Friday, January 25, 2019

PRP and Kaposi’s: A Cautionary Tale

Our colleague, Professor Khalifa Sharquie from Baghdad, Iraq presents a 27-year old woman seen in his skin department with a dramatic facial rash and swelling of nine months duration.  Quite early on, the condition started as bruise-like discoloration and slight swelling around both eyes that slowly increased over a period of ~ three months “Figure. 1”.

The patient sought treatment at a  private clinic in Jordan.  A skin biopsy at that time showed "mucin deposition." She received peri-ocular plasma rich platelets (PRP) injections and afterwards, new lesions appeared more rapidly on her face; and then, after months, on other parts of her integument.  When seen at the Baghdad clinic she was severely ill with shortness of breath and difficulty in swallowing. “Figure. 2”.

Please see  the attached article.  and the click the link to download.
Your thoughts will be appreciated.

Figure 1

Figure 2

Nathaniel Hawthorne:  The Birthmark
In which Beauty meets Science and is destroyed.  Science’s servant in this parable is called "Aminadab"!

Saturday, January 19, 2019

Retroauricular Dermatitis: An Orphan Disease

The patient is an 11 year-old girl with a one-year history of a dermatitis in the right retroauricular sulcus.  She has a history of  an eczematous  eruption on her thighs. She was prescribed mupirocin and betamethasone valerate ointmens.  They both caused burning and pruritus and she refused to use them.  There is a history of a vaginal dermatitis a year or so ago, which was successfully treated with topical corticosteroids.

O/E:  There is erythema, crusting and mild fissuring in the above-mentioned area.  The left retorauricular area is mildly affected.  Presently there are no findings of atopic dermatitis in the usual areas.

Clinical Image:

Lab:  Wound culture was positive for 3+ Staph aureus and 3+ Group B Strep.

Diagnosis:  Retroauricular dermatitis.

We prescribed cephalexin 250 mg q.i.d. and a small amount of Vaseline for the dryness and fissuring.  Patch testing will be recommended if there are further symptoms suggestive of contact dermatitis.

Comments:  Retroauricular dermatitis, also called "infra-auricular fissures," appears to be an under-reported entity.  Although it is common in atopic dermatitis, there have been few articles about it. I see a few cases a year and the vast majority yield coagulase positive Staph aureus and occasionally strep when cultured. Most respond quickly to mupirocin ointment and a  low to moderate strength topical steroid.  This patient’s symptoms make her an outlier.  In addition, she has no findings of atopic dermatitis at this time.
Do any of you have thoughts on this entity?  The take home message here is that, as with atopic dermatitis, these lesions are frequently colonized with Staph aureus.

1. Infra-auricular fissures in atopic dermatitis.
Tada J, et. al. Acta Derm Venereol. 1994 Mar;74(2):129-31.
Abstract: Retro-auricular or auricular dermatitis in atopic dermatitis (AD) is common and important for the diagnosis of AD in infancy and even in adulthood. Particularly, "infra-auricular fissures", acute eczematous changes like fissures at the adhesive junction of ear lobes, seem to be prominent features for the diagnosis of AD. Of 137 patients with AD, 81.8% showed present or past existence of infra-auricular fissures, but only one of the 30 controls. Of the 46 patients with severe AD, 98% had infra-auricular fissures, compared to 74% in those with moderate and mild AD. Our findings suggest that infra-auricular fissures are important for the diagnosis of AD and should be cited in a list of criteria for the diagnosis of AD.

2. Streptococcal perianal disease in children. Kokx NP, Comstock JA, Facklam RR.  Pediatrics. 1987 Nov;80(5):659-63.  PubMed Link.

3. Psoriasis inversa: A separate identity or a variant of psoriasis vulgaris?
Omland SH, Gniadecki R. Clin Dermatol. 2015 Jul-Aug;33(4):456-61.
Abstract: Psoriasis is a chronic skin disorder affecting approximately 2% of the European and American population. The most common form of psoriasis is the chronic plaque type. Inverse psoriasis, also named flexural or intertriginous psoriasis, is not considered a separate disease entity but rather a special site of involvement of plaque psoriasis, characterized by its localization to inverse/intertriginous/flexural body sites. We review current evidence and establish whether inverse psoriasis is a separate disease entity based on characteristics in terms of epidemiology, pathogenesis, clinical and histologic presentation, microbiology, and treatment.

Monday, January 14, 2019

Subtle Facial Lesion in a Four Year-old Boy

The patient is a four year-old boy who was referred for evaluation of a slightly rough patch on his right cheek that has been present for over a year.  He is otherwise well.

O/E:  There is a subtle 1.5 cm in diameter erythematous patch on his right cheek.  Dermatoscopy revealed a group of sharply demarcated plugs that appear to be comedones.  Clinically, this was not as evident.

Clinical and Dermatological Images:
 Diagnosis:  Small subtle nevus comedonicus.

Discussion:  I feel this is probably a nevus comedonicus.  I’ve only seen a few of these and all were obvious: not so with this case.  Not much is known about the evolution of these lesions.  Topical retinoids are of some value; but since this doesn’t bother the patient I am reluctant to have his mother rub a topical agent on the area for two to three months.  Does anyone feel that tazarotene is preferable to tretinoin in similar cases?  Comedone extraction would be easy, but can be traumatizing in a young child.  Once I hear other ideas I will discuss options with his parents.

1. Dermoscopy on nevus comedonicus: a case report and review of the literature.  Kamińska-Winciorek G1, Spiewak R.
Postepy Dermatol Alergol. 2013 Aug;30(4):252-4.  Free Full Text.

2. Nevus comedonicus: an updated review. Tchernev G, et. al. Dermatol Ther (Heidelb). 2013 May 25;3(1):33-40. Full Free Text.

Wednesday, January 09, 2019

Erysipelas in a 69 yo Woman

presented by Henry Foong
Ipoh, Malaysia

A 69-yr-old woman was seen with a 2-day history of rapidly enlarged swelling on the right cheek.  Initially she felt some discomfort on the right ear and then involved the right cheek.  She had no fever.
There was no history of trauma.  She had a history of hypertension. 

Examination showed unilateral swelling on the right cheek with increased temperature, tenderness and redness extending from right forehead to the right lower jaw.  It appeared oedematous, with swelling of the ipsilateral upper eyelid. It had a well defined raised border. The rash did not cross the bridge of the nose to the opposite cheek. No blisters were seen. Her regional nodes were not enlarged.

Clinically she has erysipelas.

TWBC 12,900 (N84%)
blood sugar  8.5 mol/l
BU and serum electrolytes normal
LFT normal

Erysipelas affects the superficial layer of the skin while cellulitis affects the deeper part of the dermis. There were no clusters of vesicles or erosions to suggest herpes zoster. She was not keen to be admitted and preferred oral medication as an outpatient  She was treated with oral cefuroxime 500mg bd for 10 days with wet compress dressing on the affected face. The erysipelas cleared with the treatment.