Skin Disorders: 5 Shots, 5 Tips (Series #1)

Case 1

Sexually active young man presents with acute-onset, painless, non-pruritic facial rash.

Key point: The profusion of plateau-shaped papules on the face, particularly in those with skin of color, is a typical appearance for secondary syphilis.

Treatment: Intramuscular bicillin, 2.4 million units.

Note: Should also test for HIV coinfection.

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Patient presents with widespread, almost confluent psoriasis with intense itching.

Key point: Even though about 80% of psoriasis cases can be managed with topical medication, the widespread nature in this case precludes topical therapy.

Treatment: A biologic drug (etanercept, adalimumab, infliximab, or ustekinumab) would be a good choice.

Note: Obesity suggests concomitant metabolic syndrome, and appropriate blood tests (fasting glucose, hemoglobin A_1c, triglycerides, cholesterol) should be considered.

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Case 3

Sexually active young man presents with dysuria and profuse purulent urethral discharge.

Key point: Symptomatic, spontaneous purulent discharge is most typical of gonorrhea.

Treatment: Intramuscular ceftriaxone 250 mg PLUS azithromycin or doxycycline.

Note: Ciprofloxacin has recently been dropped as a recommended gonorrhea therapy because of high prevalence rates of resistance.

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Case 4

Patient presents with slowly expanding, asymptomatic, soft, red to red-brown facial plaques. No antecedent trauma and no regional adenopathy. Negative review of systems.

Key point: This is a classic appearance for a rare, benign disorder of unknown etiology called granuloma faciale.

Treatment: Oral dapsone, 100 mg daily, is the treatment of choice.

Note: If medical therapy fails, this lesion often responds to laser treatment (Nd:YAG or pulsed dye lasers).

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Case 5

Patient presents with pruritic scaling of both palms for 8 months. It is getting worse. His feet do not have the same problem.

Key point: This could be tinea manum (dermatophytosis of the hands), palmar psoriasis, chronic contact dermatitis, or hand eczema. A KOH preparation and culture of the scale should be done to look for fungi and a detailed work/hobby history taken to search for repetitive exposure to potent allergens (such as concrete).

Treatment: Topical antifungal of choice or ultrapotent corticosteroid cream, depending on whether fungi are found.

Note: If therapy fails and diagnosis remains uncertain, a punch biopsy would be indicated. Phototherapy would be an alternative for both psoriasis and eczema.