A 66-year-old woman comes to the office due to rough, dry, and scaly skin. She has had these symptoms intermittently for most of her life, but they worsen during the winter and have become progressively worse in the last several years. The patient has associated mild itching but no erythema or exudates. She has attempted to treat her symptoms with topical emollients but has been unable to eliminate the problem. Medical history is unremarkable, and the patient does not smoke or drink alcohol. Vital signs are normal. An image of the patient's skin is shown below. Examination of the hands reveal increased major and minor lines in the palms. Which of the following is the most likely diagnosis?

Question

A 66-year-old woman comes to the office due to rough, dry, and scaly skin.  She has had these symptoms intermittently for most of her life, but they worsen during the winter and have become progressively worse in the last several years.  The patient has associated mild itching but no erythema or exudates.  She has attempted to treat her symptoms with topical emollients but has been unable to eliminate the problem.  Medical history is unremarkable, and the patient does not smoke or drink alcohol.  Vital signs are normal.  An image of the patient's skin is shown below.  Examination of the hands reveal increased major and minor lines in the palms.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d37e_4f1a_bc81_d5ffaeb156a3_MD0003_00 This patient has ichthyosis vulgaris, a lifelong, inherited skin disorder characterized by diffuse cutaneous scaling. It is caused by mutations of the filaggrin gene (FLG) that result in epidermal hyperplasia and defective keratinocyte desquamation. Patients with homozygous mutations have worse clinical presentation compared to those who are heterozygous. Symptoms typically appear first in infancy or childhood and worsen during the dry seasons (eg, winter). The skin is rough and dry, with fish-like scales ("ichthys" is the Greek word for "fish") that are white or light gray. There is no associated erythema or other cutaneous lesions (eg, papules, vesicles) to indicate an alternate diagnosis (eg, atopic dermatitis, psoriasis). As in this patient, ichthyosis vulgaris is more noticeable on the extensor surfaces of the legs and spares the intertriginous areas (eg, axilla) and face. It is associated with palmar hyperlinearity and atopic conditions (eg, allergic rhinitis, atopic dermatitis). palmar hyperlinearity (Choice A) Although patients with ichthyosis may have concurrent atopic dermatitis, the latter has focal lesions (eg, erythema, papules, lichenification) typically on flexural surfaces rather than diffuse scales. papules lichenification flexural surfaces (Choice B) Dry skin can occur during the winter, when ambient humidity is low; however, thick, fish-like scales and palmar hyperlinearity are not characteristic of isolated dry skin. (Choice D) Irritant contact dermatitis is caused by exposures to irritating chemicals (eg, soaps, detergents, solvents) and typically presents with marked erythema, a burning sensation, or pruritus in a localized, not diffuse, area. marked erythema (Choice E) Plaque psoriasis presents with well-demarcated, localized erythematous plaques with silvery scales over the extensor surfaces of the elbows, knees, scalp, and trunk. These features are absent in this patient. Plaque psoriasis Educational objective: Ichthyosis vulgaris is a lifelong, inherited disorder characterized by diffuse dry and rough skin with fish-like scales. These features are most noticeable on the extensor legs and during the winter. There is no associated erythema or other cutaneous lesions (eg, vesicles, papules) to indicate an alternate diagnosis. References: Ichthyosis vulgaris: the filaggrin mutation disease. (http://www.ncbi.nlm.nih.gov/pubmed/23301728)

A 66-Year-Old Woman Comes to the Office Due to Rough