BRIEF "SUPERFICIALLY SPEAKING"A DERMATOLOGY QUIZ Paul Cephus, PA, and Ted Rosen, MD Houston, Texas
This presentation is a dermatology case in quiz form with a 4-point differential. The patient, a 44-year-old man admitted to Psychiatry Service for management of chronic psychosis, was noted to have multiple, circular, wellcircumscribed violaceous cutaneous plaques resembling various dermatological conditions. This case underscores the importance of careful historical, clinical, and laboratory investigation to establish the correct diagnosis when evaluating skin lesions. Judicious laboratory testing may be helpful in excluding diseases such as syphilis and acquired immunodeficiency syndrome, which may mimic other dermatological conditions. Test your clinical acumen by deciding on a diagnosis. The correct answer is revealed in the discussion. (J Nati Med Assoc. 1991;83:825-826.) Key words * dermatology * skin lesions A 44-year-old man was admitted to the Psychiatry Service for treatment and stabilization of chronic schizophrenia. Physical examination disclosed multiple large, well-circumscribed violaceous plaques involving his arms, chest, and posterior thorax. Figures 1 and 2 illustrate presenting features. Routine admission hematological and biochemistry laboratory tests, including a
From the Psychiatry and Dermatology Services, Veterans' Affairs Medical Center, Houston, Texas. Requests for reprints should be addressed to Mr Paul Cephus, Psychiatry Service, Veterans Affairs Medical Center, 2002 Holcombe Blvd, Houston, TX 77030. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 9
serological test for syphilis, were essentially normal. What is your diagnosis? A. Kaposi's sarcoma. B. Fixed drug eruption. C. Erythema multiforme. D. Lichen planus. The correct answer is "B," fixed drug eruption. This condition closely resembles the other choices with bright-red to violaceous plaques or an occasional component of bullous lesions. Fixed drug eruptions can be differentiated on the bases of historical data and histopathological findings from biopsied tissue.' Historically, such eruptions occur repeatedly in the same general region, often in the exact location as previous lesions, whenever the offending drug or chemical is ingested or injected.' Fixed drug eruptions also can be precipitated by exposure to structurally-related materials. Of note, a site of predilection for fixed drug eruptions is the glans penis. On visual inspection,. lesions of fixed drug eruptions and erythema multiforme (EM) may appear quite similar in their gross appearance. However, histological differences begin at the lower epidermal and dermal layers, where, in drug eruptions, the inflammatory-cell infiltrate is deeper and denser, with mixed cells (neutrophils and eosinophils), and is both perivascular and interstitial.' Moreover, there is an abundance of melanophages in the papillary dermis, particularly at sites of previous lesions.1 In general, both drug eruptions and EM may be precipitated by any one of a great number of medications and chemical substances. Fixed drug eruptions are most often due to tetracycline derivatives, barbiturates, and phenolphthalein-based laxatives. This patient's eruptions were precipitated by administration of the anticonvulsant, diphenylhydantoin. Treatment obvi825
DERMATOLOGY QUIZ
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41~
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Figure 1. Circumscribed violaceous lesions on the surface of the patient's forearm.
Figure 2. Cluster of plaque lesions on the patient's upper thorax.
