Sunday, August 11, 2013

Hemorrhagic Blister

Abstract: A 58-year-old man with 2-day history of deep purple to black papule

History: A 58-year-old man presents for evaluation of a skin lesion on the right lower abdomen that has been present approximately 2 days. The patient does not remember having any trauma on that area. It seems the lesion appeared quite abruptly and the color has been darkened over past 2 days. No history of non-melanoma skin cancers or melanoma.

O/E: The skin exam shows a healthy and pleasant man with skin type III. There is a sharply demarcated 6 mm deep dark purple oval shaped papule on the right lower abdomen. It is somewhat compressible.

Clinical & Dermatoscopic Photos:

Polarized Dermatoscopic Photo
Non-Polarized Dermatoscopic Photo

Diagnosis: Hemorrhagic blister

Discussion: The lesion was lanced with an 11 blade. Blood product was drained and confirmed the diagnosis of hemorrhagic blister. Initially, the lesion did not obviously look as  a hemorrhagic blister. The dermatoscopic image did not show a typically appearing hemangioma. Our biggest concern was to make sure this is not a melanoma. Conventionally, melanoma would not appear in a 2-day period. A careful history led us to consider a hemorrahagic blister with a simple lancing. 

1. Bullous malignant melanoma: an unusual differential diagnosis of a hemorrhagic friction blister.
Vogt T, Brunnberg S, Hohenleutner U, et al. Dermatol Surg. 2003 29(1): 102-4



A 66-year-old woman presented to our outpatient clinic with a 3 x 2.5-cm tense, hemorrhagic-appearing bulla on her forefoot. Histopathology and immunohistochemistry confirmed a transtumoral-transepidermal blister formation within an advanced acrolentiginous malignantmelanoma (MM).


To study bullous malignant melanoma.


Blistering in MMs represents a rare but clinically important pitfall in clinical differential diagnosis. The blisters are typically due to the disruption of the cohesion between neoplastic cells and keratinocytes, but physical friction may also contribute.


Hemorrhagic blistering is, in many cases, a relatively insignificant finding in which frictional forces are imposed.


The case reported here underscores that in rare cases MMs, particularly if acrally located, can be complicated by hemorrhagic blistering. Because of the life-threatening consequences, one should be aware of this rare differential diagnosis.

Sunday, August 04, 2013

Rosacea-Like Demodeciasis

Abstract:  47 yo woman with ab 8 month history of a facial eruption
The patient is a 47 yo woman with a rosacea-like eruption for eight months.  Dr. Yoon Cohen suggested demodicosis and performed a scraping.  It was loaded with demodex mites.  We are considering this an example of rosacea-like demodexinfestation and treated the patient with ivermectin 250 microgram/kg x 2 a week apart and permethrin 5% cream 2 - 3 times a week. 


 After one week:

Diagnosis:  Rosacea-like Demodeciasis (most probably)

Discussion: It seems that this acneiform eruption is due to Demodex, but we need more time to be certain. Since Samuel Ayers, Jr. described this entity in 1930 it has been in the literature but there are still doubters in the dermatologic community.


1. Dermatol Online J. 2007 Oct 13;13(4):9.
Granulomatous rosacea-like demodicidosis. Free Full Text
Lee JY, Hsu CK.
Demodicidosis may present as pityriasis folliculitis, papulopustular lesions, rosacea-like eruptions, and granulomatous rosacea-like eruptions. We report a case of demodex granuloma presenting with recurrent granulomatous rosacea-like papules on the face in a middle-aged woman. The diagnosis of demodicidosis was made by finding extrafollicular mites in the perifollicular inflammatory infiltrate. The papules resolved after 3 weeks of systemic and topical metronidazole, and low-dose oral prednisolone therapy. In summary, demodex granuloma may be mistaken for granulomatous rosacea-like papules. Correct diagnosis can be facilitated by finding extrafollicular demodex mites in skin biopsy specimens.

2.  Cutis. 2007 Aug;80(2):149-51.
Recalcitrant papulopustular rosacea in an immunocompetent patient responding to combination therapy with oral ivermectin and topical permethrin.  Full Text PDF
Allen KJ, Davis CL, Billings SD, Mousdicas N.
A 68-year-old healthy man presented with papulopustular rosacea (PPR) recalcitrant to multiple therapies, including permethrin cream 5%. Histologic examination detected the presence of chronic folliculitis and numerous Demodex organisms. A diagnosis of rosacealike demodicidosis was rendered, and the patient was treated with oral ivermectin and permethrin cream 5%, resulting in resolution of the folliculitis. Demodex infestation should be considered in any patient with rosacealike dermatitis resistant to conventional rosacea therapies. If infestation is demonstrated in these patients, oral ivermectin in combination with topical permethrin is a safe and effective therapeutic option.

Follicular Mucinosis?

Abstract: 80 yo man with intensely pruritic papules face and neck for 2 months

HPI:  This 80 yo man has a 2 month history of 2 – 3 mm erythematous papules, mostly on face and neck. These are few in number.  A trial cobetasol ointment was without relief.  His medications are: amlodipine, HCTZ, metroprolol, Vytorin (ezetimibe and eimvastatin), Pantoprazole.  He is in good general health.

ClinicalPhotos: These show how subtle the lesions are.

Because of symptoms a Biopsy was done.
Histopath shows: focal erosion and ulceration and ectatic blood vessels.  There is a moderate to dense superficial and deep perivascular perifollicular lymphohistiocytic infiltrate with numerous eosinophils, marked mucin deposition and conspicuous disruption of the follicular epitheliumThe pathologic diagnosis includes, “infectious etiology,” eosinophilic folliculitis, and follicular mucinosis.

Diagnosis:  Acneiform Follicular Mucinosis might be the best fit.