Photo Rounds

Exam and biopsy led to a diagnosis of erythema dyschromicum perstans. Notably, the punch biopsy was performed as superficially as possible to avoid injuring the marginal mandibular branch of the facial nerve. Histology showed focal vacuolar interface changes, pigmentary incontinence, and prominent dermal melanophages—consistent with erythema dyschromicum perstans.

Erythema dyschromicum perstans is an uncommon dermal macular hyperpigmentation that can affect patients of all ages. It is more often seen in patients with Fitzpatrick skin types III and IV. Some patients have a preceding inflammatory phase with associated erythema.

It is believed that erythema dyschromicum perstans may be a form of pigmented lichen planus with similar histologic changes. Genetic predisposition and medications, such as penicillamine and omeprazole, have been suggested as predisposing risk factors, although these risk factors are not always present. Similarly, cases of erythema dyschromicum perstans associated with human immunodeficiency virus and hepatitis C virus have been reported, but a causal link has not been established. Commonly affected sites include the face and neck, although patches on the trunk and extremities occur, as well.

The differential diagnosis includes lichen planus, discoid lupus, drug-induced hyperpigmentation, Hansen disease, and fixed drug eruption.

Erythema dyschromicum perstans is resistant to most therapies, yet it may clear spontaneously over the years. Therapies that have been successful in case reports include Q-switched ruby laser, topical steroids, UV therapy, isotretinoin, and clofazimine. This patient used desonide cream 0.05% bid for 3 weeks without improvement. She then used camouflage concealer for a year, at which point the area had faded almost completely.

‌

Photos and text for Photo Rounds Friday courtesy of Jonathan Karnes, MD (copyright retained). Dr. Karnes is the medical director of MDFMR Dermatology Services, Augusta, ME.

Exam and biopsy led to a diagnosis of erythema dyschromicum perstans. Notably, the punch biopsy was performed as superficially as possible to avoid injuring the marginal mandibular branch of the facial nerve. Histology showed focal vacuolar interface changes, pigmentary incontinence, and prominent dermal melanophages—consistent with erythema dyschromicum perstans.

Erythema dyschromicum perstans is an uncommon dermal macular hyperpigmentation that can affect patients of all ages. It is more often seen in patients with Fitzpatrick skin types III and IV. Some patients have a preceding inflammatory phase with associated erythema.

It is believed that erythema dyschromicum perstans may be a form of pigmented lichen planus with similar histologic changes. Genetic predisposition and medications, such as penicillamine and omeprazole, have been suggested as predisposing risk factors, although these risk factors are not always present. Similarly, cases of erythema dyschromicum perstans associated with human immunodeficiency virus and hepatitis C virus have been reported, but a causal link has not been established. Commonly affected sites include the face and neck, although patches on the trunk and extremities occur, as well.

The differential diagnosis includes lichen planus, discoid lupus, drug-induced hyperpigmentation, Hansen disease, and fixed drug eruption.

Erythema dyschromicum perstans is resistant to most therapies, yet it may clear spontaneously over the years. Therapies that have been successful in case reports include Q-switched ruby laser, topical steroids, UV therapy, isotretinoin, and clofazimine. This patient used desonide cream 0.05% bid for 3 weeks without improvement. She then used camouflage concealer for a year, at which point the area had faded almost completely.

‌

Photos and text for Photo Rounds Friday courtesy of Jonathan Karnes, MD (copyright retained). Dr. Karnes is the medical director of MDFMR Dermatology Services, Augusta, ME.

Exam and biopsy led to a diagnosis of erythema dyschromicum perstans. Notably, the punch biopsy was performed as superficially as possible to avoid injuring the marginal mandibular branch of the facial nerve. Histology showed focal vacuolar interface changes, pigmentary incontinence, and prominent dermal melanophages—consistent with erythema dyschromicum perstans.

Erythema dyschromicum perstans is an uncommon dermal macular hyperpigmentation that can affect patients of all ages. It is more often seen in patients with Fitzpatrick skin types III and IV. Some patients have a preceding inflammatory phase with associated erythema.

It is believed that erythema dyschromicum perstans may be a form of pigmented lichen planus with similar histologic changes. Genetic predisposition and medications, such as penicillamine and omeprazole, have been suggested as predisposing risk factors, although these risk factors are not always present. Similarly, cases of erythema dyschromicum perstans associated with human immunodeficiency virus and hepatitis C virus have been reported, but a causal link has not been established. Commonly affected sites include the face and neck, although patches on the trunk and extremities occur, as well.

The differential diagnosis includes lichen planus, discoid lupus, drug-induced hyperpigmentation, Hansen disease, and fixed drug eruption.

Erythema dyschromicum perstans is resistant to most therapies, yet it may clear spontaneously over the years. Therapies that have been successful in case reports include Q-switched ruby laser, topical steroids, UV therapy, isotretinoin, and clofazimine. This patient used desonide cream 0.05% bid for 3 weeks without improvement. She then used camouflage concealer for a year, at which point the area had faded almost completely.

‌

Photos and text for Photo Rounds Friday courtesy of Jonathan Karnes, MD (copyright retained). Dr. Karnes is the medical director of MDFMR Dermatology Services, Augusta, ME.

