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Open Access Publications from the University of California

Dermatology Online Journal

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Dermatology Online Journal is an open-access, refereed publication intended to meet reference and education needs of the international dermatology community since 1995. Dermatology Online Journal is supported by the Department of Dermatology UC Davis, and by the Northern California Veterans Administration.

Volume 21, Issue 5, 2015

Case Report

Angioinvasive opportunistic filamentous mycoses in immunocompromised patients

Immunocompromised individuals are at greater risk for disseminated fungal infections. Immunocompromised individuals in the community have increased because of medical advances, thereby increasing the incidence and prevalence of opportunistic mycoses [1]. The following case series illustrates the importance of having a high clinical suspicion for skin manifestations concerning for deep fungal infections.

Tobacco-associated yellow discoloration of upper lip hair: smoker's mustache

Background: Hair is susceptible to exogenous sources of discoloration. There are several exogenous etiologies for yellow hair discoloration, including tobacco.

Purpose: We describe the clinical features of five men with tobacco-associated yellow discoloration of their mustache, a condition known as "smoker's mustache." We also review the characteristics of men with tobacco-associated yellow discoloration of their scalp or mustache hair.

Materials and methods: The features of five men with smoker's mustache are presented. Using PubMed, the following terms were searched and relevant citations assessed: 4-4'-methylenedianiline, acid, dithranol, MDA, mustache, nicotine, picric, resorcin, smoker, tar, tobacco, and yellow. In addition, the literature on smoker's mustache is reviewed.

Results: Smoker's mustache was an incidental finding and not the reason for patients presenting for medical attention. The condition was asymptomatic. In our patients, 60% (3 of 5) also had tobacco-related clinical findings on the distal soft tissue and/or nails of their fingers.

Conclusion: Smoker's mustache refers to tobacco-associated discoloration of the hair of the upper lip of men. It is an asymptomatic condition that usually presents as an incidental finding. Indeed, patients tend to be unaware of the condition until it is brought to their attention. In addition to hair manifestations, patients may also demonstrate other tobacco-associated skin and nail findings, particularly brown or yellow-brown discoloration of their fingertip and/or fingernail. We postulate that discontinuation of smoking would eventually result in spontaneous resolution of the condition. However, all of our patients were determined to continue smoking.


What can U.S. dermatology learn from health care systems abroad? An observation of Taiwan’s system of clinical efficiency as a possible model for increased patient access to care and affordability

Background: Difficulty in patient access to care and affordability are major problems faced by our dermatology specialty in the United States.  However, Taiwan provides adequate and affordable dermatologic care for all of its citizens.  Herein we describe our first-hand observations and findings of the outpatient dermatology experience in Taipei, and contrast it to the experience in the United States.

Observation: In Taipei, Taiwan, we observed patient management, electronic documentation, and billing during outpatient dermatology visits in five settings: one academic hospital outpatient dermatology department, one academic hospital Information Technology department, and three private dermatologists’ offices. Through our observations, we found that the dermatology specialty in Taiwan is able to overcome challenges with access to care and affordability through three key system features: (1) short yet frequent patient visits (2) close proximity of ancillary staff, and (3) an integrated and paperless electronic medical record and billing system.

Conclusions: The Taiwan system is attained with some sacrifice, such as shorter time spent with patients and less personalized care. However,  because this system can meet the basic dermatological needs of the entire population, possibly better than our current system, it behooves us to study the Taiwan system with respect and care.

Case Presentation

Widespread calciphylaxis and normal renal function: no improvement with sodium thiosulfate

Although calciphylaxis generally occurs in patients with chronic renal failure, we present a patient with widespread calciphylaxis in the setting of normal renal function following renal transplant. IV and IL sodium thiosulfate injections were not beneficial in our patient.

Zosteriform metastasis of rectal adenocarcinoma: a case report

Cutaneous metastases manifesting as zosteriform eruptions are uncommon. To our knowledge, we report the second case of zosteriform cutaneous metastasis arising from a rectal carcinoma in a 58-year-old man who presented with a painless popular eruption in the T12 dermatomal distribution nine months after his primary diagnosis of rectal carcinoma was made. Furthermore, we discuss a review of the literature regarding zosteriform cutaneous metastases and the possible pathogenesis of these lesions.

Pseudo-kaposi sarcoma (acroangiodermatitis): occurring after bullous erysipelas

Pseudo-Kaposi sarcoma is a benign reactive vascular proliferative disorder, which can be seen at any age. It occurs when the chronic venous pressure changes result in vascular proliferation in the upper and mid dermis. This disease is divided into two subtypes: the most frequent subtype is the Mali type and seen in early ages. The Mali type is seen in chronic venous insufficiency and in those patients with arteriovenous shunts. The rare subtype is the Stewart-Bluefarb type. This disease must be distinguished from Kaposi sarcoma because of their clinical resemblance. Herein, we present a patient with pseudo-Kaposi sarcoma, which developed after bullous erysipelas.

Acantholytic dermatosis of the vulva

Acantholytic dermatosis of the vulva is a rare condition, presenting with papular eruption in the genital area without history of Darier disease or Hailey-Hailey disease. We report a case with a papular pruritic eruption in the region of the vulva, coalescing into plaques. Biopsy specimen showed irregular acanthosis with an area of split-like bullous formation in the deeper part of the epidermis, as well as acantholytic cells, marked hypergranulosis and hyperkeratosis, compatible with the rare diagnosis of acantholytic dermatosis of the vulva. We review the clinical and histological characteristics of this uncommon disease.

