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Hydroxychloroquine (HCQ) is an antimalarial agent that is commonly used in the management of rheumatic skin disease. Few reports exist documenting exacerbation of dermatomyositis (DM) related to HCQ. Herein, we describe three adult patients with worsening DM cutaneous disease after starting HCQ and resolution or improvement with cessation. The time to exacerbation ranged from two weeks to nine months after the initiation of HCQ 400mg/day. Two of the three patients had antibodies to transcription intermediary factor 1γ (TIF1γ) and the other had antibodies to anti-nuclear matrix protein 2 (NXP2). After discontinuation of HCQ, the time to improvement or resolution of cutaneous symptoms ranged from six weeks to six months. Hydroxychloroquine may be associated with worsening cutaneous features in DM. In patients who are not improving despite escalation of immunosuppressive medications, or are worsening, we recommend a trial of discontinuing HCQ.

Combined internal medicine and dermatology (med-derm) training programs were created to advance complex medical dermatology and inpatient dermatology care. A prior study demonstrated that compared to categorical dermatology residents, med-derm residents had less program satisfaction, yet indicated a stronger desire to pursue careers in academia. No follow-up data on practice patterns after training has been reported. We aimed to characterize differences in residency program satisfaction and practice patterns between physicians trained in categorical dermatology compared to med-derm residency programs. We surveyed physicians who graduated from combined med-derm programs along with their counterparts, from six institutions, that either currently or historically had a combined med-derm training, from 2008-2017. Fifty-five percent of med-derm and forty-one percent of categorical-trained physicians responded. The practice patterns between the two groups were similar. A quarter of med-derm physicians continued to provide general internal medicine services. Categorical trained physicians were significantly more satisfied with their training (P=0.03) and performed more excisions on the head/neck (P=0.02). The combined graduates had significantly greater confidence in multidisciplinary care (P=0.003), prescribed more biologic (P

BackgroundHidradenitis suppurativa (HS) is associated with comorbidities that contribute to poor health, impaired life quality, and mortality risk.ObjectiveTo provide evidence-based screening recommendations for comorbidities linked to HS.MethodsSystematic reviews were performed to summarize evidence on the prevalence and incidence of 30 comorbidities in patients with HS relative to the general population. The screening recommendation for each comorbidity was informed by the consistency and quality of existing studies, disease prevalence, and magnitude of association, as well as benefits, harms, and feasibility of screening. The level of evidence and strength of corresponding screening recommendation were graded by using the Strength of Recommendation Taxonomy (SORT) criteria.ResultsScreening is recommended for the following comorbidities: acne, dissecting cellulitis of the scalp, pilonidal disease, pyoderma gangrenosum, depression, generalized anxiety disorder, suicide, smoking, substance use disorder, polycystic ovary syndrome, obesity, dyslipidemia, diabetes mellitus, metabolic syndrome, hypertension, cardiovascular disease, inflammatory bowel disease, spondyloarthritis, and sexual dysfunction. It is also recommended to screen patients with Down syndrome for HS. The decision to screen for specific comorbidities may vary with patient risk factors. The role of the dermatologist in screening varies according to comorbidity.LimitationsScreening recommendations represent one component of a comprehensive care strategy.ConclusionsDermatologists should support screening efforts to identify comorbid conditions in HS.

Superficial granulomatous pyoderma (SGP) is a rare pyoderma gangrenosum (PG) variant that differs from classic PG in that the ulcers tend to be more superficial, lack a rapidly advancing border, and are not typically associated with an underlying systemic disease. The ulcers are most commonly painless and located on the trunk, with a clean granulating base. They generally do not show undermining but may have a vegetative border. Lesions usually respond well to either topical or intralesional corticosteroids with complete healing. The classic histopathologic finding is a "three-layer granuloma" in the superficial dermis consisting of central neutrophilic inflammation and necrosis, a surrounding layer of histiocytes and multinucleated giant cells, and an outer most layer of plasma cells and eosinophils. Herein, we present a unique case of SGP with sporotrichoid-like distribution on the lower extremity.

Pembrolizumab, a programmed cell death protein 1 (PD1) inhibitor, has been known to be associated with several adverse reactions, including immune related adverse events. In less than one percent of patients, PD1 inhibitors have been linked to the development of connective tissue disease. Patients with previously known connective tissue disease are hypothesized to be at increased risk of flares in as many as 40% of cases. A 70-year-old man with a past medical history significant for rheumatoid arthritis in remission and stage IV lung adenocarcinoma presented to the dermatology clinic after one cycle of nivolumab and eight cycles of pembrolizumab exhibiting worsening, painful bilateral lower extremity ulcers for approximately one month. On the lower legs, three large black retiform eschars and bullous purpuric plaques were observed. Vasculitis is a rare complication of PD1 inhibitor therapy, with the majority of cases reported in literature either medium vessel or large vessel vasculitis. Only glucocorticoids have proven effective for PD1-induced vasculitis and these patients generally require multi-specialty management.

