Dermatology Board Review 2005 Julia Akaah M.D.

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 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

Acrodermatitis enteropathica

AR disorder associated with defective transport protein in the GI tract, resulting in impaired absorption of dietary zinc 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 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 occurs with CF, celiac disease and patients on TPN w/o zinc Zinc deficiency  altered keratin synthesis Zinc deficiency  altered keratin synthesis Diagnosis is confirmed by low serum zinc levels Diagnosis is confirmed by low serum zinc levels Tx: zinc sulfate 5mg/kg/d with topical corticosteroids Tx: zinc sulfate 5mg/kg/d with topical corticosteroids

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 vulgaris

Ichthyosis describes group of inherited and acquired disorders of keratinization which are all associated with scaling 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 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) 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 Improves over time 50% of children also have atopic dermatitis 50% of children also have atopic dermatitis Treatment: Keratolytics (lactic a., glycolic a, urea based emolliants) and oral retinoids in severe cases Treatment: Keratolytics (lactic a., glycolic a, urea based emolliants) and oral retinoids in severe cases

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 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

Transient neonatal pustular melanosis

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

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 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

Erythema Toxicum

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

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. 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.

Papular urticaria

Delayed hypersensitivity reaction to stinging or biting arthropods (dog or cat fleas, mosquitos, lice, grass mites etc.) 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 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 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 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 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 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

Adenoma sebaceum

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

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 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

Trichotillomania

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

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 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

Linear scleroderma

Scleroderma is a C.T. disorder with autoimmune etiology 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 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 Linear scleroderma develops in band like distribution, unilateral, involve extremities, face and trunk

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

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 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

Rhus dermatitis (poison ivy)

Poison ivy is a type IV delayed hypersensitivity reaction that occurs in patients with contact dermatitis 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 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 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 Langerhans cells process the contact allergen and vary over the skin surface Reaction subsides over 2-4 weeks if no treatment given Reaction subsides over 2-4 weeks if no treatment given Tx: cool tap water compresses, topical lotions and steroids and antihistamines Tx: cool tap water compresses, topical lotions and steroids and antihistamines

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

Rosacea

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

Pustules are recurrent and difficult to heal 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 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 Tx: avoidance of chocolate, nuts, cheese, cola, alcohol, spices, seefood Metronidazole gel, tetracycline Metronidazole gel, tetracycline