Joe R. Monroe, MPAS, PA

When he was about 12, a now 41-year-old man noticed that the skin on his left chest was darkening. For several years afterward, the darkness spread and deepened, and the area became hairy. In young adulthood, he experienced occasional outbreaks of what looked like acne on the lesion; this eventually cleared.

He now finds the hairiness increasingly bothersome, so he shaves the worst parts of it. Upon consulting his primary care provider, he was assured that the lesion is “a birthmark.” Unsatisfied with this answer, the patient took the advice of a friend and decided to consult dermatology.

EXAMINATION
A polygonal, hyperpigmented, hypertrichotic patch covers most of the patient’s left pectoral area. The lateral margin is irregular but well-defined. There is obvious partial regrowth of the shaved hair on the lateral margin, but it stops abruptly at that point.

The breast and surrounding tissue appear normal. No areas of hyperpigmentation or hypertrichosis are seen elsewhere.

What is the diagnosis?

The researchers were also surprised to find that only 30% of the reported lesions occurred above the nipple, because the first descriptions of BN gave the impression that the shoulder and chest were most commonly affected. We now know that BN can also be found on arms and legs.

Usually a benign condition, BN can be associated with skeletal or soft-tissue deformities in the affected area (eg, ipsilateral breast hypoplasia). Malignancies—most notably melanoma—have also been reported with BN but are especially uncommon.

The differential includes the café-au-lait macules of neurofibromatosis, Albright disease, and congenital melanocytic nevus. The history of BN (ie, presentation, hypertrichosis, gender of patient, and distribution) usually allow a clinical diagnosis.

Treatment is limited to laser hair removal or laser removal or reduction of pigment.

TAKE-HOME LEARNING POINTS

• Becker nevus (BN) is far more common in males than females.
• BN typically manifests during puberty, which aligns with the suspected androgenic etiology.
• Though the shoulders and chest are the most commonly affected areas, BNs can also appear on the flank, arms, or legs.
• The lesions are rarely associated with serious pathology; hypoplasia of the ipsilateral breast is the most common of these complications.

When he was about 12, a now 41-year-old man noticed that the skin on his left chest was darkening. For several years afterward, the darkness spread and deepened, and the area became hairy. In young adulthood, he experienced occasional outbreaks of what looked like acne on the lesion; this eventually cleared.

He now finds the hairiness increasingly bothersome, so he shaves the worst parts of it. Upon consulting his primary care provider, he was assured that the lesion is “a birthmark.” Unsatisfied with this answer, the patient took the advice of a friend and decided to consult dermatology.

EXAMINATION
A polygonal, hyperpigmented, hypertrichotic patch covers most of the patient’s left pectoral area. The lateral margin is irregular but well-defined. There is obvious partial regrowth of the shaved hair on the lateral margin, but it stops abruptly at that point.

The breast and surrounding tissue appear normal. No areas of hyperpigmentation or hypertrichosis are seen elsewhere.

What is the diagnosis?

The researchers were also surprised to find that only 30% of the reported lesions occurred above the nipple, because the first descriptions of BN gave the impression that the shoulder and chest were most commonly affected. We now know that BN can also be found on arms and legs.

Usually a benign condition, BN can be associated with skeletal or soft-tissue deformities in the affected area (eg, ipsilateral breast hypoplasia). Malignancies—most notably melanoma—have also been reported with BN but are especially uncommon.

The differential includes the café-au-lait macules of neurofibromatosis, Albright disease, and congenital melanocytic nevus. The history of BN (ie, presentation, hypertrichosis, gender of patient, and distribution) usually allow a clinical diagnosis.

Treatment is limited to laser hair removal or laser removal or reduction of pigment.

TAKE-HOME LEARNING POINTS

• Becker nevus (BN) is far more common in males than females.
• BN typically manifests during puberty, which aligns with the suspected androgenic etiology.
• Though the shoulders and chest are the most commonly affected areas, BNs can also appear on the flank, arms, or legs.
• The lesions are rarely associated with serious pathology; hypoplasia of the ipsilateral breast is the most common of these complications.

When he was about 12, a now 41-year-old man noticed that the skin on his left chest was darkening. For several years afterward, the darkness spread and deepened, and the area became hairy. In young adulthood, he experienced occasional outbreaks of what looked like acne on the lesion; this eventually cleared.

He now finds the hairiness increasingly bothersome, so he shaves the worst parts of it. Upon consulting his primary care provider, he was assured that the lesion is “a birthmark.” Unsatisfied with this answer, the patient took the advice of a friend and decided to consult dermatology.

EXAMINATION
A polygonal, hyperpigmented, hypertrichotic patch covers most of the patient’s left pectoral area. The lateral margin is irregular but well-defined. There is obvious partial regrowth of the shaved hair on the lateral margin, but it stops abruptly at that point.

The breast and surrounding tissue appear normal. No areas of hyperpigmentation or hypertrichosis are seen elsewhere.

What is the diagnosis?

The researchers were also surprised to find that only 30% of the reported lesions occurred above the nipple, because the first descriptions of BN gave the impression that the shoulder and chest were most commonly affected. We now know that BN can also be found on arms and legs.

Usually a benign condition, BN can be associated with skeletal or soft-tissue deformities in the affected area (eg, ipsilateral breast hypoplasia). Malignancies—most notably melanoma—have also been reported with BN but are especially uncommon.

The differential includes the café-au-lait macules of neurofibromatosis, Albright disease, and congenital melanocytic nevus. The history of BN (ie, presentation, hypertrichosis, gender of patient, and distribution) usually allow a clinical diagnosis.

Treatment is limited to laser hair removal or laser removal or reduction of pigment.

TAKE-HOME LEARNING POINTS

• Becker nevus (BN) is far more common in males than females.
• BN typically manifests during puberty, which aligns with the suspected androgenic etiology.
• Though the shoulders and chest are the most commonly affected areas, BNs can also appear on the flank, arms, or legs.
• The lesions are rarely associated with serious pathology; hypoplasia of the ipsilateral breast is the most common of these complications.

About six months ago, an 8-year-old girl developed an asymptomatic rash near her ear. Her mother suspects it is psoriasis, which runs heavily in the family—but their primary care provider favors a fungal diagnosis. He prescribes a succession of topical and oral antifungal medications (including nystatin and terbinafine), which yield no discernable improvement. At this point, referral to dermatology is made.  

The child’s mother denies any history of recent infections (eg, strep throat) on her daughter’s behalf. Furthermore, there are no reports of pain associated with the rash or elsewhere.

EXAMINATION
The rash, which is confined to the external right ear, is composed of uniformly smooth white scale on a faintly salmon base. The entire lesion measures about 3 cm at its widest point, and the margins are arciform and well-defined.

No such lesions are seen elsewhere, but tiny pits can be seen on one fingernail.

What is the diagnosis?

In psoriasis, keratinocytes matriculate upward from the basal layer to the skin surface at four times the normal rate—so quickly that they have no chance to lose their nuclei (as they normally would). They then pile up, creating plaques of micaceous white scale on a salmon-pink base. Histologically, the smoothly undulating dermoepidermal junction is jammed together, producing fused ridges with clumps of neutrophils on their tips.

While it favors extensor surfaces of extremities, psoriasis can show up anywhere on the body—on the genitals, mouth, and in the nails, where it can cause pits, dystrophy, discoloration, onycholysis, and onychorrhexis.

Unfortunately, this is probably just the beginning of this child’s psoriasis. The good news is that we’re in a golden age of psoriasis treatment, with more drugs than ever to choose from and even more in development. For this patient, we used a keratolytic agent (urea lotion) to thin out the surface scale, in order to allow a class 4 steroid cream to reach the pink inflammatory portion. Within a month, most of this patch had cleared, though we can be fairly sure it and others like it will be back. Education and ongoing follow-up will be needed, in case she is among the 20% to 25% of patients who will develop psoriatic arthropathy, a crippling form of arthritis.

It is certainly possible to develop a fungal infection on or in an ear, but for that to happen, there has to be a source (eg, animal, person, soil). Moreover, the scale would look entirely different, with clearing centers and advancing margins. The likely truth is that this was called “fungal” for lack of any other suspects.

TAKE-HOME LEARNING POINTS

• White scale on a salmon-pink base typifies psoriasis vulgaris, a very common diagnosis that is often mistaken for fungal infection; biopsy can be extremely helpful in establishing or ruling out this diagnosis.
• Psoriasis has a genetic basis, with many gene loci identified to date, but only about 30% of affected patients can attest to a family history.
• In addition to having unsightly, often itchy lesions, psoriasis patients are also at risk for psoriatic arthropathy, a potentially crippling condition.
• The best news is that we have many drugs with which to treat this disease, including a whole family of drugs termed “the biologics,” which directly (and successfully!) address the disease.

