Bullous Impetigo: A Mimicker of Immune-mediated Dermatoses.

The differential diagnosis of vesiculobullous lesions can be intimidating to the primary care provider. While some entities such as bullous impetigo may easily be diagnosed clinically if the patient's demographics as well as the lesion morphology and distribution present classically, atypical presentations may require additional laboratory studies for confirmation. We describe a case of bullous impetigo with characteristics that clinically mimicked two rare immunobullous dermatoses. Although extensive diagnostic testing was performed, we recommend an approach for primary care providers to initiate empiric treatment while maintaining awareness of less common immunobullous entities.

Doctor in a bottle: examining the increase in essential oil use.

In recent years there has been a push for more natural medicine, attributed to the rise of the Internet and easy accessibility to information and misinformation. Unfounded claims leading to the antivaccination and anti-Big Pharma movements have caused patients to seek control over their own health care. Simple ingredient names and lack of larger "scary-sounding" chemicals also have attributed to this shift. The perceived benefits of essential oils are the lack of a prescription needed to obtain them and the guise that natural is better for the body. The dangers in these thought processes are the lack of prescriber supervision and the many natural chemicals that can be toxic to humans whether consumed or topically applied. However, recent interest in some of these ancient medicines has prompted research into unfounded health claims and has unearthed some potential for legitimacy and future treatment options.

A fluorescing spot on the temple: a helpful reminder for a detailed history and physical exam.

We discuss a woman with a history of non-melanoma skin cancer who presented with a new erythematous macule on her right temple. On examination with Wood lamp the well-demarcated macule fluoresced pink making neoplasm unlikely. Further history and physical examination suggested an inadvertent ink stain and the patient was spared a biopsy highlighting the importance of eliciting a good history and performing a detailed physical examination with additional tools such as a Wood lamp when necessary.

Segmental distribution of nodules on trunk.

A 70-year-old Caucasian man presented with a longstanding history of numerous nontender, fleshy, skin-colored papules on his trunk, ranging from 3 to 8 mm in size. They were noted incidentally during an examination of unrelated nonhealing lesions on the patient's left cheek. He said the lesions on his trunk first appeared when he was 28 years old and had continued to grow in size and number. The patient said his son had at least one similar lesion on his upper back, but otherwise there was no family history of these lesions. A biopsy was performed on one of the nodules. WHAT IS YOUR DIAGNOSIS? HOW WOULD YOU TREAT THIS PATIENT?

Linear atrophy and vascular fragility following ultrasoundguided triamcinolone injection for DeQuervain tendonitis.

A 64 year-old woman presented with a one-yearhistory of purpuric, atrophic, linear patches alongthe left lateral forearm. The patient had receivedtwo ultrasound-guided triamcinolone injectionsone year earlier into her left extensor pollicis brevisand abductor pollicis longus tendon sheathsfor DeQuervain tendonitis. In the seven monthsfollowing the second injection, the patient developedatrophy, purpura, and telangiectasias starting at thesite of injection and extending proximally, followingthe course of her left cephalic vein. The patient wastreated initially with amlactin and moisturizing creamcontaining alpha-hydroxy acid cream to aid in dermalrepair. Despite treatment, she continued to haveproximal progression of the atrophy and purpura.A 4mm punch biopsy revealed a normal-appearingepidermis overlying horizontal dermal fibrosis, alongwith atrophic-appearing adipocytes with accentuatedcapillaries in the subcutaneous fat, consistent witha diagnosis of corticosteroid atrophy. These grossand microscopic changes presumably resulted fromlymphatic uptake and spread of the corticosteroidfollowing the injections for tendonitis. Although localatrophy and vascular fragility are well-documentedside effects of corticosteroid injections, linear spreadof these symptoms is rarely reported, and to this pointhas not been demonstrated in the literature followingultrasound-guided steroid injection for DeQuervaintendonitis.