The Dermatology Online Journal (DOJ) is an internationally renowned, PubMed-indexed, peer-reviewed, open-access journal dedicated to sharing high-quality dermatology research and clinical insights. Founded in 1995 as the first online open-access medical journal, DOJ has been indexed in PubMed for decades and is read by researchers, clinicians, and healthcare stakeholders worldwide. DOJ publishes original research, reviews, case reports, and educational content that catalyze innovation and advance the practice and science of dermatology. Its publications are widely cited and contribute meaningfully to the global dermatologic evidence base. The journal is led by Editor-in-Chief Dr April Armstrong and Deputy Editor Dr Nicholas Brownstone, both globally recognized dermatologists and clinical researchers. Guided by an expert Editorial Board of board-certified dermatologists, the journal is committed to the rapid, accessible dissemination of trustworthy dermatologic scholarship that advances knowledge and improves patient care. DOJ was founded by Dr Arthur C. Huntley, whose vision helped establish the journal as a pioneering platform for online dermatologic publishing. The journal was later expertly stewarded for many years by former Editor-in-Chief Dr Barbara A. Burrall, whose leadership helped shape its longstanding reputation for rigor, accessibility, and innovation in dermatology scholarship. Archives of issues published prior to June 2025 are available on eScholarship. Editor-in-chief: April W. Armstrong, MD MPH, University of California Los Angeles, Los Angeles, CA Deputy Editor: Nicholas Brownstone, MD, The Kimberly and Eric J. Waldman Department of Dermatology, Mount Sinai Health System, New York, NY Managing Editor: Lauren DeBusk, MD, UT Southwestern Medical Center, Dallas, TX
Surgical site infection with Mycobacterium fortuitum following Mohs micrographic surgery in an immunocompromised patient and review
Mycobacterium fortuitum (M. fortuitum) is a rare infection typically occurring in immunocompromised patients and in healthcare settings, primarily after surgery or exposure to contaminated medical equipment or tap water. A few cases have been reported following cutaneous procedures, including acupuncture, mesotherapy, and tattooing, although no report, to our knowledge, has been described after Mohs micrographic surgery (MMS). Treatment typically requires at least 2 oral antibiotics for several months owing to the persistent nature of the infection. We present a patient who had previously undergone MMS with bilobed flap and developed infection with M. fortuitum, treated with moxifloxacin 400 mg daily and trimethoprim-sulfamethoxazole 400 mg/80 mg daily.
Copyright (c) 2026 David X. Gao, Natalia E. Plotnikova (Author) https://creativecommons.org/licenses/by/4.0
Pellagra associated with iron deficiency
Copyright (c) 2026 Jonathan Young, Alison Bonello Boffa, Daniel Micallef, Michael Boffa (Author) https://creativecommons.org/licenses/by/4.0
Demodicosis: A frequently underrecognized cause of recalcitrant ear pruritus
Copyright (c) 2026 Ayse Serap Karadag, Gulfem Unsal (Author) https://creativecommons.org/licenses/by/4.0
Association of alopecia areata with COVID-19 vaccination: A vaccine adverse events reporting system analysis
Copyright (c) 2026 Aarushi Parikh, Shari Lipner (Author) https://creativecommons.org/licenses/by/4.0
Gender based price differences in 5% minoxidil foam: The impact of generic alternatives and bulk packaging
Copyright (c) 2026 Lauren McGrath, Steven Feldman (Author) https://creativecommons.org/licenses/by/4.0
Retrospective analysis of filler complications reported in the manufacturer and user facility device experience database from 2015 to 2025
Copyright (c) 2026 Priyanka Kadam, Shari Lipner (Author) https://creativecommons.org/licenses/by/4.0
Characterizing barriers to care in patients with hidradenitis suppurativa
Copyright (c) 2026 Josiah Williams, Veronica Emmerich, Emily Moya, Anita Rong, Steven Feldman, Rita Pichardo (Author) https://creativecommons.org/licenses/by/4.0
Large cell acanthoma: A benign lesion masquerading as malignant melanoma
We present the case of a 54-year-old woman with a clinically suspected malignant melanoma. Histology, however, revealed the unexpected diagnosis of large cell acanthoma. This is a benign epidermal neoplasm that is poorly understood and underreported in the literature. The clinical and dermoscopic appearance in our patient differs from previously reported cases. We draw attention to this heterogeneous lesion and encourage further investigation into its classification and distinguishing features, which may ultimately inform optimal management for patients.
