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En relación con el artículo “¿Se deben confiar actividades profesionales en cirugía mínimamente invasiva al médico general? Una propuesta basada en el aprendizaje experiencial” de los doctores Neil Valentín Vega-Peña y Luis Carlos Domínguez-Torres, publicado en el número 37 de la Revista Colombiana de Cirugía, páginas 364-76, nos gustaría hacer algunos comentarios a través de esta carta.

Raynaudrsquo;s phenomenon (RP), a common presenting symptom of systemic sclerosis (SSc), is a painful and debilitating condition of the digits caused by increased vascular reactivity.1,2.

Retiform purpura is a potentially ominous cutaneous sign that develops secondary to vascular compromise by either vasculitis or a vasculopathic disorder. The wide array of associated complications mandate a thorough investigation in a timely fashion. This review provides an overview of the frequent causes of retiform purpura in hospitalized adult patients and proposes a diagnostic approach for the inpatient dermatologist. Early recognition of the primary cutaneous morphology in retiform purpura is especially important as this can help generate a focused differential and workup plan. A high-yield skin biopsy result warrants a proper site selection and an adequate depth. Further workup and treatment depend on the underlying pathogenic process. For patients with underlying systemic vasculitis, rituximab is emerging as an effective treatment. Rivaroxaban was found to have excess risk (increased thromboembolic and bleeding events) and no benefit when compared to warfarin in a trial of high-risk anti-phospholipid syndrome patients. The differential diagnosis of retiform purpura is broad and a systematic approach is required to identify and treat the underlying cause.

Una de las primeras experiencias como ser humano en un centro médico es la visita al pediatra para poder conocer el desarrollo de nuestro organismo, así como también en el fortalecimiento de nuestro sistema inmunológico por medio de la aplicación de todas las vacunas pertinentes. El poder establecer un desarrollo sano se requiere un esfuerzo de las personas que están a nuestro alrededor. A pesar de los parámetros externos, como la condición del medio ambiente, así como también de la condición geográfica del lugar de residencia son catalizadores de muchas de las enfermedades que padecemos en la infancia. Estas principales enfermedades son las que afectas las vías respiratorias. Cada órgano que forma parte de este sistema tiene una función primordial para el desarrollo de nuestro organismo, y más si en la etapa infantil estos están en pleno crecimiento y desarrollo haciendo las más vulnerables a estas condiciones externas

Dermatomyositis is a rare inflammatory disease with characteristic cutaneous findings and varying amounts of systemic involvement. Patients may present with skin disease alone, have concomitant muscle disease, or have extracutaneous manifestations such as pulmonary disease or an associated malignancy. Given such diverse presentations, dermatomyositis is both a diagnostic and therapeutic challenge. However, a prompt diagnosis is of utmost importance to institute adequate therapy and screen patients for an associated malignancy. Dermatologists should play a crucial role in the diagnosis and management of patients with dermatomyositis as cutaneous disease tends to be chronic, negatively impact quality of life, and be more recalcitrant to therapy. In this review, we discuss diagnosis, with a focus on myositis-specific antibodies and their associated phenotypes. We also review therapies available for this often refractory skin disease.

This case series characterizes the initial presentation and treatment of lupus erythematosus panniculitis/profundus and its association with systemic lupus erythematosus and discoid lupus erythematosus.

Cutaneous lupus erythematosus (CLE) is a chronic skin disease that significantly impacts quality of life (QOL). This study tested a novel method to measure QOL in CLE using willingness-to-pay (WTP) stated preferences, and aimed to determine which of nine domains of life are most affected by CLE. Twenty-one participants with CLE ranked the domains in order of impact on CLE-related QOL, and then stated how many United States dollars they would be willing to pay for a hypothetical cure for each domain. Eighty-one percent of participants were female; mean age was 42.4 years. Photosensitivity was ranked highest by 71.4% of respondents. Participants were willing to pay the most for a hypothetical cure for CLE specific to photosensitivity (median = $200,000), the least for a cure specific to self-care (median = $0). Participants were willing to pay a median of $1,000,000 for an overall cure for CLE. Limitations include a small sample size for this pilot study and that willingness-to-pay may be influenced by individual perception of money and socioeconomic factors. This study successfully pilot-tested a WTP method and ranking task for health-related QOL. Photosensitivity was the domain of life most affected by CLE, which is a domain unique to our novel tool.

