Dermatology

MILAN – A teletriage approach significantly reduced the waiting time for underserved patients to see dermatologists in a specialty outreach clinic, and optimized primary care physicians’ care of nonreferred patients, Cory Simpson, MD, PhD, reported at the World Congress of Dermatology.

Kari Oakes/MDedge News

With implementation of teledermatology, patient wait times for specialist input dropped from 13.9 days to 1.6 days (P less than .00001).

By allowing dermatologists to evaluate photographs of lesions and perform their own triage of referrals from primary care physicians (PCPs), the teletriage pilot program reduced the number of patients for whom dermatology consults were deemed necessary and also allowed optimal management for the nonreferred patients, said Dr. Simpson, of the University of Pennsylvania, Philadelphia.

“Teledermatology has the potential to increase access to dermatologist-level care, especially for underserved patients,” he commented. “It allows us to educate primary care physicians in resource-limited settings, and it also allows us to avoid suboptimal care of skin disease by nonspecialists – especially the more judicious use of antimicrobial agents and corticosteroids.”

Dr. Simpson explained to the international audience that, for many in the United States, access to a dermatologist requires a lengthy wait that can extend to months.

In Philadelphia, University of Pennsylvania dermatology residents and attending physicians volunteer in an outreach program that serves an uninsured population of primarily Latino immigrants. Operating 1 or 2 evenings a month, the medical and surgical dermatology clinics can accommodate from 8-12 appointments per clinic.

The clinic had been overwhelmed with referrals from PCPs, but Dr. Simpson and his colleagues realized that many of the conditions they were seeing – verruca vulgaris, hand dermatitis, and psoriasis, for example – did not necessarily need a face-to-face dermatologic evaluation.

The AccessDerm app, available at no cost by the American Academy of Dermatology, allows PCPs and dermatologists to communicate and collaborate. “This is a store-and-forward program, meaning the primary physician takes the photos and sends them to an off-site dermatologist who can then review them at his or her convenience,” Dr. Simpson said. “It’s a smartphone-based app, so actually, while I was at this conference, even though I’m thousands of miles from Philadelphia, I got through three consults this morning on my smartphone. It’s a very convenient way to be a volunteer.”

The consultation is between the PCP and the dermatologist, he added. “It’s the dermatologist talking to the PCP, and the patient receives the care recommendations from their primary doctor – so there’s no direct communication with the patient.”

Using the app, PCPs photographed skin lesions and completed simple history and physical exam modules within the app. Then, Dr. Simpson and his dermatology colleagues reviewed the photos and pertinent information.

If diagnostic uncertainty persisted after the teledermatology review, or if Dr. Simpson and his colleagues judged that a procedure such as a biopsy or lesion destruction was required, then the patient was scheduled for an appointment, with an interim plan put in place. Otherwise, patients were managed by teledermatology alone.

Of the 131 patients involved in the pilot study, 48 (37%) were female; the average patient age was 31.7 years (range, 1-92 years).

About 40% of patients were seen for inflammatory conditions, and another 20% for nonpigmented neoplasms. Almost 18% were seen for infectious reasons, with the remainder divided between pigmented neoplasms, hair disorders, and other conditions.

It turned out, said Dr. Simpson, that about two-thirds (65%) of the teletriage consultations ended in a definitive plan not requiring a face-to-face dermatology appointment. About a quarter (23%) were deferred to an in-person dermatology appointment, and the remaining 12% had an interim plan while more information was gathered.

Of the 32 neoplasms addressed by the teletriage strategy, 21 (66%) were deferred to an in-person visit. By contrast, 24 of the 95 non–neoplastic teletriage encounters were deferred to an in-person visit (P less than .001).

Overall, the strategy opened up 18% more appointment slots for new patients, Dr. Simpson said.

As part of the teletriage process, PCPs provided their proposed plan of care before receiving a dermatologist’s advice. When comparing the PCP’s plan to the dermatologist’s final plan, he and his colleagues found that there was a complete change of plan for three-quarters of visits (76%). A partial change happened 14% of the time, and only one in ten patients had no change in treatment plan as a result of the teledermatology consult. “This indicates again that specialist input matters,” he noted.

“This also gives us an opportunity to educate primary care physicians,” Dr. Simpson said, pointing out that in replies, he and his dermatologist colleagues included information about common diagnoses, including first-line treatments and “worrisome features they should be thinking about.”

He and his collaborators found that proper treatment would have been provided 30% of the time without a teledermatology consult, but that patients would have been undertreated 27% of the time. Overtreatment would have occurred at a rate of 11%, and care would have been unnecessarily delayed for about one in four patients. Unnecessary ED visits were averted for 6% of patients with the teletriage approach.

Examples of undertreatment included use of a weak topical steroid, missing infections or the need for referral, and using a suboptimal acne regimen. On the other hand, Dr. Simpson said, overtreatment with unnecessary antibiotics, antifungals, and antivirals also was averted; on some occasions, the PCP plan for an oral corticosteroid or an overly potent topical steroid was shifted to a more appropriate plan by teledermatology.

In sum, said Dr. Simpson, “teletriage via AccessDerm allowed us to reduce by tenfold the wait time for specialist input in dermatology cases. We were able to remove almost two-thirds of people from the queue ... waiting for dermatology appointments, which was very helpful to our clinic.”

And most importantly, he added, “this allowed us to allocate the limited number of in-person appointments that we had at this volunteer clinic to those that were more complicated cases.”

Dr. Simpson reported that he had no relevant disclosures. The project was funded by Penn Medicine and the American Academy of Dermatology.

koakes@mdedge.com

MILAN – A teletriage approach significantly reduced the waiting time for underserved patients to see dermatologists in a specialty outreach clinic, and optimized primary care physicians’ care of nonreferred patients, Cory Simpson, MD, PhD, reported at the World Congress of Dermatology.

Kari Oakes/MDedge News

With implementation of teledermatology, patient wait times for specialist input dropped from 13.9 days to 1.6 days (P less than .00001).

By allowing dermatologists to evaluate photographs of lesions and perform their own triage of referrals from primary care physicians (PCPs), the teletriage pilot program reduced the number of patients for whom dermatology consults were deemed necessary and also allowed optimal management for the nonreferred patients, said Dr. Simpson, of the University of Pennsylvania, Philadelphia.

“Teledermatology has the potential to increase access to dermatologist-level care, especially for underserved patients,” he commented. “It allows us to educate primary care physicians in resource-limited settings, and it also allows us to avoid suboptimal care of skin disease by nonspecialists – especially the more judicious use of antimicrobial agents and corticosteroids.”

Dr. Simpson explained to the international audience that, for many in the United States, access to a dermatologist requires a lengthy wait that can extend to months.

In Philadelphia, University of Pennsylvania dermatology residents and attending physicians volunteer in an outreach program that serves an uninsured population of primarily Latino immigrants. Operating 1 or 2 evenings a month, the medical and surgical dermatology clinics can accommodate from 8-12 appointments per clinic.

The clinic had been overwhelmed with referrals from PCPs, but Dr. Simpson and his colleagues realized that many of the conditions they were seeing – verruca vulgaris, hand dermatitis, and psoriasis, for example – did not necessarily need a face-to-face dermatologic evaluation.

The AccessDerm app, available at no cost by the American Academy of Dermatology, allows PCPs and dermatologists to communicate and collaborate. “This is a store-and-forward program, meaning the primary physician takes the photos and sends them to an off-site dermatologist who can then review them at his or her convenience,” Dr. Simpson said. “It’s a smartphone-based app, so actually, while I was at this conference, even though I’m thousands of miles from Philadelphia, I got through three consults this morning on my smartphone. It’s a very convenient way to be a volunteer.”

The consultation is between the PCP and the dermatologist, he added. “It’s the dermatologist talking to the PCP, and the patient receives the care recommendations from their primary doctor – so there’s no direct communication with the patient.”

Using the app, PCPs photographed skin lesions and completed simple history and physical exam modules within the app. Then, Dr. Simpson and his dermatology colleagues reviewed the photos and pertinent information.

If diagnostic uncertainty persisted after the teledermatology review, or if Dr. Simpson and his colleagues judged that a procedure such as a biopsy or lesion destruction was required, then the patient was scheduled for an appointment, with an interim plan put in place. Otherwise, patients were managed by teledermatology alone.

Of the 131 patients involved in the pilot study, 48 (37%) were female; the average patient age was 31.7 years (range, 1-92 years).

About 40% of patients were seen for inflammatory conditions, and another 20% for nonpigmented neoplasms. Almost 18% were seen for infectious reasons, with the remainder divided between pigmented neoplasms, hair disorders, and other conditions.

It turned out, said Dr. Simpson, that about two-thirds (65%) of the teletriage consultations ended in a definitive plan not requiring a face-to-face dermatology appointment. About a quarter (23%) were deferred to an in-person dermatology appointment, and the remaining 12% had an interim plan while more information was gathered.

Of the 32 neoplasms addressed by the teletriage strategy, 21 (66%) were deferred to an in-person visit. By contrast, 24 of the 95 non–neoplastic teletriage encounters were deferred to an in-person visit (P less than .001).

Overall, the strategy opened up 18% more appointment slots for new patients, Dr. Simpson said.

As part of the teletriage process, PCPs provided their proposed plan of care before receiving a dermatologist’s advice. When comparing the PCP’s plan to the dermatologist’s final plan, he and his colleagues found that there was a complete change of plan for three-quarters of visits (76%). A partial change happened 14% of the time, and only one in ten patients had no change in treatment plan as a result of the teledermatology consult. “This indicates again that specialist input matters,” he noted.

“This also gives us an opportunity to educate primary care physicians,” Dr. Simpson said, pointing out that in replies, he and his dermatologist colleagues included information about common diagnoses, including first-line treatments and “worrisome features they should be thinking about.”

He and his collaborators found that proper treatment would have been provided 30% of the time without a teledermatology consult, but that patients would have been undertreated 27% of the time. Overtreatment would have occurred at a rate of 11%, and care would have been unnecessarily delayed for about one in four patients. Unnecessary ED visits were averted for 6% of patients with the teletriage approach.

Examples of undertreatment included use of a weak topical steroid, missing infections or the need for referral, and using a suboptimal acne regimen. On the other hand, Dr. Simpson said, overtreatment with unnecessary antibiotics, antifungals, and antivirals also was averted; on some occasions, the PCP plan for an oral corticosteroid or an overly potent topical steroid was shifted to a more appropriate plan by teledermatology.

In sum, said Dr. Simpson, “teletriage via AccessDerm allowed us to reduce by tenfold the wait time for specialist input in dermatology cases. We were able to remove almost two-thirds of people from the queue ... waiting for dermatology appointments, which was very helpful to our clinic.”

And most importantly, he added, “this allowed us to allocate the limited number of in-person appointments that we had at this volunteer clinic to those that were more complicated cases.”

Dr. Simpson reported that he had no relevant disclosures. The project was funded by Penn Medicine and the American Academy of Dermatology.

koakes@mdedge.com

MILAN – A teletriage approach significantly reduced the waiting time for underserved patients to see dermatologists in a specialty outreach clinic, and optimized primary care physicians’ care of nonreferred patients, Cory Simpson, MD, PhD, reported at the World Congress of Dermatology.

Kari Oakes/MDedge News

With implementation of teledermatology, patient wait times for specialist input dropped from 13.9 days to 1.6 days (P less than .00001).

