Perplexing Periodic Pruritus

This case was posted by David Elpern MD as a rapid publication for VGRD
We have been having technical problems with VGRD and have elected to publish this case here. Your comments will be appreciated -- please mail them directly DJ Elpern and we will post them to VGRD when it is up and running,

78 yo man with episodic incapacitating pruritus

Duration: 4 years

Distribution: Generalized, but sparing head and feet


The patient is a 78-year-old semi-retired music producer who presents with a four-year history of episodic intense pruritus that is generalized but has spared the face and the feet. It may have begun on the brachioradial areas of the arms but over a period of time spread to involve the sacrum, the chest, the back and the legs. He describes “a burning itch that you just cannot ignore.” At times he has “gone into a panic” over this. The itch can feel like “hot needles” applied to certain areas of the skin. He has also had scrotal pruritus for two years

The patient has seen a number of different physicians for this including four dermatologists. He has had biopsies done with nonspecific findings and direct and indirect immunofluorescence studies also have been noncontributory. There have been positive ANAs but no one has been able to correlate those with his pruritus.

His brother, has a similar problem and has been treated with CsA and azathioprine with good results.

Treatment:
1. multiple antihistamines -†no help.
2. multiple topical steroids -†no help.
3. Gabapentin - caused severe dizziness...unable to use.)
4. prednisone, three courses - resolved or alleviated symptoms.
(though less completely the second and third time.)
5. plaquenil, one month†- no help.
6. naltrexone, 2 weeks†- no help.
7. dapsone, 2 weeks†- no help.
8. pentoxifylline 400 qd x 2 weeks†- no help.
9. cellcept 2000 mg x 19 days†- no help.
10. Local heat hot compress seems to resolve it quickly though only temporarily).
11. Immuran

O/E: Excoriated papules – some crusted. Arms, legs, lower back, sacrum – sparing mid back, face. No vesicles or bullae.

Bx:
A superficial perivascular and interstitial lymphocytic infiltrate with scattered eosinophils and occasional neutrophils . Note : These changes are urticarial in nature. The histologic differential diagnosis includes urticaria or a dermal hypersensitivity reaction such as a drug eruption or insect bite reaction. Clinico-pathologic correlation is suggested.

Diagnosis: Uncertain. Possibly Subacute Prurigo

Reason Presented:
For diagnostic and therapeutic suggestions.. Have you seen similar cases? What has been the outcome?

DISCUSSION: All of his dermnatologists thought of D.H. but the biopsies have not confirmed this and dapsone and gluten free diet have not helped.

Please respond directly to DJ Elpern

Nail Abnormality in a young girl

This case was submitted by Dr Choon Siew Eng FRCP, a dermatologist from Johor Bahru, Malaysia

A 14-year-old Malay girl presented with a 7-month history of asymptomatic nail abnormality affecting all fingernails. Good general health. No previous of current skin problem or hair loss. No family history of skin problem. No personal or family history of atopy. No family history of autoimmune disease. No nail biting habit. Never varnish nails and no excessive wet work. No on any medication, traditional preparations or supplements.

All fingernails are abnormal ranging from mild horizontal lamellar dystropy, longitudinal, v-shaped, u-shaped and w-shaped sulci as shown in images with variable erythema at the edges of abnormalities. Majority of eponychium appeared normal. Lunula and periungual skin no capillary dilatation noted although some had streaky hyperpigmentation. No palmar erythema. Finger pulps, toe nails, scalp and oral mucosa normal. No other skin lesions

Laboratory: Fungal culture negative

Histopathology: Reject biopsy.

Diagnosis: Lichen Planus, Part of connective tissue disease,

Comments: Would appreciate help in diagnosis and suggestion on further investigations and management.

Questions: Am puzzled by how normal and healthy the unaffected parts of nails look. Had never seen such pattern of erythema. Have anyone seen similar abnormality? Is it justifiable to offer patient systemic steroid to prevent further nails damage and scarring without an histologic diagnosis?

Mistakes

Osler urged us to "Carry a small note-book, and never ask a new patient a question without note-book and pencil in hand......Begin early to make a three-fold category - clear cases, doubtful cases and mistakes. And learn to play the game fair, no self-deception, no shrinking from the truth; mercy and consideration for the other man, but none for yourself, upon whom you have to keep an incessant watch. It is only by getting your cases grouped in this way that you can make any real progress in your post-collegiate education; only in this way you gain wisdom with experience."

In this spirit, I present the case of G.K. an 82 yo woman who I have been following for 6 months for a pustulo-vesicular dermatitis of her feet. It had features of dyshidrotic eczema at only minimal control.

On August 31, 2007 the patient was reevaluated. Clinically and dermoscopically there was a suggestion of burrows and a scabies prep was taken. To my great surprise there were 4 - 5 mites and numerous eggs and feces in the mineral oil mount. She has no eruption of arms or torso and her only itching was on her feet.




I took this image from the web, but it shows what I saw -- a number of mites and eggs.

Diagnosis: Localized Norwegian Scabies. This patient is confined to a wheelchair, but is active and alert. Further history revealed that her grown children had scabies three years ago and all were treated (as was this patient) with 5% permethrin cream. Seemingly, they all got better, but then three years later this patient has a localized form of Norwegian scabies. There are only one or two case reports of localized Norwegian scabies, and none in patients like this.

Treatment: The patient, her husband and son who all live together will be treated with Elimite. She will have treatments every other day for two weeks for her feet and complete skin treatments twice, one week apart. She will be seen back in two weeks. A culture was taken for the question of secondary infection (this grew out coagulase sensitive Staph and she was placed on an appropriate antibiotic).

Over the years, I have been humbled by scabies time and again. Scabies localized to the plantar aspects of the feet is just the latest incarnation.

Addendum: Here is an article which addresses localized Nowegian scabies co-authored by the prolix Ted Rosen. Our patient is presumable immunocompetent.

Localised genital Norwegian scabies in an AIDS patient.
Perna AG, Bell K, Rosen T. Sex Transm Infect 2004;80:72-3.
OBJECTIVES: We present a case of an AIDS patient with Norwegian scabies manifest
by a single, crusted plaque localised to the glans penis. METHODS: A 45 year old
man with AIDS presented to our clinic complaining of a red papular pruritic rash
on his abdomen and anterior thighs and a single, thick, crusted, non-pruritic
lesion on the penis. He had been treated with lindane topically prior to the
development of the penile lesion without resolution of the pruritus or red
papular lesions. A mineral oil preparation was obtained from the hyperkeratotic
penile lesion and revealed numerous mite eggs and faeces. RESULTS: The diagnosis
of localised, genital Norwegian scabies was made. The patient was treated with
ivermectin 200 micro g/kg per dose taken as two doses, 14 days apart, with
complete resolution of both pruritus and skin lesions. CONCLUSIONS: This patient
is the first known report of Norwegian scabies localised as a single lesion on
the penis. He was successfully treated with oral ivermectin monotherapy.

Rosacea

This posting is from Liliana Rivis, a F.P. resident from Augusta, ME. It is intended for her colleagues as a learning experience, but others are welcome to read and comment if they wish.

The patient is a 43 yo CNA with a two year history of a facial eruption. She had tried metrolgel on a number of occasions and doxycycline for seven days at a time without significant improvement. She is a smoker( 1PPD x years).

O/E; She has an erythema on the cheeks, chin, bridge of the nose and up to the forehead. It spares the nasolabial folds and the hair line. On this erythematous rash are many red papules ( involving even the lower eye lid) covered with very dry skin. There are no obvious teleangiectasias.

She was started on doxycycline 50 mg PO QD for 1 month and I will see her in 2 weeks. I did not give her anything topical . I did not know if I can combine PO doxy and topical metrogel, and for how long. In Habif says to start doxy at 100-200 a day and taper off after rash is resolving.

