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#2 Derm > 23 - Papulosquamous Disease > Flashcards

23 - Papulosquamous Disease Flashcards

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Dermatology Board Prep flashcards
1
Q

Papulosquamous disease definition

A
  • “A heterogeneous group of disorders characterized by scaling papules or plaques.”
  • Papular lesions
  • Overlying scales
  • May be grouped into plaques with overlying scales
  • Etiology is largely unknown
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2
Q

Papule

A
  • A primary skin lesion
  • Defined as small elevated, firm skin lesions under 0.5cm in diameter that are above, rather than within, the surrounding skin
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3
Q

Plaque

A
  • A primary skin lesion
  • Elevated, plateau-like confluence of papules
  • Usually when all the papules start to come together you get scaling of the skin
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4
Q

Scale

A
  • A secondary skin lesion
  • Thickened stratum corneum that exfoliates. Accumulated debris of dead epidermal cells resulting in flakes that lift off of the skin.
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5
Q

Common papulosquamous disease

A
  • Lichen Planus
  • Psoriasis
  • Pityriasis Rosea
  • Pityriasis Rubra Pilaris
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6
Q

Lichen planus

A

First described 1869 by Erasmus Wilson
o Flat topped, polygonal, violaceous papules of unknown cause

Possible causes
o	Drug reactions
o	Infection
o	Emotional stress
o	Idiopathic 
The 6 Ps of lichen planus 
o	Planar (flat topped), Purple, Polygonal, Pruritic, Papules, Plaques
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7
Q

Characteristics of lichen planus

A
  • Oral lesions found in up to 1/3 of patients
  • Nails are involved in 10% of patients
  • Wickham’s Striae - Delicate white lace-like pattern
  • Size: Individual lesions 1-2 mm in diameter, coalesced lesions 4-5 mm in diameter
  • Men = Women
  • Usually affects ages 20-60
  • Children and elderly less commonly affected
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8
Q

Acute lichen planus

A
  • Occurs rapidly over several days
  • Can last up to 18 months
  • Extremely pruritic
  • Location: Anterior legs, Flexor surface of arms, Lumbar area, Hands, Ankles, Feet
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9
Q

Chronic lichen planus

A
  • Higher incidence of oral lesions which may lead to squamous cell carcinoma
  • May evolve from acute form or occur spontaneously and last for years
  • Hypertrophic and follicular forms more common
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10
Q

Clinical presentation of lichen planus

A

Koebner’s phenomenon
o Lesions will develop in areas of mild trauma (i.e. scratching)

***Nail Presentation
o 10% of patients
o Atrophy, ridging, grooving or splitting
o Lysis common
o Pterygium may be seen (forward growth of cuticle over nail plate)
o May be confused with onychomycosis

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11
Q

Subtypes and variants of lichen planus

A
  • Actinic lichen planus
  • Annular lichen planus
  • Atrophic lichen planus
  • Bullous lichen planus
  • Follicular lichen planus
  • Hypertrophic lichen planus
  • Lichen amyloidosus
  • Lichen planus erythematous
  • Lichen nitidus
  • Lichen dermatitis
  • Vesicular lichen planus

Now we will go through each subtype…

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12
Q

Actinic lichen planus

A
  • Mildly pruritic
  • Sun exposed areas or sunburned skin
  • Similar in appearance to granuloma annulare
  • Pigmented and/or dyschromic
  • Koebnerization present
  • Scalp and nails usually not involved
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13
Q

Annular lichen planus

A
  • Lesions form in annular pattern
  • Ring of small confluent papules with central clearing and peripheral spreading
  • Lower extremities and penis
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14
Q

Atrophic lichen planus

A
  • When active lesion go into remission
  • Often on mucosal surfaces
  • Has scaly white crust with “melting” edges
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15
Q

Bullous lichen planus

A
  • Tense bullous lesions (on unaffected skin or areas of preexisting lichen planus)
  • Common on lower extremities and feet
  • Changes to characteristic appearance after blister eruption
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16
Q

Follicular lichen planus

A
  • Lichen planus of hair follicles
  • Scalp and lower extremity prevalence
  • Sharp pointed, keratotic, follicular papules
  • Occasional concurrent skin atrophy and alopecia (may become permanent )
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17
Q

