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Medicare’s restrictive coverage policies are denying patients with early Alzheimer's disease access to novel treatments. And private payers are following suit.

Dear Payers: Drugs for Early Alzheimer's Disease are ‘Worth It’

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 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 64-year-old woman with a history of basal cell carcinoma presents to the dermatologist for skin cancer surveillance. She is incidentally noted to have bruising on her upper eyelids (above). On questioning, she reports experiencing recurrent intermittent eyelid bruising for several years. She denies a history of trauma to her face, pain, or other associated symptoms.

Her medical history is significant for hyperlipidemia, hepatitis C (diagnosed >30 years earlier), osteoporosis, celiac disease, and idiopathic proteinuria for several years. Her surgical history includes appendectomy and carpal tunnel repair.

Pertinent family history includes her mother dying of multiple myeloma and her father of complications of diabetes.

Review of systems is significant for vague symptoms of gastrointestinal discomfort. On more directed questioning, she reports the eyelid purpura is temporally related to the Valsalva maneuver/ strained bowel movements. Her medications include atorvastatin, risedronate sodium, a daily multivitamin, calcium, vitamin D, and aspirin.

Her examination reveals no bruising elsewhere and no findings of interest on skin or mucous membranes.

B. Allergic contact dermatitis, purpuric type

Eyelid bruising was observed on a 64-year-old woman during routine skin cancer follow-up. She denied trauma or pain. What does this look like to you? 

Image IQ: Recurrent Eyelid Purpura 

A 3-year-old boy is seen for unilateral swelling on the left side of the face, in front of and behind the left ear. Findings on examination of ears, oral cavity, and teeth are normal. He is afebrile (temp, 37°C [98.6°F]), cooperative, and in no distress. He is otherwise healthy. Past medical history includes 1 MMR vaccination.

The child is bright and alert and has no fever. The swelling is on the left side of the face only. Find other clues to a diagnosis in the accompanying video.  

3-Year-Old Boy With Unilateral Facial Swelling 

This 13-year-old boy presents with hyperpigmented skin on his neck. He is 66.75 inches and weighs 232 pounds.

This 13-year-old boy presents with hyperpigmented skin on his neck. He is 66.75 inches and weighs 232 pounds. Your suspicion?

13-year-old With Hyperpigmented Rash

Acromegaly was diagnosed in a 36-year-old woman who presented with loss of vision in the right eye that had initially involved the peripheral field. MRI scans of the brain revealed a 6 × 6 × 4-cm sellar mass with suprasellar and parasellar extension encasing the right cavernous sinus and carotid artery.

A. Excess growth hormone production from the pituitary gland as a result of a functional adenoma is the most common cause.

B. It remains undiagnosed for up to 10 years on average.

C. The diagnostic test of choice is an oral glucose tolerance test.

D. End-organ manifestations (eg, arthropathy, cranial nerve palsies, diabetes) contribute to overall mortality increase.

Acromegaly was diagnosed in a 36-year-old woman who presented with loss of vision in the right eye that had initially involved the peripheral field. Which statement about acromegaly is NOT true?

Acromegaly: A Pop Quiz

Sue Peschin, MHS

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