Introduction: Eruptive squamous atypia (ESA) is an uncommon, clinically aggressive, but histologically ambiguous dermatologic condition. It is characterized by the abrupt emergence of multiple keratoacanthoma-like lesions, typically manifesting in sun-exposed or previously traumatized skin.1 The condition predominantly affects immunosuppressed patients, and its management remains poorly defined. Case Presentation: We report the case of a 61-year-old woman with a 25-year history of autoimmune hepatitis treated with azathioprine, who presented with recurrent, painful, hyperkeratotic papules along her extremities. Prior to her presentation to dermatology, she underwent more than 15 surgical excisions for biopsy-proven squamous cell carcinomas (SCCs), many of which reappeared at prior biopsy or excision sites, despite clear margins. Biopsies consistently revealed well-differentiated squamous proliferations with keratoacanthomatous characteristics. Considering the clinical morphology, eruptive nature, distribution along prior sites of trauma, and lesion recurrence, a diagnosis of ESA was established. Intervention and Outcomes: A non-operative treatment plan was initiated, combining alternating courses of topical clobetasol ointment and 5-fluorouracil cream, intralesional Kenalog injections, and ultimately with the addition of an oral systemic retinoid, acitretin. The patient experienced marked clinical improvement, including reduced lesion count, cessation of new eruptions, and the avoidance of further surgical intervention. Over 12 months of follow-up, no new invasive SCCs were detected, and the therapy was well-tolerated without adverse events. Conclusion: ESA remains an underrecognized entity with significant diagnostic and therapeutic challenges. This case demonstrates that a multimodal medical approach with systemic retinoid therapy and topical immunomodulatory agents, can effectively halt disease progression. Early clinical recognition of ESA is essential to minimize procedural burden and improve outcomes.
Background:Physician-patient communication may be limited by time, especially in dermatology, where providers often see a high-volume of patients. Awareness of common patient frustrations may prepare dermatologists to optimize healthcare visits. Objective:This study employs Reddit to characterize sentiment toward dermatologists to identify opportunities to improve patient-physician communication. Methods:We obtained sentiment scores (SSs) for the top 1000 posts in the "r/Psoriasis," "r/Eczema," and "r/TS_Withdrawal" subreddits using the Valence Aware Dictionary and sEntiment Reasoner. Paragraphs containing dermatologist-related terms (DPs) and had negative SSs were extracted and reviewed by the authors to identify themes. Results:In all subreddits, DPs had negative mean SSs (mean SS, r/Eczema: -0.097; r/Psoriasis: -0.024; r/TS_Withdrawal: -0.062). Paragraphs without DPs had positive mean SSs (mean SS, r/Eczema: 0.032; r/Psoriasis: 0.012; r/TS_Withdrawal: 0.090). Differences between these paragraph types were significant (r/Eczema: P = .0037; r/Psoriasis: P = .0016; r/TS_Withdrawal: P < .001). Two themes emerged among negative DPs: 1) Patients feel they are not respected by dermatologists, and 2) Negativity toward being repeatedly prescribed topical steroids without adequate explanation of risk. Conclusion:Reddit may serve as a useful window into patient perceptions of dermatologic care that can inform dermatologists of common concerns, facilitating positive communication and improving the doctor-patient relationship in dermatology.
Background:Apalutamide is an androgen receptor antagonist used to treat patients with nonmetastatic castration-resistant prostate cancer (nmCRPC) or metastatic castration-sensitive prostate cancer (mCSPC). One of the most frequent adverse events associated with apalutamide is skin rash, particularly in Japanese patients. However, preventive skin care may reduce the frequency of apalutamide-induced skin rashes. Objective:We sought to compare the cumulative incidence of skin rashes in patients on apalutamide therapy with and without preventive skin care. Methods:This retrospective, real-world study included 27 patients in the control group (those who were not administered skin care) and 38 patients in the skin care group (those who were administered preventative skin care). Results:After a median follow-up of 7 months, grade 3 apalutamide-induced skin rashes occurred in 8.1% (3/37) of patients in the skin care group and 53.6% (15/28) of patients in the control group. Based on Gray's test, the difference in incidence between groups was statistically significant (P = .002). Conclusion:Preventive skin moisturization may reduce apalutamide-induced adverse skin events in patients with mCSPC or nmCRPC. Incorporating routine skin care may help patients experience the full efficacy of apalutamide while maintaining a good quality of life.
Background: Atypical fibroxanthoma (AFX) is a rare cutaneous spindle cell neoplasm that typically affects elderly men on sun-exposed sites. Mohs micrographic surgery (MMS) and wide local excision (WLE) are common treatments, but comparative outcomes remain incompletely defined. Objective: This study evaluated recurrence, metastasis, and surgical outcomes of AFX treated with MMS versus WLE, with emphasis on immunosuppression as a prognostic factor. Methods: A retrospective review was performed of 23 patients with histologically confirmed AFX treated at a single academic center from 2010 to 2024. Demographic, clinical, and surgical variables were abstracted. Outcomes included local recurrence, metastasis, and defect size. Fisher exact and Mann-Whitney U tests were used for exploratory analysis. Results: Fourteen patients underwent MMS and 9 underwent WLE. Recurrence rates were similar between groups (14% versus 11%). However, all recurrences and the single metastasis occurred in immunosuppressed patients, who had a higher recurrence rate than immunocompetent patients (67% versus 5%; P = .10). Postoperative defect size was smaller with MMS than with WLE (3.1 cm versus 5.5 cm; P < .001). Conclusion: MMS provided effective tumor clearance with tissue conservation. Immunosuppression was strongly associated with adverse outcomes, underscoring the need for close surveillance in this high-risk subgroup.
Background:Psoriatic arthritis (PsA) is a heterogeneous, immune-mediated inflammatory disease affecting peripheral joints, entheses, skin, and nails. Despite multiple available biologic therapies, unmet needs persist, particularly in patients with multisystem involvement or prior biologic failure. Interleukin (IL)-17 and IL-23 pathway inhibitors are widely used in PsA; however, important differences exist in their clinical efficacy across disease domains. Methods:A comprehensive literature review was conducted using PubMed, Scopus, and Google Scholar to identify randomized controlled trials, long-term extension studies, mechanistic studies, and meta-analyses evaluating IL-17 and IL-23 inhibitors in PsA and related spondyloarthritides. A multidisciplinary panel of expert dermatologists and rheumatologists convened for a structured roundtable discussion. A modified Delphi process was used to develop and approve consensus statements. Strength of Recommendation Taxonomy (SORT) criteria were applied to each statement. Results:Eight consensus statements were unanimously adopted. These statements address radiographic progression, axial disease, mechanistic considerations of IL-17A and IL-17F inhibition, comparative efficacy of bimekizumab, treatment sequencing, and safety considerations, including candidiasis, hepatic effects, and psychiatric outcomes. Conclusion:Based on the totality of available evidence, IL-17 inhibitors play an important role in the management of PsA across multiple disease domains. Differences between IL-17 and IL-23 pathway inhibition have important implications for treatment selection, particularly in patients with axial disease, significant skin involvement, or prior biologic failure.
Background: Hidradenitis suppurativa (HS) is a chronic inflammatory skin condition that disproportionately affects women, African Americans, and individuals of biracial descent. It is associated with substantial physical and psychiatric morbidity, reducing quality of life. Objective: This review analyzed disparities in treatment outcomes, disease progression, and healthcare access among HS patients based on insurance type. Methods: Using PRISMA guidelines, a comprehensive literature search identified 7 studies meeting inclusion criteria. Owing to data heterogeneity, studies were qualitatively analyzed. Results: Findings consistently demonstrated that Medicaid patients experienced worse outcomes than those with private insurance or Medicare. Medicaid patients had higher rates of comorbid conditions, including cellulitis and psychiatric disorders, greater reliance on emergency departments, and higher utilization of prescription pain medications, particularly opioids. They were also less likely to access specialized dermatologic care or advanced treatments such as biologics, despite a higher HS prevalence. These disparities were attributed to socioeconomic factors, barriers to specialist care, and limited insurance coverage for evidence-based treatments. Conclusion: Addressing insurance-related disparities could reduce disease severity, enhance medication adherence, and decrease reliance on emergency care and opioids. Future research should evaluate the impact of alternative treatments, such as laser hair removal, and examine insurance-related disparities in detail to improve outcomes for underserved populations.
Background:Dermoscopy has demonstrated utility in several connective tissue diseases. However, in dermatomyositis, it has been poorly studied for both cutaneous and nailfold involvement. Results:We report the cutaneous and nailfold dermoscopic features in 11 patients with dermatomyositis and compare them with previously published data. Methods:Key cutaneous findings included linear vessels with a uniform distribution, white scales observed in all 11 patients, structureless white areas in 9 patients, brown globules in 9 patients, and mottled brown pigmentation in 8 patients. Nailfold dermoscopy revealed dilated capillaries and avascular areas in all patients, architectural disorganization in 10 patients, tortuous vessels in 8 patients, hemorrhages in 7 patients, and megacapillaries in 2 patients. Few studies have described dermoscopic features in dermatomyositis, some of them being isolated case reports with incomplete and heterogeneous clinical data. The largest published series included 29 patients and described polymorphic cutaneous vascular patterns, predominantly sparse white scales, as well as nailfold megacapillaries and dilated capillaries, without reporting follicular structures, shapes, or colors. Conclusion:Larger studies are needed to more precisely identify the distinctive dermoscopic signs of dermatomyositis and to evaluate the potential of dermoscopy as a prognostic tool for disease activity and progression.
Background:Deucravacitinib is a novel, allosteric, selective TYK2 inhibitor FDA-approved for the treatment of moderate-to-severe plaque psoriasis in adults. Currently, deucravacitinib is under investigation in numerous clinical trials to establish its efficacy and safety for other indications. Thus, this expert consensus panel was assembled to provide clinical guidance on the applications of and clinical considerations for deucravacitinib. Objective:The aim of this study was to assess the literature and formulate consensus statements covering the indications, safety, and efficacy of deucravacitinib. Methods:A comprehensive literature search of PubMed, Scopus, and Google Scholar was completed for English-language original research articles regarding deucravacitinib. The expert panel, which included eight dermatologists with advanced knowledge on both dermatologic and rheumatologic conditions, reviewed the pertinent literature and developed consensus statements regarding the additional indications, safety, and efficacy of deucravacitinib. Using a modified Delphi process, each statement had supermajority approval and was designated a strength of recommendation based on the Strength of Recommendation Taxonomy criteria. Key Findings:The panel unanimously voted to adopt 14 consensus statements and recommendations: 11 were a strength of "A", 1 was a strength of "B", and two were a strength of "C". The 14 consensus statements created by the expert panel provide expert recommendations regarding the efficacy, safety, and additional potential indications for deucravacitinib. Additionally, the expert panel notes that deucravacitinib is generally safe, as it can be safely combined with conventional synthetic DMARDs, immunosuppressants, and biologics and currently does not have data that support elevated malignancy risk, tuberculosis reactivation, increased risk for herpes zoster, or associated laboratory abnormalities. Conclusion:Deucravacitinib is an established treatment for plaque psoriasis that has shown strong evidence supporting safety and efficacy for psoriatic arthritis, cutaneous lupus, and systemic lupus erythematosus. Overall, deucravacitinib is a versatile and safe medication that may warrant further therapeutic consideration by clinicians. The expert panel concludes that deucravacitinib is an exciting medication that will likely have a larger role in the treatment of various conditions in the future.
Background:Hidradenitis suppurativa (HS) is linked to cardiometabolic disease (CMD), and guidelines recommend annual primary care visits. This study examined predictors of primary care utilization among patients with HS. Methods:In this cross-sectional study, 307 patients with HS were analyzed. χ2 tests, one-way analysis of variance, and multivariable logistic regression assessed associations among barriers to care, primary care provider (PCP) adherence, HS severity, and CMD presence. Results:Mean age was 39.4 years; 26.4% had Hurley stage III disease. Overall PCP adherence was 85.0% but lower in patients under 30 years (71.0%). CMD prevalence included hypertension (33.9%), type 2 diabetes (17.6%), and hypercholesterolemia (32.9%). Patients without CMD were 74.0% less likely to adhere to annual PCP visits (adjusted odds ratio [AOR], 0.26; P = .001), and being uninsured reduced adherence by 82.0% (AOR, 0.18; P = .01). HS severity did not predict adherence, but Hurley stage III disease was associated with more PCP visits and independently predicted type 2 diabetes (AOR, 2.26; P = .02). Conclusion:Primary care engagement is influenced more by CMD and insurance than HS severity. Coordinated dermatology-primary care strategies may enhance preventive care, especially for younger patients without CMD.
