Allergic Contact Dermatitis (ACD) to Topical Products in Orthopedic Surgery: Clinical Characteristics and Treatment Strategies.

The potential for many of the commonly used surgical site wound adhesives, skin antiseptic solutions, topical antibiotics, and suture materials to sensitize and subsequently result in allergic contact dermatitis (ACD) has become increasingly recognized within orthopedic surgery. Particularly with subsequent exposure to the offending allergen, the cutaneous allergic reaction may present in a similar fashion to cellulitis, thus making early differentiation between the two etiologies to initiate the appropriate and timely treatment crucial. Recognition of the characteristic appearance and severity of ACD surrounding a surgical wound often drives the initial management. This typically consists of anti-histamines, topical corticosteroids, and possible removal of the offending allergen for low grade findings and oral steroids and prophylactic oral antibiotics for the more severe reactions. Multidisciplinary care, including the expertise of a dermatologist or wound care specialist when faced with this challenging clinical scenario is critical and elective patch testing may be indicated to ascertain the exact allergen involved, particularly in patients with a prior history of wound issues. Finally, any clinical cases of ACD following an orthopedic procedure should be documented in the patient's chart so that exposure can be avoided with any future surgery.

Necrobiosis lipoidica.

A 58-year-old woman presented with a seven-year history of an eruption on her lower legs that was associated with edema, weeping, pruritus, and a burning sensation. Past medical history included Hashimoto thyroiditis, which was diagnosed eight years prior to presentation. Histopathologic examination was consistent with necrobiosis lipoidica (NL). To our knowledge, NL that is associated with Hashimoto thyroiditis has been described in only one prior report. NL is a chronic, cutaneous, granulomatous condition with degenerative connective-tissue changes of unknown etiology. Our patient responded well to a potent topical glucocorticoid and topical tretinoin. Although our patient did not have diabetes mellitus, 75 percent of patients with NL have diabetes mellitus at the time of diagnosis or will subsequently develop diabetes mellitus. This association with diabetes mellitus mandates screening for glucose intolerance in all patients with NL.

Facial follicular porokeratosis: a case report.

Porokeratosis is a disorder of keratinization, characterized clinically by a peripheral keratotic ridge and histologically by the cornoid lamella. We describe a patient with follicular porokeratosis with a distinctive clinical presentation. We believe that follicular porokeratosis is a unique histopathologic variant of porokeratosis, with cornoid lamellae centered in follicular infundibula. Further, this is the only report of follicular porokeratosis involving the face exclusively.

Lymphedema praecox.

A 57-year-old man presented with the post-pubertal onset of asymptomatic swelling of the left arm and legs that had been complicated by recurrent bouts of cellulitis. The presentation and disease course are consistent with lymphedema praecox, which is a subtype of primary lymphedema with onset at puberty and a slowly progressive course. The subtypes of lymphedema, pathogenesis, and treatment are reviewed.

Phacomatosis pigmentokeratotica associated with hemihypertrophy and a rhabdomyosarcoma of the abdominal wall.

Phacomatosis pigmentokeratotica (PPK) represents a specific "twin nevus" syndrome in which a speckled lentiginous nevus (SLN) is associated with an organoid nevus with sebaceous differentiation. A boy with a large nevus sebaceus on the left face and upper part of the trunk, a giant segmental SLN extending from the abdomen to the feet bilaterally, and right hemihypertrophy developed an embryonal rhabdomyosarcoma of the right abdominal wall at age 6 months. A variety of musculoskeletal, neurologic, and ocular anomalies have been observed in patients with PPK, reflecting the individual manifestations of both SLN and Schimmelpenning syndromes. This report adds hemihypertrophy to the spectrum of extracutaneous manifestations of PPK and, to our knowledge, represents the first observation of a rhabdomyosarcoma arising in contiguity with an SLN in a patient with PPK. The development of a rhabdomyosarcoma in our patient likely reflects both increased propensity for growth (as evidenced by the hemihypertrophy) and the pluripotent nature of neural-crest derived cells within the field defect that underlies an SLN.

Scleredema and diabetic sclerodactyly.

