The most common skin cancer is basal cell carcinoma. The neoplasm is characterized by several different morphologic presentations; the most frequent morphologic variants are superficial and nodular. Each clinical presentation of the tumor has a corresponding histologic presentation. The biological behavior of a basal cell carcinoma depends not only on its histologic subtype but also on its location. Surgical excision is the treatment of choice for most basal cell carcinomas; this intervention is typically used for basal cell carcinomas that demonstrate aggressive behavior. Nonsurgical treatment, such as topical 5% imiquimod cream, may be considered for lower-risk tumors. After consultation with the dermatologist, I (a 65-year-old man) decided to treat my primary nodular basal cell carcinoma on my right periocular temple by applying 5% imiquimod cream daily to the neoplasm and the adjacent skin. The cancer was treated for a total of 45 days; during treatment, I had to discontinue the therapy twice because I developed severe, medication-related, local cutaneous adverse side effects, which included inflammation, eschar, and ulcers. I achieved complete clinical clearance of the carcinoma; the only residual finding at the previous tumor site was an atrophic patch. The management of basal cell carcinoma includes noninvasive and invasive modalities. Mohs micrographic surgery is the treatment of choice for most facial basal cell carcinomas and tumors of infiltrative histologic subtype. Mohs surgery is an invasive procedure; it can be associated with not only postoperative complications and scar but also possibly inferior cosmetic results. However, the advantages of Mohs surgery are not only its 97.5% cure rate for primary basal cell carcinomas but also the very low rate of tumor persistence following the procedure. Superficial basal cell carcinomas on the neck, trunk, or extremities can be treated with a daily topical application of 5% imiquimod cream, five times per week, for six weeks. In contrast to surgical excision, topical imiquimod has a lower cure rate; however, it is a noninvasive therapy and may result in cosmetically superior results. Nodular basal cell carcinomas, including periocular tumors, have also been successfully treated with topical 5% imiquimod cream. Treatment using topical 5% imiquimod cream for a basal cell carcinoma, compared to Mohs surgical excision, has several potential disadvantages. Some of these include a lower cure rate, a longer treatment duration (such as six weeks with five daily applications each week to treat a superficial basal cell carcinoma versus a single day of surgery), and the development of localized adverse cutaneous reactions that occur both on the tumor-containing epithelium and the skin surrounding the cancer. In conclusion, the management of basal cell carcinoma is an individualized decision for which several factors need to be evaluated. Although surgery is the gold standard of treatment, patients who do not want surgical intervention and possibly a better cosmetic result without a surgical scar may appropriately elect potentially effective noninvasive therapies, which have lower cure rates, longer treatment duration, and more frequently have associated adverse cutaneous reactions. This experience has taught me as a patient and as a physician that the topical management of a basal cell carcinoma with 5% imiquimod cream can result in more complicated adverse cutaneous effects than anticipated.

A dermatologist may choose to become an autobiographic author. Once that decision has been made, there are many potential writing presentations that have been used by these individuals to share their information. Writing a comprehensive autobiography and presenting the content in a book is the classic approach. The intent of the authors is to present a pair of papers summarizing the features of dermatologists who have published as autobiographic authors. In our first paper (Part 1), succinct biographic sketches summarize the characteristics of 10 dermatologists who have written autobiographies. In this paper (Part 2), the features of dermatologists who either provide autobiographic interviews, contribute to magazine columns regarding their interactions with patients, share memoirs of life-threatening non-dermatologic conditions, or write medical case reports about themselves are described; they include Dr Benjamin Barankin, Dr Jeffrey Benabio, Dr David Biro, Dr Philip R. Cohen, and Dr Alan S. Rockoff. Indeed, a variation on the traditional presentation of providing a complete autobiography has been adopted by two dermatologists; these individuals elected to only discuss their transition from being a physician to becoming a patient and to focus the novel that they wrote on a single life-threatening condition. Several alternative methods, however, have been embraced by other dermatologists. For example, a dermatologist selected various dermatologists and asked them to answer a series of questions that would allow them to share autobiographic information in their replies; he subsequently edited two volumes of a book that included the content he received in short chapters from 100 dermatologists. Thereafter, using a similar format, he created and edited a monthly journal feature that succinctly summarized the professional achievements and personal insights of a dermatologist in each issue. Monthly features that are published in dermatology magazines provide two dermatologists an opportunity to share insights into not only their personality and perspective toward dermatology but also their interactions with patients. One dermatologist, in addition, has decided to publish individual case reports that discuss not only his benign but also his more serious medical conditions. In conclusion, dermatologists who publish as autobiographical authors are a unique group of highly motivated individuals who have a sincere passion for sharing personal aspects of their life journey.

