Dermatology

Some degree of hyperpigmentationdevelops in most pregnantwomen. This coloration is more pronouncedin dark-skinned women; onnaturally pigmented areas, such as theareolae, perineum, and umbilicus; andon the axillae, inner thighs, and otherregions that are prone to friction.

A 24-year-old woman's firstpregnancy was uneventful until thesixth month when mild malaise and ahighly pruritic abdominal rash occurred(Figure 1). A biopsy and directimmunofluorescence confirmedthe suspected diagnosis of herpesgestationis.

Foot ulcerations and infections are the leading cause of hospitalizationamong patients with diabetes; they occur in about15% of these patients. Given the rapidly increasing incidenceof diabetes, physicians can expect to see a growing numberof diabetic foot problems. Here, a group of experts, many ofwhom practice at the renowned Joslin-Beth Israel DeaconessFoot Center in Boston, offer guidance on all aspects of diabeticfoot care. The topics covered range from proven preventivestrategies to cutting-edge wound care techniques that drawon such new developments as growth factors and living skinequivalents. A detailed review of the pathophysiology of thediabetic foot is also included. The emphasis throughout is ona multidisciplinary approach that incorporates the servicesof diabetologists, podiatrists, orthopedic surgeons, orthotists,diabetic nurse educators, and others. Numerous black-and-whiteand color photographs, drawings, algorithms, and charts illustratethe text.

Although many patients with primary HSV-1 infection have no clinicalrecurrences, the failure to seroconvert occurs very seldom-inno more than 1% of patients.

Two asymptomatic lesions that had been present for 1 year on the left upper chest of a 61-year-old man were excised. Pathologic examination revealed the raised, dark brown medial lesion to be an interdermal nevus; the lateral, light tan lesion with papules was a papillomatous interdermal nevus with primary macular amyloidosis.

Match each picture with the phrase below that best describes it. The organisms in these pictures might be microscopicor macroscopic, and they can be recovered from skin lesions or clothing by the patient and/or clinician.

A 72-year-old man slipped and fell backward in the bathroom, hitting hishead on the toilet seat; he suffered only minimal discomfort. The followingday, he presented with mild back pain and extensive bruising.

A middle-aged woman reports that for several days she has hada facial rash, some mild facial discomfort, and a low-grade fever. She deniesprevious illness, recent contacts with infected persons, or history of a similarrash.

For 3 days, a 36-year-old woman has had a painful rash on the dominant lefthand. She had noticed a tingling sensation before the lesions erupted. Thepatient is otherwise healthy and takes no medications. She is a teacher.

Match each picture with the phrase below that best describes it. The organisms in these pictures might be microscopicor macroscopic, and they can be recovered from skin lesions or clothing by the patient and/or clinician.Answers and discussion appear on the following page

A 39-year-old man sought evaluation ofnewly erupted skin lesions on his arms.Ten days earlier he had fallen on hisforearms, but no bruises appeared atthat time.

A 65-year-old man had had an asymptomatic lesion on his left lateral lower leg for several weeks. The dark maroon, almost black, 3- to 4-mm, circular, elevated lesion had a convoluted surface of dilated vessels. Dr Robert P. Blereau of Morgan City, La, excised the papule via a punch biopsy; pathologic examination identified an angiokeratoma.

Is there a meaningful percentage of patients who contract Lyme disease but havenone of the early symptoms-neither the rash nor the flu-like symptoms (eg, fever,myalgia, headache, and stiff neck)-and in whom the disease only becomes clinicallyevident in a later stage when it is much harder to treat?

An otherwise healthy 18-month-old boy presented with palpable purpura over the legs, arms, and buttocks; his face, neck, and trunk were spared. The patient was otherwise asymptomatic, alert, and playful. His mother reported that the child had a “stuffy nose and cough” 1 month earlier.

For 1 week, a 2-year-old boy has hadasymmetric erythematous patcheson the anterior trunk. There is nofamily or personal history of eczema.His mother has not used new soapsor detergents recently; there are nopets in the household.

Highly pruritic, 2- to 4-mm, papular lesions with central ulceration erupted on the back of a 66-year-old woman. She had had 2 similar outbreaks in the past. The patient was taking conjugated estrogens, alprazolam, and alendronate.

A 58-year-old black woman sought evaluation of areas of increased pigmentation on her cheeks that had been present for many years. Bleaching agents did not lighten the area; new, non–nickel-containing eyeglass frames had no effect. A 3-week course of halobetasol cream failed to fade the hyperpigmentation.

A 76-year-old woman had a 40-year history of rheumatoid arthritis (RA). She had repeatedly refused treatment with disease-modifying drugs, including methotrexate. Nodules began to develop 15 years after the initial diagnosis; they recurred after surgical removal.

Cutaneous manifestations develop inapproximately 30% of persons withdiabetes. Premature atherosclerosisis a common complication of thedisease and can cause peripheral infarction,ulceration, and necrosis.

Syndrome The mother of a 7-year-old boy with cardiofaciocutaneous syndrome sought treatment for the cutaneous aspects of her son’s disease. Dry skin and keratosis pilaris of the upper outer arms were noted. Cardiofaciocutaneous syndrome- a rare autosomal dominant genetic disorder-had been diagnosed when the child was 3 years old.

A 42-year-old woman presented with a papular eruption that first appeared during childhood. Severe pruritus, which worsened during the summer, accompanied the lesions. The patient reported that family members, including her mother and brother, had a similar skin problem. A biopsy of a characteristic lesion on the patient’s chest revealed diffuse acantholytic dyskeratosis, which confirmed the clinical diagnosis of Darier’s disease.

This patient with long-standing insulin-dependent diabetes has difficultyclosing his hand because of “tight skin.” Diabetes is the cause: this findingoccurs more often in persons with microvascular complications, such asretinopathy and nephropathy. The condition may occur even in patients withwell-controlled diabetes.

This huge blister developed spontaneously on the foot of a woman withdiabetes mellitus. There was no area of redness around the blister, whichnormally occurs with burns and inflamed lesions. Spontaneous blisters andother skin manifestations are common in persons with diabetes.

Numerous brown spots on his leg brought this man with long-standing diabetes mellitus to his physician. He thought the spots were related to trauma.

This patient with long-standing insulin-dependent diabetes mellitus has difficulty in closing his hand because the skin is "very tight."

Numerous brown spots on the leg of a man with longstandingdiabetes are diabetic dermopathy. This is amicroangiopathy of the small arterioles of the legs, whichresults in atrophic brown papules.

The atrophic patches on the lower legs of this 47-year-old woman who has haddiabetes mellitus for over 20 years are those of necrobiosis lipoidica diabeticorum.These areas involve degeneration of collagen and elastic fibers in thelower dermis and changes in blood vessel walls. The lesions usually begin assingle or multiple elevated reddish nodules, most commonly in the pretibialarea. Over time, they expand and coalesce into distinctive brownish yellowpatches. These areas may be somewhat tender, but as they spread, theyfrequently become painless-unless they ulcerate. Because the involved skinis fragile, ulcers can form after any minor trauma.

Levofloxacin, 500 mg/d, had been prescribed for a 74-year-old woman who had a urinary tract infection. The patient had type 2 diabetes and hypertension. She was allergic to sulfa drugs. Two hours after taking the first oral dose of the antibiotic, painful blisters developed on the lower lip and soft palate.

A 75-year-old Hispanic woman presented with a slowly growing, asymptomatic facial lesion of about 3 years’ duration.

Numerous plaques, some with yellow crusting and central scarring, had erupted primarily on the face and neck of a 46-year-old man. A single lesion had developed on his left elbow as well. The lesions were initially diagnosed as impetigo, but they failed to resolve after 2 courses of oral cephalexin.