In These United States

The quality of care in the U.S. varies quite a bit. Everyday, I see patients who might do better elsewhere but can not afford specialist care. There are lots of docs here who specialize in diseases of the rich and well-insured.

Case in point. 55 year old woman with no health insurance. She has an epidermal inclusion cyst of the left inner canthus. It was 2 mm from the lacrimal duct.



I said: You should see an ophthalmologist.
She said: I have no insurance. Can't you do this?
I said: I can try, but I am not sure this will shell out easily.
She said: Please try -- anything will be better than this. How much will it cost?
I said: Okay. How about $45.
She said: Fine, I thought you'd ask a few hundred.

Procedure: Under local 1% xylocaine with epi I dissected the cyst. Luckily, it shelled out nicely. I had hoped not to have to close the defect; but needed to place a 6-0 nylon suture.
I guess it will look better.




I felt like a doctor for a brief moment. The doctor who was there. I knew an ophthalmologist could have done better; but most of them take their patients to an operating room where there is a big charge. This is the reality of health care here.

George Bascom said it better. See "Being There" Click on poem to enlarge.

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Iatrogenic Striae

A 17 year old boy was seen by his pediatrician for a crural rash.
He was prescribed Clotrimazole/betamethasone diproprionate cream to use b.i.d for three weeks. At the end of that time, he called his doctor and said he still had the rash. He relates that he was told to continue for another three weeks.



Shortly thereafter, he noticed a discoloration in his groin and some tingling and erythema of the scrotum. The exam showed striae in crural folds and perhaps mild scrotal erythema.

Photo courtesy of DermNet

I see a few cases of striae secondary to this combination cream each year. The medication seems to have more risks than benefits. It should probably not be used for more than a week in groin or axillae. I have also occasionally encountered men with painful burning scrotums secondary to potent topical steroids (including this combination) and suspect that "scrotodynia" can be caused in this manner. This patient has mild symptoms scrotodynia, but I suspect they will resolve.

Here is a pertinent reference:
Clotrimazole/betamethasone diproprionate: a review of costs and complications in the treatment of common cutaneous fungal infections.

Greenberg HL, Shwayder TA, Bieszk N, Fivenson DP.

Pediatr Dermatol. 2002 Jan-Feb;19(1):78-81.


The use of antifungal/corticosteroid combinations as topical therapy for dermatophytoses has been criticized as being less effective, more expensive, and the cause of more adverse cutaneous reactions than antifungal monotherapy. The combination of clotrimazole and betamethasone diproprionate (Lotrisone) is a mix of an azole antifungal and a high-potency corticosteroid, and is one of the most widely prescribed of these combinations. Our objective was to describe the beneficial and deleterious effects of Lotrisone in the treatment of common cutaneous fungal infections and its relative cost-effectiveness. We did a literature review documenting clinical trial data and adverse reactions to Lotrisone and collected a cost analysis of topical antifungal prescribing data over a 2-month period from a large midwestern staff-model health maintenance organization (HMO). Lotrisone is approved by the U.S. Food and Drug Administration (FDA) for the treatment of tinea pedis, tinea cruris, and tinea corporis in adults and children more than 12 years of age. Treatment is limited to 2 weeks in the groin area and 4 weeks on the feet. The most concerning adverse effects of Lotrisone were reported in children and included treatment failure, striae distensae, hirsuitism, and growth retardation. This combination was also reported to have decreased efficacy in clearing candidal and Trichophyton infections as compared to single-agent antifungals. Lotrisone was considerably more expensive than clotrimazole alone and was found to account for more than 50% of topical antifungal expenditures as prescribed by primary care physicians, but only 7% of topical antifungals prescribed by dermatologists. We found that Lotrisone was shown to have the potential to induce many steroid-related side effects and to be less cost effective than antifungal monotherapy. This combination should be used judiciously in the treatment of cutaneous fungal infections and may not be appropriate for use in children.

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The Mask

6/15/07


Every day one sees something unique: either a new disorder or a singular variant of common process. A 90 yo woman was seen yesterday 3 - 4 week after the onset of Herpes zoster of the second division of the trigeminal nerve. She was left with an impressive escar covering a large portion of the dermatome. It was relatively easy to debride most of the escar off. No anesthesia was necessary. I'll affix a follow-up photo when I see her back. Follow-up care was with cool compresses and Silvadene cream.

This woman lives alone, drives her own car and is the family matriarch. Hopefully, the zoster will not derail her.

The above photo is a bit out of focus. My fault.


