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dermatology cases

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1.

Acanthosis
nigricans
Can see with DM,
new GI or lung
malignancies that
are aggressive and
quickly spreading

4.

Obese pt with:
Polyuria
Velvety pigmented rash in folds of neck
and axilla
Fasting glucose >125
2.

Atopic dermatitis
(eczema)

5.

Bullous
pemphigoid
Usually biopsy
Increasing in
frequency
Onset middle
ages, pruritic
bullae,
improves with
steroids
Ddxdermatitis
herpetiformisnot restricted
to flexural
areas,
presents with
assc disease
like celiac dz

Middle aged male, itchy recurrent skin rash


Pruritic papulosquamous lesions in axilla, progress to
vesicles and bulla
Vesicles burst, giving erosions
Lesions not symmetric, don't always occur in the same
place
Normal mucosal surfaces
Improved with potent topical corticosteroids

Condyloma
accuminata
Confused with
condyloma
lata of syphilis
(flat, wet, not
verrucous)

Adolescent with asthma presents with:


long standing intermittent, pruritic,
papulosquamous eruption over
antecubital fossa, behind knees; worse
after hot showers
3.

Basal cell CA
Key: pearly
papules. May
ulcerate

Sexually active pt with:


multiple painless, cauliflower-like, verrucous lesions
on the external genitalia
6.

Middle aged Caucasian woman with:


Skin lesion on forehead
HO extensive sun exposure as child with
repeated sunburns
Flesh colored papular lesion with pearly
sheen, multiple telangiectasias

Contact
dermatitis
Common
triggers:
plants (poison
ivy, oak),
nickle,
perfumes,
rubber,
synthetic shoe
materials

Pt develops:
Itchy, papulosquamous rash on abdomen- scaly, well
circumscribed lesion at the area of the belt buckle

7.

8.

9.

Erythema
multiforme
with genital
HSV
Usually assc
with new HSV
infection, can
also see with
mycoplasma
infection

Erythema
nodosum
Bilateral
painful nodules
over shins= E.
nodosum!
Assc. with GAS
pharyngitis,
Coccidiodes,
Histoplasmosis,
TB, sarcoidosis
(with hilar
adenopathy),
IBD (with abd
pain)
75% idiopathic

Fixed drug
eruption
Same rash every
time
Frequently in
the genital
region

10.

Geographic
tongue-yellowish
or looks like
patchs of "missing
tongue"; Only
tongue condition
that is migratory
(changes
position)

Sexually active adult with:


Pain in the genital region
Rash on forearm
Multiple small painful blisters on external genitalia
with surrounding erythema
11.
Several small target shaped lesions on forearm Guttate psoriasis.
Get small,
without scale or itch
droplike 1-10mm
No mucosal lesions
salmon-pink
papules with fine
scale. Guttate
comes fro latin
"gutta" which
means drop.
History of URI
may precede
eruption, esp due
to strep;

Previously healthy female with:


12.
Fever
Sore throat
3 wks painful, erythematous nodules on shins->
bruises

Hairy
Leukoplakia
Caused by EBV
DDx- thrushwhole mouth,
can be removed
with red
undersurface

Pt prescribed Doxycycline for rx of pneumonia,


after 3 days develops:
Large erythematous annular plaque in the genital
region
Had same rash as teen when given Doxy for acne
Resolves with DC of Abx

Pt with:Intermittent mild pain and


burning on the tongue
Variable, raised, yellow pattern on the
tongue that changes position

22 y/o woman presents with hundreds


of 2-5 mm scaly red papules on trunk
and extremities that are moderately
pruritic. Lesions appeared abruptly
about 2 wks prior to exam and quickly
spread. Pt had sore throat the prior
month. What's dx?

Pt with:
Wt. loss x 3 mo
Intermittent fevers
Bilateral white plaques on the lateral
aspect of the tongue that cannot be
removed with a tongue depressor
+ HIV ELISA, Western Blot

13.

Hidradentis
suppurativa
DDx- boils
(furuncles, not
symmetric, get
central necrosis),
acne conglobata
(not in axilla)

16.

Multiple actinic
keratosis with
squamous cell CA
in situ
AKs turn into SCC

Middle aged Caucasian woman with:


Skin lesion on forehead
HO extensive sun exposure as child with
,multiple sunburns
Multiple rough scaly patches on
forehead, dorsum of hands
One patch on the forehead has a firm
hyperkeratotic macule

Female presents with:


Pain under both axilla x 2 mo- began as
small bumps but getting larger
Significant pain and erythema around
the bumps x 24 hrs
Deep, nodular lesions in both axilla
without any cental area of necrosis
Few comedones in the axilla
14.

17.

Melanoma
Remember the
ABCDEs

Middle aged Caucasian woman with


Skin lesion on her thigh
HO extensive sun exposure as a child
with repeated sunburns
Flat, asymmetric, pigmented lesion, lacks
uniform color, is 8mm in size
Enlargement over the last few months
15.

Molluscum
contagiosum
Key- central
umbilication
Have depressed
center to the
lesions
Can be large,
numerous with
HIV

Pt with:
Multiple, painless clustered papules with
central umbilication on the arm (or
anywhere else)

Necrobiosis
lipoidica
diabeticorum
Painful nodules
would be E.
Nodosa. These are
yellow plaques

Diabetic pt with:
Yellowish irregular plaques with purplish
pigment at the edges over both shins
18.

Pediculosis
capitus= head lice
Might see nits,
louse picture

Adolescent from a group home with:


Scalp itching
Erythema at the base of the scalp
Mild bilateral posterior auricular
lymphadenopathy
Woods lamp- small area of pale blue
fluorescence at the base of multiple hair
shafts

19.

20.

Pediculosis
pubis = pubic
lice
Blue macules
not always
present
Can be visible
Ddx scabies- see
itching in other
parts of the
body as well

22.

20's y/o with:


Bilateral itchy, erythematous plaques in knees,
elbows that develop an adherant silvery scale that
bleeds when removed
Similar plaques on the scalp
multiple tiny pits in some of the nail beds

Young sexually active adult with:


Itching in pubic region
Multiple small bluish macules along the
upper abdomen and inner thighs
Palpable small inguinal lymph node

Pityriasis rosea

23.

Young patient with:


Asymtomatic rash on back 1 wk after
circular salmon-colored scaly patch on
chest
Multiple plaques on back with long axis
oriented in direction of skin lines in
"christmas tree" distribution; No tx
necessary and usually clears within 6-8
wks.
21.

Porphyria
cutanea tarda
Always think of
with Hep C,
isolated rash on
hands
Urine
uroporprin
levels just
confirm it
Can be scaly,
blistering,
vesicles

Psoriasis
Assc with
spondyloarthropathies

Pt with active ulcerative colitis presents with:


Pretibial sore, began as erythematous pustule>nodular->ulcer, ragged with purple raised border
Skin bx- tissue necrosis with neutrophilic infiltrate
cx- Staph, but no AFB or fungi
24.

Pt with Hep C, cirrhosis with:


Blistering lesions on dorsum of hands,
began as erythematous macules with
adherent scale
Intermittent sun exposure in past month
Elevated urine uroporphyrin levels

Pyoderma
gangrenosum
Keys: UC, neutrophilic
infiltrate; Assoc with
IBD (crohn's and UC);
May also be assoc with
RA. Usually has a
violaceous hue.

Rosacea
Keys: lack of
comedones, worse
with alcohol,
telangiectasias

Middle-aged female develops:


"Acne" on the cheeks
Repeated eruptions of facial flushing and
erythematous papular lesions, made worse with
alcohol intake
Multiple small papules on the cheeks without
comedones
Scattered telangiectasias

25.

Scabies
May describe mite
burrow
Intense itching,
ESP axillary and
interdigital webs

28.

Nursing home pt with:


Itching, worse at night, x1 month
Multiple excoriations in both axilla and
groin, on the wrists, between fingers
26.

27.

Seborrheic
dermatitis
Can also present
on eyebrows,
lashes, facial hair
HIV can have a
much worse
presentation; Due
to a lipophilic
yeast in skin
called
Pityrosporum
ovale and can be
tx with
ketoconazole
cream, ciclopirox
gel or low
potency topical
steroid.

29.

Adult pt with:
"dandruff" and scaly rash around the
nose with underlying redness when the
scales are removed

This is
seborrheic
keratoses
and it may be
a marker for
a non-skin
malignancy
but is
completely
benign and
not a
precancerous
lesion.
Usually has
"stuck on"
appearance
(like you
stuck on a
piece of clay)
with warty
surface.

What's this and is it a marker for malignancy.

Tinea capitis
Keys: elderly,
African
American,
barber, black
dots. Usually
an unclean
razor

African American male, complains of hair loss after


getting his hair cut by an electric razor
Annular scaly patch of hair loss
Small black dots over the hair follicles
Palpable small posterior cervical lymph nodes

Stevens-Johnson
syndrome
Triggers: sulfas,
abxs, allopurinol,
antiepileptics
(esp phenytoin,
carbamazapine),
NSAIDs
Skin sloughing of
>30%= toxic
epidermal
necrolysis
Pt with HIV:
prescribed Bactrim for presumed
pneumocystis infection
2 days later, gets fever, painful
erythematous blistering rash on <10% of
body surface, including mucous
membranes, mouth, and conjunctiva

30.

31.

Tinea corporis
Clues: cat. Could
be wrestler.
Often confused
with herald patch
of pityriasis, but
that doesn't itch.
Granuloma
annulare doesn't
scale. Nummular
eczema looks
different on
micro

33.

Pt with:
annular scaly rash on arm, present since
week after getting a new cat
Clear towards center of rash with raised
advancing erythematous margin and
scale

Tinea pedis
Can also see
vesicles, nail
thickening

Pt wears heavy shoes and goes to then


gym with:
Itchy rash between toes
Multiple intensely pruritic pinpoint
vesicles between the toes
32.

Tinea versicolor
Patches tend to
be worse in the
summer
Disseminated
skin rashes can be
syphilis, micro
gives diagnosis
From malassezia
furfur; very
difficult to tx.

Dark skinned individual presents with:


Scaly rash on chest
Numerous hypo and hyper pigmented
areas
No large isolated patch
No itching
KOH stain- spaghetti and meatball
fungal hyphae

Verrucus vulgaris
(plantar warts)
Keys: wt bearing
parts of feet,
verrucous
appearance,
disruption of nl
skin lines

Pt with:
Pain with walking
Multiple raised verrucous growths on
the heels and balls of the feet that
obscure the nl skin markings and are
painful when palpated