Dermatology

A 45-year-old man had a red, somewhat annular, slightly scaly plaque studded with red nodules that covered the back of his right hand. Nail dystrophy was evident on the middle finger. The patient's left hand was free of lesions, but the soles of both feet were slightly red and scaly, and there was an annular, serpiginous border on the left foot.

For the past 3 years, comedones, papules, pustules, and nodules had been erupting on the face of a 16-year-old boy. Acne vulgaris had been diagnosed. Topical tetracycline cream and oral tetracycline were used without success.

A 27-year-old man presented with intensely pruritic, violaceous, flat-topped papules on the lateral aspect of his left leg. He reported that the lesions developed a few weeks after the area was severely scraped in an accident several months earlier.

For the past 2 days, a 30-year-old man had experienced scant hemoptysis. He had also lost a significant amount of weight-5 kg (11 lb)-over the last 2 months. The patient, a recent emigrant from Ecuador, had no history of tuberculosis (TB) or of exposure to this disease, and he had not been skin tested with purified protein derivative (PPD). He denied exposure to risk factors for HIV infection.

A 54-year-old woman with breast cancer metastatic to the lungs had been treated with four courses of docetaxel, to which she partially responded. Following the first cycle of chemotherapy, the patient experienced arrested growth of her fingernails and toenails. Progressively worsening onycholysis then developed.

A 16-year-old girl with seizures and mental retardation presented for a routine examination. Tuberous sclerosis had been diagnosed during infancy.

Basal cell carcinomas, the most common form of skin malignancy, are slow growing and rarely metastasize. They are seen most frequently in men over age 50, and more than 90% occur on sun-exposed areas of the head and neck. Cure rates approach 100%.

A recent outbreak of small-plaque and guttate psoriasis was confined primarily to the arms of this 32-year-old woman. The slightly scaly, brick-red, linear plaques and clusters consisted of 3- to 10-mm papules, some of which were surrounded by a faint whitish ring. It was quickly ascertained that many of these lesions corresponded to areas where the patient had been scratched by her cat.

An obese 17-year-old boy sought treatment of an apparent abscess of the umbilicus. Hot soaks, black salve, and oral cephalexin were prescribed. Although there was some drainage, the lesion persisted and the patient returned for further evaluation.

For 3 weeks, a 14-year-old boy had been aware of an enlarging lesion on the back of his hand. He recalled no trauma to the affected area. Further questioning by Dr D. Keith Cobb of Savannah, Ga, revealed that a 4-mm verruca, or wart, had been removed from the same site 6 months earlier with cryosurgery by a different physician.

Erythema elevatum diutinum (EED) is a rare and usually chronic form of vasculitis. It has been postulated that EED is the result of immune complex formation in small vessels secondary to some antigenic stimulation.

Referral for biopsy was made because a 6-mm, red and black, dome-shaped papule on a 43-year-old woman's left groin resembled a melanoma. The patient had numerous cherry hemangiomas on her trunk-bright red, 2- to 5-mm papules that are among the most common vascular anomalies.

Concerned about this unsightly and painful lesion, a 34-year-old man asked to have it removed. The patient first noted this eruption on his back several months before. This lesion is an infundibular cyst.

Redness and swelling of the left cheek, chin, and ear bothered a 51-year-old man. The initial diagnosis was cellulitis and/or allergic dermatitis; oral amoxicillin/clavulanate, 500 mg tid, and a low- to medium-potency corticosteroid cream, alclometasone, were prescribed. Within 1 to 2 days, pimples emerged in the reddened areas and rapidly crusted.

Hyperpigmentation involving the neck developed in this 8-year-old obese girl. The affected area resembled unwashed skin. The patient had worn a uniform to school-a jumper and blouse with a collar-for 6 months.

A 6-month-old girl presented with a reddish mass on the abdomen that was not apparent at birth and was first noted when the child was 1 month old. The lesion-which was asymptomatic-started to shrink and fade when the child was 3 years old. A year later, the color was very faint. When the child was 6 years old, the lesion was hardly visible.

For several weeks, a 78-year-old woman had an intensely pruritic, diffuse, raised, slightly scaly, erythematous rash that persisted despite the use of several over-the-counter topical medications (such as hydrocortisone and clotrimazole cream). Since her last visit about 3 months earlier for a blood pressure reading, she had been well except for 2 episodes of night sweats. For several years, she had been taking levothyroxine and reserpine/hydrochlorothiazide; about 6 months ago, valsartan/hydrochlorothiazide had been prescribed.

A mildly painful, nonpruritic rash on the forearms and legs prompted a 42-year-old man to go to the emergency department (ED). The patient noted the rash when he awoke that morning. He had had joint pain and fever for the past 7 days and generalized malaise with chills that began about 3 days earlier. He had no significant medical history.

A 57-year-old man with a history of venous stasis leg ulceration wondered about the “white spots” on his leg.

A male infant was delivered at term to a 24-year-old woman. The pregnancy had been uncomplicated; the vaginal delivery was normal. Apgar scores were 7 at 1 minute and 9 at 5 minutes. Birth weight was 3020 g (6 lb 11 oz); length, 51 cm (20 in); and head circumference, 36 cm (14 in).

This lesion consists of a dilated central feeding arteriole and smaller radiating branches that together suggest a spider's body and legs. The lesion blanches when pressure is applied. Pulsations visible in larger nevi are evidence of the arterial source of the lesion.

A 6-year-old boy presented with a painless, bluish swelling in the superotemporal orbital quadrant (A) that had been enlarging since infancy.

A 40-year-old man was hospitalized with the superficial, reddening, and painful facial lesion seen here. Its borders were sharp, and it had developed rapidly. The patient had a temperature of 40°C (104°F) and chills. His erythrocyte sedimentation rate was elevated, and he had neutrophilic leukocytosis.

After 1 week of scratching a pruritic, reddish rash on a swollen hand and enduring a “burning sensation,” a 43-year-old man visited his physician. The patient worked as a meatpacker. He had no other medical conditions, took no medications, and had no known drug allergies.

A 68-year-old man presented with a sudden-onset, 2.5 × 2-cm, rock-hard, erythematous, nontender nodule on the right side of the chest. A dense mat of telangiectases surrounded the solitary lesion. The remainder of the cutaneous examination was unremarkable.

Tortuous, dilated varicosities; multiple smaller caliber abnormal perforating vessels; and chronic brawny edema of chronic venous insufficiency (CVI) were seen on a 70-year-old man's left leg. He reported that the edema and discoloration had worsened over the last 15 years. The brawny edema stopped just above the ankle, indicating that compression by the patient's sock controlled the signs and symptoms of CVI.

A 60-year-old woman was referred by her gynecologist because of a lesion on the buttocks of which the patient first became aware when she noticed blood on her underwear. Physical examination revealed an irregularly pigmented and slightly eroded asymmetric plaque. Examination with a magnifier highlighted a slightly rolled border, from which a shave biopsy was performed.

After more than 15 years of wondering what the “white specks” on his legs were, a 64-year-old man consulted his physician. The patient was taking medication to control hypertension; he was otherwise healthy.

Following an uncomplicated pregnancy, a 30-year-old gravida 2, para 1 mother delivered a term infant boy. The neonate's Apgar scores were 7 at 1 minute and 9 at 5 minutes. Birth weight was 3.2 kg (7.1 lb); length, 50 cm (19.7 in).

Erythematous, scaly lesions with double-edged borders had been present on a 14-year-old boy's left upper arm and lower legs for about a year. The lesions were occasionally pruritic, and some resembled ringworm. At times, fine yellow crusting suggestive of impetigo was present. The boy took very hot baths and showers.