Challenging Cases in Dermatology Volume 2 Advanced Diagnoses and Management Tactics Mohammad Ali El-Darouti

Challenging Cases in Dermatology
Volume 2 Advanced Diagnoses and

Management Tactics Mohammad Ali
El-Darouti
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Mohammad Ali El-Darouti
Faiza Mohamed Al-Ali
Challenging Cases in
Dermatology Volume 2
Advanced Diagnoses
and Management Tactics
123
Challenging Cases in Dermatology Volume 2
Mohammad Ali El-Darouti • Faiza Mohamed Al-Ali
Challenging Cases in
Dermatology Volume 2
Advanced Diagnoses and Management
Tactics
Mohammad Ali El-Darouti Faiza Mohamed Al-Ali
Faculty of Medicine Dubai Health Authority
Cairo University Rashid Hospital
Cairo Dubai
Egypt United Arab Emirates
ISBN 978-3-030-21854-6 ISBN 978-3-030-21855-3 (eBook)

https://doi.org/10.1007/978-3-030-21855-3
© Springer Nature Switzerland AG 2019

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is
concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction
on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation,
computer software, or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not
imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and
regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed
to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty,
expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been
made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
To our patients, who trusted us to be part of their journey.
Preface
Once again, similar to the book published in 2014, in this second volume of Challenging Cases
in Dermatology, you will be challenged with a new collection of unusual cases laid out in 72
chapters. The journey of each chapter starts with the clinical data that leads to a list of thor-
oughly discussed differential diagnoses. Each case is then meticulously studied with succinct
clinical, radiological, and lab investigations, as well as histological information that will boost
your diagnostic skills. The chapter titles are self descriptive. The diagnosis is only revealed at
the end of the exploring pathway, after which the management is elucidated. None of the cases
are straightforward, classic, or ordinary. Some are so rare that they have been reported only
once. Others are combined with features that have never been reported in the literature. Indeed,
you may hardly encounter such cases throughout your professional career. Nevertheless, this
book focuses on the strategic way of thinking, analyzing data, and utilizing all resources to
arrive at a diagnosis. It is all about developing advanced diagnostic and management tactics.
Mark Twain once said, “If you eat a frog first thing in the morning, that will probably be the
worst thing you do all day.”
Tackling such cases makes your ability to handle daily dermatologic cases an easy task.
We hope you will have a thrilling, fruitful, and extraordinary journey through each
chapter.
Cairo, Egypt Mohammad Ali El-Darouti

Dubai, UAE Faiza Mohamed Al-Ali
vii
Acknowledgments
First and foremost, praise and thanks to the Almighty, for His showers of blessings that have
given us the ability and knowledge to have this work completed successfully. Indeed, writing
a book is harder than we thought, even if it is the second volume of an already published book.
Nevertheless, it is more rewarding than we could have ever imagined.
To our colleague doctors and residents, Ahmed Mourad, Dina El-Antably, Hagar El-Sayed,
and Mona Korany, we cannot express enough thanks for your contribution. Your efforts are
greatly appreciated and sincerely valued.
A special gratitude to our editors in Springer; your insightful feedback and support through-
out this project was invaluable.
Mohammad Ali El-Darouti & Faiza Mohamed Al-Ali
ix
Contents
Part I Atrophic Skin
1 Neck Scarring, with Defects of Ears and Eyes�� 3

Clinical Data�� 3
Differential Diagnosis�� 4
Investigations �� 4
Biopsy Findings �� 4
Based on the Following Findings�� 4
About the Diagnosis�� 5
Definition �� 5
Epidemiology�� 5
Pathogenesis and Etiology �� 5
Clinical Features�� 5
Histological Features �� 5
Definite Diagnosis�� 5
Treatment �� 5
Management of This Case�� 6
Message�� 6
Bibliography�� 6
2 Loss of Subcutaneous Fat, Muscle Hypertrophy,
Diabetes and Hyperlipidemia�� 7
Definition �� 7
Prognosis�� 10
Treatment �� 10
Message�� 11
xi
xii Contents
3 A Congenital Oval Plaque �� 13

