Chronic Localized Folliculitis

The patient is a healthy 28 yo man with a five year history of erythematous papules and pustules on the central upper chest.  No improvement over the past few years.

O/E:  There are erythematous crusted papules and pustules mid upper chest.  No other cutaneous lesions.

Clinical Photos:

Path:  4 mm punch bx x 2: Both specimens show a dense perifollicular neutrophilic iinfiltrate forming abscesses and infiltrating follicular epithelium with admixed lymphocytes, plasma cells and histiocytes.  GMS and PAS and gram stain negative.
Deon Wolpowitz, M.D. of B.U. Skin Pathology provided these impressive microscopic photographs.

Lab:  Two bacterial cultures taken from a pustules a year apart show only coagulase negative staph. 

Diagnosis: Chronic Localized Folliculitis.  Simplistically, I am thinking about Majocci's granuloma or an atypical form of acne.

The patient is reluctant to try isotretinoin or systemic antibiotics.  He is a healthy person in all other respects and has fears about messing with is microbiome and has read about isotretinoin and is worried.

Chronic Recurrent Axillary Dermatitis

Six yo old boy with > 3 year history of recurrent dermatitis

HPI:  The patient is an otherwise healthy six year-old boy with a > three year history of a dermatitis in the left axilla.  There is no pertinent family history.  He has had similar areas since infancy.  A culture taken in February 2013 showed many coag + Staph aureus. He was treated then with mupirocin ointment and betamethasone valerate 0.1% cream with good results.

O/E:  Localized crusted erosions left axilla. No other lesions today.

Clinical Photos 10/31/16)

Lab: Repeat bacterial culture taken.

Sulzberger on Caring for Patients

Yoon Cohen sent this quotation to us.  Readers of VGRD will appreciate it:

I know of no better way to start teaching a student of medicine than by repeating over and over the old-time physician's concept of his responsibilities toward his patients: to cure sometimes; to help often; to comfort always.

Perhaps the most fundamental requirement to become a more than ordinary practitioner is to be able to put yourself as wholly as possible into the patient's place. This is not as easy to do as it sounds. I told my young colleagues: "As you sit opposite your patient, try to think about his or her problems so intensely that you lift yourself mentally into his shoes, his seat, his pants, his home, his work, his problems."

They were told over and over again: "Every patient who comes to us is in trouble. Whether the complaint seems serious or trivial to you, it is serious to the patient and deserves your full attention and your best efforts. You may have just seen ten patients with more grave or more interesting skin diseases, but to the patient you are now examining, his trouble is the most important in the world at that moment. You must be kind and patient even with those who are over-demanding, unreasonable, even antagonistic. Remember that those attitudes too are signs of illness and often the results of fear, anxiety, or ignorance."  

Marion B. Sulzberger

Florid Acneiform Eruption

Presented by: 
Marina Delgado, M.D.
Apache Junction, Arizona

The patient, a 21 woman  with a 9 year history of acne is studying in Arizona.  Her acne, present since age 12, was relatively quiescent until it flared three months ago when she was doing research in Southern China.  In the past, she had been treated with topicals, antibiotics and oral contraceptives.  None were effective; but her acne was not florid as it is now.

10.9.2016

 After treatment with prednisone and isotretinoin.

5.12.2017

Photos are presented with the young woman's consent.
 
One of our pediatric dermatology colleagues suggested that this woman has pyoderma faciale.

We recommended isotretinoin plus prednisone but, because of iPledge, the patient has to wait a month to qualify for isotretinoin.

Have you managed similar patients?  What suggestions do you have?  What do you see as the role for prednisone and how long shoould it be continued?

References:

1. Pyoderma faciale: Successful treatment with isotretinoin

Victor J. Marks, Robert A. Briggaman

J Am Acad Dermatol 17, 1062–106. 1987  PDF.

2. Henry Foong. Pyoderma faciale, Virtual Grant Rounds in Dermatology, October 2001.

3.

Combination of low-dose isotretinoin and pulsed oral azithromycin in the management of moderate to severe acne: a preliminary open-label, prospective, non-comparative, single-centre study.  De D1, Kanwar AJ. Clin Drug Investig. 2011;31(8):599-604.

RESULTS: Sixty-two (93.9%) of 66 eligible patients had complete clearance of disease activity after a mean treatment duration of 21 weeks. The mean total cumulative dose of isotretinoin was 49.6 mg/kg. Seven (11.3%) patients had a relapse of disease during the post-treatment follow-up period. Fifty-three adverse effects were observed. Three patients had initial aggravation of disease that was managed with prednisolone and disappeared with continuation of treatment.

CONCLUSION: A combination of low-dose isotretinoin and oral azithromycin pulse is effective in severe acne and has a reasonably acceptable adverse-effect profile and low post-treatment relapse rates.  Abstract.

 

Extensive Darier's Disease

This 55 yo man presents with a flare of Darier’s disease. In his own words, he suffers from “mental illness” and has been on lithium for decades. He very embarassed about his skin and feels that he looks “hideous” because of this. Two yeas ago he had squamous cell carcinoma of the base of the tongue that was treated with surgery, radiation and chemothreapy.  This is in remission presently.

O/E: The examination shows widespread discrete and confluent reddish-brown greasy papules on the the chest and back. 

We have treated him successfully with isotretinoin in the past and were concerned about the possible interaction between lithium and isotretinoin, but the patient is at his wits end with his disease.

PLAN: He was requalified for iPledge today. He will be started on 40 mg of isotretinoin a day. In a month, we will do biochemistry survey, CBC, lipid profile, and lithium level.  We will obtain his last lithium level, in addition.

Have you managed similar patients and if so, what are your recommendations?

The patient was treated with 40 mg of isotretinoin daily.  After a few months, he is completely clear and his dosage is being tapered.

 

References

Isotretinoin treatment of Darier's disease.
J Am Acad Dermatol. 1982 Apr;6(4 Pt 2 Suppl):721-6.
Dicken CH, et, al.

Airborn Contact Dermatitis?

The patient is an 83 yo woman who has had a recurring pruritic dermatitis located mostly on face, neck and upper chest for two years.  It seems to be more prominent seasonally.  She has a history of a lymphoma ~ five years ago.  She had alopecia universalis for many years that spontaneously remitted ~ two years ago.

O/E:  Florid erythema of face and neck.  Submental area does not appear to be spared.

This woman has a somewhat "leonine" facies.

Diagnosis:  Initially, I thought she had a contact dermatitis or the "red face syndrome" from overuse of topical corticosteroids. She has been off the latter for > 1 year.  The has needed prednisone to control this; but I prefer a long-term medication with less side-effects.  Given her history of lymphoma, further evaluation may be necessary.


References:

Azathioprine versus betamethasone for the treatment of parthenium dermatitis: a randomized controlled study.

Verma KK1, Mahesh R, Srivastava P, Ramam M, Mukhopadhyaya AK.

Indian J Dermatol Venereol Leprol. 2008 Sep-Oct;74(5):453-7

Author information: prokverma@hotmail.com

Abstract

CONCLUSIONS: Azathioprine and betamethasone appear to be almost equally effective (P=0.0156 vs. 0.0005) in the treatment of parthenium dermatitis. However, adverse effects and relapses were observed to be more frequent in patients treated with betamethasone. Free Full Text

Postiive Band-Aid Sign

The patient is a 77 y.o. man who presented with a number of skin lesions.  He has a past history of non-melanoma skin cancer.

The lesion in question has been present for a few months.  It is an almost 5 cm in diameter exophytic tumor.

Diagnosis:  Probable Squamous Cell Carcinoma.

I anesthetized the lesion and shaved it off.  There was a fair amount of bleeding.  I curretted it and cautrized the base. It was not as soft as a typical SCC or BCC.  Specimen submitted and I'll attach a follow-up with the path.

Pathology:  Well-differentiated squamous cell carcinoma

This is a particularly good example of the "Positive-Band Aid" sign.  Most of us know this, but it has not been well-reported in the literature.  We presented this sign on the VGRD Blog in 2007.

The Tortured Tube

The patient is a 25 yo man with a 4 mo hx of an eyelid dermatitis.  His mother, a health professional, gave him 0.1% triamcinalone oinment to apply ~ 2 months ago.  It has run out and he came in for an appointment.  He is healthy and has a history of atopic dermatitis that is now quiescent.

Diagnosis and Discussion: I think this is an example of "steroid acne."  It's hard to tell what preceded it.  Most topical corticosteroids when applied for weeks or more to thin skin such as is seen on the face (expecially eyelids or around the mouth) or the genitalia can cause this.  It's a type of steroid addiction.

The standard treatment is to stop the topical steroid, apply cold compresses two time a day and doxycycline 100 mg b.i.d. for a month or more.  The longer this has been going on, the harder it is to treat.

Reference:  Dr. Ken Fowler and I reported a similar patient in 2001.

Tortured tube" sign. Fowler KP, Elpern DJ.  West J Med. 2001 Jun;174(6):383-4. Free FullText Online.

