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Proliferating Papules on Abdomen Test your knowledge with multiple-choiceDERM cases C This month – 6 cases: ASE 1.Proliferating Papules on Abdomen 2.Yellowish Discolouration of Toenails 3.Asymptomatic Lip Papule p.23 Small Lumps on the Lower Eyelids p.24 4. AReddish,GrowingMass p.25 5. 6.AWomanwithBackHair p.26 Copyright© p.27 Case 1 p.28 Not for Sale or Commercial Distribution Unauthorised use prohibited. Authorised users can download, Proliferatingdisplay, view a Papulesnd print a single co onpy for Abdomenpersonal use A3-year-oldmalepresentswithproliferatingpapules on his abdomen. They are mildly pruritic. He has been feeling unwell recently. What is your diagnosis? a. Molluscum contagiosum b. Common warts c. Pemphigus vulgaris d. Xanthogranulomas e. Xanthomas Answer Molluscum contagiosum MCV-1 poxvirus, and it most(answer commonly a) affects young children, but it also affects sexuallyis active caused by the adults and immunosuppressed individuals (especially those with HIV). Lesions in adults are typically found in the groin and genital region. Individual lesions are smooth, firm, dome-shaped, are key, and treatment is not always necessary since skin-coloured papules measuring 2 to 5 mm, some of this is a self-resolving condition. If lesions are wide- which will show evidence of umbilication.There may spread and therapy is requested, treatment options be adjacent eczema in some cases, and secondary include liquid nitrogen cryotherapy (older children bacterial infection of excoriated molluscum papules and adults), cantharidin application, curettage, sali- may also be present. cylic acid, topical tretinoin, imiquimod cream, or oral It is a clinical diagnosis, although, occasionally a cimetidine. skin biopsy is required. Education and reassurance Benjamin Barankin, MD, FRCPC, is a Dermatologist practicing in Toronto, Ontario. The Canadian Journal of CME / February 2012 23 DERMCASE Case 2 Yellowish Discolouration of Toenails A 52-year-old male presents with long standing change in texture and yellowish discolouration of his toenails. What is your diagnosis? a. Onychogryphosis b. Psoriasis c. Onychomycosis Terbinafine is a more effective treatment with fewer Answer side effects as compared to other oral antifungals. Onychomycosis (answer c) is a nail infection caused Itraconazole is effective treatment for nondermatophyte by fungus. Dermatophytes are the main causes of toe- mold and yeast onychomycosis. Other agents include nail onychomycosis. Prevalence varies from 4 to 18%. griseofulvin and fluconazole. Diagnosis is clinical. A potasium hydroxide (KOH) Cherinet Seid, MD, LMCC, CCFP, DTM (RCPS Glas), is the Lead Physician with the North Renfrew Family Health preparation of scrapings from the nail bed to demon- Team,DeepRiver,Ontario.HeisalsoanEmergency strate hyphae and arthrospores can also be used. Fungal PhysicianatDeepRiverandDistrictHospitalandan culture can be done in KOH negative cases. Assistant Professor at the Northern Ontario School of Medicine, Sudbury, Ontario. Topical therapies are generally ineffective. Thus oral antifungal agents are the mainstay of treatment. Craig O’Brien, RN (EC), is a Nurse Practitioner with the NorthRenfrewFamilyHealthTeam,DeepRiver,Ontario. IN SCALP PSORIASIS, What could LuxiqTM Foam do for your patients? LUXIQ™ Foam is a medium potency Pediatric patients may be topical corticosteroid indicated for the relief of the more susceptible to systemic toxicity infl ammatory and pruritic manifestations of moderate to severe from equivalent doses because of their larger skin psoriasis of the scalp for up to 4 weeks in adult patients. surface to body mass ratios. Safety and effectiveness of LUXIQ™ Foam in pediatric patients <18 years of age have not been LUXIQ™ Foam is contraindicated in patients who are hypersensitive to this drug or to any established. Use in pediatric patients is not recommended. ingredient in the formulation or component of the container; patients who are hypersensitive to other corticosteroids; patients with viral (e.g. herpes or varicella) lesions of the skin, Topical corticosteroids should be used with caution in psoriasis as rebound relapses, bacterial or fungal skin infections, parasitic infections, skin manifestations relating to development of tolerances, risk of generalised pustular psoriasis and development of local tuberculosis or syphilis, eruptions following vaccinations, treatment or rosacea or perioral or systemic toxicity due to impaired barrier function of the skin have been reported in some dermatitis and in topical application to the eye. cases. When used in psoriasis careful patient supervision is important. Local hypersensitivity reactions may resemble symptoms of the condition under treatment. LUXIQ™ Foam should not be used under occlusion due to increased