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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 23, Issue 8, 2017

Original

Quantitative ABCD parameters measured by a multispectral digital skin lesion analysis device for evaluation of suspicious pigmented skin lesions strongly correlate with clinical ABCD observations

Background/Study Aim: A multispectral digital skin lesion analysis (MSDSLA) device has proven to be sensitive and specific for malignant melanoma (MM) detection by dermatologists and may have other useful applications. This study aimed to develop and test objective quantitative Asymmetry, Border irregularity, Color, and Diameter (qABCD) parameters for MSDSLA and correlate them with the presence of clinical ABCD features to aid the decision to biopsy a suspicious pigmented skin lesions (PSLs).

Methods: 1632 benign and malignant [175 MM/High Grade Dysplastic Nevi (HGDN)] were evaluated for their qABCD parameters. Quantitative characteristics were correlated with the presence of clinical ABCD features identified by independent dermatologists.

Results: qA, qB, qC, and qD had correlations of 78%, 73%, 76%, and 86%, respectively, for non-MM/HGDN lesions. The correlations for qA, qB, qC, and qD for MM/HGDN lesions was 86.3%, 83%, 89%, and 89%, respectively. All repeatability parameters were statistically significant.

Conclusions: This study demonstrates qABCD values are repeatable and strongly correlate with the clinical ABCD features. qABCD characteristics provide an additional objective and reliable means of identifying PSLs that need further evaluation to rule out MM and, in combination with the clinical ABCDs, may allow for improved assessment when evaluating the malignant potential of PSLs.

Commentary

The impact of ultraviolet radiation on sunburn-related search activity

We establish a strong, positive relationship between the Ultraviolet Index and Google search engine activity for sunburn-related terms in the United States. Using the Google Trends utility and data available from the National Weather service, we combine data from a twelve-year period to produce panel data for each state. We fit a time-series regression model of search activity and perform statistical tests on the resulting parameter estimates. This study lays the groundwork for using search-related data to assess the prevalence of, and attitudes about sunburn. By tracking the frequency of searches about preventative measures like “sunscreen” or “protective clothing” versus treatment measures like “sunburn relief,” researchers could measure the effectiveness of awareness and prevention programs.

Telangiectasia macularis eruptiva perstans: an old terminology, still frequently used

The term telangiectasia macularis eruptiva perstans (TMEP) was originally used to describe a rare form of cutaneous mastocytosis (CM) that was limited to the skin with lesions consisting of irregular, telangiectatic macules ranging in color from red to brown. Recent guidelines, however, recommended that the sole presence of telangiectasias should not form the basis of a distinct variant of CM. We conducted a review of the literature from 1930 to 2017 and found 76 cases that were reported as TMEP. Owing to a general misconception about diagnosis of CM and SM, there is a need for further discussion and awareness of the newly proposed World Health Organization (WHO) guidelines.

Case Report

Dermatologic manifestations of acromegaly: A case in point and a focused review

Acromegaly is a systemic syndrome caused by overproduction of growth hormone. Cutaneous, endocrine, cardiovascular, skeletal, and respiratory systems are affected. Cutaneous changes in acromegaly relate to overexpression of growth hormone and insulin-like growth factor 1 on skin cells and adnexa. Dermal glycosaminoglycan accumulation and edema cause skin distention that is most prominent in the face, hands, and feet. Oily skin with large pores, hypertrichosis, and excessive sweating are common features. Pigmented skin tags, acanthosis nigricans, and psoriasis are also encountered. Cutaneous manifestations of acromegaly are various and prominent, and are an important clue for the early diagnosis and treatment of this high-morbidity disorder.

Cowden syndrome: clinical case and a brief review

Cowden syndrome is a rare genodermatosis of autosomal dominant inheritance characterized by multiple hamartomas in several organs and an increased risk of malignancies. We present the case of a 53-year-old man with a history of benign and malignant thyroid disease, intestinal polyposis, and Chiari malformation. He had several trichilemmomas, papillomatosis of the oral cavity, macular pigmentation of the glans penis, among other clinical features suggestive of Cowden syndrome. Given the suspicion, genetic study was conducted and PTEN mutation was identified. Cowden syndrome affects 1:200,000 individuals. Mucocutaneous lesions are almost always present and there may be other typical features involving other organs, namely thyroid, colon, and brain. Mucocutaneous lesions may be the initial manifestation of this disorder and usually precede the onset of malignant lesions, making timely diagnosis essential for proper monitoring and screening.

A toxic epidermal necrolysis-like presentation of linear IgA bullous dermatosis treated with dapsone

Linear IgA bullous dermatosis is a rare autoimmune vesiculobullous disease characterized by linear deposition of IgA along the basement membrane zone. It is classically idiopathic, but may also arise secondary to drug exposure. A heterogeneous spectrum of clinical features has been described, including a rare, morbid variant mimicking toxic epidermal necrolysis. Herein, we present a case of vancomycin-induced linear IgA bullous dermatosis that manifested clinically as toxic epidermal necrolysis and resolved with dapsone therapy.

An unusual presentation of primary cutaneous amyloidosis

Primary localized cutaneous amyloidosis refers to a group of disorders characterized by deposition of amyloid in the dermis without any systemic involvement. It comprises the following clinical types: macular, lichenoid, nodular, and biphasic. There are also rare variants such as amyloidosis cutis dyscromica and poikiloderma-like cutaneous amyloidosis. We report a case of primary cutaneous amyloidosis in a 17-year-old boy with unusual pigmentation of various patterns (reticulate and diffuse pigmentation with mottling and rippling at places) and hypopigmented atrophic macules. Our patient also had nail, oral, and mucosal pigmentation that have not been described. Amyloid deposits were shown histopathologically in both hyperpigmented and hypopigmented macules.

Unique urticarial presentation of minocycline-induced lupus erythematosus

We present a 17-year-old boy who developed a generalized urticarial eruption, malar rash, fever, and arthralgia within one week of initiating minocycline therapy for acne. His workup showed positive antinuclearand anti-histone antibodies. His symptoms quickly resolved after discontinuing minocycline and starting oral prednisone. We believe the constellation of his symptoms, laboratory findings, and temporalassociation of minocycline initiation was suggestive of minocycline-induced lupus. Unique to this case is that his urticarial presentation was so striking that it could have been initially regarded as drug induced urticaria without considering drug-induced lupus. Since minocycline is so widely prescribed for acne among the dermatology community, we believe that it is important for dermatologists to be aware of this alternative clinical presentation of minocyclineinduced lupus.

Case Presentation

Treatment of selective antibody deficiency with IVIG resulting in decreased frequency of streptococcal infection and improvement of guttate psoriasis

The association between guttate psoriasis and infection with group A Streptococcus (GAS) has been well established in the medical literature. However, responses to treatments aimed at GAS eradication such as systemic antibiotics or tonsillectomy are inconsistent. Further complicating treatment recommendations for a disease with a suspected microbial trigger, the standard therapy for severe psoriasis is with systemic immunosuppressant medications. This case report illustrates the role ofGAS as a trigger for acute onset severe psoriasis in a child whose skin disease initially worsened with a trial of methotrexate. An immune evaluation confirmed a co-existing selective antibody deficiency. Subsequent treatment with intravenous immune globulin dramatically improved his underlying immune function and decreased GAS infections.This improvement in overall immune function and decrease in GAS infections cleared his skin disease. An interval change in formulation to subcutaneous immune globulin was not as effective.

Folliculin mutation-negative trichodiscomas in a patient with multiple endocine neoplasia type I syndrome

Multiple endocrine neoplasia (MEN) type I, an autosomal dominant disorder caused by mutations in the MEN1 gene, is classically associated with parathyroid, pituitary, and pancreatic tumors. Patients with MEN type I also frequently exhibit multiple cutaneous lesions, specifically facial angiofibromasand collagenomas. Herein we describe a patient with genetically confirmed MEN type I syndrome who presented with trichodiscomas, skin tumorscharacteristic of Birt-Hogg-Dubé (BHD) syndrome. Although BHD is associated with mutations in the folliculin (FLCN) gene, this patient with trichodiscomaswas negative for the FLCN mutation.

Oral involvement of cutaneous T-cell lymphoma

Mycosis fungoides (MF) is the most common cutaneous T cell lymphoma that involves the oral mucosal. The manifestation of lesions within the oralcavity generally correlates with a poor prognosis. Management of MF includes skin directed therapies and localized radiation treatment, with systemicbiologic therapies and chemotherapy used for more advanced stages. The clinical and histologic features of MF in a patient with oral disease are reviewed.

