The store-and-forward feature of teledermatology allows patient medical information (including history and visual data) obtained from one provider's location to be electronically transferred to a provider in another location (Roman & Jacob, 2015). The construct of the TeleDermViewPoint column is such that cases are presented in a standardized teledermatology reader format reflective of an actual teledermatology report.
TELEDERMATOLOGY READER REPORT1
History
Chief complaint: presenting for diagnosis of lesion.
History of Present Illness
A 52-year-old man presents with acute-onset red-brown macules covered at points with scales that developed over the past few weeks. His prior treatment: topical antifungals. His primary symptoms: pruritus. Prior biopsies: none.
IMAGE QUALITY ASSESSMENT
Fully satisfactory.
TELEDERMATOLOGY IMAGING READER REPORT1
There is one image provided with this consult. The image shows an erythematous, eruptive process that is located at the ankle primarily, spreading superiorly as well as inferiorly to the dorsum of the foot. More closely, it consists of stippling, hemorrhagic macules that coalesce to form plaques with scaling (see Figure 1).
INTERPRETATION OF IMAGES
Lesion A
Findings
The morphology of the lesions, distribution, and history are characteristic of eczematid-like purpura of Doucas and Kapetanakis.
RECOMMENDATIONS
Skin Care Recommendations
Oral bioflavonoid (rutoside, 50 mg twice a day) combined with ascorbic acid (50 mg twice a day) is recommended (Devere & Patel, 2012). Topical mid-potency steroids (e.g., triamcinolone acetonide 0.1% cream once per day) may be used to reduce the associated pruritus. Over-the-counter knee-high compression socks (8-15 mmHg) should be worn daily, off at night, to reduce the hydrostatic pressure on the capillaries.
MEDICATION RECOMMENDATIONS
Other Treatment Recommendations
Eczematid-like purpura of Doucas and Kapetanakis is a clinical diagnosis. The Hess test (application of sphygmomanometer) can evaluate capillary fragility, but its reliability remains questionable (Devere & Patel, 2012). However, it is important to determine whether a systemic disease process is occurring, because its correction is demanded. Recommend to check a complete blood count and coagulation tests.
RECOMMENDED FOLLOW-UP
Type of Visit
Return to primary care for follow-up after 4 weeks. Refer to dermatology if no improvement in 6 weeks.
CLINICAL PEARL
The exact mechanism of eczematid-like purpura of Doucas and Kapetanakis is unclear. A T-cell-driven process, given its characteristic histologic appearance of perivascular lymphocytic infiltration in the papillary dermis among extravasated red blood cells, has been suggested (Mehregan, 2015). The clinical ruddy presentation is secondary to by-products of the extravasated erythrocytes breaking down in the skin, resulting in hemosiderin deposition. It has further been suggested that leaky vessels are a result of vascular deposition of IgM, IgA, C3, and C1q (Devere & Patel, 2012).
This rare condition has no predilection to race and usually erupts in summer and spring. Most commonly, it presents on the lower legs with the classic stippling erythematous macules with overlying scaly patches (Doucas & Kapetanakis, 1953). Classically, it usually erupts over 15-30 days and often resolves without treatment after several months to years.
Treatment is not always effective for this condition, and treatment approaches are largely anecdotal, aimed at relieving symptoms. Some of the most promising options, though, include oral bioflavonoid combined with ascorbic acid and narrowband Ultraviolet B and psoralen plus Ultraviolet A (Devere & Patel, 2012).
REFERENCES