Mixed Topics

The Cutis editorial staff is proud to announce that Vincent A. DeLeo, MD, Editor-in-Chief, was honored with the Master Dermatologist Award at the 2026 Annual Meeting of the American Academy of Dermatology (AAD) in Denver, Colorado.

Presented as part of the AAD’s “Stars of the Academy” program, this award is reserved for physicians whose careers have advanced dermatology through leadership, service, and meaningful contributions to patient care, education, and research. The award reflects Dr. DeLeo’s impact across the specialty.

“Vince’s passion for dermatology has impacted all aspects of our specialty. He has been at the forefront of basic science research, clinical dermatology, education, mentoring, and leadership of specialty organizations and societies.” –Susan C. Taylor, MD

During the presentation, outgoing AAD president Susan C. Taylor, MD, emphasized Dr. DeLeo’s wide-ranging influence, noting his reputation as a researcher, compassionate physician, and skilled diagnostician. He is adept at managing complex cases and improving patient outcomes. Dr. DeLeo is widely recognized for his expertise in contact dermatitis, photomedicine, and photoprotection, as well as for his contributions to dermatologic education.

Beyond his clinical and editorial leadership of Cutis for the past 25 years, Dr. DeLeo is committed to mentorship and leadership by serving on the AAD Board of Directors as well as other specialty organizations such as the American Contact Dermatitis Society.

We congratulate Dr. DeLeo on this well-deserved distinction and thank him for his continued vision and dedication to our readers and the specialty at large.

The Cutis editorial staff is proud to announce that Vincent A. DeLeo, MD, Editor-in-Chief, was honored with the Master Dermatologist Award at the 2026 Annual Meeting of the American Academy of Dermatology (AAD) in Denver, Colorado.

Presented as part of the AAD’s “Stars of the Academy” program, this award is reserved for physicians whose careers have advanced dermatology through leadership, service, and meaningful contributions to patient care, education, and research. The award reflects Dr. DeLeo’s impact across the specialty.

“Vince’s passion for dermatology has impacted all aspects of our specialty. He has been at the forefront of basic science research, clinical dermatology, education, mentoring, and leadership of specialty organizations and societies.” –Susan C. Taylor, MD

During the presentation, outgoing AAD president Susan C. Taylor, MD, emphasized Dr. DeLeo’s wide-ranging influence, noting his reputation as a researcher, compassionate physician, and skilled diagnostician. He is adept at managing complex cases and improving patient outcomes. Dr. DeLeo is widely recognized for his expertise in contact dermatitis, photomedicine, and photoprotection, as well as for his contributions to dermatologic education.

Beyond his clinical and editorial leadership of Cutis for the past 25 years, Dr. DeLeo is committed to mentorship and leadership by serving on the AAD Board of Directors as well as other specialty organizations such as the American Contact Dermatitis Society.

We congratulate Dr. DeLeo on this well-deserved distinction and thank him for his continued vision and dedication to our readers and the specialty at large.

The Cutis editorial staff is proud to announce that Vincent A. DeLeo, MD, Editor-in-Chief, was honored with the Master Dermatologist Award at the 2026 Annual Meeting of the American Academy of Dermatology (AAD) in Denver, Colorado.

Presented as part of the AAD’s “Stars of the Academy” program, this award is reserved for physicians whose careers have advanced dermatology through leadership, service, and meaningful contributions to patient care, education, and research. The award reflects Dr. DeLeo’s impact across the specialty.

“Vince’s passion for dermatology has impacted all aspects of our specialty. He has been at the forefront of basic science research, clinical dermatology, education, mentoring, and leadership of specialty organizations and societies.” –Susan C. Taylor, MD

During the presentation, outgoing AAD president Susan C. Taylor, MD, emphasized Dr. DeLeo’s wide-ranging influence, noting his reputation as a researcher, compassionate physician, and skilled diagnostician. He is adept at managing complex cases and improving patient outcomes. Dr. DeLeo is widely recognized for his expertise in contact dermatitis, photomedicine, and photoprotection, as well as for his contributions to dermatologic education.

Beyond his clinical and editorial leadership of Cutis for the past 25 years, Dr. DeLeo is committed to mentorship and leadership by serving on the AAD Board of Directors as well as other specialty organizations such as the American Contact Dermatitis Society.

We congratulate Dr. DeLeo on this well-deserved distinction and thank him for his continued vision and dedication to our readers and the specialty at large.

Triatome bugs cause painful bites and serve as vectors for Chagas disease. In this article, we will address diagnosis and vector identification.

Key Morphologic Features

Insects from the subfamily Triatominae are identifiable by their long legs and a shieldlike abdomen behind a platelike pronotum that covers the thorax. Their half-membranous wings overlap, covering the central abdomen but leaving the lateral portions visible. Tigerlike stripes are characteristically prominent on the visible portions of the lateral abdomen. The stalklike head has an articulated beaklike mouth that can be retracted and used to deliver a powerful bite (Figure 1).

Feeding Mechanisms and Host Reactions

Triatome bugs are blood-feeding arthropods that hide in cracks and crevices in domestic structures by day and feed at night. They are shy feeders, and laboratory colonies have been known to die rather than feed in daylight. They are particularly common in thatched or wattle-and-daub dwellings, where they can be present in great numbers and descend on sleeping inhabitants at night. Triatome bugs require regular blood meals throughout the 5 developmental nymph stages in order to undergo successful molting.

In the wild, triatome bugs feed on a range of animals with little specificity, but in domestic settings they feed largely on humans. Thermosensors in the antennae help them locate blood vessels under the skin, which they penetrate easily due to their long mouthparts. Like other blood-sucking arthropods, they release an anticoagulant that facilitates continuous blood flow while feeding, which accounts for many of the cutaneous reactions observed after the host sustains a triatomine bite.¹

Triatomine bugs have trouble feeding through clothing and seek out exposed skin, particularly the eyelids, producing the characteristic unilateral eyelid swelling known as the Romaña sign. Other bite reactions include purpura; macular erythema; and vesiculobullous, papular, and urticarial lesions (Figure 2).² Associated lymphangitis or lymphadenopathy may be noted, and anaphylaxis has been reported. Similar to those of cockroaches, triatome antigens have been associated with atopic dermatitis and asthma.³

Chagas Disease Risk and Transmission

Triatomine reduviids are the primary vector of Chagas disease, and the geographic range of both continues to expand, particularly in North America. The disease remains endemic in Latin America, with the highest incidence now reported in Brazil.⁴ An estimated 240,000 to 350,000 individuals in the United States are infected, primarily immigrants from Mexico, Central America, and South America; approximately 30% of those infected will develop cardiac and/or gastrointestinal complications.⁴ If left untreated, Chagas disease leads to autonomic ganglion destruction and subsequent gastrointestinal and cardiac complications, including megacolon, dilated cardiomyopathy, and heart failure.⁵

Trypanosoma cruzi, the microorganism responsible for Chagas disease, is spread to humans through triatomine fecal matter scratched into the bite wound.⁶ Triatomine bugs have a highly developed gastrocolic reflex and defecate liberally as they feed. Fecal volume is heavily dependent on species and sex, with fifth-stage female nymphs producing the highest volume of excrement and thereby acting as particularly adept disease vectors.⁶ Triatoma infestans and members of the genus Mepraia are key vectors of T cruzi.¹ In areas of South America where populations of T infestans are controlled through public health measures, Mepraia emerge as a largely uncontrolled disease vector.^1,7 While endemic to the southern United States and South America, T cruzi has spread to much of North America and Europe by way of Triatominae as naturalized or invasive species.⁸

There are 3 phases of Chagas disease: acute, indeterminate, and chronic. A chagoma is a localized erythematous swelling at the site of the bite. The acute phase often lacks systemic symptoms but may include fever, myalgia, and headache. The intermediate phase may include fatigue and recurrent fevers. The most serious manifestations occur in the chronic phase and include cardiomyopathy with signs of congestive heart failure, irregular heartbeat, cardiac arrest, abdominal pain, constipation, and dysphagia.

