Dermatology therapy essentials - part 9 doc

S Saethre-Chotzen syndrome ᭤ Acrocephalosyndactyly Sailor’s neck ᭤ Actinic elastosis Salivosudoriparous syndrome ᭤ Auriculotemporal syndrome Salmon patch Synonym(s) Stork bite ; angel’s kiss ; nevus simplex ; erythema nuchae Definition Vascular malformation, present in infancy, consisting of ectatic capillaries Pathogenesis Possible persistent fetal circulatory pattern Clinical manifestation Pink-to-red macule or patch on the nape of the neck, glabella, forehead, upper eyelid, or nasolabial region; present at birth in about 40% of cases Differential diagnosis Hemangioma; Sturge-Weber syndrome; child abuse; insect bite reaction Therapy No therapy indicated References Mallory SB (1991) Neonatal skin disorders. Pedi- atric Clinics of North America 38(4):745–761 Salmonellosis Synonym(s) Typhoid fever ; paratyphoid fever Definition Infection caused by bacteria in the genus Salmonella, usually contracted by eating contaminated food PART19.MIF Page 513 Friday, October 31, 2003 12:22 PM 514 San Joaquin Valley fever Pathogenesis Infection caused by salmonellae, gram-neg- ative, rod-shaped bacteria of the family Enterobacteriaceae; most common sources of bacteria: beef, poultry, eggs Clinical manifestation Skin signs: light red papules (rose spots) occurring in crops on trunk during second to fourth week of illness; erythema nodo- sum, Sweet’s syndrome, pustular dermatitis and generalized erythroderma (erythema typhosum) Gastrointestinal signs: loose stool or watery diarrhea; abdominal pain; mild hepatosplenomegaly Differential diagnosis Viral gastroenteritis; shigellosis; ingestion of preformed toxins (“food poisoning”); campylobacter infection; cryptosporidio- sis; cyclospora infection; escherichia coli infection; listeriosis; vibrio infection Therapy Antibiotics only for patients with severe disease or those at high risk of invasive disease: ciprofloxacin; amoxicillin ᭤ Typhoid fever References Stutman HR (1994) Salmonella, shigella, and campylobacter: common bacterial causes of infectious diarrhea. Pediatric Annals 23(10):538– 543 San Joaquin Valley fever ᭤ Coccidioidomycosis Sandworm disease ᭤ Cutaneous larva migrans Sanfilippo syndrome Synonym(s) Mucopolysaccharidosis type III-A ; mucopolysaccharidosis type III-B ; mucopolysaccharidosis type III-C Definition Inherited metabolic storage disease from a deficiency of either heparan sulfate sulfamidase, N- acetyl-alpha-D-glucosaminidase, acetyl-CoA alpha-glucosamide N- acetyl- transferase, or N- acetyl-alpha-D-glucosamine-6-sulfatase Pathogenesis Autosomal recessive trait; deficiency of either heparan sulfate sulfamidase, or N- acetyl-alpha-D-glucosaminidase, or acetyl- CoA alpha-glucosamide N- acetyltrans- ferase, or N- acetyl-alpha-D-glucosamine-6- sulfatase, resulting in accumulation of mucopolysaccharides in the lysosomes of the cells in the connective tissue Clinical manifestation Onset of symptoms from age 2–6 years; organs most involved: bone, viscera, connective tissue, and brain; regression of psy- chomotor development and neurologic signs, including severe mental retardation, hyperactivity, autistic features, and behav- ioral disorders; thickened facial features; coarse hair; hirsutism; genu valgum; short neck; progressive deterioration and death, usually before age 20 years Differential diagnosis Hunter syndrome; Hurler syndrome; Scheie syndrome; Gaucher’s disease; Niemann- Pick disease Therapy None References Yogalingam G, Hopwood JJ (2001) Molecular ge- netics of mucopolysaccharidosis type IIIA and PART19.MIF Page 514 Friday, October 31, 2003 12:22 PM Say syndrome 515 S IIIB: Diagnostic, clinical, and biological impli- cations. Human Mutation 18(4):264–281 Sao Paulo fever ᭤ Rocky Mountain spotted fever Sarcoidosis Synonym(s) Angiolupoid sarcoid ; Besnier-Boeck-Schau- mann disease ; Boeck's sarcoid Definition Chronic multisystem disease, characterized by noncaseating epithelioid