Friday, June 16, 2017

The Fung Shui Nevus

Presented by: Micah Ashkenazi
Root Town, Ohio

The patient is a 19 year-old American-born, Chinese college student living in Ohio.  Her mother brings her in for an office visit regarding a nevus..  The 2 mm in diameter lesion has been present near the bulb of the nose for years with no worrisome changes.

Diagnosis:  Acquired melanocytic nevus.  Possibly a blue nevus.

Discussion:  I reassured the patient's mother that this is a benign lesion and can be safely observed.  The mother only speaks Cantonese.  She and her daughter have a longish conversation in Chinese.  The daughter tells me that her mother believes that moles on this part of the nose have bad fung shui.  In that case, I acquiesced and agreed to remove the mole which can be done with a 3 mm punch.  A shave may leave some residual pigment and that would be unacceptable to them.

The patient and her mother take fung shui seriously and want the lesion removed.  This will be scheduled at a propitious time as decided by their astrologer in Chinatown.

Clearly, this is a cultural issue, not a medical one.  Failure to consider that might have led to a disconnect between the patient, her family and the physician. How many other similar scenarios have I missed over the years?

Reference:
PubMed is strangely silent on Feng Shui; however there are many references on Google.

Face Reading Feng Shui in Chinese Five Arts.  It says, " If there is a mole on the nose, it will be bad luck between 40 to 50 years old."

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  

Thursday, June 15, 2017

Single Digit Leuconycia

The patient is a 64 yo school teacher who presents for a white nail.
Anamnesis: "The nail has been white for at least 6 months.  No other fingernails or toenails are white.  I had a ring on that finger that got super tight. I have finally removed the ring.  Sometimes the finger hurts, even now, like it may be arthritic."

O/E:  The nail of the 4th finger of the left hand is uniformly white.  There is no flaking or friability.  Other than the color, the nail plate looks normal. All other finger- and toenails are normal

Photo:

Diagnosis:  Singe Digit Leuconycia.  This does not look like superficial white onycholysis.  At the time I saw the patient, I did not think to do a KOK prep since the nail plate looked so normal.  In retrospect, I think this should be done.

The patient's questions are:
Is there something I can do to get it back to being a normal color?
Will it ever go back on its own to being normal - no longer white?

Wednesday, June 07, 2017

Between a Rock and a Hard Place

This is the saga of a man whose care poses therapeutic dilemmas.

HPI:  The patient is a 69 yo man with a greater than 40 year history of severe psoriasis.  He was a research subject at a prestigious university hospital for many years.  Over that time, he has received PUVA, methotrexate and an investigational drug, Rapamycin.  He has been treated with NB UVB and acitretin with some improvement.  As a result of his therapies, he has developed numerous squamous cell carcinomas.  These pose therapeutic challenges They are painful, foul smelling and difficult for the patient to care for.  An additional problem is occasionally disabling trigeminal neuralgia.  He has had many well-differentiated SCCs excised over the past decade.  He has atrial fibrillation, Factor 5 deficiency and is on warfarin and a host of cardiac medication.

O/E:  Wide-spread erythema and scale covering entire integument except head and neck.  There is a 3 cm exophytic tumor of the left pre-tibial area and smaller similar tumors on right leg, back and chest.

Clinical Photos (6.6.17)
L. Pretibial
Diagnosis:  Generalized psoriasis, Squamous cell carcinomas

Questions:  Should these lesions be excised? Should we consider  one of the new targeted therapies?  Do any of our members have expertise with them?  This man has a number of co-morbidities which may make therapy more difficult.

References:

Oral therapy for nonmelanoma skin cancer in patients with advanced disease and large tumor burden: a review of the literature with focus on a new generation of targeted therapies.
Rudnick EW, Thareja S, Cherpelis B. Int J Dermatol. 2016 Mar;55(3):249-58
Author information
Abstract: This review of the literature aims to describe previous and current treatment options for oral therapy in locally advanced and metastatic NMSC otherwise unamenable to standard treatment. Oral Smoothened (Smo) inhibitors Vismodegib, Sonidegib, and Taladegib have shown to be effective in several trials. Oral tyrosine kinase inhibitors Erlotinib and Gefitinib, which target epidermal growth factor receptor (EGFR), have early supporting data and are currently undergoing large multicenter trials. Oral therapy in NMSC is useful in high risk patients with recurrent and aggressive disease who may not tolerate other systemic therapies.