A Skin Blog

Bizarre skin condition

2007-07-22T23:50:00.000+08:00

Just want to share this interesting picture.
I read it in MMR.
Spotted in Unbounded Medicine.
Also in WFMU.

Derm round 24

2007-06-23T21:56:00.001+08:00

45 years old lady presented with fever of 5 days duration, associated with chills, rigors, nausea, and bodyache. There was history of dengue outbreak in neighborhood. At day 5, fever resolved and the above rashes appeared mostly over her arms.

Clinically, multiple red spots with rim of halo noted over her arms. Full blood count showed leucopenia with lymphocytosis and thrombocytopenia, consistent with viral picture. Dengue IgM was positive.

Derm round 23

2007-03-05T20:28:00.000+08:00

A 70 years old man was referred to the clinic for further management of multiple pruritic rashes over the body and lower limbs of two years duration.

The lesions over the body and lower limbs appeared well-demarcated erythematous rashes with scaling and excoriation. In addition, he has generalized skin dryness (xerosis).

I would have dismissed the case as 'another chronic eczema', until I find these lesions over the anterior chest.

A large ring-like lesion with central paling. There was reduced pin-prick sensation.

He also has this hand appearance, fixed flexion deformities of the right 4th and 5th fingers; suggesting of an ulna nerve lesion. The ulna nerve was thick on palpation. In addition, he has sparce eyebrows.

Slit-skin smears confirmed the diagnosis.
(Pic taken with my SE750)

eMedicine
WHO
Leprosy Review
DermNet NZ

Derm round 22

2007-02-28T23:25:00.000+08:00

13 months old baby boy was admitted to the ward for prolonged fever. Clinically, he has hepato-splenomegaly. Full blood count showed pancytopenia. Peripheral blood film and the bone marrow aspirate were unremarkable. "Biohazard" screenings were all negative. Blood C&S has no growth and the rest of the investigations were unremarkable.

He was treated empirically with IV antibiotic (Cloxacillin and Ceftriaxone). After one week in the ward, and the temperature was still spiking, he developed numerous small papular lesions over the body and more marked over the lower limbs.

On examination, there were monomorphic, skin-colored, small papular eruptions, scattered over the face, body, upper limbs and numerously over the lower limbs (see pictures).

What is it?
We were thinking, more of molluscum contagiosum.

But the paediatricians thought otherwise, ? Gianotti-Crosti syndrome.

See:
eMedicine
DermNet NZ

Derm round 21

2007-02-25T18:42:00.000+08:00

14 years old boy presented with the above lesions over the sole for 7 months.

Spot diagnosis?
See related post.

Derm round 20

2007-02-24T21:08:00.000+08:00

27 years old gentleman presented with the above erythematous rashes over the malar region and alopecia of one year duration. There was no photosensitivity, oral ulcer or joint pain. Review of other system was unremarkable.

On examination, there was erythematous and slightly scaly lesion over the malar eminence as well as over the scalp. Similar lesions were also noted over the forearms and the back of trunk with areas of scarring. In addition, there was also scarring alopecia noted.

Diagnosis?
Discoid lupus.

More:
DermNet NZ
DermAtlas
BAD
lupus.org.uk

Derm round 19

2007-02-23T21:59:00.000+08:00

50 years old gentleman, presented to me with the above lesions over his hands and feet of one month duration. He gave history of washing the floor mat with concentrated bleach solution three days before he started developing such lesions. He also stepped on the mat as well.

Clinically, the lesions appeared well-defined, dried and scaly with cracks, on an erythematous base. There were also maculo-papular rashes over the body. There was no scalp involvement or nail changes. Fungal scrapping was negative.

Although from the history, it sounded like contact dermatitis, clinically, the lesions appeared more "psoriatic". Furthermore, the lesions were more extensive and involved other non-exposure sites (body).

Diagnosis?
?Allergic contact dermatitis.
?Psoriasiform dermatitis.

Anyway, I treated him as having contact dermatitis.

Derm round 18

2007-02-22T19:20:00.000+08:00

46 years old lady presented with the above very pruritic lesions over the body of two months duration. She is a hawker selling Char Koay Teow by the road side. On examination, there were extensive papular lesions over the forearms, lower limbs, neck and body especially over the sun exposed areas.