Hypertrophic lichen planus

A
  • Highly pruritic
  • Confluent, firm, lichenified, scaly, and violaceous or hyperpigmented plaques
  • Location: Anterior shins, ankles and soles
  • Often becomes chronic, making it more likely to become malignant
  • Skin becomes heavily pigmented (often permanent)
  • Skin feels rough or “warty”
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18
Q

Lichen amyloidosus

A
  • Predilection for dark skinned middle aged people of Central or South America
  • Pruritic papules on anterior shins and ankles which may coalesce into plaques
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19
Q

Lichen planus erythematous

A
  • Soft, nonpruritic, round, erythematous papules
  • Forearms and ankles
  • Older women
20
Q

Lichen nitidus

A
  • Mildly pruritic
  • Flesh colored to erythematous, tiny, discrete, sharply demarcated, round or flat-topped, shiny papules
  • Penis, arms, legs, ankles, back and abdomen, occasionally found on palms, soles and toes
  • Hyperkeratotic scale commonly present
  • Koebner phenomenon
  • Nail changes present – pitting, ridging, thickening and brittleness
21
Q

Lichen dermatitis

A
  • Caused by medications or chemical exposure
  • Color changes from bright red to violaceous to rust brown
  • Lesions resolve with removal of cause
22
Q

Vesicular lichen planus

A
  • Precursor or variant of bullous
  • Mildly to moderately pruritic
  • Violaceous vesicles
  • Often found with other forms of lichen planus
23
Q

Treatment for lichen planus

A
  • Self-limiting disease - 60-80% spontaneous clearance in 1 year
  • Remove questionable offending agents if medically possible

Treat patient’s symptoms (pruritus)
o Anti-histamines
o Topical anti-pruritics
o Soothing baths
o Topical, cool, wet dressings
o Topical steroids with or without occlusion
o Intralesional corticosteroid injections (triamcinolone acetonide 10mg)
o Tapered Oral corticosteroid (Medrol dose pack)
o Rest and relaxation to reduce stress

Severe cases
o Dapsone or PUVA (8-methoxypsoralen photochemotherapy)

24
Q

Pityriasis rosea characteristics

A

o Self-limiting, asymptomatic skin eruption
o Found most frequently on the trunk or proximal extremities
o Starts as solitary round to oval lesion 2 to 10 cm termed herald patch
o Eruptive phase begins with spread of smaller lesions
o 20% of patients have recent history of infection with fever, fatigue, sore throat and lymphadenitis
o Lesions typically resolve in 1 to 3 months

KNOW HERALD PATCH

25
Q

Diagnosis of pityriasis rosea

A

o History and physical

o Biopsy

26
Q

Treatment of pityriasis rosea

A

o Self-limiting disease

o Treat the symptoms with topical steroids, oral antihistamines, direct sunlight

27
Q

Pityriasis rubra pilaris characteristics

A

o Progressive yet self-limiting
o Thick scaling with red follicular papules that can spread into a generalized eruption
o Difficult to distinguish from psoriasis
o Initial lesion is a small, smooth, red, scaling plaque that slowly enlarges
o Soles and palms start to thicken
o Eruption can last for months to years (80% of patients clear within 3 years)

28
Q

Diagnosis of pityriasis rubra pilaris

A

o History and physical

o Biopsy

29
Q

Treatment of pitiryasis rubra pilaris

A

o Self-limiting disease
o Topical emollients
o Systemic retinoids

30
Q

Psoriasis facts

A
  • Affects 2% of population, variable in expression
  • Not curable but is manageable
  • More common in fair skinned
  • Stress and illness make worse
  • Rest and sunshine make better
  • Have faster rate of skin turnover and proliferation
31
Q

Characteristics of psoriasis

A
  • Red to brown, slightly raised patches with silvery scales
  • Affects extensor surfaces primarily
  • Small papules to large plaques
  • Heal centrally during treatment, giving ring like appearance
  • Removal of scales cause pinpoint bleeding (Auspitz’s sign)
  • Koebnerization present
  • Nail involvement common (may look very similar to onychomycosis)
  • 10-15% of patients will have arthritic changes
32
Q

Areas commonly affected in psoriasis

A
  • Elbows
  • Knees
  • Back
  • Scalp
  • Dorsum of feet (can get on plantar aspect, but more commonly the dorsum)
  • Fingernails and toenails
  • Extensor surfaces
33
Q

What is Auspitz’s sign?

