Sarcoidosis and atopic dermatitis (AD) are chronic inflammatory conditions with distinct immunologic profiles but overlapping disparities in prevalence and severity among Black Americans populations. We report a rare case of a 58-year-old Black woman with refractory cutaneous sarcoidosis and AD overlap, who presented with severely pruritic, erythematous, scaly lesions primarily on the face, scalp, and neck. Histopathologic examination revealed granulomatous inflammation. Standard topical and systemic therapies were ineffective. Initiation of upadacitinib, a selective Janus kinase (JAK) inhibitor, resulted in dramatic symptom improvement within 1 month, with a pruritus reduction from a peak pruritus Numeric Rating Scale score of 9/10 to 1/10. This case underscores the therapeutic potential of JAK inhibition in addressing convergent inflammatory pathways across traditionally distinct dermatoses, particularly in patients from populations at increased risk for treatment-refractory disease.
Cutaneous vasculitis is frequently encountered in dermatology practice and is often limited to the skin. However, a subset of patients may have associated systemic involvement affecting the renal, gastrointestinal, pulmonary, or neurologic systems. Distinguishing self-limited cutaneous disease from potentially serious systemic vasculitis can be clinically challenging, particularly in the absence of formal diagnostic guidelines. This brief report reviews factors associated with systemic involvement, including constitutional symptoms, gastrointestinal complaints, hematuria, and ulcerative or necrotic lesions. The role of laboratory evaluation, histopathology, and direct immunofluorescence in guiding risk stratification and targeted workup escalation is also discussed. A focused, evidence-based approach may help dermatology clinicians reduce diagnostic uncertainty while avoiding unnecessary testing.
Confluent and reticulated papillomatosis (CARP) is a rare keratinization disorder typically presenting as hyperpigmented, scaly papules that coalesce into reticulated plaques on the trunk of adolescents and young adults. Hypopigmented variants have only rarely been reported and are frequently misdiagnosed as tinea versicolor, resulting in delayed diagnosis and unnecessary antifungal therapy. We describe 2 young adults with biopsy-confirmed hypopigmented CARP who initially received multiple courses of oral and topical antifungal agents with minimal to no benefit. Both patients demonstrated widespread hypopigmented, scaly, coalescing plaques. Following histopathologic confirmation, antifungal treatments were discontinued, and oral minocycline was initiated, leading to clinical improvement. These cases add to the limited literature describing hypopigmented CARP and underscore that the disease's defining features are distribution and morphology rather than pigmentation. Recognition of this rarely reported variant is essential for timely diagnosis and initiation of appropriate treatment.
OBJECTIVE:To demonstrate the safety and enhanced cosmetic outcomes of the combination of microneedling with a pigment-correcting peel when treating hyperpigmented skin across diverse Fitzpatrick skin types. METHODS:A total of 31 patients (Fitzpatrick skin types I-V) with facial hyperpigmentation were enrolled in the study. Each participant received 2 different treatments on the face: 1 side was treated with a pigment-correcting peel combined with microneedling, while the other side received microneedling alone (3 sessions, 4 weeks apart). Assessments included Mexameter measurements, dermatologist grading, and standardized clinical imaging. Self-assessment questionnaires were completed by participants at different timepoints. RESULTS:The 31 participants completed the study; both microneedling alone and the combination treatment were well tolerated. The combined approach yielded significantly better results according to dermatologist efficacy assessment for clarity/brightness, evenness of skin tone (pigmentation and redness), overall appearance and texture (P<0.05), and patient perception, with 94% reporting a significant or noticeable improvement on skin discoloration/hyperpigmentation on the side treated with combination therapy and 90% reporting they prefer the results of the combination therapy vs microneedling alone (P<0.0001). LIMITATIONS:A primary limitation of this study was the restricted assessment window, which proved to be insufficient to achieve significant clinical improvement for parameters such as fine lines, wrinkles, and pore size. CONCLUSION:This research showed that combining a pigment-correcting peel with microneedling can be significantly more effective at improving overall skin appearance than microneedling alone. This combined therapy was safe, well tolerated, and preferred by participants across a diverse population.
