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Lichen planus is a chronic auto-inflammatory disease that primarily affects mucocutaneous regions. There are many variants of lichen planus including cutaneous, oral, nail, follicular, and erosive forms. Without any disease-specific treatment options, multi-variant lichen planus can be a challenging disease to manage. We present a 61-year-old woman with multivariant lichen planus that was refractory to numerous systemic and topical therapies. Subsequently, her cutaneous and vulvovaginal lesions improved with the use of oral baricitinib and the erosive oral lesions improved with topical ruxolitinib.

Sneddon-Wilkinson disease, also known as subcorneal pustular dermatosis (SPD), is a rare disease characterized by vesicles or pustules that may rapidly expand and coalesce. Idiopathic in nature, SPD's clinical presentation of "half-half" blisters, with half of each blister containing pus and half containing clear fluid, is characteristic of this disease. We describe a previously healthy 21-year-old man who developed acute pustular vesicular eruptions consistent with SPD eight days following the Moderna COVID-19 vaccination.

We present a 76-year old man who developed papulopustular rosacea after receiving nivolumab treatment for his esophageal carcinoma, metastatic to the lungs. Nivolumab is an emerging cancer therapy whose immune-related adverse events are still not fully recognized and likely underreported. The treatment has been reported to cause a myriad of cutaneous immune-related adverse events. However, nivolumab-induced-papulopustular rosacea has been scarcely reported. Thus, this case presents a clinically important finding that physicians should be aware of when seeing patients on nivolumab therapy.

Purpose: Lower socioeconomic status is associated with decreased sun protection practices. This survey study investigated practices and beliefs surrounding sun protection based on health insurance., Methods: 401 surveys were administered May to June 2019 at two dermatology clinics in Sacramento, California. 384 surveys by private insurance, Medi-Cal (California's Medicaid), and Medicare coverage were analyzed., Results: Patients with Medi-Cal are twice as likely to rarely or never use sunscreen (OR=2.37; 95% CI 1.45-3.87; P<0.001) compared to those with private insurance. Patients with Medi-Cal or Medicare are less likely to use sunscreen (P<0.001), protective clothing (P=0.025), and sun avoidance (P=0.028). Medi-Cal patients more often used tanning beds (OR=4.90; 95% CI 1.30-18.50; P=0.019). Over half of patients with Medi-Cal agreed it is worth getting burned for a tan (54.6%, OR=2.54; 95% CI 1.41-4.62; P=0.0021). There were no significant differences in opinion that sunscreen is a hassle to apply or expensive. Groups did not differ significantly in ethnicities or skin type., Conclusion: Those with Medi-Cal are less likely to use all forms of sun protection and more likely to value tanning. Negative opinions of sunscreen and perceived knowledge and concern for skin cancer were similar, pointing to additional factors influencing these disparities.

We present a patient with anti-MDA5 negative, anti-Ku positive clinically amyopathic dermatomyositis (CADM). A 61-year-old woman presented with a chief complaint of a 20-year history of a pruritic rash that was active on her face, chest, hands, legs, and back. A mildly scaly, erythematous, photo-distributed eruption along with slightly violaceous, scaly papules accentuated on the wrist, metacarpophalangeal joints, proximal interphalangeal and distal interphalangeal joints. Antibody profile was significant for positive ANA and anti-dsDNA, elevated anti-TIF-1gamma (RDL)/p155, and weakly positive anti Ku. Biopsy was consistent with dermatomyositis. Melanoma differentiation-associated gene 5 antibody (anti-MDA-5) has been identified as the most commonly associated autoantibody found in CADM and is associated with poor prognosis and a biomarker for the diagnosis of rapidly progressive interstitial lung disease. To our knowledge, our patient is the first case of negative anti-MDA-5 and anti-Ku positive CADM.

Lichen planopilaris is an uncommon dermatological manifestation of lichen planus of the scalp and results in cicatricial alopecia. We present a patient with lichen planopilaris and significant post-inflammatory pigmentary alteration, confirmed by histopathology. The patient's case represents a clinically important variation from an expected typical pattern of dyschromia at periphery of alopecic zones in lichen planopilaris.

