Dermatology

What are the latest recommendations concerning the treatmentof dermatomyositis?

For 15 years, a 33-year-old man hashad scale on the soles of his feet;the condition has failed to respondto various topical antifungal agents.He has no other rashes. He ishealthy except for a history of seasonalallergies controlled by overthe-counter medications.

I noticed that “Sebaceous Cyst” was used as the title of arecent Photoclinic case, contributed by Drs Leslie, Hillel,and Shlomo Trope (CONSULTANT, June 2004, page 1025)(Figure).

Instead of nail removal, another option for treating a subungualabscess is to scrub the digit and drill a hole in thenail plate with a hot wire loop.

A 101-year-old woman has had an occasionallypruritic and tender growthon her face for about 2 months. Thegrowth has doubled in size over the past2 weeks. She has no personal or familyhistory of cancer or significant dermatologicdisorders.

A painful scalp eruption of 4 days’duration brings an 81-year-old man toyour office. He has taken a lipid-loweringagent and an antihypertensivefor years but has not started any newmedications recently. One week earlier,he had a haircut. He denies recenttrauma to the scalp.

Contact dermatitis on the dorsumof the foot is often treated as aleather or rubber allergy that isexacerbated by the patient’s shoes.

My patient has a test-proven Candida allergy. Because hepatitis B virus (HBV)vaccine contains yeast, another physician would not give it to him. I administereda diluted dose and then a full-strength dose of the HBV vaccine, and the patienthad no adverse reaction.

I am seeing an increasing number of patients with tattoos, including radiationtattoos.

When you treat a patient for tineacruris (jock itch), always check hisfeet as well.

A 48-year-old African Americanwoman with HIV infection who hadbeen hospitalized several days earlierfor presumed Pneumocystis cariniipneumonia (PCP) is readmittedbecause of worsening dyspnea and atemperature of 38.8oC (102oF).She also complains of painful swellingand erythema on her right arm.Her symptoms have worseneddespite treatment with trimethoprimsulfamethoxazole.

Despite major advances in the treatment of cancer, prevention remains the bestmethod of control. Here, an international panel of experts describe screening techniquesand provide concise summaries of current guidelines. In addition, theydiscuss the epidemiology and biology of various cancers, including breast, cervical,ovarian, endometrial, colorectal, hepatocellular, oropharyngeal, esophageal, gastric,prostate, testicular, skin, and lung; sensitivity and specificity of the screeningmethods; cost-effectiveness; and indications for referral. One section is devoted tofuture prospects in cancer screening, such as the application of molecular geneticsand new radiologic techniques. Another section addresses medicolegal issues.Also included are screening techniques used in countries with a high incidence ofcertain types of cancer (eg, stomach cancer in Japan, esophageal cancer in China).Numerous algorithms provide step-by-step overviews of screening, evaluation, andsurveillance.

A 51-year-old man presents with aseverely infected leg and 1- to 2-cmlesions on all of his extremities andtrunk; the bases of the lesions aredepressed, atrophic, and scarred.According to the patient, the lesionstypically appear as tender nodulesor pustules, which spontaneouslyburst, drain purulent material, andeventually heal as pictured.

In Dr Sean Eric Koon's Case In Point, "Puzzling Rash in an Older Woman"(CONSULTANT, April 15, 2003, page 629), I agree with his conclusion that thispatient had cutaneous leukocytoclastic vasculitis (CLV) (Figure). I also agreethat she met the American College of Rheumatology's 1990 criteria for a diagnosisof hypersensitivity vasculitis.1 However, given the patient's history and laboratoryresults, I believe further evaluation was warranted to determine whether the medication was indeed to blame for her CLV or whether an underlying systemicdisease was responsible.Her white blood cell (WBC) count was 72,000/?L. CLV is known to producea mild leukocytosis--presumably caused by the inflammatory response of the vasculitis.Thus, one would expect to see only a slight elevation in the WBC count.Also, if the elevation had been produced by the inflammatory response of the CLV,the patient's erythrocyte sedimentation rate (ESR) would have been significantlyelevated. However, her ESR was 12 mm/h, which is essentially normal in awoman this age.The discovery of a value that is not consistent with the disease process makesme question Dr Koon's final diagnosis--or at least want to add to his differentiala disease that could be responsible for both the CLV and the level of leukocytosisseen here: hairy cell leukemia.Other facts in the case that tend not to support the conclusion that the patient'sCLV resulted from a drug reaction include the following:One would expect to see systemic symptoms, such as fever, malaise, anorexia,and/or myalgias if a drug reaction caused the CLV; this woman reportedly didnot experience any of these.Rashes associated with CLV produced by a drug reaction are generally describedby patients as pruritic, painful (sometimes significantly so), and/or associatedwith paresthesias, such as a burning or stinging sensation; this patient's rash isdescribed as "painless and nonpruritic."Thus, although an exogenous agent such as trimethoprim-sulfamethoxazole(TMP-SMX) can cause CLV, it would have been prudent in view of the findingsin this case to search for an endogenous cause, such as an underlying systemicdisease or malignancy.----Pamela Moyers Scott, MPAS, PA-CWilliamsburg, WVaThank you for your comments. You detected a typo; this patient's leukocytecount was actually 7200/?L. A value of 72,000/?L would indeedbe of concern and would prompt a new differential diagnosis. HerWBC count when last checked was 7300/?L.Ultimately, my determination was that the patient's rash was mostlikely triggered by a viral infection and not by the TMP-SMX. I felt that anotherhealth care provider had inappropriately treated her upper respiratory tractinfection with an antibiotic, so I stopped the medication. Because I could notcompletely rule out the antibiotic as a cause of this potentially serious condition,I recommended that she avoid it in the future. This is yet another exampleof how the treatment of colds with antibiotics can confuse the clinical pictureand possibly harm the patient.--Sean Eric Koon, MD  &nbspFontana, Calif