Dave Elpern's Comments:
This is a woman with moderately severe rosacea. There's a good discussion on rosacea on eMedicine.com. Sometimes, one of the triggers is important (sunlight, hot liquids, alcohol, sunlight, etc.) but more often it's a combination of factors. If the patient is computer literate, I refer them to Dermnet.org.nz. A lot of this is moot because these patients usually respond to doxycycline or minocycline. Mostly start with 100 mg b.i.d. and taper after a couple of months. (Small patients of less than 50 kg may get dizzy on this dose of minocycline so start lower and increase over 1 - 2 weeks). Even tetracycline can work well with a starting dose of 500 mg bid or tid. During the summer, one needs to warn the patients against TCN and doxycycline because these can cause a phototoxic eruption, Minocycline only very rarely does this. If no response to a tetracyclihne in 2 - 3 months consider isotretinoin.

The seven days of doxycycline she had was not a long enough trial. Milder cases maay do well with topical metronidazole cream or gel (Metrogel, Metrocream, Noritate cream). Severe cases or those who do not respond to the tetracyclines should be considered for isotretinoin which usually works in doses lower than those employed for cystic acne. The biggest pitfall is not giving the drug enough time to work -- one must tell the patients to give it eight to twelve weeks. This patient needs to be encouraged to stick with the oral medication.
References:
1. eMedicine.com
2. Dermnet.org.nz

Evolving Lupus Variant?

Your thoughts are most welcome with regards to this patient. I don't have a firm diagnosis yet, but suspect this will turn out to be a form of lupus -- possibly subacute or acute LE..

HPI: A 47 year old woman was seen on June 11th, 2007 with with one month history of two 8 cm. plaques on her legs, KOH negative. Did not look like panniculitis. Initially thought to be Lyme disease, the lesions did not respond to doxycycline.

Because of progression of lesions and question of hypersensitivity disorder per biopsy the patient was treated with prednisone and the eruption subsided over a few weeks.

On 10 mg of pred a day, around 5 weeks after starting prednisone, the patient experienced a marked flare. This was during a long weekend at the beach. She said the weather was overcast and she wasn't out that much. Initial lesions recurred and there were some new papules and plaques on arms and legs. She has marked facial erythema and erythema of neck and upper chest. Other than pruritus, she feels well. No new meds.

Late August to Sept. 2007. Patient's eruption flared on legs and arms. On September 4, for the first time a definite butterfly rash on malar eminences. She feels well other than pruritus and has no arthralgias or constitutional symptoms. Sept. 5th, butterfly rash gone.

O/E: Erythematous plaques on legs. Facial erythema. Flushing of neck. Scattered papules and plaques legs and to a lesser extent arms. See photographs

6/30/07



8/28/07


9/4/07




Lab: 7/4/07 CBC and chemistries normal. ESR 24
8/28/07 Repeat CBC (normal) ESR 17, ANA + anticentromere 1:360
9/4/07 Repeat CBC, PLT normal, ESR still 17

Pathology: 6/30/07
Mild epidermal spongiosis with focal lymphocytic exocytosis and mild to moderate superficial and deep perivascular and interstitial lymphohistiocytic infiltrate with scattered neutrophils and rare eosinophils , extravasated erythrocytes and papillary dermal edema .

Pathologist's Note : These changes are consistent with an allergic dermal hypersensitivity reaction with mild vasculopathy, and may be seen in erythema chronicum migrans . These are not the changes of erythema nodosum . The differential diagnosis includes , in the appropriate clinical setting , a drug eruption or a pigmented purpuric eruption . P.A.S. stain is negative for fungal organisms. Clinico-pathologic correlation is suggested.

Pathology 8/27/07
Hyperkeratosis , focal parakeratosis , flattened epidermis , mild papillary dermal edema , ectatic blood vessels, a mild to moderately dense superficial and mid perivascular lymphocytic infiltrate with occasional plasma cells and extravasated erythrocytes .

Pathologist's Note : These changes are non-diagnostic . The differential diagnosis includes , in the appropriate clinical setting , a deep gyrate erythema, a collagen vascular disease , or possibly a drug eruption . The paucity of eosinophils does not favor the lymphocytic variant of urticarial vasculitis. P.A.S. stain is negative for fungal organisms. P.A.S. stain is negative for fungal organisms.

Repeat Biopsy: 9/4/07 Awaited.

Discussion: I think this patient most likely has subacute L.E. Other than her skin she feels well. There is a suggestion of photosensitivity from the facts that the process began in early June and exacerbated after visits to the beach and Labor Day weekend when it was warm and sunny. Her hemogram is normal, renal function and UA normal, no fever or serositis. I've watched this evolve over three months. It's been interesting and I could be wrong. I will start her on hydroxychloroquine and get an eye consult.

Your thoughts are important to me.

The Orphan Patient

Walter Shelley wrote this important poem about those patients who challenge all of us. We published it in Dermanities a while back and recently Bhushan Kumar from Chandigarh brought it to our attention again. Thank you, Bhushan! Some of the patients who find their way onto this Blog or VGRG

Here it is for those who may have missed it in Dermanities.

Prayer of the Orphan Patient to the Doctor

Walter B. Shelley
Dermanities May 5, 2007; 5(1)

Prayer of the Orphan Patient to the Doctor

Walter B. Shelley & E. Dorinda Shelley

Listen to me

Don’t be cynical, indifferent, or in a hurry.
Ask me what makes my problem better or worse.
Ask me what I think the cause is.
Ask me to look for clues and teach me what they are.

Think about me

Think of my problem when you read those books, journals, and atlases.
Think of my problem when you attend meetings.
Think of asking your colleagues about me.

Test me

Order specific tests to help you decide on my diagnosis and treatment.
Could I have AIDS, cancer, or lupus?
Do I need a biopsy? A challenge with a medication?
Do I need hospital help?
Do I need to see a consultant?

Don’t give up on me

There is always one more treatment you can try. Just imagine I have a different disease and treat me for that.
See me during an attack to get new ideas and new tests.
Ask me lots of questions during every visit.

I won’t give up on you, for I am an orphan

Mokihana Dermatitis

Presented by Caitlin Stiglmeier

I am a 23-year old woman with Type 1 skin who was gathering the fragrant mokihana berries in Kokee, Kauai’s mountain park. Twenty-four hours later, I developed a rash of red marks on my arms, half of which later developed into vesiculo-bullous eruptions. The bullae were left alone; the large blister on the forearm was accidentally burst; the remaining smaller eruptions eventually collapsed over a week’s period.

Pelea anisata, (common name: mokihana) is native only to Kauai, Hawaii, growing at elevations of 1,200 to 4,000 feet. The berries are used in lei-making. It is a multi-trunked tree that grows somewhat vine-like. The oils from its leaves and berries have an anise-like aroma and contain furocoumarin which is the cause of the phytophotodermatitis.

Mokihana is found in the mountain areas of Kauai


The berries are prised for their anise-like fragrance.


My Mokihana Dermatitis at day 5


One month later


Reference:
Elpern DJ, Mitchell JC. Phytophotodermatitis from mokihana fruits (Pelea anisata H. Mann, fam. Rutaceae) in Hawaiian lei. Contact Dermatitis. 1984 Apr;10(4):224-6.
Abstract: Bullous dermatitis, which resolved leaving hyperpigmentation and which was clinically consistent with phytophotodermatitis , affected the skin of the neck of 2 individuals who wore Hawaiian leis (as neck garlands ) made of the fruits of Pelea anisata . In a Daniels culture plate system portions of the fruits showed phototoxicity.