Skin is the largest peripheral endocrine organ and functions as a hormone target and endocrine gland. A cutaneous hypothalamus-pituitary-adrenal (HPA)-like axis enables the skin to respond to stress and regulates its steroidogenic activity. The pilosebaceous unit is a site for production and metabolism of a number of steroid hormones, including stress and sex hormones. This is an overview of the important role that the cutaneous HPA-like-axis plays in the pathogenesis and treatment of inflammatory pilosebaceous disorders, including acne, rosacea, seborrheic dermatitis, and hidradenitis suppurativa.

Necrobiosis lipoidica is a chronic granulomatous disease of unknown etiopathogenesis, which is often difficult to treat. While data from randomized controlled trials for the treatment of necrobiosis lipoidica is lacking, several treatments of varying efficacy for necrobiosis lipoidica have been reported in the scientific literature. We present a case of a 29-year-old female with uncontrolled diabetes and treatment-resistant necrobiosis lipoidica which was responsive to ustekinumab.

Ultraviolet (UV) radiation is associated with negative health effects, including sun damage and skin cancer. The purpose of this study is to compare the protective effects of the shade provided by a sun umbrella versus that provided by a tree. Sun sensors that register the level and dose of UV radiation were placed in the shade and in direct sunlight. Measurements were recorded every half hour between the hours of 12:30 p.m. and 3:00 p.m. in Sacramento, California. The results suggest that the level of UV radiation in the shade is not zero. The sensors located in tree shade indicated that over 5% of UV radiation was detected in the shade. The sensors located in sun-umbrella shade showed that greater than 17% of UV radiation reached the shade. The sun sensors used in our study collected UV radiation data relevant to UV index; however, they did not differentiate between UVA, UVB, visible, and infrared light. The amount of UV radiation detected in the shade is not zero, thus regular sunscreen use and other sun protective practices should be followed to reduce the risk of sun damage and skin cancer.

The role of the microbiome in healthy and disease states of the human body is progressively being found to extend beyond the gastrointestinal tract and into other organ systems such as the skin. Researching the microbiome thus has become paramount to understanding additional physiological and pathophysiological mechanisms that may be at play between microbes and their hosts. Cell cultures have traditionally been used to study the microbiome, but in our current day and age, advanced metagenomic techniques - such as 16S rRNA amplicon sequencing and whole metagenomic shotgun sequencing - are better able to classify the microorganisms making up the microbiome. Utilizing metagenomics alone, however, does not allow for the study of the more complex effects of the microbiome, such as changes in gene expression and metabolic byproducts. Thus, incorporation of other modalities such as metatranscriptomics, metaproteomics, and metabolomics are needed to further elucidate the extensive intricacies of the skin microbiome.

The role of exogenous progestin in the development of acne is unclear. Progestins are known for their androgenic potential, but newer generations of progestins have low or anti-androgenic activity. This review will evaluate the association between progestins found in hormonal long-acting reversible contraceptives (intrauterine devices and subdermal implants) and acne, as well as the role of oral contraceptives in acne management. Our review demonstrates that the cause and effect relationship between progestins and acne is difficult to establish and future studies that seek to understand how progestins modulate acne are necessary.

Store-and-forward teledermatology involves transmission of a patient's images to a healthcare provider and subsequent response from the provider about the diagnosis or management. Furthermore, teledermatology in which mobile phones (e.g. smartphones) are utilized for communication between the patient and their provider is referred to as mobile-teledermatology. In this study, we investigate the use of mobile-teledermatology in the management of actinic keratoses. We demonstrate that mobile-teledermatology may enhance communication between the patient and their provider when managing cutaneous disease and that even individuals in older age groups are highly satisfied with this type of follow up.

Hidradenitis suppurativa is a recurrent inflammatory skin condition characterized by abscesses and boils, predominantly in the groin, armpit, and buttocks areas. HS is not a life-threatening condition, but severely impairs quality of life in those affected. Finding a successful treatment approach for HS has been challenging, in part because of the lack of a gold-standard treatment method, limited research-based information, and the nature of clinical variation in the disease. Treatment commonly consists of antibiotics, anti-inflammatory therapy, hormonal therapy, and more invasive clinical procedures. Treatment is chosen by the degree of severity by which the condition presents and is modified accordingly. This review describes the roles of hormones in the pathogenesis of hidradenitis suppurativa and describes the use of hormonal therapy such as, finasteride, dutasteride, spironolactone, and oral contraceptives. The outcomes of the use of these modalities in various clinical studies are summarized.

Eruptive actinic keratosis (AK) consequent to systemic chemotherapy can be confused with drug allergies. We present the first case of inflamed AKs in one patient after receiving combination therapy with pemetrexed and carboplatin.A 68-year-old woman with non-small cell lung adenocarcinoma (NSCLC) presented with numerous pruritic ill-defined, gritty, erythematous papules consistent with AKs on her upper chest, upper back, and arms two weeks after completing the first cycle of combination therapy with carboplatin and pemetrexed. The care team managed her with topical steroids and the lesions resolved within one month. The patient resumed the second cycle of chemotherapy and reported the occurrence of a similar but milder eruption.This case illustrates that eruptive AKs should be considered in the differential diagnosis of drug-related rashes, especially if the physical exam is suggestive. The mainstay of treatment should be directed at symptomatic improvement, and chemotherapy may be continued.

Pseudoxanthoma elasticum (PXE) is an autosomal recessive disorder characterized by atypical elastic fibers that causes connective tissue abnormalities of the skin, eyes, and heart, among other organs. The disorder is rare, with a classic presentation of yellow-orange cobblestone-like papules on flexural areas, lax skin, ocular degeneration, and moribund vasculature in multiple organs. There is wide variability in the presentation of the affected organs [1]. We present two sisters with classic cutaneous findings of PXE with the additional unusual findings of numerous open comedones on the neck. To our knowledge, this is the first report of numerous open comedones in familial PXE.

The association between guttate psoriasis and infection with group A Streptococcus (GAS) has been well established in the medical literature. However, responses to treatments aimed at GAS eradication such as systemic antibiotics or tonsillectomy are inconsistent. Further complicating treatment recommendations for a disease with a suspected microbial trigger, the standard therapy for severe psoriasis is with systemic immunosuppressant medications. This case report illustrates the role of GAS as a trigger for acute onset severe psoriasis in a child whose skin disease initially worsened with a trial of methotrexate. An immune evaluation confirmed a co-existing selective antibody deficiency. Subsequent treatment with intravenous immune globulin dramatically improved his underlying immune function and decreased GAS infections. This improvement in overall immune function and decrease in GAS infections cleared his skin disease. An interval change in formulation to subcutaneous immune globulin was not as effective.

We present a rare case of acute febrile neutrophilic dermatosis, also known as Sweet syndrome, associated with recurrence of metastatic cervical cancer. This report highlights similar reports and serves as an important reminder of the relationship between Sweet syndrome and cervical cancer. Increasing awareness of Sweet syndrome assists clinicians in recognizing characteristic findings and encourages evaluation of patients for new-onset or recurrent neoplastic disease. Additionally, we discuss the typical presentation of the syndrome, the proper workup and treatment, and a common pitfall encountered in the diagnosis of Sweet syndrome.

The use of botanical products and vitamins in skin care creams and sunscreens is prevalent. Herein we conduct an evaluation of sunscreens to quantitatively assess how often sunscreens incorporate botanically derived products and vitamins. The most commonly used botanicals products and vitamins are identified and stratified based on the sunscreen sun protection factor (SPF). The overall prevalence for the use of botanical agents and vitamins was 62% and 79%, respectively. Aloe vera and licorice root extracts were the most common botanical agents used in sunscreens. Retinyl palmitate was the most common vitamin derivative utilized in sunscreens. The prices of sunscreens significantly increased when more than one botanical product was added. Botanical products and vitamins are widely utilized in sunscreens and more research is needed to assess how their inclusion may enhance or alter the function of sunscreens.

Alopecia can be one of the many symptoms of secondary syphilis and the clinical presentations include essential syphilitic alopecia or symptomatic syphilitic alopecia. In this report, we present a case of a patient with essential syphilitic alopecia whose sole presenting symptom of syphilis was alopecia. Despite an initial negative rapid plasma reagin (RPR) test, he was ultimately found to have syphilis on scalp biopsy. His alopecia improved following treatment with benzathine penicillin. This presentation serves as a reminder to clinicians to be cognizant of alopecia as a presenting sign of syphilis. A review of the specificity and sensitivity of the typical tests used for the diagnosis is presented.