By allowing dermatologists to evaluate photographs of lesions and perform their own triage of referrals from primary care physicians (PCPs), the teletriage pilot program reduced the number of patients for whom dermatology consults were deemed necessary and also allowed optimal management for the nonreferred patients, said Dr. Simpson, of the University of Pennsylvania, Philadelphia.

“Teledermatology has the potential to increase access to dermatologist-level care, especially for underserved patients,” he commented. “It allows us to educate primary care physicians in resource-limited settings, and it also allows us to avoid suboptimal care of skin disease by nonspecialists – especially the more judicious use of antimicrobial agents and corticosteroids.”

Dr. Simpson explained to the international audience that, for many in the United States, access to a dermatologist requires a lengthy wait that can extend to months.

In Philadelphia, University of Pennsylvania dermatology residents and attending physicians volunteer in an outreach program that serves an uninsured population of primarily Latino immigrants. Operating 1 or 2 evenings a month, the medical and surgical dermatology clinics can accommodate from 8-12 appointments per clinic.

The clinic had been overwhelmed with referrals from PCPs, but Dr. Simpson and his colleagues realized that many of the conditions they were seeing – verruca vulgaris, hand dermatitis, and psoriasis, for example – did not necessarily need a face-to-face dermatologic evaluation.

The AccessDerm app, available at no cost by the American Academy of Dermatology, allows PCPs and dermatologists to communicate and collaborate. “This is a store-and-forward program, meaning the primary physician takes the photos and sends them to an off-site dermatologist who can then review them at his or her convenience,” Dr. Simpson said. “It’s a smartphone-based app, so actually, while I was at this conference, even though I’m thousands of miles from Philadelphia, I got through three consults this morning on my smartphone. It’s a very convenient way to be a volunteer.”

The consultation is between the PCP and the dermatologist, he added. “It’s the dermatologist talking to the PCP, and the patient receives the care recommendations from their primary doctor – so there’s no direct communication with the patient.”

Using the app, PCPs photographed skin lesions and completed simple history and physical exam modules within the app. Then, Dr. Simpson and his dermatology colleagues reviewed the photos and pertinent information.

If diagnostic uncertainty persisted after the teledermatology review, or if Dr. Simpson and his colleagues judged that a procedure such as a biopsy or lesion destruction was required, then the patient was scheduled for an appointment, with an interim plan put in place. Otherwise, patients were managed by teledermatology alone.

Of the 131 patients involved in the pilot study, 48 (37%) were female; the average patient age was 31.7 years (range, 1-92 years).

About 40% of patients were seen for inflammatory conditions, and another 20% for nonpigmented neoplasms. Almost 18% were seen for infectious reasons, with the remainder divided between pigmented neoplasms, hair disorders, and other conditions.

It turned out, said Dr. Simpson, that about two-thirds (65%) of the teletriage consultations ended in a definitive plan not requiring a face-to-face dermatology appointment. About a quarter (23%) were deferred to an in-person dermatology appointment, and the remaining 12% had an interim plan while more information was gathered.

Of the 32 neoplasms addressed by the teletriage strategy, 21 (66%) were deferred to an in-person visit. By contrast, 24 of the 95 non–neoplastic teletriage encounters were deferred to an in-person visit (P less than .001).

Overall, the strategy opened up 18% more appointment slots for new patients, Dr. Simpson said.

As part of the teletriage process, PCPs provided their proposed plan of care before receiving a dermatologist’s advice. When comparing the PCP’s plan to the dermatologist’s final plan, he and his colleagues found that there was a complete change of plan for three-quarters of visits (76%). A partial change happened 14% of the time, and only one in ten patients had no change in treatment plan as a result of the teledermatology consult. “This indicates again that specialist input matters,” he noted.

“This also gives us an opportunity to educate primary care physicians,” Dr. Simpson said, pointing out that in replies, he and his dermatologist colleagues included information about common diagnoses, including first-line treatments and “worrisome features they should be thinking about.”

He and his collaborators found that proper treatment would have been provided 30% of the time without a teledermatology consult, but that patients would have been undertreated 27% of the time. Overtreatment would have occurred at a rate of 11%, and care would have been unnecessarily delayed for about one in four patients. Unnecessary ED visits were averted for 6% of patients with the teletriage approach.

Examples of undertreatment included use of a weak topical steroid, missing infections or the need for referral, and using a suboptimal acne regimen. On the other hand, Dr. Simpson said, overtreatment with unnecessary antibiotics, antifungals, and antivirals also was averted; on some occasions, the PCP plan for an oral corticosteroid or an overly potent topical steroid was shifted to a more appropriate plan by teledermatology.

In sum, said Dr. Simpson, “teletriage via AccessDerm allowed us to reduce by tenfold the wait time for specialist input in dermatology cases. We were able to remove almost two-thirds of people from the queue ... waiting for dermatology appointments, which was very helpful to our clinic.”

And most importantly, he added, “this allowed us to allocate the limited number of in-person appointments that we had at this volunteer clinic to those that were more complicated cases.”

Dr. Simpson reported that he had no relevant disclosures. The project was funded by Penn Medicine and the American Academy of Dermatology.

koakes@mdedge.com

MILAN – In a region where scabies is endemic, a strategy of mass drug treatment for scabies resulted in durable reduction of both scabies and impetigo, findings that may have implications for future treatment of scabies or other infestations in other regions, dermatologist Margot Whitfield, MD, said at the World Congress of Dermatology.

“Mass drug administration is highly effective and safe in the treatment of endemic scabies,” she said.

Using a strategy of directly observed treatment (DOT) with oral ivermectin or topical permethrin for all residents of two separate island groups in Fiji, Dr. Whitfield, together with epidemiologist Lucia Romani, PhD, both of the University of New South Wales, Sydney, and coinvestigators, demonstrated large and sustained decreases in the rates of scabies and impetigo (N Engl J Med. 2015 Dec 10;373[24]:2305-13).

Across study arms, which included a usual care arm, the baseline rate for scabies ranged from 30% to 40%. With usual care, the rate dropped from 36.6% to 18.8% at the end of 12 months, a relative reduction of 49%. However, the 15.8% prevalence rate 12 months after permethrin DOT (from 41.7%), and the 1.9% rate 12 months after ivermectin DOT (from 32.1%) – reductions of 62% and 94%, respectively – represented much larger decreases, “especially since these reductions were seen without any further interventions,” Dr. Whitfield said. “This was extremely exciting, and a game-changer as far as the management of endemic scabies is concerned.”

At baseline, impetigo rates hovered around 20%-25%, and usual care resulted in a 32% reduction at 12 months. With permethrin DOT, the impetigo rate dropped by 54%; with ivermectin DOT, the impetigo rate dropped by 67%. “The community level of impetigo went down, purely as a result of treating the scabies,” Dr. Whitfield said.

The outcomes of this study, she noted, “have contributed to the global discussion of the treatment of scabies.”

Two years after the mass drug administration (MDA) campaign, scabies prevalence remained much lower than at baseline, with clinical scabies diagnosed in 15.2% of the usual care group, 13.5% of the permethrin group, and just 3.6% of the ivermectin group. “The exciting thing for us was that these levels ... were able to be sustained at 2 years,” Dr. Whitfield noted.

The islands that had received ivermectin saw a continued decline in impetigo prevalence as well: By 24 months, impetigo was seen in 2.6% of participants in that arm.


Scabies is a neglected – but highly treatable – tropical disease, she noted. It is associated with intense pruritus, which results in reduced quality of life, and excoriations predispose those affected to bacterial superinfections, commonly impetigo in the young.

In Fiji, the scabies mite infests nearly 40% of those aged 5-9 years, and over one-third of those younger than 5 years. Rates drop steeply with increasing age and then climb again for the elderly; still, prevalence tops 10% for all Fijian age groups, Dr. Whitfield pointed out. Overall, scabies prevalence is 23% in Fiji, with resultant impetigo affecting 19% of the population.

Providing more details about the study, she said that she and her collaborators – working in conjunction with the Fijian Ministry of Health – took advantage of the geography of the island country, whose 850,000 residents live on 300 islands, to compare mass drug treatment with either ivermectin or permethrin with usual care. “We actually didn’t look for ‘infected scabies,’ ” she explained. “We looked for scabies as one outcome, and infection as another.”

The study was designed to take advantage of lessons from previous public health work addressing filariasis and soil-transmitted helminths, and addressed the following question: In Fiji, could a single round of MDA for scabies control lead to sustained reductions in scabies and impetigo prevalence 12 months later, compared with standard care?

For one MDA arm, island residents received oral ivermectin via DOT. A second DOT dose was administered for those with clinically diagnosed scabies. For pregnant and breastfeeding women, children weighing less than 15 kg, and those with ivermectin hypersensitivity, permethrin was used, Dr. Whitfield said.

The individuals in the permethrin MDA arm received one topical dose via DOT, with a second round of topical permethrin for those with topical scabies.

In all, 803 Fijians were assigned to receive standard of care, 532 permethrin MDA, and 716 ivermectin MDA. Of these, 623 received ivermectin DOT, and 93 received permethrin. In all, DOT was achieved for 96% of those receiving the first dose. At baseline, 230 patients had scabies, with 200 receiving ivermectin and 30 permethrin; the DOT rate was 100% for the second dose.

For the permethrin arm, just 307 of 532 participants (58%) had DOT, though all were given permethrin. Scabies was present at baseline for 222 participants, and of these, 181 had DOT. “It’s much easier to do the direct observed therapy with an oral medication than with a cream,” Dr. Whitfield said. Data were not collected for the Fijians who received usual care at community health centers.

Outcomes were clinically determined via the child skin assessment algorithm of the World Health Organization’s International Management of Childhood Illness (IMCI) guidelines.

Dr. Whitfield acknowledged that the study was not a true cluster-randomized trial, and differences existed between the communities studies. Also, “dermatoscopy was not a practical option” for this real-world trial in a resource-limited setting, but validated clinical criteria were used, she said.

Going forward, she and her colleagues are continuing to track durability of reduced scabies rates, as well as downstream sequelae such as impetigo and septicemia. Also, “we need to see whether this community- and island-based project could be scaled up to a national or regional level,” she said.

The burden of disease from scabies globally is probably underestimated, and changing migration patterns may bring endemic scabies to the doorsteps of more developed nations, prompting consideration of MDA as a strategy in expanded circumstances.

Dr. Whitfield reported that she had no relevant conflicts of interest.

koakes@mdedge.com

MILAN – In a region where scabies is endemic, a strategy of mass drug treatment for scabies resulted in durable reduction of both scabies and impetigo, findings that may have implications for future treatment of scabies or other infestations in other regions, dermatologist Margot Whitfield, MD, said at the World Congress of Dermatology.

“Mass drug administration is highly effective and safe in the treatment of endemic scabies,” she said.

Using a strategy of directly observed treatment (DOT) with oral ivermectin or topical permethrin for all residents of two separate island groups in Fiji, Dr. Whitfield, together with epidemiologist Lucia Romani, PhD, both of the University of New South Wales, Sydney, and coinvestigators, demonstrated large and sustained decreases in the rates of scabies and impetigo (N Engl J Med. 2015 Dec 10;373[24]:2305-13).

Across study arms, which included a usual care arm, the baseline rate for scabies ranged from 30% to 40%. With usual care, the rate dropped from 36.6% to 18.8% at the end of 12 months, a relative reduction of 49%. However, the 15.8% prevalence rate 12 months after permethrin DOT (from 41.7%), and the 1.9% rate 12 months after ivermectin DOT (from 32.1%) – reductions of 62% and 94%, respectively – represented much larger decreases, “especially since these reductions were seen without any further interventions,” Dr. Whitfield said. “This was extremely exciting, and a game-changer as far as the management of endemic scabies is concerned.”