6/18/07

Same Patient -- Three days later. Note involvement of nasal tip. 2nd branch of trigeminal but with nasal tip involvement (and patient had sorneal ulcer!) indicating perhaps involvement of nasociliary branch of trigeminal (which should not happen) -- aberrant innvervation? She seems much brighter today and not complaining of much pain.

Six Weeks Later
7/27/07

The patient's skin has healed nicely but she has persistent numbness around left ala and left naso-labial fold. Also lancinating episodic pain and resultant depression. A neurologist has put her on Neurontin which I do not feel is helpful. Post-herpetic neuralgia is a complex disorder and I think there's a huge "illness behavior" component. I don't think pharmacotherapy is the answer. Nonetheless, I gave her EMLA cream to use.

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Case for Diagnosis

Presented by Choon Siew Eng FRCP, Johor Bahru, Malaysia.

46 years old woman with 3-year history of gradually enlarging asymptomatic indurated plaques on her neck, both axillae right side of abdomen, right groin and lower back. She is otherwise well with good general health. There was no significant family history.

Physical examination revealed multiple indurated erythematous to hyperpigmented plaques on right side of her neck, right flank, both groins and axillae. The overlying skin is atrophic with brownish adherent scales.
There were multiple groups of hyperpigmented papules on abdomen, upper thighs and legs. Some papules appeared yellowish. Palms, soles, nails, scalp and mucosae are spared.

I am thinking of treating her as sarcoidosis since she is distressed by her extensive lesions
Differential Diagnoses: Nodular amyloidosis, Scleromyxoedema, Morphoea, xanthogranuloma

Repeated blood tests such as full blood count,BUSE, LFT, thyroid functions, serum and urine calcium and autoimmune screening were normal. Her ESR was also normal . CXR was normal and Mantoux test was negative.Sputum for AFB X3 negative. Biopsy from abdominal lesion showed numerous granulomata composed of epithelioid histiocytes, lymphocytes and multinucleated giant cells, Langhan’s type. Special stains for Acid fast bacilli (ZN, Wade fite) and fungal bodies (PAS) were negative. No abnormal deposits of eosinophilic amorphous material seen. No foreign body seen by polarised light.

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Case For Diagnosis

Presented by Dr. Amanda Oakley, Hamilton, New Zealand

A month ago, a 14-year old girl presented to the paediatricians with a fever, arthralgia and small purpuric and possibly target-like spots on her legs. She had been previously well and had taken no medications. After extensive negative investigation she was commenced on penicillin in case she had bacterial endocarditis, and was sent home.
She was readmitted yesterday with on-going fever and arthralgia, and crops of extremely painful plaques mainly affecting her face. Earlier lesions on her abdomen and limbs have resolved leaving marked hypo-hyperpigmentation or scarring. Biopsy of the plaque on her neck shows full thickness necrosis histologically with little inflammation. EM-like. Several new plaques have been observed to arise overnight despite an initial dose of prednisone 40mg. There is no mucosal involvement to date.
All tests so far negative - we are thinking up some more tests but we don't know the correct diagnosis. No other drugs as far as we can ascertain.
Has anyone seen anything like this? Is it erythema multiforme? Other possible diagnosis? Treatment?

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Case for Diagnosis

The patient is a 54 yo woman with a 2 week history of a rash on the arms and chest. Two months ago, she had erythema nodosum with atypical features (on her legs). The work-up eventually discovered Crohn's disease. She was started on Asacol around a month ago and around 2 weeks ago developed erythematous papules on arms and anterior chest.

0/E: The new lesions are 6 - 8 mm in diameter erythematous papules with the suggestion of central punctae. The E.N. has resolved.

Lab: Representative lesions were biopied.

Question: What are your thoughts? We will post pathology in around a week.

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Continuous Medical Education

VGRD and this VGRD Blog have been around for a number of years now. Both serve as forums at which dermatologists and other physicians can post and comment on interesting and challenging cases. Other sites such as the Skin Cancer Clinic blog out of Queensland, Australia serve a similar function and are better attended. We came across an article recently which lends credence to this activity and indicates that this interactive format may be a better way of providing continuing professional education than the lectures which we traditionally attend at conferences and hospital rounds.

The article appeared in The Journal of General Internal Medicine in 2004. Here are the particulars:

Toward Continuous Medical Education
Roni F Zeiger, MD
Gen Intern Med. 2005 January; 20(1): 91–94.
For full article click on PDF locate .pdf download access it.

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.

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