Deforestation has been identified as a driving factor in the spread of Chagas disease, as the disease vectors shift from wilderness areas and animal hosts to inhabited areas where humans are the most readily available food source. Triatome bugs in areas experiencing higher levels of development or forest harvesting are forced into human-populated areas. As a result, instances of Chagas disease are on the rise in these communities.⁷ Salvador, Bahia, Brazil, has been identified as one such target of increased vector presence due to heavy deforestation, and the hottest months were identified as having the greatest threat of vector exposure.⁹ Brazil became the leading geographic area for the disease partly because of heavy loss of forested land.¹⁰

Vector Control and Prevention Strategies

Elimination of cracks and crevices in walls; replacement of wattle and daub with stucco, plaster, and other solid building materials; and the use of insecticides with durability in the environment have been used to reduce triatome bug infestation in homes. However, highly persistent insecticides carry greater environmental risk and may drive resistance as declining concentrations select for resistant arthropods. Repellents have less environmental impact and play an important role in vector control. Citronella essential oil has been observed to repel several species of triatome bugs that are common in Arizona; specifically, the component alcohols geraniol and citronellol were found to be effective at inhibiting triatome feeding.¹¹

Early detection of Chagas disease is essential, as end-stage cardiomyopathy and megacolon are difficult to treat. Newly developed multiantigen testing has shown promising results, suggesting a potential for more accurate testing for Chagas disease.⁸ Geospatial tracking and mapping of T cruzi vectors now are employed to track seasonal vector changes and disease patterns.⁹ Researchers also have developed a dedicated dichotomous key for the identification of triatome bugs endemic in Brazil with the hope of better identification and mapping of disease vector presence and density.¹⁰ The key consists of a series of statements with 2 choices in each step. It uses observable features of the arthropod to lead users to the correct identification.

Final Thoughts

Identification of triatome bugs can help with public health efforts to control the spread of disease. Patients with unilateral eyelid swelling should be evaluated for possible bedbug or triatome exposure.

Triatome bugs cause painful bites and serve as vectors for Chagas disease. In this article, we will address diagnosis and vector identification.

Key Morphologic Features

Insects from the subfamily Triatominae are identifiable by their long legs and a shieldlike abdomen behind a platelike pronotum that covers the thorax. Their half-membranous wings overlap, covering the central abdomen but leaving the lateral portions visible. Tigerlike stripes are characteristically prominent on the visible portions of the lateral abdomen. The stalklike head has an articulated beaklike mouth that can be retracted and used to deliver a powerful bite (Figure 1).

Feeding Mechanisms and Host Reactions

Triatome bugs are blood-feeding arthropods that hide in cracks and crevices in domestic structures by day and feed at night. They are shy feeders, and laboratory colonies have been known to die rather than feed in daylight. They are particularly common in thatched or wattle-and-daub dwellings, where they can be present in great numbers and descend on sleeping inhabitants at night. Triatome bugs require regular blood meals throughout the 5 developmental nymph stages in order to undergo successful molting.

In the wild, triatome bugs feed on a range of animals with little specificity, but in domestic settings they feed largely on humans. Thermosensors in the antennae help them locate blood vessels under the skin, which they penetrate easily due to their long mouthparts. Like other blood-sucking arthropods, they release an anticoagulant that facilitates continuous blood flow while feeding, which accounts for many of the cutaneous reactions observed after the host sustains a triatomine bite.¹

Triatomine bugs have trouble feeding through clothing and seek out exposed skin, particularly the eyelids, producing the characteristic unilateral eyelid swelling known as the Romaña sign. Other bite reactions include purpura; macular erythema; and vesiculobullous, papular, and urticarial lesions (Figure 2).² Associated lymphangitis or lymphadenopathy may be noted, and anaphylaxis has been reported. Similar to those of cockroaches, triatome antigens have been associated with atopic dermatitis and asthma.³

Chagas Disease Risk and Transmission

Triatomine reduviids are the primary vector of Chagas disease, and the geographic range of both continues to expand, particularly in North America. The disease remains endemic in Latin America, with the highest incidence now reported in Brazil.⁴ An estimated 240,000 to 350,000 individuals in the United States are infected, primarily immigrants from Mexico, Central America, and South America; approximately 30% of those infected will develop cardiac and/or gastrointestinal complications.⁴ If left untreated, Chagas disease leads to autonomic ganglion destruction and subsequent gastrointestinal and cardiac complications, including megacolon, dilated cardiomyopathy, and heart failure.⁵

Trypanosoma cruzi, the microorganism responsible for Chagas disease, is spread to humans through triatomine fecal matter scratched into the bite wound.⁶ Triatomine bugs have a highly developed gastrocolic reflex and defecate liberally as they feed. Fecal volume is heavily dependent on species and sex, with fifth-stage female nymphs producing the highest volume of excrement and thereby acting as particularly adept disease vectors.⁶ Triatoma infestans and members of the genus Mepraia are key vectors of T cruzi.¹ In areas of South America where populations of T infestans are controlled through public health measures, Mepraia emerge as a largely uncontrolled disease vector.^1,7 While endemic to the southern United States and South America, T cruzi has spread to much of North America and Europe by way of Triatominae as naturalized or invasive species.⁸

There are 3 phases of Chagas disease: acute, indeterminate, and chronic. A chagoma is a localized erythematous swelling at the site of the bite. The acute phase often lacks systemic symptoms but may include fever, myalgia, and headache. The intermediate phase may include fatigue and recurrent fevers. The most serious manifestations occur in the chronic phase and include cardiomyopathy with signs of congestive heart failure, irregular heartbeat, cardiac arrest, abdominal pain, constipation, and dysphagia.

Deforestation has been identified as a driving factor in the spread of Chagas disease, as the disease vectors shift from wilderness areas and animal hosts to inhabited areas where humans are the most readily available food source. Triatome bugs in areas experiencing higher levels of development or forest harvesting are forced into human-populated areas. As a result, instances of Chagas disease are on the rise in these communities.⁷ Salvador, Bahia, Brazil, has been identified as one such target of increased vector presence due to heavy deforestation, and the hottest months were identified as having the greatest threat of vector exposure.⁹ Brazil became the leading geographic area for the disease partly because of heavy loss of forested land.¹⁰

Vector Control and Prevention Strategies

Elimination of cracks and crevices in walls; replacement of wattle and daub with stucco, plaster, and other solid building materials; and the use of insecticides with durability in the environment have been used to reduce triatome bug infestation in homes. However, highly persistent insecticides carry greater environmental risk and may drive resistance as declining concentrations select for resistant arthropods. Repellents have less environmental impact and play an important role in vector control. Citronella essential oil has been observed to repel several species of triatome bugs that are common in Arizona; specifically, the component alcohols geraniol and citronellol were found to be effective at inhibiting triatome feeding.¹¹

Early detection of Chagas disease is essential, as end-stage cardiomyopathy and megacolon are difficult to treat. Newly developed multiantigen testing has shown promising results, suggesting a potential for more accurate testing for Chagas disease.⁸ Geospatial tracking and mapping of T cruzi vectors now are employed to track seasonal vector changes and disease patterns.⁹ Researchers also have developed a dedicated dichotomous key for the identification of triatome bugs endemic in Brazil with the hope of better identification and mapping of disease vector presence and density.¹⁰ The key consists of a series of statements with 2 choices in each step. It uses observable features of the arthropod to lead users to the correct identification.

Final Thoughts

Identification of triatome bugs can help with public health efforts to control the spread of disease. Patients with unilateral eyelid swelling should be evaluated for possible bedbug or triatome exposure.

Triatome bugs cause painful bites and serve as vectors for Chagas disease. In this article, we will address diagnosis and vector identification.

Key Morphologic Features

Insects from the subfamily Triatominae are identifiable by their long legs and a shieldlike abdomen behind a platelike pronotum that covers the thorax. Their half-membranous wings overlap, covering the central abdomen but leaving the lateral portions visible. Tigerlike stripes are characteristically prominent on the visible portions of the lateral abdomen. The stalklike head has an articulated beaklike mouth that can be retracted and used to deliver a powerful bite (Figure 1).

Feeding Mechanisms and Host Reactions

Triatome bugs are blood-feeding arthropods that hide in cracks and crevices in domestic structures by day and feed at night. They are shy feeders, and laboratory colonies have been known to die rather than feed in daylight. They are particularly common in thatched or wattle-and-daub dwellings, where they can be present in great numbers and descend on sleeping inhabitants at night. Triatome bugs require regular blood meals throughout the 5 developmental nymph stages in order to undergo successful molting.

