Thursday, December 19, 2019

ABOUT VGRD

Founded in 2000, Virtual Grand Rounds in Dermatology (VGRD) is a gathering place for dermatologists the world over to meet with one another and share interesting and/or challenging patients. In addition, we welcome all other health care practitioners with an interest in cutaneous disorders.  One may want to ask a question about diagnosis or therapy, present an interesting clinical photo or post a photomicrograph. We are a group of clinical and academic dermatologists who believe that web-based teledermatology can be both personally and professionally enriching.

Digital photography makes it possible to post clinical and microscopic images with ease. There are a dizzying number of cameras to choose from. The site creators will help you with advice here if you want.  In the past few years, smart phones have improved to the point where their images are more than acceptable.

Even if one lives in a city with a major medical center it is often difficult to get one's patients to Grand Rounds. And if one does, the turnout and discussion may be disappointing. VGRD is always available. You can post a message at 6:00 p.m. in Boston, Henry Foong may see it at 6:00 a.m. in Ipoh, Malaysia as he sits down at his home computer. Often, you will have received a few suggestions or comments when you log on the next morning.

VGRD has been a virtual consultative and collegial community for over 15 years. John Halle, the 16th Century English physician/poet, penned these perceptive words about the consultation in a long forgotten tract:

    When thou arte callde at anye time,
    A patient to see:
    And dost perceave the cure to grate,
    And ponderous for thee:

    See that thou laye disdeyne aside,
    And pryde of thyne own skyll:
    And think no shame counsell to take,
    But rather wyth good wyll.

    Get one or two of experte men,
    To helpe thee in that neede;
    To make them partakers wyth thee
    In that work to procede....

Halle's words guide us as we gather 500 years later in a consultative community the likes of which he probably could not have fathomed. So, let us "laye disdeyne aside,/ And pryde of [our] own skyll:/ And think no shame counsell to take,/ But rather wyth good wyll" join us in this global community of peers to help our patients and educate each other and ourselves.
        

  
                                                                                                  
                 
                 

Friday, November 03, 2017

Atypical Pigmented lesion in an 81 yo Man

The patient is a light-complected Caucasian with Type I skin and a personal history of non-melanoma skin cancer.  His daughter has a history of melanoma.

He presented for a skin exam and was found to have an atypical pigmented lesion on his right shoulder.  He remembers that this lesion had been biopsied years ago at another facility and he was told it was fine.

O/E:  On the right shoulder there was a 1.2 mm in diameter irregularly pigmented macule with a play of color.  The dermatoscopic picture was worrisome and he was scheduled for an excisional biopsy.
Dermatoscopic image
Pathology:  The excisional biopsy showed a melanoma 0.3 mm thick, 0 mitoses per mm squared.  Free margins, but narrow.

(The old biopsy report from 2007 was reviewed.  This was a shave biopsy that showed a junctional nevus with mild to moderate atypia and margins were clear in the sections examined.)

Discussion:  The patient has a thin melanoma arising in the site of a previous biopsy.  This raises the question of whether shave biopsies of pigmented lesions are appropriate.  At any rate, a thin melanoma, 0.3 mm thick just requires a wide-local excisison with one cm margins.  Sentinel node biopsy is not indicated.  The patient will have regular skin exams from this point on.


Monday, October 16, 2017

Linear Scleroderma in a 40 year-old Woman

Presented by Hamish McDougall
Cape Breton, Nova Scotia

The patient is a 37 year old woman with a four year history of a slowly progressively asymptomatic area of induration on the posterior aspect of the left thigh (photo).  A biopsy showed thickened collagen bundles in the reticular dermis and a sparse superficial and deep lymphoplasmacytic infiltrate consistent with morphea.

Strangely, her father-in-law is seriously ill with systemic sclerosis.  He lives far from the patient and her husband.  At this time, we have discovered no common exposures the patient and her father-in-law have.  The patient lives in an endemic area for Lyme Disease and serological testing will be offered.

Questions:
Is there any value in obtaining serologies, other than Lyme studies, on this woman?
What treatment might be of value? 
Do you have alternate diagnoses?




References:
1. Localized Scleroderma Review Article (Like a chapter in a text book)
2. Morphea Sculpted in Silica: A Case Report of Limited Cutaneous Systemic Sclerosis in a Woman with Long-Time Exposure to Silica Dust.

Pedro Gomes J, Shoenfeld Y.  Free Full Text.
3.  "Borrelia-associated early-onset morphea": a particular type of scleroderma in childhood and adolescence with high titer antinuclear antibodies? Results of a cohort analysis and presentation of three cases.

