Segmental Pityriasis Rosea

Abstract: 32 yo woman with seven week history of a dermatitis on l. chest and breast.

HPI: Her dermatitis began with a single erythematous plaque on the left breast. Within one to two weeks, it spread to the present extent (almost all was on the upper chest and breast). She had used a topical imidazole cream without relief. No new medications.

O/E: There are discrete and confluent scaly erythematous papules and small plaques on left chest and breast. A few similar but more subtle lesions are present on right chest and abdomen.

Lab: KOH prep was negative.

Clinical Pictures: Taken on initial visit and after two weeks.

February 14, 2012

February 27, 2012

Impression: This is probably segmental pityriasis rosea.

Course: She was given clobetasol 0.05% ointment with instructions to use for no more than 7 - 10 days. After three days the lesions were gone and she stopped using the medicine. (Her insurance allows only certain topical corticosteroids, otherwise I would have prescribed a weaker one)

Questions: Do you accept this diagnosis? Any alternative suggestions?

References:
1. Zawar V, Godse K. Segmental lesions in pityriasis rosea: a rare presentation. Skinmed. 2011 Nov-Dec;9(6):382-4.
Skin Diseases Centre, Shreeram Sankul, Opp Hotel Panchavati, Vakilwadi, Nashik, Maharashtra State, India. vijayzawar@yahoo.com

based on a comment by Dr. Zawar, we found the following:
2. Ahmed I, Charles-Holmes R. Localized pityriasis rosea. Clin Exp Dermatol. 2000 Nov;25(8):624-6.
Abstract: Pityriasis rosea is a relatively common skin disorder. In its typical form it is easily recognizable; however, atypical forms can pose diagnostic problems. We report a 44-year-old woman with an acute onset of a localized eruption on her left breast. The morphology of the rash and the time course were typical of pityriasis rosea. Localized pityriasis rosea is an unusual variant, which has been described previously.

Periocular Dermatitis in a Child

Melanie Austin, a pediatrician asks:
"This is a 4 y/o with 10 day history of this rash around only her right eye. No eye discharge. The rash is not bothersome - mother describes at times it looks worse. H/o eczema, keratosis pilaris
I don't recognize the rash and I didn't want to start and topical steroids due to proximity to eye. Mom denies any make up or topical treatments at home...
What are your thought?
Thanks!!

Dialysis Patient with Atypical Ulcers

Abstract: 77 y.o.woman on dialysis with skin ulcers for over a year

HPI: The patient is a 77 yo woman with diabetes and ESRD on hemodialysis for a number of years. She had a diagonsis of porphyria cutanea tarda over four years ago, but no lab studies are available and it's unclear if this was a clinical or laboratory diagnosis. For over a year she has had painful skin ulcers which are located on the abdomen, scalp, breast and hands. These do not heal with good wound care. Her medications include Lantus insulin, sevelamer, cinacalcet (used to treat secondary hyperpartahyroidism), midodrine, risedronate, pravastatin, omeprazole, fenofibrate, famotadine.

O/E: This is a chronically ill-appearing woman. She has a periungual ulceration on her right ring finger. There are ulcers with escars on the abdomen, buttock, sccalp and extremities. The ulcers vary from one to 4 cm in diameter.

Clinical photos (presented with patient's permission)




Photo above is L. buttock and to right is abdomen

Labs; Although a diagnosis of PCT was made four years ago, the only reference to porphyrin levels is that they were "low." We do not have parathyroid hormone or Ca++ levels. These should be available from her nephrologists.

Pathology: Bx. 11/20/11 Read by Dan Carter, M.D.
Histologic changes consistent with "acquired perforating dermatosis of dialysis."

Diagnosis: Atypical Skin Ulcers in a Renal Transplant Patient. The etiology of her ulcers is unclear at this time.

Discussion: The patient is anemic with iron deficiency and her nephrologists are reluctant to treat with i.v. iron because of the past diagnosis of PCT. The current lesions do not look like classic PCT. Nor do they look like perforating dermatosis. They are also quite atypical for calciphylaxis.

Questions: What are your thoughts? Serum porphyrin levels could be done prior to and after iron infusion. Perhaps a deeper biopsy. Has she been checked for hyperparathyroidism? Has anyone seen a case like this?

References: I could find no helpful references for this case.

Update from her nephrologist: After this posting, this woman had a GI bleed and developed very painful decubitus ulcers. Last Friday I spoke with her while she was on dialysis. Her quality of life has been poor and no reasonable expectation that things were going to improve for her. She and I agreed that dialysis was no longer allowing her to have the acceptable quality of life she has had on dialysis for over 12 years. She terminated her dialysis treatment and passed away about 48 hours later.

