A 46-year-old woman quick in emerge...

A 46-year-old woman quick in emergenciesed for her annual well-woman examination and Papanicolaou smear. She had no complaints, exclude for occasional itchiness associated with skin lesions (see accompanying figure) that were symmetrically at hand in both axillae.

[FIGURE OMITTED]

forward further questioning, she revealed that she had always been overweight and had multiple family members with sign 2 diabetes. She had not not long ago changed bathing soap, deodorant, or laundry detersive brands. She also denied having myalgias, arthralgias, or other rashes.

forward examination, she was obese, with any hair growth on her upper lip. Skin examination revealed hyperpigmented lesions in the axillae. Thyroid examination was normal. Laboratory conclusions showed a borderline elevated posterity glucose level and normal clean blood count.

Question

Based in succession the patient's history and physical examination, which single in kind of the following is the correct diagnosis?

[] A. Cutaneous lupus.

[] B Acanthosis nigricans.

[] C Contact dermatitis.

[] D Superficial spreading melanoma.

[] E Erythrasma.

Discussion

The correct answer is B: acanthosis nigricans. The lesion seen in the figure is called acanthosis nigricans. Acanthosis nigricans is a nonspecific skin change most numerous commonly found in flexural areas as it is as the axillae, beltline, or the nuchal plicature It is associated with insulin resistance, most numerous commonly caused by obesity. When the lesion is seen in a patient without apparent diabetes or obesity, evaluation for other causes should be pursu like as hypothyroidism, gastrointestinal malignancy, or other causes of insulin resistance (eg polycystic ovary syndrome rare lipodystrophies).

Melanoma is in the differential of any pigmented skin lesion; however, the large size and symmetric location of these axillary lesions would greatly decrease suspicion of melanoma.

Chronic skin prospect to an irritant or allergen may lead to lichenification and hyperpigmentation, unless contact dermatitis is less likely to be the cause of this patient's lesions because no topical in all senses is recalled and no modern deodorant, soap, or detergent has been used.

Systemic lupus erythematosus has been associated with acanthosis nigricans, especially in black women However, this patient has no other signs suggestive of this disease. Lupus is les likely, given the lack of myalgias or arthralgias and a completely normal descendants count.

Erythrasma is a bacterial infection caused from Corynebacterium minutissimum. While it is principally commonly seen in the groin area, it also may involve the axillae. The brown or brick-red color may appear similar to acanthosis nigricans, on the contrary there is no velvety thickening of the skin with erythrasma. This skin infection usually rejoins rapidly to oral or topical antibiotics, whereas acanthosis nigricans would be unaffected.

Weight los and regulate of blood glucose levels may improve acanthosis nigricans caused by dint of obesity and insulin resistance. Topical retinoic acid or oral isotretinoin (Accutane) has been prescribed for cosmetic improvement, with variable reports of succes (1) Additionally, topical alphahydroxy acid solutions may be useful for softening the lesions. (1)

The opinions and assertions contained herein are the private views of the authors and are not to be constru as official or as reflecting the views of the U Navy Medical Department or the U Navy Service at large.

REFERENCES

1 Habif TP Cutaneous manifestations of internal disease. In: Habif TP ed Clinical dermatology: a color guide to diagnosis and therapy. 3d ed St. Louis: Mosby, 1996:788-9.

The editors of AFP welcome submission of photographs and material for the Photo Quiz department. emit photograph and discussion to Genevieve Ressel AFP Editorial, 11400 Tomahawk small bay Parkway, Leawood, KS 66211-2672 (jressel @aafp.org).

ELIZABETH A. LEONARD, LT MC USN ANTHONY J VIERA, LCDR MC USNR Naval Hospital Jacksonville Jacksonville, FL

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