At baseline, impetigo rates hovered around 20%-25%, and usual care resulted in a 32% reduction at 12 months. With permethrin DOT, the impetigo rate dropped by 54%; with ivermectin DOT, the impetigo rate dropped by 67%. “The community level of impetigo went down, purely as a result of treating the scabies,” Dr. Whitfield said.

The outcomes of this study, she noted, “have contributed to the global discussion of the treatment of scabies.”

Two years after the mass drug administration (MDA) campaign, scabies prevalence remained much lower than at baseline, with clinical scabies diagnosed in 15.2% of the usual care group, 13.5% of the permethrin group, and just 3.6% of the ivermectin group. “The exciting thing for us was that these levels ... were able to be sustained at 2 years,” Dr. Whitfield noted.

The islands that had received ivermectin saw a continued decline in impetigo prevalence as well: By 24 months, impetigo was seen in 2.6% of participants in that arm.


Scabies is a neglected – but highly treatable – tropical disease, she noted. It is associated with intense pruritus, which results in reduced quality of life, and excoriations predispose those affected to bacterial superinfections, commonly impetigo in the young.

In Fiji, the scabies mite infests nearly 40% of those aged 5-9 years, and over one-third of those younger than 5 years. Rates drop steeply with increasing age and then climb again for the elderly; still, prevalence tops 10% for all Fijian age groups, Dr. Whitfield pointed out. Overall, scabies prevalence is 23% in Fiji, with resultant impetigo affecting 19% of the population.

Providing more details about the study, she said that she and her collaborators – working in conjunction with the Fijian Ministry of Health – took advantage of the geography of the island country, whose 850,000 residents live on 300 islands, to compare mass drug treatment with either ivermectin or permethrin with usual care. “We actually didn’t look for ‘infected scabies,’ ” she explained. “We looked for scabies as one outcome, and infection as another.”

The study was designed to take advantage of lessons from previous public health work addressing filariasis and soil-transmitted helminths, and addressed the following question: In Fiji, could a single round of MDA for scabies control lead to sustained reductions in scabies and impetigo prevalence 12 months later, compared with standard care?

For one MDA arm, island residents received oral ivermectin via DOT. A second DOT dose was administered for those with clinically diagnosed scabies. For pregnant and breastfeeding women, children weighing less than 15 kg, and those with ivermectin hypersensitivity, permethrin was used, Dr. Whitfield said.

The individuals in the permethrin MDA arm received one topical dose via DOT, with a second round of topical permethrin for those with topical scabies.

In all, 803 Fijians were assigned to receive standard of care, 532 permethrin MDA, and 716 ivermectin MDA. Of these, 623 received ivermectin DOT, and 93 received permethrin. In all, DOT was achieved for 96% of those receiving the first dose. At baseline, 230 patients had scabies, with 200 receiving ivermectin and 30 permethrin; the DOT rate was 100% for the second dose.

For the permethrin arm, just 307 of 532 participants (58%) had DOT, though all were given permethrin. Scabies was present at baseline for 222 participants, and of these, 181 had DOT. “It’s much easier to do the direct observed therapy with an oral medication than with a cream,” Dr. Whitfield said. Data were not collected for the Fijians who received usual care at community health centers.

Outcomes were clinically determined via the child skin assessment algorithm of the World Health Organization’s International Management of Childhood Illness (IMCI) guidelines.

Dr. Whitfield acknowledged that the study was not a true cluster-randomized trial, and differences existed between the communities studies. Also, “dermatoscopy was not a practical option” for this real-world trial in a resource-limited setting, but validated clinical criteria were used, she said.

Going forward, she and her colleagues are continuing to track durability of reduced scabies rates, as well as downstream sequelae such as impetigo and septicemia. Also, “we need to see whether this community- and island-based project could be scaled up to a national or regional level,” she said.

The burden of disease from scabies globally is probably underestimated, and changing migration patterns may bring endemic scabies to the doorsteps of more developed nations, prompting consideration of MDA as a strategy in expanded circumstances.

Dr. Whitfield reported that she had no relevant conflicts of interest.

koakes@mdedge.com

MILAN – In a region where scabies is endemic, a strategy of mass drug treatment for scabies resulted in durable reduction of both scabies and impetigo, findings that may have implications for future treatment of scabies or other infestations in other regions, dermatologist Margot Whitfield, MD, said at the World Congress of Dermatology.

“Mass drug administration is highly effective and safe in the treatment of endemic scabies,” she said.

Using a strategy of directly observed treatment (DOT) with oral ivermectin or topical permethrin for all residents of two separate island groups in Fiji, Dr. Whitfield, together with epidemiologist Lucia Romani, PhD, both of the University of New South Wales, Sydney, and coinvestigators, demonstrated large and sustained decreases in the rates of scabies and impetigo (N Engl J Med. 2015 Dec 10;373[24]:2305-13).

Across study arms, which included a usual care arm, the baseline rate for scabies ranged from 30% to 40%. With usual care, the rate dropped from 36.6% to 18.8% at the end of 12 months, a relative reduction of 49%. However, the 15.8% prevalence rate 12 months after permethrin DOT (from 41.7%), and the 1.9% rate 12 months after ivermectin DOT (from 32.1%) – reductions of 62% and 94%, respectively – represented much larger decreases, “especially since these reductions were seen without any further interventions,” Dr. Whitfield said. “This was extremely exciting, and a game-changer as far as the management of endemic scabies is concerned.”

At baseline, impetigo rates hovered around 20%-25%, and usual care resulted in a 32% reduction at 12 months. With permethrin DOT, the impetigo rate dropped by 54%; with ivermectin DOT, the impetigo rate dropped by 67%. “The community level of impetigo went down, purely as a result of treating the scabies,” Dr. Whitfield said.

The outcomes of this study, she noted, “have contributed to the global discussion of the treatment of scabies.”

Two years after the mass drug administration (MDA) campaign, scabies prevalence remained much lower than at baseline, with clinical scabies diagnosed in 15.2% of the usual care group, 13.5% of the permethrin group, and just 3.6% of the ivermectin group. “The exciting thing for us was that these levels ... were able to be sustained at 2 years,” Dr. Whitfield noted.

The islands that had received ivermectin saw a continued decline in impetigo prevalence as well: By 24 months, impetigo was seen in 2.6% of participants in that arm.


Scabies is a neglected – but highly treatable – tropical disease, she noted. It is associated with intense pruritus, which results in reduced quality of life, and excoriations predispose those affected to bacterial superinfections, commonly impetigo in the young.

In Fiji, the scabies mite infests nearly 40% of those aged 5-9 years, and over one-third of those younger than 5 years. Rates drop steeply with increasing age and then climb again for the elderly; still, prevalence tops 10% for all Fijian age groups, Dr. Whitfield pointed out. Overall, scabies prevalence is 23% in Fiji, with resultant impetigo affecting 19% of the population.

Providing more details about the study, she said that she and her collaborators – working in conjunction with the Fijian Ministry of Health – took advantage of the geography of the island country, whose 850,000 residents live on 300 islands, to compare mass drug treatment with either ivermectin or permethrin with usual care. “We actually didn’t look for ‘infected scabies,’ ” she explained. “We looked for scabies as one outcome, and infection as another.”

The study was designed to take advantage of lessons from previous public health work addressing filariasis and soil-transmitted helminths, and addressed the following question: In Fiji, could a single round of MDA for scabies control lead to sustained reductions in scabies and impetigo prevalence 12 months later, compared with standard care?

For one MDA arm, island residents received oral ivermectin via DOT. A second DOT dose was administered for those with clinically diagnosed scabies. For pregnant and breastfeeding women, children weighing less than 15 kg, and those with ivermectin hypersensitivity, permethrin was used, Dr. Whitfield said.

The individuals in the permethrin MDA arm received one topical dose via DOT, with a second round of topical permethrin for those with topical scabies.

In all, 803 Fijians were assigned to receive standard of care, 532 permethrin MDA, and 716 ivermectin MDA. Of these, 623 received ivermectin DOT, and 93 received permethrin. In all, DOT was achieved for 96% of those receiving the first dose. At baseline, 230 patients had scabies, with 200 receiving ivermectin and 30 permethrin; the DOT rate was 100% for the second dose.

For the permethrin arm, just 307 of 532 participants (58%) had DOT, though all were given permethrin. Scabies was present at baseline for 222 participants, and of these, 181 had DOT. “It’s much easier to do the direct observed therapy with an oral medication than with a cream,” Dr. Whitfield said. Data were not collected for the Fijians who received usual care at community health centers.

Outcomes were clinically determined via the child skin assessment algorithm of the World Health Organization’s International Management of Childhood Illness (IMCI) guidelines.

Dr. Whitfield acknowledged that the study was not a true cluster-randomized trial, and differences existed between the communities studies. Also, “dermatoscopy was not a practical option” for this real-world trial in a resource-limited setting, but validated clinical criteria were used, she said.

Going forward, she and her colleagues are continuing to track durability of reduced scabies rates, as well as downstream sequelae such as impetigo and septicemia. Also, “we need to see whether this community- and island-based project could be scaled up to a national or regional level,” she said.

The burden of disease from scabies globally is probably underestimated, and changing migration patterns may bring endemic scabies to the doorsteps of more developed nations, prompting consideration of MDA as a strategy in expanded circumstances.

Dr. Whitfield reported that she had no relevant conflicts of interest.

koakes@mdedge.com

Based on the areas of necrosis, the FP suspected that a brown recluse spider bite caused the lesions. He suspected that the whole area of swelling and erythema was the bite reaction, and the 3 ulcerated areas were the regions of necrosis (often there is only 1 central area). The FP considered cellulitis as part of the differential diagnosis and debated whether to prescribe an antibiotic.

While the patient and FP believed that the most likely diagnosis was a spider bite, they were not completely certain of this diagnosis because the patient never saw the spider. Therefore, the patient requested an antibiotic in case this was a bacterial infection. A bacterial culture of the ulcer was performed and the patient was given a 5-day course of oral cephalexin 500 mg 4 times a day.

The FP recommended over-the-counter oral diphenhydramine to be taken around the clock as tolerated along with ibuprofen at mealtimes. The FP kept in contact with the patient by phone and improvement was noted daily. The bacterial culture came back negative, and the lesions all healed with time.

Spider bites can be difficult to diagnose as many lesions are blamed on spiders without evidence of a bite or spider. Conversely, spider bites may be missed as the spider is not typically available for easy identification. To this day, the FP and patient believe these lesions were the work of a brown recluse spider.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux, EJ, Usatine R. Pyoderma gangrenosum. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill; 2019:1147-1152.

To learn more about the newest 3rd edition of the Color Atlas and Synopsis of Family Medicine, see: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/

You can get the Color Atlas of Family Medicine app by clicking on this link: usatinemedia.com

Based on the areas of necrosis, the FP suspected that a brown recluse spider bite caused the lesions. He suspected that the whole area of swelling and erythema was the bite reaction, and the 3 ulcerated areas were the regions of necrosis (often there is only 1 central area). The FP considered cellulitis as part of the differential diagnosis and debated whether to prescribe an antibiotic.

