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.

68 year-old woman with subcutaneous lesions

This 68-year-old woman presented for evaluation of painful lesions under the skin that have been present for 3-4 months. She has a history of psoriasis, which is in remission, fibromyalgia, hypertension.  There is no personal history of malignancy.  No exotic travel.  She had smoked over two ppd for decades.

EXAMINATION: The examination shows a woman who appears slightly older than her stated age. She has 6-8 freely movable subcutaneous smooth-surfaced lesions on the back, posterior nuchal area, and the upper chest. The largest is ~ 5 mm in diameter. The remainder of the exam plus breast palpation was unremarkable.  No adenopathy appreciated.

INITIAL MPRESSION: Subcutaneous skin lesions, present for only a short period of time. Etiology is unclear.

PLAN: An excisional biopsy was taken today from the lesion on the right upper back.

Pathology: 

The first two are H&E of nodule in the fat, showing atypical cells with duct-like vacuoles. The second two are representative immunoperoxidase stains. GATA 3 is the nuclear one (dot-like pattern) and mammoglobin is the cytoplasmic staining.

Plan:  Mammography and breast ultrasound. Referral to oncologist.

Your thoughts will be appreciated.

References:

1. Mammaglobin, a Valuable Diagnostic Marker for Metastatic Breast Carcinoma Zhiqiang Wang1, et. al. Int J Clin Exp Pathol (2009) 2, 384-389

Free Full Text.

Abstract:  Identification  of  metastasis  and  occult  micrometastases  of  breast  cancer  demands  sensitive  and  specific  diagnostic  markers.  In  this  study,  we  assessed  the  utility  of  a  mouse  monoclonal  antibody  to  human  mammaglobin  for  one  such  purpose.  Immunohistochemical  stains  were  performed  on  paraffin-embedded  sections  from  a  total  of  284  cases,  which  consisted  of  primary  breast  invasive  carcinomas  (41  cases)  with  matched metastases to ipsilateral axillary lymph nodes, metastatic breast carcinoma to liver (1 case) and kidney (1 case), non-breast neoplasms (161 cases), and normal human tissues (39 cases). The results showed 31 of the 41 cases of primary breast cancer with axillary lymph node metastases were positive for mammaglobin (76%). In the meantime, we documented expression of mammaglobin in occasional cases of endometrial carcinoma (17%). Our data further validated that mammaglobin is a valuable diagnostic marker for metastatic carcinoma of breast origin, although endometrial carcinoma should be considered as a major differential diagnosis. 

2. GATA3 Expression in Common Gynecologic Carcinomas: A Potential Pitfall. Tatjana Terzic  et. al.  Int J Gynecol Pathol, 38, 485-492 2019

Abstract: GATA binding protein 3 (GATA3) immunohistochemistry is primarily used as a marker of breast and urothelial differentiation, particularly in metastatic settings. In the gynecologic tract it also serves a robust marker for mesonephric and trophoblastic tumors. Full Abstract: pubmed.gov PMID: 30059453

 

Melanoma-in-Situ

This 79 yo man has a pigmented lesion that has been slowly enlarging on his right arm for around a decade.

O/E:  There is a 3 cm pigmented patch with a subtle play of color on the dorsal surface of his right arm.  The border is slightly irregular.  Dermatoscopy confirms the play of color showing variations in brown patches containing black dots admixed with reticular hypopigmented areas.

Pathology:  A 4 mm punch biopsy was taken.  This showed atypical melanocytic hyperplasia arranged in nests and single cells at and above the dermal epidermal junction and extending along the adnexae.  (Photomicrographs courtesy of Dr. Lynne Goldberg, Department of Dermatology, Boston University School of Medicine)

Diagnosis: consistent with melanoma in situ (MIS).

Questions:

1) Is it possible to suspect MIS on dermatoscopy over melanoma in this case?

2) Although excision is the preferable treatment, would Mohs, or even imiquimod be acceptable alternatives?

