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Many patients find cognitive behavioral therapy effective for management of their insomnia, but there aren’t enough clinical psychologists trained in the area.

Managing Insomnia With Behavioral Therapy: Is Shorter Better?

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 

A 5-year-old boy with a history of atopic dermatitis since 6 weeks of age, presents with a rash around his mouth that has been present for approximately 1 year. The patient’s mother reports that desonide topical cream was applied to the affected area for about 5 days, which initially resulted in improvement, however the rash returned after this medication was discontinued. The rash also recently improved after the patient took amoxicillin for an infection. She also notes that the patient has been licking his lips more frequently.

On examination there is an erythematous papulopustular eruption restricted to the perioral region, with sparing of the vermillion border. Mild hyperpigmentation is noted on the patient’s neck. There is no active involvement of other areas of the body.

The eruption has been present for 1 year and is restricted to the perioral region. What is included in your differential? 

Clinical Topics

Rash Around the Mouth of a 5-year-old Child


This intensely itchy, blistering rash on the forearms and upper chest of a 13-year-old girl occurred after a day at the beach. The girl had polymorphic light eruption (PMLE), the most common abnormal reaction to UV light.

A. PMLE classically presents as a papular or papulovesicular eruption on the arms and anterior chest

B. The reaction usually begins 12 to 24 hours after an initial exposure to light of a suddenly increased intensity

C. Some parts of the body are severely involved while similarly exposed areas are paradoxically spared

D. The rash resolves after 7 to 10 days, often leaving whitish scarring

What are the characteristics of this blistering rash caused by exposure to UV light? 

Intensely Pruritic Rash After Sun Exposure in a Tween Girl 

A 66-year-old woman had a mildly pruritic rash on the buttocks, lower back, abdomen, and upper posterior thighs. The eruption had been present for approximately 18 months.

A 66-year-old woman had a mildly pruritic rash on the buttocks, lower back, abdomen, and upper posterior thighs. The eruption had been present for approximately 18 months. Your diagnosis?

“Swimsuit Area” Rash: Your Dx?

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 76-year-old woman seeks your attention for an asymptomatic “red spot” on her neck. She has a history of multiple non-melanoma skin cancers.

Squamous cell carcinoma in situ (Bowen  disease)

Lichenoid keratosis (an inflammatory variant of seborrheic keratosis)

A 76-year-old woman seeks your attention for an asymptomatic “red spot” on her neck. What does this look like to you?

What's This "Red Spot"?

Wendy Troxel, PhD

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