Arcuate and Circinate Facial Eruption

Presented by   Dr. Arnulfo Macadangdang

Cebu City, Philippines

Abstract:  18 year-old student with one week history of facial eruption

HPI:  The patient is an 18 yo man with a one-week history of an eruption on face and neck.  It is mostly asymptomatic.  He is an athlete, takes no medications and has no risky behaviors.  He had an upper respiratory infection around a month before onset. 

O/E:  There are arcuate and circinate lesions on cheeks, neck, and forehead.  Two similar lesions on u upper back. The scale is greasy.  No lymphadenopathy.

Clinical Photos:

Lab:  KOH negative

Diagnosis:  This has some features of seborrheic dermatitis, but it is not typical.  Sebosporiasis was another thought.  Evolving psoriasis?  Relationship to "URI" in October?

Questions:  Does this clinical picture suggest any specific diagnosis?

Follow-up:
5 Day F/U photos

 
The patient was seen 5 days after starting desonide 0.05% cream.  His skin lesions have esolved completely with mild post-inflammatory hypopigmentation.  The three lesions on back (not treated) have persisted. No new lesions.  Our tentative diagnosis is atypical seborrheic dermatitis.  Atypical Pityriasis rosea is also considered.  We do not feel serology for syphilis and HIV are indicated at this point, based on a discussion of risky behaviors.   Will taper desonide over the next two weeks and see patient back in a month as necessary.

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Psoriasis vs. PRP: Your Thoughts

Presented by Dr. Henry Foong, Ipoh, Malaysia
Abstract: A 65 year old man presented with a history of erythroderma for 3 weeks.

History: A 65 year old man presented with pruritic scaly erythematous patches on the chest about 3 weeks ago.  Then he noticed the rashes spreading to the abdomen and back.  Now it has spread to the face and both upper and lower extremities. He had no fever or other constituional symptoms.  He denied taking any previous medication or health supplements.There was no past history of psoriasis or eczema.

Examination showed extensive multiple scaly erythematous patches on the abdominal wall, entire back and thighs.  His scalp was scaly too.  Over the lower back and abdominal wall, the erythema was confluent and generalised with multiple erythematous patches with islands of white in between. The lesions has an irregular margin. There is no follicular hyperkeratosis.  The nails were normal. Both palms and soles appeared normal and not hyperkeratotic.

Photos:

Pathology: 

The epithelium shows parakeratosis. The squamous epithelium does not show spongiosis or basal layer degeneration. The upper dermis shows mild perivascular and interstitial infiltrates of lymphocytes and eosinophils. The deep dermis is normal. Features do not suggest psoriasis. 

INTERPRETATION

Features are compatible with pityriasis rubra pilaris without follicular involvement.

Diagnosis: Erythroderma - Extensive psoriasis vs pityriasis rubra pilaris

Reason for posting: This is an interesting diagnostic problem as whether erythroderma is due to PRP or psoriasis.  Though there are features of psoriasiform changes over the extremioties and lower back, the presence of "islands of white" within patches of erythema is suggestive of PRP. As our experience with generalised PRP is limited, it is difficult to make a definitve diagnosis.  A biopsy was done to help to make a more definitive diagnosis.  In terms of treatment, however, oral retinoids such as acitretin would be useful in both conditions.

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Interesting Follow-up: Paronychia in a Child

In October 2007, we presented the case of an eight year old girl with chronic paronychial inflammation located on the left index finger (Paronychia in a Child). She had no other dermatoses. The patient is adopted so we have no family history. We assumed this was some kind of localized psoriasis or acrodermatitis continua. Clobetasol ointment was prescribed which she has used since. (Photo above from 10/2007)

The patient was seen in follow-up recently. The paronycial inflammation had subsided but the finger tip was still abnormal, especially on the palmar surface and there is now hypopigmentation and atrophy distal to the area of inflammation. This latter is likely secondary to the clobetasol. Her topical therapy was switched to calcipotriene cream (the ointment is no longer available in the US.)

Photos:






Questions:
1) What do you think the diagnosis is?
2) Side-effects on the fingers from super-potent topical corticosteroids are rarely reported. One suspects that they are not that unusual. When does the treatment get worse than the disease? (I should have been more diligent in follow-up)
3) Who thinks that these preparations can cause bone changes?
Your comments will be appreciated.

References:
1. Deffer TA, Goette DK.. Distal phalangeal atrophy secondary to topical steroid therapy. Arch Dermatol. 1987 May;123(5):571-2.