Buttock Necrosis

The patient is a 50 yo nurse who presented to my office on July 31, 2007. Here is the history in her words:

"On June 28th I fell off of my horse. Large dark hematomas covered left buttocks cheek, vagina, and coccyx. Per doctors orders warm, moist heat applied. Thw first picture, taken by my daughter ten days after the fall, shows where the circular area of skin fell off as a result of the compress. I then applied collagenase santyl cream for two weeks but was still unable to debride. One month later, in addition to area on left cheek, new symptoms have arrived which include headaches, 10 - 15 pound weight loss due to diarrhea, burning sensation in face and ears, chest pain, pain between shoulder blades and in neck. There are currently blood tests being done to confirm the existence of what is believed to be a blood disorder. [CBC and Comprehensive chem profile normal except for a slightly elevated BUN of 24 mg%]

O/E: I know this patient well as a care giver and was surprised to see how thin and pale she looked. There is a 9 cm escar on the left buttock. The tissue is necrotic and can not be debrided at this time.

Lab: A culture of the exudate under the eschar grew out many Pseudomonas aeroginosa -- sensitive to Cipro and levofloxacillin.



Discussion:
The trauma seems to have caused skin necrosis. Pseudomonas may be related as well since this looks like echthyma gangrenosum, but the patient has a presumably normal immune system and feels well otherwise. It's unclear if there was fat or muscle necrosis in addition or whether there was a compartment syndrome. The patient is now going to a wound clinic where she can get this are properly debrided.
I have not seen necrosis like this from trauma before. Similar (but more irregular necrosis) can follow brown recluse spider bite. Here, I suspect trauma was the cause; however at one month out the patient has systemic symptoms. One wonders if a CT of the buttock might be of any value.

One week later:
Wound started to drain and was explored at wound clinic. A large cavity was found under the gluteus maximus muscle (around seven cm in diameter). it was irrigated and packed. I am not sure if the cavity contained blood or pus. Today, it was clean with no drainage. The area will likely need surgical intervention as it will take months to heal by the appearance. We will seek surgical opinions.

A Textbook Case

A 76 year old woman presented to the dermatologist with a four month history of darkening of the skin of her neck, axillae, inframammary areas and groin. She had vague G.I. symptoms and had seen her primary care doctor around four times with these complaints. Although her abdomen was "bloated" she'd lost 5 - 10 pounds over the past month. Her sister had died of pancreatic cancer. (Her daughter who works at a neurosurgery office had tried to get her seen by a dermatologist but none had time. It took two months to get her seen at my office which I see as a personal failure)

The patient is a pleasant outgoing woman who appears about her stated age. She has velvety hyperpigmentation of her skin folds.



In addition, she has developed around 10 verrucous tumors measuring 8 - 10 mm in diameter on arms and legs. One of these was biopsied.

A C.T. scan performed on the day of the dermatology visit revealed what appeared to be metastatic tumors in the peritoneum. The workup is in progress.

Most cases of acanthosis nigricans (AN) are benign and related to ethnicity, obesity or endocrinopathy. AN developing in an elderly individual should be a red light to pursue a work-up for malignancy. AN is an easy diagnosis to make and a four month delay in diagnosis is unfortunate. In all likelihood, this tumor had metastasized before the AN became manifest, but it seems unfortunate that the delay in diagnosis occurred.

A good review of AN can be found on eMedicine.

Fingertip Eczema

The patient is a 52 yo warehouseman with a two year history of a painful fingertip eczema of the first three fingers of his right hand and first four fingers of his left (dominant) hand. He handles cardboard boxes and drives a fork lift. He is also an avid golfer. The dermatitis is not seasonal.



He has been only minimally helped by super-potent topical corticosteroids.

Patch testing is scheduled but all we have available here is T.R.U.E. Test. If not helpful, he will be sent to an occupational dermatology department for further testing.