Crusted (Norwegian) scabies is a rare, highly contagious form of scabies characterized by an extreme mite burden and the development of hyperkeratotic plaques. It typically occurs in individuals with compromised cell-mediated immunity. We present the case of a 34-year-old immunocompetent male with a 12-month history of generalized erythematous lesions. The lesions, which were initially pruritic and later became painful, began on the abdomen and progressed to form extensive hyperkeratotic crusts with areas of exudation and adherence to clothing. Physical examination revealed involvement of approximately 90% of the total body surface area, featuring papules, pustules, and verrucous hyperkeratotic crusts, with a predilection for the dorsal hands, groin, and axillae. Direct microscopic examination of skin scales confirmed the presence of numerous Sarcoptes scabiei var. hominis mites. Laboratory investigations demonstrated leukocytosis, eosinophilia, microcytosis, hypoalbuminemia, and an elevated erythrocyte sedimentation rate. Serological testing for human immunodeficiency virus (HIV), human T-lymphotropic virus (HTLV)-1/2, hepatitis B surface antigen, and syphilis returned negative results. The patient was treated with oral ivermectin, topical 5% permethrin cream, and urea-based emollients, which resulted in a positive clinical response. He was discharged after three days with comprehensive instructions for environmental decontamination. This case underscores that crusted scabies can occur in the absence of demonstrable immunosuppression, highlights the critical role of diagnostic aids such as microscopy and dermoscopy, and reinforces the necessity of multi-dose ivermectin therapy combined topical scabicidal and keratolytic agents, supplemented by rigorous environmental control measures.
Granuloma annulare (GA) is a chronic dermatologic condition which may be poorly responsive to treatment and impose a significant psychological burden. A 74-year-old female presented to dermatology clinic with pink, annular skin lesions on her legs, arms, and back, persisting for five years and causing distress due to their appearance. Biopsy confirmed the clinical diagnosis of GA. The patient underwent numerous treatments without improvement, including clobetasol ointment, tacrolimus ointment, hydroxychloroquine, doxycycline, adalimumab, narrowband UVB phototherapy, and UVA1 phototherapy. Given her lack of response to prior established therapies, she was started on upadacitinib, a JAK1 (Janus Kinase) selective inhibitor, for its action on JAK-STAT (Janus kinase-signal transducer and activator of transcription) related cytokines upregulated in GA. Within 2 months she reported initial signs of improvement and flattening of her lesions and at her 3 month follow up visit, only post inflammatory pigmentary changes were noted on exam. This improvement was sustained during her 10-month course of treatment and at last follow up 3 months off treatment. JAK inhibitors have emerged as potential therapies for treatment-resistant GA, and we review the literature to date on their use in this setting. This case of extensive body surface area involvement and dramatic response to upadacitinib adds to the clinical experience of using selective JAK inhibition for recalcitrant GA.
Background: Safe, non-invasive, or minimally invasive techniques are available for facial rejuvenation, and recent research on exosomes has revealed promising avenues for new treatment options. The pilot study objective was to assess the efficacy of a facial rejuvenation treatment with autologous exosomes released from preconditioned platelet-rich plasma with the MCT System. Methods: A prospective, single-center, randomized, controlled pilot study was conducted on patients with facial aging signs who received three sessions of autologous exosomes obtained using the MCT System. Results were assessed by measuring the subepidermal low-echogenic band using ultrasonography, taking photographs with a compact stereophotogrammetric 3D imaging system, and obtaining patients' feedback on skin aspect and improvement in appearance. Results: Eleven patients (100% women) with a mean age of 57 (SD 4.1, range 51-65) were recruited; nine (81.8%) completed the study. Ultrasonographic measurements one month after the last treatment showed a mean percentage reduction in the subepidermal low-echogenic band thickness of 61.4% in the cheekbone and 39.35% in the cheek. Regarding patients’ perception, 77.8% reported skin improvement. Conclusions: Treatment with autologous exosomes obtained using the MCT System was well tolerated and yielded substantial results in facial rejuvenation, reducing the subepidermal low-echogenic band and enhancing patients' perceived skin appearance.
