MISCELLANEOUS SKIN CONDITIONS Flashcards
- benign SUBCUTANEOUS tumor
- soft, rounded and movable against overlying skin
LIPOMA
lipomas are composed of
fat cells that have the same morphology as normal fat cells
an autosomal dominant trait appearing in early adulthood where an individual may have hundreds of lipomas
Familial Lipoma Syndrome
very common, button-like dermal nodule
dermatofibroma
- lesion may be tender
- benign, but can be confused with dangerous lesions
epidermoid cyst can also be called
sebaceous cyst
infundibular cyst
epidermal cyst
most common cutaneous cyst
epidermoid cyst
how does an epidermoid cyst form
- derived from epidermis or epithelium of a hair follicle
- formed by cystic enclosure of epithelium; becomes filled with keratin & lipid-rich debris
- rupture is common, and may result in painful inflammatory mass
- may become secondarily infected, communicates with skin
usual onset of vitiligo
20s-30s
where do vitiligo lesions primarily occur
lesions primarily occur on the face, upper trunk, fingertips, hands, armpits, genitalia, bony prominences and perioral region
hair may appear white in those areas
PATHOPHYS OF VITILIGO
autoimmune - formation of antibodies to melanocytes
**Vitiligo often occurs in the context of other autoimmune conditions such as
⦁ Pernicious anemia
⦁ Hashimoto’s thyroiditis
VITILIGO TREATMENT
TREATMENT
- re-pigmentation can be achieved to variable degrees with
⦁ topical steroids
⦁ tacrolimus
⦁ Psoralens = light-sensitive drug that absorbs UV
⦁ UVA / UVB
⦁ surgical skin grafting
- treatment = a long process that requires patient commitment
- may need psychological support
- rare, chronic, potentially fatal disease of the mucous membranes and skin
- Intraepidermal blistering secondary to an autoimmune process
PEMPHIGUS
PEMPHIGUS = ____________ blistering secondary to an autoimmune process
INTRAEPIDERMAL
diagnosis of pemphigus
biopsy
pemphigus rash
starts out as FLACCID BULLAE in the oropharynx, then may spread to face, scalp, chest, axillae, groin
the bullae are tender and painful
Nikolsky sign (superficial detachment of skin under pressure - pulls off in sheets)
pemphigus vulgaris (but not bullous pemphigoid)
also with SJS / TEN
starts out as FLACCID BULLAE in the oropharynx, then may spread to face, scalp, chest, axillae, groin
the bullae are tender and painful
pemphigus vulgaris
treatment for pemphigus
- recognize & refer!
- may require hospital admission for severe dz
- treat with systemic corticosteroids & immunosuppressives
⦁ 1st line = high-dose corticosteroids!
⦁ immunosuppressives: MTX**, azathioprine, cyclophosphamide, etc
- local wound care (treat like burns), treat 2ndary infections with antibiotics
_________ is intraepidermal blistering
_________ is subepidermal blistering
pemphigus vulgaris = intraepidermal
bullous pemphigoid = subepidermal
________ occurs more in younger patients (30s-40s)
__________ occurs almost exclusively in older patients (>60)
pemphigus vulgaris
bullous pemphigoid
pemphigus vulgaris = younger (30s-40s) & is intraepidermal
bullous pemphigoid = older (>60) & is subepidermal (so no nikolsky sign)
most common presentation of bullous pemphigoid
widespread blistering eruption
bullous pemphigoid rash
- *NO NIKOLSKY SIGN (unlike pemphigus vulgaris) - more urticarial plaques with tense bullae that don’t rupture easily
- have associated urticarial plaques; blisters are tense and fluid filled
Diagnosis = biopsy required
diagnosis of bullous pemphigoid
biopsy
treatment of bullous pemphigoid
- recognize & refer!