This case series reports the clinical presentation and course of treatment for 32 women with biopsy-proven idiopathic granulomatous mastitis.

Epidermolysis bullosa acquisita (EBA) is a rare, acquired subepidermal blistering disease. EBA is characterized by autoantibodies to collagen VII,which serves to link the epidermis to the dermis. The two most common presentations of EBA are classical noninflammatory EBA and bullous pemphigoid-like EBA. Diagnosis of EBA can be challenging as it sharesclinical and histopathologic features with other blistering diseases. Treatment is often recalcitrant and will often necessitate multiple therapies. We presenta case of a thirty-six-year-old Chinese man with EBA and review the literature.

Multiple placebo-controlled trials have assessed locally applied topical nitrate preparations in treating Raynaud's phenomenon (RP).The objective of this meta-analysis was to assess the effects of local topical nitrates in primary and secondary RP with respect to a combined end point integrating parameters of digital blood flow and clinical severity.A systematic review was performed using MEDLINE, Embase, and the Cochrane library. Only trials comparing locally applied topical nitrates with placebo comparators were included. Studies were appraised for bias by 2 independent reviewers.A total of 7 placebo-controlled trials including 346 patients were used in the meta-analysis; 4 trials used nitroglycerin ointments, 2 used the nitroglycerin gel vehicle MQX-503, and 1 used compounded nitrite. The meta-analysis results supported a moderate-to-large treatment effect in RP (standardized mean difference [SMD] = 0.70; 95% CI, 0.35-1.05; P .0001). Subgroup analyses showed a large treatment effect in secondary RP (SMD = 0.95; 95% CI, 0.25-1.65; P = .008) and moderate effect in primary RP (SMD = 0.45; 95% CI, 0.05-0.85; P = .03).Limitations include the inclusion of multiple topical nitrate preparations and integration of different outcomes assessments.Local topical nitrates have significant efficacy in the treatment of both primary and secondary RP.

The evaluation of the vulva should always begin with a detailed clinical history. The clinician should be very familiar with vulvar anatomy and the changes it undergoes depending on the patient's age and hormonal status. A systematic approach should be developed when examining the vulva so as to not leave out any parts. Finally, there is a wide array of ancillary tests and diagnostics procedures that can be pursued to arrive at the correct diagnosis and begin proper management.

We present a 38-year-old woman with local heat urticaria confirmed by heat provocation testing. Heat urticaria is a rare form of physical urticaria that istriggered by exposure to a heat source, such as hot water or sunlight. Although it is commonly localized and immediate, generalized and delayed onset forms exist. Treatment options include antihistamines and heat desensitization. A brisk, mechanical stroke elicited a linear wheal. Five minutes after exposure to hot water, she developed well-demarcated,erythematous blanching wheals that covered the distal forearm and entire hand.

Lichen planus is an inflammatory skin conditionwith characteristic histopathological findings thathas many clinical variants. Recently, there have been25 cases reported in the literature of lichen planuspigmentosus (LPPi) that preceded the developmentof frontal fibrosing alopecia (FFA), which is a variantof lichen planopilaris (LPP). We review the literatureregarding LPPi, LPP, and FFA and present a case of a40-year-old African American woman with LPPi andLPP.

Phrynoderma is a type of follicular hyperkeratosis associated with nutritional deficiencies. It is rarely seen in developed countries, although cases have been reported in patients with severe malnutrition or malabsorption secondary to various causes. This report describes a 19-year-old patient with poorly controlled Crohn's disease and malnutrition who developed the characteristic hyperkeratotic papules and plaques on his trunk and extremities in the setting of low serum vitamin A levels. To our knowledge, there are no reports of phrynoderma associated with Crohn's disease. It is likely that our patient's low vitamin A level and subsequent phrynoderma was the result of increased Crohn's disease activity and malnutrition.

An 8-year-old girl with recurrent oral thrush as an infant and toddler, multiple diaper yeast infections, recurrent ear infections that required multiple ear-tube placements, a long history of mild atopic dermatitis, and at least 7 Staphylococcus aureus abscesses on the extremities presented with new-onset thickening of the thumbnail that had failed therapy with 40% urea cream (Figure 1). Of note, she had no history of bronchopulmonary infections. Periodic acidSchiff stained sections of a nail-plate clipping revealed yeast