BACKGROUND Permanent hair reduction is an integral part of gender-affirming medical care, especially for transgender patients undergoing surgeries such as phalloplasty and vaginoplasty. Hair removal helps reduce complications and alleviate gender dysphoria associated with unwanted facial and body hair. OBJECTIVE To examine the methods, efficacy, and access issues of hair removal in transgender patients, with a focus on its role in surgical preparation and gender dysphoria reduction. MATERIALS AND METHODS A literature review was conducted to analyze the effectiveness of laser hair removal (LHR) and electrolysis for permanent hair reduction. The review also explored regional regulatory barriers and insurance coverage limitations affecting access to these services. RESULTS Laser hair removal and electrolysis are both effective for hair removal, with LHR being less painful and faster. Laser hair removal is often preferred but requires multiple treatments and proper laser settings. Insurance coverage remains inconsistent, limiting access to these procedures. Postoperative hair regrowth in neovaginal or neourethral sites can be managed with hormonal adjustments and further treatments. CONCLUSION Hair removal plays an essential role in reducing surgical complications and gender dysphoria in transgender patients. A multidisciplinary approach between dermatologists and surgeons is essential, and addressing regulatory and access barriers is critical for equitable care.

The number of men interested in nonsurgical cosmetic procedures has been increasing in recent years. Given the gender differences in cutaneous biology and anatomy, the aesthetic treatment of men requires certain nuances and modifications from the more frequently completed procedures in women. In addition, photoaging and sun protective practices can vary between gender, which may be a consequence of the stigma that surrounds skin care and its relation to traditional gender roles. We have reviewed pertinent biologic, anatomic, and behavioral aspects of men as they relate to cosmetic injectable treatments. Men may require higher doses of injectable neuromodulators due to their larger and stronger facial mimetic muscles. Injectable soft-tissue fillers should also accentuate the ideal facial shape of men, which includes a squared jawline and inferomedial projection of the cheeks. The approach to injectable treatments differs between men and women in the aesthetic setting, and this should be addressed by practitioners.

BACKGROUND Cryolipolysis is an effective means of noninvasive fat reduction. There are numerous relative contraindications to cryolipolysis including scars, hernias, and cold-related disorders such as Raynaud disease, because cryolipolysis has a theoretical risk of exacerbating these conditions. OBJECTIVE To examine predictors of negative outcomes of cryolipolysis, especially as it pertains to safety of cryolipolysis in patients with Raynaud disease. MATERIALS AND METHODS A retrospective review of patients who received consultation for cryolipolysis was conducted and analyzed. RESULTS Patients with Raynaud disease did not experience any exacerbations of their underlying condition after cryolipolysis. Side effects in all patients, regardless of medical history, were mild, temporary, and not associated with any predisposing factors. CONCLUSION Cryolipolysis seems to be safe in patients with mild–moderate Raynaud disease.

