Sunday, December 19, 2021
Friday, February 26, 2021
Presented by Dr. Kaare Nordqvist
Grand Forks, North Dakota
The patient is a 35 y.o. television news reporter in a Midwestern state. For the past two yeas she has had inflammatory facial cysts. She had acne when younger, but it was not like this. Recently she’s been treated with intralesional triamcinalone, spironolactone (100 mg/d) and doxycycline 100 mg bid. She has relocated to her family home in North Dakota due to Covid-19.
History: Anamnesis reveals that she had been receiving Restylane and Juvederm for the past two years for old acne scars.
It’s not clear that this pauci cystic diathesis was typical of her earlier acne.
O.E: Deep cysts, 1.5 – 3 cm in diameter in cheeks, chin and nasolabial folds. At any time there are no more than two to three lesions. No other evidence of acne.
Diagnosis: Are we
dealing with pauci cystic acne or a reaction to HA fillers? It is known that
injected material can migrate and the literature suggests that HA reactions may be more common after viral infections.
This young woman was on the television news nightly. She is understandably concerned about these lesions and subsequent scarring once she in back in the public's eye.
1.Ofir Artzi et. al.
Delayed Inflammatory Reactions to Hyaluronic Acid Fillers: A Literature Review and
Proposed Treatment Algorithm. Clin Cosmet Investig Dermatol. 2020 May
2. Katie Beleznay et al. Delayed-onset nodules secondary to a smooth cohesive 20 mg/mL hyaluronic acid filler: cause and management. Dermatol Surg. 2015 Aug;41(8):929-39.
Monday, February 15, 2021
History: A 48-year-old woman was seen because of her concern about a
lesion on the left buttock. She is
worried that she had gotten a spider bite six months prior. It healed but she has had two similar episodes since then.
The patient is in her usual state of health. Her only medication is sertraline. She says she is not under any stress but I know that she has a 20-year-old daughter with psychiatric disease who is a great concern for her. She has one sexual partner who is asymptomatic.
O/E: On examination, the patient
has a cluster of resolving vesicular lesions on the left buttock.
Images: (Photos taken by patient and two weeks after acyclovir)
Further history reveals that she has seen a neurologist for sciatic symptoms down the left leg extending to the foot and has been diagnosed with sciatica, meralgia paresthetica and small fiber neuropathy. She was prescribed gabapentin for this (which she discontinued).
IMPRESSION: I believe she has
recurrent sacral herpes simplex. This
has also called been called "herpes buttockalis" in Iraq, and "herpes okolealis" in Hawaii. Some of these patients have secodary neurological symptoms.
I discussed this with her and prescribed acyclovir 400 mg t.i.d. which she will take for a month or so and then the dose will be lowered depending on symptoms.
Discussion: This patient interested me, because I saw a similar case in the mid 1980s and researched the topic at that time. He was in his 60s and had a history of recurrent sciatica and urinary obstruction. He’d been worked up by neurology, orthopedics and urology. One day, he came in with sacral HSV and anamnesis revealed that this had been going on a few times a years and seemed to be related to his recurrent HSV. I found the article by a Layzer and Conant1. When they wrote it, acyclovir was not on the market, but it was in 19852. I placed that patient on the then new acyclovir and his chronic neuropathy and urinary symptoms improved. I have always remembered this man.
This recent patient is similar. I did a Pubmed search on "Sciatica Herpes simplex" and found only 8 hits. Most old.
I suspect this may be an under-reported entity that is worth discussing. This woman likely underwent
an unnecessary neurological work-up and now is labeled now with "small fiber
neuropathy." It was recently reported in the Online Journal of Community and Patient-Centered Dermatology and Our Dermatology Online.
1. R B Layzer, M A Conant. Neuralgia in recurrent herpes simplex. Arch Neurol. 1974 Oct;31(4):233-7.
2. Oral form of acyclovir approved. FDA Drug Bull. 1985 Apr;15(1):3-4.
3. Herpes Okolealis. OJCPCD August 2015
4. Sharquie K. et. al. Herpes simplex (Buttockalis) of the buttock is a variant of herpes simplex genitalis Khalifa E. Our Dermatology Online 2020;11(e):e170.1-e170.5.
Monday, February 01, 2021
Then felt I like some watcher of the skies
When a new planet swims unto his ken…
The patient is a 35 yo OB/Gyn junior faculty with a 2 month history
of “Maskacne.” She uses a standard surgical mask for ~ 12 hrs a day. Her skin
care regimen is: “wash with Aveno cleanser, apply Cerave moisturizer. If going
out will apply Shiseido sunscreen as well. I try not to wear makeup under mask,
but if I do it will be Tarte foundation and a blush
Night time: wash with Avene cleanser, sometimes apply toner, and followed by Cerave moisturizer."
Prior to Covid 19 she only used a mask in the OR and
Labour & Delivery room but for the past 10 months she’s been masked 10 – 16 hrs a day.
O/E: Papules and pustules on the lower face.
Acneiform eruption under a mask in a young woman with no previous history of inflammatory acne.
In the Differential Dx
1) Perioral dermatitis
2) Demodex folliculitis
3) Oil acne/Occlusive acne
4) Acne mechanica (A report from the BMJ in 1976 is helpful. Strangely, this entity has been understudied)
Has any reader had experience with Maskacne? Your thoughts will be appreciated.
Addendum: I week after posting the patient writes "I just cleaned face without moisturizers this past week and it is improving
everyday. Still doesn’t look great but the pustules are gone (photos
1. Yu J, et. al. Occupational dermatitis to facial personal protective equipment in health care workers: A systematic review J Am Acad Dermatol. 2021 Feb;84(2):486-494. PMC Full Text.
2. Jillson OF, Perioral dermatitis. Cutis 1984 Nov;34(5):457-8.
3. Khalifa E Sharquie et.
al. Topical therapy of acne vulgaris using 2% tea lotion in comparison with 5%
zinc sulphate solution. Saudi Med J. 2008 Dec;29(12):1757-61. PMID. (See Prof. Sharquie's comment on this patient.
Conclusion: Two percent tea lotion was a good alternative remedy to be used in the treatment of acne vulgaris, and was much superior than topical 5% zinc sulphate solution.
4. Acne mechanica. BMJ 1976 Jan 17;1(6002):130. PMC1638630 Free Full Text
Wednesday, January 20, 2021
Presented by Dr. Henry Foong
The patient is a 50-year-old chef who presented initially with blisters on the left leg. Within 3 days, the leg had swollen, painful with redness over the left leg. He was admitted to the local hospital and was treated by an orthopedic surgeon for cellulitis for 10 days. He requested AOR (at own risk) discharge and came in to seek for 2nd opinion. His other medical history included COAD and hypertension.
Gabriella Santa Lucia et. al.J Am Acad Dermatol. 2020 Nov 25;S0190-9622(20)33059-0.
Conclusion: Unna boot (UBs) are an inexpensive and noninvasive treatment strategy in which compression, antioxidants, physical restraint, and improved topical medication absorption enhance healing as well as quality of life measure. Even though the UB has been employed successfully by dermatologists for over a century, prior research regarding diseases treated, concurrent therapies used, and adverse events reported is minimal and UBs remain underutilized. Our findings suggest clinicians should consider using UB for a wide variety of dermatologic diseases when conservative management is a viable option. These results highlight that UBs are effective and well tolerated across a spectrum of pathologies, but also versatile in the locations where they can be applied.
Wednesday, January 06, 2021
Presented by Dr. Rosamonde St. Pierre, Laval, PQ, Canada
The patient, a 14-year-old girl, who presented with a mildly painful
process on the lateral borders of the tongue for about 4 months. She is a
healthy child whose only medication is oral contraceptives for heavy menstrual
cycles. She has never used inhaled steroids or nose drops; but did have mononucleosis at 4 or 5
years old. There is no history of blood transfusions. The affected areas are sensitive when she
eats spicy or acidic foods.
OE: The examination shows rough, whitish papillae on the lateral margins of the tongue. KOH prep was negative for Candida
October 2020 (taken by patients mother:
January 2021 (taken at dermatologist office)
Diagnosis: Oral Hairy Leukoplakia (OHL) must be considered. Although
OHL was first described in association with HIV/AIDS, it has been reported in otherwise
was first described in 1984, and initially all OHL patients had HIV/AIDS. Over the years, it has been seen in people
with other immunedeficiencies and even in patients with normal immune
systems. This patient has no risk
factors for immune compromise or HIV/AIDS. The question Dr. St. Pierre asks is how aggressively
this 14 year-old should be worked up? Florid OHL is much more impressive in its appearance. This patient's lesions are subtle and appear to be resolving without treatment.
Oral Hairy Leukoplakia
Manu Rathee 1 , Prachi Jain 2
In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan.
2020 Apr 22. Free Full Text.
2. Darling MR et al. Oral Hairy Leukoplakia in
Patients With No Evidence of Immunosuppression: A Case Series and Review of the
Literature. J Can Dent Assoc 2018 May;84:i4.
Abstract: Objectives: Oral hairy leukoplakia (OHL) is caused by Epstein-Barr virus (EBV) and is often associated with HIV and other immunosuppressive conditions. It is rare in HIV-negative patients, but has been reported in patients who use immune-modulating medications (e.g., cyclosporine).
Study design: A series of 7 new cases of OHL among HIV-negative patients is described. Langerhans cells were counted using an immunoperoxidase stain for CD1a and light microscopy.
Results: The 7 patients were male, ranging in age from 26 to 69 years. Clinically, all lesions were diagnosed as leukoplakia on the lateral border of the tongue. Microscopic examination revealed hyperparakeratosis and candidiasis in some cases, acanthosis and a band-like zone with clearing of cells in the upper spinous layer, which were EBV-positive by in-situ hybridization. There was a significant decrease in Langerhans cell counts in OHL patients.
Conclusion: OHL can occur in HIV-negative patients.
3. Shanahan D et. al. Oral hairy leukoplakia in
healthy immunocompetent patients: a small case series. Oral Maxillofac Surg.
Conclusion: Physicians must have a high index of suspicion for OHL when considering a differential diagnosis for white patches on the lateral borders of the tongue in apparently healthy immunocompetent patients. OHL should no longer be solely attributed to HIV infection, or immunosuppression. Greater awareness of OHL may lead to further cases in immunocompetent people being reported, particularly as our population ages.
4. Kyle Burke Jones, Richard Jordan. White lesions in the oral cavity: clinical presentation, diagnosis, and treatment. Semin Cutan Med Surg. 2015 Dec;34(4):161-70
tongue; hairy tongue; leukoedema; nicotine stomatitis; oral frictional
hyperkeratosis; oral leukoplakia; oral lichen planus; oral lichenoid reaction;
oral squamous cell carcinoma; smokeless tobacco keratosis; white sponge nevus. (see comment # 7)
Thursday, December 24, 2020
The patient is a 6-month-old infant who presents with a history of “eczema” since age 3 months.
The parents’ main concern is uncontrolled rubbing and scratching. He lives with his parents. They have a dog (a Yorkie) and 2 cats. His mother had eczema as a baby in Brazil and her sister has atopic dermatitis. His aunt's eczema is still quite active although the mother is doing better. She does, however, have respiratory allergies and is on immunotherapy per allergist.
They are using hydrocortisone 2.5% cream as necessary, avoiding bathing as much as possible, and have found that Vaseline seems to work the best. The real problem is that Vinny rubs and scratches his skin daily.
On one occasion, when the dog licked him, he developed contact urticaria, which lasted a few minutes and disappeared, but the dog licks him all the time and mostly there have not been problems.
EXAMINATION: The examination shows a pleasant, well-cared for infant. He has a suggestion of Dennie-Morgan folds. His skin is generally xerotic but there is no acute crusting. There are some mildly erythematous patches. Otherwise, the exam was unremarkable. Photographs were taken.
IMPRESSION: Generalized pruritus in an infant. He has little in the way of skin findings. Relatively strong family history of eczema. Animals at home. The child was bottle-fed. The parents have tried many different types of formula and present he is on Similac. He is eating solids, but problem began before that.
The main problem is how to control his itching since this leads to rubbing and scratching.
1. Should one consider alternative diagnoses?
Is there a role for
lab tests? CBC, CMP, IgE, others
2. What is the role of allergy testing at age six months?
RAST tests to foods, environmental and animals
3. Should antihistamines be prescribed, and it so what is your choice for an infant?
1. Martin Metz et. al. Chronic pruritus associated with dermatologic disease in infancy and childhood: update from an interdisciplinary group of dermatologists and pediatricians. Pediatr Allergy Immunol. 2013 Sep;24(6):527-39. Abstract.
2. U Blume-Peytavi, M Metz. Atopic dermatitis in children:
management of pruritus. J Eur Acad Dermatol Venereol. 2012 Nov;26 Suppl 6:2-8. Abstract.