Dermatology Case Study 11

INITIAL OFFICE EVALUATION

Developed a right breast carcinoma approximately 3 years ago, which was treated by a surgical resection.  She subsequently developed metastases about 1-1/2 years ago in the right hip and right shoulder.  These have been treated with a combination of radiation plus tamoxifen, and she has done really quite well with a regression of the metastases, stabilization, and no apparent significant progression.  Approximately a year and a half ago, immediately concomitant with her radiation therapy, she developed a persistent and intensely pruritic dermatitis at the radiation port on the midchest.  This dermatitis has remained stable without spread over the past year and a half.  Approximately
3 weeks ago she developed a similar but intensely pruritic weeping lesion on the dorsal aspect of the proximal phalanx of the left index finger.  This dermatitis rapidly spread to involve the left elbow.

Examination reveals that she has had a right mastectomy.  The scar is well healed, and there is no evidence of local or deep recurrence.  Examination of the midchest reveals a localized, lichenified, excoriated, eczematous eruption consistent with a lichen simplex chronicus.  On the dorsum of the left second digit, proximal phalanx, there is an area of moist, weeping, eczematous dermatitis.  Similar involvement is noted over the left elbow.

It is my impression that the lesions on the chest represent a lichen simplex chronicus, i.e., a chronic localized eczematous dermatitis, probably induced by the trauma of the radiation.  The lesions present there do not resemble those usually seen in cutaneous metastases of the breast carcinoma.  In addition, one would have expected significant progression over this period of time.  The lesions on her left second digit and elbow are consistent with a wet form of nummular eczema.  This type of eczema is common in elderly patients because of their dry skin and represents a combination of an eczematous response to a
low-grade superficial secondary infection.

I have advised her that I do not feel this eruption is related to her previous breast carcinoma, and I definitely do not feel that there is any relationship to her tamoxifen therapy.  I have started her today on oral erythromycin 250 mg t.i.d. and triamcinolone cream 0.1% with small amounts of menthol and phenol added, to be applied t.i.d. to all affected areas and in addition as needed to control itch.  I have asked her to recheck with me in approximately 2 weeks to note progress.  Provided the eruptions regress, then no further investigation is indicated.  Should they fail to regress promptly, I would consider a diagnostic punch biopsy.

FOOTNOTE

Line 9 (Page 1).  Metastasis was changed to metastases for plural agreement.

Lines 16, 25 (Page 1).  Alternative:  Mid chest.

Lines 49, 50 (Page 1).  The redundant p.r.n. was deleted.