Check, check, check
More mistakes are made by not looking than not knowing!
It's essential in almost every instance that the skin is examined in its entirety. This should also include the mucous membranes. Sometimes the diagnostic signs of a condition are evident in areas that are easy to overlook – such as the major flexures (groins and axillae), the genital skin, and also the feet. It is easy to leave their socks on!
Here are two examples where I may have missed the diagnosis had I not looked everywhere.
Example 1
This baby has been scratching since the age of eight weeks. This started after the introduction of formula feed as mum was unable to breastfeed. The initial diagnosis was felt to be eczema. His elder sibling and father both had eczema.
Indeed, there was an eczematous eruption affecting the trunk. However, on removing the baby's socks, the diagnostic signs of burrows, indicating scabies, were found.
Scabies can be an easy diagnosis and can also be terribly difficult. Burrows tend to be present on the sides of the fingers, the palms, wrists and also the soles, heels and Achilles tendons. Scabies nodules are also diagnostic, but they also need to be looked for. Check the axillae, nipples, the gluteal folds, scrotum and penis. In the setting of an itchy patient, scabies nodules are as diagnostic as burrows. Do not be bashful and explain why you need to look everywhere!
Example 2
The second patient was in his sixties. He had a six-week history of a rash on his chest.
He had not been feeling well and also had a headache. The rash on his trunk was a faint papulosquamous eruption. There were no lesions on his palms, but again on removing his socks, he had these macular lesions, shown above, on his soles. These are highly suspicious of secondary syphilis. His syphilis serology proved positive and further testing for STIs and contact tracing, then ensued.
Had I not looked at his feet, I might have missed the diagnosis!
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Comments
26 June 26
Raul
I thought the presence on palms and soles are characteristics of secondary syphilis
25 June 26
Ali
This fact, could save lives, like missed strangulated hernia. absolutely this is a must.
25 June 26
Shaunagh
Thank you for these interesting cases. I work in allergy and have seen a few chronic spontaneous urticaria referrals that were in fact longstanding scabies. The diagnosis of scabies once it becomes chronic can be clinically tricky.
25 June 26
Mahmoud Khalifa Marzouq
Scabies in infants is usually affects all the body specially in the face and soles as in the 1st photo.
2 July 26
Nagappan
I always look at the axillae and scrotum in boys when in doubt. Always ask if anyone else is scratching in the family or school/hostel.
25 June 26
Annette
Yay, got them both right! I missed a secondary syphilis in my early years as a GP, and have never forgotten that rash.
25 June 26
David
The brown macules on the palms/soles may be the only overt sign of secondary Syphilis, especially late in its evolution. Indeterminate hand scaling may be diagnosed by finding Tinea Pedis which may also elucidate the two feet, one hand eruption. Beware the eczematous eruption of the soles, and heels, that is, in fact, Psoriasis.
25 June 26
David
The brown macules on the palms/soles may be the only overt sign of secondary Syphilis, especially late in its evolution. Indeterminate hand scaling may be diagnosed by finding Tinea Pedis which may also elucidate the two feet, one hand eruption. Beware the eczematous eruption of the soles, and heels, that is, in fact, Psoriasis.
24 June 26
Shabbir
Interesting
These 2 cases highlighted an important point
24 June 26
Ramana
EXCELLENT LESSON TO BE LEARNED (AND i HAVE LEARNED IT FROM OWN EXPERIENCE)
24 June 26
Nina Sawicki
How common are macular lesions on the soles in Syphilis ??
I have never seen them there
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