A 17-year-old female originally from Nigeria presents due to a swelling around her earlobe. She had her ears pierced around three months ago and has noticed the gradual development of an erythematous swelling since. On examination a keloid scar is seen.
What is the most appropriate management?
Correct Answer C: Keloid scars are tumour-like lesions that arise from the connective tissue of a scar and extend beyond the dimensions of the original wound.
Keloid scars: Predisposing factors:
Keloid scars are less likely if incisions are made along relaxed skin tension lines*
Treatment:
*Langer lines were historically used to determine the optimal incision line. They were based on procedures done on cadavers but have been shown to produce worse cosmetic results than when following skin tension lines.
Ear Lobe Keloid Scar.
A 58-year-old woman presents with a persistent erythematous rash on her cheeks and a 'red nose'. She describes occasional episodes of facial flushing. On examination erythematous skin is noted on the nose and cheeks associated with occasional telangiectasia.
Correct Answer A: Given that this woman has mild symptoms, topical metronidazole should be used first line.
Acne Rosacea: Treatment:
Acne rosacea: Acne rosacea is a chronic skin disease of unknown aetiology.
Features:
Management:
A 78-year-old nursing home resident is reviewed due to the development of an intensely itchy rash. On examination red linear lesions are seen on the wrists and elbows, and red papules are present on the penis.
Correct Answer A: Lichen planus may give a similar picture but the intense itching is more characteristic of scabies. It is also less common for lichen planus to present in the elderly - it typical affects patients aged 30-60 years.
Scabies: Scabies is caused by the mite Sarcoptes scabiei and is spread by prolonged skin contact. It typically affects children and young adults.
The scabies mite burrows into the skin, laying its eggs in the stratum corneum. The intense pruritus associated with scabies is due to a delayed type IV hypersensitivity reaction to mites/eggs which occurs about 30 days after the initial infection.
Patient guidance on treatment (from Clinical Knowledge Summaries):
The BNF advises to apply the insecticide to all areas, including the face and scalp, contrary to the manufacturer's recommendation. Patients should be given the following instructions:
Norwegian scabies: interdigital scale.
Sarcoptes scabiei var. hominis. Adult female with eggs present in a skin scraping.
(a) Typical scabies in the finger webs. (b) Pruritic papules and nodules on the penis in scabies infestation. The genitalia should be examined in all instances of suspected scabies infestation, especially when the patient reports itching. (c) Papular lesions on the nipples and areolae are a common location for scabies in women. Given this woman’s history of pruritus, scabies was easily identified by the finding of scabies in this location. (d) A typical linear burrow with a tiny vesicle at the distal end. (e) Numerous scabies burrows on the palm. Such obvious lesions are rarely seen, as they are usually obscured by eczema, impetigo or both. The more common presentation of scabies with eczematization of the scratched lesion is shown in (f). The chronic pruritus of scabies rapidly leads to scratching and explains why eczema is frequently observed.
A 63-year-old man who is known to have type 2 diabetes mellitus presents with a number of lesions over his shins. On examination there are a number of 3-4 mm smooth, firm, papules which are hyperpigmented and centrally depressed.
What is the most likely diagnosis?
Correct Answer D:
Granuloma annulare
Basics:
A number of associations have been proposed to conditions such as diabetes mellitus but there is only weak evidence for this.
Granuloma annulare of the foot.
Granuloma annulare on the dorsum of the hand – a typical site.
Generalized granuloma annulare showing a clear photo-distribution over the ‘V’ of the neck and shoulders.
A 50-year-old chronic alcoholic presents with a persistent skin rash on his hands, arms, neck and face. The rash is red-brown in colour, symmetrical and scaly. He also complains of a poor appetite, nausea and diarrhoea.
Which vitamin deficiency is most likely to have caused his symptoms?
Correct Answer A: Pellagra is a caused by nicotinic acid (niacin) deficiency. The classical features are the 3 D's - dermatitis, diarrhoea and dementia.
Pellagra may occur as a consequence of isoniazid therapy (isoniazid inhibits the conversion of tryptophan to niacin) and it is more common in alcoholics.
Pellagra Features:
Pellagra of the hands.
Broad hyperpigmented ’collar-like’ scaly plaques on the photo-exposed area of the neck and upper chest in a patient with pellagra; often referred to as the Casal necklace.
Click to expand