Diagnosis?
We are treating her as having some form of photodermatitis or polymorphic light eruption.

She was given Betnovate 1:6 cream, aques cream as emollient and anti-histamine. However, her response was unsatisfactory, with persistent disturbing pruritic lesions. One factor contributing to her condition was, she still works by the roadside and wear T-shirt with short pants despite been advice against doing so.

Any comment or suggestion?

More:
BAD
eMedicine

Update (On Derm round 1)

2007-02-21T09:25:00.000+08:00

This lady presented with granulomatous lesions over the face of 6 months duration (Derm round 11). She had a skin biopsy done and was empirically covered with T. EES (Erythromycin) 400mg BD for two weeks.

Her biopsy was later reported as chronic granulomatous lesion, suggestive of atypical mycobateria infection.

On two weeks follow-up, surprisingly, the lesions had flattened >50% with areas of scaling and crusting.

We extended another two weeks of EES and will be discussing her HPE in the next combine meeting. KIV may need to start on anti-TB if indicated.

Derm round 17

2007-02-17T23:22:00.000+08:00

50 years old gentleman, presented with right gluteal swelling of one year duration. The swelling bled easily on physical contact. He had symptoms of anaemia with loss of weight but normal apetite.

Clinically, the tumor is cauliflower-liked with ulceration and area of bleeding spots.

He was referred to dermatologist for opinion because of the HPE report:
Section showed skin with underlying spindle shaped illed-define lesion. The cells show a storiform pattern of arrangement. The cells have moderately pleomorphic muclei and few mitotic figures are seen. Foamy macrophages are noted with occasional large bizarre cells. The is no necrosis noted. There is no evidence of malignancy in this biopsy. Diagnosis: Benign fibrous histiocytoma.

However clinically, the lesion looked aggressive. There were multiple inguinal lymph nodes felt. No organomegaly felt. His Hb was 5.9 gm/dl. Other blood investigations were unremarkable. His chest X-ray was normal. CT scan of the lesion showed a soft tissue mass arising from the skin. CT scan chest/abdomen/pelvis revealed multiple lung nodules, inguinal lymphadenopathy and right ilium bone erosion.

In view of the clinical findings, this tumour behaved as malignant with evidence of metastasis.

A repeat biopsy was done on 13/2/2007.

Read:
Fibrous histiocytoma
Atlas of genetics and cytogenetics in oncology and haematology
GpNotebook
Malignant fibrous histiocytoma

Update (2/3/2007):
Repeat biopsy report:
Sections show skin tissue with underlying dermis. A diffuse cellular lesion is noted in the dermis. The lesion composed of spindle-shaped cells arranged in stori-form pattern. The spindle-shaped to plump cells exhibit mild to moderate pleomorphic vesicular nuclei and prominent nucleoli. Mitotic figures are seen. Infiltration by acute and chronic inflammatory cells is noted.
Immunohistochemical stain: The spindle-shaped cells are positive for vimentin.
Diagnosis: Dermatofibrosarcoma protuberans.

Derm round 16

2007-02-15T20:21:00.000+08:00

Diagnosis?
Acute generalized erythematous pustulosis (AGEP).

The above patient was admitted for an elective surgery of left obstructive uropathy due to ureteric calculi. On third day, she developed spiking temperature in the ward, and thus the procedure was cancelled. She was empirically started on IV Cefoperazone. She then developed the above small pustular lesion over the limbs as well as some scattered lesions over the trunk after two days. Blood investigations were unremarkable.

On review of her old notes, she was diagnosed as having AGEP two months before, and responded to a course of oral Itraconazole.

Assuming that she might be having similar candida infection, she was prescribed Itraconazole again. However, the lesions resolved completely the next day before Itraconazole was managed to be given. The antibiotic was stopped and she became afebrile.

Is the AGEP due to Cefoperazone or due to infection?

More:
AGEP due to herbal remedy.
IJDVL.
Archieve of Dermatology.
RegiScar Project.
Rev. Inst. Med trop. S. Paulo.
Dermatology Online Journal.
Medscape.

Derm round 15

2007-02-15T19:46:00.000+08:00

Case 1

14 years old girl, had the above lesions since birth.

