12 - Metabolic Diseases Flashcards
1
Q
Metabolic disease with derm findings
A
- Diabetes Mellitus = our focus for today
- Gout
- Thyroid disease
- Hyperlipidemia
- Vitamin Disorders
2
Q
Diabetes mellitus
A
30% of all diabetics will have some skin complication during the course of their disease o Necrobiosis Lipoidica Diabeticorum o Diabetic Dermopathy (“Shin Spots”) o Diabetic Bullosis o Pigmented Purpura o Granuloma Annulare o Ulcerations (Neuropathic, Gangrenous) o Eruptive Xanthomas o Yellow Skin and Nails
3
Q
Diabetes mellitus - Necrobiosis lipoidica diabeticorum
A
- Unknown etiology, skin begins to discolor
- Diabetic prevalence
o 1/3 diabetic
o 1/3 abnormal glucose tolerance
o 1/3 normal glucose tolerance - 3:1 Female to Male ratio
- Location
o Anterior shin
o Dorsum of foot - Description
o Well circumscribed, oval, violateous to red plaques
o Advancing red border with yellow brown central area
– May have waxy feel to it
– Border may be elevated in larger lesions central area depressed
– May have central thinning with telangectasias
o Ulceration common, especially after trauma, due to abnormal skin condition - Treatment
o Usually none, because asymptomatic
o Local wound care if ulcerations present, but usually self-limiting
o Topical corticosteroids (may cause skin atrophy)
4
Q
Diabetes mellitus - Diabetic dermopathy
A
- One of the most common skin problems associated with Diabetes
- Location
o Anterior shins - Description
o Round to oval
o Flat topped, red, scaly papules
o May ulcerate
o May precede Diabetes by many years
o Usually clear on their own
5
Q
Diabetes mellitus - Diabetic bullosis
A
- Two types
o Non scarring
– Forms on tips and dorsal aspect of fingers and toes
– Erythematous periphery
– Non hemorrhagic
– Heals spontaneously (unless infection develops)
o Scarring
– Occasionally hemorrhagic
– Inflammatory base present - Found in long standing diabetics ages 40-75
- Usually no history of trauma, the blisters just randomly appear (can be frustrating)
- Treatment
o Leave bulla intact
o If very tense (can’t fit shoes on), may aspirate using aseptic technique
o Roof should be left intact if possible – serves as a covering over wound
6
Q
Diabetes mellitus - Pigmented purpura
A
- May occur with diabetic dermopathy
- Etiology
o Deposition of red blood cells
o Petechiae coalesce to form spots - Description
o Orange or brown pigmentation
o “Cayenne-pepper” spots
7
Q
Diabetes mellitus - Granuloma annulare
A
- Generalized or disseminated granuloma annulare is found up to 33% of patients with diabetes
- Locations
o Backs of hands and fingers
o Doral and lateral aspect of feet, ankles, and legs
o In disseminated form may be body wide - Description
o Distinctive skin eruption
o Ring of firm, well-defined, small, pink to red papules - Histologically similar to necrobiosis lipoidica and rheumatoid nodules
- Treatment
o Usually not necessary because asymptomatic
o If symptomatic, inject advancing borders with equal parts steroid and local anesthetic
o Dapsone for disseminated form
8
Q
Diabetes mellitus - neuropathic ulcers
A
- Etiology
o Neuropathy in conjunction with high pressure areas - Description
o Punched out central core with thick peripheral callous
o Sometimes may need to debride callus to find underlying ulcer
Callus will often have hemosiderin deposits (red discolored tissue) - Treatment
o Debride callous and necrotic tissue
o Offload area in shoe with accomodative insoles or specialized boot/shoes/cast
o Surgery may be necessary to correct biomechanical etiology, remove bony prominence
9
Q
Diabetes mellitus - Gangrene
A
- Diabetes can cause large and small vessel disease
- Even a small injury can result in gangrenous changes due to loss of blood supply to heal
- Treatment
o Revascularization if possible = Do NOT surgically debride unless…
– Revascularized OR acutely infected - Local wound care to keep gangrene dry and stable
10
Q
Diabetes mellitus - Xanthoma eruptivum
A
- Description
o Not common – Frush has never actually seen this
o Firm, non-tender, yellow papules arising on an erythematous base - Location
o Knees, elbows, back, buttocks, trunk, and heel - Associated with hyperlipidemia, hyperglycemia and glycosuria (glucose in the urine)
- Histology
o Foamy, lipid-laden histiocytes with mixed inflammatory cells - Treatment
o Usually resolve with control of blood glucose and resolution of elevated lipid levels
11
Q
Diabetes mellitus - Yellow skin and nails
A
- Typically present with concomitant dermatological conditions
- Plantar calloused skin mostly involved
o Cause unknown, considered to just be due to the diabetes itself - Yellow nails in 50% of diabetics
o Single or multiple nail involvement
o Partial or complete nail involvement
o Possible caused by decrease circulation to nail bed and matrix
o Other common cause is onychomycosis
12
Q
Gout
A
- Disorder of purine metabolism resulting in hyperuricemia o Increased uric acid production o Decreased uric acid excretion o Both (can be due to diet, medications, surgery stress, etc.) - Persistent hyperuricemia causes monosodium urate acid crystals to precipitate in joints - Precipitated by o Minor injury o Surgery o Increased alcohol intake o Excessive dietary protein intake o Stress o Medications - Men>Women
