No abstract

The sensitivity, specificity, and positive and negative likelihood ratios were 57.7%, 72.3%, 2.08, and 0.59, respectively. (ROC curves were not plotted for case patients aged 2 years or younger because of the small numbers.)There was significant correlation of serum TARC levels with the SCORAD index (r ¼ 0.538; 95% confidence interval [CI], 0.36-0.68), QOL indices (Infants' Dermatitis QOL: r ¼ 0.823; 95% CI, 0.40-0.96; Children's Dermatology Life Quality Index: r ¼ .380; 95% CI, 0.16-0.57), peripheral eosinophils, and LDH in children older than 2 years but not in the younger age groups (Table II). The correlation with IgE was not significant. In the same age group, for SCORAD index, the correlation was highest with LDH (r ¼ 0.582; 95% CI, 0.40-0.72), followed by serum TARC (r ¼ 0.538; 95% CI, 0.36-0.68), peripheral eosinophils (r ¼ 0.397; 95% CI, 0.19-0.57), and serum IgE (r ¼ 0.331; 95% CI, 0.11-0.52). In concurrence with previous studies, our results suggest that TARC correlates with the severity of AD and QOL indices. 1,5 The sensitivity and specificity were lower than those previously reported (83%-85% and 92%-96%, respectively), possibly due to choosing control individuals with diseases mimicking AD and the use of different enzyme-linked immunosorbent assay systems. 2,4

Fig 1. Skin manifestations of atopic dermatitis on the patient's trunk (A) and alopecia areata on his head (B) at his first visit to our hospital (two months before receiving dupilumab), and 3 months after starting dupilumab treatment (C, D).

A review of PHTS in children showed that dermatological features were reported in 31 of 47 patients. 2 Tan et al. 3 have proposed a clinical scoring system to guide germline PTEN mutation testing in children: macrocephaly and at least one additional criterion such as dermatologic features are required. Therefore, recognizing cutaneous features may be decisive for the diagnosis of PHTS in children. Three of the four patients reported herein had painless, translucent, dome-shaped, skin-coloured, slightly supra-millimetric palmoplantar papules, with a central depression. In our institution, most of the patients with PHTS, including adults not reported herein, have such papules. Except for one, none had more than three such lesions (D. Lipsker, personal observation). Moreover, we have so far not observed such palmoplantar papules in patients without suspected or proven PHTS. Acral cutaneous features have been rarely reported with PHTS in children: acral neuromas are also dome-shaped translucent papules, possibly localized on the palmar surface, but they are usually numerous and painful. 4,5 Acral keratoses have been rarely reported in children: they were numerous, keratotic and usually located on the dorsal aspect of hands and feet. 3,6 Starink et al. 7 reported that up to 91% of 21 patients with CS had multiple translucent palmoplantar keratoses but there was only one paediatric patient. The series of four patients reported herein emphasizes the importance of a careful examination of the entire skin and mucosa since dermatological features may prompt PTEN sequencing in children. We particularly highlight translucent palmoplantar papule as a specific feature of PHTS.

of dermatologist-dermatopathologists, which to our knowledge have not been assessable with past survey studies. 5,6 Of note, most dermatologist-dermatopathologists billing for dermatopathology services also continued to provide officebased and/or outpatient care. The practice mix of dermatologistdermatopathologists in the western US showed a greater proportion of outpatient visits than in other regions. Regional variation in the practice mix for pathology and EM services may be associated with the density of dermatopathologists and characteristics of the regional patient population (including regional differences in Medicare coverage rates), among other health care market factors; however, an evaluation of these factors was beyond the scope of this study. Of note, billing trends were stable during the observation period, suggesting the presence of a specific population of dual-trained physicians.Several limitations may affect the generalizability of these findings. The data set prevented the study of dermatopathologists not trained in dermatology, whose geographic distribution and pathology billing patterns may differ from those of dermatologist-dermatopathologists. Also, this analysis was limited to dermatologist-dermatopathologists who billed Medicare independently. Their practice patterns may differ from those reimbursed by other means. In addition, we may not have completely captured the billing patterns of physicians who may also have been employed by group pathology practices. Although our investigation focused on a narrow subset of the dermatology and dermatopathology workforce, it is, to our knowledge, the only study that has examined the dermatopathology billing patterns in the past decade.Further work is needed to understand the heterogeneity in dermatopathologist billing patterns and the degree to which dual-trained dermatologist-dermatopathologists practice both specialties. Our findings may be used as a baseline from which to study the effects of future changes in reimbursement and dermatopathology training on the dermatologist-dermatopathologist workforce.