Dermatology Case Challenge: Colorful Skin Patches on a Man With Fatigue Who Smokes Cigars

Malgorzata K. Nowakowska, BS; Saira George, MD


November 22, 2022

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.


An 80-year-old man presents to a dermatology clinic for skin screening and treatment of large "golden" patches on his chest and shoulders. The yellow-orange patches are asymptomatic but have steadily deepened in color and have progressed in extent. After his wife first noticed the patches 6 months ago, he was evaluated by a dermatologist and underwent a punch biopsy of a representative patch. On the basis of the biopsy finding of foamy, lipid-laden macrophages in the dermis, he was told the plaques were a skin finding seen in patients with underlying lipid disorders.

His medical history is significant for hypercholesterolemia that has been well controlled on atorvastatin (10 mg daily), which he has taken for over 20 years. He also has hypertension, which is managed with valsartan (160 mg daily). His dermatologic history is significant only for actinic keratoses and cutaneous squamous cell carcinomas. He has no significant family history of illness.

He has no new medications, supplements, or exposures related to the onset of his skin changes and has been in his usual state of health, with no recent illnesses. He has never smoked cigarettes or used smokeless tobacco. He occasionally smokes cigars. His current alcohol use consists of about one standard drink per day. On a review of systems, he reports only mild fatigue with no fevers, chills, night sweats, weight loss, or malaise.


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