DERMCASE. Proliferating Papules on Abdomen. Case 1. 4.Small Lumps on the Lower Eyelids p.26 5.A Reddish,GrowingMass p.27 6.A WomanwithBackHair p.

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1 Test your knowledge with multiple-choice cases This month 6 cases: 1.Proliferating Papules on Abdomen p.23 2.Yellowish Discolouration of Toenails p.24 3.Asymptomatic Lip Papule p.25 Case 1 Copyright 4.Small Lumps on the Lower Eyelids p.26 5.A Reddish,GrowingMass p.27 6.A WomanwithBackHair p.28 Not for Sale or Commercial Distribution Unauthorised use prohibited. Authorised users can download, display, view and print a single copy for personal use Proliferating Papules on Abdomen A3-year-oldmalepresentswithproliferatingpapules on his abdomen. They are mildly pruritic. He has been feeling unwell recently. a. Molluscum contagiosum b. Common warts c. Pemphigus vulgaris d. Xanthogranulomas e. Xanthomas Molluscum contagiosum (answer a) is caused by the MCV-1 poxvirus, and it most commonly affects young children, but it also affects sexually active 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, skin-coloured papules measuring 2 to 5 mm, some of which will show evidence of umbilication. There may be adjacent eczema in some cases, and secondary bacterial infection of excoriated molluscum papules may also be present. It is a clinical diagnosis, although, occasionally a skin biopsy is required. Education and reassurance are key, and treatment is not always necessary since this is a self-resolving condition. If lesions are widespread and therapy is requested, treatment options include liquid nitrogen cryotherapy (older children and adults), cantharidin application, curettage, salicylic acid, topical tretinoin, imiquimod cream, or oral cimetidine. Benjamin Barankin, MD, FRCPC, is a Dermatologist practicing in Toronto, Ontario. The Canadian Journal of CME / February

2 Case 2 Yellowish Discolouration of Toenails A 52-year-old male presents with long standing change in texture and yellowish discolouration of his toenails. a. Onychogryphosis b. Psoriasis c. Onychomycosis Onychomycosis (answer c) is a nail infection caused by fungus. Dermatophytes are the main causes of toenail onychomycosis. Prevalence varies from 4 to 18%. Diagnosis is clinical. A potasium hydroxide (KOH) preparation of scrapings from the nail bed to demonstrate hyphae and arthrospores can also be used. Fungal culture can be done in KOH negative cases. Topical therapies are generally ineffective. Thus oral antifungal agents are the mainstay of treatment. Terbinafine is a more effective treatment with fewer side effects as compared to other oral antifungals. Itraconazole is effective treatment for nondermatophyte mold and yeast onychomycosis. Other agents include griseofulvin and fluconazole. Cherinet Seid, MD, LMCC, CCFP, DTM (RCPS Glas), is the Lead Physician with the North Renfrew Family Health Team,DeepRiver,Ontario.HeisalsoanEmergency PhysicianatDeepRiverandDistrictHospitalandan Assistant Professor at the Northern Ontario School of Medicine, Sudbury, Ontario. Craig O Brien, RN (EC), is a Nurse Practitioner with the NorthRenfrewFamilyHealthTeam,DeepRiver,Ontario. IN SCALP PSORIASIS, What could Luxiq TM Foam do for your patients? LUXIQ Foam is a medium potency topical corticosteroid indicated for the relief of the infl ammatory and pruritic manifestations of moderate to severe psoriasis of the scalp for up to 4 weeks in adult patients. LUXIQ Foam is contraindicated in patients who are hypersensitive to this drug or to any 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, bacterial or fungal skin infections, parasitic infections, skin manifestations relating to tuberculosis or syphilis, eruptions following vaccinations, treatment or rosacea or perioral dermatitis and in topical application to the eye. LUXIQ Foam should not be used under occlusion due to increased risk of systemic exposure and infection. When used under occlusive dressing, over extensive areas or on the face, scalp, axillae or scrotum, suffi cient absorption may occur to result in adrenal suppression and other systemic effects. Systemic absorption of topical corticosteroids has produced reversible hypothalamicpituitary adrenal (HPA) axis suppression, manifestations of Cushing s syndrome, hyperglycemia, and glucosuria in some patients. Pediatric patients may be more susceptible to systemic toxicity from equivalent doses because of their larger skin surface to body mass ratios. Safety and effectiveness of LUXIQ Foam in pediatric patients <18 years of age have not been established. Use in pediatric patients is not recommended. Topical corticosteroids should be used with caution in psoriasis as rebound relapses, development of tolerances, risk of generalised pustular psoriasis and development of local or systemic toxicity due to impaired barrier function of the skin have been reported in some cases. When used in psoriasis careful patient supervision is important. Local hypersensitivity reactions may resemble symptoms of the condition under treatment. If hypersensitivity reactions occur, the drug should be discontinued and appropriate therapy initiated if there are signs of reaction. Prolonged use of topical corticosteroid preparations may produce striae or atrophy of the skin or subcutaneous tissue. If skin atrophy is observed, treatment should be discontinued. In case of systemic absorption in patients with renal or hepatic impairment, metabolism and elimination may be delayed leading to increased risk of systemic toxicity; therefore, minimum quantity should be used for the minimum duration.

