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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 5, 2013

Review

Psychopharmacological Therapies in Dermatology

When patients with psychodermatologic disorders present in clinic, the dermatologist can refer them to psychiatrists or other mental health care professionals. However, it is often the case that these patients will refuse a psychiatric referral because they either do not believe they have a disorder of psychiatric nature or they feel there is societal stigma associated with psychiatric illness. Therefore, it is essential for dermatologists to understand the common classifications for psychodermatological cases and to know how to optimally treat these patients with pharmacotherapy. The intent of this article is to help guide physicians in understanding the classifications of psychodermatological cases and in managing these conditions with pharmacotherapies. In this article, two classifications for psychodermatological cases are presented, followed by a discussion of medical therapies used to treat the main categories of psychopathologies that are more frequently encountered in dermatology. These include depression, anxiety, delusions, and obsessive-compulsive disorder.

Case Report

Carbamazepine-induced DRESS syndrome in a child: Rapid response to pulsed corticosteroids

DRESS syndrome is an idiosyncratic reaction to drugs, which can occur in both adults and children. To date there is no agreed upon criteria for its diagnosis; there is even less consensus on its management. We report the case of a 14- year-old boy with carbamazepine induced DRESS syndrome, predominantly involving the liver. He responded rapidly to high dose pulsed intravenous corticosteroids.

Case Presentation

Cutaneous Metastasis of Cervical Adenocarcinoma to the Vulva

Cervical cancer is one of the most common cancers and cause of cancer-related deaths in women worldwide. Cutaneous metastasis of cervical cancer, however, is exceedingly rare. It is generally seen late in the disease course and portends a poor prognosis. Herein we report a woman with a history of recurrent cervical cancer complicated by an unusual occurrence of metastasis to the vulva.

Multiple Cutaneous Nodules Presenting as Metastatic Squamous Cell Carcinoma of the Esophagus

A 62-year-old man with weight loss and dysphagia developed 3 cutaneous nodules. Fine needle aspirate of one of the nodules identified squamous cell carcinoma, which was found to be a metastasis from esophageal cancer.

An unusual case of sporotrichoid nodules: Metastatic cutaneous squamous cell carcinoma

A 63-year-old immunocompetent patient presented with a 4 month history of 12 painless nodules in a linear array on his right arm. He had a history of a surgery for a cutaneous tumor on the dorsum of his right middle finger about a year prior, but he did not follow up after the surgery. A differential diagnosis of sporotrichosis, atypical mycobacteria, deep fungal infection, and metastatic cutaneous squamous cell carcinoma (SCC) was considered. Skin biopsy revealed islands of dysplastic squamous cells and keratin pearls in a desmoplastic stroma in the deep dermis and subcutaneous tissue. The behavior of the disease was very aggressive, with rapid dissemination in a linear array, mimicking an infectious sporotrichoid spread. To our knowledge, this is the second case report of sporotrichoid metastases to the skin from cutaneous SCC in an immunocompetent patient.

A case of tinea incognito

Tinea incognito is a dermatophyte infection of the skin that presents atypically because it has previously been treated with imunnosuppresive medication. Herein we present a case of a middle-aged man who was initially clinically diagnosed to have plaque-type psoriasis on his arms. Over the course of two months of topical hydrocortisone and calciptriol treatment as well as phototherapy, the rash worsened. At the time of presentation to hospital the patient had a pruritic, widespread, sloughing, erythematous rash with areas of eschar. A punch biopsy skin confirmed dermatophyte fungal infection of the skin. Fungal culture was positive for Trichophyton Rubrum and the eruption resolved with systemic anti-fungal therapy. Patient specific risk factors for atypical presentation included poor hygiene and hepatatic disease.

Soft tissue chondroma of the index finger: Clinical, histological and radiological findings in a unique case

A chondroma is a benign, slow-growing cartilaginous tumor. When arising in the medullary cavity of a bone it is referred to as an enchondroma-a very common bone tumor. When occurring in soft tissue without any connection to bone, which is extremely rare, it is known as a soft-tissue chondroma (STC). A 38-year-old female presented with a 2- year history of right index finger pulp swelling in the absence of trauma. On physical examination a firm, immobile nodule, approximately 1 cm in diameter, was observed on the palmar side of the right index finger. The overlying skin was normal. Plain X-ray showed a dense, soft tissue shadow without calcification in the right index finger pulp, but the adjacent bones were intact. MRI showed a 1-cm diameter, well-demarcated lesion with intermediate signal intensity on T1-weighted images and high signal intensity on T2-weighted images. MRI also showed that the tumor had no bony involvement and that the adjacent bones were normal. Histopathological examination of the biopsy specimen showed lobules of mature hyaline cartilage with chondrocytes in the lacunae in the dermal and subdermal layers. Mitotic figures and an increase in cellular atypism were not observed. Based on the histopathological and radiological findings, the mass was thought to be an STC and total excision was performed. Examination of the excised mass confirmed the diagnosis of STC. STC should be considered in patients with a slowly growing, mildly painful cutaneous mass.

Report of a Family with Idiopathic Knuckle Pads and Review of Idiopathic and Disease-associated Knuckle Pads

Knuckle pads are a rare, frequently overlooked, thickening of the skin usually overlying the extensor surface of the proximal interphalangeal joints. They are well- circumscribed, benign lesions that generally do not require treatment. Idiopathic knuckle pads must be differentiated from similar appearing lesions or trauma-induced pseudo-knuckle pads. Knuckle pads have been observed in association with autosomal dominant conditions such as Bart-Pumphrey syndrome, Dupuytren's contracture, Ledderhose disease, and Peyronie's disease. To the best of our knowledge, idiopathic familial knuckle pads have not previously been described in the English language literature. We describe a sister and brother with familial idiopathic knuckle pads with no associated conditions.

A Hyperpigmented Perianal Nodule

Basal cell carcinoma (BCC) is the most common cutaneous malignancy. Ultraviolet light is an important risk factor for the pathogenesis of BCCs; the vast majority are found in sun-exposed areas. BCCs occurring in the perianal or genital regions are seldom seen. Less than 1% of all BCCs occur at these sites. Etiologic factors other than solar exposure must be taken into account for such cases. We report a rare case of BCC that was initially detected during a routine colonoscopy.

Hobnail Hemangioma on the Trunk

Hobnail hemangioma is a rare, benign vascular growth that typically presents in the third and fourth decades of life. It classically presents as a targetoid lesion with a violaceous central papule surrounded by a peripheral ecchymotic rim. Common sites of involvement include extremities and trunk. We present this case of hobnail hemangioma in a 10-year- old boy because of its rarity.

Photo Vignette

Ulcerated nasal infantile haemangioma treated by oral propranolol

Infantile hemangioma affects about 10% of neonates, but usually involutes without significant complications. Complications may include disfigurement, bleeding, and ulceration, along with airway, cardiac, hepatic, and spinal complications depending upon site. Oral propranolol is now the treatment of choice in many situations. Herein we present an infant with a large hemangioma on the nose tip and show the dramatic results with the use of propranolol. The patient received seven months of therapy at 2 mg/kg/day propranolol orally in three divided doses. The response started within a few weeks and by the eighth week ulceration had healed completely without scarring.

Letter

Adherence to Adalimumab in Patients with Moderate to Severe Psoriasis

Background

The chronic and relapsing course of psoriasis is often associated with poor adherence to treatment. Adherence to topical treatment is abysmal. Adherence to systemic treatments also decreases over time, with an overall adherence rate of 67% for injectable biologic medications. Whereas overall trends in poor adherence have been documented, the fine details of adherence in individual patients is not well characterized.

Purpose

To assess adherence to adalimumab in patients with moderate to severe psoriasis.

Methods

Data on adherence were obtained from a 1-year open label trial including seven patients with moderate to severe psoriasis who agreed to participate in a randomized trial of standard physician education materials plus extended nurse education versus standard physician education materials alone. Adherence to treatment was recorded with electronic monitoring via Medication Event Monitoring System (MEMS) caps undisclosed to the patients. Patients were also instructed to note the time and date they used treatment in a journal.

Results

The subjects exhibited a broad range of adherence behaviors.

Conclusions

Adherence to adalimumab therapy for moderate-to-severe psoriasis is variable and can be very poor. The clinical impact of poor adherence to injectable biologic medications is not yet well characterized.

Sorafenib Induced Eruptive Melanocytic Lesions

Sorafenib is a multikinase inhibitor FDA-approved for the treatment of advanced renal cell and hepatocellular carcinoma. Dermatologic side effects include hand-foot skin reaction, facial and scalp erythema and desquamation, splinter subungual hemorrhages, alopecia, pruritus, xerosis, keratoacanthomas, and squamous cell carcinomas. We report sudden eruption of melanocytic nevi diffusely in a patient receiving sorafenib.

Striae: a potential precipitating factor for Koebner phenomenon in psoriasis?

The Köebner phenomenon (isomorphic response) is defined as the development of typical lesions of a dermatosis that occur in areas of trauma in previously uninvolved skin. Rare reports have suggested that striae are a form of injury to the skin that can result in koebnerization of psoriasis, vitiligo, and lichen planus. We herein report a 27-year-old female patient with plaque psoriasis who developed psoriatic lesions along striae distensae.

Lupus Vulgaris Erythematoides: report of a patient initially misdiagnosed as dermatitis

A small percentage of patients with tuberculosis present with cutaneous findings, which may be difficult to diagnose. We present a patient diagnosed with a rare, non-scarring form of cutaneous tuberculosis (CTB), classically termed as lupus vulgaris erythematoides