Desquamation and Vesicular Bullae

Question 1

Erythema multiforme pathophysiology

Answer 1

immunologically mediated:
hypersensitivity: bacterial, viral (HSV), chemical products
primary rxn: 9-14 days after initiation of offender
recurrent exposure: hours to 1-2 days

Question 2

Erythema multiforme etiology

Answer 2

Herpes Simplex Virus and other infections
Drugs: sulfa drugs; anticonvulsants
**always check ptn’s drug hx

Question 3

Erythema multiforme epidemiology

Answer 3

M:F = 2:1

rare 50 years old

Question 4

Erythema multiforme presentation

Answer 4

target or iris legions w/ 2 zones: central dusky or red, pale pink or edematous, peripheral red ring
centripetal (“center seeking”) spread

Question 5

Erythema multiforme minor presentation

Answer 5

starts with flu-like
3 days - abrupt onset rash
nonpruritic

Question 6

Erythema multiforme major presentation

Answer 6

flu like prodrome
prominent mucosal involvement
legions stay put

Question 7

Erythema multiforme treatment

Answer 7

symptomatic treatment
hydration/check fluids
withdraw suspected drug trigger and any unnecessary meds
eye lube/get opthalmologist if eye involvement
antiviral if associated with HSV - prevention only

Question 8

Steven Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN)

Answer 8

Immune-complex-mediated hypersensitivity
can affect any epithelial layer
distinct from EM - acute disseminated epidermal necrosis (necrolysis)
SJS 30%

Question 9

SJS and TEN etiology

Answer 9

4 catgeories
infectious
drug
malignancy
idiopathic
adults/elderly: drug or malignancy
pediatrics: infectious

Question 10

SJS and TEN presentation

Answer 10

NONPRURITIC lesions
if pruritic, it’s contact dermatitis
oral mucositis may limit ability to eat
conjuctival or cornal inflammation common

begin: nonspecific URI lasting 1-14 days (flu like symptoms)

Question 11

SJS & TEN prognosis

Answer 11

SCORTEN score – mainly measures of dehydration
based on: age, extent of epidermal involvement (BSA), serum urea level (dehydration)
better in kids
negative factors: resp failure, thrombocytopenia, sepsis

Question 12

SJS & TEN treatment

Answer 12

no serologic test for diagnostics
TREATED LIKE A BURN
check Tetanus status
plasmapheresis and immunosuppressive therapy
aggressive lube if ocular inflammation

Question 13

TEN Sequelae

Answer 13

hypo-/hyperpigmentation
nail lost
hypohidrosis
scarring, alopecia
occular:
sjogrenlike syndrome (less tears causes dry eye and cornea scarring)
plapebral synchiae (eyelids stick together)

Question 14

Bullous pemphigoid

Answer 14

chronic, autoimmune
some mucosal involvement
lasts years w/o treatment
w/ treatment 1.5-5 yrs

Question 15

Bullous pemphigoid presentation

Answer 15

subacute or acute onset
widespread (localized or generalized) 
tense bisters filled with clear fluid
Pruritic
precipitated by UV light

Question 16

Bullous pemphigoid: bullous form

Answer 16

any part of skin but usually flexural areas
rare: oral and minor ocular involvement
heal w/o scarring or miliation

Question 17

Bullous pemphigoid: vesicular form

Answer 17

less common
groups of small tense blisters
“herpetiform vesicles”

often erythematous or urticarial

Question 18

Bullous pemphigoid: workup & treatment

Answer 18

immunofluorescent tests (direct & indirect)
anti-inflammatories (corticosteroids, tetracyclines)
anti-CD20 antibody (rituximab) - targets antibody producing B cells