Dermatology

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.

A 65-year-old man consults his primary care physician because of concern about nonpruritic yellowish lesions on his eyelids. He says they have been present for the past few years but have recently become more numerous.

The bites of only a few spider species produce medically significant effects in humans.

An 80-year-old man has had an asymptomatic, flesh-colored swelling on his right ear for 4 to 5 months. In the center is a 1-mm white scab pointing downward from the helix. At times, the patient shaves a white spicule that grows in this crusted area. He sleeps on his right side and does not use a cell phone.

A 38-year-old man sought treatment for the intensely pruritic swellings that had arisen on his upper lip 2 weeks earlier (A). These sharply demarcated, tender, boggy, granulomatous, pustular tumefactions are kerions, write Florence Isaac, MD, of Mohammad Dossary Hospital in Saudi Arabia and Shaun Isaac, MD, of St Petersburg, Fla. The diagnosis is based on the history of acute onset, the clinical appearance of the lesions, and the demonstration of a fungus by a potassium hydroxide (KOH) preparation of loose hairs removed from the affected area and by fungal culture. In this case, the KOH preparation revealed fungal filaments, which on culture grew Microsporum canis. A pus swab test should be performed to detect any bacterial copathogen. The differential diagnosis of kerion includes impetigo and carbuncle.

A 4-year-old girl presents with a highly pruritic rash. The day before, she had been playing outdoors at her grandmother's house. No pets were present, and the patient does not recall being stung or bitten by insects. There are bushes on the grandmother's property.

Two children, one with a history of infection, the other with a history of an allergic reaction were noted to have postinflammatory hyperpigmentation.

Application of liquid nitrogen often must be repeated several times when used to treat thick seborrheic keratoses--and still may be ineffective. For an immediate and excellent cosmetic result, try liquid nitrogen for 5 seconds, followed by gentle curettage. Any pinpoint bleeding can be stopped with aluminum chloride.

For as long as he could remember, a 27-year-old man had had a recurrent eruption on the palms and sides of the fingers. The rash was characterized by intense pruritus followed by the formation of small water blisters and increased perspiration that resolved with peeling of the skin. The dorsa of the hands were unaffected. Results of a potassium-hydroxide preparation and fungal culture of skin scrapings were negative for hyphae. The thyrotropin level was normal.

Pruritic eruptions on both arms of a 12-year-old who has played outdoors all summer; a rash on the hand of a teenage baseball player . . . might sports be responsible for these lesions?

A 38-year-old man sought treatment for the intensely pruritic swellings that had arisen on his upper lip 2 weeks earlier. These sharply demarcated, tender, boggy, granulomatous pustular tumefactions are kerions.

For as long as he could remember, a 27-year-old man had had a recurrent eruption on the palms and sides of the fingers. The rash was characterized by intense pruritus followed by the formation of small water blisters and increased perspiration that resolved with peeling of the skin. The dorsa of the hands were unaffected. Results of a potassium-hydroxide preparation and fungal culture of skin scrapings were negative for hyphae. The thyrotropin level was normal.

Squamous cell carcinoma (SCC), the second most common type of skin cancer, most often occurs on the sun-exposed skin of elderly men and women. Marjolin ulcers are SCCs that result from exposure to radiation and can arise in areas of chronic injury, typically on the extremities.