Dermatology

A thriving boy was brought to the office 3 weeks after his first birthday. His mother reported that there was something wrong with his knee. On visual examination, the knee appeared perfectly normal. On palpation, however, a 4-cm linear induration was evident over the knee fat pad, just medial and distal to the patella. It appeared soft, crepitant, and associated with the skin. No tenderness was noted on palpation; the infant did not object to palpation of this density any more than to auscultation, otoscopy, or anthropometric measurements.

vvd

To facilitate the assessment of jugular venous pressure, shine a beam of light tangentially across the skin overlying the jugular vein while the patient's neck muscles are relaxed.

Suggest that patients make a "rice sock" whenever they have a musculoskeletal injury, abscess, stye, or other condition that might benefit from heat therapy. Tell them to pour uncooked rice (the amount depends on the size of the area to be treated) into a clean cotton tube sock, tie off the open end of the sock, then microwave it for about 1 minute until warm (not hot). A rice sock holds heat longer than a hot towel and molds itself to the body part being treated.

This 3-mm, purplish pink papillary lesion with a crusted top had been present for 6 months at the outer vermilion border of the lower lip of a 65-year-old man. The lesion was asymptomatic.

An 80-year-old woman has a 3-month history of increasing dysphagia (withboth solids and liquids), fatigue, and dyspnea on exertion. She has also involuntarilylost 50 lb during the same period. She reports no abdominal pain orchange in bowel function.

A pruritic rash under the left breast has bothered a 67-year-old woman forthe past month. She takes an antihypertensive and is otherwise healthy.

A 52-year-old woman presents with a3-month history of a tender, erosivedermatitis on the nipples and in thevulvar/perineal region. Can youidentify these lesions?

For the past week, a 16-year-old boy has had a progressively worsening dry, irritating cough; dyspnea on exertion; and intermittent fever and chills. During the past 24 hours, he has had no appetite and has vomited greenish material 3 or 4 times.

A 32-year-old woman, who recently gave birth, seeks evaluation of 2 lesions onher neck. A linear, medium brown, warty, 4-cm lesion has been present sinceshe was born; there has been no disproportionate growth or change in color.The crusted 0.5-cm nodule at the most cephalad aspect of the linear lesiondeveloped in early pregnancy and has gradually enlarged.

A 67-year-old man complains of a lesion on the floor of his mouth that hasenlarged over the past year. When he touches the lesion, it bleeds easily andis friable and intermittently tender. The lesion has been present for manymonths; initially, it was a painless whitish area. The patient has no other lesionsin his mouth, and he has no dysphagia, dysarthria, or other problemsthat indicate oral dysfunction.

A 56-year-old African American man presents with a painful “raw” lip that hasgradually developed during the summer. Physical examination reveals a geographic,superficial erosion; notably, the erosion is surrounded by hypopigmentedand, most distally, hyperpigmented rings. The patient believes that exposureto sunlight has aggravated the condition.

For several days, a 35-year-old woman has had a swollen, painfulfinger. She is otherwise healthy and has no significant medical history.

For 3 months, a 41-year-old womanhas had a pruritic acneiform eruptionon the lateral aspects of the neck andthe left side of the face. She is otherwisehealthy and takes no medication.

A 16-year-old boy presents for evaluation of various lesionsthat have appeared on his extremities since he joined thewrestling team 2 months earlier. He is otherwise healthyand takes no medications.

A 51-year-old woman has had a progressiverash on the trunk, proximalarms, and legs for 2 weeks, followingthe latest round of chemotherapy forbreast cancer. Around the time thatthe rash erupted, she was also takinglevofloxacin for a productive cough.Cutaneous lupus erythematosus wasdiagnosed years ago, but she hasbeen disease-free for the past 5 years.Chemotherapy is being withheldpending diagnosis of the rash.

A 46-year-old man presents with right-sided facial paralysis. His symptoms beganthe previous evening when he had difficulty in closing his right eye; by morning,paralysis had developed. He also reports headache and mild photophobia.

To minimize pain when repacking anabscess, remove the old packing, thensquirt 1 mL of 1% lidocaine into theopen wound with a syringe (no needlenecessary).

Patients with mycotic toenails whoare unable to take oral antifungalagents may find relief with this oldremedy.

My patient-an 84-year-old woman with hypertension-presented with itchingand blistering of 3 days’ duration on her right foot (Figure).

What Are Trigger Points?Tender areas, swellings, or knots under the skin are referred to as“trigger points.” Injection of these trigger points with medication mayalleviate discomfort. At times you may feel pain in an area distant fromthe trigger point. Your doctor will feel the various muscle groups tolocate the trigger points and the most tender areas.

An area of pigment loss in the skinand surrounding hair is noted on thehead of a 10-year-old boy. Examinationof the vertex of the scalp revealsa nevus encircled by depigmentation.

A 35-year-old woman has a lifelong history of recurrent blisters on the handsand feet that heal without scarring. No other family members have this condition,and she has no children. She is visiting your office for the first time toseek new treatment options.

A recent Dermclinic case featured a teenaged girl with seborrheic dermatitis thatmanifested as a scaly, slightly itchy rash on her upper eyelids (CONSULTANT,April 15, 2002, page 611).

A 12-month-old previously healthy boypresented to the pediatric emergencydepartment (ED) with a 10-day historyof fever, irritability, and anorexia.The patient’s mother had originallynoted the development of 3 erythematouspapules on the patient’s back, leftaxilla, and chest; these were followedby the onset of daily fevers, with temperaturesranging from 38.8°C to41.1°C (102°F to 106°F). The lesionsgrew progressively larger and erythematous,and became ulceratedwith central eschars.

For several weeks, a 68-year-old man has had painful blisterson his hands that crusted as they healed. The patienthas diabetes mellitus, hypertension, and chronic renalfailure, for which he is undergoing hemodialysis. His longtermmedications include a hypoglycemic agent and adiuretic.

Case 1: A 42-year-old woman presents for anevaluation of an acute pruritic eruptionthat began 2 days earlier on herface, trunk, and extremities. The lesionsresolve and recur at differentsites from one day to the next. Theoutbreak began after the patient ateChinese food the night before; shealso had a recent sinus infection. Shetakes vitamins and hormone replacementtherapy.

A 9-year-old boy, who has no significantmedical history, presents with a generalizedpruritic eruption of 2 weeks’ duration.One week earlier, another practitionerruled out scabies and treatedhim presumptively for varicella.

Until they can see a physician,patients can try using cold milk compresses(whole milk, low-fat, or skim)for temporary relief from the itchingof poison ivy or simple eczema.

When sterile saline is needed for repeatedhome use (eg, for daily cleansingof a foot ulcer), suggest thatthe patient buy an over-the-counter,