Nail Dystrophy x 3 Years

Abstract:  52 yo woman with 3 year history of a nail dystrophy

HPI:  The patient has had this problem for three years.  She works out a lot and recalls trauma to the toe,

O/E:  The left great toe nail is dystrophic,  The nail is quite short and there is brownish green discoloration under the abnormal nail.  There is some hemorrhage under the proximal nail fold.  

Clinical Photos:

Dermatoscopiic Image

Lab:  KOH was positive for hyphae, but fungal culture is negative at 14 days.

Impression:  Nail dystrophy in a 52 year-old woman.  While this is probably traumatic, the long history is of concern and I feel that biopsy should be considered to rule out malignancy.

Questions:  What is your diagnosis?  Would you obtain a biopsy to rule out malignancy given the long history.

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Vellus Hair Cysts

Abstract: 17 yo boy with scores of papules on abdomen, chest, neck

HPI:  This 17 yo boy has had 2 - 3 mm papules on chest, abdomen and neck slowly progressive since age 10.  Occasionally the lesions become iflamed.

OE: Scores of 2 - 3 mm somewhat cystic lesions in above areas.  Some are slightly greyish

Clinical Photo:

 Pathology: (Photomicrographs taken by Dr. Deon Wolpowitz, Department of Dermatopathology, Boston University School of Medicine.
Within the dermis there is a cyst lined by squamous epithelium with a granular layer and containing laminated keratin and numerous vellus hairs.

4x

20x

Diagnosis:  Vellus Hair Cysts

Questions: Has anyone had success treating VHC?  Do they just disappear over time?  Who has seen an adult with with VHC?

Learning Points: (from reference 2)

1. Eruptive vellus hair cysts are a benign, asymptomatic condition, occurring predominantly in children and young adults.

2. Differential diagnoses include milia, comedones, keratosis pilaris, molluscum contagiosum and steatocystoma multiplex.

3.Risk of scarring should always be carefully considered before embarking on surgical or laser treatment.

References:

1.  Vellus Hair Cysts  - eMedicine

2.  Papules on the trunk. Eruptive vellus hair cysts.

Roberts CM, Birnie AJ, Kaye P, Murphy R.

Clin Exp Dermatol. 2010 Apr;3:74-5. doi: 10.1111/j.1365-2230.2009.03494

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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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New Onset Plaques in an Exchange Student in Malaysia

Presented by Henry Foong
Ipoh, Malaysia

Abstract: 26 yo man with 2 month history of plaques face and chest

HPI:  The patient is a 26-yr-old healthy Libyan student who presented with a two month history of erythematous plaques on the face and chest.  He first noticed the reddish plaques on the chest and subsequently spread to the face.  Presently, it also involves the elbows and knees. It is asymptomatic and does not appear to be transient.  It does not seem to be aggravated by sunlight, heat, cold or physical activity.  He is otherwise well and is not on any long term medications/herbs/OTC.

O/E:  Shows few erythematous raised annular plaques 1-2 cm on the anterior chest wall, forehead, cheek, extensor surfaces of the elbows and knees. They do not blanch with pressure.  There are a few patches of alopecia with underlying erythematous skin noted on the occipital scalp. 

Clinical Images:

 

 

 

Lab: Blood counts and biochemistry were normal.  VDRL was negative. Anti-nuclear antibody serology was 1:320 titre.  

Path: Skin biopsy results: Section shows skin composed of epidermis and dermis. Hyperkeratosis and atrophied epidermis are seen. There is basal layer degeneration. Pigment laden macrophages are seen in the upper dermis. Perivascular lymphocytic infiltrates are seen in the upper and mid dermis. No granulomas are seen.

Diagnosis:  Lupus erythematosus

Plan: The immediate plan is to institute oral prednisolone 30mg daily and hydroxychloroquine 400mg daily with advise on sunblocks. However, on examination by ophthalmologist, he found maculopathy in this patient and raised the question of suitability of hydroxychloroquine in this patient.

Questions
Which type of LE would this patent fit into.  Subacute LE?
Which steroid sparing agent would you use? cellcept or imuran?

Comment by Richard Sontheimer, M.D.

The clinical and histopathologic features are highly suggestive of lupus-specific skin disease. From the photographs I cannot tell if this is subacute cutaneous LE or generalized discoid LE (induration of the lesions would be more consistent with discoid LE). Lesions in the scalp would argue more for discoid LE. However, the positive ANA would be more typical of SCLE. If possible I would check this patient's Ro/SS-A and La/SS-B autoantibody status. It is possible at times to see overlapping features of subacute SCLE and discoid LE concurrently. I would also establish a baseline for possible development of clinically significant systemic LE in the future with the following laboratory screening: Complete blood count with differential, serum chemistry screen, erythrocyte sedimentation rate and urinalysis.

