Leg Ulcer in a Heart Transplant Patient

The patient is a 49 yo man with a one month history of a very painful leg ulcer.He is 8 years s/p heart transplant.His medications include: CsA, CellCept, Pred, Diltiazem, Ranitidine.There was no history of trauma and no similar ulcers in the past. He works at a supermarket and is on his feet all day long at work.This ulcer is periodically painful. He has had leg edema for over a year.The examination shows an 8 mm in diameter ulcer with as slightly...

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Retroauricular Dermatitis

The patient is a 25 year old registered nurse with a few month history of a painful and pruritic process in the right retroauricular area. She also has mild scalp pruritus and some increased scaling of the scalp.The exam shows a superficial erosion in the right retroauricular sulcus.Bacterial Culture: Positive for Many Staph aureus - resistant to Pen and ErythroPt. Started on mupirocin creamNote: She is an obstetrical nurse and has contact with...

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Periocular Dermatitis

The patient is a 35 year old man who has had a right-sided eyelid dermatitis for around eight months. He was given a moderate strength topical steroid for this by his primary care physician and has been using it off and on since. When the process flares, he applies it again.There are discrete erythematous papules around the upper and lower lids on the right side. The left eyelids are clear.The clinical picture suggests a steroid-induced periocular...

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A Hunter in Deer Season

The Hunter as Hunted[Your comments are welcomed]This 72 year old man was deer hunting on December 2, 2006. He remembers sitting on a log for 45 minutes and feeling as if he was being bitten. Later that day, his hunting companion removed three ticks from him. He presented on Monday, December 5 for an evaluation. The picture is taken from his left hip. The tick was gently removed and photographed with a paper clip. Since the tick was attached...

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Difficult BCC

From A.R. PitoNorfolk Island, S.P.A friend from Australia sent me this photo with the following note."A.R.: I just saw this 56 yo man with a two year history of a large ulcero-nodular plaque on his left temple. Biopsy is pending but this appears to be a morpheaform BCC. Assuming this is BCC, what would your therapeutic suggestions be.Radiotherapy?Mohs?In our area, we do not have a specialized cutaneous radiation centre, but he could be sent to...

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5 year old girl with perioral rash

This 5 year-old girl presents with a 5 month history of a dermatitis at angle of mouth and upper lip. There are areas of patchy erythema with scale and discrete acneiform papules. She has been treated with mupirocin cream, ketoconazole cream, and 1% HC cream. None of these have helped. She is not atopic, has no family history of atopy and is not a lip licker.Althoug subtle, I think this is perioral dermatitis of childhood. Tetracycline is contraindicated....

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A Patient from Ghana - Please comment

Anak VGRD members have been asked to comment on a 16 year old Ghanaian girl from a small village without any specialized medical care. In otherwise good health and of normal intelligence, since age two she has a history of small hyperpigmented papules on her face. The larger lesions on her forehead appeared over the last two years. She patient states that she doesn't manipulate any of the lesions and that they are asymptomatic. There has been...

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? Segmental Neurofibromatosis

The patient is a three year-old girl with 2 cafe au lait spots on right arm and chest since she was a few months old and many small "freckles" on right chest and axilla (see photo). There are a few freckles on the right upper back as well. No pigmented lesions on any other area. Have not looked for Lisch nodules yet.Athough it may be too early to tell, I suspect this is segmental neurofibromatosis. Most cases of segmental NF are diagnosed because...

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BCC of Eyelid

This is a 75 yo man who came in for an unrelated problem.This tumor was obvioius, however.Two years ago, and ENT physician told him he had a "blocked duct."This 6 mm in diameter lesion looks like a BCC.I propose to excise it but am worried about pulling down the lower lid.I don't think C&E or Aldara would be appropriate. Mohs might be overkill.Do you have any comments? I would, oif course, try to undermine the tiss...

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84 yo Man with Atrophie Blanche

The patient is an 84 yo man with a ten year history of extremely painful ulcerations of his lower legs.Other than whirlpool baths, I have found nothing to be of value.His health is good and he has bounding dorsalis pedis and posterial tibial pulses.I assume this is Atrophie Blanche. Do you have any therapeutic suggestoi...

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Localized Hyperkeratosis

39 yo man with > 15 year hx of localized hyperkeratosis of right great toe. No unusual trauma to area. He's used mostly over the counter emollients without much help.Are you aware of any localized forms of hyperkeratosis?I have started him on Salex cream.Pictured below are his affected right and normal left great to...

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Recent Onset Acne in Young Woman

This 21 yo woman experienced the sudden onset of acne one month ago.No new med. No unusual stresses. She has never had acne like this before.Do you think this is a mild case of pyoderma faciale rather than typical ac...

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BCC Scalp

The patient is a 75 yo man with a three month hisory of a lesion at the vertex of the scalp.Exam: Man with Type II - III skin. 2 x 1.6 cm diameter erythematous plaque scalp. There are some small crusted areas.Biopsy shows superficial BCC.Question: Is Aldara appropriate?C + E will take ages to heal.Excision could n ot be closed without a graft or a fl...

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19 year old student with acneiform eruption

History: 19 year-old man with a 5 year history of acneiform eruption predominately on torso and proximal extremitiesl Some facial involvement, but less than on torso. He is in good health, no history of diabetes or steroid use. No antibiotics for months. In the past he has used benzoyl preoxide ceams and washes, topical retinoids, topical antibiotics and tetracycline and its derivatives. Mome has ever helped.Exam: Healthy young man with Type...

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Atypical Nail Pits

Case for Discussion:This 40 year-old woman presented for evaluation of a nail dystrophy present for 2-3 months.She has a history of Hashimoto's thyroiditis. About 9 months ago she developed vitiligo.Her health is otherwise normalMeds. Synthyroid and ironLab: Thyroid Perox AB 248 (Nl. 0 - 34 IU/ML) ANA < 1:40Physical Exam: Vitiligenous patches left neck and left upper back Around 4 finger nails show a distinctive pitting....

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Hemangioma of Auricle

This 4 month infant girl was born with hemangiomas of the chin and left ear.The lesion on the chin (not pictured) measures 1 cm in diameter and is typical of a congenital hemangioma.The abnormality of the left ear involves the triangular fossa and the helix. I am concerned that as this involutes it could cause disfigurement. At the same time, I wonder if anyone has experience handling similar lesions in this site. A PubMed site found only a paucity...

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Nevus, Congenital

This 20 yo college student presented in consultation for removal of a congenital nevus.The lesion is located just distal to her left knee. She's been embarrassed about this since childhood and for the past six or seven years won't let anyone see it. Indeed she covers it at all times with bandaids.The lesion measures 5.2 cm in diameter.I have referred her to a surgeon for removal since I think that's better than psychotherapy. To minimize the scar...

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Imiquimod Side-Effect?

This 66 yo woman began topical imiquimod on July 27, 2005 for a biopsy proven superficial BCC of the right upper lip. One week later, she developed aphthous ulcers on the mucous membrane surface of the area just below the site treated. A literature search retrieved a reference to his occurence. This is another unexpected adverse effect. It is unclear how common this is.Aphthous ulcers associated with imiquimod and the treatment of actinic cheilitis.Chakrabarty...

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46 year old woman with indurated depressed lesion

A 46-year-old woman presented with 7 years history of depressed lesion just above the left side of mouth. It was asymptomatic. She has seen few dermatologists and a plastic surgeon but none really helped her lesion. She did not have polyarthalgia or other constitutional symptoms. Drug history was nil significance.Examination showed 2 areas of depression, almost tethered to the underlying dermis just above the left side of the mouth and another...

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Basal Carcinoma - Deconstructed

August 9, 2006.LATE BREAKING!! BIOPSY HERE SHOWED THE LESION TO BE AN INTRADERMAL NEVUS.I should have paid more attention to the history.MORE... The patient underwent an excision - and the final report was a Basal Cell + an intradermal nevus. Quite unusual. The initial clinical impression was more accurate that the incisional biopsy. This is sobering.This 57 yo man presented with an 8 mm in diameter papule that has bled since he started to wear...

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84 yo man with Pemphigus

This 84 yo man was seen around weeks ago with an erosive bullous process on torso, head and neck of 4 months duration. He was on no meds by mouth and in good general health.My initial impression was pemphigus vulgaris vs. impetigo. The skin culture showed many coag + staph, and the bx showed an acantholytic bulla. The DIF was positive for intracellular IgG.He was treated with dicloxacillin 250 mg qid and prednisone 20 mg tid.He cleared quickly....

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40 yo woman with scarring alopecia

The patient is a 40 yo woman with an eight year history of scarring alopecia. Her ANA is + at 1:160 - all other labs are normal. No other cutaneous findings or systemic disease other than "fibromyualgia."She has been treated with 200 mg of plaquenil b.i.d. for a number of years. This has not been of much help.The patient is quite concerned about her scalp. She's going through a divorce and worries about her appearance.Questions?1) Any value to...

