Derm SAS/Review Flashcards
What are the signs and symptoms of DRESS?
Drug Reaction with Eosinophilia and Systemic Symptoms
- A drug-induced hypersensitivity reaction
-
Skin eruption with systemic symptoms and internal organ invovlement
- Macular exanthem
- Centrofacial swelling
- Fever
- Malaise
- Lymphadeonpathy
- Involvement of other organs
- >70% of patients have eosinophilia
What is the importance of filaggrin breakdown products in skin function?
Filaggrin is an important protein in the skin’s barrier function
Breakdown products normally keep skin hydrated
Non-functioning or reduced filaggrin is associated with atopic dermatitis and ichthyoses
Which cells in the epidermis function as mechanoreceptors?
Merkel cells
Which inflammatory myopathy is most strongly associated with malignancy?
Dermatomyositis (adult presentation)
Juvenile DM is not associated with malignancy
Describe the presentation of subacute cutaneous lupus
- Scaling, annular pink papules and plaques
- No scarring
- Low tendency for systemic disease
- Associated with Anti-SSA (Ro)
- This antibody is also implicated in neonatal lupus
- Take a complete drug history!
The discovery of ovarian cancer 6 months into the development of weakness would suggest
A: PM
B: DM
C: IBM
D: None of the above
B: DM
How does UVA light affect the skin?
Which skin cancer is it associated with?
- 320-400 nm
- Contributes to tanning and photoaging
- -> Squamous cell carcinoma
- Penetrates clouds and windows
- Used in tanning beds
A child presents with multiple cafe-au-lait spots and lisch nodules on the iris.
What gene is likely mutated?
What is the prognosis?
Deletion of neurofibromin, a tumor suppressor gene
- -> RAS activation
- Prognosis
- Optic gliomas, dermal neurofibromas may become malignant
- Learning and speech issues
What is the treatment for vitiligo?
- Phototherapy
- Topical steroids
- Topical immunosuppressants
- Tacrolimus
- Lasar therapy
- Depigmentation
- For widespread vitiligo, option may be to depigement the pigmented areas rather than try to restore pigmentation to the affected areas
What condition is caused by antibodies that target Keratin 5 and Keratin 14?
Epidermolysis bullosa simplex
- Genetic disease
- Presents in younger patients
- Results in fragile blisters
- Cleavage of basal layer keratinocytes from each other
What is the pathogenesis of this legion?
This is a keloid - results from abnormal wound healing
- Normal wound healing involves collagen production and degradation
- In keloids, there is an imbalance, leading to excessive collagen production, and less degradation
- This allows the scar to grow out of control in all directions
A patient presents with new-onset alopecia areata.
What is the most important hormone to check?
Thyroid Stimulating Hormone
- Thyroid disorders are the most common other autoimmune disorder in patients with alopecia ariata
- Also look for vitiligo, diabetes
Autoantibodies against the hemidesmosome lead to which skin condition?
Bullous pemphigoid (pictured)
- -> Separation of the basal keratinocytes from the basement membrane
- -> Tense bullae
Note: Autoantibodies against desmosomes -> Pemphigus vulgaris, characterized by non-tense blisters and erosions due to separation of keratinocytes from each other
Which appendage of the skin is labeled by c?
Sweat glands
38-year-old man who presents with one month of small blisters on his feet. They are slightly itchy
KOH shows branched, septated hypae.
What is the most likely diagnosis?
Tinia pedis
“Athlete’s foot”
What causes Hand, Foot, Mouth disease?
Describe the clinical presentation
Coxsackie virus A-16 or Enterovirus 71
- Fever
- Ulcerovesicular stromatitis
- Acral erythematous vesicles
- Buttock lesions
Psoriasis is best characterized as :
- Infectious disorder of the skin characterized by sensitivity to bacterial pathogens
- An inflammatory disorder characterized by activation of T-cells and overexpression or certain cytokines
- An autoimmune condition caused by immune cells attacking cell nuclear proteins
- A skin limited condition that never affects other organ systems
b. An inflammatory disorder characterized by activation of T-cells and overexpression or certain cytokines
(TNF-alpha, IL-17, IL-23)
Medications that block TNF-alpha, IL-23, and/or IL-17 would be helpful in treating which skin condition?
Psoriasis
Use if disease is widespread
Topical corticosteroids for local disease
A patient presents with several linearly arranged pruritic edematous excoriated 5mm papules on both of her legs. These seem to come in crops. It is winter and she has no known exposure to mosquitoes. Her husband may have had a few similar lesions. You recommend:
A. Use of DEET when she goes outdoors
B. Treatment for shingles
C. Professional extermination
D. She should get a new mattress
C. Professional extermination
Bedbugs! Must be professionally esterminated
What is the treatment for IgA vasculitis?
Why is it important to treat?
Supportive care
Glucocorticoids if kidney is involved to prevent damage
(Rash will heal on its own w/o scarring; steroids will not help)
A patient presents wtih these itchy lesions.
What is your next step in diagnosing the patient?
