A Diagnostic Dilemma

presented by Hamish Dunwoodie
Tracadie, New Brunswick

The patient is a 60 yo man who presented with a six months history of two asymptomatic erythematous nodules on the torso.  He has been in his usual state of health otherwise. No history of fever, chills or night sweats.

O/E:  There are two erythematous nodules located on the right abdomen and the left upper back.  They measure 3 - 4 cm in diameter. No other cutaneous findings.

Clinical Photos:

New Lesion 10.25,16 R, Upper Back)

Pathology:
A superficial and deep nodular and interstitial infiltrate of CD20 positive B-lymphocytes admixed with CD3 positive T-lymphocytes with slight preponderance of B-cells.  There is a scattering of CD30 positive lymphocyres.  There appears to be a Grenz zone.  Gene rearrangement studies are not indicative of either a clonal T or B cell lymphoproliferative disorder.

 

CD 3

CD 20

Lab: CBC, Chemistries, Serum protein electrophoresis all normal. IgG, IgM and IgG were all normal.

Diagnosis: The differential is between an atypical lymphoid infiltrate and a cutaneous lymphoma.  We are leaning towards the former.  Note: The last clinical photo was taken ~ 1 month after the others and shows progression.  We plan to excise this recurring tumor for help with diagnosis.

Questions:  

Should we treat? and if so how?

Should we follow with active surveillance?
Would any of you make a a more specific diagnosis?
Is any further testing indicated at this time?

Follow-up 2.3.16
The patient's lesions come and go.  All tests for systemic disease are negative.  New lesion (see photo) on left chest 2 cm in diameter seen today.  Will try to treat with clobetasol ointment.

10.16.16.  Old lesions have disappeared and new lesions develop.  Bo evidence of systemic disease.

Reference:
1. Atypical lymphoid proliferations: the pathologist's viewpoint. Hussein MR. Expert Rev Hematol. 2013 Apr;6(2):139-53. doi: 10.1586/ehm.13.4.

Abstract: Lymphoid proliferations are traditionally thought to be either benign conditions (reactive hyperplasia and lymphadenitis) or malignant lymphomas. However, not all lymphoid lesions at present can be precisely placed into one of these categories. 

2. Cutaneous B-cell lymphomas: 2015 update on diagnosis, risk-stratification, and management. Wilcox RA.  Am J Hematol. 2015 Jan;90(1):73-6. Free Full Text Online.  

Difficult Leg Ulcer

The patient is an otherwise healthy 84 y.o. woman with a two year history of a progressively expanding and debilitating leg ulcer.  It has not improved after attention from three wound care centers (two of which were associated with medical schools).

This woman, a compliant retired teacher, is depressed about her debilitating leg ulcer; especially so since her PCP has been talking about "end of life care."What can we do to put life into her years?

Photos taken by her visiting nurse.

Acral Lentiginous Melanoma

Abstract: 72-year-old diabetic Indian housewife

HPI: An  72-year-old Indian housewife present with a pigmented growth on the right sole for a year.  Started as a small growth and gradually increased in size.  She saw a GP earlier and was advised to remove it. However she was not keen then.  Recently she felt pain when she walked and this prompted her to seek medical attention again.

O/E: An ulcerated pigmented warty growth 2 x 3 cm on the sole of the right foot with surrounding pigmented satellite lesions.  Her regional nodes
(popliteal and inguinal) were not enlarged.

Clinical Image:

Pathology:
Nests of atypical cells are seen in the epidermis and dermis. Most of the cells contain melanin pigment. They show pleomorphism, have vesicular nuclei and eosinophilic cytoplasm. These features are suggestive of malignant melanoma. Suggest wide excision for definite diagnosis.

Diagnosis: Malignant melanoma, acral lentiginous type with nodular component.

Questions:
How would you approach this patient?
Do you think Sentinel Lymph Node Biopsy is important in her case?
What would give her the best quality of life?
After surgery, is there a role for topical imiquimod?

Reference:
1) Kanzler MH. Sentinel node biopsy and standard of care for melanoma: a re-evaluation of the evidence. J Am Acad Dermatol. 2010 May;62(5):880-4.

"There is probably no more controversial area of melanoma management than sentinel node biopsy.  Patients are routinely offered this procedure as if it improves outcome; which it emphatically does not."  See:  Dermatology Central for link to article.

2) No survival benefit for patients with melanoma undergoing sentinel lymph node biopsy: critical appraisal of the Multicenter Selective Lymphadenectomy Trial-I final report. Sladden M1, Zagarella S, Popescu C, Bigby M. Br J Dermatol. 2015 Mar;172(3):566-71.  PubMed.

3) Aral lentiginous melanoma treated with topical imiquimod cream: possible cooperation between drug and tumour cells.

Clin Exp Dermatol. 2015 Jan;40(1):27-30.

Savarese I, et. al.

Abstract: An 85-year-old woman presented with a lesion on the sole of her right foot, which was histologically confirmed as acral lentiginous melanoma. Because of the large field involved and because the patient refused any invasive or painful treatment, topical treatment with imiquimod was commenced. At the 20-month follow-up, the patient was still continuing treatment with topical imiquimod, and no metastases to the lymph nodes or viscera were found, either clinically or in imaging studies. We believe that the success of the treatment cannot be explained only by the stimulation of the immune system induced by imiquimod. A possible explanation might be 'tumour dormancy', where a tumour grows very slowly because of a balance between the neoplasia and the immune (and nonimmune) mechanisms of tumour control. The use of imiquimod has so far allowed our patient to avoid surgery, and perturbation of the mechanisms of tumour regulation, such as local immunity and angiogenesis, has not taken place.

 

Unusual Eyelid Dermatitis

The patient is a 23 y.o. man with a 3 month history of an eyelid dermatitis.  He was treated with a topical corticosteroid and a topical antifunal.  Neither was effective.  Personal history is significant for Crohn’s disease (in remission for years with 6-mercaptopurine).  His father has rosacea.

O/E:  There are erythematous, slightly scaly papules at the left outer canthus and lower lid.  The lower lid margin is slightly red.  Right eye completely normal.

Photos:

O.S.

O.D.

Pathology:

3 mm punch biopsy obtained.

Diagnosis:

Eyelid Dermatotis:  Consider granulomatous rosacea, demodeciasis.  Cutaneous Crohn’s disease (unlikely)

Follow-up:  Biopsy is c/w rosacea.  No demodex noted.  No granulomatous changes.

Collision Lesion

81 yo woman with two year history of a lesion on the left nasal sidewall.

O/E:  8 mm papule with two distinct parts.  One is a pearly papule with tortuous vessels and the other is a greasy keratotic papule with a pebbly surface.

Photos:

Diagnosis: Likely Collision lesion:  Basal Cell/Seborrheic Keratosis

Plan:  Scheduled for excision

Reference:Letter: Collision tumor: importance of the new auxiliary tools for diagnosis (an illustrative case report).  Free Full Text

Menezes N, et. al. Dermatol Online J. 2011 Jul 15;17(7):12.

Abstract: Collision tumor is a term used to refer to the association of various types of tumors in time and space. Despite most of them not being clinically relevant, sometimes there is a union between a benign lesion and a malignant one. The clinical diagnosis in these cases is usually extremely difficult, particularly if one of the lesions is pigmented. Dermoscopy and confocal microscopy are noninvasive diagnostic methods that make possible the visualization of morphologic structures not visible to the naked eye, thus making diagnosis of these lesions possible. Here we describe a case in which the corrected diagnosis of a collision between a seborrheic keratosis and a basal cell carcinoma was only possible by means of confocal microscopy.

Majocci's Granuloma (presumptive)

The patient is a 67 yo man with a three month history of a dermatitis on the left wrist.  It began under his watch.  Initially treated with "a steroid cream" prescribed by his PCP.  The rash cleared but recurred shortly after he stopped the cream.  He'd moved his watch to his right arm which has developed no rash after three months.  Patient has two cats at home which occasionally scratch and bite.

O/E:  2.5 c.m. annular, scsaly plaque l. wrist.  Borders are erythematous and indurated.  No other similar lesions.