I assume this is an occupational contact dermatitis and have recommended that he use cotton gloves at work if possible.

Your ideas as to etiology and treatment pending definitive patch testing will be appreciated.

Turtles, Birds and Bears

Dermatologists in the U.S. spend a fair bit of time screening patients for skin cancers. In spite of this, there is little evidence that this screening decreases the mortality from skin cancer (mainly melanoma).

"Cancers follow three basic patterns: turtles, birds and bears.
1. Turtles move so slowly that you can still capture them while they’re moving slowly along;
2. The birds fly away so quickly that you can’t catch them in time;
3. The bears can escape if you ignore them, but if you catch them in time, you can capture them."

This simple but brilliant formula comes from a superb article by Christie Aschwanden on sunscreens and skin cancer that appeared in the July 10, NY Times.

Doctors Balk at Cancer Ad, Citing Lack of Evidence See Permalink.

This is a reasoned piece which quotes the best evidence-based information we have. Please read the article and draw your own conclusions.

Atypical Cheilitis

The patient is a 58 yo gynecologist who has had a scaly lower lip for over seven months. When it began, she was wearing orthodontic braces. These were removed around four months ago, but the scaling on the lower lip has persisted. She is a non-smoker. She has treated patients with genital warts with a laser for years and had questions about virus in the plume.

O/E: Hyperkeratosis of lateral portions of the lower lip. This is not the picture of leukoplakia usually seen with lichen planus or actinic cheilitis.




She was treated with hydrocortisone valerate 0.2% cream which was marginally helpful and then clobetasol ointment which was not effective.

Please tell me your thoughts. I am planning a biopsy. Most likely a 3 mm punch -- would you punch or shave?

Thank you.

Lactating Mother

The patient is a 23 yo woman who is nursing a 4 month old infant. She has had psoriasis since childhood, often quite severe. A single mother, she comes from a disadvantaged family and is trying to do all the right things for her young daughter. Her breasts are painful from the plaques and nursing.

[I apologize for the blurry picture. The battery was low and would not allow me to use macro function -- but you can get the idea.]



I think this is psoriasis of areolae caused by the trauma of nursing. The question is how to treat. The young mother wants to continue breast feeding for a few more months.
How would you treat the aroelae and nipples considering that a baby will be sucking on the area?

In These United States

The quality of care in the U.S. varies quite a bit. Everyday, I see patients who might do better elsewhere but can not afford specialist care. There are lots of docs here who specialize in diseases of the rich and well-insured.

Case in point. 55 year old woman with no health insurance. She has an epidermal inclusion cyst of the left inner canthus. It was 2 mm from the lacrimal duct.



I said: You should see an ophthalmologist.
She said: I have no insurance. Can't you do this?
I said: I can try, but I am not sure this will shell out easily.
She said: Please try -- anything will be better than this. How much will it cost?
I said: Okay. How about $45.
She said: Fine, I thought you'd ask a few hundred.

Procedure: Under local 1% xylocaine with epi I dissected the cyst. Luckily, it shelled out nicely. I had hoped not to have to close the defect; but needed to place a 6-0 nylon suture.
I guess it will look better.




I felt like a doctor for a brief moment. The doctor who was there. I knew an ophthalmologist could have done better; but most of them take their patients to an operating room where there is a big charge. This is the reality of health care here.

George Bascom said it better. See "Being There" Click on poem to enlarge.

Iatrogenic Striae

A 17 year old boy was seen by his pediatrician for a crural rash.
He was prescribed Clotrimazole/betamethasone diproprionate cream to use b.i.d for three weeks. At the end of that time, he called his doctor and said he still had the rash. He relates that he was told to continue for another three weeks.



Shortly thereafter, he noticed a discoloration in his groin and some tingling and erythema of the scrotum. The exam showed striae in crural folds and perhaps mild scrotal erythema.