In the wild, triatome bugs feed on a range of animals with little specificity, but in domestic settings they feed largely on humans. Thermosensors in the antennae help them locate blood vessels under the skin, which they penetrate easily due to their long mouthparts. Like other blood-sucking arthropods, they release an anticoagulant that facilitates continuous blood flow while feeding, which accounts for many of the cutaneous reactions observed after the host sustains a triatomine bite.¹

Triatomine bugs have trouble feeding through clothing and seek out exposed skin, particularly the eyelids, producing the characteristic unilateral eyelid swelling known as the Romaña sign. Other bite reactions include purpura; macular erythema; and vesiculobullous, papular, and urticarial lesions (Figure 2).² Associated lymphangitis or lymphadenopathy may be noted, and anaphylaxis has been reported. Similar to those of cockroaches, triatome antigens have been associated with atopic dermatitis and asthma.³

Chagas Disease Risk and Transmission

Triatomine reduviids are the primary vector of Chagas disease, and the geographic range of both continues to expand, particularly in North America. The disease remains endemic in Latin America, with the highest incidence now reported in Brazil.⁴ An estimated 240,000 to 350,000 individuals in the United States are infected, primarily immigrants from Mexico, Central America, and South America; approximately 30% of those infected will develop cardiac and/or gastrointestinal complications.⁴ If left untreated, Chagas disease leads to autonomic ganglion destruction and subsequent gastrointestinal and cardiac complications, including megacolon, dilated cardiomyopathy, and heart failure.⁵

Trypanosoma cruzi, the microorganism responsible for Chagas disease, is spread to humans through triatomine fecal matter scratched into the bite wound.⁶ Triatomine bugs have a highly developed gastrocolic reflex and defecate liberally as they feed. Fecal volume is heavily dependent on species and sex, with fifth-stage female nymphs producing the highest volume of excrement and thereby acting as particularly adept disease vectors.⁶ Triatoma infestans and members of the genus Mepraia are key vectors of T cruzi.¹ In areas of South America where populations of T infestans are controlled through public health measures, Mepraia emerge as a largely uncontrolled disease vector.^1,7 While endemic to the southern United States and South America, T cruzi has spread to much of North America and Europe by way of Triatominae as naturalized or invasive species.⁸

There are 3 phases of Chagas disease: acute, indeterminate, and chronic. A chagoma is a localized erythematous swelling at the site of the bite. The acute phase often lacks systemic symptoms but may include fever, myalgia, and headache. The intermediate phase may include fatigue and recurrent fevers. The most serious manifestations occur in the chronic phase and include cardiomyopathy with signs of congestive heart failure, irregular heartbeat, cardiac arrest, abdominal pain, constipation, and dysphagia.

Deforestation has been identified as a driving factor in the spread of Chagas disease, as the disease vectors shift from wilderness areas and animal hosts to inhabited areas where humans are the most readily available food source. Triatome bugs in areas experiencing higher levels of development or forest harvesting are forced into human-populated areas. As a result, instances of Chagas disease are on the rise in these communities.⁷ Salvador, Bahia, Brazil, has been identified as one such target of increased vector presence due to heavy deforestation, and the hottest months were identified as having the greatest threat of vector exposure.⁹ Brazil became the leading geographic area for the disease partly because of heavy loss of forested land.¹⁰

Vector Control and Prevention Strategies

Elimination of cracks and crevices in walls; replacement of wattle and daub with stucco, plaster, and other solid building materials; and the use of insecticides with durability in the environment have been used to reduce triatome bug infestation in homes. However, highly persistent insecticides carry greater environmental risk and may drive resistance as declining concentrations select for resistant arthropods. Repellents have less environmental impact and play an important role in vector control. Citronella essential oil has been observed to repel several species of triatome bugs that are common in Arizona; specifically, the component alcohols geraniol and citronellol were found to be effective at inhibiting triatome feeding.¹¹

Early detection of Chagas disease is essential, as end-stage cardiomyopathy and megacolon are difficult to treat. Newly developed multiantigen testing has shown promising results, suggesting a potential for more accurate testing for Chagas disease.⁸ Geospatial tracking and mapping of T cruzi vectors now are employed to track seasonal vector changes and disease patterns.⁹ Researchers also have developed a dedicated dichotomous key for the identification of triatome bugs endemic in Brazil with the hope of better identification and mapping of disease vector presence and density.¹⁰ The key consists of a series of statements with 2 choices in each step. It uses observable features of the arthropod to lead users to the correct identification.

Final Thoughts

Identification of triatome bugs can help with public health efforts to control the spread of disease. Patients with unilateral eyelid swelling should be evaluated for possible bedbug or triatome exposure.

Practice Gap

Pyogenic granulomas (PGs) are benign endothelial tumors of the skin or mucosae that frequently become ulcerated and may cause patients substantial discomfort or distress due to rapid enlargement and bleeding.¹ These lesions often manifest as solitary red papules or polyps following localized trauma or irritation. They can grow up to 1 cm over a few weeks to several months. Pyogenic granulomas can develop at any age, but they most commonly are seen in children and young adults, with a slight male predominance.^1,2 The differential diagnosis for PG includes amelanotic melanoma, bacillary angiomatosis, Kaposi sarcoma, glomus tumor, infantile hemangioma, and irritated melanocytic nevus.¹ Histologically, PGs are well-circumscribed exophytic or pedunculated proliferations of small capillaries that often are arranged in a lobular pattern. Early lesions show packed endothelial cells, while advanced lesions display more ectatic vessels, erosion, and crusting.³ The term pyogenic granuloma is a misnomer, as these lesions display neither an infectious etiology nor granulomatous tissue on dermatopathologic examination.⁴ A more accurate clinical description for this lesion is a lobular capillary hemangioma.

Numerous surgical and laser techniques have been used to treat PGs, with varying degrees of success. Treatment often consists of either shave excision followed by electrosurgery at the base or full excision with suturing under local anesthesia for patients who can tolerate anesthetic injections.¹ Pulsed dye laser has been proven to be a safe alternative treatment option, particularly in children who otherwise would not tolerate surgical procedures.⁵ Topical beta-blockers, silver nitrate cauterization, sclerotherapy, and liquid nitrogen all have been used as alternative treatment methods.¹

Pyogenic granulomas often recur after first-line treatments, and patients may hesitate to try more invasive techniques when the first choice has failed. Children may not be amenable to any of these curative techniques, as they may not tolerate the pain associated with lidocaine injection and/or have a fear of needles or surgical intervention; even adults may be reluctant to have a procedure they perceive as painful. We present a less invasive technique for treatment of recurrent PGs using table salt and cryotherapy.

The Technique

A 51-year-old woman with no notable medical history presented to the emergency department for evaluation of a black dot on the pulp of the right third fingertip of 1 week’s duration. The patient reported rapid progression to an ulcerated red nodule with associated bleeding for the past 3 days (Figure 1). Direct pressure temporarily alleviated the bleeding, but it started again upon cessation of pressure. She denied any preceding trauma to the area or any associated systemic symptoms such as fever, chills, nausea, or vomiting.

The inpatient dermatology team recommended that the patient be discharged following silver nitrate cautery, with a referral sent to outpatient dermatology; however, the patient returned to the dermatology clinic 4 days later, at which time physical examination revealed a well-circumscribed, 5-mm, bright-red, erosive papule with overlying hemorrhagic crust that was not actively bleeding, as well as fissuring of the surrounding skin. The entire lesion was removed using tangential excision followed by electrodesiccation at the base. Pathology revealed small capillaries arranged in a lobular pattern, confirming the diagnosis of PG. At a 2-week follow-up visit, the patient noted that the lesion had recurred within 24 hours after the procedure and was larger (Figure 2). At this visit, management was switched to a single treatment of cryotherapy (3 cycles for 5 seconds per cycle), and the table salt method was recommended based on a literature review for alternative nonpainful approaches for PG.^6-11 We used this technique in our patient as an adjuvant to cryotherapy with the goal of reducing the need for additional painful procedures, but table salt also can be used as a standalone treatment without prior cryotherapy.

