A 47-year-old woman is bothered by the numerous small, smooth, darkbrown papules that have developed on her face and neck during the pastdecade. She asks if the asymptomatic lesions can be removed.
1. Small, smooth facial papules
A 47-year-old woman is bothered by the numerous small, smooth, darkbrown papules that have developed on her face and neck during the pastdecade. She asks if the asymptomatic lesions can be removed.What is this condition, and what do you tell the patient?
1. Small, smooth facial papules:
The patient has
a disorder that occurs in 35% to75% of black persons. Women are affected twice as oftenas men.
Histologically, these lesions are identical to seborrheickeratoses; they differ only in their gross appearanceand racial predilection.
The multiple small, smooth,dome-shaped, brown-to-black papules of dermatosis papulosa nigra develop slowly during adolescence on themalar regions of the face, the neck, and the upper chest.Seborrheic keratoses can arise anywhere on the body ofpatients who, generally, are older than 30 years; the lesionsoften are waxy or have a pasted-on appearance.This patient's lesions can be surgically removed.Light electrodesiccation--a minimally traumatic and rapidtechnique--can be performed comfortably without localanesthesia. This procedure can remove the lesion withoutpermanent hyperpigmentation or hypopigmentation.
Grimes PA, Arora S, Minus HR, Kenney JA Jr. Dermatosis papulosa nigra.
Morganroth GS, Leffell DJ. Nonexcisional treatment of benign and premalignantcutaneous lesions.
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Kauh YC, McDonald JW, Rapaport JA, et al. A surgical approach for dermatosispapulosa nigra.
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Kenney JA Jr. Dermatosis papulosa nigra and seborrheic keratoses: clinicalaspects.
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2. Infant with blue-gray areas and red marks
Numerous areas of blue-gray pigmentation and red lesions on their infant'sback prompt the parents to seek medical evaluation. You reassure themthat the red areas are an innocuous nevus flammeus, or port-wine stain.Is the blue-gray pigmentation similarly benign?
2. Infant with blue-gray areas and red marks:
or incidentalhypermelanosis, are single or multiple blue-gray to black areas that are mostcommonly seen in black neonates. The congenital hyperpigmented lesionsgenerally occur over the central lumbosacral area. A single large lesion withhazy, ill-defined borders can dominate the child's back, or several smaller suchareas may be present.Mongolian spots often disappear by age 5 years; rarely, they may persistinto adulthood. There is no risk of malignant transformation. No treatment isnecessary.
3. Follicular papulesand pustules
The widespread irritation andscarring on a 35-year-old man's facebegan with a small area of follicularpapules and pustules on his neck. Thepatient's attempt to eliminate the rashby shaving daily with a sharp, straightrazor has only exacerbated the condition;the inflammation now involvesthe entire beard area.What treatment will yourecommend?
3. Follicular papules and pustules:
Approximately halfof black men have
an irritantdermatitis that affects shaved areas of the face. The inflammatoryforeign-body reaction is caused by ingrownhairs. Sharp-tipped, closely shaved facial hairs that grow atan acute angle can pierce the side of the follicle or thedermal layers. These hairs may emerge from the follicles,coil downward, and penetrate the epidermis.Continued shaving further irritates the inflamedareas and exacerbates the pseudofolliculitis. Secondary infectionscaused by
and other bacteriaare not uncommon. Hypertrophic scars and keloidscan occur.The patient was advised to stop shaving for at least amonth to allow the beard to grow out and to scrub hisface daily with a coarse sponge. When he resumes shaving,he will need to use an electric shaver, which cuts thehair more bluntly than a straight razor. The patient wasshown how to free ingrown hairs by inserting an alcoholwipedneedle or other pointed object into the loop formedby the hair as it reenters the skin; he was told to applyalcohol to the site afterward.Cephalexin (500 mg tid for 7 to 10 days) can begiven to patients in whom secondary infection develops.Topical mupirocin applied to the affected area and thenares is an alternative.
4. Hypopigmented lesions on back
Hypopigmented, circular cropsof nodules--some of which haveformed in scars--are noted on theupper back of a 35-year-old man.What do you suspect is responsiblefor these lesions?
4. Hypopigmented lesions on back:
are numerous and varied. This multisystemdisorder often requires a biopsy to confirm the diagnosis.Noncaseating granulomas and enhanced cellular immuneresponse at involved sites characterize the disease.Sarcoidosis typically arises in adults between ages 20and 40 years. Disease prevalence is difficult to ascertainbecause many cases remain undiagnosed; however, in theUnited States, it is estimated to occur in blacks 8 to 10times more often than in whites. Moreover, whereas whitemen and women are equally affected, sarcoidosis is twiceas prevalent in black women as in black men.
Cutaneous presentations include the hypopigmentednodules seen in this patient
as well as macular, papular,scaly
lesions that can develop on the trunk and extremitiesas well as the eyes, nose, cheeks, earlobes, andscalp. Systemic disease that affects the lungs, heart, kidneys,liver, and nervous system can cause significant morbidityand death in some patients.Self-limited cutaneous disease requires only supportivetreatment. Monoclonal antibody therapy is amongthe modalities now used for sarcoidosis
; however, corticosteroidsremain the mainstay of treatment. Topical orsystemic corticosteroids can be given for extensive or disfiguringlesions. Skin sarcoidosis resolves in about 60% ofpatients in 2 years or less.
National Heart, Lung, and Blood Institute. Sarcoidosis. NIH publication95-3093. Available at:http://www.nhlbi.nih.gov/health/public/lung/other/sarcoidosis/index.htm. Accessed October 1, 2003.
Meyerle JH, Shorr A. The use of infliximab in cutaneous sarcoidosis.
Saboor SA, Johnson NM. Sarcoidosis.
Br J Hosp Med.