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Challenging Cases in Dermatology provides a strategic and analytic way of thinking about unusual dermatologic presentations. Every case presented within this book is a unique story, but the clinical decision pathways used to reach an appropriate solution are similar. A wide range of cases are covered including many extremely rare diseases and rare presentations of diseases that are not, themselves, uncommon. A familiarity with such unusual cases will provide the dermatologist with increased knowledge, a wider perspective, and innovative techniques that can be used to solve diagnostic dilemmas.
The author has used his vast experience in practicing dermatology to create a visual reference for skin disease, with the emphasis on working through each case as presented, starting with the clinical data, histological slides, and other available investigations. Each chapter includes a brief discussion of each extraordinary case and includes epidemiology, pathogenesis, clinical and histological features, differential diagnosis, definite diagnosis, prognosis, and management.
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Contents
Part I Genodermatoses
1 Hyperkeratotic Palms and Soles with Periorificial Keratosis . . . . . . . . . . . . . . . 3
2 Indurated, Dark, Hairy Plaques, with Arthritis and Deafness . . . . . . . . . . . . . . 9
3 Cleft Palate, with a Peculiar Limb Deformity . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
4 Blisters, Hypodontia, Deafness and Alopecia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
5 Mucocutaneous Pigmentation, Alopecia and Candidiasis . . . . . . . . . . . . . . . . . . 39
6 Congenital Alopecia Associated with Papular Eruption
and Abnormal Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
7 Photosensitivity, Lipodystrophy, Mental Retardation
and Joint Contractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
8 Dark, Thick Nipples and Areolas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
9 Thick Nails, Palms and Soles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
10 Eczema, Recurrent Abscesses and Recurrent Respiratory
Tract Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
11 Senile at the Age of 20 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
12 Infantile Alopecia, Characteristic Facies and Sclerosed Atrophic Limbs . . . . . 79
13 A Child with Sagging Cheeks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
14 Acrodermatitis Enteropathica Like Eruption . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
15 Acrodermatitis Enteropathica-Like Eruption, Another Unusual Cause . . . . . . 101
16 A Child with Hoarse Cry, Subcutaneous Nodules and Joint Contracture . . . . . 107
17 Stubborn Leg Ulcers, Stiff Joints, Acral Sclerodermoid Changes
and Fragile Skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Part II Neutrophilic Dermatoses and Related Disorders
18 Unusual Presentations of an Uncommon Ulcerative Disorder . . . . . . . . . . . . . . 121
Part III Vascular Disorders and Vasculitis
19 An Unexpected Cause of Leg Ulceration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
20 Limb Ulcer and Paresis; Acquired and Congenital . . . . . . . . . . . . . . . . . . . . . . . 143
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21 Recurrent Abortions and Atrophic Telangiectatic Leg
Lesions with Ulcerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
22 Acral Necrosis in a Heavy Smoker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Part IV Vascular Malformations and Tumors
23 A Persistent Hemorrhagic Swelling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
24 Peripheral Gangrene Affecting a Family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
25 Vascular Eruption in a Long-Standing Systemic Sclerosis . . . . . . . . . . . . . . . . . 181
26 Pendulous Breasts with Reticulate, Vascular and Necrotic Plaques . . . . . . . . . . 187
27 Disseminated Ulcerative Vascular Plaques in a Child . . . . . . . . . . . . . . . . . . . . . 193
28 Diffuse Congenital Vascular Lesions Affecting One Limb
with Reduced Limb Size . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
29 Multiple Painless Bluish Nodules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
30 A Painful Bluish Nodule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
31 An Aggressive Lesion Involving the Scalp of an Elder . . . . . . . . . . . . . . . . . . . . . 219
Part V Cutaneous Lymphomas and Lymphocytic Infiltrate
32 An Unusual Differential Diagnosis of Leg Ulcer . . . . . . . . . . . . . . . . . . . . . . . . . . 231
33 A Disease Hiding in a Granuloma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
34 Aggressive Follicular Lesions Involving Head and Neck . . . . . . . . . . . . . . . . . . . 243
35 Non-resolving Chronic Eyelid Swelling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
36 Rapidly Growing Ulcers on the Face . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
37 Persistent Papules and Nodules on the Side of the Tongue . . . . . . . . . . . . . . . . . 267
38 Ulceration in the Flank of a Middle-Aged Man . . . . . . . . . . . . . . . . . . . . . . . . . . 273
39 Pyoderma Gangrenosum-Like Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
40 Unexplained Anemia with Pyoderma Gangrenosum-Like Ulcer . . . . . . . . . . . . 287
41 A Long History of Panniculitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
42 Ulcerated Nodules in a Healthy Woman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301
43 EBV-Associated Granulomatous Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
Part VI Metabolic and Nutritional Disorders
44 Facial and Flexural Deposits Associated with Scalp Swelling . . . . . . . . . . . . . . . 319
45 Generalized Mottled Hyper and Hypopigmentation,
Without Systemic Abnormalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327
Part VII Infections of the Skin
46 Two Infections Coexisting in One Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335
47 An Atypical Presentation of a Cutaneous Infection . . . . . . . . . . . . . . . . . . . . . . . 343
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48 An Infection Presenting as a Connective Tissue Disease . . . . . . . . . . . . . . . . . . . 349
