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Shingles Strikes With a Vengeance
Herpes zoster is simple to diagnose—unless it manifests in less common populations, such as children, younger adults, and the immunocompromised....
3. A 31-year-old man has a relatively asymptomatic penile rash that has repeatedly manifested and resolved over a period of months. A round, papulosquamous, bright pink patch on the distal right shaft of his circumcised penis measures > 3 cm in diameter and has a shiny appearance with slightly irregular margins. A similar rash is seen behind both ears, in the umbilicus, and patches of dandruff are noted. Despite good health, he has been under a great deal of stress recently.
Diagnosis: Seborrheic dermatitis (SD), also known as seborrhea, is an extremely common chronic papulosquamous disorder patterned on the sebum-rich areas of the scalp, face, and trunk. Although not directly caused by the highly lipophilic commensal yeast Malassezia furfur, it does appear to be related to increases in the number of those organisms, as well as to immunologic abnormalities and increased production of sebum. It can range from a mild scaly rash to whole-body erythroderma and can affect an astonishing range of areas, including the genitals.
SD, especially in this case, represents the perfect example of the need to “look elsewhere” for clues when confronted with a mysterious rash. Patients can certainly have more than one dermatologic diagnosis at a time, but a single explanation is considerably more likely and should therefore be sought. In this case, corroboration for the diagnosis of SD was readily found by looking for it in its known locations.
In this case, treatment comprised a combination of oxiconazole lotion and 2.5% hydrocortisone cream. Many other combinations have been used successfully, including pimecrolimus or tacrolimus combined with ketoconazole cream.
Whatever is used, a cure will not be forthcoming, since the condition is almost always chronic. The main value of an accurate diagnosis in such a case lies in easing the patient’s mind regarding the terrible diseases he doesn’t have.
For more information, see “Relatively Asymptomatic, but Still Problematic." Clinician Reviews. 2014 April;24(4):15-16.