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Follow the steps of experts to unravel the mystery of skin diseases.
Written by丨Meditation
The skin, as the largest organ of the human body, has complex and diverse disease manifestations. Every skin disease is like an independent medical puzzle that needs to be carefully studied and analyzed. Recently, at the 29th Annual Meeting of the Chinese Medical Association on Dermatology and Venereology held in Qingdao, Professor Zhang Liwen from the Second People's Hospital of Chengdu gave us an in-depth analysis of four dermatology cases selected from BMJ.
Picture 1: Professor Zhang Liwen gave a wonderful sharing (Source: Speaker PPT)
Case 1: Finger rash recurring and self-limiting
Professor Zhang Liwen first introduced a case [1] of a 37-year-old female patient who had been suffering from recurrent ecchymosis and itching pain in her hands for 20 years (Figure 2). Whenever these rashes appear, they resolve spontaneously within about one to two weeks (Figure 3) without the need for special medical intervention.
Figure 2: The initial condition of the patient (Source: Speaker's PPT)
Figure 3: The patient's hand condition after 2 weeks (Source: Speaker's PPT)
Although the patient had been in multiple hospitals and underwent a number of tests, including blood count, coagulation and autoantibody profile, the results were normal and could not clearly reveal the root cause of her condition.
When interpreting this case, Professor Zhang Liwen pointed out that the patient's rash was mainly concentrated on the finger area, whether it was the back of the finger or the finger surface, it was affected, and even part of the palm was affected. At follow-up two weeks later, he found that the patient's lesions had largely resolved, further confirming the self-limiting nature of the rash. It is important to note that during this period, the doctor did not give the patient any special treatment.
Faced with such a difficult case, Professor Zhang Liwen said that the nature of the disease is particularly mysterious because the onset of the rash is neither affected by the season, nor is it related to temperature changes, and there is no obvious trigger before the attack. After careful diagnosis and evaluation, the patient was eventually diagnosed with paroxysmal digital hematoma.
Paroxysmal digital hematoma is a disease whose pathogenesis is unknown, mainly in middle-aged women, and is usually spontaneous. However, a small number of patients may mention experiences of minor trauma or mechanical movements prior to the onset of the disease. The disease typically presents with sudden bruising of the fingers or palms, which may be accompanied by itching and swelling, usually unilateral. However, in this patient, a rare bilateral involvement was observed, with recurrent episodes of symptoms.
When making a differential diagnosis, doctors need to take into account other possible disorders such as Raynaud's phenomenon and vascular thrombosis. In terms of treatment, the rash usually does not require special treatment because of its self-limiting nature. For people with significant itching and pain, doctors will give symptomatic treatment to relieve symptoms.
Case 2: telangiectasia, this case is very special
Professor Zhang Liwen went on to introduce that this is a 7-week-old baby girl [2] who has had significant erythema, papules, and significant telangiectasias on her left cheek since birth, and these symptoms have not changed significantly since birth (Figure 4).
Figure 4: The child's facial condition (Source: Speaker's PPT)
After detailed analysis, Professor Zhang Liwen believes that these skin features are fully consistent with the description of a special type of infantile hemangioma, namely reticular or absent growth (IH-MAG), also commonly referred to as abrupt hemangioma. He further noted that this type of hemangioma is more common in baby girls, especially in the lower extremity area.
In describing the characteristics of the lesions, Professor Zhang Liwen detailed that the baby girl had a pink patch on the left cheek covered with linear and branched vasodilations, and localized red papules were clearly visible, which were surrounded by distinct pale circles.
More interestingly, through careful observation under dermoscopy (Fig. 5), he found a unique and beautiful sight: the coarse blood vessels are distributed in a linear and branched manner like a tree branch, while the terminal capillaries are curled into a ball like a leaf, echoing the red papules on the surface of the skin, forming a picture similar to that of a persimmon tree in winter.
Figure 5: Persimmon-shaped blood vessel distribution (Source: Speaker's PPT)
For the differential diagnosis of this type of hemangioma, Professor Zhang Liwen said that although it is necessary to rule out a variety of possibilities such as bright red spot nevus, early lesions of infantile hemangiomas and congenital hemangiomas, he tends to diagnose the reticular or microproliferative type of infantile hemangioma according to the specific symptoms and unique manifestations of the baby girl under dermoscopy.
This type of infantile hemangioma is characterized by very few hyperplasias, usually less than 25% of the total area, and relatively stable disease, with only slight hyperplasia and progression in some areas. In terms of treatment and management, it is the same as the classical treatment of infantile hemangioma, and it is necessary to formulate a personalized treatment plan according to the specific condition and the overall condition of the child.
Case 3: A 9-year-old boy developed skin atrophy
In this case, Professor Zhang Liwen emphasized that a 9-year-old male child had atrophic patches on the right side of his face for 6 years without itching pain, but the skin lesions showed progressive development and accompanied by hair loss (Figure 6). After clinical observation and dermoscopy, the diagnosis was made of insect erosion of skin atrophy, which is a type of atrophic keratosis pilaris.
Insect erosion of skin atrophy is characterized by hyperkeratized follicular papules on the cheeks, surrounded by erythema. Over time, these lesions may further develop into confluent follicular depressions, forming honeycomb or insect-eaten atrophic patches. The condition usually begins in childhood and may continue into adolescence.
Figure 6: Patient's facial condition (Source: Speaker's PPT)
Professor Zhang Liwen elaborated that under dermoscopy, the atrophic patches appeared as a reticular structure, and the scattered keratinizing papules were observed at magnification.