An unsuspected homicide in a decedent was considered when the meticulous cutaneous examination of the deceased resulted in the discovery of an intravenous injection site. A 24-year-old woman was found dead in her home. Initial assessment by the crime scene investigator and detective could not determine either the cause or the manner of death. Law enforcement personnel returned to the scene after the assistant medical examiner found a single intravenous needle puncture site during her cutaneous examination of the left antecubital fossa of the dead woman. Additional evidence located near the deceased woman's home included a bag with a butterfly needle and its plastic cap, a syringe with blood stain on the inside, and two empty vials of propofol. The investigators were able to identify the nurse who had obtained the propofol vials, and the forensic pathologist recommended that propofol be included among the other drugs routinely being evaluated during the toxicology studies. The discovery of an intravenous needle mark led to further evaluation of the death scene, resulting in the appropriate toxicology studies being ordered, which revealed that the cause of death was due to propofol, making it a homicide. A meticulous and thorough examination of the cutaneous and mucosal surfaces may provide an essential forensic dermatologic clue to the cause of death, the manner of death, or both.

A 75-year-old man presented to dermatology clinic with a rapidly expanding violaceous plaque across the right side of his chest, crossing midline. Biopsy demonstrated poorly differentiated, angioinvasive epithelioid cells. Immunohistochemical and imaging work-up led to a diagnosis of metastatic salivary duct carcinoma. The patient was diagnosed with carcinoma hemorrhagiectoides, a distinct inflammatory pattern of intravascular cutaneous metastases. This clinical presentation is termed the Shield Sign, due to lesion distribution resembling a medieval knight’s shield1,2. The Shield Sign is rare and has only been reported in association with salivary duct and breast cancers. Its presentation should prompt a work-up for malignancy.

An autobiography allows the author to share his or her life's journey with the reader. We present a pair of papers that include dermatologists who are autobiographic authors. Biographic sketches that describe some of the features of ten dermatologists who have written autobiographies are presented in this contribution (Part 1). Several physicians have written autobiographies, and many prolific dermatologists have chosen to write about themselves. This paper summarizes the characteristics of 10 dermatologists and provides a brief introduction to these individuals. It includes succinct biographic sketches of these dermatologists: Alex Anstey, John Thorne Crissey, Karl Holubar, Eyal K. Levit, Douglas N. Naversen, Robert A. Norman, Perry Robins, Alan S. Rockoff, Walter B. Shelley, and Marion B. Sulzberger. The characteristics of dermatologists who conduct autobiographic interviews, write monthly columns in dermatologic magazines about their interactions with patients, document how they dealt with life-threatening non-dermatologic conditions, or describe their dermatologic or medical diseases in case reports are summarized in the second paper (Part 2).

Authors of fiction are unique. They develop the characters of their novels for their readers, with the main character of a book being the protagonist. Other important characters include the antagonist and the deuteragonist. This paper focuses on fiction novels in which one of the key characters is a dermatologist. Biographic sketches that describe some of the features of the authors who write these novels are provided. The authors include nine non-medical writers: Sue Civil-Brown, Tom Jordon, Janice Kaplan, Lynn Schnurnberger, Carolyn See, Terry Southern, Camy Tang, Bruce Wagner, and Sheila Gewirtzman. They also include a non-dermatologist physician (Sara Cohen who is a physiatrist and writes under the pseudonym Freida McFadden), and dermatologists Terry Cronin and Garry Gewirtzman (who writes with his wife Sheila, who is an accountant). A total of 10 dermatologists are included in the 18 books in which a dermatologist is a main character; one author wrote three books that had the same dermatologist as a protagonist, and a husband and wife team of writers wrote a series of seven novels in which a dermatologist was featured. The fictional dermatologists were either the protagonist (seven dermatologists in 15 novels), the antagonist (two dermatologists), or the deuteragonist (one dermatologist). The 18 novels were written by 12 authors. Nine of the authors had not attended medical school; however, three of the authors were physicians. Seven books were written by a husband and wife team (a dermatologist and his accountant wife). One book was written by two women who were not physicians. The dermatologist is a man as in six of the dermatologists or a women as in four of the dermatologists. All four of the women dermatologists were characters in novels written by women (five authors). The six men were included in books by either a man (four authors) or a woman (one author) or coauthors (including both a man and a woman). Some writers publish their novels under a pseudonym, with the authors having various personal reasons for using a pen name. Six of the 12 (50%) of the authors who wrote a novel with a dermatologist as the main character either used a pseudonym in that novel, or a different book, or both. Many of the non-physician authors (five of nine, 56%) used a pen name; these included four women and two men. Only the woman physician author used a pseudonym. One of the men used a shortened version of his first name and did not include the suffix after his last name; both of the men did not include their middle name or the first letter of their middle name. The dermatologist-as either a protagonist, an antagonist, or a deuteroantagonist-provides the reader with an intriguing character in a novel.

