Volcanic Eruption

The patient is an 88 yo woman who came as a "walk-in" today.
She said she had a "volcano erupt" on her leg two weeks ago.

The examination shows an alert actve 88 yo woman with Type II skin. She has a dome-shaped tumor on her right shin which measures 2.1 cm in diameter. It seems to have a collarette surrounding it. She has marked actinic damage.



The history suggests keratoacanthoma. Some dermatologists call this "Squamous Cell Carcinoma -- Keratoacanthoma type." I suspect this is a coding ploy to make them seem malignant.

My question is what to do?
1) It would be hard to close after excision in this site.
2) If it is curetted and dessicated, it make take weeks to months to heal.
3) It could be observed, however, some of these larger lesions can be locally agressive.
4) Intralesional methotrexate is a possibility.

My instinct is to treat with C and E, but I'd like some suggestions. I might follow that with Aldara. I am open to suggestions.

Thank you.

David Elpern

May 4, 2006
At the advice of a few of you, I did a shave biopsy and curetted and dessicated the lesion. The base was mostly gritty (a good sign). I will follow closely. She's 88 year-old. So, I'll observe before any further intervention. May try imiquimod. Will play by ear.

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Cream Complacency

A 60 yo man was seen yesterday for pruritic papules on scalp and extremities. He had seen another dermatologist over the years and had been treated with a host of topicals including liquid nitrogen. Biopsy showed Prurigo nodularis.


[Contents of Bag Brought in by Patient]




After a few years, he developed a febrile illness, was seen in the ER where a CBC showed a WBC of 80,000. He was eventually diagnosed with a rare T-cell lymphoma. Four courses of CHOP have put him in remission.

If his prurigo becomes more active again, one wonders if this will be a harbinger of recurrence.

Sobering lesson. Prurigo may be realated to an underlying malignancy. We can all be lulled into a cream complacency and miss an important clue. I can think of one or two patients over the years with unexplained excoriations who turned out to have a lymphoproliferative malignancy.

Reference:
Seeburger J, Anderson-Wilms N, Jacobs R.
Lennert's lymphoma presenting as prurigo nodularis.
Cutis. 1993 May;51(5):355-8.
Section of Dermatology, Loma Linda University School of Medicine, California.
Abstract:
Lennert's lymphoma is a peripheral T-cell lymphoma that only rarely involves the skin. We present the case of a forty-two-year-old man who experienced severe pruritus for ten months. He was repeatedly diagnosed as having neurodermatitis
and prurigo nodularis before subtle hematologic clues suggested, and subsequent examination of bone and lymph node biopsy specimens confirmed, the diagnosis of Lennert's lymphoma. This report describes the case and presents a brief review
of Lennert's lymphoma.

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U.P in a Newborn

I saw a new born today at the neonatal ward. He is the first child, just delivered today by LSCS for fetal distress. Noted to have generalized erythematous wheals and papules. Some of the wheals and papules appear to form blisters. The mother had no history of any infection during her pregnancy. On examination the child appeared comfortable and not in distress. Sleeping and quiet. Afebrile. Generalised erythematous raised papules and wheals were noted on the face, trunk and upper limbs. Some of the wheals blanche with pressure. Tried to elicit darier’s sign – mild erythema but not raised. The wheals were intensely erythematous and inflamed on certain parts of the neck and face.

Clinically he has urticaria pigmentosa

His blood counts : TWBC 3100 Eosinophils 20% 
Platelets 44 000
G6PD - pending

Though the rash appeared intense, the child was comfortable. Would you have started him on oral hydroxizine? Would you investigate further – hematological malignancy, etc the parents were advised about trigger factors (rubbing) and drugs (anesthetics, etc). thanks, Henry Foong

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