The patient was instructed to apply table salt to the lesion once daily for 2 weeks by pressing the lesion into a small amount of salt placed on a clean plate and then applying an occlusive dressing such as surgical or paper tape. She also was advised to apply petroleum jelly around the periphery of the lesion prior to salt application to protect the unaffected skin from irritation. Complete resolution of the lesion was seen when the patient followed up 2 weeks later (Figure 3). At the most recent follow-up 2 months after treatment, no further recurrence of the PG was reported.

Practice Implication

Pyogenic granulomas can be distressing for both patients and providers because they are cosmetically bothersome and prone to spontaneous bleeding. Various medical and surgical options exist to treat PGs, but there is no clear consensus on a superior modality. A 2019 study by Daruwalla and Dhurat⁶ highlighted a less invasive treatment option for PGs using table salt applied once daily for 2 weeks under an occlusive dressing with good outcomes and without involving other treatments such as cryotherapy. Several other case reports have endorsed this approach, adding anecdotal evidence for its utility.^7-11 Topical sodium chloride may treat PGs primarily through osmotic desiccation, drawing water out of the lesion and leading to endothelial cell shrinkage and collapse of its capillary network. This hyperosmolar environment also may induce microvascular thrombosis and ischemia, promoting lesion necrosis. Additionally, repeated application creates a dry, mildly irritative surface that may suppress angiogenesis and encourage regression of the vascular proliferation.

Consider topical application of table salt for treatment of PGs in certain subsets of patients; for example, patients who are not amenable to surgery or are too young for advanced surgical techniques may be good candidates for this method, as it does not require anesthetic injections and generally is pain free. Patients with resistant or recurrent PGs that did not respond to first-line treatments such as cryotherapy, tangential excision, or electrodesiccation may be more amenable to a less invasive secondary approach.

Importantly, we used a dual-therapy approach in our patient, initially using a single application of cryotherapy followed by the table salt method once daily for 2 weeks. This imposes limitations on the generalizability of table salt as a standalone approach for treating PGs. In this case, we did not have prior practical experience using table salt for this condition and only had small reports to justify its use. As a result, we attempted a more traditional treatment initially (cryotherapy) to avoid potential delays in resolution. The clinicians recommended table salt as an adjuvant prior to seeing the cryotherapy results because this treatment was benign and offered potential additive results, and therefore waiting was not necessary. However, various other cases have reported similar success using table salt as monotherapy.^6-9,11 Patients should be advised of potential mild adverse events, such as irritation to the surrounding skin. Higher-level evidence studies are required to further vet the utility of the table salt method for treatment of PGs.

Practice Gap

Pyogenic granulomas (PGs) are benign endothelial tumors of the skin or mucosae that frequently become ulcerated and may cause patients substantial discomfort or distress due to rapid enlargement and bleeding.¹ These lesions often manifest as solitary red papules or polyps following localized trauma or irritation. They can grow up to 1 cm over a few weeks to several months. Pyogenic granulomas can develop at any age, but they most commonly are seen in children and young adults, with a slight male predominance.^1,2 The differential diagnosis for PG includes amelanotic melanoma, bacillary angiomatosis, Kaposi sarcoma, glomus tumor, infantile hemangioma, and irritated melanocytic nevus.¹ Histologically, PGs are well-circumscribed exophytic or pedunculated proliferations of small capillaries that often are arranged in a lobular pattern. Early lesions show packed endothelial cells, while advanced lesions display more ectatic vessels, erosion, and crusting.³ The term pyogenic granuloma is a misnomer, as these lesions display neither an infectious etiology nor granulomatous tissue on dermatopathologic examination.⁴ A more accurate clinical description for this lesion is a lobular capillary hemangioma.

Numerous surgical and laser techniques have been used to treat PGs, with varying degrees of success. Treatment often consists of either shave excision followed by electrosurgery at the base or full excision with suturing under local anesthesia for patients who can tolerate anesthetic injections.¹ Pulsed dye laser has been proven to be a safe alternative treatment option, particularly in children who otherwise would not tolerate surgical procedures.⁵ Topical beta-blockers, silver nitrate cauterization, sclerotherapy, and liquid nitrogen all have been used as alternative treatment methods.¹

Pyogenic granulomas often recur after first-line treatments, and patients may hesitate to try more invasive techniques when the first choice has failed. Children may not be amenable to any of these curative techniques, as they may not tolerate the pain associated with lidocaine injection and/or have a fear of needles or surgical intervention; even adults may be reluctant to have a procedure they perceive as painful. We present a less invasive technique for treatment of recurrent PGs using table salt and cryotherapy.

The Technique

A 51-year-old woman with no notable medical history presented to the emergency department for evaluation of a black dot on the pulp of the right third fingertip of 1 week’s duration. The patient reported rapid progression to an ulcerated red nodule with associated bleeding for the past 3 days (Figure 1). Direct pressure temporarily alleviated the bleeding, but it started again upon cessation of pressure. She denied any preceding trauma to the area or any associated systemic symptoms such as fever, chills, nausea, or vomiting.

The inpatient dermatology team recommended that the patient be discharged following silver nitrate cautery, with a referral sent to outpatient dermatology; however, the patient returned to the dermatology clinic 4 days later, at which time physical examination revealed a well-circumscribed, 5-mm, bright-red, erosive papule with overlying hemorrhagic crust that was not actively bleeding, as well as fissuring of the surrounding skin. The entire lesion was removed using tangential excision followed by electrodesiccation at the base. Pathology revealed small capillaries arranged in a lobular pattern, confirming the diagnosis of PG. At a 2-week follow-up visit, the patient noted that the lesion had recurred within 24 hours after the procedure and was larger (Figure 2). At this visit, management was switched to a single treatment of cryotherapy (3 cycles for 5 seconds per cycle), and the table salt method was recommended based on a literature review for alternative nonpainful approaches for PG.^6-11 We used this technique in our patient as an adjuvant to cryotherapy with the goal of reducing the need for additional painful procedures, but table salt also can be used as a standalone treatment without prior cryotherapy.

The patient was instructed to apply table salt to the lesion once daily for 2 weeks by pressing the lesion into a small amount of salt placed on a clean plate and then applying an occlusive dressing such as surgical or paper tape. She also was advised to apply petroleum jelly around the periphery of the lesion prior to salt application to protect the unaffected skin from irritation. Complete resolution of the lesion was seen when the patient followed up 2 weeks later (Figure 3). At the most recent follow-up 2 months after treatment, no further recurrence of the PG was reported.

Practice Implication

Pyogenic granulomas can be distressing for both patients and providers because they are cosmetically bothersome and prone to spontaneous bleeding. Various medical and surgical options exist to treat PGs, but there is no clear consensus on a superior modality. A 2019 study by Daruwalla and Dhurat⁶ highlighted a less invasive treatment option for PGs using table salt applied once daily for 2 weeks under an occlusive dressing with good outcomes and without involving other treatments such as cryotherapy. Several other case reports have endorsed this approach, adding anecdotal evidence for its utility.^7-11 Topical sodium chloride may treat PGs primarily through osmotic desiccation, drawing water out of the lesion and leading to endothelial cell shrinkage and collapse of its capillary network. This hyperosmolar environment also may induce microvascular thrombosis and ischemia, promoting lesion necrosis. Additionally, repeated application creates a dry, mildly irritative surface that may suppress angiogenesis and encourage regression of the vascular proliferation.

Consider topical application of table salt for treatment of PGs in certain subsets of patients; for example, patients who are not amenable to surgery or are too young for advanced surgical techniques may be good candidates for this method, as it does not require anesthetic injections and generally is pain free. Patients with resistant or recurrent PGs that did not respond to first-line treatments such as cryotherapy, tangential excision, or electrodesiccation may be more amenable to a less invasive secondary approach.

Importantly, we used a dual-therapy approach in our patient, initially using a single application of cryotherapy followed by the table salt method once daily for 2 weeks. This imposes limitations on the generalizability of table salt as a standalone approach for treating PGs. In this case, we did not have prior practical experience using table salt for this condition and only had small reports to justify its use. As a result, we attempted a more traditional treatment initially (cryotherapy) to avoid potential delays in resolution. The clinicians recommended table salt as an adjuvant prior to seeing the cryotherapy results because this treatment was benign and offered potential additive results, and therefore waiting was not necessary. However, various other cases have reported similar success using table salt as monotherapy.^6-9,11 Patients should be advised of potential mild adverse events, such as irritation to the surrounding skin. Higher-level evidence studies are required to further vet the utility of the table salt method for treatment of PGs.

