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Background A lack of representation of skin of color (SoC) in dermatology curricula is well-documented across North American medical schools and may present a barrier to equitable and comprehensive undergraduate medical education. Objectives This study aims to examine representation in dermatologic educational materials and appreciate a link between bias in dermatologic education and student diagnostic ability and self-rated confidence. Design The University of Toronto Dermatology Undergraduate Medical Education curriculum was examined for the percentage photographic representation of SoC. A survey of 10 multiple-choice questions was administered to first- and third-year medical students at the University of Toronto to assess diagnostic accuracy and self-rated confidence in diagnosis of 5 common skin lesions in Fitzpatrick skin phototypes (SPT) I-III (white skin) and VI-VI (SoC). Results The curriculum audit showed that Conclusions This preliminary assessment identified a lack of confidence in diagnosing dermatologic conditions in SoC, a finding which may impact health outcomes of patients with SoC. This project is an important first step in diversifying curricular materials to provide comprehensive medical education.

Vitiligo is the most common depigmenting disorder. However, therapies prove to be time-consuming, costly, or slow to show efficacy. Here, we present a case of a 74-year-old female with vitiligo who underwent full-body depigmentation treatment 50 years ago. Brown patches of repigmentation appeared on the patient’s face and arms and were eventually treated with 88% phenol. Patient was later switched to compounded 3% glutathione cream for a more sustained effect. Phenol was an accessible, economical, and easily administrable therapeutic option that can result in short-term depigmentation.

Tumor necrosis factor-α antagonists have become a therapeutic mainstay for various inflammatory diseases including Hidradenitis Suppurativa. Despite their clinical efficacy, these medications have been associated with the rare development of demyelinating diseases. We report a 29-year-old male who developed neurological symptoms while taking adalimumab, a tumor necrosis factor-α antagonist, for treatment of Hidradenitis Suppurativa. The patient was subsequently diagnosed with radiologically isolated syndrome based on magnetic resonance imaging findings. The exact temporal relationship between demyelinating disease and tumor necrosis factor-α antagonists is poorly understood. Also, there remain a few effective treatment options for severe inflammatory diseases like Hidradenitis Suppurativa. In cases where a patient exhibits clinical stability and structural resolution following the development of neurological symptoms after tumor necrosis factor-α antagonist therapy, and there is a lack of other effective treatments to control extensive inflammatory disease, restarting the tumor necrosis factor-α antagonist could be considered provided there is neurology approval and close monitoring.

Various forms of skin hypopigmentation can occur spontaneously. When multiple forms of hypopigmentation occur simultaneously, the diagnoses may seem unclear. This article illustrates a patient who presented simultaneously with each of vitiligo, (idiopathic) guttate hypomelanosis (IGH), and a rarely noted hypopigmented variant of seborrhoeic keratosis. We outline distinguishing clinical features for clinicians to consider on encountering a patient with adult-acquired hypopigmentation. Subsequently, we present a useful approach to diagnosing common acquired forms of localised hypopigmentation seen in primary care. A 61-year-old black female presented to her GP with white patches on her back (Figure 1a), and was diagnosed with vitiligo. Management included tacrolimus 0.1% ointment for daily use and referral to a dermatologist. She was also advised to avoid sun exposure to the affected areas. In the interim, the patient was exposed to ultraviolet radiation (UVR) while vacationing in Jamaica and noted improvement in the white patches. At her first dermatology visit, she displayed repigmenting patches of vitiligo with brown macules perifollicularly (Figure 1b). She queried whether new hypopigmented lesions were also vitiligo. Specifically, her back had light ‘stuck on’ papules and her arms and back had other 5-mm hypopigmented macules (Figure 1c and 1d). She queried why select back lesions improved after sun exposure despite being advised to avoid it. Her dermatologist explained that her initial back patches of vitiligo had repigmented due to UVR from …

Alopecia areata (AA) is an autoimmune-mediated, nonscarring form of hair loss. Despite its prevalence, current management options are limited, especially when the disease has progressed to alopecia totalis (AT) or alopecia universalis (AU). Recent evidence that janus kinase (JAK) signaling contributes to AA pathogenesis prompted the investigation of JAK inhibitors such as tofacitinib and ruxolitinib as possible oral treatments. However, the potential for significant adverse effects with systemic JAK inhibition makes local administration a more attractive option. Yet, a paucity of data exists on topical JAK inhibition in AA. A success of topical ruxolitinib (0.6% cream) use in a young patient with AU has been reported to date. Here we report the treatment of a 66-year-old with AA with the same formulation of topical ruxolitinib, where it failed to induce hair growth. Our report demonstrates the importance of examining the factors contributing to variation in treatment response in a clinical trial of topical JAK inhibitors in AA. It is likely that both intrinsic factors specific to individual patients and extrinsic factors relating to treatment regimen are involved. Furthermore, characterisation of the specific JAKs overexpressed in AA may better target medication. Finally, this report highlights the need to compare the outcomes of topical vs oral ruxolitinib administration in patients with severe AA, AT, and AU and may support the possibility that extensive disease is more adequately treated with oral administration of ruxolitinib.

