Cutaneous Manifestation of Systemic Disease

Question 1

2 key neutrophilic dermatoses

Answer 1

sweets syndrome

yoderma gangrenomsum

Question 2

• 56yo M

• 4 day history of mild lower leg swelling and painful spots on his legs
How do we describe his skin lesions? what could be happening?

Answer 2

erythematous raised papules that are coalescing into plaques. looks like petechiae. distributed over the lower extremities.

palpable purpura are heavily associated with vasculitis–could be solely cuteaneous but we should look also for systemic symptosm– claudication, lung and kidney problems (ANCA associated vasculitis)

Question 3

where does palpable purpura manifest?

Answer 3

in the dermal vasculature layer. neutrophil inflammation in the papillary dermis causes prupura.

Question 4

treatment for cutaneous small vessel vasculitis

Answer 4

• supportive care (leg elevation/rest)
• identify trigger and labs– ANCA associated? be aware of the systemic implications specifically glomerular neprhitis or pulmonary infiltrates or alveolar hemorrage.
• NSAIDS, antihistmaines for a skin limited disease
• if systemic, remission requires high dose of systemic steroids followed by biologics or DMARD therapy like azothiaprine

Question 5

Answer 5

palpable purpura with central necrotizing erosion

Question 6

Answer 6

palpable purpura

Question 7

Answer 7

palpable purpura

Question 8

note:

vasculitis involving medium or large vessels does not usually present with palpable purpura

Question 9

You are the dermatology resident on call and are called to see a patient in the emergency room.

She has felt unwell for several days and developed new skin lesions
this morning

Answer 9

erythematous tender patches that are showing signs of epidermal sloughing or necrotization. did she take any drugs? this might be SJS or sweet syndrome.

Question 10

outline the morphology and dx

Answer 10

sweet syndrome

tender non-prurutic erythematous plaques with uneven mamillated surface, pronouned edema

• pseudovesicular or pseudopustular appearance
• favors head and neck and upper extremities
• 20% have internal malignancies.

this is a clue to serach for a systemic disease

Question 11

•They tell you the patient developed what started as a bug bite two days ago and now is progressing rapidly with extreme pain

• presents with this erosion

Answer 11

necrotizing borders with large erosions/ulcerations. pyoderma gangrenosum.

ulcer with necrotic undermined grey colored border. very painful. need to rule out infection. this might not be necrotizing fascitis– if we debride and it turns out to be PG instead of NF, it can turn out worse.

Question 12

key lesion in diagnosing pyodermal gangrenosum

Answer 12

sieve like cribiform lesions

Question 13

disease associations with pG

Answer 13

Question 14

treatment of PG

Answer 14

Question 15

• The next day your neighbor, who knows you are a medical student, approaches you when you are out walking with your family.
• They are feeling fine but have been getting these very itchy welts on their arms and body for a couple of days.
• They’d like to know what it is and if they should be worried!

Answer 15

erythematous raised plaques. almost annular.it is short term– maybe urticaria

Question 16

Answer 16

urticaria

Question 17

if urticaria is fixed for more than 24 hours, tink ___ ___ rather than hives

Answer 17

sweet syndrome rather than hives.

• most poeple wiith hives are well, it’s not a systemic conditions

Question 18

Question 19

key thing to rule out when someone presents with urticaria

Answer 19

make sure it’s not anaphylaxis– presents with angioedema, difficulty swallowing, breathing

Question 20

a huge chunk of acute urticaria is due to

Answer 20

URTI

Question 21

lines of therapy for urticaria

Answer 21

first line: non-sedating antihistamine like cetirizine

second line: if symptoms persist after two weeks, increase dose to as much as four times the standard dose

3. third line; add on to second line treatment omalizumab or cyclosporine

Question 22

is this cellulitis?

Answer 22

probably not, cellulitis is not usually bilaterla. this is probably Erythema Nodosum

Question 23

in erythema nodosum, there is an acute eruption of tender, erythematous subcutaneous nodules over
____ areas (can also be on __ and __).

Associated ____, ___, _____, malaise

• Delayed hypersensitivity to variety of antigens (___, ___,
___ agents, etc)

Answer 23

• Acute eruption of tender, erythematous subcutaneous nodules over pretibial areas (can also be on thighs and forearms)
• Last days-weeks then slowly involute without scarring
• Associated arthritis, arthralgia, fever, malaise
• Delayed hypersensitivity to variety of antigens (bacteria, viruses, chemical agents, etc)

Question 24

Answer 24

erythema nodosum

Question 25

erythema nodosum systemic associations (THINK NODOSUM)

Answer 25

Question 26