physicians, it is important for us to treat any underlying conditions related to the hair and scalp in black patients. Common dermatologic conditions such as seborrheic dermatitis, lupus, folliculitis, and alopecia can affect patients’ hair health. In addition to traumatic hair care practices, inflammation secondary to bacterial infections can contribute to the onset of central centrifugal cicatricial alopecia.⁶ Therefore, a detailed history and physical examination are needed to evaluate the etiology of associated symptoms. Treatment of these associated symptoms will aid in the overall care of patients.

Transitioning to Natural Hairstyles

Following evaluation and treatment of any hair or scalp conditions, how can dermatologists help black patients transition to natural hairstyles? The term transition refers to the process of switching from a chemically relaxed or thermally straightened hairstyle to a natural hairstyle. Dermatologists must understand the common terminology used to describe natural hair practices in this patient population.

There are several methods patients can use to transition from chemically treated hairstyles to natural hairstyles. Patients may consider the option of the “big chop,” or cutting off all chemically treated hair. This option typically leaves women with very short hairstyles down to the new growth, or hair that has grown since the last chemical relaxer. Other commonly used methods during the transition phase include protective styling (eg, braids, weaves, extensions) or simply growing out the chemically treated hair.

Protective styling methods such as braids, weaves, and extensions allow hair to be easily styled while the chemically treated hair grows out over time.⁷ Typically, protective styles may be worn for weeks to months, allowing hair growth without hair breakage and shedding. Hair weaving is a practice that incorporates artificial (synthetic) or human hair into one’s natural scalp hair.⁸ There are various techniques to extend hair including clip-in extensions, hair bonding and fusion with adhesives, sewing hair into braided hair, or the application of single strands of hair into a cap made of nylon mesh known as a lace front. Braided styles, weaves, and hair extensions cannot be washed as often as natural hair, but it is important to remind patients to replenish moisture as often as possible. Moisturizing or greasing the exposed scalp and proximal hair shafts can assist with water retention. It is imperative to inform patients that overuse of tight braids and glues for weaves and extensions may further damage the hair and scalp. Some of the natural ingredients commonly used in moisturizers include olive oil, jojoba oil, coconut oil, castor oil, and glycerin. These products can commonly cause pomade acne, which should be recognized and treated by dermatologists. Furthermore, long weaves and extensions can put excess weight on natural hair causing breakage. To prevent breakage, wearing an updo (a hairstyle in which the hair is pulled upward) can reduce the heavy strain on the hair.

Dermatologists should remind patients who wish to grow out chemically treated hair to frequently moisturize the hair and scalp as well as to avoid trauma to prevent hair breakage. As the natural hair grows out, the patient will experience varying hair textures from the natural curly hair to the previously processed straightened hair; as a result, the hair may tangle and become damaged. Manual detangling and detangling conditioners can help prevent damage. Patients should be advised to detangle the hair in sections first with the fingers, then with a wide-tooth comb working retrograde from the hair end to the roots.

Frequent hair trimming, ranging from every 4 to 6 weeks to every 2 to 4 months, should be recommended to patients who are experiencing breakage or wish to prevent damage. Trimming damaged hair can relieve excess weight on the natural hair and remove split ends, which promotes hair growth. Braiding and other lengthening techniques can prevent the hair from curling upon itself or tangling, causing less kinking and thereby decreasing the need for trimming.⁷ Wearing bonnets, using satin pillowcases, and wearing protective hairstyles while sleeping also can decrease hair breakage and hair loss. A commonly used hairstyle to protect the hair while sleeping is called “pineappling,” which is used to preserve and protect curls. This technique is described as gathering the hair in a high but loose ponytail at the top of the head. For patients with straightened hair, wrapping the hair underneath a bonnet or satin scarf while sleeping can prevent damage.

Managing Natural Hairstyles

An important factor in the management of natural hairstyles is the retention of hair moisture, as there is less water content in African hair compared to other hair types.⁵ Overuse of heat and harsh shampoos can strip moisture from the hair. Similar to patients with atopic dermatitis who should restore and maintain the skin barrier to prevent transepidermal water loss, it is important to remind patients with natural hairstyles to avoid using products and styling practices that may further deplete water content in the hair. Moisture is crucial to healthy hair.

A common culprit in shampoos that leads to hair dryness is sodium lauryl sulfate/sodium laureth sulfate, a detergent/surfactant used as a foaming agent. Sodium lauryl sulfate is a potent degreaser that binds dirt and excess product on the hair and scalp. It also dissolves oil in the hair, causing additional dryness and breakage.

Patients with natural hairstyles commonly use sulfate-free shampoos to prevent stripping the hair of its moisture and natural oils. Another method used to prevent hair dryness is co-washing, or washing the hair with a conditioner. Co-washing can effectively cleanse the hair while maintaining moisture. The use of cationic ingredients in conditioners aids in sealing moisture within the hair shaft. Hair consists of the negatively charged protein keratin, which binds to cationic surfactants in conditioners.⁹ The hydrophobic ends of the surfactant prevent the substance from being rinsed out and act to restore the hair barrier.

Silicone is another important ingredient in hair care products. In patients with natural hair, there are varying views on the use of products containing silicone. Silicones are added to products designed to coat the hair, adding shine, retaining moisture, and providing thermal protection. Silicones are used to provide “slip.” Slip is a term that is commonly used among patients with natural hair to describe how slippery a product is and how easily the product will help comb or detangle the hair. There are 2 basic types of silicones: water insoluble and water soluble. Water-insoluble silicones traditionally build up on the hair and require surfactant-containing shampoos to becompletely removed. Residue buildup on the hair weighs the hair down and causes damage. In contrast, water-soluble silicones do not build up and typically do not cause damage.

Silicones with the prefixes PEG- or PPG- typically are water soluble and will not build up on the hair. Dimethicone copolyol and lauryl methicone copolyol are other water-soluble silicones. In general, water-soluble silicones provide moisturizing properties without leaving residue. Other silicones such as amodimethicone and cyclomethicone are not water soluble but have properties that prevent buildup.

It is common practice for patients with natural hairstyles to avoid using water-insoluble silicones. As dermatologists, we can recommend silicone-free conditioners or conditioners containing water-soluble silicones to prevent hair dehydration and subsequent breakage. It may be advantageous to have patients try various products to determine which ones work best for their hair.

More Resources for Patients

Dermatologists have extensive knowledge of the pathophysiology of skin, hair, and nail diseases; however, despite our vast knowledge, we also need to recognize our limits. In addition to increasing your own knowledge of natural hair care practices to help your patients, it is important to recommend that your patients search for additional resources to aid in their transition to natural hairstyles. Natural hairstylists can be great resources for patients to help with hair management. In the current digital age, there also are thousands of blogs and social media forums dedicated to the topic of natural hair care. Advising patients to consult natural hair care resources can be beneficial, but as hair specialists, it also is important for us to dispel any false information that our patients may receive. As physicians, it is essential not only to manage patients who present to our offices with conditions resulting from damaging hair practices but also to help prevent such conditions from occurring. Although there may not be an overwhelming amount of evidence-based medical research to guide our decisions, we also can learn from the thousands of patients who have articulated their stories and experiences. Through observing and listening to our patients, we can incorporate this new knowledge in the management of our patients.

The phenomenon of natural (nonchemically treated) hair in individuals of African and Afro-Caribbean descent is sweeping across the United States. The ideals of beauty among this patient population have shifted from a relaxed, straightened, noncurly look to a more natural curly and/or kinky appearance. The discussion on natural hair versus straight hair has been brought to the mainstream by films such as Good Hair (2009). Furthermore, major hair care companies have increased their marketing of natural hair products to address the needs of these patients.

Popular traumatic hair care practices such as chemical relaxation and thermal straightening may lead to hair damage. Although the role of hair care practices in various scalp and hair disorders is ambiguous, traumatic practices commonly are performed by patients who are diagnosed with dermatologic conditions such as scarring alopecia.¹ Alopecia is the fourth most common dermatologic diagnosis in black patients.² Central centrifugal cicatricial alopecia is the most common form of scarring alopecia in this patient population³ and has been associated with traumatic hair care practices. As a result, many patients have switched to natural hairstyles that are less traumatic and damaging, often due to recommendations by dermatologists.

As the US population continues to become more diverse, dermatologists will be faced with many questions regarding hair disease and natural hair care in patients with skin of color. A basic understanding of hair care practices among black individuals is important to aid in the diagnosis and treatment of hair shaft and scalp disorders.⁴ When patients switch to natural hairstyles, are dermatologists prepared to answer questions that may arise during this process? This article will familiarize dermatologists with basic hair care terminology and general recommendations they can make to black patients who are transitioning to natural hairstyles.

Characteristics of Hair in the Skin of Color Population

A basic understanding of the structural properties of hair is fundamental. Human hair is categorized into 3 groups: Asian, Caucasian, and African.⁵ African hair typically is curly and, depending on the degree of the curl, is more susceptible to damage due to increased mechanical fragility. It also has a tendency to form knots and fissures along the hair shaft, which causes additional fracturing with simple manipulation. African hair grows more slowly than Asian and Caucasian hair, which can be discouraging to patients. It also has a lower water concentration and does not become coated with sebum as naturally as straightened hair.⁵ A simplified explanation of these characteristics can help patients understand how to proceed in managing and styling their natural hair.

As physicians, it is important for us to treat any underlying conditions related to the hair and scalp in black patients. Common dermatologic conditions such as seborrheic dermatitis, lupus, folliculitis, and alopecia can affect patients’ hair health. In addition to traumatic hair care practices, inflammation secondary to bacterial infections can contribute to the onset of central centrifugal cicatricial alopecia.⁶ Therefore, a detailed history and physical examination are needed to evaluate the etiology of associated symptoms. Treatment of these associated symptoms will aid in the overall care of patients.

Transitioning to Natural Hairstyles

Following evaluation and treatment of any hair or scalp conditions, how can dermatologists help black patients transition to natural hairstyles? The term transition refers to the process of switching from a chemically relaxed or thermally straightened hairstyle to a natural hairstyle. Dermatologists must understand the common terminology used to describe natural hair practices in this patient population.

There are several methods patients can use to transition from chemically treated hairstyles to natural hairstyles. Patients may consider the option of the “big chop,” or cutting off all chemically treated hair. This option typically leaves women with very short hairstyles down to the new growth, or hair that has grown since the last chemical relaxer. Other commonly used methods during the transition phase include protective styling (eg, braids, weaves, extensions) or simply growing out the chemically treated hair.

Protective styling methods such as braids, weaves, and extensions allow hair to be easily styled while the chemically treated hair grows out over time.⁷ Typically, protective styles may be worn for weeks to months, allowing hair growth without hair breakage and shedding. Hair weaving is a practice that incorporates artificial (synthetic) or human hair into one’s natural scalp hair.⁸ There are various techniques to extend hair including clip-in extensions, hair bonding and fusion with adhesives, sewing hair into braided hair, or the application of single strands of hair into a cap made of nylon mesh known as a lace front. Braided styles, weaves, and hair extensions cannot be washed as often as natural hair, but it is important to remind patients to replenish moisture as often as possible. Moisturizing or greasing the exposed scalp and proximal hair shafts can assist with water retention. It is imperative to inform patients that overuse of tight braids and glues for weaves and extensions may further damage the hair and scalp. Some of the natural ingredients commonly used in moisturizers include olive oil, jojoba oil, coconut oil, castor oil, and glycerin. These products can commonly cause pomade acne, which should be recognized and treated by dermatologists. Furthermore, long weaves and extensions can put excess weight on natural hair causing breakage. To prevent breakage, wearing an updo (a hairstyle in which the hair is pulled upward) can reduce the heavy strain on the hair.

Dermatologists should remind patients who wish to grow out chemically treated hair to frequently moisturize the hair and scalp as well as to avoid trauma to prevent hair breakage. As the natural hair grows out, the patient will experience varying hair textures from the natural curly hair to the previously processed straightened hair; as a result, the hair may tangle and become damaged. Manual detangling and detangling conditioners can help prevent damage. Patients should be advised to detangle the hair in sections first with the fingers, then with a wide-tooth comb working retrograde from the hair end to the roots.

Frequent hair trimming, ranging from every 4 to 6 weeks to every 2 to 4 months, should be recommended to patients who are experiencing breakage or wish to prevent damage. Trimming damaged hair can relieve excess weight on the natural hair and remove split ends, which promotes hair growth. Braiding and other lengthening techniques can prevent the hair from curling upon itself or tangling, causing less kinking and thereby decreasing the need for trimming.⁷ Wearing bonnets, using satin pillowcases, and wearing protective hairstyles while sleeping also can decrease hair breakage and hair loss. A commonly used hairstyle to protect the hair while sleeping is called “pineappling,” which is used to preserve and protect curls. This technique is described as gathering the hair in a high but loose ponytail at the top of the head. For patients with straightened hair, wrapping the hair underneath a bonnet or satin scarf while sleeping can prevent damage.

Managing Natural Hairstyles

An important factor in the management of natural hairstyles is the retention of hair moisture, as there is less water content in African hair compared to other hair types.⁵ Overuse of heat and harsh shampoos can strip moisture from the hair. Similar to patients with atopic dermatitis who should restore and maintain the skin barrier to prevent transepidermal water loss, it is important to remind patients with natural hairstyles to avoid using products and styling practices that may further deplete water content in the hair. Moisture is crucial to healthy hair.

A common culprit in shampoos that leads to hair dryness is sodium lauryl sulfate/sodium laureth sulfate, a detergent/surfactant used as a foaming agent. Sodium lauryl sulfate is a potent degreaser that binds dirt and excess product on the hair and scalp. It also dissolves oil in the hair, causing additional dryness and breakage.

Patients with natural hairstyles commonly use sulfate-free shampoos to prevent stripping the hair of its moisture and natural oils. Another method used to prevent hair dryness is co-washing, or washing the hair with a conditioner. Co-washing can effectively cleanse the hair while maintaining moisture. The use of cationic ingredients in conditioners aids in sealing moisture within the hair shaft. Hair consists of the negatively charged protein keratin, which binds to cationic surfactants in conditioners.⁹ The hydrophobic ends of the surfactant prevent the substance from being rinsed out and act to restore the hair barrier.

Silicone is another important ingredient in hair care products. In patients with natural hair, there are varying views on the use of products containing silicone. Silicones are added to products designed to coat the hair, adding shine, retaining moisture, and providing thermal protection. Silicones are used to provide “slip.” Slip is a term that is commonly used among patients with natural hair to describe how slippery a product is and how easily the product will help comb or detangle the hair. There are 2 basic types of silicones: water insoluble and water soluble. Water-insoluble silicones traditionally build up on the hair and require surfactant-containing shampoos to becompletely removed. Residue buildup on the hair weighs the hair down and causes damage. In contrast, water-soluble silicones do not build up and typically do not cause damage.

Silicones with the prefixes PEG- or PPG- typically are water soluble and will not build up on the hair. Dimethicone copolyol and lauryl methicone copolyol are other water-soluble silicones. In general, water-soluble silicones provide moisturizing properties without leaving residue. Other silicones such as amodimethicone and cyclomethicone are not water soluble but have properties that prevent buildup.

