Stumped...

Abstract: 60 yo man with unusual cutaneous ulcers and erosions
Presented by Dr. Hamish Dunwoodie, Moncton, New Brunswick
HPI: The patient is a disabled physician's assistant who injured his scalp on a low basement ceiling beam around a year ago. When he was first seen he had a thick escar over the area. This was debrided and cultured. It grew Staph aureus with the usual sensitivities and he was treated with wet compresses, dicloxacillin and bactroban ointment. Since his initial visit 4 months back it has not gotten smaller and now the central portion reaches the calvarium. Over the past six weeks, he has developed similar lesions on shoulders and upper back. By history these began at sites of ECG leads.

Pertinent medical history is positive for insulin-dependent diabetes, hypertension and coronary artery disease. His medications include insulin, warfarin, enalapril, furosemide, ASA, oxycodone.

O/E: 3 cm ulcer mid parietal area of scalp. Erosions on both shoulders, surface somewhat escharotic. Some with irregular borders.

Photos:


4 months later








Lab: Occasional skin cultures positive for S. aureus (not MRSA), CBC shows mild normochromic normocytic anemia. (Hct 32.6.Hgb 11.2).

Pathology: "Ulceration with scar. No evidence of malignancy." Repeat biopsy April 18, 2008 from new lesion on shoulder send to Canadian National Pathology Lab.

Diagnosis: Non-healing erosions etiology unclear. One always considers factitial disease in health care professionals with atypical skin lesions and this man also has free access to needles as a diabetic. In a year, the scalp lesion has shown no tendency to improve.

Further Treatment: He was treated with topical corticosteroids in case this was erosive pustular dermatitis of the scalp (no response) and imiquimod in case erosion might have been hypergranulation tissue. (no response) We ordered Duoderm dressings, but they were too expensive for the patient.

Questions: Where would you go from here? Diagnostic and therapeutic suggestions.

A Leg to Stand On

Abstract: 85 yo man with cellulitis and lymphedema s/p bypass surgery

HPI: In 2000, this retired professor had CABG surgery with saphenous vein harvesting of the left leg, In 2002, while visiting Vienna, he was hospitalized for cellulitis of the left leg and treated with i.v. antibiotics. In the subsequent years, he has had progressive lymphedema of the left leg with the development of elephiantiasis nostra verrucosa. In the past 6 months he has had four documented episodes of cellulitis which have necessitated antibiotics. Recently, he has developed a generalized dermatitis. His medications include: atenolol, amiodarone, digoxin, diovan, thyrpid, Coumadin, Lovastatin, ASA. He has a possible allergy to penicillin (has not taken it in 40 years). He is otherwise quite healthy and intellectually alert.

O/E: Chronic lymphedema left leg with erythema, scale and some honey-colored crust. The leg in involved from just below the knee to the foot. The left leg is only minimally warmer than the right leg. In addition, he has a wide-spread dermatitis consisting of erythematous scaly patches on legs, arms and abdomen -- sparing the face.

Photos:






Lab: His internist did a skin culture and CBC b efore sending him here (results not back) . He was on Bactrim at the time of the culture.

Diagnosis: Recurrent Cellulitis s/p saphenous veif harvesting wit the development of chronic lymphedema and early elephiantiasis nostras. This was reported in 1982 (see Reference). The wide-spread dermatitis may be an "id" reaction.

Questions:
1) What has been learned about this entity since 1982?
2) Should he be rechallenged with penicillin and kept on long-term antibiotic prophylaxis.
3) What role does "hypersensitivity" to bacterial exotoxins play in the dermatitis.
4) Does anyone have magic for cases such as this?
5) Allergic contact dermatitis will be ruled out by patch testing.

Comment: My plan at the moment is to "clean up" any residual infection, consider prophylactic antibiotics and work on the dermatitis. I will refer him to a lymphedema center, if possible, for evaluation. Aggressive management of his leg swelling will help. He was told not to bathe the leg and I think this sets him up for infection. Your thoughts will be greatly appreciated. This man's life revolves around his leg. He is a keen student, a political scientist and in his later years he must focus exclusively on a leg. Let's give him "a leg to stand on!"

Follow-up: The patient was treated with compression stockings, cephalexin 250 mg qid for two weeks (based on sensitivities), desoximetasone 0.25% cream and lymphatic massage. There was no evidence of tinea pedis. He has improved markedly.
Photos taken June 10, 2008





Reference:

Recurrent cellulitis after saphenous venectomy for coronary bypass surgery.
Baddour LM, Bisno AL.
Ann Intern Med. 1982 Oct;97(4):493-6.

We describe a previously unreported complication of coronary artery bypass
grafting, recurrent cellulitis. Five patients had 20 episodes of acute
cellulitis, each occurring in the lower extremity in which saphenous venectomy
had been done. The cases were striking because the patients presented with high
fever and considerable systemic toxicity. The appearance of the lesions, presence
in one case of obvious associated lymphangitis, and prompt response in three
instances to therapy with penicillin alone all suggest group A streptococcal
infection. In one case, a beta-hemolytic, bacitracin-susceptible Streptococcus
strain was isolated from the lesion. The pathogenesis of this syndrome remains
obscure but, based on our understanding of postsurgical erysipelas, this
cellulitis likely results from the interplay of several factors, including local
compromise of lymphatic drainage, direct bacterial invasion, and acquired
hypersensitivity to streptococcal exotoxins.

Recurrent Cheilitis in a 37 yo Woman

Abstract: 37 yo woman with 18 year recurrent cheilitis

HPI: This 37 yo woman has had recurrent cheilitis for 18 – 20 years. She works as a medical assistant. At one time, she was thought to be latex sensitive because blowing up balloons makes her feel sick, but a RAST test was negative. The episodes last five to six days. The day before the present episode she had eaten a “Mediterranean Dip” which included cucumber, garlic, feta, tomato, and horseradish. She noted nothing till the next morning when there was mild erythema of upper lip. She may have a history of mild atopic dermatitis. She can recall no meds she took before this or other episodes.

O/E: Erythema and mild crusting of lips and adjacent glabrous skin. Remainder of exam normal. Occasionally she’ll have mild erythema around outer canthi.

Photos:




Lab/Path: N/A

Diagnosis: ? Allergic Cheilitis. Role of Foods? Doubt Fixed Drug Eruption. To me this looks like an allergic contact cheilitis.

Questions: What would be the best way to work this up? This woman has 3 - 4 episodes per year, so it is unlikely that her cheilitis is related to something whe uses daily, and she does not recall anything she applies only intermittently.

Reference:
Allergic contact cheilitis in the United Kingdom: a retrospective study.
Strauss RM, Orton DI.
Am J Contact Dermat. 2003 Jun;14(2):75-7.

Abstract: Environmental and Contact Dermatitis Unit, Amersham Hospital, Whielden Street,
Amersham, Buckinghamshire, HP7 0JD, United Kingdom. strauss@strauss.karoo.co.uk

BACKGROUND: To date, only a few cohorts of patients with allergic cheilitis have
been described, most of them from Australia and Asia. OBJECTIVE: To establish the
prevalence of cheilitis in a UK specialist contact dermatitis clinic and to
identify the most common allergens. METHOD: We analyzed our patch-test database
in a tertiary referral center in the United Kingdom, retrospectively. All
patients presenting with cheilitis over a 19-year period (1982 to 2001) were
included. RESULTS: Data were available from a total of 146 patients. A positive
allergic patch-test reaction was thought to be relevant in 15% of the patients (n
= 22) and to be of possible relevance in 6.8% (n = 10). Of the 22 patients with
relevant allergic results, 95% (n = 21) were women. The most common allergens
included fragrance mix (mainly cinnamaldehyde, oak moss, and isoeugenol) in 41%
of patients, shellac in 18%, colophony in 18%, and Myroxylon pereirae in 14%. For
half of the patients, the allergen was believed to stem from lipsticks or lip
products. Eighteen percent of patients with allergic cheilitis reacted to only
their own products. CONCLUSIONS: Patients should be tested to extended
lipstick/cosmetic vehicle series in addition to standard series. As a significant
percentage of patients react to their own products only, a thorough clinical
history and testing to patients' own products are important.

Double Helix

We often see problems for which there may be no simple solution. Ear lobe keloids are encountered with regularity; but keloids of the helix and triangular fossae are unusual. Some of you may have a simple trick for patients like these:

Patient # 1.
Abstract: 25 yo woman with ear keloid.

HPI: This 25 yo Asian woman pierced the triangular fossa of her right ear 2 years ago and developed a keloid which is pruritic and whose appearance bothers her.

O/E:


Patient # 2
As I was getting case # 1 ready to publish on this site, a second patient presented for evaluation and treatment.
This is a 16 yo girl with a one year history of a keloid of the left triangular fossa. She had a professional piercing done two years ago. This lesion is painful.




This patient had an "Industrial Piercing" with a 14 guage stainless steel rod.

Comment: Earlobe keloids are commonly seen and reported. But I could find no helpful articles about helix and triangular fossa keloids. I suspect that these lesions are not rare, since I have seen two in a few weeks in a small New England town. Perhaps, these are harbingers of an epidemic! One of these young women pierced her own ear, and the other was a professional job.

Questions:
These can not be simply excised and then injected with TAC like the more common ear lobe keloid. Wound closure would be problematic.
How would you approach these women?
Any role for shave excision followed by imiquimod?
Do you think TAC alone will work? 20 mg per cc, 40 mg per cc?
Does anyone have experience with similar lesions?

Weird Erythema

Presented by Omid Zargari
Rasht, Iran

This patient referred to me with a weird erythema on his frontal area for the past two years.
He is a 45 y.o. kidney transplant patient whose medications include cellcept, cyclosporine, erythropoetin alpha and simvastatin. He believes that this began after he started simvastatin.



Your thoughts will be appreciated.

Acrolentiginous Melanoma from Malaysia

Here is a case from Jahor Baru, Malaysia. In North America, Europe and Australia the patient would have had more extensive studies; but one must keep in mind that there are disorders in Malaysia that are better handled there than here. Melanoma is far less common in SE Asia and their resources are allocated differently.

Abstract: 70 yo woman with ALM right sole

Presented by S.E. Choon, Consultant Dermatololgist

HPI: This 70 year-old Chinese lady presented in April 2006 with a 1-year history of a growth on right sole which was biopsied and diagnosed as melanoma. We do not have level and thickness. She refused below knee amputation and hence was referred to us in July 2006. She had radiotherapy in Sep/Oct 2006 in private centre.

P.M.H: Diabetes mellitus of 10 years, well-controlled with metformin 500 mg bd and glibenclamide 5mg daily.

O/E: see figure Fig. This shows her lesion in 2006 before XRT. There were no other positive findings. The current lesion very similar. Patient coming back next week.

















Work UP: CXR and CT neck, thorax and abdomen were clear in 2006 - in February 2008 CT scan last week showed several small right obturator lymph nodes. I was not too happy without a repeat CT and get one done last week. Size of LN not mentioned.

Pathology:
2006: Superficial spreading type (apparently down to subcutis for initial biopsy. Pathologist in Singapore wrote: "nodular type with vertical growth and ?superficial spreading"
2008: Recent lesion biopsy report was short and sweet-recurrent melanoma

Diagnosis: Acrolentigious Melanoma

Questions:
1. How would you classify this patient?
2. What would you recommend for this patient?
3. The patient initially refused amputation. Is there a lesser procedure that might help her now?

Your answers and comments are welcome.

Painful Edematous Plaques

Abstract: 24 yo woman with 2 month history of transient plaques torso and extremities.
HPI: This 24 yo woman was diagnosed with hyperthyroidism in October of 2007. She was treated with radioactive iodine and carbamazole in November and December. Her dermatological manifestations began after both treatments. She reports ~ 20 episodes of painful plaques on torso and extremities. These last 1 - 3 days and clear completely. They are hot, tender, and painful in certain locations. She was first seen in my office on February 26, 2008 with an acute episode which was 24 hours old.
O/E: Healthy-appearing young woman. A solitary plaque was noted on the upper back. The borders were well-defined. The area was hot and painful and slightly erythematous. The patient had trouble taking her shirt off for the exam.
Photos:
Note: The border is outlined for clarity with a blue marking pen in photos 2 and 3.

