Miscellaneous Skin Conditions Flashcards
Epidemiology of Psoriasis
Men = Females
Hereditary
More prevalent further from the equator
Pathophysiology of Psoriasis
Cell turnover: 4 days
Normal cell keratinization does not take place
Subnormal blood vessel dilation
Autoimmune component: T lymphocytes
Psoriasis Risk Factors
Family Hx
Strep infection can trigger guttate psoriasis
Medications: beta blockers, lithium, anti-malaria
Smoking, obesity, & alcohol
Vitamin D deficiency?
Presentation of Psoriasis
Bimodal age distribution: 30-39, 50-69
Gradual or sudden in onset
Pruritus common
Hx of improvement with sun exposure
Associated Conditions with Psoriasis
Psoriatic arthritis CV disease Malignancy DM Metabolic syndrome HTN IBD Serious Infections Ocular involvement: swollen lids, conjunctivitis, xerosis, uveitis
Types of Psoriasis
Plaque Inverse Guttate Erythrodermic Pustular Nails
Where does plaque psoriasis typically appear?
Knees Scalp Elbows Lower back Can affect the nails
Plaque Psoriasis Presentation
Salmon pink papule & plaques
Sharply marginated with marked silvery-white scaling
Scales are loose, easily removed by scratching
Auspitz sign
Koebner’s phenomenon
Define Auspitz Sign
Pinpoint bleeding under the scale
Define Koebner’s Phenomenon
Psoriasis plaques that form at the site of a skin injury
Occurs 1-2 weeks after injury
What can Koebner’s phenomenon occur from?
Bug bites Bruises & scrapes Poison ivy or poison oak Burns (sun & chemical) Constant pressure & rubbing Injections or vaccinations Skin blemishes from acne, herpes, or chickenpox Acupuncture or tattoo needles
Distribution of Psoriatic Lesions
Symmetrical
Favors elbows, knees, intertriginous areas
Can be localized or all over the body
Extensor surfaces
Inverse Psoriasis Locations
Axilla Groin Naval Submammary region Palms Scalp Soles
Inverse Psoriasis Characteristics
Common in overweight persons
No scales
Biopsy to differentiate from candidiasis
Define Guttate Psoriasis
Eruptive psoriasis
Characteristics of Guttate Psoriasis
Small teardrop shape erythematous papule
Scattered diffusely on proximal extremities & trunk
Treatment of Guttate Psoriasis
Self limiting (weeks to months)
Erythrodermic Psoriasis Presentation
Erythema & scaling head to toe
Inflammatory
Severe pruritis & pain as skin reddens & sheds
What is erythrodermic psoriasis have a high risk of?
Systemic infection
Electrolyte imbalances
Presentation of Pustular Psoriasis
Acute onset Widespread erythema, scaling, & sheets of pustules with erosions Malaise Fever Diarrhea Leukocytosis Hypocalcemia
WHICH SKIN conditions can be life-threatening?
Erythrodermic psoriasis
Pustular psoriasis
Pemphigus
Bullous Pemphigoid
Nail Psoriasis
Associated with psoriatic arthritis
Appear before onset of cutaneous psoriasis
Presentation of Nail Psoriasis
Nail pitting
Oil drop sign
Subungual hyperkeratosis
Treatment of Plaque Psoriasis
Exacerbating factors
Topical therapy
Systemic therapy
Drugs That May Exacerbate Psoriasis
Beta-blockers NSAIDs Lithium ACEi Digoxin
Topical Therapy for Plaque Psoriasis
Emollients Steroids Vitamin D analogues Topical retinoids Calcineurin inhibitors Coal tar preparations Phototherapy: UVA, UVB
MOA of Emollients
Hydrate stratum corneum
Decrease water evaporation
Soften the scales
Examples of Emollients
Eucerin
Lubriderm
Moisturel
Education of Emollients
Apply after bathing while skin is still damp
What is first line for plaque psoriasis?
Topical steroids
What are topical steroids used in conjunction with?
Topical vitamin D analoge
Topical retinoid
UVB therapy
When do you use Calcipotriol (Dovonex), a vitamin D analogues?
Mild to moderate plaque psoriasis
SE of Calcipotriol (Dovonex)
Hypercalcemia
Hypercalcuria
Where can you not use Calcipotriol (Dovonex)?