Copyright (c) 2026 Kalina Bridgewater, Laszlo Intzedy, Caroline Mills, Ausama Atwan (Author) https://creativecommons.org/licenses/by/4.0
A New World disease: Dual diagnostic challenges in travelers returning from Costa Rica
Cutaneous diseases in returning travelers encompass a wide spectrum of etiologies and often pose diagnostic challenges. We present the cases of a 50-year-old man and a 57-year-old woman who presented with a 3-month history of erythematous, ulcerated plaques with well-defined elevated borders and a necrotic center on the lower limbs that began 3 weeks after returning from vacation in Costa Rica. Cutaneous biopsy revealed epidermal ulceration and extensive caseating granulomas throughout the full thickness of the dermis. Giemsa staining revealed no amastigotes. Microbiological examinations identified Leishmania braziliensis and excluded mycobacteria and fungi. The diagnosis of cutaneous leishmaniasis was established. Owing to clinical severity and antimonial unavailability, the man was treated with liposomal amphotericin B. The woman underwent surgical excision of the single lesion, along with oral fluconazole. Complete resolution was documented in both patients. These cases, which posed diagnostic and therapeutic challenges, highlight that cutaneous leishmaniasis, in all its versatile and often perplexing presentations, is a parasitic infection that should always be considered in dermatologic patients returning from vacation in endemic countries.
Copyright (c) 2026 Cláudia Brazão, João Borges-Costa, Sofia Antunes-Duarte, Dora Mancha, Lanyu Sun, Tiago Marques, Maria João Gargaté, Anabela Vilares, Tânia Reis, Pedro de Vasconcelos, Luís Soares-de-Almeida, Paulo Filipe (Author) https://creativecommons.org/licenses/by/4.0
Aquagenic wrinkling of the palms in a healthy adolescent
Aquagenic wrinkling of the palms (AWP) is a rare dermatologic condition characterized by rapid wrinkling, edema, and papules on the palms after brief water exposure. It is commonly associated with cystic fibrosis (CF) or CF carrier status but can also occur in individuals without these conditions. We report a healthy 12-year-old girl who presented with AWP without a family history of CF or related symptoms. After 4 minutes of water immersion, she exhibited typical wrinkling and translucent papules on the palms, which resolved completely within 15 minutes. A sweat test for CF was negative. The patient was managed with moisturizers and advised to minimize prolonged water exposure. This case highlights AWP as a potential early marker for CF or carrier status, even in the absence of other symptoms. Recognition of AWP may guide genetic screening and early intervention, underscoring the role of dermatologists in identifying this condition and facilitating timely diagnosis and management of CF.
Copyright (c) 2026 César Bimbi, Amanda Nichele, João Pedro Locatelli Cezar, Camila Machado, André Anjos da Silva (Author) https://creativecommons.org/licenses/by/4.0
Patchy presentation of central centrifugal cicatricial alopecia
Central centrifugal cicatricial alopecia (CCCA) is a form of scarring alopecia typically characterized by progressive hair loss that begins at the crown or vertex of the scalp and expands circumferentially over time. Although most commonly described and diagnosed in women of African descent, CCCA can also occur in men. We describe the case of a 38-year-old man of African descent with a patchy presentation of CCCA. Unlike the classic distribution reported in the literature, this patient exhibited multifocal patchy areas of scarring hair loss. This case highlights the importance of considering CCCA in younger men presenting with atypical alopecia patterns to ensure accurate diagnosis and appropriate management.
