SEATTLE DERMATOLOGIC SOCIETY

Officers 2007-2008:

Secretary’s Address:

President:

Melanie Kuechle, M.D.

UW Dermatology, Box 356524

Secretary:

Andy Chien, M.D., Ph.D.

Seattle WA  98195-6524

Treasurer:

Marc Antezana, M.D.

206-543-5290

 

November 7, 2007

Announcements

1.  The November meeting will be held on Wednesday, November 14 beginning with the lecture at 4:30 pm at Virginia Mason Medical Center (1100 – 9th Avenue).  Dr. Kyle Garton will present a lecture entitled, "Too much of a good thing - monoclonal gammopathy associated dermatoses."  Please note we will meet in the Diabetes Conference Room located next to Volney Richmond Auditorium.  Patient presentations will begin at 5:30 followed by patient discussion, business meeting.  Dinner will be at Moxie on First at 7:45 pm (530 – 1st Avenue North (206-283-6614) - located between Mercer and Republican.)  Street parking is available on 1st or behind the restaurant (or nearby at the underground parking garage at the Metropolitan Market at 1st and Mercer.) 

 

2.  Please send dues payment ($75) by December 1st to Marc Antezana.

 

3. CALL FOR NOMINATIONS:  Seattle Derm's Secretary, Andy Chien (University of Washington), will be stepping down from his position effective this month.  Dr. Marc Antezana, the current Treasurer, will be taking over as Secretary and thus as President-Elect for 2008-9.  The Society will accept nominations for a new Treasurer.

 

4. The 2007-2008 Seattle Dermatologic Society is noted below.  Please mark these dates on your calendar and advise your staff now of your plans to attend.  Let’s boost participation this year!

2007-2008 Seattle Dermatologic Society Meeting Schedule

Wednesday

September 19, 2007

4:30 pm

Virginia Mason Medical Center

Friday

October 19, 2007

12:30 pm

UW Dermatology Clinic

Wednesday

November 14, 2007

4:30 pm

Virginia Mason Medical Center

Friday

January 18, 2008

4:30 pm

Virginia Mason Medical Center

Wednesday

February 20, 2008

4:30 pm

Virginia Mason Medical Center

Wednesday

March 19, 2008

4:30 pm

Virginia Mason Medical Center

Wednesday

April 16, 2008

4:30 pm

Virginia Mason Medical Center

Friday

May 23, 2008

12:30 pm

UW Dermatology Clinic

Wednesday

June 18, 2008

4:30 pm

Virginia Mason Medical Center

October and May meetings are held in conjunction with WSDA and the annual Pommerening and Odland lectures.

 

Minutes from September 19 meeting

 

KEYNOTE SPEAKER

Dr. Brenda Newman presented the keynote lecture for today’s meeting, speaking on her experience in Myanmar/Burma.  She noted that she had no financial disclosures, no conflict of interest, and received no compensation for her talk today.

 

MEETING NOTES

Our new President, Dr. Melanie Kuechle, called the first meeting of the academic year to order at 6:15 p.m.  Dr. Kuechle also asked members to contact her when possible to try and make the patient presentations more predictable in patient number from month to month.  Dr. Olerud introduced the new residents from the University’s Dermatology Division.

 

Dr. Sybert announced that it was time for Guittard chocolates, which can be ordered through her at near wholesale prices.  Deadline is Oct. 1st, and she needs the cash up front before placing the order.

 

Dr. Lisa Williams and Dr. Michelle Heath were brought up for membership in the society.  Members will officially vote on their selection at the next meeting.

 

A plea was made for members to pay their dues in a timely manner to new Treasurer Dr. Marc Antezana.  Remember, your funds keep Seattle Derm functioning.

 

Note that next month’s meeting will be the Pommerening lecture at the University of Washington.  Also note that there is a change for November, when the meeting will be on the second rather than the third Wednesday of the month on November 14th .

 

PATIENT PRESENTATIONS

1.  Patient A.D. (Dr. Russell Caldwell)

This 34 yo F has a 5 month history of pruritic darkening skin that started on the trunk and legs, but has spread to involve the arms and chest as well, with continued spreading.  The pathology reviewed by Dr. Dan Lantz showed eosinophilic globules in the papillary dermis that were subtle, but otherwise quite good for macular amyloidosis.  In fact, Dr. Lantz considered the biopsy as diagnostic.  The crowd appeared satisfied with the diagnosis, and Dr. Caldwell appealed to the group for therapy.  However, he did note that the patient appeared to be improving on Dovonex and topical steroids.  Dr. Olerud felt that rubbing was important in the etiology, since many patients with lichen amyloidosis have an etiology related to chronic scratching or rubbing.  Dr. J.Y. Chang noted that in Taiwan, dermabrasion on the thickest areas was successful in stopping itching.  This therapy was foreign to the predominantly U.S.-trained crowd.

 

2.  Patient A.L. (Dr. James Harnisch)

This 57 yo F presented with intermittent red itchy bumps, which start with pruritus followed by a persistent papule that lasts two weeks.  These papules appear to erupt in crops of multiple papules, and a biopsy showed a superficial and deep perivascular and interstitial dermatitis with eosinophils amongst the mixed infiltrate.  Both leukocytoclasis and flame figures were pointed out by Dr. Lantz on the biopsy.  Dr. Lantz felt that a neutrophilic dermatosis was not out of the question with these findings, although this biopsy was the type that engendered a differential diagnosis rather than a specific diagnosis.  Arthropod assault, drug reaction, and certain vasculitides such as Churg-Strauss were mentioned by Dr. Lantz.  Dr. Harnisch felt that arthropod bite was quite unlikely given her history, including the fact that she can get these eruptions even when she is away from home.  Despite her history of irritable bowel syndrome, her recent colonoscopy was unrevealing.  The patient does associate the eruption with stress.  Dr. Harnisch thought this could be a small vessel vasculitis, although the findings did not fit classic or even atypical Churg-Strauss.  Dr. Kuechle brought up that there is an epidemic of bedbugs at this time, which could still be possible even with the travel.  Dr. Fleckman suggested topical doxepin, with the rationale that it works well for arthropod assaults.  Dr. Jane Yoo suggested a DIF to rule out dermatitis herpetiformis, and the consensus was that this would be a good idea, especially given the hint of a subepidermal split with neutrophils on the biopsy.

 

3. Patient T.N. (Dr. Ulrike Ochs)

This 41 yo F has a history of a rash on the leg for almost two decades that had been diagnosed as disseminated superficial actinic porokeratosis (DSAP).  Dr. Ochs sent her to Dr. Ben Goffe, where Fraxal laser and topicals including Aldara and Tazerac were tried.  In addition, PDT was tried.  All these therapies were not successful, and since 2001, the rash has worsened.  Dr. Ochs was unenthusiastic about a repeat biopsy, and the group appeared to agree given that her rash was fairly characteristic of DSAP.  In addition, the rash gets better in the winter, consistent with a role for ambient UV in this patient that would fit DSAP.  The patient reportedly is aggressive about sun protection, which was brought up.  Dr. Kelly Arntzen suggested Solaraze, but Dr. Ochs has tried this as well in the past without success.  Etretinate and retinoids were considered in the past.  Dr. Lantz suggested some type of more aggressive chemical peel, although none of the members in the audience admitted to doing this type of procedure.  Cryotherapy was also suggested, and Dr. Ochs may consider this option.  Dr. Caldwell asked about topical steroids or silicone to treat the inflammation.  Dr. Daniel Berg suggested ALA-PDT as an option, and Dr. Kuechle found a reference for anecdotal Dovonex.  Dr. Birkby had seen multiple AKs treated with Unna boot and Efudex, although this possibility was met with some skepticism by the crowd.

 

4.  Patient W.W.N. (Dr. Phil Fleckman and Dr. San Hwan Chen)

This is a 65 yo M with a 35 year history of ankle swelling, rash and intermittent leg ulcers.  His last biopsy was five years ago, and he carries the diagnosis of polyarteritis nodosa (PAN).  He is currently on  prednisone and azathioprine for immunosuppression.  The pathology was reviewed by Dr. Dan Lantz, who pointed out vasculitis with a mixed infiltrate in a large vessel.  Dr. Lantz, who read the biopsy originally, suspects an arteritis based on the caliber of the vessel.  Dr. Lantz pointed out that arteritis is seen more commonly with the cutaneous variant of PAN rather than the systemic variant of PAN.  Dr. Fleckman noted that the patient flares below 7mg QDay of prednisone, or if he lowers his azathioprine below the current dose of 150 mg QDay.  Dr. Fleckman’s reading of the literature suggested that prednisone was the main effective therapy, with some other reports of success with NSAIDS, with MTX and azathioprine representing anecdotally used medications.  Dr. Kuechle was struck by the sclerodermoid nature of the rash, which is not characteristic of PAN.  Dr. Newman brought up the diagnosis of nodular vasculitis related to TB, noting that the patient reported flares concomitant with the placement of PPD tests.  Dr. Lantz pointed out that nodular vasculitis would be mainly a lobular panniculitis, rather than primarily an arteritis.  Dr. Langlois reported prior success with colchicines for cutaneous PAN. 

