DERM CASE TTeesstt yyoouurr kknnoowwlleeddggee wwiitthh mmuullttiippllee--cchhooiiccee ccaasseess This month — 6 cases: 1. Eczematous Plaques around the Lips p.39 4. Right-sided Throat Pain p.43 2. A Bleeding Papule on the Chin p.40 5. White Patches on the Knee p.44 3. Brownish Papules on the Thigh p.42 6. Skin Erythema and Fever p.46 © right ibution py istr ad, Co l D ownlo Case 1 rcia can d me users use om orised sonal r C . Auth or per e o hibited copy f Sal se pro ingle for ised u rint a s ot author and p N Un y, view Eczemdiasplta ous Plaques around the Lips A five-year-old male presents with a localized, eczema- tous plaque around the lips. What is your diagnosis? a. Lip licker’s dermatitis b. Perleche c. Candidiasis d. Periorificial dermatitis Answer Lip licker’s dermatitis (answer a) is commonly seen in children who habitually lick their lips and the sur- rounding skin area. It is a form of irritant contact dermatitis that is caused by saliva and usually pre- sents with dry lips and a scaly, erythematous plaque Periorificial dermatitis typically presents as mul- around the mouth. tiple, erythematous papules and/or pustules around Perleche, also known as angular cheilitis, is a the mouth with classic sparing of the skin immedi- condition affecting the corners of the mouth. It typ- ately bordering the lips. Perinasal and periorbital ically presents as erythema, scaling, macerations, distributions are seen less frequently. This is gener- and fissures. Drooling, thumb sucking, and lip lick- ally considered to be a self-limited disease. ing are common causes in young children. Excess Diana Kang is a Fourth Year Medical Student at the moisture can make these areas prone to infection. University of British Columbia. Candidiasis is a fungal infection that can affect Joseph M. Lam, MD, FRCPC(C), is a Clinical Assistant moist areas around the mouth. Perioral lesions are Professor of Pediatrics and an Associate Member of the typically erythematous papules and/or plaques with Department of Dermatology and Skin Sciences at the University of British Columbia. He practices in Vancouver, classic satellite lesions. British Columbia. The Canadian Journal of CME / June 2014 39 DERM CASE Case 2 A Bleeding Papule on the Chin A seven-and-a-half-year-old, previously healthy boy presents with a six-week history of a bleeding papule on the left chin. What is your diagnosis? a. Amelanotic melanoma b. Spitz nevus c. Pyogenic granuloma d. Infantile hemangioma Answer Pyogenic granuloma (PG) (answer c) is one of the most common benign, acquired, vascular tumours found in infants and children. A PG is also known by its A Spitz nevus can present as a red, dome-shaped histopathologic description as lobular capillary heman - papule with varying degrees of pigmentation. It usual - gioma. A PG usually presents as a single, red, rapidly- ly increases in size over time, but its growth stabilizes growing papule or nodule with a subtle collarette of and can even eventually regress. The most common scale. It is commonly found on the head, neck, and type of Spitz nevus is a solitary, asymptomatic, pink or extremities; however, it can present on virtually any red, hairless, firm, and dome-shaped papule. It does not body site, including the mucous membranes. Minimal typically bleed, although some bleeding and eroded trauma often triggers profuse bleeding that can be diffi - lesions have been reported. cult to control (known as the “band-aid sign”). Infantile hemangioma (IH) is the most common A PG does not involute spontaneously, unlike most benign tumour of childhood. An IH has a rapid prolif - infantile hemangiomas, but treatment with simple erative phase within the first year of life, followed by a shave excision and electrocautery is usually curative slower involution phase. IH generally completes its with good cosmetic results. Recurrence and satellite course by the age of 7- to 10-years. Despite the vascu - lesions surrounding the original PG are rare, but they lar nature of IH, it does not have a tendency to bleed have been reported. Other treatment options include often or profusely like PG. Ulceration does occur in curettage, laser surgery (with carbon dioxide or pulsed about 15% of patients with IH but often during the pro - dye lasers), cryotherapy, and topical imiquimod. liferative phase and frequently at sites that are exposed Amelanotic melanoma is the most dangerous and to moisture and friction. worrisome of the list of differential diagnoses. Diana Diao is a Second Year Dermatology Resident at the Amelanotic melanoma can be difficult to diagnose, but University of British Columbia in Vancouver, British it often presents as a changing, odd-looking, asymmet - Columbia. rical and irregular, pink lesion with a small amount of Joseph M. Lam, MD, FRCPC(C), is a Clinical Assistant focal and irregular pigmentation. It does not usually Professor of Pediatrics and an Associate Member of the have the round, friable, “beefy-red” appearance of PG. Department of Dermatology and Skin Sciences at the University of British Columbia. He practices in Vancouver, British Columbia. 