Cutis

Access to specialty care such as dermatology is a challenge for patients living in underserved communities.¹ In 2019, there were 29.6 million individuals without health insurance in the United States—9.2% of the population—up from 28.6 million the prior year.² Furthermore, Black and Hispanic patients, American Indian and Alaskan Natives, and Native Hawaiian and other Pacific Islanders are more likely to be uninsured than their White counterparts.³ Community service activities such as free skin cancer screenings, partnerships with community practices, and teledermatology consultations through free clinics are instrumental in mitigating health care disparities and improving access to dermatologic care. In this article, we build on existing models from dermatology residency programs across the country to propose actionable methods to expand service-learning opportunities in dermatology residency training and increase health care equity in dermatology.

Why Service Learning?

Service learning is an educational approach that combines learning objectives with community service to provide a comprehensive scholastic experience and meet societal needs.⁴ In pilot studies of family medicine residents, service-learning initiatives enhanced the standard residency curriculum by promoting clinical practice resourcefulness.⁵ Dermatology Accreditation Council for Graduate Medical Education requirements mandate that residents demonstrate an awareness of the larger context of health care, including social determinants of health.⁶ Likewise, dermatology residents must recognize the impact of socioeconomic status on health care utilization, treatment options, and patient adherence. With this understanding, residents can advocate for quality patient care and improve community-based health care systems.⁶

Service-learning projects can effectively meet the specific health needs of a community. In a service-learning environment, residents will understand a community-based health care approach and work with attending physician role models who exhibit a community service ethic.⁷ Residents also can gain interprofessional experience through collaborating with a team of social workers, community health workers, care coordinators, pharmacists, nurses, medical students, and attending physicians. Furthermore, residents can practice communicating effectively with patients and families across a range of socioeconomic and cultural backgrounds. Interprofessional, team-based care and interpersonal skill acquisition are both Accreditation Council for Graduate Medical Education requirements for dermatology training.⁶ Through increased service-learning opportunities, dermatology trainees will learn to recognize and mitigate social determinants of health with a holistic, patient-centered treatment plan.

Free or low-cost medical clinics provide health care to more than 15 million Americans, many of whom identify with marginalized racial and ethnic groups.⁸ In a dermatology access study, a sample of clinics listed in the National Association of Free and Charitable Clinics database were contacted regarding the availability of dermatologic care; however, more than half of the sites were unresponsive or closed, and the remaining clinics offered limited access to dermatology services.⁹ The scarcity of free and low-cost dermatologic services likely contributes to adverse skin health outcomes for patients in underserved communities.¹⁰ By increasing service learning within dermatology residency training programs, access to dermatologic care will improve for underserved and uninsured populations.

Actionable Methods to Increase Service Learning in Dermatology Residency Training Programs

Utilize Programming Offered Through National Dermatology Associations and Societies
The American Academy of Dermatology (AAD) has developed programming through which faculty, residents, and private practice dermatologists perform community service targeting underserved populations. SPOT me , a skin cancer screening program, is the AAD’s longest-standing public health program through which it provides complimentary screening forms, handouts, and advertisements to facilitate skin cancer screening. AccessDerm is the AAD’s philanthropic teledermatology program that delivers dermatologic care to underserved communities. Camp Discovery and the Shade Structure Grant Program are additional initiatives promoted by the AAD to support volunteer services for communities while learning about dermatology. Residents may apply for AAD grants to subsidize participation in the Native American Health Service Resident Rotation Program, the Skin Care for Developing Countries program, or an international grant.

The Women’s Dermatologic Society hosts 3 primary umbrella community outreach initiatives: Play Safe in the Sun, Coast-2-Coast, and the Transforming Interconnecting Project Program Women’s Shelter Initiative. From uplifting and educating individuals in women’s shelters about skin care, oral hygiene, self-care, nutrition, and social skills to providing complimentary skin cancer screenings, the Women’s Dermatologic Society provides easily accessible tool kits and syllabi to facilitate project composition and completion by its members.

Implement Residency Class Service-Learning Projects
Incoming dermatology residents are regularly encouraged to draft research proposals at the beginning of each academic year. Encouraging residency classes to work collectively on a dermatology service-learning project likely will increase resident camaraderie and project success while minimizing internal competition. In developing a service-learning proposal, residents should engage with community leaders and groups to best understand how to meet the skin health needs of underserved communities. The project should have clear objectives, benchmarks, and full support of the dermatology department. Short-term service-learning projects are completed when set goals are achieved, while sustainable projects continue with each new resident class.

Partner With Existing Community or Federally Funded Clinics
Establishing partnerships with free or federally funded health centers is a reliable way to increase service-learning opportunities in dermatology residency training. Personal malpractice carriers often include free clinic coverage, and most states offer limited liability or immunity for physicians who volunteer their professional services or subsidize malpractice insurance purchases.¹¹ In light of the global coronavirus disease 2019 pandemic, teledermatology options should be explored alongside in-person services. Although logistics may vary based on institutional preference, the following are our recommendations for building community partnerships for dermatology service learning (Figure):

• Secure departmental and institutional support. This includes requesting supplies, donations, and dermatopathology support

• Designate a resident or faculty community service champion to lead clinic correspondence and oversee operative logistics. This individual will establish a working partnership with the community clinic, assess the needs of the patient population, and manage the clinic schedule. The champion also will initiate and maintain open lines of communication with community providers for continuity of care. This partnership with community providers allows for shared resources and mutual learning

• Solicit residents to volunteer on a rotating schedule. Although some residents are fully committed to community service and health care justice, all residents need to participate in the service-learning program

• Participate in sustainable community engagement on a schedule that suits the needs of the community and takes into consideration resident and attending availability

Final Thoughts

Service learning in dermatology residency training is essential to improve access to equitable dermatologic care and train clinically competent dermatologists who have experience practicing in resource-limited settings. Service learning places cultural awareness and an understanding of socioeconomic determinants of health at the forefront.¹² Some dermatology residency programs treat a high percentage of medically underserved patients; others have integrated service learning into dermatology rotations, and a few programs offer community engagement–focused residency tracks.^13-16 Each dermatology program should evaluate its workforce, resources, and nearby underserved communities to strategically develop a program-specific service-learning program. Service-learning clinics often are the sole means by which patients from underserved communities receive dermatologic care.¹⁷ A commitment to service learning in dermatology residency programs will improve skin health equity and improve dermatology residency education.

Access to specialty care such as dermatology is a challenge for patients living in underserved communities.¹ In 2019, there were 29.6 million individuals without health insurance in the United States—9.2% of the population—up from 28.6 million the prior year.² Furthermore, Black and Hispanic patients, American Indian and Alaskan Natives, and Native Hawaiian and other Pacific Islanders are more likely to be uninsured than their White counterparts.³ Community service activities such as free skin cancer screenings, partnerships with community practices, and teledermatology consultations through free clinics are instrumental in mitigating health care disparities and improving access to dermatologic care. In this article, we build on existing models from dermatology residency programs across the country to propose actionable methods to expand service-learning opportunities in dermatology residency training and increase health care equity in dermatology.

Why Service Learning?

Service learning is an educational approach that combines learning objectives with community service to provide a comprehensive scholastic experience and meet societal needs.⁴ In pilot studies of family medicine residents, service-learning initiatives enhanced the standard residency curriculum by promoting clinical practice resourcefulness.⁵ Dermatology Accreditation Council for Graduate Medical Education requirements mandate that residents demonstrate an awareness of the larger context of health care, including social determinants of health.⁶ Likewise, dermatology residents must recognize the impact of socioeconomic status on health care utilization, treatment options, and patient adherence. With this understanding, residents can advocate for quality patient care and improve community-based health care systems.⁶

Service-learning projects can effectively meet the specific health needs of a community. In a service-learning environment, residents will understand a community-based health care approach and work with attending physician role models who exhibit a community service ethic.⁷ Residents also can gain interprofessional experience through collaborating with a team of social workers, community health workers, care coordinators, pharmacists, nurses, medical students, and attending physicians. Furthermore, residents can practice communicating effectively with patients and families across a range of socioeconomic and cultural backgrounds. Interprofessional, team-based care and interpersonal skill acquisition are both Accreditation Council for Graduate Medical Education requirements for dermatology training.⁶ Through increased service-learning opportunities, dermatology trainees will learn to recognize and mitigate social determinants of health with a holistic, patient-centered treatment plan.

Free or low-cost medical clinics provide health care to more than 15 million Americans, many of whom identify with marginalized racial and ethnic groups.⁸ In a dermatology access study, a sample of clinics listed in the National Association of Free and Charitable Clinics database were contacted regarding the availability of dermatologic care; however, more than half of the sites were unresponsive or closed, and the remaining clinics offered limited access to dermatology services.⁹ The scarcity of free and low-cost dermatologic services likely contributes to adverse skin health outcomes for patients in underserved communities.¹⁰ By increasing service learning within dermatology residency training programs, access to dermatologic care will improve for underserved and uninsured populations.

Actionable Methods to Increase Service Learning in Dermatology Residency Training Programs

Utilize Programming Offered Through National Dermatology Associations and Societies
The American Academy of Dermatology (AAD) has developed programming through which faculty, residents, and private practice dermatologists perform community service targeting underserved populations. SPOT me , a skin cancer screening program, is the AAD’s longest-standing public health program through which it provides complimentary screening forms, handouts, and advertisements to facilitate skin cancer screening. AccessDerm is the AAD’s philanthropic teledermatology program that delivers dermatologic care to underserved communities. Camp Discovery and the Shade Structure Grant Program are additional initiatives promoted by the AAD to support volunteer services for communities while learning about dermatology. Residents may apply for AAD grants to subsidize participation in the Native American Health Service Resident Rotation Program, the Skin Care for Developing Countries program, or an international grant.

The Women’s Dermatologic Society hosts 3 primary umbrella community outreach initiatives: Play Safe in the Sun, Coast-2-Coast, and the Transforming Interconnecting Project Program Women’s Shelter Initiative. From uplifting and educating individuals in women’s shelters about skin care, oral hygiene, self-care, nutrition, and social skills to providing complimentary skin cancer screenings, the Women’s Dermatologic Society provides easily accessible tool kits and syllabi to facilitate project composition and completion by its members.

Implement Residency Class Service-Learning Projects
Incoming dermatology residents are regularly encouraged to draft research proposals at the beginning of each academic year. Encouraging residency classes to work collectively on a dermatology service-learning project likely will increase resident camaraderie and project success while minimizing internal competition. In developing a service-learning proposal, residents should engage with community leaders and groups to best understand how to meet the skin health needs of underserved communities. The project should have clear objectives, benchmarks, and full support of the dermatology department. Short-term service-learning projects are completed when set goals are achieved, while sustainable projects continue with each new resident class.

Partner With Existing Community or Federally Funded Clinics
Establishing partnerships with free or federally funded health centers is a reliable way to increase service-learning opportunities in dermatology residency training. Personal malpractice carriers often include free clinic coverage, and most states offer limited liability or immunity for physicians who volunteer their professional services or subsidize malpractice insurance purchases.¹¹ In light of the global coronavirus disease 2019 pandemic, teledermatology options should be explored alongside in-person services. Although logistics may vary based on institutional preference, the following are our recommendations for building community partnerships for dermatology service learning (Figure):

• Secure departmental and institutional support. This includes requesting supplies, donations, and dermatopathology support

• Designate a resident or faculty community service champion to lead clinic correspondence and oversee operative logistics. This individual will establish a working partnership with the community clinic, assess the needs of the patient population, and manage the clinic schedule. The champion also will initiate and maintain open lines of communication with community providers for continuity of care. This partnership with community providers allows for shared resources and mutual learning

• Solicit residents to volunteer on a rotating schedule. Although some residents are fully committed to community service and health care justice, all residents need to participate in the service-learning program

• Participate in sustainable community engagement on a schedule that suits the needs of the community and takes into consideration resident and attending availability

Final Thoughts

Service learning in dermatology residency training is essential to improve access to equitable dermatologic care and train clinically competent dermatologists who have experience practicing in resource-limited settings. Service learning places cultural awareness and an understanding of socioeconomic determinants of health at the forefront.¹² Some dermatology residency programs treat a high percentage of medically underserved patients; others have integrated service learning into dermatology rotations, and a few programs offer community engagement–focused residency tracks.^13-16 Each dermatology program should evaluate its workforce, resources, and nearby underserved communities to strategically develop a program-specific service-learning program. Service-learning clinics often are the sole means by which patients from underserved communities receive dermatologic care.¹⁷ A commitment to service learning in dermatology residency programs will improve skin health equity and improve dermatology residency education.

Access to specialty care such as dermatology is a challenge for patients living in underserved communities.¹ In 2019, there were 29.6 million individuals without health insurance in the United States—9.2% of the population—up from 28.6 million the prior year.² Furthermore, Black and Hispanic patients, American Indian and Alaskan Natives, and Native Hawaiian and other Pacific Islanders are more likely to be uninsured than their White counterparts.³ Community service activities such as free skin cancer screenings, partnerships with community practices, and teledermatology consultations through free clinics are instrumental in mitigating health care disparities and improving access to dermatologic care. In this article, we build on existing models from dermatology residency programs across the country to propose actionable methods to expand service-learning opportunities in dermatology residency training and increase health care equity in dermatology.

Why Service Learning?

Service learning is an educational approach that combines learning objectives with community service to provide a comprehensive scholastic experience and meet societal needs.⁴ In pilot studies of family medicine residents, service-learning initiatives enhanced the standard residency curriculum by promoting clinical practice resourcefulness.⁵ Dermatology Accreditation Council for Graduate Medical Education requirements mandate that residents demonstrate an awareness of the larger context of health care, including social determinants of health.⁶ Likewise, dermatology residents must recognize the impact of socioeconomic status on health care utilization, treatment options, and patient adherence. With this understanding, residents can advocate for quality patient care and improve community-based health care systems.⁶

Service-learning projects can effectively meet the specific health needs of a community. In a service-learning environment, residents will understand a community-based health care approach and work with attending physician role models who exhibit a community service ethic.⁷ Residents also can gain interprofessional experience through collaborating with a team of social workers, community health workers, care coordinators, pharmacists, nurses, medical students, and attending physicians. Furthermore, residents can practice communicating effectively with patients and families across a range of socioeconomic and cultural backgrounds. Interprofessional, team-based care and interpersonal skill acquisition are both Accreditation Council for Graduate Medical Education requirements for dermatology training.⁶ Through increased service-learning opportunities, dermatology trainees will learn to recognize and mitigate social determinants of health with a holistic, patient-centered treatment plan.

Free or low-cost medical clinics provide health care to more than 15 million Americans, many of whom identify with marginalized racial and ethnic groups.⁸ In a dermatology access study, a sample of clinics listed in the National Association of Free and Charitable Clinics database were contacted regarding the availability of dermatologic care; however, more than half of the sites were unresponsive or closed, and the remaining clinics offered limited access to dermatology services.⁹ The scarcity of free and low-cost dermatologic services likely contributes to adverse skin health outcomes for patients in underserved communities.¹⁰ By increasing service learning within dermatology residency training programs, access to dermatologic care will improve for underserved and uninsured populations.

Actionable Methods to Increase Service Learning in Dermatology Residency Training Programs

Utilize Programming Offered Through National Dermatology Associations and Societies
The American Academy of Dermatology (AAD) has developed programming through which faculty, residents, and private practice dermatologists perform community service targeting underserved populations. SPOT me , a skin cancer screening program, is the AAD’s longest-standing public health program through which it provides complimentary screening forms, handouts, and advertisements to facilitate skin cancer screening. AccessDerm is the AAD’s philanthropic teledermatology program that delivers dermatologic care to underserved communities. Camp Discovery and the Shade Structure Grant Program are additional initiatives promoted by the AAD to support volunteer services for communities while learning about dermatology. Residents may apply for AAD grants to subsidize participation in the Native American Health Service Resident Rotation Program, the Skin Care for Developing Countries program, or an international grant.

