Granuloma Annulare and Contact Dermatitis From Topical Corticosteroid

Figure 1

Figure 2

For several months, a 59-year-oldwoman has had numerous asymptomaticlesions on her arms andlegs. During this period, she has notbeen exposed to the sun and hastaken no new medications.

What does this look like to you?
A. Granuloma annulare.
B. Subacute lupus erythematosus.
C. Tinea corporis.
D. Psoriasis.
E. Erythema annulare centrifugum.

Figure 1

Figure 2

Case 1: The patient has granulomaannulare, A, a condition that hasno known cause. The rash persistsfor months or years before spontaneouslyinvoluting, and it is refractoryto most treatments. Subacutelupus erythematosus, tinea corporis,and psoriasis all present with scaleand are usually pruritic. Erythemaannulare centrifugum manifests withtrailing scale.

After 2 weeks of scratching an itchy rash on his foot, a 16-year-old boy requestedmedical treatment. He had been using an over-the-counter hydrocortisonecream for 10 days to treat juvenile plantar dermatosis, but the preparationfailed to cure the rash-and, in fact, it appears to have made it worse.

You would:
A. Tell the patient to stop using the hydrocortisone cream.
B. Perform a bacterial culture and prescribe oral antibiotics.
C. Perform a potassium hydroxide evaluation.
D. Prescribe a different topical corticosteroid.
E. Perform a skin biopsy.

Case 2: Topical corticosteroids, as well as the other components that make up the vehicle,have been reported to induce contact dermatitis. The patient was told to stop using the over the-counter preparation, A, and to try a different, prescribed topical corticosteroid in a hypoallergenicbase, D; the rash resolved quickly.

A 43-year-old woman has been bothered by an enlarging, painful plaque for2 weeks. Treatment with cephalexin and amoxicillin-potassium clavulanatewas unsuccessful. The patient also reports mild joint aches and low-gradefever. Her white blood cell count is somewhat elevated, with a slight leftshift.

What do you suspect-and how will you confirm the diagnosis?
A. Methicillin-resistant Staphylococcus aureus infection.
B. Deep fungal cellulitis.
C. Atypical mycobacterial infection.
D. Sweet syndrome.
E. Leukemia cutis.

Case 3: A biopsy confirmed the diagnosisof Sweet syndrome, D. Inmost patients, the eruption appearsfollowing an upper respiratory tractinfection; however, in about 10%, thecondition heralds a hematologic malignancy,such as leukemia or lymphoma.Less commonly, Sweet syndromeis associated with oral contraceptiveuse or pregnancy. Effectivetreatments include prednisone,colchicine, dapsone, and NSAIDs.The lack of response to antibioticsrules out a typical cellulitisbut not a methicillin-resistantStaphylococcus aureus or an atypicalmycobacterial infection. A biopsy isnecessary to confirm the other diagnosesin the differential.

For several years, a 43-year-old woman has noticed a slowly increasingnumber of discrete, asymptomatic papules around her eyelids.

Can you identify these lesions?
A. Sebaceous hyperplasia.
B. Milia.
C. Syringomas.
D. Seborrheic keratoses.
E.Warts.

Case 4: The papules are syringomas,C, benign sweat gland tumors thatare generally confined to the eyelids.Typically, lesions first appear duringthe third or fourth decade and slowlybecome more numerous, as in the63-year-old patient shown here. Theyhave no malignant potential and maybe removed surgically for cosmeticreasons.

The lesions of sebaceous hyperplasiaare yellowish papules arounda central punctum. Milia are discretewhite papules that appear as small,closed comedones. Seborrheic keratoseshave patulous follicles and,like warts, a characteristic verrucousappearance.