Cutaneous sarcoidosis masquerading as chronic cutaneous lupus erythematosus - case report

BACKGROUND

Sarcoidosis is a multisystemic granulomatous disease of unknown origin. Chronic cutaneous lupus erythematosus (CCLE) is an autoimmune disease that is associated with autoantibody production and T-cell dysfunction. Cutaneous manifestations of sarcoidosis may mimic CCLE and vice versa making it difficult to reach a diagnosis clinically.

CASE PRESENTATION

We present a case of a 57-year-old woman with long-standing sarcoidosis who presented to clinic with diffuse painful plaques that were very distinct and suggestive of CCLE. She had a family history of both sarcoidosis and CCLE. The patient was immediately started on topical corticosteroids and oral hydroxychloroquine. Skin biopsy and the absence of direct immunofluorescence confirmed a skin manifestation of her previously diagnosed sarcoidosis, despite the clinical morphology favoring classic CCLE.

CONCLUSION

Sarcoidosis may have diverse manifestations and may mimic other disease processes. A detailed history along with a low threshold for biopsy is important for determining a diagnosis.

Vesicular eruption in a 2-year-old boy

A bath with scented soap prompted a flare of the boy's eczema. Days later, he was hospitalized with diffuse erosions covering 90% of his body. What was the cause?

Key opinion leaders: where they come from and how that affects the drugs you prescribe

Key opinion leaders (KOLs), also known as thought leaders, are the experts in their field upon whom we depend for original research leading to disease understanding and new therapies. We rely on them to write the articles, author the textbooks, and give the presentations that we absorb to become better dermatologists. KOLs have become intimately entwined with the marketing of pharmaceuticals and medical devices, used not only to lend credibility to claims of efficacy and safety but also to promote anecdotal and off-label use of these medications to increase industry profits. Identification and marketing of the KOLs themselves is being done more and more often by KOL management companies who are hired by industry to turn those involved in medical education and research into efficient and productive members of the sales force.

"I swear!" Physician oaths and their current relevance

Most graduating medical students will take some sort of oath that is to inspire them to take their proper place in the comradeship of physicians and remind them of their obligations to their patients, society, and their profession. The nature of these oaths has changed over the years as society itself has changed. What may be considered moral, ethical, or legal at one time can appear quaint or outrageous in another time and place. Several classic and newer oaths can be compared and contrasted in what they are tasking the newly minted physician to do.

No more pens: what the 2009 Pharmaceutical Research and Manufacturer's Association code changes really mean

In 2002, new guidelines for interactions with the pharmaceutical industry and physicians were published as an official code of conduct. Adherence to the guidelines was voluntary, and there were no provisions for discipline to companies who did not subscribe to the code or who subscribed but did not comply. Many of the code standards are routinely violated, sometimes egregiously, with many violations on easy display at national professional meetings. In response to further problems and complaints, tougher code standards-now famous for the specific ban on logo pens and coffee cups-were adopted in 2009. Subscription to the new code is voluntary, and there are no provisions for discipline or punishment for those companies who chose not to subscribe or who may violate its standards.

Keratosis punctata of the instep

We present a case of keratosis punctata involving the instep of both feet in addition to palmar and plantar creases, a finding not previously reported to our knowledge. We also discuss a closely related entity, keratosis punctata palmaris et plantaris (KPPP), and why we believe our case does not simply represent a variant of keratosis punctata of the palmar creases (KPPC).

A different kind of residency--a different kind of resident

The military dermatologist requires a set of job skills beyond that of the civilian dermatologist. When military dermatologists complete their training, they must be prepared to function in remote locations with limited subspecialty support. Military dermatologists must be competent in the broad range of disciplines that encompass dermatology and have special expertise in tropical and environmental dermatology. They also must maintain a broad knowledge of biological and chemical agents. Three US military training programs currently exist. The largest, in San Antonio, Texas, was formed in 1996 when Wilford Hall Medical Center and Brooke Army Medical Center merged their resources and residents to create a single large program. The contributions of military dermatologists are discussed in the context of how the joint Army/Air Force program is structured to meet a broad set of needs.

Biological warfare from a dermatologic perspective

Biological warfare agents have been used in this century by both organized armed forces and terrorist organizations. Beset with many problems that limit their tactical value on the battlefield, such "weapons of mass destruction" have tremendous terror appeal. Unusual presentations or clustering of diseases associated with biowarfare might alert the clinician that an attack has occurred. The clinical presentations, current recommended treatments, and preventive measures of agents such as anthrax, smallpox, plague, and the viral hemorrhagic fevers are discussed, as well as some of the issues that have been raised as authorities are considering how and when to resume smallpox vaccinations. References focus on current Internet web sites, which will provide up-to-date information and advice for allergists with immunization questions or who feel they might have encountered a patient with one of these diseases.

Lichen sclerosus: an atypical presentation

We describe the case of a 66-year-old Hispanic man with an atypical presentation of lichen sclerosus (LS). The unusual presentation included bilateral axilla involvement (not previously reported to our knowledge), scrotal involvement (not common in men, despite common vulvar involvement in women), and an uncommonly thick plaque on his back.

Dermoscopy in the diagnosis of tinea nigra plantaris

Tinea nigra is a relatively uncommon dermatiaceous fungal infection, usually caused by Phaeoannellomyces werneckii, that may mimic a melanocytic lesion. We describe the value of epiluminescent dermoscopy of tinea nigra plantaris compared with other common diagnostic tools and procedures available (clinical appearance, potassium hydroxide [KOH], culture, culture mount preparation, and biopsy). A case of tinea nigra plantaris was evaluated clinically, microscopically with KOH, and dermatoscopically. Dermatoscopic findings were evaluated according to the Stolz system. Dermoscopy, clinical presentation, and microscopy with KOH all confirmed the diagnosis, with dermoscopy being the fastest and simplest procedure. Dermoscopy is a useful clinical adjuntive tool in differentiating tinea nigra from a melanocytic lesion.

Polypoid clear cell acanthoma of the scalp

Clear cell acanthoma (CCA) is a rare, benign epithelial tumor most frequently found on the lower extremities. Its clinical appearance may vary considerably, and cases of multiple lesions have been reported. The diagnosis is made by viewing the characteristic histologic features. This case describes an unusual scalp lesion that clinically and histologically shows unique polypoid features.

Migratory poliosis: A forme fruste of alopecia areata?

We describe a 19-year-old African-American man with a 14-year history of migratory poliosis. We suggest that this phenomenon may represent a forme fruste of alopecia areata.

Galvanic urticaria

A variety of environmental stimuli, such as vibration, ultraviolet radiation, and exposure to water, are recognized as causes of "physical urticaria." A medical student, participating in a demonstration of a galvanic device used in the treatment of hyperhidrosis, demonstrated urticaria in response to this galvanic stimulation.

Environmental skin diseases and the impact of common dermatoses on medical readiness

The environmental extremes in which soldiers exercise and fight, like the environmental extremes in which many civilians encounter occupationally and recreationally, can prove to be a significant cause for morbidity and decreased effectiveness. A variety of skin diseases are related to occupational exposure to dusts and ultraviolet radiation as a well known cause of cutaneous damage. As more is understood about the biochemical factors involved in frostbite injury, treatment recommendations have changed. Too much water, hot or cold, is a continued source of cutaneous misery to the soldier in the field. Finally, even common minor skin ailments can incapacitate the sufferer when confronted with unfavorable environments.

Primary anetoderma

Primary anetoderma is a rare disorder characterized by sac-like herniations and depressions in previously normal skin. On histologic examination, elastic fibers are destroyed by an inflammatory infiltrate. We describe a striking case of primary anetoderma and review the classification, differential diagnosis, causes, and treatment.

Treatment of oral granulation tissue with the flashlamp pulsed dye laser

BACKGROUND

Surgical excision and debridement is the standard therapy for cutaneous and intraoral pyogenic granulomas (PGs). Occasionally the mass of granulation tissue proves unresponsive to the usual treatment methods.

OBJECTIVE

We report a case in which the flashlamp pulsed dye laser (PDL), previously reported as useful in cutaneous PGs, was used in a patient with persistent granulation tissue around dental implant posts.

METHODS

An illustrative case is presented with a brief discussion of the use of lasers in dentistry and in the treatment of PGs.

RESULTS

Previously resolute tissue responded well to a series of treatments with the PDL.

CONCLUSION

The PDL may have utility in this oral condition, providing a new venue for cooperation between dentists and dermatologists.

The "teepee" sign in inflammatory scalp disease

Psoriasis and other diffuse inflammatory diseases of the scalp can cause a unique physical findings that we call the "teepee sign" because the hair forms pyramidal tufts at regular intervals that resemble an American Indian encampment. A pathological mechanism for this finding is proposed, with the description of two cases in Air Force basic trainees, one of a severe seborrheic dermatitis and the other psoriasis. The significance with regard to physical qualification for entry into military service is discussed.

Cutaneous sporotrichosis presenting as a keratoacanthoma

Sporothrix schenckii is a ubiquitous dimorphic fungus with a variety of clinical presentations, including imitation of other diseases such as pyoderma, rosacea, and pyoderma gangrenosum. A case in which sporotrichosis appeared as a keratoacanthoma-like nodule on the lower lip of a young woman is presented, with treatment considerations and diagnostic pitfalls.

Primary cutaneous Aspergillus ustus infection: second reported case

We describe the second case of primary cutaneous Aspergillus ustus infection in an immunocompromised patient. Cutaneous aspergillosis was confirmed both by culture and positive fluorescent antibody staining. Few species of Aspergillus are pathogenic in human beings, and fewer still cause primary cutaneous disease. The only other reported case of aspergillosis from Aspergillus ustus occurred in an immunosuppressed patient who was temporally and geographically separated from ours.

"Toxic sock" syndrome

For several months, a 17-year-old male athlete noticed that his feet had an itchy, burning sensation at the heels and toes. His foot odor had become so malodorous (somewhat akin to rotting fish) that he would not remove his shoes except immediately before washing his feet. Washing made the odor somewhat milder, but only for a short time. The patient had tried an over-the-counter "athlete's foot" powder without results. He had no other health problems and was not taking any medication. The accompanying figure shows the toes of his right foot.

'Dimpling' is not unique to dermatofibromas

The dimpling of the skin with lateral compression or 'Fitzpatrick's sign' is considered by many to be pathognomonic for dermatofibromas (DFs). Despite the description of this sign in all major textbooks, not all DFs dimple and all that dimple are not DFs. Other diagnostic investigations such as the use of dermatoscopy may help to confirm the clinical suspicion of DF.

A polypous carbuncle

A carbuncle usually presents as a deep-seated mass of fistulous tracts between infected hair follicles. We present a case in which what appeared to be an inflamed, benign neoplasm turned out to be a very unusual presentation for this condition, the first we could find in the literature. A 62-year-old woman presented with a bothersome 'mole' on her flank of uncertain duration but it was initially pruritic and irritated by her clothing. Owing to the pain, she wanted its removal. A 1 cm soft, pink, stalked papule revealed multiple, closed,, comedo-like spots on its surface (Fig. 1). The lesion was mildly tender and freely mobile on a broad-based stalk. A pre-biopsy diagnosis of irritated intradermal nevus or neurofibroma was made, and the lesion was blade-shaved flush with the skin surface. Histologically, the papule demonstrated small abscesses which seemed to connect, as well as foci of granulation tissue and marked dermal edema (Fig. 2). Fragments of infundibular epidermis were found throughout the lesion. No residual melanocytic or neural neoplasms were identified.

Eczematous hypersensitivity from aqueous vitamin K injection

Hypoprothrombinemic states are commonly treated with injectable vitamin K. Cutaneous vitamin K hypersensitivity can manifest as eczematous or sclerodermoid lesions and historically has been related to the use of fat-soluble vitamin K1. We present a case of warfarin-induced hypoprothrombinemia treated with aqueous vitamin K1, which resulted in the appearance of eczematous vitamin K1 hypersensitivity.