Tuesday, April 28, 2015

Collision Lesion

81 yo woman with two year history of a lesion on the left nasal sidewall.

O/E:  8 mm papule with two distinct parts.  One is a pearly papule with tortuous vessels and the other is a greasy keratotic papule with a pebbly surface.


Diagnosis: Likely Collision lesion:  Basal Cell/Seborrheic Keratosis

Plan:  Scheduled for excision

Reference:Letter: Collision tumor: importance of the new auxiliary tools for diagnosis (an illustrative case report).  Free Full Text
Menezes N, et. al. Dermatol Online J. 2011 Jul 15;17(7):12.
Abstract: Collision tumor is a term used to refer to the association of various types of tumors in time and space. Despite most of them not being clinically relevant, sometimes there is a union between a benign lesion and a malignant one. The clinical diagnosis in these cases is usually extremely difficult, particularly if one of the lesions is pigmented. Dermoscopy and confocal microscopy are noninvasive diagnostic methods that make possible the visualization of morphologic structures not visible to the naked eye, thus making diagnosis of these lesions possible. Here we describe a case in which the corrected diagnosis of a collision between a seborrheic keratosis and a basal cell carcinoma was only possible by means of confocal microscopy.

Monday, April 20, 2015

Majocci's Granuloma (presumptive)

The patient is a 67 yo man with a three month history of a dermatitis on the left wrist.  It began under his watch.  Initially treated with "a steroid cream" prescribed by his PCP.  The rash cleared but recurred shortly after he stopped the cream.  He'd moved his watch to his right arm which has developed no rash after three months.  Patient has two cats at home which occasionally scratch and bite.

O/E:  2.5 c.m. annular, scsaly plaque l. wrist.  Borders are erythematous and indurated.  No other similar lesions.

KOH scraping was negative.

Dx: Presumptive diagnosis is Majocci Granuloma.

Fungal culture taken.
Started on betamethasome disproprionate/clotrimazole cream b.i.d. for two weeks only.
Follow-up visit scheduled for two weeks.
Low threshold for biopsy if culture negative and if he is not doing well.
Switch to ketoconazole 2% cream; consider oral terbinafine.


Treatment-Resistant Plaque on the Thigh  (Free Full Text)
Collins MA, Lloyd R. Am Fam Physician. 2011 Mar 15;83(6):753-754.

Tuesday, April 14, 2015

Giant Molluscum

Presented by Henry Foong
Ipoh, Malaysia

The patient is a one year old child with a four week history of a giant molluscum on the lower eyelid. There are a few smaller papules on the trunk; but the solitary lesion pictured below is therapeutically challenging. 

I tried to curette it but was unsuccessful as the child was very fretful.
What suggestions do you have any other method of removing this?
There are many clinical reports of giant molluscum associated with HIV.  Would you test this child for that?
Your suggestions will be helpful.

Monday, April 13, 2015

Eccrine Hidrocystoma (Dermatoscopic Image)

The patient is a 21 year-old woman who has noticed a blue-purple papule on the bulb of the nose for two to three months.  If traumatized, it extrudes a clear fluid.

O/E:  There is a two mm in diameter bluish papule on the nose.  It was punctured with a # 11 blade and a drop of crystal clear fluid was extruded.

Dermatoscopic image shows a blue papule with a dark center and a paler periphery.

Diagnosis:  Probable Eccrine Hidrocystoma.

Plan:  This could be excised with a 2-mm punch biopsy.  It could also be observed.

Kluger N, et.al. Acta Derm Venereol. 2010 Sep;90(5):555-6.

Friday, April 10, 2015

2 Year Old with Nail Dystrophy

The patient is a two year-old girl with a 6 - 12 month history of a nail dystrophy.  Her brother had a similar process but this cleared without therapy after a few months.  Her pediatrician has prescribed ketoconazole cream which was not effective after 1 - 2 months.

O/E:  All nails on the left foot and two nail of the right foot are lusterless and show horizontal ridges and oil-droplet changes.  There is mild onycholysis.  Her fingernails are normal.  No other skin changes.

Clinical Photos:
The child was very apprehensive and for that  reason I did not do a KOH prep.

Diagnosis: In the differential diagnosis I included onychomycosis, evolving 20 Nail Distrophy and psoriasis.  I will see her back in 2 - 3 months. If there is no improvement, KOH prep will be performed.  I need to ask if either patent or sibling has a nail dystrophy.

Wednesday, April 08, 2015

Black Heel

The patient is a 17 year-old boy with a 6 month history of a black area on the heel of the right foot.  This began after wearing a new pair of soccer cleats.  He developed a blisters and has believed that this is from "astroturf" embedded in his skin.

O/E: A localized uniformly black area on the heel of the right foot.

Here is the dermatoscopic image.

This is most likely black heel aka "talon noir."  The dermatoscopic photo was taken after paring down the keratin and shows black globules.  I should have applied some peroxide to dissolve the hemoglobin.  Will ask the patient to do so.

Foreign body secondary to astroturf has not been reported, and this looks like black heel.  There are no good dermatoscopic images on PubMed.


Black heel, talon noir or calcaneal petechiae?
Urbina F1, León L, Sudy E. Australas J Dermatol. 2008 Aug;49(3):148-51.
Abstract:  We describe a series of six patients with superficial cutaneous haemorrhages of the feet, including a classical case of black heel (talon noir) and other similar cases with diverse clinical presentations that do not match the typical description of that process. The main differences lay in production mechanism, morphology and location. The causes of these 'atypical' lesions were: burns with hot sand, friction against the rough edge of a swimming pool, wearing new shoes, jogging, or pricking a blister with a needle. Clinically, they consisted of isolated or multiple, small, large or linear, brown or black lesions located in areas that did not include the convex part of the heel, in which talon noir usually appears; on the contrary, the lesions affected the back third of the soles, the toes, periungual fold and plantar arch. As the presence of blood in the horny layer was a common final factor in all these cases, a better name for this process would be 'post-traumatic cutaneous intracorneal blood' to describe black heel and its diverse clinical presentations.

Sunday, April 05, 2015

Scalp Burn Post-Beauty Parlor Visit

Abstract: 54 yo woman with localized hair loss after a visit to the beauty parlor

HPI: The patient is a 54-year-old woman who was seen for evaluation of a localized hair loss and dermatitis of the scalp since she had her hair roots bleached 4 – 5 weeks ago.

She notes that the roots of her hair were left exposed to the chemical for about 4 hours after application.  On a next morning, her scalp was sore and burning, and somewhat swollen throughout the day. She was seen at ER  for evaluation that night and told that her scalp was probably burnt by the hair product; and was advised to wash her hair with cool water and was given a topical medication to apply, the name of which she cannot recall today. She has been using icepack and the medication that was given from ER, which helped. She has noticed that her hair was falling out in the mid parietal area since a few days after the insult.. She was reevaluated by her primary care physician two weeks ago for dryness and pruritus of the scalp and was prescribed another topical medication but does not remember the name.

Past medical history reveals bariatric surgery in  four years ago and had an episode of transient hair loss thereafter. She has been using hair products from the same store, JCP salon, since the episode, and has not had any problems until this recent hair dye/bleach treatment. She washes her hair once weekly, and takes multiple vitamins (including biotin) for her health in general.

The patient is quite upset, angry and tearful about the situation. Currently, she is seeing a therapist for the stress. She fears that the condition will be permanent.

O/E: The skin exam shows a healthy but distraught woman with a well-defined 9.5 x 1.3 cm alopecic patch with many scattered black short broken hairs on the mid parietal scalp to vertex region. There is mild erythema on the involved scalp without evidence of atrophy or cicatrix. Her roots of the surrounding hair are dark brown to blackish about 1 cm from the root.

Clinical Photos:

Impression: Irritant dermatitis with alopecia secondary to her recent hair dye/bleach process

Plan: We had a lengthy discussion of her recent hair damage. This is likely irritant dermatitis most likely secondary to the hair dye/bleach. There is no evidence of scarring today, and her hair will likely grow back although it will take some time. We reassured the patient that we will support her while she is recovering from the recent trauma. 

Follow-up Photo: Around 7 months after chemical burn.

Marked improvement, but patient still feels traumatized.


Hair highlights and severe acute irritant dermatitis ("burn") of the scalp. Chan HP, Maibach HI. Cutan Ocul Toxicol. 2010 Dec;29(4):229-33. PubMed

2. Chemical burns to the scalp from hair bleach and dye.  Jensen CD, Sosted H.  Acta Derm Venereol. 2006;86(5):461-2.  Free Full Text

3. The hair color-highlighting burn: a unique burn injury.
Peters W. J Burn Care Rehabil. 2000 Mar-Apr;21(2):96-8.
Abstract: A unique, preventable, 2.8 x 3.7-cm, full-thickness scalp burn resulted after a woman underwent a professional color-highlighting procedure at a hair salon. The burn appeared to result from scalp contact with aluminum foil that had been overheated by a hair dryer during the procedure. The wound required debridement and skin grafting and 3 subsequent serial excisions to eliminate the resulting area of burn scar alopecia. The preventive aspects of this injury are discussed.

4.  Curling iron-related injuries presenting to U.S. emergency departments.
Qazi K et. al. Acad Emerg Med. 2001 Apr;8(4):395-7. PubMed.

Wednesday, April 01, 2015

FTM Transgender Alopecia?

This is the history of a ftm transgendered man with relatively early androgenetic alopecia.  In spite of his exogenous testosterone, the frontal hairline is preserved.  Most of the alopecia is in parietal and vertex areas.  There is only one PubMed reference that is pertinent, and that is not available full text.(1)

I am a ftm Transman. I started my transition December 2013 and have been on testosterone for about 1 year and  4 months. My resources are limited. I have been a queer female all my life, and as a result of this, economically marginal. I am very serious about my transition to male,. I realize that gender is a fluid spectrum and that I am not yet sure how I will finally present as male.

I have just turned 60 years old, though I look about 20 years younger. I have been very athletic and have always eaten healthfully and have taken care of myself.  Perhaps this is because, subconsciously, I knew that I would have to venture into gender transition at some point, and thus prepared myself.

I am a musician and performer with disabling social anxieties and gender dysphoria. This has severely hampered my ability to perform. My appearance, as an artist, and someone who must go before the public, is a critical issue for me. My biggest problem with transition at present is that I am beginning to bald on the vertex of my head. If this continues unabated, I will wind up with the typical horseshoe pate of male pattern balding.

None of the men in my family, on either side, have this type of balding. Yes they have receding hairlines on my father's side. Thus, I do think my particular balding (and its rapidity) is impacted greatly by the effect of the testosterone. This is a very disturbing and unwanted consequence of testosterone injections. In general, I want to use testosterone for my transition,  but I do not want to be used by testosterone. I don't accept the assessment, “well at your age, men bald.” That does not fly with me. I want to know what my options are proactively.  I have done extensive research on the Internet in regards to balding. I have spent a lot of money trying a number of natural DHT blockers. The problem with this, as with Propecia, is that they work by consequence of increasing female hormones, which is unwanted in ftm transition, and also, block facial hair, a secondary sexual characteristic very important for most trans guys. Secondly, it is not even clear that they work to prevent balding.

Presently, I have started to use Rogaine 5% foam (just this week, so the jury is out).  Currently, I am switching my health care to a clinic that specializes in transgenders individuals. That way, I can also evaluate my balding in terms of testosterone levels. The endocrinologist I see presently is not skilled enough in this regard.

I am extremely interested in any research or techniques that can be offered to me to prevent my balding and turn it around. I am doing all I can on my own at present, but feel there are other options and knowledge out there to which I haven't access.

I am not out to my family yet regarding my transition to male. My appearance, and the quality of my appearance is very personally important to my journey as a man and to my profession as a public performer. I need to continue to be healthy, and to look good.  I want to cure my gender dysphoria so that I can have a life. I do not want to create more obstacles blocking my success in life.

It has been a difficult journey! And, I am willing to do all I can. Unfortunately, I am not in an economic position to do all I could otherwise. I do not want this to be a limitation to my successful transition.  Thus, I am seeking all the support and help I can possibly get in relation to a truly successful transition, unlimited by my financial circumstances. I cannot adequately express my gratitude for any help on this challenging crossing.  Any benefit I receive in these ways are not only for myself, but will be knowledge freely disseminated, for the use of all transmen now and in the future.

1) Short- and long-term clinical skin effects of testosterone treatment in trans men. Wierckx K, et al.  J Sex Med. 2014 Jan;11(1):222-9.
Testosterone (T) treatment increased facial and body hair in a time-dependent manner. The prevalence and severity of acne in the majority of trans men peaked 6 months after beginning T therapy. Severe skin problems were absent after short- and long-term T treatment. PubMed.