tag:blogger.com,1999:blog-98701142024-03-13T17:14:12.768+00:00VIRTUAL GRAND ROUNDS IN DERMATOLOGY 2.0This is a rapid publication site that replaces Virtual Grand Rounds in Dermatology (vgrd.org). Please join and feel free to post cases. You can share the URL with friends. Since 2000, VGRD has been a valuable means to share cases in real time from one's home or office. "AND GLADLY WOLDE HE LERNE AND GLADLY TECHE" has served as an enduring and inspirational motto. For more information, see the "About Page."Humane Medicine Huihttp://www.blogger.com/profile/07113291188306363130noreply@blogger.comBlogger567125tag:blogger.com,1999:blog-9870114.post-39301244278097989262024-02-06T19:17:00.001+00:002024-02-06T19:21:01.285+00:00Acne Scarring<p>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.</p><p>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.<br /></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjDyfK4puIVBmla-gys3IL0m6izD_ODS3doDTocAUDHfW8u0AhSgVgzLO7ylgJ83hm62VerAnY37bKXMCh6gxYj0Wyy5CSCyD_6iLhnVRXRzBlPHhuq4MEkdpoODau8-D_j0q32xKSQ_fJlqncXaTijGotbVKIDRbIMmagfeMONFM_G-XBmVzPU/s432/Acne%20Scarring2.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="432" data-original-width="324" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjDyfK4puIVBmla-gys3IL0m6izD_ODS3doDTocAUDHfW8u0AhSgVgzLO7ylgJ83hm62VerAnY37bKXMCh6gxYj0Wyy5CSCyD_6iLhnVRXRzBlPHhuq4MEkdpoODau8-D_j0q32xKSQ_fJlqncXaTijGotbVKIDRbIMmagfeMONFM_G-XBmVzPU/s320/Acne%20Scarring2.jpg" width="240" /></a></div><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgXiYUGBH0fUWaSephFUK0BZC9GAWhRrzlRYQz74Gz5EIiJr4YCawPFYSo__gwueYfBVG0z68NPIXGZTHezWOACYJLNzyWfi9Splg-5eDqsDczMF3E80AB7lvBPPwcEcYnWsSnkPVEhtiZUGuNhve8bBXho0YKYL4qVgpB3SLQ1XptCiRj6OULf/s432/Acne%20Scarring1.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="432" data-original-width="324" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgXiYUGBH0fUWaSephFUK0BZC9GAWhRrzlRYQz74Gz5EIiJr4YCawPFYSo__gwueYfBVG0z68NPIXGZTHezWOACYJLNzyWfi9Splg-5eDqsDczMF3E80AB7lvBPPwcEcYnWsSnkPVEhtiZUGuNhve8bBXho0YKYL4qVgpB3SLQ1XptCiRj6OULf/s320/Acne%20Scarring1.jpg" width="240" /></a></div><br /><p>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.<br /></p><p><b>Questions:</b></p><p>Is there a value to starting him on isotretinoin? With Prednisone?<br /></p><p>His previous dermatologist used intralesional triamcinalone without benefit.<br /><br />The patient may need to pay for procedures out of pocket; but his insurance will cover isotretinoin.<br /></p><p><br /></p>Humane Medicine Huihttp://www.blogger.com/profile/07113291188306363130noreply@blogger.com1tag:blogger.com,1999:blog-9870114.post-78503211183174335102024-02-02T17:45:00.000+00:002024-02-02T17:45:51.950+00:00Painful Leg Ulcer in an Octogenarian<p>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.)<br /></p><p>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.<br /></p><p>12.12.23<br /> <br /></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgfS4r206lbcxcvO1SlxB_EA_SXKJA0gQtFPyjO8KTDJOoFM8-16eTv7ckvCZstny6WhfXWqlry2jsUuui71Ul5TMH-Tv-ORxFSqQszbO1YOoJ3swKOdZ4eVBh3ETW_EVxQToon5qDR2WU0tH-hk4hcRrpzAZ-m3qYueqQzUwnVMT2-X4nG5s6j/s576/H.Gutschow%2012.1223(1).jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="576" data-original-width="474" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgfS4r206lbcxcvO1SlxB_EA_SXKJA0gQtFPyjO8KTDJOoFM8-16eTv7ckvCZstny6WhfXWqlry2jsUuui71Ul5TMH-Tv-ORxFSqQszbO1YOoJ3swKOdZ4eVBh3ETW_EVxQToon5qDR2WU0tH-hk4hcRrpzAZ-m3qYueqQzUwnVMT2-X4nG5s6j/s320/H.Gutschow%2012.1223(1).jpg" width="263" /></a></div><p></p><p>1.27.24<br /></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj6Wv4k5F4N0hV_mUeINIxODpetWkwSvN507IiXw6BtZ5odLv3kMVuQm7c8rvLm8OT2dAoFfx3-UB6cng_yf7GCNdT_6J5CHxKpQzEje205eFt9UhTgJQ5SeTSOcqo8ambmqXDWwPggjTYRJT5XbBNxaSYxXAzJKoabMEUOxcrZTnh_-g5w2dib/s576/Helga.1.27.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="576" data-original-width="475" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj6Wv4k5F4N0hV_mUeINIxODpetWkwSvN507IiXw6BtZ5odLv3kMVuQm7c8rvLm8OT2dAoFfx3-UB6cng_yf7GCNdT_6J5CHxKpQzEje205eFt9UhTgJQ5SeTSOcqo8ambmqXDWwPggjTYRJT5XbBNxaSYxXAzJKoabMEUOxcrZTnh_-g5w2dib/s320/Helga.1.27.jpg" width="264" /></a></div><p>What is your diagnosis and what do you think is the best way to care for this ulcer?</p>Humane Medicine Huihttp://www.blogger.com/profile/07113291188306363130noreply@blogger.com2tag:blogger.com,1999:blog-9870114.post-37681387772853960752023-12-31T22:49:00.000+00:002024-01-06T14:45:18.390+00:00Congenital Dystrophy of the Great Toe Nails<p><b>April 2022 </b><br /></p><p> A concerned mother brought in her 20 month infant for diagnosis of a nail dystrophy that she had first appreciated when he was a few months old. The toddler was normal in all other respects. She had seen two pediatricians who could not come up with a diagnosis and she hoped for some clarity.</p><p>The examination showed a healthy well-cared toddler. Both great toe nails were short, thickened and lusterless. There was some cross ridging and the distal edge of the nails seems to be growing into the hyponychium. His other nails were all normal.</p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEitR4ZD_EX0c-Qx23K09b_Fy6wng7SjWCfpB8eyjyb3hZD-xPzH7jEABmQoVnbS8NLQEyNQB6hluZixZRL6MxHyhkGoO8OCwtmUSpk4fUpnwxpz8oOTPS7aT5QaUS2pqv1bLRm6648b8ULtErGJiFOg7D2ePg0Yy3ifshNIiB_0CPLaD3mz0Q/s2995/Samman%20Nail2.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="2401" data-original-width="2995" height="257" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEitR4ZD_EX0c-Qx23K09b_Fy6wng7SjWCfpB8eyjyb3hZD-xPzH7jEABmQoVnbS8NLQEyNQB6hluZixZRL6MxHyhkGoO8OCwtmUSpk4fUpnwxpz8oOTPS7aT5QaUS2pqv1bLRm6648b8ULtErGJiFOg7D2ePg0Yy3ifshNIiB_0CPLaD3mz0Q/s320/Samman%20Nail2.jpg" width="320" /></a></div><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgowrJSnqK7YSFJ8h0ZT0fJe2-PLUc0OmQx0dYdPxx2HU0QDsJMphKAztfiNC6brZ7XdnyZJ1p8Cn-Hg01IFadvGboMDjAsCbCjw0MAvBm8BKAEX4feysu-yk6kEt-FSILMDElNCo7_ER--qSWeLPoCICgOTPFwVrj6GJAEiXTQfe0VlNnY5A/s371/Samman%20Nail%203.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="371" data-original-width="322" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgowrJSnqK7YSFJ8h0ZT0fJe2-PLUc0OmQx0dYdPxx2HU0QDsJMphKAztfiNC6brZ7XdnyZJ1p8Cn-Hg01IFadvGboMDjAsCbCjw0MAvBm8BKAEX4feysu-yk6kEt-FSILMDElNCo7_ER--qSWeLPoCICgOTPFwVrj6GJAEiXTQfe0VlNnY5A/s320/Samman%20Nail%203.jpg" width="278" /></a></div><p>Diagnosis: Congenital Dystrophy of the Great Toe Nails</p><p>This entity was well-described by PD Samman <span style="font-size: small;">(1978)</span>:<br />
<span style="font-size: small;"><span style="font-family: inherit;"><span>"The
condition is present at birth but in no case has there been a family history of
a</span><span> </span><span>similar condition. The nail is seen to be of a dark
colour, shorter than a normal nail and tends</span><span> </span><span>to be pointed.</span></span>"<br />Much has been learned since 1978, and the condition has been renamed as Congenital Malalignment of the Great Toenail (CMGT) (4). </span></p><p><span style="font-size: small;">Note: As we learned about CMGT, it became obvious that to help this child perhaps, a pediatric podiatrist would be the best person to see. We will reach out to find one in the area he and his parents live in. In the mean time, we will start him on tretinoin cream.<br /></span></p><p><span style="font-size: small;"><b>Follow-up December 2023</b></span></p><p>The patient presents at 3 years old with worsening symptoms. His mother relates that he complains of pain in the toes now and that the great toenails have continued to grow abnormally.<br />
<br />
On exam, both great toenails are thickened, discolored and there is onycholysis of the left great toenail.<span style="font-size: small;"><b> </b></span></p><p><span style="font-size: small;"><b>Question: </b>Do any of our readers have experience with children with similar problems.<br /><br /></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgCvu9_1QxdGI24mNOCqv2uquSPAQLElEs0uBisY-NEphQqco2BJsNulK3f_pgKL0KW-nnsJvs-E9h3cUZN1doMw4iykQqZnOZUw7qvaIuT7VoIZ4sm3QQN4QeogZDl_O92TX4jVMgKhuM7Yxy2wIi8o640ec22S7wnvFvONGNz0c5rfZOhNUPm/s576/NailDyst1.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="510" data-original-width="576" height="283" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgCvu9_1QxdGI24mNOCqv2uquSPAQLElEs0uBisY-NEphQqco2BJsNulK3f_pgKL0KW-nnsJvs-E9h3cUZN1doMw4iykQqZnOZUw7qvaIuT7VoIZ4sm3QQN4QeogZDl_O92TX4jVMgKhuM7Yxy2wIi8o640ec22S7wnvFvONGNz0c5rfZOhNUPm/s320/NailDyst1.jpg" width="320" /></a></div><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiiIJD4O7EpsODHJJ13kdN4FWyd3yvDRBjMnScG7ECMbL3vw3hqnWoTRYit1cgRwe5fsl-jmhz9w1hewzfV_wiWw83Krjg2G5QY9Ot9zKQqsCH1M8B4-rAqoVTRgLKzA5G0ueJ4uRcFk8pPEoPgnyUyVSlOCQUSC6NMe9F_RvhE_2mO6TSqaEul/s576/IMG_8322%20copy.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="409" data-original-width="576" height="227" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiiIJD4O7EpsODHJJ13kdN4FWyd3yvDRBjMnScG7ECMbL3vw3hqnWoTRYit1cgRwe5fsl-jmhz9w1hewzfV_wiWw83Krjg2G5QY9Ot9zKQqsCH1M8B4-rAqoVTRgLKzA5G0ueJ4uRcFk8pPEoPgnyUyVSlOCQUSC6NMe9F_RvhE_2mO6TSqaEul/s320/IMG_8322%20copy.jpg" width="320" /></a></div><br /><p class="MsoNormal"><span style="font-size: small;">Reference:<br />1. P.D.Samman.<span> </span>Great toe
nail dystrophy. Clinical and Experimental Dermatology (1978) 3, 8r.<br /><br /></span></p><p class="MsoNormal"><span style="font-size: small;">
</span></p><p class="MsoNormal"><span style="font-size: small;"><span color="windowtext" style="font-family: "Times", "serif";">2. Dawson TA. An
inherited nail dystrophy principally affecting the great toe nails. Clin Exp
Dermatol. 1979. PMID: 509763.<br />Summary::A nail dystrophy transmitted by an autosomal dominant gene of variable expression is described. The great toe nails are principally affected. In some cases grossly deformed nails are present, in others little more than slight opacity and discoloration of the nails is apparent.<br /></span></span></p><span style="font-size: small;">
</span><p class="MsoNormal"><span style="font-size: small;"><span color="windowtext" style="font-family: "Times", "serif";">3. Dawson TA. An inherited
nail dystrophy principally affecting the great toe nails: further observations.
Clin Exp Dermatol. 1982. PMID: 7127894 <br />Conclusion: I would also like to suggest that the dystrophy is not uncommon, ten further cases having been identified in this area since 1978, that the great toenails on the right side may be more frequently and more severely affected than those on the left and that, paradoxically, some affected great toe nails<br />may eventually appear rather larger than average. Finally I think it worth noting again that other nails apart from the great toe nails may occasionally be affected. [Dawson noted: That spontaneous resolution can occur. Although Samman considered that the condition was probably permanent,</span></span><br /><br /><span style="font-size: small;"><span color="windowtext" style="font-family: "Times", "serif";">
<span style="font-family: "Times", "serif";">4. Benjamin
Buttars, et. al. Congenital Malalignment of the Great Toenail, the Disappearing
Nail Bed, and Distal Phalanx Deviation: A Review. Skin Appendage Disord. 2022
Jan; 8(1): 8–12.<span> </span><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8787503/">Full Text<br /></a></span></span></span><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8787503/"><br /></a><span style="font-size: small;"><span color="windowtext" style="font-family: "Times", "serif";"><span style="font-family: "Times", "serif";">
<span style="font-family: "Times", "serif";">5. </span></span> Judith Domínguez-Cherit,
Anabell Andrea Lima-Galindo. Congenital malalignment of the great toenail:
Conservative and definitive treatment. Pediatr Dermatol. 2021
May;38(3):555-560.</span></span></p>
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{page:WordSection1;}</style></p>Humane Medicine Huihttp://www.blogger.com/profile/07113291188306363130noreply@blogger.com11tag:blogger.com,1999:blog-9870114.post-38154867155297578902023-11-30T20:43:00.002+00:002023-11-30T20:43:43.416+00:00Leg Ulcer<p>The patient is an 81 y.o. woman with a 4 year history of an ulcer of her right leg. She has received treatments from a variety of specialists during this time and the ulcer was unsuccessfully grafted ~ 3 months ago. The patient is an asthenic vegetarian but takes multivitamins and there is no evidence of anemia. Her arterial circulation is normal per doppler studies. She is taking doxycline because of purulence but a culture was not done.<br /></p><p>O/E: There is a 12 x 8 shallow ulcer over the lower right leg. The foot is warm and a dorsalis pedis pulse was present. There is an early champagne bottle deformity and lymphedema of the affected leg..</p><p>Clinical Photos:</p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhfvDk3LNoI8gqZQ9NNDGIKhbK4F7rJ3wiHqf9SFP8FCTcLUfEibUXQOt_1Hsp3wA7wAXbaoAWEfZc7vZ4TQSBM_9oTz-BlqQ3Pb_9k4mrYBAJnh6JmZZwMThBbNu-IgHUHRMInqRPe1FR_CDUiPSbj43Kckx5NmTnd532FSUO3qFiUZmAQq76N/s4032/IMG_8166.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="3024" data-original-width="4032" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhfvDk3LNoI8gqZQ9NNDGIKhbK4F7rJ3wiHqf9SFP8FCTcLUfEibUXQOt_1Hsp3wA7wAXbaoAWEfZc7vZ4TQSBM_9oTz-BlqQ3Pb_9k4mrYBAJnh6JmZZwMThBbNu-IgHUHRMInqRPe1FR_CDUiPSbj43Kckx5NmTnd532FSUO3qFiUZmAQq76N/s320/IMG_8166.jpg" width="320" /></a></div><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjxRkBKdDTk-0FbKZxCSbQMm4P4qfZawaIClxPk72MgISETeXzKXhHN17MW8spI8GG0zOK2fMho4ZhKTrz3qav3Drz9hnDSn-u8Q5yU6nu07tddLo7UNfSmZvsNMq-3JYjV86spwOzG6aFupelzCA89Ulhje5g6WV_VEJGDVvizco72eYx6uG5U/s4032/IMG_8165.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="3024" data-original-width="4032" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjxRkBKdDTk-0FbKZxCSbQMm4P4qfZawaIClxPk72MgISETeXzKXhHN17MW8spI8GG0zOK2fMho4ZhKTrz3qav3Drz9hnDSn-u8Q5yU6nu07tddLo7UNfSmZvsNMq-3JYjV86spwOzG6aFupelzCA89Ulhje5g6WV_VEJGDVvizco72eYx6uG5U/s320/IMG_8165.jpg" width="320" /></a></div><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjl36lSqXf3fLuqyxGgQHJfXnYy1nFydsbAZk2tAxqLFKYJQgO1hmLd76ZNxSkJycZKHOEuJawvPYWMd_7-Ba4cAojW2BqZF5uZxXlG-VY3jycdiDNHt0-BoR4DNUV12QKQvhGetgmP02LTkGNTKPPQiNqWalRHRrwiydKPMNLALyQJrIjvb5Yz/s4032/IMG_8164.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="4032" data-original-width="3024" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjl36lSqXf3fLuqyxGgQHJfXnYy1nFydsbAZk2tAxqLFKYJQgO1hmLd76ZNxSkJycZKHOEuJawvPYWMd_7-Ba4cAojW2BqZF5uZxXlG-VY3jycdiDNHt0-BoR4DNUV12QKQvhGetgmP02LTkGNTKPPQiNqWalRHRrwiydKPMNLALyQJrIjvb5Yz/s320/IMG_8164.jpg" width="240" /></a></div><p></p><p>Impression: Large venous leg ulcer.</p><p>Discussion: The patient, who lives independently with her husband, has mild to moderate cognitive decline and does not seem overly concerned about the ulcer. The ulcer continues to advance in spite of medical attention. Without intensive care, it is unlikely that such a large ulcer will heal. Her case is presented for discussion and therapeutic suggestions.</p><p>References:</p><p>1. Alavi A et al. What’s new: Management of venous leg ulcers: Treating venous leg ulcers. J Am Acad Dermatol. 2016 Apr;74(4):643-64 <br /></p><p>2. Alavi A e.al. What's new: Management of venous leg ulcers: Approach to venous leg ulcers. J Am Acad Dermatol. 2016 Apr;74(4):627-40. Alavi A. Et al. J Am Acad Dermatol. 2016 Apr;74(4):627-40; quiz 641-2.</p><p><span style="font-size: small;">3. <span style="font-weight: normal;"><span class="gmail-authors-list-item">Chunhu Shi<span class="gmail-comma">, et. al. </span></span>Compression bandages or stockings versus no compression for treating venous leg ulcer. </span></span><span style="font-size: small;">Meta-Analysis</span><span style="font-size: small;"><span class="gmail-period">Cochrane Database Systematic Reviews. </span><span class="gmail-cit">2021 Jul 26;7(7):CD013397. </span></span><span style="font-size: small;"><span class="gmail-free-label">Free PMC article</span></span></p><sup><span class="authors-list-item"></span></sup><p></p>Humane Medicine Huihttp://www.blogger.com/profile/07113291188306363130noreply@blogger.com6tag:blogger.com,1999:blog-9870114.post-73279887838541385752023-09-25T22:11:00.011+00:002023-12-03T20:27:00.455+00:00A Case for Palliative Dermatology<p>The patient is an 87 yo woman who lives with her grandson in a small Kentucky hill town many miles from a medical center. Two years ago, a squamous cell carcinoma was excised and grafted from her scalp. It has recurred and is now a management problem. The patient has a moderate dementia but is happy and comfortable at home with a large supportive family. She has no life-threatening medical problems other than this lesion.</p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEivFSZm0auTB3wybxoW_usCR1qKEia6FPKS9Zve_LV1UQoT1nUR57gsgcePCaLGDOUV0WsktKxuBCgx8uKxlcnHknhypEhZb8cyQRbQVD1gSMp4Uuqkzfy0ClaZlzEX9CVCySohjfZldnscKBL3RjN_8aDHuGjwvgF94Liuh3ryQowjiSfsXuUp/s432/Giant%20SCC1.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="432" data-original-width="348" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEivFSZm0auTB3wybxoW_usCR1qKEia6FPKS9Zve_LV1UQoT1nUR57gsgcePCaLGDOUV0WsktKxuBCgx8uKxlcnHknhypEhZb8cyQRbQVD1gSMp4Uuqkzfy0ClaZlzEX9CVCySohjfZldnscKBL3RjN_8aDHuGjwvgF94Liuh3ryQowjiSfsXuUp/w323-h400/Giant%20SCC1.jpg" width="323" /></a></div><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiA8N1j2fXDHJaZKoUcUvJDTD8NnsAFuf_kjXKPsfXXkcd1OOwYqZNLgfRDJOj8wC2cTYCl3bkzmacAn2K8sC8zd_e-O1-iUqHjs5VrMouG6tUnuamHJ0-0bXH99iUh6aYV_6FE7oKknV2qsnrwDSiH8nUHyyw8XxJbpBUsooiuvML7xDe_YkDc/s432/Giant%20SCC2.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="432" data-original-width="399" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiA8N1j2fXDHJaZKoUcUvJDTD8NnsAFuf_kjXKPsfXXkcd1OOwYqZNLgfRDJOj8wC2cTYCl3bkzmacAn2K8sC8zd_e-O1-iUqHjs5VrMouG6tUnuamHJ0-0bXH99iUh6aYV_6FE7oKknV2qsnrwDSiH8nUHyyw8XxJbpBUsooiuvML7xDe_YkDc/s320/Giant%20SCC2.jpg" width="296" /></a></div><p>The tumor was debulked, cultured and a Xeroform dressing applied. Her daughter-in-law was instructed how to change the dressings.</p><p>Post-op appearance:<br /></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjupOERBfGgCMNcEgBmcj77JgA1UBFbCaIpcpOVIjrLhbzz-FXm-J_PJWbrgSydmTH-ZxR-8M0xbiIXPJWQ_qw1VrVQaDBuXtLPU1KpgqRoaekJvawo5OQRS7n-KakDtinW6JirTi0bij-Ua_idhK79V5ZYuvDQFfeBadEh7ekE9Lc9-3YxHOlS/s432/Veber%203.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="432" data-original-width="365" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjupOERBfGgCMNcEgBmcj77JgA1UBFbCaIpcpOVIjrLhbzz-FXm-J_PJWbrgSydmTH-ZxR-8M0xbiIXPJWQ_qw1VrVQaDBuXtLPU1KpgqRoaekJvawo5OQRS7n-KakDtinW6JirTi0bij-Ua_idhK79V5ZYuvDQFfeBadEh7ekE9Lc9-3YxHOlS/s320/Veber%203.jpg" width="270" /></a></div><br /><p>Pathology showed a moderately differentiated squamous cell carcinoma extending to the base of the specimen.</p><p>Her family wants to do as little as possible with the goal of supporting her quality of life.</p><p>Palliative care in dermatology has only recently been getting attention. </p><p>Some options for this woman include<br />1. Intralesional 5 Fluorouracil or topical 5FU<br />2. Short Course Radiotherapy (1)<br />3. Palliative Mohs surgery (2)</p><p><b>Note: On 10.6.23 the patient had micrographic surgery. </b>This showed squamous cell carcinoma ectending to the calvarium and invading it. In addition, there was infiltrating basal cell carcinoma at the periphery. Chemotherapy with pembrolizumab may help some healthier patients, but is not practablew for this woman. Palliative care is appropriate, but guidelines are limited.<br />Clinical photo 1 week afte4r Mohs micrographic surgery:<br /></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgtVHHpJeIY5_jQHBvwVabYsvfZsaoBXiQ1LvCa40eDPhHdsTdWY_njj-T9uwNsJ-FMCp1-UiFjvcBeCuIW7VoWHgQcUEOOUuKiN4-McA3Zpp7HSGrpaF00IJP9ceHtcsTotqFSj0j0L3wmlrEgqwaFPPkzv5NDAQKLzf3QVMcWxnLtWDYDkL71/s631/Veber%20p2.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="631" data-original-width="504" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgtVHHpJeIY5_jQHBvwVabYsvfZsaoBXiQ1LvCa40eDPhHdsTdWY_njj-T9uwNsJ-FMCp1-UiFjvcBeCuIW7VoWHgQcUEOOUuKiN4-McA3Zpp7HSGrpaF00IJP9ceHtcsTotqFSj0j0L3wmlrEgqwaFPPkzv5NDAQKLzf3QVMcWxnLtWDYDkL71/s320/Veber%20p2.jpg" width="256" /></a></div><p> Your thoughts will be helpful.</p><p><b>Post-Script: The patient stayed home for two months after we saw her. We arranged for a visiting nurse to come and do dressing changes. She was comfortable and required no pain meds. Then she had a seizure, was admitted to hospital and died two days later. The tumor had eroded through her skull and she had a terminal event. The palliative approach assured that she spent her last few months at home without being subjected to worthless and time-consuming procedures.</b> <br /></p><p></p><p>References:<span style="font-size: x-small;"> </span><span style="font-size: small;"><span style="font-weight: normal;"><br />1. Milena F et. al. A Short course Accelerated RadiatiON therapy (SHARON) dose-escalation
trial in older adults head and neck non-melanoma skin cancer. </span><span class="gmail-period">Br. J Radiol. </span><span class="gmail-cit">2022 Jun 1;95(1134):20211347.</span></span></p><p><span style="font-size: small;"><span class="gmail-cit">2. </span><span class="gmail-authors-list-item"><span style="font-weight: normal;">Noriaki Nakai et al.</span><sup class="gmail-affiliation-links"><span class="gmail-author-sup-separator"> </span></sup></span><span style="font-weight: normal;">Clinical
