Focal Photodamage on the Occipital Scalp Within the Next Week

Letters

Acute Infection by Staphylococcus simulans contact with animals may be infected with S simulans of the in the Hand of a Man hands. Diagnosis and early treatment are important to pre- Staphylococcus simulans is a common animal pathogen that vent infection of vital organs. occasionally can colonize human skin. Fátima Tous Romero, MD Report of a Case | A man in his 60s with a history of hyperten- Carlota Gutiérrez García-Rodrigo, MD sion and diabetes mellitus, who worked as a butcher and Virginia Velasco Tamariz, MD occasional hunter and had contact with hares and rabbits, pre- Rafael Llamas Martín, MD sented with lesions on left hand evolving over 3 days. Ini- tially, vesiculobullous lesions appeared on the dorsal aspect Author Affiliations: Department of Dermatology, Hospital 12 de Octubre, Madrid, Spain. of his left hand and extended into the web space between the Corresponding Author: Fátima Tous Romero, MD, Avda de Córdoba s/n, CP first and second fingers (Figure, A). Within 2 days, the lesion 28041, Madrid, Spain ([email protected]). extended to the palm and ventral aspect of the thumb with an Published Online: May 4, 2016. doi:10.1001/jamadermatol.2016.0959. eroded area on which pustules appeared (Figure, B). No fever Conflict of Interest Disclosures: None reported. or other systemic symptoms were present. 1. Razonable RR, Lewallen DG, Patel R, Osmon DR. Vertebral osteomyelitis and Considering the acute onset of vesiculobullous and pus- prosthetic joint infection due to Staphylococcus simulans. Mayo Clin Proc. 2001; tular lesions of the hand in a patient in repeated contact with 76(10):1067-1070. animals, the differential diagnosis included bullous impetigo 2. Vallianou N, Evangelopoulos A, Makri P, et al. Vertebral osteomyelitis and and ringworm, which are more common in the general popu- native valve endocarditis due to Staphylococcus simulans: a case report. J Med Case Rep. 2008;2:183. lation, or erysipelas, an infection typically associated with un- cooked meat. 3. Désidéri-Vaillant C, Nédelec Y, Guichon JM, et al. Staphylococcus simulans osteitis in a diabetic patient. Diabetes Metab. 2011;37(6):560-562. A fungal culture was negative; the bacterial culture showed 4. Mallet M, Loiez C, Melliez H, Yazdanpanah Y, Senneville E, Lemaire X. S simulans. A biopsy specimen of the lesion was obtained for Staphylococcus simulans as an authentic pathogenic agent of osteoarticular polymerase chain reaction analysis for Erysipelothrix rhusio- infections. Infection. 2011;39(5):473-476. pathiae, but the findings were negative. Thus, the diagnosis was pyoderma with S simulans. The patient was treated with azithromycin, 500 mg/d, for 3 days, and the lesions resolved Focal Photodamage on the Occipital Scalp within the next week. Baseball caps are commonly worn in the United States, in part for photoprotection. Public health efforts to prevent skin Discussion | Staphylococcus simulans is a common animal patho- cancers recommend wide-brimmed hats over baseball caps gen that occasionally can colonize human skin. Human infec- owing to caps’ incomplete coverage for face, neck, and ears; tions with S simulans have rarely been reported, but they do however, to our knowledge, their relative efficacy for scalp occur in patients who have repeated contact with animals (eg, photoprotection has not been investigated. We report a case butchers and veterinarians). Most cases reported are cardiac of focal chronic photodamage and actinic keratoses on a pa- or osteoarticular infections.1-4 A few reports have associated tient’s alopecic scalp despite his adherence to baseball cap use S simulans with bacteremia, infectious endocarditis, postsur- for photoprotection. gical osteomyelitis, prosthetic joint infection, and urinary tract infection. Pyoderma by S simulans has been frequently de- Report of a Case | A 65-year-old white man with Fitzpatrick pho- scribed in animals but to our knowledge has not been re- totype 2 skin presented with a well-demarcated semicircular ported in humans. The clinical appearance is similar to bul- poikilodermatous patch on the occipital scalp and scattered lous impetigo. It is important to keep in mind that patients in erythematous gritty papules on the occiput (Figure 1) and the

Figure. Clinical Images of the Patient’s Affected Left Hand

A Initial presentation B Two days after initial presentation

A, Initially hemorrhagic bullous lesions appeared. B, The disease evolved over 2 days to include surface erosion with pustular lesions.

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Figure 1. Semicircular Poikilodermatous Patch and Erythematous Scaly Papules on the Occipital Scalp

A Clinical view B Inadequately sun-protective cap

A, Focal actinic damage and actinic keratoses on the occipital scalp. B, Snapback hat worn by patient with window of solar exposure.

frequently wearing baseball caps since age 20 years and noted Figure 2. Illustrations of Baseball Cap Style Variations tanning on his posterior scalp for years as his hair loss gradu-

A Fitted cap ally progressed. He was diagnosed with actinic keratoses, treated with cryotherapy, and extensively counseled on the use of wide- brimmed hats to reduce further sun exposure. Owing to personal stylistic preferences, he declined to wear wide- brimmed hats but agreed to daily application of sun protection factor (SPF) 30+ sunscreen onto sun-exposed skin.

Discussion | Frequent wearing of wide-brimmed hats and pho- B Snapback hat toprotective clothing is an important intervention to reduce solar UV exposure and skin cancer risks. Wide-brimmed hats provide photoprotection to the scalp as well as adjuvant protection, with SPF equivalents ranging from 2 to 10 to facial sites such as the nose, ears, and neck.1 Prior research has assessed the relative degree of sun protection between hat styles, including “jungle” hats, “deerstalker” hats, Legionnaires hats, bucket hats, berets, straw hats, baseball caps, and others.1,2 These studies showed that baseball caps failed to provide adequate photoprotection for the cheeks, chin, ears, and neck.1,2 Our case study C Trucker hat highlights the previously underappreciated UV exposure of the occipital scalp despite frequent wearing of baseball caps. Photoprotection offered by different baseball cap styles has not been well characterized. Style variations include fitted caps that completely cover the posterior scalp, “snapback” hats that include semicircular windows, and “trucker” hats that addi- tionally incorporate a net-like mesh posteriorly (Figure 2). The snapback, as worn by the present patient, and trucker styles provide inadequate solar coverage for the posterior scalp. A, Fitted cap (left) with complete scalp coverage (right). B, Snapback hat (left) with window of occipital exposure (right). C, Trucker hat (left) with mesh In addition, diminished terminal hair density on the ver- covering (right). tex and occipital scalp in this patient with androgenetic alopecia contributed to the focal development of actinic damage and actinic keratoses. The long-term photoprotective role of left nose, all of years’ duration. No similar lesions were found hair has been invoked by the sex differences in the topographi- in hair-bearing regions of the scalp. He had no personal or fam- cal patterns of melanomas and keratinocyte carcinomas.3,4 ily history of any skin cancers but reported extensive long- Higher incidence of skin cancers in the scalp, ears, and other term sun exposures while previously working as a ware- chronically sun-exposed areas of the head and neck in men house manager and numerous sunburns. He reported than in women has been hypothesized to be attributable to

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differences in hair coverage.3,5 The natural photoprotective ef- hands: prominent disease on her functional side with sparing fect offered by hair is quantitated as exponential to scalp hair of her immobilized side. Our observation provides clinical evi- density.5 Therefore, patients with alopecia should be coun- dence supporting the idea that external trauma, movement, seled on using additional sun protection by wearing hats with and stretch may be requisite for the genesis of certain skin complete coverage for the scalp; applying SPF 30+ sunscreen lesions in DM. lotion, spray or stick; or using handheld umbrellas to further minimize exposure to UV radiation. Report of a Case | A woman in her 60s presented for evaluation Since baseball caps remain a popular style among US adults, of a persistent pruritic eruption on her left hand. She had ex- the general public, particularly men at risk of developing an- perienced a stroke 2 years before, which left her with residual drogenetic alopecia, should be made aware of their shortcom- right-sided hemiparesis. Her medical history was otherwise ings in photoprotection and should be counseled to use addi- unremarkable. tional means to protect against skin cancer development, On examination, discrete hyperkeratotic, lichenoid, ery- especially on the scalp. thematous papules were present on her left proximal and dis- tal interphalangeal joints (Figure, A). Prominent nailfold cap- Howa Yeung, MD illary dilatation and dropout as well as cuticular dystrophy were Kevin Man-Hin Luk, BS also present on the left hand. Her right hand, by comparison, Suephy C. Chen, MD, MS was unaffected (Figure, B). The remainder of her examination demonstrated bilateral violet periorbital discoloration, dif- Author Affiliations: Department of Dermatology, Emory University School of fuse scalp erythema, and thinning of her scalp hair density. A Medicine, Atlanta, Georgia (Yeung, Luk, Chen); Division of Dermatology, Atlanta Veterans Affairs Medical Center, Decatur, Georgia (Chen). biopsy was performed on her left index finger, which showed Corresponding Author: Suephy Chen, MD, MS, Department of Dermatology, hyperkeratosis and interface dermatitis compatible with con- Emory University School of Medicine, 1525 Clifton Rd NE, Atlanta, GA 30322 nective tissue disease. Together, her clinical and histopatho- ([email protected]). logic findings were consistent with DM. Published Online: April 13, 2016. doi:10.1001/jamadermatol.2016.0733. Apart from residual right-sided weakness related to her Conflict of Interest Disclosures: Dr Chen has served as a consultant for stroke, she had no other strength deficits. Her serum muscle Astellas, investigator for Hoffman-Laroche and Celgene, and received royalties enzymes and pulmonary function tests were normal, and a for quality-of-life instruments from Novartis (for Scalpdex) and Foamix and Cutanea Life Sciences (for RosaQoL). No other disclosures are reported. comprehensive malignancy screening was negative. She was treated with hydroxychloroquine and methotrexate, and within Additional Contributions: We thank the patient for granting permission to publish this information. We also thank Kacie Baker, BS, for her illustrations. She 3 months had improvement of her left hand lesions as well as received no compensation for her contributions. her periorbital and scalp erythema. 1. Gies P, Javorniczky J, Roy C, Henderson S. Measurements of the UVR protection provided by hats used at school. Photochem Photobiol. 2006;82(3): Discussion | Recently, novel insights explaining the character- 750-754. istic localization of cutaneous DM have emerged. Specifi- 2. Diffey BL, Cheeseman J. Sun protection with hats. Br J Dermatol. 1992;127(1): cally, CD44v7, a cell adhesion molecule that plays a role in 10-12. autoimmunity, was found to be inducible by mechanical 3. Lesage C, Barbe C, Le Clainche A, Lesage FX, Bernard P, Grange F. Sex-related location of head and neck melanoma strongly argues for a major role of sun stretching and appears to act together with osteopontin, a pro- exposure in cars and photoprotection by hair. J Invest Dermatol. 2013;133(5): tein upregulated in DM skin, to produce Gottron papules.1 In- 1205-1211. creased osteopontin expression in response to mechanical 4. Youl PH, Janda M, Aitken JF, Del Mar CB, Whiteman DC, Baade PD. Body-site trauma has also been shown.2 These preclinical studies sug- distribution of skin cancer, pre-malignant and common benign pigmented gest that a key component to the expression of Gottron pap- lesions excised in general practice. Br J Dermatol. 2011;165(1):35-43. ules and possibly other DM skin lesions may relate to stretch and 5. de Gálvez MV, Aguilera J, Bernabó JL, Sánchez-Roldán C, Herrera-Ceballos E. Human hair as a natural sun protection agent: a quantitative study. Photochem mechanical trauma, thereby accounting for our patient’s uni- Photobiol. 2015;91(4):966-970. lateral presentation, as the lack of movement on her paralyzed limb prevented the development of cutaneous lesions. Unilateral Gottron Papules in a Patient Following Unilateral presentations of psoriasis have also been re- a Stroke: Clinical Insights Into the Disease ported in the setting of hemiparesis.3,4 The observed unilat- Mechanisms and Pathophysiology erality of these cases has been attributed to the absence of the of Cutaneous Dermatomyositis isomorphic response on the immobilized limb. Furthermore, Dermatomyositis (DM) is an autoimmune disorder with a char- neurogenic inflammation might contribute to the develop- acteristic pattern of skin and muscle disease. Preclinical stud- ment of psoriatic lesions, and after nerve injury has occurred, ies have implicated abnormal stretch receptor signaling and this inflammatory trigger is removed. Whether neurogenic external trauma as necessary components for the expression inflammation also plays a role in cutaneous DM remains of certain cutaneous manifestations.1,2 These studies corre- unknown. late with clinical findings, as DM preferentially affects UV- Our case report serves as a clinical example that substan- irradiated skin and frequently traumatized sites, such as over tiates the idea that stretch and movement may be key patho- bony prominences on the hands and elbows. We evaluated a genetic factors for the genesis of some cutaneous DM lesions. patient with residual hemiparesis from a stroke who devel- While classic Gottron papules were seen on our patient’s func- oped cutaneous DM with a strikingly unilateral pattern on the tional side, these lesions were remarkably absent on her

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