Faculty Bibliography

Background: Skin complaints are a frequent cause of outpatient visits in Ghana and other developing nations. Many skin diseases pose significant health problems for local populations and a financial burden for families. However, epidemiologic studies on the true burden of disease are lacking in many regions. The WHO has therefore solicited studies that expand geographic representation and add to the growing knowledge base of skin disease epidemiology. Objective: The purpose of this study is to document the types and frequencies of skin conditions seen at the outpatient dermatology clinic at Korle Bu Teaching Hospital (KBTH), a tertiary care hospital in Accra, Ghana. This information will be valuable in guiding educational efforts and resource allocation. Methods: We performed a retrospective chart review of all new patients presenting to the KBTH Dermatology Clinic, over a 1-year time period in 2014. Patient charts were reviewed for basic demographic data and clinical information such as referral diagnosis, diagnostic tests, diagnoses, treatments and number of follow-up visits. Ethical clearance was obtained from the local and US partner IRBs. Results: 632 new patients who were seen at the KBTH dermatology clinic met criteria for inclusion, and 529 had medical records available for review. The majority of the 529 patients studied were female (56.6%) and the mean age was 32.1 +/- 23.5 years. In total, 678 discrete diagnoses were made. The most commonly diagnosed skin conditions were infections (24.6%) and dermatitis/eczema (24.4%). 18 biopsies were performed. The treatments most commonly prescribed to patients were antihistamines (44.2%), topical steroids (38.0%), and keratolytics (26.8%). Patients attended an average of 2.7 +/- 2.4 clinic visits, with many patients only attending one visit (40.6%). Conclusions: Our results are in agreement with earlier studies from Ghana and other developing countries. A 1995 study of skin disease in Kumasi, a central Ghanaian city, showed infectious etiologies and dermatitis to be common. Our study also showed that biopsies were infrequent, likely due to the lack of local dermatopathology resources. Local affordable formulary was limited, but generally adequate. Limitations: Frequency data were obtained retrospectively from a single outpatient clinic; therefore, results are subject to a selection bias and may not be generalizable to the general population

To understand the role that tattooists play in providing skin care advice, we conducted an online, survey-based study of 90 licensed tattooists in New York City. The survey asked tattooists about their exposure to adverse tattoo events, advising on tattoo removal/correction, behaviors regarding preexisting skin conditions and aftercare, confidence in addressing client questions about adverse events and preexisting conditions, and prior training about skin conditions related to tattoos. Most tattooists (92.8%) reported being asked by clients to evaluate adverse tattoo reactions, 85% were asked about tattoo removal, and 90% were asked about the safety of getting a tattoo with a preexisting skin condition. About half (56.1%) had received training about skin conditions related to tattoos. Tattooists with prior training reported higher rates of optimal skin care behaviors and higher confidence with tattoo-related skin conditions; 91.4% reported interest in skin care education. Tattooists play a major role in the skin health of their clients. Providing education for tattooists may improve skin care in populations less likely to see a dermatologist.

Peripheral nerve injury has been associated with the development of periungual pyogenic granuolomas (PGs). We present the case of a 39-year-old woman with an eight-month history of periungual PGs in the setting of a four-to-five year history of a traumatic inciting event that produced symptoms consistent with complex regional pain syndrome (CRPS). Although recurrent, these periungual PGs have remitted after treatment with topical timolol maleate. This case exhibits an underappreciated association between peripheral neurologic abnormalities, which include CRPS, and cutaneous abnormalities. It also presents evidence that supports the concept that PGs that are not appropriate for surgical treatments may be treated with topical timolol maleate.

We present a case of exogenous ochronosis in a 53-year-old woman with skin type IV, who used a topical hydroquinone preparation of an unknown concentration for several years. Traditionally, exogenous ochronosis was thought to occur exclusively in patients with darker skin types who use high concentrations of hydroquinone cream. Reports now document cases in patients of all skin types and in patients even using low concentrations of hydroquinone cream for short periods of time. Although the incidence of exogenous ochronosis in the United States is unclear, it may be more common than many clinicians believe. It is important for clinicians and patients to be aware of exogenous ochronosis in order to prevent exacerbation in patients with this rare side effect.

A 55-year-old woman presented after a four-year history of impetiginized eczema that was distributed over her face, scalp, chest, and back and a recent diagnosis of breast cancer. A skin biopsy specimen for direct immunofluorescence demonstrated intercellular IgG4. Anti-desmoglein 1 and 3 antibodies were present. Indirect immunofluorescence testing was positive on monkey but not rat esophagus. These findings were consistent with a diagnosis of pemphigus foliaceus in association with a malignant condition. After many years of the use of topical glucocorticoids and oral antibiotics, the patient's disease was ultimately managed with methotrexate and a small dose of prednisone. Increasing data supports a role for a steroid-sparing effect of methotrexate in pemphigus vulgaris and likely pemphigus foliaceus.

Palmoplantar lichen planus (PPLP) is an uncommon variant of lichen planus that affects the palms and soles. Clinical findings are varied although they have been conceptualized into two large groupings, an erythematous scaly pattern and a hyperkeratotic pattern. Histopathologic features are those of classic LP. We present a case of PPLP that improved with methotrexate after failing treatment with acitretin.

BACKGROUND: Clinical photography enhances medical care, research, and teaching. Empirical data are needed to guide best practices regarding dermatologic photography. OBJECTIVE: To investigate patient opinion about clinical photography and identify demographic factors that influence these opinions. METHODS AND MATERIALS: Four hundred patients representing a broad range of ages, self-identified ethnic/racial groups, and socioeconomic levels were recruited from 4 dermatology settings in New York City. Patients were administered a survey about perceptions of photography, willingness to allow photographs to be used in a variety of settings, preferences for photographer and photographic equipment, and methods of consent. RESULTS: Eighty-eight percent of patients agreed that photography enhanced their quality of care. Most patients would allow their photographs to be used for medical, teaching, and research purposes with significantly more acceptance when patients were not identifiable. Patients preferred photographs taken by a physician rather than a nurse or student, photographers of the same gender, clinic-owned cameras to personal cameras or cell phones, and written consent to verbal consent. There were significant racial/ethnicity and age-related variations in responses, with white and older patients being more permissive than other groups. CONCLUSION: We use the results of this study to recommend best practices for photography in dermatology.

IMPORTANCE Medications as well as chemical and food exposures have been causally linked to the development of pigmented purpuric dermatosis (PPD). We describe herein what is to our knowledge the first reported case of isotretinoin-induced PPD. OBSERVATIONS A woman in her 30s presented with purpura annularis telangiectodes of Majocchi on the lower extremities 2 months after initiating isotretinoin for the treatment of refractory nodulocystic acne. CONCLUSIONS AND RELEVANCE We believe isotretinoin was the most likely causative agent in this case because the lesions began after initiation of isotretinoin treatment and resolved shortly after its termination, and the pathologic findings were consistent with other described cases of drug-induced PPD. The lesions have continued to fade, and no new lesions have developed in a 3-month follow-up period. Drug-induced PPD is distinct from idiopathic PPD, and it is important to consider isotretinoin as a potential inciting agent.