About six months ago, an 8-year-old girl developed an asymptomatic rash near her ear. Her mother suspects it is psoriasis, which runs heavily in the family—but their primary care provider favors a fungal diagnosis. He prescribes a succession of topical and oral antifungal medications (including nystatin and terbinafine), which yield no discernable improvement. At this point, referral to dermatology is made.  

The child’s mother denies any history of recent infections (eg, strep throat) on her daughter’s behalf. Furthermore, there are no reports of pain associated with the rash or elsewhere.

EXAMINATION
The rash, which is confined to the external right ear, is composed of uniformly smooth white scale on a faintly salmon base. The entire lesion measures about 3 cm at its widest point, and the margins are arciform and well-defined.

No such lesions are seen elsewhere, but tiny pits can be seen on one fingernail.

What is the diagnosis?

In psoriasis, keratinocytes matriculate upward from the basal layer to the skin surface at four times the normal rate—so quickly that they have no chance to lose their nuclei (as they normally would). They then pile up, creating plaques of micaceous white scale on a salmon-pink base. Histologically, the smoothly undulating dermoepidermal junction is jammed together, producing fused ridges with clumps of neutrophils on their tips.

While it favors extensor surfaces of extremities, psoriasis can show up anywhere on the body—on the genitals, mouth, and in the nails, where it can cause pits, dystrophy, discoloration, onycholysis, and onychorrhexis.

Unfortunately, this is probably just the beginning of this child’s psoriasis. The good news is that we’re in a golden age of psoriasis treatment, with more drugs than ever to choose from and even more in development. For this patient, we used a keratolytic agent (urea lotion) to thin out the surface scale, in order to allow a class 4 steroid cream to reach the pink inflammatory portion. Within a month, most of this patch had cleared, though we can be fairly sure it and others like it will be back. Education and ongoing follow-up will be needed, in case she is among the 20% to 25% of patients who will develop psoriatic arthropathy, a crippling form of arthritis.

It is certainly possible to develop a fungal infection on or in an ear, but for that to happen, there has to be a source (eg, animal, person, soil). Moreover, the scale would look entirely different, with clearing centers and advancing margins. The likely truth is that this was called “fungal” for lack of any other suspects.

TAKE-HOME LEARNING POINTS

• White scale on a salmon-pink base typifies psoriasis vulgaris, a very common diagnosis that is often mistaken for fungal infection; biopsy can be extremely helpful in establishing or ruling out this diagnosis.
• Psoriasis has a genetic basis, with many gene loci identified to date, but only about 30% of affected patients can attest to a family history.
• In addition to having unsightly, often itchy lesions, psoriasis patients are also at risk for psoriatic arthropathy, a potentially crippling condition.
• The best news is that we have many drugs with which to treat this disease, including a whole family of drugs termed “the biologics,” which directly (and successfully!) address the disease.

About six months ago, an 8-year-old girl developed an asymptomatic rash near her ear. Her mother suspects it is psoriasis, which runs heavily in the family—but their primary care provider favors a fungal diagnosis. He prescribes a succession of topical and oral antifungal medications (including nystatin and terbinafine), which yield no discernable improvement. At this point, referral to dermatology is made.  

The child’s mother denies any history of recent infections (eg, strep throat) on her daughter’s behalf. Furthermore, there are no reports of pain associated with the rash or elsewhere.

EXAMINATION
The rash, which is confined to the external right ear, is composed of uniformly smooth white scale on a faintly salmon base. The entire lesion measures about 3 cm at its widest point, and the margins are arciform and well-defined.

No such lesions are seen elsewhere, but tiny pits can be seen on one fingernail.

What is the diagnosis?

In psoriasis, keratinocytes matriculate upward from the basal layer to the skin surface at four times the normal rate—so quickly that they have no chance to lose their nuclei (as they normally would). They then pile up, creating plaques of micaceous white scale on a salmon-pink base. Histologically, the smoothly undulating dermoepidermal junction is jammed together, producing fused ridges with clumps of neutrophils on their tips.

While it favors extensor surfaces of extremities, psoriasis can show up anywhere on the body—on the genitals, mouth, and in the nails, where it can cause pits, dystrophy, discoloration, onycholysis, and onychorrhexis.

Unfortunately, this is probably just the beginning of this child’s psoriasis. The good news is that we’re in a golden age of psoriasis treatment, with more drugs than ever to choose from and even more in development. For this patient, we used a keratolytic agent (urea lotion) to thin out the surface scale, in order to allow a class 4 steroid cream to reach the pink inflammatory portion. Within a month, most of this patch had cleared, though we can be fairly sure it and others like it will be back. Education and ongoing follow-up will be needed, in case she is among the 20% to 25% of patients who will develop psoriatic arthropathy, a crippling form of arthritis.

It is certainly possible to develop a fungal infection on or in an ear, but for that to happen, there has to be a source (eg, animal, person, soil). Moreover, the scale would look entirely different, with clearing centers and advancing margins. The likely truth is that this was called “fungal” for lack of any other suspects.

TAKE-HOME LEARNING POINTS

• White scale on a salmon-pink base typifies psoriasis vulgaris, a very common diagnosis that is often mistaken for fungal infection; biopsy can be extremely helpful in establishing or ruling out this diagnosis.
• Psoriasis has a genetic basis, with many gene loci identified to date, but only about 30% of affected patients can attest to a family history.
• In addition to having unsightly, often itchy lesions, psoriasis patients are also at risk for psoriatic arthropathy, a potentially crippling condition.
• The best news is that we have many drugs with which to treat this disease, including a whole family of drugs termed “the biologics,” which directly (and successfully!) address the disease.

About six months ago, the parents of this 1-year-old boy first noticed the lesion on his shoulder. It started as a pinpoint papule but has grown to its current size—at which point, it caught their full attention. Although there are no associated symptoms, the parents request referral to dermatology to clear up the matter.

The child is reportedly healthy in all other respects, maintaining weight as expected, and normally active and reactive to verbal and visual stimuli.

EXAMINATION

A distinctive orangish brown, ovoid, 8 x 4–mm nodule is located on the child’s right superior shoulder. The lesion has a smooth, soft surface, and there is no tenderness on palpation. No additional lesions are seen elsewhere.

Eye examination reveals normal and symmetrical red reflexes.

What is the diagnosis?

Juvenile xanthogranuloma (JXG) is a rare, benign variant of non-Langerhans cell histiocytosis. This patient’s lesion is typical, but JXG can vary in appearance; some patients present with darker or larger lesions—or multiple lesions.

JXGs are essentially granulomatous tumors that, on histologic examination, display multinucleated giant cells called Touton giant cells. These macrophage-derived foam cells are seen in lesions with high lipid content.

JXG tends to favor the neck, face, and trunk but can appear around or (rarely) inside the eye, typically unilaterally in the iris. Benign in all other respects, ocular JXG lesions can cause spontaneous hyphema, glaucoma, or blindness; they must therefore be dealt with by a specialist. Fortunately, only about 10% of patients display ocular involvement.

JXGs can be confused with compound nevi, warts, or Spitz tumors. Therefore, biopsy is often necessary to establish the diagnosis.

TAKE-HOME LEARNING POINTS

• Juvenile xanthogranuloma (JXG) is a rare non-Langerhans cell tumor usually seen on the neck, face, or trunk of children younger than 2.
• The orangish brown, soft appearance of this patient’s papule was typical.
• Although atypical JXG lesions may require shave biopsy to confirm the diagnosis, they typically resolve on their own without treatment.
• When JXG lesions appear in the eye (most commonly in the iris), there is potential for serious complications, including heterochromia, glaucoma, spontaneous hyphema, or even blindness.

About six months ago, the parents of this 1-year-old boy first noticed the lesion on his shoulder. It started as a pinpoint papule but has grown to its current size—at which point, it caught their full attention. Although there are no associated symptoms, the parents request referral to dermatology to clear up the matter.

The child is reportedly healthy in all other respects, maintaining weight as expected, and normally active and reactive to verbal and visual stimuli.

EXAMINATION

A distinctive orangish brown, ovoid, 8 x 4–mm nodule is located on the child’s right superior shoulder. The lesion has a smooth, soft surface, and there is no tenderness on palpation. No additional lesions are seen elsewhere.

Eye examination reveals normal and symmetrical red reflexes.

What is the diagnosis?

Juvenile xanthogranuloma (JXG) is a rare, benign variant of non-Langerhans cell histiocytosis. This patient’s lesion is typical, but JXG can vary in appearance; some patients present with darker or larger lesions—or multiple lesions.

JXGs are essentially granulomatous tumors that, on histologic examination, display multinucleated giant cells called Touton giant cells. These macrophage-derived foam cells are seen in lesions with high lipid content.

JXG tends to favor the neck, face, and trunk but can appear around or (rarely) inside the eye, typically unilaterally in the iris. Benign in all other respects, ocular JXG lesions can cause spontaneous hyphema, glaucoma, or blindness; they must therefore be dealt with by a specialist. Fortunately, only about 10% of patients display ocular involvement.

