Dermatology World Insights and Inquiries
Dr. Heymann frequently contributes to discussions in dermatology through regular publications in the American Academy of Dermatology’s weekly Insights and Inquiries. As Editor of the Dermatology World Insights and Inquiries Editorial Board, Dr. Heymann gives practical and thought-provoking advice on current dermatologic literature that physicians can use in their clinics.
Stages of the drug epidemic in the US include dark moments in our history and the ongoing threat of increasingly dangerous, untested, or misunderstood compounds that infiltrate users’ supply lines without their knowledge. Not only is this dangerous to the overall health and well-being of a person, but it also poses severe risks of some of the worst skin lesions and dermatologic symptoms a person can experience. Xylazine, street name “Tranq” is one such drug. The vasoconstricting and bradycardiac effects, among others, can contribute to necrosis, infections, ulcerations, and decreased wound healing that leads to severe skin and soft tissue damage. It reveals that dermatologic care is increasingly essential to users’ multidisciplinary approach to healing and getting clean.
When performing dermoscopy, being confident about the ridge pattern you’re looking at is key to understanding whether a sample is positive for melanoma or a growing number of other benign conditions that do not require extensive treatment. One new addition to the benign column is pagetoid dyskeratosis (PD), in which discolored regions on the hands and feet contain parallel ridge patterns that look like acral lentiginous melanoma, consisting of several straight columns of parallel ridges.
A devastating diagnosis for newborns is restrictive dermopathy (RD), a laminopathy that is lethal to infants after, often, premature birth. After decades of research, new pathologies have emerged and given clarity to prenatal testing for indicators of the genetic markers that lead to convincing diagnoses that can help families plan for future pregnancies. In extrapolating the findings of the mechanisms of RD, however, there may hold new insights and novel anti-aging therapies through the use of gene therapy or inhibiting certain pathways that lead to RD.
Lipodystrophias, or conditions that cause the body to lose adipose tissue, in some cases nearly completely. These conditions are rare and complex, often resulting from secondary or genetic conditions that are either localized or generalized. In some cases, however, they can be attributed to repeated injuries to areas such as the thighs or glutes – such as sitting on a chair with a rigid edge or leaning against a sink repeatedly for many years (lipodystrophia semicircularis, LS). Although anxiety-inducing in some dermatologists, the prevalence of benign depressions in areas of repeated micro-injuries is probably underreported and requires little to no monitoring other than eliminating the potentially injurious habit that caused it.
Identifying and treating Dupuytren’s disease (DD) is typically left up to the expert orthopedic or hand surgeons you refer out to as a dermatologist. However, knowing the stage and severity of the condition can help your patients identify the condition early, leading to better outcomes and lower risk of permanent, disabling contracture of the fifth digit.
Telangiectasis can present itself in many ways, with somatic symptoms, additional types of lesions, and varied placement of the lesions. A relatively new addition to the telangiectasia family is TEMPI syndrome. As the disease can be fatal and is still in its early stages of understanding, diagnosing the condition early is crucial for dermatologists, who might be integral for identifying a person’s symptoms along with the rest of their healthcare team.
Symptoms of neutrophilic fixed drug eruption (nFDE) can be easily identified clinically but can imitate many systemic disorders that deserve different or additional treatment, including drug-induced Sweet’s syndrome, or recurrent neutrophilic dermatoses. Establishing a correlation between both clinical and pathological criteria is therefore critical to diagnosing and treating the right condition.
As dermatologists, you might sometimes have to take off the clinician hat and put on a psychologist’s one. Patients will arrive from all walks of life, all types of experiences, and all manner of conditions. In this article, Dr. Heymann shares his insights into being a “good psychiatrist and a superb psychologist” as an effective dermatologist.
Do home remedies work for thinning hair or extremely thick nails? Dr. Heymann joined The People’s Pharmacy to answer listeners’ questions about some common hair and nail conditions and what actually works from a dermatologist’s perspective. He discusses the difference between types of drugs and forms of them for addressing issues like male pattern baldness, as well as what might be on the horizon for these common issues.
The average dermatologist sees a patient with skin tags at least once a week if not once a day. However, these seemingly straightforward polyps, keratoses, or lesions may not just be benign random occurrences, but rather an indicator of some other internal issue. Especially for repeat patients or those with a prior history of cosmetic skin tags, taking a full medical history, including symptoms of GI issues or other metabolic syndromes might warrant referring a patient to another specialist or procedure, such as a colonoscopy. In other cases, simply removing the lesion through typical means is all that’s required.
Although rituximab has many FDA-approved indications and guidelines for beneficial use cases for the drug, it’s also a highly complicated compound that, unfortunately, can result in conditions like pyoderma gangrenosum – specifically vulvovaginal pyoderma gangrenosum (VVPG). Dermatologists, therefore, should be aware of the general profile of patients suffering from VVPG or PG before prescribing rituximab, especially in non-life-threatening conditions.