The clinical findings and medical history were consistent with drug-induced hyperpigmentation and minocycline was the likely culprit. Other medications commonly implicated in drug-induced hyperpigmentation include heavy metals (eg, gold, iron, silver), anticonvulsants, hydroxychloroquine, and amiodarone.

Common sites for minocycline pigment deposition—besides the fingernails—include the gingiva, dorsal hands, shins, and old scars. The diagnosis of drug-induced hyperpigmentation is clinical and does not require a biopsy.

While the use of antibiotics for chronic disease can lead to antimicrobial resistance (and should be avoided when possible), certain cases of rosacea may require chronic therapy, and tetracyclines most commonly are used. When minocycline is chosen as a chronic therapy, part of the treatment surveillance should include monitoring for drug-induced hyperpigmentation.

When drug-induced hyperpigmentation does occur, treatment involves discontinuing the offending agent. It can take years for pigment to develop and years for it to resolve—if it completely resolves at all.

In this case, the physician was concerned about the pigmentation worsening or spreading to other sites, so he discontinued the minocycline and prescribed a topical agent for the patient’s rosacea. Ultimately, the patient required occasional use of doxycycline for flares.

‌

Photos and text for Photo Rounds Friday courtesy of Jonathan Karnes, MD (copyright retained). Dr. Karnes is the medical director of MDFMR Dermatology Services, Augusta, ME.

The clinical findings and medical history were consistent with drug-induced hyperpigmentation and minocycline was the likely culprit. Other medications commonly implicated in drug-induced hyperpigmentation include heavy metals (eg, gold, iron, silver), anticonvulsants, hydroxychloroquine, and amiodarone.

Common sites for minocycline pigment deposition—besides the fingernails—include the gingiva, dorsal hands, shins, and old scars. The diagnosis of drug-induced hyperpigmentation is clinical and does not require a biopsy.

While the use of antibiotics for chronic disease can lead to antimicrobial resistance (and should be avoided when possible), certain cases of rosacea may require chronic therapy, and tetracyclines most commonly are used. When minocycline is chosen as a chronic therapy, part of the treatment surveillance should include monitoring for drug-induced hyperpigmentation.

When drug-induced hyperpigmentation does occur, treatment involves discontinuing the offending agent. It can take years for pigment to develop and years for it to resolve—if it completely resolves at all.

In this case, the physician was concerned about the pigmentation worsening or spreading to other sites, so he discontinued the minocycline and prescribed a topical agent for the patient’s rosacea. Ultimately, the patient required occasional use of doxycycline for flares.

‌

Photos and text for Photo Rounds Friday courtesy of Jonathan Karnes, MD (copyright retained). Dr. Karnes is the medical director of MDFMR Dermatology Services, Augusta, ME.

The clinical findings and medical history were consistent with drug-induced hyperpigmentation and minocycline was the likely culprit. Other medications commonly implicated in drug-induced hyperpigmentation include heavy metals (eg, gold, iron, silver), anticonvulsants, hydroxychloroquine, and amiodarone.

Common sites for minocycline pigment deposition—besides the fingernails—include the gingiva, dorsal hands, shins, and old scars. The diagnosis of drug-induced hyperpigmentation is clinical and does not require a biopsy.

While the use of antibiotics for chronic disease can lead to antimicrobial resistance (and should be avoided when possible), certain cases of rosacea may require chronic therapy, and tetracyclines most commonly are used. When minocycline is chosen as a chronic therapy, part of the treatment surveillance should include monitoring for drug-induced hyperpigmentation.

When drug-induced hyperpigmentation does occur, treatment involves discontinuing the offending agent. It can take years for pigment to develop and years for it to resolve—if it completely resolves at all.

In this case, the physician was concerned about the pigmentation worsening or spreading to other sites, so he discontinued the minocycline and prescribed a topical agent for the patient’s rosacea. Ultimately, the patient required occasional use of doxycycline for flares.

‌

Photos and text for Photo Rounds Friday courtesy of Jonathan Karnes, MD (copyright retained). Dr. Karnes is the medical director of MDFMR Dermatology Services, Augusta, ME.

An annular morphology was appreciated on close inspection and small pustules were seen at the edges—features consistent with tinea faciei, a fungal infection of facial skin. A skin exam did not reveal any scaling or erythema on the scalp, hands, feet, trunk, or nails. The diagnosis was confirmed during the visit with a skin scraping and examination in potassium hydroxide with parker pen blue ink (Swartz-Lamkins stain) which revealed hyphae. The diagnosis was made with the knowledge that a history of eczema increases the risk of fungal, viral, and bacterial infections due to an impaired skin barrier.

Tinea faciei is an uncommon diagnosis that often is misdiagnosed as facial dermatitis, rosacea, or acne. The differential diagnosis also includes discoid lupus and psoriasis. Rarely is the annular presentation as obvious as it was here. Diagnosing tinea faciei in a patient can be made more challenging if the patient is already being treated with steroids. That’s because the steroids may decrease the clinical signs of tinea and allow subtle, slow progression of disease.

