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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 

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? 

Clinical Topics

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

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?

This image of the dorsum of the tongue of a 42-year-old African American woman shows parallel linear black coatings.

After a “swig” of  Kaopectate, this patient noticed tongue discoloration. Is this coincidental, or is there a clinical connection? 

Black Coating on a Woman’s Tongue

7 factors that lead Americans to Skip Health Screenings 

A new survey of US adults on the factors that lead them to become delinquent with regular health care screenings, eg, for breast and colorectal cancer,  diabetes, hypertension, and other conditions, revealed familiar themes that revolved around access to care. 

, commissioned by the American Association of Nurse Practitioners, "...underscore the ongoing crisis of access to primary health care [in the US], which cuts across many communities," Stephen A Ferrara, DNP, AANP president said in an association news release. Among the findings, nearly 40% of survey respondents must travel more than 10 miles for access to care. According to the release, this year's findings echo those from AANP research in 2023 that found more than 25% of adults had waited more than 2 months for an appointment. 

Click through the brief slide show above for a snapshot of other factors restricting regular screening.     

Essential health screenings and immunizations are declining among US adults. A new survey identified 7 issues that help drive the reduced rates.  

7 Factors That Lead Americans to Skip Health Screening 

A 32-year-old man presents with dysphagia to solid foods. His symptoms have increased in frequency during the past 6 months. He has taken to eating much more slowly and needs water to help swallow food. His history is remarkable for seasonal allergies, for which nasal fluticasone is prescribed. He undergoes an upper endoscopy, which demonstrates diffuse rings, longitudinal furrows, and white plaques. Esophageal biopsies reveal dense eosinophilia throughout.

A. Start swallowed topical corticosteroids

B. Refer to allergist for skin prick testing

C. Begin treatment with an acid suppressant

These endoscopic findings help explain worsening dysphagia in a 32-year-old man. Esophageal biopsies prove positive for eosinophilia. How would you proceed? 

Esophageal Rings, Furrows, and Plaques: What Next?

A 66-year-old woman had a mildly pruritic rash on the buttocks, lower back, abdomen, and upper posterior thighs. The eruption had been present for approximately 18 months.

A 66-year-old woman had a mildly pruritic rash on the buttocks, lower back, abdomen, and upper posterior thighs. The eruption had been present for approximately 18 months. Your diagnosis?

“Swimsuit Area” Rash: Your Dx?

Charles Nakar, MD

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