Elizabeth V. Seiverling

Actinic Keratosis Clinical Practice Guidelines: An Appraisal of Quality

Actinic keratosis (AK) is a common precancerous skin lesion and many AK management guidelines exist, but there has been limited investigation into the quality of these documents. The objective of this study was to assess the strengths and weaknesses of guidelines that address AK management. A systematic search for guidelines with recommendations for AK was performed. The Appraisal of Guidelines for Research and Evaluation (AGREE II) was used to appraise the quality of guidelines. Multiple raters independently reviewed each of the guidelines and applied the AGREE II tool and scores were calculated. Overall, 2,307 citations were identified and 7 fulfilled the study criteria. The Cancer Council of Australia/Australian Cancer Network guideline had the highest mean scores and was the only guideline to include a systematic review, include an evidence rating for recommendations, and report conflicts of interest and funding sources. High-quality, effective guidelines are evidence-based with recommendations that are concise and organized, so practical application is facilitated. Features such as concise tables, pictorial diagrams, and explicit links to evidence are helpful. However, the rigor and validity of some guidelines were weak. So, it is important for providers to be aware of the features that contribute to a high-quality, practical document.

Dermal mucinosis as a sign of venous insufficiency

Dermal mucinoses are a heterogeneous group of disorders characterized by abnormal deposition of dermal mucin, an amorphous substance composed of hyaluronic acid and sulfated glycosaminoglycans. We describe two cases of dermal mucinosis in the setting of chronic venous insufficiency. Both patients presented with painful, edematous lower extremity plaques. Biopsies of all lesions showed striking dermal mucin deposition, a slight increase in small blood vessel density, slightly thickened vessel walls and no inflammation. Neither patient showed laboratory or clinical findings consistent with a secondary mucinosis such as thyroid dysfunction, lupus erythematosus, dermatomyositis, scleroderma, granuloma annulare, graft‐vs.‐host disease or mucin deposition post‐ultraviolet or photochemotherapy treatment. Both patients were diagnosed with localized cutaneous mucinosis secondary to venous insufficiency. The clinicopathological features of this entity are described, and a pathogenic mechanism is proposed.

Erythema Ab Igne due to Heating Pad Use: A Case Report and Review of Clinical Presentation, Prevention, and Complications.

Erythema ab igne is an asymptomatic cutaneous condition caused by exposure to heat. Cases of erythema ab igne may prove to be diagnostically challenging due to lack of familiarity with the condition. While this dermatosis carries a favorable prognosis, nonmelanoma skin cancers have been reported to arise within lesions of erythema ab igne. Erythema ab igne is preventable, and, thus, clinicians should provide education regarding safe use of heating devices to patients using these products in both outpatient and inpatient settings.

Pressure and Friction Injuries in Primary Care

Pressure and friction injuries are common throughout the lifespan. A detailed history of the onset and progression of friction and pressure injuries is key to aiding clinicians in determining the underlying mechanism behind the development of the injury. Modifying or removing the forces that are creating pressure or friction is the key to both prevention and healing of these injuries. Proper care of pressure and friction injuries to the skin is important to prevent the development of infection. Patient education on positioning and ergonomics can help to prevent recurrence of pressure and friction injuries.

An eruption of yellow-red papules on the trunk, arms, and legs of an adult

A 68-year-old Caucasian man presented with a 6-month history of firm skin papules, starting on his face then gradually moving caudally, progressing to his arms, trunk, and legs (Figure 1). Many of his lesions were asymptomatic. However, a few of the papules were pruritic. The itching was alleviated by topical steroids. On physical exam, multiple yellow-brown to red firm papules and small nodules were noted on the face, trunk, and proximal extremities. Dermoscopic examination demonstrated orange-yellow color surrounded by an erythematous border with occasional linear branched vessels (Figure 2). Histopathologic evaluation of 4 of the lesions revealed spindle cells in the upper dermis (Figure 3). All 4 specimens had similar findings. Immunohistochemical studies showed positivity for CD163, as well as Factor XIIIa. There was no significant positivity for CD34. Laboratory data revealed a hemoglobin A1C of 9.3% and triglycerides of 461 mg/dL. An ophthalmology consult was obtained and no ocular pathology was found. A serum protein electrophoresis was negative. With this information, a diagnosis of adult eruptive xanthogranulomas was made.

