Case 17

28-year-old with a rash – Mr. Moeller

Author: Cynthia H. Ledford, M.D., Ohio State University College of Medicine

Summary of Clinical Scenario 1: Mr. Moeller is a 28-year-old gentleman

admitted for a Crohn’s flare and found to have a pigmented lesion, prompting
suspicion for melanoma. Mr. Moeller's lesion is a 1.5 cm patch located on the
mid-back, varying in color from tan to darker brown/black, with an irregular
border and a 3-mm depth nodularity just left of center. It is biopsied…

Summary of Clinical Scenario 2: Mr. Bragg is an adult male with a new-onset

pruritic rash after ingestion of antibiotics for a sinus infection. The rash is
erythematous and macular involving the extremities, trunk, and face as well as
coalescing in patches. He is given an antihistamine and prednisone for an adverse
drug reaction.

Summary of Clinical Scenario 3: Mr. Filmore is a 38-year-old man who has

been treated for cellulitis on his left arm that is not responsive to therapy. His
exam reveals a clearly demarcated, erythematous, warm patch with a central 4
mm ulceration and crusting on the left forearm, extending just above the elbow
and to the wrist, with a small amount of central fluctuance. MRSA is cultured and
antibiotics are changed.

Summary of Clinical Scenario 4: Ms. Martinez is a 49-year-old woman with

longstanding, uncontrolled diabetes. On medial surface of both ankles, she has
symmetric-scaling, well-demarcated, minimally erythematous patches. In
addition, there are hemosiderin deposition changes on both legs and fine silvery
scales between toes and around her heels. She has yellow, opaque fissuring and
thickened toenails.

Summary of Clinical Scenario 5: Mr. Murphy is a 42-year-old man with HIV

disease diagnosed 6 years ago with increasing dandruff and facial rash. He is
diagnosed with seborrheic dermatitis.

Summary of Clinical Scenario 6: Ms. Johnson is a 28-year-old woman with an

itchy rash involving her eyelids after using a new eye cream designed to reduce

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 wrinkles. She is diagnosed with contact dermatitis and treated with a topical
corticosteroid.

Case Highlights: Six patients highlight a variety of skin disorders. The

differential for pigmented lesions and dermatitis is generated. Bacterial, viral,
fungal, and spirochetal skin infections are featured. Diabetes- and HIV-related
skin disorders are discussed.

Key Teaching Points

Knowledge
The risk factors for melanoma are a personal or family history of melanoma, sun
sensitivity or exposure, and multiple benign or atypical moles. A history of
spontaneous bleeding or change in a mole size increases the chance a lesion
might be skin cancer.

Five features, the ABCDE criteria, help identify pigmented lesions most likely to be
melanoma. Asymmetry, Border irregularity, Color variegation, Diameter greater
than 6 mm, and Evolving (change in size, shape, symptoms, surface, or shades of
color) indicate lesions at high risk for melanoma. Ulcerated skin lesions are at
high risk for cancer and should always be evaluated further. The gold standard for
diagnosing melanoma is histopathological examination of excised tissue.

Tinea pedis, commonly known as athlete's foot, causes scaling, flaking, and
itching of the affected skin. It most often occurs between the toes, especially the
web space between the fourth and fifth digits. Although it can usually be
diagnosed by visual inspection of the skin, the diagnosis should always include
microscopy of a potassium hydroxide preparation or KOH test to confirm presence
of fungus. If no fungus is seen, then consider alternative diagnoses, such as
eczema or psoriasis.

Tinea capitis is a superficial fungal infection of the scalp that typically occurs in
childhood. It may appear as scale or boggy swelling and may have a ringworm
appearance.

Rosacea begins as erythema of the central face and cheeks, typically sparing the
scalp and ears. As it progresses, telangiectasias, papules, and pustules may
develop. It is often confused with acne vulgaris or seborrheic dermatitis. Rosacea
is most common among Caucasian women between the ages of 30 and 60.

Acne vulgaris is most common among adolescents and typically presents with
papules and pustules.

Kaposi's sarcoma is a slow-growing skin cancer found mainly among persons with
untreated HIV disease. It starts as red or purple patches, but can evolve into
nodules and plaques that can be pigmented and spongy. Human herpes virus-8 is
necessary for the development of Kaposi's sarcoma. In many patients with HIV

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 disease and Kaposi's sarcoma, the lesion resolves with the use of highly active
antiretroviral therapy (HAART).

Dermatitis, i.e., inflammation of the skin, presents as an erythematous,

papulovesicular rash in the acute phase and as an erythematous, scaling rash in
the chronic phase. The five diagnoses that most commonly present this way are
atopic dermatitis, contact dermatitis, nummular eczema, seborrheic dermatitis or
stasis dermatitis. The key to determining the type of dermatitis is the pattern of
distribution. These five types of dermatitis must be differentiated from bacterial
and fungal infections of the skin:

Atopic dermatitis, also called atopic eczema, usually presents in individuals with
personal or family history of asthma or allergies, typically beginning in childhood.
This dermatitis is chronic with intermittent flares, sometimes associated with
secondary infections due to staphylococci, viruses or fungi. Pruritis is a prominent
symptom. Treatment targets topical immunosuppression via glucocorticoids,
emollients for chronic lichenification, and management of secondary infections.

Contact dermatitis can be either due to irritant or allergen. Contact dermatitis can
be acute, subacute or chronic depending on duration of exposure to the inciting
chemical or allergen. The dermatological findings can range from erythema,
papules, and vesicles to chronic lichenification and scale. Diagnosis of allergen is
made by patch testing. Treatment of contact dermatitis should focus on
avoidance. Acute disease can be managed by topical or systemic glucocorticoids
and oral antihistamines.