Although many aspiring or future dermatologists go through medical school hearing that nevus sebaceous, a common congenital lesion, has a high risk of becoming malignant during the course of the patient’s life, the reality is more complex and fortunately, less risky. In recent studies classically defined nevus sebaceous has proven to have a relatively small risk of secondary malignancies, meaning treatment for these abnormalities can be put off until a patient is better suited to undergo the minimal surgery that the condition requires.
Generally known as benign “anemic” spots with a blueish tint, Bier spots (BS or Bier anemic spots) may pose a greater risk than thought. A closely related disorder, Bier Anemic Spots, Cyanosis with Urticaria-Like Eruption (BASCULE), has associations with fainting episodes while exercising as well as painful lesions and heart block. Dr. Heymann suggests it’s worth double-checking patients who present with BS or similar symptoms the next time you encounter one and check for additional lesions or symptoms before dismissing the case as benign and self-correcting.
In the 100 years since first being synthesized, it has become ubiquitous for people with diabetes mellitus type 2 as a daily treatment to help improve glucose control. In recent data, metformin has also been associated with a lower risk of developing squamous cell carcinoma, offering a potential additional line of defense for those at risk of developing subsequent skin cancer. These findings are preliminary and not as comprehensive as to recommend widespread, standard use in lowering the risk of skin cancer, but they are nevertheless valuable.
Pressure ulcers (PUs), more commonly known as bed sores, are generally understood to be caused by static, unrelenting pressure in areas of the skin over a long time. However, the issue involves more than just irritation or lack of blood flow. Desensitization, nutrition, underlying health conditions (such that would lead someone to be in a hospital bed), and even mental acuity complicate the condition and finding a suitable treatment. The latest research into silicone adhesive multilayered dressings reveals they can be used to help alleviate pressure ulcers, but they are ultimately no more useful than traditional measures to alleviate this potentially devastating complication.
The scars and dyspigmentation caused by cutaneous lupus erythematosus (CLE) can be life-altering for affected patients. As it stands, there are many first, second, and third treatment options from topical steroids to antimalarial drugs and more, however, not all patients find a suitable therapy or remission for CLE. Research has identified a new type of drug that interrupts the immune system dysfunction that causes the activation of T and B cells that result in tissue decay and pigmentation. Approved by the FDA in July of 2021, this drug, Anifrolumab, is ready and holds great promise for use in patients with CLE in addition to their current treatment regimen.
In a reflection on 40 years of marriage and 40 years of practicing medicine, Dr. Heymann reflects on and presents data about the inequities that plague the medical industry, specifically in households with partners who are both physicians. Female physicians who are married to another physician statistically bear more of the household burden while receiving less pay and fewer opportunities for advancement. Dr. Heymann calls for equity both at home, in the relationship, and in the workplace for these common couples where both are practicing physicians in any field.
Infantile digital fibromatosis has been classified as a rare fibrous tumor growth in the digits, except in the thumb and big toe, that gradually appears, rapidly grows, then spontaneously regresses with no symptoms other than visible tumors. Once thought to be exclusive to newborns and children, this condition has lately been discovered in adults with highly correlated symptoms and history. Treatments for this benign condition include simply watching and waiting, with some success found with drugs like imiquimod and 5-fluorouracil.
The rapid approval of JAK inhibitors (JAKi) has largely outpaced the clinical understanding of when it’s appropriate to prescribe them, despite there being extensive literature on the subject. One of the most common side effects of these drugs includes acne, a surprising result given the anti-inflammatory benefits JAKi usually provides. However, these results raise more questions than answers, as a comprehensive understanding of acne cases in trials of JAKi is lacking. Further research will provide a better understanding of the pathogenesis and ideal treatment options for various patient profiles.
A single case report has the potential to change the world: Could JAK inhibition alter the trajectory of multicentric reticulohistiocytosis?
Although it’s right for a vast majority of dermatologic advancement to be focused on common disorders, it’s important to not lose sight of the human impact of the rarest diseases. In the case of the 300 or so reported cases of multicentric reticulohistiocytosis (MR), the effects can be debilitating and concurrent with serious conditions such as autoimmune disorders or cancer. Until the development and approval of JAK inhibitors, little seemed to help MR patients across the board due to a lack of precise understanding of this condition. The dramatic symptomatic relief that one individual was able to have with a JAK1 inhibitor is a hopeful outcome that has sadly come too late for many MR patients.
Although acne and diabetes have had numerous successful methods of treatment for decades, there’s always something to learn about the interplay of dermatologist drugs and your body systems that can be surprising. In a recent case of a woman treated with isotretinoin for acne, her blood sugar became suddenly more difficult to control compared to before the treatment regimen. As it turns out, the insert for isotretinoin acknowledges this rare complication, although it should have a little long-term effect on diabetics and non-diabetics alike.