A 66-year-old man presented with a grayish 1mm macule on the left cheek. Dermatoscopic examination revealed annular-granular structures partially surrounding a single follicular ostium. Histopathologic examination demonstrated atypical, confluent single melanocytes at the basal layer with nesting, crowding, and upward migration descending along the hair follicle, consistent with the diagnosis of lentigo maligna (LM). This case presents evidence in support of the Schiffner progression model for LMs, starting with asymmetric pigmented follicular openings composed of annular-granular structures, which later coalesce into gray to dark black/brown streaks, and then form pseudo-networks or rhomboidal structures. The finding of annular-granular structures partially surrounding a single hair follicle may be the earliest recognizable dermatoscopic feature of an LM and may help clinicians diagnose facial LMs earlier.

Background: Validated, inclusive and easy‐to‐use outcomes for hidradenitis suppurativa are essential both in the clinical trial setting and clinical practice. The continuous IHS4 is a validated tool that dynamically assesses nodules/abscesses/draining tunnels and classifies disease severity as mild/moderate/severe. However, dichotomous outcomes are often required for clinical trials reporting. Objective: To develop and validate a dichotomous outcome based on IHS4 that can be used in clinical trial settings and day‐to‐day clinical practice. Methods: De‐identified data from the PIONEER‐I and ‐II studies were accessed through Vivli. Potential IHS4 thresholds were analysed using baseline to Week 12 data from adalimumab‐ and placebo‐treated hidradenitis suppurativa patients in the PIONEER‐I trial. The final threshold was chosen based on its ability to discriminate between patients treated with adalimumab or placebo and its association with reduction in inflammatory lesions. The final threshold was validated using data from baseline to Week 12 from adalimumab‐ and placebo‐treated hidradenitis suppurativa patients in both the PIONEER‐II and the combined PIONEER‐I and ‐II studies. Results: The best performing cut‐off for the IHS4 was a 55% reduction of the IHS4 score (IHS4‐55). Patients who achieved the IHS4‐55 had an odd's ratio of 2.00 [95%‐CI 1.26–3.18, p = 0.003], 2.79 (95%‐CI 1.76–4.43, p < 0.001) and 2.16 (95%‐CI 1.43–3.29, p < 0.001) for being treated with adalimumab rather than placebo in PIONEER‐I, PIONEER‐II and the combined dataset, respectively. Additionally, the achievement of the IHS4‐55 was associated with a significant reduction in inflammatory nodules, abscesses and draining tunnels in all analysed datasets. Conclusions: IHS4‐55, a novel dichotomous IHS4 version, based on a 55% reduction of the total score was developed. The IHS4‐55 performs similarly to the HiSCR in discriminating between adalimumab‐ and placebo‐treated hidradenitis suppurativa patients and shows significant associations with reductions in lesion counts. Moreover, the IHS4‐55 addresses some of the HiSCR drawbacks by dynamically including draining tunnels in a validated manner. By allowing the analysis of hidradenitis suppurativa patients with an abscess and nodule count below 3 but many draining tunnels, this outcome measure will improve inclusivity in clinical trials. [ABSTRACT FROM AUTHOR]

Objective: To perform a systematic review of available literature regarding the use of 5‐aminolevulinic acid (ALA) and ALA derivative photodynamic therapy (PDT) in the treatment of hidradenitis suppurativa (HS) and provide recommendations on its use. Methods: A systematic review was performed of all published studies up to September 1, 2019 from nine databases, including PubMed, that evaluated PDT in the treatment of HS. For each study, quality of evidence and risk of bias was evaluated. Recommendations from the body of evidence were created based on Strength of Recommendation and Taxonomy (SORT) criteria. Results: Eighteen studies met inclusion criteria. The majority of studies had a high risk of bias. Blue light PDT with 20% ALA and red light PDT with 16% methyl aminolevulinate (MAL) demonstrated some benefit based on a small number of poor‐quality studies with a high risk of bias (Grade C, level III evidence). The most promising results were for 1%–5% ALA with intralesional diode, with good to complete response in 78%–94% of anatomic sites treated (Grade B, level II evidence). Limitations: The majority of studies contained high levels of bias, with significant heterogeneity between studies. Conclusions are limited by small samples sizes, lack of randomized controlled trials, and differing protocols. Conclusion: Further studies are needed to determine the clinical efficacy of 20% ALA with blue light and MAL with red light. Intralesional diode PDT shows the most promise and warrants further investigation in larger, randomized controlled trials. [ABSTRACT FROM AUTHOR]