Dermatology

A middle-aged man with"jock itch" that has failed torespond to antifungal creams.An older woman who has diffusehyperkeratosis of predominantlyweight-bearing surfaces.A young man with mildlypruritic, small, salmon pinkpapules and thick white scaleon his trunk and arms.

A 30-year-old man presents with scalingand erythema of the scalp that extendspast the anterior hairline. Thepatient has a family history of psoriasis.For the past 5 years, he has experiencedwintertime flares of the diseasethat affect his scalp and the extensorsurfaces of the extremities.

A 46-year-old man complains that his"jock itch" failed to respond to antifungalcreams. The patient has hadpsoriasis on his elbows and knees formany years.

A 72-year-old man presents with skinlesions and nail abnormalities. Erythematous,sharply defined, demarcatedpapules and rounded plaquescovered by silvery micaceous scaleare noted on the elbows, knees, andscalp. Involved areas appear to be bilaterallysymmetric. Localized psoriasisvulgaris is diagnosed.

4A:Small, slightly pruritic, salmonpink papules with thick white scalehave arisen over the past 5 days onthe trunk and arms of a 24-year-oldman. The patient has a history ofvery mild psoriasis vulgaris of the elbows,knees, and scalp; he deniesstreptococcal pharyngitis or other recentinfections. Guttate psoriasis isdiagnosed.

Focal, painless discoloration of theleft thumbnail (A) developed severalyears earlier in this 46-year-old man.Oral antifungal therapy had no effecton the lesion.

A 35-year-old man presents with extensiveplaques over much of thetrunk and extremities. This severeflare of psoriasis developed after astressful emotional experience.

A 60-year-old man with a long historyof psoriasis vulgaris required a systemiccorticosteroid for a severe exacerbationof asthma. Soon after theErythrodermic or Pustular Psoriasiscorticosteroid was discontinued, generalizederythema and scaling of theskin developed.

A 1-cm, tan-brown lesion had developed years earlier at the posterior helix of a61-year-old man’s right ear. Central ulceration and crusting were noted on thepapule. The patient sought medical evaluation when the lesion became nodularand began to flake.

A 45-year-old woman presented with a slowly enlarging, mildly tender lesionon the left sole. The large indurated plaque was studded with multiple firmpapules and nodules that involved the instep and extended onto the medialaspect of the foot. There was no regional adenopathy.

A 65-year-old woman presents with a 1-cm raised, light brown, circular, nodularlesion on the top of her head, which has progressively enlarged during the last6 months. The growth was removed by shave excision; electrodesiccation andcurettage were performed on the base. Pathologic evaluation determined thelesion was a basal cell carcinoma.

A 38-year-old man presented with a fleshy lesion beneath the tip of his penis. He had discovered it about 18 months before the initial evaluation. A second similar lesion resembling a “cauliflower” had appeared several weeks after the first. Both lesions had grown and had begun to bleed during intercourse.

For 5 years, a 54-year-old woman had been bothered by an intermittent dermatitis on her left hand and wrist. The rash had remained constant during the past year. The patient, a hairdresser, usually wears gloves when she works. Moderate erythema and flaking were noted on her hands.

A 40-year-old man presented with a 5-year history of progressively increasing bilateral leg swelling that was neither painful nor pruritic. There was no history of dyspnea, jaundice, or groin surgery. The patient reported multiple previous episodes of superimposed cellulitis, which were treated with antibiotics. There was no family history of similar illness.

Bullae had recently appeared on the dorsa of the hands and fingers of a 46-year-old man. His medical history was significant for alcoholism, discoid lupus erythematosus (DLE), and hepatitis C. Systemic lupus erythematosus (SLE) was ruled out; the patient’s symptoms did not meet the American Rheumatism Association criteria for SLE.

A blue-black nodule has been present next to a 19-year-old woman’s left eyesince birth. After recent accidental trauma, the lesion has enlarged.

Dry, pruritic, scaly skin was noted on a 65-year-old woman who came to the emergency department with bronchitis. She reported that her skin had had this texture all of her life.

The parents of a 6-year-old girl were concerned about the hyperpigmentation of their child’s fingers. Two weeks earlier, lime juice was accidentally spilled on the patient’s fingers during a barbecue on a sunny beach. By the following morning, the affected digits had turned red. A few days later, the erythematous areas became hyperpigmented.

Several lesions had appeared 1 week earlier on the left distal thigh of a 47-year-old woman. The affected area featured erythema with irregular faded borders and central redness with very fine papules over the L3 dermatome. The indurated and tender central areas suggested inflammation or necrosis. There were no vesicles and there was no drainage.

A painful, 4.8-cm nodule developed over 3 weeks on the face of a 76-year-old man. The results of a generous shave biopsy suggested a keratoacanthoma, a benign but locally destructive tumor that typically arises abruptly and enlarges rapidly. Curettage and desiccation were subsequently performed.

A 12-month-old infant is brought to your office for evaluation of ared, swollen left index finger, which her parents first noted the prior evening.The mother denies any known trauma or recent illness. She tells you that theinfant is slightly fussy and is not taking her bottle as well as usual.

The abrupt onset of widespread cutaneous eruptions prompted a 66-year-old man to seek medical evaluation. The patient had had chronic myelogenous leukemia for 5 years.

A network of purplish pink lesions recently developed on a 28-year-old woman’sarms and legs. The asymptomatic rash becomes more prominent with exposureto cold. The patient denies fever, aches, arthralgias, oral erosions, chestpain, and photosensitivity.

A 47-year-old woman who wasseropositive for HIV-1 presented tothe emergency department with severemaculopapular, erythematouseruptions. Her antiviral regimen hadrecently been changed from zidovudine, 300 mg bid; lamivudine, 150 mgbid; and saquinavir, 600 mg tid, tolamivudine, 150 mg bid; stavudine, 40mg bid; and nevirapine, 200 mg/d.

The sudden onset of a petechial rashon the upper and lower extremities,ecchymosis of the tongue, and anepisode of epistaxis prompted a78-year-old woman to seek medicalevaluation. She reported having takenone of her husband’s quinine pills aday earlier to alleviate leg cramps.The patient was otherwise in goodhealth and took no other medications.

This lesion on her knee had been present for 5 years, reported a 22- year-old woman. It was not related to any trauma; its size had not changed, but occasionally it became darker or lighter.

For 2 years, an asymptomatic mass had been present in the left iliac crest area of a 6-year-old boy. The soft, rubbery, lobulated mass was not attached to the overlying skin or to the underlying structures.

Leprosy, or Hansen disease, had recently been diagnosed in a 39-year-old man. He presented to the tropical disease unit of Harare Hospital, Zimbabwe, for follow-up.

A 72-year-old woman presented to the emergency department with epistaxis and generalized telangiectasia. The patient was known to have Rendu-Osler-Weber syndrome, or hereditary hemorrhagic telangiectasia, an autosomal dominant disorder that is associated with arteriovenous fistulae of many organs.

The sudden onset of a petechial rashon the upper and lower extremities,ecchymosis of the tongue, and anepisode of epistaxis prompted a78-year-old woman to seek medicalevaluation. She reported having takenone of her husband’s quinine pills aday earlier to alleviate leg cramps.The patient was otherwise in goodhealth and took no other medications.