3) How likely is this lesion to become invasive?  It's been present now for 10 years or greater.
4) Under what circumstances would "active surveillance" be appropriate.

References:

1. M A Pizzichetta  et.al.

Dermoscopic Criteria for Melanoma in Situ Are Similar to Those for Early Invasive Melanoma. Cancer, 91 (5), 992-7 2001

2. Kevin Phan, Asad Loya. Mohs Micrographic Surgery Versus Wide Local Excision for Melanoma in Situ: Analysis of a Nationwide Database. Int. J. Dermatol 58 (6), 697-702, Jun 2019

Conclusion: Adjusted analyses demonstrated no differences in overall survival or cancer-specific survival between MIS patients treated with MMS compared with WLE.

3. Long-Term Outcomes of Melanoma In Situ Treated With Topical 5% Imiquimod Cream: A Retrospective Review

Andrew J Park et. al. Long-Term Outcomes of Melanoma In Situ Treated With Topical 5% Imiquimod Cream: A Retrospective Review. Dermatol Surg: 43 (8), 1017-1022 Aug 2017

Results: Of 12 patients with histologically confirmed MIS treated with topical 5% imiquimod cream, there were 2 recurrences (17%) during a median follow-up time of 5.5 years.

Conclusion: Although surgery is still considered the gold standard for the treatment of MIS, imiquimod may represent a potentially effective noninvasive treatment option for patient who are not surgical candidates.

4.  D Tio, et. al. Variation in the Diagnosis and Clinical Management of Lentigo Maligna Across Europe: A Survey Study Among European Association of Dermatologists and Venereologists Members. J Euro Acad Dermatol, 32 (9), 1476-1484 2018

70 yo man with scaly plams and soles

A 70 year-old pediatric colleague from the Florida Keys sent us the following:

“I’ve been doing battle for the past few years with a rash that seemed to appear first on front of my right knee that seemed scaly, responded to clobetasol. Then, it decided to affect soles of both feet and palms of both hands,.  These were dry, thickened and split.  The fissures can be quite tender. Flares come and go over few months span.  I have noticed no pitting of my nails however I’ve either developed hypertrophic great toenails or fungus.  Topical antifungals were of no avail. The rash actually flared badly enough this last year that my great toe nails fell off. Of course they are growing back with similar thickening. I have not done KOH of any scrapings.  Topical clobetasol and moisturizing are my treatment at this time.

I am curious of your thoughts.  Please share these photos with colleagues  The were were taken after a two hour dive session.

Clinical Images:

Addendum: One of the commentators asked what medications this man is on.  The only one is tamsulosin.  Another asked about saturation diving.  No history of that.

21 year-old woman with solitary eschar

This 21 year-old college student presented with a 5 week history of an evolving lesion on the right leg.  She is in good health and takes no medications by mouth.  The lesion started with pruritus and pain and a solitary evolving bulla on her right leg.  She had walked through a wooded area the night before this developed. It has evolved into a dry eschar.  She has a history of a DVT on her right leg 2 years ago after tonsillectomy, bed rest and a long plane trip while on oral contraceptives.  To date, she has been treated with mupirocin ointment and a topical corticosteroid.

O/E: When seen there was a solitary 2 cm eschar on her right leg.  No erythema, no purulence.

Photos:

September 8, 2019 a.m.

September 8, 2019 p.m.

September 9, 2019

September 28, 2019

October 9, 2019

October 16, 2019 (Date of visit)

Labs: Pending

Diagnosis: Eschar.  Etiologic considerations:

Envenomation – Brown Recluse Spider Bite

Echthyma gangrenosum
Pyoderma gangrenosum (Antiphospholipid syndrome)

A lesion such as this in a young healthy immunocompetent woman suggests an antecedent insult such as a brown recluse spider bite, but we have no history to confirm that.  She is being worked up for underlying disorders that might predispose to echthyma.  However the antecedent DVT makes one consider an underlying problem such as the antiphospholipid syndrome.

