Pretty, Ugly Thing

This 64 yo light-complected carpenter noticed a few rough spots on his chest. Since he vacations in Mexico two to three times a years, he is worried re: skin cancer.

A skin exam showed a 4 mm nodular BCC on his chest and a few hypertrophic AKs on the chest.  An incidental finding (that he was unaware of) was a 6 mm in diameter irregularly pigmented papule on the right upper back.  The dermatoscopic image is ugly and worrisome.

He is scheduled for an excisional biopsy.

This case is very similar to that presented on VGRD last week.  Therefore, this patient probably has a SSM that is < 1 mm thick.  We will see.

New Pigmented Lesion

Thiss 56 year-old man was brought into the office by his wife who has noticed a new pigmentedlesion on his mid-back for around a year.  He did not see the point in coming in, but she made the appointment and came in with him.

The exam showed a 1.1 cm pigmented nodule with a play of color and irregular borders.  The dermatoscopic exam shows whitish areas, black areas, and pigment dots (among other things).

Clinically, I thought this was a superficially spreading melanoma.  I could not be 100% sure it was not a seborrheic keratosis.

An excisional biopsy was done.  Pathology will be added in a few days.
Pathology:  Superficial spreading melanoma, at greatest, 0.68 mm thick.
I will recommend a WLE.  Not further studies.

Note:  Often, a wife will make the appointment for her husband who is reluctant to see the physician.  This patient insisted on going to work as a pipe-fitter after the excision.  When a wife finds a lesion on her skin and asks her husband to take a look; he often says to her, "If your worried, see a doctor."

A Case for Diagnosis

History: The patient is an otherwise healthy 67 year-old writer with a three month history of an intensely pruritic papular and pustular dermatitis in an otherwise.  He’s been on Welbutrin, HCTZ and Lipitor for years.   Previously treatments with triamcinolone 0.1% ointment and prednisone for two weeks were not helpful. 

O/E:  There are hundreds of 2 – 3 mm erythematous papules on arms, legs, torso, scalp.  Face spared.  No lesions on hands, feet or genitalia.

Clinical Images:

Pathology:

Lab:  CBC, Chemistries normal.  Wound culure grew 2+ SAUR sensitive to everything.
The patient was treated with Keflex 250 mg qid for a week and Prednisone starting at 40 mg a day.  He cleared quickly, but when he stopped the prednisone after ~ 3 weeks, the eruption and pruritus recurred.  The new lesions are distinct erythematous papules mostly on the torso.  Background looks normal.

Thoughts:  Could this be "subacute prurigo" othewise known as Itchy Red Bump Disease?  I will have slides reviewed and offer another biopsy to the patient.

Cutaneous Sarcoidal Granulomas

thinking outside of the box

57 year-old woman with a one-year history of an eruption on arms and legs

This 57 y.o. woman first noticed asymptomatic, erythematous patches on arms and legs a year ago.  She is in otherwise good health and was taking Losartan/ HCTZ and Pravastatin for hypertension and cholesterol by mouth.  She lived in Texas for five years in the 1980s, but otherwise spent her entire life in Western Massachusetts.

In September 2016, biopsies obtained from the right arm and left leg showed sarcoidal granulomatous dermatitis.

Clinical:
Her skin lesions, mostly on the arms and legs, are few and scattered. They are erythematous, slightly scaly, ill-defined plaques with irregular borders.

Pathology:
Photomicrographs graphs and interpretations courtesy of Dr. Deon Wolpowitz
Boston University, Department of Dermatology
The specimen exhibits superficial and deep, nodular well-formed collections of epithelioid histiocytes and multinucleated giant cells forming granulomas with sparse to mild lymphocytic rims and a moderate superficial and mid perivascular lymphocytic infiltrate. The histologic differential diagnosis includes sarcoidosis, a foreign body reaction, and infectious etiologies including mycobacterial infections. Polariscopic examination is negative. Fite stain is negative for mycobacteria. PAS stain is negative for fungal organisms.

Lab:  CBC and chemistries were normal, as was her chest x-ray.

Discussion:  This woman has no risk factors for sarcoidosis, but did spend five years in a geographic setting where sarcoid is more commonly seen. The only thing we came up with was that she was using a cat litter with silica in it and there is one reference in the literature to that being associated with sarcoidosis.

