“What's new for blue skin?” asked an eighty-one-year-old man. He had had dark blue-black discoloration of his skin for the past forty-one years, and wondered if anything could be done. It all began after the injection of a sclerosant solution into his severe varicose veins. Examination revealed extensive bluish areas of the lower legs, with streaks following the pathway of veins. On the trunk, the skin was a slate gray color, whereas the sun-exposed areas were blue-black to black. His face was disfigured with the color being most prominent on the sun-favored areas of the cheeks, nose, and eyebrows. The depths of his wrinkles were less pigmented.

The darkening had come slowly. He knew the cause. It was the silver nitrate that had been injected into his leg veins over forty years ago, causing the well known argyria. Back then there was an ever expanding pool of these patients, most of whom had taken Argyrol®, one of the most popular remedies. This silver protein compound was taken by mouth for everything from stomach ulcers to arthritis. Only recently did we realize that Argyrol® cured peptic ulcers by killing the causative Helicobacter spirochetes in the stomach, similar to modern antibiotics. It was truly a “proto-antibiotic.” This was the same Argyrol® whose soaring sales brought monies for purchase of modern art treasures, now displayed in the Barnes Foundation Art Museum just outside Philadelphia.

“Look at my arm. It's all messed up,” opened our consultation with a twenty-eight-year-old woman. And we did look. What we saw was a left arm swollen to three times its size. We saw not only a hand, but a forearm and upper arm completely denuded of the outer skin. The entire limb was dusky red in color, and oozing clear fluid that dripped on the floor. Four physicians had seen her in the four weeks since it had all started. None could help despite intensive cortisone therapy and steroid salves. Day by day the problem had worsened.

This called for immediate hospitalization, for both therapy and diagnosis. Her history did not help. She had always been in perfect health. The only skin disease she had ever had was poison ivy dermatitis in her childhood.

We were worried that she had suffered a blood clot in her arm, but the vascular surgeons found nothing wrong. A Doppler study confirmed that she had normal circulation. Then began a circus of consultations and laboratory studies. During her three weeks in the hospital, she was seen by a parade of internists, anesthesiologists, and psychiatrists.

We kept the arm wrapped in compresses, and the anesthesiologists provided nerve blocks to improve circulation. The dermatitis gradually subsided and the arm became less swollen. But on day three, and again on day fifteen of hospitalization, we came in to find a huge soft purple swelling on the back of her left hand.

It wasn't the patient complaining, it was the nurses! The nurses and staff complained of the odor of rotten fish permeating their entire hospital floor. Some days it was overwhelming, but some days it was not there, coming only episodically, but several days a week. It was not hard to track down the source. It came from a thirty-one-year-old man institutionalized with severe mental retardation, and it came from his urine as well.

We at once suspected that this man had the “fish odor syndrome,” because years before we had encountered a twelve-year-old boy with this same foul odor. He had been virtually ostracized from school and society, because no amount of bathing, oral hygiene, or deodorant powders helped. Every breath repelled his friends. Otherwise, he was healthy, normal, and attractive.

But this patient was a tragic victim of a toxemic pregnancy and multiple abscesses in infancy. He still could not walk, talk, or raise his head when he was six years old. Institutionalized nearly all of his life, he had an IQ of 5 and a mental age below six months.

Physical examination disclosed a unique individual who had massive folds of skin on his forehead and soft skin that could be stretched out for inches. He kept hitting the sides of his head and was generally self-abusive. There was a strong fish odor present. His blood studies were normal.

But did he have the fish odor syndrome?

“Doc, I want you to drain my blood blisters,” was the request of a sixty-six-year-old man. He told us the “blisters” had been coming out for the past two months. He also told us that three or four months ago he had felt a lump over his left shoulder blade area. It was painless, but getting bigger.

When he slipped off his shirt we saw several hundred black bumps on his chest and back. They were not blood blisters, but hard pitch-black tumors generally ranging in size from a pinhead to a walnut. The largest one on the back was an irregular lobulated mass three inches in diameter. Only a few small lesions dotted his face and arms.

As we took his history the problem became more ominous. He had been a construction worker all his life, going shirtless in the summer months, with no attempt to use sunscreens. He was retired and lived alone, with no one to tell him that the mole on his back had begun to enlarge and turn black. His health had been good until recently, when he noted how easily he became short of breath and that his legs were becoming swollen.

Sadly, we had to tell him there were no blisters to drain. We explained that only by sampling his skin tumors and studying them under the microscope would we solve the mystery of his lesions. We told him we feared he had a very serious problem.

