Dermatology

Three years ago, my patient sustained a burn from a hot greasespill. Biopsy has shown that the nubby areas (Figure)are live skin; however, I am unsure of how to treat thewound.

Use this ABCDE mnemonic to distinguishnecrotizing fasciitis, which usuallyrequires surgery, from cellulitis,which can be treated with antibioticsalone:

A 38-year-old overweight woman presents with an asymptomatic rash ofat least 2 months’ duration that had not responded to a combinationcorticosteroid/antifungal agent. She has mild hypertension and type 2 diabetesmellitus that is being managed with diet and exercise. She is otherwisehealthy.

A 7-year-old girl presents for evaluation of a pink, polypoid, 2 x 2-mm lesionon her inner lower lip, which has been present for several weeks. The child isasymptomatic and denies any trauma to the mouth.

My patient is a woman in her midtwentieswho recently presented with anerythematous, slightly pruritic lesionon her thigh.

Suturing the circular wound that resultsfrom a punch biopsy can bedifficult.

I enjoyed the article by Kenneth H. Fye, MD, "Rheumatic Disease: How to Use theLab in the Workup" (CONSULTANT, March 2004, page 369). However, I foundthe following statement to be misleading: "Anti-SS-A and anti-SS-B determinationsare necessary to rule out Sjgren syndrome in patients with sicca complaints."If the results of these tests are negative, but Sjgren syndrome was initiallysuspected based on the history, labial biopsy is required. Many persons with thisdisease have negative antibody test results.Unfortunately, it often takes years before Sjgren syndrome is correctly diagnosedin most patients. This is usually because a health care provider rules it outbased on negative results of anti-SS-A and anti-SS-B tests.---- Paula Hochberg, ARNPSarasota, FlaYou are correct that negative results of tests foranti-SS-A and anti-SS-B antibodies do not ruleout Sjgren syndrome. Although the majorityof patients with this syndrome have these antibodies,a significant minority do not. If, in thislatter group of patients, Sjgren syndrome is strongly suspectedon clinical grounds, a minor salivary gland biopsyshould be considered. Biopsy is the most specific andsensitive test for Sjgren syndrome. Although a biopsy isnot required to make the diagnosis in every patient, thereare clearly those with negative tests for anti-SS-A andanti-SS-B in whom a biopsy is necessary to confirm suspectedSjgren syndrome. Thus, my statement shouldhave read instead, "Positive anti-SS-A and anti-SS-B determinationssupport a diagnosis of Sjgren syndrome inpatients with sicca complaints."---- Kenneth H. Fye, MDClinical Professor of MedicineRheumatology DivisionUniversity of California, San Francisco,School of Medicine

An estimated 20million Americansare currentlyinfectedwith humanpapillomavirus (HPV). Assuch, HPV is now the mostprevalent sexually transmitteddisease (STD) in thiscountry. Answers to commonquestions like the onesabove are therefore of particularinterest to physicians.The issue of when and howto use testing for HPV hasbecome especially crucial.

A 73-year-old man is admittedto the hospital with pulmonary tuberculosis.A 3-drug fixed combination-isoniazid, rifampicin, and pyrazinamide-and ethambutol are given.Within an hour, a global urticarialrash erupts (A and B).

For nearly 3 years, my patient has had frequent recurrences (now, almost monthly)of erythematous, slightly pruritic lesions on the lower back, inguinal area, orbuttocks-but never on the genitalia.

A 53-year-old woman, who has a remote history of acne, says that facial rednessappears each time she has a migraine. Her migraine medication, fiorinalwith codeine, ameliorates the headache, but the erythema lingers for days.

A 47-year-old man has had a posterior neck mass for severalmonths. The mass is not painful and has not changed color, but it continues toenlarge.

A painful scalp eruption of 4 days’duration brings an 81-year-old man toyour office. He has taken a lipid-loweringagent and an antihypertensivefor years but has not started any newmedications recently. One week earlier,he had a haircut. He denies recenttrauma to the scalp.

A 9-year-old boy, who has no significantmedical history, presents with a generalizedpruritic eruption of 2 weeks’ duration.One week earlier, another practitionerruled out scabies and treatedhim presumptively for varicella.

Francisella tularensis is anonsporulating, nonmotile,aerobic gram-negative coccobacillusthat is usually transmittedto humans frominfected rabbits and other small animalsvia ticks, fleas, or deer flies orby direct contact

In his Photoclinic case of a man with a nevus verrucosus on his temple (CONSULTANT,April 15, 2003, page 637), Dr Robert Blereau notes that there were alsoother lesions on the patient’s face, including actinic keratoses and inclusion cysts.

Impetigo developed on the face of a 7-year-old boy who had chickenpox. Thepatient was given a 10-day course of oral cephalexin and mupirocin ointment;the infection resolved promptly.

For 2 days, a 35-year-old woman has had a tender eruption on the right palm.She takes no medications. The patient recalls that 1 or 2 years earlier a similarrash cleared following a course of antibiotics.

Ask patients with nonhealing colostomy wounds if theyare cleaning the area with hydrogen peroxide.

This 2 1/2-year-old boypresents for evaluation ofan asymptomatic, nonpruritic,nonblanchable rashthat is primarily confined tohis cheeks. There is someerythema on the extensorsurfaces of the proximalextremities. The motherreports that the child hadan upper respiratory illnessabout 3 days earlier, withcough and a slight fever.He took no medication forthat illness. Because thesymptoms were so mild,she had not brought thechild in for medical attention.The rash appearedafter the fever and coughresolved. The child isotherwise healthy and hetakes no medication.

This 40-year-old woman has had multiple lesions on her facefor several months. She also reports occasional fevers, slight weight loss, andintermittent fatigue.

For several months, a 26-year-old man has had persistent bumps on his scalpand the back of his neck. Some hair loss has also occurred at the site.

In recent years, the role of the immunesystem in the pathogenesis of psoriasishas been extensively delineated. Thisresearch has spawned a new classof medications that target specific immunefactors and hold great promiseas psoriasis therapies. The Table highlightsthe significant features of 4 ofthese biologic agents.

Smallpox, which is caused byinfection with poxvirus variola,may follow variouscourses. An erythematouseruption can precede theappearance of tense, deep-seatedpapules that rapidly transform intovesicles. The lesions may be sparseor so numerous that they becomeconfluent.

The emphasis in this clinically focused text is on syndromesand patient care rather than on pathogens. Among the topicscovered are antimicrobial pharmacokinetics and pharmacodynamics;head and neck infections; upper respiratory tractinfections; bronchitis and pneumonia; endocarditis; pericarditisand myocarditis; peritonitis, liver abscess, and biliary tractinfections; viral hepatitis; CNS infections; skin and soft tissueinfections; animal and human bites; osteomyelitis and infectiousarthritis; foot infections in patients with diabetes; scarletfever and toxic shock syndromes; fever of unknown origin;bacterial, viral, and protozoal diarrhea; obstetric-gynecologicinfections; urinary tract infections; sexually transmitted diseases;infectious complications of HIV infection; tuberculosis;tropical diseases; zoonoses; bioterrorism; and fungal infections.Color and black-and-white photographs, photomicrographs,CT scans, radiographs, drawings, tables, and flowchartshighlight seminal points in the text.