40 The Canadian Journal of CME / June 2014 DERM CASE Case 3 Brownish Papules on the Thigh A 15-year-old boy presents with brownish papules on the anterolateral aspects of both arms. The patient is otherwise well. What is your diagnosis? a. Folliculitis b. Acne c. Phrynoderma d. Keratosis pilaris Answer Keratosis pilaris (answer d) is characterized by the presence of minute, discrete, keratotic, follicular papules with variable perifollicular erythema. The lesions are not grouped and show no tendency to coalesce to form plaques. The affected skin looks skin cleansing; taking brief, tepid showers, rather than like gooseflesh and feels like sandpaper. The condi - long, hot baths; using mild soaps; and humidifying the tion is caused by keratin failing to exfoliate and home. In mild cases, an emollient, such as hydrophilic plugging the follicle, leading to a sterile papular or petrolatum or a 10 to 20% urea cream, usually allevi - pustular eruption. The lesions are not pruritic and ates the rough surface. More pronounced or wide - present most commonly on the lateral upper arms spread lesions may require treatment with a keratolyt - and thighs. They are less commonly seen on the ic agent, such as lactic acid, salicylic acid, or urea in torso and buttocks. While keratosis pilaris may start combination with a topical corticosteroid or retinoic to develop during childhood, it peaks during adoles - acid. cence. It is estimated that at least 50% of adoles - Collin Luk is a Medical Student at the University of cents are affected by this condition with a higher Calgary in Calgary, Alberta. prevalence in girls (up to 80%). Alexander K.C. Leung, MBBS, FRCPC, FRCP(UK&Irel), Measures should be taken to prevent excessive skin FRCPCH, FAAP, is a Clinical Professor of Pediatrics at dryness. These include decreasing the frequency of the University of Calgary in Calgary, Alberta. 42 The Canadian Journal of CME / June 2014 DERM CASE Case 4 Righ-sided Throat Pain An 18-year-old female visited the office complain - ing of pain on the right side of her throat. Upon examination, a white-yellow spot over her right ton - sil is visible. What is your diagnosis? a. Abscess b. Tonsil stones c. Mononucleosis d. Right tonsil cancer Answer Tonsil stones (answer b), also known as tonsil - loliths, are irregularly shaped, whitish-yellow, foul- smelling globs of mucus and bacteria that get caught in the back of the throat. If left to continue to Tonsil stones do not occur frequently. They can grow, they can also become larger and irritating in either come loose by themselves or be easily removed the throat. Tonsil stones can cause sore throats, with a swab or water spray. If they are causing major enlarged tonsils, bad breath, earaches, and difficul - problems, are very large or hard, or if the tonsils are ty swallowing; they can also be a source of repeated very well hidden, the best solution may be to surgical - infection. ly remove both tonsils completely. Jerzy K. Pawlak, MD, MSc, PhD, is a General Practitioner in Winnipeg, Manitoba. The Canadian Journal of CME / June 2014 43 DERM CASE Case 5 White Patches on the Knee A nine-year-old boy presents with a one-year history of white patches over the popliteal fossa. What is your diagnosis? a. Vitiligo b. Segmental pigmentation disorder c. Hypomelanosis of Ito d. Nevus anemicus e. Nevus depigmentosus Answer Vitiligo (answer a) is thought to be secondary to autoimmune-mediated destruction of melanocytes. Vitiligo is characterized by well-defined, depigmented lesions that fluoresce under Wood’s lamp. In children, it often occurs in a localized area. Initial lesions mostly patients, including seizures, mental retardation, poly - occur in sun-exposed areas, such as the face, back of dactyly, strabismus, and dental problems. the hands, and neck, but lesions may also occur over Nevus anemicus is a hypopigmented patch with bony prominences. Vitiligo has numerous associations, irregular margins in any portion of the body. It either including Graves’ disease, alopecia areata, diabetes presents at birth or during early childhood, and it per - mellitus, and Addison’s disease. There is a multifactor - sists throughout life. When pressed with a glass slide, it ial genetic link, including 23% concurrence in monozy - becomes indistinguishable from its surrounding skin. gotic twins. The mechanism relates to vasoconstriction, secondary Segmental pigmentation disorder is most common - to increased sensitivity to catecholamines. There is an ly seen during the first several months of infancy or association with port wine stains and neurofibromato - even at birth. It can be present either as hyperpigment - sis type 1.