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Patients undergoing Mohs micrographic surgery frequently experience anxiety as a result of multiple potential factors. There is currently no data regarding how this anxiety compares to other common procedures performed in dermatology offices, such as shave biopsy and excision, relative to a general dermatology visit. Herein, we conducted a survey of 471 dermatology patients at an academic medical center, using a validated tool (Visual Analogue Scale from 1 "no anxiety at all" to 10 "extremely anxious").

Leprosy is a chronic granulomatous disease caused by Mycobacterium leprae, an intracellular acid-fast bacillus that tends to infect the skin and peripheral nerves. Because of the wide array of cutaneous manifestation, diagnosis is not always straightforward, especially in nonendemic regions of the world such as the United States. The authors report an unusual case of borderline tuberculoid leprosy in an 80-year-old white woman from California. Clinical examination revealed multiple nonscaly annular plaques, with central clearing and absence of lesional anesthesia, distributed over the trunk and extremities initially clinically diagnosed as granuloma annulare (GA). After 2 years of unsuccessful treatment with topical corticosteroid, biopsy revealed a palisaded and interstitial granulomatous infiltrate with necrobiosis, without discrete granulomas, compatible with GA. However, the presence of perineural lymphocytes in the reticular dermis prompted a Fite stain, which revealed acid-fast bacilli within the Schwann cells of a small peripheral nerve, pathognomonic for leprosy. This is the first reported case of leprosy masquerading both clinically and histologically as GA. Dermatopathologists should be aware of the possibility of leprosy given the presence of perineural lymphocytes amidst any pattern of granulomatous infiltrate and obtain a Fite stain.

We report a case of an increasing number of discrete patches of darkly pigmented terminal hair in a patient with nevoid basal cell carcinoma syndrome. This case adds to a small case series of three patients which have previously reported this observation. We report this case to highlight hairy patches as an important clinical feature associated with nevoid basal cell carcinoma syndrome.

Application to dermatology residency is a highly competitive process. Although factors associated with successfully matching have been studied, less is known regarding the ability of admissions committees to screen applicants in a uniform manner or the importance of the interview in ranking applicants. Our goal was to retrospectively measure our admission committee evaluators' concordance regarding residency application credentials and interview performance, and ultimately the effects on final applicant ranking.

Complications from radiation exposure during fluoroscopic guidance of cardiac catheterization may occur. With repeated procedures, the risk for cutaneous injuries increases. Herein, we describe a 59-year-old man with extensive coronary artery disease, who had undergone multiple revascularization procedures and developed a non-healing ulcer on his left inferior scapula. The patient's medical history, physical exam findings, and histopathology gave clues to a case of radiation-induced dermatitis and necrosis.

Complications from radiation exposure during fluoroscopic guidance of cardiac catheterization may occur. With repeated procedures, the risk for cutaneous injuries increases. Herein, we describe a 59-year-old man with extensive coronary artery disease, who had undergone multiple revascularization procedures and developed a non-healing ulcer on his left inferior scapula. The patient's medical history, physical exam findings, and histopathology gave clues to a case of radiation-induced dermatitis and necrosis.

ImportanceThe dynamics of the medical care team, including interactions between physicians and nursing staff, has a large role to play in patient care, patient satisfaction, and future possible reimbursement determination. In order to implement changes to improve this dynamic within the medical team, it is imperative that appropriate assessments are completed to determine baseline satisfaction of our patients and nursing staff in addition to provider self-assessment. ObjectiveWe aimed to investigate patient and nursing staff satisfaction with regards to provider quality of care in an outpatient academic dermatology clinic setting. We also sought out to determine provider insight in regards to satisfaction of patient and nursing staff. MethodsOur nursing staff, patients, and providers completed a questionnaire. We then compared nursing satisfaction data and patient satisfaction data with provider self-assessment to determine provider self-awareness. ResultsA total of 23 provider and nurse surveys and 562 patient satisfaction surveys were completed. Paired comparison and descriptive statistics were utilized to compare patient satisfaction, nursing satisfaction, and provider self-assessments. ConclusionsOverall, the results of the surveys demonstrated that the nursing staff and patients had high satisfaction in their interactions with the dermatology physicians. The physicians had appropriate insight into how they were perceived by the nursing staff and patients. Attending physicians as compared to resident physicians and male physicians as compared to female physicians tended to underrate themselves.

