Rosacea

This posting is from Liliana Rivis, a F.P. resident from Augusta, ME. It is intended for her colleagues as a learning experience, but others are welcome to read and comment if they wish.

The patient is a 43 yo CNA with a two year history of a facial eruption. She had tried metrolgel on a number of occasions and doxycycline for seven days at a time without significant improvement. She is a smoker( 1PPD x years).

O/E; She has an erythema on the cheeks, chin, bridge of the nose and up to the forehead. It spares the nasolabial folds and the hair line. On this erythematous rash are many red papules ( involving even the lower eye lid) covered with very dry skin. There are no obvious teleangiectasias.

She was started on doxycycline 50 mg PO QD for 1 month and I will see her in 2 weeks. I did not give her anything topical . I did not know if I can combine PO doxy and topical metrogel, and for how long. In Habif says to start doxy at 100-200 a day and taper off after rash is resolving.

Dave Elpern's Comments:
This is a woman with moderately severe rosacea. There's a good discussion on rosacea on eMedicine.com. Sometimes, one of the triggers is important (sunlight, hot liquids, alcohol, sunlight, etc.) but more often it's a combination of factors. If the patient is computer literate, I refer them to Dermnet.org.nz. A lot of this is moot because these patients usually respond to doxycycline or minocycline. Mostly start with 100 mg b.i.d. and taper after a couple of months. (Small patients of less than 50 kg may get dizzy on this dose of minocycline so start lower and increase over 1 - 2 weeks). Even tetracycline can work well with a starting dose of 500 mg bid or tid. During the summer, one needs to warn the patients against TCN and doxycycline because these can cause a phototoxic eruption, Minocycline only very rarely does this. If no response to a tetracyclihne in 2 - 3 months consider isotretinoin.

The seven days of doxycycline she had was not a long enough trial. Milder cases maay do well with topical metronidazole cream or gel (Metrogel, Metrocream, Noritate cream). Severe cases or those who do not respond to the tetracyclines should be considered for isotretinoin which usually works in doses lower than those employed for cystic acne. The biggest pitfall is not giving the drug enough time to work -- one must tell the patients to give it eight to twelve weeks. This patient needs to be encouraged to stick with the oral medication.
References:
1. eMedicine.com
2. Dermnet.org.nz

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Evolving Lupus Variant?

Your thoughts are most welcome with regards to this patient. I don't have a firm diagnosis yet, but suspect this will turn out to be a form of lupus -- possibly subacute or acute LE..

HPI: A 47 year old woman was seen on June 11th, 2007 with with one month history of two 8 cm. plaques on her legs, KOH negative. Did not look like panniculitis. Initially thought to be Lyme disease, the lesions did not respond to doxycycline.

Because of progression of lesions and question of hypersensitivity disorder per biopsy the patient was treated with prednisone and the eruption subsided over a few weeks.

On 10 mg of pred a day, around 5 weeks after starting prednisone, the patient experienced a marked flare. This was during a long weekend at the beach. She said the weather was overcast and she wasn't out that much. Initial lesions recurred and there were some new papules and plaques on arms and legs. She has marked facial erythema and erythema of neck and upper chest. Other than pruritus, she feels well. No new meds.

Late August to Sept. 2007. Patient's eruption flared on legs and arms. On September 4, for the first time a definite butterfly rash on malar eminences. She feels well other than pruritus and has no arthralgias or constitutional symptoms. Sept. 5th, butterfly rash gone.

O/E: Erythematous plaques on legs. Facial erythema. Flushing of neck. Scattered papules and plaques legs and to a lesser extent arms. See photographs

6/30/07



8/28/07


9/4/07




Lab: 7/4/07 CBC and chemistries normal. ESR 24
8/28/07 Repeat CBC (normal) ESR 17, ANA + anticentromere 1:360
9/4/07 Repeat CBC, PLT normal, ESR still 17

Pathology: 6/30/07
Mild epidermal spongiosis with focal lymphocytic exocytosis and mild to moderate superficial and deep perivascular and interstitial lymphohistiocytic infiltrate with scattered neutrophils and rare eosinophils , extravasated erythrocytes and papillary dermal edema .

