Dermatology is 1 of the least diverse medical specialties in North America. Despite this, the barriers that Underrepresented in Medicine (URiM) students face in pursuing dermatology are poorly understood. This study aims to explore the challenges URiMs encounter in pursuing dermatology in Canada, with the goal of informing initiatives to enhance diversity and inclusivity within the field. Using critical qualitative inquiry and purposive sampling to ensure gender, race/ethnicity, geographical, and trainee year heterogeneity, we recruited self-identifying URiMs across Canadian medical schools. Online in-depth semi-structured interviews were conducted and transcribed verbatim. Transcripts were analyzed through an inductive reflexive narrative thematic process, and key themes and subthemes were identified. Twenty-four URiMs were included in this study. The interviews revealed 3 major themes that characterized their experiences: journey to medicine and dermatology, sense of belonging in the field, and access to dermatology. URiMs identified limited mentorship, insufficient exposure to the field, financial constraints, undervaluation of advocacy efforts, feelings of isolation, and microaggressions as key barriers to pursuing dermatology. They recommended strategies to address these challenges, including mentorship programs, more holistic residency program selection approaches, and leveraging social media to increase exposure and highlight diversity in dermatology programs. This study highlights key barriers URiMs face in pursuing dermatology and provides a foundation for future research and policy changes to increase diversity in the specialty. We strongly encourage dermatology residency programs to implement these recommendations, as doing so will foster greater inclusivity and ultimately improve care for diverse patient populations.
Pediatric dermatoses presenting as follicular papules are common entities encountered in clinical practice. These are a heterogeneous group of disorders of infectious or noninfectious origin that commonly present as regularly spaced, small papules with or without perifollicular inflammation. Inflammatory causes include follicular eczema, pityriasis rubra pilaris, lichen nitidus, follicular seborrheic dermatitis, keratosis pilaris and its variants, keratosis circumscripta, follicular psoriasis, lichen spinulosus, follicular lichen planus, follicular mucinosis, perforating folliculitis, follicular porokeratosis, and follicular dermographism. These conditions may arise due to filaggrin mutations, keratinization defects, autoimmunity, or microbial triggers. Nutritional causes include phrynoderma and scurvy, while connective tissue diseases such as dermatomyositis and chronic cutaneous lupus erythematosus are autoimmune. Additional categories include infectious, genetic, hormonal, environmental, frictional, malignant, nevus-related, iatrogenic, and idiopathic entities. An early and accurate diagnosis is essential for proper management and reducing disease-associated apprehension in children and/or their parents. This review attempts to describe the role of history taking and clinical examination, including morphology, location, pattern of distribution, and associated features, while dealing with a child with follicular-based papules. In addition, it delineates the role of dermoscopy and pathological examination in reaching a correct diagnosis. Furthermore, it describes the available treatment options and disease course of various follicle-based dermatoses.
Alternative diagnostic labels for melanoma in situ may better reflect its lower risk (15-y survival of 98%) compared with invasive melanoma (10-y survival ranging from 98% for American Joint Committee on Cancer stage IA to 19% for stage IV). Secondary analysis of an online randomized experiment in Australian adults without melanoma. Participants were randomized to a hypothetical diagnosis of "melanoma in situ (MIS)" (control), "low-risk melanocytic neoplasm," or "low-risk melanocytic neoplasm, in situ" and completed a survey. Perceived risk measures were future invasive melanoma and mortality risk (0%-100%), comparative risk, affective risk, and vulnerability (7-point Likert scales). Calculated risk measures were lifetime invasive melanoma risk (from participants' risk factors) and melanoma mortality probability (Australian sex-/age-specific mortality rates). An intention-to-treat analysis across randomized groups was performed, unadjusted and adjusted for covariates (linear regression models). In total, 1,668 adults were recruited. Compared with MIS, perceived melanoma mortality risk was lower for low-risk melanocytic neoplasm (-10.4%, 95% confidence interval [CI]: -13.1% to -7.63%, P < 0.001) and for low-risk melanocytic neoplasm, in situ (-7.4%, 95% CI: -10.2% to -4.6%, P < 0.001). Similar patterns were observed for perceived risk of invasive melanoma; comparative, affective risk; and vulnerability. Participants in all groups substantially overestimated their lifetime risk of invasive melanoma (by 48.7%) and of dying from melanoma (by 32.0%) compared with the calculated risk; overestimation was lower in alternative label groups. Diagnostic labels without the word "melanoma" reduced risk overestimation, supporting MIS relabeling to mitigate overdiagnosis harm by reflecting its largely indolent nature. ANZCTR: 386943HighlightsAlternative diagnostic labels for melanoma in situ that do not include the word "melanoma" significantly decreased perceived risk compared with melanoma in situ.Participants substantially overestimated their risk; alternative labels reduced this overestimation of perceived risk compared with calculated risk.A new label for melanoma in situ may better communicate the lower risk of adverse outcomes for this lesion compared with invasive melanoma. This may reduce patient anxiety and allow for management decisions that align with their values and preferences.