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Melanonychia in a Six Year-Old Child

Presented byDr. Chee Meng Loh RMGSingaporeE mail: bliss88@singnet.com.sgThe patient is a six year old Chinese girl who developed a dark pigmented longitudinal band on the nail of her right index finger about 1 year ago. It started as a narrow, light brown band and grew in darkness (black in centre of band, and lighter shade of brown at edge of band) and width. The band is now about 3 mm in width. It has not changed in the past 3 months.There is...

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16 yo girl with papulonecrotic lesions

The patient is a 16 yo girl with a 2 year history of papulonodular lesions on the extremities and face. There is no evidence that these are excoriations. Biopsy 9 months ago from the arm was read as prurigo nodularis, but lesions look atypical and have now started to appear on the face. She is well otherwise. A repeat biopsy on June 27. 2005 showed:DIAGNOSIS: Skin - Left Temple: Epidermal necrosis with s cale crust containing neutrophils , sub-epidermal...

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Bullous Eruption after Surgery

This 72 yo man had a laparoscopic cholecystectomy four months ago in Florida. Within a few weeks, he developed a bullous eruption around the area of surgery. His surgeon and primary care physician have treated with cephalosporins, topical mupirocin and triamcinalone cream. All without avail.A culture obtained at my office showed: coagulase negative staph resistant to everything except tetracyclines and rifampin. This is probably not significant.The...

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Rapidly Growing Lesion in a 57 yo woman

The patient is a 57 yo woman with a 6 month history of a papule on the right arm.The lesion measures 6 mm in diameter and had not diagnostic features. An excisional biopsy done since this was a rapidly growing lesion which was not clearly benign.Pathology shows a malignant melanoma, 2.3 mm thick, Level IV.Signed out as superficial spreading, but clinically looks more like a nodular melanoma.She has been referred to a dermatologic oncologist for wide...

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78 year old woman with unusual tumor

This 78 yo woman presented with a two week history of a dark growth on the posterior aspect of her shoulder. She had myalgias and felt unusually tired. The exam showed a tick engorged with blood. I could not tell if this was the deer tick that may carry Lyme Disease. Lyme antibidoes were ordered and she was started on amoxicillin 500 mg. tid for three weeks. She's a light complected Caucasian and doxycycline may cause photosensitivity in this...

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Cold Urticaria

1 month history Originally uploaded by David Elpern. MAY 31, 2005This 17-year-old high school student presented for evaluation of hives after exposure to cold air or products. This may have followed an upper respiratory infection. It has been present for only about a month. EXAMINATION: Dermographia is negative. After applying a cold soda can to her arm for two minutes, she developed an urticarial area exactly in the shape of the can...

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55 yo woman with new facial lesion

This 55 yo woman has has a one week history of a painful necrotic lesion on her left temple. She suffers from chronic pain and depression but is on no new meds. Her health is otherwise good. Her hemogram is unremarkable. Two days ago, she developed a similar lesion on her left shoulder. At present, it is just an erythematous papule with a surface erosion. He internist started her on cephalexin 500 mg bid before I saw her.Both lesions, by history,...

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23 yo woman with facial erythema

This 23 yo woman has had facial erythema and acuminate micropapular lesions since childhood. She has extensive keratosis pilaris of her arms and thighs in addition. She has not gone out in public without thick make-up for 10 years. Her fiance has never seen her without make-up. She is desperate to haved this treated. I suspect this is a variant of KP rubra facei, possibly with ulerythema oopryogenes KPRF 005 Originally uploaded by David...

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Seven Year Old Boy with Chronic Dermatitis

A.D. is a 7 year-old boy who was adopted from Siberia by a family in western Massachusetts at 21 months of age. Since adoption he has had recurrent dermatitis on torso and extremities. The lesions are mostly nummular by history. They have responded to systemic antibiotics on occasion. He was seen here yesterday for the first time for a second opinion.The child appears normal otherwise. He has no evidence of atopy. This is the largest lesion....

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A Change of Pace

The patient accompanied her "mother" to the office. She is a 12 yo chihuaha with autoimmune thyroid disease and extensive alopecia areata. I was aksed what could be done and injected large areas of her skin with intralesional triamcinalone. Unfortunately, there is no billing code for this - the dog lacked health insurance. (Actually, I deferred treatment until I hear from my august colleagues)Note tail alopecia in Fig. 3Fig 1Fig 2Fig. 3Ref:A...

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