It is common practice for patients with natural hairstyles to avoid using water-insoluble silicones. As dermatologists, we can recommend silicone-free conditioners or conditioners containing water-soluble silicones to prevent hair dehydration and subsequent breakage. It may be advantageous to have patients try various products to determine which ones work best for their hair.

More Resources for Patients

Dermatologists have extensive knowledge of the pathophysiology of skin, hair, and nail diseases; however, despite our vast knowledge, we also need to recognize our limits. In addition to increasing your own knowledge of natural hair care practices to help your patients, it is important to recommend that your patients search for additional resources to aid in their transition to natural hairstyles. Natural hairstylists can be great resources for patients to help with hair management. In the current digital age, there also are thousands of blogs and social media forums dedicated to the topic of natural hair care. Advising patients to consult natural hair care resources can be beneficial, but as hair specialists, it also is important for us to dispel any false information that our patients may receive. As physicians, it is essential not only to manage patients who present to our offices with conditions resulting from damaging hair practices but also to help prevent such conditions from occurring. Although there may not be an overwhelming amount of evidence-based medical research to guide our decisions, we also can learn from the thousands of patients who have articulated their stories and experiences. Through observing and listening to our patients, we can incorporate this new knowledge in the management of our patients.

According to Current Procedural Terminology (CPT), modifier -25 is to be used to identify “significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.”¹ Modifier -25 frequently is integral to the description of patient visits in dermatology. Dermatologists use modifier -25 more than physicians of any other specialty, and in recent years, more than 50% of dermatology evaluation and management (E/M) visits have been appended with this modifier.

When patients present for assessment and management of various skin findings, a dermatologist may deem it appropriate to proceed with a diagnostic or therapeutic procedure at the same visit after obtaining the patient’s medical history, completing a review of systems, and conducting a clinical examination. Most commonly, a skin biopsy or destruction of a benign or malignant lesion may be performed, but other simple procedures also may be appropriate. The ability to assess and intervene during the same visit is optimal for patients who subsequently may require fewer follow-up visits and experience more immediate relief from their symptoms.

When E/M Cannot Be Billed Separately

Regulatory guidance from the National Correct Coding Initiative (NCCI) dated January 2013 indicates that procedures with a global period of 90 days are major surgical procedures, and if an E/M service is performed on the same day as such a procedure to decide whether or not to perform that procedure, then the E/M service should be reported with modifier -57.² On the other hand, CPT defines procedures with a 0- or 10-day global period as minor surgical procedures, and E/M services provided on the same day of service as these procedures are included in the procedure code and cannot be billed separately. For review, common dermatologic procedures with 0-day global periods include biopsies (CPT code 11000), shave removals (11300–11313), debridements (11000, 11011–11042), and Mohs micrographic surgery (17311–17315); procedures with 10-day global periods include destructions (17000–17286), excisions (11400–11646), and repairs (12001–13153). If an E/M service is performed on the same day as one of these procedures to decide whether to proceed with the minor surgical procedure, this E/M service cannot be reported separately. Additionally, the fact that the patient is new to the physician is not sufficient to allow reporting of an E/M with such a minor procedure.

When E/M Can Be Billed Separately

However, a “significant and separately identifiable E/M service unrelated to the decision to perform the minor procedure” is separately reportable with modifier -25. According to the NCCI, the minor procedure and the E/M do not require different diagnoses, but the E/M service must be above and beyond what is usually required for the minor surgical procedure.² Because a certain amount of so-called preservice time is built into minor procedure codes, the implication is that substantially more E/M was needed than envisioned in this preservice time, necessitating inclusion of an E/M in addition to a minor procedure when there is a single diagnosis.

When there is a single diagnosis, the physician has to decide when such a significant and separately identifiable service exists. If the physician determines that it is appropriate to code for E/M in addition to the minor procedure, clear documentation of the additional E/M service provided will reduce the likelihood of this choice being questioned. Specifically, it may be helpful to describe the additional history, examination results, medical knowledge, professional skill, and work time above and beyond what is usually required for the minor surgical procedure.

When there are many diagnosis codes for a single visit and only a subset of them are associated with the minor procedure, as is common in dermatology, then the decision to include an E/M service is simpler. In this case, if E/M services were provided that pertained to a diagnosis or diagnoses other than the one(s) associated with the minor procedure(s), then these additional E/M services will clearly not be included in the preservice time for the procedure and an E/M can virtually always be coded separately. For instance, if a patient presents with a growing scaly bump (clinically apparent squamous cell carcinoma) on the leg that the dermatologist deems is appropriate for biopsy but concurrently notices nummular dermatitis of the legs, which the patient describes as itchy and uncomfortable, then the diagnosis and management of the dermatitis would clearly be a separate E/M service and would not be included in the workup for the biopsy. The E/M code that is applied should, of course, reflect the services provided exclusive of those integral to the minor procedure. To make it easier for regulators and auditors, it may be helpful to clearly itemize the additional diagnoses unrelated to the minor procedure and describe the specific E/M services provided for these diagnoses. Although it is certainly not necessary or required, it also may be helpful to physically separate the documentation for the minor procedure from the E/M services for the additional diagnoses within the medical chart.

Final Thoughts

It is clear that frequent use of modifier -25 is appropriate in routine, high-quality dermatologic practice. Simultaneous provision of E/M services and minor procedures often is in the patient’s best interest, as it minimizes unnecessary office visits and expedites treatment. When modifier -25 is appropriately appended, careful documentation by the dermatologist can help to clarify the precise basis for its use. Recent NCCI edits provide guidelines for use of this modifier that can be adapted by individual dermatologists for particular patient circumstances.²

According to Current Procedural Terminology (CPT), modifier -25 is to be used to identify “significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.”¹ Modifier -25 frequently is integral to the description of patient visits in dermatology. Dermatologists use modifier -25 more than physicians of any other specialty, and in recent years, more than 50% of dermatology evaluation and management (E/M) visits have been appended with this modifier.

When patients present for assessment and management of various skin findings, a dermatologist may deem it appropriate to proceed with a diagnostic or therapeutic procedure at the same visit after obtaining the patient’s medical history, completing a review of systems, and conducting a clinical examination. Most commonly, a skin biopsy or destruction of a benign or malignant lesion may be performed, but other simple procedures also may be appropriate. The ability to assess and intervene during the same visit is optimal for patients who subsequently may require fewer follow-up visits and experience more immediate relief from their symptoms.

When E/M Cannot Be Billed Separately

Regulatory guidance from the National Correct Coding Initiative (NCCI) dated January 2013 indicates that procedures with a global period of 90 days are major surgical procedures, and if an E/M service is performed on the same day as such a procedure to decide whether or not to perform that procedure, then the E/M service should be reported with modifier -57.² On the other hand, CPT defines procedures with a 0- or 10-day global period as minor surgical procedures, and E/M services provided on the same day of service as these procedures are included in the procedure code and cannot be billed separately. For review, common dermatologic procedures with 0-day global periods include biopsies (CPT code 11000), shave removals (11300–11313), debridements (11000, 11011–11042), and Mohs micrographic surgery (17311–17315); procedures with 10-day global periods include destructions (17000–17286), excisions (11400–11646), and repairs (12001–13153). If an E/M service is performed on the same day as one of these procedures to decide whether to proceed with the minor surgical procedure, this E/M service cannot be reported separately. Additionally, the fact that the patient is new to the physician is not sufficient to allow reporting of an E/M with such a minor procedure.

