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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 24, Issue 8, 2018


Erosio interdigitalis blastomycetica: A review of interdigital candidiasis

Erosio interdigitalis blastomycetica (EIB) is a Candida infection affecting the third web space, between the third and fourth fingers. In 1915, Gougerot and Goncea first described saccharomycetic organisms isolated from the hands and feet. Johannes Fabry later named it in 1917, well before the genus Candida was introduced in 1923. EIB is most common among those who work with their hands frequently in water, such as dishwashers, launderers, bartenders, and homemakers. Clinical presentation most commonly consists of a central erythematous erosion surrounded by a rim of white macerated skin involving at least one interdigital web space. The differential diagnosis is narrow, consisting of irritant contact dermatitis (ICD), erythrasma, inverse psoriasis, and bacterial infection (i.e. impetigo). The diagnosis is made by clinical examination in addition to fungal culture and KOH testing. The prognosis is good and treatment options include avoidance of frequent water immersion and topical or oral antifungal agents. Suspicion for secondary infections such as erysipelas and cellulitis should remain high until lesions have resolved. This review aims to address the history, epidemiology, pathophysiology, histopathology, clinical presentation, differential diagnoses, diagnosis, prognosis, and management of EIB. It also suggests an alternative name in place of the current misnomer.


PatientsLikeMe and atopic dermatitis: characterizing the atopic dermatitis patient profile

Introduction: Atopic Dermatitis (AD) is a common dermatologic disorder that affects 17.8 million individuals in the United States. Online medical communities have become increasingly popular over the last several years, providing an additional avenue of therapy for patients.

Purpose: This retrospective analysis looks to characterize the AD patient profile to better assess features of the AD community and appraise PatientsLikeMe data with current AD literature.

Methods: PatientsLikeMe data recorded by April 2018 from persons who reported AD as their primary or secondary diagnosis were included in the analysis.

Results: The PatientsLikeMe database had 410 individuals reporting AD as of April 2018. Of these, 61.46% (252/410) report AD as their primary disease. Of those reporting, 180/199 (90.45%) were diagnosed by a medical professional whereas 19/199 (9.55%) were self-diagnosed. The number of persons recording predefined PatientsLikeMe symptoms are as follows: stress (20), fatigue (132), pain (126), anxious mood (118), and depressed mood (103). Significance: Patient-oriented medical communities are a valuable resource for those affected by various conditions. Although clinical applications are still uncertain, this data allows practitioners access to profiles self-defined by online users.

Editorial boards of dermatology journals and their potential financial conflict of interest

Background: Financial relationships between editorial board members of peer-reviewed journals and pharmaceutical and medical device manufacturing companies can potentially lead to biases and loss of objectivity of the medical literature. The purpose of this study was to evaluate the potential financial conflicts of interest that exist among editorial board members of dermatology journals.

Methods: Editorial board members for 36 dermatology journals were identified and searched using the Open Payments database on the Center for Medicare and Medicaid Services website. The total amount of general payments made to these physician editors were collected and stratified using a tier system: 1) nothing reported, 2) >$0 and <$10,000, 3) >$10,000 and <$100,000, and 4) >$100,000.

Results: We identified 551 editors from 36 dermatology journals for use in our analysis. Some form of general payment was made to 87% of these physicians (480 of 551). Four journals had >25% of their editorial staff receiving >$100,000.

Conclusions: Financial relationships exist between editorial board members of dermatology journals and pharmaceutical/medical device manufacturing companies, which could lead to financial conflicts of interest. Publications coming from journals with highly paid physician editors have more potential to be biased.


Assessment of melanoma follow-up trends in Medicare patients: a large scale, multi-regional analysis

Background: Research on patient follow-up compliance after a diagnosis of melanoma has been limited.

Objective: To assess the timelines for follow-up among patients who are diagnosed with melanoma and to assess the socioeconomic and provider factors which influence follow-up adherence.

Methods: A retrospective, population-based study using nationally representative data from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database was conducted to evaluate 10,813 patients who were diagnosed with melanoma from 2005-2013. Results: We found that 97% of the individuals with melanoma had at least one follow-up visit, with 80.5% having their first follow-up visit within the first 6 months and 88.6% having their first follow-up visit within 12 months. Patients who had a dermatologist as the diagnosing provider were significantly more likely to follow up. Additionally, patients who returned were more likely to live in a community with a higher socioeconomic status.