2. Tosti A, Fanti PA, Morelli R, Bardazzi F. Psoriasiform acral dermatitis. Report of three cases. Acta Derm Venereol. 1992;72(3):206-7.
Department of Dermatology, University of Bologna, Italy.
The authors report 3 patients affected by psoriasiform acral dermatitis, a distinctive clinical entity characterized by a chronic dermatitis of the terminal phalanges, associated with marked shortening of the nail beds of the affected fingers. The skin biopsy showed in all cases the pathological features of a subacute spongiotic dermatitis. X-ray examination of affected fingers showed no bone or soft tissue changes. Differential diagnosis of psoriasiform acral dermatitis included psoriasis, atopic or contact dermatitis and corticosteroid-induced distal phalangeal atrophy.

3. Brill TJ, Elshorst-Schmidt T, Valesky EM, Kaufmann R, Thaçi D. Successful treatment of acrodermatitis continua of Hallopeau with sequential combination of calcipotriol and tacrolimus ointments. Dermatology. 2005;211(4):351-5.
Department of Dermatology, J.W. Goethe University, Frankfurt, Germany.
Acrodermatitis continua of Hallopeau (ACH) is a rare type of pustular psoriasis affecting the digits. We report on a 43-year-old female patient who had been suffering from ACH for more than 20 years. Despite the fact that the disease was localized on one finger during the whole period, several topical and systemic treatments resulted in only temporary or partial improvement of the lesion. Although the monotherapies with calcipotriol and tacrolimus ointments gave no satisfying results in the long-term management of the disease, the combination of both agents led to a continuous improvement of the patient's skin condition. Copyright 2005 S. Karger AG, Basel.

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Magic Cure?

Abstract: 45 yo man with two year history of painful fingers
Posted by DJ Elpern
HPI: The patient is a 45 yo electrician and professional pianist who developed hyperkeratotic patches on his hands two years ago. Nothing new in exposures. After much questioning, he remembered that his mother-in-law moved in with them around that time. (not kidding). The fissures are very painful, especially when playing keyboard. He can use gloves doing electrical work. Patch testing has not been done but is planned.
O/E: Hyperkeratotic areas around thumb and middle finger tips bilaterally. Fissures are deep but clean. He has had similar areas on thenar and hypothenar eminences in past. Remainder of cutaneous exam is unremarkable.
Photos:






Diagnosis: Hyperkeratotic Hand Eczema, Psoriasis variant? Fristional Contact Dermatitis
Treatment: He has tried potent topical steroids with occlusion and with the Soak and Smear technique. Crazy glue for fissures. Intralesional triamcinalone 10 mg/cc helped the palmar keratoses. He has had one month of methotrexate 10 mg per week. Only the intralesional TAC has helped but he does not want finger tips injected at this time.
Questions:
1. What do you think the diagnosis is? The role of trauma may be key as he works with his hands as an electrician and his fingers are "traumatized" on the keyboard.
2. Do you have any magical therapeutic suggestions?
3. I have heard that X-ray treatment was used in the past. Any rational for Grenz?
4. Further work-up
Reason Presented: This man is at his wit's end with pain. He can't play the piano since every time he hits a key he has exquisite pain. I have had one or two similar patients -- they just got better over a few years seemingly not related to treatment.
Reference:
E. McMullen, D.J. Gawkrodger, Physical friction is under-recognized as an irritant that can cause or contribute to contact dermatitis. Br J Dermatol. 2006:154;154-156
Department of Dermatology, Royal Hallamshire Hospital, Sheffield U.K.
Full Text of Article
Background The role of physical friction as an irritant in the causation of contact dermatitis is under-recognized. Frictional dermatitis is defined as an eczematous process in which physical frictional trauma contributes to the induction of a dermatitis process.
Objectives To examine the clinical background of patients in whom friction was contributing to dermatitis.
Methods Over a 30-month period during which 2700 new patients were seen, frictional irritancy was identified as playing a role in the dermatosis in 31 cases: in 27 of these, case notes were evaluated for a range of parameters.
Results Physical friction was identified as causing or contributing to the dermatitis in 18 men and nine women, mean age at onset 42 years. The hands, usually the fingers of the dominant hand, were affected in all but two cases. Occupational frictional activities were found in 25 cases: commonly handling small metal components, paper, cardboard or fabric, and driving. Potential frictional activities in hobbies were noted in 12 cases. Wet work irritancy contributed in four cases (15%). Patch testing showed relevant contact allergies as cofactors in seven of 25 subjects tested (26%). Psoriasis was a cofactor in four (15%), and atopic dermatitis in 11. The study was selective, being based in a teaching hospital clinic with a special interest in contact dermatitis. Frictional irritancy is often one of several factors contributing to dermatitis.
Conclusions The contribution of friction to contact dermatitis is under-recognized probably because dermatologists do not think about the potential for physical forces to induce eczematous changes in the skin.

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