3 - Inflammatory Disorders Flashcards
What physically and emotionally disabling skin condition starts in childhood, persists into adulthood, and is worse in winter?
Chronic plaque psoriasis
People with chronic plaque psoriasis are at increased risk for:
Psoriatic arthritis
Describe the morphology of chronic plaque psoriasis
Begins as red, discrete flat-topped scaling papules
that coalesce to form round to oval plaques
Thick, adherent, silvery-white scale
What is Auspitz sign?
Removal of scales of plaque psoriasis leading to pinpoint bleeding
Distribution of plaque psoriasis
Scalp
Extensor surfaces
Presacral and groin
Usually symmetric and bilateral
Diffuse or confluent
Pitting or “oil spots” on nails
Etiology of chronic plaque psoriasis
Hyperproliferation of the epidermis
7x faster transit than normal (4 days vs 30 days)
Cells pile up and cannot be released fast enough
Management of chronic plaque psoriasis
If over 5% BSA: systemic therapy (methotrexate, soriatane, cyclosporine, biologics, UVA)
If under 5% BSA: topical therapy
- Class I or II and taper to triamcinolone as plaque thins
- steroid vacation (take a break)
- control stress
- keratolytic (salicylic acid) can be used prior to steroid to remove scale
non steroid Topical meds for chronic plaque psoriasis
Topical Vit D - Calcitriol - very effective - even better when combined with steroid
Calcipotriene (Dovonex) - Vit D3 derivative
Tazarotene - topical retinoid
Txt of scalp plaque psoriasis?
Keratolytic gel, tar shampoo, triamcinolone
Diffuse and thick scale - calcipotriene and betamethasone dipropionate lotion
Slide 11
Meds
How will plaque psoriasis appear if it’s in the intertriginous areas?
Smooth, red plaques with a macerated surface
Pitting psoriasis of nail matrix results in loss of:
Parakeratotic cells from surface of nail plate
What is Guttate psoriasis?
Sudden appearance of scaling papules on the trunk / extremities (spares palms/soles), typically happens following a strep / viral URI
Indicates propensity to develop chronic plaque psoriasis
Describe the morphology of Guttate Psoriasis
Teardrop, diffuse, scattered
Multiple, tiny discrete red papules with thick white scale
May have classic plaques on elbows, knees
Guttate psoriasis distribution
Truncal and proximal extremities
May have nail pitting
May be on classic areas (knees / elbows)
Etiology of Guttate psoriasis
Genetic and environmental factors leading to an
aberrant immune response in the skin may contribute to disease development (Strep/Viral infxn)
Management of Guttate psoriasis
Throat cx to r/o strep
UVB 6-8 weeks = 1st line!
Topicals usually impractical due to diffuse area
Keep moist with emollients
What’s the deal with pustular psporiasis
Rare but sometime fatal
Toxic, febrile, leukocytosis
Middle age, usually
Painful
Smokers
Morphology of pustular psoriasis
Numerous tiny, sterile pustules evolve from an
erythematous base and coalesce into lakes of pus
Deep-seated pustules middle of palm or sole of foot) primary
Pustules don’t rupture - they dry up, harden, and fall off
Management of pustular psoriasis
Class I topical
NO ORAL STEROIDS
ABX for secondary infx
Emollients
Oral or topical PUVA
Retinoids
Cyclosporine
Methotrexate
Relapses common
Describe seborrheic dermatitis:
Common, chronic inflammatory dz
Peaks in infancy, maternity, teens (high hormonal periods)
Flares in dry winter, stress, change in hygiene
Severe in elderly
What is one of the MC cutaneous manifestations of AIDS?
Seborrheic dermatitis
Morphology of seborrheic dermatitis?
Fine white or yellow greasy flakes
May have an inflamed base
Pruritic
Red papules
Annular with raised edge
Cradle cap
Secondary staph infx
Distribution of seborrheic dermatitis
Scalp and scalp margins
Eyebrows and base of eyelashes
Nasolabial folds
EAC’s
Etiology of seborrheic dermatitis
Hereditary - flared by environment, possibly caused by yeast
Hyperproliferation process (similar to psoriasis)
Glandular problem (oily skin)
Tends to persist in adults with periods of remission and exacerbation
Management of seborrheic dermatitis
OTC anti-dandruff shampoos
Selenium sulfide
Tar based
Ketaconazole for yeast overgrowth
Topical steroids
Dicloxacillin for secondary infx
Oral antifunfgals for bad cases
Atopic dermatitis
Chronic, pruritic eczematous disease
Almost always begins in childhood
Remitting/recurring course
Improves with age
FHX or allergies, atopy, asthma, sinusitis
Flares with cold, dry weather, stress, illness, irritants
Morphology of atopic dermatitis
Erythema progressing to papules and plaques with:
- flaking
- xerosis
- cracking
- excoriations
- fissures
Patchy or confluent
Lichenification over time
Secondary staph with flares
Where would you see atopic dermatitis in adults on PE:
Bilateral flexor creases Hands Neck Waist Wrists and ankles Spares the face except the eyelids
Where would you see atopic dermatitis in kids?
