Case report: Uncommon colour

We see many rashes at our walk-in clinic. Most are of relatively recent origin—and some have been recurrent. A thorough history often provides clues as to the origin of a rash—as does the appearance in many cases. A 33-year-old, light brown-skinned woman recently from India, came for an opinion, possibly a diagnosis—but especially treatment of a rash she has had for seven months. The rash had been spreading, initially on the backs of her legs, now virtually everywhere. The main feature of the rash, curiously enough, since the majority of rashes usually present with itch, was severe burning pain. The pain was aggravated by eating and being in bed with covers. The patient was in good health, with no (known) underlying illness. She was taking no medications, reporting only a penicillin allergy. She had never experienced a rash previously, and there was no family history of rashes or other systemic illness. She had seen a physician who diagnosed “eczema” and suggested moisturizers. Prolonged use of moisturizers had not helped and the rash continued to spread. Apart from progression and pain, the patient was now also concerned about the appearance.Indeed, the rash was dramatic (see picture). Slightly raised, blackish patches of dermatitis covered all portions of her body—no inflammation. Despite the appearance and progression, the patient’s only acute concern was the severe pain she was experiencing. Tylenol and Advil had been suggested previously, with little relief. I was reluctant to prescribe “pain” medication, with no diagnosis. I did not think that the patient was just seeking pain medication—a common problem at walk in clinics.,With the peculiar dark colour of the patient’s rash, the only diagnosis which occurred to me was possibly Acanthosis Nigricans (which I have never seen before). The patient will need blood work to rule out asymptomatic diabetes (and lupus etc.), Because of the duration of the problem, with no acute change,I elected to refer the patient back to her family physician, with a note. She will require fairly urgent referral to a dermatologist, best done through her established contacts. My only suggestion for her pain, was a short course of oral prednisone, keeping in mind that if diabetes was involved, it could be temporarily worsened.I would be interested in the opinion, diagnosis and acute care, other physicians might have considered.Dr. Robert Dickson is a family physician in Hamilton. This report is based on a real case from Dr. Dickson’s files.

Case report: Uncommon colour

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