References:

1. Cat litter is a possible trigger for sarcoidosis.

Drent M, Wijnen PA, Boots AW, Bast A. Eur Respir J. 2012 Jan;39(1):221-2.  Free Full Text.  This is the fascinating report of a single case of pulmonary  sarcoidosis that appeared to be causally related to silica containing kitty litter.

2. Mahony J, Helms SE, Brodell RT.  The sarcoidal granuloma: A unifying hypothesis for an enigmatic response. Clin Dermatol. 2014 Sep-Oct; 32(5):654-9

Abstract: Although the cause of sarcoidosis is unknown, there is growing support for the concept that sarcoidal granulomas result from a hypersensitivity reaction producing a nonspecific response to an extrinsic or intrinsic (autoimmune) antigen in genetically susceptible individuals. The immune milieu associated with these antigens, localized in a specific cutaneous area, produces a variant of Ruocco's "immunocompromised district." This may explain the predilection for sarcoidal granulomas in association with foreign bodies, tattoos, herpes zoster-affected dermatomes, and scars. Similar antigenic stimulation produces sarcoidal granulomas surrounding internal tumors. Finally, systemic sarcoidosis, as manifested by hilar adenopathy, may reflect the lymphatic spread of foreign antigens.

Chronic Localized Folliculitis

The patient is a healthy 28 yo man with a five year history of erythematous papules and pustules on the central upper chest.  No improvement over the past few years.

O/E:  There are erythematous crusted papules and pustules mid upper chest.  No other cutaneous lesions.

Clinical Photos:

Path:  4 mm punch bx x 2: Both specimens show a dense perifollicular neutrophilic iinfiltrate forming abscesses and infiltrating follicular epithelium with admixed lymphocytes, plasma cells and histiocytes.  GMS and PAS and gram stain negative.
Deon Wolpowitz, M.D. of B.U. Skin Pathology provided these impressive microscopic photographs.

Lab:  Two bacterial cultures taken from a pustules a year apart show only coagulase negative staph. 

Diagnosis: Chronic Localized Folliculitis.  Simplistically, I am thinking about Majocci's granuloma or an atypical form of acne.

The patient is reluctant to try isotretinoin or systemic antibiotics.  He is a healthy person in all other respects and has fears about messing with is microbiome and has read about isotretinoin and is worried.

Chronic Recurrent Axillary Dermatitis

Six yo old boy with > 3 year history of recurrent dermatitis

HPI:  The patient is an otherwise healthy six year-old boy with a > three year history of a dermatitis in the left axilla.  There is no pertinent family history.  He has had similar areas since infancy.  A culture taken in February 2013 showed many coag + Staph aureus. He was treated then with mupirocin ointment and betamethasone valerate 0.1% cream with good results.

O/E:  Localized crusted erosions left axilla. No other lesions today.

Clinical Photos 10/31/16)

Lab: Repeat bacterial culture taken.

Sulzberger on Caring for Patients

Yoon Cohen sent this quotation to us.  Readers of VGRD will appreciate it:

I know of no better way to start teaching a student of medicine than by repeating over and over the old-time physician's concept of his responsibilities toward his patients: to cure sometimes; to help often; to comfort always.

Perhaps the most fundamental requirement to become a more than ordinary practitioner is to be able to put yourself as wholly as possible into the patient's place. This is not as easy to do as it sounds. I told my young colleagues: "As you sit opposite your patient, try to think about his or her problems so intensely that you lift yourself mentally into his shoes, his seat, his pants, his home, his work, his problems."

They were told over and over again: "Every patient who comes to us is in trouble. Whether the complaint seems serious or trivial to you, it is serious to the patient and deserves your full attention and your best efforts. You may have just seen ten patients with more grave or more interesting skin diseases, but to the patient you are now examining, his trouble is the most important in the world at that moment. You must be kind and patient even with those who are over-demanding, unreasonable, even antagonistic. Remember that those attitudes too are signs of illness and often the results of fear, anxiety, or ignorance."  

Marion B. Sulzberger

Florid Acneiform Eruption

Presented by: 
Marina Delgado, M.D.
Apache Junction, Arizona

The patient, a 21 woman  with a 9 year history of acne is studying in Arizona.  Her acne, present since age 12, was relatively quiescent until it flared three months ago when she was doing research in Southern China.  In the past, she had been treated with topicals, antibiotics and oral contraceptives.  None were effective; but her acne was not florid as it is now.

10.9.2016

 After treatment with prednisone and isotretinoin.

5.12.2017

Photos are presented with the young woman's consent.
 
One of our pediatric dermatology colleagues suggested that this woman has pyoderma faciale.

We recommended isotretinoin plus prednisone but, because of iPledge, the patient has to wait a month to qualify for isotretinoin.

Have you managed similar patients?  What suggestions do you have?  What do you see as the role for prednisone and how long shoould it be continued?

References:

1. Pyoderma faciale: Successful treatment with isotretinoin

Victor J. Marks, Robert A. Briggaman

J Am Acad Dermatol 17, 1062–106. 1987  PDF.

2. Henry Foong. Pyoderma faciale, Virtual Grant Rounds in Dermatology, October 2001.

3.

Combination of low-dose isotretinoin and pulsed oral azithromycin in the management of moderate to severe acne: a preliminary open-label, prospective, non-comparative, single-centre study.  De D1, Kanwar AJ. Clin Drug Investig. 2011;31(8):599-604.

RESULTS: Sixty-two (93.9%) of 66 eligible patients had complete clearance of disease activity after a mean treatment duration of 21 weeks. The mean total cumulative dose of isotretinoin was 49.6 mg/kg. Seven (11.3%) patients had a relapse of disease during the post-treatment follow-up period. Fifty-three adverse effects were observed. Three patients had initial aggravation of disease that was managed with prednisolone and disappeared with continuation of treatment.

CONCLUSION: A combination of low-dose isotretinoin and oral azithromycin pulse is effective in severe acne and has a reasonably acceptable adverse-effect profile and low post-treatment relapse rates.  Abstract.

 

Extensive Darier's Disease

This 55 yo man presents with a flare of Darier’s disease. In his own words, he suffers from “mental illness” and has been on lithium for decades. He very embarassed about his skin and feels that he looks “hideous” because of this. Two yeas ago he had squamous cell carcinoma of the base of the tongue that was treated with surgery, radiation and chemothreapy.  This is in remission presently.

O/E: The examination shows widespread discrete and confluent reddish-brown greasy papules on the the chest and back. 

We have treated him successfully with isotretinoin in the past and were concerned about the possible interaction between lithium and isotretinoin, but the patient is at his wits end with his disease.

PLAN: He was requalified for iPledge today. He will be started on 40 mg of isotretinoin a day. In a month, we will do biochemistry survey, CBC, lipid profile, and lithium level.  We will obtain his last lithium level, in addition.

Have you managed similar patients and if so, what are your recommendations?

The patient was treated with 40 mg of isotretinoin daily.  After a few months, he is completely clear and his dosage is being tapered.

 

References

Isotretinoin treatment of Darier's disease.
J Am Acad Dermatol. 1982 Apr;6(4 Pt 2 Suppl):721-6.
Dicken CH, et, al.

Airborn Contact Dermatitis?

The patient is an 83 yo woman who has had a recurring pruritic dermatitis located mostly on face, neck and upper chest for two years.  It seems to be more prominent seasonally.  She has a history of a lymphoma ~ five years ago.  She had alopecia universalis for many years that spontaneously remitted ~ two years ago.

O/E:  Florid erythema of face and neck.  Submental area does not appear to be spared.

This woman has a somewhat "leonine" facies.

Diagnosis:  Initially, I thought she had a contact dermatitis or the "red face syndrome" from overuse of topical corticosteroids. She has been off the latter for > 1 year.  The has needed prednisone to control this; but I prefer a long-term medication with less side-effects.  Given her history of lymphoma, further evaluation may be necessary.


References:

Azathioprine versus betamethasone for the treatment of parthenium dermatitis: a randomized controlled study.

Verma KK1, Mahesh R, Srivastava P, Ramam M, Mukhopadhyaya AK.

Indian J Dermatol Venereol Leprol. 2008 Sep-Oct;74(5):453-7

Author information: prokverma@hotmail.com

Abstract

CONCLUSIONS: Azathioprine and betamethasone appear to be almost equally effective (P=0.0156 vs. 0.0005) in the treatment of parthenium dermatitis. However, adverse effects and relapses were observed to be more frequent in patients treated with betamethasone. Free Full Text

Postiive Band-Aid Sign

The patient is a 77 y.o. man who presented with a number of skin lesions.  He has a past history of non-melanoma skin cancer.

