Steroid atrophy scarring treated with fat grafting in a patient with complex regional pain syndrome: A case report

Subcutaneous atrophy is a known complication of steroid injections. Excellent results with fat grafting for the treatment of steroid atrophy have been documented. However, the benefit of treating steroid-induced subcutaneous atrophy in an extremity diagnosed with complex regional pain syndrome (CRPS) has not been described. CRPS, known formerly as reflex sympathetic dystrophy or RSD, causalgia, or reflex neurovascular dystrophy, is a severe, progressive musculoskeletal pain syndrome characterized by pain which is disproportionate to the severity of the inciting event, edema, or skin changes. Common treatment modalities include pharmacotherapy, physical therapy, and nerve blocks—each therapy producing varying results. We present a literature review of CRPS and the case of a 15-year-old female who developed CRPS of the left lower leg after arthroscopic debridement with retrograde drilling of an osteochondral lesion. Steroid atrophy of the involved area following a saphenous nerve block complicated the patient's treatment course. The area of atrophy was treated with autologous fat grafting. Following the adipose injection procedure, the patient experienced almost complete resolution of her CPRS-associated pain symptoms, along with improved cosmetic appearance of the area.     

Apatinib‐induced Grade 3 hand‐foot syndrome in advanced lung adenocarcinoma successful treated with thalidomide: A case report

Hand‐foot syndrome (HFS) is a specific cutaneous toxicity caused by a variety of antitumor drugs. The most common drugs include capecitabine, pegylated liposomal doxorubicin and fluorouracil (PLD), tyrosine kinase inhibitor. It is a dose‐limiting cutaneous toxicity of these drugs. We reported an advanced lung adenocarcinoma female patient, who developed a Grade 3 HFS after a third‐line treatment with apatinib of 250 mg for 10 days, the patient developed intolerable pain with pruritus. Large erythema on the skin of the hand, with local ulceratio, exudation, and desquamation of cutaneous lesions. After treatment with 100 mg of thalidomide every night for 1 week, the patient's HFS was significantly relieved, and the duration of the remission was about 2 months, which not only significantly improved the patient's quality of life, but also maintained the antitumor strength.     

Novel nonsense GNAS mutation in a 14‐month‐old boy with plate‐like osteoma cutis and medulloblastoma

Plate‐like osteoma cutis (PLOC) is a dermatological disorder characterized by superficial ossification and rarely occurs without any underlying tissue abnormalities or pre‐existing calcification. The hereditary form of PLOC is mainly due to inactivating mutation in the GNAS gene. Inactivating mutation of the GNAS gene is associated with several diseases, which commonly manifest heterotopic ossification and hormonal resistance; however, the development of malignant neoplasm has never been reported. Herein, we report a case of a patient with a novel nonsense mutation in the GNAS gene, who presented with concurrent PLOC and medulloblastoma.     

Heterotopic ossification related to toxic epidermal necrolysis in a patient with Behçet's disease

We describe a 44‐year‐old woman with an 18‐year‐history of Behçet's disease (BD) in whom heterotopic ossification (HO) developed as a complication of toxic epidermal necrolysis (TEN). The patient presented with high fever, a progressive erythematous rash including target‐like lesions, flaccid blister formations, and severe detachment. The patient was diagnosed with TEN, and methylprednisolone therapy was started. In the 2nd month of her hospital course, painful limitation developed in both her elbow and shoulder joints. Laboratory and radiographic findings confirmed HO of these areas. BD associated with TEN and HO is a previously unreported entity. In such a condition, determination of underlying genetic abnormality is important. Additionally, HO should be considered as a potential cause of the symptoms related to the joints.     

Psoriasis improvement after gastric bandage in a patient partial responder to infliximab

Patients overweight or obese have more severe psoriasis than normal weight patients. Sometimes the excessive weight is related to a lack of efficacy of systemic treatment. We report a case of a psoriatic patient that experienced a dramatic improvement of psoriasis after weight loss surgery by gastric bandage. The great weight loss was accompanied by an effectiveness gain of response to infliximab. The mechanism responsible for this association is not certain, but it is probably multifactorial, involving genetic, environmental and immune‐mediated factors. It has been suggested that adipose tissue can dramatically alter the volume of drug distribution and limit drug efficacy. Moreover, a reduction of weight could favour the response to therapy and remission of the disease, inducing an improvement in patient's quality of life. Gastric bandage has a scarce rate of complications, a fast recovery and scarce life‐threatening complications. It should be considered in obese patient that not shown effectiveness to therapy.     

Leg ulcerations due to livedo vasculitis: successful combined therapy with pentoxifylline and nifedipine

We report a patient with livedo vasculities with painful leg alterations in whom prolonged combined therapy with pentoxifylline and nifedipine of 2 years duration induced a remarkable and long-lasting improvement of the disease. During the period no occurrence of the ulcerations has been observed.     

