Chapter 4 Flashcards
What 5 syndromes are secondary to disease-producing mutations in 12 genes?
- altered pain & temp sensation
- trophic changes
- sweating abnormalities
- ulcers of hands and feet
- self mutilating behavior
what is another name for mal perforans pedis and definition
neuropathic ulceration or perforating ulcer of the foot.
chronic ulcer on sole at site of constant trauma resulting in loss of pain sensation
The primary cause lies in the posterolateral tracts of the cord/ lateral tracts/ or peripheral nerve in which disorders?
posterolateral = arteriosclerosis and tabes dorsalis
lateral = syringomyelia
peripheral n. = diabetes or Hansen’s dz
complication of mal perforans pedis
osteomyelitis of the metatarsal or tarsel bones
treatment for mal perforans pedis
relief of pressure through total-contact cast + debridement of surrounding callus
morphology of mal perforans pedis
soft, moist, maloderous lesion w or w/o pruulent discharge –> necrotic ulcer
Most common cause for sciatic nerve injury & Most common finding
improper needle placement
paralytic foot drop
thin, shiny, edematous skin that has no sensation will often have what other finding
absence of sweating (sciatic nerve injury)
treatment for sciatic nerve injury
surgical exploration and repair
Syringomyelia disease process
begins insidiously and gradually causes muscular weakness, hyperhidrosis, and sensory disturbances
MC area affected with syringomyelia
thumb, index, middle fingers
difference between syringomyelia and Hansen’s dz
syringomyelia does NOT interfere with sweating or block the flare around a histamine wheal
Burns are the most freq lesions but what else can be found in syringomyelia
contractures, gangrene, bullae, warts
treatment for syringomyelia
early surgical tx to prevent progression and improve sx
what is the first responder to pruritogenic stimuli and how is it transmitted to the brain?
keratinocytes
via the lateral spinothalamic tract
Name the 4 categories of itch:
- Pruritoceptive itch (skin d/o)
- Neurogenic itch (CNS caused by systemic d/o)
- Neuropathic itch (anatomic lesions of the CNS or PNS)
- Psychogenic itch (observed in parasitophobia)
General guidelines for itchy patient
- keep cool
- avoid hot baths/showers, wool
- use soap only in axilla and inguinal area
How does benzecaine work for relieving pruritis?
contact sensitization
What does EMLA stand for and caution for EMLA
eutectic mixture of lidocaine and prilocaine ointment;
Caution - EMLA may be TOXIC if used in large areas
Most important internal cause of itching?
liver disease, renal failure, diabetes, hypo/hyperthyroidism
What is the first symptom of hodgkins dz and how would you describe it?
pruritis - continuous and sometimes accompanied w severe burning (side note: leukemia pruritis is less severe)
Recommended workup for patients with chronic, generalized pruritis
history/ physical/ labs
- CBC w diff; thyroid, liver, renal panels; hepatitis C serology; HIV antibody; UA; stool for occult blood; serum electrophoresis; CXR
Presence of eosinophilia on CBC likely means what?
parasitic disease; if pt is on systemic steroids then check stool for ova & parasites
Most common systemic c/o pruritis
Chronic kidney dz
treatment options for CKD pruritis
- emollients, soaking & smearing
- gabapentin 100mg 3x/wk after hemodialysis
- NB UVB or broad band
- Naltrexone, tacrolimis, ondansetron
How can a patient with CKD eliminate pruritis?
renal transplant
Treatment options for chronic liver disease pruritis
- cholestyramine 4-16 g/d
- *rifampin 150-300 mg/d *Caution: may cause hepatitis
- naltrexone (not used bc of SE)
- Sertraline, UVB
What is Ursodeoxycholic acid used for?
pruritis in intrahepatic cholestasis of pregnancy
Definitive treatment of end stage liver disease and relief from severe pruritis is seen with what therapy?
liver translant
What population is affected by primary biliary cirrhosis?
women over 30
Jaundice + dark hyperpigmentation of entire skin with a spared area of hypopigmentation on upper back =
primary biliary cirrhosis
Eruptive xanthelasma, planar xanthomas of palms, xanthelasma, tuberous xanthomas of joints
primary biliary cirrhosis
what test is positive in primary biliary cirrhosis
antimitochondrial antibody test
what labs would you expect to be elevated in primary biliary cirrhosis
bilirubin, alk phos, ceruloplasmin, hyaluronate, cholesterol
What % of pts with polycythemia vera have itching and when does it occur?
1/3 , induced by temp changes or after bathing
Treatments for PCV itching
Aspirin, PUVA/ NB UVB, Paroxetine, IFN alpha-2, Jak
Describe Soak and smear for winter itch
soak at comfortable temp for 20 mins before bedtime + apply TAC ointment to wet skin + old pair of PJs {use plain petrolotum ointment if no inflammation present}
Medicaments, fragrant toilet tissue, or preservatives can cause what
pruritis ani d/t ALLERGIC contact dermatitis
GI causes such as hot spices or failure to cleanse the area, or leaking d/t physical changes may lead to
pruritis ani d/t IRRITANT contact dermatitis
mycotic pruritis ani will show what on KOH
candida albicans, epidermophyton floccosum, trichophton rubrum
treatment for pruritis ani
- Tucks, Balneol
- non infectious –> steroid or tacrolimus or pramoxine
- sitz baths then petrolatum over wet skin (provides barrier)
MC type of pruritis scroti
psychogenic pruritis
fungal infections
spare the scrotum, except for candidiasis
scrotum candidasis symptoms
burning (not itching), eroded, weepy, crusted
pruritis scroti tx
mainstay = corticosteroids
or tacrolimus, pramoxine, dozepin and simple petrolatum (after sitz bath)
5 MC causes of pruritis vulvae
unspecified dermatitis, LSC, chronic vulvovaginal candidasis, dysethetic vulvodynia, psoriasis
T vaginalis shape
piriform
lichen planus vulva tx
high potency steroids
lichen sclerosis vulva tx
pulsed dosing high potency steroid or tacrolimus or pimecrolimus
Itchy points is another name for what condition?
