A description of Kaposi sarcoma risk factors and outcomes in HIV-positive and HIV-negative patients at a tertiary care medical center from 2005 to 2020

Kaposi sarcoma (KS) is a low-grade vascular malignancy caused by human herpesvirus-8 (HHV-8), also known as Kaposi's sarcoma-associated herpesvirus (KSHV). There are four established subtypes of KS, which are described by unique risk factors, presentation, and disease course. A "non-epidemic" variant to describe HIV-negative men who have sex with men (MSM) is emerging as a fifth subtype. We retrospectively examined patients with KS at an academic medical center in central Ohio, USA. To our knowledge, this is the first US-based report to describe KS risk factors and outcomes in the context of HIV status. Data were extracted from patient charts including demographic information, history at time of KS diagnosis, and information about KS disease course. HIV-positive and HIV-negative patients were grouped into established categories. HIV-negative patients who did not fit an existing subtype were described as "Unclassified-KS-Type." Demographic characteristics for AIDS-KS patients in our cohort match established trends in this subtype, such as male, MSM, and younger age at diagnosis compared to HIV-negative patients. Most Unclassified-KS-Type patients fit well into the emerging "non-epidemic KS" subtype. These patients are described as healthy, middle-aged, HIV-negative MSM with lower extremity lesions. This descriptive report provides an updated view of KS risk factors and outcomes to improve detection and treatment in dermatology.

Concordance of diagnostic modalities in atypical skin and soft tissue infections in hospitalized patients

Skin and soft tissue infections (SSTIs) have high rates of morbidity and mortality worldwide but lack reliable standards for diagnostic workup. As a result, atypical infections, more prevalent among immunocompromised patients, can be missed due to deviance from classic features only to be revealed later through inconsistently performed ancillary studies. Our objectives included to evaluate the sensitivities of clinical impression, histopathology, tissue culture, and molecular and non-molecular ancillary tests in diagnosing inpatient SSTIs, as well as to qualitatively discuss the unusual features making a subset of infections "atypical." To do so, we retrospectively reviewed the histopathologic reports and charts of inpatient dermatologic consults at a single tertiary care institution over a 3-year period. We identified a total of 111 cases of SSTIs evaluated by the inpatient dermatology consultation service with concurrent skin or soft tissue biopsy, with 32.4% representing atypical infections. Among these, clinical impression suggested infection in 9(25.0%), routine histopathology in 21(58.3%), specialized stains for microorganisms in 22(68.8%), and tissue culture in 15(68.2%). Due to incomplete picture that each modality by itself creates, we conclude that clinicians and pathologists should carry a low threshold for including SSTIs in their differential diagnoses and should evaluate with skin biopsy, special stains for microorganisms, and ancillary studies, particularly in critically ill individuals who necessitate timely diagnoses.

Characterizing risk factors for hospitalization for psoriasis patients

Psoriasis is a chronic autoimmune disease with a large economic impact. Inpatient care is a significant expense, and about one-third of patients admitted for psoriasis are readmitted. Reducing hospitalizations and readmissions is an important goal for improving outcomes for psoriasis patients. The objective of this study is to characterize patients who are hospitalized for psoriasis, and differentiate features for patients with a single hospitalization from those who were hospitalized multiple times during the study period. Hospitalized psoriasis patients were identified from an in-patient database at a single academic institution. Differences between psoriasis patients with one hospitalization and those with multiple hospitalizations were characterized, as were differences between patients who were hospitalized primarily for psoriasis and those who were admitted primarily for other reasons. Patients who were primarily hospitalized for psoriasis had fewer comorbidities, shorter hospitalizations, and a lower death rate than those hospitalized for other reasons. Patients with multiple hospitalizations had more comorbidities and worse outcomes than patients with a single hospitalization. Patients who are hospitalized primarily for psoriasis are more likely to be pustular, and tend to have fewer comorbidities and better outcomes than patients with psoriasis who are hospitalized with psoriasis as a secondary diagnosis. One limitation of this study is the lack of data available to consistently quantify disease severity, such as percent of body surface area affected by psoriasis or Physician's Global Assessment score.

Development of a Skin-Directed Scoring System for Stevens-Johnson Syndrome and Epidermal Necrolysis: A Delphi Consensus Exercise

Importance

Scoring systems for Stevens-Johnson syndrome and epidermal necrolysis (EN) only estimate patient prognosis and are weighted toward comorbidities and systemic features; morphologic terminology for EN lesions is inconsistent.

