02-24 6 Topics in 60 Minutes

Question 1

Your patient just returned from a Central or South American country with this lesion.

• Describe the clinical findings you see
• Cause
• Given these findings + this history, what’s the dx?

Answer 1

Bot fly myiasis

• Findings
  
  • Tender red nodule with 2-3 mm central opening (breathing tube)
  • Scalp, Face, Upper Body
  • Enlarges, Drains, More Painful, Necrotic, some bleeding, breathing tube clearly visible
  • 1 to 1.5 cm soft white larvae, with spicules (barbs, i.e. hard to remove)
• Caused by female Bot Fly (Dermatobia hominis)
  
  • Central and South America
  • Uses Mosquitos to transmit eggs

Question 2

Pt just returned from Peru (or Europe, Asia, Africa…) with this lesion.

• Describe the clinical findings you see
• Cause?
• Given these findings + this history, what’s the dx?

Answer 2

Leishmaniasis

CAUSE

• Caused by one of many protozoan parasite in the Leishmania genus
• Transmitted by sand flies
• Cutaneous, Mucocutaneous, Systemic
• Old World: Europe, Asia, Africa
  
  • – L. tropica, L. major, L. infantum, L. donovania
• New World: Americas
  
  • – L. mexicana, L. braziliensis, L. peruviana

PRESENTATION

• Starts: typical arthropod bite w/ painful 2-5mm papule;
  
  • slowly over 2 mos: Asymptomatic, red-violaceous bordered ulcer
• Dz course can be:
  
  • skin only
  • mucosa-involved
  • lethal systemic situation
• Treatment is complicated
  
  • In US: contact CDC for typing and tx guidelines

Question 3

Your patient just returned from a beach vacation in either the Carribean, South America, Central America or (rarely) a domestic sandbox with this lesion.

• Describe the clinical findings you see
• Cause?
• Given these findings + this history, what’s the dx?

Answer 3

Cutanea Larva Migrans

CAUSE

• “Creeping Eruption”
• Ancyclostomia braziliense hookworm
  
  • Carribean, South American, Central American Beaches
  • Sandy soils
  • Sandbox, Chilren
• Hookworm eggs passed from animal feces
• Larvae penetrate skin

PRESENTATION

• Red violaceous “winding serpigenous” tract
• Usu. feet and ankles
• Can have intense itching → scratching → 2° infx

TX

• Cryotherapy (freezing) can be curative
• 2-4 weeks after returning from a beach vacation

Question 4

Your patient just took a new type of inhaled medication for the first time and wound up with this rash.

• Describe the clinical findings you see
• Cause?
• Given these findings + this history, what’s the dx?
• DDx
• Tx

Answer 4

ACUTE URTICARIA (HIVES)

PRESENTATION

• Pruritic, red-pink, polycyclic (i.e. individual wheals within one eruption come and go) wheals
  
  • coalesce, migrate, recur
  • local or generalized
• Acute vs Chronic: 6 week cut-off
• No good laboratory test
• Variations: Physical, Cold, Solar, Cholinergic

CAUSE

• Histamine release triggered by foods, meds, other allergens (Five I’s)

DDX

• Chornic urticaria ( > 6 wks)
• Thyroid disease, viral infections, occult (usu. tooth) abscess, malignancy can all also cause urticarial lesions
• Urticarial vasculitis: vasculitis that shows up s/p hives w/ bruise-like purpura

TX

• antihistamines (may need H1 & H2 blockers in bad cases)
• remove triggers
• Epi + oral prednisone in emergency/flare

Question 5

The 5 I’s: Causes of Hives

Answer 5

• ingested (esp meds, herbs)
• injected (shots of any kind)
• inhaled (esp. meds)
• infected (esp URI)
• internal dz

Question 6

This pediatric patient produces these wheals upon stroking her skin.

• Describe the clinical findings you see
• Cause?
• Given these findings + this history, what’s the dx?
• DDx

Answer 6

Urticaria pigementosum

• variant of urticaria (classive hives)
• caused by mast cell infiltrative disease of the skin
• pigmented lesions that wheal-up when stroked

Question 7

What is physical urticaria?

Answer 7

hives caused by:

• rubbing (dermatographism)
• cold exposure
• sun- or UV-light exposure (solar urticaria)
• exercise (cholinergic urticaria)

Question 8

This third trimester woman presents to clinic with this itchy rash.

• Describe the clinical findings you see
• Cause?
• Given these findings + this history, what’s the dx?