When E/M Can Be Billed Separately

However, a “significant and separately identifiable E/M service unrelated to the decision to perform the minor procedure” is separately reportable with modifier -25. According to the NCCI, the minor procedure and the E/M do not require different diagnoses, but the E/M service must be above and beyond what is usually required for the minor surgical procedure.² Because a certain amount of so-called preservice time is built into minor procedure codes, the implication is that substantially more E/M was needed than envisioned in this preservice time, necessitating inclusion of an E/M in addition to a minor procedure when there is a single diagnosis.

When there is a single diagnosis, the physician has to decide when such a significant and separately identifiable service exists. If the physician determines that it is appropriate to code for E/M in addition to the minor procedure, clear documentation of the additional E/M service provided will reduce the likelihood of this choice being questioned. Specifically, it may be helpful to describe the additional history, examination results, medical knowledge, professional skill, and work time above and beyond what is usually required for the minor surgical procedure.

When there are many diagnosis codes for a single visit and only a subset of them are associated with the minor procedure, as is common in dermatology, then the decision to include an E/M service is simpler. In this case, if E/M services were provided that pertained to a diagnosis or diagnoses other than the one(s) associated with the minor procedure(s), then these additional E/M services will clearly not be included in the preservice time for the procedure and an E/M can virtually always be coded separately. For instance, if a patient presents with a growing scaly bump (clinically apparent squamous cell carcinoma) on the leg that the dermatologist deems is appropriate for biopsy but concurrently notices nummular dermatitis of the legs, which the patient describes as itchy and uncomfortable, then the diagnosis and management of the dermatitis would clearly be a separate E/M service and would not be included in the workup for the biopsy. The E/M code that is applied should, of course, reflect the services provided exclusive of those integral to the minor procedure. To make it easier for regulators and auditors, it may be helpful to clearly itemize the additional diagnoses unrelated to the minor procedure and describe the specific E/M services provided for these diagnoses. Although it is certainly not necessary or required, it also may be helpful to physically separate the documentation for the minor procedure from the E/M services for the additional diagnoses within the medical chart.

Final Thoughts

It is clear that frequent use of modifier -25 is appropriate in routine, high-quality dermatologic practice. Simultaneous provision of E/M services and minor procedures often is in the patient’s best interest, as it minimizes unnecessary office visits and expedites treatment. When modifier -25 is appropriately appended, careful documentation by the dermatologist can help to clarify the precise basis for its use. Recent NCCI edits provide guidelines for use of this modifier that can be adapted by individual dermatologists for particular patient circumstances.²

According to Current Procedural Terminology (CPT), modifier -25 is to be used to identify “significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.”¹ Modifier -25 frequently is integral to the description of patient visits in dermatology. Dermatologists use modifier -25 more than physicians of any other specialty, and in recent years, more than 50% of dermatology evaluation and management (E/M) visits have been appended with this modifier.

When patients present for assessment and management of various skin findings, a dermatologist may deem it appropriate to proceed with a diagnostic or therapeutic procedure at the same visit after obtaining the patient’s medical history, completing a review of systems, and conducting a clinical examination. Most commonly, a skin biopsy or destruction of a benign or malignant lesion may be performed, but other simple procedures also may be appropriate. The ability to assess and intervene during the same visit is optimal for patients who subsequently may require fewer follow-up visits and experience more immediate relief from their symptoms.

When E/M Cannot Be Billed Separately

Regulatory guidance from the National Correct Coding Initiative (NCCI) dated January 2013 indicates that procedures with a global period of 90 days are major surgical procedures, and if an E/M service is performed on the same day as such a procedure to decide whether or not to perform that procedure, then the E/M service should be reported with modifier -57.² On the other hand, CPT defines procedures with a 0- or 10-day global period as minor surgical procedures, and E/M services provided on the same day of service as these procedures are included in the procedure code and cannot be billed separately. For review, common dermatologic procedures with 0-day global periods include biopsies (CPT code 11000), shave removals (11300–11313), debridements (11000, 11011–11042), and Mohs micrographic surgery (17311–17315); procedures with 10-day global periods include destructions (17000–17286), excisions (11400–11646), and repairs (12001–13153). If an E/M service is performed on the same day as one of these procedures to decide whether to proceed with the minor surgical procedure, this E/M service cannot be reported separately. Additionally, the fact that the patient is new to the physician is not sufficient to allow reporting of an E/M with such a minor procedure.

When E/M Can Be Billed Separately

However, a “significant and separately identifiable E/M service unrelated to the decision to perform the minor procedure” is separately reportable with modifier -25. According to the NCCI, the minor procedure and the E/M do not require different diagnoses, but the E/M service must be above and beyond what is usually required for the minor surgical procedure.² Because a certain amount of so-called preservice time is built into minor procedure codes, the implication is that substantially more E/M was needed than envisioned in this preservice time, necessitating inclusion of an E/M in addition to a minor procedure when there is a single diagnosis.

When there is a single diagnosis, the physician has to decide when such a significant and separately identifiable service exists. If the physician determines that it is appropriate to code for E/M in addition to the minor procedure, clear documentation of the additional E/M service provided will reduce the likelihood of this choice being questioned. Specifically, it may be helpful to describe the additional history, examination results, medical knowledge, professional skill, and work time above and beyond what is usually required for the minor surgical procedure.

When there are many diagnosis codes for a single visit and only a subset of them are associated with the minor procedure, as is common in dermatology, then the decision to include an E/M service is simpler. In this case, if E/M services were provided that pertained to a diagnosis or diagnoses other than the one(s) associated with the minor procedure(s), then these additional E/M services will clearly not be included in the preservice time for the procedure and an E/M can virtually always be coded separately. For instance, if a patient presents with a growing scaly bump (clinically apparent squamous cell carcinoma) on the leg that the dermatologist deems is appropriate for biopsy but concurrently notices nummular dermatitis of the legs, which the patient describes as itchy and uncomfortable, then the diagnosis and management of the dermatitis would clearly be a separate E/M service and would not be included in the workup for the biopsy. The E/M code that is applied should, of course, reflect the services provided exclusive of those integral to the minor procedure. To make it easier for regulators and auditors, it may be helpful to clearly itemize the additional diagnoses unrelated to the minor procedure and describe the specific E/M services provided for these diagnoses. Although it is certainly not necessary or required, it also may be helpful to physically separate the documentation for the minor procedure from the E/M services for the additional diagnoses within the medical chart.

Final Thoughts

It is clear that frequent use of modifier -25 is appropriate in routine, high-quality dermatologic practice. Simultaneous provision of E/M services and minor procedures often is in the patient’s best interest, as it minimizes unnecessary office visits and expedites treatment. When modifier -25 is appropriately appended, careful documentation by the dermatologist can help to clarify the precise basis for its use. Recent NCCI edits provide guidelines for use of this modifier that can be adapted by individual dermatologists for particular patient circumstances.²

Squamous cell carcinoma (SCC) is the second most common form of skin cancer. Pseudoglandular SCC, also known as adenoid SCC or acantholytic SCC, is an uncommon variant that was first described by Lever¹ in 1947 as an adenoacanthoma of the sweat glands. Of the many variants of SCC, pseudoglandular SCC generally is considered to behave aggressively with intermediate (3%–10%) risk for metastasis.² The metastatic potential of pseudoglandular SCC may be conferred in part by diminished expression of intercellular adhesion molecules, including desmoglein 3, epithelial cadherin, and syn-decan 1.^3,4 Pseudoglandular SCC presents most often on sun-damaged skin of elderly patients, especially the face and ears, as a pink or red nodule with central ulceration and a raised indurated border. It may be mistaken clinically for basal cell carcinoma (BCC) or keratoacanthoma.

