derma

A 50-year-old female with type 2 diabetes

controlled with insulin complains of a rash
that has developed on her legs over the past
year. It started as a small patch on her left leg
and then "spread" to her right leg. It is
neither painful nor pruritic.
You are impressed by the rash she shows
you
The most appropriate next step in the management of these lesions is which
of the following?
A-A topical mid-potency steroid under occlusion or intralesional steroids
B-Discontinue insulin
C-Increase her insulin dose
D-Liberal use of emollients (e.g., petrolatum)
E-Leg elevation and application of compressive stockings
The correct answer is "A."
This patient has developed necrobiosis lipoidica, a benign condition of the skin
affecting a small percent of diabetics, usually those on insulin .
Look for brownish red patches or plaques with yellowish areas through the
center. The center is often shiny with telangiectasias.
The legs are most often involved and the lesions may be painful.
The name describes the pathology: necrobiosis refers to the inflammation
around destroyed collagen, and lipoidica refers to the yellowish color associated
with lipid deposits.
It does not seem to be caused by insulin or affected by glucose control, so "B"
and "C" are not appropriate choices.
These lesions can be confused for eczema, and in fact may respond to topical
steroids ("A"); however, emollients are not useful.
Finally, necrobiosis lipoidica might be confused with the skin changes associated
with venous stasis and chronic edema, which would be treated as in "E.”
Patients should know that necrobiosis lipoidica is often chronic and difficult to
treat but benign. The diagnosis is clinical but can be confirmed by biopsy, and
treatment is not always necessary.
Your patient also
complains of thick,
dark, velvety patches
under her arms
She's unsure of the duration,
but states, "They've been with
me a while. I just wondered if
my medication might cause
these." She gives you an
accusing look, and you have to
admit that she takes more than
a few medicines related to her
diabetes.
Which medication provides a clue to the diagnosis?
A-Aspirin
B- lisinopril
C-insulin
D-simvastatin
The correct answer is "C." The lesions are typical of acanthosis nigricans, a hyperkeratotic,
hyperpigmented condition affecting skin folds (neck, inguinal area, axilla, etc.).
The common causes of acanthosis nigricans are
obesity, insulin resistance, and diabetes.
From med school, we all remember acanthosis nigricans as a cutaneous manifestation of
internal malignancy. But such a presentation is rare. Cancer is more likely in patients with
extensive and quickly progressing lesions, and as you might expect, it's not a good sign.
Your patient returns a year later and the lesions on her legs have essentially
disappeared. Now she has a new concern.
She reports a sore on the bottom of her great toe. She's uncertain how it
occurred and thinks it has only been present for a few days. You find a 1-cm
circular ulcer at the plantar aspect of her great toe. Pulses are diminished.
Which of the following should be the next step in treatment?
A-Culture the wound
B-Perform an MRI of the foot
C-Perform monofilament testing to check sensation in the foot
D-Debride the wound
E-Obtain ankle–brachial indices
The correct answer is "E."
The described wound is most likely a diabetic foot ulcer, but the location and the patient's
history of diabetes do elicit concern for an ulcer related to vascular disease. Additionally, good
vascular supply to the foot is necessary for wound healing. Therefore, you need to know the
status of blood flow to the foot.
This may be accomplished by physical examination. For patients at high risk for peripheral
vascular disease or without strong pulses, ankle–brachial indices would be the next step
 Culture of an open foot ulcer is pretty much worthless as it will likely return as polymicrobial. X-
ray may be warranted as well as probing the lesion to see if it reaches the bone in order to
evaluate for osteomyelitis, but MRI is jumping the gun.
Knowledge of a patient's baseline sensation is important and good general foot care (shoes that
fit, meticulous skin and nail care, can help in the prevention of future ulcers.
Wound debridement will help to remove necrotic tissue and improve the speed of wound
healing. The biofilm must be removed down to healthy tissue in order to maximize healing.
Ankle–brachial indices in both legs are normal. The rest of her skin is in good condition.
Through her diligent care and control of her diabetes, the ulcer heals. She returns 3 months
later with a new skin concern. On her anterior shin, she has developed a clear fluid-filled
blister about 1 cm in diameter and irregular in shape. There is no erythema, no pruritus, and
no pain. She denies trauma and new environmental contacts.
Which of the following is the most likely diagnosis?
A-Dyshidrotic eczema
B-Contact dermatitis
C-Staphylococcal scalded skin syndrome (SSSS)
D-Bullosis diabeticorum
E-Drug eruption
The correct answer is "D."
Bullosis diabeticorum, or bullous disease of diabetes, occurs in less than 1% of diabetic patients.
However, patients may be alarmed by it and seek treatment.
The cause is unknown, but it typically follows a benign course and resolves spontaneously over a
few weeks or months. Because it requires no intervention, it is useful to distinguish bullosis
diabeticorum from dyshidrotic eczema and contact dermatitis, both of which may mimic the
disease except for pruritus and inflammation.
Bullosis diabeticorum, or bullous
disease of diabetes, occurs in less
than 1% of diabetic patients.
However, patients may be alarmed
by it and seek treatment.

The cause is unknown, but it

typically follows a benign course
and resolves spontaneously over a
few weeks or months. Because it
requires no intervention, it is useful
to distinguish bullosis diabeticorum
from dyshidrotic eczema and
contact dermatitis, both of which
may mimic the disease except for
pruritus and inflammation.
Dyshidrotic eczema causes small blisters to appear on a person's hands or feet. These blisters
are often itchy and can be painful
Dyshidrotic eczema may be caused by:
high stress levels
seasonal allergies
staying in water for too long
Excessive sweating of the hands or fee
Case 2
A patient presents to your office with a 1-week history of a pruritic rash that comes and goes.
No lesion is present for more than 24 hours. It involves his entire body except for his face. He
cannot remember any new products with which he has been in contact (soaps, detergents,
etc.). He is quite concerned. You correctly diagnose urticaria
Your next step is:
A-Skin testing for various commercial products
B-Viral titers for CMV, EBV, etc.
C-RAST test (radioallergosorbent test) for common allergens
D-Recommend no further evaluation.
E-Prescribe an epinephrine injection for emergency use at home
The correct answer is "D."
No workup is needed at this time.
Urticaria should be classified as "acute" (<6 weeks) or "chronic" (>6 weeks).
Acute urticaria requires no further workup and should be treated
symptomatically with antihistamines. In patients with chronic urticaria, a more
detailed history should be taken looking for other symptoms or signs of
infection, with laboratory testing as appropriate. In fact, beyond a good history,
an extensive workup is pretty much futile.
It is almost impossible to identify a cause of urticaria by laboratory
testing. "E," an epinephrine injector, is not indicated for the
treatment of urticaria but would be appropriate if this patient has
experienced an anaphylactic reaction.
Urticaria is categorized as which of the following?
A-Type I hypersensitivity reaction
B-Type II hypersensitivity reaction
C-Type III hypersensitivity reaction
D-Type IV hypersensitivity reaction
E-None of the above
The correct answer is "A.”

Urticaria is a clinical feature of a type I reaction. Other clinical presentations of

type I reactions include anaphylaxis and angioedema.
You decide to provide symptomatic care for this patient. Appropriate medications include
which of the following?
A-Ranitidine
B-Doxepine
C- Diphenhydramine
D-Cetirizine
E-All of the above
The correct answer is "E."
All of the above can be useful in the symptomatic treatment of urticaria.
Patients should be started on sedating and nonsedating anti-histamines to control their
symptoms.
Doses greater than the recommended daily dose are frequently required.
H2-blockers are effective in the 10% to 15% of patients who do not respond to H1-blockers.
Of note, H2-blockers also are used in anaphylaxis treatment but the evidence is weak.
Finally, doxepine is a particularly effective H1- and H2-blocker that can be used as a sedating
antihistamine.
The patient returns to see you 6 weeks later and is still having symptoms. You are wondering a
bit more about potential causes of this unfortunate individual's urticaria.
Which of the following are causes of urticaria?
A-Sweating
B-Cold
C-Water
D-Pressure
E-All of the above
The correct answer is "E."
All of the above can cause urticaria. In fact, these are not uncommon causes and can be
identified by history.
Patients may develop urticaria with exercise and sweating (cholinergic urticaria), cold (during
the winter), and pressure (e.g., walking).
Of particular note is water urticaria that occurs with water contact, including bathing and
showering.
CAUSES OF URTICARIA

Medications (Direct
Physical Urticaria Allergic Systemic Mast Cell
Degranulators)

•Pressure •Foods (nuts, fsh) •Malignancy •NSAIDs

•Water •Insect stings •SLE •Aspirin
•Vibration •Drugs (IgE mediated) •RA •Opiates
•Cold •Chronic Hep B and C •ACE Inhibitors
•Sunlight •EBV •Contrast dye
You decide that this patient probably has cold urticaria (the fact that it is summer does not
dissuade you as it may be related to all of that air conditioning!).
The next drug you might want to try on this patient is:
A-Cyproheptadine (Periactin)
B-Predinsone
C-Montelikast
D-Nifedipine
E-Aspirin
The correct answer is "A."
The physical urticarias (cold and pressure especially) may respond better to cyproheptadine
than other modalities.
If this patient had a "typical" urticaria, you might want to try prednisone, one of the leukotriene
inhibitors or nifedipine (which interferes with mast cell degranulation).
Remember that leukotriene inhibitors, steroids, etc. are second line and should be used only
when first-line drugs have failed or are not tolerated (cyproheptadine for physical
urticaria;doxepin , anti-histamines, etc., for "typical" urticaria).
There are no good studies on the effectiveness of leukotriene inhibitors (anecdotal evidence
only), but they might be worth trying when all else fails
Thanks

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