Dermatology

An 18-month-old girl presents with a mass in the lateralupper right orbital area (lateral brow). The lesion can bepalpated beneath the eyelid just inside the lateral aspect ofthe orbital rim. The lesion does not appear to interferewith the girl’s vision. The extraocular movements all appearnormal and, grossly, the child appears to visualizenormally with her right eye. CT reveals a well-circumscribed,cystic mass without bony involvement or deep intracranialextension.

For 6 months, a 69-year-old man has experiencedpain in his right shoulder; hetakes NSAIDs for relief. During the lastmonth, the pain has worsened, weaknessand tingling have developed in his righthand, and the skin on the right side ofhis face has become dry. The patient alsoreports a 1-month history of melanoticstools. He had smoked 1 pack of cigarettesa day for 50 years before quittinglast year

The parents of a 3-year-old girl seekmedical evaluation of the nodules ontheir daughter’s back. The lesionshave been present since birth andhave grown with the child.

A 24-year-old African American man presents for a routine eye examination. Theocular findings are unremarkable; however, well-circumscribed areas of whitenedskin are noted on his forehead and hands (A and B). The patient reportsthat the patchy loss of pigment has been progressing over a number of years.

A 47-year-old woman is bothered by the numerous small, smooth, darkbrown papules that have developed on her face and neck during the pastdecade. She asks if the asymptomatic lesions can be removed.

During the past 3 decades, the prevalence of asthma andallergies in children has increased steadily. Today, about 5million American children have asthma, which is the leadingcause of absence from school. The editors and authors ofthis textbook-who are recognized authorities in theirfields-discuss recent advances in the field of allergy andimmunology and tailor this new information to the specialneeds of children. Children’s immune systems are in theprocess of development; this offers special opportunities forprevention and intervention. Presented here is detailedguidance in the diagnosis and management of immunologicdiseases, upper airway allergies, asthma, food allergies, allergicskin and eye diseases, and drug allergies. Differentialdiagnoses, approaches to evaluation, environmental triggers,and both established and emerging treatments are alladdressed. The latest immune-directed therapies are discussedin depth. Photographs, graphs, tables, and figuresappear throughout the text.

An 11-year-old boy has had a persistent foot rash since he started to play baseball2 months earlier. The eruption has not responded to over-the-counter antifungalcreams.

A 64-year-old woman presentsto the emergency department withworsening crampy abdominal painthat began the night before. Afterthe pain started, she had a bowelmovement containing a significantamount of blood; since then she hashad episodes of diarrhea. She hadbeen previously healthy, denies traumaand fever, and knows no one withsimilar symptoms. She reports norecent enema, endoscopy, or otherabdominal procedure.

A 36-year-old womanhas had a rash on her hands and feetfor the past week. She denies recentillness, pruritus, fever, chills, sorethroat, and abdominal discomfort.She is currently in a monogamousrelationship with her fiancé.

For 3 days, a 60-year-old woman hashad a tender rash on her forehead. Thelesions erupted 2 days after she sustainedminor trauma to the left side ofthe forehead (Figure 1); no scratchesor bleeding were associated with theinjury. She noted a burning sensationand mild tenderness at the site shortlybefore the lesions arose.

Prolonged exposure to coldtemperatures can have a profoundeffect on the skin.When tissues are exposed toabove-freezing temperatures,localized vasoconstriction and increasedblood viscosity reduce bloodflow and decrease the amount ofoxygen available to tissues. Whentissues are exposed to freezing temperatures,water within those tissueschanges into ice crystals; this resultsin either intracellular or extracellulardamage and tissue necrosis.

A 73-year-old man is admittedto the hospital with pulmonary tuberculosis.A 3-drug fixed combination-isoniazid, rifampicin, and pyrazinamide-and ethambutol are given.Within an hour, a global urticarialrash erupts (A and B).

