Home Is Where the Match Is: Mentorship and Dermatology Residency Match Trends Before and During the COVID-19 Pandemic

Dermatology is one of the most competitive residencies for matching among medical school applicants. A strong connection with a residency program through research or clinical rotations may distinguish between similarly qualified applicants. Our previous study of research-mentor relationships among matched dermatology applicants corroborated the importance of program connections.1 However, the 2020-2021 residency match cycle was uniquely affected by the COVID-19 pandemic, which prevented applicants from fostering connections with faculty at outside institutions. Our study objectives were to evaluate research-mentor relationships among matched dermatology applicants in the 2020-2021 pandemic match cycle with comparisons to pre-pandemic match cycles.

Fatal low-dose methotrexate toxicity: A case report and literature review

Methotrexate (MTX) is a chemotherapeutic agent that acts primarily by inhibiting the folic acid cycle. In addition to its application for treating malignancies, MTX is also used to treat chronic inflammatory diseases including psoriasis. Adverse effects have been reported even at low doses (up to 25 mg/week), and there is risk of toxicity in the form of myelosuppression, hepatotoxicity, or pulmonary fibrosis. Here, we report a case of a 67-year-old male with a past medical history of end stage renal disease on peritoneal dialysis and moderate-to-severe psoriasis with psoriatic arthritis presented with abdominal pain, diarrhea, rash, mucositis, and mucocutaneous ulcers and erosions. The patient was taking methotrexate 10 mg weekly without folic acid supplementation and was found to be pancytopenic. Despite treatment, the patient developed multiorgan failure and passed away after 16 days of hospitalization. Myelosuppression is considered the most serious side effect with the highest risk of mortality. Risk factors for toxicity include renal insufficiency, advanced age, lack of folate supplementation, drug interactions, and medication errors. Importantly, serum levels of MTX do not correlate with toxicity; therefore, folinic acid rescue therapy should be started as soon as MTX toxicity is suspected. MTX toxicity is rare with low dose, proper dose scheduling, and adherence to the recommended guidelines. It is imperative that physicians considering therapy with low dose MTX for dermatologic indications take into consideration a patient's risk factors for toxicity and monitor appropriately.

Extrafacial Merkel Cell Carcinoma Presenting as a Cyst

Merkel cell carcinoma (MCC) is a rare, aggressive neuroendocrine skin tumor that presents as an erythematous or violaceous nodule in elderly white males with an extensive history of sun exposure. Herein, we report two cases of extrafacial MCC. On exam, lesions presented as a cystic nodule and a firm plaque. We summarize tools from literature review that may aid in earlier diagnosis of MCC as well as implications of primary tumor location in prognosis. In addition, we provide an algorithm for diagnostic workup. MCC is an aggressive malignancy with a poor prognosis and a high risk of local recurrence and nodal metastasis. It is imperative to include MCC in differential diagnosis of cyst/nodule in order to facilitate early detection. J Drugs Dermatol. 2022;21(3):304-308. doi:10.36849/JDD.6248.

Laser in the Treatment of Granulomas on the Nose Produced by Polymethylmethacrylate: A Case Series

BACKGROUND

The search for aesthetic non-surgical procedures is growing. The use of polymethylmethacrylate (PMMA) as a filling material in the nose represents one of the many options among these aesthetic procedures. Its use, however, can lead to complications. The treatment of these complications is often challenging.

METHODS

We performed a retrospective clinical analysis of the medical records of patients undergoing treatment of PMMA granulomas of the nose at a private clinic from January, 2015, to January, 2021. A short-pulsed neodymium-YAG (Nd:YAG) laser was applied intranasally or directly by cutaneous incision in the granulomas. Laser-tissue interaction heats the alloplastic material, fragments the product and creates cleavage paths, thereby facilitating the removal of PMMA, either by intercartilaginous removal or aspiration.

RESULTS

Twenty-seven patients were included in the study. All had a history of PMMA injection in the nose. All patients were treated with an intralesional pulsed 1064nm Nd:YAG laser. The material removed after laser-tissue interaction was sent for histopathological examination; this showed the presence of microparticles of exogenous material compatible with PMMA. The partial removal of the alloplastic material was shown to be effective in all cases. One patient developed a small blister in the nasal dorsum. Follow-up ranged from six to 47 months.

CONCLUSIONS

The use of intralesional Nd:YAG laser for the treatment of PMMA granulomas on the nose proved to be an effective and safe procedure with improvement of nasal shape, without compromising respiratory function. This technical option represents yet another alternative in the treatment of PMMA granuloma complications. J Drugs Dermatol. 2021;20(11): 1161-1166. doi:10.36849/JDD.6550.

Early cutis marmorata telangiectatica congenita masquerading as ulcerated retiform purpura: a diagnostic trap

Cutis marmorata telangiectatica congenita (CMTC) is a rare congenital cutaneous vascular anomaly with a reticular marbled erythematous pattern, which can result in isolated benign skin lesions or less commonly be associated with systemic anomalies. Occasionally, the characteristic pattern of CMTC lesions is masked on initial presentation, creating a diagnostic conundrum that can result in unnecessary workups to rule out vasculopathy. We present the case of a female newborn with a red-blue ulcerated skin lesion on the right leg and foot, which initially appeared as retiform purpura but evolved to exhibit the mottled pattern of CMTC by 5 days of age. Clinicians must be made aware of this potential diagnostic trap in early CMTC to avoid invasive skin biopsies and unnecessary laboratory testing in neonates.

Erosive pustular dermatosis of the scalp: causes and treatments

Erosive pustular dermatosis of the scalp is a rare condition which primarily affects older women after local trauma and has historically been treated with topical steroids. As it is a rare entity and resembles other dermatologic conditions, it may easily be misdiagnosed. Identifying the causes and evaluating the efficacy of treatments of erosive pustular dermatosis of the scalp (EPDS) is of great importance to both avoid misdiagnosis and ensure optimal treatment of this rare condition. There are numerous causes. In addition to surgeries and physical injuries, topical and procedural treatments for actinic keratoses and androgenetic alopecia can trigger the development of lesions. There are also documented associations with several autoimmune and systemic conditions. Besides corticosteroids, topical tacrolimus and photodynamic therapy were the most commonly used treatments for EPDS. They were effective with few recurrences and adverse effects. Other successful treatment options were topical dapsone, silicone gels, calcipotriol, acitretin, and isotretinoin. Oral dapsone can be used in cases of disseminated disease. Zinc sulfate should be considered with low-serum zinc levels. While cyclosporine was effective, there were adverse effects that may limit its use. It is important for dermatologists to be aware of the wide array of potential causes of erosive pustular dermatosis and include it on their differential. Additionally, although high-potency topical steroids have been historically used as the first-line treatment, there are many other effective treatments that may avoid recurrence and skin atrophy, particularly in the elderly population.

Nodules on the Nasal Tip: Think Before You Laser

Cosmetic consultations are routinely part of a dermatologist’s day. Often, patients present after consultation from another dermatologist or other physician with an established diagnosis and would like a particular treatment to resolve their condition. However, it is imperative to take a full history and physical exam prior to rendering treatment in the event of a missed or new diagnosis.

Aquagenic Urticaria: A Perplexing Physical Phenomenon

Aquagenic urticaria (AQ) is a rare physical urticaria induced by contact with water. It may be distinctive clinically, evident as 1-2 mm folliculopapular urticaria, a pattern also characteristic of cholinergic urticaria. AQ has a truncal and upper extremity distribution within 20-30 minutes after contact with water, regardless of its temperature or source. AQ is usually symptomatic with mild to severe pruritus and a burning sensation. The mechanism by which water produces mast cell degranulation and histamine release remains unclear. We review its clinical presentation, diagnostic parameters, differential diagnosis, and treatment.

In vivo confocal microscopy in clinical practice: comparison of bedside diagnostic accuracy of a trained physician and distant diagnosis of an expert reader

BACKGROUND

Reflectance confocal microscopy (RCM) is an imaging tool that allows the visualization of cellular details without biopsy. To our knowledge, RCM sensitivity and specificity has not been studied in a telemedicine setting.

OBJECTIVE

We sought to assess RCM diagnostic accuracy in a support teleconsultation setting.

METHODS

Between June 2010 and September 2011, 340 lesions were imaged using a confocal scanning microscope. The images were evaluated by 2 readers, one on site, and the other at a distance.

RESULTS

A total of 334 cases were included. For each reader the sensitivity was greater than 90% and specificity for each reader was greater than 60%. Both readers had a combined sensitivity of 98.6% and 44% specificity.

LIMITATIONS

RCM may be limited in the correct classification of epithelial tumors.

CONCLUSIONS

RCM is a tool in the clinical diagnosis of skin lesions, providing a high diagnostic accuracy in teleconsultation use.

Vitiligo surgical, laser, and alternative therapies: a review and case series

INTRODUCTION

Vitiligo is a condition caused by the destruction of melanocytes, resulting in areas of skin without pigmentation. While many topical therapies exist for its treatment, not all patients respond to such treatments. Various surgical, laser and other alternative therapies are available for use as well.

OBJECTIVE

The objective of this review was to describe the various surgical, laser, and alternative therapies available for vitiligo. A literature review was conducted through Pubmed and Ovid using the search terms "Vitiligo treatment", "Vitiligo surgery", "Vitiligo laser". Since no articles were available about needling on both Pubmed and Ovid using the search criteria, individual articles were sought out through Google.

RESULTS

The literature review yielded many possible surgical interventions including autologous mini-punch grafting, suction epidermal blister grafting, split-thickness grafting, and cultured and noncultured melanocyte keratinocyte transfer. Laser options included the helium-neon and xenon-chloride lasers, with tattooing and needling serving as other options. While all the above techniques can provide improvement to pigmentation in vitiliginous patches, physician comfort and experience are important factors with regards to outcome. Our case series of four patients treated with the needling method yielded favorable results, with repigmentation rates ranging from 25-50%, with one patient having 90% repigmentation.

CONCLUSION

There are many surgical, laser, and alternative treatment options available for vitiligo when conventional medical therapy fails or for use in conjunction with medical therapies. Autologous mini punch grafting and needling both have minimal equipment requirements and are easy to learn. Physician experience and comfort play a large role in outcome and availability of services.

Adalimumab for the treatment of pityriasis rubra pilaris: a case report

Pityriasis rubra pilaris (PRP) is a chronic papulosquamous eruption of the skin characterized by follicular hyperkeratosis, salmon pink scaly plaques with islands of unaffected skin, and palmoplantar keratoderma. Widely used oral systemic and topical treatments are not greatly effective. We present a 62-year-old man with PRP of 2 years' duration who used routine topical treatments, oral retinoids, and UV therapy without improvement, but his symptoms greatly improved with the initiation of adalimumab.

In vivo reflectance confocal microscopy features of discoid lupus erythematosus

BACKGROUND

Discoid lupus erythematosus (DLE) is an inflammatory condition characterized by round demarcated lesions with varying amounts of erythema, telangiectasia, scaling, follicular plugging, dyspigmentation, atrophy, and scarring. Clinical diagnosis can be confirmed through biopsy samples; reflectance confocal microscopy (RCM) is also emerging as an accurate diagnostic tool.

OBJECTIVE AND METHODS

Our objective was to examine the features of discoid lupus erythematosus on reflectance confocal microscopy. Two patients presenting with discoid lupus erythematosus were imaged using RCM. Features seen in RCM were correlated with those seen in histopathology.

RESULTS

Reflectance confocal microscopy images of discoid lupus erythematosus yielded features characteristically seen in histopathological samples including inflammatory cells, inflammation at the dermo-epidermal junction, pigment incontinence, and vacuolar degeneration.

CONCLUSION

Reflectance confocal microscopy is a useful tool in the diagnosis of discoid lupus erythematosus. Features described in these two cases as well as prior research have yielded sufficient data to allow for the formulation of useful RCM diagnostic algorithms. Further studies with a larger patient population will help in confirming and describing new features of DLE on RCM.