02-24 Red Scaly Rashes

Question 1

Dx?

Decription

Exam findings?

Variants?

Features unique to this dz?

Mimickers?

Answer 1

Psoriasis

[Classic presentation on reverse; guttate variety here]

• Description: An inflammatory papulosquamous disease of the skin, hair and nails, cause is related to genetic predisposition and environmental triggers, and associated with inflammatory diseases of other organs, including psoriatic arthritis, myocardial infarction, hypertension, hyperlipidemia and obesity.
• Examination: Pink to red, inflamed, well-demarcated geographic plaques, with thick white scale, and generalized over extensor surfaces.
• Variants: Guttate or “raindrop-like” eruption, Palmar Plantar Pustulosis, Erythrodermic, Pustular, Acrodermatitis (Continua of Hallopeau), Inverse.
• Unique Features: Extensor distribution, “silvery” scale, nail pitting and other nail dystrophies, plaques sometimes located in the umbilicus and gluteal cleft, thick scale on scalp, strong familial association
• Mimickers: Eczematous Dermatitis, Pityriasis Rosea, Drug Rash.

Question 2

Dx?

Decription

Exam findings?

Variants?

Features unique to this dz?

Mimickers?

Answer 2

Pityriasis Rosea

• Description: Self-limited, asymptomatic papulosquamous disease related to a viral illness (Human herpes virus 6 and 7)
• Examination: pink to salmon oval shaped patches with thin trailing central scale, sparsely scattered over the central trunk
• Variants: Purpuric and vesicular in children.
• Unique Features: Larger “Herald Patch” at onset, seasonal outbreaks, rare on the face.
• Mimickers: Syphilis, Psoriasis, Drug Rash, Eczema.

BUZZ WORDS

• Christmas Tree pattern
• Herald patch
• Salmon oval patches
• Trailing Edge of scale
• Not too itchy
• abdomen or trunk

Question 3

Dx?

Decription

Exam findings?

Variants?

Features unique to this dz?

Mimickers?

Answer 3

Syphilis

[2° shown on reverse, 1° shown here]

• Description: A multi-organ infection caused by the spirochete, Treponema pallidum that evolves through primary, secondary and tertiary stages. A disease of historical significance
• Examination: The primary chancre is typically less painful than herpes simplex, may have “kissing” ulcerative lesions in the genital mucosa
• Secondary syphilis shows generalized round pink scaly asymptomatic patches, which are non-descript (not unique).
• Variants: Primary, Secondary, Tertiary, Congenital.
• Unique Features: History of primary chancre; may NOT feel ill during early secondary syphilis stage
• Mimickers: Pityriasis Rosea, the “Great Mimicker”

Question 4

Dx?

Decription

Exam findings?

Variants?

Features unique to this dz?

Mimickers?

Answer 4

Lichen Planus

• Description: An inflammatory papulosquamous disease of the skin, hair and nails.
• Examination:
• red to violaceous
• white lacy lines (Wiccam’s striae)
• mild scale
• if on wrist w/ lines scratching
• on shins common
• also oral mucosa
• also genital mucosa
• Variants: Hypertrophic lichen planus, Genital involvement, Oral erosive lichen planus, Nail dystrophy, Lichen planopilaris (hair follicle scarring process).
• Unique features: Wickham’s striae (white lines within papules and plaques), linear confluent papules, development in areas of injury (Koebner phenomenon), erosions within mucosa, pterygium (scar) formation of nails.
• Mimickers: Eczema, Psoriasis

Question 5

Dx?

Decription

Exam findings?

Variants?

Features unique to this dz?

Mimickers?

Answer 5

Tinea / Dermatophytosis

• Description: A common infection of the skin, hair and nails, with multiple species of fungi.
• Examination: Pink annular patches with an inflamed border and central clearing with trailing scale; many clinical variations.
• Variants: Named by location; Capitis, Faciei, Corporis, Crurus, Unguium, Pedis, Incognito, Manum (seen on reverse).
• Unique Features: Inflamed raised border, central clearing, may use nail as a reservoir, KOH positive
• Mimickers: Many! Eczema, Psoriasis, Granuloma Annulare, Mycosis Fungoides

Question 6

Dx?

Decription

Exam findings?

