Sunday, March 27, 2005

20 yo man with cutaneous larva migran

The patient is a 20-year-old man who noticed multiple intensely pruritic creeping lesions on his abdominal wall for more than a month. He is a body building enthusiast.

Examination showed multiple 2-3mm wide serpiginous raised erythematous tunnels on the left periumbilical and right upper quadrant of the abdominal wall.
Treatment was with freezing 1cm distal to the end of the trail with liquid nitrogen and adding oral mebendazole (zentel) 200mg bd for 3 days. It was successfully eradicated within a week of treatment.


 Posted by Hello

Wednesday, March 23, 2005

10 year old girl with endogenous cheilitis

This patient presented with recurrent dry and fissured lips for more than 2 years. She has a strong family history of atopy. Her brothers and sisters have asthma and allergic rhinitis. Fortunately she didn't use any lipstick.

Examination showed fissures and dryness on both the upper and lower lips. There were crusts formations on the lips

Clinically she has endogenous (atopic) cheilitis

There are few factors that need to be considered here. is there a contact allergen element here? Lipstick would be the biggest culprit here. Is there a need to do a patch test?

Irritants can be an aggravating factor too. Lip smacking and hot spicy food can aggravate the eczema. Even toothpaste with strong mint flavour can be a factor too. I have seen several patients whose cheilitis was aggravated by our local "Darlie" toothpaste.

Moisturisers eg vaselin would be very helpful and they can be applied 4-5 times daily. Mild topical corticosteroids eg 1% hydrocortisone ointment or cutivate ointment helps. I prefer ointment to cream base in this situation.

 Posted by Hello

34 year old man with multiple erythematous plaques

Recently I saw this interesting patient: a 34 yr old factory worker presented with redness over the thigh and lower abdomen for a week. Started as "burning discomfort" over the left knee and then spread to the right knee, thigh and lower abdomen. He has no fever. No history of diabetes. He denied any insect bite. There was no preceding drug history.
Examination showed diffuse and glistening redness on the thighs and lower abdomen. On the right thigh, there was a single non hemorrhagic blister. Regional nodes were not enlarged. The lesion was not particularly tender. He was afebrile.

Impression: cellulitis - right thigh. Unusual site for cellulitis though. what is your take on this patient?


Tuesday, March 22, 2005

18 yo girl just returned from Costa Rica

This 18 year old girl just returned from a school trip to Costa Rica. Her group explored streams and swamps. She developed asymptomatic papules and pustules on the dorsae of her feet after being in stagnant muddy water and a running stream. I am wonderind if this is a gram negative organism or a parasite. Any thoughts?

36 yo man with lesion on back

This 36 yo man presented with a 1.6 cm in diameter pigmented plaque on his back for approximately 2 years. Barely elevated. Has enlarged over past few months. Dx: Melanoma vs. Seborrheic keratosis. An excisional bx was performed today.

Path Report
DIAGNOSIS: Skin - Right Mid Back:

Malignant melanoma.

Type: Superficial spreading
Greatest thickness: 0.90 mm.
Anatomic level: II
Margins: Complete excised
Radial growth phase: Present
Vertical growth phase: Absent
Mitoses: None
Tumor infiltrating lymphocytes: Present, non-brisk
Ulceration: Absent
Regression: Present
Microsatellites: Absent
Vascular invasion: Absent
Precursor lesion: Not identified

NOTE: The lesion represents a severely atypical compound melanocytic neoplasm characterized by a predominantly intra-epidermal component with marked confluent lentiginous and nested melanocytic hyperplasia , pagetoid spread, extension into adnexae, and by a severely atypical dermal component with papillary dermal regression.

Sunday, March 20, 2005

2 yo girl with segmental hypopigmentation

This is a 2 year old girl who has a patch of hypopigmentation on her left shoulder since birth. It extends from back of neck to the left shoulder. It was asymptomatic. Examination showed a hypopigmented macule 5cm by 10cm on the back of left shoulder. It is segmental in distribution and has an irregular border. There was no central hypoaesthesia. She has no ophthalmic or CNS defects.

Clinically she has nevus depigmentosus or some form of pigmentary mosaicism. Biopsy of the lesion was not done.

This is usually a benign skin disorder and is caused by the functional defects of melanocytes and the morphologic abnormalities of melanosomes.

Newborn with Varicella

Posted for Dr. Jayakar Thomas of Royapuram, Chennai, India. Please comment here or reply directly to Dr. Thomas at

The patient is a 21 day old female infant who presented with multiple generalized vesicles of two days duration. Her mother had developed varicella two days post-partum.

Physical Exam: A normally nourished child with multiple vesicles over erythematous base. Child had low grade fever. There were no oral or genital lesions and no other mucosae were invoved.

Laboratory: Nil relevant

Histopathology: Not done

Diagnosis: Neonatal varicella (NV)

Comments: NV is not seen very commonly. It usually occurs when the mother has an attack of varicella during post partum period as in this case. The child presented here was treated with IV aciclovir with good results.

Varicella occuring in the mother during pregnancy may end up in congenital varicella syndrome in the new born.

Questions: What are the members' experience with neonatal varicella.
Some pediatricians do not use aciclovir and manage with supportive measures and antibiotics. Are they justified?
I personally feel that all children with varicella should be treated with aciclovir or appropraite antivirals. This will definitely bring down the chances of herpes zoster at a later date, given the scarring, pain, and other sequelae of herpes zoster.

Thursday, March 17, 2005

3 yo with nail dystrophy

This 3 yo boy has had a malformed left great toe nail since infancy. Recently, he traumatized it and may have had a subungual hematoma. His pediatrician tried to drain it with a hot paperclip, but was unsuccessful. His parents want to know what could be done to improve this nail.

Nail Dystrophy, Child

Nail Dyst - Closeup

Wednesday, March 16, 2005

Sunday, March 13, 2005

Atopic Infant

The patient is a one year old boy with an almost life-long history of atopic dermatitis. His father (age 30) has persistent facial eczema. His mother has significant food allergies (nuts and fruit cause angioedema and laryngeal edema). This child's facial eczema has proved difficult to control. Topical steroids have been of value (fluocinalone 0.25% ointment); but topical tacrolimus and pimecrolimus have not been effective. I suspect he may have food allergies. In addition, there is a cat at home. I think he needs to be tested for cat allergy. Food testing is controversial. Would serum IgE measurement be of value? Role of staph superinfection needs to be considered as staph, acting as a superantigen, may be driving this. I'd appreciate your thoughts. DJE

Child S.A.D. Posted by Hello

Child S.A.D. Posted by Hello

Saturday, March 12, 2005

Genital Papules in a 25 yo woman

Presented by:
Dr. Jayakar Thomas
KK CHILDS Trust Hospital, & Apollo Hospitals, Chennai, India
E mail:

The patient is a 25 yo married woman from Chennai, India who presented with itchy papules over the vulval area for the last two years. There was no history suggestive of risk of acquiring any STD.

Physical Exam: Clinical examination revealed a healthy very good-looking young lady with multiple papules over her genital region.

Lab: Nil relevant

Histopathology : Not done

Diagnosis: Verruca plana

Comment: We see verruca vulgaris and condyloma usually in these site.

25 yo woman Posted by Hello
Verruca plana is not common. This lady was in the habit of shaving her pubic hairs which has resulted in spread and persistence of lesions.
Topical 5% imiqumod should help if used with caution.

Question: What do the members feel would be the management strategy?

2o yo man with painful plaque


MARCH 07, 2005

Sam D. was seen today on a same day basis. He has a few day's history of a tender, erythematous area on the right lower leg. This is at the site of a twine ankle bracelet that he had been wearing for two years. He feels a bit run down although he has not had a fever. 

EXAMINATION: The examination shows an area of localized erythema and mild central scaling on the left lower leg just proximal to the ankle medially. It has a sharp margin. KOH prep was negative. There is definite heat at this site.  The regional inguinal lymph nodes are enlarged.

IMPRESSION: Probable cellulitis. Doubt contact. Doubt tinea.  Doubt phlebitis.


1. Warm compresses. 
2. Dicloxacillin 500 mg q.i.d. 
3. Return for follow-up in four days. 

Follow-up visit March 11
S: Patient feels a bit better energy wise, but leg still red and tender.
He hasn't been able to rest - has classes, lots of responsibilities. Has not been able to do warm compresses more than twice in past 5 days.
No systemic symptoms.
O: No marked change in plaque
A: I still favor a diagnosis of cellulitis.
P: Post on ANAK VGRD for suggestions. How long should this take to resolve?
Clinically, this does not look like erythema nodosum. It began after prolonged microtrauma from a twine ankle bracelet.

20 yo man with painful plaque Posted by Hello

Friday, March 11, 2005

56 yo woman with erosions for two years

This 56 yo woman has an alomst two year history of intense pruritus. She dates the onset to April 23, 2003 when she was exposed to toxic fumes at work. Since then, she wakes at night excoriating her skin. Other than a mild anemia and eosinophilia, all studies have been unremarkable. She has not worked since April 30, 2003. The is an intelligent person. Divorced, mother of three adult children (one with Turner's Syndrome) she worked in retail and latterly as a security guard. Skin biopsy was not helpful.

3/10/05 Posted by Hello

Back Posted by Hello

CLOSEUP Posted by Hello

Sunday, March 06, 2005

56 year-old woman with metastatic melanoma

This 56 yo woman presented on February 10, 2005 with multiple subcutaneous nodules, present for around a month. Some were hemorrhagic. Biopsy showed metastatic melanoma. Work-up revealed pancreatic, brain, lung and possibly adrenal mets. The biopsy site has not healed. A four centimeter exophytic tumor has appeared at the site of incision. The patient is lucid and has refused chemotherapy or radiotherapy. The tumor pictured below is a management problem. The part we see is only the visible portion of a larger deeper mass. The site of her primary melanoma has not been identified.

February 10, 2005 Posted by Hello

March 5, 2005 Posted by Hello

72 yo woman with Lupus Pernio

This 72 yo woman has a five year history of biopsy proven lupus pernio. She also has a 30 year history of stable chronic leukemia (I don't know the form). Her rheumatologist treated the sarcoid with hydroxyplaquenil and Methotrexate (without any benefit). The questions: 1) topical tacrolimus 2) Infliximab and possible contraindications b/c of chronic leukemia. Strangely, her insurance carrier has denied tacrolimus ointment, but this is bein contested.

March 5, 2005 Posted by Hello

March 5, 2005 Posted by Hello

Friday, March 04, 2005

53 year old man with 4 month history of lesion back

This 53 year-old man noted a lesion on right upper back around 4 months ago. It has tripled in size since then. On first glance it looks like a BCC, but BCCs rarely grow like this. The patient has Type I - II skin and is covered with freckles. He has a strong family history of skin cancer. I excised this lesion immediately because I was worried that it might be an amenanotic melanoma. If the latter, this is scary since it will be a thick lesion. Say a prayer for this patient that this is BCC.

Nodule Right Upper Back Posted by Hello

Wednesday, March 02, 2005

51 year old woman with incidental lesion

This 7 mm in diameter lesion was noted on the left upper back of a 51 yo woman with type II skin. She was concerned about another lesion on the lower back. The latter lesion was benign in appearance. The lesion pictured below was biopsied and I will post the results in a week. The patient was unaware of this lesion, it being on a part of the back that is difficult to visualize.

incidental lesion Posted by Hello