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Topical Prescription Contrition

from ArchDerm - 01 Nov 14

Shortly after I began prescribing certain topical medications in the early 1990s, I started to question the ritual. That universal thrill new clinicians experience when confidently knowing the diagnosis and its treatment was soon tempered by the realization that many patients had arrived already knowing both, and they resented a system that required the time, effort and expense of a formal appointment solely to procure what they deemed an effective but harmless remedy that they would then have t



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Mid-Level Practitioners in Dermatology A Need for Further Study and Oversight

from ArchDerm - 01 Nov 14

Since the passing of the Congressional Balanced Budget Act in 1997, the scope of practice of mid-level health care providers, namely nurse practitioners and physician assistants (hereinafter “mid-level providers”), has rapidly expanded. While originally envisioned to improve access to primary care in underserved areas under the supervision of a physician, mid-level providers have expanded their scope of practice and are now able to bill independently for the procedures they perform.



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Scope of Physician Procedures Independently Billed by Mid-Level Providers in the Office Setting

from ArchDerm - 01 Nov 14

ImportanceMid-level providers (nurse practitioners and physician assistants) were originally envisioned to provide primary care services in underserved areas. This study details the current scope of independent procedural billing to Medicare of difficult, invasive, and surgical procedures by medical mid-level providers.ObjectiveTo understand the scope of independent billing to Medicare for procedures performed by mid-level providers in an outpatient office setting for a calendar year.DesignAnaly



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Association of Pain and Itch With Depth of Invasion and Inflammatory Cell Constitution in Skin Cancer Results of a Large Clinicopathologic Study

from ArchDerm - 01 Nov 14

ImportanceThis study highlights a simple bedside evaluation of itch and pain for suspicious skin lesions.ObjectiveTo examine the correlation of pain and itch with histologic features of skin cancers.Design, Setting, and ParticipantsThis large, prospective, clinicopathologic study enrolled patients who filled out questionnaires that assessed itch and pain intensity of their skin tumors at the time of excision. Study participants were from the patient population presenting to the Department of Der



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Supply-and-Demand Discrepancy in Academic Pigmented Lesion Clinics A Case for a New Health Care Delivery Model

from ArchDerm - 01 Nov 14

ImportanceThere is an increasing demand for a limited number of pigmented lesion clinic (PLC) visits at dermatology centers.ObjectiveTo determine the proportion of visits to PLCs that are more frequent (“additional screening”) than the recommended (“standard”) follow-up schedule and to determine if certain patient characteristics correlate with the demand for these visits.Design, Setting, and ParticipantsA retrospective medical chart review of all PLC visits at an academic dermatology center fro



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High Frequency and Clinical Prognostic Value of MYD88 L265P Mutation in Primary Cutaneous Diffuse Large B-Cell Lymphoma, Leg-Type

from ArchDerm - 01 Nov 14

ImportanceThe activating mutation of MYD88 L265P is a frequent feature of primary cutaneous diffuse large B-cell lymphoma, leg-type (PCLBCL-LT), reported in up to 69% of the cases. Whether patients with MYD88 mutation display specific clinical and evolutive features has not been evaluated.ObjectiveTo identify the clinical characteristics associated with MYD88 mutation, confirm its high prevalence, and evaluate its effect on prognosis in patients with PCLBCL-LT.Design, Setting, and ParticipantsA



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Presence of Human Polyomavirus 6 in Mutation-Specific BRAF Inhibitor–Induced Epithelial Proliferations

from ArchDerm - 01 Nov 14

ImportanceA frequent adverse effect of mutation-specific BRAF inhibitor therapy is the induction of epithelial proliferations including cutaneous squamous cell carcinomas. To date, the only factor identified contributing to their development is the activation of the mitogen-activated signal transduction cascade by mutations in the RAS genes. However, these mutations explain only 60% of the tumors; hence, it is important to identify what is causing the remaining tumors.ObjectiveTo test for the pr



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Local Fasciocutaneous Sliding Flaps for Soft-Tissue Defects of the Dorsum of the Hand

from ArchDerm - 01 Nov 14

ImportanceAppropriate coverage of defects that expose tendon, joints, and/or neurovascular structures is necessary to preserve optimal hand function. Local, random-pattern flaps and skin grafts may be inadequate because of the hand’s finite skin reservoir or the presence of a poorly vascularized and mobile wound bed. Described herein is a novel method of dorsal hand reconstruction.ObservationsA fasciocutaneous sliding flap and the underlying vascular anatomy of the dorsal hand are described. The



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Acquired Cutis Laxa Associated With Heavy Chain Deposition Disease Involving Dermal Elastic Fibers

from ArchDerm - 01 Nov 14

ImportanceAcquired cutis laxa is a rare cutaneous manifestation of hematologic malignancy. We report a case of ? heavy chain deposition disease (HCDD) associated with acquired cutis laxa, renal involvement, and hypocomplementemia and propose a mechanism of elastic fiber degradation in the skin of this patient with HCDD.ObservationsTo determine the localization of immunoglobulin heavy chains and complement activation in the skin of a patient with HCDD, we examined her skin biopsy specimens under



