SUBJECTIVE: A (XX)-year-old woman is seen in consultation for evaluation of a rash that began during chemotherapy. The patient has had five cycles of Taxol and carboplatin, receiving this weekly along with radiation therapy, for stage III lung carcinoma that was diagnosed within the past couple of months. She reports that beginning with either the second or third course of chemotherapy, she developed slightly itchy red lesions on her arms and legs. The redness of the lesions has increased with each chemotherapy cycle. She is more concerned about what it represents rather than symptomatic from the rash. In the past, she has used Benadryl ointment on it with no improvement and is not applying anything presently.
OBJECTIVE: Alert and oriented x3. On examination of her face, neck, chest, breasts, abdomen, back, upper and lower extremities, hands and feet bilaterally, there are numerous erythematous, slightly keratotic, 2-10 mm in diameter macules on the dorsal surface of the proximal and to a great extent distal arms, and on her proximal and distal anterior legs. Posterior legs show very few lesions. No lesions on the proximal posterior legs. No lesions on the trunk. No lesions on the face. There is mild erythema on her upper chest and upper back corresponding to recent radiation therapy.
ASSESSMENT: She has numerous actinic keratoses on the sun exposed areas of the arms and legs that are becoming markedly inflamed with chemotherapy. This is most likely reaction to the carboplatin.
PLAN: The patient was reassured with explanation of the eruption. We discussed with her that there is no reason to discontinue the chemotherapy and that actually this will be quite beneficial to the numerous precancerous lesions on her skin; that with continued chemotherapy, these are likely to eventually resolve. We discussed with her that her skin is more photosensitive, and she should be trying to protect her skin with clothing for any outdoor activities. She states she has been avoiding outdoor activities largely. We advised Aquaphor healing ointment to the upper and lower extremities several times a day for symptomatic relief, and she can certainly apply this prior to chemotherapy. Followup, because of history of SCC, scheduled for six months.
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SUBJECTIVE: The patient is a (XX)-year-old female here for her six-month history of tender nodules of her legs of unclear etiology. The patient is currently using Unna boots weekly and reports her nodules are significantly improved. She feels overall she is doing well. She developed nodules on the lower extremities. She noticed small tender nodules on her right calf. Then, over the course of the following three months, she developed further lesions on the left ankle and the left pretibial area. Her dermatologist initially suspected panniculitis versus erythema nodosum, and she was treated with Augmentin and prednisone with no improvement. She had an excisional biopsy performed, which showed an acute abscess with superficial ulceration, abundant gram positive cocci. Features favored infectious process, component of stasis dermatitis was possible. There was no evidence of any underlying primary vasculopathy or typical features recognizable from a primary folliculitis. Her tissue cultures at that time revealed MSSA and Pseudomonas; however, this was taken from the out base of the ulcer. Fungal culture, bacterial culture, and AFB cultures were all negative. In addition to her above treatment, she has had PPD that was negative. She was treated with topical steroids, NSAIDs including diclofenac and meloxicam, without improvement. She also was tried with minocycline 100 mg b.i.d. for two weeks and also Bactrim. She started with her application of Unna boots and also 50 mg of dapsone daily. She has completed five weeks of Unna boot treatment and had significant improvement over the past several weeks. She denies any new lesions. She has not had any drainage. No fever or chills. No neuropathy symptoms, weakness, or fatigue.
OBJECTIVE: Today, she is alert and oriented, in no acute distress, nontoxic. Focused cutaneous exam of the bilateral lower extremities was noted to have along the right posterior calf approximately 3 x 2 mildly tender hyperpigmented violaceous plaques that appear more atrophied today. She has one pinpoint ulcer noted along the left calf, left malleolus. There are several small scattered erythematous hyperpigmented nodules resolving. Her pulses are intact. There is no edema noted.
ASSESSMENT AND PLAN: Six-month history of tender nodules of unclear etiology, thought to be a possible reactive panniculitis from previous bacterial infection or nonspecific panniculitis, most probably related to her varicose veins. To date, her cultures have been negative. She continues to improve using dapsone 50 mg daily. She did a CBC, pending. She is starting to improve with Unna boot therapy. She will continue Unna boots and will follow up in clinic in one week or sooner if there is any new problem.
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SUBJECTIVE: The patient is a (XX)-year-old woman who comes in today for psoriasis. She notes that the psoriasis is actually getting a bit worse on her forearms. She only has it there. She also had some erythema on her nasal columnar that we had frozen with liquid nitrogen for the chance that it could be an actinic keratosis. She also has some brown discoloration in the right nasal ala that we were watching and did look relatively benign and she notes it has not changed. She notes she does not really go out much. She is using DesOwen lotion twice a day to the elbows as well as desonide twice a day.
OBJECTIVE: Well-appearing female, normal respiratory effort, oriented, normal affect and mood. Exam included the forearms and the nose.
ASSESSMENT AND PLAN: Psoriasis: The patient had several very thin pink plaques on her forearms, and it does look like she has new patches of psoriasis. We discussed that since she does not get really any sunlight, to give herself 15 minutes every day and that itself can help clear psoriasis. She can continue on with the desonide twice a day and the Dovonex twice a day as the lesions do look relatively thin and minimal. She had a little bit of macular erythema on the nasal columnar but no evidence of any scaling, and we discussed with her she can just simply watch this. She also had the brown discoloration on the right nasal ala that looks actually improved from last time and not concerning, and we will continue to watch this. It could be a small patch of postinflammatory hyperpigmentation. We will see her back in six months.
