Wednesday, June 28, 2006

Eye Lash Alopecia

The patient is an eight year old girl who has had a dermatitis of her eyelid margins off an on for around a year. She gets crusted areas which itch and her mother feels she plucks her eyelashes. On the day of the visit the lids looked quiet, but there was definite loss of some eyelashes. There is some evidence of broken lashes.

Is this eyelash trichotillomania or isolated alopecia areata of the eyelashes? I favor trichotillomania
What is the prognosis for spontaneous recovery?

My plan is to see her if and when the dermatitis is more acute and obtain a culture to see if she has a bacterial blepharitis.

Saturday, June 24, 2006

Bed Bugs

This 35 year-old man went to Mamaronek, New York to watch the New York Open Golf Championship last weekend. The closest motel room he could find was in Bridgeport, Connecticut. The latter is a city with a fairly poor reputation. Two days after returning home to Massachusetts he developed the lesions pictured here on arms and to a lesser extend on torso and legs.

They are consistent with bedbug bites (Cimex lenticularis). For a brief description go to:

In November of 2005 a bedbug epidemic was reported in New York in the New York Times. I saw a couple of cases from there here in Williamstown, MA, 150 miles away. I suppose there's a similar problem in Bridgeport now.

Wednesday, June 21, 2006

Lyme Disease

This 52 year-old woman presented as a walk-in patient today. She has a five day history of an erythematous nodule on the right shoulder which has developed a ring around it. The ring measures 9 by 11 centimeters in diameter. Initially, the nodule was painful for a few days; but the pain has subsided. She has had no fever or constutional symptoms and has continued to work as a school teacher.

The patient lives in rural New Hampshire and gardens a fair bit. She was seen two times at a primary care clinic where a diagnosis of spider bite was made. First she was given Keflex, then amoxicillin.

Diagnosis: I am uncertain. I favor Lyme Disease but this has atypical features. The central nodule is unusual, although the peripheral ring looks like Lyme. I also considered atypical Sweet's Disease and a pyogenic process. Lastly, I thought of eosinophilic cellulitis (Well's Syndrome) which I have never seen.

Plan: Since she feels well, I prescribed Doxycycline 100 mg bid, and ordered a cbc, Lyme titers and a G6PD (if the lesion becomes necrotic may want to try Dapsone. I considered biopsy but was strapped for time and thought Lyme most likely. Now, I am uncertain. Biopsy will be done when she is seen in follow-up unless she is significantly better.

Your thoughts will be welcome.


Path Report:
DIAGNOSIS: Skin - (A) Right Shoulder-Periphery-Ring Surrounding Nodule:
Tight, mild superficial and deep perivascular lymphocytic infiltrate .
NOTE : These changes are those of a dermal hypersensitivity reaction to an exogenous antigen and, given the clinical presentation, are consistent with erythema chronicum migrans .

DIAGNOSIS: Skin - (B) Right Shoulder-Nodule:
Broad scale crust containing neutrophils , epidermal hyperplasia , marked papillary dermal edema and a superficial and deep perivascular and interstitial mixed inflammatory cell infiltrate composed of lymphocytes , neutrophils , histiocytes and plasma cells with rare eosinophils consistent with arthropod bite reactio n.
NOTE : These changes may be seen in a tick bite and erythema chronicum migrans . Clinico-pathologic correlation is suggested.

The Lyme Titer is positive.

In my opinion, this is not definitive, but the onus is on me at this time to continue to treat for Lyme.
The patient is on doxycycline and will continue on this at a dose of 100 mg bid for three weeks.
The patient reports that after three days of doxycycline the lesion is smaller. This, too, is not definitive, however, one can not ignore that either.

One Week Follow-up.
The patient feels better. Has mild insomnia.
Although initial lab titer was positive -- the Western Blot was negative indicating an early infection. Our infectious disease consultant expected them to be negative. Early treatment can prevent conversion. Will probably repeat in 2 weeks.

Picture on June 29, 2006

Wednesday, June 07, 2006

Erosio interdigitalis blastomycetica

Why do dermatologists love these cumbersome terms??

The patient is a 30 yo woman with a two week history of a sore area between the 3rd and 4th toes of the left foot. She is in good general health. Not pregnant and on no oral contraceptives. Both parents have Type II diabetes. At the time of onset she was on doxycycline for rosacea.

The examination shows an erosion in the toe web. The KOH prep was positive for pseudohyphae consistent with the diagnosis of erosio interdigitalis blastomycetica

Given her family history she should be worked up for diabetes. The doxycycline may have also played a role.

The role of maceration was discussed. She will keep toes separated and use ketoconazole cream. If this in not effective, I will ask her to dry area after bathing with a hair dryer and continue an imidazole cream or solution.

This is from
Intertrigo: Intertrigo typically presents with erythema, cracking, and maceration with soreness and pruritic symptoms. Lesions typically have an irregular margin with surrounding satellite papules and pustules. Web spaces of affected fingers or toes are macerated and have the appearance of soft white skin, which is a condition termed erosio interdigitalis blastomycetica (interdigital candidosis).

A good source for the treatment of intertrigo is at: