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Alikhan & Hocker dermatology > 3. General Dermatology > Flashcards

3. General Dermatology Flashcards

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1
Q

Worldwide prevalence of psoriasis?

A

2%

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2
Q

What percentage of psoriatic patients develop symptoms of psoriatic arthritis(PsA) ?

A

5-30%

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3
Q

Psoriasis age peak & distribution

A

Bimodal distribution

Peaks at 20-30 & 50-60 yrs

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4
Q

Name some genetic factors of psoriasis

A
  • PSORS-1 susceptibility locus (on chromosome 6p)
  • HLA- Cw6
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5
Q

HLA - B27 is ass/w ?

A

Sacroilitis- associated psoriasis

PsA

Pustular psoriasis

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6
Q

HLA - Cw6 & Psoriasis

A
  • 10–15 times ↑risk
  • Positive in 90% of early-onset psoriasis
  • 50% of late onset
  • strongly a/w guttate psoriasis
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7
Q

Strongest HLA risk factor for early-onset disease?

A

HLA-Cw6

( Cw6> B57,DR7 )

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8
Q

HLA ass/w with guttate and erythrodermic psoriasis?

A

HLA B13 & B17

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9
Q

HLA associated with palmoplantar pustulosis

A

HLA-B8, Bw35, Cw7, and DR3

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10
Q

Pathogenesis of psoriasis

A

Primarily T-cell disorder

  • CD8+ in epidermis
  • mix of CD4+/CD8+ in dermis
  • Increased Th1 cytokines, IL-1, IL-6, TNF-a
  • Decreased IL-10
  • ↑dendritic cells in psoriatic skin
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11
Q

Triggering factors of psoriasis

A
  • External: Trauma (Koebner phenomenon)
  • Internal:
  1. Infections ( streptococcal pharyngitis n.1, HIV)
  2. Endocrine factors
  3. Stress
  4. Drugs
  5. Obesity
  6. Smoking, alcohol consumption
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12
Q

Triggering factor in generalized pustular psoriasis?

A

Hypocalcemia

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13
Q

Triggering factor in impetigo herpetiformis?

A

Pregnancy

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14
Q

MC drugs that can exacerbate/trigger psoriasis

A
  • Lithium
  • IFNs
  • β-blockers
  • Antimalarials
  • TNF-a inhibitors
  • CS tapers in pustular psoriasis
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15
Q

Length of latency period btw trauma (Koebner) and appearance psoriatic lesions?

A

2-6 weeks

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16
Q

TNF-a inhibitors may induce which type of psoriasis?

A

Plaque psoriasis

+/- palmoplantar pustulosis

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17
Q

Latency period btw drug initiation & psoriatic skin eruption

A
  • Short latency (<4 weeks): terbinafine, NSAIDs
  • Intermediate latency (4 to 12 weeks):
    antimalarials, ACEIs
  • Long latency (>12 weeks): β-blockers,
    lithium
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18
Q

Dx?

A

Chronic plaque psoriasis

Sharply demarcated, erythematous, scaly plaques

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19
Q

Dx?

A

Multiple large plaque psoriasis

Obvious symmetry of the plaques on the upper extremities

+/- pruritus & hemorrhagic crusts due to scratching

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20
Q

Dx?

A

Annular plaques of psoriasis due to central clearing

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21
Q

Dx?

A

Sunburn related Koebner phenomenon

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22
Q

Dx?

A

Guttate psoriasis

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23
Q

Dx?

A

Linear Koebner

+ widely scattered guttate lesions

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24
Q

Dx?

A

Generalized pustular psoriasis

Broad areas of erythema with numerous pustules & formation of lakes of pus

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25
Q

Dx?

A

Annular pustular psoriasis

Multiple annular inflammatory plaques whose active borders are studded with pustules followed by desquamation. As these lesions enlarge, there is central clearing

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26
Q

Dx?

A

Pustulosis of the palms and soles

Multiple sterile papules are admixed with yellow–brown macules on the palm

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27
Q

Dx?

A

Acrodermatitis continua of Hallopeau

Erythema and slight scale of the distal digit, pustules within the nail bed, and partial shedding of the nail plate

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28
Q

Dx?

A

Scalp psoriasis with extension onto the neck

  • Note the involvement of the external auditory canal
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29
Q

Dx?

A

Psoriasis inversa

Shiny erythematous plaques of the inframammary folds that LACK SCALE

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30
Q

Dx?

A

Nail psoriasis

Nail plate pitting, distal onycholysis, oil drop changes, and subungual and proximal hyperkeratosis are seen. There is also proximal nail-fold inflammation with loss of the cuticle, especially of the forefingers

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31
Q

Dx?

A

fissured tongue (black arrow)

and

geographic tongue (blue arrow) in psoriatic patient

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32
Q

Pinpoint papules surrounding existing psoriatic plaques indicate…?

A

Unstable phase of disease

During exacerbations, psoriatic lesions often itch

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33
Q

MC type of psoriasis?

A

Chronic plaque psoriasis

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34
Q

Chronic plaque psoriasis features

A

MC type of psoriasis

  • relatively symmetric distribution of sharply defined, erythematous, scaly plaques
  • scalp, elbows, knees and lumbosacral area
  • genitalia involved in up to 45% of pts
  • Course of disease is chronic
  • periods of complete remission do occur and remissions of 5 years have been reported in ~15% of pts
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35
Q

Guttate psoriasis features

A

MC seen in children and adolescents

  • frequently preceded by URTI (1-3 weeks prior to onset) or GAS infection (oral or perianal)
  • >50% of pts have ↑ antistreptolysin O, anti- DNase B or streptozyme titer
  • 40% progress to plaque type
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36
Q

Clues to diagnosing psoriatic erythroderma

A
  • previous plaques in classic locations
  • characteristic nail changes
  • central facial sparing
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37
Q

Erythrodermic psoriasis features

A
  • generalized erythema and scale (>90% BSA)
  • Triggers: poor management decisions most common
    (e. g., abrupt withdrawal of systemic steroids)
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38
Q

Generalized pustular psoriasis

A
  • Histology: infiltration of neutrophils

=> explaining the bright erythema and sterile pustules

  • MC triggers: pregnancy, rapid tapering of corticosteroids (or other systemic therapies), hypocalcemia, infections
  • If localized => think of TOPICAL IRRITANTS
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39
Q

Name the 4 distinct subtypes of generalized pustular psoriasis

A
  • von Zumbusch pattern
  • Annular pattern
  • Exanthematic type
  • Localized pattern
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40
Q

Von Zumbuch features

A
  • generalized eruption starting abruptly with erythema and pustulation
  • Fever, ill patient
  • Painful skin
  • After several days, pustules usually resolve and extensive scaling is observed
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41
Q

Annular pustular psoriasis

A
  • Annular lesions, consisting of erythema & scaling with pustulation at the advancing edge
  • lesions enlarge by centrifugal expansion over a period of hours to days
  • healing occurs centrally
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42
Q

Exanthematic pustular psoriasis

A
  • acute eruption of small pustules, abruptly appearing and disappearing over a few days
  • following an infection or drug initiation (lithium)
  • usually no systemic symptoms
  • Overlap btw pustular psoriasis & pustular drug eruptions (AGEP)
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43
Q

Localized pustular psoriasis features

A
  • pustules appear within or at the edge of existing psoriatic plaques
  • can be seen during the unstable phase of chronic plaque psoriasis
  • following the application of irritants, e.g. tars, anthralin
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44
Q

Pustulosis of palms and soles features

A
  • Localized “sterile” pustules of the palmoplantar surfaces admixed with yellow-brown macules
  • Triggering factors: focal infections, stress
  • Smoking may aggravate the condition
  • Ass/w sterile inflammatory bone lesions (SAPHO syndrome)
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45
Q

SAPHO syndrome

A
  • Synovitis
  • Acne
  • Pustulosis
  • Hyperostosis
  • Osteitis
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46
Q

Clinical scores for psoriasis

A
  • PASI: Range from 0 to 72, evaluates “erythema, induration, scaling, BSA”.
  • NailPSI: used to assign a score to each nail for nail bed and nail matrix psoriasis. nail plate is divided into quadrants by imaginary longitudinal and horizontal lines. Range from 0-8 or 0-32 (thorough examination)
  • DLQI: ten-question questionnaire used to measure the impact of skin disease on the quality of life of an affected person. designed for people aged 16 years and above. Range from 0-30
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47
Q

Acrodermatitis continua of Hallopeau features

A
  • rare manifestation of psoriasis
  • pustules on the distal portions of fingers & sometimes toes
  • may be accompanied by annulus migrans of the tongue
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48
Q

Scalp psoriasis

A
  • MC sites for psoriasis
  • Psoriatic lesions often advance onto the periphery of the face, the retroauricular areas and the posterior upper neck
  • scales sometimes have an asbestos-like appearance and can adhere to hair shafts in clumps (pityriasis amiantacea
  • Alopecia occasionally develops within involved areas, including in the setting of TNF inhibitor-induced psoriasis
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49
Q

Patients with dermatomyositis involving the scalp may have lesions that resemble psoriasis

T/F ?

A

True

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50
Q

Flexural psoriasis features

A
  • shiny, pink to red, sharply demarcated thin plaques
  • much less scale than in untreated chronic plaque psoriasis
  • Often central fissure is seen
  • MC sites include retroauricular fold, intergluteal cleft, inguinal crease, axilla, and inframammary region
  • ꜛ incidence of erythrasma in pts with inverse psoriasis
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51
Q

Oral mucosa psoriatic lesions

A
  • Migratory annular erythematous lesions with hydrated white scale (annulus migrans) in pts with Hallopeau/ & generalized pustular psoriasis
  • Geographic tongue
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52
Q

Nail Psoriasis features

A
  • fingernails > toenails (vs opposite pattern in onychomycosis)
  • Proximal matrix → pits
  • Distal matrix → leukonychia and loss of
    transparency; subungual hyperkeratosis
  • Nail bed → oil spots, Salmon patches, splinter hemorrhages, onycholysis, and subungual
    hyperkeratosis
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53
Q

PsA features

A
  • up to 30% of psoriasis pts
  • correlated w/ skin severity
  • typically RF negative (“seronegative”)
  • classic early symptom = morning joint stiffness lasting >1hr
  • vast majority have nail changes +/− tendon/ligament involvement (enthesopathy/enthesitis)
  • strong genetic predisposition (50% HLA-B27+)
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54
Q

Rx of PsA?

A

biologics, MTX, apremilast, cyclosporine, and tofacitinib

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55
Q

MC pattern of PsA + its features

A

Asymmetric mono-oligoarthritis

  • Oligoarthritis w/ swelling and tenosynovitis of hands (60%–70%)
  • affects DIP + PIP joints of hand and feet
  • may → “sausage digit” +/− large joint involvement
  • spares MCP (vs RA)
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56
Q

Other forms of PsA

A
  • Asymmetric DIP involvement + nail changes (16%): exclusively affects DIP → “sausage digit,” nail damage
  • Rheumatoid arthritis-like (15%): symmetric polyarthritis of small and medium joints (PIP, MCP, wrist, ankle, and elbow); hard to DDx from RA and may be RF+
  • ​Ankylosing spondylitis (5%): axial arthritis
    +/− sacroiliac, knee and peripheral joint involvement; M > F, usually HLA-B27+, a/w IBD and uveitis
  • Arthritis mutilans (5%): least common, most severe (osteolysis of phalanges/metacarpals→ short, wide, and soft digits w/ “telescoping phenomenon”)
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57
Q

Table of PsA types

A
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58
Q

SITES OF INVOLVEMENT IN PSORIATIC ARTHRITIS AND REACTIVE ARTHRITIS

A
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59
Q

Dx?

A
  • Asymmetric involvement of the DIP & PIP joints
  • A “sausage” digit (third digit bilaterally) results from involvement of both the DIP & PIP joints
  • Note the yellowing, thickening and crumbling of several fingernails
60
Q

Comorbidities ass/w psoriasis

A
  • ↓risk of allergic diseases (AD, asthma, urticaria, ACD)
  • ↓risk of superinfection (due to ↑antimicrobial peptides)
  • Possible ↑risk of lymphoma
  • ↑risk of cardiovascular diseases, HLD, HTN,
    NASH, and metabolic syndrome
61
Q

Disorders related to psoriasis

A
  • Inflammatory linear verrucous epidermal nevus (ILVEN)
  • Reactive arthritis (formerly Reiter disease), [urethritis, arthritis, ocular findings and oral ulcers, in addition to psoriasiform skin lesions, caused by Chlamydia trachomatis]
  • Sneddon–Wilkinson disease (subcorneal pustular dermatosis)
62
Q

Dx?

A

Inflammatory linear verrucous epidermal nevus

63
Q

Dx?

A

Sneddon-Wilkinson disease

Annular and polycyclic plaques in the axilla with small pustules, erosions and scale in the border

Numerous, fragile, subcorneal pustules arising within a background of erythema.

64
Q

Clinical features of ILVEN

A
  • linear psoriasiform lesions (scaling & erythematous plaques) that follow the lines of Blaschko
  • Based upon its chronicity and resistance to therapy, ILVEN is thought to be an entity separate from linear psoriasis
65
Q

Clinical features of Reiter arthritis

A
  • Most commonly caused by Chlamydia trachomatis or Shigellosis
  • Conjunctivitis, uveitis, iritis
  • Polyarthritis, sacroilitis
  • Urethritis ( with compl => cystitis, cervicitis, salpingitis)
  • Keratoderma blenorrhagicum
  • Balanitis circinata
  • ass/w HLA B27 & HIV (severe form)
  • Self-limiting, lasting weeks-months
66
Q

Dx and Tx?

A

Circinate balanitis (Psoriatic plaques on the penis)

  • Topical 0,1% tacrolimus (results within 1 week)
  • Topical 1% pimecrolimus
67
Q

Pt with arthritis, urethritis & conjunctivitis

Dx?

A

Keratoderma blennorrhagicum

68
Q

Clinical features of Sneddon-Wilkinson disease

A
  • Annular or polycyclic lesions commencing on flexures
  • Very superficial (subcorneal) sterile pustules (Dx hallmark)
  • Cyclic course of Dx (pustules resolve => replaced by scaling => new pustules form again)
  • ass/w IgA paraproteinemia
69
Q

Frequencies of atopic dermatitis, asthma, urticaria and allergic contact dermatitis have been found to be higher in pts with psoriasis

T/F ?

Why?

A

False

Psoriasis => Th1 response

Atopic dermatitis => Th2 response

70
Q

Psoriasis and lichen simplex chronicus

A

Bi-directional relationship

  • If a psoriatic lesion is pruritic, superimposed LSC may develop and the surface becomes shiny with increased skin markings. Because the LSC itself is pruritic, the resultant rubbing may worsen the psoriasis (Koebner phenomenon). The patient then enters a vicious cycle
71
Q

When could be used the terms “sebopsoriasis”?

A
  • Seborrheic dermatitis: pink to red patches with yellowish, sometimes greasy, scales
  • Areas of predilection: scalp, central face, ears, presternal area, and intertriginous zones
  • This term could be used when diagnostic lesions of psoriasis are not present elsewhere
72
Q

Secondary skin infections are more common in pts with atopic dermatitis or psoriasis? Why?

A

AD>>> Psoriasis

In psoriasis => increased production of skin-derived antimicrobial peptides, e.g. defensins, SKALP/elafin

73
Q

Psoriasis & other ass/d disorders

A
  • Decreased incidence of AD, ACD, asthma, urticaria
  • Decreased secondary skin infections
  • ^ incidence of onychomycosis (dermatophyton or Candida)
  • ^ incidence of concomitant Candida or Corynebacterium infections in flexural psoriasis
  • ^ CRP levels => risk factor for CVD
  • ^ incidence of NASH (fatty liver infiltration, AST:ALT> 1, obesity, hyperlipidemia, metabolic syndrome)
74
Q

DD of plaque psoriasis

A

Seborrheic dermatitis

LSC

Dermatomyositis

Mycosis fungoides

Hypertrophic lichen planus (if shins are involved)

75
Q

DDx of guttate psoriasis

A
  • Guttate psoriasis rarely involves palms & soles
  • Parapsoriasis
  • Pityriasis lichenoides cronica
  • Secondary syphilis
  • Pityriasis rosea
  • Tinea corporis (if limited lesions in number or annular)
  • Pemphigus foliaceus (if upper trunk is involved)
76
Q

Flexural psoriasis DDx

A
  • Intertrigo
  • Seborrheic dermatitis
  • Contact dermatitis
  • Cutaneous candidiasis
  • Tinea incognito
  • Erythrasma
  • Extramammary Paget disease
  • Langerhans cell histiocytosis (in infants)
77
Q

DDx of of subcorneal/intraepidermal neutrophilic
pustules

A
78
Q

Define an active psoriatic lesion

A

A fully developed guttate lesion or the marginal zone of an enlarging psoriatic plaque

79
Q

Histologic hallmarks of pustular psoriasis

A
  • spongiform pustules of Kogoj
  • microabscesses of Munro
  • Large clusters of neutrophils in upper epidermis
80
Q

Name the classical histologic hallmarks of psoriasis

on mature plaques

A
  • Confluent parakeratosis
  • Regular acanthosis w/ elongated rete ridges
  • Thinning of the suprapapillary plates
  • ↓ or absent stratum granulosum
  • Dilated capillaries in dermal papillae
  • Micropustules of Kogoj (stratum spinosum) and
    microabscesses of Munro (stratum corneum)
81
Q

Name the classical histologic hallmarks of psoriasis

on guttate psoriatic lesions

A
  • Milder acanthosis, spongiosis, foci of intraepidermal neutrophils, mounded parakeratosis, ↓granular layer
  • Thin, tortuous capillaries in papillary dermis
  • Mixed perivascular infiltrate w/ scattered neutrophils
82
Q

Name 2 phenomena that can be seen in psoriatic pts using topical corticosteroids

A
  • Tachyphylaxis
  • Rebound phenomenon
83
Q

Indications and contraindications for topical corticosteroids

in psoriasis

A
84
Q
  • Maximum improvement from topical corticosteroids in psoriasis occurs after …?
  • What can be done to attenuate phenomena as tachyphylaxis & rebound?
A

2 weeks

Intermittent treatment schedule

(e.g. once every 2 or 3 days or on weekends)

85
Q

Major MoA of Vitamin D3 analogues

A
  • When epidermis is hyperproliferative

=> vitamin D3 inhibits epidermal proliferation

=> induces normal differentiation by enhancing cornified envelope formation and activating transglutaminase;

  • it also inhibits several neutrophil functions.
86
Q

Indications and contraindications for anthralin

A
87
Q

Indications and contraindications for topical tazarotene

A

Maximum area that can be treated is 10-20% of BSA

Can be combined with corticosteroids topically to avoid pruritus, erythema, burning

88
Q

What to do if psoriatic plaques have thick scale?

A
  • Apply salicylic acid 5-10% (substantial keratolytic effect), 1v/die if localized, 2-3/weekly if extended

=> this is to prevent systemic intoxication in infants or those with impaired renal function

  • Crude coal tar => anti-inflammatory, anti-pruritus
89
Q

Facial & flexural psoriasis Tx?

A

Topical calcineurin inhibitors

(tacrolimus, pimecrolimus)

90
Q

Indications and contraindications for photo(chemo)therapy for psoriasis

A
  • Phototherapy with broadband or narrowband UVA or UVB following ingestion of or topical application of a psoralen
91
Q

Indications and contraindications for methotrexate

A
92
Q

PUVA + cyclosporine in pts with psoriasis can lead to?