Background: Rosacea and melasma are two common skin conditions in dermatology. Both conditions have a predilection for the centrofacial region where the sebaceous gland density is the highest. However it is not known if sebaceous function has an association with these conditions., Aims and Objectives: We aimed to assess the relationship between facial glabellar wrinkle severity and facial sebum excretion rate for individuals with rosacea, melasma, both conditions, and in those with rhytides. Secondly, the purpose of this study was to utilize high resolution 3D facial modeling and measurement technology to obtain information regarding glabellar rhytid count and severity., Materials and Methods: A total of 21 subjects participated in the study. Subjects were divided into four groups based on facial features: rosacea-only, melasma-only, rosacea and melasma, rhytides-only. A high resolution facial photograph was taken followed by measurement of facial sebum excretion rate (SER)., Results: The SER was found to decline with age and with the presence of melasma. The SER negatively correlated with increasing Wrinkle Severity Rating Scale. Through the use of 3D facial modeling and skin analysis technology, we found a positive correlation between clinically based grading scores and computer generated glabellar rhytid count and severity., Conclusion: Continuing research with facial modeling and measurement systems will allow for development of more objective facial assessments. Future studies need to assess the role of technology in stratifying the severity and subtypes of rosacea and melasma. Furthermore, the role of sebaceous regulation may have important implications in photoaging.

Squamous cell carcinoma (SCC) developing in chronic hidradenitis suppurativa (HS) is rare, but failing to recognize the condition may have significant consequences. Dermatologists must be aware of the potential for malignant transformation and should have a low threshold for biopsy when clinical presentation is atypical. Herein we describe a 64-year-old woman with metastatic vulvar SCC that developed within an area of chronic HS. Like SCC associated with other chronic inflammatory disorders (Marjolin's ulcers), mortality is significant. Past reviews have reported death rates above 40% and our most recent update continues to support poor prognoses for these patients.

Excessive sun exposure is known to be the leading cause of skin cancer. The direct cellular damage inflicted by the ultraviolet (UV) radiation from the sun results in premature aging, DNA damage, and mutations that ultimately lead to skin cancer. Sunscreens are highly recommended to protect against UV radiation. However, little research has been conducted on the economic burden of sunscreen use. In this study, we aimed to evaluate the annual cost of sunscreen under both ideal and actual use conditions while stratifying for the sun protection factor (SPF) and by the name brand or equivalent store brand sunscreen. Pricing data was collected for sunscreens of SPF 30, 50, 70, and 100. For each type of sunscreen, the size and price of the container were recorded. Our results demonstrated that sunscreen prices increased with SPF but purchasing a generic sunscreen resulted in savings of 40%-50%. Our estimates reveal that sunscreens are affordable with annual expenditures ranging from $30.21 to $61.94, depending on brand, for SPF 50 sunscreens used with minimal application density for the average person.

Solar urticaria is an uncommon condition characterized by erythema and whealing shortly after exposure to ultraviolet (UV) and/or visible light. We report a 25-year-old woman with an erythematous, edematous, pruritic reaction minutes after sun exposure while she was taking terbinafine for onychomycosis. Phototesting revealed a UVB-sensitive urticarial reaction, confirming the diagnosis of solar urticaria. This report describes the first patient with possible terbinafine-associated solar urticaria.

Drug Rash (or Reaction) with Eosinophilia and Systemic Symptoms (DRESS) is a potentially life-threatening hypersensitivity reaction to drugs characterized by rash, fever, lymphadenopathy, hematologic abnormalities, and involvement of internal organs. Initially coined in 1996, the term is used to refer to an idiosyncratic reaction to several drugs, the most common of which are carbamazepine, allopurinol, sulfasalazine, and phenobarbital. We report the first case of DRESS related to rufinamide in a ten year old boy with a history of a complex seizure disorder.

We report a case of epidermolysis bullosa simplex (EBS) associated with a family cluster of EBS and a novel KRT5 mutation. The case is presented in the context of recent advances in the study of the disease.

Calciphylaxis is a rare but life-threatening disease characterized by deposition of calcium within small and medium sized vessels, with subsequent thrombosis, cutaneous ischemia, and necrosis. Because of its systemic nature, calciphylaxis is typically a symmetrical, bilaterally-distributed phenomenon. Here, we present an unusual case of unilateral leg calciphylaxis in the setting of relative chronic arterial insufficiency of the affected extremity secondary to steal syndrome.

We present perspectives from four fourth year medical students who matched into dermatology that highlight the factors they believed helped them most. The purpose is to offer advice to medical students interested in dermatology. We divide the paper into four areas of discussion: academics, extracurricular activities, research, and mentorship. All four factors are crucial for a strong dermatology application. We believe the paper provides valuable suggestions and guidance to students considering a career in dermatology.