Dear Colleagues,Please help me with a 4 year-old lad who was referred today by his GP for genital warts. A court-appointed foster parent brought him in for evaluation. His 21 year-old mother left him recently with relatives. She is an inattentive parent with an alcohol and possibly a drug problem. The child was in pre-school but was suspended a few days ago because he was using sexually explicit language, being physically abusive to his peers, discussing French kissing and saying he was going to shoot himself.The exam showed a quiet, calm and...
Friday, December 29, 2006
Wednesday, December 27, 2006
Unusual Case
This 53 yo man presented with a three week history of a pustular eruption on the left small finger. It began as a papule and slowly enlarged.History reveals that he has a farm with 500 sheep. He has also been exposed to cats and dressed a deer around a month ago.Diagnostic tests were done.Follow-up: The KOH prep was positive. The fungal culture is positive at ten days. Thus, this is inflammatory tinea manus. Await fungal culture for typing of...
Saturday, December 16, 2006
Unilateral Bullae
HistoryThe patient is a 28 yo man referred on a walk-in basis with an eight month history of a bullous eruption on the dorsum of his left hand. He gets one or two painless lesions a month. No history was sent over with the patient and he is a poor historian. His medications include Welbutrin, Clozeril and Soma (carisprodol/aspirin)Exam:The only findings are on the dorsum of the left hand. Here, there is a hemorrhagic bulla, a vesicle and areas...
Sunday, November 5, 2006
Mystery Rash in Runners
The Williams Cross Country running team went to a meet on the Connecticut shore on Saturday, October 28. There had been a big storm the previous day. The course took them through brackish water sometimes thigh deep. Within a 24 - 48 hours, around half of the runners had developed intensely pruritic lesions on arms and legs. The vast majority of the lesions were on exposed skin. The primary lesion appears to be a juicy papule or a clear vesicle....
Sunday, October 22, 2006
Teenager with a Red Nose
This 14 year-old girl has had a red nose for the past two years. It followed as severe sunburn. Her nose never looks normal. Occasionally, there are small cysts with bleeding and purulent drainage. I have seen this picture occasionally in teenagers. It looks like a rosacea variant. I'd also consider demodex. Your suggestions are anticipated and will be welco...
Sunday, September 24, 2006
30 year old woman with changing mole
This 30 yo woman has noticed an enlarging pigmented lesion in her right axilla for almost a year. Her mother, a registered nurse, asked her to see a dermatologist. Her husband did not notice it.The patient has Type II skin. The general cutaneous exam was unremarkable save for a 1.2 cm in diameter barely elevated plaque. There is a play of pigment and outline is irregular.An excisional biopsy was performed.Pathology: Malignant melanoma in situ...
Tuesday, September 19, 2006
Positive Band Aid Sign
Most dermatologists know about the "positive band aid sign." To me, it means a skin cancer has been lurking there for a while.This 82 yo man came in with a one year history of a "sore" on his back. The drainage stained his shirt. When the band aid was removed, there was a one cm in diameter clean friable tumor, most likely a basal cell. The lesion was shave biopsied and desicated and curetted. I'll affix a copy of the biopsy report when I get...
Wednesday, August 30, 2006
BCC of Eyelid
This 43 yo man has a one year history of a lesion of the left lower lid. It measures 8 mm in diameter.Biopsy from "X" confirms "nodular BCC."Question: What is best therapy?1) Mohs2) Mohs + closure by ophthalmic plastic surgeon3) Ophthalmic plastic surgeon handle all4) Another approachCada vendador allabe sus agujas.Every peddler praises his needl...
Wednesday, August 2, 2006
Therapeutic Question
The patient is an 83 year-old woman with a two year history of a lesion on the nose. Clinically, this is a basal cell. My question is what you would recommend as therapy and why?1) Micrographic surgery with forehead advancement flap.*2) Micrographic surgery with graft or allowed to heal by secondary intention.3) Radiotherapy3) Other * Repair of defects on nasal sebaceous skin.Dzubow LM.Department of Dermatology, University of Pennsylvania...
Wednesday, July 26, 2006
An Incidental Finding
The patient is an 85 yo man who presented for generalized pruritus which has been present for two years. He has a history of prostate cancer and gastrointestinal bleeding. He's had a few transfusions over the past year or so and was concerned that they caused his itching.He did not complain about his nose. I asked about it and he and his daughter gave this history: Three years ago he was hospitalized for pneumonia. He delvelped an inflammation...
Monday, July 24, 2006
Tale of Two Lesions
I saw these two patients today. Your comments are most welcome. Path reports will be affixed when available.1) 69 yo man with 1.5 month history of lesion right pinna. The lesion is slowly growing. The patient's son, a family doctor, asked him to make an appointment. This is a subtle lesion that could be a lentigo or a lentigo maligna. Two representative areas were biopsied.2) A 55 year-old priest whose parishioner noted a lesion on his left...
Wednesday, July 19, 2006
Hypopigmentation in atopic dermatitis
This is a 7-year-old boy who developed multiple patches of hypopigmentation on the dorsum of the hands for 3 years. He had a history of atopic dermatitis and had severe eczema of the hands prior to development of the hypopigmentation on the hands. According to the mother, he had secondary infection with crusts formation on the hands. The lesions were patchy hypopigmented macules mainly on the dorsum of the hands and feet. There were no family...
Wednesday, July 12, 2006
A Case from New Brunswick
A friend from coastal New Brunswick sent this interesting case:Dear Dr. Elpern,The patient is a 91 year-old working lobsterman who was sent in by his GP for evaluation of a large fungating tumour on his left temple. By history, the lesion has been present for 15 years but has only really increased in size in the past 18 months. He's in vigourous good health otherwise.On close examination, the tumour was found to be on a stalk. It's surface measured...
Thursday, July 6, 2006
Probably Lyme
The patient is a 56 year old man in good general health.Six days ago, he developed an erythematous papule on the left abdomen. Over the past week, this has grown into an oval 10 centimeter pruritic erythematous plaque.This is a solitary lesion and the remainder of the cutaneous exam is unremarkable.There is no history of tick bite, but this is an endemic area and the patient has an outdoor life-style.I suspect this is Lyme Disease and that it is...
Wednesday, June 28, 2006
Eye Lash Alopecia
The patient is an eight year old girl who has had a dermatitis of her eyelid margins off an on for around a year. She gets crusted areas which itch and her mother feels she plucks her eyelashes. On the day of the visit the lids looked quiet, but there was definite loss of some eyelashes. There is some evidence of broken lashes.Question:Is this eyelash trichotillomania or isolated alopecia areata of the eyelashes? I favor trichotillomaniaWhat...
Saturday, June 24, 2006
Bed Bugs
This 35 year-old man went to Mamaronek, New York to watch the New York Open Golf Championship last weekend. The closest motel room he could find was in Bridgeport, Connecticut. The latter is a city with a fairly poor reputation. Two days after returning home to Massachusetts he developed the lesions pictured here on arms and to a lesser extend on torso and legs.They are consistent with bedbug bites (Cimex lenticularis). For a brief description...
Tuesday, June 20, 2006
Lyme Disease
This 52 year-old woman presented as a walk-in patient today. She has a five day history of an erythematous nodule on the right shoulder which has developed a ring around it. The ring measures 9 by 11 centimeters in diameter. Initially, the nodule was painful for a few days; but the pain has subsided. She has had no fever or constutional symptoms and has continued to work as a school teacher.The patient lives in rural New Hampshire and gardens...
Wednesday, June 7, 2006
Erosio interdigitalis blastomycetica
Why do dermatologists love these cumbersome terms??The patient is a 30 yo woman with a two week history of a sore area between the 3rd and 4th toes of the left foot. She is in good general health. Not pregnant and on no oral contraceptives. Both parents have Type II diabetes. At the time of onset she was on doxycycline for rosacea.The examination shows an erosion in the toe web. The KOH prep was positive for pseudohyphae consistent with the...
Wednesday, May 24, 2006
Genital Pain in a 60 yo Man
Dear Pre-VGRD,Thank you for allowing me to present this difficult case.The patient is a 60-year-old journalist, who presents for evaluation of genital pain that has been present for about six months. He has been in his usual state of health. No new sports or traumas. His medications include atorvastin, buproprion and the generic omeprazole. He has an annoying, painful sensation on the ventral shaft of the penis. He has noted some hyperpigmentation there and occasionally the skin here gets red. He thinks this lasts for a few hours but he is...
Thursday, May 18, 2006
Photosensitive dermatitis from bleaching creams
My friend, David Elpern MD, a dermatologist from Williamstown, USA sent this note to me. "NY TimesMay 14, 2006A Vision of Pale Beauty Carries Risks for Asia's WomenBy THOMAS FULLERMAKHAM KHU, Thailand - Neighbors gawk and children yell, "Ghost!" The manager of the restaurant where Panya Boonchun worked simply told her she was fired.The cream that she applied to her face and neck was supposed to transform her into a white-skinned beauty, the kind...
Wednesday, May 17, 2006
Onycholysis
The patient is a healthy 58 year old woman with a 3 year history of onycholysis. Fungal culture has grown out Candida zeylanoides. Bacterial culture negative.Topicals have not been of help. (imidazoles and thymol in chloroform)Would fluconazole be of value?Should the nail be avulsed?Who has had success treating this kind of probl...
Thursday, May 11, 2006
Pellagra in Alcoholics
In Iraq, pellagra is only seen in sporadic cases in patients with alcoholism. I describe here a case of pellagra in 30 year old man who used to drink alcohol one litre a day of a local beverage called ARAK. In addition, his nutrition was poor. He developed a typical rash of pellagra in photosensitive area, some lesions are bullous together with beefy tongue. The rash resolved quickly after vitamin replacement but recurred when he resumed alcohol...
Monday, May 8, 2006
Nail Bed Carcinoma
The patient is s 70 yo man who was seen today for a three year follow-up of micrographic surgery for a sqaumous cell carcinoma of the nail bed. There is no evidence of recurrence and the results are cosmetically excellent.I had another patient with a similar lesion. He was a VA patient and they did not approve him for microgrpahic surgery. He had the distal part of his thumb excised. Bizarre that health insurance trumps the interests of the ...
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