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Toasted: The Perils of Home Remedy
CLINICAL CHALLENGES AND IMAGES IN GI Bilal Hameed, Uma Mahadevan, and Kay Washington, Section Editors
Toasted: The Perils of Home Remedy Bryan F. Curtin,1,2,3 Sonia Abichandani,3,4 and Erik C. von Rosenvinge1,3
Q1
1
Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland; 2National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland; 3Gastroenterology Section, VA Maryland Health Care System, Baltimore, Maryland; 4Department of Internal Medicine, University of Maryland Medical Center, Baltimore, Maryland
print & web 4C=FPO
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Question: A 55-year-old man with a history of chronic back pain decided to wean himself off of longstanding high-dose opiates. As he self-titrated down his opiate dose, he developed increasingly severe abdominal pain. To alleviate this pain, he applied a heating pad to his abdomen on a daily basis, a practice that he continued for a 6-month period. He presented to our clinic for evaluation of his abdominal pain and reported that the heating pad helped to ease his pain, but that he had progressively developed a rash over his abdomen. On physical examination, a prominent reddish-purple reticulated rash was present over the abdomen (Figure A). What is the diagnosis? Look on page 000 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and images in GI.
Conflicts of interest The authors disclose no conflicts. © 2017 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2017.01.038
Gastroenterology 2017;-:1–2 DIS 5.4.0 DTD YGAST60954 proof 29 June 2017 6:15 pm ce
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Answer to: Image 1
: Erythema ab igne
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Given the rash’s appearance and the history of chronic heating pad use, a diagnosis of erythema ab igne was made. Erythema ab igne, sometimes referred to as “toasted skin syndrome,” is a benign dermatologic condition caused by chronic and repetitive heat exposure leading to a reticulated reddish-purple hyperpigmentation.1 The persistent venous dilatation from heat combined with pressure eventually leads to hyperpigmentation of the exposed skin owing to melanin and hemosiderin deposition. It can be confused with livedo reticularis, cutis marmorata, and graft-versus-host disease, because they can all be similar in appearance.2 In classic erythema ab igne, the affected skin initially develops reticulated erythema that progresses into a reticulated reddish-purple hyperpigmentation. Atypical erythema ab igne can be associated with bullae formation. Erythema ab igne can be aesthetically unpleasing, but is generally a benign, asymptomatic condition. Skin biopsy, which is only required if the diagnosis is unclear, displays epidermal and dermal atrophy, hyperkeratosis, squamous atypia, and melanin and hemosiderin deposits.3 Prognosis is favorable, and the main treatment is removal of the heat source. In most cases, the skin hyperpigmentation disappears altogether over time. Patients with erythema ab igne should be provided alternative treatments for chronic pain and advised to remove the heat source and allow time for the rash to improve.
References 1. 2. 3.
Miller K, Hunt R, Chu J, et al. Erythema ab igne. Dermatol Online J 2011;17:2. Riahi RR, Cohen PR, Robinson FW, et al. Erythema ab igne mimicking livedo reticularis. Int J Dermatol 2010; 49:1314–1317. Cavallari V, Cicciarello R, Torre V, et al. Chronic heat-induced skin lesions (erythema ab igne): ultrastructural studies. Ultrastruct Pathol 2001;25:93–97.
For submission instructions, please see the Gastroenterology website (www.gastrojournal.org).
2 DIS 5.4.0 DTD YGAST60954 proof 29 June 2017 6:15 pm ce
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Toasted: The Perils of Home Remedy Bryan F. Curtin,1,2,3 Sonia Abichandani,3,4 and Erik C. von Rosenvinge1,3
Q1
1
Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland; 2National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland; 3Gastroenterology Section, VA Maryland Health Care System, Baltimore, Maryland; 4Department of Internal Medicine, University of Maryland Medical Center, Baltimore, Maryland
print & web 4C=FPO
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58
Question: A 55-year-old man with a history of chronic back pain decided to wean himself off of longstanding high-dose opiates. As he self-titrated down his opiate dose, he developed increasingly severe abdominal pain. To alleviate this pain, he applied a heating pad to his abdomen on a daily basis, a practice that he continued for a 6-month period. He presented to our clinic for evaluation of his abdominal pain and reported that the heating pad helped to ease his pain, but that he had progressively developed a rash over his abdomen. On physical examination, a prominent reddish-purple reticulated rash was present over the abdomen (Figure A). What is the diagnosis? Look on page 000 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and images in GI.
Conflicts of interest The authors disclose no conflicts. © 2017 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2017.01.038
Gastroenterology 2017;-:1–2 DIS 5.4.0 DTD YGAST60954 proof 29 June 2017 6:15 pm ce
59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116
CLINICAL CHALLENGES AND IMAGES IN GI 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174
Answer to: Image 1
: Erythema ab igne
---
Given the rash’s appearance and the history of chronic heating pad use, a diagnosis of erythema ab igne was made. Erythema ab igne, sometimes referred to as “toasted skin syndrome,” is a benign dermatologic condition caused by chronic and repetitive heat exposure leading to a reticulated reddish-purple hyperpigmentation.1 The persistent venous dilatation from heat combined with pressure eventually leads to hyperpigmentation of the exposed skin owing to melanin and hemosiderin deposition. It can be confused with livedo reticularis, cutis marmorata, and graft-versus-host disease, because they can all be similar in appearance.2 In classic erythema ab igne, the affected skin initially develops reticulated erythema that progresses into a reticulated reddish-purple hyperpigmentation. Atypical erythema ab igne can be associated with bullae formation. Erythema ab igne can be aesthetically unpleasing, but is generally a benign, asymptomatic condition. Skin biopsy, which is only required if the diagnosis is unclear, displays epidermal and dermal atrophy, hyperkeratosis, squamous atypia, and melanin and hemosiderin deposits.3 Prognosis is favorable, and the main treatment is removal of the heat source. In most cases, the skin hyperpigmentation disappears altogether over time. Patients with erythema ab igne should be provided alternative treatments for chronic pain and advised to remove the heat source and allow time for the rash to improve.
References 1. 2. 3.
Miller K, Hunt R, Chu J, et al. Erythema ab igne. Dermatol Online J 2011;17:2. Riahi RR, Cohen PR, Robinson FW, et al. Erythema ab igne mimicking livedo reticularis. Int J Dermatol 2010; 49:1314–1317. Cavallari V, Cicciarello R, Torre V, et al. Chronic heat-induced skin lesions (erythema ab igne): ultrastructural studies. Ultrastruct Pathol 2001;25:93–97.
For submission instructions, please see the Gastroenterology website (www.gastrojournal.org).
2 DIS 5.4.0 DTD YGAST60954 proof 29 June 2017 6:15 pm ce
175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232