Face
Groin
Example of a Vitamin D Analogue
Calcipotriol
Example of a Vitamin A Derivative
Tazarotene (Tazorac)
MOA of Tazarotene (Tazorac)
Modulates differentiation & proliferation of epithelial tissue
Exerts some degree of anti-inflammatory & immunological activity
Examples of Topical Calcineurin Inhibitors
Tacrolimus (Protopic)
Pimecrolimus (Elidel)
MOA of Topical Calcineurin Inhibitors
Inhibt T-lymphocyte activation by binding to an intracellular protein & complex with calcineurin dependent proteins to inhibit calcineurin phosphatase activity
Coal Tar Topical Preparations
Enhance effects of UVB therapy
OTC
Stains clothes & odor
Add-od therapy
MOA Phototherapy
Anti-proliferative effects by slowing keratinization & anti-inflammatory effects by inducing apoptosis of pathogenic T-cells
Systemic therapy for psoriasis
Methotrexate Acetretin: Psoriatane Systemic calcineurin inhibitor: cyclosporine Infliximab (Remicade) Hydroxyurea Azathiprine
Define Urticaria
Hives
Immune mediated skin eruption of well-circumscribed wheals on an erythematous base
Define Angioedema
Hypersensitivity reaction involving the deep layers of the skin
Where does angioedema usually occur?
Lips Eyelids Palms Soles Genitalia
Pathophysiology of Urticaria & Angioedema
Allergen
IgE antibody attached to mast cell
Sudden release of immunologic mediators
Inflammation
Presentation of Urticaria
Characteristic edematous, erythematous, well-circumscribed blanching wheals
Serpiginous borders
Define Dermatographism
Gentle stroking of the skin produces immediate wheal & far response
Define Pressure Urticaria
Pressure to skin at right angle results in red swelling after latent period of up to 4 hours
Define Cold Urticaria
Eruptions within minutes following application of cold
Define Cholinergic Urticaria
Punctate hives triggered by exercise or hot shower
Define Aquagenic Urticaria
Hives after contact with water
Define Solar Urticaria
Hives develop following exposure to UV light
Management of Urticaria & Angioedema
Avoidance of etiologic agents
Avoidance of substances that may aggravate: ASA, NSAIDs, ETOH, ACEi
Symptomatic Relief for Urticaria & Angioedema
Antihistamines: H1-blockers, H2-blockers, Doxepin (Sinequan)
Steroids: systemic or local
SubQ Epinephrine: anaphylaxis
Important Principles of Urticaria & Angioedema
Chronic urticaria can be frustrating EDUCATION Investigate for thyroid or H. pylori Epipen Referral to allergist
Where do vitiligo lesions occur?
Face Upper trunk Finger tips Hands Arm pits Genitalia Bony prominences Perioral region
Define Vitiligo
Destruction of melanocytes
Pathophysiology of Vitligo
Autoimmune: antibodies to melanocytes
Occurs with pernicious anemia & Hashimoto’s thyroiditis
Treatment of Vitiligo
Some regimentation with topical steroids, tacrolimus, psoralens, UVA, UVB, surgical skin grafting
Need psychological support
Describe Pemphigus
INTRA-epidermal blistering secondary to an autoimmune process
Define Pamphigus
Chronic, potentially fatal disease of the mucous membranes & skin
Clinical Presentation of Pemphigus
Flaccid bullae
Bullae tender & painful
Nikolsky’s sign
Skip biopsy
Where are the bullae most present?
Oropharynx Scalp Face Chest Axillae Groin
Treatment of Pemphigus
Recognize & refer
Hospital admission
Systemic steroids & immunosuppressives
Define Bullous Pemphigoid
Chronic, SUB-epidermal blistering autoimmune disease
Common Presentation of Bullous Pemphigoid
Widespread blistering eruption
Epidemiology of Bullous Pemphigoid
Triggered by drug reaction or infection
Exclusively in the elderly (>60)
Increased mortality
Describe Blisters of Bullous Pemphigoid
Tense
Fluid filled
Treatment of Bullous Pemphigoid
Recognize & refer
1st: topical high dose or oral steroids
Immunosuppressants (maybe)
Synonyms of Epidermoid Cyst
Sebaceous cyst
Infundibular cyst
Epidermal cyst
Cutaneous cyst
Describe Epidermoid Cyst
Cystic enclosure of epithelium
Cysts filled with keratin & lipid-rich debris
Rupture common: painful inflammatory mass
May be secondarily infected
Define Dermatofibroma
Button-like dermal nodule
Lesion may be tender
Define Lipoma
Soft, rounded, & movable against the overlying skin
Composed of fat cells
