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.