Tag Archive | EHK

Fish out of water Part duex…

Ask and you shall receive, maybe not the first try, but try, try again we did! We recently reached out asking for advice from our readers about their knowledge and/or experience with nevus owners overheating. We received a lot of good information but nothing lined up with Mermaid’s “LEN” so I began doubting the cause. I started researching and honestly, came up a bit empty handed so I went back to ground zero and looked at her biopsy again. I often forget that the official pathology report came back as Epidermolytic Hyperkeratosis WITH Linear Epidermal Nevus, not vice versa so I restarted my search on the EHK and wouldn’t you know, it was everywhere!

EHK is a form of Ichthyosis and the information linking the two with potential overheating was abundant. It was relieving to know that my original gut feeling that the cause was related to her genetic disease but a small piece of me needed validation. After all, what if I was wrong and ignored signs of some other underlying condition. The chances seemed slim since she has otherwise been a healthy thriving child but I reached out anyway.

Our first (and I anticipated only) connection was with Mermaid’s general dermatologist. I was shocked that without a doubt not only did he say that her LEN had zero connection but he stated that I possibly misunderstood her biopsy and she did not in fact have EHK. I spoke to him about a plethora of information we had received from the children’s hospital directly related to her EHK and he admittedly stated that this was out of his wheelhouse but stood by his stance that there was no connection. Perplexed and frustrated I reached out to her Primary Care Doctor as the dermatologist advised to begin the search for an underlying cause.

Primary Care seemed as equally perplexed as I was and again eluded to this being a bit out of their wheelhouse, they were slightly taken back at us being directed to them but did some research and found a few possibilities. There were a few “conditions” that also had links to dermatological conditions that could be the underlying cause so we agreed to go forward with testing. Her PCP felt obligated to search for anything he could and being that we were led his direction we were going to travel that road with him without question. That same night with the promise of SEVEN new toys (thank the lord for the dollar store) I carted a screaming Mermaid in for blood tests and her chart was sent to neurology for a chart review. Most of the tests were straight forward and results poured in less than 24 hours later. Negative after negative after negative. I was happy, but still felt frustrated to have no concrete answer or validation.

The following morning as soon as I started seeing the negative results I made one last attempt at answers and reached out to Oregon Health and Science University where the Pediatric specialist for dermatology we previously met with resides. On our luck he had a same day appointment and off we went.

I left happy, aggravated yet understanding on all fronts. On our third connection we were assured that yes, Mermaid DOES in fact have a bit of a double whammy. She has EHK & LEN, just as I thought, EHK is a form of Ichthyosis and BOTH of them have the potential to cause overheating depending on the location. The vast majority of Mermaids fills her left armpit and as a result has clogged her sweat glands preventing her body from cooling itself properly. Essentially it causes her to internally heat up quicker. I suppose this sheds a small light on my midget sized nudist.

So now what? Well, the PNW has had some higher than normal temps and we have definitely learned that above 90 in direct sun she enters her danger zone. In the absence of a body of water we are limited to where we go if it the heat reaches that range. We started using Tazorac for a few weeks to see if we can thin the thickening near her sweat pores to allow some breathing room. There is no guarantee but smack dab in the middle of summer, any small relief is a huge feat. We followed up with all entities to ensure them it was in fact a direct result of her genetic disease and also advised that a body temperature above 105 is directly to the ER opposed to attempting to cool her ourselves at home. I guess I should replace that thermometer she broke.

We appreciate everyone that reached out to us and shared your wisdom, I can assure you that the moment you see your little one turn purple, vomit and fall asleep so deeply it’s hard to wake them, you too would be in a bit of a panic. I can’t possibly begin to imagine how she felt. I compare it to those of us without an underlying condition attempting to run a marathon in 105 degree weather while wearing a sweat suit and no water to drink. I’m so proud of how smart my Mermaid is to recognize when she has been out in the sun long enough. She is very vocal in telling me it has been enough and time to go, brings herself inside to cool off knows to continue staying hydrated. She has had so much to learn about in her short 4 years on this earth and always adjusts without a hitch. Maybe Mermaid’s are smarter than we ever knew!

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Here’s to hoping we have an otherwise eventless summer!

Thanks for walking with us today!

Mermaid’s Mommy

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…And… We are back!