Decedents can have lesions of their skin, mucosa, hair, or nails that may be related to their cause of death; alternatively, these lesions may be coincidentally present and not have associated forensic implications. Superficial fungal infection of the skin, such as tinea corporis and tinea pedis, can mimic other cutaneous conditions, including diseases, neoplasms, or infection. Two decedents had superficial fungal infections that mimicked other conditions, and the cutaneous presentation of their dermatophyte infection was selected to be reported based on their illustrative value. Dermatophyte infections of the body can present with extensive involvement of the skin; a decedent had diffuse tinea corporis that clinically mimicked psoriasis vulgaris, dermatitis, and cutaneous T-cell lymphoma; the diagnosis of a fungal infection of the skin was established after microscopic examination of lesional skin biopsies. The fungal organisms could not be readily visualized on the hematoxylin and eosin-stained sections; however, the fungal hyphae were easily observed after the sections were stained with periodic acid-Schiff stain. Another decedent had two different acquired skin conditions; the first appeared as cutaneous plaques; the differential diagnosis included ichthyosis, dermatitis, and tinea corporis. Examination of the epidermis from a skin biopsy showed the absence of both the granular layer and fungal hyphae on hematoxylin and eosin-stained sections, and the periodic acid-Schiff stain did not demonstrate any fungal organisms; this confirmed the suspected diagnosis of acquired ichthyosis. The second skin disease appeared as severe hyperkeratosis of the soles; the plantar lesions prompted the consideration of secondary syphilis plantar lesions; serologic evaluation was negative for spirochetal infection, and the periodic acid-Schiff-stained sections of the plantar skin biopsy showed fungal hyphae, establishing the diagnosis of hyperkeratotic (moccasin-type) tinea pedis. In summary, a cutaneous dermatophyte infection can morphologically present like a skin condition, a cutaneous malignancy, or an infection with mucocutaneous symptoms. In addition, more than one skin condition may be concurrently present in a decedent. Therefore, in conclusion, the forensic pathologist should entertained the possibility of performing a skin biopsy of any papulosquamous skin lesion on a decedent; importantly, the microscopic evaluation of the tissue section should not only be stained with hematoxylin and eosin but also with a stain which readily allows superficial fungal hyphae to be observed in the stratum corneum of the epidermis such as periodic acid-Schiff stain.

Forensic dermatology is not only a worldwide phenomenon but also an important subspecialty of both forensic medicine and dermatology. It encompasses traditional forensic dermatology (by aiding in establishing the cause and manner of death of decedents) and clinical forensic dermatology (by assessing live victims of abuse and neglect, human trafficking, and torture). Forensic dermatology assists in legal and criminal investigations by carefully examining the skin, mucosa, hair, and nails and accurately assessing the findings. A forensic dermatologist may use the forensic dermatology expert analytic report to summarize not only the observations but also their evaluation as an expert witness during a trial. Collaboration, documentation, and education are the pillars of forensic dermatology. To provide a forum for advancing knowledge in forensic dermatology, a new section dedicated to this field of medicine has been added to Clinics in Dermatology.

