Discoloration on the elbow

67 y, AA woman, h/o HTN, GERD and recurrent UTI presents to the office with skin discoloration over her Lt elbow that started about 5 weeks ago. She denies any discomfort or pruritus at the site. She does not have similar lesions anywhere else on the body. Her current meds include Enalapril, Aciphex, Valium, Vaginal estrogens and Ciprofloxacin.
Exam shows a 4-6 cm hypopigmented macule over the lt. elbow. Neurological exam was normal.
Which of the following statements is most appropriate?

1. This is a complication of treatment she received for tennis elbow 3 months ago.
2. She has pityriasis alba.
3. Tuberculoid leprosy should be considered as the most likely diagnosis.
4. This is a ash-leaflet hypopigmented macule suggestive of tuberous sclerosis
5. This is a new onset vitiligo, she might respond to topical steroids.

Insect bites or psychogenic lesions

56 y man, no significant PMH, presented to the office with diffuse skin lesions that he states started with some insect bites sustained a few days ago. He has been picking on the lesions and cleaning with alcohol, taking multiple showers everyday to get rid of the eggs and larvae that might be present in the lesions. His wife has been helping him with the entire “cleansing process”. He cannot say for sure if all these lesions started after insect bites or whether some were created in an attempt towards digging under the skin with nails and other sharp instruments to remove the suspect eggs and larvae. On exam, he has multiple superficial skin ulcers with excoriations on his chest and upper extremities.

Which of the following is the appropriate statement?

1. Patient is suffering from neurotic excoriations
2. He has delusions of parasitosis
3. It is too early to state if he has a psychological disorder- ANSWER
4. Factitious syndrome is a likely diagnosis.
5. Body dysmorphic disorder should be considered.

Old lady with ptosis

67 y relatively healthy white woman presents to the ER with progressive Lt temporal headache over the last 7 to 10 days followed by Lt eye ptosis that she noticed on the day of presentation. Exam shows profound Lt eye ptosis and restricted extraocular movements without pupillary involvement. Which of the following is the correct statement?

1. The lesion has spared the oculomotor nerve nucleus- ANSWER.
2. Instilling topical cocaine in the eyes will confirm the suspected diagnosis.
3. Unilateral ptosis makes the diagnosis of ocular myasthenia gravis unlikely.
4. Patient has Kearns- Sayre syndrome
5. Efficacy of steroids has been demonstrated through several randomized placebo-controlled studies.