Summary Objective To investigate changes in sebum cytokines in response to hair cosmetics. Design and setting A prospective study at a University hospital. Methods We used a novel method for scalp surface sebum collection (Sebutape®) on three visits, sequentially a week apart, to investigate changes in six cytokines in 36 healthy women before and after shampoo and compared various chemical treatments (ammonium thioglycolate, “lye” sodium hydroxide and “no-lye” guanidine hydroxide relaxers) performed by a professional hairdresser. Results Significant levels detected were IL-1 alpha (IL-1α) and IL-1 receptor antagonist (IL-1ra), which were higher in untreated scalp vs. forehead: P

Hand, foot, and mouth disease is an enteroviral infection characterized by vesicles on the hands, feet, and oral mucosa. Given its rising incidence among adults, it is important to recognize its variable presentations and sequelae. These include onychomadesis, a complication of hand, foot, and mouth disease that is well described in children, with limited reports in adults. We present the unique case of a pregnant woman who developed onychomadesis following hand, foot, and mouth disease, with no adverse pregnancy outcomes. This case illustrates that (1) onychomadesis can occur in pregnant women with hand, foot, and mouth disease; (2) onychomadesis is typically a benign change that can occur following hand, foot, and mouth disease; and (3) onychomadesis is not necessarily associated with more severe disease or adverse pregnancy outcomes.

To investigate changes in sebum cytokines in response to hair cosmetics. Design and setting A prospective study at a University hospital.We used a novel method for scalp surface sebum collection (Sebutape(®)) on three visits, sequentially a week apart, to investigate changes in six cytokines in 36 healthy women before and after shampoo and compared various chemical treatments (ammonium thioglycolate, "lye" sodium hydroxide and "no-lye" guanidine hydroxide relaxers) performed by a professional hairdresser. Significant levels detected were IL-1 alpha (IL-1α) and IL-1 receptor antagonist (IL-1ra), which were higher in untreated scalp vs. forehead: P0.001. Baseline levels of scalp sebum IL-1α were 18 times higher than IL-1ra. The levels of IL-1α decreased uniformly after shampoo (visit 1) and various chemical treatments (both crown and vertex all P0.001 - visit 2) but increased on follow-up at visit 3. Decreases in IL-1ra mimicked IL-1α at the vertex [after shampoo (P = 0.018) and visit 3 (P = 0.014)], but not on the crown, a finding which may suggest site-specific scalp predisposition to inflammation. The ratio of IL-1ra/IL-1α increased in all groups after all chemical treatments and on follow-up (all P0.001) but was surprisingly not significantly different from natural hair that underwent shampoo. A wider cytokine panel may reveal response differences in treatment groups. Baseline inflammatory scalp cytokines are higher than expected and reduce with shampooing. Scrutiny of the influence of hair moisturizer formulations and shampoo intervals and studies investigating pro-fibrotic cytokines are required. This may elucidate the predilection of afro-textured hair to scarring alopecia.

BACKGROUND Ontario is one of the most underserved provinces in Canada for providing Mohs micrographic surgery (MMS). A new MMS clinic was opened in Ottawa, Ontario, in June 2009 to help combat the increasing incidence of nonmelanoma skin cancer (NMSC) in this region. OBJECTIVE To prospectively compare MMS cases completed in Ottawa with cases completed in Houston, Texas, and examine the differences in tumor characteristics. MATERIALS AND METHODS The first 150 cases performed in Ottawa were prospectively compared with 150 consecutive cases performed at a Mohs surgery clinic in Houston, Texas. Patient demographics, tumor diagnosis, primary or recurrent disease, tumor dimension, number of surgical stages, defect size, complexity of the procedure, and closure method were compared. RESULTS The average preoperative tumor area was three times as great in Ottawa as in Houston. Almost one entire additional stage was required to clear the tumors treated in Ottawa. Postoperative defects were 87% larger in Ottawa. The number of advanced reconstructive repairs was significantly higher in Ottawa (93%) than Houston (14%). CONCLUSIONS A significantly higher NMSC disease burden and greater surgical complexity was observed in the tumors treated in Ottawa than in Houston. The authors have indicated no significant interest with commercial supporters.

Background: We report four cases of chronic actinic dermatitis (CAD) occurring in middle-aged men with significant outdoor exposure. Objective: The aim of this report is to show the spectrum of presentations of patients with CAD and to outline the proper diagnostic workup of these individuals. Methods: Phototesting was performed to determine the minimal erythema doses to ultraviolet (UV)A (315–400 nm) and UVB (280–315 nm) and photopatch testing and patch testing for each individual with the North American Contact Dermatitis Group Standard series and the Chemotechnique Plant series, supplemented by the Hausen Plant series and the patients' own products. Results: All patients were men, over 45 years, who worked outdoors or had outdoor hobbies. Two had a past known history of allergic contact dermatitis. Two had atopic dermatitis. Three had positive reactions to Compositae plants and sesquiterpene lactone; one had a reaction to lichen acid mix. All had photocontact dermatitis or contact dermatitis to sunscreen chemicals, including benzophenone 3 (oxybenzone), butyl methoxydibenzoylmethane (avobenzone), and ethylhexyl methoxycinnamate (octinoxate). All reacted to fragrance mix; two reacted to balsam of Peru and two to colophony. All had biopsies showing an eczematous pattern. Conclusion: CAD is persistent, with a classic presentation, and requires a specific diagnostic workup. Effective therapeutic options exist for patients with CAD.