Psoriasis in a 9 yo Girl

The patient is a 9 year old girl who presents to the office for evaluation of psoriasis of 4 months duration. Initially, this started on the bilateral knees with erythematous scaly plaques that have generalized since onset. She was prescribed topical mometasone by her pediatrician with little improvement. 

Physical exam: On exam, patient has erythematous, scaly plaques varying in size on the chest, back, upper extremities, abdomen and lower extremities. She has also started to develop a few smaller plaques on the face. 

This has been difficult on the patient who has been made to sit out of her swim classes due to the instructors fear of her spreading the rash to other students. Her parents are going through a contentious divorce and her mother feels her skin is causing the patient significant distress. Otherwise, the child is healthy and denies any recent illnesses. There is no family history of psoriasis.

We are presenting her case to seek advice from those who have treated widespread psoriasis in pediatric patients. She is currently using clobetasol ointment, however we wonder if systemic treatment is necessary at this time. 

 

Clinical Images

Note: While this is relatively mild at this time, the short history suggests that it may become more or a problem, and it is impacting on the patient's life at this time. We are reluctant to prescribe MTX for a 9 year old and NB UVB is not an option as she lives far from a unit.

 

 Reference:

1. Das D, Ludvigsson J. Early childhood stress and the risk of developing psoriasis: a cohort study. J Invest Dermatol 2025 Sep 2 PubMed 40907801.
Children experiencing the psychological stress of a "New family structure" during the first 8 years of life have an increased risk of developing psoriasis later. 

2. Yang Y et. Al. The Burden of Pediatric Psoriasis: A Systematic Review Am J Clin Dermatol. 2025 Sep;26(5):695-710.Angela Yang.  PMID 40694272. Psoriasis leads to high burden for pediatric patients and caregivers. Evaluation and management decisions should include and incorporate a thorough assessment of burden. Additional studies using validated tools are necessary to fully assess psychosocial and family burdens of psoriasis.

Linear Forehead Dermatitis

 The patient is an otherwise healthy 30 yo man in good general health.  For two months he has had a slightly pruritic dermatitis on his forehead.

Clinically, we considered En Coup de Sabre (Linear scleroderma)

Dermatoscopic Image: (Courtesy of Makayla Powers PA-C)

Punch biopsy showed:
Lichenoid interface and perifollicular dermatitis with postinflammatory pigment alteration.  No features of localized scleroderma.  These findings are suggestive of discoid L.E. or linear L.P.
Photomics courtesy of David Jones, MD, Berkshire Medical Center, Pittsfield, Massachusetts.

Treatment was initiated with clobetasol ointment.  Will switch to tacrolimus ointment if response is good.

 References
1. Rodriguez E et. Al. Acute Onset Linear Lichen Planus Pigmentosus of the Forehead: A Case Series  J Drugs Ddermatol 2023 Jan 1;22(1):94-97.  Free Full Text

2. Khelifa E.  Linear sclerodermic lupus erythematosus, a distinct variant of linear morphea and chronic cutaneous lupus erythematous. Int J Dermatol 2011 Dec;50(12):1491-5. PMID 22097995

3. Reference suggested by Dr. Sontheimer.  Dao DP, Sahni DR, Sontheimer DR. Linear discoid lupus erythematous simulating en coup de sabre morphea in a female chronic granulomatous disease carrier. Dermal Online J. 2023 Dec 15;29(6). Free Full Text. 

4. Das A et al. Linear lesions in dermatology: a clinicoaetiopathological study. Clin Exp Dermatol 2021 Dec;46(8):1452-1461. PMID: 34022084 

5. Urur YG. Et. Al. Dermoscopic Characteristics of Cutaneous Lupus Erythematosus According to Subtype, Lesion Location, Lesion Duration, and CLASI Score. Dermatol Pract Concep. 2024 Jan 1;14(1):e2024040. Free Full Text.

Lentigo maligna

The patient is a 73 year old woman with a pigmented macule at the commisure of the lip for a number of years.  The lesion measured 2 mm in diameter and it was excised with a 3 mm punch.  She has Type II skin and has had BCC of her nose treated with Mohs surgery a number of years ago.  She is in good general health.

Photos taken after suture removal.

Pathology: There is a confluent junctional proliferation of pleomorphic melanocytes that exhibit pagetoid upward migration on a background of epidermal atrophy and solar elastosis.

These are the features of the lentigo maligna variant of melanoma in situ.

Diagnosis: Melanoma-in-situ, Lentigo maligna type

Question:  This is an early lesion and surgical treatment may be overkill.  What are your thoughts re: imiquimod, vs. Mohs (with MART-1), vs. watchful waiting?

