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Friends Don't Let Friends Ignore Skin Problems
This 58-year-old woman was unaware there was a problem with her neck skin until friends took a picture and showed it to her. She was surprised and distressed, thinking the changes were new and therefore representative of serious disease.
She denies having any associated symptoms but does admit to a great deal of sun exposure over the years. Her history is significant for a basal cell carcinoma, removed from her chest many years ago. She also has a history of smoking and early COPD.
EXAMINATION
A solid sheet of fine, blanchable telangiectasias spreads across the patient’s upper anterior neck, extending down onto her chest. It spares the skin directly under her chin, leaving an unaffected white oval area.
Elsewhere, the patient has a great deal of dermatoheliosis superimposed on her type II skin, including solar lentigines, weathering, and focal solar elastosis.
What is the diagnosis?
This particular pattern of mottled hyper- and hypopigmented skin is a result of overexposure to UV light. The name for this common problem—seen far more commonly in women than in men—is poikiloderma of Civatte (PC). This case is typical in that the changes manifested and progressed so slowly that the patient didn’t notice.
PC can manifest with combinations of red, brown, and yellow discoloration around the neck. In this case, the dominant color was red. The oval area of spared skin was created by the shade of the patient’s chin.
Similar changes can be seen with other conditions, such as poikiloderma vasculare atrophicans, a manifestation of small plaque parapsoriasis. However, this typically affects areas below the waist and does not have areas of sparing.
Treatment has been attempted with lasers and peels, yielding mixed success. Because of her condition’s benignancy, this patient did not opt for treatment.
TAKE-HOME LEARNING POINTS
- Poikiloderma of Civatte (PC) is a permanent skin change caused by overexposure to the sun or another UV source; it is more common in women than men.
- PC manifests with mottled hyper- or hypopigmented patches of skin on the anterior neck and upper chest, which develop gradually over the course of decades. Many patients also have sheets of telangiectasias covering the affected area.
- A distinct area of sparing (usually oval) is typically seen on the upper anterior neck, due to the chin’s shading of this area.
- Laser treatment has been somewhat successful in lightening the affected skin.
This 58-year-old woman was unaware there was a problem with her neck skin until friends took a picture and showed it to her. She was surprised and distressed, thinking the changes were new and therefore representative of serious disease.
She denies having any associated symptoms but does admit to a great deal of sun exposure over the years. Her history is significant for a basal cell carcinoma, removed from her chest many years ago. She also has a history of smoking and early COPD.
EXAMINATION
A solid sheet of fine, blanchable telangiectasias spreads across the patient’s upper anterior neck, extending down onto her chest. It spares the skin directly under her chin, leaving an unaffected white oval area.
Elsewhere, the patient has a great deal of dermatoheliosis superimposed on her type II skin, including solar lentigines, weathering, and focal solar elastosis.
What is the diagnosis?
This particular pattern of mottled hyper- and hypopigmented skin is a result of overexposure to UV light. The name for this common problem—seen far more commonly in women than in men—is poikiloderma of Civatte (PC). This case is typical in that the changes manifested and progressed so slowly that the patient didn’t notice.
PC can manifest with combinations of red, brown, and yellow discoloration around the neck. In this case, the dominant color was red. The oval area of spared skin was created by the shade of the patient’s chin.
Similar changes can be seen with other conditions, such as poikiloderma vasculare atrophicans, a manifestation of small plaque parapsoriasis. However, this typically affects areas below the waist and does not have areas of sparing.
Treatment has been attempted with lasers and peels, yielding mixed success. Because of her condition’s benignancy, this patient did not opt for treatment.
TAKE-HOME LEARNING POINTS
- Poikiloderma of Civatte (PC) is a permanent skin change caused by overexposure to the sun or another UV source; it is more common in women than men.
- PC manifests with mottled hyper- or hypopigmented patches of skin on the anterior neck and upper chest, which develop gradually over the course of decades. Many patients also have sheets of telangiectasias covering the affected area.
- A distinct area of sparing (usually oval) is typically seen on the upper anterior neck, due to the chin’s shading of this area.
- Laser treatment has been somewhat successful in lightening the affected skin.
This 58-year-old woman was unaware there was a problem with her neck skin until friends took a picture and showed it to her. She was surprised and distressed, thinking the changes were new and therefore representative of serious disease.
She denies having any associated symptoms but does admit to a great deal of sun exposure over the years. Her history is significant for a basal cell carcinoma, removed from her chest many years ago. She also has a history of smoking and early COPD.
EXAMINATION
A solid sheet of fine, blanchable telangiectasias spreads across the patient’s upper anterior neck, extending down onto her chest. It spares the skin directly under her chin, leaving an unaffected white oval area.
Elsewhere, the patient has a great deal of dermatoheliosis superimposed on her type II skin, including solar lentigines, weathering, and focal solar elastosis.
What is the diagnosis?
This particular pattern of mottled hyper- and hypopigmented skin is a result of overexposure to UV light. The name for this common problem—seen far more commonly in women than in men—is poikiloderma of Civatte (PC). This case is typical in that the changes manifested and progressed so slowly that the patient didn’t notice.
PC can manifest with combinations of red, brown, and yellow discoloration around the neck. In this case, the dominant color was red. The oval area of spared skin was created by the shade of the patient’s chin.
Similar changes can be seen with other conditions, such as poikiloderma vasculare atrophicans, a manifestation of small plaque parapsoriasis. However, this typically affects areas below the waist and does not have areas of sparing.
Treatment has been attempted with lasers and peels, yielding mixed success. Because of her condition’s benignancy, this patient did not opt for treatment.
TAKE-HOME LEARNING POINTS
- Poikiloderma of Civatte (PC) is a permanent skin change caused by overexposure to the sun or another UV source; it is more common in women than men.
- PC manifests with mottled hyper- or hypopigmented patches of skin on the anterior neck and upper chest, which develop gradually over the course of decades. Many patients also have sheets of telangiectasias covering the affected area.
- A distinct area of sparing (usually oval) is typically seen on the upper anterior neck, due to the chin’s shading of this area.
- Laser treatment has been somewhat successful in lightening the affected skin.
What’s Her Dry-agnosis?
ANSWER
The correct answer is eczema/atopic dermatitis (choice “c”).
Patients with eczema have a low threshold for itching, so they scratch, often making the condition appear far worse than it really is. In such cases, it’s typical for the problem to be mistaken for impetigo (choice “a”) or yeast infection (choice “d”). The latter, much like psoriasis (choice “b”), is quite rare in the perioral area. Furthermore, the patient had no indicative signs of psoriasis.
DISCUSSION
Eczema is one of several manifestations of atopic dermatitis, a syndrome that affects more than 20% of newborns in this country. These children have extraordinarily dry, thin skin that overreacts to wetting and drying, as well as scratching. Certain areas are especially prone to these changes and consequently develop scaling and itching.
The perioral area is one, in large part because it is kept moist by food, drink, nasal secretions, and saliva (due to habitual lip licking). The scaly rash becomes inflamed; on people with skin of color, this frequently manifests with hyperpigmentation.
When picked enough, this type of rash can become impetiginized—that is, superficially infected with staph or strep. But in this patient’s case, antibiotics were of no practical use.
A topical steroid ointment (hydrocortisone 2.5%) was used, and the patient was urged to stop picking (or licking!) and to use moisturizers (eg, petroleum jelly). The family was educated about the problem and its origins, and the parents were reassured of the self-limiting nature of postinflammatory hyperpigmentation (a major source of concern).
In this case, the key to making the correct diagnosis was the significance of the personal and family history of atopy—and an appre
ANSWER
The correct answer is eczema/atopic dermatitis (choice “c”).
Patients with eczema have a low threshold for itching, so they scratch, often making the condition appear far worse than it really is. In such cases, it’s typical for the problem to be mistaken for impetigo (choice “a”) or yeast infection (choice “d”). The latter, much like psoriasis (choice “b”), is quite rare in the perioral area. Furthermore, the patient had no indicative signs of psoriasis.
