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Case of the Month
A 56-year-old Hispanic female with a past medical history significant for basal cell carcinoma presented with a history of itchy, erythematous papules on her right cheek. Four days prior, she presented for suture removal after reconstruction with an island pedicle flap following Mohs micrographic surgery. She experienced a similar rash on her forearm following another surgery in the past.
a) Cellulitis
b) Contact dermatitis
c) Herpes simplex virus
Diagnosis: Contact dermatitis secondary to Mastisol and Steri-Strips
Contact dermatitis is a localized, pruritic, erythematous rash that occurs after contact with a certain allergen or irritant. The disorder is typically classified as either allergic contact dermatitis or irritant contact dermatitis.
Allergic contact dermatitis is a T cell–mediated, type-IV, delayed-type hypersensitivity reaction that requires prior sensitization with the causative agent before the patient becomes allergic to it. The typical rash of pruritus, erythema, edema, and vesicle formation occurs with further exposures.
The mechanism of immune response to a particular allergen requires that the antigen be of low molecular weight (less than 500 d) in order to penetrate the stratum corneum and gain access to the immunologic system. CD4, CD8, T regulatory cells, and natural killer T cells have all been implicated.
The process is composed of an afferent (sensitization) phase and an efferent (elicitation) phase.
Common haptens or immunogenic agents include nickel, urushiol from poison ivy resin, ultraviolet light, dyes, and fragrances.
This patient revealed a history of a similar reaction to the one presented in this case following wound dressing on her forearm with two products: Steri-Strips and Mastisol liquid adhesive. Unfortunately, she did not reveal this history until she had experienced the reaction a second time. The patient was instructed to apply hydrocortisone 1% cream twice daily to the red areas only and to follow up with a clinic visit in 4-5 days. Documentation of her allergy was included in her medical record.
This case was submitted by Dr. Keyvan Nouri; Dr. Katlein Franca; Jennifer Ledon; and Jessica Savas of the University of Miami.
–Donna Bilu Martin, M.D.
A 56-year-old Hispanic female with a past medical history significant for basal cell carcinoma presented with a history of itchy, erythematous papules on her right cheek. Four days prior, she presented for suture removal after reconstruction with an island pedicle flap following Mohs micrographic surgery. She experienced a similar rash on her forearm following another surgery in the past.
a) Cellulitis
b) Contact dermatitis
c) Herpes simplex virus
Diagnosis: Contact dermatitis secondary to Mastisol and Steri-Strips
Contact dermatitis is a localized, pruritic, erythematous rash that occurs after contact with a certain allergen or irritant. The disorder is typically classified as either allergic contact dermatitis or irritant contact dermatitis.
Allergic contact dermatitis is a T cell–mediated, type-IV, delayed-type hypersensitivity reaction that requires prior sensitization with the causative agent before the patient becomes allergic to it. The typical rash of pruritus, erythema, edema, and vesicle formation occurs with further exposures.
The mechanism of immune response to a particular allergen requires that the antigen be of low molecular weight (less than 500 d) in order to penetrate the stratum corneum and gain access to the immunologic system. CD4, CD8, T regulatory cells, and natural killer T cells have all been implicated.
The process is composed of an afferent (sensitization) phase and an efferent (elicitation) phase.
Common haptens or immunogenic agents include nickel, urushiol from poison ivy resin, ultraviolet light, dyes, and fragrances.
This patient revealed a history of a similar reaction to the one presented in this case following wound dressing on her forearm with two products: Steri-Strips and Mastisol liquid adhesive. Unfortunately, she did not reveal this history until she had experienced the reaction a second time. The patient was instructed to apply hydrocortisone 1% cream twice daily to the red areas only and to follow up with a clinic visit in 4-5 days. Documentation of her allergy was included in her medical record.
This case was submitted by Dr. Keyvan Nouri; Dr. Katlein Franca; Jennifer Ledon; and Jessica Savas of the University of Miami.
–Donna Bilu Martin, M.D.