Photo courtesy of DermNet

I see a few cases of striae secondary to this combination cream each year. The medication seems to have more risks than benefits. It should probably not be used for more than a week in groin or axillae. I have also occasionally encountered men with painful burning scrotums secondary to potent topical steroids (including this combination) and suspect that "scrotodynia" can be caused in this manner. This patient has mild symptoms scrotodynia, but I suspect they will resolve.

Here is a pertinent reference:
Clotrimazole/betamethasone diproprionate: a review of costs and complications in the treatment of common cutaneous fungal infections.

Greenberg HL, Shwayder TA, Bieszk N, Fivenson DP.

Pediatr Dermatol. 2002 Jan-Feb;19(1):78-81.


The use of antifungal/corticosteroid combinations as topical therapy for dermatophytoses has been criticized as being less effective, more expensive, and the cause of more adverse cutaneous reactions than antifungal monotherapy. The combination of clotrimazole and betamethasone diproprionate (Lotrisone) is a mix of an azole antifungal and a high-potency corticosteroid, and is one of the most widely prescribed of these combinations. Our objective was to describe the beneficial and deleterious effects of Lotrisone in the treatment of common cutaneous fungal infections and its relative cost-effectiveness. We did a literature review documenting clinical trial data and adverse reactions to Lotrisone and collected a cost analysis of topical antifungal prescribing data over a 2-month period from a large midwestern staff-model health maintenance organization (HMO). Lotrisone is approved by the U.S. Food and Drug Administration (FDA) for the treatment of tinea pedis, tinea cruris, and tinea corporis in adults and children more than 12 years of age. Treatment is limited to 2 weeks in the groin area and 4 weeks on the feet. The most concerning adverse effects of Lotrisone were reported in children and included treatment failure, striae distensae, hirsuitism, and growth retardation. This combination was also reported to have decreased efficacy in clearing candidal and Trichophyton infections as compared to single-agent antifungals. Lotrisone was considerably more expensive than clotrimazole alone and was found to account for more than 50% of topical antifungal expenditures as prescribed by primary care physicians, but only 7% of topical antifungals prescribed by dermatologists. We found that Lotrisone was shown to have the potential to induce many steroid-related side effects and to be less cost effective than antifungal monotherapy. This combination should be used judiciously in the treatment of cutaneous fungal infections and may not be appropriate for use in children.

The Mask

6/15/07


Every day one sees something unique: either a new disorder or a singular variant of common process. A 90 yo woman was seen yesterday 3 - 4 week after the onset of Herpes zoster of the second division of the trigeminal nerve. She was left with an impressive escar covering a large portion of the dermatome. It was relatively easy to debride most of the escar off. No anesthesia was necessary. I'll affix a follow-up photo when I see her back. Follow-up care was with cool compresses and Silvadene cream.

This woman lives alone, drives her own car and is the family matriarch. Hopefully, the zoster will not derail her.

The above photo is a bit out of focus. My fault.


6/18/07

Same Patient -- Three days later. Note involvement of nasal tip. 2nd branch of trigeminal but with nasal tip involvement (and patient had sorneal ulcer!) indicating perhaps involvement of nasociliary branch of trigeminal (which should not happen) -- aberrant innvervation? She seems much brighter today and not complaining of much pain.

Six Weeks Later
7/27/07

The patient's skin has healed nicely but she has persistent numbness around left ala and left naso-labial fold. Also lancinating episodic pain and resultant depression. A neurologist has put her on Neurontin which I do not feel is helpful. Post-herpetic neuralgia is a complex disorder and I think there's a huge "illness behavior" component. I don't think pharmacotherapy is the answer. Nonetheless, I gave her EMLA cream to use.

Case for Diagnosis

Presented by Choon Siew Eng FRCP, Johor Bahru, Malaysia.

46 years old woman with 3-year history of gradually enlarging asymptomatic indurated plaques on her neck, both axillae right side of abdomen, right groin and lower back. She is otherwise well with good general health. There was no significant family history.

