CASE11
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A 94-year-old man presents complaining of acne. He has no major health problems and spends his free time fishing. Examination of his face reveals open comedones (blackheads) scattered on the nose, forehead, and cheeks. In addition, coarse facial wrinkles and furrows are observed. His medical history is negative for skin cancer and he denies experiencing any acne as a teenager
ANSWER
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Favre-Racouchot syndrome is a condition characterized by the presence of open and closed comedones occurring within actinically-damaged skin. The disorder afflicts elderly individuals who have spent years in the sun. Many patients give a history of heavy cigarette smoking. The most common locations are the forehead and periorbital regions. Inflammatory lesions are not present. Extraction using a looped instrument (comedo extractor) provides cosmetic improvement. Prevention of new lesions is best accomplished with topical retinoids and sun protection
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CASE12
A 19-year-old African-American woman presents with an annular, reddened rash on her central forehead and upper nasal bridge. She states that the condition first appeared a few months ago as two discrete patches that later became confluent. The rash has remained asymp- tomatic. She denies any muscle or joint pain, recent sun exposure, or use of prescription medications. Physical examination finds an erythematous, arcuate plaque with slight induration and no scale. The surrounding skin appears normal
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ANSWER
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Erythema annulare centrifugum is classified as a gyrate erythema. It may occur in association with medications, systemic disease, infection, or malignancy, although many cases are never traced to a specific cause. Lesions begin as small erythematous papules that spread peripherally to produce polycyclic or annular plaques and can occur on the head, neck, trunk, or proximal extremities. Topical or intralesional steroids, or a combination of both, may hasten resolution of lesions. The differential diagnosis includes sarcoidosis, systemic lupus erythematosus, and erythema migrans
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CASE13
A 65-year-old man complains of a painful lesion on his finger that appeared approximately three weeks ago. He gives a history of arthritis. Examination of the affected digit reveals a 0.5-cm translucent, shiny nodule with a slightly erythematous border situated on the distal phalangeal joint. Light palpation elicits tenderness and expresses a viscous fluid
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ANSWER
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A digital myxoid cyst is a flesh-colored-to-translucent papule or nodule located on either a finger or a toe and filled with hyaluronic acid, which has a jellylike consistency. Many cases arise secondary to friction or minor trauma and are associated with a history of osteoarthritis. Typical locations are the distal interphalangeal joint and the proximal nail fold. Asymptomatic cysts do not require therapy. Painful lesions may be drained, but they will frequently recur
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CASE14
This two-year-old boy presents with an erythematous rash and bullae that developed within 24 hours. There was no antecedent inguinal or perianal dermatitis, but the rash was preceded by two days of low-grade fever, slightly decreased oral intake, and irritability. He takes no oral medications. Examination reveals mild inguinal lymphadenopathy, normal vital signs, and no evidence of dehydration. Mucous membranes are unaffected. Exquisite tenderness of the perineal skin is elicited. Nikolsky’s sign is positive on both bullae and surrounding skin. Ruptured bullae reveal moist skin with shallow erosions. A culture of aspirated fluid from intact bullae revealed no growth
.
ANSWER
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This patient has localized staphylococcal scalded skin syndrome (SSSS). The condition is caused by toxigenic strains of Staphylococcus aureus and most commonly afflicts infants and young children. Its presention ranges from isolated bullae to generalized erythroderma. In the latter, toxin released during the inflammatory process leads to widespread desquamation of the epidermis. Toxic epidermal necrolysis (TEN) is included in the differential diagnosis. This is because both TEN and SSSS may exhibit a positive Nikolsky’s sign, in which gentle stroking of the skin leads to epidermal separation. However, TEN is often drug induced and uncommon in this age group. Localized SSSS responds to oral antibiotics such as dicloxacillin. More generalized cases require admission, intravenous antibiotics, and adequate hydration
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CASE15
A 51-year-old man seeks consultation because his wife noted a new mole on his back. The lesion is asymptomatic. The patient gives negative family and personal histories for skin cancer and atypical nevi. He is in good general health and lives in a wooded area, where he spends much time outdoors and owns a variety of animals including dogs and horses
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ANSWER
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Ticks are blood-sucking arachnoids. Many different species exist; among the most commonly encountered by humans are the dog (Dermacentor variabilis) and deer (Ixodes scapularis) varieties. Ticks do not fly or jump, but crawl onto their hosts. Some species are capable of transmitting serious infections including Lyme disease, babesiosis, ehrlichiosis, and Rocky Mountain spotted fever. For this reason, ticks should be completely removed as soon as possible after discovery. This patient’s “mole” was eradicated with fine-tipped forceps
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CASE16
A 16-year-old high school student developed a rash on his forehead six days ago. Two days after onset, he was seen by a family practitioner who prescribed cephalexin for a suspected staphylococcal infection. Despite treatment, the eruption continued to spread. He complains of mild fatigue but denies fever or swollen glands. He is a wrestler and has a match in two days. Examination of his forehead reveals multiple erythematous papules and papulovesicles
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ANSWER
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This patient is experiencing a primary episode of herpes simplex infection, probably acquired from skin-to-skin contact with another wrestler (herpes gladiatorum). He was advised of the contagious nature of the disease and that other wrestlers must not be exposed to active lesions. Herpes gladiatorum most commonly manifests as vesicular lesions on the head and neck. Primary infection may be accompanied by malaise, low-grade fever, and regional lymphadenopathy. This patient was treated with oral valacyclovir
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CASE17
The parents of a one-year-old boy who has a rash on his back seek medical consultation. The eruption was first noted approximately four weeks ago, at which time a pediatrician recommended application of an over-the-counter 1% hydrocortisone cream twice a day. Subsequently, both of two affected areas began to enlarge. Examination reveals annular, erythematous patches with raised borders and central clearing. Family history is negative for eczema. Two kittens live in the house
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ANSWER
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Tinea corporis is characterized by well-demarcated, erythematous, scaling patches and plaques. Because a cell-mediated immune response results in central clearing, hyphae are best identified from the border. Many cases arise from direct contact with an infected dog or cat. The condition is often misdiagnosed as eczema and treated with topical steroids, which results in gradual extension of the lesions. Tinea corporis responds readily to treatment with an antifungal cream, although more extensive cases may benefit from an additional course of oral therapy
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CASE18
A 14-year-old boy who says he has had a sore mouth for the past two days also complains of a slight fever, abdominal discomfort, and loss of appetite. His previous medical history is unremarkable. Examination of the oral cavity reveals erosive lesions on his tongue and palate. Also noted on his hands and feet are scattered, erythematous papulovesicles that are asymptomatic
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ANSWER
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Hand-foot-and-mouth disease (HFMD) is an infectious disorder characterized by vesicular lesions occurring within the mouth and on the hands and feet. Most cases are caused by strains of coxsackie virus. Epidemics among school-aged children are not uncommon. Oral lesions rapidly progress from macules to vesicles that become erosive and painful. Associated findings may include fever, malaise, abdominal pain, and anorexia. Signs and symptoms resolve within seven days. The differential diagnosis of HFMD includes aphthous ulcers and herpes simplex virus
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CASE19
A 25-year-old African-American man presents with a chronic scalp condition. He has been treated with numerous oral antibiotics in the past without success. He complains of discomfort, pimple formation, drainage, and bleeding of the mid- and posterior scalp. Physical examination finds dusky erythema accompanied by follicular papules and pustules, as well as evidence of scarring alopecia. Some areas are tender to palpation and exhibit slight purulence
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ANSWER
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Folliculitis decalvans is a scarring alopecia associated with chronic infection of the scalp. Culture most commonly reveals growth of Staphylococcus aureus, although response to antibiotics is variable. The pronounced inflammatory infiltrate destroys the hair follicle, leading to scar formation and permanent hair loss within the involved areas. A 10-week course of therapy combining oral rifampin and oral clindamycin proved helpful in this case
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CASE20
A 14-year-old girl complains of a discolored tongue. She denies sore throat, change in taste, or difficulty swallowing. Her medical history is unremarkable and she takes no oral medications. Physical examination finds whitened, irregularly shaped patches on the dorsal surface of her tongue. The papillae are not enlarged. The remainder of the oral cavity, including the upper and lower palate, exhibits no visible
abnormalities
abnormalities
ANSWER
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Geographic tongue, or migratory glossitis, is a benign condition that presents with raised, white patches intermingled with reddened, atrophic areas on the dorsal surface of the tongue. The map-like appearance of the tongue gives the condition its name. Women are affected more than men and most patients are asymptomatic. A concomitant systemic or cutaneous abnormality is rarely detected, and there is no correlation with cigarette smoking. In most cases, the only treatment required is reassurance
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WAIT FOR NEXT EPISODE ON TRUE SCENE BY DR BASSEM ELBAZ
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