We report the first case of cutaneous inoculation of atypical Mycobacteria secondary to tattooing. The diagnosis of atypical Mycobacteria infection of the skin was confirmed on the basis of the clinical and histologic appearance, the detection of acid-fast bacilli on Ziehl-Neelsen stain, and positive polymerase chain reaction. The medical complications of tattooing, which are manifold, are briefly summarized. This case emphasizes the need for federal regulation of tattooing, which is an invasive procedures associated with infectious and noninfectious complications.

Iconography : A tattooed butterfly as a vector of atypical Mycobacteria

BACKGROUND
On April 29, 2015, the Florida Department of Health in Miami-Dade County (DOH-Miami-Dade) was notified by a local dermatologist of three patients with suspect nontuberculous mycobacterial (NTM) infection after receiving tattoos at a local tattoo studio.


METHODS
DOH-Miami-Dade conducted interviews and offered testing, described below, to tattoo studio clients reporting rashes. Culture of clinical isolates and identification were performed at the Florida Bureau of Public Health Laboratories (BPHL). Characterization of NTM was performed by the Centers for Disease Control and Prevention (CDC) and the United States Food and Drug Administration (FDA), respectively. Whole-genome sequencing (WGS) and single-nucleotide polymorphism (SNP) analyses were used to construct a phylogeny among 21 Mycobacterium isolates at FDA.


RESULTS
Thirty-eight of 226 interviewed clients were identified as outbreak-associated cases. Multivariate logistic regression revealed individuals who reported grey tattoo ink in their tattoos were 8.2 times as likely to report a rash [95% CI: 3.07-22.13]. Multiple NTM species were identified in clinical and environmental specimens. Phylogenetic results from environmental samples and skin biopsies indicated that two M. fortuitum isolates (greywash ink and a skin biopsy) and 11 M. abscessus isolates (five from the implicated bottle of greywash tattoo ink, two from tap water, and four from skin biopsies) were indistinguishable. In addition, M. chelonae was isolated from five unopened bottles of greywash ink provided by two other tattoo studios in Miami-Dade County.


CONCLUSIONS
WGS and SNP analyses identified the tap water and the bottle of greywash tattoo ink as the sources of the NTM infections.

Outbreak of Tattoo-Associated Nontuberculous Mycobacterial Skin Infections—Miami, Florida, 2015

Sustained reduction in no-show rate with the integration of teledermatology in a Federally Qualified Health Center.

Accessibility of direct-to-consumer teledermatology to underserved populations.

