Eczematous and Papulosquamous disorders Flashcards
1
Q
How do papulosquamous disorders present? What are these disorders?
A
with papules and scales
- lichen planus
- pityriasis rosea
2
Q
Eczematous disorders have what kind of characteristics?
A
- scaling
- crusting
- serous oozing
- dermatitis is used to describe mult. type of skin disorders
3
Q
What is atopic dermatitis? AKA? How common and when do they manifest?
A
- AKA eczema
- common (11% of US pop)
- 85% of cases present by ages 5-7
- 40% clear by adulthood
4
Q
Two theories behind pathogenesis of atopic dermatitis?
A
1- impaired epidermal barrier fxn due to intrinsic structural and fxnl abnormalities in the skin - abnormal epidermal barrier as the primary defect
2- immune fxn disorder in which Langerhans cells, T cells, and immune effector cells modulate an inflammatory response to enviro factors - previously thought to be due to allergies but support for this is lacking
5
Q
Clinical manifestations of atopic dermatitis? hallmark?
A
- hallmark - pruritus
- scratching leads to eczematous change and lichenification
- tiny erythematous, edematous ill-defined blisters
- lesions may ooze, crust, and become purulent: may need tx for bacterial infection
6
Q
Characteristics of atopic dermatitis for adults and kids?
A
- MC in flexure creases
- adults:
location - neck, wrists, behind ears, antecubital and popliteal flexure areas - children: all the locations listed above and including the cheeks/face
- worry about scratching leading to secondary infection (staph)
7
Q
Tx of atopic dermatitis?
A
- eliminate exacerbating factors: avoid poss. triggers (heat, low humiditiy, perspiration)
tx stress and anxiety - antihistamine used to tx pruritus - doxepin (TCA) or vistaril (antidepressants with antihistamine SEs)
- Hydration - first line***
- topical steroids (don’t use topical benadryl in kiddos)
- burrow’s soln for oozing lesions
- tx skin infections when appropriate
8
Q
Tx for mild to moderate cases of atopic dermatitis?
A
- topical corticosteroids and emollients
- topical steroids can be applied 1 or 2x daily for 2-4 wks
- mild to mod: use low potency corticosteroid cream or ointment (desonide 0.05% or hydrocortisone 2.5%)
- moderate disease use medium to high potency corticosteroids (fluocinolone 0.025%, triamcinolone 0.1%, betamethasoine dipropionate 0.05%)
** don’t use steroids for over a month - break down skin
9
Q
SEs of topical steroid use?
A
- atrophy, telangiectasia, purpura, striae, and acneform eruption
- higher the potency the more likely to have SEs
- limit higher potency topical steroids to no more than 45g/week for no longer than 2 wks
- use less potent steroids for face, dorsum of hands and genitalia
- use even lower potency for around the eyes
10
Q
What is used in atopic dermatitis pts if the face is affected and they need long term therapy?
A
- pts who reqr therapy to face or skin folds for more than 3 wks can be tx with a *topical calcineurin inhibitor
- tacrolimus (protopic) or pimecrolimus (Elidel) rather than topical steroids
- less side effects and is as effective as medium potency topical steroids
- topical med used BID
- immunomodulators
11
Q
BBW for topical calcineurin inhibitors? Who can’t use these?
When should these be used?
A
- BBW: may increase the incidence of skin cancer and lymphoma with long term use
- 2nd line agents
- not for use under 2yo
- not for continual use
- not for use in immunocompromised
- use for lesions on face, eyelids, neck and skin folds (b/c steroids cause more atrophy in these places)
12
Q
What is nummular eczema?
A
- atopic dermatitis that is described as coin shaped lesions
- tx is same as atopic dermatitis (topical steroids, hydration)
- usually occurs on trunk and lower extremities (esp on dorsal hand, feet extensor surface)
13
Q
Tx of atopic dermatitis - if pt fails first line tx?
A
- most pts do respond to hydration and topical meds
- a small number are resistant to tx
- may reqr:
phototherapy with UV light
or immunosuppressants: methotrexate, azithiorpine, cyclosporine, systemic steroids, IV immunoglobulin
14
Q
What is lichen simplex chronicus? What is an easy tx for this?
A
- this is what occurs as result of chronic eczematous changes and scratching (itch and scratch cycle)
- circumscribed plaque of thickened skin with increasing markings with some scaling
- stop the scratching and lesions may regress
- can use topical steroids
15
Q
What is dyshydrotic eczema?
A
- cause is unknown
- vesicular eruption on skin of hands and feet marked by intense itching (vesicles are deep)
- scaling, fissures, and lichenification may follow
16
Q
Tx of dyshydrotic eczema?
A
- high potency topical steroids
- may need to be given with occlusion (ointment and covered in saran wrap)
- hydration of the skin with emollient cream
17
Q
What is contact dermatitis?
A
- direct exposure to a substance
- from allergy or irritation
18
Q
Most common plant causes in North America - of contact dermatitis?
A
Oleoresin urushiol which is found in:
- poison ivy
- poison oak
- poison sumac
- skin of mangoes
- gingko fruit
- may spread from pets or from oils trapped under finger nails
19
Q
What are other common offenders of contact dermatitis other than plants?
A
- nickel (jewelry, buttons, belts)
- formaldehyde, quanternium-15 (clothing, nail polish)
- perfumes, cosmetics
- preservatives (topical meds, cosmetics)
- rubber and chemicals in shoes
- topical hydrocortisone, topical abx (neomycin, bacitracin), topical meds - benzecaine, thimersol
- laundry detergents may be a rare cause
20
Q
Presentation of contact dermatitis?
A
- intense pruritus
- rash
- papular, erythematous lesions
- papules from fluid in epidermis and in severe cases produces vesicles and serous oozing
- exposure may have been as far back as 2 wks ago
- may develop a rxn to products that have been used for months - years
21
Q
Tx of plant based contact dermatitis?
A
- topical sx therapy: oatmeal baths, cool, wet compresses, calamine lotion, burrow’s or Domeboro soln for weeping lesions, zanfel soap
- antihistamines: rxn isn’t due to histamine release so use for sedation
- topical corticosteroids: high potency - clobetasol 0.05% cream
- systemic corticosteroids: needed if large area, face or genitals, 2-3 week taper of prednisone (max: 60 mg/day)
22
Q
Tx of other types of contact dermatitis other than plant caused?
A
- remove offending agent
- topical sx therapy
- medium to high potency topical steroids: clobetasol 0.05% cream
- systemic steroids in severe cases (more than 10% of BSA): medrol dose pack or prednisone 40 mg x 6 d followed by 20 mg x 6 d
- burrows soln for weeping blisters
- antihistamines for tx of pruritus
- tx any recognized secondaray bacterial infections
23
Q
What is diaper dermatitis? What secondary infection may occur?
A
- caused by combo of wetness, pH elevation and friction
- elevated pH activates proteolytic enzymes that injure the skin
- secondary infection may occur with Candida albicans (will be in skin folds)
- if sparing skin folds - diaper dermatitis (will have erythema where diaper touches baby)
24
Q
Clinical presentation of diaper dermatitis?
A
- erythema in diaper area
- if predominantly in creases and there are satelite lesions (will appear as plaques and pustules) most likely have candidal infection as well
- need to determine if it is from wetness, irritation from the diaper or yeast infection
25
Tx of diaper dermatitis?
- w/o secondary yeast infection: frequent diaper changes, barrier tx with vaseline or Desitin
- w/ secondary yeast infection:
topical antifungal such as nystatin, miconazole or clotrimazole
barrier lubricants such as vaseline, no steroids (thin skin - systemic absorption)
26
Tx of diff types of candidiasis?
- thrush: nystatin, clotrimazole
- cutaneous:
powder for macerated areas (nystatin), clotrimazole (lotrimin), ketoconazole
- if failure to topical therapy: oral fluconazole (diflucan)
27
What is perioral dermatitis? Clinical manifestations?
- etiology: unknown but does have a strong correlation with topical steroid use
- clinical manifestations:
1-2 mm clustered erythematous papules, papulovesicles or papulopustules with or w/o scale
- occurs most often around the mouth **sparing the vermillion border
- can be asx or assoc with burning or stinging
28
Dx and findings suggestive of POD?
- dx can be made clinically
- PE supports dx
other findings suggestive of POD:
- sparing of skin adjacent to vermillion border
- co-existing feature of eczematous dermatitis
- burning/stinging
- recent use of topical, nasal or inhaled steroids
- hx of lesions worsening after withdrawal of steroids in the past
29
Tx of perioral dermatitis?
```
- may resolve on it's own
1st line:
-topical calcineurin inhibitor (pimecrolimus, protopic 1% cream)
- or topical erythomycin
- or topical metronidazole
```
for moderate to severe cases:
- systemic agents: tetracycline, doxycycline, or minocycline
* systemic therapy for kids - use erythromycin
- use combo therapy of topical and systemic (just don't use same abx)
30
What is seborrheic dermatitis? May be widespread in what pts? Caused by what?
- etiology is unknown
- may be widespread in HIV and Parkinson's disease
- erythematous scaling patches develop in areas of sebaceous glands (scalp, face, trunk)
- thought to be caused by saphrophyte infection by Malessezia (aka Pityrosporum ovale).
Colonization noted on skin of affected individuals, normal skin flora but to a lesser degree
31
What are the clinical manifestations of seborrheic dermatitis?
- erythema (reddish or pink color)
- swollen and greasy appearance
- scale (white or yellowish)
- some pruritus
- distribution:
lateral sides of nose
eyebrows
glabella
scalp
may also involve: chest, upper back, axillae
32
Dx of seborrheic dermatitis?
- usually made by PE
bx:
-mounds of parakeratotic scale around hair follicles
- mild superficial inflammatory cell infiltrate of lymphocytes
- increased number of malessezia furfur spores in stratum corneum on periodic acid schiff or gomori methenamine silver stains
33
Tx of seborrheic dermatitis depends on what?
- location
34
Tx of seborrheic dermatitis - scalp?
antiproliferative shampoo:
- T gel extra
- selenium sulfide (selsun, exelderm)
- zinc pyrithione (Head and shoulders, zincon, DHS zinc)
Antifungal shampoo:
- ketoconazole 2% (rx better than 1% OTC formulation), or ciclopirox shampoo 1%
- used 2x weekly x 4 wks then may be used periodically for maintenance
35
Tx of non-scalp seborrhea?
- 1st line: ketoconazole 2% cream or gel (BIDx 4 wks)
- ciclopirox 1% cream: BIDx 4 weeks then q day x 4 weeks
- tacrolimus 0.03% and 0.1%
- pimecrolimus 1% cream
- severe cases add low potency topical corticosteroid for 1-2 wks and taper off to QOD x 1wk
36
What is stasis dermatitis?
- occurs from blood pooling due to chronic venous insufficiency
- increased pressure in capillaries with subsequent extravasation
- hemosiderin from blood cells stain the skin
- erythema, scaling, hyperpigmentation can lead to erosions, crusts and can develop venous stasis ulcers
- may be assoc with generalized eczematous dermatitis
37
tx for stasis dermatitis?
- tx is aimed at prevention of edema and blood pooling with compression stockings and elevation of the legs
- skin cleansing, emollients, topical steroids for pruritus, wet dressings for crusts or open lesions
- need to keep skin hydrated!
- compression stockings
- keep legs elevated
38
What is lichen planus? locations?
- uncommon disorder of unknown cause - may be med induced (griseofulvin, ketoconazole, tetracyclines, ACEI, BBlockers, hydroxycholorquine, diuretics, sulfonylureas, NSAIDs, PPIs)
- MC affects middle-aged adults
- may effect:
skin (cutaneous lp)
oral cavity (oral lp)
genitalia (penie or vulvar lp)
scalp (lichen planopilaris)
nails
esophagus
39
Clinical manifestations of lichen planus? Dx?
- shiny, flat, polygonal, **violaceous papules or plaques with white lacy pattern called Wickham's striae
- white reticulate lesions occur on mucosal surfaces
- see on wrists, ankles
- intensely pruritic (very hard to tx)
- dx: bx
40
Tx of lichen planus?
- high potency or super high potency topical corticosteroids as initial tx of localized cutaneous lp on trunk or extremities
- intralesional corticosteroids can be helpful in pts with hypertrophic lp
- pts with widespread cutaneous disease may benefit from phototherapy, acitretin (oral retinoid - causes photosensitivity, only for severe cases), or short course of systemic glucocortiocoid therapy
41
What is Pityriasis rosea? Characterisitcs?
- etiology is unclear, self-limiting, likely viral source (reactivation of HHV-7 and HHV-6)
- more common in spring and fall, can mimic syphilis so get RPR if sexually active
- 1st sign is a herald patch then multiple new lesions appear usually on central trunk
- lesions are often oval with long axis paralleling the lines of skin stress
- rash may have christmas tree pattern
- lesions resolve in 6-10 weeks
- may be pruritic
- not contagious
42
Tx of pityriasis rosea?
- generally self limiting
- if needed for pruritus: medium potency topical steroid
- oatmeal baths
- acyclovir or phototherapy for severe cases
43
Greasy or yellow appearing scales, esp at margins of hair, eyebrows and facial folds are characteristic of?
- seborrheic dermatitis
44
What is the mildest form of seborrheic dermatitis?
- dandruff
45
If the lesion starts small and grows and it has central clearing - it is mostly likely what?
- fungal
46
Should you tx fungal infections with a steroid?
- NO! it will help the infection grow
47
How do you diff b/t vitiligo and tinea versicolor?
- looking carefully for scaling - this should be present in TV
48
Simple tx for fungal infection?
Dry, dry, dry!
49
Simple tx for eczema?
- hydrate, hydrate, hydrate!
50
5 p's of lichen planus?
- purple
- polygonal
- planar
- pruritic
- papules
w/ fine scales and irregular borders
- lacy lesions common in oral mucosa (wickham striae)