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Eruptive Hypomelanosis A Novel Exanthem Associated With Viral Symptoms in Children

from ArchDerm - 01 Nov 14

ImportanceRecognition of different clinical presentations of viral and virally triggered (“paraviral”) exanthems is necessary for patients to be appropriately diagnosed and counseled.ObservationsNine children presented with eruptions of hypopigmented macules following coryzal symptoms. Other diagnostic considerations, such as pityriasis alba, pityriasis versicolor, and progressive macular hypomelanosis, were excluded. This novel clinical presentation, eruptive hypomelanosis, may represent a para



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Disseminated Lyme Disease Presenting With Nonsexual Acute Genital Ulcers

from ArchDerm - 01 Nov 14

ImportanceNonsexual acute genital ulceration (NAGU) is a rare vulvar skin condition typically affecting girls and young women, characterized by acute onset of singular or multiple painful vaginal ulcers. The etiology of this ulcerative dermatosis has not been identified, although it has been associated with systemic infections. To our knowledge, this is the first report of an association with Lyme disease.ObservationsA case of a woman with early disseminated Lyme disease presenting with NAGU is



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Extreme Pain From Brown Recluse Spider Bites Model for Cytokine-Driven Pain

from ArchDerm - 01 Nov 14

ImportanceBites from the brown recluse spider (BRS) can cause extreme pain. We propose cytokine release as a cause of the discomfort and a central mechanism through glial cell upregulation to explain measured pain levels and time course.ObservationsTwenty-three BRS bites were scored at a probable or documented level clinically, and an enzyme-linked immunosorbent assay was used to confirm the presence of BRS venom. The mean (SD) pain level in these cases 24 hours after the spider bite was severe:



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Involution of Eruptive Melanocytic Nevi on Combination BRAF and MEK Inhibitor Therapy

from ArchDerm - 01 Nov 14

ImportanceEruptive melanocytic nevi (EMN) are characterized by the sudden onset of numerous melanocytic nevi and have been traditionally described in the setting of immunosuppression. Selective BRAF inhibitors such as vemurafenib cause multiple cutaneous adverse effects, including the formation of cutaneous squamous cell carcinoma, as well as EMN. We describe the first reported case, to our knowledge, of involution of BRAF inhibitor–induced EMN following the concomitant addition of a MEK inhibit



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Farewell to the Evidence-Based Dermatology Section

from ArchDerm - 01 Nov 14

In December 1999, Michael Bigby, MD, introduced the Evidence-Based Dermatology Section of this journal. The purpose was to alert clinicians to important advances in dermatology by selecting articles with results most likely to be true and useful to the busy physician when making decisions about patient care. For 15 years, Dr Bigby led the section and fulfilled the mission with the support of the following assistant section editors, who have served varying terms throughout the years: Damiano Aben



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Combined Use of Systemic Agents for Psoriasis A Systematic Review

from ArchDerm - 01 Nov 14

ImportanceCombined use of systemic agents may be necessary to achieve disease control in therapy-resistant patients. However, to our knowledge, an overview of evidence, including quality assessments, is not yet available, and no guidance on monitoring, contraindications, and interactions exists.ObjectivesTo summarize and critically appraise the evidence on efficacy and safety of combination therapy with systemic agents in plaque-type psoriasis.Evidence ReviewThrough March 2013, an electronic sea








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Efficacy of Systemic Treatments for Atopic Dermatitis in Racial and Ethnic Minorities in the United States

from ArchDerm - 01 Nov 14

Most evidence supporting systemic therapy for atopic dermatitis (AD) is derived from randomized clinical trials (RCTs) performed outside the United States, particularly in Europe. However, the US population vastly differs from that of Europe and other regions, with greater racial and ethnic diversity and heterogeneity. This is not a trivial point given recent studies demonstrating greater prevalence and severity of AD and quality-of-life impairment from AD in blacks. Furthermore, blacks have a d



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Binding of the Trichodysplasia Spinulosa–Associated Polyomavirus Small T Antigen to Protein Phosphatase 2A: Elucidation of a Potential Pathogenic Mechanism in a Rare Skin Disease

from ArchDerm - 01 Nov 14

Trichodysplasia spinulosa is a disfiguring skin disease caused by the trichodysplasia spinulosa–associated polyomavirus (TSPyV). Like other polyomaviruses, TSPyV expresses the large T and small T (sT) antigens, but how these proteins regulate trichodysplasia spinulosa pathogenesis is unknown. In the closely related human pathogen Merkel cell polyomavirus, sT acts as a transforming oncoprotein in vitro because it alone is sufficient to transform rodent fibroblast cells. Interestingly, this mechan



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The Lack of Information in Racial and Ethnic Minorities and Their Response to Therapeutics

from ArchDerm - 01 Nov 14

Every schoolchild in the United States learns the line from the Declaration of Independence that “all men are created equal.” The aforementioned statement addresses certain inalienable rights. Yet, from a medical standpoint, are we all the same, do we manifest disease the same way, and do we respond to treatments equally?



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Histologic Features Mimicking Mycosis Fungoides Induced by Imiquimod, 5% A Potential Pitfall for Dermatopathologists

from ArchDerm - 01 Nov 14

Imiquimod is a topical immune response modifier with potent antiviral and antitumor effects. It induces an immune-mediated response, demonstrated by changes in the lymphocytic infiltrate and locally produced cytokines.


 

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