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Fall 2014 - CM Dermatology > Papulosquamous and Inflammatory Dermatoses > Flashcards

Papulosquamous and Inflammatory Dermatoses Flashcards

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1
Q

KERATOSIS PILARIS

Etiology/Epidemiology

A
  • disorder of keratinization of hair follicles of the skin
  • exact etiology unclear, but some genetic link
  • sex: F > M
  • may appear at any age; affect 50-80% of all adolescents and 40% of adults
  • associated with other dry skin conditions: ichthyosis vulgaris, xerosis, atopic dermatitis
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2
Q

KERATOSIS PILARIS

Clinical Features

A
  • small (1-2mm) rough folliculocentric keratotic papules, sometimes pustules
  • erythematous papules w/ light red halo
  • distribution: posterolateral upper arms, anterior of thighs, buttocks, face, can affect any area, spares palms and soles
  • asymptomatic (most) to mild pruritus
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3
Q

KERATOSIS PILARIS

  1. Diagnosis
  2. Differential diagnosis
A
  1. clinical appearance

2. miliaria rubra, acne/folliculitis, drug eruption

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4
Q

KERATOSIS PILARIS

Treatment

A
  • mild cleansers
  • emollients
  • keratolytic: 12% ammonium lactate, urea cream, topical retinoids (RetinA, tazorac)
  • topical steroids
  • patient education: reassure b/c not contagious and won’t cause problems
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5
Q

XEROSIS

A
  • dry skin
  • important feature of the atopic state
  • affects all ages
  • decreased barrier function of skin
  • aggravating factors: winter, low humidity, hot water, harsh products (soaps, fragranced lotions)
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6
Q

XEROSIS

Clinical appearance

A
  • erythema, horizontal linear splits (cracks)
  • most common on extensor surfaces but not limited to these areas
  • increased sensitivity, easily irritated
  • may itch or burn
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7
Q

XEROSIS

Diagnosis

A

-clinical appearance

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8
Q

XEROSIS

Treatment

A
  • avoid triggers: 100% cotton, mild detergent, no bleach or fabric softener, use mild or no soap, clip nails to decrease abrasion, avoid frequent washing and drying
  • topical therapies: wet dressings, short cool showers, emollients immediately after bathing, frequent soaking and greasing, oils > ointments > creams > lotions
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9
Q

ICHTHYOSIS VULGARIS

Etiology

A
  • disorder of keratinization characterized by the development of dry, rectangular scales
  • onset at birth or later in life??
  • various forms: inherited (95% of cases) and acquired
  • autosomal dominant
  • sex M = F
  • often seen in AD patients: keratosis pilaris, hyperlinear palmar creases, atopy
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10
Q

ICHTHYOSIS VULGARIS

Clinical features

A
  • fine, white, adherent, polygonal scale with central tacking
  • extensor extremities: lower > upper
  • flexural folds and diaper = spared
  • improves as adult
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11
Q

ICHTHYOSIS VULGARIS

  1. Diagnosis
  2. Treatment
A
  1. clinical appearance
  2. emollients; lactic acid, urea, or alpha-hydroxy acids for severe scaling; patient education about avoiding drying environments; humidification
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12
Q

PSORIASIS

A
  • common, chronic, inflammatory, papulosquamous disease that affects the skin, nails and joints
  • several distinct clinical forms
  • severity and extent of disease varies widely
  • once expressed, generally follows relentless, waxing and waning course
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13
Q

PSORIASIS

Pathophysiology

A
  • proliferation of the outer layers of skin due to abnormal T lymphocyte and dendritic cell function/communication
  • reactive increase in growth of epidermal and vascular cells
  • 8 fold shortening of epidermal cell cycle (build up of cells)
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14
Q

PSORIASIS

Epidemiology

A
  • 1-3% of the population
  • inherited genetic factors and known environmental triggers
  • age: onset any age; peaks in 20s and 50s
  • heredity: 1/3 have positive family history
  • sex: M = F
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15
Q

PSORIASIS

Triggers/Predisposing conditions

A
  • trauma (Koebner phenomenon)
  • infection (strep, HIV, candida, dental)
  • stress/winter season
  • smoking/alcohol
  • drugs: beta blockers, lithium, systemic steroids, antimalarials, NSAIDs, ACE inhibitors
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16
Q

