8 research outputs found

    A Robust Case of Allergic Contact Dermatitis to Propolis

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    Allergic contact dermatitis (ACD) occurs when an individual comes into cutaneous contact with a substance to which he or she has been sensitized to, causing a delayed-type hypersensitivity reaction. While the diagnosis may in some cases be easily suspected due to a classic history and exam, not all cases are obvious. Patch testing is an extremely useful process that allows for the diagnosis of ACD to be made while also identifying the specific chemical trigger. Present in beeswax and composed of a mixture of resins, waxes, oils, pollen, and various organic compounds, propolis is a well-known cause of ACD. Here we present the case of ACD to propolis in an unusual product and with impressive clinical findings. A 58 year-old woman of Native American descent with a history of Sjogren\u27s syndrome presented to Dermatology for a one year history of a painful and pruritic rash on her lips and face. She had temporary improvement with a previous course of prednisone followed by relapse upon tapering, but otherwise the rash had been worsening despite the use of high-potency topical steroids. She was also using bear grease and lip butter as moisturizers. On physical exam she had a well-demarcated symmetric perioral erythematous lichenified scaly plaque, as well as confluent erythema and scaling of her mucosal lips. After tinea incognito was ruled out by fungal culture, she subsequently underwent patch testing for suspected ACD. The diagnosis was confirmed with positive reactions at both the 2 day and 7 day reads to propolis and her bear grease and lip butter, both of which contained beeswax. The patient had complete resolution shortly after discontinuation of these products, and she was advised to avoid other products that contain propolis. With a soft and pliable texture and pleasant aroma, propolis is present in many creams, ointments, waxes, lipsticks, and balms. Moreover, with it\u27s reported anti-inflammatory and antimicrobial properties, it can also be found in various cosmeceutical, naturopathic, and homeopathic products. Made from bear fat and beeswax, the bear grease product the patient was using was advertised as having natural healing benefits and was purchased at a Native American craft store. This case is unique, as it represents a common allergen found in an uncommon vehicle. Moreover, it illustrates the importance of taking a comprehensive history when assessing for ACD, as well as the utility of patch testing.https://scholarlycommons.henryford.com/merf2020caserpt/1111/thumbnail.jp

    27426 A young man with an impressive ulcer on the chest

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    Diffuse large B cell lymphoma (DLBCL) is the most common type of non-Hodgkin lymphoma (NHL), and when cutaneous, may be limited to the skin or internal with metastasis to the skin. Morphologies of cutaneous metastases may be variable, and lymphomas most commonly present with pink-violet to red-brown papulonodules. Although less common, it is important to consider malignancy in the differential when evaluating an ulcer. Here we present the case of a 23-year-old morbidly obese Hispanic male who was hospitalized for inability to ambulate and was found to have nodal diffuse large B cell lymphoma, with full body imaging concerning for metastatic spread. Dermatology was consulted for a 3-month history of an ulcer on his chest, which was originally treated by the surgery team with debridement and antibiotics without improvement. On examination, he had a 8 × 7 × 5 cm ulcer over his left breast with a surrounding violaceous indurated plaque. Punch biopsy showed sheets of large atypical cells in the dermis with immunohistochemistry mirroring that of the lymph node biopsy (positive CD20 and BCL6, negative CD10, and MUM-1). As such, the ulcer was diagnosed as a cutaneous metastasis of nodal DLBCL, and he was started on chemotherapy with rituximab, doxorubicin, vincristine, and prednisone (R-CHOP) followed by radiation to the chest wound

