Conundrums 4

Persistent rash for 10 years
This otherwise healthy 30 year old male presented for evaluation of an asymptomatic rash of 10 years duration that had failed to respond to any treatment. He had tried topical antifungal creams as well as topical steroid creams without any improvement. The rash was confined to his lower chest, abdomen and back. No one else in the family had it. There was no exposure history and denied any medications. The clinical examination showed a hyperpigmented patchy rash without scale on his trunk that had this unusual pattern.

What is your diagnosis?

Answer: This patient had confluent and reticulated papillomatosis of Gougerot and Carteaud. Confluent and reticulated papillomatosis presents as asymptomatic hyperpigmented papules that can form larger plaques, and is located on the upper trunk in older teens and young adults. The cause of confluent and reticulated papillomatosis is not known. The condition can last months to years with relapses not uncommon. Fortunately this condition responds to an oral antibiotic such as minocycline or azithromycin.

Conundrums 3

This 29 year old female is 2 months post partum and has developed these bumps on her chin over the last three weeks. She is told that this is acne due to the all the recent hormonal changes with delivery and stress of taking care of new born. She is still breastfeeding and is seeking safe treatment options.

What is your diagnosis?

Answer: Plane or flat warts are flat topped flesh colored papules with minimal scaling and only slight elevation and are 2–4 mm in diameter. They are more common on young adults. Sites of predilection are the face, back of hands, and the shins. Treatment can be challenging so as to leave no scarring. Patients are advised against using destructive approaches for flat warts due to their tendency to spread after treatment. Fortunately there are a variety of topical treatments available while breastfeeding and these lesions responded to therapy over a three week period.

Conundrums 2

This 59 year old female presented with a one year history of itchy eyelids that had been persistent. She had tried changing all eye makeup then stopped completely for two months without improvement. She changed detergent, fabric softener, facial cleanser, and moisturizer without avail. She knew she was sensitive to fragrances so she switched out everything to fragrance free and did not wear any scent. The rash would respond to topical corticosteroids then promptly returned upon discontinuation.

What is your diagnosis?

Answer: This mystery rash of an allergic airborne contact dermatitis due to her husband’s cologne. Fragrance allergy is common, affecting approximately 1% of the general population. Common locations for contact allergy include axilla, face (including the eyelids) and neck, well-circumscribed patches in areas of "dabbing-on" fragrances (wrists, behind the ears) and (aggravation of) hand eczema. The cause was not “false scent” and she improved with his discontinuation of his cologne.

granuloma annulare

This teenaged female presented with a persistent annular lesion near her ankle that had been present for over a month. It was asymptomatic and had grown slowly. She is otherwise healthy and takes no medications. She denies any exposure history but does spend time outdoors in the summer when this lesion appeared. They have tried an over-the-counter antifungal cream for over a week without any improvement. She denies any rashes elsewhere.

What is your diagnosis?

Answer: This is a case of granuloma annulare, a benign self-limited condition more commonly seen in younger patients and more commonly in females. It is typically not responsive to treatment but will spontaneously resolve without a trace within a few months. Ringworm is usually more scaly and will be itchy. Lyme disease is not endemic in Kansas and usually presents as an expanding flat red patch after a tick bite (which is often not noted when it is a seed tick). Warts have more surfaces changes with increased texture, unlike what is seen here.

Adult and Pediatric Dermatology
4601 W. 109th St., Suite 116  •  Overland Park, Kansas 66211  •  913-469-1115