Dermatopathology Case Challenge: Recognizing Mimics and Masqueraders
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1 Dermatopathology Case Challenge: Recognizing Mimics and Masqueraders Rosalie Elenitsas, M.D. Professor of Dermatology Director, Dermatopathology University of Pennsylvania
2 DISCLOSURE OF RELATIONSHIPS WITH INDUSTRY Rosalie Elenitsas F0131 Dermatopathology Case Challenge DISCLOSURES None relevant to this talk Others: Royalties Lippincott Williams Wilkins Lever s Histopathology of the Skin
3 Case 1 A 74 year old healthy woman presents with rash on face Perioral papules, non-pruritic No response to 2.5% hydrocortisone and 0.1% triamcinolone
4 Biopsy of chin
5
6
7
8 What is the next step? A. T cell markers B. B cell markers C. Stains for EBV and HSV D. GMS and Fite E. Sign out as perioral dermatitis
9 What is the next step? A. T cell markers B. B cell markers C. Stains for EBV and HSV D. GMS and Fite E. Sign out as perioral dermatitis
10 Pathology Granulomatous dermatitis No definitive follicular rupture noted Polarization negative for refractile material PAS and Fite stains negative for organisms
11
12 What is the next step? A. T cell markers B. B cell markers C. Stains for EBV and HSV: NEGATIVE D. GMS and Fite E. Sign out as perioral dermatitis
13
14 History The rash developed in the areas of cosmetic treatment for facial rejuvenation Started 2 days after her most recent microneedling treatment Treated in past without any adverse reactions
15 Diagnosis Granulomatous dermatitis from microneedling
16 JAMADermatol.2014;150(1):68-72
17 JAMADermatol.2014;150(1):68-72
18
19 Daily s
20 Microneedling aka collagen induction therapy Uses: acne scarring, photoaging and rejuvenation Also: alopecia, hyperpigmentation, actinic keratosis, verruca Repetitive puncturing of skin with sterilized microneedles Theory: Trauma incites growth factors that stimulate production of collagen and elastin
21 Microneedling Journal of Plastic, Reconstructive & Aesthetic Surgery (2018) 71,1e14
22 Microneedling
23 Microneedling Advantages: less training necessary to use (astheticians more readily able to do it), less cost, less down time Topicals are frequently applied prior to the procedure, ranging from antioxidants to pro-collagen producing factors
24 Our patient
25
26 Follow up for our patient The patient was patch tested to the cosmeceutical product without any reaction at 2, 3, and 5 days post-application Intralesional triamcinolone was administered with some improvement
27
28 Treatment Doxycycline Minocycline
29 Take home Microneedling may cause facial granulomatous reaction mimicking perioral dermatitis
30 Case 2 73 year old woman Swelling of lower lip 4 years
31 Past Medical History Healthy No history of inflammatory bowel disease
32 Punch biopsy submitted r/o Melkersson-Rosenthal syndrome Granulomatous cheilitis + facial palsy + fissured tongue Absence of Crohn s disease
33 Site: Lower lip
34
35 What is your diagnosis? A. Lipophagic panniculitis B. Cutaneous liposarcoma C. Pleomormphic lipoma D. Mycobacterial infection E. Silicone granuloma
36 What is your diagnosis? A. Lipophagic panniculitis B. Cutaneous liposarcoma C. Pleomormphic lipoma D. Mycobacterial infection E. Silicone granuloma
37 Contact the dermatologist Me: Has the patient had any silicone injections? Derm: No, she denies any injections or treatments to her lips
38
39 CD68
40 More stains Fite AFB GMS S100 All negative
41 Contact the dermatologist Me: Please, ask the patient again if they had any injections CALL THE PATIENT Derm: The only injection she ever had was botox Nothing in her lips
42 Contact the dermatologist Me: Please get the name of the doctor so that we can get details about the injection CALL THE PATIENT AGAIN Derm: No doctor. She got her Botox on the sides of her nose at a Botox party 6 years ago
43 Diagnosis Silicone granuloma Silicone migration
44
45 Key Concepts Consumer demand for counterfeit products containing botulinum neurotoxin may be fueling a proliferation of illicit toxin producers. Scientific American June 2010, p84
46 Our case Likely silicone used with or without botulinum toxin
47 The American Journal of Medicine (2018) 131,
48 Vulvar Asymmetry Due to Silicone Migration and Granulomatous Immune Response Following Injection for Buttock Augmentation 4 years after injection J Clin Aesthet Dermatol. 2017;10(4):50 54.
49 Silicone Group of synthetic polymeric organosilicon compounds Solid, liquid, gel forms Uses Cosmetic enhancement Prostheses Implants Coating of needles and syringes IV tubing
50 Liquid Injectable Silicone Polydimethyl siloxane Soft tissue augmentation Non-carcinogenic Minimally-antigenic Easily sterilized Viscosity constant at various temperatures in human body
51 Liquid Injectable Silicone Pharmaceutical grade/microdroplet technique Minimal migration Granuloma formation Large volumes/unknown purity Prone to migration Edema, cellulitis, pneumonitis Granuloma formation
52 Silicone Granulomas Migrate along tissue planes Form nodules with redness and swelling Seen in lymphatics Occur years after injection Up to 28 years later May mimic systemic disease Fever, weight loss
53 Silicone Granulomas: Treatment Intralesional steroids Systemic steroids Oral antibiotics Surgical excision Immunotherapy: tacrolimus, etanercept, and imiquimod
54 Take home message Persistence about the clinical history helps complete the clinical-pathology correlation Migrating silicone mimics granulomatous cheilitis Botox party not really Botox
55
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