Dr. Heymann has a personal connection with onychopapilloma (OP) – a benign nail disease that causes one fingernail to develop a white or pigmented line up the nailbed, terminating in a splinter-shaped hyperkeratosis. This is why a study that proposed some cases of OP can be or become malignant caught his eye. When people with OP or similar distinguishing symptoms suddenly experience changes, it’s possible that a benign condition has become malignant and should be biopsied for treatment.
There are many instances in which dermatologists are able to preemptively diagnose serious conditions that may or may not have originated in the skin. Diseases such as inflammatory bowel disease, including Crohn’s disease and ulcerative colitis, can present lesions or general signs of illness that will inevitably lead to a life-changing diagnosis. The key identifier of this disorder is endoscopic evaluation with biopsies, as well as measuring fecal calprotectin. For dermatologists, some experts say that taking fecal calprotectin levels is useful as a negative predictor of IBD. This can mean avoiding specialist tests and treatment and providing peace of mind for those who don’t test positive.
Although for many the spring and summer months bring a much-awaited break in cold temperatures, for people with anhidrosis, warmer weather can be life-threatening. Anhidrosis, or the inability to sweat, can be concurrent with other dermatologic conditions or appear on its own with seemingly no cause. These cases of acquired idiopathic generalized anhidrosis (AIGA) are rare but should receive the proper attention for diagnosis and treatment with steroids to improve the quality of life of the patient and perhaps be life-saving.
One of the conditions encapsulated in the oral-facial granulomatosis (OFG) category of granulomata-causing diseases is granulomatous cheilitis, which can cause severe emotional and physical tolls on the patient, especially when it is not isolated and diagnosed for their specific pathologies. Forms of OFG can arise from a myriad of conditions and have numerous causes that have been largely unexplored since first identifying the disease back in the late 1980s. Advances in therapy and the understanding of the pathogenesis of OFG are needed to enhance the diagnosis and treatment to provide the full range of care these patients deserve.
As a monkeypox outbreak reaches headlines and the US, Dr. Heymann reassures readers that this disease is nothing like the COVID-19 pandemic and has no risk of becoming one. He shares several basic tips for dermatologists and patients alike to recognize and protect themselves from contracting this potentially deadly viral infection.
Although dermatologists have been trained for over a decade that lymphocytic thrombophilic arteritis (LTA) is a type of cutaneous polyarteritis nodosa due to the similarities in symptoms (though not severity) and pathology, Dr. Heymann attempts to complicate this classification by reviewing literature that suggests LTA is a rare and distinct disorder with its own etiology.
The latest developments in the revolutionary treatment for melanoma for lymphocyte activation gene 3 (LAG-3) show encouraging results when combined with other therapies alone. In one global double-blind trial, LAG-3 checkpoint inhibitors in tandem with PD-1 inhibitors show greater benefit than the PD-1 inhibitor treatment alone. Along with expectedly minimal or treatable side effects, it seems to show that LAG-3 inhibitors will soon be in dermatologist’s toolkit for stopping the progression of advanced melanoma with or without concurrent therapy.
Although the name implies the presence of something “false” or “fake,” eruptive psuedoangiomatosis (EP) is very real even if it does resolve on its own for the vast majority of patients who present with its rare set of symptoms. These lesions commonly affect children, especially in response to vaccinations such as the COVID-19 shot and many viral illnesses, but also have been found in adults with similar conditions. This seemingly harmless condition is intriguing to dermatologists who have yet to identify what’s causing the cytokine responses to these little red lesions.
With clinical applications for oxymetazoline having been around for more than a decade at this point, it’s exciting to see its vasoconstrictive benefits finding new applications dermatologically and cosmetically. In addition to its use for treating nasal decongestion or helping maintain hemostasis during dermatologic surgery, it’s now approved for use in treating mild blepharoptosis, or drooping of the upper eyelid. There is little risk of mild adverse events when taking the 0.1% solution regularly, and Dr. Heymann’s practice manager enjoyed her results from a quick trial immensely.
One Toker Over the Line: Clarifying Toker Cell Hyperplasia in Zuska Disease and its Relationship to Hidradenitis Suppurativa
Zuska disease (ZD), unlikely to be familiar to many clinical dermatologists, is a relevant condition when diagnosing Toker cell hyperplasia (TCH) as distinct from a close mimic, Paget disease (PD). ZD is most likely a localized form of hidradenitis suppurativa, which is rarely complicated by squamous cell carcinoma. However, when symptoms point toward PD, it’s important to collect mucin and immunohistochemical stains to differentiate this condition from the benign TCH.
As is well-known and increasingly well-documented in dermatological literature, rituximab is associated with late-onset neutropenia (LON) in an average of 6% of patients or more. While many patients weather this condition without additional intervention, rituximab-induced LON can result in fatalities, which is why it’s important to monitor patients carefully to note any adverse reactions early in treatment with rituximab.
With a tongue-in-cheek acronym like BADAS, it’s easy for dermatologists to remember to screen for this dermatosis when patients present with a medical history that makes them more likely to develop the disorder. Bowel-associated dermatosis arthritis syndrome (BADAS) results in arthritic symptoms and skin eruptions throughout the upper extremities and torso. This condition is more common in patients with a history of gastrointestinal disorders and treatments, including gastric bypass surgery.
