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Tuberculin-type hypersensitivity is characterized by marked spongiotic dermatitis with intraepidermal and subepidermal vesiculation and scattered eosinophils.

Atypical Tuberculin Skin Test Responses

These are the hands of a 60-year-old black woman who, besides a chronic palmar discoloration, has a history of joint pain, muscle weakness, and Raynaud phenomenon. Physical examination showed proximal muscle weakness and mild synovitis in her metacarpophalangeal joints. She was mildly anemic, but renal function and urinalysis results were normal. Her creatine phosphokinase level was elevated at 3435 U/L. Her chest x-ray showed mild interstitial changes at the lung bases.

The 60-year-old black woman has a history of joint pain, muscle weakness, and Raynaud phenomenon. Why the “dirty hands”?

Clinical Topics

Dirty Hands

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 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

A 9-year-old boy presented with a 1-week history of pruritus and rash on his elbows, knees, back, and legs. Several areas of excoriation were noted. He had recently run through a field of tall grass but denied any other exposure history.

A 9-year-old boy presented with a 1-week history of pruritus and rash on his elbows, knees, back, and legs. He had recently run through a field of tall grass but denied any other exposure history. Your Dx?

What Cause of This Itchy Rash?

This 15-year-old has a pruritic, flat-topped, monomorphic papular rash on his face and arms for the past 6 days. He takes no medications, has not been sick recently, and has not been exposed to poison oak.

A.  Papular acrodermatitis of childhood (Gianotti-Crosti)

This monomorphic papular rash is unrelated to medications, recent sickness, or exposure to poison oak. It developed about 6 days earlier. 

Teen With Itchy Papular Rash on Face and Arms

This relatively small (1 cm), pigmented nodule of uncertain duration was noticed on the left arm of a 57-year-old man with a history of skin cancer.

This relatively small (1 cm), pigmented nodule of uncertain duration was noticed on the left arm of a 57-year-old man with a history of skin cancer. What do you suspect here?

Nodule With Dark Black Pigmentation: Your Dx?

Kirk H. Waibel, MD

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