An Orphan Patient

History/Physical: This  53 yo woman presented with a 15 year history of a painful and disabling dermatitis of her buttocks and to a lesser extent face, extremities and torso.  She has been seen by many dermatologists, allergists, gynecologists and primary care physicians during this time and even underwent a hysterectomy in an attempt to cure her when the mistaken diagnosis of autoimmune progesterone dermatitis was rfendered. Her partner recently left her because of the disabling nature of dermatitis.

Routine lab studies are unremarkable and ANA was negative.  Some special tests are pending.

Clinical Images

March 2024

Photos from 3 - 5 years ago sent by patient

Shoulder

 Histopathology: Biopsy were taken from the left and right buttock:  Both specimens contain a small vessel vasculitis.  The more recent lesions on the right buttock show the changes of leukocytoclastic vasculitis.
Biopsy from left buttock, March 2024.  Four mm punch biopsied from each buttock showed similar changes, but left buttock had a more psoriasiform epidermis.
Thanks to Dr. David Jones, dermato- pathologist, Berkshire Medical Center, for the histopath images.

Tentative Diagnosis:  Urticarial Vasculitis

She is being presented your thoughts and recommendations.  Complement levels are pending.  She has a very high deductable so we are limiting extensive testing that may be unnecessary.

Photo after 5 days of prednisone 20 mg b.i.d. 

Reference:
Stephanie L Gu, Joseph L Jorizzo.  Urticarial vasculitis.  Int J Womens Dermatol. 2021 Jan 29;7(3):290-297.  PMID: 34222586  PMCID: PMC8243153 (Full Text)

Acne Scarring

The patient is a 26 year old man who presents to the office for evaluation of acne. He has struggled with acne on the face, back and chest since for over 6 years. He was previously prescribed a few different antibiotics over the past few years, however none of them have provided significant improvement in his acne. He had reactions to minocycline and doxycycline and therefore, his dermatologist recommended he stay away from these medications. Otherwise, he is a healthy man without any other concerns.

On exam, the patient has severe hypertrophic scarring on the chest and back. He has a couple active erythematous cysts on the back, chest and neck.

Assessment and plan: Hypertrophic and keloidsl acne scarring is difficult to treat. We  wonder if isotretinoin will trigger more scarring or whether it may actually help him.

Questions:

Is there a value to starting him on isotretinoin? With Prednisone?

His previous dermatologist used intralesional triamcinalone without benefit.

The patient may need to pay for procedures out of pocket; but his insurance will cover isotretinoin.

Painful Leg Ulcer in an Octogenarian

The patient is a, otherwise healthy 84 yo woman who had a squamous cell carcinoma of the left pretrial area in 2018 that was treated with radiation.  The area took 18 - 24 months to heal after XRT.  Due to concerns about a new crusted area at the site, it was biopsied in April 2023; but has not healed since then.  In August 2023, there was a 6 mm in diameter ulcer.  In July of 2024, she had moved to another state and a wound care physician re-biopsied the area and curretted it,  In the ensuing three months the ulcer has grown to its present size of 3.7 x 2.7 cm and is constantly painful.  (Both biopsies showed no evidence of cancer.)

She has good pedal and dorsals pulses and has had arterial and venous studies of her leg show normal findings. Ankle Brachial and Toe Brachial Indexes are normal.Wound cultures have repeatedly grown out a mixture of Pseudomonas, Coagulase Negative Staph and Strep species.

12.12.23

1.27.24

What is your diagnosis and what do you think is the best way to care for this ulcer?