Dermatology

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Dermatology

• Board Review 2005
• Julia Akaah M.D.

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Case 1

• 6 month old infant has a 2 month history of
  erythematous erosions around the mouth, hands,
  feet, and in the perineum. There is crusting of
  the scalp and hair is sparse. The infant has
  experienced diarrhea and poor weight gain for the
  past month. The infant was weaned from breast
  milk to formula at 2 months of age

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Acrodermatitis enteropathica
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• AR disorder associated with defective transport
  protein in the GI tract, resulting in impaired
  absorption of dietary zinc
• Human milk contains a protein that facilitates
  xinc absorption therefore symptoms appear after
  infant is weaned
• Zinc deficiency occurs with CF, celiac disease
  and patients on TPN w/o zinc
• Zinc deficiency ? altered keratin synthesis
• Diagnosis is confirmed by low serum zinc levels
• Tx zinc sulfate 5mg/kg/d with topical
  corticosteroids

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Case 2

• You are asked to evaluate a boy with dry skin.
  He has history of mild atopic dermatitis. The
  boys father also has scaly skin and allergic
  rhinitis. PE reveals generally dry skin and thin
  scales that have a pasted on appearance on the
  extensor surface of the legs and butttocks

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Ichthyosis vulgaris
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• Ichthyosis describes group of inherited and
  acquired disorders of keratinization which are
  all associated with scaling
• Ichthyosis vulgaris is most common AD, apparent
  between 3m to 5 years
• Thin scales with elevated edges, with pasted on
  appearance, extensor surfaces of lower
  extremities, trunk and upper extremities (face
  antecubital and popliteal fossa are spared)
• Improves over time
• 50 of children also have atopic dermatitis
• Treatment Keratolytics (lactic a., glycolic a,
  urea based emolliants) and oral retinoids in
  severe cases

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Case 3

• You are asked to evaluate a 1 day old healthy
  term infant with a rash. Scattered pustules
  without surrounding erythema involving the trunk
  and forehead and several small hyperpigmented
  macules, some of which possess a collarette of
  scale

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Transient neonatal pustular melanosis
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• Condition begins in utero
• At birth there are pustules and 2-3 mm
  hyperpigmented macules
• Macules are surrounded by collarette of scale
  that represents remnant of a pustule roof
• A gram or Wright stain will reveal PMNs without
  organisms
• Benign self limited disorder
• Diff dx erythema toxicum, neonatal acne, milia

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Case 4

• Your are asked to evaluate a 1 day old full term,
  healthy infant with a rash. There are
  erythematous macules and in the center of each
  macule is a solitary papule or occasionally a
  vesicle

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Erythema Toxicum
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• Benign, self limited eruption occurs in 50 of
  term newborns
• Develop 2-3 cm erythematous macules that have a
  central papule, pustule or vesicle
• Can involve any body surface area except palms or
  soles
• Eruption begins 24-48 hours of life and lasts 4-5
  days
• Wright stain of vesicles reveals eosinophils
• DDx milia, neonatal acne, and transient pustular
  melanosis

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Case 5

• 18 month old boy presents with 2 month history of
  recurring pruritic eruption. Outbreaks last 1-2
  weeks. No one else in the household is similarly
  affected. Physical exam reveals clustered
  erythematous papules 4-6mm in diameter. Several
  papules have a central punctum.

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Papular urticaria
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• Delayed hypersensitivity reaction to stinging or
  biting arthropods (dog or cat fleas, mosquitos,
  lice, grass mites etc.)
• Affected children are 18 months to 7 years and
  only members of household to have symptoms
• Each crop of papules last 2-10 days and
  recurrences may be observed for 3-9 months
• Tx remove the offending agent, topical
  corticosteroid and oral antihistamine if pruritis
  is severe, apply insect repellent (with DEET) if
  outdoor insects are implicated

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Case 6

• 14 yo girl with tuberous sclerosis comes for
  evaluation of rash on the face. The only
  medication she takes is felbamate for seizures.
  Examination of face reveals numerous 1-3 mm pink
  papules in the malar areas bilaterally

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Adenoma sebaceum
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• These lesions are angiofibromas, benign tumors
• Appear during childhood or adolescence but
  occasionally observed at birth
• These lesions do not involute and may coalesce to
  form plaques

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Case 7

• 8 year old presents with localized loss of scalp
  hair of 2 months duration. PE reveals patch of
  alopecia within which hairs are of differing
  lengths. Remainder of the scalp is normal with
  no erythema, scaling, or black dot hairs

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Trichotillomania
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• Alopecia from repetitive twirling, rubbing, or
  plucking of the hair
• Scalp, eyebrows and lashes are affected
• Often result of habit and stress
• Irregularly shaped patch of alopecia without
  erythema or scaling containing hairs of differing
  lengths
• Diff Dx traction alopecia, alopecia areata and
  tinea capitus

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Case 8

• Healthy 14 yr old girl is worried about an area
  of skin thickening, tightness and discoloration,
  that developed 3 months ago. No trauma and no
  associated symptoms. PE shows shiny
  hypopigmented patch with a brown border, skin is
  immobile and firm and has bound down feeling

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Linear scleroderma
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• Scleroderma is a C.T. disorder with autoimmune
  etiology
• Lesions begin as an area of indurated skin
  surrounded by a violaceous halo. Over time the
  violaceous halo takes on a waxy, ivory
  appearance. As the disease remits it becomes
  atrophic with hyper and hypopigmentation
• Linear scleroderma develops in band like
  distribution, unilateral, involve extremities,
  face and trunk

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• Self limited with disease activity lasting 3-5
  yrs
• Morbidity when face is involved or joint function
  is compromised

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Case 9

• 7 year old girl develops widespread linear red
  papules and vesicles over her arms and legs.
  Seven days earlier she had been riding her bike
  in the woods with her dog. The rash began 3 days
  ago and new blisters are continuing to develop

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Rhus dermatitis (poison ivy)
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• Poison ivy is a type IV delayed hypersensitivity
  reaction that occurs in patients with contact
  dermatitis
• Following a period of sensitization of 1-2 wks
  predisposed individuals develop a cutaneous
  reaction on re-exposure to allergen
• Following exposure to poison ivy, the skin rash
  can spread for several days
• Langerhans cells process the contact allergen and
  vary over the skin surface
• Reaction subsides over 2-4 weeks if no treatment
  given
• Tx cool tap water compresses, topical lotions
  and steroids and antihistamines

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Case 10

• 40 year old female comes in for evaluation of
  flushing around the nose and cheeks associated
  with dilated veins

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Rosacea
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• Pustular eruption with flushing and
  telangiectasias of the butterfly area of the face
• Adults 40-60yrs of age
• Severe longstanding cases eventuate in the
  bulbous, greasy, hypertrophic nose
  characterisitic of rhinophyma

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• Pustules are recurrent and difficult to heal
• Disease is influenced by oily skin, excessive
  alcohol ingestion, spicy foods and hot drinks,
  sun exposure and stress
• Tx avoidance of chocolate, nuts, cheese, cola,
  alcohol, spices, seefood
• Metronidazole gel, tetracycline