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A definitive gout diagnosis is based on demonstration of  monosodium urate crystals on aspiration of an affected joint or tophus.

Gout Diagnosis: 4 Common Misconceptions

A 67-year-old woman seen in clinic for unrelated concerns is incidentally noted to have a “rash” on her flank. She says it appeared in adulthood and has been stable for some years. On the right lower back, there is an asymptomatic reticulated erythema without scale or ulceration

. The patient admits to regular heating pad use on her lower back for pain. The remainder of the skin examination is within normal limits.

The patient says the incidental finding appeared in adulthood and has been stable for years. Can you identify this reticulated erythema?

Clinical Topics

An Asymptomatic Rash on the Low Back of an Older Woman 

This asymptomatic, hyperpigmented, hairy lesion is on the left upper back of a 16-year-old boy. The pigmentation was first noted 5 years earlier; the coarse and dark hair confined to the hyperpigmented area had appeared at age 13 years. History and physical examination findings were unremarkable.

This asymptomatic, hyperpigmented lesion was first noted 5 years earlier on the left upper back of a 16-year-old boy. A nevus? Cafe au lait spot? 

Hairy Brownish Patch


These 2 patients presented with a swollen hand and rapidly proximally progressive edema secondary to a bite.

These 2 patients presented with a swollen hand and rapidly proximally progressive edema secondary to a bite. What creature did the biting?

Swollen Hands-What’s Biting?

A 67-year-old woman noted the appearance of several non-tender, rock-hard, purple-colored nodules on her legs. Her medical history was significant for distant non-Hodgkin lymphoma.

A 67-year-old woman noted the appearance of several non-tender, rock-hard, purple-colored nodules on her legs. Her medical history was significant for distant non-Hodgkin lymphoma. The violaceous color and configuration of the skin lesions suggests which of the following? 

Hard Purple Nodules: Your Dx?

A 42-year-old man presents with a pruritic rash characterized by pink, scaly plaques with a few crusted erosions on the elbows

knees, lower back, and buttocks. Review of systems was negative, although there was a strong positive family history of celiac disease. He took no medications and was otherwise healthy.

A pruritic, scaly rash appeared on this 42-year-old man's elbows, knees, lower back, and buttocks. Can you ID? 

Elbow Erosions 

A 64-year-old woman with a history of basal cell carcinoma presents to the dermatologist for skin cancer surveillance. She is incidentally noted to have bruising on her upper eyelids (above). On questioning, she reports experiencing recurrent intermittent eyelid bruising for several years. She denies a history of trauma to her face, pain, or other associated symptoms.

Her medical history is significant for hyperlipidemia, hepatitis C (diagnosed >30 years earlier), osteoporosis, celiac disease, and idiopathic proteinuria for several years. Her surgical history includes appendectomy and carpal tunnel repair.

Pertinent family history includes her mother dying of multiple myeloma and her father of complications of diabetes.

Review of systems is significant for vague symptoms of gastrointestinal discomfort. On more directed questioning, she reports the eyelid purpura is temporally related to the Valsalva maneuver/ strained bowel movements. Her medications include atorvastatin, risedronate sodium, a daily multivitamin, calcium, vitamin D, and aspirin.

Her examination reveals no bruising elsewhere and no findings of interest on skin or mucous membranes.

B. Allergic contact dermatitis, purpuric type

Eyelid bruising was observed on a 64-year-old woman during routine skin cancer follow-up. She denied trauma or pain. What does this look like to you? 

Image IQ

Image IQ: Recurrent Eyelid Purpura 

Naomi Schlesinger, MD

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