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Old 06-14-2011
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Skin Cool Dermatology cases

1-A 47-year-old man sees a dermatologist for an evaluation of a skin condition. He has had the condition before. There is little associated pain or itching. The patient’s condition is shown in the figure. Which of the following is his most likely diagnosis?

Cool  Dermatology cases-forehead.jpg
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A. Acne vulgaris
B. Erythrasma
C. Plaque sarcoidosis
D. Rosacea
E. Seborrheic dermatitis


2-A 67- year-old retired construction worker presents to his physician for a routine health maintenance examination. At present he has no complaints. The physician notes a 5-cm patch on his left cheek with several overlying blue-black papules. The patch is markedly variegated with gray, blue, and black hues. It has a geographic shape with irregular borders, poor definition and loss of skin surface markings. A review of the patient's last visit 5 years ago, reveals that at that time the lesion was 1 cm and had a stain-like appearance of black on a brown background without red or blue pigmentation or papules. What is the most likely diagnosis?

Answer Choices

A. Acral-lentiginous melanoma
B. Amelanotic melanoma
C. Lentigo maligna melanoma
D. Nodular melanoma
E. Superficial spreading melanoma


3-A young mother brings her 9-year-old girl to a physician. She is concerned about a strange skin rash accompanied by headache and a mild fever. Her mother found the rash several days ago, and notes no change in its color or texture. On physical exam, the child’s temperature is 37.7°C (99.9°F), and her other vitals are within normal limits. Her back has an erythematous maculopapular rash roughly arranged in the shape of a triangle. What is the treatment of choice for this condition?

A. Antihistamines
B. Corticosteroids
C. Gold compounds
D. Liquid nitrogen freezing
E. Phlebotomy
F. Ultraviolet (UV) light
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Thanks Miss Patho for great dermatology cases!

1. This man has seborric dermatitis!

2. Second case-I would choose Lentigo maligna melanoma. Lentigo maligna for a few years and now malignant change. Not 100% sure. Other options sound good too.

3. I think this child has systemic contact dermatitis. So need to identify allergens. In your options, antihistamin and steroids are good answers. If I have picked only one, will go with antihistamin!
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Default Lentigo maligna melanoma looks like this!

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case 1

Option D (Rosacea) is correct. The rash shown is a flushed region of coarse skin with a nongreasy, papulopustular eruption on an erythematous background without comedos. This is the appearance of rosacea.

Option A (Acne vulgaris) is incorrect. The hallmark of acne is comedo formation, which are distinctly absent in this patient’s particular rash and in rosacea in general.

Option B (Erythrasma) is incorrect. Erythrasma is a chronic superficial infection of intertriginous areas by Corynebacterium minutissimum. The rash show is not in an intertriginous area.

Option C (Plaque sarcoidosis) is incorrect. Plaque sarcoidosis can produce a scaly facial rash similar to rosacea. The lesions are better-defined brown-purple plaques without an erythematous background. The condition is much rarer than rosacea.

Option E (Seborrheic dermatitis) is incorrect. Seborrheic dermatitis is also a papulopustular eruption. It is has a greasier appearance and is associated with considerable burning and itching.

High-yield Hit 1
Rosacea
This chronic inflammatory disease of the face is characterized by erythema, telangiectasia, and pustules.
The etiology of rosacea is unknown.
Telangiectatic dilatation of the upper dermal vessels is common, and it causes erythema. Fragments of the mite Demodex folliculorum are commonly found in follicles, but its role in the pathogenesis is unclear.
Follicular pustules often develop in the markedly dilated hair follicles.
Rupture of the follicles leads to the development of a florid, lumpy form of rosacea, the result of a giant cell granulomatous reaction in response to follicular content release.
Clinical presentation-It typically affects the middle-aged or elderly, with a slightly higher incidence in women. It may persist for years, and it is often complicated by:
Rhinophyma-hyperplasia of sebaceous glands and connective tissue of the nose.
Eye involvement-blepharitis (inflammation of the eyelids) and conjunctivitis.
The condition is exacerbated by sunlight and topical steroids.
Management is by oral antibiotic treatment (e.g., tetracycline or erythromycin). Plastic surgery is required for rhinophyma.
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case 2

Option C (Lentigo maligna melanoma) is correct. This patient has melanoma, of the lentigo maligna subtype. There are a variety of subtypes, the most important of which are presented here as distractors. Lentigo maligna melanoma consists of approximately 5% to 15% of all melanomas. It evolves from lentigo maligna, a melanoma in situ, over a period of many years. Once it becomes a true invasive melanoma, there is variegated color, a “geographical pattern,” (highly irregular border causing the lesion to look like a map of a region or country) and overlying papules. Most of the lesions are on the face. It usually occurs in individuals in their 60s who have evidence of heavily sun damaged skin.

