Berkowitz’s – Section XI: Dematologic Disorders

Acne

Monica Sifuentes, MD
CASE STUDY
A 15-year-old male comes to your office for a preparticipation sports physical evaluation. He is healthy and has no questions, complaints, or concerns. The adolescent is well developed and well nourished, with normal vital signs, including blood pressure. The physical examination is entirely normal except for the skin. Multiple closed comedones (whiteheads) are noted along the hairline. Erythematous papules and pustules are present across the forehead and over both cheeks. Scattered open comedones (blackheads) are located over the nose and cheeks as well. The chest and back are clear, with no lesions.
Questions
1. What is the pathogenesis of acne vulgaris?
2. What are some contributing factors in the development of acne?
3. What are the different types of acne lesions?
4. What management options are available for the treatment of mild, moderate, and severe acne in adolescents?
5. What are the indications for the use of isotretinoin?
6. What is the prognosis for adolescent patients with acne?

Disorders of the Hair and Scalp

Ki-Young Yoo, MD; Kathy K. Langevin, MD, MPH; and Noah Craft, MD, PhD
CASE STUDY
A 6-year-old girl presents with a 1-month history of a swelling on the right side of her scalp that is associated with hair loss. She has previously been in good health, and she has no history of fever. On examination, she is afebrile, has normal vital signs, and appears well. An area of non-tender, boggy swelling 2 3 2 cm with associated alopecia is apparent over the scalp in the right temporal area. Small pustular lesions are scattered over the involved area. Generalized scaling of the scalp and occipital adenopathy are evident.
Questions
1. What are the common causes of circumscribed hair loss in children?
2. What are the common causes of diffuse hair loss in children?
3. What are the common causes of scalp scaling in children?
4. What features distinguish tinea capitis from alopecia areata?
5. What is the treatment for tinea capitis? Is there a role for topical antifungal agents?

Diaper Dermatitis

Ki-Young Yoo, MD; Kathy K. Langevin, MD, MPH; and Noah Craft, MD, PhD
CASE STUDY
A 6-month-old boy has a 3-day history of a rash in the diaper area. The mother has been applying cornstarch, but the rash has gotten worse and has spread to the inner thighs and abdomen. The infant has no history of fever, upper respiratory tract symptoms, vomiting, or diarrhea. He was seen in the emergency department 1 week ago for acute gastroenteritis, which has since resolved. On examination, a poorly demarcated, shiny, erythematous rash is noted over the convex surface of the buttocks, lower abdomen, and genitalia, with relative sparing of the intertriginous creases. The rest of the physical examination is within normal limits.
Questions
1. What are the common causes of rashes in the diaper area (diaper dermatitis)?
2. What are the features that distinguish one type of diaper dermatitis from another?
3. What systemic diseases may present with diaper dermatitis?
4. What are some common treatments for diaper dermatitis?

Papulosquamous Eruptions

Ki-Young Yoo, MD; Kathy K. Langevin, MD, MPH; and Noah Craft, MD, PhD
CASE STUDY
A 6-month-old girl presents with an erythematous, confluent, slightly raised and scaly rash on the cheeks. The extremities are also covered with a fine papular rash. The infant has had some scaling behind the ears and on the scalp since early infancy, but the symptoms have recently increased. The mother has been applying baby oil to the scalp to relieve the scaliness. Except for some intermittent rhinorrhea, the infant has otherwise been well. Immunizations are deficient; she received only the first set when she was 2 months old. The family history is positive for bronchitis. The infant’s weight is at the 75th percentile and height is at the 50th percentile. Vital signs are normal. The physical examination is normal except for the presence of the rash.
Questions
1. What are the characteristics of papulosquamous eruptions?
2. What are the common conditions associated with papulosquamous eruptions in children?
3. What are the appropriate treatments for common papulosquamous eruptions?
4. When should children with papulosquamous eruptions be referred to a dermatologist?

Morbilliform Rashes

Kathy K. Langevin, MD, MPH, and Noah Craft, MD, PhD
CASE STUDY
A 10-month-old girl is brought to the office with a history of rhinorrhea, cough, and fever for 3 days prior to the onset of a confluent, erythematous rash. The rash started on her face. She has been irritable, and her eyes are red and teary. Her immunizations include 3 sets of diphtheria, tetanus, and acellular pertussis; polio; rotavirus; Haemophilus influenzae type b; conjugated pneumococcal; and hepatitis B vaccines. No one at home is ill. The girl was seen in the emergency department 2 weeks earlier because she caught her finger in a car door. On physical examination, the girl’s temperature is 102.2°F (39°C). A confluent eruption of erythematous macules and papules is evident on the face, trunk, and extremities. Rhinorrhea and conjunctivitis are also present.
Questions
1. What are the common causes of febrile macular/papular or morbilliform rashes in children?
2. What features distinguish one disease from another?
3. How does a child’s nutritional status affect his or her reaction to certain exanthem-inducing viruses?
4. What are the public health considerations concerning viral exanthems in children?

Vesicular Exanthems

Kathy K. Langevin, MD, MPH, and Noah Craft, MD, PhD
CASE STUDY
A 2-year-old boy is evaluated for a 2-day history of fever (temperature: 103.1°F [39.5°C]), runny nose, decreased appetite, and a rash over the abdomen. The boy has had no previous known exposures to chickenpox (varicella) and no history of varicella vaccination. He attends child care daily. No one at home is ill. The boy is currently taking no medications except for acetaminophen for fever, and he has no history of dermatologic problems. On physical examination, the heart rate is 120 beats/min, the respiratory rate is 20 breaths/min, and the temperature is 100.4°F (38.0°C). The toddler’s overall appearance is nontoxic. The skin examination is significant for a few scattered erythematous vesicular lesions over the abdomen and one erythematous papule on the back. The rest of the examination is normal.
Questions
1. What are the most likely causes of vesicular exanthems in febrile children?
2. How can types of vesicular rashes be differentiated on the basis of patient history?
3. What are the key historical questions to ask?
4. What is the natural course of varicella?
5. What treatment options are available for children with varicella? What options are available for other vesicular exanthems?