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.
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