JXGs can be confused with compound nevi, warts, or Spitz tumors. Therefore, biopsy is often necessary to establish the diagnosis.

TAKE-HOME LEARNING POINTS

• Juvenile xanthogranuloma (JXG) is a rare non-Langerhans cell tumor usually seen on the neck, face, or trunk of children younger than 2.
• The orangish brown, soft appearance of this patient’s papule was typical.
• Although atypical JXG lesions may require shave biopsy to confirm the diagnosis, they typically resolve on their own without treatment.
• When JXG lesions appear in the eye (most commonly in the iris), there is potential for serious complications, including heterochromia, glaucoma, spontaneous hyphema, or even blindness.

About six months ago, the parents of this 1-year-old boy first noticed the lesion on his shoulder. It started as a pinpoint papule but has grown to its current size—at which point, it caught their full attention. Although there are no associated symptoms, the parents request referral to dermatology to clear up the matter.

The child is reportedly healthy in all other respects, maintaining weight as expected, and normally active and reactive to verbal and visual stimuli.

EXAMINATION

A distinctive orangish brown, ovoid, 8 x 4–mm nodule is located on the child’s right superior shoulder. The lesion has a smooth, soft surface, and there is no tenderness on palpation. No additional lesions are seen elsewhere.

Eye examination reveals normal and symmetrical red reflexes.

What is the diagnosis?

Juvenile xanthogranuloma (JXG) is a rare, benign variant of non-Langerhans cell histiocytosis. This patient’s lesion is typical, but JXG can vary in appearance; some patients present with darker or larger lesions—or multiple lesions.

JXGs are essentially granulomatous tumors that, on histologic examination, display multinucleated giant cells called Touton giant cells. These macrophage-derived foam cells are seen in lesions with high lipid content.

JXG tends to favor the neck, face, and trunk but can appear around or (rarely) inside the eye, typically unilaterally in the iris. Benign in all other respects, ocular JXG lesions can cause spontaneous hyphema, glaucoma, or blindness; they must therefore be dealt with by a specialist. Fortunately, only about 10% of patients display ocular involvement.

JXGs can be confused with compound nevi, warts, or Spitz tumors. Therefore, biopsy is often necessary to establish the diagnosis.

TAKE-HOME LEARNING POINTS

• Juvenile xanthogranuloma (JXG) is a rare non-Langerhans cell tumor usually seen on the neck, face, or trunk of children younger than 2.
• The orangish brown, soft appearance of this patient’s papule was typical.
• Although atypical JXG lesions may require shave biopsy to confirm the diagnosis, they typically resolve on their own without treatment.
• When JXG lesions appear in the eye (most commonly in the iris), there is potential for serious complications, including heterochromia, glaucoma, spontaneous hyphema, or even blindness.

An 85-year-old black man presents with a nonhealing, asymptomatic lesion on his cheek. He says the problem began several months ago, during a fishing trip, when some fishing line got caught in his beard, pulling out a few hairs in the process.

An accompanying relative, however, is quite certain that the lesion predates the fishing incident (for which he was present). He believes the lesion has been there for two years. He also advises that the patient’s memory is “not what it used to be.”

The patient has a significant history of sun exposure from his job as a stonemason, which kept him outdoors most of the time. He has been seen by a variety of providers and diagnosed with several infections, including pyoderma—but antibiotics have had no effect on the lesion.

EXAMINATION
Located on the right lateral cheek is a 2.4-cm, full-thickness ulceration that penetrates well into adipose tissue. Little if any redness can be seen around the lesion, and no adjacent nodes are palpable. A shave biopsy of the lesion is obtained.

What is the diagnosis?

This case effectively illustrates a key message: Nonhealing lesions should be considered cancerous until proven otherwise (via biopsy). This remains true even in individuals with darker skin; they may have lower risk for skin cancer than do fair-skinned individuals, but they do not have no risk—especially if there is a lifetime history of sun exposure.

The depth and width of the lesion suggest it had been present for many years, slowing growing. This timeframe, along with the lack of response to antibiotics, made infection unlikely. Furthermore, an infection serious enough to cause ulceration would be red and painful.

The mixed picture on the pathology report is unusual but not at all unknown; it just means the lesion had features of both basal and squamous cell carcinoma. Unfortunately, the biopsy results, in conjunction with the lesion’s dimensions, indicate an increased risk for metastasis (or at least spread to local nodes). There could also be perineural involvement if the cancer cells spread to deeper structures through the penetrating nerves.

The entire clinical picture in this case made the patient a candidate for Mohs surgery, which would ensure two things: clear excision margins and optimal wound closure. Should the surgeon find perineural involvement, he or she might advise postoperative radiation therapy to guarantee complete eradication of the cancer.

TAKE-HOME LEARNING POINTS

• Nonhealing lesions should be considered cancerous until proven otherwise by biopsy.
• Even though dark-skinned individuals have far less risk for skin cancer than those with fair skin, a lifetime of sun exposure can overcome the odds.
• Size and depth of the lesion increases risk for metastasis or perineural involvement (spreading to deeper structures through the nerves).
• Mohs surgery, as well as postoperative radiation therapy, can be used to completely eradicate the cancer.

An 85-year-old black man presents with a nonhealing, asymptomatic lesion on his cheek. He says the problem began several months ago, during a fishing trip, when some fishing line got caught in his beard, pulling out a few hairs in the process.

An accompanying relative, however, is quite certain that the lesion predates the fishing incident (for which he was present). He believes the lesion has been there for two years. He also advises that the patient’s memory is “not what it used to be.”

The patient has a significant history of sun exposure from his job as a stonemason, which kept him outdoors most of the time. He has been seen by a variety of providers and diagnosed with several infections, including pyoderma—but antibiotics have had no effect on the lesion.

EXAMINATION
Located on the right lateral cheek is a 2.4-cm, full-thickness ulceration that penetrates well into adipose tissue. Little if any redness can be seen around the lesion, and no adjacent nodes are palpable. A shave biopsy of the lesion is obtained.

What is the diagnosis?

This case effectively illustrates a key message: Nonhealing lesions should be considered cancerous until proven otherwise (via biopsy). This remains true even in individuals with darker skin; they may have lower risk for skin cancer than do fair-skinned individuals, but they do not have no risk—especially if there is a lifetime history of sun exposure.

The depth and width of the lesion suggest it had been present for many years, slowing growing. This timeframe, along with the lack of response to antibiotics, made infection unlikely. Furthermore, an infection serious enough to cause ulceration would be red and painful.

The mixed picture on the pathology report is unusual but not at all unknown; it just means the lesion had features of both basal and squamous cell carcinoma. Unfortunately, the biopsy results, in conjunction with the lesion’s dimensions, indicate an increased risk for metastasis (or at least spread to local nodes). There could also be perineural involvement if the cancer cells spread to deeper structures through the penetrating nerves.

The entire clinical picture in this case made the patient a candidate for Mohs surgery, which would ensure two things: clear excision margins and optimal wound closure. Should the surgeon find perineural involvement, he or she might advise postoperative radiation therapy to guarantee complete eradication of the cancer.

TAKE-HOME LEARNING POINTS

• Nonhealing lesions should be considered cancerous until proven otherwise by biopsy.
• Even though dark-skinned individuals have far less risk for skin cancer than those with fair skin, a lifetime of sun exposure can overcome the odds.
• Size and depth of the lesion increases risk for metastasis or perineural involvement (spreading to deeper structures through the nerves).
• Mohs surgery, as well as postoperative radiation therapy, can be used to completely eradicate the cancer.

An 85-year-old black man presents with a nonhealing, asymptomatic lesion on his cheek. He says the problem began several months ago, during a fishing trip, when some fishing line got caught in his beard, pulling out a few hairs in the process.

An accompanying relative, however, is quite certain that the lesion predates the fishing incident (for which he was present). He believes the lesion has been there for two years. He also advises that the patient’s memory is “not what it used to be.”

The patient has a significant history of sun exposure from his job as a stonemason, which kept him outdoors most of the time. He has been seen by a variety of providers and diagnosed with several infections, including pyoderma—but antibiotics have had no effect on the lesion.

EXAMINATION
Located on the right lateral cheek is a 2.4-cm, full-thickness ulceration that penetrates well into adipose tissue. Little if any redness can be seen around the lesion, and no adjacent nodes are palpable. A shave biopsy of the lesion is obtained.

What is the diagnosis?

This case effectively illustrates a key message: Nonhealing lesions should be considered cancerous until proven otherwise (via biopsy). This remains true even in individuals with darker skin; they may have lower risk for skin cancer than do fair-skinned individuals, but they do not have no risk—especially if there is a lifetime history of sun exposure.

The depth and width of the lesion suggest it had been present for many years, slowing growing. This timeframe, along with the lack of response to antibiotics, made infection unlikely. Furthermore, an infection serious enough to cause ulceration would be red and painful.

The mixed picture on the pathology report is unusual but not at all unknown; it just means the lesion had features of both basal and squamous cell carcinoma. Unfortunately, the biopsy results, in conjunction with the lesion’s dimensions, indicate an increased risk for metastasis (or at least spread to local nodes). There could also be perineural involvement if the cancer cells spread to deeper structures through the penetrating nerves.

The entire clinical picture in this case made the patient a candidate for Mohs surgery, which would ensure two things: clear excision margins and optimal wound closure. Should the surgeon find perineural involvement, he or she might advise postoperative radiation therapy to guarantee complete eradication of the cancer.

TAKE-HOME LEARNING POINTS

• Nonhealing lesions should be considered cancerous until proven otherwise by biopsy.
• Even though dark-skinned individuals have far less risk for skin cancer than those with fair skin, a lifetime of sun exposure can overcome the odds.
• Size and depth of the lesion increases risk for metastasis or perineural involvement (spreading to deeper structures through the nerves).
• Mohs surgery, as well as postoperative radiation therapy, can be used to completely eradicate the cancer.

A 38-year-old Latino man self-refers to dermatology for evaluation of a mass on his back that first appeared three years ago. Since then, it has grown steadily. There is no pain or discomfort associated with the lesion, and the patient claims to be quite healthy otherwise. There is no antecedent history for the affected area.

EXAMINATION
There is a subcutaneous, rubbery mass in the left infrascapular area. It measures 11 x 6 cm. Palpation reveals the lesion to be uniformly smooth and readily mobile. The overlying skin is free of abnormalities and increased warmth.

What is the diagnosis?

Lipomas are actual tumors, composed completely of adipose tissue contained in a thin, fragile, membranous capsule. Their tendency to develop can be hereditary, though most are spontaneous. They can manifest internally as well.

Superficial lipomas, which often manifest as multiple lesions on the arms and trunk, are usually easy to remove surgically. Lesions that are deeper and older or that appear on the face, however, often require considerable dissection to be freed from surrounding tissue. When excision is attempted, it is essential to remove the entire lesion to prevent recurrence. And, as always, the specimen must be sent for pathologic examination.

Patients often decide against surgery once they understand the issues. This is acceptable, but any deviation from the norm—such as pain, irregular surface texture, change in overlying skin, lack of mobility, or rapid growth—would constitute reasonable grounds for excision.

This man’s lesion likely extended down to the muscle fascia if not into the muscle itself. As a result, surgery would require general anesthesia and placement of a drain in the inferior portion of the wound, since such a large defect would likely invite a collection of blood and serum. For these reasons, he was referred to a general surgeon.

The differential for lipoma includes liposarcoma and angiolipoma. The latter are common and benign but become painful and are often more firm than normal. Histologically, they’re often indistinguishable from ordinary lipomas. Liposarcomas, when superficial, can imitate ordinary lipomas, but their surfaces tend to be more irregular and firm and the lesions themselves less mobile.

TAKE-HOME LEARNING POINTS

• Lipomas are the most common soft-tissue tumor encountered in outpatient practices.
• While the vast majority are benign and easy to remove surgically, most lipomas can be safely left alone.
• When excision is attempted, the entire lesion must be removed lest it regrow.
• Patients with larger, deeper lesions, or those in busy anatomical areas, should be referred to a general surgeon.

A 38-year-old Latino man self-refers to dermatology for evaluation of a mass on his back that first appeared three years ago. Since then, it has grown steadily. There is no pain or discomfort associated with the lesion, and the patient claims to be quite healthy otherwise. There is no antecedent history for the affected area.

EXAMINATION
There is a subcutaneous, rubbery mass in the left infrascapular area. It measures 11 x 6 cm. Palpation reveals the lesion to be uniformly smooth and readily mobile. The overlying skin is free of abnormalities and increased warmth.

What is the diagnosis?

Lipomas are actual tumors, composed completely of adipose tissue contained in a thin, fragile, membranous capsule. Their tendency to develop can be hereditary, though most are spontaneous. They can manifest internally as well.

Superficial lipomas, which often manifest as multiple lesions on the arms and trunk, are usually easy to remove surgically. Lesions that are deeper and older or that appear on the face, however, often require considerable dissection to be freed from surrounding tissue. When excision is attempted, it is essential to remove the entire lesion to prevent recurrence. And, as always, the specimen must be sent for pathologic examination.

Patients often decide against surgery once they understand the issues. This is acceptable, but any deviation from the norm—such as pain, irregular surface texture, change in overlying skin, lack of mobility, or rapid growth—would constitute reasonable grounds for excision.

This man’s lesion likely extended down to the muscle fascia if not into the muscle itself. As a result, surgery would require general anesthesia and placement of a drain in the inferior portion of the wound, since such a large defect would likely invite a collection of blood and serum. For these reasons, he was referred to a general surgeon.

The differential for lipoma includes liposarcoma and angiolipoma. The latter are common and benign but become painful and are often more firm than normal. Histologically, they’re often indistinguishable from ordinary lipomas. Liposarcomas, when superficial, can imitate ordinary lipomas, but their surfaces tend to be more irregular and firm and the lesions themselves less mobile.

TAKE-HOME LEARNING POINTS

• Lipomas are the most common soft-tissue tumor encountered in outpatient practices.
• While the vast majority are benign and easy to remove surgically, most lipomas can be safely left alone.
• When excision is attempted, the entire lesion must be removed lest it regrow.
• Patients with larger, deeper lesions, or those in busy anatomical areas, should be referred to a general surgeon.

A 38-year-old Latino man self-refers to dermatology for evaluation of a mass on his back that first appeared three years ago. Since then, it has grown steadily. There is no pain or discomfort associated with the lesion, and the patient claims to be quite healthy otherwise. There is no antecedent history for the affected area.

EXAMINATION
There is a subcutaneous, rubbery mass in the left infrascapular area. It measures 11 x 6 cm. Palpation reveals the lesion to be uniformly smooth and readily mobile. The overlying skin is free of abnormalities and increased warmth.

What is the diagnosis?

Lipomas are actual tumors, composed completely of adipose tissue contained in a thin, fragile, membranous capsule. Their tendency to develop can be hereditary, though most are spontaneous. They can manifest internally as well.

Superficial lipomas, which often manifest as multiple lesions on the arms and trunk, are usually easy to remove surgically. Lesions that are deeper and older or that appear on the face, however, often require considerable dissection to be freed from surrounding tissue. When excision is attempted, it is essential to remove the entire lesion to prevent recurrence. And, as always, the specimen must be sent for pathologic examination.

Patients often decide against surgery once they understand the issues. This is acceptable, but any deviation from the norm—such as pain, irregular surface texture, change in overlying skin, lack of mobility, or rapid growth—would constitute reasonable grounds for excision.

This man’s lesion likely extended down to the muscle fascia if not into the muscle itself. As a result, surgery would require general anesthesia and placement of a drain in the inferior portion of the wound, since such a large defect would likely invite a collection of blood and serum. For these reasons, he was referred to a general surgeon.

The differential for lipoma includes liposarcoma and angiolipoma. The latter are common and benign but become painful and are often more firm than normal. Histologically, they’re often indistinguishable from ordinary lipomas. Liposarcomas, when superficial, can imitate ordinary lipomas, but their surfaces tend to be more irregular and firm and the lesions themselves less mobile.

TAKE-HOME LEARNING POINTS

• Lipomas are the most common soft-tissue tumor encountered in outpatient practices.
• While the vast majority are benign and easy to remove surgically, most lipomas can be safely left alone.
• When excision is attempted, the entire lesion must be removed lest it regrow.
• Patients with larger, deeper lesions, or those in busy anatomical areas, should be referred to a general surgeon.

A 13-year-old girl is referred to dermatology by her pediatrician for evaluation of “warts” that manifested several months ago. The asymptomatic lesions are simply a cosmetic concern—albeit a persistent one.

Treatments including liquid nitrogen, salicylic acid–based OTC products, and an electric device (purchased online) have been tried, but none have helped. The topical products caused pain and blistering, and although they did eliminate several of the lesions, more soon appeared to take their place.

Further history-taking reveals that the child (like her family) is highly atopic, with seasonal allergies and a history of eczema, hives, and asthma. Two of her siblings have had similar lesions, which cleared fairly quickly without treatment.

EXAMINATION
Approximately 20 papules are randomly arranged on the patient’s anterior neck. They are pink and round, each measuring 2 to 3 mm. Closer inspection reveals that most display a central umbilication. The lesions are firm on palpation.

The child is multiracial; her type IV skin is quite dry but otherwise free of lesions.

What is the diagnosis?

This virus is transmitted through direct contact with an infected individual, which often occurs during the summertime when many children swim. Though the warts cause little if any harm, they can be a source of embarrassment for the child and can be concerning to parents, who are often given erroneous information about the diagnosis.

