Test Your Knowledge With Multiple-Choice Cases Case 1 Rosacea Treatment Trouble A 42-year-old female being treated with minocycline for rosacea presents with multiple, blue-grey, irregular patches on her forearms. She first noticed the lesions one year ago and they are progressing. What is the diagnosis? a. Ecchymoses b. Ochronosis c. Common blue nevus d. Minocycline pigmentation e. Sclerosing hemangioma The patient has minocycline pigmentation (answer d). She had been taking minocycline daily for more than six years to control her rosacea. Pigmentation is a well-establised adverse effect of minocycline therapy (incidence of 2% to 15%). It is thought that the abnormal pigment is likely a metabolic derivative of minocycline. It often results from long-term use of minocycline, with cumulative doses often exceeding 100 g. Cutaneous or oral pigmentation can appear in the absence of long-term dosing. Sites typically affected include the skin, nails, mouth, eyes, bones and thyroid. We suggest the patient discontinue the minocycline and use a different antibiotic to control her rosacea. Minocycline pigmentation of the skin is not harmful and can resolve slowly over months to years once the drug is discontinued, but pigmentation of other sites is often permanent. Cover-up cream can help camouflage the lesions. Laser therapy is not done routinely for minocycline pigmentation. All patients on minocycline, especially those treated for more than one year, should be screened for the development of pigmentation. This month 6 cases: 1. Rosacea Treatment Trouble 2. Why s my arm so rough? 3. Pruritic Purple Papules! 4. What s on my tummy? 5. Nailing the Problem 6. Soothe my itchy arm, doc! John Kraft, BSc, is a third-year medical student, University of Toronto, Toronto, Ontario; Carrie Lynde, BSc, is a first-year medical student, University of Toronto, Toronto, Ontario; and Charles Lynde, MD, FRCP(C), is a Dermatologist, Toronto, Ontario. The Canadian Journal of CME / September 2005 67
Case 2 Why s my arm so rough? A 12-year-old female presents with concerns regarding the unsightliness and roughness of her extensor arms. What can it be? a. Folliculitis b. Keratosis pilaris c. Acne d. Pityriasis rubra pilaris e. Lichen nitidus Keratosis pilaris (answer b) is a very common and benign disorder affecting the hair follicles. It is characterized by grouped, keratotic follicular papules located most commonly on the posterolateral upper arms and anterior thighs. It is usually asymptomatic except for its cosmetic appearance. Treatment is modestly effective and only provides temporary relief. It is due to a lack of proper desquamation of keratinocytes, thus, plugging the follicular orifice with keratin, resulting in a keratotic papule and a variable degree of perifollicular erythema. It is a clinical diagnosis. Education and reassurance are most important as this condition improves with age. Topical emollients may help rough surfaces in mild cases, although a topical keratolytic agent, such as lactic acid, salicylic acid or urea preparations may be beneficial in more extensive cases. The Canadian Journal of CME / September 2005 69
Case 3 Pruritic Purple Papules! A 45-year-old male presents with pruritic, purple papules on his shins, ankles and wrists. What can it be? a. Guttate psoriasis b. Lichen planus c. Allergic contact dermatitis to nickel d. Pityriasis rosea e. Lichen simplex chronicus Lichen planus (LP) (answer b) is a relatively common, pruritic inflammatory disease of unknown etiology. It predominantly affects the skin and can also affect the hair follicles, mucous membranes and nails (5% to 10%). The characteristic lesions are small violaceous, flat-topped, polygonal papules. On the surface of some lesions, grey or white streaks may be noted (Wickham s striae), although this is most commonly seen on the mucous membranes. There is a predilection for the flexor wrists, shins, ankles and glans penis. Koebner s phenomenon occurs with LP. It is a clinical diagnosis, although a biopsy is sometimes needed for confirmation. It is considered a self-limited disease, often resolving in 10 to 15 months. Mild to moderate cases can be managed with moderate to potent topical steroids. More severe or generalized involvement can be treated with phototherapy and occasionally systemic steroids. Less commonly, cyclosporine or acitretin have been used. 70 The Canadian Journal of CME / September 2005
