What is a Dilated Pore of Winer?

Patient Presentation
A 22-year-old female came to clinic with a lesion along her hairline near her ear. She said that it has been there “for a long time.” It hadn’t changed much in size but is always there. When she manipulates it, “This hard thing like a grain of rice comes out and then some other white stuff. It seems to get smaller then but then comes back and there is a black spot like acne.” She denies any pain or swelling unless she has just manipulated it. “It’s small now but I don’t want it to grow larger and its not getting better,” she related to the pediatrician. She had a history of mild to moderate comedomal acnes that was controlled with retinoids and benzoyl peroxide.

The pertinent physical exam showed a healthy female with normal vital signs. She had some mild comedomal acne on her nose and cheeks and a few lesions on her forehead and upper back. None were near this lesion. Near her right ear and slightly above was a 3 mm round, slightly papular lesion with a central pore that appeared to be filled with keratin material that was darkened and somewhat hardened. Light manipulation did not express any material. It was not vesicular. There was no surrounding erythema.

The pediatrician explained to the patient and medical student who was present that she thought this could be several things, “It could be an acne lesion but that doesn’t seem right as it is harder and less like a blister, and doesn’t change locations. It could be an inclusion cyst but those are usually rounder under the skin and this isn’t. Also given the location it could be an ear pit but that usually would have been noticed when you were younger and this seems too high up from the ear for that. I also remember there is something with a special name that is benign but has a big, dilated pore which this looks like. I can’t remember that name since we don’t see them much in kids.” After discussion with the patient she was referred to a dermatologist as the patient wanted to have the lesion excised, and the dermatologist confirmed the diagnosis of a dilated pore of Winer.

Discussion
Dilated pore of Winer (DPW) was first described by Louis H. Winer in 1954 in his article entitled “The Dilated Pore, A Trichepithelioma.”

It is a benign follicular tumor with particular histopathological characteristics. Its’ differential diagnosis includes:

  • Comedomal acne
  • Pilar sheath acanthoma – seen as a solitary papule with keratin plug on the central area of face
  • Nevus comedomes – multiple dark comedomes with central dilated dark openings
  • Epidermal inclusion cysts – more nodular with or without keratin plug where the keratin material has a foul odor
  • Tricofolliculoma
  • Basal cell carcinoma – occasionally seen on biopsy

Learning Point
DP presents as a single, enlarged pore which can be relatively small to several millimeters across. The pore is often occluded with a keratin plug that if expressed has white, soft creamy, keratin material behind it. The end of the keratin plug can be quite dark and the plug can be quite hard because of inspissation. It can also present as a papule with a follicular pore. They generally occur on the face, head and neck, but can also occur on the trunk. They are more common in males than females and in middle-older aged adults. However they can occur in older adolescents and young adults.

DPs are asymptomatic (but can be irritated by manipulation) and usually have been present for a long time before consulting a physician. The history may include that the keratin plug and material has been expressed only to refill over the next few weeks.

Diagnosis is usually clinical with biopsy for treatment or if needed for another reason. No specific treatment is required but excision may be completed for cosmetic or functional concerns.

Questions for Further Discussion
1. How do you treat acne?
2. What are indications for excision of a dermatological lesion?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Skin Conditions

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Winer LH. The Dilated Pore, A Trichoepithelioma. Journal of Investigative Dermatology. 1954;23(3):181-188. doi:10.1038/jid.1954.97

Tellechea O, Cardoso JC, Reis JP, et al. Benign follicular tumors. An Bras Dermatol. 2015;90(6):780-798. doi:10.1590/abd1806-4841.20154114

Bishnoi A, Aggarwal D, Vinay K, Radotra BD. Visual Dermatology: Dilated Pore of Winer. J Cutan Med Surg. 2019;23(3):332-332. doi:10.1177/1203475419825770

Benedetto CJ, Riley CA, Athalye L. Dilated Pore Of Winer. In: StatPearls. StatPearls Publishing; 2022. Accessed August 5, 2022. http://www.ncbi.nlm.nih.gov/books/NBK532967/

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

What Causes Anal Itching?