3 Case 3 Asymptomatic Lip Papule A 52-year-old male developed an asymptomatic papule on his lower lip. He doesn t recall any preceding trauma. He does not drink nor smoke and is otherwise healthy with a stable weight. a. Milia cyst b. Pilar cyst c. Basal cell carcinoma d. Dermatofibroma e. Mucosal fibroma A mucosal fibroma (answer e), the most common benign tumour of the oral cavity, is an overgrowth of fibrous connective tissue. It is a firm, pink nodule, typically less than 1 cm in size. They can remain unchanged for many years. It appears to be in response to irritation or injury. The overlying tissue is normal in colour and appearance. These lesions can occur on the lip and commonly on the buccal mucosa along the biting line. These benign lesions can be ignored or surgically excised. Recurrence after excision is rare. Benjamin Barankin, MD, FRCPC, is a Dermatologist 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 format 1 * Demonstrated efficacy Significantly more LUXIQ TM 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 weeks 1 NEW Vehicle Foam BMV Lotion LUXIQ TM Foam 19% n=32 46% p< for LUXIQ TM vs vehicle foam and p= vs BMV lotion (0.12%) n=63 67% n=64 BMV = betamethasone valerate %ofpatients Adapted from Product Monograph 1 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%). * Comparative clinical signifi cance has not been established. Clinical signifi cance has not been established. Improvements were rated using an Investigator s Global Assessment (ISGA) score for the target lesion at day 29 of clear or almost clear of disease using a 7 point score. TM Used under license by GlaxoSmithKline Inc., Stiefel, a GSK company, Mississauga (Ontario) L5N 6L4 VERSAFOAM is a registered trademark of Stiefel Laboratories Inc., used under licence by GlaxoSmith- Kline Inc

4 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. a. Syringioma b. Xanthelasma palpebrarum c. Hidrocystoma d. Adenoma sebaceum The patient has Hidrocystomas (answer c). Eccrine hidrocystomas more commonly occur as multiple lesions and are thought to result from blockage of the sweat duct apparatus. They are closly related to apocrine hidrocystomas, which are also known as apocrine cystadenomas and apocrine retention cysts. Apocrine hidrocystomas are benign cystic proliferations of the apocrine secretory glands. Apocrine hidrocystomas most commonly appear as solitary, soft, dome-shaped, translucent papules or nodules, and most frequently are located on the eyelids, especially the inner canthus. Apocrine hidrocystomas grow slowly and usually persist indefinitely. They may also occur on the head, neck, trunk, penis, axilla, and anus. The cause is unknown, but they are considered to be benign adenomatous cystic proliferations of the apocrine glands. Multiple apocrine hidrocytomas are associated with Schöpf-Schulz- Passarge syndrome, a rare autosomal recessive syndrome in which ectodermal dysplasia occurs. Schopf-Schulz-Passarge syndrome often features palmoplantar hyperkeratosis, hypodontia, nail dystrophy,andhypotrichosis.anassociationofmultiple apocrine hidrocystomas with a peculiar form of focaldermalhypoplasiaalsohasbeenreported. Additional therapies to consider are those used for multiple eccrine hidrocystomas, which include botulinum toxin, atropine, pulsed-dye laser, and, most recently, the 595 nm long-pulsed laser. JerzyK.Pawlak,MD,MSc,PhD,isaGeneral Practitioner, Winnipeg, Manitoba. T.J.KroczakisaGeneralPractitioner,Winnipeg, Manitoba. 26 The Canadian Journal of CME / February 2012

