Thursday, November 29, 2007

Winter's Toes

Abstract: 18 yo boy with pruritic, erythematous toes.

History: The patient was referred by his pediatrician with complaints of red, itchy lesions on his toes for two to three weeks. The pediatrician was concerned because some of the lesions looked vasculitic. The patient is in good general health. A non-smoker. He recollected as the interview progressed that he'd had similar but less severe problems in the past.

Physical Exam: Erythematous macules, some hemorrhagic in appearance on toes. One lesion slightly necrotic.

Lab: CBC, ANA and other tests ordered at pediatric office
Pathology: none

Diagnosis: Chilblains (Lupus Pernio)
Reasons Presented and Questions: Similar patients are seen two or three times a year in my office. The typical case is a child or young adult with pruritic erythematous macules or papules on the toes or fingers. The lesions can look necrotic and sometimes ulcerate. The person is otherwise healthy. Pernio is most commonly seen in fall or winter, but I've seen it in spring, too. The lesions are worrisome in appearance to physician, parent, patient. The index case here was worried that "my toes will rot off." His mother was worried about "lupus." I reassured them that this is a common, self-limited problem. While nifedipine may help, it's not necessary. Wear warm socks. Give it time. There's a good review on It says: "The direct cause of pernio is cold exposure. Chronic pernio may be secondary to various systemic diseases as follows:
Chronic myelomonocytic leukemia
Anorexia nervosa
Cryoglobulinemia, cryofibrinogenemia, cold agglutinins
Antiphospholipid antibody syndrome
Raynaud disease"

But it's usually easy to differentiate which ones are worrisome and the vast majority will be simple chilblains. One may need to use some clinical judgment. Not rush to unnecessary testing. In my experience, and from what I've read, this occurs more when it is cold and damp in thin individuals. Not bone chilling cold, but the cold of early winter. When it is really cold, good socks and footwear may be more the norm and can protect a susceptible individual from chilblains.

11/29/07 -- Patient just seen:
These are the toes of a 70 yo man who has had chilblains for the past 30 winters. His toes are uncomfortable, itchy and occasionally painful. He's had no chronic illnesses and enjoys good health.

Here is an excellent full text reference: "Pernio in Children" from the journal, Pediatrics.

Friday, November 23, 2007

Notched Nose

This 55 year-old woman had micrographic surgery for a basal cell of the left ala three years ago. The graft did not take and she has been left with a notched ala. The defect, in the center of her face, is more disfiguring than it appears in this photo.

Question: What kind of repair could be done at this time to give her a better functional and cosmetic repair.

Sunday, November 18, 2007

Uncommon Warts

Welcome, New Members from the Penang Conference

Early morning, view before we convened for our scientific sessions. Penang is an amazing place to meet new friends, relax and sample a singular culture.

Please look at two interesting cases.

This is the tale of two young patients with warts who were seen back to back on November 17, 2007. Verruca vulgaris (the common wart) is sometimes quite "uncommon."

1. This is a seven year old boy who has had acute lymphocytic leukemia fr three years. He has had recalcitrant warts for the past nine months. At present he has failed liquid nitrogen, TCA and imiquimod. His present medications include methotrexate, 6 mercaptopurine, vincristine and dexamethasone. Each therapy for his warts has resulted in more florid reappearance. This child has suffered a lot over the past few years. Clearing his warts would be a small but pleasant victory for him. Your comments will be appreciated.

2. This is a 12 year old girl who initially had a small wart on her knee. Her physician treated with TCA and then liquid nitrogen over a few months. Each time the wart recurred larger. One can see concentric rings from previous treatments. I'd like to find a treatment that won't cause permanent scarring. In theory, the wart will disappear in a year or two, so the therapy should be benign. I prefen not the use liquid nitrogen or cautery here. Have you had success with warts like these?

Friday, November 16, 2007

Eczema herpeticum

A 2-year-old boy presented with a 3-day history of vesicular eruptions on the mouth followed by extensive pruritic skin eruptions on the upper and lower limbs. This was preceded by fever. He was otherwise well.

Examination of the skin showed extensive eczematous lesions on the lower and upper limbs. Excoriations, erosions and vesicles were also noted on the affected areas. Vesicular lesions and erosions were noted around the mouth. He was afebrile.

Clinically he has eczema herpeticum.

This is disseminated herpes infection at sites of epidermal disruptions. He was treated with oral acyclovir 50mg 5x daily and oral cloxacillin 125mg qid. Wet compresses with diluted KMNO4 and topical mometasone cream was used for the weepy eczematous eruptions. The lesions gradually subsided with the treatment.

Buttock eruptions

This is an 11-month-old girl with a one day history of skin eruptions on the shoulders and gluteal areas. She was otherwise well. no fever. Feeding well. She was referred to me by a pediatrician.

Exam: symmetrical patches of erythematous vesiculopapules on the gluteal areas. Similar lesions were noted on the shoulders and chest. No lesions were noted on the upper limbs. Hep B was not checked.

Is this viral? Gianotti Crosti Syndrome?