- 1st line = topical high dose steroids (preferred) or oral steroids
- may require immunosuppressants
urticaria is _________ mediated
IgE
- hives
- immune-mediated skin eruption of well-circumscribed wheals on an erythematous base
urticaria
- hypersensitivity reaction involving the deep layers of the skin
- swelling of the lips, eyelids, palms, soles and genitalia
ANGIOEDEMA
if pt has urticaria, be on the lookout for
angioedema…and vice/versa
⦁ 50% urticaria + angioedema
⦁ 40% urticaria alone
⦁ 10% angioedema alone
PATHOPHYS OF URTICARIA & ANGIOEDEMA
PATHOPHYS: allergen exposure –> IgE antibody attaches to mast cell –> sudden release of histamine –> inflammation
⦁ principle mediator released by mast cells = HISTAMINE**
Idiopathic chronic urticaria thought to be caused by ___________ process
autoimmune
edematous, erythematous, well-circumscribed blanching wheals
hives / urticaria
- can range from a few mm to several cm in diameter
- has serpiginous borders
- lesions may persist for 12-24 hours, but most resolve sooner than this
- has serpiginous borders
hives / urticaria
URTICARIA DUE TO FOOD OR DRUGS
⦁ attacks tend to be brief
⦁ usually do NOT cause chronic urticaria
⦁ may be accompanied by angioedema
PHYSICAL URTICARIAS (different types)
⦁ Dermatographism - gentle stroking of skin produces immediate wheal & flare response
⦁ Pressure Urticaria = pressure to skin @ right angle –> 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 = hives after exposure to UV light
theory to describe the idiopathic cases of chronic urticaria that occur
AUTOIMMUNE disease potentially…
ASSOCIATION OF URTICARIA & INFECTIOUS DISEASE
- hep B
- h. pylori
urticarial symptoms occur during prodromal phase of Hepatitis B**
There are reports that some patients with chronic “idiopathic” urticaria had resolution of symptoms following treatment for Helicobacter pylori infection
goal of urticaria / angioedema
Goal = identify a specific cause or precipitant
Key to the evaluation of urticaria / angioedema is a
thorough history (much more important than the physical)
substances that may aggravate urticaria / angioedema
ASA, NSAIDS, ETOH, ACEI
management of urticaria / angioedema
MANAGEMENT = avoid the etiologic agent(s) if identified, and avoid substances that may aggravate the condition (ASA, NSAIDS, ETOH, ACEI)
empiric measures for symptomatic relief of urticaria / angioedema
o Antihistamines
⦁ sedating and/or non-sedating H1-blockers (Diphenhydramine, fexofenadine)
⦁ refractory (stubborn) cases = H2-blockers (Ranitidine)
⦁ Doxepin (Sinequan) = TCA with some H1 & H2 blocking activity
o Steroids = systemic or local: generally reserved after a trial of max antihistamine doses
o SubQ Epi = for severe attacks (anaphylaxis rxn)
h. pylori association with urticaria
⦁ It is thought that infection with H. pylori increases the permeability of the stomach lining and thus increases the exposure to allergens in the GI tract
If the mass (usually a cyst) is epidermal, it is going to feel more ______. If subcutaneous, generally _______
fixed = epidermal
mobile = subcutaneous
often occurs in the context of other autoimmune conditions such as pernicious anemia and hashimoto’s thyroiditis.
vitiligo
if urticaria = consider checking for
thyroid dz
h. pylori
hep B
the principle mediator of the inflammation with urticaria and angioedema is
HISTAMINE
which is why one of the staple treatments = antihistamines
psoriasis is more prevalent the further away from the
equator
biggest risk factor for psoriasis
family hx!
psoriasis is HEREDITARY
40% of patients have a 1st degree relative with psoriasis or psoriatic arthritis
PATHOPHYS OF PSORIASIS
- patients have increased cell turnover (usual cell turnover = 27 days, but in psoriasis = 4 days)
- have a massive increase in number of cells produced & normal cell keratinization does not take place
- Subdermal blood vessel dilation also seen –> contributes to the erythema
autoimmune component = buildup of T cells in psoriatic lesions. Have excess of T cells & dendritic cells in psoriatic lesions, so treatment = T-lymphocyte suppressants
can trigger guttate psoriasis
strep infxn
which medications are risk factors for psoriasis
beta blockers
lithium
anti-malarial medications
risk factors for psoriasis
⦁ family hx
⦁ strep infection - can trigger guttate psoriasis
⦁ medications - beta blockers, lithium, anti-malarial meds
⦁ smoking
⦁ obesity
⦁ alcohol
⦁ vitamin D deficiency?
hx of improvement of psoriasis with
sun exposure
presentation of psoriasis
- bimodal age distribution
⦁ early = 30-39
⦁ late = 50-60 - can also occur in children, but less common than in adults
- may be gradual in onset or sudden
- pruritus = common
- hx of improvement with sun exposure
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CONDITIONS THAT ARE OFTEN ASSOCIATED 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
most common type of psoriasis
plaque
AUSPITZ SIGN
psoriasis
removing scales results in small blood droplets
pinpoint bleeding under the scale
KOEBNER’S PHENOMENON
Plaques develop at sites of former skin injury
this isn’t specific to plaque psoriasis, can occur with eczema, etc.). Up to 50% of patients may experience this; get plaques at sites of injury 1-2 weeks after injury
- may occur from ⦁ bug bites ⦁ bruises / scrapes ⦁ poison ivy / poison oak ⦁ burns (chemical or sunburn) ⦁ constant pressure / rubbing, medical processes such as injections or vaccinations, skin blemishes from acne, herpes or chickenpox, or from acupuncture / tattoo needles
PSORIATIC LESION DISTRIBUTION
- often symmetrical
- favors elbows / knees / intertriginous areas
- uncommon on the face
- can be single lesions, lesions localizied to one area, or over entire body
INVERSE PSORIASIS
- sharply demarcated plaques - found in axilla, groin, naval, sub-mammary region, palms, scalp, soles
- no scales, like plaque psoriasis
- more common in overweight persons
- difficult to distinguish from candidiasis without biopsy (even in same areas as candidiasis)
psoriasis that occurs in young adults / children
guttate psoriasis
is abrupt in onset
also called eruptive psoriasis
strong association with recent strep infection
guttate psoriasis
have multiple small tear-drop shaped erythematous papules
guttate psoriasis
guttate psoriasis locations
proximal arms & trunk
not classically on elbows / knees / scalp
psoriasis with no scales
inverse psoriasis
guttate psoriasis
- also known as eruptive psoriasis = abrupt onset
- characteristically occurs in young adults & children
⦁ ***strongly associated with recent STREP INFECTION (usually strep pharyngitis) in the preceding 2-3 weeks - have multiple small tear-drop shaped erythematous papules
- scattered diffusely on proximal extremities and trunk (not classically on elbows/knees/scalp)
- usually self-limited in a few weeks to months
- psoriasis that is most generalized - often affects most or all of the body’s surface
erythrodermic psoriasis
least common psoriasis
ERYTHRODERMIC PSORIASIS
2 forms of psoriasis that are emergent
erythrodermic psoriasis
pustular psoriasis
- HIGH RISK OF SYSTEMIC INFECTION & ELECTROLYTE IMBALANCES
erythrodermic psoriasis
most common precipitating factor for erythrodermic & pustular psoriasis
ACUTE WITHDRAWAL OF SYSTEMIC CORTICOSTEROIDS
⦁ can occur with or without prior hx of psoriasis; can have another form of psoriasis and then get one of these, or may never have had psoriasis before and get one of these
may appear before the onset of cutaneous psoriasis
nail psoriasis
nail psoriasis is more closely associated with
psoriatic arthritis
nail psoriasis signs
pitting nails
oil drop signs & onycholysis
subungual hyperkeratosis
drugs that may exacerbate psoriasis
⦁ beta blockers ⦁ NSAIDS ⦁ lithium ⦁ ACEI ⦁ digoxin
tx = consider switching med if possible
- combination therapy for treatment is the trend to minimize side effects
topical therapy for psoriasis
- Emollients
- Steroids
- Vitamin D analogues (calcipotriol)
- Topical retinoids (tazorac)
- Calcineurin inhibitors
- Coal tar preparations
- Phototherapy: UVA / UVB
EMOLLIENTS ( therapy for psoriasis)
useful in ALL cases as an adjunct; hydrates the stratum corneum and decreases water evaporation. Softens the scales of the plaues. Apply lubricating creams BID after bathing, while skin is still damp
⦁ eucerin
⦁ lubriderm
⦁ moisturel
1st line treatment for psoriasis
topical steroid therapy
betamethasone or clobetasol
vitamin D analogue drug
Calcipotriol (Dovonex)
SE of calcipotriol (dovonex)
hypercalcemia
hypercalcuria
CALCIPOTRIOL (DOVONEX)
causes immune modulation;
used in mild to moderate plaque psoriasis
⦁ SE = Hypercalcemia & Hypercalcuria when topical doses > 100g/wk
- too irritating on face or groin
- can be used as monotherapy with steroids for breakthrough, or just a few days a week
vitamin A analog for psoriasis
Tazarotene (Tazorac) = retinoid
TAZORAC FOR PSORIASIS
- modulates differentiation & proliferation of epithelial tissue, and exerts some degree of anti-inflammatory and immunological activity
- may cause skin irritation
- effective with little systemic absorption
good for use in intertriginous areas & the face where steroid use should be limited
calcineurin inhibitors
- Tacrolimus (Protopic)
- Pimecrolimus (Elidel)
MOA of Calcineurin Inhibitors (for psoriasis tx)
= inhibits T-lymphocyte activation by binding to an intracellular protein, FKBP-12 and complexes with calcineurin dependent proteins to inhibit calcineurin phosphatase activity
Calcineurin inhibitors inhibit the action of calcineurin. Calcineurin is an enzyme that activates T-cells of the immune system (so it is an immunosuppressant)
tends to enhance the effects of UVB therapy
COAL TAR THERAPY
COAL TAR THERAPY FOR PSORIASIS
- when used alone = only as effective as mild to mid-potency topical steroids
- primarily used as add-on therapy
- also tends to enhance the effects of UVB therapy
- tar shampoos = beneficial for scalp lesions in combo with topical steroid solutions
- OTC
- use is limited by staining of clothes & odor
PHOTOTHERAPY FOR PSORIASIS
- has anti-proliferative effects by slowing keratinization
- has anti-inflammatory effects by inducing apoptosis of pathogenic T cells
- UV radiation accelerates photodamage & the risk of skin cancer
- UVB
- PUVA = UVA radiation administered with Psoralen bath or oral dose (photosensitizing drug)
SYSTEMIC THERAPY FOR PSORIASIS
- for severe cases that are resistant to topical treatment
⦁ MTX
⦁ Acetretin (Psoriatane) = systemic retinoid
⦁ Cyclosporine = systemic calcineurin inhibitor
⦁ Infliximab (Remicade) = Biologic agents
⦁ Hydroxyurea, Azathioprine = other immunosuppressants
