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This month — 9 cases: © 1. Dark, Fuzzy Spots on the Back p.37 5. Longtitudinal Fingernail Bands p.41 rigPhersistent, Pruritic Plaques p.4n2 2. Thin, Concave Fingernails Copp.y38 6. tributio A Stye and Eyelid Swelling p.39 7. White Cheelk PDatcihses , p.43 3. ercia ownload Discolouration of the Legs p.40 m Discolouratiso nc oafn th de Shoulder p.44 4. r Com 8. sed user le o AuthorEi ruption on the Innnear lB uicseep p.45 r Sa ohibited. 9. for perso ot fo d use pr gle copy N authorise rint a sin Un iew and p display, v

Case 1 Dark, Fuzzy Spots on the Back

A 37-year-old woman presents with several dark and fuzzy spots on her back of several years duration. What is your diagnosis? a. Seborrheic keratoses b. Compound nevi c. Pedunculated nevi d. Dysplastic nevi e. Lentigines Answer Atypical nevi are moles with clinically unusual fea- tures. A biopsy with histopathology will provide the diagnosis of dysplastic nevi (answer d). The concern is that it can be hard to tell whether a dys- People with atypical or dysplastic nevi are at a plastic might already be an early melanoma; slightly higher risk than the general population of hence, they are often biopsied or excised. developing melanoma (especially if they have five They can occur sporadically or can be inherited. or more atypical nevi). These patients should be Atypical nevi are often asymmetric, have fuzzy or educated about sun protection and avoidance, and blurred borders, have variegated or multiple colours, they should be taught how to examine their skin. are bigger than 5 mm in diameter, and/or may They should also have their skin periodically change in size or colour over time (these are reviewed by a physician. referred to as the ABCDE rules). Sporadic, atypical nevi are much more common in fair-skinned per- Benjamin Barankin, MD, FRCPC, is Medical Director and Dermatologist at the Toronto Centre in sons, especially if they have had a fair bit of sun or Toronto, Ontario. tanning salon exposure.

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Case 2 Thin, Concave Fingernails

An 89-year-old, Caucasian woman is admitted to the coronary care unit with a complaint of chest pain radiating to her back. She was recently diag - nosed with an ascending aortic aneurysm. Physical examination is remarkable only for hypertension and thin fingernails that have a concave appear - ance. CT reveals progression of her ascending aneurysm and a new descending thoracic aortic dis - section. The patient’s aortic dissection is managed medically with improvement in her BP control, and a surgery is planned to repair her ascending Figure 1: Thin Fingernails Figure 2: Thin Fingernails with a aneurysm. Distinguishable Concave Appearance What is your diagnosis? a. Hyperthyroidism should also consider gynecological causes of blood b. Iron deficiency anemia loss. Other causes include renal failure, pulmonary c. Psoriasis hemosiderosis, and intravascular hemolysis. d. Endocarditis Diagnosis is based on a thorough history and phys - e. Bronchiectasis ical examination. Laboratory investigations consistent with iron deficiency anemia include a microcytic ane - Answer mia, decreased reticulocyte count, low serum iron, This patient exhibits koilonychia, commonly referred to increased total iron binding capacity, low transferrin as spoon nails, owing to the upward curvature of the saturation level, and low serum ferritin. Treatment distal nail plate, which gives the nail a spoon-like should be aimed at correcting the underlying cause. The appearance. This abnormality is most often associated patient did acknowledge a past history of iron deficien - with iron deficiency anemia (answer b) . There are cy anemia. other causes, including trauma, hemochromatosis, sys - Brent M. McGrath, MD, MSc, PhD, is an Associate temic lupus erythematosus, hypothyroidism, nail-patel - Chief Resident in the Department of Medicine at Saint la syndrome, and occupational exposure to petroleum- John Regional Hospital in Saint John, New Brunswick, based products. It is often a normal finding in infants. and Dalhousie University in Halifax, Nova Scotia. Koilonychia is a cutaneous manifestation of a systemic Nicholas A. Forward, MD, MSc, is a Resident in the disease, rather than a primary nail abnormality. Department of Medicine at Dalhousie University in Halifax, Nova Scotia. Iron deficiency anemia usually results from blood loss, most often from the gastrointestinal tract. Other Corey Stevens, BSc, is a Medical Student at Dalhousie Medicine New Brunswick in Saint John, New gastrointestinal conditions commonly implicated Brunswick, and the Faculty of Medicine at Dalhousie include celiac sprue, gastritis, inflammatory bowel University in Halifax, Nova Scotia. diseases, and diets deficient in iron. In women, one

