Leg Ulcer in a Heart Transplant Patient

The patient is a 49 yo man with a one month history of a very painful leg ulcer.
He is 8 years s/p heart transplant.
His medications include: CsA, CellCept, Pred, Diltiazem, Ranitidine.
There was no history of trauma and no similar ulcers in the past. He works at a supermarket and is on his feet all day long at work.
This ulcer is periodically painful. He has had leg edema for over a year.

The examination shows an 8 mm in diameter ulcer with as slightly purulent surface and ragged edges.. The borders are grayish. The area surrounding the ulcer has 2+ pitting edema and is erythematous.



Bacterial culture shows only staph species
Peripheral pulses are present but weak.

No response to support stocking used for the past three weeks.

This is probably a venous ulcer, but it's a bit unusual for a 49 yo man. Diltiazem can cause edema.
The pain is out of proportion to what one would expect. I have known the patient for six years and he has not had pain like this before.

Please help with diagnostic and therapeutic suggestions.

Retroauricular Dermatitis

The patient is a 25 year old registered nurse with a few month history of a painful and pruritic process in the right retroauricular area. She also has mild scalp pruritus and some increased scaling of the scalp.

The exam shows a superficial erosion in the right retroauricular sulcus.



Bacterial Culture: Positive for Many Staph aureus - resistant to Pen and Erythro

Pt. Started on mupirocin cream

Note: She is an obstetrical nurse and has contact with newborns. Her staph infection is of potential import here.

Reference:
Marks MB, Gluck JC, Lavi E, Halem-Sinclair E.
J Am Acad Dermatol. 1981 May;4(5):519-22
An unsuspected sign of cutaneous allergy.
An eczematous eruption in the superior retroauricular areas of the scalp and often on the posterior aspects of the pinnas may be seen in about 30% of allergic children. The eruption is not generally noticed because the overhanging hair covers the affected areas. The dermatitis is seen mainly in those children afflicted with bronchial asthma, perennial allergic rhinitis, or both. A previous history of atopic or seborrheic dermatitis is, as a rule, not elicited.

Periocular Dermatitis

The patient is a 35 year old man who has had a right-sided eyelid dermatitis for around eight months. He was given a moderate strength topical steroid for this by his primary care physician and has been using it off and on since. When the process flares, he applies it again.

There are discrete erythematous papules around the upper and lower lids on the right side. The left eyelids are clear.

The clinical picture suggests a steroid-induced periocular acne.
Treatment: cold tap water compresses, doxycycline 100 mg. bid. Is there a role for tacrolimus ointment?

Affected Right Eye


Normal Left Eye


References:
1.
J Am Acad Dermatol. 1999 Sep;41(3 Pt 1):435-42.
Eyelid dermatitis to red face syndrome to cure: clinical experience in 100
cases.
Rapaport MJ, Rapaport V.

A retrospective review of all eyelid dermatitis patients seen over an 18-year
period revealed a large subgroup of patients who had, as the basis for their
ongoing problem, an addiction to the use of topical or systemic corticosteroids.
This group of 100 patients often sought many consultations with various
physicians. Unrelenting eyelid or facial dermatitis often resulted in the use of
increasing amounts of corticosteroids for longer periods of time. Soon the skin
became addicted. Once the work-up ruled out other causes, the remedy for the
problem was absolute total cessation of corticosteroid usage. This article
describes the typical history of the problem, the evaluation of these patients,
and the distinctive pattern of flaring erythema that ensued when the
corticosteroids were ceased. We stress the absolute necessity of total cessation
of corticosteroid use as the only treatment for corticosteroid addiction. We
also demonstrate that no additional therapy or further consultations were
necessary once remission was obtained after topical corticosteroid abuse was
stopped.

2.
West J Med. 2001 Jun;174(6):383-4.
"Tortured tube" sign.
Fowler KP, Elpern DJ.
Medical University of South Carolina Charleston, SC. Williamstown, MA, USA.
(This is available as full text - go to http://www.pubmed.gov find this article and you can see the full text version. This was a patient Dr. Fowler saw in my office 5 years ago.)