KOH scraping was negative.

Dx: Presumptive diagnosis is Majocci Granuloma.

Plan:
Fungal culture taken.
Started on betamethasome disproprionate/clotrimazole cream b.i.d. for two weeks only.
Follow-up visit scheduled for two weeks.
Low threshold for biopsy if culture negative and if he is not doing well.
Switch to ketoconazole 2% cream; consider oral terbinafine.

Reference:

Treatment-Resistant Plaque on the Thigh  (Free Full Text)

Collins MA, Lloyd R. Am Fam Physician. 2011 Mar 15;83(6):753-754.

Giant Molluscum

Presented by Henry Foong
Ipoh, Malaysia

The patient is a one year old child with a four week history of a giant molluscum on the lower eyelid. There are a few smaller papules on the trunk; but the solitary lesion pictured below is therapeutically challenging. 

I tried to curette it but was unsuccessful as the child was very fretful.

What suggestions do you have any other method of removing this?

There are many clinical reports of giant molluscum associated with HIV.  Would you test this child for that?

Your suggestions will be helpful.

Eccrine Hidrocystoma (Dermatoscopic Image)

The patient is a 21 year-old woman who has noticed a blue-purple papule on the bulb of the nose for two to three months.  If traumatized, it extrudes a clear fluid.

O/E:  There is a two mm in diameter bluish papule on the nose.  It was punctured with a # 11 blade and a drop of crystal clear fluid was extruded.

Dermatoscopic image shows a blue papule with a dark center and a paler periphery.

Diagnosis:  Probable Eccrine Hidrocystoma.

Plan:  This could be excised with a 2-mm punch biopsy.  It could also be observed.

Reference:

A Bluish Pigmented Cystic Lesion of the Nose.

Kluger N, et.al. Acta Derm Venereol. 2010 Sep;90(5):555-6.

2 Year Old with Nail Dystrophy

The patient is a two year-old girl with a 6 - 12 month history of a nail dystrophy.  Her brother had a similar process but this cleared without therapy after a few months.  Her pediatrician has prescribed ketoconazole cream which was not effective after 1 - 2 months.

O/E:  All nails on the left foot and two nail of the right foot are lusterless and show horizontal ridges and oil-droplet changes.  There is mild onycholysis.  Her fingernails are normal.  No other skin changes.

Clinical Photos:

The child was very apprehensive and for that  reason I did not do a KOH prep.

Diagnosis: In the differential diagnosis I included onychomycosis, evolving 20 Nail Distrophy and psoriasis.  I will see her back in 2 - 3 months. If there is no improvement, KOH prep will be performed.  I need to ask if either patent or sibling has a nail dystrophy.

Black Heel

The patient is a 17 year-old boy with a 6 month history of a black area on the heel of the right foot.  This began after wearing a new pair of soccer cleats.  He developed a blisters and has believed that this is from "astroturf" embedded in his skin.

O/E: A localized uniformly black area on the heel of the right foot.

Here is the dermatoscopic image.

This is most likely black heel aka "talon noir."  The dermatoscopic photo was taken after paring down the keratin and shows black globules.  I should have applied some peroxide to dissolve the hemoglobin.  Will ask the patient to do so.

Foreign body secondary to astroturf has not been reported, and this looks like black heel.  There are no good dermatoscopic images on PubMed.

Reference:

Black heel, talon noir or calcaneal petechiae?

Urbina F1, León L, Sudy E. Australas J Dermatol. 2008 Aug;49(3):148-51.

Abstract:  We describe a series of six patients with superficial cutaneous haemorrhages of the feet, including a classical case of black heel (talon noir) and other similar cases with diverse clinical presentations that do not match the typical description of that process. The main differences lay in production mechanism, morphology and location. The causes of these 'atypical' lesions were: burns with hot sand, friction against the rough edge of a swimming pool, wearing new shoes, jogging, or pricking a blister with a needle. Clinically, they consisted of isolated or multiple, small, large or linear, brown or black lesions located in areas that did not include the convex part of the heel, in which talon noir usually appears; on the contrary, the lesions affected the back third of the soles, the toes, periungual fold and plantar arch. As the presence of blood in the horny layer was a common final factor in all these cases, a better name for this process would be 'post-traumatic cutaneous intracorneal blood' to describe black heel and its diverse clinical presentations.

Scalp Burn Post-Beauty Parlor Visit

Abstract: 54 yo woman with localized hair loss after a visit to the beauty parlor

HPI: The patient is a 54-year-old woman who was seen for evaluation of a localized hair loss and dermatitis of the scalp since she had her hair roots bleached 4 – 5 weeks ago.

She notes that the roots of her hair were left exposed to the chemical for about 4 hours after application.  On a next morning, her scalp was sore and burning, and somewhat swollen throughout the day. She was seen at ER  for evaluation that night and told that her scalp was probably burnt by the hair product; and was advised to wash her hair with cool water and was given a topical medication to apply, the name of which she cannot recall today. She has been using icepack and the medication that was given from ER, which helped. She has noticed that her hair was falling out in the mid parietal area since a few days after the insult.. She was reevaluated by her primary care physician two weeks ago for dryness and pruritus of the scalp and was prescribed another topical medication but does not remember the name.

Past medical history reveals bariatric surgery in  four years ago and had an episode of transient hair loss thereafter. She has been using hair products from the same store, JCP salon, since the episode, and has not had any problems until this recent hair dye/bleach treatment. She washes her hair once weekly, and takes multiple vitamins (including biotin) for her health in general.

The patient is quite upset, angry and tearful about the situation. Currently, she is seeing a therapist for the stress. She fears that the condition will be permanent.

O/E: The skin exam shows a healthy but distraught woman with a well-defined 9.5 x 1.3 cm alopecic patch with many scattered black short broken hairs on the mid parietal scalp to vertex region. There is mild erythema on the involved scalp without evidence of atrophy or cicatrix. Her roots of the surrounding hair are dark brown to blackish about 1 cm from the root.

Clinical Photos:

Impression: Irritant dermatitis with alopecia secondary to her recent hair dye/bleach process

Plan: We had a lengthy discussion of her recent hair damage. This is likely irritant dermatitis most likely secondary to the hair dye/bleach. There is no evidence of scarring today, and her hair will likely grow back although it will take some time. We reassured the patient that we will support her while she is recovering from the recent trauma. 

Follow-up Photo: Around 7 months after chemical burn.

Marked improvement, but patient still feels traumatized.

References:

1. Hair highlights and severe acute irritant dermatitis ("burn") of the scalp. Chan HP, Maibach HI. Cutan Ocul Toxicol. 2010 Dec;29(4):229-33. PubMed

2. Chemical burns to the scalp from hair bleach and dye.  Jensen CD, Sosted H.  Acta Derm Venereol. 2006;86(5):461-2.  Free Full Text

3. The hair color-highlighting burn: a unique burn injury.

Peters W. J Burn Care Rehabil. 2000 Mar-Apr;21(2):96-8.

Abstract: A unique, preventable, 2.8 x 3.7-cm, full-thickness scalp burn resulted after a woman underwent a professional color-highlighting procedure at a hair salon. The burn appeared to result from scalp contact with aluminum foil that had been overheated by a hair dryer during the procedure. The wound required debridement and skin grafting and 3 subsequent serial excisions to eliminate the resulting area of burn scar alopecia. The preventive aspects of this injury are discussed.

4.  Curling iron-related injuries presenting to U.S. emergency departments.

Qazi K et. al. Acad Emerg Med. 2001 Apr;8(4):395-7. PubMed.

FTM Transgender Alopecia?

This is the history of a ftm transgendered man with relatively early androgenetic alopecia.  In spite of his exogenous testosterone, the frontal hairline is preserved.  Most of the alopecia is in parietal and vertex areas.  There is only one PubMed reference that is pertinent, and that is not available full text.(1)

I am a ftm Transman. I started my transition December 2013 and have been on testosterone for about 1 year and  4 months. My resources are limited. I have been a queer female all my life, and as a result of this, economically marginal. I am very serious about my transition to male,. I realize that gender is a fluid spectrum and that I am not yet sure how I will finally present as male.