A 23-year-old woman presented with medial and lateralpruritic keloids on her right earlobe, which had beenpierced several years earlier. These lesions began to developduring the patient’s pregnancy 2 years earlier.Keloids also were noted on the presternal region. Thepatient reported that these had begun as pimples thatspontaneously enlarged.

My patient is a 7-year-old girl with multiple plantar warts on both feet.

A 10-year-old boy presents with abdominaldistension that has progressed slowlyfor the past 2 years. The distension,which is painless, does not impair hisdaily activities. He has not observedany changes in bowel or voiding habits.

A 3-year-old boy is brought to the office by his mother. Theprevious evening, she had noticed a single large red spot on the back of histhigh. This morning, his whole body was covered with a similar rash, andhe had a temperature of 38.8°C (102°F). The mother administered 1 doseof acetaminophen at home for the fever; the rash was asymptomatic.

Allopurinol has been usedto treat gout for well over3 decades. In addition,this drug is prescribed toprevent urate nephropathyin patients who are receiving cancerchemotherapy.

For several months, a 59-year-oldwoman has had numerous asymptomaticlesions on her arms andlegs. During this period, she has notbeen exposed to the sun and hastaken no new medications.

A 67-year-old man with poorly controlled type 2 diabetes mellitus presents withleg pain and swelling that began 3 days earlier. Multiple ulcers are noted at thelateral malleolus. His temperature is 38.9°C (102.1°F). Right lower extremitycellulitis is diagnosed, blood samples are taken for culture, and the patient ishospitalized.

What caused these linear, grouped, pigmented papules on a child's back? These symmetrical hyperpigmented patches on a man's face? Test your diagnostic skills.

A 28-year-old woman complains that her acne has worsened since she startedtaking minocycline for the skin condition 6 weeks earlier. She also uses a norgestimate/ethinyl estradiol oral contraceptive, which has an indication for acnetreatment. Numerous small, pruritic, erythematous follicular papules are presenton the patient’s forehead, cheeks, and nose

A 29-year-old woman presents with a painful erosive dermatitis that has spreadin a perioral distribution during the last 2 days. She complains of a low-gradefever and swollen lymph nodes. The patient has a history of atopy; she isotherwise healthy and takes no medications.

During the past few weeks, a 14-year-old boy has noticed blood on the proximalnail folds of the second and third fingers of his dominant hand. He deniesany pain or pruritus. The patient is otherwise healthy and takes no prescriptionmedications.

For 2 days, a 43-year-old woman has had a slightly tender rash on her trunk andextremities. Five days earlier, the patient was given levofloxacin for an upperrespiratory tract infection; because she is prone to yeast infections while takingantibiotics, fluconazole also was prescribed. Her only other medication is an oralcontraceptive, which she has been taking for several years.

For 2 weeks, a 35-year-old woman has had a mass on her hand.Although it was initially painless, it now causes discomfort in the forearm,especially when the patient extends her wrist. She has no history of recenttrauma, illness, or a similar mass.

The parents of a 6-year-old child are concerned about blisterson her hands that erupted 3 days earlier and are spreading. The child isotherwise healthy and had attended a summer day camp. The parents areunaware of any trauma or exposure to allergens or toxic substances.

For several months, a 16-year-old girl has had an asymptomatic papulosquamousdescending linear eruption on 1 leg.

For 3 months, a 57-year-old woman has had a persistent green nail that is occasionallyslightly sore; the nail plate has lifted. Another physician prescribed a7-day course of levofloxacin for a suspected Pseudomonas infection; the treatmenthad no effect on the nail. A subsequent 7-day course of norfloxacin wasalso unsuccessful. The patient is otherwise healthy.

During a routine skin examination,periungual erythema and increasedcurvature of the nail plate are notedin a 78-year-old man. The patient hasemphysema and a smoking historyof more than 50 pack-years. Currently,he requires oxygen support forregular daily activity.

For the past 2 days, an elderly woman has had severe pain in and discharge from the right ear. She has diabetes, which is well controlled with anoral hypoglycemic agent, and eczematous dermatitis.