Thursday, February 28, 2019

Cupping Comes to the Boondocks

The patient is a 65 yo man who came in for a dermatitis of his scalp.  He requested a complete skin exam  This was remarkable for circular ecchymoses on his left back.  I asked about this.  He sees a massage therapist for back pain and she recommended cupping.  His wife was horrified to see these bruises until he explained how they were acquired.
Clinical Image: 

 With cupping, traditionally, a cotton ball soaked in alcohol is burned inside the glass cup and removed right before placement to create the vacuum. Bamboo and other materials can be used as alternatives to glass. The procedure breaks superficial blood vessels in the papillary dermis, creating ecchymoses, purpura, and petechiae, which is seen as evidence that the ailment is being drawn from the body.

Clearly, this traditional Asian remedy is entering the mainstream in Western Massachusetts. Our Asian readers probably see this all the time.  
For a few laughs, see Cupping Video.

1. Dermatoses caused by cultural practices: Therapeutic cultural practices.
Vashi NA. J Am Acad Dermatol. 2018 Jul;79(1):1-16.
Abstract: With globalization and widespread immigration, physicians increasingly encounter patients from varying backgrounds and diverse customs. Although certain cultural practices are widely performed, there is limited medical literature describing their dermatologic and systemic effects and complications. Population diversity and sharing of traditions make it increasingly important for dermatologists to understand the role of cultural practices and recognize physiologic and pathologic sequelae. In addition, dermatologists are often adjured to assess skin findings that may be mistaken for abuse. Child abuse misdiagnosis can be traumatizing to all those involved, and immigrant families with limited English proficiency may have difficulty explaining their traditional practices. The first article of this 2-part continuing medical education series begins with a review of therapeutic cultural practices, including traditional Chinese medicine, Ayurveda, acupuncture, cupping, moxibustion, and coining, and the clinically relevant complications that may occur. Therapeutic practices can cause a range of complications, including contact dermatitis, heavy metal toxicity, and severe cutaneous adverse reactions.

Monday, February 18, 2019



32nd  Annual Hot Spots in Dermatology
Turtle Bay Resort, Oahu, Hawaii
August 16 – 18, 2019
Please consider joining us for our 2019 meeting. Hot Spots addresses clinical dermatology, emerging technologies and humane aspects of medicine.  We keep the number of attendees small to assure meaningful informal sessions at which registrants and speakers have time to interact as colleagues.

Hot Spots specifically excludes speakers who are paid stipends from PhRMA or any special interest group.  Our registrants are not a captive audience to promote any products, either directly or subtly.

The Hot Spots web site, will answer most of your questions.

Nevus Lipomatosus Superficialis

There are some lesions that only a dermatologist could love.  Nevus Liopmatosus Superficialis (NLS) may be one.

Recently, a 63 yo woman presented with a pedunculated mass on her right costal margin.  It had been present for a few years and did not bother her; but her internist told her to see a dermatologist to have it removed.

Being compliant, she made an appointment.  It was a 3 cm, soft, fleshy, skin-colored nodule on a slender stalk.  At her request I removed it with a simple scissor snip and sent it for pathology.  The clinical diagnosis was “fibroepithelial polyp vs. nevus lipomatosus.”
Clinical Photo:
The pathology showed mature adipose tissue replacing large portions of the dermis.

Photomicrographs courtesy of Lynne Goldberg, dermatopathologist, Boston University Skin Path:

Diagnosis:  Solitary Nevus Lipomatosus Superficialis

Reference:  (PubMed has 30 citations on NLS)
1. Nevus lipomatosus superficialis: A rare cutaneous hamartoma.
Pujani M, et. al.  Indian Dermatol Online J. 2014 Jan;5(1):109-10. Free Full Text.

Sunday, February 03, 2019

Acute Lymphedema

Presented by Dr. Henry Foong
Ipoh, Malaysia

The patient is a 50-yr-old man with a history of swelling of the right leg for 2 months. He noted that the right foot was swollen initially and a few weeks later the swelling has progressed to the right leg.  Over the past week the swelling has progressed to the right thigh. The swelling was mildly painful but overall the past week the swelling has progressed a lot.  The swelling was so severe that he was unable to wear his normal shoe. He has a history of hypertension and a history of “stroke” where he lost his consciousness and was told by his doctor he suffered from a minor stroke.  He was treated as cellulitis by his doctor with penicillin but did not improve.  In fact he had developed a generalised maculopapular eruptions over the trunk a week after starting on IV penicillin.

O/E: Shows a severe unilateral swelling of the right leg extending from the foot to the thigh.  There was superficial erythema, desquamation with small blisters. The affected areas are well-demarcated especially on right thigh.  The leg swelling was indurated and mildly pitting.  The measured circumference of the right leg at mid-calf level was 51 cm compared with the corresponding left leg of 39 cm.  His right inguinal nodes were markedly enlarged. Rest of exam was unremarkable.


Differential Diagnosis
1.  Erysipelas right leg
2.  Filariasis
3.  Deep vein thrombosis

Hb 13.5 gm%, TWBC 17,900 (N87%, L10%, E0.1%, B1% M2%) ESR 79mm/hr Biochemistry unremarkable. Culture from the right leg grew Staphylococcal aureus.  Doppler ultrasound right leg did not show any evidence of deep vein thrombosis but enlarged right inguinal nodes.

He was advised to stop penicillin and started on IV moxifloxacin 400mg od, IV hydrocortisone 200mg qid,  and wet compress. Blood was sent for microfilaria (x3) which was negative.

Follow-up Photo after 5 days of IV moxifloxacin and IV hydrocortisone.


Marked improvement after 5 days of IV moxifloxacin and IV hydrocortisone.  There is a 5 cm reduction in the circumference of the right call. The patient would be scheduled for a MRI lower pelvis/right thigh soon, but he has refused since he is feeling so much better.

Your thoughts will be appreciated.