A 47-year-old man comes to the physician with a scaly rash on his face. Two weeks ago, he went to an urgent care clinic and was treated with a topical corticosteroid and antifungal agent. Despite consistent use of these agents, the rash has not improved. He also has new areas on his arms and legs. He reports that he feels constantly embarrassed by his condition.
The skin examination findings are shown in the photograph below.

Which of the following is the best next step in management of this patient?

Question

A 47-year-old man comes to the physician with a scaly rash on his face.  Two weeks ago, he went to an urgent care clinic and was treated with a topical corticosteroid and antifungal agent.  Despite consistent use of these agents, the rash has not improved.  He also has new areas on his arms and legs.  He reports that he feels constantly embarrassed by his condition.
The skin examination findings are shown in the photograph below.

Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_9784_e8aa_853d_a7a163b3fe13_MD0002_00 Seborrheic dermatitis is a common inflammatory disease that affects areas with sebaceous glands such as the scalp (dandruff), face (eyebrows, nasolabial folds, external ear canal/posterior ear), chest, and intertriginous areas. This condition occurs in all age groups but is seen in increased frequency with Parkinson disease. It can also be the initial presentation of HIV in patients with CD4 counts < 400 cells/µL. Patients typically present with pruritic erythematous plaques with fine, loose, yellow, and greasy-looking scales. Seborrheic dermatitis tends to be more severe and extensive in HIV patients, especially those with CD4 < 200 cells/µL. HIV patients can develop lesions in unusual sites (eg, extremities) and may be resistant to topical corticosteroids and antifungals. This patient was treated appropriately for seborrheic dermatitis but was unresponsive and now requires HIV testing. (Choice A) The classic butterfly rash of systemic lupus erythematosus appears as erythema and scaling over the cheeks and bridge of the nose with sparing of the nasolabial folds. Some patients develop discoid lesions that appear as photosensitive, erythematous, and well defined and heal to cause hair loss, skin atrophy, deep scarring, and peripheral hyperpigmentation. systemic lupus erythematosus (Choice C) Topical metronidazole is the most frequently prescribed initial therapy for rosacea. Rosacea presents with facial erythema, telangiectasias, papules or pustules, and episodic flushing over the cheeks, nose, and chin. Flushing may be precipitated by heat, acute stress, medications, and other causes of rapid body temperature changes. rosacea (Choice D) Classic rash of secondary syphilis presents with diffuse maculopapular lesions that involve the trunk and extremities, including the palms and soles. Lesions are reddish-brown and may be pustular or nodular (but not vesicular). secondary syphilis (Choice E) Plaque psoriasis is frequently treated with topical corticosteroids and vitamin D analogs. Lesions are symmetrically distributed over the scalp and extensor surfaces such as elbows, knees, and trunk. Facial involvement is rare. Plaques appear as erythematous, sharply demarcated lesions covered with a silvery scale. Plaque psoriasis Educational objective: Seborrheic dermatitis that is severe and extensive should prompt testing for HIV. In this patient population, it can involve unusual sites (eg, extremities) and is often resistant to commonly prescribed therapy. Treatment includes antifungals and corticosteroids, often for a prolonged period. __________ References: Seborrheic dermatitis. (http://www.ncbi.nlm.nih.gov/pubmed/12956195) Seborrheic dermatitis in patients with acquired immunodeficiency syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/2934444)

A 47-Year-Old Man Comes to the Physician with a Scaly