A previously healthy 3-month-old male presented to the hospital with an acute onset of vesicles coalescing into tense bullae on the hands and feet. On admission, vesicles, erosions and tense bullae were noted on the palms and soles (figure 1). Complete blood count showed mildly elevated white blood cells with peripheral eosinophilia. A punch biopsy revealed a subepidermal …

Acne vulgaris is a common reason why adult women present to dermatologists and can be a clinical challenge to treat. It may also be an important sign of an underlying endocrine disease such as Polycystic Ovary Syndrome (PCOS). Although standard acne therapies can be successfully used to treat acne in adult female patients, hormonal treatment is a safe and effective therapeutic option that may provide an opportunity to better target acne in this population, even when other systemic therapies have failed. In this article, a practical approach to the adult female patient with acne will be reviewed to enhance the dermatologist's ability to use hormonal acne therapies and to better identify and evaluate patients with acne in the setting of a possible endocrine disorder.

Hydroxyurea is a drug that has been long forgotten for the treatment of psoriasis. In addition to its anti-psoriatic effects, it has also been shown to have antiviral effects. This dual effect makes it a drug that dermatologists may want to consider when treating psoriasis in HIV-infected patients. Currently, no studies are available that discuss the safety and efficacy of hydroxyurea in the treatment of psoriasis in this immunocompromised group; however, numerous reports discuss the safety and efficacy of hydroxyurea in psoriasis and HIV separately. This review suggests that hydroxyurea is generally safe and effective. The main risk involves the hematologic adverse events (anemia, leukopenia, thrombocytopenia, and macrocytosis), which appear to be dose dependent. Because of the common hematologic adverse events, hydroxyurea may be considered a viable therapeutic option for patients with generalized psoriasis that is inadequately responsive to other safer options, whether or not the patient is HIV positive.

Epidemiological studies suggest that a high dietary intake of flavanols, a subclass of flavonoids, is associated with reduced risk of vascular disease. Clinical studies have also shown that the consumption of certain flavanol-rich foods (e.g., cocoa, tea, red wine), as well as intake of the individual flavanol (-)-epicatechin, can result in improvement in a number of parameters associated with vascular disease, including improved endothelial function, reduced platelet reactivity, and reduced oxidative stress. The present study assessed the effects of a flavanol-rich supplement on platelet reactivity and plasma oxidant defense in a group of smokers, a population at an elevated risk for vascular disease. Male smokers were randomly assigned to a placebo (n = 10) or a flavanol-rich grapeseed extract (FRGSE; n = 13) group, and after an overnight fast, blood samples were collected before and at 1, 2, and 6 hours following consumption of the placebo or supplement. The FRGSE supplement, but not the placebo, significantly decreased ADP-stimulated platelet reactivity at 1, 2, and 6 hours following intake (P < .05) compared to baseline levels. Similarly, the supplement, but not the placebo, decreased epinephrine-stimulated platelet reactivity 2 hours following consumption. Plasma antioxidant capacity (total radical trapping antioxidant potential), lipid oxidation (plasma thiobarbituric acid-reactive substances), and serum uric acid concentrations were not affected in either group. Thus smokers may obtain some health benefits from the consumption of certain flavanol-rich foods, beverages, and supplements.

