Monday, April 10, 2017

Pruritic Nodules

The patient is a 32 year old Hispanic woman with a 2 year history of pruritic nodules on her knees, right ankle and dorsum of right hand.Her health is good otherwise and she takes no medications by mouth.  She denies kneeling, rubbing or manipulating the skin.  Her primary physician has give her various topical steroids which were not effective.

O/E:  There are a few hyperpigmented nodules in these areas.  She has Type IV skin.

Lab:  None

Diagnosis: Similar lesions have been seen after  trauma from habitual pressure from kneeling, surfing, praying: but thepatient denies these.

I am not hopeful about impacting here.  What thoughts do you have?  Are any lab tests or biopsy indicated?

Thursday, April 06, 2017

78 yo man with scalp lesions

Abstract:  78 yo man with 1 year history of scalp lesions.

May 9,2016:  Cryotherapy 4 keratoses on vertex of scalp
August 11, 2016: Crusted lesions at site of cryotherapy.  Clinical diagnosos of erosive pustular dermatosis of scalp made.  Treated with mupirocin oint and clobeyasol ointment  Initially improved.
Sept 9 2016:  Resolved
10/24/2016: Continued to do well
April 4, 2017: Recurrent lesions on vertex of scalp.  Thick crusted lesions (see photo)  The crusts were brownish and dirty looking, but unfortunately I removed them before taking the photo of April, 2017.

O/E:  What was initially hypertrophic keratosit papules were transformed into ~ 1 cm crusted erosive lesions.

Clinical  Photos:
Note pustule
4.4.17 (after crusts removed)
s/p 1 week Chlorhexidine, 4 days tacrolimus 0.1%

Lab:  August 11, 2016: + Staph aureus from lesion Vx scalp - usual sensitivities

This is either erosive pustular dermatosis of the scalp or squamous cell ca.  The rapid worsening since cryotherapy suggests the former.  It appears that biopsy may be necessary.  Not all cases of EPD respond to clobetasol ointment.

Questions:  Is this EPD or are these lesions squamous cell carcinomas.  Patient is reluctant to have a biopsy done. This process appears to have been gtriggered by the trauma of liquid nitrogen and did respond initially to clobetasol.  10 - 20% of EPD cases appear to be non-responders ro clobetasol.

Follow-up.  Marked improvement following chlorhexidine wash daily and topical tacrolimus 0.1% ointment at the suggestion of a colleague.  He recurred after clobetasol ointment.

1. Erosive pustular dermatosis of the scalp: Clinical, trichoscopic, and histopathologic features of 20 cases.  [Current and thorough review]
Starace M, et. al.: J Am Acad Dermatol. 2017 Feb 14.
BACKGROUND: Erosive pustular dermatosis of the scalp is a chronic eruption that leads to scarring alopecia.
OBJECTIVE: The clinical, dermoscopic, and histopathological features and the course of the disease in 20 patients were reviewed and compared with the reports in the literature.
RESULTS:The mean age was 59.4 years. Androgenetic alopecia was present in 12 patients, 6 of whom showed actinic damage. Trauma was reported in 9 patients. Four patients were affected by autoimmune disorders. The vertex was the most common location. In all 20 patients trichoscopy showed an absence of follicular ostia with skin atrophy. Histopathology revealed 3 different features, depending on the disease duration. A reduction of inflammatory signs was observed in 14 patients treated with topical steroids and in all 3 patients treated with topical tacrolimus 0.1%.
CONCLUSIONS: The relatively high number of patients allowed us to identify a better diagnostic approach, using trichoscopy, and a more effective therapeutic strategy, with high-potency steroids or tacrolimus, which should be considered as first-line treatment.

2.  Disseminated Erosive Pustular Dermatosis also Involving the Mucosa: Successful Treatment with Oral Dapsone (Free Full Text)
Jamison D. Feramisco.  Acta Derm Venereol. 2012 Jan; 92(1): 91–92.