central centrifugal cicatricial alopecia
Copyright (c) 2026 Ruhi Nayak, Alvaro Laga, Alicia Kenyon, Connie Shi (Author) https://creativecommons.org/licenses/by/4.0
A 34-year-old man from Guinea-Bissau presented with a rapidly growing tumor on his right foot over 6 months, arising from a long-standing pigmented papule present for more than 20 years. Clinical examination revealed an exophytic black tumor with ipsilateral inguinal lymphadenopathy. Histopathological analysis showed an epithelioid and fusiform melanocytic proliferation in the dermis with abundant melanin. Immunohistochemical staining demonstrated diffuse positivity for Sox-10, Melan-A, HMB45, and PRAME. A diagnosis of blue nevus–like melanoma (BNM) was confirmed. BRAF V600 mutation testing on a cutaneous metastasis was negative. Staging imaging revealed widespread metastases involving lymph nodes, brain, lungs, liver, stomach, duodenum, colon, adrenal glands, pancreas, gallbladder, and bones. Despite 4 cycles of ipilimumab/nivolumab immunotherapy, the disease progressed, and the patient died 4 months after diagnosis. BNM is a rare melanoma variant, often arising from a pre-existing blue nevus, with aggressive potential and frequent lymph node metastasis. The molecular heterogeneity of BNM and the limited therapeutic options underscore the need for further research into targeted therapies and prognostic biomarkers for this rare melanoma subtype.
Copyright (c) 2026 Lanyu Sun, Mafalda Pinho, Catarina Quadros, Diogo de Sousa, Inês Abreu, Gustavo Silva, Pedro de Vasconcelos, Luís Soares-de-Almeida, Paulo Filipe (Author) https://creativecommons.org/licenses/by/4.0
Childhood granulomatous periorificial dermatitis: Ivermectin as a novel therapeutic approach
We report the case of a 9-year-old boy with typical clinical and histopathologic features of childhood granulomatous periorificial dermatitis. Despite multiple previous treatment attempts, the condition persisted. The patient had a concurrent history of asthma and was receiving daily inhaled fluticasone therapy. Management was challenging, as the patient exhibited resistance to conventional treatments, possibly owing to the use of inhaled corticosteroids, where discontinuation is usually the first step. Therapy with topical and a single dose of oral ivermectin was employed successfully, likely owing to its anti-inflammatory and anti-parasitic effects on Demodex spp. To our knowledge, this is the first case of ivermectin use in this condition. Both topical and systemic ivermectin appear to be safe and efficacious therapeutic options.
Copyright (c) 2026 Madalena Pupo Correia, Sónia Fernandes, Pedro de Vasconcelos, Luís Soares-de-Almeida, Paulo Filipe (Author) https://creativecommons.org/licenses/by/4.0
Applicability of bilobed transposition flaps in extranasal locations
The bilobed flap is a local transposition flap originally described for the reconstruction of surgical defects of the nose. Its success and versatility are well recognized in this anatomical region; however, its use in extranasal reconstructions is less common. We present 5 clinical cases of extranasal applications of the bilobed flap that highlight its versatility across a wide range of anatomical sites. The locations include the hand (n = 1), foot (n = 1), ear and periauricular region (n = 1), chin (n = 1), and temporal region (n = 1). The surgical defects ranged from medium to large in size, with maximum diameters between 20 and 55 mm. All procedures were performed in a single session under local anesthesia, with no associated complications. All patients achieved good functional and aesthetic outcomes.
Copyright (c) 2026 Bárbara Vieira Granja, Carlos Marques (Author) https://creativecommons.org/licenses/by/4.0
Lupus erythematosus panniculitis in a 77-year-old woman
Lupus erythematosus panniculitis (LEP) is an uncommon variant of lupus erythematosus, characterized by subcutaneous indurated nodules or plaques that often heal with lipoatrophy or scarring. We report a 77-year-old woman who presented with a 4-month history of painful subcutaneous nodules and erythematous plaques. She had a history of discoid lupus erythematosus in her 30s, which was successfully managed with topical treatments and had since resolved. Deep incisional biopsy of a plaque on her back confirmed the diagnosis of LEP. The patient improved with treatment including methotrexate, folic acid, and prednisone. This case highlights a unique clinical presentation of LEP, both in terms of patient age and lesion distribution, and underscores the critical role of histopathology in excluding subcutaneous panniculitis–like T-cell lymphoma.
