A 64-year-old woman presents with diffuse hair loss. She says that her hair is “coming out by the handfuls” after shampooing. She was treated for severe communityacquired pneumonia 2 months ago but has regained her strength and is exercising regularly. She is taking no medications. Examination reveals diffuse hair loss. Several hairs can be removed by gentle tugging. The scalp is normal without scale or erythema. Her general examination is unremarkable; in particular, her vital signs are normal, she has no pallor or inflammatory synovitis, and her reflexes are normal with a normal relaxation phase.
What is the best next step in her management?
This patient’s diffuse hair loss after a severe illness is caused by telogen effluvium. Normal hair follicles go through a life cycle. Approximately 5% are in the death (telogen) phase where the hair shaft is released. In telogen effluvium, the hair follicles are “shocked” by the systemic stress, and many enter the telogen phase at the same time. The diagnosis is made by careful history and physical examination. CBC, ANA, and hormonal levels will be normal. Topical treatments are ineffective. The patient will recover fully in a month or two, although a wig may be necessary to hide cosmetically troubling alopecia in the meantime.
Diffuse hair loss may be seen with many drugs or with systemic illnesses such as hypothyroidism, systemic lupus, syphilis, or iron deficiency, but there is no evidence of any of these illnesses in this patient. Male pattern baldness (androgen-dependent alopecia) is seen in normal men, in some older women, and in women with androgen excess, but the hair loss affects the crown and frontal region rather than the scalp diffusely. The dramatic and acute hair loss of telogen effluvium does not occur in male pattern baldness.
A 30-year-old African American woman has a 2-month history of nonproductive cough and a painful skin eruption in the lower extremities. She denies fever or weight loss. Physical examination shows several nontender raised plaques around the nares and scattered similar plaques around the base of the neck. In the lower extremities she has several erythematous tender nonulcerated nodules, measuring up to 4 cm in diameter. Chest x-ray reveals bilateral hilar adenopathy and a streaky interstitial density in the right upper lobe.
What is the best way to establish a histo-logical diagnosis?
This patient probably has sarcoidosis; rarely tuberculosis or granulomatous fungal infections can cause the same syndrome. The painful nodules on the legs represent erythema nodosum, a hypersensitivity reaction associated with this patient’s illness. Erythema nodosum can be associated with sarcoidosis, TB, inflammatory bowel disease, several other infectious processes or can be idiopathic. Biopsy of one of the tender nodules would reveal a nonspecific panniculitis (inflammation of the subcutaneous fat) and would not be helpful diagnostically. Biopsy of one of the plaques, however, would reveal noncaseating granulomas characteristic of sarcoidosis and would be helpful in ruling out the less likely infectious pathogens. Skin biopsy is safer and less expensive than an invasive procedure such as mediastinoscopy. In the absence of sputum production, fever, or weight loss, AFB and fungal studies are unlikely to be productive. The serum ACE assay is nonspecifically elevated in many systemic granulomatous diseases and plays a minor role in the assessment and management of a patient with sarcoidosis.
A 72-year-old woman presents with pruritus for the past 6 weeks. She is careful to moisturize her skin after her daily shower and uses soap sparingly. The itching is diffuse and keeps her awake at night. Over this time she has lost 15 lb of weight and has noticed diminished appetite. She has previously been healthy and takes no medications. Physical examination shows no evidence of rash; a few excoriations are present. She appears fatigued with mild temporal muscle wasting. The general examination is otherwise unremarkable.
In 20% of cases, diffuse itching is a manifestation of systemic illness. Renal insufficiency, obstructive liver disease (especially primary biliary cirrhosis), hematological conditions such as polycythemia vera or lymphoma, and thyroid disorders can all present in this fashion. Although most patients with pruritus will have dry skin (xerosis) or dermatitis (usually the primary dermatitis is apparent from the examination), this patient’s weight loss and anorexia should prompt a search for an underlying disorder. Topical agents, oral antihistamines, or doxepin (a tricyclic antidepressant with potent H 1 and H2 blocking effects) can be used for symptomatic purposes but should not replace a search for an underlying cause in this elderly patient with new onset of symptoms. Depression can cause weight loss,but severe pruritus would be an unlikely presenting symptom. Excoriations are nonspecific manifestations of scratching; unless a specific primary lesion (eg, papule, vesicle) is found, skin biopsy will rarely be helpful in the evaluation of pruritus.
A 53-year-old woman presents to the clinic with an erythematous lesion on the dorsum of her right hand. The lesion has been present for the past 7 months and has not responded to topical corticosteroid treatment. She is concerned because the lesion occasionally bleeds and has grown in size during the past few months. On physical examination you notice an 11-mm erythematous plaque with a small central ulceration. The skin is indurated with mild crusting on the surface.
Which of the following describes this process?
Cutaneous squamous cell carcinoma (SCC) is a malignant neoplasm of the keratinocytes; it can grow rapidly and may metastasize (1%-3% of cases). Actinic keratosis is considered a precancerous lesion. Clinically, SCC commonly presents as an ulcerated erythematous nodule or superficial erosion on the skin. SCC can occur anywhere on the body but is most common on areas of sun-damaged skin, including the lower lip. Nodular lesions should be excised. Psoriasis is a chronic inflammatory disease characterized by well-marginated erythematous papules and plaques covered by a silvery scale. A complication of this disease is asymmetric arthritis of the distal and proximal interphalangeal joints. Ulceration is not seen in psoriatic plaques. Melanomas are malignant neoplasms of the melanocytes that have the potential to metastasize. Metastasis and prognosis are related to depth of invasion. Melanomas, however, usually have areas of definite hyperpigmentation. Basal cell carcinoma (BCC) is the most common skin cancer, accounting for 70% to 80% of nonmelanoma skin cancers. It usually has a characteristic rolled or undermined border with telangiectasias around the lesion. Local invasion can be a serious problem, but BCCs almost never metastasize.
A 50-year-old woman develops pink macules and papules on her hands and forearms in association with a sore throat. The lesions are targetlike, with the centers a dusky violet.
What is the most likely cause of this patient’s rash?
Target lesions, especially with nonblanching violet or petechial centers, are classic manifestations of erythema multiforme. Blanchable lesions and blisters may be found as well. Common causes of erythema multiforme include drugs and herpesvirus infections (especially herpes simplex or Epstein-Barr virus). It is most important to identify the offending agent, as continuation of a causative drug can lead to oral involvement, systemic illness, and the fullblown Stevens-Johnson syndrome. The rash may take 4 to 6 weeks to resolve. Readministration of the causative agent should be scrupulously avoided. Phenytoin, sulfa drugs, barbiturates, and penicillin are common causes. The rash, with its target lesions, should not be confused with toxic shock syndrome, which causes a blanchable erythema. Rocky Mountain spotted fever causes a distal petechial rash as a result of endothelial damage. Neurodermatitis (associated with anxiety) and xerotic eczema (associated with drying agents) would not cause target lesions.
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