What's Your Assessment?

Barbara Bielan

Disclosures

Dermatology Nursing. 2005;17(1):30-31. 

The "What's Your Assessment?" series includes a short case presentation and differential diagnosis. It is followed by a discussion of the disease or condition and the rationale used in each step of the assessment.

This 86-year-old male presented to the dermatology clinic with a consultation request stating "please evaluate atypical tinea present for a few years." The patient states that both his feet are always itchy, especially the distal dorsum. Over the past few years a darker area has emerged on the sole of one foot and is slowly enlarging. He had been applying a topical antifungal cream daily for many months, saw no improvement, and discontinued it over 3 months ago. He also had lesions on the distal dorsa of both feet as well as scaly, thickened palms. His mother had psoriasis but denies any family history of atopy. He was born in Italy and was a cook for many years, attributing his lifelong hand dermatitis to frequent handwashing. A KOH prep was preformed of the scale from the heel area and was negative for hyphae. The patient had a stroke many years ago and his only present medications are one aspirin qd and lisinopril 40 mg.

Figure 1 shows scaling and thickening of both palms, the left much more involved than the right. Figure 2 is of both pedal dorsa. The primary lesion is a red papule. The dorsa of the feet near the proximal phalanges of the toes are involved. There are erythematous plaques involving each toe.

Scaling and thickening of both palms.

The primary lesion is a red papule. The dorsa of the feet near the proximal phalanges of the toes are involved.

Figures 3 and 4 show the plantar aspect of the foot. There is hyperkeratosis of the plantar surface of the foot extending from the heel to toes. Note on the distal half of the sole a sharply marginated hyperpigmented dermal plaque.

There is hyperkeratosis of the plantar surface of the foot extending from the heel to toes.

Note on the distal half of the sole a sharply marginated hyperpigmented dermal plaque.

  1. Tinea pedis

  2. Psoriasis with a darker plaque of tinea on the psoriatic lesion

  3. Psoriasis

  4. Psoriasis with Kaposi sarcoma

  1. Tinea should always be considered when there is scale. Any scaly plaque can be misdiagnosed as a papulosquamous dermatitis until a KOH scraping is done. Tinea is not the correct answer for several reasons: (a) the KOH was negative; (b) tinea would involve the plantar aspect of the feet, and almost always sparing the dorsum; and (c) tinea manuum can involve the entire palm but this patient only has involvment of a small area of one palm. On neither hand are digits involved.

  2. Psoriasis with a darker plaque of tinea. Actually, the patient does have psoriasis on his hands and feet. This diagnosis was confirmed by history and by finding similar plaques on the elbows and by nail pitting. Thus, one part of the diagnosis is correct. However, the darker plaque is a dermal plaque and tinea is superficial, not invading the dermal layer. Also, patients with psoriasis on their feet do not develop tinea of the feet.

  3. Psoriasis is part of the correct answer as discussed in #2.

  4. Psoriasis with Kaposi sarcoma is the correct answer. A biopsy from the lesion confirmed the diagnosis of Kaposi sarcoma.

This case graphically demonstrates that a patient can have more than one dermatologic condition at the same site. Fortunately, it is rare for a patient to have two distinct dermatologic conditions at the same site but it would have been detrimental to this patient's future health to not establish the diagnosis of Kaposi sarcoma.

Kaposi sarcoma has been a very common finding in patients with AIDS in the past 10 years. More recently, with the advent of the triple therapy cocktail, the incidence of HIV-related Kaposi sarcoma has decreased greatly. When the biopsy confirming the diagnosis of Kaposi sarcoma was made, it became important to rule out AIDS. A HIV test was negative. There are two forms of Kaposi's sarcoma and both appear the same clinically and histologically. The non-HIV Kaposi sarcoma occurs in patients of Mediterranean descent. It is a sarcoma and should be monitored frequently because it could progress and require radiation. The good news is that although it is a sarcoma, it grows very slowly and usually does not require therapy. It is a radio-sensitive tumor and can also be treated with intralesional or systemic chemotherapy.

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