ously begins with withdrawing the offending drug agent and continues with local management using appropriate measures. Topical corticosteroids may hasten the involution of fixed drug eruptions. Answer "A," Kaposi's sarcoma (KS), may, at times, be seen on the upper extremities and chests of patients suffering from the acquired immunodeficiency syndrome. The violet to dark blue lesions involving the
priate investigation may be helpful in excluding secondary syphilis,4 AIDS, and certain types of malignancies. Treatment is tailored to the patient's condition. Antipyretics, analgesics, hydration, and in some cases, systemic corticosteroids may be indicated.4 Finally, lichen planus (LP), answer "D," is classically characterized by small, flat-topped, papular, light-violaceous lesions with networks of whitish streaks (Wickham's striae) on their surfaces.4 Typical lesions of LP usually occur along the flexor surfaces. However, so-called hypertrophic lichen planus, commonly encountered on the anterior aspect of the lower extremities on black patients, may clinically present with larger and darker plaques closely resembling KS, EM, and fixed drug eruptions.5 All forms of LP can be differentiated on skin biopsy due to a rather pathognomonic histologic appearance. Treatment of patients with LP can include the use of a topical corticosteroid, intralesional corticoid injections, and systemic anxiolytic agents.4
lower extremities, however, represent a more "classic" manifestation.2 Further, lesions of KS tend to enlarge progressively with the disease and, on occasion, ulcerate, requiring treatment of any secondary infections with antibiotics.2 Laboratory testing in cases of
suspected KS begins with the enzyme linked immunosorbent assay (ELISA) for the human immunodeficiency virus antibody (HIV-Ab). Positive results should be confirmned by the Western blot procedure for increased specificity.3 Erythema multiforme, answer "C," may appear as either macular, papular, vesicular, nodular, or purpuric lesions. Such lesions may assume concentric rings or "bull's eye" patterns, and are usually seen on the extensor surfaces in a symmetrical configuration.4 Frequently, lesions of EM are also on the mucous membranes, palms, or soles.4 This condition can be associated with internal disorders such as mycoplasma infections, dermatomyositis, ulcerative colitis, systemic lupus erythematosus, malignancy, and may be seen as a seemingly idiopathic dermatological disorder.4 Although EM is felt to be a hypersensitivity, its exact etiology remains uncertain. Laboratory testing is of little value in making this diagnosis. However, appro826
Literature Cited 1. Ackerman AB, Troy JL, Rosen LB, Jerasutus S, White CR Jr, King DF. Differential Diagnosis in Dermatopathology I. Philadelphia, Pa: Lea & Febiger; 1988:14-17. 2. Gross DJ, Parris A, Safai B. Update on AIDS. Hospital Medicine. 1989;25:22-26. 3. Morrissett WR. HIV-antibody counseling and testing. Physician Assistant. 1 988;1 2:96. 4. Rees RB Jr. Skin and appendages. In: Krupp MA, Chatten MJ, eds. Current Medical Diagnosis and Treatment. Los Altos, Calif: Lange Medical Publishers; 1978:39-48. 5. Rosen T, Martin S. Atlas of Black Dermatology. Boston, Mass: Little, Brown & Co; 1981:28-31.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 9
This presentation is a dermatology case in quiz form with a 4-point differential. The patient, a 44-year-old man admitted to Psychiatry Service for management of chronic psychosis, was noted to have multiple, circular, wellcircumscribed violaceous cutaneous plaques resembling various dermatological conditions. This case underscores the importance of careful historical, clinical, and laboratory investigation to establish the correct diagnosis when evaluating skin lesions. Judicious laboratory testing may be helpful in excluding diseases such as syphilis and acquired immunodeficiency syndrome, which may mimic other dermatological conditions. Test your clinical acumen by deciding on a diagnosis. The correct answer is revealed in the discussion. (J Nati Med Assoc. 1991;83:825-826.) Key words * dermatology * skin lesions A 44-year-old man was admitted to the Psychiatry Service for treatment and stabilization of chronic schizophrenia. Physical examination disclosed multiple large, well-circumscribed violaceous plaques involving his arms, chest, and posterior thorax. Figures 1 and 2 illustrate presenting features. Routine admission hematological and biochemistry laboratory tests, including a
From the Psychiatry and Dermatology Services, Veterans' Affairs Medical Center, Houston, Texas. Requests for reprints should be addressed to Mr Paul Cephus, Psychiatry Service, Veterans Affairs Medical Center, 2002 Holcombe Blvd, Houston, TX 77030. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 9
serological test for syphilis, were essentially normal. What is your diagnosis? A. Kaposi's sarcoma. B. Fixed drug eruption. C. Erythema multiforme. D. Lichen planus. The correct answer is "B," fixed drug eruption. This condition closely resembles the other choices with bright-red to violaceous plaques or an occasional component of bullous lesions. Fixed drug eruptions can be differentiated on the bases of historical data and histopathological findings from biopsied tissue.' Historically, such eruptions occur repeatedly in the same general region, often in the exact location as previous lesions, whenever the offending drug or chemical is ingested or injected.' Fixed drug eruptions also can be precipitated by exposure to structurally-related materials. Of note, a site of predilection for fixed drug eruptions is the glans penis. On visual inspection,. lesions of fixed drug eruptions and erythema multiforme (EM) may appear quite similar in their gross appearance. However, histological differences begin at the lower epidermal and dermal layers, where, in drug eruptions, the inflammatory-cell infiltrate is deeper and denser, with mixed cells (neutrophils and eosinophils), and is both perivascular and interstitial.' Moreover, there is an abundance of melanophages in the papillary dermis, particularly at sites of previous lesions.1 In general, both drug eruptions and EM may be precipitated by any one of a great number of medications and chemical substances. Fixed drug eruptions are most often due to tetracycline derivatives, barbiturates, and phenolphthalein-based laxatives. This patient's eruptions were precipitated by administration of the anticonvulsant, diphenylhydantoin. Treatment obvi825
DERMATOLOGY QUIZ
~~
41~
~
Figure 1. Circumscribed violaceous lesions on the surface of the patient's forearm.