3.  Erosive pustular dermatosis of the scalp: a review with a focus on dapsone therapy.
Broussard KC. J Am Acad Dermatol. 2012 Apr;66(4):680-6
BACKGROUND: Erosive pustular dermatosis of the scalp (EPDS) is an inflammatory disorder of unknown origin characterized by pustules, erosions, and crusting in areas of alopecia that tend to be atrophic, actinically damaged, or both. The most common treatments reported include antibiotics and topical anti-inflammatories, which can be ineffective. In the search for effective treatment for EPDS, we share our experience with topical dapsone 5% gel.
OBSERVATIONS:We present 4 patients with EPDS, all with classic clinical presentations and histologic findings of EPDS, who had failed a variety of treatments including oral, intralesional, or topical steroids, tacrolimus, and antibiotics. All patients demonstrated rapid improvement or resolution with topical dapsone 5% gel.
CONCLUSION: Our observations demonstrate topical dapsone 5% gel to be a novel, safe, and efficacious therapeutic alternative for mild to moderate EPDS.

Monday, April 03, 2017

Herpes Zoster in a 10 year-old

The patient is an otherwise healthy ten year-old boy with a two day history of grouped zosteriform vesicles on the left arm, anterior shoulder and upper back.  He has mild discomfort.  No known illnesses and on no medication.  He had two immunizations for varicella at the approopriate ages.

Observation:  All of the grouped vesicles appeared to be of uniform size.

Lab:  A Tzanck smear was positive for multinucleated giant cells.

Diagnosis:  Herpes zoster roughly C3 - 6.

Herpes zoster in children is unusual but not all that rare.  There are a few cases of HZ after vaccination for varicella.  As he felt well, and as the effect of specific antiviral therapy is not striking; after discussion with his mother it was elected to simply follow.  In out opinion, in healthy children and young adults the course of HZ is usually relatively mild and almost never followed by post-herpetic neuralgia.  Immunity seems to wear off over time and it appears that this attenuated vaccine is capable of causing H.Z.  The other possibility is that this is zosteriform simplex.  We did not culture for that. 
While researching this case, we looked up "zosteriform simplex."  An observation (ref 4) indicates that in these patients the vesicles are of uniform size (as we see here).  This would tilt us towards a diagnosis of Zosteriform Herpes Simplex here, and not of vaccine failure.  Should this child get a recurrence, that would clinch the diagnosis.

1. Herpes zoster in children.
Peterson N, Goodman S, Peterson M. Cutis. 2016 Aug;98(2):94-5.


Herpes zoster (HZ) in immunocompetent children is quite uncommon. Initial exposure to the varicella-zoster virus (VZV) may be from a wild-type or vaccine-related strain. Either strain may cause a latent infection and subsequent eruption of HZ. We present a case of HZ in a 15-month-old boy after receiving the varicella vaccination at 12 months of age. A review of the literature regarding the incidence, clinical characteristics, and diagnosis of HZ in children also is provided. 
2. Herpes zoster and zosteriform herpes simplex virus infections in immunocompetent adults.

Kalman CM, Laskin OL. Am J Med. 1986 Nov;81(5):775-8.

Abstract: Among 111 immunocompetent patients referred to a general hospital setting with the clinical diagnosis of herpes zoster, viral cultures were obtained from 47 patients. Six of these patients (13 percent) had herpes simplex virus isolated, with four of the six infections involving the facial distribution, and the other two involving the T4 (breast) distribution. Excluding those in whom herpes simplex virus was isolated, the mean age (+/- SD) of the remaining 105 patients was 50 +/- 19 years. Thirty-two percent of the patients were at least 65 years old; however, 39 percent were younger than 40 years of age. Thus, herpes zoster frequently occurs in young, immunocompetent adults. Also, since zosteriform rashes may be caused by herpes simplex virus, viral cultures of lesions are useful to differentiate infections caused by herpes simplex virus from those due to varicella-zoster virus. The need to distinguish between these two viruses may be important with the advent of antiviral drugs and for use of the proper epidemiologic isolation procedures.
3. Varicella Vaccine (Wiki)
Vaccines are less effective among high-risk patients, as well as being more dangerous because they contain attenuated live virus. In a study performed on children with an impaired immune system, 30% had lost the antibody after five years, and 8% had already caught wild chickenpox in that five-year period.

4. Zosteriform herpes simplex and herpes zoster: A clinical clue

Sanath Aithal, Sheela Kuruvila, and Satyaki Ganguly. Indian Dermatol Online J. 2013 Oct-Dec; 4(4): 369.  Free Full Text.

Excerpt: An important clinical observation by many authors that the vesicles of herpes simplex are uniform in size in contrast to the vesicles seen in herpes zoster, which vary in size. In other words, vesicles of herpes simplex are uniform within a cluster.

Sunday, March 05, 2017

Vascular Lesion in a Six Year-Old

The patient is a 6-year-old boy who was seen for evaluation of a lesion on his right knee that has been present since infancy.  When he is active it swells up a bit and is uncomfortable, if not painful. He is in otherwise good health and his identical twin has no such lesion.  The child has seen by his family practitioner and two or three pediatricians.  He has had ultrasounds and x-rays, but none were diagnostic.  

O/E:  The examination shows a subtle dusky area on the right knee.  There are some vascular lesions within the area that are a millimeter in diameter or less.   Dermatoscopy more clearly defines them.

Clinical Photos:

PLAN:  A 4 mm punch biopsy was taken for diagnostic purposes. He may need to be referred to a center where they deal with vascular anomalies.   

Lymphatic malformation consistent with, in the appropriate clinical setting, lymphangioma.
The specimen exhibits compact hyperkeratosis, papillomatous epidermal hyperplasia, focal acanthosis, a sparse superficial perivascular lymphocytic infiltrate, and multiple dilated, irregular thin-walled vessels lined by a single layer of bland endothelial cells in the papillary dermis.

IMPRESSION:  Vascular anomaly: Lymphangioma    

Thursday, March 02, 2017

FitBit Dermatitis

The patient is a 54-year-old woman with a history of severe  atopic dermatitis.  She was seen today for evaluation of a dermatitis on the left wrist that began under her Fitbit Alta.  She thought that it might be an infection so she started applying Neosporin and within a day, it was much worse. 
During the intervierw, the patient said, with feeling, "I love my FitBit."

O/E:  The examination shows a localized area of dermatitis with crusting on the left wrist.  It is quite inflamed.


IMPRESSION:  Possible irritant versus allergic reaction to Fitbit followed by application of Neosporin with what appears to be an allergic contact dermatitis.           

PLAN:  She will need to stop the Fitbit for the time being.  Fluocinonide 0.05% ointment twice a day to area.  Wet compresses.  Return as necessary.


Initially, "Fitbit recalled the trackers and blamed rashes on allergic reactions to the nickel and glue in the wristband. However, scientists at the Consumer Product Safety Commission were testing a different theory.

They found that sweat in the charger caused a chemical reaction that produced a toxic compound, saying: "This scenario is supported by one consumer stating their injury occurred after charging... and a skin burn the shape of the charging port in another incident."
See: Possible cause of Fitbit rashes uncovered.

This it is unclear at this point.  Nickel allergy is easy to test for, however.


Friday, February 24, 2017

A Nail Struggle

Isolated Nail Dystrophy - Left Thumb

My Nail 2 March 2015
March 2015
"I’m not sure exactly how I damaged my nail, but it happened in May 2014 when I was working outdoors clearing brush. Either I banged it really hard or dropped something on it. It never really hurt, but it quickly became unsightly, with lots of bruising, mottling from black to deep mahogany to orange to yellow. The nail developed a significant ridge until October 2014, when it came off in one piece.

Underneath was what you saw pictured above, a partial nail that is quite horny and yellow on the lower right and not tightly attached; it seems to grow outward rather than lie flat. I had an acrylic nail put on when I had to be very public for a couple of weeks; otherwise I’ve mainly kept a bandaid over it so that I won’t keep hitting it and also because it’s so ugly."

