Dermatology, hair and nails Flashcards
Most common clinical manifestation of SLE
And most common people with SLE
85% of cases present with skin lesions 90% of patients have joint involvement 85% of cases are in females 1:250 black women are diagnosed 1:1000 white women are diagnosed
Systemic features of SLE
fever, anorexia, malaise, weight loss
Mnemonic for lupus symptoms
SOAP BRAIN MD
S=serositis O=oral ulcers A=arthritis P=photosensitivity, pulmonary fibrosis B=blood cells R=renal, Raynauds A=ANA I=immunologic (anti-Sm, anti-dsDNA) N=neuropsych M=malar rash D=discoid rash
Treatments for SLE
Based upon intensity of the disease
Start with NSAIDs and hydrochloroqine
If does not improve add
Low-dose steroids.
AcuteCutaneousLE:
Butterfly malar rash +/- forehead, chin and V-neck, spares NL folds → sun-exposed areas
- Widespread morbilliform or exanthematous eruption of extensor arms and wrists sparing the knuckles
- Severely acute can simulate toxic epidermal necrolysis
- Lasts hours, days, weeks. NO scarring involved unless 2° bacterial infection
SubacuteCutaneousLE:
erythematous macules/plaques on sun-exposed areas more so upper extremities, trunk, shoulders
- Less transient that ACLE, heal with more pigment change
DiscoidLE:
induration, greater hyper/hypopigmentation, atrophic dermal scarring, follicular plugging, and adherent scale, scarring alopecia
- Classic red-purple macules, papules, small plaques that evolve into discoid erythematous plaques covered by prominent adherent scale that extends into orifices of dilated hair follicles
- “Carpet tack” sign = keratotic spikes beneath adherent scale
Raynaud’s disease: dermatologic manifestations
- Paroxysmal bilateral finger pallor and cyanosis followed by rubor
- Precipitated by cold or emotional stress, relieved by warmth
- Primary form (Raynaud disease, idiopathic) is benign
- Secondary form (rheumatic disease, especially scleroderma) for can lead to ulceration and gangrene of digits
What is scleroderma?
Meaning; hardening of the skin of the hands.
A chronic connective tissue disease generally classified as one of the autoimmune rheumatic diseases
What and who does scleroderma effect?
Hardening and tightening of the skin and connective tissues
- Can effect skin, vessels, internal organs, gi tract
Affects more women then men and most commonly between the ages of 30 and 50
What are the limited symptoms of scleroderma
CREST syndrome: Cutaneous calcification, Raynaud’s, Esophageal dysfunction, Sclerodactyly, Telangiectasia
Hands, feet, face, trunk, mucous membrane
What causes Livedo reticularis?
Thought to be caused by a spasm of the blood vessels or abnormality of the circulation near the surface of the skin.
Can just be a result of being chilled or an indication of a serious vascular condition, endocrine disorder, or rheumatologic condition.
Primary and secondary Livedo reticularis:
- Idiopathic LR: disappears after warming, a physiologic phenomenon
- Secondary LR: starburst or lightning-like pattern, net-like but with open meshes, often confined to lower extremities and butt. Signifies systemic disease.
What is Erythema nodosum?
An inflammatory disorder. It involves tender, red nodules under the skin.
most common on the shins. It may also occur on other areas of the body such as buttocks, calves, ankles, thighs, and arms.
The lesions begin as flat, firm, hot, red, painful lumps that are about an inch across. Within a few days, they may become purplish in color. Over several weeks, the lumps fade to a brownish, flat patch.
Behcet’s Syndrome
Unknown etiology: but vascular
S/sx: oral apthous ulcers, genital ulcers, papulopustules, erythema nodosum-like lesions, uveitis, and arthropathy.
Pyoderma gangrenosum
Eti: unknown but thought to be autoimmune
Associated with: IBD, RA, crohn’s
- Acute: Painful, boggy, blue-red hemorrhagic ulcers with undetermined borders and purulent necrotic bases, either de novo or post-trauma +/- “phenomenon of pathergy” (needle stick, insect bite, biopsy, other minimal trauma triggers lesion)
- Chronic: slow progression over larger areas of the body with granulation and hyperkeratosis, less painful
What is polyarteritis nodosa?
acute multisystem disease with a relatively short prodrome (ie, weeks to months)
What are the constitutional and MSK symptoms of polyarteritis nodosa?
S/sx: Fever, malaise, fatigue, anorexia, wt. loss, myalgia, arthralgia of large joints
What are the organ systems affected by polyarteritis nodosa?
