Early Organ Metastasis in Granulomatous Mycosis Fungoides: A Systematic Review.

BACKGROUND: Granulomatous mycosis fungoides (GMF) is a rare form of cutaneous T-cell lymphoma characterized by a granulomatous inflammatory infiltrate. OBJECTIVE: The impact of granulomatous inflammation on the prognosis of the disease remains controversial as there have been both favorable and unfavorable outcomes documented. METHODS: We performed a systematic review of 116 GMF cases previously described in the literature. RESULTS: In contrast to the classic Alibert-Bazin type of mycosis fungoides (MF), cutaneous lesions in GMF tend to involve distal extremities (lower legs, feet, hands) early in the disease course. In the literature, 30% of GMF patients developed organ metastasis, most frequently to the lung. The median time to stage progression was 25 months. CONCLUSION: GMF is an aggressive form of MF. Therefore, screening for distant metastases should be considered at presentation and repeated during follow-up.

In Situ Follicular B-Cell Neoplasm Presenting as Miliary Facial Papules: A Unique Clinical Presentation and Spontaneous Regression.

ABSTRACT: In situ follicular B-cell neoplasm (ISFN) is a variant of follicular lymphoma, presenting as an incidental histologic finding in lymph node biopsy or excisional specimens. ISFN presents with a B-cell population that strongly expresses BCL2 and CD10 within the germinal centers of a lymph node or extranodal site. Genetic analysis shows t(14;18) translocation. Herein, we report a case of ISFN presenting as military and agminated facial papules in a young woman, which resolved spontaneously in the postpartum period. To our knowledge, this is the only report of a cutaneous site of involvement of this rare entity.

Mitigating diagnostic performance bias in a skin-tone balanced dermatology curriculum.

INTRODUCTION: Individuals with skin of colour (SoC) have delayed diagnosis and poorer outcomes when presenting with some dermatologic conditions when compared to individuals with light skin (LS). The objective of this study was to determine if diagnostic performance bias can be mitigated by a skin-tone balanced dermatology curriculum. METHODOLOGY: A prospective randomised intervention study occurred over 2 weeks in 2020 at a Canadian medical school. A convenience sample of all first-year medical students (n = 167) was chosen. In week 1, all participants had access to dermatology podcasts and were randomly allocated to receive non-analytic training (NAT; online patient 'cards') on either SoC cases or LS cases. In week 2, all participants received combined training (CT; NAT and analytic training through workshops on how to apply dermatology diagnostic rules for all skin tones). Participating students completed two formative assessments after weeks 1 and 2. RESULTS: Ninety-two students participated in the study. After week 1, both groups had a lower diagnostic performance on SoC (p = 0.0002 and p = 0.002 for students who trained on LS 'cards' and SoC 'cards', respectively). There was a significant decrease in mean skin tone difference in both groups after week 2 (initial training on SoC: 5.8% (SD 12.2) pre, -1.4% (14.7) post, p = 0.007; initial training on LS: 7.8% (15.4) pre, -4.0% (11.8%) post, p = 0.0001). Five students participated in a post-study survey in 2023, and all found the curriculum enhanced their diagnostic skills in SoC. CONCLUSIONS: SoC performance biases of medical students disappeared after CT in a skin tone-balanced dermatology curriculum.

Atopic dermatitis and skin infections are a poorly documented crisis in Canada's Indigenous pediatric population: It's time to start the conversation.

Canadian Indigenous youth continue to face higher rates of health disparities than their non-Indigenous counterparts. In dermatology, this includes a high burden of atopic dermatitis, as well as secondary skin and soft tissue infections. Unfortunately, numerous barriers to treatment exist, including systemic and institutional racism, poverty, crowded housing conditions on reserves, access and cost of basic skin care regimens, and clean water access. As per the Truth and Reconciliation Commission, Canadian dermatologists have been called upon to train more First Nations, Metis, and Inuit physicians to ensure we are providing high-quality, anti-racist, culturally appropriate care to Indigenous peoples.

Understanding Dermatologic Concerns Among Persons Experiencing Homelessness: A Scoping Review and Discussion for Improved Delivery of Care.

