DERMCASE

Test your knowledge with multiple-choice cases

This month – 8 cases:

1. Leg, Arm, and Chest Papules p.30 5. Pruritic, Purple Papules p.35
2. Asymptomatic Nose Lesion p.31 6. The Shy Toe p.36
3. Black and White Papules p.32 7. Skin Coloured Bumps p.38
4. Elevated, Tan Coloured Lesion p.34 8. Hanging Skin Growths p.40

Case 1

Leg, Arm, and Chest Papules

This 50-year-old male has been experiencing devel-
oping papules on his legs, arms, and chest over the
past 15 years. Those on the left thigh are violaceous,
grouped, and tender. His mother has similar lesions.
He has a history of renal cancer.

What is your diagnosis?

a. Multiple leiomyomata
b. Glomus tumours
c. Angiomata
d. Spiroadenomata
e. Angiolipomas

Answer
Multiple leiomyomata (answer a) are benign tumours
arising from the arrector pili muscles. They may also Most patients with multiple leiomyomata have a muta-
arise in dartotic, vulvar, or mammillary muscle. tion in the fumarate hydratase gene. As the lesions are
Multiple, cutaneous leiomyomata are firm, benign, they can be left alone, excised, or ablated if
brownish to violaceous papules, ranging in size symptomatic or cosmetically unacceptable. Patients
from 2 mm to 20 mm, single or grouped on the with multiple leiomyomata should be appropriately
trunk and extremities. Most commonly they appear checked for renal carcinoma as well as uterine leiomy-
in individuals who are10- to-40-years-of-age. omata in women.
This type is inherited as a dominant trait. There
Stanley Wine, MD, FRCPC, is a Dermatologist in North
is a predisposition to type 2 papillary renal carcino- York, Ontario.
ma (Reed’s Syndrome), and women are prone to
uterine leiomyomata.

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Case 2

Asymptomatic Nose Lesion

A 35-year-old-male is noted to have a stable, asympto-
matic lesion on his nose of over 10-years duration.

What is your diagnosis?

a. Pyogenic granuloma
b. Nevus sebaceous
c. Nevus anemicus
d. Fibrous papule
e. Basal cell carcinoma

Answer
Fibrous papule (answer d) is a common, benign
tumour of the face. It is best considered to be a vari-
ant of an angiofibroma. Pathology reveals a prolif-
eration of dendritic cells within fibrous tissue.
Clinical examination displays a translucent-white The main differential diagnosis is a basal cell carci-
papule with a smooth dome shaped surface in a young noma (BCC). BCC is characterized by rapid growth
adult to middle aged person. The majority of lesions with a history of spontaneous bleeding. Fibrous
are asymptomatic, although there may be a history of papules may be removed on a cosmetic basis or due to
bleeding with minor trauma. The most common site of a medical concern to rule out the possibility of BCC.
involvement is the nose, although it may occur else- Simple shave excision is sufficient for a nice cosmetic
where on the face and body. Fibrous papule tends to result.
be solitary in nature and measure less than 5 mm in Simon Lee, MD, FRCPC, is a Dermatologist who
diameter. practices in Richmond Hill, Ontario

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Case 3
Black and White Papules
An eight-and-a-half-year-old girl presents with a linear
plaque of white and black papules above the left
nasolabial fold. It has been present for a year.

What is your diagnosis?

a. Lichen striatus
b. Facial angiofibromas
c. Milia
d. Acne vulgaris
e. Nevus comedonicus

Answer
Nevus comedonicus (answer e) is a rare lesion of fol-
licular origin. It is usually present at birth and may
become more evident during the first decade of life. It
appears as a plaque composed of hyperkeratotic frequently affected than boys. Most commonly, it
papules and horny plugs resembling the comedones of affects the extremities. The lesions are usually asymp-
acne vulgaris. They often present in a linear distribu- tomatic and resolve spontaneously within 3 to 24
tion. The lesions may give the texture of the skin a months (with a mean duration of six months).
grater-like feeling. Nevus comedonicus tends to grow Milia are small retention cysts commonly seen on
in proportion with the affected child. Management is the faces of newborns. They result from retention of
very challenging, as most medical therapies are keratin within the dermis and appear as tiny 1 to 2 mm
ineffective. Definitive therapy for cosmetically signifi- pearly white or yellow papules. They are most promi-
cant lesions is surgical excision. nent on the cheeks, nose, chin, and forehead. Milia usu-
Facial angiofibromas are benign dermal neo- ally disappear by the first three to four weeks of life and
plasms that consist of dermal fibroplasia and dilat- require no therapy. Secondary milia may also occur
ed blood vessels. Multiple facial angiofibromas are following blistering or trauma and also in certain pre-
frequently seen in patients with tuberous sclerosis disposing conditions, such as bullous pemphigoid,
(also known as adenoma sebaceum complex), inherited and acquired epidermolysis bullosa, bullous
multiple endocrine neoplasia type 1, and Birt-Hogg- lichen planus, porphyria cutanea tarda, and burns.
Dubé syndrome. Lesions of adenoma sebaceum are Variants of milia include milia en plaque and multiple
discrete, firm, reddish papules that frequently eruptive milia.
develop in the nasolabial folds during late childhood Acne vulgaris is an extremely common disease and
to early adolescence, increasing in size and number is characterized by noninflammatory, open or closed
during puberty. These may be removed by laser comedones and by inflammatory papules, pustules, and
treatment. nodules. Acne vulgaris affects the areas of skin with the
Lichen striatus is a self-limiting dermatitis that pre- densest population of sebaceous follicles, including the
sents with a unilateral-curvilinear collection of small, face, the upper part of the chest, and the back.
erythematous, flat-topped papules that follow Jack Chang is a final year Medical Student at the University
Blaschko’s lines (the path of ectodermal embryologic of British Columbia, Vancouver, British Columbia.
development of skin). The mean age of onset is four- Joseph M. Lam is a Clinical Assistant Professor of
years-of-age, and girls are two-to-three-times more Paediatrics and Associate Member of the Department of
Dermatology and Skin Sciences at the University of British
32 The Canadian Journal of CME / May 2012 Columbia. He practices in Vancouver, British Columbia.
 DERMCASE

Case 4

Elevated, Tan Coloured Lesion

This lesion was detected during this man’s yearly phys-
ical. Though he was not concerned about it, as he has
had it for about 10 years now, he did, however, wish to
know what the lesion could be symtomatic of.

What is your diagnosis?

a. Keratoacanthoma
b. Basal cell carcinoma
c. Hypertophic lichen planus
d. Seborrheic keratosis

Answer
Seborrheic keratosis (answer d) (also known as sebor-
rheic verruca, senile keratosis, and senile wart) is a non-
cancerous benign skin growth that originates in ker-
atinocytes. Seborrheic keratoses are seen more often in refer to seborrheic keratosis as “seborrheic warts;”
aging persons. In fact, they are sometimes humorously however, these lesions are usually not associated with
referred to as “the barnacles of old age.” HPV, and, therefore, such nomenclature should be
Seborrheic keratoses are benign, but secondary discouraged.
tumours, however, Bowen’s disease (squamous cell car- Generally, the treating physician should reassure the
cinoma in situ) or malignant melanoma may occasion- patient of the benign nature of these lesions, however,
ally arise within the lesion. Seborrheic keratoses can becasue they can be unsightly, there are some treatment
also catch on clothing and become irritated. They can options available to ameliorate their appearance.
itch, grow, and bleed. Ketoconazole cream can be applied twice daily, keto-
They appear in various colours, from light tan to conazole tablets 200 mg q.d. for 7 to 14 days can be
black. They are round or oval, feel flat or slightly ele- tried as well. Low potency glucocorticoid creams can
vated (like the scab from a healing wound), and range give very good results; the lesions can also
in size from very small to more than 2.5 cm across. be surgically removed.
They can resemble warts, though they do not have a Hayder Kubba, MBChB, LMCC, CCFP, FRCS(UK),
viral origin. They can also resemble melanoma skin DFFP, DPD, graduated from the University of Baghdad,
cancer, though they are unrelated to melanoma as well. where he initially trained as a Trauma Surgeon. He
moved to Britain, where he received his FRCS and
Because only the top layers of the epidermis are worked as an ER Physician before specializing in Family
involved, seborrheic keratosis are often described as Medicine. He is currently a Family Practitioner in
Mississauga, Ontario.
having a “pasted on” appearance. Some dermatologists

34 The Canadian Journal of CME / May 2012

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Case 5

Pruritic, Purple Papules

A 43-year-old, overweight female presents with prurit-
ic, purple papules on her shins and wrists.

What is your diagnosis?

a. Lichen planus
b. Pustular psoriasis
c. Nummular eczema
d. Pityriasis rosea
e. Lichen simplex chronicus

Answer
Lichen planus (answer a) is a fairly common, pruritic,
inflammatory disease of unknown etiology. These
lesions are characteristically small, violaceous, flat-
topped, polygonal papules. They predominantly affect
the skin and can also affect the hair follicles, mucous considered a self-limited disease, often resolving with-
membranes, and nails (5 to 10%). On the surface of in 10 to 15 months. Mild to moderate cases can be man-
some lesions, grey or white streaks may be noted aged with moderate to potent topical steroids. More
(Wickham’s striae), although this is most commonly severe or generalized involvement can be treated with
seen on the mucous membranes. It has a predilection phototherapy and in some cases with systemic steroids
for the flexor wrists, shins, ankles, and glans penis. or oral retinoids.
Lichen planus is a clinical diagnosis, although Benjamin Barankin, MD, FRCPC, is a Dermatologist
a biopsy is sometimes needed for confirmation. It is practicing in North York, Ontario.

The Canadian Journal of CME / May 2012 35

 DERMCASE
In patients with seasonal allergic
rhinitis, AVAMYS® significantly
reduced Total Nasal Symptom Scores
(rTNSS) and Total Ocular Symptom
Case 6 Scores (rTOSS) vs. placebo.1*
[Reductions in daily rTNSS: AVAMYS® -4.94 vs.
placebo -3.18, p<0.001; reductions in daily rTOSS:
AVAMYS® -3.00 vs. placebo -2.26, p<0.001.]

AVAMYS® is indicated for the treatment of seasonal

The Shy Toe and perennial allergic rhinitis and their associated
symptoms in patients 12 years of age and older and
for the treatment of seasonal and perennial allergic
rhinitis in pediatric patients 2 to <12 years of age.
AVAMYS® is contraindicated in patients with a hyper-
sensitivity to any of its ingredients.
The most common adverse events observed in adults/
adolescents with seasonal or perennial allergic
rhinitis treated with AVAMYS® 110 mcg/placebo
were: headache (9%/8%), epistaxis (8%/5%),
pharyngolaryngeal pain (3%/1%), nasal septum
ulceration (1%/<1%), nasopharyngitis (2%/2%),
back pain (1%/<1%), upper respiratory tract infection
(1%/1%), and nausea (1%/<1%). In a 1-year study
in adults/adolescents, adverse events were similar
in type and rate between AVAMYS® and placebo.
However epistaxis occurred more frequently in the
group receiving AVAMYS® vs. placebo (20% vs. 8%,
respectively) and was of mild intensity in the majority
of patients (AVAMYS®: 83/123; placebo: 17/17).
The most common adverse events observed in children
with seasonal or perennial allergic rhinitis treated
with AVAMYS® 55 mcg/AVAMYS® 110 mcg/placebo
were: headache (8%/8%/7%), nasopharyngitis
An abnormality of an infant male’s toe is noticed (5%/5%/5%), epistaxis (5%/4%/4%), pyrexia
(5%/4%/2%), pharyngolaryngeal pain (4%/3%/3%),
during a routine visit to the clinic. cough (3%/4%/3%), and bronchitis (3%/2%/3%).
Avoid use in patients with recent nasal ulcers, nasal
surgery, or nasal trauma.
What is your diagnosis? There is no evidence of HPA axis suppression following
prolonged (12 months) treatment with AVAMYS®.
a. Syndactyly When intranasal steroids are used at higher than
b. Congenital curly toe (clinodactyly) recommended dosages or in susceptible individuals
at recommended dosages, systemic corticosteroid
c. Club foot effects may occur such as hypercorticism, suppression
of HPA function, and/or reduction of growth velocity
d. Normal variation in children or teenagers. A phase IV clinical trial
(one-year linear growth study) is being carried out
to evaluate the effect of AVAMYS® on long term
Answer growth in pediatric patients. Physicians should closely
monitor the growth of children taking corticosteroids.
Congenital curly toe (answer b) is a condition of an Based on data with another glucocorticoid
metabolized by CYP3A4, co-administration with
underlapping toe. Commonly involved toes are the ritonavir is not recommended.
third, fourth, or fifth toes of both feet. Although the Corticosteroids may mask some signs of infection
and new infections may appear. Potential worsening
exact cause of this condition is unknown, it tends to of existing tuberculosis; fungal, bacterial, viral,
or parasitic infections; or ocular herpes simplex
follow a familial pattern. may occur.
Choice of treatment depends on the degree of the Nasal and inhaled corticosteroids may result in the
development of glaucoma and/or cataracts. Close
deformity, presence of symptoms, and age of the monitoring is warranted in patients with a change
child. If the patient’s symptoms are minimal, the in vision or with a history of increased intraocular
pressure, glaucoma, and/or cataracts.
wait-and-see approach is recommended. If surgery *Study #FFR103184. A 2-week, randomized, double-blind,
parallel-group, multicentre, placebo-controlled study
is indicated, the plastic surgeon will release the comparing AVAMYS® 110 mcg QD as 2 sprays in each nostril;
(n=141) vs. placebo (n=144) in patients with seasonal
tendon in the bottom of the toe for flexible deformi- allergic rhinitis.
ty. Removal of a small portion of the toe might be REFERENCE: 1. Product Monograph of AVAMYS®.
GlaxoSmithKline Inc. September, 2011.
necessary.
Cherinet Seid, MD, LMCC, CCFP, DTM (RCPS Glas),
is the Lead Physician of the North Renfrew Family Health
Team, Deep River, Ontario, Emergency Physician at Deep
River and District Hospital, and Assistant Professor at AVAMYS® is a registered trademark used under license
Northern Ontario School of Medicine, Sudbury, Ontario. by GlaxoSmithKline Inc.
© 2012 GlaxoSmithKline Inc. All rights reserved.

36 The Canadian Journal of CME / May 2012

See prescribing summary
on page 
OCULAR
O CULAR SYMPTOM
SYMPTOM RELIEF:
RELIEF:
IN
I N PROGRESS
PROGRESS...

NASAL
N ASAL SYMPTOM
SYMPTOM R
RELIEF:
ELIEF:
IN
I N PROGRESS
PROGRESS...

Proven performance in allergic rhinitis.

 DERMCASE

Case 7

Skin Coloured Bumps

A 16-month-old girl presents with skin coloured
papules over the left axillae and trunk of five-weeks
duration.

What is your diagnosis?

a. Eruptive vellus hair cysts
b. Papular urticaria
c. Impetigo
d. Molluscum contagiosum
e. Fox-Fordyce disease

Answer
Molluscum contagiosum (answer d), caused by a
member of the poxvirus family, presents with
smooth, skin coloured, dome shaped papules and is
common in children. The lesions can range from response to insect bites that commonly occur in
2 to 8 mm and may contain a small central depres- open, exposed areas.
sion that houses the viral bodies. The papules usual- Impetigo typically presents as erythematous
ly present in clusters and occasionally in linear con- papules with honey yellow coloured crusting,
figurations, due to koebnerization. This infection caused by a superficial staphylococci or streptococ-
spreads from skin-to-skin contact, usually in areas ci skin infection. These papules occur most fre-
where rubbing occurs. Some children may also pre- quently on exposed areas of the body and can occur
sent with a red, scaly dermatitis surrounding the as a secondary complication of atopic dermatitis.
papules, which can be itchy. Molluscum is self-lim- Fox-Fordyce disease is rare in prepubertal chil-
iting and spontaneously clears over the years. dren and is a chronic papular eruption in apocrine
Common interventions to expedite clearance for gland-bearing areas, such as the axillae, and per-
cosmetic purposes include topical tretinoin cream, ineal regions. The papules are similar in appearance
cantharidin blistering agent (off-label use), to molluscum, but erythema and pruritis can be
imiquimod cream, cryotherapy, and curettage. more pronounced.
Although eruptive vellus hair cysts are similar in Michelle Long is a final year Medical Student at the
appearance to molluscum, hair cysts are often University of Saskatchewan, Saskatoon, Alberta.
hyperpigmented and are commonly found on the
Gabriel Hung is a third year Medical Student at the
anterior chest. The lesions are comparatively small- University of British Columbia, Vancouver, British
er in size, ranging from 1 to 3 mm. Columbia.
Papular urticaria is characterized by intense pru- Joseph M. Lam is a Clinical Assistant Professor of
ritis and surrounding erythema, often preceded by a Pediatrics and Associate Member of the Department of
weal at the same site. These lesions form in Dermatology and Skin Sciences at the University of British
Columbia. He practices in Vancouver, British Columbia.

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Case 8

Hanging Skin Growths

A 51-year-old male presents with multiple papules on
the neck, axillae, and groin, which have been multiply-
ing over the years.

What is your diagnosis?

a. Molluscum contagiosum
b. Common warts
c. Seborrheic keratoses
d. Achrocordons
e. Pedunculated nevi

Answer
Achrocordons or skin tags (answer d) are common,
benign hanging growths, commonly found on the neck,
armpits, groin, and eyelids. Both genders are affected,
and they become increasingly common with age and Treatment for cosmesis includes, electrosurgery,
weight gain. They are particulary common in pregnan- laser ablation, snip excision, and cryotherapy.
cy and obesity, and those with type 2 diabetes mellitus.
Benjamin Barankin, MD, FRCPC, is a Dermatologist
Chaffing/rubbing, and HPV may also play a role. They practicing in North York, Ontario.
are typically flesh-coloured, though they can also be
darker, and they range in size from 1 to 10 mm.

40 The Canadian Journal of CME / May 2012