A 40-year-old man presented with hardening of the skin of his hands and upper back, which had slowly worsened with time. His medical history included insulin-dependent diabetes mellitus since childhood. Histopathologic features of a biopsy specimen from the skin of his back showed a thick reticular dermis with collagen bundles in a haphazard array, which were separated by increased deposits of connective-tissue mucin. Scleredema and diabetic sclerodactyly are both well recognized skin findings that may occur in patients with diabetes mellitus. It is important to differentiate this condition from scleroderma. Treatment is difficult, and therefore many modalities have been used. This patient has improved with aminobenzoate, colchicine, and DMSO gel.

Diffuse large cell non-Hodgkin's lymphoma, CD30+, T-cell phenotype.

A 63-year-old Chinese man presented with an eczematous dermatitis that progressed into a multifocal nodular eruption. Histopathologic examination demonstrated a nodular and diffuse infiltrate in the reticular dermis, which was composed of lymphocytes, macrophages with granulomatous inflammation, and numerous eosinophils. Reactive lymphoid follicles with germinal centers also were present. Immunohistochemistry showed CD30 and LCA. ALK-1 and CD20 were negative. A diagnosis of CD30+ cutaneous T-cell lymphoma was made, and the patient is currently undergoing staging of his disease. Treatment options include excision of nodules, radiation therapy, and systemic chemotherapy.

Berloque dermatitis mimicking child abuse.

Berloque dermatitis is a type of photocontact dermatitis. It occurs after perfumed products containing bergamot (or a psoralen) are applied to the skin followed by exposure to sunlight. Striking linear patterns of hyperpigmentation are characteristic, corresponding to local application of the scented product. In the acute phase, erythema and even blistering can be seen. We report a case of berloque dermatitis in a 9-year-old girl that was initially reported as child abuse. To our knowledge, this is the first report of berloque dermatitis mimicking child abuse. Questioning to elicit a history of perfume application coupled with sunlight exposure should help to prevent this misdiagnosis in children.

Birt-Hogg-Dube syndrome.

27-year-old woman presented with multiple growths on her face and upper body, which she has had for several years. She also reported that her mother and maternal grandmother have similar lesions and that her mother has been diagnosed with Birt-Hogg-Dube syndrome. Histopathologic features of one papule demonstrated basaloid cells emanating from a dilated follicular infundibula surrounded by a well-circumscribed fibromucinous stroma. Birt-Hogg-Dube syndrome is an autosomal-dominant-inherited condition characterized by fibrofolliculomas, trichodiscomas, and acrochordons. It is associated with renal tumors, spontaneous pneumothoraces, and possibly intestinal polyps. Treatment includes evaluation for associated renal, lung, and intestinal findings as well as cosmetic removal of skin lesions.

Dermatomyositis.

A 51-year-old woman presented with weakness in her arms and legs and an eruption on the dorsal aspects of the hands, upper back, and face. Histopathologic features showed vacuolar alteration of the basal layer, a thick basement membrane, and deposits of connective-tissue mucin in the papillary dermis and the upper reticular dermis. Dermatomyositis is an idiopathic disease that is characterized by specific cutaneous manifestations and myopathy, which may be associated with occult malignancy. Treatment options include corticosteroids and other immunosuppressive agents such as methotrexate, cyclosporine, mycophenolate mofetil, and azathioprine.

A case of hermansky-pudlak syndrome with pulmonary sarcoidosis.

Hermansky-Pudlak syndrome is an autosomal recessive disorder of lysosomal storage characterized by the triad of occulocutaneous albinism, bleeding diathesis, and pulmonary fibrosis. Sarcoidosis is a disease characterized by the development of noncaseating granulomas, most commonly affecting the lungs. The pathophysiology, histological findings, clinical symptoms, and treatment of the pulmonary manifestations of Hermansky-Pudlak syndrome are distinct from those of sarcoidosis. As patients with occulocutaneous and bleeding manifestations of Hermansky-Pudlak syndrome may also develop pulmonary fibrosis, the authors present this case to illustrate that pulmonary symptoms must be carefully evaluated in those with this syndrome because in this case, the patient developed underlying pulmonary sarcoidosis. To the authors' knowledge, this is the first documented case of Hermansky-Pudlak syndrome with concomitant pulmonary sarcoidosis.