Linear Pruritic Lesions

Dr. Yogesh Jain would appreciate your comments about the following patient:

18 year old man with no significant past medical history, presented with these lesions to the OPD.  He revealed that he has been having such lesions ever since he was 2 years of age. These excoriative lesions are very itchy, but not painful. They extends from the left groin till the medial malleolus in a continous pattern. And also involve the left arm in a similar fashion affecting the palm as well. He is not on any medications.   There are no other systemic positive finding.

Dermatitis Neglecta

The patient is a 15 yo boy with a three month history of a dermatosis of his cheeks.

O/E: Slightly greenish symmetrical dermatosis of cheeks.  Othewise, normal.

Photos taken by patient's mother and emailed to me.

Dermatoscopic images before and after area was cleansed with an alcohol pledget.

Diagnosis:  Dermatitis Neglecta

There are no descriptions of the dermatoscopic appearance of this disorder.

Laugier Hunziker syndrome

The patient is a 74 yo man with a long history of oral hyperpigmentation.  He was presented on VGRD in 2012, but we have further history now.  The pigmentation has been present many years. His mother had a similar process by history.

He has a history of colon polyps. His paternal grandmother had colon cancer. His mother had colonic polyps and breast cancer. His father and his father’s brother both had leukemia.

O/E:  There are multiple dark brown irregular lenticular hyperpigmented macules of 2–5 mm diameteron the lower lip ant tongue.  No other hyperpigmentation was noted.

Clinical Image:

Diagnosis: Laugier Hunziker syndrome vs Peutz Jeghers syndrome

Case to be discussed at Hot Spots 2016

References:

1. Laugier–Hunziker Syndrome: A Rare Cause of Oral and Acral Pigmentation

Silonie Sachdeva, Shabina Sachdeva, and Pranav Kapoor

J Cutan Aesthet Surg. 2011 Jan-Apr; 4(1): 58–60.

Abstract: Laugier–Hunziker syndrome (LHS) is an acquired, benign pigmentary skin condition involving oral cavity including lower lip in the form of brown black macules 1–5 mm in size, frequently associated with longitudinal melanonychia. There is no underlying systemic abnormality or malignant predisposition associated with LHS, and therefore the prognosis is good. Important differential diagnoses include Peutz Jeghers syndrome and Addison’s disease among other causes of oral and acral pigmentation.  PubMed Central.

Annular Lesions in a 50 yo woman

This image was sent by Dr. Yogesh Jain from India for diagnostic suggestions.
The only history provided was that the process is present on the hands and feet and has been ongoing for 25 years. The lesions regress after a number of months.

Other than a variant of granuloma annulare or elastosis perforans serpiginosa, what are your thoughts?

Biopsy is important but so is the dermatopathologist who reads it.

What is Right Care?

The patient is a 90 year-old man, homebound with a dementia.  His 87 year-old wife is a steadfast, loving and loyal caregiver.  His dermatologist has made house calls for the past four months. 

There are non-melanoma skin cancers on the left cheek  and mid upper lip.  The former lesion has increased from 1.3 to 1.5 mm in diameter and the the lip lesion has increased from 1.8 to 2.2 mm in diameter in the past two months.  Both are somewhat inflammatory and crusted. He picks on the lip lesion, but because of his dementia he can not articulate what it is that bothers him.

7.28/15

March 2016

6.28.2016

8.11.16

Thoughts: The question is what is the best treatment for this man.  The lesion on the left cheek could be curetted and desiccated in the office. The lesion on the lip is a more complicated problem. 

A trial of topical 5-FU plus imiquimod may be helpful, especially for the lesion on the lip, as a palliative procedure.  The lesion on the malar eminence which grew rapidly ~ 6 months ago and is either a squamous cell or a keratoacanthoma) could be curetted and dessicated.

The patient can not make a decision for himself and his wife wants to just watch these lesions.  She understands that treatment is not likely impact on his quality of life at this point and want’s to spare him the trauma or surgery.

As physicians, we feel compelled to “do something.”  Is this the right time to “not just do something, but to sit there.”

Reference:

1. Linos E. Treatment of nonfatal conditions at the end of life: nonmelanoma skin cancer.  JAMA Intern Med. 2013 Jun 10;173(11):1006-12

CONCLUSIONS AND RELEVANCE: Most NMSCs are treated surgically, regardless of the patient's life expectancy. Given the very low tumor recurrence rates and high mortality from causes unrelated to NMSC in patients with limited life expectancy, clinicians should consider whether these patients would prefer less invasive treatment strategies.  PubMed.  PMC Free Full Text.

