To the Editor: Worldwide reports describe cutaneous findings, including maculopapules, pseudo-chilblain, vesicles, urticaria, livedo, and multisystem inflammatory syndrome, as manifestations of coronavirus disease 2019 (COVID-19).1Recalcati S. Cutaneous manifestations in COVID-19: a first perspective.J Eur Acad Dermatol Venereol. 2020; 34: e212-e213Crossref PubMed Scopus (913) Google Scholar, 2Galván Casas C. Català A. Carretero Hernández G. et al.Classification of the cutaneous manifestations of COVID-19: a rapid prospective nationwide consensus study in Spain with 375 cases.Br J Dermatol. 2020; 183: 71-77Crossref PubMed Scopus (939) Google Scholar, 3de Masson A. Bouaziz J.D. Sulimovic L. et al.Chilblains are a common cutaneous finding during the COVID-19 pandemic: a retrospective nationwide study from France.J Am Acad Dermatol. 2020; 83: 667-670Abstract Full Text Full Text PDF PubMed Scopus (145) Google Scholar, 4Jia J.L. Kamceva M. Rao S.A. et al.Cutaneous manifestations of COVID-19: a preliminary review.J Am Acad Dermatol. 2020; 83: 687-690Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar, 5Shulman S.T. Pediatric coronavirus disease-2019–associated multisystem inflammatory syndrome.J Pediatr Infect Dis Soc. 2020; 9: 285-286Crossref PubMed Scopus (24) Google Scholar Here, we report on the cutaneous findings observed in hospitalized COVID-19–positive patients at Columbia University Irving Medical Center by the adult dermatology consultation service between March 25, 2020, and May 1, 2020. Cases were included if COVID-19 was most likely associated with or contributed to skin findings observed after other potential causes were excluded. Although previous studies on the cutaneous manifestations of COVID-19 have focused primarily on outpatients and those with mild disease,2Galván Casas C. Català A. Carretero Hernández G. et al.Classification of the cutaneous manifestations of COVID-19: a rapid prospective nationwide consensus study in Spain with 375 cases.Br J Dermatol. 2020; 183: 71-77Crossref PubMed Scopus (939) Google Scholar,3de Masson A. Bouaziz J.D. Sulimovic L. et al.Chilblains are a common cutaneous finding during the COVID-19 pandemic: a retrospective nationwide study from France.J Am Acad Dermatol. 2020; 83: 667-670Abstract Full Text Full Text PDF PubMed Scopus (145) Google Scholar this study provides insights into the cutaneous manifestations of severe disease. This study was approved by the institutional review board at Columbia University Irving Medical Center. Nine patients developed signs of acral ischemia, including duskiness, necrosis, and bulla (Fig 1, A). Eight of these patients with acral ischemia required admission to the intensive care unit, and the location of ischemia included fingers, toes, ears, and genital skin (Supplemental Table I available via Mendeley at https://data.mendeley.com/datasets/nywrhw3d8y/1). Two patients with severe lesions had a confirmed deep vein thrombosis, highlighting the potential for thrombotic events (cases 7 and 9). Three patients developed livedo racemosa, 1 of whom had livedo as a presenting sign of COVID-19 and 2 of whom developed livedo during their hospitalization. One patient developed vesicles in association with his livedoid eruption (case 10). All 3 patients required intensive care unit admission and had evidence of coagulopathy (cases 10 to 12) (Fig 1, B). Two patients developed evidence of bleeding diatheses. One, a critically ill man in his 60s (case 14), developed petechiae, with perivascular lymphocytic infiltrate with prominent red blood cell extravasation on biopsy. He was mildly thrombocytopenic (114,000 per μL) and had mild coagulopathy (prothrombin time/international normalized ratio 14.7 seconds/1.2, activated partial thromboplastin time 36.2 seconds, and D-dimer 3.95 μg/mL). The other patient, a man in his 70s, developed purpura fulminans with areas of necrosis and superficial desquamation on the chest and axilla (case 13). Laboratory data were consistent with disseminated intravascular coagulation, and ultimately, the patient died. Erythema multiforme–like lesions were observed in a woman in her 80s 1 week following discharge after treatment for COVID-19–associated pneumonia (case 15). She had no other risk factors for development of erythema multiforme–like lesions, including active herpes simplex virus infection, and received no new medications in the last 3 days of her hospitalization or on discharge. No pseudo-chilblain (COVID toes) was observed in the hospitalized patients evaluated. Pseudo-chilblain may be more strongly associated with mild disease or present after acute illness has resolved. In summary, cutaneous manifestations in hospitalized COVID-19 patients are varied and are an important part of this potentially life-threatening illness. Findings in critically ill patients may differ from those in outpatients with mild disease. Limitations of our study include that cases were limited to a single institution, there was a lack of histology on the majority of cases, and there was inability to establish the pathophysiologic role of severe acute respiratory syndrome coronavirus 2 in the reported skin diseases. Additionally, less severe skin findings may not have required dermatology consultation. Further large-scale cohort studies with classification of histology are necessary to better describe both the frequency and etiology of these findings.