PSORIASIS

Clinical features

A
  • chronic plaque psoriasis: most common form
  • red, scaly, round to oval plaques
  • symmetrical, sharply marginated
  • loosely adherent silvery white scale
  • extensor surfaces: predominantly elbows, knees, scalp; also gluteal cleft, umbilicus, penis; spares the palms, soles and face
  • degree of pruritus varies by individual and type
  • Auspitz sign: pinpoint bleeding when scale removed
  • Koebner phenomenon: psoriasis develops at site of trauma
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17
Q

Types of Psoriasis

A
  • chronic plaque
  • guttate (acute eruptive)
  • pustular
  • erythrodermic
  • inverse psoriasis (intertriginous)
  • light sensitive
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18
Q

GUTTATE PSORIASIS

A
  • gutta = “drop” in Latin
  • > 30% of first episodes are before 20 y.o
  • usually preceded 1-2 weeks by strep pharyngitis or viral infection
  • resolves spontaneously in weeks to months
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19
Q

GUTTATE PSORIASIS

Clinical features

A
  • small, scaly papules SUDDENLY appear
  • trunk and extremities
  • uniform lesions
  • spares palms and soles
  • may or may not have pruritus
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20
Q

PUSTULAR PSORIASIS

A
  • localized: small sterile pustules on a red base on palms and soles
  • generalized (von Zumbusch’s syndrome): widespread sterile pustules can coalesce into large areas of pus; life threatening
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21
Q

INVERSE PSORIASIS

A
  • uncommon
  • smooth, red and sharply defined plaques
  • found in flexural or intertriginous areas (groin, axilla, under breasts)
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22
Q

ERYTHRODERMIC PSORIASIS

A
  • entire skin surface is involved
  • generalized erythema and scaling
  • can be very severe
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23
Q

Conditions Associated with Psoriasis

A
  • arthritis: affects 5-8% of psoriasis patients; with or w/o cutaneous psoriasis; rheumatoid factor negative; most common is asymmetric, oligoarticular form (70% of psoriatic arthritis)
  • IBS, cardiovascular disease, depression
  • nail disease: 1/3 of patients; pitting subungual debris; oil drop sign; nail dystrophy and onycholysis
  • scalp: dense scale covering part or all of scalp; can be difficult to determine seborrheic dermatitis
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24
Q

PSORIASIS

Diagnosis

A
  • clinical appearance
  • biopsy (punch)
  • labs: positive anti streptolysin O titer/throat culture (guttate); KOH to rule out candida; HIV titer; autoimmune screens (ANA, ESR, RF)
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25
Q

GUTTATE PSORIASIS

Differential diagnosis

A
  • chronic plaque: seborrheic dermatitis, nummular eczema, tinea corporis, drug eruption
  • guttate: pityriasis rosea, secondary syphilis, drug eruption
  • inverse: candida, contact dermatitis, bacterial infection
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26
Q

PSORIASIS

Treatment

A
  • topical steroids/intralesional
  • tar preparations
  • salicylic acid (scalp)
  • vitamin D analogues
  • retinoid creams
  • anthralin
  • phototherapy UVB
  • systemic: methotrexate, cyclosporine, acitretin, PUVA, biologics
  • patient education
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27
Q

PITYRIASIS ROSEA

A
  • acute, self-limiting skin eruption
  • etiology unclear, but thought to be viral in origin
  • sex: M = F
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28
Q

PITYRIASIS ROSEA

Predisposing factors

A
  • age: >75% between 10-35 y.o.; rare in young and old
  • seasonal: more common in cooler months (spring/fall)
  • clustered in families/close contacts
  • higher incidence in immunocompromised
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29
Q

PITYRIASIS ROSEA

Clinical features

A
  • mild URI prodrome
  • primary lesion: Herald patch - a solitary lesion, usually annular, 2-6 cm, round to oval, most common on trunk and neck but can occur anywhere
  • secondary lesions: 1-2 wks after 1ary; generalized eruption on trunk and proximal limbs; salmon pink; 0.5-1.5 cm macules or patches; Christmas tree distribution; collarette scale (inward facing cigarette paper-like appearance)
  • symmetrical eruption, but spares palms/soles
  • atypical presentations: small papules common in young and pregnancy
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30
Q

PITYRIASIS ROSEA

  1. Diagnosis
  2. Differential dx
A
  1. clinical appearance; biopsy not typically required
  2. guttate psoriasis, viral exanthems (kids), tinea corporis (ring worm), nummular eczema, lichen planus, drug eruptions, seborrheic dermatitis, secondary syphilis
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31
Q

PITYRIASIS ROSEA

Treatment

A
  • no treatment (self-limiting)
  • emollients for scale
  • topical corticosteroids (class V) for itching
  • PO antihistamines, antipruritic lotions
  • NO topical lidocains or benadryl!
  • UVB phototherapy/direct sun
32
Q

LICHEN PLANUS

Etiology/Epidemiology

A
  • inflammatory cutaneous and mucous membrane reaction pattern
  • unknown etiology
33
Q

LICHEN PLANUS

Predisposing factors

A
  • sex: F > M
  • age: may occur at any age; adults most common 30-60; rare in kids under 5
  • family history: 10% positive FHx
  • may be associated w/ chronic active hep C
  • lichen planus-like eurptions due to medications, chemical exposure, post bone marrow transplant
34
Q

LICHEN PLANUS

Clinical features (location and the 5 Ps)

A
  • location: skin, mucous membranes, genitalia, nails, scalp; flexor surfaces of wrist, forearms, legs just above ankles
  • pruritic
  • planar (flat top)
  • polyangular
  • purple (violaceous)
  • papules
35
Q

LICHEN PLANUS

Clinical features (size, grouping, special/unique characteristics)

A
  • 1 mm - 1 cm
  • random clusters, discrete, linear, annular, or diffusely papular (guttate)
  • Koebner phenomenon: lesion in response to injury/scratch
  • Wickham striae: white, lacy reticular pattern of criss crossed lines
  • new lesions appear pink/white then become purple with waxy luster
  • heals w/ post inflammatory hyperpigmentation
36
Q

Papular Lichen Planus

A
  • most common form
  • found on wrist, forearm, ankles and low back typically
  • often chronic - average 4 years
37
Q

Hypertrophic Lichen Planus

A
  • 2nd most common
  • can be anywhere, but most common on shins and ankles
  • become confluent, rough red-brown thick
  • may have severe itching and last for avg 8 years
  • can develop vesicle/bullae
38
Q

Follicular Lichen Planus

A
  • localized to hair follicles
  • may occur with papular form
  • causes hair loss (can be permanent from scarring)
39
Q

Mucosal Lichen Planus

A
  • mucosal membrane (oral, vulva, glans penis)
  • oral: can occur w/o cutaneous lesions
  • F>M, mean age onset 60 y.o
  • seen in greater than 50% with cutaneous lesions
  • most common form is non-erosive with white lacy pattern on buccal mucosa
  • erosive form more severe and painful; 0.5-3% develop into SCC
40
Q

Lichen Planus Nail Disease

A
  • longitudinal grooving, ridging, splitting, thinning and red streaks/dots, pterygium
  • tenting or pup tent = elevation of nail plate
  • 25% of pts with nail LP have LP at other sites before or after nail disease is noted
  • most common age 50s-60s
41
Q

LICHEN PLANUS

  1. Diagnosis
  2. Differential dx
A
  1. clinical appearance; biopsy for confirmation if needed; AST/ALT/alk phos (liver fx tests), HIV, Hep C tests
  2. cutaneous: syphilis, lichen simplex chronicus, guttate vs plaque psoriasis
    mucosal: candida, SCC, leukoplakia
42
Q

LICHEN PLANUS

Treatment

A
  • refer to derm: generalized or mucosal disease, scarring alopecia, and refractory cases
  • topical corticosteroids: initial Tx of localized disease
  • intralesional corticosteroids sometimes used for hypertrophic lesions
  • anti-histamines for pruritus
  • topical corticosteroids in orabase for oral lesions
43
Q

GRANULOMA ANNULARE

A
  • benign, inflammatory/reactive dermatosis; self-limited
  • unknown pathophysiology
  • several clinical variants; localized GA is most common
44
Q

GRANULOMA ANNULARE

Predisposing conditions

A
  • sex: 2F:M
  • age: localized GA most common in kids and adults <10 or adults 30-60
  • seasonal: worse in summer, better in winter
45
Q

GRANULOMA ANNULARE

Clinical features

A
  • primary lesion: firm, 1-2 mm, skin colored to erythematous papules; slowly progressing; grouped lesion expand to arcuate or annular plaques; central depression; smooth and non-scaling
  • dorsal surface of hands/feet/fingers; extensor of arms and legs; rare on face, scalp, genitals
  • asymptomatic or mild pruritus
  • duration: variable; weeks to decades; spontaneous involution w/in 2 years in 50%
46
Q