Option A (Acral-lentiginous melanoma) is incorrect. This form of melanoma is most common in Asians and African Americans. Owing to the dark pigmentation in African Americans, this lesion is often not discovered until it has become nodular, resulting in a poor prognosis. It most commonly presents on the palm and sole, as well as subungually (usually in the nail bed first, then the nail matrix, eponychium, and nail plate). Again, there is usually marked variegation of blue-black colors.

Option B (Amelanotic melanoma) is incorrect. Amelanotic melanoma may appear as any of the four subtypes listed in this question. As the name suggests, the lesion is hypopigmented.

Option D (Nodular melanoma) is incorrect. Nodular melanoma appears quickly as a “blueberry nodule” that is uniformly dark in color. It often has an early vertical growth pattern, causing it to have a poor prognosis.

Option E (Superficial spreading melanoma) is incorrect. This is the most common melanoma and is best described as a plaque that meets the ABCDE rule, (ABCDE rule = Asymmetry in shape, Border is irregular, Color is not uniform, Diameter is large (>6 mm), and the lesion is Elevated or Enlarging). It usually presents in a slightly younger population than lentigo maligna melanoma. The lesions can present anywhere on the body.

High-yield Hit 1
Melanoma
BASIC INFORMATION
DEFINITION
Melanoma is a skin neoplasm arising from the malignant degeneration of melanocytes. It is classically subdivided in four types:
Superficial spreading melanoma (70%) (Fig. 1-146, A)
Nodular melanoma (15% to 20%) (Fig. 1-146, B)
Lentigo maligna melanoma (5% to 10%)
Acral lentiginous melanoma (7% to 10%)
SYNONYMS
ICD-9CM CODES
172.9 Melanoma of the skin, site unspecified

Malignant melanoma
EPIDEMIOLOGY & DEMOGRAPHICS
Annual incidence of melanoma is 13 cases/100,000 persons.
Melanoma has doubled to tripled in incidence over the past 25 years.
Melanoma is the most common cancer among women 20-29 yr of age.
Lifetime risk of cutaneous melanoma for white Americans is 1/90.
Melanoma is the leading cause of death from skin disease.
Median age at diagnosis is 53 yr.
Superficial spreading melanoma occurs most often in young adults on sun-exposed areas.
Acral lentiginous melanoma is most often found in Asian Americans and African Americans and is not related to sun exposure.
Death rate for white men with melanoma is 3/100,000.
8%-10% of melanomas arise in people with a family history of the disease.


Figure 1-146 A, Superficial spreading melanoma. B, Nodular melanoma. (From Abeloff MD [ed]: Clinical oncology, ed 2, New York, 2000, Churchill Livingstone.)
PHYSICAL FINDINGS & CLINICAL PRESENTATION
Variable depending on the subtype of melanoma:
Superficial spreading melanoma is most often found on the lower legs, arms, and upper back. It may have a combination of many colors or may be uniformly brown or black.
Nodular melanoma can be found anywhere on the body, but it most frequently occurs on the trunk on sun-exposed areas. It has a dark-brown or red-brown appearance, can be dome shaped or pedunculated; they are frequently misdiagnosed because they may resemble a blood blister or hemangioma and may also be amelanotic.
Lentigo maligna melanoma is generally found in older adults in areas continually exposed to the sun and frequently arising from lentigo maligna (Hutchinson's freckle) or melanoma in situ. It might have a complex pattern and variable shape; color is more uniform than in superficial spreading melanoma.
Acral lentiginous melanoma frequently occurs in soles, subungual mucous membranes, and palms (sole of the foot is the most prevalent site). Unlike other types of melanoma, it has a similar incidence in all ethnic groups.
The warning signs that the lesion may be a melanoma can be summarized with the ABCD rules:
A: Asymmetry (e.g., lesion is bisected and halves are not identical)
B: Border irregularity (uneven, ragged border)
C: Color variegation (presence of various shades of pigmentation)
D: Diameter enlargement (>6 mm)
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case 3

Option F (Ultraviolet (UV) light) is correct. The patient is presenting with pityriasis rosea. The rash is usually pink, flaky, and oval-shaped. A single "herald" patch may occur 1–20 days before smaller, more numerous patches of rash, although the "herald" patch may either not be noticed or not appear. Other "herald" patches may appear as a cluster of smaller oval spots rather than a single patch. The rash occurs in patches arranged in a triangular pattern, like a "Christmas tree”. A quarter of people with pityriasis rosea get mild to severe itching that fades as the rash develops. It may be accompanied by headache, fever, nausea, and fatigue. If itching is present, it may be treated with corticosteroids, but the treatment for the rash is UV light, and the rash will resolve on its own in 8–10 weeks.

Option A (Antihistamines) is incorrect. Antihistamines are useful for conditions of excess mast cell degranulation such as atopic or contact dermitis and urticaria. This patient is presenting with pityriasis rosea, which is treated with UV light.