I have just turned 60 years old, though I look about 20 years younger. I have been very athletic and have always eaten healthfully and have taken care of myself.  Perhaps this is because, subconsciously, I knew that I would have to venture into gender transition at some point, and thus prepared myself.

I am a musician and performer with disabling social anxieties and gender dysphoria. This has severely hampered my ability to perform. My appearance, as an artist, and someone who must go before the public, is a critical issue for me. My biggest problem with transition at present is that I am beginning to bald on the vertex of my head. If this continues unabated, I will wind up with the typical horseshoe pate of male pattern balding.

None of the men in my family, on either side, have this type of balding. Yes they have receding hairlines on my father's side. Thus, I do think my particular balding (and its rapidity) is impacted greatly by the effect of the testosterone. This is a very disturbing and unwanted consequence of testosterone injections. In general, I want to use testosterone for my transition,  but I do not want to be used by testosterone. I don't accept the assessment, “well at your age, men bald.” That does not fly with me. I want to know what my options are proactively.  I have done extensive research on the Internet in regards to balding. I have spent a lot of money trying a number of natural DHT blockers. The problem with this, as with Propecia, is that they work by consequence of increasing female hormones, which is unwanted in ftm transition, and also, block facial hair, a secondary sexual characteristic very important for most trans guys. Secondly, it is not even clear that they work to prevent balding.

Presently, I have started to use Rogaine 5% foam (just this week, so the jury is out).  Currently, I am switching my health care to a clinic that specializes in transgenders individuals. That way, I can also evaluate my balding in terms of testosterone levels. The endocrinologist I see presently is not skilled enough in this regard.

I am extremely interested in any research or techniques that can be offered to me to prevent my balding and turn it around. I am doing all I can on my own at present, but feel there are other options and knowledge out there to which I haven't access.

I am not out to my family yet regarding my transition to male. My appearance, and the quality of my appearance is very personally important to my journey as a man and to my profession as a public performer. I need to continue to be healthy, and to look good.  I want to cure my gender dysphoria so that I can have a life. I do not want to create more obstacles blocking my success in life.

It has been a difficult journey! And, I am willing to do all I can. Unfortunately, I am not in an economic position to do all I could otherwise. I do not want this to be a limitation to my successful transition.  Thus, I am seeking all the support and help I can possibly get in relation to a truly successful transition, unlimited by my financial circumstances. I cannot adequately express my gratitude for any help on this challenging crossing.  Any benefit I receive in these ways are not only for myself, but will be knowledge freely disseminated, for the use of all transmen now and in the future.

Reference:
1) Short- and long-term clinical skin effects of testosterone treatment in trans men. Wierckx K, et al.  J Sex Med. 2014 Jan;11(1):222-9.

Testosterone (T) treatment increased facial and body hair in a time-dependent manner. The prevalence and severity of acne in the majority of trans men peaked 6 months after beginning T therapy. Severe skin problems were absent after short- and long-term T treatment. PubMed.

Darkness Visable: A Worrisome Image

Abstract: 75 yo man with an ominous lesion on his back

HPI: The patient is a 75 year-old man who rarely sees physicians.  His wife noticed a large number of lesions on his back.  His son had a melanoma of an upper eye-lid.  The patient has never had a skin cancer. His wife had some 5 fluorouracil cream that was over 10 years old and had applied it for a few weeks to the large lesion on his back.

O/E:  His back reminds one of Van Gogh's Starry Night."  Amidst the constellations of starry lesions, one lonely planet stands out.  It is 2.5 cm in diameter.

Clinical Photos: (all images taken by Dr. Yoon Cohen with an iPhone 6)

Dermatoscopic Images:

Diagnosis:  Probably Melanoma.  Presentation may have been modified by 5FU Cream.

The biopsy showed no evidence of malignancy.  Six weeks later, we saw the patient in follow-up.  The lesion looked a bit less worrisome,  A large incisional biopsy was taken. Findings will be reported when pathology is ready.

