Neutrophilic dermatoses Flashcards
Epi of sweets syndrome?
The average age of onset is 30-60, female predominance of 4 to 1
What is the treatment effect that suggests that something is Sweet’s syndrome?
Rapid response to steroids
What are the two major criteria for Sweet’s syndrome?
- Abrupt onset of typical cutaneous lesions
- Histopathology consistent with Sweet syndrome
What are the 5 major clinical and histological subtypes of Sweet’s syndrome?
Classic (60-70%), cancer-associated (10-20%), Inflammatory disease-related (10-15%), drug-induced (5%), and pregnancy (2%)
What is the clinical presentation of Sweet’s syndrome?
Upper RTI or flu-like illness frequently precedes the development of the syndrome
Fever occurs in 40–80% of patients
Tender, non-pruritic, erythematous plaques or papules, which may enlarge or coalesce to form plaques
favors the head, neck and upper extremities (including the dorsal aspect of the hands)
malignancy-associated cases =more widespread distribution
EN like lesions (neutrophilic panniculitis) = subcutaneous sweets
+pathergy (Like PG)
Resolves in 5-12 weeks, recurs in 30%
What is the clinical progression of Sweet’s syndrome?
Resolves in 5-12 weeks, recurs in 30%
When do lesions usually occur in drug-induced Sweet’s as compared to drug administration?
Usually 1-2 weeks after drug administration
Aside from the skin, what other sx’s can be seen in sweet’s syndrome?
Fever (50-80%), malaise, preceding URI or flu-like sx’s, leukocytosis (70%), arthralgias/arthritis, ocular involvement (conjunctivitis, episcleritis, iridocyclitis)
What are some infectious triggers of Sweet’s?
Viral: URI, CMV, HBV, HCV, HIV
Bacteria: Strep, Yersinia
Mycobacteria: atypical mycobacteria, BCG vaccination, M. tuberculosis, M. Leprae
Fungi: dimorphic, including sporotrichosis and coccidiomycosis
What autoimmune disorders are associated with sweet syndrome?
SLE, RA, DM, relapsing polychondritis, Sjögren syndrome, autoimmune thyroid dz, sarcoidosis, behçet disease
What malignancies can be associated with Sweet’s?
Hematologic (10-20% of cases), in particular, AML
- Myelodysplasia
- Solid-organ, predominantly the more common primary carcinomas
What is the histology of Sweet’s syndrome?
Dense, diffuse infiltration of superficial to deep dermis and sometimes underlying panniculus, by neutrophils
Lymphocytes, histiocytes, and eosinophils also present
Leukocytoclastic debris
Papillary dermal edema, sometimes marked
Vasculopathy with perivascular neutrophilic inflammation that extends to traverse endothelial linings common; however, true vasculitis with fibrinoid necrosis is absent
What uncommon systemic findings can be seen in Sweet’s Syndrome?
Neutrophilic alveolitis (CXR findings of interstitial infiltrates, nodules, pleural effusions), multifocal steril osteomyelitis, renal involvement, myositis, hepatitis, pnacreatitis, ileitis, colitis, aseptic meningitis, encephalitis, hearing loss
What is hystiocytoid sweets more strongly associated with and what stain should be done?
Dermal and or SQ infiltrate of neutrophils and “histiocytoid” cells, stain for MPO –> strong a/w malignancy
What is subcutaneous sweets?
Neutrophils involve subcutis in a lobular pattern; p/w deep-seated red nodules on extremities
What is neutrophilic dermatoses of dorsal hands?
This is tender, erythematous to violaceous plaques that may become bullous or ulcerative. May represent a subtype of Sweet’s
What is the treatment for Sweet’s?
Sweet syndrome is a “benign” condition which, if left untreated, may persist for weeks or months.
Cutaneous lesions then involute spontaneously, rarely leaving scars
recurrences develop in ~30% of patients (with or without treatment)
more often in those with hematologic disorders (~50%)
Therapy: oral prednisone (0.5–1.0 mg/kg/day) for 2–6 weeks.
There is prompt relief of not only the cutaneous, but also the extracutaneous, manifestations.
In some patients, prolonged low-dose prednisone for an additional 2–3 months may be necessary to suppress recurrences.
If lesions = few and localized topical superpotent or intralesional corticosteroids may prove helpful.
What are some alternative steroid-sparing drugs that can be used in Sweet’s?
Potassium iodide (900mg/day), dapsone (100-200mg/day), and colchicine
What is the pathogenesis of pyoderma gangrenosum?
The disease is idiopathic in 25–50% of patients,
However, an underlying immunologic abnormality likely, given its frequent association with AI systemic diseases
Enhanced activity of the IL-1 pathway is thought to play a role in PG, as it does in several autoinflammatory disorder
What types of pyoderma gangrenosum are most strongly a/w malignancy?
Bullous (less destructive than ulcerative form)
What is the clinical progression of classic (ulcerative) pyoderma gangrenosum?
Lesions usually begin as a tender papulopustule with surrounding erythematous/ violaceous induration, an erythematous nodule, or a bulla
the papulopustule may be follicular
All lesions undergo necrosis leading to a central shallow or deep ulcer
loss of tissue can expose underlying tendons or muscles.
When fully developed, ulcer has a purulent base with an irregular, undermined and overhanging, gunmetal-colored border which extends centrifugally
Re-epithelialization occurs from the margins and the ulcers heal with atrophic cribriform pigmented scar
What diseases is vegetative pyoderma gangrenosum associated with?
None
What is the histology of pyoderma gangrenosum?
- Earliest lesions present as intraepidermal or subepidermal neutrophilic abscesses
- Variable epidermal necrosis
- Ulcers characteristically undermine
- Diffuse, dense neutrophilic infiltrate within the dermis in later lesions
- True vasculitis is lacking
What are some treatments for pyoderma gangrenosum?
Good wound care
Search for underlying dz
For mild dz can consider intralesional steroids or systemic steroids for more severe dz (.5-1mg/kg/day)
For recalcitrant dz can try infliximab and cyclosporine