Tips�� 15
Definition �� 16
Tips�� 16
Prognosis�� 17
Treatment �� 17
Message�� 17
4 A Newborn with Scalp Defect and Terminal Limbs Anomalies�� 19
Prognosis�� 24
Treatment �� 24
Message�� 25
Part II Blistering eDisorders
5 Anhidrosis, Atrophic Skin, Dystrophic Teeth, with Blister Formation �� 29

Clinical Data (Case-1)�� 29
Contents xiii

Prognosis�� 35
Treatment �� 35
Management of These Cases�� 35
Message�� 35
6 An Oral Hemorrhagic Blister That Heals Spontaneously�� 37
Tips�� 39
Prognosis�� 40
Treatment �� 40
Message�� 41
7 A Baby with Yellowish Erythematous Plaque and Bullae�� 43
Prognosis�� 46
Treatment �� 46
xiv Contents

Message�� 46
8 Oral Ulceration and Skin Eruption After a High Dose of MTX�� 49
Prognosis�� 53
Treatment �� 53
Message�� 55
9 Livedo Reticularis Associated with Ulceration�� 57
Pathogenesis and Aetiology �� 59
Tips�� 60
Difinite Diagnosis�� 60
Prognosis�� 61
Treatment �� 61
Message�� 62
Part III Diseases Predominantly Affecting One Side the Body
10 A Child with Hemihypertrophy, Omphalocele, and Organomegaly�� 67

Contents xv

Prognosis�� 72
Treatment �� 72
Message�� 72
11 Unilateral Scaly Erythema and Limb Dystrophy �� 75
Prognosis�� 81
Treatment �� 81
Message�� 81
12 A Newborn with Giant Cerebriform Mass and Multiple Nevi�� 83
Prognosis�� 87
xvi Contents
Treatment �� 87

Message�� 87
Part IV Erythematous Eruptions
13 Acrodermatitis Enteropathica-Like Eruption with

Neurological Symptoms�� 91
Clinical Data – Case 1�� 91
Clinical Data – Case 2�� 91
Tips�� 93
Prognosis�� 96
Treatment �� 96
Message�� 97
14 Annular Erythema Proved to Be an Unusual Disorder�� 99
Prognosis�� 103
Treatment �� 104
Message�� 106
15 Itchy Erythematous Rash with Lymphadenopathy�� 107
Contents xvii

Prognosis�� 114
Message�� 114
16 Persistent Pityriasiform Eruption�� 117
Tips�� 118
Prognosis�� 121
Message�� 122
17 Periodic Fever with Skin Rash and Arthritis�� 123
xviii Contents

Prognosis�� 126
Message�� 127
18 A Self-Limited Unilateral Exanthem �� 129
Tips�� 129
Prognosis�� 133
Message�� 133
19 Periorificial and Acral Erythema in a Patient with Nephrotic Syndrome�� 135
Tip�� 138
Tip�� 139
Prognosis�� 140
Message�� 142
Contents xix
Part V Hair Disorders
20 Ectodermal Dysplasia with Cleft Palate and Ankyloblepharon�� 147

Prognosis�� 152
Message�� 152
21 Hypoplastic Clavicles with Alopecia�� 155
Prognosis�� 159
Message�� 159
22 Malformation of Hair, Nose, and Phalanges�� 161
Contents xxxi

Tip�� 367
Prognosis�� 367
Message�� 368
49 Resistant Subcutaneous Swellings, in a Healthy Adolescent�� 369
Tip�� 374
Prognosis�� 375
Message�� 375
50 A Child with a Disfiguring Rhinofacial Lesion �� 377
Prognosis�� 381
Message�� 382
xxxii Contents
51 A Slowly Growing Erythematous Plaque�� 385