Case 4 What s on my tummy? A five-year-old male presents with umbilicated, translucent, eroded papules on his abdomen and axillae. What do you think? a. Milia b. Keratosis pilaris c. Molluscum contagiosum d. Varicella infection e. Warts Molluscum contagiosum (answer c) is caused by a poxvirus, usually molluscum contagiosum virus-1. Typically, young children are affected, as well as sexually active adults and immunosuppressed individuals (especially those with HIV). Individual lesions are smooth, firm, domeshaped, pearly papules measuring 3 mm to 5 mm, some of which will show evidence of umbilication. In children, they are often generalized, ranging from a few to over 100 lesions. There may be adjacent eczema in some cases and secondary bacterial infection of excoriated molluscum papules can also occur. It is a clinical diagnosis, although, uncommonly, a skin biopsy is required. Treatment options include liquid nitrogen cryotherapy (in older children and adults), cantharidin application, salicylic acid, curettage, cimetidine, topical tretinoin and imiquimod cream. 72 The Canadian Journal of CME / September 2005
Case 5 Nailing the Problem A 55-year-old male with a past medical history of porphyria presents with an increasing whitetranslucent area on the distal nail plate of several nails. What would you diagnose? a. Onychophagia b. Onychoschizia c. Onychonychia d. Onychomadesis e. Onycholysis Take blood ACCURETIC* ACCURETIC* is indicated is indicated essential in essential hypertension hypertension when combination when combination therapy is therapy appropriate. is appropriate. The fixed The combination fixed combination is not indicated is not indicated for initial for therapy. initial therapy. ACCUPRIL* ACCUPRIL* is indicated is indicated essential in essential hypertension hypertension when diuretics when diuretics or beta-blockers or beta-blockers are unsuitable. are unsuitable. WARNING: WARNING: As with all As ACE with inhibitors, all ACE inhibitors, please refer please to specific refer to warnings specific warnings regarding regarding drug discontinuation drug discontinuation in angioedema in angioedema and pregnancy. and pregnancy. Please refer Please to Product refer Monographs to Product Monographs for complete for dosing complete information. dosing information. Multicentre, Multicentre, 8-week, double-blind, 8-week, double-blind, forced-titration forced-titration study in 368 study patients in 368 randomized patients randomized to three parallel to three treatment parallel groups. treatment Patients groups. included Patients men included and women, and 18 years women, or 18 older years with or supine older with DBP supine 105 and DBP 120 105 mmhg and 120 at end mmhg of at end of placebo phase. placebo During phase. the first During four the weeks first patients four weeks received patients once-daily received quinapril once-daily 10 quinapril mg plus 10 placebo mg plus OR placebo quinapril OR 10 quinapril mg plus 10 HCTZ mg 12.5 plus mg HCTZ OR 12.5 placebo mg OR plus placebo HCTZ 12.5 plus mg. HCTZ After 12.54 mg. weeks After of therapy, 4 weeks doses of therapy, were doses doubled were doubled and treatment and continued treatment for continued another 4 for weeks another unless 4 weeks supine unless BP was supine <120/80 BP was mmhg <120/80 or if mmhg there was or if any there other was clinical any other reason, clinical then reason, doses were then not doses doubled. were not Data doubled. from 318 Data patients from 318 in the patients low dose in the group low and dose from group 284 and patients from 284 patients in the high dose in the group high dose were group used for were efficacy used evaluation. for efficacy Change evaluation. in supine Change BP in from supine baseline BP from to endpoint baseline to was: endpoint -13.1/-12.1 was: mmhg -13.1/-12.1 for quinapril mmhg for 10 quinapril mg; -11.6/-12.5 10 mg; mmhg -11.6/-12.5 for HCTZ mmhg 12.5 for mg; HCTZ 17.7/-14.6 12.5 mg; 17.7/-14.6 mmhg for the mmhg for the low-dose combination; low-dose combination; -19.7/-17.0 mmhg -19.7/-17.0 for quinapril mmhg for 20 quinapril mg; -20.4/-17.2 mg; mmhg -20.4/-17.2 for HCTZ mmhg 25 for mg; HCTZ and 25-27.1/-19.5 mg; and mmhg -27.1/-19.5 for the mmhg high-dose for the combination. high-dose combination. One price for One all price dosage for strengths. all dosage Price strengths. does not Price include does pharmacy not include professional pharmacy professional fees. Please fees. refer Please to Product refer Monograph to Product Monograph for complete for dosing complete information. dosing information.