2.  Knocking on Heaven’s Door by Katie Butler is an honest, sobering book that describes what awaits so many elderly people and their caregivers, who are often family members.  It is relevant to how one manages a patient such as the man described and discussed here.

Hypopigmentation in an African

The patient is a 39 yo man from Ghana.  His wife noticed these spots on his back recently.  My first diagnosis was tinea versicolor; but KOH prep showed only spores.  Is this just quiescent T.v.?  It's symmetrically distributed over upper back (no where else).  In differential diagnosis was vitiligo -- but this is incomplete hypopigmentyation (which can occur with vitiligo, but less commonly).  I suggested ketoconazole cream and a follow-up in 3 months.  If still present, may do a biopsy.
What are your thoughts?

References:

1. The utility of dermoscopy in the diagnosis of evolving lesions of vitiligo.

Thatte SS1, Khopkar US.  Indian J Dermatol Venereol Leprol. 2014 Nov-Dec;80(6):505-8.

BACKGROURD: Early lesions of vitiligo can be confused with various other causes of hypopigmentation and depigmentation. Few workers have utilized dermoscopy for the diagnosis of evolving lesions of vitiligo.

CONCLUSION: Pigmentary network changes, and perifollicular and perilesional hyperpigmentation on polarized light examination, and a diffuse white glow on ultraviolet light examination were noted in evolving vitiligo lesions. Histopathological examination was comparatively less reliable. Dermoscopy appears to be better than routine histopathology in the diagnosis of evolving lesions of vitiligo and can obviate the need for a skin biopsy. Free Full Text.

2. Dermoscopy as an ancillary tool for the diagnosis of pityriasis versicolor.

Zhou H, Tang XH, Chen MK. J Am Acad Dermatol. 2015 Dec;73(6):e205-6. (this is only reference in PubMed on T.v. and dermsocopy and it is not particularly helpful)

3. Dermatoscope--the dermatologist's stethoscope.

Lallas A, Argenziano G.  Indian J Dermatol Venereol Leprol. 2014 Nov-Dec;80(6):493-4. Full Free Text 

This is an interesting somewhat philosophical article.  The references are extensive and helpful.

Alopecia Universalis in a Teenage Girl

Presented by Henry Foong, Ipoh, Malaysia

Here is a patient I saw recently.  She is a 17-year-old girl who has a history of severe alopecia since the age of 12 years.  It was abrupt and sudden with marked loss of scalp hair followed by eye brows and other body hair.  Within a month, she had developed alopecia universalis.  She was initially treated with intralesional triamcinolone and topical minoxidil but did not help.  Subsequently she had NB-UVB 3 times weekly in the local hospital but that also did not do much good.  She was advised to go to tertiary centres in KL but was disappointed with only one visit.  She could not go to NSC in Singapore because of financial constraints.  As a Malay, she always wears a tudong to cover her scalp.  There was no other systemic complaints.  She is the 4th in the family of 5 siblings.  No family history of alopecia. 

She saw me yesterday.  Am trying out DPCP diphencyprone sensitisation for her.  She had a previous sensitisation done but quit after one treatment.  She had total alopecia affecting the scalp, eyebrow, eyelash, axillary and suprapubic area. Used 0.1% DPCP concentration, left on the scalp for 24 hours and reviewed the next day.  She does have good reaction with small vesicles and plan to do it weekly till her hair grows.  The eyebrow hair loss was treated with intralesional triamcinolone acetonide injection of 10 mg/ml strength.  According to literature, topical minoxidil 5% solution, topical clobetasol ointment and weekly methotrexate 25mg/wk do help too.  Other novel therapy would include JAK inhibitors.
Comment:  Who has had real success treating patients with AU? Are there any lab tests of real value?

After DPCP sensitization

References:

1. Clinical Efficacy of Diphenylcyclopropenone in Alopecia Areata: Retrospective Data Analysis of 50 Patients.  Chiang KS, Mesinkovska NA, Piliang MP, Bergfeld WF. J Investig Dermatol Symp Proc. 2015 Nov;17(2):50-5.