While the patient and FP believed that the most likely diagnosis was a spider bite, they were not completely certain of this diagnosis because the patient never saw the spider. Therefore, the patient requested an antibiotic in case this was a bacterial infection. A bacterial culture of the ulcer was performed and the patient was given a 5-day course of oral cephalexin 500 mg 4 times a day.

The FP recommended over-the-counter oral diphenhydramine to be taken around the clock as tolerated along with ibuprofen at mealtimes. The FP kept in contact with the patient by phone and improvement was noted daily. The bacterial culture came back negative, and the lesions all healed with time.

Spider bites can be difficult to diagnose as many lesions are blamed on spiders without evidence of a bite or spider. Conversely, spider bites may be missed as the spider is not typically available for easy identification. To this day, the FP and patient believe these lesions were the work of a brown recluse spider.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux, EJ, Usatine R. Pyoderma gangrenosum. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill; 2019:1147-1152.

To learn more about the newest 3rd edition of the Color Atlas and Synopsis of Family Medicine, see: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/

You can get the Color Atlas of Family Medicine app by clicking on this link: usatinemedia.com

Based on the areas of necrosis, the FP suspected that a brown recluse spider bite caused the lesions. He suspected that the whole area of swelling and erythema was the bite reaction, and the 3 ulcerated areas were the regions of necrosis (often there is only 1 central area). The FP considered cellulitis as part of the differential diagnosis and debated whether to prescribe an antibiotic.

While the patient and FP believed that the most likely diagnosis was a spider bite, they were not completely certain of this diagnosis because the patient never saw the spider. Therefore, the patient requested an antibiotic in case this was a bacterial infection. A bacterial culture of the ulcer was performed and the patient was given a 5-day course of oral cephalexin 500 mg 4 times a day.

The FP recommended over-the-counter oral diphenhydramine to be taken around the clock as tolerated along with ibuprofen at mealtimes. The FP kept in contact with the patient by phone and improvement was noted daily. The bacterial culture came back negative, and the lesions all healed with time.

Spider bites can be difficult to diagnose as many lesions are blamed on spiders without evidence of a bite or spider. Conversely, spider bites may be missed as the spider is not typically available for easy identification. To this day, the FP and patient believe these lesions were the work of a brown recluse spider.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux, EJ, Usatine R. Pyoderma gangrenosum. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill; 2019:1147-1152.

To learn more about the newest 3rd edition of the Color Atlas and Synopsis of Family Medicine, see: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/

You can get the Color Atlas of Family Medicine app by clicking on this link: usatinemedia.com

Acute graft-vs-host disease (GVHD) is a T-cell mediated immunogenic response in which T lymphocytes from a donor regard host tissue as foreign and attack it in the setting of immunosuppression.¹ The most common cause of acute GVHD is allogeneic stem cell transplantation, with solid-organ transplantation being a much less common cause.² The incidence of acute GVHD following orthotopic liver transplantation (OLT) is 0.1%, as reported by the United Network for Organ Sharing, compared to an incidence of 40% to 60% in hematopoietic stem cell transplant recipients.^3,4

Early recognition and treatment of acute GVHD following liver transplantation is imperative, as the mortality rate is 85% to 90%.² We present a case of acute GVHD in a liver transplantation patient, with a focus on diagnostic criteria and comparison to acute GVHD following hematopoietic stem cell transplantation.

Case Report

A 68-year-old woman with a history of hepatitis C virus infection, hepatocellular carcinoma, and OLT 1 month prior presented to the hospital with fever and abdominal cellulitis in close proximity to the surgical site of 1 week’s duration. The patient was started on vancomycin and cefepime; pan cultures were performed.

At 10 days of hospitalization, the patient developed a pruritic, nontender, erythematous rash on the abdomen, with extension onto the chest and legs. The rash was associated with low-grade fever but not with diarrhea. Physical examination was notable for a few erythematous macules and scattered papules over the neck and chest and a large erythematous plaque with multiple ecchymoses over the lower abdomen (Figure 1A). Erythematous macules and papules coalescing into plaques were present on the lower back (Figure 1B) and proximal thighs. Oral, ocular, and genital lesions were absent.

Over a 2-day period, the rash progressed to diffuse erythematous papules over the chest (Figure 2A) and bilateral arms (Figure 2B) including the palms. The patient also developed erythematous papules over the jawline and forehead as well as confluent erythematous plaques over the back with extension of the rash to involve the legs. She also had erythema and swelling bilaterally over the ears. She reported diarrhea. The low-grade fever resolved.

Comment

GVHD Subtypes
The 2 types of GVHD are humoral and cellular.⁵ The humoral type results from ABO blood type incompatibility between donor and recipient and causes mild hemolytic anemia and fever. The cellular type is directed against major histocompatibility complexes and is associated with high morbidity and mortality.

Presentation of GVHD
Acute GVHD following OLT usually occurs 3 to 5 weeks after transplantation,⁶ as in our patient. Symptoms include rash, fever, pancytopenia, and diarrhea.² Skin is the most commonly involved organ in acute GVHD; rash is the earliest manifestation.¹ The rash can be asymptomatic or associated with pain and pruritus. Initial cutaneous manifestations include palmar erythema and erythematous to violaceous discoloration of the face and ears. A diffuse maculopapular rash can develop, involving the face, abdomen, and trunk. The rash may progress to formation of bullae or skin sloughing, resembling Stevens-Johnson syndrome or toxic epidermal necrolysis.¹ The skin manifestation of acute GVHD following OLT is similar to hematopoietic stem cell transplantation (Table).^7,8

Prevention
Acute GVHD following OLT can be prevented by eliminating donor T lymphocytes from the liver before transplantation. However, because the incidence of acute GVHD following OLT is very low, this approach is not routinely taken.²

Conclusion

Acute GVHD following liver transplantation is a rare complication; however, it has high mortality, necessitating further research regarding treatment and prevention. Early recognition and treatment of this condition can improve outcomes. Dermatologists should be familiar with the skin manifestations of acute GVHD following liver transplantation due to the rising number of cases of solid-organ transplantation.

Acute graft-vs-host disease (GVHD) is a T-cell mediated immunogenic response in which T lymphocytes from a donor regard host tissue as foreign and attack it in the setting of immunosuppression.¹ The most common cause of acute GVHD is allogeneic stem cell transplantation, with solid-organ transplantation being a much less common cause.² The incidence of acute GVHD following orthotopic liver transplantation (OLT) is 0.1%, as reported by the United Network for Organ Sharing, compared to an incidence of 40% to 60% in hematopoietic stem cell transplant recipients.^3,4

Early recognition and treatment of acute GVHD following liver transplantation is imperative, as the mortality rate is 85% to 90%.² We present a case of acute GVHD in a liver transplantation patient, with a focus on diagnostic criteria and comparison to acute GVHD following hematopoietic stem cell transplantation.

Case Report

A 68-year-old woman with a history of hepatitis C virus infection, hepatocellular carcinoma, and OLT 1 month prior presented to the hospital with fever and abdominal cellulitis in close proximity to the surgical site of 1 week’s duration. The patient was started on vancomycin and cefepime; pan cultures were performed.

At 10 days of hospitalization, the patient developed a pruritic, nontender, erythematous rash on the abdomen, with extension onto the chest and legs. The rash was associated with low-grade fever but not with diarrhea. Physical examination was notable for a few erythematous macules and scattered papules over the neck and chest and a large erythematous plaque with multiple ecchymoses over the lower abdomen (Figure 1A). Erythematous macules and papules coalescing into plaques were present on the lower back (Figure 1B) and proximal thighs. Oral, ocular, and genital lesions were absent.

Over a 2-day period, the rash progressed to diffuse erythematous papules over the chest (Figure 2A) and bilateral arms (Figure 2B) including the palms. The patient also developed erythematous papules over the jawline and forehead as well as confluent erythematous plaques over the back with extension of the rash to involve the legs. She also had erythema and swelling bilaterally over the ears. She reported diarrhea. The low-grade fever resolved.

Comment

GVHD Subtypes
The 2 types of GVHD are humoral and cellular.⁵ The humoral type results from ABO blood type incompatibility between donor and recipient and causes mild hemolytic anemia and fever. The cellular type is directed against major histocompatibility complexes and is associated with high morbidity and mortality.

Presentation of GVHD
Acute GVHD following OLT usually occurs 3 to 5 weeks after transplantation,⁶ as in our patient. Symptoms include rash, fever, pancytopenia, and diarrhea.² Skin is the most commonly involved organ in acute GVHD; rash is the earliest manifestation.¹ The rash can be asymptomatic or associated with pain and pruritus. Initial cutaneous manifestations include palmar erythema and erythematous to violaceous discoloration of the face and ears. A diffuse maculopapular rash can develop, involving the face, abdomen, and trunk. The rash may progress to formation of bullae or skin sloughing, resembling Stevens-Johnson syndrome or toxic epidermal necrolysis.¹ The skin manifestation of acute GVHD following OLT is similar to hematopoietic stem cell transplantation (Table).^7,8

Prevention
Acute GVHD following OLT can be prevented by eliminating donor T lymphocytes from the liver before transplantation. However, because the incidence of acute GVHD following OLT is very low, this approach is not routinely taken.²

Conclusion

Acute GVHD following liver transplantation is a rare complication; however, it has high mortality, necessitating further research regarding treatment and prevention. Early recognition and treatment of this condition can improve outcomes. Dermatologists should be familiar with the skin manifestations of acute GVHD following liver transplantation due to the rising number of cases of solid-organ transplantation.

Acute graft-vs-host disease (GVHD) is a T-cell mediated immunogenic response in which T lymphocytes from a donor regard host tissue as foreign and attack it in the setting of immunosuppression.¹ The most common cause of acute GVHD is allogeneic stem cell transplantation, with solid-organ transplantation being a much less common cause.² The incidence of acute GVHD following orthotopic liver transplantation (OLT) is 0.1%, as reported by the United Network for Organ Sharing, compared to an incidence of 40% to 60% in hematopoietic stem cell transplant recipients.^3,4

Early recognition and treatment of acute GVHD following liver transplantation is imperative, as the mortality rate is 85% to 90%.² We present a case of acute GVHD in a liver transplantation patient, with a focus on diagnostic criteria and comparison to acute GVHD following hematopoietic stem cell transplantation.

Case Report

A 68-year-old woman with a history of hepatitis C virus infection, hepatocellular carcinoma, and OLT 1 month prior presented to the hospital with fever and abdominal cellulitis in close proximity to the surgical site of 1 week’s duration. The patient was started on vancomycin and cefepime; pan cultures were performed.

At 10 days of hospitalization, the patient developed a pruritic, nontender, erythematous rash on the abdomen, with extension onto the chest and legs. The rash was associated with low-grade fever but not with diarrhea. Physical examination was notable for a few erythematous macules and scattered papules over the neck and chest and a large erythematous plaque with multiple ecchymoses over the lower abdomen (Figure 1A). Erythematous macules and papules coalescing into plaques were present on the lower back (Figure 1B) and proximal thighs. Oral, ocular, and genital lesions were absent.

Over a 2-day period, the rash progressed to diffuse erythematous papules over the chest (Figure 2A) and bilateral arms (Figure 2B) including the palms. The patient also developed erythematous papules over the jawline and forehead as well as confluent erythematous plaques over the back with extension of the rash to involve the legs. She also had erythema and swelling bilaterally over the ears. She reported diarrhea. The low-grade fever resolved.

