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Case 58

64-year-old man presents with lesions which suddenly appeared on his buttocks

I noticing them taking a shower; the skin felt bumpy back there.

The lesions don't seem to be bothering the patient much, but let's explore further.

Yes, from time to time.

Important question. The answer can help with the differential diagnostic process.

I think so. I didn't go to the doctor.

It is always good to know if you are dealing with an acute or chronic problem. Unfortunately, here the patient is not sure.

I am in informatics.

This question might sound silly at first, but it gives you lots of information. Here we learn that the patient sits a great deal, so perhaps his skin problem is triggered by pressure and occlusion.

Yes, I get fever blisters once in awhile, especially when I am really exhausted.

Good question, which helps in the differential diagnosis.

I think so. I don't go to the doctor much.

The patient feels well, but might have an underlying disease, since he hasn't been checked closely.


Most people know if diabetes mellitus, cancer or heart problems are common in their family. When it comes to skin diseases, this question often just causes confusion, as psoriasis and atopic dermatitis, for example, are confused.

Choose the right efflorescences:

No scales are seen here.

Erosions are superficial defects; the patient could induce them by scratching, but has not done so here.

These are classic red-yellow grouped papules.

Choose the right diagnosis:

The buttocks is a common spot for folliculitis, especially in those who sit a lot (desk jobs, truck drivers). One would expect pustules and more erythema, so the diagnosis is unlikely.

Very good. These are classic eruptive xanthomas—tiny red-yellow papules that appear suddenly, usually on buttocks. The patient almost certainly has elevated triglycerides and is at risk for diabetes mellitus. He must be evaluated by his family doctor or internist.

Allergic vasculitis usually features palpable purpura (not yellow papules) and is most common on the legs, not the buttocks.

Herpes occurs on the buttocks, but with group blisters, almost certainly unilateral, healing with erosions and crusts. In addition, herpes simplex is almost always symptomatic—with burning or itching.

Choose the right therapy(ies):

A biopsy would be appropriate, but there are too many lesions to excise. In the case of xanthelasma with just a few lesions, excision is an option.

This is not an infection, so this approach has nothing to offer.

Of course—once the diagnostic evaluation is complete. In rare instances, there are normolipemic xanthomas, so once cannot blindly start therapy.

Once again, lasers can destroy the lesions, but the real issue is defining the underlying abnormality. For xanthelasma, lasers are a good option to surgery.

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