Diagnosis?
Congenital nevomelanocytic nevus, giant.

See also:
Congenital nevi.

Case 2
45 years old gentleman presented with the above pruritic lesion over the scrotum. Fungal scrapping was negative.

Diagnosis?
Lichen simplex chronicus.

Derm round 14

2007-02-12T22:57:00.000+08:00

This eight years old boy has the above non-pruritic scalp lesions since infancy. He currently presented because the mother noted significant hair loss of one month duration. The lesions are very scaly plague with ill-defined borders. Wood's lamp and fungal scrapping were negative.

What is it?
I treated the patient for Seborrheic capitis (seborrheic dermatitis of the scalp).

Derm round 13

2007-02-12T22:43:00.000+08:00

This 9 years old girl, presented with the above non-pruritic lesion of 2 months duration. It is a well-defined, slightly erythematous and scaly lesion. Wood's lamp was negative and fungal scrapping was negative.

What is it?
? Pityriasis alba.

What other differentials?

By the way, I gave her Hydrocortisone ointment.

Pompholyx

2007-02-09T16:21:00.000+08:00

19 years old student presented with the aboce very pruritic small vesicular lesions of both hands of two days duration.

Diagnosis?
Acute eczema, dyhidrotic eczematous dermatitis, vesicular palmar eczema.

Chromoblastomycosis

2007-02-09T15:54:00.000+08:00

62 year old man presented to us in 2003 with the above lesions over his left lateral thigh region of nine years duration.

(The hyperpigmented areas are actually healed, photo taken 4 years after started on treatment).

The HPE was reported as:
Section shows skin tissue with central, irregular, benign, stratified squamous epithelial layer exhibiting acantholysis and mild pseudoepitheliomatous hyperplasia. The upper dermis shows presence of scattered, suppurative granulomas with neutrophils, multinucleated giant cells and ingested, pigmented "chest nut brown" rounded refractile fungal bodies. In addition, the dermis shows presence of numerous lymphocytes and plasma cells. Intrepretation: Chromoblastomycosis.

We repeated our own specimen and our HPE was reported as:
Section showing mild hyperplasia of squamous epithelium with foci of granulomatous inflammation in the superficial dermis. Scattered multinucleated cells are seen. The dermis is infiltrated by neutrophils and lymphoplasma cells. No fungal bodies identified in this specimen. Interpretation: Chronic granulomatous inflammation, consistent with fungal infection.

He was started on C. Itraconazole 200 mg OD till now. The lesion has improved more than 50%.
The question is, how long should we continue with the anti-fungal treatment?

Papular eczema

2007-02-07T11:40:00.000+08:00

8 years old girl presented with the above very pruritic papules over her forearm and hands of 5 years duration. She was very embarrassed and depressed because her classmates made fun of her and refused to befriend her.

Derm round 12

2007-02-07T11:31:00.000+08:00

30 years old man presented with the above lesions over the supra-pubic/base of penis since the age of 18 years old (12 years). He denied history of sexual exposure when he first had the lesions.

These lesions looked something like this one too.

What is the diagnosis?
?Viral wart.

Below, I included some viral wart pictures from DermNet.com:

Derm round 11

2007-02-06T22:42:00.000+08:00

65 years old lady presented with the above lesions over the face of 6 months duration.

What are these lesions?
? Granuloma faciale.

We did a biopsy and the result came back as such:
" Multiple sections showed skin tissue with marked granulomatous lesion in the dermis consists of aggregates of epitheliod cells, lymphocytes and some multinucleated giant cells. No obvious central caseous necrosis seen. No atypical cell seen. No evidence of malignancy seen. Stains for fungal, AFB and leprae bacilli are negative. Diagnosis: Chronic granulomatous lesion, suggestive of atypical mycobacterial infection."

Hmn, rather non-specific isn't is?
What features actually point to atypical mycobacterial infection, huh?
Anyway, we will discuss the case in the HPE discussion session with the pathologists cm.

Derm round 10

2007-02-03T12:57:00.000+08:00

The same lady with ?deep fungal infection (Derm round 4, case 2), was discharged and followed up in the clinic. The initial swab C&S grew Staphylococcus aureus (Sensitive to Cloxacillin). She was treated earlier with IV Unasyn and Metronidazole for one week. She had also been given two weeks of oral Cloxacillin.