Questions:

1.  What diagnoses do you entertain?

2.  At this time, what therapies do you recommend?

About Hydrocolloid Dressings.
1. Background.
2. Another useful resource on hydrogels.
3. Video Demonstration.

Reference:

The rash that leads to eschar formation. Dunn C, Rosen T.

Clin Dermatol. 2019 Mar - Apr;37(2):99-108. Author information

Abstract:  When confronted with an existent or evolving eschar, the history is often the most important factor used to put the lesion into proper context. Determining whether the patient has a past medical history of significance, such as renal failure or diabetes mellitus, exposure to dead or live wildlife, or underwent a recent surgical procedure, can help differentiate between many etiologies of eschars. Similarly, the patient's overall clinical condition and the presence or absence of fever can allow infectious processes to be differentiated from other causes. This contribution is intended to help dermatologists identify and manage these various dermatologic conditions, as well as provide an algorithm that can be utilized when approaching a patient presenting with an eschar.  Full Text.

73 year-old woman with wide-spread plaques

The patient is a 73-year-old woman with a two month history of an eruption that began on the buttocks and thighs. It has spread to the arms. The clinical picture was not diagnostic, so biopsies have been done.

She is in her usual state of health.  There is no history of systemic illness. Her medications include: amlodopine, metooprolol, ASA, all for a number of years.  She had a tetanus booster a week before the onset of the rash.

I thought this would probably be indolent but she has has developed marked pruritus.  Because of her symptoms she was treated with fluocinolnide oinment. This had no effect. Doxycycline was not tolerated due to GI symptoms.

Laboratory studies were done. CBC and chemistries were within normal limits. Her Lyme tighter was negative.

Examination shows large plaques on the buttocks and thighs that they are now appearing on the arms. The remainder of the examination is unremarkable. 

Clinical Images:

Pathology:

Dermal interstitial proliferation of histiocytes with focally increased dermal mucin and increased dermal mucin.  Individual collagen fibers are circumferentially ringed with histiocytes.  The dermatopathologist  feels this is either interstitial granuloma annulare or interstitial granulomatous dermatitis.  Images courtesy of Lynne Goldberg, Boston University Skin Path.

 Diagnosis: Interstitial granuloma annulare versus interstitial granulomatous dermatitis.
There is one reference on PubMed to granuloma annulare following DT vaccination.

Reference:
1. A case of granuloma annulare in a child following tetanus and diphtheria toxoid vaccination.

Baskan EB, et. al. J Eur Acad Dermatol Venereol. 2005 Sep;19(5):639-40

What are your thoughts?

Hypopigmented Macules in a Child

The patient is a 4 1/2-year-old boy who is seen today for evaluation of hypopigmented macules on the arms and legs for less than a week. His parents first notice this four or five days ago. He has been in his usual state of health although two days ago he developed a fever to 104.7  and was seen by his pediatrician who felt it was a viral syndrome. Throat culture was negative for strep.

On examination: This is a healthy appearing child. He does have a raspy cough. He has 5 to 7 mm in diameter hyperpigmented macules scattered over the arms and legs. Some of these lesions have a so much angular outline.

The patient's mother is a neighbor who lives about a one minute walk from my house, so they walked over and I took a look.

My initial thoughts are that this may be the onset of vitiligo,  The lesions are larger than itiopathic guttate hypomelanosis; but if this occurs in children it must be very rare. 

Your thoughts will be appreciated.  Should any tests be done at this time?

Wart in a 9 y.o. girl

The patient is a healthy 9 year-old girl.  Her pediatrician referred her for a two-year history of a wart on the right middle toe after the child could not tolerate cryosurgery.
On questioning, the child states that the wart rarely bothers her.  She can walk and run without discomfort. 

My advice was to leave it alone as it will probably regress over time.  I discussed how this occurs with the girl and her grandmother.

Would you treat this?  And if so, how?

If the comment function of VGRD is too cumbersome, you can email me directly at DJE.