DISCUSSION
Eczema is one of several manifestations of atopic dermatitis, a syndrome that affects more than 20% of newborns in this country. These children have extraordinarily dry, thin skin that overreacts to wetting and drying, as well as scratching. Certain areas are especially prone to these changes and consequently develop scaling and itching.
The perioral area is one, in large part because it is kept moist by food, drink, nasal secretions, and saliva (due to habitual lip licking). The scaly rash becomes inflamed; on people with skin of color, this frequently manifests with hyperpigmentation.
When picked enough, this type of rash can become impetiginized—that is, superficially infected with staph or strep. But in this patient’s case, antibiotics were of no practical use.
A topical steroid ointment (hydrocortisone 2.5%) was used, and the patient was urged to stop picking (or licking!) and to use moisturizers (eg, petroleum jelly). The family was educated about the problem and its origins, and the parents were reassured of the self-limiting nature of postinflammatory hyperpigmentation (a major source of concern).
In this case, the key to making the correct diagnosis was the significance of the personal and family history of atopy—and an appre
ANSWER
The correct answer is eczema/atopic dermatitis (choice “c”).
Patients with eczema have a low threshold for itching, so they scratch, often making the condition appear far worse than it really is. In such cases, it’s typical for the problem to be mistaken for impetigo (choice “a”) or yeast infection (choice “d”). The latter, much like psoriasis (choice “b”), is quite rare in the perioral area. Furthermore, the patient had no indicative signs of psoriasis.
DISCUSSION
Eczema is one of several manifestations of atopic dermatitis, a syndrome that affects more than 20% of newborns in this country. These children have extraordinarily dry, thin skin that overreacts to wetting and drying, as well as scratching. Certain areas are especially prone to these changes and consequently develop scaling and itching.
The perioral area is one, in large part because it is kept moist by food, drink, nasal secretions, and saliva (due to habitual lip licking). The scaly rash becomes inflamed; on people with skin of color, this frequently manifests with hyperpigmentation.
When picked enough, this type of rash can become impetiginized—that is, superficially infected with staph or strep. But in this patient’s case, antibiotics were of no practical use.
A topical steroid ointment (hydrocortisone 2.5%) was used, and the patient was urged to stop picking (or licking!) and to use moisturizers (eg, petroleum jelly). The family was educated about the problem and its origins, and the parents were reassured of the self-limiting nature of postinflammatory hyperpigmentation (a major source of concern).
In this case, the key to making the correct diagnosis was the significance of the personal and family history of atopy—and an appre
The persistent rash around this 5-year-old African-American girl’s mouth is causing a great deal of concern for her parents, who request referral to dermatology after four months of attempted treatment. Oral and topical antibiotics, as well as antifungal products (nystatin and fluconazole), have been used to no good effect.
The patient is often seen licking her lips, which dries and irritates them. Fine crusting surrounds her mouth, particularly the left lateral oral commissure. The skin in the affected areas is darker than the rest.
Elsewhere, her type IV skin is quite dry, with focal areas of scaling on the arms and antecubital region. No rash is seen on extensor areas, nor are there any changes in her nails.
The child is markedly atopic, as are her siblings, who are present for the exam. The patient and her siblings are all congested, breathing through their mouths (“allergies,” according to their parents).
The Princess and the Pea-sized Nodule
For years, this 33-year-old woman has had a firm, pea-sized nodule on her left upper back. It was never a problem until recently, when it suddenly enlarged and became red, swollen, and tender.
She was prescribed antibiotics (trimethoprim and sulfa) by a provider at her local urgent care center. Dubious of the diagnosis—carbuncle—she sought referral to dermatology.
The patient claims to be in otherwise excellent health, with no history of similar problems. She denies manual manipulation of the lesion.
EXAMINATION
The patient is afebrile and in no distress. On her upper left back is a round, cystic lesion measuring 3.5 cm. It appears swollen and red. The erythema, though impressive, is confined to
the area immediately around the margins. Palpation reveals increased warmth and modest tenderness. A central punctum can be seen in the center of the fluctuant lesion.
After a brief discussion of options, the lesion is incised and drained under sterile conditions with lidocaine and epinephrine. Cheesy, odoriferous material is expressed, effectively flattening the lesion.
What is the diagnosis?
Epidermal cysts are utterly common, especially in oil-rich areas such as the upper back. They are often mistakenly called sebaceous cysts; however, true sebaceous cysts are quite rare and contain only pure, clear oil.
When ruptured by trauma, epidermal cysts become inflamed and cheesy material leaks into deep tissues. This activates an immune response in which the body sends out white cells to clean up the leakage—what we call inflammation.
There are many types of cysts (eg, acne cysts, ganglion cysts, Bartholin gland cysts) but none resemble epidermal cysts. Providers often mistake epidermal cysts for carbuncles or boils and may prescribe oral or systemic antibiotics, or incise the cysts and pack the space. The truth is that inflamed epidermal cysts do not represent infection—hence the limited area of redness. By contrast, cellulitis or carbuncle would manifest with tenderness and blush of erythema over the entire area.
The fact that this lesion arose from a longstanding antecedent nodule is consistent with the diagnosis, as are the cheesy, odoriferous contents liberated by incision and drainage. Liberating the contents merely buys the patient relief from the pressure and pain, since the cyst wall is still present and will almost certainly fill up again. The ultimate solution is excision after the emptied cyst has had time to shrink back to its original size, which will minimize the scarring. There is no need to pack such cysts after incision and drainage, though they will continue to drain for a few days.
TAKE-HOME LEARNING POINTS
- Epidermal cysts are common, especially in oil-rich areas such as the face, back, chest, and neck.
- Epidermal cysts are often mistakenly called sebaceous cysts, but these are actually quite rare, containing clear sebum (oil) and no cheesy material.
- Even though such inflamed cysts are often mistaken for boils, carbuncles, and abscesses, they have nothing to do with bacteria or infection and therefore do not require antibiotics or packing after incision and drainage.
- For recurrent inflamed cysts, the treatment of choice is complete excision, done only after the cyst has shrunk to its smallest size.
For years, this 33-year-old woman has had a firm, pea-sized nodule on her left upper back. It was never a problem until recently, when it suddenly enlarged and became red, swollen, and tender.
She was prescribed antibiotics (trimethoprim and sulfa) by a provider at her local urgent care center. Dubious of the diagnosis—carbuncle—she sought referral to dermatology.
The patient claims to be in otherwise excellent health, with no history of similar problems. She denies manual manipulation of the lesion.
EXAMINATION
The patient is afebrile and in no distress. On her upper left back is a round, cystic lesion measuring 3.5 cm. It appears swollen and red. The erythema, though impressive, is confined to
the area immediately around the margins. Palpation reveals increased warmth and modest tenderness. A central punctum can be seen in the center of the fluctuant lesion.
After a brief discussion of options, the lesion is incised and drained under sterile conditions with lidocaine and epinephrine. Cheesy, odoriferous material is expressed, effectively flattening the lesion.
What is the diagnosis?
Epidermal cysts are utterly common, especially in oil-rich areas such as the upper back. They are often mistakenly called sebaceous cysts; however, true sebaceous cysts are quite rare and contain only pure, clear oil.
When ruptured by trauma, epidermal cysts become inflamed and cheesy material leaks into deep tissues. This activates an immune response in which the body sends out white cells to clean up the leakage—what we call inflammation.
There are many types of cysts (eg, acne cysts, ganglion cysts, Bartholin gland cysts) but none resemble epidermal cysts. Providers often mistake epidermal cysts for carbuncles or boils and may prescribe oral or systemic antibiotics, or incise the cysts and pack the space. The truth is that inflamed epidermal cysts do not represent infection—hence the limited area of redness. By contrast, cellulitis or carbuncle would manifest with tenderness and blush of erythema over the entire area.
