Dermatology clinicians are used to seeing some pretty strange diagnoses. But DEF Advisory Council member Wendy Cantrell, DNP, had a particularly interesting one. Inspired by the Stranger Dx™ theme for DERM2023, she shared the case of a 24-year-old male patient who presented with complaints of an intermittent rash that appears 2 to 3 times per month—after a bowel movement. Can you solve the case? Also in this episode, Adam J. Friedman, MD offers insights on sensitive skin and Gilly Munavalli, MD shares tips to encourage patients to use SPF.
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Dermatology clinicians are used to seeing some pretty strange diagnoses. But DEF Advisory Council member Wendy Cantrell, DNP, had a particularly interesting one. Inspired by the Stranger Dx™ theme for DERM2023, she shared the case of a 24-year-old male patient who presented with complaints of an intermittent rash that appears 2 to 3 times per month—after a bowel movement. Can you solve the case? Also in this episode, Adam J. Friedman, MD offers insights on sensitive skin and Gilly Munavalli, MD shares tips to encourage patients to use SPF.
Like what you're hearing? Have a topic you want to hear more about? Hit us up and spread the word on Instagram!
Transcript has not been edited and is not final. It may contain errors.
Welcome to the Dermalorian Podcast from the Dermatology Education Foundation. In this episode, we explore what it means to have sensitive skin and how you can encourage patients to use SPF,
but first, dermatology clinicians are used to seeing some pretty strange diagnoses. diagnoses. In fact, the theme for Derm 2023 was Stranger DX. As part of the conference,
Nurse Practitioner and DEF Advisory Council member Wendy Cantrell, DNP, shared one of her strangest cases. Can you make the diagnosis? Her patient is a 24 -year -old man who presents with complaints of an intermittent rash that appeared.
two to three times per month. He says that it starts on his palms and soles and spreads up his extremities over his body.
It does come up as exquisitely tender red bumps and he, as he's telling me this, I notice he's getting more and more uncomfortable. It's like he's embarrassed about this rash and so I was in a little bit of a shock.
bit intrigued. He said that it intensely itched and that he had significant joint pain and fatigue for two to three days.
In fact, he said that the intense symptoms last about 30 to 40 minutes. And he actually had to go to bed to lie down to take a nap in order for him to to even recover.
He does say that he didn't really know what to take, but sometimes he thinks that benadryl helps. And he, but he wonders, he said, you know, I wonder if it just helps me sleep because I'm in so much pain and every time I move my joints hurt.
So he's not sure if the benadryl really helps or it just helps symptomatically, helps put him to sleep for a little while. So here's the kicker. kicker. It only happens after he has a bowel movement.
And he said, you know, sometimes, especially on the more severe times that he has had this rash, he said,
sometimes his his his bowel movement is loose, but other times it's completely normal. And he has no really simple that warn him that that this reaction is coming.
So, now I'm intrigued, right. He's a healthy six foot male normal weight 160 pounds. He says he's not on any medication medications on a daily basis.
He did tell me he sometimes takes a bit of drill when it happens. He denies any surgery. surgeries. He denies drinking alcohol. He says he doesn't smoke or vape.
He says he doesn't have any personal history of Bible issues, like no irritable Bible, no inflammatory Bible, no colon cancer. So again, I'm super intrigued by this and really to be honest with you,
very confused at what I'm gonna do. So I talk to him further. and you know nurse practitioners and physician assistants, one of the things that we hear quite frequently is that often we take the time to talk to our patients to understand exactly how their condition is impacting them.
This patient gets almost teary at how one embarrassed he is. he has no idea who's he gonna he said who am I gonna talk to about this um he says that at work he can't go into his boss and say hey when I have a poop I might have this rash and I can't come to work for three days um he doesn't feel like he can disclose that um to to his employer um so he's had multiple sick days because sometimes it's two and
three days days that he just cannot physically get out of bed because he is hurting. He feels like he is not progressing in the company and feels like that he is kind of messing up his chance to climb the ladder.
And then also, so it's like a social impact, you know, we can't minimize the fact that he's embarrassed a couple of things that popped into my mind. I'm scabies, you know.
does describe the itching as intense with erythematous papules. But the downside is that it comes and goes. So that doesn't fit, that negative doesn't fit.
Again, I have no idea. Then I think, okay, well, maybe hand -foot mouth because it does have painful erythematous papules on his palms and soles at start.
But again, negatively, that doesn't fit. kind of goes against that as it does come and go. You know, and then some sort of arthritis, some sort of autoimmune something. And then I thought,
I have a friend and she is a rectal cancer survivor. At 40, she was diagnosed, so almost 10 years ago, she was diagnosed with stage two rectal cancer.
And thank heavens they were diagnosed with stage two rectal cancer. she was really concerned. She didn't want a colostomy bag and they worked hard to help her with that.
But in treating it and not going the colostomy route, she was at risk because they formed a little pouch and she has had to train her body so that she can have bowel movements.
regularly. And one of the things that she was at risk for was something called Bowel Biopass Syndrome.
And another name. And so I was like, okay, so let me look into this. Let me see if this can happen. If he hasn't had a bowel diagnosis or a bowel surgery.
And so this is what we're going to do. is kind of where I went with the diagnosis. So bowel bypass syndrome is also known as bowel associated dermatosis arthritis syndrome.
I love the acronym BADAS, right? So I'm like, okay, maybe I'm getting somewhere. It can also be known as blind loop syndrome.
This is a really, this is a really, course. It's associated with arthritis and rash. Sometimes patients say that a fever will accompany the outbreak and it was first described in 1971.
And that, it was described specifically after we started doing the full gastric bypass for obesity and weight loss. And it's a relapsing course.
And it was identified that up to 20 % of patients with bowel shortening surgeries for obesity, Crohn's disease, ulcerative colitis, some diverticulitis and colon cancer,
and then other colon surgeries have been reported as well to have this bowel bypass syndrome. A lot is not known about this,
but it is. as we know it is an overgrowth of bacteria in a blind loop where digested food doesn't pass. So that makes sense that it was from a bowel surgery is the most common.
You can see here that E. coli is the most common bacteria that's found but there can be others as well. I mean what happens is bacterial overgrowth in this blind loop you it releases bacterial antigens into the circulations and those are called Pepidoglycans.
They bind with circulating antibodies in the blood and it deposits those those those antibodies and that that complex will deposit in the skin and joints.
Typically it is seen one to six years after bowel surgery but it can be sooner. and sometimes it can be later than that.
And it typically lasts a lot longer than it did with my patients. That's one part that didn't necessarily fit with my patient, typically lasts two to four weeks.
And it does relapse every four to six weeks, which does fit with the history that my patient had given me. So you have cutaneous and non -cutaneous. -cutaneous symptoms.
Cutaneous symptoms, small red papules, blisters, pustules on truck and upper arms, and it may resemble sweets,
so a neutrophilic dermatosis. It can resemble erythema nodosum or penicillitis. For my patient, it did seem he was describing,
although it wasn't present. more of the, you know, do some presentation, but any of these can, it can present in any of these ways. Non -cutaneous symptoms,
fever, not all the time, but some muscle aches and pains, non -destructive parliarthritis, and, you know,
tendons. You know, your tendons can actually hurt with tynenosavidin. teninosovitis as well. There are some reports that it can be a little bit ulcerative looking as well.
So, bowel bypass syndrome without bowel bypass without bowel surgery is pretty rare. There's there's some interesting case reports out there. So,
these are two case studies of patients without bowel surgery and what with done to treat them. The first case was metronidazole and cyprofloxacin.
And after they were treated for two weeks and after within one week, the symptoms recurred. So they started the metronidazole four times a day and they waited until she was clear before they stopped it.
The other case was metronidazole and cyprofloxacin. the second case was they treated with prednisone and metronidazole three times a day, and they slowly tapered the prednisone and continued the antibiotics for a month.
So that was treated successfully. So that kind of gave me some other ways on how we were gonna treat this patient. So the thing to remember remember is they're inconsistent clinical features.
They're inconsistent histological features. And oftentimes they relapse after the treatment is withdrawn. So, and then again, it can recur after you think it's gone.
So it's a little bit of a, a little bit of a, you know, interesting phenomenon that happens and you can actually, actually understand why my patient was withdrawn.
He was afraid to put himself out there, is because after it went away, it was just a matter of time before it came back. So this was something that was significantly impacting his life.
So here's a case report of a viral associated dermatosis dermatosis. and arthritis syndrome or BADAS treated by secukinumab.
So interestingly enough, it does make sense that because we know secukinumab is approved to treat bowel conditions and Crohn's disease and ulcerative colitis,
but it does make sense that secukinumab or other biologics might treat this bowel bypass syndrome. And it's important to investigate and treat any GI condition.
And so that was concerning to my patient 'cause he didn't report any. He reported to me normal bowel habits, no family history.
history, nothing, no appendicitis, nothing that was associated with the gut at all. So here is an example of what we might see on histology.
We often will see the erythrimanus macules and papules that some can become vesicular pustular. And on histology, there is often papillary dermal edema and a dense peridotum.
perivascular neutrophilic infiltrate. And based on the kind of random and interesting ways that this bottle bypass syndrome can manifest cutaneously,
we shouldn't be surprised that these that um necrosis,
they're typically absent. So if you're able to get a biopsy, it's probably not going to point to bowel bypass syndrome, but if you were able to isolate the neutrophilic infiltrate,
it might point you in the direction if you combine the clinical presentation as well. So how do you manage a case of BADAS? We'll find out. out in a moment, but first let's pause for the Dermalorian Derm Decoder.
Lots of patients complain about sensitive skin, but what do they really mean? Derm faculty member, Dr. Adam Friedman, weighs in. When discussing sensitive skin,
I really like to distinguish between sensitive skin as a primary skin disease for when you have nothing else. So, a patient who says, "My skin stings, burns, anything I put on it hurts," but they don't have rosacea,
they don't have eczema, they don't have acne, they don't have anything. So there's primary sensitive skin and then there's secondary sensitive skin resulting from a primary skin disease or some underlying disorder that leads to barrier dysfunction.
So I think it's important to distinguish between the two. That's maybe an easier thing. The next piece is one. well, what do you do about it? We don't have a lot of good guidance on it.
Certainly recommending a product that is labeled for sensitive skin would make the most sense, right? We're assuming that if it says sensitive skin, it's for sensitive skin, it would be helpful. We published on several folds on patients who say they have sensitive skin,
use products for sensitive skin, and spoiler alert, they actually induce sensitive skin. So I think that's where we kind of are in terms of how do we guide these patients?
We don't have great guidance. I think certainly aiming for these products are important. Other things that are emerging are environmental triggers. Temperature change, heat seem to play a very big role.
In line with that, maybe even sweating might play a role in sensitive skin. This is all cutting edge on the cusp type data, so we certainly need more of it. But what we are trying to do,
especially in Washington, DC, with our kind of Sense of Skin Care Research Program, is first better characterize primary sensitive skin. What is it? What are the defining features?
How can we follow it with validated research tools like the Sensee Scale? Can we use to identify these patients and then of course follow their progress? And then of course is, well, what do we do about it? And we've generated a lot of impressive internet.
data that will help guide us in making those recommendations for diagnostic criteria. The next piece is using that information to identify what products work the best.
Let's return to another sensitive topic, as Wendy Cantrell tells us how she treated her patient with BADAS. So what do you do? What do you do when patients have this?
So patients with a history of fouls. surgery, you need to make sure you're evaluating for changes that are secondary to malabsorption.
You wanna make sure that you're looking at their creatine, their electrolyte imbalance, and look and see if their malabsorption might lead to abnormal liver function test.
If you're able to get a skin biopsy, you do want to do that. that and look for those, those neutrophils as well. So that's the first step.
Treatment options for patients with bowel surgery is find that blind loop and you can revise it with, revise that bowel bypass surgery.
That's going to be the curative cure for that for this. condition. Some systemic corticosteroids might prevent some systemic relief while you're waiting on the antibiotics or a biologic,
if you choose to go that way, to work. Minocycline, erythromycin, clindamycin, you know, bacterium and metronidazole have all been shown to show some benefit.
benefits. The problem is, is how do you know, how do you know when to stop it? Some of the case studies that are reviewed and shared with you show that often when you stop it,
it's back within one to two weeks. The rash can come back pretty quickly. So, you know, it's kind of a trial and error with this condition.
condition, but these are the antibiotics that have been shown. So let's go back to our patient. I really felt like that it was considered consistent with bowel associated dermatosis arthritis syndrome.
You know, the 24 year old patient really liked that he had a BADAS diagnosis. So, but I did talk to him and referred to him, and referred to him. to GI for an upper and a lower evaluation to make sure that he didn't have the early signs of any bowel disease or gut disease.
I decided to start doxycycline 50 milligrams twice a day at the load, you know, at a relatively low anti inflammatory type dose similar to what we would do with say rosacea.
rosacea. And I told him that he could continue to take the antihistamines if he felt like that he needed it. And I wanted him to keep a symptom diary and a calendar of when he had the outbreak,
what he had done before, you know, if he could remember any Bible habits or Bible issues that he had, you know, a couple of days before this.
you know, particular flair. So I wanted to see him back in three months, but I told him, please call me, you know, we can up the dose,
we can change the antibiotic. I can get you on some corticosteroids, you know. So I mean, I told him to give us a call, but at the three month follow up, he came in a static.
He had only, he reported one event. since his last visit. They decreased in intensity. He felt like he was recovering completely within 12 to 24 hours.
So decreased joints, joint pain and arthritis. But as not no surprise, a 24 year old is not going to want to go have a colonoscopy and an upper GI.
So he did not go to the GI appointment. And I asked him a pretty good amount of time that visit, again, talking to him. We wanna catch things early.
There's systemic medications we can put you on if you're diagnosed with Crohn's or ulcerative colitis that might better treat this. So,
I did encourage him to go to GI. I also encouraged him to really talk to his parents. grandparents about any GI history in the in the recent past and in their family history to see if if he could maybe ascertain any family history or family risk factors that that he might not know about so follow up visit to a six months later he's continued to see improvement he reported zero flares since his life.
visit, and he said that he was not going to not take his antibiotic. He said he was very compliant with that. And again,
guess what? He hadn't seen his GI yet, and again spent some time talking to him about the importance of following up with the GI. He was excited.
He started dating again, and he actually had had a promotion at work. because he wasn't having those missed days. So he was loving life at this point,
really happy with the treatment and what he thought was the resolution or the successful treatment of this issue.
So follow -up three was one year after I saw him initially, He reported a total of five flares in 12 months, which was much better than He was reporting,
but he said they only lasted about 15 minutes mild itching Minimal to no rash and minimal joint pain. He was able to function immediately after the flare He did go to GI and he did get an upper upper GI and a lower and a colonoscopy.
He had been taking doxycycline daily instead of twice a day and he felt like that he didn't see significant. When he decreased that dose,
he said I didn't see any significant worsening and he's really pleased with the results. I haven't seen him since. since this was this was relatively recently.
So we decided to keep him on the 50 milligrams daily. I did tell him and he has enough medication that if if he started having more significant flares that he could go back to twice daily if he needed to.
DEF will be publishing more stranger DX cases over the next few months. Stay tuned online . or in your inbox. Now, let's take a moment to hear how Durham faculty member Dr.
Gilly Munavalli talks to his patients about the importance of sunscreen in a way that truly resonates. I think skin patients come to us all the time with issues on their skin,
medical and cosmetic, and there's an overlap between the two. It's really the older we get, the more more we accumulate pigment, dark pigment, red spots, wrinkles,
and all those things as a result of the UV damage, the same UV damage that causes skin cancer. So really it's an overlap between, we're trying to prevent patients from getting cancer. We talk about sunscreen all the time,
how to use it, what to use. In the same vein, we're actually trying to help people promote their youthful skin. So there's an overlap. and I think sometimes it's better to get patients' attention just by telling them they're gonna look older than they really are,
than they kind of wake up and say, "Oh, really?" But if you tell patients they're gonna have a skin cancer 15 years down the road, that doesn't always resonate. If you're not a dermatologist or don't work in a dermatologist setting,
you don't always appreciate the effective UV light, and so a good knowledge of sunscreen. sunscreen, which ones are the best ones to use, what's setting to use them in,
how to reapply them will go a long way in helping the patient. It sounds very cliche, but it's very true. I mean, I've had patients that have just been given that advice and they've used sunscreen for years before they've seen me and I can always tell.
It seems like vanity may have its benefits after all. That's it for this episode of the Dermalorian