Assessment of Pain, Healing Time, and Wound Contraction in Postoperative Auricular Defects Healing Secondarily With and Without the Use of a Porcine Xenograft, a Pilot Study.

BACKGROUND: Postoperative auricular defects heal well with secondary intention healing (SIH); however, potential complications include postoperative pain, perichondritis, and chondritis. OBJECTIVE: To compare postoperative pain and wound healing in auricular defects healing by secondary intention with and without the placement of a porcine xenograft. MATERIALS AND METHODS: Twenty-one subjects were enrolled in the study. The primary outcome was self-reported pain, measured on a 0 to 10 scale for 14 postprocedure days. Secondary outcomes included time to greater than 90% of reepithelialization and degree of wound contraction. RESULTS: There was a 1 to 2 point difference in median pain scores between the porcine graft and control groups during postoperative days 4 to 7, 12, and 13. Time to 90% or greater reepithelialization was not statistically different between groups (p = .94). The average wound contraction was 34.1% for the porcine group and 34.0% for the control group (p = .95). CONCLUSION: In this pilot study, overall pain scores were low in both groups. Placement of a porcine xenograft resulted in a slight reduction of median pain compared with traditional SIH. Patients in the control group were more likely to require analgesics. Similar rates of reepithelialization and degree of wound contracture were observed.

Limiting Residency Applications to Dermatology Benefits Nearly Everyone.

With a 34-percent increase in dermatology residency applications in the past decade, residency programs are increasingly faced with the daunting task of reviewing more applications for a relatively fixed number of residency positions. Other specialty programs, including otolaryngology, orthopedics, plastic surgery, and ophthalmology, have called for limiting the number of residency applications. Dermatology programs have developed various ways to decrease the number of reviewed applications, from cutoffs for Step 1 board scores to Alpha Omega Alpha membership to secondary applications. While this can decrease the applicant pool, it limits a more holistic review of applications. We propose an application cap of 20 programs, which will decrease the number of applications each program receives 3- to 5-fold. Each applicant can approach the process more thoughtfully in choosing the best programs for them and will save money in application fees. As program directors rank "perceived interest" in their residency program as a primary factor for selecting applicants, a cap will allow program directors to know that all applicants are interested in their specific program. Ultimately, we contend that application caps would improve match outcomes with applicants receiving training in the best program for them, increasing the likelihood of successful fit for clinical training, opening the field to a more diverse set of applicants, and saving everyone time and money.

Hereditary Trichilemmal Cysts are Caused by Two Hits to the Same Copy of the Phospholipase C Delta 1 Gene (PLCD1).

The autosomal dominant presentation of trichilemmal cysts is one of the most common single gene familial diseases in humans. However, the genetic basis for the inheritance and genesis of these lesions has remained unknown. We first studied patients with multiple trichilemmal cysts using exome and Sanger sequencing. Remarkably, 21 of 21 trichilemmal cysts from 16 subjects all harbored a somatic p.S745L (c.2234 G > A) mutation in phospholipase C delta 1 (PLCD1), a proposed tumor suppressor gene. In addition to this specific somatic mutation in their tumors, 16 of the 17 subjects with multiple trichilemmal cysts were also heterozygous for a p.S460L (c.1379 G > A) germline variant in PLCD1 which is normally present in only about 6% of this population. The one patient of 17 that did not show the p.S460L germline variant had a germline p.E455K (c.1363 C > T) mutation in the same exon of PLCD1. Among 15 additional subjects, with a history suggesting a single sporadic trichilemmal cyst, six were likely familial due to the presence of the p.S460L germline variant. Of the remaining truly sporadic trichilemmal cysts that could be sequenced, only half showed the p.S745L somatic mutation in contrast to 100% of the familial cysts. Surprisingly, in contrast to Knudsen's two hit hypothesis, the p.S745L somatic mutation was always on the same chromosome as the p.S460L germline variant. Our results indicate that familial trichilemmal cysts is an autosomal dominant tumor syndrome resulting from two hits to the same allele of PLCD1 tumor suppressor gene. The c.1379 G > A base change and neighboring bases are consistent with a mutation caused by ultraviolet radiation. Our findings also indicate that approximately one-third of apparently sporadic trichilemmal cysts are actually familial with incomplete penetrance. Sequencing data suggests that the remaining, apparently sporadic, trichilemmal cysts are genetically distinct from familial cysts due to a lack of the germline mutations that underlie familial cysts and a decreased prevalence of the p.S745L somatic mutation relative to familial trichilemmal cysts.

A pilot study evaluating biomarker development for drug-induced chronic eczematous eruptions of aging individuals.

BACKGROUND: Identifying the drug(s) responsible for drug-induced chronic eczematous eruptions of aging individuals (CEEA) is a clinical challenge in patients on multiple medications. Reliable in vitro testing methods and biomarkers are needed to identify the causative agent and allow simultaneous assessment of T-cell responses to multiple drugs being taken concurrently. This study examined the feasibility of using in vitro, drug-specific T cell activation responses as a biomarker for drug-induced CEEA. METHODS: This was a single center, proof-of-concept pilot study at the University of Utah Hospital, Salt Lake City, Utah. Eight aging study subjects having a history suggestive of chronic eczematous drug eruptions suspected to have resulted from calcium channel blocker (CCB) and/or hydrochlorothiazide (HCTZ) hypersensitivity plus three matched aging control subjects were identified. Drug patch testing for CCB and/or HCTZ, in vitro drug antigen-induced lymphocyte proliferation assays, and multianalyte-determined cytokine release assays were performed before and after HCTZ and/or CCB incubation. RESULTS: All study and control subject blood samples tested failed to demonstrate detectable enhanced lymphocyte proliferation or cytokine release to in vitro CCBs or HCTZ challenge when tested with a fairly wide range of drug concentrations. Additionally, none of the enrolled patients developed a positive patch test to CCBs and/or HCTZ. CONCLUSIONS: This pilot study aimed to correlate in vitro drug-induced T lymphocyte transformation and cytokine production with the presence of drug-induced CEEA. Failure to identify T cell proliferative responses to CCB drug antigens in our in vitro studies could have, in part, resulted from a pharmacologic inhibiting effect of CCB on T cell activation.

Benign Glandular Schwannoma With Ancient Change.

Benign glandular schwannomas are rare and should be distinguished from malignant peripheral nerve sheath tumors with similar divergent tissue differentiation. The authors present a benign glandular schwannoma with ancient change that developed in the subcutis of a 46-year-old man's posterior calf. He lacked stigmata of neurofibromatosis type 1 (NF1). The glandular elements stained positively for epithelial membrane antigen and pancytokeratin. The spindled cells stained positively for SOX10 and S100 protein, supporting schwannian (neural crest) differentiation. The tumor's location and histopathology suggest that the pathogenesis stems from entrapment of sweat glands. Finally, it must be recognized that ancient change may mimic malignancy in these neoplasms as the malignant counterparts have a greater association with NF1 and a poorer prognosis.

Type I Cutaneous Meningioma (Rudimentary Meningocele) With Intradural Attachment to the Phylum Terminale.

Cutaneous meningiomas (CM) are a small subset of meningiomas, further classified into three subtypes. The authors present a 15-year-old male with a symptomatic congenital type I CM and describe the histopathological and immunohistochemical findings. To the authors' knowledge, this is the first report of an extraspinal lumbar type I CM with intradural attachment to the phylum terminale.

Occupational Contact Dermatitis: Workers' Compensation Patch Test Results of Portland, Oregon, 2005-2014.

BACKGROUND: Workers are exposed to potential irritants and allergens with constant introduction of new industrial chemicals in the workplace. OBJECTIVE: Characterize the final diagnoses, demographics, occupations, exposures, clinical presentations, patch test results, dermatologic histories, and risk factors of workers evaluated for suspected work-related allergic contact dermatitis (ACD). METHODS: A retrospective chart review of 310 workers' compensation independent medical examinations evaluated for suspected work-related ACD was performed. Workers were seen in a community dermatology clinic in Portland, Oregon, from 2005 to 2014. Evaluation included history, physical examination, patch testing, and further diagnostic workup when indicated. RESULTS: Hand dermatitis was the most common presentation (n = 148, 47.7%). Prevalent occupations included health care workers (n = 51, 16.5%), custodial staff (n = 41, 13.2%), and machinists (n = 36, 11.6%). Allergic contact dermatitis (47.5%) was more common than irritant contact dermatitis (ICD) (38.9%) in those diagnosed as having occupational skin disease (n = 185). The highest-frequency work-related allergens were thiuram mix (21 of 88, 23.9%), carba mix (20 of 88, 22.7%), potassium dichromate (9 of 88, 10.2%), and epoxy resin (9 of 88, 10.2%). CONCLUSIONS: Allergic contact dermatitis and ICD are common occupational skin disorders. In this population of workers' compensation referrals, ACD was more common, with 73.3% of those cases work related, compared with 86.7% of ICD. Blue collar work and wet work were risk factors for the development of ACD and ICD.

Metrics and clinical relevance of percutaneous penetration and lateral spreading.

BACKGROUND: Percutaneous penetration of urea in vivo in man has been documented. If urea can penetrate the skin, it may also move laterally. Lateral spreading of topical substances leads to unpredictable penetration dynamics and increased skin surface area exposure. METHODS: The ability of urea, a low molecular-weight hydrophilic model, to penetrate the stratum corneum (SC) and spread outside the application site was investigated in vitro using tape stripping with spectroscopy. The parameters investigated were the following: time between urea application and tape stripping, formulations containing urea and use of a petrolatum-covered ring barrier around the marked application area. RESULTS: The percentage of urea was determined in and around the application site. The spreading of topically applied urea to neighboring areas occurred and was time but not formulation dependent. A significant difference between protocols with and without the petrolatum ring was observed. CONCLUSION: These results suggest the clinical importance of lateral spreading, occurring predominately on the skin surface. SC thickness varies between anatomical sites, predisposing areas such as the face and scalp margins to increased percutaneous penetration of topical products. The use of a protective petrolatum ring can inhibit lateral spreading of hair dye in individuals allergic to hair dye, limit systemic absorption and increase accuracy when assessing penetration dynamics.

Dermatotoxicologic clinical solutions: hair dying in hair dye allergic patients?

This article describes how to identify allergic contact dermatitis resulting from hair dye, and outlines interventions and prevention principles for those who wish to continue dyeing their hair despite being allergic. Hair dye chemicals thought to be the most frequent sensitizers are discussed with instructions for health care providers on how to counsel patients about techniques to minimize exposure to allergenic substances. This framework should allow many patients to continue dyeing their hair without experiencing adverse side effects.

Dermatotoxicologic clinical solutions: textile dye dermatitis patch testing.

The authors provide a framework for working up and counseling a patient with suspected textile dermatitis, focusing on identifying which textile materials are most likely to be the cause of the eczematous lesions, the current clinical guidelines, the utility and appropriateness of patch testing, the limitations of these guidelines, and our pro tempore recommendations. While there are many challenges to correctly identify and counsel patients on how to avoid the offending textile products in a patient with suspected textile dye dermatitis, there is value in following the guidelines set forth to help identify the causative textile(s). Although patch tests can be useful, dermatologists should understand the limitations of standardized patch testing for patients with suspected textile dye-induced dermatitis. These guidelines are expected to increase the likelihood of identifying the causative textile(s), so that patch testing can be supplemented with swatch testing and chemical dye extraction to help discover the allergenic dye.

In vitro skin decontamination model: comparison of salicylic acid and aminophylline.

OBJECTIVE: This study compared three model decontaminant solutions (distilled water, 10% distilled water and soap and methanol) for their ability to remove salicylic acid and aminophylline from an in vitro skin model. MATERIALS AND METHODS: Human abdominal skin was dosed with 20 µL of either [(14)C]-aminophylline or [(14)C]-salicylic acid on 1 cm(2) per skin. After each exposure time (5, 30 and 60 min post-dosing, respectively), surface skin was washed three times with each solution and tape stripped 10 times. Wash solutions, tape strips, receptor fluid and remaining skin were then analyzed with liquid scintillation counting to quantify the amount of salicylic acid and aminophylline. RESULTS: Total mass balance recovery for each chemical at three time exposure points was between 73.6 and 101.5%, except at 60 min where aminophylline was only 42.5%. Majority of salicylic acid and aminophylline were recovered from washing solution when compared to stratum corneum, epidermis, dermis, surrounding skin and receptor fluid. CONCLUSION: The three tested decontaminates possessed similar effectiveness in removing lipophilic and hydrophilic chemicals from the skin. Due to diminishing decontamination efficacy with time, it is suggested that skin should be washed as soon as possible following contamination to minimize percutaneous penetration and the deleterious effects associated with skin reservoir content.

Dermatotoxicologic clinical solutions: clinical management of fragrance mix #1 #2 patients?

