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.

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.

Gluteal Lupus Vulgaris

Case Presentation
by Dr. Henry Foong
Ipoh, Malaysia

A 50-yr-old man presented with painful fissures at the right perianal area for one month.  It started as a small lesion and subsequently increased in size.  it was occasionally painful. 

He had seen a general surgeon previously and was treated with recurrent courses of antibiotics but had not improved. There was no bleeding per rectal.  He had no history of contact with TB.

Examination showed an ulcerated indurated plaque 8 x 22 cm on the right perianal area extending to the right gluteal area.  A similar plaque 3 x 7 cm was noted on the left perianal area. The edge of the lesion was irregular, slightly raised and nodular.  His regional nodes were not enlarged. 

A skin biopsy was performed. Section shows a fragment of skin composed of epidermis and dermis. A granulomatous inflammation is seen in the dermis. The granulomas are composed of epithelioid cells, lymphocytes and plasma cells. Infiltrates of neutrophils and eosinophils are also seen. Multi-nucleated giant cells and Langhan's giant cells are seen. In one granuloma caseation necrosis is seen. The overlying epidermis is unremarkable. There is no evidence of malignancy. Ziehl-Neelsen stain for acid fast bacilli is negative.
Periodic acid Schiff stain for fungi is negative.

Diagnosis: Cutaneous tuberculosis (lupus vulgaris)

Discussion

Base on the clinical and histopathological examination features this patient most likely has cutaneous tuberculosis (lupus vulgaris).  The word "lupus" means wolf and indeed the appearance of the face chewed by a wolf. Apart from the face, it can also affect the buttocks and the legs. The plaque type as seen in this patient is the commonest, though there are several variants eg ulcerative, hypertrophic, vegetating and nodular type. 0.5 to 10% develop complications of malignancy eg SCC/BCC.The diagnosis of cutaneous TB is often delayed when the index of suspicion is low.  Hence, it is often missed when it should not be missed because of its sequelae.

We welcome comments.  If you have trouble uploading them, you can send them to DJ Elpern and he will upload them.  Thank you! 

Within an hour of uploading this, Professor Sharquie alerted us to a similar case he published this year.  See Reference 1.

Reference: 

1. Granulomatous Reaction at the Site of Positive Tuberculin Skin Test is a Marker of Active TB (Clinical and Histopathological Study) American Journal of Dermatology and Venereology 2019;  8(4): 55-60  Khalifa E. Sharquie, Adil A. Noaimi, Fatima A. Khalaf Department of Dermatology, College of Medicine, University of Baghdad, Iraq FREE FULL TEXT [Courtesy of Professor Sharquir)

Select item 26333572. Clinicohistological Profile of Cutaneous Tuberculosis in Central Nepal.

 Mathur M, Pandey SN. Kathmandu Univ Med J (KUMJ). 2014 Oct-Dec;12(48):238-41.

No Worst, There Is None

The patient is a 26 yo man with an eight-year history of Hidradenitis supprativa (HS).  This began in his axillae but has progressed to groin, perineum and scrotum.  He has been treated doxycycline, minocycline, resection for groin and buttocks sinus tracts three years ago, and lastly Humira for over the past year, utilizing the standard doses recommended in the literature.*  He has constant pain for which he takes oxycodone 20 mg six times a day.  He was seen this week because of continuing pain, drainage and low grade fever (38 C).   He is essentially home bound and is cared for by a devoted mother.

The most affected area at present is his genitalia.   He has massive involvement of his scrotum with inflammatory draining lesions. 

Clinical Image:

Impression:  Ongoing hidradenitis stage III mostly affecting the scrotum at this point.  The picture is similar to what some label as “Scrotal Elephantiasis.”

Discussion: I do not think the Humira is impacting on the local disease at this time and he may need a surgical approach.  This could be ongoing inflammatory disease; but may eventuate into chronic lymphedema.  Another possibility is that the resection of the groin lesions may have caused impaired drainage.  Against this is the lack of leg edema.

We are looking for therapeutic suggestions and whether any of our members have successfully treated similar patients.  There are a few articles on surgical approaches in the urology literature.

References:

1.  Scholl L1, et. al. [Surgical treatment options for hidradenitis suppurativa/acne inversa].

[Article in German] Hautarzt. 2018 Feb;69(2):149-161.

Abstract:  Hidradenitis suppurativa/acne inversa (HS/AI) is a chronic inflammatory skin disease. Therapy consists of conservative and surgical treatment options. In Hurley stages II and III, surgical intervention is regarded as the method of choice for areas with irreversible tissue destruction. Resection techniques with different grades of invasiveness are described in the literature. Nevertheless, there is no generally accepted concept regarding resection and reconstruction techniques or specific postoperative care. Due to lack of definitions of recurrence after surgery and poor study quality, recurrence rates are difficult to determine.

2. Kimball AB, et. al. Two Phase 3 Trials of Adalimumab for Hidradenitis Suppurativa.

N Engl J Med. 2016 Aug 4;375(5):422-34. Full Free Text.

3. Hormonal therapies for hidradenitis suppurativa: Review.

Clark AK, Quinonez RL, Saric S, Sivamani RK. Dermatol Online J. 2017 Nov 12;23(10)..

Abstract: Hidradenitis suppurativa is a recurrent inflammatory skin condition characterized by abscesses and boils, predominantly in the groin, armpit, and buttocks areas. HS is not a life-threatening condition, but severely impairs quality of life in those affected. Finding a successful treatment approach for HS has been challenging, in part because of the lack of a gold-standard treatment method, limited research-based information, and the nature of clinical variation in the disease. Treatment commonly consists of antibiotics, anti-inflammatory therapy, hormonal therapy, and more invasive clinical procedures. Treatment is chosen by the degree of severity by which the condition presents and is modified accordingly. This review describes the roles of hormones in the pathogenesis of hidradenitis suppurativa and describes the use of hormonal therapy such as, finasteride, dutasteride, spironolactone, and oral contraceptives. The outcomes of the use of these modalities in various clinical studies are summarized.

*  The discounted retail cost of Humira for HS (40 mg weekly) is $10,000 USD a month or $120,000 year year.

 

Congenital Nail Dystrophy

The patient is a nine month old fraternal twin with mild developmental delays. No other pertinent history

She has opaque toenails that grow at an upward angle from the nail bed since birth. The great toenails continue to have an increasingly severe upward slant so that they are almost at a 90 degree angle to the nail bed. The nail plates show no thickening. Her fingernails are all normal. The skin of the feet and the rest of the body appear normal. No peeling or scale. No rash. The foot anatomy is grossly otherwise normal. The twin does not have the same condition. The parents are unable to put shoes on her because she seems to be in pain from her toenails. She does not seem bothered by socks or soft slippers. She is not walking yet, but should be within 2-3 months. they cut the nails short, but it doesn't offer enough relief to use shoes.  

Clinical Image:

Has anyone seen a similar patient?  What are your thoughts?

Note:  The infant will be seen by a dermatologist in a few days and a KOH prep will hopefully be done.