The Women’s Dermatologic Society hosts 3 primary umbrella community outreach initiatives: Play Safe in the Sun, Coast-2-Coast, and the Transforming Interconnecting Project Program Women’s Shelter Initiative. From uplifting and educating individuals in women’s shelters about skin care, oral hygiene, self-care, nutrition, and social skills to providing complimentary skin cancer screenings, the Women’s Dermatologic Society provides easily accessible tool kits and syllabi to facilitate project composition and completion by its members.

Implement Residency Class Service-Learning Projects
Incoming dermatology residents are regularly encouraged to draft research proposals at the beginning of each academic year. Encouraging residency classes to work collectively on a dermatology service-learning project likely will increase resident camaraderie and project success while minimizing internal competition. In developing a service-learning proposal, residents should engage with community leaders and groups to best understand how to meet the skin health needs of underserved communities. The project should have clear objectives, benchmarks, and full support of the dermatology department. Short-term service-learning projects are completed when set goals are achieved, while sustainable projects continue with each new resident class.

Partner With Existing Community or Federally Funded Clinics
Establishing partnerships with free or federally funded health centers is a reliable way to increase service-learning opportunities in dermatology residency training. Personal malpractice carriers often include free clinic coverage, and most states offer limited liability or immunity for physicians who volunteer their professional services or subsidize malpractice insurance purchases.¹¹ In light of the global coronavirus disease 2019 pandemic, teledermatology options should be explored alongside in-person services. Although logistics may vary based on institutional preference, the following are our recommendations for building community partnerships for dermatology service learning (Figure):

• Secure departmental and institutional support. This includes requesting supplies, donations, and dermatopathology support

• Designate a resident or faculty community service champion to lead clinic correspondence and oversee operative logistics. This individual will establish a working partnership with the community clinic, assess the needs of the patient population, and manage the clinic schedule. The champion also will initiate and maintain open lines of communication with community providers for continuity of care. This partnership with community providers allows for shared resources and mutual learning

• Solicit residents to volunteer on a rotating schedule. Although some residents are fully committed to community service and health care justice, all residents need to participate in the service-learning program

• Participate in sustainable community engagement on a schedule that suits the needs of the community and takes into consideration resident and attending availability

Final Thoughts

Service learning in dermatology residency training is essential to improve access to equitable dermatologic care and train clinically competent dermatologists who have experience practicing in resource-limited settings. Service learning places cultural awareness and an understanding of socioeconomic determinants of health at the forefront.¹² Some dermatology residency programs treat a high percentage of medically underserved patients; others have integrated service learning into dermatology rotations, and a few programs offer community engagement–focused residency tracks.^13-16 Each dermatology program should evaluate its workforce, resources, and nearby underserved communities to strategically develop a program-specific service-learning program. Service-learning clinics often are the sole means by which patients from underserved communities receive dermatologic care.¹⁷ A commitment to service learning in dermatology residency programs will improve skin health equity and improve dermatology residency education.

Onychomycosis is the most prevalent nail condition worldwide and has a significant impact on quality of life.¹ There were 10 million physician visits for nail fungal infections in the National Ambulatory Medical Care Survey from 2007 to 2016, which was more than double the number of all other nail diagnoses combined.² Therefore, it is important for dermatologists to be familiar with the most current data on diagnosis and treatment of this extremely common nail disease as well as antifungal medication safety.

Onychomycosis Diagnosis

Diagnosis of onychomycosis using clinical examination alone has poor sensitivity and specificity and may lead to progression of disease and unwanted side effects from inappropriate therapy.^3,4 Dermoscopy is a useful adjunct but diagnostically is still inferior compared to mycologic testing.⁵ Classical methods of diagnosis include potassium hydroxide staining with microscopy, fungal culture, and histopathology. Polymerase chain reaction is a newer technique with wide accessibility and excellent sensitivity and specificity.⁶ Although these techniques have excellent diagnostic accuracy both alone and in combination, the ideal test would have 100% sensitivity and specificity and would not require nail sampling. Artificial intelligence recently has been studied for the diagnosis of onychomycosis. In a prospective study of 90 patients with onychodystrophy who had photographs of the nails taken by nonphysicians, deep neural networks showed comparable sensitivity (70.2% vs 73.0%) and specificity (72.7% vs 49.7%) for diagnosis of onychomycosis vs clinical examination by dermatologists with a mean of 5.6 years of experience.⁷ Therefore, artificial intelligence may be considered as a supplement to clinical examination for dermatology residents and junior attending dermatologists and may be superior to clinical examination by nondermatologists, but mycologic confirmation is still necessary before initiating onychomycosis treatment.

Treatment of Onychomycosis

There are 3 topical therapies (ciclopirox lacquer 8%, efinaconazole solution 10%, and tavaborole solution 5%) and 3 oral therapies (terbinafine, itraconazole, and griseofulvin) that are approved by the US Food and Drug Administration for onychomycosis therapy. Griseofulvin rarely is used due to the availability of more efficacious treatment options. Fluconazole is an off-label treatment that often is used in the United States.⁸

There are new data on the efficacy and safety of topical onychomycosis treatments in children. A phase 4 open‐label study of efinaconazole solution 10% applied once daily for 48 weeks was performed in children aged 6 to 16 years with distal lateral subungual onychomycosis (N=62).^9,10 The medication was both well tolerated and safe in children. The only treatment-related adverse event was onychocryptosis, which was reported by 2 patients. At week 52, mycologic cure was 65% and complete cure was 40% (N=50). In a pharmacokinetic assessment performed in a subset of 17 patients aged 12 to 16 years, efinaconazole was measured at very low levels in plasma.⁹

A phase 4 open-label study also was performed to evaluate the safety, pharmacokinetics, and efficacy of tavaborole for treatment of distal lateral subungual onychomycosis in children aged 6 years to under 17 years (N=55).¹¹ Tavaborole solution 5% was applied once daily for 48 weeks; at week 52, mycologic and complete cures were 36.2% and 8.5%, respectively (N=47). Systemic exposure was low (C_max=5.9 ng/mL [day 29]) in a subset of patients aged 12 years to under 17 years (N=37), and the medication demonstrated good safety and tolerability.¹¹

Fosravuconazole was approved for treatment of onychomycosis in Japan in 2018. In a randomized, double-blind, phase 3 trial of oral fosravuconazole 100 mg once daily (n=101) vs placebo (n=52) for 12 weeks in patients with onychomycosis (mean age, 58.4 years), the complete cure rate at 48 weeks was 59.4%.¹² In a small trial of 37 elderly patients (mean age, 78.1 years), complete cure rates were 5.0% in patients with a nail plate thickness of 3 mm or greater and 58.8% in those with a thickness lessthan 3 mm, and there were no severe adverse events.¹³ In addition to excellent efficacy and proven safety in elderly adults, the main advantage of fosravuconazole is less-potent inhibition of cytochrome P450 3A compared to other triazole antifungals, with no contraindicated drugs listed.

Safety of Antifungals

There are new data describing the safety of oral terbinafine in pregnant women and immunosuppressed patients. In a nationwide cohort study conducted in Denmark (1,650,649 pregnancies [942 oral terbinafine exposed, 9420 unexposed matched cohorts]), there was no association between oral or topical terbinafine exposure during pregnancy and risk of preterm birth, small-for-gestational-age birth weight, low birth weight, or stillbirth.¹⁴ In a small study of 13 kidney transplant recipients taking oral tacrolimus, cyclosporine, or everolimus who were treated with oral terbinafine, there were no severe drug interactions and no clinical consequences in renal grafts.¹⁵

There also is new information on laboratory abnormalities in adults, children, and patients with comorbidities who are taking oral terbinafine. In a retrospective study of 944 adult patients without pre-existing hepatic or hematologic conditions who were prescribed 3 months of oral terbinafine for onychomycosis, abnormal monitoring liver function tests (LFTs) and complete blood cell counts (CBCs) were uncommon (2.4% and 2.8%, respectively) and mild and resolved after treatment completion. In addition, patients with laboratory abnormalities were an average of 14.8 years older and approximately 3-times more likely to be 65 years or older compared to the overall study population.¹⁶ There were similar findings in a retrospective study of 134 children 18 years or younger who were prescribed oral terbinafine for superficial fungal infections. Abnormal monitoring LFTs and CBCs were uncommon (1.7% and 4.4%, respectively) and mild, resolving after after treatment completion.¹⁷ Finally, in a study of 255 patients with a pre-existing liver or hematologic condition who were prescribed oral terbinafine for onychomycosis, worsening of LFT or CBC values were rare, and all resolved after treatment completion or medication discontinuation.¹⁸

Final Thoughts

Mycologic confirmation is still necessary before treatment despite encouraging data on use of artificial intelligence for diagnosis of onychomycosis. Efinaconazole solution 10% and tavaborole solution 5% have shown good safety, tolerability, and efficacy in children with onychomycosis. Recent data suggest the safety of oral terbinafine in pregnant women and kidney transplant recipients, but these findings must be corroborated before its use in these populations. Fosravuconazole is a promising systemic treatment for onychomycosis with no drug-drug interactions reported to date. While baseline laboratory testing is recommended before prescribing terbinafine, interval laboratory monitoring may not be necessary in healthy adults.¹⁹ Prospective studies are necessary to corroborate these findings before formal recommendations can be made for prescribing terbinafine in the special populations discussed above, including children, and for interval laboratory monitoring.

Onychomycosis is the most prevalent nail condition worldwide and has a significant impact on quality of life.¹ There were 10 million physician visits for nail fungal infections in the National Ambulatory Medical Care Survey from 2007 to 2016, which was more than double the number of all other nail diagnoses combined.² Therefore, it is important for dermatologists to be familiar with the most current data on diagnosis and treatment of this extremely common nail disease as well as antifungal medication safety.

Onychomycosis Diagnosis

Diagnosis of onychomycosis using clinical examination alone has poor sensitivity and specificity and may lead to progression of disease and unwanted side effects from inappropriate therapy.^3,4 Dermoscopy is a useful adjunct but diagnostically is still inferior compared to mycologic testing.⁵ Classical methods of diagnosis include potassium hydroxide staining with microscopy, fungal culture, and histopathology. Polymerase chain reaction is a newer technique with wide accessibility and excellent sensitivity and specificity.⁶ Although these techniques have excellent diagnostic accuracy both alone and in combination, the ideal test would have 100% sensitivity and specificity and would not require nail sampling. Artificial intelligence recently has been studied for the diagnosis of onychomycosis. In a prospective study of 90 patients with onychodystrophy who had photographs of the nails taken by nonphysicians, deep neural networks showed comparable sensitivity (70.2% vs 73.0%) and specificity (72.7% vs 49.7%) for diagnosis of onychomycosis vs clinical examination by dermatologists with a mean of 5.6 years of experience.⁷ Therefore, artificial intelligence may be considered as a supplement to clinical examination for dermatology residents and junior attending dermatologists and may be superior to clinical examination by nondermatologists, but mycologic confirmation is still necessary before initiating onychomycosis treatment.

Treatment of Onychomycosis

There are 3 topical therapies (ciclopirox lacquer 8%, efinaconazole solution 10%, and tavaborole solution 5%) and 3 oral therapies (terbinafine, itraconazole, and griseofulvin) that are approved by the US Food and Drug Administration for onychomycosis therapy. Griseofulvin rarely is used due to the availability of more efficacious treatment options. Fluconazole is an off-label treatment that often is used in the United States.⁸

There are new data on the efficacy and safety of topical onychomycosis treatments in children. A phase 4 open‐label study of efinaconazole solution 10% applied once daily for 48 weeks was performed in children aged 6 to 16 years with distal lateral subungual onychomycosis (N=62).^9,10 The medication was both well tolerated and safe in children. The only treatment-related adverse event was onychocryptosis, which was reported by 2 patients. At week 52, mycologic cure was 65% and complete cure was 40% (N=50). In a pharmacokinetic assessment performed in a subset of 17 patients aged 12 to 16 years, efinaconazole was measured at very low levels in plasma.⁹

A phase 4 open-label study also was performed to evaluate the safety, pharmacokinetics, and efficacy of tavaborole for treatment of distal lateral subungual onychomycosis in children aged 6 years to under 17 years (N=55).¹¹ Tavaborole solution 5% was applied once daily for 48 weeks; at week 52, mycologic and complete cures were 36.2% and 8.5%, respectively (N=47). Systemic exposure was low (C_max=5.9 ng/mL [day 29]) in a subset of patients aged 12 years to under 17 years (N=37), and the medication demonstrated good safety and tolerability.¹¹

Fosravuconazole was approved for treatment of onychomycosis in Japan in 2018. In a randomized, double-blind, phase 3 trial of oral fosravuconazole 100 mg once daily (n=101) vs placebo (n=52) for 12 weeks in patients with onychomycosis (mean age, 58.4 years), the complete cure rate at 48 weeks was 59.4%.¹² In a small trial of 37 elderly patients (mean age, 78.1 years), complete cure rates were 5.0% in patients with a nail plate thickness of 3 mm or greater and 58.8% in those with a thickness lessthan 3 mm, and there were no severe adverse events.¹³ In addition to excellent efficacy and proven safety in elderly adults, the main advantage of fosravuconazole is less-potent inhibition of cytochrome P450 3A compared to other triazole antifungals, with no contraindicated drugs listed.

Safety of Antifungals

There are new data describing the safety of oral terbinafine in pregnant women and immunosuppressed patients. In a nationwide cohort study conducted in Denmark (1,650,649 pregnancies [942 oral terbinafine exposed, 9420 unexposed matched cohorts]), there was no association between oral or topical terbinafine exposure during pregnancy and risk of preterm birth, small-for-gestational-age birth weight, low birth weight, or stillbirth.¹⁴ In a small study of 13 kidney transplant recipients taking oral tacrolimus, cyclosporine, or everolimus who were treated with oral terbinafine, there were no severe drug interactions and no clinical consequences in renal grafts.¹⁵

There also is new information on laboratory abnormalities in adults, children, and patients with comorbidities who are taking oral terbinafine. In a retrospective study of 944 adult patients without pre-existing hepatic or hematologic conditions who were prescribed 3 months of oral terbinafine for onychomycosis, abnormal monitoring liver function tests (LFTs) and complete blood cell counts (CBCs) were uncommon (2.4% and 2.8%, respectively) and mild and resolved after treatment completion. In addition, patients with laboratory abnormalities were an average of 14.8 years older and approximately 3-times more likely to be 65 years or older compared to the overall study population.¹⁶ There were similar findings in a retrospective study of 134 children 18 years or younger who were prescribed oral terbinafine for superficial fungal infections. Abnormal monitoring LFTs and CBCs were uncommon (1.7% and 4.4%, respectively) and mild, resolving after after treatment completion.¹⁷ Finally, in a study of 255 patients with a pre-existing liver or hematologic condition who were prescribed oral terbinafine for onychomycosis, worsening of LFT or CBC values were rare, and all resolved after treatment completion or medication discontinuation.¹⁸

Final Thoughts

Mycologic confirmation is still necessary before treatment despite encouraging data on use of artificial intelligence for diagnosis of onychomycosis. Efinaconazole solution 10% and tavaborole solution 5% have shown good safety, tolerability, and efficacy in children with onychomycosis. Recent data suggest the safety of oral terbinafine in pregnant women and kidney transplant recipients, but these findings must be corroborated before its use in these populations. Fosravuconazole is a promising systemic treatment for onychomycosis with no drug-drug interactions reported to date. While baseline laboratory testing is recommended before prescribing terbinafine, interval laboratory monitoring may not be necessary in healthy adults.¹⁹ Prospective studies are necessary to corroborate these findings before formal recommendations can be made for prescribing terbinafine in the special populations discussed above, including children, and for interval laboratory monitoring.

Onychomycosis is the most prevalent nail condition worldwide and has a significant impact on quality of life.¹ There were 10 million physician visits for nail fungal infections in the National Ambulatory Medical Care Survey from 2007 to 2016, which was more than double the number of all other nail diagnoses combined.² Therefore, it is important for dermatologists to be familiar with the most current data on diagnosis and treatment of this extremely common nail disease as well as antifungal medication safety.

Onychomycosis Diagnosis

Diagnosis of onychomycosis using clinical examination alone has poor sensitivity and specificity and may lead to progression of disease and unwanted side effects from inappropriate therapy.^3,4 Dermoscopy is a useful adjunct but diagnostically is still inferior compared to mycologic testing.⁵ Classical methods of diagnosis include potassium hydroxide staining with microscopy, fungal culture, and histopathology. Polymerase chain reaction is a newer technique with wide accessibility and excellent sensitivity and specificity.⁶ Although these techniques have excellent diagnostic accuracy both alone and in combination, the ideal test would have 100% sensitivity and specificity and would not require nail sampling. Artificial intelligence recently has been studied for the diagnosis of onychomycosis. In a prospective study of 90 patients with onychodystrophy who had photographs of the nails taken by nonphysicians, deep neural networks showed comparable sensitivity (70.2% vs 73.0%) and specificity (72.7% vs 49.7%) for diagnosis of onychomycosis vs clinical examination by dermatologists with a mean of 5.6 years of experience.⁷ Therefore, artificial intelligence may be considered as a supplement to clinical examination for dermatology residents and junior attending dermatologists and may be superior to clinical examination by nondermatologists, but mycologic confirmation is still necessary before initiating onychomycosis treatment.

Treatment of Onychomycosis

There are 3 topical therapies (ciclopirox lacquer 8%, efinaconazole solution 10%, and tavaborole solution 5%) and 3 oral therapies (terbinafine, itraconazole, and griseofulvin) that are approved by the US Food and Drug Administration for onychomycosis therapy. Griseofulvin rarely is used due to the availability of more efficacious treatment options. Fluconazole is an off-label treatment that often is used in the United States.⁸

There are new data on the efficacy and safety of topical onychomycosis treatments in children. A phase 4 open‐label study of efinaconazole solution 10% applied once daily for 48 weeks was performed in children aged 6 to 16 years with distal lateral subungual onychomycosis (N=62).^9,10 The medication was both well tolerated and safe in children. The only treatment-related adverse event was onychocryptosis, which was reported by 2 patients. At week 52, mycologic cure was 65% and complete cure was 40% (N=50). In a pharmacokinetic assessment performed in a subset of 17 patients aged 12 to 16 years, efinaconazole was measured at very low levels in plasma.⁹

A phase 4 open-label study also was performed to evaluate the safety, pharmacokinetics, and efficacy of tavaborole for treatment of distal lateral subungual onychomycosis in children aged 6 years to under 17 years (N=55).¹¹ Tavaborole solution 5% was applied once daily for 48 weeks; at week 52, mycologic and complete cures were 36.2% and 8.5%, respectively (N=47). Systemic exposure was low (C_max=5.9 ng/mL [day 29]) in a subset of patients aged 12 years to under 17 years (N=37), and the medication demonstrated good safety and tolerability.¹¹

Fosravuconazole was approved for treatment of onychomycosis in Japan in 2018. In a randomized, double-blind, phase 3 trial of oral fosravuconazole 100 mg once daily (n=101) vs placebo (n=52) for 12 weeks in patients with onychomycosis (mean age, 58.4 years), the complete cure rate at 48 weeks was 59.4%.¹² In a small trial of 37 elderly patients (mean age, 78.1 years), complete cure rates were 5.0% in patients with a nail plate thickness of 3 mm or greater and 58.8% in those with a thickness lessthan 3 mm, and there were no severe adverse events.¹³ In addition to excellent efficacy and proven safety in elderly adults, the main advantage of fosravuconazole is less-potent inhibition of cytochrome P450 3A compared to other triazole antifungals, with no contraindicated drugs listed.

Safety of Antifungals

There are new data describing the safety of oral terbinafine in pregnant women and immunosuppressed patients. In a nationwide cohort study conducted in Denmark (1,650,649 pregnancies [942 oral terbinafine exposed, 9420 unexposed matched cohorts]), there was no association between oral or topical terbinafine exposure during pregnancy and risk of preterm birth, small-for-gestational-age birth weight, low birth weight, or stillbirth.¹⁴ In a small study of 13 kidney transplant recipients taking oral tacrolimus, cyclosporine, or everolimus who were treated with oral terbinafine, there were no severe drug interactions and no clinical consequences in renal grafts.¹⁵

There also is new information on laboratory abnormalities in adults, children, and patients with comorbidities who are taking oral terbinafine. In a retrospective study of 944 adult patients without pre-existing hepatic or hematologic conditions who were prescribed 3 months of oral terbinafine for onychomycosis, abnormal monitoring liver function tests (LFTs) and complete blood cell counts (CBCs) were uncommon (2.4% and 2.8%, respectively) and mild and resolved after treatment completion. In addition, patients with laboratory abnormalities were an average of 14.8 years older and approximately 3-times more likely to be 65 years or older compared to the overall study population.¹⁶ There were similar findings in a retrospective study of 134 children 18 years or younger who were prescribed oral terbinafine for superficial fungal infections. Abnormal monitoring LFTs and CBCs were uncommon (1.7% and 4.4%, respectively) and mild, resolving after after treatment completion.¹⁷ Finally, in a study of 255 patients with a pre-existing liver or hematologic condition who were prescribed oral terbinafine for onychomycosis, worsening of LFT or CBC values were rare, and all resolved after treatment completion or medication discontinuation.¹⁸

Final Thoughts

Mycologic confirmation is still necessary before treatment despite encouraging data on use of artificial intelligence for diagnosis of onychomycosis. Efinaconazole solution 10% and tavaborole solution 5% have shown good safety, tolerability, and efficacy in children with onychomycosis. Recent data suggest the safety of oral terbinafine in pregnant women and kidney transplant recipients, but these findings must be corroborated before its use in these populations. Fosravuconazole is a promising systemic treatment for onychomycosis with no drug-drug interactions reported to date. While baseline laboratory testing is recommended before prescribing terbinafine, interval laboratory monitoring may not be necessary in healthy adults.¹⁹ Prospective studies are necessary to corroborate these findings before formal recommendations can be made for prescribing terbinafine in the special populations discussed above, including children, and for interval laboratory monitoring.

The Diagnosis: Extragenital Lichen Sclerosus Et Atrophicus 

Histopathologic evaluation revealed hyperkeratosis, follicular plugging, epidermal atrophy, and homogenization of papillary dermal collagen with an underlying lymphocytic infiltrate (Figure 1). Direct immunofluorescence of a plaque with a superimposed bulla was negative for deposition of C3, IgG, IgA, IgM, or fibrinogen. Accordingly, clinicopathologic correlation supported a diagnosis of extragenital lichen sclerosus et atrophicus (LSA). Of note, the patient's history of genital irritation was due to genital LSA that preceded the extragenital manifestations. 

Lichen sclerosus et atrophicus is an inflammatory dermatosis that typically presents as atrophic white papules of the anogenital area that coalesce into pruritic plaques; the exact etiology remains to be elucidated, yet various circulating autoantibodies have been identified, suggesting a role for autoimmunity.^1,2 Lichen sclerosus et atrophicus is more common in women than in men, with a bimodal peak in the age of onset affecting postmenopausal and prepubertal populations.¹ In women, affected areas include the labia minora and majora, clitoris, perineum, and perianal skin; LSA spares the mucosal surfaces of the vagina and cervix.² In men, uncircumscribed genital skin more commonly is affected. Involvement is localized to the foreskin and glans with occasional urethral involvement.²  

In contrast, extragenital LSA tends to present as asymptomatic papules and plaques that develop atrophy with time, involving the back, shoulders, neck, chest, thighs, axillae, and flexural wrists^2,3; an erythematous rim often is present,⁴ and hyperkeratosis with follicular plugging may be prominent.⁵ Our patient's case emphasizes the predilection of plaques for the chest and intermammary skin (Figure 2A). Approximately 15% of LSA cases have extragenital involvement, and extragenital-limited disease accounts for roughly 5% of cases.^6,7 Unlike genital LSA, extragenital disease has not been associated with an increased risk for squamous cell carcinoma.¹ Bullae formation within plaques of genital or extragenital LSA has been reported^3,8 and is exemplified in our patient (Figure 2B). Intralesional bullae formation likely is due to a combination of internal and external factors, mainly the inability to withstand shear forces due to an atrophic epidermis with basal vacuolar injury overlying an edematous papillary dermis with altered collagen.⁸ Dermatoscopic findings may aid in recognizing extragenital LSA9,¹⁰; our patient's plaques demonstrated the characteristic findings of comedolike openings, structureless white areas, and pink borders (Figure 3). 

The clinical differential diagnosis for well-demarcated, pink, scaly plaques is broad. Nummular eczema usually presents as coin-shaped eczematous plaques on the dorsal aspects of the hands or lower extremities, and histology shows epidermal spongiosis.¹¹ Nummular eczema may be considered due to the striking round morphology of various plaques, yet our patient's presentation was better served by a consideration of several papulosquamous disorders. 

Lichen planus (LP) presents as intensely pruritic, violaceous, polygonal, flat-topped papules with overlying reticular white lines, or Wickham striae, that favor the flexural wrists, lower back, and lower extremities. Lichen planus also may have oral and genital mucosal involvement. Similar to LSA, LP is more common in women and preferentially affects the postmenopausal population.¹² Additionally, hypertrophic LP may obscure Wickham striae and mimic extragenital LSA; distinguishing features of hypertrophic LP are intense pruritus and a predilection for the shins. Histology is defined by orthohyperkeratosis, hypergranulosis, sawtooth acanthosis, and vacuolar degeneration of the basal layer with Civatte bodies or dyskeratotic basal keratinocytes overlying a characteristic bandlike infiltrate of lymphocytes.¹² 

Lichen simplex chronicus (LSC) is characterized by intense pruritus and presents as hyperkeratotic plaques with a predilection for accessible regions such as the posterior neck and extremities.¹³ The striking annular demarcation of this case makes LSC unlikely. Comparable to LSA and LP, LSC also may present with both genital and extragenital findings. Histology of LSC is characterized by irregular acanthosis or thickening of the epidermis with vertical streaking of collagen and vascular bundles of the papillary dermis.¹³ 

Subacute cutaneous lupus erythematosus (SCLE) is important to consider for a new papulosquamous eruption with a predilection for the sun-exposed skin of a middle-aged woman. The presence of papules on the volar wrist and history of genital irritation, however, make this entity less likely. Similar to LSA, histologic examination of SCLE reveals epidermal atrophy, basal layer degeneration, and papillary dermal edema with lymphocytic inflammation. However, SCLE lacks the band of inflammation underlying pale homogenized papillary dermal collagen, the most distinguishing feature of LSA; instead, SCLE shows superficial and deep perivascular and periadnexal lymphocytes and mucin in the dermis.¹⁴ 

Lichen sclerosus et atrophicus may be chronic and progressive in nature or cycle through remissions and relapses.² Treatment is not curative, and management is directed to alleviating symptoms and preventing the progression of disease. First-line management of extragenital LSA is potent topical steroids.¹ Adjuvant topical calcineurin inhibitors may be used as steroid-sparing agents.² Phototherapy is a second-line therapy and even narrowband UVB phototherapy has demonstrated efficacy in managing extragenital LSA.^15,16 Our patient was started on mometasone ointment and calcipotriene cream with slight improvement after a 6-month trial. Ongoing management is focused on optimizing application of topical therapies.  

The Diagnosis: Extragenital Lichen Sclerosus Et Atrophicus 

Histopathologic evaluation revealed hyperkeratosis, follicular plugging, epidermal atrophy, and homogenization of papillary dermal collagen with an underlying lymphocytic infiltrate (Figure 1). Direct immunofluorescence of a plaque with a superimposed bulla was negative for deposition of C3, IgG, IgA, IgM, or fibrinogen. Accordingly, clinicopathologic correlation supported a diagnosis of extragenital lichen sclerosus et atrophicus (LSA). Of note, the patient's history of genital irritation was due to genital LSA that preceded the extragenital manifestations. 

Lichen sclerosus et atrophicus is an inflammatory dermatosis that typically presents as atrophic white papules of the anogenital area that coalesce into pruritic plaques; the exact etiology remains to be elucidated, yet various circulating autoantibodies have been identified, suggesting a role for autoimmunity.^1,2 Lichen sclerosus et atrophicus is more common in women than in men, with a bimodal peak in the age of onset affecting postmenopausal and prepubertal populations.¹ In women, affected areas include the labia minora and majora, clitoris, perineum, and perianal skin; LSA spares the mucosal surfaces of the vagina and cervix.² In men, uncircumscribed genital skin more commonly is affected. Involvement is localized to the foreskin and glans with occasional urethral involvement.²  

In contrast, extragenital LSA tends to present as asymptomatic papules and plaques that develop atrophy with time, involving the back, shoulders, neck, chest, thighs, axillae, and flexural wrists^2,3; an erythematous rim often is present,⁴ and hyperkeratosis with follicular plugging may be prominent.⁵ Our patient's case emphasizes the predilection of plaques for the chest and intermammary skin (Figure 2A). Approximately 15% of LSA cases have extragenital involvement, and extragenital-limited disease accounts for roughly 5% of cases.^6,7 Unlike genital LSA, extragenital disease has not been associated with an increased risk for squamous cell carcinoma.¹ Bullae formation within plaques of genital or extragenital LSA has been reported^3,8 and is exemplified in our patient (Figure 2B). Intralesional bullae formation likely is due to a combination of internal and external factors, mainly the inability to withstand shear forces due to an atrophic epidermis with basal vacuolar injury overlying an edematous papillary dermis with altered collagen.⁸ Dermatoscopic findings may aid in recognizing extragenital LSA9,¹⁰; our patient's plaques demonstrated the characteristic findings of comedolike openings, structureless white areas, and pink borders (Figure 3). 

The clinical differential diagnosis for well-demarcated, pink, scaly plaques is broad. Nummular eczema usually presents as coin-shaped eczematous plaques on the dorsal aspects of the hands or lower extremities, and histology shows epidermal spongiosis.¹¹ Nummular eczema may be considered due to the striking round morphology of various plaques, yet our patient's presentation was better served by a consideration of several papulosquamous disorders. 