Practice Gap

Pyogenic granulomas (PGs) are benign endothelial tumors of the skin or mucosae that frequently become ulcerated and may cause patients substantial discomfort or distress due to rapid enlargement and bleeding.¹ These lesions often manifest as solitary red papules or polyps following localized trauma or irritation. They can grow up to 1 cm over a few weeks to several months. Pyogenic granulomas can develop at any age, but they most commonly are seen in children and young adults, with a slight male predominance.^1,2 The differential diagnosis for PG includes amelanotic melanoma, bacillary angiomatosis, Kaposi sarcoma, glomus tumor, infantile hemangioma, and irritated melanocytic nevus.¹ Histologically, PGs are well-circumscribed exophytic or pedunculated proliferations of small capillaries that often are arranged in a lobular pattern. Early lesions show packed endothelial cells, while advanced lesions display more ectatic vessels, erosion, and crusting.³ The term pyogenic granuloma is a misnomer, as these lesions display neither an infectious etiology nor granulomatous tissue on dermatopathologic examination.⁴ A more accurate clinical description for this lesion is a lobular capillary hemangioma.

Numerous surgical and laser techniques have been used to treat PGs, with varying degrees of success. Treatment often consists of either shave excision followed by electrosurgery at the base or full excision with suturing under local anesthesia for patients who can tolerate anesthetic injections.¹ Pulsed dye laser has been proven to be a safe alternative treatment option, particularly in children who otherwise would not tolerate surgical procedures.⁵ Topical beta-blockers, silver nitrate cauterization, sclerotherapy, and liquid nitrogen all have been used as alternative treatment methods.¹

Pyogenic granulomas often recur after first-line treatments, and patients may hesitate to try more invasive techniques when the first choice has failed. Children may not be amenable to any of these curative techniques, as they may not tolerate the pain associated with lidocaine injection and/or have a fear of needles or surgical intervention; even adults may be reluctant to have a procedure they perceive as painful. We present a less invasive technique for treatment of recurrent PGs using table salt and cryotherapy.

The Technique

A 51-year-old woman with no notable medical history presented to the emergency department for evaluation of a black dot on the pulp of the right third fingertip of 1 week’s duration. The patient reported rapid progression to an ulcerated red nodule with associated bleeding for the past 3 days (Figure 1). Direct pressure temporarily alleviated the bleeding, but it started again upon cessation of pressure. She denied any preceding trauma to the area or any associated systemic symptoms such as fever, chills, nausea, or vomiting.

The inpatient dermatology team recommended that the patient be discharged following silver nitrate cautery, with a referral sent to outpatient dermatology; however, the patient returned to the dermatology clinic 4 days later, at which time physical examination revealed a well-circumscribed, 5-mm, bright-red, erosive papule with overlying hemorrhagic crust that was not actively bleeding, as well as fissuring of the surrounding skin. The entire lesion was removed using tangential excision followed by electrodesiccation at the base. Pathology revealed small capillaries arranged in a lobular pattern, confirming the diagnosis of PG. At a 2-week follow-up visit, the patient noted that the lesion had recurred within 24 hours after the procedure and was larger (Figure 2). At this visit, management was switched to a single treatment of cryotherapy (3 cycles for 5 seconds per cycle), and the table salt method was recommended based on a literature review for alternative nonpainful approaches for PG.^6-11 We used this technique in our patient as an adjuvant to cryotherapy with the goal of reducing the need for additional painful procedures, but table salt also can be used as a standalone treatment without prior cryotherapy.

The patient was instructed to apply table salt to the lesion once daily for 2 weeks by pressing the lesion into a small amount of salt placed on a clean plate and then applying an occlusive dressing such as surgical or paper tape. She also was advised to apply petroleum jelly around the periphery of the lesion prior to salt application to protect the unaffected skin from irritation. Complete resolution of the lesion was seen when the patient followed up 2 weeks later (Figure 3). At the most recent follow-up 2 months after treatment, no further recurrence of the PG was reported.

Practice Implication

Pyogenic granulomas can be distressing for both patients and providers because they are cosmetically bothersome and prone to spontaneous bleeding. Various medical and surgical options exist to treat PGs, but there is no clear consensus on a superior modality. A 2019 study by Daruwalla and Dhurat⁶ highlighted a less invasive treatment option for PGs using table salt applied once daily for 2 weeks under an occlusive dressing with good outcomes and without involving other treatments such as cryotherapy. Several other case reports have endorsed this approach, adding anecdotal evidence for its utility.^7-11 Topical sodium chloride may treat PGs primarily through osmotic desiccation, drawing water out of the lesion and leading to endothelial cell shrinkage and collapse of its capillary network. This hyperosmolar environment also may induce microvascular thrombosis and ischemia, promoting lesion necrosis. Additionally, repeated application creates a dry, mildly irritative surface that may suppress angiogenesis and encourage regression of the vascular proliferation.

Consider topical application of table salt for treatment of PGs in certain subsets of patients; for example, patients who are not amenable to surgery or are too young for advanced surgical techniques may be good candidates for this method, as it does not require anesthetic injections and generally is pain free. Patients with resistant or recurrent PGs that did not respond to first-line treatments such as cryotherapy, tangential excision, or electrodesiccation may be more amenable to a less invasive secondary approach.

Importantly, we used a dual-therapy approach in our patient, initially using a single application of cryotherapy followed by the table salt method once daily for 2 weeks. This imposes limitations on the generalizability of table salt as a standalone approach for treating PGs. In this case, we did not have prior practical experience using table salt for this condition and only had small reports to justify its use. As a result, we attempted a more traditional treatment initially (cryotherapy) to avoid potential delays in resolution. The clinicians recommended table salt as an adjuvant prior to seeing the cryotherapy results because this treatment was benign and offered potential additive results, and therefore waiting was not necessary. However, various other cases have reported similar success using table salt as monotherapy.^6-9,11 Patients should be advised of potential mild adverse events, such as irritation to the surrounding skin. Higher-level evidence studies are required to further vet the utility of the table salt method for treatment of PGs.

The American Academy of Dermatology’s 2026 Annual Meeting in Denver, Colorado, showcased advances in clinical practice and dermatology research. Selected key updates are summarized here for concise review of emerging dermatology data relevant to clinical practice.

AI Holds Promise in Dermatology, Issues Remain to be Addressed

Artificial intelligence (AI) is rapidly advancing in dermatology, improving image analysis, clinical decision support, and workflow efficiency; however, concerns remain about ethical use, training gaps, and potential skill loss among clinicians. While AI may enhance productivity and care, experts emphasize the need for cautious implementation, education, and ongoing evaluation of real-world performance.

Phase 2b Findings Support Novel Agent to Treat Alopecia Areata

A phase 2b trial of rezpegaldesleukin for severe alopecia areata showed considerably greater reductions in SALT scores vs placebo over 36 weeks, with higher response rates and no treatment plateau. The biologic, which enhances regulatory T-cell activity, demonstrated a favorable safety profile, with mainly mild injection-site reactions and no new safety signals.

JAK Inhibitors: Identifying Ideal Candidates and Putting Real-World Risks in Context

Emerging evidence suggests Janus kinase (JAK) inhibitors are safer in dermatology than early rheumatoid arthritis data indicated. Risks for cardiovascular events, thrombosis, and malignancy appear low and largely driven by baseline patient factors. With appropriate screening and monitoring, these agents can be used safely in most patients with inflammatory skin diseases.

Nemolizumab Phase 2 Findings Positive for Children 2-11 Years Old With Atopic Dermatitis

A phase 2 open-label study of nemolizumab in children aged 2 to 11 years with moderate to severe atopic dermatitis showed notable improvements in skin clearance, disease severity, and itch with weight-based dosing. Responses were rapid, durable through 52 weeks, and consistent with prior data, with no new safety signals identified in this population.

Melasma: A New Era of Topical Treatment Options Galore

Melasma treatment is rapidly expanding beyond traditional agents such as hydroquinone and triple combination therapy, with newer topicals including tranexamic acid, cysteamine, azelaic acid, thiamidol, and emerging compounds showing variable efficacy. While promising, evidence is still evolving, and combination regimens plus strict photoprotection remain the cornerstone of management.

