Dermatology

A 24-year-old woman complains ofa pruritic rash that erupted after shesoaked in a hot tub a few days earlier.The patient is otherwise healthy;her only medication is an oralcontraceptive.

This painful, blistery eruption recentlydeveloped on the hand of ateenage girl. She claims she has hadno other such lesions. What doesthis look like?

The parents of a 6-year-old boy are concerned about the asymptomatic bumpsthat have developed on their son’s abdomen during the last few months.

A 26-year-old man who presentswith acne mentions that he has had“Raynaud’s” for 10 years. His eyelidsare pinkish violet and swollen. Nailfold telangiectases are present,and violaceous papules and scaleoverlie the joints. The patient deniesany other symptoms.

To relieve an itch, have patients ruban ice cube over the affected areainstead of scratching with their fingernails.

For 1 week, a 35-year-old woman’s left ear has been very painful, erythematous,and swollen. There is no history of insect bite or trauma. Her conditionimproved only slightly after the physician she initially consulted prescribedmethylprednisolone and cephalexin.

A 73-year-old woman presents with apainless, nonpruritic rash of recent onseton her right lower ankle. She has nofever, chills, nausea, vomiting, malaise,or other systemic complaints. Her medicalhistory includes fibromyalgia, osteoarthritis,stable angina, and anxiety;there is no history of connective tissuedisease.

Lentigines small, well demarcatedtan or brown macules often encircledby sun-damaged skin can alsoappear on normal skin. Thesemacules, which become more numerouswith advancing age, usuallyappear in groups.

Actinic (solar) keratoses are found on sun-exposed skin of elderly white persons-in particular redheaded or blond patients, who tend to burn frequently and tan poorly. Actinic keratoses are the most common sun-related growths in white persons.

Cutaneous horn is a descriptive rather than diagnostic term that refers to horn projections of tissue that are caused by a variety of neoplasms, including actinic keratosis, warts, Bowen disease, granular cell tumors, Paget disease, sebaceous neoplasms, basal and squamous cell carcinoma, and seborrheic keratosis.

I enjoyed Dr Henry Schneiderman’s “What’s Your Diagnosis?” case of an elderly woman with severe facial ecchymoses from a fall. Would Dr Schneiderman elaborate on several points about that case? This woman did not trip or complain of dizziness before she fell. What caused her to fall?

Excessive sweating, or hyperhidrosis, can be primary or secondary. Cardiac disease can cause hyperhidrosis. If the results of his laboratory workup are normal and he does not show evidence of leukemia, lymphoma, infection, or diabetes, then I would try treating him for primary hyperhidrosis.

ABSTRACT: Painful recurrent ulceration of gingival tissue suggests a secondary intraoral presentation of herpes simplex virus (HSV) infection. Unlike the lesions of HSV, lesions associated with coxsackievirus do not erupt in the anterior mouth but rather on the soft palate and pharynx. Furthermore, unlike HSV infection, coxsackie infections may recur, because there is considerable viral variation. Patients with atrophic or erythematous candidiasis report burning pain and a metallic taste. The typical patient with benign mucous membrane pemphigoid is a woman older than 50 years; the condition usually involves the attached gingiva around the teeth. The lesions of erythema multiforme may erupt on any intraoral mucosa; biopsy may be required to rule out other conditions with similar presentations.

Seborrheic keratoses are the most common neoplasms in elderly persons and affect up to 60% of this population. Risk factors for these lesions are thought to include genetic predisposition, age, and sun exposure.

Concern about the large, hairy mole on his left shoulder prompted a 24-year-old African American man to seek medical attention. The lesion first appeared during early adolescence as a group of small, dark blotches. These eventually coalesced into a hyperpigmented patch with hair and acne.

For 4 years, a 50-year-old man of African origin had flesh- colored, annular, verrucous plaques with a waxy appearance on his face, right earlobe, and scalp. The patient was in good health otherwise. Physical examination showed no anomalies. A complete blood cell count was normal, as was the biochemical profile. A chest radiograph was also normal.

An 81-year-old woman presented with a widespread pruritic eruption of 1 month's duration. She had hypertension but was otherwise healthy and was taking no new medications.

For years, a 46-year-old African American woman had had progressive weight gain (despite a low-calorie diet), fatigue, and severe muscle cramps. On examination, Mandeep Hundal, MD, Rashid Khan, MD, Rajeev Garg, MD, and Niraj Mehta, MD, of the University of Texas Health Science Center at Houston, noted symmetrically distributed fatty lumps in the patient's neck, axillary and mammary regions, and proximal segments of the arms and legs. These findings are characteristic of Madelung disease, which is also known as multiple symmetric lipomatosis (MSL) or Launois-Bensaude syndrome.

The false sensation of bugs crawling on or within the skin is a sensory hallucination commonly associated with psychostimulant drugs. It was first reported in chronic cocaine users in 1889. Patients with this disorder often have self-induced dermatosis caused by intense picking and scratching of the skin.

Abstract: Allergic drug reactions are mediated by IgE. Other immunologic drug reactions are mediated by IgG and complement, T cells, systemic cytokine release, and mast cell activation. True drug allergies, which are IgE-mediated, account for less than 10% of all adverse drug reactions. IgE-mediated reactions are commonly seen with penicillins, but also occur with some other antibiotics, chemotherapeutic agents, therapeutic proteins, and neuromuscular blockers. They are often limited to urticaria but also include life-threatening anaphylaxis. Skin testing to identify patients who are allergic is available for many agents associated with IgE-mediated reactions. Protocols for desensitization permit the use of some culprit agents when indicated. (J Respir Dis. 2006;27(11):463-471)

A 38-year-old African American man with HIV infection presents with numerous dyspigmented macules and patches on the extremities, abdomen, and chest; the lesions are smooth, nontender, and minimally pruritic. He has been noncompliant with antiretroviral therapy since his diagnosis 3 years earlier.