Maculopathy in such a young male is quite unusual. Were there any associated visual field deficits with this maculopathy? If not, I would not exclude the possibility of an ongoing trial of oral hydroxychloroquine or chloroquine with careful ophthalmology followup. In addition, antimalarial therapy with oral quinacrine could be considered as this antimalarial drug does not add risk for retinal toxicity. Thalidomide at could also be considered in such case presuming it was available to the patient and appropriate followup for neurologic toxicity could be assured.

With respect to immunosuppressive steroid-sparing effect I would first consider methotrexate. After that I would consider CellCept as Imuran is relatively more toxic. In addition aggressive topical corticosteroid therapy would also be advised.

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Talon Zumba

Abstract: 36 yo woman with brown-black macule on heel

HPI:  A 36 year-old woman presented in a panic with a recently discovered dark-brown to black macule on the heel of her left foot.  It had been brought to her attention by her pedicurist.  The patient had consulted the Internet and found articles about acrolentiginous melanoma which worried her greatly. Anamnesis revealed that she had been Zumba dancing a few days before this was discovered.

O/E: The lesion measured eight mm in diameter and was dark brown to black in color.  Dermoscopy revealed a black color with a parallel ridge pattern.

Clinical Photos:

On the suspicion that this represents hemorrhage into the strateum corneum (a condition, when on the foot, called black heel or talon noir) the lesion was pared down with a # 15 blade and some of the dark pigment was easily debrided leaving a skin colored base centrally and some petechael spots were seen at the periphery.  The patient was asked to debride the area gently with a heel shaver andgiven a return appointment in two weeks.

Talon noir can be a frightening entity for a patient.  Lacking a history, a physician can be fooled, since the parallel ridge pattern seen on dermoscopy is also present in acral melanomas.  History trumps clinical appearance,

Follow-up:
At two weeks out, the area is almost completely resolved, this confirming the diagnosis of talon noir.

Two weeks after initial visit.

 

Reference: 

1. Talon Noir(Primary care Dermatology Society)  This is an excellent reference and there is no need for more.

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Erosive Pustular Dermatosis

Presented by Hamish Dunwoodie, MBBS
The Pas,  Manitoba Canada

Abstract:  98 yo woman with exophitic tumor of the forehead

HPI:  The patient is a light complected Caucasian with a 4 month history of a keratotic lersion on the forehead.  She has a history of nonmelanoma skin cancer.  She is a poor historian.

O/E:  4 cm in diameter crusted tumor forehead.

Photos:

After crust removed

Procedure:  The lesion was compressed with a warm wet gauze pad for 10 minutes and the crust was easily removed.  A deep shave biopsy wes performed and the lesion was electrodessicated and curretted.

Histopathology:
The specimen shows cocally confluent ulceration with underlhying granulation tissue and a moderate to dense lymphoplasmacytic infiltrate.  This is consistent with erosive pustular dermatosis.

Diagnosis:  Erosive Pustular Dermatosis

Discussion:  Clinically, I thought this was a nonmelanoma skin cancer.  Most cases of EPD are on the scalp but they have been described in other sites.

Photo:  3 week post op:

Based on path report, she was treated with clobetasol ointment 0.05% b.i.d.  for two weeks; and after this pictures wwas taken she was switched to fluocinalone 0.025% ointment for two more weeks.

References:
1, emedicine.com Erosive Pustular Dermatosis

2. Erosive pustular dermatosis of the scalp and nonscalp.

Van Exel CE, English JC 3rd.
J Am Acad Dermatol. 2007 Aug;57(2 Suppl):S11-4.

University of Pittsburgh, Department of Dermatology, PA
Abstract; Erosive pustular dermatosis of the scalp is characterized by an idiopathic pustular eruption occurring in association with iatrogenic or incidental, antecedent trauma to actinically damaged skin. We present two cases of erosive pustular dermatosis, one of which occurred on the scalp, the other of which was primarily located on the face. (The editor can send a link to full text if you want.)

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Nonspecific Oral and Genital Lesions

Abstract:  92 year-old woman with 6 year history of painful oral and genital lesions

HPI:  The patient is an otherwise healthy and alert 92 year old woman with painful erosions of tongue and vulva for six years. She has marked pain with eating and urination.  Mouth lesions preceded genital lesions by a few years.  She has been followed for erosive lichen planus but it is unclear if any biopsies were positive.  She has lost weight because her painful tongue causes her to avoid eating.  She has been treated with clobetasol ointment,  Viscous Lidocaine was not effective.

O/E:  Erosive lesions of tongue and labia.  No bullae noted. Remainder of cutaneous exam unremarkable.

Clinical Photos:

Pathology:  Biopsy of genital labial skin shows papillary dermal fiborsis and a mild superficial perivascular mixed inflammatory cell infiltrate.  No lichenoid infiltrate.  Direct immunofluorescence from perilesional skin was negative.  PASD negative for fungi.

Diagnosis:  Painful erosions mouth and genitalia.  At present no support for lichen planus or bullous process histologically.

Questions:  What are your thoughts? Her oral pain makes eating difficult and negatively affects her quality of life.  Are there other therapies that we could consider?

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