Well hello there! Welcome to 2017! We last left you a note that we were taking the holiday season off and that’s just what we did; but it’s time to dive back into things. As I’m sure you all know, the holiday season can be all encompassing. We wanted some time to focus on another project and be present in all the winter festivities. Some things went as planned and we promise to share about that later but honestly, life had a different plan for us these past few months and we went through some personal struggles regarding loss. That too, we will share down the road but I’m not quite ready to go there.

For now, let’s catch up on where we are at in the Nevus world. We gained some new followers during our break and fresh faces are always looking so I will give a quick reminder of why we are here.

My daughter was born with Epidermolytic Hyperkeratosis, specifically Aconthotic and hyperkeratotic epidermis with focal dyskeratosis including linear epidermolytic epidermal nevus and epidermolytic acanthoma, a hemangioma and a stork bite, also a form of nevus, on her neck. The hemangioma never grew, it’s the same size now as it was at birth but her stork bite, also a form of nevus, has continued to grow and her LEN has opted not to slow down. In comparison to others we feel blessed, her LEN remains light in color and relatively flat but continuously changing.

What does all of that even mean?

Broken down, it essentially means she has EHK and LEN.

Linear Epidermal Nevus (LEN) is a rare genetic skin disease effecting about 1 in 100,000 people that typically effects the limbs and torso. Her particular kind sticks to one side of the body, in our case, her left side. In infancy it is light tan and flat but will thicken, darken and often become warty as one ages. There is a possibility of skeletal, bone, ocular and neuro abnormalities that may develop; in which case it would be consider a “syndrome”; the lesions alone do not indicate a syndrome. There is a chance that the lesions may develop tumors, some benign, some cancerous. Open lesions are susceptible to infection, causing further health risks. About one in five people will experience a malignant cancer in their lesions.

There are many other forms of Nevus including Congenital, Sebaceous, giant, and closest in kind, ILVEN. It is caused by a genetic mutation in the ectoderm during gestation. At this time there is no “cure” – though there are potential medicines and procedures to help with discomfort and visualization. Occasionally, surgery will be warranted if the size or site indicate so. Excision is the only true “cure” for LEN or ILVEN. The rest is all maintenance so it all depends on how severe your specific case is.

The subtype of Epidermolytic Hyperkeratosis (EHK) is even rarer than LEN. It effects about 1 in 250,000 people and makes Mermaid’s skin fragile. There are two types of EHK, my daughter’s is the NPS type. We will explore that more this coming year. The dyskeratosis and aconthosis is a fancy way of saying there is an abnormalization of the skin keratin causing thickening.

So where are we today?

Currently, we are on our 3rd dermatologist and live day to day with what the future may hold. We have been blessed that thus far she has not developed any of the potential abnormalities and most likely wont, with one exception. Her vision, her eyes were checked about 1.5 years ago and they questioned her vision a little bit. As a result our new dermatologist recommended we follow up. We will be seeing the same pediatric opthomologist, which we LOVED,  for our second time in a few short weeks. The obvious things they are looking for are cataracts and colobomas, some people refer to an abnormality as a “key-hole.”

Additionally, Mermaid’s disease is growing on her hand, over the joints. Nothing has been set in stone but all 3 dermatologists have mentioned the potential of needing excision surgery near school age. We are a ways off from that so I can’t speak to that more than saying it is a possibility.

One of the first things we were told was to be aware of was the potential of developing “Wilm’s tumor” – childhood kidney disease. This has been controversial from source to source but nonetheless, is there. She will officially be in the clear at age 6.

Over the past few months Mermaid has developed a new spot on her back and the base of her skull that are itchy, raised and extremely bothersome. We are waiting them out to see if they progress but will probably go in to have them checked soon.

Where we are today is night and day to where we began. In the beginning I was scared, plagued with anxiety, confused and uneducated. I now have a good grasp on what we are dealing with and the anxiety has mostly subsided. I say “mostly” because there is always that lingering fear of cancer, be it in the form of melanoma or kidney cancer, that, I will never shake, though it is far from the forefront of my mind, more of a foot note.

We have grown so much as a result of my relentless research and support from everyone here at Mommy’s Mermaid.

To our new followers, we welcome you, and thank you for joining us, to those just browsing, thanks for stopping by, and for our long time friends and followers, we appreciate and love you all.

We look forward to spending the next year sharing our journey, hearing your stories and hopefully making progress and new discoveries in the nevus world.

Cheers to 2017!

Thanks for walking with us today!

Mermaid’s Mommy

A,B,C,D,EHK,LEN,ILVEN,ENS…

Navigating the world of Epidermal Nevus can be confusing. No matter how hard I try, I will never be able to forget the day I received Mermaid’s diagnosis. I know now that it’s going to be ok and we can jump whatever hurdle presents, but I didn’t always feel that way, we are constantly gaining new followers, many who feel the way we all did in the beginning. Lost. I feel like It’s been a while since we have broke down the basics, like what do all these acronyms mean? So many are used interchangeably that it may cause confusion and more fear. So, today I am going to break down 4 of the most commonly used terms surrounding EN that I see. LEN, ILVEN, EHK and ENS. I will touch briefly on other forms but highlight these 4 acronyms.

It is so important to understand that where all these terms refer to Epidermal Nevus, LEN is different than ILVEN, EHK is slightly different than both LEN and ILVEN and MOST IMPORTANTLY, having a diagnosis of Epidermal Nevus does NOT mean that you have the syndrome.

Here is a reminder of Mermaid’s official biopsy report:

-Epidermolytic hyperkeratosis.

Exam demonstrates aconthotic and hyperkeratotic epidermis with focal dyskeratosis. The differential includes linear epidermolytic epidermal nevus and epidermolytic acanthoma.

Though we were told that ILVEN has not yet been ruled out.

(linear epidermal nevus occurs in 1 out of 1,000 people. However, epidermolytic hyperkeratosis only occurs in 1 out of 2/300,000 people worldwide)

Epidermal nevus is a clinical term for a family of skin lesions that involve the outer portion of skin, the epidermis, and are distributed in a linear and often swirled pattern.  The lesions may be single or multiple and are usually present at birth.  All epidermal nevi show some changes in texture which can range from very rough, warty and spiny, and often darker than the surrounding normal or uninvolved skin (verrucous epidermal nevus), to red and scaly (inflammatory linear verrucous epidermal nevus or ILVEN),  to yellowish, rough and pebbly appearance due to proliferation of oil- or ’sebaceous’ gland-like structures (nevus sebaceous).

Epidermal nevi are genetically ‘mosaic’, meaning that the mutation causing the nevi are not found in other cells of the body. Mosaicism arises when the genetic mutation occurs in one of the cells of the early embryo sometime after conception; such mutations are called ‘somatic’ mutations.  This mutated cell, like the other normal cells, continues to divide and gives rise to mutated daughter cells that will populate a part of the body.  The linear patterning of the epidermal nevus reflects the movement of the mutant daughter cells during fetal growth.  These linear, developmental patterns are termed the ‘lines of Blaschko’.  Many epidermal cells within these affected areas harbor the mutant gene, while most or all cells from uninvolved areas do not.  After birth, the nevus “grows with the child”, although some new areas of involvement and/or extension of the nevus to new areas can occur.  ILVEN is an exception: here, lesions often do not appear until later in infancy or childhood.

Types of epidermal naevi:

The skin lesions most often referred to as epidermal naevi are due to an overgrowth of keratinocytes (horny skin cells).

  • Linear epidermal naevus
  • Epidermolytic epidermal naevus
  • Acantholytic epidermal naevus
  • Systematised epidermal naevus
  • Linear porokeratosis

However, several other conditions are also characterised by benign overgrowth of the epidermis and its appendages (organoid naevi)

  • ILVEN
  • Sweat gland naevi
  • Sebaceous Nevus
  • Comedone Nevus
  • Becker Nevus

Let’s start with LEN: Linear Epidermal Nevus:

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Linear epidermal nevus (LEN) is an uncommon skin condition. It usually affects the limbs and torso on one side of the body. The lesions are typically present at birth. LEN is the result of a genetic abnormality. It is not inherited but arises from somatic mutations in cells that occur after conception.

This is a type of birthmark that is usually present at birth, but may develop later in childhood. They are usually light or dark brown in color. They may start as a flat area in the shape of a line or as a “skin tag.” Over time, they grow and become thicker like a wart. They can be located anywhere on the body. Often, epidermal nevi follow a pattern on the skin known as the lines of Blaschko. The lines of Blaschko, which are invisible on skin, are thought to follow the paths along which cells migrate as the skin develops before birth.

