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A red tumor on the wrist. How useful is the dermoscopy: A case report

Ibtissam Al Faker

Department of Dermatology, University Hospital Center Tangier- Tetouan- Al Hoceima, Abdelmalek Essaadi University, Morocco

E-mail : bhuvaneswari.bibleraaj@uhsm.nhs.uk

Soukayna Kabbou

Department of Dermatology, University Hospital Center Tangier- Tetouan- Al Hoceima, Abdelmalek Essaadi University, Morocco

Farah Marraha

Department of Dermatology, University Hospital Center Tangier- Tetouan- Al Hoceima, Abdelmalek Essaadi University, Morocco

Najlae Rahmani

Department of Dermatology, University Hospital Center Tangier- Tetouan- Al Hoceima, Abdelmalek Essaadi University, Morocco

Younes Benyamna

Department of Dermatology, University Hospital Center Tangier- Tetouan- Al Hoceima, Abdelmalek Essaadi University, Morocco

Salim Gallouj

Department of Dermatology, University Hospital Center Tangier- Tetouan- Al Hoceima, Abdelmalek Essaadi University, Morocco

DOI: 10.15761/CMR.1000161

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Abstract

A cutaneous red tumor can be a diagnostic challenge for clinicians; Dermoscopy enhances diagnostic accuracy by showing more specific signs that allow ruling out other differential diagnoses. We report in this case of orf nodule the dermoscopic features found of the acute stage.

Key words

orf, dermoscopy, milker’s nodule, botriomycoma, keratoacanthoma, leishmaniasis

Case report

A 45-year-old fishmonger, with no pathological antecedents, who present (Figure 1), two weeks after contact with a sheep in Aid Al-Adha holiday, three erythematous lesions, on examination, they are well-defined, raised lesions with a central weepy ulcer in two nodules, located on the external face of the right wrist, he had no pain or itching, and systemic examination was unremarkable.

Figure 1: Clinical picture, inflamed acute lesions

Dermoscopic examination shows central ulceration, yellowish crust, partially surrounded by a structureless white area and an erythematous halo (ring) on the periphery with light red globular vessels (Figure 2).

Figure 2: Dermoscopic features: kissing nodules with central ulceration, yellowish crust, partially surrounded by a structureless white area and an erythematous halo (ring) on the periphery with light red globular vessels

The evolution was marked by spontaneous disappearance of nodules after one month, only an antiseptic was prescribed to avoid any secondary infection (Figure 3).

Figure 3: Evolution after one month

Discussion

Also known as ecthyma contagiosum, infectious or contagious pustular dermatitis, the Orf nodule is a zoonotic infection caused by a parapoxvirus genus belong to the family Poxviridae, transmitted to humans from sick animals, sheep, goats or cattle. It results in tumor-like nodular lesions.

The diagnosis is usually based on the history of the disease, physical examination and even her evolution. Histology, PCR and reflectance confocal microscopy can also be used. Dermoscopy is a non-invasive tool that could be useful for the diagnosis of this infection.

Humans contract the infection either through direct contact with infected animals, especially lambs and kids [1] or indirectly through contaminated objects. This disease generally affects farmers, veterinarians and slaughterhouse staff, but an epidemic peak during Eid al-Adha holidays is noticed. The lesion usually occurs on the dorsal side of the hands and fingers, but unusual locations have sometimes been described namely the face, scalp, genitals and conjunctival mucosa [1]. It passes through 6 clinical stages each lasting approximately one week: maculopapular stage with an erythematous macule or papule 3 to 7 days after inoculation; target stage with a necrotic center and a red outer halo; acute stage or sweating nodule that dries up at the regenerative stage; the papillomatous stage where the lesion becomes papillomatous and forms a dry crust and finally, the nodule disappear without leaving a scar at the regression stage. Some authors merge the acute stage with the regenerative one [2]. Secondary infection, erythema multiforme [3,4] and the extensive course are the main complications of the disease.

The differential diagnosis includes Milker’s nodule, botriomycoma, keratoacanthoma, fungal infections, giant molluscum, atypical mycobacterial infections and cutaneous leishmaniasis (Table 1).

Table 1. Dermoscopic aspects of differential diagnosis

Differential diagnosis

Dermoscopic signs

Reference

Milker’s nodule

Type 1: central yellow-white area, erythematous ring, black dot, and grayish-whitish steaks

Type 2: orange-yellow streaks, grayish-whitish streaks, black dot, milky-red globule, erythematous ring

Type 4: ulcerations, yellow-white ring, polymorphic vessels, Grayish-whitish streaks

[4]

Botriomycoma

Red and white structureless areas with thick white lines, striated scaling, and rainbow pattern, irregular linear vessels, ulceration, blood spots, Peripheral collarette

[5]

Keratoacanthoma

hemorrhages, keratin, and keratinizing pearls with a vascular pattern of hairpin, coil, and serpentine vessels.

[6]

Giant molluscum

multiple shiny, white clods within the nodule.

[7]

Cutaneous leishmaniasis

Generalized erythema (dusky, light and yellowish red), Vascular structures (Arborizing vessels with peripheral distribution, regularly distributed hairpin vessels, Micro arborizing vessels), yellow tears, and white starburst-like pattern

[8]

Dermoscopy provides increasingly features and signs guiding the diagnosis. The most described – from 31 cases reported in the literature - are central ulceration with crust, structureless white area, grey-brown streaks, black dots, dotted and comma vessels, peripheral erythematous ring [2,4,9-11]. These finding may vary according to the different clinical stages (Table 2) [4]. The signs found in our patient join those described in the literature at the acute stage (class 3) [4], thus, we believe that the use of dermoscopy fully serves to make the diagnosis, to reduce skin biopsies, minimize additional examinations and to avoid unnecessary treatments.

Table 2. Dermoscopic signs of different clinical stages of Orf’s nodule

Clinical stages

Dermoscopic features

Type 1

central yellow-white area, erythematous ring, dot vessels

Type 2

orange-yellow streaks, grayish-whitish streaks, black dot, blue-gray area, ulceration, erythematous ring 

Type 3

ulceration, yellow-white ring, erythematous ring and black dot

Type 4

ulcerations, yellow-white ring, polymorphic vessels (predominated dot and comma vessels), Grayish-whitish streaks

References

  1. Bergqvist C, Kurban M, Abbas O (2017) Orf virus infection. Rev Med Virol 27. [Crossref]
  2. Tognetti L, Cinotti E, Habougit C, Fiorani D, Cambazard F, et al. (2019) Ecthyma contagiosum (Orf): Reflectance confocal microscopy and histopathological correlates. Skin Res Technol 25: 234-237. [Crossref]
  3. Joseph RH, Haddad FA, Matthews AL, Maroufi A, Monroe B, et al. (2015) Erythema multiforme after orf virus infection: a report of two cases and literature review. Epidemiol Infect 143: 385-390. [Crossref]
  4. Ayhan E, Aktas H (2017) Dermoscopic features and types of orf and milker's nodule. Postepy Dermatol Alergol 34: 357-362. [Crossref]
  5. Elmas ÖF, Akdeniz N, Acar EM, Kilitçi A (2019) Pyogenic granuloma and nodular Kaposi’s sarcoma: dermoscopic clues for the differential diagnosis. Turk J Med Sci 49: 1471-1478. [Crossref]
  6. Kuonen F, Durack A, Gaide O (2016) Clues in DeRmoscopy: Dermoscopy of keratoacanthoma. Eur J Dermatol 26: 419-420. [Crossref]
  7. Mun JH, Ko HC, Kim BS, Kim MB (2013) Dermoscopy of giant molluscum contagiosum. J Am Acad Dermatol 69: e287-e288. [Crossref]
  8. Serarslan G, Ekiz Ö, Özer C, Sarikaya G (2019) Dermoscopy in the Diagnosis of Cutaneous Leishmaniasis. Dermatol Pract Concept 9: 111-118. [Crossref]
  9. Chavez-Alvarez S, Barbosa-Moreno L, Villarreal-Martinez A, Vazquez-Martinez OT, Ocampo-Candiani J (2016) Dermoscopy of contagious ecthyma (orf nodule). J Am Acad Dermatol 74: e95-e96. [Crossref]
  10. Aslan Kayiran M, Uzunçakmak TK, Cebeci F, Akdeniz N, Çobanoglu Simsek B (2018) Dermoscopic features of Orf disease. Int J Dermatol 57: 115-116. [Crossref]
  11. Rezende ALRA, Bernardes Filho F, de Paula NA, Towersey L, Hay R, et al. (2018) Clinical Manifestation, Dermoscopy, and Scanning Electron Microscopy in Two Cases of Contagious Ecthyma (Orf Nodule). Case Rep Dermatol Med 2018: 2094086. [Crossref]

Editorial Information

Editor-in-Chief

Article type

Case Report

Publication History

Received: July 20, 2021
Accepted: August 23, 2021
Published: August 30, 2021

Copyright

©2021 Al Faker I. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Citation

Al Faker I, Kabbou S, Marraha F, Rahmani N, Benyamna Y, et al. (2021) A red tumor on the wrist. How useful is the dermoscopy: A case report. Clin Med Rep 4: DOI: 10.15761/CMR.1000161.

Corresponding author

Ibtissam AL Faker

Department of dermatology, university hospital center of Tangier, Tetouan, Al hoceima, Faculty of medicine and pharmacy Tangier, Abdelmalek Essaadi University, Tangier, Morocco

E-mail : bhuvaneswari.bibleraaj@uhsm.nhs.uk

Figure 1: Clinical picture, inflamed acute lesions

Figure 2: Dermoscopic features: kissing nodules with central ulceration, yellowish crust, partially surrounded by a structureless white area and an erythematous halo (ring) on the periphery with light red globular vessels

Figure 3: Evolution after one month

Table 1. Dermoscopic aspects of differential diagnosis

Differential diagnosis

Dermoscopic signs

Reference

Milker’s nodule

Type 1: central yellow-white area, erythematous ring, black dot, and grayish-whitish steaks

Type 2: orange-yellow streaks, grayish-whitish streaks, black dot, milky-red globule, erythematous ring

Type 4: ulcerations, yellow-white ring, polymorphic vessels, Grayish-whitish streaks

[4]

Botriomycoma

Red and white structureless areas with thick white lines, striated scaling, and rainbow pattern, irregular linear vessels, ulceration, blood spots, Peripheral collarette

[5]

Keratoacanthoma

hemorrhages, keratin, and keratinizing pearls with a vascular pattern of hairpin, coil, and serpentine vessels.

[6]

Giant molluscum

multiple shiny, white clods within the nodule.

[7]

Cutaneous leishmaniasis

Generalized erythema (dusky, light and yellowish red), Vascular structures (Arborizing vessels with peripheral distribution, regularly distributed hairpin vessels, Micro arborizing vessels), yellow tears, and white starburst-like pattern

[8]

Table 2. Dermoscopic signs of different clinical stages of Orf’s nodule

Clinical stages

Dermoscopic features

Type 1

central yellow-white area, erythematous ring, dot vessels

Type 2

orange-yellow streaks, grayish-whitish streaks, black dot, blue-gray area, ulceration, erythematous ring 

Type 3

ulceration, yellow-white ring, erythematous ring and black dot

Type 4

ulcerations, yellow-white ring, polymorphic vessels (predominated dot and comma vessels), Grayish-whitish streaks