Currently, the lesions appeared to have dried up, but her left foot was still edematous. There were thick scale-like lesions on her left foot, which bled on removal of the scales.

Still unsure what this lesions were due to. I was comtemplating to do a skin biopsy next.

Derm round 9

2007-02-03T12:40:00.000+08:00

20 years old gentleman presented with the above slightly painful, pruritic and smelly lesions over the the soles of three days duration. He is a kitchen helper.
Fungal scrapping was negative.

What is it?

? Pitted keratolysis as well.
I gave him a course of oral Erythromycin, KMNO4 soak and anti-fungal cream.

Fixed drug reaction

2007-02-03T12:26:00.000+08:00

This gentleman developed the aboved lesions within 12 hours of taking Paracetamol for high grade fever. Review of his case notes, actually documented that he had history of allergic to Paracetamol. According to the patient, he felt terrible because of the fever and took the medication despite the known allergy.

What other alternative if the patient has allergy to Paracetamol?

Derm round 8

2007-02-03T12:19:00.000+08:00

25 years old lady presented with the above lesions over the posterior neck region of 5 years duration.

The lesions appeared warty or cauliflower-like.

What is it?

?Viral wart.
?Epidermal naevus.

Lichen amyloidosus

2007-01-30T00:11:00.000+08:00

78 years old man presented with the above pruritic rashes of 6 months duration.

Dermatoses of Pregnancy

2007-01-29T23:30:00.000+08:00

Here are two cases of pruritic lesions in pregnant patients:

Case 1

26 years old G1P0 at 27 weeks of POA, presented with the above pruritic papules and nodules over her abdomen, upper and lower limbs. She claimed the lesions were drier 2 days post-partum.

Case 2

25 years old G1 P0 at 12 week of POA, presented with the above pruritic papules over the upper and lower limbs of three weeks duration.

What is it among the 6 types of dermatoses of pregnancy?
Prurigo of pregnancy.

Related case in Derm round 1.

Derm round 7

2007-01-23T18:46:00.000+08:00

Case 1

25 years old man presented with the above lesions of three weeks duration.

Diagnosis?
Pitted keratolysis.

More:
DermNet NZ.
eMedicine.

Case 2

58 years old lady, with history of right breast CA and mastectomy done, developed the above lesions after given two cycles of chemotherapy.

Diagnosis?
?Vitiligo

Case 3

65 years old man presented with the above painful lesions over the anterior chest wall with small vesicles and discharges. He was told by the GP that it was shingles. Patient was very concerned and decided to seek 2nd opinion.

The lesion appeared in a straight line, with areas of crusting and serous discharge. It did not confine to a typical dermatomal area.

Diagnosis?
Most likely insect bite reaction.

Case 4

29 years old guy, presented with the above non-pruritic rashes over three weeks duration over the body, first started over the left shin.

On examination, there was scattered ring-liked erythematous papules with skight scaling over the back of the trunk. There was also a bigger such lesion over the left shin. Fungal scrapping was negative.

Diagnosis?
Pityriasis rosea (Note the herald patch).

Case 5

25 years old lady presented with the above pigmented lesions over the back of three years duration, which were non-pruritic.

On inspection, there was areas of reticular hyperpigmented macules with fine scaling seen.
Fungal scrapping was negative.

Diagnosis?
Initially thought it was Pityriasis vesicolor, however scrapping was negative.
My friend suggested that it could be Becker's naevus. (However, I didn't see obvious overlying hair).
The above lesions were noted on the body of a 55 years old man. He is asymptomatic. He said such lesions had appeared on the body since he was teenage.

Diagnosis?
Becker's naevus (Note the overlying hair).

Derm round 6

2007-01-20T09:11:00.000+08:00

Case 1
29 years old gentleman, presented with the above pruritic lesions of two years duration. He has been applying numerous creams he took from GP clinics as well as bought from the phamarcies.

Diannosis?
Tinea incognito.

More:
DermNet NZ.

Case 2

39 years old gentleman, with long-standing DM of more than 10 years, presented with the above lesions of 3 years duration. He is asymptomatic.

Diagnosis?
Pityriasis vesicolor.