Tip�� 385
Prognosis�� 388
Message�� 388
Part XII Scaly and Ichthyotic Disorders
52 Generalized Spontaneous Skin Peeling�� 393

Tip: Common Features in the Four Cases�� 393
Prognosis�� 401
Message�� 401
53 Ichthyosis in a Child with Organomegaly�� 403
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Lawn Benches Made from Old Bedsteads
Painted Green, These Rebuilt Bedsteads Served as Lawn Benches
Old bedsteads were converted into serviceable lawn, or porch,

benches, as shown in the photograph reproduced, by the addition of
a suitable seat, properly supported. The transformation was a simple
one. Only the foot and headpieces of the bedsteads were used. The
front legs and other pieces were made from other wood. The front
legs are of square stock, about 2¹⁄₂ by 2¹⁄₂ in. The crosspieces,
supporting the wide board seats, are mortised into the legs and
fastened with glue and screws. The seat is fastened from the under
side by cleats. The lumber was carefully planed and sandpapered so
that the benches presented a smooth finish when painted green, to
match other outdoor furniture.—F. E. Tuck, Nevada City, Calif.
Repairing Wood-Wind Instruments
Wood-wind instruments sometimes “leak” at the joints or keys and
make playing of the instrument difficult. Many such instruments are
made in sections, with ends that telescope to form a tight fit. This fit
is maintained by the use of a cork band cemented around the tenon
end of the telescoping joint. The renewal of these cork joints, and the
addition of new pads on the keys, will make an old instrument nearly
as good as it was when new, so far as playing is concerned,
provided the work is correctly done and the wood of the sections
themselves has not cracked. Many musicians have spare time and
can do this work themselves. The outlay for materials for the job is
from 75 cents to $1.00. A small alcohol, or even a kerosene, lamp
and an old knife, or old file, are required.
The Cork is Fitted Carefully into Place, and Glued
All traces of the old cork on the joint can be removed with
sandpaper, leaving it as shown at the left. The cork comes in strips
of about the proper thickness, and wide and long enough to allow for
trimming. The ends of the strip should be beveled to make a ¹⁄₄-in.
lap joint.
A small quantity of the cement is heated over the lamp and six
drops poured on the joint; then with the end of the file, which should
be heated also, it is spread to give an even, thin coating. The
beveled ends of the strip are similarly treated. By working quickly
and carefully, the coating on the joint and strip are brought to a
plastic state by holding in the flame, and the strip is quickly laid in
place. Before the cement has time to harden, press the cork in,
forming a neat joint. Bind a rag around the cork, leaving it until the
cement is thoroughly set.
The corked joint will be too large to go into the joining section of
the instrument. File and sandpaper it to a twisting fit. Though the
cork should be truly cylindrical, it may be tapered a trifle smaller at
the forward end. A coating of tallow applied to the joint will make it
easy-fitting, but air-tight and moisture-proof.
The pads are disks of felt incased in thin sheepskin. After long
usage, they become too hard to make an air-tight fit. Repadding
should, therefore, be anticipated. Shellac will give good results in
putting on pads. It is heated until liquid and poured into the key
recess. The new pad is pressed into the liquid shellac, care being
taken to have it well centered. For different keys, it will be necessary
to use varying quantities of shellac to make the pad sit higher or
lower, as required.—Donald A. Hampson, Middletown, N. Y.
¶A simple method of bracing a screen door is to stretch a stout wire

diagonally across the lower portion of it.
Rustic Trellis to Shade Door or Window
Rustic Trellises are Easily Constructed and When Covered with Vines Add
to the Attractiveness of the Home
Proper preparation in the early spring will make it possible for the
householder to shade doors and windows from the hot summer’s
sun by means of inexpensive rustic trellises that add not a little to the
beauty of the home. A suggestion for a trellis at a doorway and one
for a window are shown in the illustration. They are made of straight
tree trunks and small limbs, having the bark on them. The curved
portions of the window trellis may be made easily by using twigs that
are somewhat green. Morning-glories, or other suitable climbing
plants, may be trained over the trellises.—J. G. Allshouse,
Avonmore, Pa.
Making Scale Enlargements with a Rubber Band
For reducing or enlarging maps, and similar drawings of irregular
design, the device shown in the illustration will replace the ordinary
instruments, and enable the draftsman to turn out a given amount of
work in much less time than required when proportional dividers are
used. The materials needed are an eraser, a rubber band, two pins,
two thumb tacks, and a few drops of rubber cement. From the eraser
two pieces are cut, as shown in the sketch, about ¹⁄₄ by ¹⁄₂ by 1¹⁄₄ in.
Cut deep slits in each end of these pieces. Insert the end of the
rubber band, cut at the splice, in one of these slits and place a thumb
tack in the other. A pin is thrust through the eraser and trimmed
close, to prevent the thumb tack from tearing the eraser. Cement the
slits with rubber cement, and place the assembled device under a
book weight, until the cement has set.
This Simple Device Is Useful in Enlarging or Reducing Drawings and Maps
Assuming that a contour map is to be enlarged, the rectangular

divisions of the original map, ordinarily section lines or the
boundaries of quarter sections, are drawn on the larger sheet as a
base for the reproduction. Place the device on the original map, as
indicated, the edge of the rubber band touching a “horizontal” section
line between two “vertical” ones, the rubber band under slight
tension. On the black surface of the band, dot white points, with
water color, along the section line at which the contour lines intersect
it. Also place a dot at each end of the band to indicate the position of
the two “vertical” section lines between which the band is set.
Transfer the device to the same relative position on the
enlargement, stretching the rubber band. Make dots at each end,
denoting the “vertical” section lines, for the corresponding lines on
the enlargement. The series of intermediate points along the band
will be in the same relative position on the enlargement as they were
on the original. They can be connected on the enlargement with as
accurate a result as obtained by the use of proportional dividers, and
more rapidly.
After the points are indicated upon the enlargement, the
reproducing device is removed and the surface of the rubber band
cleaned instantly by touching it with a moist cloth. The exposed part
of the rubber band is a variable, and the device can be made with
this dimension adapted to the work. It is capable of enlarging or
reducing at a ratio not greater than six to one, above which the
rubber band approaches its elastic limit.—H. L. Wiley, Seattle, Wash.
Signal Telegraph with Green and Red Lights
By arranging a circuit with batteries, lights, and keys, as shown in

the diagram, a signal telegraph may be made that will afford much
pleasure to boys and may be used for practical purposes. The keys
A and B are wired into the circuit with a battery C and a red and a
green incandescent lamp. A simple set of signals may be devised
easily so that messages may be sent in the code.—James R.
Townsend, Itasca, Texas.
A Circular Swing
By DAVIS FOSS GETCHELL
W hile on the farm I constructed a circular swing which proved very

attractive to my boys and their friends. By its side, and
suspended from the same tree branch, was an ordinary swing.
During the eight weeks of our stay the latter was seldom in use. The
circular swing was a far greater favorite with all the young people,
boys and girls alike.
Around a branch of a large elm and 18 or 20 ft. from the tree trunk
was looped a 10-ft. length of chain and to the hanging end of this
was made fast a 1-in. rope nearly 10 ft. longer than was needed to
reach the ground. Directly beneath the point where the chain went
around the limb, as determined by a plumb bob, was set a 6-in.
piece of cedar post 3¹⁄₂ ft. into the ground. This was sawed off
square 2¹⁄₂ ft. above the ground. Into the top of this post was set a
¹⁄₂-in. rod, to serve as a pivot for the swing. It was set in firmly about
6 in. and projected about 3 in. from the top of the post.
The Circular Swing will be Found Very Safe and Pleasurable, but, as is the
Case of an Ordinary Swing, Anyone Careless Enough to Get in the Way of It
will Get Badly Bumped
A straight-grained piece of pine board, 15 ft. long, 8 in. wide, and 1

in. thick, was procured and a hole bored in one end large enough to
make it turn freely on the pin in the upper end of the post. Two holes
were bored in the other end of the board large enough to admit the
rope. The first hole was 6 in. from the end, and the second hole, 3 ft.
The hanging end of the rope was passed down through one of these
holes and back up through the other and then made fast to itself
about 3 ft. above the board after the board had been adjusted so that
it would swing throughout its length at the height of the post, or 2¹⁄₂
ft. from the ground. The swing was then complete except for a
swivel, which was put in the rope within easy reach of one standing
on the board, so that it could be oiled.
One good push would send the board with a boy on the end three
or four times about the 90-ft. circle. The little fellows would like to get
hold of the board in near the post and shove it around. Once started,
it could be kept going with very little effort.
In putting up such a swing, make sure to have the post set solidly
in the ground, as it has a tendency to work loose. Tie all the knots
tightly. Do not look upon the swivel as unnecessary. The first swing I
put up was without one, and the rope twisted off in a few days.
It is not necessary to climb a tree; just throw a stout cord over the
limb by means of a stone or nut tied to the end, then haul the rope
and chain up over the limb with the cord. Before the chain leaves the
ground loop the end of it and pass the cord through the loop. The
higher the limb from the ground the better the swing will work, but 25
ft. will be about right.
Hand-Operated Motorboat Whistle
Bellows Operated by Hand for Blowing a Whistle on a Power Boat
Anyone with a power boat can construct a blower for the whistle
very cheaply. The whistle is attached to a suitable length of pipe,
threaded on each end. The blower is made of two white-pine boards,
1 in. thick, cut as shown at A; a thin piece of leather is cut like the
pattern B, to form the bellows part, and after it is shaped, the edges
of the boards are glued and the leather placed in position, where it is
fastened with tacks driven in about 1 in. apart. The bellows are
fastened to the under side of a seat with screws, and a tension
spring is attached to the bottom of the bellows and the floor of the
boat. A cord is fastened to the lower board of the bellows and run up
through to the cabin roof over suitable pulleys to a handle within
convenient reach of the operator.—Contributed by John I. Somers,
Pleasantville, N. J.
Filling In Broken Places on Enamel
Ordinary putty will not do to fill in cracks or broken spots on an
enameled surface, such as a clockface. Fine sealing wax is much
better, as it hardens at once, takes color without absorbing the oil,
and does not shrink like putty. Use a wax of the proper color to
match the surface as closely as possible. Fit it in and smooth with a
warm, flexible piece of metal, such as a palette knife. Give it one or
two coats of thin color to exactly match the other surface, and
varnish. If the article has not a high polish, the gloss of the varnish
can be cut a little with pumice stone.
A Twisting Thriller Merry-Go-Round
By R. E. EDWARDS
“Stepdime!”
right up; three twisting thrillers for a penny—a tenth of a
was the familiar invitation which attracted customers to
the delights of a homemade merry-go-round of novel design. The
patrons were not disappointed, but came back for more. The power
for the whirling thriller is produced by the heavy, twisted rope,
suspended from the limb of a tree, or other suitable support. The
rope is cranked up by means of the notched disk A, grasped at the
handle B, the car being lifted off. The thriller is stopped when the
brakeplate I rests on the weighted box L.
The Supporting Ropes are Wound Up at the Disk A, the Car is Hooked into
Place, and the Passengers Take Their Seats for a Thrilling Ride, Until the
Brakeplate I Rests on the Box
Manila rope, ³⁄₄ in. or more in diameter, is used for the support,
and is rigged with a spreader, about 2 ft. long, at the top, as shown.
The disk is built up of wood, as detailed, and notches, C, provided
for the ropes. The rope is wound up and the car is suspended from it
by the hook, which should be strong, and deep enough so that it
cannot slip out, as indicated at H.
The car is made of a section of 2 by 4-in stuff, D, 10 ft. long, to
which braces, E, of 1 by 4-in. stuff are fastened with nails or screws.
The upper ends of the pieces E are blocked up with the centerpiece
F, nailed securely, and the wire link G is fastened through the joint.
The seats J are suspended at the ends of the 2 by 4-in. bar, with
their inner ends lower, as shown, to give a better seating when the
thriller is in action. The seats are supported by rope or strap-iron
brackets, K, set 15 in. apart. The box should be high enough so that
the seats do not strike the ground.

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Challenging Cases in Dermatology

Volume 2 Advanced Diagnoses and

Moriello's Small Animal Dermatology, Volume 1 -

Harper's Textbook of Pediatric Dermatology 2 Volume Set

Challenging Concepts in Respiratory Medicine: Cases

Environmental Stresses in Soybean Production Soybean

Harper s Textbook of Pediatric Dermatology 2 Volume Set

Thoracic Surgery: 50 Challenging cases 1st Edition

Diabetes and Retinopathy: Computer-Assisted Diagnosis

Challenging Concepts in Oral and Maxillofacial Surgery:

ISBN 978-3-030-21854-6 ISBN 978-3-030-21855-3 (eBook)

© Springer Nature Switzerland AG 2019

Cairo, Egypt Mohammad Ali El-Darouti

Mohammad Ali El-Darouti & Faiza Mohamed Al-Ali

Part I Atrophic Skin

1 Neck Scarring, with Defects of Ears and Eyes��������������������������������������������������������� 3

Part II Blistering eDisorders

5 Anhidrosis, Atrophic Skin, Dystrophic Teeth, with Blister Formation ����������������� 29

Management of This Case�������������������������������������������������������������������������������������� 46

Part III Diseases Predominantly Affecting One Side the Body

10 A Child with Hemihypertrophy, Omphalocele, and Organomegaly��������������������� 67

Based on the Following Findings������������������������������������������������������������������������������� 70

Part IV Erythematous Eruptions

13 Acrodermatitis Enteropathica-Like Eruption with

Part V Hair Disorders

20 Ectodermal Dysplasia with Cleft Palate and Ankyloblepharon����������������������������� 147

51 A Slowly Growing Erythematous Plaque����������������������������������������������������������������� 385

Part XII Scaly and Ichthyotic Disorders

52 Generalized Spontaneous Skin Peeling��������������������������������������������������������������������� 393

Painted Green, These Rebuilt Bedsteads Served as Lawn Benches

Old bedsteads were converted into serviceable lawn, or porch,

The Cork is Fitted Carefully into Place, and Glued

¶A simple method of bracing a screen door is to stretch a stout wire

Assuming that a contour map is to be enlarged, the rectangular

By arranging a circuit with batteries, lights, and keys, as shown in

W hile on the farm I constructed a circular swing which proved very

A straight-grained piece of pine board, 15 ft. long, 8 in. wide, and 1

Bellows Operated by Hand for Blowing a Whistle on a Power Boat

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Cairo, Egypt Mohammad Ali El-Darouti

Part I Atrophic Skin

1 Neck Scarring, with Defects of Ears and Eyes�� 3

Part II Blistering eDisorders

5 Anhidrosis, Atrophic Skin, Dystrophic Teeth, with Blister Formation �� 29

Management of This Case�� 46

Part III Diseases Predominantly Affecting One Side the Body

10 A Child with Hemihypertrophy, Omphalocele, and Organomegaly�� 67

Based on the Following Findings�� 70

Part IV Erythematous Eruptions

13 Acrodermatitis Enteropathica-Like Eruption with

Part V Hair Disorders

20 Ectodermal Dysplasia with Cleft Palate and Ankyloblepharon�� 147

51 A Slowly Growing Erythematous Plaque�� 385

Part XII Scaly and Ichthyotic Disorders

52 Generalized Spontaneous Skin Peeling�� 393