Onycholysis (answer e) is a separation of the nail plate, beginning at the distal margin and progressing proximally. If a yellow-brown hue is also noticed ( oil spot ), psoriasis should be strongly suspected. The nail itself is smooth and firm. Onycholysis is associated with lichen planus, eczema, thyroid disease, pregnancy and porphyria (as in this case). It is also reported with bacterial, viral and fungal infections. Chemical causes include the use of solvents, nails hardeners and artificial nails. Chemotherapeutic agents can cause onycholysis and, more commonly, medications, such as the tetracyclines, can cause photo-onycholysis. Trauma should be avoided and the nail bed kept dry. The affected portion of the nail can be clipped. The underlying cause should be identified and treated. pressure control further...with Extend Extend the the control control of quinapril of quinapril or HCTZ or HCTZ alone, alone, with with the the fastest fastest growing growing fixed-dose fixed-dose combination ACCURETIC* ACCURETIC* is the is the fastest fastest growing growing Significantly Significantly greater greater BP lowering BP lowering power power than quinapril than quinapril or HCTZ or HCTZ in monotherapy in monotherapy (p>0.05) (p>0.05) 6 6 Excellent Excellent tolerability tolerability profile profile 3 3 The flexibility The flexibility of 7 dosage of 7 dosage options options across across the ACCUPRIL* the ACCUPRIL* and ACCURETIC* and ACCURETIC* range, range, all at all the at same the same price 1,3,4 price 1,3,4 ACE-I/HCTZ ACE-I/HCTZ fixed-dose fixed-dose combination combination choice choice in new and in new total and total prescriptions prescriptions 5 5 The most The frequent most frequent adverse events adverse for events ACCURETIC* for ACCURETIC* in controlled in controlled trials were trials were headache headache (6.7%), dizziness (6.7%), dizziness (4.8%), cough (4.8%), (3.2%) cough and (3.2%) fatigue and (2.9%). fatigue For (2.9%). For the complete the complete list of adverse list of events, adverse please events, refer please to the refer Product to the Product Monograph. Monograph. 2005 2005 Pfizer Canada Pfizer Inc. Canada Inc. Kirkland, Quebec Kirkland, Quebec *TM Parke, Davis *TM Parke, & Company Davis & Company H9J 2M5 H9J 2M5 Pfizer Canada Pfizer Inc., Canada licenseeinc., licensee (quinapril (quinapril hydrochloride hydrochloride and hydrochlorothiazide) and hydrochlorothiazide) POWER POWER OF COMBINED OF COMBINED CONTROL CONTROL For prescribing For prescribing information information see page see 104 page 104
Case 6 Soothe my itchy arm, doc! A 44-year-old male presents with a progressively worsening itchy lesion on his arm. During the past 12 days, the lesion has become a painful, draining plaque. In the emergency department, a week ago, he received an injection consisting of methylprednisolone acetate, oral ampicillin and oral diphenhydramine hydrochloride. The medication failed to resolve the lesion. The patient is otherwise healthy, and exercises by doing yard work. Can you identify the lesion? a. Poison ivy rash with secondary bacterial infection b. Brown recluse spider bite c. Black widow spider bite d. Gram-positive bacterial cellulitis e. Factitial dermatitis The patient had a contact dermatitis, most likely poison ivy, contracted while gardening, with a secondary bacterial infection (answer a). Spider bites and cellulitis are not initially pruritic. The patient s history did not support a factitial dermatitis. The corticosteroid he received is more appropriate for chronic conditions, such as arthritis. Methylprednisolone acetate is not adequate therapy for acute skin problems. The prescribed antibiotic, oral ampicillin, did not cover the secondary staphylococcal infection, which was provoked by intense scratching of the pruritic poison ivy. Diphenhydramine hydrochloride can ameliorate pruritus, but it plays no role in the treatment of poison ivy. Intramuscular triamcinolone acetonide, and a cephalosporin, produced dramatic improvement within two days. Dr. David L. Kaplan is the original author. Printed with permission from Consultant and Cliggot Publishing Co. 76 The Canadian Journal of CME / September 2005