A 70-years old male patient with 11 years history of RA, pre | Figure 1

A 70-years old male patient

A 70-years old male patient with 11 years history of RA, presented to my office with 20 days history of both lips erosion which are not healing. After few days he developed bilateral rash under and behind his mandible, on his neck, which is pruriginous. Also he started to have ear pruritus. He didn't have any other problems. He used gentamicin cream and ciprofloxacin tablets based on result from erosion swab, but without improvement. His skin lesions were progressing.

PHx

He is allergic to penicillin. As patient stated, after he was diagnosed with RA 11 years ago, he getting rituximab injections every 6 months. Last injection he got just before current problems started. Previously he was on prednisone and sulphosalazine, but he stopped using this drugs because he didn't have pain in his joints.

Diagnosis

My provisional diagnosis is herpes infection which could not heal itself because of immunosuppression, so I prescribed acyclovir 400 mg, tid, and ordered serology for HSV1 and HSV2, and suggested follow up for a few days.

Opinion Sought

What is your opinion on this case? I am confused with skin changes on lateral sides of the neck so I asked for dermatologist consult. Could this be also atypical herpes infection?

Additional Cases

A 16-year old boy

A 16-year old previously healthy boy presented to my office with 5 days history of pustular and erythematous skin rash on his legs and 2 days of macular rash on his torso. Everything started 7 days ago with a fever up to 38°C and a sore throat. He was seen by GP who prescribed cefixime. He took the ordered medicine, all symptoms receded quickly but then he developed a painful pustular rash on his legs, and one of the skin changes were in form of purulent small flaccid bullae. During the next few days, he developed erythema of the legs and two days ago he developed a rash on the upper body. On exam, pustular skin changes are painful to touch, and the area around them is slightly tender. The rash is not pruriginous. Besides the rash, the rest of the exam is normal. What could this be, and what would be your approach? I am thinking about subcorneal pustular dermatosis but I didn't ever see the case of this condition.

A 36-year old man

A 36-year old man came to my office because of skin changes on his legs which appeared 4 days before the visit. The first change he noticed is the ulcer on the left shin skin which was followed by drainage of serous liquid and appearance of pustular changes on the whole shin. He used some cream and also he used honey to the ulcer. The ulcer was painful, but pain disappeared when ulcer started to heal. He didn't have any other complaints. The patient gave a history of similar skin changes which appeared out of nowhere many times during the last 7 years, and he only treated with topical therapy. PHx: unremarkable. Physical examination showed young man in good health state with three kinds of changes on his left shin: 1) partially healed ulcer with crust and 2) pustular changes with surrounding erythema and 3) maculopapular changes (probably first stage of 2nd type). Left shin has few maculopapular changes with slight erythema. The test for HIV was negative. What is your opinion on this case?

A 21-year old male

A 21-year old male with 12 years skin change on his right shoulder. He came to my office because of some unrelated problem, but I noticed this hyperpigmentation. He stated that this change appeared sometime after he was at the beach and got sunburned. The texture was a little papular on touch. What could it be?

A 54-year old male

A 54-year old male with a 2-day history of this skin changes. Everything started when he felt a tingling sensation on his back in the area of right scapula, shortly after which he saw those skin changes. He didn't have any other symptoms. Because erythema is quite unusual with such straight edges, I considered that this is artificially induced skin change (some kind of a burn), but he denied such contact and didn't recall any events that were previous to the appearance of these skin changes. He works in a hospital laundry unit. What is your opinion on this case? I also considered herpes zoster (shingles), but it is unlikely.