Pathologist's Note : These changes are consistent with an allergic dermal hypersensitivity reaction with mild vasculopathy, and may be seen in erythema chronicum migrans . These are not the changes of erythema nodosum . The differential diagnosis includes , in the appropriate clinical setting , a drug eruption or a pigmented purpuric eruption . P.A.S. stain is negative for fungal organisms. Clinico-pathologic correlation is suggested.

Pathology 8/27/07
Hyperkeratosis , focal parakeratosis , flattened epidermis , mild papillary dermal edema , ectatic blood vessels, a mild to moderately dense superficial and mid perivascular lymphocytic infiltrate with occasional plasma cells and extravasated erythrocytes .

Pathologist's Note : These changes are non-diagnostic . The differential diagnosis includes , in the appropriate clinical setting , a deep gyrate erythema, a collagen vascular disease , or possibly a drug eruption . The paucity of eosinophils does not favor the lymphocytic variant of urticarial vasculitis. P.A.S. stain is negative for fungal organisms. P.A.S. stain is negative for fungal organisms.

Repeat Biopsy: 9/4/07 Awaited.

Discussion: I think this patient most likely has subacute L.E. Other than her skin she feels well. There is a suggestion of photosensitivity from the facts that the process began in early June and exacerbated after visits to the beach and Labor Day weekend when it was warm and sunny. Her hemogram is normal, renal function and UA normal, no fever or serositis. I've watched this evolve over three months. It's been interesting and I could be wrong. I will start her on hydroxychloroquine and get an eye consult.

Your thoughts are important to me.

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The Orphan Patient

Walter Shelley wrote this important poem about those patients who challenge all of us. We published it in Dermanities a while back and recently Bhushan Kumar from Chandigarh brought it to our attention again. Thank you, Bhushan! Some of the patients who find their way onto this Blog or VGRG

Here it is for those who may have missed it in Dermanities.

Prayer of the Orphan Patient to the Doctor

Walter B. Shelley
Dermanities May 5, 2007; 5(1)

Prayer of the Orphan Patient to the Doctor

Walter B. Shelley & E. Dorinda Shelley

Listen to me

Don’t be cynical, indifferent, or in a hurry.
Ask me what makes my problem better or worse.
Ask me what I think the cause is.
Ask me to look for clues and teach me what they are.

Think about me

Think of my problem when you read those books, journals, and atlases.
Think of my problem when you attend meetings.
Think of asking your colleagues about me.

Test me

Order specific tests to help you decide on my diagnosis and treatment.
Could I have AIDS, cancer, or lupus?
Do I need a biopsy? A challenge with a medication?
Do I need hospital help?
Do I need to see a consultant?

Don’t give up on me

There is always one more treatment you can try. Just imagine I have a different disease and treat me for that.
See me during an attack to get new ideas and new tests.
Ask me lots of questions during every visit.

I won’t give up on you, for I am an orphan

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Mokihana Dermatitis

Presented by Caitlin Stiglmeier

I am a 23-year old woman with Type 1 skin who was gathering the fragrant mokihana berries in Kokee, Kauai’s mountain park. Twenty-four hours later, I developed a rash of red marks on my arms, half of which later developed into vesiculo-bullous eruptions. The bullae were left alone; the large blister on the forearm was accidentally burst; the remaining smaller eruptions eventually collapsed over a week’s period.

Pelea anisata, (common name: mokihana) is native only to Kauai, Hawaii, growing at elevations of 1,200 to 4,000 feet. The berries are used in lei-making. It is a multi-trunked tree that grows somewhat vine-like. The oils from its leaves and berries have an anise-like aroma and contain furocoumarin which is the cause of the phytophotodermatitis.

Mokihana is found in the mountain areas of Kauai


The berries are prised for their anise-like fragrance.


My Mokihana Dermatitis at day 5


One month later


Reference:
Elpern DJ, Mitchell JC. Phytophotodermatitis from mokihana fruits (Pelea anisata H. Mann, fam. Rutaceae) in Hawaiian lei. Contact Dermatitis. 1984 Apr;10(4):224-6.
Abstract: Bullous dermatitis, which resolved leaving hyperpigmentation and which was clinically consistent with phytophotodermatitis , affected the skin of the neck of 2 individuals who wore Hawaiian leis (as neck garlands ) made of the fruits of Pelea anisata . In a Daniels culture plate system portions of the fruits showed phototoxicity.

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Buttock Necrosis

The patient is a 50 yo nurse who presented to my office on July 31, 2007. Here is the history in her words:

"On June 28th I fell off of my horse. Large dark hematomas covered left buttocks cheek, vagina, and coccyx. Per doctors orders warm, moist heat applied. Thw first picture, taken by my daughter ten days after the fall, shows where the circular area of skin fell off as a result of the compress. I then applied collagenase santyl cream for two weeks but was still unable to debride. One month later, in addition to area on left cheek, new symptoms have arrived which include headaches, 10 - 15 pound weight loss due to diarrhea, burning sensation in face and ears, chest pain, pain between shoulder blades and in neck. There are currently blood tests being done to confirm the existence of what is believed to be a blood disorder. [CBC and Comprehensive chem profile normal except for a slightly elevated BUN of 24 mg%]

O/E: I know this patient well as a care giver and was surprised to see how thin and pale she looked. There is a 9 cm escar on the left buttock. The tissue is necrotic and can not be debrided at this time.

Lab: A culture of the exudate under the eschar grew out many Pseudomonas aeroginosa -- sensitive to Cipro and levofloxacillin.



Discussion:
The trauma seems to have caused skin necrosis. Pseudomonas may be related as well since this looks like echthyma gangrenosum, but the patient has a presumably normal immune system and feels well otherwise. It's unclear if there was fat or muscle necrosis in addition or whether there was a compartment syndrome. The patient is now going to a wound clinic where she can get this are properly debrided.
I have not seen necrosis like this from trauma before. Similar (but more irregular necrosis) can follow brown recluse spider bite. Here, I suspect trauma was the cause; however at one month out the patient has systemic symptoms. One wonders if a CT of the buttock might be of any value.

One week later:
Wound started to drain and was explored at wound clinic. A large cavity was found under the gluteus maximus muscle (around seven cm in diameter). it was irrigated and packed. I am not sure if the cavity contained blood or pus. Today, it was clean with no drainage. The area will likely need surgical intervention as it will take months to heal by the appearance. We will seek surgical opinions.

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A Textbook Case

A 76 year old woman presented to the dermatologist with a four month history of darkening of the skin of her neck, axillae, inframammary areas and groin. She had vague G.I. symptoms and had seen her primary care doctor around four times with these complaints. Although her abdomen was "bloated" she'd lost 5 - 10 pounds over the past month. Her sister had died of pancreatic cancer. (Her daughter who works at a neurosurgery office had tried to get her seen by a dermatologist but none had time. It took two months to get her seen at my office which I see as a personal failure)

The patient is a pleasant outgoing woman who appears about her stated age. She has velvety hyperpigmentation of her skin folds.



In addition, she has developed around 10 verrucous tumors measuring 8 - 10 mm in diameter on arms and legs. One of these was biopsied.

A C.T. scan performed on the day of the dermatology visit revealed what appeared to be metastatic tumors in the peritoneum. The workup is in progress.

Most cases of acanthosis nigricans (AN) are benign and related to ethnicity, obesity or endocrinopathy. AN developing in an elderly individual should be a red light to pursue a work-up for malignancy. AN is an easy diagnosis to make and a four month delay in diagnosis is unfortunate. In all likelihood, this tumor had metastasized before the AN became manifest, but it seems unfortunate that the delay in diagnosis occurred.

A good review of AN can be found on eMedicine.

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Fingertip Eczema

The patient is a 52 yo warehouseman with a two year history of a painful fingertip eczema of the first three fingers of his right hand and first four fingers of his left (dominant) hand. He handles cardboard boxes and drives a fork lift. He is also an avid golfer. The dermatitis is not seasonal.



He has been only minimally helped by super-potent topical corticosteroids.

Patch testing is scheduled but all we have available here is T.R.U.E. Test. If not helpful, he will be sent to an occupational dermatology department for further testing.

I assume this is an occupational contact dermatitis and have recommended that he use cotton gloves at work if possible.

Your ideas as to etiology and treatment pending definitive patch testing will be appreciated.

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