Barriers to guideline‐compliant psoriasis care: analyses and concepts

Despite the availability of effective therapeutics and evidence‐based treatment guidelines, a substantial proportion of patients with moderate‐to‐severe psoriasis does not receive appropriate care. This under‐provision of health care may cause further worsening of health, remarkable limitations of the patient's quality of life, and indirect costs for the health care system. In order to provide guideline‐compliant care for every psoriasis patient, it is important to identify barriers obstructing optimal care. Studies have identified various barriers on the physician's and on the patient's side; however, respective studies approached only single barriers, and not all of them in the context of psoriasis. Other publications that describe barriers systematically did not focus on psoriasis either. The objective of this literature review was to identify barriers and facilitators, based on studies analysing quality of care and single barriers, resulting in a comprehensive model of causal factors. Our analyses revealed three categories of barriers – patient‐related, physician‐related and external factors: On the patient side, we found non‐adherence to therapies to be an important barrier, often in close association with psychiatric factors. Barriers on the physician's side predominantly are incomplete knowledge of the guidelines as well as the complexity of psoriasis comorbidity. In some countries, payment for patients with complex disease status is poor and inconsistent reimbursement regulations potentially interfere with optimal care. The current analysis indicates that most barriers are interdependent. Thus, measures approaching related barriers simultaneously are required. To improve care for psoriasis patients, further studies systematically addressing all potentially relevant barriers in conjoint are needed.     

Treatment of pruritus in early‐stage hypopigmented mycosis fungoides with aprepitant

Pruritus is a symptom that significantly affects the patient's quality of life in cutaneous T cell lymphoma (CTCL). The most effective treatments are those that address the condition itself; however, it is often not possible to control this symptom. Lymphoma‐related pruritus normally becomes more severe as CTCL progresses, constituting an important factor for quality of life in these patients. Substance P is a neuromodulator which appears to play a key role in pruritus. Aprepitant is a neurokinin‐1 receptor antagonist affecting the substance P receptor. So far, several cases have been documented with an antipruritic response to the drug aprepitant in advanced‐stage mycosis fungoides (MF). In this paper, we describe an excellent response to aprepitant in a female patient with severe pruritus secondary to hypopigmented stage I MF. We would also like to stress the absence of nausea and vomiting of this combined therapy of interferon and aprepitant. Aprepitant could improve tolerance to interferon.     

Treatment satisfaction and health status in patients with systemic sclerosis

Background: Systemic sclerosis (SSc) is a rare connective tissue disease. Few data are available on treatment satisfaction, determinants of quality of life, and the health status of dermatology patients with SSc. Patients and methods: Cross‐sectional study based on 72 consecutive dermatological patients with SSc. Objective clinical data were collected with a physician's questionnaire and subjective data were collected with a patients’ questionnaire on disease characteristics, treatment satisfaction, quality of life, depressive symptoms, and Antonovsky's sense of coherence (SOC). We also tested the significance of possible determinants of treatment satisfaction. Results: Treatment satisfaction was 72.0 (± 22.2; VAS 1–100). The assessment of professional competence of the treating physician was the most important determinant of treatment satisfaction and was independent of the patient's age and sex. The assessment of physician empathy, information about the disease, and the patient's own evaluation of the severity of disease were also associated with treatment satisfaction. The mean health‐related quality of life (QoL; EQ‐5D) was 0.74 (± 0.28) and the mean SOC was 72.6 (± 10.6). 58 % of patients reported moderate to severe pain and 13 % were treated for pain symptoms. In 69 % there was evidence of probable depression (CES‐D $ 22); 8 % were on antidepressants. Conclusions: Treatment satisfaction was average and correlated especially with the sense of professional competence of the treating physician. In SSc patients, a diminished health‐related quality of life as well as pain and evidence of depression are common and seem to be inadequately treated. However, the SOC indicates a lower general vulnerability. In the future, screening for pain and symptoms of depression should part of routine practice in SSc patients and, if necessary, interdisciplinary care should be initiated.     

The signature featureTM: A new concept in beauty

Signature Feature^TM (SF) is a universal, yet highly personalized treatment approach to aesthetic facial enhancement that applies to all patients, independent of age, gender, or ethnicity. Its philosophical basis maintains that a patient's beauty is anchored by their most distinctive invariant features (invariant features like eyes, nose, cheekbones, or jawline), and preservation of such signature features should be an essential consideration in any aesthetic treatment plan. The principles central to the SF concept include: (a) identifying the patient's most distinctive signature feature, (b) matching the patient's persona to their signature feature while preserving alignment with their cultural/ethnic aesthetic, and (c) highlighting the patient's signature feature by increasing the “signal‐to‐noise” ratio between the strength of the signature feature and those factors that may be interfering with it (lines, wrinkles, and sun damage). Every patient represents a new combination of treatment challenges which are not only related to the patient's physical baseline characteristics but also by their subjective self‐perceptions. This subjective gray area is where the SF treatment approach has the greatest contribution to the patient's positive self‐perception and self‐esteem, as the practitioner can help the patient realize their own personal brand through enhancement of their signature feature using an array of aesthetic options.     

FACE‐Q Skin Cancer Module for measuring patient‐reported outcomes following facial skin cancer surgery

People who have surgery to remove skin cancer on the face are often left with a scar. After surgery, a patient's satisfaction with their appearance is an important but often overlooked treatment outcome (meaning goal), and a patient's opinion on the aesthetic outcome of their surgery (meaning how much it affects how they look) may differ from the surgeon's. Studies have shown that the patient's perspective of their facial scar after skin cancer surgery can influence their perception of the care they received, and their quality of life. This study tested the ‘Face‐Q Skin Cancer Module’, designed to measure facial and scar appearance, appearance‐related psychosocial distress (how much the scar impacts on the patient's emotional wellbeing), cancer worry and the patient experience. Each of these scales within the Face‐Q Skin Cancer Module was tested using responses from 209 patients undergoing facial skin cancer surgery, and the study found that the FACE‐Q Skin Cancer Module provides doctors with a comprehensive set of meaningful and scientifically sound set of scales for the facial skin cancer population. This Module will be useful in clinics with patients, but also in research.     

Case study methodology in tissue viability. Part 2: A study to determine the levels of knowledge of nurses providing care for patients with leg ulcers in an acute hospital setting

One of the main components of the clinical governance framework is a comprehensive programme of quality improvement activity that includes the implementation of evidence-based, everyday clinical practice. This paper addresses the challenges surrounding the implementation of one area of evidence-based practice, the management of leg ulcers in an acute hospital trust. The aim of the study was to distinguish the levels of knowledge of nurses providing care for patients with leg ulcers within an acute hospital setting. The design used was that of a collective case study. Each 'case' was a patient with a leg ulcer and the nurses who cared for that patient. They were studied in order to provide insight into the nurses' understanding of leg ulcer management. A number of themes were identified as being common to all the cases. They are: evidence-based practice, nursing skills, quality of life, patient understanding of their ulcer and pain. Each of these themes identified areas of knowledge deficit in the nurses. As part of the implementation of a leg ulcer policy an education programme is being developed to address these deficits.     

Subcutaneous botulinum toxin‐A injection for treating postherpetic neuralgia

Postherpetic neuralgia (PHN) is a debilitating disease characterized by continuous, intense pain following an outbreak of herpes zoster. The pain associated with PHN can severely affect a patient's quality of life, quality of sleep, and ability to participate in activities of daily living. The aim of this study was to explore the clinical efficacy of the subcutaneous injection of botulinum toxin‐A (BTX‐A) for the treatment of PHN. Thirteen patients with PHN were enrolled in this study and treated once with BTX‐A. The effects of BTX‐A on pain were measured with the visual analogue scale (VAS) 1, 2, 4, 8, 12, and 16 weeks after administration. Compared with pretreatment scores, VAS pain scores decreased at 2 weeks post‐treatment in all patients. All patients felt varying degrees of pain relief but remained comfortable. Compared with oral analgesic drugs, VAS scores were significantly different at 2, 4, 8, 12, and 16 weeks post‐treatment (p < .05). These results demonstrated that subcutaneous administration of BTX‐A can decrease pain in patients with PHN.     

Remission of extensive intrahepatic metastasis by C‐arm computed tomography guided chemoembolization in uveal melanoma

As soon as uveal melanoma has metastasized to the liver, response rates to systemic chemotherapy are low. It can be improved by development of special locoregional procedures. A 24‐year‐old woman suffered from inoperable hepatic metastases which grew to life‐endangering size despite both systemic chemotherapy with gemc‐itabine/treosulfan and conventional intrahepatic chemoembolization with fotemustine and starch particles. We subsequently performed two angiographic C‐arm CT‐guided, superselective chemoembolizations of the hepatic arteries feeding the tumor, using cisplatin, starch microspheres and ethiodized oil. Following this treatment, no vital tumor tissue was detectable by MRI. This remission lasted for more than 6 months and the patient's quality of life was good. A subsequent local relapse could not be treated with chemoembolization because of thrombosis of the portal vein due to tumor compression. And the patient died 20 months after first detection of metastases. However, the selective angiographic C‐arm CT‐guided chemoembolization resulted in prolongation of life with good quality despite the advanced stage of the disease.     

