Rwecalcitrant Warts

The patient is an 11 yo girl with difficult-to-treat warts present for 4 years.  Her pediatrician has used cryotherapy, and a vesicant.  They have tried salicylic acid under occlusion for a month and the warts have grown.

The child is very self-conscious.  What would you do?

A Thing of Beauty

The patient is a 7 year-old boy with a lesion present since infancy.  He was adpopted at age 11 months and prior history is unknown.  The lesion has changed only minimumly over the past few years.

O/E:  7 mm lesion with macular dots and two darker pigmented papules on the left abdomen. He has a small area of segmental vitiligo on the left neck.

Ckinical and Dermatoscopic Images:

Workup:  None at this time

Diagnosis:  Nevus spilus, Speckled Lentiginous Nevus
Note:  An association of segmental vitiligo with SLN has not been reported.

Reference:

Speckled lentiginous naevus: which of the two disorders do you mean?

Happle R1.  Clin Exp Dermatol. 2009 Mar;34(2):133-5

Abstract: Speckled lentiginous naevus (synonym: naevus spilus) no longer represents one clinical entity, but rather, two different disorders can be distinguished. Naevus spilus maculosus is consistently found in phacomatosis spilorosea, whereas naevus spilus papulosus represents a hallmark of phacomatosis pigmentokeratotica. The macular type is characterized by dark speckles that are completely flat and rather evenly distributed on a light brown background, resembling a polka-dot pattern. In contrast, naevus spilus papulosus is defined by dark papules that are of different sizes and rather unevenly distributed, reminiscent of a star map. Histopathologically, the dark spots of naevus spilus maculosus show a 'jentigo' pattern and several nests of melanocytes involving the dermoepidermal junction at the tips of the papillae, whereas most of the dark speckles of naevus spilus papulosus are found to be dermal or compound melanocytic naevi. The propensity to develop Spitz naevi appears to be the same in both types of speckled lentiginous naevus, whereas development of malignant melanoma has been reported far more commonly in naevus spilus maculosus.

Rhinophyma

The patient is a 73-year-old semi-retired carpenter who presents for evaluation of lesions on his back and eyelids.  Surprisingly, he did not mention his nose.

O/E: He has two epidermal inclusion cysts on the back some and some small skin tags around the right upper and lower lids (these lesions were snip excised).

More significantly, the skin of the distal nose it grossly thickened and patulous.

Clinical Photos:

Diagnosis:  Rhinophyma, Grade 3.

Although he did not initially express concerns regarding his nose, when I mentioned that there are treatments, the patient was very interested.

References:

1. Basal cell carcinoma masked in rhinophyma.

De Seta D1, Russo FY, De Seta E, Filipo R.  Case Rep Otolaryngol. 2013;2013:201024.  Free Full Text.

2. Basal cell carcinoma and rhinophyma. Leyngold M et. al. Ann Plast Surg. 2008 Oct;61(4):410-2.

Abstract: Rhinophyma, the end stage in the development of acne rosacea, is characterized by sebaceous hyperplasia, fibrosis, follicular plugging, and telangiectasia. Although it is commonly considered a cosmetic problem, it can result in gross distortion of soft tissue and airway obstruction. Basal cell carcinoma (BCC) is a rare finding in patients with rhinophyma. The objective of this study is to review the literature of BCC in rhinophyma and report on a case. A 70-year-old male presented with long-standing rosacea that resulted in a gross nasal deformity. The patient suffered from chronic drainage and recurrent infections that failed conservative treatment with oral and topical antibiotics. The patient decided to proceed with surgical intervention and underwent tangential excision and dermabrasion in the operating room. Since 1955 there have been 11 cases reported in the literature. In our case, the pathology report noted that the specimen had an incidental finding of a completely resected BCC. The patient did well postoperatively and at follow-up remains tumor-free. Despite the uncommon occurrence of BCC in resection specimens for rhinophyma, we recommend that all specimens be reviewed by a pathologist. If BCC is detected, re-excision may be necessary and careful follow-up is mandatory. Larger studies would be needed to determine the correlation between the 2 conditions.

Cryotherapy Gold Mine

Percent Reimbursement for Cryo per Medicare Payment

CPT Codes

17000 – Cryotherapy for One Lesion Reimbursed at: $59.88

17003 – Cryotherapy for > 1 Lesion   Reimbursed at: $8.05/lesion

Cryotherapy pattern of six dermatologists with practices in same area of New England.  All in private practice.  This only shows Medicare reimbursements (that probably account for 34 -- 40% of gross income).  

Excoriated Acne with Hyperpigmentation

A 37 yo Haitian woman was seen complaining about hyperpigmented lesions on face and back.  By history, these followed acne which she has excoriated.  Her health is good otherwise and she takes no medication by mouth.

O/E:  Hyperpigmented papules and macules on face and torso in a young woman with Type V skin.  Some lesions show mild excoriation.

Clinical Photos:

Diagnosis:  Post-inflammatory hyperpigmentation in excoriated acne.

Comment:  In my area, we have few patients with Type V and VI skin.  This is a common problem, but I do not have much experience treating it.  What is your protocol?  I started her on tretinoin 0.05% cream as this may be covered by her insurance.

Note:  A Pubmed search for hyperpigmented acne scars retrieves only three references and all are to laser surgery which this patient can not afford. This problem must be extraordinarily common; yet the biomedical literature is strangely silent about it.

Active Nevus

17 yo boy seen for another problem.  Atypical nevus noted on left shoulder.

O/E:  Type III-IV skin. 5 mm papule with slight play of color clinically.  Pt. unaware of lesion.

Dermoscopic images shows pigment dots of varying sizes.

Dx:  Actively growing nevus.  Easy to excise with a 6 mm punch.  Best to do this of just observe?  Patient will be leaving for college in another city in a few months.

Unusual Facial Dermatosis

Abstract:  16 yo girl with 3 month history of annular dermatosis mid-forehead.

HPI:  This healthy 16 yo has had a 4 cm roughley circular plaque on the mid-forehead.  Takes no medications by mouth and is not aware of any OTC meds taken infrequently,  She has bued 1% hydrocortisone cream and also a topical imidazole without improvement.

O/E:  The lesion has fairly sharp borders.  The surface is somewhat gready.  KOH prep failed to demonstrate hyphae or spores.  The remainder of the cutaneous examination is unremarkable.

Clinical Photo:

Diagnosis:  The picture is suggestive of seborrheic dermatitis, but the circular nature is unusual. What are your thoughts?

Plan:  Betamethasone valerate 0.1% cream b.i.d. x 2 weeks sand then Elidel cream.  If it does not respond or if it recurs a biopsy will be done.

Unilateral/Segmental Vitiligo in a 9-year-old boy receiving Melagenina as treatment

HPI: The patient is a 9-year-old boy who developed loss of pigmentation on the right side of his face over a 3-month-period. The depigmentation of the skin progressed rapidly with no antecedent eruption, redness or trauma. There was no history of exposure to a chemical or irritant prior to depigmentation of the skin.

No medical history of hypothyroidism or other medical conditions.  No family history of vitiligo or autoimmune diseases. He often spends 2 to 6 hours in the sun playing outside only beginning to wear sunscreen recently. 

Diagnosis:  He appears to have a segmental or unilateral vitiligo.

He lives in Cozumel, Quintana Roo, Mexico and has been evaluated by a dermatologist locally who confirmed the diagnosis clinically.  No biopsy was obtained.

Labs: TSH, complete blood count and chemistry panel were normal.

Prior/Current Treatment:  Melagenina solution

Since the patient is a citizen of Mexico, he and his family were able to travel freely to Cuba and obtained an appointment in the Vitiligo clinic evaluation and treatment after a 6-month wait. Their first visit to Cuba was in August, and they are expected follow-up in 6 months. He was given Melagenina solution to be applied twice a day to the depigmented areas of skin. Melagenina solution can only be obtained in Cuba at this time.  It is derived from placental extract that is mixed with an alcohol solution. He will return to Cuba in February 2016 for a follow-up visit and to obtain more Melagenina.

Images:

 

His mother has noticed some repigmentation of the treated areas.  The pictures shown are after using the treatment for 4 months.

