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Rash on Baby's Face DERM CASE DERM CASE Test your knowledge with multiple-choice cases This month – 8 cases: 1. Rash on Baby’s Face p.26 5. Scaly, Brown, Itchy Skin on Knees p.30 2. Skin-coloured Papule on Shoulder p.27 6. Areas of Hair Loss on the Face p.31 3. Dermatitic Eruption Around Lips p. 28 7. Growing Face Lump p.32 4. Itchy Back Eruption p. 29 8. Fish-like Scales p.33 Case 1 Rash on Baby’s Face This two-and-a-half-month-old baby was brought to my office by his mother, as she was extremely anx - ious about his facial rash, which began to appear when he was four-weeks-old. He was a normal- term, vaginal delivery and is being bottle fed. Apart from the rash, he is quite healthy. tion What is your diagnosis? © ibu t tr ad, a. Psoriasis h is nlo b. Impetigo rig l D dow y ia can use c. Seborrheic dermatitis p rc ers nal o e us rso d. Candidiasis C m ised r pe m hor y fo o Aut op C d. le c r ite ing Answer o hib a s le pro int Seborrheic dermatitis (answaer c) uisea papulopsrqua - benign, and self-limiting and they usually clear spon - S ed and mous disorder afofecrting othreisareasiewwith the most taneously during the first 12 to 24 months of life, but f uth y, v sebum, suoch tas thenscaalp, facpel,aand trunk. An associ - a small number can be particularly troublesome and N U dis ation with yeast infection, has been known for some require treatment. Mild lesions usually improve with time. Malassezia furfur appears to be the species hydrocortisone ointment. Moderate cases may need associated with infantile seborrheic dermatitis. hydrocortisone ointment combined with tar or vio - Differential diagnosis includes dermatophytosis, can - form (locacorten tar, locacorten vioform). In severe didiasis (potassium hydroxide [KOH] examination cases, fluorinated steroids may be used, taking into and cultures will help), and atopic dermatitis (which consideration their side-effects. is more pruritic than seborrheic dermatitis), may overlap in patients with psoriassis. This condition is Hayder Kubba, MBChB, LMCC, CCFP, FRCS (UK), DFFP, DPD, graduated from the University of Baghdad, referred to as seb-psoriasis. in patients with psoriasis, where he initially trained as a Trauma Surgeon. He so called sebo-psoriasis. moved to Britain, where he received his FRCS and The majority of cases of seborrheic dermatitis are worked as an ER Physician before specializing in Family Medicine. He is currently a Family Practitioner in Mississauga, Ontario. 26 The Canadian Journal of CME / June 2011 DERM CASE Case 2 Skin-coloured Papule on Shoulder A 43-year-old female presents with a skin-coloured papule on her left shoulder. What is your diagnosis? a. Acrochordon b. Nevus c. Neurofibroma d. Basal cell carcinoma Answer An acrochordon (answer a) also known as a skin tag or fibroepithelial polyp, is a common, benign, skin- coloured papule, typically occurring on the axillae or neck. Skin tags may appear smooth and flat, folded, or pedunculated. The clinical differential diagnosis may simply snipping with scissors. include wart, nevus, neurofibroma, and seborrheic Lesley Latham MSc, is a Research Assistant, Division of keratosis. Dermatology, Dalhousie University, in Halifax, Nova Lesions are usually asymptomatic but may infarct Scotia. if they become twisted, appearing as a black or crust - Dr. Richard G. B. Langley MD FRCPC, is a Professor of ed papule. Patients may find the lesions bothersome, Dermatology, and the Director of Research, in the either cosmetically or because pronounced skin tags Department of Medicine, Division of Dermatology, at Dalhousie University, in Halifax, Nova Scotia. can catch on clothing and jewelry. Lesions may be removed by cryosurgery, electrodessication, or by DERM CASE Case 3 Dermatitic Eruption Around Lips A six-year-old girl presents with a six month histo - ry of a well demarcated dermatitis eruption around the lips. What is your diagnosis? a. Heck's disease b. Atopic dermatitis c. Perioral dermatitis d. Lip licker's dermatitis e. Perl èche Answer Lip licker's dermatitis (answer d) is a type of irritant dermatitis caused by habitual and repetitive licking of the lips and the adjacent skin. The constant moisture aimed at maintaining skin moisture and avoiding aller - and saliva break down of the skin, causes the dermati - gic reactants and irritants. Topical steroids may be tis. Children with chronic lip licker’s dermatitis present required. with dry lips, lichenification, and hyperpigmentation in Perioral dermatitis also known as periorificial der - the area around the lips. Treatment is aimed at moistur - matitis is a self-limited skin condition that is common izing the area and breaking the lip licking habit. in children. It presents with erythematous papules and Heck’s disease is a skin condition that occurs in chil - papulopustules that can turn into an area of diffuse red - dren and young adults, and it is characterized by hyper - ness. Affected areas include the perioral, nasolabial, plasia of the mucous membranes in the oral cavity with and periocular regions. Spontaneous resolution may painless, round papules namely found on the lips and take months to years. The use of topical steroids is tongue. It is suspected to be caused by the human papi - known to precede the presentation of perioral dermati - loma virus. It can last for several months, sometimes tis. Treatment options include topical antibiotics. years, before resolution. Perlèche is a common disorder characterized by Atopic dermatitis is a common skin disorder that inflammation and fissuring of the corners of the mouth presents with pruritus and eczematous changes. The caused by moisture collecting at the mouth angles. eczematous changes are associated with a Type I (IgE- Perlèche may be seen in conjunction with dental mal - mediated) hypersensitivity reaction and the cellular occlusion, braces, and lip licking. Therapy is best response produces prolonged and severe pruritus. Skin accomplished by correction of the underlying predis - changes include mild erythema to severe lichenifica - posing factor. Treatment consists of the application of a tion and excoriations, which are secondary to scratch - topical corticosteroid, topical antifungals, and antibi - ing. Lesions are age-specific and appear on the face, otics if needed. neck, and extensor surfaces for infants and children, Joseph M. Lam is a Clinical Assistant Professor of and on flexural regions in older children. Treatment is Pediatrics and an Associate Member of Dermatology. He practices in Vancouver, British Columbia. 28 The Canadian Journal of CME / June 2011 DERM CASE Case 4 Itchy Back Eruption This 49-year-old woman has had an itchy eruption and excriation. on her back for the past 10 years. Notalgia pare - thetica occurs What is your diagnosis? in all races and a. Neurotic excoriations is equal in sex b. Contact dermatitis predilection with an onset in middle age. Symptoms c. Lichen simplex chronicus may be mild and infrequent to severe, recurrent, and d. Notalgia paresthetica debilitating. When warranted, a radiographic work- up to rule out cervical thoracic abnormalities should Answer be done. Notalgia paresthetica (answer d) is a sensory neu - Treatment is mainly focused on ameliorating ropathic syndrome of the back, characterized by symptoms, as the cause is rarely found. Topical focal burning pain, itch, or paresthesia. It is usually steroids, with or without menthol or camphor added, a unilateral well-circumscribed, hyperpigmented and products containing topical capsaicin are most patch in the midline or infrascapular area. The cause often used. Intralesional steroids are also of value. is unknown, but increased dermal innervations, tho - Gabapentin tends to be the most consistently help - racic disc disease, and nerve impingement have ful modality in severe cases. been proposed. Neurologic examinations, however, Stanley Wine, MD, FRCPC, is a Dermatologist in North tend to be normal and skin biopsies show only York, Ontario. hyperpigmentation as secondary to chronic rubbing The Canadian Journal of CME / June 2011 29 DERM CASE Case 5 Scaly, Brown, Itchy Skin on Knees A 60-year-old female from Haiti presents with scaly brown bumps on her knees and shins that first appeared decades ago. The patient states that the bumps are itchy; as a result, she scratches her legs very often. She denies having similar lesions any - where else on the body. What is your diagnosis? a. Tinea corporis b. Lichen simplex chronicus c. Lichen amyloidosis d. Prurigo nodularis Answer Lichen amyloidosis (answer c) is the most common apple-green birefringence may be observed under form of primary, localized, cutaneous amyloidosis. polarizing light. Amyloidosis can be either systemic or primary cuta - The treatment of lichen amyloidosis is often neous in nature. Primary cutaneous amyloidosis has unsatisfactory and is mainly directed at the reduc - been classified into three types: macular, lichen, and tion of pruritus. Patients should be advised to avoid nodular. It is a skin disorder characterized by amy - scratching or rubbing the skin as such actions can loid deposition in the skin without visceral involve - aggravate the lesions. Treatment options include ment. The exact etiology of amyloid deposit in the topical and/or intralesional steroids and topical skin is not known. Some cases have a genetic pre - dimethyl sulfoxide. Topical treatment with occlu - disposition. Lichen amyloidosis can be associated sion may produce a more satisfying result. with rheumatological diseases, such as systemic Systemic retinoids have been used for more severe lupus erythematosus and scleroderma. Clinically, it cases. Phototherapy and dermabrasion may also be presents as multiple skin-coloured to red-brown considered. hyperkeratotic papules with fine scaling. Papules Kellen K.N. Liu, MBBS, Dip Dermatology, is an may coalesce to form plaques. They are most com - International Fellow of Dermatology, at the Harvard monly located on the lower extremities, especially Medical School, in Boston, Massachusetts.
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