Isotretinoin: Rare Side-Effects

Isotretinoin (Acutane, RoAcutane, Sotret, Claravis, Amnesteen) is a true wonder drug that has revolutionized the treatment of severe cystinc acne since its introduction in 1980. Over twenty million people have used it. There are some rare idiosyncratic reactions. We welcome comments here from patients, their families and practitioners.

The index case is a is an outgoing 16 yo girl with severe cystic acne with scarring. She was started on isotretinoin 30 mg per day (0.5 mg/kg per day) after routine lab tests were normal. She was on no other medications and had declined oral contraceptives since she is abstinent.

After two weeks, she reported the onset of vivid nightmares. These involved her being in contact with Nazis who were persecuting Christians. (Her step-father is a minister, and she had been studying the Holocaust at school). There is one reference to dreams on isotretinoin, but no reports of nightmares with the drug in the literature. I elected to continue the medication at the same dose and the nightmares resolved.

At week seven of isotretinoin therapy, she started to experience auditory hallucinations. These occurred at school and at home. The voices at home were telling her to kill herself. She developed a mild nosebleed which is a common isotretinoin side-effect the night before an emergency visit to my office, and reported that the voices told her she might as well "finish the job." Scared, she told her parents.

The drug was stopped and the hallucinations disappeared. At her request, she was rechallenged with 10 mg per day. Within a few days, the auditory hallucinations recurred and isotretinoin was discontinued with resolution of symptoms.

Physicians often tend to discount such reports from patients if the reaction is not documented in our medical literature; however patients need to be heard. This case was recently reported.

How many other patients may have had similar symptoms? Is this a coincidence, or a true neuropsychiatric drug-effect?

Have you had an unusual side-effect with isotretinoin? The VGRD Blog may be used as a vehicle to collect singular side-effects to medications, in this case isotretinoin. All responses will be anonymous. We would like to establish a database for idiosyncratic isotretinoin effects that may help other patients and their care givers.

Reference: The Voice of Isotretinoin

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Erosive Diaper Dermatitis

Here is a tough one:

Abstract: Thirteen yo boy with 6 month history of erosive diaper dermatitis.
HPI: The patient is a 13 yo boy with Down's Syndrome. As an infant he had Hirschprung's disease corrected by surgery. Subsequently, he has had problems with bowel movements and at this time is still incontinent of stool. He needs diapers to prevent soiling. Six months ago, he was diagnosed with Crohn's Disease. Since his colonoscopy, he has developed a painful and recalcitrant diaper dermatitis. See mother's note below*.

O/E: There is an erosive papular dermatitis of the perirectal area. Penis and scrotum not involved.

Clinical Photo:

(the artifact in the photo is a Maalox and Aquaphor mixture)

Diagnosis: Erosive papular dermatitis of perirectal area, most likely "Jacquet's Diaper Dermatitis."

Comment and Questions: The patient was difficult to examine and was very disruptive. Frustrating as the office visit was, I marveled at the patience of his mother for whom he is a full-time job. My experience with erosive diaper dermatitis is limited and this boy's mother told me her son has been seen by three pediatricians and a gastroenterologist and his problem persists. I suppose the Hirschprung's has set up a situation where he is incontinent of stool and his Down's makes management of that even more difficult. Ted Rosen described a similar patient (see references) and the management was fairly simple. I will get Ted's opinion. Please let me know your thoughts.

* Mother's note: Hi Doctor, Thank-you for today's appointment. I'm grateful for your taking the time to research this. My partner and I were at our wits end watching J. suffer with this. I forgot to mention one other product that I use on him is Caldesene powder. This has worked well but only if it is timed just right. Meaning, if we were lucky after applying it, Jarod would stay dry /continent for a long period of time, like through the entire night, and the powder would dry it out and it would begin healing. He has an average of 4 to 5 bowel movements a day, sometimes more sometimes less and his stool is the consistency of toothpaste most of the time. Is there any other info. I could share with you that would be helpful in figuring a treatment plan ?
Thank-you again for your help. I really appreciate it. Sincerely, W.

References:

1. Van L, Harting M, Rosen T. Jacquet erosive diaper dermatitis: a complication of adult urinary incontinence. Cutis. 2008 Jul;82(1):72-4.

Abstract: Jacquet erosive diaper dermatitis is typically described as a severe irritant dermatitis of the perianal region. However, Jacquet erosive diaper dermatitis, perianal pseudoverrucous papules and nodules, and granuloma gluteale infantum/ adultorum have been regarded as discrete entities or all part of the same clinical spectrum, representing the result of chronic, severe, irritant contact dermatitis. We present a case of Jacquet erosive diaper dermatitis and a discussion of the clinical spectrum of diseases to which it belongs.

2. Clinical Presentation and Treatment of Diaper Dermatitis (Full Text)