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.

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.

Infiltrating BCC of the Ala

The patient is a 58 yo man in fair health.  He suffers from anxiety and depression as well as diabetes and coronary heart disease and is status past CABG.  He was brought in by his female companion who noticed a lesion of the left ala.

O/E There is a nine mm indurated lesion with some surface erosion.

Image:

A 3 mm punch biopsy was difficult because of his severe agitation.  The pathology showed a deeply infiltrating basal cell.

Questions:

Given this patient’s pervasive anxieties, should one consider XRT over Mohs surgery?  The latter might also cause some deformity and may require a complicated reconstruction.  Of course, I will lay out the choices to the patient and his companion; but I thought this was a good question for our members to consider and weigh in on.  Some great unknown medical sage said, “Sometimes, it is may be more important to treat the patient who has the lesion, than it is to simply treat the lesion the patient has.”

Extensive Pruritic Vulvar Plaque in an 84 year old Woman

An 84-yr-old woman presented with a pruritic vulvar plaque for more than a year.  It was increasing in size extending from the vulva to the surrounding areas. She was otherwise well and did not have any constitutional symptoms such as fever or weight loss. She had seen few doctors and a gynaecologist but did not improve. She was treated with topical fucidin cream, clotrimazole cream and moisturisers. Her past medical history was insignificant.  She is a housewife.

Examination showed an irregular asymmetrical extensive erythematous plaque on the vulva extending to the suprapubic, groins, perianal areas and anus.  Some of the lesions on the periphery appeared hyperpigmented and nodular.  Her regional nodes were not enlarged.

Diagnosis: Extramammary Paget Disease

Differentials needed to be considered included Bowen disease and malignant melanoma

A skin biopsy was done and pending results.  She may need assessment of other malignancy eg urological or gynaecological cancers.

Treatment could be challenging as the plaques are so extensive.  Surgical excision probably not advisable at her age  - may need multi disciplinary surgeons eg O & G, urologist, plastic and colorectal surgeon. Not sure about role of radiotherapy but am starting her on topical imiquimod cream every other day.

A Young Girl with Ulcerated Lips

A 14-yr-old girl had severe blisters on the lower lip of 5 days duration.  It was painful and developed into superficial painful ulcerations of the lips.  Then she experienced eye discomfort with eye discharge esp in early morning.  There were no red eyes though.  She did not have any fever or any polyarthralgia.  No genital ulcerations. She is a secondary school student and stays with parents with no unusual habits. There was no family history of similar illness.  There was no recent drug history including OTC products, supplements and traditional chinese medicines. 

Examination was unremarkable except superficial ulcerations on the lower lip and to a certain extent on the upper lip too. The ulcerations was covered with yellowish slough and crusts.  Superficial erosions were noted on the inner buccal mucosa. No genital ulcerations.  No blisters elsewhere. 

Rest of exam unremarkable.

Diagnosis

Aphthous ulcerations - severe

Differentials considered were First episode orolabial HSV infection, drug eruptions, pemphigus vulgaris, erythema multiforme.

Blood counts and biochemistry was done as well as ANA serology.  HSV I and II serology was not done due to financial reasons. If she does not improve I think this patient may require a biopsy.

She was treated with oral prednisolone 20mg bd, topical triamcinolone gel bd and oral azithromycin 250mg daily. Your comments on this patient would be highly appreciated.

References:

1. Mucosal erosions as the presenting symptom in erythema multiforme: a case report. Spencer S, Buhary T, Coulson I, Gayed S. Br J Gen Pract. 2016 Mar;66(644):e222-4.  Free Full Text.

Follow up: Good response to treatment with oral prednisolone and azithromycin. Lesions were drying up and clearing.

-->