3/23/2012
CASE STUDIES IN DERMATOLOGY Melinda F. Greenfield, DO Albany Dermatology Clinic Albany, Georgia
Case Report #1 39
year old female with history of poorly controlled ulcerative colitis develops lesion on ankle Starts out small and rapidly enlarges after debridement Patient thought to have ‘flesh eating bacteria’ or gangrene, amputation is being considered
Case 1
Lesion started as a small papule which then broke down resulting in an ulcer The ulcer deepened and widened rapidly Characteristically, the edge of the ulcer is purple and undermined as it enlarges It is usually very painful
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Pyoderma Gangrenosum
Rapidly evolving, chronic, severely debilitating skin disease usually associated with ulcerative colitis Starts out as painful nodule that may occur with trauma, rapidly progresses with ulcer formation Ulcer is dusky red or purple with prominent rolled borders Lesions exhibit ‘pathergy’- slight trauma will cause new lesions to develop, even at distant sites These lesions should never be debrided, tx is with steroids or other immunosuppressive drugs This patient’s ulcer completely resolved with oral prednisone within one week
Case Report #2 38
year old IV drug abuser develops high fever and these painful lesions
Bacterial Endocarditis Osler’s
Nodes
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Bacteria Endocarditis
Microbial infection implanted on a heart valve Characterized by fever, valvular destruction, murmur and peripheral embolization 2 types of skin lesions: 1. Janeway lesions-painless, small hemorrhagic macules on palms, soles 2. Osler’s nodes- painful Also see subungual splinter hemorrhages (nail)
Case Report #3 47
year old female with 8 day history of mildly pruritic vesicular rash on entire body, sparing the face Had similar eruption in 2008
Case Report #3
PE: intact vesicles on an erythematous base noted, along with crusted papules in varying stages of healing Patient is not ill, afebrile, no recent travel or insect bites
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Case Report #3
Varicella Biopsy
was done in 2008 revealing herpetic lesions HSV 1,2 IgG Abs>5 (positive) HSV 1,2IgM –negative VZVIgG 1.72 (positive) VZVIgM 1.64 (positive) Immunologic workup was normal, including HIV and immunoglobulins Patient was treated with antivirals
Recurrent Varicella
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Case Report #4 16
year old female comes back from spring break and her mother sees these spots on her back Mother is extremely concerned
Halo Nevus
Halo Nevi Nevi
with a halo, or white ring around it know as Sutton nevus or leukoderma acquisitum centrifugum This is considered an autoimmune process and the reason for attack is unknown If occurring in an adult, biopsy is warranted to rule out melanoma or other atypical lesions Also
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Case Report #5
65 year old male with a 3 month history of an extremely pruritic rash on the feet PMD tx with various antifungals and hydrocortisone cream Patient is very unhappy because he hasn’t been able to golf for 3 months
Case Report #5 Clues???
Why isn’t this fungal? Keep talking to your patient…
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Case #5
Contact dermatitis to shoe leather
chromium salts used in the tanning of leather formaldehyde thiurams carba compounds colophony based adhesives, thioureas glutaraldehyde dyes rubber compounds, methacrylates and epoxy based adhesives
Case Report #6 13
year old boy presents with a rash on the lower legs, which are palpable purpura, fever, joint pain and abdominal pain
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Henoch Schonelin Purpura Aka.
Hypersensitivity Vasculitis to antigens from infectious agents, drugs, or other external/internal sources Skin: “palpable purpura” Systemic: vascular involvement in the kidneys, muscles, joints, GI, peripheral nerves HSP is assoc. with IgA Hypersensitivity
Case Report #7
7 month old with 1 month history of rash on body, arms and legs Treated with various topical anti-fungal and steroid creams without any improvement No family history of atopy No one else in family has a rash or is itching. Parents are young and often have a ‘lot of friends over’ Father has a Mohawk
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Scabies
Crusted Scabies
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Case Report 13
year old girl with 6 month history of ‘eczema’ not responding to topical steroids or antifungals. Rash is getting worse
Mycosis Fungoides
Cutaneous T-cell lymphoma Malignancy of the helper T-cells Sezary syndrome: leukemic form Often mistaken as eczema or chronic dermatitis A great example of why you always biopsy something if it doesn’t respond like you think it should
Mycosis Fungoides
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Case Report 39
year old female with erythematous, scaly plaques of the face Worse with sun exposure Heals with scarring What is this and the pathognomonic finding in this eruption?