Objectives

To establish consensus among expert dermatologists on EN terminology, morphologic progression, and most-affected sites, and to build a framework for developing a skin-directed scoring system for EN.

Evidence Review

A Delphi consensus using the RAND/UCLA appropriateness criteria was initiated with a core group from the Society of Dermatology Hospitalists to establish agreement on the optimal design for an EN cutaneous scoring instrument, terminology, morphologic traits, and sites of involvement.

Findings

In round 1, the 54 participating dermatology hospitalists reached consensus on all 49 statements (30 appropriate, 3 inappropriate, 16 uncertain). In round 2, they agreed on another 15 statements (8 appropriate, 7 uncertain). There was consistent agreement on the need for a skin-specific instrument; on the most-often affected skin sites (head and neck, chest, upper back, ocular mucosa, oral mucosa); and that blanching erythema, dusky erythema, targetoid erythema, vesicles/bullae, desquamation, and erosions comprise the morphologic traits of EN and can be consistently differentiated.

Conclusions and Relevance

This consensus exercise confirmed the need for an EN skin-directed scoring system, nomenclature, and differentiation of specific morphologic traits, and identified the sites most affected. It also established a baseline consensus for a standardized EN instrument with consistent terminology.

Mpox in Young Woman with No Epidemiologic Risk Factors, Massachusetts, USA

We describe a case of mpox characterized by a circularly distributed facial rash but no identified risk factors. Fomite transmission of monkeypox virus from contaminated linen at a massage spa was suspected. Clinicians should consider mpox in patients with consistent clinical syndromes, even in the absence of epidemiologic risk factors.

Hospital triage and skin disease: hospital outcomes are differentially associated with cutaneous morphology

BACKGROUND

Determining the exact dermatologic diagnosis is difficult in the inpatient setting.

OBJECTIVE

Determine whether morphologic classification rather than specific diagnosis is associated with hospital outcomes.

METHODS

Retrospective single-center study. Information from 1798 inpatient dermatology consults at The Ohio State University Wexner Medical Center from 2012 to 2014 was queried. Dermatologic diseases were categorized into 16 groups based on appearance. Logistic regression was performed comparing mortality rate vs morphology. Linear regression was performed comparing the length of stay (LOS) vs morphology.

RESULTS

Morphology was associated with a mortality rate (P = 0.038). The morphologic subgroups acneiform/follicular/occlusion (P = 0.011), blistering disorders (P = 0.009), retiform purpura (P = 0.011), and vasculitis/vascular (P = 0.007) were associated with increased mortality. Morphology was associated with LOS (P = 0.004), and the morbilliform subgroup was associated with increased LOS (P < 0.001).

CONCLUSION

This study demonstrated the importance of morphologic diagnosis and its association with mortality rate and LOS. This information may help triage cutaneous disorders in the inpatient setting and determine the relative risk of dermatologic conditions when assessing the need for hospital transfers and more aggressive therapies.

Defining Drugs that are High-Risk Associations for Drug Reactions Within the Hospital Setting

OBJECTIVE

We sought to evaluate medication exposures during an entire hospitalization, with the goal of describing medications and demographic conditions that are associated with developing a drug eruption during hospitalization.

METHODS

468 patients that developed a cutaneous drug eruption were identified from a cohort of 18,140 unique inpatients with dermatologic diagnoses; medication lists and demographic information were assimilated, and drug eruption frequency tables were created.

RESULTS

The agents most commonly associated with drug eruptions included many antineoplastic, antifungal, and antibiotic therapeutics: idarubicin (27.78% reaction rate), daunorubicin (26.43%), sorafenib (25.00%), lenalidomide (23.53%), all-trans-retinoic acid (22.58%), decitabine (21.57%), aztreonam (15.15%), posaconazole (14.29%), and voriconazole (13.78%) among many others. Patients diagnosed with drug eruptions were more likely to have private insurance (3.29% vs. 2.58% reaction rate) and were on average older (56.7 vs. 52.6 years), had longer inpatient stay (14.2 vs. 7.9 days), and higher inpatient mortality (5.95% vs. 2.58%) than patients without eruptions.

LIMITATIONS

This was a single-center cross-sectional study. Drug reaction codes were used substantially less frequently than more general codes for non-specific eruptions, further, the analysis was stratified by full hospitalization data to account for delayed reactions.

CONCLUSION

Hospitalizations in which patients receive medications common to malignancies, such as cytotoxic and antifungal therapies represent the highest risk hospitalizations for the development of drug eruptions. When diagnosing and treating drug eruptions, clinicians should consider these medication classes with a high index of suspicion.