KOH exam
- If you see branched, septated hypae = tinea corporis
- Dermatophyte
33 yo obese patient reports developing recurrent painful nodules on the axilla for the past 5 years.
What do you tell her about her condition?
A. It is caused by lack of proper hygiene
B. It is a chronic condition that can affect axilla, groin, buttocks
C. The medications available can achieve long term cure
D. This condition is best treated surgically
B. It is a chronic condition that can affect axilla, groin, buttocks
- This is hidradenitis suppurativa
- Blockage of hair follicles -> painful bumps
- Not caused by lack of proper hygiene
- Smoking, excess weight and metabolic syndrome might play a role in the pathogenesis
-
Keys to diagnosis
- Recurrent painful nodules for several years
- Affects axilla, groin, buttocks
A pearly papule with rolled borders and telangiectasias that bleeds easily is most likely which kind of skin tumor?
How would you treat it?
Basal cell carcinoma
(This is nodular BCC = classic presentation)
- Unlikely to metastasize, but may be locally invasive
- Surgical excision (Mohs if on the face)
Medications that block IL-4 and IL-13 would be useful in treating which skin condition?
Atopic dermatitis
- IL-4 and IL-13 mediate the Th2 response and result in the downregulation of filaggrin
76 year old develops these tense blisters:
A. Antibodies targeting the hemidesmosome
B. Antibodies targeting the desmosomes
C. Antibodies targeting keratin 5 and Keratin 14
D. Antibodies targeting keratin 1 and 10
A. Antibodies targeting the hemidesmosome
Hemidesmosome anchors epidermis to basement membrane
Desmosome attaches epidermis cells to each other
-
Bullous pemphigoid
- Older patient
- Antibodies targeting the hemidesmosome
- Separation of the basal layer and the basement membrane
Which skin tumors are most common in patients who are immunosuppressed?
Squamous cell carcinoma
(Basal cell most common in general population)
A fungal infection living in the hair shafts and causing hair loss is most likely…
Tinia captis
What manifestations of viral rashes should prompt HIV testing?
- Widespread or giant Molluscum lesions, especially if the face is involved
- Caused by poxvirus
- Disseminated herpes zoster, large ulcerated herpes zoster
- Caused by Reactivation of varicella zoster
- Lesions suspicious of Kaposi Sarcoma
- Caused by HHV8
What percentage of melanomas arise within pre-existing nevi?
30%
The rest arise de novo
What is the most common melanoma subtype?
Association with what exposure?
What mutation?
Superficial spreading melanoma
Intermittent sun exposure
BRAF mutation
Which kind of tumor is most likely to develop from an actinic keratosis?
Squamous cell carcinoma
BUT not all SCCs are preceded by actinic keratoses
Which skin diorder is caused by overproduction of TNF-alpha, IL-17, and IL-23?
Psoriasis
Production of these cytokines driven by Th1 and Th17 helper T cells
Describe the cutaneous presentation of calciphylaxis
Violacious, reticulated patches
Bullae -> tissue necrosis -> ulceration
Very painful!
- Suspect in older patinets with kidney failure
28 year old woman develops a painful widespread rash.
What would be the most important information to gather from the patient to establish the diagnosis and etiology?
A. medication history
B. her exposure to other contacts
C. her recent travel history
D. her vaccination history
A. medication history
Toxic epidermal necrolysis
- Painful, widespread rash affecting >30% of body
- <10% = SJS
- Large sheets of desquamation; leaves behind dermis and some epidermis
- Usually triggered by adverse drug reaction
- Anticonvulsants: Carbamazepine, phenytoin
- Antibiotics: Bactrim, sulfas
Identify the basement membrane
Which patients are at particular risk of complications due to chicken pox?
- Pregnant women
- Neonates
- Immunocomproised patients
Who should receive a shingles vaccine?
People ages 60+
Even if they haven’t had chicken pox, or have already had shingles
Identify the subcutis
Describe the presentation of calcinosis cutis.
Which connective tissue diseases is it associated with?
Hard, painful nodules favoring sites of trauma
Advanced dermatomyositis (more common in juvenile)
Systemic Sclerosis (the C of CREST syndrome)
A patient is placed on an anti-TNF medication adalimumab to treat her psoriasis.
What is the most important condition to screen for in a patient who is on a TNF alpha blocker?
Latent TB infection
In which epidermal layers are keratinocytes most likely proliferating?
Basal layer
What lesion is this?
Benign or malignant?
Dermatofibroma
- Single, small, round, firm papule
- Pink to reddish brown
- Dimple sign
- Common on lower extremities
- Basically a scar; usually initiated by skin injuries (ex: insect bite)
Describe the presentation of acute cutaneous lupus erythematosus
- Classic malar rash
- Butterfly rash on cheeks, extends onto nose
- Spares nasolabial folds; sharp demarcation
- Dermatomyositis does not spare nasolabial folds
- Variable appearance: erythema, edema, telangiectasia, erosions
- Triggered by sun exposure
- Associated with anti-dsDNA antibody, systemic disease
44 year old healthcare worker reports several year hist of the following itchy rash that improves when he is away from work.