Weight-Loss Drug–Biologic Combination Boosts Relief in Psoriatic Arthritis

In a phase 3b trial, combining tirzepatide with ixekizumab significantly improved joint and skin outcomes in patients with psoriatic arthritis and overweight/obesity (P<.05) compared with ixekizumab alone (P<.001). The combination yielded higher American College of Rheumatology and Psoriasis Area and Severity Index response rates, early symptom improvement, and meaningful weight loss, with safety profiles consistent with known effects.

Tips on Using Biologics for Psoriasis in Context of HIV

Evidence for biologic use in HIV-positive patients with moderate to severe psoriasis is limited, but available case reports suggest tumor necrosis factor inhibitors and newer IL-targeted biologics are generally effective without major impacts on viral load or CD4 counts. Experts recommend prioritizing nonimmunosuppressive options and coordinating care with HIV specialists due to potential infection risks.

Upadacitinib Results in Significant Improvements in Nonsegmental Vitiligo in Phase 3 Studies

Two phase 3 trials showed that the Janus kinase 1 inhibitor upadacitinib significantly improved repigmentation outcomes in adolescents and adults with nonsegmental vitiligo vs placebo over 48 weeks (P<.0001 for both), with a higher proportion achieving clinically meaningful reductions in Vitiligo Area and Severity Index scores. Benefits increased over time without plateau, and no new safety signals were identified.

The American Academy of Dermatology’s 2026 Annual Meeting in Denver, Colorado, showcased advances in clinical practice and dermatology research. Selected key updates are summarized here for concise review of emerging dermatology data relevant to clinical practice.

AI Holds Promise in Dermatology, Issues Remain to be Addressed

Artificial intelligence (AI) is rapidly advancing in dermatology, improving image analysis, clinical decision support, and workflow efficiency; however, concerns remain about ethical use, training gaps, and potential skill loss among clinicians. While AI may enhance productivity and care, experts emphasize the need for cautious implementation, education, and ongoing evaluation of real-world performance.

Phase 2b Findings Support Novel Agent to Treat Alopecia Areata

A phase 2b trial of rezpegaldesleukin for severe alopecia areata showed considerably greater reductions in SALT scores vs placebo over 36 weeks, with higher response rates and no treatment plateau. The biologic, which enhances regulatory T-cell activity, demonstrated a favorable safety profile, with mainly mild injection-site reactions and no new safety signals.

JAK Inhibitors: Identifying Ideal Candidates and Putting Real-World Risks in Context

Emerging evidence suggests Janus kinase (JAK) inhibitors are safer in dermatology than early rheumatoid arthritis data indicated. Risks for cardiovascular events, thrombosis, and malignancy appear low and largely driven by baseline patient factors. With appropriate screening and monitoring, these agents can be used safely in most patients with inflammatory skin diseases.

Nemolizumab Phase 2 Findings Positive for Children 2-11 Years Old With Atopic Dermatitis

A phase 2 open-label study of nemolizumab in children aged 2 to 11 years with moderate to severe atopic dermatitis showed notable improvements in skin clearance, disease severity, and itch with weight-based dosing. Responses were rapid, durable through 52 weeks, and consistent with prior data, with no new safety signals identified in this population.

Melasma: A New Era of Topical Treatment Options Galore

Melasma treatment is rapidly expanding beyond traditional agents such as hydroquinone and triple combination therapy, with newer topicals including tranexamic acid, cysteamine, azelaic acid, thiamidol, and emerging compounds showing variable efficacy. While promising, evidence is still evolving, and combination regimens plus strict photoprotection remain the cornerstone of management.

Weight-Loss Drug–Biologic Combination Boosts Relief in Psoriatic Arthritis

In a phase 3b trial, combining tirzepatide with ixekizumab significantly improved joint and skin outcomes in patients with psoriatic arthritis and overweight/obesity (P<.05) compared with ixekizumab alone (P<.001). The combination yielded higher American College of Rheumatology and Psoriasis Area and Severity Index response rates, early symptom improvement, and meaningful weight loss, with safety profiles consistent with known effects.

Tips on Using Biologics for Psoriasis in Context of HIV

Evidence for biologic use in HIV-positive patients with moderate to severe psoriasis is limited, but available case reports suggest tumor necrosis factor inhibitors and newer IL-targeted biologics are generally effective without major impacts on viral load or CD4 counts. Experts recommend prioritizing nonimmunosuppressive options and coordinating care with HIV specialists due to potential infection risks.

Upadacitinib Results in Significant Improvements in Nonsegmental Vitiligo in Phase 3 Studies

Two phase 3 trials showed that the Janus kinase 1 inhibitor upadacitinib significantly improved repigmentation outcomes in adolescents and adults with nonsegmental vitiligo vs placebo over 48 weeks (P<.0001 for both), with a higher proportion achieving clinically meaningful reductions in Vitiligo Area and Severity Index scores. Benefits increased over time without plateau, and no new safety signals were identified.

The American Academy of Dermatology’s 2026 Annual Meeting in Denver, Colorado, showcased advances in clinical practice and dermatology research. Selected key updates are summarized here for concise review of emerging dermatology data relevant to clinical practice.

AI Holds Promise in Dermatology, Issues Remain to be Addressed

Artificial intelligence (AI) is rapidly advancing in dermatology, improving image analysis, clinical decision support, and workflow efficiency; however, concerns remain about ethical use, training gaps, and potential skill loss among clinicians. While AI may enhance productivity and care, experts emphasize the need for cautious implementation, education, and ongoing evaluation of real-world performance.

Phase 2b Findings Support Novel Agent to Treat Alopecia Areata

A phase 2b trial of rezpegaldesleukin for severe alopecia areata showed considerably greater reductions in SALT scores vs placebo over 36 weeks, with higher response rates and no treatment plateau. The biologic, which enhances regulatory T-cell activity, demonstrated a favorable safety profile, with mainly mild injection-site reactions and no new safety signals.

JAK Inhibitors: Identifying Ideal Candidates and Putting Real-World Risks in Context

Emerging evidence suggests Janus kinase (JAK) inhibitors are safer in dermatology than early rheumatoid arthritis data indicated. Risks for cardiovascular events, thrombosis, and malignancy appear low and largely driven by baseline patient factors. With appropriate screening and monitoring, these agents can be used safely in most patients with inflammatory skin diseases.

Nemolizumab Phase 2 Findings Positive for Children 2-11 Years Old With Atopic Dermatitis

A phase 2 open-label study of nemolizumab in children aged 2 to 11 years with moderate to severe atopic dermatitis showed notable improvements in skin clearance, disease severity, and itch with weight-based dosing. Responses were rapid, durable through 52 weeks, and consistent with prior data, with no new safety signals identified in this population.

Melasma: A New Era of Topical Treatment Options Galore

Melasma treatment is rapidly expanding beyond traditional agents such as hydroquinone and triple combination therapy, with newer topicals including tranexamic acid, cysteamine, azelaic acid, thiamidol, and emerging compounds showing variable efficacy. While promising, evidence is still evolving, and combination regimens plus strict photoprotection remain the cornerstone of management.

Weight-Loss Drug–Biologic Combination Boosts Relief in Psoriatic Arthritis

In a phase 3b trial, combining tirzepatide with ixekizumab significantly improved joint and skin outcomes in patients with psoriatic arthritis and overweight/obesity (P<.05) compared with ixekizumab alone (P<.001). The combination yielded higher American College of Rheumatology and Psoriasis Area and Severity Index response rates, early symptom improvement, and meaningful weight loss, with safety profiles consistent with known effects.

Tips on Using Biologics for Psoriasis in Context of HIV

Evidence for biologic use in HIV-positive patients with moderate to severe psoriasis is limited, but available case reports suggest tumor necrosis factor inhibitors and newer IL-targeted biologics are generally effective without major impacts on viral load or CD4 counts. Experts recommend prioritizing nonimmunosuppressive options and coordinating care with HIV specialists due to potential infection risks.

Upadacitinib Results in Significant Improvements in Nonsegmental Vitiligo in Phase 3 Studies

Two phase 3 trials showed that the Janus kinase 1 inhibitor upadacitinib significantly improved repigmentation outcomes in adolescents and adults with nonsegmental vitiligo vs placebo over 48 weeks (P<.0001 for both), with a higher proportion achieving clinically meaningful reductions in Vitiligo Area and Severity Index scores. Benefits increased over time without plateau, and no new safety signals were identified.

