Tuesday, February 06, 2024

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.


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.

Friday, February 02, 2024

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.



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

Sunday, December 31, 2023

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.

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.


Thursday, November 30, 2023

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.


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

Monday, September 25, 2023

A Case for Palliative Dermatology

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.

The tumor was debulked, cultured and a Xeroform dressing applied.  Her daughter-in-law was instructed how to change the dressings.

Post-op appearance:

Pathology showed a moderately differentiated squamous cell carcinoma extending to the base of the specimen.

Her family wants to do as little as possible with the goal of supporting her quality of life.

Palliative care in dermatology has only recently  been getting attention.  

Some options for this woman include
1. Intralesional 5 Fluorouracil or topical 5FU
2. Short Course Radiotherapy (1)
3. Palliative Mohs surgery (2)

Note: On 10.6.23 the patient had micrographic surgery.  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.
Clinical photo 1 week afte4r Mohs micrographic surgery:

 Your thoughts will be helpful.

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.

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.
Br. J Radiol. 2022 Jun 1;95(1134):20211347.

2. Noriaki Nakai et al. 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. J Dermatol. 2015 Apr;42(4):405-7.

3.  Leah L Thompson et. al. Palliative care in dermatology: A clinical primer, review of the literature, and needs assessment. J Am Acad Dermatol. 2021 Sep;85(3):708-717. J Am Acad Dermatol. 2021 Sep;85(3):708-717.

4. Fidanzi C, Davini G, Dini V, et al. Palliative management of a recurrent destructive cutaneous squamous cell carcinoma of the scalp with brain exposure. Wounds. 2022;34(1):E7-E9. PMID 35119380
(Full Text)


Friday, September 01, 2023


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.  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.

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.

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.

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:

    When thou arte callde at anye time,
    A patient to see:
    And dost perceave the cure to grate,
    And ponderous for thee:

    See that thou laye disdeyne aside,
    And pryde of thyne own skyll:
    And think no shame counsell to take,
    But rather wyth good wyll.

    Get one or two of experte men,
    To helpe thee in that neede;
    To make them partakers wyth thee
    In that work to procede....

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.

Thursday, August 31, 2023

Dodging Scalpels

Presented by:
Dorinda Johnstone, M.D., Dermatologist
Scottsdale, Arizona

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.
The pathologist reported a superficial squamous cell carcinoma and the patient was scheduled for excision by the mid-level professional’s plastic surgeon employer.
The patient was anxious about the surgery and sought the opinion of a DJ, a dermatologist she had seen in the past.

"x" marks center of the lesion that was biopsied

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.

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.

Take a messages:
1. Some mid-level providers working for high-volume surgical and dermatology practices serve as feeders for big-ticket procedures to their employers.
2. These surgeons and dermatologists rarely question biopsy reports.
3. It can be important to have the pathology reviewed by a board certified dermatopathologist.
4. The dermatologist who saw this patient tries to apply a palliative approach to elderly patients to spare them unnecessary procedures.
5. As long as we have fee-for-service medical care this kind of comedy will continue to happen.