Alright, think we're ready for case number 2.
So this is a 33-yr old real estate agent
with well-controlled type 1 diabetes,
presents with a rash on her chest, looks like we
can also see that it's up on her neck and face.
She states that the rash developed during
her recent 10-day vacation in Puerto Rico
good for her!
and hasn't gone away despite applying
an aloe-based lotion.
People use all kinds of stuff to self medicate.
She's been using that everyday.
It's not itchy, family history's not
contributory, her vital signs are all good
What we find on exam is multiple,
scaly, hypopigmented macules
scattered along her upper chest,
her neck and we can see them very clearly on her face,
coalescing into some large patches.
No vesicles, and no pustules.
Alright, so which of the following
is the most likely to diagnosis?
We've got pityriasis rosea, seborrheic dermatitis,
tinea versicolor again, vitiligo, and candida intertrigo.
So, what do you remember about pityriasis rosea?
Feel free to pause the screen.
Alright, things that should come to mind immediately
with pityriasis rosea are that it is non-infectious,
though accompanied by some viral URI symptoms.
Don't forget about the herald patch which can
precede the rest of the lesions by a few days.
The lesions you'll ultimately see are oval in shape, scaly,
itchy maculopapules distributed in that Christmas tree pattern
So let's think about that in our particular patient.
So we're not getting a story of a herald patch.
That being said, she does have multiple lesions of varying sizes
and shapes scattered on her upper chest and probably on her back.
but these lesions are hypopigmented rather than
erythematous which is what we'd see with pityriasis rosea.
They're not itchy and she didn't describe any viral
URI prodrome so I'm thinking that one's off our list,
Next up, seborrheic dermatitis.
Now when you hear seborrheic dermatitis,
you may often think of 'cradle cap' associated with infants.
Which we'll get to in a moment.
So Seb Derm is a chronic, relapsing, mild dermatitis.
It's of unknown etiology,
we don't know exactly what causes it
though there is this association with Malassezia furfur.
And as I mentioned, cradle cap occurs in infants
but you'll oftentimes see it in the elderly as well
and it can actually be quite severe in folks with HIV.
It's gonna be appearing on the
scalp, behind the ear, the eyebrows,
the blephara, nasolabial folds,
and potentially on the upper chest and back.
These lesions are scaly, flaky, and one of the classic
descriptive terms you'll see is 'greasy-looking' plaques.
So, these lesions may be in the right location,
somewhere on the face, somewhere on the upper chest
but she really is the wrong demographic for it.
She's a woman on her 30's and the appearance isn't
quite right, we're not seeing these greasy plaques.
It'd be very atypical to have such a
wide distribution on the upper chest
and not much of other locations so I think we
can safely take this one off the list as well.
Alright, another quick review.
Again, feel free to pause this screen.
What do you remember about tinea versicolor?
Okay, hopefully you came up with
hyper or hypopigmented patches.
Hopefully you remember that there's scale involved
that may be worsened by going to tropical climates.
And the organism that's the culprit
microbe is Malassezia globosa
So, I think we're gonna have to keep this one on the list
simply by virtue of its association with hypopigmented patches