Comment

GVHD Subtypes
The 2 types of GVHD are humoral and cellular.⁵ The humoral type results from ABO blood type incompatibility between donor and recipient and causes mild hemolytic anemia and fever. The cellular type is directed against major histocompatibility complexes and is associated with high morbidity and mortality.

Presentation of GVHD
Acute GVHD following OLT usually occurs 3 to 5 weeks after transplantation,⁶ as in our patient. Symptoms include rash, fever, pancytopenia, and diarrhea.² Skin is the most commonly involved organ in acute GVHD; rash is the earliest manifestation.¹ The rash can be asymptomatic or associated with pain and pruritus. Initial cutaneous manifestations include palmar erythema and erythematous to violaceous discoloration of the face and ears. A diffuse maculopapular rash can develop, involving the face, abdomen, and trunk. The rash may progress to formation of bullae or skin sloughing, resembling Stevens-Johnson syndrome or toxic epidermal necrolysis.¹ The skin manifestation of acute GVHD following OLT is similar to hematopoietic stem cell transplantation (Table).^7,8

Prevention
Acute GVHD following OLT can be prevented by eliminating donor T lymphocytes from the liver before transplantation. However, because the incidence of acute GVHD following OLT is very low, this approach is not routinely taken.²

Conclusion

Acute GVHD following liver transplantation is a rare complication; however, it has high mortality, necessitating further research regarding treatment and prevention. Early recognition and treatment of this condition can improve outcomes. Dermatologists should be familiar with the skin manifestations of acute GVHD following liver transplantation due to the rising number of cases of solid-organ transplantation.

A 97-year-old woman with a history of atrial fibrillation and nonmelanoma skin cancer presented to our clinic from an assisted living facility with a several-month history of rapidly growing forehead lesions. She denied symptoms, other than some bleeding and crusting, but was concerned about their appearance. She reported a notable history of sun exposure.

The patient had 3 confluent, but distinct, lesions on her forehead: an erythematous crateriform nodule with overlying hyperkeratotic scale (FIGURE, Lesion A); a nodular hyperpigmented plaque with irregular color and borders (Lesion B); and a pearly well-vascularized erythematous nodule with surrounding hemorrhagic crust (Lesion C).

She also had scattered, thin, gritty pink papules and plaques on the face that were thought to be actinic keratosis and nonmelanoma skin cancers based on clinical morphology; however, the patient deferred workup and treatment of these lesions to focus on the forehead lesions. The decision was made to biopsy all 3 clinical morphologies seen. The risks and benefits of biopsy were reviewed with the patient and her daughter, and they opted to proceed. The areas were anesthetized with an injection of 1% lidocaine and epinephrine 1:100,000; 3 shave biopsies were performed. Hemostasis was obtained with electrodesiccation.

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

 

 

Diagnosis: Skin cancer

A histopathology report revealed that Lesion A was squamous cell carcinoma (SCC), Lesion B was a melanoma with a Breslow depth of at least 1.2 mm, and Lesion C was basal cell carcinoma (BCC). It is unusual to have a patient present with BCC, SCC, and melanoma concurrently in the same anatomic region.

Two of the lesions were nonmelanoma skin cancers (NMSC). BCC is the most common NMSC in the United States, affecting more than 3.3 million people per year.¹ Although there are several subtypes of BCC with varying clinical presentations, the most classic appearance is a pearly papule with or without surface telangiectasias.²

The findings in this case serve as an important reminder to biopsy lesions with varying morphologies even when they are in close proximity to one another.

SCC has an incidence of 200,000 to 400,000 cases per year in the United States and the lifetime risk is 9% to 14% in men and 4% to 9% in women.³ SCC most commonly presents as a hyperkeratotic papule or plaque.² Lesions suspicious for SCC and BCC should be biopsied and the diagnosis confirmed by histopathologic analysis. These NMSCs are locally destructive, but rarely metastatic with a generally good prognosis. The standard treatment for both is surgical excision with consideration for other treatment modalities, such as topical therapies, chemotherapy, and radiation, depending on tumor characteristics as well as whether the patient is a good surgical candidate.^1,3

Melanoma is rising in incidence each year, with nearly 100,000 new cases expected in the United States this year.⁴ It is the leading cause of skin cancer related mortality.⁵ The most common suspicious lesions are variably pigmented macules with irregular borders. Biopsy and subsequent histopathologic analysis will confirm the diagnosis.

When a lesion is clinically suspicious for melanoma, it is particularly important to consider an excisional biopsy to allow for proper staging.⁵ Examples of appropriate excisional biopsies include elliptical excisions, punch biopsies, and deep shave biopsies.⁵ Definitive treatment involves a wider and deeper excision with histologically confirmed clear margins.⁵

Continue to: This case required a multidisciplinary team

This case required a multidisciplinary team

The patient underwent magnetic resonance imaging and positron emission tomography/computed tomography; the scans revealed no metastatic disease. She was evaluated by a multidisciplinary head and neck cancer team, and various treatment options were explored. Resection typically is the definitive treatment for localized cutaneous melanoma; however, given the configuration of the lesions, it was deemed impractical to resect this patient’s melanoma and not the other lesions. Radiotherapy can be effective for BCC and SCC, but it is traditionally not as effective for melanoma.⁶ The options presented to the patient were radiotherapy or surgical resection to all 3 lesions, and she decided to pursue resection.

The patient was cleared for surgery; however, after the patient held her warfarin in preparation for the resection, she suffered a left frontal operculum infarction. At this point, she was re-evaluated by her head and neck physician, cardiologist, and anesthesiologist. Consensus was reached that the patient was at high perioperative risk for morbidity and mortality, and surgical intervention was no longer considered a viable option.

The patient then opted for palliative radiation therapy to all 3 lesions, with the understanding that the local control offered by radiotherapy would be inferior to what resection would provide for the melanoma lesion. Although not curative, radiotherapy was expected to provide local symptom relief for the melanoma, consistent with the patient’s palliative goals of care. In the past, melanoma was thought to be resistant to radiation, but recent evidence suggests that it may be at least partially susceptible to hypofractionated courses of radiation.⁶

Radiation oncology recommended a 6 to 15 fraction regimen and she had a good clinical response with > 50% decrease in the size of all 3 lesions along with cessation of bleeding.

The take-home lesson. The findings in this case serve as an important reminder to biopsy lesions with varying morphologies—even when they are in close proximity to one another. Foregoing any of the biopsies in this case would have led to a missed diagnosis, which has implications for optimal management and treatment.

CORRESPONDENCE
Jennifer L. Hsiao, MD, 2020 Santa Monica Boulevard, Suite 510, Santa Monica, CA 90404; jhsiao@mednet.ucla.edu

A 97-year-old woman with a history of atrial fibrillation and nonmelanoma skin cancer presented to our clinic from an assisted living facility with a several-month history of rapidly growing forehead lesions. She denied symptoms, other than some bleeding and crusting, but was concerned about their appearance. She reported a notable history of sun exposure.

The patient had 3 confluent, but distinct, lesions on her forehead: an erythematous crateriform nodule with overlying hyperkeratotic scale (FIGURE, Lesion A); a nodular hyperpigmented plaque with irregular color and borders (Lesion B); and a pearly well-vascularized erythematous nodule with surrounding hemorrhagic crust (Lesion C).

She also had scattered, thin, gritty pink papules and plaques on the face that were thought to be actinic keratosis and nonmelanoma skin cancers based on clinical morphology; however, the patient deferred workup and treatment of these lesions to focus on the forehead lesions. The decision was made to biopsy all 3 clinical morphologies seen. The risks and benefits of biopsy were reviewed with the patient and her daughter, and they opted to proceed. The areas were anesthetized with an injection of 1% lidocaine and epinephrine 1:100,000; 3 shave biopsies were performed. Hemostasis was obtained with electrodesiccation.

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

 

 

Diagnosis: Skin cancer

A histopathology report revealed that Lesion A was squamous cell carcinoma (SCC), Lesion B was a melanoma with a Breslow depth of at least 1.2 mm, and Lesion C was basal cell carcinoma (BCC). It is unusual to have a patient present with BCC, SCC, and melanoma concurrently in the same anatomic region.

Two of the lesions were nonmelanoma skin cancers (NMSC). BCC is the most common NMSC in the United States, affecting more than 3.3 million people per year.¹ Although there are several subtypes of BCC with varying clinical presentations, the most classic appearance is a pearly papule with or without surface telangiectasias.²

The findings in this case serve as an important reminder to biopsy lesions with varying morphologies even when they are in close proximity to one another.

SCC has an incidence of 200,000 to 400,000 cases per year in the United States and the lifetime risk is 9% to 14% in men and 4% to 9% in women.³ SCC most commonly presents as a hyperkeratotic papule or plaque.² Lesions suspicious for SCC and BCC should be biopsied and the diagnosis confirmed by histopathologic analysis. These NMSCs are locally destructive, but rarely metastatic with a generally good prognosis. The standard treatment for both is surgical excision with consideration for other treatment modalities, such as topical therapies, chemotherapy, and radiation, depending on tumor characteristics as well as whether the patient is a good surgical candidate.^1,3

Melanoma is rising in incidence each year, with nearly 100,000 new cases expected in the United States this year.⁴ It is the leading cause of skin cancer related mortality.⁵ The most common suspicious lesions are variably pigmented macules with irregular borders. Biopsy and subsequent histopathologic analysis will confirm the diagnosis.

When a lesion is clinically suspicious for melanoma, it is particularly important to consider an excisional biopsy to allow for proper staging.⁵ Examples of appropriate excisional biopsies include elliptical excisions, punch biopsies, and deep shave biopsies.⁵ Definitive treatment involves a wider and deeper excision with histologically confirmed clear margins.⁵

Continue to: This case required a multidisciplinary team

This case required a multidisciplinary team

The patient underwent magnetic resonance imaging and positron emission tomography/computed tomography; the scans revealed no metastatic disease. She was evaluated by a multidisciplinary head and neck cancer team, and various treatment options were explored. Resection typically is the definitive treatment for localized cutaneous melanoma; however, given the configuration of the lesions, it was deemed impractical to resect this patient’s melanoma and not the other lesions. Radiotherapy can be effective for BCC and SCC, but it is traditionally not as effective for melanoma.⁶ The options presented to the patient were radiotherapy or surgical resection to all 3 lesions, and she decided to pursue resection.

The patient was cleared for surgery; however, after the patient held her warfarin in preparation for the resection, she suffered a left frontal operculum infarction. At this point, she was re-evaluated by her head and neck physician, cardiologist, and anesthesiologist. Consensus was reached that the patient was at high perioperative risk for morbidity and mortality, and surgical intervention was no longer considered a viable option.

The patient then opted for palliative radiation therapy to all 3 lesions, with the understanding that the local control offered by radiotherapy would be inferior to what resection would provide for the melanoma lesion. Although not curative, radiotherapy was expected to provide local symptom relief for the melanoma, consistent with the patient’s palliative goals of care. In the past, melanoma was thought to be resistant to radiation, but recent evidence suggests that it may be at least partially susceptible to hypofractionated courses of radiation.⁶

Radiation oncology recommended a 6 to 15 fraction regimen and she had a good clinical response with > 50% decrease in the size of all 3 lesions along with cessation of bleeding.

The take-home lesson. The findings in this case serve as an important reminder to biopsy lesions with varying morphologies—even when they are in close proximity to one another. Foregoing any of the biopsies in this case would have led to a missed diagnosis, which has implications for optimal management and treatment.

