Faculty Bibliography

Participation in ice-skating sports, particularly figure skating, ice hockey and speed skating, has increased in recent years. Competitive athletes in these sports experience a range of dermatological injuries related to mechanical factors: exposure to cold temperatures, infectious agents and inflammation. Part I of this two part review discussed the mechanical dermatoses affecting ice-skating athletes that result from friction, pressure, and chronic irritation related to athletic equipment and contact with surfaces. Here, in Part II, we review the cold-induced, infectious and inflammatory skin conditions observed in ice-skating athletes. Cold-induced dermatoses experienced by ice-skating athletes result from specific physiological effects of cold exposure on the skin. These conditions include physiological livedo reticularis, chilblains (pernio), Raynaud phenomenon, cold panniculitis, frostnip and frostbite. Frostbite, that is the literal freezing of tissue, occurs with specific symptoms that progress in a stepwise fashion, starting with frostnip. Treatment involves gradual forms of rewarming and the use of friction massages and pain medications as needed. Calcium channel blockers, including nifedipine, are the mainstay of pharmacological therapy for the major nonfreezing cold-induced dermatoses including chilblains and Raynaud phenomenon. Raynaud phenomenon, a vasculopathy involving recurrent vasospasm of the fingers and toes in response to cold, is especially common in figure skaters. Protective clothing and insulation, avoidance of smoking and vasoconstrictive medications, maintaining a dry environment around the skin, cold avoidance when possible as well as certain physical manoeuvres that promote vasodilation are useful preventative measures. Infectious conditions most often seen in ice-skating athletes include tinea pedis, onychomycosis, pitted keratolysis, warts and folliculitis. Awareness, prompt treatment and the use of preventative measures are particularly important in managing such dermatoses that are easily spread from person to person in training facilities. The use of well ventilated footgear and synthetic substances to keep feet dry, as well as wearing sandals in shared facilities and maintaining good personal hygiene are very helpful in preventing transmission. Inflammatory conditions that may be seen in ice-skating athletes include allergic contact dermatitis, palmoplantar eccrine hidradenitis, exercise-induced purpuric eruptions and urticaria. Several materials commonly used in ice hockey and figure skating cause contact dermatitis. Identification of the allergen is essential and patch testing may be required. Exercise-induced purpuric eruptions often occur after exercise, are rarely indicative of a chronic venous disorder or other haematological abnormality and the lesions typically resolve spontaneously. The subtypes of urticaria most commonly seen in athletes are acute forms induced by physical stimuli, such as exercise, temperature, sunlight, water or particular levels of external pressure. Cholinergic urticaria is the most common type of physical urticaria seen in athletes aged 30 years and under. Occasionally, skaters may develop eating disorders and other related behaviours some of which have skin manifestations that are discussed herein. We hope that this comprehensive review will aid sports medicine practitioners, dermatologists and other physicians in the diagnosis and treatment of these dermatoses.

Figure skaters, ice-hockey players and speed skaters experience a range of dermatologic conditions and tissue-related injuries on account of mechanical trauma, infectious pathogens, inflammatory processes and environmental factors related to these competitive pursuits. Sports medicine practitioners, family physicians, dermatologists and coaches should be familiar with these skin conditions to ensure timely and accurate diagnosis and management of affected athletes. This review is Part I of a subsequent companion review and provides a comprehensive review of mechanical dermatoses experienced by ice-skating athletes, including skater's nodules and its variants, pump bumps, piezogenic pedal papules, talon noir, skate/lace bite, friction bullae, corns and calluses, onychocryptosis, skater's toe and skate blade-induced lacerations. These injuries result from friction, shear forces, chronic pressure and collisions with surfaces that occur when athletes endure repetitive jump landings, accelerated starts and stops and other manoeuvres during rigorous training and competition. Ill-fitting skates, improper lacing techniques and insufficient lubrication or protective padding of the foot and ankle often contribute to the development of skin conditions that result from these physical and mechanical stresses. As we will explain, simple measures can frequently prevent the development of these conditions. The treatment of skater's nodules involves reduction in chronic stimulation of the malleoli, and the use of keratolytics and intralesional steroid injections; if malleolar bursitis develops, bursa aspirations may be required. Pump bumps, which result from repetitive friction posteriorly, can be prevented by wearing skates that fit correctly at the heel. Piezogenic pedal papules may be treated conservatively by using heel cups, compressive stockings and by reducing prolonged standing. Talon noir usually resolves without intervention within several weeks. The treatment of skate bite is centred on reducing compression by the skate tongue of the extensor tendons of the anterior ankle, which can be accomplished by use of proper lacing techniques, increasing pliability of the skate tongue and using protective padding, such as Bunga Pads. Anti-inflammatory medications and cold compresses can also help reduce inflammation. Friction bullae are best managed by careful lancing of painful blisters and application of petrolatum or protective dressings to accelerate healing; preventative measures include the use of well fitting skates, proper lacing techniques and moisture-wicking socks. Corns and calluses are similarly best prevented by the use of well fitted skates and orthotic devices. Symptomatic, debridement reduces the irritant effect of the thick epidermis, and can be accomplished by soaking the area in warm water followed by paring. Application of creams with high concentrations of urea or salicylic acid can also soften callosities. Cases of onychocryptosis benefit from warm soaks, antibiotic ointments and topical steroids to reduce inflammation, but sometimes chemical or surgical matricectomies are required. Preventative measures of both onychocryptosis and skater's toe include cutting toenails straight across to allow for a more equal distribution of forces within the toe box. Finally, the prevention and treatment of lacerations, which constitute a potentially fatal type of mechanical injury, require special protective gear and acute surgical intervention with appropriate suturing. The subsequent companion review of skin conditions in ice skaters will discuss infectious, inflammatory and cold-induced dermatoses, with continued emphasis on clinical presentation, diagnosis, treatment and prevention.

