Recurrent Eruption Buttock

Abstract: 65 yo man with recurrent eruption of left buttock

Presented by DJ Elpern

History: This 65 yo engineer lives in the United Arab Emirates and was seen while visiting Massachusetts. For the past few years, he has had pruritic and painful eruptions on his left buttock. He is well and takes no medications by mouth. He was seen by practitioners in Dubai and England. On both occasions, he was treated with oral antibiotics which were not helpful. Over the past few months, he has developed tingling sensations in his left foot and pain in the left leg.

O/E: Photos were taken by patient in the UAE. This shows confluent pustules on buttock. When seen at my office, only pigment changes and mild scarring were noted.

Clinical Photo(s)


Suggestion of grouped vesicles becoming purulent


Appearance at time of office visit. Some mild atrophic scarring and color change is noted.

Lab: None
Histopathology: None

Diagnosis: Recurrent Sacral Herpes Simplex.

Comment: The buttocks and lower back are probably the third most common area for HSV recurrence. Had someone listened to the patient's history one would have heard "recurrent episodes" which suggests HSV. Then the history of clear vesicles at the outset makes the diagnosis. Strictly speaking, this is not "genital herpes." After the mouth and genitalia, the buttocks and thighs are probably the most common sites for recurrent HSV. Sciatic pain has been associated with sacral HSV (see reference) and often these patients are worked up for renal calculi or sciatica. There may be more constant pain, similar to the post herpetic neuralgia seen after herpes zoster.
It would be nice to see the patient with an acute episode so a Tzanck smear could be done. With his travel history, this may not be practical.
Rx: The acute episodes can be treated with acyclovir or a related drug. When patients have neuralgic pain as this man does, there may be some value in long term suppressive therapy with acyclovir. Dose 400 mg tid for three or four weeks.

Reason(s) Presented: This is a relatively common disorder, although it is frequently misdiagnosed as bacterial infection or "bite." The key points are recurrent eruptions associated with itching or pain. Grouped vesicles at onset which quickly become purulent. The lesions resolve in one to two weeks. Sacral herpes is commonly associated with neuralgic pain, in my experience.

References: There are few articles on this common disorder. In 1974 RB Layzer and MA Conant published what remains until today as the most important paper on this subject.
Neuralgia in recurrent herpes simplex.
Arch Neurol. 1974 Oct;31(4):233-7.
A PDF of this article is available. Thank you to Barbara Harness, Librarian and CME Co-Coordinator at Maine General Medical Center facilitated the retrieval of this article.
Basically, it reports on four patients with neuralgic pain associated with HSV infections. One of these had sciatica as the prodrome to new episodes. More needs to be written about this entity.

25 Year History of Foot and Hand Dermatitis

Abstract: 47 yo woman with plantar dermatitis x 25 years

Presented by Natalie Karishev and David Elpern

History: This 47 yo woman has a 25 y h/o a persistent relapsing vesicular dermatitis of the L sole and to lesser extent R sole and both palms. The dermatitis is associated with mild itching, and painful fissures. KOH prep and culture on one occasion in the distant past was positive for T. rubrum. She was treated with Lamisil po for two months without any improvement. At present the rash is managed by Triamcinolone 0.025% without significant results as well. The involved area is expending

O/E: Well defined scaly patches with deep seated vesicles on the lsft palm and localized non-inflammatory scaling on localized areas of the palms.

Clinical Photo(s)







Lab: Repeat KOH prep and fungal culture are negative (April 2008)
Histopathology: NA
Diagnosis or DDx:

Tinea pedis (appears unlikely)

vs Pompholyx, Dyshidrotic Eczema) Cronic and recurrent vesicular hand/foot dermatitis

vs Psoriasis

Reason(s) Presented: For diagnostic and treatment suggestions

Comment: One of us thinks that Fran Storrs article (referenced below) is helpful for understanding this process, although she addresses a similar condition primarily of the hands. The patient described here needs patch testing (if it has not been done) and a bit more work-up. If there are frank pustules, the diagnosis of pustulosis plantaris need to be added. If diagnostic uncertainty persists, biopsy of an acute lesion may be helpful.

References: Acute and recurrent vesicular hand dermatitis not pompholyx or dyshidrosis. Storrs FJ. Arch Dermatol. 2007 Dec;143(12):1578-80.
So now do we know what pompholyx is and what causes it? I am afraid not. I join the European Dermatolo-Epidemiology Network study’s lament that we use inexact terminology in defining all kinds of hand eczema. This lack of precision in definition has rendered accurate analysis of causation and comparisons of therapeutic strategies impossible. Thorough descriptions of methods and definitions of interpretations and relevance are lacking or are simply not adhered to. In short, as the European Dermato-Epidemiology Network study suggests, we should “start again.”
Clearly, the terms pompholyx and dyshidrosis are obsolete in that really no modern investigators use them as originally defined. Some dermatologists (old ones like me) define them rigidly for use in our own patients’ care, but in studies and reviews such rigidity seldom prevails. Until a more concise label can be agreed on, I propose the use of “acute and recur- rent vesicular hand dermatitis,.” This will not include feet-only situations, but dermatologists caring for these patients know that feet can be included in this primarily hand condition. It is time for pompholyx and dyshidrosis to exit. The full article can be obtained as a PDF from Dave Elpern.

