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Answers by;

O.Zargari, MD

Assistant professor of Dermatology

Case 1:Rosacea
Rosacea is a common disease, especially in individuals who have their roots in northwest Europe and although is commonest in the third to fourth decades, it not uncommonly occurs in both the elderly and the adolescent.

Rhinophyma is a complication of rosacea that is found more commonly in men. It has four variants;1.Glandular form,2.Fibrous form,3.Fibroangiomatous form and 4.Actinic form.

There are many famous peoples with this disease and one of them.!


Case 2: Dupuytren's contracture
This is a fibromatous hyperplasia of the palmar aponeurosis which is characterized by nodular thickening of the fascia with associated flexion contractures of one or more digits.

Palmar fibromatosis is often familial, and may be inherited as an autosomal dominant trait. The associated disorders are; alcoholic cirrhosis, diabetes mellitus,epilepsy,gout,periarthritis of the shoulder, chronic lung disease, trauma , ulnar nerve damage and other fibrosing conditions.Propranolol and phenytoin has been suspected as an inciting agent in the occasional cases. Also there is an association with smoking.

In this patient, family history for similar condition was positive (her mother), but there was no definite associated disorder although she is suffering from breast cancer and is under chemotherapy and radiotherapy at present.

Case 3: Paederus dermatitis
Paederus dermatitis is characterized by vesicles, bullae and sometimes small pustules on an erythematous base with sudden onset of a stinging burning sensation.

It is a peculiar contact dermatitis that occurs after contact with the vesicant chemical contained in the body fluids of three major families of beetles;1.Meloidae, 2.Oedermeridae and 3.Staphylinidae.In the third family (including genus Paederus) the vesicant agent is pederin.

PD is most frequently seen in regions with a hot, tropical climate and reported in many countries including Iran, Turkey,Australia and Malaysia.


Case 4: Juvenile xanthogranuloma
Juvenile xanthogranulomas are benign tumours of histiocytic cells which occur predominantly in infancy and early childhood and spontaneously regress.

JXG is the most common form of nonhistiocytosis X.It has two main clinical forms; The papular form is characterized by numerous lesions and the nodular form which is less frequent and occurs as one or a few lesions.

Juvenile xanthogranuloma has been associated with neurofibromatosis, Niemann-Pick disease, myelogenous leukemia and urticaria pigmentosa.

Case 5: Lepromatous Leprosy
    In lepromatous leprosy (LL) the first clinical manifestations are likely to be dermal and consist of macules, diffuse papules, infiltration or nodules, or all four.

If the patient remains untreated the lines of the forehead become deeper as the skin thickens (leonine facies), and eyebrows and eyelashes become thinned or lost (madarosis) as in this patient.

Case 6: Granuloma Faciale
Granuloma faciale is characterized by one to several soft, erythematous to livid papules, plaques or nodules, usually occurring on the face, although lesions may appear anywhere on the skin. It is a disorder mainly of middle-aged white men, but the disease can be seen at any age and also have been identified in blacks and Orientals.

GF possesses clinical characteristics that are usually distinctive, but sometimes may be confused clinically with sarcoidosis, discoid lupus erythematosus, mycosis fungoides, benign lymphocytic infiltrate of Jessner, leprosy, erythema elevatum diutinum, polymorphous light eruption, lymphoma, fixed drug eruption, pigmented nevi, and granuloma annulare