49 Asymptomatic Acral Exanthem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355
50 Draining Ulcers in a Healthy Boy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 359
51 A Child with Fever, Lymphadenitis and Rash . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
52 An Extremely Rare Cause of Erythroderma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
53 Painless Disfiguring Tumors with Draining Sinuses . . . . . . . . . . . . . . . . . . . . . . . 379
54 Exquisitely Painful, Rapidly Progressing Lesions . . . . . . . . . . . . . . . . . . . . . . . . 387
55 A Rare Cause of Mucocutaneous Ulceration . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393
56 A Rare and Severe Variant of a Common Disease . . . . . . . . . . . . . . . . . . . . . . . . 401
57 Pyogenic Granuloma-Like Nodules in AIDS Patient . . . . . . . . . . . . . . . . . . . . . . 409
58 A Scalp Abscess Without an Overlying Wound . . . . . . . . . . . . . . . . . . . . . . . . . . 415
59 An Unusual Kerion-Like Scalp Tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421
Part VIII Disorders of Connective Tissue
60 Tiny Linear Yellowish Papules on the Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429
61 Widespread Hardening of the Skin with Nodular Thickening
and Leg Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433
62 Dysmorphic Facies, Tight Skin and Early Death . . . . . . . . . . . . . . . . . . . . . . . . . 441
63 Atrophic Blaschkoid Lines Associated with Syndactyly . . . . . . . . . . . . . . . . . . . 447
Part IX Tumors of Skin Surface and Skin Appendages
64 A Painful and Wet Purple Plaque . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 455
65 A Rare Epidermal Tumor Mimicking Seborrheic Keratosis . . . . . . . . . . . . . . . . 461
66 Enumerable Tiny Follicular Papules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465
67 Bluish Discrete Follicular Papules of Gradual Onset . . . . . . . . . . . . . . . . . . . . . . 475
68 Clinically Non-specific, Histologically Very Specific Tumor . . . . . . . . . . . . . . . . 481
69 A Slowly Growing Tumor in Elderly Females . . . . . . . . . . . . . . . . . . . . . . . . . . . . 485
70 A Long Standing Ulcerative Large Tumor on the Scalp . . . . . . . . . . . . . . . . . . . 493
71 An Eye Lid Tumour That Destroyed the Eye and Extended
to the Scalp and Face . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 499
72 A Keratotic Penile Lesion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 505
Part X Lichenoid Disorders
73 A Rare Violaceous and Reticulate Lichenoid Eruption with Greasy
Scales on the Face . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 515
Part XI Pigmentary Disorders
74 Diffuse Pigmentation with Guttate Hypomelanosis
in an Anemic Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 523
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75 Diffuse Hyperpigmentation with Guttate Hypomelanosis
and Light Hair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 529
76 Recurrent Pruritic Eruption Resolving with Reticulate Pigmentation . . . . . . . 539
77 A Child with Hypopigmented Skin, Grey Hair, Neurological
and Immunological Defects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 545
78 Guttate Hypopigmentation and Punctate Palmoplantar Keratoderma . . . . . . . 551
Part XII Blistering Disorders
79 An Adult with Blisters and Milia on Trauma-Prone Sites . . . . . . . . . . . . . . . . . . 559
80 Traumatic Blisters on the Extremities and White Papules
on the Lumbosacral Area of Early Onset . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 567
81 Acral Blisters with Decreased Sensation and Muscle Wasting . . . . . . . . . . . . . . 579
82 Extensive and Persistent Erosions Involving the Eyes, Oral Mucosa,
Vulva and Skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 587
83 Painful Blisters and Erosions on the Scalp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 597
84 Extremely Pruritic Polymorphous Eruption in an Elderly Male . . . . . . . . . . . . 603
Part XIII Systemic Diseases and the Skin
85 Pruritus Without a Skin Lesion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 613
86 Early-Onset Jaundice with Severe Pruritus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 619
87 Porcelain-Like Scars in a Sick Child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 625
88 Different Granulomatous and Pustular Skin Lesions Caused
by One Underlying Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 631
89 A Healthy Female with Migratory Pruritic Figurate Erythema . . . . . . . . . . . . . 645
Part XIV Neurogenic Disorders and Tumors
90 Post-traumatic Burning Pain, Swelling, and Vasomotor
Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 655
91 Middle-Aged Female with Asymptomatic Rapidly
Growing Nodule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 663
92 Blueberry-Muffin Lesions in a Baby . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 671
Part XV Fibrohistiocytic Tumors
93 A Young Woman with Red-White Plaques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 679
94 A Rare Benign Bump on a Child’s Digit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 685
95 A Recurrent Tender Nodule on the Tip of the Middle Finger . . . . . . . . . . . . . . . 691
Part XVI Eosinophilic Disorders
96 Post-traumatic, Rapidly Expanding Tongue Lesion . . . . . . . . . . . . . . . . . . . . . . . 699
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97 Recurrent Urticaria and Angioedema Associated
with Persistent Eosinophilia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 703
Part XVII Histiocytoses
98 Self-Limited Ulcerative Lesions in an Infant . . . . . . . . . . . . . . . . . . . . . . . . . . . . 717
99 Mucocutaneous Yellowish Papules and Polyuria . . . . . . . . . . . . . . . . . . . . . . . . . 723
Part XVIII Metastatic Tumors of the Skin
100 Hemorrhagic Papules and Nodules on a Male Breast . . . . . . . . . . . . . . . . . . . . 733
101 A Hemorrhagic Nodule on the Scalp of an Elderly Woman . . . . . . . . . . . . . . . 739
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 743
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