A Case for Diagnosis

Presented by  Dr. Henry Foong, Ipoh, Malaysia

The patient, a Chinese woman in her 30s, presented with sudden flare of her skin eruptions on the legs past 2 weeks.  She had been having multiple erythematous plaques on the abdominal wall and legs since March 2020 and had tried various topical creams and oral supplements.  As it happened during lockdown she had tried online medications and topical creams.  The lesions on the abdominal wall improved but suddenly those on the legs flared up with painful pustules.  She denied any fever.  Apparently she was on oral methotrexate previously for psoriasis but according to her, MTX did not help her much.  

Clinical:

Her vital signs are stable. No signs of dehydration. 

Extensive erythematous plaques on the lower limbs.  Edges well demarcated. scaly surface. some of the larger lesions had a central smooth glazed appearance surrounded by crops of tiny superficial pustules.  Post inflammatory hyperpigmentation were prominent on the anterior abdominal wall.

No nail changes were noted.  Joints were normal.

Images:

Diagnosis:

Generalised pustular psoriasis of von Zumbusch

Note:  We presented a similar patient two years ago.

I suspect she may have taken oral corticosteroids and when she stopped the oral medications, the lesions flare up.  A skin biopsy was done.  This may be useful to exclude AGEP.  Blood counts/biochem/swab culture including serum calcium were done and pending.   

In the meantime, she is on IV fluids, IV antibiotics, topical moisturisers, KMNO4 soaks and topical corticosteroids.

Q1.  Would IV hydrocortisone be useful in this patient or avoided at all costs?

Q2.   Is it worthwhile to try MTX weekly dose again?  Cyclosporin? Oral acetretin would not be practical for a woman of child bearing age group. 

Q3.  Biologics may have a role.  Anti IL-36 recently was found to be useful in pustular psoriasis but this drug is not available yet.  Which other biologics would be useful? Risankizumab?

Thank you for your thoughts on this patient.

Angiokeratoma of the Vulva

The patient is a 32-year-old woman who was seen today for lesions on the vulvae.  She saw a gynecologist because one of them was bleeding and he told her that they were cherry angiomas and that she should see a dermatologist. 

  

EXAMINATION:  The examination shows a pleasant, moderately obese woman.  On the vulva, she has scores of purple papules measuring 1-2 mm in diameter. 

    

Photo

IMPRESSION:  These are angiokeratomas of the vulvae.  They are different from cherry angiomas.  There was one lesion that has been occasionally bleeding although today is quiescent.  I could remove that with ED&C when it becomes more active. 

Reference:

1. Angiokeratoma of the Vulva

[Article in English, Portuguese]

Leticia Fogagnolo  1 , et. al 

An Bras Dermatol Mar-Apr 2011;86(2):333-5. PMID: 21603817
Abstract: Angiokeratomas are benign tumors characterized by ectasia of blood vessels in the papillary dermis associated with acanthosis and hyperkeratosis of the epidermis. Dermatological examination of angiokeratomas of Fordyce is characterized by papular keratotic lesions of erythematous-violet color. They are more common in the scrotum, and vulvar involvement is rarely reported. Histopathology is particularly important to distinguish them from other benign and malignant tumors. The article reports the case of a middle-aged black woman with a history of chronic constipation, varicose veins of the lower limbs and cesarean section performed 20 years ago who had had multiple vulvar angiokeratomas for three months.

She’s Not Handling This Well

The patient is a 65 year-old woman with a two-month history of hand dermatitis.  She has had no new medications in a year and has been laid off from a job in sales due to Covid 19.  After 25 years, she’s had to sell her house and is moving into an apartment in three days time.  Holding up her hands up in front of her, without irony, she said, “I’m not handling this situation well.”

Clinical Exam: The palms of both hands are dry with marked scale plates.  The dorsae of the hands are normal.  There are no other cutaneous findings.  In the photo above, there is a suggestion of Dennie-Morgan Lines.  Her feet are normal.

Discussion:  In the differential diagnosis I considered traumiterative hand dermatitis, psoriasis, contact dermatitis, tinea (KOH was negative).

But I keep wondering about that phrase in English, “She can’t handle it.”  Why is that aphorism there?  Did the Ancients know something we’ve forgotten?

She will be treated with clobetasol ointment employed with a “Soak and Smear” protocol.  If she does not clear by a few weeks after her move, biopsy, patch testing, and a medical workup will be pursued, but she has other things on her plate just now.