Botulinum Toxin in Hidradenitis Suppurativa: A Systematic Review

BACKGROUND

Hidradenitis suppurativa disproportionately affects women, minorities, and skin of color. Botulinum toxin is a potential therapy; however, literature regarding its utility is sparse.

OBJECTIVE

We analyzed evidence surrounding botulinum toxin in the treatment of hidradenitis suppurativa.

METHODS

We conducted a database search of PubMed, Embase, and Cochrane library for studies addressing botulinum toxin therapy for hidradenitis suppurativa through June 10, 2020. Review articles, meta-analyses, and studies without published results were excluded.

RESULTS

Seven studies met criteria for inclusion and review. Botulinum toxin administration resulted in either clinical improvement or improved quality of life in 96.8% (n = 30/31) of patients. Level of evidence was moderate.

LIMITATIONS

Results are limited by the quantity and evidence level of reviewed studies.

CONCLUSION

Botulinum toxin is a safe and potentially effective alternative for hidradenitis suppurativa patients resistant to standard of care therapies. Dermatologists can address this health disparity by strengthening recommendations with high-quality investigations regarding its therapeutic potential. J Drugs Dermatol. 2022;21(4):408-412. doi:10.36849/JDD.5747.

Sexual and gender minority publication trends in the dermatology literature

In the greater medical literature, publication rates on topics relevant to the lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ) communities have been on the rise. The publication rates in the dermatology literature have not yet been described. We performed an analysis of the dermatology literature from 1980-2020 to characterize LGBTQ-relevant publication rates and themes over time. PubMed, CINAHL, and Embase were searched using terminology related to sexual and gender minorities and dermatology. Articles were included if they were published in a peer-reviewed dermatology journal, used human subjects, and included terminology related to sexual or gender minorities in the title or abstract. Publication year, journal, study design, corresponding author country, and best-fit article theme were recorded. The searches yielded 2,019 articles, with 225 meeting inclusion criteria. LGBTQ-relevant articles increased substantially over time, particularly between 2015 and 2020. Overall, most centered on HIV and other infectious diseases (62.2%), followed by other dermatologic conditions (20.4%), workforce and culturally competent care (12.4%), and gender-affirming procedures (4.9%). Although the number of infectious disease-related articles also increased over time, representation of the other three themes increased substantially, particularly since 2011. Although sexually transmitted diseases remain a common theme in the dermatology literature, the last 10 years have seen an explosion of publications on other topics such as non-infectious dermatoses, gender-affirming procedures, and access to culturally competent care.

Long-term Physical and Psychological Outcomes of Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis

Importance

Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is known to cause multiple end-organ complications in its acute phase, but less is known about the long-term association with patients' mental health and quality of life.

Objective

To examine the chronic physical and psychological sequelae affecting patients with SJS/TEN.

Design, Setting, and Participants

A survey study conducted at 11 academic health centers in the US evaluated 121 adults diagnosed with SJS/TEN by inpatient consultive dermatologists between January 1, 2009, and September 30, 2019.

Interventions

Patients completed a survey that included the following validated questionnaires: Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), Primary Care Post-Traumatic Stress Disorder Screen (PC-PTSD), and the 12-item Short Form Health Survey (SF-12). The survey also included questions created by the study team regarding fear, patient education, and long-term sequelae relevant to SJS/TEN.

Main Outcomes and Measures

Primary outcome measures were the percentage of patients reporting long-term physical sequelae; the percentage of patients with positive results on PHQ-9, GAD-7, and PC-PTSD screening; and the numeric score on the SF-12 (score of 50 defined as average physical and mental well-being).

Results

A total of 121 individuals (73 women [60.3%]; mean [SD] age, 52.5 [17.1] years) completed the survey (response rate, 29.2%). The most common long-term physical sequelae reported were cutaneous problems (102 of 121 [84.3%]), ocular problems (72 of 121 [59.5%]), and oral mucosal problems (61 of 120 [50.8%]). A total of 53.3% (64 of 120) of the respondents had results indicating depression on the PHQ-9, 43.3% (52 of 120) showed signs of anxiety on the GAD-7, and 19.5% had results indicating PTSD on the PC-PTSD. The mean (SD) SF-12 Physical Component Summary score was 42.4 (22.8), and the mean Mental Component Summary score was 46.1 (20.9). A total of 28.2% (33 of 117) of the respondents were unable to work, 68.1% (81 of 119) were fearful of taking new medications, and 30.0% (36 of 120) avoided taking prescribed medications for a diagnosed medical condition.

Conclusions and Relevance

This survey study found that long-term physical sequelae, depression, and anxiety appear to be common in patients with SJS/TEN, with implications for health and well-being. Improved awareness of these complications may assist health professionals in offering medical care, counseling, and support to patients with SJS/TEN.

A Case of Vancomycin-induced Acute Generalized Exanthematous Pustulosis Confirmed by Patch Testing

Acute generalized exanthematous pustulosis (AGEP) is a rare cutaneous drug reaction that presents with the rapid onset of disseminated pustules, erythema, and edema. It is commonly associated with pristinamycin and aminopenicillins, but a few cases of vancomycin induced AGEP have been reported. Here, we describe a patient who presented with AGEP 12 hours following vancomycin administration, and had an atypical clinical course, with the AGEP persisting for weeks. Vancomycin was confirmed to be the etiologic agent with patch testing, a modality with growing evidence for utility in drug-induced reaction cases.

Improved patient access and outcomes with the integration of an eConsult program (teledermatology) within a large academic medical center

BACKGROUND

Insurance, racial, and socioeconomic health disparities continue to pose significant challenges for access to dermatologic care. Studies applying teledermatology to increase access to underinsured individuals and ethnic minorities are limited.

OBJECTIVE

To determine how the implementation of a teledermatology program affects access to health care and patient outcomes.

METHODS

A cross-sectional evaluation was performed of all ambulatory dermatology referrals and electronic dermatology consultations (eConsults) at Ohio State University within a 25-month period.

RESULTS

Compared with ambulatory referrals, eConsults served more nonwhite patients (612 of 1698 [36.0%] vs 4040 of 16,073 [25.1%]; P < .001) and more Medicaid enrollees (459 of 1698 patients [27.0%] vs 3266 of 16,073 [20.3%]; P < .001). In addition, ambulatory referral patients were significantly less likely to attend their scheduled appointment compared with eConsult patients, as either "no-shows" (246 of 2526 [9.7%] vs 3 of 62 [4.8%]) or cancellations (742 of 2526 [29.4%] vs 8 of 62 [12.9%]; P = .003). There were fewer median days to extirpation for eConsult patients compared with ambulatory referral patients (interquartile range; 80.7 ± 79.8 vs 116.9 ± 86.6 days; P = .004).

CONCLUSION

Integrating dermatologic care through a telemedicine system can result in improved access for underserved patients through improved efficiency outcomes.

The impacts of oral health symptoms, hygiene, and diet on the development and severity of psoriasis

Numerous studies have suggested a correlation between oral health, the oral microbiome, and various dermatologic conditions, particularly psoriasis. In this study, we utilize a specially designed questionnaire administered to 265 patients at The Ohio State University's dermatology clinics to explore the relationship between psoriasis and a combination of factors that included dietary habits, oral health, and oral hygiene practices. Age, family history of psoriasis, previous diagnosis of strep throat or rheumatoid arthritis, and oral pain or discomfort experienced within the last 12 months were all found to be significant predictors of psoriasis. Additionally, higher body mass index scores, poor gum health, and speech difficulties related to dental problems were all correlated with more severe psoriasis symptoms. Conversely, patients who reported consuming fresh fruit at least once a day experienced milder symptoms. Our goal is to develop a better understanding of how and why psoriasis incidence is correlated with some of the oral health factors under review.

Countertorque testing and histomorphometric analysis of various implant surfaces in canines: a pilot study

As surface roughness may play a role in the mechanical attachment of an implant surface to bone, various implant surfaces have been prepared and analyzed by removal torque (countertorque) or push-out tests in a variety of animal model systems. Rougher surfaces generally have displayed higher mechanical testing values, indicating a stronger implant-bone interface. This pilot study was undertaken to test the countertorque values for integrated threaded implants with surfaces prepared by machining, blasting, and acid-etching, to compare the various implant surface types histomorphometrically for percentage of bone-implant contact under loaded and unloaded conditions, and to determine the degree of correlation between countertorque values and bone-implant contact with varying degrees of surface roughness. The results of this animal investigation suggest that the strength of the bone-implant interface, as determined by countertorque testing, is influenced by different surface characteristics. Acid-etched surfaces resisted countertorque forces more successfully as compared with blasted or machined surfaces. Histologic evaluation of bone contact with the various implant surfaces did not demonstrate a definite advantage for rougher surfaces in regard to percentage of bone contact at the light microscopic level.