To the Editor: It is common for dermatologists to use photography for the purpose of biopsy-site identification. However, lack of standardization of photographs, absence of anatomic landmarks, scars from previous procedures, inadequate documentation, and poor image quality can make biopsy-site triangulation challenging.1 Physicians and patients incorrectly identify 5.9% and 16.6% of surgical sites, respectively.2 Proper photography can be helpful in accurate biopsy-site identification.3 Here, we describe the use of facial recognition and augmented reality to provide lesion triangulation.

Dermatology is one of the least diverse medical fields, partly owing to the low number of international medical graduates that apply and match to dermatology residency programs in the United States each year. Our objective was to determine and outline the factors that can increase competitiveness of international applicants interested in applying to dermatology residency in the U.S. Higher match rates for IMGs were associated with several applicant-dependent characteristics, including higher USMLE scores, higher research participation and numbers of publications, strong recommendation letters, and dermatology rotations. Although states with a greater number of dermatology residency positions (New York, Massachusetts, and California) had more IMGs matched from 2013 to 2018, certain states with a smaller number of residency positions, namely Colorado and Georgia, had the highest dermatology match rates for IMGs when adjusted for the total number of matched applicants. Evidenced-based application guidance for international applicants, as outlined in this literature review, may improve the competitiveness of IMGs and increase diversity within the field of dermatology. Rotating and applying to dermatology residency programs in states that have historically accepted a higher number of IMGs may further improve the applicants' chances of matching into a dermatology residency.

A 34-year-old man with acquired immunodeficiency syndrome (AIDS) presented with 2 years of pruritic, slowly growing lesions after discontinuation of all antiviral medications. On examination, he had a cobblestoned, dark brown plaque on the perioral cutaneous and mucosal lip (Fig 1) and 2 large annular brown plaques with heaped-up mounds of scale and violaceous rims on the right shin and posterior thigh (Fig 2) with a smaller similar lesion on the scrotum. A skin biopsy of the perioral and right thigh plaques found a lichenoid infiltrate with numerous plasma cells (Fig 3). An immunostain is shown in Fig 4.Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 3View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 4View Large Image Figure ViewerDownload Hi-res image Download (PPT) Question 1: What is the diagnosis?A.PsoriasisB.Majocchi granulomaC.Rupioid syphilisD.Hypertrophic lichen planusE.Lobomycosis Answers:A.Psoriasis – Incorrect. Although psoriasis can have a rupioid morphology, the presence of spirochetes on immunostains supported an infectious diagnosis.B.Majocchi granuloma – Incorrect. Majocchi granuloma is a deep folliculitis caused by a cutaneous dermatophyte infection. Skin scraping in this case had no growth in dermatophyte test media, and tissue cultures were negative for bacteria, fungus, and atypical mycobacteria.C.Rupioid syphilis – Correct. This patient's rapid plasma reagin was reactive with a titer of 1:512, and his Treponema pallidum hemagglutination assay was positive. Rupioid syphilis is characterized by well-demarcated hyperkeratotic scaly plaques with a thick, adherent crust that resembles the back of an oyster shell.1Krase I.Z. Cavanaugh K. Curiel-Lewandrowski C. A case of rupioid syphilis.JAAD Case Rep. 2016; 2: 141-143Abstract Full Text Full Text PDF Scopus (6) Google ScholarD.Hypertrophic lichen planus – Incorrect. The presence of spirochetes on immunostains supported an infectious diagnosis.E.Lobomycosis – Incorrect. Lobomycosis is a chronic fungal infection presenting with keloidal-like plaques. Round yeast-like structures were not seen on histology. Question 2: Which of the following disease subtypes does this case best represent?A.CongenitalB.PrimaryC.SecondaryD.TertiaryE.Endemic Answers:A.Congenital – Incorrect. Congenital syphilis is usually the result of transplacental infection of the fetus from an infected mother and has varied clinical manifestations including prematurity, rhinorrhea, and mucocutaneous lesions (in early congenital syphilis) and interstitial keratitis, neurosyphilis, bone disease, and cardiovascular disease (in late congenital syphilis).B.Primary – Incorrect. The chancre, an indurated painless ulcer, is the initial lesion of syphilis and appears about 21 days after exposure.C.Secondary – Correct. This patient has late latent secondary syphilis. Lesions of secondary syphilis are protean in clinical presentation and histology and have easily identified organisms with immunostain, as seen in our patient.2Lautenschlager S. Cutaneous manifestations of syphilis: recognition and management.Am J Clin Dermatol. 2006; 7: 291-304Crossref PubMed Scopus (59) Google Scholar The distinction between early and late latent secondary syphilis is based on whether the primary infection occurred within the past 12 months.D.Tertiary – Incorrect. Cutaneous manifestations of late latent secondary and tertiary syphilis are notably different. Tertiary syphilis typically presents with granulomatous lesions without identifiable spirochetes on biopsy.E.Endemic – Incorrect. Endemic syphilis is a form of nonvenereal syphilis and clinically presents with lesions in the oral and nasopharyngeal mucosa. Question 3: The clinical morphology seen in this case has been reported in all of the following EXCEPT:A.PsoriasisB.Reactive arthritisC.ScabiesD.HistoplasmosisE.Dermatomyositis Answers:A.Psoriasis – Incorrect. Rupioid lesions have been reported in psoriasis.3Chung H.J. Marley-Kemp D. Keller M. Rupioid psoriasis and other skin diseases with rupioid manifestations.Cutis. 2014; 94: 119-121Google ScholarB.Reactive arthritis – Incorrect. Rupioid lesions have been reported in reactive arthritis.3Chung H.J. Marley-Kemp D. Keller M. Rupioid psoriasis and other skin diseases with rupioid manifestations.Cutis. 2014; 94: 119-121Google ScholarC.Scabies – Incorrect. Rupioid lesions have been reported in keratotic scabies.3Chung H.J. Marley-Kemp D. Keller M. Rupioid psoriasis and other skin diseases with rupioid manifestations.Cutis. 2014; 94: 119-121Google ScholarD.Histoplasmosis – Incorrect. Rupioid lesions have been reported in disseminated histoplasmosis.3Chung H.J. Marley-Kemp D. Keller M. Rupioid psoriasis and other skin diseases with rupioid manifestations.Cutis. 2014; 94: 119-121Google ScholarE.Dermatomyositis – Correct. Rupioid morphology has been described in association with all of the other answer choices including psoriasis, reactive arthritis, keratotic scabies, and disseminated histoplasmosis. Rupioid lesions of syphilis are most commonly seen in patients with varied degrees of immunosuppression including HIV, malnutrition, diabetes, or pregnancy.4Zhu K. Zhou Q. Han R. Cheng H. Acute monoarthritis in a delayed diagnosis of syphilis patient with persistent rupioid psoriasis-like lesions.BMC Infect Dis. 2012; 12: 338Google Scholar

Facial erythema after allogeneic stem cell transplantation (SCT) is most commonly caused by acute graft-versus-host disease (aGVHD), although viral exanthema, drug reactions, and chemotherapy toxicity are also on the differential.1 Immunosuppressed patients have higher rates of more severe infestations with Demodex folliculorum, and there are few reports of demodicidosis presenting as facial erythema after SCT.2-5 We report 2 cases of Demodex folliculitis presenting as erythematous papules on the face resembling aGVHD but with a distinctive cutoff sign at the scalp that may serve as an important diagnostic tool in differentiating demodicidosis from the other etiologies of facial erythema.

