INTRODUCTION
In the store and forward teledermatology modality, there is a transfer of patient medical information electronically (including history and visual data) obtained in one location to a provider who is in another location (Roman & Jacob, 2015). The construct of the Teledermatology Viewpoint column is such that cases are presented in a standardized teledermatology reader format reflective of an actual teledermatology report.
TELEDERMATOLOGY READER REPORT
Teledermatology Viewpoint: Purple Polygonal Papules
History
Chief complaint: presenting for diagnosis.
History of present illness
A 41-year-old female presents with a 5-month history of a severely itchy rash, which began on the wrists but has now become widespread, diffuse across the shoulders and back. Prior treatment: topical over-the-counter corticosteroids and twice-daily antihistamines, without alleviation. Her primary symptom: severe itch. Prior biopsy: none. She has no personal or family history of skin cancer or melanoma. Other significant laboratory/study findings: none.
IMAGE QUALITY ASSESSMENT
Fully satisfactory.
TELEDERMATOLOGY IMAGING READER REPORT
One image was provided that shows many small, raised, flat-topped, polygonal purple-hued papules diffusely spread across the upper back and onto the dorsal sides of bilateral arms. One area near the right scapula shows linearity consistent with Koebner phenomenon, likely because of excoriation (see Figure 1).
Interpretation of Images
Lesion A
Findings
The presented lesions and associated linear distribution consistent with Koebner phenomenon (lesions caused by trauma) are most consistent with the diagnosis of lichen planus (LP).
RECOMMENDATIONS
Skin Care and Treatment Recommendations
Gentle non-soap-based cleansers and emollients containing ceramides are recommended.
Medications are as follows: (a) triamcinolone 0.1% ointment twice daily; (b) fexofenadine 180 mg daily in the morning; (c) cetirizine 10 mg in the evening; and (d) doxepin 10 mg at night, to help control itch. In preparation for systemic treatment, the patient should be evaluated for hepatitis, liver function tests, fasting lipid profile, thyroid function, and complete blood count, and bring these results to the consultation appointment. Because a portion of cases of LP are because of a hypersensitivity to a medication, a careful review of the patient's medication history is warranted. Withdrawal of any potential offending medications is recommended, with alternate class substitution for medically necessary medications.
RECOMMENDED FOLLOW-UP
Type of Visit
Face-to-face consultation with a dermatologist or dermatology nurse practitioner is recommended to evaluate the patient for the stigmata of the disorder (e.g., Wickham striae [gray-white reticulated streaks on the buccal mucosa], nail ptergyium formation [ridging, fissuring, or lateral thinning], etc.) and potential initiation of phototherapy or systemic immunosuppressive medication (e.g., retinoids, methotrexate, azathioprine, or cyclosporine).
CLINICAL AND PRACTICE PEARLS
LP is a common inflammatory disorder of unclear etiology that can affect the skin, mucous membranes, nails, or hair. "The five Ps" is a well-known mnemonic to remember the classic skin findings that characterize LP: (a) purple, (b) planar, (c) polygonal, (d) pruritic, and (e) papule (Tan, Craft, Fox, Goldsmith, & Tharp, 2015). The lesions are usually symmetrical over the bilateral extremities, specifically the volar wrists and flexor surfaces. Other common sites include lower back, trunk, neck, oral mucous membranes, and genitalia. The rash usually develops over several weeks and may continue to spread for months. Koebnerization phenomenon, describing the process where linear lesions appear because of trauma (often induced by scratching), is also often indicated.
Of note, there is a drug-induced form that is more often seen in older patients, has a more generalized distribution, is often in light or sun-exposed areas, tends to spare mucous membranes, and less often shows Wickham's striae. Associated medication triggers include thiazide diuretics, ACE inhibitors, calcium channel blockers, sulfonylurea hypoglycemic agents, non-steroidal anti-inflammatory drugs, ketoconazole, phenothiazine, antimalarials, gold, and penicillamine (Tan et al., 2015). Patch testing has been used to determine a trigger in a study by Scalf, Fowler, Morgan, and Looney (2001), suggesting a potential role of delayed-type hypersensitivity.
In the practice of teledermatology, templates are commonly required to assure adequate sharing of, at a minimum, basic patient information in association with the initial consult (see Table 1). This case highlights the importance of thoroughness of the initial consult, as no other significant medical history or current medications were available other than the limited information noted above. Historical information is vital to best care for the patient, especially given that LP is a dermatologic condition that can have notable etiologic associations, such as Hepatitis C infection or medication use.
REFERENCES