Superficial acne-like openings and follicular angular plugs (Figure 6). Dermoscopic images of the area of hair loss resemble a scarring appearance, showing multiple bright white streaks, and the hair follicle structure openings disappear so that no hair is visible. Pathological examination showed that the dermal collagen was homogeneous and abnormal, accompanied by hyperplasia and density, while the appendage structures such as hair follicles were not seen (Fig. 8).
Figure 7: Dermoscopic phenomena (Source: Speaker PPT)
Figure 8: Pathological examination (Source: Speaker's PPT)
Professor Zhang Liwen pointed out that atrophic keratoses pilaria is a group of diseases including insect erosion skin atrophy, erythema cicatricial on the eyebrows, and acanthotic follicular keratoses, which are characterized by inflammatory keratotic papules, which may lead to hair loss and keloidal changes. Insect-eaten skin atrophy is one of these lesions that is characterized by distinctive skin lesions and may sometimes be a cutaneous manifestation of certain syndromes, so the presence of systemic disease should be considered in the diagnosis and treatment.
Unfortunately, there is currently no specific treatment for insect-eaten skin atrophy. Although some literature has reported that systemic use of tretinoin may help control lesion progression, in this case this patient this treatment did not work as well as the lesions continued to progress slowly. Therefore, Professor Zhang Liwen emphasized that further research and exploration are still needed for the treatment of such diseases to find more effective treatments.
Case 4
Finally, Professor Zhang Liwen conducted an in-depth analysis of the leukonychia symptoms in a 60-year-old male patient [4]. The patient had leukonychia symptoms for 6 months (Fig. 9) and had a history of hypertension and diabetes for many years, with renal insufficiency starting five years ago and receiving dialysis treatment three years ago. In the face of this complex clinical situation, Professor Zhang Liwen proposed a targeted diagnostic pathway.
Figure 9: Patient Baijia (Source: Speaker PPT)
Upon closer inspection, Professor Zhang Liwen found that the proximal part of the patient's nail showed ground-glass white changes (Figure 10), which contrasted sharply with the narrow pink area that remained distal. However, at follow-up, this white area gradually evolved into two parallel white bands.
Figure 10: Ground-glass white change appears in the proximal part (Source: Speaker's PPT)
Professor Zhang Liwen elaborated that the phenomenon of white nails can usually be divided into three types: true white nails, apparent white nails, and false white nails (Figure 11). True leukonychia arises from abnormalities of the nail plate itself, such as punctate leukonychia, Mees lines, and hereditary pantoonychia; On the other hand, the appearance of white nails appears to be white due to abnormal changes in the nail bed, including Muehrcke lines, Lindsay's nails, and Terry's nails. Pseudoleukonychia is caused by external factors such as foreign body staining or onychomycosis.
Figure 11: Identification of three types of white nails (Source: Speaker PPT)
In this case, the patient's leukonychia changes are one of the types of leukonychia that appear to be leukonychia. Professor Zhang Liwen emphasized that although this white nail manifestation may also occur in healthy people, it is more common in the specific reflection of systemic diseases on the nails. Considering that the patient has long-term hypertension, diabetes, and concomitant renal insufficiency and dialysis treatment, these manifestations of white nails may be the embodiment of their systemic diseases on the nails.
Expert Profile
Prof. Liwen Zhang
- Zhang Liwen, Deputy Chief Physician, Master of Medicine, graduated from Tongji Medical College of Huazhong University of Science and Technology
- He is mainly engaged in basic and clinical research in skin imaging and psoriasis
- He has presided over and completed 4 provincial and municipal scientific research projects
- It has won 4 provincial and municipal medical science and technology awards and 1 patent
- 以第一作者在BMJ、J Travel Med、CMAJ、Travel Med Infect Dis、Med J Aust、Clin Infect Dis、JEADV等SCI杂志及核心期刊发表论文100余篇，单篇最高IF107.7，累计IF＞1200
- BMJ、The Lancet Infectious Diseases、JEADV、Cleve Clin J Med、Clin Exp Dermatol、Eur J Dermatol等期刊审稿人
- He was awarded the title of "Sichuan Good Doctor" in the first "Sichuan Good Doctor Chengdu" selection activity
- 2022 Wiley China Open Science High Contribution Author Award
- Member of the Dermatology and Venereal Disease Prevention and Treatment Branch of Sichuan Preventive Medicine Association
- Youth member of the Dermatology and Venereology Professional Committee of Sichuan Medical Association
- Member of the Dermatology Professional Committee of Sichuan Geriatrics Association.
"Icebergs under the surface of a calm lake, this disease is often misdiagnosed as bright red spots! >> Scan the QR code below or click the link to read the original article to take a look 👇
Bibliography:
[1] Zhang L, Wu J. Unusual bruising of the fingers[J]. bmj, 2024, 385.
[2] Zhang LW, Wu J, Chen T, Xu RH. A pink patch on the face of an infant. BMJ. 2023 Nov 23; 383:e075505. doi: 10.1136/bmj-2023-075505. PMID: 37996114.
[3] Zhang LW, Wu J, Xu RH, Chen T. Solitary circumscribed alopecia. BMJ. 2024 Feb 22; 384:e076986. doi: 10.1136/bmj-2023-076986. PMID: 38387993.
[4] Zhang LW, Wu J, Chen T, Xu RH. Proximally white and distally pink nails. BMJ. 2023 Sep 21; 382:e076299. doi: 10.1136/bmj-2023-076299. PMID: 37734754.
Review of this article: Professor Zhang Liwen
Editor in charge: Liu Sisi
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