Erin T. Landis

Gulliver’s sign: A recognizable transition from inflammatory to healing stages of pyoderma gangrenosum

Abstract Background: Pyoderma gangrenosum (PG) often necessitates long-term immunosuppressant therapy. Many patients may receive treatment for longer periods and higher doses than is clinically necessary because clinicians may have difficulty differentiating between active disease and an inactive residual ulcer that is often slow to heal. Objective: Recognition of the correct point to begin tapering therapy can help reduce the risk of adverse effects associated with treatment. Results: This article describes Gulliver’s sign, a recognizable transition in PG patients which indicates that inflammation is under control. Conclusion: This sign can be used to guide the tapering of corticosteroids and other immunosuppressant therapies in the treatment of PG.

Complementary and Alternative Medicine Use in Dermatology in the United States

BACKGROUND Complementary and alternative medicine (CAM) has an increasing presence in dermatology. Complementary therapies have been studied in many skin diseases, including atopic dermatitis and psoriasis. OBJECTIVES This study sought to assess oral CAM use in dermatology relative to medicine as a whole in the United States, using the National Ambulatory Medical Care Survey. DESIGN Variables studied include patient demographic characteristics, diagnoses, and CAM documented at the visits. A brief literature review of the top 5 CAM treatments unique to dermatology visits was performed. RESULTS Most CAM users in both dermatology and medicine as a whole were female and white and were insured with private insurance or Medicare. Fish oil, glucosamine, glucosamine chondroitin, and omega-3 were the most common complementary supplements used in both samples. CONCLUSIONS CAM use in dermatology appears to be part of a larger trend in medicine. Knowledge of common complementary therapies can help dermatologists navigate this expanding field.

Isotretinoin and oral contraceptive use in female acne patients varies by physician specialty: analysis of data from the National Ambulatory Medical Care Survey

Abstract Objective: To determine whether oral contraceptives (OCPs) are underutilized in the treatment of acne in women of reproductive age, how use of OCPs compares with use of isotretinoin and whether adequate use and documentation of OCPs is occurring with isotretinoin. Material and methods: The National Ambulatory Medical Care Survey (NAMCS) was analyzed over the years 1993–2008 for isotretinoin and OCP use in females aged 12–55 with acne. Results: Isotretinoin was prescribed more often than OCPs at both first visits (4.7% vs. 3.3%) and overall visits (13% vs. 2.6%) for acne. Documentation of OCP or other contraceptive use occurred only 4.1% of the time overall in patients treated with isotretinoin. Specialties varied in both OCP use for acne and contraceptive use with isotretinoin, with ob/gyn specialists most likely to prescribe OCPs and isotretinoin and to report contraceptive use in patients using isotretinoin, and dermatologists least likely to prescribe OCPs. Conclusions: The findings of the current study indicate that OCPs may be underutilized in women with acne. Underreporting of contraceptive use with isotretinoin and variations between specialties in OCP and isotretinoin use indicate a potential for education about the viability of OCPs in acne treatment and the importance of reporting contraceptive use with isotretinoin.

Comparing Demographic Characteristics and Adverse Event Rates at Two Dermatologic Surgery Practices

Background: Patient demographics and operative techniques may contribute to adverse events after surgeries. Objective: To identify differences in adverse event rates between different dermatologic surgery centers and potential contributing features affecting these rates. Methods: Data regarding demographics, procedure type, and adverse events were collected at two dermatologic surgery centers. Results: The most common adverse event at both sites was infection: 2.1% at site 1 versus 0.5% at site 2 (p < .001). Using multivariate logistic regression, procedure type (Mohs surgery), geographic location (being at site 1), older age, and anatomic location of surgery were associated with a higher risk of infection. Conclusion: Adverse event rate appears to correlate with patient demographics, procedure type, and setting of surgery more than use of prophylactic antibiotics. Identification of differences in adverse event rates and potential contributing variables at different practices may allow for identification of opportunities to prevent adverse events.

Early Congenital Syphilis: Recognising Symptoms of an Increasingly Prevalent Disease:

Background: Congenital syphilis (CS) is an infectious disease resulting from transplacental transmission of Treponema pallidum spirochetes from an infected mother to fetus during pregnancy. While uncommon, CS has shown an increased incidence in Canada and the United States since 2001 and 2012, respectively. Case Report: We present the case of a 5-week-old female infant with blistering rash on the palms and soles. The infant displayed decreased movement of the left upper extremity, clinically consistent with Parrot pseudoparalysis. Cutaneous involvement was limited to few tan crusted papules on the palms and soles. Mother reported a “false-positive” result of rapid plasma reagin (RPR) testing at 31 weeks. Cerebrospinal fluid studies of the infant resulted with positive Venereal Disease Research Laboratory (VRDL) test and positive microhemagglutination assay (MHA-TP). Histopathology of a crusted papule revealed a lichenoid infiltrate composed of lymphocytes, histiocytes, and plasma cells. Immunohistochemical staining for T pallidum was negative. The patient completed treatment with a 10-day course of intravenous penicillin. Discussion: While CS is largely considered a historic entity, it has been increasing in incidence in the United States since 2012 and in Canada since the early 2000s. Diagnosis of CS can be difficult as infants may be asymptomatic or present with nonspecific signs. This case highlights the presentation of minimal cutaneous involvement as well as skeletal involvement after birth. RPR testing may result in false negatives or indeterminate results, further complicating diagnosis. Given these difficulties in screening and the increasing incidence of CS, clinicians may need to refamiliarise themselves with its clinical findings.

Methotrexate for the treatment of pediatric alopecia areata

Abstract Purpose: Alopecia areata is a form of nonscarring hair loss that occurs in pediatric and adult patients, with presentation varying from round or ovoid patches of alopecia to alopecia totalis or universalis. While frustrating for patients, it can also be frustrating for clinicians to treat, as there is no definitive treatment. Dermatologists are very familiar with the use of methotrexate for psoriasis and other inflammatory skin diseases, and this medication is generally well tolerated in children. Materials/Methods: This study presents a case series reviewing the efficacy of methotrexate in our pediatric patients with alopecia areata, making use of a retrospective chart review design from 2011 to 2016. Results: In this data set, 8/14 subjects (57%) experienced good regrowth with methotrexate, while 3/14 (21%) had a response that could not be assessed due to loss to follow-up or premature discontinuation of the medication. No cases discontinued the medication due to recognized methotrexate side effects. Conclusions: This review suggests methotrexate is a generally safe and often effective medication in pediatric alopecia areata.

Post-Chikungunya Rheumatic Disease in a 13-Year-Old Boy

Chikungunya is a mosquito‐borne viral infection that causes an acute febrile illness and can result in acute or chronic musculoskeletal disease. A 13‐year‐old boy presented with post‐Chikungunya rheumatic disease featuring connective tissue disease signs including digital ulcerations, cuticular dystrophy, dilated capillary loops, and digital tapering.