Allergic contact dermatitis to methylisothiazolinone in hair care products: report of a case

Methylisothiazolinone (MI) is commonly used as a preservative in personal care products and is a frequent cause of allergic contact dermatitis. Wepresent a patient with allergic contact dermatitis caused by MI in hair care products and discuss this allergen to bring attention to this common cause ofcontact dermatitis, and to highlight its frequent use in hair care products. If allergy to MI is suspected, testing should be performed to this individual preservative, as testing solely for the combination preservative,methylisothiazolinone/methylchloroisothiazolinone (Kathon CG®), may miss many cases of MI allergy.

Multiple eccrine spiradenomas in a zosteriform pattern

Eccrine spiradenoma (ES) typically presents as a solitary tender lesion. Multiple ES is a rare variant of ES and can present in a segmental, linear, blaschkoid, or zosteriform pattern. The etiology of multiple ES is unknown, but several theories have been suggested including a multipotent stem cell origin. We report the case of a 30-year-old woman with multiple painful ES in a zosteriform pattern on the mid-back and abdomen. Skin biopsy of a representative lesion demonstrated a circumscribed tumor nodule encapsulated by a fibrous capsule with diffuse dense basophilic proliferation located in the dermis. The lesions were then excised on two separate sessions without recurrence.

Mycobacterium marinum infection contracted from seaweed wrap in a psoriasis patient undergoing treatment with adalimumab

We report a patient with psoriasis who developed Mycobacterium marinum (M. marinum) infection after seven years of treatment with adalimumab, a human anti-TNF (tumor necrosis factor) monoclonal antibody. TNF is a pro-inflammatory cytokine that plays a central role in the pathogenesis of psoriasis and a number of other immune-mediated inflammatory diseases. TNF plays an important role in granuloma formation and host defense against mycobacterial infections. Several cases of atypical mycobacterial infections in patients on TNF inhibitors have been reported. To our knowledge, this is the second reported case of M. marinum infection in a patient on adalimumab for the treatment of psoriasis.

Trimethoprim-sulfamethoxazole-induced linear IgA bullous disease presenting as toxic epidermal necrolysis

BACKGROUND: Linear IgA bullous dermatosis (LABD) is an autoimmune blistering skin disorder characterized by linear IgA deposits along the dermoepidermal junction. Usually idiopathic, LABD can be drug-induced.

OBJECTIVE: To report the atypical characteristics of a case of trimethoprim-sulfamethoxazole-induced LABD presenting as toxic epidermal necrolysis (TEN).

METHODS: A 63-year-old woman treated with trimethoprim-sulfamethoxazole for Pneumocystis jirovecii infection developed a generalized maculopapular rash with herpetiform lesions, rosette-like lesions, and tense bullae with Nikolsky sign.

RESULTS: Anti-basement membrane zone antibodies were negative, but immunoblot revealed a 160 kDa band corresponding to subepidermal class IgA desmoglein 1. Skin biopsy specimens revealed a subepidermal bulla and direct immunofluorescence showed linear IgA deposition along the basement membrane zone. A diagnosis of toxic epidermal necrolysis was excluded and replaced by trimethoprim-sulfamethoxazole-induced LABD.

CONCLUSION: We report a case of trimethoprim-sulfamethoxazole-induced LABD with a 160 kDa IgA desmoglein 1 found by immunoblotting analysis, probably by epitope spreading.

A case of probable trimethoprim-sulfamethoxazole induced circulating antineutrophil cytoplasmic antibody-positive small vessel vasculitis

Cutaneous leukocytoclastic vasculitis (LCV) can occur as skin-limited disease or as part a systemic vasculitis. Appropriate workup includes the evaluation of antineutrophil cytoplasmic antibodies (ANCAs), with a positive titer raising concern for the associated primary vasculitides including microscopic polyangiitis (MPA), granulomatosis with polyangiitis (GPA), or eosinophilic granulomatosis with polyangiitis (EGPA). In the absence of systemic findings, however, a drug etiology must also be considered. Tumor necrosis factor (TNF) inhibitors, propylthiouracil, levamisole-adulterated cocaine, hydralazine, and minocycline have been previously documented to induce ANCA-positive vasculitis (APV), which may present with conspicuously high ANCA titers. Herein we report trimethoprim-sulfamethoxazole as another culprit in drug-induced APV. Our case reinforces the need to consider drug etiology for APV and cautions against interpreting positive ANCAs as equivalent to evidence of systemic disease.

Staphylococcus lugdunensis cutaneous infection with sporotrichoid distribution

We report the occurrence of Staphylococcus lugdunensis cutaneous infection with sporotrichoid distribution of the left lower limb of a 60-year-old man. Recent studies have confirmed that Staphylococcus lugdunensis is a significant pathogen in causing skin and soft tissue infections that usually manifest in abscesses, surgical wound infections, and cellulitis. It used to be considered a skin commensal bacteria, but if unrecognized it can lead to  fulminant endocarditis, meningitis, skin abscesses, peritonitis, and spondylodiscitis.

Letter

Cutaneous infection with Mycobacterium fortuitum after subcutaneous injection of human chorionic gonadotropin

Background: Weight loss clinics are common in the United States. Unfortunately, some offer dubious weight loss methods such as self-administered human chorionic gonadotropin (HCG) injections. HCG products are unregulated, yet, widely available. Infection is among the risks potentially associated with this treatment. We report a case of skin infection caused by Mycobacterium fortuitum after HCGinjection.

Case Presentation: A 51-year-old woman with a history of hypogammaglobulinemia presented with an eight week history of a tender abdominal lesion. The lesion was at the site of a previous HCG injection.Acid-fast bacilli (AFB) culture grew Mycobacterium fortuitum. Based on the organism’s susceptibility profile, sulfamethoxazole-trimethoprim 800-160mg and ciprofloxacin 500 mg were both prescribed. The case was referred to the Missouri Department of Health. Based on clinical progress treatment was continued for a total of six months.

Conclusions: This case illustrates the potential for cutaneous infection by Mycobacterium fortuitum and other rapidly growing mycobacteria after HCGinjections. Clinicians should maintain a high index for suspicion for rapidly growing mycobacteria when evaluating persistent skin lesions at sites of trauma or skin puncture.

A case of de novo palmoplantar psoriasis with psoriatic arthritis and autoimmune hypothyroidism after receiving nivolumab therapy

Nivolumab, a monoclonal antibody against the programmed cell death protein 1 (PD-1), has shown promising results in patients with advanced malignancies, including melanoma, lung cancer, and renal cancer. Immune-related adverse events (irAEs) have been reported, including both organ-specific toxicities and skin toxicities. Herein, we report a case of predominantly palmoplantar psoriasis with severe nail involvement, psoriatic arthritis, and autoimmune hypothyroidism after receiving nivolumab treatment for lung cancer. We also summarize the case reports that have been published previously. The knowledge of these irAEs in patients undergoing anti-PD1 therapy is important since it will enable earlier recognition and appropriate management, with the aim of maintaining effective dose without disruption.

Clinical improvement of a patient with both amyopathic dermatomyositis and psoriasis following treatment with cyclosporine

Clinically amyopathic dermatomyositis (CADM) is an uncommon subtype of dermatomyositis that rarely presents simultaneously with psoriasis. There are subsequently few reports discussing the management of concurrent CADM and psoriasis. Furthermore, skin lesions of CADM are often recalcitrant to first line dermatomyositis interventions. We present a case of a 45-year-old woman with both CADM and psoriasis whose lesions were resistant to multiple therapies; she eventually achieved disease control and remission with cyclosporine.

Atypical presentations of pityriasis rosea: a reply

Pityriasis rosea (PR) may have atypical presentations as regards morphology and distribution of the lesions. Recently, several forms of PR considered atypical for the course of the disease have been described. Differently from the typical PR that resolves within 2-12 weeks, relapsing and persistent PR forms (lasting longer than 12 weeks) have been described in adults and children. Lesions of the oral mucosa in PR may be more common than as reported in the literature. Formerly, the occurrence of oral lesions in PR has been considered more frequent in dark-skinned patients compared to light-skinned patients. However, in 12 Caucasian adult patients with persistent PR that have been recently described, oral lesions were very common (75% of cases). Another study on the clinical features and virological parameters of 31 Caucasian children with PR showed that painless oropharyngeal lesions were present in 35% of them, a rate much higher than those reported in adult dark-skinned (9%) and Caucasian patients (16%) with typical PR.

Essential telangiectasia in an infant: a diagnosis to be considered

Essential generalized telangiectasia as the result of postcapillary venule dilatation, is characterized by the sudden development of generalized telangiectasias, sometimes involving the conjunctiva. A few pediatric cases have been reported. The main condition in the differential diagnosis includes syndromes with telangiectasia such as hereditary hemorrhagic telangiectasia of Rendu-Osler, unilateral nevoid telangiectasia, and neonatal lupus erythematous. We present an 11-month-old boy that presented because of telangiectasia located on the face and neck. The telangiectasias appeared at two months of age and followed a progressive course. Nd-YAG laser therapy could be an interesting therapeutic approach in cosmetically compromised cases.