The phenomenon of skin quickly wrinkling in patients with cystic fibrosis (CF) has been known for decades as a non-invasive indicator of the presence of the disease. It’s called aquagenic wrinkling of the palms (AWP) and it is a helpful way for people suspected of having CF to find early treatment for the best hope of good outcomes.
As students all over the country discover whether they’ve made the cut during dermatology match day for residency candidates, Dr. Heymann provides dozens of dermatologists’ best effort on whether to take a further step to bolster your resume with a research gap year. While for individuals a gap year can be a powerful way to enhance their status and gain valuable insight, it may not be the healthiest trend to recommend every medical student automatically take this step. Since not everyone has the opportunity for this optional career move, by legitimizing its importance, we risk further broadening the inequity built into healthcare and medical schooling. The idea of taking a gap year should be carefully considered by each hopeful dermatology resident based on their passions and unique opportunities.
With increasing awareness and experience with generalized pustular psoriasis (GPP), novel effective therapies including IL-36 inhibitors offer better benefits with fewer risks for patients suffering from severe forms of GPP. However, in recent trials of this drug, spesolimab, several side effects occurred, including common urinary tract infections and drug rejection by the body. With more and larger trials, we will learn more about this type of GPP treatment and whether it’s right to prescribe it to people with varying degrees of the disorder.
By Warren R. Heymann, MD, FAAD, March 2, 2022, Vol. 4, No. 9
Ulcerous eruptions in the mucous membranes can be difficult to definitively identify, with many symptoms appearing similar to those caused by, for example, Stevens-Johnson syndrome. Recently, a team of researchers published a meta study of mysterious or ill-defined mucosal ulcers to identify a better term to describe these conditions and provide clarity for treatment protocols. Building on their definition of “Mycoplasma-induced rash and mucositis,” or MIRM, other researchers have further defined a catch-all for diseases concurrent or triggered by secondary infections, “reactive infections mucucutaneous eruption,” or RIME. These new distinctions should provide better diagnostic language and a path for further exploration into what triggers RIME pathologically.
By Warren R. Heymann, MD, FAAD, February 23, 2022, Vol. 4, No. 8
A rare but troubling disorder, Verruciform Xanthoma (VX), appears similar in appearance and behavior to some skin cancers, notably squamous cell carcinoma. However, this specific pathology is not malignant, meaning it doesn’t need to be treated the same way as squamous cell. Proper diagnosis and long-term monitoring of patients who have the lesions associated with trauma, irritation, or inflammation is recommended, as the disorder can recur in certain circumstances.
By Warren R. Heymann, MD, FAAD, February 16, 2022, Vol. 4, No. 7
Far from a cosmetic concern, those with thin skin and other characteristic symptoms of vascular Ehlers-Danlos syndrome (vEDS) are extremely high-risk for significant health complications such as arterial and bowel rupture, uterine rupture, and other potentially life-threatening conditions. While the current recommended treatment protocols sometimes involve dozens of doctors and medical professionals, there is hope that future research will reveal a specific targeted therapy for treating the risks associated with this disease. For now, dermatologists should be familiar with the common visible cutaneous characteristics in order to refer patients to the specialists they need to receive proper care and preventative treatment.
By Warren R. Heymann, MD, FAAD, February 9, 2022, Vol. 4, No. 6
With dozens of potential treatments for a common and upsetting condition, melasma, it’s hard to know which protocol and which compounds are most effective and least risk factor-increasing for specific patients with specific preferences. The common triple combination therapy includes a potentially carcinogenic treatment of hydroquinones. This category of products can be both medically and preferentially undesirable, which is why commercially available products such as cysteamine are a spot of hope for people with melasma who want to reduce their pigmentation without the risks of traditional treatments. However, the literature has failed thus far to confirm its effectiveness, although anecdotal evidence shows it’s a viable alternative with relatively comparable results.
By Warren R. Heymann, MD, FAAD, February 2, 2022, Vol. 4, No. 5
With increasing attention and research pointed at discovering the optimal therapeutic approach to treating a physically and emotionally painful condition called hidradenitis suppurativa (HS), you’d think the most promising treatments would be with novel approaches. However, as studies increasingly show a lack of evidence for various treatments, Dr. Heymann’s preferred approach from decades ago may still be the best option for people suffering from this condition. What’s new isn’t the treatment itself but rather the dosage, proving, in this scenario, that an old dog doesn’t always need to learn new tricks, but rather how to learn to use them more effectively.
By Warren R. Heymann, MD, FAAD, January 26, 2022, Vol. 4, No. 4
Of the rare disorders taught to dermatologists early in their training, we have learned a surprising amount about eccrine syringofibroadenoma (ESFA), including the fact that it’s likely not a single causality but rather heterogeneous histopathologies that will have a meaningful influence on diagnosis and treatment. The key to recognizing the variants and diagnosing ESFA is to pay attention to the clinical presentation of the condition and the findings of the biopsy report. Fortunately, most cases are self-resolving, although it’s still important to note the presence of malignant cases of ESFA as well.
