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  Refractory Erythema Annulare Centrifugum Treated with Roflumilast

  Mitchell Brady, Pamela Calderon, Hamza Ajmal, and Francisca Kartono

  Publication Date: 5-9-2024

  Erythema annulare centrifugum (EAC) is the most common of the major figurate erythemas, which also include erythema marginatum, erythema migrans, and erythema gyratum repens, being classified as a reactive erythema. It has been suggested that the epidermal spongiosis histologically represents a reaction to one of many antigens, of which could be infectious agents, drugs, Crohn’s disease, pregnancy, autoimmune endocrinopathies, and occasionally, neoplasms. Lesions present first as firm pink papules that expand centrifugally and develop central clearing, then enlarge centrifugally again to form a large plaque. Asymmetrical plaques can appear polycyclic. The peak incidence for EAC is the fifth decade of life, however EAC can appear throughout all age groups, with no known gender predilection. EAC typically resolves with treatment of the underlying condition, however topical or systemic corticosteroids, antibiotics, or antihistamines have been used to treat the condition itself.

  Roflumilast 0.3% cream is a topical phosphodiesterase-4 (PDE-4) inhibitor. It is currently Food and Drug Administration approved to be used as a treatment for plaque psoriasis, including intertriginous skin in patients six years of age and older. We report a case of EAC refractory to conventional treatments, successfully treated with roflumilast, which, to our knowledge, has not been previously reported in literature.

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  Assessing Knowledge and Comfort Level of Primary Care Resident Physicians in the Management of Hidradenitis Suppurativa: Quality Improvement Study

  Zachary Burr, Pamela Calderon, and Francisca Kartono

  Publication Date: 5-9-2024

  Hidradenitis suppurative (HS) is a chronic inflammatory skin condition with lesions that include deep-seated nodules and abscesses, draining tracts, and fibrotic scars, most commonly occurring in the axillae and groin.

  The progression of HS leads to complications, including inflammation, abscesses, scarring, chronic pain, lymphatic obstruction, and squamous cell carcinoma.

  Management is considerably easier with a correct early diagnosis, yet there is an average delay of seven years to make the definitive diagnosis.

  Psychological impacts include depressed mood and anxiety, affecting work efforts and social relationships.

  Our research aimed to assess the baseline knowledge and comfort of primary care residents in diagnosing and managing HS. We analyzed whether a ten-minute educational session would change comfort levels.

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  Zosteriform HSV: A Unique Presentation of a Common Disease

  Amanda Greenspan, Mitchell Brady, and Brett Bender

  Publication Date: 5-9-2024

  We present the case of an 83-year-old male with painful vesicles in the right lumbar region. He reported a similar lesion that had appeared and resolved intermittently in the same area for the past 15 years. He also experienced localized pain and allodynia in the affected area. The patient did not report any other symptoms, including rashes or lesions elsewhere. He had never received a formal diagnosis or treatment for the condition. His past medical history includes glaucoma and hypertension, for which he is treated with Latanoprost eye drops and Lisinopril. The patient is neither immunocompromised nor on immunosuppressive medications. PCR testing confirmed the presence of HSV-2, which is particularly noteworthy as most cases of zosteriform HSV are typically caused by HSV-1.

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  Cutaneous Aleukemic Myeloid Sarcoma

  Nathanial Hansen, Shelby Boock, and Maureen Cliffel

  Publication Date: 5-9-2024

  The patient is an 83 year old female with a past medical history of hypertension, dyslipidemia, endometriosis who presented with “red bumps” on her right anterior shin. She first noticed the lesions around 6 weeks prior to the examination. The lesions were non-itchy, non-tender, and had been slowly enlarging since she first noticed them. She had no previous history of similar lesions and no personal or family history of skin cancer. She denied fever, cough, night sweats, shortness of breath, gastrointestinal changes, dysuria, myalgias and arthralgias. She stated that she lost 10 pounds over the past year

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  Verrucous Psoriasis Treated with Secukinumab

  Nathanial Hansen, Madison Reed, and Joshua Aron

  Publication Date: 5-9-2024

  Psoriasis is a chronic inflammatory skin disease marked by keratinocyte hyperproliferation and immune dysregulation. Verrucous psoriasis, a rare variant, presents with thick, hyperkeratotic, wart-like plaques that are often refractory to standard treatments. Secukinumab, a monoclonal antibody targeting IL-17A, has demonstrated efficacy in plaque psoriasis, but data on its use in verrucous psoriasis is limited. This case highlights complete remission of verrucous psoriasis with secukinumab.