Summary Background The reproducible evaluation of facial redness is critical to the assessment of erythematotelangiectatic rosacea. Assessments have typically focused on the use of photography with the use of semi-quantitative grading scales based on evaluator rating. However, few studies have utilized computer-based algorithms to evaluate facial redness. Aim The purpose of this clinical study was to assess whether there is correlation between clinical grading of facial redness to the assessment of a quantitative computer-based facial modeling and measurement. Material and Methods In this prospective study, a set of high-resolution facial photographs and cross-polarized subsurface photographs for erythema detection were obtained for 31 study participants. A computer algorithm was then utilized to detect and quantify facial redness in the photographs and compare this to semi-quantitative evaluator-based grading for facial redness. Results There was a strong correlation between computer-based cross-polarized subsurface erythema quantification and clinical grading for redness intensity (Clinical Erythema Assessment), redness distribution, and overall redness severity (Modified Clinical Erythema Assessment). Conclusion Overall, facial redness measurements by facial imaging and computer analysis correlated well to clinical grading scales for both redness intensity and distribution. Future studies should incorporate facial modeling and analysis tools for assessments in clinical studies to introduce greater objectivity and quantitative analysis in facial erythema-based analyses.

Difficulty in patient access to care and affordability are major problems faced by our dermatology specialty in the United States. However, Taiwan provides adequate and affordable dermatologic care for all of its citizens. Herein we describe our first-hand observations and findings of the outpatient dermatology experience in Taipei, and contrast it to the experience in the United States.In Taipei, Taiwan, we observed patient management, electronic documentation, and billing during outpatient dermatology visits in five settings: one academic hospital outpatient dermatology department, one academic hospital Information Technology department, and three private dermatologists' offices. Through our observations, we found that the dermatology specialty in Taiwan is able to overcome challenges with access to care and affordability through three key system features: (1) short yet frequent patient visits (2) close proximity of ancillary staff, and (3) an integrated and paperless electronic medical record and billing system.The Taiwan system is attained with some sacrifice, such as shorter time spent with patients and less personalized care. However, because this system can meet the basic dermatological needs of the entire population, possibly better than our current system, it behooves us to study the Taiwan system with respect and care.

Polycystic ovary syndrome (PCOS) is an endocrine syndrome with variable phenotypic expression and important systemic associations and sequelae, including obesity, insulin resistance, infertility, risk of endometrial cancer, and possible risk of cardiovascular events. PCOS is recognized as a condition influenced by genetic and environmental factors and distinct manifestations in all stages of life, including the prenatal period, childhood, adolescence, and adulthood. Identification of this disorder in childhood and adolescence has received growing attention, in part because of emerging evidence of the benefit of early intervention, but the diagnosis and management of PCOS in children and adolescents can be challenging. Diagnostic and therapeutic considerations of PCOS in children are reviewed to enhance identification and evaluation of patients suspected of having this disorder. When a diagnosis of PCOS is suspected in a child but cannot be confirmed, a provisional diagnosis is strongly recommended so as to prompt ongoing monitoring with an emphasis on important early interventions such as obesity reduction.

Alefacept (Amevive®) was the first biologic agent to be approved by the FDA for use in moderate to severe chronic plaque psoriasis and remains one of the safest systemic agents. However, alefacept is the least utilized of all the biologic agents due to the finding that it is only effective in a small proportion of patients and its maximal efficacy is not seen until approximately 6 weeks after treatment completion.To determine whether intralesional injections with a biologic agent can predict who will be a responder or a non-responder to the medication.This was a single-center 22-week study consisting of three phases: i) intralesional injection to a target plaque, ii) intramuscular alefacept injections for 12 weeks (standard dose) and iii) post-treatment follow-up.There appears to be a perfect correlation between patients who show a response to an intralesional injection of alefacept to a small, target plaque and those who eventually respond to a full 12-week systemic course of the medication (achieve at least 70% improvement in their PASI scores from baseline) (p = 0.0003).This study had a small sample size and was limited by the fact that it was open-label without a control arm.The results from this pilot study demonstrated that alefacept appears to work intralesionally and this may be usable to predict systemic response. More importantly, these results strongly suggest that a biologic agent can work locally - a novel concept that contradicts the common notion that biologic agents must work "systemically".

