Friday, January 27, 2017

Toddler with Black Nevus

This 18 month by was seen for a pigmented lesion of 2 - 3 months duration.  It has growm over this

O/E:  Light complected Caucasian with 6 mm in diameter black papule right anterior thigh.  The dermatoscopic appearance shows a somewhat starburst appearance at the periphery.

Photomicrographs (courtesy of Deon Wolpowitz, Boston University Skin Path)

Diagnosis:  Clinically and dermatoscopically and pathologically, this is a Reed Nevus.

Plan: The lesion has been excised with modest margins..


Dermatol Pract Concept. 2016 Apr 30;6(2):37-41. (Full Text)
Spitz/Reed nevi: a review of clinical-dermatoscopic and histological correlation.
Pedrosa AF et. al.
BACKGROUND: Spitz/Reed nevi are melanocytic lesions that may mimic melanoma at clinical, dermatoscopic and histopathological levels. Management strategies of these lesions remain controversial.
We aim a correlation among clinical-dermatoscopic and histological features of a series of Spitz/Reed nevi diagnosed during 7 years at the Department of Dermatology.
METHODS: Clinical, dermatoscopic and histological features of Spitz/Reed nevi diagnosed at our tertiary hospital from 2008 to 2014 were reviewed in order to seek correlation.
RESULTS: All described dermatoscopic patterns for Spitz/Reed nevi were found among the 47 enrolled patients; starburst and atypical/multicomponent patterns prevailed (57.4%). Reticular pattern predominated among children younger than 12 years, whereas homogeneous pattern was more frequent in patients older than 12 years, although these differences were not statistically significant (P=0.785). Among histological atypical lesions, all dermatoscopic patterns were represented, but the atypical/multicomponent predominated (56.3%). Two out of 11 dermatoscopically atypical lesions did not show histopathological counterpart.
CONCLUSIONS: The excision of Spitz/Reed nevi in adults is supported, given the inability to accurately predict those with histopathological atypia, based on clinical and dermatoscopic features, which may raise concern about malignancy.


Thursday, January 19, 2017

Raynaud's with Digital Ulcerations in a Smoker

The patient is a 63-year-old waitress who presents for evaluation of painful fingertip ulcerations that have been present for ten months. She has been seen by a number of physicians including the Wound Care Center. Nothing has helped.  She has had Raynaud’s Disease for 7 – 8 years.  She has been a heavy smoker for decades and has cut down from two packs per day to 1/2 ppd a month or so ago.

Medications: Nifedipine for her fingertip ulcers without any help.  She’s also taking lisinopril and carvedilol for hypertension. Her ulcerations were treated with Bactrim and oral clindamycin without effect.

The Examination shows a pleasant articulate woman. She has markedly erythematous hands that appear somewhat puffy. There are two purulent subungual digital ulcers.

Clinical Photos: (1/16/17)
The erythema was quite dramatic.  I should have taken my associate's hand next to the patient's hand for comparison.

Raynaud’s disease with ulcerations. Should we consider progression to scleroderma?  Could this be Buerger’s Diasease?. Her history of smoking may be significant.

Lab: ANA 1:2560 Centromere, RF 25, C4 low 94, C3, nl.  Low titer antibeta 2GP Igm. Negative ACA and LAC, negative ENA, dsDNA, CCP
Xray: resorption of distal L small finger

Raynaud's occurs in two main types:
  • Primary Raynaud's is the most common form of the disorder and is not connected to an underlying disease or related medical problem. It is also called Raynaud’s phenomenon.
  • Secondary Raynaud's is also called Raynaud's phenomenon. This form is caused by an underlying, or related, problem. Secondary Raynaud's is less common than the primary form, but it tends to be a more serious disorder. Symptoms of secondary Raynaud's often first appear at later ages — around 40 — while people with the primary form often see symptoms earlier.

PLAN: I had a long discussion with the patient. We talked about the need to stop smoking and she promised to do so. A prescription for Bactroban ointment was given and she will be seen back in one week.

With her permission, she is being presented here on VGRD.

The digital ulceration of the left fifth finger has progressed to distal reabsorption with bone protrusion.  X-rays and orthopedic consultation is pending.

Comments of Richard Sontheimer, M.D.
These are extended and useful remarks that begin with: "This patient’s digital ulceration and the puffiness of her fingers together argue strongly in favor of systemic sclerosis. The fingertip ulceration in your patient would be highly atypical for isolated benign Raynaud's disease.  And, Buerger's disease would not typically produce the sausage-like digital swelling,"  Please read the entire link as it is very helpful.
Also see Reference # 3 below.


1. Ann Dermatol Venereol. 2013 Aug-Sep;140(8-9):549-54. doi: 10.1016/j.annder.2013.02.010. Epub 2013 Apr 11.
[Minimal work-up for Raynaud syndrome: a consensus report. Microcirculation working group of the Société française de médecine vasculaire]. [in French]

Pistorius MA1, Carpentier PH; le groupe de travail « Microcirculation » de la Société française de médecine vasculaire.

Abstract: About ten to fifteen percent of the French population suffer from Raynaud's phenomenon. Most of the time, it is considered as primary Raynaud's phenomenon, without underlying disease. The aim of this expert consensus from the "microcirculation group" for the French Society of Vascular Medicine and the French Society for Microcirculation, was to define clinical guidelines in patients consulting for Raynaud's phenomenon. The recommended minimal screening includes clinical examination, nailfold capillaroscopy and antinuclear antibodies. In particular, the aim of this screening is to identify patients with a significant risk for scleroderma, who would need a careful follow up.
2. A portable dermatoscope for easy, rapid examination of periungual nailfold capillary changes in patients with systemic sclerosis.
Muroi E, et. al. Rheumatol Int. 2011 Dec;31(12):1601-6. doi: 10.1007/s00296-010-1532-0. Epub 2010 May 27.

Abstract: excerpt “The presence of two or more enlarged capillaries in one or more fingers showed 83.1% sensitivity and 100% specificity for SSc. Among patients with SSc with anti-topoisomerase I antibody, the disease duration correlated negatively with the dermatoscopic number of enlarged capillaries and hemorrhages. Dermatoscope allows the easy and rapid identification of capillary nailfold morphological changes in SSc and should be routinely used for diagnosing SSc.”
3. Proximal nailfold microhemorrhage events are manifested as distal cuticular (eponychial) hemosiderin-containing deposits (CEHD) (syn. Maricq sign) and can aid in the diagnosis of dermatomyositis and systemic sclerosis.
McBride JD, Sontheimer RD.  Dermatol Online J. 2016 Feb 17;22  Free Full Text Online


Cuticular (eponychial) hemosoderin-containing deposits (CEHD) are in fact hemosiderin-containing deposits that can reflect the active inflammatory phase of microvascular injury occuring in autoimmune disorders such as DM and SSc. CEHD can be visualized and documented at the bedside with tools commonly available to any dermatologist (portable dermatoscope and compact digital camera).

Monday, January 16, 2017

Neonatal Acne

Presented by Dr. Henry Foong, Ipoh Malaysia

21 day old boy
normal full term delivery
breast feeding
1 week history, initially forehead then spread too cheeks and nose area

mother is healthy and asymptomatic.

O/E: symmetrical/bilateral vesicles/ pustules/ papules/comedone on affected areas
 Dx: neonatal acne/ cephalic pustulosis
A benign condition.  i think it revolves with our treatment

Treatment:  reassurance!!

Comment by a pediatric dermatology colleague: "Neonatal acne is a common newborn eruption, and it can be seen in about 20% of healthy babies. The scalp, face, neck and back and chest are commonly affected, and open comedones are usually absent as this finding would make one consider infantile acne. The lesions are usually not present at birth, but typically appear within the first 2-4 weeks of life, and generally improve by about 4-6 months of age. This condition is self-limited, however, one can consider topical antifungal or low potency topical corticosteroid if the parents seek for medical treatment. Usually reassurance would comfort the parents." [The role of P. ovale is considered]


Neonatal Malassezia furfur pustulosis.
Rapelanoro R, et. al.
Arch Dermatol. 1996 Feb;132(2):190-3.
Papulopustular eruptions of the face in neonates are frequently referred to as neonatal acne or sebaceous miliaria. Our findings suggest that there is an association between this type of eruption and Malassezia furfur infection.
Direct examination of pustule smears showed M furfur yeasts in eight of 13 cases involving neonates with erythema and papulopustules of the face, neck, and scalp (mean age at onset, 22 days [range, 7 to 30 days]). The pustules were predominantly neutrophilic. Treatment with 2% ketoconazole cream applied topically twice daily was effective in 1 week.
Malassezia furfur is frequently associated with a common nonfollicular pustulosis of the newborn, probably improperly termed neonatal acne.

Friday, January 06, 2017

Aquagenic Wrinkling of the Palms

The patient is a 19 yo woman who presents with a four month history of a peculiar eruption of her palms after showering.  She spends 15 - 20 minutes in the shower.  The process resolves within a 1/2 hour.  It is mildly pruritic.

O/E:  The eruption is comprised of 1 - 2 mm in diameter white papules, discrete and confluent, on the palms.  We demonstrated these lesions in the office and they cleared within 10 minutes.  Here feet are unaffected, by history.

Clinical Photos provided by patient: (directly after shower, and when returned to baseline.

 Diagnosis:  Aquagenic Wrinkling of the Palms

Question:  The literature states that this is more common in people with cystic fibrosis and CF carriers.  This patient has no history to suggest CF.  Should genetic testing be offerred? 

Reference: There are many case reports; but the Dermnet site is a great overview. 

CF Genetic Testing. (from Cystic Fibrosis Foundation web site)
In the United States, the number of people who carry a CF gene mutation is about:
  • 1 in 29 Caucasian-Americans
  • 1 in 46 Hispanic-Americans
  • 1 in 65 African-Americans
  • 1 in 90 Asian-Americans