By Warren R. Heymann, MD, FAAD, January 19, 2022, Vol. 4, No. 3
It wasn’t until 2008 that an old, well-known disease became associated with increasing the risk of fetal loss or miscarriage when it was studied in-depth for its effect on pregnant women. Now it’s understood that pityriasis rosea (PR) should raise warning signs for dermatologists treating people early in their pregnancy. While there is still much to learn about PR’s risk factor for pregnancy and childbirth complications, there is fair evidence to say that in some cases the condition should be treated with acyclovir for people who are pregnant.
By Warren R. Heymann, MD, FAAD, January 12, 2022, Vol. 4, No. 2
The available treatments for psoriasis and similar skin conditions have come a long way since the first remedies, which included topically applying crude tar to the area. However, more research into compounds and pathways that made such an application has revealed unique treatment opportunities that early physicians stumbled upon in tar treatments. Despite promising findings, tapinarof, an agent likely at play in tar therapy’s effectiveness, still shows disturbing statistical outcomes in the most well-respected studies. More work is needed to fully understand this compound and how it would become truly beneficial in a dermatologist’s treatment offerings.
By Warren R. Heymann, MD, FAAD, January 5, 2022, Vol. 4, No. 1
Originally developed as a blood pressure medication, minoxidil has been known for years to be the active ingredient in hair regrowth products and prescriptions. Well-known for its topical use as a treatment for various alopecias (hair loss) these days, its intended use was as a low-dose oral medicine for high blood pressure. However, this oral dosage was seen to stimulate hair growth, and a topical form was produced and approved for men in 1988 and women in 1991. In recent years, researchers have turned their attention back to low-dose oral minoxidil (LDOM) as a potentially more convenient, cost-effective, and even safer way to stimulate hair growth than the topical form, bringing the study of this chemical nearly full-circle.
By Warren R. Heymann, MD, FAAD, December 15, 2021, Vol. 3, No. 49
Most commonly seen in patients who are immunocompromised, trichodysplasia spinulosa is a relatively rare disorder that has the potential to become more common. It frequently presents after a solid organ transplant or in patients being treated with iatrogenic immunosuppression. There’s no accepted standard treatment plan, although what usually works is easing up on the immunosuppression if possible, as well as trying certain oral and topical medications.
By Warren R. Heymann, MD, FAAD, December 8, 2021, Vol. 3, No. 48
Propranolol was a remarkable new therapy when it was discovered to treat infantile hemangiomas, and its usefulness may be expanding. Studies continue to show promising results of treating neutrophil dermatoses with propranolol, including generalized pustular psoriasis, Sweet’s syndrome, and rheumatoid neutrophilic dermatitis to name a few. Although not expanded to human trials just yet, the future is hopeful to add propranolol to the potential treatment for neutrophil-mediated disorders.
By Warren R. Heymann, MD, FAAD, December 1, 2021, Vol. 3, No. 47
You may not have heard of it, but VEXAS (Vacuoles, E1 enzyme, X-linked, Autoinflammatory, Somatic) syndrome may have already crossed your path at some point. This syndrome presents with a variety of symptoms, including fever, chondritis, and vasculitis. VEXAS syndrome has been shown to co-occur with disorders such as Sweet syndrome and relapsing polychondritis and is not uncommonly fatal. Opening the mind for diagnosing this condition through exosome analysis is crucial to identifying overlapping disorders that continue to reveal how VEXAS links seemingly disparate conditions.
By Warren R. Heymann, MD, FAAD, November 17, 2021, Vol. 3, No. 46
Although used regularly by many people who are looking to improve their hair and nail health, are biotin supplements effective? Dr. Heymann reviews when biotin supplements are prescribed for people with congenital or acquired biotin deficiencies, which have good outcomes with the right dosage. However, there is a dearth of evidence to show that supplements that achieve up to 166 times your recommended daily intake of biotin have any effect on hair and nail growth.
By Warren R. Heymann, MD, FAAD, November 10, 2021, Vol. 3, No. 45
In recent years, more instances of similar yet distinct diseases that appear to be drug-induced toxic epidermal necrolysis (TEN) have been chronicled and studied. Collectively, these diseases are known as Acute Syndrome of Apoptotic Pan-epidermolysis, or ASAP. Dr. Heymann notes here that diagnosing these conditions correctly and quickly is key to a good prognosis, as TEN and TEN-like diseases respond differently to various treatments.
By Warren R. Heymann, MD, FAAD, November 3, 2021, Vol. 3, No. 44
Feeling a development of a painful bump on your scalp can be a terrifying experience, but fortunately for people diagnosed with alopecia and aseptic nodules of the scalp, the prognosis is good. What’s challenging about this diagnosis is that it’s rarely given, as the disorder is both rare and newly identified, meaning many dermatologists may not recognize its symptoms.
