Thursday, December 24, 2015

Post-Auricular Basal Cell

The patient is an 84 year-old man with a one to two week history of bleeding from a lesion in the sulcus behind the left ear and overlying the mastoid process.  He had noticed a tumor there for a longer period of time and has covered that with a Band-aid.  The area was recently traumatized and he was seen at the Dermatology Clinic. He has a history of basal cell carcinoma of the glabella.

O/E:  There is a 2 cm erosive lesion behind the left ear that extends over the mastoid bone. 

A shave biopsy was taken from two representative areas.

Clinical Photo:
Pathology:  Basal cell carcinoma. Probably nodular, but deeper areas may show other features

Diagnosis:  The pathology confirms the clinical impression of basal cell carcinoma.

Discussion:  This is a particularly worrisome area.  While some nonmelanoma skin cancers in octogenarians can be observed, lesions in this area can be invasive into the underlying bone.  For this reason, we will recommend Mohs micrographic surgery.

Invasive basal cell carcinoma of the temporal bone.
Gussack GS et. al.
Abstract: Basal cell carcinomas involving the ear represent a spectrum of diseases, from a small superficial auricular lesion to an advanced destructive malignancy invading the temporal bone. The biologic activity of the morphea-form basal cell carcinoma variant of tumor and a postauricular location predispose to an aggressive biologic pattern. Management requires a thorough evaluation with determination of the degree of cranial and possible intracranial invasion. These lesions usually can be managed with partial temporal bone resections, although prognosis for patients with advanced lesions may be poor.
(No proof of bone invasion in this case; however, this is a setting where one needs to consider it)

Sunday, December 20, 2015

Towards Continuous Medical Education

With VGRD, since the year 2000, we have tried to provide a new paradigm of CME.  At its best VGRD provides Continuous Medical Inspiration (CMI).  This platform preceded the landmark article by Roni Zieger that we introduce you to here:

Toward Continuous Medical Education (Free Online Full Text)
Roni F Zeiger, MD. J Gen Intern Med. 2005 Jan; 20(1): 91–94.
While traditional continuing medical education (CME) courses increase participants' knowledge, they have minimal impact on the more relevant end points of physician behavior and patient outcomes. The interactive potential of online CME and its flexibility in time and place offer potential improvements over traditional CME. However, more emphasis should be placed on continuing education that occurs when clinicians search for answers to questions that arise in clinical practice, instead of that which occurs at an arbitrary time designated for CME. The use of learning portfolios and informationists can be integrated with self-directed CME to help foster a culture of lifelong learning.

Keywords: continuing medical education, Internet, distance learning, library services

Sunday, December 13, 2015

Perplexing Recurrent Cheilitis

Presented by Henry Foong
Ipoh, Malaysia
Abstract: A 20-year-old man presented with recurrent cheilitis 

HPI: A 20-year-old student presented with recurrent peeling of the lips for about 3 years. It usually began on the upper lip then involved the lower lip. Then the cycle repeated. The entire process takes about 3 weeks. He has no known drug allergy. He denied any lip smacking. He was using a moisturising non-SLS tooth paste.

Examination showed peeling of the lower and upper lip as a single friable sheet. His oral cavity and genitalia were unremarkable.

Clinical Images

Patch Tests:                                 
Gold sodium thiosulphate  ++ at 48 and 96 hours;
Iodopropynyl butylcarbamate  + at 48 and – at 96 hours
Sodium bisulphide + at 48 and 96 hours
Thimerosal +/- at 48 and 96 hours

Histopathology: The sections show a fragment of tissue surfaced by parakeratinised stratified squamous epithelium. The underlying connective tissue is moderately collagenous with mild chronic inflammatory cells infiltration and a few small blood vessels. A few lobules of minor salivary glands are observed. No granuloma seen in the sections examined. Final Path Diagnosis: Lower labial mucosa: Histologically non-specific 

Diagnosis: Chronic cheilitis

Reason for presentation  
Despite avoiding all the trigger factors such as lip smacking and use of non-SLS toothpaste, his symptoms persisted. The patch test results are probably irrelevant in his case. In a study from Singapore, toothpastes were the commonest cause of allergic contact cheilitis in males. Ricinoleic acid and the patient's own lip preparations were the commonest relevant contact allergens. The absence of granuloma practically make granulomatous cheilitis unlikely.

What is the most likely diagnosis? Could this be a case of exfoliative cheilitis? Exfoliative cheilitis, a rare, localized condition, is a chronic superficial inflammatory condition that is characterized by regular peeling of a superficial excessive layer of keratin. the cause of this condition is unknown but may be associated with depressive illness. Two other differential diagnosis comes to mind - pemphigus vulgaris and Crohn's disease.

1. Mani SA, Shareef BT. Exfoliative cheilitis: report of a case. J Can Dent Assoc. 2007 Sep;73(7):629-32. AbstractFull Free Text.

2. Lim SW, Goh CL. Epidemiology of eczematous cheilitis at a tertiary dermatological referral centre in Singapore.Contact Dermatitis. 2000 Dec;43(6):322-6. Abstract.

3.  Contact allergy in cheilitis.  O'Gorman SM, Torgerson RR.  Int J Dermatol. 2015 Nov 6.  Abstract. (See Dr. Sharquie's comments)

4. Exfoliative Cheilitis DermNet-NZ. (excellent synopsis)

chronic cheilitis, exfoliative cheilitis