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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Palmar Lichen Planus?

This case was presented by Dr Khalil Alhamdi, Basrah Medical College, Iraq.

S.G, 62 yo woman, presented with bilateral itchy palms 2 years duration with poor response to treatment. Physical examination is normal apart from bilateral diffuse hyperkeratotic violaceous palms. All laboratory investigations were normal

Histopathology: histopathological examination showed typical features of lichen plaus.

Diagnosis: palmer lichen planus.

What is the experience of our colleagues in seeing such a presentation of palmer lichen planus? comment please.

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Epidermal nevus affecting foot

A 22 year old man presented with a history of linear hyperkeratotic lesion on the right foot since age 7 yrs. It hurts his foot when he wear his shoes.

Examination of the right foot showed a localised hyperkeratotic plaque extending linearly to the medial malleolus. It was not tender or inflamed. My impression is that of an epidemal nevus. Appreciate your thoughts on diagnosis and treatment options.

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Annual Hot Spots Program

Conference Web Site

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Winter's Toes

Abstract: 18 yo boy with pruritic, erythematous toes.

History: The patient was referred by his pediatrician with complaints of red, itchy lesions on his toes for two to three weeks. The pediatrician was concerned because some of the lesions looked vasculitic. The patient is in good general health. A non-smoker. He recollected as the interview progressed that he'd had similar but less severe problems in the past.

Physical Exam: Erythematous macules, some hemorrhagic in appearance on toes. One lesion slightly necrotic.

Photos:

Lab: CBC, ANA and other tests ordered at pediatric office
Pathology: none

Diagnosis: Chilblains (Lupus Pernio)
Reasons Presented and Questions: Similar patients are seen two or three times a year in my office. The typical case is a child or young adult with pruritic erythematous macules or papules on the toes or fingers. The lesions can look necrotic and sometimes ulcerate. The person is otherwise healthy. Pernio is most commonly seen in fall or winter, but I've seen it in spring, too. The lesions are worrisome in appearance to physician, parent, patient. The index case here was worried that "my toes will rot off." His mother was worried about "lupus." I reassured them that this is a common, self-limited problem. While nifedipine may help, it's not necessary. Wear warm socks. Give it time. There's a good review on emedicine.com. It says: "The direct cause of pernio is cold exposure. Chronic pernio may be secondary to various systemic diseases as follows:
Chronic myelomonocytic leukemia
Anorexia nervosa
Dysproteinemias
Macroglobulinemia
Cryoglobulinemia, cryofibrinogenemia, cold agglutinins
Antiphospholipid antibody syndrome
Raynaud disease"

But it's usually easy to differentiate which ones are worrisome and the vast majority will be simple chilblains. One may need to use some clinical judgment. Not rush to unnecessary testing. In my experience, and from what I've read, this occurs more when it is cold and damp in thin individuals. Not bone chilling cold, but the cold of early winter. When it is really cold, good socks and footwear may be more the norm and can protect a susceptible individual from chilblains.

11/29/07 -- Patient just seen:
These are the toes of a 70 yo man who has had chilblains for the past 30 winters. His toes are uncomfortable, itchy and occasionally painful. He's had no chronic illnesses and enjoys good health.


Here is an excellent full text reference: "Pernio in Children" from the journal, Pediatrics.

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Notched Nose

This 55 year-old woman had micrographic surgery for a basal cell of the left ala three years ago. The graft did not take and she has been left with a notched ala. The defect, in the center of her face, is more disfiguring than it appears in this photo.


Question: What kind of repair could be done at this time to give her a better functional and cosmetic repair.

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