More:
eMedicine

Derm round 5

2007-01-15T22:25:00.000+08:00

Case 1

A 15 years old lady with port wine stain lesions over her left upper arm was treated in the Plastic surgery clinic with laser.

She was referred to the dermatology clinic for further management of the above lesions over the right upper arm which were present since childhood (>10 years). The patient is asymptomatic.

Diagnosis?
By one look, this is Keratosis pilaris.
(On further questioning, similar lesions were present over her thigh).

More:
eMedicine
KeratosisPilaris.org
AOCD
DermNet NZ

Case 2

65 years old man was recently diagnosed to have SVT and hypertension two months ago presented with the above pruritic body rashes of 2 weeks duration. He was prescribed aspirin, metoprolol, amiodarone and perindopril.

Clinically, he had generalized erythrodermic skin which was thickened, dry and scaly with areas of scratch marks as well as excoriation, sparing the buttock and upper thigh.

Diagnosis?
Drug-induced photodermatitis.

Which drug is the most likely cause?
Amiodarone.
(Further history, patient admitted having exposed under sunlight regularly without shirt on during gardening)

More:
DermNet NZ
University of Maryland Medical Center

Cx of CryoTx

2007-01-15T22:17:00.000+08:00

Overzealous application of liquid nitrogen on a plantar wart, resulting in a huge bulla over the foot of a five-year-old boy after five days.

Derm round 4

2007-01-11T22:13:00.000+08:00

Case 1

24 years old lady, G1P0 at 15 week of POA was found to be anaemic (Hb 7.8gm/dl) during routine blood check and was admitted for further management. Further history, she complained of red facial rashes started since she was found pregnant. She also complained of mild on and off arthralgia. The was no alopecia, oral ulcer or proximal myopathy. Her TWBC was low (3.4) and her ESR was also high (78 mm). Clinically, she has erythematous facial rashes in distribution suggestive of possible photodermatitis (pic not shown). The above was the appearance of her hands, which showed periungual erythema. We are currently working her up for connective tissue disease.

Case 2

78 years old lady, with no previous medical illness, presented with the above nodular and hyperpigmented lesions over her lower limbs of 10 months duration. Note that, there were some healed hyperpigmented scars. Currently, she presented with worsening lesions with pain, ulceration and pus discharge. We thought it might be some deep fungal infection (?Acinomycetoma)

Case 3

The above 78 years old man, with previous history of IHD/DM/HPT/Dyslipidaemia/old stroke, presented with the above pruritic body lesions of one month duration. The lesion over the right knee had been there for 6 months. There was also a previous surgical scar of right knee surgery.
The body and upper limbs lesions were well defined, hyperpigmented, dry and scaly. Scalp and nails were normal. Fungal scrapping was negative.
I am thinking of some form of discoid ezema; with some differentials of ?psoriasis/? CTCL.

Any comment regarding the above pictures?

Derm round 3

2007-01-11T21:10:00.000+08:00

Case 1

A 13-year-old boy, presented with Dengue encephallitis and later developed Dengue Shock Syndrome, was ventilated in ICU for two weeks. He developed nosocomial infection and his blood C&S grew Acinetobacter species. He completed two weeks of IV Sulperazon and later transferred out to the general ward for further management. In the ward, he developed spikes of temperature again, which he was covered with IV Meropenem and IV Vancomycin. He had developed the above rashes over the body for few days, even before his spiking temperature and the introduction of IV antibiotics. The managing team was worried about the rashes, as they thought it might be the source of the sepsis, and thus referral to dermatologist.

Diagnosis?
Miliaria crystalina.
More:
Wikipedia.
eMedicine.
Dermnet.
Merck manuals.

Case 2

46 years old lady, presented with the above mild pruritic plague over her left shin of three years duration. Her blood sugar was normal.

Diagnosis:
Necrobiosis lipoidica (diabeticurom).

*Note:
Relationship to DM- 1/3 have clinical DM, 1/3 have abnormal glucose tolerance, 1/3 have normal glucose tolerance.

The above patient was found to be diabetic after 3 years on follow-up.

More:
eMedicine.

Case 3

Nail changes:
Sandwich of red and white longitudinal bands, with a V-shaped nick at the free margin of the nail.