5 Case 5 AReddish,GrowingMass A 7-month-old boy presents with a reddish mass on his right forearm. The lesion was first noted in the neonatal period as a telangiectatic patch that has subsequently increased in size. a. Nevus flammeus b. Salmon patch c. Spider angioma d. Infantile hemangioma The patient has an infantile hemangioma (answer d). Histologically, infantile hemangiomas consist of collections of dilated vessels surrounded by masses of proliferating endothelial cells. In Caucasions, infantile hemangioma affects approximately 1.1 to 2.6% of newborn infants and 10 to 12% of children by the first year of life. The female to male ratio is approximately 3:1. Typically, infantile hemangiomas appear in the first few weeks of life as areas of pallor, followed by telangiectatic patches. They then grow rapidly in the first three to six months of life. Superficial lesions are bright red, protuberant, and sharply demarcated and are often referred to as strawberry hemangiomas. Deeplesionsarebluishanddome-shaped,feellikea bag of worms, and are compressible. Infantile hemangiomas have a predilection for the head and neck region. Most infantile hemangiomas exist as solitary lesions. Infantile hemangiomas continue to grow until 9- to 12-months-of-age, at which time the growth rate slows down to parallel the growth of the child. Half of these lesions will show complete involution by the time a child reaches age five; 70% will have disappeared by age seven; and 95% will have regressed by ages 10 to 12. The majority of infantile hemangiomas require no treatment. Indications for active intervention include severe or recurrent hemorrhage unresponsive to treatment, threatening ulceration in areas where serious complications might ensue, interference with vital structures, pedunculated hemangiomas, and significant disfigurement. Treatment options include systemic corticosteroids, intralesional corticosteroids, interferon, pulsed-dye laser, propanolol, and surgical resectioning. Alexander K.C. Leung, MBBS, FRCPC, FRCP (UK&Irel), FRCPCH, is a Clinical Professor of Pediatrics, at the University of Calgary, Calgary, Alberta. The Canadian Journal of CME / February

6 Case 6 AWomanwithBackHair A68-year-oldCaucasianwomanisnotedonphysical examination to have a large tuft of dark hair over the midline of the lumbar spine. The patient states that this has been present for as long as she can remember and describes only tenderness to palpation over the affected area. a. Dermal sinus b. Spina bifida occulta c. Diastomatomyelia d. Hirsuitism e. Exencephaly Spina bifida occulta (answer b), a spinal dysraphism, is a disorder of primary neurulation wherein there is a failure of fusion of the vertebral bodies dorsal to the spinal cord. In the occult form, the defect is typically localized in the lumbosacral region with the overlying skin remaining intact. This patient exhibits lumbar hypertrichosis (commonly referred to as a faun tail), which is a common feature of spina bifida occulta. Spina bifida occulta is frequently diagnosed incidentally on physical exam or by radiographs of the lumbosacral spine. The reported incidence for all forms of neural tube defects combined is one in one thousand pregnancies. The most important modifiable risk factor is maternal folate deficiency in pregnancy as well as exposure to certain medications, most notably anticonvulsants. The occult form is usually asymptomatic and typically requires no medical or surgical intervention. Brent M. McGrath, MD, MSc, PhD, is a Resident in the Department of Medicine, Saint John Regional Hospital, Saint John, New Brunswick, Canada and Dalhousie University, Halifax, Nova Scotia, Canada. Joanna R. Middleton, MD, CCFP(EM) is an Emergentologist, Department of Emergency Medicine, Saint John Regional Hospital, Saint John, New Brunswick, Canada. 30 The Canadian Journal of CME / February 2012