Sponsored by: Committed to the future of dermatology ournal of the American Osteopathic College of Dermatology 2012-2013 OFFICERS J President: David Grice, DO, FAOCD President-Elect: Suzanne Rozenberg, DO, FAOCD First Vice President: Rick Lin, DO, FAOCD Second Vice President: Alpesh Desai, DO, FAOCD Third Vice President: Karthik Krishnamurthy, DO, FAOCD Secretary-Treasurer: Jere Mammino, DO, FAOCD (2010-2013) Editor-in-Chief Immediate Past President: Karthik Krishnamurthy, DO Bradley Glick, DO, FAOCD Trustees: Danica Alexander, DO, FAOCD (2012-2015) Reagan Anderson, DO, FAOCD (2012-2015) Mark Kuriata, DO, FAOCD (2010-2013) Sponsors: Daniel Ladd, DO, FAOCD (2012-2013) John Minni, DO, FAOCD (2011-2014) Bayer Bryan Sands, DO, FAOCD (2012-2014) Executive Director: Galderma Marsha Wise Resident Coordinator: Global Pathology Laboratory John Grogan FounJdAinOg CSpDonsor Administrative Grants Coordinator: Medicis Shelley Wood FounJdAinOg CSpDonsor Ranbaxy AOCD • 1501 E. Illinois • Kirksville, MO 63501 800-449-2623 • FAX: 660-627-2623 www.aocd.org COPYRIGHT AND PERMISSION: Written permission must be obtained from the Journal of the Ameri- JAOCD can Osteopathic College of Dermatology for copying or reprinting text of more than half a page, tables Founding Sponsor or figures. Permissions are normally granted contingent upon similar permission from the author(s), inclusion of acknowledgement of the original source, and a payment of $15 per page, table or figure of reproduced material. Permission fees are waived for authors wishing to reproduce their own articles. Request for permission should be directed to JAOCD c/o AOCD, PO Box 7525, Kirksville, MO 63501. Copyright © 2003 by the Journal of the American Osteopathic College of Dermatology Print and layout by: The Dimensional Group, Mason City, IA 50401 Copy editing: Julia Layton, Freelance Writing and Editing C able of ontents Fall 2012, Volume 24 FEATURED ARTICLE Purpura: A Clinical Review Helia Eragi, DO, Khasha Touloei, BS, David C. Horowitz, DO, FAOCD..................................................................................................9 T JAOCD Editors ............................................................................................................................................................................................................4 Letter from the Editor-in-Chief.................................................................................................................................................................................5 Letter from the Executive Director.......................................................................................................................................................................... .6 Letter from the President. ..........................................................................................................................................................................................7 Dermatofibroma-Like Glomus Tumor On The Knee Zhi Zhong Wang, MD, MSc, Andrew A. Simone, MD............................................................................................................................15 Day Spa Disasters: Patients' Injuries on the Rise Jonathan Crane, DO, FAOCD, Richard Flexner, JD, David Jackson, BS..................................................................................................16 Transient Reactive Aquagenic Acrokeratoderma on the Palms of a 62-Year-Old Female Brent Loftis, DO, Donna D. Tran, MSIV, Yoon Cohen, DO, Bill V. Way, DO, FAOCD..........................................................................19 A 49-Year-Old Male With Tender Firm Nodules On His Posterior Lower Legs Paul Aanderud, DO, R. Scott Thomas, MSIV, George Murakawa, MD...................................................................................................21 Plaque of the Glans Penis: Differential Diagnosis Melinda F. Greenfield, DO, Joseph M. Dyer, BS..........................................................................................................................................25 Advancement Flap for Distal Nasal Defects Albert E. Rivera, DO, FAOCD, Roger I. Ceilley, MD, Andrew K. Bean, MD, Joshua B. Wilson, MD..................................................27 