Patient Presentation
A 7-year-old male came to clinic with a history of 2 days of significant anal itching. It was worse at night and he had seen “white stuff in my poop.” He and his mother denied any general skin problems but she noted, “he’s not always the best with cleaning himself after using the restroom.” There was no diarrhea, constipation or encopresis, changes in soaps, lotions, detergents, or other skin products. His diet was unchanged. He did attend a before and after school childcare program that had recently visited a local farm. There were no known ill contacts. The past medical history was non-contributory.

The pertinent physical exam revealed a healthy appearing boy with normal growth parameters and vital signs. His examination was normal except for general irritation around his anus and excoriation marks. No specific track or burrows were seen.

The diagnosis of probable pinworms was made. The patient was treated empirically with anti-helminths which his mother said had worked when he returned for his next health supervision visit.

Discussion
Pinworms are caused by the parasite Enterobius vermicularis. Humans are the only known reservoir and are infected by fecal-oral transmission of eggs or indirectly such as through contaminated clothing or bedding. It is commonly seen in children and can easily pass to family members, plus people can become easily reinfected. The incubation period is usually 1-2 months and eggs can survive outside humans for 2-3 weeks. Adult worms migrate at night from the anus to the perianal skin and vulvar areas causing anal or vulvar itching. The itching can cause sleep problems and scratching can cause secondary bacterial infection. The worms can exist in alternative locations such as the vagina, Bartholins glands and the urethra.

Diagnosis is by direct visualization of the adult worms about 2-3 hours after sleep or by the “scotch-tape test” where upon wakening the patient has clear cellophane tape applied to the perianal skin. The tape is then reviewed under a microscope to identify the adult worms. In many cases pinworms are treated presumptively because of the difficulty of obtaining specimens. Treatment is by antihelminthic agents such as mebendazole, albendazole, and pyrantel pamoate. Handwashing and laundering items in hot water helps to decrease transmission.

As pain and itch nerves travel together it can be difficult for patients to be able to distinguish between the two different sensations. Patients may complain of general genital area pain or specific anal pain and not pruritis. Significant pruritis can also cause pain too.

In younger children, soiling and hygiene issues along with skin conditions probably are the most common causes of anal pain and/or itch, but pinworms are quite common in this population and should be suspected.

Learning Point
Pruritis ani is “…an itch localised to the anus and peri-anal skin without a rash.” Peri-anal dermatosis is different and is caused by inflammatory diseases affected the anal area occurring with a rash. Given that patients often present with excoriation it can be difficult with some causes to tell these apart.

Causes of pruritis ani include:

  • Infection
    • Parasites – pinworms, scabies, swimmer’s itch
    • Bacterial – Streptococcus, Staphlococcus
    • Fungal – candida
    • Viral – pox and others
    • Sexually transmitted infections
  • Skin
    • Dermatitis – contact, atopic
    • Hidradenitis suppurative
    • Lichen sclerosis et atrophicus
    • Paget disease
    • Psoriasis
  • Soiling and hygiene
    • Encopresis
    • Diarrhea
    • Incontinence
    • Intertrigo
    • Hygiene products and medication – soaps, detergents, creams
    • Sweating
  • Anorectal problems
    • Anatomic abnormalities – rectal prolapse, hemorrhoid prolapse
    • Abscess
    • Fissures
    • Fistula
  • Diet
    • Acid containing products – citrus fruits, tomatoes
    • Beer
    • Caffeine containing products – chocolate, cola, coffee, tea
    • Milk
  • Systemic
    • Cancer – anal, rectal, colon, leukemia
    • Diabetes
    • Hepatic problem
    • Thyroid problems
  • Other
    • Drugs – chemotherapy
    • Psychological

Questions for Further Discussion
1. How often do you see parasites in your practice and what kinds?
2. How do you treat scabies?
3. What would be indications for consultation with a gastroenterologist for pruritis ani?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Anal Disorders and Pinworms.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Stermer E, Sukhotnic I, Shaoul R. Pruritus ani: an approach to an itching condition. J Pediatr Gastroenterol Nutr. 2009;48(5):513-516. doi:10.1097/MPG.0b013e31818080c0

Abu-Asi MJ, White IR, McFadden JP, White JML. Patch testing is clinically important for patients with peri-anal dermatoses and pruritus ani. Contact Dermatitis. 2016;74(5):298-300. doi:10.1111/cod.12514

Ng NBH, Lin JB. Pruritus ani in a school age boy. BMJ. 2022;376:e067817. doi:10.1136/bmj-2021-067817

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

How Can a Consultation Be Made Better?

Patient Presentation
“You’ll want to look at this new patient who was added to your schedule this afternoon,” the nurse said to a pediatrician. It was a referral from an outside optometrist who had noted an optic nerve problem in an otherwise healthy school age child during a routine examination. The optometrist referred the patient for further medical evaluation including possible imaging. It was unclear if additional ophthalmological care had also been requested for the patient. The patient had not been seen within the health system and no additional information was available. The pediatrician contacted the on-call ophthalmologist who agreed that this was an eye problem first and potential medical problem second. The ophthalmologist contacted his colleagues in neuroophthalmology who worked the patient in that day.

Discussion
Most physicians go into medicine because they like people and want to help them and their families. Clinical patient care can also be fun, interesting, intellectually challenging and provide a creative outlet. All physicians will never know everything and need help with patient care problems that arise. That is when a patient should be referred for a consultation. Effective consultations have several important components which can be overlooked. When clear questions with background information are asked and the consultant provides specific clear recommendations answering the question but also planning for contingencies, the patient will get excellent care and both the requesting physician and the consultant will both learn from the consultation.

Patients and families should understand why the consultation is being requested so they can help the consultant and understand the consultant’s recommendations.

Learning Point
Some tips for effective consultations include:

  • What is the Question?
    • As the requesting physician (RP) actually phrase your question in the form of a question just like the television show Jeopardy! Don’t make the consultant guess what you want to know. Help the consultant to help you.
      • Ask “What antibiotics should be started and for how long should the treatment be? or What else should be considered in the differential diagnosis at this time and what additional evaluations should be considered? “
    • Give the consultant enough background information so they have a context with which to understand the question. Provide this in the consultation request in a letter, fax or the electronic medical record. Urgent or emergent requests should be done verbally.
      • “Rule out fracture” without saying where the pain is doesn’t help the radiologist who has to guess. Add the location, mechanism of injury etc.
      • Similarly, new cough and fever for 3 days is different than increasing cough and new fever after recent pneumonia for the radiologist and the infectious disease specialist.
  • What is the Timing?
    • When do you need to know the answer?
    • Is it emergent, urgent or elective?
    • Elective consultations can go through the usual request channels but urgent and especially emergent ones need to be verbally communicated directly.
    • Again tell the consultant directly what your expectations are. You may see it as emergent when the consultant sees it as urgent and decreases its priority in his/her workload.
    • The urgent consultation can become emergent too if the patient’s clinical situation changes.
  • Is It the Right Consultant?
    • It maybe unclear who would be the right consultant
      • A patient with a problem cough could see the allergist or the pulmonologist
      • A hand issue could be a hand surgeon, plastic surgeon or orthopaedic surgeon
    • As the RP ask if this is the right consultant, and the consultant should ask themselves if they are the right person too to answer the question.
    • RP and other providers who usually work outside a specific health system may not “know the system” and patients should be re-referred to the appropriate service if needed.
  • Who “Owns” the Patient or Problem after the Consultation?
    • The RP should be clear about if they still want to continue to be the “owner” of the patient and provide the overall management or if they would like the consultant to take over the care. “Owner” of the specific problem is similar. This should also be clearly stated in the consultation request.
    • Consultants should also be clear about who “owns” the patient or problem and not “steal” the patient or “ignore” the patient. “Stealing” or “ignoring” can be the RP’s viewpoint if “ownership” is not clear.
    • “Ownership” is fluid and may change as the patient’s clinical status changes too.
    • “Ownership” should be expressed to the patient so they understand who they should be communicating with regarding the “final say” in their care.
    • Whether the consultant “owns” the patient or problem, there should be appropriate periodic follow-up based on the patient’s clinical status.
  • What are the Recommendations?
    • As the RP, check the chart for elective recommendations. This is time efficient for the consultant and yourself.
    • Emergent and urgent matters should usually be discussed between the different people.
    • Communication between the RP and consultant is cheap and effective. It can provide information quickly, clarify questions and develop rapport and trust between the individuals.
    • Both the PP and consultant should be willing to say they don’t know the answer or only have part of the answer and seek additional help as needed.
  • Recommendations Should Be Brief and Specific
    • The consultant shouldn’t rewrite the entire medical record but should recap the salient points for the consultation and why the question is being asked.
    • The recommendations should be clear and specific so the recommendations can be understood and additional time isn’t needed for clarification. Reasons for the recommendations should be clear. The RPs are asking for help and therefore they do not have that expertise, so providing them with specific information will allow them to take great care of the patient and also learn at the same time.
  • Provide Contingency Plans
    • Patient’s clinical status changes and therefore provide information for when to talk with you again or a second line of care if the initial one doesn’t work for the patient.
    • Anticipating potential problems and communicating a plan is good for everyone.
  • Learning Goes Both Ways
    • Consultations are a great way to provide education to the RP about the problem. The RP usually will be interested in learning more, but they also will probably never be an expert in this problem like the consultant is. The RP will hopefully learn, and gain confidence in their clinical skills for the next time they face a similar problem. The RP should also be gracious in learning about their lack of knowledge for a problem. The consultant too can learn from the RP about their scope of practice, and their own clinical care expertise, and can use this for improving the specific recommendations they put into the consultation and their verbal discussions with RPs.
  • Use Your Manners and Be Gracious
      It should go unsaid that both the RP and the consultant are courteous, cordial and professional in their verbal and written communication.
      Legitimate disagreements occur and should be discussed verbally. The patient medical record is not the place for this type of discourse.
      “Pleases” and “Thank yous” go a long way to express your appreciation for the expertise and clinical skills of all the physicians involved.

Questions for Further Discussion
1. What other tips do you have for an effective consultation?

Related Cases

    Disease: Consultation and Referral | Communication

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Goldman L, Lee T, Rudd P. Ten commandments for effective consultations. Arch Intern Med. 1983;143(9):1753-1755.

Wilkie V, Ralphs A. The pressures on general practice. BMJ. 2016;353:i2580. doi:10.1136/bmj.i2580.

Kneebone R. Dissecting the consultation. The Lancet. 2019;393(10183):1795. doi:10.1016/S0140-6736(19)30898-0

Scaioli G, Schafer WLA, Boerma WGW, Spreeuwenberg PMM, Schellevis FG, Groenewegen PP. Communication between general practitioners and medical specialists in the referral process: a cross-sectional survey in 34 countries. BMC Fam Pract. 2020;21(1):54. doi:10.1186/s12875-020-01124-x

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Which Side Are the Organs On?

A 13-day-old male came to clinic for his health supervision visit.
He was breastfeeding, gaining weight well and was past his birth weight. He was breathing and eliminating without problems. The past medical history showed that the baby had had an abnormal prenatal ultrasound that was consistent with an abdominal lateralization defect. After delivery, the baby was well but taken to the neonatal intensive care nursery as a precaution and his evaluation showed a left sided liver with appropriate vasculature and a patent biliary system. His bowel also was rotated, and he had one spleen that was on the left side. He had normal position and anatomy in his thorax.

The pertinent physical exam showed a vigorous infant with no jaundice. His growth parameters were in the 50-75%. His cardiac examination was normal. On abdominal examination his liver was palpable on the left side. The diagnosis of a healthy infant with situs ambiguous was confirmed. “He looks and acts just like any other baby and they told he he may never have any problems. The surgeons are still deciding if anything should be done to prevent a problem though. We are supposed to see them in a couple of weeks,” the parents said. “I’m obviously happy to help you and will help the surgeons or any other specialist if they need it. As you know a lot of baby’s spit up, but with his different anatomy we’ll have to watch that more closely though,” remarked the pediatrician. “Yes, the surgeons are okay with the little baby spit up we’ve seen with our daughter, but if it is more forceful or occurs a lot or doesn’t look like the breastmilk, we’re supposed to call them and go to the emergency room,” the parents stated.

Discussion
Although externally vertebrates present with bilateral symmetry, this is not necessarily true internally for humans. Humans have a normal left-right asymmetry of their internal organs. For example, the right lung has 3 lobes and is slightly larger than the left lung with 2 lobes. The normal asymmetry is called situs solitus (SS). Complete reversal of the normal abdominal and thoracic organ positions is called situs inversus totalis (SIT). Variations on the laterality between situs solitus and SIT has been referred to by different names including situs ambiguous or heterotaxy. For this case, the term situs ambiguous (SA) will be used. Overall the incidence is 1 in 15,000 for all lateralization defects, with SIT being reported from 1 in 6,500-25,000. Laterality problems are associated with some specific syndromes and genes. Anatomic variations overall are very common and an illustrated atlas can be found here.

Learning Point
Such lateral anatomical variation may never cause any significant problems, but certainly has the potential to do so. Congenital heart defects, respiratory and hepatic problems are usually thought about first as they can cause acute life-threatening problems. However, patients may also have functional asplenia and increased risks of infection. Medical procedures may be more difficult to perform because of the differences in laterality, and imagine the surprise thoughts of the trauma surgeon who must also confront vast anatomical differences in an emergency situation.

SA like SIT is highly associated with cardiac defects. Congenital heart disease is associated with SS is only 0.6%, but is 3-9% for SIT and almost 80% for SA. SA also has many vascular anomalies especially those serving the hepatic system. Biliary atresia is also more common. Polysplenia or asplenia is also associated with SA.

SIT is associated with many different problems including congenital heart disease (e.g. complex and single lesions), gastrointestinal (e.g. biliary problems, anal atresia), respiratory system (e.g. bronchial dysplasia, primary ciliary disease), skeletal system (e.g. thoracic deformities, spinal deformities, polydactyly), urinary system (e.g. chronic kidney disease, uronephrosis, chronic kidney disease), and various others (e.g. dwarfism, cleft lip and palate, hernia, intellectual disability, precocious) among others. SIT is highly associated with various ciliopathies, a review of which can be found here.

Questions for Further Discussion
1. How often have you seen lateralization defects?
2. What is the general pediatrician’s role for patients with rare diseases? A review can be found here

Related Cases

    Disease: Situs Ambiguous | Anatomic Variation | Anatomy

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Anatomy

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Knowles M, Zariwala M, Leigh M. Primary Ciliary Dyskinesia. Clin Chest Med. 2016;37(3):449-461. doi:10.1016/j.ccm.2016.04.008

Chen W, Guo Z, Qian L, Wang L. Comorbidities in situs inversus totalis: A hospital-based study. Birth Defects Research. 2020;112(5):418-426. doi:10.1002/bdr2.1652

Eitler K, Bibok A, Telkes G. Situs Inversus Totalis: A Clinical Review. Int J Gen Med. 2022;15:2437-2449. doi:10.2147/IJGM.S295444

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa