Spilling the Tea: Important Observations to Help Clinicians

Hello, I'm Dr. Jim LaRosso, a dermatologist in Las Vegas, Nevada, and very happy to bring you another Derms and Conditions podcast, where I'm flying solo today, spilling the tea, important observations to help clinicians. So let's move on to the next slide. So an area that I want to talk about, which we obviously see commonly in clinical practice, is itching on the scalp. And there is a reference, which is available on PubMed, Open Access, which discusses this topic. But I want to focus specifically on something that we don't see very commonly, but something that's very important to pick up. It may help you in identifying the patient. And that's the fact that many patients with dermatomyelitis. Itching is extremely common. Over 90% of patients with dermatomyelitis present with pruritus, and very often it involves the scalp. And they will typically have some redness and flaking, erythema, maybe some scales, and a non-scarring alopecia. Next slide. So we're looking at two different presentations. The one on the left is a chronic alopecia. It's a common presentation where the patient. They may have some hair thinning from a telogen effluvium, which can sometimes happen, or maybe what they present with naturally. But you'll see that erythema and often fine scaling, which looks very much like seborrheic dermatitis. But this is a patient presenting with dermatomyositis. They may have other clinical signs of dermatomyositis, like the classic Gotren's papules, you know, and some of the proximal muscle weakness, and some of the other cutaneous manifestations. But not always. Sometimes they have the scalp pruritus first. And then on the right, you're seeing from Dr. Kalen, that was published in Clinical Rheumatology Reports, an example that looking at it, you might think it's a localized plaque of psoriasis, but it's a patient presenting with dermatomyositis affecting the scalp. So keep this in the back of your mind. Because that's obviously a diagnosis that's significant, both in terms of the patient often having muscle involvement, and sometimes underlying malignancy, or severe lung disease. Next slide. Also remember, and I remember picking up a couple of cases by knowing about this, and I looked like a star when I was a student at the Cleveland Clinic and picked up a case of dermatomyositis. And I was like, "Oh, my God, I'm going to die." And I was like, "I'm going to die." And I was like, "I'm going to die." I was like, "I'm going to die." And I was like, "I'm going to die." And I was like, "I'm going to die." not only in one area, And then there are the irreversible findings that are fibrotic or already scarred. They may be visible scars, sometimes with areas of hyperpigmentation, sometimes flat or palpable scars, sometimes colloidal scars. And then those fistulas that are no longer draining are fibrotic. So their tunnels, the wall, the shell is fibrotic, but there's no longer inflammation within those lesions. We say those are irreversible because your agents that we have that reduce the inflammation are not going to change those areas that are fibrosed or scarred. So they may need to be handled, especially if. If they're symptomatic or problematic surgically. So hidratonitis suppurativa, it's important to do a full examination, explain that to the patient. A lot of them may be uncomfortable and not ever have had someone look at all the areas before. So it's important to be sensitive about that conversation and discuss it with them. And also be respectful when you're examining those areas and realize they can have a lot of pain in these areas. So. If you're going to touch or palpate, you need to let them know and do it gently. So let's look at the next slide, okay? Talking about how important it is not to just look, but to palpate. Because you might not necessarily be able to tell that there's lesions and tracks and tunnels underneath, or whether it's a soft lesion or a fibrotic scar type of lesion. So it is important to. To palpate the different areas gently. Now, a lot of people have lesions in the genital and the groin area. So obviously, we need to be very sensitive about that and respectful of that. And always have a chaperone. Whether it's a male or a female patient, always have a chaperone. Next slide. So this is a very illustrative, important example. This is a close-up of an area from the slide before. And you can. You can see here, you see some openings up above. And those might be multiple comedones. Or they can be empty areas of sinus tracts. So it's important to palpate around to see if there's any purulent drainage. But this lesion that's in the center on the bottom, you see somewhat of a linearity within that lesion. So you don't know whether this is an abscess, okay? Or if there's a sinus tract, which is the same thing as a fistula under there. The next slide shows putting some gentle pressure below that lesion. You're expressing that purulent drainage that you didn't see without putting a little bit of palpable pressure. And so this shows you it is a draining fistula or sinus tract. Right? So it is. It is an inflammatory lesion. If it didn't have that drainage, it would be a non-inflammatory lesion, a fibrotic lesion, that you would either leave or potentially excise or treat another way if it was symptomatic. Now, we're going to end with our final case here. This is a case that I wish I never saw. And I'm going to give you a little bit of background about this case. I'm not at liberty to discuss all the information. I'm going to give you a little bit of information about the case. But what I can tell you is a 42-year-old woman that was undergoing treatment with a Janus kinase inhibitor that primarily inhibits Janus kinase 1 with some inhibition of Janus kinase 2. But it could have been any of the Janus kinase inhibitors that the patient was being treated with, right? And this patient. Had a very interesting history. They had laboratory testing that came back that showed a creatine kinase, which is the same thing as creatinine phosphokinase, the CPK evaluation. In more modern times, we call it creatine kinase. You're measuring the same enzyme. And it does reflect a few things, but primarily what's happening in muscle. Okay. So it's not. It's not uncommon, even though it's not part of the required baseline assessment with Janus kinase inhibitors, patients may have elevations of creatine kinase, which sometimes are not necessarily associated with any symptomatology. But they can be sometimes associated with symptomatology where patients have muscle fatigue and weakness. They don't feel well. And they can spill myoglobin into their blood, which can. They can then go to the kidneys and cause a situation called rhabdomyolysis, which causes acute kidney injury. That's a very, very serious situation. So on a laboratory test, this patient had a creatine kinase level of over 2,000. That's off the charts in terms of the elevation. Called her up. She was away. She was at a camp with her daughter who was playing softball. She felt perfectly fine. I talked to her about it. I said, well, you know, we're going to need to get you back in next week. And she was fine. She was. I said, if you have any muscle weakness, have you been working out? Have you had an intramuscular injection, something that could have increased that creatine kinase? Because if somebody starts working out heavily or had an injection into muscle, or had an intramuscular injection, something that could have increased that creatine kinase because if somebody starts working out heavily or had an injection into muscle, or had an injection into muscle, or had an injection into muscle recently, that can raise that level. There was really no explanation, and she was asymptomatic. Well, that next week, we had brought her in to repeat it, and she had told me that, and my staff, that she wasn't feeling well, and she already had an appointment with a primary care doctor. And we did the blood test again, and she wasn't feeling well, and she already had an appointment with a primary care doctor. And we did the blood test again and got her over to a primary care doctor. Her primary care doctor was very concerned. She had some muscle aching, some muscle fatigue. She was sent to the hospital, and she did have rhabdomyolysis. Fortunately, caught pretty early, and she did not have any kidney injury. But here's the kicker. She was on that Janus kinase inhibitor, so intuitively you might have thought that that was the cause. But there was another part of the history that, honestly, I sound like a child of the 60s, blew my mind. This patient had a history of hypothyroidism that she had had for years. She was on levothyroxine, generic, generic of a brand called Synthroid, levothyroxine. Levothyroxine, which is dirt cheap. She was on it chronically, had gone back to the pharmacy, was unable to get it refilled because the pharmacy told her, you already picked it up, and insurance will not pay for it, right? She says, I did not pick it up, and I need to be on this every day. She tried to get it from the pharmacy. They pushed back. She went six weeks without recovery. She went six weeks without her levothyroxine, which was dirt cheap enough that being a pharmacist in the past, I would have just given it to her. It's pennies to make sure that she didn't have an interruption in her treatment, right? So she just went forward with it. I guess they tried to get in touch with her doctor. There was a question about never really having the communication. And so if you look at the next slide. Okay. I went to the literature and found that hypothyroidism, it's not frequently associated with rhabdomyolysis, but there are reports of it causing severe increase in creatine kinase and rhabdomyolysis, right? So what was the situation here? Could the Janus kinase inhibitor have been contributory? Possibly. But this hypothyroidism that was neglected for six weeks because they didn't want to have the patient on a medicine they needed regularly, right, did not give it to her, was to me an inducing factor, right? She asked me what I thought. I said I would be pushing back on this with the insurance carrier, with the pharmacy, and myself, I would consult legally on this. Because it's inexcusable that this patient was not able to get something that was really pennies, and they didn't even offer that as an option. You know, this is not a very expensive medication. You know, do you want to pay for it? ended up fortunately did well because it was caught early and dealt with early. So these things happen. It's really unfortunate, but we deal with the situation where there's a lot of mechanical things that go on where professional people are not stopping and thinking in a way that that's the way I was raised to look at cases. And I think it was unfortunate what happened to this patient. Fortunately, she's doing extremely well. She's still on her Janus kinase inhibitor and has not had any particular problems. And her condition is doing well and her hypothyroidism is controlled. But she had to be treated in the hospital with supplemental thyroid hormone and a lot of support to overcome the rhabdomyolysis. So the next slide tells us where we are right now. I hope this information was helpful to you. I hope that you learned something from this. So until we meet again on another Spilling the Tea, this is Dr. Del Rosso signing off.