Answer 8

PPUPPP: Pruritic Urticarial Papules and Plaques of Pregnancy

• urticarial changes on the abdomen, often in line w/ striae (per Dr. Aaron at art lecture)
• no problem, just itchiness and discomfort
• no effect on fetus

Question 9

Your patient bumped his knee lightly reccently and presents with what he thinks is an “infection” caused the bump that won’t go away.

• Describe the clinical findings you see
• How to dx?
• DDx?
• Cause?
• ASSOCIATIONS?
• Given these findings + this history, what’s the dx?
• Tx

Answer 9

• NOT an infection!
• not truly gangrenous but definitely necrotic
• almost alway multiple
• results from minor trauma (usu.)

FEATURES

• Lesions are multiple, on the legs, very painful
• start as small pustules → large ulcerations
• purple (vascular congestion)
• “undermined border”
  
  • border tucked-in/rolled-in around the edges

DX

• Histo often not helpful, clinical dx
• would see neutrophilic infiltrate

DDX

• Can be mis-dx as
  
  • Sweet’s Syndrome
  • systemic vasculitis
  • Behcet’s dz
  • infection (really looks like one!)

CAUSES

• Inflammatory skin disease, results in ulceration, necrosis
• Starts with mild trauma (“pathergic”), rapidly expands
• neutrophillic inflammatory pattern

ASSOCIATIONS

• Associated with inflammatory bowel disease (30%)
  
  • Associated with gammopathies, too
• Often misdiagnosed as:
  
  • an infection
  • vasculitis
  • Sweet’s syndrome

TREATMENT

• Treatment: Immunosuppression (steroids, cyclosporine, mycophenolate mofetil, dapsone, thalidomide)
• Newer rx: TNF-inhibitors (etanercept, adalimumab, infliximab)
• Cover w/ plain vasline or zinc oxide so that dressing doesn’t stick
• DON’T DEBRIDE/SCRAPE/CUT/DO SURGERY

Question 10

Sweet’s syndrome?

Answer 10

a skin disease characterized by the sudden onset of fever, leukocytosis, and tender, erythematous, well-demarcated papules and plaques that show dense infiltrates by neutrophil granulocytes on histologic examination.

Question 11

Skin Types: I – VI?

Answer 11

• I = super pale skin blue/green eyes, blond/red hair –> always burns, does not tan
• …to…
• VI = super dark –> never burns, always dark

Question 12

Cause of increased pigment in darker skin?

Answer 12

• Melanosomes: increased number, size and production in darker skin types
• Melanocytes: same number (NOT increased)

Question 13

Changes in epidermis in darker skin?

Answer 13

Epidermis: thicker in darker skin

Hair Follicles: acute angle with black skin vs. more perpendicular, with asian/white/hispanic skin

Question 14

Your Afican American patient comes to you concerned about this lesion.

• Describe the clinical findings you see
• Cause?
• Given these findings + this history, what’s the dx?
• DDx

Answer 14

Keloid

PRESENTATION

• firm, flesh-colored nodules that are either a-sx or tender
• Extends beyond area of trauma (vs. hypertrophic scar does not extend beyond area of trauma
• More common in patients darker skin

CAUSE

• Usually response to trauma (can be very minor) or burns
  
  • Can also be spontaneous
• Technically a collagenous tumor caused by hyperproliferative dermal collagen

TX

• Can’t cut it out cause that’s more trauma
• Intralesional steroids may help

Question 15

Describe the clinical findings you see
Cause?
Given these findings + this history, what’s the dx?
DDx

Answer 15

DX: Pomade Acne

PRESENTATION

• Open and closed comedones along temples and forehead

CAUSE

• hair product drips down

DDX

• Acne vulgaris (would not be limited to temples and forehead)

TX

• avoid comedogenic products for hair and face

Question 16

Answer 16

Traction Alopecia

• Usually at frontal and temporal harilines
• change hair style

Question 17

Answer 17

Sarcoidosis

• More common and more severe in African Americans
• Likes peri-orifical, peri-nasal
• Red-brown, apple jelly-like/waxy nodules (man’s lip in center of picture above)

DX

• Little biopsy is usu. diagnostic: non-caseating granulomas
• Is a great mimicker
• Look at lungs!
  
  • (40% of sarcoid pts have lung involvement, only 25% have derm)

TX

• Systemic +/- intralesional steroids
• Systemic anti-malarials for some reason, too

Question 18

Skin Cancer - Racial Differences in:

• Melanoma
• Basal Cell
• Squamous Cell

Answer 18

• Melanoma
  
  • 10 times greater in white skin
  • In people of African, Asian and Native American descent: more common at acral sites (fingertips/toes)
  • Harder to see: ill-defined, dark brown, blue-black or black macules
• Basal Cell Carcinoma
  
  • Uncommon in black/darker skin
  • Similar distribution to white skin
  • Almost always pigmented BCC type in darker skin = tricky dx
• Squamous Cell Carcinoma
  
  • Most common skin cancer in Black skin w/ high mortality b/c:
    
    • late dx
    • tumors may actually be more aggressive
  • In contrast to white skin: often in non-sun-exposed areas (e.g. chronically-irriated legs)
  • Biopsy any non-healing ulcerated area in any pt of any skin color

Question 19

Answer 19

Melanoma in acral site of dark-skinned pt

Question 20

Answer 20

Squamous Cell in Darker SKin

Question 21

Answer 21

Mycoses Fungoides

• Variant of Cutaneous T-cell lymphoma (systemic lymphoma that presents in skin)
• Many stages: MF, patch, plaque, tumor
  
  • Look at slides for varying presentation
• Exam:
  
  • Lesions evolve over time through stages: MF → patch → plaque → tumor
    
    • MF: Thin, pink, scaly patches over trunk…annular, arcuate
      
      • “psuedo-psorasis or -eczema”
    • Patch/plaque: annular, round, arcuate, sepiginous elevated plaques that migrate, expand, ulcerate, and “nodulate”
• Sezary Syndrome: systemic erythroderma
  
  • whole skin hot and red
• Differential Diagnosis: Eczema, Psoriasis, Tinea
  
  • Do a biopsy
  • Often mis-dx
  • If doesn’t respond to steroids, consider Mycoses Fungoides/CTCL

Question 22

Drug rash type?

Presentation?

Cause?

Answer 22

• Don’t say maculopapular: if it’s raised, it’s papular!
• Drug Rash: Morbilliform (measle-like) pattern
• • a common type of drug rash

PRESENTATION

• begins a few days to 2 weeks after starting a drug
• exam: pink to red, oval shaped macules
  
  • begin on the central trunk and expand centrifugally to the extremities
  • macules may become slightly elevated, scaly, coalesce and be pruritic, often sparing the face
  • [More purpuric presentation on this card]

CAUSE

• antibiotics are the most common culprit, but any medication can produce this type of reaction,
• treatment is drug cessation

Question 23

Name?

Presentation?

Common Causes?

Answer 23

NAME: Fixed-Drug Eruption

PRESENTATION

• uncommon round red-purple asymptomatic patch
• may eventually erode or desquamate and even blister, but does not generalize
• common locations: fingers, hands and genitalia, esp the glans penis
• eruption occurs in the same location, after each exposure

CAUSES

• aspirin, ibuprofen, tetracyclines and sulfa drugs are common culprits.

Question 24

Name?

Answer 24

Phototoxic drug reaction

Question 25

Name this drug rxn?

Common drug cause?

Answer 25

• pigmentory drug rxn
• amiodarone

Question 26

Name this drug rxn

describe its shape

common causes?

Answer 26

1. name = erythema multiforme
2. shape = minor: targetoid macules or (sometimes “and”) on palms/soles on skin only
   
   • major: becomes more generalized: erosive, bloody-looking mucosa membranes
   • may even progress to internal involvement
3. Common causes
   
   • ABx? is single presentation
   • HSV 1 or 2 infx if chronic

Question 27

What drug rxn?

Answer 27

Acute Generalized Exanthematous Pustulosis

Question 28

Name this drug rxn

Answer 28

SJS: Stevens-Johnson Syndrome

• Parvovirus causing E.M. Major
• oral mucosal sloughing
• if skin is blistering, trachea, interal organs might be, too
• derm emergency when mucosal involvement

Question 29

Name this drug rxn

Answer 29

Warfarin/Coumadin Necrosis

Question 30

Answer 30

Toxic Epidermal Nercolysis

• severe, life-threatening drug eruption, w/ 40% mortality
• consider transfering to burn unit
• skin initially resembles a morbilliform eruption or erythema multiforme like rxn, w/ mild mucosal involvement
• quickly evolves into generalized erythroderma, full-thickness epidermal necrosis and skin sloughing, with or without significant mucosal involvement and inflammation of many internal organs: liver, lungs, gastrointestinal, renal, lymph nodes, joints.