granulomas Pathogenesis May result from exposure of a genetically susceptible host to specific environmental agents, such as infectious organisms, alu- minium, zirconium, talc, pine tree pollen, and clay, that the immune system is unable to effectively clear Clinical manifestation Skin: asymptomatic, red-brown macules and papules commonly involving the face, periorbital, nasolabial folds, extensor surfaces of extremities; round-to-oval, red- brown-to-purple, infiltrated plaques, the center of which may be atrophic; non- tender, firm, oval, flesh-colored or violaceous nodules on extremities or trunk (Darier-Roussy sarcoidosis); inflitration of scars Pulmonary system: involvement in most patients; dyspnea; dry cough; chest tight- ness or pain Lymphatic system: palpable lymph nodes Ocular involvement: anterior uveitis, associated with fever and parotid swelling (uve- oparotid fever) Neurologic system: central nervous system involvement sometimes fatal; seventh cra- nial nerve palsy most frequent finding; mis- cellaneous findings: myocardial involvement, arthritis, proximal muscle weakness, renal failure Differential diagnosis Tuberculosis; lymphoma; pseudolymphoma; foreign body granuloma; drug reaction; granuloma annulare; granuloma faciale; lichen planus; lupus erythematosus; leprosy; syphilis; psoriasis; tinea corporis; necrobiosis lipoidica Therapy Cutaneous involvement: triamcinolone 3 mg per ml intralesional Severe, recalcitrant disease: methotrexate; azathioprine; hydroxychloroquine Symptomatic systemic disease: prednisone ଙ References Vourlekis JS, Sawyer RT, Newman LS (2000) Sar- coidosis: developments in etiology, immunolo- gy, and therapeutics. Advances in Internal Medicine 45:209–257 Sarcoma botryoides ᭤ Rhabdomyosarcoma Savill’s syndrome ᭤ Sulzberger-Garbe syndrome Say syndrome ᭤ Barber-Say syndrome PART19.MIF Page 515 Friday, October 31, 2003 12:22 PM 516 Scabies Scabies Synonym(s) Seven-year itch Definition Contagious infestation of the skin by arach- nid mite Sarcoptes scabiei, var hominis Pathogenesis Causative organism is mite, Sarcoptes scabiei; disease spreads through direct and prolonged contact between hosts; possible transmission through fomites, such as infected bedding or clothing, but less likely; delayed type IV hypersensitivity reaction to mites, eggs, or scybala (packets of feces) which causes intense pruritus Clinical manifestation Intense pruritus, particularly at night; slightly elevated, pink-white, linear, curved, or s-shaped line (burrow), located in webbed spaces of fingers, flexor surfaces of wrists, elbows, axillae, belt line, feet, and scrotum in men and areolae in women; bur- rows on the palms and soles in infants; vesi- cles; red papules on penile shaft Nodular variant: pink, tan, brown, or red nodules lasting for weeks Crusted (Norwegian) variant: occurs in immunocompromised and institutional- ized patients; minimally pruritic, hyperkeratotic, crusted plaques over large areas; nail dystrophy; scalp lesions Differential diagnosis Atopic dermatitis; dermatitis herpeti- formis; pityriasis lichenoides; lichen planus; insect bite reaction; contact dermatitis; psoriasis; ecthyma; impetigo; xerotic eczema; transient acantholytic dermatosis; linear IgA bullous dermatosis; seborrheic dermatitis; erythroderma from other causes such as Sézary syndrome and pemphigus foliaceus; Langerhans cell histiocy- tosis; fiberglass dermatitis; dyshidrotic eczema; pityriasis rosea; animal scabies; pediculosis; delusions of parasitosis; metabolic pruritus Therapy Permethrin; ivermectin; prednisone for severe symptoms References Wendel K, Rompalo A (2002) Scabies and pediculosis pubis: an update of treatment regimens and general review. Clinical Infectious Diseases 35(Suppl 2):S146–151 Scalded skin syndrome ᭤ Staphylococcal scalded skin syndrome Scalp and head syndrome ᭤ Adams-Oliver Syndrome Scalp cyst ᭤ Pilar cyst Scabies. Scaly and fissured papules and plaques in the