Nummular eczema is a coin-shaped scaly patch, usually worse in winter months,

which is often associated with dry skin. The cause most often appears to be
irritantion associated with detergent or other products; it sometimes is associated
with medications. The cause is rarely allergic. Treatment with a short course of
topical glucocorticoids can be beneficial.

Seborrheic dermatitis of the adult is a chronic dermatitis that involves the

sebaceous areas of the face (e.g. scalp, eyebrows, nasolabial folds, ears) and may
also involve the upper chest and intertriginous areas. It is a common problem in
patients with HIV disease.

Stasis dermatitis occurs in patients with venous hypertension and chronic edema
of the legs. It is a chronic dermatitis that involves the skin of the anterior shins
and medial malleolae. Treatment should target improved venous return through
surgery and graded compression stockings, topical glucocorticoids, and oral
antihistamines.

Diabetic dermopathy is characterized by light brown or reddish, oval or round,

slightly indented scaly patches often located on the shins. One of the most
common skin problems in patients with diabetes, diabetic demopathy occurs in up
to 30% of patients. It is unclear what causes diabetic dermopathy; it occurs more
frequently in diabetics with retinopathy, neuropathy, and nephropathy and is
associated with elevated glycosylated hemoglobin.

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 Psoriasis is a chronic disorder affecting the skin, nails, and joints. It causes red
scaly patches with silvery-white scales to appear on extensor surfaces, such as
elbows and knees. Fingernails and toenails can become dystrophic. 10% to 15%
percent of people with psoriasis also have psoriatic arthritis.

Leg ulcers

Types Description Treatment

Venous ulcers 70% of leg ulcers; Compression with

typically occur at wraps or stockings.
ankles.

Arterial ulcers Due to large vessel Restore arterial

atherosclerosis and supply.
ischemia.

Diabetic ulcers Neuropathic; occur at Offload pressure with

pressure points of casts, special shoes.
feet. Associated with Restore arterial
atherosclerosis. supply.

Skills:
History and Physical Exam

In general, the focused history of a patient with skin disease should include:

Onset, spread and duration, as well as location

Symptoms (particularly pain), pruritis, fever, malaise, and arthralgias

Previous treatments and skin care products

Past medical history of systemic diseases

Medications, allergies, and occupational as well as other exposures from sun,

chemicals, sex, and travel

The description of skin findings should document configuration and distribution, as

well as the presence of primary lesions, secondary lesions, and special features.

Primary lesions may be macules, patches, papules, plaques, nodules, pustules,

vesicles, and bullae or combinations of these types. Secondary lesions are crusts,
erosions, ulcerations, atrophy, or scars. Dermatological findings may include
more rare conditions such as wheals, scales, excoriations, comedones, milia,

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 burrows, lichenification, telangiesctasia, petechiae, and purpura.

Differential diagnosis

The most serious cause of a pigmented lesion is melanoma, but many pigmented
lesions are due to localized increase in pigmentation. Seborrheic keratosis is more
typical in an older person and often has a 'stuck-on' appearance. Melasma is
common among pregnant women. Freckles, or solar lentigenes, are another
common cause of localized hyperpigmentation. Less common causes include
post-inflammatory hyperpigmentation, hemosiderin deposition, and diffuse
hyperpigmentation. Diffuse hyperpigmentation can occur with Addison's disease,
hemochromatosis, or phototoxic reaction to a medication.

Acute erythematous maculopapular eruptions are common and may be drug

reactions, viral exanthems or bacterial infections. The eruption may be urticarial,
with evanescent wheals; scarlatiniform, with sandpaper papules; rubelliform,
having lentil-sized macules and faint papules; morbilliform; or evolve into
erythema multiforme.

Characteristic maculopapular viral and spirochetal exanthems include measles,

rubella, erythema infectiosum, infectious mononucleosis, secondary syphilis, and
non-polio enteroviruses.

Maculopapular bacterial exanthems include scarlet fever, toxic shock syndrome,

rickettsial infection, and meningococcemia.

It's virtually impossible to differentiate viral exanthems from drug eruptions,

although timing of the eruption relative to the medication may be helpful. Drug
eruptions typically appear 5-10 days after starting the medication and resolve 1-3
weeks after the drug is stopped. The common drugs causing morbilliform
eruptions are ampicillin, amoxicillin, allopurinol and
trimethoprim/sulfamethoxizole. Urticaria reactions are commonly caused by
aspirin, penicillin, and blood products.

Pityriasis rosea can present with diffuse patches or plaques usually starting with a
herald patch. It has a characteristic Christmas tree distribution. It resolves
spontaneously.

In cellulitis, the most likely organisms are those which colonize the skin (e.g. S.
aureus and S. pyogenes). A history of a portal of entry, like an abrasion or bite, is
common. Both S. pyogenes and S. aureus are also associated with impetigo,
which can manifest crusting. The prevalence of methicillin-resistant S. aureus
(MRSA) is increasing in the community. Risk factors for MRSA include past MRSA
infection, exposure to others with MRSA, and/or contact with healthcare or prison
environments.

Pseudomonas infections are associated with hot tubs or hospitals. Pasturella is

associated with cat and dog bites.

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 Management
Skin cancer prevention includes using broad-spectrum sunscreen with Sun
Protection Factor (SPF) of at least 15, even on cloudy days, or wearing a
long-sleeved shirt, hat, and sunglasses.

To prevent community-associated MRSA, the National Institute of Allergy and

Infectious Diseases recommends keeping cuts and scrapes clean and covered until
healed; avoiding contact with other people's wounds, bandages, and personal
items; and washing soiled sheets, towels, and clothes in hot water with bleach.

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