ABSTRACT: Melanomas usually do not arise from nevi; they are thought to result from UV radiation-induced DNA damage and genetic factors. The most important risk factors for melanoma are a personal history of atypical nevi, a family or personal history of melanoma, and large numbers of nevi. The ABCD criteria (asymmetry, border irregularity, color variegation, diameter larger than 6 mm) help identify early, thin tumors that might otherwise be confused with benign pigmented lesions. The E criterion has recently been added: an evolving lesion (one that shows any change in size, shape, symptoms, surface, or color) warrants prompt evaluation. If melanoma is suspected, total excision--rather than shave biopsy--is required. Melanomas that are detected and treated in the radial or early vertical phase have an excellent prognosis.

ABSTRACT: Risk factors for oral cancer include tobacco use and alcohol intake (especially in conjunction with tobacco use). Many benign conditions may be confused with squamous cell carcinoma, the most common type of intraoral neoplasm. Any red and/or white lesion that has surface corrugation, stippling, or induration is considered dysplastic or neoplastic until proved otherwise. Even without these clinical signs, white plaques of any size that persist for several months may represent dysplasia. These lesions should be assessed by biopsy. Risk factors for lichen planus include stress, exposure to certain foods and medications, and systemic illness. Erosive lichen planus may cause significant pain and oral dysfunction.

Generalized papular, erythematous, nonpruritic, hyperpigmented lesions had appeared on the face, arms (A), chest, and abdomen of a 25-year-old homosexual man with AIDS during the previous month. Anupama Ravi, MD, of Atlanta also noted purple-red, nodular lesions in the right conjunctiva (B) and oral cavity, especially the lower gingiva (C). Other pertinent physical findings included facial edema and hepatosplenomegaly.

ABSTRACT: Only a small number of patients with celiac disease exhibit the textbook symptoms of malabsorptive diarrhea with steatorrhea, weight loss, and nutritional deficiencies. Others may present with a subclinical enteropathy, GI complaints without constitutional symptoms, persistent travelers' diarrhea, or extraintestinal manifestations alone. Be alert for suggestive signs, such as weight loss, skin lesions, oral aphthae, muscle atrophy, de-enamelization of the teeth, and vague GI symptoms, such as bloating. Helpful serologic tests include IgG and IgA antigliadin antibodies, enzyme tissue transglutaminase antibodies, antiendomysial antibodies, and total IgA. Typical endoscopic findings are mucosal atrophy, fissuring, and scalloping. In addition to a gluten-free diet, management encompasses repletion of vitamins and minerals, including iron, folate, calcium, and vitamin D; screening for thyroid disease and diabetes mellitus; bone densitometry and age-appropriate cancer screening; and pneumococcal vaccination.

A 38-year-old African American man with HIV infection presents with numerous dyspigmented macules and patches on the extremities, abdomen, and chest; the lesions are smooth, nontender, and minimally pruritic.

ABSTRACT: Risk factors for oral cancer include tobacco use and alcohol intake (especially in conjunction with tobacco use). Many benign conditions may be confused with squamous cell carcinoma, the most common type of intraoral neoplasm. Any red and/or white lesion that has surface corrugation, stippling, or induration is considered dysplastic or neoplastic until proved otherwise. Even without these clinical signs, white plaques of any size that persist for several months may represent dysplasia. These lesions should be assessed by biopsy. Risk factors for lichen planus include stress, exposure to certain foods and medications, and systemic illness. Erosive lichen planus may cause significant pain and oral dysfunction.

ABSTRACT: Only a small number of patients with celiac disease exhibit the textbook symptoms of malabsorptive diarrhea with steatorrhea, weight loss, and nutritional deficiencies. Others may present with a subclinical enteropathy, GI complaints without constitutional symptoms, persistent travelers' diarrhea, or extraintestinal manifestations alone. Be alert for suggestive signs, such as weight loss, skin lesions, oral aphthae, muscle atrophy, de-enamelization of the teeth, and vague GI symptoms, such as bloating. Helpful serologic tests include IgG and IgA antigliadin antibodies, enzyme tissue transglutaminase antibodies, antiendomysial antibodies, and total IgA. Typical endoscopic findings are mucosal atrophy, fissuring, and scalloping. In addition to a gluten-free diet, management encompasses repletion of vitamins and minerals, including iron, folate, calcium, and vitamin D; screening for thyroid disease and diabetes mellitus; bone densitometry and age-appropriate cancer screening; and pneumococcal vaccination.

Generalized papular, erythematous, nonpruritic, hyperpigmented lesions had appeared on the face, arms, chest, and abdomen of a 25-year-old homosexual man with AIDS during the previous month. Anupama Ravi, MD, of Atlanta also noted purple-red, nodular lesions in the right conjunctiva and oral cavity, especially the lower gingiva. Other pertinent physical findings included facial edema and hepatosplenomegaly.

An 89-year-old woman is seen for a rash on her back of 2 days' duration. Has Broca aphasia and dense right hemiparesis from an old stroke; remains highly communicative without words, and interactive, in the nursing home where she lives. Long-standing diabetes mellitus and hypertension contributed to the stroke and to marked peripheral arterial disease.