A Hunter in Deer Season

The Hunter as Hunted

[Your comments are welcomed]

This 72 year old man was deer hunting on December 2, 2006. He remembers sitting on a log for 45 minutes and feeling as if he was being bitten. Later that day, his hunting companion removed three ticks from him. He presented on Monday, December 5 for an evaluation. The picture is taken from his left hip. The tick was gently removed and photographed with a paper clip.





Since the tick was attached for around three days, I elected to treat the patient with doxycycline 100 mg. bid for 10 days. The tick was sent to the lab for identification. I may get serologies in a few weeks. ADDENDUM: The tick was identified as a deer tick, Ioxides dammini.

Rationale for Treatment (from www.emedicine.com)
Ten days of doxycycline seem innocuous enough.
Although most patients do not require treatment, consider tick bite prophylaxis on a case-by-case basis. Base the decision on the species of the tick, duration of attachment (degree of engorgement of the tick is a surrogate marker), geography (percentage of ticks infected where the bite took place), method of tick removal, anxiety level of patient, and pregnancy (lower threshold to treat pregnant women).
After performing this exercise in clinical decision-making, one may decide to treat a given patient with prophylactic antibiotics. In the studies mentioned previously, no patient in the treatment group (which received 10 d of antibiotic treatment) had the disease. Historically, if one were to choose to treat, 10 days of oral amoxicillin, doxycycline, or cefuroxime axetil would seem prudent, depending on patient factors such as age, allergy, and pregnancy.
In one of the most recent studies (2001), a single 200-mg dose of doxycycline was used for prophylaxis with excellent results.

Difficult BCC

From A.R. Pito
Norfolk Island, S.P.

A friend from Australia sent me this photo with the following note.
"A.R.: I just saw this 56 yo man with a two year history of a large ulcero-nodular plaque on his left temple. Biopsy is pending but this appears to be a morpheaform BCC. Assuming this is BCC, what would your therapeutic suggestions be.
Radiotherapy?
Mohs?
In our area, we do not have a specialized cutaneous radiation centre, but he could be sent to Sydney, I suspect."

Thank you for your suggestions. You can post here or send to oslerian@gmail.com. I will append the pathology when my colleague forwards it.

5 year old girl with perioral rash

This 5 year-old girl presents with a 5 month history of a dermatitis at angle of mouth and upper lip. There are areas of patchy erythema with scale and discrete acneiform papules. She has been treated with mupirocin cream, ketoconazole cream, and 1% HC cream. None of these have helped. She is not atopic, has no family history of atopy and is not a lip licker.
Althoug subtle, I think this is perioral dermatitis of childhood. Tetracycline is contraindicated. I wonder if systemic erythromycin would be helpful. Based on the literature, I started her on metronidazole cream and told her mother that this may take weeks to months to get better.
I would appreciate your suggestions.

A Patient from Ghana - Please comment

Anak VGRD members have been asked to comment on a 16 year old Ghanaian girl from a small village without any specialized medical care. In otherwise good health and of normal intelligence, since age two she has a history of small hyperpigmented papules on her face. The larger lesions on her forehead appeared over the last two years. She patient states that she doesn't manipulate any of the lesions and that they are asymptomatic. There has been no treatment. HIV status and family history are unknown. This unfortunate young woman feels like an outcast because of these lesions.

We welcome you thoughts and advice. There are medical students in her community who could perhaps perform diagnostic testing if needed.

? Segmental Neurofibromatosis

The patient is a three year-old girl with 2 cafe au lait spots on right arm and chest since she was a few months old and many small "freckles" on right chest and axilla (see photo). There are a few freckles on the right upper back as well. No pigmented lesions on any other area. Have not looked for Lisch nodules yet.

Athough it may be too early to tell, I suspect this is segmental neurofibromatosis. Most cases of segmental NF are diagnosed because of tumors. There are probably some that only manifest as CLS or freckling. Of course, we will have to wait years in this case to see what develops.

Does anyone have ideas as to wha to tell the parents?

BCC of Eyelid

This is a 75 yo man who came in for an unrelated problem.
This tumor was obvioius, however.
Two years ago, and ENT physician told him he had a "blocked duct."
This 6 mm in diameter lesion looks like a BCC.
I propose to excise it but am worried about pulling down the lower lid.
I don't think C&E or Aldara would be appropriate. Mohs might be overkill.
Do you have any comments? I would, oif course, try to undermine the tissue.

84 yo Man with Atrophie Blanche

The patient is an 84 yo man with a ten year history of extremely painful ulcerations of his lower legs.
Other than whirlpool baths, I have found nothing to be of value.
His health is good and he has bounding dorsalis pedis and posterial tibial pulses.
I assume this is Atrophie Blanche.
Do you have any therapeutic suggestoins?

Localized Hyperkeratosis

39 yo man with > 15 year hx of localized hyperkeratosis of right great toe. No unusual trauma to area. He's used mostly over the counter emollients without much help.

Are you aware of any localized forms of hyperkeratosis?

I have started him on Salex cream.

Pictured below are his affected right and normal left great toes.

Recent Onset Acne in Young Woman

This 21 yo woman experienced the sudden onset of acne one month ago.
No new med. No unusual stresses.
She has never had acne like this before.

Do you think this is a mild case of pyoderma faciale rather than typical acne?

BCC Scalp

The patient is a 75 yo man with a three month hisory of a lesion at the vertex of the scalp.
Exam: Man with Type II - III skin. 2 x 1.6 cm diameter erythematous plaque scalp. There are some small crusted areas.
Biopsy shows superficial BCC.

Question: Is Aldara appropriate?
C + E will take ages to heal.
Excision could n ot be closed without a graft or a flap.

19 year old student with acneiform eruption

History: 19 year-old man with a 5 year history of acneiform eruption predominately on torso and proximal extremitiesl Some facial involvement, but less than on torso. He is in good health, no history of diabetes or steroid use. No antibiotics for months. In the past he has used benzoyl preoxide ceams and washes, topical retinoids, topical antibiotics and tetracycline and its derivatives. Mome has ever helped.

Exam: Healthy young man with Type IV skin. On torso and proximal extremities he has discrete erythematous papules and an occasional pustule. No cysts. Face largely clear.




Lab: nil

Pathology: Initial reading showed marked perifollicular lymphoneutrophilic infiltrate c/w acute folliculitis. PAS negative.





Diagnosis: Probable Pityrosporon folliculitis

Discussion: Are the yeasts incidental or indicative of pityrosporum folliculitis. I asked for more cuts and this showed numerous PAS (+)"fungal spores" in the follicular ostia.
I have started him on itraconazole 200 mg per day and Nizoral 2% shampoo to torso. The literature does not have good guidelins for how to treat this; but I suspect 4 - 6 weeks woth oral meds.
Please suggest diagnostic and therapeutic alternatives.

Atypical Nail Pits

Case for Discussion:
This 40 year-old woman presented for evaluation of a nail dystrophy present for 2-3 months.
She has a history of Hashimoto's thyroiditis. About 9 months ago she developed vitiligo.
Her health is otherwise normal
Meds. Synthyroid and iron
Lab: Thyroid Perox AB 248 (Nl. 0 - 34 IU/ML)
ANA < 1:40

Physical Exam:
Vitiligenous patches left neck and left upper back
Around 4 finger nails show a distinctive pitting. The pits are fairly uniform and the affected nails are rough and lusterless. There are no cutansous lesions of psoriasis.

Discussion and Questikon:
The picture is atypical for psoriatic nail pits but that is not excluded.
I favor a relationship to the underlying autoimmunity that has caused the Hashimoto's and vitiligo.
The picture is similar to that seen with alopecia areata, but the patient has not has any alopecic patches.
Nail dystrophy has occasionally been described before the development of A. areata. And patients with Hashimoto's thyroiditis have a higher than expected incidence of alopecia areata.
We welcome your thoughts or suggestions.

Hemangioma of Auricle

This 4 month infant girl was born with hemangiomas of the chin and left ear.
The lesion on the chin (not pictured) measures 1 cm in diameter and is typical of a congenital hemangioma.

The abnormality of the left ear involves the triangular fossa and the helix. I am concerned that as this involutes it could cause disfigurement. At the same time, I wonder if anyone has experience handling similar lesions in this site. A PubMed site found only a paucity of pertinent references.

Ref:
Cavernous hemangioma of the external ear canal.
Reeck JB, Yen TL, Szmit A, Cheung SW.
Laryngoscope. 2002 Oct;112(10):1750-2. Related Articles, Links
Division of Otology, Neurotology and Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, Veterans Administration Medical Center, San Francisco, California, USA.