BACKGROUND:Hidradenitis suppurativa (HS) is a chronic inflammatory disease that significantly affects the patient's quality of life. Multiple studies have shown a strong association between HS and inflammatory bowel disease (IBD). Our primary goal was to explore the in-hospital burden of HS on patients with IBD. Our secondary goal was to establish unique baseline characteristics and comorbidities of IBD patients with HS.METHODS:This was a retrospective cohort study using the National Inpatient Sample (NIS) database for the years 2004 through 2014. All patients with ICD-9 CM codes for any diagnosis of IBD and HS were included. The primary outcome was the medical and financial burden of HS on patients with IBD. Medical burden was measured by in-hospital morbidity and mortality, and financial burden was measured by resource utilization.RESULTS:A total of 3,079,332 admissions with IBD were recorded, of which 4369 had a concomitant diagnosis of HS. IBD-HS patients were significantly younger and mostly African-American females; they were more likely to be smokers, obese, and have diabetes mellitus, depression, and anemia. There was no mortality difference between the IBD-HS and IBD-only groups; nevertheless, there was a higher likelihood of developing sepsis in the IBD-HS cohort (4.9% vs. 2.6%; P < 0.001). Patients with IBD-HS had an increased hospital length of stay (5 vs. 4 days; P < 0.001) and higher total hospitalization costs ($13,272 vs. $12,237; P = 0.013).CONCLUSIONS:This large-scale study strengthens the evidence that these two inflammatory conditions are truly associated and establishes their joint effect on overall morbidity, mortality, and resource utilization.

Brain hemodynamics serve as a proxy for neural activity in a range of noninvasive neuroimaging techniques including functional magnetic resonance imaging (fMRI). In resting-state fMRI, hemodynamic fluctuations have been found to exhibit patterns of bilateral synchrony, with correlated regions inferred to have functional connectivity. However, the relationship between resting-state hemodynamics and underlying neural activity has not been well established, making the neural underpinnings of functional connectivity networks unclear. In this study, neural activity and hemodynamics were recorded simultaneously over the bilateral cortex of awake and anesthetized Thy1-GCaMP mice using wide-field optical mapping. Neural activity was visualized via selective expression of the calcium-sensitive fluorophore GCaMP in layer 2/3 and 5 excitatory neurons. Characteristic patterns of resting-state hemodynamics were accompanied by more rapidly changing bilateral patterns of resting-state neural activity. Spatiotemporal hemodynamics could be modeled by convolving this neural activity with hemodynamic response functions derived through both deconvolution and gamma-variate fitting. Simultaneous imaging and electrophysiology confirmed that Thy1-GCaMP signals are well-predicted by multiunit activity. Neurovascular coupling between resting-state neural activity and hemodynamics was robust and fast in awake animals, whereas coupling in urethane-anesthetized animals was slower, and in some cases included lower-frequency (<0.04 Hz) hemodynamic fluctuations that were not well-predicted by local Thy1-GCaMP recordings. These results support that resting-state hemodynamics in the awake and anesthetized brain are coupled to underlying patterns of excitatory neural activity. The patterns of bilaterally-symmetric spontaneous neural activity revealed by wide-field Thy1-GCaMP imaging may depict the neural foundation of functional connectivity networks detected in resting-state fMRI.

An almost sinusoidal, large amplitude ~0.1 Hz oscillation in cortical hemodynamics has been repeatedly observed in species ranging from mice to humans. However, the occurrence of 'slow sinusoidal hemodynamic oscillations' (SSHOs) in human functional magnetic resonance imaging (fMRI) studies is rarely noted or considered. As a result, little investigation into the cause of SSHOs has been undertaken, and their potential to confound fMRI analysis, as well as their possible value as a functional biomarker has been largely overlooked. Here, we report direct observation of large-amplitude, sinusoidal ~0.1 Hz hemodynamic oscillations in the cortex of an awake human undergoing surgical resection of a brain tumor. Intraoperative multispectral optical intrinsic signal imaging (MS-OISI) revealed that SSHOs were spatially localized to distinct regions of the cortex, exhibited wave-like propagation, and involved oscillations in the diameter of specific pial arterioles, indicating that the effect was not the result of systemic blood pressure oscillations. fMRI data collected from the same subject 4 days prior to surgery demonstrates that ~0.1 Hz oscillations in the BOLD signal can be detected around the same region. Intraoperative optical imaging data from a patient undergoing epilepsy surgery, in whom sinusoidal oscillations were not observed, is shown for comparison. This direct observation of the '0.1 Hz wave' in the awake human brain, using both intraoperative imaging and pre-operative fMRI, confirms that SSHOs occur in the human brain, and can be detected by fMRI. We discuss the possible physiological basis of this oscillation and its potential link to brain pathologies, highlighting its relevance to resting-state fMRI and its potential as a novel target for functional diagnosis and delineation of neurological disease.