Clinical Application Questions

A 16-year-old female comes to your office complaining of a pruritic generalized eruption of gradually increasing intensity over the prior 4 months. The pruritus now frequently awakens her during the night. You suspect a scabies infestation. 1. What pertinent history should you seek from this patient 2. What primary lesions should you look for on physical examination that support a diagnosis of scabies 3. What is the typical distribution of scabies in an adolescent female 4. How should you...

Conditions That May Simulate Verruca Vulgaris

The distinction between warts and plantar calluses is sometimes difficult and is important because the latter can be treated with keratolytics and debridement alone and do not require the more destructive therapies used on verrucae. The difference can be determined by paring the lesion down with a scalpel blade. Warts will show a single or sometimes multiple cores that interrupt normal skin lines. They also exhibit dark red or black speckles, which are the thrombosed ends of the feeder vessels....

Conditions That May Simulate Lichen Planus

These have been reported with a large number of medications. Thiazide diuretics, gold, antimalarials, -blocking agents, vitamins, and NSAIDs are among those most commonly cited. This differential must be carefully evaluated in every case of LP. Some reactions are clinically identical to idiopathic LP however, subtle findings on routine biopsy may help to distinguish them. Immunopathology is not helpful. LP-like drug reactions resolve slowly and require a good deal of support and confidence on...

Specific History

Human scabies is an infestation caused by an organism named Sarcoptes scabiei var. hominis, an obligate human parasite. The disease is most common in schoolchildren and young adults, but may be seen in all age groups and is also common in nursing home settings. Within family units, it is not unusual for the presenting case to be quite removed from the index case that brought the disease into the family. History of overnight house guests, school contacts, or close friends with symptoms is...

History Review

A 70-year-old man is seen at your office for multiple raised pigmented lesions over his back and chest. These have developed gradually over several years. There are two lesions on the mid-lower back that intermittently itch intensely and are somewhat larger and much darker than the other lesions, which number 50 or more. Physical examination of the entire region reveals multiple seborrheic keratoses. Except for the two lesions in question there are no other suspect lesions. The patient is very...

How should you treat this patients basal cell carcinoma

Answer Excision followed by microscopic confirmation of clear margins is the treatment of choice. The type and complexity of the excision and repair are determined by the microscopic pattern of the basal cell carcinoma, the defect required to obtain clear margins, and the patient's desires regarding cosmetic results. Certain superficial basal cell carcinomas on the trunk and extremities are better treated by curettage and electrodesiccation. Following treatment, reevaluation of the surgical...

Indicated Supporting Diagnostic Data

In most instances, herpes simplex recidivans can be diagnosed clinically from the historical data and a typical skin lesion. There are occasions however, where special circumstances make laboratory confirmation desirable. A smear of material from a fresh, ruptured blister base is placed on glass slide and immediately stained with Giemsa or some similar stain. A positive smear will show her-pesvirus effect by the presence of keratinocytes with balloon nuclei and multinucleated giant cells with...

Dermatologic Physical Exam

Primary lesions are comma-shaped or irregular burrows or tracks about 3 to 4 mm in length with a scale at the entrance point and a papulovesicle at the distal point where the mite is located (see Photos 41-43). 1. Generalized small urticarial papules that are intensely pruritic. These occur about a month after infestation and are part of the immune reaction. Scraping these papular lesions in search of organisms is a worthless exercise (see Photo 44). 2. Excoriations are frequent and widespread...

Answers To Clinical Application Questions

A 50-year-old male diabetic presents with an extensive eruption on the lower back and buttock areas. He complains of intermittent pruritus and occasional tender deep pimplelike lesions. 1. List the disorders that you should consider in the differential diagnosis of this patient's eruption. d. Mild atopic eczema (pityriasis alba). 2. How would you distinguish tinea corporis from the other disorders in your differential diagnosis Answer Only tinea corporis has a positive KOH preparation. If KOH...

How should this patient be treated

Answer After the presence of an active tinea pedis is confirmed by KOH preparation, initial treatment should consist of systemic treatment for the tinea pedis. In many instances, the lichen planus will remit when the fungal infection is eradicated. If drug-induced lichen planus is suspected, elimination of the suspect medication is the first measure. In idiopathic lichen planus, treatment may range from topical steroids to systemic retinoids, depending on the stage and extent of the disease.

Foods

Strawberries Cheese crisps Saccharin t Once found in most OTC laxative preparations. Banned for use in the United States. Periodic self-treatment with prescription or OTC medications is almost always the underlying cause of a fixed drug reaction. Supplemental Review From General History An intensive and repetitive review of all medication used must be undertaken. The questions should focus on medication taken intermittently. All prescription medications, OTC drugs, foods, and nutritional...

Introduction

Atopic dermatitis is the cutaneous component of a complex hereditary predisposition that also includes a tendency toward bronchial asthma and immediate type I allergy to a range of environmental antigens manifest by allergic conjunctivitis. The linkage among the three is poorly understood but with careful history taking, 75 to 80 of patients are found to have a positive family history. Atopic dermatitis is a multifaceted problem and exhibits diverse physiological defects, which continue to lead...

List the disorders that should be considered in this patient Answer

Pityriasis rosea-like drug eruption. 2. Is tinea corporis still part of the differential diagnosis, and if not, why not Answer Tinea corporis enters the differential diagnosis when single or small numbers of lesions are present however, tinea corporis does not spread at this rate and does not produce large numbers of individual lesions. Also, topical antifungal agents are usually effective over a 2-week treatment period. A negative KOH preparation would have ruled out tinea corporis at the...

Cold weather

Trauma Local trauma to the skin of any sort sufficient to injure the epidermis and upper dermis can induce active lesions at the site of injury. This is known as the Koebner phenomenon and is common in cases of eruptive exanthematic PV. It is considered a supporting diagnostic feature. 7. Sunlight Sunlight improves most cases, but 5 of patients are worsened and this must be taken into account prior to starting treatment. Severe sunburn can dramatically flare PV even in patients who have been...

What should you look for on physical exam Answer

The extent and distribution of the lesions. b. The degree of oiliness or seborrhea. c. The relative mixture of noninflammatory papules, inflammatory papules, pustules, nodules, cysts, and sinus tracts in each area. d. The degree of scarring in each involved area. 3. What general treatment measures other than medication should you institute a. Explain the general nature and course of the disease, and the need for a certain level of maintenance treatment once control is achieved. c. Review...

List the reasons why immediate treatment is indicated Answer

The warts are continuing to spread. b. Some of the warts are split and tender and they interfere with manual activities. c. Warts are contagious and the child is a source of infection for playmates and family members. d. The child may become a social outcast due to the disfiguring appearance of these lesions. 2. What preparation is required before active treatment begins Answer Before treatment begins, the mother and child must understand that treatment will require an indeterminate number...

Conditions That May Simulate Asteatosis

This common condition produces coin-like circular lesions, and in elderly patients may begin initially in an area of asteatosis. Lesions are discrete and much more inflammatory than those of asteatosis. Excoriation of the lesions is prominent, the surface is moist and eczematous, and the surface lacks the canal-like or craquel pattern. Initially, itching is confined to individual lesions. This scaling condition in its fully developed form resembles dominantly inherited ichthyosis vulgaris....

Conditions That May Simulate Atopic Dermatitis

This eruption is partially eczematous and partially papulosquamous. Onset and distribution are similar to those for infantile atopic dermatitis. Differentiation is particularly difficult when the eczema component is predominant. Both conditions may exhibit heavy scale. While the scale of seborrhea is yellow and greasy, that of atopy is white and dry. The distinction is not always easy to make. Seborrhea lesions tend to have sharp margins, while those of atopic dermatitis are indistinct. In...

Conditions That May Simulate Psoriasis Vulgaris

SD of the scalp, face, and ears may be clinically and microscopically indistinguishable from PV. Biopsy is often of no value because at this point both diseases can show similar findings. Family history and follow-up will usually separate the two. The lesions of PV develop a deeper color, are more raised, and develop a silvery rather than yellow scale. In addition, PV lesions tend to be more fixed and circumscribed than SD lesions. In the absence of other lesions, the presence of linear nail...

Conditions That May Simulate Toxicodendron Dermatitis

Delayed Contact Allergy to Other Plants Many other plants, reaction including house plants, trees, and ornamental garden covers, can cause a delayed hypersensitivity. Depending on the plant and mode of contact, the pattern may show streaks of acute vesicular eczema indistinguishable from toxicodendron dermatitis. The source must be sought from the history and confirmed with a patch test. Certain wild plants, some varieties of meadow grass, and some common garden plants contain a...

Macrodistribution

Hair-bearing areas scalp, axillae, eyebrows in both men and women, beard, and presternal area in men (see Fig. 6). 2. Creases and folds nasolabial folds, perialar creases, glabellar creases, postauricular creases, intertriginous creases in both men and women, and inframammary creases in women (see Fig. 6). 3. Pinna, concha, and the outer third of the external auditory canal. 5. Upper back, shoulders, and chest, usually in the form of large patches, or may be confluent over the whole region in...

Microdistribution None

Macrodistribution SKs are seen primarily on the face, upper back, and central chest. They can occur at almost any site. Only the palms, soles, and mucous membranes are spared (see Fig. 1). Occasionally SKs will follow lines of cleavage (see Photo 2). This may produce a Christmas tree pattern. Generally they are randomly distributed. Figure 1 Macrodistribution of seborrheic keratosis. Figure 1 Macrodistribution of seborrheic keratosis. Indicated Supporting Diagnostic Data The vast majority of...

What should you tell the patient about keratoacanthoma

Answer Keratoacanthoma is classified as a benign lesion but shows many signs and microscopic features of malignancy. Although true keratoacanthomas do not metastasize, they can cause significant scarring and alteration when they occur on a cosmetically sensitive site. Treatment is recommended to minimize scarring and to distinguish keratoacanthoma from squamous cell carcinoma. 5. Should you treat keratoacanthoma in this patient, and if so, how Answer When a keratoacanthoma is small or occurs in...

Appendix A Table of Primary Lesions and Related Disorders

Erysipelas Part III Erythema multiforme Part III Fixed drug eruption Part III Impetigo Part VI Tinea (large, multiloculated) Part III Urticaria (bullae as secondary lesions) Part III Macules Actinic keratosis (erythematous) Part V Atypical nevi Part V Common benign nevi (pigmented) Part V Ephelides Part V Erysipelas (erythematous) Part III Erythema multiforme (erythematous) Part III Erythrasma Part III Fixed drug eruption Part III Halo nevi Part V Impetigo (deep red) Part VI Lentigines Part V...

Conditions That May Simulate Tinea

Tinea of the scalp may be confused with any scalp disorder that causes patchy alopecia, inflammation, or scale. The presence of hairs broken off a short distance above or right at the scalp surface should cause immediate suspicion. Occasionally TCa does not produce hair breakage. The noninfectious dermatidities seborrhea and psoriasis can both cause inflammation and scaling of the scalp, but do not cause patchy hair shedding. Both are more diffuse than TCa. When any inflammatory scalp condition...

Dermatologic Physical Examination

Apocrine Gland Distribution

The four components of the dermatologic physical examination are (1) primary lesions, (2) secondary lesions, (3) distribution, and (4) configuration. Because primary and secondary lesions are rather constant with most dermatitides, they should be relied on heavily to lead to the correct diagnosis. The two other basic components of the physical exam, distribution and configuration, are used for support and confirmation. Some skin disorders lack a distinct distribution or configuration....

Dermatologie Physical Exam

A rapidly growing dome-shaped papule with a central dull pebbly core (see Photo 40). 2. A rapidly growing dome-shaped nodule with a central dull pebbly core (see Photos 41,42). The initial lesion is a papule with a central depression or dell. The peripheral epithelial lip can vary from flesh-colored to pink or orange-red depending on the degree of inflammatory reaction and the number of dilated (telangiectatic) vessels. There is no infiltration of the skin peripheral to the margins of the...

Therapy

The treatment of acne involves skillful use of medications, avoidance of provoking factors, physical evacuation of cysts and comedones, and in some cases intense emotional support. Therapy must be tailored to each case and must be adjusted regularly as condi- Figure 4 Macrodistribution of acne vulgaris. Figure 4 Macrodistribution of acne vulgaris. tions change. In general, grade I and mild grade II acne can be treated with topical regimens. Moderate to severe grade II and grade III disease...

Conditions That May Simulate Herpes Simplex Recidivans

Both diseases are common in the central facial region, and both begin with small clear vesicles on an inflammatory base. Herpetic lesions tend to remain fixed and discrete, and the vesicles are small, 1 to 2 mm across, tightly grouped, and persist for longer periods. Facial HSV occasionally develops secondary impetigo, causing some diagnostic confusion. A smear with a Gram stain will often show bacteria with cases of impetigo. A Tzanck smear of a blister base will show herpes virus cytopathic...

Application Guidelines Systemic Lupus Erythematosus

If a malar rash is present at onset, it usually appears abruptly. Photosensitivity can be present but is not as prominent a feature in SLE as in cutaneous lupus erythematosus. Although skin lesions occur in 80 of SLE patients during the course of their disease, they are a presenting sign in only about 13 . Joint and other visceral symptoms predominate. Cutaneous lesions are nevertheless important because they constitute four of the 11 criteria used by the American Rheumatism Association to...

How is history helpful in the diagnosis

Answer In addition to information regarding sexual activity and cyclical recurrences, specific questions establish the following facts a. Onset is heralded by an aura of itching and burning 12 hours before a visible lesion. b. Lesions have recurred at approximately the same site each time. c. The patient clearly describes an evolution from a red welt to bumps, blisters, and crusts. d. Evolution of each episode is about 10 days from start to finish. e. Lesions are described as irritable and...

Conditions That May Simulate Acne Vulgaris

Papulopustular rosacea may resemble acne, but usually occurs on a backdrop of flushing and telangectasia. Comedones and cysts are absent except in rare cases when both diseases occur simultaneously. Most rosacea lesions are on the face. This localized eruption is almost exclusively limited to female patients. It presents with a localized papular and eczematous eruption with tiny pinpoint pustules in the perioral, perinasal, or periocular areas of the face. It superficially resembles acne, but...

Molluscum Contagiosum Dimple Warts

Medical Dermatology Human Figure

A 16-year-old male high school student presents with a large number of papular lesions of recent onset in the right thoracic and axillary region. There is a second grouping of similar lesions on the right knee. The patient is on the wrestling team, desires removal of the lesions, and was sent to you by his wrestling coach to find out if they might be contagious. You suspect this is molluscum contagiosum. 1. What are the primary lesions you would expect to find in molluscum contagiosum 2. What...