How might AI enhance the detection of key histologic features in drug eruptions compared to traditional microscopy?

DR. BRIDGES: AI offers the potential to enhance detection of histologic features in drug eruptions by systematically analyzing entire whole-slide images. Convolutional neural networks and attention-based models can identify subtle or focal findings such as scattered dyskeratotic keratinocytes, focal spongiosis, early interface change, rare eosinophils, or microvascular injury, which may be overlooked during routine microscopy due to sampling limitations. This capability is particularly relevant in drug eruptions, where histologic changes often are heterogeneous and patchy.

AI-generated attention heatmaps can highlight diagnostically relevant regions across the slide, improving consistency and completeness of slide reviews. While AI has demonstrated high sensitivity and specificity in broader dermatopathology tasks, particularly neoplastic conditions, drug eruption–specific validation data are currently lacking. As such, the most realistic application at present is AI functioning as a sensitivity-enhancing adjunct or “second reader,” improving consistency and completeness of slide review while preserving expert human interpretation.

Which histologic patterns in drug eruptions are hardest to quantify, and how could AI help standardize their assessment?

DR. BRIDGES: AI-based image analysis can standardize the assessment of histologic patterns through objective reproducible quantification. Deep learning algorithms can segment epidermal and dermal compartments, identify inflammatory cell types, and calculate metrics such as eosinophil density per unit area, percentage of epidermis with vacuolar alteration, or number of affected vessels. Studies in quantitative immunohistochemistry demonstrate high accuracy for tissue segmentation and cell counting, suggesting feasibility for similar applications in inflammatory dermatopathology. While these tools would not replace diagnostic interpretation, they could provide standardized measurements that enhance reproducibility and improve clinicopathologic correlation.

What training challenges must be addressed in AI and drug eruption histology?

DR. BRIDGES: Training AI models for drug eruption histopathology faces several challenges, including the limited availability of high-quality, well-annotated datasets, as most existing AI dermatopathology research focuses on neoplastic conditions. Drug eruptions also exhibit marked histologic heterogeneity, ranging from spongiotic and lichenoid to vasculitic and cytotoxic patterns, often with significant overlap. Accurate labeling, therefore, requires robust clinicopathologic correlation, including medication history, timing, laboratory data, and clinical outcomes—information that is often incomplete or retrospective.

Inaccurate or inconsistent annotations can significantly degrade model performance, and expert disagreement in borderline cases further complicates the creation of reliable ground truth. Additionally, training data may reflect institutional or demographic biases, risking unequal performance across patient populations. Addressing these challenges will require multicenter collaboration, standardized annotation protocols, inclusion of diverse patient cohorts, and careful attention to bias mitigation. At present, these barriers place drug eruption AI firmly in the investigational rather than clinical domain.

How important is AI explainability in the interpretation of diagnostic suggestions?

DR. BRIDGES: Explainability is essential for trust, particularly in the evaluation of drug eruptions, where diagnostic decisions can have serious clinical consequences. Dermatopathologists must understand which histologic features are driving an AI model’s assessment to ensure that conclusions align with morphologic reality and clinicopathologic reasoning. Explainable AI tools (such as attention heatmaps, feature importance rankings, and methods like Shapley Additive Explanations or Local Interpretable Model-Agnostic Explanations) can help clarify which histologic features are driving the AI model’s assessment.

Without transparency, AI systems function as “black boxes,” limiting their utility in high-stakes settings where diagnostic accountability and clinical communication are paramount. Explainability also supports appropriate skepticism, allowing pathologists to recognize when model outputs may be unreliable due to artifacts, atypical patterns, or out-of-distribution cases. In cases of drug eruptions—where diagnosis relies on combining histology, clinical timing, and medication history—explainability is essential for proper use.

How could AI pattern recognition be integrated into your workflow to enhance diagnostic efficiency and accuracy? What safeguards would be required?

DR. BRIDGES: In the near term, AI pattern recognition can be useful as an assistive tool rather than a diagnostic authority. One potential application is pre-screening whole-slide images to flag cases with features such as prominent interface change, increased keratinocyte necrosis, eosinophil-rich infiltrates, or vascular injury, prompting expedited review in clinically concerning scenarios. During sign-out, AI overlays could aid efficiency by highlighting rare but relevant features and providing quantitative summaries that support standardized reporting.

Safeguards are essential. AI systems must be validated across diverse practice settings, staining protocols, and scanning platforms. Human oversight is mandatory, with the dermatopathologist retaining full diagnostic responsibility. AI involvement should be clearly documented for medicolegal transparency, and performance should be continuously monitored to detect algorithmic drift as new drug eruption patterns emerge. Given current limitations, AI is best viewed as a tool to refine and support expert judgment, not replace it.

What data-sharing or privacy challenges must be addressed to develop robust AI models for diverse drug-eruption histopathology?

DR. BRIDGES: Developing robust AI models for drug eruptions requires large diverse datasets, raising significant privacy and governance challenges. Rigorous de-identification protocols, clear informed consent frameworks, and strong institutional oversight are therefore essential. Multicenter collaborations must employ secure data-use agreements and governance structures that clearly define access, ownership, and downstream use of data.

Ensuring equitable representation is equally critical, as underrepresentation of certain populations may lead to biased performance and disparities in care. Standardized data formats and interoperable systems are needed to facilitate collaboration while preserving security. Transparent governance structures, clear rules regarding data use, and trust-building with patients and institutions will ultimately determine willingness to participate. Addressing these challenges is foundational to advancing AI research in drug eruptions responsibly and ethically.

How might AI enhance the detection of key histologic features in drug eruptions compared to traditional microscopy?

DR. BRIDGES: AI offers the potential to enhance detection of histologic features in drug eruptions by systematically analyzing entire whole-slide images. Convolutional neural networks and attention-based models can identify subtle or focal findings such as scattered dyskeratotic keratinocytes, focal spongiosis, early interface change, rare eosinophils, or microvascular injury, which may be overlooked during routine microscopy due to sampling limitations. This capability is particularly relevant in drug eruptions, where histologic changes often are heterogeneous and patchy.

AI-generated attention heatmaps can highlight diagnostically relevant regions across the slide, improving consistency and completeness of slide reviews. While AI has demonstrated high sensitivity and specificity in broader dermatopathology tasks, particularly neoplastic conditions, drug eruption–specific validation data are currently lacking. As such, the most realistic application at present is AI functioning as a sensitivity-enhancing adjunct or “second reader,” improving consistency and completeness of slide review while preserving expert human interpretation.

Which histologic patterns in drug eruptions are hardest to quantify, and how could AI help standardize their assessment?

DR. BRIDGES: AI-based image analysis can standardize the assessment of histologic patterns through objective reproducible quantification. Deep learning algorithms can segment epidermal and dermal compartments, identify inflammatory cell types, and calculate metrics such as eosinophil density per unit area, percentage of epidermis with vacuolar alteration, or number of affected vessels. Studies in quantitative immunohistochemistry demonstrate high accuracy for tissue segmentation and cell counting, suggesting feasibility for similar applications in inflammatory dermatopathology. While these tools would not replace diagnostic interpretation, they could provide standardized measurements that enhance reproducibility and improve clinicopathologic correlation.

What training challenges must be addressed in AI and drug eruption histology?

DR. BRIDGES: Training AI models for drug eruption histopathology faces several challenges, including the limited availability of high-quality, well-annotated datasets, as most existing AI dermatopathology research focuses on neoplastic conditions. Drug eruptions also exhibit marked histologic heterogeneity, ranging from spongiotic and lichenoid to vasculitic and cytotoxic patterns, often with significant overlap. Accurate labeling, therefore, requires robust clinicopathologic correlation, including medication history, timing, laboratory data, and clinical outcomes—information that is often incomplete or retrospective.

Inaccurate or inconsistent annotations can significantly degrade model performance, and expert disagreement in borderline cases further complicates the creation of reliable ground truth. Additionally, training data may reflect institutional or demographic biases, risking unequal performance across patient populations. Addressing these challenges will require multicenter collaboration, standardized annotation protocols, inclusion of diverse patient cohorts, and careful attention to bias mitigation. At present, these barriers place drug eruption AI firmly in the investigational rather than clinical domain.

