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A 15-year-old girl is brought in by her mother for evaluation of a rash that developed following a “candling” treatment she underwent two weeks ago at a beauty spa.
The treatment, which was performed to eliminate scaling in her external ear canal, involved dripping hot wax from a burning candle into the external auditory meatus. The cooled wax was peeled away, along with the attached scaling. A new, asymptomatic, scaly rash has since appeared in the same area—far worse than the original.
There is no history of recent infection or joint pain, or family history of skin disease.
EXAMINATION
Heavy, uniform, white scaling on a salmon-colored base covers the external auditory meatus, extending 3 or 4 mm into the concha. Similar, milder changes are observed in the left ear.
There are scattered pits in three fingernails, white scaling in the scalp above and behind both ears, and faint pink scaly patches on both knees and elbows.
What is the diagnosis?
Psoriasis is extremely common, affecting about 3% of the white population in this country, and is one of a handful of conditions that manifest with the Koebner phenomenon. This means that any trauma (ie, scrapes, burns, scratches, or cuts) can trigger or extend the condition. In this case, the hot wax was likely the culprit.
The patient’s primary care provider, it turns out, was treating the elbow and knee rashes with antifungal creams (to no avail). He hadn’t made the connection between her various skin problems. It was the acute manifestation in the ear that prompted a broader assessment of the patient’s condition—proving the maxim that to find a diagnosis, you have to look for it.
Given its mild nature, this patient’s condition was easily treated with topical steroids and vitamin D-derived cream (calcipotriene). She was advised of the need to avoid exacerbating factors, such as smoking, obesity, excess alcohol intake, and stress.
There is the possibility of the disease worsening despite treatment. The patient also has about a 25% chance of developing psoriatic arthropathy. For these reasons, she will need to be followed by dermatology.
TAKE-HOME LEARNING POINTS
- Psoriasis, though very common, does not always manifest in its typical form.
- Any trauma (ie, burn, scrape, or cut) can trigger preexisting psoriasis, a response called the Koebner phenomenon.
- Several other conditions—including lichen planus, warts, and molluscum—can exhibit this same phenomenon.
- When psoriasis is suspected, potential corroboratory sites of involvement (eg, knees, elbows, nails, and scalp) should be examined. Biopsy is often needed to confirm the diagnosis.
A 15-year-old girl is brought in by her mother for evaluation of a rash that developed following a “candling” treatment she underwent two weeks ago at a beauty spa.
The treatment, which was performed to eliminate scaling in her external ear canal, involved dripping hot wax from a burning candle into the external auditory meatus. The cooled wax was peeled away, along with the attached scaling. A new, asymptomatic, scaly rash has since appeared in the same area—far worse than the original.
There is no history of recent infection or joint pain, or family history of skin disease.
EXAMINATION
Heavy, uniform, white scaling on a salmon-colored base covers the external auditory meatus, extending 3 or 4 mm into the concha. Similar, milder changes are observed in the left ear.
There are scattered pits in three fingernails, white scaling in the scalp above and behind both ears, and faint pink scaly patches on both knees and elbows.
What is the diagnosis?
Psoriasis is extremely common, affecting about 3% of the white population in this country, and is one of a handful of conditions that manifest with the Koebner phenomenon. This means that any trauma (ie, scrapes, burns, scratches, or cuts) can trigger or extend the condition. In this case, the hot wax was likely the culprit.
The patient’s primary care provider, it turns out, was treating the elbow and knee rashes with antifungal creams (to no avail). He hadn’t made the connection between her various skin problems. It was the acute manifestation in the ear that prompted a broader assessment of the patient’s condition—proving the maxim that to find a diagnosis, you have to look for it.
Given its mild nature, this patient’s condition was easily treated with topical steroids and vitamin D-derived cream (calcipotriene). She was advised of the need to avoid exacerbating factors, such as smoking, obesity, excess alcohol intake, and stress.
There is the possibility of the disease worsening despite treatment. The patient also has about a 25% chance of developing psoriatic arthropathy. For these reasons, she will need to be followed by dermatology.
TAKE-HOME LEARNING POINTS
- Psoriasis, though very common, does not always manifest in its typical form.
- Any trauma (ie, burn, scrape, or cut) can trigger preexisting psoriasis, a response called the Koebner phenomenon.
- Several other conditions—including lichen planus, warts, and molluscum—can exhibit this same phenomenon.
- When psoriasis is suspected, potential corroboratory sites of involvement (eg, knees, elbows, nails, and scalp) should be examined. Biopsy is often needed to confirm the diagnosis.
A 15-year-old girl is brought in by her mother for evaluation of a rash that developed following a “candling” treatment she underwent two weeks ago at a beauty spa.
The treatment, which was performed to eliminate scaling in her external ear canal, involved dripping hot wax from a burning candle into the external auditory meatus. The cooled wax was peeled away, along with the attached scaling. A new, asymptomatic, scaly rash has since appeared in the same area—far worse than the original.
There is no history of recent infection or joint pain, or family history of skin disease.
EXAMINATION
Heavy, uniform, white scaling on a salmon-colored base covers the external auditory meatus, extending 3 or 4 mm into the concha. Similar, milder changes are observed in the left ear.
There are scattered pits in three fingernails, white scaling in the scalp above and behind both ears, and faint pink scaly patches on both knees and elbows.
What is the diagnosis?
Psoriasis is extremely common, affecting about 3% of the white population in this country, and is one of a handful of conditions that manifest with the Koebner phenomenon. This means that any trauma (ie, scrapes, burns, scratches, or cuts) can trigger or extend the condition. In this case, the hot wax was likely the culprit.
The patient’s primary care provider, it turns out, was treating the elbow and knee rashes with antifungal creams (to no avail). He hadn’t made the connection between her various skin problems. It was the acute manifestation in the ear that prompted a broader assessment of the patient’s condition—proving the maxim that to find a diagnosis, you have to look for it.
Given its mild nature, this patient’s condition was easily treated with topical steroids and vitamin D-derived cream (calcipotriene). She was advised of the need to avoid exacerbating factors, such as smoking, obesity, excess alcohol intake, and stress.
There is the possibility of the disease worsening despite treatment. The patient also has about a 25% chance of developing psoriatic arthropathy. For these reasons, she will need to be followed by dermatology.
TAKE-HOME LEARNING POINTS
- Psoriasis, though very common, does not always manifest in its typical form.
- Any trauma (ie, burn, scrape, or cut) can trigger preexisting psoriasis, a response called the Koebner phenomenon.
- Several other conditions—including lichen planus, warts, and molluscum—can exhibit this same phenomenon.
- When psoriasis is suspected, potential corroboratory sites of involvement (eg, knees, elbows, nails, and scalp) should be examined. Biopsy is often needed to confirm the diagnosis.