On microscopic examination, the lesion is predominantly located in the dermis and may extend to the subcutis. There usually is connection to the overlying epidermis, which often shows hyperkeratosis and parakeratosis. Epidermal squamous dysplasia may be present. The dermis typically contains nests of squamous cells with a variable degree of central acantholysis. The morphology on low-power magnification consists of tubules of irregular size and shape, which are present either focally or throughout the lesion (Figure 1). The tubules are typically admixed with foci of keratinization. One or more layers of cohesive cells line the tubules. Partial keratinization may be found in the lining of tubules with more than 1 cell layer. The tumor cells are polygonal with eosinophilic cytoplasm, ovoid hyperchromatic or vesicular nuclei, and prominent nucleoli. Mitoses are common. The tubular lumina are filled with acantholytic cells, either singly or in small clusters, which may demonstrate residual bridging to tubular lining cells (Figure 2). The acantholytic cells show some variability in size and may be large, multinucleated, or keratinized. The tubules may contain material that is amorphous, basophilic, periodic acid–Schiff positive, diastase sensitive, and mucicarmine negative.⁵ Eccrine ducts at the periphery of the tumor may show reactive dilatation and proliferation. Tumor cells show positive immunostaining for epithelial membrane antigen, 34βE12, CK5/6, and tumor protein p63.^6-8 There is negative immunostaining for carcinoembryonic antigen, amylase, S-100 protein, and factor VIII.⁵

Figure 1. Glandlike tubular structures admixed with foci of keratinization (H&E, original magnification ×40). Figure 2. Pseudoglandular spaces containing acantholytic cells (H&E, original magnification ×100).

The differential diagnosis includes adenoid BCC, angiosarcoma, eccrine carcinoma, and metastatic adenocarcinoma of the skin. In adenoid BCC, excess stromal mucin imparts pseudoglandular architecture (Figure 3). However, features of conventional BCC, including peripheral nuclear palisading and retraction artifact often are present as well.

Figure 3. Thin strands of basaloid cells in a reticulate pattern with prominent stromal mucin in adenoid basal cell carcinoma. There also is palisading and retraction artifact of conventional basal cell carcinoma (H&E, original magnification ×40).

Angiosarcoma shows slitlike vascular spaces lined by hyperchromatic endothelial cells (Figure 4). Further, there is positive immunostaining for vascular markers CD31 and CD34.

Figure 4. Slitlike vascular spaces lined by hyperchromatic endothelial cells in angiosarcoma (H&E, original magnification ×100).

In eccrine carcinoma, there are invasive ductal structures lined by either a single or double layer of cells that may contain luminal material that is periodic acid–Schiff positive and diastase resistant (Figure 5).⁹ The tumor cells show positive immunostaining for cytokeratins, epithelial membrane antigen, carcinoembryonic antigen, and S-100 protein.¹⁰

Figure 5. Invasive ductal structures of malignant eccrine carcinoma (H&E, original magnification ×100).

Pseudoglandular SCC is susceptible to misdiagnosis as adenocarcinoma by sampling error if biopsies do not capture areas with typical features of SCC, including dysplastic squamous epithelium and keratinization. Metastatic adenocarcinoma of the skin is more likely to present with multiple nodules in older individuals. Lack of epidermal connection of the tumor and minimal to no acantholytic dyskeratosis further support cutaneous metastasis (Figure 6). Review of the patient’s clinical history might be helpful if adenocarcinoma was previously diagnosed. Immunohistochemical evaluation may aid in the prediction of the primary site in patients with metastatic adenocarcinoma of unknown origin.¹¹

Figure 6. The dermis is filled with malignant glandular epithelium that is CK7 positive, CK20 negative, and thyroid transcription factor 1 positive (immunohistochemistry not shown), consistent with metastatic adenocarcinoma of lung origin (H&E, original magnification ×40).

Squamous cell carcinoma (SCC) is the second most common form of skin cancer. Pseudoglandular SCC, also known as adenoid SCC or acantholytic SCC, is an uncommon variant that was first described by Lever¹ in 1947 as an adenoacanthoma of the sweat glands. Of the many variants of SCC, pseudoglandular SCC generally is considered to behave aggressively with intermediate (3%–10%) risk for metastasis.² The metastatic potential of pseudoglandular SCC may be conferred in part by diminished expression of intercellular adhesion molecules, including desmoglein 3, epithelial cadherin, and syn-decan 1.^3,4 Pseudoglandular SCC presents most often on sun-damaged skin of elderly patients, especially the face and ears, as a pink or red nodule with central ulceration and a raised indurated border. It may be mistaken clinically for basal cell carcinoma (BCC) or keratoacanthoma.

On microscopic examination, the lesion is predominantly located in the dermis and may extend to the subcutis. There usually is connection to the overlying epidermis, which often shows hyperkeratosis and parakeratosis. Epidermal squamous dysplasia may be present. The dermis typically contains nests of squamous cells with a variable degree of central acantholysis. The morphology on low-power magnification consists of tubules of irregular size and shape, which are present either focally or throughout the lesion (Figure 1). The tubules are typically admixed with foci of keratinization. One or more layers of cohesive cells line the tubules. Partial keratinization may be found in the lining of tubules with more than 1 cell layer. The tumor cells are polygonal with eosinophilic cytoplasm, ovoid hyperchromatic or vesicular nuclei, and prominent nucleoli. Mitoses are common. The tubular lumina are filled with acantholytic cells, either singly or in small clusters, which may demonstrate residual bridging to tubular lining cells (Figure 2). The acantholytic cells show some variability in size and may be large, multinucleated, or keratinized. The tubules may contain material that is amorphous, basophilic, periodic acid–Schiff positive, diastase sensitive, and mucicarmine negative.⁵ Eccrine ducts at the periphery of the tumor may show reactive dilatation and proliferation. Tumor cells show positive immunostaining for epithelial membrane antigen, 34βE12, CK5/6, and tumor protein p63.^6-8 There is negative immunostaining for carcinoembryonic antigen, amylase, S-100 protein, and factor VIII.⁵

Figure 1. Glandlike tubular structures admixed with foci of keratinization (H&E, original magnification ×40). Figure 2. Pseudoglandular spaces containing acantholytic cells (H&E, original magnification ×100).

The differential diagnosis includes adenoid BCC, angiosarcoma, eccrine carcinoma, and metastatic adenocarcinoma of the skin. In adenoid BCC, excess stromal mucin imparts pseudoglandular architecture (Figure 3). However, features of conventional BCC, including peripheral nuclear palisading and retraction artifact often are present as well.

Figure 3. Thin strands of basaloid cells in a reticulate pattern with prominent stromal mucin in adenoid basal cell carcinoma. There also is palisading and retraction artifact of conventional basal cell carcinoma (H&E, original magnification ×40).

Angiosarcoma shows slitlike vascular spaces lined by hyperchromatic endothelial cells (Figure 4). Further, there is positive immunostaining for vascular markers CD31 and CD34.

Figure 4. Slitlike vascular spaces lined by hyperchromatic endothelial cells in angiosarcoma (H&E, original magnification ×100).

In eccrine carcinoma, there are invasive ductal structures lined by either a single or double layer of cells that may contain luminal material that is periodic acid–Schiff positive and diastase resistant (Figure 5).⁹ The tumor cells show positive immunostaining for cytokeratins, epithelial membrane antigen, carcinoembryonic antigen, and S-100 protein.¹⁰

Figure 5. Invasive ductal structures of malignant eccrine carcinoma (H&E, original magnification ×100).

