Thursday, December 19, 2019


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.

Monday, January 14, 2019

Subtle Facial Lesion in a Four Year-old Boy

The patient is a four year-old boy who was referred for evaluation of a slightly rough patch on his right cheek that has been present for over a year.  He is otherwise well.

O/E:  There is a subtle 1.5 cm in diameter erythematous patch on his right cheek.  Dermatoscopy revealed a group of sharply demarcated plugs that appear to be comedones.  Clinically, this was not as evident.

Clinical and Dermatological Images:
 Diagnosis:  Small subtle nevus comedonicus.

Discussion:  I feel this is probably a nevus comedonicus.  I’ve only seen a few of these and all were obvious: not so with this case.  Not much is known about the evolution of these lesions.  Topical retinoids are of some value; but since this doesn’t bother the patient I am reluctant to have his mother rub a topical agent on the area for two to three months.  Does anyone feel that tazarotene is preferable to tretinoin in similar cases?  Comedone extraction would be easy, but can be traumatizing in a young child.  Once I hear other ideas I will discuss options with his parents.

1. Dermoscopy on nevus comedonicus: a case report and review of the literature.  Kamińska-Winciorek G1, Spiewak R.
Postepy Dermatol Alergol. 2013 Aug;30(4):252-4.  Free Full Text.

2. Nevus comedonicus: an updated review. Tchernev G, et. al. Dermatol Ther (Heidelb). 2013 May 25;3(1):33-40. Full Free Text.

Wednesday, January 09, 2019

Erysipelas in a 69 yo Woman

presented by Henry Foong
Ipoh, Malaysia

A 69-yr-old woman was seen with a 2-day history of rapidly enlarged swelling on the right cheek.  Initially she felt some discomfort on the right ear and then involved the right cheek.  She had no fever.
There was no history of trauma.  She had a history of hypertension. 

Examination showed unilateral swelling on the right cheek with increased temperature, tenderness and redness extending from right forehead to the right lower jaw.  It appeared oedematous, with swelling of the ipsilateral upper eyelid. It had a well defined raised border. The rash did not cross the bridge of the nose to the opposite cheek. No blisters were seen. Her regional nodes were not enlarged.

Clinically she has erysipelas.

TWBC 12,900 (N84%)
blood sugar  8.5 mol/l
BU and serum electrolytes normal
LFT normal

Erysipelas affects the superficial layer of the skin while cellulitis affects the deeper part of the dermis. There were no clusters of vesicles or erosions to suggest herpes zoster. She was not keen to be admitted and preferred oral medication as an outpatient  She was treated with oral cefuroxime 500mg bd for 10 days with wet compress dressing on the affected face. The erysipelas cleared with the treatment.