A brave New World: Virtual Grand Rounds in Dermatology

Two dermatologist friends, widely separated by geography, had the dream to build a virtual grand rounds that could connect colleagues around the world for diagnostic and therapeutic suggestions as well a intellectual stimulation. They recrulted 2 students and constructed the site over a summer vacation. Virtual Grand Rounds in Dermatology is a prototype for what can be launched by nonacademic practitioners with few resources. We envision Virtual Grand Rounds in Dermatology as a service to dermatologists who practice at a remove from university hospitals and tertiary referral centers, as well as to others who wish to collaborate with colleagues distributed over a wide geographical net. For us, this has been a voyage into a brave new world with many exciting vistas. It can be accessed online: http://www.vgrd.org.     

Randomized controlled trial comparing store‐and‐forward teledermatology alone and in combination with web‐camera videoconferencing

Background. Studies on the reliability of teledermatology have shown considerable variability in results. Only one study has compared asynchronous and synchronous methods. Objectives. This report describes DERMATEL, a prospective, randomized diagnostic‐concordance study that sought to evaluate the relative advantages, in terms of reliability, of two remote consultation techniques. Methods. Patients referred by 18 general practitioners were randomized (4 : 4 : 2) to three study groups: store and forward (SF), hybrid videoconferencing‐SF (VC–SF), and a control group. In total, 457 patients were assigned: 192 to the SF group, 176 to the VC–SF group and 89 to the control group. High‐quality still images were used throughout, with additional use of standard web‐camera (webcam) videoconferencing in the VC–SF group. All patients were also seen by the same dermatologist in a face‐to‐face (FTF) consultation, considered the practical reference standard. Two different dermatologists assessed concordances between the teledermatology and FTF consultations. Results. There were no significant differences in age, gender or diagnostic category between the three groups, and the images (82%), clinical history (91%) and diagnostic confidence (89%) were high‐quality. Online management was possible for 70% of cases. Agreement between teledermatology and the FTF consultation was high for both diagnosis (> 0.85) and treatment (> 0.78). Concordance in diagnosis was influenced by image quality (P < 0.001), confidence in diagnosis (P < 0.001) and need for conventional consultation (P < 0.001), rather than by quality of clinical history (P = 0.58) or method of teleconsultation (P = 0.340). Conclusions. Intraobserver reliability is very high in teledermatology. When history taking and training in digital photography are standardised, a hybrid system with audio is no better than SF alone.     

Authors’ willingness for second‐opinion teledermatology in difficult‐to‐manage cases: ‘an online survey’

Background Expert non‐availability for an instant difficult‐to‐manage case may limit the online discussion group to provide second‐opinion teledermatology for registered dermatologists. Author‐based second‐opinion teledermatology (AST) is proposed and assessment of authors’ response to answer queries and their willingness to participate in teledermatology consultation is analysed. Materials and methods Authors of 292 articles from seven non‐open access dermatology and three general medical journals addressing difficult‐to‐manage cases from June 2007 to December 2008 participated in this online dermatology authors’ survey. Authors’ response to reprint requests, answer literature queries and willingness to offer second‐opinion teledermatology were the main outcome measures. Perceived views were also documented. Results The scores for reprints requests vs. received were (χ² = 13.57, n = 292), P = 0.000. The scores for articles read, analysed and literature queries sent vs. authors answered were (χ² = 11.09, n = 190), P = 0.001. The scores for authors responded to reprints vs. willing to offer second‐opinion teledermatology consultation were (χ² = 5.65, n = 190), P = 0.017 and authors responded to reprint requests, answered queries and willing to offer second‐opinion (χ² = 5.65, n = 190), P = 0.017. Conclusion A dermatologist obtains literature, answered queries and constructive suggestions with additional informative material and pools second‐opinions from the authors using their e‐mail to deliver quality health care. AST is an alternative to online discussion group for second‐opinion teledermatology practice in difficult‐to‐manage cases. Uniform international laws are to be framed to facilitate telemedicine care for a difficult‐to‐manage case.     

Itolizumab provides sustained remission in plaque psoriasis: a 5‐year follow‐up experience

There is an unmet need for psoriasis therapies that provide long‐term remission. Itolizumab is a humanized recombinant anti‐CD6 monoclonal antibody shown to be effective in psoriasis. We report a patient who received itolizumab in a phase 2 clinical trial, and experienced long‐term remission. At baseline, the patient's Psoriasis Area and Severity Index (PASI) was 12.2, and Physician's Global Assessment (PGA) score was 3. After 8 weeks of treatment, the patient achieved 97% improvement in PASI. She continued to have ≥ 90% improvement, initially for 4 weeks (follow‐up phase), and later for 20 weeks (follow‐up extension phase). She continued to visit the hospital after the final study visit; her most recent visit was on 10 May 2013. PGA results during the visits revealed sustained response for 4 years and 5 months after stopping itolizumab. Itolizumab could be therefore an important treatment option for moderate to severe psoriasis, with potential to provide long‐lasting remission.     

Pilomatrix carcinoma: 12‐year experience and review of the literature

Pilomatrix carcinoma is a rare, locally aggressive tumor with a tendency to recur. Distant metastases have been reported, with pulmonary lesions being the most frequent manifestation. Similar to pilomatrixoma, pilomatrix carcinoma typically presents as a nontender, firm dermal swelling and is found most commonly in the head and neck region. Although pilomatrixomas and pilomatrix carcinoma are well‐recognized lesions, clinically they are frequently misdiagnosed as other skin conditions. By reviewing the literature over the past 10 years, the aims of this review are to analyze the cause, clinical presentation, histopathologic features, management and outcomes of pilomatrix carcinoma amongst children and adults.     

Low‐dose acitretin in Papillon–Lefèvre syndrome: treatment and 1‐year follow‐up

The Papillon–Lefèvre syndrome (PLS) is a rare, autosomal recessive disease that manifests with palmoplantar keratoderma and destructive periodontitis resulting in early onset periodontal breakdown in deciduous and permanent dentition. Management of this condition is difficult. Here we report one 11‐year‐old consanguineous Muslim boy suffering from PLS. After failing to get any benefit from methotrexate, three cycles of acitretin, each for 2 months, were given 1 month apart. In each cycle, acitretin (25 mg) was given every other day. At the end of the third cycle, treatment was stopped for 4 months to observe the extent of relapse. Thereafter, acitretin (25 mg) was given twice weekly for 4 months and then the patient was followed up for 1 year. Treatment with acitretin resulted in excellent improvement of periodontitis, increase in the alveolar bone height, and periodontal attachment. Improvement remained stable at the end of 1‐year follow‐up. There was excellent (>75%) improvement in keratoderma at the end of active therapy. Mild worsening of palmoplantar keratoderma was noticed whenever the drug was stopped. It improved when the drug was restarted. Other areas remained stable. At the end of 1‐year follow‐up, good improvement (50%) in palmoplantar keratoderma was achieved.     

Metastatic Spiradenocarcinoma Occurring in an 8‐Year‐Old Boy

We recently saw the case of an 8‐year‐old boy with histologic findings of spiradenocarcinoma. Malignant adnexal tumors in children are exceedingly rare, and cases of spiradenocarcinoma in children are absent in the literature. We report the case of an 8‐year‐old boy with metastatic spiradenocarcinoma. A biopsy 2 years before his presentation at our institution was interpreted as a benign lesion, but when the lesion regrew, a repeat biopsy was performed that demonstrated ominous findings, prompting a reexcision. This reexcision demonstrated an area with significant necrosis, many mitoses, and cellular pleomorphism apparently arising out of a sharply demarcated, adjacent, lower‐grade area. The histologic features of this patient's biopsies were those of spiradenocarcinoma, potentially arising out of a preexisting spiradenoma, a finding that has not been documented previously in this age group. Staging studies demonstrated multiple bilateral pulmonary nodules, which were confirmed using thoracoscopic biopsy to be metastatic disease. His chemotherapy regimen has included several cycles of cisplatin and 5‐flourouracil, with ongoing disease progression of pulmonary disease. It has been 16 months since he presented to our institution (>3 years since the appearance of his initial lesion). Imaging studies demonstrate a slowly increasing size and number of pulmonary lesions. The long‐term prognosis is guarded.