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Open Access Publications from the University of California

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Dermatology Online Journal is an open-access, refereed publication intended to meet reference and education needs of the international dermatology community since 1995. Dermatology Online Journal is supported by the Department of Dermatology UC Davis, and by the Northern California Veterans Administration.

Volume 19, Issue 10, 2013

Commentary

Adherence to a five day treatment course of topical fluocinonide 0.1% cream in atopic dermatitis

Background: Adherence in the treatment of chronic inflammatory skin diseases such as atopic dermatitis is poor. Methods to improve adherence have proven difficult.

Purpose: To determine whether a short course of treatment with a high-potency corticosteroid will improve adherence compared to longer treatment studies and if improvement in disease and itch continues after treatment.

Methods: 10 patients with mild to moderate atopic dermatitis were instructed to apply fluocinonide 0.1% cream twice daily for 5 days. Adherence was self-reported and electronically monitored. Treatment outcomes were assessed in terms of Visual Analog Scale of Itch (VAS), Eczema Area and Severity Index (EASI), and Investigator Global Assessment (IGA) scores.

Results: The median adherence rate was 40% (range of 0-100). The median percent change in VAS from baseline measures on days 7 and 14 were 90% (range -13, 100, p=0.02) and 52% (range 0, 100, p=0.004). On days 7 and 14, 20% and 70% patients achieved an EASI-75 and 40% and 60% an IGA of 0 or 1.

Limitations: Small sample size limited subgroup analyses.

Conclusions: Adherence rates with short-term treatment were similar to previously reported rates in longer term treatment studies. However, even non-adherent patients had significant improvement in itch and disease severity.

An Update of Dermatologist Usage of the Physician Quality Reporting System in Colorado for 2011

The Physician Quality Reporting System (PQRS) was established in 2006 by the Centers for Medicare and Medicaid Services (CMS) as part of an incentive process to improve healthcare preventive practices.  As of 2011, there were 235 PQRS measures but only three specific to skin diseases, specifically melanoma. To measure current usage of the PQRS among dermatologists in Colorado, a survey was distributed at the 2011 Colorado Dermatological Society Meeting.  Of the 120 physician attendees, 60 responded, yielding a response rate of 50%.

Compared with responses from a similar 2010 survey, a significantly higher number of physicians are using PQRS, as well as E-prescribing and EHR systems.  This is likely owing to the fact that CMS will require mandatory reporting of these measures in 2015. Respondents from the current survey commented that a major hurdle to PQRS reporting is the inability to submit data through existing EHR or billing systems.  Currently, CMS requires PQRS reporting through a designated registry such as that provided by the AAD. Some practices have opted to report metrics such as tobacco and alcohol screening, since these can be reported through their billing systems. The results suggest structural improvements in the PQRS reporting system could improve compliance.

Case Report

Elastolytic giant cell granuloma: clinic-pathologic review of twenty cases

Background: O’Brien described four histopathological patterns of actinic granuloma (AG). Since then, only single cases and a few series have been reported in the literature, most corresponding to cases of the giant cell type.

Methods: We reviewed all the cases diagnosed as AG or elastolytic giant cell granuloma (EGCG) in our department from 1988 until 2010. The biopsies were classified into the four patterns previously described.

Results: Giant cell pattern was found to be the most frequent (70% of the cases). In four cases, the biopsies showed more than one histopathologic pattern. All the lesions were located on sun-exposed areas or were related to chronic heat exposure. Diabetes mellitus was associated in 40 % of the cases.

Conclusions: The giant cell pattern of EGCG is the most frequent. Some cases may share histopathologic features of more than one variant and thus, we consider they may be categorized as mixed patterns. Diabetes mellitus is the most common associated disease and should always be ruled out.

Gefitinib-associated vitiligo: report in a man with parotid squamous cell carcinoma and review of drug-induced hypopigmentation

Gefitinib is a tyrosine kinase inhibitor that targets and inhibits epidermal growth factor receptors. It was initially used to treat non-small cell lung cancer but has increasingly been used for other solid tumors such as those in the breast, colorectal sites, and head and neck, as in our patient. Vitiligo is an autoimmune disorder that results in the destruction of melanocytes and subsequent skin depigmentation and hypopigmentation. Previously described mucocutanous side effects of gefitinib at 250-500 mg/day include alopecia, asteatotic dermatitis, desquamation, hyperpigmentation, papulopustular acneiform eruption, pruritus, seborrheic dermatitis, and skin fragility. A 54-year-old man with metastatic squamous cell carcinoma to the parotid gland developed vitiligo within 1 month of starting gefitinib therapy. We retrospectively reviewed the medical literature using PubMed, searching: (1) gefitinib side effects, (2) drugs and (3) vitiligo. The patient with gefitinib-induced vitiligo continued to receive treatment with the drug during which time areas of skin hypopigmentation persisted and progressed. Etiology of drug-induced vitiligo includes alopecia areata therapies, anticonvulsants, antimalarials, antineoplastics, anti-Parkinson medications, and other miscellaneous drugs. No other individuals have been described with gefitinib-induced vitiligo. Albeit rare, gefitinib may be associated with the development of vitiligo.

A Case of Infraorbital Lichen Sclerosus

We present a 57-year-old man with erosive lichen sclerosus isolated to the infraorbital area.

Skin infection caused by Scedosporium apiospermum in immunocompromised patients. Report of two cases

Scedosporium apiospermum is a filamentous fungus that can cause cutaneous or extracutaneous disease. A large number of cases have been published over the last decades, mainly in patients immunocompromised as a result of their disease or treatment. These kinds of infections can progress rapidly and become disseminated, leading to very serious or even fatal complications. We report two new cases of skin infection by Scedosporium apiospermum from our hospital.