There is a paucity of information surrounding dermatologic care for persons experiencing homelessness (PEH). This scoping review aims to map existing literature and provide a summary of the most common cutaneous manifestations among PEH, risk factors for dermatologic disease, describe any reported interventions, as well as identify research gaps for future studies. Search strategies developed for MEDLINE and hand searching yielded 486 articles. Out of the 486 articles screened, 93 articles met the inclusion criteria. The majority were cohort studies, cross-sectional studies, and case-control studies concentrated in North America and Europe. Excluding the pediatric population, the prevalence of dermatologic conditions ranged from 16.6% to 53.5%. Common skin conditions described in PEH were: acne, psoriasis, seborrheic dermatitis, atopic dermatitis, and lichen simplex chronicus. There were no studies comparing the extent or severity of these cutaneous diseases in PEH and the general population. PEH have a higher prevalence of skin infections and non-melanoma skin cancers. This scoping review has direct implications on public health interventions for PEH and highlights the need for evidence-based interventions to provide optimum and safe dermatologic healthcare for PEH. We propose several recommendations for improved care delivery, including addressing upstream factors and comorbidities impacting skin health, providing trauma informed care, reducing barriers to care, preventing and managing skin conditions, as well as including PEH in the planning and implementation of any proposed intervention.

Evaluation of Alitretinoin for the Treatment of Mycosis Fungoides and Sézary Syndrome.

BACKGROUND: Mycosis fungoides (MF) and Sézary syndrome (SS) are the most common subtypes of cutaneous T-cell lymphoma (CTCL). There is currently no cure for CTCL, and treatment is aimed at limiting disease progression. This study evaluated the efficacy and tolerability of alitretinoin in CTCL management. METHODS: A retrospective, multicenter study was conducted on CTCL patients treated with alitretinoin as a primary agent or in combination with standard therapies. RESULTS: Forty-eight patients with MF (n = 40) and SS (n = 8) with a median age of 59.7 years (±14.3) were eligible for study inclusion. Treatment response data were evaluated in 40 patients and safety in 42 patients. 40.0% of the patients had early-stage, 43.8% had advanced-stage CTCL, and in 16.7% of patients there was insufficient information for staging. 40.0% (16/40) of the patients achieved a complete or partial response, whereas 47.5% (19/40) achieved stable disease, 12.5% (5/40) had progressive disease, and there were no cases of disease relapses in responders. Both early and advanced stages of CTCL were responsive to alitretinoin as a primary or combined modality. Alitretinoin was well tolerated, and 64.3% (27/42) of patients did not report any side effects. The most commonly observed side effect was hypertriglyceridemia. CONCLUSIONS: This retrospective analysis supports the efficacy and safety of alitretinoin in clearing skin disease and preventing disease progression in CTCL as a monotherapy or in combination with standard therapies.

The Clinical Spectrum of Primary Cutaneous CD4+ Small/Medium-Sized Pleomorphic T-Cell Lymphoproliferative Disorder: An Updated Systematic Literature Review and Case Series.

BACKGROUND: Primary cutaneous CD4+ small/medium pleomorphic T-cell lymphoproliferative disorder (SMPLPD) is a provisional entity within the 2016 World Health Organization classification of primary cutaneous lymphomas. The condition is currently classified as a lymphoproliferative disorder to emphasize its benign course and discourage aggressive, systemic treatment modalities. OBJECTIVE: To provide a relevant synthesis for the dermatological practitioner on the prevalence, presentation, and treatment of SMPLPD. METHODS: We conducted an updated systematic literature review and a retrospective chart review of diagnosed cases of SMPLPD from 2 Canadian academic cutaneous lymphoma centers. RESULTS: A total of 23 studies with 136 cases were extracted from the systematic review and 24 patients from our retrospective chart review. SMPLPD proved relatively common accounting for 12.5% of all cutaneous T-cell lymphomas encountered in our cutaneous lymphoma clinics, second in frequency only to mycosis fungoides. The typical clinical presentation was that of an older individual (median age 59 years) with an asymptomatic solitary lesion on their upper extremity. The most common clinical differentials were cutaneous lymphoid hyperplasia, basal cell carcinoma, and lymphoma unspecified. T follicular helper markers were reliably detected. The main treatment modalities were surgical excision, local radiation therapy, and topical or intralesional steroids. Cure was achieved in the vast majority of cases. CONCLUSIONS: SMPLPD is an underdiagnosed T-cell lymphoma with an overtly benign clinical course. The condition has an excellent prognosis and responds well to skin-directed therapies. Practitioners should be aware of this condition to avoid aggressive systemic treatments.

Does self-modulated learning vs. algorithm-regulated learning of dermatology morphology affect learning efficiency of medical students?