The location of fungal disease has implications for treatment. While some cases of tinea faciei may respond to topical antifungals, involvement of the eyebrows and glandular structures of the mid-face are beyond the depth of penetration of topical formulations. In these cases, systemic antifungals such as terbinafine, griseofulvin, or itraconazole are more effective.

Because of eyebrow and glandular involvement, this patient was given oral terbinafine 250 mg/d for 3 weeks and the lesion cleared completely in that time.

‌

Photos and text for Photo Rounds Friday courtesy of Jonathan Karnes, MD (copyright retained). Dr. Karnes is the medical director of MDFMR Dermatology Services, Augusta, ME.

An annular morphology was appreciated on close inspection and small pustules were seen at the edges—features consistent with tinea faciei, a fungal infection of facial skin. A skin exam did not reveal any scaling or erythema on the scalp, hands, feet, trunk, or nails. The diagnosis was confirmed during the visit with a skin scraping and examination in potassium hydroxide with parker pen blue ink (Swartz-Lamkins stain) which revealed hyphae. The diagnosis was made with the knowledge that a history of eczema increases the risk of fungal, viral, and bacterial infections due to an impaired skin barrier.

Tinea faciei is an uncommon diagnosis that often is misdiagnosed as facial dermatitis, rosacea, or acne. The differential diagnosis also includes discoid lupus and psoriasis. Rarely is the annular presentation as obvious as it was here. Diagnosing tinea faciei in a patient can be made more challenging if the patient is already being treated with steroids. That’s because the steroids may decrease the clinical signs of tinea and allow subtle, slow progression of disease.

The location of fungal disease has implications for treatment. While some cases of tinea faciei may respond to topical antifungals, involvement of the eyebrows and glandular structures of the mid-face are beyond the depth of penetration of topical formulations. In these cases, systemic antifungals such as terbinafine, griseofulvin, or itraconazole are more effective.

Because of eyebrow and glandular involvement, this patient was given oral terbinafine 250 mg/d for 3 weeks and the lesion cleared completely in that time.

‌

Photos and text for Photo Rounds Friday courtesy of Jonathan Karnes, MD (copyright retained). Dr. Karnes is the medical director of MDFMR Dermatology Services, Augusta, ME.

An annular morphology was appreciated on close inspection and small pustules were seen at the edges—features consistent with tinea faciei, a fungal infection of facial skin. A skin exam did not reveal any scaling or erythema on the scalp, hands, feet, trunk, or nails. The diagnosis was confirmed during the visit with a skin scraping and examination in potassium hydroxide with parker pen blue ink (Swartz-Lamkins stain) which revealed hyphae. The diagnosis was made with the knowledge that a history of eczema increases the risk of fungal, viral, and bacterial infections due to an impaired skin barrier.

Tinea faciei is an uncommon diagnosis that often is misdiagnosed as facial dermatitis, rosacea, or acne. The differential diagnosis also includes discoid lupus and psoriasis. Rarely is the annular presentation as obvious as it was here. Diagnosing tinea faciei in a patient can be made more challenging if the patient is already being treated with steroids. That’s because the steroids may decrease the clinical signs of tinea and allow subtle, slow progression of disease.

The location of fungal disease has implications for treatment. While some cases of tinea faciei may respond to topical antifungals, involvement of the eyebrows and glandular structures of the mid-face are beyond the depth of penetration of topical formulations. In these cases, systemic antifungals such as terbinafine, griseofulvin, or itraconazole are more effective.

Because of eyebrow and glandular involvement, this patient was given oral terbinafine 250 mg/d for 3 weeks and the lesion cleared completely in that time.

‌

Photos and text for Photo Rounds Friday courtesy of Jonathan Karnes, MD (copyright retained). Dr. Karnes is the medical director of MDFMR Dermatology Services, Augusta, ME.

This lesion was diagnosed as an accessory tragus. Although sometimes called a preauricular skin tag, it is more aptly named accessory tragus since it arises embryonically along with the tragus from the first branchial arch. It usually is slightly anterior to the ear and can be seen unilaterally or bilaterally. The lesions usually feel firm to palpation due to an underlying cartilaginous component.

While this finding can be seen in congenital syndromes—most commonly oculoauriculovertebral syndrome (also known as Goldenhar syndrome)—it usually occurs in isolation. If there are no other abnormalities on exam to suggest a congenital syndrome, no additional work-up is necessary.

Concerns have been raised about a possible association with decreased hearing. Routine hearing screens are performed in the United States and this child’s screen was normal, so no further investigation for inner ear abnormalities was warranted.

These lesions usually are asymptomatic (unless traumatized). If removal is desired, it is important to remove the cartilaginous component, which can be deep and require additional dissection rather than simple transection at the base. Incomplete removal of the cartilage can cause chondritis, impede skin healing, and lead to infection.

‌

Photo and text courtesy of Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.

This lesion was diagnosed as an accessory tragus. Although sometimes called a preauricular skin tag, it is more aptly named accessory tragus since it arises embryonically along with the tragus from the first branchial arch. It usually is slightly anterior to the ear and can be seen unilaterally or bilaterally. The lesions usually feel firm to palpation due to an underlying cartilaginous component.

While this finding can be seen in congenital syndromes—most commonly oculoauriculovertebral syndrome (also known as Goldenhar syndrome)—it usually occurs in isolation. If there are no other abnormalities on exam to suggest a congenital syndrome, no additional work-up is necessary.

Concerns have been raised about a possible association with decreased hearing. Routine hearing screens are performed in the United States and this child’s screen was normal, so no further investigation for inner ear abnormalities was warranted.

These lesions usually are asymptomatic (unless traumatized). If removal is desired, it is important to remove the cartilaginous component, which can be deep and require additional dissection rather than simple transection at the base. Incomplete removal of the cartilage can cause chondritis, impede skin healing, and lead to infection.

‌

Photo and text courtesy of Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.

This lesion was diagnosed as an accessory tragus. Although sometimes called a preauricular skin tag, it is more aptly named accessory tragus since it arises embryonically along with the tragus from the first branchial arch. It usually is slightly anterior to the ear and can be seen unilaterally or bilaterally. The lesions usually feel firm to palpation due to an underlying cartilaginous component.

While this finding can be seen in congenital syndromes—most commonly oculoauriculovertebral syndrome (also known as Goldenhar syndrome)—it usually occurs in isolation. If there are no other abnormalities on exam to suggest a congenital syndrome, no additional work-up is necessary.

Concerns have been raised about a possible association with decreased hearing. Routine hearing screens are performed in the United States and this child’s screen was normal, so no further investigation for inner ear abnormalities was warranted.

These lesions usually are asymptomatic (unless traumatized). If removal is desired, it is important to remove the cartilaginous component, which can be deep and require additional dissection rather than simple transection at the base. Incomplete removal of the cartilage can cause chondritis, impede skin healing, and lead to infection.

‌

Photo and text courtesy of Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.

This patient’s circular ecchymotic patches were due to cupping. One of the clues that this was iatrogenic was the regular and repeated pattern on the skin.

Cupping is a centuries old treatment for pain relief (among other things) that involves applying glass globes or other hollow materials to the skin to create a vacuum. Traditionally, this vacuum is created by heating the air inside the vessel and then holding the vessel in place as the air cools. Practitioners may also use more modern instruments to induce the vacuum that are similar to those used to assist in vaginal deliveries. The mechanical devices leave these circular ecchymotic marks. The ecchymosis fades over time, and this procedure has been shown to significantly reduce myofascial neck and back pain in small trials.

It is important to recognize geometric patterns that are iatrogenic or due to abuse when evaluating skin findings. If skin findings do not follow dermatomal distributions, typical exanthem, or other classic patterns or presentations, there is the possibility that the pattern may be the result of neglect or abuse. On inspection, consider whether an odd pattern may have been caused from a belt buckle, striking instrument, furniture, medical equipment, or a hand strike.

This patient’s findings were consistent with his history of visiting a physical therapist for cupping. No treatment was required; the patient’s back pain from his car accident was improving, and the cupping marks were not troubling him.

‌

Photo and text courtesy of Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.

This patient’s circular ecchymotic patches were due to cupping. One of the clues that this was iatrogenic was the regular and repeated pattern on the skin.

Cupping is a centuries old treatment for pain relief (among other things) that involves applying glass globes or other hollow materials to the skin to create a vacuum. Traditionally, this vacuum is created by heating the air inside the vessel and then holding the vessel in place as the air cools. Practitioners may also use more modern instruments to induce the vacuum that are similar to those used to assist in vaginal deliveries. The mechanical devices leave these circular ecchymotic marks. The ecchymosis fades over time, and this procedure has been shown to significantly reduce myofascial neck and back pain in small trials.

It is important to recognize geometric patterns that are iatrogenic or due to abuse when evaluating skin findings. If skin findings do not follow dermatomal distributions, typical exanthem, or other classic patterns or presentations, there is the possibility that the pattern may be the result of neglect or abuse. On inspection, consider whether an odd pattern may have been caused from a belt buckle, striking instrument, furniture, medical equipment, or a hand strike.

This patient’s findings were consistent with his history of visiting a physical therapist for cupping. No treatment was required; the patient’s back pain from his car accident was improving, and the cupping marks were not troubling him.

‌

Photo and text courtesy of Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.

This patient’s circular ecchymotic patches were due to cupping. One of the clues that this was iatrogenic was the regular and repeated pattern on the skin.

Cupping is a centuries old treatment for pain relief (among other things) that involves applying glass globes or other hollow materials to the skin to create a vacuum. Traditionally, this vacuum is created by heating the air inside the vessel and then holding the vessel in place as the air cools. Practitioners may also use more modern instruments to induce the vacuum that are similar to those used to assist in vaginal deliveries. The mechanical devices leave these circular ecchymotic marks. The ecchymosis fades over time, and this procedure has been shown to significantly reduce myofascial neck and back pain in small trials.

It is important to recognize geometric patterns that are iatrogenic or due to abuse when evaluating skin findings. If skin findings do not follow dermatomal distributions, typical exanthem, or other classic patterns or presentations, there is the possibility that the pattern may be the result of neglect or abuse. On inspection, consider whether an odd pattern may have been caused from a belt buckle, striking instrument, furniture, medical equipment, or a hand strike.

This patient’s findings were consistent with his history of visiting a physical therapist for cupping. No treatment was required; the patient’s back pain from his car accident was improving, and the cupping marks were not troubling him.

