Case 1Case submitted by Ms Patel and Dr Schleicher. A 54-year-old woman presents to the ED for evaluation of an asymptomatic lesion on her right forearm, which she states developed several weeks before presentation. She has a history of hypertension and thyroid disease, for which she takes several medications (none recently commenced). She admits to ample past sun exposure from living in Florida for 30 years, but denies a history of skin cancer. Examination reveals a well-demarcated, slightly elevated, annular dusky erythematous plaque with scale. No similar lesions are noted elsewhere. A dermatology consult is requested for biopsy. What is your diagnosis?
Case 2Case submitted by Ms Remaly and Dr Schleicher. A 32-year-old woman without a significant medical history presents with a facial eruption of 3 days’ duration. She states that the rash began with swelling and redness on her left eye, at which time she visited a local ED, was diagnosed with cellulitis, and prescribed cephalosporin and a topical antibiotic. The dermatitis, however, continued to intensify to the point where she is now unable to open her eye due to the edema. Patient denies any other discomfort. On physical examination, she is noted to have a well-demarcated dermatitis manifesting clinically as erythema and vesicles. Preauricular and cervical lymph nodes are nonpalpable. What is your diagnosis?
Ms Patel is a second year medical student at the Commonwealth Medical College in Scranton, Pennsylvania. Ms Remaley is a physician assistant at Reading Dermatology Associates in Reading, Pennsylvania. Dr Schleicher, editor of “Diagnosis at a Glance,” is director of the DermDOX Center in Hazleton, Pennsylvania, a clinical instructor of dermatology at King’s College in Wilkes-Barre, Pennsylvania, an associate professor of medicine at the Commonwealth Medical College in Scranton, Pennsylvania, and an adjunct assistant professor of dermatology at the University of Pennsylvania in Philadelphia. He is also a member of the EMERGENCY MEDICINE editorial board.
Answer
Case 1
The histopathology of the punch biopsy revealed a lichenoid actinic keratosis (LAK). The term lichenoid refers to a mixed cell inflammatory infiltrate that involves the dermo-epidermal junction. Actinic or solar keratoses are induced in fair-skinned individuals by cumulative exposure to sunlight and are considered premalignant lesions. The LAK variant occurs as a solitary lesion on the extensor surfaces of the arms and, less commonly, on the face. Not clinically distinctive, LAK may resemble lichen planus or a fixed drug eruption. Subjective symptoms are minimal or absent. As a small percentage of actinic keratoses may evolve into squamous cell carcinomas, eradication is generally recommended. Current surgical and topical treatment options include cryosurgery, curettage (with or without electrosurgery), photodynamic surgery, fluorouracil, diclofenac 3%, imiquimod 5%, and ingenol mebutate.
Case 2
The patient’s symptoms are characteristic of reactivation of varicella-zoster virus (VZV) within dorsal root ganglia, resulting in herpes zoster. Since the eye is affected in up to 50% of cases, involvement of the ophthalmic branches of the trigeminal nerve is a medical emergency requiring aggressive treatment.1 Complications of herpes zoster ophthalmicus (HZO) include iritis, glaucoma, corneal tissue ulcerations, and loss of vision. Sequelae may also include scarring and postherpetic neuralgia. HZO warrants systemic antiviral therapy, which is best commenced within
72 hours of onset.2
References
1. Catron T, Hern HG. Herpes zoster ophthalmicus. West J Emerg Med. 2008;9(3):174-176.
2. Shaikh S, Ta CN. Evaluation and management of herpes zoster ophthalmicus. Am Fam Physician. 2002;66(9):1723-1730.