Abstract: Diphenylcyclopropenone (DPCP) is widely considered the most effective topical immunotherapy for refractory or extensive alopecia areata (AA), but questions regarding how long to try DPCP therapy before terminating and what factors are prognostic of therapeutic success still remain unanswered. In this retrospective study of 50 AA patients, we evaluated DPCP efficacy and identified patient factors predictive of therapeutic success/failure. The median duration of DPCP treatment was 3 years, with 47% patients experiencing their first regrowth in the first 6 months of DPCP therapy, 20% between 6 months-1 year, and 8% between 1-2 years. In our study, treatment success, defined as ⩾50% terminal hair regrowth, was reached in 71% of alopecia totalis patients and in 56% of alopecia universalis patients. Three factors were statistically significant predictors of poor treatment outcome-extent of hair loss before DPCP treatment, history of thyroid disease, and extent of body hair involvement. Relapse was observed in 44% of patients and significantly associated with history of thyroid disease. Common side effects were itching, rash, and local lymphadenopathy. The results of this study support our belief that DPCP therapy is a viable treatment option, can be successfully accomplished at home, and should not be terminated before 2 years.

2.  Pulse corticosteroid therapy for alopecia areata: study of 139 patients.

Nakajima T1, Inui S, Itami S. Dermatology. 2007;215(4):320-4.

Author information

Abstract: Of the patients, 72.7% had hair loss on > 50% of their scalp area. Among the recent-onset group (duration of AA < or = 6 months), 59.4% were good responders (> 75% regrowth of alopecia lesions), while 15.8% with > 6 months duration showed a good response. Recent-onset AA patients with less severe disease (< or = 50% hair loss) responded at a rate of 88.0%, but only 21.4% of recent-onset patients with 100% hair loss responded. No serious adverse effects were observed.

3. Association between vitamin D levels and alopecia areata.

Mahamid M, Abu-Elhija O, Samamra M, Mahamid A, Nseir W. Isr Med Assoc J. 2014 Jun;16(6):367-70.

RESULTS: Mean CRP values were significantly higher in the AA group than the control group (1.1 +/- 0.7 mg/dl vs. 0.4 +/- 0.8 mg/ dl, P < 0.05). Vitamin D levels were significantly decreased in the AA group (11.32 +/- 10.18 ng/ml vs. 21.55 +/- 13.62 ng/ml in the control group, P < 0.05). Multivariate analysis showed that CRP (odds ratio 3.1, 95% confidence interval 2.6-4.2, P = 0.04) and serum vitamin D levels < 30 ng/ml (OR 2.3, 95% CI 2.2-3.1, P = 0.02) were associated with AA.

CONCLUSIONS: We found a significant correlation between AA and vitamin D deficiency. Vitamin D deficiency can be a significant risk factor for AA occurrence.

4. Pulse corticosteroid therapy with oral dexamethasone for the treatment of adult alopecia totalis and universalis JAAD, May 2016  Link.

Chronic Stasis Dermatitis

Abstract: 68 yo man with chronic dermatitis of left leg

History: The patient has had a chronic dermatitis of left leg for over ten years.  He has been seen at the Wound Care Clinic for over three years.  What worked best in the past was an Unna boot but these are not used as commonly anymore as we have newer, more high-tech types of bandages. 

O/E: He has chronic lymphedema of the left leg, which periodically develops elephantiasis-like changes. The examination woody edema left leg, that is erythematous with crusted areas.  It looks clean today and there is no evidence of secondary infection.

Impression:  Chronic dermatitis of his left leg.  It is most likely a chronic stasis eczema. 

Comments: He has been diligent about home care.  For the time being, he will use wet dressings with a dilute bleach (a half cup of Chlorox per 40 gallons of water in a bathtub) and zinc oxide-like paste.  He will be seen back in two weeks.  Consider going back to an Unna boot.

What are your thoughts?

Unusual Tumor in a 53 yo Man

53-year-old man who was seen for a general skin examination.  He has Crohn's disease and has been on 6-MP for the past 8-10 years.  His gastroenterologist said because of this he should have a skin examination. 

O/E:  The patient has type II skin.  He has a 6 mm in diameter pink papule on the calf of the left leg.  Dermoscopically, this lesion has a dotted vascular pattern.

IMPRESSION:  Lesion left calf.  Etiology unclear.  

Plan:  Excisional biopsy was obtained. 

Reference:
Inflammatory Bowel Disease Treatment and Non-melanoma Skin Cancer: Jacqueline F De Luca, MD, Yun Sun Lee, MD, and Douglas Johnson, MD, Hawaii J Med Public Health. 2012.7:324–325.

Abstract:Immunosuppressant medications for Inflammatory Bowel Disease can help with both symptoms and disease progression. However, like immunosuppressants used in transplant patients, they are now suspect of contributing to nonmelenoma skin cancer (NMSC). Presented is a case of a 57-year-old Jewish man with Crohn's Disease who was diagnosed with a total of 84 NMSCs. We hope to elucidate the risk of immunosuppressants, particularly the thiopurines, on the development of NMSC.