There’s also the unfortunate fact that the occasional MC lesion fills with pus, turning red and swollen—a fair imitation of bacterial infection. This is simply a sign that the lesion is dying and will soon disappear, but it’s understandably frightening to parents.

As this case illustrates so well, destroying a few MC lesions does nothing to keep a whole new crop from taking their place. And although the condition is self-limiting, it is common for the warts to take two or more years to go away.

The truth is, to date, there has been no proven, safe, painless, effective treatment for MC. Modalities include laser, electrodessication, and simple curettage.

A new treatment that combines dilute povidone-iodine with dimethyl sulfoxide in an OTC compounded liquid mixture (applied bid) has shown some promise in limited trials (Capriotti et al. J Clin Aesthet Dermatol. 2017;10[3]:41). This is what the case patient was treated with. I have given it to perhaps a dozen patients over the past several months, but to date, none have returned to report results. (This, as far as I know, is not a proprietary product and I have no financial interest in it.)

TAKE-HOME LEARNING POINTS

• Firm, 2- to 3-mm, umbilicated papules on children are almost certainly molluscum contagiosum (MC), usually related to atopy.
• MC is acquired by direct contact but can be spread by scratching or picking.
• It often appears admixed with eczema, especially in the antecubital and popliteal areas.
• Although MC eventually resolves with or without treatment, the process can take a while, making patient/parent education important.
• The newest treatment (that I am aware of) is a mixture of povidone-iodine and dimethyl sulfoxide, to be applied bid.

A 13-year-old girl is referred to dermatology by her pediatrician for evaluation of “warts” that manifested several months ago. The asymptomatic lesions are simply a cosmetic concern—albeit a persistent one.

Treatments including liquid nitrogen, salicylic acid–based OTC products, and an electric device (purchased online) have been tried, but none have helped. The topical products caused pain and blistering, and although they did eliminate several of the lesions, more soon appeared to take their place.

Further history-taking reveals that the child (like her family) is highly atopic, with seasonal allergies and a history of eczema, hives, and asthma. Two of her siblings have had similar lesions, which cleared fairly quickly without treatment.

EXAMINATION
Approximately 20 papules are randomly arranged on the patient’s anterior neck. They are pink and round, each measuring 2 to 3 mm. Closer inspection reveals that most display a central umbilication. The lesions are firm on palpation.

The child is multiracial; her type IV skin is quite dry but otherwise free of lesions.

What is the diagnosis?

This virus is transmitted through direct contact with an infected individual, which often occurs during the summertime when many children swim. Though the warts cause little if any harm, they can be a source of embarrassment for the child and can be concerning to parents, who are often given erroneous information about the diagnosis.

There’s also the unfortunate fact that the occasional MC lesion fills with pus, turning red and swollen—a fair imitation of bacterial infection. This is simply a sign that the lesion is dying and will soon disappear, but it’s understandably frightening to parents.

As this case illustrates so well, destroying a few MC lesions does nothing to keep a whole new crop from taking their place. And although the condition is self-limiting, it is common for the warts to take two or more years to go away.

The truth is, to date, there has been no proven, safe, painless, effective treatment for MC. Modalities include laser, electrodessication, and simple curettage.

A new treatment that combines dilute povidone-iodine with dimethyl sulfoxide in an OTC compounded liquid mixture (applied bid) has shown some promise in limited trials (Capriotti et al. J Clin Aesthet Dermatol. 2017;10[3]:41). This is what the case patient was treated with. I have given it to perhaps a dozen patients over the past several months, but to date, none have returned to report results. (This, as far as I know, is not a proprietary product and I have no financial interest in it.)

TAKE-HOME LEARNING POINTS

• Firm, 2- to 3-mm, umbilicated papules on children are almost certainly molluscum contagiosum (MC), usually related to atopy.
• MC is acquired by direct contact but can be spread by scratching or picking.
• It often appears admixed with eczema, especially in the antecubital and popliteal areas.
• Although MC eventually resolves with or without treatment, the process can take a while, making patient/parent education important.
• The newest treatment (that I am aware of) is a mixture of povidone-iodine and dimethyl sulfoxide, to be applied bid.

A 13-year-old girl is referred to dermatology by her pediatrician for evaluation of “warts” that manifested several months ago. The asymptomatic lesions are simply a cosmetic concern—albeit a persistent one.

Treatments including liquid nitrogen, salicylic acid–based OTC products, and an electric device (purchased online) have been tried, but none have helped. The topical products caused pain and blistering, and although they did eliminate several of the lesions, more soon appeared to take their place.

Further history-taking reveals that the child (like her family) is highly atopic, with seasonal allergies and a history of eczema, hives, and asthma. Two of her siblings have had similar lesions, which cleared fairly quickly without treatment.

EXAMINATION
Approximately 20 papules are randomly arranged on the patient’s anterior neck. They are pink and round, each measuring 2 to 3 mm. Closer inspection reveals that most display a central umbilication. The lesions are firm on palpation.

The child is multiracial; her type IV skin is quite dry but otherwise free of lesions.

What is the diagnosis?

This virus is transmitted through direct contact with an infected individual, which often occurs during the summertime when many children swim. Though the warts cause little if any harm, they can be a source of embarrassment for the child and can be concerning to parents, who are often given erroneous information about the diagnosis.

There’s also the unfortunate fact that the occasional MC lesion fills with pus, turning red and swollen—a fair imitation of bacterial infection. This is simply a sign that the lesion is dying and will soon disappear, but it’s understandably frightening to parents.

As this case illustrates so well, destroying a few MC lesions does nothing to keep a whole new crop from taking their place. And although the condition is self-limiting, it is common for the warts to take two or more years to go away.

The truth is, to date, there has been no proven, safe, painless, effective treatment for MC. Modalities include laser, electrodessication, and simple curettage.

A new treatment that combines dilute povidone-iodine with dimethyl sulfoxide in an OTC compounded liquid mixture (applied bid) has shown some promise in limited trials (Capriotti et al. J Clin Aesthet Dermatol. 2017;10[3]:41). This is what the case patient was treated with. I have given it to perhaps a dozen patients over the past several months, but to date, none have returned to report results. (This, as far as I know, is not a proprietary product and I have no financial interest in it.)

TAKE-HOME LEARNING POINTS

• Firm, 2- to 3-mm, umbilicated papules on children are almost certainly molluscum contagiosum (MC), usually related to atopy.
• MC is acquired by direct contact but can be spread by scratching or picking.
• It often appears admixed with eczema, especially in the antecubital and popliteal areas.
• Although MC eventually resolves with or without treatment, the process can take a while, making patient/parent education important.
• The newest treatment (that I am aware of) is a mixture of povidone-iodine and dimethyl sulfoxide, to be applied bid.

A 63-year-old man says the 20-year-old rash on his face first appeared one summer. Although it slackens a bit each winter, it flares up again when the weather warms—despite a bevy of OTC and prescription topical treatments.

The patient has consulted many providers, including several dermatologists, who have diagnosed the butterfly rash of lupus. But blood tests failed to bear out that theory, and no one has ever biopsied it.

The patient spent many years working in the sun with minimal to no protection. He denies fever, malaise, joint pain, or other illness. He denies having a similar rash elsewhere on his body.

EXAMINATION
A symmetrical, strikingly red, extensive rash covers most of both sides of the patient’s face. There is epidermal scaling and roughness and large areas of obvious follicular enlargement, atrophy, and telangiectasias.

Punch biopsy shows a multitude of changes: atrophic epithelium, basal vacuolar changes, an intense dermal lymphocytic infiltrate, liquefaction degeneration, and apoptotic keratinocytes. Compact orthokeratosis is noted on the surface, and increased mucin formation in the dermis.

What is the diagnosis?

DLE is the most common type of chronic cutaneous lupus, occurring in about 17 to 48 of every 100,000 people in the general population. It affects far more women than men, mostly those ages 20 to 40. More blacks than whites are affected by DLE, which is thought to be a polygenic autoimmune disease linked to various human leukocyte antigen groups.

DLE affects sun-exposed areas, including the scalp (where it often goes undiagnosed, leading to scarring alopecia). It can also occur in the mouth, manifesting as annular eroded areas. In this patient’s case, the combination of UV exposure and apparent genetic predisposition caused his malady.

Following workup to rule out systemic disease, the patient was started on hydroxychloroquine HCL (200 mg bid) and given strict instructions to protect himself from the sun. This should yield considerable improvement, although the scarring on large sections of his face (eg, the posterior cheeks) will be permanent. He will also be monitored for possible progression to SLE.

TAKE-HOME LEARNING POINTS

• Discoid lupus erythematosus (DLE) is a form of chronic cutaneous lupus caused by overexposure to the sun in a genetically susceptible individual.
• Most DLE patients never develop systemic lupus, though it’s far from unknown (17%).
• DLE, an autoimmune disease, is far more common in women (ages 20 – 40) than in men.
• Diagnosis is often made clinically, but biopsy reveals characteristic findings that confirm the disease.
• Besides sun protection, DLE is treated with the oral antimalarial hydroxychloroquine HCL (200 mg bid) and topical steroids as needed.