2-12 ys - Flexural areas
Face and scalp
Patchy or generalized body eczema
Infants - cheeks
Etiology of atopic dermatitis
The “itch that rashes”
Dryness that causes cracking which causes itch which causes a rash (eczematous)
Hereditary
May flare with acute allergic situations
Management of atopic dermatitis (general)
Hydrate
Wash less often (milder soap)
Shorter bathing time, tepid water
Moisturize immediately after washing
Meds for atopic dermatitis inflammation
Mid to high strength topical steroids
Group V fluticasone proprionate cream safe in kids > 3 mos for severe
Important treatment aspect of atopic dermatitis management includes breaking the:
Itch-scratch cycle
Use hydroxyzine or diphenhydramine
Use of pimecrolimus cream in atopic dermatitis
Apply thin layer to affected areas BID
For immunocompetent patients older than 2 yrs
No occlusive dressings
NO burning sensation
Tacrolimus ointment for atopic dermatitis
Apply thin layer to affected areas BID
For patients who have failed other topicals
No occlusive dressings
Burning sensation can happen
What is the MC inflammatory skin disease?
Eczema
Characteristics include - erythema, scale, and vesicles
3 stages of eczema?
Can occur in any order
- Acute
- Subacute
- Chronic
Etiology of acute eczema?
Contact allergy (Rhus)
Acute nummular eczema
Stasis derm
Pompylox
Acute eczema presents with:
Intense erythema
Intense itch
Vesicles
Bullae
Txt for acute eczema?
Cold wet compress
PO or topical steroids
Antihistamine
ABX if secondarily infected
Subacute eczema will present how?
Erythema
Scaling
Fissuring
Parched appearance
Moderate itching, pain, burning
Etiologies of subacute eczema?
Contact allergy
Irritant
Atopic
Nummular eczema
Asteatotic eczema
Txt for subacute eczema?
Topical steroids (occlusion PRN)
Emollients after
Antihistamines
ABX
Chronic eczema will present with:
Thickened skin
Accentuated skin lines
Excoriations
Fissuring
Moderate to intense itch
Etiologies of chronic eczema
Atopic
Habitual scratching
LSC
Nummular eczema
Asteatotic eczema
Treatment for chronic eczema?
Topical steroids with occlusion for best results
Antihistamines
ABX
Emollients
What is dyshidtrotic eczema (pomphyolyx)?
Distinctive reaction pattern - symmetric vesicular hand and foot dermatitis
Moderate to severe itching PRECEDES the appearance of vesicles
Unknown etiology (maybe atopic, stress, irritants…)
Most common in teens to middle age
Describe dyshidtrotic eczema (pompholyx)?
Multiple tiny deep seated vesicles (tapioca lesions)
Palms and lateral aspects of fingers and hands or feet
Palms may be red and wet with perspiration
Surrounding erythema
Very pruritic
Explain the progression of dyshidrotic eczema:
Vesicles slowly resolve in 3-4 weeks
Replaces with scale…progresses to lichenification and cracking, peeling, and fissuring
Pain then replaces pruritis
Secondary infx can be problematic
Management of dyshidrotic eczema?
Lifestyle mods (avoid water, irritants, trauma)
Use bland emollients
Potent steroid then wean
ABX if indicated
Hydroxyine for pruritus
Cool, wet compress
Elimination diet (figure out a potential cause)
IF ALL ELSE FAILS - low dose methotrexate
What is asteatotic eczema?
Occurs after excessive drying in the winter months and among the elderly
Atopic patients more likely
More of an itch than a rash
Describe the morphology of asteatotic eczema
Lower legs - dry and scaly with accentuation of the skin lines (xerosis)
Red plaques with thin, long, horizontal superficial fissures - resembles cracked porcelain
Minimal erythema
Excoriations without other lesions
Etiology of asteatotic eczema
Cold, dry weather and long, hot showers
Management of asteatotic eczema?
Shower less, and not with hot water, mild soap
Emollients immediately after bath
Steroids if bad enugh
If oozing, crusts, infx - wet compress, ABX
Who gets nummular eczema?