Acanthosis Nigricans

Abstract: 76 yo woman with 6 months history seen on July 25, 2007.
History: This elderly woman presented for progressive hyperpigmentation of skin folds (neck, axillae, groin, and inframammary folds). She felt she was in good general health, but noted some recent weight loss, "bloating" and scalp pruritus. She had a sister who died of pancreatic cancer.
O/E: Velvety gray-black hyperpigmentation of affected areas. In addition some she has some verrucous tumors on arms and legs.
Clinical Photo(s):




Lab: Ultrasound of abdomen showed ascites. Abdominal CT revealed "focal masses involving the omentum and peritoneal cavity most likely representing metastatic disease. Extensive ascites, hepatic custs and a left lower lobe nodule of uncertain significance. Exploratory lap found wide-spread metastatic disease, exact cell-type could not be determined.
Histopathology: N/A
Diagnosis: Malignant Acanthosis Nigricans.
Reason Presented: For interest.
Discussion:"The exact incidence of AN is unknown. In an unselected population of 1412 children, the changes of AN were present in 7.1%. Obesity is closely associated with AN, and more than one half of the adults who weigh greater than 200% of their ideal body weight have lesions consistent with AN. The malignant form of AN is far less common, and, in one study, only 2 of 12,000 patients with cancer had signs of AN.
Malignant AN is associated with significant complications because the underlying malignancy is often an aggressive tumor. Average survival time of patients with signs of malignant AN is 2 years, although cases in which patients have survived for up to 12 years have been reported. In older patients with new onset AN, most have an associated internal malignancy." (from eMedicine chapter)
Follow-up: The patient was seen back on April 18, 2008. She has had chemotherapy and is doing OK. She was again complaining about the hyperpigmentation. She looked pretty good; but understands she has metastatic disease of unknown origin. She was looking forward to going to Florida in a few weeks to visit a daughter. She would like the dark areas treated. Tretinoin may be of some value and will be tried when she returns. In the face of a grave prognosis she is a feisty septuagenarian with a smile and a sense of humor.
References: eMedicine Chapter on A.N.

Perplexing Dermatosis of Legs

Abstract: 33 year-old man with perplexing rash on legs and feet
Presented by Natasha Karishev and Dave Elpern

HPI: This 33-year old man was seen at the FMI on April 11, 2008. He has noticed an asymptomatic eruption on legs and feet for the past few months. He had Graves Disease treated over ten years ago and now is hypothyroid. In addition, he suffers with hypertension and bipolar disorder. His medications include: HCTZ , Depakote, Levothyroxine, Imipramine, Zolpidem, Caduet ((Amlodipine/Atorvastatin)

O/E: Both lower legs are covered with orange-brown, some rust-colored, speckled, cayenne pepper–like discoloration. Spared area under socks. The “Cayenne Pepper-Like” spots are punctate areas of hemorrhage. The patient has exophthalmos, a residual effect of his past Grave’s disease.

Photos: Click on image to enlarge



Diagnosis: Pigmented Purpuric Dermatosis: Subtype: Schamberg Disease

Reason Presented: As a teaching opportunity re: an easily recognized entity that can be misdiagnosed if not known about. This is what is called “A Dermatologic Vignette.”

Discussion: From eMedicine: “The pigmented purpuric dermatoses are a group of chronic diseases of mostly unknown etiology that have a very distinctive clinical appearance. They are characterized by extravasation of erythrocytes in the skin with marked hemosiderin deposition. The etiology is unknown. Venous hypertension, exercise, and gravitational dependency are important cofactors that appear to influence disease presentation. No medical intervention is of proven benefit for the treatment of the pigmented purpuric dermatoses.
* If pruritic use topical corticosteroids and antihistamines.
* Associated venous stasis should be treated by compression stockings.
* Prolonged leg dependency should be avoided.”

In the present case, it is likely that his drugs are playing a role. These may lead to venous hypertension and resulting leakage of rbc. There are old reports of HCTZ causing PPD. The clear areas under his socks indicate that compression stockings may be the best approach here. It is thought that PPDs are caused by capillaritis which leads to leaky vessels. The extravasated RBCs are red (Cayenne Pepper Spots) and when these are reabsorbed they leave hemosiderin behing (the golden brown rusty color)

Reference: The chapter on PPD in eMedicine is an adequate introduction:

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: