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Disease-a-Month journal homepage: www.elsevier.com/locate/disamonth

Clinical pearls in dermatology 2013 Dawn Davis, MD, Scott Litin, MD, John B. Bundrick, MD

Case 1 A 28-year-old female is concerned about a worsening facial rash, thought to be dermatitis. She originally placed over-the-counter hydrocortisone on the rash twice a day without improvement. She then borrowed her daughter's triamcinolone prescription for use twice daily. The rash continues to progress. The patient is otherwise healthy and has normal menstrual cycles (Fig. 1). Question What is the best treatment for this condition? A. B. C. D. E.

Institute topical clobetasol BID Discontinue cosmetics and patch test for allergic contact dermatitis Discontinue topical steroids and institute judicious sunscreen use Discontinue topical steroids and institute topical metronidazole BID Discontinue topical steroids and institute topical tretinoin QHS

Discussion Perioral dermatitis is a common papulopustular facial eruption in adult, menstrual females. It usually begins around the mouth and spreads slowly to the nasal sidewalls, glabella, and periocular skin. Due to its erythema and progressive spread, it is often misdiagnosed as atopic, allergic, or irritant dermatitis. Dermatitic eruptions show patches and plaques of inflamed skin, rather than papules and pustules, and are frequently pruritic. In photosensitive facial eruptions, the distribution of erythema involves the convex areas, such as the forehead, central cheeks, and nasal bridge. There is relative sparing of shadowed areas, such as the inferior eyelids, proximal upper lip, and proximal chin. Topical steroid use worsens perioral dermatitis. Recommended treatment options include topical metronidazole twice daily and oral cycline antibiotics. http://dx.doi.org/10.1016/j.disamonth.2014.04.010 0011-5029/& 2014 Mosby, Inc.. All rights reserved.

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Fig. 1. 28-year-old female with facial rash.

Clinical pearl Topical steroids worsen perioral dermatitis. Topical metronidazole is the preferred treatment. Reference 1. Lipozencic J, Ljubojevic S. Perioral dermatitis. Clin Dermatol. 2011;29(2):157–161. Case 2 A 61-year-old woman presents to your clinic for progressive itching. Your colleague treated her with permethrin for presumed scabies, although she had no known exposure to an infestation. The intensity of the itching continues to worsen, especially at night. She has tried soaking in warm water baths and applying hypoallergenic moisturizers without improvement. The patient denies feelings of depression or anxiety, but the pruritus is emotionally fatiguing. Laboratory evaluation, including a CBC, TSH, creatinine, and alkaline phosphatase, is normal. A thorough review of systems is negative (Fig. 2). Question What is the best next step in the management of this patient? A. B. C. D. E.

Initiate fluoxetine Obtain a chest x-ray Obtain a urine drug screen Prescribe oral ivermectin, one dose today, repeat in 1 week Initiate fexofenadine

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Fig. 2. 61-year-old female with progressive itching.

Discussion Generalized pruritus incidence and severity usually increase with age due to physiologic decline of the skin barrier. Sensitive skin care measures relieve primary pruritus in a majority of patients. Pruritus without a rash in an otherwise seemingly healthy individual can indicate systemic and cutaneous disease, however, including lymphoma, anemia, thyroid disease, renal and liver abnormalities, and occult immunobullous disease of the skin. In this patient, a normal CBC and TSH rule out anemia and thyroid disease, respectively. A chest x-ray would be imperative to assess for occult lymphoma. The need to initiate fluoxetine for depression is less likely in this patient as she does not meet criteria for the disorder. Although certain prescription and illicit drugs can cause pruritus, this patient is at low risk for covert drug intake and has no other symptoms to support suspicion. Oral ivermectin is FDA indicated for strongyloidiasis and onchocerciasis, with off-label use for scabies. This patient has already been treated for scabies infestation, and no burrows or mites are visible on examination. Fexofenadine may help decrease the pruritus but does not alter its underlying cause. It may be used adjunctively while a primary cause is investigated, but due to the severity and persistence of the pruritus, it is not suggested as monotherapy in isolation. Clinical pearl Generalized pruritus without rash can be secondary to occult systemic and cutaneous disease. References 1. Sommer F, Hensen P, Bockenholt B, et al. Acta Derm Venereol. 2007;87:510–516. 2. Polat M, Oztas P, Ilhan M, et al. Generalized pruritus: a prospective study concerning etiology. Am J Clin Dermatol. 2008;9(1):39–44.


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Case 3 A 43-year-old female is concerned about her thinning hair. The loss of hair is limited to the scalp and has been slowly escalating for several months. She originally thought it was “just my imagination,” but now that it is noticed by her friends, husband, and hairdresser, she is quite worried. The patient denies any new styling products, tight braids, or heavy hairpieces. She otherwise feels well, and a thorough review of systems is negative (Fig. 3).

Fig. 3. 43-year-old female with thinning hair.

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Question What is the best treatment option for this patient? A. B. C. D. E.

Minoxidil 5% foam to the crown of the scalp once daily Finasteride 1-mg tablet by mouth once daily Hydroxychloroquine 200-mg tablet by mouth once daily Iron 65-mg tablet by mouth once daily Triamcinolone injections, 10 mg/mL, to the crown of the scalp

Discussion Androgenetic alopecia, frequently called “male-patterned baldness,” is a common nonscarring hair disorder in both males and females. The pattern of hair loss is predictable but differs by gender, with men noticing loss of the temporal hair, followed by the crown, and subsequently maintaining only the occipital hair in advanced stages. For females, the anterior hairline and parietal and occipital scalp hair is always maintained, with a progressive thinning of the crown of the scalp. This is often first noticed as a widened part while styling the hair, but with further loss, the entire crown can be almost bald. Topical minoxidil is a popular and effective over-the-counter medication that helps maintain hair density via mechanisms that are not well understood. The medication must be used faithfully to sustain its effects of decreased shedding of terminal hair. A recent study by BlumePeytavi et al. has shown once daily use of “maximum-strength” (5%, marketed to men) topical minoxidil to be just as effective on female-patterned androgenetic alopecia as the customary usage of twice daily strength “for women” (2%). The use of the medication once daily increases patient satisfaction and improves compliance while reducing cost. Oral finasteride is a 5 alpha reductase inhibitor indicated for androgenetic alopecia in males. However, it is not indicated in women (in whom mere exposure to the drug is strictly prohibited on account of risk to the male fetus). Hydroxychloroquine is frequently used off-label for scarring forms of alopecia but has not been found useful in non-scarring hair disorders. Iron supplementation is helpful in patients with alopecia areata secondary to iron deficiency. Alopecia areata classically presents with well-defined circular areas of hair loss randomly on the scalp, and not uncommonly, eyebrow and eyelash loss. Similarly, triamcinolone injections are effective in the treatment of alopecia areata but have not been proven beneficial in androgenetic alopecia. Clinical pearl Once daily use of 5% topical minoxidil in female patients with androgenetic alopecia is as effective as twice daily 2% topical minoxidil usage. Reference 1. Blume-Peytavi U, et al. A randomized, single-blind trial of 5% minoxidil foam once daily versus 2% minoxidil solution twice daily in the treatment of androgenetic alopecia in women. J Am Acad Dermatol. 2011;65(6):1126–1134. Case 4 A 50-year-old man returns to your clinic because the psoriasis medications you prescribed are no longer effective. For over 20 years, you have managed his generalized plaque psoriasis successfully with topical steroids and tar. However, despite compliance, the plaques persist. You

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recommend natural sunlight in moderation and initiate methotrexate. There is no clinical improvement on the subsequent clinical visit. You add adalimumab, and the plaques are again unchanged on follow-up. The patient proudly tells you he is otherwise improving his health because he is trying to lose weight and quit smoking as you have suggested. A thorough review of systems is negative (Fig. 4). Question What is the best next step in the management of this patient? A. B. C. D. E.

Check serum levels of thiopurine methyltransferase (TPMT) Check gene study for rapid metabolism of MTX Recommend HIV testing Initiate oral prednisone at 1 mg/mg/day, with close follow-up Add folate 1 mg/day

Discussion Psoriasis is a common inflammatory skin disease with significant impact on a patient's quality of life. Most patients are successfully managed with topical medications, including steroids, vitamin D analogs, salicylic acid, and medical tar. Severe, refractory psoriasis is usually responsive to systemic medications, including methotrexate and biologic therapy. When psoriasis becomes refractory to advanced treatments, HIV infection should be considered. It is a common cause of worsening or intractable disease. Thiopurine methyltransferase is an enzyme that metabolizes thiopurine medications, such as azathioprine and 6-mercaptopurine, which were not used in this patient. Rapid metabolism of methotrexate may be present in this patient but would not explain the persistence of the psoriasis with multiple other treatment modalities. Oral prednisone can be used in acute pustular psoriasis flares but is not standard of care for plaque type psoriasis.

Fig. 4. 50-year-old male with worsening psoriasis.

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Folate supplementation for patients on methotrexate is imperative to prevent side effects, such as hair loss, anemia, stomatitis, and myelosuppression, but is not known to exacerbate psoriasis.

Clinical pearl Patients with persistent or worsening psoriasis who are unresponsive to conventional medical therapies should be tested for HIV.

References 1. Leal L, Ribera M, Dauden E. Psoriasis and HIV infection. Actas Dermosifiliogr. 2008;99:753– 763. 2. Goh B-K, Chan R, Sen P, et al. Spectrum of skin disorders in human immunodeficiency virusinfected patients in Singapore and the relationship to CD4 lymphocyte counts. Int J Dermatol. 2007;46:695–699. Case 5 A 38-year-old female patient, well known to you, returns to the clinic concerned her burning mouth syndrome is worsening. She has a history of depression, which is well controlled on fluoxetine. The patient says she does not feel depressed. A repeat laboratory evaluation, including TSH, fasting glucose, FSH, LH, and vitamin levels, is normal. She is very compliant with your previous advice to use hypoallergenic toothpaste, avoid lipstick, and remove hot, spicy, and acidic foods from her diet. She recently went to the dentist, who assured the patient that her oral examination was normal (Fig. 5).

Fig. 5. 38-year-old female with burning mouth syndrome.

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Question What is the best treatment option for this patient? A. B. C. D. E.

Increase her dose of fluoxetine Nystatin solution, swish and swallow, five times daily Amoxicillin solution, swish and swallow, twice daily Diluted capsaicin solution, swish and swallow, three times daily Clonazepam tablet, suck and spit, three times daily

Discussion Burning mouth syndrome (BMS) is an oral pain disorder of unknown etiology. Secondary factors, such as mood disorders, endocrine abnormalities, infection, and nutritional deficiencies, often complicate its management. These factors must be addressed and treated. Primary BMS has no gold-standard treatment. However, clonazepam 1-mg tablets, suck at the site of pain for 3 min and then spit, used three times daily, has been effective for many patients. Increasing the dose of fluoxetine in this patient when her mood is stable is not justified. Nystatin solution would be beneficial if the patient had oral candidiasis, but a normal oral examination makes this very unlikely. Similarly, a bacterial infection, such as strep throat, would be appropriately treated with amoxicillin, but the history and examination do not support this concern. Capsaicin solution is used in pain disorders but is not a first-line therapy and can paradoxically worsen local pain. Clinical pearl Clonazepam tablets, suck and spit TID, are an effective treatment modality for BMS. Reference 1. Torgerson R. Burning mouth syndrome. Dermatol Ther. 2010;23(3):291–298.

Case 6 A 45-year-old woman is concerned she has “nail fungus.” Her fingernail changes occurred upon returning from a recent camping trip with her family. She did submerge her hands in lake water for recreational activities, and she also placed her hands in boiled water for cooking and cleaning. No other family members have developed similar nail findings. She denies any contact with animals, but she did spend a significant amount of time walking amongst weeds. Her past medical history is significant for constipation and rosacea, controlled with polyethylene glycol and doxycycline, respectively. Her physical examination shows her toenails are unaffected (Fig. 6). Question What is the most likely cause of her nail changes? A. Allergic nail reaction from contact with Rhus plant species

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Fig. 6. 45-year-old female with fingernail changes.

B. C. D. E.

Pseudomonas nail infection from water submersion Onychomycosis from Trichophyton exposure in soil Photoonycholysis from ingestion of doxycycline Onychomadesis from prolonged water submersion

Discussion Nail discoloration and separation (onycholysis) is common and frustrating for patients. The separation of the nail plate from the nail bed is often painful and can limit usual activities. Patients most commonly assume that nail dystrophy is due to onychomycosis, but many other nail disorders cause discoloration and separation. Cycline class oral antibiotics commonly cause nail bed inflammation when the digits are exposed to prolonged or intense ultraviolet light. This leads to abrupt onycholysis, frequently accompanied by discomfort. Rhus plant species, such as poison ivy, can cause a dermatitis that ranges from mild to severe. Inflammation limited to the nail bed, with normal surrounding skin, is unlikely. Pseudomonas infection can be limited to the nail bed and leads to slow or abrupt green discoloration of the nail plate with potential plate elevation. The patient lacks green discoloration to the nail, and diffuse nail involvement makes this choice doubtful. Trichophyton infection within a nail, true onychomycosis, is a possibility. However, a slow onset to a limited number of fingernails is the most common presentation. Onychomadesis, complete fracturing and loss of the nail plate, is rare and due to nail matrix growth arrest, such as during severe illness. Clinical pearl Certain oral medications, including oral cycline antibiotics, can cause onycholysis upon prolonged or intense ultraviolet light exposure. Reference 1. Baran R, Juhlin L. Photoonycholysis. Photodermatol Photoimmunol Photomed. 2002;18:202–207.

