31-year-old man is referred because of red area on right foot. He has already seen numerous physicians.
How long have you had this area on your foot?
For 2 years, but I had surgery on my foot 10 and 12 years ago after an accident, and I think there is a connection.
The clinical course often helps determine the etiology.
Have you ever had problems with your leg veins?
The skin around the medial malleolus is a site of predilection for skin changes secondary to chronic venous insufficiency.
Do you have other complaints?
Yes, my ankle hurts occasionally. It has ever since the accident.
Other signs and symptoms sometimes help diagnose a skin disorder.
Have you been bitten by ticks?
Yes, 3-4 times a year over the past years.
Always think of this possibility.
Are your feet swollen at night?
No. At the beginning the red areas was a bit puffy but now it is flatter.
Look for possible causes; a positive answer might suggest chronic venous insufficiency.
Have you ever used a cortisone cream here?
No, I have never tried any treatment.
Cortisone creams can cause skin changes, such as atrophy, when used for long periods of time.
Do you have similar lesions elsewhere on your body?
The total picture of a skin disease often firsts leads to the diagnosis.
Choose the right efflorescences:
Atrophic skin is sometimes tense, and may resemble cigarette paper.
Poikiloderma features atrophy, telangiectases and pigmentary disorders. All these features are not seen.
Lichenification is the result of chronic rubbing and features exaggerated skin markings.
The changes are flat, so technically macular, but here erythema is the preferred term.
There is no transient swelling.
Choose the right diagnosis:
There are no varicosities and no other signs of chronic venous insufficiency.
ACA is characterized by erythema and atrophy, which persists after treatment.
Even though the patient is trying overly hard to connect his current problems to the old accident, no evidence of an artifact is seen.
Vasculitis usually presents with palpable purpura symmetrically on the legs.
Morphea is the major differential diagnostic consideration, but it usually has a lilac ring and central clearing.
Choose the right therapy(ies):
This is inadequate therapy for extracutaneous borreliosis.
Reasonable alternative therapy during pregnancy. Inform the patient that the atrophy will persist.
The standard therapy. In the absence of joint pain, 21 days is sufficient. With joint involvement, 30 days is suggested. Inform the patient that the atrophy will persist.
This is the therapy for syphilis, and not sufficient for borreliosis.
Not every dermatologic disease is treated with corticosteroids.