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Case 3

A Stye and Eyelid Swelling

A 14-year-old male presents with a stye on his right eyelid, which first appeared a few days ago. He later noticed swelling of the same eyelid. He denies trauma, blurry vision, or pain. What is your diagnosis? a. Dacryocystitis b. Orbital cellulitis c. Periorbital cellulitis d. Angioedema e. Blepharitis movement, chemosis (conjunctival edema), and even proptosis (bulging forward of the eyeball). Answer Periorbital cellulitis is usually treated with a 7 to 10 Periorbital cellulitis (commonly known as preseptal day course of oral antibiotics, allowing for coverage cellulitis) (answer c) usually occurs from exogenous of Staphylococcus aureus and Streptococcus pyo - sources such as trauma, insect bites, and infections. genes , which are the two most common pathogens It can also be an extension of an eyelid infection, such involved. Antibiotic choices include cephalexin, clin - as a chalazion or hordeolum. On examination, damycin, and amoxicillin/clavulanate. Further investi - patients with periorbital cellulitis will have an erythe - gation and treatment may be warranted if there is fail - matous, swollen, and painful eyelid. Patients may also ure to improve within two to three days, and there have a mild fever. The eyeball itself is usually unaf - should be close vigilance for the development of fected, unless it extends to an orbital cellulitis. One orbital cellulitis. way to differentiate between periorbital and orbital Kimmy Goyal, MD, CCFP, ABFM, is a Family Doctor in cellulitis is that the latter can be accompanied by a Brampton, Ontario. decrease in vision, less reactive pupils, pain with eye Fenny Goyal, MD, is a Medical Graduate from the Windsor University School of Medicine in Cayon, Saint Kitts-Nevis.

The Canadian Journal of CME / February 2014 39 DERM CASE

Case 4 Discolouration of the Legs

A 62-year-old female presents with reddish-brown dis - colouration on the right and left pretibial areas of her legs. On examination, there are nonblanching, red, pin - point dots within the lesions. What is your diagnosis? a. Pigmented purpuric dermatoses b. Thrombocytopenic purpura c. Stasis dermatitis d. Psoriasis Answer Pigmented purpuric dermatoses (PPD) (answer a) are characterized by a reddish-brown discolouration of the skin that occurs primarily on the lower extremities and occasionally extends to the lower Drug-induced cases of PPD often have a rapid trunk and upper extremities. The four clinical vari - onset and a quick recovery, upon discontinuation of ants of PPD are known as Schamberg disease, the drug; however, the majority of PPD cases are Majocchi disease, Gougerot-Blum disease, and idiopathic, insidious, and long lasting. Onset is . While the etiology is not entirely more likely to happen between the ages of thirty and known, it is believed that the primary mechanism sixty, and males are affected more often than is cell-mediated immune injury of blood vessels females. PPD can be cosmetically disfiguring, and with subsequent red blood cell extravasation. patients often seek treatment for the lesions. Degradation of the erythrocytes and the formation Compression stockings may be help with PPD, and of hemosiderin are believed to be the primary caus - topical steroids may be helpful if dermatitis occurs. es of the characteristic brown discolouration. Other Ereni Neonakis is a Research Assistant in the Division of etiologic factors that increase the incidence of PPD Dermatology at Dalhousie University in Halifax, Nova are trauma, pressure, and certain drugs, such as Scotia.

NSAIDs and diuretics. Richard Langley, MD, FRCPC, is a Professor of Dermatology and Director of Research in the Division of Dermatology at Dalhousie University in Halifax, Nova Scotia.

