Browsing by Author "Wong, Christopher"
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Item Demonstration of Steroid Atrophy From Chronic Topical Steroid Use in Various Fitzpatrick Skin Types(2024-03-21) Martinez, Maria Francesca Ysabelle; Du, Wenqin; Wong, Christopher; Hall, Marshall; Scheufele, Christian; Weis, StephenBackground: Topical steroids are commonly prescribed first-line medications for various inflammatory and autoimmune dermatologic conditions. Their widespread use raises the importance of proper use. Topical steroids have well-known side effects including skin atrophy, redness, striae, and telangiectasias. These side effects have not been well documented in patients of various skin tones. Primary care clinicians must recognize topical steroid side effects and their appearance in various skin tones. This paper will focus on representing skin atrophy, the most common steroid side effect, in a variety of Fitzpatrick skin types. Case Presentation: We present a series of images illustrating skin atrophy after prolonged topical steroid use on various Fitzpatrick skin types. The first case shows Fitzpatrick V skin with areas of erythema, hypopigmentation, and hyperpigmentation on the trunk. The second case presents thin skin with bright erythema and purpuric papules on the upper extremities of Fitzpatrick II skin. A third case showcases symmetric, parallel, linear, maroon dermal scars perpendicular to tension lines in the background of epidermal atrophy circum-anally and on the buttocks of Fitzpatrick IV skin. A fourth case exhibits Fitzpatrick III skin with shiny, thin skin and patches of hypopigmentation and telangiectasias on bilateral cheeks. The fifth case is a Fitzpatrick IV skin type with plaque psoriasis on the lower extremity and a background of skin thinning, hypopigmentation, and visible underlying vasculature from chronic topical steroid use. The final case represents Fitzpatrick VI skin with pyoderma gangrenosum, atrophied skin with overt hypopigmented patches adjacent to a cribriform scar. These cases feature the diverse presentations of skin atrophy on different Fitzpatrick skin types. Conclusion: Steroid atrophy is the most common side effect of chronic topical steroid use. Topical steroids are widely used for dermatologic conditions such as atopic dermatitis and plaque psoriasis. Steroids work to quell these inflammatory and autoimmune conditions and are overall tolerated well with proper use. Overuse of topical steroids is common and can cause known side effects of skin atrophy, erythema, striae, and telangiectasias. Recognition of steroid overuse requires knowledge of its presentation in various skin tones. In lighter skin types, atrophy is apparent with visible underlying vasculature and bright red erythema. In darker skin types, atrophy is more subtle and underlying vasculature may appear burgundy or maroon. Awareness of these differences in presentation will allow for quick recognition and immediate cessation of steroid use to prevent further side effects.Item Iatrogenic Corticosteroid Atrophy Mimicking Bilateral Morphea en Coup de Sabre: A Case Report(2024-03-21) Do Valle, Rafael; Wong, Christopher; Pool, Jade; Kenny, Cassandra; Wilkes, DustinBackground: Corticosteroids affect numerous downstream cytokines to exert anti-inflammatory and immunosuppressive effects. Intralesional corticosteroid injection provides several advantages, including bypassing the stratum corneum to deliver a higher concentration of drug locally, while reducing systemic exposure. Intralesional corticosteroids are used in a variety of dermatologic conditions, and suboccipital steroid injection has been described as a novel treatment for cluster headaches. Case Presentation: A 52-year-old Caucasian female presented to the outpatient dermatologic clinic with indented skin lesions on the scalp and forehead for six weeks. The indentation started on her left frontal scalp and spread down gradually to her forehead and temple. She later noticed the same indentation appearing on her right side. She reported severe pain and the “worst headache” before the lesions started, but there was no further pain after the lesions appeared. Dermatologic examination demonstrated two symmetric hypopigmented linear atrophic plaques extending from the lateral forehead to the frontoparietal scalp on each side. A punch biopsy from the left superior central forehead showed epidermal atrophy with compact orthokeratosis, and scattered telangiectasias within the papillary dermis. Elastin van Giesonstaining demonstrated a loss of elastic fibers in the papillary