Copyright (c) 2026 Allison Bai, Erika Elliott, Gabriela Cobos (Author) https://creativecommons.org/licenses/by/4.0
Verrucous keratotic melanoma: A misleading form of recurrence
Verrucous keratotic melanoma (VKM) is a rare variant, accounting for approximately 3% of melanomas. Its deceptive clinical presentation, often mimicking benign lesions such as warts or seborrheic keratoses, contributes to frequent misdiagnoses and delayed management. We report the case of an 84-year-old woman with a history of nodular melanoma of the left foot, presenting with recurrent keratotic verrucous lesions at the site of prior surgical excision. Histopathological analysis confirmed VKM with a Breslow thickness of 2 mm and Clark level III. No metastases were detected on positron emission tomography. This case underscores the plasticity of melanoma, which can recur in atypical forms, and highlights the importance of considering VKM in the differential diagnosis of hyperkeratotic lesions. Early recognition and surgical excision are critical to optimizing patient outcomes and reducing the risk of systemic dissemination. Increased awareness of VKM characteristics may improve diagnostic accuracy and management.
Copyright (c) 2026 Firdaouss Boukamza, Ouiame El Jouari, Aicha Mai, Mouna Rimani, Salim Gallouj (Author) https://creativecommons.org/licenses/by/4.0
Disguised discoloration: Minocycline-induced pigmented cardiac valves
Tetracyclines are used for a variety of dermatologic conditions, and a known side effect of this therapy is hyperpigmentation in multiple tissues throughout the body. We present the case of a 66-year-old man who underwent aortic valve replacement and was found to have discoloration of the aortic valve leaflets associated with his chronic use of minocycline for rosacea. Minocycline-induced pigmentation of cardiac valves is a documented, although uncommon, phenomenon. There is no evidence linking valve pigmentation to functional valve defects. This case highlights an infrequent manifestation of minocycline-induced pigmentation.
Copyright (c) 2026 Natasha Salmen, Taylor Pong, Sabrina Bennett, Deborah Cook, Joseph Pierson (Author) https://creativecommons.org/licenses/by/4.0
Severe exposure keratopathy secondary to oncologic surgery in a patient with epidermodysplasia verruciformis
The case of a 43-year-old woman who presented with multiple exophytic lesions on both eyelids of the left eye is described. The patient underwent excisional biopsy of the lesions, and later 2 more interventions were necessary for the excision of the affected margins. She was followed by dermatology and medical oncology specialists, as she presented several skin tumors in other locations. Two years after the intervention, she developed a lower corneal abscess in the left eye, with cultures positive for Candida spp. Approximately 12 months later, the infection had completely resolved, leaving a leukoma with both superficial and deep vascularization in the lower cornea. Lagophthalmos was observed along with a predominantly lateral cicatricial ectropion of the lower eyelid, accompanied by increased corneal vascularization, lipoid degeneration, and greater central opacity. The patient underwent cauterization of the superficial vessels and intrastromal bevacizumab injection into the deep vessels and has now been offered penetrating keratoplasty. Epidermodysplasia verruciformis is a rare skin condition characterized by the development of squamous cell carcinomas and flat warts. When these lesions involve the eyelid, close communication between dermatologists, corneologists, and oculoplastic surgeons is essential for optimal management of these patients.
Copyright (c) 2026 Albert Arnaiz-Camacho, Javier Puig-Galy, Sara Martín-Nalda, Laia Bisbe-López, Alfredo Pueyo-Ferrer, Yann Bertolani, Sara García-Hidalgo, Tatiana Pablos-Jiménez, Armand Pairó-Salvador, Miguel-Ángel Zapata (Author) https://creativecommons.org/licenses/by/4.0
New-onset erythrodermic psoriasis associated with antiepileptic drug use
Erythrodermic psoriasis is a severe and potentially life-threatening dermatologic condition that can be triggered or unmasked by medications. We report the case of a 73-year-old patient who developed new-onset erythrodermic psoriasis following treatment with antiepileptic drugs (AEDs), specifically carbamazepine and levetiracetam, for autoimmune encephalitis. Despite discontinuation of the AEDs, the patient’s condition persisted and improved only after systemic biological therapy. Clinical presentation, together with histopathologic findings, supported a diagnosis of new-onset psoriasis rather than a drug-induced psoriasiform reaction. This case highlights the importance of recognizing AEDs as potential triggers for psoriasis in patients with no prior history. Given the severe complications associated with erythroderma, timely diagnosis and initiation of appropriate therapy are essential. Clinicians should maintain a high index of suspicion for medication-induced dermatologic conditions in patients presenting with new or progressive skin eruptions.
Copyright (c) 2026 James Feng, Payal Shah, Jeffrey Cloutier, Jonathan Glass, Dorothea Barton (Author) https://creativecommons.org/licenses/by/4.0
Common cutaneous signs unmasking a severe hematological disorder: GATA2 deficiency
GATA2 deficiency is a rare genetic disorder with heterogeneous clinical manifestations affecting the immune, hematologic, and vascular systems. We report the case of a 31-year-old woman with primary lymphedema progressing since childhood, associated with diffuse treatment-resistant warts and severe monocytopenia. Genetic testing revealed a mutation in the GATA2 gene (c.1078T>C), resulting in complete loss of protein function. The patient also exhibited leukopenia and anemia, and bone marrow evaluation confirmed progression to acute myeloid leukemia. The immune deficiencies caused by this mutation explain the increased susceptibility to recurrent infections, particularly persistent human papillomavirus infections responsible for the extensive warts in this patient. The frequent progression to myelodysplastic syndromes and leukemia underscores the severity of this condition and the importance of early diagnosis. Management requires close monitoring, with hematopoietic stem cell transplantation representing the only curative option to improve prognosis and prevent progression to life-threatening complications. This case highlights the need for prompt identification of GATA2 mutations in patients with suggestive clinical features to optimize surveillance and treatment.
Copyright (c) 2026 Firdaouss Boukamza, Ouiame El Jouari, Farah Hacht, Afaf Lamzouri, Salim Gallouj (Author) https://creativecommons.org/licenses/by/4.0
Periungual palisaded encapsulated neuroma in skin of color
Palisaded encapsulated neuroma (PEN) is a nerve sheath tumor most commonly found on the face. These benign tumors are less commonly reported in skin of color and may be confused with other forms of nerve sheath tumors. Detection of the distinctive histopathologic features of PEN and recognition of its various subtypes are key to an accurate diagnosis. We report a 68-year-old Black man with a pink to skin-colored papule on the right second fingertip of 6- to 12-month duration. We describe the clinical and pathologic diagnosis of PEN and discuss the differential diagnosis. This case highlights the importance of maintaining a broad differential when managing and treating neoplasms of the nail unit, including rare or uncommon diagnoses.
Copyright (c) 2026 Christina Pierce, Federico Galar, Joshua Owen (Author) https://creativecommons.org/licenses/by/4.0
Multibacillary leprosy relapse presenting as hypopigmented patches and concurrent erythema nodosum leprosum after initial multidrug therapy
Leprosy is a chronic granulomatous disease of the skin, peripheral nerves, and mucosal membranes caused by Mycobacterium leprae. Although curable with multidrug therapy (MDT), relapse, reinfection, or immunologic reactions can occur. Leprosy reactions are abnormal immune responses ranging from type IV hypersensitivity to immune-complex–mediated phenomena, such as erythema nodosum leprosum (ENL). We report a 23-year-old man who completed MDT for multibacillary leprosy 1 year prior and presented with a 2-week history of tender, erythematous subcutaneous nodules, systemic symptoms, and pre-existing hypopigmented patches. Imaging revealed lymphadenopathy and splenomegaly, suggesting systemic inflammation. Biopsies showed granulomatous collections of epithelioid to foamy histiocytes centered on dermal nerve bundles and adnexal structures, with focal early vasculitic changes and scattered neutrophils. Fite-Faraco staining demonstrated numerous weakly acid-fast bacilli. These findings were consistent with leprosy relapse and concurrent ENL. Treatment was initiated with monthly rifampin, moxifloxacin, and minocycline (RMM), alongside methotrexate and prednisone. This case highlights an unusual presentation of leprosy relapse with concurrent ENL following completion of MDT. Ongoing surveillance and follow-up are essential to monitor for relapse, reinfection, and reactions, particularly in high-risk patients.
Copyright (c) 2026 Mildred Min, Yasmin Khalfe, Yve Huttenbach, Vicky Ren (Author) https://creativecommons.org/licenses/by/4.0
Scalp cooling and chemotherapy-induced alopecia: Evaluating cost-effectiveness and insurance coverage
Chemotherapy-induced alopecia (CIA) substantially affects patients’ quality of life. Scalp cooling, or cold capping, reduces chemotherapy uptake in hair follicles and can help preserve hair, but insurance coverage remains inconsistent, limiting access. We conducted a cost-effectiveness analysis from a payer perspective comparing scalp cooling with 2 dermatologic management strategies for CIA. The incremental cost-effectiveness ratio (ICER) for scalp cooling was $3,050 per QALY versus dermatologic management plus minoxidil and –$2,950 per QALY versus dermatologic management plus minoxidil and platelet-rich plasma. Both ICERs fall below common United States willingness-to-pay thresholds, indicating that scalp cooling is cost-effective. These findings suggest that scalp cooling is a financially reasonable supportive care intervention and should be considered for routine insurance coverage.
Copyright (c) 2026 Lauren McGrath, Alice Mikulinsky, Steven Feldman (Author) https://creativecommons.org/licenses/by/4.0
Beyond the scalpel: Rare and experimental nonsurgical treatments for basal cell carcinoma
Basal cell carcinoma (BCC) is typically found on sun-exposed skin and is the most common form of skin cancer. Risk factors include male sex, fair skin, increased ultraviolet radiation exposure, prior history of BCC, chronic arsenic exposure, genetic predisposition, and immunosuppression. BCC is a slow-growing tumor that typically presents as a shiny and pink papule or nodule with telangiectasias. However, its presentation varies depending on the histological type, which can be confirmed by biopsy. First-line therapies for low-risk BCC include standard surgical excision and curettage and electrodesiccation, whereas the gold standard for high-risk BCC is Mohs microscopic surgery. This review summarizes the current guidelines for BCC treatment and discusses the mechanism of action and clinical implications of alternative rare, experimental, and anecdotal treatments in the literature.
Copyright (c) 2026 Elen Deng, Amor Khachemoune (Author) https://creativecommons.org/licenses/by/4.0
Poroma with pigment network–like structures on dermoscopy
Copyright (c) 2025 Toshiyuki Sato, Monika Valiuskyte, Satomi Fujii, Yoshimasa Nobeyama, Ryoichi Kamide, Akihiko Asahina (Author) https://creativecommons.org/licenses/by/4.0
Dupilumab prescribers used fewer days of systemic and topical corticosteroids compared with conventional immunosuppressant prescribers
Copyright (c) 2025 Brad R. Woodie, Alan B. Fleischer Jr (Author) https://creativecommons.org/licenses/by/4.0
A new ultrasonographic pattern of infundibular cysts associated with Gardner syndrome
Copyright (c) 2025 Irene Sánchez-Gutiérrez, Belén Romero-Jiménez, Laura Nájera-Botello, Gaston Roustan-Gullón, Fernando Alfageme-Roldán (Author) https://creativecommons.org/licenses/by/4.0
Copyright (c) 2025 Zane Attard, Sarah Borg Grech, Leonie Mifsud, Miljan Milic, David J. Camilleri, Michael J. Boffa (Author) https://creativecommons.org/licenses/by/4.0
In-vitro fertilization–induced autoimmune progesterone dermatitis
Copyright (c) 2025 Osmanege Atliya, Esra Adışen (Author) https://creativecommons.org/licenses/by/4.0
Virtual care nurse triage protocols cost-effectively reduce dermatologist burnout
Copyright (c) 2025 Mason Seely, Khushnood Faraz, Margaret-Anne Atkins, La’Vonne Lancaster, Michelle Bradsher, Emily Greene, Megan Jamison, Matilda Nicholas, Anne L. Marano (Author) https://creativecommons.org/licenses/by/4.0