A 56-year-old Hispanic female with a past medical history significant for basal cell carcinoma presented with a history of itchy, erythematous papules on her right cheek. Four days prior, she presented for suture removal after reconstruction with an island pedicle flap following Mohs micrographic surgery. She experienced a similar rash on her forearm following another surgery in the past.
a) Cellulitis
b) Contact dermatitis
c) Herpes simplex virus
Diagnosis: Contact dermatitis secondary to Mastisol and Steri-Strips
Contact dermatitis is a localized, pruritic, erythematous rash that occurs after contact with a certain allergen or irritant. The disorder is typically classified as either allergic contact dermatitis or irritant contact dermatitis.
Allergic contact dermatitis is a T cell–mediated, type-IV, delayed-type hypersensitivity reaction that requires prior sensitization with the causative agent before the patient becomes allergic to it. The typical rash of pruritus, erythema, edema, and vesicle formation occurs with further exposures.
The mechanism of immune response to a particular allergen requires that the antigen be of low molecular weight (less than 500 d) in order to penetrate the stratum corneum and gain access to the immunologic system. CD4, CD8, T regulatory cells, and natural killer T cells have all been implicated.
The process is composed of an afferent (sensitization) phase and an efferent (elicitation) phase.
Common haptens or immunogenic agents include nickel, urushiol from poison ivy resin, ultraviolet light, dyes, and fragrances.
This patient revealed a history of a similar reaction to the one presented in this case following wound dressing on her forearm with two products: Steri-Strips and Mastisol liquid adhesive. Unfortunately, she did not reveal this history until she had experienced the reaction a second time. The patient was instructed to apply hydrocortisone 1% cream twice daily to the red areas only and to follow up with a clinic visit in 4-5 days. Documentation of her allergy was included in her medical record.
This case was submitted by Dr. Keyvan Nouri; Dr. Katlein Franca; Jennifer Ledon; and Jessica Savas of the University of Miami.
–Donna Bilu Martin, M.D.
Make The Diagnosis
A 51 year-old-male presented with asymptomatic violaceous, indurated plaques on his left and right cheeks. He also had follicular plugging in the right ear. What’s your diagnosis?
Images courtesy Dr. Donna Bilu Martin
Diagnosis: Lupus Erythematosus Panniculitis
Lupus panniculitis, or lupus profundus, represents 2%-3% of all patients with lupus erythematosus. It most commonly occurs in adults aged 20-60. Patients present with tender subcutaneous nodules and plaques that tend to develop on the face, upper outer arms, shoulders, hips, and trunk. The distal extremities are usually spared. The overlying skin can show features of chronic cutaneous lupus including scaling, follicular plugging, atrophy, dyspigmentation, telangiectasias, and ulceration.
Histopathology reveals a primarily lobular panniculitis with a marked predominance of lymphocytes and scattered plasma cells. One characteristic feature is hyalin necrosis of fat lobules that can extend into the septa.
Treatment options include sunscreen, potent topical and intralesional corticosteroids, antimalarials, systemic steroids (in initial phases of disease), dapsone, cyclophosphamide, and thalidomide. This patient was treated with thalidomide, which resulted in improvement of his lesions.
This case was first presented at Maryland Derm, at the University of Maryland School of Medicine in Baltimore, by Dr. Bilu Martin and Dr. Anthony Gaspari.
Image courtesy Dr. Donna Bilu Martin
Histology shows a lobular panniculitis with a marked predominance of lymphocytes and scattered plasma cells.
A 51 year-old-male presented with asymptomatic violaceous, indurated plaques on his left and right cheeks. He also had follicular plugging in the right ear. What’s your diagnosis?
Images courtesy Dr. Donna Bilu Martin
Diagnosis: Lupus Erythematosus Panniculitis
Lupus panniculitis, or lupus profundus, represents 2%-3% of all patients with lupus erythematosus. It most commonly occurs in adults aged 20-60. Patients present with tender subcutaneous nodules and plaques that tend to develop on the face, upper outer arms, shoulders, hips, and trunk. The distal extremities are usually spared. The overlying skin can show features of chronic cutaneous lupus including scaling, follicular plugging, atrophy, dyspigmentation, telangiectasias, and ulceration.
Histopathology reveals a primarily lobular panniculitis with a marked predominance of lymphocytes and scattered plasma cells. One characteristic feature is hyalin necrosis of fat lobules that can extend into the septa.
Treatment options include sunscreen, potent topical and intralesional corticosteroids, antimalarials, systemic steroids (in initial phases of disease), dapsone, cyclophosphamide, and thalidomide. This patient was treated with thalidomide, which resulted in improvement of his lesions.
