Marie Leger

Patient perspectives on medical photography in dermatology.

BACKGROUND Clinical photography enhances medical care, research, and teaching. Empirical data are needed to guide best practices regarding dermatologic photography. OBJECTIVE To investigate patient opinion about clinical photography and identify demographic factors that influence these opinions. METHODS AND MATERIALS Four hundred patients representing a broad range of ages, self-identified ethnic/racial groups, and socioeconomic levels were recruited from 4 dermatology settings in New York City. Patients were administered a survey about perceptions of photography, willingness to allow photographs to be used in a variety of settings, preferences for photographer and photographic equipment, and methods of consent. RESULTS Eighty-eight percent of patients agreed that photography enhanced their quality of care. Most patients would allow their photographs to be used for medical, teaching, and research purposes with significantly more acceptance when patients were not identifiable. Patients preferred photographs taken by a physician rather than a nurse or student, photographers of the same gender, clinic-owned cameras to personal cameras or cell phones, and written consent to verbal consent. There were significant racial/ethnicity and age-related variations in responses, with white and older patients being more permissive than other groups. CONCLUSION We use the results of this study to recommend best practices for photography in dermatology.

Self‐reported adverse tattoo reactions: a New York City Central Park study

Although permanent tattoos are becoming increasingly commonplace, there is a paucity of epidemiological data on adverse tattoo reactions. Several European studies have indicated that tattoo reactions may be relatively common, although the extent of this phenomenon in the United States is largely unknown.

Annular lichenoid dermatitis of youth in an American boy

Cancer Centers Sarcoma Group. Am J Surg Pathol 2003;27:27-39. 5. Llombart B, Sanmartin O, Lopez-Guerrero JA, Monteagudo C, Serra C, Requena C, et al. Dermatofibrosarcoma protuberans: clinical, pathological, and genetic (COL1A1-PDGFB) study with therapeutic implications. Histopathology 2009;54:860-72. 6. Bianchini L, Maire G, Guillot B, Joujoux JM, Follana P, Simon MP, et al. Complex t(5;8) involving the CSPG2 and PTK2B genes in a case of dermatofibrosarcoma protuberans without the COL1A1-PDGFB fusion. Virchows Arch 2008;452:689-96. 7. Abbott JJ, Oliveira AM, Nascimento AG. The prognostic significance of fibrosarcomatous transformation in dermatofibrosarcoma protuberans. Am J Surg Pathol 2006;30:436-43.

A Case of Isotretinoin-Induced Purpura Annularis Telangiectodes of Majocchi and Review of Substance-Induced Pigmented Purpuric Dermatosis

IMPORTANCE Medications as well as chemical and food exposures have been causally linked to the development of pigmented purpuric dermatosis (PPD). We describe herein what is to our knowledge the first reported case of isotretinoin-induced PPD. OBSERVATIONS A woman in her 30s presented with purpura annularis telangiectodes of Majocchi on the lower extremities 2 months after initiating isotretinoin for the treatment of refractory nodulocystic acne. CONCLUSIONS AND RELEVANCE We believe isotretinoin was the most likely causative agent in this case because the lesions began after initiation of isotretinoin treatment and resolved shortly after its termination, and the pathologic findings were consistent with other described cases of drug-induced PPD. The lesions have continued to fade, and no new lesions have developed in a 3-month follow-up period. Drug-induced PPD is distinct from idiopathic PPD, and it is important to consider isotretinoin as a potential inciting agent.

In response to Ginsberg et al: “A potential role for the dermatologist in the physical transformation of transgender people: A survey of attitudes and practices within the transgender community”

To the Editor: We read with interest the article of Ginsberg et al, ‘‘A potential role for the dermatologist in the physical transformation of transgender people: A survey of attitudes and practices within the transgender community.’’ Ginsberg et al provided an excellent overview of the surgical and cosmetic interventions that dermatologists may provide to patients undergoing a gender transition. Their article also raised important questions regarding medical dermatology for the transgender community, and in particular, the use of isotretinoin. Dermatologists are familiar with the iPLEDGE system, which regulates the use of isotretinoin. The iPLEDGE program patient introductory brochure consistently refers to patient gender in binary terms, but does not account for the fact that for many patients, gender identity and chromosomal sex may be incongruent. With increased visibility of the transgender community and the risk of acneiform eruptions in patients taking hormones to assist in gender transitions, dermatologists have a duty to be more sensitive to the needs of these patients. Not only does the iPLEDGE system potentially alienate transgendered patients with its binary reference to gender, but it also may inadvertently lead to confusion between the transgendered patient and physician. For example, how should a dermatologist treat a patient who was born with the chromosomal sex of a woman, identifies as male gender, and is currently transitioning to male sex? Although the potential for pregnancy is the main concern in determining laboratory monitoring and counseling for isotretinoin, confusion over sex and gender

Communicating biopsy results to patients in a new technological era.

Although the landscape of communication in medicine is changing, there is no established standard for how dermatologists should communicate biopsy results to patients, a gap identified in the article by Choudhry et al.1 Uncertainty about the Health Insurance Portability and Accountability Act regulations governing what patient information can and cannot be shared through current technological modalities has further complicated this issue for dermatologists. Historically, the training of physicians has deemed faceto-face conversations as the criterion standard for breaking bad news to patients. These conversations provide an interactive forum for a physician to project empathy and to respond to the patient’s nonverbal cues. Choudhry et al report, however, that patients prioritize the rapidity of receiving test results, which has shifted their preference from face-to-face communication to telephone conversations for discussing biopsy results, even if the result is abnormal. Traditional face-to-face conversations may not always be practical because of scheduling follow-ups, length of wait time for appointments, loss of work time, and distance traveled. Telling a patient that their results are too serious to be discussed over the telephone and must be discussed in person can create a tremendous amount of fear about the potential diagnosis until the appointment. The change in patient preference parallels the change in technology as the medical world is adopting electronic health records and online patient portals. It may be time to harness these changes and evolve the physician-patient interaction to match both patient preference and technological advances. The future will likely continue the trend toward online portals. According to the article, both the younger population and patients who were more familiar with the use of online portals had an inclination toward electronic communication for normal results. Ultimately, different patients will have different communication preferences, and giving patients the choice of how to receive biopsy results is ideal. Choudhry et al suggest including a question on the biopsy consent form about how patients want notification of their results, which allows communication to be tailored to the individual patient. Creating a professional standard within the field of dermatology for sharing both normal and abnormal biopsy results would help to close this gap. There are lessons we can learn from the field of mammography based on standards that they have established for communicating results. The Mammography Quality Standards Reauthorization Act formalized the standards for communicating mammography results to patients in a timely fashion,2 and it was found that patient satisfaction and timeliness of reporting results improved after implementation of this act.3 Barriers to closing this gap include inconsistent and poorly understood state and federal regulations about electronic patient-physician communication, which makes it difficult to create a universal standard for all dermatologists. The dogma of traditional teaching and the novelty of online patient portals may result in an initial resistance to adopting this method of communication on the part of physicians and patients. It may be time to adjust curriculums to include updated paradigms of breaking bad news that integrate current technology.