OBJECTIVE:To describe the clinical characteristics, treatment responses, and outcomes of patients with Trichophyton indotineae infection in New York state and to contribute to the collective knowledge necessary for appropriate antifungal stewardship and management strategies. METHODS:We conducted a retrospective cohort study of 20 patients with culture-confirmed T. indotineae infection seen across New York City between June 2023 and April 2025. Demographic data, clinical features, medical history, and treatment outcomes were collected. All patient data were deidentified, and informed consent was waived. RESULTS:Patients were evenly distributed by gender, with a mean age of 43.8 years for men and 33.4 years for women. All patients reported pruritus and, notably, 90% had intact immune function. Common presentations included tinea corporis and tinea cruris. Itraconazole was the most effective first-line therapy; however, there was a high rate of recurrence after stopping the treatment. Griseofulvin, voriconazole, and fluconazole showed some success. LIMITATIONS:This study is limited by a small sample size and reliance on self-reported medical histories. Additionally, the study did not assess the impact of topical antifungal use or combination oral antifungal therapy on treatment efficacy. CONCLUSION:T. indotineae presents diagnostic and therapeutic challenges due to its atypical clinical features and antifungal resistance. Early recognition and appropriate systemic antifungal therapy are critical. Itraconazole remains the preferred first-line agent based on current clinical experience. Greater clinician awareness and further research are urgently needed to address the rising burden of this infection.
BACKGROUND:Hedgehog pathway inhibitors (HHIs) target aberrant Hedgehog signaling as a treatment of basal cell carcinomas (BCCs) but are limited by poorly tolerated adverse events (AEs) and development of resistance. To address these challenges, combination regimens have been investigated to improve tumor clearance while mitigating toxicity. OBJECTIVE:To investigate the landscape and mechanisms behind combination therapies involving HHIs for locally advanced BCC and identify patient populations most likely to benefit from each combination regimen. METHODS:Comprehensive PubMed and ClinicalTrials.gov searches were conducted for BCC combination therapies involving HHIs. Literature was analyzed following PRISMA guidelines and reviewed independently by 2 reviewers, with a third resolving conflicts. Nine studies were included, involving either vismodegib or sonidegib with concomitant itraconazole, radiation therapy, photodynamic therapy (PDT), pembrolizumab, intratumoral immunotherapy, or surgical debulking. Outcomes from combination therapies were compared to respective monotherapy outcomes from the ERIVANCE and STEVIE trials for vismodegib and the BOLT trial for sonidegib. RESULTS:Of studies reviewed, 89% demonstrated superior outcomes measured in objective response ratio (ORR) compared to monotherapy. The highest mean ORR of 100% was demonstrated in the combination therapies of sonidegib with radiation and vismodegib with PDT. The regimen with the worst efficacy was vismodegib with pembrolizumab, with an ORR of 29%, which was worse than the respective monotherapies. Additionally, 71% of combination studies revealed a smaller percentage of patients lost to AE when compared to the respective monotherapy trials. Most tolerable combinations included sonidegib with itraconazole, sonidegib with radiation, and vismodegib with intratumoral immunotherapy. Lastly, 75% of combination therapy studies reported a better tolerability profile when compared to monotherapy. LIMITATIONS:Limitations included the low number of studies in the literature on HHI combination therapies, small study population sizes, lack of heterogeneity of regimens, and study designs involving case reports and series. CONCLUSION:Combination strategies for HHI therapy represent a promising avenue to optimize efficacy, improve tolerability, and expand therapeutic options for patients with BCC.