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  Ciprofloxacin Induced Palmar Desquamation

  Dan Myers and Brett Bender

  Publication Date: 5-9-2024

  Cutaneous adverse drug reactions (CADR), also known as toxidermia, are skin manifestations resulting from systemic drug administration. These reactions range from mild erythematous skin lesions to life threatening desquamative disorders.

  Epidermal desquamation is the highly regulated process of invisible shedding of corneocytes from the outermost layers of the stratum corneum. This occurs through the interplay between proteases and their inhibitors that control the degradation of corneodesmosomes.

  Skin peeling is often encountered in dermatology and refers to exaggerated visible superficial desquamation which can occur in inherited and acquired conditions such as tinea infections, atopic dermatitis, immune disorders, and as a side effect of medications.

  Ciprofloxacin is a fluoroquinolone antibiotic currently used to treat a broad range of bacterial infections. Ciprofloxacin has been shown to stimulate matrix degrading protease activity from fibroblasts and reduce collagen I synthesis.

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  A Case of Pleomorphic Liposarcoma of the Superficial Distal Upper Extremity

  Suraj Patel and Francisca Kartono

  Publication Date: 5-9-2024

  Pleomorphic liposarcoma (PLS) is the rarest subtype of liposarcoma, accounting for 5-10% of all liposarcomas.

  PLS typically arises in deep soft tissue (e.g. retroperitoneal region, extremities) with aggressive behavior characterized by high rate of local recurrence (42%) and distant metastases (45%).

  In contrast, ~25% of PLS develops within the dermis and superficial subcutaneous tissue. Superficial cases exhibit lower rates of recurrence and metastasis.

  PLS is diagnosed under microscopic examination revealing multi-vacuolated pleomorphic lipoblasts. Without any specific immunohistochemical or molecular features, diagnostic challenges can arise when biopsy reveals scant lipoblasts.

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  Efficacy of Upadacitinib in Resolving Refractory Oral Lichen Planus: A Case Study

  Alyssa P. Quinn, Trevor Nessel, and Francisca Kartono

  Publication Date: 5-9-2024

  Lichen planus (LP) is an autoimmune disorder mediated by T-cells, where inflammatory cells target an unidentified protein in the skin and mucosal keratinocytes.

  LP affects 1 in 100 individuals globally, primarily adults over the age of forty. • About 50% of LP patients develop oral lesions, occurring more often in women compared to men.

  Cutaneous LP often clears within a few years while mucosal LP can persist for more than a decade.

  Genetic predisposition, stress, tissue injury, contact allergy, and drug reactions are risk factors.

  Common treatment options: Topical and intralesional corticosteroids, topical immunosuppressants (tacrolimus and pimecrolimus).

  There is some evidence supporting the efficacy of upadacitinib in achieving rapid resolution of oral LP.

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  VEXAS Syndrome, A Novel Entity with Cutaneous Manifestations

  Akber Sheikh, Trevor Nessel, Nathanial Hansen, and Michael Mahon

  Publication Date: 5-9-2024

  Vacuoles, E1 enzyme, X-linked, Autoinflammatory, Somatic (VEXAS) Syndrome: typically seen in older males > 50 years old.1

  2/2 Somatic mutations in the UBA1 gene on the X chromosome -> decreased E1 ubiquitination.2

  Systemic inflammation, fever, bone marrow vacuolation (particularly affecting myeloid and erythroid precursor cells), elevated inflammatory markers, and cytopenias.1

  Hypercellular bone marrow -> macrocytic anemia and thrombocytopenia, potentially progressing to myelodysplastic syndrome (MDS), multiple myeloma (MM), or monoclonal gammopathy of undetermined significance (MGUS).2

  Skin is the most commonly affected organ; common dermatologic presentations: neutrophilic dermatosis, chondritis, vasculitis/vasculopathy, periorbital angioedema, and erythema nodosum.1

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  Case Report: Delay in Diagnosis of Drug-Induced Eruptive Lichen Planus

  Aili Swan, Mina Albayati, and Francisca Kartono

  Publication Date: 5-9-2024

  Drug-induced lichen planus is an uncommon cutaneous adverse reaction associated with various medications including Antihypertensives, antimalarials, TNF-alpha inhibitors, diuretics, and NSAIDs.