Middle age to elderly
What’s nummular eczema all about?
Intense itching, recurs in the same spot every winter, excessive scratching leads to lichenification
Describe the morphology of nummular eczema:
Discrete, round, coin-shaped red plaque
1-5cm in diameter
Intensely erythematous plaques
Thin, sparse scale that may flake
May become thicker with vesicles on the surface
MC location of nummular eczema?
Back of the hand
Also found on lower legs, forearms, flanks, hips
How do we manage nummular eczema?
Potent steroids for 4-6 weeks (group III-IV)
Correct dryness of skin and environment
Antipruritic PRN
What is lichen simplex chronicus? (LSC)
Basically the end result of chronic scratching over time - possibly a defense mechanism against recurrent trauma (scratching)
Any age
Morphology of LSC?
Red papules coalesce to a red, scaly, thick plaque with accentuation of skin lines
Excoriations
Cracks and fissures possible
Hyperpigmentation
Nodules (prurigo nodularis)
Management of lichen simplex chronicus
Long-term therapy to soften and break down lichenified skin
Stop the itch-scratch cycle
Behavior modification
Temovate or Diprolene ointment
Possibly intralesional steroids
Emollients for dryness
1st gen antihistamines for night-time scratching
Who gets pityriasis rosea?
Young adults (10-35 yrs old)
What causes pityriasis rosea?
Possible viral origin - some association with HHV 6
Hx of proceeding URI
Morphology of pityriasis rosea?
Have have herald patch (first and largest lesion, patients may think they have ringworm)
Then eruptive phase - round to oval 1-2cm plaques (salmon pink in white people, hyperpigmented in darker-skinned people)
“Christmas Tree” distribution
Trunk and proximal extremities
Management of pityriasis rosea?
Patient reassurance, most do not require treatment
Group V topical steroids and antihistamines for the itch
If severe: oral steroids, UVB, oral acyclovir
What should be considered in the differential of pityriasis rosea?
Syphilis
What is lichen planus?
A unique inflammatory cutaneous and mucocutaneous membrane reaction
Can happen at any age (avg 20-60yrs)
Can be without cause or caused by meds, chemicals, transplants
Can be part of a Koebner phenomenon (lesion associated with trauma)
Describe the morphology of lichen planus
The 5 P’s:
- Pruritic
- Planar (flat-topped)
- Polygonal
- Purple
- Papules / plaques
Also, “persistent”…so it’s really six P’s? These slides are terrible…
What is Wickham’s Striae?
White lacy pattern of crisscrossed lines on lesion (increase visualization with immersion oil)
Seen in lichen planus
Where is lichen planus found?
Basically anywhere
Acral - hands and feel, ankles and wrists
Oral lesions (white lacy pattern, erosive and painful)
Nail splitting and dystrophy
Scarring hair loss on scalp
Genital lesions
What confirms the dx of lichen planus?
Bx
Etiology of lichen planus
Like most of this crap, we don’t know
But we say..
Maybe associated with liver disease
Maybe associated with Hep C
Management of cutaneous lichen planus
Control the itching with Hydroxyzine
Topical I or II - may need occlusion
Intralesional steroid injection every 3 to 4 weeks
Management of mucous membranous lichen planus
Challenging
Steroids in an adhesive base
Azathioprine in resistant cases
Management of generalized lichen planus
PO steroids for about 3 weeks
What are the two main types of contact dermatitis?
Irritant (damages barrier, non-immunologic)
Allergic (absorption of antigen - sensitization - with subsequent exposure eruption)
MC types of irritant dermatitis?
Occupational - hand dermatitis
Diaper dermatitis
Morphology of irritant dermatitis ?
Damage to the stratum corneum
Inflamed, cracked, fissured skin
When acute, could be exudative and/or vesicular
If chronic - scaly, flaky, lichenified with less erythema
Management of irritant dermatitis?
Avoid the irritant (duh)
Use emollients
Cool compress for acute inflammation
Topical steroids if severe
What is the MC allergic contact derm?
Nickel
Poison ivy is 2nd MC
Morphology of allergic contact derm?
Very red
Inflamed, swollen, vesicular to bullous, exudative and crusty, intensely pruritic
Can be linear (poison ivy) or shaped (ring, watch)
Management of allergic contact derm
Minimize topical products
Wet compress
Potent topical or PO steroid for 2-3 weeks
Antihistamines
Triamcinolone spray
Kim kardashian was diagnosed with psoriasis
He doctor assured her it wouldn’t affect her ability to do nothing