BACKGROUND: Deliberate practice is an important method of skill acquisition and is under-utilized in dermatology training. We delivered a dermatologic morphology training module with immediate feedback for first year medical students. Our goal was to determine whether there are differences in accuracy and learning efficiency between self- regulated and algorithm-regulated groups. METHODS: First year medical students at the University of Calgary completed a dermatologic morphology module. We randomly assigned them to either a self-regulated arm (students removed cases from the practice pool at their discretion) or an algorithm-regulated arm (an algorithm determined when a case would be removed). We then administered a pre-survey, pre-test, post-test, and post-survey. Data collected included mean diagnostic accuracy of the practice sessions and tests, and the time spent practicing. The surveys assessed demographic data and student satisfaction. RESULTS: Students in the algorithm-regulated arm completed more cases than the self-regulated arm (52.9 vs. 29.3, p<0.001) and spent twice as much time completing the module than the self-regulated participants (34.3 vs. 17.0 min., p<0.001). Mean scores were equivalent between the algorithm- and self-regulated groups for the pre-test (63% vs. 66%, n = 54) and post-test (90% vs. 86%, n = 10), respectively. Both arms demonstrated statistically significant improvement in the post-test. CONCLUSION: Both the self-regulated and algorithm-regulated arms improved at post-test. Students spent significantly less time practicing in the self-directed arm, suggesting it was more efficient.

Ustekinumab for the treatment of recalcitrant pyoderma gangrenosum: A case report.

Pyoderma gangrenosum is an ulcerating disease associated with a high degree of morbidity and mortality. Currently, little is known about the pathophysiology of pyoderma gangrenosum, though it has been linked to increased levels of inflammatory cytokines including interleukin-23. As pyoderma gangrenosum is a rare disease, evidence for pyoderma gangrenosum treatment is dependent on reporting of cases with successful therapies. Here, we describe a case of pyoderma gangrenosum developing on the lateral leg of a medically complex 47-year-old male already on chronic immunosuppressive therapy, who achieved successful wound healing with the use of ustekinumab, a monoclonal antibody targeting inhibition of interleukin-12 and interleukin-23. This case lends further evidence for the role of interleukin-23 in the pathogenesis of recalcitrant pyoderma gangrenosum and also suggests that healthcare providers may consider a trial of ustekinumab in pyoderma gangrenosum that has failed previous topical treatments or systemic immunosuppression.

Skin cancer knowledge and photoprotective practices of organ transplant recipients.

BACKGROUND: Long-term use of immunosuppressive medications by organ transplant recipients (OTRs) leads to an increased risk of non-melanoma skin cancers (NMSCs). The objective of this study was to assess photoprotective knowledge and practices among OTRs and to identify predictors of poor sunscreen adherence and barriers to photoprotection. METHODS: A written survey was administered to 300 solid OTRs attending the Southern Alberta Transplant Program. Demographics, transplant and NMSC history, ultraviolet radiation (UVR) exposure, photoprotective knowledge and practices, and barriers to implementing photoprotection were collected. Relevant statistical analyses and univariate and multivariable regression models on sunscreen use were performed. RESULTS: One hundred and seventy-nine of the 300 respondents reported not using sunscreen most days despite 79.3% recalling have received photoprotection education. Of the surveyed OTRs, 45.7% reported no barriers to implementing photoprotective practices. On average, respondents scored 74.5% on a commonly used tool to assess photoprotective knowledge (SD 30.6%). In multivariable analyses, older age, male gender, and lack of post-secondary education were associated with lower rates of self-reported sunscreen use. The most commonly patient-reported barriers to photoprotection were "hassle/time consuming" (16.7%) and "sunscreen is uncomfortable or unpleasant" (10.0%). CONCLUSIONS: Despite OTRs self-reporting having received sufficient sun-protective knowledge and demonstrating reasonable recollection of photoprotective education on assessment, implementation of sun protection in the studied OTRs remains suboptimal.

Assessment of a Bidirectional Association Between Major Depressive Disorder and Alopecia Areata.

