Cutaneous

A 55-year-old man with type 2 diabetes presents to the emergency department with widespread skin sloughing and flaccid blisters that extend further when lateral pressure is applied. The denuded areas involve his entire anterior and posterior torso, and he also has painful erosions inside his mouth. Using the rule of nines, which of the following is the most likely diagnosis?

A 6-year-old boy with a long-standing history of moderate-to-severe atopic eczema, currently using topical corticosteroids for flares, is brought to the emergency department with a 3-day history of a rapidly spreading rash. His mother reports he was systemically unwell yesterday with poor feeding and lethargy. On examination he is febrile at 38.7°C, heart rate 130/min, and appears unwell. Over his face, neck and flexural surfaces there are numerous discrete, monomorphic, punched-out erosions with a scalloped border, some with haemorrhagic crusting, superimposed on background eczematous skin. There is tender bilateral cervical lymphadenopathy. There is no periorbital swelling or ocular discharge. Which of the following is the most likely diagnosis?

A 65-year-old retired farmer presents to the emergency department after his wife noticed a mole on his back had become darker and larger over the past four months. He has a background of hypertension and a lifetime of significant occupational sun exposure, with Fitzpatrick skin type II. He denies bleeding, itch or ulceration of the lesion and has no personal or family history of skin cancer. Vital signs are normal. On examination there is a 9 mm irregularly bordered, variably pigmented macule on the left upper back. Dermoscopy performed by the treating clinician reveals asymmetry of structures, an atypical pigment network and a blue-white veil. There is no palpable regional lymphadenopathy. What is the most appropriate next step in management?

A 6-month-old girl is brought to the emergency department because of a rapidly enlarging lesion adjacent to her left upper eyelid. Her parents report that the area was normal at birth but developed a faint pink mark at around 3 weeks of age, which has grown steadily since. On examination she is afebrile with normal vital signs and is feeding and growing well. The lesion is a bright red, rubbery, well-demarcated, lobulated plaque measuring approximately 2 cm x 1.5 cm that partially overhangs the upper eyelid margin. It is warm, non-tender, minimally compressible and does not ulcerate or bleed on gentle handling. The parents note increasing eyelid swelling over the past fortnight, though the infant still opens both eyes symmetrically to visual threat. There is no proptosis, no other cutaneous lesions, and no hepatosplenomegaly. What is the most likely diagnosis?

A 40-year-old woman presents to the emergency department with a 3-week history of mildly itchy patches on her trunk and upper arms, which she first noticed after a recent backpacking trip through Thailand and Vietnam. She reports that the patches have become far more obvious since she has been sunbathing over the past fortnight, as the surrounding skin has tanned while the patches have remained pale. She is otherwise well, afebrile, and has no significant past medical history or exposure to cats, soil, or thorny plants. On examination there are multiple discrete and coalescing hypopigmented macules with a fine, powdery scale distributed over the upper back, chest and proximal arms; gentle scratching of a lesion accentuates the scale. There is no annular active border, no silvery thick plaque, and no sharply demarcated depigmented macule. Vital signs are normal. What is the most likely diagnosis?

A 68-year-old man is reviewed in the emergency short-stay unit three days after admission with a right middle cerebral artery ischaemic stroke. He has dense left hemiparesis and reduced sensation on the affected side, and has been largely bedbound since admission with a Braden score of 12 (high risk). His temperature is 36.8°C, heart rate 82/min, blood pressure 128/76 mmHg, and he is normoglycaemic with a low serum albumin. On examination of the left heel there is a 3 x 4 cm area of intact skin that is purplish-maroon in colour, boggy on palpation and does not blanch with pressure. There is no open wound, no exudate, no surrounding warmth or cellulitis, and no fluctuance. What is the most appropriate next step in management?