Lichen planus hypertrophicus

Age: 50 years
Gender: Male
Site: Legs
Duration: 6 months
History: Severe pruritus
Findings:
* Firm, skin-colored and brownish thick plaques with verrucous surface
* Some plaques are discrete and others are confluent
* No other site was involved and no mucous membrane, nail or scalp involvement
Differential diagnosis:
1. LP hypertrophicus
2. Prurigo nodularis
3. Lichen amyloidosis
4. Lichen simplex chronicus
Diagnosis: LP hypertrophicus (clinical and skin biopsy)
Treatment:
Ultra-potent topical CS under occlusion plus oral antihistaminics gave modest improvement. Oral prednisone 30 mg per day was added (discontinued few weeks later because of adverse effects!). Lastly, oral cyclosporine in a dosage of 5 mg per kg body weight per day was given instead of prednisone and the result was excellent. Two months later cyclosporine was reduced to 2.5 mg per kg per day as a maintenance dose.    

Dermatosis neglecta

Age: 20 years
Gender: Female
Site: Back
Duration: 2 months
History:
* History of operative fixation of thoracic and lumbar vertebrae.
* Hyperesthesia over the site of operation.
* Lack of cleaning of the involved area.
* Asymptomatic, dirt-like plaques on both sides of the operation.
Findings:
* Midline scar of previous operation.
* Brown-black dirt-like plaques on both sides of the scar.
* Eradication of the rash on vigorous rubbing with 70% isopropyl alcohol (the right side of the rash evident in the second photo).
Diagnosis:
Primarily clinical and can be confirmed by disappearance of the rash through vigorous rubbing with 70% isopropyl alcohol.
Treatment:
Rubbing the rash with 70% isopropyl alcohol or vigorous cleaning with soap and water can abolish the rash , this can be considered as both diagnostic and therapeutic test!

N.B: The only difference between dermatosis neglecta and terra firma-forme dermatosis is that there is no history of lack of hygiene or cleaning in the latter!

Molluscum contagiosum in an immunocompromized patient

Age: 25 years
Gender: Male
Site: Genital area
Duration: 3 years
History:
* Asymptomatic papules since three years
* History of lymphoblastic lymphoma under chemotherapy since three years
Findings:
* Myriads of umbilicated flesh-colored papules involved the genital and surrounding area
* Similar lesions involved the chin
* No clinical evidence of other STDs
Investigations:
* Complete work up regarding lymphoma
* HIV antibodies were negative
Treatment:
Imiquimod (Aldara) 5% cream three times a week for 12 months gave good control and eradication of most lesions (together with improvement of lymphoma)

Multiple strawberry nevi

Age: 4 months

Gender: Male

Site: Face (Cheek and lower eyelid)

Duration: Since birth

History: The main concern is cosmetic!

Findings: 

Two slightly elevated vascular swelling with few surrounding telengiectatic vessels.

Diagnosis: Clinical

Treatment: 

* Reassurance about prognosis

* To facilitate response, Timolol maleate 0.5% eye drops (a beta blocker) applied twice daily to the surface of the lesions (contemplated to be used for 3-6 months).

Trichotillomania

Age: 6 years
Gender: Male
Site: Scalp
Duration: 6 months
History: Habit of hair pulling
Findings:
* An asymptomatic, large, non-scarring patch of hair loss
* The hairs are cut with different length above the surface of the scalp
* No redness (inflammation) or scales
Diagnosis: Primarily clinical
Investigations: Direct and KOH examination of hair under LM are negative (To exclude tinea capitis)
Treatment: Reassurance and explanation of the nature of this hair-pulling obsessive-compulsive disorder
Response: Full regrowth of hair within 3 months   

Lichenoid dermatosis

Age: 18 years
Gender: Male
Site: Side of the nape of the neck
Duration: 6 weeks
History:
* Outdoor worker
* An asymptomatic lesion
Findings:
* Weel-defined solitary oval red-violaceous plaque with slightly scaly lichenified surface
* No mucosal, scalp or nail involvement
* No previous drug intake
Diagnosis: Primarily clinical
Treatment:
* Sun protection (High level broad collars and sunblock cream)
* Topical potent CS (Clobetasol propionate 0.05%) cream twice daily
* Response: Remarkable within few weeks

Chancre-like ecthyma

Age: 25 years
Gender: Male
Site: Glans penis distal to the coronal sulcus
Duration: 6 weeks
History: An asymptomatic ulcer started as a painless papule that eroded into an ulcer within few days and increased in size gradually.
Findings:
* Well-defined rounded ulcer with an elevated punched-out border and clean granular base.
* Firm-hard on palpation.
* No regional lymphadenopathy.
Investigations:
VDRL: Negative (repeated twice)
TPHA: Negative (repeated twice)
Gram smear: yielded G-positive cocci
Culture: Mixed Staphylococcus aureus and Strepotococcus pyogenes
Treatment:
Benzathin penicillin 2.4 mega units i.m once every week for 3 weeks with no response (Given by another dermatologist on assumed diagnosis of primary syphilis)!!!
After investigations, it is diagnosed as ECTHYMA and treated with Ciprofloxacillin tablet 500 mg b.i.d plus topical fucidic acid cream twice daily for 10 days with an excellent response!

Lichen planopilaris

Age: 44 years
Gender: Male
Site: Scalp
Duration: 6 months
History:
Mild itching and burning sensation
Negative history of relevant drug intake
Findings:
* Localized purplish patches with hair loss
* The red-violaceous patches are mainly perifollicular
* Some hair follicles are completely destructed (whitish scarred areas) others still seen!
* Some hair loss was due to androgenetic alopecia (unrelated to lichen planopilaris)
* No mucous membrane, other cutaneous or nail involvement
Diagnosis: Primarily clinical (The patient refuse taking skin biopsy)
Treatment:
1. Clobetasol propionate 0.05% ointment applied once at night plus Tacrolimus 0.1% ointment applied once at morning
2. Hydroxychloroquine 200 mg twice daily orally (After ophthalmologic examination and relevant serological tests had been done)
Response: Follow up after 2 months showed disappearance of the symptoms and decreasing intensity of the inflammation with some hairs regrowth again.
According to the degree of response, other measures can be tried like: Tetracycline eg doxycycline, Acitretin, Methotrexate, Ciclosporin, Mycophenlate mofetil and the oral antidiabetic: Pioglitazone (PPAR-γ agonist).

Congenital mixed infantile hemangioma

Age: 3 months
Gender: Female
Site: Tip of the nose
Duration: 3 months (Since birth)
History: Non-significant apart from onset since birth
Finding:
1) More superficial bright red vascular slightly elevated plaque or swelling (Strawberry nevus or hemangioma) at the tip of the nose
2) Deeper spongy blue red compressible swelling underlying the strawberry nevus and extended beyond its boundaries to involve a large area of the dorsal surface of the nose
Diagnosis: Clinical
Treatment: Reassurance and avoidance of trauma
Prognosis: > 90% of strawberry hemangiomas disappear spontaneously within 1-3 years whereas cavernous hemangiomas are usually persistent and don't regress. Pulsed dye laser might be tried later however the result is questionable in such type of infantile hemangioma!

Cellulitis complicating a boil

Age: 16 years
Gender: Female
Site: Dorsal surface of the hand
Duration: 3 days
History:
Severe local pain and fever
History of an injury by a sharp edge of knife
No history of contact with animals or meat
Findings:

* A red nodule with central pus formation (Orf-like boil)
* An ill-defined red tender swelling
Investigations:
Normal blood glucose level
Lesional swab yielded gram-positive cocci
Culture: Heavy growth of Staphylococcus aureus
Treatment:

Systemic cefixime 400 mg b.i.d plus fusidic acid cream twice daily for 10 days and oral analgesic (Mefanemic acid 500 mg capsule on need)
Response: Complete resolution

Nummular Eczema

Age: 18 years
Gender: Male
Site: Hands & Feet
Duration: 4 weeks
History:
Pruritus
Positive family history of atopy
Findings:
Multiple discoid oozy and crusted plaques
Investigations:
None
Treatment:
Systemic CS (Prednisolone 15 mg per day for one week)
Topical potent CS (Clobetasole propionate) + Fusidic acid for 3 weeks
Oral antihistaminics (Hydroxyzine 25 mg at night on need)
Response: Good response with more than 80% improvement.

Bullous Insect Bite

Age: 15 years
Gender: Female
Site: Foot
Duration: 2 weeks
History: Living in a rural area
Findings:
Large bulla containing a clear fluid
Few healed nearby lesions
Investigations:
None
Treatment:
Topical potent corticosteroid (Clobetasol cream) twice daily for 10 days
Response:
Disappearance of the blister within 2 weeks without any sequel 

Psoriasis-like Tinea capitis

Age: 6 years
Gender: Male
Site: Scalp
Duration: 3 months
History: Positive contact with a pet
Findings:
Multiple scaly patches with hair loss
Hair is easily and painlessly pulled out
Lusterless hair
Investigations:
Direct hair examination under LM: Fungal hyphae and spores
Treatment:
Griseofulvin 10 mg per kg per day orally for 6 weeks
Response: Dramatic response with clinical and mycological cure