puncta pruritica; it is followed by SKS at the same site as itchy points
what is aquagenic pruritus and who gets is
= itching, prickling discomfort when exposed to water that goes away when not exposed.
1/3 = older men w PCV
2/3 = younger women no underlying dz
Tx for aquagenic pruritis
soak & smear, antihistamines, sodium bicarb in bath water, propranolol, SSRIs, ASA, pregabalin, montelukast,, NB UVB, possibly tight clothes
What is aquadynia and what tx is useful
15-45 min PAIN after water exposure,
clonidine and propranolol provide relief
how to distinguish between scalp pruritus vs inflammatory causes
scalp pruritus lacks excoriations, scaling, or erythema
Tx for scalp pruritus
tar shampoos, sal acid shampoos, steroid gels, mousse , ILK, minocycline, oral antihistamines, doxepin
African americans treated for malaria will sometimes get
drug induced pruritus d/t antimalarial
Hydroxyethyl startch (HES) and opioid use
cause drug induced pruritus
prurigo simplex morphology
itchy red bump, dome shaped + vesicle
prurigo simplex initial tx
topical steroids, oral antihistamines
prurigo simplex recalcitrant tx
UVB, PUVA
25 year old Japanese women in the winter and spring with hx of weight loss, diet, aorexia, diabeties, ketouria
think prurigo pigmentosa (mucous membranes spared)
DOC for prurigo pigmentosa
minocycline 100-200mg/d
Dapsone + diet change (STEROIDS NOT EFFECTIVE)
Japanese male over 55 with flat topped red, brown itchy papules that spare skinfolds is called what?
Papuloerythroderma of Ofuji
blood eosinophelia and deck-chair sign is found in
Papuloerythroderma of Ofuji
DOC for PEO
systemic steroids
another name for LSC
circumscribed neurodermatitis
main symptom + findings of LSC
paroxysmal pruritus + crisscross pattern striae and flat-topped shiny, smooth quadrilateral facets
Goal for treating LSC and how to achieve it
goal = avoid scratching how = use high potency steroid cm/oint, occlusion of medium potency, ILK, botox, unna boot
describe prurigo nodularis
multiple itchy nodules on extremities in linear fashion; worse w stress
treatment for prurigo nodularis
ILK or topical steroid (soak & smear), cordran, UVB, Vit D3 ointment/ calcipotriene/ tacrolimus, ISOTRETINOIN (random)
Thalidomide risks
dose-dependent neuropathy at cummulative doses of 40-50g *can be used for prurigo
Lenalidomide
less neuropathy SE than thalidomine, but may cause myelosuppression, venous thrombosis, and SJS
Psychosis defined
presence of delusional ideation (fixed misbelief not shared by subculture)
ohychophagia
biting nails
dermatophagia
habit or compulsion
Russell’s sign
crusted papules on dersum of hand from cuts by teeth - bulimia
initial step for delusions of parasitosis and other name for this condition
exclude a true infestation; Morgellons dz
Pimozide SE
stiffness, restlessness, prolonged QT interval, extrapyramidal signs
treats tourettes and delusions of parasitosis
delusions of parasitosis first line agents
risperidone or olanzapine (atypical antipsychotic)
treatment neurotic excorations
doxepin (anti depression/ antipruritic)
MC psychopathologies assoc w psychogenic excoriations
depression, anxiety, OCD
Linear excavations superficial or deep, more on left side for right handed person and vice versa
psychogenic/ neurotic excoriations
difference between malingering and dermatitis artefacta
malingering pt goal = material gain
DA goal = unconscious goal to gain attention and assume sick patient role
distinctive, geometric, bizarre lesions found in unemployed middle aged women
factitious dermatitis / dermatitis artefacta
Munchausen syndrome or munchausen by proxy
subset of the factitious dermatitis / dermatitis artefacta patients
ways to prove diagnosis that has been faked
biopsy, occlusive dressings to protect lesions from pt
Tx for factitious dermatitis / dermatitis artefacta
Psychotherapy (pt will reject and doc shop for more tx), best to provide symptomatic tx and nonjudgemental support + SSRI or low dose antipsychotics
trichotillomania defined
urge to pull out hair, “friar tuck” vertex and crown alopecia
What is it called when a trichobezoar extends from stomach to the intestine
rapunzel syndrome
onychophagy in a stressed out girl with broken hairs that look twisted on microscope likely suffers from ___. What else would you look for
trichotillomania, comorbid psycholopathology like most common OCD, depression or anxiety
trichomalacia defined
deformed hair shafts
Alternative technique to biopsy childs scalp
shave a part of involved area and observe for regrowth of normal hairs
treatment for trichomania
- child: psychiatrist for CBT (habit reversal training)
- adult: clomipramine, N-acetycysteine
- bezoars: surgical removal
