Tuesday, December 23, 2008

Young woman with pregnancy-associated dermatosis

Abstract: 31 yo woman with atypical blood vessels on right arm and chest.
History: This healthy 31 yo woman has had an asymptomatic slowly progressive erythematous process on her right arm and shoulder. She is in her second trimester of pregnancy. The reddish areas are slowly getting more pronounced.
O/E: Mat-like telangiectasias on right arm and shoulder: Dermatomal distribution.
Clinical Photo(s):

Lab: N/A
Histopathology: N/A
Diagnosis: Unilateral Nevoid Telangiectasia
Reason(s) Presented: For Interest. This is a benign entity, uncommonly encountered, but easy to recognize. The patient appreciates reassurance.
Reference: Unilateral nevoid telangiectasia (UNT) is a cutaneous condition consisting of congenital or acquired patches of superficial telangiectases in a unilateral linear distribution. Described in 1899 by Blaschko, its segmental pattern suggests a mechanism of somatic mosaicism apparent early in life or unmasked in states of relative estrogen excess, such as that in pregnancy or in chronic liver disease. Full Article

Sunday, December 14, 2008

Retroauricular Dermatitis

Abstract: 16 yo boy with 3-4 year history of retroauricular dermatitis
History: This 16-year-old boy was seen for evaluation of a retroauricular dermatitis that has been present for 3-4 years. He is in his usual state of health. He does not have a history of atopy. He does not wear glasses.
O/E: Honey-colored crusting in the superior retroauricular sulci bilaterally.
Clinical Photo:

click image to enlarge
Lab: Culture positive for many Staph. aureus with usual sensitivities.
Histopathology: N/A
Diagnosis or DDx: Retroauricular Dermatitis: This is felt to be a marker for atopic dermatitis or atopy. However, this boy is not atopic and the finding may not be all that specific. Only one article has appeared on this subject (see Reference).
Questions: Does anyone have any comments on this entity?
Reason(s) Presented: For interest.
Treatment: The patient was given a sample tube of retapamulin ointment to use b.i.d. for one week. The next photo shows appearance after one week of use as monotherapy. I plan to now use fluocinalone 0.025% ointment daily for a week or two for the residual dermatitis. This may well recur. The natural history of retroauricular dermatitis is poorly defined. There is only one article in the medical literature that discusses this entity.

status post 0ne week of retapamulin ointment

Marks MB, et. al. An unsuspected sign of cutaneous allergy. J Am Acad Dermatol. 1981 May;4(5):519-22.
An eczematous eruption in the superior retroauricular areas of the scalp and often
on the posterior aspects of the pinnas may be seen in about 30% of allergic
children. The eruption is not generally noticed because the overhanging hair covers
the affected areas. The dermatitis is seen mainly in those children afflicted with
bronchial asthma, perennial allergic rhinitis, or both. A previous history of atopic
or seborrheic dermatitis is, as a rule, not elicited.

Sunday, December 7, 2008

Tuberous sclerosis

This 15-year old boy presented to my office with multiple asymptomatic papules on the face since age of three.

click on images to enlarge
Note the firm papulonodular lesions with a friable vascular surface distributed on the nose and right nasolabial fold. These lesions, called adenoma sebaceum, are actually angiofibromas - a form of cutaneous hamartoma. The patient has no neurological deficit, but tuberous sclerosis can affect many organ systems: heart, brain, kidney, liver and eyes. The lesions can be removed by light cautery and curettage or carbon dioxide laser therapy. The latter is more expensive and not much better.

A good review can be found on emedicine.com

Submitted by Henry Foong, Ipoh, Malaysia. Contact Dr. Foong.

Friday, November 28, 2008


This is an interesting case from Ipoh, Malaysia. A large group practice like FMI will see a child with Staphyloccal Scalded Skin Syndrome occasionally. Dermatologist Henry Foong sent the pictures and the history.

HPI: This 11 mo old infant presented with symmetrical and bilateral dry scaly eruptions around the eyes and mouth for 3 days. Apparently it started with periorbital eruptions after taking some chocolates. The mother had thought it was allergy to chocolates. He has seen at least one pediatrician and a general practitioner before consulting us. There was a history of asthma. 3 other siblings had impetigo recently.

On examination, he appeared fretful. He had a low grade fever temp 37.4 degC. Marked diffuse scaling and erythema on both perioral and periorbital areas were noted bilaterally and symmetrically. The neck and axilla were similarly affected. Diffuse erythema and flushing was noted on the trunk.

Clinical Photos:

Note: The child appears irritable and uncomfortable with exudations and crusting around the mouth and eyes. Skin globally is erythematous. Healing with appropriate antibiotics is complete within 14 days.
Diagnosis: Clinically he has staphylococcal scalded skin syndrome

Lab: TWBC 12,000 N50 L36 E1 M11
Culture was negative.