Prinz JC, et. al. J Am Acad Dermatol. 2009 Feb;60(2):248-55. CONCLUSION:B burgdorferi infection may be relevant for the induction of a distinct autoimmune type of scleroderma; it may be called "Borrelia-associated early onset morphea" and is characterized by the combination of disease onset at younger age, infection with B burgdorferi, and evident autoimmune phenomena as reflected by high-titer antinuclear antibodies. As exemplified by the case reports, it may take a particularly severe course and require treatment of both infection and skin inflammation.

Thursday, September 28, 2017

Metastatic melanoma in an elderly man

Presented by Henry Foong, M.D.
Ipoh, Malaysia

The patient is a 80-year-old man who presented with swelling of the left leg for 3 months. 

About 3 years ago he had a motor vehicle accident where he injured his left leg.  His attending doctor noticed a pigmented growth on the left foot associated with inguinal node swelling. A surgeon excised the pigmented growth on the left foot and removed some nodes from the left groin.  No histological reports were available at the moment.  The patient was well until recently when he noticed gradual swelling of the left leg with multiple pigmented nodules on the surface.  The leg was occasionally painful at night. He did not have any constitutional symptoms.  There was no family history of skin cancers. No significant other medical illness.

On examination his left leg was swollen and oedematous with many pigmented papules and nodules on the foot and lower 1/3 of the left leg.  A pigmented ulcerating tumour  5 x 5 cm was noted on the left foot which extended to the heel.  A firm matted lymph node swelling was noted on the left groin.  There was a surgical scar over the left groin.  No hepatosplenomegaly was present.

Biopsy of the pigmented papule on the foot was done and confirmed malignant melanoma.
Sheets and nests of malignant cells are seen invading the dermis. The
tumour cells show marked pleomorphism, have increased nucleo-cytoplasmic ratio, vesicular nuclei with prominent nucleoli and eosinophilic cytoplasm. Many of the cells contain melanin pigment. Numerous mitotic figures are seen. The tumour is seen at the margins. Masson Fontana stain is focally positive.
Skin biopsy Report: Features are consistent with malignant melanoma.

His work up included an oncology referral. CT scan of abdomen and pelvis which showed pelvic and para-aortic  lymph 
node metastasis.  CXR normal.  TWBC was 16,400. BRAF gene mutation studies pending 

He was being treated for concomitant cellulitis with IV antibiotics.

Questions:  What are the treatment options (targeted therapy) for his metastatic melanoma? Would oral vemurafenib and Anti PD-1 antibodies e.g.  pembrolizumab be useful?  They are very expensive though for most patients in Malaysia.
It's almost certain this patient will probably opt for palliative treatment. What local treatment of the in-trasit metastasis would be useful for him?

Thank you for your thoughts!






Wednesday, September 20, 2017

17 year-old girl with 8 year history of scalp dermatitis


The patient is a 17 year-old girl with an 9 year history of thick scales on her scalp.  She has used multiple medications without relief.  The patient has been bullied at school where she has been called “lice girl.”  Socially, this has been traumatic.

O/E:  She is a well-developed and well-nourished 17 yo with thick chestnut colored hair or normal intelligence.  There are no areas of alopecia. Thick, silvery adherent scales are present on the occipital, parietal and temporal scalp.  When these are removed, hair roots come out, too.  The remainder of the cutaneous examination is normal.  No nail dystrophy.
Clinical Images (July 2017)
Lab: Fungal culture negative.  Bacterial culture 3+ Staph aureus.

Failed Treatments (per mother):

"Every single otc dandruff shampoo
Every prescription medicated dandruff shampoo
Scalpicin
Prescribed scalp drops with and without coal tar
Every Tea Tree product you can find otc
Hot oil treatments
P & S Oil
Nutrogena T-gel and T-sal
Olive oil"
Terbinafine 250 mg p.o. x 1 month
Keflex 500 mg b.i.d. x 2 weeks

Scalp Biopsy read by Lynne Goldberg (Boston University Skin Path): was felt to be most compatible with psoriasis.  Seborrhea was in the differential diagnosis but less likely.

Diagnosis:  Working Dx:  Tinea amiantacea secondary to psoriasis.

Discussion: This 17 yo girl has suffered with what appears to be tinea aminatacea for almost a decade.  It appears unlikely that this is psoriasis. Tinea capitis has been ruled out by culture.  Her bacterial culture showed 3+ S. aureus but I suspect this is a secondary invader as she did not improve with cewplanexin.  Since the fungal  culture was negative and these approaches were not helpful, I may recommend isotretinoin.  The use of this has been reported for T. aminatacea only and in a Korean case report.

Dr. Goldberg's rotocol for Scalp Psoriasis, Tinea amiantacea and Related disorders:
1. Wet hair at night
2. Apply Dermasmoothe scalp oil liberally to scalp. Leave on overnight
3. Sleep with this overnight in a shower cap (to protect pillow)
4. Shampoo in the morning with T-Sal or other dandruff shampoo

Do this nightly at first if possible, but after a week or so she will be better and will not need to do it every night.



References:

1. Abdel-Hamid I et al. Pityriasis amiantacea: a clinical and etiopathologic study of 85 patients. Int J Dermatol. 2003 Apr;42(4):260-4.

2. Kwon JI.  Isotretinoin for Tinea amiantacea (A Case Report). Korean J Dermatol 2012;50(11):1002-1005 (In Korean)

3.  Mannino G, McCaughey C, Vanness E. A case of pityriasis amiantacea with rapid response to treatment WMJ. 2014 Jun;113(3):119-20.  Full Free Text.


4. Scalp psoriasis: European consensus on grading and treatment algorithm.  Ortonne J. J Eur Acad Dermatol Venereol. 2009 Dec;23(12):1435-44.

Monday, September 18, 2017

Cheilitis Query


The patient is a 70 yo Caucasian who has lived on Moorea, French Polynesia, for the past 50 years.  She contacted us recently about her painful lips because there is no dermatologist available to her at present.  Here is her anamnesis:
In early July when I went to Montreal, my lips started to bother me. I thought maybe it was 18 hours on a plane, or even maybe it was a sunburn from being in the pool with my grandchildren in sunny Vancouver a couple weeks before. It didn't subside and I bought several lip therapies - cocoa butter, Vaseline, Aquaphor. When I came home I used a mild steroid ointment for a couple weeks, but to no effect. I now carry Aquaphor with me all the time and apply it constantly. Chapstick with SPF (from a friend in the States) stings my lips, as does toothpaste. My lips are not chapped, as in flaky or peeling, but they feel and look burnt, even blistery sometimes, and they can feel severely tight, dry and very sore. Actually, my upper lip is not as involved as my lower lip, and the corners are not affected. 

Photo sent by patient to VGRD

Diagnosis: This appears to be actinic cheilitis or possibly allergic/irritant cheilitis.  Strangely,  the patient got more sun in Vancouver than she does in French Polynesia!

What are your thoughts?

References:

1. Actinic cheilitis: a treatment review.
Shah AY, Doherty SD, Rosen T.
Abstract:  All other factors being equal, the presence of actinic cheilitis, a pre-invasive malignant lesion of the lips, doubles the risk of squamous cell carcinoma developing in this anatomic area. Various forms of local ablation, immunomodulation and surgical extirpation have been proposed as therapeutic interventions. This paper critically evaluates the available medical literature to highlight the evidence-based strength of each recommended therapy for actinic cheilitis. Vermilionectomy remains the gold standard for efficacy; trichloroacetic acid application is easy and convenient, but the least efficacious overall.

2. Contact allergy in cheilitis.
O'Gorman SM, Torgerson RR. Int J Dermatol. 2016 Jul;55(7):e386-91.
BACKGROUND: Recalcitrant non-actinic cheilitis may indicate contact allergy.
CONCLUSIONS: Contact allergy is an important consideration in recalcitrant cheilitis. Fragrances, antioxidants, and preservatives dominated the list of relevant allergens in our patients. Nickel and gold were among the top 10 allergens. Almost half (45%) of these patients had a final diagnosis of ACC. Patch testing beyond the oral complete series should be undertaken in any investigation of non-actinic cheilitis.

Tuesday, September 05, 2017

Man from India with Wide-Spread Vesicular Eruption


Presented by Dr. Bassem Ghali
Jagadguru Sri Shivarathreeswara University
Mysuru, India


The patient is a 60 yo man with a  pmhx of COPD who noted a recent eruption of vesicles on trunk, as well as his forehead and scalp. No fever. No other pertinent history. No itch. No pain. No new meds.
It started as blisters on the trunk, slightly itchy but no other symptoms, and not painful. The lesions opened up with clear fluid being expressed and leaving shallow ulcers. They have started become generalized with new lesions on the scalp and genitalia.

O/E:  Lesions appear like small bullae/vesicles on chest and abdomen, with clear fluid. In the center is what appears to be a black point, probably the hair follicle. There is no erythema on or around these lesions. 

Clinical Photo:

 Diagnosis:  What are your thoughts?