Amelanotic Spindle Cell Melanoma in a Hispanic Male Charlotte Noorollah, DO, Suzanne Friedler, MD, Marvin Watsky, DO, FAOCD...................................................................................29 Cutis Marmorata Telangiectatica Congenita: A Case Report and Discussion Mari M. Batta, DO, Brandon G. Shutty, BS, Stephen Kessler, DO, Ronald C. Hansen, MD ................................................................31 A Suspicious Lesion Arising in a 28-Year-Old Female After Administration of Melanotan II Daniel Child, BS, Paul Aanderud, DO, Steven Grekin, DO, FAOCD.......................................................................................................33 Herpes Simplex Vegetans: An Uncommon Presentation in Human Immunodeficiency Virus Infection Theresa Cao, DO, Angela Combs, DO, Tracy Favreau, DO, David Droller, MD, Eli Piatigorsky, MD................................................34 Microcystic Adnexal Carcinoma in a 7-Year-Old Female Cathy Koger, DO, Chris Weyer, DO, Lloyd J. Cleaver, DO, Michael B. Morgan, MD............................................................................36 Periocular Verruca Plana Following Use of a Carbon Dioxide Laser Roxanna Menendez, DO, Jacqui Thomas, DO, Matthew Uhde, PA-C, Layne Nisenbaum, DO, FAOCD...........................................41 Hypopigmented Patches in a Young Columbian Boy Kurt Grelck, DO, Sheena Nguyen, BS, Andleeb Usmani, DO, Robin Shecter, DO, FAOCD..................................................................44 Reed Syndrome: Hereditary Leiomyomatosis and Renal Cell Cancer Peter J. Morrell, DO, FAOCD.......................................................................................................................................................................46 Primary Cutaneous Anaplastic Large-cell Lymphoma Ali Daneshvar, Indira Misra-Higgins, DO, FAOCD...................................................................................................................................48 A Case of Segmental Neurofibromatosis Alison Himes, DO, Kristi Hawley, DO, Dawn Sammons, DO..................................................................................................................50 Combined Nevus: Blue Nevus and Balloon Cell Nevus Justin Rubin, DO, Panagiotis Mitropoulos, DO, Carlos Gomez-Meade, DO, FAOCD, Evangelos Poulos, MD, Tracy Favreau, DO, FAOCD, Angela Combs, DO, FAOCD.........................................................................................................................................................55 A Case of Telangiectasia Macularis Eruptiva Perstans (TMEP) Samuel M. Wilson, DO, R. Scott Thomas, Allison K. Divers, MD, Daniel S. Hurd, DO, FAOCD........................................................57 Clinically Benign-appearing Papule: A Treatment Conundrum Brooke Walls, DO, David Dorton, DO, FAOCD.........................................................................................................................................63 Editor-in-Chief Founding Editor Copy Editor Karthik Krishnamurthy, DO Jay Gottlieb, DO Julia Layton, BA, MFA a e ssociate ditors Aaron Bruce, DO Michelle Foley, DO Scott Wickless, DO Loveland, CO Ormond Beach, FL Durango, CO e B ditorial oard Melinda Greenfield, DO Albany, GA Adriana Ros, DO Clifton, NJ 4 JAOCD EDitOrs e - -C etter from the ditor in hief L KarthiK Krishnamurthy, do, Faocd editor-in-chieF, Jaocd Dear AOCD Members and Residents, It is with great honor that I assume editorship of this fine journal. After 10 years of dedicated service, Dr. Jay Gottlieb has left our college with a proud legacy, and one that will continue to prosper. The JAOCD and the AOCD, sharing the same not-for-profit status, are more intimately connected starting this year.  Owing to this, and to foster transparency, I have created an Associate Editors Committee to serve as a resource for decision-making and future development. Aaron Bruce, DO, Michelle Foley, DO, Michael Scott, DO, and Scott Wickless, DO, have graciously stepped up to this task.  Each is fit to bring a fresh prospective and lend to the integrity of the articles we publish: Dr. Bruce in surgery, Dr. Foley in general dermatology and cosmetics, Dr. Wickless in dermatopathology, and Dr. Scott in dermatological wisdom that cannot be taught but only developed through experience.  In addition, we continue to boast a robust Editorial Board, currently consisting of 55 reviewers! I am constantly amazed by the loyalty and dedication of the members of our College. Please remember what a unique resource this journal is for our subspecialty college and the potential it possesses.  Please continue to submit your articles and encourage your colleagues to do so, too.  The better we make it, the broader its impact.  “Continued quality” will be the first focus going forward, relying on the following litmus tests: 1)      The article is written in brief language and in a professional, medical tone. 2)      The submission includes clinical photographs and/or pathology, when applicable. In the next year, with the implementation of stricter submission criteria, I hope to have the JAOCD approved for CME reading credits! I would like to thank my family for their support of my involvement in the College, as well as Dr. Cindy Hoffman, my program director, without whom I would not be practicing dermatology and experiencing all the happiness that brings.  I would also like to thank Marsha Wise, who is a fantastic resource in our home office.  Dr. Gottlieb, thank you for all your dedication and for entrusting me with your “baby.”  Thank you to Ranbaxy, Global, Bayer/Intendis, Medicis, and Galderma, whose generous donations keep the journal in print and coming to you.  Finally, I would like to thank Julia Layton, our copy editor, who is a pleasure to work with and without whom the JAOCD could not exist. Best, Karthik Krishnamurthy, DO, FAOCD Editor-in-Chief, JAOCD Third Vice President, AOCD LEttEr frOm thE EDitOr-in-ChiEf 5 e d etter from the xeCutive ireCtor L marsha Wise executiVe director, aocd Greetings, everyone! The 2012 Annual Meeting is now behind us, and new officers were elected at our annual business meeting on Monday, October 8, 2012. The AOCD has many committees working for the entire AOCD membership. If you would like to be a member of a commit- tee, please contact the AOCD office for more information. AOCD OFFICE UPDATE The AOCD is excited to announce that the office will be moving to a larger space. The move should be completed by December 21, 2012. Our post office box, 7525, is our preferred mailing address, and all correspondence should be sent there. We will continue to accept shipments at our 1501 E. Illinois St. address until the move is completed, and notice of our new physical address will be sent to the membership. 2013 AOCD Dues Renewal Notices were handed out in San Diego to those who attended OMED. If you did not attend, or did not pick up a renewal notice, we will mail your notice to you. In addition to renewing your AOCD dues, you may also designate additional funds to go to accounts earmarked for the AOCD Edu- cational Research Fund, the Koprince Award, AAD Camp Discovery, the Dermatopathology Fund (to help support fellowship candi- dates enrolled at the Ackerman Academy), and the Foundation for Osteopathic Dermatology. Meetings Update AOCD Midyear Meeting 2013 will be held January 23-26, 2013, in Winter Park, CO. Please call the Winter Park Hotel directly for your room reservations. Meeting Evaluations and Surveys AOA requirements for CME continue to evolve. Thank you to everyone for participating in the various surveys throughout the year and for returning meeting evaluations. The results are tabulated and reviewed by the Board of Trustees and the CME committee. Locations for future AOCD Midyear Meetings will be chosen based on survey results. ACGME UPDATE The American Osteopathic Association (AOA), the Accreditation Council for Graduate Medical Education (ACGME), and the American Association of Colleges of Osteopathic Medicine (AACOM ) have entered into an agreement to pursue a single, unified accreditation system for graduate medical education programs in the United States beginning in July 2015. As developments and details unfold, information for the osteopathic family can be found at www.osteopathic.org/acgme. There, you can find answers to frequently asked questions, the AOA’s joint press release, a timeline of the issue, and other resources. The AOCD Board of Trustees and the staff at the National Office wish everyone a happy and healthy holiday season. Marsha Wise Executive Director, AOCD 6 LEttEr frOm thE ExECutivE DirECtOr P etter from the resident L daVid l. Grice, do, Faocd President, aocd Our annual meeting in San Diego was filled with beautiful weather, great lectures and the opportunity to renew friendships. I would like to acknowledge my fellow Program Chairs, Brad Glick and Suzanne Rozenberg, for their assistance with putting together and running an outstanding meeting. I also want to thank the faculty and resident presenters who made this meeting both educational and interesting. The AOCD Board of Trustees made several significant decisions while in San Diego. First, we approved the move of our national office in Kirksville to a larger building, a much-needed move for our cramped executive director, Marsha Wise, and staff. Second, we are looking to improve our website, with the goal of having a more user-friendly site for our members, residents, and the public. You should see some of these changes in 2013. In other technologic news, our college already has an iPhone App and is close to releas- ing an Android version. Three new members of the American Osteopathic Board of Dermatology were approved by the BOT: Rene Bermudez, Tanya Ermolovich, and Scott Wickless. At our annual business meeting, Reagan Anderson was re-elected as an AOCD trustee, and three new trustees were elected: Danica Alexander, Bryan Sands, and Dan Ladd. On the political front, the AOCD is partnering with the AAD to stand firm against the new nurse practitioners’ doctorate degree, which would give nurses the title "doctor" and would therefore, we believe, deceive the public. Also, recently, the Women’s Derma- tologic Society had a bylaws change that reclassified osteopathic-trained dermatologists from active members to associate members. With the help of several leaders in the AOCD, the WDS President, Janet Hickman, M.D., and Immediate Past President Diane Ber- son, M.D., issued a letter stating that the Society leadership unanimously agrees to return osteopathic members to active status, pend- ing membership approval. First VP and Program Chair Rick Lin is busy preparing an outstanding lineup of speakers for our upcoming Midyear meeting at the Winter Park Lodge in Winter Park, Colorado, January 23-26, 2013. Please join us for the meeting, and later on the slopes for some great skiing! Best regards to you and your families, David L. Grice, DO, FAOCD President, AOCD LEttEr frOm thE PrEsiDEnt 7 Galderma: we know skin outside and in. Important Safety Information Oracea® (doxycycline, USP) is indicated for the treatment of only infl ammatory lesions (papules and pustules) of rosacea in adult patients. In clinical trials, the most common adverse events reported were gastrointestinal upsets, nasopharyngitis/pain, and nasal congestion/sinusitis. Oracea® should not be used to treat microbial infections, and should be used only as indicated. This drug is contraindicated in people who have shown hypersensitivity to any of the tetracyclines, and, like other tetracycline drugs, may cause fetal harm when administered to a pregnant woman. Oracea® should not be used during pregnancy, by nursing mothers, or during tooth development (up to the age of 8 years). Although photosensitivity was not observed in clinical trials, Oracea® patients should minimize or avoid exposure to natural or artifi cial sunlight. All contraindications, warnings, and precautions associated with tetracyclines must be considered before prescribing Oracea®. The safety of Oracea® treatment beyond 9 months has not been established. Galderma is a registered trademark. ©2011 Galderma Laboratories, L.P. Galderma Laboratories, L.P., 14501 N. Freeway, Fort Worth, TX 76177 GEN-316 Printed in USA. 08/11 P : a c r urPura linical eVieW Helia Eragi, DO,* Khasha Touloei, BS,** David C. Horowitz, DO, FAOCD*** *Dermatology Resident, Second Year, Western University/Pacific Hospital of Long Beach, Long Beach, CA **4th-year Medical Student, Western University of Health Sciences, Pomona, CA ***Program Chairman/Dermatology Residency Director, Western University/Pacific Hospital of Long Beach, Long Beach, CA ABSTRACT: Purpura is a common and nonspecific term used in medicine to describe the appearance of red or purple discoloration of the skin that does not blanch when pressure is applied. Purpura, petechiae and ecchymosis are caused by extravasation of red blood cells into the dermis. Petechiae are less than 5mm, purpura 5mm to 1 cm, and ecchymosis greater than 1 cm. Purpura is a common presenting problem at both inpatient and outpatient medical settings, with an extensive variety of underlying causes. This paper will review different case scenarios for patients presenting with purpura, differential diagnoses, and workups and algorithms necessary to rule in or rule out the underlying cause for the presenting symptom. Case 1: Purpura secondary Thrombocytopenia is either due to Based on the history, physical exam decreased platelet production, increased findings and the algorithm above, the to thrombocytopenia platelet destruction, or platelet sequestration patient has immune thrombocytopenic (1). Clinically, thrombocytopenia can manifest purpura (ITP). ITP presents as an isolated A 23-year-old female presents as purpura, petechiae, ecchymosis, mucosal thrombocytopenia one to six weeks after a complaining of a two-day history of a rash bleeding, meno-metrorrhagia in females, viral infection, secondary to an autoimmune involving both lower extremities. She also easy bruising, epistaxis, gastrointestinal process, and undergoes spontaneous reports some gingival bleeding that she first bleeding, hematuria or intracranial bleeding resolution within two months (4). Among noticed a couple of days ago. She states she (2). Bleeding doesn’t usually occur until adults under the age of 50, such as in the just got over a severe flu, but is feeling better. platelet count drops below 20,000 (3). Table 1 above case, the condition is more chronic Her past medical history is unremarkable, may be used to determine which tests should and persists longer than six months. The she denies a family history of bleeding be ordered to rule in or out a specific disease. disease mainly affects women between 20 disorders, and she is taking no medications. Vital signs are normal. Physical examination demonstrates small, non-palpable, punctate Table 1 Purpura, normal platelet count Purpura, decreased platelet count Purpura with sepsis purple lesions involving bilateral lower Vitamin K deficiency Alloimmune thrombocytopenia Trauma during birth extremities. CBC shows hemoglobin 14.0 g/dL (normal 12-16g/dL), hematocrit Trauma Maternal autoimmune Septicemia 42% (normal 36-46%), leukocyte count 7,000/mm3 (normal 4,000-12,000/mm3), thrombocytopenia (MAT) and platelet count 10,000/mm3 (normal In utero exposure to drugs Congenital amegakaryocytic Disseminated intravascular 150,000-400,000/mm3). Coagulation studies shows prothrombin time (PT) of thrombocytopenia coagulation (DIC) 10 seconds (normal 10-13 seconds), partial Hemophilia A/B Wiskott-Aldrich syndrome (WAS) TORCH infections thromboplastin time (PTT) of 35 seconds (normal 25-39 seconds), and international Child abuse Immune thrombocytopenic purpura Osteopetrosis normalized ratio (INR) 1.5 (normal 0.8- (ITP) Leukemia 1.2). Fibrinogen and fibrinogen degradation products are both within normal limits. What is the diagnosis? Algorithim 1: Differential Diagnosis: Immune thrombocytopenic purpura (ITP) Thrombotic thrombocytopenic purpura (TTP) Hemolytic uremic syndrome (HUS) Glanzmann disease (GD) Hermansky-Pudlak syndrome (HPS) Langerhans histiocytosisBernard Soulier disease (BS) von Willebrand disease (vWD) ErAgi, tOuLOEi, hOrOwitz 9 and 40 years of age (5). Chronic ITP commonly occurs in patients Based on the history, physical exam, and the algorithm, the with a history of alcohol or heroin abuse and patients with AIDS patient has either hemophilia A or B, X-linked recessive bleeding and/or prior rubella exposure (6). Chronic ITP most often presents disorders secondary to deficiency of either factor VIII or IX, with scattered petechiae of the distal arms and legs and possibly with respectively. Spontaneous bruising occurs in patients with hemophilia deep-lying ecchymoses. One distinguishing factor of ITP is that it is and presents as palpable ecchymosis but is not as common as rarely accompanied by splenomegaly (7). hemarthrosis, observed most commonly in knee joints (13). Large-area bruising occurs with vitamin