Plan: Waiting for reading of second biopsy.

We welcome any comments and diagnostic thoughts.

72 yo man with malaise, rash and leucopenia

Presented by Hamish Dunwoodie
Moncton, New Brunswick

Abstract:  72 yo man with two weeks of malaise, 5 days of rash and low wbc

HPI:  The patient lives in rural New Brunswick and is an avid outdoors man who hikes weekly year-round. He noted the onset of malaise and decreased exercise tolerance ~ two weeks ago.  He'd been seen by his G.P., E.R. doctors, and a urologist.  A blood count was done ~ two weeks ago at the E.R. and he was told it his white cells were low, but that he probably had a viral infection.  He developed a rash ~ 5 days ago and sent photos to our New Brunswick teledermatoloy service. 

O/E:  The rash is mostly on his torso. There are 1 - 3 cm erythematous plaques on his torso, some with central clearing.

Clinical Photos:

Lab:  20.3.15  White count: 1600, other parameters normal, save for slight shift to the left. Lyme and anaplasmosis titers have been drawn. Repeat CBC 22.3.15 WBC 1300 (PMN 53, Bands 1, Lym 34, Mono 10, EO 2), PLT 233.
Lyme and Ehrlichiosis titers were negative.  

Pathology:

Diagnosis:  Leucopnia.  In spite of negative Lyme and Ehrlichia serologies a co-infection with Lyme and Ehrlichia still needs to be considered.

Course:  Over the past week, the patient has felt a bit better and his rash has subsided. 

Comments:  The patient lives distant from dermatological and infectious disease specialists.  He was started on doxycycline pending traveling to Moncton, NB to be seen at our hospital centre.  The differential diagnosis is large, but in an outdoors man with leucopenia, malaise and a peculiar rash tick born infection or co-infection needs to be considered.  The rash looks more like secondary Lyme, but thelow wbc goes along with anaplasmosis. Co-infections have been reported.  He has been started on doxycycline 100 mg b.i.d. until he is seen.

What are your thoughts?  We will update this post as more information is collected.

Update:  The patient's wbc bottomed out at 610 before rising to normal levels over a two week period.  His Lyme and Ehrlichia titers were negative x 2.  His rash gradually cleared and he felt better.  We assume he had Ehrlichiosis with negative titers and possibly co-infection with Lyme, but he may have had another infectious process.

Dermatoscopic Dilemmas

The dermatoscope is a source of endless wonder.  Here are two cases seen in the past week.

1. Congenital Nevus of Special Site

This 5 month old bi-racial (Black/Caucasian) foster infant was noted to have a slowly enlarging pigmented lesion in his left crural fold since around one month of age.

photo taken by Dr. Yoon Cohen

Question/Comment: Would anyone do anything other than follow this child?  Is the gray veil significant? The symmetrically distributed brown clods are to my mind markers for a benign growing nevus (cobblestone pattern).  There is no pertinent literature about growth in small congenital nevi.  Melanoma, in this age group and ethnicity, is exceedingly rare.

2. Unusual Subungual Hematoma

A 72 yo woman noted nail pigmentation that appeared shortly after knee replacement surgery.  I do not know if she had been anticoagulated after surgery, but the information would help.  The subungual color under the cuticle may be an example of a "pseudo-Hutchinson sign."

1 month follow-up

Note:  The one month follow-up shows distal progression of pigmented area confirming the clinical impression of subungual hematoma.

Question/Comment: The fact that this appeared shortly after surgery strongly suggests trauma rather than neoplasia.  If the patient was anticoagulated during surgery, that would be one more helpful historical fact.  The pattern of the long band could be called the "tadpole sign" -- I wonder if it is specific for subungual hematoma.

References:
1. Precursors to melanoma and their mimics: nevi of special sites.

Elder DE. Precursors to melanoma and their mimics: nevi of special sites. Mod Pathol. 2006 Feb;19 Suppl 2:S4-20.  Free Full Text.

