case21
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A 43-year-old woman presents with red lesions on her hands. Her family history is significant for systemic lupus erythematosus affecting her mother. Physical examination reveals erythematous- to-violaceous papules on the dorsal surface of all fingers, including both the proximal and the distal interphalangeal joints. The papules are asymptomatic. Examination with a magnifying glass reveals telangiectasia involving the proximal nail folds. A facial rash is also noted. The patient denies any systemic complaints, including muscle weakness
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Answer
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This patient was diagnosed with Gottron’s papules, which are associated with dermatomyositis. Classified as a connective tissue disease, dermatomyositis presents with various cutaneous manifestations, including proximal nail fold telangiectasia, Gottron’s papules, and heliotrope rash (a purplish erythema and edema of the malar and periorbital regions of the face). Proximal muscle weakness may precede or follow the onset of skin findings. Systemic involvement
correlates with elevated muscle-associated enzymes. Treatment usually entails use of high-dose oral steroids and may also require antimalarials and immunosuppressive agents
correlates with elevated muscle-associated enzymes. Treatment usually entails use of high-dose oral steroids and may also require antimalarials and immunosuppressive agents
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case 22
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An 82-year-old man presents for evaluation and treatment of a slowly enlarging
growth on the right side of his neck. He states that the growth is not tender but occasionally drains a foul-smelling, cheesy substance. Examination of the site reveals a 3 cm by 3 cm, freely movable dermal nodule. On closer inspection, a central pinpoint opening on the skin surface is noted. Pressure on the lesion results in expression of a malodorous, caulk-like material
growth on the right side of his neck. He states that the growth is not tender but occasionally drains a foul-smelling, cheesy substance. Examination of the site reveals a 3 cm by 3 cm, freely movable dermal nodule. On closer inspection, a central pinpoint opening on the skin surface is noted. Pressure on the lesion results in expression of a malodorous, caulk-like material.
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Answer
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This patient has an epidermoid cyst, an invagination of the skin characterized by the accumulation of cellular debris and keratin within an epithelial-lined sac. Over time, the material develops a pungent odor. These lesions are most commonly found on the back and chest but can arise on virtually any part of the body. Treatment utilizing incision and drainage will effectively shrink the lesion, but recurrence is common unless the entire wall is excised. Epidermoid cysts have no malignant potential
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case 23
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A 45-year-old woman presents with a widespread,
itchy, red rash on her trunk, neck, and extremities that began approximately two days ago. She denies any history of a similar condition, as well as any swelling of the lips or difficulty breathing. Her family physician recently prescribed a thiazide diuretic for hypertension and mild leg edema. Examination reveals a diffuse, erythematous, urticarial eruption involving more than 50% of her skin surface
itchy, red rash on her trunk, neck, and extremities that began approximately two days ago. She denies any history of a similar condition, as well as any swelling of the lips or difficulty breathing. Her family physician recently prescribed a thiazide diuretic for hypertension and mild leg edema. Examination reveals a diffuse, erythematous, urticarial eruption involving more than 50% of her skin surface.
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Answer
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This patient’s history and clinical presentation are classic for a drug hypersensitivity reaction. Antibiotics (most notably amoxicillin) and diuretics are common causative agents. A reaction to medication should be suspected in any patient who develops a morbilliform or urticarial skin rash. A detailed medical history and complete list of medications are of utmost importance in establishing causality. Immediate cessation of the offending agent usually results in prompt clearing. Oral antihistamines and topical steroids may hasten resolution. More severe cases may warrant a short course of oral prednisone
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case 24
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A 72-year-old woman developed a small
, asymptomatic papule on her left arm several weeks ago. Since then, the papule has rapidly expanded in size. Today?s examination finds this 2-cm nodule with its raised, erythematous border and crusted center. Scattered actinic keratoses are noted on the patient?s hands and face. Axillary lymph nodes are not detected. Her past medical history is positive for basal cell carcinoma affecting her forehead
, asymptomatic papule on her left arm several weeks ago. Since then, the papule has rapidly expanded in size. Today?s examination finds this 2-cm nodule with its raised, erythematous border and crusted center. Scattered actinic keratoses are noted on the patient?s hands and face. Axillary lymph nodes are not detected. Her past medical history is positive for basal cell carcinoma affecting her forehead.
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Answer
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The lesion was removed by curettage, and biopsy confirmed a diagnosis of keratoacanthoma. This tumor, which is considered a variant of squamous cell carcinoma, is characterized by a rapid growth phase and the presence of a dome-shaped nodule with a central keratin plug or ulceration. Sun-exposed areas are most susceptible. Although many cases will spontaneously involute, there have been occasional reports of metastatic spread. For this reason, most clinicians recommend surgical removal or, when this is not feasible, radiation therapy
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case 25
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A 23-year-old man presents for evaluation of an asymptomatic growth
under his right great toenail. He states that the lesion has been slowly increasing in size for several years and that he is now seeking treatment because of the cosmetic disfigurement. Physical examination reveals toenails that appear normal except for a ridge alongside the right great toenail. Noted is a shiny, pink, firm, subungual tumor protruding beneath the nail of this toe. Palpation does not elicit tenderness
under his right great toenail. He states that the lesion has been slowly increasing in size for several years and that he is now seeking treatment because of the cosmetic disfigurement. Physical examination reveals toenails that appear normal except for a ridge alongside the right great toenail. Noted is a shiny, pink, firm, subungual tumor protruding beneath the nail of this toe. Palpation does not elicit tenderness.
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Answer
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Biopsy revealed that the lesion was a digital fibroma. These benign connective tissue growths usually present as a smooth, dome-shaped, solitary nodule, most often on the great toe. Multiple lesions may be associated with tuberous sclerosis. Antecedent trauma is sometimes correlated with onset. Digital fibromas can exert pressure on the nail matrix, resulting in distortion of the nail. Treatment, when requested for either cosmesis or relief of discomfort, entails surgical excision of the tumor
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case 26
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An 81-year-old, fair-skinned
woman presents for evaluation of lesions that she has had for about two years on both legs. She admits to ample sun exposure in the past and has had a skin cancer removed from her face. Although the lesions are largely asymptomatic, several have bled following minor trauma. An examination of the patient?s legs reveals mild edema as well as multiple erythematous patches and thin plaques of varying sizes
woman presents for evaluation of lesions that she has had for about two years on both legs. She admits to ample sun exposure in the past and has had a skin cancer removed from her face. Although the lesions are largely asymptomatic, several have bled following minor trauma. An examination of the patient?s legs reveals mild edema as well as multiple erythematous patches and thin plaques of varying sizes.
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Answer
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Disseminated superficial actinic porokeratosis (DSAP) presents as multiple flat to barely elevated brownish-red patches on the extremities. The inheritance pattern of the disorder is autosomal dominant with variable penetrance. In genetically predisposed individuals, chronic sun exposure is implicated in the development of lesions, which tend to appear beginning in the fourth decade. Most cases can be diagnosed based on clinical appearance; histopathology will confirm the diagnosis. Uncommonly, DSAP may evolve into squamous cell carcinoma. Some lesions may respond to cryosurgery or topical application of 5-fluorouracil or imiquimod cream
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case 27
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An obese 76-year-old nursing home 
resident suffers from a recurrent blistering rash on her abdomen. The patient is immobile and frequently scratches the lesions. She is currently on oral medications to control hypertension and diabetes. On physical examination, tense bullae scattered on the abdomen are noted in addition to excoriations and superficial ulcerations
resident suffers from a recurrent blistering rash on her abdomen. The patient is immobile and frequently scratches the lesions. She is currently on oral medications to control hypertension and diabetes. On physical examination, tense bullae scattered on the abdomen are noted in addition to excoriations and superficial ulcerations.
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Answer
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Punch biopsy acquired from a newly developed lesion revealed bullous pemphigoid. This chronic condition involves deposition of immunoglobulins within the dermis resulting in subepidermal tense blisters. The average age of onset is 65, with an equal incidence in males and females. This patient was treated with ultra-high potency topical steroids and secondary infection was prevented with topical mupirocin ointment. More extensive disease often requires systemic prednisone for adequate control
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case 28
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A 70-year-old man 
presents for evaluation of an asymptomatic scalp lesion that has been increasing in size over the past six weeks. His medical history includes actinic keratoses that have been treated cryosurgically with liquid nitrogen. Examination of the mid-scalp reveals a 1.8-cm indurated plaque with central scaling. Multiple keratoses are noted elsewhere on his scalp as well as on his face. Cervical lymph nodes are not palpable
presents for evaluation of an asymptomatic scalp lesion that has been increasing in size over the past six weeks. His medical history includes actinic keratoses that have been treated cryosurgically with liquid nitrogen. Examination of the mid-scalp reveals a 1.8-cm indurated plaque with central scaling. Multiple keratoses are noted elsewhere on his scalp as well as on his face. Cervical lymph nodes are not palpable.
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Answer
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Atypical fibroxanthoma most commonly presents as a reddened, dome-shaped nodule that arises rapidly on the head or neck of an elderly individual. Most cases appear to be related to chronic sun exposure or localized radiation therapy. Differential diagnosis includes squamous cell carcinoma, malignant melanoma, and angiosarcoma. Although the majority of lesions treated with simple curettage or shave excision do not recur, spread to lymph nodes has been reported, prompting some clinicians to recommend removal by either full excision or Mohs micrographic surgery
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case 29
.An 86-year-old resident of a nursing home has a chronic blistering rash on her hands and feet. She has multiple medical problems and is on several oral medications. Examination of her palms and soles reveals scattered flattened bullae and slightly indurated, well-demarcated, erythematous plaques. Several nails manifest dystrophy and hyperkeratosis, and coarse scales of her scalp are noted as well
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Answer
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The patient has acral pustular psoriasis. An uncommon variant of psoriasis, this chronic condition is characterized by brightly erythematous plaques and pustules, the latter sterile in nature. The nails are frequently affected. Adequate control may require administration of systemic agents such as acitretin, cyclosporine, and methotrexate. A combination of oral psoralen and ultraviolet light (PUVA) may also prove beneficial, as may the so-called "biologics" etanercept, efalizumab, and alefacept
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case 30
.A 66-year-old woman presents with an enlarging lesion of her right axilla, which she believes to be a wart. She reports that it bled recently, prompting her to seek medical attention. The patient is a cigarette smoker with no history of skin cancer. Examination of the affected area reveals a 3- x 5-cm erythematous plaque with a hyperkeratotic, crusted core. Cervical and axillary nodes are not palpable
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Answer
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Cutaneous biopsy of this lesion revealed invasive squamous cell carcinoma. This second most prevalent form of skin cancer is rarely seen in sun-protected skin folds. Cigarette smoking is a risk factor. If left untreated, up to 20% of cases may metastasize. The uncommon location in this case illustrates the need for total body skin examination
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