Paraneoplastic Dermatoses and Cutaneous Metastases

Paraneoplastic syndromes include a variety of cutaneous presentations that have an associated internal malignancy. Some syndromes have a strong correlation to specific internal malignancies, whereas others are associated with a multitude of tumors. There are many cutaneous manifestations that suggest hematologic disorders, which will be reviewed in detail. Cutaneous metastases are commonly from breast and lung cancers and can present as nodules, vascular lesions, eczematous dermatitis, or inflammatory lesions. The most common histologic presentation of cutaneous metastasis is that of a dermal-based or subcutaneous-based nodule with sparing of the epidermis. Determination of origin of tumor requires immunohistochemistry and clinical correlation.

Results From the First Annual Association of Professors of Dermatology Program Directors Survey

The first annual Association of Professors of Dermatology (APD) program director (PD) survey was distributed in November 2022 and included 53 respondents from individual Accreditation Council for Graduate Medical Education (ACGME) programs. This survey included 137 in-depth questions to identify similarities and differences among programs regarding 12 broad categories: program characteristics; PD demographics; impact of the COVID-19 pandemic on residency training; available resources; quality improvement; clinical instruction; didactic instruction; research content; diversity, equity, and inclusion; wellness; evaluation systems; and graduation outcomes of postgraduate year (PGY) 4 residents. The survey provided preliminary insight to similarities and differences between programs, such as varying academic time and research resources, while also challenging norms seen in areas of diversity, equity, and inclusion. As future surveys are optimized to obtain greater response rates, these metrics can be captured in a centralized database accessible to PDs to reflect trends and identify strengths and weaknesses of dermatology residency programs.

From the Cochrane Library: Interventions for Pityriasis Rosea

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Milestones 2.0: An advancement in competency-based assessment for dermatology

In 2013, Next Accreditation System and Milestones became the competency-based assessment framework required for all specialties accredited by the Accreditation Council for Graduate Medical Education. Dermatology residency programs implemented Milestones 1.0 in the 2013-2014 academic year. The Accreditation Council for Graduate Medical Education committed to review and revise Milestones 1.0 within 3 to 5 years. Subsequently, feedback from key stakeholders influenced the goals for revision, including reducing complexity, enhancing community engagement, and providing additional resources for programs. In 2019, the Dermatology Milestones 2.0 work group streamlined the specialty-specific patient care and medical knowledge subcompetencies. The harmonized milestones allowed for greater uniformity across specialties in systems-based practice, practice-based learning and improvement, professionalism, and interpersonal communication and skills. The work group developed a supplemental guide with specialty-specific context to help program directors, clinical competency committee members, and other faculty understand individual milestones. Dermatology Milestones 2.0 reduces the number of subcompetencies from 28 to 21. Milestones 2.0 represents an advancement in competency-based assessment for dermatology. The first year of reporting for Dermatology Milestones 2.0 is 2021.

Skin Cancer in the Incarcerated Population-A Single-Center Study

BACKGROUND

The incarcerated population may have variable access to specialty care that may affect the detection and diagnosis of skin cancer.

OBJECTIVE

The purpose of the study was to characterize skin cancers in the incarcerated population and determine time to treatment initiation (TTI) after biopsy.

METHODS

A retrospective cohort study was performed using data from a single-center referral hospital of incarcerated patients with biopsy-proven basal cell carcinoma (BCC), squamous cell carcinoma (SCC), or melanoma between January 2009 and December 2019. The main outcome measured was TTI after biopsy.

RESULTS

One hundred thirteen patients, majority men (96.5%) and of Caucasian race (89.4%), were diagnosed and/or treated for 191 skin cancers. Of these 191 skin cancers, 118 were BCC (61.8%), 58 were SCC (30.4%), and 15 were melanomas (7.9%). The average TTI after biopsy for melanoma was 57 days (range: 21-136, median: 51, 95% confidence interval: 39.89-74.10) with an average Breslow depth of 1.57 mm.

CONCLUSION

The average TTI of melanoma in the incarcerated population in this study was greater than 30 days, which may have increased mortality risk.

Intralesional 5-Fluorouracil for Treatment of Non-Melanoma Skin Cancer: A Systematic Review

BACKGROUND

Surgical excision is the paradigm treatment option for non-melanoma skin cancer (NMSC), however intralesional fluorouracil (IL 5-FU) is an efficacious alternative and superior to other chemotherapy agents in NMSC. Yet, little summative data exists on the topic.

OBJECTIVE

To assess the efficacy of IL 5-FU in the treatment of NMSC.

METHODS AND MATERIALS

A systematic review was performed using PubMed, Embase and Web of Science databases. 19 studies were included. ANOVA test was used to compare the duration of lesion prior to therapy and resolution time following IL 5-FU treatment. A two-way proportion test was performed to compare the clearance rate between squamous cell carcinoma (SCC), basal cell carcinoma (BCC), and keratoacanthoma (KA).

RESULTS

There was no significant difference between the clearance rate of SCC and BCC after IL 5-FU therapy (87 % vs 91.4%, respectively; P=0.2); however, the clearance rate of both SCC and BCC was significantly greater than that of KA (74.5%; P<0.007); 95% CI [2.56%–19.1%]. Lesion duration and resolution time did not significantly differ across SCC, BCC, and KA (P>0.3).

CONCLUSION

While majority of data is derived from individual cases, IL 5-FU achieved higher clearance rate in SCC and BCC groups than in KA group. J Drugs Dermatol. 2021;20(2):192-198. doi:10.36849/JDD.5518.

