Diabetes is associated with many complications, including foot ulcers. Individuals with diabetes have a 15% to 25% likelihood of developing a foot ulcer in their lifetime. The pathophysiologic ...mechanisms are multifactorial but the major etiologic factors are peripheral vascular disease and diabetic neuropathy. Foot examinations are recommended at least annually for patients with diabetes to assess the risk of foot ulcers and to detect, diagnose, and manage them. Management includes avoidance of walking, weight-bearing limitation, use of therapeutic footwear, use of dressings and debridement, and antibiotics. Due to immune dysfunction, diabetic neuropathy, and poor circulation, patients with diabetes are at increased risk of other types of infections. These include erythrasma, candidiasis, paronychia, onychomycosis, necrotizing fasciitis, Fournier gangrene, otitis externa, and nontuberculous mycobacterial skin infections. A high index of suspicion is required to diagnose these conditions. Patient evaluation may include a detailed physical examination, imaging, laboratory tests, and biopsies and cultures. Management may involve mechanical or surgical debridement, topical and oral antibiotics, and abscess drainage.
During summer of 2018, ME to WE organized a dermatology volunteer trip in Masai Mara region of Kenya. Our volunteer group included physicians, physician assistants and medical assistants. We ...volunteered at the Baraka Hospital along with the local staff there. Our goal was to help treat and triage patients with skin conditions and in the process educate local staff about Dermatology. We saw patients with a variety of skin conditions, including Filariasis, Onchocerciasis, Chromoblastomycosis, Discoid Lupus and others. In addition, we visited local schools to screen students with common skin conditions. We saw approximately 800-100 patients during our time there. On our last day at the hospital we organized lectures to teach the local team about common skin conditions. The key challenges to our work there were limited resources and time available, socio-economic difficulties of the local population, lack of an established dermato-pathology center, etc. The key strengths of the trip were very well organized trip from ticketing to lodging to itinerary, very supportive local staff and how grateful patients were with evaluation of their conditions. Our trip also included local cultural programs that allowed us to learn more about the people there. In a short span of one week, we were able to help in the care of the local patient population and in the process learn about local culture, socio-economic structure and medical practice there.
Porphyria cutanea tarda (PCT) is characterized by a skin blistering eruption that develops in sun exposed areas of the skin. It is the most common cutaneous porphyria world-wide, and classically ...associated with hepatic injury but also estrogen use, cigarette smoking, and HIV. In any case of photodistributed persistent blistering skin condition, PCT must be high on the differential. This case of a carpenter diagnosed with PCT not only illustrates a classic case but also the opportunity to achieve significant response to therapy in a motivated patient particularly with improved access to direct-acting antivirals (DAA) for hepatitis C treatment.
Hidradenitis suppurativa (HS) is a chronic skin disorder of the terminal follicular epithelium of apocrine sweat glands, manifesting as painful and exudative papules, pustules, cysts or nodules. This ...inflammatory condition often presents with other systemic and cutaneous disorders. We present the case of an African-American man with HS who was also diagnosed with neutrophilic dermatoses and diverticular disease. Neutrophilic dermatosis was identified based on histopathology findings. Our patient underwent multiple surgeries for flaring of his skin condition. Colchicine and doxycycline were started, but the patient was not able to tolerate them. Humira was planned for treatment of HS and neutrophilic dermatosis but could not be pursued because of the pericolic abscess. Colonoscopy and radiological investigation revealed multiple colonic diverticuli, for which he initially underwent percutaneous drainage followed by surgical removal of sigmoid mass and colocutaneous fistula. Culture from the specimen revealed abnormal growth of Actinomyces.
The association between guttate psoriasis and infection with group A Streptococcus (GAS) has been well established in the medical literature. However, responses to treatments aimed at GAS eradication ...such as systemic antibiotics or tonsillectomy are inconsistent. Further complicating treatment recommendations for a disease with a suspected microbial trigger, the standard therapy for severe psoriasis is with systemic immunosuppressant medications. This case report illustrates the role of GAS as a trigger for acute onset severe psoriasis in a child whose skin disease initially worsened with a trial of methotrexate. An immune evaluation confirmed a co-existing selective antibody deficiency. Subsequent treatment with intravenous immune globulin dramatically improved his underlying immune function and decreased GAS infections. This improvement in overall immune function and decrease in GAS infections cleared his skin disease. An interval change in formulation to subcutaneous immune globulin was not as effective.
Recent guidelines from the American Joint Committee on Cancer (AJCC) and National Comprehensive Cancer Network (NCCN) have been proposed for the assessment of “high-risk” cutaneous squamous cell ...carcinomas (cSCCs). Though different in perspective, both guidelines share the common goals of trying to identify “high-risk” cSCCs and improving patient outcomes. Thus, in theory, both definitions should identify a similar proportion of “high-risk” tumors. We sought to evaluate the AJCC and NCCN definitions of “high-risk” cSCCs and to assess their concordance. Methods. A retrospective review of head and neck cSCCs seen by an academic dermatology department from July 2010 to November 2011 was performed. Results. By AJCC criteria, most tumors ( n = 211,82.1 %) were of Stage 1; 46 tumors (13.9%) were of Stage 2. Almost all were of Stage 2 due to size alone (≥2 cm); one tumor was “upstaged” due to “high-risk features.” Using the NCCN taxonomy, 231 (87%) of tumors were “high-risk.” Discussion. This analysis demonstrates discordance between AJCC and NCCN definitions of “high-risk” cSCC. Few cSCCs are of Stage 2 by AJCC criteria, while most are “high-risk” by the NCCN guidelines. While the current guidelines represent significant progress, further studies are needed to generate a unified definition of “high-risk” cSCC to optimize management.
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