This case was first presented at Maryland Derm, at the University of Maryland School of Medicine in Baltimore, by Dr. Bilu Martin and Dr. Anthony Gaspari.
Image courtesy Dr. Donna Bilu Martin
Histology shows a lobular panniculitis with a marked predominance of lymphocytes and scattered plasma cells.
A 51 year-old-male presented with asymptomatic violaceous, indurated plaques on his left and right cheeks. He also had follicular plugging in the right ear. What’s your diagnosis?
Images courtesy Dr. Donna Bilu Martin
Diagnosis: Lupus Erythematosus Panniculitis
Lupus panniculitis, or lupus profundus, represents 2%-3% of all patients with lupus erythematosus. It most commonly occurs in adults aged 20-60. Patients present with tender subcutaneous nodules and plaques that tend to develop on the face, upper outer arms, shoulders, hips, and trunk. The distal extremities are usually spared. The overlying skin can show features of chronic cutaneous lupus including scaling, follicular plugging, atrophy, dyspigmentation, telangiectasias, and ulceration.
Histopathology reveals a primarily lobular panniculitis with a marked predominance of lymphocytes and scattered plasma cells. One characteristic feature is hyalin necrosis of fat lobules that can extend into the septa.
Treatment options include sunscreen, potent topical and intralesional corticosteroids, antimalarials, systemic steroids (in initial phases of disease), dapsone, cyclophosphamide, and thalidomide. This patient was treated with thalidomide, which resulted in improvement of his lesions.
This case was first presented at Maryland Derm, at the University of Maryland School of Medicine in Baltimore, by Dr. Bilu Martin and Dr. Anthony Gaspari.
Image courtesy Dr. Donna Bilu Martin
Histology shows a lobular panniculitis with a marked predominance of lymphocytes and scattered plasma cells.
Make the Diagnosis
Diagnosis: Contact Dermatitis to Paraphenylenediamine
The patient’s mother reported blisters, erythema, and scabbing in the area of the tattoo. Six months later, the patient underwent paraphenylenediamine patch testing and exhibited a reaction.
The patient was treated with mild topical steroids and a 4-day prednisone course prior to presentation. A week of clobetasol ointment improved the pruritus and erythema.
Henna is a green powdered extract derived from the leaves of the Lawsonia alba plant. The active ingredient is lawsone. Middle Eastern and Indian cultures use the extract to dye the hair, skin, and nails. Contact with the skin for an extended period of time yields a brownish orange pigment. In Western countries, Henna tattoos have gained popularity as a temporary alternative to ink tattoos.
Henna may be used in its pure form, however, paraphenylenediamine (PPD) is often added to darken the pigment, expedite drying time, and improve design accuracy. PPD is an allergen found in hair dyes and photographic film processing. It is a potent T-cell stimulator, and its efficacy is directly related to concentration and duration of exposure. Patch tests among individuals with henna contact dermatitis are negative to pure henna powder but react strongly to PPD, which has lead to the assumption that PPD is the main allergen in henna paste.
Henna tattoo inks have been found to have PPD concentrations as high as 15%-30%, and, often, the inks are in contact with the skin for several days after application. The hypersensitivity can sensitize individuals to PPD-containing substances such as dark hair dyes and dark clothing. Cross reaction may cause hypersensitivity to natural rubber latex, azo dyes, thiurams, PABA sunscreen, para-aminosalicylic acid, and benzocaine.
The initial inflammatory response may present as erythematous, eczematous, pruritic, or papulovesicular eruption in the area or boundary of the original design. Edema, anaphylaxis, and collapse are less common manifestations. The inflammation can result in scarring, keloid formation, and permanent, post-inflammatory pigment changes.
As demonstrated in my patient, hypopigmentation occurs more frequently in children than adults. Therapy includes protection of the blistered area, antihistamines, treatment of infection, and aggressive topical corticosteroid therapy.
This case was first presented at Maryland Derm, at the University of Maryland School of Medicine in Baltimore, by Dr. Martin, Dr. Vera David, and Dr. Anthony Gaspari.
Diagnosis: Contact Dermatitis to Paraphenylenediamine
The patient’s mother reported blisters, erythema, and scabbing in the area of the tattoo. Six months later, the patient underwent paraphenylenediamine patch testing and exhibited a reaction.
