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Identifying Lesions on Skin of Color

Carly A Elston, MD; Dirk M Elston, MD | October 26, 2022 | Contributor Information

A 32-year-old woman with a history of recent urinary tract infection (UTI) that was treated with ciprofloxacin presents with the clinical findings shown. A similar lesion occurred in the same location a few years ago following a previous UTI. Which of the following is the most likely diagnosis?

  1. Brown recluse spider bite
  2. Erythema multiforme
  3. Erythema migrans
  4. Fixed drug eruption
Image courtesy of Dirk M Elston, MD.

Identifying Lesions on Skin of Color

Carly A Elston, MD; Dirk M Elston, MD | October 26, 2022 | Contributor Information

Answer: D. Fixed drug eruption

This patient has an oval, sharply demarcated, erythematous-to-hyperpigmented patch that is consistent with a fixed drug eruption.[1,2] The history of recurrence in the same location is an important clue to the diagnosis. As with other drug reactions, common causes include antibiotics, anticonvulsants, analgesics, and muscle relaxants.[1,2] Nonpigmented fixed drug eruptions have been reported following ingestion of pseudoephedrine, tadalafil, sorafenib, cotrimoxazole, fluoroquinolones, and piroxicam.[3] Treatment typically consists of identifying, removing, and avoiding the offending agent, as well as symptomatic care.[1,2]

Image courtesy of Dirk M Elston, MD.

Identifying Lesions on Skin of Color

Carly A Elston, MD; Dirk M Elston, MD | October 26, 2022 | Contributor Information

A 37-year-old Indian woman presents with a 2-month history of brown-gray macules and patches on the neck, trunk, and proximal extremities (shown). Which of the following is the most likely diagnosis?

  1. Drug-induced pigmentation
  2. Fixed drug eruption
  3. Erythema dyschromicum perstans
  4. Morphea
Image courtesy of Dirk M Elston, MD.

Identifying Lesions on Skin of Color

Carly A Elston, MD; Dirk M Elston, MD | October 26, 2022 | Contributor Information

Answer: C. Erythema dyschromicum perstans

Erythema dyschromicum perstans, or ashy dermatosis, is an idiopathic inflammatory condition of unknown etiology characterized by progressive appearance of oval-to-polygonal gray-brown macules and patches on the neck, trunk, and extremities that most commonly affects individuals with skin types III and IV. The lesions may have an erythematous rim. Involvement is generally symmetrical, progressive, and poorly responsive to treatment.[4]

Image courtesy of Dirk M Elston, MD.

Identifying Lesions on Skin of Color

Carly A Elston, MD; Dirk M Elston, MD | October 26, 2022 | Contributor Information

A 36-year-old Black woman presents with a 5-year history of the skin lesions shown. The lesions involve her arms, face, and scalp. Which of the following represents the likelihood that this patient will go on to develop systemic lupus erythematosus (SLE)?

  1. 0%
  2. 5-15%
  3. 50%
  4. 75%
Image courtesy of Dirk M Elston, MD.

Identifying Lesions on Skin of Color

Carly A Elston, MD; Dirk M Elston, MD | October 26, 2022 | Contributor Information

Answer: B. 5-15%

This patient has scattered atrophic depigmented and erythematous plaques with a surrounding rim of hyperpigmentation that is characteristic of discoid lupus erythematosus.[5] Patients with discoid lupus have a 5-15% risk of developing SLE,[5,6] and discoid lesions are one of the 11 criteria for the diagnosis of SLE.[5,6] The risk of progression is thought to be slightly higher in patients with widespread disease.[5,6]

Image courtesy of Dirk M Elston, MD.

Identifying Lesions on Skin of Color

Carly A Elston, MD; Dirk M Elston, MD | October 26, 2022 | Contributor Information

A 47-year-old Black woman presents with a 2-month history of the asymptomatic skin findings shown. Biopsy from the nasal ala would demonstrate which of the following features?

  1. A lichenoid band of lymphocytic inflammation, sawtooth rete ridges, hyperkeratosis, and hypergranulosis
  2. Noncaseating granulomas with few surrounding lymphocytes
  3. Vacuolar interface dermatitis with superficial and deep lymphocytic inflammation and follicular plugging
  4. A subcorneal pustule with many gram-positive cocci
Image courtesy of Dirk M Elston, MD.

Identifying Lesions on Skin of Color

Carly A Elston, MD; Dirk M Elston, MD | October 26, 2022 | Contributor Information

Answer: B. Noncaseating granulomas with few surrounding lymphocytes

This patient has reddish purple plaques on the nose that are characteristic of lupus pernio, one of the more common presentations of cutaneous sarcoidosis.[7] Lupus pernio has a 2:1 female predominance and is more common in African ethnic groups than in White individuals. Recognition of this manifestation of sarcoidosis is important as approximately three quarters of patients have associated pulmonary involvement, and half of patients have upper respiratory tract involvement.[7]

Image courtesy of Dirk M Elston, MD.

Identifying Lesions on Skin of Color

Carly A Elston, MD; Dirk M Elston, MD | October 26, 2022 | Contributor Information

A 16-year-old otherwise healthy girl presents with a life-long history of the skin finding shown on her posterior legs. Which of the following is the most likely cause?

  1. Phytophotodermatitis
  2. Normal development
  3. Shiitake mushroom dermatitis
  4. Incontinentia pigmenti
Image courtesy of Dirk M Elston, MD.

Identifying Lesions on Skin of Color

Carly A Elston, MD; Dirk M Elston, MD | October 26, 2022 | Contributor Information

Answer: B. Normal development

The photo demonstrates pigmentary demarcation lines, also known as Futcher or Voigt lines, caused by the normal pattern of physiologic pigmentation, in which dorsal surfaces are hyperpigmented relative to ventral surfaces, with a localized smooth transition between lighter and darker pigmentation.[8] These bilateral, symmetrical lines are more easily seen in individuals with darker skin types and can be observed on the posteromedial legs (shown) and anterolateral upper arms, as well as on the central chest and midback regions.[8.9]

Image courtesy of Dirk M Elston, MD.

Identifying Lesions on Skin of Color

Carly A Elston, MD; Dirk M Elston, MD | October 26, 2022 | Contributor Information

A 32-year-old woman has a 2-year history of depigmented patches that started over her knuckles and elbows and progressed to involve much of her body. Which of the following conditions is she at an increased risk of developing?

  1. Pernicious anemia
  2. Autoimmune diseases
  3. Uveitis
  4. All of the above
Image courtesy of Dirk M Elston, MD.

Identifying Lesions on Skin of Color

Carly A Elston, MD; Dirk M Elston, MD | October 26, 2022 | Contributor Information

Answer: D. All of the above

The image demonstrates depigmented macules that coalesce into larger patches, features characteristic of vitiligo. Note the sparing of the perifollicular skin (arrow), which is common with vitiligo. Vitiligo exhibits koebnerization, with skin lesions often first affecting areas of frequent trauma, such as the fingertips and bony prominences.[10]

Vitiligo is an acquired pigmentary disorder of the skin and mucous membranes characterized by well-demarcated, depigmented macules and patches surrounded by healthy skin.[10] This condition has been linked to the same autoimmunity predisposition genes as those for pernicious anemia, autoimmune thyroid disease, adult-onset autoimmune diabetes, SLE, rheumatoid arthritis, psoriasis, and Addison disease.[11]

Vogt-Koyanagi-Harada syndrome is a systemic multiorgan autoimmune disorder in which patients develop vitiligo of the head, neck, inner ear, and meninges.[12] In addition to vitiligo, affected individuals develop severe uveitis, aseptic meningitis, dysacusis, tinnitus, poliosis, and alopecia.[10]

Image courtesy of Dirk M Elston, MD.

Identifying Lesions on Skin of Color

Carly A Elston, MD; Dirk M Elston, MD | October 26, 2022 | Contributor Information

A 5-year-old Black boy presents with a 2-week history of a scaly plaque on the scalp and posterior cervical lymphadenopathy. Which of the following organisms is most likely to grow from a culture of this lesion?

  1. Microsporum canis
  2. Microsporum audouinii
  3. Trichophyton violaceum
  4. Trichophyton tonsurans
Image courtesy of Dirk M Elston, MD.

Identifying Lesions on Skin of Color

Carly A Elston, MD; Dirk M Elston, MD | October 26, 2022 | Contributor Information

Answer: D. Trichophyton tonsurans

T tonsurans is the most common cause of tinea capitis in the United States and predominantly affects Black children,[13] in whom tinea is more likely to present with seborrheic-like scales (circled area) and hair loss, rather than with kerion (severely inflamed deep abscesses).[13]T tonsurans causes an endothrix infection, which is characterized by fungal forms within the hair shaft, leading to hair fiber breakage that is seen as black dots on the surface of the scalp ("black dot tinea capitis") and alopecia.[13]

Image courtesy of Dirk M Elston, MD.

Identifying Lesions on Skin of Color

Carly A Elston, MD; Dirk M Elston, MD | October 26, 2022 | Contributor Information

A 42-year-old Black man presents with a 5-year history of tender, draining scalp nodules. Which of the following is the most likely diagnosis?

  1. Dissecting cellulitis
  2. Furunculosis
  3. Kerion
  4. Acne keloidalis nuchae
Image courtesy of Dirk M Elston, MD.

Identifying Lesions on Skin of Color

Carly A Elston, MD; Dirk M Elston, MD | October 26, 2022 | Contributor Information

Answer: A. Dissecting cellulitis

Dissecting cellulitis, also known as perifolliculitis capitis abscedens et suffodiens of Hoffman, is a chronic inflammatory disorder of the scalp that leads to the development of cicatricial alopecia.[14,15] This condition—the draining nodules and sinus tracts of which are pictured above—predominantly affects Black men in their 20s to 40s. It is part of the follicular occlusion triad that includes hidradenitis suppurativa and acne conglobate, or tetrad, with pilonidal cysts.[14,15]

Workup includes bacteriologic cultures of purulent discharge (arrow) from the lesions and, possibly, fungal cultures to exclude kerion.

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