Lab: She has had various blood tests done by other physicians and I've called for results. I ordered a CBC and ESR yesterday. Thyroid antibodies will be obtained unless her other physicians have ordered these.
Pathology: A deep incisional wedge biopsy into the panniculus was obtained.
Diagnosis: I have not seen anything like this. The short duration of the lesions suggests angioedema or urticarial vasculitis. But, I have never seen a similar case with such large lesions. One wonders about the relationship of her thyroid disease and possible autoantibodies.
Reason Presented and Questions: It is instructive to present an undiagnosed case for discussion. Others may have seen a similar patient. Every day, we see something unique to us. In some cases, our colleagues may be of invaluable assistance. Your comments are most welcome.

Facial Pigmentation in a 31 yr old woman with Protein S deficiency

A 31 yr old woman presented with one year history of pigmentation on her face. It appeared as sun burn and confined to the facial areas with sparing of the areas underneath the eyes and nose. It was made worse after application of some skin care products. She was otherwise well.

She had a past history of hypercoagulation and mitral valve prolapse with Protein S deficiency and is on warfarin.

Examination of the skin showed diffuse hyperpigmentation on the face extending to the frontal hairline, preauricular hairline and mentum. The areas under the eyes and nose were spared.

Blood counts and biochemistry were normal ANA serology mildly positive. Titre 1:80 (RR<80)

Differentials: photodermatitis > LE > melasma > irritant dermatitis

Q Is the serology titre of 1:80 significant? Could this be LE or melasma? Would you biopsy her skin? If you biopsy, where would you biopsy her? Thanks for your comments.

Asymptomatic annular lesions on face and hands

Submitted by Khalil Alhamdi M.D.
Associate Professor of Dermatology
Basrah, Iraq

Abstract: A 25-year old woman with 3-year history of asymptomatic annular lesions on face and hands

History: A 25-year-old woman presented with 3-year history of multiple asymptomatic annular lesions involving the face and the dorsa of both hands that gradually increase in size. She had received different modalities of treatment without improvement.

O/E: Young aged women presnted with multiple asymptomatic annular atrophied hyperpigmented patches with hyperkeratotic border that affect the face in a mask-shaped destribution and the dorsa of both hands.

Clinical Photo:

Lab: All relevant investigations were normal.

HPE: revealed features suggestive of porokeratosis

Diagnosis: Porokeratosis of Mibelli

Comments: This woman was misdiagnosed as fungal infection and lichen planus for which she received treatment without benefit. On clinical and histopathological bases we put her on topical 5Fu in addition to irregular courses of isotretnion because of poor compliance and inavailability of the latter drug in our country.

Questions:

1. What is the experience of our colleagues in seeing such unusual presentation?
2. What is your treatment suggestion to help this poor lady.

Umbilical Erosions

[ See end for final diagnosis]
Abstract: 71 yo woman with three week history of genital, anal and umbilical erosions.
HPI: This healthy 71 yo woman had vaginal prutitus for a few weeks. She saw her gynecologist who prescribed an estrogen cream. It got worse. She was then given clobetasol oint. It did not improve. She tried acyclovir ointment -- not much change. I saw her at this point. I recommended continuing clobetasol ointment, but after a few days getting worse. No new meds. Takes occasional acetoaminophen and diphenylhydramine.
O/E: Periumbilical erosive dermatitis. No frank vesicles. There was only faint erythema of the vulva and anal areas and very slight erosion left groin.



Lab: CBC normal, Chemistries normal. KOH from umbilicus negative. Bacterial culture taken.
Pathology: Biopsies for H&E and perilesional for DIF done Feb. 8, 2008
Diagnosis: I am considering the following:
A vesiculobullous disorder
Fixed drug eruption (but have no likely candidates)
Contact dermatitis unlikely.
HSV a long shot.
Periumbilical cellulitis? B-Strep perianal cellulitis can look similar
What have I missed?
Questions: What are your thoughts? Biopsy and culture should be ready in three days.

The bacterial skin culture grew out Group A Beta Strep. The pathology was consistent with cellulitis. No evidence of an acantholytic process. It is likely that this began with a perianal/vaginal streptococcal cellulitis and spread to the umbilicus. Periumbilical streptococcal cellulitis has not been reported in adults. The patient was started on Pen VK 250 mg qid and mupirocin ointment. Fout days later she was almost completely clear. Unfortunately, the fluorescent correction was not on when picture was taken.

Question from Iraq

Dear Colleagues,

Pityriasis alba, a disease of young children, is a superficial dermatitis which often presents in two stages: first the erythematous stage which over time developes into (the second) a whitish stage. In Iraq, we see, not infrequently, children with pityriasis alba-like patches that change over time into true vitiligo and then progress and spread to vitiligo in other parts. Many of these patients have a positive family history of vitiligo. At the initial visit it is sometimes is very difficult to tell parents whether their children have vitiligo or not and we fall into big dilemma.

I see many of these and treat them as vitiligo. They respond as well as as those we treat for pityriasis alba.

Question: I would like to ask our colleagues whether you have any similar observation? I intend to initiate a study about this problem shortly.

Khalifa Sharquie

Note: The current case on the classic VGRD site is also from Iraq. Please view it, too.
Baghdad, Iraq

Black Papule in a Child

Abstract: 11 yo boy with long history of black lesion left arm
History: The lesion has been present for years, little change but patient and parent are worried bout it.
O/E: 5 mm diameter papule with a peculiar serrated border
Clinical Photo(s)


Dermoscopic Image

Lab:
Pathology:

Diagnosis or DDx: Reed Nevus (aka Pigmented spindle cell nevus)
Questions: For inerest
Reason(s) Presented: When I first saw this patient, I thought it was a blue nevus. I sent the history and digital images to a few friends. Drs. Ian McColl and Stelios Minas thought it was a Reed nevus and recommended excision. Biopsy was done and confirmed their opinion.
References: The Reed Nevus is considered a variant of the Spitz nevus. It presents as a well-circumscribed deeply pigmented nodule on the extremities of young adults. Under the microscope, it resembles the Spitz nevus but is composed of spindled melanocytes with heavy melanin pigmentation. As in a Spitz nevus, this nevus is symmetrical with maturation and lack of deep dermal mitotic figures. Excision of suspected Reed nevi is recommended. For more information see: The Doctor's Doctor

Eyelid Tumors

Submitted by Arash Abtahian from Shiraz, Iran

Abstract: 24 yo man with three year hx of eyelid lesions
History: This 24 man has come with 3 years hx of multiple translucent papule and nodules on the left upper lid. They are asymptomatic but he'd like them removed.
O/E: revealed multiple translucent papules and nodules some of which showed bluish hue.
Clinical Photo(s):




Lab: N/A
Histopathology: Apocrine Hidrocystoma
Diagnosis or DDx: Apocrine Hidrocystoma
Questions: What is the best treatment?
Reason(s) Presented: Therapeutic suggestions?
References: Apocrine Hidrocystoma eMedicine: " Apocrine hidrocystomas can be incised and drained; however, electrosurgical destruction of the cyst wall often is recommended to prevent recurrence. Punch, scissors, or elliptical excision also can remove tumors. Multiple apocrine hidrocystomas can be treated with carbon dioxide laser vaporization. Multiple apocrine hidrocystomas can also be effectively treated with trichloroacetic acid."

Papular Unticaria

Abstract: 20 yo student with pruritic papules for three weeks

History: While on a ski trip in New Mexico, this young woman developed a few pruritic papules around the neck. Over the next few days, these spread to torso and extremities. Some of the lesions were grouped in a "breakfast, lunch and dinner" distribution. She is in excellent health: a ski racer.

Exam: 1/3/08: There were 40 - 60 6 - 8 mm in diameter erythematous papules on torso, upper and lower extremities and to a lesser extent face. No lesions on doubly covered areas. After treatment with topical steroids this improved, but then flared around a week later.
1/10/08: Many new papules, neck, torso, extremities. No longer "breakfast, lunch and dinner" distribution.





Lab: CBC pending

Pathology: Consistent with arthropod bites or drug reaction. Will add photos later. Specimen shows parakeratosis, epidermal hyperplasia with focal eosinophilic exocytosis and a moderately dense superficial and mid perivascular interstitial lymphocytic infiltrate with scatterred eosinophils.