Case Presentation

A Polymorphic, Mucocutaneous Eruption in a Patient with End-Stage Renal Disease

An 81-year-old man is presented who developed cryptococcal infection after treatment for Clostridium difficile infection.

Schimmelpenning syndrome

Schimmelpenning syndrome (SS) includes an organoid nevus that follows the lines of Blaschko and defects of brain, eyes, bones, or other systems.

We report a case of a 3-month old female infant, who presented with several thin plaques, with irregular borders, yellowish color, which had a verrucous appearance, following the lines of Blaschko, mainly occupying the left side of posterior trunk, the left face, the right side of the anterior trunk, and the right upper limb. These plaques had been present since birth. In addition, she had a flat salmon to yellow nevus on the left parietal and temporal region of the scalp, with a bald patch. She was diagnosed after birth with an interauricular communication.

The skin biopsy from the lesion of the right arm revealed an epidermal nevus that occupied the epidermis completely. Routine and other complementary laboratory blood tests, including platelet count, thyroid function tests, 25-hydroxy-vitamin D, parathyroid hormone, and plasma and urinary levels of calcium and phosphorus were negative. Cerebral magnetic resonance and renal ultrasound were normal. The diagnosis of SS was established.

She is being followed in the clinics of Dermatology, Cardiology, Pediatrics, and Pediatric Neurology. We report this case to point out the importance of investigating patients with epidermal nevus to identify associated conditions

Divided or kissing nevus of the penis

The divided or kissing nevus is an unusual congenital melanocytic nevus. By definition, these nevi appear on skin that separates during embryological development. These lesions have been reported on the eyelids, fingers, and rarely the penis. We describe an 18 year old uncircumcised male who presented with an asymptomatic darkly pigmented patch on the glans penis. He reported that the lesion had appeared recently and was enlarging. Physical examination revealed a second symmetric lesion on the adjacent foreskin. Punch biopsy of the lesion on the glans penis showed abundant intradermal melanocytes devoid of mitoses and atypia, consistent with an intradermal melanocytic nevus. Based on the benign histologic nature and clinical exam, the lesion was diagnosed as a divided or kissing nevus of the penis. Proposed treatments include excision and grafting as well as Nd:YAG laser therapy. However, these patients may be safely monitored with regular follow-up skin examinations because there is minimal risk of malignant transformation.

Acute generalized exanthematous pustulosis due to dextromethorphan

Acute generalized exanthematous pustulosis (AGEP) is a rare, severe, pustular, cutaneous reaction. We report a case in which a patient developed AGEP after the intake of 3 different antitussive agents containing dextromethorphan as the only ingredient in common.

Indeterminate cell histiocytosis successfully treated with narrowband UVB

We present a 47-year-old man with a sudden eruption of more than 100 reddish-brown papules, which histologically exhibited a dense dermal proliferation of large mononuclear cells with vesicular nuclei and abundant pale cytoplasm. Electron microscopy and immunohistochemistry revealed findings consistent with indeterminate cell histiocytosis and the patient responded well to treatment with narrowband UVB therapy.

Vestibular papillomatosis as a normal vulvar anatomical condition

At the beginning of the nineteen-eighties, vulvar vestibular papillomatosis (VVP) was thought to be a human papilloma virus (HPV) disease. Based upon these findings many clinicians have been treating this condition with laser ablation or by topical application of podophyllin or trichloroacetic acid.

Currently, most authors believe that VVP should be considered an anatomical variant of the vestibular mucosa and not HPV related. We present a case of VVP in which there was no histological or molecular evidence of HPV; unnecessary treatment should be avoided.

Photo Vignette

Cutaneous B-Cell Chronic Lymphocytic Leukaemia resembling a Granulomatous Rosacea

B-cell chronic lymphocytic leukemia (B-CLL) is a low-grade lymphoproliferative disease. Cutaneous involvement of B-CLL is limited and, in most cases, it represents non-specific manifestations related to an impaired immune system. Leukemic skin infiltrates (leukemia cutis) occur in 4–20% of patients. Herein we report the case of a 65-year-old woman with B-CLL presenting with papular, nodular, and plaque skin infiltrates affecting the nose, mimicking granulomatous rosacea. We discuss several aspects of rare cutaneous manifestations of B-CLL involving the face.

A metastatic cancer to skin in an otherwise asymptomatic young man: an unusual presentation

Cutaneous metastasis is a rare complication of visceral malignancies. We present a very unusual case of a 33 year-old seemingly healthy man with a sudden and rapidly enlarging skin lesion that was diagnosed as a skin metastasis of his visceral malignancy. Abdominopelvic CT scan revealed thickening of the anterior wall of the urinary bladder and the fundus and body of the stomach. Skin biopsy histopathological findings were suggestive of poorly differentiated metastatic carcinoma. The origin of the primary carcinoma was bladder adenocarcinoma or/and gastric adenocarcinoma, but the tumor was so poorly differentiated that the original source of the tumor could not be defined with certainty.

Childhood sarcoidosis: diagnostic issues

Childhood sarcoidosis is a rare granulomatous disorder that affects several systems including the lungs, skin, eyes, and bones. On histopathology, non-caseating granuloma is the classic feature. We present a case of late childhood sarcoidosis of the skin, lungs, and bones demonstrating granulomas with fibrinoid necrosis, making distinction from tuberculosis difficult.