Option B (Corticosteroids) is incorrect. The patient is presenting with pityriasis rosea. The biggest hint to the diagnosis is the triangular shaped rash, or “Christmas tree” rash. For this disorder, corticosteroids may be used to treat the itching, but this patient does not note pruritis. UV light is used for treatment.

Option C (Gold compounds) is incorrect. Gold salts have anti-inflammatory properties and are used in the treatment of inflammatory conditions such as rheumatoid arthritis, inflammatory bowel disease, psoriatic arthritis, membranous nephritis, lupus erythematosus and, infrequently, juvenile rheumatoid arthritis. These compounds include: auranofin, aurothioglucose, disodium aurothiomalate, sodium aurothiosulfate, sodium aurothiomalate.

Option D (Liquid nitrogen freezing) is incorrect. Liquid nitrogen may be used to treat localized lesions such as seborrheic keratosis. This patient has a more extensive rash, and liquid nitrogen would not be useful in treatment for this condition.

Option E (Phlebotomy) is incorrect. Phlebotomy is a treatment for polycythemia vera and primary hemochomatosis or bronze diabetes. In the autosomal recessive disease hemochromatosis excess iron is deposited in the liver, pancreas, heart and skin. Polycythemia vera is characterized by a high hematocrit and may present with pruritus, particularly after a hot shower.

High-yield Hit 1
Pityriasis rosea
This common, acute, benign, and self-limiting condition is thought to be of viral origin. It begins with a "herald patch," an oval or round, scaly, erythematous macule on the trunk, neck or proximal part of limbs. This is followed within 1-3 days by a shower of smaller dull pink macules on the trunk in a so-called "Christmas tree" pattern following the lines of the ribs. Spontaneous resolution occurs within 6-8 weeks.
No treatment is required.
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Default chrismas tree = triangular!

Quote:
Originally Posted by miss patho View Post
case 3

Option F (Ultraviolet (UV) light) is correct. The patient is presenting with pityriasis rosea. The rash is usually pink, flaky, and oval-shaped. A single "herald" patch may occur 1–20 days before smaller, more numerous patches of rash, although the "herald" patch may either not be noticed or not appear. Other "herald" patches may appear as a cluster of smaller oval spots rather than a single patch. The rash occurs in patches arranged in a triangular pattern, like a "Christmas tree”. A quarter of people with pityriasis rosea get mild to severe itching that fades as the rash develops. It may be accompanied by headache, fever, nausea, and fatigue. If itching is present, it may be treated with corticosteroids, but the treatment for the rash is UV light, and the rash will resolve on its own in 8–10 weeks.

Option A (Antihistamines) is incorrect. Antihistamines are useful for conditions of excess mast cell degranulation such as atopic or contact dermitis and urticaria. This patient is presenting with pityriasis rosea, which is treated with UV light.

Option B (Corticosteroids) is incorrect. The patient is presenting with pityriasis rosea. The biggest hint to the diagnosis is the triangular shaped rash, or “Christmas tree” rash. For this disorder, corticosteroids may be used to treat the itching, but this patient does not note pruritis. UV light is used for treatment.

Option C (Gold compounds) is incorrect. Gold salts have anti-inflammatory properties and are used in the treatment of inflammatory conditions such as rheumatoid arthritis, inflammatory bowel disease, psoriatic arthritis, membranous nephritis, lupus erythematosus and, infrequently, juvenile rheumatoid arthritis. These compounds include: auranofin, aurothioglucose, disodium aurothiomalate, sodium aurothiosulfate, sodium aurothiomalate.

Option D (Liquid nitrogen freezing) is incorrect. Liquid nitrogen may be used to treat localized lesions such as seborrheic keratosis. This patient has a more extensive rash, and liquid nitrogen would not be useful in treatment for this condition.

Option E (Phlebotomy) is incorrect. Phlebotomy is a treatment for polycythemia vera and primary hemochomatosis or bronze diabetes. In the autosomal recessive disease hemochromatosis excess iron is deposited in the liver, pancreas, heart and skin. Polycythemia vera is characterized by a high hematocrit and may present with pruritus, particularly after a hot shower.

High-yield Hit 1
Pityriasis rosea
This common, acute, benign, and self-limiting condition is thought to be of viral origin. It begins with a "herald patch," an oval or round, scaly, erythematous macule on the trunk, neck or proximal part of limbs. This is followed within 1-3 days by a shower of smaller dull pink macules on the trunk in a so-called "Christmas tree" pattern following the lines of the ribs. Spontaneous resolution occurs within 6-8 weeks.
No treatment is required.
Thanks

Yes of course in retrospect! Rash distribution chrismas tree = triangular!
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3. I think this child has systemic contact dermatitis. So need to identify allergens. In your options, antihistamin and steroids are good answers. If I have picked only one, will go with antihistamin!
[/QUOTE]

i choose like u also but wrong
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