Eritematodescamativas

Question 1

A 6-year-old male has a 10-day history of a rash and sore throat. The patient has had no fevers or upper respiratory symptoms. The patient has erythema of the posterior pharynx and 1- to 10-millimeter erythematous plaques over the trunk in a random pattern. A rapid strep screen is positive, and the patient is treated with antibiotics. What should the parents be told about the rash?

1. It will clear within 2 weeks and not recur
2. It will improve but may persist for life
3. It is contagious and the rest of the family will need to watch for signs of the rash
4. There will be post inflammatory depigmentation

Answer 1

2 - It will improve but may persist for life

• The small lesions with random distribution are most characteristic of guttate psoriasis.
• This condition can flare in response to streptococcal pharyngitis.
• The condition may require topical steroids and occasionally phototherapy. These patients are at risk for psoriasis vulgaris as they age.
• Guttate psoriasis is most common in people under 30 years of age and often follows an oropharyngeal or perianal streptococcal infection. The sudden onset of papular lesions following a streptococcal infection can be the exacerbation of long-standing plaque psoriasis or the initial presentation of guttate psoriasis. Guttate psoriasis is nonscarring and often runs a limited course over a few months.

Question 2

A 65-year-old male complains that an abdominal wound has not healed properly several months after surgery. On clinical examination, the clinician observes a well-demarcated linear, erythematous, and scaly plaque at the site of the excision. General physical examination reveals scaly plaques in his scalp and irregular pitting of two fingernails. A biopsy of the skin plaques surrounding the wound was taken and sent for histopathology, which demonstrated spongiform pustules, microabscesses with the neutrophil collection in the upper epidermis. Histopathology also reveals orthokeratosis and tortuous dilated papillary capillaries. Which of the following is the most likely diagnosis?

1. Lichen planus
2. Wound infection
3. Stitch granuloma
4. Psoriasis

Answer 2

4 - Psoriasis

• Koebnerisation is the development of skin diseases such as psoriasis, lichen planus, or vitiligo at the site of trauma, which can range from a superficial scratch to a full-thickness surgical wound. Psoriasis is suspected when a persistent circumscribed erythematous plaque with a silvery scale appears at the site of the scar within a few weeks of surgery.
• When considering a diagnosis of psoriasis, examine the common sites for the disease such as the scalp, elbows, and knees. Scalp psoriasis may be suspected when scaling is very persistent and does not relieve with an antidandruff shampoo.
• Nail involvement occurs in 40% of patients with psoriasis and maybe its first and only site. Signs in one, several, or all nails may include irregular pitting, ridging, nail plate thickening, onycholysis, subungual hyperkeratosis, and yellowish discoloration. Psoriatic nail dystrophy is a risk factor for psoriatic arthritis of the finger and toe joints.
• Patients with chronic plaque psoriasis should be educated about their skin condition, its management, and the lack of curative treatment. They should be assessed for comorbidities such as inflammatory arthritis, metabolic syndrome, and diabetes mellitus.

Question 3

A pregnant patient has an extensive pustular eruption that forms along the margins of erythematous patches. What is the most likely diagnosis?

1. Generalized pustular psoriasis
2. Pruritic urticarial papules and plaques of pregnancy
3. Prurigo gravidarum
4. Intrahepatic cholestasis of pregnancy

Answer 3

1 - Generalized pustular psoriasis

• Generalized pustular psoriasis is a rare pustular eruption that forms along the margins of erythematous patches. It can arise in pregnancy.
• Generalized pustular psoriasis was formerly known as impetigo herpetiformis, but it has no relation to either impetigo or herpes infections.
• Generalized pustular psoriasis is characterized by recurrent, acute flares. The skin becomes dry, fiery red, and tender. Within hours, 2 mm to 3 mm pustules appear and after a day, the small pustules coalesce to form pustular lakes. These dry out and peel to leave a glazed smooth surface where new crops of pustules appear. Successive crops of pustules appear and erupt every few days or weeks.
• Flares of generalized pustular psoriasis may result in chills, fever, headache, tachycardia, decreased appetite, nausea, vomiting, and muscle weakness. Remission may occur within days or weeks and the skin eventually reverts to its previous state or erythroderma may develop. Relapses are common.