K-dependent factor deficiency more so Hemolytic uremic syndrome (HUS) presents with purpura in than with hemophilia. The vitamin K-dependent factors are II, VII, the lower extremities, hemolytic anemia, thrombocytopenia, and IX and X, protein C, and protein S. Causes of vitamin K deficiency renal failure and is associated with E. coli 0157:H7. Thrombotic include cholestasis, fat malabsorption, prolonged antibiotic use, and thrombocytopenic purpura (TTP) has many similarities to HUS, but cystic fibrosis (14). A patient with DIC will have a history of septicemia, this disease mainly affects adults (8). TTP also exhibits neurological trauma, or shock (15). In liver failure, the liver is unable to synthesize defects and fever, which this patient did not exhibit. The patient in coagulation factors (16). The findings are similar to DIC but will also the above case did not have an increased partial thromboplastin include decreased levels of the vitamin K clotting factors. This can time (PTT) or family history of bleeding disorders, which rules also present with purpura, but more so with ecchymosis and other out von Willebrand disease (6). Glanzmann disease (GD) is another bleeding disorders (17). Liver function tests are helpful for diagnosis, differential that should be considered. The disease is characterized and risk factors for liver disease should be investigated. by improper platelet aggregation and manifests with multiple bruises and purpura (9). Bernard Soulier manifests with severe bleeding during Case 3: Purpura in age group birth to 2 years injury or surgery (10). However, this patient had no history of trauma or surgery. Patients with Langerhans histiocytosis also present with A 12-month-old boy is referred for evaluation of white eye reflex. thrombocytopenia, but will have other physical manifestations His mother suspects a hearing problem because he does not such as lymphadenopathy, hepatosplenomegaly, anemia and a papular, respond when she calls out his name. The physical examination vesicular, and purpuric rash. This syndrome is diagnosed by skin biopsy (11). reveals a continuous, machine-like murmur over the second right intercostal space and purple lesions on his arms and chest that were Another disease that may present with purpura secondary to apparent since birth. The initial investigation reveals thrombocyto- platelet dysfunction is Hermansky-Pudlak syndrome (HPS), which penia. What is the most likely diagnosis? is a very rare genetic disorder characterized by oculocutaneous albinism and accumulation of ceroid lipofuscin, a lipid-protein Differential Diagnosis complex, in lysosomes. The disease is commonly found in albino Purpura, normal platelet count Purpura, decreased platelet count Purpura with sepsis Puerto Ricans. Diagnosis is made by clinical presentation, a platelet Vitamin K deficiency Alloimmune thrombocytopenia Trauma during birth function test, and electron microscopy to analyze the dense-body Trauma Maternal autoimmune Septicemia granules in platelets (12). thrombocytopenia (MAT) Case 2: Purpura secondary to a coagulation disorder In utero exposure to drugs Congenital amegakaryocytic Disseminated intravascular thrombocytopenia coagulation (DIC) A 25-year-old male presents with a purpuric, swollen, tender Hemophilia A/B Wiskott-Aldrich syndrome (WAS) TORCH infections right thigh with some joint swelling after bumping into a table in Child abuse Immune thrombocytopenic purpura Osteopetrosis his living room. Pulsation is decreased over the left popliteal artery. (ITP) Leukemia He has a family member who suffered from a clotting disease with bleeding into joints. Given his family history of bleeding disorder, Algorithm 3: what is the diagnosis? Differential Diagnosis: Hemophilia A Hemophilia B Disseminated intravascular coagulation (DIC) Hematoma secondary to contusion/trauma Liver failure Vitamin K deficiency Algorithm 2: The classic triad of congenital rubella syndrome is sensorineural deafness, cardiac malformations, and cataracts (18). The purpuric rash described in the above case, also known as blueberry muffin baby, along with history and physical exam is consistent with congenital rubella, which is one of the TORCH infections (toxoplasmosis, other [syphilis], rubella, 10 PurPurA: A CLiniCAL rEviEw