Changing Mole

Presented by: Liliana Rivis

Abstract: 14 yo boy with a changing mole.

History: 14 yo teenage boy of fair complexion, remembers having this mole for at least 5 years. He had hx of sunburn in the past 5 years during the summer. For the past year the mole started to show darker pigment in the middle, seems a little bigger, and lately was noticed to have a white halo around it.

O/E: Spongy ,elevated, dark brown with darker pigment in the middle, pretty symmetrical mole , located in the anterior mid-chest. It is surrounded by a halo. Size is 6x7 mm.

Clinical Photo(s)

Lab: N/A
Histopathology: N/A

Diagnosis or DDx: Probable Halo Nevus
Questions: Should it come out now?

References: There is a good chapter on Halo Nevus in eMedicine.com
Here is a section regarding management:

Medical Care: Halo nevi are benign, and no treatment is necessary.

Consultations: The chief diagnostic consideration in patients with halo nevi is melanoma that is undergoing regression, although making this distinction is not usually difficult. Primary melanoma is usually solitary, whereas halo nevi are commonly multiple. Furthermore, children are affected more commonly with halo nevi; adults are affected far more commonly by melanoma.

See article for more details.

10 Year History of Intertrigo

Abstract: 59 yo man with Intertrigo and AODM

History: This 59 yo disabled man has had a resistant intertrigo for ten years. He was referred by his PCP because he did not respond to miconazle and Nystatin. Meds include oral hypoglycemics, metoprolol, HCTZ, statins.

O/E: Erythematous plaques covering groin, genitalia, axillae. Complete exam revealed erythema and crusting in gluteal cleft in addition (no one had looked there).
Clinical Photo(s)

Great T-shirt!








Gluteal Cleft

Lab: KOH prep negative
Histopathology: Biopsy Pending
Diagnosis or DDx: Inverse Psoriasis
Questions/Comments: This patient was followed for a yeast intertrigo for ten years by his physicians. It was assumed to be Candida because of his diabetes. The tip off was the sharp margination and the scale. When I checked the gluteal cleft, that clinched the diagnosis. We'll see if the biopsy confirms the clinical diagnosis. In addition, it is known that beta-blockers can exacerbate psoriasis and his metoprolol may be playing a role.
Reason(s) Presented: For interest. If one thinks of the diagnosis one can do the appropriate test: a simple punch biopsy.
References:
Clinical analysis of 48 cases of inverse psoriasis: a hospital-based study.
Eur J Dermatol. 2005 May-Jun;15(3):176-8.Wang G, Li C, Gao T, Liu Y.
Department of Dermatology, Xijing Hospital, Fourth Military Medical University,
15 Changlexi Road, Xi'an 710032 China. xjwgang@fmmu.edu.cn

Inverse psoriasis, rare in clinical practice, refers to psoriasis only or mainly
occurring at flexural sites, such as the axilla, antecubital fossae, popliteal
fossae, and inguinal creases. It is also known as flexural psoriasis. With a
total collection of psoriatic cases from September 2002 to December 2003 at
Xijing hospital, we made a retrospective analysis of the disease history,
clinical characteristics, and treatment of the patients affected with inverse
psoriasis. The results showed that the major clinical manifestations of inverse
psoriasis were sharply demarcated erythematous plaques with varying degrees of
infiltration and minimal or no scales. Affected areas often involve the groin,
axilla, genitals, and umbilicus. The disease responds well to the narrow band UVB
therapy. Compared with common psoriasis, inverse psoriasis has similar and unique
characteristics in terms of the affected areas, clinical symptoms, and responses
to the treatment.

Cystic Acne

Abstract: 14 year old boy with acne for one year.
History: This 14 y.o. boy has had acne for a year. He has painful lesions on the chest and back. Topical treatment and doxycycline has not been helpful. His father may have had similar lesions.
O/E: Small to moderate sized cysts on chest and back. There are hemorrhagic crusts and early scarring. Facial involvement less significant.
Clinical Photo(s)



Lab: Prior to initiating isotretinoin: CBC, Comprehensive Chem Panel, Fasting Lipids. (Women need two negative pregnancy tests 19 days apart)
Histopathology: N/A
Diagnosis or DDx: Acne, cystic.
Reason(s) Presented: This is the type of patient for whom isotretinoin should be the first line of therapy. Indeed, in patients such as this, it is often wise to treat with prednisone at the initiation of isotretinoin therapy to avoid a flare that may cause more scarring in the long run. In areas like Augusta, where access to dermatologists in limited, it would be important for this drug to be available from a non-dermatologist. Prescribing isotretinoin is not all that difficult; but one has to adhere to the iPledge program. The big risk with this drug is teratogenicity, so women of childbearing potential need to have pregnancy tests done before starting the medication and monthly while on it and one month after discontinuing therapy.
References: