3. General Dermatology Flashcards
1
Q
Worldwide prevalence of psoriasis?
A
2%
2
Q
What percentage of psoriatic patients develop symptoms of psoriatic arthritis(PsA) ?
A
5-30%
3
Q
Psoriasis age peak & distribution
A
Bimodal distribution
Peaks at 20-30 & 50-60 yrs
4
Q
Name some genetic factors of psoriasis
A
- PSORS-1 susceptibility locus (on chromosome 6p)
- HLA- Cw6
5
Q
HLA - B27 is ass/w ?
A
Sacroilitis- associated psoriasis
PsA
Pustular psoriasis
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
7
Q
Strongest HLA risk factor for early-onset disease?
A
HLA-Cw6
( Cw6> B57,DR7 )
8
Q
HLA ass/w with guttate and erythrodermic psoriasis?
A
HLA B13 & B17
9
Q
HLA associated with palmoplantar pustulosis
A
HLA-B8, Bw35, Cw7, and DR3
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
11
Q
Triggering factors of psoriasis
A
- External: Trauma (Koebner phenomenon)
- Internal:
- Infections ( streptococcal pharyngitis n.1, HIV)
- Endocrine factors
- Stress
- Drugs
- Obesity
- Smoking, alcohol consumption
12
Q
Triggering factor in generalized pustular psoriasis?
A
Hypocalcemia
13
Q
Triggering factor in impetigo herpetiformis?
A
Pregnancy
14
Q
MC drugs that can exacerbate/trigger psoriasis
A
- Lithium
- IFNs
- β-blockers
- Antimalarials
- TNF-a inhibitors
- CS tapers in pustular psoriasis
15
Q
Length of latency period btw trauma (Koebner) and appearance psoriatic lesions?
A
2-6 weeks
16
Q
TNF-a inhibitors may induce which type of psoriasis?
A
Plaque psoriasis
+/- palmoplantar pustulosis
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
18
Q
Dx?
A
Chronic plaque psoriasis
Sharply demarcated, erythematous, scaly plaques
19
Q
Dx?
A
Multiple large plaque psoriasis
Obvious symmetry of the plaques on the upper extremities
+/- pruritus & hemorrhagic crusts due to scratching
20
Q
Dx?
A
Annular plaques of psoriasis due to central clearing
21
Q
Dx?
A
Sunburn related Koebner phenomenon
22
Q
Dx?
A
Guttate psoriasis
23
Q
Dx?
A
Linear Koebner
+ widely scattered guttate lesions
24
Q
Dx?
A
Generalized pustular psoriasis
Broad areas of erythema with numerous pustules & formation of lakes of pus
25
Dx?
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
26
Dx?
Pustulosis of the palms and soles
Multiple sterile papules are admixed with yellow–brown macules on the palm
27
Dx?
Acrodermatitis continua of Hallopeau
Erythema and slight scale of the distal digit, pustules within the nail bed, and partial shedding of the nail plate
28
Dx?
Scalp psoriasis with extension onto the neck
* Note the involvement of the external auditory canal
29
Dx?
Psoriasis inversa
Shiny erythematous plaques of the inframammary folds that LACK SCALE
30
Dx?
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
31
Dx?
fissured tongue (black arrow)
and
geographic tongue (blue arrow) in psoriatic patient
32
Pinpoint papules surrounding existing psoriatic plaques indicate...?
Unstable phase of disease
During exacerbations, psoriatic lesions often itch
33
MC type of psoriasis?
Chronic plaque psoriasis
34
Chronic plaque psoriasis features
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
35
Guttate psoriasis features
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
36
Clues to diagnosing psoriatic erythroderma
* previous plaques in classic locations
* characteristic nail changes
* central facial sparing
37
Erythrodermic psoriasis features
* generalized erythema and scale (\>90% BSA)
* Triggers: poor management decisions most common
(e. g., abrupt withdrawal of systemic steroids)
38
Generalized pustular psoriasis
* 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**
39
Name the 4 distinct subtypes of generalized pustular psoriasis
* von Zumbusch pattern
* Annular pattern
* Exanthematic type
* Localized pattern
40
Von Zumbuch features
* generalized eruption starting abruptly with erythema and pustulation
* Fever, ill patient
* Painful skin
* After several days, pustules usually resolve and extensive scaling is observed
41
Annular pustular psoriasis
* 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
42
Exanthematic pustular psoriasis
* 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)**
43
Localized pustular psoriasis features
* 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
44
Pustulosis of palms and soles features
* 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)
45
SAPHO syndrome
* Synovitis
* Acne
* Pustulosis
* Hyperostosis
* Osteitis
46
Clinical scores for psoriasis
* 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
47
Acrodermatitis continua of Hallopeau features
* rare manifestation of psoriasis
* pustules on the distal portions of fingers & sometimes toes
* may be accompanied by annulus migrans of the tongue
48
Scalp psoriasis
* 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
49
Patients with dermatomyositis involving the scalp may have lesions that resemble psoriasis
T/F ?
