An unusual case of Darier disease complicated with a parasitic infestation

A 40-year-old woman living in the countryside near Cali, Colombia, presented with exacerbation of papules located on her face and neck and an ulcer located on the left retroauricular area of 2 weeks' duration. She stated that her skin lesions appeared erratically, beginning at 13 years of age and that her father and daughter had similar skin lesions. Physical examination revealed multiple erythematous, hyperkeratotic papules, and yellowish brown crusts that coalesced to plaques located on symmetrical areas of the forehead, neck, and periauricular areas with excoriation and malodor (Figure 1a and 1b). There were flat-topped papules on the dorsal aspect of her hands. The fingernails exhibited subungual hyperkeratotic fragments, V-shaped notches at the free edges of some nails, distal onycholysis, and white longitudinal bands (Figure 1c). We also discovered a foul-smelling left retroauricular cavity, approximately 3 cm in length and 3 cm in depth, with multiple fly larvae inside of it (Figure 2). We made the diagnosis of retroauricular myiasis and obtained skin biopsy specimens from her forehead and scalp, to confirm the presumptive diagnosis of Darier disease.