Second Opinion in USA and Plan:

We recommended adding tacrolimus (Protopic 0.1%) ointment and a low-dose steroid such as mometasone furoate cream to his Melagenina treatment regimen to be applied twice a day. The patient was counseled on the importance of using a titanium and zinc oxide waterproof sunscreen on the face to prevent further darkening of the surrounding area and to protect the areas of depigmentation.

Discussion:

Vitiligo is a common skin disorder affecting about 1 to 2% of the world population. It commonly affects children and can be seen in different patterns.  This patient appears to have a unilateral or segmental pattern but not necessarily dermatomal. 

It has been shown that segmental vitiligo in children is relativley common and less frequently associated with systemic autoimmune diseases or endocrine disorders.

Treatment in the USA and Mexico includes using narrow band UVB phototherapy or psoralen with UVA phototherapy as well as topical low-dose steroids and tacrolimus combinations. Narrow band UVB phototherapy is considered one of the most efficacious treatments and can be used alone and in combination with topical steroids and tacrolimus. Some patients are also treated with the excimer lasers and have undergone melanocyte transplants. Melagenina or placental extracts are not used currently.

In the General de Mexico hospital, up to 50 cases of vitiligo are seen per day.  Many efforts are being made to increase awareness about vitiligo. One controversial issue in Mexico has been the exploration of naturalist physician care and unresearched treatments options. As we are aware, this is a consideration in the U.S. as well. Although the medical community wants to be open to new ideas involving topical and oral nutritional and botanical substances, in Mexico the concern is that patients will use their limited financial resources on unsubstantiated treatments. Phototherapy clinics treat vitiligo patients in the larger cities of Mexico, but unfortunately many patients, including this patient, could not travel regularly to these established clinics due to financial and transportation limitations.

1)   How safe, well regulated and efficacious is the Melangenina solution in the treatment of vitiligo? Should this be something explored more for patients in the USA?

2)   Should the patient inform the physicians in Cuba that they will be adding other topical medications to the regimen?

Out of respect to the Cuban dermatologists, we encouraged them to inform the clinic that a second opinion was sought out and new medications were started.  The patient and his family were unsure if the treatment with Melagenina was part of a clinical trial.

3)   Should we consider oral minipulse therapy with methylprednisolone? 

Although there are relapses and other considerations with oral steroid use in children, a few case reports and clinical trials have shown some benefits.

 

Lo, Yuan-Hsin, Gwo-Shing Cheng, Chieh-Chen Huang, Wen-Yu Chang, and Chieh-Shan Wu. "Efficacy and Safety of Topical Tacrolimus for the Treatment of Face and Neck Vitiligo." The Journal of Dermatology 37.2 (2010): 125-29. Web.

 http://onlinelibrary.wiley.com/doi/10.1111/j.1346-8138.2009.00774.x/full

Majid, Imran et al. “Childhood vitiligo: response to methylprednisolone oral minipulse therapy and topical fluticasone combination.” Indian Journal of Dermatology 54.2 (2009): 124–127. PMC.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2807150/ 
 

 Shrestha, S., AK Ha, and DP Thapa. "An Open Label Study to Compare the Efficacy of Topical Mometasone Furoate with Topical Placental Extract versus Topical Mometasone Furoate with Topical Tacrolimus in Patients with Vitiligo Involving Less than 10% Body Surface Area." Nepal Medical College Journal 16.1 (2014): 1-4. Web.

Xu, Aie, Dekuang Zhao, and Yongwei Li. "Melagenine Modulates Proliferation and Differentiation of Melanoblasts." International Journal of Molecular Medicine Int J Mol Med (2008): n. pag. Web.

 http://www.spandidos-publications.com/ijmm/22/2/193

Confluent and Reticulated Papillomatosis

The patient is a 21 yo man with a six month history of subtle scaly patches on both axillae.  He was treated by is internist with ketoconazole cream without effect.  A KOH prep was done and was negative.

Clinical Image:

Patches are slightly yellowish and there are islands of sparing.


Pathology: Hyperkeratosis, papillomatosis (increased compared to specimen B), mild epidermal hyperplasia and a superficial perivascular lymphocytic infiltrate consistent with confluent and reticulated papillomatosis.
NOTE: The differential diagnosis could include acanthosis nigricans. PAS stain is negative for fungal organisms.
Photomicrographs courtesy of Jonathan Ho MD MS, Department of Dermatopathology, Boston University School of Medicine

Diagnosis: confluent and reticulated papillomatosis.