Question 4

A 59-year-old man presents with complaint of diffuse rash. He states he initially developed dry flaking scalp that ‘came up overnight’ and spread to involve his entire head about four weeks ago. He has been using over the counter pyrithione zinc shampoo with no improvement. About two weeks ago, he developed a bumpy red rash on the top of his fingers followed by a diffuse red rash on the chest, back, and abdomen. On exam, the temperature is 98.6 degrees Fahrenheit, blood pressure 118/78 mmHg, heart rate 80 beats per minute, respiratory rate 14 breaths per minute. There is a diffuse, well-demarcated red-orange plaque with prominent follicular hyperkeratosis on chest, abdomen, back, and extremities with intervening areas of normal skin and orange hyperkeratotic scale on palms and soles. What is the most appropriate first-line systemic treatment for this disease?

1. Phototherapy
2. Oral retinoid
3. Oral corticosteroids
4. Allopurinol

.

Answer 4

2 - Oral retinoid

• Clinical timeline for pityriasis rubra pilaris (PRP) varies based on disease subtype. In many cases, PRP is self-limited and asymptomatic therefore does not necessarily require treatment.
• Treatment often involves a combination of topical and systemic therapy.
• The generally accepted first-line systemic agents for both adults and children are oral retinoids. Oral isotretinoin, 1 to 1.5 mg/kg/day, has been shown to induce clearance in as little as 3 to 6 months.
• Methotrexate, TNF-alpha inhibitors, secukinumab, ustekinumab, and phototherapy along with numerous other medications have shown some promise in small studies and case reports.

Question 5

A 59-year-old man presents with the complaint of diffuse rash. He states he initially developed dry flaking scalp that “came up overnight” and spread to involve his entire head about 4 weeks ago. He has been using over the counter pyrithione zinc shampoo with no improvement. About 2 weeks ago, he developed a bumpy red rash on the top of her fingers followed by a diffuse red rash on the chest, back, and abdomen. He denies recent illness or new medication use. On exam, temperature 98.6 degrees Fahrenheit, blood pressure 118/78 mmHg, heart rate 80 beats per minute, respiratory rate 14 breaths per minute. There is a diffuse, well-demarcated red-orange plaque with prominent follicular hyperkeratosis on chest, abdomen, back, and extremities with intervening areas of normal skin and orange hyperkeratotic scale on palms and soles. What is the most likely diagnosis?

1. Psoriasis
2. Seborrheic dermatitis
3. Pityriasis rubra pilaris
4. Allergic contact dermatitis

Answer 5

3 - Pityriasis rubra pilaris

• Pityriasis rubra pilaris (PRP) is a rare inflammatory papulosquamous disorder of unknown etiology.
• Cardinal features that appear across subtypes in variable degrees include red-orange papules and plaques with classic “islands of sparing,” hyperkeratotic follicular papules and palmoplantar hyperkeratosis.
• Overlapping features especially early on may overlap with and should be distinguished from seborrheic dermatitis and psoriasis.
• Complications include erythroderma with greater than 90% body surface area involvement in some cases.

Question 6

A 65-year-old man has a long history of stable chronic plaque psoriasis. He presents with an exacerbation of psoriasis, which is extending to new sites and causing more itch than usual. She also has a past medical history of hypertension for which was taking a combination drug, including valsartan and hydrochlorothiazide. Recently, her clinician changed her medication for hypertension. Which of the following medications started a few weeks earlier may have caused his psoriasis to flare?