13
Q
Acute gout
A
- Most commonly affects 1st MPJ but can affect any joint
- Characterized by red, hot, swollen joint
o Erythema, increased soft tissue temperature and localized edema
o Intense pain with hypersensitivity (most will say even sheet touching foot is painful) - Diagnosis
o “Gold standard” – joint aspirate with findings of negative birefringent crystals
o Often made by clinical diagnosis and labs
o Need to rule out septic joint or Charcot arthropathy because can present similarly - Treatment of acute gout
o Oral NSAIDs – typically Indomethacin used
o Oral steroids
o Steroid injection
o Rest - Symptoms resolve quickly once treatment is initiated
- Commonly exfoliation (“slough off”) with mild erythema occurs with resolution of symptoms
14
Q
Chronic gout
A
- Multiple attacks to one joint can cause precipitation of crystals causing tophi/joint destruction
o Tophi may form in and around joints, leading to erosive changes
o Skin can become thin, discolored and ulcerated
o Cellulitis and infection can occur - Treatment
o Medical management usually by internal medicine
Allopurinol
Probenecid
Sulfinpyrazone
o Surgery
Removal of tophi
Joint destructive procedures for eroded joints
Amputation (potential, but only for very extreme cases)
15
Q
Thyroid disease
A
- Cutaneous disorders associated with:
o Decreased thyroid hormone (Hypothyroidism)
o Increased thyroid hormone (Hyperthyroidism)
o Not related to presence of thyroid hormone - Treatment aimed at achieving appropriate thyroid hormone levels
16
Q
Hypothyroidism
A
- Causes
o Congenital absence or small thyroid gland
o Thyroid atrophy or tissue loss
o Pituitary or hypothalamic failure
o Impairment of thyroid hormone biosynthesis
o Surgical or chemical ablation of thyroid gland - Derm manifestations
o Cold skin
Due to cutaneous vasoconstriction and decreased metabolism
o Xerosis
Absences of skin sweating
Change in skin texture – skin atrophy and wrinkling
o Pale mottled skin
Mucopolysaccharides and water in dermal layers
o Yellow discoloration
Increased carotene in stratum corneum (thicker parts of skin) - Keratoderma of feet – scaling and thick fissuring of heels
- Dry brittle hair
- Toenails thick, brittle, ridged and may grow slowly
17
Q
Hyperthyroidism
A
- Causes
o Graves’ disease
o Multinodular goiter
o Thyroid adenoma
o Excessive thyroid hormone administration - Derm manifestations
o Warm skin
Peripheral vasodilation
o Moist and soft skin
o Pink or red skin
Particularly elbows, palms and soles
o Smooth texture, skin is normal thickness
o Hyperhidrosis
o Hyperpigmentation (face and lower legs )
o Hypopigmentation or vitiligo (face, knees, elbows, hands and feet)
18
Q
Thyroid disease - Pretibial myxedema
A
- General
o This is a manifestation of thyroid disease that is NOT related to thyroid hormone levels
o Sharply circumscribed, flesh-colored, pink, or violaceous plaques nodules - Found on anterior lower legs
o Bilateral (but not usually symmetrical) - May have translucent or waxy appearance
- Legs may become cylindrical in appearance
- Plaques with dilated follicular openings
o Orange peel appearance - Possible exaggerated telangiectasia
- Produced by large deposits of acid mucopolysaccharides (chondroitin sulfate, hyaluronic acid)
- May get massively swollen feet
o Due to mucin deposits
o Skin stony hard to palpation
o Hyperpigmentation may be present - Treatment
o Mild cases may spontaneously resolve
o Chronic cases
Topical corticosteroid under occlusion with compressive dressing
Intralesional steroid injection
o The longer the condition persists, the less effective the treatment
19
Q
Hyperlipidemia
A
- General
o Group of disorders characterized by lipid deposition in the skin
o Flat , yellow plaques, papules or nodules
o No relationship established between type of xanthoma and specific lipid disorder
o Treatment focused on controlling lipid levels - Various types
20
Q
Types of hyperlipidemia lesions
A
o Xanthoma eruptiva (see diabetes section)
Small, yellow plaques or papules that appear suddenly
o Xanthoma planum
Small palmar and planar lipid papules
o Xanthoma tuberosum
Slow-forming, yellow papules/nodules on the knees, elbows, extensor surfaces
o Xanthoma Tendinosum
Smooth, deep nodules attached to tendons, ligament, and deep fascia
Found on dorsal aspect of hand (MCP)
Most often found on the Achilles Tendon
21
Q
Scurvy vitamin deficiency
A
- Lack of vitamin C (ascorbic acid)
o Unbalance diet (sailors out at sea)
o Alcoholism or other substance abuse
o Chronic illness or GI disease - Vitamin C needed for collagen and certain protein synthesis
- Onset is about 2 months after vitamin C depletion
o Petechial hemorrhages
o Small ecchymosis early, large ecchymosis later in disease
o Follicular hyperkeratosis on lower extremities
Has red hemorrhagic halo - Treatment
o Replenish vitamin C
o Derm findings will disappear 2-3 weeks after treatment (go away on its own)