OBJECTIVE:To elucidate the critical necessity of a foundational background in primary or acute care for physicians, nurses, nurse practitioners (NPs), and physician associates (PAs) transitioning into the specialty of medical aesthetics, focusing on the identification of previously missed or undiagnosed health issues and enhanced patient safety. MAIN POINTS OF DISCUSSION:The aesthetic medicine industry has seen a surge in providers from diverse backgrounds. However, without the diagnostic rigor and comprehensive patient assessment skills gleaned in primary or acute care settings, practitioners are at risk of overlooking significant medical conditions that can impact treatment outcomes, patient safety, and overall wellbeing. This article discusses how extensive experience in both acute care and general medicine provide the essential competencies needed to identify subtle red flags missed by others, manage complex comorbidities, and respond effectively to health emergencies within the aesthetic setting. It also discusses the need for a standardized board certification in the specialty of medical aesthetics to qualify the provider's previous experience along with assessing their current aesthetic knowledge base. CONCLUSION:A robust background in primary or acute care should be a recognized prerequisite for physicians, nurses, NPs, and PAs entering the specialty of medical aesthetics. This foundational experience is key to developing comprehensive assessment skills, rapid health history, and differential diagnosis formation, along with developing the much needed "gut instinct" or "sixth sense," elevating the standard of practice, ensuring comprehensive patient care, and enhancing patient safety in a specialty often focused predominantly on objective cosmetic outcomes. To assure providers have a foundational knowledge base in both medicine and aesthetics, a national certifying body with examination is recommended.
INTRODUCTION:Access to dermatologic care remains a persistent challenge in the United States, particularly in rural and underserved areas. Delays in dermatologic evaluation and treatment are compounded by provider shortages, long wait times, and geographic barriers. Emerging tools such as artificial intelligence (AI), AI-assisted triage, and teledermatology platforms might offer scalable solutions to improve access and reduce delays. This article evaluates whether AI-assisted technology, compared to traditional in-person dermatology care, shortens wait times to less than 30 days for patients living in provider shortage areas. METHODS:A systematic review was conducted between March and June 2025 following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed and academic library databases were queried using the following Boolean queries: "Artificial intelligence triage dermatology" and "dermatology AND access AND teledermatology AND care AND wait times." Studies were screened for relevance, and 41 met the inclusion criteria. A narrative synthesis was used due to heterogeneity in study designs and outcome measures. Each study was appraised using the Joanna Briggs Institute (JBI) critical appraisal tools. RESULTS:Included studies demonstrated that AI-assisted technologies, particularly when integrated into teledermatology systems, significantly reduced dermatology wait times, often to fewer than 30 days. Store-and-forward platforms enabled expedited triage, while AI-supported decision tools improved diagnostic accuracy (85-97% sensitivity) and reduced unnecessary referrals. Task shifting to nonspecialist providers with AI support was found to be safe and effective. Despite promising outcomes, concerns related to image quality, algorithmic bias, and uneven implementation remain. CONCLUSION:AI-assisted dermatologic tools show strong potential to improve access to care and reduce wait times in provider shortage areas. These technologies could support timely diagnosis, streamline referrals, and enable safe task shifting to primary care teams. Importantly, findings highlight the role of nurse practitioners (NPs), particularly those with limited dermatology training, in leveraging AI as both an educational and clinical decision support tool. By providing differential diagnoses, confidence scores, and visual explanations, AI can strengthen NP diagnostic confidence, reduce unnecessary referrals, and expand access to timely dermatologic care in underserved settings. Future research should focus on implementation in resource-limited settings, nurse-led AI triage models, and long-term health outcomes.
Dermatological Conditions in Skin of Color is a column that provides insight on the different presentations, misdiagnoses, and other challenges that patients with skin of color can present with at the dermatology office.
BACKGROUND:Atrophic scars have a significant psychosocial and functional impact on quality of life. Chemical reconstruction of skin scars (CROSS) using trichloroacetic acid (TCA) has emerged as an effective procedure for targeted treatment of atrophic scars, yet application methods and efficacy vary across scar types and patient populations. OBJECTIVE:To evaluate the methodology, indications, efficacy, and safety profile of the TCA CROSS technique in atrophic scarring and to compare TCA CROSS outcomes to other therapeutic modalities and assesses its adjunctive use. METHODS:A PubMed literature search was performed for clinical studies evaluating TCA application in scar management; inclusion criteria focused on studies using the CROSS technique published after 2002. Two reviewers independently screened 133 results: 34 publications (20 clinical trials, 4 comparative/cohort studies, 4 case series, 2 case reports, and 4 expert opinions) met eligibility criteria. RESULTS:In total, 937 patients (predominantly female, aged 4-65 years, Fitzpatrick skin types I-V) were included. TCA CROSS was primarily used for ice pick and boxcar acne scars, but it was also used for varicella and leishmaniasis scars. Application techniques varied, with fine-gauge needles and paintbrushes enabling more precise delivery. Multiple sessions yielded greater improvement, and higher TCA concentrations increased the risk of complications. Patient satisfaction was generally high, with improvement rates of 50% to 80%. The most common adverse events were transient postinflammatory pigmentary changes. CONCLUSION:TCA CROSS is a safe, effective option for treating atrophic scars. Methodical application and multimodality approaches optimize patient outcomes; further research should address technique standardization and efficacy across diverse skin types.