Lichen planus (LP) presents as intensely pruritic, violaceous, polygonal, flat-topped papules with overlying reticular white lines, or Wickham striae, that favor the flexural wrists, lower back, and lower extremities. Lichen planus also may have oral and genital mucosal involvement. Similar to LSA, LP is more common in women and preferentially affects the postmenopausal population.¹² Additionally, hypertrophic LP may obscure Wickham striae and mimic extragenital LSA; distinguishing features of hypertrophic LP are intense pruritus and a predilection for the shins. Histology is defined by orthohyperkeratosis, hypergranulosis, sawtooth acanthosis, and vacuolar degeneration of the basal layer with Civatte bodies or dyskeratotic basal keratinocytes overlying a characteristic bandlike infiltrate of lymphocytes.¹² 

Lichen simplex chronicus (LSC) is characterized by intense pruritus and presents as hyperkeratotic plaques with a predilection for accessible regions such as the posterior neck and extremities.¹³ The striking annular demarcation of this case makes LSC unlikely. Comparable to LSA and LP, LSC also may present with both genital and extragenital findings. Histology of LSC is characterized by irregular acanthosis or thickening of the epidermis with vertical streaking of collagen and vascular bundles of the papillary dermis.¹³ 

Subacute cutaneous lupus erythematosus (SCLE) is important to consider for a new papulosquamous eruption with a predilection for the sun-exposed skin of a middle-aged woman. The presence of papules on the volar wrist and history of genital irritation, however, make this entity less likely. Similar to LSA, histologic examination of SCLE reveals epidermal atrophy, basal layer degeneration, and papillary dermal edema with lymphocytic inflammation. However, SCLE lacks the band of inflammation underlying pale homogenized papillary dermal collagen, the most distinguishing feature of LSA; instead, SCLE shows superficial and deep perivascular and periadnexal lymphocytes and mucin in the dermis.¹⁴ 

Lichen sclerosus et atrophicus may be chronic and progressive in nature or cycle through remissions and relapses.² Treatment is not curative, and management is directed to alleviating symptoms and preventing the progression of disease. First-line management of extragenital LSA is potent topical steroids.¹ Adjuvant topical calcineurin inhibitors may be used as steroid-sparing agents.² Phototherapy is a second-line therapy and even narrowband UVB phototherapy has demonstrated efficacy in managing extragenital LSA.^15,16 Our patient was started on mometasone ointment and calcipotriene cream with slight improvement after a 6-month trial. Ongoing management is focused on optimizing application of topical therapies.  

The Diagnosis: Extragenital Lichen Sclerosus Et Atrophicus 

Histopathologic evaluation revealed hyperkeratosis, follicular plugging, epidermal atrophy, and homogenization of papillary dermal collagen with an underlying lymphocytic infiltrate (Figure 1). Direct immunofluorescence of a plaque with a superimposed bulla was negative for deposition of C3, IgG, IgA, IgM, or fibrinogen. Accordingly, clinicopathologic correlation supported a diagnosis of extragenital lichen sclerosus et atrophicus (LSA). Of note, the patient's history of genital irritation was due to genital LSA that preceded the extragenital manifestations. 

Lichen sclerosus et atrophicus is an inflammatory dermatosis that typically presents as atrophic white papules of the anogenital area that coalesce into pruritic plaques; the exact etiology remains to be elucidated, yet various circulating autoantibodies have been identified, suggesting a role for autoimmunity.^1,2 Lichen sclerosus et atrophicus is more common in women than in men, with a bimodal peak in the age of onset affecting postmenopausal and prepubertal populations.¹ In women, affected areas include the labia minora and majora, clitoris, perineum, and perianal skin; LSA spares the mucosal surfaces of the vagina and cervix.² In men, uncircumscribed genital skin more commonly is affected. Involvement is localized to the foreskin and glans with occasional urethral involvement.²  

In contrast, extragenital LSA tends to present as asymptomatic papules and plaques that develop atrophy with time, involving the back, shoulders, neck, chest, thighs, axillae, and flexural wrists^2,3; an erythematous rim often is present,⁴ and hyperkeratosis with follicular plugging may be prominent.⁵ Our patient's case emphasizes the predilection of plaques for the chest and intermammary skin (Figure 2A). Approximately 15% of LSA cases have extragenital involvement, and extragenital-limited disease accounts for roughly 5% of cases.^6,7 Unlike genital LSA, extragenital disease has not been associated with an increased risk for squamous cell carcinoma.¹ Bullae formation within plaques of genital or extragenital LSA has been reported^3,8 and is exemplified in our patient (Figure 2B). Intralesional bullae formation likely is due to a combination of internal and external factors, mainly the inability to withstand shear forces due to an atrophic epidermis with basal vacuolar injury overlying an edematous papillary dermis with altered collagen.⁸ Dermatoscopic findings may aid in recognizing extragenital LSA9,¹⁰; our patient's plaques demonstrated the characteristic findings of comedolike openings, structureless white areas, and pink borders (Figure 3). 

The clinical differential diagnosis for well-demarcated, pink, scaly plaques is broad. Nummular eczema usually presents as coin-shaped eczematous plaques on the dorsal aspects of the hands or lower extremities, and histology shows epidermal spongiosis.¹¹ Nummular eczema may be considered due to the striking round morphology of various plaques, yet our patient's presentation was better served by a consideration of several papulosquamous disorders. 

Lichen planus (LP) presents as intensely pruritic, violaceous, polygonal, flat-topped papules with overlying reticular white lines, or Wickham striae, that favor the flexural wrists, lower back, and lower extremities. Lichen planus also may have oral and genital mucosal involvement. Similar to LSA, LP is more common in women and preferentially affects the postmenopausal population.¹² Additionally, hypertrophic LP may obscure Wickham striae and mimic extragenital LSA; distinguishing features of hypertrophic LP are intense pruritus and a predilection for the shins. Histology is defined by orthohyperkeratosis, hypergranulosis, sawtooth acanthosis, and vacuolar degeneration of the basal layer with Civatte bodies or dyskeratotic basal keratinocytes overlying a characteristic bandlike infiltrate of lymphocytes.¹² 

Lichen simplex chronicus (LSC) is characterized by intense pruritus and presents as hyperkeratotic plaques with a predilection for accessible regions such as the posterior neck and extremities.¹³ The striking annular demarcation of this case makes LSC unlikely. Comparable to LSA and LP, LSC also may present with both genital and extragenital findings. Histology of LSC is characterized by irregular acanthosis or thickening of the epidermis with vertical streaking of collagen and vascular bundles of the papillary dermis.¹³ 

Subacute cutaneous lupus erythematosus (SCLE) is important to consider for a new papulosquamous eruption with a predilection for the sun-exposed skin of a middle-aged woman. The presence of papules on the volar wrist and history of genital irritation, however, make this entity less likely. Similar to LSA, histologic examination of SCLE reveals epidermal atrophy, basal layer degeneration, and papillary dermal edema with lymphocytic inflammation. However, SCLE lacks the band of inflammation underlying pale homogenized papillary dermal collagen, the most distinguishing feature of LSA; instead, SCLE shows superficial and deep perivascular and periadnexal lymphocytes and mucin in the dermis.¹⁴ 

Lichen sclerosus et atrophicus may be chronic and progressive in nature or cycle through remissions and relapses.² Treatment is not curative, and management is directed to alleviating symptoms and preventing the progression of disease. First-line management of extragenital LSA is potent topical steroids.¹ Adjuvant topical calcineurin inhibitors may be used as steroid-sparing agents.² Phototherapy is a second-line therapy and even narrowband UVB phototherapy has demonstrated efficacy in managing extragenital LSA.^15,16 Our patient was started on mometasone ointment and calcipotriene cream with slight improvement after a 6-month trial. Ongoing management is focused on optimizing application of topical therapies.  

A casual survey of my dermatology co-residents yielded overwhelmingly unanimous results: A complete skin check goes from head to toe but does not routinely include an examination of the genital area. This observation contrasts starkly with the American Academy of Dermatology’s Basic Dermatology Curriculum, which recommends inspection of the entire skin surface including the mucous membranes (ie, eyes, mouth, anus, genital area) as part of the total-body skin examination (TBSE).¹ It even draws attention to so-called hidden areas where lesions easily can be missed, such as the perianal skin. My observation seems far from anecdotal; even a recent attempt at optimizing movements in the TBSE neglected to include examination of the genitalia in the proposed method,^2-4 and many practicing dermatologists seem to agree. A survey of international dermatologists at high-risk skin cancer clinics found male and female genitalia were the least frequently examined anatomy sites during the TBSE. Additionally, female genitalia were examined less frequently than male genitalia (labia majora, 28%; penis, 52%; P=.003).⁵ Another survey of US academic dermatologists (23 dermatologists, 1 nurse practitioner) found that only 4% always visually inspected the vulva during routine annual examinations, and 50% did not think that vulvar examination was the dermatologist’s responsibility.⁶ Similar findings were reported in a survey of US dermatology residents.⁷

Why is the genital area routinely omitted from the dermatologic TBSE? Based on the surveys of dermatologists and dermatology residents, the most common reason cited for not examining these sites was patient discomfort, but there also was a dominant belief that other specialties, such as gynecologists, urologists, or primary care providers, routinely examine these areas.^5,7 Time constraints also were a concern.

Although examination of sensitive areas can be uncomfortable,⁸ most patients still expect these locations to be examined during the TBSE. In a survey of 500 adults presenting for TBSE at an academic dermatology clinic, 84% of respondents expected the dermatologist to examine the genital area.⁹ Similarly, another survey of patient preferences (N=443) for the TBSE found that only 31.3% of women and 12.5% of men preferred not to have their genital area examined.¹⁰ As providers, we may be uncomfortable examining the genital area; however, our patients mostly expect it as part of routine practice. There are a number of barriers that may prevent incorporating the genital examination into daily dermatologic practice.

Training in Genital Examinations

Adequate training may be an issue for provider comfort when examining the genital skin. In a survey of dermatology residency program directors (n=38) and residents (n=91), 61.7% reported receiving formal instruction on TBSE technique and 38.3% reported being self-taught. Examination of the genital skin was included only 40% of the time.¹¹ Even vulvar disorder experts have admitted to receiving their training by self-teaching, with only 19% receiving vulvar training during residency and 11% during fellowship.¹² Improving this training appears to be an ongoing effort.²

Passing the Buck

It may be easier to think that another provider is routinely examining genital skin based on the relative absence of this area in dermatologic training; however, that does not appear to be the case. In a 1999 survey of primary care providers, only 31% reported performing skin cancer screenings on their adult patients, citing lack of confidence in this clinical skill as the biggest hurdle.¹³ Similarly, changes in recommendations for the utility of the screening pelvic examination in asymptomatic, average-risk, nonpregnant adult women have decreased the performance of this examination in actual practice.¹⁴ Reviews of resident training in vulvovaginal disease also have shown that although dermatology residents receive slightly less formal training hours on vulvar skin disease, they see more than double the number of patients with vulvar disease per year when compared to obstetrics and gynecology residents.¹⁵ In practice, dermatologists generally are more confident when evaluating vulvar pigmented lesions than gynecologists.⁶

The Importance of the Genital Examination

Looking past these barriers seems essential to providing the best dermatologic care, as there are a multitude of neoplastic and inflammatory dermatoses that can affect the genital skin. Furthermore, early diagnosis and treatment of these conditions potentially can limit morbidity and mortality as well as improve quality of life. Genital melanomas are a good example. Although they may be rare, it is well known that genital melanomas are associated with an aggressive disease course and have worse outcomes than melanomas found elsewhere on the body.^16,17 Increasing rates of genital and perianal keratinocyte carcinomas make including this as part of the TBSE even more important.¹⁸

We also should not forget that inflammatory conditions can routinely involve the genitals.^19-21 Although robust data are lacking, chronic vulvar concerns frequently are seen in the primary care setting. In one study in the United Kingdom, 52% of general practitioners surveyed saw more than 3 patients per month with vulvar concerns.²² Even in common dermatologic conditions such as psoriasis and lichen planus, genital involvement often is overlooked despite its relative frequency.^23-27 In one study, 60% of psoriasis patients with genital involvement had not had these lesions examined by a physician.²⁸

Theoretically, TBSEs that include genital examination would yield higher and earlier detection rates of neoplasms as well as inflammatory dermatoses.^29-32 Thus, there is real value in diagnosing ailments of the genital skin, and dermatologists are well prepared to manage these conditions. Consistently incorporating a genital examination within the TBSE is the first step.

An Approach to the Genital Skin Examination

As with the TBSE, no standardized protocol for the genital skin examination exists, and there is no consensus for how best to perform this evaluation. Ideally, both male and female patients should remove all clothing, including undergarments, though one study found patients preferred to keep undergarments on during the genital examination.^10,33,34

In general, adult female genital anatomy is best viewed with the patient in the supine position.^6,33,35 There is no clear agreement on the use of stirrups, and the decision to use these may be left to the discretion of the patient. One randomized clinical trial found that women undergoing routine gynecologic examination without stirrups reported less physical discomfort and had a reduced sense of vulnerability than women examined in stirrups.³⁶ During the female genital examination, the head of the bed ideally should be positioned at a 30° to 45° angle to allow the provider to maintain eye contact and face-to-face communication with the patient.³³ This positioning also facilitates the use of a handheld mirror to instruct patients on techniques for medication application as well as to point out sites of disease.

For adult males, the genital examination can be performed with the patient standing facing a seated examiner.³⁵ The patient’s gown should be raised to the level of the umbilicus to expose the entire genital region. Good lighting is essential. These recommendations apply mainly to adults, but helpful tips on how to approach evaluating prepubertal children in the dermatology clinic are available.³⁷

The presence of a chaperone also is optional for maximizing patient comfort but also may be helpful for providing medicolegal protection for the provider. It always should be offered regardless of patient gender. A dermatology study found that when patients were examined by a same-gender physician, women and men were more comfortable without a chaperone than with a chaperone, and patients generally preferred fewer bodies in the room during sensitive examinations.⁹

Educating Patients About the TBSE

The most helpful recommendation for successfully incorporating and performing the genital skin examination as part of the TBSE appears to be patient education. In a randomized double-arm study, patients who received pre-education consisting of written information explaining the need for a TBSE were less likely to be concerned about a genital examination compared to patients who received no information.³⁸ Discussing that skin diseases, including melanoma, can arise in all areas of the body including the genital skin and encouraging patients to perform genital self-examinations is critical.³⁵ In the age of the electronic health record and virtual communication, disseminating this information has become even easier.³⁹ It may be beneficial to explore patients’ TBSE expectations at the outset through these varied avenues to help establish a trusted physician-patient relationship.⁴⁰

Final Thoughts

Dermatologists should consistently offer a genital examination to all patients who present for a routine TBSE. Patients should be provided with adequate education to assess their comfort level for the skin examination. If a patient declines this examination, the dermatologist should ensure that another physician—be it a gynecologist, primary care provider, or other specialist—is routinely examining the area.^6,7

A casual survey of my dermatology co-residents yielded overwhelmingly unanimous results: A complete skin check goes from head to toe but does not routinely include an examination of the genital area. This observation contrasts starkly with the American Academy of Dermatology’s Basic Dermatology Curriculum, which recommends inspection of the entire skin surface including the mucous membranes (ie, eyes, mouth, anus, genital area) as part of the total-body skin examination (TBSE).¹ It even draws attention to so-called hidden areas where lesions easily can be missed, such as the perianal skin. My observation seems far from anecdotal; even a recent attempt at optimizing movements in the TBSE neglected to include examination of the genitalia in the proposed method,^2-4 and many practicing dermatologists seem to agree. A survey of international dermatologists at high-risk skin cancer clinics found male and female genitalia were the least frequently examined anatomy sites during the TBSE. Additionally, female genitalia were examined less frequently than male genitalia (labia majora, 28%; penis, 52%; P=.003).⁵ Another survey of US academic dermatologists (23 dermatologists, 1 nurse practitioner) found that only 4% always visually inspected the vulva during routine annual examinations, and 50% did not think that vulvar examination was the dermatologist’s responsibility.⁶ Similar findings were reported in a survey of US dermatology residents.⁷

Why is the genital area routinely omitted from the dermatologic TBSE? Based on the surveys of dermatologists and dermatology residents, the most common reason cited for not examining these sites was patient discomfort, but there also was a dominant belief that other specialties, such as gynecologists, urologists, or primary care providers, routinely examine these areas.^5,7 Time constraints also were a concern.