Discoid Lupus Look
for follicular plugging of the lesions seen on the skin, scalp and in the ears
Look Alikes
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LOOK ALIKES…
4 year old boy with a 1 year history of a rash on face, not responding to topical steroids or anti-fungal creams Mom says it gets worse in the sun Does not itch or hurt
LOOK ALIKES…
PHYSICAL EXAM: well-defined, erythematous, scaly red plaque on the right cheek Closer inspection of the scale reveals what appears to be a ‘follicular plugging’ or ‘stuck-on’ type of scale
LOOK ALIKES… We
were convinced that this biopsy would come back showing lupus Biopsy showed deep, intense fungal infection Topical steroids were just driving the infection in deeper
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Look Alikes #2 23
year old with a 3 year history of a mildly pruritic, tender rash on face Unresponsive to low-potency steroid creams and antifungals
Look Alikes #2 Physical
exam: well-defined, erythematous, scaly plaques in a malar distribution. The scale appears ‘stuck-on’
Look Alikes #2 Once
again we were convinced this was Discoid Lupus Biopsy showed seborrheic dermatitis
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Look Alikes #3
17 year old female with several year history of pruritic rash on face Admits to doing a lot of scratching and picking Patient was originally diagnosed with excoriated acne on the face, and an excoriated eczematous-like condition on the body Her acne was treated and she was given a mild topical steroid for the pruritus and told to stop scratching and picking at her face
Look Alikes #3 2
months later these very well defined lesions were noted
Look Alikes # 3
Biopsy showed discoid lupus Patient is being treated with topical steroid, topical immunomodulator, and daily use of broad spectrum sunscreen Systemic workup was negative
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Look Alikes #4 21
year old with persistent rash on nose, developed after delivering her baby 4 months ago No other associated symptoms
Look Alikes #4 Erythematous
plaque with stuck on scale and follicular plugging Biopsy showed discoid lupus
Treat these patients before they reach this point
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3/23/2012
“Ring Worm” Is Not Clearing… Erythematous
indurated annular plaque on a 7 year old girl Not responding to antifungal creams What is the differential diagnosis? How do you treat?
Granuloma Annulare Benign,
pruritic granulomatous condition often seen in children Self-limiting, but can last up to years
A Dirty Neck???? Hyperpigmented,
lichenified, velvety plaques on the neck What is it? What do you have to consider when making this diagnosis?
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Acanthosis Nigricans Seen
most commonly in overweight or obese females Need to consider: endocrine abnormalities Insulin hypersensitivity Or malignancy Check Hemoglobin A1C, insulin levels and get these kids on a diet and exercise program
Rash On Legs Not Clearing.. Waxy,
yellowish plaques located bilaterally on the shins What disease does this patient most likely have?
Necrobiosis Lipoidica Diabeticorum Seen
most commonly in diabetics or patients on their way to becoming diabetic
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Case Report-A Very Itchy Rash 53
year old man developed extremely pruritic rash 3 days after crawling under house to remove family cat who had kittens Swears that the line is ‘moving’ and is ‘alive’
Cutaneous larva migrans Also
known as ‘creeping eruption’ Penetration of the epidermis by various nematode parasites Usually hookworm of cat or dog
Sacral Skin Tags
16 month old with history of skin tags in sacral region for 2 months No developmental delays or other history Mother wants these cut off, how do you proceed?
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Sacral Skin Tags
Is this a ‘sacral sign’? 80% of babies with spinal cord abnormalities have an overlying skin abnormality: ie. Tuft, dimple, lump, tag or sinus Can also be indicator of GI or renal abnormalities
Sacral Skin Tags Ultrasound
of spine and kidneys was ordered to rule out spinal cord or renal abnormalities Results were normal Mom was back in office 1 month later still wanting tags removed. Annoyed about delay in removing these.
Unresponsive Rash On Chin
Several year history of rash on chin not responding to any topical or oral acne treatment. Acne remains localized just to chin area. Underlying erythema remains on chin. Patient c/o pruritus
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Rash On Chin Denies
new tooth paste or tooth whitening product Acne started after placement of permanent retainer Retainer is made of 14k gold
Rash on Chin Material
data sheet obtained from orthodontist showed the contents of the permanent retainer to be: 58% gold, 1.56% silver, 28-31% copper, 0.3-6.5% nickel, 5-6.3% zinc. Patient did give a history of having an allergy to various jewelry in the past.
Rash On Chin Within
8 days after removal of the retainer, the acne was clearing and the pruritus was completely gone
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3 months later…..
Discussion
There have been several case reports describing dermatological reactions to orthodontic appliances Nickel is the most commonly used metal in orthodontics Even when gold is used there is always an alloy involved The level of nickel increases in saliva once the orthodontic is implanted, possibly due to corrosion or oxidation
Discussion The
glue or cement used can also be a source of sensitization Once hypersensitivity is established all oral mucosa can be involved There are case reports of systemic reactions including eczema of palms, soles, scalp and abdomen, all clearing with removal of the device
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