Lesions

Skin Deep: Don’t look too closely

Life-threatening necrosis

An elderly man presents with a non-healing leg ulcer. CASE STUDY AN 88-year-old man presents with a two-month history of a non-healing ulcer on his right lower limb. The lesions started insidiously as multiple red nodules that progressively became ulcerated and painful. The patient has hypertension and is on warfarin due to his atrial fibrillation. On examination, he is found to have extensive necrotic ulceration of his shin, covered by black haemorrhagic crust (Figure 1). Figure 1: Extensive necrotic ulceration of the shin, covered by black haemorrhagic crust. ...

The variations of pityriasis versicolor

CASE STUDY A 52-YEAR-OLD man presents for a routine skin check and is noted to have erythematous scaly macules covering his back and shoulders (Figure 1). He was unaware of these, although six months earlier he had been diagnosed with pityriasis versicolor, which responded to twice-weekly application of 2% ketoconazole shampoo. Figure 1: Multiple erythematous macules coalescing on the shoulder. PITYRIASIS VERSICOLOR Pityriasis versicolor (PV) is a superficial, chronically recurring disease of the stratum corneum. It typically presents with scaly, irregular macules on the trunk and ...

Unassuming papules

Cutaneous papules with evidence of vascular disease are suggestive of an inherited metabolic disorder. CASE HISTORY A 33-YEAR-OLD male heavy smoker presented with a history of lesions on the neck, and in the axillae and groin which had been present since childhood. He had recently consulted an ophthalmologist for progressively worsening vision. Though he had never needed spectacles before, in the past few years his visual acuity had declined. He also described episodes of lower extremity muscle cramping on exertion. The cutaneous lesions were non-pruritic with no scaling, discharge or oozing, but the ...

GPs bowing to patient pressure driving high skin excision rate

PATIENT pressure may be causing GPs to excise a large number of benign skin lesions, a new study has shown. Queensland researchers analysed the factors affecting the number of benign skin lesions being excised by primary care physicians. They found 154 family medicine physicians, working in mainstream general practice or primary care skin cancer clinics, excised 11,403 skin lesions, more than a quarter of which were pigmented. For pigmented lesions, the number needed to excise or biopsy (NNE) to diagnose one melanoma was 19.6, while the NNE for non-pigmented lesions was 1.5. Dr Stephen Shumack, ...

Epidermoid cysts

Management of an occipital scalp cyst. PATIENT PRESENTATION A 79-year-old retired labourer from Greece presented with a nine-month history of an occipital scalp cyst. Although the cyst had gradually enlarged, it was asymptomatic other than for the ‘lump’ sensation he felt when lying recumbent at night. There was no preceding trauma or history of previous cysts On examination, there was a solitary well-circumscribed 3 cm x 3 cm firm cyst located on the posterior scalp with no overlying skin changes (pictured below). Hair growth was scant over the cyst with no obvious central punctum ...

Mastocytosis

An infant presents with a recurrent generalised rash. A NINE-MONTH-OLD boy presented with a history of a recurrent pruritic rash. His parents denied any initiating factors or associated symptoms, and his past medical history was insignificant. On examination, there were multiple brownish-red papules and plaques in a widespread symmetrical distribution sparing the face, palms and soles. A tense blister was present on the mid-back. Darier’s sign was present as indicated by the formation of a wheal and erythema after rubbing one of the lesions (pictured). There was no hepatosplenomegaly or bone tenderness. Lab tests showed ...

Kaposi's sarcoma

An HIV patient presents with characteristic skin lesions. A 51-year-old Caucasian man with HIV was admitted to hospital with Pneumocystis carinii pneumonia. His recent CD4 count was 0.13x10 9 . He complained of some purple lesions on his chest and abdomen, which had been present for a few years and recently increased in size. He had developed a new lesion in his mouth causing soreness, and one on his toe had recently ulcerated. On examination, he had several non-blanching purple papules on the neck, chest (Figure 1) and abdomen. On the plantar surface of ...

Plantar problems: warts and corns

Identifying and treating common plantar conditions. PLANTAR lesions are among the most common presentations to general practice, with high rates of warts (verrucae), corns and calluses. Distinguishing between such lesions can be aided by simple dermatoscopic examination for their characteristic features.   CASE HISTORY An 88-year-old lady presented with discomfort under the first metatarsal head of her right foot. Despite repeated paring and debridement, the lesion quickly returned. Given the location and hyperkeratotic appearance of this plantar lesion, it was diagnosed as a plantar corn ( Figure 1 ). ...

Erythema multiforme

  A young man presents with evolving circular erythematous lesions predominantly on the extensor surfaces of his arms and legs. CASE HISTORY TWO days after developing a mild upper respiratory tract infection, a 24-year-old man notices lesions appearing on his hands and feet. These then spread centripetally. Figure 1. Target lesions on the extensor surface of the arm. Figure 2. Ulcerating lesions on the lips. The lesions are not painful, but are occasionally associated with ...

Solar keratoses

A man is worried about the roughness of the skin on his temples and hands. A 65-year-old man presents because he is concerned about the roughness of the skin on his temples and the backs of his hands. He has worked for many years outdoors as a gardener, wears a cap rather than a broad-brimmed hat, and uses sunscreen only occasionally. The diagnosis is one of multiple solar keratoses (SK). Fig 1. Multiple solar keratoses (SK) Solar keratoses are precancerous lesions affecting a majority of ...

Psoriasis in children

Psoriasis is often missed in children. Dr Gayle Fischer advises on its diagnosis and treatment. PSORIASIS is a very common genetic disorder. Although it is understood that the mechanism of the skin lesions is too-rapid turnover of the epidermis, the exact pathogenesis remains unknown, as does the exact mode of inheritance. Nevertheless we know that psoriasis runs strongly in families. Psoriasis is usually considered to be a condition with onset in young adulthood, but it can and does present in children from infancy onwards. The prevalence in children is unknown. ...

Porphyria cutanea tarda

A rash which requires permanent lifestyle modification. A 35-YEAR-OLD Caucasian barman presents with a painful rash on his hands and face that has developed gradually over the past two weeks. His skin has become more fragile over the last month, starting after a sea fishing trip. He has no history of any skin complaints in the past. He is not on any medication and there is no family history of skin disease. On average his alcohol consumption is 70 units per week and he smokes 20 cigarettes per day. On inspection, the rash ...

A common response to the cold

An elderly woman presents with burning, itching fingers during winter. CASE HISTORY AN 86-year-old Caucasian lady complained of tender, dark blue-violet lesions on her fingers. Her main symptom was a sensation of burning and itching. The lesions appeared during the winter months and resolved spontaneously within a few weeks. She had had them for years. On examination, she had violaceous macules and papules on an erythrocyanotic background on the fingers of both hands (pictured). She was otherwise well. In particular, she had no rash elsewhere, no fevers and no ­arthralgias. ...