How to improve sun protection counseling in a primary care setting

Skin cancer is a significant public health concern in the United States as there continues to be an increasing number of cancers annually. Ultraviolet exposure is linked to the risk of developing skin cancer, but only a little more than half of the American practice sun protection. While many studies have shown that counseling can increase patient knowledge about sun protection, the counseling rate by physicians can be very low, especially in a primary care setting. Given that majority of the patients in this nation will likely see a primary care doctor before a dermatologist, we sought to see the rate at which a primary care physician provides counseling about sun protection. A survey was sent to primary care doctors and dermatologists in the Detroit and Ann Arbor area. Survey results showed that primary care doctors counsel significantly less than dermatologists. Also, primary care doctors are less likely to perform a full skin exam or use sunscreen themselves. Based on the results of the study, we were able to identify the barriers to primary care doctors performing counseling. We followed up our survey by providing educational intervention to the participating internal medicine doctors in the form of a lecture and an informative email. These doctors took the survey again after the intervention. Post-intervention survey results showed that doctors who participated in the intervention were more likely to wear sunscreen during the winter and were more accurate in counseling their patients on reapplication of sunscreen. Although statistically insignificant, post-intervention doctors trended towards being more comfortable providing information on sun protection and higher frequency of counseling their patients on sun exposure, sun protection, and tanning bed use. Based on our study results we conclude that primary care physicians need to be educated on how to provide better sun-protection counseling. Interventions such as lectures and emails may be helpful, but future studies with higher power are needed to further investigate these interventions

Neutrophilic dermatosis of the dorsal hands

We report a case of a 78-year-old white gentleman who presented with a three to four week history of lesions on the dorsal aspect of his bilateral hands. The areas were associated with edema, pruritus and pain. Physical exam revealed edematous hemorrhagic plaques with focal areas of ulceration, predominantly on bilateral dorsal hands. Punch biopsy of a plaque on his left dorsal hand showed a diffuse neutrophilic infiltrate with areas of leukocytoclasis. In addition, there was hemorrhage and endothelial swelling with neutrophils noted within vessel walls. Tissue culture was obtained with a negative gram stain. Fungal culture was also negative and acid-fast bacilli were not present. The patient was treated with prednisone 80 mg daily, approximately 1 mg/kg with substantial improvement in edema, pruritus and pain. Neutrophilic dermatosis of the dorsal hands (NDDH) is a rare, localized variant of Sweet\u27s syndrome first described in 1996. This condition has been observed in patients with myelodysplasia, leukemia, inflammatory bowel disease, sarcoidosis, lymphoma and hepatitis C. Presentation of this condition varies greatly including, but not limited to, violaceous edematous or ulcerated plaques with bullous or hemorrhagic lesions also being described. Fever, neutrophilic leukocytosis and elevated sedimentation rate have been reported in one-third of patients. Treatment is similar to Sweet\u27s syndrome with first line therapy considered to be systemic corticosteroids. Dapsone, colchicine, azathioprine, tetracyclines, and cyclosporine have also been reported as treatment options

Pseudoverrucous papules and nodules in the setting of a chronically draining abscess

We report a case of a 48-year-old African American male with a history of poorly controlled diabetes and hypertension was admitted to the hospital for a chronically draining left mid back paraspinal abscess for over one year. He had a history of recurrent abscesses on different areas of his skin, however the one on his left back had been persistent. On physical exam, on the mid back to the left of midline there was a collection of verrucous, keloidal papules and nodules coalescent into a large irregularly shaped plaque with surrounding erythema, tenderness and fluctuance. Punch biopsies of the exophytic nodules showed acanthosis, hyperkeratosis, papillomatosis, fibrotic dermis with increased vessels, and sparse lymphoid inflammation. These histologic findings were consistent with the diagnosis of pseudoverrucous papules and nodules (PPN). After failing multiple oral antibiotics, per the Infectious Disease team the patient was treated with IV daptomycin and the goal was to keep the skin clean and dry. PPN has been commonly described in the perianal or peristomal region in children or adults with chronic urinary and/or fecal incontinence for multiple reasons. It was first noted around urostomy sites. In all cases of PPN, prolonged wetness seems to be the key factor. It has been proposed that Jacquet erosive diaper dermatitis and granuloma gluteal infantum/adultorum are a spectrum of disease with PPN. The most important factor in treating PPN is removing the irritant. Zinc oxide creams can restore the barrier function of the skin and topical steroids decrease inflammation