OBJECTIVE: To document the occurrence of a cavernous hemangioma of the external ear canal and to review the relevant literature.STUDY DESIGN Case report and literature review. METHODS: Review of a patient chart, imaging studies, operative report, and histologic findings. RESULTS: A cavernous hemangioma of the external ear canal not involving the tympanic membrane was surgically excised without complication. This is the third documented cavernous hemangioma of the external ear canal without tympanic membrane involvement in the English literature. Computed tomography scan is invaluable to narrow the differential diagnosis. Complete removal is curative. CONCLUSIONS: Cavernous hemangioma of the external ear canal with or without tympanic membrane involvement is a rare otologic entity amenable to surgical treatment. Temporal bone computed tomography scan imaging is an important preoperative diagnostic tool.

Nevus, Congenital

This 20 yo college student presented in consultation for removal of a congenital nevus.
The lesion is located just distal to her left knee. She's been embarrassed about this since childhood and for the past six or seven years won't let anyone see it. Indeed she covers it at all times with bandaids.
The lesion measures 5.2 cm in diameter.
I have referred her to a surgeon for removal since I think that's better than psychotherapy. To minimize the scar it may need staged excision.
The young woman appears normal in all other respects - she is very upset about the lesion and the questions she gets about it.
I wonder if this has been reported. I would hardly call this Body Dysmprphic Syndrome.
Your thoughts are appreciatged.

Not much written about this area -- here's a ref that may touch on it:


Congenital melanocytic nevi. Evaluation and management.
Marghoob AA., Dermatol Clin. 2002 Oct;20(4):607-16, viii.
Department of Medicine, Dermatology Division, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA. marghooa@mskcc.org

This article discusses the care of patients with CMN, who often require
a multidisciplinary approach involving pediatricians, family physicians,
internists, dermatologists, psychologists, plastic surgeons,
neurologists, and radiologists. The cosmetic and psychosocial issues,
combined with the knowledge of the increased risk of developing
melanoma or NCM, is a huge burden that many of these patients
and their families have to carry. This article describes the importance
for physicians to help these patients and families come to terms
with these issues, as well as remind their patients and their family
members that although melanoma, NCM, or other complications can
develop, most affected individuals do not develop any complications.
The article mentions that there are many healthy, happy, functional
adults with large, small, and multiple CMN alive today.

Imiquimod Side-Effect?

This 66 yo woman began topical imiquimod on July 27, 2005 for a biopsy proven superficial BCC of the right upper lip. One week later, she developed aphthous ulcers on the mucous membrane surface of the area just below the site treated. A literature search retrieved a reference to his occurence. This is another unexpected adverse effect. It is unclear how common this is.

Aphthous ulcers associated with imiquimod and the treatment of
actinic cheilitis.
Chakrabarty AK, Mraz S, Geisse JK, Anderson NJ.
J Am Acad Dermatol. 2005 Feb;52(2 Suppl 1):35-7.
Solano Clinical Research, Davis, California, USA. chakak3@yahoo.com

Our case series report is the first documented depiction of the
appearance of aphthous ulcers secondary to imiquimod
application. This case series presentation discusses the
underlying pathophysiology of aphthous ulcer development and
imiquimod therapy in terms of the stimulation of pro-
inflammatory cytokines, such as tumor necrosis factor alpha
(TNF-alpha). The literature review suggests more than just a
mere coincidence for the development of aphthous ulcers
subsequent to the treatment of actinic cheilitis with imiquimod
application.

46 year old woman with indurated depressed lesion

A 46-year-old woman presented with 7 years history of depressed lesion just above the left side of mouth. It was asymptomatic. She has seen few dermatologists and a plastic surgeon but none really helped her lesion. She did not have polyarthalgia or other constitutional symptoms. Drug history was nil significance.
Examination showed 2 areas of depression, almost tethered to the underlying dermis just above the left side of the mouth and another a bit above the angle of mouth. There is no induration on deep palpation. The inner buccal mucosa appeared normal.
Serology for lupus including ANA, anti Ro, Anti La, and other extractable nuclear antigens were negative. Possible diagnoses would include lupus profundus and morphoea. Biopsy with immunofluorescence studies should help. Anyone has any therapeutic pearls for this lady??

Basal Carcinoma - Deconstructed

August 9, 2006.

LATE BREAKING!! BIOPSY HERE SHOWED THE LESION TO BE AN INTRADERMAL NEVUS.
I should have paid more attention to the history.

MORE... The patient underwent an excision - and the final report was a Basal Cell + an intradermal nevus. Quite unusual. The initial clinical impression was more accurate that the incisional biopsy. This is sobering.



This 57 yo man presented with an 8 mm in diameter papule that has bled since he started to wear glasses a year or so ago. He has been aware of a slowly growing lesion in this area since age 19 (38 years ago).
The lesion has been biopsied and I await the results. It appears to be a BCC. The long history underscores the benign behavior of many of these lesions. While we have all seen case reports of aggressive BCCs that have caused loss of eyes, ears, nose - these are likely in the very small minority. It is the growth characteristics and behavior of these lesions which is likely key, not their appearance micorscopically. Our therapy for these indolent tumors may be too aggressive based on the slow growth and lack of metastatic potential.

84 yo man with Pemphigus

This 84 yo man was seen around weeks ago with an erosive bullous process on torso, head and neck of 4 months duration. He was on no meds by mouth and in good general health.
My initial impression was pemphigus vulgaris vs. impetigo. The skin culture showed many coag + staph, and the bx showed an acantholytic bulla. The DIF was positive for intracellular IgG.
He was treated with dicloxacillin 250 mg qid and prednisone 20 mg tid.
He cleared quickly. At present he is on 30 mg per day of prednisone and tapering by 5 mg every two weeks. He's had no new lesions since therapy was initiated and his itch has disappeared.
Questions:
1) Value of adjuvent therapy? I am thinking of starting in a benign manner with minocycline/
2) Should I try to get on alt. day steroid first?
3) Any suggestions?
Follow-up (August 6, 2005) The patient continues to do well. He is now on Prednisone 20 mg per day. No symptoms and no new lesions. His prednisoe will be dropped by 5 mq every 10 days until 10 mg per day - then we will convert to alt day therapy. I may add minocycline 100 mg bid.

40 yo woman with scarring alopecia

The patient is a 40 yo woman with an eight year history of scarring alopecia.
Her ANA is + at 1:160 - all other labs are normal.
No other cutaneous findings or systemic disease other than "fibromyualgia."
She has been treated with 200 mg of plaquenil b.i.d. for a number of years. This has not been of much help.
The patient is quite concerned about her scalp. She's going through a divorce and worries about her appearance.
Questions?
1) Any value to a biopsy?
2) Would scalp reduction be an option?
3) Role for hari transplantation? Should a biopsy be done first

Melanonychia in a Six Year-Old Child

Presented by
Dr. Chee Meng Loh
RMG
Singapore
E mail: bliss88@singnet.com.sg

The patient is a six year old Chinese girl who developed a dark pigmented longitudinal band on the nail of her right index finger about 1 year ago. It started as a narrow, light brown band and grew in darkness (black in centre of band, and lighter shade of brown at edge of band) and width. The band is now about 3 mm in width. It has not changed in the past 3 months.

There is no history of trauma to the right index finger. There is also no complaint of pain in that finger.

The girl suffers from eczema and is on steriod medication (hydrocortisone 1% cream). She is otherwise healthy. There is no history of melanoma in the girl, her parents or grand parents. Neither her parents have pigmented bands on their nails.

Physical Exam: Dark longitudinal pigmented band on right index finger.
Colour ranges from black to brown.
Width is about 3 mm.
(Pictures attached)

Biopsy not performed.

Diagnosis: Melanonychia of right index finger.

Questions:
What are the likely causes of melanonychia in this child?
What is the likelihood that the cause is melanoma?
Should biopsy be performed to rule out melanoma?
If yes, what biopsy procedure is appropriate and what is the risk of permanent damage to the nail?
If a wait and see approach is appropriate, what other signs should the parents watch out for and within what time frame?

Melanonychia
Originally uploaded by David Elpern.

Melanonychia
Originally uploaded by David Elpern.

