Clinical pearls in dermatology, 2016

Case 1

This patient has an itching scalp. He has tried ketoconazole shampoo 2%, but still has severe itching of the scalp.

Which of the following would be the best treatment?

• (A)

  Hydrocortisone cream 1%

• (B)

  Tacrolimus ointment 0.1%

• (C)

  Clobetasol or fluocinonide 0.05% ointment

• (D)

  Clobetasol or fluocinonide 0.05% foam

• (E)

  Triamcinolone 0.1% cream

Discussion

Seborrheic dermatitis is the most common cause of an itchy scalp. Other common causes include psoriasis and sebopsoriasis. Seborrheic dermatitis is thought to represent a hypersensitivity reaction to a fungus, Malassezia furfur.

It is best treated with topical corticosteroid preparations. Because the scalp is thick, one can apply a very strong/potent topical steroid to the scalp such as clobetasol or fluocinonide. Creams and ointments do not rub well into the scalp because of hair (although they

Clinical pearls

• (A)

  Most common cause of scalp itching is seborrheic dermatitis.

• (B)

  Use a potent topical corticosteroid daily in foam, solution, or spray form.

Reference

• 1.

  Kastarinen H, Oksanen T, Okokon EO, et al. Topical anti-inflammatory agents for seborrheic dermatitis of the face or scalp. Cochrane Database Syst Rev. 2016;5:CD009446. doi: 10.1002/14651858.CD009446.pub2. [PubMed PMID:24838779; in preparation].

Discussion

Angular cheilitis is a common clinical presentation. Patients present with cracked lips at the corners of their mouth. It is due to chaffing at the corners of the mouth, most commonly secondary to rubbing of the upper lip against the lower lip in this area and complicated by Candidiasis and may be exacerbated by dribbling or drooling. It is simply treated with a combination of a topical antifungal (such as ketoconazole cream) and a mild topical corticosteroid (1% hydrocortisone cream available

Clinical pearls

• (A)

  Angular cheilitis is a common clinical presentation with red, fissured skin at the corners of the mouth.

• (B)

  It is easily treated with topical antifungals and mild topical corticosteroids.

References

• 1.

  Park KK, Brodell RT, Helms SE. Angular cheilitis, Part 1: local etiologies. Cutis. 2016;87(6):289–295 [PubMed PMID: 21838086; in preparation].

• 2.

  Park KK, Brodell RT, Helms SE. Angular cheilitis, Part 2: nutritional, systemic, and drug-related causes and treatment. Cutis. 2016;88(1):27–32 [PubMed PMID: 21877503; in preparation].

Case 3

This young man has fallen off his skateboard.

Which of the following do you suggest in addition to daily cleansing with soap and water?

• (A)

  Topical neomycin

• (B)

  Topical mupirocin

• (C)

  Topical gentamycin

• (D)

  Topical bacitracin

• (E)

  Petroleum jelly

Discussion

This patient has skin abrasions on the side of his face. It will heal up well, but it is important to give appropriate wound care to prevent an infection such as cellulitis supervening. Soap and water, and petroleum jelly (e.g., vaseline) applied daily will be sufficient wound care.

Topical antibiotics such as neomycin, gentamycin, mupirocin, and bacitracin should be avoided, not only because of the development of resistant organisms, but also because the rate of allergic contact dermatitis of

Clinical pearl

Do not routinely use topical antibiotics on a wound.

References

• 1.

  Sood A, Taylor JS. Bacitracin: allergen of the year. Am J Contact Dermat. 2003;14(1):3–4.

• 2.

  Sasseville D. Neomycin. Dermatitis. 2010;21(1):3–7 [PubMed PMID: 20137735].

• 3.

  Levender MM, Davis SA, Kwatra SG, Williford PM, Feldman SR. Use of topical antibiotics as prophylaxis in clean dermatologic procedures. J Am Acad Dermatol. 2012;66(3):445–51. doi: 10.1016/j.jaad.2011.02.005. [Epub August 6, 2011; PubMed PMID: 21821310].

Case 4

This patient presents with a leg ulcer.

What of the following is the best type of dressing for this patient’s leg ulcer?

• (A)

  Gauze

• (B)

  Hydrocolloids

• (C)

  Hydrogels

• (D)

  Collagen

• (E)

  Alginates

Discussion

This patient has a venous ulcer. It is slightly dry. It would be appropriate to use something moisturizing such as a hydrogel to this after cleansing it with soap and water daily.

A hydrocolloid should be avoided, since the edges of this ulceration appear friable (a hydrocolloid adheres to the edge of an ulceration: the friable edges of this ulceration have the potential to break down when the adhesive is pulled off).

Ideal wound healing environment is considered to be “moist”—neither too wet nor

Clinical pearls

• (A)

  There are many causes of skin ulcerations. It is important to treat these underlying causes. Venous ulcerations should be compressed.

• (B)

  For management of wounds, it is important to keep the wounds clean with soap and water or debridement, and keep the wounds moist—for dry wounds, use hydrating wound dressings, for wet wounds, use alginates or foams.

References

• 1.

  Palfreyman SJ, Nelson EA, Lochiel R, Michaels JA. Dressings for healing venous leg ulcers. Cochrane Database Syst Rev. 2006;(3)6:CD001103.

• 2.

  Jull AB, Arroll B, Parag V, Waters J. Pentoxifylline for treating venous leg ulcers. Cochrane Database Syst Rev. 2012;12:CD001733. doi:10.1002/14651858.CD001733.pub3. [PubMed PMID: 23235582; in preparation].

Case 5

This elderly patient is being transferred from her hospital in Hawaii for further management of her multiple comorbidities.

What is the best management of her observed ulcers?

• (A)

  Topical neomycin gel

• (B)

  Vaseline

• (C)

  Oral acyclovir

• (D)

  Duoderm

• (E)

  Pressure relief

Discussion

The patient has grouped ulcerations with an erythematous base. A swab confirmed herpes simplex type 2. Grouped ulcerations raise the possibility of herpes simplex. Herpes simplex type 2 most commonly affects the genitalia, but may also affect the buttocks; viral shedding from the genital tract has been demonstrated to be active in about 20% of individuals during an outbreak involving buttocks and patients should be cautioned about this.

On the buttocks, pressure ulcerations would be a common

Clinical pearl

HSV is often seen on the buttocks; therefore, ulcerations should be swabbed for HSV and if positive, treated appropriately.

Reference

• 1.

  Kerkering K, Gardella C, Selke S, Krantz E, Corey L, Wald A. Isolation of herpes simplex virus from the genital tract during symptomatic recurrence on the buttocks. Obstet Gynecol. 2006;108(4):947–52 [PubMed PMID: 17012458].

Case 6

The patient presents with an itching rash with painful cracks (fissures) involving the palms and fingers.

Which of the following would you advise?

• (A)

  Oral prednisone 40 mg daily

• (B)

  Clobetasol ointment topical BID

• (C)

  Cephalexin 500 mg QID orally × 10 days

• (D)

  Tacrolimus ointment BID

• (E)

  Vaseline.

Discussion

This patient has hand dermatitis. Hand dermatitis can be exceptionally hard to treat. Principles of management of hand dermatitis involve the aggressive use of moisturizers to the hands as well as potent topical corticosteroids (hand skin is tough and thick, especially on the palms, and can tolerate higher potency topical steroids at least for a few weeks).

One common regimen that I suggest twice daily.

• (A)

  Liquid glue to any cracks/fissures on the skin (liquid glue or super glue).

• (B)

  A high-potency

Clinical pearls

• (1)

  Hand Dermatitis (eczema) is common.

• (2)

  Intensive topical treatments will help.

• (A)

  Glues for cracks (fissures)!

• (B)

  Potent corticosteroid ointments.

• (C)

  Constant moisturizers.

• (D)

  The adequate use of moisturizers is key to controlling hand dermatitis.

Reference

• 1.

  Warshaw E, Lee G, Storrs FJ. Hand dermatitis: a review of clinical features,therapeutic options, and long-term outcomes. Am J Contact Dermat. 2003;14(3):119–137 [PubMed PMID: 14744403; in preparation].

Case 7

A patient presents with a 1-year history of intermittently painful feet and legs. The pain is associated with marked flushing of the legs: they are bright red and hot to touch during episodes of pain.

Which tests are most likely to be abnormal?

• (A)

  Complete blood count

• (B)

  Hemoglobin A1c

• (C)

  Neurologic evaluation (EMG and tests of small fiber neuropathy)

• (D)

  Skin biopsy

• (E)

  Alpha galactosidase A level

Discussion

The patient has erythromelalgia (intermittent red, hot, and painful feet). This is an underrecognized syndrome, and many patients self-diagnose. When you see the patient in the office, they may have no clinical signs, since this is intermittent, and when they come to a doctor, the feet may look normal.

Although myeloproliferative disease may underlie erythromelalgia, this only occurs in a minority of patients (5–10%). It is increasingly being recognized that either a large (40–50%) or small

Clinical pearl

Erythromelalgia is often underrecognized by physicians. When a patient tells you they get intermittently or constantly red, hot feet or hands, think of this diagnosis. While a CBC should be checked for underlying myeloproliferative disease, neuropathy (small and/or large fiber) is most common comorbidity in patients with erythromelalgia.

References

• 1.

  Davis MD, Sandroni P, Rooke TW, Low PA. Erythromelalgia: vasculopathy, neuropathy, or both? A prospective study of vascular and neurophysiologic studies in erythromelalgia. Arch Dermatol. 2003;139(10):1337–1343 [PubMed PMID:14568838].

• 2.

  Davis MD, O’Fallon WM, Rogers RS 3rd, Rooke TW. Natural history of erythromelalgia: presentation and outcome in 168 patients. Arch Dermatol. 2000;136(3):330–336 [PubMed PMID: 10724194].

Case 8

A 22-year-old male developed leg ulcer associated with a rash. Intensive wound care has been initiated.

Which of the following would you recommend in addition?

• (A)

  Observation

• (B)

  Topical corticosteroids

• (C)

  Systemic corticosteroids

• (D)

  ACE wraps

• (E)

  Surgical consultation for possible revascularization procedure

Discussion

This patient has a small-vessel vasculitis. Because he has progressive vasculitis (not onlyhas he developed papular purpura but it is advancing, and he has ulceration of the foot), it is appropriate to treat this with systemic corticosteroids. Generally prednisone in a dose of approximately 0.5 mg/kg per day is sufficient. Alternatives are dapsone and colchicine. If the vasculitis is mild and nonprogressive and the cause is known, observation alone may be reasonable.

Diagnosis of small-vessel

Clinical pearls

• 1.

  Vasculitis can cause skin ulcerations.

• 2.

  If it is progressive and severe, consider treatment with prednisone.

• 3.

  Infections and drugs are the most common underlying cause of small-vessel vasculitis;connective tissue diseases and other causes are less common.

Reference

• Kinney MA Jorizzo JL. Small-vessel vasculitis. Dermatol Ther. 2012;25(2):148–57. doi: 10.1111/j.1529-8019.2012.01535.x [PubMed PMID:22741934].