By Warren R. Heymann, MD, FAAD, October 27, 2021, Vol. 3, No. 43
When a baby’s hair appears matted, tightly coiled and is difficult to comb, it could be the result of a rare genetic abnormality known as woolly hair (WH). When this condition is isolated to a spot on the scalp, there’s no cause for alarm. However, dermatologists should prioritize checking the palms and feet for keratoderma. Keratoderma with woolly hair (KWWH) is a syndrome that can cause a lethal heart condition later in life, meaning steps should be taken quickly to implant a defibrillator.
By Warren R. Heymann, MD, FAAD, October 20, 2021, Vol. 3, No. 42
Pigmented purpuric (PP) eruptions are often distressing to parents and children with this benign disorder, with the appearance of pigmented lesions throughout the body. Although many therapies have been shown to effectively treat PPs, no one solution works in all scenarios. Although much has changed since dermatologists first diagnosed this condition, the consensus on how best to treat it has not: simply wait and watch and the condition often resolves itself.
By Warren R. Heymann, MD, FAAD, October 13, 2021, Vol. 3, No. 41
Although many know the most common physical indicators of down syndrome (DS), dermatologists are discovering new cutaneous manifestations that correlate with DS every year. This is important because babies born with DS may require multi-faceted approaches to care, including dermatologic care, early in life as well as throughout life. Dr. Heymann reports new studies on the correlation of hidradenitis suppurativa, psoriasis, and Riga-Fede disease with down syndrome.
By Warren R. Heymann, MD, FAAD, October 6, 2021, Vol. 3, No. 40
New research has expanded the domain of axillary granular parakeratosis to include all of the skin, not just in the underarm. The newly termed general parakeratosis (GP) is often caused by a reaction to some skin irritant, substances from personal hygiene products to laundry detergent. Treatment is simple in that use of topical steroids and removing the irritant from the patient’s environment.
By Warren R. Heymann, MD, FAAD, Sept. 29, 2021, Vol. 3, No. 39
Receiving a lab report with CD30+ cell presence can lead to a rocky path of diagnosing lesions as lymphomas or other disorders. The reason this is so delicate a diagnosis is due to the possibility of prescribing potentially dangerous therapy when lymphoma is not present. Dr. Heymann reminds us in this article that taking these lab results with careful thought and follow-up leads to a better outcome and accurate diagnosis.
By Warren R. Heymann, MD, FAAD, Sept. 22, 2021, Vol. 3, No. 38
A few years back, Dr. Heymann penned an opinion piece on Dermatology Insights and Inquiries lamenting the use of the word “endorse” to describe a patient’s symptoms, as in “He endorsed nausea and diarrhea.” While his position on this potentially confusing use of the word still holds strong, Merriam-Webster now officially allows the use of “endorse” to mean “noting the presence of symptoms.
By Warren R. Heymann , MD, FAAD, Sept. 8, 2021, Vol. 3, No. 36
Acute hemorrhagic edema of infancy (AHEI) comes on suddenly and dramatically, with symptoms including red skin lesions throughout the body, as well as hemorrhagic lacrimation. Understandably, both parents and care providers often panic upon seeing these symptoms in their infant, but fortunately, the prognoses in nearly all cases are good, with the condition clearing up within a few days. More research on AHEI and how it differs from a similar condition, Henoch-Schönlein purpura (HSP) can help better direct the type of care needed to hasten recovery.
By Warren R. Heymann, MD, FAAD, Sept. 1, 2021, Vol. 3, No. 35
Formerly known as severe or atypical outbreaks of hydroa vacciniforme (HV), hydroa vacciniforme-like lymphoproliferative disorder (HVLPD) can be a severe, life-threatening condition that scientists have no real understanding of the cause. It’s known that ultraviolet light plays some role in the pathology of HV and HVLPD, but other causes remain elusive.
By Warren R. Heymann, MD, FAAD, Aug. 18, 2021, Vol. 3, No. 33
Scientific literature has not come to the consensus that hard water aggravates or is even correlated with increased incidence of atopic dermatitis in infants and young children. However, this is not to say that trying softer water for patients with the condition, and an ongoing study seeks to show more conclusive evidence of a verdict one way or another.
By Warren R. Heymann, MD, FAAD July 28, 2021, Vol. 3, No. 30
If you’ve never heard of a disease, it’s difficult to diagnose it. Also known as paroxysmal finger hematoma, Achenbach syndrome is characterized by acute pain in one or more fingers, followed by a blue discoloration of the skin. Statistically, it primarily affects women with a median age of about 50 years, most commonly on the right index finger. Achenbach syndrome is a benign condition that resolves on its own in a few to several days and can be recurrent.