The fact that this lesion arose from a longstanding antecedent nodule is consistent with the diagnosis, as are the cheesy, odoriferous contents liberated by incision and drainage. Liberating the contents merely buys the patient relief from the pressure and pain, since the cyst wall is still present and will almost certainly fill up again. The ultimate solution is excision after the emptied cyst has had time to shrink back to its original size, which will minimize the scarring. There is no need to pack such cysts after incision and drainage, though they will continue to drain for a few days.
TAKE-HOME LEARNING POINTS
- Epidermal cysts are common, especially in oil-rich areas such as the face, back, chest, and neck.
- Epidermal cysts are often mistakenly called sebaceous cysts, but these are actually quite rare, containing clear sebum (oil) and no cheesy material.
- Even though such inflamed cysts are often mistaken for boils, carbuncles, and abscesses, they have nothing to do with bacteria or infection and therefore do not require antibiotics or packing after incision and drainage.
- For recurrent inflamed cysts, the treatment of choice is complete excision, done only after the cyst has shrunk to its smallest size.
For years, this 33-year-old woman has had a firm, pea-sized nodule on her left upper back. It was never a problem until recently, when it suddenly enlarged and became red, swollen, and tender.
She was prescribed antibiotics (trimethoprim and sulfa) by a provider at her local urgent care center. Dubious of the diagnosis—carbuncle—she sought referral to dermatology.
The patient claims to be in otherwise excellent health, with no history of similar problems. She denies manual manipulation of the lesion.
EXAMINATION
The patient is afebrile and in no distress. On her upper left back is a round, cystic lesion measuring 3.5 cm. It appears swollen and red. The erythema, though impressive, is confined to
the area immediately around the margins. Palpation reveals increased warmth and modest tenderness. A central punctum can be seen in the center of the fluctuant lesion.
After a brief discussion of options, the lesion is incised and drained under sterile conditions with lidocaine and epinephrine. Cheesy, odoriferous material is expressed, effectively flattening the lesion.
What is the diagnosis?
Epidermal cysts are utterly common, especially in oil-rich areas such as the upper back. They are often mistakenly called sebaceous cysts; however, true sebaceous cysts are quite rare and contain only pure, clear oil.
When ruptured by trauma, epidermal cysts become inflamed and cheesy material leaks into deep tissues. This activates an immune response in which the body sends out white cells to clean up the leakage—what we call inflammation.
There are many types of cysts (eg, acne cysts, ganglion cysts, Bartholin gland cysts) but none resemble epidermal cysts. Providers often mistake epidermal cysts for carbuncles or boils and may prescribe oral or systemic antibiotics, or incise the cysts and pack the space. The truth is that inflamed epidermal cysts do not represent infection—hence the limited area of redness. By contrast, cellulitis or carbuncle would manifest with tenderness and blush of erythema over the entire area.
The fact that this lesion arose from a longstanding antecedent nodule is consistent with the diagnosis, as are the cheesy, odoriferous contents liberated by incision and drainage. Liberating the contents merely buys the patient relief from the pressure and pain, since the cyst wall is still present and will almost certainly fill up again. The ultimate solution is excision after the emptied cyst has had time to shrink back to its original size, which will minimize the scarring. There is no need to pack such cysts after incision and drainage, though they will continue to drain for a few days.
TAKE-HOME LEARNING POINTS
- Epidermal cysts are common, especially in oil-rich areas such as the face, back, chest, and neck.
- Epidermal cysts are often mistakenly called sebaceous cysts, but these are actually quite rare, containing clear sebum (oil) and no cheesy material.
- Even though such inflamed cysts are often mistaken for boils, carbuncles, and abscesses, they have nothing to do with bacteria or infection and therefore do not require antibiotics or packing after incision and drainage.
- For recurrent inflamed cysts, the treatment of choice is complete excision, done only after the cyst has shrunk to its smallest size.
Getting a Candle on Her Condition
A 15-year-old girl is brought in by her mother for evaluation of a rash that developed following a “candling” treatment she underwent two weeks ago at a beauty spa.
The treatment, which was performed to eliminate scaling in her external ear canal, involved dripping hot wax from a burning candle into the external auditory meatus. The cooled wax was peeled away, along with the attached scaling. A new, asymptomatic, scaly rash has since appeared in the same area—far worse than the original.
There is no history of recent infection or joint pain, or family history of skin disease.
EXAMINATION
Heavy, uniform, white scaling on a salmon-colored base covers the external auditory meatus, extending 3 or 4 mm into the concha. Similar, milder changes are observed in the left ear.
There are scattered pits in three fingernails, white scaling in the scalp above and behind both ears, and faint pink scaly patches on both knees and elbows.
What is the diagnosis?
Psoriasis is extremely common, affecting about 3% of the white population in this country, and is one of a handful of conditions that manifest with the Koebner phenomenon. This means that any trauma (ie, scrapes, burns, scratches, or cuts) can trigger or extend the condition. In this case, the hot wax was likely the culprit.
The patient’s primary care provider, it turns out, was treating the elbow and knee rashes with antifungal creams (to no avail). He hadn’t made the connection between her various skin problems. It was the acute manifestation in the ear that prompted a broader assessment of the patient’s condition—proving the maxim that to find a diagnosis, you have to look for it.
Given its mild nature, this patient’s condition was easily treated with topical steroids and vitamin D-derived cream (calcipotriene). She was advised of the need to avoid exacerbating factors, such as smoking, obesity, excess alcohol intake, and stress.
There is the possibility of the disease worsening despite treatment. The patient also has about a 25% chance of developing psoriatic arthropathy. For these reasons, she will need to be followed by dermatology.
TAKE-HOME LEARNING POINTS
- Psoriasis, though very common, does not always manifest in its typical form.
- Any trauma (ie, burn, scrape, or cut) can trigger preexisting psoriasis, a response called the Koebner phenomenon.
- Several other conditions—including lichen planus, warts, and molluscum—can exhibit this same phenomenon.
- When psoriasis is suspected, potential corroboratory sites of involvement (eg, knees, elbows, nails, and scalp) should be examined. Biopsy is often needed to confirm the diagnosis.
A 15-year-old girl is brought in by her mother for evaluation of a rash that developed following a “candling” treatment she underwent two weeks ago at a beauty spa.
The treatment, which was performed to eliminate scaling in her external ear canal, involved dripping hot wax from a burning candle into the external auditory meatus. The cooled wax was peeled away, along with the attached scaling. A new, asymptomatic, scaly rash has since appeared in the same area—far worse than the original.
There is no history of recent infection or joint pain, or family history of skin disease.
EXAMINATION
Heavy, uniform, white scaling on a salmon-colored base covers the external auditory meatus, extending 3 or 4 mm into the concha. Similar, milder changes are observed in the left ear.
There are scattered pits in three fingernails, white scaling in the scalp above and behind both ears, and faint pink scaly patches on both knees and elbows.
What is the diagnosis?
Psoriasis is extremely common, affecting about 3% of the white population in this country, and is one of a handful of conditions that manifest with the Koebner phenomenon. This means that any trauma (ie, scrapes, burns, scratches, or cuts) can trigger or extend the condition. In this case, the hot wax was likely the culprit.
The patient’s primary care provider, it turns out, was treating the elbow and knee rashes with antifungal creams (to no avail). He hadn’t made the connection between her various skin problems. It was the acute manifestation in the ear that prompted a broader assessment of the patient’s condition—proving the maxim that to find a diagnosis, you have to look for it.
Given its mild nature, this patient’s condition was easily treated with topical steroids and vitamin D-derived cream (calcipotriene). She was advised of the need to avoid exacerbating factors, such as smoking, obesity, excess alcohol intake, and stress.
There is the possibility of the disease worsening despite treatment. The patient also has about a 25% chance of developing psoriatic arthropathy. For these reasons, she will need to be followed by dermatology.
TAKE-HOME LEARNING POINTS
- Psoriasis, though very common, does not always manifest in its typical form.
- Any trauma (ie, burn, scrape, or cut) can trigger preexisting psoriasis, a response called the Koebner phenomenon.
- Several other conditions—including lichen planus, warts, and molluscum—can exhibit this same phenomenon.
- When psoriasis is suspected, potential corroboratory sites of involvement (eg, knees, elbows, nails, and scalp) should be examined. Biopsy is often needed to confirm the diagnosis.
A 15-year-old girl is brought in by her mother for evaluation of a rash that developed following a “candling” treatment she underwent two weeks ago at a beauty spa.
The treatment, which was performed to eliminate scaling in her external ear canal, involved dripping hot wax from a burning candle into the external auditory meatus. The cooled wax was peeled away, along with the attached scaling. A new, asymptomatic, scaly rash has since appeared in the same area—far worse than the original.
There is no history of recent infection or joint pain, or family history of skin disease.
EXAMINATION
Heavy, uniform, white scaling on a salmon-colored base covers the external auditory meatus, extending 3 or 4 mm into the concha. Similar, milder changes are observed in the left ear.
There are scattered pits in three fingernails, white scaling in the scalp above and behind both ears, and faint pink scaly patches on both knees and elbows.
What is the diagnosis?
Psoriasis is extremely common, affecting about 3% of the white population in this country, and is one of a handful of conditions that manifest with the Koebner phenomenon. This means that any trauma (ie, scrapes, burns, scratches, or cuts) can trigger or extend the condition. In this case, the hot wax was likely the culprit.
The patient’s primary care provider, it turns out, was treating the elbow and knee rashes with antifungal creams (to no avail). He hadn’t made the connection between her various skin problems. It was the acute manifestation in the ear that prompted a broader assessment of the patient’s condition—proving the maxim that to find a diagnosis, you have to look for it.
Given its mild nature, this patient’s condition was easily treated with topical steroids and vitamin D-derived cream (calcipotriene). She was advised of the need to avoid exacerbating factors, such as smoking, obesity, excess alcohol intake, and stress.
There is the possibility of the disease worsening despite treatment. The patient also has about a 25% chance of developing psoriatic arthropathy. For these reasons, she will need to be followed by dermatology.
TAKE-HOME LEARNING POINTS
- Psoriasis, though very common, does not always manifest in its typical form.
- Any trauma (ie, burn, scrape, or cut) can trigger preexisting psoriasis, a response called the Koebner phenomenon.
- Several other conditions—including lichen planus, warts, and molluscum—can exhibit this same phenomenon.
- When psoriasis is suspected, potential corroboratory sites of involvement (eg, knees, elbows, nails, and scalp) should be examined. Biopsy is often needed to confirm the diagnosis.
All Is Not Swell
ANSWER
The correct answer is elephantiasis nostras verrucosa (ENV; choice “d”). Cellulitis (choice “a”), venous insufficiency (choice “b”), and lymphedema (choice “c”) are all factors in the broader diagnosis of ENV.
DISCUSSION
ENV is an unusual condition that represents hypertrophic fibrosis secondary to repeated episodes of lymphangitis. This begins with venous insufficiency, which is made worse by increasing obesity (which impedes venous return) and repeated bouts of cellulitis. With ENV, fibroblasts are increased due to extravasation of high-molecular-weight protein (lymphorrhea), which leads to a buildup of keratinocytes, ultimately expressing as extreme hyperkeratosis.
In this patient’s case, his sedentary lifestyle and constant seated position contribute to the problem. Many of his past treatments were reasonable, but—as in many ENV cases—his condition is beyond the point of treatment.
Typically, in-home treatment includes compression and elevation of the legs. Topical application of urea creams is often used to soften the rough skin, but in this patient’s case, the cream burned so badly that it was of no use. Alas, the very things he needs to do are those he cannot: walk, burn calories, and avoid long periods of inactivity.
ANSWER
The correct answer is elephantiasis nostras verrucosa (ENV; choice “d”). Cellulitis (choice “a”), venous insufficiency (choice “b”), and lymphedema (choice “c”) are all factors in the broader diagnosis of ENV.
DISCUSSION
ENV is an unusual condition that represents hypertrophic fibrosis secondary to repeated episodes of lymphangitis. This begins with venous insufficiency, which is made worse by increasing obesity (which impedes venous return) and repeated bouts of cellulitis. With ENV, fibroblasts are increased due to extravasation of high-molecular-weight protein (lymphorrhea), which leads to a buildup of keratinocytes, ultimately expressing as extreme hyperkeratosis.
In this patient’s case, his sedentary lifestyle and constant seated position contribute to the problem. Many of his past treatments were reasonable, but—as in many ENV cases—his condition is beyond the point of treatment.
Typically, in-home treatment includes compression and elevation of the legs. Topical application of urea creams is often used to soften the rough skin, but in this patient’s case, the cream burned so badly that it was of no use. Alas, the very things he needs to do are those he cannot: walk, burn calories, and avoid long periods of inactivity.
ANSWER
The correct answer is elephantiasis nostras verrucosa (ENV; choice “d”). Cellulitis (choice “a”), venous insufficiency (choice “b”), and lymphedema (choice “c”) are all factors in the broader diagnosis of ENV.
DISCUSSION
ENV is an unusual condition that represents hypertrophic fibrosis secondary to repeated episodes of lymphangitis. This begins with venous insufficiency, which is made worse by increasing obesity (which impedes venous return) and repeated bouts of cellulitis. With ENV, fibroblasts are increased due to extravasation of high-molecular-weight protein (lymphorrhea), which leads to a buildup of keratinocytes, ultimately expressing as extreme hyperkeratosis.
In this patient’s case, his sedentary lifestyle and constant seated position contribute to the problem. Many of his past treatments were reasonable, but—as in many ENV cases—his condition is beyond the point of treatment.
Typically, in-home treatment includes compression and elevation of the legs. Topical application of urea creams is often used to soften the rough skin, but in this patient’s case, the cream burned so badly that it was of no use. Alas, the very things he needs to do are those he cannot: walk, burn calories, and avoid long periods of inactivity.
A 70-year-old man is referred to dermatology after trying “everything else” for problems he has had for at least 15 years. In that time, he has been hospitalized repeatedly for swelling and pain in his legs, with odoriferous drainage.
Despite extensive treatment attempts—multiple antibiotics, oral and topical steroids, and OTC creams—the condition is worsening. In ho
The patient denies having cancer or deep vein thrombosis (both of which he has been thoroughly checked for), as well as congestive heart failure. He states that almost every morning, upon rising, the swelling in his legs is considerably lessened.
Both legs are swollen, red, and edematous from just below the knees down. Advanced, pebbly, hyperkeratotic plaques cover the lower two-thirds of both legs, favoring the anterior over the posterior portions. Pitting edema is elicited with minimal digital pressure but does not cause any pain.The patient is in no acute distress but is clearly uncomfortable. He has been confined to a wheelchair for years due to back problems; he can barely stand when asked to do so. He is extremely obese.
My, How You've Grown
Six years ago, a lesion appeared on this now 39-year-old woman’s forehead. It grew steadily to its current size, impinging on her brow line. Although it has been asymptomatic, the patient is concerned about malignancy, since she has a significant personal and family history of skin cancer. She has had several lesions removed from her face and back over the years.
EXAMINATION
There is a 2.2-cm, roughly round, white, cicatricial, concave lesion on the patient’s lower right forehead, extending into the brow line. Around the periphery are several 2- to 5-mm eroded papules. There are no palpable nodes on the head or neck.
Several scars are seen elsewhere on the patient’s face and back, consistent with her history. Her type II/VI skin is quite fair and sun-damaged.
A 6-mm deep punch biopsy of the lesion is obtained.
What is the diagnosis?
Biopsy reveals a morpheaform basal cell carcinoma (BCC; also known as cicatricial BCC) with perineural involvement that extends to the margin of the sample. While BCCs are almost never fatal, if ignored, their relentless growth can be problematic. This case illustrates that, along with the wide variety of morphologic presentations.
Of the different types of BCC, the most common are nodular. These present as pearly (ie, translucent) papules or nodules, with or without focal erosion or frank ulceration; they often have prominent telangiectasias coursing over their surfaces. BCCs can also appear as rashes (superficial BCC) that may not attract attention.
This patient’s lesion is one of the least common variations: It combines features of a morpheaform (scarlike) BCC with focal noduloulcerative papular lesions studding its periphery. The concavity of the scarlike portion, along with its prolonged presence, predicted deep involvement of adjacent tissue—confirmed by the biopsy results.
At a minimum, this patient will need Mohs micrographic surgical removal, with closure by skin graft or secondary intention. Given the deep perineural involvement, surgery alone may not clear the cancer; radiation therapy may be necessary.
TAKE-HOME LEARNING POINTS
- Morpheaform basal cell carcinoma (BCC), also known as cicatricial BCC, can present as a white, scarlike patch, often with an atrophic surface.
- This type of BCC is more aggressive than most, often requiring Mohs surgery.
- There are at least three other types of BCC, most of which involve nonhealing ulcerative papules or nodules.
- This patient’s history of sun-caused skin cancers makes recurrence likely.
Six years ago, a lesion appeared on this now 39-year-old woman’s forehead. It grew steadily to its current size, impinging on her brow line. Although it has been asymptomatic, the patient is concerned about malignancy, since she has a significant personal and family history of skin cancer. She has had several lesions removed from her face and back over the years.
EXAMINATION
There is a 2.2-cm, roughly round, white, cicatricial, concave lesion on the patient’s lower right forehead, extending into the brow line. Around the periphery are several 2- to 5-mm eroded papules. There are no palpable nodes on the head or neck.
Several scars are seen elsewhere on the patient’s face and back, consistent with her history. Her type II/VI skin is quite fair and sun-damaged.
A 6-mm deep punch biopsy of the lesion is obtained.
What is the diagnosis?
Biopsy reveals a morpheaform basal cell carcinoma (BCC; also known as cicatricial BCC) with perineural involvement that extends to the margin of the sample. While BCCs are almost never fatal, if ignored, their relentless growth can be problematic. This case illustrates that, along with the wide variety of morphologic presentations.
Of the different types of BCC, the most common are nodular. These present as pearly (ie, translucent) papules or nodules, with or without focal erosion or frank ulceration; they often have prominent telangiectasias coursing over their surfaces. BCCs can also appear as rashes (superficial BCC) that may not attract attention.
This patient’s lesion is one of the least common variations: It combines features of a morpheaform (scarlike) BCC with focal noduloulcerative papular lesions studding its periphery. The concavity of the scarlike portion, along with its prolonged presence, predicted deep involvement of adjacent tissue—confirmed by the biopsy results.
At a minimum, this patient will need Mohs micrographic surgical removal, with closure by skin graft or secondary intention. Given the deep perineural involvement, surgery alone may not clear the cancer; radiation therapy may be necessary.
TAKE-HOME LEARNING POINTS
- Morpheaform basal cell carcinoma (BCC), also known as cicatricial BCC, can present as a white, scarlike patch, often with an atrophic surface.
- This type of BCC is more aggressive than most, often requiring Mohs surgery.
- There are at least three other types of BCC, most of which involve nonhealing ulcerative papules or nodules.
- This patient’s history of sun-caused skin cancers makes recurrence likely.
Six years ago, a lesion appeared on this now 39-year-old woman’s forehead. It grew steadily to its current size, impinging on her brow line. Although it has been asymptomatic, the patient is concerned about malignancy, since she has a significant personal and family history of skin cancer. She has had several lesions removed from her face and back over the years.
EXAMINATION
There is a 2.2-cm, roughly round, white, cicatricial, concave lesion on the patient’s lower right forehead, extending into the brow line. Around the periphery are several 2- to 5-mm eroded papules. There are no palpable nodes on the head or neck.
Several scars are seen elsewhere on the patient’s face and back, consistent with her history. Her type II/VI skin is quite fair and sun-damaged.
A 6-mm deep punch biopsy of the lesion is obtained.
What is the diagnosis?
Biopsy reveals a morpheaform basal cell carcinoma (BCC; also known as cicatricial BCC) with perineural involvement that extends to the margin of the sample. While BCCs are almost never fatal, if ignored, their relentless growth can be problematic. This case illustrates that, along with the wide variety of morphologic presentations.
Of the different types of BCC, the most common are nodular. These present as pearly (ie, translucent) papules or nodules, with or without focal erosion or frank ulceration; they often have prominent telangiectasias coursing over their surfaces. BCCs can also appear as rashes (superficial BCC) that may not attract attention.
This patient’s lesion is one of the least common variations: It combines features of a morpheaform (scarlike) BCC with focal noduloulcerative papular lesions studding its periphery. The concavity of the scarlike portion, along with its prolonged presence, predicted deep involvement of adjacent tissue—confirmed by the biopsy results.
At a minimum, this patient will need Mohs micrographic surgical removal, with closure by skin graft or secondary intention. Given the deep perineural involvement, surgery alone may not clear the cancer; radiation therapy may be necessary.
TAKE-HOME LEARNING POINTS
- Morpheaform basal cell carcinoma (BCC), also known as cicatricial BCC, can present as a white, scarlike patch, often with an atrophic surface.
- This type of BCC is more aggressive than most, often requiring Mohs surgery.
- There are at least three other types of BCC, most of which involve nonhealing ulcerative papules or nodules.
- This patient’s history of sun-caused skin cancers makes recurrence likely.
Sunny Side's Up
A year ago, this 60-year-old man noticed an asymptomatic lesion on the dorsum of his right hand. When it grew in size over the course of a few months, he showed it to his primary care provider, who believed it to be a wart and froze it with liquid nitrogen. This reduced its size, but only temporarily. It has since been treated with topical and oral antibiotics to no avail.
The patient has had several basal cell carcinomas removed from his face, arms, and trunk in the past.
EXAMINATION
On the mid dorsum of the patient’s right hand is a 1.5-cm ovoid nodule with a smooth surface and very firm feel. It appears in the context of fully sun-exposed, sun-damaged skin. Several scars are noted in the area, consistent with his history of sun-caused skin cancers.
The lesion is removed by deep shave biopsy, and the base curetted. The entire lesion is sent to pathology.
What’s the diagnosis?
The pathology report shows a low-grade, well-differentiated squamous cell carcinoma (SCC)—in this case, a keratoacanthoma (KA). This common form of SCC is usually found on the sun-exposed skin of older patients. The lesions can range in size from 3 mm to 3 cm or larger and are usually round to oval and dome-like, with symmetrical architecture and, often, a central keratotic core. The differential includes cysts, warts, and seborrheic keratosis.
Histologically, KAs are composed of uniformly staining (blue) cells of similar size and shape (connoting relative benignancy), to which we apply the term well-differentiated. Poorly-differentiated cellular composition manifests with cells of different sizes, shapes, and colors; these characteristics suggest more aggressive malignancy.
Even though KAs are skin cancers, they are quite low-grade, which means they rarely metastasize; if left alone, they can resolve completely over time. However, their odd appearance and rapid growth are usually concerning enough to prompt their removal.
When suspected KAs are removed, it’s essential that the entire lesion be submitted for pathologic examination. This allows for the architecture of the entire lesion—its cellular composition and margins—to be evaluated. When only part of the lesion is removed for biopsy, the diagnosis will be “squamous cell carcinoma, well differentiated, without evidence of invasion.” In the minds of many dermatology providers, this diagnosis demands excision—but a KA lesion completely removed by shave biopsy is considered cured.
