Keywords: Dermatology; Multiple
diagnosis; Consultation
General Practioners (GPs) in the Primary Health Care especially in
rural areas often seen naiive and new skin diseases and due to requirement of
wide medical knowledge, the dermatology knowledge of GPs is limited and, thus,
they may consult Dermatology specialists to ensure diagnosis and best treatment
for the patient.
Also in a tertiary hospital, dermatologists are consulted to ensure
improved diagnosis and management of cutaneous issues early with the aim to
minimize unnecessary investigations, improve the quality of healthcare, reduce
hospital burden and facilitate outpatient follow-up2.
At a specialist appointment, more than one skin issue may be
detected. Thus, the dermatology specialist need to examine carefully the
patient’s whole skin and keep in mind simultaneous different and variants of
dermatologic disorders at the same time in the same patient. We describe 4
cases with different dermatologic diagnosis as examples of multiple
simultaneous diverse skin manifestations of a patient needing to pay attention
to.
Case Reports
Case 1
A female born in 1964 had coeliacia and dermatitis herpetiformis
both been in a stabile stage by diet. She also had alopecia areata developing
to total alopecia areata 4 years later and she weared a wig. She had also
diagnosed a mild dermatitis atopica. Rhinitis symptoms were present during
spring time for birch pollen and she experienced symptoms from apple, kiwi,
tomato and raw potato. In 2013 at dermatology clinic, psoriasis vulgaris
lesions on soles and dorsal aspects of hands were detected. Topical treatments
included emollients, strong (Class III) and superpotent (Class IV)
corticosteroids and calcipotriol-betamethasone ointment and later
calcipotriol-betamethasone foam.
Patient files from 1998 informed a Phenoxymethylpenicillin allergy
due to throat infection with a guttate psoriasis developed that was treated
topically. However, no antibiotic medication was used in reality.
In summer 2024, her psoriasis worsened with also guttate-type
lesions. Methotrexate was considered but continued by topical treatments.
Case 2
A male born in 1959 was sent in 2014 to Dermatology clinic by a
General Practioner (GP) referral due to treatment-resistant wide psoriasis
vulgaris treated topically by emollients and strong (Class III) corticosteroids
and calcipotriol-betamethasone ointment. The patient was also diagnosed with
Birt-Hogg-Dube genodermatosis that has an increased risk for renal malignancy
and pulmonary emphysema needing a follow-up.
At dermatologits’ patient meeting, acitretretin 25 mg daily was
started with a good response and laboratory follow-up, with previous topical
treatments. UVB light therapy was unpractical due to patient’s long distance to
University Hospital for treatments.
In summer 2022, psoriasis started to worsen. In December 2022
acitretin was changed to metotrexate 10 mg/week with 5 mg folic acid with a
good response as followed to Jan 2025. Tacrolimus 0.1% ointment was used for
facial psoriasis and to other areas calcipotriol-betamethase foam with topical
steroids and emollients were used.
Case 3
A male born in 1951 with Type 2 diabetes came in 2017 to Dermatology
clinic by a GP referral due to itchy dermatitis in upper extremities, head and
beard area. Histology revealed unspecific dermatitis and serum
transglutaminase-Abs were negative. Patient had started glutein-free diet and
felt his skin situation better.
Dermatologist diagnosed seborrheic dermatitis and clinically lichen
planus in antebrachial areas. These were treated by topical
miconazole-hydrocortisone or triamcinolone-econazole cream and cyclopirox
olamine shampoo. In addition, at his left lower back, there was a suspicious
pigmented lesion that was excised with diagnosis of superficial Breslow 0.8 mm
melanoma. New biopsies were taken from antebrachial blistering lesion:
histology revealed nonspecific dermatitis and paralesional IF-study was
negative.
Two years later, numerous seborrheic keratosis lesions and skin tags
causing functional disadvantages were detected and treated with liquid
nitrogen. A few benign capillary hemangiomas were not treated.
At control and follow-up for melanoma in Jan 2022, no melanoma
recidives were detected, but lichen planus lesions in lower legs were treated
with clobetasol and betamethasone cream. Also, the skin was found rather dry,
thus, asteatosis cutis diagnosis was set, without any evidence for atopy. Later
follow-up until Feb 2025 has revealed no new malignancies.
Case 4
A male born in 1956 having a Type 2 diabetes treated with insulin
and hypertonia, was sent in June 2015 to Dermatology clinic by a GP referral
due to severe scaly psoriasis vulgaris. Due to heavy alcohol use, he had had
numerous pancreatitis episodes. PASI was 10.8.
The patient was decided to be treated by topical treatment by 3%
salicylic acid - 0.05% betamethasone ointment with sun bathing.
At control 5 months later, his alcohol consumption was decreased,
thus acitretin 25 mg daily was started with frequent laboratory value
follow-up. At control 4 months later, acitretin was found to give first a good
response. However, acitretin was later stopped due to loss of efficacy and
increased Alat value and narrowband UVB therapy was started in Sept 2016, but
after the first dose, a blistering dermatosis was detected at inner thighs.
Skin biopsies from right lower extremity was taken: histology
revealed bullotic dermatosis and IF-study showed typical features for
pemphigoid. Further treatments in Nov 2016 included oral prednisolone 10 mg
daily with calcium/D-vitamin substitution and topical clobetasol or
methylprednisolone aceponate crem or 3 % salicylic acid - 0.05% betamethasone
ointment. After 9 months, some psoriatic plaques were detected but no signs for
pemphigoid. Three months later Prednisolon was decreased to 7.5 mg/day. The patient
had stopped oral prednisolone in Dec 2018 due to increase in blood sugar level,
without relapse of pemphigoid.
At control in Aug 2020, skin erythrodermia with itch was noted and
oral prednisolone 10 mg daily was started. A month later erythrodermia level
was markedly decreased and prednisolone was continued by 5 mg/day. At control 2
months later, a relapse in erythrodermia was treated by prednisolone 7,5 mg
daily. Slowly situation went better on March 2021.
A relapse in erythrodermia was noted in Nov 2011. Prednisolone 7,5
mg daily and calcipotriol-betamethasone foam were used for treatment. At
control 3 months later in Feb 2022, erythrodermic skin area was 99%.
Prednisolone dose was same and metotrexate 10 mg/wk with 5 mg folic acid was
initiated. At control 3 months later, no clear response was noted, methotrexate
was increased to 15 mg/wk and prednisolone was continued by 5 mg/day for a few
months. Antihistamines gave some relief for itch.
In June 2022, erythrodermia continued, thus rizankizumab (Skyrizi)
was started with standard protocol, but after 2 doses, no clear response was
found, but continued for additional 2 doses (6 months), Pemphigoid antibodies
were negative. The erythrodermia continued, thus, at control in May 2023
rizankizumab was changed to bimekizumab (Bimzelx), giving a clear response, as
noted in control in Aug 2024. Three control biopsies from different locations
revealed mild unspecific dermatitis without signs for T-cell lymphoma.
Discussion
At the first dermatologist appointment, also other diagnosis can be
found that need even immediate attention, like melanoma.
By another author experience (RJH, unpublished results about 20
years ago), a GP’s paper referral for excision of right scapula nodular
basalioma was directly scheduled to the operation room; however, it was found 3
other nodular basaliomas on the back skin, but also a melanoma in the middle of
back between scapulas about 7 cm apart from the nodular basalioma that was
originally sent for referral; all 5 lesions were removed at the same
appointment session.
Also new skin disorders or the older disease can appear or
reactivate during controls and follow-ups and disease can convert to another
type, like plaque psoriasis to erythrodermic form as difficult to treat. When
the patients get older, the risk for malignancies increase, as seen also in
North-Savo Skin Cancer Project; new skin malignancies may develop in risk
patients (data not shown).
It is crucial to make a careful evaluation and inspection each time
when the patient is in front of a doctor, whether dermatologist or GP. After
the patient has got the skin disease diagnosis by a dermatologist, the patient
often is transferred to GP’s follow-up. Further consultations may be performed
by teledermatology3 or by modern internet-based communication methods as WeChat4. The use of
Artificial Intelligence is a growing area which may be beneficial to improve
diagnostic accuracy in a dermatologist’s hands.
Ethical Approval
The patients have given their consent for this case report.
Conflict of
Interest
Authors declare no conflicts of interests.
References