What is the mechanism of action?
Delayed (Type IV) hypersensitivity reaction
- Driven by T cell sand monocytes/macrophages
- Do patch testing to determine specific allergen
A patient complains of itchy finger webs and on examination has scaling between the fingers, a few scaly papules on the wrists, and edematous pink papules and a few nodules on the scrotum. Next step:
A. Recommend testing for STDs
B. Skin scraping for KOH to evaluate for tinea manuum
C. Skin scraping for Scabies preparation
D. Treatment for psoriasis
C. Skin scraping for Scabies preparation
“Scrotal nodules are scabies until proven otherwise”
Identify the layers of the epidermis in this image
- Basement membrane is pink, under the basal layer
- Not labeled
- Basal = single layer
- Spinous layer is thick
- Granular layer is thin, cells are flatter
- Cornified layer is thick; no nuclei - the keratinocytes are dead
28 year old otherwise healthy male develops this rash 3 weeks after URI symptoms. He reports the rash started with one large patch, then multiple small oval patches appeared few days later.
What is the best treatment?
A. Oral steroids
B. Oral tetracycline antibiotics
C. Oral macrolide antibiotics
D. Topical steroids and reassurance
D. Topical steroids and reassurance
- This is pityriasis rosea
-
Keys:
- Rash 3 weeks after URI
- Begins with a large patch
- Small oval patches appear days later
- May have “Christmas tree” pattern on back
-
Will resolve on its own
- Topical steroids if itchy/uncomfortable
- **If palms of hands and soles of feet are involved, test for secondary syphillis**
Identify the dermis
Lithium and Beta-blockers are medications that could cause flares of which skin condition?
Psoriasis
Which protein imparts tensile strength to the skin and makes up 75% of its dry weight?
Interstitial collagen
Found in the dermis
Gottron’s papules, extensor surface eczema, heliotrope rash involving eyelids and nasolabial folds, shawl sign, and calcinosis are characteristics of what autoimmune disorder?
What non-cutaneous findings might be present?
Dermatomyositis
- Proximal muscle weakness
- Dysphagia
- Malignancy
- Strong assoociation with dematomyositis in adults and malignancy; may be present at initial manifestation of disease, usually appears within a few years
- Interstitial lung disease
Describe IgA Vasculitis (Henoch-Scholein Purpura)
- “Typical Patient”:
- Arteries affected:
- Presentation:
IgA Vasculitis (Henoch-Scholein Purpura)
- “Typical Patient”: Children 3-15 y/o
- Arteries affected: Small vessels; immune complex mediated
- Presentation:
- Recent URI
- Palpable purpura
-
GI
- Colicky abdominal pain
- Vomiting, diarrhea
- Joint pain/myalgia
-
Hematuria
- “Cola-colored urine”
“Increased keratinocyte proliferation and turnover, leading to thick scaly plaques” characterizes which skin disease?
Psoriasis
A patient presents with this rash.
Physical exam reveals multiple, extensive round papules and plaqes diffusely distributed around the body. They are a little scaly.
The patient reports a recent sore throat treated with antibiotics
What is the most likely cause of this condition?
How should it be treated?
Guttate psoriasis
- May be initial presentation of psoriasis, or in patients who have had psoriasis for many years
- Multiple, extensive round papules and plaques; diffuse
- Will scaly
- Triggered by:
- Strep pharyngitis
- Beta blockers
- Lithium
- Stress
-
Treatment: widespread disease
- UV light phototherapy with narrow spectrum of UVB
- Biologics targeted against TNF-alpha, IL-23, or IL-17
What is the most important predictor of melanoma prognosis?
Breslow thickness
- Deeper tumors = worse prognosis
- Vertical spreading is more indicative than horizontal spreading
Which drugs are most likley to cause urticarial reactions?
- Pain medications
- NSAIDs
- Opiates (morphine may cause histamine release)
- ACE inhibitors (-> angioedema)
What cause pemphigus vulgaris?
Describe the presentation
Autoantibodies against the desmosome
Non-tense blisters and erosions due to separation of keratinocytes from each other (especially those in the spinous layer)
Describe the clinical presentation of HSV skin lesions
- Cluster of grouped vesicles with an erythematous base
- If the lesion is old, you will see crusted erosions
- Tingling, itching, burning on the skin before vescicles appear
-
Recurrent, painful
- Remains dormant in local nerve ganglia – this allows it to reactivate periodically (usually in the same area)
- Usually no constitutional symptoms
- May be triggered by UVB radiation or stress
18 year old has a history of a chronic itchy rash since childhood that waxes and wanes in intensity.
What drives the pathophysiology of this condition?
Impaired barrier function of the skin;
This is Atopic Dermatitis
Mutation in filaggrin -> decreased filaggrin
or
Cytokines IL-4, IL-13 -> decreased filaggrin
25 yo suddenly breaks out into this widespread rash on her trunk composed of thin oval slightly scaly patches. It initially started with one large patch. 3 weeks ago she had a slight fever and cold like symptoms
How would you treat this condition?
