02-24 6 Topics in 60 Minutes Flashcards
• Tropical and Travel Dermatology • Urticaria (Hives) • Pyoderma Gangrenosum • Black and Ethnic Skin • Mycosis Fungoides ——(Cutaneous T-Cell Lymphoma) • Drug Rashes
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?
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
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?
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
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?
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
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
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
The 5 I’s: Causes of Hives
- ingested (esp meds, herbs)
- injected (shots of any kind)
- inhaled (esp. meds)
- infected (esp URI)
- internal dz
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
Urticaria pigementosum
- variant of urticaria (classive hives)
- caused by mast cell infiltrative disease of the skin
- pigmented lesions that wheal-up when stroked
What is physical urticaria?
hives caused by:
- rubbing (dermatographism)
- cold exposure
- sun- or UV-light exposure (solar urticaria)
- exercise (cholinergic urticaria)
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?
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
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
- 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
Sweet’s syndrome?
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.
Skin Types: I – VI?
- I = super pale skin blue/green eyes, blond/red hair –> always burns, does not tan
- …to…
- VI = super dark –> never burns, always dark
Cause of increased pigment in darker skin?
- Melanosomes: increased number, size and production in darker skin types
- Melanocytes: same number (NOT increased)
Changes in epidermis in darker skin?
Epidermis: thicker in darker skin
Hair Follicles: acute angle with black skin vs. more perpendicular, with asian/white/hispanic skin
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
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
Describe the clinical findings you see
Cause?
Given these findings + this history, what’s the dx?
DDx
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
Traction Alopecia
- Usually at frontal and temporal harilines
- change hair style
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
Melanoma in acral site of dark-skinned pt
Squamous Cell in Darker SKin
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”
- MF: Thin, pink, scaly patches over trunk…annular, arcuate
- Lesions evolve over time through stages: MF → patch → plaque → tumor
- 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
Drug rash type?
Presentation?
Cause?
- 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
Name?
Presentation?
Common Causes?
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.
Name?
Phototoxic drug reaction
Name this drug rxn?
Common drug cause?
- pigmentory drug rxn
- amiodarone
Name this drug rxn
describe its shape
common causes?
- name = erythema multiforme
- 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
- Common causes
- ABx? is single presentation
- HSV 1 or 2 infx if chronic
What drug rxn?
Acute Generalized Exanthematous Pustulosis
Name this drug rxn
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
Name this drug rxn
Warfarin/Coumadin Necrosis
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.
