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von Willebrand disease affects up to 1% of the population yet diagnosis is  delayed an average of 16 years after onset of symptoms, especially in women. 

The Most Common Bleeding Disorder in Your Patients Could be Hiding in Plain Sight 

An 89-year-old woman with a history of biopsy-proven actinic keratosis on her scalp is seen for a new erosion on the right frontal area. Two weeks of twice-daily mupirocin has brought no improvement and now crusting and purulent exudate are seen. Skin cultures taken show normal flora.

C. Erosive pustular dermatosis of the scalp

E. Chronic actinic damage with secondary infection

An 89-year-old woman is seen for an erosion on the frontal area of the scalp. History is positive for actinic keratosis. What's your Dx?

Clinical Topics

Crusty Scalp Lesion 

A 76-year-old woman seeks your attention for an asymptomatic “red spot” on her neck. She has a history of multiple non-melanoma skin cancers.

Squamous cell carcinoma in situ (Bowen  disease)

Lichenoid keratosis (an inflammatory variant of seborrheic keratosis)

A 76-year-old woman seeks your attention for an asymptomatic “red spot” on her neck. What does this look like to you?

What's This "Red Spot"?

A 67-year-old woman noted the appearance of several non-tender, rock-hard, purple-colored nodules on her legs. Her medical history was significant for distant non-Hodgkin lymphoma.

A 67-year-old woman noted the appearance of several non-tender, rock-hard, purple-colored nodules on her legs. Her medical history was significant for distant non-Hodgkin lymphoma. The violaceous color and configuration of the skin lesions suggests which of the following? 

Hard Purple Nodules: Your Dx?


These 2 patients presented with a swollen hand and rapidly proximally progressive edema secondary to a bite.

These 2 patients presented with a swollen hand and rapidly proximally progressive edema secondary to a bite. What creature did the biting?

Swollen Hands-What’s Biting?

A 5-year-old boy with a history of atopic dermatitis since 6 weeks of age, presents with a rash around his mouth that has been present for approximately 1 year. The patient’s mother reports that desonide topical cream was applied to the affected area for about 5 days, which initially resulted in improvement, however the rash returned after this medication was discontinued. The rash also recently improved after the patient took amoxicillin for an infection. She also notes that the patient has been licking his lips more frequently.

On examination there is an erythematous papulopustular eruption restricted to the perioral region, with sparing of the vermillion border. Mild hyperpigmentation is noted on the patient’s neck. There is no active involvement of other areas of the body.

The eruption has been present for 1 year and is restricted to the perioral region. What is included in your differential? 

Rash Around the Mouth of a 5-year-old Child

Many people with chronic pain also have problems with sleep. Although commonly thought to be a unidirectional issue (ie, chronic pain causes sleep problems), impaired sleep can both cause and exacerbate pain. Depression, another common comorbid condition with chronic pain, can also cause sleep problems, can be secondary to sleep issues and also cause and exacerbate pain. 

Based on these issues, clinicians should try to avoid treatments that might worsen sleep for patients with chronic pain. It is a common belief that any medication that is sedating is also beneficial for sleep, but more important is how the sedating medication affects sleep architecture. A recent review examined how commonly used analgesics affect sleep architecture.

 In the slides below, find results and important takeaways for clinicians. 

1. Antila H, Lilius TO, Palada V, et al. 

Effects of commonly used analgesics on sleep architecture: a topical review

2. de Mendonça FMR, de Mendonça GPRR, Souza LC, et al. 

Benzodiazepines and sleep architecture: a systematic review.

Findings from a recent review highlight the impact of common analgesic medications on sleep patterns in people with chronic pain.

Effects of Common Analgesic Medications on Sleep: A Topical Review

Charles Nakar, MD

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