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.

70 y.o. man with pre-auricular plaque

Presented by Dr. Henry Foong, Ipoh, Malaysia

The patient is a 70-yr-old man with a 2-month history of mildly pruritic skin eruption on the right preauricular area.  It has gradually increased in size and also felt "thicker" and more "lumpy".  He is otherwise in good health.

O/E shows a well demarcated hyperpigmented patch on the right preauricular area 7.5 cm x 3.0 cm.  on palpation it felt boggy. Regional nodes were not enlarged.  There was no facial nerve palsy.

 

Biopsy:

Microscopic:  Dense superficial and deep infiltrate of lymphocytes and plasma cells.  The deeper dermis shows markedly increases eosinophils. Angiolymphoid proliferation is absent as are granulomas or nerve hypertrophy.

 

Diagnosis:  My thoughts are lymphocytoma cutis versus angiolymphoid hyperplasia with eosinophila (ALHE)' but I have limited experience with these. 

Your suggestions would be appreciated.

 

Reference:

Burhan Engin, et. al. Lymphocytic infiltrations of face. Clin Dermatol. Jan-Feb 2014;32(1):101-8.
Abstract:  The immune system protects our organism and, of course, our skin from harmful factors. One of the key elements of the immune system is lymphocytes. Lymphocytes play a role in the pathogenesis of various skin diseases. Lymphocytic infiltrates are seen in many skin diseases. Some of the skin diseases characterized by lymphocytic infiltration show up in specific anatomic locations, whereas other entities can be placed in all areas of the body. The course of lymphocytic infiltrations of the face is variable and unpredictable, most often lasting from months to years. The most important diseases with lymphocytic infiltration of the face are pseudolymphomas. This review discusses various types of cutaneous pseudolymphomas and other diseases with lymphocytic infiltration mainly involving the face.

 

 

Cystic Acne vs. Filler Reaction

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.

Clinical Images:

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.

References

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 18;13:371-378. PMC

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.

Herpes Simplex Neuralgia

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.

 

References:

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.

Maskacne

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.

 Diagnosis:  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 below).

Reference:
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

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

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.

3.19.20 Addendum:
CBC and HIV tests are both normal.  We are considering the diagnosis of "oral frictional keratosis" in this otherwise healthy teenager.  Further history reveals that she is seeing an oral surgeon for bruxism.  Her tongue is symptomatic and she complains of pain when eating acidic foods. (See reference 5)

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)

5. Sook-Bin Woo, Dorothy Lin. Morsicatio mucosae oris--a chronic oral frictional keratosis, not a leukoplakia. J Oral Maxillofac Surg. 2009 Jan;67(1):140-6.
Conclusions: MMO is a form of chronic oral frictional keratosis that has no malignant potential, and should be signed out as such and not merely "hyperparakeratosis and acanthosis" so that it can be removed from the category of leukoplakia where it does not belong.