Scott M. Jackson · Lee T. Nesbitt

Diff erential Diagnosis for the Dermatologist

Scott M. Jackson · Lee T. Nesbitt

Diff erential Diagnosis for the Dermatologist

Second Edition

ISBN 978-3-642-28005-4 ISBN 978-3-642-28006-1 (eBook)DOI 10.1007/978-3-642-28006-1Springer Heidelberg New York Dordrecht London

Library of Congress Control Number: 2012936977

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Scott M. Jackson, M.D.Health Sciences CenterDermatologyLouisiana State UniversityBaton Rouge, LAUSA

Lee T. Nesbitt Jr., M.D.Health Sciences CenterDermatologyLouisiana State UniversityNew Orleans, LAUSA

It is with great pleasure that I introduce the second edition of Diff erential Diagnosis for the Dermatologist . My goal with this book has been to create a quick and easily accessible source of information for practicing derma-tologists. My dream is that this book will be placed in the work area and will be used “on the go” for a rapid source of information about the dif-ferential diagnosis of a given skin problem.

I had always wished for the text to have a section for treatment options but the task of compiling treatment options as well as compiling the dif-ferential diagnoses proved to be too daunting for me in the fi rst edition. However, with this second edition, my eff orts were focused in part to bring treatment options to the fi ngertips of the dermatologist. For all commonly treated skin diseases and skin lesions, the reader can fi nd a list of the treatment options. While they are listed in no particular order, the fi rst-line and most reliable treatments are underlined. Treatment options for genetic skin diseases and diseases that are treated by nondermatolo-gists are not given.

Th e reader will also fi nd several other changes in the second edition. Th ere are 50 new photographs in the text, and there are 25 new diagnoses or entry headings. Many of the references have been updated to provide a more current supporting literature for the text. Th e last major change in the book involves the use of underlining to indicate to the reader the skin diseases that more closely simulate the heading diagnosis. In addition, the associations that are most commonly identifi ed with a given diagno-sis are underlined as well.

Preface to the Second Edition

vi Preface to the Second Edition

It is my sincere hope that dermatologists will fi nd this information useful in their daily practice.

Scott M. Jackson, M.D.

Preface I to the First Edition

Th is book originated as a small reference manual that I created to serve as an educational supplement for the dermatology residents at Louisiana State University Health Sciences Center. Deeming the compiled informa-tion to be useful for all dermatologists, I decided to expand the text and publish it. Every major category of the patient evaluation, from the chief complaint to the diagnosis, is addressed with regard to the dermatologi-cal diff erential diagnosis.

Th e establishment of a precise diff erential diagnosis for a given cutane-ous problem is the fundamental challenge that the dermatologist faces with every patient. Th is unique exercise is very intellectual; in a short period of time, the clinician must select from a list of perhaps several hundred dis-eases a few possibilities that match the clinical presentation. Th is is per-formed while also negotiating the patient interaction, examining the patient, and beginning to formulate a plan of action. Profi ciency in the for-mulation of a diff erential diagnosis that is brief and simultaneously thor-ough allows for consideration of all possibilities, proper evaluation, and, hopefully, rapid diagnosis. We hope to provide the target readers (derma-tologists and dermatologists in training) with some assistance in carrying out this frequently complicated task. For the confrontation with an atypical presentation of a common disease or the classic presentation of an uncom-mon disease, the reader will hopefully fi nd this book very useful.

Th e dermatologist may move toward the diagnosis of a particular cuta-neous presentation with a morphology-driven approach and/or a diagno-sis-driven approach. Classically, the dermatologist is trained to fi rst recognize the morphology of the disease and then ponder all of the causes of that type of lesion. For example, if a patient presents with a papu-losquamous eruption, then several diagnoses are suggested on the basis

viii Preface I to the First Edition

of morphology alone. While morphology of lesions is essential, distribu-tion, patient demographics, and associated features are left out in this approach. On the other hand, a diagnosis-driven approach is also advan-tageous and possibly more inclusive and yet still specifi c. With the exhaus-tive section organized by dermatologic diagnosis, we believe this text will help clinicians formulate a diagnosis-driven approach to the diff erential diagnosis. For example, if a patient presents with a rash that resembles a certain dermatosis (e.g., pityriasis rosea), the clinician now has quick access to the diff erential diagnosis of that dermatosis (and any subtypes or variants) so that all alternative diagnoses are considered, not just diag-noses that share morphology. While recognition and appreciation of morphology is still critical, a diagnosis-based approach to the diff erential diagnosis is sometimes also helpful when faced with a diagnostic dilemma. In addition, the book provides supporting information for each diagno-sis, including recommended evaluative studies, diagnostic criteria, and a source article to reference.

Although inclusiveness was a primary goal of the project, we are aware of the limitations of this text. It was a diffi cult task to decide which of the many diagnoses in the dermatologic literature to include in the large chapter on diagnosis. Th ere is a tremendous amount of controversy sur-rounding the existence of many diagnoses, and we were forced to take a position on the controversies when including or excluding certain dis-eases. An eff ort was made to exclude diseases that have not been described in over 20 years. We also wanted to include many of the more recently described diagnoses from the past 2 years. It was also diffi cult to generate the lists under each diagnosis with an acceptable level of sensitivity and specifi city. We felt that erring on the side of too many diagnoses was more acceptable than missing a potential important diagnostic alternative. We welcome any criticisms or suggestions that would improve the sensitivity and specifi city of the lists for future editions.

We sincerely hope that you fi nd this text useful in your training or in your daily practice.

Scott M. Jackson, M.D.

Preface II to the First Edition

Ah, but a man’s reach should exceed his grasp….

robert browning

Probably, the most satisfying aspect of being a chairman or residency program director in academic medicine is to be associated with, and help, bright young people who are anxious to learn and contribute to our body of medical knowledge. In my 35 years in academic dermatology, Scott Jackson is one of the brightest people that I have had the opportu-nity to teach and from which to learn. He has been one of our most motivated residents in becoming the best he can be and in trying to learn almost every fact in dermatology that can possibly be learned. Scott has attempted a mastery of the specialty, a goal many of us have hoped to attain but have come to realize, with time, that we will always fall short. Nevertheless, it is a loft y ideal, as stated so well by the poet Robert Browning when he wrote the line “Ah, but a man’s reach should exceed his grasp….”

In addition to trying to learn almost every fact he could in dermatol-ogy during 3 years of residency training, Scott attempted to teach and transmit that knowledge base to all other residents in the program. He even initiated a weekly game of dermatologic questions for all the resi-dents, a game he called “Jeopardy,” complete with diff erent weekly catego-ries for everyone to study. Because of his thirst for knowledge, he made all residents in the program more knowledgeable.

In producing this text, which he worked on for long hours during his residency, and now as a junior faculty member, Scott Jackson has

x Preface II to the First Edition

succeeded in a giant undertaking. I applaud his success and know that with each grasp he takes up the ladder of dermatology, he will continue to extend his reach.

Lee T. Nesbitt Jr., M.D.

Acknowledgements

I would like to thank my wife Angie for giving me the time, space, and support I needed to edit this text. I also thank Hannah and Mary for let-ting me work on this book when they would rather be playing with me. I also thank Dr. Lee Nesbitt for inspiring me to enter the fi eld of clinical dermatology and assisting with the publication of this text. For the love and encouragement they have given me over the years, I thank my par-ents. Special thanks are given to Dr. Ashley Record, Dr. Steven Klinger, Dr. Kevin Guidry, Dr. Trent Massengale, Dr. Aimee Mistretta, Dr. Matthew Lambert, Dr. Erin Bardin, and Dr. Ann Zedlitz for the contribution of photographs. I also would like to thank those who supported the fi rst edi-tion as they made this second edition possible. Finally, I would like to thank my high school math teacher, Ms. Barbara Stott; for without her guidance, I would not be doing all that I am doing today.

Introduction

Th e Handbook of Diff erential Diagnosis for the Dermatologist was written for the purpose of providing the reader with quick access to the diff eren-tial diagnosis of a variety of common and uncommon chief complaints, physical exam fi ndings, dermatopathologic features, diagnoses, and more. An understanding of how this text was organized is essential prior to its use in order to facilitate rapid access to essential information. Firstly, the authors created an exhaustive list of virtually every dermatologic prob-lem, including all important dermatologic diagnoses. Th en, these various problems were sorted into chapters based on the key components of the dermatologic workup. All specifi c diagnoses were placed in the diagnosis chapter. Entities such as pruritus or keratoderma, not being specifi c diag-noses, were placed in the chief complaint or physical exam chapters, respectively. Useful supporting information was supplied for every prob-lem when appropriate. Finally, each entry is referenced with a recent source article that attempts to increase the reader‘s understanding of the diff erential diagnosis of that disease. A summary of the contents of each chapter follows.

Chapter 1

“Th e Chief Complaint” focuses on complaints that patients make that cannot be more specifi cally sorted as a diagnosis or physical exam fi nd-ing. Examples of items included in this brief chapter are pruritus, hyper-hidrosis, and fl ushing.

xiv Introduction

Chapter 2

“Th e Past Medical History, Social History, and Review of Systems” high-lights the major diagnostic considerations that arise in patients who pres-ent with an element of the past medical history, social history, or review of systems that may or may not be relevant to the encounter. In this chap-ter, one can fi nd the dermatologic manifestations of internal diseases, skin fi ndings in patients reporting certain social activities, and diagnostic considerations in patients revealing key components of the review of systems.

Chapter 3

“Th e Physical Exam” provides the reader with diagnostic considerations associated with a variety of regional and morphological physical exam fi ndings. Entries included in this chapter are those fi ndings which cannot better be sorted as specifi c diagnoses.

Chapter 4

“Th e Biopsy” presents the diff erential diagnosis of several major histo-logic reaction patterns or features.

Chapter 5

“Th e Laboratory Results” focuses on the most important or most com-mon laboratory abnormalities that are encountered by dermatologists and the dermatologic diseases that should be considered in the evaluation of the patient.

xvIntroduction

Chapter 6

“Th e Diagnosis” contains an exhaustive alphabetical list of virtually every dermatologic diagnosis. An eff ort was made to include only the diagnoses that have been reported or discussed in the literature in the past two decades. Under each heading, the reader can fi nd a list of subtypes (if any), the diff erential diagnosis of the disease and any subtypes, published diagnostic criteria, associations of the disease, associated medications (if any), and recommended initial evaluatory tests, and, new to the second edition, treatment options. When searching this text for the diagnosis in question, it is recommended that the reader search for the most unique term in the name and not descriptive adjectives, such as neutrophilic or superfi cial or common words such as dermatitis.

Chapter 7

Th e “Glossary” provides the reader with brief defi nitions of the rare diag-noses that can be found in the lists of diff erential diagnoses. Th ese diag-noses were not given special attention in Chap.6 because they are very rare or because they do not have a lengthy diff erential diagnosis.

1 Th e Chief Complaint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Th e Past Medical History, Social History,

and Review of Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233 Th e Physical Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 714 Th e Biopsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2455 Th e Laboratory Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2816 Th e Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2937 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1405

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1447

Contents