Charles M. Phillips

The annual cost of psoriasis

BACKGROUND The need for comparative cost figures for psoriasis therapy has become increasingly important. OBJECTIVE Our purpose was to compare the yearly costs of various psoriasis treatments. METHODS Ten patients were selected for each treatment modality and the average total cost per year, per patient was evaluated. RESULTS All treatments evaluated were cheaper than inpatient therapy, with Goeckerman treatment in the day-care setting the most expensive and hydroxyurea the cheapest. Cyclosporine, which was used for comparison, was at least twice as expensive as all the other treatments except for Goeckerman treatment in the day-care setting, compared with which it was about 70% more expensive. CONCLUSION No single treatment appears to be universally superior to others. In considering specific treatment for psoriasis, cost analyses, including appropriate laboratory and other specialized evaluations, must be taken into account. With use of these data, practitioners and health care organizations may be better able to select appropriate therapy.

Cutaneous Mastocytosis: A Review Focusing on the Pediatric Population

Cutaneous mastocytosis can be divided into 4 different clinical variants—urticaria pigmentosa, solitary mastocytoma, diffuse cutaneous mastocytosis, and telangiectasia macularis eruptiva perstans. Skin findings are often accompanied by symptoms secondary to mast cell release of mediators. These symptoms can be both localized to the skin lesion and systemic because of the release of mediators into the bloodstream. The majority of pediatric cases of cutaneous mastocytosis show a good prognosis with gradual resolution of both symptoms and skin lesions. This article will review each of the 4 clinical presentations focusing on pediatric-onset of disease while reviewing the literature.

Teledermatology: Issues in remote diagnosis and management of cutaneous disease

Abstract Since the 1970s, long distance communication technology has become highly developed. Along with the communications revolution has been a parallel in the use of the technology to deliver health care. Early work in rural Western states, Canada, and Europe laid the groundwork for the rapid expansion of telemedicine programs throughout the world in the 1990s. Dermatology has played an important role in many programs because of the visual nature of the field. Pilot programs in both interactive video and store-and-forward have demonstrated effectiveness in diagnosing cutaneous disease and skin tumors. Equally important to the delivery of teledermatologic care is the ability of dermatologists to make management recommendations beyond the training of most primary care physicians. Telemedicine technology is continuing to advance with improvements in cameras, lenses, and monitors and increased access to higher-end communications options such as integrated services digital network and digital subscriber lines. Further advances over the next decade in both hardware and software will likely further enhance the ability to diagnose cutaneous disease at a distance. As with any clinical practice, understanding the legal ramifications is very important before entering into a field. Licensure issues continue to be a barrier for teleconsultations across state lines. Consent for teleconsultations, credentialing where applicable, and liability and liability insurance issues are very important to address before starting a teleconsultation service. The technology of telemedicine, although decreasing in cost, still has a high price tag. To date there are few good data to justify teleconsultations on a cost savings basis. Intangible factors such as distance traveled for a live consultation and time away from work become important in the overall cost-effectiveness analysis but have little direct financial benefit for a practicing physician. Improvements in technology and increased accessibility often mean lower costs, which may eventually favor teleconsultations. Despite the cost and difficulties associated with teledermatology, it still presents itself as a very viable form of health care for rural or underserved populations and may serve to reach communities where dermatologists are not readily available. (Curr Probl Dermatol 2002;14:1-40.)

Retinoids Bias Integrin Expression and Function in Cutaneous T-Cell Lymphoma

Cutaneous T-cell lymphoma (CTCL) is a heterogeneous group of malignancies characterized by accumulation of malignant T-cells within the skin. Retinoids, metabolic derivatives, and synthetic analogs of vitamin A embody an effective CTCL therapy with over three decades of clinical use. The established mechanism of action is induction of growth arrest and apoptosis. However, the natural role of retinoids in T-cell biology is imprinting gut-homing properties by inducing integrin α4β7 expression. How the natural role of retinoids relates to therapeutic effectiveness in CTCL has not been addressed and merits investigation. Here we provide evidence that retinoids, including Bexarotene, selectively induce CTCL lineages to increase integrin β7 expression and function prior to growth arrest and apoptosis. Interestingly, augmented CTCL cell adhesion obtained with retinoid exposure was potently attenuated by 1,25-dihydroxyvitamin D3, a metabolic vitamin derivative involved in prompting immune cell skin homing. The integrin-dependent adhesion changes in CTCL cells occurred through synergistic activation of RAR and RXR nuclear receptors. These data explore the early cellular changes induced by retinoids that may be pivotal to sensitizing CTCL cells to growth arrest and apoptosis.

Review of teleconsultations for dermatologic diseases

Background: Telemedicine has been increasingly used in some areas to provide consultation for isolated populations that might otherwise have difficulty accessing specialty care. Little information exists on what types of patients or diseases are being seen in dermatology telemedicine consultation services. Objective: To review our consultations done over a regional telemedicine network with an emphasis on looking at what type of patient, cutaneous diseases, and diagnostic or therapeutic recommendations were made. Results: Between August 1992 and December 1997, 796 teleconsultations were done. The most common diagnoses made were eczemas, follicular based diseases, skin infections, and skin tumours. Steroids were the most commonly recommended therapy, along with antibiotics, antihistamines, and antifungal therapy. Diagnostic recommendations commonly made were a skin biopsy and potassium hydroxide preparation. Conclusion: Common skin problems were seen by our dermatology teleconsultation service. A significant number of diagnostic biopsies and potassium hydroxide preparations were recommended. The efficacy of telemedicine in the delivery of dermatologic care is reviewed.

Parasitic Diseases With Cutaneous Manifestations

Parasitic diseases result in a significant global health burden. While often thought to be isolated to returning travelers, parasitic diseases can also be acquired locally in the United States. Therefore, clinicians must be aware of the cutaneous manifestations of parasitic diseases to allow for prompt recognition, effective management, and subsequent mitigation of complications. This commentary also reviews pharmacologic treatment options for several common diseases.

RARα/RXR synergism potentiates retinoid responsiveness in cutaneous T‐cell lymphoma cell lines

Retinoids, natural and synthetic derivatives of vitamin A, induce cellular changes by activating nuclear retinoic acid receptors (RAR) and retinoid X receptors (RXR). Although the ability of retinoids to govern gene expression is exploited clinically for cancer therapeutics, the full benefit of retinoid‐based strategies is unrealized due to detrimental side effects. Delineating the receptors that prompt cellular outcomes is critical to advancing retinoid‐based approaches. Here, we identify the receptors that evoke multiple responses in cutaneous T‐cell lymphoma (CTCL). The data demonstrate that RARα drives integrin β7‐dependent adhesion and CCR9‐mediated chemotaxis in CTCL cells. Of note, concomitant activation of RARα and RXR nuclear receptors yielded synergistic increases in adhesion and migration at concentrations where single agents were ineffective. As the established paradigm of retinoid action in CTCL is apoptosis and growth arrest, the role of RARα/RXR in these events was studied. As with adhesion and migration, RARα/RXR synergism prompted apoptosis and dampened CTCL cell proliferation. Strikingly, RARα/RXR synergism induced responses from CTCL cell lines previously reported to be unresponsive to retinoids. These data provide a novel framework that may further refine a proven CTCL therapy.

Patient Preferences During Skin Cancer Screening Examination

Discussion | This study provides a framework that facilitates meaningful clinical interpretation of the numerical mMASI score. The ranges for mMASI provided herein correspond to global levels of severity using the MSS. Such categorization in MSS levels can assist clinicians in interpreting clinical trial data, severity of disease, and response to treatment. The mMASI is a simple, reliable validated tool that is a modification of the most commonly used outcome measure for melasma. This user-friendly tool can now be correlated with the newly proposed clinical ranges of severity presented in the Figure, which can be used to assist researchers in determining entry criteria for clinical trains for melasma and improvement of melasma with treatment.

Acantholytic dyskeratotic epidermal nevus with eccrine differentiation: a case report and review of literature

Terminology regarding classification of benign lesions with prominent eccrine differentiation can be confusing as these lesions can have overlapping clinical and histologic characteristics. In this report, we examine a case and review of the literature to suggest that these entities may be better classified as a spectrum of benign lesions with overlapping features rather than distinct entities. We describe a case of an acantholytic dyskeratotic epidermal nevus with eccrine differentiation on the back of a 2‐year‐old patient. We then discuss the classic clinical and histologic presentations of eccrine nevi and epidermal nevi with eccrine differentiation as they relate to each other and to our case.

The Hypertrichosis of Esau

The story of Jacob and Esau is told in the Old Testament book of Genesis (Genesis 25:19-33:20. NIV). Jacob and Esau were the twin sons of Rebekah and Isaac. The story is one of struggle starting before birth and through their adulthood. Esau, we are told, was the first born and was covered with red hair “like a hairy mantle.” Other translations are “garment,” “fur coat,” while others translate it as “it (hair) was all over his body.” The diagnosis of hypertrichosis congenita is rare. The differential diagnosis is well elucidated in 2 review articles on the subject. Hypertrichosis can be divided into localized and generalized variants, and the generalized variants may have associated other findings, such as mental retardation, spina bifida, gingival hyperplasia, and short stature. Esau had a truly congenital hypertrichosis in that he was born hairy. From the rest of his story it is hard to find any other associated physical findings. He was accomplished and presumably enjoyed good health and mentation; In Genesis 25: 27 we learn that Esau became a good hunter and an outdoorsman. Chapter 26, describes a plot that was hatched to steal the blessing from Isaac that would be directed at Isaac’s eldest son, Esau. With the help of his mother, Jacob covered his skin with the hide of a goat to cover the smooth skin on his neck and arms to mimic his hairier brother Esau. His elderly, blind father then mistook Jacob for Esau and bestowed his blessing on the younger brother, Jacob. Despite these setbacks and excessive hairiness, Esau went on to be successful in his own right; he married, led an group of 400 men, and fathered many children and grandchildren. He was so successful that he had to move his family away from Jacob to find enough land to support his flocks. The hypertrichosis in the story of Esau was congenital and persisted throughout his life. Despite his excessive hair and the betrayal at the hand of his brother Jacob, Esau went on to be a successful patriarch and businessman.