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A 29 year old woman was admitted to the medical ward feeling generally unwell with a one week history of bilateral leg weakness, increased anxiety, and labile mood. She also described a five month history of blistering on the face, chest, and dorsum of her hands, without a confirmed diagnosis. She had previously seen her general practitioner and also attended the emergency department complaining of abdominal and back pain, sometimes associated with vomiting, but no diagnosis had been made and she had not been referred to dermatology. Her medical history included bipolar disease diagnosed five years ago, which was controlled with sodium valproate, and bulimia. On examination, there were multiple angulated erosions on her face and upper chest (fig 1A⇓). A single large irregularly shaped tense bulla was present on the dorsum of the right hand surrounded by a few smaller erosions on both hands. Scarring and milia were also noted at sites of previous blisters (fig 1B⇓). Systemic examination was unremarkable. Blood testing showed a normal full blood count and liver and renal function. Sodium level was low at 130 mEq/L. (normal range 133-146), C reactive protein was

A 74 year-old woman presented with a 9 month history of a slowly enlarging exophytic lesion over her left nasal alar. Examination revealed a firm, cystic mass fixed to underlying skin. It was pedunculated with occasional superficial telangiectasia and a violaceous hue. A differential diagnosis of dermoid or sebaceous cyst, dermatofibroma, and neurofibroma was considered. Histopathological examination confirmed the rare diagnosis of chondroid syringoma (CS), which has a reported incidence of 0.01- 0.098% of excised skin tumors. It is unusual for CS to present in an elderly woman, as these benign primary skin tumors normally present in adult males. Dermoscopy does not reveal any specific features and the diagnosis is difficult to make based on clinical examination alone.

Summary Toxic epidermal necrolysis (TEN) is a life-threatening, immune-mediated reaction, characterized by severe cutaneous and mucosal blisters and erosions. It often presents with flu-like symptoms, followed by a maculopapular, urticarial, purpuric or erythema multiforme-like eruption, which then evolves into blisters and sheet-like erosions. Presentation with pustules, however, is not well described in the English literature, and may lead to delayed diagnosis. We present two unusual cases of TEN that initially presented with pustular lesions.

A 74 year-old woman presented with a 9 month history of a slowly enlarging exophytic lesion over her left nasal alar. Examination revealed a firm, cystic mass fixed to underlying skin. It was pedunculated with occasional superficial telangiectasia and a violaceous hue. A differential diagnosis of dermoid or sebaceous cyst, dermatofibroma, and neurofibroma was considered. Histopathological examination confirmed the rare diagnosis of chondroid syringoma (CS), which has a reported incidence of 0.01- 0.098% of excised skin tumors. It is unusual for CS to present in an elderly woman, as these benign primary skin tumors normally present in adult males. Dermoscopy does not reveal any specific features and the diagnosis is difficult to make based on clinical examination alone.

Colloid degeneration is a rare but well-recognized entity, usually occurring on chronically sun-exposed skin. We report a case occurring on penile skin with no history of such exposure.

Treatment of trigeminal trophic syndrome is challenging and often unsatisfactory, particularly in patients with cognitive impairment. We report the novel use of a thermoplastic dressing in two patients with trigeminal trophic syndrome. Use of the dressing resulted in successful healing of ulceration in both patients, which has been maintained in the short term, representing a simple and economical therapeutic option in the management of this difficult condition.

An 87 year old woman presented with a non-itchy rash that began three weeks ago on the abdomen. Since then it had spread to most of her trunk, face, and lower limbs. She was not systemically unwell. Her medical history included atrial fibrillation, cerebrovascular disease, hypertension, and an intertriginous reaction for which oral terbinafine 250 mg daily had been started three days before the rash began. Current long term drugs included aspirin, warfarin, alendronic acid, bisoprolol, calcium supplements, candesartan, furosemide, loperamide, and omeprazole. She had no known drug allergies. On examination, large confluent patches and plaques of oedematous erythema were present especially on the trunk, face, and lower limbs. The palms and soles were spared. Hundreds of small non-follicular based pustules were seen within these areas. No ulceration or blistering was seen. Blood tests showed normal renal and liver function, C reactive protein (31 mmol/L; normal 0-1.7), total white cell count (15.7 ×109/L; 4.0-11.0), neutrophil count (13.6×109/L; 2.5-7.5), lymphocyte count (1.36×109/L), eosinophil count (0.32×109/L; 0.04-0.44). Haemoglobin and platelet counts were within the normal range. A swab from a pustule showed no bacterial growth. Histological analysis showed subcorneal pustules. Terbinafine was stopped immediately and the patient was treated with topical steroids and emollients. The rash began to resolve within a week. ### 1 What is the diagnosis in this case of generalised pustulosis? #### Short answer On the basis of the history and clinical and histopathological findings the diagnosis is acute generalised exanthematous pustulosis. #### Long answer Acute generalised exanthematous pustulosis is an adverse cutaneous drug eruption in which many small sterile pustules develop within large areas of erythema (figure⇓), often within a few …

Cutaneous ulceration caused by nicorandil is well described at perianal(1) , anal(2) , peristomal(3) , oral(4) , vulval(5) and cutaneous sites(6) , and most recently on the conjunctiva(7) . We present the first reported cases of nicorandil-induced ulceration on the temple and the nasal mucosa, which were referred as possible skin malignancies. Patient 1 was an 88-year-old gentleman with a 3-week history of a painful ulcer on his left temple. He had been receiving 20mg twice-daily nicorandil for the previous 2 years. This article is protected by copyright. All rights reserved.

A 33-year-old man with recessive dystrophic epidermolysis bullosa presented with a 3-month history of an enlarging mass within scarring on the posterior aspect of the right shoulder. The clinical appearance of the mass with an almost cobbled, verrucous surface, and its rapid evolution suggested the development of a squamous cell carcinoma (SCC) in a chronically scarred site. Histopathological examination of a biopsy taken from the lesion subsequently revealed it to be a verruciform xanthoma. This case shows that benign phenomena can mimic SCC and underlines the need for a biopsy to be taken promptly.