Cheilitis Oscura

Abstract:  59 yo woman with eight month history of cheilitis.

HPI: The patient is a 59 yo woman with an eight month history of a pruritic dermatitis which began on the upper lip. It spread to the lower lip and recently to some fingers. For dental hygiene, she has used Crest toothpaste, a white ceramic nasal irrigator, dental floss, a WaterPic and a Sonic Dental Care apparatus on a daily basis.  She has changed this protocol somewhat over the past few months.  Initially, she used Desonide ointment for three to four weeks with minimal help.  She also used clobetasol ointment 0.05% for 10 days with complete clearing. After a protocol of erythromycin gel, steroid ointment, protopic 0.03% the iritation largely disappeared. However, she continues to get flare ups with no apparent cause. Symptoms always include burning, itching and redness. She uses Vaseline on a regular basis to moisten and sooth her lips. A similar dermatitis has appeared around the nail of her right ring finger, and has lingered there for 3 months. In addition, her left ear has several similar spots, and other similar spots have come and gone around her eye lids, eye brow and forehead. Most recently, she has used tacrolimus 0.03% ointment with minimal help, and for the last few weeks only Vaseline, which seems to help the most.  Because of the concern for "steroid addiction" of the facial skin, she only used topical steroids for short periods and only under close supervision.  The process waxes and wanes unpredictably.

O/E:  The process is localized, erythematous and scaly.  The secondary lesions on the fingers and ears look similar.

Clinical Photos:
12/11/11

4/8/12

4/28/12

Laboratory:

Patch Test (T.R.U.E.) all 29 negative.  More focused patch testing is indicated.

Lip culture:  Staph epidermitis and alpha hemolytic strep (interpreted as normal skin organisms)

Biopsy:  Considered, but not done at this time.

Diagnosis and Discussion: Initially, I presumed this to be an allergic contact dermatitis.  I suspect that part of her regimen is the culprit. The sharp border is unusual and could suggest a koebnerized psoriasiform process from an oral hygiene devices that comes in contact with the area.  In children, lip licking would be considered (lick eczema) but the history here does not support that diagnosis.  If the process recurs, I would ask patient to let it develop and then biopsy the lesion.  If that was not helpful, then patch testing with a dental tray would settle the issue of allergic contact dermatitis. 

Questions: Have you encountered similar cases? What are your thoughts?

Reference:  
1.  This is a helpful reference which goes into the many causes of contact dermatitis around the mouth and lips.  Available Free Full Text.  Andrew Scheman, MD, et. al.  Part 3 of a 4-part series Lip and Common Dental Care Products: Trends and Alternatives.  Data from the American Contact Alternatives Group.  Clin Aesthet Dermatol. 2011 September; 4(9): 50–53. 

2.  Here is another useful reference on persistent cheilitis, also available Free Full Text. 

Plexiform Neurofibroma

The patient is a 33 yo man seen for evaluation of a large tumor involving the left thigh.  He lives in a rural area and his last medical visit was at age sixteen.  Sadly, he was without medical insurance until recently.  He lived with his father until recently when the latter died, and now he has been taken in by a family in his community.

The examination showed a pleasant man with a sunny disposition and a broad smile.  While mildly retarded he answers questions appropriately.  His care-giver accompanied him and it is clear that she and her family have welcomed him.

The patient has the stigmata of neurofibromatosis (NF1) with scores of cafe au lait spots and neurofibromas.  Most compelling is a large plexiform NF of the right thigh.  He has other plexiform NFs of the buttock and left chest, but these are smaller.

We will attempt to have him evaluated and treated at a center which specializes in the care of patients with NF.  This post will be updated periodically.

Photos:  Left thigh, anterior and posterior views

 Your comments will be appreciated.

References: 

1. Type 1 NF  eMedicine.  Full text online.

2, KT Power, et. al. Management of Massive Lower Limb Plexiform Neurofibromatosis – When to Intervene?  Ann R Coll Surg Engl. 2007 November; 89(8): 807  Free Full Text Online

Dermoscopy Rocks

Presented by Hamish Dunwoodie, MBBS
Locum Tenens Physician,
Dakota First Nation, Portage La Prairie, Manitoba

Overview:  The patient is an otherwise healthy artist from Moncton, New Brunswick who is studying native pottery production with a First Nation's band in Manitoba.  She presented to our clinic with a one week history of a black macule on the left thenar eminence.  The patient has a past history of nonmelanoma skin cancer and is worried that this may be a melanoma.

O/E:  There is a 1 mm black macule in the above-mentioned area.  Dermoscopic image suggests a vascular lesion.  Note reddish black globules.

The lesions was shaved off, a small amount of H2O2 was applied and the residual hemorrhagic area was digested. The lesion disappeared!

Photographs:  Clinical Image, Dermatoscopic Image before shaving. Dermatoscopic image after shave and H2O2.

Discussion:  Dermoscopy established that this is a vascular lesion, a "subcorneal haematoma."  Once the dermatoscopic image was appreciated, it was gently shaved off with a # 15 scalpel and it vanished.  End of story.  We needed no special tools in this isolated practice setting to put the patient's mind at ease.  I am sure that some of our dermatoscopy experts will have more to day.

Reference:
Zalaudak I, et. al.  Dermoscopy of subcorneal hematoma. Dermatol Surg  Dermatol Surg. 2004 Sep;30( 9):1229-32.
Abstract
BACKGROUND:
Subcorneal hematoma is a pigmented skin lesion usually occurring on palms or soles after a trauma or sport activity. Clinically, it may exhibit overlapping features with acral melanoma or acral melanocytic nevi, leading to unnecessary excision of this otherwise harmless skin lesion.
OBJECTIVE:
The objective was to describe the dermoscopic features in a series of subcorneal hematomas.
METHODS:
Dermoscopic images of 15 subcorneal hematomas were evaluated for the presence of different colors and dermoscopic structures.
RESULTS:
In our series, a red-black hue was the most frequent color seen by dermoscopy (40% of the lesions) and a homogeneous pattern of pigmentation was the most frequent dermoscopic structure (53.3%). Remarkably, 40% of the lesions exhibited a parallel-ridge pattern that is usually found in early melanoma of palms and soles. In 46.7% of the lesions, red-black globules were additionally seen at the periphery as satellites disconnected from the lesion's body. Only two lesions showed either parallel-furrow or fibrillar pattern. A scratch test performed in four lesions, allowed complete or partial removal of the pigmentation.
CONCLUSION:
Dermoscopic features of subcorneal hematomas may be similar to those observed in acral melanocytic lesions. Nevertheless, in most cases the correct diagnosis can be facilitated by the presence of a red-black homogeneous pigmentation, often combined with satellite globules. A positive scratch test may be considered as an additional diagnostic clue.

Imiquimod and Keloids

The patient is a 42 yo man who had a cyst I&D's on his mid-back four years ago. Postoperatively,  a keloidal scar developed.  It is very painful and pruritic.  He has had intralesional triamcinalone acetonide 40 mg/cc without much effect.

The lesion measures almost 4 cm in diameter, but, being sessile, the base is only ~ 2 cm wide.

Plan and Question:  We propose to shave this off and use imiquimod post-operatively as has been done with earlobe keloids.  Does anyone have any experience with this for keloids at sites other than earlobes?  Any other suggestions?  The literature on imiquimod use after keloid removal is all over the map.  One wonders whether employing imiquimod followed by judicial use of intralesional triamcinaloine might be appropriate.

5 Weeks p Shave excision: C&E, followed by imiquimod 5 days per week.  At this point we will stop the imiquimod and follow.  Patient does not live near to my office and can be seen only once a month or less frequently.

8 weeks p shave excision:  The patient stopped imiquimod 2 - 3 weeks ago and just applied Vaseline.  The wound is looking better.  There's a slightly raised area in the middle of the erythema.

6 months after surgery.  These is a subtle scar in the mid-portion of the excision.  The area is still quite pruritic.  Will try clobetasol ointment to area, Monday, Wednesday and Friday.  Scars are rich in mast cells and this likely explains the itching;

1 year follow-up shows small hypertrophic scar which is a considerable improvement over baseline.