An eighteen-year-old college wrestler was admitted directly to the hospital. For five days he had suffered widespread blisters of his forearm, neck, forehead and scalp, which were now oozing and crusted. We counted over fifty such plaques. On the day of admission his right knee had become markedly tender, hot, and swollen.

He gave a past history of having had shingles when he was four years old, a severely wrenched right knee at age eleven, and an allergy to sulfa drugs. He had never had fever blisters or cold sores.

We knew what his skin problem was. It was the result of the fever blister virus (Herpes simplex) being rubbed into each of those fifty areas. One of his fellow wrestlers must have had an active cold sore which contaminated the wrestling mat. Since this was his first contact with the virus, every site touched by the virus developed a cold sore. He essentially had fifty fever blisters simultaneously. He would not have developed a single one if only he had had a prior fever blister on his lip, due to immunity to the virus. Only his own virally-infected nerves would then set off periodic flares of a cold sore, always in the same location.

Yes, we knew his skin story well. He had herpes gladiatorum, an occupational disease of wrestlers. We later learned that two of the men he wrestled with also came down with the same problem.

“It's my right cheek. It burns and oozes,” a twenty-eight-year-old woman told us. It had been that way for months. Cortisone had given some temporary help, but antibiotics were ineffectual.

What we saw was a weeping dermatitis extending downward from her right lower eyelid to the medial right cheek. The left cheek and her skin elsewhere were completely normal. Her past history was unremarkable, except for the loss of her right eye five years ago following an accident. The eye had been surgically enucleated and she wore a prosthesis.

We puzzled over the cause of her dermatitis, so localized to the right cheek. We eliminated the possibility of unilateral rosacea, because the eruption was too eczematous. Could she be allergic to a salve she was applying? We knew that some people even become allergic to the hydrocortisone in healing creams sold over the counter. A trial of complete avoidance of topical measures, soaps, and sprays had no effect. Could it be due to an underlying sinusitis of just that side? It seemed unlikely, because x-rays failed to reveal any sinusitis.

The most likely diagnosis was infectious eczematoid dermatitis, a condition in which chronic purulent drainage produces a band of acute dermatitis in the drainage area. We had seen it in patients with a chronic draining ear infection, in the form of an eczematous band on the face below the infected ear. Yes, our patient did have some drainage from the right eye socket, but it was not purulent.

“I can't take a bath without crying, the pain is so bad,” was the strange complaint of an eighty-two-year-old woman. She told us she suffered with severe burning pain in her skin following every bath. It had been a problem for over six years. The pain began within minutes after she got out of the bath and lasted for nearly an hour. It was so severe that she limited her bathing to once a week. The pain never came on as long as she was in the tub, so she tended to prolong her bath time. It made no difference whether the bath water was hot or cold. She had further learned that adding bicarbonate or salt to the bath water gave no relief. Staying in the bath for an hour or so seemed to reduce the amount of postbath pain, but she was unable to reduce the pain by repeated bathing every hour. Antihistaminics had given no protection.

Her problem was unique and we had only a few leads. It was not something she had experienced as a child, but had come on late in life. No one else in her family had this problem. We could find no reference to it in a computer search of medical articles. Could it be feigned? Could it be due to stress, hypochondriasis, a neurosis, or even a psychosis? As we became acquainted with this lady over a period of months, none of these possibilities seemed reasonable.

A sixty-three-year-old man came to us with his entire skin fiery red and tender. And, it had been that way for over a year. He had what is known as chronic erythroderma or exfoliative dermatitis, (French: l'homme rouge). He had lost most of his hair and fifty pounds of weight.

The mystery was the cause, not the diagnosis. Erythroderma has many causes. We could eliminate the two most common ones, longstanding eczema and psoriasis, because he had never had any skin disease before.

We ruled out a malignant lymphoma by skin biopsy, and also eliminated internal tumors by x-rays and CT scans. But the cause of his total body rash still eluded us, although we had clues it was due to an allergy. His complete blood count (CBC) showed an eosinophilia of 36%, which meant that a large number of his white cells were eosin staining, a certain sign of allergy (in contrast to the normal 0% to 5%). Furthermore, a second skin biopsy suggested that drug allergy might be the cause. However, he was taking no medications by mouth, and had only occasional cortisone injections to calm down his redness, itch and scaling.

Yet, there was one more item of medication to be considered, his eyedrops. They seemed so innocent and insignificant, used to control his glaucoma. We were, of course, reluctant to eliminate them, fearing progressive blindness. But until we finally stopped them, we could not control the eczema which covered every square inch of his body.

“Can you do anything about getting my color back?” asked a forty-three-year-old black man with depigmented skin of his hands, forearms, lips, and ears. His affected skin areas were ivory in color. The pigment loss had begun on his hands within months of being assigned to a new job as dielectric tester. Although he had worked for eighteen years at the same company, a spark plug factory, this was the first time he had worked with a solvent. Despite wearing synthetic rubber (Neoprene®) gloves, his hands were frequently wet with the solvent, tetrachloroethylene (perchloroethylene). Because the factory environment was hot, he frequently brushed away sweat from his face with the solvent-soaked gloves. He worked in this setting for three years until being transferred, and during this time the white skin areas enlarged. Particularly significant was the pigment loss on the ventral forearms, a site of contact with the solvent when he rested his arms. He denied any strange sensations or tightness in his fingers.

Once he had been removed from the solvent work, there had been some repigmentation of his fingers. There was no family history of vitiligo, the idiopathic heritable loss of color. Nor did he have any associated illness. He denied taking any medications. Detailed studies of his blood and urine showed them to be normal as were x-rays of his hands.

A biopsy of the affected skin showed an absence of melanin pigment in the epidermis, but otherwise nothing unusual.

“I've tried a dozen creams and lotions on him but nothing helps” was the plaintiff comment of the mother of an eight-year-old boy. The boy's upper arms were as rough as sandpaper, studded with numerous tiny plugs of keratin, the protective outer skin protein. On skin biopsy they were seen as compact plugs filling the hair pores, with no inflammation. Most of the doctors had dismissed it as trivial and insignificant, hardly worthy of a prescription. Actually, they did not know of an effective remedy, prescription or otherwise. Here was another orphan patient, not because his disease was rare, but because it was so common as to be accepted as a mundane non-disease.

Rough skin due to dry keratotic material in the upper hair follicles can be the presenting complaint of at least ten dermatologic disorders. We ruled out the rough skin colleague, keratosis follicularis (Darier's disease), by both biopsy and its localization. Another diagnostic possibility, pityriasis rubra pilaris, was similarly discarded, for this rare disease is, as its name indicates, red and scaly. Since the lesions had no spines in the hair follicles, lichen spinulosus was dropped from consideration. To continue the polysyllabic diagnostic litany, he did not have keratosis pilaris decalvans or keratosis pilaris atrophicans, for there was no hair loss or scarring. It was also not the Vitamin A deficiency of phrynoderma, seen in the malnourished.

“It began on my left breast two years ago,” recited a seventy-six-year-old woman. It looked like ringworm, but it wasn't. Today she had extensive large, red, circular plaques on her left breast, right armpit, both thighs, and the groin. The borders were rimmed by thickened red skin.

She had never had skin disease before, but she was sensitive to sulfonamide and tetracycline medications. She was taking five different pills for heart disease. Nothing had helped her skin.

Our examination revealed no fungi on skin scrapings, and a skin biopsy confirmed our clinical diagnosis of granuloma annulare. This ring of cord-like chronic inflammation is a strange skin reaction with many different causes. We have seen it from yeast infection, but anti-yeast medication did not clear hers. We have seen it disappear completely simply as a result of taking a skin biopsy, but no such luck for her. We also have seen it from a focus of bacterial infection, but even our best antibiotic for cystitis did not prevent new lesions from appearing on her skin. Her blood studies were normal and gave us no clue as to where to turn.

We tried another antibiotic, and yet another, to no avail. There were new lesions on her left forearm. They were mammoth. We tried suppressing her immunity with no help. We now found that she had developed diabetes and hoped her internist's treatment for this would help, but it did not.

She entered the hospital for surgery on her spine.

A woman came to us with a three year history of hives. For over 1,000 days and nights she has seen and felt her skin itch, turn red, stretch and swell in lumps, bumps, and welts. All this would slowly recede within a day without a trace, only to be followed by new hives without rhyme or reason. Hers was not a rare disease. Indeed, several million people in our country suffer from this chronic urticaria. Hers was a common disease but, as it turned out, the cause was so rare it had never been previously described.

Chronic hives calls for courage and patience on the part of the victim as well as the doctor. No disease has a more daunting and diverse set of causes. There is no quick fix. The cause must be found and eliminated. Otherwise, there is only the search for relief with a variety of antihistamines. These, in turn, have their own side effects, and their own drug interactions, a few having turned fatal. Likewise, the new cutting edge therapies with intravenous immunoglobulin, the immunosuppressant, cyclosporine, or “washing” the blood with plasmapheresis, provide only temporary relief.

Chronic hives calls for the best in Sherlock Holmesian medical detection. Before searching for the criminal, it is wise to review the anatomy of the crime. Although our patient had “chronic” urticaria, every bump and lump was really “acute.” Only the daily succession of acute attacks made it chronic urticaria. What is urticaria?

“My complexion is awful” was the complaint of a thirty-four-year-old woman. She had been referred to us for treatment of a facial rash, which had resisted the therapies of a half dozen doctors over the past thirteen years. Several biopsies had been done with the principal finding being intense inflammatory changes around the blood vessels.

Upon examining her, we saw redness, acne-like pimples, some small blisters, and yellow crusts on her face. Her problem had defied not only therapy, but also classification. It wasn't exactly rosacea or acne. We were puzzled, but intensive questioning opened a door of understanding. We asked, “Does it get worse before your menstrual period?” Her answer was, “I have no idea – it's worse all the time.” But several visits later she came in saying, “You know, it really does get worse before my period! I had never noticed that and you are the first doctor to ask me.” We now suspected she was allergic to her own ovarian hormone, progesterone.

Years before we had demonstrated that women could become sensitive to their own progesterone. This hormone can induce a variety of skin changes, including itching, hives, and even water blisters. The clue to progesterone sensitivity is the observation that the problem is always worse just before the period – the time when the highest blood levels of progesterone are found. Once the menses are over, progesterone levels drop and the skin reaction abates.

“It's my hands, Doc. They've been itching and burning for the past month and they're driving me crazy,” a thirty-eight-year-old woman complained. What we mainly saw were the rough red scaling backs of her hands. But on her palms we also saw some scattered pinpoint-sized deep blisters filled with fluid, the so-called vesicles. Her skin elsewhere was clear. She had no fungus infection of her feet.

She was a housewife and had just passed a complete physical examination with blood studies, trying to find out why her hands itched and were so inflamed.

It was another case of “round up the usual suspects,” with the line up including contactants, drugs, and foods. There was no unusual exposure of her hands to solvents, detergents or disinfectants. She denied excessive handwashing, a compulsive behavior easily controlled with fluoxetine (Prozac®). She had no hobbies such as flower arranging, with exposure to chrysanthemums, primula, or tulip bulbs. Her problem was a straightforward eczema. We could elicit no medication as a cause. She did not have a photodermatitis, for other light-exposed areas were clear.

Much to her surprise, we focused on foods as a cause. We have seen many chronic hand eczemas due to food allergy – not just from contact, but from eating a particular food. Pork is one of the most common causes. “Ham sandwich” hand dermatitis is quite common and often unrecognized.

When a fifty-one-year-old man first walked into our office that August afternoon, covered from head to foot with a rash, we knew he needed to be hospitalized. But he refused. “It'll go away, Doc, next month.” So, as our nurse gave him an emergency injection of steroids, we sat down to listen to his intriguing story.

It had all begun five summers before as a hand eczema. He associated the problem with taking up a new sport: golf. He was an automotive repair specialist who had never been bothered by any of the sprays or paints with which he came in contact. Steroid creams had helped, but his hands never really cleared until golf season was over.

Each subsequent summer the eruption reappeared when he resumed golf. And each summer it had become worse, eventually involving his wrists, arms, legs, neck, and face. Last winter, for the first time, involution did not come and his hands never cleared. Again, this summer he was having to go to doctors for steroid injections. But, play golf he would.

We could certainly agree that he had golf course dermatitis. But why? We struggled to bring out more history. He observed that his right hand, used to pick up the golf ball, was always the worst. And then came his seminal observation that the worst flare ever came explosively the day after he walked by some men spraying the greens.

The race was on. What was in the spray?

“I can't spit, my mouth is so dry,” was the complaint of a fifty-six-year-old man. He told us he had had a dry mouth for the past few months. As an executive in a large corporation he had noted difficulty in speaking, as his tongue and lips were very dry. His dentist was concerned about the appearance of caries, and food had little taste. There was none of the normal salivation upon seeing, smelling, or tasting his favorite foods. Dry food was hard to swallow. He was often at the drinking fountain and was frequently sucking on lozenges, to little avail. Even sourballs, which increase salivary flow to twenty times normal, gave only temporary relief.

All this confirmed the diagnosis of xerostomia, or dry mouth. Normally, he should be secreting over a quart of saliva every day, mostly during the daytime. However, we estimated he was putting out barely a tablespoonful. It is saliva that enables smooth tongue movements and lip motion, important in enunciation. It is also saliva that aids in the tasting and swallowing of dry foods. And it is saliva which flushes and degerms the teeth, preventing caries. Saliva contains the same germicidal lysozyme found in tears to protect the eye, as well as antibodies and other antibacterial chemicals.

But why did this man have a dry mouth? It was not the dry mouth of the fearful public speaker, which passes once the person is off stage.