Diagnosis: Papular Urticaria (PU)

Questions: This woman is a competitive athlete. She does not want to take prednisone while racing. The lesions are very widespread and potent corticosteroid creams do not give much relief. Hydroxizine, too, will blunt her competitive edge. What would you recommend.

Reference: There was a good review of PU by Hernandez and Cohen in Pediatrics in 2006. "Insect bite-induced hypersensitivity and the SCRATCH principles: a new approach to papular urticaria." It is available in full-text: Hernandez/Cohen

Your thoughts and suggestions are welcome.

Unusual Keratoderma

Presenters:
Susan Walsh, DPM
Foot Care Specialists of Boston Medical Center

Jag Bhawan, MD
Boston University School of Medicine
Boston, MA

Abstract: 44 year man with congenital keratoderma left foot

Hx: The patient was born with this problem. He has never seen a podiatrist or dermatologist. No other skin problems. He tries to keep callus under control by regular soaks of foot and using razor.
Past Medical History
2004- 3v CABG surgery
CHOLECYSTECTOMY
DEPRESSION
HYPERTENSION
HYPERCHOLESTEROLEMIA






Reasons for presentation:
-Diagnosis?
-Patient & wife inquiring about options such as skin graft, or laser
-Should be biopsied?
-started on CARMOL 20 20 % CREAM (UREA) apply to feet bid x one week then daily every day

Zebibah

The zebibah, Arabic for raisin, is a dark circle of callused skin, or in some cases a protruding bump, between the hairline and the eyebrows. It emerges on the spot where worshipers press their foreheads into the ground during their daily prayers.

Here is a fine article in the NY Times on the ZEBIBAH.

One of our editors, Ben Barankin, published a letter on prayer marks in the International Journal of Dermatology. Barankin Letter

Dr. Barankin's letter was a comment on:

Prayer marks.
Abanmi AA, et. al.
Int J Dermatol. 2002 Jul;41(7):411-4.
Dermatology Department, Research Center,
Riyadh Al Kharj Armed Forces Hospital

Iatrogenic or Not?

Your opinion is sought.
The patient is a 42 y.o. woman with a long history of cystic acne. Typically she gets a few lesions a year. She has many ice pick scars from previous lesions. She was offered isotretinoin years ago but declined and indeed the lesions are less frequent now. She presents for intralesional triamcinalone when whe wishes to have the cysts treated. She was seen on December 5, 2007 with a tender cyst on the medial aspect of the left eyebrow. It looked like a typical acne cyst and was injected with Kenalog 3 mg per cc. Two days later she started to develop eyelid edema. She went to the Emergency Room and was given parenteral Rocephin and Cipro 500 mg bid. The swelling persists.



On examination, one can see where the initial cyst was. It's ~ 90% resolved. Below it there's a firm linear band that feels like a lymphangitic vessel.

I assume this must be related to the initial inflammatory lesion or the intralesional injection. I searched MEDLINE but could come up with no similar cases. If this is secondary to intralesional steroids, it is not reported. Could the original lesion have been a pyogenic infection that looked like her past cysts and could eyelid edema be secondary to lymphatic obstruction? The ER doc recommended another dose of Rocephin.
Addendum: The patient has never had fever, headache or other findings suggestive of a pyogenic infection.

Has anyone seen a similar case? Diagnostic and therapeutic suggestions are welcome.

Palmar Lichen Planus?

This case was presented by Dr Khalil Alhamdi, Basrah Medical College, Iraq.

S.G, 62 yo woman, presented with bilateral itchy palms 2 years duration with poor response to treatment. Physical examination is normal apart from bilateral diffuse hyperkeratotic violaceous palms. All laboratory investigations were normal

Histopathology: histopathological examination showed typical features of lichen plaus.

Diagnosis: palmer lichen planus.

What is the experience of our colleagues in seeing such a presentation of palmer lichen planus? comment please.

Epidermal nevus affecting foot

A 22 year old man presented with a history of linear hyperkeratotic lesion on the right foot since age 7 yrs. It hurts his foot when he wear his shoes.

Examination of the right foot showed a localised hyperkeratotic plaque extending linearly to the medial malleolus. It was not tender or inflamed. My impression is that of an epidemal nevus. Appreciate your thoughts on diagnosis and treatment options.