The Use of Brodalumab in Three Patients with Psoriasis and Psychiatric Comorbidities

Brodalumab, a first-in-class interleukin-17 (IL-17) receptor blocker, carries a black box warning for suicidal ideation and behavior, yet it is also one of the most powerful biologic agents in our armamentarium. We wish to highlight three patients with moderate-to-severe psoriasis and comorbid depression who were successfully treated with brodalumab. The patients were chosen by an expert panel comprising dermatologists, psychiatrists, and psychologists. Psoriasis disease severity was measured using the Psoriasis Area and Severity Index (PASI) score. All three patients experienced PASI 100 after treatment with brodalumab (N=3). Importantly, depressive symptoms improved or resolved in two out of three patients. One patient, who had a history of psychiatric hospitalizations, required in-patient psychiatric treatment during treatment. The use of brodalumab in patients with psoriasis can provide rapid-onset improvement in both skin and depressive symptoms.

Laser safety: the need for protocols

Lasers are being used in ever-expanding roles in dermatology. As our understanding of laser energy grew, the need for safety guidelines became apparent. The US Food and Drug Administration (FDA) published the first safety guidelines in 1984, which are updated on a regular basis. However, these are just guidelines, and their implementation is voluntary by the laser practitioner. In this article, we discuss the 4 regulatory entities for laser safety in the United States, laser principles in general, ocular hazards, laser-generated airborne contaminants (LGACs), fires, and unintended laser beam injuries. We also review the use of checklists in reducing adverse outcomes and the need for safety protocols for laser practitioners. We provide a modifiable checklist, which pertains specifically to lasers and can be customized to meet the needs of the individual laser practitioner.

Discrepancies by dermatology resident gender in diagnostic confidence and management of female and male genital lichen sclerosus

Physician gender may impact their exposure to genital dermatoses during residency. The purpose of this study was to survey current dermatology residents regarding their comfort in diagnosing and managing lichen sclerosus. As residents progress through training, confidence improves in diagnosing and managing both male and female lichen sclerosus. However, residents overall feel less comfortable with male genital lichen sclerosus, with female residents displaying the greatest confidence discrepancy. This study highlights gender discrepancies with dermatology resident confidence and practice habits and may serve to further guide curricula to address these disparities.

The effect of Instagram and photograph editing on seeking dermatologic care

BACKGROUND

Photograph editing has become popular for individuals using social media like Instagram. However, it is unknown if the use of social media and photograph editing applications by young adults has an association with seeking dermatologic care.

AIMS

To assess the frequency of photograph editing among a cohort of young adults using Instagram and the association with seeking dermatologic care.

METHODS

A population-based survey was administered to undergraduate students from April 2019 to May 2019 through an online platform.

RESULTS

Of the 257 responses, 228 (88.7%) reported that they edited a photograph prior to posting on Instagram. Of those who reported editing a photograph, 145 (63.6%) edited a skin lesion, 104 (45.6%) whitened teeth, and 70 (30.7%) altered the size of their body. Of those who edited skin lesions, 128 (88.3%) edited acne/acne scars. Those who felt the editing made them more aware of their skin lesions were significantly more likely to feel they needed to see a dermatologist (P = .02, 95% CI).

CONCLUSION

Photograph editing is common among young adults using Instagram, especially in individuals with acne/acne scars. The effect of this behavior may be a motivating factor for individuals seeking dermatologic care.

Teaching dermatology to the millennial learner

Millennial learners have educational needs and preferences that differ from those of prior generations. They prefer learning from online resources, appreciate interactive didactic sessions, and desire frequent feedback and guidance. Understanding and adapting to these learner attributes may allow for optimization of the educational environment for members of this generation. The following recommendations were developed to advance a dermatology residency program's curriculum to accommodate the modern learner. Although the efficacy of these teaching tips has yet to be fully established, they are grounded by theory and are evidence-informed. Medical educators who are able to employ these strategies are likely to be successful in teaching and engaging the millennial learner.

Presence of arthralgia exacerbates decreased quality of life in hidradenitis suppurativa patients

Hidradenitis suppurativa is characterized by chronic follicular occlusion that presents with recurrent nodules, inflamed abscesses, and scarring. Research has shown that these patients have a decreased quality of life. In addition to its psychosocial effects, hidradenitis suppurativa has recently been associated with joint pathology. In this study, we distributed a survey consisting of the Short Form 12 Health Survey, used for assessing health outcomes, along with additional questions about joint pain to an online hidradenitis suppurativa support group in order to understand the effect of comorbid arthralgia on quality of life in this disease. The respondents in this study had significantly reduced physical health composite scores-12 (PCS-12), (35.8 versus 50, P<0.001) and mental health composite scores-12 (MCS-12), (33.7 versus 50, P<0.001) scores compared to the general population. Additionally, patients reporting severe arthralgia had significantly lower PCS-12 (32.3 versus 36.5; P<0.05) and MCS-12 (33.3 versus 40.5; P<0.001) scores compared to those with mild arthralgia. Despite the effect of comorbid arthralgia on quality of life, only 11% reported having been asked about joint pain by their dermatologist. Routine screening questions concerning associated arthralgia and diminished quality of life may be helpful during clinician assessment and treatment of hidradenitis suppurativa patients.

Use of topical imiquimod in the treatment of VIN: a case report and review of the literature

Vulvar intraepithelial neoplasia (VIN) is a premalignant disease of the vulvar squamous epithelium. Standard treatment for VIN lesions is surgical excision. Alternative therapeutic options for conservative treatment have been sought by patients to prevent disfigurement and to preserve sexual function. We present such a patient in whom topical imiquimod was used with a successful outcome. Imiquimod is effective in the treatment of VIN, as well as convenient, self-administered, and generally well tolerated.