A 63-year-old man says the 20-year-old rash on his face first appeared one summer. Although it slackens a bit each winter, it flares up again when the weather warms—despite a bevy of OTC and prescription topical treatments.

The patient has consulted many providers, including several dermatologists, who have diagnosed the butterfly rash of lupus. But blood tests failed to bear out that theory, and no one has ever biopsied it.

The patient spent many years working in the sun with minimal to no protection. He denies fever, malaise, joint pain, or other illness. He denies having a similar rash elsewhere on his body.

EXAMINATION
A symmetrical, strikingly red, extensive rash covers most of both sides of the patient’s face. There is epidermal scaling and roughness and large areas of obvious follicular enlargement, atrophy, and telangiectasias.

Punch biopsy shows a multitude of changes: atrophic epithelium, basal vacuolar changes, an intense dermal lymphocytic infiltrate, liquefaction degeneration, and apoptotic keratinocytes. Compact orthokeratosis is noted on the surface, and increased mucin formation in the dermis.

What is the diagnosis?

DLE is the most common type of chronic cutaneous lupus, occurring in about 17 to 48 of every 100,000 people in the general population. It affects far more women than men, mostly those ages 20 to 40. More blacks than whites are affected by DLE, which is thought to be a polygenic autoimmune disease linked to various human leukocyte antigen groups.

DLE affects sun-exposed areas, including the scalp (where it often goes undiagnosed, leading to scarring alopecia). It can also occur in the mouth, manifesting as annular eroded areas. In this patient’s case, the combination of UV exposure and apparent genetic predisposition caused his malady.

Following workup to rule out systemic disease, the patient was started on hydroxychloroquine HCL (200 mg bid) and given strict instructions to protect himself from the sun. This should yield considerable improvement, although the scarring on large sections of his face (eg, the posterior cheeks) will be permanent. He will also be monitored for possible progression to SLE.

TAKE-HOME LEARNING POINTS

• Discoid lupus erythematosus (DLE) is a form of chronic cutaneous lupus caused by overexposure to the sun in a genetically susceptible individual.
• Most DLE patients never develop systemic lupus, though it’s far from unknown (17%).
• DLE, an autoimmune disease, is far more common in women (ages 20 – 40) than in men.
• Diagnosis is often made clinically, but biopsy reveals characteristic findings that confirm the disease.
• Besides sun protection, DLE is treated with the oral antimalarial hydroxychloroquine HCL (200 mg bid) and topical steroids as needed.

A 63-year-old man says the 20-year-old rash on his face first appeared one summer. Although it slackens a bit each winter, it flares up again when the weather warms—despite a bevy of OTC and prescription topical treatments.

The patient has consulted many providers, including several dermatologists, who have diagnosed the butterfly rash of lupus. But blood tests failed to bear out that theory, and no one has ever biopsied it.

The patient spent many years working in the sun with minimal to no protection. He denies fever, malaise, joint pain, or other illness. He denies having a similar rash elsewhere on his body.

EXAMINATION
A symmetrical, strikingly red, extensive rash covers most of both sides of the patient’s face. There is epidermal scaling and roughness and large areas of obvious follicular enlargement, atrophy, and telangiectasias.

Punch biopsy shows a multitude of changes: atrophic epithelium, basal vacuolar changes, an intense dermal lymphocytic infiltrate, liquefaction degeneration, and apoptotic keratinocytes. Compact orthokeratosis is noted on the surface, and increased mucin formation in the dermis.

What is the diagnosis?

DLE is the most common type of chronic cutaneous lupus, occurring in about 17 to 48 of every 100,000 people in the general population. It affects far more women than men, mostly those ages 20 to 40. More blacks than whites are affected by DLE, which is thought to be a polygenic autoimmune disease linked to various human leukocyte antigen groups.

DLE affects sun-exposed areas, including the scalp (where it often goes undiagnosed, leading to scarring alopecia). It can also occur in the mouth, manifesting as annular eroded areas. In this patient’s case, the combination of UV exposure and apparent genetic predisposition caused his malady.

Following workup to rule out systemic disease, the patient was started on hydroxychloroquine HCL (200 mg bid) and given strict instructions to protect himself from the sun. This should yield considerable improvement, although the scarring on large sections of his face (eg, the posterior cheeks) will be permanent. He will also be monitored for possible progression to SLE.

TAKE-HOME LEARNING POINTS

• Discoid lupus erythematosus (DLE) is a form of chronic cutaneous lupus caused by overexposure to the sun in a genetically susceptible individual.
• Most DLE patients never develop systemic lupus, though it’s far from unknown (17%).
• DLE, an autoimmune disease, is far more common in women (ages 20 – 40) than in men.
• Diagnosis is often made clinically, but biopsy reveals characteristic findings that confirm the disease.
• Besides sun protection, DLE is treated with the oral antimalarial hydroxychloroquine HCL (200 mg bid) and topical steroids as needed.

A 70-year-old man self-refers to dermatology for evaluation of a “risin’ in my finger,” which has existed for “at least 40 years.” While the lesion doesn’t really hurt, the patient wants it gone because he traumatizes it almost daily while working on his farm.

He has tried innumerable removal methods, including acids, blood root, and duct tape. Most recently, his primary care provider attempted treatment with cryotherapy.

The patient’s health is excellent in other respects, with no history of similar lesions elsewhere.

EXAMINATION
A dome-like pink nodule is seen on the palmar surface of the patient’s left index finger. The 1-cm lesion is smooth, moderately firm, and nontender. Although the majority of the lesion protrudes above the skin’s surface, there is an intradermal component. Normal skin lines on the surface are preserved, and there is no surface punctum. Palpation of the epitrochlear and axillary areas above the hand reveals no masses.

What is the diagnosis?

EICs differ from the more common epidermoid (or epidermal) cyst for several reasons. For one, epidermoid cysts are confined almost exclusively to oily skin (usually above the waist, with the back being the most common location). Unlike EICs, epidermoid cysts almost always have at least one central comedone, which acts as a plug, preventing the discharge of its contents.

The differential also includes pilar cysts—another common type, popularly known as “wens.” But these occur almost exclusively in the scalp and only rarely display a central punctum.

All of these cysts have an organized wall that contains their characteristic cheesy contents, and all can be removed surgically—preferably in one piece—under local anesthesia. Once excised, the lesion should always be submitted for pathologic examination, since cystic lesions can (albeit rarely) undergo malignant transformation.

In this case, excision was performed with anesthesia via digital block, supplemented with small amounts of lidocaine and epinephrine for hemostasis. The lesion was removed in one transverse elliptical piece and with special care to avoid trauma to underlying structures (visualized with the aid of a tourniquet). The wound was closed with interrupted sutures.

The pathology report confirmed the preoperative diagnosis, and the patient recovered uneventfully.

TAKE-HOME LEARNING POINTS

• Epidermal inclusion cysts (EICs) result from a puncture wound that buries surface follicular infundibula and their sebaceous glands under the skin, where they continue to produce material that collects in a sac.
• Unlike the more common epidermoid (epidermal) cysts, which affect the oily areas of the body (above the waist), EICs don’t have a central punctum.
• EICs can be left alone or excised, but removal must be done in one piece, lest they recur. The same is true for all aforementioned cysts.

A 70-year-old man self-refers to dermatology for evaluation of a “risin’ in my finger,” which has existed for “at least 40 years.” While the lesion doesn’t really hurt, the patient wants it gone because he traumatizes it almost daily while working on his farm.

He has tried innumerable removal methods, including acids, blood root, and duct tape. Most recently, his primary care provider attempted treatment with cryotherapy.

The patient’s health is excellent in other respects, with no history of similar lesions elsewhere.

EXAMINATION
A dome-like pink nodule is seen on the palmar surface of the patient’s left index finger. The 1-cm lesion is smooth, moderately firm, and nontender. Although the majority of the lesion protrudes above the skin’s surface, there is an intradermal component. Normal skin lines on the surface are preserved, and there is no surface punctum. Palpation of the epitrochlear and axillary areas above the hand reveals no masses.

What is the diagnosis?

EICs differ from the more common epidermoid (or epidermal) cyst for several reasons. For one, epidermoid cysts are confined almost exclusively to oily skin (usually above the waist, with the back being the most common location). Unlike EICs, epidermoid cysts almost always have at least one central comedone, which acts as a plug, preventing the discharge of its contents.

The differential also includes pilar cysts—another common type, popularly known as “wens.” But these occur almost exclusively in the scalp and only rarely display a central punctum.

All of these cysts have an organized wall that contains their characteristic cheesy contents, and all can be removed surgically—preferably in one piece—under local anesthesia. Once excised, the lesion should always be submitted for pathologic examination, since cystic lesions can (albeit rarely) undergo malignant transformation.

In this case, excision was performed with anesthesia via digital block, supplemented with small amounts of lidocaine and epinephrine for hemostasis. The lesion was removed in one transverse elliptical piece and with special care to avoid trauma to underlying structures (visualized with the aid of a tourniquet). The wound was closed with interrupted sutures.

The pathology report confirmed the preoperative diagnosis, and the patient recovered uneventfully.

TAKE-HOME LEARNING POINTS

• Epidermal inclusion cysts (EICs) result from a puncture wound that buries surface follicular infundibula and their sebaceous glands under the skin, where they continue to produce material that collects in a sac.
• Unlike the more common epidermoid (epidermal) cysts, which affect the oily areas of the body (above the waist), EICs don’t have a central punctum.
• EICs can be left alone or excised, but removal must be done in one piece, lest they recur. The same is true for all aforementioned cysts.

A 70-year-old man self-refers to dermatology for evaluation of a “risin’ in my finger,” which has existed for “at least 40 years.” While the lesion doesn’t really hurt, the patient wants it gone because he traumatizes it almost daily while working on his farm.

He has tried innumerable removal methods, including acids, blood root, and duct tape. Most recently, his primary care provider attempted treatment with cryotherapy.

The patient’s health is excellent in other respects, with no history of similar lesions elsewhere.

EXAMINATION
A dome-like pink nodule is seen on the palmar surface of the patient’s left index finger. The 1-cm lesion is smooth, moderately firm, and nontender. Although the majority of the lesion protrudes above the skin’s surface, there is an intradermal component. Normal skin lines on the surface are preserved, and there is no surface punctum. Palpation of the epitrochlear and axillary areas above the hand reveals no masses.

What is the diagnosis?

EICs differ from the more common epidermoid (or epidermal) cyst for several reasons. For one, epidermoid cysts are confined almost exclusively to oily skin (usually above the waist, with the back being the most common location). Unlike EICs, epidermoid cysts almost always have at least one central comedone, which acts as a plug, preventing the discharge of its contents.

The differential also includes pilar cysts—another common type, popularly known as “wens.” But these occur almost exclusively in the scalp and only rarely display a central punctum.

All of these cysts have an organized wall that contains their characteristic cheesy contents, and all can be removed surgically—preferably in one piece—under local anesthesia. Once excised, the lesion should always be submitted for pathologic examination, since cystic lesions can (albeit rarely) undergo malignant transformation.

In this case, excision was performed with anesthesia via digital block, supplemented with small amounts of lidocaine and epinephrine for hemostasis. The lesion was removed in one transverse elliptical piece and with special care to avoid trauma to underlying structures (visualized with the aid of a tourniquet). The wound was closed with interrupted sutures.

The pathology report confirmed the preoperative diagnosis, and the patient recovered uneventfully.

TAKE-HOME LEARNING POINTS

• Epidermal inclusion cysts (EICs) result from a puncture wound that buries surface follicular infundibula and their sebaceous glands under the skin, where they continue to produce material that collects in a sac.
• Unlike the more common epidermoid (epidermal) cysts, which affect the oily areas of the body (above the waist), EICs don’t have a central punctum.
• EICs can be left alone or excised, but removal must be done in one piece, lest they recur. The same is true for all aforementioned cysts.

The lesion on this 8-year-old girl’s face was first noted about a year ago. Recently, however, it has started to grow, prompting her parents to consult the child’s primary care provider (PCP). The lesion is completely asymptomatic but nonetheless concerning to the parents and to the PCP, who has no idea what it could be. He therefore refers them to dermatology.

The child is otherwise healthy. There is no family history of chronic or inheritable disease.

EXAMINATION
The lesion is a 2-cm subcutaneous firm round mass located along the superior aspect of the right jawline. The only overlying skin change is a bluish discoloration. No surface punctum is seen. No other lesions are seen or felt on examination of the rest of the head and neck.

What is the diagnosis?

This patient’s lesion was typical in size, although they can vary from 3 mm (the smallest I’ve seen) to more than 20 cm. The firm feel, lack of a punctum (which would suggest an epidermal cyst), and bluish discoloration are all typical features.

These lesions generally merit little or no concern. However, in the rare instance when the patient has multiple lesions, the possibility of at least two conditions should be considered: Gardner disease and myotonic seizure.

In terms of treatment, pilomatricoma can be safely left alone; understandably, though, most parents will only be satisfied by excision. It is important to note that, unlike most true cysts, pilomatricomas have a very poorly defined cyst wall with contents that are equally odd—watery and full of tiny white flecks that represent calcified cells. All of this must be totally removed to prevent recurrence. In most cases, defects must be closed in two layers, to minimize “dead” space that might otherwise fill with blood.

One could argue that this child’s lesion should have been removed by a plastic surgeon—but the family had no insurance. Excision was therefore the treatment of choice; the most difficult aspect was persuading the patient to cooperate. (Sometimes, you have to wait years for the child to mature before you attempt it.) The outcome in this case proved to be quite acceptable. Of course, the lesion was sent to pathology, which confirmed the pre-op diagnosis.

The differential includes epidermal cysts (which are almost unknown in prepubertal children), and sweat gland cysts. 

TAKE-HOME LEARNING POINTS

• Pilomatricomas are benign cysts that originate from hair matrix cells, usually appearing on the head, neck, face, and upper extremities of children.
• The cysts are typically firm and round and often display a faintly bluish tone (as seen in this case).
• As solitary lesions, they are of little or no significance; when seen in multiples, however, pilomatricomas suggest the possibility of Gardner syndrome or myotonic seizure.
• Excision is the best treatment, though these can be left alone long enough to allow the patient to mature sufficiently to cooperate with the surgical process.

The lesion on this 8-year-old girl’s face was first noted about a year ago. Recently, however, it has started to grow, prompting her parents to consult the child’s primary care provider (PCP). The lesion is completely asymptomatic but nonetheless concerning to the parents and to the PCP, who has no idea what it could be. He therefore refers them to dermatology.

The child is otherwise healthy. There is no family history of chronic or inheritable disease.

EXAMINATION
The lesion is a 2-cm subcutaneous firm round mass located along the superior aspect of the right jawline. The only overlying skin change is a bluish discoloration. No surface punctum is seen. No other lesions are seen or felt on examination of the rest of the head and neck.

What is the diagnosis?

This patient’s lesion was typical in size, although they can vary from 3 mm (the smallest I’ve seen) to more than 20 cm. The firm feel, lack of a punctum (which would suggest an epidermal cyst), and bluish discoloration are all typical features.

These lesions generally merit little or no concern. However, in the rare instance when the patient has multiple lesions, the possibility of at least two conditions should be considered: Gardner disease and myotonic seizure.

In terms of treatment, pilomatricoma can be safely left alone; understandably, though, most parents will only be satisfied by excision. It is important to note that, unlike most true cysts, pilomatricomas have a very poorly defined cyst wall with contents that are equally odd—watery and full of tiny white flecks that represent calcified cells. All of this must be totally removed to prevent recurrence. In most cases, defects must be closed in two layers, to minimize “dead” space that might otherwise fill with blood.

One could argue that this child’s lesion should have been removed by a plastic surgeon—but the family had no insurance. Excision was therefore the treatment of choice; the most difficult aspect was persuading the patient to cooperate. (Sometimes, you have to wait years for the child to mature before you attempt it.) The outcome in this case proved to be quite acceptable. Of course, the lesion was sent to pathology, which confirmed the pre-op diagnosis.

The differential includes epidermal cysts (which are almost unknown in prepubertal children), and sweat gland cysts. 

TAKE-HOME LEARNING POINTS

• Pilomatricomas are benign cysts that originate from hair matrix cells, usually appearing on the head, neck, face, and upper extremities of children.
• The cysts are typically firm and round and often display a faintly bluish tone (as seen in this case).
• As solitary lesions, they are of little or no significance; when seen in multiples, however, pilomatricomas suggest the possibility of Gardner syndrome or myotonic seizure.
• Excision is the best treatment, though these can be left alone long enough to allow the patient to mature sufficiently to cooperate with the surgical process.

The lesion on this 8-year-old girl’s face was first noted about a year ago. Recently, however, it has started to grow, prompting her parents to consult the child’s primary care provider (PCP). The lesion is completely asymptomatic but nonetheless concerning to the parents and to the PCP, who has no idea what it could be. He therefore refers them to dermatology.

The child is otherwise healthy. There is no family history of chronic or inheritable disease.

EXAMINATION
The lesion is a 2-cm subcutaneous firm round mass located along the superior aspect of the right jawline. The only overlying skin change is a bluish discoloration. No surface punctum is seen. No other lesions are seen or felt on examination of the rest of the head and neck.

What is the diagnosis?