risk of systemic If hypersensitivity reactions occur, the drug should be discontinued and appropriate therapy exposure and infection. When used under occlusive dressing, over extensive areas or on initiated if there are signs of reaction. the face, scalp, axillae or scrotum, suffi cient absorption may occur to result in adrenal Prolonged use of topical corticosteroid preparations may produce striae or atrophy of the suppression and other systemic effects. skin or subcutaneous tissue. If skin atrophy is observed, treatment should be discontinued. Systemic absorption of topical corticosteroids has produced reversible hypothalamic- In case of systemic absorption in patients with renal or hepatic impairment, metabolism pituitary adrenal (HPA) axis suppression, manifestations of Cushing’s syndrome, and elimination may be delayed leading to increased risk of systemic toxicity; therefore, hyperglycemia, and glucosuria in some patients. minimum quantity should be used for the minimum duration. DERMCASE Case 3 Asymptomatic Lip Papule A 52-year-old male developed an asymptomatic papule on his lower lip. He doesn’t recall any preceding trau- ma. He does not drink nor smoke and is otherwise healthy with a stable weight. What is your diagnosis? a. Milia cyst b. Pilar cyst c. Basal cell carcinoma unchanged for many years. It appears to be in response d. Dermatofibroma to irritation or injury. The overlying tissue is normal in e. Mucosal fibroma colour and appearance. These lesions can occur on the lip and common- Answer ly on the buccal mucosa along the biting line. These A mucosal fibroma (answer e), the most common benign lesions can be ignored or surgically excised. benign tumour of the oral cavity, is an overgrowth of Recurrence after excision is rare. fibrous connective tissue. It is a firm, pink nodule, typ- Benjamin Barankin, MD, FRCPC, is a Dermatologist ically less than 1 cm in size. They can remain practicing in Toronto, Ontario. THE ONLY FOAM CORTICOSTEROID INDICATED FOR MODERATE-TO-SEVERE SCALP PSORIASIS* A medium potency† corticosteroid (betamethasone valerate) delivered in a novel foam format1* NEW Demonstrated effi cacy Significantly more LUXIQTM Foam patients were rated as “completely clear” or “almost clear” by Investigator’s Global Assessment score versus betamethasone valerate lotion and vehicle foam at 4 weeks1‡ p<0.0001 for LUXIQTM vs vehicle foam and p=0.0202 vs BMV lotion (0.12%) Vehicle Foam 19% n=32 BMV Lotion 46% n=63 TM LUXIQ Foam 67% n=64 %ofpatients Adapted from Product Monograph1 BMV = betamethasone valerate The most common adverse reactions reported in clinical trials with LUXIQ™ Foam were local skin reactions (burning, stinging, itching) and included mild to moderate: pruritus (2%), psoriasis (2%), acne (2%), and alopecia (2%). TM Used under license by GlaxoSmithKline Inc., Stiefel, a GSK company, Mississauga (Ontario) L5N 6L4 * Comparative clinical signifi cance has not been established. VERSAFOAM® is a registered trademark of Stiefel †Clinical signifi cance has not been established. Laboratories Inc., used under licence by GlaxoSmith- ‡ Improvements were rated using an Investigator’s Global Assessment (ISGA) score for the target Kline Inc. lesion at day 29 of clear or almost clear of disease using a 7 point score. ©2012 84823 6HH SUHVFULELQJ VXPPDU\ DQG VWXG\ SDUDPHWHUV RQ SDJH 41 DERMCASE Case 4 Small Lumps on the Lower Eyelids A69-year-oldwomancomplainedaboutsmalllumps thathavebeendevelopingslowlyonherlowerlids over the past 15 years. On examination, numerous 2 to 3 mm, translucent papules were present on both of her lower eyelids. What is your diagnosis? a. Syringioma b. Xanthelasma palpebrarum c. Hidrocystoma d. Adenoma sebaceum Answer The patient has Hidrocystomas (answer c). Eccrine hidrocystomas more commonly occur as multiple hidrocytomas are associated with Schöpf-Schulz- lesions and are thought to result from blockage of Passarge syndrome, a rare autosomal recessive syn- the sweat duct apparatus. They are closly related to dromeinwhichectodermaldysplasiaoccurs. apocrine hidrocystomas, which are also known as Schopf-Schulz-Passarge syndrome often features apocrine cystadenomas and apocrine retention palmoplantar hyperkeratosis, hypodontia, nail dys- cysts. trophy,andhypotrichosis.Anassociationofmulti- Apocrine hidrocystomas are benign cystic prolif- ple apocrine hidrocystomas with a peculiar form of erations of the apocrine secretory glands. Apocrine focaldermalhypoplasiaalsohasbeenreported. hidrocystomas most commonly appear as solitary, Additional therapies to consider are those used soft, dome-shaped, translucent papules or nodules, for multiple eccrine hidrocystomas, which include and most frequently are located on the eyelids, espe- botulinum toxin, atropine, pulsed-dye laser, and, cially the inner
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