Generalised papules in a 33 yr old man

The patient, a 33-year-old man presented with one month history of severe generalized pruritus over the trunk. There was no fever. He had a history of exposure with CSW several weeks ago. He was otherwise well.

Examination of the skin showed extensive distribution of discrete erythematous papules 1-2mm diameter on the back of the lower trunk, periumbilical area, dorsum of hands, and thighs bilaterally. Excoriations were noted over the papules. There were no ulcers or erosions. Examination of the mouth and genitalia were normal. The lesions spares the face.

HIV screen negative
Hb 16.1gm%
TWBC 11 700 (N70%, L19%, M6%, E5%)
ESR 2 mm/hr
RBS, LFT and renal function normal
VDRL negative

I suspect scabies would be an important diagnosis to consider and exclude. Occasionally prurigo and pruritic papular eruption of HIV can present like this too. A skin biopsy is being contemplated for him. Any thoughts on this patient?

Giant Pompholyx?

A 21 year-old man presented with a one-week history of blisters on his hands and feet. It started on the hands with blisters which later involved the feet as well. The blisters then became bigger into a bulla which remain intact. It was very pruritic. About 3 months ago, he sustained injury to the left ankle which he sought treatment from GPs and traditional practitioners. These did not help and in fact got worse. There was no preceding insect bites or other injury.

Examination of the skin showed numerous vesicles and large bulla (2-3cm diameter)on the palms and soles. The bulla remained intact and did not have an erythematous base. Weepy and exudative eczematous changes were note on the medial malleolus of the right ankle.

Clinically he has severe pompholyx and infected discoid eczema (left ankle).

Swab was sent for culture and was negative. Awaiting IgE level.

He was treated with dil. KMNO4 wash bd, IV hydrocortisone 200mg 6hrly, oral cefuroxime 250mg bd, topical dermovate cream under occlusion (hands/feet) and topical Diprocel ointment (left ankle).

A skin biopsy was done too ( awaiting results). This was done because of the atypical nature of the pompholyx and also to make sure we are not dealing with bullous pemphigoid or epidermolysis bullosa simplex/acquisita.

He had so far responded well to treatment and would be discharged from ward in a day or two.

Unresolved tinea cruris

A 37 year old man was seen for generalised pruritus for a year. He has seen few GPs but the lesions never cleared.

Clinical exam showed large discrete erythematous macules with well defined raised margin on the cervical region and the inguinal area. There was central clearing on the neck lesion.

A bedside KOH preparation showed presence of hyphae.

I find bedside KOH prep to be very useful in practice. Once confirmed, I would treat with either a topical antifungal or an oral antifungal agent. In this case I used oral terbinafine 250mg daily for 2 weeks.

The skin scrappings were also sent for culture. This is important to identify the dermatophyte involved.

I am at the moment doing a small research study on the prevalence of dermatophyte infection in my clinic. The results of this study would be interesting and useful for epidemiology of superficial fungal infection in Perak region.