Monday, March 30, 2009

Ear Keloids and Imiquimod

We presented this patient around a year ago (she is patient # 2). The woman, now 19 years old, presented in March of 2008 for a keloidal scar in the left triangular fossa. On 12/18/08 based on suggestions and a report in MEDLINE, the lesion was shave excised and a week after surgery, imiquimod was applied nightly for six weeks. She is now one month out after stopping imiquimod. At this point, she looks very good. We will have to see if this is a long term solution.

1. Berman B, Kaufman J. Pilot study of the effect of postoperative imiquimod 5% cream on the recurrence rate of excised keloids. J Am Acad Dermatol. 2002 Oct;47(4 Suppl):S209-11.
New adjunctive treatments are needed to reduce the high recurrence rates (50%) of excised keloids. Interferon alfa injections have been shown to decrease the size of stable keloids. This study examined the effects of postoperative imiquimod 5% cream on the recurrence of 13 keloids excised surgically from 12 patients.Starting on the night of surgery, imiquimod 5% cream was applied for 8 weeks. Patients were examined at weeks 4, 8, 16, and 24 for local erythema, edema,
erosions, pigment alteration, and/or recurrence of keloids. Of the 11 keloids evaluated at 24 weeks, none (0%) recurred. Incidences of hyperpigmentation were 63.6%. Two cases of mild irritation and superficial erosion cleared withtemporary discontinuation of imiquimod. Both patients completed the 8 weeks of topical therapy and the final 24-week assessment. At 24 weeks, the recurrence rate of excised keloids treated with postoperative imiquimod 5% cream was lower than recurrence rates previously reported in the literature.

Sunday, March 29, 2009

Nodules in Search of a Diagnosis

Presented by
J. Erin Reid, M.D. Dermatology Resident &
Stephen P. Stone, M.D. Professor of Dermatology
Southern Illinois School of Medicine

Abstract: 70 yo man with a five year history of exophytic nodules on the lower extremities.

HPI: A 70 year old white male presented with a five year history of exophytic nodules on the lower extremities. They were increasing in number. A few had been removed by shave excision, and the areas that were treated did not regrow.
Over the past few years he had numerous nodules measuring up to 4 cm in diameter. A few of them were excoriated and crusted. There was no lymphadenopathy. He also had extensive areas of erythema and scale on his forearms, upper arms, and thighs.
He had been in the Navy over 50 years ago and served in Japan. He also went to Bangkok and Hong Kong 20 years ago. No significant past medical history

O/E: On the pre-tibial area the patient has multiple nodular lesions, as well as some erythematous and hypopigmented scars where previous lesions have been removed by shave excision. The lesions range from 1 cm to 3-4 cm in diameter.


Pathology: Many biopsies have been performed. In May, 2006, a biopsy showed “superficial perivascular dermatitis of the mixed type, with eosinophilic spongiosis and pustules consistent with an allergic etiology”.
In February, 2007, biopsies of the right anterior and lateral leg showed “marked epidermal hyperplasia, spongiosis, and mixed intraepidermal and superficial dermal inflammatory cell infiltrate”. There was no evidence of malignancy or infection at that time, but there was evidence of chronic venous stasis change.
In January, 2009, we excised another nodule. This was read as “marked epidermal hyperplasia with acute and chronic inflammation” and was negative for fungal, bacterial and acid fast bacilli stains. There is also no evidence of malignancy or carcinoma. Cultures for fungus, anaerobes and AFP were all negative. Flow cytometry was negative.

Diagnosis: What is your differential diagnosis?
Questions: What further information would you want? What additional studies? How would you treat this man?

References will be added when available.