The crime scene investigation effect manifests as unrealistic attitudes among jurors based on fictional crime scene cases they have seen on television; jurors are influenced by the accuracy of forensic evidence and the speed with which these televised cases are resolved, and they expect the same standards they observe on television to be upheld in the courtroom. The definition of the crime scene investigation effect can be expanded to include information accessible not only from magazines that are readily available to the public but also from the internet and social media because these sources can provide jurors with unrealistic expectations of a crime scene evaluation similar to those they acquire from television. Forensic dermatology focuses on the evaluation of lesions involving the skin, mucosa, hair, and nails to determine the cause and manner of death in a decedent. In addition, clinical forensic dermatology includes the assessment of living victims of abuse and neglect, human trafficking, and torture. A comparison of real-world circumstances regarding dermatologic information and crime scene dermatologic evidence from other sources that may influence jurors is provided. Evaluation of heavy metal exposure, identification of decedents and suspects based on their tattoos, and microscopic evaluation of tissue specimens from mucocutaneous lesions are potential aspects of forensic dermatology that may lead the jury to unrealistic, preconceived standards based on their exposure to these topics on television, in magazines, and on social media. To minimize the crime scene investigation effect, dermatologists should testify in a clear, concise manner that engages jurors and provides them with relevant, reliable information so they can appropriately evaluate whether a defendant is guilty.

In this contribution, we present an original modern-day detective story that we have created based upon Sherlock Holmes and Dr John H. Watson, both fictional characters created by the British author and physician, Sir Arthur Conan Doyle (1859-1930). In our tale, an elderly woman is slowly going deaf and experiencing vertigo. Her physicians are unable to determine the etiology of her symptoms but suspect that she was exposed to an ototoxic agent while a prisoner at the Ravensbrück concentration camp during World War II. The patient was a forced subject in Nazi medical experiments, but theNazis destroyed the information about thems at the War's end. Holmes and Watson travel to Germany to interview the last living Nazi doctor in a desperate effort to save the lives of the patien, and possibly other family member, by finding out exactly what ototoxic agent was injected into the patient while she was an inmate at Ravensbrück. All the characters in this story are fictitious as are the details of the Nazi medical experiment described herein. In a postscript to this contribution, we address internet speculation concerning whether such an experiment took place at Ravensbrück.

Runners are susceptible to developing sports-related disorders. A 66-year-old man developed a unique cutaneous condition affecting his armpits while participating in a 13.1-mile race. Friction from the shirt he was wearing resulted in the development of sports-associated clothing related axillary tangled clumped hairs (SCRATCH). Removal of the hairs that had become tangled and clumped resulted in temporary localized patches of alopecia. The incidence of SCRATCH remains to be established. The condition results from the seams of the shirt rubbing against the axillary hairs and creating a mass of tangled and clumped hairs that are painful when the runner moves their arms. Removal of the hair masses can result in focal areas of alopecia in the affected axillae; subsequently, the tractional alopecia created by the hair removal resolves. SCRATCH does not occur in individuals who regularly shave their axillary hairs. The condition can be prevented by shaving or cutting the axillary hairs prior to running, possibly by applying a salve to the axillary hairs so that they do not adhere to the shirt, or by wearing shirts that do not rub against the axillae. A comprehensive summary of sports-associated dermatologic conditions in runners is presented. In conclusion, individuals who participate in ambulatory activities are susceptible to many dermatologic conditions related to their sport and SCRATCH can be added to the list of potential cutaneous disorders that can occur in runners.

Dermatology encompasses the evaluation and management of localized conditions that affect the nail plate, including trauma, primary dermatoses involving the nail bed and nail matrix, and systemic disorders with manifestations that impact the nail unit. In addition to traumatic events that can alter the nail unit, localized conditions such as periungual dermatitis and infections, as well as generalized diseases, can affect the nail matrix, resulting in temporary growth arrest of the nail plate. This can present as a groove (Beau's line) in the nail plate that progressively grows out as the nail continues to grow. Forensic pathology includes forensic anthropology. Disease and starvation are the most common etiologies associated with growth arrest of the long bones near the epiphyseal plate; the radiolucent horizontal bands (Harris lines) are only observable on the roentgenogram. Localized injuries, malnutrition, and childhood illnesses can result in growth arrest of enamel formation in the teeth (linear enamel hypoplasia); this condition appears as white pits, grooves, and/or bands on the crowns of permanent teeth. A 65-year-old man experienced a trauma-associated Beau's line on his left great toenail plate. He developed a subungual hematoma; approximately 10 weeks after the injury, he noted the appearance of a Beau's line. Growth arrest of the nail plate (Beau's lines), growth arrest of the long bones near the epiphyseal plate (Harris lines), and growth arrest of the teeth's enamel formation (linear enamel hypoplasia) can be caused by adverse events such as systemic illnesses, malnutrition, medication effects, and trauma. In conclusion, diagnostic stigmata of growth arrest, such as Beau's lines of the nail plate, Harris lines of the long bones, and linear enamel hypoplasia of the teeth, can be detected during the cutaneous inspection of the nails, the radiologic evaluation of the long bone, and the oral examination of the teeth.