dermis. There was no dermal sclerosis. The adnexal structures, CD34 expression, and the elastic component of the reticular dermis were intact. Direct immunofluorescence studies were negative. Upon further questioning, the patient revealed that she had injections with an unknown medication to the occipital and frontal scalps due to severe headaches from a motor vehicle accident. A diagnosis of steroid-induced skin atrophy was made from clinicopathologic correlation. Conclusions: The adverse effects related to intralesional corticosteroid injections include hypopigmentation, telangiectasias, striae, and atrophy of the skin and subcutaneous fat. When present on the frontal and temporal scalp, atrophic plaques can mimic morphea en coup de sabre, a form of linear localized scleroderma with an autoimmune etiology. Several cases of bilateral morphea en coup de sabre have been previously reported. This case study highlights the importance of obtaining a comprehensive patient history in formation of a differential diagnosis. It also showcases the potential complications of intralesional corticosteroid injections, emphasizing the informed consent process for patients to fully understand possible adverse effects from treatment.Item Presentations of Cutaneous Disease in Various Skin Pigmentations: Atopic Dermatitis(2023) Thompson, Jordan; Nguyen, Cecilia; Nguyen, Daniel; Wong, Christopher; Scheufele, Christian; Carletti, Michael; Weis, StephenBackground Atopic dermatitis (AD), commonly known as eczema, is a chronic inflammatory skin disorder classically affecting flexural areas of the body. It presents in any age group, but commonly develops during infancy and early childhood and morphologic subtypes exist due to varying skin tones. Children with darker skin were approximately six times more likely to develop atopic dermatitis in comparison to children with lighter skin. African American and Asian patients more frequently have atopic dermatitis compared to Caucasian patients. Presentations of atopic dermatitis vary due to duration, age and color of skin. Acute lesions are clinically characterized as ill-defined pruritic, erythematous plaques (raised, >1cm) while chronic lesions are dry, hyperpigmented plaques (raised, >1cm) with lichenification and prurigo nodules. Differential diagnosis includes scabies, seborrheic dermatitis, ichthyoses, and psoriasis. This review article will showcase clinical images with varying presentations of atopic dermatitis in ranging age groups and skin color according to the Fitzpatrick scale. Case Information The Fitzpatrick scale provides a classification system for an individual’s skin type based on the ability to burn and/or tan when exposed to ultraviolet light. It is used to approximate the degree of skin pigmentation. This review article focuses on 5 distinct cases of varying ages and skin types to present 5 atypical presentations of atopic dermatitis. Case 1 presents a 40-year-old, Fitzpatrick I, with chronic atopic dermatitis. Case 2 presents a 6-month-old, Fitzpatrick III, with acute atopic dermatitis. Case 3 presents a 11-year-old, Fitzpatrick IV, with subacute atopic dermatitis. Case 4 presents a 21-year-old, Fitzpatrick IV, with chronic atopic dermatitis. Case 5 presents a 3-year-old, Fitzpatrick V, with chronic atopic dermatitis. Discussion In the United States, atopic dermatitis affects approximately 11.3 – 12.7% and 6.9 – 7.6% of children and adults, respectively. Presentations of atopic dermatitis can vary due to duration, age and color of skin. Post inflammatory dyspigmentation is observed more in African American patients due to decreased healthcare access and different clinical manifestations, notably with erythema. Atopic dermatitis can have a significant quality of life impairment and disease burden in diagnosed individuals, especially those with darker skin pigmentation. The disease can progress to a systemic disorder, "atopic march” causing allergic conditions including asthma, allergic rhinitis and food allergies. Pruritus, a hallmark symptom of atopic dermatitis, may lead to increased sleep disturbances, fatigue, and mental health symptoms which ultimately affects growth, school performance, attention, and accident rates in children. Atopic dermatitis has been linked to attention-deficit hyperactivity disorder in children and increased rates of depression and anxiety in teengagers and adults. The purpose of this review article is to outline atypical presentations of atopic dermatitis to allow practitioners to gain a better understanding to aid in diagnosing patients with different skin tones.