Keratosis Follicularis

Presented by DJ ElpernPhotomicrographs by Jag BhawanAbstract: 10 yo girl with 4 month history of a dermatosis on the neckHPI: The patient is a pleasant 10 year old who presents for evaluation of a symmetrical papular eruption on the sides of the neck which has been present for about 4-5 months. She has been treated with a number of different topicals by her pediatrician without relief. The patient lives with a grandmother and there is no pertinent...

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Facial flush in a pregnant woman

Presented by Henry FoongIpoh, MalaysiaA 37 year old restaurant waitress had these rashes on the face for several years, but worse recently since her pregnancy. She is G2P1 at the end of her first trimester. The rash was described as itching, burning. She had seen a dermatologist in Japan and was diagnosed as rosacea. There was no fever or polyarthralgia. Family history was insignificant. Drug history nil.She feels very uncomfortable. Examination...

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Neurotic Excoriations

Abstract: 37 yo woman with few year history of excoriationsHPI: The patient is a disabled 37 yo woman who has suffered with painful sores on face, arms, buttocks, upper back for a few years. She was a trainer of race horses till a few years ago. She has a history of alcoholism. A few years back, she was diagnosed with alcoholic hepatitis and hemochromatosis (she gets regular phlebotomies). There is a history of sexual abuse starting at age...

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Painful Red Scrotum

Over the past twenty years, we have seen a few patients a year with scrotal burning and/or redness (erythema). Some of these individuals had used topical steroids for prolonged periods, some only for a few weeks. I don't recall if any had not used steroid creams. The condition is called scrotodynia, scrotopyrosis, and red scrotum syndrome. The medical literature gives few clues to its etiology, except that topical steroids can play a significant role in some (or many) of these patients. There is a condition called "vulvodynia" which is similar...

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20 y.o. man with multisystem disease

Presented by Henry B.B. FoongFoong Skin Clinic, Ipoh, MalaysiaAbstract: 20 yo man with mouth ulcers, arthralgias, skin nodulesHPI: The patient is a 20 yr old student who presented with a 3 year history of recurrent mouth ulcers, polyarthralgia (knee, ankles), fever and tender nodules over the shoulders, elbows and legs. The attacks occur about every 6 months and responded to oral prednisolone. Apparently the nodules run a predictable course - initial...

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Tumor in Vaccination Site

Abstract: 59 yo woman with six month history of tumor l. armHPI: The patient, a kindergarten teacher, was bitten on the hand by a child on March 20, 2011. School policy did not allow the child to be tested for hepatitis or HIV. Therefore, it was recommended that she receive hepatitis B vaccination. She had three shots ( March, June and December 2010) in the left deltoid area. In late January or early February 2011 she developed a tumor...

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Temple Bracelet Dermatitis

Abstract: 20 yo woman with allergic contact dermatitis to a bracelet purchased at a temple in BeijingHPI: This young woman purchased some prayer beads at a Beijing temple in early September, 2011. Within two - three weeks she developed a rash under the bracelet. She treated this with a number of topicals including a neomycin containing cream. She was seen in an ER a few days before she presented to my office and started on prednisone and Keflex.O/E:...

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Lupus Erythematosus?

presented by Henry Foong:A case in progress... 14 year-old Malaysian boy with photosensitive eruptionHPI:The patient is a 14 year old student with one year history of erythematous patches on the face, made worse with sun exposure. He is otherwise healthy with no systemic complaints. He has been on no medications byh mouth.Examination showed few discrete 2-4 cm erythematous plaques on the cheeks, nose, upper and lower eyelids. No alopecia. No scarring.I...

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Painful Brusing in a 29 yo Woman

Presented by Hamish Dunwoodie, MBBSMoncton, New Brunswick, CanadaAbstract: 29 yo woman with one week history of painful bruising on thighsHPI: The patient is an otherwise healthy 29 yo woman with a one week history of painful bruises on her thighs. Five years ago she had leucocytoclastic vasculitis of her lower legs and very mild proteinuria. A renal consult felt she probably had mild IgA nephropathy. This has cleared. Her only medication is...

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Traumatic Ulcer

Abstract: 40 year-old man with non-healing woundHPI: The patient is a 40 yo man who sustained traumatic abrasions of his leg and arm from a motorcycle accident on May 31, 2011. He has a history of chronic vesicular dermatitis of hands and feet complicated by recurrent staphyloccal cellulitis of legs. The wound on his right knee became infected and he was hospitalized over the summer on two occasions for parenteral antibiotics and debridement....

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Insect Bite Lymphangitis

Presented by Nai-Chien YeatWilliams College, Williamstown, MassachusettsAbstract: 20 year-old Malaysian college student with one day history of an itchy line on right arm.Yeat's History:I developed itchy welts all over my body shortly after moving into my new dorm room. A bite on my right wrist caused extensive swelling and intense itching within 24 hours of first discovery. Within 36 hours, a swollen, pruritic red streak extended from my wrist to...

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Erythema multiforme major

Presented by: Dr. Henry FoongIpoh, MalaysiaAbstract: Five Year-old boy with E. multiformeThe patient is a 5 year old boy presented with 3 day history of fever and generalised skin eruptions. Apparently it started with superficial lower lip erosion and the next day he had high fever and generalised skin eruptions on trunk, the upper and lower extremities. There was no family history of similar skin problems.O/E he was afebrile. Generalised erythematous...

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Raccoon Purpura

I received this email from an otherwise healthy 23 yo woman who I saw a month ago for an unrelated problem: "I was wondering if you might have any insight to another skin problem I am having. After receiving some terrible news, I have popped a number of blood vessels around my eyes and face to the the point of having dark purple bruises around and on my eyes. I do not know what to do. I look like a victim of abuse and would like to heal my face...

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Post-Operative Contact Dermatitis

Abstract: 63 yo woman with 5 day history of a dermatitisHPI: A 63 yo woman developed a dermatitis 2 d post surgery. An arterial line had been placed in the L. radial artery pre-op. The area was first prepped with chlorhexidine, the line was placed, and the area covered with 6 x 7 cm Tegaderm Film. A venous line was placed in the R. external jugular vein and covered with Tegaderm w/o dermatitis.O/E: An 8 x 8 cm erythematous vesicular and hemorrhagic...

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Two Patients with Longitudinal Nail Dystrophy

This past month, I saw two patients with median nail dystrophies. This is an area that has only rarely been written about. These patients are presented for your interest and thoughts. If you experience difficult with the comment function, you can email DJ Elpern with your thoughts.Case 1.55 yo man with a 1-2 year history of a linear striation of the left thumbnail. This is painful with pressure and occasionally spontaneously painful. There is...

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Congenital Hypopigmented Macules

Presented by Henry Foong, Ipoh, MalaysiaA healthy 16 year old girl complains of asymptomatic 1-2 mm in diameter hypopigmented macules on both shins since birth. There are similar, but to a lesser extent, macules on the arms. Her elder sister has similar lesions. In an older individual with later onset I would have thought of idiopathic guttate hypomelanosis. However, these lesions were congenital and her sister is similarly affected. It does not...

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KS in Renal Transplant Patient

Omid Zargari, a dermatologist from Rasht, Iran, is asking for your help regarding a 74 year old man with extensive Kaposi's sarcoma after renal transplantation. The disease began about two years ago, when he was on Cyclosporine (plus prednisolone). At that time, I asked the nephrologist to change CsA with Sirolimus. Now, he's on Pred+cellcept+sirolimus.I've seen several cases of post-transplant KS. All of them regressed after discontinuing CsA and...

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Smart Phone Fingers?

The patient is a 15 yo girl with a 2-3 year history of painful thumbs. The palmar surface of her thumbs were glazed with decreased fingerprint markings. She has mild hyperhidrosis palmaris. One great toe has mild plantar hyperkeratosis but is not glazed like the thumbs. I noticed a cell phone in her back pocket and asked her to show me how she uses it (see below). She's had this for three years. Her father said she's on the smart phone for hours...

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BCC Tip Nose

The patient is a 70 yo woman who had a nasal bulb lesion biopsied in September 2010. This was an ill-defined area and two, 2-mm biopsies were taken. One showed a superficial and nodular BCC ang the other a melanocytic nevus. This was probably a collision lesion. The patient elected to wait and see what developed.Today, April 29, 2010, the exam shows a residual lesion with arborizing blood vessels on dermoscopy. This lesion requires definitive...

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Melanonychia Totalis

Abstract: 70 yo African-American woman with black toe-nails for many years.HPI: This otherwise healthy 70 yo woman was seen for lichen simplex chronicus of the dorsum of the feet. An incidental finding was that of black toe nails. Anamnesis reveals that this has been present for greater than ten years. She is was on no meds by mouth when this developed.O/E: Most of her toe-nails are black. One or two have longitudinal melanocytic striae. Her...

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Amelanotic Acral Lentiginous Melanoma

Abstract: 61 yo man with 4 - 5 year hx of a tumor on foot.HPI: The patient is a healthy 61 year old man with a 4 - 5 year history of a slowly growing lesion on the plantar aspect of his right foot. On a recent trip to Jamaica it bled, leading him to consult a podiatrist who astutely did a biopsy. The patient has sarcoidosis which has been treated with weekly i.m. methotrexate for the past two years. (I do not know the dose byt presume it is around...

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A Complex Patient

The patient is a 61 year-old woman with long-standing insulin-dependent diabetes, rheumatoid arthritis and insulin-dependent diabetes. Her rheumatologist has treated her with methotrexate which she stopped b/c of side-effects. She has also had side-effects (mostly urticaria) with Humira and Remicaide. She was referred for her psoriasis by another dermatologist. Her meds include insulin and prednisone 10 mg per day.O/E: The patient appears older...

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