Dermatology

A healthy 31-year-old man was referred to a dermatologist with a diagnosis of tinea versicolor that did not respond to oral ketoconazole and topical selenium sulfide.

The entire scalp of this 1-month-old boy shows the diffuse yellow scaling of seborrheic dermatitis. Called “cradle cap” in infants, this dermatitis typically begins on the scalp during the first 3 months and may spread over the entire face. An associated stubborn diaper rash may develop in some infants.

A 70-year-old man was concerned about these dark lesions that covered his back and legs.

Shortly after arriving from Puerto Rico, a 59-year-old man presented with right-sided frontal head pain and decreased vision in his right eye. He was concerned about a “sore” that first developed 9 months earlier on his head. The patient denied fever, chills, and syncope.

A 7-year-old boy with a history of atopic dermatitis presented with an intensely pruritic linear rash on his upper extremity. His mother reports that the rash has been “growing” despite use of topical corticosteroid creams.

A 57-year-old man who had recently arrived in the United States from El Salvador presented with a nodular growth in his left naris. He reported that the lesion, which had been slowly progressing for several months, now completely blocked his left nostril. His only symptom was impaired inhalation.

For 3 years, a gradually enlarging, raised, purple, cystic lesion had been present on the left upper lip vermilion of a 51-year-old man. The asymptomatic lesion measured 0.5 cm in diameter. The patient was given a local anesthetic, and the lesion was excised by wedge resection in the office; pathologic examination confirmed the diagnosis of benign cavernous hemangioma.

The mother of a 1-month-old infant was concerned because her child's umbilicus looked abnormal. The condition was diagnosed as umbilicus cutis.

A 46-year-old man with diabetes presented for evaluation of gradual fingernail deterioration, which had failed to respond to several courses of griseofulvin and a recent 3-month course of daily terbinafine. The patient-who worked as a bartender-was otherwise healthy.

A 12-year-old boy presented with a 6-month history of a papule on the corona of the glans penis. The lesion was asymptomatic.

Acute herpes zoster ophthalmicus of the right eye was diagnosed in a 70-year-old woman by her primary care physician, who prescribed oral acyclovir. After 1 week of therapy, the patient's eye became red and painful and she experienced photophobia and epiphora. She was referred for consultation.

A 66-year-old man presented with numerous cutaneous tumors. He had dementia and thus was unable to provide an accurate history.

This asymptomatic lesion on the upper arm of a 60-year-old man had been present for 2 years. The patient had used several over-the-counter antifungal and hydrocortisone creams to treat what he thought was ringworm.

For 3 years, a 53-year-old man had noted increasingly extensive changes in his skin, including facial thickening, a progressive reddish tinge, and annular lesions on his trunk. He also complained of itching on the periphery of his face.

Exquisite pain of 3-days' duration in his right index finger sent a 19-year-old man for medical consultation. He recalled that a thorn had become embedded in the finger while gardening 1 week earlier.

A 68-year-old woman was referred from an acute care clinic for evaluation of a persistent cellulitis. Ten days before, erythematous, pruritic plaques developed on her ankles; these slowly enlarged, and pustules formed. The patient denied fever or chills. Her past medical history was unremarkable, and conjugated estrogen, medroxyprogesterone acetate tablets, and multivitamins were the only medications and nutritional supplements she was taking.

Four months after a patchy, macular, erythematous spot erupted on the dorsum of a 63-year-old woman's left foot, the area became ulcerated, tender, and painful. The 1.2-cm ulcer was covered by a hemorrhagic crust surrounded by a cyanotic reticular discoloration of the skin.

This red papule developed 6 months ago at the base of a 53-year-old woman's thumb. The lesion was asymptomatic, but it bled easily when traumatized. It was treated definitively with surgical excision, and the biopsy report was consistent with the clinical diagnosis of pyogenic granuloma. This most commonly appears on the face or fingers and may result from minor trauma.

A painful skin eruption surrounding her colostomy stoma had appeared several months ago and was slowly increasing in size, complained a 64-year-old woman with Crohn's disease. The lesion consisted of several coalescent ulcers with a yellow, fibrinoid base and a violaceous, undermined border.

A 42-year-old woman had had athlete's foot for years, but the condition suddenly worsened when inflamed, pruritic vesicles appeared on both feet. A few days later, tiny, mildly itchy vesicles erupted on her palms; the rest of the hands were not involved. One week after the palmar eruptions, the patient noted 2 round, reddish brown, asymptomatic 3-cm macules on her trunk. These lesions had faint scaling on the trailing edge of the slowly advancing arciform borders.

Five days after beginning aggressive treatment with intravenous corticosteroids for inflammatory bowel disease, this 26-year-old man noticed the sudden eruption of this mildly pruritic rash.

The mother of a 6-year-old boy was concerned because there was a whitish mass between the glans and foreskin of her son's penis. She thought that this might be an accumulation of “pus.”

A 67-year-old man had been aware of a painless, firm, red nodule that had been growing slowly on the right temporal area for 1 year. The lesion occasionally bled.

A 76-year-old woman had a 40-year history of rheumatoid arthritis (RA). She had repeatedly refused treatment with disease-modifying drugs, including methotrexate. Nodules began to develop 15 years after the initial diagnosis; they recurred after surgical removal.

A 65-year-old woman, who was confined to a wheelchair because of severe rheumatoid arthritis, was concerned about nodules that had erupted on her fingers and hands during the previous 3 weeks. Her medical history included colon cancer, chronic renal insufficiency, anemia, and hypertension. The nonpruritic nodules were painful when they began to form under the skin; however, once they erupted, the pain disappeared.

A variety of rheumatic diseases-systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and the vasculitides among them-manifest as “lumps, bumps, and holes” involving the extremities. Each of these diseases works through specific mechanisms on different structures of the skin to produce a distinctive pathology. In doing so, each provides clues to the cause, which the history and physical examination can help confirm.

This 64-year-old woman has had rheumatoid arthritis for 15 years; her hands show classic rheumatic changes. She also had a leg ulcer that had failed to heal in 8 years despite three skin grafts.

Various types of cutaneous lesions may occur in association with RA, including rheumatoid nodules, rheumatoid neutrophilic dermatitis, vasculitis, palpable purpura, and pyoderma gangrenosum. Many of these manifestations-including rheumatoid nodules-are specific for RA. The presence of these nodules is associated with seropositive disease and with a more severe, erosive clinical presentation. The nodules appear in 20% to 30% of patients with RA. Sites of predilection are those subject to shear stress, including the subcutaneous tissues over the extensor aspects of the elbow region, over the sacrum in bedridden persons, and at the pericardial and pleural surfaces.

Cutaneous and subcutaneous lesions of the extremities may be clues to the presence of rheumatic diseases such as systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and the vasculitides. The history and physical examination can generally help confirm the cause. Skin biopsy is sometimes necessary for a definitive diagnosis; useful results depend on a technique that gives the depth necessary to see the pathology and proper interpretation of biopsy specimens by an experienced dermatopathologist.

Pyoderma gangrenosum (PG) is a chronic, recurrent condition characterized by cutaneous ulceration. In half of patients, PG is associated with an underlying illness, such as inflammatory bowel disease, RA, SLE, or a lymphoproliferative disorder.