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Diabetes mellitus is a significant worldwide health concern and cutaneous manifestations are common. This review describes characteristic skin findings of diabetes, general skin findings related to diabetes, and findings related to diabetes treatment with a focus on clinical presentation, diagnosis, pathophysiology, epidemiology, and treatment. As the prevalence of diabetes continues to rise, cutaneous manifestations of diabetes mellitus likely will be encountered more frequently by physicians in all disciplines including dermatologists and primary care physicians. Accordingly, knowledge regarding the prevention, diagnosis, and management of cutaneous manifestations is an important aspect in the care of patients with diabetes.

The Fourth Annual Symposium on Hidradenitis Suppurativa (SHSA) took place on November 1-3, 2019, at the Westin Book Cadillac Hotel in Detroit, Michigan. This symposium was a joint meeting of the US Hidradenitis Suppurativa Foundation and the Canadian Hidradenitis Suppurativa Foundation. This cross-disciplinary meeting with experts from around the world was an opportunity to discuss the most recent advances in the study of hidradenitis suppurativa (HS) pathogenesis, clinical trials, classification, scoring systems, complementary/alternative medical treatments, diet, pain management, surgical and laser treatment, and ultrasonographic assessment. A special preconference workshop was held on the use of neodymium-doped yttrium-aluminum-garnet laser hair reduction, sinus tract deroofing, and carbon dioxide laser excision with ultrasonographic mapping and tumescent anesthesia for the treatment of HS. The focused workshops on establishing an HS clinic, setting up an HS support group, the Hidradenitis Suppurativa Prospective Observational Registry and Biospecimen Repository, and wound care were held during the meeting. A special program called HS Ambassadors was established for patients who may have questions about the conference presentations, and in addition, a meet and greet for patients and HS Ambassadors was arranged. To facilitate networking between those early in their careers and clinical and research experts, a mentoring reception was held.

Keloids are a recurrent benign neoplastic condition that result from a traumatic injury to the skin in susceptible individuals. Keloid tissue extends beyond the margins of the injured site; this characteristic distinguishes it from hypertrophic scars. Individuals of African, Hispanic, or Asian descent appear to be at increased risk for keloids.1 Keloids tend to be asymptomatic but may cause pain or itching and have functional, aesthetic, or psychosocial impact on patients.2 The extent of scar formation is influenced by the duration and extent of the inflammatory phase of wound healing, which is longer in patients with hidradenitis suppurativa (HS). The prevalence of keloids among African-American and biracial individuals in the US population is higher than that among white patients.3 Some cutaneous areas are more prone to keloid scar development, likely caused by the vulnerability to trauma such as ear lobes. Other types of direct skin causes include body piercings, burns, lacerations, and surgical wounds. Keloids can also result from inflammatory processes including acne and folliculitis.4 HS is a chronic inflammatory skin disease characterized by persistent or recurrent flares of inflamed painful nodules, sinus tracts, and scars in the intertriginous areas.5 The prevalence of HS is estimated at 1% worldwide with a female/male ratio of 3:1.6 The pathogenesis of HS is not completely understood. Follicular occlusion is believed to initiate the process, trapping commensal bacteria within the follicle. The rupture of the pilosebaceous unit and activation of the innate immune system leads to a chronic tissue inflammation that is difficult to extinguish.7 Characteristic HS lesions commonly heal with different types of scars. Atrophic scars are shallow and, in some cases, cribriform, whereas hypertrophic scars can present as firm plaques or rope-like scars. In individuals prone to keloid, chronic inflammatory HS lesions may lead to keloid formation that may contain both mixed of inflammatory lesions and scars. Two reported cases exist in the literature of keloids in HS and successful treatment with adalimumab.8, 9 We present a case series of 10 more patients with keloid formation in HS wounds and discuss the clinical presentation and therapeutic options.

Hidradenitis suppurativa is a severe and debilitating dermatologic disease. Clinical management is challenging and consists of both medical and surgical approaches, which must often be combined for best outcomes. Therapeutic approaches have evolved rapidly in the last decade and include the use of topical therapies, systemic antibiotics, hormonal therapies, and a wide range of immunomodulating medications. An evidence-based guideline is presented to support health care practitioners as they select optimal medical management strategies and is reviewed in this second part of the management guidelines. A therapeutic algorithm informed by the evidence available at the time of the review is provided.

This systematic review identifies and critically evaluates the mechanistic and clinical evidence of new promising therapeutic targets in hidradenitis suppurativa (HS). Evidence for these targets is largely based on observational data with limited ex vivo and translational data from clinical trials. A number of placebo-controlled studies have been completed or are underway utilizing IL-1, IL-23, IL-17, complement, and Jak inhibition, although there is concern regarding elevated placebo response rates and the questionable validity of clinical scores in some participant subsets. Knowledge gaps are identified suggesting a direction for future mechanistic studies in HS, including more comprehensive inflammatory endotype profiling of disease.

Leg ulcerations are a common problem, with an estimated prevalence of 1% to 2% in the adult population. Venous leg ulcers are primarily treated in outpatient settings and often are managed by dermatologists. Recent advances in the diagnosis and treatment of leg ulcers combined with available evidence-based data will provide an update on this topic. A systematized approach and the judicious use of expensive advanced therapeutics are critical. Specialized arterial and venous studies are most commonly noninvasive. The ankle brachial pressure index can be performed with a handheld Doppler unit at the bedside by most clinicians. The vascular laboratory results and duplex Doppler findings are used to identify segmental defects and potential operative candidates. Studies of the venous system can also predict a subset of patients who may benefit from surgery. Successful leg ulcer management requires an interdisciplinary team to make the correct diagnosis, assess the vascular supply, and identify other modifiable factors to optimize healing. The aim of this continuing medical education article is to provide an update on the management of venous leg ulcers. Part I is focused on the approach to venous ulcer diagnostic testing.

Although the role of immune dysregulation in hidradenitis suppurativa (HS) has yet to be elucidated, recent studies identified several complement abnormalities in patients with HS. The complement system serves a critical role in the modulation of immune response and regulation of cutaneous commensal bacteria. Complement is implicated in several inflammatory skin diseases including systemic lupus erythematosus, angioedema, pemphigus, bullous pemphigoid, and HS. A model of HS pathogenesis is proposed, integrating the role of commensal bacteria, cutaneous immune responses, and complement dysregulation. The role of complement in disease pathogenesis has led to the development of novel anticomplement agents and clinical trials investigating the efficacy of such treatments in HS.

Necrobiosis lipoidica is a granulomatous condition presenting as indolent atrophic plaques, often on the lower extremities. There is a multitude of case reports suggesting possible associations and documenting different therapeutic alternatives with varied success. Important complications include ulceration and the development of squamous cell carcinoma. The disease course is often indolent and recurrent despite treatment. This article reviews the etiopathogenesis, clinical presentations, and evidence for treatment alternatives of this condition.

Erythema nodosum migrans (ENM) is a rare clinical variant of erythema nodosum (EN). It is a septal panniculitis characterized by asymmetrical, mildly tender, nodules that migrate over time. Fever, sore throat, or arthralgias may also accompany the cutaneous manifestations of the disease; however, this is uncommon. The treatment of choice for ENM is potassium iodide. We present a case of a 77-year-old woman with a 5- month history of ENM that was treated successfully with topical clobetasol.

Necrobiosis lipoidica (NL) is a rare chronic granulomatous disease that has historically been associated with diabetes mellitus. Debate exists regarding the etiology and pathogenesis of NL with a widely accepted theory that microangiopathy plays a significant role. NL typically presents clinically as erythematous papules on the front of the lower extremities that can coalesce to form atrophic telangiectatic plaques. NL is usually a clinical diagnosis, but if the clinical suspicion is uncertain, skin biopsy specimen can help differentiate it from sarcoidosis, necrobiotic xanthogranuloma, and granuloma annulare. NL is a difficult disease to manage despite a large armamentarium of treatment options that include topical and intralesional corticosteroids, immunomodulators, biologics, platelet inhibitors, phototherapy, and surgery. Randomized control trials are lacking to evaluate the many treatment methods and establish a standard regimen of care. Disease complications such as ulceration are common, and lesions should also be monitored for transition to squamous cell carcinoma, a less common sequelae.

While hidradenitis suppurativa (HS) is not an orphan disease in terms of its prevalence, it has often been a lower priority in comparison to other dermatologic conditions in terms of notice, interest, and ongoing research. HS is a chronic,painful, inflammatory skin disease affecting a young, active population. Although genetic factors are suspected contributors, unfortunately, there are multiple uncertainties in that the etiology and pathophysiology of HS have yet to be fully elucidated. Treatments used in the management of this condition remain off-label. Traditional therapies, such as systemic antibiotics, retinoids, immunosuppressants, and antiandrogens all have been used with limited success. The phenotype of the disease has a wide spectrum, with different morphologic features. This leads us to this question: If these manifestations are within the spectrum of one disease, could we apply the same treatment algorithm to all HS phenotypes? There is a paucity of high-level evidence to support current treatments, and there are few randomized, controlled trials investigating the efficacy and safety of medical therapies in particular. The heterogeneity in clinical studies and the assessment tools make the evaluation even more difficult. The responses to treatment and clinical results have been measured by various endpoints, but there are still limited data or consensus with respect to the best tool to accurately measure the treatment outcomes. Surgery is another established treatment, particularly for patients with severe HS, but recurrence of the disease is the rule rather than the exception. The diffuse involvement of skin in certain phenotypes is a challenge for surgical therapy. Moreover, invasive surgery can lead to scarring, contractures, and reduced mobility, but conservative surgery can be inadequate to treat advanced HS. 1 Progress is being made, however, and there is cause for optimism and enthusiasm. In May of 2015, the US Food and Drug Administration designated a clinical development program for HS, such that the biologic agent (adalimumab) was granted an orphan drug designation for investigational treatment of moderate to severe HS, graded as Hurley stage II and III disease. In September 2015, adalimumab received FDA approval for the management of moderate to severe HS. Unpacking the complete story of HS remains to be done. The association of HS with the metabolic syndrome increases the burden of the disease. To what extent lifestyle modifications, such as weight control and smoking cessation, together with medical therapies will effectively manage the chronic condition remains to be explored in wellcontrolled, clinical trials. The lack of interdisciplinary care and decentralization of care have resulted in a highly variable approach to the signs and symptoms of HS with unsatisfactory outcomes. This fragmentation is also reflected by a significant diagnostic delay of 5 to 9 years in many countries, highlighting an unmet need for medical

Diabetes mellitus is a serious, life-long condition that is the sixth leading cause of death in North America. Dermatologists frequently encounter patients with diabetes mellitus. Up to 25% of patients with diabetes mellitus will develop diabetic foot ulcers. Foot ulcer patients have an increased risk of amputation and increased mortality rate. The high-risk diabetic foot can be identified with a simplified screening, and subsequent foot ulcers can be prevented. Early recognition of the high-risk foot and timely treatment will save legs and improve patients' quality of life. Peripheral arterial disease, neuropathy, deformity, previous amputation, and infection are the main factors contributing to the development of diabetic foot ulcers. Early recognition of the high-risk foot is imperative to decrease the rates of mortality and morbidity. An interprofessional approach (ie, physicians, nurses, and foot care specialists) is often needed to support patients' needs.