usefulness of Mohs' chemosurgery for palliative purposes in patients
with cutaneous squamous cell carcinoma with risk factors or
without indication for surgery: three case report. </span><span style="font-weight: normal;"><span class="gmail-period">J Dermatol. </span><span class="gmail-cit">2015 Apr;42(4):405-7.</span></span></span></p><p><span style="font-size: small;"><span style="font-weight: normal;"><span class="gmail-cit">3. </span></span></span><span style="font-size: small;"><span class="gmail-authors-list-item">Leah L Thompson et. al. </span><span style="font-weight: normal;">Palliative care in dermatology: A clinical primer, review of the literature, and needs assessment. <span class="gmail-period">J Am Acad Dermatol. </span><span class="gmail-cit">2021 Sep;85(3):708-717. </span></span><span class="gmail-period">J Am Acad Dermatol. </span><span class="gmail-cit">2021 Sep;85(3):708-717.</span></span></p><p><span style="font-size: small;"><span class="gmail-cit">4. </span></span>Fidanzi C, Davini G, Dini V, et al. Palliative management of a recurrent
destructive cutaneous squamous cell carcinoma of the scalp with brain
exposure. <i>Wounds</i>. 2022;34(1):E7-E9. <a href="https://pubmed.ncbi.nlm.nih.gov/35119380/">PMID 35119380<br /></a>(<a href="https://www.hmpgloballearningnetwork.com/site/wounds/case-report/palliative-management-recurrent-destructive-cutaneous-squamous-cell">Full Text</a>)<br /></p><p><span style="font-size: small;"><span class="gmail-cit"> </span>
<span class="gmail-authors-list-item"></span></span></p><br />Humane Medicine Huihttp://www.blogger.com/profile/07113291188306363130noreply@blogger.com0tag:blogger.com,1999:blog-9870114.post-41573157981628584632023-09-01T08:41:00.000+00:002023-09-01T16:16:29.539+00:00ABOUT VGRD<div class="MsoNormal"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEgyLLoHhAoih_x2V2ljHs8MNBvZafcOqKMbo3UNqr0tBj8-_Eu5G-4jGNk7nkeHVpaseLZlLEY8VWRn9oCTdl3UloPO72o2Q29UYiTgiRLffKp_grOTPeTihqBebtBmNLbvoDZVAJ82hEt4gy_yBfPNMHKmEbj1-CYiTLp0zuDfb1TJjXnG6Q=s2048" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="288" data-original-width="2048" height="90" src="https://blogger.googleusercontent.com/img/a/AVvXsEgyLLoHhAoih_x2V2ljHs8MNBvZafcOqKMbo3UNqr0tBj8-_Eu5G-4jGNk7nkeHVpaseLZlLEY8VWRn9oCTdl3UloPO72o2Q29UYiTgiRLffKp_grOTPeTihqBebtBmNLbvoDZVAJ82hEt4gy_yBfPNMHKmEbj1-CYiTLp0zuDfb1TJjXnG6Q=w640-h90" width="640" /></a></div>
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.<span style="mso-spacerun: yes;"> </span>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.</div><br />
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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:</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-spacerun: yes;"> </span>When thou arte
callde at anye time,</div>
<div class="MsoNormal">
<span style="mso-spacerun: yes;"> </span>A patient to see:</div>
<div class="MsoNormal">
<span style="mso-spacerun: yes;"> </span>And dost perceave
the cure to grate,</div>
<div class="MsoNormal">
<span style="mso-spacerun: yes;"> </span>And ponderous for
thee:</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-spacerun: yes;"> </span>See that thou laye
disdeyne aside,</div>
<div class="MsoNormal">
<span style="mso-spacerun: yes;"> </span>And pryde of thyne
own skyll:</div>
<div class="MsoNormal">
<span style="mso-spacerun: yes;"> </span>And think no shame
counsell to take,</div>
<div class="MsoNormal">
<span style="mso-spacerun: yes;"> </span>But rather wyth
good wyll.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-spacerun: yes;"> </span>Get one or two of
experte men,</div>
<div class="MsoNormal">
<span style="mso-spacerun: yes;"> </span>To helpe thee in
that neede;</div>
<div class="MsoNormal">
<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>To make them partakers wyth thee</div>
<div class="MsoNormal">
<span style="mso-spacerun: yes;"> </span>In that work to
procede....</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
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.</div>
Humane Medicine Huihttp://www.blogger.com/profile/07113291188306363130noreply@blogger.com0tag:blogger.com,1999:blog-9870114.post-22159217916424581182023-08-31T13:08:00.001+00:002023-09-01T16:32:54.842+00:00Dodging Scalpels<p>Presented by: <br />Dorinda Johnstone, M.D., Dermatologist<br />Scottsdale, Arizona<br /><br />The patient is a vibrant, independent-living nonogenarian who saw a mid-level provider at a plastic surgery office for a skin screening. A lesion was noted on her right nasolabial fold and a shave biopsy was taken (expand image to see "x"). Also, a few actinic keratoses were also treated with liquid nitrogen.<br />The pathologist reported a superficial squamous cell carcinoma and the patient was scheduled for excision by the mid-level professional’s plastic surgeon employer.<br />The patient was anxious about the surgery and sought the opinion of a DJ, a dermatologist she had seen in the past.</p><p>"x" marks center of the lesion that was biopsied <br /></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjRnVc34m-DCfZH1FrEt5zomofbJtQ7nWqi-fyClxUDyg3rKOpiiyg0sXmzd2y2iqActvT2j5O3rgRYxc1MCV2sdRTbHyUAOh32KdrR4-4Fsle0QyOo6VWxt86tgY2yznZcneVRJM_Uaa8bNpwLDuodmjexPU6BWrBwxDgW__nK0ShbBWu1G5nA/s576/Blanch%20Palliative.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="576" data-original-width="432" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjRnVc34m-DCfZH1FrEt5zomofbJtQ7nWqi-fyClxUDyg3rKOpiiyg0sXmzd2y2iqActvT2j5O3rgRYxc1MCV2sdRTbHyUAOh32KdrR4-4Fsle0QyOo6VWxt86tgY2yznZcneVRJM_Uaa8bNpwLDuodmjexPU6BWrBwxDgW__nK0ShbBWu1G5nA/s320/Blanch%20Palliative.jpg" width="240" /></a></div>DJ did not feel the lesion needed urgent treatment. She got a copy the path report and saw that it had been signed out by a general pathologist. She asked a dermatopathologist colleague of the general pathologist’s to take a look at the slide. The dermatopathologist felt the legion was an actinic keratosis.<br /><br />The patient was called and the revised diagnosis who is related. She expressed great relief. She will make a follow up in three months to see the dermatologist and decide whether anything needs to be done.<br /><br />Take a messages:<br />1. Some mid-level providers working for high-volume surgical and dermatology practices serve as feeders for big-ticket procedures to their employers.<br />2. These surgeons and dermatologists rarely question biopsy reports.<br />3. It can be important to have the pathology reviewed by a board certified dermatopathologist.<br />4. The dermatologist who saw this patient tries to apply a palliative approach to elderly patients to spare them unnecessary procedures.<br />5. As long as we have fee-for-service medical care this kind of comedy will continue to happen.<p></p><p style="text-align: center;">IT’S A JUNGLE OUT THERE.</p>Humane Medicine Huihttp://www.blogger.com/profile/07113291188306363130noreply@blogger.com0tag:blogger.com,1999:blog-9870114.post-49599735100107114402023-08-24T20:02:00.003+00:002023-08-24T20:02:48.876+00:00A Thing of Beauty<p> Dermatoscopy has profoundly changed the practice of dermatology. We have learned a lot and there is much more to discover. A 30 yo woman was seen recently for a changing lesion on her abdomen. The dermatoscopic picture looked benign, but it was unusual.</p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEizib6L1CqJzqHpJxOGgb5x_IXJDM6RLaAs7M_7gZHcGh1r2giYgK-YenI54kv9k5dv6mUksolW0kwmpoCmhXTN5k4dgIk-cjadHG1GB-8lw8Y6Q1An6xQUmGxjD9DFtoIJqvxz1ugKSFcSJiunetqrrBaZ_zaHLDbguHrFHge5V37zlT4-iLl8/s1228/Dermatoscopy%20Artefact.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="974" data-original-width="1228" height="254" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEizib6L1CqJzqHpJxOGgb5x_IXJDM6RLaAs7M_7gZHcGh1r2giYgK-YenI54kv9k5dv6mUksolW0kwmpoCmhXTN5k4dgIk-cjadHG1GB-8lw8Y6Q1An6xQUmGxjD9DFtoIJqvxz1ugKSFcSJiunetqrrBaZ_zaHLDbguHrFHge5V37zlT4-iLl8/s320/Dermatoscopy%20Artefact.jpg" width="320" /></a></div><p>Clinically, this looked like seborrheic keratosis, but the pattern was unusual. A biopsy was done to reassure the patient and so that we could learn something.</p><p>Later, we learned that she was using a self-tanner. The clods seen in the image above represent the chemical in the horn cysts. A similar pattern has been reported from hair dye. The reference is the only one we could locate on PubMed.</p><p>The biopsy confirmed that this was a seborrheic keratosis, No artifacts were seen, but they were probably washed out in processing, <br /></p><p>Reference:<br /><span class="authors-list-item" face=""system-ui", -apple-system, "Segoe UI", Roboto, Oxygen, Ubuntu, Cantarell, "Fira Sans", "Droid Sans", "Helvetica Neue", sans-serif" style="background-color: white; box-sizing: inherit; color: #5b616b; display: inline-block; font-size: 16px;">Sidharth Sonthalia<span class="comma" style="box-sizing: inherit;">, </span></span><span class="authors-list-item" face=""system-ui", -apple-system, "Segoe UI", Roboto, Oxygen, Ubuntu, Cantarell, "Fira Sans", "Droid Sans", "Helvetica Neue", sans-serif" style="background-color: white; box-sizing: inherit; color: #5b616b; display: inline-block; font-size: 16px;">Pankaj Tiwary. </span><span style="background-color: white; color: #212121; font-family: Merriweather, Georgia, Cambria, "Times New Roman", Times, serif;">Colored dots on trichoscopy-beware of artifacts. </span><span face="BlinkMacSystemFont, -apple-system, "Segoe UI", Roboto, Oxygen, Ubuntu, Cantarell, "Fira Sans", "Droid Sans", "Helvetica Neue", sans-serif" style="background-color: white; color: #0071bc; font-style: inherit; font-variant-caps: inherit; font-variant-ligatures: inherit;">J Am Acad Dermatol</span><span class="period" face=""system-ui", -apple-system, "Segoe UI", Roboto, Oxygen, Ubuntu, Cantarell, "Fira Sans", "Droid Sans", "Helvetica Neue", sans-serif" style="background-color: white; box-sizing: inherit; color: #0071bc; font-size: 16px;">. </span><span class="cit" face=""system-ui", -apple-system, "Segoe UI", Roboto, Oxygen, Ubuntu, Cantarell, "Fira Sans", "Droid Sans", "Helvetica Neue", sans-serif" style="background-color: white; box-sizing: inherit; color: #5b616b; display: inline-block; font-size: 16px;">2019 Jun;80(6):e143-e144. </span><span class="id-label" face=""system-ui", -apple-system, "Segoe UI", Roboto, Oxygen, Ubuntu, Cantarell, "Fira Sans", "Droid Sans", "Helvetica Neue", sans-serif" style="background-color: white; box-sizing: inherit; color: #212121; font-size: 16px;">PMID: </span><span class="current-id" face=""system-ui", -apple-system, "Segoe UI", Roboto, Oxygen, Ubuntu, Cantarell, "Fira Sans", "Droid Sans", "Helvetica Neue", sans-serif" style="background-color: white; box-sizing: inherit; color: #212121; font-size: 16px;" title="PubMed ID">30529542</span></p><p><br /><br /></p>Humane Medicine Huihttp://www.blogger.com/profile/07113291188306363130noreply@blogger.com0tag:blogger.com,1999:blog-9870114.post-85924334979095371352023-05-06T14:48:00.009+00:002023-05-06T14:54:32.816+00:00A Photosensitive Eruption in a College Student<p> Presented by Makayla Powers, PA</p><div class="separator" style="clear: both; text-align: left;"><div class="separator" style="clear: both; text-align: left;">
<p class="MsoNormal"><b><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";">HPI</span></b><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";">: This 20-year-old college student presented for </span></p><p class="MsoNormal"><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";">evaluation of a facial eruption. She states that </span></p><p class="MsoNormal"><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";">about one to two months
ago, she developed a rash on</span></p><p class="MsoNormal"><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";">the face. And was evaluated at the health center and </span></p><p class="MsoNormal"><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";">she was given topical steroid cream. She used this for </span></p><p class="MsoNormal"><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";">about 2 weeks an noted
improvement, but when she </span></p><p class="MsoNormal"><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";">stopped she it recurred and was worse. At the </span></p><p class="MsoNormal"><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";">same time, <span style="mso-spacerun: yes;"> </span>she developed a vesicular,
erythematous </span></p><p class="MsoNormal"><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";">rash on the dorsal hands. Anamnesis reveals last summer <br />she had a
bullous rash on the lower extremities that was <br />treated with antibiotics.</span></p>
<p class="MsoNormal"><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";">No history muscle pain
or weakness or other constitutional</span></p><p class="MsoNormal"><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";"> symptoms. There is no significant family
medical history. </span></p><p class="MsoNormal"><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";">Patient was born in Cambodia and moved to Louisiana </span></p><p class="MsoNormal"><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";">with her
family when she was 15 years old. The eruption </span></p><p class="MsoNormal"><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";">on the face and hands has
caused her significant discomfort </span></p><p class="MsoNormal"><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";">and she has difficulty sleeping. </span><span style="font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"> </span></p>
<p class="MsoNormal"><b><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";">Physical exam</span></b><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";">: On exam, patient has an erythematous,</span></p><p class="MsoNormal"><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";"> crusted eruption on the lower half of the face on the cheeks,</span></p><p class="MsoNormal"><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";"> lips, perioral area, chin
and neck. Her dorsal hands show </span></p><p class="MsoNormal"><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";"> erythematous crusted plaques over the
joints of a few digits </span></p><p class="MsoNormal"><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";">suspicious for Gottron papules.</span></p><p class="MsoNormal"><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";"> </span></p><p class="MsoNormal"><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";"><b>Photos:</b></span></p><p class="MsoNormal"><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";"><b>Summer 2022</b></span></p><p class="MsoNormal"><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";"><b></b></span></p><div class="separator" style="clear: both; text-align: center;"><b><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhAL-1Apf-i7R-e7-VdE-JokrJnUV59OWjoG1Rixr6vDv3GadSQ2iyMDeBhX6iunc9SoaZ48of8Dif7Zdu-Lhzk9wIwNIl_vhBHuFM6-QG1lcGM-_77bdJ0ljxnJijXmqKBK-wsVYsGlwrKuo4TJBb5ZL4VeMDoZkHz1D8u3NrdvVccT4oLLQ/s3300/2%20Summer%202022%20(2).jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="3300" data-original-width="2475" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhAL-1Apf-i7R-e7-VdE-JokrJnUV59OWjoG1Rixr6vDv3GadSQ2iyMDeBhX6iunc9SoaZ48of8Dif7Zdu-Lhzk9wIwNIl_vhBHuFM6-QG1lcGM-_77bdJ0ljxnJijXmqKBK-wsVYsGlwrKuo4TJBb5ZL4VeMDoZkHz1D8u3NrdvVccT4oLLQ/s320/2%20Summer%202022%20(2).jpg" width="240" /></a></b></div><b><br /> <div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjHUxlNVsQwWhi6nuzDi7JRLY-OVYDkaglz4Hdqla7rc9x0wPGBfQplp9HjXbgApD4Za7-CqbmNyKJNEuuRXLvinTwov-qE9oTcBjoigAiOXJ08Yap3BRlJuvSaRcbbHShblUnp04uAlFBmgAIYmKLQSnXvQe5ORaMGPVqw4dbeDwJ-dQpcQg/s2732/4%20Beginning%20of%20pussing%20on%20face.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="2732" data-original-width="2550" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjHUxlNVsQwWhi6nuzDi7JRLY-OVYDkaglz4Hdqla7rc9x0wPGBfQplp9HjXbgApD4Za7-CqbmNyKJNEuuRXLvinTwov-qE9oTcBjoigAiOXJ08Yap3BRlJuvSaRcbbHShblUnp04uAlFBmgAIYmKLQSnXvQe5ORaMGPVqw4dbeDwJ-dQpcQg/s320/4%20Beginning%20of%20pussing%20on%20face.jpg" width="299" /></a></div><br /></b> <span style="font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"></span><p></p>
<p class="MsoNormal"><b><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";"> April 2023</span></b><b><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";"></span></b></p><div class="separator" style="clear: both; text-align: center;"><b><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhHd3pXivGq0cHU2yQcR684AIH2xK04LPd6fi17yIILC1_HZHqls2VGha6oCGOg6pViJxpp-jgfqMFZcPfB7MUBFUaaChkse67UJSJoamvo-6RspIJTIDLKMJvyhMXiG94rpc96aFY5Q7dEmo7fC5QOCNgc1pX_mwKjcgpXlS891RrhjeWNfg/s4032/IMG_6726.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="4032" data-original-width="3024" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhHd3pXivGq0cHU2yQcR684AIH2xK04LPd6fi17yIILC1_HZHqls2VGha6oCGOg6pViJxpp-jgfqMFZcPfB7MUBFUaaChkse67UJSJoamvo-6RspIJTIDLKMJvyhMXiG94rpc96aFY5Q7dEmo7fC5QOCNgc1pX_mwKjcgpXlS891RrhjeWNfg/s320/IMG_6726.jpg" width="240" /></a></b></div><b><br /></b><p></p><p class="MsoNormal"><b><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";">Subtle Nail Fold Image<br /> <br /></span></b></p><div class="separator" style="clear: both; text-align: center;"><b><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjnf_VYQUQ2ObzUNDejLriV5K6K8ew04D3s_giWVLoynzJ0BecMluh9_TDeC69tJPSGgllMdFMXO5qc1BL5OWSbYde8LuZN8WFahp5IJ8W84JQphXzu2hkKdmDZigANJcMuusL9yZnYvYV1uAYqJCInfATxtetH5VooUsPLNnwc0un24pJrSA/s1465/DM%20Nail%20Fold.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1001" data-original-width="1465" height="219" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjnf_VYQUQ2ObzUNDejLriV5K6K8ew04D3s_giWVLoynzJ0BecMluh9_TDeC69tJPSGgllMdFMXO5qc1BL5OWSbYde8LuZN8WFahp5IJ8W84JQphXzu2hkKdmDZigANJcMuusL9yZnYvYV1uAYqJCInfATxtetH5VooUsPLNnwc0un24pJrSA/s320/DM%20Nail%20Fold.jpg" width="320" /></a></b></div><b><br /></b><p></p><p class="MsoNormal"><b><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";">Assessment and plan</span></b><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";">: We are concerned she has </span></p><p class="MsoNormal"><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";">dermatomyositis and
ordered <span style="mso-spacerun: yes;"> </span> CK, ANA, CBC, CMP, </span></p><p class="MsoNormal"><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";">TSH, ESR,
CRP. Pending results we prescribed </span></p><p class="MsoNormal"><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";">tacrolimus for her face as she stated she would
like to </span></p><p class="MsoNormal"><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";">avoid oral steroids. </span><span style="font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"> </span></p>
<p class="MsoNormal"><b><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";">Update:</span></b><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";"> When seen 3 days later the eruption on her face <br />and hands was improved. </span><span id="docs-internal-guid-975a26d6-7fff-0e7e-767c-548b173e5b72" style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-size: 9.5pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">She had blood work done<br />and early results show an elevated CK of 3030</span><span style="font-family: "Times New Roman";"> </span><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";">(nl < 145)<br />and ESR 39 and a negative ANA. (She is not a gym rat) </span><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";"><br />Her hemogram and chemistries age normal.</span><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";"> CRP. </span></p><p class="MsoNormal"><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";">The lab tests with the physical findings are suggestive of
<br />dermatomyositis. We discussed that with her and <br />she
agreed to start oral prednisone. She will avoid <br />sun exposure.<span style="mso-spacerun: yes;"> </span>It’s the end of the semester and final <br />exams are
looming,<span style="mso-spacerun: yes;"> </span>We have located an academic
<br />dermatologist near her home and further workup will <br />be done when she returns there for the summer.<span style="mso-spacerun: yes;"> </span>We did <br />not want to
impact her life at the end of her academic <br />year.<br /></span></p><p class="MsoNormal"><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";">Note: CK levels in dermatomyositis can range from <br />normal to >50,000.</span></p><p class="MsoNormal"><span style="color: black; font-family: "Times New Roman"; font-size: 9.5pt; mso-fareast-font-family: "Times New Roman";"><b><br />Diagnosis: </b> At this time, we favor dermatomyositis; but she<br />may have an undifferentiated collagen vascular disease or<br />some form of photosensitivity. We feel that a definitive <br />work-up can wait until she can be seen at a center with <br />more expertise than we have.<br /><br /></span>
</p>
<h3><span style="font-size: x-small;"><span style="color: black;">References:<br />
</span><span style="color: black; font-weight: normal;">1.
</span><span style="color: black; font-weight: normal;">Morgan
DJ, et. al. </span><span style="color: black; font-weight: normal;">Diagnostic Stewardship to Prevent Diagnostic Error</span><span style="color: black; font-weight: normal;">. </span><span style="color: black; font-weight: normal;">JAMA. 2023 Apr 18;329(15):1255-1256</span><span style="color: black; font-weight: normal;"><br />
</span><span style="color: black; font-weight: normal;">Diagnostic
stewardship optimizes testing to reduce diagnostic error and improve
diagnosis.1,2 With better diagnosis, more targeted and effective therapy can be
initiated. Interventions used for diagnostic stewardship are built into the
clinical workflow and often use methods from behavioral economics to nudge
clinicians toward better decisions. Changes may be made to diagnostic testing
at the steps of test ordering, test performance, or results reporting.</span></span></h3><h3>
</h3><h3>
</h3><h3><span style="font-size: 12pt; font-weight: normal;"></span>
</h3><h3><span style="color: #0d0d0d; font-weight: normal;"><span style="font-size: x-small;">2. <span> </span>Sontheimer
RD, Dermatomyositis: an overview of recent progress with emphasis on
dermatologic aspects. Dermatol Clin. 2002 Jul;20(3):387-408. <a href="https://pubmed.ncbi.nlm.nih.gov/12170874/">PMID</a></span></span></h3><div><span style="font-weight: normal;"><span style="color: #0d0d0d;">3. Mosca M. </span><span style="background-color: white; color: #212121; font-family: Merriweather, Georgia, Cambria, "Times New Roman", Times, serif;"><span style="font-size: x-small;">The diagnosis and classification of undifferentiated connective tissue diseases. </span></span><span face=""system-ui", -apple-system, "Segoe UI", Roboto, Oxygen, Ubuntu, Cantarell, "Fira Sans", "Droid Sans", "Helvetica Neue", sans-serif" style="background-color: white; color: #4d8055; font-size: 14px;">J</span><span face=""system-ui", -apple-system, "Segoe UI", Roboto, Oxygen, Ubuntu, Cantarell, "Fira Sans", "Droid Sans", "Helvetica Neue", sans-serif" style="background-color: white; font-size: 14px;"> Autoimmun. 2014 Feb-Mar;48-49:50-2. <a href="https://pubmed.ncbi.nlm.nih.gov/24518855/">PubMed</a> (This reference is put in for interest)</span><br /><br /></span></div>
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{page:WordSection1;}</style><span style="color: black; font-family: "Times New Roman"; font-size: medium; mso-fareast-font-family: "Times New Roman";">Your thoughts will help to guide us.</span><p class="MsoNormal"><span style="color: black; font-family: "Times New Roman"; font-size: medium; mso-fareast-font-family: "Times New Roman";">Thank you,<br /></span></p>
<p class="MsoNormal"><span style="font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"> </span></p>
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{page:WordSection1;}</style></div><br /><br /><br /></div><br /><p></p>Humane Medicine Huihttp://www.blogger.com/profile/07113291188306363130noreply@blogger.com0tag:blogger.com,1999:blog-9870114.post-68811137357903813552023-04-30T00:22:00.007+00:002023-04-30T13:45:30.236+00:00American Health Care's Two Tiered System<p>The patient is a 45-year-old uninsured day laborer in a remote area of Southern California. He has a slowly growing tumor of his right malar eminence. In our clinics he would have a biopsy and, after that, probably Mohs micrographic surgery. However, that is not this man's reality.<br /></p><p>Are there any clinics in California or Arizona that would see such a patient? Your thoughts will be helpful.</p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjElpeSG7vK5cqhy5XIlyW2_Ty1VCROMsvBqsWZOLAETxxrOD5Y55QDoWjsQ9M8xIj1w5GxxvnREgtFo0uo-xSTeq7SaVlpP9M_JJyoututHNR7UHQAjrtqc7xmm4AlHeuutIBYXfT-qcVZv2F-tQ_SLZGhRClcbIXvpuiYckeZR5to8Z5nDA/s4032/IMG_1835.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="4032" data-original-width="3024" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjElpeSG7vK5cqhy5XIlyW2_Ty1VCROMsvBqsWZOLAETxxrOD5Y55QDoWjsQ9M8xIj1w5GxxvnREgtFo0uo-xSTeq7SaVlpP9M_JJyoututHNR7UHQAjrtqc7xmm4AlHeuutIBYXfT-qcVZv2F-tQ_SLZGhRClcbIXvpuiYckeZR5to8Z5nDA/s320/IMG_1835.jpg" width="240" /></a></div><br /><p>Please email <a href="mailto:djelpern@gmail.com">David Elpern</a> with suggestions.<br /></p>Humane Medicine Huihttp://www.blogger.com/profile/07113291188306363130noreply@blogger.com0tag:blogger.com,1999:blog-9870114.post-73326450738557564802023-04-19T00:15:00.013+00:002023-05-06T14:40:36.955+00:00Mystery Plaque<p dir="ltr" id="docs-internal-guid-4ebd2145-7fff-67aa-cf72-a0e55c9eba70" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-size: 10.5pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">Presented by Makayla Powers, PA </span></p><p dir="ltr" id="docs-internal-guid-4ebd2145-7fff-67aa-cf72-a0e55c9eba70" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-size: 10.5pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;"> </span></p><p dir="ltr" id="docs-internal-guid-4ebd2145-7fff-67aa-cf72-a0e55c9eba70" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-size: 10.5pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;"><b>History: </b>The patient is a 37 year old man who </span></p><p dir="ltr" id="docs-internal-guid-4ebd2145-7fff-67aa-cf72-a0e55c9eba70" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-size: 10.5pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">presents for an eruption on the right leg. This </span></p><p dir="ltr" id="docs-internal-guid-4ebd2145-7fff-67aa-cf72-a0e55c9eba70" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-size: 10.5pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">developed about 8 months ago as a small area </span></p><p dir="ltr" id="docs-internal-guid-4ebd2145-7fff-67aa-cf72-a0e55c9eba70" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-size: 10.5pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">of erythema. He was initially evaluated in the </span></p><p dir="ltr" id="docs-internal-guid-4ebd2145-7fff-67aa-cf72-a0e55c9eba70" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-size: 10.5pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">ER and was prescribed antibiotics. Since then </span></p><p dir="ltr" id="docs-internal-guid-4ebd2145-7fff-67aa-cf72-a0e55c9eba70" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-size: 10.5pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">he has been on numerous rounds of antibiotics </span></p><p dir="ltr" id="docs-internal-guid-4ebd2145-7fff-67aa-cf72-a0e55c9eba70" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-size: 10.5pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">and he is currently on augmentin. At one point, </span></p><p dir="ltr" id="docs-internal-guid-4ebd2145-7fff-67aa-cf72-a0e55c9eba70" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-size: 10.5pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">his right knee became swollen and he reports</span></p><p dir="ltr" id="docs-internal-guid-4ebd2145-7fff-67aa-cf72-a0e55c9eba70" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-size: 10.5pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">fluid was drained from it in the hospital. The </span></p><p dir="ltr" id="docs-internal-guid-4ebd2145-7fff-67aa-cf72-a0e55c9eba70" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-size: 10.5pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">eruption has continued to spread and has become </span></p><p dir="ltr" id="docs-internal-guid-4ebd2145-7fff-67aa-cf72-a0e55c9eba70" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-size: 10.5pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">painful when palpated. He has been seeing a provider </span></p><p dir="ltr" id="docs-internal-guid-4ebd2145-7fff-67aa-cf72-a0e55c9eba70" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-size: 10.5pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">at the wound care clinic who usually cleans and </span></p><p dir="ltr" id="docs-internal-guid-4ebd2145-7fff-67aa-cf72-a0e55c9eba70" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-size: 10.5pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">dresses the area, however the eruption is not </span></p><p dir="ltr" id="docs-internal-guid-4ebd2145-7fff-67aa-cf72-a0e55c9eba70" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-size: 10.5pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">improving. </span></p><p><br /><span style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-size: 10.5pt; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre;">Physical exam</span><span style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-size: 10.5pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">: On exam, patient has an erythematous <br />plaque on the right lower leg that measures about <br />12 cm x 6 cm and is located just below the knee. <br />There are a few areas that are weeping a yellow fluid. </span></p><p><span style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-size: 10.5pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;"></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhthPmSP7KAraL95X2UzCWm87GCBwk5wKKd7d56dGWnMoujr4EzWJXMRZWlIP0ZVuE3A67r5wsogMuoWXHfjpPwf2Nj6N4PgAbm2j-erSydFU2uV_IDX6t6wHQymhJw3MWeNv4Xn7-5P4tibxjNIrogbIKcJKwWIvb2K_e0aqd8zL_3-R7gQg/s2977/Unk%20MP.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="2539" data-original-width="2977" height="341" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhthPmSP7KAraL95X2UzCWm87GCBwk5wKKd7d56dGWnMoujr4EzWJXMRZWlIP0ZVuE3A67r5wsogMuoWXHfjpPwf2Nj6N4PgAbm2j-erSydFU2uV_IDX6t6wHQymhJw3MWeNv4Xn7-5P4tibxjNIrogbIKcJKwWIvb2K_e0aqd8zL_3-R7gQg/w400-h341/Unk%20MP.jpg" width="400" /></a></div><p>A bacterial culture and biopsy was done. </p><p>Wound culture showed Coagulase Positive Staph MRSA type.<br /></p><p>Pathology.<br />Photomicrographs courtesy of David Jones, MD. Berkshire Medical Center. Note Reference # 1.<br /></p><p>First Biopsy 4.17.23</p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjAYaQ3cApwSW7DtVIBhkPEoChCJIbGrfq9I-O_xeESiHXg13HLsvz7071Dsh9CLB2NaEIx1fpDVvyAE4mmNoV6KeOqMsa8s7td5AXY_tKjk-LZdMxsjEO4zBr2jcnp7uvaLYetdH7iCwKmaKlyL1s85P9Bg3XfKLsnia0T7R7orB9Nl0sDlg/s3840/DB1.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="2748" data-original-width="3840" height="229" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjAYaQ3cApwSW7DtVIBhkPEoChCJIbGrfq9I-O_xeESiHXg13HLsvz7071Dsh9CLB2NaEIx1fpDVvyAE4mmNoV6KeOqMsa8s7td5AXY_tKjk-LZdMxsjEO4zBr2jcnp7uvaLYetdH7iCwKmaKlyL1s85P9Bg3XfKLsnia0T7R7orB9Nl0sDlg/s320/DB1.jpg" width="320" /></a></div><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiV3q7p8R3WnMxbYjDWuy2WxysiUPavdvpfdkpymEBhy8LHjPqu0cQyFwmy3TPaDgaJl6J7tjW_T6QB_p7eGlAT75bnRyP8G6FsKJmpLDeVl_LY8iWbGMu4Pm040-cEaroYt9RfIiffQXyPiy3St9_cT2-mz5gra8nmcO98dB96t3hSH2_CcQ/s3029/DB2.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="2740" data-original-width="3029" height="289" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiV3q7p8R3WnMxbYjDWuy2WxysiUPavdvpfdkpymEBhy8LHjPqu0cQyFwmy3TPaDgaJl6J7tjW_T6QB_p7eGlAT75bnRyP8G6FsKJmpLDeVl_LY8iWbGMu4Pm040-cEaroYt9RfIiffQXyPiy3St9_cT2-mz5gra8nmcO98dB96t3hSH2_CcQ/s320/DB2.jpg" width="320" /></a></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh6C6LBN239tblmwERgIjKWIMMsNaPLXYa0xRNY2GXqx4pYeVyDD3TncUeWsoHKH5SDT4HCi9iu60wwzIdvtLJSp0DYDCfQ5Upr3my8HJFOgZ5uh9mQlktfOMsOZYy3Ct9nd0el8hThCE7omkhePqQL7UBB2jY_U2GihQHllpyLcM0-h9U3_g/s3840/DB3.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="2748" data-original-width="3840" height="229" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh6C6LBN239tblmwERgIjKWIMMsNaPLXYa0xRNY2GXqx4pYeVyDD3TncUeWsoHKH5SDT4HCi9iu60wwzIdvtLJSp0DYDCfQ5Upr3my8HJFOgZ5uh9mQlktfOMsOZYy3Ct9nd0el8hThCE7omkhePqQL7UBB2jY_U2GihQHllpyLcM0-h9U3_g/s320/DB3.jpg" width="320" /></a></div><p><span style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-size: 10.5pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">Repeat Biopsy 4/24/23 shows rare spores consistent with Blastomycosis (PAS stain)</span></p><p><span style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-size: 10.5pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;"></span></p><div class="separator" style="clear: both; text-align: center;"><span style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-size: 10.5pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg6GQHDJPC1ca8_My-oIByZ5aAgAsmPJaISZ0TLDpLpQ4qcZh5Z31mVGVcOfqaLW_RviIfSVu-YSSWHXKEjWfEMVLVCkVzcHJvr7NDR3kfr8l4LfUWbcePl59JBwJEcdMuQOTEEuHfVgSdE4nGP_XHTbWNrCHUnVS0Nyg3B4IIc_DaXfXFpZA/s3840/Duncanson%20Spore1.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="2748" data-original-width="3840" height="229" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg6GQHDJPC1ca8_My-oIByZ5aAgAsmPJaISZ0TLDpLpQ4qcZh5Z31mVGVcOfqaLW_RviIfSVu-YSSWHXKEjWfEMVLVCkVzcHJvr7NDR3kfr8l4LfUWbcePl59JBwJEcdMuQOTEEuHfVgSdE4nGP_XHTbWNrCHUnVS0Nyg3B4IIc_DaXfXFpZA/s320/Duncanson%20Spore1.jpg" width="320" /></a></span></div><span style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-size: 10.5pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">Enlarge image below and look for the arrow.<br /></span><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjTqdRthU18Xcw_Dt3KooPIyrM9NYX8WGFu2qt5A-VprxNFd81HRQxO8Z_mWkQFCpH6GIePFRCCOGLDcr2kZ2iISAwDGgbZ-MZ_63F97Po_rpfROO8fwYXJ7HgtvL5fhU0cMn0KXBnYrQ_2oMk86hx3X-rdvoEicdBO-l0GlN5tyyUVlcZinw/s3840/Duncanson%20SporeHP_edited-1.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="2748" data-original-width="3840" height="229" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjTqdRthU18Xcw_Dt3KooPIyrM9NYX8WGFu2qt5A-VprxNFd81HRQxO8Z_mWkQFCpH6GIePFRCCOGLDcr2kZ2iISAwDGgbZ-MZ_63F97Po_rpfROO8fwYXJ7HgtvL5fhU0cMn0KXBnYrQ_2oMk86hx3X-rdvoEicdBO-l0GlN5tyyUVlcZinw/s320/Duncanson%20SporeHP_edited-1.jpg" width="320" /></a></div>Diagnosis: Cutaneous Blastomycosis. <br />We plan to have patient get a CXR,<br /><p></p><p><span style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-size: 10.5pt; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;"> Your thoughts will be appreciated and we will update <br />this presentation as new findings emerge. </span></p><p><span style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;">References</span></p><p class="MsoNormal"><span>1. <span>Blastomycosis in the
Capital District of New York State: A Newly Identified Emerging Endemic Area. Adam
Austin<span> </span><b>David M Jones</b><span> </span>et. al. Am J Med. 2021 Feb;134(2):e101-e108. PMID:
33091391<br />
Abstract<br />Background: The
Centers for Disease Control and Prevention and New York State Department of
Health recently identified the Capital District of New York (CDNY) as an
emerging endemic area for blastomycosis. However, no clinical or
epidemiological description of blastomycosis in the CDNY has been published.<br />Methods: We
performed a retrospective analysis of blastomycosis cases at Albany Medical
Center (AMC) and Albany Stratton Veterans Affairs Medical Center (VAMC) from
January 1, 2000, through June 1, 2019. Patients were identified via an
institution-approved informatics system at the hospital's microbiology
laboratory.<br />Results: We
identified 20 patients diagnosed with blastomycosis over the past 2 decades.
There was a nearly 9-fold increase in the annual number of cases in 2016-2019
compared with 2000-2015. The majority of patients resided in the CDNY (90%),
and 65% lived within the Mohawk River valley. Most cases (85%) were assumed to
be malignancies or non-mycotic infections prior to diagnosis, with median time
between presentation and diagnosis of 53 days.<br /></span><b><span>Conclusions: Our data support recent reports
that blastomycosis is an emerging disease in the CDNY</span></b><span>. Most patients were misdiagnosed as
malignancy or non-mycotic infection, which led to treatment delays.</span></span></p><p class="MsoNormal"><span><span> </span></span></p><p class="MsoNormal"><span><span>2. </span></span><span style="mso-bidi-font-size: 14.0pt;">Ross JJ, et. al.
Blastomycosis in New England: 5 Cases and a Review. Open Forum Infect Dis. 2023
Jan 20;10(1):ofad029 Jan.<span style="mso-spacerun: yes;"> </span><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9887255/">Free PMCarticl<br /></a>Abstract<br />The geographic range
of blastomycosis is thought to include New England, but documentation is
sparse. We report 5 cases of infection with Blastomyces dermatitidis that were
likely acquired in New England between 2011 and 2021. Our experience suggests that
chart coding for the diagnosis of blastomycosis is imprecise and that mandatory
reporting might help resolve uncertainties about the prevalence and extent of
blastomycosis.</span></p><p class="MsoNormal"><span style="mso-bidi-font-size: 14.0pt;"> </span></p><p class="MsoNormal"><span style="mso-bidi-font-size: 14.0pt;">3. </span>Elena Gonzalez Caldito, Camila Antia, Vesna Petronic-Rosic. <b style="mso-bidi-font-weight: normal;">Cutaneous Blastomycosis</b>. JAMA Dermatol.