A

^ frequency of SCCs

93
Q

Side effects of MTX

A
94
Q

Indications and contraindications for cyclosporine

A
95
Q

Indications and contraindications for acitretin

A
96
Q

Indications and contraindications for acitretin

A
97
Q

IL-23 monoclonal antibodies

A
98
Q

Anti IL-17 & IL-23 monoclonal antibodies

A
99
Q

Biological drugs psoriasis

A
100
Q

Additional systemic therapies for psoriasis

A
101
Q

Indications for biologic drugs in psoriasis

A
102
Q

CIs to biologic drugs in psoriasis

A
103
Q

Management of psoriasis at specific sites

A
104
Q

Treatment of psoriasis in the setting of comorbidities

A
105
Q

Sites of psoriatic arthritis and reactive arthritis

A
106
Q

Dx?

A
  • Psoriatic arthritis. Asymmetric involvement of the DIP & PIP joints.
  • Sausage digit, results from involvement of both the DIP and PIP joints
107
Q

Woronnof ring

A

pale blanching ring around psoriatic lesions

108
Q

Auspitz sign

A
  • scraping of psoriasis scale → pinpoint bleeding (due to dilated capillaries and suprapapillary plate thinning)
109
Q

Treatment of choice for psoriasis subtypes

A

■ Pustular (von Zumbusch): acitretin (>cyclosporine,
MTX, and biologics)

■ Impetigo herpetiformis: early delivery, prednisone

■ Guttate: BB-UVB at erythemogenic doses (>NB-UVB)

■ Erythrodermic: cyclosporine, infliximab, and acitretin

110
Q

Dx?

A

Pityriasis Rubra Pilaris (PRP)

111
Q

Clinical features of PRP

Synonyms : Lichen ruber pilaris/acuminatus, Devergie disease

A
  • Bimodal age distribution: 1st & 6th decade
  • Unknown etiology
  • Classically begins on head/neck → progresses caudally
  • Follicular hyperkeratosis on erythematous base (especially on dorsal aspect of proximal fingers)
  • Papules coalesce into orange to salmon-colored plaques w/ “islands of sparing” on trunk and extremities
  • → can progress to erythroderma w/ exfoliation
112
Q

Other diagnostic hallmarks of PRP

A
  • Scalp erythema w/ fine, diffuse scaling
  • Orange-red waxy keratoderma of palms/soles (“sandal-like PPK”) w/ fissures
  • Thick, yellow-brown nails w/ subungual debris; lacks nail pits (vs Pso)
113
Q

Subtypes of PRP (number)

MC subtype?

A

6

Type I (55%) : Classic adult

114
Q

Subtypes of PRP

A
115
Q

Clinical features of PRP subtypes

A
  • Type I: MC (55%), classic adult, rapid onset, good prognosis
  • Type II: 5%, atypical adult, slow onset, ichthyosiform leg lesions + keratoderma w/ coarse & lamellated scale +/− alopecia; chronic course
  • Type III: 10%, classic juvenile. Same as type I, peaks in adolescence and first 2 yrs of life
  • Type 4: (25%, circumscribed juvenile): MC form in children; only localized form of PRP; p/w follicular papules and erythema on elbows & knees; prepubertal onset; variable course
  • Type 5: 5%, atypical juvenile. first few years of life,
    PRP + sclerodermoid changes of hands/feet; chronic
  • Type 6: generalized PRP in HIV patients w/ hidradenitis suppurativa, acne conglobata, and elongated follicular spines
116
Q

Histopathology in PRP

A
  • Psoriasiform dermatitis with irregular hyperkeratosis and alternating vertical and horizontal ortho- and parakeratosis
  • Follicular plugging
  • “Shoulder parakeratosis” (parakeratosis at edges of hair follicle orifice)
  • Irregular acanthosis w/ thickened suprapapillary plates (vs Pso)
  • Focal acantholysis or acantholytic dyskeratosis
117
Q

Tx of PRP?

A
  • First line: isotretinoin or acitretin
  • Others: high-dose vitamin A, MTX, TNF-α inhibitors, phototherapy
118
Q

Prognosis of PRP?

A
  • Classic forms (type 1 and 3) reliably self-resolve in 3–5 yrs
  • Atypical and circumscribed forms (types 2, 4, and 5) persist much longer
  • Phototherapy may induce flares → phototesting recommended
119
Q

Dx?

A

Adult seborrheic dermatitis of the face, ear and scalp

120
Q

Dx?

A

Infantile seborrheic dermatitis

121
Q

Pathogenesis of seborrheic dermatitis

A
  • Multifactorial etiology
  • ↑Malassezia furfur in cutaneous lesions
  • Sebum composition altered (↑triglycerides/cholesterol; ↓squalene and FFA)
  • Immune dysregulation (some cases)
  • ↑incidence and severity in HIV and Parkinson’s
122
Q

Clinical features of pediatric seborrheic dermatitis

A
  • Erythematous, scaly, sometimes pruritic rash affecting “seborrheic” areas (scalp, face, postauricular, presternal, and intertriginous areas)
  • Infants often present w/ “cradle cap” (greasy yellow scales adherent to scalp)
  • Erythematous, scaly, macerated plaques in body creases (anterior neck crease, axillae, groin, and popliteal fossae)
123
Q

Clinical features of adult seborrheic dermatitis

A
  • Well-defined, pink-yellow patches w/ “greasy” scale in highly sebaceous areas (scalp, eyebrows, nasolabial folds, forehead, ears/retroauricular, central chest, and intertriginous areas)
  • Often itchy (particularly scalp)
  • Dandruff (pityriasis simplex capillitii) – mild form on scalp
124
Q

Tx of seborrheic dermatitis

A
  • Gold standard = topical azoles(ketokonazole 2%)
  • Other options: ciclopirox, topical CS, TCIs, pyrithione zinc, selenium sulfide, salicylic acid, and coal tar shampoos
  • “Cradle cap:” frequent shampooing (antiseborrheic shampoos), baby or mineral oil, brushing/combing, and low potency topical CS
125
Q

Prognosis of seborrheic dermatitis

A
  • Infants: spontaneous resolution by 8–12 months
  • Adolescents: tends to be more chronic
  • Adults: chronic and relapsing
126
Q

Histological features of seborrheic dermatitis

A
  • Irregular to psoriasiform acanthosis, spongiosis, “shoulder parakeratosis,” superficial perivascular/ perifollicular lymphocytic infiltrate
127
Q

Pityriasis simplex capillitii

A

Dandruff

  • diffuse, slight to moderate, fine white or greasy scaling of the scalp and terminal hair- bearing areas of the face (beard area)
  • without significant erythema or irritation
  • Scales accumulate visibly on dark clothing
  • Mildest form of seborrheic dermatitis of the scalp
128
Q

DDx

infantile seborrheic dermatitis

vs

atopic dermatitis

A

Infantile seborrheic dermatitis:

  • Earlier onset ( one week after birth, up to several months)
  • Absence of pruritus, irritability, sleepness
  • Different distribution pattern
129
Q

DDx

infantile seborrheic dermatitis

vs

irritant diaper dermatitis

A

Irritant diaper dermatitis:

  • confined to the diaper area
  • tends to spare the skin folds
130
Q

DDx

seborrheic dermatitis of the scalp

vs

psoriasis

If indistinguishable => sebopsoriasis

A

Psoriatic plaques:

  • tend to be thicker, with silvery white scale
  • more discrete, less pruritic, unassociated with seborrhea
  • Features of psoriasis evident elsewhere in body
131
Q

Name some 1st & 2nd line therapeutic choices for seborrheic dermatitis

A

1st line:

  • Ketokonazole 2% (shampoo or cream/body)
  • Ciclopirox olamin (shampoo)

2nd line:

  • Zinc pyrithione
  • Selenium sulfide
  • Topical calcineurin inhibitors
  • Low potency Corticosteroids, emollients (initial stages)
132
Q

DDx of intertriginous dermatoses in adults (table)

A
133
Q

Dx?

A

Pityriasis rosea of Gilbert

134
Q

Pityriasis rosea clinical features

A
  • Female predominance; 10–35 yo
  • Peaks in spring and fall
  • Possibly viral (HHV-7 >> HHV-6)
  • Drug-induced PR: ACE inhibitors (most common),
  • *NSAIDs**, gold, bismuth, β-blockers, barbiturates, isotretinoin, metronidazole, and clonidine
135
Q

Describe the primary & secondary lesions of Pityriasis rosea

A

Primary:

  • Begins w/ “herald patch” = solitary pink, enlarging plaque w/ fine central scale and larger trailing collarette of scale; favors trunk

Secondary:

  • Diffuse eruption (begins hours to weeks later): oval patches/plaques on trunk and proximal extremities
  • Lesions appear similar to “herald patch,” but smaller
  • Vertical axes oriented along Langer’s lines (“Christmas
    tree pattern”)
  • 25% experience significant pruritus
136
Q

Name some atypical patterns of Pityriasis rosea

A
  • Inverse PR pattern: prominent involvement of
    intertriginous sites, or more prominent involvement
    of limbs (> trunk)
  • Papular, vesicular, or targetoid morphology
    ○ PR is often more papular and extensive in African American children
  • Oral involvement (e.g., ulceration)
  • Drug-induced PR-like eruptions: ↑inflammation/pruritus, lacks herald patch; older patient population
137
Q

Tx and prognosis of pityriasis rosea

A
  • Not required; symptomatic treatment w/ topical CS, antipruritic lotions
  • Oral erythromycin hastens clearance
  • Self-limited (6–8 weeks)
  • Drug induced PR-like eruptions resolve rapidly (<2 weeks) after discontinuing drug
138
Q

If lesions of pityriasis rosea do not resolve within 5 months, what to suspect?

A

Pityriasis lichenoides cronica

139
Q

Dx?

A

Granular parakeratosis

140
Q

Clinical features of intertriginous/axillary granular parakeratosis

A
  • Adult women > infants (diaper area)
  • Pruritic, keratotic red-brown papules and plaques
    in intertriginous areas (axillae > inguinal,
    inframammary     )
  • Possible defect in filaggrin metabolism → retention of
    keratohyaline granules in stratum corneum
  • Alternative theories: irritant dermatitis, reaction to
    deodorants/antiperspirants
  • Can be chronic/recurrent
141
Q

Histologic features of granular parakeratosis

A
  • characteristic thickened eosinophilic stratum corneum w/ prominent parakeratosis and retained keratohyalin granules
  • vascular ectasia
142
Q

Tx of granular parakeratosis

A
  • topical (corticosteroids, vitamin D analogues, keratolytics, and antifungals)
  • destructive (cryotherapy)
  • systemic (isotretinoin, antifungals)
143
Q

Dx?

A

Pityriasis rotunda

(Tinea/Pityriasis circinata)

144
Q

Clinical features of pityriasis rotunda

A
  • Asymptomatic dermatosis seen primarily in the Far East and Mediterranean basin and in individuals of African descent
  • large circular and polycyclic lesions that are often 10 cm (but may be up to 30 cm) in diameter
  • fine scale, moderately hyperpigmented with a sharp margin and no inflammation
  • Possibly due to malnutrition or internal diseases (cancer,infections)
145
Q

Tx of pityriasis rotunda

A
  • Relatively difficult to treat
  • Firstly reverse any underlying disorder
  • topical lactic acid, urea, tars, emollients, and corticosteroids
  • Topical tretinoin cream 0.1%
146
Q

Define erythroderma

A

Erythema and scaling involving >80–90% of BSA

147
Q
A

Alikhan & Hocker dermatology (16 decks)

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