  This case report focuses on eruptive lichen planus triggered by amlodipine therapy, highlighting a delay in diagnosis due to insufficient histopathological clinical correlation.

• 

  Refractory Erythema Annulare Centrifugum Treated with Roflumilast

  Mitchell Brady, Pamela Calderon, Hamza Ajmal, and Francisca Kartono

  Publication Date: 5-4-2023

  Erythema annulare centrifugum (EAC) is the most common of the major figurate erythemas, which also include erythema marginatum, erythema migrans, and erythema gyratum repens, being classified as a reactive erythema.[1] It has been suggested that the epidermal spongiosis histologically represents a reaction to one of many antigens, of which could be infectious agents, drugs, Crohn’s disease, pregnancy, autoimmune endocrinopathies, and occasionally, neoplasms.[2] Lesions present first as firm pink papules that expand centrifugally and develop central clearing, then enlarge centrifugally again to form a large plaque. Asymmetrical plaques can appear polycyclic. The peak incidence for EAC is the fifth decade of life, however EAC can appear throughout all age groups, with no known gender predilection.[1] EAC typically resolves with treatment of the underlying condition, however topical or systemic corticosteroids, antibiotics, or antihistamines have been used to treat the condition itself.

  Roflumilast 0.3% cream is a topical phosphodiesterase-4 (PDE-4) inhibitor.[3] It is currently Food and Drug Administration approved to be used as a treatment for plaque psoriasis, including intertriginous skin in patients six years of age and older.[3] We report a case of EAC refractory to conventional treatments, successfully treated with roflumilast, which, to our knowledge, has not been previously reported in literature.

• 

  Assessing Knowledge and Comfort Level of Primary Care Resident Physicians in the Management of Hidradenitis Suppurativa Quality Improvement Study

  Zachary Burr, Pamela Calderon, and Francisca Kartono

  Publication Date: 5-4-2023

  Hidradenitis suppurative (HS) is a chronic inflammatory skin condition with lesions that include deep-seated nodules and abscesses, draining tracts, and fibrotic scars, most commonly occurring in the axillae and groin.1-2

  ▪ The progression of HS leads to complications, including inflammation, abscesses, scarring, chronic pain, lymphatic obstruction, and squamous cell carcinoma.1,3

  ▪ Management is considerably easier with a correct early diagnosis, yet there is an average delay of seven years to make the definitive diagnosis.3-4

  ▪ Psychological impacts include depressed mood and anxiety, affecting work efforts and social relationships.1,3 ▪ Our research aimed to assess the baseline knowledge and comfort of primary care residents in diagnosing and managing HS. We analyzed whether a ten-minute educational session would change comfort levels.

• 

  Cutaneous Aleukemic Myeloid Sarcoma

  Nathanial Hansen, Shelby Boock, and Maureen Cliffel

  Publication Date: 5-4-2023

  The patient is an 83 year old female with a past medical history of hypertension, dyslipidemia, endometriosis who presented with “red bumps” on her right anterior shin. She first noticed the lesions around 6 weeks prior to the examination. The lesions were non-itchy, non-tender, and had been slowly enlarging since she first noticed them. She had no previous history of similar lesions and no personal or family history of skin cancer. She denied fever, cough, night sweats, shortness of breath, gastrointestinal changes, dysuria, myalgias and arthralgias. She stated that she lost 10 pounds over the past year

• 

  Ciprofloxacin Induced Palmar Desquamation

  Dan Myers and Brett Bender

  Publication Date: 5-4-2023

  Cutaneous adverse drug reactions (CADR), also known as toxidermia, are skin manifestations resulting from systemic drug administration. These reactions range from mild erythematous skin lesions to life threatening desquamative disorders.

