A 58-year-old man with a history of chronic obstructive pulmonary disease presents to your emergency department with more than 100 asymptomatic, umbilicated papules ranging in diameter from 2 to 7 mm. The patient first noticed the lesions on his lower abdomen six months ago; they then spread rapidly to other parts of his body. Recently, he began having night sweats and losing weight. Physical examination also reveals palpable inguinal lymph nodes
ANSWER
This patient has widespread molluscum contagiosum. The condition is caused by a poxvirus and transmitted by direct skin contact. It most commonly infects children, sexually active adults, and immunosuppressed individuals, causing umbilicat-ed, dome-shaped papules between 1 and 5 mm in diameter. After further diagnostic testing, this patient was found to be HIV-positive. Almost all patients infected with HIV and molluscum contagiosum will have a helper T-cell count below 100 and will be diagnosed with AIDS
CASE 2
A 47-year-old woman with a history of hypertension and hypothyroidism presents with progressive, symmetrical loss of pigment involving her hands, axillae, shoulders, and groin. She first began to notice the changes several months ago. The affected areas are asymptomatic but highly susceptible to sunburn
ANSWER
This patient has vitiligo, an acquired autoimmune disorder of pigmentation. Depigmented patches are typically symmetrical and occur most commonly on the face, chest, hands, axillae, and groin. The hair in these areas may also turn white. The disorder occurs in up to 1% of the population and often appears before age 20. Family history is positive for vitiligo in 30% of cases. Treatment options include ultrapotent topical steroids, tacrolimus, phototherapy, and skin grafting. Patients should be advised to avoid exposing affected areas to sunlight and to use sunscreen during outdoor activities
CASE3
A 17-month-old girl presents to your emergency department with a rash and a fever. The rash began on her chest and abdomen three days ago and has progressed to cover her back, chest, abdomen, extremities, and face. She was seen by her pediatrician about 10 days ago, diagnosed with otitis media, and started on amoxicillin. Her parents tell you she has had swollen knees and ankles for the past two days as well as hesitancy ambulating. She has a fever of 101.5°F taken rectally and is mildly tachycardic. Physical exam confirms swollen and tender knees and ankles. There does not appear to be any mucous membrane involvement
ANSWER
This child is exhibiting a serum sickness-like reaction to amoxicillin. Patients usually present with rash, fever, polyarthralgias or polyarthritis, refusal to walk, lymphadenopathy, and abdominal pain. Symptoms generally start one to two weeks after exposure to the causative agent—typically an antibiotic and most commonly cefaclor. Trimethoprim-sulfamethoxazole, penicillin, amoxicillin, and other cephalosporins may also provoke such reactions. The differential diagnosis includes Kawasaki disease, connective tissue disorder, erythema multiforme, Stevens-Johnson syndrome, Still disease, rheumatic fever, and meningococcal or gonococcal infection. The condition is usually self-limited and has an excellent prognosis. Treatment typically consists of antihistamines, nonsteroidal anti-inflammatory drugs, and a short course of corticosteroids in severe cases
CASE4
A 70-year-old man presents with a generalized cutaneous eruption. He states that the rash started as blisters on the left side of his scalp and forehead, then spread to his trunk and extremities five days later. According to his description, the rash is mildly pruritic but not painful, and he denies fever or malaise. He is immunocompetent with no history of cancer, organ transplantation, or HIV infection. Physical examination finds multiple, erythematous, crusted papules and scattered vesicles in the affected areas
ANSWER
Herpes zoster results from reactivation of the varicella zoster virus. The syndrome is characterized by a painful, vesicular skin eruption that is generally restricted to one dermatomal distribution. In patients with cancer, HIV infection, a history of organ transplantation, or other conditions in which immunosuppressive agents are used, it may become disseminated. Disseminated zoster is clinically indistinguishable from primary chicken pox. Zoster infection is usually diagnosed on the basis of clinical appearance and is supported by a positive Tzanck smear. An antiviral agent, such as acyclovir, should be administered immediately upon diagnosis
CASE5
A 33-year-old African-American man requests treatment for severe scarring on his posterior scalp. The condition has gotten progressively worse over the last two years. The lesions usually begin as hard papules and are occasionally pruritic. At times, some are painful, cystic, and filled with pus. The patient’s medical history is unremarkable. Examination of his scalp reveals marked scarring and alopecia with discrete papules and cystic nodules at the periphery
ANSWER
The patient has scarring alopecia secondary to inflammation of scalp hair follicles. Clinical names for this condition include acne keloidalis nuchae and folliculitis decalvans. Cicatricial alopecia of this nature occurs almost exclusively in African-American men and is preceded by either a folliculitis or an abscess formation. The condition can be painful and result in significant cosmetic disfigurement. Afflicted individuals should avoid trauma (especially razor haircuts) and may benefit from long-term therapy with an antibiotic such as doxycycline. New lesions, as well as existing keloids and cysts, often respond to intralesional steroid injections. Surgical excision of affected areas may be indicated in refractory cases
CASE6
A 59-year-old man presents to your emergency department with a recurrent, intensely pruritic rash on his chest. The eruption has waxed and waned in severity over the past three years, flaring in the summer months. Topical therapies provide limited relief. Examination reveals multiple discrete, erythematous papules with mild hyperkeratosis and scale affecting the hair-bearing regions of the upper trunk and abdomen. Several lesions are excoriated
ANSWER
Punch biopsy of a lesion reveals Grover’s disease, or transient acantholytic dermatosis. Acantholysis refers to the separation of epidermal cells secondary to loss of intercellular adhesiveness. The condition most frequently occurs on the trunk and is most prevalent in middle-aged men. Heat and humidity are exacerbating factors. The eruption consists of multiple hyperkeratotic papules that vary in color from reddish to brown. Despite the label of “transient,” the rash may actually persist for weeks or even years, often accompanied by severe pruritus. The differential diagnosis includes bacterial and pityrosporum folliculitis as well as dermatitis herpetiformis. Topical steroids may help relieve symptoms
CASE7
An 85-year-old man arrives at your emergency department with an erythematous, mildly pruritic, slightly scaling rash affecting his eyebrows, nasolabial folds and ear canals. It tends to worsen during the colder months and times of stress. His medical history is negative for Parkinson disease and AIDS. He has tried several nonprescription creams that produced no significant improvement
ANSWER
This patient has seborrheic dermatitis, a common chronic inflammatory disease characterized by erythema and scale. The condition, seen more often in male patients, peaks within the first three months of infancy and once more after the fourth decade. Classic sites for involvement include the scalp, eyebrows, nasolabial folds, ear canals, posterior auricular regions, and chest. While the etiology is unknown, many cases have been linked to colonization with the yeast Malassezia ovalis. Severe seborrheic dermatitis may occur in association with Parkinson disease or HIV infection. The condition is treated topically with an antifungal medication (such as ketoconazole), selenium sulfide foam, or low-potency steroids
CASE8
A 37-year-old man gives a four-day history of a pruritic rash on his upper back accompanied by malaise and chills. Examination reveals erythematous, slightly indurated patches and plaques. A similar eruption has appeared in each of the preceding three years during the late spring. For the past two weeks he has spent a great deal of time exposed to the sun. He denies any use of oral medications or new skin care products; he says calamine lotion provides partial relief of the pruritus
ANSWER
This patient is experiencing a polymorphic light eruption, which is the most common photodermatosis developing hours to days after sunlight exposure. Common morphologic forms include papular and plaque variants. Papulovesicular, eczematous, hemorrhagic, and erythema multiforme types have also been documented. Other symptoms in addition to the erythematous eruption may include chills, nausea, and malaise. Light sensitivity tends to decrease with repeated sun exposure, a phenomenon known as hardening. Use of sunscreens and protective clothing and avoiding the midday sun may help prevent recurrence. Treatment options include topical steroids, ultraviolet phototherapy to induce hardening, and antimalarial medications such as hydroxychloroquine
CASE9
A 24-year-old woman presents with firm, flesh-colored papules in the periorbital region bilaterally. She reports that they have been increasing in number for five years. The lesions are asymptomatic, but treatment is requested for cosmetic purposes. She denies any history of systemic disease and her serum triglyceride level is normal. The patient states that an aunt has a similar condition
ANSWER
The proper diagnosis is syringoma, benign tumors of the intraepidermal eccrine sweat duct. The papules are typically 1 to 5 mm, firm, and flesh-colored. They usually appear on the eyelids or, less often, the forehead, cheeks, chest, abdomen, or vulva. The condition is more common in women and may develop at any age, but it is most frequently seen during or after puberty. These lesions were successfully treated with electrodesiccation
CASE10
A 50-year-old woman presents with a 10-month history of skin fragility and blister formation affecting her hands. She has also noticed bruising and scarring after minimal trauma. The affected areas are occasionally pruritic, and topical therapy with hydrocortisone cream has proven ineffectual. Several years ago, the patient was diagnosed with hepatitis C, but she is not currently on any oral medications. She states that since completing antiviral therapy her viral load is no longer detectable. Examination of her hands reveals scattered denuded patches and atrophic scars. No other cutaneous abnormalities are noted
ANSWER
Porphyria cutanea tarda should be suspected given the clinical presentation and history of hepatitis C. The diagnosis can be confirmed by a markedly elevated uroporphyrin level in a 24-hour urine collection. The cutanea tarda subset is the most common type of porphyria and results from a deficiency of hepatic uroporphyrinogen decarboxylase activity. The disease is most commonly induced by alcohol and is linked to hepatitis C infection. Clinical features include bullae in sun-exposed areas, skin fragility, facial hypertrichosis, sclerodermoid features, and milia. The preferred treatment is phlebotomy to lower serum iron levels. Ancillary measures include sun avoidance and abstaining from alcohol
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