Misc Skin Conditions Flashcards
Psoriasis
- normal cell turnover vs cell turnover in psoriasis
- what is this
- cause
- MC age
- onset
- MC sx
-normal cell turnover is about 27 days, but in posriasis, cell turnover is reduced to about 4 days
What
- massive increase in the number of cells produced and normal cell keratinization does not take place
- subdermal blood vessel dilation (erythema)
Cause:
- autoimmune component: multiple T cells are present in psoriatic lesions, therapies that suppress T cells are very effective
- strep infection can trigger guttate psoriasis
Age
-Early 30-39 years or late 50-69 years
Onset
-gradual or sudden
MC sx
-pruritus
Psoriasis
- associated conditions
- types
- MC type
Associated conditions
- psoriatic arthritis
- CV disease, malignancy, DM, metabolic syndrome, HTN, IBD
- ocular involvement: swollen lids, conjunctivitis, xerosis, uveitis
Types
- plaque (MC)
- inverse
- guttate
- erythrodermic
- pustular
- nails
Plaque psoriasis
- onset
- distribution
- presentation
Onset
-slow-forming, stable
Distribution
- appears on the knees, scalp, elbows, lower back and can affect the nails
- symmetrical
- uncommon on the face
- can be a single lesion, can be localized, can be widespread
presentation
- well defined and symmetrical
- salmon pink papules and plaques, sharply marginated with marked silvery-white scaling
- scales are loose and easily removed by scratching
- removal of scales results in small blood droplets (Auspitz sign)
- plaques at sites of former skin injury (Koebner’s phenomenon
What is Auspitz sign?
what is Koebner’s phenomenon?
Auspitz sign=pinpoint bleeding under the scale
Koebner’s phenomenon= psoriasis plaques that form at the site of skin injury (from bug bites, bruises or scrapes, burns, poison ivy)
Inverse psoriasis
- distribution
- MC in who
- presentation
Distribution
- found in axilla, groin, naval, submammary region, palms, scalp, soles
- sharply demarcated plaques
MC in overweight people
Presentation
- No scales (unlike plaque psoriasis)
- difficult to distinguish from candidiasis without bx
Guttate psoriasis
- AKA
- onset
- MC in who
- strong association with what?
- presentation
- distribution
- prognosis
- AKA
- -eruptive psoriasis
- onset
- -abrupt onset
- MC in who
- -young adults and children
- strong association with what?
- -recent strepococcal infection (usually pharyngitis) in the preceding 2-3 weeks
- presentation
- -multiple small teardrop shaped erythematous papules
- may have scale
- distribution
- -scattered diffusely on the proximal extremities and trunk
- prognosis
- self limiting in a few weeks to months
Erythrodermic psoriasis
- distribution
- presentation
- high risk of what
- management
Distribution
-generalized, affects most or all of the bodys surface
Presentation
- erythema and saling from head to toe
- inflammatory
- severe itching and pain as skin reddens and sheds
High risk of systemic infection and electrolyte imbalances
- difficult to distinguish from SJS, history will help.
- you don’t have to have psoriasis to get this
- LIFE THREATENING****
Management
-inpatient
Pustulat psorisasis
- distribution
- onset
- presentation
- associations
Distribution
-generalized
Onset
-acute
Presentation
- severe form of psoriasis with LIFE THREATENING complications
- widespread erythema, scaling, and sheets of superifical pustules with erosions
Associations with
-malaise, fever, diarrhea, leukocytosis, hypocalcemia
MC precipitating factor for erythrodermic and pustular psoriasis?
Withdrawal of systemic corticosteroids :/ :/ ;(
Nail psoriasis
- closely associated with?
- may appear before the onset of?
- what is the oil drop sign?
- closely associated with psoriatic arthritis
- may appear before the onset of cutaneous psoriasis
- oil drop sign=translucent discoloration in the nail bed that resembles a drop of oil beneath the nail plate
Treatment of plaque psoriasis
-exacerbating factors (what can you do to help with these)
- Some drugs may exacerbate psoriasis, such as: beta blockers, NSAIDs, lithium, ACEI, digoxin
- consider switching med if possible
Treatment of plaque psoriasis
-topical therapy options and ex of each
Emollients
- hydrate stratum corneum
- decrease water evaporation
- soften scales on plaques
- ex. eucerin, lubriderm, moisturel
Steroids(topical)
- first line***
- use as long as pt has thick active lesions
- ex. betamethasone 0.05%, clobetasol propionate 0.05%
Vitamin D analogues
- Calcipotriol (Dovonex)
- causes immune modulation
- too irritating for face or groin
- SE=hypercalcemia/uria
Topical retinoids
- Tazarotene (Tazorac)
- modulates differentiation and proliferation of epithelial tissue and exerts some degree of anti-inflammatory and immunological activity
Calcineurin inhibitors
- ex. Tacrolimus (Protopic) or Pimecrolimus (Elidel)
- inhibits T lymphocyte activation
- good for intertriginous areas and the face (where steroid use should be limited)
Coal tar preparations
- when used alone only as effective as mild to midpotency topical steroids
- OTC, shampoos beneficial for scalp lesions in combination with topical steroid solutions
- use is limited d/t odor and staining of clothes
Phototherapy (UVA, UVB)
-has antiproliferative effects by slowing keratinization and anti-inflammatory effects by inducing apoptosis of pathogenic T-cells
Treatment of plaque psoriasis
-systemic therapy
*use only for severe cases resistant to topical tx
- methotrexate
- acetretin (systemic retinoid)
- -psoriatane
- systemic calcineurin inhibitor
- -cyclosporine
- biologic agents
- -infliximab (remicade)
- other immunosuppressants
- -hydroxyurea
Urticaria
- what is this?
- presentation
Angioedema
-what is this
Pathophysiology of both
Urticaria
- immune mediated skin eruption of well-circumscribed wheals on an erythematous base, IgE mediated
- presentation: edematous, erythematous, well circumscribed blanching wheals
Angioedema
-hypersensitivity reaction involving the deep layers of the skin. Swelling of the lips, eyelids, palms, soles, genitals
Patho
- allergen…IgE antibody attached to mast cell…sudden release of immunologic mediators…inflammation
- principle mediator released by mast cells is histamine
*idiopathic chronic urticaria thought to be caused by autoimmune process
Types of physical urticarias
- dermatographism: gentle stroking of the skin produces immediate wheal and flare response
- pressure urticaria: pressure to skin at right angle result in red swelling after latent period of up to 4 hours
- cold urticaria: eruptions within minutes following application of cold
- cholinergic urticaria: punctate hives triggered by exercise or hot shower
- aquagenic urticaria: hives after contact with water
- solar urticaria: hive develop following exposure to UV light
Urticaria associations
- autoimmune disease: theory to describe the idiopathic cases of chronic urticaria that are encountered
- infectious disease: sx tend to occur in prodromal phase of hep B and some correlation with h pylori
- consider testing the thyroid (because it says so)
Urticaria/angioedema
-management
- avoid etiologic agents if identified
- avoid substances that aggravate (ASA, NSAIDs, ETOH, ACEI)
- antihistamines
- steroids
- subQ Epi for severe attacks
- allergist referral
Vitiligo
- age of onset
- distribution
- patho
- tx
Age
-onset usually in early life (age 20-30)
Distribution
- face, upper trunk, fingertips, hands, ,arm pits, genitalia, bony prominences, and perioral region
- hair involed may be white
Patho
- autoimmune mechanism with formation of antibodies to melanocytes
- often occurs with pernicious anemia and hashimotos thyroiditis
Tx
- repigmentation by:
- -topical steroids
- -tacrolimus
- -psoralens
- -UVA, UVB
- -surgical skin grafting
- long process, requires pt commitment
- may require psych support
Pemphigus
- what is this?
- mortality rate
- presentation
- dx
- tx
What
- rare, chronic, potentially fatal disease of the mucous membranes and skin
- INTRAEPIDERMAL blistering secondary to an autoimmune process
Mortality rate: high as 5%
Presentation
- FLACCID* bullae that often begin in the oropharynx and then may spread to involve the scalp, face, chest, axillae, and groin
- bullae are tender and painful
- Nikolsky sign:a skin finding in which the top layers of the skin slip away from the lower layers when slightly rubbed.
Dx
-bx required for dx
Tx
- recognize and refer
- hospital admission
- corticosteriods and immunosuppressives (since its an autoimmune process)
Bullous Pemphigoid
- what is this
- cause
- MC in who
- MC presentation
- mortality
- dx
- tx
What
-chronic, SUBEPIDERMAL blistering autoimmune disease
Cause
-may possibly be triggered by a drug reaction or infection
MC in the elderly
MC presentation
- widespread blistering eruption
- blisters are tense and fluid filled
Mortality
-increased…
Dx
-skin bx
Tx
-may require immunosuppressants
Epidermoid Cyst
-AKA
-how does this form?
-
AKA- sebaceous cyst, infundibular cyst, epidermal cyst
Formation
-cystic closure of the epithelium… becomes filled with keratin and lipid rich debris…rupture may result…may become secondarily infected
Dermatofibroma
-presentation
- very common, button like dermal cyst
- lesion may be tender
- benign
Lipoma
- what is this
- presentation
- composition
What
-benign subcutaneous tumors
Presentation
-soft, rounded, and moveable against the overlying skin
Composition
-fat cells that have the same morphology as normal fat cells
what is the most important thing for the PCP to know about vitiligo?
it often occurs in the presence of other autoimmune conditions
an epidermal mass will feel more ___ while a subQ mass will generally be more ___.
an epidermal mass will feel more FIXED while a subQ mass will generally be more mobile.
