Granulomatous Rosacea

A 34-year-old sociologist presented for evaluation of forehead lesions, which have been present for about 2 years.  These began about a year after her daughter's birth.  Before that, she was on oral contraceptives and was fine, but she has not been on any hormonal birth control since then.  She saw another dermatologist and was treated with topicals, a SilkPeel, Tretinoin.  She also took doxycycline for 2 – 4 weeks. Nothing helped.  She is anxious about her appearance. 

O/E:   The examination shows a pleasant, outgoing woman.  She has a somewhat pebbly appearance to the forehead with many, mostly not inflammatory discrete and confluent submillimeter papules.  There were a few erythematous papules.

Clinical Photos:

Initial Diagnosis:  I considered an acneiform eruption.  A 4 mm punch biopsy was performed.

Pathology:  Thanks to Assistant Professor Hye Jin Chung, MD from Boston University Skin Pathology for kindly providing these beautiful photomicrographs.
There is a moderate and superficial perivascular and perifollicular infiltrat.  Focal granulomas formation is noted.
                          

Presumptive Final Diagnosis: Granulomaous Rosacea
  

Discussion:  Is this really a subset of rosacea, or is it an acneiform disease sui generis? Clinically, it does not look like rosacea and it appears to be defined by dermatopathologists who only see small plugs of skin.  Similarly, perioral dermatitis is an acneiform disorder of uncertain etiology, but the diagnosis is strictly clinical.

References:

1. Lee GL, Zirwas MJ. Granulomatous Rosacea and Periorificial Dermatitis: Controversies and Review of Management and Treatment. Dermatol Clin. 2015 Jul;33(3):447-55.
Abstract: Granulomatous rosacea and periorificial dermatitis are common skin conditions affecting the face. This article examines the historical origin, causes, clinical presentation, and management strategies for these entities.  Link to Full Text.

2. Omar Khokhar and Amor Khachemoune. A Case of granulomatous rosacea: Sorting granulomatous rosacea from other granulomatous diseases that affects the face. Dermatology Online Journal 2004 10 (1): 6  Free Full Text.
Abstract: Granulomatous rosacea is a variant of rosacea that may present similar to other granulomatous diseases. We present the case of a 45-year-old woman with a 2-year history of facial erythema with multiple papules and pustules on the cheeks, chin, and glabella. The patient responded to minocycline, resulting in healing 6 months without residual scarring. This patient's clinical and histological presentation and treatment outcome are to our assessment consistent with granulomatous rosacea. However, other clinically and histologically related entities will be discussed. These entities include, but are not limited to, perioral dermatitis, granulomatous periorificial dermatitis, lupus miliaris disseminatus faciei, facial afro-caribbean eruption syndrome, and sarcoidosis.

Solitary Tricholemmoma

The patient is a 39-year-old home visitor who presents for evaluation of a lesion on the bulb of
the nose that has been present for about six months.

O/E: The examination shows a healthy, outgoing woman with type I skin. There is a solitary 3 mm in diameter dome-shaped papule with a central keratin on the bulb of the nose. The remainder of the cutaneous examination is unremarkable.
Clinical and Dermatoscopic Images: 

Preoperative diagnosis: This has the appearance of keratoacanthoma, squamous cell carcinoma, or hypertrophic actinic keratosis.

PLAN: The lesion was shave excised. The base was lightly electrodesiccated and curetted and a
specimen was submitted for pathology.

Pathology: Assistant Professor Hye Jin Chung, MD from Boston University Skin Pathology kindly provided the photomicrographs.

At x4:  parakeratosis, papillomatosis and a lobular proliferation of pale cells
At x10: peripheral palisading with focal eosinophilic hyaline basement membrane
Diagnosis:  Solitary Tricholemmoma

Daignosis:  Solitary tricholemmoma.  Tricholemmomas can be a marker for Cowden's disease.  However, I don't feel that a solitary tricholemmoma is a red flag in a 39 yo woman.  I asked the patient about a personal or family history of cancer and there was no history of thyroid, lung or colon.

This case is presented because there are few to no accessible cases of solitary tricholemmoma online and no dermatoscopic images that I could fine..

Reference:

Spiegel JH, Khodai N. Tricholemmoma of the nose. Am J Otolaryngol. 2006 Nov-Dec;27(6):430-2.

Abstract

OBJECTIVES: The objectives of this case report are to (1) identify clinical presentations of tricholemmoma, (2) discuss the characteristics of Cowden syndrome and the relationship between this syndrome and tricholemmoma, and (3) differentiate tricholemmoma from other superficial cutaneous tumors such as basal cell carcinoma and granulomas.

RESULTS:

Tricholemmoma was first described as a cutaneous neoplasm in 1962. It is associated with the Cowden syndrome and can be misdiagnosed as a more aggressive cutaneous malignancy. We report an unusual case of tricholemmoma presenting as a nasal mass.

CONCLUSIONS: Tricholemmoma is described as having a predilection for the head and neck, yet little information has been published about this disorder within the Otolaryngology literature. Otolaryngologist-head and neck surgeons must be familiar with this neoplasm because it can be frequently misdiagnosed as an aggressive cutaneous malignancy and hence can be incorrectly treated. We describe the presentation and diagnosis of tricholemmoma, describe the frequent association of this neoplasm with Cowden syndrome, and report an unusual presentation of tricholemmoma as an intranasal mass.

Renal Transplant Patient with a Black Toe

The patient is a 70 yo man who had a renal transplant around 10 years ago.  His immunosuppression consists of oral tacrolimus and prednisone, and he is seen annually by a dermatologist.  He had a 3 cm superficial squamous cell carcinoma ofhis scalp 5 years ago that was treated successfully with topical 5FU.

O/E: The current exam revealed a black area under the nail of the second toe on the left foot.  He said it's been like his for around a year and has not changed much.

Clinical and Dermatoscopic Images:

Diagnosis and Discussion:
While I am pretty certain that this is a subungual hematoma; if his history is accurate that may be worrisome.  There is little downside to removing the nail and biopsying the nail base if it is pigmented and this was scheduled in a week's time.  The fact that this is Morton's toe also favors subungual hematoma.