Double Helix

We often see problems for which there may be no simple solution. Ear lobe keloids are encountered with regularity; but keloids of the helix and triangular fossae are unusual. Some of you may have a simple trick for patients like these:

Patient # 1.
Abstract: 25 yo woman with ear keloid.

HPI: This 25 yo Asian woman pierced the triangular fossa of her right ear 2 years ago and developed a keloid which is pruritic and whose appearance bothers her.

O/E:


Patient # 2
As I was getting case # 1 ready to publish on this site, a second patient presented for evaluation and treatment.
This is a 16 yo girl with a one year history of a keloid of the left triangular fossa. She had a professional piercing done two years ago. This lesion is painful.




This patient had an "Industrial Piercing" with a 14 guage stainless steel rod.

Comment: Earlobe keloids are commonly seen and reported. But I could find no helpful articles about helix and triangular fossa keloids. I suspect that these lesions are not rare, since I have seen two in a few weeks in a small New England town. Perhaps, these are harbingers of an epidemic! One of these young women pierced her own ear, and the other was a professional job.

Questions:
These can not be simply excised and then injected with TAC like the more common ear lobe keloid. Wound closure would be problematic.
How would you approach these women?
Any role for shave excision followed by imiquimod?
Do you think TAC alone will work? 20 mg per cc, 40 mg per cc?
Does anyone have experience with similar lesions?

Weird Erythema

Presented by Omid Zargari
Rasht, Iran

This patient referred to me with a weird erythema on his frontal area for the past two years.
He is a 45 y.o. kidney transplant patient whose medications include cellcept, cyclosporine, erythropoetin alpha and simvastatin. He believes that this began after he started simvastatin.



Your thoughts will be appreciated.

Acrolentiginous Melanoma from Malaysia

Here is a case from Jahor Baru, Malaysia. In North America, Europe and Australia the patient would have had more extensive studies; but one must keep in mind that there are disorders in Malaysia that are better handled there than here. Melanoma is far less common in SE Asia and their resources are allocated differently.

Abstract: 70 yo woman with ALM right sole

Presented by S.E. Choon, Consultant Dermatololgist

HPI: This 70 year-old Chinese lady presented in April 2006 with a 1-year history of a growth on right sole which was biopsied and diagnosed as melanoma. We do not have level and thickness. She refused below knee amputation and hence was referred to us in July 2006. She had radiotherapy in Sep/Oct 2006 in private centre.

P.M.H: Diabetes mellitus of 10 years, well-controlled with metformin 500 mg bd and glibenclamide 5mg daily.

O/E: see figure Fig. This shows her lesion in 2006 before XRT. There were no other positive findings. The current lesion very similar. Patient coming back next week.

















Work UP: CXR and CT neck, thorax and abdomen were clear in 2006 - in February 2008 CT scan last week showed several small right obturator lymph nodes. I was not too happy without a repeat CT and get one done last week. Size of LN not mentioned.

Pathology:
2006: Superficial spreading type (apparently down to subcutis for initial biopsy. Pathologist in Singapore wrote: "nodular type with vertical growth and ?superficial spreading"
2008: Recent lesion biopsy report was short and sweet-recurrent melanoma

Diagnosis: Acrolentigious Melanoma

Questions:
1. How would you classify this patient?
2. What would you recommend for this patient?
3. The patient initially refused amputation. Is there a lesser procedure that might help her now?

Your answers and comments are welcome.