Dermatology

Several of my female patients have chronic itchy, burningvulvitis.

A 75-year-old woman complained of“tired and heavy eyes” and being unableto keep her eyelids open to readat night.

Incarcerated umbilical herniations occur through the umbilical canal that is bordered by the umbilical fascia posteriorly, the linea alba anteriorly, and the medial edges of the 2 rectus sheaths on each side.

A 62-year-old woman presented with a rash and intermittent pain of the right upper quadrant. The reticular, brown hyperpigmentation was also seen on her right flank and around the umbilicus. The patient reported that she often applied heating pads to these areas for pain relief.

A 63-year-old woman seeks evaluation of a persistent, rough, red area onthe dorsum of her left index finger. The lesion has been present for severalmonths. The patient’s manicurist is convinced it is a wart.

A 37-year-old woman complains of “itchy bumps” that erupted just above herwaist 2 or 3 days earlier. She denies having had this condition in the past.The patient is otherwise healthy and takes no medications. An avid gardener,she claims to be able to identify and avoid poisonous plants.

I read with interest Dr Virenda Parikh’s case of a young woman with extensiveanal condylomata acuminata (CONSULTANT, April 15, 2001, page 737).

The mother of this 5-month-old boy was concerned about the large birthmark in the infant's diaper area.

My patient reports that erythemanodosum occurred when she took anoral contraceptive (OC) in the1990s.

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.