Diagnosis:
Darier's disease.

More:
eMedicine.

Acrodermatitis continua of hallopeau

2007-01-11T19:52:00.000+08:00

A 55 years old gentleman with long history of chronic plague psoriasis, had the following hand appearances.

At a glance, I thought it was psoriatic athritis mutilans, as there were deformities over the distal phalanges. It was characterized by fixed flexion deformity of the distal interphalangeal joints with obvious distal phalanges resorption.

However, my friend told me, it was Acrodermatitis continua of Hallopeau.

Below are five pictures I downloaded from the internet, but they look quite different:

Here is a picture of arthritis multilans:

Acrodermatitis continua of Hallopeau is a chronic skin disorder characterized by recurrent sterile, pustular eruptions of the digits with marked involvement of the nail beds. The intermittent pustulations may lead to atrophy, onichodystrophy and even osteolysis.

More links:
www.vgrd.org
Dermatology:Case report (PDF)
Dermatology Online Journal

Derm round 2

2007-01-09T22:23:00.000+08:00

Case 1

A 64 years old Chinese lady who has bilateral knee OA, was admitted two days earlier for an elective left total knee replacement. Previously, she had her surgery postponed once due to some non-specific ECG changes and she was asymptomatic.

On the day of the planned surgery, she complained to the doctor during morning round that she had this slightly pruritic rashes over the shin for more than three weeks. The plan was, surgery immediately cancelled, referal to dermatologist and to get new date in three weeks.

On inspection, there were patches of well-defined erythematous scaly lesions.

Diagnosis?
Tinea corporis (Fungal scrapping positive).
Poor little old lady.

Case 2

This is the second time I am seeing this kind of skin rashes.

65 years old Chinese man, complaint of numerous red spots over his lower limbs and some over the forearms, which were non-pruritic, of three weeks duration. No significant drug or allergy history. He just started working as a guard performing night duties in a guest house.

On inspection, there were multiple red spots with surrounding rim of hypopigmentation (halo-liked) noted mostly over the extensor surfaces of the limbs.

Diagnosis:
Insect bite reaction.
(Clue: Lesions only appeared on the areas not covered by clothing, he wore shorts all the time).

Derm round 1

2007-01-09T21:40:00.000+08:00

Case 1

A 22 years old lady, currently pregnant (2nd pregnancy) at 12 weeks POA, presented with such prutitic rashes over the abdomen of one week duration. Similar condition appeared during her first pregnancy at 28 weeks POA.

Diagnosis?
Pruritic urticarial papules and plaques of pregnancy (PUPPP).

Dermatoses of pregnancy:
1. PUPPP.
2. Phemphigoid gestationis.
3. Prurigo of pregnancy.
4. Pruritic folliculitis.
5. Pustular psoriasis of pregnancy (Impetigo herpetiformis).
6. Cholestasis of pregnancy (Obstetric choletasis).

Case 2

Diagnosis?
Lichen amyloidosus.

More:
eMedicine

Case 3

7 years old Indian girl has such hyperpigmented rash over the right thigh since birth. It has increased in size over the years. For the last three months, she complained of tender on touching the lesion. On palpation, there were multiple subcutaneous nodules felt, which were tender. In addition, she has mulitple (>10) cafe-au-lait spots over her back.

Other significant history was, her father also has numerous cafe-au-lait spots, as well as numerous neurofibromata and axillary freckling; clinically consistent with Neurofibromatosis type1.

Diagnosis?
I am not too sure about it.
My boss said it is congenital hairy nevomelanocytic nevus, probably not related to NF1.

Anatomy and Physiology of the Skin

2006-12-09T17:53:00.000+08:00

Skin is the largest organ of the body.

The skin consists of four distinct layers: the epidermis, the basement membrane zone, the dermis and the subcutaneous layer.

Functions of the skin:

1. Physical barrier against friction and shearing forces.
2. Protection against infection, chemicals, ultraviolet irradiation, particles.
3. Prevention of excessive water loss or absorption.
4. Ultraviolet induced synthesis of vitamin D.
5. Temperature regulation.
5. Sensation (pain, touch and temperature).
6. Temperature regulation.

7. Antigen presentation/immunological reactions/wound healing.