Tuesday, February 25, 2014


Abstract: 36 yo Ecuadorian man with asymptomatic truncal hyperpigmentation x 8 months

HPI: The patient was seen on 2 January, 2014 complaining of the gradual development of hyperpigmentation on chest, abdomen and neck.  Good general health. He takes no medications by mouth.

O/E: confluent uniformly tan papules and plaques chest, abdomen, axillae and neck.  The primary lesions are barely elevated confluent papules and plaques. KOH negative.

Clinical Photos:

One Month Follow-up (Minocycline 100 mg b.i.d.)

Hyperkeratosis and papilloimatosis  c/w CARP
Photos courtesy of Lynne Goldberg, Dermatologist.  Boston University School of Medicine.  Department of Dermatology and Dermatopathology

Diagnosis:  Confluent and Reticulated Papillomatosis of Gougerot and Cartaud (CARP)

Course:  The patient was placed on minocycline 100 mg b.i.d. and will be seen in followup in one month.  At one month, his CARP has resolved completely,

Discussion: CARP is a true "dermatologic vignette."  Once it is seen a few times, the diagnosis is clear.  Etiology is still a question, but the disorders remarkable improvement with minocycline should give us some clues.  Azithromycin appears equally as effective.  It also costs less than minocycline and has a more benign side-effect profile.

1. eMedicine CARP

2.   Confluent and reticulated papillomatosis : a review of the literature.
Scheinfeld N.  Am J Clin Dermatol. 2006;7(5):305-13.
Confluent and reticulated papillomatosis (CARP) was first described >60 years ago. It is distinct from acanthosis nigricans. This article presents the results of a review of the literature in MEDLINE through May 2006 using the terms 'confluent and reticulated papillomatosis', 'reticulated and confluent papillomatosis of Gougerot and Carteaud', and 'reticulated papillomatosis'. A recent report has linked the presence of Dietzia spp. (family: Dietziaceae; suborder: Corynebacterineae; order: Actinomycetales) in the skin to CARP. CARP has also been linked to defects in keratinization. CARP has been reported worldwide and occurs in both sexes, all age groups, and all races. The disorder can initially manifest as hyperkeratotic or verrucous papules that coalesce to form a reticular pattern peripherally and confluent plaques centrally. Although a variety of treatments for CARP exist, oral minocycline 50-100mg twice daily has been the preferred treatment. However, recent reports of the effectiveness of azithromycin 250-500mg three times weekly may make azithromycin the preferred treatment for CARP, since it has a more benign adverse effect profile than minocycline. Other effective antibacterial treatments include fusidic acid 1000mg daily, clarithromycin 500mg daily, erythromycin 1000mg daily, tetracycline 500mg twice daily, and cefdinir 300mg twice daily. If a recent finding that CARP is caused by a bacterial microorganism is replicated, treatment should likely be determined by bacterial sensitivities, antibacterial adverse effect profiles, and cost considerations. Other oral treatments of CARP that are effective but currently disfavored because of the effectiveness of minocycline include isotretinoin, acitretin, and etretinate. There have been mixed reports regarding the effectiveness of topical treatments, which include selenium sulfide, ketoconazole cream, tretinoin, tazarotene, tacalcitol, and calcipotriene (calcipotriol).

Wednesday, February 12, 2014

Prurigo Nodularis with Squamous Cell Carcinioma

Abstract: 63 yo man with 10 month history of intense pruritus and excoriated papules and nodules

HPI:   This 63 yo retired radio announcer presents with a 10 month history of intense pruritus and excoriated papules and nodules. He is in reasonable health.  Medications include Welbutrin (bupropion) and occasional prednisone for his itching.  He's tried topical steroids and anti-histamines without relief.  Smokes ~ 5 cigarettes a day.

O/E: Skin thin from actinic damage.  There are excoriated papules and nodules on the torso and extremities.  There are two or three more exophytic lesions.

Clinical Photos:

Lab:  CBC, chemistries normal.  IgE 867 IU/Ml

Pathology:  Initial bx signed out as SCC.  Since he has scores of lesions repeat biopsies of an early and more developed lesion were taken.  Thanks to Dr. Lynne Goldberg (Boston University Skin Path) for the beautiful photomics.
Prurigo Nodularis

Well_differentiated Squamous Cell Carcinoma

Diagnosis: Prurigo Nodularis with Squamous Cell Carcinoma

Discussion and Questions:The association of SCC with Prurigo Nodularis has only been reported one time (ref 5).  Yet we do not feel this is a chance association.  There are also some articles about P.n. and KA in the literature.
Has anyone seen a similar case?  He will be treated with gabapentin and followed. A follow-up will be posted in a month or so.  The SCCs will not be re:excised at this time.
Thaldomide has been recommended for P.N. in the literature, however, it is now > $10,000 per month!

1. Journal of the American Academy of Dermatology
Volume 69, Issue 3, Pages 426-430, September 2013
Keratoacanthomas arising in association with prurigo nodules in pruritic, actinically damaged skin
Timothy P. Wu, BA, Kristen Miller, MD, David E. Cohen, MD, Jennifer A. Stein, MD, PhD  jennifer.Stein@nyumc.org

2. J Clin Pharm Ther. 2013 Feb;38(1):16-8. doi: 10.1111/jcpt.12005. Epub 2012 Sep 26.
Treatment of prurigo nodularis with pregabalin.
Mazza M, Guerriero G, Marano G, Janiri L, Bria P, Mazza S.

3. Dermatol Ther. 2010 Mar-Apr;23(2):194-8. doi: 10.1111/j.1529-8019.2010.01314.x.
Therapeutic hotline: Treatment of prurigo nodularis and lichen simplex chronicus with gabapentin.
Gencoglan G, Inanir I, Gunduz K.  (no real data on patient background)

4. Eur J Dermatol. 2008 Jan-Feb;18(1):85-6. Epub 2007 Dec 18.
Gabapentin for the treatment of recalcitrant chronic prurigo nodularis.
Dereli T, Karaca N, Inanir I, Oztürk G.  Available Free Full Text.

5.  Saudi Med J. 2000 Mar;21(3):300-1.
Squamous cell carcinoma complicating prurigo nodularis.
Al-Waiz MM, Maluki AH.
Abstract:  Squamous cell carcinoma complicating ulcerative prurigo nodularis is described in 2 patients who were having prurigo nodularis on dorsum of the feet for duration of many years. Biopsy specimens from the ulcerating nodules showed features of squamous cell carcinoma. This finding has not been previously reported. Squamous cell carcinoma should be considered in the evaluation of long standing ulcerative lesion of prurigo nodularis especially when not responding to conventional therapy.

Saturday, February 01, 2014

Changing Nevus

Presented by:
Dr. Salvatore Donatello
Dermatologica e Venereologia. Catania, Sicilia

Abstract:  44 year old man with changing naevus

HPI:  The patient was seen in July of 2012 for a general cutaneous exam. He has Type IV skin. A naevus was noted on his right shoulder.  Dermatoscopic exam was felt to be not particularly worrisome but he was asked to return to have the lesion rechecked in six months.  He returned 18 months later.  The patient thought it had been present for many years and had not noted change.

O/E: July 2012:  5 mm in diameter dark brown papule  on right shoulder.  At the time, I thought the dermatoscopic exam looked normal.  It did look like an active lesions

January 2014:  The lesion is still 5 mm in diameter.  However, the brown clods noted on dermatoscopy in 2012 have disappeared and the lesion now looks uniformly dark gray.

Clinical photos:

Clinical Photo 31.1.14
Dermatoscopic Photo 31.1.14
Plan:  The lesion was excised with 3 mm margins on 31.1.14

Follow-up:  The biopsy report showed that this is an intradermal melanocytic without any atypical features. The brown clods in the first biopsy most likely are a sign of an active growing lesion.

Discussion:  Neither lesion on its own was very worrisome.  However, fortunately we have dermatoscopic images from July 2012 and January 2014.  The brown clods have disappeared and the lesion looks uniformly gray. Although the patient was asked to return in six months he did not do so.  We have no way of knowing if the change would have been noted then.
The pathology will tell us the story.  Is this an evolving naevus or a melanoma.  The practice of medicine can be humbling. There are few articles on evolving naevi in the literature.  This case will teach us something.

We will add an update after the biopsy is signed out. I have sent the specimen to a dermatologist in Napoli with a special interest in pigmented lesions.