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Why has this woman's nose become discoloured and lumpy?

Dr Mike Wyndham explains how a small cosmetic complaint lead him to a more serious diagnosis in this elderly woman

The Patient

This 73-year-old woman and has been with the practice for the last year. She has osteoarthritis of her knees, treated with co-dydramol. She presented complaining of a change in the colour of her nose. This had developed over a period of weeks and was becoming unsightly, which bothered her a little.

First instinct

My first comments were about the cosmetic appearance – it's important not to underestimate the significance of the psychological impact of skin disease.

The nose certainly had a bluish discoloration. It was not evenly distributed – there was more discolouration on the left side. The affected areas were slightly raised and thickened. There were no significant rashes elsewhere apart from a little actinic change on one of her hands, which did not appear to be related to her nose.

Differential diagnosis

  • Systemic lupus erythematosus(SLE)
  • Acne rosacea
  • Sarcoidosis

SLE occurs more commonly in women than men, but is most likely to develop in the 15-40 age group. The rash did not appear to have a distribution across her cheeks. While she had joint pains, these had been longstanding and consistent with osteoarthritis. There was the possibility that this could be discoid lupus but there was no evidence of scarring and hypopigmentation.

Acne rosacea usually develops in middle age but it certainly can occur in older people. Papules and pustules develop on the nose and cheeks but may also be found on the chin and forehead. But there did not appear to be any papules or pustules present, just thickened skin. Additionally, the nose appeared to be the only part of her face affected.

Lupus pernio is a skin complication of sarcoidosis. It usually consists of purple coloured plaques and nodules that affect the cheeks, nose and ears. This seemed to be the most likely diagnosis based on appearance.

Getting on the right track

I arranged for various blood tests including angiotensin converting enzyme (ACE),and a chest X-ray. The ACE tests came back raised, at 103. Her chest X-ray showed bilateral hilar lymphadenopathy and a subsequent CT scan showed extensive calcified hilar and mediastinal lymphadenopathy. This was a chronic sarcoid and as it was not causing any symptoms, could be left alone. I treated the skin of her nose with fludroxycortide tape. If it does not respond then I will try topical tacrolimus.

 

Dr Mike Wyndham is a GP in Edgware, north London

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Readers' comments (1)

  • brilliant diagnosis - the man is a legend!

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