Chief Medical Editor`s Message:Solving a Puzzle

A patient came to our Veterans Administration dermatology clinic this summer with a unilateral papular, pruritic, red eruption of the left chest/breast area. The diagnosis was uncertain — a folliculitis seemed most likely — so the patient was treated with topical clindamycin. The eruption did not resolve, but when the patient returned, the diagnosis suddenly became apparent. The dermatologist’s suspicions were confirmed when the patient buttoned the shirt that he had removed to show the rash. Coincidently, a second patient with a nearly identical unilateral pruritic left chest rash presented that very day. This time the dermatologist asked a question. “You’re a smoker aren’t you?” “Yes,” the patient replied. “You should quit smoking and that will cure the rash,” the dermatologist told him. Playing Detective Diagnosing contact dermatitis, the topic of this month’s cover story, can be one of the most fun aspects of dermatology. At times, contact dermatitis presents in ways that can only be described as Sherlockian. We all have cases we vividly remember. There was the young woman with unilateral eyelid dermatitis . . . she was a medical technology student using a monocular microscope with a rubber eyepiece. Then there was the middle-aged woman with the red, scaly “actinic keratosis” of the upper cheek without any other signs of photodamage. We asked to see her glasses for signs of wear, but her glasses were plastic. We asked for her other glasses, and she showed us the worn metal sunglasses with the underlying nickel exposed. And, then there was the young man with the worsening rash adjacent to an “unrelated burn” — unrelated in the mind of the patient — but clearly related to the neomycin being applied to treat the burn. Putting the Pieces Together Sometimes the pattern is a well established one: nickle dermatitis to earrings or the clasp of a necklace, or eyelid dermatitis from nail polish. But the real fun is in figuring out unexpected ones. There’s just something irresistible about a puzzle, especially a meaningful one, one whose solution will change someone’s life. Oh, and why would quitting smoking cure a pruritic left chest rash, you may still be wondering? Because quitting smoking means the patient wouldn’t carry a metal lighter in their left shirt pocket anymore. Steven Feldman, M.D., Ph.D. Chief Medical Editor

A patient came to our Veterans Administration dermatology clinic this summer with a unilateral papular, pruritic, red eruption of the left chest/breast area. The diagnosis was uncertain — a folliculitis seemed most likely — so the patient was treated with topical clindamycin. The eruption did not resolve, but when the patient returned, the diagnosis suddenly became apparent. The dermatologist’s suspicions were confirmed when the patient buttoned the shirt that he had removed to show the rash. Coincidently, a second patient with a nearly identical unilateral pruritic left chest rash presented that very day. This time the dermatologist asked a question. “You’re a smoker aren’t you?” “Yes,” the patient replied. “You should quit smoking and that will cure the rash,” the dermatologist told him. Playing Detective Diagnosing contact dermatitis, the topic of this month’s cover story, can be one of the most fun aspects of dermatology. At times, contact dermatitis presents in ways that can only be described as Sherlockian. We all have cases we vividly remember. There was the young woman with unilateral eyelid dermatitis . . . she was a medical technology student using a monocular microscope with a rubber eyepiece. Then there was the middle-aged woman with the red, scaly “actinic keratosis” of the upper cheek without any other signs of photodamage. We asked to see her glasses for signs of wear, but her glasses were plastic. We asked for her other glasses, and she showed us the worn metal sunglasses with the underlying nickel exposed. And, then there was the young man with the worsening rash adjacent to an “unrelated burn” — unrelated in the mind of the patient — but clearly related to the neomycin being applied to treat the burn. Putting the Pieces Together Sometimes the pattern is a well established one: nickle dermatitis to earrings or the clasp of a necklace, or eyelid dermatitis from nail polish. But the real fun is in figuring out unexpected ones. There’s just something irresistible about a puzzle, especially a meaningful one, one whose solution will change someone’s life. Oh, and why would quitting smoking cure a pruritic left chest rash, you may still be wondering? Because quitting smoking means the patient wouldn’t carry a metal lighter in their left shirt pocket anymore. Steven Feldman, M.D., Ph.D. Chief Medical Editor