Case Studies

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71. Hair loss on scalp

A 6-year-old boy was brought to his family physician (FP) after his mother noticed areas of hair loss and a rash on his scalp. The mother said that she didn’t know how long this had been going on, but it had become noticeable after his recent haircut. The boy had no symptoms and was otherwise in good health

Gratefully sourced with permission from Photo Rounds in The Journal of Family Practice

 

73. Scarring alopecia in a woman with psoriasis

A 57-year-old African American woman came to our dermatology clinic to reestablish care.

She had a long history of plaque psoriasis involving her trunk and extremities.

More recently, she had developed progressive hair loss, which her previous physician had attributed to the psoriasis.

Before this visit, our patient had been treating her psoriasis with topical clobetasol and calcipotriene.

A physical exam revealed multiple welldemarcated, erythematous, scaly plaques consistent with plaque psoriasis on her trunk and extremities.

She also said her scalp was itchy, and we noted significant cicatricial (scarring) alopecia of the scalp, with faint perifollicular erythema, that was predominantly affecting the frontotemporal region (FIGURE).

We performed a scalp biopsy.

Gratefully sourced with permission from Photo Rounds in The Journal of Family Practice

 

75. A progressive scalp lesion

A 47-YEAR-OLD AFRICAN AMERICAN WOMAN sought care at our clinic for multiple progressive scalp lesions.

She said that she first noticed the lesions 13 years ago when her children were diagnosed with ringworm on the scalp. At that time, her physician thought that she, too, had tinea capitis, and she was treated with 6 weeks of griseofulvin. The lesions persisted, however.

She told us that the lesions were nonpruritic and that she didn’t have any other symptoms.

The patient did not have a history of trauma or exposure of chemicals to the scalp, and she was not taking any prescription or over-the-counter medications.

Examination of her scalp revealed scattered irregularly shaped, nontender lesions that were centrally hypopigmented and peripherally hyperpigmented. She also had scarring and hair loss (FIGURE 1).

She had no other lesions on her body.

Our 47-year-old patient had multiple scattered scalp lesions that were nontender and centrally hypopigmented. scarring, alopecia, and surrounding areas of hyperpigmentation were also visible

Gratefully sourced with permission from Photo Rounds in The Journal of Family Practice

 

77. Progressive hair loss

A 66-year-old white woman presented to her primary care clinic with concerns about hair loss, which began 2 years ago.

Recently, she had noticed some “bumps” on her cheeks, as well.

On physical examination, the physician noted hair loss in a symmetric 2-cm band-like distribution across her frontal and temporal scalp (FIGURES 1 and 2). In both areas, there was moderate perifollicular erythema, scale, and what appeared to be scarring.

The patient had lost most of her eyebrow hairs, and had prominent temporal veins (FIGURE 2) and flesh-colored papules on her cheeks.

She had no significant medical history, was emotionally stable, and recently had a satisfactory health care maintenance exam.

The postmenopausal patient’s last menses was 15 years earlier, and she was not taking hormone replacement.

Gratefully sourced with permission from Photo Rounds in The Journal of Family Practice

 

79. Alopecia with perifollicular papules and pustules

A 23-Year-Old African American Man sought care at our medical center because he had been losing hair over the vertex of his scalp for the past several years.

He indicated that his father had early-onset male patterned alopecia.

As a result, he considered his hair loss “genetic.”

However, he described waxing and waning flares of painful pustules associated with occasional spontaneous bleeding and discharge of purulent material that occurred in the same area as the hair loss.

Physical examination revealed multiple perifollicular papules and pustules on the vertex of his scalp with interspersed patches of alopecia (FIGURE 1). There were no lesions elsewhere on his body and his past medical history was otherwise unremarkable.

Gratefully sourced with permission from Photo Rounds in The Journal of Family Practice

 

81. Green fingernail

A 34-year-old woman came to our clinic because she was concerned about her thumbnail, which had turned green.

Although her finger didn’t hurt, she was bothered by its appearance.

Several months earlier, the woman had sought care at a different clinic because the same nail had become brittle and come loose from the nail bed, which was spongy.

The physician advised her that she had onychomycosis and prescribed ciclopirox lacquer, but it didn’t help.

Over the next 3 weeks, she noticed a faint green hue developing at the tip of the nail, which expanded and intensified in color (FIGURE).

The patient was a mother who worked at home, washed dishes by hand daily, and bathed her children.

Her past medical history was significant for type 1 diabetes mellitus and Hashimoto’s thyroiditis.

She had no other symptoms.

Gratefully sourced with permission from Photo Rounds in The Journal of Family Practice

 

83. Persistent rash on extremities

A 52-year-old woman presented to her family physician (FP) with a 4-month history of a recurrent, pruritic rash on her extremities.

The FP noted that the lesions were raised, annular wheals.

The patient said that topical 1% hydrocortisone didn’t help.

She also said that the only medication she was taking was acetaminophen, as needed, for various aches and pains, but that she didn’t think the rash was brought on by the acetaminophen.

Gratefully sourced with permission from Photo Rounds in The Journal of Family Practice

 

85. Sore throat and ear pain

A 79-year-old man sought care for pain in his left ear and a severe sore throat that had been bothering him for 2 days.

He also complained of pain when he swallowed, a decreased appetite, and dizziness.

He denied weight loss, fever, tinnitus, subjective hearing loss, unilateral facial droop, or weakness.

The patient had vesicles on an erythematous base on the left side of his hard palate that didn’t cross the midline.

The left pinna was mildly erythematous and swollen without obvious vesicles. The tympanic membrane was normal, as was the patient’s right ear.

Gratefully sourced with permission from Photo Rounds in The Journal of Family Practice

 

87. Worsening rash

A 41-year-old woman presented to her family physician (FP) with a rash on her arms and legs that she’d had for 2 months.

She’d previously been seen in the emergency department, where she was given a short course of oral prednisone.

The patient said her rash became worse when she completed the course of prednisone, noting even more areas of pus on her skin.

She had no history of skin conditions.

Gratefully sourced with permission from Photo Rounds in The Journal of Family Practice

 

89. Rash on abdomen

A 25-year-old man presented to his family physician (FP) with a new rash on his abdomen.

He said that it was itchy, but not painful.

The FP noted an annular pattern and suspected tinea corporis, but a potassium hydroxide (KOH) preparation came back negative.

Searching for more clues, the FP found pitting in many of the patient’s fingernails.

The patient denied any joint pain or morning stiffness.

He also denied using tobacco and said he rarely drank alcohol; he was, however, overweight.

Gratefully sourced with permission from Photo Rounds in The Journal of Family Practice

Photo Rounds in The Journal of Family Practice

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