TELEDERMATOLOGY READER REPORT
History
Chief complaint: presenting for diagnosis of a lesion.
History of present illness: A 24-year-old lady with a history of Takayasu's arteritis presents with a crusting area on her neck that she states started as a small inflamed bump that has intermittently flared and resolved with scarring. Prior treatment: courses of oral doxycycline, ciprofloxacin, clindamycin, and isotretinoin. She also has been treated with topical antibiotics (bacitracin and mupirocin). All prior treatments have been without improvement. Her primary symptom: soreness and scabbing. Prior biopsy: granulomatous dermatitis and pyogenic abscess. She has no personal or family history of skin cancer or melanoma. Other significant laboratory/study findings: negative indirect immunofluorescence.
IMAGE QUALITY ASSESSMENT
Fully satisfactory.
TELEDERMATOLOGY IMAGING READER REPORT
One image was provided that shows a large verrucous plaque on the right neck. At the periphery of the plaque is shiny pink skin suggestive of a scarring process (see Figure 1).
INTERPRETATION OF IMAGES
Lesion A
Findings
The presented lesion and history are most consistent with the diagnosis of a pyoderma gangrenosum (PG) vegetans. Notably, the peripheral scarring supports this diagnosis as the ulcerations often heal with cribiform scarring.
RECOMMENDATIONS
Skin Care and Treatment Recommendations
Gentle nondebriding cleansing, followed by triamcinolone 0.1% ointment mixed with equal parts of Bactroban ointment twice a day.
RECOMMENDED FOLLOW-UP
Type of Visit
Recommend that the patient present for face-to-face evaluation with a dermatology provider for rebiopsy of a newly developing lesion for hematoxylin and eosin histopathologic analysis and tissue culture, possible commencement of high-potency topical steroid therapy, review of systems, and appropriate laboratory evaluations. The patient will need to be monitored routinely for response and, if recalcitrant, may need to be maintained with a systemic immunosuppressive medication (such as dapsone, azathioprine, mycophenolate mofetil, or cyclosporine) dosed by weight and response to therapy.
CLINICAL PEARL
PG is a relatively rare ulcerative cutaneous condition and often a diagnosis of exclusion. The etiology is uncertain but is thought to involve dysregulation of neutrophil chemotaxis. That said, it has been reportedly associated with a number of systemic diseases, such as collagen vascular diseases (e.g., lupus and Sjogren syndrome), infections (e.g., hepatitis and syphilis), inflammatory bowel disease (e.g., Crohn's disease or ulcerative colitis), malignancy (e.g., myelocytic leukemias), and vasculiditis. PG shows the pathognomic "pathergy reaction" where new lesions occur at sites of trauma and often begin as a painful pustule (which patients may associate as a bite reaction; Jackson, 2014).
The mainstay of therapy for PG is the utilization of anti-inflammatory agents, such as corticosteroids, immunosuppressive agents, and biologic agents, sometimes in conjunction with antibiotic therapy. The disease may be recalcitrant and recur with notable residual scarring.
The standardized teledermatology reader report format is available for authors on the submissions Web site and outlined in Table 1.
REFERENCE