By Warren R. Heymann, MD, FAAD July 21, 2021, Vol. 3, No. 29
When diagnosing a newborn or infant with neonatal lupus erythematosus (NLE), many parents immediately worry about the risk of long-term effects on the skin, including scarring and cutaneous sequelae. However, the prognosis is usually very good for many cases, although for early, extensive disease is a risk factor for residual lesions. Mothers who are at risk for giving birth to a child with NLE may benefit from hydroxychloroquine during gestation according to recent studies of anti-SSA/Ro-exposed pregnancies.
By Warren R. Heymann, MD, FAAD July 14, 2021, Vol. 3, No. 28
It’s well-known that humans are creatures of habit. And when it comes to diagnosing and prognosing dermatologic disorders, dermatologists are no exception to this trait. So when Dr. Heymann found himself ordering lactate dehydrogenase (LDH) levels as part of lab work for a patient with cutaneous T cell lymphoma, he wondered why. Studies have consistently shown that LDH levels are good indicators of staging in advanced melanoma and lymphoma, but have failed to show their usefulness with other diagnoses. It seems that LDH levels have a limited, specific utility and do not contribute as a helpful data point broadly.
By Warren R. Heymann , MD, FAAD July 7, 2021, Vol. 3, No. 27
In the past 20 years, the treatment for pemphigus and pemphigus variants has changed in light of new evidence that Rituximab, an FDA-approved drug for the treatment of diseases like rheumatoid arthritis and non-Hodgkin lymphoma, can achieve remission in a high percentage of patients. This has shifted the typical thinking of using mycophenolate mofetil as a first-line treatment, based on new trial designs and more data about this rare condition. Although more research is always needed to further prove its efficacy, Rituximab is well indicated to help patients with Pemphigus Vulgaris get into sustained, complete remission.
By Warren Heymann, MD, June 16, 2021, Vol. 3, No. 24
New insights and knowledge of how dermatofibrosarcoma protuberans (DFSP) begins may lead to novel therapies when the preferred surgical method of treatment is not recommended. For those with rare and locally aggressive tumors who are not indicated for surgery, imatinib has been FDA-approved as an alternative treatment. Additionally, armed with the knowledge that Akt-mTOR pathways are likely involved in tumorigenesis, dermatologists can explore new possibilities for improved non-surgical outcomes.
By Warren Heymann, MD, June 9, 2021, Vol. 3, No. 23
Even as the news out of India reports steadily declining infection rates of COVID-19, there remains a towering challenge for healthcare workers in the form of mucormycosis, which can prey on those suffering from severe COVID-19 infections. The fungal infection should be reported and treated as soon as possible and is especially prevalent in people with diabetes.
By Warren Heymann, MD June 2, 2021, Vol. 3, No. 22
It may not be well-known that topical therapeutic drugs like imiquimod can cause pemphigus or pemphigus-like eruptions although it’s well established that pemphigus and PLEs can be drug-induced. When patients present with this condition, it’s important to consider whether they have been treated with imiquimod in the past, as eruptions can occur at or distal to the site of topical treatment.
By Warren Heymann, MD May 26, 2021, Vol. 3, No. 21
The systemic effects of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) require a multidisciplinary effort to stem the dysregulation of many tissues, including gastrointestinal, ocular, pulmonary, and renal. For survivors of patients with TEN, the aftermath of dealing with the disease was both physical and psychological. With noticeable changes to the body including hyper- or hypopigmentation, scarring, changes in nail tissue and hair, as well as eruptive nevi and other cutaneous manifestations. For this publication, Dr. Heymann is joined by a patient who graciously shared their testimony in recovering from and living with the lasting impact TEN has made on their life.
By Warren Heymann, MD May 12, 2021, Vol. 3, No. 19
Up until October of 2019, people diagnosed with Erythropoietic Protoporphyria (EPP) had few options for mitigating their substantially life-altering symptoms, usually presenting with severe phototoxicity, as well as conditions such as gallstones and, in rare cases, liver failure. Fortunately, the FDA approved afamelanotide under the brand name Scenesse. Afamelanotide helps relieve the pain of EPP and leads to a dramatic and measurable increase in the quality of life for patients who receive it. Although it is not a cure, afamelanotide does help people suffering from EPP in a statistically significant way while potentially providing value in treating other photodermatoses and cutaneous diseases.
By Warren Heymann, MD May 5, 2021, Vol. 3, No. 18
Because the pathogenesis of lupus erythematosus panniculitis (or profundus, depending on what you’re reading), LEP for short, is not well known, neither are its first- and second-line treatments for widespread success in treating the condition. This leads to a crucible in treating LEP, as the symptoms are painful not only physically but also emotionally, and doctors can’t rely on well-established treatments. Additionally, LEP should be differentiated from subcutaneous panniculitis-like T-cell lymphoma to avoid misdiagnosis.
By Warren Heymann, MD April 28, 2021, Vol. 3, No. 17
The incidence of the once-rare neonatal skin disorder called Staphylococcal scalded skin syndrome (SSSS) is rising in the US and around the world. Because of this and the disease’s high mortality rate in adults, it’s vital that dermatologists know that the disease presents on a spectrum, and should be treated aggressively for patients who are immunocompromised or have renal impairment.
