Dermatological research in the 21st century: our fantastic future.

During the second half of the twentieth century, dermatology came of age. Just as clinical dermatology, through new diagnostic and therapeutic modalities, matured to a point where the dermatologist could affect peoples' lives profoundly, so too did dermatological research enhance our understanding of skin diseases enormously. Dermatology should not be viewed as a scientific discipline-advances come from fundamental scientific areas such as cell and molecular biology, biochemistry, immunology, microbiology, technology, the clinical sciences and others. Thus, dermatology and skin biology live within a universe of science, only a small part of which is dermatology and skin biology, and our patients and our science are dependent on integration and interdigitation with the universe of science for future success. In this lecture I will elaborate on where I think the next 10-20 years will take us in this universe.     

The role of the police power in 21st century public health.

The police power is the right of the state to take coercive action against individuals for the benefit of society. The companion article by Potterat et al., "Invoking, monitoring, and relinquishing a public health power: the health hold order," is a classic use of the police power in the control of a communicable disease, yet one that is increasingly controversial. Reaching an acceptable balance between the rights of society and those of individuals is the central issue facing public health in the next millennium, and the police power is at the center of this balance. This article reviews the constitutional basis of the police power, its historical use in public health, and the structural reasons why health departments preoccupied with personal health care cannot effectively use the police power to carry out public health enforcement.     

Dermatologists and office-based care of dermatologic disease in the 21st century

Most professional care of skin diseases is provided in physicians' offices. In the past 25 y, medical practice has changed substantially. Since 1973, the National Ambulatory Medical Care Survey has provided data about patients seen in physicians' offices. Using 1974, 1980, and 1989 data, we have previously analyzed these data as they pertain to skin diseases. To provide a more current assessment of dermatologists' practices and the care of skin diseases in office-based practice, we analyzed National Ambulatory Medical Care Survey data for 1999 to 2000. We used statistical methods for survey data to estimate the number and characteristics of visits to dermatologists and others for skin diseases. We compared the characteristics of dermatologists' office-based practices with those of other physicians. In 1999 to 2000, there were approximately 35 million visits annually to office-based dermatologists, double the number for 1974. Eight diagnostic groups account for 65% of all visits to dermatologists. Acne is still the most frequent primary diagnosis at visits to dermatologists, but since 1974 the proportion of all visits that were for acne has decreased by half. Compared to other office-based physicians, dermatologists are significantly more likely to own their practices (OR, 2.78; 95% CI, 1.52-5.02) and much less likely to see capitated patients (OR, 0.30; 95% CI, 0.17-0.53). Over 26 y, utilization of dermatologists' services has grown in proportion to the increase in the number of office-based dermatologists. The organization of their practices has changed little. Dermatologists dominate the care of many of the same diagnoses as they did 20 y ago.     

Metal allergen of the 21st century--a review on exposure, epidemiology and clinical manifestations of palladium allergy

Consumers are mainly exposed to palladium from jewellery and dental restorations. Palladium contact allergy is nearly always seen together with nickel allergy, as palladium and nickel tend to cross-react. We aimed to analyse the available palladium patch test data and case reports to determine whether the prevalence of palladium mono-sensitization has increased. Based on available patch test data from the period 1986-2008, a total of 10 778 patients were patch tested with palladium chloride. The median prevalence of palladium allergy was 7.8% (range <1.0-19.0%) in dermatitis patients and 7.4% (range 1.3-13.9%) in dental patients. The median prevalence of palladium mono-sensitization (defined as the presence of palladium allergy and the absence of nickel allergy) was 0.2% (range 0-1.6%) in dermatitis patients and 0.5% (range 0-7.2%) in dental patients. A slight increase in the prevalence of palladium mono-sensitization was observed over the study period. We conclude that clinically relevant palladium allergy should mainly be suspected in patients who present with allergic contact granulomas at sites of piercing, but also in patients who have clinical disease and palladium patch test reactivity without concomitant nickel reactivity. Palladium salts should be included in dental screening patch test series. Palladium use in jewellery should be limited until we know more about the risk of sensitization.     

Melanoma genetics and therapeutic approaches in the 21st century: moving from the benchside to the bedside

Metastatic melanoma is notoriously one of the most difficult cancers to treat. Although many therapeutic regimens have been tested, very few achieve response rates greater than 25%. Given the rising incidence of melanoma and the paucity of effective treatments, there is much hope and excitement in leveraging recent genetic and molecular insights for therapeutic advantage. Over the past 30 years, elegant studies by many groups have helped decipher the complex genetic networks involved in melanoma proliferation, progression and survival, as well as several genes involved in melanocyte development and survival. Many of these oncogenic loci and pathways have become crucial targets for pharmacological development. In this article we review: (1) our current understanding of melanoma genetics within the context of signaling networks; (2) targeted therapies, including an extensive discussion of promising agents that act in the Bcl-2 signaling network; (3) future areas of research.     

Super giant basal cell carcinoma of the abdominal wall: still possible in the 21st century

Basal cell carcinoma (BCC) is very common and usually encountered when it is small in size. Giant BCC (i.e. greater than 5 cm in diameter) is quite rare and comprises 0.5 percent of all BCC. Extremely rarely, tumors larger than 20 cm have been reported. Herein, a case with an enormous, vegetating BCC of the abdominal wall, 30 x 20 cm in size, is described. This report demonstrates that such a case can still be observed in the civilized world of the 21st century, which remains profoundly astonishing. A literature survey was performed and revealed only 7 cases with such super giant BCC (i.e. larger than 20 cm in diameter). Generally, this tumor attains these enormous proportions due to neglect on the patient’s part, and is usually located at sites covered by clothes. Treatment is mainly surgical and generally curative, resulting also in an improved quality of life. Tumor size of more than 10 cm in diameter is associated with increased risk for metastatic disease, severe morbidity and consequently impaired prognosis.     

Leprosy in Brazil in the 21st century: analysis of epidemiological and operational indicators using inflection point regression

The objective of this study was to analyze the trend of epidemiological and operational indicators of leprosy in Brazil, from 2001 to 2017. This was a time series study involving nine indicators. The inflection point regression model was used. Decreasing trends were observed for the following: general detection (−4.8%), children under 15 (−3.7%), prevalence (−7.0%), and grade 2/million inhabitants (−3.5%). The proportion of individuals with grade 2 disability showed an upward trend (2.0%) from 2001 as well as contacts examined from 2003 (5.0%). The proportions of cure and of individuals with a degree of disability assessed at the time of the diagnosis and the cure showed a stationary behavior. Although advances are noted, there are still challenges to be overcome.     

Scabies and lice: review of the clinical features and management principles

Health care providers frequently encounter human infestations of scabies and lice. When a person is identified as having either of these infestations, he/she should be treated. More importantly, their close contacts should be examined and treated if needed. It is vital for dermatology nurses to understand the epidemiology, transmission, symptoms, distribution, diagnosis, complications, and treatment for scabies and lice infestations.     

Developments in the treatment of nail psoriasis, melanonychia striata, and onychomycosis. A review of the literature

Nail psoriasis, melanonychia striata, and onychomycosis are relatively common nail disorders that have generated much research into their pathophysiology and treatment. The authors hope this discussion of the recent therapeutic developments for treating these disorders will not only inform but will also inspire further investigation so that therapeutic advances may continue.