This is pityriasis rosea
- Oval, salmon colored thin macules or patches with a thin scale
- Mostly affects the trunk
- May have “christmas tree pattern” on the back
- Acute presentation
- May be due to reactivation of HHV 6 or 7
Treat with reassurance and topical steroids if itchy/uncomfortable
- Will self-resolve in 3-8 weeks
Describe the pathogenesis of neurofibromatosis
- Deletion of neurofibromin gene (a tumor suppressor
- -> Activation of RAS
- -> Cafe-au-lait spots, lisch nodules on the iris
Describe the presentation of dermatomyositis
- Proximal weakness
-
Dysphagia
- More common in dermatomyositis than polymyositis
- F>M
- Affects children and adults
- Childhood onset not associated with malignancy
-
Skin manifestations
- Polymyositis + skin manifestations = dermatomyositis?
- Sun-exposed erythema
- Heliotrope rash
- Involves nasolabial folds
- Eczema on extensor surface of joints
What are these flat brown spots?
Benign or malignant?
Solar Lentigines - benign
- Flat, light brown macules
- Lighter than typical nevi
- Common on sun-exposed areas
- Caused by increaed melanin (same number of melanocytes)
- No treatment necessary, but recommend sun protection
What features help to distinguish psoriatic arthritis from other arthritis?
Psortiatic arthritis is associated with:
- History of psoriasis
- Sausage digits
- Both erosive and new bone changes on x-ray
- Nail pitting
If a patient presents with sebaceous adenomas or carcinomas, what should you screen for?
Mutations in DNA mismatch repair genes
- Sebaceous adenomas are carcinomas are rare in the general population, but common in people with the Muire-Torre subset of hereditary non-polyposis colorectal cancer (Lynch syndrome)
What skin lesion is this?
Benign or malignant?
Lipoma
- Soft, ill-defined, rubbery, painless
- Subcutaneous nodule
- Much larger than a cyst
- Does not drain/discharge like a cyst
Which cells of the epidermis are important for presenting antigens to T cells and sensitizing the immune system to that antigen?
Langerhans cells
Describe the skin reaction associated with gluten sensitivity
Dermatitis herpetiformis
- Pruitic papulovesicles or excoriated papules
- Extensor surfaces, buttocks, back
- Caused by deposition of IgA in the papillary dermis
- -> Immune cascade
- Treatment = gluten avoidance, dapsone
Which germ line mutations are associated with melanoma?
CDKN2A / P16
CDK4
Bleeding gingivae, petichiae, ecchymosis, follicular hyperkeratosis and corkscrew hairs would increase your suspicion for which nutritional disease?
Scurvy
(Ascorbic acid aka Vitamin C deficiency)
Staphylococcus bacteria are implicated in many bacterial skin infections.
Which relatively common bacterial skin infection is not caused by staph?
Erysipelas - caused by Group A streptococcus
- Pain, superficial erythema, plaque-like edema
- Seems deeper than most things caused by staph?
Note - bacillus antrhacis can also cause skin lesions, but these are not common are present with a “black eschar”
Reactivation of HHV 6 or 7 may result in which skin rash?
Pityriasis Rosea
- Rash will self resolve, treat with topical corticosteroids if itchy/uncomfortable
What treatment is used to treat widespread psoriasis?
- Ultraviolet light phototherapy with narrow spectrum of UVB
- Targeted therapy (immune-modulating agents)
- TNF-alpha blockers
- IL-23 blockers
- IL-17 blockers
A patinet presents with complaints of GI upset and this skin rash.
What is the most appropriate treatment?
This is likely dermatitis herpetiformis, the skin version of celiac disease
Treatment = Avoid gluten, dapsone
- Pruritic papulovesicles or excoriated papules
- Extensor surfaces, buttocks, back
Caused by IgA deposition in the papillary dermis
Which vaccine vaccinates against HPV?
Which types?
Grdasil
HPV 6, 11, 16, 18
6, 11 = low risk of causing cancer
16, 18 = high risk of causing cancer
A 42-year-old white male presents with a “new mole” on his back, first noticed by his wife 4 months ago. It is itchy sometimes and bleeds easily.
What is this skin lesion?
Benign or malignant?
Sebhorrheic keratosis - Benign
- Superficial, raised epidermal growth
- Stuck-on quality
- Gently picking/scratching -> crumbling, flaking, lifitng off
- Do not go away
Which of the following is among the common causes of Stevens-Johnson syndrome?
a. Syphilis
b. Pneumococcal Pneumoniae
c. Cytomegalovirus
d. Phenytoin
e. Herpes simplex virus
d. Phenytoin
- Sulfa abx
- Anticonvulsants (Phenytoid, lamotrigine, carbamazepine)
- NSAIDs
- Tetracyclines
What protein is most important for wound healing?
Collagen
Which cells in the epidermis produce melanin?
Melanocytes
Which of the following is true about these nail changes associated with psoriasis?
A. She needs to get a clipping to test for onychomycosis
B. Repeated trauma caused these nail changes
C. Topical treatments will improve her nails
D. The condition may wax and wane
D. The condition may wax and wane
Nail changes can wax and wane, just like skin lesions
Which form of contact dermatitis requires sensitization to an antigen?
Which cells in the skin participate in this process?
Allergic contact dermatis requires sensitization
(Irritatnt contact dermatitis does not)
Langerhans cells in the epidermis present antigen to T cells to sensitize the immune system
List the 4 layers of the epidermis and the basic function of each layer
From deep to superficial
- Basal layer:
- Anchorage to the basement membrane via hemidesmosomes
- Proliferation (these are stem cells)
- Spinous layer
- Adhesion to each other via desmosomes
- Granular layer
- Differentiation
- Stratum corneum
- Death
Which antibody is associated with this skin rash?
Anti-dsDNA
- This is acute cutaneous lupus erythematosus
- MUST evaluate for SLE
- Acute cutaneous lupus erythematosus is associated wtih systemic diseas
Phototherapy can be useful in treating which skin conditions?
Psoriasis
Eczema
Possibly vitiligo
A patient with a history of psoriasis sees you in the office and reports a sudden worsening rash that started 3-4 weeks ago. She says it looks different than her typical psoriasis
- She should have an immediate skin biopsy to rule out another condition
- The condition she has may have been triggered by a strep pharyngitis
- The condition she has may have been triggered by excessive sun exposure
- She should have blood tests to rule out the condition in question
b. The condition she has may have been triggered by a strep pharyngitis
- This is guttate psoriasis
- May be the initial presentation, or can occur in patients who have had psoriasis for many years
- Multiple, extensive round papules and plaques; diffuse
- A little scaly
- Triggered by strep pharyngitis
Describe the presentation of discoid lupus erythematosus
- Chronic
- Scaly, pink/brown plaques
- Annular (round with central clearance)
- More common among African Americans
- Usually confined to the skin
Describe the presentation of leukocytoclastic vasculitis
- Crops of palpable purpura
- May be necrotic
- May have constitutional symptoms
Extensive workup required! Many etiologies
Ex: IgA vasculitis (aka HSP) is a type of leukocytoclastic vasculitis
Describe the presentation of neonatal lupus erythematosus
- Annular, pink, scaly plaques
- Like subacute cutaneous lupus erythematosus
- Periorbital location
- NOT photodependent
- Resolves with dyspigmentation that may persist for several months
-
Most worrisome complication = heart block
- If mom has Anti-SSA (Ro) antibodies, make sure you have specialists on hand at delivery
Which layer of the skin is labeled by #3?
Hypodermis
Describe the presentation of Toxic Epidermal Necrolysis
-
Tender, erythematous plaques with a dusky center
- Dusky center = necrosis
-
Erosions may be present
- Sheets of epidermis may be coming off
- Diffuse - affects >30% of body surface
- Stephens-Johnson Syndrome is the same thing but affecting <10% of the body
A tzank smear of a herpes vesicle will show which kind of cells?
Multinucleated giant cells
Caused by abnormal cell division in epidermal cells
What are actinic keratosis?
Pre-malignant skin lesions: gritty, scaly, thin, red-pink papules scattered on sun-exposed areas. Sandpaper feel
- Potential for transforming into squamous cell carcinomas
- Originate from keratinocytes
- Most do not progress, but should be treated
- Local therapy: Cryosurgery
- Field therapy: Topical 5-fluorouracil, imiquimod, photodynamic therapy
Identify the dermis
A 35-year-old male presents with a 1.5 cm nodule on the upper back and the chief complaint, “my wife keeps trying to pop this ‘bump’, but it just refills with nasty-smelling white material.”
From which structure in the skin does this lesion arise?
Hair follicles
This is an epidermal inclusion cyst
- Mobile subcutaneous nodule
- Often with an overlying punctum
- Arises from a hair follicle
- Debris collect within the sac
- May discharge foul-smelling cheesy white material
Which layer of the skin is labeled by #2?
Dermis
What are these lesions?
Benign or malignant?
Skin tags (acrochordons)
Benign
62 year old patient with rash on the dorsal hands, around the eyes.
What other symptoms would you suspect?
How would you manage this patient?
This is dermatomyositis. We know because:
- Dorsal hands, knuckles only
- Around the eyes (Heliotrope)
- Also look for shawl sign +/- rash in the V of the neck
Other symptoms: Proximal muscle weakness
- Difficulty climbing steps or standing from a seated position
- Difficulty blowdrying or styling hair
What skin manifestations would increase your suspicion for sarcoidosis?
- Lupus perino (pictured)
- Papulonodules and plaques involving areas affected by cold
- Lofgren’s syndrome
- Erythema nodosum
- Hilar adynopathy
- Fever
- Polyarthritis
What autoimmune conditions may be associated with vitiligo?