    A Man with Multiple Ulcerated Papules on His Face: A Muir-Torre Story

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    HISTORY: A 61 year-old Caucasian man with a history of cardiac transplant in 2014 secondary to non-ischemic cardiomyopathy (on tacrolimus and mycophenolate), sebaceous adenomas, and sebaceous carcinomas presented for full body skin exam. His previous sebaceous carcinomas were on his right neck and right buttock, and were treated with wide local excision and Mohs micrographic surgery, respectively. He denied any specific lesions of concern since his last visit 3 months prior. EXAMINATION: On his right and left forehead, and on left cheek, there were three erythematous papules. The right forehead and left cheek lesions had central ulceration. On dermoscopy, a partial crown of vessels appearance was observed. He also had multiple scattered yellow umbilicated papules across his face. On his right neck and right buttock there were well-appearing scars. The remainder of his examination was unremarkable.HISTOPATHOLOGYThere are numerous hypercellular islands of sebocytes with mitotic figures extending from the epidermis into the dermis. COURSE AND THERAPY: The patient was referred to Mohs, where all three lesions were removed and left to heal by secondary intention. He continues to follow up for skin checks every 3 months. He has yearly upper and lower endoscopies; his most recent were normal in 10/2017. DISCUSSION: Muir-Torre syndrome (MTS) is a familial condition that is characterized by both cutaneous and visceral tumors, and is considered a subset of Lynch syndrome. It is inherited in an autosomal dominant pattern, and is caused by mutations in genes responsible for DNA mismatch repair (MLH1, MSH2, or MSH6). In the case of this patient, MLH1 immunostaining was negative on a previous biopsy.Sebaceous neoplasms, including sebaceous adenomas, sebaceous epitheliomas, and sebaceous carcinomas, are the most typical dermatologic manifestations of MTS. These often present as skin-colored to yellow papules or nodules on the head, neck, and trunk, with or without ulceration. Whereas sebaceous carcinomas are more common around the eye in sporadic cases, they are more likely to be extraocular when associated with MTS. Other potential skin findings of MTS include keratoacanthomas, Fordyce spots, and basal cell epitheliomas with sebaceous differentiation.Immunohistochemistry to stain for proteins corresponding to the aforementioned genes should be performed on all sebaceous neoplasms given their prevalence in patients with MTS and how uncommon they are in the general population. Pending the results of IHC, microsatellite instability and/or germline mutation analysis may be considered. Internal malignancies, most commonly colorectal and urogenital, are an important component of MTS. The family history of this patient includes colon cancer in his mother, maternal grandfather, and maternal uncle, as well as uterine cancer in a cousin. As the cutaneous findings often precede the visceral findings, it is important to diagnose MTS as early as possible to start early preventative cancer screening. As for treatment of the cutaneous neoplasms themselves, surgical removal is first-line. For sebaceous carcinoma specifically, wide local excision or Mohs micrographic surgery with consideration of radiation therapy is recommended. This particular patient had Mohs for all three carcinomas, but declined RT. In addition to routine clinician-performed full body skin examinations, Fotofinder total body mapping has recently been added to his monitoring regimen, demonstrating an exciting and novel application of this technology.https://scholarlycommons.henryford.com/merf2019caserpt/1018/thumbnail.jp

    32388 Demographic and socioeconomic factors drive disparate outcomes in mycosis fungoides

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    Background: Mycosis fungoides (MF) occurs more frequently in young Black patients, though debate persists as to whether this group is at uniformly increased risk of poorer outcomes. Recent studies have postulated that outcomes among Black patients are heterogeneous, though previous literature suggests that demographics may play a role in MF. Methods: Clinicopathologic, sociodemographic, and follow-up data were analyzed for patients with MF at Henry Ford Health Systems in Detroit, MI, over 19 years. Data were analyzed for factors predicting progression-free survival (PFS) via multivariable stepwise Cox proportional hazards regression models and Kaplan-Meier analysis of intersectional demographic groups based on age at diagnosis (\u3c40 or ≥40), race, and sex. Results: Of the 440 patients, a majority (52.7%) were male, and the most common race/ethnicity was White/Caucasian (50.2%), followed by Black/African American (40%). Medicaid insurance was an independent predictor of shortened PFS (HR 3.13, 95% CI 1.46-6.69) regardless of race, and young Black patients had the shortest PFS, with young Black female patients experiencing shorter PFS than their older Black female (P =.027) and younger Black male (P =.014) counterparts. Conclusions: This study provides the strongest evidence to date that demographic and socioeconomic factors should be a part of the prognostic picture in MF. Their predictive value is likely based on societal and additional health-related variables, such as access to care/medication, health literacy, and bias in a provider or health system. It is our hope that this analysis will spur continued discussion as to the cause and effect of such differences in MF outcomes
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