Simple cases
Case 7
72-year-old women with pruritic ulcerated dermatitis on trunk
History
How long have you had this skin problem?
It has been red for years but the itching and open sore have been present for about one year.
Important question, since this dermatitis appears years to decades after exposure to ionizing radiation.
Is it painful? Does it itch?
Yes, it itches a lot and sometimes burns.
The chronic inflammatory reaction can lead to itching, burning or pain.
Do you have any idea what could have caused this?
Yes, I think so. I received radiation therapy to this site about 15 years ago in old East Germany. The doctors said I had something in my abdomen, performed surgery and then gave me x-rays.
Very important question, as in this case, the history is the answer!
Have you used any creams or ointments?
Have you used any creams or ointments?
This question is always importantboth to plan further treatment and to explore a possible reaction to a medication.
Do you have any other medical problems?
Do you have any other medical problems?
Another important question - both for planning treatment and to look for other predisposing causes.
Could it be that you frequently scratch this area and keep the wound open?
No, not really. It itches a lot but I keep my hands away.
Important to try and rule out self-induced changes.
Lesion
Choose the right efflorescences:
False
False
Correct. Very good. The key feature to this disorder is a relatively well-circumscribed atrophy of the skin, subcutaneous fat and sometimes even musculature. The skin is typically smooth, hypo- and hyperpigmented, hairless, and dry (atrophy of adnexal structures). There are many small vessels (telangiectases). The whole picture is called poikiloderma.
False. An erosion is more superficial and heals without scarring.
Correct. Such ulcers are the result of local trophic changes. They appear punched out and heal poorly.
Diagnosis
Choose the right diagnosis:
False. Burns are acute, painful, and if widespread, life-threatening. They are divided into grades 1-3.
Correct. Depending on the dose of ionizing radiation, the irradiated area can develop chronic changes after years to decades. It serves as an area of least resistance, sensitive to light, mechanical damage and other physical factors.
False. The patient did not create this lesion.
False. The patient did not apply something that created the lesion.
Therapy
Choose the right therapy(ies):
False. Not helpful and may worsen atrophy.
Correct. Protective or lubricating creams and ointments may be helpful. The ulcers heal poorly.
Correct. Excision and coverage with a graft is often helpful.
False. This is absolutely contraindicated; it can only worsen the situation.
False. The skin should be protected, not challenged.
Test
The following questions are related to the current case. Try to solve them.
