Granuloma Annulare in a 59-Year-Old Woman and Topical Corticosteroid–Induced Contact Dermatitis

December 31, 2006

For several months, a 59-year-oldwoman has had numerous asymptomaticlesions on her arms andlegs. During this period, she has notbeen exposed to the sun and hastaken no new medications.

Case 1:

For several months, a 59-year-old woman has had numerous asymptomatic lesions on her arms and legs. During this period, she has not been exposed to the sun and has taken no new medications.

What does this look like to you?
A. Granuloma annulare.
B. Subacute lupus erythematosus.
C. Tinea corporis.
D. Psoriasis.
E. Erythema annulare centrifugum.

(answer on next page)



Case 1:
The patient has granuloma annulare, A, a condition that has no known cause. The rash persists for months or years before spontaneously involuting, and it is refractory to most treatments. Subacute lupus erythematosus, tinea corporis, and psoriasis all present with scale and are usually pruritic. Erythema annulare centrifugum manifests with trailing scale. 
Case 2:

After 2 weeks of scratching an itchy rash on his foot, a 16-year-old boy requested medical treatment. He had been using an over-the-counter hydrocortisone cream for 10 days to treat juvenile plantar dermatosis, but the preparation failed to cure the rash-and, in fact, it appears to have made it worse.

You would:
A. Tell the patient to stop using the hydrocortisone cream.
B. Perform a bacterial culture and prescribe oral antibiotics.
C. Perform a potassium hydroxide evaluation.
D. Prescribe a different topical corticosteroid.
E. Perform a skin biopsy.

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Case 2:
Topical corticosteroids, as well as the other components that make up the vehicle, have been reported to induce contact dermatitis. The patient was told to stop using the over-the- counter preparation, A, and to try a different, prescribed topical corticosteroid in a hypoallergenic base, D; the rash resolved quickly.
Case 3:

A 43-year-old woman has been bothered by an enlarging, painful plaque for 2 weeks. Treatment with cephalexin and amoxicillin–potassium clavulanate was unsuccessful. The patient also reports mild joint aches and low-grade fever. Her white blood cell count is somewhat elevated, with a slight left shift.

What do you suspect-and how will you confirm the diagnosis?
A. Methicillin-resistant Staphylococcus aureus infection.
B. Deep fungal cellulitis.
C. Atypical mycobacterial infection.
D. Sweet syndrome.
E. Leukemia cutis.

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Case 3:
A biopsy confirmed the diagnosis of Sweet syndrome, D. In most patients, the eruption appears following an upper respiratory tract infection; however, in about 10%, the condition heralds a hematologic malignancy, such as leukemia or lymphoma. Less commonly, Sweet syndrome is associated with oral contraceptive use or pregnancy. Effective treatments include prednisone, colchicine, dapsone, and NSAIDs. The lack of response to antibiotics rules out a typical cellulitis but not a methicillin-resistant Staphylococcus aureus or an atypical mycobacterial infection. A biopsy is necessary to confirm the other diagnoses in the differential.
Case 4:

For several years, a 43-year-old woman has noticed a slowly increasing number of discrete, asymptomatic papules around her eyelids.

Can you identify these lesions?
A. Sebaceous hyperplasia.
B. Milia.
C. Syringomas.
D. Seborrheic keratoses.
E. Warts

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Case 4: The papules are syringomas, C, benign sweat gland tumors that are generally confined to the eyelids. Typically, lesions first appear during the third or fourth decade and slowly become more numerous, as in the 63-year-old patient shown here. They have no malignant potential and may be removed surgically for cosmetic reasons. The lesions of sebaceous hyperplasia are yellowish papules around a central punctum. Milia are discrete white papules that appear as small, closed comedones. Seborrheic keratoses have patulous follicles and, like warts, a characteristic verrucous appearance.