Physical examination revealed multiple indurated erythematous to hyperpigmented plaques on right side of her neck, right flank, both groins and axillae. The overlying skin is atrophic with brownish adherent scales.
There were multiple groups of hyperpigmented papules on abdomen, upper thighs and legs. Some papules appeared yellowish. Palms, soles, nails, scalp and mucosae are spared.

I am thinking of treating her as sarcoidosis since she is distressed by her extensive lesions
Differential Diagnoses: Nodular amyloidosis, Scleromyxoedema, Morphoea, xanthogranuloma

Repeated blood tests such as full blood count,BUSE, LFT, thyroid functions, serum and urine calcium and autoimmune screening were normal. Her ESR was also normal . CXR was normal and Mantoux test was negative.Sputum for AFB X3 negative. Biopsy from abdominal lesion showed numerous granulomata composed of epithelioid histiocytes, lymphocytes and multinucleated giant cells, Langhan’s type. Special stains for Acid fast bacilli (ZN, Wade fite) and fungal bodies (PAS) were negative. No abnormal deposits of eosinophilic amorphous material seen. No foreign body seen by polarised light.

Case For Diagnosis

Presented by Dr. Amanda Oakley, Hamilton, New Zealand

A month ago, a 14-year old girl presented to the paediatricians with a fever, arthralgia and small purpuric and possibly target-like spots on her legs. She had been previously well and had taken no medications. After extensive negative investigation she was commenced on penicillin in case she had bacterial endocarditis, and was sent home.
She was readmitted yesterday with on-going fever and arthralgia, and crops of extremely painful plaques mainly affecting her face. Earlier lesions on her abdomen and limbs have resolved leaving marked hypo-hyperpigmentation or scarring. Biopsy of the plaque on her neck shows full thickness necrosis histologically with little inflammation. EM-like. Several new plaques have been observed to arise overnight despite an initial dose of prednisone 40mg. There is no mucosal involvement to date.
All tests so far negative - we are thinking up some more tests but we don't know the correct diagnosis. No other drugs as far as we can ascertain.
Has anyone seen anything like this? Is it erythema multiforme? Other possible diagnosis? Treatment?

Case for Diagnosis

The patient is a 54 yo woman with a 2 week history of a rash on the arms and chest. Two months ago, she had erythema nodosum with atypical features (on her legs). The work-up eventually discovered Crohn's disease. She was started on Asacol around a month ago and around 2 weeks ago developed erythematous papules on arms and anterior chest.

0/E: The new lesions are 6 - 8 mm in diameter erythematous papules with the suggestion of central punctae. The E.N. has resolved.

Lab: Representative lesions were biopied.

Question: What are your thoughts? We will post pathology in around a week.

Continuous Medical Education

VGRD and this VGRD Blog have been around for a number of years now. Both serve as forums at which dermatologists and other physicians can post and comment on interesting and challenging cases. Other sites such as the Skin Cancer Clinic blog out of Queensland, Australia serve a similar function and are better attended. We came across an article recently which lends credence to this activity and indicates that this interactive format may be a better way of providing continuing professional education than the lectures which we traditionally attend at conferences and hospital rounds.

The article appeared in The Journal of General Internal Medicine in 2004. Here are the particulars:

Toward Continuous Medical Education
Roni F Zeiger, MD
Gen Intern Med. 2005 January; 20(1): 91–94.
For full article click on PDF locate .pdf download access it.

While traditional continuing medical education (CME) courses increase participants' knowledge, they have minimal impact on the more relevant end points of physician behavior and patient outcomes. The interactive potential of online CME and its flexibility in time and place offer potential improvements over traditional CME. However, more emphasis should be placed on continuing education that occurs when clinicians search for answers to questions that arise in clinical practice, instead of that which occurs at an arbitrary time designated for CME. The use of learning portfolios and informationists can be integrated with self-directed CME to help foster a culture of lifelong learning.