True
50
Flexural psoriasis features
* 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
51
Oral mucosa psoriatic lesions
* Migratory annular erythematous lesions with hydrated white scale (annulus migrans) in pts with Hallopeau/ & generalized pustular psoriasis
* Geographic tongue
52
Nail Psoriasis features
* 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
53
PsA features
* 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+)
54
Rx of PsA?
biologics, MTX, apremilast, cyclosporine, and tofacitinib
55
MC pattern of PsA + its features
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)**
56
Other forms of PsA
* **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”)
57
Table of PsA types
58
SITES OF INVOLVEMENT IN PSORIATIC ARTHRITIS AND REACTIVE ARTHRITIS
59
Dx?
* 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
Comorbidities ass/w psoriasis
* ↓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
Disorders related to psoriasis
* 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
Dx?
Inflammatory linear verrucous epidermal nevus
63
Dx?
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
Clinical features of ILVEN
* 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
Clinical features of Reiter arthritis
* 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
Dx and Tx?
Circinate balanitis (Psoriatic plaques on the penis)
* Topical 0,1% tacrolimus (results within 1 week)
* Topical 1% pimecrolimus
67
Pt with arthritis, urethritis & conjunctivitis
Dx?
Keratoderma blennorrhagicum
68
Clinical features of Sneddon-Wilkinson disease
* 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
Frequencies of atopic dermatitis, asthma, urticaria and allergic contact dermatitis have been found to be higher in pts with psoriasis
T/F ?
Why?
**False**
Psoriasis =\> **Th1 response**
Atopic dermatitis =\> **Th2 response**
70
Psoriasis and lichen simplex chronicus
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
When could be used the terms "sebopsoriasis"?
* 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
Secondary skin infections are more common in pts with atopic dermatitis or psoriasis? Why?
AD\>\>\> Psoriasis
In psoriasis =\> increased production of skin-derived antimicrobial peptides, e.g. defensins, SKALP/elafin
73
Psoriasis & other ass/d disorders
* 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
DD of plaque psoriasis
Seborrheic dermatitis
LSC
Dermatomyositis
Mycosis fungoides
Hypertrophic lichen planus (if shins are involved)
75
DDx of guttate psoriasis
* 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
Flexural psoriasis DDx
* Intertrigo
* Seborrheic dermatitis
* Contact dermatitis
* Cutaneous candidiasis
* Tinea incognito
* Erythrasma
* Extramammary Paget disease
* Langerhans cell histiocytosis (in infants)
77
DDx of of subcorneal/intraepidermal neutrophilic
pustules
78
Define an active psoriatic lesion
A fully developed guttate lesion or the marginal zone of an enlarging psoriatic plaque
79
Histologic hallmarks of pustular psoriasis
* spongiform pustules of Kogoj
* microabscesses of Munro
* Large clusters of neutrophils in upper epidermis
80
Name the classical histologic hallmarks of psoriasis
on **mature plaques**
* 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
Name the classical histologic hallmarks of psoriasis
on guttate psoriatic lesions
* Milder acanthosis, spongiosis, foci of intraepidermal neutrophils, mounded parakeratosis, ↓granular layer
* Thin, tortuous capillaries in papillary dermis
* Mixed perivascular infiltrate w/ scattered neutrophils
82
Name 2 phenomena that can be seen in psoriatic pts using topical corticosteroids
* Tachyphylaxis
* Rebound phenomenon
83
Indications and contraindications for topical corticosteroids
in **psoriasis**
84
* Maximum improvement from topical corticosteroids in psoriasis occurs after ...?
* What can be done to attenuate phenomena as tachyphylaxis & rebound?
2 weeks
Intermittent treatment schedule
(e.g. once every 2 or 3 days or on weekends)
85
Major MoA of Vitamin D3 analogues
* 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
Indications and contraindications for anthralin
87
Indications and contraindications for topical tazarotene
Maximum area that can be treated is 10-20% of BSA
Can be combined with corticosteroids topically to avoid pruritus, erythema, burning
88
What to do if psoriatic plaques have thick scale?
* 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
Facial & flexural psoriasis Tx?
Topical calcineurin inhibitors
(tacrolimus, pimecrolimus)
90
Indications and contraindications for photo(chemo)therapy for psoriasis
* Phototherapy with broadband or narrowband UVA or UVB following ingestion of or topical application of a psoralen
91
Indications and contraindications for methotrexate
92
PUVA + cyclosporine in pts with psoriasis can lead to?