Although examination of sensitive areas can be uncomfortable,⁸ most patients still expect these locations to be examined during the TBSE. In a survey of 500 adults presenting for TBSE at an academic dermatology clinic, 84% of respondents expected the dermatologist to examine the genital area.⁹ Similarly, another survey of patient preferences (N=443) for the TBSE found that only 31.3% of women and 12.5% of men preferred not to have their genital area examined.¹⁰ As providers, we may be uncomfortable examining the genital area; however, our patients mostly expect it as part of routine practice. There are a number of barriers that may prevent incorporating the genital examination into daily dermatologic practice.

Training in Genital Examinations

Adequate training may be an issue for provider comfort when examining the genital skin. In a survey of dermatology residency program directors (n=38) and residents (n=91), 61.7% reported receiving formal instruction on TBSE technique and 38.3% reported being self-taught. Examination of the genital skin was included only 40% of the time.¹¹ Even vulvar disorder experts have admitted to receiving their training by self-teaching, with only 19% receiving vulvar training during residency and 11% during fellowship.¹² Improving this training appears to be an ongoing effort.²

Passing the Buck

It may be easier to think that another provider is routinely examining genital skin based on the relative absence of this area in dermatologic training; however, that does not appear to be the case. In a 1999 survey of primary care providers, only 31% reported performing skin cancer screenings on their adult patients, citing lack of confidence in this clinical skill as the biggest hurdle.¹³ Similarly, changes in recommendations for the utility of the screening pelvic examination in asymptomatic, average-risk, nonpregnant adult women have decreased the performance of this examination in actual practice.¹⁴ Reviews of resident training in vulvovaginal disease also have shown that although dermatology residents receive slightly less formal training hours on vulvar skin disease, they see more than double the number of patients with vulvar disease per year when compared to obstetrics and gynecology residents.¹⁵ In practice, dermatologists generally are more confident when evaluating vulvar pigmented lesions than gynecologists.⁶

The Importance of the Genital Examination

Looking past these barriers seems essential to providing the best dermatologic care, as there are a multitude of neoplastic and inflammatory dermatoses that can affect the genital skin. Furthermore, early diagnosis and treatment of these conditions potentially can limit morbidity and mortality as well as improve quality of life. Genital melanomas are a good example. Although they may be rare, it is well known that genital melanomas are associated with an aggressive disease course and have worse outcomes than melanomas found elsewhere on the body.^16,17 Increasing rates of genital and perianal keratinocyte carcinomas make including this as part of the TBSE even more important.¹⁸

We also should not forget that inflammatory conditions can routinely involve the genitals.^19-21 Although robust data are lacking, chronic vulvar concerns frequently are seen in the primary care setting. In one study in the United Kingdom, 52% of general practitioners surveyed saw more than 3 patients per month with vulvar concerns.²² Even in common dermatologic conditions such as psoriasis and lichen planus, genital involvement often is overlooked despite its relative frequency.^23-27 In one study, 60% of psoriasis patients with genital involvement had not had these lesions examined by a physician.²⁸

Theoretically, TBSEs that include genital examination would yield higher and earlier detection rates of neoplasms as well as inflammatory dermatoses.^29-32 Thus, there is real value in diagnosing ailments of the genital skin, and dermatologists are well prepared to manage these conditions. Consistently incorporating a genital examination within the TBSE is the first step.

An Approach to the Genital Skin Examination

As with the TBSE, no standardized protocol for the genital skin examination exists, and there is no consensus for how best to perform this evaluation. Ideally, both male and female patients should remove all clothing, including undergarments, though one study found patients preferred to keep undergarments on during the genital examination.^10,33,34

In general, adult female genital anatomy is best viewed with the patient in the supine position.^6,33,35 There is no clear agreement on the use of stirrups, and the decision to use these may be left to the discretion of the patient. One randomized clinical trial found that women undergoing routine gynecologic examination without stirrups reported less physical discomfort and had a reduced sense of vulnerability than women examined in stirrups.³⁶ During the female genital examination, the head of the bed ideally should be positioned at a 30° to 45° angle to allow the provider to maintain eye contact and face-to-face communication with the patient.³³ This positioning also facilitates the use of a handheld mirror to instruct patients on techniques for medication application as well as to point out sites of disease.

For adult males, the genital examination can be performed with the patient standing facing a seated examiner.³⁵ The patient’s gown should be raised to the level of the umbilicus to expose the entire genital region. Good lighting is essential. These recommendations apply mainly to adults, but helpful tips on how to approach evaluating prepubertal children in the dermatology clinic are available.³⁷

The presence of a chaperone also is optional for maximizing patient comfort but also may be helpful for providing medicolegal protection for the provider. It always should be offered regardless of patient gender. A dermatology study found that when patients were examined by a same-gender physician, women and men were more comfortable without a chaperone than with a chaperone, and patients generally preferred fewer bodies in the room during sensitive examinations.⁹

Educating Patients About the TBSE

The most helpful recommendation for successfully incorporating and performing the genital skin examination as part of the TBSE appears to be patient education. In a randomized double-arm study, patients who received pre-education consisting of written information explaining the need for a TBSE were less likely to be concerned about a genital examination compared to patients who received no information.³⁸ Discussing that skin diseases, including melanoma, can arise in all areas of the body including the genital skin and encouraging patients to perform genital self-examinations is critical.³⁵ In the age of the electronic health record and virtual communication, disseminating this information has become even easier.³⁹ It may be beneficial to explore patients’ TBSE expectations at the outset through these varied avenues to help establish a trusted physician-patient relationship.⁴⁰

Final Thoughts

Dermatologists should consistently offer a genital examination to all patients who present for a routine TBSE. Patients should be provided with adequate education to assess their comfort level for the skin examination. If a patient declines this examination, the dermatologist should ensure that another physician—be it a gynecologist, primary care provider, or other specialist—is routinely examining the area.^6,7

A casual survey of my dermatology co-residents yielded overwhelmingly unanimous results: A complete skin check goes from head to toe but does not routinely include an examination of the genital area. This observation contrasts starkly with the American Academy of Dermatology’s Basic Dermatology Curriculum, which recommends inspection of the entire skin surface including the mucous membranes (ie, eyes, mouth, anus, genital area) as part of the total-body skin examination (TBSE).¹ It even draws attention to so-called hidden areas where lesions easily can be missed, such as the perianal skin. My observation seems far from anecdotal; even a recent attempt at optimizing movements in the TBSE neglected to include examination of the genitalia in the proposed method,^2-4 and many practicing dermatologists seem to agree. A survey of international dermatologists at high-risk skin cancer clinics found male and female genitalia were the least frequently examined anatomy sites during the TBSE. Additionally, female genitalia were examined less frequently than male genitalia (labia majora, 28%; penis, 52%; P=.003).⁵ Another survey of US academic dermatologists (23 dermatologists, 1 nurse practitioner) found that only 4% always visually inspected the vulva during routine annual examinations, and 50% did not think that vulvar examination was the dermatologist’s responsibility.⁶ Similar findings were reported in a survey of US dermatology residents.⁷

Why is the genital area routinely omitted from the dermatologic TBSE? Based on the surveys of dermatologists and dermatology residents, the most common reason cited for not examining these sites was patient discomfort, but there also was a dominant belief that other specialties, such as gynecologists, urologists, or primary care providers, routinely examine these areas.^5,7 Time constraints also were a concern.

Although examination of sensitive areas can be uncomfortable,⁸ most patients still expect these locations to be examined during the TBSE. In a survey of 500 adults presenting for TBSE at an academic dermatology clinic, 84% of respondents expected the dermatologist to examine the genital area.⁹ Similarly, another survey of patient preferences (N=443) for the TBSE found that only 31.3% of women and 12.5% of men preferred not to have their genital area examined.¹⁰ As providers, we may be uncomfortable examining the genital area; however, our patients mostly expect it as part of routine practice. There are a number of barriers that may prevent incorporating the genital examination into daily dermatologic practice.

Training in Genital Examinations

Adequate training may be an issue for provider comfort when examining the genital skin. In a survey of dermatology residency program directors (n=38) and residents (n=91), 61.7% reported receiving formal instruction on TBSE technique and 38.3% reported being self-taught. Examination of the genital skin was included only 40% of the time.¹¹ Even vulvar disorder experts have admitted to receiving their training by self-teaching, with only 19% receiving vulvar training during residency and 11% during fellowship.¹² Improving this training appears to be an ongoing effort.²

Passing the Buck

It may be easier to think that another provider is routinely examining genital skin based on the relative absence of this area in dermatologic training; however, that does not appear to be the case. In a 1999 survey of primary care providers, only 31% reported performing skin cancer screenings on their adult patients, citing lack of confidence in this clinical skill as the biggest hurdle.¹³ Similarly, changes in recommendations for the utility of the screening pelvic examination in asymptomatic, average-risk, nonpregnant adult women have decreased the performance of this examination in actual practice.¹⁴ Reviews of resident training in vulvovaginal disease also have shown that although dermatology residents receive slightly less formal training hours on vulvar skin disease, they see more than double the number of patients with vulvar disease per year when compared to obstetrics and gynecology residents.¹⁵ In practice, dermatologists generally are more confident when evaluating vulvar pigmented lesions than gynecologists.⁶

The Importance of the Genital Examination

Looking past these barriers seems essential to providing the best dermatologic care, as there are a multitude of neoplastic and inflammatory dermatoses that can affect the genital skin. Furthermore, early diagnosis and treatment of these conditions potentially can limit morbidity and mortality as well as improve quality of life. Genital melanomas are a good example. Although they may be rare, it is well known that genital melanomas are associated with an aggressive disease course and have worse outcomes than melanomas found elsewhere on the body.^16,17 Increasing rates of genital and perianal keratinocyte carcinomas make including this as part of the TBSE even more important.¹⁸

We also should not forget that inflammatory conditions can routinely involve the genitals.^19-21 Although robust data are lacking, chronic vulvar concerns frequently are seen in the primary care setting. In one study in the United Kingdom, 52% of general practitioners surveyed saw more than 3 patients per month with vulvar concerns.²² Even in common dermatologic conditions such as psoriasis and lichen planus, genital involvement often is overlooked despite its relative frequency.^23-27 In one study, 60% of psoriasis patients with genital involvement had not had these lesions examined by a physician.²⁸

Theoretically, TBSEs that include genital examination would yield higher and earlier detection rates of neoplasms as well as inflammatory dermatoses.^29-32 Thus, there is real value in diagnosing ailments of the genital skin, and dermatologists are well prepared to manage these conditions. Consistently incorporating a genital examination within the TBSE is the first step.

An Approach to the Genital Skin Examination

As with the TBSE, no standardized protocol for the genital skin examination exists, and there is no consensus for how best to perform this evaluation. Ideally, both male and female patients should remove all clothing, including undergarments, though one study found patients preferred to keep undergarments on during the genital examination.^10,33,34

In general, adult female genital anatomy is best viewed with the patient in the supine position.^6,33,35 There is no clear agreement on the use of stirrups, and the decision to use these may be left to the discretion of the patient. One randomized clinical trial found that women undergoing routine gynecologic examination without stirrups reported less physical discomfort and had a reduced sense of vulnerability than women examined in stirrups.³⁶ During the female genital examination, the head of the bed ideally should be positioned at a 30° to 45° angle to allow the provider to maintain eye contact and face-to-face communication with the patient.³³ This positioning also facilitates the use of a handheld mirror to instruct patients on techniques for medication application as well as to point out sites of disease.

For adult males, the genital examination can be performed with the patient standing facing a seated examiner.³⁵ The patient’s gown should be raised to the level of the umbilicus to expose the entire genital region. Good lighting is essential. These recommendations apply mainly to adults, but helpful tips on how to approach evaluating prepubertal children in the dermatology clinic are available.³⁷

The presence of a chaperone also is optional for maximizing patient comfort but also may be helpful for providing medicolegal protection for the provider. It always should be offered regardless of patient gender. A dermatology study found that when patients were examined by a same-gender physician, women and men were more comfortable without a chaperone than with a chaperone, and patients generally preferred fewer bodies in the room during sensitive examinations.⁹

Educating Patients About the TBSE

The most helpful recommendation for successfully incorporating and performing the genital skin examination as part of the TBSE appears to be patient education. In a randomized double-arm study, patients who received pre-education consisting of written information explaining the need for a TBSE were less likely to be concerned about a genital examination compared to patients who received no information.³⁸ Discussing that skin diseases, including melanoma, can arise in all areas of the body including the genital skin and encouraging patients to perform genital self-examinations is critical.³⁵ In the age of the electronic health record and virtual communication, disseminating this information has become even easier.³⁹ It may be beneficial to explore patients’ TBSE expectations at the outset through these varied avenues to help establish a trusted physician-patient relationship.⁴⁰

Final Thoughts

Dermatologists should consistently offer a genital examination to all patients who present for a routine TBSE. Patients should be provided with adequate education to assess their comfort level for the skin examination. If a patient declines this examination, the dermatologist should ensure that another physician—be it a gynecologist, primary care provider, or other specialist—is routinely examining the area.^6,7

To the Editor:

Unilateral nevoid telangiectasia (UNT) is a rare cutaneous disease characterized by superficial telangiectases arranged in a unilateral linear pattern. First described by Alfred Blaschko in 1899, this rare disease has been reported in higher frequency in recent years, with approximately 100 cases published in the literature according to a PubMed search of articles indexed for MEDLINE using the term unilateral nevoid telangiectasia.¹ Unilateral nevoid telangiectasia can be congenital or acquired; occurs more commonly in women; and typically involves the dermatomal distributions of the trigeminal, cervical, and upper thoracic nerves. Although the pathogenesis of the disease remains unknown, the currently proposed etiology involves hyperestrogenic states, including puberty, pregnancy, and chronic liver disease.² We report a case of progressively worsening, pruritic, unilateral telangiectases of unknown etiology.

A 55-year-old woman presented to our dermatology clinic with progressive red spots involving the right side of the upper body of 3 years’ duration. She noted pruritus, and the rash was otherwise asymptomatic. Her medical history was notable for hypertension, dyspepsia, sciatica, uterine fibroids, and a hysterectomy. Her medications included lisinopril, hydrochlorothiazide, tramadol, aspirin, and a multivitamin. The patient did not report the use of oral contraceptive pills or hormone replacement therapy. She also denied the use of cigarettes or illicit drugs but reported occasional alcohol consumption. A review of systems was negative for any constitutional symptoms or symptoms of liver disease. Her family history also was noncontributory.

Physical examination revealed multiple, 1- to 3-mm, telangiectatic macules and patches in a blaschkoid distribution on the right side of the upper chest, back, shoulder, and arm (Figure, A–C). Darier sign was negative. There was no evidence of palmar erythema, hepatosplenomegaly, ascites, thyromegaly, or thyroid nodules. Dermoscopy confirmed the presence of telangiectasia (Figure, D). More specifically, dermoscopy revealed plump telangiectasia with faint pigment in the background, consistent with UNT. Additionally, there was no pink-white, shiny, scarlike background, and vessels were not thin or arborized, further supporting our diagnosis vs other entities included in the differential diagnosis.

Our case provides another unique presentation of UNT. Our patient was a healthy adult woman with no hyperestrogen-based etiology for disease. Importantly, our patient also represented a rare instance of UNT presenting with symptoms such as pruritus, though UNT classically is described as an asymptomatic phenomenon. In our patient, treatment with PDL was suggested and believed to be warranted not only for cosmetic improvement but also in light of the fact that her lesions were symptomatic.

To the Editor:

Unilateral nevoid telangiectasia (UNT) is a rare cutaneous disease characterized by superficial telangiectases arranged in a unilateral linear pattern. First described by Alfred Blaschko in 1899, this rare disease has been reported in higher frequency in recent years, with approximately 100 cases published in the literature according to a PubMed search of articles indexed for MEDLINE using the term unilateral nevoid telangiectasia.¹ Unilateral nevoid telangiectasia can be congenital or acquired; occurs more commonly in women; and typically involves the dermatomal distributions of the trigeminal, cervical, and upper thoracic nerves. Although the pathogenesis of the disease remains unknown, the currently proposed etiology involves hyperestrogenic states, including puberty, pregnancy, and chronic liver disease.² We report a case of progressively worsening, pruritic, unilateral telangiectases of unknown etiology.

A 55-year-old woman presented to our dermatology clinic with progressive red spots involving the right side of the upper body of 3 years’ duration. She noted pruritus, and the rash was otherwise asymptomatic. Her medical history was notable for hypertension, dyspepsia, sciatica, uterine fibroids, and a hysterectomy. Her medications included lisinopril, hydrochlorothiazide, tramadol, aspirin, and a multivitamin. The patient did not report the use of oral contraceptive pills or hormone replacement therapy. She also denied the use of cigarettes or illicit drugs but reported occasional alcohol consumption. A review of systems was negative for any constitutional symptoms or symptoms of liver disease. Her family history also was noncontributory.

Physical examination revealed multiple, 1- to 3-mm, telangiectatic macules and patches in a blaschkoid distribution on the right side of the upper chest, back, shoulder, and arm (Figure, A–C). Darier sign was negative. There was no evidence of palmar erythema, hepatosplenomegaly, ascites, thyromegaly, or thyroid nodules. Dermoscopy confirmed the presence of telangiectasia (Figure, D). More specifically, dermoscopy revealed plump telangiectasia with faint pigment in the background, consistent with UNT. Additionally, there was no pink-white, shiny, scarlike background, and vessels were not thin or arborized, further supporting our diagnosis vs other entities included in the differential diagnosis.

Our case provides another unique presentation of UNT. Our patient was a healthy adult woman with no hyperestrogen-based etiology for disease. Importantly, our patient also represented a rare instance of UNT presenting with symptoms such as pruritus, though UNT classically is described as an asymptomatic phenomenon. In our patient, treatment with PDL was suggested and believed to be warranted not only for cosmetic improvement but also in light of the fact that her lesions were symptomatic.

To the Editor:

Unilateral nevoid telangiectasia (UNT) is a rare cutaneous disease characterized by superficial telangiectases arranged in a unilateral linear pattern. First described by Alfred Blaschko in 1899, this rare disease has been reported in higher frequency in recent years, with approximately 100 cases published in the literature according to a PubMed search of articles indexed for MEDLINE using the term unilateral nevoid telangiectasia.¹ Unilateral nevoid telangiectasia can be congenital or acquired; occurs more commonly in women; and typically involves the dermatomal distributions of the trigeminal, cervical, and upper thoracic nerves. Although the pathogenesis of the disease remains unknown, the currently proposed etiology involves hyperestrogenic states, including puberty, pregnancy, and chronic liver disease.² We report a case of progressively worsening, pruritic, unilateral telangiectases of unknown etiology.

A 55-year-old woman presented to our dermatology clinic with progressive red spots involving the right side of the upper body of 3 years’ duration. She noted pruritus, and the rash was otherwise asymptomatic. Her medical history was notable for hypertension, dyspepsia, sciatica, uterine fibroids, and a hysterectomy. Her medications included lisinopril, hydrochlorothiazide, tramadol, aspirin, and a multivitamin. The patient did not report the use of oral contraceptive pills or hormone replacement therapy. She also denied the use of cigarettes or illicit drugs but reported occasional alcohol consumption. A review of systems was negative for any constitutional symptoms or symptoms of liver disease. Her family history also was noncontributory.

Physical examination revealed multiple, 1- to 3-mm, telangiectatic macules and patches in a blaschkoid distribution on the right side of the upper chest, back, shoulder, and arm (Figure, A–C). Darier sign was negative. There was no evidence of palmar erythema, hepatosplenomegaly, ascites, thyromegaly, or thyroid nodules. Dermoscopy confirmed the presence of telangiectasia (Figure, D). More specifically, dermoscopy revealed plump telangiectasia with faint pigment in the background, consistent with UNT. Additionally, there was no pink-white, shiny, scarlike background, and vessels were not thin or arborized, further supporting our diagnosis vs other entities included in the differential diagnosis.

Our case provides another unique presentation of UNT. Our patient was a healthy adult woman with no hyperestrogen-based etiology for disease. Importantly, our patient also represented a rare instance of UNT presenting with symptoms such as pruritus, though UNT classically is described as an asymptomatic phenomenon. In our patient, treatment with PDL was suggested and believed to be warranted not only for cosmetic improvement but also in light of the fact that her lesions were symptomatic.

The Diagnosis: Cutaneous Metaplastic Synovial Cyst 

Gross examination of the excised nodule revealed a 2.5×1.2×1.0-cm, intact, gray-white, thin-walled, smooth-lined nodule filled with clear mucinouslike material. Hematoxylin and eosin-stained sections demonstrated a dermal-based cystlike structure composed of a lining of connective tissue with hyalinized material and fibrin as well as spindle and epithelioid cells with a mild mixed inflammatory infiltrate (Figure). These histopathologic findings led to the diagnosis of cutaneous metaplastic synovial cyst (CMSC).  

Cutaneous metaplastic synovial cyst, also known as synovial metaplasia of the skin, is an uncommon benign cystic lesion that was first reported by Gonzalez et al¹ in 1987. Histologically, CMSC lacks an epithelial lining and therefore is not a true cyst but rather a pseudocyst.² Clinically, the lesion typically presents as a solitary subcutaneous nodule that may be tender or painless. In a literature review of CMSC cases performed by Fukuyama et al,³ distribution of reported cases according to body site varied; however, limbs were found to be the most commonly involved area. A PubMed search of articles indexed for MEDLINE as well as a Google Scholar search using the term cutaneous metaplastic synovial cyst revealed at least 37 cases reported in the English-language literature,^3-9 including our present case. The pathogenesis remains uncertain; however, a majority of previously reported cases of CMSC characteristically have been associated with a pre-existing lesion, with most presentations developing at surgical scar sites secondary to operation or trauma.⁵ Relative tissue fragility secondary to rheumatoid arthritis¹⁰ and Ehlers-Danlos syndrome^9,11,12 has been linked to CMSC in some documented reports, while a minority of cases report no antecedent events triggering formation of the lesion.^13-15 

As evidenced by our patient, CMSC clinically mimics several other benign entities; histopathologic examination is necessary to confirm the diagnosis. Although nodular hidradenoma also may clinically present as a solitary firm intradermal nodule, microscopy reveals a dermal-based lobulated tumor containing cystic spaces and solid areas composed of basophilic polyhedral cells and round glycogen-filled clear cells.¹⁶ Epidermoid cysts are differentiated from CMSC by the presence of a cyst wall lining composed of stratified squamous epithelium and associated laminated keratin within the lumen,¹⁷ which corresponds to its pearly white appearance on gross examination. Cutaneous ciliated cysts predominantly occur on the lower extremities of young women and are lined by simple cuboidal or columnar ciliated cells that resemble müllerian epithelium.¹⁸ Similar to CMSC, ganglion cysts are pseudocysts that lack a true epithelial lining but differ in appearance due to their mucin-filled synovial-lined sac.¹⁹ Additionally, ganglion cysts most often occur on the dorsal and volar aspects of the wrist. 

Excisional biopsy is indicated as the preferred treatment of CMSC, given the lesion's benign behavior and low recurrence rate.⁶ Our case highlights this rare entity and reinforces its inclusion in the differential diagnosis of subcutaneous mobile nodules, especially in the setting of prior tissue injury secondary to trauma, surgical procedures, or conditions such as rheumatoid arthritis or Ehlers-Danlos syndrome. Unlike most previously reported cases, our patient reported no preceding tissue injury associated with formation of the lesion, and she was largely asymptomatic on presentation. Considering the limited number of CMSC cases demonstrated in the literature, it is important to continue reporting new cases to better understand characteristics and presentations of this uncommon lesion. 

The Diagnosis: Cutaneous Metaplastic Synovial Cyst 

Gross examination of the excised nodule revealed a 2.5×1.2×1.0-cm, intact, gray-white, thin-walled, smooth-lined nodule filled with clear mucinouslike material. Hematoxylin and eosin-stained sections demonstrated a dermal-based cystlike structure composed of a lining of connective tissue with hyalinized material and fibrin as well as spindle and epithelioid cells with a mild mixed inflammatory infiltrate (Figure). These histopathologic findings led to the diagnosis of cutaneous metaplastic synovial cyst (CMSC).  

Cutaneous metaplastic synovial cyst, also known as synovial metaplasia of the skin, is an uncommon benign cystic lesion that was first reported by Gonzalez et al¹ in 1987. Histologically, CMSC lacks an epithelial lining and therefore is not a true cyst but rather a pseudocyst.² Clinically, the lesion typically presents as a solitary subcutaneous nodule that may be tender or painless. In a literature review of CMSC cases performed by Fukuyama et al,³ distribution of reported cases according to body site varied; however, limbs were found to be the most commonly involved area. A PubMed search of articles indexed for MEDLINE as well as a Google Scholar search using the term cutaneous metaplastic synovial cyst revealed at least 37 cases reported in the English-language literature,^3-9 including our present case. The pathogenesis remains uncertain; however, a majority of previously reported cases of CMSC characteristically have been associated with a pre-existing lesion, with most presentations developing at surgical scar sites secondary to operation or trauma.⁵ Relative tissue fragility secondary to rheumatoid arthritis¹⁰ and Ehlers-Danlos syndrome^9,11,12 has been linked to CMSC in some documented reports, while a minority of cases report no antecedent events triggering formation of the lesion.^13-15 

As evidenced by our patient, CMSC clinically mimics several other benign entities; histopathologic examination is necessary to confirm the diagnosis. Although nodular hidradenoma also may clinically present as a solitary firm intradermal nodule, microscopy reveals a dermal-based lobulated tumor containing cystic spaces and solid areas composed of basophilic polyhedral cells and round glycogen-filled clear cells.¹⁶ Epidermoid cysts are differentiated from CMSC by the presence of a cyst wall lining composed of stratified squamous epithelium and associated laminated keratin within the lumen,¹⁷ which corresponds to its pearly white appearance on gross examination. Cutaneous ciliated cysts predominantly occur on the lower extremities of young women and are lined by simple cuboidal or columnar ciliated cells that resemble müllerian epithelium.¹⁸ Similar to CMSC, ganglion cysts are pseudocysts that lack a true epithelial lining but differ in appearance due to their mucin-filled synovial-lined sac.¹⁹ Additionally, ganglion cysts most often occur on the dorsal and volar aspects of the wrist. 

Excisional biopsy is indicated as the preferred treatment of CMSC, given the lesion's benign behavior and low recurrence rate.⁶ Our case highlights this rare entity and reinforces its inclusion in the differential diagnosis of subcutaneous mobile nodules, especially in the setting of prior tissue injury secondary to trauma, surgical procedures, or conditions such as rheumatoid arthritis or Ehlers-Danlos syndrome. Unlike most previously reported cases, our patient reported no preceding tissue injury associated with formation of the lesion, and she was largely asymptomatic on presentation. Considering the limited number of CMSC cases demonstrated in the literature, it is important to continue reporting new cases to better understand characteristics and presentations of this uncommon lesion. 

The Diagnosis: Cutaneous Metaplastic Synovial Cyst 

Gross examination of the excised nodule revealed a 2.5×1.2×1.0-cm, intact, gray-white, thin-walled, smooth-lined nodule filled with clear mucinouslike material. Hematoxylin and eosin-stained sections demonstrated a dermal-based cystlike structure composed of a lining of connective tissue with hyalinized material and fibrin as well as spindle and epithelioid cells with a mild mixed inflammatory infiltrate (Figure). These histopathologic findings led to the diagnosis of cutaneous metaplastic synovial cyst (CMSC).  

Cutaneous metaplastic synovial cyst, also known as synovial metaplasia of the skin, is an uncommon benign cystic lesion that was first reported by Gonzalez et al¹ in 1987. Histologically, CMSC lacks an epithelial lining and therefore is not a true cyst but rather a pseudocyst.² Clinically, the lesion typically presents as a solitary subcutaneous nodule that may be tender or painless. In a literature review of CMSC cases performed by Fukuyama et al,³ distribution of reported cases according to body site varied; however, limbs were found to be the most commonly involved area. A PubMed search of articles indexed for MEDLINE as well as a Google Scholar search using the term cutaneous metaplastic synovial cyst revealed at least 37 cases reported in the English-language literature,^3-9 including our present case. The pathogenesis remains uncertain; however, a majority of previously reported cases of CMSC characteristically have been associated with a pre-existing lesion, with most presentations developing at surgical scar sites secondary to operation or trauma.⁵ Relative tissue fragility secondary to rheumatoid arthritis¹⁰ and Ehlers-Danlos syndrome^9,11,12 has been linked to CMSC in some documented reports, while a minority of cases report no antecedent events triggering formation of the lesion.^13-15 

As evidenced by our patient, CMSC clinically mimics several other benign entities; histopathologic examination is necessary to confirm the diagnosis. Although nodular hidradenoma also may clinically present as a solitary firm intradermal nodule, microscopy reveals a dermal-based lobulated tumor containing cystic spaces and solid areas composed of basophilic polyhedral cells and round glycogen-filled clear cells.¹⁶ Epidermoid cysts are differentiated from CMSC by the presence of a cyst wall lining composed of stratified squamous epithelium and associated laminated keratin within the lumen,¹⁷ which corresponds to its pearly white appearance on gross examination. Cutaneous ciliated cysts predominantly occur on the lower extremities of young women and are lined by simple cuboidal or columnar ciliated cells that resemble müllerian epithelium.¹⁸ Similar to CMSC, ganglion cysts are pseudocysts that lack a true epithelial lining but differ in appearance due to their mucin-filled synovial-lined sac.¹⁹ Additionally, ganglion cysts most often occur on the dorsal and volar aspects of the wrist. 

Excisional biopsy is indicated as the preferred treatment of CMSC, given the lesion's benign behavior and low recurrence rate.⁶ Our case highlights this rare entity and reinforces its inclusion in the differential diagnosis of subcutaneous mobile nodules, especially in the setting of prior tissue injury secondary to trauma, surgical procedures, or conditions such as rheumatoid arthritis or Ehlers-Danlos syndrome. Unlike most previously reported cases, our patient reported no preceding tissue injury associated with formation of the lesion, and she was largely asymptomatic on presentation. Considering the limited number of CMSC cases demonstrated in the literature, it is important to continue reporting new cases to better understand characteristics and presentations of this uncommon lesion. 

To the Editor:

The evolution in the understanding of psoriasis and psoriatic arthritis has unfolded many new facets of this immune-mediated inflammatory disease. Once considered to be just a cutaneous disease, psoriasis is not actually confined to skin but can involve almost any other system of the body. Cardiovascular morbidity and mortality are the major concerns in patients with psoriasis. We report the sudden death of a young man with severe psoriasis.

