Iatrogenic Striae

A 17 year old boy was seen by his pediatrician for a crural rash.
He was prescribed Clotrimazole/betamethasone diproprionate cream to use b.i.d for three weeks. At the end of that time, he called his doctor and said he still had the rash. He relates that he was told to continue for another three weeks.



Shortly thereafter, he noticed a discoloration in his groin and some tingling and erythema of the scrotum. The exam showed striae in crural folds and perhaps mild scrotal erythema.

Photo courtesy of DermNet

I see a few cases of striae secondary to this combination cream each year. The medication seems to have more risks than benefits. It should probably not be used for more than a week in groin or axillae. I have also occasionally encountered men with painful burning scrotums secondary to potent topical steroids (including this combination) and suspect that "scrotodynia" can be caused in this manner. This patient has mild symptoms scrotodynia, but I suspect they will resolve.

Here is a pertinent reference:
Clotrimazole/betamethasone diproprionate: a review of costs and complications in the treatment of common cutaneous fungal infections.

Greenberg HL, Shwayder TA, Bieszk N, Fivenson DP.

Pediatr Dermatol. 2002 Jan-Feb;19(1):78-81.


The use of antifungal/corticosteroid combinations as topical therapy for dermatophytoses has been criticized as being less effective, more expensive, and the cause of more adverse cutaneous reactions than antifungal monotherapy. The combination of clotrimazole and betamethasone diproprionate (Lotrisone) is a mix of an azole antifungal and a high-potency corticosteroid, and is one of the most widely prescribed of these combinations. Our objective was to describe the beneficial and deleterious effects of Lotrisone in the treatment of common cutaneous fungal infections and its relative cost-effectiveness. We did a literature review documenting clinical trial data and adverse reactions to Lotrisone and collected a cost analysis of topical antifungal prescribing data over a 2-month period from a large midwestern staff-model health maintenance organization (HMO). Lotrisone is approved by the U.S. Food and Drug Administration (FDA) for the treatment of tinea pedis, tinea cruris, and tinea corporis in adults and children more than 12 years of age. Treatment is limited to 2 weeks in the groin area and 4 weeks on the feet. The most concerning adverse effects of Lotrisone were reported in children and included treatment failure, striae distensae, hirsuitism, and growth retardation. This combination was also reported to have decreased efficacy in clearing candidal and Trichophyton infections as compared to single-agent antifungals. Lotrisone was considerably more expensive than clotrimazole alone and was found to account for more than 50% of topical antifungal expenditures as prescribed by primary care physicians, but only 7% of topical antifungals prescribed by dermatologists. We found that Lotrisone was shown to have the potential to induce many steroid-related side effects and to be less cost effective than antifungal monotherapy. This combination should be used judiciously in the treatment of cutaneous fungal infections and may not be appropriate for use in children.

The Mask

6/15/07


Every day one sees something unique: either a new disorder or a singular variant of common process. A 90 yo woman was seen yesterday 3 - 4 week after the onset of Herpes zoster of the second division of the trigeminal nerve. She was left with an impressive escar covering a large portion of the dermatome. It was relatively easy to debride most of the escar off. No anesthesia was necessary. I'll affix a follow-up photo when I see her back. Follow-up care was with cool compresses and Silvadene cream.

This woman lives alone, drives her own car and is the family matriarch. Hopefully, the zoster will not derail her.

The above photo is a bit out of focus. My fault.


6/18/07

Same Patient -- Three days later. Note involvement of nasal tip. 2nd branch of trigeminal but with nasal tip involvement (and patient had sorneal ulcer!) indicating perhaps involvement of nasociliary branch of trigeminal (which should not happen) -- aberrant innvervation? She seems much brighter today and not complaining of much pain.

Six Weeks Later
7/27/07

The patient's skin has healed nicely but she has persistent numbness around left ala and left naso-labial fold. Also lancinating episodic pain and resultant depression. A neurologist has put her on Neurontin which I do not feel is helpful. Post-herpetic neuralgia is a complex disorder and I think there's a huge "illness behavior" component. I don't think pharmacotherapy is the answer. Nonetheless, I gave her EMLA cream to use.

Case for Diagnosis

Presented by Choon Siew Eng FRCP, Johor Bahru, Malaysia.

46 years old woman with 3-year history of gradually enlarging asymptomatic indurated plaques on her neck, both axillae right side of abdomen, right groin and lower back. She is otherwise well with good general health. There was no significant family history.

Physical examination revealed multiple indurated erythematous to hyperpigmented plaques on right side of her neck, right flank, both groins and axillae. The overlying skin is atrophic with brownish adherent scales.
There were multiple groups of hyperpigmented papules on abdomen, upper thighs and legs. Some papules appeared yellowish. Palms, soles, nails, scalp and mucosae are spared.

I am thinking of treating her as sarcoidosis since she is distressed by her extensive lesions
Differential Diagnoses: Nodular amyloidosis, Scleromyxoedema, Morphoea, xanthogranuloma

Repeated blood tests such as full blood count,BUSE, LFT, thyroid functions, serum and urine calcium and autoimmune screening were normal. Her ESR was also normal . CXR was normal and Mantoux test was negative.Sputum for AFB X3 negative. Biopsy from abdominal lesion showed numerous granulomata composed of epithelioid histiocytes, lymphocytes and multinucleated giant cells, Langhan’s type. Special stains for Acid fast bacilli (ZN, Wade fite) and fungal bodies (PAS) were negative. No abnormal deposits of eosinophilic amorphous material seen. No foreign body seen by polarised light.

Case For Diagnosis

Presented by Dr. Amanda Oakley, Hamilton, New Zealand

A month ago, a 14-year old girl presented to the paediatricians with a fever, arthralgia and small purpuric and possibly target-like spots on her legs. She had been previously well and had taken no medications. After extensive negative investigation she was commenced on penicillin in case she had bacterial endocarditis, and was sent home.
She was readmitted yesterday with on-going fever and arthralgia, and crops of extremely painful plaques mainly affecting her face. Earlier lesions on her abdomen and limbs have resolved leaving marked hypo-hyperpigmentation or scarring. Biopsy of the plaque on her neck shows full thickness necrosis histologically with little inflammation. EM-like. Several new plaques have been observed to arise overnight despite an initial dose of prednisone 40mg. There is no mucosal involvement to date.
All tests so far negative - we are thinking up some more tests but we don't know the correct diagnosis. No other drugs as far as we can ascertain.
Has anyone seen anything like this? Is it erythema multiforme? Other possible diagnosis? Treatment?

Case for Diagnosis

The patient is a 54 yo woman with a 2 week history of a rash on the arms and chest. Two months ago, she had erythema nodosum with atypical features (on her legs). The work-up eventually discovered Crohn's disease. She was started on Asacol around a month ago and around 2 weeks ago developed erythematous papules on arms and anterior chest.

0/E: The new lesions are 6 - 8 mm in diameter erythematous papules with the suggestion of central punctae. The E.N. has resolved.

Lab: Representative lesions were biopied.

Question: What are your thoughts? We will post pathology in around a week.

Continuous Medical Education

VGRD and this VGRD Blog have been around for a number of years now. Both serve as forums at which dermatologists and other physicians can post and comment on interesting and challenging cases. Other sites such as the Skin Cancer Clinic blog out of Queensland, Australia serve a similar function and are better attended. We came across an article recently which lends credence to this activity and indicates that this interactive format may be a better way of providing continuing professional education than the lectures which we traditionally attend at conferences and hospital rounds.

The article appeared in The Journal of General Internal Medicine in 2004. Here are the particulars:

Toward Continuous Medical Education
Roni F Zeiger, MD
Gen Intern Med. 2005 January; 20(1): 91–94.
For full article click on PDF locate .pdf download access it.

While traditional continuing medical education (CME) courses increase participants' knowledge, they have minimal impact on the more relevant end points of physician behavior and patient outcomes. The interactive potential of online CME and its flexibility in time and place offer potential improvements over traditional CME. However, more emphasis should be placed on continuing education that occurs when clinicians search for answers to questions that arise in clinical practice, instead of that which occurs at an arbitrary time designated for CME. The use of learning portfolios and informationists can be integrated with self-directed CME to help foster a culture of lifelong learning.

Thorny, Horny Dilemma

Ian McColl from Queensland, Australia, is presenting a five year-old girl for opinions. He doesn't have much information at this time. We will present her case formally on VGRD in a week or two, but I know he'd appreciate rapid responses at this time, too.

Ian writes:
"She had been seen elsewhere for treatment of her "severe psoriasis" which she had for the last two years. Clinically this is chronic mucocutaneous candidiasis. There is no family history. She has had vaginal candidiasis before and UTIs. She is otherwise well. She did have shotty glands in neck, groin and axillae.

Has anyone had recent experience of treating a case? Ketoconazole orally ? toxicity? Fluconazole orally? How long for? Best wishes, Ian."

Case from Inuvik

From Alex Wong, PGY II Internal Medicine, UAB, Calgary:
I'm currently on a rotation up in the Northwest Territories and I just came back from a three-day travel clinic in Inuvik. We were asked to consult on a 40 yo woman who essentially has wide-spread rash. Was wondering whether you guys had any ideas.
Hx and O.E: Sudden-onset maculopapular pruritic rash on the trunk (both front + back) and upper extremities including hands, no obvious triggers or contacts according to the GP. Tried steroid cream + Benadryl with no effect, used Prednisone and cleared almost immediately. Took the Prednisone away and immediately came back, so restarted the Prednisone a second time and tried to taper off slowly this time... again, when Prednisone was taken away, rash came back (although during taper apparently she didn't have any symptoms.
Biopsy:They got a skin biopsy, and unfortunately don't remember the exact details of the biopsy (sorry), except that it raised the possibility of SLE.
Lab: GP did ANA, which was positive. Subsequently did C3/C4 + dsDNA, which were negative.
Steroids being slow-tapered again, and she had no rash when I saw her yesterday afternoon. She works on/off as hotel housekeeper, but insists no new contacts / cleaning products.
Your thoughts would be greatly appreciated.

'Tis the Season

A 78 yo man with a history of non-melanoma skin cancer presented today for a general skin exam: a six month check-up. It is high spring now and everyone is outdoors doing something. On his left mid-back I spied this unusual "tumor." The patient was unaware of it. He was pruning apple trees two days ago.



If he hadn't come in for a routine exam, who knows when this would have been discovered.

I pulled the tick out with forceps, gave him 200 mg of doxycycline to take and will see him back as necessary.

Strange and stranger. What some call an "incidentaloma."

Positive Band Aid Sign

Most of us use the term "Positive Band Aid Sign." Let's call it PBAS
PUBMED has no articles on this entity and Google only had one or two hits.

I've seen three PBASs in the past week. What do you think of them? What lesions would you guess underlie the bandaids.


1. 72 yo woman with one month history of a lesion on upper lip



















2. 22 yo woman with 3 month history of lesion on arm
















3, 93 yo woman with one month history of lesion on arm

Palm Pense-Bête

You may remember La Maladie du Petit Papier which was reported here on January 27th. Today, Twentysomething Generation's equivalent emerged.

I propose calling it: La Maladie du Palm Pense-Bête. This was brought in by a 24 yo woman. Will the ingenuity of our patients never cease? "O brave new world [electronic]!"

Dermatomyositis -- New York Times

An interesting article appeared in the New York Times today on myositis. It is well-written and researched. You will benefit from and also enjoy perusing it. In addition, your patients will read it and may bring it to your attention.

March 27, 2007
An Elusive Diagnosis, and One That Comes With a Risk of Cancer

By RONI CARYN RABIN

To read the article click on Permalink

Is Treatment Worse Than Disease?

The patient is a 48 yo woman with many actinic keratoses on face and chest. After discussing therapeutic options, she elected to use fluouracil cream. She was started on nightly 5% 5FU cream and at two weeks was noted to have a moderate inflammatory response. The 5FU was continued. By 23 days, I got an email indicating that she wasn't sleeping and was very concerned. I had her come in and the pictures speak for themselves.

I stopped the 5FU, placed her on cold compresses b.i.d. and desonide cream. Ambien 5 mg was given for sleep since she had not slept well for 4-5 nights and requested a soporific.






















1) What would you have done differently?
2) Is this a good argument for PDT?

One Year Follow-up

The patient still does not feel she is perfect. However, her skin looks great and she has virtually no AKs.

Your comments will be appreciated.

Dave Elpern

Infant with Scalp Mass

The patient is a twenty-week-old infant with a scalp mass present for 2-3 months. It appears to be growing slowly. He was seven weeks premature; but otherwise all milestones have been normal. He had a type one intracranial bleed post partum but it was not complicated. He did have scalp vein IVs whilst in hospital, but it's unclear where they were.

The examination shows a 4x2.5 cm in diameter freely movable mass on the left parietal area. It feels firm. Skin and hair normal over it (in the photo it the hair looks a bit sparser over the lesion). Ultrasound was done and was interpreted as normal.



The mass looks benign. Do you have any suggestions about what this might represent and what to do at this point? Skull x-ray and CT may be indicated, however, I thought I'd get some opinions first.

Case from Cambodia

These photos were sent to Dr. Doug Johnson from Cambodia without any information.
It's sad to think that adequate medical care could have likely prevented most of this.
Your comments are welcome.

The Case of the Maltese Cur

A 69-year-old woman presented with a six-month history of a lesion on the bulb of the nose. This began after her Maltese dog scratched her on the nose and the area has never healed. She used mupirocin ointment without relief, in addition.

EXAMINATION: The examination shows a light-complected Caucasian. She has an irregular 1 cm in diameter crusted area on the bulb of the nose.

Pathology: A shave biopsy was taken for diagnostic purposes. This showed an infiltrating BCC. The photomicrographs were taken by Dr. Jag Bhawan, SkinPath at Boston University School of medicine.




4x













10x








20x








Plan: I will recommend micrographic surgery.

Question: I hear this story frequently. My cat, dog, grandkid scratched me on my nose, cheek, etc. and it didn't heal properly. I assume it's just chance -- but what do you think. Should she put the dog down? What would PETA say?

Fascinoma

Every day one sees something one never encountered before.
Here's a diagnostic and perhaps therapeutic challenge.

This well-nourished, alert, well-oriented 82 yo woman presents with a six month history of an erosive dermatitis of the perirectal and vaginal area. Over the past year she has had pathological fractures of both femurs and a history of herpes zoster (not cofirmed). Remarkably, she has put up with these erosions which are apparently not that painful.

O/E: Sharply marginated clean erosions around rectum and vagina. Similar lesions are found in skin folds (abdominal and under breasts). She has some oral ulcerations under her dentures and crusted lesions on the scalp. No vesicles or bullae seen or noted by other physicians.

Lab: At this time CBC normal. Antibodies for pemphigus and pemphigoid are negative.

Biopsies performed on Feb. 8, 2007 for H&E and DIF.

Who has seen a similar picture?

I am thinking about:
Pemphigus variant
Necrolytic migratory erythema
Acrodermatitis enteropathica

Will order zinc and glucagon levels if pathology is not helpful. Someone may have seen this picture before.

Updated February 16, 2007
Here's a follow-up on this patient...
Path: Shows:
Subepidermal blister with dense superficial and mid perivascular and interstitial mixed inflammatory cell infiltrate including lymphocytes, plasma cells, eosinophils , dermal edema, and papillary dermal fibrosis .
NOTE : These changes are non-diagnostic but suggestive of cicatricial pemphigoid in view of the immunofluorescence findings (see below).

See immunofluorescence results and note. (Photo by Jag Bhawan)
DIRECT IMMUNOFLUORESCENCE RESULTS : Linear "Immunostaining" was observed with IgG, IgA and intermittent with C3 at dermal epidermal junction and with C3 and IgA around blood vessels and appendages.
NOTE : These changes are non-diagnostic but consistent with cicatricial pemphigoid.

Putting this together, I suspect this is indeed an unusual variant of cicatricial pemphigoid. I have started her on prednisone 20 mg tid and tacrolimus ointment 0.1% (but insurance plans here do not always cover the ointment). A G6PD was ordered since I will probably use Dapson as well. I expect the management will be difficult.

February 22
Patient seen in f/u. To my surprise, there is early reepithelialization of perineal erosions. Oral erosions still prominent. I've lowered her prednisone to 20 mg bid -- awaiting G6PD results. Perhaps, the tacrolimus is helping. The comments havc been helpful.

Winter Itch

The Cold has finally hit us here in the Northeast. People are streaming into dermatology practices with "Winter Itch." This is an article from today's NY Times which should help our computer savvy patients.

Winter Itch

New York Times: Skin Deep Section  February 8, 2007

Feeling Parched? Itching Like Crazy? It Must Be Winter
By LAUREL NAVERSEN GERAGHTY

It gets worse as the winter drags on, and weeks of air that is too cold and heat that is too dry take their toll. Arms, thighs, knees, elbows and calves start looking like the surface of the moon: cracked, chalky and stretched. And then comes the itch.

Alexandra Lynner Gilbert, 25, an interior design assistant from Greenwich, Conn., said it has become so bad that she once begged a co-worker to trade sweaters because she needed cotton against her skin.

Allison Schwartz, 33, a graduate student from Brooklyn and self-proclaimed “queen of irrational rashes,” said she now wears only cashmere because any other wool makes her squirm.

Lisa Ziegler, 38, of Fresh Meadows, Queens, said after a hot shower she feels the urge to claw her skin.

And Lisa Henke, 32, of Seattle, said that it took a move from Washington to the drenched air of Washington State to make her skin problems go away.

“Winters in D.C. were horrible for me,” she wrote in an e-mail message. “My skin would become scaly and itchy and would require multiple latherings of lotion to keep from falling off.”

The lower temperatures, humidity-free air and layers of wool and other fabrics can leave skin irritated and uncomfortable.

“A good 25 percent of the population has some degree of winter itch, if not more,” said Dr. Julie Schaffer, an assistant professor of dermatology at New York University School of Medicine. “It’s common to the point where it’s almost a normal thing to have in the winter.”

For most people, it is just an annoyance. But those with conditions that cause itch, like psoriasis or eczema, can really suffer.

“Torturous is a good word for what some people experience,” said Dr. Jeffrey D. Bernhard, who wrote “Itch” (McGraw-Hill, 1994), a textbook.

“People may gouge at their skin, or they may rub and scratch till they bleed,” said Dr. Bernhard, a professor at the University of Massachusetts Medical School in Worcester and editor of the Journal of the American Academy of Dermatology. “Many people would rather put up with pain than itch.”

Dr. Bernhard said it is a lack of moisture that creates the problems. “You have a combination of exceptionally dry, cold air — which indoor heating makes even drier — overbathing and use of harsh soaps,” which can strip the skin of its moisture, he said. “At some point, the dry air will suck water out of your skin like a sponge.”

Without moisture, the skin hardens and flakes and begins to irritate the nerves closest to the surface. “When the outermost skin cells dry out, they have more ragged and sharp edges, and they may be stimulating those fine itch nerve endings in the skin,” Dr. Bernhard said.

In young people there is no difference in skin dryness across ethnicities, said Dr. Victoria Holloway Barbosa, who is the director of L’Oréal Institute for Ethnic Hair and Skin Research. But those who described themselves as African-American or Caucasian in skin studies tend to have increasingly dry skin with age and may be particularly vulnerable to itch later in life, she said. Those who identify themselves as Asian or Latino did not have similar complaints. Doctors said there is no magic cure for itch, but there are simple steps to diminish the problem.

Dr. Michael Tharp, the chairman of the dermatology department at Rush University Medical Center in Chicago, said it should be standard operating procedure “to shower not in hot water, but in lukewarm water.” The hotter the shower water, he said, the more moisture will be extracted from the skin.