To the Editor: We read with interest the letters by Korman and Fabbro1Korman A.M. Fabbro S.K. Direct-to-consumer pharmaceutical services in dermatology: ethical implications.J Am Acad Dermatol. 2021; 85: 1067-1068https://doi.org/10.1016/j.jaad.2021.02.059Google Scholar and Ranpariya and Lipoff2Ranpariya V.K. Lipoff J.B. Direct-to-consumer teledermatology platforms may have inherent conflicts of interest.J Am Acad Dermatol. 2021; 85: e259-e260https://doi.org/10.1016/j.jaad.2021.04.102Google Scholar outlining issues related to the expansion of direct-to-consumer (DTC) teledermatology. DTC applications advertise readily accessible dermatologic care via the internet that bypasses the need for a pre-existing physician-patient relationship. As discussed, significant concerns exist, including conflict of interest, treatment by nondermatologists, and prescription of medication absent a thorough history.1Korman A.M. Fabbro S.K. Direct-to-consumer pharmaceutical services in dermatology: ethical implications.J Am Acad Dermatol. 2021; 85: 1067-1068https://doi.org/10.1016/j.jaad.2021.02.059Google Scholar,2Ranpariya V.K. Lipoff J.B. Direct-to-consumer teledermatology platforms may have inherent conflicts of interest.J Am Acad Dermatol. 2021; 85: e259-e260https://doi.org/10.1016/j.jaad.2021.04.102Google Scholar Such deficiencies are countered by the presumption that these services provide increased access to care. Here we examine if the features of popular DTC teledermatology platforms are structured to accommodate underserved populations. Google queries were performed using the key words “best telemedicine platform dermatology” and “online dermatology appointment.” Fourteen DTC websites were identified from the top hits displaying lists of teledermatology applications. Of these, 4 (28%) provided the option of a non-English language interface. Spanish was available on 2 platforms, and no Asian languages were offered on any application. All sites required email registration and used store-and-forward photography as the primary diagnostic modality. Six (43%) services accepted commercial insurance and 2 (14%) also accepted Medicaid. On many sites, the follow-up arrangement in the event of worsening or insufficient improvement was not clearly defined (Table I). A limitation of this study is that the websites evaluated do not constitute a comprehensive list of DTC teledermatology platforms but rather represent the most likely services to be encountered upon an internet search.Table IFeatures of direct-to-consumer teledermatology platforms∗Sources: https://www.verywellhealth.com/best-online-dermatologists-5095650; https://www.onlinedoctor.com/best-online-dermatologists/; https://www.byrdie.com/best-online-dermatologists-5113094; and https://www.healthline.com/health/dermatology-telemedicine-best-websitesPlatformWebsite language optionsRegistration and email requirementInsurance acceptanceFollow-up arrangementFirst DermEnglish, European Spanish, Norwegian, German, SwedishYesNoneUnknownDermatologist On CallEnglishYesNoneWithin 30 days of initial visitApostropheEnglishYesNoneUnknownSKYMDEnglishYesCommercial, Medicare, MedicaidWithin 7 days of initial visitDirectDermEnglish†According to the website, patients are to call for Spanish instructions.YesCommercial, MedicareFollow-up question acceptedTeladocEnglish, Canadian French, Canadian EnglishYesCommercial, Medicare, MedicaidVaries depending on the provideriDoc24‡Powered by First Derm.English, European Spanish, Swedish, French, ItalianYesNoneUnknownDermUtopiaEnglishYesNoneUnknownSnapMedEnglish, Norwegian, SwedishYesNoneUnknownMandelEnglishYesRegistration required to determine if the plan is acceptedYesPlushCareEnglishYesCommercial insuranceUnknownMD Live§Powered by Dermatologist On Call.EnglishYesRegistration required to determine if the plan is acceptedUnknownTibotEnglishYesFree to use artificial intelligence service, unknown insurance acceptanceNot includedOnline Skin SpecialistEnglishYesNoneWithin 7 days of initial visit∗ Sources: https://www.verywellhealth.com/best-online-dermatologists-5095650; https://www.onlinedoctor.com/best-online-dermatologists/; https://www.byrdie.com/best-online-dermatologists-5113094; and https://www.healthline.com/health/dermatology-telemedicine-best-websites† According to the website, patients are to call for Spanish instructions.‡ Powered by First Derm.§ Powered by Dermatologist On Call. Open table in a new tab One of the largest medically underserved populations in the United States is the Hispanic/Latino community, comprising over 60 million residents.3Profile Hispanic/Latino Americans. U.S. Department of Health and Human Services.https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=64Date accessed: August 10, 2021Google Scholar Among this group, 28.4% report limited English proficiency, a well-understood barrier to access.3Profile Hispanic/Latino Americans. U.S. Department of Health and Human Services.https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=64Date accessed: August 10, 2021Google Scholar Surprisingly, only 2 sites offered a Spanish language interface, and both were based in Europe and restricted from prescribing in the United States. In addition to language, nonnative speakers, minority groups, and low-income populations are less likely to activate and use a patient portal, suggesting that technological demands are an issue as well.4Cline A. Kim C. Berk-Krauss J. et al.Bridging the digital divide: the use of text message-enabled video in the public safety-net setting.J Am Acad Dermatol. 2021; 85: e97-e99https://doi.org/10.1016/j.jaad.2021.03.085Google Scholar All DTC sites required registration via email for privacy protection, and none mentioned the availability of any simplified or alternative methods of engagement. Underserved populations are more commonly underinsured or recipients of coverage through government programs. However, only 2 websites mentioned Medicaid acceptance. None described a sliding scale or other cost-saving measures. Additionally, the anonymity and limited-to-ambiguous follow-up associated with these services may be less useful in populations typically distinguished by a high prevalence of chronic health conditions, comorbidities, and confounding socioeconomic issues. Although a consumer profile of DTC teledermatology has yet to emerge, the analysis of an analogous DTC platform offering primary care found that users tended to be young, live in affluent urban communities and prefer to access care off-hours.5Jain T. Mehrotra A. Comparison of direct-to-consumer telemedicine visits with primary care visits.JAMA Netw Open. 2020; 3: e2028392https://doi.org/10.1001/jamanetworkopen.2020.28392Google Scholar Despite marketing a more egalitarian approach, DTC teledermatology, as currently structured, does not appear to mitigate well-known barriers to access such as language, digital literacy, and insurance acceptance. English-speaking, technologically savvy patients with less complex dermatological complaints are likely to find these services more attractive. Outcome measures such as user demographics, clinical improvement, and patient satisfaction are needed to truly understand the utility of DTC teledermatology in diverse populations. None disclosed. Direct-to-consumer pharmaceutical services in dermatology: Ethical implicationsJournal of the American Academy of DermatologyVol. 85Issue 4PreviewDear Dermatologist: Direct-to-consumer (DTC) teledermatology companies that facilitate electronic consultations between physicians and patients are expanding. DTC companies advertise on social media, promoting dermatologic treatments such as finasteride, spironolactone, and oral contraceptives. Many problems exist, such as issues with confirming patient identity, ascertaining the medical history of patients, prescription of non-evidence-based therapies, and providing inadequate counseling on the adverse effects of medications. Full-Text PDF Direct-to-consumer teledermatology platforms may have inherent conflicts of interestJournal of the American Academy of DermatologyVol. 85Issue 4PreviewTo the Editor: We read with interest Korman and Fabbro's research letter describing ethical concerns regarding direct-to-consumer (DTC) teledermatology companies identifying a financial conflict of interest that may exist for dermatologists working with these platforms.1 It is important to examine and characterize DTC teledermatology companies' structures to fully understand any potential conflicts. Full-Text PDF Reply to: “Accessibility of direct-to-consumer teledermatology to underserved populations”Journal of the American Academy of DermatologyVol. 86Issue 3PreviewTo the Editor: We appreciate the interest of Gao et al1 in our paper in which we discussed ethical issues that dermatologists may confront with the expansion of direct-to-consumer (DTC) teledermatology companies. Full-Text PDF 

http://www.jaad.org/article/S0190962221027274/pdf

Accessibility of direct-to-consumer teledermatology to underserved populations

Primary cutaneous lymphomas are a rare group of diseases, with an estimated incidence of 0.5-1 case per 100,000 people per year. Primary cutaneous B-cell lymphomas (pCBCLs) represent 25-30% of all primary cutaneous lymphomas. There are three main subtypes of pCBCL: primary cutaneous marginal zone lymphoma, primary cutaneous follicle center lymphoma, and primary cutaneous diffuse large B-cell lymphoma, leg type. Cutaneous B-cell lymphomas have a broad spectrum of clinical presentations, which makes diagnostic and therapeutic strategies challenging. To date, treatment recommendations for cutaneous B-cell lymphomas have been largely based on small retrospective studies and institutional experience. Recently, the pharmacotherapeutic landscape has expanded to include drugs that may modify the underlying disease pathology of pCBCLs, representing new therapeutic modalities for this rare group of diseases. Novel therapies used for other systemic B-cell lymphomas show promise for the treatment of pCBCLs and are being increasingly considered. These new therapies are divided into five main groups: monoclonal antibodies, immune checkpoint inhibitors, small-molecule inhibitors, bispecific T-cell engaging, and chimeric antigen receptor T cell. In this review, we discuss the clinical, histopathological, molecular, and cytogenetic features of the most common pCBCL subtypes with a focus on current and innovative therapeutic developments in their management. These emerging treatment strategies for B-cell lymphomas and cutaneous B-cell lymphomas may represent novel first-line options for the management of these rare diseases. 

/pdf/update-in-diagnosis-and-management-of-primary-cutaneous-b-1ll52i4r.pdf

Update in Diagnosis and Management of Primary Cutaneous B-Cell Lymphomas

Bridging the digital divide: The use of text message-enabled video in the public safety-net setting.

/pdf/pruritic-papulonodules-following-tattoo-application-12jexqucur.pdf

Pruritic Papulonodules Following Tattoo Application

/pdf/multiple-nontender-subcutaneous-nodules-on-the-finger-4qlaqaekij.pdf

Multiple nontender subcutaneous nodules on the finger.

Rosacea granulomatosis is a common, chronic skin disorder that primarily affects the central face, namely the cheek, nose, chin, and central forehead. Although rosacea is mainly a disorder of innate and adaptive immunity, a variety of endogenous and exogenous triggers such as Demodex may stimulate it. Often found as commensal organisms in human skin, Demodex can be parasitic if there is a change in the host’s cutaneous environment. This is especially relevant for immunosuppressed patients, who need prompt treatment to prevent further complications. We review the literature regarding rosacea granulomatosis in immunosuppression and present an acute myelogenous leukemia patient with severe neutropenia, which may have promoted the development of rosacea due to Demodex mite proliferation. This local proliferation of the ectoparasite on the face can cause an atypical skin rash that mimics severe infections in the setting of neutropenia.

/pdf/rosacea-granulomatosis-in-a-neutropenic-leukemic-patient-23ob0bo0.pdf

Carlos J. Sarriera-Lazaro

Papers

Update in Diagnosis and Management of Primary Cutaneous B-Cell Lymphomas

Bridging the digital divide: The use of text message-enabled video in the public safety-net setting.

Pruritic Papulonodules Following Tattoo Application

Multiple nontender subcutaneous nodules on the finger.

Rosacea Granulomatosis in a Neutropenic Leukemic Patient