Second is ILVEN: Inflammatory Linear Verrucous Epidermal Nevus:

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Inflammatory linear verrucous epidermal nevus is a special kind of epidermal nevus. Like other linear epidermal nevi, ILVEN is characterized by warty lesions that tend to group together in a linear pattern. The difference is that the lesions are red, inflamed and itchy, sometimes intensely so. The surface of the lesions may look like eczema (dry, red, scratched) or like psoriasis (red and scaly).

ILVEN most often affects one leg and may extend from the buttock to the foot. It may be present at birth, but usually arises during the first 5 years of life and spreads over months or years. ILVEN is very rarely observed during adulthood. It is somewhat more common in females.

Next up… EHK: Epidermolytic hyperkeratosis

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Epidermolytic hyperkeratosis is a skin disorder that is present at birth. Affected babies may have very red skin (erythroderma) and severe blisters. Because newborns with this disorder are missing the protection provided by normal skin, they are at risk of becoming dehydrated and developing infections in the skin or throughout the body (sepsis).

As affected individuals get older, blistering is less frequent, erythroderma becomes less evident, and the skin becomes thick (hyperkeratotic), especially over joints, on areas of skin that come into contact with each other, or on the scalp or neck. This thickened skin is usually darker than normal. Bacteria can grow in the thick skin, often causing a distinct odor.

Epidermolytic hyperkeratosis can be categorized into two types. People with PS-type epidermolytic hyperkeratosis have thick skin on the palms of their hands and soles of their feet (palmoplantar or palm/sole hyperkeratosis) in addition to other areas of the body. People with the other type, NPS-type, do not have extensive palmoplantar hyperkeratosis but do have hyperkeratosis on other areas of the body.

Epidermolytic hyperkeratosis is part of a group of conditions called ichthyoses, which refers to the scaly skin seen in individuals with related disorders. However, in epidermolytic hyperkeratosis, the skin is thick but not scaly as in some of the other conditions in the group.

Lastly… ENS: Epidermal Nevus Syndrome

The term “epidermal nevus syndrome” has generated significant controversy and confusion in the medical literature. Originally, the term was used to denote a disorder that was actually several different disorders erroneously grouped together. In the recent past, the term was used to denote a specific disorder now known as Schimmelpenning syndrome. However, the term epidermal nevus syndrome could be correctly applied to several different disorders. Therefore, the umbrella term “epidermal nevus syndromes” now represents a group of distinct disorders that have in common the presence of one of the various types of epidermal nevi. However, there is so far no general agreement how to classify the types of this diverse group of disorders, adding to the confusion within the medical literature

Epidermal nevus syndromes (ENSs) are a group of rare complex disorders characterized by the presence of skin lesions known as epidermal nevi associated with additional extra-cutaneous abnormalities, most often affecting the brain, eye and skeletal systems. Epidermal nevi are overgrowths of structures and tissue of the epidermis, the outermost layer of the skin.

In ENS, neurological involvement may include:

  • Epilepsy or infantile spasms.
  • Intellectual impairment.
  • Structural or vascular brain abnormalities.
  • Spinal lesions.

Skeletal involvement includes:

  • Incomplete formation of bony structures – eg, spina bifida.
  • Hypoplasia of bones.
  • Bony cysts.
  • Asymmetry of the skull or spine.
  • Spontaneous fractures and rickets.

Ophthalmic involvement includes:

  • Colobomas.
  • Strabismus.
  • Ptosis.
  • Nystagmus.
  • Corneal opacities.
  • Retinal changes.
  • Various other ocular abnormalities which have been described.

Endocrine features have been reported:

  • Hypophosphataemic vitamin D-resistant rickets has occurred in a number of cases.
  • Precocious puberty has been described in several cases.

Syndrome of inappropriate antidiuretic hormone (SIADH) has been reported in one case.

Other potential complications of EN:  

Complications due to Epidermal Nevus are rare; but, it is observed that there is an association with the development of basal cell carcinoma, squamous cell carcinoma, keratoacanthoma, and clear cell acanthoma.

It is suggested to search for dysplastic kidney disease in patients with neurocutaneous disorders. Neurocutaneous syndromes are disorders that lead to growth of tumors in various parts of the body. One being a Wilm’s tumor. They’re caused by the abnormal development of cells in an embryo and characterized by the tumors in various parts of the body (including the nervous system) and by certain differences in the skin. It is important to understand this is very rare but something to be aware of.

Whew, that was a lot of information, I hope it brought a small amount of clarity surrounding all the terms thrown out there.

Thanks for walking with us today!

Mermaid’s Mommy