Nail Dystrophy in 59 yo Woman

The patient is a healthy librarian who noticed a reddish area under the left thumb nail ~ 3 months ago.  Shortly after that, the distal portion of the nail become yellowish.  She has not history of trauma and the area is not painful

O/E:  There is erythema noted medically in the nail bed and the nail plate is onycholytic.  No abnormality of the nail plate is noted other than the yellowish area and possibly a Beau's line.  The patient feels that the red area has migrated medially.

Clinical Image:

My thoughts:  I am concerned that there may be a tumor under the nail plate.  The fact that it is painless argues against glomus tumor.  I welcome suggestions.

Thank you,
DJE

Non-healing ulcer after surfing injury

Surfer's Sore

The patient is a 70 year-old surfer living in Hawaii.  Two months ago, he sustained a cut over his shin bone on a lava rock/sandstone shelf of a reef on Kauai.  It has not healed in spite of cleaning area daily with chlorhexidine scrub and applying Medihoney and triple anti bacteria ointment.  He says, "What is weird and kinda creepy is it feels like something is crawling around in there from time to time, especially while sleeping?"  The patient, a light-complected Caucasian, has a history of non-melanoma skin cancer.  He is scrupulous about sun-protection, but has spent more than a half a century with significant sun-exposure.

 

This is the sandstone slab on which the injury took place:

What are your thoughts?

References

1.  Sea Ulcers Andrew Nathanson, MD,  Surfing Medicine (Journal of Surfing Medical Association) Dec, 2014

Two year-old with enanthem and exanthem for two weeks

Presented by Will Shepard, M.D.

Gillette, WY

The patient is a two year-old girl with a two week history of oral and skin lesions.  She has been well and healthy otherwise and all of her milestones have been normal.  The present illness began with two ulcers on her tongue.   A few days later she started to develop skin lesions, first on the arms.  The new lesions start with erythematous macules and became crusted after 12 – 18 hrs.  She has continued to develop new lesions on the torso, face and extremities.  Throughout this period she has been healthy, no fevers, appetite normal and in no discomfort.

O/E:  The tongue lesions have disappeared.  The skin lesions are few in number and measure 0.5 to 1 cm in diameter.  They are scaly annular macules on an erythematous base.

Clinical Images:

Rough area from Bandaid

New Lesion present since patient seen yesterday:

Impression:  The onset of an acute problem with first oral and then skin lesions in an otherwise healthy toddler suggests a viral process.

References:

1  [Paraviral exanthems]. [Article in German]

Fölster-Holst R, Zawar V, Chuh A. Hautarzt. 2017 Mar;68(3):211-216.

Abstract: Paraviral exanthems are distinct skin diseases due to infections with different viruses. Although no virus has been identified so far in some exanthems, the main age of manifestation, the clinical course of the exanthem, and the extracutaneous symptoms are suggestive for a viral genesis. While many viral infections are a direct result of the infection, paraviral exanthems reflect the response of the immune system to the infectious pathogens. Viruses cannot be identified in the skin. Typical paraviral exanthems include Gianotti-Crosti syndrome, pityriasis rosea, pityriasis lichenoides, papular-purpuric gloves and sock syndrome, and asymmetrical periflexural exanthema. Unilateral mediothoracic exanthem, eruptive pseudoangiomatosis are rare and eruptive hypomelanosis has been described recently.