Saving Face: 7 Frontal Dermatosis Cases

September 7, 2016

Get an upfront view of irritating dermatologic conditions that often occur on and around the face.

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A 28-year-old woman had hyperpigmented macules on the lower lip vermilion (left) and on the inner lower lip mucosa (right). A grandmother and 1 of 2 sisters had similar lip macules. Because there was a family history of colon cancer and a history of colon polyps, she had a colonoscopy 9 months earlier that revealed 9 hamartomatous polyps, which were removed.

The patient had Peutz-Jeghers syndrome (PJS), an autosomal dominant genetic disorder that consists of benign GI hamartomatous polyps and melanotic macules, first on the lips and oral mucosa and later on the hands and feet (palms and soles). Incidence is about 1 in 25,000 to 300,000 births.

Diagnosis of PJS is by family history and typical physical findings. Molecular genetic testing is available. Bowel obstruction resulting from intussusception occurs initially between ages 6 and 18 years.

The differential diagnosis includes Addison disease, McCune-Albright syndrome, Cowden disease, juvenile polyposis syndrome, Cronkhite-Canada syndrome, mucosal prolapse/cloacogenic polyp, gastric hyperplastic polyp, and adenocarcinoma.

Patients with PJS are at increased risk for cancer of the pancreas, liver, lungs, breast, ovaries, uterus, testicles, and other organs. Because of the significant increase in cancer incidence, some authors suggest increased cancer testing, beginning at an earlier age and done at shorter intervals.

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A 36-year-old woman’s left cheek shows a dark-brown pigmented filiform lesion that had been present for years and occasionally became irritated by the bottom rim of her eyeglasses. The pathologic diagnosis was verruca (wart).

Filiform (digitate) warts are benign and most often occur on the face. The differential diagnosis includes basal cell carcinoma and melanoma.

The filiform type of warts are the easiest to treat by curette and can be done without local anesthesia, which can be an advantage in children. Alternatives are excision and electrocautery destruction.

The lesion was removed in the office under local anesthesia by iris scissors excision at its base. Monsel solution was applied for hemostasis, and topical antibiotic ointment was applied twice daily. Healing was without complication.

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A 19-month-old boy has a yellow papule at the upper chin. His mother states that the papule had been present since he was 4 or 5 months old, was very firm to touch, and had enlarged with age.

The pathologic diagnosis was subepidermal calcified nodule. This form of calcinosis cutis usually occurs as a solitary lesion on the head or extremities of infants and young children and, less frequently, on the upper extremities in adults. The cause is unknown, and the lesion is benign with no association.

The differential diagnosis includes infantile acne and bacterial pustule.

The nodule was excised with iris scissors, and the base was lightly electrodesiccated in the office with the patient under local anesthesia. Mupirocin ointment was applied topically, and healing was uneventful.

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A 27-year-old woman’s right eye shows mild bulbar and palpebral conjunctival injection with slight “cobblestoning” of the lower palpebral conjunctiva. She had lacrimation of the right eye with upper eyelid swelling for 1 or 2 days, followed by occlusion of the eyelids with dried yellow crusting.

The patient was treated with ciprofloxacin ophthalmic drops after hot compresses. Culture and sensitivities of the right eye grew MRSA-resistant to ciprofloxacin but sensitive to sulfa, among other antibiotics.

With no response after several days, treatment was changed from ciprofloxacin to sulfacetamide 10% ophthalmic drops. Later, sulfacetamide 10% ophthalmic ointment every 4 hours was added.

In the interim, the patient’s left eye also became reddened, probably from finger rubbing of both eyes. Her course also included 4 trips to the emergency department and 2 or 3 trips to an ophthalmologist. After more than 2 weeks of treatment, the patient made significant progress toward resolution.

This case demonstrates how what appears to be a simple minor conjunctivitis can have a prolonged course (maybe complicated by noncompliance?). Glad I had the culture and sensitivity at the beginning.

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A lesion in a 62-year-old man’s left postauricular area is 1.5 cm in longest diameter and skin colored with a partially raised rim that contains 2 brown papules. The lesion had been present for about 2 years and occasionally became irritated and reddened, probably from his rubbing.

The pathologic diagnosis was basal cell carcinoma completely excised. The brown pigmented papules may have resulted from previous inflammations. The differential diagnosis includes squamous cell carcinoma and melanoma.

The lesion was excised with elliptical incisions in the office with the patient under local anesthesia. Skin edges were approximated with 4-0 simple sutures and healed without complication.

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A 5-month-old girl’s left ear has a red dome-shaped lesion between the helix and antihelix. After onset at 1 or 2 weeks post birth, the lesion gradually enlarged and was asymptomatic. She is seeing a dermatologist for laser treatment.

The girl has an infantile hemangioma. Diagnosis is made by the history and clinical appearance. These congenital vascular lesions may be confused with and should be differentiated from congenital vascular malformations, which are different lesions and have different courses and treatment considerations. The differential diagnosis also includes acquired hemangioma.

If treatment of an infantile hemangioma is deemed desirable because of the location or size of the lesion, options include timolol gel, topical and oral propranolol, topical and oral corticosteroids, lasers, topical imiquimod, interferon alpha-2b, cryotherapy, electrodesiccation, and surgical removal.

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A 65-year-old Caucasian woman’s hands have varying areas of depigmentation. Similar areas were present over both axillae and her vulva. The depigmentation began when she was in her 40s and has remained asymptomatic.

This is classic vitiligo, which can affect the face, mouth, hair, eyes, and any part of the body.

The differential diagnosis includes chemical leukodermas, skin infections, genetic syndromes, postinflammatory hypopigmentation, pityriasis alba, tuberous sclerosis, nevus anemicus, and idiopathic guttate hypomelanosis.

Treatments include topical corticosteroids, topical calcineurin inhibitors, vitamin D analgesics, narrowband ultraviolet B light, monochromatic excimer laser, photo chemotherapy, topical psoralens, grafting and transplantation, systemic corticosteroids, camouflage, and depigmentation of remaining normal skin.

The patient certainly would prefer to have her normal pigmentation. She began treatment with a topical corticosteroid and was advised to stay outdoors in sunshine.