 References:
1.  Treatment of keloid scars post-shave excision with imiquimod 5% cream: A prospective, double-blind, placebo-controlled pilot study. J Drugs Dermatol. 2009 May;8(5):455-8.  URL

2.  Successful treatment of earlobe keloids with imiquimod after tangential shave excision. Dermatol Surg. 2006 Mar;32(3):380-6.  URL

3.  Failure of imiquimod 5% cream to prevent recurrence of surgically excised trunk keloids.  Dermatol Surg. 2009 Apr;35(4):629-33.  URL

54 yo man with necrotizing vasculitis

Abstract: A 54 year old man presents with long-standing rosacea and a few week history of mildly pruritic papules on his thighs.

HPI: The patient is otherwise well and has been treated with doxycycline for greater than five years for severe rosacea. Recently, it has not been effective. He presented for alternative therapy; and at the time of the visit he mentioned an a pruritic papular eruption of his thighs for two to three weeks. He has had recent onset hypertension and was started on HCTZ about a month ago.

O/E: Erythematous papules and small nodules on face. There are scattered three - four mm papules erythematous papules on the medial thighs. The remainder of the examination is unremarkable.

Clinical Photos:

Subtle Lesions on Thighs

Pathology: Necrotizing vasculitisof deep dermal artery. (Photomicrographs courtesy of Marjan Mirzabeiji, M.D., Boston University Department of Dermatology, Dermatopathology Section)

Lab: CBC normal, Chemistries normal, BUN/Cr normal, ANA 1:1280 Homogenous, ANCA panel negative

Diagnosis: Cutaneous Polyarteritis Nodosa (drug-induced) or microscopic polyangiitis. Doxycycline or HCTZ may be putative.

Discussion: This is an "interesting" case. A man walks in with rosacea and winds up with necrotizing vasculitis. He has some protein in his urine and a positive ANA. There's an old saying: It is often more important to treat the patient who has the disease than the disease the patient has. This may be a case in point.

Questions: What is your diagnosis and what more would you do?

Reference:
Rogalski C, Sticherling M. Panarteritis cutanea benigna--an entity limited to the skin or cutaneous presentation of a systemic necrotizing vasculitis? Report of seven cases and review of the literature. Int J Dermatol. 2007 Aug;46(8):817-21
Abstract: In 1931 Lindberg described a limited and benign subcutaneous form of panarteritis nodosa, which, in contrast to systemic panarteritis, only affects the skin. The terms panarteritis nodosa cutanea benigna, cutaneous polyarteritis nodosa, apoplexia cutanea Freund as well as livedo with nodules are used synonymously for this vasculitis which predominantly affects women in the fifth decade of life. Cutaneous lesions characteristically comprise painful subcutaneous nodules or vasculitis racemosa at the lower extremities. The cutaneous panarteritis may be regarded as its own entity or an isolated skin manifestation within systemic panarteritis nodosa. Full Abstract.

Cutting

Once or twice a month, I see patients with distinctive scars, mostly, but not always, confined to their arms. A recent patient prompted this post. The photo and text are presented with her approval as she feels her story needs to be told.

The patient is a 66 year old insulin dependent diabetic who presented with a dermatitis of the abdomen. It had non-specific features and was KOH negative. Most likely a xerotic eczema or an irritant contact dermatitis. Linear scars were noted on her arms and I questioned her about this. She had been the object of sexual abuse for many years as an adolescent and cutting was her outlet.

Cutting is a form of self-injury (aka nonsuicidal self-injury - NSSI). In my, albeit limited, experience, most cutters are or have been victims of abuse, often sexual abuse. These patients usually are receptive to discussion about their cutting and its causes. Viewing these lesions may be an opportunity to show compassion and understanding for these patients.

Cutting, almost always, is a sign of "Adverse Childhood Experiences." These, ACEs have negative impacts on one's health as an adult and are well described in a New Yorker article, "The Poverty Clinic."

For more on cutting:
Wikipedia
Why People Hurt Themselves
The Poverty Clinic by Paul Tough. There is a full text pdf online which I can not link here.

If you encounter a person with acute cutting, Brief Therapy Heals Trauma in Children, by Jane Brody, is worth reading.