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Case 7 A 26-year-old man is very worried about a new genital rash. It erupted only 2 days ago and is rapidly spreading. He is married with children, and states he has only one sexual partner. No one else at home has a rash. Physical examination shows skin-colored, umbilicated papules limited to the penile shaft and suprapubic abdomen. A thorough review of systems is negative (Fig. 7). Question What is the best next step in the management of this patient? A. B. C. D. E.

Prescribe permethrin, apply today and repeat in 1 week Repeat sexual history and screen for sexually transmitted diseases Biopsy a lesion for concern of oncogenic HPV strains Reassurance; this was acquired from his asymptomatic children Reassurance; these lesions are eruptive “pearly penile papules”

Discussion Molluscum contagiosum is an extremely common Poxviridae infection of the skin. It is most commonly seen in children, acquired through casual contact and sharing of fomites. Molluscum contagiosum infection in adults is a sexually transmitted illness (STI), thus comprehensive screening for other STIs is imperative. While treatment is not required for standard infections, it is recommended for genital outbreaks in sexually active adults and generalized involvement in contact athletes (such as wrestlers) to prevent spread to others. Topical permethrin is an appropriate treatment for scabies and other infestations but is not useful in treating Poxviridae infections. Genital warts have a flat or verrucous surface and lack central umbilication. While children are frequent carriers of molluscum, and commonly

Fig. 7. 26-year-old male with genital rash.

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Fig. 8. 19-year-old college male with rash.

individual papules go unnoticed due to their small size, genital involvement in a sexually active adult makes sexual contact the most likely etiology. Also, treatment of the molluscum, as well as a workup for other STIs, would be warranted. Pearly penile papules are skin-colored papules located along the rim of the glans penis. They are a common anatomical variant and are not contagious or medically concerning.

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Clinical pearl Molluscum contagiosum infection of the genitalia in adults is a sexually transmitted infection. Screening for other STIs, and treatment of the molluscum to prevent spread to sexual partners, is pertinent. Reference 1. Brown T, Yen-Moore A, Tyring S. An overview of sexually transmitted diseases, part II. J Am Acad Dermatol. 1999;41(5 Pt 1):661–677. Case 8 A 19-year-old college male is concerned about his “stubborn eczema.” He has a history of atopic dermatitis in childhood, well controlled with topical triamcinolone. He rarely has flares now, usually with friction or prolonged exercise, and the triamcinolone resolves the rash in 3–5 days. The patient otherwise feels well, and his roommates are not sick, nor do they have a rash. He admits to sexual activity with many female partners, but promises he always uses a condom. The patient states that unlike his usual dermatitis flares, this time the rash is not itchy and is spreading to typically spared areas of the trunk and extremities. Physical examination shows numerous scaly patches on the trunk, progressing onto the arms and legs. The face, genitalia, palms, and soles are spared (Fig. 8). Question What is the most likely diagnosis in this patient? A. B. C. D. E.

HIV dermopathy Tinea corporis Pityriasis rosea Secondary syphilis Nummular atopic dermatitis

Discussion Pityriasis rosea (PR) is a common papulosquamous skin eruption in children and young adults. Its exact etiology is unknown but is thought to possibly be infectious. Due to its redness and scale, it is frequently confused with other skin disorders, ranging from atopic dermatitis to syphilis. Pityriasis rosea can be differentiated from other papulosquamous conditions by many factors. The onset of the “herald patch,” a prominent, initial ovoid area of inflammation, is unique to pityriasis rosea. Also, the distribution of PR occurs along the lines of skin cleavage, and patches are more commonly oval instead of circular. The scale of PR is central, instead of peripheral, and mature patches will show central clearing. Reassurance is the treatment of choice, along with supportive measures as necessary. HIV skin disease varies widely, and this patient is otherwise well. Tinea corporis is an annular, scaly skin disorder, but rapid spread as in this patient is unlikely. Secondary syphilis classically involves the palms and soles, which are spared in this patient. Nummular atopic dermatitis would be pruritic, have diffuse scale, and would improve with the use of topical triamcinolone.

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Clinical pearl Pityriasis rosea is a common, abrupt, papulosquamous eruption in young adults. Astute skin examination is required to rule out other illnesses. Treatment is unnecessary. References 1. Chuh A, Lee A, Zawar V, et al. Pityriasis rosea: an update. Indian J Dermatol Venereol Leprol. 2005;71(5):311–315. 2. Browning J. An update on pityriasis rosea and other similar childhood exanthems. Curr Opin Pediatr. 2009;21:481–485.

Answers: 1—D; 2—B; 3—A; 4—C; 5—E; 6—D; 7—B; 8—C.

Clinical pearls in dermatology 2013.

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