Question from Iraq

Dear Colleagues,

Pityriasis alba, a disease of young children, is a superficial dermatitis which often presents in two stages: first the erythematous stage which over time developes into (the second) a whitish stage. In Iraq, we see, not infrequently, children with pityriasis alba-like patches that change over time into true vitiligo and then progress and spread to vitiligo in other parts. Many of these patients have a positive family history of vitiligo. At the initial visit it is sometimes is very difficult to tell parents whether their children have vitiligo or not and we fall into big dilemma.

I see many of these and treat them as vitiligo. They respond as well as as those we treat for pityriasis alba.

Question: I would like to ask our colleagues whether you have any similar observation? I intend to initiate a study about this problem shortly.

Khalifa Sharquie

Note: The current case on the classic VGRD site is also from Iraq. Please view it, too.
Baghdad, Iraq

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Black Papule in a Child

Abstract: 11 yo boy with long history of black lesion left arm
History: The lesion has been present for years, little change but patient and parent are worried bout it.
O/E: 5 mm diameter papule with a peculiar serrated border
Clinical Photo(s)


Dermoscopic Image

Lab:
Pathology:

Diagnosis or DDx: Reed Nevus (aka Pigmented spindle cell nevus)
Questions: For inerest
Reason(s) Presented: When I first saw this patient, I thought it was a blue nevus. I sent the history and digital images to a few friends. Drs. Ian McColl and Stelios Minas thought it was a Reed nevus and recommended excision. Biopsy was done and confirmed their opinion.
References: The Reed Nevus is considered a variant of the Spitz nevus. It presents as a well-circumscribed deeply pigmented nodule on the extremities of young adults. Under the microscope, it resembles the Spitz nevus but is composed of spindled melanocytes with heavy melanin pigmentation. As in a Spitz nevus, this nevus is symmetrical with maturation and lack of deep dermal mitotic figures. Excision of suspected Reed nevi is recommended. For more information see: The Doctor's Doctor

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Eyelid Tumors

Submitted by Arash Abtahian from Shiraz, Iran

Abstract: 24 yo man with three year hx of eyelid lesions
History: This 24 man has come with 3 years hx of multiple translucent papule and nodules on the left upper lid. They are asymptomatic but he'd like them removed.
O/E: revealed multiple translucent papules and nodules some of which showed bluish hue.
Clinical Photo(s):




Lab: N/A
Histopathology: Apocrine Hidrocystoma
Diagnosis or DDx: Apocrine Hidrocystoma
Questions: What is the best treatment?
Reason(s) Presented: Therapeutic suggestions?
References: Apocrine Hidrocystoma eMedicine: " Apocrine hidrocystomas can be incised and drained; however, electrosurgical destruction of the cyst wall often is recommended to prevent recurrence. Punch, scissors, or elliptical excision also can remove tumors. Multiple apocrine hidrocystomas can be treated with carbon dioxide laser vaporization. Multiple apocrine hidrocystomas can also be effectively treated with trichloroacetic acid."

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Papular Unticaria

Abstract: 20 yo student with pruritic papules for three weeks

History: While on a ski trip in New Mexico, this young woman developed a few pruritic papules around the neck. Over the next few days, these spread to torso and extremities. Some of the lesions were grouped in a "breakfast, lunch and dinner" distribution. She is in excellent health: a ski racer.

Exam: 1/3/08: There were 40 - 60 6 - 8 mm in diameter erythematous papules on torso, upper and lower extremities and to a lesser extent face. No lesions on doubly covered areas. After treatment with topical steroids this improved, but then flared around a week later.
1/10/08: Many new papules, neck, torso, extremities. No longer "breakfast, lunch and dinner" distribution.





Lab: CBC pending

Pathology: Consistent with arthropod bites or drug reaction. Will add photos later. Specimen shows parakeratosis, epidermal hyperplasia with focal eosinophilic exocytosis and a moderately dense superficial and mid perivascular interstitial lymphocytic infiltrate with scatterred eosinophils.

Diagnosis: Papular Urticaria (PU)

Questions: This woman is a competitive athlete. She does not want to take prednisone while racing. The lesions are very widespread and potent corticosteroid creams do not give much relief. Hydroxizine, too, will blunt her competitive edge. What would you recommend.

Reference: There was a good review of PU by Hernandez and Cohen in Pediatrics in 2006. "Insect bite-induced hypersensitivity and the SCRATCH principles: a new approach to papular urticaria." It is available in full-text: Hernandez/Cohen

Your thoughts and suggestions are welcome.

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Unusual Keratoderma

Presenters:
Susan Walsh, DPM
Foot Care Specialists of Boston Medical Center

Jag Bhawan, MD
Boston University School of Medicine
Boston, MA

Abstract: 44 year man with congenital keratoderma left foot

Hx: The patient was born with this problem. He has never seen a podiatrist or dermatologist. No other skin problems. He tries to keep callus under control by regular soaks of foot and using razor.
Past Medical History
2004- 3v CABG surgery
CHOLECYSTECTOMY
DEPRESSION
HYPERTENSION
HYPERCHOLESTEROLEMIA






Reasons for presentation:
-Diagnosis?
-Patient & wife inquiring about options such as skin graft, or laser
-Should be biopsied?
-started on CARMOL 20 20 % CREAM (UREA) apply to feet bid x one week then daily every day

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Zebibah

The zebibah, Arabic for raisin, is a dark circle of callused skin, or in some cases a protruding bump, between the hairline and the eyebrows. It emerges on the spot where worshipers press their foreheads into the ground during their daily prayers.

Here is a fine article in the NY Times on the ZEBIBAH.

One of our editors, Ben Barankin, published a letter on prayer marks in the International Journal of Dermatology. Barankin Letter

Dr. Barankin's letter was a comment on:

Prayer marks.
Abanmi AA, et. al.
Int J Dermatol. 2002 Jul;41(7):411-4.
Dermatology Department, Research Center,
Riyadh Al Kharj Armed Forces Hospital

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Iatrogenic or Not?

Your opinion is sought.
The patient is a 42 y.o. woman with a long history of cystic acne. Typically she gets a few lesions a year. She has many ice pick scars from previous lesions. She was offered isotretinoin years ago but declined and indeed the lesions are less frequent now. She presents for intralesional triamcinalone when whe wishes to have the cysts treated. She was seen on December 5, 2007 with a tender cyst on the medial aspect of the left eyebrow. It looked like a typical acne cyst and was injected with Kenalog 3 mg per cc. Two days later she started to develop eyelid edema. She went to the Emergency Room and was given parenteral Rocephin and Cipro 500 mg bid. The swelling persists.



On examination, one can see where the initial cyst was. It's ~ 90% resolved. Below it there's a firm linear band that feels like a lymphangitic vessel.

I assume this must be related to the initial inflammatory lesion or the intralesional injection. I searched MEDLINE but could come up with no similar cases. If this is secondary to intralesional steroids, it is not reported. Could the original lesion have been a pyogenic infection that looked like her past cysts and could eyelid edema be secondary to lymphatic obstruction? The ER doc recommended another dose of Rocephin.
Addendum: The patient has never had fever, headache or other findings suggestive of a pyogenic infection.

Has anyone seen a similar case? Diagnostic and therapeutic suggestions are welcome.

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