Wednesday, January 16, 2013

Single Nail Dystrophy

Abstract: 22 yo man with 4 month history of an abnormal nail

HPI:  22 yo man with 4 mo history of a nail dystrophy.  It began with erythema and small pustules on finger tip.  A few weeks later the nail started to look abnormal.  No other skin lesions.  This began after starting a new job at which he uses a "mouse" for many hours a day and he thought it might have traumatized his finger tip.  A brother has "eczema" of the knees. 

O/E:  The right small finger nail is lusterless, dystrophic and for the most part separated from the nail bed.  There is some mild thickening.   No  marked finger tip eczema at present, but mild erythema is noted.

Clinical Photo:
left and right index finger tips

 Lab:  KOH negative.  Fungal Culture negative at two weeks.

Diagnosis:  Nail dystrophy.  Acrodermatitis continua vs. Psoriasis (probably latter)

Questions:  What is your diagnosis?  How would you treat this?


Friday, January 11, 2013

Cheilitis Challenge

Dr. Yogesh Jain from  presents a dramatic case of cheilitis for your opinion.

He reports: “These lesions have been present for 6 months in this 20 year old woman.
They are rather itchy. On direct questioning she admits to a tendency to lick her lips. She also has some rawness of mouth after eating spices. There are no other systemic symptoms or signs."

Clinical Photo:

He asks "Is this lip lick dermatitis ?

Questions: Do you think this is atopic or allergic contact?  It would be good to know if this woman has a personal or family history of atopy?  If patch testing is difficult because of where she lives, what would be your approach?

Diagnosis:  Cheilitis.  Lick Eczema vs. Allergic Contact Dermatitis

1. Contact allergy in chronic eczematous lip dermatitis. Schena D, Fantuzzi F, Girolomoni G. Eur J Dermatol. 2008 Nov-Dec;18(6):688-92. doi: 10.1684/ejd.2008.0520. Epub 2008 Oct 27.  Email:  Free Full Text Link.
Abstract:  Chronic eczematous cheilitis comprises a heterogeneous group of disorders, the cause of which often remains obscure. Our object was to investigate the frequency of contact allergy in a cohort of patients with chronic eczematous cheilitis attending a tertiary referral clinic. Patients (106 females and 23 males) with chronic eczematous cheilitis were analyzed retrospectively. All patients were tested with a standard patch test series and a fraction with a dedicated patch test series. Children were also tested with atopy patch tests. Moreover, all patients were investigated for past or current presence of atopic diseases. Patch-test reactions of possible or probable relevance were detected in 84 patients (65.1%; 72 females; median age 40), of uncertain or not relevant significance in 26 (20.1%) and negative in 19 (14.7%). An extended series was necessary to reveal hapten hypersensitivity in 42 patients. The most frequent causes of allergic cheilitis were nickel, fragrances, balsam of Peru, chromium salts and manganese salts, present primarily in cosmetics, dental materials and oral hygiene products. Twenty four patients (18 females; median age 21; 18.6%) were diagnosed as having atopic dermatitis of the lips. Four children had allergic contact cheilitis to haptens or food allergens, whereas six had atopic cheilitis. Twenty one cases (16.3%) were considered irritant contact cheilitis. Allergic contact cheilitis is common in adult patients, with the haptens responsible varying with age. Patients with chronic eczematous cheilitis should undergo extended patch testing.

2. Epidemiology of eczematous cheilitis at a tertiary dermatological referral centre in Singapore. Lim SW, Goh CL. Contact Dermatitis. 2000 Dec;43(6):322-6.
Epidemiology of eczematous cheilitis at a tertiary dermatological referral centre in Singapore.
Abstract: In a retrospective epidemiologic study of 202 patients with eczematous cheilitis attending a patch test clinic, females (182 (90%)) predominated over males (20 (10%)). The mean age of our patients was 30.9 years. There was no significant difference between the mean age of females (31 years) presenting with cheilitis compared to males (29 years). Endogenous cheilitis (53%) was the commonest diagnosis, followed by allergic contact dermatitis (34%) and irritant contact dermatitis (5.4%). A personal history of atopy was recorded in 33%. There was no significant difference in the prevalence of atopy between the sexes or among the diagnoses. The mean duration of cheilitis was 16.4 months. The duration was significantly longer in males (29 months) than in females (15 months) (p=0.004). The mean number of positive patch test reaction in patients with allergic contact cheilitis (2.8) was significantly higher than in those with irritant contact cheilitis (0.2) (p = 0.012) or endogenous cheilitis (0.5) (p = 0.00). The commonest cause of allergic contact cheilitis were lip cosmetics, including lipsticks and lipbalms, followed by toothpastes. The commonest cause of irritant contact cheilitis was lip-licking, lipsticks and medication. In 81/202 (40%) patients, 1 or more causes of contact cheilitis could be ascertained. In females, lip cosmetics were the commonest cause, accounting for 54% (44/81) of cases. Toothpastes accounted for 21% (17/81), followed by topical medication 7% (6/81). For males, toothpastes were the commonest cause of allergic contact cheilitis. Ricinoleic acid and the patient's own lip preparations were the commonest relevant contact allergens.

