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Open Access Publications from the University of California

Dermatology Online Journal

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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 23, Issue 2, 2017


Apremilast for the treatment of psoriatic arthritis

Psoriatic arthritis (PsA) is a chronic inflammatoryarthropathy that affects joints and entheses andis associated with psoriasis (PsO). There are fiveclinical patterns of PsA: symmetrical polyarthritis,distal interphalangeal arthropathy, asymmetricaloligoarthritis, arthritis mutilans, and spondylitis, withor without sacroiliitis. Concerning PsA, the goals oftherapy are to control inflammation, prevent articulardamage, and reduce discomfort in the affected joints.Although there are many therapeutic options forthe treatment of PsAs, physicians most often beginwith nonsteroidal anti-inflammatory drugs (NSAIDs)for mild disease. Disease-modifying anti-rheumaticdrugs (DMARDS) are reserved for moderate to severedisease. Apremilast may be a useful option for somepatients.

Case Report

Capecitabine-induced lichenoid drug eruption: a case report

Capecitabine is a 5-fluorouracil basedchemotherapeutic drug widely used in the treatmentof solid tumors, especially colorectal and breast. Someof the most common side effects of capecitabine arecutaneous in nature, including hand-foot syndrome(palmar-plantar erythrodysesthesia). Several reports inthe literature link capecitabine use with photosensitivelichenoid eruptions. Herein, we present a case ofcapecitabine-induced lichenoid eruption in an elderlyfemale with metastatic breast cancer and discuss ourfindings in relationship to previously reported cases ofthis and other capecitabine-induced skin pathologies.

Acquired blue nevus of the nail bed

Blue nevi are benign proliferations of melaninproducingdendritic melanocytes located in thedermis. These nevi tend to occur mostly on the skin,predominantly on the head and neck, dorsal aspectsof the distal extremities, and the sacral area, butcan also occasionally appear on mucosal surfaces.Blue nevi of the nail apparatus are uncommon. Themajority originate in the nail matrix where there is ahigher density of melanocytes. Herein we report ona 47-year-old man with a rare common blue nevus ofthe nail bed, an area with low melanocyte density. Athorough review of the English language literaturefound no documented cases of acquired blue nevioriginating in the nailbed of the toe.

Tamoxifen-induced radiation recall dermatitis

Background: Radiation recall dermatitis (RRD) canpresent days to years after radiation exposure andis most commonly caused by chemotherapy drugs,with tamoxifen-induced radiation recall dermatitisbeing exceptionally rare. Purpose: To report a newcase of tamoxifen-induced radiation recall dermatitisafter 4.5 years of tamoxifen exposure, making this thelongest time of onset to RRD after tamoxifen initiation.Materials and Methods: The case of a woman withtamoxifen-induced RRD is presented. Using PubMedand Google Scholar, the terms tamoxifen, radiation,recall, dermatitis were searched. Relevant citationswere utilized and discussed. Results: An adult womanwith history of inflammatory breast carcinomadeveloped an erythematous, scaly, tender plaquelocalized to previously irradiated skin of the left chestafter more than four years of tamoxifen therapy. Thepatient was diagnosed with RRD and was treated withtopical triamcinolone 0.1% cream twice daily to theaffected areas. The patient experienced subsequentrapid improvement despite continuation of tamoxifentreatment. Biopsy revealed changes consistent withradiation dermatitis with no evidence of malignancy.Conclusion: Radiation recall dermatitis can havesignificant impact on affected patients and can posea diagnostic dilemma for clinicians who may mistakeRRD for infection or recurrence of malignancy. It isimportant to be familiar with the presenting signs andsymptoms of this entity so that affected patients canreceive timely and appropriate therapy.

Case Presentation

Congenital erythropoietic porphyria (Gunther disease) – long-term follow up of a case and review

Patients with the rare genodermatosis congenitalerythropoietic porphyria (CEP, Gunther disease)develop erosions and scarring on sun-exposedsites caused by phototoxin mediated damage.Compromised skin barrier function places patientsat higher risk of infection and long term sequelaeinclude scarring. We report a long term follow up ofa 60 year old patient born with CEP and provide anextensive literature review of CEP including recentupdates on potential management options. Multiplepatient interviews and collection of biochemistry datawere conducted for the case discussion. All Australianpathology laboratories in each state performingporphyria testing were surveyed in mid 2015 to verifyexistence of other cases of CEP in Australia with onlyone case of true congenital porphyria identifiedand one adult onset case. Congenital erythropoieticporphyria is a rare condition with no cure currentlyavailable. It is important to diagnose patients earlyto prevent and minimize complications such asscarring and secondary infection, provide longterm skin checks, and advise patients about lifestylemodification.

Folliculocentric tinea versicolor

Tinea versicolor (TV) is typically an asymptomaticfungal infection of the stratum corneum owingto Malassezia overgrowth. It presents as hypoorhyperpigmented macules with fine scale thatcoalesce into patches on the trunk, neck, and/or arms.Presented in this report is a 34-year-old man with aninteresting case of folliculocentric tinea versicolormanifesting as perifollicular hypopigmented maculeson the lower back.

Ichthyosis follicularis with alopecia and photophobia syndrome (IFAP): A Case Report

IFAP syndrome is a rare autosomal recessive X-linked disease characterized by the triad of alopecia universalis, severe photophobia, and follicular ichthyosis. It is caused by loss of function of the gene MBTPS2. Its severity varies and there are only a few reports in the literature. We present a patient with characteristic clinical features and a mutation not previously reported.

Generalized bullous fixed drug eruption treated with cyclosporine

Fixed drug eruptions (FDE) comprise 10 percent of alladverse cutaneous drug reactions and generalizedbullous fixed drug eruptions (GBFDE) are a raresubset of FDEs. We present a patient with severeGBFDE caused by ibuprofen successfully treated withcyclosporine. Further work is needed to determine ifcyclosporine can be an effective therapy for GBFDE.

Lichen planus of the eyelids: a case report and review of the literature

Lichen planus (LP) of the eyelid is an under-reportedmanifestation of a common inflammatory condition.To the best of our knowledge fewer than 20 cases ofeyelid LP have been described in the English literature.We report a case of a 29-year-old woman whopresented with 3-month history of bilateral eyelidpruritic violaceous papules and similar lesions on herchest and lower extremity. Histology examinationrevealed characteristic findings and a diagnosisof LP was established. This report further reviewsthe previously reported 18 cases and discussesmanagement strategies.

Petrified Ear – A Case Report and Review of the Literature

Petrified ear is the transformation of normal, flexibleauricular cartilage into rigid, immobile auricularcartilage due to abnormal calcification or ossification.Etiologies of petrified ear include tissue injury,systemic endocrine diseases, congenital disorders,or petrified ear of unknown origin. We present a caseof a 69-year-old male with a one-month history ofnon-painful rigidity of the right ear that was found tohave petrified ear of unknown etiology confirmed byradiography.

Unique clinical presentations of pityriasis rosea: aphthous ulcers, vesicles and inverse distribution of lesions

Pityriasis Rosea (PR) is a common skin disorderencountered in daily practice. Although its etiologyhas not been established, there has been widespreadresearch into possibilities. The lack of its characteristicmanifestations, specifically the herald patch andtruncal involvement, can lead to pitfalls in diagnosis.Whereas other conditions in the differential diagnosisshould be considered, PR can at times also manifest inan atypical manner. We wish to illustrate three casesof PR including those that presented with aphthousulcers, vesicles, and an inverse pattern.

Bullous pemphigoid of infancy – report and review of infantile and pediatric bullous pemphigoid

A 4-month-old infant was observed with an acute itchy bullous dermatosis, predominantly involving the extremities, which revealed a dermal infiltrate rich in eosinophils, C3 deposits at the dermalepidermal junction, and circulating antibodies to BP180 antigen, confirming the diagnosis of bullous pemphigoid. He was initially treated with deflazacort 1 mg/kg/day, further increased to 2 mg/ kg/day, followed by reduction over seven weeks with complete clinical resolution within this period. We discuss epidemiology, etiology, relationship with vaccination, clinical features, and treatment of thisrelatively rare bullous dermatosis in the pediatric age.

Mohs micrographic surgery and secondary intention healing of a plantar melanoma in-situ

This report details an acral melanoma in-situ on theright plantar foot that was successfully treated withMohs micrographic surgery and secondary intentionwound healing.

Photo Vignette

Lesión cribiforme en la cara de un varón de 44 años de edad

El acantoma de la vaina pilosa es un tumor benignode piel muy poco frecuente. Suele presentarse comouna pápula asintomática, con un orificio central y lalocalización más frecuente es la cara. Presentamos unnuevo caso de acantoma de vaina pilosa, apoartandoimagen dermatoscópica del tumor.

Median raphe cyst: report of two cases

Median raphe cysts are rare congenital lesions ofthe male genitalia that occur as a result of alteredembryologic development. We report two such casesof median raphe cysts in the pediatric age group. Inaddition, we review the literature.


Challenges to smartphone applications for melanoma detection

This commentary addresses the emerging market forhealth-related smartphone applications. Specific todermatology, there has been a significant increasenot only in applications that promote skin cancerawareness and education but also in those meantfor detection. With evidence showing that 365dermatology-related applications were available in2014--up from 230 in 2012--and that 1 in 5 patientsunder the age of 50 have used a smartphone tohelp diagnose a skin problem, there is clearly a largesubset of patients participating in this growing trend.Therefore, we are obligated to take a closer lookinto this phenomenon. Studies have shown thatapplications are inferior to in-person consultationswith one study showing that 3 out of 4 applicationsincorrectly classified 30% or more melanomas aslow-risk lesions. Although the FDA gained regulatoryoversight over mobile health applications in 2012and recently released their statement in 2015, theirreach only extends to cover a selected portion ofthese applications, leaving many unregulated asthey continue to be marketed toward our patients.Dermatologists should be updated on our currentsituation in order to properly counsel patients on therisks and benefits of these applications and whetherthey are acceptable for use.

Cutaneous Mycobacterium chelonae in a 95-year-old woman

We present an interesting case of cutaneousMycobacterium chelonae in a 95-year-old woman.The lesion in question was localized to her rightarm; subsequent biopsy and culture studies wereconsistent with a mycobacterial infection. Historically,these infections are treated based on the immunologicstate of the patient. In this case, taking into accountthe age of our otherwise immunocompetent patient,a course of oral antibiotics was initiated. The patientwas unable to tolerate any oral regimens for longerthan several weeks. Remarkably, even in the absenceof recommended antibiotic therapy, the lesionclinically cleared over a course of 8 months.

Erythema multiforme as a reaction to imiquimod 5% cream

We describe a patient with erythema multiformefollowing a local site reaction after the use of topicalimiquimod 5% cream and review the literature forprevious reports of this cutaneous adverse effect.

Resolution of psoriasis after tonsillectomy

A 19-year-old woman experienced recalcitrantpsoriasis after streptococcal pharyngitis. Multipletreatment regimens were employed, but results werepoor until after the patient underwent tonsillectomy.

Nódulos subcutáneos faciales de 3 meses de evolución

Siliconomas are subcutaneous nodules that usuallyappear as a consequence of the migration of freesilicon implanted in other locations. They are morefrequent in women with abnormal breast implants,such as poly implant prostheses (PIP), but they may alsoappear after illegal injection of free silicone. We reporta 57-year-old woman who attended our Dermatologyclinic complaining of relapsing facial panniculitis ofunknown origin. After a thorough work-up, thesenodules were determined to be the consequence ofdermal filler made with fluid silicone, which had beeninjected 20 years prior. High frequency skin ultrasoundof one of the nodules showed a hyperechoic image,also known as “snowstorm,” which was located in thesubcutaneous tissue. The disposition of silicone in thisplane obscures the view of any sonographic structurein the underlying plane. Cutaneous sonographyhas become one of the most useful non-invasivetechniques in diagnosis of filler complications andother inflammatory diseases. Combined treatmentwith prednisone and allopurinol was successful, withno recurrence after 1 year of follow-up.

Giant benign intradermal melanocytic nevus of rapid onset

Benign melanocytic nevi are slowly growing acquiredor congenital tumors with varied morphology,commonly encountered in dermatology clinics. Anytumor with rapid clinical growth must be assessedcarefully in order to exclude malignancy. We report awoman with a histopathologically benign intradermalnevus that presented as a rapidly evolving largecutaneous mass on the ear. Owing to the discrepancybetween the clinical and histopathological findings,an extensive histopathological work-up involvingmany deeper sections, immunohistochemical stains,and fluorescent in situ hybridization (FISH) analysiswas conducted in order to rule out malignancy.

Tumor necrosis factor antagonist-induced psoriasis in a 3-year-old boy with Kawasaki disease

Tumor necrosis factor (TNF) antagonists have beenknown to trigger new-onset psoriasis in adult andpediatric patients. Here we report a case of TNFantagonist-induced psoriasis in a 3-year-old boytreated with infliximab for Kawasaki disease. Ourpatient is a 3-year-old boy with Kawasaki diseaseunresponsive to intravenous immunoglobulinwho was then treated with one dose of infliximab.A few days later he developed psoriatic plaqueson the face and extremities. The psoriatic plaqueswere treated with topical calcineurin inhibitors andtopical corticosteroids, with marked improvement.Prior reports of TNF antagonist-induced psoriasis inthe pediatric population have been in children withinflammatory bowel disease or juvenile idiopathicarthritis. To the best of our knowledge, this is thefirst case of TNF antagonist-induced psoriasis ina pediatric patient with Kawasaki disease, andthe youngest patient to date. Although we donot fully understand the mechanism behind thisphenomenon, in vitro studies have implicated theimportance of interferon-α, a pro-inflammatorycytokine, and plasmacytoid dendritic cells. Furtherresearch is necessary to understand who is at riskfor this condition and the molecular basis for thisparadoxical reaction.

The Department of Defense: pioneers of early teledermatology

The United States (US) Department of Defense(DoD) has been a leader in using telecommunicationstechnology to provide remote medical care. The DoDhas been using telemedicine for more than twentyyears to provide medical services to military personneldeployed throughout the world, and has largelyinfluenced the development of teledermatology. Theexperiences of early military teledermatology serviceshave yielded valuable lessons that have been essentialto the creation of successful civilian programs.

Recruitment Advertisement

Dermatologists & Mohs Surgeon

The University of California, Davis, School of Medicine, Department of Dermatology, is recruiting for four academic dermatologists in the Clinical X series or Health Sciences Clinical Professor (HSCP) series at the Assistant/Associate/Professor level based on experience and qualifications. Three of these positions are for general medical dermatologists, and one is for a fellowship-trained Mohs surgeon/procedural dermatologist. The appointments may be made up to 100%.