Skin Diseases

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, andtinea capitis.

A new lesion recently arose on the right flexor forearm ofa 67-year-old man. The 1-cm, pruritic, pink, circular, slightlyraised lesion was perfectly homogeneous with no centralclearing.

A 49-year-old man was concerned about a right flexor forearmlesion that had been increasing in size for 6 weeks.The light pink, well-demarcated, 5-cm, circular lesion featuredslight peripheral elevation with ulceration, crusting,and a relatively clear central area. A culture of materialfrom the lesion was negative for fungi. A potassium hydroxideevaluation was not performed.

A 56-year-old man had an asymmetric,maculopapular, sharply demarcated,pruritic, excoriated dermatitis on hisupper thighs. The eruption had beenpresent for 2 to 3 weeks

For about 4 months, a very dry, diffuse,fine scaly, asymptomatic eruptioncovered the palms of a 28-yearoldman; several fingernails weredystrophic bilaterally as well. Beforethe onset of this condition, bilateralonychomycosis of the toenails hadbeen diagnosed. The toenails had notbeen treated and were still affectedat the time of presentation. Branchinghyphae were seen on a potassiumhydroxide preparation of a fingernailcutting. The patient had tinea manuumand tinea unguium

A methodical approach to diagnosis usually reveals the cause of fever. In patients with simple fever, a careful history taking and physical examination combined with basic laboratory and imaging studies (complete blood cell count with differential, urinalysis, and possibly a chest film and blood cultures) usually yield the diagnosis. In patients with prolonged fever whose cause remains undiagnosed after extensive examination (fever of unknown origin), repeat the history taking and physical examination; also order routine laboratory studies, an HIV test, a tuberculin skin test, 3 sets of blood cultures, and chest films. In addition, abdominal CT scanning is often useful. Further testing at this point may include fluorodeoxyglucose positron emission tomography, technetium-tagged white blood cell scanning, transesophageal echocardiography, liver biopsy, bone marrow examination, and/or temporal artery biopsy. Exploratory laparotomy is rarely indicated.

Tinea infections can be diag- nosed by potassium hydroxide (KOH) examination, which reveals fungal elements when a preparation of scale from a lesion-particularly the active border-is studied under a microscope; culture; and histopathologic examination of a skin biopsy specimen or nail clippings with periodic acid–Schiff stain. Culture may be warranted when a fungal infection is strongly suspected despite a negative KOH result. Unfortunately, dermatophyte cultures can take from 4 to 6 weeks to become positive; therefore, treatment decisions may have to be made before culture findings are reported. A topical antifungal is the initial therapy for tinea cruris, tinea corporis, tinea pedis, and tinea manuum. Tinea capitis, extensive tinea corporis, and tinea unguium are best treated initially with oral antifungal agents, because these infections usually do not respond to topical therapy.

A 13-year-old girl of African American descent is brought to the pediatrician’s office becauseof a lesion on her neck. The girl’s mother had telephoned the office before the visit, statingthat the lesion resembled a blister at first, but now looked like a burn.

Vague abdominal pain, malaise, anorexia,and the loss of 10 lb in 2months prompted a 65-year-old manto seek medical evaluation. A yearearlier he had undergone surgery forstage III carcinoma of the sigmoidcolon. Because metastases to thelymph nodes were found in the resectedcolon, the patient was given postoperativechemotherapy. Histologicexamination revealed poorly differentiatedadenocarcinoma.

An 85-year-old man was admitted to the hospital with acough and shortness of breath of 1 week’s duration anda fever and increased sputum production for 2 days. Hishistory included renal cell carcinoma and metastatic renalcancer for 2 years. The patient had smoked cigarettesfor 30 years. He had lost 30 lb during the last few months.A chest film revealed pneumonia of the right lowerlobe. Metastatic nodules were noted on the scalp; extensivelung, bone, and brain metastases also were found.

A 40-year-old man was concerned about an enlarging painlessmass on the right side of his neck that had been presentfor 6 months (A). The patient reported no other healthproblems; his medical history was unremarkable, and hewas taking no medications.There was no family or personal history of thyroiddisease or of exposure to radiation. Thyroid function testresults were within normal limits. A chest film revealed nopathology.

Signs and symptoms that strongly suggest peripheral arterial occlusive disease include diminished or absent pedal pulses, a unilaterally cool limb, and atrophic skin that is shiny and hairless. An ankle-brachial index of less than 0.5 suggests multisegment disease. Management goals are to decrease functional impairment, treat underlying atherosclerosis, and control risk factors. Smoking cessation is imperative. A graduated walking program is a mainstay of treatment and is associated with greater improvement in pain-free walking than is drug therapy. Surgery and percutaneous intervention are generally reserved for patients with lifestyle-limiting claudication, ischemic pain at rest, tissue loss, or gangrene.