The lesion in question has been present for a few months.  It is an almost 5 cm in diameter exophytic tumor.

Diagnosis:  Probable Squamous Cell Carcinoma.

I anesthetized the lesion and shaved it off.  There was a fair amount of bleeding.  I curretted it and cautrized the base. It was not as soft as a typical SCC or BCC.  Specimen submitted and I'll attach a follow-up with the path.

Pathology:  Well-differentiated squamous cell carcinoma

This is a particularly good example of the "Positive-Band Aid" sign.  Most of us know this, but it has not been well-reported in the literature.  We presented this sign on the VGRD Blog in 2007.

The Tortured Tube

The patient is a 25 yo man with a 4 mo hx of an eyelid dermatitis.  His mother, a health professional, gave him 0.1% triamcinalone oinment to apply ~ 2 months ago.  It has run out and he came in for an appointment.  He is healthy and has a history of atopic dermatitis that is now quiescent.

Diagnosis and Discussion: I think this is an example of "steroid acne."  It's hard to tell what preceded it.  Most topical corticosteroids when applied for weeks or more to thin skin such as is seen on the face (expecially eyelids or around the mouth) or the genitalia can cause this.  It's a type of steroid addiction.

The standard treatment is to stop the topical steroid, apply cold compresses two time a day and doxycycline 100 mg b.i.d. for a month or more.  The longer this has been going on, the harder it is to treat.

Reference:  Dr. Ken Fowler and I reported a similar patient in 2001.

Tortured tube" sign. Fowler KP, Elpern DJ.  West J Med. 2001 Jun;174(6):383-4. Free FullText Online.

Linear Pruritic Lesions

Dr. Yogesh Jain would appreciate your comments about the following patient:

18 year old man with no significant past medical history, presented with these lesions to the OPD.  He revealed that he has been having such lesions ever since he was 2 years of age. These excoriative lesions are very itchy, but not painful. They extends from the left groin till the medial malleolus in a continous pattern. And also involve the left arm in a similar fashion affecting the palm as well. He is not on any medications.   There are no other systemic positive finding.

Dermatitis Neglecta

The patient is a 15 yo boy with a three month history of a dermatosis of his cheeks.

O/E: Slightly greenish symmetrical dermatosis of cheeks.  Othewise, normal.

Photos taken by patient's mother and emailed to me.

Dermatoscopic images before and after area was cleansed with an alcohol pledget.

Diagnosis:  Dermatitis Neglecta

There are no descriptions of the dermatoscopic appearance of this disorder.

Laugier Hunziker syndrome

The patient is a 74 yo man with a long history of oral hyperpigmentation.  He was presented on VGRD in 2012, but we have further history now.  The pigmentation has been present many years. His mother had a similar process by history.

He has a history of colon polyps. His paternal grandmother had colon cancer. His mother had colonic polyps and breast cancer. His father and his father’s brother both had leukemia.

O/E:  There are multiple dark brown irregular lenticular hyperpigmented macules of 2–5 mm diameteron the lower lip ant tongue.  No other hyperpigmentation was noted.

Clinical Image:

Diagnosis: Laugier Hunziker syndrome vs Peutz Jeghers syndrome

Case to be discussed at Hot Spots 2016

References:

1. Laugier–Hunziker Syndrome: A Rare Cause of Oral and Acral Pigmentation

Silonie Sachdeva, Shabina Sachdeva, and Pranav Kapoor

J Cutan Aesthet Surg. 2011 Jan-Apr; 4(1): 58–60.

Abstract: Laugier–Hunziker syndrome (LHS) is an acquired, benign pigmentary skin condition involving oral cavity including lower lip in the form of brown black macules 1–5 mm in size, frequently associated with longitudinal melanonychia. There is no underlying systemic abnormality or malignant predisposition associated with LHS, and therefore the prognosis is good. Important differential diagnoses include Peutz Jeghers syndrome and Addison’s disease among other causes of oral and acral pigmentation.  PubMed Central.

Annular Lesions in a 50 yo woman

This image was sent by Dr. Yogesh Jain from India for diagnostic suggestions.
The only history provided was that the process is present on the hands and feet and has been ongoing for 25 years. The lesions regress after a number of months.

Other than a variant of granuloma annulare or elastosis perforans serpiginosa, what are your thoughts?

Biopsy is important but so is the dermatopathologist who reads it.

What is Right Care?

The patient is a 90 year-old man, homebound with a dementia.  His 87 year-old wife is a steadfast, loving and loyal caregiver.  His dermatologist has made house calls for the past four months. 

There are non-melanoma skin cancers on the left cheek  and mid upper lip.  The former lesion has increased from 1.3 to 1.5 mm in diameter and the the lip lesion has increased from 1.8 to 2.2 mm in diameter in the past two months.  Both are somewhat inflammatory and crusted. He picks on the lip lesion, but because of his dementia he can not articulate what it is that bothers him.

7.28/15

March 2016

6.28.2016

8.11.16

Thoughts: The question is what is the best treatment for this man.  The lesion on the left cheek could be curetted and desiccated in the office. The lesion on the lip is a more complicated problem. 

A trial of topical 5-FU plus imiquimod may be helpful, especially for the lesion on the lip, as a palliative procedure.  The lesion on the malar eminence which grew rapidly ~ 6 months ago and is either a squamous cell or a keratoacanthoma) could be curetted and dessicated.

The patient can not make a decision for himself and his wife wants to just watch these lesions.  She understands that treatment is not likely impact on his quality of life at this point and want’s to spare him the trauma or surgery.

As physicians, we feel compelled to “do something.”  Is this the right time to “not just do something, but to sit there.”

Reference:

1. Linos E. Treatment of nonfatal conditions at the end of life: nonmelanoma skin cancer.  JAMA Intern Med. 2013 Jun 10;173(11):1006-12

CONCLUSIONS AND RELEVANCE: Most NMSCs are treated surgically, regardless of the patient's life expectancy. Given the very low tumor recurrence rates and high mortality from causes unrelated to NMSC in patients with limited life expectancy, clinicians should consider whether these patients would prefer less invasive treatment strategies.  PubMed.  PMC Free Full Text.

2.  Knocking on Heaven’s Door by Katie Butler is an honest, sobering book that describes what awaits so many elderly people and their caregivers, who are often family members.  It is relevant to how one manages a patient such as the man described and discussed here.

Hypopigmentation in an African

The patient is a 39 yo man from Ghana.  His wife noticed these spots on his back recently.  My first diagnosis was tinea versicolor; but KOH prep showed only spores.  Is this just quiescent T.v.?  It's symmetrically distributed over upper back (no where else).  In differential diagnosis was vitiligo -- but this is incomplete hypopigmentyation (which can occur with vitiligo, but less commonly).  I suggested ketoconazole cream and a follow-up in 3 months.  If still present, may do a biopsy.
What are your thoughts?

References:

1. The utility of dermoscopy in the diagnosis of evolving lesions of vitiligo.

Thatte SS1, Khopkar US.  Indian J Dermatol Venereol Leprol. 2014 Nov-Dec;80(6):505-8.

BACKGROURD: Early lesions of vitiligo can be confused with various other causes of hypopigmentation and depigmentation. Few workers have utilized dermoscopy for the diagnosis of evolving lesions of vitiligo.

CONCLUSION: Pigmentary network changes, and perifollicular and perilesional hyperpigmentation on polarized light examination, and a diffuse white glow on ultraviolet light examination were noted in evolving vitiligo lesions. Histopathological examination was comparatively less reliable. Dermoscopy appears to be better than routine histopathology in the diagnosis of evolving lesions of vitiligo and can obviate the need for a skin biopsy. Free Full Text.

2. Dermoscopy as an ancillary tool for the diagnosis of pityriasis versicolor.

Zhou H, Tang XH, Chen MK. J Am Acad Dermatol. 2015 Dec;73(6):e205-6. (this is only reference in PubMed on T.v. and dermsocopy and it is not particularly helpful)

3. Dermatoscope--the dermatologist's stethoscope.

Lallas A, Argenziano G.  Indian J Dermatol Venereol Leprol. 2014 Nov-Dec;80(6):493-4. Full Free Text 

This is an interesting somewhat philosophical article.  The references are extensive and helpful.