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.

A 50 year-old man with fever and necrotizing leg ulcers

Presented by Dr. Henry Foong
Ipoh, Malaysia

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.

Physical examination revealed an anxious man, breathless, tachyphniec with hight temperature of 38 deg C. His left leg appeared edematous, extensively inflamed from the foot to the knee, tender, with 3 large and deep necrotic with sloughy ulcerations on the left lateral malleolus, dorsum of left foot and ankle. There was no purplish or undermining edge. The peripheral pulses dorsals pedis was good.

Diagnosis: Necrotising cellulitis left leg

Swab was taken from the leg wound but did not grow any pathogens. He was started on IV ceftriazone 1 gm bd, wash with dermazine solution, bactigrass followed by gamjee dressing.  His blood counts and biochemistry was unremarkable except severe hypoalbuminemia. He was given IV albumin 50mg daily for 3 days.  A skin biopsy was done to exclude pyoderma gangrenosum.  His CXR showed hyperinflated lungs suggestive of emphysema.  His X ray of the left was unremarkable. His fever persisted. What kind of wound dressing would you recommend? What other empirical antibiotics would you recommend - the culture did not grow any pathogens. 

 

Reference:

1. Unna Boot Efficacy in Dermatologic Diseases

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.

Oral Hairy Leukoplakia in a Healthy Teen

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

Clinical Images:

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 healthy individuals.

OHL 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.

References:.

1. 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. 2018 Sep;22(3):335-339.
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

Keywords: geographic 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)

 

 

 

 

An Infant With Uncontrolled Itching

 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. 

 

Questions:

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?

 

References:

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.

The Buried Penis

November 2020

In June of 2019 we presented a 26 yo man whose main problem was scrotal lymphedema related to hidradenitis supprativa (HS). In 2018, he had surgery at a major academic center to excise active HS lesions in both crural folds.  The operative report states that 20x8 cm were excised from the right groin and 20x6 cm from the left groin. This seems to have been antecedent to the development of scrotal lymphedema. His HS been recently managed with adalimumab, 40 mg per week. Gradually, the active inflammatory lesions have improved, although he still has some fistulous drainage. 

His main problem now is a buried penis. It’s interesting how he has adapted to this. The patient is reclusive. He lives with his parents and spends his days playing video games. When discussing these he displays a vast, enthusiastic knowledge. 

He is very anxious about spending time in hospital and prefers to stay home where his attentive parents care for him. 

We are presenting him to discuss "the buried penis," an unusual disorder, and to see if anyone has helpful suggestions. There were some recent in-depth reviews of “the buried penis” and we will see if the authors are interested in commenting.

 

Note:  It appears that there are surgical approaches that can help patients like this, but only a very small number of urologic or plastic surgeons have the interest and expertise in this topic.  Dr. Joel Gelman (see articles referenced below) kindly discussed the management of massive scrotal lymphedema  with me   He related the case of Wesley Warren whose 132 pound scrotal lymphedema he removed in 2013.   

 

Reference: 
1. Evaluation and management of adult acquired buried penis. Ho TS, Gelman J^. Transl Androl Urol. 2018 Aug;7(4):618-627. Free Full Text. 

 

2. Reconstruction of Massive Localized Lymphedema of the Scrotum: Results, Complications, and Quality of Life Improvements. Wisenbaugh E, Moskowitz D, Gelman J. Urology. 2018 Feb;112:176-180. Conclusions: Surgical treatment of MLL of the scrotum can be performed successfully for masses even up to 61 kg (134 lbs). Short-term wound complications are common, but subjective QOL scores improve dramatically. Despite expectations, most patients gained weight after mass removal, which indicates that they would benefit from a comprehensive weight loss plan that includes, but is not limited to, scrotal surgery. Free Full Text.

3. Various YouTubes of Wesley Warren's surgery can be found online.

Photoonycholysis and a Positive ANA

This 20 year-old woman developed a painful bilateral erythema of the skin at the margins of the thumbs and index fingers.  Around two weeks later, she noticed bleeding under one thumb nail and color changes under the other thumb nail.