Tranexamic Acid(TXA) has been shown to improve melasma treatment or help homeostatic in the past decade, but no report on improving surgical scars. Given that early intervention may enhance surgical scar outcomes, this split-scar study investigates whether immediate postoperative administration of TXA around the incision site can help prevent scar formation. In this prospective trial, 30 consecutive patients who underwent surgery from January 2022 to January 2024 were enrolled. TXA was injected randomly into half of each surgical wound closure immediately after surgery by plastic surgeons. The scars were assessed independently using the visual analogue scale (VAS) and the modified Stony Brook Scar Evaluation Scale (mSBSES) at follow-ups. The occurrence of complications or adverse events was also recorded. In total, 30 patients who completed the study were analyzed. The TXA-treated side achieved significantly improved VAS scores and better mSBSES scores (p< 0.05, respectively), which revealed a significant improvement in appearance and narrower scars. No severe complications were reported. This study demonstrates that immediate postsurgical TXA injections can improve the appearance of postoperative scar. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 .
Keloids are skin proliferative lesions with tumor-like characteristics. Their treatment is challenging due to their high recurrence rate. The most effective treatment against keloids is surgical excision with radiotherapy. However, the recurrence rate remains high. In this study, we modified the surgical technique by reducing the tension of an area three times larger than the residual wound area. We treated 89 patients using the modified surgical excision procedure with radiotherapy, and we assessed the appearance of the scar using the Vancouver scar scale (VSS) score. The follow-up times ranged from 12 to 28 months with an average of 16.4 months. During the follow-up period, local recurrences were observed in 13 cases (14.6%). The mean VSS score decreased significantly after treatment (P < 0.001) indicating an improvement in the cosmetic appearance of scars. The modified surgical technique combined with radiation therapy may be an effective method for treating keloids. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors  www.springer.com/00266 .
Reconstruction of midline nasal dorsum skin defects following oncologic excision is challenging because of the aesthetic prominence of the region and the limited mobility of surrounding soft tissues. Flap-based techniques are commonly recommended; however, they may be associated with donor-site morbidity, visible scarring, and multistage procedures. Auricular composite grafts are well established for select nasal subunits, but their intentional use for midline nasal dorsum skin reconstruction has not been routinely described. We describe a novel single-stage reconstructive strategy in which an auricular chondrocutaneous composite graft was deliberately utilized for midline nasal dorsum skin reconstruction following basal cell carcinoma excision. The technique was applied in a carefully selected patient with preservation of the underlying cartilaginous framework. Simultaneous structural support of the nasal dorsum and internal nasal valve was achieved without additional cutaneous incisions. Complete graft survival was observed without partial or total necrosis. At the 6-month follow-up, the reconstructed nasal dorsum skin demonstrated stable contour with satisfactory color and texture match. No graft contraction, secondary deformity, or late complications were noted. Nasal airway patency was preserved throughout the follow-up period. This technical experience suggests that auricular composite grafts may represent a feasible single-stage, low-morbidity alternative to flap-based reconstruction for midline nasal dorsum skin defects in selected cases, while preserving future reconstructive options. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Body art, including body piercing and tattooing, has evolved from cultural and religious practices to mainstream forms of self-expression. This trend is evident globally and particularly among young adults in Saudi Arabia, where traditional values are being influenced by globalization and digital media. This study aims to assess awareness, attitudes, and practices regarding body piercing and tattooing among young adults in Saudi Arabia. A cross-sectional study was conducted using an online self-administered questionnaire distributed to young adults who have undergone body piercing and/or tattooing across all regions of Saudi Arabia. The study employed a final sample of 1,472 participants, calculated to account for a 20% non-response rate. Findings may not generalize to rural populations due to the online sampling method. Descriptive and inferential statistical analyses were performed using SPSS version 28.0. The majority of participants (77.31%) were aware of health risks related to body art, though only 37.37% recognized non-infectious complications. Safety concerns were prevalent, with 77.45% doubting the hygiene standards of body art procedures. Ear piercings were the most common (83.69%), while tattoos and other piercings were less frequent. Interest in future body art was low among those without prior experience. Significant associations were found between age, gender, and perceptions of body art risks and practices. The study highlights a significant awareness gap regarding non-infectious risks associated with body art among young adults in Saudi Arabia. There is an urgent need for targeted public education and stricter regulation to ensure safe practices. The findings suggest that while awareness of risks exists, further education and improved safety standards are crucial to addressing the evolving trends in body art practices.
Hidradenitis suppurativa (HS) is a disease that impairs the quality of life (QoL), sexual functioning, and fertility of the patients. The relationship between disease characteristics and sexual function remains insufficiently characterized. The aim of this study is to evaluate the rate of sexual dysfunction among HS patients; and to evaluate its relationship to disease or patient characteristics. In this multi-centered cross-sectional study, patients were asked to complete a structured online questionnaire including demographics, disease characteristics, the Hidradenitis Suppurativa Self-Assessment Tool (HSSA), HS-specific Dermatology Life Quality Index (HS-DLQI), and validated sexual function instruments (International Index of Erectile Function-5 [IIEF-5] for males; Female Sexual Function Index [FSFI] for females). A total of 522 HS patients were included. Higher HSSA stages correlated positively with worse HS-DLQI scores (r = 0.258, p < 0.001). Lesions in the head/neck, inframammary, gluteal, and inguinal regions were associated with greater QoL impairment. Male patients had significantly lower IIEF scores and higher erectile dysfunction (ED) prevalence compared to controls; however, HS was not an independent risk factor for ED in multivariable analysis. Female patients had significantly lower total FSFI scores than controls, particularly in arousal, orgasm, satisfaction, and pain domains, whereas lubrication remained unaffected and desire scores were higher. Recall bias, the self-reported nature of questionnaires, and sociocultural barriers to discussing sexual health may have influenced results. HS significantly impairs quality of life, particularly with increasing disease severity and involvement of specific anatomical regions. HS is associated with impaired sexual function in both women and men, with a more pronounced and multifaceted impact observed in female patients. Effective pain and inflammation control may improve sexual outcomes, underscoring the importance of comprehensive, domain-specific assessment in HS management.
Scabies is a readily transmissible parasitic skin disease frequently seen in primary care and characterized by intense pruritus. While its clinical features are well described, the psychological and behavioral aspects of scabies, including anxiety, maladaptive behaviors, and their effect on quality of life, remain insufficiently explored. The aim of this study was to evaluate the clinical, psychological, and behavioral impact of scabies and to examine the associations between anxiety, behavioral changes, pruritus severity, and dermatology-related quality of life (DLQI). In this cross-sectional study, adults with confirmed scabies, diagnosed according to the 2020 International Alliance for the Control of Scabies (IACS) criteria, were included. Participants completed an online questionnaire assessing pruritus severity, pre- and post-treatment pruritus duration, behavioral changes, anxiety measured by the Generalized Anxiety Disorder-7 (GAD-7), and DLQI. Non-parametric tests, Spearman correlation analyses, and multivariable linear regression with robust standard errors were used to evaluate associations between clinical and psychosocial variables. A total of 173 participants were analyzed (median age 37 years [IQR 27-46]; 48.6% female). Median pruritus severity was high (8.0 [7.0-10.0]), while median GAD-7 and DLQI scores were 4.0 [2.0-7.0] and 8.0 [1.0-18.0], respectively. Pruritus severity was significantly correlated with behavioral change (ρ = 0.27, p < 0.001) but not with anxiety or quality-of-life impairment. In contrast, DLQI showed significant correlations with anxiety (ρ = 0.379, p < 0.001) and behavioral change (ρ = 0.211, p = 0.005). Pre-infestation fear of scabies was associated with nearly two-fold higher anxiety scores (median GAD-7 7.0 vs. 3.5, p < 0.001) and greater behavioral change. Nodular scabies independently predicted greater impairment in quality of life in multivariable analysis (β = 3.25, p = 0.047). Quality-of-life impairment in scabies was more closely related to anxiety scores and nodular presentation than to itch intensity alone. Anxiety and behavioral responses were significantly associated with DLQI scores, suggesting that management should address more than antiparasitic treatment and include psychological and behavioral dimensions. As most patients are initially evaluated in primary care, these factors can be assessed during early consultations, alongside standard treatment.
We previously found that implementing medication reviews by a physician specialised in clinical pharmacology at interdisciplinary conferences with prescribing physicians and nurses led to a relative reduction in the number of drugs and potentially inappropriate prescriptions (PIPs) in psychiatric outpatients with diabetes. Adhering to the framework of health technology assessments (HTAs) and to facilitate direct implementation, we subsequently demonstrated the intervention as cost neutral. This study aimed to identify contextual, organisational and interprofessional barriers and facilitators in implementing the intervention focusing on nurses' role at interdisciplinary conferences. We conducted semi-structured interviews with available staff and four patients from the intervention group. We conducted a primary thematic analysis with HTA as a framework, while a secondary analysis situated the themes into a contextual understanding. Interdisciplinary dialogue tailors pharmacological recommendations to patients adhering to clinical pragmatism rather than generic prescription guidelines. It enables professional growth and reciprocal learning and levels out an inherent doctor-nurse hierarchy. However, when conferences were online or hybrid, nurses did not benefit to the same extent and had the feeling of being set aside. Interdisciplinary medication reviews in psychiatry may improve the clinical relevance of pharmacological decision-making and level out an inherent physician-nurse hierarchy in psychiatry. Novel clinical interventions may often not be directly implemented due to organisational factors. To ensure direct implementation, researchers must address not only organisational factors affecting implementation but also evaluate the implementation process to better understand contextual factors influencing implementation and consequently outcomes. Based on the framework of ‘health technology assessments’ (HTA) and by including the understanding of context according to Pawson et al., we analysed the organisational process of implementing physician–led medications reviews through interdisciplinary dialogue. Within a facilitating working environment, nurses contribute significantly to pharmacological decision‐making, and their contribution should not be underestimated.
The treatment landscape for Chronic Hand Eczema (CHE) is evolving; however, evidence on patients' preferences regarding CHE treatment attributes is sparse. This discrete choice experiment (DCE) assessed how treatment attributes influence preferences among patients with moderate to severe CHE in the USA. Adults with moderate to severe CHE recruited from an online panel completed a web-based DCE survey (August-September 2025). Seven treatment attributes, identified via literature review, qualitative patient interviews, and clinical expert input, reflected efficacy (improvements in itch, skin appearance, and pain), safety (risks of infections, cancer, and major heart problems), and administration mode/frequency. Patient preferences were analyzed using conditional logistic regression. Attributes' relative importance and willingness to trade off were calculated. Sensitivity analysis excluding participants who failed ≥ 1 validity test was conducted. Of the 300 participants with CHE included (mean age: 44.9 years; 50% female; 84.7% employed), most reported multiple CHE subtypes (70.3%). The vast majority of participants reported life impairment due to CHE, including for activities of daily living (96.3%) and work productivity (92.9%). In the DCE, all treatment attributes had a significant impact on treatment preferences (p < 0.001). Attributes with the highest relative importance were related to efficacy: itch improvement (22%) and skin appearance improvement (21%); followed by those related to safety: avoiding risk of cancer (16%) and risk of infections (14%). Other important attributes for patients included pain improvement (13%) and administration mode/frequency (7%). Participants would forgo 28.1, 11.4, and 1.3 percentage points of itch improvement probability to avoid a 1-percentage-point risk of cancer, major heart problems, and infections, respectively. Improvement in efficacy outcomes (itch and skin appearance) and lower risks of certain adverse events (cancer, infections) were the most important treatment attributes for patients with CHE. This study provides insights that may help support shared decision-making to ultimately improve treatment satisfaction and adherence.
Nasal filler-related vascular compromise is uncommon but may result in serious tissue injury. Mixed fillers combining hyaluronic acid (HA) with particulate biostimulators may create emboli with dual-phase rheologic behavior that is not fully addressed in current management algorithms derived largely from HA-only events. To present an illustrative case and case-derived technical algorithm integrating high-dose hyaluronidase with superficial micropuncture decompression for early nasal ischemia following injection of a mixed HA-biostimulator filler. We describe an illustrative case of dorsal nasal artery ischemia following injection of a premixed HA-calcium hydroxylapatite (CaHA) formulation containing lidocaine with epinephrine. Early-stage ischemia was managed using a dual-approach rescue strategy consisting of track-based high-dose hyaluronidase for enzymatic debulking, followed by tension-guided superficial micropuncture for mechanical decompression, together with adjunctive supportive measures. Clinical improvement with reperfusion was observed within 24 to 48 h, with marked improvement by Day 5 and near-complete recovery by Day 7. At 4-week follow-up, the patient showed near-complete recovery without clinically evident scarring, contour irregularity, or atrophy. Pain improved markedly, and patient satisfaction was high. In this illustrative case, a dual-approach rescue strategy combining high-dose hyaluronidase with superficial micropuncture was associated with favorable early recovery. This case-derived technical framework may be considered in selected early cases of mixed-filler nasal ischemia, but its independent benefit and generalizability remain uncertain and require further evaluation in larger series. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease which imposes a significant burden in terms of pain, disability, and comorbidities. Obesity and metabolic dysfunction are highly prevalent in HS, contributing to disease severity. Glucagon-like peptide-1 receptor agonists (GLP-1RAs), widely used in type 2 diabetes and obesity, have shown additional anti-inflammatory properties that may be relevant in HS.However, data on their clinical benefit remain limited. We performed a systematic review of PubMed/MEDLINE, Scopus, Web of Science, and Embase through June 2025, following PRISMA guidelines. Studies reporting outcomes in HS patients treated with GLP-1RAs were included. Information on clinical severity, quality of life, metabolism, inflammatory markers, and healthcare use were extracted. Findings were critically assessed and summarized descriptively, with pooled analysis applied where outcomes were consistently reported. This review was registered with PROSPERO (CRD420251110220). Nineteen studies including 67,568 patients were identified. Pooled analysis showed that 60% of patients achieved clinical improvement in Hurley stage (95% CI 52-67). Dermatology Life Quality Index (DLQI) improved by a mean of -3.83 points (95% CI -5.14 to -2.51). Clinical benefit was observed despite modest weight reduction (mean BMI change -2.64 kg/m2). Inflammatory and metabolic markers improved, with significant reductions in mean C-reactive protein (-1.35 mg/L, 95% CI -2.33 to -0.36) and HbA1c (-0.39%, 95% CI -0.59 to -0.18). Large real-world cohorts showed decreased antibiotic and corticosteroid use and lower hospitalization rates, though results for biologic use, surgical procedures, and cardiovascular outcomes were mixed. Two studies reported reduced risk of major adverse cardiovascular events, while one HS-diabetes cohort suggested persistent excess cardiovascular risk compared with diabetes-only controls. This systematic review suggests that GLP-1RAs are associated with improvements in HS severity, quality of life, metabolic and inflammatory parameters, and may additionally reduce healthcare utilization and cardiometabolic risk, observed alongside weight loss. However, current evidence remains limited and heterogeneous, and the relative contribution of weight-dependent and weight-independent effects cannot be determined. Prospective studies and controlled trials are needed to clarify the role of GLP-1RAs in HS management.
We present MelOD (Melanoma Omics Dashboard), a free, web-based interactive platform integrating preprocessed data from 16 melanoma studies, including eight bulk transcriptomics, six single-cell RNA-seq, and two proteomics datasets. MelOD provides user-friendly visualization and analysis tools, differential expression, dimensionality reduction, clustering, correlation, and survival analysis without requiring local computational resources. Several datasets include annotations for immunotherapy response, facilitating exploration of resistance and response signatures. Built on RShiny with optimized handling of large datasets, MelOD supports real-time hypothesis generation, cross-study validation, and community dataset contributions. Freely accessible online, MelOD lowers barriers to multi-omics research in melanoma and related fields.
Background/Objectives: Topical corticosteroids (TCS) are a cornerstone of dermatological treatment for inflammatory skin conditions; however, irrational fear of their use known as corticophobia undermines adherence and worsens clinical outcomes. This study investigated the prevalence of TCS-related concern and phobic behaviors among the general population in Saudi Arabia and identified factors associated with TCS-related concern and phobic attitudes. Methods: A cross-sectional study was conducted between October and December 2025 using an online self-administered questionnaire distributed via social media platforms among a non-probability convenience sample across multiple geographic zones of Saudi Arabia. A total of 481 participants were enrolled. Descriptive statistics summarized demographic and clinical characteristics. Chi-square and Fisher's exact tests were used to examine differences in proportions between categorical variables and TCS concern, while independent-samples t-tests and one-way ANOVA compared mean phobia scores across subgroups. Results: Of 481 participants, 254 (52.8%, 95% CI 48.3-57.2) expressed concern about TCS use. The predominant reason for refusing prescribed TCS was fear of side effects (93.5%). Phobic behaviors included fear of long-term use (54.2%) and fear of application to sensitive skin areas (63.0%). On the Likert phobia-scale item, 237 (49.8%) totally agreed they would use TCS if prescribed; a separate dichotomous behavioral-intention item, administered only to non-current users (n = 308), showed that 201 (65.3%) would accept TCS if prescribed and 107 (34.7%) would refuse. Concern was significantly more prevalent among females (58.1%, BH-adj p = 0.005), married participants (61.7%, BH-adj p = 0.010), and those refusing prescribed TCS (77.6%, BH-adj p < 0.001). Mean phobia scores (theoretical range 7-28) were significantly higher among females (20.43 ± 4.06 vs. males 18.84 ± 4.68, p < 0.001), participants with Diploma-level education (21.64 ± 3.12, p < 0.001 across education strata), widowed/divorced individuals (21.82 ± 3.57, p = 0.008), and residents of the Southern (20.47 ± 3.99) and Northern (21.40 ± 3.34) regions (p = 0.002 across regions). Conclusions: TCS-related concern was expressed by over half the participants in this social media-recruited sample, posing a substantial barrier to effective dermatological care. Side-effect concern was the most frequently reported reason for refusing prescribed TCS. In adjusted analyses, female sex was the most consistent independent correlate of TCS-related concern and higher phobia score; married status was independently associated with greater concern. These associations should be replicated in probability-based samples before subgroup-targeted interventions are designed. Conclusions: TCS-related concern was prevalent (52.8%) among adults in Saudi Arabia and represented a substantial barrier to dermatological care. Female sex and married status were independently associated with greater concern. Clinicians should proactively address TCS misconceptions during dermatological consultations to improve treatment adherence.
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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.
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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.
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