The development of topical drug delivery systems has recently gained significant interest due to the ease of administration and lesser risks of systemic toxicity. The development of these new technologies utilizes the properties of the structure and function of the skin. The stratum corneum plays the largest role in affecting drug permeation, as the corneocytes and lipid matrix in this layer effectively prevent the diffusion of large molecules. In this review, we introduce the structure and function of the skin as it relates to topical drug delivery.

Purpose: Mortalities due to skin cancer are escalating, but early detection via skin examinations can be beneficial. To date, dermatologists have not been isolated as a high-risk population for developing skin cancer, although some evidence suggests that they are a high-risk group. Therefore, the specific aims of this study were to measure the frequency at which dermatologists perform self-skin examination and receive full-body skin examination. Patients and methods: A sample of 476 respondents provided data for this cross-sectional, nine-item survey, which was e-mailed to all registered members in the American Society for Dermatologic Surgery. The initial invitation was sent in the summer of 2007, with reminders sent at four and eight weeks. E-mails contained a unique identifier, and each member could only respond once to the survey sent to that particular e-mail address. Results: 71.7 percent of the respondents reported that they routinely gave themselves a self-skin examination, 25.4 percent reported a monthly exam, 24.5 percent every six months, 17.2 percent once per year, and 4.6 percent every five years. Performing a self-skin examination was not related to age, gender, or history of skin malignancy. Seventy-six percent of all respondents never had a full-body skin examination conducted by another dermatologist, which persisted when analyzed by age (p = 0.0490) and gender (p = 0.0184). Conclusion: Dermatologists are more likely to perform self-skin examination rather than visit another dermatologist for a full-body skin examination

BACKGROUND: Chronic actinic dermatitis (CAD) is a rare photosensitivity disorder with scant epidemiologic data. OBJECTIVE: To evaluate demographic data and results of photopatch and patch tests over a 25-year period. METHODS: Retrospective chart review of patients with CAD from 1993 to 2009. RESULTS: Forty patients had a mean age of 57.8 years, and 27 (67.5%) were men. Twelve patients (30%) were skin types I and II, and 17 (42.5%) were skin types V and VI. Nine patients (22.5%) were younger than 50 years, and 4 of these (44.4%) were men. One of the nine patients (11.1%) was skin type I, and 4 (44.4%) were skin types V and VI. Carba mix and para-phenylenediamine were the two most commonly positive agents in patch tests. Sunscreens and plants and plant derivatives were the most commonly positive agents in photopatch tests. CONCLUSIONS: Our findings suggest a trend of two new classes of North American patients at our institution being diagnosed with CAD-younger women with skin types IV to VI and older men with skin types I to III. We observed a greater-than-expected number of positive patch-test reactions to para-phenylenediamine. We suggest that patch testing and photopatch testing of individuals may be useful adjuncts in the assessment of CAD

Ultraviolet filters are the most common topical photoallergens. Although currently not available on the US market, methylene bis-benzotriazolyl tetramethylbutylphenol (referred to as bisoctrizole on product labels) represents a new class of UV filters that have both organic and inorganic properties and are widely available in different preparations in Europe, South America, and Asia. We report two patients with atopic dermatitis and chronic actinic dermatitis who had positive patch- and photopatch-test reactions, which suggested both an allergic contact and a photoallergic contact dermatitis from bisoctrizole. Neither patient could identify previous or current contact with the chemical; nonetheless, it is possible that either the allergic contact or photoallergic contact dermatitis from bisoctrizole led to their chronic actinic dermatitis

BACKGROUND: Retrospective chart reviews are periodically needed to update allergen series to detect changes in photoallergic contact dermatitis (PACD) over time. OBJECTIVE: We sought to evaluate photopatch test results during a 13-year period and extend the observations to 20 years. METHODS: A retrospective chart review was conducted in patients who were photopatch tested. RESULTS: In all, 76 patients were evaluated. A total of 69 positive photopatch and 45 positive patch test reactions were detected in 30 and 23 patients, respectively. The frequencies of the positive photopatch test reactions were sunscreens 23.2%, antimicrobial agents 23.2%, medications 20.3%, fragrances 13%, plants and plant derivatives 11.6%, and pesticides 8.7%. Of the positive photopatch reactions to antimicrobial agents, 60% were caused by Fentichlor. LIMITATIONS: This study was a retrospective chart analysis, and the number of patients was small. CONCLUSIONS: Sunscreens and antimicrobial agents were the most frequent allergens eliciting PACD, and there was a decrease in PACD caused by fragrances. The number of reactions to medications increased. This study also demonstrated that pesticides can be a cause of PACD. The detection of reactions to Fentichlor was unexpected and, although they have been attributed in some studies to cross-reactions to sulfanilamides and bithionol, such a robust association was not observed in this study. This study extends our experience of the changes in the allergens that elicit PACD to 20 years