Limitations: Applicability of the data to a non-Medicare population and confounding variables such as co-morbid conditions are limitations.

Conclusions: The majority of patients diagnosed with melanoma follow up with a provider within one year. However, socioeconomic and provider factors play important roles in influencing patient return visits.

Case Presentation

New onset erythematous nodules in an elderly woman

An 86-year- old woman with a history of recurrent bronchitis and giant cell arteritis presented for new onset, cyclic and migratory erythematous nodules associated with fatigue and weight loss. Although a systemic vasculitis was initially suspected, elevated inflammatory markers and symptoms persisted despite aggressive corticosteroid therapy. Excisional biopsy of one nodule showed dense suppurative and granulomatous inflammation that was rife with acid-fast bacilli. The patient was urgently admitted for empiric treatment of disseminated mycobacterial infection. Although T-SPOT Tuberculosis testing and direct mycobacterial PCR were negative, mass spectrometry demonstrated Mycobacterium chelonae. The patient was treated with a macrolide and quinolone combination regimen and then discharged to a rehabilitation facility.

Streptococcus dysgalactiae-associated penile bacterial disease in an elderly man acquired by fellatio: case report and literature review of penile and perianal Streptococcus dysgalactiae in men acquired by anilingus and fellatio

Streptococcus dysgalactiae subspecies equisimilis (SDSE) is a gram-positive, beta-hemolytic, large-colony-forming bacteria belonging to group C and G streptococci. It can be isolated in the normal flora of human skin, nasopharyngeal cavity, genitourinary, and gastrointestinal tracts. However, SDSE has been the cause of perianal bacterial infections associated with sexual practices. A 67-year-old man developed a penile bacterial infection secondary to SDSE. The infection presented as a painful erythematous patch on his penile distal shaft. He was successfully treated with oral cephalexin 500mg and topical mupirocin 2% ointment twice daily, for ten days. The infection resolved within ten days of treatment. Penile and perianal SDSE bacterial disease has been reported in five men, including the patient in this report. The perianal area was involved in 80 percent (4/5) of men; concurrent infection in the gluteal area was present in two men. The probable route of transmission was oral-anal (two men) or oral-genital (one man). All of the mens SDSE infections completely resolved after treatment with antibiotics. In conclusion, SDSE can cause penile and perianal bacterial disease, perhaps more frequently in individuals that receive unprotected fellatio and anilingus from asymptomatic or symptomatic carriers of the organism in their oropharynx.

Neoplasia de celulas dendriticasblastica plasmocitoide

Plasmacytoid blast dendritic cell neoplasia (NCDBP) is an uncommon malignant neoplasm, presenting clinically with cutaneous involvement and subsequent lymph node and bone marrow extension. It characteristically expresses the markers: CD56, CD4, and CD123. There is no optimal treatment, relapses are frequent, and the survival time is short. We present the case of an elderly patient with NCDBP who initially presented with cutaneous lesions, but experienced rapid systemic progression and did not, respond to treatment.

Cutaneous Crohn disease without gastrointestinal involvement in a 9-year-old boy

Cutaneous Crohn disease (CCD) is a rare dermatologic manifestation of Crohn disease and is defined as noncaseating, granulomatous skin lesions noncontiguous with the gastrointestinal tract. It most commonly affects the skin of the legs, although genital CCD is the most common presentation in children. Diagnosis of CCD is made by a combination of clinical and histopathological findings. Therapeutic options include topical, intralesional, and systemic corticosteroids as well as topical and systemic immunosuppressants and immunomodulators. Surgical excision may be considered for refractory cases. We report CCD in a 9-year old boy with penile swelling, granulomatous cheilitis-like lesions, and perianal plaques.

A case of granuloma annulare mimicking tinea cruris

Granuloma annulare (GA) is a benign, self-limited skin disease of unknown etiology characterized by annular, flesh-colored to erythematous grouped papules or plaques. Lesions of GA are typically located on the lateral or dorsal surfaces of the hands and feet, arms, thighs, and trunk. We present the case of a patient with GA who presented with erythematous, annular plaques localized to the bilateral inguinal folds, mimicking tinea cruris. On clinical examination, the lesions were thought to be tinea cruris. A subsequent punch biopsy revealed the lesions to be granuloma annulare. This case highlights an unusual location where GA can first present in a patient. It also suggests that GA should be considered among the differential diagnoses along with tinea cruris, when evaluating localized annular lesions of the groin.

Enzyme-linked immunosorbent assay as a helpful diagnostic tool for pemphigus erythematosus with equivocal histologic and immunofluorescent findings

Enzyme-linked immunosorbent assay is a sensitive and specific method for the detection of circulating autoantibodies in pemphigus vulgaris and foliaceus. Herein, pemphigus erythematosus with equivocal immunofluorescence and non-diagnostic histology, but confirmed by enzyme-linked immunosorbent assay, is described. As a non-invasive, sensitive, and specific assay with additional utility for monitoring disease activity, this case adds to growing evidence supporting ELISA as the diagnostic method of choice for common and less common variants of pemphigus.

Photo Vignette

Florid cutaneous papillomatosis as a marker of neoplastic recurrence

Florid cutaneous papillomatosis is a rare paraneoplastic dermatosis, most commonly associated with gastric adenocarcinoma. It is characterized by a sudden onset of hyperkeratotic papules, clinically indistinguishable from viral warts. We report an 80-year-old man who presented to our department with a two-month history of multiple verrucous lesions affecting the face, perioral region, and hands. Two years before, he was treated for a gastric adenocarcinoma with a subtotal gastrectomy, but showed no evidence of residual disease or recurrence. Given the clinical background, a diagnosis of florid cutaneous papillomatosis was considered. Skin biopsy excluded a viral origin, and tumour recurrence was later identified through an abdominal ultrasound. The onset of this entity is typically prior or concurrent with the diagnosis of the internal malignancy, but it may also represent the first sign of recurrence of a previously treated neoplasm. Its early recognition is essential to ensure a thorough investigation and prompt treatment.

Polypoid amelanotic melanoma: a diagnostic challenge

Melanoma is a highly aggressive cutaneous malignancy with considerable risk for metastasis. These malignant tumors are typically pigmented given that they arise from melanocytes capable of producing melanin. Amelanotic melanomas are a rare variant and there is often a delay in diagnosis owing to lack of pigmentation. Although there are various presentations of amelanotic melanoma, a solitary polypoid nodule is unusual and warrants further reporting. Herein, we present a patient with a 3-year history of a tender firm, skin-to-pink colored polypoid nodule. Excisional biopsy and work up showed an aggressive amelanotic melanoma with depth of 20mm and nodal metastasis consistent with stage IIIC disease. This case highlights the necessity of recognition and prompt management of this rare subtype of melanoma.

Lymphangioma circumscriptum of glans penis: a report of two cases

Lymphangioma circumscriptum is a developmental anomaly of lymphatic vessels, which appear as aggregates of clear or hemorrhagic vesicles on the skin or mouth. Glans penis involvement is very uncommon. Because of the sensitivity of the area, possible functional, cosmetic, or psychologic disturbances can result. Lymphangioma circumscriptum is rarely found on this location; hence, vigilance and awareness of this entity is necessary for a swift and proper diagnosis. Two cases are presented on the account of their rarity and unique representation.


Varicella zoster virus reactivation antedating ipsilateral brainstem stroke

itor Title: Varicella zoster virus reactivation antedating ipsilateral brainstem stroke Authors: Giuliana Galassi1, Maurilio Genovese2, Marisa Meacci3, Marcella Malagoli2 Affiliations: 1Department of Biomedical, Metabolic, Neural Sciences, University Hospital of Modena, Italy, 2Neuroradiology Service, University Hospital of Modena, Italy, 3Department of Laboratory Medicine and Patholgy, Microbiology and Virology Unit, University Hospital of Modena, Italy Corresponding Author: Giuliana Galassi, MD, Department of Biomedical, Metabolic, Neural Sciences, University Hospital of Modena, Via P. Giardini 1455, Modena, Italy, Tel: 39-3497325802, Email: Abstract: Varicella zoster virus (VZV) infection and reactivation are associated with a number of neurologic conditions. Unifocal large vessel infarcts may follow zoster in the trigeminal or cervical distribution as a result of transaxonal transport of virus from trigeminal or cervical afferent fibers that innervate vessels. Ophthalmic zoster (HZO) might cause ophthalmoplegic syndromes, with secondary optic neuritis. Mechanisms include local orbital muscle inflammation and, viral spread from the ophthalmic branch of the fifth nerve with associated vasculopathy. A 72-year-old man developed a vesicular rash in the territory of C5-T5-6. Within four weeks, the patient developed headache, dysphagia, left facial and extremity ataxic weakness. Magnetic resonance imaging (MRI) revealed a right pontine infarction. A 66-year-old woman presented with right-sided painfull HZO. One week later she developed complete external ophthalmoplegia and blurred vision. MRI showed ill-defined signal alteration in the retrobulbar tissue. Three weeks later, the patient was admitted because of dysarthria, deviated tongue, left-sided limb weakness, and tactile hypoesthesia. Spinal fluid contained 23 lymphocytes/mm3 and increased protein. The serum contained antibodies to VZV IgG and IgM in both cases. The patients received intravenously acyclovir with improvement. This report confirms unusual occurrence of ipsilateral brainstem stroke after VZV reactivation in immunocompetent subjects.

Varicella zoster virus reactivation and the increased risk of cerebrovascular accidents: the unexpected role dermatologists can play

Varicella zoster virus (VZV) primary infection usually causes varicella and its reactivation may lead to different clinical manifestations depending on the site of viral reactivation and its subsequent tissue spread. There is a growing recognition of the association between VZV reactivation and ensuing cerebrovascular accidents (CVA). The virus can spread to cerebral arteries, causing a wide clinical spectrum related to VZV vasculopathy. Herein we present an 80-year-old man with a previously undiagnosed immunosuppressive condition, admitted with disseminated herpes zoster, who subsequently developed an acute ischemic CVA and showed a substantial neurologic recovery under antiviral therapy.

Reaccion acneiforme noduloquistica secundaria a vemurafenib con buena respuesta a isotretinoina oralSevere acneiform eruption associated with vemurafenib with response to isotretinoin

Vemurafenib, a kinase inhibitor that targets tumors with the BRAF V600E mutation, is a promising option for unresectable or metastatic melanoma. Cutaneous side-effects have been reported including alopecia, photosensitivity, squamous cell carcinoma, keratoacanthomas, keratosis pilaris-like eruption, and palmoplantar hyperkeratosis. Acneiform eruptions have been reported in 3%-6% of the patients treated with BRAF inhibitors,and 5 cases are described in the literature. Although they responded well to topical therapies, oral antibiotics, or observation, one case required oral etretinate and the withdrawal of vemurafenib because the adverse event reached grade 3. We report one case of a severe acneiform eruption associated with vemurafenib with a good response to isotretinoin allowing continuation of the BRAF inhibitor.

Successful treatment of two individual cases of generalized granuloma annulare with amoxicillin/clavulanic acid and a combination of doxycycline and pentoxifylline

Granuloma annulare is a benign inflammatory skin disease potentially related to a delayed hypersensitivity reaction to the dermis. Generalized granuloma annulare (GGA) manifests as diffuse skin-colored to erythematous annular or nummular plaques affecting at least the trunk and either upper or lower extremities, or both. GGA is resistant to many therapeutic modalities, making it difficult to treat. Different therapeutic approaches to GGA have been attempted but definitive treatment for this disease remains elusive. This article focuses on the use of amoxicillin/clavulanic acid and a combination of doxycycline and pentoxifylline therapy as treatment options for GGA in two patients with histopathology-proven interstitial GGA. Both amoxicillin/clavulanic acid and doxycycline inhibit bacterial cell growth, raising the possibility that a bacterial pathogenesis may be of significance in GGA. This is the first reported case of successful treatment of GGA with these regimens.

Nodular scabies: a persistent nodular eruption

Nodular scabies is a hypersensitivity reaction to scabietic infestation characterized by persistent pruritic nodules that can remain even after treatment of the initial infestation. We present a demonstrative case of an infant who presented with nodular scabies.


Corrigendum: Complications associated with intimate body piercings

The original article was published on July15, 2017 and corrected on August 15, 2018.

The revised version of the article includes a correction to the spelling of an author. The change appears in the revised online PDF copy of this article.