Pseudoglandular SCC is susceptible to misdiagnosis as adenocarcinoma by sampling error if biopsies do not capture areas with typical features of SCC, including dysplastic squamous epithelium and keratinization. Metastatic adenocarcinoma of the skin is more likely to present with multiple nodules in older individuals. Lack of epidermal connection of the tumor and minimal to no acantholytic dyskeratosis further support cutaneous metastasis (Figure 6). Review of the patient’s clinical history might be helpful if adenocarcinoma was previously diagnosed. Immunohistochemical evaluation may aid in the prediction of the primary site in patients with metastatic adenocarcinoma of unknown origin.¹¹

Figure 6. The dermis is filled with malignant glandular epithelium that is CK7 positive, CK20 negative, and thyroid transcription factor 1 positive (immunohistochemistry not shown), consistent with metastatic adenocarcinoma of lung origin (H&E, original magnification ×40).

Squamous cell carcinoma (SCC) is the second most common form of skin cancer. Pseudoglandular SCC, also known as adenoid SCC or acantholytic SCC, is an uncommon variant that was first described by Lever¹ in 1947 as an adenoacanthoma of the sweat glands. Of the many variants of SCC, pseudoglandular SCC generally is considered to behave aggressively with intermediate (3%–10%) risk for metastasis.² The metastatic potential of pseudoglandular SCC may be conferred in part by diminished expression of intercellular adhesion molecules, including desmoglein 3, epithelial cadherin, and syn-decan 1.^3,4 Pseudoglandular SCC presents most often on sun-damaged skin of elderly patients, especially the face and ears, as a pink or red nodule with central ulceration and a raised indurated border. It may be mistaken clinically for basal cell carcinoma (BCC) or keratoacanthoma.

On microscopic examination, the lesion is predominantly located in the dermis and may extend to the subcutis. There usually is connection to the overlying epidermis, which often shows hyperkeratosis and parakeratosis. Epidermal squamous dysplasia may be present. The dermis typically contains nests of squamous cells with a variable degree of central acantholysis. The morphology on low-power magnification consists of tubules of irregular size and shape, which are present either focally or throughout the lesion (Figure 1). The tubules are typically admixed with foci of keratinization. One or more layers of cohesive cells line the tubules. Partial keratinization may be found in the lining of tubules with more than 1 cell layer. The tumor cells are polygonal with eosinophilic cytoplasm, ovoid hyperchromatic or vesicular nuclei, and prominent nucleoli. Mitoses are common. The tubular lumina are filled with acantholytic cells, either singly or in small clusters, which may demonstrate residual bridging to tubular lining cells (Figure 2). The acantholytic cells show some variability in size and may be large, multinucleated, or keratinized. The tubules may contain material that is amorphous, basophilic, periodic acid–Schiff positive, diastase sensitive, and mucicarmine negative.⁵ Eccrine ducts at the periphery of the tumor may show reactive dilatation and proliferation. Tumor cells show positive immunostaining for epithelial membrane antigen, 34βE12, CK5/6, and tumor protein p63.^6-8 There is negative immunostaining for carcinoembryonic antigen, amylase, S-100 protein, and factor VIII.⁵

Figure 1. Glandlike tubular structures admixed with foci of keratinization (H&E, original magnification ×40). Figure 2. Pseudoglandular spaces containing acantholytic cells (H&E, original magnification ×100).

The differential diagnosis includes adenoid BCC, angiosarcoma, eccrine carcinoma, and metastatic adenocarcinoma of the skin. In adenoid BCC, excess stromal mucin imparts pseudoglandular architecture (Figure 3). However, features of conventional BCC, including peripheral nuclear palisading and retraction artifact often are present as well.

Figure 3. Thin strands of basaloid cells in a reticulate pattern with prominent stromal mucin in adenoid basal cell carcinoma. There also is palisading and retraction artifact of conventional basal cell carcinoma (H&E, original magnification ×40).

Angiosarcoma shows slitlike vascular spaces lined by hyperchromatic endothelial cells (Figure 4). Further, there is positive immunostaining for vascular markers CD31 and CD34.

Figure 4. Slitlike vascular spaces lined by hyperchromatic endothelial cells in angiosarcoma (H&E, original magnification ×100).

In eccrine carcinoma, there are invasive ductal structures lined by either a single or double layer of cells that may contain luminal material that is periodic acid–Schiff positive and diastase resistant (Figure 5).⁹ The tumor cells show positive immunostaining for cytokeratins, epithelial membrane antigen, carcinoembryonic antigen, and S-100 protein.¹⁰

Figure 5. Invasive ductal structures of malignant eccrine carcinoma (H&E, original magnification ×100).

Pseudoglandular SCC is susceptible to misdiagnosis as adenocarcinoma by sampling error if biopsies do not capture areas with typical features of SCC, including dysplastic squamous epithelium and keratinization. Metastatic adenocarcinoma of the skin is more likely to present with multiple nodules in older individuals. Lack of epidermal connection of the tumor and minimal to no acantholytic dyskeratosis further support cutaneous metastasis (Figure 6). Review of the patient’s clinical history might be helpful if adenocarcinoma was previously diagnosed. Immunohistochemical evaluation may aid in the prediction of the primary site in patients with metastatic adenocarcinoma of unknown origin.¹¹

Figure 6. The dermis is filled with malignant glandular epithelium that is CK7 positive, CK20 negative, and thyroid transcription factor 1 positive (immunohistochemistry not shown), consistent with metastatic adenocarcinoma of lung origin (H&E, original magnification ×40).

Dermatologic emergency may sound like an oxymoron, but there are many emergencies that dermatology residents may encounter in their careers. In some instances the skin is the primary organ that is affected, while in others cutaneous symptoms and life-threatening signs are important diagnostic clues for what may lie beneath the skin.

As residents who are occasionally on call or on consultation services, it is important for us to recognize dermatologic emergencies quickly because some of these conditions can acutely evolve and become lethal if a diagnosis is not made early in the disease course with the appropriate treatment administered. Dermatologic emergencies can range from severe drug reactions, infections, autoimmune exacerbations, and inflammatory conditions (eg, erythroderma) to environmental insults such as burns (Figure 1) and child abuse.¹

Figure 1. A second-degree burn with associated severe pain, tenderness, serous-filled bullae, deep rubor, erosion, and exudation of the chest.

Critical Infections

Some dermatologic emergencies are infectious in origin, and although these infections are most commonly bacterial (eg, necrotizing fasciitis), they also can range from viral to fungal (eg, mucormycosis) in nature. Some areas with large populations of immunocompromised patients (eg, human immunodeficiency virus–positive patients, organ transplant recipients) may warrant a high index of suspicion for possible zebras (rare conditions) and opportunistic infections that may quickly escalate to life-threatening situations.

Although few cutaneous manifestations in emergent infections are pathognomonic, they sometimes can be categorized according to the appearance of the primary lesion: erythrodermic (eg, staphylococcal scalded skin syndrome), maculopapular (eg, Lyme disease), purpuric/petechial (eg, Rocky Mountain spotted fever), pustular (eg, disseminated candidiasis), or vesicular (eg, neonatal herpes simplex virus)(Table). On consultations, dermatology residents frequently get called to evaluate hemorrhagic and ischemic lesions in inpatients (Figure 2). Aside from infectious causes, the differential diagnosis may include coagulation abnormalities (eg, concurrent anticoagulant therapies), vasculitides, poisoning, vascular disease, or Stevens-Johnson syndrome and toxic epidermal necrolysis, which can occasionally present with hemorrhagic lesions.^1,2

Figure 2. Cutaneous signs of iatrogenic, vasopressor-induced ischemia; gangrene of the distal digits of the left hand; and pronounced demarcation of vessels, as well as a vascular indication of thrombosis and lack of blood flow to the affected areas.

Necrotizing Fasciitis

Dermatology residents may frequently encounter necrotizing fasciitis, either in clinic or on the wards (Figure 3). Recognition of the skin signs in this condition is essential to patient survival. As an intern, I once had an attending teach me that patients with necrotizing fasciitis only have a couple of hours to live. The rapid unfolding of this flesh-eating disease and its high morbidity and mortality has led to recent attention in the press and media.

Figure 3. Necrotizing fasciitis of the left forearm following debridement of the skin, subcutaneous tissue, and fascia, revealing the remaining muscle, tendon, and bone.

Although necrotizing fasciitis may be caused by several different bacterial organisms (eg, gram positive, gram negative, polymicrobial), it usually is rapidly progressive, destroying muscle and subcutaneous tissues in a matter of hours.³ Bacteria usually enter through a traumatic or present wound and quickly move along fascial planes, destroying blood vessels and whatever subcutaneous tissues happen to be in the way. Within the first few hours, the involved area that was initially erythematous becomes indurated, woody, extremely painful, and dusky, indicating a lack of circulation to the area. Extensive debridement is required until reaching noninfected tissue that is no longer purulent, necrotic, or woody to the touch. If necrotizing fasciitis is not diagnosed and treated early, patients may lose one or several limbs and death may occur.

Key findings of necrotizing fasciitis include systemic toxicity, localized painful induration, well-defined dusky blue discoloration, and a lack of bleeding or purulent discharge on incision and squeezing of the affected tissue. Crepitation or a crackling sensation can occasionally be felt when palpating the area secondary to gas formation in the tissue, though it is not always present. Patients with necrotizing fasciitis often initially present to dermatology clinics because the first manifestation happens to be in the skin. The role of dermatologists in treating this critical condition may prompt recognition and collaboration with other specialists to reach a viable outcome for the patient.³

Drug Reactions

Cutaneous drug eruptions usually are relatively benign, consisting of a morbilliform eruption often without any other accompanying symptoms. However, sometimes these reactions can present as exfoliative dermatitis or red man syndrome in which patients can develop total body erythema with diffuse scaling and pruritus.⁴ Aside from drug reactions, other causes of exfoliative dermatitis such as psoriasis, atopic and seborrheic dermatitis, mycosis fungoides, and lymphoma should be ruled out. Other drug eruptions that can be classified as dermatologic emergencies include leukocytoclastic vasculitis, severe urticaria or angioedema, erythema multiforme, or Stevens-Johnson syndrome and toxic epidermal necrolysis.

Figure 4. Retained bullet extracted from the back of a patient 4 years following the initial insult.

Severe Acne

If not treated promptly, serious cases of acne can lead to severe scarring and psychologic problems. Acne fulminans is characterized by a rapid eruption of suppurative and large, highly inflamed nodules, plaques, and cysts that result in ragged ulcerations and cicatrization of the chest, back, and occasionally the face. Systemic symptoms of fever, arthralgia, leukocytosis, and myalgia suggest an upregulation of the immune system in affected patients.

Final Comment

In summary, dermatologic emergencies do exist and some may present with characteristic skin findings. In almost all cases, collaboration with other departments such as trauma, burn, internal medicine, rheumatology, and infectious diseases is extremely helpful in diagnosing and treating these medical emergencies. Collaboration can provide insight into how brainstorming through different approaches can lead to a better outcome whether it be solving the cause of a puzzling rash in a patient with multiple comorbidities or surgically removing a bullet from a trauma patient (Figure 4). Recognition of specific cutaneous manifestations and early diagnosis of dermatologic emergencies can be lifesaving.

Dermatologic emergency may sound like an oxymoron, but there are many emergencies that dermatology residents may encounter in their careers. In some instances the skin is the primary organ that is affected, while in others cutaneous symptoms and life-threatening signs are important diagnostic clues for what may lie beneath the skin.

As residents who are occasionally on call or on consultation services, it is important for us to recognize dermatologic emergencies quickly because some of these conditions can acutely evolve and become lethal if a diagnosis is not made early in the disease course with the appropriate treatment administered. Dermatologic emergencies can range from severe drug reactions, infections, autoimmune exacerbations, and inflammatory conditions (eg, erythroderma) to environmental insults such as burns (Figure 1) and child abuse.¹

Figure 1. A second-degree burn with associated severe pain, tenderness, serous-filled bullae, deep rubor, erosion, and exudation of the chest.

Critical Infections

Some dermatologic emergencies are infectious in origin, and although these infections are most commonly bacterial (eg, necrotizing fasciitis), they also can range from viral to fungal (eg, mucormycosis) in nature. Some areas with large populations of immunocompromised patients (eg, human immunodeficiency virus–positive patients, organ transplant recipients) may warrant a high index of suspicion for possible zebras (rare conditions) and opportunistic infections that may quickly escalate to life-threatening situations.

Although few cutaneous manifestations in emergent infections are pathognomonic, they sometimes can be categorized according to the appearance of the primary lesion: erythrodermic (eg, staphylococcal scalded skin syndrome), maculopapular (eg, Lyme disease), purpuric/petechial (eg, Rocky Mountain spotted fever), pustular (eg, disseminated candidiasis), or vesicular (eg, neonatal herpes simplex virus)(Table). On consultations, dermatology residents frequently get called to evaluate hemorrhagic and ischemic lesions in inpatients (Figure 2). Aside from infectious causes, the differential diagnosis may include coagulation abnormalities (eg, concurrent anticoagulant therapies), vasculitides, poisoning, vascular disease, or Stevens-Johnson syndrome and toxic epidermal necrolysis, which can occasionally present with hemorrhagic lesions.^1,2

Figure 2. Cutaneous signs of iatrogenic, vasopressor-induced ischemia; gangrene of the distal digits of the left hand; and pronounced demarcation of vessels, as well as a vascular indication of thrombosis and lack of blood flow to the affected areas.

Necrotizing Fasciitis

Dermatology residents may frequently encounter necrotizing fasciitis, either in clinic or on the wards (Figure 3). Recognition of the skin signs in this condition is essential to patient survival. As an intern, I once had an attending teach me that patients with necrotizing fasciitis only have a couple of hours to live. The rapid unfolding of this flesh-eating disease and its high morbidity and mortality has led to recent attention in the press and media.

Figure 3. Necrotizing fasciitis of the left forearm following debridement of the skin, subcutaneous tissue, and fascia, revealing the remaining muscle, tendon, and bone.

Although necrotizing fasciitis may be caused by several different bacterial organisms (eg, gram positive, gram negative, polymicrobial), it usually is rapidly progressive, destroying muscle and subcutaneous tissues in a matter of hours.³ Bacteria usually enter through a traumatic or present wound and quickly move along fascial planes, destroying blood vessels and whatever subcutaneous tissues happen to be in the way. Within the first few hours, the involved area that was initially erythematous becomes indurated, woody, extremely painful, and dusky, indicating a lack of circulation to the area. Extensive debridement is required until reaching noninfected tissue that is no longer purulent, necrotic, or woody to the touch. If necrotizing fasciitis is not diagnosed and treated early, patients may lose one or several limbs and death may occur.

