Dermatologic Vignette

Abstract: 75 yo woman with 3 week history of a rash.
History: Painful rash in groin. Healthy woman. Was on antibiotics around a month ago. She used a topical cream given for another purpose by her Gyn. (It turns out the cream she had been using was clobetasol -- a super potent corticosteroid)
O/E: Firey erythema of crural folds, pubic area. Studded with fine superficial pustules.
Clinical Photo(s)

Lab: KOH prep from pustule loaded with budding heasts
Histopathology: N/A
Diagnosis or DDx: Candidiasis (Candidal Intertrigo: iatrogenic)
Reason(s) Presented: For interest. Rick factors for candida intertrigo include antibiotics, diabetes, topical and oral steroids, OCP, pregnancy. This patient took antibiotics and was applying a superpotent corticosteroid to the area. The latter acts as fertilizer for the yeast.
Reference: emedicine.com

Gouty Tophi

Abstract: 55 yo man with painful nodules on hands
History: This 55 yo laborer was seen for painful lesions of hands and associated arthritis. He was diagnosed with gout two years ago when he had an episode of podagra. Allopurinol causes an exacerbation of his pain, so he stopped taking it and maintains himself on colchicine 0.5 mg q.o.d. It is clear that he rarely sees his PCP. The patient has a history of kidney stones.
O/E: 8-10 mm in diameter nodules on some fingers. Fusiform deformities of a few fingers. Toes normal.
Clinical Photo(s):





Lab:
Histopathology: Biopsy pending. On punch biopsy the plug had a chalky look which I assume is uric acid crystals. Pathology confirms clinical impression. I will get a photomicrograph and insert it here.
Diagnosis or DDx: Tophaceous Gout
Questions: How can this man be helped?
Reason(s) Presented: For a discussion on treatment of tophaceous gout.
References:
1. eMedicine.com
2. Jelley MJ, Wortmann R.
Practical steps in the diagnosis and management of gout.
BioDrugs. 2000 Aug;14(2):99-107.
University of Oklahoma, Health Sciences Center, Tulsa Campus, Department of Internal Medicine, Tulsa, Oklahoma, USA.
One of the earliest described conditions, gout continues to plague humanity. It is characterised by the deposition of monosodium urate crystals in the joints and soft tissue. The main clinical features of gout are hyperuricaemia, acute monoarticular arthritis, tophi and chronic arthritis, along with nephrolithiasis. Gout typically occurs in middle age and more commonly in men. Asymptomatic hyperuricaemia does not require treatment. The initial attack of acute gout usually affects a single joint, often the first metatarsal phalangeal joint. Definitive diagnosis requires demonstration of urate crystals in the joint fluid. Treatment of acute gout includes nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine and corticosteroids. The most important factor in success of treatment is how quickly therapy is begun after onset of symptoms. Drug treatment of hyperuricaemia includes allopurinol, sulfinpyrazone, probenecid and benzbromarone and should be used in patients with frequent gout attacks, tophi or urate nephropathy.

A Dermatologic Vignette

Pictured below are the hands of a 35 year-old plumber I saw yesterday. He was not aware of a dermatitis of his feet, but inspection showed mild moccasin-type Tinea pedis on both feet and subtle onychomycosis. KOH prep from the right hand was positive for septate hyaline hyphae.

Dermatologists see two foot and one hand disease regularly. Why this affects both feet and often toe nails and only one hand is a mystery.

This man had been treated with various creams for "hand dermatitis" without relief. Knowing of the entity "Two Hand and One Foot Disease" will enable you to quickly make the right diagnosis. The question of why this occurs is still unanswered.

I prescribed ultramicrosized griseofulvin (Gris-Peg) 375 mg per day. We'll see how it works. I prefer griseofulvin to terbinafine (Lamisil) because I do not trust Novartis (the company that makes the latter). They marked Lamisil too aggressively.



Right Hand


Left Hand

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: