Dermatology

A 74-year-old man with a history of diabetes mellitus, atrial fibrillation, and stroke had a stable, skin-colored mass on his upper back for the past 10 years that had suddenly become swollen and red.

During a skin cancer screening, a 45-year-old male soldier was noted to have bilateral subcutaneous nodules on the dorsa of his feet. The patient reported that the nodules had remained unchanged since they first appeared in his early 20s and were asymptomatic. He had no other lesions.

Physical changes that occur in aging skin (eg, dryness and thinning) can result in pruritus and cause patients to rub, scratch, and pick at their skin. These activities produce various dermatoses and reactive changes in the skin, such as postinflammatory pigmentary alteration. Lichen simplex chronicus (LSC) develops as a physiological cutaneous response to repetitive scratching or rubbing. First-line treatment consists of topical corticosteroids and application of ice to reduce the sensation of itching. Like LSC, prurigo nodularis results from rubbing and scratching the skin. Treatment is similar; however, intralesional corticosteroids and UV therapy play more of a role because prurigo nodularis is more intensely pruritic than LSC.

A hand mirror can aid in the examination of the legs and feet of a seated patient, such as one in a wheelchair. Use of a mirror obviates the need to “stand on your head” to visualize the soles, heels, and back of the legs. In addition, patients can be taught to use a mirror to examine their own feet and legs for skin breakdown or other pathological changes that herald potentially serious problems.

A 51-year-old man is seen because of a painful groin rash. Has not cleared despite 3 months’ topical corticosteroids and antifungals.

This rash on the face and neck of a 27-year-old man appeared periodically over a 2-month period. During this time, the patient’s work involved welding inside a steel oil tank. This photo was taken immediately after the patient had stopped working. He had no accompanying fever or respiratory symptoms. The urticaria was pruritic and resolved the following morning.

Having a magnifying mirror availablein each examination roommakes it easier for both patients andphysicians to identify facial lesions.

A 79-year-old man admitted for mental status changes, with neuroimaging that reveals lacunar brain infarct.

To avoid causing any exacerbation of a skin tear or similar wound when changing a self-adherent soft silicone foam dressing, I drawn an arrow on the dressing over the spot where the skin edges meet, running perpendicular to the skin flap. This minimizes the risk of recurrent trauma from raising the skin flap during dressing changes.

This dark maroon, cystic, dome-shaped, 8-mm lesion on a 75-year-old man’s back had been present for 2 years. It would occasionally bleed after minor trauma, such as when the patient dried his back with a bath towel. He had no history of skin cancer.

Case 4: An obese 59-year-old man presents with a chronic malodorous, itchy rash in his groin.

For a few months, a 27-year-old man has had an itchy rash in the groin area. He tried an over-the-counter “jock itch” remedy, but it was not effective. He is otherwise healthy.Which of the following would you include in the differential diagnosis?

A 28-year-old man presents for evaluation of a nonresolving rash in his groin. The rash has persisted despite the patient’s use of over-the-counter antifungal creams. What do you suspect?

In his Practical Pointer, “Take a Crack at Healing Fingertip Fissures” (CONSULTANT, March 2009, page 185), Ron Passeri, MD, recommended having patients try a several nights’ regimen of applying petroleum jelly to fingertip cracks and then covering this with 2 layers of adhesive bandages applied with a bit of tension. In response, 2 readers suggested strategies of their own. These appear below, along with Dr Passeri’s reply.

Scabies is often seen in axillary folds and the periumbilical area; severe nocturnal itching is a hallmark.

To ensure accurate joint injections, mark the site by firmly pressing the end of a closed ballpoint pen against the patient's skin.

For several months, a 43-yearold woman had erythematous plaques on the cheeks that were more prominent on the right side. The patient had no pruritus but reported occasional facial burning. She had tried overthe- counter lotions but no medicated or corticosteroid topical preparations. She was otherwise healthy and was currently taking no medications.

This abdominal rash developed while a 63-year-old woman was traveling in Israel. She was admitted to the hospital, where she received intravenous antibiotics, and was discharged after 5 days. She now returns to the United States and wonders what she had, because she did not understand what the physician in Israel had told her. She has brought all of her medical records.

For 10 days, a 42-year-old woman has had this asymptomatic eruption on her trunk and proximal extremities. She is otherwise healthy.

A 63-year-old woman presents with a tender nodule of 10 days’ duration on the dorsum of her right hand. She does not remember any specific injury, but she does do her own housework. Another physician prescribed doxycycline, 100 mg bid; however, the nodule has persisted. You order a bacterial culture.

For 1 week, a 28-year-old man has had this tender, spreading rash on his chin. He is otherwise healthy. What does this look like to you?

A 72-year-old woman came to the emergency department with a tender, swollen left leg.

Several weeks earlier these slightly tender nodules erupted on the arms and legs of a 75-year-old woman with extensive sun damage.

An 80-year-old man presents for evaluation of highly pruritic blisters on the sides of his hands.

This rash on a 60-year-old man’s nose has worsened over the past few months.