HPI: The patient is an 84 yo man who presents with a three week history of a mostly painless eruption on the dorsal hands (left more than right). I have taken care of his skin for over a decade as he's had a thin melanoma and a number of non-melanoma skin cancers. In addition, he has Parkinson's disease and his only medication is carbodopa. Fourteen years ago, he had prostate Ca successfully treated with seeds. Although mentally alert, the patient has been somewhat frail for years and muscle weakness is difficult to evaluate. There are no other skin findings, no heliotrope, no poikioldermatous changes.
O/E: Dusky erythema on dorsum of left hand with a predilection for the MCP joints. Some crusting. Periungual erythema of proximal nail folds, two fingers, right hand.
Clinical Photos (April 4, 2011)
Lab: The patient saw a rheumatologist who did a thorough w/u for collagen vascular disease with a focus on dermatomyositis. All serologies, chemistries and the hemogram were completely normal. CPK was not done.
Impression: The dermatitis is suggestive of dermatomyositis (DM). It's early spring here and he may have been more exposed to light. At this point, I am considering an early and evolving DM. Amyopathic or hypomyopathic DM takes six months to confirm. Considering his age, a thorough evaluation for malignancy might be considered. This appears to be photo-located, so I considered PCT but will hold off on urinary porphyrins for the time being.
Questions: Your thoughts will be appreciated.
Addendum: Two colleagues (Amanda Oakley from NZ and Fran Storrs from Portland, OR, USA) suggested chilblains. I called the patient and asked him if he might have been out more recently without gloves. He told me his hands are usually cold and he has a 200 yard (~ 200 mtr) walk to his mailbox. He hasn't been wearing gloves recently. It's been a cold spring here -- I think chilblains is a more likely diagnosis and I asked him to wear gloves outside when it's < 50 F (10 C) and get back to me in a week. The extend of his involvement is more than we usually see with chilblains, but the dx makes good sense. I'll affix a f/u in a couple of weeks.
Did you consider perniosis?
ReplyDeleteFrom Fran Storrs, Portland OR
ReplyDeleteBiopsy??
Itch?
Wonder even about patchy nummular eczema or even chilblains. Photo derms on hands tend to spare distal dorsal fingers don’t they?