2. Dermnet.nz.org has good sections on dermtoscopy: Introduction to Dermatoscopy   Dermatoscopic Features 

3. Overview of Nail Dermatoscopy

Hot Spots Programs 2015

Please save the dates for one or both of our 2015 Hot Spots programs.   

1. Hot Spots 2.0  June 6 - 7, West Vancouver British Columbia
This is a weekend conference that is being held just before the World Congress of Dermatology meeting in Vancouver that starts on June 8.  We will  gather in West Vancouver for a meeting free from the trappings of the Medical-Industrial-Academic complex.

2. Hot Spots in Dermatology August 21 - 23, 2015, Turtle Bay, Kahuku, Oahu, Hawaii
This annual conference was inaugurated in 1987, and has been evolving ever since. Presently it has become an ohana.    




Most of the pertinent material is on our Hot Spots websites.

Hot Spots 2.0 West Vancouver, British Columbia

Hot Spots Hawaii Turtle Bay, Oahu

Either of these programs will be both personally and professionally rewarding.  Please try to join us!

Overview of Nail Dermoscopy

This is a valuable reference on nail dermoscopy. It is available free full text online.

Haenssle HA et al. When all you have is a dermatoscope-start looking at the nails. Dermatol Pract Concept. 2014 Oct 31;4(4):11-20.

Benign Congeniytal Acral Nevus

Abstract: Pigmented and non-pigmented nail alterations are a frequent challenge for dermatologists. A profound knowledge of clinical and dermatoscopic features of nail disorders is crucial because a range of differential diagnoses and even potentially life-threatening diseases are possible underlying causes. Nail matrix melanocytes of unaffected individuals are in a dormant state, and, therefore, fingernails and toenails physiologically are non-pigmented. The formation of continuous, longitudinal pigmented streaks (longitudinal melanonychia) may either be caused by a benign activation of matrix melanocytes (e.g., as a result of trauma, inflammation, or adverse drug reactions) or by a true melanocytic proliferation (e.g., in a nevus or melanoma). In general, non-continuous nail alterations, affecting only limited parts of the nail apparatus, are most frequently of non-melanocytic origin. Important and common differential diagnoses in these cases are subungual hemorrhage or onychomycosis. In addition, foreign bodies, bacterial infections, traumatic injuries, or artificial discolorations of the nail unit may less frequently cause non-continuous nail alterations. Many systemic diseases that may also show involvement of the nails (e.g., psoriasis, atopic dermatitis, lichen planus, alopecia areata) tend to induce alterations in numerous if not all nails of the hands and feet. A similar extensive and generalized alteration of nails has been reported after treatment with a number of systemic drugs, especially antibiotics and cytostatics. Benign or malignant neoplasms that may also affect the nail unit include glomus tumor, Bowen's disease, squamous cell carcinoma, and rare collision tumors. This review aims to assist clinicians in correctly evaluating and diagnosing nail disorders with the help of dermatoscopy.

Contact Dermatitis Rebound

A 35 year-old woman was seen for a dermatitis on her left arm. She has a history of severe reactions to poison ivy.   Five months ago, she developed an extensive contact dermatitis of her arms and torso that was felt to be secondary to poison ivy.  At the time, she was in the early third trimester of pregnancy and did not wish to use any topical steroids.  The process was mostly resolved when she gave birth around two months ago.  

It was still visible and only slightly itchy over torso and arms at parturition. The dermatitis on her arms flared up about a week after her son's birth and has been present, and symptomatic, for almost two months now.  By history, it may be slowly be resolving.

Question: Has anyone heard of a recall dermatitis associated with allergic contact dermatitis? Alternatively, this may be a rebound contact dermatitis associated with post-partum changes in the immune system. There are no pertinent references in PubMed.

Reference:

Ohtaki N, et. al. Delayed flare-up reactions caused by jellyfish. Dermatologica. 1986;172(2):98-103.
Abstract: Four patients had a recurrence of cutaneous lesions 1 week after being stung by jellyfish. Three patients had flare-up lesions after only one exposure to jellyfish. All of the recurring lesions were vesicular erythema, and the histological findings of case 3 corresponded to that of allergic contact dermatitis. [This is not all that similar; but it is of interest.]