By Warren R. Heymann, MD – April 14, 2021, Vol. 3, No. 15
Up to half of all diabetic patients who use insulin injections may be affected by insulin-induced cutaneous lipohypertrophy (IIDL) or other skin lesions that appear at the injection site. These benign lesions often abate on their own when the patient moves to a different injection site. However, another, underrecognized disorder, localized insulin-derived amyloidosis (LIDA) may be to blame for hardened lesions at the injection site, which significantly affects insulin effectiveness. Proper diagnosis is critical to ensure effective glycemic control in patients with injection site lesions who may have LIDA.
By Warren R. Heymann , MD – April 7, 2021, Vol. 3, No. 14
Even when not presenting with metastatic melanoma, patients with a history of cutaneous melanoma should be carefully monitored for changes in vision, as melanoma-associated retinopathy (MAR) can cause permanent eye damage years after treatment for primary melanoma. Early diagnosis through electroretinography and biopsy for autoantibodies that target retinal cells can preserve vision from this degenerative disorder.
By Warren R. Heymann, MD – March 31, 2021, Vol. 3, No. 13
Rare and often misdiagnosed, Netherton Syndrome (NS) weakens the skin barrier of the scalp, leading to hair shaft abnormalities (short, dry, dull, and brittle) and a predisposition for allergic reactions that can seem as atopic dermatitis. The difficulty of diagnosis is compounded by the lack of effective, reliable treatments, that is, until now. An exciting and hopeful therapeutic tool is on the horizon by inhibiting the overactive KLK5 molecule that causes this disorder.
By Warren R. Heymann, MD – March 24, 2021, Vol. 3, No. 12
Lipschütz ulcers (LU) are painful ulcers that occur on the external genitalia of adolescent females, often following an Epstein-Barr infection, commonly known as mono. It was believed that this condition only occurred in females until recent speculation pinned down a rare and barely known condition called juvenile gangrenous vasculitis of the scrotum as the likely male equivalent of the well-studied LU.
By Warren R. Heymann, MD – March 3, 2021, Vol. 3, No. 9
Although some studies in the mid-20th century indicated systemic steroidal therapy could cause pustule flares in patients being treated for psoriasis, the dogmatic avoidance of this treatment may not be necessary after all. Still, with many newly developed, highly effective treatments existing for psoriasis that won’t increase a patient’s risk for developing pustular psoriasis, there’s no reason to move this option to the top of the list.
By Warren R. Heymann, MD – February 24, 2021, Vol. 3, No. 8
Although when discovered and diagnosed in isolation pilomatricomas are no cause to worry, recent work lays out if and when to conduct further testing for this typically benign lesion. This is especially necessary when a family history of related illness or cancer reveals a potentially life-threatening underlying condition.
By Warren R. Heymann, MD – February 17, 2021, Vol. 3, No. 7
Diffuse dermal angiomatosis can mimic inflammatory breast carcinoma as well as ulcerated plaques, which makes it important to include in the differential diagnoses for these and related disorders that arise in response to hypoxia.
By Warren R. Heymann, MD – February 3, 2021, Vol. 3, No. 5
Although seemingly straightforward to diagnose, green nail syndrome (GNS) can often arise in conjunction with onychomycosis, and a new study recommends that dermatologists treating this disorder test for possible fungal infections before beginning treatment for GNS.
By Warren R. Heymann, MD -January 27, 2021, Vol. 3, No. 4
With FDA approval of Tirbanibulin, a tubulin inhibitor drug hopes rise for a reliable treatment for actinic keratosis, which currently is best treated with the cancer drug Fluorouracil. More studies will need to be performed before Tirbanibulin can be ruled as more effective than other actinic keratosis therapies.
By Warren R. Heymann, MD – January 20, 2021, Vol. 3, No. 3
A revolutionary treatment for a one-in-a-million disease may have broader implications than treating the rare Olmstead syndrome. Using the cancer drug erlotinib hydrochloride in low doses, the inhibitor successfully reduced the hyperkeratosis and pain associated with the disease and may pave the way for further use in treating epidermal growth factor disorders, such as atopic dermatitis.
By Warren R. Heymann, MD – January 13, 2021, Vol. 3, No. 2
Although a large majority of port wine stains are acquired from birth, they can also be acquired later in life, often due to injuries such as trauma or sunburn. However, much is still unknown of the true incidence and predispositions that can cause acquired port-wine stains, including a person’s genetics.
By Warren R. Heymann, MD – January 6, 2021, Vol. 3, No. 1
Polymerase chain reaction, or PCR, is a powerful diagnostic tool that Dr. Heymann believes may be able to aid in the sometimes tricky process of identifying a scabies infection. The potential of PCR in scabies diagnosis would allow non-experts to perform reliable tests, which could be especially useful in the case of an outbreak
2020 Dermatology World Insights & Inquiries
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2019 Dermatology World Insights & Inquiries
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