Tuesday, January 08, 2013

Lichen Striatus vs. Blaschkitis

History: The patient is three year old Filipino boy with a one year history of linear slightly elevated incompletely hypopigmented lesions on the right shoulder extending to the right arm.  He has no other significant skin lesions and his health is good otherwise.  The process seemed to resolve at one point only to recur.

O/E:  The dermatosis extends from the posterior right shoulder to the right upper arm and consists of confluent barely elevated hypopigmented papules in a linear distribution.

Clinical Photos:

Lab and Biopsy:  These will be non-contributory.

Diagnosis: Lichen striatus vs. Blaschkitis

Questions:  Can one differentiate between L.s. and Blaschlitis?  Is any treatment indicated for an asymptomatic child who is not bothered by the eruption?


Lichen striatus: clinical and laboratory features of 115 children.
Patrizi A, Email:
Department of Clinical and Experimental Medicine, Division of Dermatology, University of Bologna, Bologna, Italy.
Abstract:  To analyze the clinical features, response to treatment, and follow-up of lichen striatus and any associated symptoms or disease, we designed a retrospective study involving 115 affected children at the Pediatric Dermatology Unit of the Department of Dermatology of the University of Bologna, Bologna, Italy. Between January 1989 and January 2000 we diagnosed lichen striatus in 37 boys and 78 girls (mean age 4 years 5 months). We studied their family history and the season of onset, morphology, distribution, extent, duration, histopathology, and treatment of their lichen striatus. We found that family history was negative in all our patients except for two pairs of siblings. The majority of children had the disease in the cold seasons; precipitating factors were found in only five cases. The most frequently involved sites were the limbs, with no substantial difference between upper and lower limb involvement. When lichen striatus was located on the trunk and face, it always followed Blaschko lines; in seven children the bands on the limbs appeared to be along the axial lines of Sherrington. In 70 cases, lichen striatus was associated with atopy. The mean duration of the disease was 6 months and relapses were observed in five children, and in one instance the disease had a prolonged course. Only a few case study series of lichen striatus in children have been reported and ours is the largest to date. The etiology of lichen striatus remains unknown in the majority of our patients. The confirmed association with atopy observed in our patients may be a predisposing factor. It has generally been accepted that lichen striatus follows the lines of Blaschko, and this distribution is a sign of both a topographic and a pathogenetic concept. In patients where lichen striatus is along axial lines, a locus minoris resistentiae, we suppose that this distribution may only be an illusory phenomenon in instances in which the trigger factor prefers this route, consisting of several successive Blaschko lines, but appearing as a single band.

Wednesday, January 02, 2013

Zinc Deficiency Syndrome?

Abstract:  53 yo woman with one month history of wide-spread dermatitis.

HPI:  The patient is a massively obese woman who weighed 750 pounds a year before her office visit but at present weighs around 350 pounds.  Her weight loss has been achieved by severe calorie restriction (she lives in a care facility).  Her skin was clear until a month before the office visit.  By history, the dermatitis began on hands and arms, spread to skin folds, postauricular areas and angles of mouth.  She has had some diarrhea.

O/E:  The patient appeared alert, tired and massively obese. She had a papulosquamous eruption on arms consisting of erythematous patches with fine superficial scale.  There was erythema in all examined skin folds with mild serous discharge.  She had an erosive postauricular dermatitis and angular cheilitis (see photo).  Dental hygiene was good and KOH prep from angle of mouth showed very rare yeast forms.

Clinical Photo:

Lab:  Post auricular culture grew Staph aureus (MRSA) and Pseumonas.  Serum zinc 0.58 mcg/ml (normal 0.66 - 1.1 mcg/ml)

Biopsy from arm lesion showed orthokeratosis, subcorneal neutrophils, focal hypogranulosis and psoriasiform hyperplasia consitent with psoriasis or given her history acrodermatitis enteropathica.

Diagnosis:  The short history of dermatitis here suggests a nutritional etiology may be considered.  This woman had no history of skin disease until a month before her office visit.  She had been on a very restrictive diet and it is unclear how carefully vitamins and micronutrients had been monitored.  The low zinc level may not be the only deficiency she has.  Her MRSA should be addressed, but low zinc may have set up a situation where MRSA could thrive in skin folds (an altered skin microbiome).

Questions and Comments:  This is a complex case and it is unlikely that sinc supplements will address all of this woman's needs.  A nutritionist may help.  The angular cheilitis was a clue to "think zinc."  Her MRSA needs to be addressed as well as the intertrigo.  She is relatively young and healthy. Considering her obesity, a multidisciplinary approach could help her.  In the setting of a group home this may not be forthcoming.  Patients like this can be marginalized in any health-care setting and present diagnostic and management problems.  There are many more questions?  What did her hemogram show?