- Thyorid dysfunction
- Alopecia areata
- Diabetes mellitus
What form of cutaneous lupus is this?
Which antibody is associated with this form of disease?
Subacute cutaneous lupus erythematosus
- Scaling, annular pink papules and plaques
- Anti-SSA (Ro)
- Low tendency for systemic lupus
- Important to do a detailed drug history!
Describe the presentation of Henoch Scholein purpura
- Acute onset
- During or soon after URI
- Palpable purpura
- Arthralgias
- Colicky abdominal pain
Which layer of the skin is labeled by #1?
Epidermis
Which appendage of the skin is labeled by b?
Sebaceous glands
Which vasculitides present with “palpable purpura”?
Leukocytoclastic Vasculitis
Ex: Henoch Schonlein Purpura (HSP) aks IgA vasculitis
Widespread HSV euption would increase your suspicion for which chronic skin condition?
Eczema/atopic dermatitis
Eczema/atopic dermatitis + HSV -> Eczema herpeticum
- Eczema herpeticum
- Sudden onset of widespread, umbilicated vesicles
- Turn into small, round erosions in a patient with active atopic dermatitis
What form of lupus is this?
Is this patient at risk for systemic disease?
- Discoid Lupus Erythematosus (a chronic condition)
- Scaly, pink/brown plaques
- Annular (round with central clearance)
- 5-15% of patinets may develop SLE
- Risk is higher if discoid lupus is widespread and not limited to sun-exposed areas
- Lesion on this patinet’s back = not photodependent = increased risk of systemic disease
Which populations are most likely to be affected by molluscum contagiousum?
- Children
- Common condition that happens due to skin contact
- Can happen anywhere in the body
- Sexualy active adults
- Associated with sexual contact in adults (but not in children)
- People with impaired cellular immunity
30 year old develops an itchy rash on the abdomen.
What would be the next best step?
A. Oral antibiotics
B. Oral steroids
C. Topical steroids
D. Skin scaping for KOH microscopic examination
D. Skin scaping for KOH microscopic examination
Likely tinea corpus
- Itchy rash
- Annular
- Accentuated borders
- Papules on the edges
- Look for septated hyphae on KOH
Note: Even if you think it might be Eczema, always do KOH to confirm! Topical steroids will exacerbate fungal infection
How would you describe this skin lesion?
What is your leading diagnosis?
Solitary, pearly pink papule with telangiectasias
This is basal cell carcinoma
Which layer of the skin makes up the bulk of the skin?
Dermis
Contains lots of collagen
Maintains skin pliability and tensile strength
32 year old has a 3 week history of sudden eruptive raised red growth that bleeds with minimal trauma
What skin lesion is this?
Benign or malignant?
Pyogenic granuloma - benign
- Eruptive, small, solitary
- Sessile or pedunculated
- Vascular (red)
- Papule
- Bleeds easily with trauma
Which skin disease is this?
Palmoplantar psoriasis
What causes bullous pemphigoid?
Describe the presentation
Autoantibodies against the hemidesmosome
- Break between the basal keratinocytes and the basement membrane
- Results in tense bullae
Describe Lentigo maligna melanoma.
What exposure is it associated with?
What mutation?
Chronic sun exposre
c-KIT and NRAS mutations
Note - these look very different from solar lentigos
A patient presents with mild itchiness in this skin lesion, which began in July.
What would you expect to see on KOH?
This is tinea versicolor
Caused by overgrowth of malassezia, a lipophilic yeast that is a normal resident in the skin and hair follicles
KOH would show spaghetti and meatballs
What form of cutaneous lupus is this?
Which antibody is associated with this form of disease?
Subacute cutaneous lupus erythematosus
- Scaling, annular pink papules and plaques
- Ant-SSA (Ro)
- Low tendency for systemic lupus
Describe the presentation of Acthanosis Nigricans.
Which endocrine disorder is it associated wtih?
Velvety, hyperpigmented plaques in flexural surfaces
Most commonly occurs in overweight persons with insulin resistance (Diabetes mellitus)
76 year old with renal failure presents with painful lesions. This process involves…
A. Autoimmune process targeting hemidesmosomes
B. Progressive vascular calcification
C. Infectious spread through dermis
D. Autoimmune process involving desmosomes
B. Progressive vascular calcification
This is calciphylaxis
- Renal failure
- Painful
- Older patient
Caused by renal failure, not autoimmune process
What is the treatment of this legion?
This is a keloid - results from abnormal wound healing
- Excessive collagen production, and less degradation in the wound healing process
Treat with steroid injection
Which form of lupus does this patient most likely have?
What is the important next step in their management?
Subacute cutaneous lupus erythematosus
- Scaling, annular pink papules and plaques
Take a detailed medication history; low risk for systemic disease, so don’t worry about kidney biopsy or other work-up at this point
12 year old develops malaise, fatigue, low grade fevers, and these skin lesions.
What is your most likely diagnosis?
Chicken pox
- Widespread skin lesions in various stages
- “Dewdrop on a rose petal”
- Constitutional symptoms = not eczema herpeticum
23 yo female develops this acute rash on the hands and body.
What is the diagnosis?
A. Syphilis
B. Erythema multiforme
C. Psoriasis
D. Tinea corporis
B. Erythema multiforme
- Multiple targetoid macules and papules
- Caused by a hypersensitivity reaction after infection
- HSV
- EBV
- Mycoplasma pneumoniae
- Acute, self-limiting, resolves without complication
These skin lesions are associated with which viral infection?
Hepatitis C
This is Lichen planus
What is the major cell type in the epidermis?
Keratinocytes
(Called coryneocytes when they die and exist in the stratum corneum)
These skin lesions are typically associated with disease of which internal organ?
GI tract - Crohn’s and Ulcerative Colitis
This is pyoderma gangrenosum;
- Cutaneous ulceration with gunmetal grey border with undermining edges
- Cribiform appearance
- Other associations:
- Hep C
- Rheumatoid arthritis
- Hematoologic malignancy
- Idiopathid
44 yo African American female presents with 2-3 hist of these progressive papules on her nose.
What is causing this condition?
What would be the findings of the skin biopsy?
Sarcoid
Granulomas on biopsy (histiocytes and multinucleate giant cell)
- Firm papules
- Develop over time
- Around the nose
- Coalesce to form plaques
- More common in Black patients
- Concern for lung involvement - refer to pulm
Mutation in which gene/protein is associated with atopic dermatitis?
FLG/Filaggrin 1
- Filaggrin is reponsible for maintaining skin barrier function
- Mutation explains 20-30% of atopic dermatitis in patients of Northern European or Asian descent
- Mutation = you can’t see filaggrin granules in the epidermis
- Cutaneous inflammation (IL-4, IL-13) can result in acquired atopic dermatitis
New born presents with annular rash. Mother has a similar rash worse with sun exposure. Which of the following is true?
A. The child should be evaluated for cardiac involvement
B. These skin lesions will be lifelong
C. Mothers of patients with this condition will always have symptoms
A. The child should be evaluated for cardiac involvement
- Neonatal lupus, related to maternal anti-Ro and anti-La antibodies
- Congential heart block is the most worrisome complication
The skin lesions will resolve after the maternal antibodies clear out
What are the characteristics of seborrheic dermatitis?
What might be causing this condition?
Redness, and thin yellow (waxy) flaking around the nose (nasolabial folds), eyebrows, beard area, ears, hairline, scalp
- Associated with yeast; Pityrosporum ovale
- Treat with antifungal cream + mild topical steroid
What will you see on a tzank smear of a chicken pox vesicle?
Multinucleated giant cells
Small, firm umbilicated papules (has a central dell) with smooth, waxy or pearly surface are most likely caused by…
Molluscum contagiousum
- Skin to skin transmission
- Enveloped, dsDNA virus
24 yo old female on OCPs develops tender erythematous nodules on the legs. What is the diagnosis?
A. Erythema Nodosum
B. Vasculitis
C. Psoriasis
D. Bed bug bites
A. Erythema Nodosum
- Young female
- Oral contraceptive pills
- No constitutional symptoms
- Bed bug bites might be red and swollen, but more likely itchy instead of tender
Which skin disease is causing these nail changes?
Psoriasis
- Pitting
- Onycholoysis
- Yellow discoloration caused by lifiting of the nail plate from the bed
A 33 year old female presents with a changing mole on her upper shoulder. She reports a significant history of tanning bed exposure. What is the next best step?
- Reassurance of the benign nature of the mole
- Observation and close follow-up
- Partial biopsy of the lateral edge of the mole
- Excisional biopsy of the entire mole
d. Excisional biopsy of the entire mole
This is melanoma. Partial biopsy may miss cancer some areas
- Sun-exposed area
- Changing
- Hx of tanning bed use
- Asymmetric
- Irregular shape
- Also look for
- Blue-grey veil
Note: in basal and squamous cell skin cancer, okay to take just a piece for biopsy if the lesion is large - if part of the skin lesion has cancer, all of it will; if part is fine, all of it is fine
What skin legion is this?
Benign or malignant?
Cherry angioma - Benign
- Non-tender
- They don’t bleed
- “Shiny, bright red papule”
Which form of cutaneous lupus is most likely the result of a medication interaction?
Subacute cutaneous lupus erythematosus
- Scaling, annular pink papules and plaques
- Anti-SSA (Ro)
- Low tendency for systemic lupus
Describe the presentation of measles.
What are the potential complications?
- High fever
- Malaise
- Conjunctivitis
- URI
- Rash
- Starts 1-7 days after onset of constitutional symptoms
- Starts around the ears -> face -> body
- Koplick spots in the buccal mucosa
- Complications
- Otitis media
- Pneumonia
- Encephalitis (1%) can be fatal
Patient was hiking in Connecticut and has fevers, fatigue, headache and joint pain and this slowly expanding rash.
What would be the next best step?
