Dermatology

An 82-year-old man is seen for annual physical examination in the nursing home. He has resided there for 1 year because of the aggregate impact of multiple medical problems including, most prominently, laryngeal swallowing dysfunction associated with vocal cord paralysis.

Tinea corporis appears as an annular plaque with a rim of scaly erythema.

Tinea that occurs on the hands is referred to as tinea manuum.

Maceration or scale between isolated web spaces of the fingers suggests erosio interdigitalis blastomycetica (interdigital candidiasis). It most often occurs in the web space between the middle and ring fingers; sometimes the toes are affected. Erosio can spread and can be painful.

A fungal folliculitis (Majocchi granulomas) can occur if a superficial fungal infection is treated with topical corticosteroids. Fungal folliculitis is best treated with a short course of oral itraconazole or fluconazole.

Candidal infection can also occur at the lateral angles of the mouth; it causes erosions and breakdown of the skin. Angular cheilitis, or perleche, resembles the relationship between intertriginous candidiasis and intertrigo in that it is part infection and part inflammatory response to the impairment of epidermal integrity.

Tinea that occurs on the hands is referred to as tinea manuum. For unknown reasons, tinea often affects two feet and one hand. Tinea manuum must be distinguished from allergic contact dermatitis of the hands, which it resembles; this can be done by examination of a potassium hydroxide preparation. Tinea manuum can be treated with a topical antifungal agent.

This infection is usually caused by Candida albicans, whichis often present in body folds. Candidiasis is common in persons with diabetes and in obese persons. Other predisposing factors are the use of antibiotics, topical corticosteroids, or immunosuppressive drugs; poor nutrition; and immunosuppression.

Tinea pedis, or athlete's foot, is common in elderly persons. It manifests as maceration in the interdigital web folds and as scaly plaques on the plantar surfaces of the feet. A potassium hydroxide evaluation can establish the diagnosis. Tinea pedis is commonly associated with xerosis. It is best treated with a topical antifungal agent; treatment can be aided by a keratolytic such as lactic acid 12% cream.

Oral candidiasis, or thrush, is not uncommon in elderly persons. It can be related to poor dentition or immunosuppression, particularly as a result of oral corticosteroid use.

Tinea corporis occurs most often on the torso of elderly persons. It commonly appears as an annular plaque with a rim of scaly erythema. Occasionally, tinea corporis manifests with polycyclic annuli or with nummular plaques, which mimic nummular dermatitis. The examination of a potassium hydroxide preparation can establish the diagnosis. Tinea corporis can be treated effectively with a topical antifungal agent.

The prevalence of onychomycosis increases with age; it is less than 1% in persons younger than 19 years and rises to about 18% in those who are 60 to 79 years. The infection is more common in men than in women. Among the predisposing factors are diabetes mellitus, psoriasis, a family history of onychomycosis, use of immunosuppressive drugs, and peripheral vascular disease.

What is the most likely cause of these painful plantar ulcers? Can youidentify this well-demarcated rash that arose at the site of vein grafting?

While scuba diving in the Philippines, a healthy 36-year-old man noticed a red rash on his wrists and dorsa of both hands after he surfaced from a dive. Within a couple of hours, the rash had become painful, swollen, itchy, and papular.

A 77-year-old African American man with type 2 diabetes mellitus and coronary artery disease presented to the emergency department with acute scrotal swelling and pain. His testicles were erythematous with focal areas of necrosis and associated tissue destruction. Similar skin changes were apparent in the lower abdominal and inguinal regions.

ABSTRACT: Prevention of skin cancer requires photoprotection (eg, the use of a sunscreen with both UVB and UVA protection) and regular monitoring of the skin for suspicious lesions. Encourage patients to examine all areas of their skin, including the interdigital and genital regions, for unusual macules, papules, and nodules. Teach patients the "ABCDE" warning signs of melanoma (asymmetry, border irregularity, color variegation, diameter greater than 0.5 cm, evolving lesion). Office skin examinations are recommended for patients with risk factors for skin cancer and for those with obvious sun damage. Correct lighting, preferably daylight, and cross-illumination are crucial. Palpation may be helpful in detecting lesions such as actinic keratoses, which have a gritty, sandpaper-like surface.

or several years, a 71-year-old man has had a pruritic eruption on both legs that occurs every winter and resolves in the spring. He is scheduled to undergo knee surgery, but the surgeon will not perform the operation until the rash has cleared. The patient has not used a new soap or changed his bathing habits recently.

Frightened but lucid man who appears stated age. Vital signs are normal. No mass palpable in abdomen, though there is a faint suggestion of upper-abdominal distension. No supraclavicular lymphadenopathy, umbilical nodules, or upper-abdominal vascular bruit.

A medium-sized brown pigmented lesion had been present on the right temple of a 61-year-old man since birth. The patient complained that during the last several months the lesion had formed a fine scale and begun to itch. Actinic keratoses and inclusion cysts were also noted on his face.

Topical corticosteroids remain the mainstay of treatment, especially in patients with erythematous, acutely inflamed psoriatic plaques. The topical immunomodulators tacrolimus and pimecrolimus are used to treat psoriasis, although neither has FDA approval for this indication. Unlike corticosteroids, immunomodulators do not cause skin atrophy, irreversible striae, acne, or tachyphylaxis. Newer topical vehicles of delivery (eg, foam clobetasol propionate) and newer drug combinations (eg, once-daily calcipotriene/betamethasone dipropionate ointment) may improve efficacy and reduce side effects. Reserve systemic therapy for patients with moderate to severe psoriasis. Until more long-term safety data become available, be cautious about prescribing biologic agents for patients at risk for infection (particularly tuberculosis) and malignancy.

A 60-year-old man was hospitalized with fever and hypotension secondary to recurrent cellulitis of the left leg. He had a history of polysubstance abuse and hepatitis C. Elephantiasis nostras verrucosa was diagnosed based on bilateral nonpitting edema and hyperkeratotic verrucous lesions in the pretibial area. The patient's erythrocyte sedimentation rate and white blood cell count showed evidence of infection; osteomyelitis of the left fifth metatarsal head was suspected.

A 13-year-old girl noticed that the skin around a "mole" on her abdomen had gradually changed color. This patient was told that she had a halo nevus--a pigmented (nevocellular) nevus surrounded by a tight ring of depigmentation--which is benign and usually regresses spontaneously over time.

A middle-aged man hospitalized for intensive pulmonary toilet and topical and systemic treatment of a refractory skin disorder. Cough and moderate dyspnea with even mild exertion. Complains of scaling, uncomfortable dermopathy that he finds deeply cosmetically disfiguring and emotionally distressing.

A 65-year-old woman seeks evaluation of a tender, pruritic patchy rash on the trunk and extremities, as well as tender lips. Her symptoms began after she started taking a new NSAID for osteoarthritis. She has no known drug allergies and has not changed any other medications. The photographs were taken 2 days apart.

Since his twenties, a 71-year-old man had had multiple tiny, pinhead, whitish yellow papules on his palms. They were asymptomatic but made his skin feel like sandpaper. Other members of his family had similar lesions.

A 34-year-old woman who was coinfected with HIV and hepatitis C virus complained of acute abdominal pain and generalized pruritus of 3 weeks' duration. She was noncompliant with her antiretroviral medications.

A linear, severely pruritic rash erupted on the lateral and plantar aspectsof the left foot (A) of a 72-year-old woman who had recently been campingon a Caribbean beach. Antihistamines and locally applied antifungal agentsoffered no relief.

Loss of pigmentation was noted around the left eyeof a 49-year-old man-the same eye in which hehad a detached retina. In addition, the patient'shearing was impaired on that side. These findingswere consistent with the diagnosis of Alezzandrinisyndrome, the major manifestations of which includeunilateral degenerative retinitis, ipsilateral facial vitiligo,poliosis of the eyebrows and eyelashes, and ipsilateralhearing deficits.

ABSTRACT: A 4-pronged approach that includes patient education, skin and nail care, appropriate footwear, and proactive surgeries can effectively prevent diabetic foot problems. Teach patients with diabetes to examine their feet daily to detect new onset of redness, swelling, breaks in the integrity of the skin, blisters, calluses, and macerated areas. Have them follow a daily foot care regimen that includes warm water soaks and lubrication, and have them keep toenails properly trimmed. Recommend that patients select shoes that fit properly and have sufficient padding and toe box space; have them use inserts, lifts, orthoses, or braces--as recommended-to correct abnormal gait patterns. Finally, if deformities develop, simple proactive surgical procedures can correct these problems before they result in the development of wounds.

This polymicrobial infection, characterized by rapidly advancing deep tissue necrosis, is caused by Gram-positive and Gram-negative bacteria and anaerobes such as Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa.