Lentigo maligna

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

Photos taken after suture removal.

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

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

Diagnosis: Melanoma-in-situ, Lentigo maligna type

Question:  This is a very early lesion and surgical treatment may be overkill.  What are your thoughts re: imiquimod, vs. Mohs, vs. watchful waiting?

Squamous Cell Carcinoma Scalp

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

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

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

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

An Orphan Patient

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

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

Clinical Images

March 2024

Photos from 3 - 5 years ago sent by patient

Shoulder

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

Tentative Diagnosis:  Urticarial Vasculitis

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

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

 

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

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

Acne Scarring

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

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

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

Questions:

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

His previous dermatologist used intralesional triamcinalone without benefit.

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

Painful Leg Ulcer in an Octogenarian

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

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

12.12.23

1.27.24

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

Congenital Dystrophy of the Great Toe Nails

April 2022

 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.

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.

Diagnosis:  Congenital Dystrophy of the Great Toe Nails

This entity was well-described by PD Samman (1978):
"The condition is present at birth but in no case has there been a family history of a similar condition. The nail is seen to be of a dark colour, shorter than a normal nail and tends to be pointed."
Much has been learned since 1978, and the condition has been renamed as Congenital Malalignment of the Great Toenail (CMGT) (4).

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.

Follow-up December 2023

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.

On exam, both great toenails are thickened, discolored and there is onycholysis of the left great toenail.

Question: Do any of our readers have experience with children with similar problems.

Reference:
1. P.D.Samman.  Great toe nail dystrophy. Clinical and Experimental Dermatology (1978) 3, 8r.

2. Dawson TA. An inherited nail dystrophy principally affecting the great toe nails. Clin Exp Dermatol. 1979. PMID: 509763.
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.

3. Dawson TA. An inherited nail dystrophy principally affecting the great toe nails: further observations. Clin Exp Dermatol. 1982. PMID: 7127894
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
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,

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.  Full Text

5.  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.

 

Leg Ulcer

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.

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..

Clinical Photos:

Impression: Large venous leg ulcer.

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.

References:

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

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.

3. Chunhu Shi, et. al. Compression bandages or stockings versus no compression for treating venous leg ulcer.  Meta-AnalysisCochrane Database Systematic Reviews. 2021 Jul 26;7(7):CD013397. Free PMC article