Cutaneous vasculitis: a presentation with endocarditis to keep in mind*

Initially, TTS lesions were believed to be a sequel of impaired nerve fibers resulting in the loss of neuronal trophic factors.6 Later, researchers realized that the condition is caused by self manipulation of the desensate itchy skin in a reflexive action to get rid of the troublesome dysethesias.3,6 Although TTS characteristically affects the ipsilateral nasal ala, cheeks, and upper lip, involving the V2 or V3 dermatomes, it can appear anywhere in the trigeminal innervation territory.6 TTS following herpes zoster involving the scalp and forehead is a less common presentation. Differential diagnosis of TTS includes various diseases manifesting as facial ulcers such as squamous cell carcinoma, basal cell carcinoma, infections, vasculitis, pyoderma gangrenosum, and factitial dermatitis.1,2,4,5 Treatment should be centered on behavioral modification intended to reduce self-induced trauma.7,8 Occlusive dressings can also prevent handling and perpetuation of the skin lesions by the patients. Pharmacotherapy with carbamazepine, amitriptyline, diazepam, chlorpromazine, and pimozide has been used with varying results.8 Other reported modalities of management include hydrocolloid dressings, transcutaneous electrical nerve stimulation, plastic surgery with innervated flaps, and negative pressure wound therapy.2,4,5 The present case was successfully managed with counseling, occlusive dressings, and carbamazepine. q FIgure 1: Crescent-shaped ulcer involving the left frontal scalp and a small ulcer above the lateral aspect of the eyebrow