INTRODUCTION:Palmoplantar psoriasis is a clinically challenging variant of psoriasis in which lesions confined to the palms and soles frequently impair function and prove refractory to conventional therapeutic approaches. A range of therapies, including topical corticosteroids, phototherapy, systemic agents, small molecules, and biologics, are used in palmoplantar psoriasis. Among biologics, those targeting interleukin (IL)-17 and IL-23 are guideline-endorsed for moderate-to-severe disease and are commonly employed in palmoplantar involvement, although responses are often less predictable than in plaque psoriasis. Brodalumab, an IL-17 receptor A (IL-17RA) antagonist, uniquely inhibits signaling from multiple IL-17 family cytokines, which could account for its efficacy in patients who fail other targeted therapies. CASE REPORT:This is a case report on a patient presenting with palmoplantar psoriasis that was resistant to topical and systemic corticosteroids. A 62-year-old White male patient with obesity presented with chronic palmoplantar psoriasis and was unsuccessfully treated with guselkumab and ixekizumab. Disease persistence severely affected the patient's work performance. Brodalumab initiation resulted in complete skin clearance within 3 months with no adverse effects, and the patient resumed working full-time. CONCLUSION:This case highlights the potential role of IL-17RA blockade in localized, treatment-resistant psoriasis and supports further investigation into its use for palmoplantar disease.
BACKGROUND:Clinical guidelines serve as summaries of available treatment options, often coupled with specific recommendations related to treatment selection, and have benefits and limitations. Guidelines often influence how individual clinicians and/or third-party payors select treatments for patients. OBJECTIVE:This expert position article reviews the intent of treatment guidelines, discusses guidelines for topical psoriasis therapies, and provides recommendations for guideline updates. The recommended approaches discussed in this article by the authors align directly with therapy selection made when clinicians incorporate shared decision-making with the individual patient. METHODS:A comprehensive literature search of PubMed, Scopus, and Google Scholar was completed on May 20, 2025, using a combination of keywords "psoriasis," "topical," "treatments," "adverse effects," and "clinical guidelines" along with Boolean term "AND" for English-language original research articles, systematic reviews, narrative reviews, and meta-analyses without date restrictions. The expert position presented by the authors is limited to a discussion of topical therapies for psoriasis. RESULTS:Clinical guidelines are developed with the overall intent of enhancing healthcare quality; however, they are not designed to constrain or supplant the clinician's decisions in determining a suitable treatment for an individual patient. Limitations of published guidelines include susceptibility to becoming outdated, lack of individualized care, variability in development, and incomplete reflection of evolving practice patterns or individual patient circumstances. The results of this review of clinical guidelines reflect the authors' conclusions from analysis of the published data, including the evaluation of how they may influence treatment selection for psoriasis by clinicians. Regarding topical psoriasis treatment, initial therapy should be supported by Food and Drug Administration (FDA) approval and labeling. These include topical roflumilast, tapinarof, topical corticosteroids, and vitamin D analogs in the same category, with no utilization management criteria dictating order of use. LIMITATIONS:The results of this review are limited by the inability to include literature that was not present in the databases queried. As this review is based on previously published data, there is potential for reporting and publication bias. CONCLUSION:This expert position paper encourages decision-makers to work with clinicians in providing individualized, accessible care, rather than relying solely on treatment guidelines to establish utilization management protocols. It is crucial that clinical guidelines evolve in a timely manner to reflect new therapeutic developments. Following FDA-approved indications, step-through requirements for any topical psoriasis therapy need to be abandoned, as this results in delays in treatment for the patient, unnecessary healthcare costs, and wasted use of healthcare resources.
BACKGROUND:Hyperbaric oxygen therapy (HBOT) has been used in ischemic and inflammatory conditions due to its ability to enhance tissue oxygenation and support wound healing. Filler-induced vascular occlusion (FIVO) is a rare but potentially devastating complication of dermal filler injections that may result in skin necrosis or vision loss. HBOT has been increasingly reported as an adjunctive intervention in FIVO, but its reported use has not been systematically summarized. OBJECTIVE:To summarize the existing literature on HBOT use in FIVO, describe reported clinical contexts and treatment parameters, and identify gaps in current knowledge. METHODS:This scoping review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines. A comprehensive search of PubMed, MEDLINE, Embase, and Google Scholar identified case reports, case series, experimental studies, and reviews describing FIVO cases managed with HBOT. Articles published in English or Spanish between January 2011 and May 2025 were included. Data were synthesized descriptively. RESULTS:Twenty-four studies met inclusion criteria, consisting primarily of case reports and small case series. HBOT was most often used as an adjunct to established therapies, including hyaluronidase, antiplatelet agents, vasodilators, and thrombolytic therapy. Reported HBOT protocols varied substantially, with treatment pressures of 2.0 to 3.0 atmospheres absolute and session durations of 60 to 120 minutes. Outcomes were heterogeneous and frequently confounded by multimodal management. CONCLUSION:HBOT has been reported as an adjunctive intervention in selected cases of FIVO, but evidence remains limited to low-level observational data, highlighting the need for standardized protocols and prospective studies.
Atopic dermatitis (AD) and alopecia areata (AA) are chronic immune-mediated disorders that frequently coexist in the same patient, an observation noted in both pediatric and adult populations. The clinical implications of a patient experiencing both disease states simultaneously underscores the need for a deeper understanding of pathophysiology of both disease states, how to optimally utilize specific therapeutic options to achieve synergistic outcomes, suggest simplified rational approaches to treatment selection, how to integrate care with other specialists when needed, and hopefully reach the ultimate goal of clinicians incorporating more personalized treatment selection through immunophenotype-guided therapy. This article , based primarily on emerging case reports and off-label data, reviews all the above implications when encountering a patient with both AD and AA. Continued research and real-world clinical evidence are needed in this important area that affects many individuals that clinicians encounter in their practice, including within the pediatric population.
OBJECTIVE:To investigate the association between skin bleaching agents and the development of cutaneous malignancy. METHODS:A scoping literature search was conducted in the PubMed and Google Scholar databases to identify studies and reports that included both skin depigmentation practices and development of cutaneous malignancy. Articles published in English and French were considered for review. RESULTS:To date, reports are limited to a relatively small number of case reports in Africa. The most common skin bleaching agents used were topical clobetasol and hydroquinone with a duration of at least 15 years. Most patients had a reported skin phenotype of Fitzpatrick VI, and the most common skin cancer reported in patients was squamous cell carcinoma (SCC). The majority of these lesions were large, invasive, and/or ulcerated lesions in chronically sun-exposed areas. The most common site of metastasis was the lungs, and the mortality rate was high. LIMITATIONS:This is a literature review; information included is limited to what is available in the literature. CONCLUSION:Skin bleaching agents have a powerful presence among a broad population, yet the consequences of their use in skin of color are poorly understood and potentially dangerous. Based on the available literature, there is potential for skin bleaching practices to be implicated as the causative agent for cutaneous SCC, especially in darker skin phenotypes. Therefore, there is a growing need for dermatologists to address this topic as a major public health concern with high morbidity and potential mortality to prompt further investigation.
OBJECTIVE:To improve patient-centered dermatology care by identifying how patients prefer to approach medical decision-making and structuring their visit, using a brief 4-question intake survey focused on cognitive style. METHODS:New patients at 2 dermatology clinics within the California Skin Institute completed a multiple-choice intake questionnaire before their first visit. The survey asked patients how many concerns they wanted to address, how much guidance they preferred in selecting treatment, whether they prioritized diagnosis or treatment during the visit, and their expected timeline for results. Associations between patient responses and demographics (sex, age, chief complaint) were analyzed using χ2 tests. RESULTS:Among 257 patients (mean age: 38; 43% female), 96% of patients preferred to address only 1 or 2 concerns during their first visit; 75% preferred shared decision-making and 70% prioritized discussing treatment over their medical history. Patients bringing multiple concerns were significantly more likely to prefer autonomous decision-making (χ2=24.0; P<0.001). Women more often preferred to discuss multiple concerns and to balance history with treatment (both P<0.01), while men leaned toward single-concern, treatment-focused visits. LIMITATIONS:Single-center design and moderate sample size may limit generalizability. CONCLUSION:This brief, previsit framework offers a structured method to align dermatologic care with patients' cognitive and decision-making preferences-enhancing efficiency, rapport, and mutual understanding prior to the clinical encounter. By facilitating clearer communication from the outset, it may improve the quality of patient-centered care. Future studies will explore whether tailoring consultation styles to patient preferences can impact adherence, satisfaction, and clinical outcomes.
OBJECTIVE:To evaluate whether a 3-part dermatology-specific curriculum improves resident competency in process mapping, root cause analysis, and adverse event disclosure. METHODS:A pre-post educational intervention study was conducted in 2025 across 3 ACGME-accredited dermatology residency programs affiliated with a Texas-based academic medical center. The curriculum consisted of 3 sequential 1-hour sessions covering patient safety fundamentals, quality improvement tool application via flipped classroom, and peer-led adverse event disclosure simulation. Primary outcomes measured self-reported confidence in systems analysis, root cause analysis, and disclosure communication using 5-point Likert scales. Secondary outcomes assessed the knowledge of dermatology-specific error types and disclosure components. Twenty-seven residents completed pre-intervention surveys and 20 completed post-intervention surveys. Data were analyzed using Mann-Whitney U test and Fisher exact test. RESULTS:Residents demonstrated significant improvements across all primary competencies. Median confidence in process mapping increased from 1 to 4 (P<0.001), fishbone diagramming from 2 to 4 (P<0.001), and adverse event disclosure from 3 to 4 (P=0.001). Knowledge of common outpatient dermatology error types improved from 7.4% to 60% correct responses (P=0.00019). No significant differences were observed by postgraduate year level. Postcourse evaluations showed 95% rated duration as appropriate and 100% reported improved knowledge. LIMITATIONS:Study limitations include reliance on self-reported measures, anonymous survey design precluding paired analysis, modest sample size, lower postintervention response rates with potential volunteer and nonresponse bias due to voluntary participation, and single-institution implementation without long-term follow-up assessment; the curriculum was locally developed without external funding or institutional support that influenced its design or implementation. CONCLUSION:This dermatology-specific curriculum significantly improved resident competencies in systems analysis, root cause analysis, and adverse event disclosure. The specialty-focused design and scalable peer-led simulation model offer a practical approach for adoption across dermatology residency programs.
Psoriasis is a chronic immune-mediated inflammatory disease associated with systemic comorbidities, including gastrointestinal disorders. Emerging evidence supports a bidirectional gut-skin axis, with shared immunologic pathways involving the interleukin (IL)-23/IL-17 axis. Irritable bowel syndrome (IBS), traditionally considered a functional disorder, has also been linked to low-grade inflammation and cytokine dysregulation. We report a case of a 67-year-old man with moderate plaque and inverse psoriasis and longstanding IBS with diarrhea (IBS-D) who experienced complete resolution of gastrointestinal symptoms following treatment with risankizumab, an IL-23 inhibitor. Improvement in IBS symptoms began within weeks of therapy initiation and was sustained at follow-up, alongside complete skin clearance. No other changes in medications or lifestyle were identified. This case highlights a potential role of IL-23-mediated inflammation in IBS pathophysiology and suggests that targeted inhibition of the IL-23/IL-17 axis may benefit select patients with concurrent dermatologic and gastrointestinal disease.
