73 year-old woman with wide-spread plaques

The patient is a 73-year-old woman with a two month history of an eruption that began on the buttocks and thighs. It has spread to the arms. The clinical picture was not diagnostic, so biopsies have been done.

She is in her usual state of health.  There is no history of systemic illness. Her medications include: amlodopine, metooprolol, ASA, all for a number of years.  She had a tetanus booster a week before the onset of the rash.

I thought this would probably be indolent but she has has developed marked pruritus.  Because of her symptoms she was treated with fluocinolnide oinment. This had no effect. Doxycycline was not tolerated due to GI symptoms.

Laboratory studies were done. CBC and chemistries were within normal limits. Her Lyme tighter was negative.

Examination shows large plaques on the buttocks and thighs that they are now appearing on the arms. The remainder of the examination is unremarkable. 

Clinical Images:

Pathology:

Dermal interstitial proliferation of histiocytes with focally increased dermal mucin and increased dermal mucin.  Individual collagen fibers are circumferentially ringed with histiocytes.  The dermatopathologist  feels this is either interstitial granuloma annulare or interstitial granulomatous dermatitis.  Images courtesy of Lynne Goldberg, Boston University Skin Path.

 Diagnosis: Interstitial granuloma annulare versus interstitial granulomatous dermatitis.
There is one reference on PubMed to granuloma annulare following DT vaccination.

Reference:
1. A case of granuloma annulare in a child following tetanus and diphtheria toxoid vaccination.

Baskan EB, et. al. J Eur Acad Dermatol Venereol. 2005 Sep;19(5):639-40

What are your thoughts?

Hypopigmented Macules in a Child

The patient is a 4 1/2-year-old boy who is seen today for evaluation of hypopigmented macules on the arms and legs for less than a week. His parents first notice this four or five days ago. He has been in his usual state of health although two days ago he developed a fever to 104.7  and was seen by his pediatrician who felt it was a viral syndrome. Throat culture was negative for strep.

On examination: This is a healthy appearing child. He does have a raspy cough. He has 5 to 7 mm in diameter hyperpigmented macules scattered over the arms and legs. Some of these lesions have a so much angular outline.

The patient's mother is a neighbor who lives about a one minute walk from my house, so they walked over and I took a look.

My initial thoughts are that this may be the onset of vitiligo,  The lesions are larger than itiopathic guttate hypomelanosis; but if this occurs in children it must be very rare. 

Your thoughts will be appreciated.  Should any tests be done at this time?

Wart in a 9 y.o. girl

The patient is a healthy 9 year-old girl.  Her pediatrician referred her for a two-year history of a wart on the right middle toe after the child could not tolerate cryosurgery.
On questioning, the child states that the wart rarely bothers her.  She can walk and run without discomfort. 

My advice was to leave it alone as it will probably regress over time.  I discussed how this occurs with the girl and her grandmother.

Would you treat this?  And if so, how?

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