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Ted Rosen, MD

Ted Rosen, MD

Dr Rosen is Professor of Dermatology at Baylor College of Medicine and Chief of the Dermatology Service at the Veterans Affairs Medical Center, both in Houston, Texas.
 

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These wounds occurred when this 77-year-old woman fell when chasing her dog. Such wounds—a combination of ecchymoses and erosion caused by blunt and sheering forces on fragile skin—are common in the elderly, even after relatively mild trauma. Simple interventions will promote healing.

These classic linear, wide-mouthed, red to purple, atrophic patches are classic for stretch marks (striae distensae). The patient was in the middle of his growth spurt.

The patient assumed that the itchy rash was due to insect bites. The shape, size, color, and presence of 6 legs of the insect he captured were consistent with bedbugs and bedbug bites.

The red patch on this woman's neck is lichenoid keratosis, a variant of seborrheic keratosis. Diagnostic contenders included Bowen disease and superficial basal cell carcinoma.

Both morphology and location favor the diagnosis of psoriasis. The presence of nail pitting, and a strongly positive family history for psoriasis, confirmed the diagnosis.

These widely scattered, dome-shaped pruritic inflammatory papules suggest insect bites. A biopsy showed mixed dermal infiltrate consisting of lymphocytes and eosinophils, consistent with an arthropod assault.

The differential diagnostic possibilities for this tender nodule included hypertrophic actinic keratosis, keratoacanthoma, squamous cell carcinoma, and verruca. The possibility of squamous cell carcinoma dictated removal with histologic examination.

A multiplicity of colors in a pigmented lesion usually dictates the need for a biopsy. In this woman with many nevi and a history of malignant melanoma, biopsy revealed an inflamed blue nevus and was also curative.

The development of eccentric pigmentation within a previously stable pigmented lesion may indicate malignant degeneration, as was the case here. Of all melanomas, lentigo maligna melanoma has the best overall prognosis.

Round plaques like this one, each composed of many small erythematous papules, are classic for granuloma annulare. Large numbers of these lesions and widespread distribution is often associated with diabetes mellitus.

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