To The Editor: Pressure injuries, a common skin finding that significantly impacts the quality of life in hospitalized patients, are associated with increased mortality and result in increased healthcare costs.1Mervis J.S. Phillips T.J. Pressure ulcers: pathophysiology, epidemiology, risk factors, and presentation.J Am Acad Dermatol. 2019; 81: 881-890Abstract Full Text Full Text PDF PubMed Scopus (207) Google Scholar In COVID-19 infection, pressure injury sites are associated with purpuric lesions.2Chand S. Rrapi R. Lo J.A. et al.Purpuric ulcers associated with COVID-19 infection: a case-series.JAAD Case Rep. 2021; https://doi.org/10.1016/j.jdcr.2021.01.019Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar This study investigates the epidemiology and laboratory findings of these lesions to elucidate their etiology. From March 12, 2020, to May 31, 2020, at a single institution, 1216 adults hospitalized with laboratory-confirmed SARS-CoV-2 infection were retrospectively reviewed. A centralized clinical data registry with search functionality combined with a manual chart review identified patients with skin lesions. At least 2 dermatologists, with a third dermatologist for adjudication, evaluated patient records for pressure injury and identified the presence or absence of purpuric features. Altogether, 84 patients (6.9%) with 118 pressure injuries having onset concurrent with COVID-19 hospitalization were identified (Fig 1). The dermatologists were aided by photographs of 73.8% (n = 62/84) of the patients. The pressure injuries were associated with a prolonged length of stay (mean of 37.3 days) and high rates of endotracheal intubation (81.9%) (Table I). A portion of the patients (32.5%; n = 27/83) had pressure injuries with purpuric features. Laboratory values related to coagulopathy at lesion onset did not differ between patients with and without purpura, with the exception of D-dimer values, which were higher (P = .016) for patients with purpuric features (Supplemental Table I; available at https://doi.org/10.17632/vkzxr32ffr.1).Table IComparison of patients with nonpurpuric and purpuric pressure injuriesCharacteristicPatients with nonpurpuric pressure injury∗4 patients had multiple pressure injuries of which some had purpuric features and others had only nonpurpuric features. Values for these patients are tabulated in both columns. (n = 61)Patients with purpuric pressure injury∗4 patients had multiple pressure injuries of which some had purpuric features and others had only nonpurpuric features. Values for these patients are tabulated in both columns. (n = 27)Total patients with pressure injury (n = 84)P value†Statistical testing is performed comparing patients having pressure injuries with purpuric features to patients having pressure injuries none of which had purpuric features.Lesion evaluation Day of injury onset since admission (mean ± SD)11.2 ± 8.014.3 ± 10.012.0 ± 9.0.25 Dermatology consultation obtained4 (6.6%)7 (25.9%)10 (11.9%).0070 Photographs obtained40 (65.6%)25 (92.6%)62 (73.8%).0075Demographics Age in years (mean ± SD)60.9 ± 15.663.6 ± 14.861.9 ± 15.3.49 SexMale45 (73.7%)21 (77.8%)61 (73.5%).54Female16 (26.2%)6 (22.2%)22 (26.5%)Patient past medical history BMI (mean ± SD)31.8 ± 7.933.6 ± 9.632.1 ± 8.3.25 Hypertension25 (40.9%)15 (55.6%)38 (45.9%).21 Diabetes25 (40.9%)14 (51.9%)36 (43.4%).28 Chronic heart disease5 (8.2%)1 (3.7%)6 (7.2%).39 Chronic lung disease7 (11.5%)6 (22.2%)12 (14.5%).16 Stroke/cerebrovascular accident3 (4.9%)2 (7.4%)5 (6.0%).71 Smoking/cigarette use24 (39.3%)15 (55.6%)36 (42.9%).16Hospitalization Length of stay in days (mean ± SD)36.5 ± 20.442.3 ± 25.137.3 ± 21.9.15 Intensive care unit admission52 (85.2%)24 (88.9%)71 (85.6%).55 Death13 (21.0%)4 (14.8%)17 (20.5%).37 Treatment courseEndotracheal intubation50 (81.9%)23 (85.2%)68 (81.9%).59Orogastric/nasogastric intubation48 (78.6%)21 (77.8%)64 (77.1%).92Urinary catheterization52 (85.2%)24 (88.9%)71 (85.5%).55Rectal intubation49 (80.3%)22 (81.5%)66 (79.5%).76Parenteral nutrition11 (18.0%)3 (11.1%)12 (14.5%).55 Clinical courseCerebrovascular accident-1 (3.7%)1 (1.2%)-Deep vein thrombosis5 (8.2%)1 (3.7%)6 (7.2%).39Pulmonary embolism5 (8.2%)3 (11.1%)8 (9.6%).76Intracranial hemorrhage2 (3.3%)-2 (2.4%)- On therapeutic anticoagulation at onset of first injury12 (19.7%)8 (29.6%)18 (21.4%).26BMI, Body mass index; SD, standard deviation.∗ 4 patients had multiple pressure injuries of which some had purpuric features and others had only nonpurpuric features. Values for these patients are tabulated in both columns.† Statistical testing is performed comparing patients having pressure injuries with purpuric features to patients having pressure injuries none of which had purpuric features. Open table in a new tab BMI, Body mass index; SD, standard deviation. The incidence of pressure injury in this study (6.9%) is comparable to previous estimates of 5%-15% of hospitalized patients, depending on clinical context.1Mervis J.S. Phillips T.J. Pressure ulcers: pathophysiology, epidemiology, risk factors, and presentation.J Am Acad Dermatol. 2019; 81: 881-890Abstract Full Text Full Text PDF PubMed Scopus (207) Google Scholar With respect to COVID-19 hospitalization specifically, the especially tenuous respiratory status in these critically ill patients frequently interfered with standard preventative measures to turn patients for inspection and pressure offloading.1Mervis J.S. Phillips T.J. Pressure ulcers: pathophysiology, epidemiology, risk factors, and presentation.J Am Acad Dermatol. 2019; 81: 881-890Abstract Full Text Full Text PDF PubMed Scopus (207) Google Scholar,3Tang J. Li B. Gong J. Li W. Yang J. Challenges in the management of critical ill COVID-19 patients with pressure ulcer.Int Wound J. 2020; 17: 1523-1524Crossref PubMed Scopus (26) Google Scholar Placing patients in a prone position has been demonstrated to reduce the development of pressure injuries and is associated with improved outcomes in the setting of a poor respiratory status.4Li L. Li R. Wu Z. et al.Therapeutic strategies for critically ill patients with COVID-19.Ann Intensive Care. 2020; 10: 1-9Crossref PubMed Scopus (91) Google Scholar However, this study discovered 36 pressure ulcers (30.5%) occurring on the face, likely resulting from proning, emphasizing specific challenges affecting patients with COVID-19 and the importance of prophylactic measures to prevent these injuries in proned patients. This study only found elevated D-dimer levels in patients with purpuric pressure injuries, corroborating previous reports of elevation of fibrin and fibrinogen degradation products in COVID-19.5Connors J.M. Levy J.H. COVID-19 and its implications for thrombosis and anticoagulation.Blood. 2020; 135: 2033-2040Crossref PubMed Scopus (155) Google Scholar Thromboembolic events and abnormalities in other markers of coagulation were not found to be more common in patients with purpuric pressure injuries within our cohort. Biopsies were obtained in 4 patients and previously reported as exhibiting epidermal and eccrine gland necrosis, supportive of pressure-induced injury, with fibrin thrombi in superficial dermal vessels only.2Chand S. Rrapi R. Lo J.A. et al.Purpuric ulcers associated with COVID-19 infection: a case-series.JAAD Case Rep. 2021; https://doi.org/10.1016/j.jdcr.2021.01.019Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar These findings suggest that purpuric features of pressure injuries are less likely indicative of occult pathology resulting from COVID-19 infection and emphasize the usual prevalence of pressure injuries in critically ill patients, highlighting the importance of identifying risk factors, encouraging preventative measures, and reinforcing the known standard of care. Taking steps to address predisposing factors in hospitalized COVID-19 patients is essential in preventing these lesions and improving outcomes.1Mervis J.S. Phillips T.J. Pressure ulcers: pathophysiology, epidemiology, risk factors, and presentation.J Am Acad Dermatol. 2019; 81: 881-890Abstract Full Text Full Text PDF PubMed Scopus (207) Google Scholar,3Tang J. Li B. Gong J. Li W. Yang J. Challenges in the management of critical ill COVID-19 patients with pressure ulcer.Int Wound J. 2020; 17: 1523-1524Crossref PubMed Scopus (26) Google Scholar The authors would like to thank the clinicians who cared for these patients during the COVID-19 pandemic and created the documentation necessary to make this study possible. None disclosed.