Today's fragrances are present in more than just perfumes, having become ubiquitous in skin care products such as creams, shampoos, sun tan lotion and deodorants. While aromatics can arouse the senses, aromatic compounds applied to skin can also cause allergic contact dermatitis. This article describes diagnosis, limitations of patch testing for fragrance mix 1 and fragrance mix 2, the relevance of fragrance concentration in products, use testing of common consumer products and our current recommendations in regards to the management of fragrance contact allergy.

Sampling the stratum corneum for toxic chemicals.

Dermal exposure is an important pathway in environmental health. Exposure comes from contaminated water, soil, treated surfaces, textiles, aerosolized chemicals, and agricultural products. It can occur in homes, schools, play areas, and work settings in the form of industrial sources, consumer products, or hazardous wastes. Dermal exposure is most likely to occur through contact with liquids, water, soil, sediment, and contaminated surfaces. The ability to detect and measure exposure to toxic materials on the skin is an important environmental health issue. The stratum corneum is the skin's first and principal barrier layer of protection from the outside world. It has a complex structure that can effectively protect against a wide variety of physical, chemical, and biological contaminants. However, there are a variety of chemical agents that can damage the stratum corneum and the underlying epidermis, dermis and subcutis, and/or enter systemic circulation through the skin. There are numerous ways of sampling the stratum corneum for these toxic materials like abrasion techniques, biopsy, suction blistering, imaging, washing, wipe sampling, tape stripping, and spot testing. Selecting a method likely depends on the particular needs of the situation. Hence, there is a need to review practical considerations for their use in sampling the stratum corneum for toxins.

Biology of percutaneous penetration.

BACKGROUND: Percutaneous penetration is a passive process that can occur following skin exposure to chemicals used in agriculture, industry, pharmaceuticals, cosmetics, and in the household. Once a penetrant is absorbed into the skin it may cause a local reaction or enter systemic circulation to produce widespread effects. Improved understanding of the skin barrier and biological aspects that impede absorption of topical substances is essential for advancing the fields of dermatotoxicology and dermatopharmacology as they pertain to percutaneous penetration. METHODS: Pubmed search results for "percutaneous penetration", "absorption", "stratum corneum", "xenobiotics", "skin factors", "decontamination", and "transdermal" were reviewed from 1965 to 2014. Relevant articles discussing the influence of biological factors on percutaneous penetration of topical substances were included. RESULTS: Absorption of a topical substance across the skin is most notably influenced by concentration, contact duration, frequency, and the surface area exposed. The interplay between these factors, along with skin biology and the physiochemical properties of the penetrant, can lead to enhanced percutaneous penetration. CONCLUSION: Percutaneous penetration is a highly complicated and dynamic process influenced by numerous skin and environmental factors. Although research over the last few decades has provided plenty of new insights to improve our understanding of percutaneous penetration, many areas lack clarity due to conflicting data.

Percutaneous absorption from soil.

Abstract Some natural sites, as a result of contaminants emitted into the air and subsequently deposited in soil or accidental industrial release, have high levels of organic and non-organic chemicals in soil. In occupational and recreation settings, these could be potential sources of percutaneous exposure to humans. When investigating percutaneous absorption from soil - in vitro or vivo - soil load, particle size, layering, soil "age" time, along with the methods of performing the experiment and analyzing the results must be taken into consideration. Skin absorption from soil is generally reduced compared with uptake from water/acetone. However, the absorption of some compounds, e.g., pentachlorophenol, chlorodane and PCB 1254, are similar. Lipophilic compounds like dichlorodiphenyltrichloroethane, benzo[A]pyrene, and metals have the tendency to form reservoirs in skin. Thus, one should take caution in interpreting results directly from in vitro studies for risk assessment; in vivo validations are often required for the most relevant risk assessment.

Textile allergic contact dermatitis: current status.

MATERIALS AND METHODS: We conducted a thorough review of Pubmed search results for "textile percutaneous penetration" and "textile absorption". We also determined relevant articles that discussed percutaneous penetration of textiles into the skin and their associated disease states. LIMITATIONS: Due to limitations in current and past publications, we are uncertain of the extent of the clinical problem; however, for patients allergic to textile dye, it is of practical importance, both clinically and in their everyday life. CONCLUSIONS: There are many challenges to correctly identifying the offending textile products in a patient with suspected textile dye dermatitis. Different populations may exhibit varying degrees of allergic contact dermatitis (ACD), but more studies must be done to draw further conclusions. This is further complicated when counseling the patient on how to avoid the textile products most likely to cause a recurrence of ACD skin lesions.