MSK CNS Peripheral nervous Cutaneous nervous GI etc.. continue
Dermatomyositis, what is it?
Cutaneous changes in the setting of muscle weakness
Dermatomyositis skin changes?
Violet-colored or dusky red rash develops, most commonly on the face and eyelids and on areas around the nails, knuckles, elbows, knees, chest and back.
- The rash can be patchy with bluish-purple discolorations is often the first sign of dermatomyositis.
Dermatomyositis muscle weakness?
Progressive proximal muscle weakness (hips, thighs, shoulders, upper arms and neck). Bilateral
What is urticaria?
Superficial sharply demarcated pruritic wheals (transient, edematous, papules/plaques)
- IgE dependent, associated with food, parasites and penicillin
Angioedema
Same process as urticaria but involves the dermis and subQ tissues often around the eyes or lips.
Acanthosis nigricans
Asmmetric velvety thickening and darkening of the skin
Location: neck, axilla, groin and other body folds
- Marker related to hereditary, obesity, endocrine disorders (esp. DM), drug admin.
- Malignancy should be suspected in older adults non-obese adults with new onset (associated with GI tumors).
Erythema multiforme
Hypersensitivity rreaction usually triggered by infections, most commonly HSV.
- May begin as round erythematous papules that evolve into classic target lesions.
Dist: Most symetrical distribution on the extensor surfaces of the acral extremities: Face, neck, palms, soles, flexural surfaces of extremities.
Sarcoidosis
A systemic granulomatous disease of unknown cause.
Primarily affecting the lungs
Skin: papules, translucent yellow-red with apple jelly appearance on diascopy.
Erythema nodosum is the most common non-speciic lesion in the skin in early sarcoidosis.
Pemphigus vulgaris
Autoimmune disease of the skin and mucous membranes
- flaccid blisters on skin and erosions on mucous membranes
- Serious and often fatal unless treated with immunosuppressive agents.
Tx: by dermatologist
Bullous pemphigoid
Autoimmune disease usually in the elderly
- pruritic, papular or urticarial lesions with large tense bullae
Differentail diagnosis for hirsutism?
DDx: PCOS: causing irregular periods, obesity, infertility and sometimes cysts on the ovaries
Cushings syndrome, congenital adrenal hyperplasia, androgen-secreting tumors, medications
Workup for Hirsutism?
Testosterone, dehydroepiandrosterone sulfate (DHEAS), dexamethasone suppresion, adrenocorticotropin stimulation, cortisol suppression, serum prolactin or PSH, DM screening, PSA
Ddx for alopecia with scarring?
Chemical or physical trauma, lichen planopilaris bacterial or fungal infections severe herpes zoster chronic SLE Scleroderma Excessive radiation
DDX for non-scarring alopecia?
SLE, secondary syphilis, hyper or hypothyroidism, iron deficiency anemia, pituitary insufficiency
Work up for women with non-scarring alopecia
DHEAS, iron, total iron-binding capacity, thyroid function tests, CBC
Alopecia areata
Sudden hair loss that starts with one or more circular bald patches that may overlap.
Associated with: thyroid autoimmunity, vitiligo, atopic dermatitis, some link to DM type 1.
Trichotillomania
Pulling ones own hair out, patches of hair loss irregular and short growing hairs always present, patches often unilateral.
- Occur on the same side as patients dominate hand.
Beau’s lines
Transverse, band like depressions in the nail, extending from lateral edge to the other.
DDx: High fever, postnatal, cytotoxic drugs (chemo), cutaneous drug reaction, dermatologic dz, viral infection, kawaskai syndrome, peripheral ischemia
Clubbed nails
Hypertrophy of soft-tissue digital pulp.
CV: aortic aneurysm, congential and acquired CV disease
Bronchopulm: intrathoracic neoplasms, chronic intrathoracic suppurative disorders
GI: IBD, GI neoplasms, hepatic disorders…
Terry’s nails
Leukonychia: opque white plate obsurcing lunula and extending 1-2mm from distal nail edge.
DDx: Hepatic disorders
Splinter hemorrhages
Lines 2-3 mm long, arranged in the long axis of the nail, plumb color that darkens in 1-2 days
Distal: minor trauma most common, psoriasis, atopic derm
Proximal: trauma, sideropenic anemia (Fe def), bacterial endocarditis, trichinosis
Pitting nails
Punctate depressions, small, shallow, vary in size, shape and depth.
Ddx: psoriasis, atopic derm, alopecia areta
Spooned nails
Koilonychia: nail flattening followed by upward eversion
Hereditary and congenital
- plummer-vinson syndrome (iron def anemia + dysphagia + glossitis