Practical compendium for psoriasis management

Psoriasis management is complex and challenging. It should be tailored for each patient. Treatment strategy differs according to patient's age, sex, disease type, disease severity, burden on patient's quality of life, comorbidities, involvement of specific sites, and pregnancy. The choice of the appropriate therapeutic must take into consideration the availability, the price, and the patient's preferences. It is very important that the chosen treatment is not more unpleasant, intolerable, or dangerous than the disease itself. According to the disease type, severity, and effect on patient's quality of life, dermatologist chooses whether to start with topical therapy, phototherapy or systemic therapy, or a combination of two or more of them. Under each category, there are different types of therapies that can be the first line therapeutics, second line, or even contraindicated. In this compendium, we provide dermatologists with different treatment plans considering all the mentioned variables so that a dermatologist can choose the optimum plan for the patient.     

Effective treatments for paronychia caused by oncology pharmacotherapy

Cutaneous adverse events are relatively common in patients being treated with molecular‐targeted drugs. Paronychia is one of the cutaneous adverse events that influences the patient's quality of life because of pain, and it often affects anticancer treatments in severe cases. However, there are few effective treatments, especially for severe paronychia. Here, we present our experiences of treatment for paronychia due to oncology pharmacotherapy. Although we treated paronychia with various methods, only corticosteroid ointment and phenol chemical matricectomy significantly improved the paronychia. Dermatologists must perform appropriate and effective treatments for paronychia in order to enable patients to continue anticancer drug treatment without impairing their quality of life.     

Psychodermatologic Effects of Atopic Dermatitis and Acne: A Review on Self‐Esteem and Identity

Atopic dermatitis (AD) and acne vulgaris are among the most‐prevalent skin diseases in children. Both have been well documented in the literature to have significant negative effects on quality of life. Herein, we discuss the results of a comprehensive literature review aimed at assessing the impact of acne and AD on self‐esteem and identity. We highlight clinical tools for their assessment and offer coping strategies for patients and families. Multiple factors including relationships with parents and classmates, sports participation, and the sex of the patient contribute to the development of self‐esteem and identity in individuals with AD and acne. Atopic dermatitis was found to have significant behavioral effects on children, ultimately resulting in a lack of opportunity to develop proper coping. AD had a more‐prominent role in identity formation and gender roles in girls. Acne vulgaris was found to have a more direct effect on self‐esteem, self‐confidence and identity, especially in girls. The Cutaneous Body Image Scale is reviewed and offered as an easy and reliable tool to evaluate a patient's mental perception of the appearance of their skin. Coping strategies that may be offered to patients and families include empowerment and cognitive adaptation.     

The relationship between clinical severity and outcome measures in patients with chronic venous insufficiency with or without leg ulcer

PurposeTo evaluate the relationship between clinical severity and functionality, sleep quality, depression, and quality of life (QoL) in patients with CVI with or without leg ulcers.MethodsA total of sixty patients with CVI were enrolled in the study. The patients were C2-6 according to the CEAP classification. All the patients were assessed with Venous Clinical Severity Score (VCSS) for clinical severity, Visual Analog Scale (VAS) for pain, right and left lower limb (RLL and LLL) circumference measurements for edema, 6-min-walk test (6-MWT) for functional capacity, Lower Extremity Functional Scale (LEFS) for functionality, Pittsburg Sleep Quality Index (PSQI) for sleep quality, Beck Depression Inventory version I (BDI-I) for depression, and The Quality of Life Questionnaire for Chronic Venous Diseases-20 (CIVIQ-20) for QoL.ResultsThe mean age of the patients was 45.83 ± 13.25 years, and the mean duration of disease was 8.30 ± 7.42 years. There was a significant association between VCSS and VAS-rest/activity, edema-RLL/LLL, PSQI, BDI-I, LEFS, and CIVIQ-20 in patients without leg ulcers. In addition, a significant association was found between VCSS and VAS-rest/activity and CIVIQ-20 in patients with leg ulcers.ConclusionThe current study showed that an association has been found between clinical severity and pain at rest and during activity, edema, sleep quality, depression, lower extremity function, and QoL in patients without ulcers. However, clinical severity has been correlated with only pain at rest and during activity, and QoL in patients with leg ulcers.     

Regression of diffuse B‐cell lymphoma of the leg with intralesional gentian violet

In this case report, a patient of primary cutaneous diffuse B‐cell lymphoma, leg type was treated with intralesional gentian violet as she was judged to be too medically fragile for conventional chemotherapy due to advanced age and multiple serious comorbidities. Gentian violet (crystal violet/hexamethyl pararosaniline) is a triphenylmethane dye. It has been shown to have an inhibitory effect on NADPH oxidase, an enzyme family which is found in abundance in reactive oxygen‐driven tumors such as melanoma and lymphoma. We hypothesize that intralesional gentian violet treatment caused signalling changes in the lymphoma which allowed for immune clearance of the lymphoma. Complete resolution of the patient's lesion was noted on a follow‐up visit.