finger web spaces PART19.MIF Page 516 Friday, October 31, 2003 12:22 PM Schamberg’s progressive pigmented purpura 517 S Scarlatina ᭤ Scarlet fever Scarlet fever Synonym(s) Scarlatina Definition Bacterial infection caused by toxin-produc- ing group-A beta hemolytic streptococci Pathogenesis Eruption caused by erythemogenic toxin as consequence of local production of inflammatory mediators and alteration of the cutaneous cytokines Clinical manifestation Abrupt onset of fever, headache, vomiting, malaise, chills, and sore throat, with rash appearing after 1–4 days; exudative tonsilli- tis a common site of infection; mucous membranes usually bright red; scattered petechiae and small, red papules on soft palate; during first days of infection, white membrane coating on tongue through which edematous, red papillae protrude (white strawberry tongue); after white membrane sloughs, tongue red with prominent papillae (red strawberry tongue); exanthem consisting of fine red, punctate papules, appearing within 1–4 days follow- ing the onset of illness; first appear on upper trunk and axillae and then general- ize, with accentuation in flexural areas; may appear more intense at dependent sites and sites of pressure, such as the buttocks; sand- paper feel to affected skin; transverse areas of hyperpigmentation with petechiae in the axillary, antecubital, and inguinal areas (Pastia lines); flushed face with circumoral pallor; rash fades with fine desquamation after 4–5 days Differential diagnosis Viral exanthem, including rubella, rubeola, fifth disease; toxic shock syndrome; Kawa- saki syndrome; lupus erythematosus; drug reaction Therapy Penicillin VK ଙ ; benzathine penicillin G; penicillin allergy – cephalexin, erythromy- cin References Chiesa C, Pacifico L, Nanni F, Orefici G (1994) Re- current attacks of scarlet fever. Archives of Pediatrics & Adolescent Medicine 148(6):656– 660 Scarring pemphigoid ᭤ Cicatricial pemphigoid Schamberg disease ᭤ Benign pigmented purpura Schamberg’s progressive pigmented purpura ᭤ Benign pigmented purpura Scarlet fever. Bright red tongue with prominent papillae PART19.MIF Page 517 Friday, October 31, 2003 12:22 PM 518 Scheie syndrome Scheie syndrome Synonym(s) Mucopolysaccharidosis type I-H/S ; mucopolysaccharidosis type I-S ; Hurler-Scheie syndrome Definition Inherited metabolic storage disease arising from a deficiency of alpha-L-iduronidase Pathogenesis Autosomal recessive trait; deficiency of alpha-L-iduronidase, which results in accumulation of mucopolysaccharides in the lysosomes of the cells in the connective tissue Clinical manifestation Onset of symptoms from age 2–4 years; signs and symptoms similar to those of Hurler syndrome, but milder, with slower progression; lichenified, dry, thick skin with diminished elasticity; increased pig- mentation on the dorsum of the hands; sclerodermalike changes; hypertrichosis of the extremities; pale colored hair; mild skeletal deformation and deformity of the hands; growth sometimes normal; aortic stenosis or regurgitation sometimes present; hepatosplenomegaly; intelligence usually normal Differential diagnosis Hurler syndrome; Hunter syndrome; Gau- cher’s disease; Niemann-Pick diseae; osteo- genesis imperfecta Therapy None References Schiro JA, Mallory SB, Demmer L, Dowton SB, Luke MC (1996) Grouped papules in Hurler- Scheie syndrome. Journal of the American Academy of Dermatology 35(5 Pt 2):868–870 Schenck's disease ᭤ Sporotrichosis Schilder-Addison syndrome ᭤ Addison-Schilder disease Schnitzler syndrome Synonym(s) Schnitzler’s syndrome Definition Disorder characterized by chronic urticaria, in association with recurrent fever, bone pain, and IgM monoclonal gammopa- thy Pathogenesis May be related to deposition of the IgM paraprotein, leading to immune complex deposition and complement activation Clinical manifestation Chronic urticaria; individual episode usually resolves within few hours; fevers per- sist for up to 