Erythema annulare centrifugum (EAC) is a reactive eruption that typically presents with annular or polycyclic erythematous lesions on the trunk and proximal extremities, often with a trailing scale.1 EAC is one of the major figurate erythemas, along with erythema marginatum, erythema migrans, and erythema gyratum, and can occur as a paraneoplastic phenomenon called paraneoplastic EAC eruption. EAC is usually self-resolving, assuming that the inciting cause, if any, is addressed. Typical treatment options for the symptomatic disease include topical or systemic corticosteroids, antihistamines, or antibiotics.

*Massachusetts General Hospital Dermatology and Laser Cosmetic Center, Harvard Medical School, Boston, Massachusetts Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.dermatologicsurgery.org). M.M. Avram is a consultant, is on the advisory board, and/or has stock options for Allergan, Cytrellis, Inc., Sciton, Zeltia, Merz, La Jolla Nanoparticle, and Soliton, Inc.

Cutaneous manifestations have been associated with COVID-19 infection and their significance in hospitalized patients remains unclear. This study catalogues the exanthems observed in hospitalized COVID-19 patients to determine prevalence and inform clinicians in devising diagnostic and management strategies.

Background: Cutaneous manifestations have been associated with COVID-19 infection and their clinical significance in hospitalized patients remains unclear Methods: A retrospective chart review of 1216 patients older than 18 years of age hospitalized with laboratory-confirmed SARS-CoV-2 infection from March 12, 2020 to May 31, 2020 at a large urban academic medical center A keyword search query of patient records combined with manual chart review by at least two dermatologists identified a study group having cutaneous manifestations concurrent with COVID-19 infection, specifically between 14 days prior to admission and up to discharge Results: 122 patients with 195 skin lesions concurrent with COVID-19 hospitalization were identified Dermatology reviewers evaluated clinical photographs for 116 lesions (59 5%) and inpatient dermatology consultations for 42 lesions (21 5%) The most common cutaneous findings in patients with COVID-19 hospitalization were pressure injuries (n=118;60 5%) and morbilliform eruptions (n=33;16 9%) A very small number of patients (0 6%;n=7/1216) had exanthems occurring within 2 weeks of COVID-19 symptom onset The majority of exanthems developed within 14 days of exposure to possible culprit drugs and beyond the 14-day window of COVID-19 symptom onset, making viral association unlikely Conclusion: Skin lesions concurrent with COVID-19 hospitalization were most frequently linked to hospitalization-related factors, such as pressure injuries or drug-related exanthems, rather than due to novel pathologies related to SARS-CoV-2 itself