  Epidermal desquamation is the highly regulated process of invisible shedding of corneocytes from the outermost layers of the stratum corneum. This occurs through the interplay between proteases and their inhibitors that control the degradation of corneodesmosomes.

  Skin peeling is often encountered in dermatology and refers to exaggerated visible superficial desquamation which can occur in inherited and acquired conditions such as tinea infections, atopic dermatitis, immune disorders, and as a side effect of medications.

  Ciprofloxacin is a fluoroquinolone antibiotic currently used to treat a broad range of bacterial infections. Ciprofloxacin has been shown to stimulate matrix degrading protease activity from fibroblasts and reduce collagen I synthesis.

• 

  Efficacy of Upadacitinib in Resolving Refractory Oral Lichen Planus A Case Study

  Alyssa P. Quinn, Trevor Nessel, and Francisca Kartono

  Publication Date: 5-5-2023

  Lichen planus (LP) is an autoimmune disorder mediated by T-cells, where inflammatory cells target an unidentified protein in the skin and mucosal keratinocytes.

  LP affects 1 in 100 individuals globally, primarily adults over the age of forty.

  About 50% of LP patients develop oral lesions, occurring more often in women compared to men.

  Cutaneous LP often clears within a few years while mucosal LP can persist for more than a decade.

  Genetic predisposition, stress, tissue injury, contact allergy, and drug reactions are risk factors.

  Common treatment options: Topical and intralesional corticosteroids, topical immunosuppressants (tacrolimus and pimecrolimus).

  There is some evidence supporting the efficacy of upadacitinib in achieving rapid resolution of oral LP.

• 

  Case Report: Delay in Diagnosis of Drug-Induced Eruptive Lichen Planus

  Aili Swan, Mina Albayati, and Francisca Kartono

  Publication Date: 5-4-2023

  Drug-induced lichen planus is an uncommon cutaneous adverse reaction associated with various medications including Antihypertensives, antimalarials, TNF-alpha inhibitors, diuretics, and NSAIDs.

  This case report focuses on eruptive lichen planus triggered by amlodipine therapy, highlighting a delay in diagnosis due to insufficient histopathological clinical correlation.

• 

  A Case of Morphea Following Intra-articular Injection

  Aili Swan, Olivia A. Failla, and Maureen Cliffel

  Publication Date: 9-1-2023

  Morphea is an inflammatory and sclerosing skin disorder that is brought on by immune dysregulation, external factors, and genetic predisposition. It is benign, self-limiting, and typically confined to the skin and underlying tissues, without serious risk for morbidity. It is important to distinguish localized and limited morphea and scleroderma from a systemic presentation, as management and treatment as well as other risk factors and organ involvement vary greatly in systemic disease.

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  Eosinophilic Fasciitis Presenting as an Ichthyosiform Eruption of the Bilateral Ankles

  Nedyalko Ivanov, Ashley Garvin, Michael Mahon, and Sean Stephenson

  Publication Date: 5-2022

  Introduction Eosinophilic fasciitis (EF) is a rare connective tissue disease which closely resembles other scleroderma-like diseases. EF presents with painful swelling and hardening of the distal limbs and is often preceded by a history of strenuous exercise. The marked fascial fibrosis in EF can lead to joint contractures and causes significant morbidity in affected individuals. The authors present a rare case of EF presenting as an ichthyosiform eruption of the bilateral ankles with gradual improvement after the implementation of oral prednisone, hydroxychloroquine and methotrexate.

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  Innovative Minimally Invasive Technique for the Lower Blepharoplasty

  Katherine McClure, Erika Tvedten, and Eric Seiger

  Publication Date: 5-2022

  Introduction • There is natural pseudoherniation of the orbital fat pads through the orbital septum and orbicularis oculi with aging • This creates a less cosmetically youthful lid-cheek junction • A lower blepharoplasty can greatly improve the aesthetics in this area • There are three lower orbital fat pads: nasal, central and lateral