Letters Sophia Akhiyat, BS Table. Odds Ratios of Preference for a Quick Response Given Online Portal Experience, Prior Skin Biopsy, Misty G. Eleryan, MD Personal/Family History of Melanoma, and Sex Serena Durrani, BA Charles B. Mitchell, MD Characteristic Odds Ratio (95% CI) P Value Online portal experience 3.767 (1.846-7.687) <.001 Author Affiliations: The George Washington University School of Medicine and Prior skin biopsy 0.297 (0.115-0.768) .01 Health Sciences, Washington, DC (Akhiyat, Mitchell); The George Washington Personal/family history 1.043 (0.500-2.176) .91 Medical Faculty Associates, Washington, DC (Eleryan, Mitchell); Johns Hopkins of melanoma University, Baltimore, Maryland (Durrani). Female 1.011 (0.502-2.037) .98 Corresponding Author: Sophia Akhiyat, BS, The George Washington University School of Medicine and Health Sciences, 2300 I St NW, Washington, DC 20052 Results | The survey yielded an estimated 85% response rate, ([email protected]). with 204 patients out of an estimated 240 patients agreeing Accepted for Publication: September 22, 2016. to participate. The population was 56.37% male and 43.63% Published Online: December 7, 2016. doi:10.1001/jamadermatol.2016.4349 female with no statistically significant difference, and Author Contributions: Dr Mitchell and Ms Akhiyat had full access to all of the 62.25% of participants had a college degree or higher level data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. of education. Concept and design: Akhiyat, Mitchell. The highest ranked notification preferences were the on- Acquisition, analysis, or interpretation of data: All Authors. line portal (59.40%) and telephone call (48.95%). About 54% Drafting of the manuscript: Akhiyat, Eleryan, Mitchell. Critical revision of the manuscript for important intellectual content: All Authors. of patients reported their preference would change depend- Statistical analysis: Eleryan, Durrani. ing on whether biopsy results were normal or abnormal Administrative, technical, or material support: Eleryan, Mitchell. (P < .001). For a normal skin biopsy result, most patients Supervision: Akhiyat, Mitchell. (n = 143) reported a preference for an online portal (55.20%). Conflict of Interest Disclosures: None reported. For abnormal results, most patients (n = 145) indicated a pref- 1. Stewart MA. Effective physician-patient communication and health erence for a telephone call (69.2%). outcomes: a review. CMAJ. 1995;152(9):1423-1433. Among participants with previous online portal experi- 2. Meza JP, Webster DS. Patient preferences for laboratory test results notification. Am J Manag Care. 2000;6(12):1297-1300. ence, 52.05% indicated a preference for online portals. Of the participants who did not have experience using online por- 3. Choudhry A, Hong J, Chong K, et al. Patients’ preferences for biopsy result notification in an era of electronic messaging methods. JAMA Dermatol. 2015; 2 tals, 61.11% indicated a preference for a telephone call; χ tests 151(5):513-521. suggested a correlation between age and online portal expe- rience, as well as age and online portal notification prefer- ence (P = .05). White Scale Sign for Xeroderma Most participants ranked depth of information received Xeroderma, also known as xerosis cutis, is a common condi- (44.78%) and amount of time to discuss results (35.82%) as their tion that has become ever more important to diagnose in light most important factors for selecting a notification modality of the number of aging patients. The condition is frequently when receiving abnormal results. Other demographic data did seen among the elderly, but it has also been observed in not significantly influence ranking of preferred factors for being younger patients affected by atopic dermatitis.1 The clinical fea- notified of abnormal results. tures of xeroderma are flaky, dry, and cracked skin areas. Po- Patients who indicated that they preferred a quicker tentially because of its high frequency, xeroderma lacks diag- method of skin biopsy result notification did not differ based nostic criteria and signs. Most clinicians tend to wait to make on history of skin biopsies or skin cancers. However, the odds the diagnosis of xeroderma until they see several skin areas of patients with online portal experience preferring a quicker are flaky, dry, and cracked, and this tendency to delay the di- method was statistically significant (Table). agnosis until the condition is full-blown is unnecessary. Clear- cut, microscopic, early signs are therefore required. We pro- Discussion | Our findings support that online portals are the most pose a dermoscopic sign that, in our experience, invariably preferred method of skin biopsy result disclosure among pa- appears in pathologically dry skin areas. tients, particularly when results are normal. Patients re- The brunt of the pathologic changes in xeroderma is in the ported that amount of information and time to discuss re- stratum corneum and epidermis. Single corneocytes shed from sults were their most important factors for choosing a modality the surface during the physiologic process of renewal are nor- for receiving abnormal results. In addition, the odds of pa- mally invisible. In xeroderma, however, because the normal tients with online portal experience preferring a quicker no- process of shedding and removal of intercellular adhesion is tification method was significant. disturbed,2 whitish scales form. This effect of scale produc- There were study limitations that warrant discussion. tion starts microscopically, usually on the shins, and later We had a small sample size. Our location in a metropolitan spreads to the thighs, proximal extremities, and trunk. The seb- area and large percentage of participants with college orrheic areas of the body are always spared. When the inten- degrees or higher education may not be representative of sity is reached that is clinically obvious, branlike scales are shed other communities in the United States. We also did not col- in large amounts that can form dusty clouds when patients re- lect demographic information regarding participant racial/ move their stockings. This clinically obvious scaling, to- ethnic group. gether with pruritus, is what finally prompts most clinicians jamadermatology.com (Reprinted) JAMA Dermatology February 2017 Volume 153, Number 2 231 Copyright 2017 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 Letters to recognize xeroderma. Subsequently, cracks and fissures of Figure. White Scales in Xeroderma Detectable by Dry Dermoscopy the stratum corneum can develop, along with asteatotic ec- zema that causes dull, chronic inflammation. Histologic stud- A Patient 1, clinical photograph B Patient 1, dry dermoscopy ies reveal little alteration of stratum corneum, nor epidermis,3 early on. In later stages, eczematous changes (eczema cra- quelé) develop. Methods | Overall, we included 11 patients (6 women aged 26 to 82 years and 5 men aged 67 to 87 years) in the study, which we conducted between March 1, 2015, and April 1, 2016. The study was approved by Kantonale Ethikkommission Zürich and written patient informed consent was obtained. Results | In xerotic areas of any size, stage, and race, white scales were always detectable in dermoscopy (Figure, A-D). We call C Patient 2, clinical photograph D Patient 2, dry dermoscopy this occurrence the white scale sign (WSS). These scales were large amounts of corneocytes that stuck together and were only visible by dermoscopy on dry skin (Figure, E). On moist skin, however, such as when ethanol was applied for dermoscopy (Figure, F), the white scales disappeared at once. When dry skin was treated with emollients at the locus of a positive WSS, the white scales disappeared 15 minutes later (Figure, G). Thus, the WSS was useful in detecting xeroderma on native, untreated skin. The histopathological features of a biopsy specimen taken in a spot of xeroderma with a positive WSS showed parakera- tosis and features of eczema (Figure, H). E Patient 3, dermoscopy without fluid F Patient 3, dermoscopy with 90% ethanol Discussion | We have taken a positive WSS as a cue to discuss and usually prescribe emollients. Many patients are not aware that they are affected by xeroderma. In our experience, the WSS revealed the condition in many cases; clinically, xeroderma would have been missed because of the absence of wide- spread and clinically obvious scaling. Xeroderma occurs not only in old age4,5 but also among younger adults with eating disorders, HIV infection, essential fatty acid deficiency, atopic dermatitis, and many forms of ichthyosis. Scaling without xe- roderma is usually temporary and can occur after inflamma- G H tory rashes. As yet, few to no clinical criteria for detecting and Patient 3, treated with an Patient 1, hematoxylin-eosin stain emollient before dermoscopy diagnosing xeroderma exist. We propose that clinicians look for the WSS in patients of all ages. The WSS can contribute to the detection and diagnosis of xeroderma and thus allow suit- able treatment before asteatotic eczema develops. Amrei Klemmer, MagDr Florian Anzengruber, MD Dmitry Kazakov, MD Alexander A. Navarini, MD, PhD Xeroderma (XD) with features of beginning asteatotic eczema, Fitzpatrick skin type II: A, Clinical view. B, Dermoscopy (original magnification ×10). XD, Fitzpatrick skin type IV: C, Clinical view. D, Dermoscropy (original magnification Author Affiliations: Department of