2022 Sep 1;158(9):1064. </p>
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<p class="MsoNormal"><span style="font-size: x-small;"><span> </span></span></p>
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{page:WordSection1;}</font></style><span style="background-color: transparent; color: black; font-family: 'Times New Roman'; font-size: x-small; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre;"> </span></p>Humane Medicine Huihttp://www.blogger.com/profile/07113291188306363130noreply@blogger.com0tag:blogger.com,1999:blog-9870114.post-88971499958998340412023-03-25T17:56:00.354+00:002023-04-16T16:27:00.429+00:00Paraneoplastic Rash Leading to Lymphoma Diagnosis<div style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt; text-align: left;"><span style="font-family: Arial; font-size: 11pt; white-space: pre-wrap;">Presented by Elizabeth Miller, BSc and Brenda Dintiman, MD</span><span style="font-family: times;"><br />DermUtopia, Fairfax, Virginia<br /></span><p style="clear: both; text-align: center;"></p>
<p class="MsoNormal"><span lang="EN" style="font-family: "Times New Roman"; font-size: 12pt; line-height: 115%;">History and physical: <br />
This is a 75-year-old man who was referred to our practice by his
allergist for a pruritic rash on the legs and arms. The patient reported that
he had first developed a rash on his trunk in July of 2021 following three
courses of amoxicillin. At that time, it was described as bright red to
purplish in color, with associated fluid-filled vesicles and pruritus. The rash
was treated with a topical steroid cream and resolved within 10 days. <br />In February 2022, the patient began to develop purpuric, pruritic patches and
urticarial wheals on his ankles, calves and forearms that progressively worsened
and seemed to be aggravated by heat and friction from clothing. The patient had
tried multiple courses of topical steroids without response. He was given
several short courses of oral prednisone by his primary care doctor and
although the rash resolved while he was on prednisone, it would return and
progressively worsen as soon as the course was complete. He denied any
constitutional symptoms such as fever, chills, cough, lymphadenopathy, night
sweats, abdominal pain, or weight loss. </span></p>
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<p class="MsoNormal"><span lang="EN" style="font-family: "Times New Roman"; font-size: 12pt; line-height: 115%;">Assessment: </span></p>
<p class="MsoNormal"><span lang="EN" style="font-family: "Times New Roman"; font-size: 12pt; line-height: 115%;">The patient initially presented to our practice
with a subtle erythematous eruption on the arms and legs and evidence of post-inflammatory
pigmentation. Subsequently, he returned with a worsening violaeous, painful
rash on his lower extremities and red indurated nodules on his arms just three
days after his first visit:<span style="mso-no-proof: yes;"> </span></span></p>
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{page:WordSection1;}</style><span style="background-color: transparent; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline;"><div style="color: black; font-family: times; font-size: 11pt; font-style: normal; font-variant-caps: normal; font-variant-ligatures: normal; font-weight: 400; text-align: left; text-decoration-line: none; white-space: pre;"><span style="font-size: 11pt;"><br /></span></div><div style="text-align: left;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj5FGeCM__623OwnHhzCuJ3KU1SeAkMZhwhQuiBbfsb0cqRrHOAGO9hfZC6u6TzYP3pFEk3IUFviP9aq2sqHThoalPhajMBJFFSNmGE3bxMYOUO32LkIt1zmgdUNSeEsOYgi9cXD6AKHHGAzTWxUbTwdbSh5W0_TmWhHuQZCzam8zj8CVy2yw/s312/EM%201.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="238" data-original-width="312" height="238" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj5FGeCM__623OwnHhzCuJ3KU1SeAkMZhwhQuiBbfsb0cqRrHOAGO9hfZC6u6TzYP3pFEk3IUFviP9aq2sqHThoalPhajMBJFFSNmGE3bxMYOUO32LkIt1zmgdUNSeEsOYgi9cXD6AKHHGAzTWxUbTwdbSh5W0_TmWhHuQZCzam8zj8CVy2yw/s1600/EM%201.jpg" width="312" /></a></div><div style="color: black; font-family: times; font-size: 11pt; font-style: normal; font-variant-caps: normal; font-variant-ligatures: normal; font-weight: 400; text-align: center; text-decoration-line: none; white-space: pre;"><br /></div><div style="text-align: center;"><div class="separator" style="clear: both; color: black; font-family: times; font-size: 11pt; font-style: normal; font-variant-caps: normal; font-variant-ligatures: normal; font-weight: 400; text-align: center; text-decoration-line: none; white-space: pre;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEhQkKqCRKjGTI1OEkoyYRPC62Uym5kyJfGY2ZpzJ8rIpymi-nmbZTi96n472aozYarDCVrdMSIiKUQdjj4_5UDcjNj-Nx3z1I9ryGlJQbme8Ooi0h5CucDly6riAeaCPRD9QNuXSpljaU4pKmLxflOqetQa23c0tPruwza8hH-KZuP9HGwEeQ" style="margin-left: 1em; margin-right: 1em;"><img data-original-height="366" data-original-width="478" height="245" src="https://blogger.googleusercontent.com/img/a/AVvXsEhQkKqCRKjGTI1OEkoyYRPC62Uym5kyJfGY2ZpzJ8rIpymi-nmbZTi96n472aozYarDCVrdMSIiKUQdjj4_5UDcjNj-Nx3z1I9ryGlJQbme8Ooi0h5CucDly6riAeaCPRD9QNuXSpljaU4pKmLxflOqetQa23c0tPruwza8hH-KZuP9HGwEeQ=w320-h245" width="320" /></a></div><div class="separator" style="clear: both; color: black; font-family: times; font-size: 11pt; font-style: normal; font-variant-caps: normal; font-variant-ligatures: normal; font-weight: 400; text-align: center; text-decoration-line: none; white-space: pre;"><br /></div><div class="separator" style="clear: both; text-align: center;"><div class="separator" style="clear: both; color: black; font-family: times; font-size: 11pt; font-style: normal; font-variant-caps: normal; font-variant-ligatures: normal; font-weight: 400; text-align: center; text-decoration-line: none; white-space: pre;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEhXdYOTuj4sgEO68v7Uh5dd34iEruNE56cU3qiW-a7HZPPavhpn243XsoWZ11013wsRU0HexUutdNAiLHz0GbV907HVdjyBX5UaayrrKVA95lTGulZPpukvF9lQ-LFudOBlB6JRjhU-TQkgxb6vz1n0kKUXT2lXtFjexx0fH6kTdZHl9Ugvvw" style="margin-left: 1em; margin-right: 1em;"><img data-original-height="528" data-original-width="446" height="320" src="https://blogger.googleusercontent.com/img/a/AVvXsEhXdYOTuj4sgEO68v7Uh5dd34iEruNE56cU3qiW-a7HZPPavhpn243XsoWZ11013wsRU0HexUutdNAiLHz0GbV907HVdjyBX5UaayrrKVA95lTGulZPpukvF9lQ-LFudOBlB6JRjhU-TQkgxb6vz1n0kKUXT2lXtFjexx0fH6kTdZHl9Ugvvw=w271-h320" width="271" /></a></div><div class="separator" style="clear: both; color: black; font-family: times; font-size: 11pt; font-style: normal; font-variant-caps: normal; font-variant-ligatures: normal; font-weight: 400; text-align: center; text-decoration-line: none; white-space: pre;"><br /></div><div style="text-align: left;"><span lang="EN" style="font-family: "Times New Roman"; font-size: 12pt; line-height: 115%;">Workup: </span>
<p class="MsoNormal"><span lang="EN" style="font-family: "Times New Roman"; font-size: 12pt; line-height: 115%;">The patient’s differential included drug
reaction, vasculitis, hypereosinophilic syndrome, bullous pemphigoid, or
lymphoproliferative syndrome. Biopsies were taken from active lesions, and lab
work including CBC, CMP, SPEP, RF, ANA, and bullous pemphigoid antigen was
ordered. He was also referred to rheumatology and oncology for further
investigations. </span></p>
<p class="MsoNormal"><span lang="EN" style="font-family: "Times New Roman"; font-size: 12pt; line-height: 115%;">Results: </span></p>
<p class="MsoNormal"><span lang="EN" style="font-family: "Times New Roman"; font-size: 12pt; line-height: 115%;">Lab results were remarkable for eosinophilia
(7.2%), elevated C-reactive protein (5.2), and a highly positive rheumatoid
factor (>1000). The patient had a negative ANA, negative bullous pemphigoid
antigen, and a normal SPEP. </span></p>
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{page:WordSection1;}</style><p style="text-align: left;"><span style="font-family: times;"><span style="font-size: 14.6667px; white-space: pre;">Pathology:</span></span></p></div></div></div></div><p style="text-align: center;"><span style="font-family: times;"><span style="font-size: 11pt; white-space: pre;"><img height="267" src="https://lh3.googleusercontent.com/87DgKbJ4H5N53jul4ZJtOdBqqL79Vbny9uyIxzTHpG-bMNJ45vlZ4JOeCBgJgjrSCXgtnX8uXzehxNEQ5nVlyJlsv0NFmRR7Z3-AXBbA8y0yBxhNkqHGov2MNF-niq6Aca8CaQSmUi4jqFrSTdz1pso=w400-h267" style="font-size: 11pt; margin-left: 0px; margin-top: 0px;" title="4x. The histologic sections show a superficial and deep infiltrate that extends into subcutis and includes hemorrhage within the dermis and subcutis" width="400" /></span></span></p><p style="text-align: left;"><i>4x. The histologic sections show a superficial and deep infiltrate that extends into subcutis and includes hemorrhage within the dermis and subcutis.</i></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEh8pq6kDuRiTaijUyeJIOL03dE3jIE8Dx_An5xghhhXNvW14S2b3pOBuVhoFbge7KwOi3exn4WWZGdf3T6CY6Ae8P7S88LGHvy3Tyl2Qm6kvgBSg1E8ig6tFxyPapkjjWZ2Armkgto3CQ7eDVdi7PC8xUlcz3SwMLD87JaDBgBAWMLJfcjzGA" style="margin-left: 1em; margin-right: 1em;"><img data-original-height="340" data-original-width="452" height="301" src="https://blogger.googleusercontent.com/img/a/AVvXsEh8pq6kDuRiTaijUyeJIOL03dE3jIE8Dx_An5xghhhXNvW14S2b3pOBuVhoFbge7KwOi3exn4WWZGdf3T6CY6Ae8P7S88LGHvy3Tyl2Qm6kvgBSg1E8ig6tFxyPapkjjWZ2Armkgto3CQ7eDVdi7PC8xUlcz3SwMLD87JaDBgBAWMLJfcjzGA=w400-h301" width="400" /></a><span style="font-family: times;"><i><br />20x superficial dermis. Within the upper dermis, the infiltrate is seen to include numerous lymphocytes, neutrophils, and eosinophils. Hemorrhage is present. No leukocytoclastic vasculitis is identified.</i></span></div></span><span style="background-color: transparent; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline;"><p class="MsoNormal" style="text-indent: 0.5in;"><span lang="EN" style="font-family: "Times New Roman"; font-size: 12pt; line-height: 115%;"><br />Diagnosis and Treatment:<br />The patient’s primary
care doctor ordered a CT of the abdomen which showed retroperitoneal
lymphadenopathy in the upper pelvis. Subsequently, a PET scan showed widespread
low-grade adenopathy above and below the diaphragm.<br /><br />The patient underwent a
bone marrow biopsy and inguinal lymph node biopsy, which were consistent with
CD5-negative mantle cell lymphoma (MCL). He had stage IV disease. He was
started on a course of rituxan for his lymphoma, and he was continued on
systemic corticosteroids to manage his rash.<br /><br />Discussion:<br />This case is an example
of a patient with an indolent recurring skin eruption which required a
multidisciplinary effort to correctly diagnose and manage. He had a negative workup
by an allergist prior to being evaluated by dermatology and being referred to
oncology and rheumatology. It is also interesting to note that he had few to no
constitutional symptoms preceding his skin eruption and diagnosis with MCL.<br />One review of the
literature estimates that only 2-10% of patients with MCL have cutaneous
disease, most often caused by involvement of the lymphoma in the skin. This
case, where biopsies did not show involvement of the lymphoma in the skin but
rather suggested a paraneoplastic reaction, seems to be even more rare. We could
only find only one similar case report in PubMed. In that case, therapy with
rituximab was successful in treating the patient’s eruption. </span></p></span>
<p class="MsoNormal"><span lang="EN" style="font-family: "Times New Roman"; font-size: 12pt; line-height: 115%;">References:</span></p>
<p style="margin-bottom: .0001pt; margin: 0in;"><span style="color: black; font-family: "Times","serif";">1. de Souza PK, Amorim RO, Sousa LS, Batista MD. Dermatological
manifestations of hematologic neoplasms. Part I: secondary specific skin
lesions. An Bras Dermatol. 2023;98(1):5-12. doi:10.1016/j.abd.2022.06.002</span></p>
<p><span style="color: black; font-family: "Times","serif";">2. de Souza PK, Amorim
RO, Sousa LS, Batista MD. Dermatological manifestations of hematologic
neoplasms. Part II: nonspecific skin lesions/paraneoplastic diseases. An Bras
Dermatol. 2023;98(2):141-158. doi:10.1016/j.abd.2022.08.005</span></p>
<p><span style="color: black; font-family: "Times","serif";">3. </span>Geropoulos
G, Psarras K, Vlachaki E, et al. Cutaneous manifestations of mantle cell
lymphoma: an extensive literature review. <i style="mso-bidi-font-style: normal;">Acta
Dermatovenerol Alp Pannonica Adriat</i>. 2020;29(4):185-191.<span style="color: black; font-family: "Times","serif";"></span></p>
<p class="MsoNormal"><span lang="EN" style="font-family: "Times New Roman"; font-size: 12pt; line-height: 115%;">4. Nemets A, Ronen M, Lugassy G. Chronic
paraneoplastic cutaneous syndrome preceding an indolent variant of mantle cell
lymphoma: favorable response to rituximab. <i style="mso-bidi-font-style: normal;">Acta
Haematol</i>. 2006;115(1-2):113-116. doi:10.1159/000089477</span></p>
<p class="MsoNormal"><span lang="EN" style="font-family: "Times New Roman"; font-size: 12pt; line-height: 115%;"> </span></p>
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{page:WordSection1;}</span></style><p style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt; text-align: left;"><span style="font-family: times; font-size: 11pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"></span></p>E. Millerhttp://www.blogger.com/profile/17498316267138295445noreply@blogger.com0tag:blogger.com,1999:blog-9870114.post-61373908016194184672023-02-27T21:46:00.005+00:002023-02-27T22:10:30.159+00:00Solitary Lymphocytic Tumor: Benign or Malignant?<p class="MsoNormal"><span color="windowtext" style="font-size: 10pt; mso-fareast-font-family: "Times New Roman";">A </span><span color="windowtext" style="font-size: 10pt; mso-fareast-font-family: "Times New Roman";">healthy 8</span><span color="windowtext" style="font-size: 10pt; mso-fareast-font-family: "Times New Roman";">0-year-old Chinese man presented with a 2-month
history of a 6 x 6 cm erythematous plaque on the right forearm that had
gradually increased in size. He saw a dermatologist 2 months ago, had a biopsy
and was told it was an insect bite reaction. However, he did not recall any
insect bite reaction. I repeated his skin biopsy as it was not
responding to treatment.. </span></p><p class="MsoNormal"><span color="windowtext" style="font-size: 10pt; mso-fareast-font-family: "Times New Roman";"> </span></p><p class="MsoNormal"><span color="windowtext" style="font-size: 10pt; mso-fareast-font-family: "Times New Roman";">Clinical and Histopatological Photos <br /><br /></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiw04kTf-WDIhtP551ljN2F1l2-wrvwngoNKvVVjhraaBZ5Q0ck5CztdrBRGKeZreRUzKUei-jOGwam6l-2R_lszGHO4x4P6STd9viXG-cdd6Y4bHDx6GAmkNB52wuYAHqBL99cUcgmZgsSkjjAuaiQ8Arq2LC2OsVHvYQXXz4-4lMhzJbvWw/s1280/PHOTO-2023-02-08-11-47-52.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1280" data-original-width="960" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiw04kTf-WDIhtP551ljN2F1l2-wrvwngoNKvVVjhraaBZ5Q0ck5CztdrBRGKeZreRUzKUei-jOGwam6l-2R_lszGHO4x4P6STd9viXG-cdd6Y4bHDx6GAmkNB52wuYAHqBL99cUcgmZgsSkjjAuaiQ8Arq2LC2OsVHvYQXXz4-4lMhzJbvWw/s320/PHOTO-2023-02-08-11-47-52.jpg" width="240" /></a></div><br /><p></p><div class="separator" style="clear: both; text-align: center;"><span color="windowtext" style="font-size: 10pt; mso-fareast-font-family: "Times New Roman";"></span><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj54TwtycoboL15h0JxfxYbBKlZ7NOR9dlNP9Kuv7lvl6_w5x0YGz48v5XW9ne1sAiqy-0EAruhA0nHPyGD-nCN6U9D3iypVX6IADYbNk0Q7K-ZBXc5NDob09RuuVrLGzPVzQERUYXQPGyTcuODp8VS7VJYRUTnkmjXtMIJnwMofFIHyraJxA/s1358/PHOTO-2023-02-22-11-07-57.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="769" data-original-width="1358" height="181" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj54TwtycoboL15h0JxfxYbBKlZ7NOR9dlNP9Kuv7lvl6_w5x0YGz48v5XW9ne1sAiqy-0EAruhA0nHPyGD-nCN6U9D3iypVX6IADYbNk0Q7K-ZBXc5NDob09RuuVrLGzPVzQERUYXQPGyTcuODp8VS7VJYRUTnkmjXtMIJnwMofFIHyraJxA/s320/PHOTO-2023-02-22-11-07-57.jpg" width="320" /></a></div><span color="windowtext" style="font-size: 10pt; mso-fareast-font-family: "Times New Roman";"><br /></span><div class="separator" style="clear: both; text-align: center;"><span color="windowtext" style="font-size: 10pt; mso-fareast-font-family: "Times New Roman";"></span><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgJHLtO644IeLC0s0m0gZWqz4MKDYannoTMif_xv4izsP0pS5clUbqgPv9-Y3Ktk3F4KXxLi5gOMnforul4UntWpt_XdR8HAMOhrJTFppHYtMMK-URMPtTtizhAzNmHpSzI-XHRqY6cI7ARQzd3H79IfJaELQYnueIuyjcSORfQ0ohzoqIouw/s1371/PHOTO-2023-02-22-11-01-43%203.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="790" data-original-width="1371" height="184" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgJHLtO644IeLC0s0m0gZWqz4MKDYannoTMif_xv4izsP0pS5clUbqgPv9-Y3Ktk3F4KXxLi5gOMnforul4UntWpt_XdR8HAMOhrJTFppHYtMMK-URMPtTtizhAzNmHpSzI-XHRqY6cI7ARQzd3H79IfJaELQYnueIuyjcSORfQ0ohzoqIouw/s320/PHOTO-2023-02-22-11-01-43%203.jpg" width="320" /></a></div><span color="windowtext" style="font-size: 10pt; mso-fareast-font-family: "Times New Roman";"><br /></span><p class="MsoNormal"><span color="windowtext" style="font-size: 10pt; mso-fareast-font-family: "Times New Roman";">Pathology: Section shows epidermis with mild spongiosis. The
dermis shows dense, superficial and deep perivascular infiltration of
lymphocytes and plasma cells. There is no significant increase of
eosinophils. The infiltrate extends along the sweat ducts, hair follicles
and sebaceous glands. The superficial subcutaneous fat shows lymphocytes
and plasma cells infiltration. The deeper dermis shows marked increased in
eosinophils. There is no granulomatous lesion or atypical bizzare
lymphocytes seen. The deeper dermis and subcutaneous fat are normal.<span style="mso-spacerun: yes;"> </span>No granuloma or nerve hypertrophy seen.</span></p>
<p class="MsoNormal"><span color="windowtext" style="font-size: 10pt; mso-fareast-font-family: "Times New Roman";"><br />
INTERPRETATION<br />
Reactive lymphoid proliferative disorder or lymphocytoma cutis.<br />
No granuloma seen to suggest leprosy or cutaneous TB.</span><span style="font-size: 10pt;"> </span></p>
<p class="MsoNormal"><span color="windowtext" style="font-size: 10pt; mso-fareast-font-family: "Times New Roman";">Follow up with IHC stains. <br />CD3: CD20 showed mixed populations of the lymphoid cells.<br />CD10: positive weak for genimal centre<br />BCL2: negative for geminal centre<br />BCL6: positive for geminal centre<br />CD30 negative<br />EBER: negative<br />cMYC negative<br />EMA negative<br />Ki67 no marked increase in mitosis<br /><br /></span></p>
<p class="MsoNormal"><span color="windowtext" style="font-size: 10pt; mso-fareast-font-family: "Times New Roman";">Discussion: </span><span style="font-size: 10pt; mso-fareast-font-family: "Times New Roman";">The </span><span color="windowtext" style="font-size: 10pt; mso-fareast-font-family: "Times New Roman";">pathologists concluded reactive lymphoid
proliferative disorder or lymphocytoma cutis.</span></p>
<p class="MsoNormal"><span color="windowtext" style="font-size: 10pt; mso-fareast-font-family: "Times New Roman";">Questions: Is this benign or does it have a malignant potential? <span style="mso-spacerun: yes;"> Does he warrant further work up or perhaps follow up closely to watch his progression?</span></span><span style="font-size: 10pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-spacerun: yes;"> Thanks for your input!</span></span><span color="windowtext" style="font-size: 10pt; mso-fareast-font-family: "Times New Roman";"></span></p>
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{page:WordSection1;}</style></p>Humane Medicine Huihttp://www.blogger.com/profile/07113291188306363130noreply@blogger.com0tag:blogger.com,1999:blog-9870114.post-51292433295925444912023-02-11T16:37:00.004+00:002023-02-20T15:02:41.704+00:00Keratinocyte Skin Cancer in a Centenarian<p class="MsoNormal">The patient is a 100 year-old widow who lives independently
in an apartment complex.<span style="mso-spacerun: yes;"> </span>She’s been on
supplemental oxygen for almost 20 years.<span style="mso-spacerun: yes;">
</span>She has friends who visit regularly, but no close relatives nearby.<span style="mso-spacerun: yes;"> </span>She enjoys life and is a great sports fan.</p>
<p class="MsoNormal"> </p>
<p class="MsoNormal">She has a biopsy proven nodular basal cell on the left second toe and a biopsy proven superficial squamous cell carcinoma involving
most of the dorsum of left middle finger.<span style="mso-spacerun: yes;">
</span>The closest Mohs surgeon is an hour away.</p>
<p class="MsoNormal"> </p>
<p class="MsoNormal">Clinical Photos<br /><br /></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhSer1K-aoZcB812cYzFta0IBhgz4gdqQnUQrHHZNTXIZLhvrmBPYEJ05cSUzGl8HDxp9isD1aMC5MX4y8nGLc7F4qJZF8jurW0H2wdNUWnCQi4yf2IYMMsnHiINPQp2kDa13etHJVb9iES_YorH7IB7kNw1h32ZlvUGk5rXOXrhvGVJW3KSQ/s576/Sprague2.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="432" data-original-width="576" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhSer1K-aoZcB812cYzFta0IBhgz4gdqQnUQrHHZNTXIZLhvrmBPYEJ05cSUzGl8HDxp9isD1aMC5MX4y8nGLc7F4qJZF8jurW0H2wdNUWnCQi4yf2IYMMsnHiINPQp2kDa13etHJVb9iES_YorH7IB7kNw1h32ZlvUGk5rXOXrhvGVJW3KSQ/s320/Sprague2.jpg" width="320" /></a></div><br />
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj8YDkk4smay8e_F_d_L9xxnLxyvAhgX9gKZRGdKPTiyztSC9AB17TiKw1G-0DjFverobzRQcbffTbDW4dnyz3tLEQyvxxMFExSshZi09YkhoKVawOJRg423YLf-cAa3tXwQgZTcUYx59JB5g6oMzQmz10glmgEFheX0lrXVJDgWZHkyy-wmg/s576/Sprague1.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="491" data-original-width="576" height="273" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj8YDkk4smay8e_F_d_L9xxnLxyvAhgX9gKZRGdKPTiyztSC9AB17TiKw1G-0DjFverobzRQcbffTbDW4dnyz3tLEQyvxxMFExSshZi09YkhoKVawOJRg423YLf-cAa3tXwQgZTcUYx59JB5g6oMzQmz10glmgEFheX0lrXVJDgWZHkyy-wmg/s320/Sprague1.jpg" width="320" /></a></div><br /><p class="MsoNormal">Discussion: Optimal treatment of these lesions would be
micrographic surgery, but this may be too aggressive for this relatively frail
woman and wound care at home would be difficult. Individuals of this age may
not live long enough to benefit from “gold standard” therapy, however,
unchecked tumor progression can worsen their quality of life if treatment is
withheld. Radiotherapy would also be difficult as many trips for fractionated care would be taxing for her.<br /></p>
<p class="MsoNormal"> </p>
<p class="MsoNormal">There are few therapeutic guidelines for patients like this.<span style="mso-spacerun: yes;"> </span>We would appreciate your
suggestions as we plan to address the patient and her tumors.</p>
<p class="MsoNormal"> </p>
<p class="MsoNormal">References:</p>
<p class="MsoNormal">1. A J G Leus, et. al. Treatment of keratinocyte carcinoma
in elderly patients - a review of the current literature. J Eur Acad Dermatol
Venereol. 2020 Sep;34(9):1932-1943.<span style="mso-spacerun: yes;"> </span><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7496368/">Free PMC article</a></p>
<p class="MsoNormal"> </p>
<p class="MsoNormal">2. Christopher McLaughlin, Mark A Russell. Single-fraction
high-dose palliative radiotherapy for facial cutaneous squamous cell carcinoma:
a case report. Ann Palliat Med. 2022 Oct;11(10):3337-3340.</p>
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{page:WordSection1;}</style></p>Humane Medicine Huihttp://www.blogger.com/profile/07113291188306363130noreply@blogger.com0tag:blogger.com,1999:blog-9870114.post-9448882074429526822023-01-16T17:24:00.037+00:002023-02-01T18:38:16.417+00:00Unilateral thoracic eruption <p><b>Presented by Makayla Powers, PA-C</b><br /></p><p><b style="font-family: "Times New Roman";">HPI</b><span style="font-family: "Times New Roman";">: The patient is a 4 year old girl who presents with her parents for a skin eruption. Her parents state this has been present for about 2 months now. This eruption started as one erythematous patch on the left flank. The area started to resolve after a few days, however it then worsened again. She saw her pediatrician who suspected this was ringworm and she was prescribed clotrimazole. They used the clotrimazole for a couple weeks, however the rash continued to worsen and spread. They then started using mupirocin ointment, without significant improvement. She was then prescribed triamcinolone cream to use in addition to the mupirocin and she has been using both of these without any resolution. Around a month ago the patient was started on cephalexin which also was did not cure the rash. The eruption is asymptomatic. </span></p>
<p style="font-family: "Times New Roman"; font-stretch: normal; line-height: normal; margin: 0px;"><span>Her mother notes prior to onset of this eruption, patient had COVID and two ear infections which required two rounds of antibiotics. </span></p><p style="font-family: "Times New Roman"; font-stretch: normal; line-height: normal; margin: 0px;"><span><br /></span></p><p style="font-stretch: normal; line-height: normal; margin: 0px;"><span><span style="font-family: Times New Roman;">They have two cats, two bunnies and one dog at home. No one else in the household has a rash. </span></span></p>
<p style="font-family: "Times New Roman"; font-stretch: normal; line-height: normal; margin: 0px; min-height: 12px;"><span><br /></span></p>
<p style="font-family: "Times New Roman"; font-stretch: normal; line-height: normal; margin: 0px;"><span><b>Physical exam</b>: On exam, patient has multiple erythematous circular patches on the left flank extending to the back and chest, with some newer lesions have vesicles and are in a zosteriform distribution. She has an erythematous macule as well as an erythematous papule on the left upper outer arm. </span></p><p style="font-family: "Times New Roman"; font-stretch: normal; line-height: normal; margin: 0px;"><span style="font-size: x-small;"><br /></span></p><p style="font-family: "Times New Roman"; font-stretch: normal; line-height: normal; margin: 0px;"><span style="font-size: x-small;"></span></p><div class="separator" style="clear: both; text-align: center;"><span style="font-size: x-small;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjztJO25sBkeOLFp7mwS8quUy8gGaeUUpwvLzx04XLEU0TFyF-ki2Q9ZRXRhJxdHBuKtr4Q-A2FaxKJWeKrKNl6RvlZxqCVWk-kAsEwXi8ZUPx00zBJANrFdPQb4Qe0dk1Y8KnGYoeLK7RXIWAJzJ4ib3NWg7kfTO0BxgbrTMts4xySsfnG1Q/s2048/Rosie3.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="2048" data-original-width="1536" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjztJO25sBkeOLFp7mwS8quUy8gGaeUUpwvLzx04XLEU0TFyF-ki2Q9ZRXRhJxdHBuKtr4Q-A2FaxKJWeKrKNl6RvlZxqCVWk-kAsEwXi8ZUPx00zBJANrFdPQb4Qe0dk1Y8KnGYoeLK7RXIWAJzJ4ib3NWg7kfTO0BxgbrTMts4xySsfnG1Q/s320/Rosie3.jpg" width="240" /></a></div><br /><br /></span></div><span><br /><div class="separator" style="clear: both; font-size: small; text-align: center;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhCHcxHOu51GTifGu569E6-WAJjMyh8mulGTZ1pwfEhjIfchzBqUrwnaSK8Mazhf2CrXNbBML-Hi5Yaf5W-uJT77DQ0Aq5h3yFD7oEMw--yN2tZdBgAjubG_CrA7br05bCa_uuGJAqOGw10Y8slBDIJb8xgvCC3ZEgk3Q3Yg1ouWNP2s2tKYQ/s2048/Posie2.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="2048" data-original-width="1536" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhCHcxHOu51GTifGu569E6-WAJjMyh8mulGTZ1pwfEhjIfchzBqUrwnaSK8Mazhf2CrXNbBML-Hi5Yaf5W-uJT77DQ0Aq5h3yFD7oEMw--yN2tZdBgAjubG_CrA7br05bCa_uuGJAqOGw10Y8slBDIJb8xgvCC3ZEgk3Q3Yg1ouWNP2s2tKYQ/s320/Posie2.jpg" width="240" /></a></div><br /></div><div class="separator" style="clear: both; text-align: center;"><br /></div>Here is a picture of the rash from a couple weeks ago:</span><p></p><p style="font-family: "Times New Roman"; font-stretch: normal; line-height: normal; margin: 0px;"><span style="font-size: x-small;"><br /></span></p><p style="font-family: "Times New Roman"; font-stretch: normal; line-height: normal; margin: 0px;"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi7np8pTNp3fQQRhdQKePpWWavt5Wt9i06uDYgFeMkihN06RyUq7lieV2e8c-0f5e-M43kl7meVCiiCjAHeYwq1t6beuhtfM0zPdzABwDtKwOPqptV8tDupLOkdlcHd0NkiN2OMOWwEQ7wnBxZSEqy25a6kTC4aP8TzFlExv7nAWsUoGfnWFw/s414/IMG_7864%20(1).jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="414" data-original-width="355" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi7np8pTNp3fQQRhdQKePpWWavt5Wt9i06uDYgFeMkihN06RyUq7lieV2e8c-0f5e-M43kl7meVCiiCjAHeYwq1t6beuhtfM0zPdzABwDtKwOPqptV8tDupLOkdlcHd0NkiN2OMOWwEQ7wnBxZSEqy25a6kTC4aP8TzFlExv7nAWsUoGfnWFw/s320/IMG_7864%20(1).jpg" width="274" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><p>Because of the diagnostic uncertainty, a punch biopsy was done.</p><p>Pathology:<br />Photomics are courtesy of dermatopathologist, David Jones, Berkshire Medical Center</p><p><br />The biopsy shows perifollicular inflammation<br /></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi6qjyW89FN01CZaKU2XbhJJI8U2BePtMmzsj78CsX5nbqbjbta7oISzym8uO7lI43sH-IvBPBAw_fi80z8yYgQ2rtq3mbHich5z5gqyuvpaPFUFRqyvvrtA84YRdMEiUlyahhChOnTIb3ekTtsLz-ntA90G1XANCfTyNKmdhTrzN2wkVdrlA/s3840/Posie2.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="2748" data-original-width="3840" height="229" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi6qjyW89FN01CZaKU2XbhJJI8U2BePtMmzsj78CsX5nbqbjbta7oISzym8uO7lI43sH-IvBPBAw_fi80z8yYgQ2rtq3mbHich5z5gqyuvpaPFUFRqyvvrtA84YRdMEiUlyahhChOnTIb3ekTtsLz-ntA90G1XANCfTyNKmdhTrzN2wkVdrlA/s320/Posie2.jpg" width="320" /></a></div><br /> and PASD stain shows spores in the hair follicles.<br /><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiPiltZkRzlRy-LCPlXLYXnwV9NG1c5GFHasyZIUTopUt04YXtd6GNig0mkjORBcb3rNL1ZQBitsuQ4n-qDJAuPzqsN5U1NwWOTf3hBrdWWhFn5jzk6TMqvfOb0J1TzEDhDbuhKXnugRza5NlX23ERiFKCZHzk-wtzTCAcJnmV19MwJdM88UQ/s3840/Posie%20PAS.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="2748" data-original-width="3840" height="229" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiPiltZkRzlRy-LCPlXLYXnwV9NG1c5GFHasyZIUTopUt04YXtd6GNig0mkjORBcb3rNL1ZQBitsuQ4n-qDJAuPzqsN5U1NwWOTf3hBrdWWhFn5jzk6TMqvfOb0J1TzEDhDbuhKXnugRza5NlX23ERiFKCZHzk-wtzTCAcJnmV19MwJdM88UQ/s320/Posie%20PAS.jpg" width="320" /></a></div><br /><div class="separator" style="clear: both; text-align: center;"></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhJKKC0y-nBgiA-PSU1x1YG-0AGDCvB5FvLZ6TSbEJglUmc3exQtNTpA05orNjEGUsBQ8U_MgeCcs87qFw7ynUikFbKnnmW7heFU2PeNN0nIZT5jrilttLuxu_n_ClILipymKgq-x3aWQRnKto-IknQFqGufKa3C54AAV4JfPlFs96oLr4t3A/s3840/Posie%203.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="2748" data-original-width="3840" height="229" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhJKKC0y-nBgiA-PSU1x1YG-0AGDCvB5FvLZ6TSbEJglUmc3exQtNTpA05orNjEGUsBQ8U_MgeCcs87qFw7ynUikFbKnnmW7heFU2PeNN0nIZT5jrilttLuxu_n_ClILipymKgq-x3aWQRnKto-IknQFqGufKa3C54AAV4JfPlFs96oLr4t3A/s320/Posie%203.jpg" width="320" /></a></div><p>Diagnosis: Fungal folliculitis, endothrix. This is not Majocchi's granuloma yet, but may be moving in that direction.</p><p>Plan:</p><p>A fungal culture was taken from skin scrapings and the patient was started on terbinafine 125 mg daily. We plan to keep her on it for 6 weeks.<br /></p><p>Reference<span style="font-size: 14pt; font-weight: normal; mso-bidi-font-weight: bold; mso-fareast-font-family: "Times New Roman";"><br />Majocchi's granuloma: current
perspectives. Infect Drug Resist. 2018 May 22;11:751-760.<span style="mso-spacerun: yes;"> </span><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5968791/">PMC Free Full Text</a>. Note: The English is not good, but the article is comprehensive. There are no comparable reviews of MG.<br /></span></p><br />mpowershttp://www.blogger.com/profile/04082488482391065496noreply@blogger.com0tag:blogger.com,1999:blog-9870114.post-25394099153566380172022-12-14T23:20:00.013+00:002022-12-18T22:26:52.115+00:00Keratosis Pilaris Rubra<p><span style="font-family: "Times New Roman"; font-size: small;">Presented by Makayla Powers PA-C<br />Pontoosac Shores, Massachusetts<br /></span></p><p><span style="font-size: small;"><b style="font-family: "Times New Roman";">HPI</b><span style="font-family: "Times New Roman";">: Patient is a 15-year-old boy who presents, with his mother, for a facial eruption. His mother states this rash on his face has been present for about three years. His pediatrician prescribed a topical tretinoin, however, his mother has not used this for him yet as she is worried about it causing more skin irritation. Patient has asthma and currently uses a Flo-vent inhaler daily and albuterol inhaler as needed.</span></span></p><span style="font-size: small;">
</span><p style="font-family: "Times New Roman"; font-stretch: normal; line-height: normal; margin: 0px;"><span style="font-size: small;"><b>Physical exam</b>: On exam, patient has erythematous patches with follicular papules on the bilateral cheeks, extending to the neck. He also has these erythematous follicular papules on the bilateral upper arms.</span></p><p style="font-family: "Times New Roman"; font-size: 12px; font-stretch: normal; line-height: normal; margin: 0px;"><br /></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjSLo8Sg9zInh-R0BVfse-Lw2xdEzwkydV1MarT56jW46SecVzALhriRA21O4-A_L-YO_Y4ek9hZhDrnlpk7AlwSD2AoCmJiRE6XR3dndUvFeF6OtvgSsk5OQ8w3iY2sNO4RczAgXpw3hG2vTVYQXj_ZEkzF0t7C_xSK677WoIakF-0IxEXEA/s3161/KPR.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="3161" data-original-width="2694" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjSLo8Sg9zInh-R0BVfse-Lw2xdEzwkydV1MarT56jW46SecVzALhriRA21O4-A_L-YO_Y4ek9hZhDrnlpk7AlwSD2AoCmJiRE6XR3dndUvFeF6OtvgSsk5OQ8w3iY2sNO4RczAgXpw3hG2vTVYQXj_ZEkzF0t7C_xSK677WoIakF-0IxEXEA/s320/KPR.jpg" width="273" /></a></div><br />
<span style="font-size: small;">
</span><p style="font-family: "Times New Roman"; font-stretch: normal; line-height: normal; margin: 0px;"><span style="font-size: small;"><b>Diagnosis: </b>Keratosis Pilaris Rubra</span></p><span style="font-size: small;">
</span><p style="font-family: "Times New Roman"; font-stretch: normal; line-height: normal; margin: 0px; min-height: 15px;"><span style="font-size: small;"><br /></span></p><span style="font-size: small;">
</span><p style="font-family: "Times New Roman"; font-stretch: normal; line-height: normal; margin: 0px;"><span style="font-size: small;"><b>Discussion</b>: We believe the patient has keratosis pilaris rubra. From the research we have been doing, topical therapies do not seem to not work well and laser therapy may be the most effective. We are asking if any of our readers has any experience treating this entity and what treatments they have found to be most successful? Thank you in advance for your time!</span></p>
<p style="font-family: "Times New Roman"; font-size: 12px; font-stretch: normal; line-height: normal; margin: 0px; min-height: 15px;"><br /></p><p style="font-family: "Times New Roman"; font-size: 12px; font-stretch: normal; line-height: normal; margin: 0px; min-height: 15px;"><br /></p>
<span style="font-size: small;">
</span><p style="font-family: "Times New Roman"; font-stretch: normal; line-height: normal; margin: 0px;"><span style="font-size: small;">References:</span></p><span style="font-size: small;">
</span><p style="background-color: white; color: #191919; font-family: "Times New Roman"; font-stretch: normal; line-height: normal; margin: 0px;"><span style="font-size: small;">1. Marqueling AL, et. al. Keratosis pilaris rubra: a common but underrecognized condition. Arch Dermatol. 2006 Dec;142(12):1611-6. doi: 10.1001/archderm.142.12.1611. PMID: 17178988.</span></p><span style="font-size: small;">
</span><p style="font-family: "Times New Roman"; font-stretch: normal; line-height: normal; margin: 0px; min-height: 15px;"><span style="font-size: small;"><br /></span></p><span style="font-size: small;">
</span><p style="background-color: white; color: #191919; font-family: "Times New Roman"; font-stretch: normal; line-height: normal; margin: 0px;"><span style="font-size: small;">2. Schoch JJ, et. al. Successful Treatment of Keratosis Pilaris Rubra with Pulsed Dye Laser. Pediatr Dermatol. 2016 Jul;33(4):443-6. doi: 10.1111/pde.12892. Epub 2016 Jun 10. PMID: 27282957.</span></p><p style="background-color: white; color: #191919; font-family: "Times New Roman"; font-stretch: normal; line-height: normal; margin: 0px;"><span style="font-size: small;"> </span></p><p class="MsoNormal"><span style="font-size: small;">3. </span><span style="font-family: "Times New Roman"; font-size: small; line-height: 106%;">Fekete GL, et. al., Keratosis pilaris atrophicans faciei: An
observational, descriptive, retrospective clinical study. Exp Ther Med. 2021
Nov;22(5):1331. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8495552/" target="_blank">Free PMC article</a>. [Dr. Warren Heymann brought this to our
attention]</span></p><p class="MsoNormal"><span style="font-family: "Times New Roman"; font-size: small; line-height: 106%;">See: Comment # 1 from Omid Zargari <br /><br /></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiyncD3sTHRLO_IS-WPseLhf9GJ29ODbRpu6fB0mHJoOmmqwIpZLmvn9ZinN6t-zUQqPnRNJpMty0m8Ra8mLRyMD6-iXeoLHqbhCb03wcayN36rxmeiuAhJ2llzTE9yN9MUhTKi1-veSdu1gHpC9Kw9Xc1BAnCtnR5RAjruxTewUbg_EV8vgg/s640/Prince%20Harry%20and%20William_edited-1.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="532" data-original-width="640" height="266" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiyncD3sTHRLO_IS-WPseLhf9GJ29ODbRpu6fB0mHJoOmmqwIpZLmvn9ZinN6t-zUQqPnRNJpMty0m8Ra8mLRyMD6-iXeoLHqbhCb03wcayN36rxmeiuAhJ2llzTE9yN9MUhTKi1-veSdu1gHpC9Kw9Xc1BAnCtnR5RAjruxTewUbg_EV8vgg/s320/Prince%20Harry%20and%20William_edited-1.jpg" width="320" /></a></div><br /><p></p>
<p style="background-color: white; color: #191919; font-family: "Times New Roman"; font-stretch: normal; line-height: normal; margin: 0px;"><style>@font-face
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{page:WordSection1;}</style><span style="font-size: small;"> </span></p><div><br /></div>mpowershttp://www.blogger.com/profile/04082488482391065496noreply@blogger.com0tag:blogger.com,1999:blog-9870114.post-19856940693745248552022-12-03T12:35:00.006+00:002023-02-06T19:40:32.945+00:00Caruncular Tumor in a Child<p>
</p><p class="MsoNormal">The patient is an eight year-old girl with a pigmented caruncular lesion of the left eye.<span style="mso-spacerun: yes;"> </span>The child is of mixed ethnicity having light
hair and green eyes.</p>
<p class="MsoNormal"> </p>
<p class="MsoNormal">The lesion is a circumscribed dark brown to black papule with slightly irregular
borders. No worrisome dermatoscopic features.<br /><br /></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjegj5Nv8EzzNiEM10jGMbIPRClCJYg3MneNhWuELX2o8QiT-8wHN-UlsyRH8tW4rbEVfneoIhrgWrTG9FF1oTfJLiW-iUhTwVwVX6aJzDR-gDjydIhnWOeotkqfil69qlT4hBpV45abQF7wcrHR9zWHIqiau2tC6V9MXI_ozP3CKYkEbmzRA/s964/Rei.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="742" data-original-width="964" height="246" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjegj5Nv8EzzNiEM10jGMbIPRClCJYg3MneNhWuELX2o8QiT-8wHN-UlsyRH8tW4rbEVfneoIhrgWrTG9FF1oTfJLiW-iUhTwVwVX6aJzDR-gDjydIhnWOeotkqfil69qlT4hBpV45abQF7wcrHR9zWHIqiau2tC6V9MXI_ozP3CKYkEbmzRA/s320/Rei.jpg" width="320" /></a></div><br />
<p class="MsoNormal"> </p>
<p class="MsoNormal">Diagnosis:<span style="mso-spacerun: yes;">
</span>Melanocytic caruncular lesion in a child.</p>
<p class="MsoNormal"> </p>
<p class="MsoNormal">Plan:<span style="mso-spacerun: yes;"> </span>She has been
referred to a pediatric oncologic-ophthalmologist for evaluation.</p>
<p class="MsoNormal"> </p>
<p class="MsoNormal">Comment:<span style="mso-spacerun: yes;"> </span>Based on a
literature review it seems like melanoma is exceedingly rare in such a young
child.<span style="mso-spacerun: yes;"> </span>Nonetheless, it is important for
this girl to be followed by a clinician with a special interest in childhood
tumors.</p><p class="MsoNormal"> </p><p class="MsoNormal">Follow-up: The patient saw a pediatric oncological-ophthalmologist at Boston Children's Hospital. He felt her lesion is a benign caruncular nevus and will follow her at regular intervals. <br /></p>
<p class="MsoNormal"> </p>
<p class="MsoNormal">References: </p>
<p class="MsoNormal">1. Carol L Shields, et. al. Clinical Features
Differentiating Benign From Malignant Conjunctival Tumors in Children. JAMA
Ophthalmol. 2017 Mar 1;135(3):215-224. <a href="https://pubmed.ncbi.nlm.nih.gov/28125759/">Abstract</a>.</p>
<p class="MsoNormal">2. Puneet Jain, et;; al. Conjunctival melanoma treatment
outcomes in 288 patients: a multicentre international data-sharing study. Br J
Ophthalmol. 2021 Oct; 105(10): 1358–1364. [There were no pediatric patients
this study of almost 300 patients.]</p>
<p><span style="font-size: medium;">3. Camille Yvon, et. al. Caruncular lesions: A 16-year
single centre review in the United Kingdom. Eur J Ophthalmol. 2022 Nov
10;11206721221137938.</span><br />
<b><span style="font-size: 10pt;">Results: </span></b><span style="font-size: 10pt;">A total of 31 lesions from 31 patients were analysed.
18 of 31 patients were men (58%), and the age ranged from 12 to 91 years. 13
different histopathological types of lesions were identified in our case
series, including 9 melanocytic nevi (29%), 7 benign squamous papillomas (23%),
5 skin adnexal lesions (16%), 3 chronic inflammation (10%), 3 epithelial cysts
(10%), 1 basal cell carcinoma (3%), 2 malignant melanomas (6%) and l
lymphoproliferative disorder (3%). Pre-operative suspected diagnoses were often
vague but correct in 12 of 18 cases (67%), where data was available. </span><b><br />Conclusion: </b>The uncommon nature and variety of caruncular
lesions make the diagnostic process difficult. Our case series is the first
reported in the UK, showing a slightly higher proportion of malignant
melanomas, in keeping with the population demographics. Excisional biopsies
would, therefore, be prudent in the majority of cases to rule out any possible
malignancy. </p>
<p class="MsoNormal">
</p><p><span style="font-size: 14pt;">4. (Dr. Patrick Kenny (Victoria, BC, Canada) suggested Spitz/Reed nevus. This reference may be helpful) Ana F Pedrosa, et. al. <span style="mso-spacerun: yes;"> </span>Spitz/Reed nevi: a review of clinical-dermatoscopic
and histological correlation. Dermatol Pract Concept. 2016 Apr 30;6(2):37-41. </span><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4866625/"><span style="font-size: 14pt;">Full Text PubMed Central</span></a></p><p><span class="gmail-MsoHyperlink" style="color: blue;"><span color="windowtext" style="font-size: 14pt;"> 5. J Levy et. al. Lesions of the caruncle: a
description of 42 cases and a review of the literature. Eye volume 23, 1004–1018
(2009) <a href="https://www.nature.com/articles/eye2008316" style="color: blue;">Full Text</a>. Helpful review. This study presents the
clinical and histological data of 42 consecutive caruncular lesions processed
at our laboratory and reviews previously reported cases of caruncular lesions.</span></span><span style="font-size: 14pt;"> <br /></span></p><p>
</p>
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{page:WordSection1;}</style></p>Humane Medicine Huihttp://www.blogger.com/profile/07113291188306363130noreply@blogger.com0tag:blogger.com,1999:blog-9870114.post-87736635029020475952022-04-28T08:54:00.001+00:002022-04-29T09:25:32.379+00:00Hydroxychloroquine-induced Hyperpigmentation<p> Presented by DJ Elpern<br /></p>
<p class="MsoNormal"> </p>
<p class="MsoNormal">This 23-year-old woman presents for evaluation of patchy hyperpigmentation
of her face, arms, and abdomen that has been progressing for the past two
years. <span style="mso-spacerun: yes;"> </span>She has had systemic lupus
erythematosus with renal involvement for a decade.<span style="mso-spacerun: yes;"> </span>Her current medications include prednisone 15
mg a day, mycophenolic acid, 2 tablets twice a day, hydroxychloroquine (HQ) 400
mg a day, torsemide, Zoloft, olanzapine, losartan, and recently voclosporin. <span style="mso-spacerun: yes;"> </span>She has been on 400 mg of HQ since the early
days of her Lupus diagnosis.</p>
<p class="MsoNormal"> </p>
<p class="MsoNormal"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;">OE:<span style="mso-spacerun: yes;"> </span>The examination shows large
hyperpigmented patches on the face, ears, arms and in the abdominal striae.<span style="mso-spacerun: yes;"> </span>There is no scarring.<span style="mso-spacerun: yes;"> </span>She has Cushingoid facies.<br /> </span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj8AU8ei6EKb0RSjTErvzTvBMSvnn7dX00YZNvFFZuEIZm-Dqpjh7GrtdhPDc62IolQfgr6xotC7-30EJfTj4Foo1KVAMAmZciH1o51vxeptxQw4FQhmbzfsQpg97f35iycCOxnqTCHASLT9FmQMt2q_w8P1d1ddQuqkzpYvct9k7xc96h8wg/s2048/Carr1_edited-1.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1536" data-original-width="2048" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj8AU8ei6EKb0RSjTErvzTvBMSvnn7dX00YZNvFFZuEIZm-Dqpjh7GrtdhPDc62IolQfgr6xotC7-30EJfTj4Foo1KVAMAmZciH1o51vxeptxQw4FQhmbzfsQpg97f35iycCOxnqTCHASLT9FmQMt2q_w8P1d1ddQuqkzpYvct9k7xc96h8wg/s320/Carr1_edited-1.jpg" width="320" /></a></div><br /><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi5ZMm6bXbx3tV_GDxM-PLDhTrEekeBDCAv8WfHhqhtL0UdWplqGuvMrj2cpDX2jsLbK-wH3IhahMG3ARbjm7qB2UU7ufZyQfvdk_vj69sXviiVBswNKaID5lZ6j8Av8YOhbtUAmHLeVeA0c0UQtweGfQDDe4sbyjz5on438v8pxfc13U396Q/s2048/Carr3.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="2048" data-original-width="1536" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi5ZMm6bXbx3tV_GDxM-PLDhTrEekeBDCAv8WfHhqhtL0UdWplqGuvMrj2cpDX2jsLbK-wH3IhahMG3ARbjm7qB2UU7ufZyQfvdk_vj69sXviiVBswNKaID5lZ6j8Av8YOhbtUAmHLeVeA0c0UQtweGfQDDe4sbyjz5on438v8pxfc13U396Q/s320/Carr3.jpg" width="240" /></a></div><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEixHdH38KT3GFdYHRDbHClSGzrswgKKgStKx-ku-uvTPDft_rYmQxmDN17QX6FRgfbiI-3PMhbpo6Iy9GTHKgudGy5arRaYBfxhcpSZMj3BNshWsaEJX7gsq2EN8b086NDEOjGe6y67r-IPu8ORf8kryz7HYH9__TOSoTUb7UVOFke6tq9P0Q/s2048/Carr2.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1536" data-original-width="2048" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEixHdH38KT3GFdYHRDbHClSGzrswgKKgStKx-ku-uvTPDft_rYmQxmDN17QX6FRgfbiI-3PMhbpo6Iy9GTHKgudGy5arRaYBfxhcpSZMj3BNshWsaEJX7gsq2EN8b086NDEOjGe6y67r-IPu8ORf8kryz7HYH9__TOSoTUb7UVOFke6tq9P0Q/s320/Carr2.jpg" width="320" /></a></div><br />
<p class="MsoNormal"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;"> </span></p>
<p class="MsoNormal"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;">IMPRESSION: Hydroxychloroquine-induced Hyperpigmentation</span></p>
<p class="MsoNormal"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;"> </span></p>
<p class="MsoNormal"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;"> </span></p>
<p class="MsoNormal"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;">PLAN:<span style="mso-spacerun: yes;"> </span>We will consult some
colleagues with experience in this area and see the patient back in a few
weeks.<span style="mso-spacerun: yes;"> </span>Recent serologies may be
helpful.<span style="mso-spacerun: yes;"> </span></span></p>
<p class="MsoNormal"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;"> </span></p>
<p class="MsoNormal"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;">Discussion:<span style="mso-spacerun: yes;"> </span>HQ hyperpigmentation
is well-reported; but most of the articles are small case reports.<span style="mso-spacerun: yes;"> </span>It seems to be related to duration of
treatment.<span style="mso-spacerun: yes;"> </span>This young woman has been on 400
mg of HQ for at least eight years.<span style="mso-spacerun: yes;"> </span>Other
than stopping HQ, it’s unclear what may help.<span style="mso-spacerun: yes;">
</span>The drug may have been of value for her renal disease; but the downside
– the hyperpigmentation – is a significant problem for this young person.<span style="mso-spacerun: yes;"> </span>So, too is the Cushingoid effects of her
prednisone.<span style="mso-spacerun: yes;"> </span>A review of the literature
was not helpful for therapeutic guidelines regarding the hyperpigmentation other than discontinuing the HQ.</span></p>
<p class="MsoNormal"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;"> </span></p>
<p class="MsoNormal"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;"> </span></p>
<p class="MsoNormal"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;">References:</span></p>
<p class="MsoNormal"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;">1. Daniel Kwak, Pearl E Grimes. A case of hyperpigmentation induced by
hydroxychloroquine and quinacrine in a patient with systemic lupus
erythematosus and review of the literature. Int J Womens Dermatol. 2020 Jun
30;6(4):268-271. Free PMC</span></p>
<p class="MsoNormal"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;"> </span></p>
<p class="MsoNormal"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;">2. Moez Jallouli. Hydroxychloroquine-induced pigmentation in patients
with systemic lupus erythematosus: a case-control study. JAMA Dermatol. 2013
Aug;149(8):935-40.</span></p>
<p class="MsoNormal"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;"> </span></p>
<p class="MsoNormal"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;">3. Michela Gasparotto et. al. Lupus nephritis: clinical presentations
and outcomes in the 21st century. Rheumatology (Oxford). 2020 Dec
5;59(Suppl5):v39-v51.<span style="mso-spacerun: yes;"> </span>Free PMC.</span></p><p class="MsoNormal"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;"> </span>
</p><p class="Body" style="border: none; mso-border-shadow: yes; mso-padding-alt: 31.0pt 31.0pt 31.0pt 0in;">4. Sendhil Kumaran Muthu. Low-dose oral isotretinoin
therapy in lichen planus pigmentosus: an open-label non-randomized prospective
pilot study. Int J Dermatol. 2016 Sep;55(9):1048-54. PMID 27062273</p>
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{page:WordSection1;}</style></p>Humane Medicine Huihttp://www.blogger.com/profile/07113291188306363130noreply@blogger.com0tag:blogger.com,1999:blog-9870114.post-87890809878151976212022-04-22T00:17:00.003+00:002022-04-22T00:18:36.251+00:00Anogenital Papular Acantholytic Dysteratosis<p><b><span style="font-size: medium;">Presented by Makayla Powers, PA-C & David Elpern<br /></span></b></p><p>
</p><p class="Body"><span style="font-family: "Times New Roman"; font-size: 12pt; mso-bidi-font-family: "Arial Unicode MS";">HPI: An 18 year old woman was seen for
lesions in her genital area. She noticed pruritus ani
about 3 months earlier and was seen by a gynecologist who initially prescribed antibiotics, which
patient states caused the lesions to “flatten,” but not completely resolve. A biopsy was performed that a pathologist signed out as molluscum. Blood work for STIs was all normal. She was seen in the dermatology clinic for therapeutic suggestions. We requested a review of the biopsy by a dermatopathologist.</span><span style="font-family: "Times New Roman"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";"> </span></p><p class="Body"><br /></p><p><style>@font-face
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{page:WordSection1;}</style></p><p><span lang="FR" style="font-family: "Times New Roman"; font-size: 12pt; mso-ansi-language: FR; mso-bidi-font-family: "Arial Unicode MS";"><b>On exam</b>, </span><span style="font-family: "Times New Roman"; font-size: 12pt; mso-bidi-font-family: "Arial Unicode MS";">multiple white papules in the perianal area and on the labia majorum. </span></p><p><b>Clinical Photos:</b><span> <br /></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjUcXuhv0ZDUuXuDR7rOOqluMRD26dwezkibw7-eQGB7hwDZyVoXugqYYObZYBjRkfm31_5CrqGasFAnMKR5CkN8RcRwhCmJOYKm-t9S1PiSWGuFP9Dj5_9BtPipFqkKL6VfdiqfOQU-K0hUNwd8dnN97XlyyNoo5BTLNIwtXJlpsX2Ue9sDw/s3024/Focal%20Acan%20Vulva.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="3020" data-original-width="3024" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjUcXuhv0ZDUuXuDR7rOOqluMRD26dwezkibw7-eQGB7hwDZyVoXugqYYObZYBjRkfm31_5CrqGasFAnMKR5CkN8RcRwhCmJOYKm-t9S1PiSWGuFP9Dj5_9BtPipFqkKL6VfdiqfOQU-K0hUNwd8dnN97XlyyNoo5BTLNIwtXJlpsX2Ue9sDw/s320/Focal%20Acan%20Vulva.jpg" width="320" /></a></div><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><span> </span><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh4nMSx6wCoUUL3kMLDYkVHAEG-Z88cRy-PZuc_oHGaqOj8qJkr50LIFGU_CYAJ8-YJXAldYr2nIQk3JoUzyX9JGOBNYauq-2LEO_9f0XrCFmLZxZ9ySpz6dKsxxTUL70nMvQyE0rRnRR8ztWD_r_-3kWHxzLKSfTpwYk1bVikSuakkM4cmuQ/s586/FAD2.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="586" data-original-width="529" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh4nMSx6wCoUUL3kMLDYkVHAEG-Z88cRy-PZuc_oHGaqOj8qJkr50LIFGU_CYAJ8-YJXAldYr2nIQk3JoUzyX9JGOBNYauq-2LEO_9f0XrCFmLZxZ9ySpz6dKsxxTUL70nMvQyE0rRnRR8ztWD_r_-3kWHxzLKSfTpwYk1bVikSuakkM4cmuQ/s320/FAD2.jpg" width="289" /></a></div><div class="separator" style="clear: both; text-align: left;"><br /> </div><div class="separator" style="clear: both; text-align: left;"><b>Pathology:</b> </div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: "Times New Roman"; font-size: 12pt; mso-bidi-font-family: "Arial Unicode MS";">This shows hyperkeratosis, parakeratosis and acantholytic
dyskeratosis, characterized by suprabasilar clefting with acantholytic and
dyskeratotic cells including corps ronds and grains within the epidermis.</span></div><div class="separator" style="clear: both; text-align: left;"> </div><div class="separator" style="clear: both; text-align: left;">Photomicrographs (courtesy of Dr. David Jones, Berkshire Medical Center)</div><div class="separator" style="clear: both; text-align: left;">40x<br /></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiZTFD7Jaan3kBJliJy4U6-GeFfEbmNyR19MMibpnib3dYucB1hGAtks56dXEUx-5xIr2SyDSBrAD9dY7j3Pv_sjyMC7xYqDXrZD4cC6Xmf3zhpfO7pBUYocmIifMSDVjUQQvCdIJZ_hNXADcUgftjv7LFI10NUvtZl1jExV3MuWYWXfDfv4g/s3840/JM40X_edited-2.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="2748" data-original-width="3840" height="229" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiZTFD7Jaan3kBJliJy4U6-GeFfEbmNyR19MMibpnib3dYucB1hGAtks56dXEUx-5xIr2SyDSBrAD9dY7j3Pv_sjyMC7xYqDXrZD4cC6Xmf3zhpfO7pBUYocmIifMSDVjUQQvCdIJZ_hNXADcUgftjv7LFI10NUvtZl1jExV3MuWYWXfDfv4g/s320/JM40X_edited-2.jpg" width="320" /></a></div><p></p><p>100x<br /></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhiTsIsMmy4HB0bNyRAQ6xYIj-2LfZaznZsCKy3a7JCv9qHcIMA6RmFjVl0DNktkiCHcnHa8D_qgfgntd2oeTOaKd5sxDV9OaV8GQaTwDdoB2JuXJ1m8au0tHdxJRu-6j0Vagybc2bkTIjFVvDuuIg3QnIF4tVeEOCUTAbr7xU9quh8seVE8A/s3840/JM100X.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="2748" data-original-width="3840" height="229" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhiTsIsMmy4HB0bNyRAQ6xYIj-2LfZaznZsCKy3a7JCv9qHcIMA6RmFjVl0DNktkiCHcnHa8D_qgfgntd2oeTOaKd5sxDV9OaV8GQaTwDdoB2JuXJ1m8au0tHdxJRu-6j0Vagybc2bkTIjFVvDuuIg3QnIF4tVeEOCUTAbr7xU9quh8seVE8A/s320/JM100X.jpg" width="320" /></a></div><p></p><p>400x<br /></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjnZ5U3zbO8hGCMq682ysiLAHdQAZmvqf_HWAbG7xLr4gxun-kSbAS5BbS-3Ozm2T1CwxzAZEsOaBsdd3vCqGmX1iGyzPe1lIMdzomw9PhqHcWzR721_GAUG8y2c6Pl0eX5SUoDr-OZQYpKUvstCmifPCYUzRaRJOVEfiZd3qJnVTtxpBGk6Q/s3840/JM400X.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="2748" data-original-width="3840" height="229" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjnZ5U3zbO8hGCMq682ysiLAHdQAZmvqf_HWAbG7xLr4gxun-kSbAS5BbS-3Ozm2T1CwxzAZEsOaBsdd3vCqGmX1iGyzPe1lIMdzomw9PhqHcWzR721_GAUG8y2c6Pl0eX5SUoDr-OZQYpKUvstCmifPCYUzRaRJOVEfiZd3qJnVTtxpBGk6Q/s320/JM400X.jpg" width="320" /></a></div><p></p><p class="Body"><span style="font-family: "Times New Roman"; font-size: 12pt; mso-bidi-font-family: "Arial Unicode MS";"><b>Diagnosis: Anogenital Papular Acantholytic Dyskeratosis <br /></b><br /></span></p>
<p class="Body"><b><span style="font-family: "Times New Roman"; font-size: 12pt; mso-bidi-font-family: "Arial Unicode MS";">Discussion:</span></b><span style="font-family: "Times New Roman"; font-size: 12pt; mso-bidi-font-family: "Arial Unicode MS";"><br />This is a rare entity that
currently does not have many successful treatment options. On review of the literature,
this condition may be seen with Hailey-Hailey disease and we wonder if it may
be a localized variant of Hailey-Hailey. We reassured the young woman that she does not
have an STI, however she is very self-conscious about the appearance of these
lesions in her anogenital area. She is currently in a relationship with a partner
who she is comfortable with, however she worries about what future partners
may think of her condition.<br /><br /></span></p><p class="Body"><b>Question:</b><span style="font-family: "Times New Roman"; font-size: 12pt; mso-bidi-font-family: "Arial Unicode MS";"><b> </b>Do any of our readers have experience managing patients with this disorder?</span>
</p><p class="Body"><span style="font-family: "Times New Roman"; font-size: 12pt; mso-fareast-font-family: "Times New Roman";"> </span></p>
<p class="Body"><b><span style="font-family: "Times New Roman"; font-size: 12pt; mso-bidi-font-family: "Arial Unicode MS";">References:</span></b></p>
<p class="Default" style="line-height: normal; margin-top: 0in;"><span style="background: white none repeat scroll 0% 0%; color: #212121; font-family: "Times New Roman"; mso-bidi-font-family: "Arial Unicode MS";">Bell HK, Farrar CW, Curley RK. Papular
acantholytic dyskeratosis of the vulva. Clin Exp </span><span lang="IT" style="background: white none repeat scroll 0% 0%; color: #212121; font-family: "Times New Roman"; mso-ansi-language: IT; mso-bidi-font-family: "Arial Unicode MS";">Dermatol. 2001
Jul;26(5):386-8. doi: 10.1046/j.1365-2230.2001.00840.x. PMID: 11488821.<br /><br /></span>
</p>
<p class="Default" style="line-height: normal; margin-top: 0in;"><span style="background: white none repeat scroll 0% 0%; color: #212121; font-family: "Times New Roman"; mso-bidi-font-family: "Arial Unicode MS";">Dittmer CJ, Hornemann A, Rose C, Diedrich K,
Thill M. Successful laser therapy of a papular </span><span lang="PT" style="background: white none repeat scroll 0% 0%; color: #212121; font-family: "Times New Roman"; mso-ansi-language: PT; mso-bidi-font-family: "Arial Unicode MS";">acantholytic dyskeratosis of the vulva: case
report and review of literature. Arch GynecolObstet. 2010
Apr;281(4):723-5. doi: 10.1007/s00404-009-1313-8. Epub 2009 Dec 15.</span><span style="background: white none repeat scroll 0% 0%; color: #212121; font-family: "Times New Roman"; mso-bidi-font-family: "Arial Unicode MS";">PMID: 20012979.<br /><br /></span>
</p>
<p class="Default" style="line-height: normal; margin-top: 0in;"><span style="background: white none repeat scroll 0% 0%; color: #212121; font-family: "Times New Roman"; mso-bidi-font-family: "Arial Unicode MS";">Hadjicharralambous E, Diamond S, Mehregan D.
Papular acantholytic dyskeratosis of vulva in setting of Hailey-Hailey. Int J
Dermatol. 2017 Jun;56(6):e126-e128. doi: 10.1111/ijd.12486. Epub 2017 Apr 12.
PMID: 28401649.</span><span style="background: white none repeat scroll 0% 0%; color: #212121; font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"></span></p>
<p class="Default" style="line-height: normal; margin-top: 0in;"><span style="background: white none repeat scroll 0% 0%; color: #212121; font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"> </span></p>
<p class="Default" style="line-height: normal; margin-top: 0in;"><span style="background: white none repeat scroll 0% 0%; color: #212121; font-family: "Times New Roman"; mso-bidi-font-family: "Arial Unicode MS";">Lee SH, Jang JG. Papular acantholytic
dyskeratosis of the genitalia. J Dermatol. 1989 Aug;16(4):312-4. doi:
10.1111/j.1346-8138.1989.tb01270.x. PMID: 2689491.</span><span style="background: white none repeat scroll 0% 0%; color: #212121; font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"></span></p>
<p class="Default" style="line-height: normal; margin-top: 0in;"><span style="background: white none repeat scroll 0% 0%; color: #212121; font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"> </span></p>
<p class="Default" style="line-height: normal; margin-top: 0in;"><span style="background: white none repeat scroll 0% 0%; color: #212121; font-family: "Times New Roman"; mso-bidi-font-family: "Arial Unicode MS";">Roh MR, Choi YJ, Lee KG. Papular acantholytic
dyskeratosis of the vulva. J Dermatol. 2009 Jul;36(7):427-9. doi:
10.1111/j.1346-8138.2009.00660.x. PMID: 19583693.</span><span style="background: white none repeat scroll 0% 0%; color: #212121; font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"></span></p>
<p class="Default" style="line-height: normal; margin-top: 0in;"><span style="background: white none repeat scroll 0% 0%; color: #212121; font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"> </span></p>
<p class="Default" style="line-height: normal; margin-top: 0in;"><span style="background: white none repeat scroll 0% 0%; color: #212121; font-family: "Times New Roman"; mso-bidi-font-family: "Arial Unicode MS";">Sá</span><span lang="IT" style="background: white none repeat scroll 0% 0%; color: #212121; font-family: "Times New Roman"; mso-ansi-language: IT; mso-bidi-font-family: "Arial Unicode MS";">enz AM, Cirocco A, Avenda</span><span lang="ES-TRAD" style="background: white none repeat scroll 0% 0%; color: #212121; font-family: "Times New Roman"; mso-ansi-language: ES-TRAD; mso-bidi-font-family: "Arial Unicode MS";">ño M, Gonz</span><span style="background: white none repeat scroll 0% 0%; color: #212121; font-family: "Times New Roman"; mso-bidi-font-family: "Arial Unicode MS";">ález F, Sardi JR. Papular acantholytic
dyskeratosis of the vulva. Pediatr Dermatol. 2005 May-Jun;22(3):237-9. doi:
10.1111/j.1525-1470.2005.22312.x. PMID: 15916573.</span><span style="background: white none repeat scroll 0% 0%; color: #212121; font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"></span></p>
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh7XksPEJ0J9YVgTEhC6hLuYuqPENqxM6-t1q7f-MU0CyEyChfenWE6V01P-ZtaJza7CTQFmzkwWMdfnkOZTLyL7inK80K3tqH4yk6Aeb6c4OFZxaSnfIyxbzBoME8VeZ0y6XDZipDU6_3rj6-Lf3C6DSPNAIjqn1KAVZjjtq_BWqIepnov6A/s3024/Focal%20Acan%20Vulva.jpg" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><br /></a></div><span dir="ltr" face="sans-serif" role="presentation" style="font-size: 19.9253px; left: 89.823px; top: 920.674px; transform: scaleX(1.04378);"></span>Humane Medicine Huihttp://www.blogger.com/profile/07113291188306363130noreply@blogger.com0tag:blogger.com,1999:blog-9870114.post-29435980879607499672022-03-15T08:37:00.000+00:002022-03-15T08:37:00.588+00:00Acral Lentiginous Melanoma During the COVID Pandemic<p></p><div class="separator" style="clear: both; text-align: left;">presented by Dr. Henry Foong, </div><div class="separator" style="clear: both; text-align: left;">Ipoh, Malaysia</div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;">During the pandemic, clinical services in general hospitals were disrupted and patients tend to delay treatment due to lockdown and restriction in movement. Here is one such example where the tumor had progressed to an advanced stage before the patient sought treatment from healthcare service.</div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;"><span style="font-family: times;">This is the case of a 65-year-old housewife from <a href="https://en.wikipedia.org/wiki/Sungai_Siput">Sungai Siput</a> who presented with a 2-year history of an asymptomatic pigmented growth on the left foot. It started as a pigmented macule which gradually increased in size. She tried topical creams and traditional topical ointments without any improvement. She denied any excessive sun exposure. There was no family history of skin cancer. Her medical history included hypertension, diabetes mellitus and hypercholesterolemia. She is not on any immunosuppressive drugs. She is married and has 4 children.</span></div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;">Examination showed a darkly pigmented nodular growth 4 x 5 cm on the interdigital webspace of the 2nd/3rd left toe. The lesion was well demarcated, and hard in consistency. The regional nodes were not enlarged. There were no surrounding satellite lesions.</div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;">Clinically this patient has an <b>acral lentiginous melanoma</b></div><div class="separator" style="clear: both; text-align: left;"><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEj50PYgNqgulE4fOv0A4XdnXRKN4GDt3aFDrlCYFALAvUYeETgJgEcAtJd-YbFKPmhPhrZBs8zySg6kCTC6-OB4wQxQ9u89fgqn1JJBjL1466xOxDnjA3Nfb_I3gR4wog61TGRb_NuVSPmrBLjP2I0rVVsCSH50eZN-CQ8UWdu_mlPDUMINRw=s2416" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="2416" data-original-width="1929" height="320" src="https://blogger.googleusercontent.com/img/a/AVvXsEj50PYgNqgulE4fOv0A4XdnXRKN4GDt3aFDrlCYFALAvUYeETgJgEcAtJd-YbFKPmhPhrZBs8zySg6kCTC6-OB4wQxQ9u89fgqn1JJBjL1466xOxDnjA3Nfb_I3gR4wog61TGRb_NuVSPmrBLjP2I0rVVsCSH50eZN-CQ8UWdu_mlPDUMINRw=s320" width="255" /></a></div></div><div class="separator" style="clear: both; text-align: left;"><b><br /></b></div><div class="separator" style="clear: both; text-align: left;">A skin biopsy was performed. <br /><br /></div><div class="separator" style="clear: both;"><div class="separator" style="clear: both;"><div class="separator" style="clear: both;"><span style="font-family: times;">MICROSCOPIC APPEARANCE</span></div><div class="separator" style="clear: both;"><span style="font-family: times;">Sections of the ulcerated epidermis show irregular nevus nests at the epidermis as well as the </span><span style="font-family: times;">dermis. The irregular nevus cells are distributed along the basal layer of the epidermis and </span><span style="font-family: times;">Pagetoid spread of these atypical nevus cells are noted. The dermis shows irregular distribution </span><span style="font-family: times;">with lack of maturation. The nevus cells exhibit nuclear enlargement, contour angulation, nuclear </span><span style="font-family: times;">hyperchromatic and prominent nucleoli. Moderate lymphocytic upper dermal infiltrate is present. </span><span style="font-family: times;">The mitosis figure is 3 per mm squared. </span><span style="font-family: times;">Maximum Tumor Thickness Breslow: 4.0 mm</span></div><div class="separator" style="clear: both;"><span style="font-family: times;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-family: times;">INTERPRETATION</span></div><div class="separator" style="clear: both;"><span style="font-family: times;">Skin punch biopsy Left foot: Malignant melanoma.</span></div><div class="separator" style="clear: both;"><span style="font-family: times;">Maximum Tumor Thickness Breslow thickness Specify: 4.0 mm.</span></div><div class="separator" style="clear: both;"><span style="font-family: times;">Ulcerated</span></div><div class="separator" style="clear: both;"><span style="font-family: times;"><br /></span></div><div class="separator" style="clear: both;"><span style="font-family: times;">No immunohistochemisty was done.</span></div></div></div><p></p><div class="separator" style="clear: both; text-align: center;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEgwA54QwrJHmkvhDTSwULdENpEFGSSVAoQqDN3YZJDfxWoyQYpOuUreodDTOql5NE3FEs8H9LigBL-5NqGpjjEENQ_KwUq-w0_8raqZVCATw3oC2ojqxB3ZvKOz_ju5WGmfWryfFmfBRLVqkQvN3RkE59P-T5CbN9issW_RGMMGeVdRRTrntw=s868" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="478" data-original-width="868" height="176" src="https://blogger.googleusercontent.com/img/a/AVvXsEgwA54QwrJHmkvhDTSwULdENpEFGSSVAoQqDN3YZJDfxWoyQYpOuUreodDTOql5NE3FEs8H9LigBL-5NqGpjjEENQ_KwUq-w0_8raqZVCATw3oC2ojqxB3ZvKOz_ju5WGmfWryfFmfBRLVqkQvN3RkE59P-T5CbN9issW_RGMMGeVdRRTrntw=s320" width="320" /></a></div></div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: center;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEgEKf0crtEnhoCeNcaxlWO1t9aFXD5mC-KNW8XzqcjDOYknnQXW4yZAadIS5kUx7NmdWhOyQAwzpk70p_Q-i5Y3LyjobPHbT3zCFO-PqcUdUCR41Qz6ou7YlHvX8u24XoXzo-vkA3OBl2P-lPyhhLl7gUfrQv13l7s0ISSd5B2FyPaoLbUP8w=s865" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="486" data-original-width="865" height="180" src="https://blogger.googleusercontent.com/img/a/AVvXsEgEKf0crtEnhoCeNcaxlWO1t9aFXD5mC-KNW8XzqcjDOYknnQXW4yZAadIS5kUx7NmdWhOyQAwzpk70p_Q-i5Y3LyjobPHbT3zCFO-PqcUdUCR41Qz6ou7YlHvX8u24XoXzo-vkA3OBl2P-lPyhhLl7gUfrQv13l7s0ISSd5B2FyPaoLbUP8w=s320" width="320" /></a></div><br /></div><br /> <p></p><p><br /></p><p><br /></p><p><br /></p><p> </p><p> </p><p>Follow-up: She is doing well
at the moment. She was seen at the Department of Orthopedic Surgery,
Ipoh General Hospital and had surgical ray amputation of the toes. She is
due for follow-up by the chemotherapy team from <span>Kuala Lumpur Hospital, a Malaysian government-owned public hospital </span>later this month.</p><p> </p><p><b>Discussion:</b></p><p>While acral lentiginous melanoma is rare in the Western population, it is among the commonest type of malignant melanoma in the South East Asian countries (29-46% of melanomas in Asians). Accurate pathological staging of the melanoma is useful to guide the treatment and management of the tumor. </p><p>Questions:<br />Is sentinel node biopsy necessary in this patient? </p><p>In Malaysia, it is commonly managed by orthopaedic surgeons together with the oncology team, most of the time partial amputation of the fore foot with the preservation of the ankle is done.<br />What approaches would a dermatological surgeon have?<br /></p><p>References:</p><p>1. <span style="font-family: times;"> </span><span style="color: black;">J Pailoor et al <span style="background-color: white; caret-color: rgb(33, 33, 33); font-family: times; font-style: inherit; font-variant-caps: inherit;">Malays J Pathol </span><span class="cit" style="box-sizing: inherit; caret-color: rgb(33, 33, 33); display: inline-block; font-family: times;">2012 Dec;34(2):97-101 </span></span><span style="caret-color: rgb(33, 33, 33); color: #212121; font-family: times;">Cutaneous malignant melanoma: clinical and histopathological review of cases in a Malaysian tertiary referral centre</span></p><p><span style="caret-color: rgb(33, 33, 33); color: #212121; font-family: times;">2. A I Zainal et al. Med J Malay 2012:67;1:60-65 </span><span style="caret-color: rgb(17, 17, 17); color: #111111; font-family: times;">Acral melanoma of the extremities: A study of 33 cases in Sarawakian patients</span></p><p class="MsoNormal"><span style="font-size: small;"><span style="font-family: times;"><span style="caret-color: rgb(17, 17, 17); color: #111111;">3. </span><span class="abstract"><span>F Durbec , L Martin, C Derancourt, F Grange. Melanoma of the
hand and foot: epidemiological, prognostic and genetic features. A systematic
review. Br J Dermatol. 2012 Apr;166(4):727-39.</span></span></span></span><span style="font-size: small;"><span style="font-family: times;"><span class="abstract"><span><br />Abstract</span></span></span></span><span style="font-size: small;"><span style="font-family: times;"><span class="abstract"><span><br />Background: While early recognition and prognosis of
melanoma as a whole have improved, particular forms of rarer, under-recognized
or more severe tumours require increasing attention. Among them, melanomas
located on the hand and/or foot (hand and foot melanoma, HFM) have been the
subject of few and heterogeneous studies, with variable and sometimes confusing
results, and have not been targeted to date by comprehensive literature
reviews.</span></span></span></span></p><span style="font-size: small;"><span style="font-family: times;"></span></span><span style="font-size: small;"><span style="font-family: times;"><span class="abstract"><span>Objectives: To perform a formal, systematic review of the
literature, focusing on epidemiology, risk factors, prognosis and genetic
characteristics of HFM. Methods All data sources were identified through
searches on Medline, Scopus and Cochrane databases. Articles were selected and
evaluated according to predefined quality criteria</span></span></span></span><span style="font-size: small;"><span style="font-family: times;">
</span></span><p class="MsoNormal"><span style="font-size: small;"><span style="font-family: times;"><span class="abstract"><span>Results: Among 1185 articles screened for relevance, 37 met
the inclusion criteria. Data analysis brought to light important
particularities of HFMs: they are rare in all ethnic groups of developed
countries, but have been insufficiently studied in the developing world. About
half are of the specific acral lentiginous melanoma (ALM) subtype. Previous
trauma and naevi on the soles/toes were identified as two main risk factors in
case-control studies. Genetic or environmental factors other than sun exposure
are likely to play a role but require further investigation. Compared with
melanoma at other sites, their prognosis is poor mainly as a consequence of
later diagnosis, but possibly also because of an intrinsic negative effect of
the HFM/ALM subtype. Standard prognostic factors of melanoma have been
insufficiently validated to date in HFM. Finally, their molecular genetic
particularities could lead to specific targeted therapies in the near future.</span></span></span></span></p><span style="font-size: small;"><span style="font-family: times;">
</span></span><p class="MsoNormal"><span style="font-size: small;"><span style="font-family: times;"><span class="abstract"><span>Conclusions: Overall, HFM could represent a particular
subgroup of rare, potentially severe melanomas, requiring specific management
from their prevention up to their treatment.</span></span></span></span></p>
<p><span style="caret-color: rgb(17, 17, 17); color: #111111; font-family: times;"><style>@font-face
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{page:WordSection1;}</style> </span></p>Henry Foonghttp://www.blogger.com/profile/02804592640968503188noreply@blogger.com0tag:blogger.com,1999:blog-9870114.post-61317285056681981762022-03-12T17:33:00.013+00:002022-03-15T08:44:22.585+00:00Melanoma Neglecta<p class="MsoNormal">Presented by Jorge Delgado, M.D.<br />Brownsville, Texas
</p><p class="MsoNormal"> </p>
<p class="MsoNormal">The patient is a single 65 yo man who lives alone.<span style="mso-spacerun: yes;"> </span>He does not have a physician and has received
no medical care in years.<span style="mso-spacerun: yes;"> </span>His sister,
who lives outside of the country, came to visit and noted that his shirts were
stained by a malodorous exudate of blood and pus. Questioning, led to the
discovery of a tumor on his back that apparently had been growing for months to
years.</p>
<p class="MsoNormal"> </p>
<p class="MsoNormal">Usually fastidious about his personal hygiene, she also observed
that he’d become forgetful, unsteady on his feet and had fallen recently.</p>
<p class="MsoNormal"> </p>
<p class="MsoNormal">The examination showed a 5 cm tumor on his back,
portions of which had ulcerated.<span style="mso-spacerun: yes;"> </span>No
pigment was discernable.</p><p class="MsoNormal"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEiZ4AagGc_MXx9Yi-FvFg1WNhvjU387sRB_AWnjtdMZQoNpu9X2ky89pwd9_Du5Q8hrSG7XvX2Oh-0yNxTuf2RNynnF3ThG1jr0oM9QrXDgUXie83o2zn0LEDc-4jXW155nGVVqaLBmSsVm-PmVqyuh7uNL9F6oku_LaQjCCL5Fdq6_GHIzHw=s664" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="664" data-original-width="499" height="320" src="https://blogger.googleusercontent.com/img/a/AVvXsEiZ4AagGc_MXx9Yi-FvFg1WNhvjU387sRB_AWnjtdMZQoNpu9X2ky89pwd9_Du5Q8hrSG7XvX2Oh-0yNxTuf2RNynnF3ThG1jr0oM9QrXDgUXie83o2zn0LEDc-4jXW155nGVVqaLBmSsVm-PmVqyuh7uNL9F6oku_LaQjCCL5Fdq6_GHIzHw=s320" width="240" /></a></div><br /> <p></p>
<p class="MsoNormal"> </p>
<p class="MsoNormal">She took him to a dermatology clinic where a biopsy was
done. <span style="mso-spacerun: yes;"> </span>It was reported as melanoma,
greater than 4 mm thick with many mitoses.<span style="mso-spacerun: yes;">
</span>We don’t have the path report.</p>
<p class="MsoNormal"> </p>
<p class="MsoNormal">This represents an example of <i style="mso-bidi-font-style: normal;">Melanoma Neglecta.</i><span style="mso-spacerun: yes;"> </span>People
who lack basic medical care, who are isolated or who live in undeserved
areas are recognized to be at risk for tumors that are detected at a late
stage.</p>
<p class="MsoNormal"> </p>
<p class="MsoNormal">References:</p>
<p class="MsoNormal">1. Ana-Maria Forsea. Melanoma Epidemiology and Early
Detection in Europe: Diversity and Disparities. Dermatol Pract Concept. 2020
Jun 29;10(3):e2020033.<span style="mso-spacerun: yes;"> </span><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7319793/">PMC</a></p>
<p class="MsoNormal"> </p>
<p class="MsoNormal">2. Sauaia A , Dellavalle RP. Health care inequities: an
introduction for dermatology providers. Dermatol Clin. 2009 Apr;27(2):103-7, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2677554/">PMC</a></p><p class="MsoNormal"> </p><p class="MsoNormal">
</p><p class="MsoNormal">3. Rachidi S, Deng Z, Sullivan DY , Lipson EJ. Shorter survival and
later stage at diagnosis among unmarried patients with cutaneous melanoma: A US
national and tertiary care center study. J Am Acad Dermatol. 2020
Oct;83(4):1012-1020.<b><span style="mso-fareast-font-family: "Times New Roman";"><br />Conclusions:
</span></b><span style="mso-fareast-font-family: "Times New Roman";">Unmarried
patients, especially men and those younger than 68 years, are diagnosed at more
advanced stages, even in readily visible sites such as the face. They also
experience worse survival independent of stage.</span>
</p><p class="MsoNormal"><style>@font-face
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{page:WordSection1;}</style></p>Humane Medicine Huihttp://www.blogger.com/profile/07113291188306363130noreply@blogger.com0tag:blogger.com,1999:blog-9870114.post-74528328978247690992022-03-02T13:49:00.002+00:002022-03-02T13:49:26.047+00:00Pumped and Tanned<p class="MsoNormal"><span style="font-size: large;"><b>Pumped and Tan, Melanotan Man</b></span></p>
<p class="MsoNormal">Presented by Dr. M. Chester Morris </p>
<p class="MsoNormal">Cosmetic and Aesthetic Dermatology Centre</p>
<p class="MsoNormal">Nanaimo, British Columbia, Canada</p>
<p class="MsoNormal"> </p>
<p class="MsoNormal">A 42 yo Man presented with a history of new naevi on torso a
few months</p>
<p class="MsoNormal"> </p>
<p class="MsoNormal">He was in good general health.<span style="mso-spacerun: yes;"> </span>His only medication was oral minoxidil, 5 mg
a day, for male pattern alopecia.</p>
<p class="MsoNormal"> </p>
<p class="MsoNormal">O/E:<span style="mso-spacerun: yes;"> </span>About a dozen naevi,
5 – 7 mm in diameter,</p><p class="MsoNormal">were scattered on his torso..<span style="mso-spacerun: yes;"> </span>They were clinically benign appearance, but
as it is unusual for a 42 year-old individual to have eruptive naevi. The most
atypical one was biopsied.</p><p class="MsoNormal"></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEip_e00K0J8yiH3vRoPoMGxJ5cuVqRpsIH8gXoKJgoyUFaUfoPlmxNHCUvdAfaEJQIg4pt2dUj35dSxtsB_ObBEHFTXq1TzSg8O9iJcb5t405Ygra_DoNKd-qiRduVW8P8oyS85xRqHysQzHgEzlIbq-W73z4KmYzDz8j9r8bebLBMAMWqyww=s2048" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="2048" data-original-width="1536" height="320" src="https://blogger.googleusercontent.com/img/a/AVvXsEip_e00K0J8yiH3vRoPoMGxJ5cuVqRpsIH8gXoKJgoyUFaUfoPlmxNHCUvdAfaEJQIg4pt2dUj35dSxtsB_ObBEHFTXq1TzSg8O9iJcb5t405Ygra_DoNKd-qiRduVW8P8oyS85xRqHysQzHgEzlIbq-W73z4KmYzDz8j9r8bebLBMAMWqyww=w240-h320" title="New Naevi in 42 yo Man" width="240" /></a></div><p> Pathology shows a junctional and compound nevus without atypia.<br /></p><p></p><div class="separator" style="clear: both; text-align: center;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEhUZ17ntp3TRKBKclP5IRW-ZInl6z3hLaWLlKOtgp1MKHf92Jc8TSS_i7QgofVek2bX9oac1SD1WotFaZ7GTrsStLyyo1Cr-jAyxxzvDk0mxVUlpfPOLJsXtDCjra8eL-tx4D41-EjgpZ32njUdmpM2dkJ_2oFfEsbaH1leY8mHw6aCk2jchw=s737" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="457" data-original-width="737" height="141" src="https://blogger.googleusercontent.com/img/a/AVvXsEhUZ17ntp3TRKBKclP5IRW-ZInl6z3hLaWLlKOtgp1MKHf92Jc8TSS_i7QgofVek2bX9oac1SD1WotFaZ7GTrsStLyyo1Cr-jAyxxzvDk0mxVUlpfPOLJsXtDCjra8eL-tx4D41-EjgpZ32njUdmpM2dkJ_2oFfEsbaH1leY8mHw6aCk2jchw=w227-h141" width="227" /></a></div><a href="https://blogger.googleusercontent.com/img/a/AVvXsEh61nu69orQH0fL7TFeVO_8LGckB5O7c4YwmQq92P-5PBpoPl3xzxHZSSzXY-EGQhJGTJfq8I6oz8H_9tmBnTyBukEbfQMEh9VRE8E8-w9lWc0K9lx2YBlpBUAtgGKm_ALel2B5A8C9SJDmSQPol-0zLz92Yue1y4B5vNQKKu8uWgNoNSZtEw=s600" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="600" data-original-width="400" height="200" src="https://blogger.googleusercontent.com/img/a/AVvXsEh61nu69orQH0fL7TFeVO_8LGckB5O7c4YwmQq92P-5PBpoPl3xzxHZSSzXY-EGQhJGTJfq8I6oz8H_9tmBnTyBukEbfQMEh9VRE8E8-w9lWc0K9lx2YBlpBUAtgGKm_ALel2B5A8C9SJDmSQPol-0zLz92Yue1y4B5vNQKKu8uWgNoNSZtEw=w133-h200" width="133" /></a></div><p></p>The patient is well-known to our clinic.
<p class="MsoNormal">He has a history of</p><ul style="margin-top: 0in;" type="disc"><li class="MsoNormal" style="mso-list: l0 level1 lfo1;">Ongoing mild alopecia
areata of the bearded area and receives ILK every few months.<span style="mso-spacerun: yes;"> </span></li><li class="MsoNormal" style="mso-list: l0 level1 lfo1;">Mild male-pattern
alopecia.<span style="mso-spacerun: yes;"> </span>He’s had 3 hair
transplants, 2 locally and one at a specialty clinic in Southern
California where they do PRP</li><li class="MsoNormal" style="mso-list: l0 level1 lfo1;">Expensive cosmetic dental
capping</li></ul>
<p class="MsoNormal"> </p>
<p class="MsoNormal">He spends lots of time in the gym (uses supplements)</p>
<p class="MsoNormal"> </p>
<p class="MsoNormal">Further history reveals that he bought <a href="https://en.wikipedia.org/wiki/Melanotan_II">Melanotan</a>. a synthetic analogue of the peptide hormone
α-melanocyte-stimulating hormone (α-MSH) that stimulates melanogenesis and is
purported to increases sexual arousal among other things, at his gym
and has been injecting himself with it for a few months.<span style="mso-spacerun: yes;"> </span>When I asked to see the product, he said he
couldn’t find it.</p>
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<p class="MsoNormal"> </p>
<p class="MsoNormal">Diagnosis: This 42 yo man developed Eruptive Melanoytic Naevi
after the use of Melanotan obtained from a contact at his gym.<span style="mso-spacerun: yes;"> </span>When I expressed interest in the drug; he
disappeared. I have known him for a few years and he appears to have body
dysmorphic syndrome (BDD) and that may have induced him to purchase Melanotan.<span style="mso-spacerun: yes;"> </span>His form of BDD has been called “Muscle
Dysmorphia” or The Adonis Complex.</p>
<p class="MsoNormal"> </p>
<p class="MsoNormal"> </p>
<p class="MsoNormal">Teaching points:</p>
<p class="MsoNormal">1. Use of Melanotan may be more widespread than we realize.</p>
<p class="MsoNormal">2. Patients such as this may have BDD, specifically the
Adonis Syndrome</p>
<p class="MsoNormal">3.<span style="mso-spacerun: yes;"> </span>There is an online
literature on Melanotan and although it is risky, some patients nonetheless
seek it out.</p>
<p class="MsoNormal"> </p>
<p class="MsoNormal">The medical literature contains references to various
possible side-effects of Melanotan. These include: darkening of previous naevi, eruptive melanocytic naevi,
isolated cases reports of melanoma and melanoma in situ, renal infarcts,
and priapism.</p>
<p class="MsoNormal"> </p>
<p class="MsoNormal">Reference:</p><p class="MsoNormal">1. Ewa A Burian<span style="mso-spacerun: yes;"> </span>1 ,
Gregor B E Jemec<span style="mso-spacerun: yes;"> </span>Eruptive Melanocytic
Nevi: A Review. Am J Clin Dermatol. 2019 Oct;20(5):669-682. </p>
<p class="MsoNormal">Abstract: Eruptive melanocytic nevi (EMN) is a phenomenon
characterized by the sudden onset of nevi. Our objective was to compile all
published reports of EMN to identify possible precipitating factors and to
evaluate the clinical appearance and course. We conducted a systematic
bibliographic search and selected 93 articles, representing 179 patients with
EMN. The suspected causes were skin and other diseases (50%); immunosuppressive
agents, chemotherapy or melanotan (41%); and miscellaneous, including
idiopathic (9%). The clinical manifestations could largely be divided into two
categories: EMN associated with skin diseases were frequently few in number
(fewer than ten nevi), large, and localized to the site of previous skin
disease, whereas those due to other causes presented most often with multiple
small widespread nevi. In general, EMN seem to persist unchanged after their
appearance, but development over several years or fading has also been
reported. Overall, 16% of the cases had at least one histologically confirmed
dysplastic nevus. Five cases of associated melanoma were reported. We conclude
that the clinical appearance of EMN may differ according to the suggested
triggering factor. Based on the clinical distinction, we propose a new
subclassification of EMN: (1) widespread eruptive nevi (WEN), with numerous
small nevi, triggered by, for example, drugs and internal diseases, and (2)
Köbner-like eruptive nevi, often with big and few nevi, associated with skin
diseases and most often localized at the site of previous skin disease/trauma.
The nature of the data precluded assessment of risk of malignant
transformation.</p><p class="MsoNormal"> </p>
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<p class="MsoNormal">2. Melanotan <a href="https://en.wikipedia.org/wiki/Melanotan_II">https://en.wikipedia.org/wiki/Melanotan_IIWikipedia</a></p>
<p class="MsoNormal"> </p>
<p class="MsoNormal">3. <span class="reference-text">Harrison G Pope Jr, Katharine
A Phillips & Roberto Olivardia, <i>The Adonis Complex: The Secret Crisis of
Male Body Obsession</i> (New York: Free Press, 2000)</span></p>
<p class="MsoNormal"><span class="reference-text"> </span></p>
<p class="MsoNormal"><span class="reference-text">4. <a href="https://en.wikipedia.org/wiki/Muscle_dysmorphia">Muscle Dymorphea</a>: https://en.wikipedia.org/wiki/Muscle_dysmorphia
</span></p>
<p class="MsoNormal"> </p>
<p class="MsoNormal">5. Louis Habbema<span style="mso-spacerun: yes;"> </span>et.
al.<span style="mso-spacerun: yes;"> </span>Risks of unregulated use of
alpha-melanocyte-stimulating hormone analogues: a review. Int J Dermatol. 2017
Oct;56(10):975-980.</p>
<p class="MsoNormal">Abstract</p>
<p class="MsoNormal">Recently, the unregulated use of untested synthetic
alpha-melanocyte-stimulating hormone (α-MSH) analogues, commonly known as
melanotan I and II, appears to have increased. These analogues are primarily
used for their tan-stimulating effects. Dermatologists see many patients in
their clinic who tan. This review provides an overview of the risks of the
unregulated use of these substances.<span style="mso-spacerun: yes;"> </span>Although
afamelanotide has been thoroughly tested and deemed safe, illegal melanotans
are likely risky for several reasons. There are questions regarding the
preparation, administration, and dosage of these substances. In addition to
these general risks, increasing numbers of case reports indicate that the
unregulated use of both melanotan I and II is associated with cutaneous
complications, particularly melanocytic changes in existing moles and newly
emerging (dysplastic) nevi. Four case reports have described melanomas emerging
from existing moles either during or shortly after the use of melanotan.
Although conclusive evidence linking these phenomena is lacking, publications
have stressed the importance of awareness that melanotan is a part of a
'tanning culture' in certain subpopulations. Multiple national health
organizations have issued safety warnings regarding the use of melanotan I and
II.</p>
<p><style>@font-face
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{margin-bottom:0in;}</style></p>Humane Medicine Huihttp://www.blogger.com/profile/07113291188306363130noreply@blogger.com0tag:blogger.com,1999:blog-9870114.post-22825249601553487282021-11-05T12:04:00.000+00:002021-11-05T12:04:36.182+00:00Recurrent Oro-labial HSV in a Four Year Old<p>
</p><p class="MsoNormal" style="mso-outline-level: 1;"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;">The patient is a four year-old boy with a
three year history of recurrent vesicular lesions around the mouth.<span style="mso-spacerun: yes;"> </span>He has two to three episodes a month.<span style="mso-spacerun: yes;"> </span>His mother had a similar problem as a child,
but now she takes valcyclovir only on an episodic basis. </span></p>
<p class="MsoNormal" style="mso-outline-level: 1;"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;"> </span></p>
<p class="MsoNormal" style="mso-outline-level: 1;"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;">He was started on acyclovir and treated with
suppressive regimen but he still had breakthroughs.<span style="mso-spacerun: yes;"> </span>He refuses to take the medication on a
regular basis but is willing to take it episodically.<span style="mso-spacerun: yes;"> </span>(How does one reason with a four year old?)</span></p>
<p class="MsoNormal"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;"> </span></p>
<p class="MsoNormal" style="mso-outline-level: 1;"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;">EXAMINATION:<span style="mso-spacerun: yes;">
</span>The examination shows a pleasant, outgoing 4-year-old.<span style="mso-spacerun: yes;"> </span>He has a cluster of vesicles on his left
lower lip.<span style="mso-spacerun: yes;"> </span>A Tzanck smear was positive
for multinuclear giant cells. </span></p>
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{page:WordSection1;}</style></p><p>Clinical Image:<br /></p><div class="separator" style="clear: both; text-align: center;"><a href="https://1.bp.blogspot.com/-hwdbiFXVZVI/YYG9sv6JumI/AAAAAAAA8hY/iws207a03goqQj6ydNmBYM7hmnXpNpLWwCNcBGAsYHQ/s1531/Recurrent%2BHSV.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1133" data-original-width="1531" height="296" src="https://1.bp.blogspot.com/-hwdbiFXVZVI/YYG9sv6JumI/AAAAAAAA8hY/iws207a03goqQj6ydNmBYM7hmnXpNpLWwCNcBGAsYHQ/w400-h296/Recurrent%2BHSV.jpg" width="400" /></a></div>
<p class="MsoNormal" style="mso-outline-level: 1;"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;">Diagnosis:<span style="mso-spacerun: yes;">
</span>Recurrent oro-labial herpes simplex in an apparently immunologically
normal child.</span></p>
<p class="MsoNormal" style="mso-outline-level: 1;"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;"> </span></p>
<p class="MsoNormal" style="mso-outline-level: 1;"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;">Questions: </span></p>
<p class="MsoNormal" style="mso-outline-level: 1;"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;">In a normal (stubborn) four year-old, is there
any therapeutically suppressive approach that will help?<span style="mso-spacerun: yes;"> </span>A suspension of acyclovir is available, but
famcyclovir and valcyclovir only come as tablets with no pediatric formulations.</span></p>
<p class="MsoNormal" style="mso-outline-level: 1;"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;"> </span></p>
<p class="MsoNormal" style="mso-outline-level: 1;"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;">Do you know of other instances where
frequently recurrent HSV runs in families?<span style="mso-spacerun: yes;">
</span>It makes sense that there is some subtle problem with normal immune
suppression in this family.</span></p>
<p class="MsoNormal" style="mso-outline-level: 1;"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;"> </span></p>
<p class="MsoNormal" style="mso-outline-level: 1;"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;">Have you had any luck with any of the topical
antivirals?<span style="mso-spacerun: yes;"> </span>The discounted price of
Denavir (</span>penciclovir) is almost $900 for a 5 gram tube? <br /></p>
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{page:WordSection1;}</style> Humane Medicine Huihttp://www.blogger.com/profile/07113291188306363130noreply@blogger.com0tag:blogger.com,1999:blog-9870114.post-33577634404035912822021-09-17T13:58:00.002+00:002021-09-17T13:58:38.176+00:00 A Case of Toxic Epidermal Necrolysis treated with Etanercept<p>Presented by Dr, Henry Foong<br />Ipoh, Malaysia <br /></p><p>A patient in his 50s with a history of non-Hodgkin lymphoma was admitted to our local hospital because of fever and generalised skin eruptions for 5 days. He had developed conjunctivitis, painful mouth ulcers, and painful genital erosions. He was on cozaar and simvastatin which was started about 3 weeks ago. He denied taking any new oral medications including OTC supplements. </p><p>On Examination: He had generalised dusky coloured targeted macules on the trunk, extremities including palms and soles. Some of the lesions appeared to be peeling. Bilateral conjunctival redness were noted in both eyes. There were superficial erosions on the lips, tongue and inner buccal cavity. superficial erosions were also noted on the glans penis. His body surface area (BSA) is estimated to be 45%. (Fig 1 and 2)</p><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://1.bp.blogspot.com/-o_7KdrjwN38/YTouCv94jxI/AAAAAAAAGGg/U5R8XWl4PG8YNeXl8d0nbnOzmjJAeW29ACLcBGAsYHQ/s2048/IMG_4148.JPG" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="2048" data-original-width="1503" height="320" src="https://1.bp.blogspot.com/-o_7KdrjwN38/YTouCv94jxI/AAAAAAAAGGg/U5R8XWl4PG8YNeXl8d0nbnOzmjJAeW29ACLcBGAsYHQ/s320/IMG_4148.JPG" width="235" /></a></div><div class="separator" style="clear: both; text-align: center;">Fig 1</div><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://1.bp.blogspot.com/-7KTdnWKAZas/YTouUZYZYlI/AAAAAAAAGGs/mnwTKF_iHvkOwcvfcauqDP7gViFy_41DACLcBGAsYHQ/s1345/IMG_4151%2B3.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1001" data-original-width="1345" height="238" src="https://1.bp.blogspot.com/-7KTdnWKAZas/YTouUZYZYlI/AAAAAAAAGGs/mnwTKF_iHvkOwcvfcauqDP7gViFy_41DACLcBGAsYHQ/s320/IMG_4151%2B3.jpg" width="320" /></a></div><div class="separator" style="clear: both; text-align: center;">Fig 2</div><div class="separator" style="clear: both; text-align: center;"> </div><div class="separator" style="clear: both; text-align: center;"><p style="text-align: left;">A diagnosis of <b>Toxic Epidermal Necrolysis </b>was made. </p><p style="text-align: left;">A skin biopsy was performed.</p><div class="separator" style="clear: both; text-align: left;">Pathology:
Section shows prominent spongiosis with focal parakeratosis. The
epidermis shows focal necrotic keratinocytes and intra-epidermis
lymphocytes. There is zonal epidermal necrosis in the center of the
biopsy, associated with hemorrhage and a perivascular lymphocytic
cuffing of the superficial dermal vessels. The dermis shows mild
perivascular neutrophils infiltration. There is no atypical lymphocyte
or malignancy seen. The deeper dermis and subcutaneous fat are normal.
Extensive lichenoid dermatosis consistent with erythema multiforme. No
atypical lymphocyte seen. (Fig 3)</div><div class="separator" style="clear: both; text-align: left;"> <br /></div></div><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://1.bp.blogspot.com/-P95IXnlizR0/YTonykq-t1I/AAAAAAAAGFk/fltgMniz4Co6ljMchggfGVDucBnneiORACLcBGAsYHQ/s609/PHOTO-2021-09-03-11-38-44.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="490" data-original-width="609" height="257" src="https://1.bp.blogspot.com/-P95IXnlizR0/YTonykq-t1I/AAAAAAAAGFk/fltgMniz4Co6ljMchggfGVDucBnneiORACLcBGAsYHQ/s320/PHOTO-2021-09-03-11-38-44.jpg" width="320" /></a></div><div class="separator" style="clear: both; text-align: center;">Fig 3</div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: left;"><div class="separator" style="clear: both;">Both
the antihypertensive and statin ( and all other non essential
medications) was withheld. He was initially treated with IV fluids, IV
hydrocortisone 200mg qid, oral toilet with sodium bicarb gargle, dilute KMNO4 wash daily, soft paraffin wax as moisturisers. His blood counts
and biochemistry were unremarkable except for raised urea, creatinine
and low bicarbonate. His SCORTEN* score was calculated to be 5 out of 7.
While waiting for s/c etanercept 50mg to arrive, he was treated with
IvIg 25 gm daily and IV hydrocortisone 100mg did as an interim measure
for 2 days. He responded well to treatment and his skin begins to heal
on day 2 of s/c etanercept. <br /><br /></div> </div><div class="separator" style="clear: both; text-align: left;">The use of TNFa inhibitors was first described in the treatment of SJS/TEN in 2002 using infliximab. (1) It was believed to be the T cells secreting TNFa induced epithelial cell death through granulysin, nitric oxide FasL pathway, CCL 27 and T reg cells. In 2014, Paradisi described the successful use of etanercept for TEN in JAAD. (2) A good systemic review of the biologic TNF a inhibitors can be found in JDD in 2019. (3)</div><div class="separator" style="clear: both; text-align: left;"> </div><div class="separator" style="clear: both; text-align: left;">In this case study, we described the successful use of etanercept in an ill patient with TEN.</div><div class="separator" style="clear: both; text-align: left;">1. Which is preferable? IV IgG vs oral cyclosporin vs s/c etanercept</div><div class="separator" style="clear: both; text-align: left;">2. Is there any role of systemic corticosteroids in SJS or TEN?</div><div class="separator" style="clear: both; text-align: left;">3. If s/c etanercept is preferable, what would be the interim treatment while waiting for the medication to arrive? None of our local Malaysian hospitals keep s/c etanercept in their drug store.</div><div class="separator" style="clear: both; text-align: left;"><span style="color: #333333; font-family: "Droid Serif"; font-size: 2.1em;"><br /></span></div><div class="separator" style="clear: both; text-align: left;"><span style="color: #333333;"><span style="font-family: "Droid Serif";">References: </span></span><br /></div><div class="separator" style="clear: both; text-align: left;">1. Fisher. Anti-TNFa (Infliximab) in the treatment of a patient with TEN. Br J Dermatol 2002:146:707-709</div><div class="separator" style="clear: both; text-align: left;">2. Paradisi et al. Etarnercept therapy for TEN. J Am Acad Dermatol 2014: 71: 278-283</div><div class="separator" style="clear: both; text-align: left;">3. <span face="BlinkMacSystemFont, -apple-system, "Segoe UI", Roboto, Oxygen, Ubuntu, Cantarell, "Fira Sans", "Droid Sans", "Helvetica Neue", sans-serif" style="background-color: white; caret-color: rgb(33, 33, 33); color: #212121;">Zhang S, Tang S, Li S, Pan Y, Ding Y. Biologic TNF-alpha inhibitors in the treatment of Stevens-Johnson syndrome and toxic epidermal necrolysis: a systemic review. J Dermatolog Treat. 2020 Feb;31(1):66-73. doi: 10.1080/09546634.2019.1577548. Epub 2019 Feb 19. PMID: 30702955.</span></div><div class="separator" style="clear: both; text-align: left;"><span face="BlinkMacSystemFont, -apple-system, "Segoe UI", Roboto, Oxygen, Ubuntu, Cantarell, "Fira Sans", "Droid Sans", "Helvetica Neue", sans-serif" style="background-color: white; caret-color: rgb(33, 33, 33); color: #212121;"> </span></div><div class="separator" style="clear: both; text-align: left;"><span face="BlinkMacSystemFont, -apple-system, "Segoe UI", Roboto, Oxygen, Ubuntu, Cantarell, "Fira Sans", "Droid Sans", "Helvetica Neue", sans-serif" style="background-color: white; caret-color: rgb(33, 33, 33); color: #212121;">SCORTEN Score is </span><span face="BlinkMacSystemFont, -apple-system, "Segoe UI", Roboto, Oxygen, Ubuntu, Cantarell, "Fira Sans", "Droid Sans", "Helvetica Neue", sans-serif" style="background-color: white; caret-color: rgb(33, 33, 33); color: #212121;"> Severity of Illness Score for Toxic Epidermal Necrolysis. See <a href="https://en.wikipedia.org/wiki/Toxic_epidermal_necrolysis">Wiki</a> and scroll down. </span></div>Henry Foonghttp://www.blogger.com/profile/02804592640968503188noreply@blogger.com0tag:blogger.com,1999:blog-9870114.post-49309573018010075682021-08-07T02:25:00.006+00:002021-09-01T19:22:07.058+00:00Isotretinoin Failure<p>
</p><p class="MsoNormal"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;">This 20-year-old woman</span> has a 6 month history of cystic acne.<span style="mso-spacerun: yes;"> </span>Although she has been on isotretinoin for
three month her response has been poor and she continues to develop new lesions.<span style="mso-spacerun: yes;"> </span>She started on 40 mg of isotretinoin a day but her acne
flared and she was dropped to 30 and then 20 mg per day.<span style="mso-spacerun: yes;"> </span>Due to her acne flare on isotretinoin, prednisone was started at 40 mg bid (tapered
after two weeks).<span style="mso-spacerun: yes;"> </span>She is on a combined
oral contraceptive but it only has 20 mcg of ethinyl estradiol and
spironolactome 100 mg per day. She was also placed on desloratadine 5 mg a day, but that did not appear to help either. She is feeling discouraged, and sees a therapist
for anxiety and that led to a prescription for BuSpar from her therapist.
</p>
<p class="MsoNormal"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;">EXAMINATION:<span style="mso-spacerun: yes;"> </span>The examination
shows a pleasant, outgoing woman.<span style="mso-spacerun: yes;"> </span>She has acne with inflammatory and cystic features
on the cheeks and forehead.<span style="mso-spacerun: yes;"> </span>Back and
chest are clear although she did have some acne on her shoulders that has
resolved.<span style="mso-spacerun: yes;"> </span>Her weight is 65 kg. There is no hirsuitism or striae.<br /></span></p><p class="MsoNormal"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;">Photos 8.5.21(aftr 12 weeks of isotretinoin)<br /> <br /></span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://1.bp.blogspot.com/-07NITakfOl8/YS_SrLjWriI/AAAAAAAA8bQ/dby2v7h2EsY0fCRJTHJKtb8oBKjS4KjDACNcBGAsYHQ/s2048/IMG-2082%2Bcopy.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="2048" data-original-width="1536" height="320" src="https://1.bp.blogspot.com/-07NITakfOl8/YS_SrLjWriI/AAAAAAAA8bQ/dby2v7h2EsY0fCRJTHJKtb8oBKjS4KjDACNcBGAsYHQ/s320/IMG-2082%2Bcopy.jpg" width="240" /></a></div><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://1.bp.blogspot.com/-oA6GZJ0Ou9g/YS_SrHLZIRI/AAAAAAAA8bM/d29voKzmjIwnWlYJFgmDJqUnTiq6_AQSQCNcBGAsYHQ/s2048/IMG-2081%2Bcopy.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="2048" data-original-width="1536" height="320" src="https://1.bp.blogspot.com/-oA6GZJ0Ou9g/YS_SrHLZIRI/AAAAAAAA8bM/d29voKzmjIwnWlYJFgmDJqUnTiq6_AQSQCNcBGAsYHQ/s320/IMG-2081%2Bcopy.jpg" width="240" /></a></div><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://1.bp.blogspot.com/-DXdxLQwRpZ4/YS_SrjQDuHI/AAAAAAAA8bU/5tpgB_JzqIAdANTbPX8kgv3uCi6B07gSgCNcBGAsYHQ/s2048/IMG-2080.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="2048" data-original-width="1536" height="320" src="https://1.bp.blogspot.com/-DXdxLQwRpZ4/YS_SrjQDuHI/AAAAAAAA8bU/5tpgB_JzqIAdANTbPX8kgv3uCi6B07gSgCNcBGAsYHQ/s320/IMG-2080.jpg" width="240" /></a></div><p></p><p class="MsoNormal"></p><div class="separator" style="clear: both; text-align: center;"></div><div class="separator" style="clear: both; text-align: center;"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;"><br /></span><div style="text-align: left;"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;">IMPRESSION:<span style="mso-spacerun: yes;"> </span>This 20-year-old
woman with severe inflammatory cystic continues to have active lesions after 3
months months on isotretinoin.<span style="mso-spacerun: yes;"> </span>Her acne
worsened significantly after her first month of isotretinoin at 40 mg a day.<span style="mso-spacerun: yes;"> </span></span></div><div style="text-align: left;"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;"><span style="mso-spacerun: yes;"> </span></span></div><div style="text-align: left;"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;"><span style="mso-spacerun: yes;"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;">Photos Removed for Privacy Issue</span> (for legitimate use please contact djelpernATgmail.com)</span></span>
</div></div>
<p class="MsoNormal"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;">PLAN:<span style="mso-spacerun: yes;"> </span>For the time being, we
will continue prednisone at 20 mg a day for the next week and then drop,
isotretinoin 20 mg a day, and continue spironolactone 100 mg a day.<span style="mso-spacerun: yes;"> </span>I discussed with her either trimethoprim or
Bactrim, but we are going to hold off on that, for the time being.<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>After
a literature review, <span style="mso-spacerun: yes;"> </span>an article about
adding amoxicillin seemed promising.<sup>1</sup></span></p><p class="MsoNormal"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;"><sup> </sup></span><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;">Questions: </span>
</p><p class="MsoNormal"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;">1. At what point would you initiate a work-up for underlying
endocrinopathy, such as Cushings?</span></p>
<p class="MsoNormal"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;">2.<span style="mso-spacerun: yes;"> </span>Have you treated similar
patients who flared with isotretinoin and were difficult to control?</span></p>
<p class="MsoNormal"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;">3. Have you had experience with adding amoxicillin in situations like
this.</span></p>
<p class="MsoNormal"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;"> </span></p>
<p class="MsoNormal"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;">Reference:</span></p>
<p class="MsoNormal"><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;">Safety and effectiveness of amoxicillin in the treatment of
inflammatory acne.</span><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;"> Guzman AK, Choi JK, James WD. Int J Womens Dermatol. 2018 Jun
8;4(3):174-175Free <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6116810/">Full Text.</a><br />Comment from Dr. James: </span><span style="mso-bidi-font-style: italic; mso-bidi-font-weight: bold;">
</span></p>
<p class="MsoNormal"><i>Amoxicillin is a very good drug for acne. I would start at
500 mg tid, very few get any side effects other than of course possible drug
eruption, but most have had penicillin in the past and know if they are allergic
or not. At three months I would then go to bid. In the paper it was early in my
using it, and I was giving it at lower doses, but I find higher dosing better
and well tolerated.</i></p><i>
</i><p class="MsoNormal"><i>You could also start at a lower dose with isotretinioin,
sometimes with prednisone as well for the first three to six weeks, almost
always tolerate it in this manner, but hard for those who have flared badly to
want to take it again. Avoiding this bad flare is why when I use isotretinoin I
start the first month at 20 mg per day, then increase. I have had to start at
ten mg per day in some that have flared in the past, along with prednisone.</i></p>
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{page:WordSection1;}</style> <br /></p>Humane Medicine Huihttp://www.blogger.com/profile/07113291188306363130noreply@blogger.com0