Dermatology

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,

Are there health or safety concerns associated with “instant”tanning products?

A 16-year-old Somali girl presents witha 3-day history of bilateral arm swellingand painful vesicular eruptions; hersymptoms are worsening. She reportsthat 5 days earlier, she and her friendshad used henna and black hair dyeto “tattoo” their skin. The others havenot experienced similar signs or symptoms.This patient has used henna(which is dark red) since childhoodfor decorative purposes. However, outliningan intricate design with hairdye is new for her.

A4-year-old boy has a 4-day historyof fever; a persistent dry,irritating cough; coryza; and anonpruritic rash. The rash startedaround the ears and then spread overthe trunk and limbs.

Dr David Kaplan presented the case of a teenager with aphthous stomatitis in aDermclinic feature.

A healthy 21-year-old man presented with a rapidly growing, filiform, ringshapedwart on his great toe (Figure).

My patient is a 70-year-old man who has had several episodesof cellulitis in his right thigh; he does not have diabetes.After the third episode, a 1-cm subcutaneous mass was excisedabove the area of recurrent cellulitis.

During a routine physical examinationof a 21-year-old man, a 1-cm cysticlesion is detected on the posterior wallof the lower nasopharynx.

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.

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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.