He also recommended washing with a mild cleanser, “preferably a moisturizing body wash, which has lots of lipids, which could theoretically put oil into the skin and help repair the barrier functions.”

After stepping out of the shower, it’s good to apply cream or Vaseline within three minutes before the dampness can evaporate, a trick dermatologists call the “soak and smear” technique.

“The only way to rehydrate the stratum corneum” — the skin’s outermost layer — “is to trap it against the skin,” using a thick emollient, said Dr. Tharp, who is a consultant to Unilever, Novartis and other skin care and drug companies.

Dr. Barbosa said a humidifier, bath oil or over-the-counter hydrocortisone cream are other ways to treat dryness and itch.

Certain ingredients can ease the urge to scratch by interfering with the itch signal that travels from the skin to the brain. Creams containing menthol, for example, “actually stimulate the same nerve ending receptors that cold and touch stimulate, so they create another sensation that substitutes for itch,” which would relieve it somewhat, Dr. Bernhard said.

For people who experience nighttime itching that disrupts their sleep, an antihistamine like Benadryl may offer relief, said Dr. Alan R. Shalita, the chairman of dermatology at SUNY Downstate Medical Center, who does consulting, lecturing and research supervision for dermatology and cosmetics companies, including Allergan, Estée Lauder, and Galderma.

“A lot of people notice the itching more at night, because whatever their activities are during the day, it distracts them from feeling the itch,” Dr. Shalita said.

In most cases, the itch should just fade away. But when it persists or becomes more than a minor nuisance, a trip to the doctor becomes worthwhile, Dr. Bernhard said.

“At some point, a diagnosis has to be made, because it could be a sign of an underlying skin disease like eczema or psoriasis or hives, or even a kidney or liver problem,” he said.

A Common Entity

How many times have you experienced this?
The waiting room is full and a patient comes in, settles down comfortably and says, "I won't take up much of your time today, I see how busy you are. So I wrote down a few questions." Thus spake a healthy 55 year old man as he sat down and pulled out this post-it from his pocket. "La Maladie du Petit Papier," I thought with resignation.

PubMed has only five references to this entity we all know. The first in Italian from 1967. * We each have our own way of handling this. Some docs grab the list from the patient and say, ""Let's have a look at this." Others say, we'll deal with only three today; you choose." I usually let them read all of them and then proceed.

How do you handle this event? A couple of years ago there was a piece in the BMJ comparing the malady of the petit papier with the newly emerging la maladie du grand printout. The latter may be more common in the major cities of North America than elsewhere.

* Iandolo C. [The "petit papier" sign] [Article in Italian]
Policlinico [Prat]. 1967 Mar 6;74(10):321-8.

Mystery from Micronesia

We received this note from a physician in Hawaii. Your thoughts will be appreciated.

"Two years ago, I was shown photos of a severe skin condition which afflicted more than 80 persons on the tiny atoll of Satowan in Chuuk. Now, more than 100 persons on Satowan are affected and about 10 on the neighboring atoll of Lekinioch.

Affected persons develop thick, pink plaques, usually on the arms and legs – this appearance resulted in the nickname “Spam.” While the condition is not life-threatening, the people with the condition are sometimes ostracized and made to feel shame and embarrassment. Anecdotally, the plaques are more common in those who work or play outdoors (particularly taro farmers) and may sometimes occur following skin trauma.

The only treatment used on the plaques has been surgical debridement. Dr. Bosco Buliche who practices in Weno, the capital of Chuuk, has seen and photographed cases on Satowan. He has posted 5 cases on the Pacific Island Healthcare Project website (through TAMC), including one with biopsy results, which showed only nonspecific inflammation – we could transport only a fixed specimen, unfortunately. Opinions from various practitioners on the cause of the condition have run the gamut from “island psoriasis” to mycobacterial infection.

So, two years later, there is still no answer. It would be wonderful to find someone with the interest and resources to investigate the problem. Suggestions will be most welcome."

Clinical Photos: