Laman, Susan D.

Background: Cutaneous calciphylaxis is a rare disorder that occurs most frequently in patients with end-stage renal disease (ESRD), those on hemodialysis, and renal transplant recipients. It is frequently associated with hyperparathyroidism and a markedly elevated calcium–phosphate product, and it carries a high mortality rate. The usual clinical presentation is of painful, stellate necrosis of the thighs or buttocks, often in the setting of livedo reticularis. Death usually results from septicemia. Objective: This report documents an unusual case of recurrent, self-limiting calciphylaxis in the setting of a patient with ESRD and discusses the clinical and pathologic features of this potentially very fatal disorder. Methods and Remits: A 52-year-old woman presented with a greater than one-year history of relapsing and remitting, exquisitely painful, necrotic, numular plaques on the abdomen, breast, and arm. This patient had a markedly elevated calcium–phosphate product and parathyroid hormone level. The diagnosis of calciphylaxis was made by wedge biopsy of the most recent plaque, revealing calcification of medium-sized subcutaneous vessels and lobular capillaries with associated epidermal necrosis. Conclusions: This case demonstrates an unusual clinical variant of calciphylaxis that presented without the characteristic stellate necrosis or livedo reticularis that normally marks this condition and spontaneous resolution without incurring septicemia. Regardless of morphology, calciphylaxis should be considered in the differential diagnosis of painful, necrotic lesions occurring in the setting of ESRD.

AbstractBackgroundDiagnosis of suspected basal cell carcinoma (BCC) is typically confirmed with incisional biopsy before referral to final surgery.ObjectiveTo investigate the clinical confidence and accuracy of physicians making a diagnosis of BCC based on dermoscopic and reflectance confocal microscopy (RCM) features.MethodsThis study was designed as a simulation to determine the certainty and willingness to refer to surgery without previous biopsy confirmation of BCC. Study subjects were identified with suspected BCC. Dermoscopic and RCM lesion images were obtained before biopsy. Eight clinicians with various expertise levels blindly interpreted these images and chose among four hypothetical treatment options: definite BCC, refer directly to surgery without biopsy; other malignancy, perform biopsy for diagnosis; uncertain diagnosis, perform biopsy; benign, do not biopsy. Decisions for treatment were based on dermoscopic images alone and, subsequently, on dermoscopic and RCM images combined.ResultsThe sensitivity for referral to surgery without biopsy was 67.6% with the use of dermoscopy; the positive predictive value (PPV) was 97.0%. Adding RCM increased the sensitivity to 76.5% and the PPV to 98.6%.ConclusionsDermoscopy provides a high PPV for BCC. The addition of RCM to dermoscopy increases diagnostic sensitivity, particularly in less experienced dermoscopists. Physician behavior might be different if actual referrals were made for surgery without biopsy.

AbstractBackgroundPrevention of skin cancer includes early diagnosis and photoprotection, such as by physician‐performed total skin examination (TSE) and patient‐performed self‐skin examination (SSE). Hypothesizing that 90% of our patients receive an annual TSE, photoprotection counseling, and SSE instruction, we assessed the extent to which this was documented in patients' records. We also sought to identify differences in documentation of TSE, photoprotection counseling, and instruction on SSE with or without use of a dictation template prompting documentation.Materials and methodsRetrospective review of a random sample of 400 patients in an outpatient dermatology practice of a tertiary care academic medical center for any dermatology appointment between May 1 and July 31, 2007. Exclusion criteria included refusal to undergo TSE, lack of access to skin (e.g. wheelchair‐bound or in cast), or inappropriate visit type (e.g. for acne, psoriasis, or lupus).ResultsOf 400 randomly selected patients, 313 met inclusion criteria. The dictation template was used in 133; of these, 89% (119/133) had documentation in their clinical note of a TSE (exclusive of the buttocks or groin area), and 98% (130/133) had documentation of instruction on sun protection and SSE. Without use of the dictation template, these percentages dropped to 78% (140/180) and 20% (36/180), respectively. Physicians using a dictation template were more likely to document having conducted a TSE and instructed patients on photoprotection and SSE.ConclusionsA dictation template aids documentation of annual TSE and patient education efforts on photoprotection and SSE.