Importance: Alopecia areata (AA) is an autoimmune disease characterized by hair loss that can impose a substantial psychological burden on patients, including major depressive disorder (MDD), yet many patients report mental health symptoms prior to the onset of AA. As such, there may be an association between MDD and AA that acts in both directions. Objective: To assess the bidirectional association between MDD and AA. Design, Setting, and Participants: This population-based retrospective cohort study included patients 10 to 90 years of age registered with The Health Improvement Network in general practices in the United Kingdom between January 1, 1986, and May 16, 2012. Statistical analysis was conducted from August 17, 2017, to April 23, 2018. To assess the risk of AA, the following 2 cohorts were defined: patients with an incident diagnosis of MDD (exposure) and a reference general population cohort. To assess the risk of MDD, the following 2 cohorts were defined: patients with an incident diagnosis of AA (exposure) and a reference general population cohort. Person-time was partitioned into unexposed and exposed time in the exposure cohorts. Main Outcomes and Measures: In the analysis of the risk of AA, development of incident AA during follow-up was considered the main outcome measure. In the analysis of the risk of MDD, development of incident MDD during follow-up was considered the primary outcome measure. Results: In the analysis of the risk of AA, 405 339 patients who developed MDD (263 916 women and 141 423 men; median age, 36.7 years [interquartile range, 26.6-50.5 years]) and 5 738 596 patients who did not develop MDD (2 912 201 women and 2 826 395 men; median age, 35.8 years [interquartile range, 25.3-52.6 years]) were followed up for 26 years. After adjustment for covariates, MDD was found to increase the risk of subsequently developing AA by 90% (hazard ratio, 1.90; 95% CI, 1.67-2.15; P < .001). Antidepressants demonstrated a protective effect on the risk of AA (hazard ratio, 0.57; 95% CI, 0.53-0.62; P < .001). In the analysis of the risk of MDD, 6861 patients who developed AA (3846 women and 3015 men; median age, 31.5 years [interquartile range, 18.2 years]) and 6 137 342 patients who did not develop AA (3 172 371 women and 2 964 971 men; median age, 35.9 years [interquartile range, 27.0 years]) were followed up for 26 years. After adjustment for covariates, AA was found to increase the risk of subsequently developing MDD by 34% (hazard ratio, 1.34; 95% CI, 1.23-1.46; P < .001). Conclusions and Relevance: These temporal analyses suggest that, while patients with AA are at risk for subsequently developing MDD, having MDD also appears to be a significant risk factor for development of AA, with antidepressant use confounding this risk.

Vitiligo and major depressive disorder: A bidirectional population-based cohort study.

BACKGROUND: Vitiligo patients often report their mental health has an effect on their skin. However, it is unknown as to whether a common mental disorder, such as major depressive disorder (MDD), can also precipitate the onset of vitiligo. OBJECTIVE: Evaluate a bidirectional relationship between MDD and vitiligo using The Health Improvement Network database. METHODS: Incident MDD and referent cohorts were followed until the development of vitiligo. Also, incident vitiligo and referent cohorts were followed until the development of MDD. Cox proportional hazards models were used, and numerous covariates were adjusted for. RESULTS: In adjusted models, MDD patients (n = 405,397) were at a 64% increased risk for vitiligo (hazard ratio 1.64, 95% confidence interval [CI] 1.43-1.87, P < .0001) compared with the referent cohort (n = 5,739,048). This risk was decreased in patients using antidepressants. Compared with the referent cohort (n = 6,137,696), patients with vitiligo (n = 7104) that were <30 years of age at diagnosis had a higher risk of developing MDD than patients ≥30 years of age (hazard ratio 1.31, 95% CI 1.14-1.50, P < .0001 vs 1.22, 95% CI 1.08-1.37, P = .001, respectively). LIMITATIONS: This study did not evaluate the severity of MDD or vitiligo on outcome development. CONCLUSION: These results highlight the burden of depression in patients with vitiligo and support the possible existence of pathophysiological connections between these 2 conditions.

Lichen planus pigmentosus inversus in children: Case report and updated review of the literature.

Lichen planus pigmentosus inversus (LPPI) is a rare variant of lichen planus characterized by slate grey to dark black-brown macules, papules, or patches occurring in the skin folds. We present a case of LPPI in an 11-year-old girl, the second-youngest case and only the third pediatric case. This article also reviews the differential diagnosis and treatment of LPPI.

Mid-dermal elastolysis: A female-centric disease; case report and updated review of the literature.

BACKGROUND: Mid-dermal elastolysis (MDE) is a rare, yet well-defined clinical and histopathologic entity manifested by fine wrinkling of the skin and mid-dermal loss of elastic fibers. This disease predominantly affects young to middle-aged Caucasian females and although it has no reported systemic features, it is psychologically bothersome and can be of great cosmetic concern. METHODS: We report a case of a healthy 45 year-old female with widespread mid-dermal elastolysis. A literature search using the search terms "mid-dermal elastolysis," "mid dermal elastolysis," "middermal elastolysis," and "elastophagocytosis" was conducted on Pubmed, using articles published from January 2008 until November 2014 to accompany Gambichler's comprehensive 1977 to 2009 review of mid-dermal elastolysis. The references of relevant papers were reviewed and further cases included as appropriate. RESULTS: We review the clinical features and histological, ultrastructural, and immunohistochemical findings of MDE, as well as differential diagnoses. There are 13 new publications of MDE since 2008. The novel findings since Gambichler's review are discussed and pathomechanisms revisited. Interestingly, given the striking female predominance of MDE, there is no known hormonal role in its etiology.