To the Editor: Acute generalized exanthematous pustulosis (AGEP) is a severe cutaneous adverse reaction, typically to a medication, that is characterized by fever, neutrophilia, and a disseminated nonfollicular pustular eruption. AGEP is typically self-resolving upon withdrawal of the offending agent; however, it is not without complications, and distributive shock due to systemic inflammatory response can lead to hemodynamic instability and organ failure.1Sidoroff A. Dunant A. Viboud C. et al.Risk factors for acute generalized exanthematous pustulosis (AGEP)—results of a multinational case-control study (EuroSCAR).Br J Dermatol. 2007; 157: 989-996Crossref PubMed Scopus (351) Google Scholar,2Jakkidi M. Basmadjian C. Roy S. An illusion of septic shock: acute generalised exanthematous pustulosis with multiorgan dysfunction.BMJ Case Rep. 2017; 2017 (bcr-2017-220612)PubMed Google Scholar These patients have been successfully treated with systemic corticosteroids.3Thienvibul C. Vachiramon V. Chanprapaph K. Five-year retrospective review of acute generalized exanthematous pustulosis.Dermatol Res Pract. 2015; 2015: 260928Crossref PubMed Scopus (19) Google Scholar Cyclosporine use in patients with AGEP has been limited to only a few case reports.4Yalçın B. Çakmak S. Yıldırım B. Successful treatment of hydroxychloroquine-induced recalcitrant acute generalized exanthematous pustulosis with cyclosporine: case report and literature review.Ann Dermatol. 2015; 27: 431-434Crossref PubMed Scopus (11) Google Scholar,5Di Lernia V. Grenzi L. Guareschi E. Ricci C. Rapid clearing of acute generalized exanthematous pustulosis after administration of ciclosporin.Clin Exp Dermatol. 2009; 34: e757-e759Crossref PubMed Scopus (21) Google Scholar To date, to our knowledge, no studies have evaluated the utility of cyclosporine in the management of AGEP. We report the largest cohort of patients with AGEP treated with cyclosporine and compare them to patients treated with systemic glucocorticoids. This was a retrospective study of adults admitted to Massachusetts General Hospital or Brigham and Women's Hospital with a diagnosis of AGEP from 2009 through 2019. The patients were identified via a query of the electronic medical record systems at both hospitals, and their records were reviewed to find those who received cyclosporine, matched to approximately 3 age- (±5 years) and sex-matched control individuals per case who received systemic glucocorticoids, amounting to a total of 23 control individuals. The patients were followed daily while inpatients and within 2 weeks of discharge. Time from treatment initiation to first noted improvement (defined by defervescence or symptomatic improvement), time to cessation of pustule formation, time to resolution of erythema, and length of hospital stay were analyzed. The data from patients who received cyclosporine and systemic glucocorticoids were analyzed, and characteristics of the study population are presented in Table I. There was a high prevalence of patients who met criteria for systemic inflammatory response syndrome among those treated with cyclosporine (62.5%) and those treated with glucocorticoids (61%), implying that this cohort consisted of patients with more severe cases of AGEP. Patient outcomes are presented in Table II. The time from drug eruption onset to cessation of pustule formation was similar in both the cyclosporine group (2.5 days) and the corticosteroid group (3 days). Patients treated with cyclosporine were able to achieve initial noted clinical improvement in 1.5 days and had comparable durations of hospitalization and time to resolution of erythema as patients who received glucocorticoids. No patients had major adverse effects from cyclosporine or glucocorticoids.Table IPatient characteristicsCategoryCyclosporine (n = 8)Corticosteroids (n = 23)P valueDose of medication3 mg/kg modified cyclosporine (Neoral; Novartis, Basel, Switzerland) divided BID for 1 week, tapered to 1.5 mg/kg divided BID for 1 week1 mg/kg methylprednisolone daily, with variable taper to oral prednisoneAge of onset, y, mean (SD)58.9 (14.2)55.4 (18.6).63Sex, n (%)>.99 Female6 (75)18 (78) Male2 (25)5 (22)BMI, kg/m2, mean (SD)32.76 (8.58)33.19 (10).92Patients with insurance, n (%)7 (87.5)21 (91.3)>.99SIRS criteria (>2), n (%)8 (100)20 (86.9).55Primary admission diagnosis, n (%).64 Rash7 (87.5)16 (69.6) Surgical procedure0 (0)3 (13) Dysphagia1 (12.5)1 (4.34) Respiratory failure0 (0)1 (4.34) Osteomyelitis0 (0)1 (4.34) Pneumonia0 (0)1 (4.34)Discharge diagnosis of AGEP, n (%)8 (100)23 (100)>.99AGEP, Acute generalized exanthematous pustulosis; BID, twice a day; BMI, body mass index; SD, standard deviation; SIRS, systemic inflammatory response syndrome. Open table in a new tab Table IIComparison of outcomes, days, median (IQR)OutcomeCyclosporine (n = 8)Corticosteroids (n = 23)P valueTime from treatment initiation to first noted clinical improvement (defervescence or subjective symptomatic improvement)1.5 (1)3.5 (2.25).034Time from treatment initiation to subjective cessation of pustule formation2.5 (1.75)3 (4).46Time to resolution of erythema7 (8)12 (11.25).21Duration of hospitalization5 (3)7 (7).086IQR, Interquartile range. Open table in a new tab AGEP, Acute generalized exanthematous pustulosis; BID, twice a day; BMI, body mass index; SD, standard deviation; SIRS, systemic inflammatory response syndrome. IQR, Interquartile range. To date, this represents, to our knowledge, the largest cohort of patients with AGEP successfully treated with cyclosporine. Cyclosporine appears to be noninferior to glucocorticoids with regard to stopping the eruption and providing clinical improvement. In this cohort, the patients who received cyclosporine were those with relative contraindications to systemic corticosteroids, such as diabetes, or history of steroid use with poor tolerance (i.e., delirium, emotional lability, etc.). Because cyclosporine was administered primarily based on provider preferences in the setting of the aforementioned comorbidities, some selection bias was unavoidable in this cohort. The small sample size and retrospective nature also limit this study. Nevertheless, cyclosporine appears to be a noninferior therapeutic alternative to glucocorticoids in appropriate patients who present with AGEP, and future prospective studies are needed to further examine its utility in AGEP.