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Case 5 Longitudinal Fingernail Bands

A 20-year-old female is concerned about white and red longitudinal bands on her fingernails as well as some flat-topped papules in the periungual areas. She also has some greasy, hyperkeratotic papules on her trunk. Her father has a similar eruption on his back and legs. What is your diagnosis? a. Seborrheic dermatitis b. Tuberous sclerosis c. Melanonychia striata d. Grover’s disease e. Darier’s disease Answer Darier disease (answer e) , also known as keratosis yellow-brown, brown, or skin-coloured; and feel like follicularis, is an autosomal dominant disorder char - coarse sandpaper. Over time, lesions become mal - acterized by the loss of intercellular adhesion (acan - odorous secondary to bacterial colonization or infec - tholysis) and abnormal keratinization of the epider - tion. Papules, fissures, and ulcers may develop on the mis, nails, and mucous membranes. The disease is palate, buccal mucosa, or tongue. Ocular features caused by mutations in the ATP2A2 gene that encodes include keratotic plaques on the eyelid and Sjögren’s a sarco/endoplasmic reticulum Ca 2+ adenosine syndrome. triphosphate isoform 2 protein (SERCA2). Patients The disease is chronic and unremitting. Treatment typically present when they are between 6- and 20- options include emollients, topical corticosteroids, years-of-age; onset peaks between 11- and 15-years- topical calcineurin inhibitors, topical 5-fluorouracil, of-age. Both sexes are equally affected, although topical retinoids, oral retinoids, dermabrasion, exci - males tend to be more severely affected than females. sion, electrodessication, cryosurgery, ablative laser, More than 95% of patients have nail changes that electron beam therapy, and photodynamic therapy. may include white and red longitudinal stripes, distal notches, splinter hemorrhages, and subungual hyperk - Alexander K.C. Leung, MBBS, FRCPC, FRCP(UK&Irel), FRCPCH, is a Clinical Professor of Pediatrics at the eratosis; these changes may precede other signs of the University of Calgary in Calgary, Alberta. disease. Skin changes are characterized by greasy, discrete, flat-topped, keratotic papules and plaques Benjamin Barankin, MD, FRCPC, is Medical Director and Dermatologist at the Toronto Dermatology Centre in that occur in seborrheic areas. Lesions are itchy; Toronto, Ontario.

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Case 6

Persistent, Pruritic Plaques

A 41-year-old male presents with a history of pro - gressive and persistent plaques on his lower legs that are intensely pruritic, violaceous, and pink in colour. What is your diagnosis? a. Psoriasis b. Lichen simplex chronicus c. d. Pityriasis rosea Answer Lichen planus (answer c) is an inflammatory der - matosis that can affect the skin, hair, nails, and mucous membranes, and it can last for months to years. Lichen planus is characterized by the five Ps: Initial management options include topical or purple, polygonal, planar, pruritic, and papular. intralesional glucocorticoids. In nonresponsive Papules are often flat-topped, and it is common for cases, phototherapy may be required; in refractory them to coalesce into plaques. Lesions often have cases, referral for consideration of systemic thera - white lines on the surface, also referred to as pies, such as cyclosporine and systemic retinoids, Wickham’s striae. may be considered. Lichen planus can have oropharyngeal involve - ment in 40 to 60% of affected individuals. The risk Richard Langley, MD, FRCPC, is a Professor of of oral squamous cell carcinoma is increased and is Dermatology and Director of Research in the Division of Dermatology at Dalhousie University in Halifax, Nova believed to be in the order of 5%. Lichen planus can Scotia. also affect hair follicles and nails.

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Case 7 White Cheek Patches

A 12-year-old, Asian boy presents with white patch - es on his cheeks. The lesions were first noted a year ago. The child is asymptomatic and healthy. What is your diagnosis? a. Tinea versicolor b. Nummular eczema c. d. e. Tuberous sclerosis Answer Pityriasis alba (answer d) is characterized by hypopigmented, round or oval macules or patches with fine, loosely adherent scales and indistinct mar - gins. The lesions appear mainly on the face, especial - Tinea versicolor rarely presents on the face ly or the malar areas, and occasionally on the arms or (trunk predominant), is uncommon in childhood, elsewhere. The lesions range from 0.5 to 5 cm in and has a distinct margin. In case of doubt, tinea diameter. Confluent lesions can give the appearance versicolor can be excluded with a potassium of larger, more amorphous lesions. Most lesions are hydroxide preparation. The lesions of nummular asymptomatic. eczema are usually plaque-like, sharply circum - Pityriasis alba occurs predominantly in children scribed, and pruritic. between the ages of 3- and 16-years. The sex inci - Nevus depigmentosus is characterized by a non - dence is approximately equal. The condition is noted progressive, well-circumscribed macule or patch of in up to 40% of dark-skinned children in the suscepti - and the appearance of the lesion ble age group. Pityriasis alba is observed more com - before three-years-of-age. The hypopigmented monly in atopic patients and during the spring and lesions of tuberous sclerosis are usually present at summer. birth or develop during the first two-years of life Xerosis is an important pathogenic factor. The and have the appearance of an ashleaf. condition is self-limited and usually lasts two to three Alexander K.C. Leung, MBBS, FRCPC, FRCP(UK&Irel), years. Moisturizing the skin is advised. Topical FRCPCH, is a Clinical Professor of Pediatrics at the calcineurin inhibitors, and, less preferably, mild topi - University of Calgary in Calgary, Alberta. cal steroids can be used for two to three weeks to Benjamin Barankin, MD, FRCPC, is Medical Director expedite resolution (though it can take a few months and Dermatologist at the Toronto Dermatology Centre in after treatment for the hypopigmentation to resolve Toronto, Ontario. completely).