CORRESPONDENCE
Jennifer L. Hsiao, MD, 2020 Santa Monica Boulevard, Suite 510, Santa Monica, CA 90404; jhsiao@mednet.ucla.edu

A 97-year-old woman with a history of atrial fibrillation and nonmelanoma skin cancer presented to our clinic from an assisted living facility with a several-month history of rapidly growing forehead lesions. She denied symptoms, other than some bleeding and crusting, but was concerned about their appearance. She reported a notable history of sun exposure.

The patient had 3 confluent, but distinct, lesions on her forehead: an erythematous crateriform nodule with overlying hyperkeratotic scale (FIGURE, Lesion A); a nodular hyperpigmented plaque with irregular color and borders (Lesion B); and a pearly well-vascularized erythematous nodule with surrounding hemorrhagic crust (Lesion C).

She also had scattered, thin, gritty pink papules and plaques on the face that were thought to be actinic keratosis and nonmelanoma skin cancers based on clinical morphology; however, the patient deferred workup and treatment of these lesions to focus on the forehead lesions. The decision was made to biopsy all 3 clinical morphologies seen. The risks and benefits of biopsy were reviewed with the patient and her daughter, and they opted to proceed. The areas were anesthetized with an injection of 1% lidocaine and epinephrine 1:100,000; 3 shave biopsies were performed. Hemostasis was obtained with electrodesiccation.

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

 

 

Diagnosis: Skin cancer

A histopathology report revealed that Lesion A was squamous cell carcinoma (SCC), Lesion B was a melanoma with a Breslow depth of at least 1.2 mm, and Lesion C was basal cell carcinoma (BCC). It is unusual to have a patient present with BCC, SCC, and melanoma concurrently in the same anatomic region.

Two of the lesions were nonmelanoma skin cancers (NMSC). BCC is the most common NMSC in the United States, affecting more than 3.3 million people per year.¹ Although there are several subtypes of BCC with varying clinical presentations, the most classic appearance is a pearly papule with or without surface telangiectasias.²

The findings in this case serve as an important reminder to biopsy lesions with varying morphologies even when they are in close proximity to one another.

SCC has an incidence of 200,000 to 400,000 cases per year in the United States and the lifetime risk is 9% to 14% in men and 4% to 9% in women.³ SCC most commonly presents as a hyperkeratotic papule or plaque.² Lesions suspicious for SCC and BCC should be biopsied and the diagnosis confirmed by histopathologic analysis. These NMSCs are locally destructive, but rarely metastatic with a generally good prognosis. The standard treatment for both is surgical excision with consideration for other treatment modalities, such as topical therapies, chemotherapy, and radiation, depending on tumor characteristics as well as whether the patient is a good surgical candidate.^1,3

Melanoma is rising in incidence each year, with nearly 100,000 new cases expected in the United States this year.⁴ It is the leading cause of skin cancer related mortality.⁵ The most common suspicious lesions are variably pigmented macules with irregular borders. Biopsy and subsequent histopathologic analysis will confirm the diagnosis.

When a lesion is clinically suspicious for melanoma, it is particularly important to consider an excisional biopsy to allow for proper staging.⁵ Examples of appropriate excisional biopsies include elliptical excisions, punch biopsies, and deep shave biopsies.⁵ Definitive treatment involves a wider and deeper excision with histologically confirmed clear margins.⁵

Continue to: This case required a multidisciplinary team

This case required a multidisciplinary team

The patient underwent magnetic resonance imaging and positron emission tomography/computed tomography; the scans revealed no metastatic disease. She was evaluated by a multidisciplinary head and neck cancer team, and various treatment options were explored. Resection typically is the definitive treatment for localized cutaneous melanoma; however, given the configuration of the lesions, it was deemed impractical to resect this patient’s melanoma and not the other lesions. Radiotherapy can be effective for BCC and SCC, but it is traditionally not as effective for melanoma.⁶ The options presented to the patient were radiotherapy or surgical resection to all 3 lesions, and she decided to pursue resection.

The patient was cleared for surgery; however, after the patient held her warfarin in preparation for the resection, she suffered a left frontal operculum infarction. At this point, she was re-evaluated by her head and neck physician, cardiologist, and anesthesiologist. Consensus was reached that the patient was at high perioperative risk for morbidity and mortality, and surgical intervention was no longer considered a viable option.

The patient then opted for palliative radiation therapy to all 3 lesions, with the understanding that the local control offered by radiotherapy would be inferior to what resection would provide for the melanoma lesion. Although not curative, radiotherapy was expected to provide local symptom relief for the melanoma, consistent with the patient’s palliative goals of care. In the past, melanoma was thought to be resistant to radiation, but recent evidence suggests that it may be at least partially susceptible to hypofractionated courses of radiation.⁶

Radiation oncology recommended a 6 to 15 fraction regimen and she had a good clinical response with > 50% decrease in the size of all 3 lesions along with cessation of bleeding.

The take-home lesson. The findings in this case serve as an important reminder to biopsy lesions with varying morphologies—even when they are in close proximity to one another. Foregoing any of the biopsies in this case would have led to a missed diagnosis, which has implications for optimal management and treatment.

CORRESPONDENCE
Jennifer L. Hsiao, MD, 2020 Santa Monica Boulevard, Suite 510, Santa Monica, CA 90404; jhsiao@mednet.ucla.edu

The FP recognized this as classic pyoderma gangrenosum (PG)—a challenging condition to treat and not within the typical scope of practice for an FP. Nonhealing, well-defined leg ulcers in a person with Crohn's disease (or any type of inflammatory bowel disease) are often seen with PG. Pathergy—the development of an exaggerated injury following minor trauma—is known to occur with PG.

The FP also noted the violet-blue coloration around the borders of the ulcers, which is referred to as a “gun-metal border.” He considered doing a biopsy on the edge of the ulcer to rule out other conditions and to see if there was a neutrophilic infiltrate that is typically seen with PG. However, the FP realized that pathergy could be stimulated by a biopsy, so he decided to refer the patient to Dermatology.

Knowing that the patient might have to wait a few months to see a dermatologist, the FP consulted online sources and prescribed topical clobetasol ointment to be applied twice daily as an initial therapy. This was not successful, so after a phone consult with the dermatologist, the FP added oral prednisone 40 mg/d for the next 2 weeks until the dermatologist could see the patient.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux, EJ, Usatine R. Pyoderma gangrenosum. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill; 2019:1147-1152.

To learn more about the newest 3rd edition of the Color Atlas and Synopsis of Family Medicine, see: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/

You can get the Color Atlas of Family Medicine app by clicking on this link: usatinemedia.com

The FP recognized this as classic pyoderma gangrenosum (PG)—a challenging condition to treat and not within the typical scope of practice for an FP. Nonhealing, well-defined leg ulcers in a person with Crohn's disease (or any type of inflammatory bowel disease) are often seen with PG. Pathergy—the development of an exaggerated injury following minor trauma—is known to occur with PG.

The FP also noted the violet-blue coloration around the borders of the ulcers, which is referred to as a “gun-metal border.” He considered doing a biopsy on the edge of the ulcer to rule out other conditions and to see if there was a neutrophilic infiltrate that is typically seen with PG. However, the FP realized that pathergy could be stimulated by a biopsy, so he decided to refer the patient to Dermatology.

Knowing that the patient might have to wait a few months to see a dermatologist, the FP consulted online sources and prescribed topical clobetasol ointment to be applied twice daily as an initial therapy. This was not successful, so after a phone consult with the dermatologist, the FP added oral prednisone 40 mg/d for the next 2 weeks until the dermatologist could see the patient.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux, EJ, Usatine R. Pyoderma gangrenosum. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill; 2019:1147-1152.

To learn more about the newest 3rd edition of the Color Atlas and Synopsis of Family Medicine, see: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/

You can get the Color Atlas of Family Medicine app by clicking on this link: usatinemedia.com

The FP recognized this as classic pyoderma gangrenosum (PG)—a challenging condition to treat and not within the typical scope of practice for an FP. Nonhealing, well-defined leg ulcers in a person with Crohn's disease (or any type of inflammatory bowel disease) are often seen with PG. Pathergy—the development of an exaggerated injury following minor trauma—is known to occur with PG.

The FP also noted the violet-blue coloration around the borders of the ulcers, which is referred to as a “gun-metal border.” He considered doing a biopsy on the edge of the ulcer to rule out other conditions and to see if there was a neutrophilic infiltrate that is typically seen with PG. However, the FP realized that pathergy could be stimulated by a biopsy, so he decided to refer the patient to Dermatology.

Knowing that the patient might have to wait a few months to see a dermatologist, the FP consulted online sources and prescribed topical clobetasol ointment to be applied twice daily as an initial therapy. This was not successful, so after a phone consult with the dermatologist, the FP added oral prednisone 40 mg/d for the next 2 weeks until the dermatologist could see the patient.

‌

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Mayeaux, EJ, Usatine R. Pyoderma gangrenosum. In: Usatine R, Smith M, Mayeaux EJ, et al. Color Atlas and Synopsis of Family Medicine. 3rd ed. New York, NY: McGraw-Hill; 2019:1147-1152.

To learn more about the newest 3rd edition of the Color Atlas and Synopsis of Family Medicine, see: https://www.amazon.com/Color-Atlas-Synopsis-Family-Medicine/dp/1259862046/

You can get the Color Atlas of Family Medicine app by clicking on this link: usatinemedia.com

For several years, this 16-year-old boy has had severe acne on his chest and back. The condition has steadily worsened despite use of OTC medications, including benzoyl peroxide–containing topical products. He has never received prescription treatment. His primary care provider, concerned that something more than acne could be involved, refers him to dermatology for evaluation and treatment.

The boy’s health is reportedly otherwise excellent. Family history is positive for severe acne on both sides of his family; two of his older siblings have had similar problems.

EXAMINATION
The central portion of the boy’s chest is covered by an impressive collection of discrete and confluent crusts and erosions. Some are quite deep, and the patient admits to picking at them. Little if any erythema surrounds the lesions.

Very little acne is seen on the boy’s face, but fairly dense acne vulgaris is observed on his upper back.

Following a brief but thorough discussion, the decision is made to start therapy with low-dose isotretinoin (20 mg/d), after the appropriate bloodwork is obtained. Within a week, the patient presents to the emergency department (ED) for worsening of his chest acne, along with pain and bleeding from some of the lesions.

What’s the diagnosis?

DISCUSSION
The risk for granulation tissue formation is a well-known though rare adverse effect of isotretinoin use—one that had been discussed thoroughly with the patient and his parents prior to prescription. There is no unanimity of opinion regarding the mechanism whereby this response occurs, but it is real. It can affect such areas as seen in this patient’s case but also causes a similar problem in the perionychial tissues, creating a condition quite similar to an ingrown toenail (cryptonychia). This author has also seen the same phenomenon in fingernails.

In this patient’s case, after discharge from the ED, he presented immediately to his primary care provider, who in turn called the dermatology clinic. When we saw him, there was clear evidence of inappropriate granulation formation—far worse than the initial acne had been.

The patient was given an intramuscular injection of 40 mg triamcinolone and prescribed minocycline 100 mg bid. He had already stopped taking the isotretinoin and was strongly advised not to restart it for the foreseeable future. In hindsight, he probably should have been started on minocycline and a 3-week prednisone taper to calm down his chest acne before the isotretinoin was started.

At a follow-up appointment 3 weeks later, his condition was much improved (at least back to baseline). But he will almost certainly develop hypertrophic scarring on his chest—and given the severity of his acne and the strong family history, he may well have a suboptimal response to isotretinoin when and if we return to that medication.

TAKE-HOME LEARNING POINTS

• In rare instances, isotretinoin therapy can trigger the formation of inappropriate granulation tissue on the face, back, chest, and even perionychial areas.
• There is evidence that the more inflamed the acne, the greater the likelihood of this adverse effect.
• With severely inflamed acne, consideration should be given to using small initial doses of isotretinoin or decreasing the inflammation through use of systemic steroids or doxycycline or minocycline.

For several years, this 16-year-old boy has had severe acne on his chest and back. The condition has steadily worsened despite use of OTC medications, including benzoyl peroxide–containing topical products. He has never received prescription treatment. His primary care provider, concerned that something more than acne could be involved, refers him to dermatology for evaluation and treatment.

The boy’s health is reportedly otherwise excellent. Family history is positive for severe acne on both sides of his family; two of his older siblings have had similar problems.

EXAMINATION
The central portion of the boy’s chest is covered by an impressive collection of discrete and confluent crusts and erosions. Some are quite deep, and the patient admits to picking at them. Little if any erythema surrounds the lesions.

Very little acne is seen on the boy’s face, but fairly dense acne vulgaris is observed on his upper back.

Following a brief but thorough discussion, the decision is made to start therapy with low-dose isotretinoin (20 mg/d), after the appropriate bloodwork is obtained. Within a week, the patient presents to the emergency department (ED) for worsening of his chest acne, along with pain and bleeding from some of the lesions.

What’s the diagnosis?

DISCUSSION
The risk for granulation tissue formation is a well-known though rare adverse effect of isotretinoin use—one that had been discussed thoroughly with the patient and his parents prior to prescription. There is no unanimity of opinion regarding the mechanism whereby this response occurs, but it is real. It can affect such areas as seen in this patient’s case but also causes a similar problem in the perionychial tissues, creating a condition quite similar to an ingrown toenail (cryptonychia). This author has also seen the same phenomenon in fingernails.

In this patient’s case, after discharge from the ED, he presented immediately to his primary care provider, who in turn called the dermatology clinic. When we saw him, there was clear evidence of inappropriate granulation formation—far worse than the initial acne had been.

The patient was given an intramuscular injection of 40 mg triamcinolone and prescribed minocycline 100 mg bid. He had already stopped taking the isotretinoin and was strongly advised not to restart it for the foreseeable future. In hindsight, he probably should have been started on minocycline and a 3-week prednisone taper to calm down his chest acne before the isotretinoin was started.

At a follow-up appointment 3 weeks later, his condition was much improved (at least back to baseline). But he will almost certainly develop hypertrophic scarring on his chest—and given the severity of his acne and the strong family history, he may well have a suboptimal response to isotretinoin when and if we return to that medication.

TAKE-HOME LEARNING POINTS

• In rare instances, isotretinoin therapy can trigger the formation of inappropriate granulation tissue on the face, back, chest, and even perionychial areas.
• There is evidence that the more inflamed the acne, the greater the likelihood of this adverse effect.
• With severely inflamed acne, consideration should be given to using small initial doses of isotretinoin or decreasing the inflammation through use of systemic steroids or doxycycline or minocycline.

For several years, this 16-year-old boy has had severe acne on his chest and back. The condition has steadily worsened despite use of OTC medications, including benzoyl peroxide–containing topical products. He has never received prescription treatment. His primary care provider, concerned that something more than acne could be involved, refers him to dermatology for evaluation and treatment.

The boy’s health is reportedly otherwise excellent. Family history is positive for severe acne on both sides of his family; two of his older siblings have had similar problems.

EXAMINATION
The central portion of the boy’s chest is covered by an impressive collection of discrete and confluent crusts and erosions. Some are quite deep, and the patient admits to picking at them. Little if any erythema surrounds the lesions.

Very little acne is seen on the boy’s face, but fairly dense acne vulgaris is observed on his upper back.

Following a brief but thorough discussion, the decision is made to start therapy with low-dose isotretinoin (20 mg/d), after the appropriate bloodwork is obtained. Within a week, the patient presents to the emergency department (ED) for worsening of his chest acne, along with pain and bleeding from some of the lesions.

What’s the diagnosis?

DISCUSSION
The risk for granulation tissue formation is a well-known though rare adverse effect of isotretinoin use—one that had been discussed thoroughly with the patient and his parents prior to prescription. There is no unanimity of opinion regarding the mechanism whereby this response occurs, but it is real. It can affect such areas as seen in this patient’s case but also causes a similar problem in the perionychial tissues, creating a condition quite similar to an ingrown toenail (cryptonychia). This author has also seen the same phenomenon in fingernails.

In this patient’s case, after discharge from the ED, he presented immediately to his primary care provider, who in turn called the dermatology clinic. When we saw him, there was clear evidence of inappropriate granulation formation—far worse than the initial acne had been.

The patient was given an intramuscular injection of 40 mg triamcinolone and prescribed minocycline 100 mg bid. He had already stopped taking the isotretinoin and was strongly advised not to restart it for the foreseeable future. In hindsight, he probably should have been started on minocycline and a 3-week prednisone taper to calm down his chest acne before the isotretinoin was started.

At a follow-up appointment 3 weeks later, his condition was much improved (at least back to baseline). But he will almost certainly develop hypertrophic scarring on his chest—and given the severity of his acne and the strong family history, he may well have a suboptimal response to isotretinoin when and if we return to that medication.

TAKE-HOME LEARNING POINTS

• In rare instances, isotretinoin therapy can trigger the formation of inappropriate granulation tissue on the face, back, chest, and even perionychial areas.
• There is evidence that the more inflamed the acne, the greater the likelihood of this adverse effect.
• With severely inflamed acne, consideration should be given to using small initial doses of isotretinoin or decreasing the inflammation through use of systemic steroids or doxycycline or minocycline.

Sequential therapy of oral propranolol then topical timolol for infantile hemangioma helped shorten duration of propranolol and maintain treatment success, according to a study published in Pediatric Dermatology.

hypotekyfidler/Getty Images

Diana B. Mannschreck, BSN, of Johns Hopkins University, Baltimore, and colleagues performed a retrospective chart review of 559 patients with infantile hemangioma seen in the dermatology clinic at Johns Hopkins between December 2008 and January 2018. Patients received any of five courses of treatment, including oral propranolol followed by topical timolol, propranolol only, and timolol only. Of the courses evaluated, propranolol followed by timolol had the shortest duration of propranolol therapy – a median of 2.2 months shorter than propranolol-only therapy (P = .0006). This sequential regimen also was associated with no reinitiations of propranolol therapy following tapering, whereas 13% of those receiving propranolol alone had to reinitiate it after tapering.

This is of interest because oral beta-blockers, including propranolol, have been associated with rare but serious adverse events, such as bronchospasm, hypotension, and hypoglycemia.

Limitations of the study include its retrospective and single-center nature. There was no funding or disclosure information given.

cpalmer@mdedge.com

SOURCE: Mannschreck DB et al. Pediatr Dermatol. 2019 Apr 9. doi: 10.1111/pde.13816.

Sequential therapy of oral propranolol then topical timolol for infantile hemangioma helped shorten duration of propranolol and maintain treatment success, according to a study published in Pediatric Dermatology.

hypotekyfidler/Getty Images

Diana B. Mannschreck, BSN, of Johns Hopkins University, Baltimore, and colleagues performed a retrospective chart review of 559 patients with infantile hemangioma seen in the dermatology clinic at Johns Hopkins between December 2008 and January 2018. Patients received any of five courses of treatment, including oral propranolol followed by topical timolol, propranolol only, and timolol only. Of the courses evaluated, propranolol followed by timolol had the shortest duration of propranolol therapy – a median of 2.2 months shorter than propranolol-only therapy (P = .0006). This sequential regimen also was associated with no reinitiations of propranolol therapy following tapering, whereas 13% of those receiving propranolol alone had to reinitiate it after tapering.

This is of interest because oral beta-blockers, including propranolol, have been associated with rare but serious adverse events, such as bronchospasm, hypotension, and hypoglycemia.

Limitations of the study include its retrospective and single-center nature. There was no funding or disclosure information given.

cpalmer@mdedge.com

SOURCE: Mannschreck DB et al. Pediatr Dermatol. 2019 Apr 9. doi: 10.1111/pde.13816.

Sequential therapy of oral propranolol then topical timolol for infantile hemangioma helped shorten duration of propranolol and maintain treatment success, according to a study published in Pediatric Dermatology.

hypotekyfidler/Getty Images

Diana B. Mannschreck, BSN, of Johns Hopkins University, Baltimore, and colleagues performed a retrospective chart review of 559 patients with infantile hemangioma seen in the dermatology clinic at Johns Hopkins between December 2008 and January 2018. Patients received any of five courses of treatment, including oral propranolol followed by topical timolol, propranolol only, and timolol only. Of the courses evaluated, propranolol followed by timolol had the shortest duration of propranolol therapy – a median of 2.2 months shorter than propranolol-only therapy (P = .0006). This sequential regimen also was associated with no reinitiations of propranolol therapy following tapering, whereas 13% of those receiving propranolol alone had to reinitiate it after tapering.

This is of interest because oral beta-blockers, including propranolol, have been associated with rare but serious adverse events, such as bronchospasm, hypotension, and hypoglycemia.

Limitations of the study include its retrospective and single-center nature. There was no funding or disclosure information given.

cpalmer@mdedge.com

SOURCE: Mannschreck DB et al. Pediatr Dermatol. 2019 Apr 9. doi: 10.1111/pde.13816.

The viscous homemade children’s plaything known as “slime” has been associated with allergic, as well as irritant, contact dermatitis of the hands thanks to an array of possible compounds with which it can be made, according to a case report in Pediatric Dermatology. The report details many possible compounds causing the dermatitis reactions seen by health care professionals.

In the case, which was reported by L. Elizabeth Anderson, MD, of the Children’s Hospital of Philadelphia and colleagues, an 11-year-old girl with a history of atopic dermatitis presented with hand dermatitis that was suspected to be related to playing with slime. After her dermatitis failed to respond to strong topical steroids, she was referred for patch testing, with positivity for methylchloroisothiazolinone/methylisothiazolinone (MCI/MI). After all contact with any products containing MCI/MI was eliminated, her hand dermatitis cleared, and bodywide atopic dermatitis improved some as well.

MCI/MI and MI are among the most commonly suspected culprits in cases of slime-related contact dermatitis. Although most cases are irritant contact dermatitis, some are allergic and can be detected using patch tests. MCI/MI is included in the T.R.U.E. Test, but according to the case report, 37% of patients with allergy to MI alone will not have positive response with the T.R.U.E. Test because of the low concentrations of MI in that test. The authors of this case report also listed many other the potential allergens in popular slime recipes; however, many are not included in the T.R.U.E. Test.

“While the T.R.U.E. Test does not capture most of the potential allergens in popular slime recipes, the recently published Pediatric Baseline Patch Test Series by Yu et al. [Dermatitis. 2018;29:206-12] does and is recommended for use in patients suspected of having dermatitis secondary to slime,” Dr. Anderson and associates wrote.

cpalmer@mdedge.com

SOURCE: Anderson LE et al. Pediatr Dermatol. 2019 Mar 13. doi: 10.1111/pde.13792.

The viscous homemade children’s plaything known as “slime” has been associated with allergic, as well as irritant, contact dermatitis of the hands thanks to an array of possible compounds with which it can be made, according to a case report in Pediatric Dermatology. The report details many possible compounds causing the dermatitis reactions seen by health care professionals.

In the case, which was reported by L. Elizabeth Anderson, MD, of the Children’s Hospital of Philadelphia and colleagues, an 11-year-old girl with a history of atopic dermatitis presented with hand dermatitis that was suspected to be related to playing with slime. After her dermatitis failed to respond to strong topical steroids, she was referred for patch testing, with positivity for methylchloroisothiazolinone/methylisothiazolinone (MCI/MI). After all contact with any products containing MCI/MI was eliminated, her hand dermatitis cleared, and bodywide atopic dermatitis improved some as well.

MCI/MI and MI are among the most commonly suspected culprits in cases of slime-related contact dermatitis. Although most cases are irritant contact dermatitis, some are allergic and can be detected using patch tests. MCI/MI is included in the T.R.U.E. Test, but according to the case report, 37% of patients with allergy to MI alone will not have positive response with the T.R.U.E. Test because of the low concentrations of MI in that test. The authors of this case report also listed many other the potential allergens in popular slime recipes; however, many are not included in the T.R.U.E. Test.

“While the T.R.U.E. Test does not capture most of the potential allergens in popular slime recipes, the recently published Pediatric Baseline Patch Test Series by Yu et al. [Dermatitis. 2018;29:206-12] does and is recommended for use in patients suspected of having dermatitis secondary to slime,” Dr. Anderson and associates wrote.

cpalmer@mdedge.com

SOURCE: Anderson LE et al. Pediatr Dermatol. 2019 Mar 13. doi: 10.1111/pde.13792.

The viscous homemade children’s plaything known as “slime” has been associated with allergic, as well as irritant, contact dermatitis of the hands thanks to an array of possible compounds with which it can be made, according to a case report in Pediatric Dermatology. The report details many possible compounds causing the dermatitis reactions seen by health care professionals.

In the case, which was reported by L. Elizabeth Anderson, MD, of the Children’s Hospital of Philadelphia and colleagues, an 11-year-old girl with a history of atopic dermatitis presented with hand dermatitis that was suspected to be related to playing with slime. After her dermatitis failed to respond to strong topical steroids, she was referred for patch testing, with positivity for methylchloroisothiazolinone/methylisothiazolinone (MCI/MI). After all contact with any products containing MCI/MI was eliminated, her hand dermatitis cleared, and bodywide atopic dermatitis improved some as well.

MCI/MI and MI are among the most commonly suspected culprits in cases of slime-related contact dermatitis. Although most cases are irritant contact dermatitis, some are allergic and can be detected using patch tests. MCI/MI is included in the T.R.U.E. Test, but according to the case report, 37% of patients with allergy to MI alone will not have positive response with the T.R.U.E. Test because of the low concentrations of MI in that test. The authors of this case report also listed many other the potential allergens in popular slime recipes; however, many are not included in the T.R.U.E. Test.

“While the T.R.U.E. Test does not capture most of the potential allergens in popular slime recipes, the recently published Pediatric Baseline Patch Test Series by Yu et al. [Dermatitis. 2018;29:206-12] does and is recommended for use in patients suspected of having dermatitis secondary to slime,” Dr. Anderson and associates wrote.

cpalmer@mdedge.com

SOURCE: Anderson LE et al. Pediatr Dermatol. 2019 Mar 13. doi: 10.1111/pde.13792.

Low-level evidence supports the safety of cutaneous laser treatment during pregnancy, according to the results of a systematic review of 22 studies.

Among 380 women in all trimesters of pregnancy who were treated with various laser wavelengths, the only clinically significant event was a case of premature rupture of membranes (PROM) “without further morbidity,” wrote Eric C. Wilkerson, MD, of Skin Laser & Surgery Specialists of NY and NJ in New York, and associates. In that case, the cause was not clear, there was no further morbidity, “and it was uncertain whether this was related to the laser procedure.”

However, only 22 studies were identified between 1960 and 2017, all of which were case reports or series, published from 1994 to 2015. “[Thus far,] the best evidence exists for the safety of the carbon dioxide laser, particularly in the treatment of condyloma,” they wrote in Dermatologic Surgery.

Elective laser treatments are usually not recommended during pregnancy, but no evidence supports this, Dr. Wilkerson and coauthors wrote. Therefore, they searched for studies indexed in PubMed, Google Scholar, the Cochrane Library, or the EBSCO CINAHL Plus Database from 1960 to 2017. They also searched LexisNexis for relevant legal cases, but found none.

The women in the 22 case reports and series were aged 14-41 years and received laser therapy for cervical adenocarcinoma, urolithiasis, condyloma acuminata, cervical carcinoma in situ, cutaneous scarring, Buschke-Löwenstein tumor, verrucous carcinoma, and acne vulgaris. Modalities included 504-nm pulsed-dye laser, 532-nm potassium titanyl phosphate, 1,064-nm neodymium:YAG, 2,100-nm holmium:YAG, and 10,600-nm CO₂.

Apart from the case of PROM, there were no instances of fetal morbidity or mortality, premature labor or preterm birth, or detectable fetal stress, the authors wrote. The case of PROM occurred at 35 weeks, 4 days after the mother had received CO₂ laser therapy for condyloma acuminata. She delivered normally approximately 1 week later. There also were several cases of premature contractions without true labor, all of which responded to tocolytic therapy. (In the same study, there also were two cases of PROM in women 7 and 10 weeks after the same procedure, but were thought to be unrelated.)

The thickness of the pregnant abdomen, uterus, and amniotic fluid makes it “very unlikely” that clinically significant amounts of laser energy would reach the fetus during cutaneous laser therapy, the authors noted. Certain topical anesthetics, such as lidocaine and prilocaine, also appear safe during pregnancy “and may potentially decrease concern for fetal stress secondary to maternal stress or pain during the procedure,” they added. “Appropriate safety measures including eye protection and laser plume management should continue to be used during laser treatment.”

The authors reported no funding sources or conflicts of interest.

SOURCE: Wilkerson EJ et al. Dermatol Surg. 2019 Jun;45(6):818-28.

Low-level evidence supports the safety of cutaneous laser treatment during pregnancy, according to the results of a systematic review of 22 studies.

Among 380 women in all trimesters of pregnancy who were treated with various laser wavelengths, the only clinically significant event was a case of premature rupture of membranes (PROM) “without further morbidity,” wrote Eric C. Wilkerson, MD, of Skin Laser & Surgery Specialists of NY and NJ in New York, and associates. In that case, the cause was not clear, there was no further morbidity, “and it was uncertain whether this was related to the laser procedure.”

However, only 22 studies were identified between 1960 and 2017, all of which were case reports or series, published from 1994 to 2015. “[Thus far,] the best evidence exists for the safety of the carbon dioxide laser, particularly in the treatment of condyloma,” they wrote in Dermatologic Surgery.

Elective laser treatments are usually not recommended during pregnancy, but no evidence supports this, Dr. Wilkerson and coauthors wrote. Therefore, they searched for studies indexed in PubMed, Google Scholar, the Cochrane Library, or the EBSCO CINAHL Plus Database from 1960 to 2017. They also searched LexisNexis for relevant legal cases, but found none.

The women in the 22 case reports and series were aged 14-41 years and received laser therapy for cervical adenocarcinoma, urolithiasis, condyloma acuminata, cervical carcinoma in situ, cutaneous scarring, Buschke-Löwenstein tumor, verrucous carcinoma, and acne vulgaris. Modalities included 504-nm pulsed-dye laser, 532-nm potassium titanyl phosphate, 1,064-nm neodymium:YAG, 2,100-nm holmium:YAG, and 10,600-nm CO₂.

Apart from the case of PROM, there were no instances of fetal morbidity or mortality, premature labor or preterm birth, or detectable fetal stress, the authors wrote. The case of PROM occurred at 35 weeks, 4 days after the mother had received CO₂ laser therapy for condyloma acuminata. She delivered normally approximately 1 week later. There also were several cases of premature contractions without true labor, all of which responded to tocolytic therapy. (In the same study, there also were two cases of PROM in women 7 and 10 weeks after the same procedure, but were thought to be unrelated.)

The thickness of the pregnant abdomen, uterus, and amniotic fluid makes it “very unlikely” that clinically significant amounts of laser energy would reach the fetus during cutaneous laser therapy, the authors noted. Certain topical anesthetics, such as lidocaine and prilocaine, also appear safe during pregnancy “and may potentially decrease concern for fetal stress secondary to maternal stress or pain during the procedure,” they added. “Appropriate safety measures including eye protection and laser plume management should continue to be used during laser treatment.”

The authors reported no funding sources or conflicts of interest.

SOURCE: Wilkerson EJ et al. Dermatol Surg. 2019 Jun;45(6):818-28.

Low-level evidence supports the safety of cutaneous laser treatment during pregnancy, according to the results of a systematic review of 22 studies.

Among 380 women in all trimesters of pregnancy who were treated with various laser wavelengths, the only clinically significant event was a case of premature rupture of membranes (PROM) “without further morbidity,” wrote Eric C. Wilkerson, MD, of Skin Laser & Surgery Specialists of NY and NJ in New York, and associates. In that case, the cause was not clear, there was no further morbidity, “and it was uncertain whether this was related to the laser procedure.”

However, only 22 studies were identified between 1960 and 2017, all of which were case reports or series, published from 1994 to 2015. “[Thus far,] the best evidence exists for the safety of the carbon dioxide laser, particularly in the treatment of condyloma,” they wrote in Dermatologic Surgery.

Elective laser treatments are usually not recommended during pregnancy, but no evidence supports this, Dr. Wilkerson and coauthors wrote. Therefore, they searched for studies indexed in PubMed, Google Scholar, the Cochrane Library, or the EBSCO CINAHL Plus Database from 1960 to 2017. They also searched LexisNexis for relevant legal cases, but found none.

The women in the 22 case reports and series were aged 14-41 years and received laser therapy for cervical adenocarcinoma, urolithiasis, condyloma acuminata, cervical carcinoma in situ, cutaneous scarring, Buschke-Löwenstein tumor, verrucous carcinoma, and acne vulgaris. Modalities included 504-nm pulsed-dye laser, 532-nm potassium titanyl phosphate, 1,064-nm neodymium:YAG, 2,100-nm holmium:YAG, and 10,600-nm CO₂.

Apart from the case of PROM, there were no instances of fetal morbidity or mortality, premature labor or preterm birth, or detectable fetal stress, the authors wrote. The case of PROM occurred at 35 weeks, 4 days after the mother had received CO₂ laser therapy for condyloma acuminata. She delivered normally approximately 1 week later. There also were several cases of premature contractions without true labor, all of which responded to tocolytic therapy. (In the same study, there also were two cases of PROM in women 7 and 10 weeks after the same procedure, but were thought to be unrelated.)

The thickness of the pregnant abdomen, uterus, and amniotic fluid makes it “very unlikely” that clinically significant amounts of laser energy would reach the fetus during cutaneous laser therapy, the authors noted. Certain topical anesthetics, such as lidocaine and prilocaine, also appear safe during pregnancy “and may potentially decrease concern for fetal stress secondary to maternal stress or pain during the procedure,” they added. “Appropriate safety measures including eye protection and laser plume management should continue to be used during laser treatment.”

The authors reported no funding sources or conflicts of interest.

SOURCE: Wilkerson EJ et al. Dermatol Surg. 2019 Jun;45(6):818-28.