Test Your Diagnostic Skills

December 31, 2006

What caused these linear, grouped, pigmented papules on a child's back? These symmetrical hyperpigmented patches on a man's face? Test your diagnostic skills.

Case 1:


A 38-year-old man complains that for the past few months his feet have periodicallybecome red and hot. The uncomfortable sensation lasts from hours todays; it is triggered by increased ambient temperature and is relieved by coolcompresses. The patient takes no medications.What is the likely cause?

A.

Urticaria.

B.

Erythema multiforme.

C.

Stasis dermatitis.

D.

Erythromelalgia.

E.

Tinea pedis.Which of the following is/are associated with this condition?

F.

Polycythemia vera.

G.

Diabetes mellitus.

H.

Calcium channel blocker therapy.

I.

Venous insufficiency.

J.

Systemic lupus erythematosus.

Case 1:

Erythromelalgia,

D

--a rareparoxysmal vasodilation of the feet--is associated with burning pain, redness,and heat that is triggered by increasedenvironmental temperature.The cause of the primary disease isunknown; however, secondaryerythromelalgia may be associatedwith polycythemia vera,

F;

diabetesmellitus,

G;

calcium channel blockertherapy,

H;

and systemic lupuserythematosus,

J

.In addition to cool or cold compresses,selective serotonin reuptakeinhibitors may provide relief for somepatients. Treat the underlying disease to ameliorate the symptoms of secondary erythromelalgia.Urticaria usually is associated with pruritus rather than pain. Erythema multiforme featuresdiscrete, targetlike lesions that were not present in this patient. Stasis dermatitis, which generally isnot painful, typically affects the lower leg rather than the bottom of the foot. Scale and pruritus arecharacteristic of tinea pedis.

Case 2:


The parents of a 4-year-old boy are concerned about the linear, grouped, pigmented,flat papules on their child's upper back. The lesions have been presentfor a few months.Do you recognize this eruption?

A.

Common warts.

B.

Linear epidermal nevus.

C.

Lichen striatus.

D.

Seborrheic keratoses.

E.

Lichen planus.Which of the following statements is/are true of this condition?

F.

Onset occurs between birth and age 10 years.

G.

The lesions are either flesh-colored or hyperpigmented.

H.

The lesions are always unilateral.

I.

It is associated with a syndrome that features CNS and other systemicabnormalities.

J.

The lesions may be inflamed and pruritic.

Case 2:

Linear epidermal nevi,

B,

are verrucouslike lesionsthat may be present at birth or can arise at any timebefore age 10 years,

F

. They may be unilateral or bilateraland can vary in color,

G.

There is no risk of malignanttransformation. No treatment is necessary; surgery maybe performed to remove the lesions for cosmetic reasonsonly.Inflammatory linear verrucous epidermal nevi(ILVEN) is an erythematous and pruritic variant of thisdisorder,

J

. The linear epidermal nevus syndrome, describedby Solomon and colleagues

1

in 1968, is associatedwith CNS, cardiovascular, skeletal, and ophthalmic abnormalities.Other skin lesions occur in this syndrome aswell; they include hemangiomas; pigmentary changes;and cutaneous malignancies, such as basal cell and squamouscell carcinomas,

I

.An extensive workup is warranted for patients withepidermal nevi who fail to meet developmental milestonesand/or have systemic abnormalities. However, most personswith these lesions, such as this patient, do not haveassociated syndromes.Common warts are flesh-colored and characterized by reddish brown dots on a vegetated surface.They arise on trauma sites; knees, fingers, and hands are frequent locations. Lichen striatusis a self-limited, asymptomatic eruption that usually extends distally on one limb and spontaneouslyclears in 1 to 2 years. Seborrheic keratoses are scattered and discrete and rarely occur in personsyounger than age 30 years. Lichen planus lesions may manifest in a linear pattern (Koebner phenomenon);however, it is unlikely for this condition to develop in a young child and as an isolatedgroup of lesions.

Case 3:

Vascular lesions have been presenton the leg of a 35-year-old womansince birth. Hemangiomas and softtissue asymmetry of the legs arenoted during the examination.Which of the following do yoususpect?

A.

Maffucci syndrome.

B.

Klippel-Trnaunay syndrome.

C.

Gorham disease.

D.

Sturge-Weber syndrome.

E.

Robert syndrome.

Case 4:

For several months, a 39-year-old man has noted symmetrical pigmentationchanges on his face. The hyperpigmentation is asymptomatic. The patient deniesa history of any similar condition. He takes no medications.What are you looking at here?

A.

Lentigines.

B.

Melasma.

C.

Hemochromatosis.

D.

Phytophotodermatitis.

E.

Peutz-Jeghers syndrome.Which of the following statements are true of this condition?

F.

Up to 10% of patients are male.

G.

It is more common in persons with a dark complexion.

H.

It is always found on sun-exposed skin.

I.

It is inherited as an autosomal dominant trait.

J.

It always disappears after consistent use of sunscreen.

References:

REFERENCE:


1. Solomon LM, Fretzin DF, Dewald RL. The epidermal nevus syndrome.

Arch Dermatol.

1968;97:273-285.