Histologic examination of these lesions is not always as straightforward as in this case. KAs can be poorly differentiated or demonstrate focal areas of invasion, which justifies excision with margins.
TAKE-HOME LEARNING POINTS
- Keratoacanthoma (KA) is an extremely common low-grade squamous cell carcinoma most often seen on directly sun-exposed skin (eg, hands, arms, face, ears) of older, sun-damaged patients.
- KA typically manifests as a round to oval, dome-like, firm nodule, often with a central keratotic core and a history of rapid growth.
- It’s important to remove these lesions in one piece (eg, by deep shave biopsy) because identification is based on architecture and cellular composition.
- The pathology report will show a well-differentiated squamous cell carcinoma with architecture consistent with KA.
- Although some believe that excision is necessary, a deep shave biopsy performed with clear margins is adequate treatment.
A year ago, this 60-year-old man noticed an asymptomatic lesion on the dorsum of his right hand. When it grew in size over the course of a few months, he showed it to his primary care provider, who believed it to be a wart and froze it with liquid nitrogen. This reduced its size, but only temporarily. It has since been treated with topical and oral antibiotics to no avail.
The patient has had several basal cell carcinomas removed from his face, arms, and trunk in the past.
EXAMINATION
On the mid dorsum of the patient’s right hand is a 1.5-cm ovoid nodule with a smooth surface and very firm feel. It appears in the context of fully sun-exposed, sun-damaged skin. Several scars are noted in the area, consistent with his history of sun-caused skin cancers.
The lesion is removed by deep shave biopsy, and the base curetted. The entire lesion is sent to pathology.
What’s the diagnosis?
The pathology report shows a low-grade, well-differentiated squamous cell carcinoma (SCC)—in this case, a keratoacanthoma (KA). This common form of SCC is usually found on the sun-exposed skin of older patients. The lesions can range in size from 3 mm to 3 cm or larger and are usually round to oval and dome-like, with symmetrical architecture and, often, a central keratotic core. The differential includes cysts, warts, and seborrheic keratosis.
Histologically, KAs are composed of uniformly staining (blue) cells of similar size and shape (connoting relative benignancy), to which we apply the term well-differentiated. Poorly-differentiated cellular composition manifests with cells of different sizes, shapes, and colors; these characteristics suggest more aggressive malignancy.
Even though KAs are skin cancers, they are quite low-grade, which means they rarely metastasize; if left alone, they can resolve completely over time. However, their odd appearance and rapid growth are usually concerning enough to prompt their removal.
When suspected KAs are removed, it’s essential that the entire lesion be submitted for pathologic examination. This allows for the architecture of the entire lesion—its cellular composition and margins—to be evaluated. When only part of the lesion is removed for biopsy, the diagnosis will be “squamous cell carcinoma, well differentiated, without evidence of invasion.” In the minds of many dermatology providers, this diagnosis demands excision—but a KA lesion completely removed by shave biopsy is considered cured.
Histologic examination of these lesions is not always as straightforward as in this case. KAs can be poorly differentiated or demonstrate focal areas of invasion, which justifies excision with margins.
TAKE-HOME LEARNING POINTS
- Keratoacanthoma (KA) is an extremely common low-grade squamous cell carcinoma most often seen on directly sun-exposed skin (eg, hands, arms, face, ears) of older, sun-damaged patients.
- KA typically manifests as a round to oval, dome-like, firm nodule, often with a central keratotic core and a history of rapid growth.
- It’s important to remove these lesions in one piece (eg, by deep shave biopsy) because identification is based on architecture and cellular composition.
- The pathology report will show a well-differentiated squamous cell carcinoma with architecture consistent with KA.
- Although some believe that excision is necessary, a deep shave biopsy performed with clear margins is adequate treatment.
A year ago, this 60-year-old man noticed an asymptomatic lesion on the dorsum of his right hand. When it grew in size over the course of a few months, he showed it to his primary care provider, who believed it to be a wart and froze it with liquid nitrogen. This reduced its size, but only temporarily. It has since been treated with topical and oral antibiotics to no avail.
The patient has had several basal cell carcinomas removed from his face, arms, and trunk in the past.
EXAMINATION
On the mid dorsum of the patient’s right hand is a 1.5-cm ovoid nodule with a smooth surface and very firm feel. It appears in the context of fully sun-exposed, sun-damaged skin. Several scars are noted in the area, consistent with his history of sun-caused skin cancers.
The lesion is removed by deep shave biopsy, and the base curetted. The entire lesion is sent to pathology.
What’s the diagnosis?
The pathology report shows a low-grade, well-differentiated squamous cell carcinoma (SCC)—in this case, a keratoacanthoma (KA). This common form of SCC is usually found on the sun-exposed skin of older patients. The lesions can range in size from 3 mm to 3 cm or larger and are usually round to oval and dome-like, with symmetrical architecture and, often, a central keratotic core. The differential includes cysts, warts, and seborrheic keratosis.
Histologically, KAs are composed of uniformly staining (blue) cells of similar size and shape (connoting relative benignancy), to which we apply the term well-differentiated. Poorly-differentiated cellular composition manifests with cells of different sizes, shapes, and colors; these characteristics suggest more aggressive malignancy.
Even though KAs are skin cancers, they are quite low-grade, which means they rarely metastasize; if left alone, they can resolve completely over time. However, their odd appearance and rapid growth are usually concerning enough to prompt their removal.
When suspected KAs are removed, it’s essential that the entire lesion be submitted for pathologic examination. This allows for the architecture of the entire lesion—its cellular composition and margins—to be evaluated. When only part of the lesion is removed for biopsy, the diagnosis will be “squamous cell carcinoma, well differentiated, without evidence of invasion.” In the minds of many dermatology providers, this diagnosis demands excision—but a KA lesion completely removed by shave biopsy is considered cured.
Histologic examination of these lesions is not always as straightforward as in this case. KAs can be poorly differentiated or demonstrate focal areas of invasion, which justifies excision with margins.
TAKE-HOME LEARNING POINTS
- Keratoacanthoma (KA) is an extremely common low-grade squamous cell carcinoma most often seen on directly sun-exposed skin (eg, hands, arms, face, ears) of older, sun-damaged patients.
- KA typically manifests as a round to oval, dome-like, firm nodule, often with a central keratotic core and a history of rapid growth.
- It’s important to remove these lesions in one piece (eg, by deep shave biopsy) because identification is based on architecture and cellular composition.
- The pathology report will show a well-differentiated squamous cell carcinoma with architecture consistent with KA.
- Although some believe that excision is necessary, a deep shave biopsy performed with clear margins is adequate treatment.
Boy’s Dark Side Comes Out
ANSWER
The correct answer is Becker nevus (BN; choice “c”).
Because the lesion was not congenital, a number of possibilities, including congenital melanocytic nevus (choice “a”), were ruled out. Another differential item that was eliminated was nevus spilus (choice “b”), a tan congenital nevus covered with darker, punctate macules that usually manifest on extremities. These have little, if any, malignant potential.
And while BN is not associated with malignancy, it is possible for it to co-exist with melanoma (choice “d”). Therefore, atypical BN cases may need to be followed or serially biopsied.
DISCUSSION
BN is unusual but not rare. Also referred to as Becker melanosis, the condition affects approximately 0.5% of the population. It primarily manifests in young men during early puberty, although women can develop BN.
Histologic signs of BN include epidermal thickening, elongation of rete ridges, and increased bundles of smooth muscle in the dermis.
Androgen causation is strongly indicated by the condition’s predominance in males and onset at puberty, as well as its associated hypertrichosis and increased density of androgen receptors in affected areas. Variations of the condition can involve the legs, arms, or face. It is possible for BN to manifest without additional hair growth. Hypoplasia of ipsilateral pectoral structures (or the ipsilateral breast in women) has also been reported.
Several types of lasers can be used to lighten the hyperpigmentation and remove hairs. This treatment modality yields variable results.
ANSWER
The correct answer is Becker nevus (BN; choice “c”).
Because the lesion was not congenital, a number of possibilities, including congenital melanocytic nevus (choice “a”), were ruled out. Another differential item that was eliminated was nevus spilus (choice “b”), a tan congenital nevus covered with darker, punctate macules that usually manifest on extremities. These have little, if any, malignant potential.
And while BN is not associated with malignancy, it is possible for it to co-exist with melanoma (choice “d”). Therefore, atypical BN cases may need to be followed or serially biopsied.
DISCUSSION
BN is unusual but not rare. Also referred to as Becker melanosis, the condition affects approximately 0.5% of the population. It primarily manifests in young men during early puberty, although women can develop BN.
Histologic signs of BN include epidermal thickening, elongation of rete ridges, and increased bundles of smooth muscle in the dermis.
Androgen causation is strongly indicated by the condition’s predominance in males and onset at puberty, as well as its associated hypertrichosis and increased density of androgen receptors in affected areas. Variations of the condition can involve the legs, arms, or face. It is possible for BN to manifest without additional hair growth. Hypoplasia of ipsilateral pectoral structures (or the ipsilateral breast in women) has also been reported.
Several types of lasers can be used to lighten the hyperpigmentation and remove hairs. This treatment modality yields variable results.
ANSWER
The correct answer is Becker nevus (BN; choice “c”).
Because the lesion was not congenital, a number of possibilities, including congenital melanocytic nevus (choice “a”), were ruled out. Another differential item that was eliminated was nevus spilus (choice “b”), a tan congenital nevus covered with darker, punctate macules that usually manifest on extremities. These have little, if any, malignant potential.
And while BN is not associated with malignancy, it is possible for it to co-exist with melanoma (choice “d”). Therefore, atypical BN cases may need to be followed or serially biopsied.
DISCUSSION
BN is unusual but not rare. Also referred to as Becker melanosis, the condition affects approximately 0.5% of the population. It primarily manifests in young men during early puberty, although women can develop BN.
Histologic signs of BN include epidermal thickening, elongation of rete ridges, and increased bundles of smooth muscle in the dermis.
Androgen causation is strongly indicated by the condition’s predominance in males and onset at puberty, as well as its associated hypertrichosis and increased density of androgen receptors in affected areas. Variations of the condition can involve the legs, arms, or face. It is possible for BN to manifest without additional hair growth. Hypoplasia of ipsilateral pectoral structures (or the ipsilateral breast in women) has also been reported.
Several types of lasers can be used to lighten the hyperpigmentation and remove hairs. This treatment modality yields variable results.
This 14-year-old boy’s family is alarmed by a darkening patch of skin on the right side of his chest and shoulder, which first appeared two years ago. Over the span of a few months, dark hairs grew on the hyperpigmented area.
The family’s primary care provider assured them that it was likely benign, but the lack of a specific diagnosis left them concerned. They requested referral to dermatology.
A large portion of the patient’s right anterior chest and shoulder is completely covered by uniformly hyperpigmented, hypertrichotic skin, which feels a bit thicker than the unaffected skin. The lesion’s borders are quite irregular and uneven; beyond them, no hairs can be seen. The problem is confined to the chest and shoulder; although the medial border extends to the sternal area, the lower edge stops short of the pectoral area.
The patient denies any symptoms and claims to be healthy in all other respects. There is no family history of similar problems.
Talk About Premature Balding...
Several months ago, this 8-year-old boy began losing hair from his scalp. Other than mild itching, there are no associated symptoms. The patient has no pets at home, but he spends his after-school hours with his cousin, who does.
The child is allergy prone but otherwise healthy. No one else in the family (ie, his two younger siblings) has been similarly affected.
EXAMINATION
About three-quarters of the hair is missing from a 6-cm oval patch on the parietal scalp. A few short hairs remain. The skin in this area is slightly edematous, with focal areas of broken, scaly skin.
Palpation of the head and neck reveals adenopathy in the nuchal area of the affected side. A KOH prep is performed with a #10 blade; the sample includes hairs as well as skin.
What is the diagnosis?
Examination of the sample revealed endothrix, in which fungal spores and hyphae are found inside the broken-off hairs, especially near the roots. A fungal culture confirmed the presence of Trychophyton tonsurans.
T tonsurans is the most common culprit in tinea captitis cases in the United States. This dermatophytic infection of the scalp is a common diagnosis in children, who typically contract it from other children. (Some causative species—such as Microsporum audouinii—spread via contact with animals, but these organisms are generally rare in the US.) Tinea capitis is seen more frequently in boys than in girls, and African-American patients are especially at risk.
Tinea capitis infects the deep hair shaft but spares the skin. Diagnosis requires a combination of clinical signs and identification of the organism in the hair shaft; the latter will also help to guide treatment. In contrast, tinea corporis is diagnosed by clinical features and KOH examination of external scales where the organism resides. Traditionally, infected hairs have needed to be removed for KOH exam—but practical experience has shown that a vigorous scrape that captures infected hairs can accomplish the same thing.
The results of fungal culture may take a month or more to finalize; in the interim, patients such as this one may be treated with griseofulvin (10 mg/kg/d) and application of topical ciclopirox cream bid to reduce infectivity. Total clearance will take at least two months.
Tinea capitis has several forms including inflammatory (which manifests with a large, swollen, inflamed mass) and black dot (named for the tips of broken hair shafts that remain in the affected areas). The differential includes psoriasis, alopecia areata, and seborrhea.
TAKE-HOME LEARNING POINTS
- Tinea capitis is a dermatophytic infection of the scalp usually caused by the dermatophytes Trychophyton tonsurans or T rubrum.
- These infections involve the hair shaft below the skin line, rather than the surface of the skin.
- The organisms that commonly cause tinea capitis in the US typically spread through contact with another person.
- Diagnosis can be made from clinical findings only, including reactive adenopathy. KOH and culture can be necessary in questionable cases, and because of the length of treatment.
Several months ago, this 8-year-old boy began losing hair from his scalp. Other than mild itching, there are no associated symptoms. The patient has no pets at home, but he spends his after-school hours with his cousin, who does.
The child is allergy prone but otherwise healthy. No one else in the family (ie, his two younger siblings) has been similarly affected.
EXAMINATION
About three-quarters of the hair is missing from a 6-cm oval patch on the parietal scalp. A few short hairs remain. The skin in this area is slightly edematous, with focal areas of broken, scaly skin.
Palpation of the head and neck reveals adenopathy in the nuchal area of the affected side. A KOH prep is performed with a #10 blade; the sample includes hairs as well as skin.
What is the diagnosis?
Examination of the sample revealed endothrix, in which fungal spores and hyphae are found inside the broken-off hairs, especially near the roots. A fungal culture confirmed the presence of Trychophyton tonsurans.
T tonsurans is the most common culprit in tinea captitis cases in the United States. This dermatophytic infection of the scalp is a common diagnosis in children, who typically contract it from other children. (Some causative species—such as Microsporum audouinii—spread via contact with animals, but these organisms are generally rare in the US.) Tinea capitis is seen more frequently in boys than in girls, and African-American patients are especially at risk.
Tinea capitis infects the deep hair shaft but spares the skin. Diagnosis requires a combination of clinical signs and identification of the organism in the hair shaft; the latter will also help to guide treatment. In contrast, tinea corporis is diagnosed by clinical features and KOH examination of external scales where the organism resides. Traditionally, infected hairs have needed to be removed for KOH exam—but practical experience has shown that a vigorous scrape that captures infected hairs can accomplish the same thing.
The results of fungal culture may take a month or more to finalize; in the interim, patients such as this one may be treated with griseofulvin (10 mg/kg/d) and application of topical ciclopirox cream bid to reduce infectivity. Total clearance will take at least two months.
Tinea capitis has several forms including inflammatory (which manifests with a large, swollen, inflamed mass) and black dot (named for the tips of broken hair shafts that remain in the affected areas). The differential includes psoriasis, alopecia areata, and seborrhea.
TAKE-HOME LEARNING POINTS
- Tinea capitis is a dermatophytic infection of the scalp usually caused by the dermatophytes Trychophyton tonsurans or T rubrum.
- These infections involve the hair shaft below the skin line, rather than the surface of the skin.
- The organisms that commonly cause tinea capitis in the US typically spread through contact with another person.
- Diagnosis can be made from clinical findings only, including reactive adenopathy. KOH and culture can be necessary in questionable cases, and because of the length of treatment.
Several months ago, this 8-year-old boy began losing hair from his scalp. Other than mild itching, there are no associated symptoms. The patient has no pets at home, but he spends his after-school hours with his cousin, who does.
The child is allergy prone but otherwise healthy. No one else in the family (ie, his two younger siblings) has been similarly affected.
EXAMINATION
About three-quarters of the hair is missing from a 6-cm oval patch on the parietal scalp. A few short hairs remain. The skin in this area is slightly edematous, with focal areas of broken, scaly skin.
Palpation of the head and neck reveals adenopathy in the nuchal area of the affected side. A KOH prep is performed with a #10 blade; the sample includes hairs as well as skin.
What is the diagnosis?
Examination of the sample revealed endothrix, in which fungal spores and hyphae are found inside the broken-off hairs, especially near the roots. A fungal culture confirmed the presence of Trychophyton tonsurans.
T tonsurans is the most common culprit in tinea captitis cases in the United States. This dermatophytic infection of the scalp is a common diagnosis in children, who typically contract it from other children. (Some causative species—such as Microsporum audouinii—spread via contact with animals, but these organisms are generally rare in the US.) Tinea capitis is seen more frequently in boys than in girls, and African-American patients are especially at risk.
Tinea capitis infects the deep hair shaft but spares the skin. Diagnosis requires a combination of clinical signs and identification of the organism in the hair shaft; the latter will also help to guide treatment. In contrast, tinea corporis is diagnosed by clinical features and KOH examination of external scales where the organism resides. Traditionally, infected hairs have needed to be removed for KOH exam—but practical experience has shown that a vigorous scrape that captures infected hairs can accomplish the same thing.
The results of fungal culture may take a month or more to finalize; in the interim, patients such as this one may be treated with griseofulvin (10 mg/kg/d) and application of topical ciclopirox cream bid to reduce infectivity. Total clearance will take at least two months.
Tinea capitis has several forms including inflammatory (which manifests with a large, swollen, inflamed mass) and black dot (named for the tips of broken hair shafts that remain in the affected areas). The differential includes psoriasis, alopecia areata, and seborrhea.
TAKE-HOME LEARNING POINTS
- Tinea capitis is a dermatophytic infection of the scalp usually caused by the dermatophytes Trychophyton tonsurans or T rubrum.
- These infections involve the hair shaft below the skin line, rather than the surface of the skin.
- The organisms that commonly cause tinea capitis in the US typically spread through contact with another person.
- Diagnosis can be made from clinical findings only, including reactive adenopathy. KOH and culture can be necessary in questionable cases, and because of the length of treatment.
When You Can’t Make a Rash Diagnosis
ANSWER
The false statement—and therefore the correct choice—is that MF is almost always fatal (choice “a”). MF can often be controlled, if not completely cured.
DISCUSSION
In its early stages, cutaneous T-cell lymphoma (CTCL) can manifest with an innocuous-appearing rash, notable for its chronicity and resistance to treatment. One example is poikiloderma vasculare atrophicans (PVA), which is identified by nonblanchable atrophic patches with fine surface vascularity that often manifest around the waistline or groin. Left undiagnosed and untreated, PVA can slowly progress to a more advanced stage, as was the case with this patient.
Several cancers can present with rash, including extramammary Paget disease, superficial squamous cell carcinoma (Bowen disease), and various types of metastatic cancer (eg, breast, colon, lung).
The confirmation of CTCL/MF may require serial biopsies over time, as the diagnostic signs can take years to become detectable. These specimens must be accompanied by pertinent clinical information to suggest a differential that includes this lymphoma.
Early-stage CTCL can be controlled with topical steroids, but as the condition advances, specialized treatment is needed. The tumor stage observed in
ANSWER
The false statement—and therefore the correct choice—is that MF is almost always fatal (choice “a”). MF can often be controlled, if not completely cured.
DISCUSSION
In its early stages, cutaneous T-cell lymphoma (CTCL) can manifest with an innocuous-appearing rash, notable for its chronicity and resistance to treatment. One example is poikiloderma vasculare atrophicans (PVA), which is identified by nonblanchable atrophic patches with fine surface vascularity that often manifest around the waistline or groin. Left undiagnosed and untreated, PVA can slowly progress to a more advanced stage, as was the case with this patient.
Several cancers can present with rash, including extramammary Paget disease, superficial squamous cell carcinoma (Bowen disease), and various types of metastatic cancer (eg, breast, colon, lung).
The confirmation of CTCL/MF may require serial biopsies over time, as the diagnostic signs can take years to become detectable. These specimens must be accompanied by pertinent clinical information to suggest a differential that includes this lymphoma.
Early-stage CTCL can be controlled with topical steroids, but as the condition advances, specialized treatment is needed. The tumor stage observed in
ANSWER
The false statement—and therefore the correct choice—is that MF is almost always fatal (choice “a”). MF can often be controlled, if not completely cured.
DISCUSSION
In its early stages, cutaneous T-cell lymphoma (CTCL) can manifest with an innocuous-appearing rash, notable for its chronicity and resistance to treatment. One example is poikiloderma vasculare atrophicans (PVA), which is identified by nonblanchable atrophic patches with fine surface vascularity that often manifest around the waistline or groin. Left undiagnosed and untreated, PVA can slowly progress to a more advanced stage, as was the case with this patient.
Several cancers can present with rash, including extramammary Paget disease, superficial squamous cell carcinoma (Bowen disease), and various types of metastatic cancer (eg, breast, colon, lung).
The confirmation of CTCL/MF may require serial biopsies over time, as the diagnostic signs can take years to become detectable. These specimens must be accompanied by pertinent clinical information to suggest a differential that includes this lymphoma.
Early-stage CTCL can be controlled with topical steroids, but as the condition advances, specialized treatment is needed. The tumor stage observed in
For years, this 64-year-old man has complained of itching and a rash around his head and neck. He has consulted several primary care providers—and even a dermatologist. A punch biopsy performed by that provider yielded no clear diagnosis. The patient was advised to return for follow-up but never did so.
Treatment was attempted with a succession of medications; none resulted in any improvement. The list includes antifungal creams (econazole, clotrimazole, and miconazole), an oral antifungal medication (a one-month course of terbinafine 250 mg/d), and a corticosteroid (a one-month course of prednisone 20 mg/d).
In addition to the rash and pruritus, the patient feels “lumps” in the affected areas. He also reports feeling more tired than usual. Prior to the onset of these symptoms, his only complaint was lifelong eczema.
Large infiltrative plaques are seen on both sides of his neck, extending into his ears and onto his scalp. A few exceed 8 cm in diameter, and all have smooth surfaces with no epidermal disturbance. Several discrete, 2- to 4-cm, fixed nodules are also seen and felt on his neck below these plaques.
A 5-mm punch biopsy is performed on one of the plaques on his occipital scalp; the pathology report shows only chronic changes consistent with eczema. The decision is made to perform another biopsy. A deeper, wider, 5-cm wedge from the left preauricular plaque is taken and submitted. The report shows changes consistent with tumor-stage mycosis fungoides (MF).
