Painful Edematous Plaques

Abstract: 24 yo woman with 2 month history of transient plaques torso and extremities.
HPI: This 24 yo woman was diagnosed with hyperthyroidism in October of 2007. She was treated with radioactive iodine and carbamazole in November and December. Her dermatological manifestations began after both treatments. She reports ~ 20 episodes of painful plaques on torso and extremities. These last 1 - 3 days and clear completely. They are hot, tender, and painful in certain locations. She was first seen in my office on February 26, 2008 with an acute episode which was 24 hours old.
O/E: Healthy-appearing young woman. A solitary plaque was noted on the upper back. The borders were well-defined. The area was hot and painful and slightly erythematous. The patient had trouble taking her shirt off for the exam.
Photos:
Note: The border is outlined for clarity with a blue marking pen in photos 2 and 3.

Lab: She has had various blood tests done by other physicians and I've called for results. I ordered a CBC and ESR yesterday. Thyroid antibodies will be obtained unless her other physicians have ordered these.
Pathology: A deep incisional wedge biopsy into the panniculus was obtained.
Diagnosis: I have not seen anything like this. The short duration of the lesions suggests angioedema or urticarial vasculitis. But, I have never seen a similar case with such large lesions. One wonders about the relationship of her thyroid disease and possible autoantibodies.
Reason Presented and Questions: It is instructive to present an undiagnosed case for discussion. Others may have seen a similar patient. Every day, we see something unique to us. In some cases, our colleagues may be of invaluable assistance. Your comments are most welcome.

Facial Pigmentation in a 31 yr old woman with Protein S deficiency

A 31 yr old woman presented with one year history of pigmentation on her face. It appeared as sun burn and confined to the facial areas with sparing of the areas underneath the eyes and nose. It was made worse after application of some skin care products. She was otherwise well.

She had a past history of hypercoagulation and mitral valve prolapse with Protein S deficiency and is on warfarin.

Examination of the skin showed diffuse hyperpigmentation on the face extending to the frontal hairline, preauricular hairline and mentum. The areas under the eyes and nose were spared.

Blood counts and biochemistry were normal ANA serology mildly positive. Titre 1:80 (RR<80)

Differentials: photodermatitis > LE > melasma > irritant dermatitis

Q Is the serology titre of 1:80 significant? Could this be LE or melasma? Would you biopsy her skin? If you biopsy, where would you biopsy her? Thanks for your comments.

Asymptomatic annular lesions on face and hands

Submitted by Khalil Alhamdi M.D.
Associate Professor of Dermatology
Basrah, Iraq

Abstract: A 25-year old woman with 3-year history of asymptomatic annular lesions on face and hands

History: A 25-year-old woman presented with 3-year history of multiple asymptomatic annular lesions involving the face and the dorsa of both hands that gradually increase in size. She had received different modalities of treatment without improvement.

O/E: Young aged women presnted with multiple asymptomatic annular atrophied hyperpigmented patches with hyperkeratotic border that affect the face in a mask-shaped destribution and the dorsa of both hands.

Clinical Photo:

Lab: All relevant investigations were normal.

HPE: revealed features suggestive of porokeratosis

Diagnosis: Porokeratosis of Mibelli

Comments: This woman was misdiagnosed as fungal infection and lichen planus for which she received treatment without benefit. On clinical and histopathological bases we put her on topical 5Fu in addition to irregular courses of isotretnion because of poor compliance and inavailability of the latter drug in our country.

Questions:

1. What is the experience of our colleagues in seeing such unusual presentation?
2. What is your treatment suggestion to help this poor lady.

Umbilical Erosions

[ See end for final diagnosis]
Abstract: 71 yo woman with three week history of genital, anal and umbilical erosions.
HPI: This healthy 71 yo woman had vaginal prutitus for a few weeks. She saw her gynecologist who prescribed an estrogen cream. It got worse. She was then given clobetasol oint. It did not improve. She tried acyclovir ointment -- not much change. I saw her at this point. I recommended continuing clobetasol ointment, but after a few days getting worse. No new meds. Takes occasional acetoaminophen and diphenylhydramine.
O/E: Periumbilical erosive dermatitis. No frank vesicles. There was only faint erythema of the vulva and anal areas and very slight erosion left groin.



Lab: CBC normal, Chemistries normal. KOH from umbilicus negative. Bacterial culture taken.
Pathology: Biopsies for H&E and perilesional for DIF done Feb. 8, 2008
Diagnosis: I am considering the following:
A vesiculobullous disorder
Fixed drug eruption (but have no likely candidates)
Contact dermatitis unlikely.
HSV a long shot.
Periumbilical cellulitis? B-Strep perianal cellulitis can look similar
What have I missed?
Questions: What are your thoughts? Biopsy and culture should be ready in three days.

The bacterial skin culture grew out Group A Beta Strep. The pathology was consistent with cellulitis. No evidence of an acantholytic process. It is likely that this began with a perianal/vaginal streptococcal cellulitis and spread to the umbilicus. Periumbilical streptococcal cellulitis has not been reported in adults. The patient was started on Pen VK 250 mg qid and mupirocin ointment. Fout days later she was almost completely clear. Unfortunately, the fluorescent correction was not on when picture was taken.