Dermatology

1. Dermatology Stolen from Dan Sontheimer MD Compiled by Gil Grimes For Jennifer Flory

2. Question 121 • Our next patient is a 21 year old man who presented to our hospital with a specific complaint, but also had this leg lesion of several weeks duration which hasn't been responding to OTC topical antifungals.  I've included his peripheral smear, and he does not have diabetes.  What is his underlying disease, and why does he have this lesion?

6. Answer 121 • Sickle cell anemia • Estimates vary, but the frequency of cutaneous ulcers, usually leg ulcers, is likely around 25%.  • These ulcers have a high level of reccurrence and as our patient walks a lot in his work can carry a high level of morbidity and disability.

7. Answer 121 • The cause of leg ulcers in sicklers is not certain, although sickling leading to thrombosis and ischemia, and poor vascular reactivity are two likely contributing factors.  • Treatment is the same as with common leg ulcers, with elevation, avoidance of edema, debridement if necessary, and there are many topical/dressing regimens that you or your wound care team can utilize such as wet to wet dressings or hydrocolloid dressings.  • See "Leg Ulcers in Sickle Cell Disease" by Eckman JR in Hematology/Oncology Clinics of North America Vol 10, number 6, 12/96 for details about the above and additional information.

8. Question 122 • Our next patient is a 22 year old woman who started developing these hand lesions 6 months ago.  She describes them as "uncomfortable and painful" and she keeps getting waves of new lesions.  She has been "popping" the lesions and getting purulent material out of them.  What does she have, and what treatment would you recommend if treatment is necessary?

11. Answer 122 • Pompholyx • This is not that uncommon in primary care • Vesicular lesions on the palms should make you think of Hand, Foot and Mouth disease • this person is older than typical and those are a single wave of lesions as are small pox and chicken pox.  • An Id reaction would be more isolated to the lateral aspects of the fingers and you need to have a fungal infection elsewhere as the inciting factor.  • The next two things would be pustular psoriasis and pompholyx

12. Answer 122 • In that this person has no other findings of psoriasis and the psoriasis should be a rather consistent long term process, my diagnosis was pompholyx, also called dyshidrosis due to the tendency of these people to have very sweaty palms and soles.  • Our patient reports always having sweaty palms and in my experience patients with pompholyx are always going after their lesions by picking, needles, biting or something to relieve their discomfort or itching. 

13. Answer 122 • Referring to the new 4th Edition of Habif's Clinical Dermatology, which just came out in November, the treatment choices are topical or oral steroids, cold wet compresses and in resistant cases consider PUVA, or evaluation for certain metal sensitivities.  • We treated our patient with systemic steroids and her lesions have resolved. 

14. Question 123 • Our next patient is a young woman who has this lesion on her scalp.  She says that she has never had any hair there and that she was told it was due to trauma at birth from a scalp electrode placement.  She is asymptomatic.  • What does our current patient have, and is there any concern when you see lesions like this?

17. Answer 123 • Cutis Congenita.  • If small, these are often mistaken as a site of trauma from a scalp electrode or amni-hook.  • In actuality, due to an insult of insufficient blood supply, or in utero infection or exposure, there is a patch of skin that does not develop or develops and then necroses.  • This case only involved the skin, but some cases can involve all tissue layers and even be associated with underlying CNS or other malformations.

18. Answer 123 • Over 80% of the lesions involve the scalp.   • Affected infants (it's a congenital lesion) should be thoroughly examined for other congenital anomalies.  • For the more superficial lesions local care such as topical antibiotics or ointments are all that is required.  • For larger or deeper defects surgical coverage may be necessary.  See Common Newborn Dermatological Conditions by Mark Stephans in the 11/03 Clinics in Family Practice for more details.

19. Question 124 • Our next patient is a young lady who asked about these small 1-2 millimeter lesions that started 4 months ago.  They seem to be spreading, but are otherwise asymptomatic.  • She had cryotherapy performed on a number of them 2 months ago and is not happy with the larger 1-2 centimeter lesions that you see in the photos.  • What is your diagnosis for the small lesions, the larger lesions, and what would you recommend for the smaller lesions if treatment is recommended.

23. Answer 124 • Flat warts.  • These small, minimally raised lesions (in contrast to the usual domed shaped commmon warts) usually affect the face and lower legs.  • Scratching or shaving can spread the lesions due to autoinoculation with HPV virus types 3, 10, 28 and 49. 

24. Answer 124 • A common treatment is light cryotherapy, IE. don't freeze these as long as common warts.  • A quick 1 mm margin of freeze with a small probe on a cryogun or twirling the cotton on a swab to a point to give a smaller application of liquid nitrogen should suffice.  • This patient was treated with cryotherapy and unfortunately, you can now see large, hyperpigmented and atrophic scars at each treatment site, so further cryotherapy and electrocautery should probably be avoided.

25. Answer 124 • She would likely better tolerate topical therapy with tretinoin, 5 fluorouracil, salicylates or imiquimod, although might still develop hyperpigmentation due to inflammation from the topicals.  • See  Imiquod Skinnner RB. Dermatologic Clinics 21(2) April 2003 and Molluscum Contagiosum and Warts. Stulberg DL, Hutchinson AG. American Family Physician 2003 March 15;67(6):1233-40 for additional details.

26. Question 125 • Our next gentleman complained of some mildly tender swelling at his right jaw.  • On his examination we found this lesion that he reports has been present for two months.  It is asymptomatic and has not bled.  • What does he have, and what treatment do you recommend if treatment is indicated?

30. Answer 125 • Pyogenic granuloma.  • The clues to this diagnosis are the fragile vascular appearance of the lesion and the characteristic subtle pale margin/collarette around it.  • We think that his jaw was tender due to a slightly swollen submandibular node.  • He was referred to his dentist for excision of the lesion since it was so close to his tooth.

31. Answer 125 • Usual treatment is to excise the overgrowth of tissue and then cauterize the base to try and prevent regrowth which occurs around 5% of the time.  • This is not uncommon on the gums in pregnant women where it is called epulis gravidarum.

32. Question 126 • Our next case is a 21 year old man who developed fevers, chills and malaise about 2-3 weeks before presentation.  • Don't ignore the clues in the photos as you think about this case.  • Name at least 2 of the findings he has, his underlying diagnosis, and what are 2 good questions to consider in his history?

35. Answer 126 • Bacterial endocarditis.  • You can see the splinter hemorrhage at his distal nail.  • He has inflamed swollen Osler nodes that you can see on his fifth finger distal phalanx.   • Some of his flat janeway lesions have ulcerated and may have been purulent as these are the end organ damage from septic emboli.

36. Answer 126 • His fundi also had Roth spots due to the same process of embolization from his infected aortic valve.

37. Answer 126 • Risks include IVDA, dental caries or disease (probably more significant than dental cleanings,) history of abnormal heart valves or recent surgical procedures.  • These people can get very sick; clues in the photo were the IV and hospital gown.  • There is a high rate of morbidity and mortality associated with bacterial endocarditis related to infection and valvular damage.   • There is also distant tissue destruction due to embolization which can cause strokes, abcesses and necrosis.

38. Question 127 • Our next patient is a 50 year old who reports this condition of his toenail for the last several years.  • He trims it occasionally and he is asymptomatic.  • What does he have, and what treatment do you recommend if treatment is indicated?

42. Answer 127 • Hypertrophic nail.  • Some of you thought it was onychomycosis and wanted to use antifungals to treat it.  That's probably why my parent corporation Intermountain Health Care requires a positive KOH (the micrograph you saw had no hyphae) or culture before paying the $250+ dollars per month for Lamisil (3 months for toenails, 6 weeks for fingernails.) 

43. Answer 127 • There was a slight greenish tinge to the nail color which led some to think of pseudomonas.  • Pseudomonas can infect the nail when the nail stays moist for extended periods of time.  • That wouldn't explain the thickening, ridging and deformity of the nail that you see on the oblique photo.  • You can also see a bit of blood at the cuticle indicating that he is still traumatizing this nail.

44. Answer 127 • This patient has nail hypertrophy, similar terms are onychogryphosis referring to abnormal shape of the nail often curving so tightly around the underlying nail bed to cause pain and onychauxis which refers to thickening of the nail.  • Hypertrophic nails are usually the result of injury, or chronic repetetive trauma from poorly fitting shoes. 

45. Answer 127 • Treatment is usually to avoid trauma, file or trim down the excessive nail to avoid mechanical pain or if necessary removal of the nail and destruction of the matrix.  See Nail Surgery by Robert Clark in Dermatologic Clinics 1/1998 Vol 16, no 1. for additional information.

46. Question 128 • Our next patient is an 8 year old girl.  She and her friend, who both ride horses and love Jacuzzis, came down with this itchy rash.  • What does she have, what is the cause/mechanism, and how would you treat it, if treatment is indicated?

49. Answer 128 • Hot tub folliculitis.  • The pattern of lesions in a bathing suit coverage distribution, the purulent centers and follicuar/perifollicular pattern with a hot tub exposure clinched the diagnosis.  • Treatment is to take better care of the chemical levels (Usu. Chlorine or Bromine) in the hot tub, and symptomatic care.  • Habif's Clinical Dermatology suggests white vinegar compresses for relief and ciprofloxacin for resistant cases.  Since this was a child we would like to avoid fluoroquinolones.

50. Question 132 • Our next patient is a 24 year old man who presents with many of these lesions on his face and hands.  • Other than scaling, he has no symptoms.  At first I thought the areas on his hands were due to trauma, but there is no history of trauma.  • What does he have, and what treatment do you recommend if treatment is indicated