Question 1: Visual Assessment: What is your diagnosis?
- Terra firma-forme dermatosis
- Malignant melanoma
- Kaposi sarcoma
Question 1: correct answer: B. Malignant melanoma
- Terra firma-forme dermatosis, also known as Duncan's dirty dermatosis, is characterized by brown to dark hyperpigmented plaque with a predilection to the head and neck area. On palpation, a roughened texture may be appreciable. Unlike a melanocytic nevus, terra firma-forme dermatosis can be removed by manual rubbing with isopropyl alcohol pad (Browning & Rosen, 2005; Linton, 2015).
- Malignant melanoma. This is a malignant skin tumor of melanocytes. Utilizing the ABCDE criteria can aid a clinician in the assessment of an atypical melanocytic nevus. Asymmetry, borders, variegated color, diameter/duckling (commonly referred to as “ugly duckling”), and evolution are features that raise concern for melanoma (Figure 1; Vassantachart & Hirokane, 2017; Zumwalt & Jacob, 2015).
- Kaposi sarcoma (KS) is a vascular tumor of endothelial cells that is strongly associated with Human Herpes Virus 8 (HHV-8), a member of herpes family. Patients who are diagnosed in the United States often have a history of immunosuppression such as HIV (AIDS form) or are solid-organ transplant recipients (iatrogenic form). Classic KS (non-HIV type) is seen in elderly men of eastern European heritage; this is a rare form in the United States. Clinically, KS presents as a purple papules and plaques, which may develop into a nodule or tumor (Régnier-Rosencher et al., 2013). As KS can involve internal organs such as the gastrointestinal tract, an oral examination should be performed (Jacob, 2016; Uldrick & Whitby, 2011).
- Dermatofibroma (DF) is a common benign cutaneous lesion. It often presents after an episode of trauma, such as mosquito bites. Although DF is often pigmented, it appears as a solitary papule with well-defined borders and with a uniform color. A lateral pressure exerted on a suspected DF lesion can produce a central depression. This is known as the dimple sign and is considered to be pathognomonic for DF (Jacob, 2016).
Question 2: Clinical Vignette
A 67-year-old man with a history of uncontrolled Type II diabetes presents with a “rash on the chest.” It started 3 months ago. The patient denies having a similar condition in the past. He reports intermittent pruritus but denies any pain or bleeding. He has not had any treatment at this time. On examination, he has greasy pink scaled papules coalescing into plaques on the hair-bearing area of the central chest.
- Allergic contact dermatitis
- Allergic dermatitis
- Seborrheic dermatitis
- Acrodermatitis enteropathica
Question 2: correct answer: C. Seborrheic dermatitis
- Allergic contact dermatitis is the clinical manifestation of a Type IV hypersensitivity reaction, characterized by sensitization to a specific offending agent known as an allergen. Sensitization occurs after a repeated exposure to an allergen in susceptible individuals. Contact allergens may be found in jewelry, home remedies, and topical antibiotics. In a sensitized individual, a cutaneous eruption starts after 48 hours or days after contact with an allergen. The skin lesion is characterized by erythema and edema; nonumbillicated vesicles can also be appreciated; oftentimes, a patient complains of intense pruritus. The gold standard in management is avoidance of identified offending agents. For acute allergic contact dermatitis, topical and/or oral corticosteroids may be given for symptom control (Gatica-Ortega et al., 2017; Mowad et al., 2016).
- Atopic dermatitis (AD) is a chronic inflammatory skin condition that is seen primarily in infants and younger adults with a predilection for the flexor surfaces (antecubital fossa and popliteal fossa). Clinically, AD presents as highly pruritic erythematous papules and/or plaques with excoriation and crusting in the acute stage. In the chronic stage, lichenification and pigmentary changes are prominent. AD has been associated with filaggrin, an epidermal protein involved in skin barrier function. Deficiency in filaggrin appears to be essential in the pathogenesis of AD (Lawton, 2011; Lee & Jacob, 2019).
- Seborrheic dermatitis is a common inflammatory condition. It classically presents with erythema and greasy scale and has a predilection to sebum-rich areas such as the scalp and central chest. An altered immune system in the setting of diabetes, as in this case, or states such as HIV and Parkinson's can predispose to exacerbations of seborrheic dermatitis (David et al., 2018; Schmidt, 2011).
- Acrodermatitis enteropathica. There are two forms: primary acrodermatitis enteropathica, which is associated with an inherited zinc transporter defect, resulting in reduced intestinal absorption of zinc, and secondary (acquired) acrodermatitis enteropathica, which can be a result of malabsorption, reduced intake, or increased demand of zinc. Classically, this condition presents with erythematous, dry, and scaly patches and plaques distributed predominantly in a periorificial and acral pattern. With greater duration of the disease, the lesions may show crusting, erosion, and vesiculobullous changes.
- History of advanced cancer and prolonged hospitalization may increase the risk of nutritional deficiency (Barratt, 2014; David et al., 2018).
Barratt N. (2014). Nutrition and wound healing: Implications for practice. Journal of the Dermatology Nurses' Association
, 6(1), 27–32. 10.1097/jdn.0000000000000020
Browning J., Rosen T. (2005). Terra firma-forme dermatosis revisited. Dermatology Online Journal
, 11(2), 15.
David A. R., Rundle C. W., Jacob S. E. (2018). Waxy papules on the central chest. Journal of the Dermatology Nurses' Association
, 10(3), 150–151. 10.1097/jdn.0000000000000398
Gatica-Ortega M. E., Pastor-Nieto M. A., Mercader-García P., Silvestre-Salvador J. F. (2017). Allergic contact dermatitis caused by (meth)acrylates in long-lasting nail polish—Are we facing a new epidemic in the beauty industry?Contact Dermatitis
, 77(6), 360–366. https://doi.org/10.1111/cod.12827
Jacob S. E. (2016). Invaginating brown spot. Journal of the Dermatology Nurses' Association
, 8(6), 336–337. 10.1097/JDN.0000000000000248
Lawton S. (2011). Atopic eczema and evidence-based care. Journal of the Dermatology Nurses' Association
, 3(3), 131–139. 10.1097/JDN.0b013e31821c0b59
Lee K. W., Jacob S. E. (2019). Red, dry, itchy plaques on arms. Journal of the Dermatology Nurses' Association
, 11(1), 36–37. 10.1097/jdn.0000000000000443
Linton C. P. (2015). Skin test. Journal of the Dermatology Nurses' Association
, 7(4), 241–243. 10.1097/jdn.0000000000000146
Mowad C. M., Anderson B., Scheinman P., Pootongkam S., Nedorost S., Brod B. (2016). Allergic contact dermatitis: Patient diagnosis and evaluation. Journal of the American Academy of Dermatology
, 74(6), 1029–1040. https://doi.org/10.1016/j.jaad.2015.02.1139
Régnier-Rosencher E., Guillot B., Dupin N. (2013). Treatments for classic Kaposi sarcoma
: A systematic review of the literature. Journal of the American Academy of Dermatology
, 68(2), 313–331. https://doi.org/10.1016/j.jaad.2012.04.018
Schmidt J. A. (2011). Seborrheic dermatitis: A clinical practice snapshot. Journal of the Dermatology Nurses' Association
, 3(5), 294–299. 10.1097/JDN.0b013e31822f48eb
Uldrick T. S., Whitby D. (2011). Update on KSHV epidemiology, Kaposi sarcoma
pathogenesis, and treatment of Kaposi sarcoma
. Cancer Letters
, 305(2), 150–162. https://doi.org/10.1016/j.canlet.2011.02.006
Vassantachart J. M., Hirokane J. (2017). 31-gene expression profile in melanoma. Journal of the Dermatology Nurses' Association
, 9(5), 248–250. 10.1097/JDN.0000000000000333
Zumwalt J. R., Jacob S. E. (2015). Growing brown spot. Journal of the Dermatology Nurses' Association
, 7(3), 167–168. 10.1097/jdn.0000000000000124