‌

Photo and text courtesy of Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.

The presence of these sterile pustules with an erythematous base led to a diagnosis of acute generalized exanthematous pustulosis (AGEP), also known as a pustular drug eruption. Although pustules are present, AGEP is an allergic response to medications and not an infection.

AGEP can be associated with fever and leukocytosis. Interestingly, antibiotics are a frequent cause—not a treatment—since the pustules are sterile. It also is worth noting, in light of the COVID-19 pandemic, that hydroxychloroquine use has been linked to AGEP, although the number of cases cited in the literature is small.

Treatment is avoidance of the offending medication and symptomatic care. AGEP typically will resolve approximately 2 weeks after discontinuing the medication causing the reaction. Systemic steroids also may be used for treatment in severe cases.

This patient had a history of repeated episodes with his chemotherapy regimen, so he was treated symptomatically with diphenhydramine for the itching. Since chemotherapy was a priority to treat his colon cancer, avoidance of the offending agent was not an option. The Family Medicine Service recommended pretreatment with diphenhydramine 25 to 50 mg orally or intravenously for future rounds of chemotherapy to blunt future responses.

‌

Photo and text courtesy of Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.

The presence of these sterile pustules with an erythematous base led to a diagnosis of acute generalized exanthematous pustulosis (AGEP), also known as a pustular drug eruption. Although pustules are present, AGEP is an allergic response to medications and not an infection.

AGEP can be associated with fever and leukocytosis. Interestingly, antibiotics are a frequent cause—not a treatment—since the pustules are sterile. It also is worth noting, in light of the COVID-19 pandemic, that hydroxychloroquine use has been linked to AGEP, although the number of cases cited in the literature is small.

Treatment is avoidance of the offending medication and symptomatic care. AGEP typically will resolve approximately 2 weeks after discontinuing the medication causing the reaction. Systemic steroids also may be used for treatment in severe cases.

This patient had a history of repeated episodes with his chemotherapy regimen, so he was treated symptomatically with diphenhydramine for the itching. Since chemotherapy was a priority to treat his colon cancer, avoidance of the offending agent was not an option. The Family Medicine Service recommended pretreatment with diphenhydramine 25 to 50 mg orally or intravenously for future rounds of chemotherapy to blunt future responses.

‌

Photo and text courtesy of Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.

The presence of these sterile pustules with an erythematous base led to a diagnosis of acute generalized exanthematous pustulosis (AGEP), also known as a pustular drug eruption. Although pustules are present, AGEP is an allergic response to medications and not an infection.

AGEP can be associated with fever and leukocytosis. Interestingly, antibiotics are a frequent cause—not a treatment—since the pustules are sterile. It also is worth noting, in light of the COVID-19 pandemic, that hydroxychloroquine use has been linked to AGEP, although the number of cases cited in the literature is small.

Treatment is avoidance of the offending medication and symptomatic care. AGEP typically will resolve approximately 2 weeks after discontinuing the medication causing the reaction. Systemic steroids also may be used for treatment in severe cases.

This patient had a history of repeated episodes with his chemotherapy regimen, so he was treated symptomatically with diphenhydramine for the itching. Since chemotherapy was a priority to treat his colon cancer, avoidance of the offending agent was not an option. The Family Medicine Service recommended pretreatment with diphenhydramine 25 to 50 mg orally or intravenously for future rounds of chemotherapy to blunt future responses.

‌

Photo and text courtesy of Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.

A 38-year-old woman presented to the primary care clinic with a growing nodule on her head (FIGURE) of 4 to 6 months’ duration. The nodule was painless but was getting caught on her hairbrush.

Physical exam revealed a firm 8 × 10-mm lobulated pink nodule near the vertex of her scalp. It did not bleed with manipulation or appear friable. There were no other lesions on the scalp or the rest of her body. A shave excision was performed.

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

A benign hemangioma was suspected; however, given its unusually large size and uncharacteristic location, other entities such as amelanotic melanoma and lobular capillary hemangioma (pyogenic granuloma) needed to be ruled out. Pathology following a shave excision (with electrocautery) confirmed that this was a cherry hemangioma.

Consider biopsy to rule out malignancies in large scalp lesions.

Cherry hemangiomas, also known as senile hemangiomas or Campbell de Morgan spots, are a nearly ubiquitous benign vascular proliferation that increase in frequency and number with age.^1,2 They also have been associated with pregnancy and some chemical exposures.^3,4 In general, they are of no clinical consequence. Typically, they are 1- to 5-mm bright pink or bright to dark red papules located on the arms and trunk, a description that has persisted since at least 1947.¹ Scalp involvement is considered rare.⁵

Differential includes malignant entities

The large size of the lesion in addition to its unusual location on the scalp prompted consideration of a malignant entity despite many features of a benign process.

Amelanotic melanomas classically are described as flesh-colored, but up to 70% of amelanotic melanomas may actually be red. Red amelanotic melanomas may account for nearly 4% of all melanomas and frequently are underrecognized.⁶ Pathology ruled out melanoma for this patient.