The rate of progression of LM to LMM is estimated to be ~ 3.5% per year. (Menzies SW, PMID 31095041 )  Does this information nudge one towards imiquimod over Mohs surgery?

Squamous Cell Carcinoma Scalp

This 93 yo woman has a biopsy proven SCC of her scalp.  She has congestive heart failure, anemia and has recently been hospitalized for pneumonia.  She lives alone and mentally is sharp.  She has had a number of other SCCs and BCCs in the past.

O/E:  4 x 3 cm erosive lesion on scalp. First picture is before debridement and second after.

Question:  What is the best approach to maximize her quality of life? 

Reference:
1. Oto Open. 2022 Feb 8;6(1):2473974X211073306.
O’Neill L. Malignant Fungating Wounds of the Head and Neck: Management and Antibiotic Stewardship. Full Free Text
Malignant fungating wounds (MFWs) are unfortunate and underreported manifestations of some advanced head and neck cancers. The management of MFWs is complex and challenging. MFWs are often mistaken for infectious processes/abscesses and treated indiscriminately with oral or intravenous antibiotics. Our aim is to promote awareness of MFWs and provide education on their management.

An Orphan Patient

History/Physical: This  53 yo woman presented with a 15 year history of a painful and disabling dermatitis of her buttocks and to a lesser extent face, extremities and torso.  She has been seen by many dermatologists, allergists, gynecologists and primary care physicians during this time and even underwent a hysterectomy in an attempt to cure her when the mistaken diagnosis of autoimmune progesterone dermatitis was rfendered. Her partner recently left her because of the disabling nature of dermatitis.

Routine lab studies are unremarkable and ANA was negative.  Some special tests are pending.

Clinical Images

March 2024

Photos from 3 - 5 years ago sent by patient

Shoulder

 Histopathology: Biopsy were taken from the left and right buttock:  Both specimens contain a small vessel vasculitis.  The more recent lesions on the right buttock show the changes of leukocytoclastic vasculitis.
Biopsy from left buttock, March 2024.  Four mm punch biopsied from each buttock showed similar changes, but left buttock had a more psoriasiform epidermis.
Thanks to Dr. David Jones, dermato- pathologist, Berkshire Medical Center, for the histopath images.

Tentative Diagnosis:  Urticarial Vasculitis

She is being presented your thoughts and recommendations.  Complement levels are pending.  She has a very high deductable so we are limiting extensive testing that may be unnecessary.

Photo after 5 days of prednisone 20 mg b.i.d.

 

After 1 week of Dapsone: 50 -75 mg per day (off prednisone for 10 days)

Reference
Stephanie L Gu, Joseph L Jorizzo.  Urticarial vasculitis.  Int J Womens Dermatol. 2021 Jan 29;7(3):290-297.  PMID: 34222586  PMCID: PMC8243153 (Full Text)

Acne Scarring

The patient is a 26 year old man who presents to the office for evaluation of acne. He has struggled with acne on the face, back and chest since for over 6 years. He was previously prescribed a few different antibiotics over the past few years, however none of them have provided significant improvement in his acne. He had reactions to minocycline and doxycycline and therefore, his dermatologist recommended he stay away from these medications. Otherwise, he is a healthy man without any other concerns.

On exam, the patient has severe hypertrophic scarring on the chest and back. He has a couple active erythematous cysts on the back, chest and neck.

Assessment and plan: Hypertrophic and keloidsl acne scarring is difficult to treat. We  wonder if isotretinoin will trigger more scarring or whether it may actually help him.

Questions:

Is there a value to starting him on isotretinoin? With Prednisone?

His previous dermatologist used intralesional triamcinalone without benefit.

The patient may need to pay for procedures out of pocket; but his insurance will cover isotretinoin.

Painful Leg Ulcer in an Octogenarian

The patient is a, otherwise healthy 84 yo woman who had a squamous cell carcinoma of the left pretrial area in 2018 that was treated with radiation.  The area took 18 - 24 months to heal after XRT.  Due to concerns about a new crusted area at the site, it was biopsied in April 2023; but has not healed since then.  In August 2023, there was a 6 mm in diameter ulcer.  In July of 2024, she had moved to another state and a wound care physician re-biopsied the area and curretted it,  In the ensuing three months the ulcer has grown to its present size of 3.7 x 2.7 cm and is constantly painful.  (Both biopsies showed no evidence of cancer.)

She has good pedal and dorsals pulses and has had arterial and venous studies of her leg show normal findings. Ankle Brachial and Toe Brachial Indexes are normal.Wound cultures have repeatedly grown out a mixture of Pseudomonas, Coagulase Negative Staph and Strep species.

12.12.23

1.27.24

What is your diagnosis and what do you think is the best way to care for this ulcer?