Dermatology

An eruption on the face of a 49-year-old woman had been misdiagnosed as a staphylococcal infection; the rash failed to respond to oral and topical antibiotics. A mid-potency topical corticosteroid also had been tried, but the eruption worsened.

Mongolian spots are benign, congenital blue-gray macules or patches commonly found in Asian, black, and Hispanic infants (and in 5% of white infants). They are most often located in the sacrogluteal area and the upper back. The lesions may be solitary or multiple, vary in color intensity, and frequently enlarge until about age 2, when they gradually fade and disappear. Approximately 5% persist into adulthood.

The widespread eruption of asymptomatic macules and flat, palpable, flesh-colored lesions prompted a 23-year-old woman to consult her physician. The lesions-some of which had dark centers-were concentrated on the patient's face, neck, and upper back; the palms, soles, anal mucosa, and genital areas were clear. The patient denied systemic symptoms. She was seronegative for HIV.

A papule on the leg of an 11-year-old boy had suddenly developed into a slightly tender pustule. The pustule had not responded to oral cephalexin and topical mupirocin prescribed by another clinician.

Cutaneous photosensitivity followed by acute, then chronic, skin lesions on sun-exposed areas characterizes this disorder.

The significant palmar erythema seen on the hands of a 60-year-old man with alcoholic cirrhosis is a sign of underlying chronic liver failure.

Two 7-year-olds show the purpuric rash of the lower body and legs that is typical of Henoch-Schönlein purpura. This disease is a vasculitis that chiefly affects small vessels of the skin, joints, gastrointestinal tract, and kidney.

A 3-mm long, double-tipped, polypoid lesion appeared just anterior to the anus on an 8-month-old girl 2 days earlier. The lesion was excised in the office: a local anesthetic was administered, and the base was lightly electrodesiccated. Antibiotic ointment was applied until the area healed. Pathologic findings identified an infantile perianal pyramidal protrusion.

A 52-year-old white man presented with a pruritic eruption on the neck of 3 months' duration. The rash had not responded to a potent topical corticosteroid prescribed by another practitioner for the presumed diagnosis of eczema.

A 13-year-old girl who had leukemia presented to the emergency department with fever; chills; weight loss; fatigue; and a painful, erythematous rash with a central black lesion on the upper thigh. The patient was neutropenic and had been undergoing chemotherapy for 1 week.

A healthy 31-year-old man was referred to a dermatologist with a diagnosis of tinea versicolor that did not respond to oral ketoconazole and topical selenium sulfide.

The entire scalp of this 1-month-old boy shows the diffuse yellow scaling of seborrheic dermatitis. Called “cradle cap” in infants, this dermatitis typically begins on the scalp during the first 3 months and may spread over the entire face. An associated stubborn diaper rash may develop in some infants.

A 70-year-old man was concerned about these dark lesions that covered his back and legs.

Shortly after arriving from Puerto Rico, a 59-year-old man presented with right-sided frontal head pain and decreased vision in his right eye. He was concerned about a “sore” that first developed 9 months earlier on his head. The patient denied fever, chills, and syncope.

A 7-year-old boy with a history of atopic dermatitis presented with an intensely pruritic linear rash on his upper extremity. His mother reports that the rash has been “growing” despite use of topical corticosteroid creams.

A 57-year-old man who had recently arrived in the United States from El Salvador presented with a nodular growth in his left naris. He reported that the lesion, which had been slowly progressing for several months, now completely blocked his left nostril. His only symptom was impaired inhalation.

For 3 years, a gradually enlarging, raised, purple, cystic lesion had been present on the left upper lip vermilion of a 51-year-old man. The asymptomatic lesion measured 0.5 cm in diameter. The patient was given a local anesthetic, and the lesion was excised by wedge resection in the office; pathologic examination confirmed the diagnosis of benign cavernous hemangioma.

The mother of a 1-month-old infant was concerned because her child's umbilicus looked abnormal. The condition was diagnosed as umbilicus cutis.

A 46-year-old man with diabetes presented for evaluation of gradual fingernail deterioration, which had failed to respond to several courses of griseofulvin and a recent 3-month course of daily terbinafine. The patient-who worked as a bartender-was otherwise healthy.

A 12-year-old boy presented with a 6-month history of a papule on the corona of the glans penis. The lesion was asymptomatic.

Acute herpes zoster ophthalmicus of the right eye was diagnosed in a 70-year-old woman by her primary care physician, who prescribed oral acyclovir. After 1 week of therapy, the patient's eye became red and painful and she experienced photophobia and epiphora. She was referred for consultation.

A 66-year-old man presented with numerous cutaneous tumors. He had dementia and thus was unable to provide an accurate history.

This asymptomatic lesion on the upper arm of a 60-year-old man had been present for 2 years. The patient had used several over-the-counter antifungal and hydrocortisone creams to treat what he thought was ringworm.

For 3 years, a 53-year-old man had noted increasingly extensive changes in his skin, including facial thickening, a progressive reddish tinge, and annular lesions on his trunk. He also complained of itching on the periphery of his face.

Exquisite pain of 3-days' duration in his right index finger sent a 19-year-old man for medical consultation. He recalled that a thorn had become embedded in the finger while gardening 1 week earlier.

A 68-year-old woman was referred from an acute care clinic for evaluation of a persistent cellulitis. Ten days before, erythematous, pruritic plaques developed on her ankles; these slowly enlarged, and pustules formed. The patient denied fever or chills. Her past medical history was unremarkable, and conjugated estrogen, medroxyprogesterone acetate tablets, and multivitamins were the only medications and nutritional supplements she was taking.

Four months after a patchy, macular, erythematous spot erupted on the dorsum of a 63-year-old woman's left foot, the area became ulcerated, tender, and painful. The 1.2-cm ulcer was covered by a hemorrhagic crust surrounded by a cyanotic reticular discoloration of the skin.

This red papule developed 6 months ago at the base of a 53-year-old woman's thumb. The lesion was asymptomatic, but it bled easily when traumatized. It was treated definitively with surgical excision, and the biopsy report was consistent with the clinical diagnosis of pyogenic granuloma. This most commonly appears on the face or fingers and may result from minor trauma.

A painful skin eruption surrounding her colostomy stoma had appeared several months ago and was slowly increasing in size, complained a 64-year-old woman with Crohn's disease. The lesion consisted of several coalescent ulcers with a yellow, fibrinoid base and a violaceous, undermined border.

A 42-year-old woman had had athlete's foot for years, but the condition suddenly worsened when inflamed, pruritic vesicles appeared on both feet. A few days later, tiny, mildly itchy vesicles erupted on her palms; the rest of the hands were not involved. One week after the palmar eruptions, the patient noted 2 round, reddish brown, asymptomatic 3-cm macules on her trunk. These lesions had faint scaling on the trailing edge of the slowly advancing arciform borders.