Lobular capillary hemangiomas (also known as pyogenic granulomas) typically manifest as rapidly growing, painless, friable papules or nodules in young adults and adolescents. Cutaneous lobular capillary hemangiomas are most often located on the head and neck, nose, face, extremities, and upper trunk. These benign lesions may grow to several centimeters in diameter and are prone to bleeding and ulceration, which this patient notably did not have.⁷

Continue to: Treatment often isn't required

Most cherry hemangiomas are asymptomatic and small enough that they don’t catch on clothing or jewelry. For larger lesions, shave excision with or without electrocautery of the base may be performed. Curettage and laser therapy also have been used with success.⁵

The patient in this case had no recurrence or development of new cherry hemangiomas 2 years after her scalp lesion was removed.

CORRESPONDENCE
J. Lane Wilson, MD, East Carolina University Family Medicine, 101 Heart Drive, Greenville, NC 27834; [email protected]

A 38-year-old woman presented to the primary care clinic with a growing nodule on her head (FIGURE) of 4 to 6 months’ duration. The nodule was painless but was getting caught on her hairbrush.

Physical exam revealed a firm 8 × 10-mm lobulated pink nodule near the vertex of her scalp. It did not bleed with manipulation or appear friable. There were no other lesions on the scalp or the rest of her body. A shave excision was performed.

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

A benign hemangioma was suspected; however, given its unusually large size and uncharacteristic location, other entities such as amelanotic melanoma and lobular capillary hemangioma (pyogenic granuloma) needed to be ruled out. Pathology following a shave excision (with electrocautery) confirmed that this was a cherry hemangioma.

Consider biopsy to rule out malignancies in large scalp lesions.

Cherry hemangiomas, also known as senile hemangiomas or Campbell de Morgan spots, are a nearly ubiquitous benign vascular proliferation that increase in frequency and number with age.^1,2 They also have been associated with pregnancy and some chemical exposures.^3,4 In general, they are of no clinical consequence. Typically, they are 1- to 5-mm bright pink or bright to dark red papules located on the arms and trunk, a description that has persisted since at least 1947.¹ Scalp involvement is considered rare.⁵

Differential includes malignant entities

The large size of the lesion in addition to its unusual location on the scalp prompted consideration of a malignant entity despite many features of a benign process.

Amelanotic melanomas classically are described as flesh-colored, but up to 70% of amelanotic melanomas may actually be red. Red amelanotic melanomas may account for nearly 4% of all melanomas and frequently are underrecognized.⁶ Pathology ruled out melanoma for this patient.

Lobular capillary hemangiomas (also known as pyogenic granulomas) typically manifest as rapidly growing, painless, friable papules or nodules in young adults and adolescents. Cutaneous lobular capillary hemangiomas are most often located on the head and neck, nose, face, extremities, and upper trunk. These benign lesions may grow to several centimeters in diameter and are prone to bleeding and ulceration, which this patient notably did not have.⁷

Continue to: Treatment often isn't required

Most cherry hemangiomas are asymptomatic and small enough that they don’t catch on clothing or jewelry. For larger lesions, shave excision with or without electrocautery of the base may be performed. Curettage and laser therapy also have been used with success.⁵

The patient in this case had no recurrence or development of new cherry hemangiomas 2 years after her scalp lesion was removed.

CORRESPONDENCE
J. Lane Wilson, MD, East Carolina University Family Medicine, 101 Heart Drive, Greenville, NC 27834; [email protected]

A 38-year-old woman presented to the primary care clinic with a growing nodule on her head (FIGURE) of 4 to 6 months’ duration. The nodule was painless but was getting caught on her hairbrush.

Physical exam revealed a firm 8 × 10-mm lobulated pink nodule near the vertex of her scalp. It did not bleed with manipulation or appear friable. There were no other lesions on the scalp or the rest of her body. A shave excision was performed.

WHAT IS YOUR DIAGNOSIS?
HOW WOULD YOU TREAT THIS PATIENT?

A benign hemangioma was suspected; however, given its unusually large size and uncharacteristic location, other entities such as amelanotic melanoma and lobular capillary hemangioma (pyogenic granuloma) needed to be ruled out. Pathology following a shave excision (with electrocautery) confirmed that this was a cherry hemangioma.

Consider biopsy to rule out malignancies in large scalp lesions.

Cherry hemangiomas, also known as senile hemangiomas or Campbell de Morgan spots, are a nearly ubiquitous benign vascular proliferation that increase in frequency and number with age.^1,2 They also have been associated with pregnancy and some chemical exposures.^3,4 In general, they are of no clinical consequence. Typically, they are 1- to 5-mm bright pink or bright to dark red papules located on the arms and trunk, a description that has persisted since at least 1947.¹ Scalp involvement is considered rare.⁵

Differential includes malignant entities

The large size of the lesion in addition to its unusual location on the scalp prompted consideration of a malignant entity despite many features of a benign process.

Amelanotic melanomas classically are described as flesh-colored, but up to 70% of amelanotic melanomas may actually be red. Red amelanotic melanomas may account for nearly 4% of all melanomas and frequently are underrecognized.⁶ Pathology ruled out melanoma for this patient.