Figure 2. Cluster of plaque lesions on the patient's upper thorax.
ously begins with withdrawing the offending drug agent and continues with local management using appropriate measures. Topical corticosteroids may hasten the involution of fixed drug eruptions. Answer "A," Kaposi's sarcoma (KS), may, at times, be seen on the upper extremities and chests of patients suffering from the acquired immunodeficiency syndrome. The violet to dark blue lesions involving the
priate investigation may be helpful in excluding secondary syphilis,4 AIDS, and certain types of malignancies. Treatment is tailored to the patient's condition. Antipyretics, analgesics, hydration, and in some cases, systemic corticosteroids may be indicated.4 Finally, lichen planus (LP), answer "D," is classically characterized by small, flat-topped, papular, light-violaceous lesions with networks of whitish streaks (Wickham's striae) on their surfaces.4 Typical lesions of LP usually occur along the flexor surfaces. However, so-called hypertrophic lichen planus, commonly encountered on the anterior aspect of the lower extremities on black patients, may clinically present with larger and darker plaques closely resembling KS, EM, and fixed drug eruptions.5 All forms of LP can be differentiated on skin biopsy due to a rather pathognomonic histologic appearance. Treatment of patients with LP can include the use of a topical corticosteroid, intralesional corticoid injections, and systemic anxiolytic agents.4
lower extremities, however, represent a more "classic" manifestation.2 Further, lesions of KS tend to enlarge progressively with the disease and, on occasion, ulcerate, requiring treatment of any secondary infections with antibiotics.2 Laboratory testing in cases of
suspected KS begins with the enzyme linked immunosorbent assay (ELISA) for the human immunodeficiency virus antibody (HIV-Ab). Positive results should be confirmned by the Western blot procedure for increased specificity.3 Erythema multiforme, answer "C," may appear as either macular, papular, vesicular, nodular, or purpuric lesions. Such lesions may assume concentric rings or "bull's eye" patterns, and are usually seen on the extensor surfaces in a symmetrical configuration.4 Frequently, lesions of EM are also on the mucous membranes, palms, or soles.4 This condition can be associated with internal disorders such as mycoplasma infections, dermatomyositis, ulcerative colitis, systemic lupus erythematosus, malignancy, and may be seen as a seemingly idiopathic dermatological disorder.4 Although EM is felt to be a hypersensitivity, its exact etiology remains uncertain. Laboratory testing is of little value in making this diagnosis. However, appro826
Literature Cited 1. Ackerman AB, Troy JL, Rosen LB, Jerasutus S, White CR Jr, King DF. Differential Diagnosis in Dermatopathology I. Philadelphia, Pa: Lea & Febiger; 1988:14-17. 2. Gross DJ, Parris A, Safai B. Update on AIDS. Hospital Medicine. 1989;25:22-26. 3. Morrissett WR. HIV-antibody counseling and testing. Physician Assistant. 1 988;1 2:96. 4. Rees RB Jr. Skin and appendages. In: Krupp MA, Chatten MJ, eds. Current Medical Diagnosis and Treatment. Los Altos, Calif: Lange Medical Publishers; 1978:39-48. 5. Rosen T, Martin S. Atlas of Black Dermatology. Boston, Mass: Little, Brown & Co; 1981:28-31.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 83, NO. 9