Optimizing medical trips to care for those with rare genetic diseases in remote settings: lessons learned from xeroderma pigmentosum

dermatoses of other origins. Int J Dermatol 2011; 50: 1518–1521. 6 Ashbee HR. Update on the genus Malassezia. Med Mycol 2007; 45: 287–303. 7 Sinsimer D, Fallows D, Peixoto B, et al. Mycobacterium leprae actively modulates the cytokine response in na€ıve human monocytes. Infect Immun 2009; 78: 293–300. 8 Itha S, Kumar A, Dhingra S, et al. Dapsone induced cholangitis as a part of dapsone syndrome: a case report. BMC Gastroenterol 2003; 3: 21.

Analysis of dermoscopy teaching modalities in United States dermatology residency programs

The use of dermoscopy in dermatology residency programs is on the rise (over 94% of chief residents reported using a dermatoscope in 2013) [1]. Despite increased use (100% of our surveyed residents reported using a dermatoscope), dermoscopy training is one of the aspects of United States dermatology residency training with the lowest resident satisfaction [2]. Diagnostic accuracy with dermoscopy is highly correlated with the amount of dermoscopy training the user has undertaken [3]. We sought to analyze dermoscopy use in US Dermatology residencies to better understand resident dermoscopy utilization and teaching modalities. We found residents learn dermoscopy via multiple teaching modalities. The most commonly reported dermoscopy teaching modality was didactic lectures, followed by time in clinic with a dermoscopy expert. Of the different teaching modalities, time in the clinic with a dermoscopy expert was reported to be the most effective. We also found that the majority of dermatology residents receive didactic dermoscopy lectures and clinical dermoscopy training on the differentiation of benign nevi from melanoma using dermoscopy, the detection of basal cell carcinoma, and the identification of seborrheic keratosis. However, few residents receive dedicated training on the use of dermoscopy in the evaluation of inflammatory dermatoses and skin infections despite dermoscopy’s demonstrated value in both areas [4–7].

Ringed telangiectasias: an unusual presentation of telangiectasia macularis eruptiva perstans

Telangiectasia macularis eruptiva perstans (TMEP) is a rare form of cutaneous mastocytosis. While most cutaneous mastocytoses occur in children and are asymptomatic, TMEP occurs predominantly in adults and is associated with systemic manifestations, requiring medical management. TMEP is typically characterised by scattered red-brown macules on the trunk and extremities, but must be differentiated from other telangiectatic conditions such as scleroderma, hereditary haemorrhagic telangiectasia and telangiectasias secondary to cirrhosis. Practitioners must be aware that variants to the classic presentation of TMEP exist, such as the ringed telangiectasias we describe. Diagnostic workup including tissue biopsy must be considered in such patients after a thorough history and physical have been performed and other telangiectatic processes have been ruled out. The treatment of cutaneous mastocytosis aims at controlling symptoms and preventing mast cell degranulation. Cosmetic treatment includes the use ofPsoralen and ultraviolet A (PUVA) therapy, total skin electron beam radiation and flashlamp pulsed-dye laser treatment.

Pruritis and palpable purpura from leeches in the Australian Rainforest

Highlights • Leech saliva contains hirudin (a thrombin inhibitor) and histamine.• Leech bites cause pruritis (itching) and purpura (visible hemorrhage into the skin).• Some Australian leeches can transmit trypanosomal infections.• Saturated salt solution, alcohol, or vinegar, may ease leech removal.