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Simple cases
Case 35
27-year-old with slowly growing tumors over the sternum and on the shoulders
History
How long have you had these lesions? Are they still growing?
I have been getting the lumps for a few years. They are still coming. As a kid I had no problems.
It is important to get a feeling for the dynamics of the skin lesions.
Do the lesions bother you?
Yes, some of them itch and they all look terrible.
Such symptoms reflect both the activity of the disease and how much the patient is suffering.
Does anyone else in the family have similar problems?
No, not that I know of.
Both this problem and the underlying disorder can be familial, but the question has no diagnostic or therapeutic relevance.
What kind of sports activities do you do? Do you take any special vitamins or the like?
I do go to the fitness studio regularly, but I am not a body builder and I don't take any pills or supplements.
Such changes in these areas are usually secondary to acne, which can be triggered by androgens. Always ask adults with acne about body building.
Did you ever have bad acne? How was it treated?
Yes, I used to have really bad acne before I got Accutane. Now I just get an occasional pimple.
Even moderate acne can trigger such growths. It is important to control the acne to reduce the likelihood of additional lesions.
Do you have any allergies?
Years ago, someone said I had milk allergy.
This is a reasonable question, but here the allergy history plays no role.
Lesion
Choose the right efflorescences:
Lichenification is caused by persistent rubbing and features exaggerated skin markings. This is not seen here.
These large raised lesions are classic nodules.
Hives are transient.
The smaller lesions are papules. A papule is officially < cm; a nodule, > 1 cm.
Diagnosis
Choose the right diagnosis:
Correct. A keloid is a proliferation of connective tissue following trauma (in this case, acne lesions). The keloid exceeds the bounds of the original injury.
Dermatofibromas also typically follow skin trauma, such as an arthropod bite. They are smaller than keloids, flatter and usually on the extremities.
Nodular fungal infections are erythematous, scaly or pustular
Cutaneous sarcoidosis can present with small nodules, but they are typically red-brown and not glistening. Scar sarcoidosis is usually not so disseminated.
Therapy
Choose the right therapy(ies):
Each time a keloid is excised, the risk is great that an even larger keloid will result.
The regular massage and pressure may help but often fails, as in this case
Occlusion with a silcone gel sheet makes the keloid softer and flatter. The corticosteroid injections also cause flattening. They can be repeated every 6 weeks. The treatment may last a year.
Freezing with liquid nitrogen may also soften the lesions; it can be combined with corticosteroid injections.
Test
The following questions are related to the current case. Try to solve them.