Key findings of necrotizing fasciitis include systemic toxicity, localized painful induration, well-defined dusky blue discoloration, and a lack of bleeding or purulent discharge on incision and squeezing of the affected tissue. Crepitation or a crackling sensation can occasionally be felt when palpating the area secondary to gas formation in the tissue, though it is not always present. Patients with necrotizing fasciitis often initially present to dermatology clinics because the first manifestation happens to be in the skin. The role of dermatologists in treating this critical condition may prompt recognition and collaboration with other specialists to reach a viable outcome for the patient.³

Drug Reactions

Cutaneous drug eruptions usually are relatively benign, consisting of a morbilliform eruption often without any other accompanying symptoms. However, sometimes these reactions can present as exfoliative dermatitis or red man syndrome in which patients can develop total body erythema with diffuse scaling and pruritus.⁴ Aside from drug reactions, other causes of exfoliative dermatitis such as psoriasis, atopic and seborrheic dermatitis, mycosis fungoides, and lymphoma should be ruled out. Other drug eruptions that can be classified as dermatologic emergencies include leukocytoclastic vasculitis, severe urticaria or angioedema, erythema multiforme, or Stevens-Johnson syndrome and toxic epidermal necrolysis.

Figure 4. Retained bullet extracted from the back of a patient 4 years following the initial insult.

Severe Acne

If not treated promptly, serious cases of acne can lead to severe scarring and psychologic problems. Acne fulminans is characterized by a rapid eruption of suppurative and large, highly inflamed nodules, plaques, and cysts that result in ragged ulcerations and cicatrization of the chest, back, and occasionally the face. Systemic symptoms of fever, arthralgia, leukocytosis, and myalgia suggest an upregulation of the immune system in affected patients.

Final Comment

In summary, dermatologic emergencies do exist and some may present with characteristic skin findings. In almost all cases, collaboration with other departments such as trauma, burn, internal medicine, rheumatology, and infectious diseases is extremely helpful in diagnosing and treating these medical emergencies. Collaboration can provide insight into how brainstorming through different approaches can lead to a better outcome whether it be solving the cause of a puzzling rash in a patient with multiple comorbidities or surgically removing a bullet from a trauma patient (Figure 4). Recognition of specific cutaneous manifestations and early diagnosis of dermatologic emergencies can be lifesaving.

Dermatologic emergency may sound like an oxymoron, but there are many emergencies that dermatology residents may encounter in their careers. In some instances the skin is the primary organ that is affected, while in others cutaneous symptoms and life-threatening signs are important diagnostic clues for what may lie beneath the skin.

As residents who are occasionally on call or on consultation services, it is important for us to recognize dermatologic emergencies quickly because some of these conditions can acutely evolve and become lethal if a diagnosis is not made early in the disease course with the appropriate treatment administered. Dermatologic emergencies can range from severe drug reactions, infections, autoimmune exacerbations, and inflammatory conditions (eg, erythroderma) to environmental insults such as burns (Figure 1) and child abuse.¹

Figure 1. A second-degree burn with associated severe pain, tenderness, serous-filled bullae, deep rubor, erosion, and exudation of the chest.

Critical Infections

Some dermatologic emergencies are infectious in origin, and although these infections are most commonly bacterial (eg, necrotizing fasciitis), they also can range from viral to fungal (eg, mucormycosis) in nature. Some areas with large populations of immunocompromised patients (eg, human immunodeficiency virus–positive patients, organ transplant recipients) may warrant a high index of suspicion for possible zebras (rare conditions) and opportunistic infections that may quickly escalate to life-threatening situations.

Although few cutaneous manifestations in emergent infections are pathognomonic, they sometimes can be categorized according to the appearance of the primary lesion: erythrodermic (eg, staphylococcal scalded skin syndrome), maculopapular (eg, Lyme disease), purpuric/petechial (eg, Rocky Mountain spotted fever), pustular (eg, disseminated candidiasis), or vesicular (eg, neonatal herpes simplex virus)(Table). On consultations, dermatology residents frequently get called to evaluate hemorrhagic and ischemic lesions in inpatients (Figure 2). Aside from infectious causes, the differential diagnosis may include coagulation abnormalities (eg, concurrent anticoagulant therapies), vasculitides, poisoning, vascular disease, or Stevens-Johnson syndrome and toxic epidermal necrolysis, which can occasionally present with hemorrhagic lesions.^1,2

Figure 2. Cutaneous signs of iatrogenic, vasopressor-induced ischemia; gangrene of the distal digits of the left hand; and pronounced demarcation of vessels, as well as a vascular indication of thrombosis and lack of blood flow to the affected areas.

Necrotizing Fasciitis

Dermatology residents may frequently encounter necrotizing fasciitis, either in clinic or on the wards (Figure 3). Recognition of the skin signs in this condition is essential to patient survival. As an intern, I once had an attending teach me that patients with necrotizing fasciitis only have a couple of hours to live. The rapid unfolding of this flesh-eating disease and its high morbidity and mortality has led to recent attention in the press and media.

Figure 3. Necrotizing fasciitis of the left forearm following debridement of the skin, subcutaneous tissue, and fascia, revealing the remaining muscle, tendon, and bone.

Although necrotizing fasciitis may be caused by several different bacterial organisms (eg, gram positive, gram negative, polymicrobial), it usually is rapidly progressive, destroying muscle and subcutaneous tissues in a matter of hours.³ Bacteria usually enter through a traumatic or present wound and quickly move along fascial planes, destroying blood vessels and whatever subcutaneous tissues happen to be in the way. Within the first few hours, the involved area that was initially erythematous becomes indurated, woody, extremely painful, and dusky, indicating a lack of circulation to the area. Extensive debridement is required until reaching noninfected tissue that is no longer purulent, necrotic, or woody to the touch. If necrotizing fasciitis is not diagnosed and treated early, patients may lose one or several limbs and death may occur.

Key findings of necrotizing fasciitis include systemic toxicity, localized painful induration, well-defined dusky blue discoloration, and a lack of bleeding or purulent discharge on incision and squeezing of the affected tissue. Crepitation or a crackling sensation can occasionally be felt when palpating the area secondary to gas formation in the tissue, though it is not always present. Patients with necrotizing fasciitis often initially present to dermatology clinics because the first manifestation happens to be in the skin. The role of dermatologists in treating this critical condition may prompt recognition and collaboration with other specialists to reach a viable outcome for the patient.³

Drug Reactions

Cutaneous drug eruptions usually are relatively benign, consisting of a morbilliform eruption often without any other accompanying symptoms. However, sometimes these reactions can present as exfoliative dermatitis or red man syndrome in which patients can develop total body erythema with diffuse scaling and pruritus.⁴ Aside from drug reactions, other causes of exfoliative dermatitis such as psoriasis, atopic and seborrheic dermatitis, mycosis fungoides, and lymphoma should be ruled out. Other drug eruptions that can be classified as dermatologic emergencies include leukocytoclastic vasculitis, severe urticaria or angioedema, erythema multiforme, or Stevens-Johnson syndrome and toxic epidermal necrolysis.

Figure 4. Retained bullet extracted from the back of a patient 4 years following the initial insult.

Severe Acne

If not treated promptly, serious cases of acne can lead to severe scarring and psychologic problems. Acne fulminans is characterized by a rapid eruption of suppurative and large, highly inflamed nodules, plaques, and cysts that result in ragged ulcerations and cicatrization of the chest, back, and occasionally the face. Systemic symptoms of fever, arthralgia, leukocytosis, and myalgia suggest an upregulation of the immune system in affected patients.

Final Comment

In summary, dermatologic emergencies do exist and some may present with characteristic skin findings. In almost all cases, collaboration with other departments such as trauma, burn, internal medicine, rheumatology, and infectious diseases is extremely helpful in diagnosing and treating these medical emergencies. Collaboration can provide insight into how brainstorming through different approaches can lead to a better outcome whether it be solving the cause of a puzzling rash in a patient with multiple comorbidities or surgically removing a bullet from a trauma patient (Figure 4). Recognition of specific cutaneous manifestations and early diagnosis of dermatologic emergencies can be lifesaving.