The patient was treated with mild topical steroids and a 4-day prednisone course prior to presentation. A week of clobetasol ointment improved the pruritus and erythema.
Henna is a green powdered extract derived from the leaves of the Lawsonia alba plant. The active ingredient is lawsone. Middle Eastern and Indian cultures use the extract to dye the hair, skin, and nails. Contact with the skin for an extended period of time yields a brownish orange pigment. In Western countries, Henna tattoos have gained popularity as a temporary alternative to ink tattoos.
Henna may be used in its pure form, however, paraphenylenediamine (PPD) is often added to darken the pigment, expedite drying time, and improve design accuracy. PPD is an allergen found in hair dyes and photographic film processing. It is a potent T-cell stimulator, and its efficacy is directly related to concentration and duration of exposure. Patch tests among individuals with henna contact dermatitis are negative to pure henna powder but react strongly to PPD, which has lead to the assumption that PPD is the main allergen in henna paste.
Henna tattoo inks have been found to have PPD concentrations as high as 15%-30%, and, often, the inks are in contact with the skin for several days after application. The hypersensitivity can sensitize individuals to PPD-containing substances such as dark hair dyes and dark clothing. Cross reaction may cause hypersensitivity to natural rubber latex, azo dyes, thiurams, PABA sunscreen, para-aminosalicylic acid, and benzocaine.
The initial inflammatory response may present as erythematous, eczematous, pruritic, or papulovesicular eruption in the area or boundary of the original design. Edema, anaphylaxis, and collapse are less common manifestations. The inflammation can result in scarring, keloid formation, and permanent, post-inflammatory pigment changes.
As demonstrated in my patient, hypopigmentation occurs more frequently in children than adults. Therapy includes protection of the blistered area, antihistamines, treatment of infection, and aggressive topical corticosteroid therapy.
This case was first presented at Maryland Derm, at the University of Maryland School of Medicine in Baltimore, by Dr. Martin, Dr. Vera David, and Dr. Anthony Gaspari.
Diagnosis: Contact Dermatitis to Paraphenylenediamine
The patient’s mother reported blisters, erythema, and scabbing in the area of the tattoo. Six months later, the patient underwent paraphenylenediamine patch testing and exhibited a reaction.
The patient was treated with mild topical steroids and a 4-day prednisone course prior to presentation. A week of clobetasol ointment improved the pruritus and erythema.
Henna is a green powdered extract derived from the leaves of the Lawsonia alba plant. The active ingredient is lawsone. Middle Eastern and Indian cultures use the extract to dye the hair, skin, and nails. Contact with the skin for an extended period of time yields a brownish orange pigment. In Western countries, Henna tattoos have gained popularity as a temporary alternative to ink tattoos.
Henna may be used in its pure form, however, paraphenylenediamine (PPD) is often added to darken the pigment, expedite drying time, and improve design accuracy. PPD is an allergen found in hair dyes and photographic film processing. It is a potent T-cell stimulator, and its efficacy is directly related to concentration and duration of exposure. Patch tests among individuals with henna contact dermatitis are negative to pure henna powder but react strongly to PPD, which has lead to the assumption that PPD is the main allergen in henna paste.
Henna tattoo inks have been found to have PPD concentrations as high as 15%-30%, and, often, the inks are in contact with the skin for several days after application. The hypersensitivity can sensitize individuals to PPD-containing substances such as dark hair dyes and dark clothing. Cross reaction may cause hypersensitivity to natural rubber latex, azo dyes, thiurams, PABA sunscreen, para-aminosalicylic acid, and benzocaine.
The initial inflammatory response may present as erythematous, eczematous, pruritic, or papulovesicular eruption in the area or boundary of the original design. Edema, anaphylaxis, and collapse are less common manifestations. The inflammation can result in scarring, keloid formation, and permanent, post-inflammatory pigment changes.
As demonstrated in my patient, hypopigmentation occurs more frequently in children than adults. Therapy includes protection of the blistered area, antihistamines, treatment of infection, and aggressive topical corticosteroid therapy.
This case was first presented at Maryland Derm, at the University of Maryland School of Medicine in Baltimore, by Dr. Martin, Dr. Vera David, and Dr. Anthony Gaspari.