My patient is a 3-year-old girl who since birth has had a dark area that looks likea bruise on her left buttock (Figure). Her mother has been told it is a mongolianspot; however, the child is blond and blue-eyed and does not have an ethnic heritagetypically associated with that condition.

All too often, when lancing a sebaceouscyst or abscess, or when relievingpressure from a traumatizednail bed, both practitioner and assistantare splattered with the materialthat is released.

A24-year-old man who worked ina warehouse is brought tothe emergency department following2 days of high fever with rigors, generalizedweakness, and a purplishrash on both lower legs that had progressedrapidly during the past24 hours. He had become ill about5 days previously, with a worseningsore throat and achiness that did notrespond to over-the-counter lozengesand ibuprofen.

A great deal of force and effort is usually required tosuccessfully inject corticosteroids into a keloid.

To remove an object from the ear,place a drop of topical skin adhesiveor superglue on the wooden end of acotton-tipped applicator.

Why does hair often change its color or texture when it regrows after it has beenlost as a result of chemotherapy?

To track the size of a patient’s skinlesion over time, place a piece of cleartape over it and outline the borderwith a pen.

Knowing the width of one of yourfingernails (mine is 15 mm) can helpyou quickly assess the size of skinlesions.

Three years ago, my patient sustained a burn from a hot greasespill. Biopsy has shown that the nubby areas (Figure)are live skin; however, I am unsure of how to treat thewound.

Use this ABCDE mnemonic to distinguishnecrotizing fasciitis, which usuallyrequires surgery, from cellulitis,which can be treated with antibioticsalone:

A 38-year-old overweight woman presents with an asymptomatic rash ofat least 2 months’ duration that had not responded to a combinationcorticosteroid/antifungal agent. She has mild hypertension and type 2 diabetesmellitus that is being managed with diet and exercise. She is otherwisehealthy.

A 7-year-old girl presents for evaluation of a pink, polypoid, 2 x 2-mm lesionon her inner lower lip, which has been present for several weeks. The child isasymptomatic and denies any trauma to the mouth.

My patient is a woman in her midtwentieswho recently presented with anerythematous, slightly pruritic lesionon her thigh.

Suturing the circular wound that resultsfrom a punch biopsy can bedifficult.

I enjoyed the article by Kenneth H. Fye, MD, "Rheumatic Disease: How to Use theLab in the Workup" (CONSULTANT, March 2004, page 369). However, I foundthe following statement to be misleading: "Anti-SS-A and anti-SS-B determinationsare necessary to rule out Sjgren syndrome in patients with sicca complaints."If the results of these tests are negative, but Sjgren syndrome was initiallysuspected based on the history, labial biopsy is required. Many persons with thisdisease have negative antibody test results.Unfortunately, it often takes years before Sjgren syndrome is correctly diagnosedin most patients. This is usually because a health care provider rules it outbased on negative results of anti-SS-A and anti-SS-B tests.---- Paula Hochberg, ARNPSarasota, FlaYou are correct that negative results of tests foranti-SS-A and anti-SS-B antibodies do not ruleout Sjgren syndrome. Although the majorityof patients with this syndrome have these antibodies,a significant minority do not. If, in thislatter group of patients, Sjgren syndrome is strongly suspectedon clinical grounds, a minor salivary gland biopsyshould be considered. Biopsy is the most specific andsensitive test for Sjgren syndrome. Although a biopsy isnot required to make the diagnosis in every patient, thereare clearly those with negative tests for anti-SS-A andanti-SS-B in whom a biopsy is necessary to confirm suspectedSjgren syndrome. Thus, my statement shouldhave read instead, "Positive anti-SS-A and anti-SS-B determinationssupport a diagnosis of Sjgren syndrome inpatients with sicca complaints."---- Kenneth H. Fye, MDClinical Professor of MedicineRheumatology DivisionUniversity of California, San Francisco,School of Medicine

An estimated 20million Americansare currentlyinfectedwith humanpapillomavirus (HPV). Assuch, HPV is now the mostprevalent sexually transmitteddisease (STD) in thiscountry. Answers to commonquestions like the onesabove are therefore of particularinterest to physicians.The issue of when and howto use testing for HPV hasbecome especially crucial.