This is lyme disease, caused by Borrelia burgdorferi
Treat with penicillin or tetracycline based antibiotic
- No need to do further testing before starting treatment
62 year old with 3 year history of slowly enlarging lesion on the nose. Occasionally bleeds without any trauma.
Is it likely to metastasize?
How should it be treated?
This is basal cell carcinoma
Not likely to metastasize, but may be locally invasive
Treat with Moh’s micrographic surgery
(Use Moh’s on face to preserve tissue)
What causes verruca vulgaris warts?
HPV
- Non-enveloped, dsDNA virus
A patient presents with these skin lesions, hilar adenopathy, fever, polyarthritis, and acute iritis.
What syndrome is this?
Which systemic disease are you concerned for?
This is erythema nodosum.
In conjunction with the other clinical findings, suspect Lofgren’s syndrome
Association with Sarcoidosis; refer to pulmonology
Note: Erythema nodosum on its own will self-resolve and is not concerning; typical patient = young, healthy woman taking oral contraceptive pills
33 yo patient reports a 10 year history of itchy rash. She reports some improvement of the rash in the summer months.
What condition does she have?
Psoriasis
- Itchy
- Chronic
- Scaly plaque overlying an erythematous lesion
- Clear-cut borders (well demarcated)
- Improves wtih UV exposure
Which systemic conditions are associated with Sweet’s syndrome?
Sweet’s syndrome = skin condition characterized by neutrophilic infiltrate
- AML
- IBD
- Infections
- Drugs
- Pregnancy
These skin lesions are associated with which endocrine disorder?
Insulin resistance
This is Acanthosis Nigricans. Typically occurs in obese patients with insulin resistance/diabetes mellitus
Which skin disease is causing these nail changes?
Psoriasis
- Pitting
- Onycholoysis
- Yellow discoloration caused by lifiting of the nail plate from the bed
- Scaly plaques overlying areas of erythema
Describe the natural history of this skin lesion?
This is a hemangioma - benign tumor of childhood
- Present at birth or within the first few weeks of life
- Raised, soft, easily compressed
- Usually on the head and neck
-
Growth within the 1st year, then slowly disappear spontaneously
- 30% gone by age 3
- 50% gone by age 5
- 70% gone by age 7
18 year old has a history of a chronic itchy rash since childhood that waxes and wanes in intensity.
What is the best treatment?
This is atopic dermatitis
- Topical corticosteroid
- Narrow Band UVB radiatio
- MTX, AZA if severe
- Dupilumab if widespread refractory to other treatment
- Biologic targeted against IL-4
What causes shingles?
Describe the presentation
Reactivation of dormant varicella zoster virus from sensory dorsal root ganglion
Varcella zoster = chicken pox
Herpes zoster = shingles
-
Crop of vesicles and pustules on an erythematous base
- Papules -> Vesicles -> Pustules
- In a dermatomal distribution - unilateral
- If bilateral, suspect underlying autoimmune condition ex: HIV
- Preceded by one-several days of numbness, tingling, or pain in the affected area
What skin disease is this?
Psoriasis
- Well-defined, raised lesions
- Thick, white, silvery scale with pomegranate/salmon color underneath
- Affects elbows and knees
76 year old with renal failure presents with painful lesions. This process involves:
A. Autoimmune process targeting hemidesmosomes
B. Progressive vascular calcification
C. Infectious spread through dermis
D. Autoimmune process involving desmosomes
B. Progressive vascular calcification
This shows Calciphylaxis/Calcific Uremic Arteriolopathy
- Associated with renal disease, older patients
- “violacious, reticulated patches”
- Progresses in 3 steps:
- bullae>tissue necrosis>ulceration.
- Other renal disease associated condition to know is pruritis
Thank you @Joo-Young!! :)
Identify the epidermis
Autoantibodies againt the desmosomes leads to which skin condition?
Pemphigus Vulgaris (pictured)
- -> Breaks between adjacent keratinocytes in the epidermis
- -> Non-tense, fragile blisters and erosions
Note: Bullous pemphigoid results from autoantibodies againt hemidesmosomes, and results in tense bullae due to separation basal keratinocytes from the basement membrane
A patient with poorly controlled HIV develops these skin lesions.
What is the most likely cause?
HHV-8 - Kaposi Sarcoma
- Raised brown, dark red, violaceous lesions (They look vascular)
What histological change occur in psoriasis?
What causes these changes?
Elongated, thickened epidermis
- Thick stratum corneum (top layer); this leads to the silvery/white scales characteristic of psoriasis
- Proliferation and dilation of capillary blood vessels (lighter staining areas of the dermis); this causes red rash underneath the scaly plaques
33 year old male develops an acute painful rash.
What is the etiology?
A. Reactivation of a varicella zoster
B. Initial infection of a varicella zoster
C. Infection of the herpes simplex virus
D. Allergic contact dermatitis
A. Reactivation of a varicella zoster
- Acute, painful
- Follos dermatome
- Close up:
- Clusters of vesicles with an erythematous background