16 yo girl with papulonecrotic lesions

The patient is a 16 yo girl with a 2 year history of papulonodular lesions on the extremities and face. There is no evidence that these are excoriations. Biopsy 9 months ago from the arm was read as prurigo nodularis, but lesions look atypical and have now started to appear on the face. She is well otherwise.





A repeat biopsy on June 27. 2005 showed:
DIAGNOSIS: Skin - Left Temple:

Epidermal necrosis with s cale crust containing neutrophils , sub-epidermal abundant neutrophils and fibrin deposition, superficial and deep perivascular lymphohistiocytic infiltrate with focal neutrophil ic microabscesses, septal and lobular panniculitis with mixed inflammatory cell infiltrate of abundant neutrophils , lymphocytes , histiocytes, and eosinophils and numerous activated endothelial cells, surrounding a medium-sized vessel with marked mixed inflammatory cell infiltrate of neutrophils , histiocytes and occasional eosinophils .

NOTE : These changes are suggestive of a medium-sized vasculitis with overlying necrosis. Elastic tissue stain (EVG) does not reveal the vessel in the deeper sections, therefore, arterial or venular distinction cannot be made. The differential diagnosis includes a large vessel vasculitis such as periarteritis nodosa or early Wegener's granulomatosis. P.A.S. stain is negative for fungal organisms. Fite stain is negative for mycobacteria . However, an infectious vasculitis cannot be entirely excluded . If the clinical suspicion persists, culture studies may be of help . The differential diagnosis also includes , in the appropriate clinical setting , factitial panniculitis with secondary vascular involvement. These are not the changes of lupus erythematosus , pityriasis lichenoides et varioliformis acuta or prurigo nodularis . Serologic studies may be helpful. Clinico-pathologic correlation is suggested.

Bullous Eruption after Surgery

This 72 yo man had a laparoscopic cholecystectomy four months ago in Florida. Within a few weeks, he developed a bullous eruption around the area of surgery. His surgeon and primary care physician have treated with cephalosporins, topical mupirocin and triamcinalone cream. All without avail.
A culture obtained at my office showed: coagulase negative staph resistant to everything except tetracyclines and rifampin. This is probably not significant.
The exam shows flaccid bullae, some with fluid levels of pus. See photos of right subcostal area.
I suspect this is a localized variant of pemphigus that followed surgical trauma.
A biopsy for DIF is planned.
Is there any value iin IIF?
I started him on minocycline for the staph on the odd chance that this is an unusual pathogenic coag negative staph; but the more I think about this, themore convinced I am that this is a benign variant of P.V.
I may start superpotent topical corticosteroids since the disease manisfestation is so localized.
Not sure if localized PV has been described after laparascopic surgery.

Bullous process
Originally uploaded by David Elpern.

Note laparoscopy scar between two bullae

Close-up
Originally uploaded by David Elpern.

Note fluid level of wbcs


Pathology
DIAGNOSIS: Skin - (A) Abdomen:
Intra-and sub-epidermal blister with numerous eosinophils , focal re-epithelialization, eosinophil ic spongiosis and mild s uperficial perivascular lymphocytic infiltrate with numerous eosinophils and papillary dermal fibrosis .
NOTE : These findings are suggestive of re-epithelialized bullous pemphigoid . The differential diagnosis includes a bullous arthropod bite reaction or bullous drug eruption . These are not the changes of pemphigus vulgaris.

DIRECT IMMUNOFLUORESCENCE RESULTS : Perilesional skin sections were incubated with 1:10-1:20 dilutions of antisera specific for IgG, IgM, IgA and C3. "Immunostaining" was not observed.

NOTE : These findings do not support the diagnosis of bullous pemphigoid ; however, they do not exclude it as some rare cases may be negative for these immunoreactants. I f the clinical suspicion persists, an additional biopsy may be of help . Clinico-pathologic correlation is suggested.

Reference:
J Am Acad Dermatol. 1989 Mar;20(3):437-40
Direct immunofluorescence in bullous pemphigoid: effects of extent and location of lesions.
Weigand DA, Clements MK.

Dermatology Service, Veterans Administration Medical Center, Oklahoma City, OK.

