CASE                               28                               

A 19-year-old male mechanic presents with a painless, fleshy mass protruding from

the region of his eponychial fold. He reports a metal splinter at that site which he removed 2 weeks ago. He reports that the mass grew quickly and often bleeds.

What is the most likely diagnosis?

1. Inclusion cyst

2. Pyoderma gangrenosum

3. Amelanotic melanoma

4. Pyogenic granuloma

5. Paronychial infection

Discussion

The correct answer is (D). It is an overgrowth of tissue particularly in an area of former trauma or irritation. It is made up of capillary tissue that is not epithelialized; therefore, it is a moist, friable lesion. It is not a truly “pyogenic” or pus producing process, as it is a result of trauma and not infection, and it does not produce purulence. An inclusion cyst is a cyst filled with shed keratinocytes that is caused by trauma that buries epithelialized skin deep to the skin surface. Pyoderma gangrenosum is an ulcerative lesion with a blue-grey or purple irregular border of the surrounding skin, and it is autoimmune in nature. An amelanotic melanoma is a type of skin cancer that does not have pigment. They are quite rare, but the presentation can be similar to pyogenic granuloma with a pinkish red color and rapid growth. Recurrence of amelanotic melanoma is quite high, and it is often fatal despite excision. A paronychial infection is characterized by pain, swelling, and redness of the paronychial tissue.

Which treatment is contraindicated for this mechanic?

1. Curettage

2. Silver nitrate cauterization

3. Electrocauterization

4. Excision and closure

5. Wide local excision and skin grafting

Discussion

The correct answer is (E). The mass is usually friable and treated with simple cautery or excision. A pedunculated stalk is typical of the lesion, so a wide excision is rarely necessary.

The patient undergoes excision of the mass and closure and has an uneventful

recovery. On follow-up, he brings his brother to the office who has a history of ulcerative colitis. The brother has a dorsal hand wound that began as a pustule but developed a central area of necrosis and ulceration. The ulcer is enlarging and has been present for several months.

Which of the following is true regarding this condition?

1. Initial treatment is wide local excision

2. The patient should receive systemic steroids and local wound care

3. Treatment of an associated ulcerative colitis flare with immunosuppressants should be avoided with this open wound

4. Skin grafting and closure of the wound halts its progression

5. Topical antifungals are effective

Discussion

The correct answer is (B). The lesion described is of pyoderma gangrenosum. This is an ulcerative lesion associated with autoimmune disorders including ulcerative colitis, Crohn’s disease, and rheumatoid arthritis among others. It also occurs in patients without autoimmune disorders. Excision is contraindicated because the condition can worsen with further tissue damage. Treatment of a flare of ulcerative colitis is recommended as pyoderma gangrenosum is thought to also be a dysfunction of the immune system and often improves with treatment of the associated disease process. Skin grafts do not take well on the ulcerated nonviable tissue. Topical antifungals have no role in the treatment of this immune modulated disease.

Objectives: Did you learn...?

Recognize the presentation and treatment of pyogenic granuloma? Recognize the presentation and treatment of pyoderma gangrenosum?