This patient’s lesion was typical in size, although they can vary from 3 mm (the smallest I’ve seen) to more than 20 cm. The firm feel, lack of a punctum (which would suggest an epidermal cyst), and bluish discoloration are all typical features.

These lesions generally merit little or no concern. However, in the rare instance when the patient has multiple lesions, the possibility of at least two conditions should be considered: Gardner disease and myotonic seizure.

In terms of treatment, pilomatricoma can be safely left alone; understandably, though, most parents will only be satisfied by excision. It is important to note that, unlike most true cysts, pilomatricomas have a very poorly defined cyst wall with contents that are equally odd—watery and full of tiny white flecks that represent calcified cells. All of this must be totally removed to prevent recurrence. In most cases, defects must be closed in two layers, to minimize “dead” space that might otherwise fill with blood.

One could argue that this child’s lesion should have been removed by a plastic surgeon—but the family had no insurance. Excision was therefore the treatment of choice; the most difficult aspect was persuading the patient to cooperate. (Sometimes, you have to wait years for the child to mature before you attempt it.) The outcome in this case proved to be quite acceptable. Of course, the lesion was sent to pathology, which confirmed the pre-op diagnosis.

The differential includes epidermal cysts (which are almost unknown in prepubertal children), and sweat gland cysts. 

TAKE-HOME LEARNING POINTS

• Pilomatricomas are benign cysts that originate from hair matrix cells, usually appearing on the head, neck, face, and upper extremities of children.
• The cysts are typically firm and round and often display a faintly bluish tone (as seen in this case).
• As solitary lesions, they are of little or no significance; when seen in multiples, however, pilomatricomas suggest the possibility of Gardner syndrome or myotonic seizure.
• Excision is the best treatment, though these can be left alone long enough to allow the patient to mature sufficiently to cooperate with the surgical process.

The lesions on this 41-year-old African-American woman’s skin have waxed and waned over the years—but they’re always on her mind. They are most prominent on her arms and trunk but crop up almost anywhere on her body.

When they manifest—for no apparent reason—they itch, creating an irresistible urge for the patient to pick at them. This provides some relief, both from the itching and from her feeling that there is “something in there” that she needs to remove. Fairly often, her digging (with fingernails) results in “finding” white bumps at the ends of tiny hairs.

As these small excoriations heal, the wounds itch—compelling her to pick the site open again. She knows she is caught in a vicious cycle but doesn’t know how to stop. Selective serotonin reuptake inhibitors have been tried, with little to no effect.

EXAMINATION
The patient’s type IV skin is covered with dark brown, maculopapular lesions that are so numerous and large (average diameter, 2 to 3 cm) that they are impossible to ignore. Her palms, soles, face, and midback are spared.

Only a few of the newer lesions are palpable, showing faint signs of central excoriation. Previous biopsies failed to show significant pathology.

The patient appears ill at ease during history-taking. She admits to picking her skin for many years but doesn’t believe she is inhabited by any kind of bug. The skin on her wrists and between her fingers is clear. Her 3-year-old daughter’s skin is free of notable changes.

What is the diagnosis?

While it has been posited as a form of obsessive compulsive disorder (OCD), dermatillomania responds poorly, if at all, to standard OCD treatments. It is considered by others to more closely resemble addiction because, despite knowing its harm, patients persistently pick at the skin and often report a subsequent sense of relief.

This patient’s type IV skin lent itself to postinflammatory hyperpigmentation upon injury. Although she knew this, she still felt that she could somehow pick the darkness away.

Bloodwork was done to rule out other conditions, such as porphyria, hematologic disease, and renal or liver disease. Had a recent biopsy not been performed, this would have been included to rule out systemic disease.

The patient was given a topical steroid cream to put on any itchy lesions and counseled to avoid picking or scratching them, since this was the only way her skin could ever clear.

TAKE-HOME LEARNING POINTS

• One common term for this patient’s disorder is dermatillomania, though the DSM-5 and ICD-10 refer to it as skin-picking disorder.
• This patient experienced postinflammatory hyperpigmentation, which caused her considerable embarrassment.
• Many affected patients have unresolved underlying psychologic issues that contribute to their problem.
• The solution (which may require extensive counseling): Stop picking, and the dark lesions will eventually resolve.

The lesions on this 41-year-old African-American woman’s skin have waxed and waned over the years—but they’re always on her mind. They are most prominent on her arms and trunk but crop up almost anywhere on her body.

When they manifest—for no apparent reason—they itch, creating an irresistible urge for the patient to pick at them. This provides some relief, both from the itching and from her feeling that there is “something in there” that she needs to remove. Fairly often, her digging (with fingernails) results in “finding” white bumps at the ends of tiny hairs.

As these small excoriations heal, the wounds itch—compelling her to pick the site open again. She knows she is caught in a vicious cycle but doesn’t know how to stop. Selective serotonin reuptake inhibitors have been tried, with little to no effect.

EXAMINATION
The patient’s type IV skin is covered with dark brown, maculopapular lesions that are so numerous and large (average diameter, 2 to 3 cm) that they are impossible to ignore. Her palms, soles, face, and midback are spared.

Only a few of the newer lesions are palpable, showing faint signs of central excoriation. Previous biopsies failed to show significant pathology.

The patient appears ill at ease during history-taking. She admits to picking her skin for many years but doesn’t believe she is inhabited by any kind of bug. The skin on her wrists and between her fingers is clear. Her 3-year-old daughter’s skin is free of notable changes.

What is the diagnosis?

While it has been posited as a form of obsessive compulsive disorder (OCD), dermatillomania responds poorly, if at all, to standard OCD treatments. It is considered by others to more closely resemble addiction because, despite knowing its harm, patients persistently pick at the skin and often report a subsequent sense of relief.

This patient’s type IV skin lent itself to postinflammatory hyperpigmentation upon injury. Although she knew this, she still felt that she could somehow pick the darkness away.

Bloodwork was done to rule out other conditions, such as porphyria, hematologic disease, and renal or liver disease. Had a recent biopsy not been performed, this would have been included to rule out systemic disease.

The patient was given a topical steroid cream to put on any itchy lesions and counseled to avoid picking or scratching them, since this was the only way her skin could ever clear.

TAKE-HOME LEARNING POINTS

• One common term for this patient’s disorder is dermatillomania, though the DSM-5 and ICD-10 refer to it as skin-picking disorder.
• This patient experienced postinflammatory hyperpigmentation, which caused her considerable embarrassment.
• Many affected patients have unresolved underlying psychologic issues that contribute to their problem.
• The solution (which may require extensive counseling): Stop picking, and the dark lesions will eventually resolve.

The lesions on this 41-year-old African-American woman’s skin have waxed and waned over the years—but they’re always on her mind. They are most prominent on her arms and trunk but crop up almost anywhere on her body.

When they manifest—for no apparent reason—they itch, creating an irresistible urge for the patient to pick at them. This provides some relief, both from the itching and from her feeling that there is “something in there” that she needs to remove. Fairly often, her digging (with fingernails) results in “finding” white bumps at the ends of tiny hairs.

As these small excoriations heal, the wounds itch—compelling her to pick the site open again. She knows she is caught in a vicious cycle but doesn’t know how to stop. Selective serotonin reuptake inhibitors have been tried, with little to no effect.

EXAMINATION
The patient’s type IV skin is covered with dark brown, maculopapular lesions that are so numerous and large (average diameter, 2 to 3 cm) that they are impossible to ignore. Her palms, soles, face, and midback are spared.

Only a few of the newer lesions are palpable, showing faint signs of central excoriation. Previous biopsies failed to show significant pathology.

The patient appears ill at ease during history-taking. She admits to picking her skin for many years but doesn’t believe she is inhabited by any kind of bug. The skin on her wrists and between her fingers is clear. Her 3-year-old daughter’s skin is free of notable changes.

What is the diagnosis?

While it has been posited as a form of obsessive compulsive disorder (OCD), dermatillomania responds poorly, if at all, to standard OCD treatments. It is considered by others to more closely resemble addiction because, despite knowing its harm, patients persistently pick at the skin and often report a subsequent sense of relief.

This patient’s type IV skin lent itself to postinflammatory hyperpigmentation upon injury. Although she knew this, she still felt that she could somehow pick the darkness away.

Bloodwork was done to rule out other conditions, such as porphyria, hematologic disease, and renal or liver disease. Had a recent biopsy not been performed, this would have been included to rule out systemic disease.

The patient was given a topical steroid cream to put on any itchy lesions and counseled to avoid picking or scratching them, since this was the only way her skin could ever clear.

TAKE-HOME LEARNING POINTS

• One common term for this patient’s disorder is dermatillomania, though the DSM-5 and ICD-10 refer to it as skin-picking disorder.
• This patient experienced postinflammatory hyperpigmentation, which caused her considerable embarrassment.
• Many affected patients have unresolved underlying psychologic issues that contribute to their problem.
• The solution (which may require extensive counseling): Stop picking, and the dark lesions will eventually resolve.