Lobular capillary hemangiomas (also known as pyogenic granulomas) typically manifest as rapidly growing, painless, friable papules or nodules in young adults and adolescents. Cutaneous lobular capillary hemangiomas are most often located on the head and neck, nose, face, extremities, and upper trunk. These benign lesions may grow to several centimeters in diameter and are prone to bleeding and ulceration, which this patient notably did not have.⁷

Continue to: Treatment often isn't required

Most cherry hemangiomas are asymptomatic and small enough that they don’t catch on clothing or jewelry. For larger lesions, shave excision with or without electrocautery of the base may be performed. Curettage and laser therapy also have been used with success.⁵

The patient in this case had no recurrence or development of new cherry hemangiomas 2 years after her scalp lesion was removed.

CORRESPONDENCE
J. Lane Wilson, MD, East Carolina University Family Medicine, 101 Heart Drive, Greenville, NC 27834; [email protected]

The patient was given a diagnosis of chondrodermatitis nodularis helicis (CNH), an inflammation of the cartilage and overlying skin causing a painful nodule of the helix. These lesions typically have a more prominent nodular component and a central ulceration or firm scale. They are thought to be due to chronic pressure on the ear.

There is a slight male predominance of CNH and onset is usually gradual. Patients often experience pain when sleeping on the affected side. The tenderness usually can be reproduced clinically by pressing on the lesion. The ears also are a high-risk area for actinic keratoses (AK) and nonmelanoma skin cancer (NMSC); if there is doubt about the diagnosis, a biopsy may be warranted to rule out AK or NMSC. In this patient, a shave biopsy was performed.

Various treatment regimens are available for CNH. The least invasive treatment approach is to use a “cut out” foam or a special donut-shaped pillow to protect the area from further pressure. By protecting from pressure and irritation, the lesion resolves in 57% to 92% of cases in clinical studies. Intralesional injection with 0.2 mL of 10 mg/mL triamcinolone acetonide is a simple in-office procedure that frequently helps the pain and may be curative; although, repeat injections may be necessary. Excision of the overlying skin and the affected cartilage is a more aggressive treatment with high success rates. More recently, treatment with topical nitroglycerin patches or photodynamic therapy have been described in small trials.

After confirming by a shave biopsy that the lesion was not cancerous, the patient returned for an elliptical excision of the lesion. A dermal curette was used to remove the rough abnormal inflammation of the underlying cartilage, and the elliptical wound was sutured with a linear closure.

‌

Photo and text courtesy of Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.

The patient was given a diagnosis of chondrodermatitis nodularis helicis (CNH), an inflammation of the cartilage and overlying skin causing a painful nodule of the helix. These lesions typically have a more prominent nodular component and a central ulceration or firm scale. They are thought to be due to chronic pressure on the ear.

There is a slight male predominance of CNH and onset is usually gradual. Patients often experience pain when sleeping on the affected side. The tenderness usually can be reproduced clinically by pressing on the lesion. The ears also are a high-risk area for actinic keratoses (AK) and nonmelanoma skin cancer (NMSC); if there is doubt about the diagnosis, a biopsy may be warranted to rule out AK or NMSC. In this patient, a shave biopsy was performed.

Various treatment regimens are available for CNH. The least invasive treatment approach is to use a “cut out” foam or a special donut-shaped pillow to protect the area from further pressure. By protecting from pressure and irritation, the lesion resolves in 57% to 92% of cases in clinical studies. Intralesional injection with 0.2 mL of 10 mg/mL triamcinolone acetonide is a simple in-office procedure that frequently helps the pain and may be curative; although, repeat injections may be necessary. Excision of the overlying skin and the affected cartilage is a more aggressive treatment with high success rates. More recently, treatment with topical nitroglycerin patches or photodynamic therapy have been described in small trials.

After confirming by a shave biopsy that the lesion was not cancerous, the patient returned for an elliptical excision of the lesion. A dermal curette was used to remove the rough abnormal inflammation of the underlying cartilage, and the elliptical wound was sutured with a linear closure.

‌

Photo and text courtesy of Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.

The patient was given a diagnosis of chondrodermatitis nodularis helicis (CNH), an inflammation of the cartilage and overlying skin causing a painful nodule of the helix. These lesions typically have a more prominent nodular component and a central ulceration or firm scale. They are thought to be due to chronic pressure on the ear.

There is a slight male predominance of CNH and onset is usually gradual. Patients often experience pain when sleeping on the affected side. The tenderness usually can be reproduced clinically by pressing on the lesion. The ears also are a high-risk area for actinic keratoses (AK) and nonmelanoma skin cancer (NMSC); if there is doubt about the diagnosis, a biopsy may be warranted to rule out AK or NMSC. In this patient, a shave biopsy was performed.

Various treatment regimens are available for CNH. The least invasive treatment approach is to use a “cut out” foam or a special donut-shaped pillow to protect the area from further pressure. By protecting from pressure and irritation, the lesion resolves in 57% to 92% of cases in clinical studies. Intralesional injection with 0.2 mL of 10 mg/mL triamcinolone acetonide is a simple in-office procedure that frequently helps the pain and may be curative; although, repeat injections may be necessary. Excision of the overlying skin and the affected cartilage is a more aggressive treatment with high success rates. More recently, treatment with topical nitroglycerin patches or photodynamic therapy have been described in small trials.

After confirming by a shave biopsy that the lesion was not cancerous, the patient returned for an elliptical excision of the lesion. A dermal curette was used to remove the rough abnormal inflammation of the underlying cartilage, and the elliptical wound was sutured with a linear closure.

‌

Photo and text courtesy of Daniel Stulberg, MD, FAAFP, Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque.

A diagnosis of guttate psoriasis was made based on the physical exam findings and the preceding group A beta-hemolytic streptococcal infection.

This condition affects approximately 2% of all patients with psoriasis; it is characterized by the acute onset of multiple erythematous and scaly papules and small plaques that look like droplets (“gutta”). It tends to affect children and young adults and typically occurs following an acute infection (eg, streptococcal pharyngitis). In this case, a rapid strep test was positive for group A Streptococcus, which supported the diagnosis.

The differential includes skin conditions such as pityriasis rosea, tinea corporis, and contact dermatitis.

The first-line treatment for streptococcal infection is amoxicillin (50 mg/kg/d [maximum: 1000 mg/d] orally for 10 d) or penicillin G benzathine (for children < 60 lb, 6 × 10⁵ units intramuscularly; children ≥ 60 lb, 1.2 × 10⁶ units intramuscularly). For the psoriasis lesions, treatment options include topical steroids, vitamin D derivatives, or combinations of both. In most cases, guttate psoriasis completely resolves. However, one-third of children with guttate psoriasis go on to develop plaque psoriasis later in life.

This patient was treated with penicillin G benzathine (1.2 × 106 units intramuscularly) and a calcipotriol/betamethasone combination gel. However, a less costly treatment is generic betamethasone (or triamcinolone) and/or generic calcipotriol (a vitamin D derivative). The streptococcal infection and skin lesions completely resolved. No adverse events were reported, and no relapse was observed after 3 months.

‌

This case was adapted from: Matos RS, Torres T. Rapid onset rash in child. J Fam Pract. 2018;67:E1-E2.

A diagnosis of guttate psoriasis was made based on the physical exam findings and the preceding group A beta-hemolytic streptococcal infection.

This condition affects approximately 2% of all patients with psoriasis; it is characterized by the acute onset of multiple erythematous and scaly papules and small plaques that look like droplets (“gutta”). It tends to affect children and young adults and typically occurs following an acute infection (eg, streptococcal pharyngitis). In this case, a rapid strep test was positive for group A Streptococcus, which supported the diagnosis.

The differential includes skin conditions such as pityriasis rosea, tinea corporis, and contact dermatitis.

The first-line treatment for streptococcal infection is amoxicillin (50 mg/kg/d [maximum: 1000 mg/d] orally for 10 d) or penicillin G benzathine (for children < 60 lb, 6 × 10⁵ units intramuscularly; children ≥ 60 lb, 1.2 × 10⁶ units intramuscularly). For the psoriasis lesions, treatment options include topical steroids, vitamin D derivatives, or combinations of both. In most cases, guttate psoriasis completely resolves. However, one-third of children with guttate psoriasis go on to develop plaque psoriasis later in life.

This patient was treated with penicillin G benzathine (1.2 × 106 units intramuscularly) and a calcipotriol/betamethasone combination gel. However, a less costly treatment is generic betamethasone (or triamcinolone) and/or generic calcipotriol (a vitamin D derivative). The streptococcal infection and skin lesions completely resolved. No adverse events were reported, and no relapse was observed after 3 months.

‌

This case was adapted from: Matos RS, Torres T. Rapid onset rash in child. J Fam Pract. 2018;67:E1-E2.

A diagnosis of guttate psoriasis was made based on the physical exam findings and the preceding group A beta-hemolytic streptococcal infection.

This condition affects approximately 2% of all patients with psoriasis; it is characterized by the acute onset of multiple erythematous and scaly papules and small plaques that look like droplets (“gutta”). It tends to affect children and young adults and typically occurs following an acute infection (eg, streptococcal pharyngitis). In this case, a rapid strep test was positive for group A Streptococcus, which supported the diagnosis.

The differential includes skin conditions such as pityriasis rosea, tinea corporis, and contact dermatitis.

The first-line treatment for streptococcal infection is amoxicillin (50 mg/kg/d [maximum: 1000 mg/d] orally for 10 d) or penicillin G benzathine (for children < 60 lb, 6 × 10⁵ units intramuscularly; children ≥ 60 lb, 1.2 × 10⁶ units intramuscularly). For the psoriasis lesions, treatment options include topical steroids, vitamin D derivatives, or combinations of both. In most cases, guttate psoriasis completely resolves. However, one-third of children with guttate psoriasis go on to develop plaque psoriasis later in life.

This patient was treated with penicillin G benzathine (1.2 × 106 units intramuscularly) and a calcipotriol/betamethasone combination gel. However, a less costly treatment is generic betamethasone (or triamcinolone) and/or generic calcipotriol (a vitamin D derivative). The streptococcal infection and skin lesions completely resolved. No adverse events were reported, and no relapse was observed after 3 months.

‌

This case was adapted from: Matos RS, Torres T. Rapid onset rash in child. J Fam Pract. 2018;67:E1-E2.