^ frequency of SCCs
93
Side effects of MTX
94
Indications and contraindications for cyclosporine
95
Indications and contraindications for acitretin
96
Indications and contraindications for acitretin
97
IL-23 monoclonal antibodies
98
Anti IL-17 & IL-23 monoclonal antibodies
99
Biological drugs psoriasis
100
Additional systemic therapies for psoriasis
101
Indications for biologic drugs in psoriasis
102
CIs to biologic drugs in psoriasis
103
Management of psoriasis at specific sites
104
Treatment of psoriasis in the setting of comorbidities
105
Sites of psoriatic arthritis and reactive arthritis
106
Dx?
* Psoriatic arthritis. Asymmetric involvement of the DIP & PIP joints.
* Sausage digit, results from involvement of both the DIP and PIP joints
107
Woronnof ring
pale blanching ring around psoriatic lesions
108
Auspitz sign
* scraping of psoriasis scale → pinpoint bleeding (due to dilated capillaries and suprapapillary plate thinning)
109
Treatment of choice for psoriasis subtypes
■ 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
Dx?
Pityriasis Rubra Pilaris (PRP)
111
Clinical features of PRP
Synonyms : Lichen ruber pilaris/acuminatus, Devergie disease
* 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
Other diagnostic hallmarks of PRP
* 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
Subtypes of PRP (number)
MC subtype?
6
Type I (55%) : Classic adult
114
Subtypes of PRP
115
Clinical features of PRP subtypes
* 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
Histopathology in PRP
* **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
Tx of PRP?
* First line: isotretinoin or acitretin
* Others: high-dose vitamin A, MTX, TNF-α inhibitors, phototherapy
118
Prognosis of PRP?
* 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
Dx?
Adult seborrheic dermatitis of the face, ear and scalp
120
Dx?
Infantile seborrheic dermatitis
121
Pathogenesis of seborrheic dermatitis
* 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
Clinical features of pediatric seborrheic dermatitis
* 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
Clinical features of adult seborrheic dermatitis
* 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
Tx of seborrheic dermatitis
* 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
Prognosis of seborrheic dermatitis
* Infants: spontaneous resolution by 8–12 months
* Adolescents: tends to be more chronic
* Adults: chronic and relapsing
126
Histological features of seborrheic dermatitis
* Irregular to psoriasiform acanthosis, spongiosis, “shoulder parakeratosis,” superficial perivascular/ perifollicular lymphocytic infiltrate
127
Pityriasis simplex capillitii
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
DDx
infantile seborrheic dermatitis
vs
atopic dermatitis
Infantile seborrheic dermatitis:
* Earlier onset ( one week after birth, up to several months)
* ***Absence of pruritus, irritability, sleepness***
* Different distribution pattern
129
DDx
infantile seborrheic dermatitis
vs
irritant diaper dermatitis
Irritant diaper dermatitis:
* confined to the diaper area
* tends to **spare the skin folds**
130
DDx
seborrheic dermatitis of the scalp
vs
psoriasis
If indistinguishable =\> sebopsoriasis
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
Name some 1st & 2nd line therapeutic choices for seborrheic dermatitis
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
DDx of intertriginous dermatoses in adults (table)
133
Dx?
Pityriasis rosea of Gilbert
134
Pityriasis rosea clinical features
* 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
Describe the primary & secondary lesions of Pityriasis rosea
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
Name some atypical patterns of Pityriasis rosea
* 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
Tx and prognosis of pityriasis rosea
* 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
If lesions of pityriasis rosea do not resolve within 5 months, what to suspect?
**Pityriasis lichenoides cronica**
139
Dx?
Granular parakeratosis
140
Clinical features of intertriginous/axillary granular parakeratosis
* 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
Histologic features of granular parakeratosis
* characteristic **thickened eosinophilic stratum corneum** w/ prominent ***parakeratosis*** and retained keratohyalin granules
* vascular ectasia
142
Tx of granular parakeratosis
* topical (corticosteroids, vitamin D analogues, keratolytics, and antifungals)
* destructive (cryotherapy)
* systemic (isotretinoin, antifungals)
143
Dx?
Pityriasis rotunda
(Tinea/Pityriasis circinata)
144
Clinical features of pityriasis rotunda
* **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)
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Tx of pityriasis rotunda
* Relatively difficult to treat
* **Firstly reverse any underlying disorder**
* topical lactic acid, urea, tars, emollients, and corticosteroids
* Topical tretinoin cream 0.1%
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Define erythroderma
Erythema and scaling involving \>80–90% of BSA
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