Blistering/Papular diseases

Question 1

Answer 1

PEMPHIGUS VULGARIS

Question 2

Answer 2

PEMPHIGUS VULGARIS

Question 3

Answer 3

PEMPHIGUS VULGARIS

Question 4

PEMPHIGUS VULGARIS

general

Answer 4

▸ Life-threatening, chronic autoimmune blistering disorder of the mucus membranes and skin
▸ Most common in patients in their 30s and 40s
▸ Associated with several medications – penicillamine, captopril, cephalosporins, phenobarbital
(PPCC)

Question 5

PEMPHIGUS VULGARIS

pathophys
Type of sensitivity

Answer 5

▸ Type II hypersensitivity reaction where autoantibodies against desmoglein lead to
acantholysis
▸ Desmoglein connects keratinocytes in the skin

Question 6

PEMPHIGUS VULGARIS

Clin man

Answer 6

▸ Painful erosion or ulceration initially, followed by painful, flaccid skin bola that rupture easily, leaving painful
denuded skin erosions that bleed easily.
▸ Initial lesion is most commonly intraoral
▸ Positive Nikolsky sign – detachment of skin under pressure/trauma

Question 7

PEMPHIGUS VULGARIS

Dx and Tx

Answer 7

Diagnosis: punch biopsy – IgG throughout the epidermis, basal keratinocytes in a pattern that resembles “a row of
tombstones”
▸ ELISA - anti-desmoglein or anti-epithelial autoantibodies
▸ Treatment: refer to dermatology
▸ Mainstay of treatment: Systemic glucocorticoids + wound care +/-rituximab, mycophenolate or azathioprine

Question 8

Answer 8

BULLOUS PEMPHIGOID

Question 9

Answer 9

BULLOUS PEMPHIGOID

Question 10

BULLOUS PEMPHIGOID

general
Induced by

Answer 10

▸ Autoimmune disorder leading to blister formation
and severe itching
▸ Primarily seen in the elderly
▸ Can be drug induced – loop diuretics, metformin

Question 11

bullous pemphigoid

pathophys and type of sensitivity

Answer 11

Type II hypersensitivity reaction – IgG
autoantibodies against hemidesmosomes and
basement membrane zone causing subepidermal
blistering

Question 12

BULLOUS PEMPHIGOID

Clin man

Answer 12

▸ Prodrome of pruritus with eczematous or urticarial erythematous plaques followed by multiple tense large bullae that easily rupture
▸ Most commonly found in the groin, axilla, trunk, flexural areas of the extremities
▸ Mucosal disease in 10-30%
▸ Negative Nikolsky sign

Question 13

bullous pemphigoid

Dx and Tx
Mild/localized and severe

Answer 13

Diagnosis: punch biopsy with direct immunofluorescence - linear C3, IgG along the dermal-epidermal junction, subepidermal blistering,
eosinophilia
▸ ELISA: autoantibodies against BP antigen 230 & 180

Treatment: refer to dermatology
▸ Localized/Mild - High potency topical corticosteroids + tetracyclines (doxycycline)
▸ Extensive/Severe - systemic corticosteroid

Question 14

Answer 14

PORPHYRIA CUTANEA TARDA

Question 15

PORPHYRIA CUTANEA TARDA

general

Answer 15

Hypersensitivity of the skin to abnormal porphyrins when exposed to light, leading to a blistering disease of sun exposed areas
▸ Enzyme: uroporphyrinogen decarboxylase

Question 16

PORPHYRIA CUTANEA TARDA

risk factors

Answer 16

Liver disease – hepatitis C, alcoholism, hemachromatosis
▸ Estrogen use, Tobacco use

Question 17

PORPHYRIA CUTANEA TARDA

cliln man

Answer 17

Chronic blistering photosensitivity of sun exposed areas – can lead to hyper- or hypopigmentation/scarring

Question 18

PORPHYRIA CUTANEA TARDA

Dx and Tx

Answer 18

Diagnosis: 24 hour urine collection, plasma porphyrin profile

▸ Treatment: treat the underlying cause
▸ phlebotomy, low-dose hydroxychloroquine, sun avoidance

Question 19

Answer 19

verruca vulgaris

Question 20

Answer 20

verruca vulgaris

Question 21

VERRUCA VULGARIS

general and types

Answer 21

Caused by human papilloma and virus
▸ HPV infects keratinized skin causing excessive proliferation and retention of the stratum corneum

▸ Types:
▸ Common: vulgaris - common on hands
▸ Plantar: plantaris
▸ Flat: plana - commonly found on face, hands, knees, and shin

Question 22

VERRUCA VULGARIS

clin man

Answer 22

firm, hyperkeratotic papules between 1-10 mm with red/brown punctations (thrombosed capillaries are
pathognomonic)

Question 23

VERRUCA VULGARIS

Dx and Tx

Answer 23

▸ Diagnosis: clinical
▸ DO NOT BIOPSY!

▸ Treatment:
▸ If immunocompetent most warts resolve within 2 years
▸ Topical: OTC salicylic acid - I recommend WartStick because it’s 40% sal acid
▸ Cryotherapy and imiquimod are also commonly used in practice

Question 24

CONDYLOMA ACCUMINATA

Caused by and can progress into

Answer 24

▸ Caused by Human papillomavirus infection
▸ If left untreated, these lesions can progress to squamous cell
carcinoma

Question 25

Answer 25

CONDYLOMA ACCUMINATA

Question 26

CONDYLOMA ACCUMINATA

Clin Man

Answer 26

▸ Vary from small, flat topped painless raised papules, which
can evolve into large, soft, flashy, cauliflower like lesions and
clusters on the anogenital mucosa and surrounding skin
▸ Ranging from skin colored to pink/red
▸ Lesions persist for months and May spontaneously resolve,
remain unchanged, or grow if untreated

Question 27

CONDYLOMA ACUMINATA

Dx and Tx

Answer 27

Diagnosis: clinical
▸ Biopsy is rarely needed – acanthosis with overlying hyperplastic hyperkeratosis koilicytotic squamous
cells and atypical keratinocytes with papillomatosis hyperplasia

▸ Treatment:
▸ 80% with HPV six, 11 will have spontaneous resolution within 18 months
▸ First line: antiproliferative agents – imiquimod, immunomodulators - podophyllotoxin, sinecatechins
▸ First line clinician administered treatments: cryotherapy, trichloracetic acid, surgical remova

Question 28

CONDYLOMA ACUMINATA

prevention

Answer 28

Gardasil 9 vaccination

Question 29

Answer 29

MOLLUSCUM CONTAGIOSUM

Question 30

MOLLUSCUM CONTAGIOSUM

general

Answer 30

Benign, often asymptomatic, viral infection of the skin
without systemic manifestations
▸ Poxviridae
▸ Most commonly seen in young, school-age children

Question 31

MOLLUSCUM CONTAGIOSUM

clin man
Hallmark

Answer 31

▸ Characterized by small, skin color to pink, dome shaped
papules with central umbilication
▸ Lesions can develop anywhere in the body but are most
commonly seen in areas of high friction
▸ Lesions can last for months to years

Question 32

MOLLUSCUM CONTAGIOSUM

Dx and Tx

Answer 32

Diagnosis: clinical

Treatment:
▸ Asymptomatic: observance
▸ First-line treatment: curettage
▸ Cryotherapy, imiquimod, topical retinoids are most commonly used in
practice