 

5.  Patient R.W. (Dr. John Olerud)

This 73 yo M presented with an annular erythematous rash with a wood-grain pattern on the trunk, along with biopsy results consistent with erythema gyratum repens (EGR).  Serial photos from Dr. Grogan, the patient’s primary physician, were also presented.  Dr. Grogan gave us a background of his very thorough workup, including a fairly comprehensive search to rule out malignancy that eventually revealed a myelodysplastic syndrome (MDS).  Dr. Sybert asked about an artifactual looking area in the center of the back, although the crowd was unable to provide more insight.  Dr. Grogan pointed out that the patient had neither scale nor pruritus, which are characteristic of cases of EGR in the literature.  Dr. Sybert asked about a possible drug etiology for the EGR, since there are reported cases associated with medications.  Dr. Robles pointed out that EGR could precede malignancy by one to ten years, so in the context of this patient with MDS, it could be a harbinger of leukemia; this point was seconded by other residents, who advocated a continual surveillance for malignancy.  A search for solid organ tumors so far has been unrevealing according to Dr. Grogan.  Dr. Harnisch thought that PET scans had different sensitivities and specificities according to the sugar label used.  The patient was most interested in some type of therapy for the rash, since at this time he is not being considered for chemotherapy for the MDS.  Several physicians advocated both reporting of this case to inform others of the link with MDS and EGR, and also consideration of treatment of the MDS.  Dr. Dan Lantz pointed out that the pathology was somewhat unusual for a gyrate erythema, and might engender the diagnosis of tumid LE (which would not be ruled out by a negative ANA), which should remain on the differential.  Dr. Olerud’s solicitation for therapy suggestions was met with little response.  Narrowband UVB and plaquenil were suggested, although plaquenil’s potential effects on the bone marrow may warrant some caution for its use.

 

Patient presentations from the WSDA/Pommerening Meeting on October 19, 2007
 
1.  A 17 yo boy presented by Dr. Virginia Sybert.  Patient has had multiple skin problems  including dermatitis, acne, and acanthosis nigricans.  His affect has been strange, he has an odd relationship with his mother and has been non-compliant with medications.  Current issues include pruritic erythematous papules, some follicular and some not, and pustules, some follicular and some not.  Biopsies of representative lesions have shown 1) superficial and deep mixed dermatitis with eosinophils and subcorneal necrosis, and 2) suppurative infundibulitis with bacteria.  The group felt that bacterial or pityrosporum folliculitis were possible entities and recommended culturing multiple pustules.  The patient’s clinical signs of insulin resistance may indicate a contributing factor as well.
 
2.  A 31 yo woman presented by Dr. Andy Chien.  Previously healthy patient with thickened plaques and atrophic areas on trunk and extremities which began several months after resolution of a systemic illness felt to be secondary to CMV infection.  Two sets of biopsies showed changes consistent with morphea.  She improved with prednisone up to 40 mg daily, but then progressed with deeper atrophy/sclerosis of the forehead.  Methotrexate was added at 15 mg per week.  She also takes hydroxychloroquine 400 mg per day.  The consensus of the group was that the diagnosis was morphea and that treatment with high dose pulse Solumedrol followed by methotrexate (as is done in pediatric cases) would be helpful.
 
3.  A 21 yo woman presented by Dr. Jerry Eisner.  Patient has Crouzon’s craniosynostosis with a history of multiple operations to correct facial defects.  She has had recurrent erythema and edema of the face for the past 20 months.  Facial outbreaks are preceded by characteristic prodrome of fatigue, anorexia, and irritability.  The erythema begins in the cheeks and gradually spreads to the remainder of the face.  Symptoms begin to taper off after 3-4 days.  Rheumatologic work-up negative.  Prednisone helps a little.  Oral antihistamines of no benefit.  Biopsy showed mild spongiosis, acanthosis and mounds of parakeratosis.  The group felt that allergic contact dermatitis, photodermatitis, solid facial edema due to multiple surgical procedures, immune complex disease and cyclical TNF-alpha disease are all possibilities.
 