Note:  A KOH scraping was negative and fungal culture was taken

Six month Follow-up.
The culture grew out (Scopulariopsis), a saprophytic fungus and the patient has been using topical Tea Tree oil.  There has been marked improvement.  We recommend continued conservative management.  The nail did not continue to do well and the patient took terbinafine 250 mg a day for 3 month (no benefit).

January 2017
The patient's nail now shows signs of onycholysis.  It now has a green color indicative of "chloronychia." This is probably psudomonas.  She has had a nail dystrophy now for ~ two years. I think probably best to treat for pseudomonas, but the patient is wondering if her nail should be removed.

February 24, 2017
Dermatoscopy of Nail Fragment
photomic of Scopularopsis (from WWW)

The nail was pared back.
The patient will apply 40% urea cream to the nail plate and bed and tape the surrounding area.
She will use topical gentamycin and a topical antifungal.

This is the appearance six weeks after nail trimmed back which was followed up by topical gentamycin for pseudomonas, Jublia, and one pulse of itraconazole (400 mg daily for seven days)  Two more pulses are planned.

What would be the best topical antifungal available in the U.S. for this patient?
Is there a role for a different systemic antifungal, such as itraconazole? (Terbinafine was not successful)
What role does the taping play?


Myung Hoon Lee, M.D., et. al. Ann Dermatol. 2012 May; 24(2): 209–213.  Free Full Text.

2. Anchor Taping Method per Dr. Hiroko Arai.

3. Onychomycosis caused by Scopulariopsis brevicaulis: report of two cases.
Lee MH1, Hwang SM, Suh MK, Ha GY, Kim H, Park JY.  PMC Full Text
Ann Dermatol. 2012 May;24(2):209-13.
Abstract: Onychomycosis is usually caused by dermatophytes, but some nondermatophytic molds and yeasts are also associated with invasion of nails. Scopulariopsis brevicaulis is a nondermatophytic mold found in soil as a saprophyte. We report two cases of onychomycosis caused by S. brevicaulis in a 48-year-old male and a 79-year-old female. The two patients presented with a typical distal and lateral subungual onychomycosis. Direct microscopic examination of the potassium hydroxide preparation revealed fungal elements. From toenail lesions of the patients, brown colonies with powdery surface, which are a characteristic of S. brevicaulis, were cultured on two Sabouraud's dextrose agar plates. Three cultures taken from nail plates within a 2-week interval yielded similar findings. Numerous branched conidiophores with chains of rough walled, lemon-shaped conidia were observed in slide culture by light microscopy and scanning electron microscopy. The nucleotide sequences of the internal transcribed spacer for the two clinical isolates were identical to that of S. brevicaulis strain WM 04.498. To date, a total of 13 cases of S. brevicaulis onychomycosis including the two present cases have been reported in Korea. Mean age of the patients was 46.1 years, with a higher prevalence in males (69.2%). Toenail involvement was observed in all cases including a case involving both fingernail and toenail. The most frequent clinical presentation was distal and lateral subungual onychomycosis in 12 cases, while one case was proximal subungual onychomycosis.

Thursday, February 09, 2017

Acneiform Drug Reaction

The patient is a 32 yo student from the Central African Republic. On coming to the US he was discovered to have "latent TB" and offered isoniazid,  He elected to take this and started it in September 2016.  Around a month later, he developed deep-seated papules and pustures on his back, chest, neck and to a lesser extent face.  Treatment with a cephalosporin and Bacrim were not successful. He has also had an undiagnosed eye problem during the same period of time.

O/E There are cystic and somewhat purulent lesions in the above-mentioned areas.  This is most pronounced on the chest.

Dx:  Acneiform eruption secondary to INH.
Plan:  1. A biopsy will be done to confirm the clinical impression. 
2. Will need to get advice on whether to treat.
3. He seems to want prophylaxis for TB. Will find out about alternatives.
Does anyone have experience treating this type of acne?