Skin Diseases

A 63-year-old woman who was on long-term hemodialysis because of diabetic end-stage renal disease had a 7-month history of waxing and waning papules and plaques on the front of both legs. The asymptomatic multiple, discrete, slightly erythematous, round to oval lesions ranged from 5 mm to 3 × 4 cm. Several had heaped-up borders and contained central crust and keratotic debris; others were superficial ulcers with central eschars. The lesions improved only slightly following twice-daily application of a superpotent topical corticosteroid preparation.

Concerned about their son's progressive hair loss during the last 6 months, his parents brought the 2-year-old into the office. The clinical appearance of hair loss extending in a band configuration around the temporal-occipital scalp margin confirmed the diagnosis of ophiasis.

A 55-year-old-man complained of joint stiffness and red, mildly tender plaques on his fingers. He had recently sustained a trauma to the hand while at his job as a fish handler. The condition was diagnosed as erysipeloid-a skin infection caused by the gram-positive bacillus Erysipelothrix rhusiopathiae.

A 41-year-old man presented with a 3-month history of itchy, scaly feet and right hand. The left hand was unaffected.

The nasal cellulitis that affects this 39-year-old woman began as right intranasal folliculitis. Because the patient was sensitive to many antibiotics, oral ciprofloxacin was prescribed.

Abnormalities of the hair shaft, whether traumatic or acquired, may result in hair breakage (which gives the appearance of failure of the hair to grow) and hair loss. Trichorrhexis nodosa-traumatic fractures of hair shaft-may result from UV exposure, permanent wave procedures, coloring of the hair, or the use of hot combs. The condition may also be congenital. The hairs have a broken, “flyaway” appearance, and characteristic grayish white nodules on the hair shaft can be seen with the naked eye.

This is a multisystem disorder characterized by oral and genital aphthae. Other symptoms include a myriad of cutaneous findings; variable systemic features include uveitis, synovitis, meningoencephalitis, and large- and smaller-vessel vascular disease.

A minute, nonpigmented, innocuous-appearing papule on the nose of a 60-year-old man did not seem cause for alarm. However, a simple, 3-mm punch biopsy saved this patient's life.

During the last 3 months, scars had developed on the sternal area of a 25-year-old black woman. She recalls having punctured an acne pustule at the site just before the scar began to develop.

Periorbital, forehead, and nasal erythema, crusting, and pain typical of herpes zoster affected a 90-year-old woman. Reactivation of the latent varicella zoster is more common in the elderly and is attributed to impaired immunologic mechanisms.

A 6-year-old girl was evaluated in the emergency department for a leg rash that had spread to the buttocks. The lesions first appeared earlier in the day and worsened hourly. The child's mother reported that her daughter was in good health until a low-grade fever, nonproductive cough, sore throat, and headache developed 5 days earlier. The youngster also complained of neck pain with movement.

A 49-year-old farmer was hospitalized because of a 3-week history of intermittent fever, fatigue, anorexia, generalized myalgias, and malodorous sweating. A nonpruritic, nonhemorrhagic, maculopapular rash recently had developed on his arms, legs, and trunk. The reddish lesions were less than 1 cm in diameter. There was no history of antibiotic or antipyretic drug therapy, and no abnormalities were found on physical examination.

The 83-year-old woman whose hands are shown in photograph A had a severe flare of arthritis in the metacarpophalangeal and proximal interphalangeal (PIP) joints after corticosteroid therapy for her asthma was stopped. The clue to the diagnosis of psoriatic arthritis is in her fingernails, which show both pitting and onycholysis.

Ten days before presenting for evaluation, a 69-year-old man began to experience neuralgic pain and noticed the eruption of painful erythematous macules and papules on the right side of his chest. Within 24 to 72 hours, vesicles and pustules arose at the site. One week after onset, several of the lesions dried and crusted.

A 35-year-old HIV-positive man had a thick, black, otherwise asymptomatic patch on the top of his tongue. He did not have diabetes.

The painless lump on this 30-year-old woman's lip is a mucous cyst, or mucocele-the result of mucus retention within a salivary gland due to trauma or obstruction of a duct. This asymptomatic, dome-shaped, translucent, blue-white cyst is usually located on the inner surface of the lower lip or on the floor of the mouth.

A 6-year-old girl presented with a huge ulcer on her right heel, seen here, that began as a minor laceration when she stepped on a rock several months earlier. On the left heel, there was a similar lesion in the process of healing that had also followed a minor injury. Her feet and hands were dry and hyperkeratotic.

The parents of a 3-year-old girl sought evaluation of their daughter's hair loss. During the past several months, a large patch of alopecia with scaling had developed. The differential diagnosis included seborrhea, trichotillomania, and tinea capitis.

This young boy complained of itchy lesions after he spent a day in a semiwooded area. The lesions appear urticarial, but note that the pattern of eruption is over areas of constrictive clothing: the arm of a shirt and the belt.

A 3-month-old female infant presented with a mass in the umbilical area. During the neonatal period, an infection of the umbilical cord had resulted in the formation of exuberant granulation tissue at the base of the umbilicus.

The parents of a 6-year-old boy with a generalized rash sought medical care for the child. The outbreak began 2 years earlier on the boy's abdomen and spread over the entire body; oral antihistamines had been prescribed for the itching. The patient had no history of allergy, insect bite, fever, or GI symptoms. His vital signs were normal.

The whitish lesions on the nose and chin of this neonate are milia-tiny keratinous inclusion cysts that occur mainly on and around the nose.

A 35-year-old dental assistant sought treatment of an itchy, painful rash on her hand that had erupted 5 days earlier.

A 78-year-old man presented with an asymptomatic, irregular lesion on the right side of the glans penis. The 0.5-cm, light purple injected, finely papular lesion had spontaneously erupted about 2 months earlier.

The onset of atopic dermatitis can be seen in infants who have a family history of inhalant allergies, (eg, seasonal allergy, allergic rhinitis, or allergy-induced asthma). The cheeks and large flexural folds of affected children are erythematous and scaly. Involved areas of the trunk and extremities may exhibit discrete patches or a generalized rash.

When this lesion was seen on the face of a 54-year-old farm worker, cutaneous melanoma was the immediate concern. Accordingly, a full-thickness excisional biopsy was performed. (Curettage and shave biopsy are contraindicated for a suspected melanoma.)

Many disorders that scar the skin also affect the scalp. Systemic lupus erythematosus, when associated with high fever and extensive systemic involvement, can cause a diffuse anagen effluvium. Hair loss caused by localized discoid lupus erythematosus (DLE) is more common. DLE may affect the scalp, where it is seen as circumscribed areas of often irreversible hair loss.

Numerous plaques, some with yellow crusting and central scarring, had erupted primarily on the face and neck of a 46-year-old man. A single lesion had developed on his left elbow as well. The lesions were initially diagnosed as impetigo, but they failed to resolve after 2 courses of oral cephalexin.

Disturbed by a pruritic rash of 5 days' duration on his chest, neck, and back, a 35-year-old man sought medical advice. The patient had no other symptoms.

For years, a 39-year-old man had an eruption on his hand, which seemed to be controlled with topical corticosteroids. The patient was a rancher.