Elastosis perforans serpiginosa is a perforating dermatosis that morphologically presents as serpiginous, annular, or curved papules and plaques whose pathologic examination demonstrates the transepidermal elimination of elastic fibers. The perforating dermatosis can be idiopathic or induced by drug exposure: most commonly, D-penicillamine. Occasionally, elastosis perforans serpiginosa is associated with a connective tissue disease. Individuals with Marfan syndrome have a defect in the FBN1 gene, which produces fibrillin. The connective tissue disease can occur spontaneously or is usually inherited in an autosomal dominant manner. Major criteria for the diagnosis of Marfan syndrome include aortic root dilatation and ectopia lentis. Patients often have musculoskeletal abnormalities, other cardiovascular features, and/or other ocular manifestations. A common cutaneous manifestation of Marfan syndrome is striae distensae on the deltoid, pectoral, and/or thigh regions. Numerous textbooks and publications have stated that elastosis perforans serpiginosa is associated with Marfan syndrome. However, the bona fide coexistence of elastosis perforans serpiginosa and Marfan syndrome has only been documented in a 23-year-old woman. She not only had biopsy-confirmed elastosis perforans serpiginosa but also skeletal abnormalities (arachnodactyly, genu valgum, and kyphoscoliosis) and numerous eye findings of Marfan syndrome. An investigation using the medical search engine PubMed for "elastosis perforans serpiginosa and Marfan syndrome" does not yield any relevant citations. Therefore, to the best of my knowledge, the literature only contains the coincidental observation of elastosis perforans serpiginosa and Marfan syndrome in a single patient. In conclusion, elastosis perforans serpiginosa is not a cutaneous manifestation of Marfan syndrome.

Forensic dermatology includes the evaluation of not only the skin and mucosa of a decedent but also that person's nails and hair. In addition to assessing decedents, forensic dermatology also encompasses the evaluation of victims of abuse, assault, deprivation, human trafficking, neglect, and torture. The dermatologist can contribute to the assessment of decedents; they can provide insight regarding the differentiation of both medication-associated reactions and benign melanocytic lesions from trauma to the skin or mucous membranes. Evaluation of nails for possible exposure to heavy metal poisoning can also be performed by the forensic dermatologist. In addition, an estimate of the time since death, the victim's body position when he or she died, and the possible cause of death can be determined when the dermatologist evaluates the decedent's lividity. Salient information can be obtained during the evaluation of tattoos by a forensic dermatologist; a unique tattoo, such as a mastectomy tattoo, or the presence of four or more random concordant tattoos, based on comparison to antemortem documentation, can possibly be used to establish a positive identification of the decedent. The pillars of forensic dermatology are collaboration, documentation, and education. A colorimetric scale for the forensic evaluation of decedents with skin of color has been established by the collaboration between a dermatologist and forensic pathologists. A template for a forensic dermatology expert analytical report, to communicate the observations made during a forensic dermatology consultation, has also been developed. Training in forensic dermatology for medical students and physicians is warranted. Subspecialties of forensic medicine traditionally include anthropology, ballistics, botany, entomology, and odontology. Forensic dermatology has recently been introduced to be a growing component of global forensic practice. In conclusion, forensic dermatology is an integral subspecialty of forensic medicine.

Fingernails and toenails can be an important source of trace evidence at a crime scene investigation. Arsenic, gold, lead, mercury, selenium, silver, and thallium are heavy metals; exposure to these metals can result not only in dyschromia of the nail, but also dystrophy of the nail plate. Mees lines, either single or multiple transverse white bands on the nail, were originally described in association with arsenic exposure. Similar white horizontal bands of transverse leukonychia have also been observed in patients following exposure to selenium and thallium. A diagnostic clue for persons who investigate forensic crime scenes to the possibility of heavy metal toxicity in the victim can be changes in the fingernails and toenails. The nails can be photographed and subsequently analyzed for the presence of the causative metal when the possibility of heavy metal exposure is entertained by crime scene investigators and/or medical examiners or coroners.