Adnexal polyp in a newborn baby

Birthmarks can frequently be seen in newborn babies, but their etiopathogenesis is often unclear. These lesions can be divided into three groups: vascular birthmarks, pigmented birthmarks, and birthmarks resulting in abnormal development. Some birthmarks may require further analysis and clinical follow-up in order to rule out underlying defects, malignant potential, or correlation with syndromic diseases.

Photo Vignette

Linear adamantinoid basal cell carcinoma in the axilla

We present a case of asymptomatic deeply pigmented linear plaque with rolled borders that we encountered in an elderly Indian male over a sun protected site, the left axilla. The diagnosis of linear adamantinoid basal cell carcinoma was confirmed on histopathological examination.

Ulcerated erythematous plaque on the right breast localized to the previously irradiated area

Radiation recall dermatitis (RRD) is an inflammatory reaction limited to previously irradiated areas and occurs following the subsequent administration of a drug [1]. Herein, we present a patient with severe RRD associated with pain and necrosis.

Sporotrichoid Mycobacterium marinum infection in an elderly woman

We describe the case of an elderly woman who acquired a Mycobacterium marinum infection following skin exposure to the bacteria through a small wound on her right ring finger, obtained while preparing fish. The resultant sporotrichoid nodules of the right hand and the distal forearm, refractory to the initial therapy with doxycycline and rifampicin, were successfully treated with oral regimen of clarithromycin.

Pachydermoperiostosis, a unique entity with distinctive clinical features

Pachydermoperiostosis, which occurs more frequently in men, is a rare entity with distinctive clinical features and an insidious onset.. We report the case of a 30-year-old man with a one-year history of acropachy, arthralgias, hiperhidrosis, and progressive skin thickening of the face and scalp.

The radiological findings were consistent with periostosis and the histopathological analysis from a facial skin biopsy showed a pandermal increase in the thickness and number of collagen bundles.

The pathogenesis of PDP is currently unknown, although an increased secretion of prostaglandin E2 (PGE2), which stimulates the overexpression of vascular endothelial growth factor (VEGF), has been suggested as a major factor. No specific treatment exists; however, in most cases, the disease tends to stabilize over time.


Hyperpigmentation and atrophy in folds as cutaneous manifestation in a case of mitochondrial myopathy

Mitochondrial myopathies are inborn metabolism defect diseases manifested by symptoms reflecting failure of the final step in the mitochondrial respiratory chain. Clinical expression of these conditions can vary widely, but typically includes organ systems with a high energy demand, such as striated muscle, myocardium, and nervous and liver tissues. In contrast, cutaneous manifestations are rare and are non-specific, most commonly presenting as pigmentation disorders. In this case report, we present a case of Alpers syndrome accompanied by hyperpigmentation and atrophy in skin folds.

Dramatic hyperpigmentation of keloids after intralesional triamcinolone acetonide injection

A 20-year old woman presented to our clinic for multiple keloids owing to various injuries over 3 years. These keloids were distributed over the flexor aspect of the left forearm, the lateral aspect of the left elbow and the superomedial aspect of the left calf. The patient was anxious for treatment to make the keloids flatter.

Rosacea-like eruption due to topical pimecrolimus

Topical calcineurin inhibitors have been used outside their approved indications for a number of conditions, including topical steroid-induced rosacea. However, tacrolimus ointment itself has been reported to trigger rosacea in a small number of cases. We report a case of a rosacea-like eruption in a 39-year-old woman occurring after the use of pimecrolimus cream for 12 months for atopic dermatitis. Withdrawal of pimecrolimus combined with treatment with oral lymecycline, topical metronidazole, and an emollient resulted in resolution of the eruption. There have been 5 previously reported cases of a topical pimecrolimus-induced rosacea-like eruption suggesting that this rare side-effect may be a class effect of all topical calcineurin inhibitors. Dermatologists prescribing these drugs should be aware of this uncommon complication and may wish to warn patients of its occurrence as a potential side-effect when using topical calcineurin inhibitors in facial skin in adults.

Systemic contact dermatitis due to amethocaine following digital rectal examination

Systemic contact dermatitis is a dermatitis that may occur in previously sensitized individuals (usually through the skin or mucosa) when they are re-exposed to the allergen systemically (oral, rectal, inhaled, intravesical, intravenous...). Although many drugs have been implicated as a cause of systemic contact dermatitis, local anesthetics derived from caines have been rarely reported. We present a case of systemic contact dermatitis after performing a digital rectal examination with a urological lubricant containing amethocaine.

Palmoplantar hyperkeratotic lesions: a rare presentation of lichen planus

Palmoplantar lichen planus is a localized and rare subtype of lichen planus (LP) often underdiagnosed. Several morphological types of palmoplantar lesions have been defined in LP. We present an unusual case of the palmoplantar kyperkeratotic variant of LP. Histopathology examination confirmed our diagnosis. We emphasize the importance of this rare entity in the differential diagnosis of palmoplantar dermatoses.