Monday, October 21, 2013

Talon Zumba

Abstract: 36 yo woman with brown-black macule on heel

HPI:  A 36 year-old woman presented in a panic with a recently discovered dark-brown to black macule on the heel of her left foot.  It had been brought to her attention by her pedicurist.  The patient had consulted the Internet and found articles about acrolentiginous melanoma which worried her greatly. Anamnesis revealed that she had been Zumba dancing a few days before this was discovered.

O/E: The lesion measured eight mm in diameter and was dark brown to black in color.  Dermoscopy revealed a black color with a parallel ridge pattern.

Clinical Photos:

On the suspicion that this represents hemorrhage into the strateum corneum (a condition, when on the foot, called black heel or talon noir) the lesion was pared down with a # 15 blade and some of the dark pigment was easily debrided leaving a skin colored base centrally and some petechael spots were seen at the periphery.  The patient was asked to debride the area gently with a heel shaver andgiven a return appointment in two weeks.

Talon noir can be a frightening entity for a patient.  Lacking a history, a physician can be fooled, since the parallel ridge pattern seen on dermoscopy is also present in acral melanomas.  History trumps clinical appearance,

At two weeks out, the area is almost completely resolved, this confirming the diagnosis of talon noir.
Two weeks after initial visit.

1. Talon Noir (Primary care Dermatology Society)  This is an excellent reference and there is no need for more.

Thursday, October 10, 2013

Erosive Pustular Dermatosis

Presented by Hamish Dunwoodie, MBBS
The Pas,  Manitoba Canada

Abstract:  98 yo woman with exophitic tumor of the forehead

HPI:  The patient is a light complected Caucasian with a 4 month history of a keratotic lersion on the forehead.  She has a history of nonmelanoma skin cancer.  She is a poor historian.

O/E:  4 cm in diameter crusted tumor forehead.


After crust removed
Procedure:  The lesion was compressed with a warm wet gauze pad for 10 minutes and the crust was easily removed.  A deep shave biopsy wes performed and the lesion was electrodessicated and curretted.

The specimen shows cocally confluent ulceration with underlhying granulation tissue and a moderate to dense lymphoplasmacytic infiltrate.  This is consistent with erosive pustular dermatosis.

Diagnosis:  Erosive Pustular Dermatosis

Discussion:  Clinically, I thought this was a nonmelanoma skin cancer.  Most cases of EPD are on the scalp but they have been described in other sites.

Photo:  3 week post op:
Based on path report, she was treated with clobetasol ointment 0.05% b.i.d.  for two weeks; and after this pictures wwas taken she was switched to fluocinalone 0.025% ointment for two more weeks.

1, Erosive Pustular Dermatosis
2. Erosive pustular dermatosis of the scalp and nonscalp.

Van Exel CE, English JC 3rd.
J Am Acad Dermatol. 2007 Aug;57(2 Suppl):S11-4.

University of Pittsburgh, Department of Dermatology, PA
Abstract; Erosive pustular dermatosis of the scalp is characterized by an idiopathic pustular eruption occurring in association with iatrogenic or incidental, antecedent trauma to actinically damaged skin. We present two cases of erosive pustular dermatosis, one of which occurred on the scalp, the other of which was primarily located on the face. (The editor can send a link to full text if you want.)

Friday, October 04, 2013

Nonspecific Oral and Genital Lesions

Abstract:  92 year-old woman with 6 year history of painful oral and genital lesions

HPI:  The patient is an otherwise healthy and alert 92 year old woman with painful erosions of tongue and vulva for six years. She has marked pain with eating and urination.  Mouth lesions preceded genital lesions by a few years.  She has been followed for erosive lichen planus but it is unclear if any biopsies were positive.  She has lost weight because her painful tongue causes her to avoid eating.  She has been treated with clobetasol ointment,  Viscous Lidocaine was not effective.

O/E:  Erosive lesions of tongue and labia.  No bullae noted. Remainder of cutaneous exam unremarkable.

Clinical Photos:

Pathology:  Biopsy of genital labial skin shows papillary dermal fiborsis and a mild superficial perivascular mixed inflammatory cell infiltrate.  No lichenoid infiltrate.  Direct immunofluorescence from perilesional skin was negative.  PASD negative for fungi.

Diagnosis:  Painful erosions mouth and genitalia.  At present no support for lichen planus or bullous process histologically.

Questions:  What are your thoughts? Her oral pain makes eating difficult and negatively affects her quality of life.  Are there other therapies that we could consider?