****8

A
  • Auspitz’s sign scaling and picking leads to pinpoint bleeding in psoriasis
34
Q

How common is psoriatic arthritis?

A
  • May be associated with psoriatic arthritis – Found in up to 20% of patients
35
Q

What do the nails look like in psoriasis?

A
  • Pitting - 25%
  • Yellow macules (oil spots)
  • Distal lysis
  • Dystrophy
  • Resembles onychomycosis
36
Q

What are the three different forms of psoriasis?

A
  • Psoriasis vulgaris
  • Guttate psoriasis
  • Pustular psoriasis
37
Q

Characteristics of psoriasis vulgaris

A
  • Most stable form
  • Patches well defined
  • Raised
  • Red base with uniform silvery scale
  • Differential diagnosis will include nummular eczema, tinea corporis, lichen simplex chronicus
38
Q

Characteristics of guttate psoriasis

A
  • Often follows strep throat
  • Small, erythematous papules
  • Appears suddenly
  • Trunk, lower legs, and feet
  • Usually resolves after 2-3 months
  • Differential diagnosis will include lichen planus, secondary syphilis, pityriasis rosea
39
Q

Characteristics of pustular psoriasis

A
  • Worse form, hardest to treat
  • Located on palms and soles, usually centrally
  • Can involve just toes where you would get acrodermatitis perstans (crusts scale over nails and the nails just fall off)
  • Yellow pustules often on erythematous base
  • Dries to brown crusts
  • Symmetrical and bilateral
  • Difficult to treat
40
Q

Treatment for psoriasis

A
  • Avoid trigger factors
  • Topical: steroids, tar, retinoids, emollients, topical vitamin D
  • Ultraviolet Light: PUVA (psoralin), UVB, narrow band UVB
  • Systemic: Methotrexate, cyclosporine, retinoids
  • Intralesional injections
41
Q

What are the DISTINGUISHING FEATURES of eczema? How do you treat it?

A

Excoriations and lichenification of skin, often on flexor surface

Treat with topical steroids and emollients

42
Q

What are the DISTINGUISHING FEATURES of lichen simplex chronicus? How do you treat it?

A

One or more plaques with lichenification in an area that is easily scratched

Treat with potent topical steroids, help patient avoid scratching and picking at skin

43
Q

What are the DISTINGUISHING FEATURES of pityiasis rosea? How do you treat it?

A

Herald patch preceding annular plaques with collarette scale

Treat with reassurance (self-limited condition)

44
Q

What are the DISTINGUISHING FEATURES of prugo nodularis? How do you treat it?

A

Puritic nodules, often on the extremities

Treat with potent topical steroids, oral antipruritic medications, help patient avoid scratching and picking at skin

45
Q

What are the DISTINGUISHING FEATURES of psoriasis? How do you treat it?

A

Plaques with thick scale on extensor surfaces

Treat with potent topical steroids, topical vitamin D and other treatments

46
Q

Notes on chart of distinguishing features

A
  • These correlate to the differential diagnoses for cutaneous lichen planus
  • She went through the ENTIRE chart, so need to know it
  • Note that most of these you will treat with topical steroids (she said this)
47
Q

Case study

A
  • 39 year old male with diffuse severe psoriasis – worse case she has ever seen
  • Medications: Humira, which is usually used for rheumatoid arthritis
  • Complains of painful toes (he is one of the 10-15% who has psoriatic arthritis)
  • Psoriatic arthritis is a little different than rheumatoid arthritis because you see more pain in the IPJ (interphalangeal joints) than the MPJ (metatarsal phalangeal joints)
  • Did surgery to fuse the toes – opened up the toe to do the arthroplasty
  • When she opened up the joint, there was erosion and no nice white shiny cartilage joint capsule
  • Psoriatic arthritis patients get the “pencil in cup” phenomenon where the bone erodes in the joint and it gets pointy
  • His hammer toes had gotten so bad, that there were problems with the MPJs as well, so that was surgically addressed as well
  • Sometimes patients with psoriasis will have an exacerbation of psoriatic plaques due to the stress of surgery, so make sure you discuss this with your patients before taking them to surgery

#2 Derm (13 decks)

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