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1rem

Authors

When should buried stitches be used in closing a laceration? Which tools are best for removing a popcorn kernel lodged in a 2-year-old's nose? How do you determine the appropriate site for a shoulder injection? These are just some of the questions that will be answered in our new feature, "Primary Care Procedures: A Photo Guide," which launches in this issue on page 1035.

Introducing a New CONSULTANT Series    "Primary Care Procedures: A Photo Guide"

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 78-year-old man had a rash for 5 days and dyspnea for 2-weeks; he also had a cough with white sputum and occasional fever without chills. He had hypertension, T2 diabetes, and mantle cell lymphoma after splenectomy. He started taking vancomycin and piperacillin/tazobactam 3 weeks earlier for osteomyelitis.

B. Drug-induced hypersensitivity syndrome

This man had been taking vancomycin and piperacillin/tazobactam for 3 weeks for osteomyelitis. What does the rash look like to you?

Rash in an Immunocompromised Man: Your Dx?

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 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?


An 11-year-old boy presents with a rash of tear-drop shaped scales spread symmetrically on his trunk and proximal extremities. The scale is adherent and attempts to scrape the lesions result in punctate bleeding. Other than a case of strep throat last week for which he was treated with antibiotics, he is otherwise in good health.

An 11-year-old boy breaks out quite suddenly with a rash of papulosquamous lesions with a silvery scale. Can you Dx? 

A Scaly Rash 

Susan Beck

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