This is a difficult diagnosis clinically and histologically.  It's  a type of "dermatological non-disease."  Without the help of an experienced dermatopathologist I doubt that this diagnosis would have been arrived at.

The patient will be treated with minocycline, 100 mg bid for a month.  If this is CARP the process will be resolved.

New Tumor

This 81 yo woman with type II skin presented with a 9 mm papule on the left anterior neck that has been present for three weeks.

The lesion has a smooth glistening surface and a distinctive vascular pattern.

Although this may well be a basal cell carcinoma, it's appearance is atypical.  Perhaps, it is an adnexal tumor.

It was shave excised for diagnostic purposes.

Pathology should be back in ~ 5 days.

Atypical Granular Cell Tumor

This 55 yo woman was seen for three painful lesions (left abdomen of two months duration and right axilla of one week duration).  She is in good general health and takes no medications by mouth.

Pathology of lesion abdomen:

Granular cell tumor with atypical features consistent with at least "atypical granular cell tumor."

NOTE: The specimen exhibits a diffuse dermal interstitial proliferation of S100-protein positive and CD68 positive epithelioid cells with abundant finely granular, eosinophilic cytoplasm that is negative for high and low molecular weight keratins and Mart-1/Melan-A. The granular cells show nuclei that are variably pleomorphic as well as that are intermittently vesicular with large nucleoli. These changes are diffuse throughout the tumor and are consistent with the atypical variant of granular cell tumor.  The photomicrographs are courtesy of Dr. Hyejin Leah Chung , a dermatopathology fellow at Boston University School of Medicine.  (They are 10x, 20x, 40x and 40x)

Axillary Lesion: Inflammatory nodule consisten with hidradenitis.

Diagnosis: Atypical granular cell tumor is a problematic diagnosis.  A small percentage of these may be malignant granular cell tumors and they have a worrisome behavior.  The fact that the axillary lesions are presumably not related is curious.  This patient needs a full work-up and follow-up.

Referencea:
1. Case for diagnosis.

Leyva AM et.al.  An Bras Dermatol. 2014 May-Jun;89(3):523-4.

Abstract: Granular cell tumour is a rare tumour of neural origin usually located on the face and the neck. The biological behaviour is usually benign. However, certain clinical and histopathological features should alert physicians to a malignant behaviour. This case report describes the occurrence of a granular cell tumour in the inguinal area that resembled a malignant tumour. The histopathological study revealed typical features of granular cell tumour and an extension study confirmed the absence of metastasis. This case highlights the importance of considering this disorder in the differential diagnosis of ulcerated nodules and of managing atypical granular cell tumor appropriately.  Free Full Text.

Two Cases for Diagnosis from India

Presented by Dr. Yogesh Jain, from Ganiyari, Bilaspur in Chhattisgarh, Central India presents

1. A 34 year old farmer with a solitary lesion on the right shin for 6 years. Mildly itchy and has no discharge from it. No systemic symptoms.
We have done a biopsy.

What are your thoughts?

2. This patient came in today's OPD with vesiculopapular lesions throughout the body for 6 years.It started on the right ring finger and is slowly progressing.

 What are your thoughts?

Post-Auricular Basal Cell

The patient is an 84 year-old man with a one to two week history of bleeding from a lesion in the sulcus behind the left ear and overlying the mastoid process.  He had noticed a tumor there for a longer period of time and has covered that with a Band-aid.  The area was recently traumatized and he was seen at the Dermatology Clinic. He has a history of basal cell carcinoma of the glabella.

O/E:  There is a 2 cm erosive lesion behind the left ear that extends over the mastoid bone. 

A shave biopsy was taken from two representative areas.

Clinical Photo:

Pathology:  Basal cell carcinoma. Probably nodular, but deeper areas may show other features

Diagnosis:  The pathology confirms the clinical impression of basal cell carcinoma.

Discussion:  This is a particularly worrisome area.  While some nonmelanoma skin cancers in octogenarians can be observed, lesions in this area can be invasive into the underlying bone.  For this reason, we will recommend Mohs micrographic surgery.

Reference:
Invasive basal cell carcinoma of the temporal bone.
Gussack GS et. al.
Abstract: Basal cell carcinomas involving the ear represent a spectrum of diseases, from a small superficial auricular lesion to an advanced destructive malignancy invading the temporal bone. The biologic activity of the morphea-form basal cell carcinoma variant of tumor and a postauricular location predispose to an aggressive biologic pattern. Management requires a thorough evaluation with determination of the degree of cranial and possible intracranial invasion. These lesions usually can be managed with partial temporal bone resections, although prognosis for patients with advanced lesions may be poor.
(No proof of bone invasion in this case; however, this is a setting where one needs to consider it)

Towards Continuous Medical Education

With VGRD, since the year 2000, we have tried to provide a new paradigm of CME.  At its best VGRD provides Continuous Medical Inspiration (CMI).  This platform preceded the landmark article by Roni Zieger that we introduce you to here:

Toward Continuous Medical Education (Free Online Full Text)

Roni F Zeiger, MD. J Gen Intern Med. 2005 Jan; 20(1): 91–94.

Abstract:

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.

Keywords: continuing medical education, Internet, distance learning, library services

Free Online Full Text

Perplexing Recurrent Cheilitis

Presented by Henry Foong
Ipoh, Malaysia

 

Abstract: A 20-year-old man presented with recurrent cheilitis 

HPI: A 20-year-old student presented with recurrent peeling of the lips for about 3 years. It usually began on the upper lip then involved the lower lip. Then the cycle repeated. The entire process takes about 3 weeks. He has no known drug allergy. He denied any lip smacking. He was using a moisturising non-SLS tooth paste.

Examination showed peeling of the lower and upper lip as a single friable sheet. His oral cavity and genitalia were unremarkable.

Clinical Images: 

Patch Tests:                                 

Gold sodium thiosulphate  ++ at 48 and 96 hours;

Iodopropynyl butylcarbamate  + at 48 and – at 96 hours

Sodium bisulphide + at 48 and 96 hours

Thimerosal +/- at 48 and 96 hours

Histopathology: The sections show a fragment of tissue surfaced by parakeratinised stratified squamous epithelium. The underlying connective tissue is moderately collagenous with mild chronic inflammatory cells infiltration and a few small blood vessels. A few lobules of minor salivary glands are observed. No granuloma seen in the sections examined. Final Path Diagnosis: Lower labial mucosa: Histologically non-specific 

Diagnosis: Chronic cheilitis

Reason for presentation  

Despite avoiding all the trigger factors such as lip smacking and use of non-SLS toothpaste, his symptoms persisted. The patch test results are probably irrelevant in his case. In a study from Singapore, toothpastes were the commonest cause of allergic contact cheilitis in males. Ricinoleic acid and the patient's own lip preparations were the commonest relevant contact allergens. The absence of granuloma practically make granulomatous cheilitis unlikely.

Questions   

What is the most likely diagnosis? Could this be a case of exfoliative cheilitis? Exfoliative cheilitis, a rare, localized condition, is a chronic superficial inflammatory condition that is characterized by regular peeling of a superficial excessive layer of keratin. the cause of this condition is unknown but may be associated with depressive illness. Two other differential diagnosis comes to mind - pemphigus vulgaris and Crohn's disease.

References

1. Mani SA, Shareef BT. Exfoliative cheilitis: report of a case. J Can Dent Assoc. 2007 Sep;73(7):629-32. Abstract.  Full Free Text.

2. Lim SW, Goh CL. Epidemiology of eczematous cheilitis at a tertiary dermatological referral centre in Singapore.Contact Dermatitis. 2000 Dec;43(6):322-6. Abstract.

3.  Contact allergy in cheilitis.  O'Gorman SM, Torgerson RR.  Int J Dermatol. 2015 Nov 6.  Abstract. (See Dr. Sharquie's comments)

4. Exfoliative Cheilitis DermNet-NZ. (excellent synopsis)

Keywords   

chronic cheilitis, exfoliative cheilitis

Sarcoidal Granulomas

Presented by Christine Shanahan, Third Year Student
University of Virginia School of Medicine

Abstract: 36 yo male with diffuse erythematous pruritic plaques

HPI: The patient is an uninsured 36 yo male with a 6 month history of diffuse erythematous pruritic plaques on the chest, back and buttocks. The condition worsened over the past 2 months. He has no history of prior skin diseases, diabetes mellitus or other systemic conditions. He denies shortness of breath, wheezing, chest pain, eye problems, night sweats, unintentional weight loss or fatigue. He usually receives medical care in South America and frequently travels between South America and the United States.

On Examination: Diffuse erythematous pruritic plaques present on the chest, back and buttocks. No evidence of eyelid margin or oral cavity involvement.

Clinical Images:

 

Lab:

Chest radiograph showed no abnormalities.

Serum angiotensin-converting enzyme (ACE) level was found to be normal.

Recommended undergoing pulmonary function tests, ophthalmologic exam and chest CT scan.

Pathology:

Punch biopsy specimen from mid-back revealed numerous well-formed epithelioid cell granulomas in various levels of the dermis, a few patchy lymphocytic infiltrates and no necrosis or suppurative inflammation. No evidence of infectious microorganisms were found with special stains for acid-fast bacilli and fungi. Second pathologist evaluated specimen and confirmed diagnosis. Tuberculoid type of Hansen’s disease was added to histologic differential diagnosis but Fite stain showed no M. leprae.

Diagnosis: Sarcoidal granulomatous inflammation consistent with Sarcoidosis.

Plan: The patient was counseled on the importance of screening tests, including pulmonary function tests and an ophthalmologic examination, due to the insidious onset of systemic sarcoidosis and the frequency of pulmonary and ocular manifestations. The patient was reluctant to have any further workup beyond treatment of the skin condition. He was treated with 1 cc of intramuscular triamcinolone acetonide 40mg/cc (kenalog®-40) and topical steroids at follow-up visit. He was scheduled for follow-up visit in 1 month and referred for further workup of systemic disease.

Discussion:

Early diagnosis of sarcoidosis can be difficult, so cutaneous lesions can be key findings in helping to expedite this diagnosis.  Cutaneous sarcoidosis occurs in 20% to 35% of patients and can present at the early onset of disease. Also, skin involvement has been associated with more rapid progression of systemic sarcoidosis. The skin manifestations are described as specific or nonspecific lesions and are usually asymptomatic with pruritus in about 10% of patients. This patient had pruritic specific lesions with noncaseating granulomas visualized as plaques, one of the various typical morphologies. Although this patient appears to be in the early stages of the disease, the plaque presentation is typically associated with chronic forms of systemic disease. Sarcoidal lesions can mimic many other conditions including Hansen’s disease, leishmaniasis and lupus vulgaris. Specifically, tuberculoid type of Hansen’s disease is histologically similar and “the Fite method” is commonly used to distinguish the diseases. Cutaneous leishmaniasis remains endemic to many countries in South America such as Brazil, Colombia and Peru. The histopathology may be similar to sarcoidosis and some recent recommendations have been made to order PCR for Leishmania-specific DNA for any presentation of sarcoidal type granulomas in patients living in endemic areas. 

Questions:

1. Could this still be Hansen’s disease with a negative Fite stain?
2. Could this be a form of Leishmaniasis?
3. Any recommendations for further workup of sarcoidosis for a low-income, uninsured patient?  
   
   
   References:
   1) Cutaneous sarcoidosis: differential diagnosis
   Clinics in Dermatology, Volume 25, Issue 3, Pages 276-287
   Esteban Fernandez-Faith, Jonelle McDonnell
    
   
   2) Hansen's Disease: An Imitator of Cutaneous Sarcoidosis
   Katsuya Chinen, Kazuhiko Hirano, Yasunori Fujioka Pictures in Clinical Medicine. Internal Medicine Vol. 50 (2011) No. 19  P 2257-2258
   
   3) Comorbidity of Leishmania Major with cutaneous sarcoidosis 
   Moravvej H, Vesal P, Abolhasani E, Nahidi S, Mahboudi F.
   

   Indian Journal of Dermatology. 2014;59(3):316. Free PMC Article 
   
   4. The Sarcoid-Lymphoma Syndrome. (MedScape)