This retrospective case-control study of 26 adults evaluates the use of cyclosporine A in the treatment of drug reaction with eosinophilia and systemic symptoms (DRESS syndrome) compared with standard systemic glucocorticosteroids.

Adverse cutaneous reactions to medications, including drug eruption with eosinophilia and systemic symptoms (DRESS) and acute generalized exanthematous pustulosis (AGEP), are rare though life-threatening. Treatment of these entities involves withdrawal of the causative drug, supportive care, and use of potent systemic or topical steroids. However, patients with diabetes or psoriasis may warrant alternatives to systemic steroids and benefit from cyclosporine treatment. Cyclosporine is an immunomodulatory agent which is widely used in the treatment of cutaneous disease. Due to its immunosuppressive properties, it is a viable option for treatment of DRESS and AGEP. The primary aim is to evaluate the impact and efficacy of cyclosporine for the treatment of adverse cutaneous reactions to medications. We report a double center observational case series of efficacious treatment of DRESS and AGEP with cyclosporine. Methods: We examined 11 cases of patients at Massachusetts General Hospital and Brigham Womens Hospital with DRESS or AGEP treated with at least 7 days of cyclosporine between 2008 and 2018. Results: Of these 11 cases, 7 patients were diagnosed with AGEP, 3 were diagnosed with DRESS, and 1 was diagnosed with DRESS/AGEP overlap. All patients by definition had systemic vital abnormalities, including tachycardia, hypotension, and fevers, that rapidly improved on cyclosporine. Mean time of cyclosporine treatment was 14.09 days with normalization of laboratory markers. Mean time of hospitalization was 5.73 days, with patients experiencing clinical improvement of rash or abnormal vital signs within 2.67 days. Cyclosporine proved to have particular utility in patients was used successfully in patients with relative contraindication to steroid therapy, including one who had developed Cushing syndrome. Conclusions: Resolution of these adverse cutaneous drug reactions can sometimes occur spontaneously within 2 weeks, though the use of cyclosporine halted progression of rash in all cases.

Nodular scabies is a hypersensitivity reaction to scabietic infestation characterized by persistent pruritic nodules that can remain even after treatment of the initial infestation. We present a demonstrative case of an infant who presented with nodular scabies.

Hydroxyurea is a medication with many well-described cutaneous side effects, notably the dermatomyositis-like eruption known as hydroxyurea dermopathy. Although systemic lupus erythematosus has been reported with hydroxyurea use, cutaneous lupus has not. We report a novel case of chronic cutaneous lupus induced by hydroxyurea and propose that this is a side effect that is distinct from hydroxyurea dermopathy.

A 31-year-old white woman presented with a 3-year history of a waxing and waning eruption associated with intense pruritus. There was otherwise no pertinent medical or family history. She had previously tried antifungal cream, topical steroids, and minocycline without much improvement. The physical examination revealed reticulated hyperpigmented patches on her chest, back, and hips. Superimposed on these patches were discrete, erythematous, pinpoint, sandpaper-like papules (Fig 1). A biopsy specimen was obtained from a patch on her chest, and the histopathologic examination revealed mild spongiosis, a focal interface dermatitis with necrotic keratinocytes, a superficial dermal and perivascular lymphocytic inflammatory infiltrate with occasional neutrophils (Fig 2), and occasional dermal melanophages (arrows, Fig 3). 1.What is the most likely diagnosis? A.Pityriasis lichenoides chronica B.Prurigo pigmentosa C.Confluent and reticulated papillomatosis D.Dermatitis herpetiformis E.Ashy dermatosis 2.Which epidemiologic factor is most strongly associated with this condition? A.Latin American B.Male C.Infancy D.African American E.Japanese 3.This disease is commonly described in patients presenting with which of the following? A.Ketosis B.Graves' disease C.Hodgkin lymphoma D.Rheumatoid arthritis E.Prolonged dapsone use Fig 2 View Large Image Figure Viewer Download Hi-res image Fig 3 View Large Image Figure Viewer Download Hi-res image