Course: He was admitted to the ward and treated with IV fluids, IV cefuroxime 150mg tid and topical moisturisers. He recovered well and discharged 3 days later. Plan to do an ASOT on follow up as culture was unhelpful.

Reason(s) Presented: For interest. This is a classic case; not sure why culture was negative except that patient may have had antibiotics before it was taken.

Reference: Patel GK. Treatment of staphylococcal scalded skin syndrome. Expert Rev Anti Infect Ther. 2004 Aug;2(4):575-87.
Humans are a natural reservoir for Staphylococcal aureus. Colonization begins soon after birth and predisposes to infection. S. aureus is one of the most common causes of skin infection, giving rise to folliculitis, furunculosis, carbuncles, ecthyma, impetigo, cellulitis and abscesses. In addition, S. aureus may cause a number of toxin-mediated life-threatening diseases, including staphylococcal scalded skin syndrome (SSSS). Epidermolytic toxins released by certain S. aureus strains cause SSSS by cleaving the epidermal cell adhesion molecule, desmogelin-1, resulting in superficial skin erosion. Recent experiments have revealed similarities in the pathophysiology of SSSS and pemphigus foliaceus, an autoimmune disorder that is characterized by antibodies targeting the same epidermal attachment protein. SSSS typically affects neonates and infants but may also occur in predisposed adults. It is painful and distressing for the patient and parents, although most cases respond to antibiotic treatment. Mortality is low in infants but can be as high as 67% in adults, and is dependent on the extent of skin involvement and the comorbid state. Thus, the management of adults who develop SSSS remains a major therapeutic challenge. The antibody response against the toxins neutralizes their effect and prevents recurrence or limits the effects to the area of infection, which is known as bullous impetigo.

Monday, November 24, 2008

Dennie Morgan Lines

Abstract: 4 yo boy with severe atopic dermatitis
History: 4 yo boy with severe atopic dermatitis. He's had severe atopic dermatitis since infancy and has asthma as well
O/E: The clinical picture shows classical Dennie Morgan Lines
Clinical Photo:

scroll down for more photos...
Lab: N/A
Histopathology: N/A
Diagnosis or DDx: Dennie-Morgan Lines of Atopic Dermatitis
Questions: None
Reason(s) Presented: Strictly for interest
References: Dennie-Morgan lines are symmetrical, depression folds that lie just beneath the lower eyelids of atopic dermatitis patients. These usually present at birth or shortly after, but not in all atopic dermatititis patients. Allergic shiners, such as darkening under the eyes can also be seen, but most often, there is periorbital edema/swelling and lichenification/hardening of the skin.

Uehara M. Infraorbital fold in atopic dermatitis. Arch Dermatol. 1981 Oct;117(10):627-9
An infraorbital fold (Dennie-Morgan fold) occurred in 74 (25%) of 300 patients with atopic dermatitis. Lower eyelid dermatitis was initially seen in 69 (23%) of these 300 patients. Of the 69 patients with lower eyelid dermatitis, 57 (83%) showed the infraorbital fold. However, such a fold was seen only in 17 (7%) of 231 patients who lacked lower eyelid dermatitis. An infraorbital fold also was observed in eight of 11 patients with contact dermatitis of the lower eyelid. Thus, it is likely that an infraorbital fold develops when the lower eyelid is affected with eczematous dermatoses of diverse origins. The frequent occurrence of an infraorbital fold in patients with atopic dermatitis may be caused by the fact that the eyelid is a site of predilection for this dermatitis

11/25/08: 15 yo girl presented for eyelid dermatitis which shows Dennie-Morgan lines and atopic shiner. She has a long history of eczema and asthma.

Wednesday, November 19, 2008

Florid Rosacea

Abstract: 42 yo man with 6 month hx of facial eruption
History: This 42 yo man was recently discharged from rehab for ETOH abuse. His is on a number of psychotrophic medications. He's been bothered with facial eruption for the past six months. Has used metronidazole gel without relief.
O/E: Marked erythema of forehead, nose, nasolabial folds. There is a suggestion of hyperpigmentation.
Clinical Photo(s):

Lab: N/A
Histopathology: N/A/
Diagnosis or DDx: Rosacea
Questions: How would you approach this patient?
Reason(s) Presented: For interest
References: http://www.emedicine.com/

Saturday, November 15, 2008

Eyelid Dermatitis

Abstract: 65 yo woman with eyelid dermatitis
History: This healthy 65 yo woman has a six month history of pruritic eyelids. She has been treated with clotrimazole cream and Neosporin ointment without relief.
O/E: Erythema and scaling of upper eyelids
Clinical Photo(s)

Lab: N/A
Histopathology: N/A
Diagnosis or DDx: Upper Eyelid Dermatitis
Questions: What would you put in the differential diagnosis?
Reason(s) Presented: For Interest
References: Later