She was seen at a walk-in clinic where no therapy was given but a battery of blood tests were done.  Among them was an ANA which was reported as positive with a homogeneous pattern and a titer of 1:640.  Her RF, C Reactive Protein and EST were normal as well as all other tests.

The positive ANA alarmed her and her parents and she sought a dermatological opinion.

The clinical images taken 3 weeks after onset show mild erythema at the margins between dorsal and palmar skin and the nail changes.

 

Further history revealed that she had been on doxycycline for acne  when the eruption occurred.

Diagnosis:  Phototoxic drug eruption from doxycycline with photoonycholysis.  I presume the positive ANA is a "false positive."  The test should probably not have been ordered.  As an incidental finding, taken out of context it can be anxiety-provoking.

References:

1. Doxycycline-induced photo-onycholysisDidier Rabar, Patrick Combemale, François Peyron.  J Travel Med. Nov-Dec 2004;11(6):386-7.
Abstract: Because  there  is  a  widespread  resistance  to  other drugs, doxycycline is often prescribed as chemoprophylaxis for malaria. Although this drug is commonly used for the treatment of acne vulgaris, no large studies have been conducted on the safety of doxycycline. However, several side effects, especially skin and nail disorders, are induced by this drug. In this article, we report a case of photoonycholysis in a woman undergoing doxycyclineprophylaxis for malaria.

2. Photo-onycholysis   Following Two   Weeks of Doxycycline. KC S, Karn D, Shrestha S. J Nepal Health Res Counc  2016 Jan - Apr;14(32):66-8
Abstract: Photo-onycholysis is a form of phototoxic reaction characterized by spontaneous separation of the nail plate from the nail bed. It usually follows drug intake and tetracycline is a well-known culprit. We present a case of 19 years gentleman who developed this rare side effect following two weeks of ingestion of doxycycline.

3. Antinuclear antibodies in healthy people and non-rheumatic diseases – diagnostic and clinical implications. Bogna Grygiel-Górniak, Natalia Rogacka, and Mariusz Puszczewicz. Reumatologia. 2018; 56(4): 243–248.  PMID: 30237629. Free Full Text.

Rotigotine Contact Dermatitis

The patient is a 90 yo man who has symptoms suggestion of Parkinson’s disease.  Four months ago his neurologist started him on Neupro^®, a Rotigotine Transdermal Therapeutic System.  His dosage was slowly increased.  The patient’s mental status is excellent, and although his back was pruritic, he could not see it.  A light-complected White with a history of skin cancer, he was seen for a regular follow-up examination during which a peculiar pattern of rectangular erythematous patches was noted.

Clinical Photo

 Diagnosis:  Probable allergic contact dermatitis to Neupro^®  (Rotigotine)

The Wikipedia page for rotigotine states:
“General side effects for rotigotine may include constipation, dyskinesia, nausea, vomiting, dizziness, fatigue, insomnia, somnolence, confusion, and hallucinations.[8][9] More serious complications can include psychosis and impulse control disorders like hypersexuality, punding, and pathological gambling.[10] Mild adverse skin reactions at the patch application site may also occur.”  However, PubMed has only one reference to  this dermatitis.  The case report was of a patient who developed ACD to the active ingredient, but not to the vehicle.

It is likely that ACD to rotigotine is not as uncommon as the literature would lead us to assume.

Reference:
Nadia Raison-Peyron, Bernard Guillot. Allergic contact dermatitis caused by rotigotine in a transdermal therapeutic system. Contact Dermatitis. 2016 Aug;75(2):121-2.
Abstract:  Allergic contact dermatitis caused by transdermal therapeutic systems (TTSs), resulting from the active drug, an adhesive, or an excipient, is rare. We report the first case of allergic contact dermatitis caused by rotigotine, a non-ergolinic dopamine receptor agonist, in a TTS in a patient treated for Parkinson’s disease.  In this patient the rotigotine patch test was positive and there were negative results with the rotigotine patch tests in 5 controls.