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Dermatology. Board Review 2005 Julia Akaah M.D. Case 1.

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Board Review 2005

Julia Akaah M.D.

case 1
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
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
case 2
Case 2

You are asked to evaluate a boy with dry skin. He has history of mild atopic dermatitis. The boy’s 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

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
case 3
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
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
case 4
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
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
case 5
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.
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
case 6
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
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
case 7
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
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
case 8
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
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
Self limited with disease activity lasting 3-5 yrs
  • Morbidity when face is involved or joint function is compromised
case 9
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
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
case 10
Case 10
  • 40 year old female comes in for evaluation of flushing around the nose and cheeks associated with dilated veins
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
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