A 31-year-old man was admitted for severe psoriasis with pustular exacerbation (Figures 1A and 1B). He had moderate to severe unstable disease during the last 8 years and was managed with oral methotrexate (0.3–0.5 mg/kg/wk). He was not compliant with treatment, which led to multiple relapses. There was no personal or family history of risk factors for cardiovascular events (CVEs). At the time of present hospitalization, his vital parameters were normal. Physical examination revealed erythematous scaly plaques on more than 75% of the body surface area. Multiple pustules also were noted, often coalescing to form plaques (Figure 1C). Baseline investigations consisting of complete blood cell count, lipid profile, liver and renal functions, and chest radiography were within reference range. Baseline electrocardiogram (ECG) at admission was unremarkable (Figure 2A), except for sinus tachycardia. Low-voltage complexes in limb leads were appreciated as well as a corrected QT interval of 420 milliseconds (within reference range). Echocardiography was normal (visual ejection fraction of 60%).

The patient was unable to tolerate methotrexate due to excessive nausea; he was started on oral acitretin 25 mg once daily. There was no improvement in psoriasis over the following week, and he reported mild upper abdominal discomfort. He did not have any chest pain or dyspnea, and his pulse and blood pressure were normal. Serum electrolytes, liver function, lipid profile, and an ultrasound of the abdomen revealed no abnormalities. A repeat ECG showed no changes, and cardiac biomarkers were not elevated. Two days later, the patient collapsed while still in the hospital. A cardiac monitor and ECG showed ventricular tachycardia (VT)(Figure 2B); however, serum electrolytes, calcium, magnesium, and phosphorus levels were within reference range. Aggressive resuscitative measures including multiple attempts at cardioversion with up to 200 J (biphasic) and intravenous amiodarone infusion failed to revive the patient, and he died.

Proinflammatory cytokines such as IL-6 and tumor necrosis factor α are increased in young people with ventricular arrhythmias who have no evidence of myocardial injury (MI), suggesting an inflammatory background is involved.¹ Psoriasis, a common immune-mediated inflammatory disease, has a chronic state of systemic inflammation with notably higher serum levels of tumor necrosis factor α, IFN-γ, IL-6, IL-8, IL-12, and IL-18 compared to controls.² This inflammation is not confined to skin but can involve blood vessels, joints, and the liver, as demonstrated by increased fluorodeoxyglucose uptake.³ It also seems to exert its influence on supraventricular beat development in patients with psoriasis who do not have a history of CVEs.⁴ Tumor necrosis factor α is one of the major cytokines playing a role in the inflammatory process of psoriasis. Studies have shown serum levels of tumor necrosis factor α to correlate with the clinical symptoms of heart failure and to supraventricular arrhythmia in animal models.⁴ Various extreme CVEs can be an expression of this ongoing dynamic process. It would be interesting to know which specific factors among these inflammatory cytokines lead to rhythm irregularities.

Another theory is that young patients may experience micro-MI during the disease course. These small infarcted areas may act as aberrant pulse generators or lead to conduction disturbances. One study found increased correct QT interval dispersion, a predictor of ventricular arrhythmias, to be associated with psoriasis.⁵ A nationwide population-based matched cohort study by Chiu et al⁶ revealed that patients with psoriasis have a higher risk for arrhythmia independent of traditional cardiovascular risk factors. Our patient also had severe unstable psoriasis for 8 years that may have led to increased accumulation of proarrhythmogenic cytokines in the heart and could have led to VT.

Acitretin as a potential cause of sudden cardiac death remains a possibility in our case; however, the exact mechanism leading to such sudden arrhythmia is lacking. Acitretin is known to increase serum triglycerides and cholesterol, specifically by shifting high-density lipoproteins to low-density lipoproteins, thereby increasing the risk for CVE. However, it takes time for such derangement to occur, eventually leading to CVE. Mittal et al⁷ reported a psoriasis patient who died secondary to MI after 5 days of low-dose acitretin. Lack of evidence makes acitretin a less likely cause of mortality.

We present a case of sudden cardiac death secondary to VT in a young patient with psoriasis and no other traditional cardiovascular risk factors. This case highlights the importance of being vigilant for adverse CVEs such as arrhythmia in psoriatic patients, especially in younger patients with severe unstable disease.

To the Editor:

The evolution in the understanding of psoriasis and psoriatic arthritis has unfolded many new facets of this immune-mediated inflammatory disease. Once considered to be just a cutaneous disease, psoriasis is not actually confined to skin but can involve almost any other system of the body. Cardiovascular morbidity and mortality are the major concerns in patients with psoriasis. We report the sudden death of a young man with severe psoriasis.

A 31-year-old man was admitted for severe psoriasis with pustular exacerbation (Figures 1A and 1B). He had moderate to severe unstable disease during the last 8 years and was managed with oral methotrexate (0.3–0.5 mg/kg/wk). He was not compliant with treatment, which led to multiple relapses. There was no personal or family history of risk factors for cardiovascular events (CVEs). At the time of present hospitalization, his vital parameters were normal. Physical examination revealed erythematous scaly plaques on more than 75% of the body surface area. Multiple pustules also were noted, often coalescing to form plaques (Figure 1C). Baseline investigations consisting of complete blood cell count, lipid profile, liver and renal functions, and chest radiography were within reference range. Baseline electrocardiogram (ECG) at admission was unremarkable (Figure 2A), except for sinus tachycardia. Low-voltage complexes in limb leads were appreciated as well as a corrected QT interval of 420 milliseconds (within reference range). Echocardiography was normal (visual ejection fraction of 60%).

The patient was unable to tolerate methotrexate due to excessive nausea; he was started on oral acitretin 25 mg once daily. There was no improvement in psoriasis over the following week, and he reported mild upper abdominal discomfort. He did not have any chest pain or dyspnea, and his pulse and blood pressure were normal. Serum electrolytes, liver function, lipid profile, and an ultrasound of the abdomen revealed no abnormalities. A repeat ECG showed no changes, and cardiac biomarkers were not elevated. Two days later, the patient collapsed while still in the hospital. A cardiac monitor and ECG showed ventricular tachycardia (VT)(Figure 2B); however, serum electrolytes, calcium, magnesium, and phosphorus levels were within reference range. Aggressive resuscitative measures including multiple attempts at cardioversion with up to 200 J (biphasic) and intravenous amiodarone infusion failed to revive the patient, and he died.

Proinflammatory cytokines such as IL-6 and tumor necrosis factor α are increased in young people with ventricular arrhythmias who have no evidence of myocardial injury (MI), suggesting an inflammatory background is involved.¹ Psoriasis, a common immune-mediated inflammatory disease, has a chronic state of systemic inflammation with notably higher serum levels of tumor necrosis factor α, IFN-γ, IL-6, IL-8, IL-12, and IL-18 compared to controls.² This inflammation is not confined to skin but can involve blood vessels, joints, and the liver, as demonstrated by increased fluorodeoxyglucose uptake.³ It also seems to exert its influence on supraventricular beat development in patients with psoriasis who do not have a history of CVEs.⁴ Tumor necrosis factor α is one of the major cytokines playing a role in the inflammatory process of psoriasis. Studies have shown serum levels of tumor necrosis factor α to correlate with the clinical symptoms of heart failure and to supraventricular arrhythmia in animal models.⁴ Various extreme CVEs can be an expression of this ongoing dynamic process. It would be interesting to know which specific factors among these inflammatory cytokines lead to rhythm irregularities.

Another theory is that young patients may experience micro-MI during the disease course. These small infarcted areas may act as aberrant pulse generators or lead to conduction disturbances. One study found increased correct QT interval dispersion, a predictor of ventricular arrhythmias, to be associated with psoriasis.⁵ A nationwide population-based matched cohort study by Chiu et al⁶ revealed that patients with psoriasis have a higher risk for arrhythmia independent of traditional cardiovascular risk factors. Our patient also had severe unstable psoriasis for 8 years that may have led to increased accumulation of proarrhythmogenic cytokines in the heart and could have led to VT.

Acitretin as a potential cause of sudden cardiac death remains a possibility in our case; however, the exact mechanism leading to such sudden arrhythmia is lacking. Acitretin is known to increase serum triglycerides and cholesterol, specifically by shifting high-density lipoproteins to low-density lipoproteins, thereby increasing the risk for CVE. However, it takes time for such derangement to occur, eventually leading to CVE. Mittal et al⁷ reported a psoriasis patient who died secondary to MI after 5 days of low-dose acitretin. Lack of evidence makes acitretin a less likely cause of mortality.

We present a case of sudden cardiac death secondary to VT in a young patient with psoriasis and no other traditional cardiovascular risk factors. This case highlights the importance of being vigilant for adverse CVEs such as arrhythmia in psoriatic patients, especially in younger patients with severe unstable disease.

To the Editor:

The evolution in the understanding of psoriasis and psoriatic arthritis has unfolded many new facets of this immune-mediated inflammatory disease. Once considered to be just a cutaneous disease, psoriasis is not actually confined to skin but can involve almost any other system of the body. Cardiovascular morbidity and mortality are the major concerns in patients with psoriasis. We report the sudden death of a young man with severe psoriasis.

A 31-year-old man was admitted for severe psoriasis with pustular exacerbation (Figures 1A and 1B). He had moderate to severe unstable disease during the last 8 years and was managed with oral methotrexate (0.3–0.5 mg/kg/wk). He was not compliant with treatment, which led to multiple relapses. There was no personal or family history of risk factors for cardiovascular events (CVEs). At the time of present hospitalization, his vital parameters were normal. Physical examination revealed erythematous scaly plaques on more than 75% of the body surface area. Multiple pustules also were noted, often coalescing to form plaques (Figure 1C). Baseline investigations consisting of complete blood cell count, lipid profile, liver and renal functions, and chest radiography were within reference range. Baseline electrocardiogram (ECG) at admission was unremarkable (Figure 2A), except for sinus tachycardia. Low-voltage complexes in limb leads were appreciated as well as a corrected QT interval of 420 milliseconds (within reference range). Echocardiography was normal (visual ejection fraction of 60%).

The patient was unable to tolerate methotrexate due to excessive nausea; he was started on oral acitretin 25 mg once daily. There was no improvement in psoriasis over the following week, and he reported mild upper abdominal discomfort. He did not have any chest pain or dyspnea, and his pulse and blood pressure were normal. Serum electrolytes, liver function, lipid profile, and an ultrasound of the abdomen revealed no abnormalities. A repeat ECG showed no changes, and cardiac biomarkers were not elevated. Two days later, the patient collapsed while still in the hospital. A cardiac monitor and ECG showed ventricular tachycardia (VT)(Figure 2B); however, serum electrolytes, calcium, magnesium, and phosphorus levels were within reference range. Aggressive resuscitative measures including multiple attempts at cardioversion with up to 200 J (biphasic) and intravenous amiodarone infusion failed to revive the patient, and he died.

Proinflammatory cytokines such as IL-6 and tumor necrosis factor α are increased in young people with ventricular arrhythmias who have no evidence of myocardial injury (MI), suggesting an inflammatory background is involved.¹ Psoriasis, a common immune-mediated inflammatory disease, has a chronic state of systemic inflammation with notably higher serum levels of tumor necrosis factor α, IFN-γ, IL-6, IL-8, IL-12, and IL-18 compared to controls.² This inflammation is not confined to skin but can involve blood vessels, joints, and the liver, as demonstrated by increased fluorodeoxyglucose uptake.³ It also seems to exert its influence on supraventricular beat development in patients with psoriasis who do not have a history of CVEs.⁴ Tumor necrosis factor α is one of the major cytokines playing a role in the inflammatory process of psoriasis. Studies have shown serum levels of tumor necrosis factor α to correlate with the clinical symptoms of heart failure and to supraventricular arrhythmia in animal models.⁴ Various extreme CVEs can be an expression of this ongoing dynamic process. It would be interesting to know which specific factors among these inflammatory cytokines lead to rhythm irregularities.

Another theory is that young patients may experience micro-MI during the disease course. These small infarcted areas may act as aberrant pulse generators or lead to conduction disturbances. One study found increased correct QT interval dispersion, a predictor of ventricular arrhythmias, to be associated with psoriasis.⁵ A nationwide population-based matched cohort study by Chiu et al⁶ revealed that patients with psoriasis have a higher risk for arrhythmia independent of traditional cardiovascular risk factors. Our patient also had severe unstable psoriasis for 8 years that may have led to increased accumulation of proarrhythmogenic cytokines in the heart and could have led to VT.

Acitretin as a potential cause of sudden cardiac death remains a possibility in our case; however, the exact mechanism leading to such sudden arrhythmia is lacking. Acitretin is known to increase serum triglycerides and cholesterol, specifically by shifting high-density lipoproteins to low-density lipoproteins, thereby increasing the risk for CVE. However, it takes time for such derangement to occur, eventually leading to CVE. Mittal et al⁷ reported a psoriasis patient who died secondary to MI after 5 days of low-dose acitretin. Lack of evidence makes acitretin a less likely cause of mortality.

We present a case of sudden cardiac death secondary to VT in a young patient with psoriasis and no other traditional cardiovascular risk factors. This case highlights the importance of being vigilant for adverse CVEs such as arrhythmia in psoriatic patients, especially in younger patients with severe unstable disease.

To the Editor:

We report the case of an 83-year-old male nursing home resident with a history of end-stage renal disease who presented with multiple small white islands on the surface of the nail plate, similar to those seen in white superficial onychomycosis (Figure 1). Minimal subungual hyperkeratosis of the fingernails also was observed. Three digits were affected with no toenail involvement. Wet mount examination with potassium hydroxide 20% showed a mite (Figure 2A) and multiple eggs (Figure 2B). Treatment consisted of oral ivermectin 3 mg immediately and permethrin solution 5% applied under occlusion to each of the affected nails for 5 consecutive nights, which resulted in complete clearance of the lesion on the nail plate after 2 weeks.

Crusted scabies was first described as Norwegian scabies in 1848 by Danielsen and Boeck,¹ and the name was later changed to crusted scabies in 1976 by Parish and Lumholt² because there was no inherent connection between Norway and Norwegian scabies. It is a skin infestation of Sarcoptes scabiei var hominis and more commonly is seen in immunocompromised individuals such as the elderly and malnourished patients as well as those with diabetes mellitus and alcoholism.^3,4 Patients typically present with widespread hyperkeratosis, mostly involving the palms and soles. Subungual hyperkeratosis and nail dystrophy also can be seen when nail involvement is present, and the scalp rarely is involved.⁵ Unlike common scabies, skin burrows and pruritus may be minimal or absent, thus making the diagnosis of crusted scabies more difficult than normal scabies.⁶ Diagnosis of crusted scabies is confirmed by direct microscopy, which demonstrates mites, eggs, or feces. Strict isolation of the patient is necessary, as the disease is very contagious. Treatment with oral ivermectin (1–3 doses of 3 mg at 14-day intervals) in combination with topical permethrin is effective.⁷

We present a case of crusted scabies with nail involvement that presented with white superficial onychomycosislike lesions. The patient’s nails were successfully treated with a combination of oral ivermectin and topical permethrin occlusion of the nails. In cases with subungual hyperkeratosis, nonsurgical nail avulsion with 40% urea cream or ointment has been used to improve the penetration of permethrin. Partial nail avulsion may be necessary if subungual hyperkeratosis or nail dystrophy becomes extreme.⁸

To the Editor:

We report the case of an 83-year-old male nursing home resident with a history of end-stage renal disease who presented with multiple small white islands on the surface of the nail plate, similar to those seen in white superficial onychomycosis (Figure 1). Minimal subungual hyperkeratosis of the fingernails also was observed. Three digits were affected with no toenail involvement. Wet mount examination with potassium hydroxide 20% showed a mite (Figure 2A) and multiple eggs (Figure 2B). Treatment consisted of oral ivermectin 3 mg immediately and permethrin solution 5% applied under occlusion to each of the affected nails for 5 consecutive nights, which resulted in complete clearance of the lesion on the nail plate after 2 weeks.

Crusted scabies was first described as Norwegian scabies in 1848 by Danielsen and Boeck,¹ and the name was later changed to crusted scabies in 1976 by Parish and Lumholt² because there was no inherent connection between Norway and Norwegian scabies. It is a skin infestation of Sarcoptes scabiei var hominis and more commonly is seen in immunocompromised individuals such as the elderly and malnourished patients as well as those with diabetes mellitus and alcoholism.^3,4 Patients typically present with widespread hyperkeratosis, mostly involving the palms and soles. Subungual hyperkeratosis and nail dystrophy also can be seen when nail involvement is present, and the scalp rarely is involved.⁵ Unlike common scabies, skin burrows and pruritus may be minimal or absent, thus making the diagnosis of crusted scabies more difficult than normal scabies.⁶ Diagnosis of crusted scabies is confirmed by direct microscopy, which demonstrates mites, eggs, or feces. Strict isolation of the patient is necessary, as the disease is very contagious. Treatment with oral ivermectin (1–3 doses of 3 mg at 14-day intervals) in combination with topical permethrin is effective.⁷

We present a case of crusted scabies with nail involvement that presented with white superficial onychomycosislike lesions. The patient’s nails were successfully treated with a combination of oral ivermectin and topical permethrin occlusion of the nails. In cases with subungual hyperkeratosis, nonsurgical nail avulsion with 40% urea cream or ointment has been used to improve the penetration of permethrin. Partial nail avulsion may be necessary if subungual hyperkeratosis or nail dystrophy becomes extreme.⁸

To the Editor:

We report the case of an 83-year-old male nursing home resident with a history of end-stage renal disease who presented with multiple small white islands on the surface of the nail plate, similar to those seen in white superficial onychomycosis (Figure 1). Minimal subungual hyperkeratosis of the fingernails also was observed. Three digits were affected with no toenail involvement. Wet mount examination with potassium hydroxide 20% showed a mite (Figure 2A) and multiple eggs (Figure 2B). Treatment consisted of oral ivermectin 3 mg immediately and permethrin solution 5% applied under occlusion to each of the affected nails for 5 consecutive nights, which resulted in complete clearance of the lesion on the nail plate after 2 weeks.

Crusted scabies was first described as Norwegian scabies in 1848 by Danielsen and Boeck,¹ and the name was later changed to crusted scabies in 1976 by Parish and Lumholt² because there was no inherent connection between Norway and Norwegian scabies. It is a skin infestation of Sarcoptes scabiei var hominis and more commonly is seen in immunocompromised individuals such as the elderly and malnourished patients as well as those with diabetes mellitus and alcoholism.^3,4 Patients typically present with widespread hyperkeratosis, mostly involving the palms and soles. Subungual hyperkeratosis and nail dystrophy also can be seen when nail involvement is present, and the scalp rarely is involved.⁵ Unlike common scabies, skin burrows and pruritus may be minimal or absent, thus making the diagnosis of crusted scabies more difficult than normal scabies.⁶ Diagnosis of crusted scabies is confirmed by direct microscopy, which demonstrates mites, eggs, or feces. Strict isolation of the patient is necessary, as the disease is very contagious. Treatment with oral ivermectin (1–3 doses of 3 mg at 14-day intervals) in combination with topical permethrin is effective.⁷

We present a case of crusted scabies with nail involvement that presented with white superficial onychomycosislike lesions. The patient’s nails were successfully treated with a combination of oral ivermectin and topical permethrin occlusion of the nails. In cases with subungual hyperkeratosis, nonsurgical nail avulsion with 40% urea cream or ointment has been used to improve the penetration of permethrin. Partial nail avulsion may be necessary if subungual hyperkeratosis or nail dystrophy becomes extreme.⁸

To the Editor:

A 28-year-old man presented to the dermatology clinic with red, tender, swollen nodules on the left arm of 5 days’ duration, which had been a recurrent issue involving both arms. He also experienced intermittent fatigue and mild myalgia but denied associated fevers or chills. Oral clindamycin prescribed by a local emergency department provided some improvement. Upon further questioning, the patient admitted to injecting an unknown substance into the muscles 10 years prior for the purpose of enhancing their volume and appearance. Physical examination revealed large bilateral biceps with firm, mobile, nontender, subcutaneous nodules and mild erythema on the inner aspects of the arms. An incisional biopsy of a left arm nodule was performed with tissue culture (Figure 1). Microscopic evaluation revealed mild dermal sclerosis with edema and sclerosis of fat septae (Figure 2A). The fat lobules contained granulomas with surrounding lymphocytes and clear holes noted within the histiocytic giant cells, indicating a likely foreign substance (Figure 2B). Immunohistochemical staining of the histiocytes with CD68 highlighted the clear vacuoles (Figure 3). Polarization examination, Alcian blue, periodic acid–Schiff, and acid-fast bacilli staining were negative. Bacterial, fungal, and mycobacterial tissue cultures and staining also were negative. The histologic findings of septal and lobular panniculitis with sclerosis and granulomatous inflammation in the clinical setting were consistent with a foreign body reaction secondary to synthol injection.

The willingness of athletes in competitive sports to undergo procedures or utilize substances for a competitive advantage despite both immediate and long-term consequences is well documented.^1,2 In bodybuilding, use of anabolic steroids and intramuscular oil injections has been documented.³ The use of site enhancements in the form of “fillers” such as petroleum jelly and paraffin have been used for more than 100 years.⁴ The use of oil for volumetric site enhancement began in the 1960s in Italy with formebolone and evolved to the use of synthol in the 1990s.⁵ Synthol is a substance composed of 85% oil in the form of medium-chain triglycerides, 7.5% alcohol, and 7.5% lidocaine.⁶ The presumed mechanism of action of injected oils consists of an initial inflammatory response followed by fibrosis and chronic macrophagocytosis, ultimately leading to expanded volume in the subcutaneous tissue.⁷ These procedures are purely aesthetic with no increase in muscle strength or performance.

There are few cases in the literature of side effects from intramuscular synthol injections. In one report, a 29-year-old man presented with painful muscle fibrosis requiring open surgical excision of massively fibrotic bicep tissue.⁸ Another report documented a 45-year-old man who presented with spontaneous ulcerations on the biceps that initially were treated with antibiotics and compression therapy but eventually required surgical intervention and skin grafting.⁹ Complications have been more frequently reported from injections of other oils such as paraffin and sesame.^10,11 Given the similar underlying mechanisms of action, injected oils share the local side effects of inflammation, infection, chronic wounds, and ulceration,^9,10 as well as a systemic risk for embolization leading to pulmonary emboli, myocardial infarction, and stroke.⁶ Although no standard of care exists for the management of complications arising from intramuscular oil injections, treatments that have been employed include antibiotics, corticosteroids, wound care, and compression therapy; definitive treatment typically is surgical excision.^6,8,9,11,12 Psychiatric evaluation also should be considered to evaluate for the possibility of body dysmorphic disorder and other associated psychiatric conditions.¹¹

Pressure for a particular aesthetic appearance, both within and outside the world of competitive sports, has driven individuals to various methods of muscular enhancement. Volumetric site enhancements have become increasingly popular, in part due to the perceived lack of systemic side effects, such as those associated with anabolic steroids.⁸ However, most users are unaware of the notable short-term and long-term risks associated with intramuscular oil injections. Synthol is widely available on the Internet and easily can be purchased and injected by anyone.¹³ Medical providers should be aware of the possibility of aesthetic site enhancement use in their patients and be able to recognize and intervene in these cases to prevent chronic damage to muscle tissue and accompanying complications. Despite extensive commercialization of these products, few reports in the medical literature exist detailing the side effects of intramuscular oil injections, which may be contributing to the trivialization of these procedures by the general public.¹²

To the Editor:

A 28-year-old man presented to the dermatology clinic with red, tender, swollen nodules on the left arm of 5 days’ duration, which had been a recurrent issue involving both arms. He also experienced intermittent fatigue and mild myalgia but denied associated fevers or chills. Oral clindamycin prescribed by a local emergency department provided some improvement. Upon further questioning, the patient admitted to injecting an unknown substance into the muscles 10 years prior for the purpose of enhancing their volume and appearance. Physical examination revealed large bilateral biceps with firm, mobile, nontender, subcutaneous nodules and mild erythema on the inner aspects of the arms. An incisional biopsy of a left arm nodule was performed with tissue culture (Figure 1). Microscopic evaluation revealed mild dermal sclerosis with edema and sclerosis of fat septae (Figure 2A). The fat lobules contained granulomas with surrounding lymphocytes and clear holes noted within the histiocytic giant cells, indicating a likely foreign substance (Figure 2B). Immunohistochemical staining of the histiocytes with CD68 highlighted the clear vacuoles (Figure 3). Polarization examination, Alcian blue, periodic acid–Schiff, and acid-fast bacilli staining were negative. Bacterial, fungal, and mycobacterial tissue cultures and staining also were negative. The histologic findings of septal and lobular panniculitis with sclerosis and granulomatous inflammation in the clinical setting were consistent with a foreign body reaction secondary to synthol injection.

The willingness of athletes in competitive sports to undergo procedures or utilize substances for a competitive advantage despite both immediate and long-term consequences is well documented.^1,2 In bodybuilding, use of anabolic steroids and intramuscular oil injections has been documented.³ The use of site enhancements in the form of “fillers” such as petroleum jelly and paraffin have been used for more than 100 years.⁴ The use of oil for volumetric site enhancement began in the 1960s in Italy with formebolone and evolved to the use of synthol in the 1990s.⁵ Synthol is a substance composed of 85% oil in the form of medium-chain triglycerides, 7.5% alcohol, and 7.5% lidocaine.⁶ The presumed mechanism of action of injected oils consists of an initial inflammatory response followed by fibrosis and chronic macrophagocytosis, ultimately leading to expanded volume in the subcutaneous tissue.⁷ These procedures are purely aesthetic with no increase in muscle strength or performance.

There are few cases in the literature of side effects from intramuscular synthol injections. In one report, a 29-year-old man presented with painful muscle fibrosis requiring open surgical excision of massively fibrotic bicep tissue.⁸ Another report documented a 45-year-old man who presented with spontaneous ulcerations on the biceps that initially were treated with antibiotics and compression therapy but eventually required surgical intervention and skin grafting.⁹ Complications have been more frequently reported from injections of other oils such as paraffin and sesame.^10,11 Given the similar underlying mechanisms of action, injected oils share the local side effects of inflammation, infection, chronic wounds, and ulceration,^9,10 as well as a systemic risk for embolization leading to pulmonary emboli, myocardial infarction, and stroke.⁶ Although no standard of care exists for the management of complications arising from intramuscular oil injections, treatments that have been employed include antibiotics, corticosteroids, wound care, and compression therapy; definitive treatment typically is surgical excision.^6,8,9,11,12 Psychiatric evaluation also should be considered to evaluate for the possibility of body dysmorphic disorder and other associated psychiatric conditions.¹¹

Pressure for a particular aesthetic appearance, both within and outside the world of competitive sports, has driven individuals to various methods of muscular enhancement. Volumetric site enhancements have become increasingly popular, in part due to the perceived lack of systemic side effects, such as those associated with anabolic steroids.⁸ However, most users are unaware of the notable short-term and long-term risks associated with intramuscular oil injections. Synthol is widely available on the Internet and easily can be purchased and injected by anyone.¹³ Medical providers should be aware of the possibility of aesthetic site enhancement use in their patients and be able to recognize and intervene in these cases to prevent chronic damage to muscle tissue and accompanying complications. Despite extensive commercialization of these products, few reports in the medical literature exist detailing the side effects of intramuscular oil injections, which may be contributing to the trivialization of these procedures by the general public.¹²

To the Editor:

A 28-year-old man presented to the dermatology clinic with red, tender, swollen nodules on the left arm of 5 days’ duration, which had been a recurrent issue involving both arms. He also experienced intermittent fatigue and mild myalgia but denied associated fevers or chills. Oral clindamycin prescribed by a local emergency department provided some improvement. Upon further questioning, the patient admitted to injecting an unknown substance into the muscles 10 years prior for the purpose of enhancing their volume and appearance. Physical examination revealed large bilateral biceps with firm, mobile, nontender, subcutaneous nodules and mild erythema on the inner aspects of the arms. An incisional biopsy of a left arm nodule was performed with tissue culture (Figure 1). Microscopic evaluation revealed mild dermal sclerosis with edema and sclerosis of fat septae (Figure 2A). The fat lobules contained granulomas with surrounding lymphocytes and clear holes noted within the histiocytic giant cells, indicating a likely foreign substance (Figure 2B). Immunohistochemical staining of the histiocytes with CD68 highlighted the clear vacuoles (Figure 3). Polarization examination, Alcian blue, periodic acid–Schiff, and acid-fast bacilli staining were negative. Bacterial, fungal, and mycobacterial tissue cultures and staining also were negative. The histologic findings of septal and lobular panniculitis with sclerosis and granulomatous inflammation in the clinical setting were consistent with a foreign body reaction secondary to synthol injection.

The willingness of athletes in competitive sports to undergo procedures or utilize substances for a competitive advantage despite both immediate and long-term consequences is well documented.^1,2 In bodybuilding, use of anabolic steroids and intramuscular oil injections has been documented.³ The use of site enhancements in the form of “fillers” such as petroleum jelly and paraffin have been used for more than 100 years.⁴ The use of oil for volumetric site enhancement began in the 1960s in Italy with formebolone and evolved to the use of synthol in the 1990s.⁵ Synthol is a substance composed of 85% oil in the form of medium-chain triglycerides, 7.5% alcohol, and 7.5% lidocaine.⁶ The presumed mechanism of action of injected oils consists of an initial inflammatory response followed by fibrosis and chronic macrophagocytosis, ultimately leading to expanded volume in the subcutaneous tissue.⁷ These procedures are purely aesthetic with no increase in muscle strength or performance.

There are few cases in the literature of side effects from intramuscular synthol injections. In one report, a 29-year-old man presented with painful muscle fibrosis requiring open surgical excision of massively fibrotic bicep tissue.⁸ Another report documented a 45-year-old man who presented with spontaneous ulcerations on the biceps that initially were treated with antibiotics and compression therapy but eventually required surgical intervention and skin grafting.⁹ Complications have been more frequently reported from injections of other oils such as paraffin and sesame.^10,11 Given the similar underlying mechanisms of action, injected oils share the local side effects of inflammation, infection, chronic wounds, and ulceration,^9,10 as well as a systemic risk for embolization leading to pulmonary emboli, myocardial infarction, and stroke.⁶ Although no standard of care exists for the management of complications arising from intramuscular oil injections, treatments that have been employed include antibiotics, corticosteroids, wound care, and compression therapy; definitive treatment typically is surgical excision.^6,8,9,11,12 Psychiatric evaluation also should be considered to evaluate for the possibility of body dysmorphic disorder and other associated psychiatric conditions.¹¹

Pressure for a particular aesthetic appearance, both within and outside the world of competitive sports, has driven individuals to various methods of muscular enhancement. Volumetric site enhancements have become increasingly popular, in part due to the perceived lack of systemic side effects, such as those associated with anabolic steroids.⁸ However, most users are unaware of the notable short-term and long-term risks associated with intramuscular oil injections. Synthol is widely available on the Internet and easily can be purchased and injected by anyone.¹³ Medical providers should be aware of the possibility of aesthetic site enhancement use in their patients and be able to recognize and intervene in these cases to prevent chronic damage to muscle tissue and accompanying complications. Despite extensive commercialization of these products, few reports in the medical literature exist detailing the side effects of intramuscular oil injections, which may be contributing to the trivialization of these procedures by the general public.¹²

Read More

Read More

Read More