24–48 hours; relapsing arthralgias; bone pain involving tibia, femur, ileum, and vertebral column; myal- gias; fatigue; weight loss Differential diagnosis Urticarial vasculitis; lupus erythematosus; adult Still disease; Waldenström mac- roglobulinemia; chronic hepatitis B infection Therapy Acute disease flare: prednisone PART19.MIF Page 518 Friday, October 31, 2003 12:22 PM Scleredema adultorum of Buschke 519 S References Lipsker D, Veran Y, Grunenberger F, Cribier B, Heid E, Grosshans E (2001) The Schnitzler syndrome. Four new cases and review of the litera- ture. Medicine 80(1):37–44 Schnitzler’s syndrome ᭤ Schnitzler syndrome Schönlein-Henoch purpura ᭤ Henoch-Schönlein purpura Schwannoma ᭤ Granular cell tumor Schweninger and Buzzi, idiopathic anetoderma of ᭤ Anetoderma Scleredema Synonym(s) Scleredema adultorum; scleredema adultorum of Buschke; scleredema diabeticorum; scleredema diabeticorum of Bus- chke Definition Disorder characterized by nonpitting, indurated plaques and histological evidence of dermal mucin deposition Pathogenesis Increased procollagen synthesis Clinical manifestation Group 1 subtype: precedes febrile illness, particularly upper respiratory tract streptococcal infection; usually clears in 6 months to 2 years Group 2 subtype: no prior history of febrile illness; insidious onset of skin lesions; at risk of developing paraproteinemias, including multiple myeloma Group 3 subtype: prior history of diabetes mellitus, usually adult onset and insulin dependent, unremitting course; ill-defined, woody, nonpitting, indurated plaques; erythema, hyperpigmentation, and/or a peau d’orange appearance; usually located on face, neck, trunk, or upper extremities Differential diagnosis Scleroderma; lichen myxedema; generalized myxedema; sclerema neonatorum; amyloidosis; cellulitis; erysipelas Therapy No effective therapy References Tate BJ, Kelly JW, Rotstein H (1996) Scleredema of Buschke: a report of seven cases. Australasian Journal of Dermatology 37(3):139–142 Scleredema adultorum ᭤ Scleredema Scleredema adultorum of Buschke ᭤ Scleredema PART19.MIF Page 519 Friday, October 31, 2003 12:22 PM 520 Scleredema diabeticorum Scleredema diabeticorum ᭤ Scleredema Scleredema diabeticorum of Buschke ᭤ Scleredema Scleredema of Buschke ᭤ Scleredema Sclerema ᭤ Sclerema neonatorum Sclerema neonatorum Synonym(s) Sclerema Definition Disorder of the subcutaneous fat in debili- tated neonates, resulting in generalized subcutaneous plaques Pathogenesis Prematurity, hypothermia, shock, and metabolic abnormalities increases saturated-to- unsaturated fatty acid ratio, possibly as a result of enzymatic alteration, allowing pre- cipitation of fatty acid crystals within lipocytes; occurs with prematurity, pneu- monia, septicemia, respiratory distress syndrome, congenital heart defects, gastroenteritis, and intestinal obstruction Clinical manifestation Firm, violaceous subcutaneous plaques appearing suddenly, first on thighs and buttocks and then spreading; may affect all parts of the body except palms, soles, and genitalia; temperature instability; restricted respiration; difficulty in feeding; decreased spontaneous movement Differential diagnosis Scleredema; scleroderma; subcutaneous fat necrosis of newborn; neonatal cold injury Therapy No specific therapy for skin disorder; insti- tution of therapy specific for the underlying disease References Fretzin DF, Arias AM (1987) Sclerema neonatorum and subcutaneous fat necrosis of the newborn. Pediatric Dermatology 4(2):112–122 Scleroderma Synonym(s) None Definition Group of disorders characterized by skin thickening secondary to increased dermal collagen production ᭤ Progressive systemic sclerosus References Haustein UF (2002) Systemic sclerosis-scleroderma. Dermatology Online Journal 8(1):3 Sclerodermoid fasciitis ᭤ Eosinophilia-myalgia syndrome PART19.MIF Page 520 Friday, October 31, 2003 12:22 PM Scrub typhus 521 S Sclerodermoid myalgia ᭤ Eosinophilia-myalgia syndrome Scleroma ᭤ Rhinoscleroma Scleromyxedema ᭤ Papular mucinosis Scleromyxedema-like illness of hemodialysis ᭤ Nephrogenic fibrosing dermopathy Scleromyxedema-like illness of renal disease ᭤ Nephrogenic fibrosing dermopathy Sclerosing angioma ᭤ Dermatofibroma Sclerosing epithelial hamartoma ᭤ Trichoepithelioma Sclerosing hemangioma ᭤ Dermatofibroma Sclerosing periphlebitis of the lateral chest wall ᭤ Mondor’s disease Scrofuloderma ᭤ Cutaneous tuberculosis Scrotal tongue ᭤ Lingua plicata Scrub typhus Synonym(s) Tsutsugamushi disease; tsutsugamushi fever Definition Acute, febrile, infectious illness caused by Rickettsia tsutsugamushi, characterized by rash and systemic signs and symptoms Pathogenesis Caused by Rickettsia tsutsugamushi (Rick- ettsia orientalis), acquired when infected chigger bites and inoculates pathogens Clinical manifestation High, severe headache, myalgia; ocular pain; wet cough; malaise; injected conjunc- tiva; eruption begins as a red, indurated PART19.MIF Page 521 Friday, October 31, 2003 12:22 PM 522 Scurvy papule that eventually enlarges to 8–12 mm, vesiculates, and ruptures, developing necrosis; 5–8 days later, onset of centrifugal- spreading macular eruption on trunk, sometimes becoming papular Differential diagnosis Tularemia; leptospirosis; typhoid fever; other rickettsial infections; viral exanthem; dengue fever Therapy Doxycycline ଙ ; chloramphenicol – 500 mg PO 4 times daily for 7–14 days References Baxter JD (1996) The typhus group. Clinics in Dermatology 14(3):271–278 Scurvy Synonym(s) Vitamin C deficiency syndrome Definition Vitamin C deficiency disease manifested by gingival lesions, hemorrhage, arthralgia, loss of appetite, and listlessness Pathogenesis Vitamin C deficiency, after at least 3 months of severe or total lack of vitamin C, resulting in defective collagen synthesis and defective folic acid and iron utilization Clinical manifestation Perifollicular hyperkeratotic papules, sur- rounded by a hemorrhagic halo; hairs are twisted like corkscrews and may be frag- mented; submucosal gingival bleeding; sub- periosteal hemorrhage causes painful bones of the legs and elsewhere; arthralgia; ano- rexia; listlessness; conjunctival hemorrhage; poor wound healing Differential diagnosis Vasculitis; physical abuse; coagulation abnormalities with leukemia; platelet abnormalities; deep vein thrombosis; thrombophlebitis Therapy Ascorbic acid 800–1000 mg per day PO for at least 1 week, then 400 mg per day until recovery complete References Hirschmann JV, Raugi GJ (1999) Adult scurvy. Journal of the American Academy of Dermatol- ogy 41(6):895–906 Scutula Definition Dense masses of mycelium and epithelial debris forming yellowish, cup-shaped crusts, seen in the favus form of tinea capi- tis References Qianggiang Z, Limo Q, Jiajun W, Li L (2002) Re- port of two cases of tinea infection with scutula-like lesions caused by Microsporum gypseum. International Journal of Dermatolo- gy 41(6):372–373 Sea boot foot ᭤ Immersion foot Sea lice ᭤ Seabather’s eruption Seabather’s eruption Synonym(s) Sea lice PART19.MIF Page 522 Friday, October 31, 2003 12:22 PM [...]... syndrome Shaving bumps Siemerling-Creutzfeldt syndrome ᭤ Pseudofolliculitis ᭤ Addison-Schilder barbae Sheep-pox disease Sign of Leser-Trelat ᭤ Orf Definition Abrupt appearance and growth of multiple seborrheic keratoses, caused by an underlying malignancy Shin spots References ᭤ Diabetic Schwartz RA ( 199 6) Sign of Leser-Trelat Journal of the American Academy of Dermatology 35(1):88 95 dermopathy Skeeter's syndrome... Varicose and telangiectatic leg veins 536 Spiegler-Fendt, pseudolymphoma of Spiegler-Fendt, pseudolymphoma of ᭤ Pseudolymphoma Spiegler-Fendt sarcoid ᭤ Pseudolymphoma Spiradenoma Therapy Surgical excisionଙ References Michal M ( 199 6) Spiradenoma associated with apocrine adenoma component Pathology, Research & Practice 192 (11):1135–11 39 Spirillary fever ᭤ Rat-bite fever Spironolactone Synonym(s) Eccrine... Streptococcus pyogenes; superantigen behavior of pyrogenic exotoxin-A (SPE-A); may also produce streptococcal pyrogenic exotoxin-B (SPEB), streptococcal pyrogenic exotoxin-C (SPE-C), streptococcal superantigen and mitogenic factor, as well as non–group-A streptococci aureus; release of tumor necrosis factor-α (TNF-α) and interleukin-1b (IL1b), which mediate signs and symptoms of disease; predisposing... seborrheic blepharitis Therapy Light electrodesiccation; liquid nitrogen cryotherapy; laser ablation; shave removal; isotretinoin for multiple lesions References de Berker DA, Taylor AE, Quinn AG ( 199 6) Sebaceous hyperplasia in organ transplant recipients: shared aspects of hyperplastic and dysplastic processes? Journal of the American Academy of Dermatology 35(5 Pt 1): 696 – 699 Sebocystomatosis ᭤ Steatocystoma... spilus ᭤ Nevus Therapy Destruction by electrodesiccation or laser vaporization spilus Spectacle frame granuloma ᭤ Acanthoma fissuratum Sphingomyelin-cholesterol lipidoses ᭤ Niemann-Pick References Requena L, Sangueza OP ( 199 7) Cutaneous vascular anomalies Part I Hamartomas, malformations, and dilation of preexisting vessels Journal of the American Academy of Dermatology 37(4):523–5 49 S Spider nevus... shock-like syndrome Strawberry patch ᭤ Nevus flammeus Streeter’s dysplasia ᭤ Amniotic band syndrome Streeter's spots ᭤ Aplasia cutis congenita Strep toxic shock syndrome ᭤ Streptococcal toxic shock-like syndrome Strep toxic shocklike syndrome ᭤ Streptococcal toxic shock-like syndrome Streptobacillary fever ᭤ Rat-bite fever Streptococcal toxic shocklike syndrome Synonym(s) Strep toxic shock-like... epidermal necrolysis; Henoch-Schönlein purpura; urticaria; viral exanthem; Kawasaki disease; figurate erythema; fixed drug eruption; lupus erythematosus; aphthous stomatitis S 542 Stewart-Bluefarb syndrome Therapy Prednisone Therapy Radical amputation of the limbଙ; radiation therapy References Prendiville J (2002) Stevens-Johnson syndrome and toxic epidermal necrolysis Advances in Dermatology 18:151–173... early positive Nikolsky sign; within 24–48 hours, rash progresses to generalized, superficial blistering eruption, with tissue paper-like sur- Veien NK ( 199 8) The clinician's choice of antibiotics in the treatment of bacterial skin infection British Journal of Dermatology 1 39 Suppl 53:30–36 Staphylococcal toxic shock syndrome ᭤ Toxic shock syndrome Stasis dermatitis Synonym(s) Venous eczema Definition... sequestration in microcirculation, with increased contact of leukocytes with the capillary endothelium and S 540 Steatoblepharon References Weingarten MS (2001) State-of-the-art treatment of chronic venous disease Clinical Infectious Diseases 32(6) :94 9 95 4 Steatoblepharon ᭤ Dermatochalasis Steatocystoma Stasis dermatitis Scaly, crusted, and eroded plaque on the lower extremity release of inflammatory mediators;... carcinoma; drug eruption; lymphoma; leukemia Therapy Trimethoprim and sulfamethoxazoleଙ; ketoconazole; itraconazole; for severe disease: amphotericin B – 0.7–1 mg per kg IV daily for 4–8 weeks, followed by trimethoprim and sulfamethoxazole for 2–3 years References Rivitti EA, Aoki V ( 199 9) Deep fungal infections in tropical countries Clinics in Dermatology 17(2):171– 190 South American pemphigus ᭤ Fogo selvagem . heparan sulfate sulfamidase, N- acetyl-alpha-D-glucosaminidase, acetyl-CoA alpha-glucosamide N- acetyl- transferase, or N- acetyl-alpha-D-glucosamine-6-sulfatase Pathogenesis Autosomal. sulfate sulfamidase, or N- acetyl-alpha-D-glucosaminidase, or acetyl- CoA alpha-glucosamide N- acetyltrans- ferase, or N- acetyl-alpha-D-glucosamine- 6- sulfatase, resulting in accumulation. extensor surfaces of extremities; round-to-oval, red- brown-to-purple, infiltrated plaques, the center of which may be atrophic; non- tender, firm, oval, flesh-colored or violaceous nodules

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