Keratosis Pilaris Rubra

Presented by Makayla Powers PA-C
Pontoosac Shores, Massachusetts

HPI: Patient is a 15-year-old boy who presents, with his mother, for a facial eruption. His mother states this rash on his face has been present for about three years. His pediatrician prescribed a topical tretinoin, however, his mother has not used this for him yet as she is worried about it causing more skin irritation. Patient has asthma and currently uses a Flo-vent inhaler daily and albuterol inhaler as needed.

Physical exam: On exam, patient has erythematous patches with follicular papules on the bilateral cheeks, extending to the neck. He also has these erythematous follicular papules on the bilateral upper arms.

Diagnosis: Keratosis Pilaris Rubra

Discussion: We believe the patient has keratosis pilaris rubra. From the research we have been doing, topical therapies do not seem to not work well and laser therapy may be the most effective. We are asking if any of our readers has any experience treating this entity and what treatments they have found to be most successful? Thank you in advance for your time!

References:

1. Marqueling AL, et. al. Keratosis pilaris rubra: a common but underrecognized condition. Arch Dermatol. 2006 Dec;142(12):1611-6. doi: 10.1001/archderm.142.12.1611. PMID: 17178988.

2. Schoch JJ, et. al. Successful Treatment of Keratosis Pilaris Rubra with Pulsed Dye Laser. Pediatr Dermatol. 2016 Jul;33(4):443-6. doi: 10.1111/pde.12892. Epub 2016 Jun 10. PMID: 27282957.

 

3. Fekete GL, et. al., Keratosis pilaris atrophicans faciei: An observational, descriptive, retrospective clinical study. Exp Ther Med. 2021 Nov;22(5):1331. Free PMC article. [Dr. Warren Heymann brought this to our attention]

See: Comment # 1 from Omid Zargari

Caruncular Tumor in a Child

 

The patient is an eight year-old girl with a  pigmented caruncular lesion of the left eye.  The child is of mixed ethnicity having light hair and green eyes.

 

The lesion is a circumscribed dark brown to black papule with slightly irregular borders.  No worrisome dermatoscopic features.

 

Diagnosis:  Melanocytic caruncular lesion in a child.

 

Plan:  She has been referred to a pediatric oncologic-ophthalmologist for evaluation.

 

Comment:  Based on a literature review it seems like melanoma is exceedingly rare in such a young child.  Nonetheless, it is important for this girl to be followed by a clinician with a special interest in childhood tumors.

 

Follow-up:  The patient saw a pediatric oncological-ophthalmologist at Boston Children's Hospital.  He felt her lesion is a benign caruncular nevus and will follow her at regular intervals.

 

References:

1. Carol L Shields, et. al. Clinical Features Differentiating Benign From Malignant Conjunctival Tumors in Children. JAMA Ophthalmol. 2017 Mar 1;135(3):215-224. Abstract.

2. Puneet Jain, et;; al. Conjunctival melanoma treatment outcomes in 288 patients: a multicentre international data-sharing study. Br J Ophthalmol. 2021 Oct; 105(10): 1358–1364. [There were no pediatric patients this study of almost 300 patients.]

3. Camille Yvon, et. al.  Caruncular lesions: A 16-year single centre review in the United Kingdom. Eur J Ophthalmol. 2022 Nov 10;11206721221137938.
Results: A total of 31 lesions from 31 patients were analysed. 18 of 31 patients were men (58%), and the age ranged from 12 to 91 years. 13 different histopathological types of lesions were identified in our case series, including 9 melanocytic nevi (29%), 7 benign squamous papillomas (23%), 5 skin adnexal lesions (16%), 3 chronic inflammation (10%), 3 epithelial cysts (10%), 1 basal cell carcinoma (3%), 2 malignant melanomas (6%) and l lymphoproliferative disorder (3%). Pre-operative suspected diagnoses were often vague but correct in 12 of 18 cases (67%), where data was available.
Conclusion: The uncommon nature and variety of caruncular lesions make the diagnostic process difficult. Our case series is the first reported in the UK, showing a slightly higher proportion of malignant melanomas, in keeping with the population demographics. Excisional biopsies would, therefore, be prudent in the majority of cases to rule out any possible malignancy.

4. (Dr. Patrick Kenny (Victoria, BC, Canada) suggested Spitz/Reed nevus.  This reference may be helpful) Ana F Pedrosa, et. al.   Spitz/Reed nevi: a review of clinical-dermatoscopic and histological correlation. Dermatol Pract Concept. 2016 Apr 30;6(2):37-41. Full Text PubMed Central

 5. J Levy et. al. Lesions of the caruncle: a description of 42 cases and a review of the literature. Eye volume 23, 1004–1018 (2009) Full Text.  Helpful review. This study presents the clinical and histological data of 42 consecutive caruncular lesions processed at our laboratory and reviews previously reported cases of caruncular lesions.