Erythematous ear with drainage.

This case reminded us that not every moist, erythematous, crusting eruption is purely infectious.

Diffuse skin rash, altered mental status · Dx?

A 74-YEAR-OLD CAUCASIAN MAN presented to the hospital with intractable back and chest pain, a diffuse skin rash, and altered mental status. He said that 2 days ago, he'd gone to a different local hospital for treatment of back pain and a headache that had begun 3 days earlier. He was treated with intravenous hydromorphone and sent home with a prescription for meperidine. He said that several hours after being treated with the hydromorphone, the rash developed on his head and then spread to his trunk and upper extremities. WHAT IS YOUR DIAGNOSIS? HOW WOULD YOU TREAT THIS PATIENT?

Tinea capitis in adults.

BACKGROUND: Tinea capitis is caused by dermatophyte fungi that utilize keratin as a nutrient source.  Scalp erythema, scaling, andcrusting are typical signs of this disease.  Although most commonly seen in prepubescent children, tinea capitis can occur in adults. RESULTS: Endothrix tinea capitis owing to Trichophyton tonsurans commonly produces generalized scaling and localized perifollicular inflammation reminiscent of lichen planopilaris. Ectothrix tinea capitis owing to Microsporum sp. produces well- demarcated erythematous plaques suggestive of psoriasis. H&E stained biopsy specimens, KOH preparations or fungal cultures will confirm the diagnosis. CONCLUSION: Because of a low index of suspicion for tinea capitis in adults with scaling and alopecia, diagnosis and appropriate treatment are often delayed. Resistance to treatment for seborrheic dermatitis or psoriasis should prompt a KOH, fungal culture orbiopsy to confirm the diagnosis of tinea capitis and initiate systemic antifungal agents.

The Clinical Learning Environment Review as a model for impactful self-directed quality control initiatives in Clinical Practice.

The Clinical Learning Environment Review (CLER) program was designed to assess the learning environment in residencies and fellowships accredited by the Accreditation Council for Graduate Medical Education (ACGME). The program's focus is preventing harm to patients. This effort was purposely separated from the residency survey process so that training programs would be open to identifying and preventing errors without fear of jeopardizing their accreditation status. In our dermatology residency program, we established a resident-centered project for quality assessment/quality improvement (QA/QI). We identified areas of potential patient harm, designed methods to quantifiably assess the problems, and developed focused and cost-effective initiatives to improve patient safety. A new initiative was presented at each monthly faculty meeting. This project jump-started QA/QI efforts in our department and has improved patient safety. Our QA/QI project also has enhanced resident/faculty communication and provided trainees with experience in designing QA/QI efforts. It could serve as a model for postresidency efforts to prevent patient harm.

Tattoo and vaccination sites: Possible nest for opportunistic infections, tumors, and dysimmune reactions.

Tattoos have gained worldwide popularity in recent years, and vaccinations are universal preventive measures designed to minimize morbidity associated with specific pathogens. Both dermal tattoos and vaccine injections may alter local immune responses, creating an immunocompromised district on or near the site of placement. This can lead to the development of opportunistic infections, benign and malignant tumors, and local dysimmune reactions. With regard to tattoos, a predominance of warts among a variety of opportunistic infections has been reported. These warts appear to result from a local immune dysregulation rather than from direct inoculation or coincidence. A variety of tumors including basal and squamous cell carcinomas, keratoacanthomas, and malignant melanoma also have been reported in association with tattoos. Granulomatous, lichenoid, and pseudolymphomatous reactions represent the most common dysimmune reactions. Vaccination sites similarly provide a setting for both benign and malignant tumors. Frequent reports of dermatofibrosarcoma protuberans would be unlikely to result from coincidence. Granuloma annulare and pseudolymphomatous reactions are relatively common dysimmune reactions.