1. Losartan
2. Metoprolol
3. Furosemide
4. Aspirin

Answer 6

2 - Metoprolol

• Chronic plaque psoriasis is a common skin condition characterized by persistent circumscribed, erythematous, and scaly plaques.
• Exacerbations of psoriasis can be due to injury, surgery, an infection, metabolic factors, psychological stress, alcohol, and smoking.
• Drugs that can precipitate or aggravate chronic plaque psoriasis include antimalarials, beta-blockers, bupropion, calcium channel blockers, captopril, fluoxetine, glyburide, granulocyte colony-stimulating factor, interferon, interleukins, lipid-lowering drugs, lithium, penicillin, and terbinafine.
• Any medication which may have caused psoriasis to develop or deteriorate, it should be discontinued. It may take weeks to months for psoriasis to improve once the causative drug has been withdrawn, and standard treatments for psoriasis should be prescribed.

Question 7

A male patient with no significant past medical history presented with a 7-day history of a rash involving the face and upper chest. Physical examination revealed an exudative and superinfected papulovesicular eruption of the face and upper chest with cutaneous necrosis in some areas. The image is below. Keratotic brownish papules covered with a sticky, greyish crust mostly were distributed on the face, chest, breasts, and middle and lower back. What is the diagnosis?

1. Impetigo
2. Kaposi varicelliform eruption in association with Darier disease
3. Photodermatosis
4. Kaposi varicelliform eruption in association with pemphigus foliaceus

Answer 7

2 - Kaposi varicelliform eruption in association with Darier disease

• Kaposi varicelliform eruption refers to a disseminated skin infection due to a virus.
• Kaposi varicelliform most commonly is caused by a disseminated herpes simplex virus infection in patients suffering from atopic dermatitis.
• Other skin diseases also have been reported in association with Kaposi varicelliform eruption such as Darier disease and pemphigus foliaceus.
• Darier disease is a genodermatosis. It is characterized by greasy hyperkeratotic papules in seborrheic regions, changes in mucous membranes, and nail abnormalities. It is an autoimmune skin disorder. The formation of superficial blisters characterizes pemphigus foliaceus.

Question 8

A 40-year-old male patient with no significant past medical history presents to his primary care physician’s office with complaints of pain and swelling of his fingers in both of his hands for the last two months. He also reports that his fingers feel stiff in the morning which improves with activity. Physical examination demonstrates tenderness and swelling of the distal interphalangeal joints of his hands. No other joint involvement is present. Skin examination shows scattered erythematous plaques on the extensor surface of his arms and legs. Which of the following will also be found in this patient?

1. “Pencil in cup deformity” of the distal interphalangeal joints on X-ray
2. A recent diarrheal illness caused by Campylobacter
3. Recent unprotected sex with a new partner
4. Recent pharyngitis

Answer 8

1 - “Pencil in cup deformity” of the distal interphalangeal joints on X-ray

• This 40-year-old male with pain and stiffness in his distal interphalangeal joints that improves with movement and erythematous plaques on the extensor surface of his arms and legs likely has psoriatic arthritis. Psoriatic arthritis is an inflammatory arthritis that occurs in up to 30% of patients with psoriasis skin disease.
• Psoriatic arthritis can affect peripheral and axial joints. It most frequently presents as polyarthritis with several patterns of joint involvement including distal arthritis (involvement of distal interphalangeal joints), asymmetric oligoarthritis (less than 5 joints affected in an asymmetric fashion), symmetric polyarthritis (closely resembling rheumatoid arthritis), or arthritis mutilans (deforming and destructive arthritis).
• It presents as joint pain, swelling, and morning stiffness that lasts >30 mins and improves upon moving the affected joints. On physical examination, joint line tenderness and joint effusions are present. 70% of patients have a history of psoriatic skin disease and 15% of patients will have active psoriatic skin lesions upon diagnosis of psoriatic arthritis. Psoriatic skin lesions present as well-demarcated, erythematous plaques with silver scales on the extensor surfaces (eg. knees, elbows). Other physical examination findings include nail pits (depressions on the nails), pitting edema of hands and feet, uveitis, conjunctivitis, enthesitis, tenosynovitis, and dactilitis.
• A common X-ray finding in psoriatic arthritis is “pencil in cup deformity” of the distal interphalangeal joints (due to periarticular bone erosions and resorption resembling a pencil in a cup).