Dermatology

A 12-year-old African American girl comes to youroffice for a well-child checkup. She is tall for herage (height above the 95th percentile) and obese(body mass index [BMI] above the 95th percentile).Physical examination reveals acanthosisnigricans on her neck, axilla, and upper abdominalregion (Figure) and a vaginal yeast infection.Routine urinalysis reveals a glucose level ofgreater than 1000 mg/dL, with negative proteinand ketones. A random blood glucose test, obtainedbecause of the glucosuria, is 249 mg/dL.

A slightly pruritic, red, scaly rash on an 8-year-old boy’shands has been progressively worsening since it appeared4 months earlier. Nail pitting also was noted. There are noother rashes on his body. The patient is active in sports;denies any new exposure to soaps, clothing, or other contactants;and spends time in the homes of his recently divorcedparents.

This condition features acutely tender nodules, marked erythema, and contusions that appear as a consequence of inflammation of subcutaneous fat.

This asymptomatic lesion had been present on a 75-year-old man's right buttock for 2 to 3 years. The 0.5 cm in diameter nodule featured an irregular, flesh-colored surface.

Reiter Syndrome (also called reactive arthritis) manifests as peripheral arthritis that is sometimes accompanied by such extra-articular findings as urethritis, conjunctivitis, and uveitis

Psoriatic Arthritis develops in approximately 20% of patients who have psoriasis.

Pyoderma Gangrenosum belongs in the differential diagnosis of lower extremity vasculitis-like ulcerating lesions.

For 3 weeks, an extremely painful lesion had been present on the right ankle of a 46-year-old man. The 7 × 6-cm tender erosion was located just superior to the lateral malleolus. An antibiotic prescribed by another practitioner for a presumed infected insect bite had failed to ameliorate the pain and clear the lesion.

The manifestations of this multisystemdisorder range from relativelybenign, self-limited cutaneous involvementto severe, potentially fatal systemicillness. Skin lesions associatedwith lupus erythematosus (LE) areclassified histologically as LE-specificor LE-nonspecific.

This inflammatory myopathy is believedto be related to immune-mediatedmuscle damage. An increased incidenceof malignancy is associatedwith dermatomyositis (DM), especiallyin patients older than 50 years.

An ulcerated lesion that measured approximately 2 cm in diameter had developed on an 80-year-old woman's scalp. The lesion featured a dark eschar that covered a slightly elevated, erythematous border. According to the patient's husband, a different lesion had been at the site 2 weeks earlier. He described the original as a "ball" that ulcerated, had no drainage, and formed a scab.

A 77-year-old African American man with type 2 diabetes mellitus and coronary artery disease presented to the emergency department with acute scrotal swelling and pain. His testicles were erythematous with focal areas of necrosis and associated tissue destruction. Similar skin changes were apparent in the lower abdominal and inguinal regions.

Several asymptomatic, erythematous papules and plaques had appeared on the hands of an otherwise healthy 11- year-old girl. The personal and family medical histories were noncontributory.

A healthy 16-year-old girl was bothered by a patch of white hair on her forehead; she also had a few white plaques on her abdomen, which had been present since birth. Her maternal great grandmother and maternal grandfather, as well as her mother, had a similar pattern of white hair.

A 63-year-old woman presents withdiffuse hyperkeratosis of the solesand palms. She also has onycholysis-separation of the nail plate fromthe nail bed-and salmon-coloredplaques behind her ears. Biopsy ofone of the plaques confirms the suspecteddiagnosis of psoriasis.

A middle-aged man with"jock itch" that has failed torespond to antifungal creams.An older woman who has diffusehyperkeratosis of predominantlyweight-bearing surfaces.A young man with mildlypruritic, small, salmon pinkpapules and thick white scaleon his trunk and arms.

A 30-year-old man presents with scalingand erythema of the scalp that extendspast the anterior hairline. Thepatient has a family history of psoriasis.For the past 5 years, he has experiencedwintertime flares of the diseasethat affect his scalp and the extensorsurfaces of the extremities.

A 46-year-old man complains that his"jock itch" failed to respond to antifungalcreams. The patient has hadpsoriasis on his elbows and knees formany years.

A 72-year-old man presents with skinlesions and nail abnormalities. Erythematous,sharply defined, demarcatedpapules and rounded plaquescovered by silvery micaceous scaleare noted on the elbows, knees, andscalp. Involved areas appear to be bilaterallysymmetric. Localized psoriasisvulgaris is diagnosed.

4A:Small, slightly pruritic, salmonpink papules with thick white scalehave arisen over the past 5 days onthe trunk and arms of a 24-year-oldman. The patient has a history ofvery mild psoriasis vulgaris of the elbows,knees, and scalp; he deniesstreptococcal pharyngitis or other recentinfections. Guttate psoriasis isdiagnosed.

Focal, painless discoloration of theleft thumbnail (A) developed severalyears earlier in this 46-year-old man.Oral antifungal therapy had no effecton the lesion.

A 35-year-old man presents with extensiveplaques over much of thetrunk and extremities. This severeflare of psoriasis developed after astressful emotional experience.

A 60-year-old man with a long historyof psoriasis vulgaris required a systemiccorticosteroid for a severe exacerbationof asthma. Soon after theErythrodermic or Pustular Psoriasiscorticosteroid was discontinued, generalizederythema and scaling of theskin developed.

A 1-cm, tan-brown lesion had developed years earlier at the posterior helix of a61-year-old man’s right ear. Central ulceration and crusting were noted on thepapule. The patient sought medical evaluation when the lesion became nodularand began to flake.

A 45-year-old woman presented with a slowly enlarging, mildly tender lesionon the left sole. The large indurated plaque was studded with multiple firmpapules and nodules that involved the instep and extended onto the medialaspect of the foot. There was no regional adenopathy.

A 65-year-old woman presents with a 1-cm raised, light brown, circular, nodularlesion on the top of her head, which has progressively enlarged during the last6 months. The growth was removed by shave excision; electrodesiccation andcurettage were performed on the base. Pathologic evaluation determined thelesion was a basal cell carcinoma.

A 38-year-old man presented with a fleshy lesion beneath the tip of his penis. He had discovered it about 18 months before the initial evaluation. A second similar lesion resembling a “cauliflower” had appeared several weeks after the first. Both lesions had grown and had begun to bleed during intercourse.

For 5 years, a 54-year-old woman had been bothered by an intermittent dermatitis on her left hand and wrist. The rash had remained constant during the past year. The patient, a hairdresser, usually wears gloves when she works. Moderate erythema and flaking were noted on her hands.

A 40-year-old man presented with a 5-year history of progressively increasing bilateral leg swelling that was neither painful nor pruritic. There was no history of dyspnea, jaundice, or groin surgery. The patient reported multiple previous episodes of superimposed cellulitis, which were treated with antibiotics. There was no family history of similar illness.

Bullae had recently appeared on the dorsa of the hands and fingers of a 46-year-old man. His medical history was significant for alcoholism, discoid lupus erythematosus (DLE), and hepatitis C. Systemic lupus erythematosus (SLE) was ruled out; the patient’s symptoms did not meet the American Rheumatism Association criteria for SLE.