Thread by @juleslipoff

I hope you brought your appetite and have a strong stomach for...

A TASTING MENU OF DERMATOLOGY

This 5 course menu is a culinary journey through food-named skin signs. Bon appetit!

#prixfixe #tweetorial #MedEd #FOAMEd #dermtwitter #dermatology #medthread h/t @AdamRodmanMD

N.B. The MENU. Skip this tweet if you prefer delightful surprises. If you're one of those people who prefers to know what's ahead, here you go.

BREAKFAST:

CAFE AU LAIT MACULES (CALMs) are light brown patches seen in neurofibromatosis types I and II ("Coast of California"-type edges) and McCune-Albright syndrome ("Coast of Maine").

For NF, a diagnostic criterium is ≥ 6 CALMs of 5mm (prepubertal), 1.5cm (postpubertal).

MILK WHITE VITILIGO.

With depigmentation seen in vitiligo (an autoimmune disease), there is loss of melanocytes, which can be best appreciated with the use of a Wood's lamp, a black light of 365nm).

For more on vitiligo - @HarrisVitiligo is the expert

Next, we'll have our toast with APPLE JELLY, the color seen on diascopy (under a glass slide pressed on the skin) of granulomatous inflammation of the skin, notably in sarcoidosis and lupus vulgaris (tuberculosis).

Always nice to start the day with BANANAS, as in the BANANA BODIES on histology of ochronosis.

Exogenous ochronosis is most associated with use of hydroquinone creams (paradoxical darkening form a bleaching cream), but also intrinisic ochronosis comes from alkaptonuria.

Next, a BLUEBERRY MUFFIN BABY, with many causes, often with poor prognosis.

Usually caused by extramedullary hematopoiesis from hemolysis (spherocytosis, ABO incompatibility) or TORCHES infections; but also hemangiomas (benign), and malignancy (neuroblastoma, leukemia)

PEAU D'ORANGE

The appearance of thick and pitted orange-peel texture of the skin from infiltration and cutaneous lymphatic edema. Examples include inflammatory breast cancer and pretibial myxedema (seen here).

Perhaps you need something to sweeten your tea? May I suggest HONEY-COLORED CRUSTS OF IMPETIGO?

Crusts are dried exudates (unlike scaling, which is excess stratum corneum or dry skin).

Impetigo is a superficial bacterial infection of the skin, usually caused by Staph.

Finally, something savory to finish out breakfast, SAUSAGE DIGITS OF PSORIATIC ARTHRITIS.

Psoriatic arthritis of the digits can be quite destructive, making a sausage appearance when both DIPs and PIPs (distal and proximal joints) are affected. The MCPs are usually not involved.

That was a pretty heavy breakfast course, but I hope you can now handle a LIGHT LUNCH!

Let's start with CHEESY DRAINAGE from epidermoid cysts, well known to you who are fans of @SandraLeeMD. This is built up keratinous debris from sebaceous secretions.

Along the cheese theme, superficial candidiasis can have a COTTAGE CHEESE appearance, as seen here in a patient with oral candidiasis.

Acute febrile neutrophilic dermatosis (aka Sweet's syndrome), is an inflammatory disease of the skin especially associated with AML.

The pseudovesicular lesions are classically referred to as JUICY, since they look about to burst.

Learn more about Sweet's from @DrStevenTChen:

https://twitter.com/DrStevenTChen/status/1165710613399527424?s=20

On the foot, you might find a callus or clavis, also known as a CORN, caused by repeated trauma or friction, here overlying a hammertoe.

Starting the fruit course of lunch is PEACH FUZZ (lanugo hairs) seen in anorexia nervosa.

Then, the GRAPES of a molluscum contagiosum crush preparations, the Henderson-Paterson bodies.

Molluscum is a harmless though contagious virus transmitted skin to skin, presenting with umbilicated papules. Most often seen in kids, and in adults also as an STI.

CHERRY HEMANGIOMAS (OR ANGIOMAS) and STRAWBERRY HEMANGIOMAS. The cherries run in families and appear later in life (though can be seen in POEMS syndrome along with glomeruloid hemangiomas, due to increased VEGF).

STRAWBERRY TONGUE has many causes, notably Kawasaki syndrome and scarlet fever.

It is caused by swelling of the tongue making it more erythematous, with the taste buds resembling strawberry seeds.

If you wanted to finish out lunch with some meat, I'll offer you some TRIPE PALMS.

Thickened, velvety palms (like acanthosis nigricans) are a paraneoplastic syndome (90%) strongly associated with internal malignancy (pulmonary and gastric carcinomas).

That was a lot to chew on, so for our SNACK COURSE, I'll give you something more.

BUBBLE GUM PINK KELOIDAL COLLAGEN

Keloids are scars that overgrow their wound edges irregularly, and the histology of the collegen is distinctive.

Now onto the DINNER course!

Let's start with a clean, well healing and granulating wound, usually described as BEEFY RED.

No sign of infection here! That's the kind of quality meat you can expect on this tasting menu of dermatology.

Now, a classic vegetable TWO WAYS!

CAULIFLOWER EAR and the classic CAULIFLOWER appearance of condylomata (genital warts, here on tongue)!

Cauliflower ear is caused by repeated trauma, seen in wrestlers, boxers, and martial arts fighters.

Condyomata are caused by HPV viruses.

Need something spicy? How about the CAYENNE PEPPER PATCHES of pigmented purpura?

These red-brown patches are caused by capillaritis (leaky capillaries), usually on the lower legs.

Time for the reinvention of a classic!

The SPAGHETTI AND MEATBALLS of the KOH (potassium hydroxide preparation) for tinea versicolor. This represents the hyphae and spores.

Tinea versicolor is a common non-contagious rash caused by Malassezia furfur.

Want to feel fancy? How about some CAVIAR SPOTS (angiokeratomas)?

Angiokeratomas of Fordyce are classically on the scrotum, but this picture is from Fabry's disease.

One last meat course with the PLUCKED CHICKEN SKIN of pseudoxanthoma elasticum (PXE) and also, keratosis pilaris (KP)

PXE is a genetic disease affecting elastic fibers.

KP is a common condition causing hyperkeratotic perifollicular papules most on the upper arms and thighs.

Would you prefer some fish?

How about the SALMON PATCHES of pityriasis rubra pilaris (PRP, with classic islands of sparing) or the SALMON colored ephemeral rash of adult Still's disease? Or even a SALMON PATCH birthmark?

Did you have this @emilyvgordon? See @TheBigSickMovie

Just a note, if the taste of your food so far is not quite to your liking, you might try adding SALT AND PEPPER confetti patches classic for scleroderma.

In the differential here would be: follicular repigmentation in vitiligo and leopard skin in onchocerciasis.

You made it this far. You deserve DESSERT!!

First, a LAYER CAKE histology of necrobiosis lipoidica, a granulomatous disease often associated with diabetes.

The palisading granulomas in the dermis create the layered appearance.

Want something lighter? How about TAPIOCA PUDDING vesicles of dyshidrotic eczema (pompholyx)?

This type of eczema often presents with fine vesicles on the lateral aspects of fingers, and can be seen on the hands and feet. Often seen in people with excessive hand washing.

A great meal, all around. Let's cap it off with a glass of PORT WINE stain!

Port wine stains (nevus flammeus) are birthmarks caused by vascular malformations.

When on the face/forehead/scalp, it's important to consider the possibility of Sturge-Weber syndrome.

That was a long meal, did you know we had a simpler option, the CIMEX SPECIAL, and been more efficient about it?

The BREAKFAST, LUNCH, and DINNER sign of bedbug bites!

This pattern of grouped bites suggests an insect that is crawling on the skin, and bedbugs are a common cause.

For more about what is biting you, check out this other #tweetorial:

https://twitter.com/juleslipoff/status/1021454810904768522?lang=en

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