Variants?

Features unique to this dz?

Mimickers?

Answer 6

Granuloma Annulare

• Description: An uncommon infiltrative granulomatous disease, unknown cause
• Examination: Asymptomatic annular patches, central clearing, without scale, on dorsal feet and hands
• Variants: Generalized
• Unique Features: Lack of scale, KOH negative
• Mimickers: Tinea, Sarcoidosis

Question 7

CC: Red, scaly rash x 2 months

HPI: Pt had been treating rash at home w/ topical anti-fungal b/c he believed this to be “jock itch”. Reports no improvement.

Dx?

Decription

Exam findings?

Variants?

Features unique to this dz?

Mimickers?

Answer 7

Mycosis Fungoides (Cutaneous T-Cell Lymphoma)

• Description: A malignant infiltrative disease of the skin that has many forms and stages, and ultimately may end up causing multi-organ failure.
• Examination: Red to violaceous patches, linear to oval and annular, with mild elevation and scale; many clinical variants.
• Variants: Depends on stage…plaques, nodules, ulcerative lesions, erythrodermic systemic variant (Sézary’s Syndrome).
• Unique Features: Histology necessary, may take multiple biopsies and immunohistochemistry to confirm the diagnosis.
• Mimickers: Eczema, Psoriasis, Tinea

Question 8

Dx?

Decription

Exam findings?

Variants?

Features unique to this dz?

Mimickers?

Answer 8

Acute Cutaneous Lupus

• Description: Immunologic and inflammatory skin disease, may be related to systemic lupus, many variants and stages.
• Examination: Acute: Inflamed tender red skin, malar area of face and sun-exposed skin Subacute: Annular and arcuate patches, may coalesce, upper chest and back Chronic (Discoid): Usually annular, elevated plaques, may depigment and scar
• Variants: Acute, Subacute, Chronic, Tumid, Panniculitis; Neonatal.
• Unique Features: Photoexacerbated, Tender to Asymptomatic, Hair Loss, Depigmentation, Scarring.
• Mimickers: Dermatomyositis. Many other cutaneous diseases.

Question 9

Dx?

Decription

Exam findings?

Variants?

Features unique to this dz?

Mimickers?

Answer 9

Drug Rashes

• Description: Inflammatory and immunologic based changes of the skin due to interactions with medications, which present with many cutaneous variations.
• Examination: No unifying characteristic features, but hives and urticaria and mobilliform eruptions are the most common. Sloughing and blistering is an ominous sign.
• Urticarial: small to large wheals which migrate form arcuate shapes and coalesce [image on reverse]
• Morbilliform: measle-like (morbilliform) distribution of pink to red round patches [image here]
• Blistering and Necrolysis: initial erythroderma, bullae formation and sloughing of dead or necrotic skin, indicates “toxic epidermal necrolysis” or TEN which has a high mortality rate.
• Variants: Urticarial, Morbilliform, Bullous, Pustular, Erythrodermic, Necrolytic, Fixed and Erythema Multiforme (major and minor).
• Unique Features: Onset within days to 2 weeks of starting a medication, pruritic, spreading centrifugally (trunk to extremities), recurrence upon re-challenge, antibiotics and antiepileptics are the most common offenders.
• Mimickers: Eczema, Psoriasis, Pityriasis Rosea, Viral Exanthem.

Question 10

Dx?

Decription

Exam findings?

Variants?

Features unique to this dz?

Mimickers?

Answer 10

Erythema Multiforme

• Description: An immunologic reaction to various internal triggers, usually viruses and medications, with some unique skin changes, major and minor variants, usually self-limited, but can progress with more systemic (internal organ) involvement.
• Examination: Red to pink “target-like” or “targetoid” macules on the palms and soles, non-descript pink macular and mobilliform changes on the trunk, mucosal erosions (oral, ocular, nasal and genital) with the major variant.
• Variants:
• Minor [image on reverse]: Description as above, with fewer lesions, without mucosal involvement
• Major [image here]: Description as above, with more lesions, with at least 1 but usually several areas of mucosal involvement, can be debilitating, can progress to internal involvement
• Unique Features: By its nature and name, has “multiple forms”, but targetoid lesions are very specific, not always diagnostic, mucosal involvement, temporal relationship with medication administration.
• Mimickers: Eczema, Viral Exanthems, Lupus … but usually not confused with other eruptions when the characteristic “targetoid” macules are present on the palms and soles

Question 11

Dx?

Decription

Exam findings?

Variants?

Features unique to this dz?

Mimickers?

Answer 11

Erythema Chronica Migrans (Lyme Disease/ECM)

• Description: Skin changes due to infection with Borrelia burgdorferi from a lyme or infected deer tick bite, Lyme disease.
• Examination: Bright red, blanchable, expanding macule to patch, with some central clearing and central blue hue, warm to touch, but usually asymptomatic.
• Variants: Multiple ECM lesions, which implies long-standing and/or systemic infection
• Unique Features: Expanding erythema, central bluish clearing within each lesion
• Mimickers: Erythema multiforme (early), Fixed Drug Eruption, Cellulitis

Question 12

Dx?

Decription

Exam findings?

Variants?

Features unique to this dz?

Mimickers?

Answer 12

Eczema

• Description: Very common inflammatory process, with many variants and overlapping features, immunologic process at the basic science level, common histology with all forms, but may be familial (atopic dermatitis), caused by contact allergy (poison ivy) or irritant. Eczema is a huge topic and a large part of dermatology.
• Examination: Pink, pruritic, scaly patches and thin plaques, poorly demarcated, diffusely spread and characteristically on the flexor surfaces.
• Variants: Atopic Dermatitis, Eczematous Dermatitis, Contact Dermatitis, Irritant Dermatitis. [TONS! See Images on PPT to review]
• Unique Features: Very Pruritic, Poorly defined areas, frequency co-infected with Staphylococcus aureus, linear when associated with contact allergy to plants, associated with asthma and hay fever, but all forms have a “spongiotic” process histologically.
• Mimickers: Psoriasis, Lichen Planus, Drug Rashes

Question 13

Dx?

Decription

Exam findings?

Variants?

Features unique to this dz?

Mimickers?

Answer 13

Scabies

• Description: Pruritic, vesicular, scaly eruption due to infection and infestation with Sarcoptes scabiei var. hominis
  mites.
• Examination: Pink pruritic papules, some scale and some small linear vesicles and burrows, often in the skin folds especially the finger web spaces.
• Variants: Nodular, Crusted (Norwegian), Genital, Secondary infection with Staphylococcus aureus.
• Unique Features: Intensely pruritic, linear vesicles and burrows, involvement of the palms and soles in infants, close contacts are almost always infected (pruritic), genital infection may be sexually transmitted in adults, fails to respond to oral steroids, pruritus may continue after appropriate therapy (immunologic response continues).
• Mimickers: Eczema, Impetigo, Lymphomatoid Papulosis, Grover’s Disease…others!

Question 14

Dx?

Answer 14

Tinea versicolor

• Atypical tinea presentation
• Causes opposite pigmentation (i.e. darker skin becomes lighter, lighter skin becomes dark)
• Tracks oil/sweat glands

Question 15

Answer 15

Chronic (Discoid) Lupus

Question 16

Answer 16

Blistering ECM of Lyme Dz

• More recent/new finding

Question 17

Answer 17

Question 18

#1. What is the diagnosis?
 • A. Scabies • B. Psoriasis • C. Lichen Planus • D. Erythema Multiforme • E. Mycosis Fungoides

Answer 18

D. Erythema Multiforme

Question 19

#2. What is the diagnosis?
 • A. Tinea Versicolor • B. Cutaneous Lupus • C. Lichen Planus • D. Granuloma Annulare • E. Drug Rash

Answer 19

A. Tinea versicolor

Question 20

3. What is the diagnosis?

• A. Psoriasis • B. Syphilis • C. Drug Rash • D. Tinea
• E. Lyme

Answer 20

C. Drug rash

Question 21

#4. What is the diagnosis?
 • A. Tinea • B. Pityriasis Rosea • C. Tinea Versicolor • D. Drug Rash • E. Eczema

Answer 21

B. pityriasis rosea

Question 22

5. What is the diagnosis?

• A. Eczema • B. Scabies • C. Psoriasis • D. Tinea
• E. Syphilis

Answer 22

A. Eczema