How important is AI explainability in the interpretation of diagnostic suggestions?

DR. BRIDGES: Explainability is essential for trust, particularly in the evaluation of drug eruptions, where diagnostic decisions can have serious clinical consequences. Dermatopathologists must understand which histologic features are driving an AI model’s assessment to ensure that conclusions align with morphologic reality and clinicopathologic reasoning. Explainable AI tools (such as attention heatmaps, feature importance rankings, and methods like Shapley Additive Explanations or Local Interpretable Model-Agnostic Explanations) can help clarify which histologic features are driving the AI model’s assessment.

Without transparency, AI systems function as “black boxes,” limiting their utility in high-stakes settings where diagnostic accountability and clinical communication are paramount. Explainability also supports appropriate skepticism, allowing pathologists to recognize when model outputs may be unreliable due to artifacts, atypical patterns, or out-of-distribution cases. In cases of drug eruptions—where diagnosis relies on combining histology, clinical timing, and medication history—explainability is essential for proper use.

How could AI pattern recognition be integrated into your workflow to enhance diagnostic efficiency and accuracy? What safeguards would be required?

DR. BRIDGES: In the near term, AI pattern recognition can be useful as an assistive tool rather than a diagnostic authority. One potential application is pre-screening whole-slide images to flag cases with features such as prominent interface change, increased keratinocyte necrosis, eosinophil-rich infiltrates, or vascular injury, prompting expedited review in clinically concerning scenarios. During sign-out, AI overlays could aid efficiency by highlighting rare but relevant features and providing quantitative summaries that support standardized reporting.

Safeguards are essential. AI systems must be validated across diverse practice settings, staining protocols, and scanning platforms. Human oversight is mandatory, with the dermatopathologist retaining full diagnostic responsibility. AI involvement should be clearly documented for medicolegal transparency, and performance should be continuously monitored to detect algorithmic drift as new drug eruption patterns emerge. Given current limitations, AI is best viewed as a tool to refine and support expert judgment, not replace it.

What data-sharing or privacy challenges must be addressed to develop robust AI models for diverse drug-eruption histopathology?

DR. BRIDGES: Developing robust AI models for drug eruptions requires large diverse datasets, raising significant privacy and governance challenges. Rigorous de-identification protocols, clear informed consent frameworks, and strong institutional oversight are therefore essential. Multicenter collaborations must employ secure data-use agreements and governance structures that clearly define access, ownership, and downstream use of data.

Ensuring equitable representation is equally critical, as underrepresentation of certain populations may lead to biased performance and disparities in care. Standardized data formats and interoperable systems are needed to facilitate collaboration while preserving security. Transparent governance structures, clear rules regarding data use, and trust-building with patients and institutions will ultimately determine willingness to participate. Addressing these challenges is foundational to advancing AI research in drug eruptions responsibly and ethically.

How might AI enhance the detection of key histologic features in drug eruptions compared to traditional microscopy?

DR. BRIDGES: AI offers the potential to enhance detection of histologic features in drug eruptions by systematically analyzing entire whole-slide images. Convolutional neural networks and attention-based models can identify subtle or focal findings such as scattered dyskeratotic keratinocytes, focal spongiosis, early interface change, rare eosinophils, or microvascular injury, which may be overlooked during routine microscopy due to sampling limitations. This capability is particularly relevant in drug eruptions, where histologic changes often are heterogeneous and patchy.

AI-generated attention heatmaps can highlight diagnostically relevant regions across the slide, improving consistency and completeness of slide reviews. While AI has demonstrated high sensitivity and specificity in broader dermatopathology tasks, particularly neoplastic conditions, drug eruption–specific validation data are currently lacking. As such, the most realistic application at present is AI functioning as a sensitivity-enhancing adjunct or “second reader,” improving consistency and completeness of slide review while preserving expert human interpretation.

Which histologic patterns in drug eruptions are hardest to quantify, and how could AI help standardize their assessment?

DR. BRIDGES: AI-based image analysis can standardize the assessment of histologic patterns through objective reproducible quantification. Deep learning algorithms can segment epidermal and dermal compartments, identify inflammatory cell types, and calculate metrics such as eosinophil density per unit area, percentage of epidermis with vacuolar alteration, or number of affected vessels. Studies in quantitative immunohistochemistry demonstrate high accuracy for tissue segmentation and cell counting, suggesting feasibility for similar applications in inflammatory dermatopathology. While these tools would not replace diagnostic interpretation, they could provide standardized measurements that enhance reproducibility and improve clinicopathologic correlation.

What training challenges must be addressed in AI and drug eruption histology?

DR. BRIDGES: Training AI models for drug eruption histopathology faces several challenges, including the limited availability of high-quality, well-annotated datasets, as most existing AI dermatopathology research focuses on neoplastic conditions. Drug eruptions also exhibit marked histologic heterogeneity, ranging from spongiotic and lichenoid to vasculitic and cytotoxic patterns, often with significant overlap. Accurate labeling, therefore, requires robust clinicopathologic correlation, including medication history, timing, laboratory data, and clinical outcomes—information that is often incomplete or retrospective.

Inaccurate or inconsistent annotations can significantly degrade model performance, and expert disagreement in borderline cases further complicates the creation of reliable ground truth. Additionally, training data may reflect institutional or demographic biases, risking unequal performance across patient populations. Addressing these challenges will require multicenter collaboration, standardized annotation protocols, inclusion of diverse patient cohorts, and careful attention to bias mitigation. At present, these barriers place drug eruption AI firmly in the investigational rather than clinical domain.

How important is AI explainability in the interpretation of diagnostic suggestions?

DR. BRIDGES: Explainability is essential for trust, particularly in the evaluation of drug eruptions, where diagnostic decisions can have serious clinical consequences. Dermatopathologists must understand which histologic features are driving an AI model’s assessment to ensure that conclusions align with morphologic reality and clinicopathologic reasoning. Explainable AI tools (such as attention heatmaps, feature importance rankings, and methods like Shapley Additive Explanations or Local Interpretable Model-Agnostic Explanations) can help clarify which histologic features are driving the AI model’s assessment.

Without transparency, AI systems function as “black boxes,” limiting their utility in high-stakes settings where diagnostic accountability and clinical communication are paramount. Explainability also supports appropriate skepticism, allowing pathologists to recognize when model outputs may be unreliable due to artifacts, atypical patterns, or out-of-distribution cases. In cases of drug eruptions—where diagnosis relies on combining histology, clinical timing, and medication history—explainability is essential for proper use.

How could AI pattern recognition be integrated into your workflow to enhance diagnostic efficiency and accuracy? What safeguards would be required?

DR. BRIDGES: In the near term, AI pattern recognition can be useful as an assistive tool rather than a diagnostic authority. One potential application is pre-screening whole-slide images to flag cases with features such as prominent interface change, increased keratinocyte necrosis, eosinophil-rich infiltrates, or vascular injury, prompting expedited review in clinically concerning scenarios. During sign-out, AI overlays could aid efficiency by highlighting rare but relevant features and providing quantitative summaries that support standardized reporting.

Safeguards are essential. AI systems must be validated across diverse practice settings, staining protocols, and scanning platforms. Human oversight is mandatory, with the dermatopathologist retaining full diagnostic responsibility. AI involvement should be clearly documented for medicolegal transparency, and performance should be continuously monitored to detect algorithmic drift as new drug eruption patterns emerge. Given current limitations, AI is best viewed as a tool to refine and support expert judgment, not replace it.

What data-sharing or privacy challenges must be addressed to develop robust AI models for diverse drug-eruption histopathology?

DR. BRIDGES: Developing robust AI models for drug eruptions requires large diverse datasets, raising significant privacy and governance challenges. Rigorous de-identification protocols, clear informed consent frameworks, and strong institutional oversight are therefore essential. Multicenter collaborations must employ secure data-use agreements and governance structures that clearly define access, ownership, and downstream use of data.

Ensuring equitable representation is equally critical, as underrepresentation of certain populations may lead to biased performance and disparities in care. Standardized data formats and interoperable systems are needed to facilitate collaboration while preserving security. Transparent governance structures, clear rules regarding data use, and trust-building with patients and institutions will ultimately determine willingness to participate. Addressing these challenges is foundational to advancing AI research in drug eruptions responsibly and ethically.