A 25-year-old college student comes to the office for evaluation of a rash. His symptoms began 2 months ago on his face and progressed over time to involve his upper chest, upper back, and axillary areas. The rash is associated with mild pruritus and erythema but no pain, fever, or exudate. The patient has a history of acne during adolescence and increasing "dandruff" over the last year; his medical history is otherwise unremarkable. He takes no regular medications. The patient does not use tobacco but drinks alcohol heavily on weekends and occasionally smokes marijuana. Temperature is 36.8 C (98.2 F), blood pressure is 118/70 mm Hg, and pulse is 64/min. BMI is 26 kg/m². Physical examination shows erythematous plaques on the eyebrows, nasal bridge, nasolabial folds, upper lip, upper chest, and back. The plaques have an indistinct margin and are covered by fine, greasy scales. Which of the following is the most appropriate next step in management of this patient?

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Explanation: 11ec2b69_be88_32a0_8f63_1f64ce002471_MD0005_00 This patient has characteristic features of seborrheic dermatitis, including mildly pruritic, erythematous plaques with greasy scales. Seborrheic dermatitis affects areas with heavy concentrations of sebaceous glands, including the scalp (where it is often referred to as "dandruff"), central face (eg, eyebrows, nasal bridge, nasolabial folds), and ears; it may also occur on the chest, upper back, axilla, and inguinal/pubic area. Treatment commonly includes topical antifungals (eg, selenium sulfide shampoo, topical ketoconazole), topical glucocorticoids (eg, betamethasone valerate), or calcineurin inhibitors (eg, pimecrolimus cream). Seborrheic dermatitis "dandruff" Seborrheic dermatitis usually occurs as an isolated condition. However, it has an increased incidence in association with central nervous system disorders (especially Parkinson disease). It is also common in HIV infection and can be a presenting feature. Physicians should consider the possibility of HIV infection in patients with a new onset of severe or widespread seborrheic dermatitis, lesions in unusual sites (eg, extremities), or who fail to respond to appropriate treatment. severe (Choice A) The diagnosis of seborrheic dermatitis is based primarily on clinical features. Biopsy findings are nonspecific and usually not needed for diagnosis. (Choice B) Potassium hydroxide preparation of skin scrapings can identify the hyphae and yeast forms of Malassezia species in patients with tinea versicolor. Although Malassezia species are also implicated in seborrheic dermatitis, their precise role in the pathogenesis is unclear and identification is not needed for diagnosis. tinea versicolor (Choice C) Antinuclear antibody assay is used as an initial test for systemic lupus erythematosus (SLE). SLE causes a characteristic rash affecting the central face and other sun-exposed areas, but, unlike in seborrheic dermatitis, the lesions are typically not scaly and the nasolabial folds, scalp, and eyebrows are relatively spared. rash (Choice D) Sarcoidosis is associated with a variety of dermal manifestations, including lupus pernio, which presents as erythematous papules and plaques affecting the central face. This patient's involvement of the scalp, eyebrows, and nasolabial folds is more characteristic of seborrheic dermatitis. lupus pernio Educational objective: Seborrheic dermatitis is characterized by pruritic, erythematous plaques with greasy scales and typically affects the scalp, central face, and ears. It usually occurs as an isolated condition but has an increased incidence in association with Parkinson disease and HIV infection, in which it may be a presenting feature. References: Diagnosis and treatment of seborrheic dermatitis. (http://www.ncbi.nlm.nih.gov/pubmed/25822272)

A 25-Year-Old College Student Comes to the Office for Evaluation