Case 7: Pyoderma Gangrenosum
Pyoderma gangrenosum (PG) is a rare, destructive inflammatory skin disease in which a painful nodule or pustule breaks down to form a progressively enlarging ulcer with a raised, tender, undermined border. Lesions are most commonly found on the lower legs, but they may occur on anywhere on the skin and present either in the absence of any apparent underlying disorder or in association with systemic diseases such as ulcerative colitis, Crohn's disease, polyarthritis, gammopathy and other conditions.
Case 8: Lichen Striatus
Lichen stiatus is a fairly uncommon eruption that as a rule occurs in children and typically seen in girls but can occur at any age. It manifests itself usually on one of the extremities as either a continous or an interrupted band composed of erythematous papules, which may have a scaly surface. Lesions are usually asymptomatic. Spontaneous involution occurs in several monts but in some cases lasts for years. The differential diagnosis includes lichen planus, nevus unius lateralis, linear porokeratosis and linear Darier's disease.
Case 9: Urticaria Pigmentosa
Urticaria Pigmentosa, although occasionally showing an autosomal dominant mode of transmission, in most instances occurs without a family history. The common age of onset is about 3-9 months and the commonest eruption consists of monomorphic pigmented maculopapular or nodular lesions mainly on the trunk.
Case 10: Granuloma Annulare
Granuloma Annulare (GA) was first described by Colcott Fox in 1985. There are several forms, including localized, generalized, subcutaneous, and perforating types. Localized GA is the most common clinical form. The lesions are characterized by erythematous or flesh-colored papules or plaques in an annular configuration or arrangement and although the disease has the potential to present anywhere on the body, it most commonly involves hands and feet. Diabetes mellitus is the most frequently reported disease associated with GA, particularly the generalized form.
Case 11: Pityriasis Lichenoides Chronica
Pityriasis Lichenoides occurs in two forms that differ in severity. The milder form, called Pityriasis Lichenoides Chronica (PLC) is characterized by recurrent crops of brown-red papules with an adherent-mica like-scale.
Case 12: Bullous Lichen Planus
Bullous Lichen Planus (BLP) is characterized by blistering which arise only on or near to the lesions of LP and have been attributed to severe liquefaction degeneration of the basal layer cell. With immunofluorescence procedures it is possible to distinguish BLP from Lichen Planus Pemphigoides (LPP).
Case 13: Tinea Corporis
Tinea Corporis is ringworm of glabrous skin of the trunk and limbs and all known dermatophytes can produce it. Clinically the site of infection is typically on exposed skin unless the infection represents an extension from a pre-existing infection. Although tinea corporis can masquerade as any of a vast number of skin diseases, in practice the diagnosis is usually straithforward.
Case 14: Cutaneous Leishmaniasis (CL)
CL is widespread throughout of the old world and is a common skin problem in Iran. CL usually affects unclothed parts of the body easily bitten  by the sand fly vector. After an incubation period of 1 week to 3 months, a red papule appear that enlarges to a plaque or nodule. The lesion often develops into an ulcer, which is well circumscribed with a violaceous border.
Case 15: Lichen Amyloidosus (LA)
LA usually presents as a persistent, pruritic papular eruptions on the extensor surfaces of extremities. The individual lesions consist of multiple discrete papules, which are scaly and often pigmented. Papules may coalesce into thickened plaques, which may closely simulate hypertrophic LP or LSC. Treatment is generally disappointing and topical potent steroids, topical retinoic acid, dermabrasion, topical application of 10% DMSO, etretinate and cyclophosphamide are among the possible therapeutic options.
Case 16: Zoster
The typical presentation of zoster is the development of local radicular pain 2 to 3 days before the characteristic eruption occurs, involving one to three contagious dermatomes. The lesions begin as macules and papules, progressing to vesicles that may coalesce to bullae, and subsequently heal with crusting and reepithelialization.
Case 17: Harlequin fetus
Harlequin fetus is a very rare congenital anomaly which present with a grotesque appearance because of the massive, plate like scales that distort facial features. Severe ectropion and eclabion are present, and hands may be deformed by mitten-like skin encasements. Affected infants usually die in the first few weeks of the life.
Case 18: Congenital Melanocytic Nevus (CMN)
The diagnosis of CMN is usually straight forward. These nevi have been arbitrarily divided into three size ranges; small lesions with diameter less than 1.5 cm, intermediate-sized with diameter between 1.5 and 20 cm and giant lesions with diameter of over 20 cm. The main important problem with these nevi is the potential for malignant changes and the resulting need for prophylactic removal.
Case 19: Keratoacanthoma (KA)
KA is a relatively common skin tumor composed of keratinizing squamous cells originating in pilosebaceous follicles. Males are affected about three times as often as females. the main problem in diagnosis is to distinguish KA from SCC. The more rapid evolution to relatively large size, the regular crateriform shape and keratotic plug, the undamaged surrounding skin and the younger age of onset help to make a distinction for a dermatologist.
Case 20: Bullous Mastocytosis
Mastocytosis comprises a heterogenous spectrum of clinical disorders with a common phenotype of mast cell hyperplasia in one or more organs. Approximately 55% of mastocytosis patients develop their disease by 2 years of age. This disorder seems to be equally distributed between males and females and has been reported in all races. Skin lesions in mastocytosis are usually present in patients with indolent disease. Some infants and children with mastocytosis may develop recurrent nonscarring vesicles or bullae. Usually, blister developement resolves by 3 to 5 years of age.In this case histopathological evaluation confirmed the diagnosis of Bullous Mastocytosis, which was similar to the diagnosis made in her neonatal period in another center. So, this case is an interesting case of BM in a 9 years of age.
Case 21: Allergic Contact Dermatitis (ACD)
The severity and clinical picture of ACD is determined by the intensity of the exposure, the level of sensitivity, the anatomic site and on the causative agent. Eruptions caused by fragrances, biocides and amphoteric detergents in hair cosmetics and shampoos are usually limited to the glabrous skin of the ear, neck and face, but may be preceded by persistent itching of the scalp. Hair dyes still remain the most important source of dermatitis and this patient is a typical case of dermatitis secondary to contact with a hair dye.
Case 22: Acanthosis Nigricans (AN)
AN is characterized by hyperkeratosis and pigmentation, and the affected skin is covered by papillomatous elevations which give it a velvety texture. Inherited, Endocrine, Idiopathic and malignant types of AN are the main types of the diseases. Histologic picture is the same in all types.
Case 23: Kaposi's Sarcoma (KS)
Kaposi's sarcoma is a multifocal neoplastic process, arising from both vascular and lymphatic endothelium. Kaposi's sarcoma can be divided into four subsections; 1. sporadic, 2. Endemic, 3. HIV related and 4. Non-HIV immunosuppression related. Clinically the lesions can generally be divided into patch, plaque and nodular stages.
Case 24: Orf
Orf is caused by a parapoxvirus and clinically is found in persons who have contact with sheep and cattle, on farms or in the meat trade. Lesions are generally solitary and start as an erythematous papule that subsequentely develops a white halo, becomes nodular and may ulcerate. In the absence of a history diagnoses such as pyogenic granuloma, atypical mycobacterial infection, malignant melanoma, Kaposi's sarcoma and eccrine poroma must be considered.
Case 25: Discoid Lupus Erythematosus (DLE)
Discoid Lupus Erythematosus (DLE) is characterized by various-sized, reddish, well-defined, scaly patches which tend to heal with atrophy, scarring and hyperpigmentation and usually involving the face. The onset of the lesions may be precipitated by a variety of factors including trauma, sun exposure, mental stress and infections.

Case 26: Darier's Disease( Keratosis Follicularis)

Darier's disease is an autosomal dominant trait with an estimated incidence of 1:100,000. An abnormal  gene on chromosome 12 has been identified and the disorder appears to be fully penetrant. It is usually appears in the teens as in this case, but delayed onset is not infrequent. Clinical manifestations include kertotic papules in a seborrheic distribution, palmar pits and nail changes in the form of nail fragility, longitudinal white and red streaks, V-shaped notches at the free edge, and subungual hyperkeratosis.Oral retinoids work well in this disease, although to avoid long-term toxicities, patient should receive the lowest dose. Sun protection should be encouraged for all patients because the disease can be triggered by UVB.
Case 27: Malignant melanoma (MM)
Malignant melanoma (MM) is a malignant tumor arising from the epidermal melanocytes. Clinical variants are Superficial spreading melanoma (SSM), nodular melanoma (NM), acral lentiginous melanoma (ALM) and lentigo maligna melanom (LMM). Although MM in Asia, is not as common as in western countries, but it should always be considered especially in the differential diagnosis of tumoral  lesions affecting palmoplantar areas.
Case 28: Ophthalmic Zoster
Herpetic rash on the tip and side of the nose is an important clue in ophthalmic zoster. This sign means that nasociliary branch is involved and a careful attention should be given to the condition of the eye in such cases.
Case 29: Steatocystoma Multiplex
The steatocystoma is the only cyst that actually contains sebaceous cells or lobules in its lining. The steatocystoma can occur singularly(simplex) but most often occurs as a multiple lesion complex known as steatocystoma multiplex. They are first noted around the time of puberty and rarely become inflamed or infected. CO2 laser, incision and drainage, cryosurgery, and electrocautery have all been reported successful in the treatment of SM.
Case 30: Metastatic carcinoma of the skin
Skin metastases are generally uncommon but have been reported more frequently in recent years. They are usually late events in the course of internal malignancy. Breast carcinoma in women and lung carcinoma in men are the most frequent internal malignancy with cutaneous metastases. This patient was a known case of laryngeal carcinoma and skin biopsy revealed a metastatic squamous cell carcinoma.
Case 31: Anthrax

Anthrax is a zoonotic disease caused by Bacillus anthracis and may be transmitted to humans by inoculation, inhalation, or ingestion. By far the most common route of infection is through skin and cutaneous anthrax is relatively common problem in Iran and middle east. The lesion of cutaneous anthrax commonly occurs on exposed skin and is usually single. After a common period of 1-5 days, an irritable papule develops at the site of inoculation and a bulla on a red edematous base soon follows. Lack of pain and localized edema are among the diagnostic clues for anthrax. Treatment should start immediately with penicillin G.

Case 32: Erythema Ab Igne (EAI)

EAI is a reticular, telangiectatic, pigmented dermatosis occurring after long-term exposure to infrared radiation that is insufficient to produce a burn. Historically, EAI was commonly seen on the shins of those who worked in front of open fires or coral stoves. This man was an interesting case of EAI confined to the left buttock. History taking revealed that in his office, he habitually works with his left posterior in close contact with a heater source. Recently an unusual case of EAI induced by a laptop computer reported by Bilic. (JAAD June 2004).

Case 33: Gianotti-Crosti syndrome

Gianotti-Crosti syndrome is a reactive cutaneous response to many infections such as Hepatitis B virus, Hepatitis A virus, Coxackie A, respiratory syncytial virus, EBV, rotavirus and BCG vaccination.

Gianotti-Crosti syndrome characterized by a monomorphus eruption of flat, nonpruritic, erythematous 1-5 mm papules suddenly erupting symmetrically over the face, buttocks and limbs.

In DDx papular pytiriasis rosea, acute lichen planus and drug eruption must be considered.

Case 34: Trichoepithelioma (Epithelioma Adenoides Cysticum)
Multiple trichoepithelioma is transmitted as an autosomal dominant trait. It usually appears in childhood and gradually increase in number. Nasolabial folds are main site of involvement.
Case 35: Nickel Dermatitis
Nickel metal is a common allergen present in various alloys, earings, watches, buttons, zippers, rings, batteries, coins, keys, door handles etc.

Dimethylglyoxime 1% can easily detect nickel in the suspected materials.

The clinical spectrum of the reaction pattern to nickel sensitivity is variable. Mostly, the problem is confined to a couple of sites where cheap metal is worn as like as this patient in wrist from watch strap. Eyelid dermatitis, lip dermatitis and hand dermatitis are among the other clinical presentations of nickel sensitivity.