Several times a year a rash erupts on the chest, axillae, and neck of a 41-year-old woman. Her father and siblings have a similar history. A biopsy of the affected skin confirmed the suspected diagnosis of benign familial pemphigus, which is also called Hailey-Hailey disease.

Diffuse petechiae suddenly arose on the back and abdomen of a 79-year-old woman. Within several days, the asymptomatic lesions covered her arms and face as well.

A 40-year-old woman who said she had asthma was admitted to the hospital with worsening dyspnea and cough. A β-adrenergic agent was her only medication. The patient denied cigarette smoking and alcohol consumption. Except for an appendectomy 20 years earlier, her medical history was unremarkable. The patient was afebrile.

A 79-year-old man was brought to the emergency department with mental status changes. A CT scan revealed a lacunar infarct. Numerous asymptomatic nodules had been present for many years on the patient’s scalp and forehead.

For 2 years, a slightly pruritic, light brown, scaly rash had been present on a 20-year-old man’s neck. During the past 8 months, the eruption spread to the upper chest and upper arms. The patient reported that the rash changes color with the seasons. Multiple round to oval, hypopigmented, slightly scaly macules were noted on the neck, chest, and upper arms. Tinea versicolor was strongly suspected.

For 3 years, a linear plaque had been slowly developing on the left palm of a 47-year-old woman who had difficulty in opening and closing her hand. There was no contributory family history.

The 2-mm, white, very slightly raised lesion on the vermilion of a 37-year-oldman’s lower lip had been present for 2 months. The lesion was asymptomatic.There was no history of injury or burn to the area.

An uncircumcised 58-yearold man presented with a persistent “rash” on his penis of 5 years’ duration. He complained of localized irritation with coitus. Over-the-counter ointments and corticosteroid preparations had failed to clear the eruption. The patient had hypertension, hyperlipidemia, and coronary artery disease. He had been monogamous for the last decade and denied any risk factors for sexually transmitted diseases.

A 34-year-old woman (gravida 3, para 2) presented at 28 weeks’ gestation with a 3-week history of a pruritic rash that had progressively worsened. Multiple vesicles and bullae were noted; erosions and crusts on older lesions were also present. The patient had had no prodromal symptoms; she denied fever, chills, nausea, and vomiting. The purplish hue on her body resulted from application of the topical antibacterial agent, gentian violet, which the patient had obtained in Mexico.

A 38-year-old man was concerned that the small lesions on his lips were flatwarts. A biopsy identified Fordyce, or sebaceous, glands of the lips.

The soft “bubble” on the mucosal surface of a 42-year-oldman’s lower lip had developed, disappeared for 3 months,and returned. The lesion caused no pain or discomfort.

A 78-year-old man with a history of asthma, coronary artery disease, chronic obstructive pulmonary disease (COPD), and recently diagnosed prostate cancer was admitted to the medical ICU with exacerbation of COPD. The obtunded patient was unable to provide a history. A 4 × 6-cm firm nodule of unknown duration was noted over the right upper quadrant of the patient’s abdomen. There were no other cutaneous lesions.

A 38-year-old African American man presented with a 10-year history of a solitary “wart” that had not responded to over-the-counter acid treatments. No other lesions were noted on the patient. Based on the clinical appearance, punctate porokeratosis was diagnosed.

A 1-year history of “dents” on her body prompted a 40-year-old African American woman to seek medical evaluation. Her medical history was unremarkable; however, there was a strong family history of severe type 2 diabetes mellitus. The patient denied having received or having self-administered injections into the affected areas. She reported no history of deep, tender nodules at the sites.

Intense pruritus centered around a sparse “rash” sent a 32-year-old Chinese man for medical evaluation. The patient’s medical and social histories were unremarkable.

A 62-year-old obese woman with adult-onset type 1 diabetes mellitus had a 6-year history of bilateral leg edema. During the last year, the edema worsened and the skin on her legs thickened. She also had multiple, bilateral, painful, superficial ulcers that drained copiously.

A 12-year-old African American girl comes to youroffice for a well-child checkup. She is tall for herage (height above the 95th percentile) and obese(body mass index [BMI] above the 95th percentile).Physical examination reveals acanthosisnigricans on her neck, axilla, and upper abdominalregion (Figure) and a vaginal yeast infection.Routine urinalysis reveals a glucose level ofgreater than 1000 mg/dL, with negative proteinand ketones. A random blood glucose test, obtainedbecause of the glucosuria, is 249 mg/dL.

A slightly pruritic, red, scaly rash on an 8-year-old boy’shands has been progressively worsening since it appeared4 months earlier. Nail pitting also was noted. There are noother rashes on his body. The patient is active in sports;denies any new exposure to soaps, clothing, or other contactants;and spends time in the homes of his recently divorcedparents.