We have reevaluated the previously reported conclusion that direct immunofluorescence in bullous pemphigoid is often negative in biopsy specimens from the legs. Duplicate tests from the trunk and legs were generally of equal intensity in a prospectively evaluated series of eight patients with generalized bullous pemphigoid. Also, in 36 patients evaluated retrospectively, the intensity of the direct immunofluorescence reaction correlated roughly with extent of disease, rather than with specific anatomic region. Localized disease predictably required less vigorous treatment to achieve control, but the intensity of the immunofluorescence reaction was not similarly predictive. Direct immunofluorescence is a less useful diagnostic test in localized bullous pemphigoid than in generalized bullous pemphigoid.

Rapidly Growing Lesion in a 57 yo woman

The patient is a 57 yo woman with a 6 month history of a papule on the right arm.
The lesion measures 6 mm in diameter and had not diagnostic features.
An excisional biopsy done since this was a rapidly growing lesion which was not clearly benign.
Pathology shows a malignant melanoma, 2.3 mm thick, Level IV.
Signed out as superficial spreading, but clinically looks more like a nodular melanoma.
She has been referred to a dermatologic oncologist for wide local excision, SLN and other studies.

Bozek2
Originally uploaded by David Elpern.

78 year old woman with unusual tumor

This 78 yo woman presented with a two week history of a dark growth on the posterior aspect of her shoulder. She had myalgias and felt unusually tired. The exam showed a tick engorged with blood. I could not tell if this was the deer tick that may carry Lyme Disease. Lyme antibidoes were ordered and she was started on amoxicillin 500 mg. tid for three weeks. She's a light complected Caucasian and doxycycline may cause photosensitivity in this season.
The tick was removed by gently grasping it with a forceps and rotating it. It appeared intact and was sent to the lab for identification.

Wynant 004
Originally uploaded by David Elpern.

Wynant 003
Originally uploaded by David Elpern.

Cold Urticaria

1 month history
Originally uploaded by David Elpern.

MAY 31, 2005

This 17-year-old high school student presented for evaluation of hives after exposure to cold air or products. This may have followed an upper respiratory infection. It has been present for only about a month.

EXAMINATION: Dermographia is negative. After applying a cold soda can to her arm for two minutes, she developed an urticarial area exactly in the shape of the can five minutes after the can was removed.

IMPRESSION: This is probably the common form of cold urticaria. Some of these cases follow upper respiratory infection. This is idiopathic.

PLAN: She was warned against swimming in very cold water and she was given hydroxyzine to take half an hour before exposure if she knows that she is going to be in a cold environment or be exposed to cold products. I will do a literature search to see what I can come up with for her.

Thoughts??

55 yo woman with new facial lesion

This 55 yo woman has has a one week history of a painful necrotic lesion on her left temple. She suffers from chronic pain and depression but is on no new meds. Her health is otherwise good. Her hemogram is unremarkable. Two days ago, she developed a similar lesion on her left shoulder. At present, it is just an erythematous papule with a surface erosion. He internist started her on cephalexin 500 mg bid before I saw her.
Both lesions, by history, began with a vesicle superimposed on an erythematous papule. She feels well otherwise and has had no fever.

1 week history
Originally uploaded by David Elpern.

In the differential disgnosis I am considering:
Ecthyma
Ecthyma gangrenosum (normal hemogram is against this)
Brown Recluse Spider bite - but these are usually not so symmetrical

A bacterial culture was done but may not be helpful since she was on cephalexin.
I doubt biopsy will help; but will be done if she continues to develop new lesions.

23 yo woman with facial erythema

This 23 yo woman has had facial erythema and acuminate micropapular lesions since childhood. She has extensive keratosis pilaris of her arms and thighs in addition. She has not gone out in public without thick make-up for 10 years. Her fiance has never seen her without make-up. She is desperate to haved this treated. I suspect this is a variant of KP rubra facei, possibly with ulerythema oopryogenes

KPRF 005
Originally uploaded by David Elpern.

KPRF 006
Originally uploaded by David Elpern.

Seven Year Old Boy with Chronic Dermatitis

A.D. is a 7 year-old boy who was adopted from Siberia by a family in western Massachusetts at 21 months of age. Since adoption he has had recurrent dermatitis on torso and extremities. The lesions are mostly nummular by history. They have responded to systemic antibiotics on occasion. He was seen here yesterday for the first time for a second opinion.

The child appears normal otherwise. He has no evidence of atopy. This is the largest lesion. All are plaques, all covered with some crust, intensely pruritic. I applied some pressure to the large plaque with a cotton tipped applicator and a small amount of creamy pus was extruded.

My working diagnosis is nummular eczema driven by hypersensitivity to staph. A culture was taken and I'll wait for results before treating. This has been going on for 5 years. I may do a biopsy, but am not sure it will be helpful.

Any thoughts would be appreciated. The parents are at their wits end. He has also been treated with mupirocin cream in past with some success. Tacrolimus was not helpful.

The culture grew out coagulase positive staph sensitive to everything; even Penicillin G. This is unusual in the U.S. where most Saph is resistant to penicillin. One wonders if this is a strain he brought over from Russia when he was adopted. I started him on Pen VK 250 mg qid. I will add a topical corticosteroid and mupirocin - the latter for nares and crural folds. Will give follow-up after a couple of weeks. If he continues to have staph infections like this, I will look into his Ig status.


Right leg

A Change of Pace

The patient accompanied her "mother" to the office. She is a 12 yo chihuaha with autoimmune thyroid disease and extensive alopecia areata. I was aksed what could be done and injected large areas of her skin with intralesional triamcinalone. Unfortunately, there is no billing code for this - the dog lacked health insurance.
(Actually, I deferred treatment until I hear from my august colleagues)

Note tail alopecia in Fig. 3


Fig 1


Fig 2


Fig. 3

Ref:
A natural canine homologue of alopecia areata in humans.
Tobin DJ, Gardner SH, Luther PB, Dunston SM, Lindsey NJ, Olivry T.
Department of Biomedical Sciences, University of Bradford, Bradford, UK.
Br J Dermatol. 2003 Nov;149(5):938-50.

BACKGROUND: Alopecia areata (AA) is suspected to be an autoimmune disease directed preferentially against hair follicles (HF) affecting both humans and various mammalian species. Recently, two rodent models of AA were described, namely the ageing C3H/HeJ mouse and the DEBR rat. Despite several case reports of canine AA in the literature, there has been no systematic assessment of the disease in these companion animals, and it is also not known whether dogs with AA could be useful as an outbred homologue of this disease in humans. OBJECTIVES: To evaluate the clinical, histopathological and immunopathological features of 25 dogs with AA and compare these data with those found in the human disease. PATIENTS/METHODS: Twenty-five client-owned dogs exhibiting macroscopic alopecia with peri- or intrabulbar lymphocytic infiltrates were selected for study. Biopsies and sera were obtained and assessed by histopathology, direct immunofluorescence of immunoreactant deposition, immunohistochemistry for lymphocyte markers, indirect immunofluorescence and immunoblotting analysis of circulating serum IgG, selective immunoprecipitation of HF proteins by serum IgG, and passive transfer of purified canine IgG into naive C57BL/10 mice. RESULTS: Clinical signs including alopecia, skin hyperpigmentation and leucotrichia usually developed during adulthood and were first seen on the face, followed by the forehead, ears and legs. Spontaneous remission of alopecia occurred in 60% of dogs and regrowing hair shafts were often non-pigmented. Histological examination of skin biopsy specimens revealed peri- and intrabulbar mononuclear cell infiltrates affecting almost exclusively anagen HF. Direct immunofluorescence analysis detected HF-specific IgG in 73% of dogs, while indirect immunofluorescence revealed circulating IgG autoantibodies to the HF inner and outer root sheaths, matrix and precortex. Immunoblotting analysis revealed IgG reactivity to proteins in the 45-60 kDa molecular weight range and with a 200-220 kDa doublet. The latter was identified as trichohyalin by selective immunoprecipitation. Purified HF-reactive IgG, pooled from AA-affected dogs, was injected intradermally to the anagen skin of naive mice where it was associated with the local retention of HFs in an extended telogen phase in AA-treated skin compared with that seen in controls. CONCLUSIONS: These findings are very similar to those reported for human AA patients; therefore, they support the consideration of dogs with AA as a useful homologue for the study of the pathogenesis of this common autoimmune disease of humans.