4.  A 38 yo man presented by Dr. John Olerud.  Patient has 9 month history of progressive tightening of skin over chest, abdomen, arms and legs.  There are widespread firm plaques with some hard, white, shiny plaques as well.  There is violaceous discoloration in places and decreased range of motion of wrists and ankles.  Biopsy showed thickened collagen bundles throughout the dermis consistent with morphea.  The group agreed with the diagnosis and treatment options discussed included pulse Solumedrol and methotrexate, PUVA, doxycycline, hydroxychloroquine, and Bosantan.  Treatment with calcitriol thus far has not been helpful.
 
5.  A 5 yo Korean boy presented by Dr. Phil Fleckman.  Patient was said to have been born with a collodian membrane which peeled leaving red, flaky skin.  He has flexural eczema with ridge-like thickening of the soles and interdigital scaling.  He has never had hair.  The nails are thick without onycholysis.  Has a small cataracts, but no other eye problems.  Hearing is normal.  He doesn’t sweat.  He has photosensitivity.  Growth has been slow, but normal.  Discussion centered on a number of genodermatoses.  Autosomal recessive ichthyosis was suggested, but patients typically do not have nail or hair problems, or eczema.  Trichothidystrophy was suggested, but patients usually have some hair.  A type of ectodermal dysplasia was suggested as well.  Dr. Sybert felt that Netherton’s syndrome was a possibility, as well as non-bullous congenital ichthyosiform erythroderma.  Connexin defects should be considered as well.  She felt that Mary Williams in San Francisco would be helpful.  Dr. Hornung leaned against Netherton’s syndrome due to the absence of hair and lack of skin infections and favored something in the lamellar ichthyosis spectrum.  Although not 100% sensitive, SPINK5 testing is available to screen for Netherton’s.  Treatment for now centered on emollients until a diagnosis is made.
 
6.  A 22 yo woman presented by John Olerud.  She has had 7 year h/o well-demarcated erythematous well-demarcated plaques scattered on the face and left scalp.  Clinically consistent with discoid lupus, no biopsy performed.  ANA neg.  She has failed treatment with dapsone.  She decreased hydroxychloroquine from 200 mg to 400 mg per day due to cost.  She has not been willing to use clobetasol or chloroquine.  The group concurred with the diagnosis and discussed photoprotection, IL Kenalog, Protopic, and an experimental protocol with an antibody to interferon alpha.
 
7.  A 15 yo boy presented by Dr. Robin Hornung.  He has a history of Bartter-GItelman syndrome who has a 16 month history of recurring severe oral ulcerations and extreme lower lip swelling.  He also experiences extreme fatigue, malaise and anorexia and has require hospitalization.  He flares every 2-4 months and his lip does not return to normal size.  Prednisone helps some.  Dapsone led to hemolysis.  Biopsy showed an ulcer with neutrophilic debris and a diffuse mixed infiltrate with neutrophils suggestive of aphthae, or Behcet’s disease.  The other diagnoses suggested were cyclic neutropenia, a pyoderma gangrenosum variant, and recurring streptococcal infections.  Factitial dermatitis was suggested as well.  Therapy to improve oral hygeine, low dose prednisone, chronic tetracycline, acyclovir, a calcineurin inhibitor and intralesional kenalog were all recommended.
 
8.  A 51 yowoman presented by Dr. John Hackett.  She has a nine month history of alopecia with shiny, scarred plaques scattered over the scalp.  Biopsy was said to be consistent with DLE or lichen planopilaris.  She has just begun betamethasone valeratae lotion.  The consensus diagnosis was lichen planopilaris.  Treatment options include topical steroids, and anti-malarials.
 
9.  A 12 yo boy presented by Dr. Robin Hornung.  He has a 5 year history of oral ulcers and rash which flare independently of each other.  The skin shows erythema and scaling on the upper eyelids  and scaly hyperpigmented and lichenified plaques over the abdomen, buttocks and upper arms.  He has ulcers on the tongue and buccal mucosa.  The skin lesions have not changed over three years.  He has had no benefit from topical steroids or Protopic.  No helpwith colchicine.  Recent diagnosis of Crohn’s disease led to treatment with infliximab which helped ulcers and rash.  Biopsy showed lichenoid dermatitis with mild acanthosis and confluent parakeratosis.  The differential diagnosis includes an unusual connective tissue disease, lichenoid drug eruption (though no eosinophils seen on path), and keratosis lichenoided chronica.  Treatment suggested was cyclosporine.