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Case 8 Discolouration of the Shoulder

A 10-year-old boy presents with an asymptomatic, white lesion on his right shoulder that has been pre - sent since birth. The lesion has been stable in shape, distribution, texture, and relative size since then. Stroking the lesion induces erythema. Wood’s lamp examination of the patch shows an off-white accen - tuation without fluorescence. What is your diagnosis? a. b. Nevus depigmentosus c. Hypomelanosis of Ito d. Tuberous sclerosis complex e. Pityriasis alba

Answer extracutaneous manifestations, such as seizures, Nevus depigmentosus (answer b) is characterized mental retardation, hemihypertrophy, and yellow by a congenital, asymptomatic, nonprogressive, scalp hair. hypopigmented macule or patch that is stable in The commonly used clinical criteria for nevus shape, distribution, texture, and relative size depigmentosus are leukoderma, presentation at throughout life. The border of the lesion is not birth or early in life, no alternation in distribution of hyperpigmented. Sites of predilection include the leukoderma throughout life, no alternation in tex - trunk, lower abdomen, and proximal extremities. In ture or change of sensation in the affected area, and most patients, the condition is asymptomatic. absence of a hyperpigmented border. With Wood’s Three morphological variants of nevus depig - lamp examination, the lesion shows an off-white mentosus are recognized: isolated, segmental, and accentuation without fluorescence. In addition, der - systematized. An isolated circular or rectangular moscopy, use of a pigment measuring device, and in macule/patch involving a small, localized part of the vivo reflectance confocal microscopy are helpful in body is the most common presentation. The margin evaluating the impaired function of . is often serrated. The majority of patients with Naturally, pigment decreases in lesional nevus depigmentosus have one lesion. The segmen - skin. tal variant presents as a unilateral streak or patch Alexander K.C. Leung, MBBS, FRCPC, FRCP(UK&Irel), that appears in a segment or along Blaschko’s lines, FRCPCH, is a Clinical Professor of Pediatrics at the as is illustrated in the present case. The systematized University of Calgary in Calgary, Alberta. variant presents with multiple whorls and streaks. Benjamin Barankin, MD, FRCPC, is Medical Director This variant is very rare and may be associated with and Dermatologist at the Toronto Dermatology Centre in Toronto, Ontario.

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Case 9

Eruption on the Inner Bicep

This 45-year-old woman noted pain and numbness of her bicep three days prior to an otherwise asymp - tomatic eruption. The eruption is localized to only the inner bicep and the ulnar aspect of her wrist. What is your diagnosis? a. Herpes simplex b. Herpes zoster c. Impetigo d. Wasp stings e. Nummular eczema Answer Herpes zoster (answer b) is the reactivation of the vari - cella zoster virus found in sensory dorsal root ganglion cells. Annual incidence is 1:1,000 in patients 45-years- This patient presents with a lesion demonstrating of-age and four times greater in those over 75-years-of- only minimal redness with fine vesicles already invo - age. Women are slightly more likely to be involved. luting. The diagnosis, therefore, can be easily missed or Immunosuppression increases the risk of occurrence confused with eczema. and, along with age, increases the likelihood of greater Stanley J. Wine, MD, FRCPC, is a Dermatologist in severity and duration of symptoms. Toronto, Ontario. In younger individuals, findings are minimal with more rapid involution as opposed to the more dramatic picture of blisters, crusting, and confluence that is seen in older populations.

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