Author(s): Foolad, Negar; Shi, Vivian Y; Prakash, Neha; Kamangar, Faranak; Sivamani, Raja K | Abstract: 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.

Background: Difficulty in patient access to care and affordability are major problems faced by our dermatology specialty in the United States. However, Taiwan provides adequate and affordable dermatologic care for all of its citizens. Herein we describe our first-hand observations and findings of the outpatient dermatology experience in Taipei, and contrast it to the experience in the United States. Observation: In Taipei, Taiwan, we observed patient management, electronic documentation, and billing during outpatient dermatology visits in five settings: one academic hospital outpatient dermatology department, one academic hospital Information Technology department, and three private dermatologists’ offices. Through our observations, we found that the dermatology specialty in Taiwan is able to overcome challenges with access to care and affordability through three key system features: (1) short yet frequent patient visits (2) close proximity of ancillary staff, and (3) an integrated and paperless electronic medical record and billing system. Conclusions: The Taiwan system is attained with some sacrifice, such as shorter time spent with patients and less personalized care. However, because this system can meet the basic dermatological needs of the entire population, possibly better than our current system, it behooves us to study the Taiwan system with respect and care.

Phototherapy is one of the oldest therapeutic modalities for the treatment of generalized psoriasis. Optimal efficacy for phototherapy is based on achieving the minimal erythema dose (MED) as quickly as possible. MED testing on every patient would be ideal to determine each individual's most effective dose. Previous methods of determining MED are cumbersome; however, the excimer laser has made MED determination easy. The excimer laser is not only a treatment modality in itself, but it can also be used to provide the clinician with a quick and easy way of determining each individual patient's MED. In this way, the laser can also significantly enhance efficacy for patients undergoing traditional narrowband ultraviolet B phototherapy.

Hydroxyurea is a drug that has been long forgotten for the treatment of psoriasis. In addition to its anti-psoriatic effects, it has also been shown to have antiviral effects. This dual effect makes it a drug that dermatologists may want to consider when treating psoriasis in HIV-infected individuals. There are currently no studies that discuss the safety and efficacy of hydroxyurea in the treatment of psoriasis in this immunocompromised group; however, there are multiple reports that discuss the safety and efficacy of hydroxyurea in psoriasis and HIV separately. This review suggests that hydroxyurea is generally safe and effective. The main risk involves the hematologic adverse events (anemia, leukopenia, thrombocytopenia, and macrocytosis) which appear to be dose-dependent. Because of the common hematologic adverse events, hydroxyurea may be considered as a viable therapeutic option for patients with generalized psoriasis inadequately responsive to other safer options, whether the patient is HIV-positive or not.

Unilateral Nevoid Telangectasia Syndrome (UNTS) is characterized by superficial telangiectasias in a unilateral distribution. Vascular endothelial growth factor (VEGF) may play a role in the pathogenesis of UNTS in patients with underlying hepatic disease. We report a case of a patient with UNTS accompanied by chronic hepatitis C virus infection, with a normal serum estrogen profile and strong positive immunohistochemical staining of lesional skin with VEGF.

Psoriatic arthritis occurs in 30% of psoriasis patients, and the treatment can be challenging in some patients. Recently, the US Food and Drug Administration approved ustekinumab, a fully human monoclonal antibody, for the management of psoriatic arthritis. In this article, we review large-scale randomized clinical trials addressing the efficacy and safety profile of ustekinumab for the treatment of psoriatic arthritis.

There have been significant advancements in the field of transdermal drug delivery with the development of microneedles. Microneedles are capable of enhancing transdermal drug delivery by creating physical conduits in the stratum corneum of the epidermis. In this chapter, we discuss the various types of microneedles with a specific focus on out-of-plane microneedles and their modes of action. We further examine the safety and efficacy of microneedles along with their applications in the field of dermatology.

We present the case of a 90-year-old woman with psoriasis vulgaris who had been treated with methotrexate for many years. The patient presented with psoriatic plaque ulcerations uniquely limited to the active border as well as acute oral ulcerations and severe gastrointestinal upset after undergoing a course of ciprofloxacin for treatment of a bacterial infection.

Acne vulgaris is a common reason why adult women present to dermatologists and can be a clinical challenge to treat. It may also be an important sign of an underlying endocrine disease such as Polycystic Ovary Syndrome (PCOS). Although standard acne therapies can be successfully used to treat acne in adult female patients, hormonal treatment is a safe and effective therapeutic option that may provide an opportunity to better target acne in this population, even when other systemic therapies have failed. In this article, a practical approach to the adult female patient with acne will be reviewed to enhance the dermatologist's ability to use hormonal acne therapies and to better identify and evaluate patients with acne in the setting of a possible endocrine disorder.

Psoriasis is a chronic, inflammatory skin condition with negative impacts both physical and psychological. Scalp psoriasis, especially around the hairline, can cause significant impairment in quality of life due to its visibility. Options for treatment of facial psoriasis, including hairline involvement, are the use of low potency topical steroids, calcineurin inhibitors, and vitamin D analogues. Though the use of excimer laser for scalp psoriasis has been reported, there are no cases or studies specifically examining excimer laser phototherapy for the treatment of hairline psoriasis. We present a case of rapid improvement of hairline psoriasis using a regimen of 308 nm excimer laser with clobetasol spray and recommend an algorithm for the optimal treatment of scalp psoriasis utilizing currently available antipsoriatic therapies.

The treatment options for psoriasis in HIV-infected individuals are limited due to the immunosuppressive nature of the therapeutic modalities and the patient's immunocompromised state. Etanercept has been shown to be safe and effective in the non-HIV psoriasis population with nearly 20 years of experience. However, there is limited data on the safety of etanercept use in the HIV patient population. The authors report a case of an HIV-infected patient with psoriasis who has remained mostly clear on continuous, uninterrupted etanercept use for over six years.

Misha M. Heller1, Eric S. Lee2, Faranak Kamangar3, Wilson Liao4 and John Y. M. Koo4 1University of Southern California, Keck School of Medicine, Los Angeles, California 2University of Nebraska Medical Center, College of Medicine, Omaha, Nebraska 3University of California Davis, School of Medicine, Sacramento, California 4University of California San Francisco, Department of Dermatology San Francisco, California USA

To critically review the body of clinical trials that report the rates of skin cancer in patients on a biologic therapy, in order to discern whether this therapy is associated with any increase risk of skin cancer.Review of MEDLINE database and the Cochrane library database was conducted, to identify randomized controlled trials and meta-analyses that evaluated the safety of biologic therapies, and specifically reported rates of skin cancer in patients on biologic therapies.Two reviewers independently evaluated eligibility and collected the data. Studies selected were large randomized controlled trials and meta-analyses with large number of patient populations from clinical trials and post-marketing surveillance data that reported specifically the rate of skin cancer while on a biologic therapy.Nine studies met the eligibility criteria. All studies were of high quality with Strength of Recommendation Taxonomy (SORT) (J Am Board Fam Pract 2004) evidence level of 1. Eight of these trials demonstrated an increased risk of non-melanoma skin cancer (NMSC) while on a biologic therapy. In addition, studies suggested a possible increased risk in patients with history of prior treatments known to also increase risk of skin cancer. Case studies with SORT evidence level 3 are also included in this review for completion; however, these data were not used in the formation of final recommendations.Biologic medications are highly efficacious and have a relatively good safety profile; however, high-quality evidence suggests that use of biologic therapies may be associated with an increased risk of detection of NMSC. Psoriatic patients may be at an increased risk due to history of treatment with other therapies also known to increase the risk of skin cancer. As such, it may be important to consider biologic therapies as an additional risk factor for development of NMSC and implement regular skin examinations for patients on these therapies.

Vitamin D as a topical treatment has become one of the mainstays for treatment of psoriasis vulgaris. Oral vitamin D on the other hand has for the most part become a forgotten option. But a review of the literature on oral vitamin D as a treatment for psoriasis reveals that this treatment is efficacious. The main side effect of this therapy is hypercalcemia, which appears to be easily monitored and avoidable with proper dosing and monitoring. The literature also suggests a correlation between low levels of serum vitamin D in this patient population associated with increased severity of disease involvement. In addition, oral vitamin D improves psoriatic arthropathy. Moreover, vitamin D has been proven to have many health benefits such as prevention of cancer, improved cardiovascular health among many others. Psoriatic patients as a population are at increased risk of developing adverse health complications such as cardiovascular disease, and oral vitamin D may prove to be of benefit in this population. Oral vitamin D is inexpensive and easily available. It is still a viable option and should not be forgotten as a possible treatment for psoriasis.

The availability of new biologic agents for the treatment of psoriasis provides hope for improved quality of life outcomes. However, the way patients come to use biologics, the potential barriers they encounter, and their attitudes towards using these medications are still not well studied. Here, we conducted a survey of 106 psoriasis patients at an academic medical center to discern patient attitudes towards biologics. We found that most patients learn of biologics through their physician and perform follow-up research using the Internet. Most patients did not find it difficult to make the decision to start a biologic. Difficulty in obtaining biologics was associated with age less than 55 (p = 0.01), lower income level (p = 0.007), and lack of insurance (p = 0.04). Patients were found to have high satisfaction and compliance rates on biologics. Of patients who missed a dose of their biologic, this was mainly due to logistical reasons such as not having the medication or forgetting to take it, rather than being depressed or overwhelmed. Patients with lower income levels had increased cut backs in personal expenses due to co-payments (p = 0.001). Among respondents, the mean annual out-of-pocket expense for a biologic was $557.12 per year, with a range of $0-7000.

To determine the effectiveness of treating scars with microporous paper tape or silicone gel sheeting (SGS) in preventing hypertrophic scarring.Forty hypertrophic scars were induced in a validated rabbit ear model. Wounds were randomized and bandaged for 30 days with either SGS (20 wounds), paper tape (20 wounds), or untreated controls (40 wounds). Two outcome measures of hypertrophic scarring included (1) histologic measurement of scar elevation index (SEI) and (2) blinded photograph analysis using a visual analog scale.In histologic comparison, no difference in mean (SE) SEI between treatment groups was seen (paper tape group, 1.32 [0.2]; SGS group, 1.41 [0.18]; control, 1.35 [0.23]; P = .51). In photographic analysis, both treatment groups were superior to the control group (P.01), whereas no difference was seen between the SGS and paper tape groups (P = .88).Paper tape and SGS demonstrated equal effectiveness in the prevention of hypertrophic scarring on visual analysis, whereas histologic analysis demonstrated no difference in treatment groups from controls. The effectiveness of paper tape in preventing hypertrophic scarring in humans will require further laboratory and clinical investigation.

The ideal repair mechanism for overcoming barrier disruption in atopic dermatitis (AD) needs to completely eliminate microbe and allergen penetration as well as transepidermal water loss. We propose the hydrogel patch as an innovative approach to complete barrier repair. It is composed of an adhesive, thin, flexible, hydrogel layer on an impermeable urethane surface. We conducted a 6-week pilot study with 15 AD patients, who applied the hydrogel patch over one lesion for 6-8 h daily and triamcinolone (TAC) 0.1% cream twice daily to another lesion. Results after 2-week no treatment follow-up showed hydrogel patch had notable efficacy, and comparable to TAC 0.1% cream. Larger studies are needed to validate these results.