GRANULOMA ANNULARE

Hypothesized Associations

A
  • diabetes
  • TB
  • insect bites/trauma
  • sun exposure
  • thyroid disease
  • viral infections: HIV, Epstein Barr, herpes zoster
47
Q

GRANULOMA ANNULARE

  1. Diagnosis
  2. Differential dx
A
  1. clinical appearance, maybe a biopsy, KOH (- to r/o ringworm)
  2. tinea, annular lichen planus, basal cell carcinoma, erythema migrans (Lyme), sarcoidosis, nummular eczema
48
Q

GRANULOMA ANNULARE

Treatment

A
  • asymptomatic localized lesion can be left untreated
  • topical corticosteroids not very effective (class I or II under occlusion, use in intervals)
  • intralesional Kenalog at the elevated border
  • cryotherapy
  • other generalized variants may need systemic treatment
49
Q

URTICARIA

A
  • reactive immunologic/inflammatory process
  • also referred to as hives or wheals
  • prevalence: may occur at any age; up to 20% of pop will have one episode; may be more common in atopic pts
  • cause undetermined in most causes
  • acute or chronic
50
Q

URTICARIA

Pathophysiology

A
  • mast cell releases histamine in response to immunologic, non-immunologic, physical and chemical stimuli
  • H1 receptors: triple response of Lewis (vasodilation-ereythema, axon reflex-pruritus, and wheal)
  • H2 receptors: vasodilation, increased gastric secretion
51
Q

URTICARIA

Acute vs. Chronic

A
  • acute: less than 6 weeks; majority of cases; lasts few hours to few weeks; more common in kids and young adults; cause usually undetermined
  • chronic: more common in young adults and middle age women; cause determined in 5-20% of cases
52
Q

URTICARIA

Clinical features

A
  • raised, red, transitory area of edema
  • various sizes and shapes: papules, plaques, annular, arcuate, polycyclic
  • newest lesions are reddest
  • no scale
  • pruritus varies in severity
  • sudden onset; each lesion last <24 hours
  • occur on any skin surface
53
Q

URTICARIA

Classifications

A
  • ordinary: 4-36 hours
  • contact: 1-2 hrs, biological or chemical
  • urticarial vasculitis: 1-7 days
  • physical: 30 min-6 hrs; aquagenic, cholinergic (stress), cold, delayed pressure, dermatographism, exercise induced, localized heat, solar, vibratory
54
Q

Dermatographism

A
  • “skin writing”
  • minor trauma/scratch = hive
  • lasts < 30 minutes
55
Q

URTICARIA

Common causes

A
  • recent infection: viral, bacterial
  • medications: ACE inhibitors, aspirin, NSAIDs, penicillins, diuretics, opioids
  • food and food additives: nuts, fish, shellfish, eggs, chocolate, strawberries, tomatoes, cheese, etc
  • chemical/contact: latex, ammonium, persulfate, perfumes, plants, cosmetics, textiles
  • other misc: parasites, arthropod bites, malignancy, hormones, autoimmune
56
Q

URTICARIA

Diagnosis

A
  • detailed H&P
  • 5 Is: infections, ingestants, inhalants, injectants, internal disease
  • contact/chemical
  • allergen testing
  • stool cultures/sinus xray
  • autoimmune/CT work up
  • malignancy work up
  • thyroid disease
57
Q

URTICARIA

Differential dx

A
  • acute: drug eruption, viral exanthem, insect bites, angioedema, urticaria vasculitis, pityriasis rosea
  • chronic: erythema multiforme, bullous pemphigoid, Lyme disease, urticarial vasculitis
58
Q

URTICARIA

Treatment

A
  • refer to derm if recurrent or chronic
  • treat underlying condition
  • antihistamines preferred initial Tx: 1st generation (sedate) = hydroxyzine and diphenhydramine (benadryl); 2nd generation (low sedating) = fexofenadine (allegra), certrizine (zyrtec), loratadine (claritin)
  • topicals: tepid or oatmeal bath
  • for difficult cases: H2 receptor antagonists, corticosteroids, tricyclic H1 and H2
59
Q

ANGIOEDEMA

Etiology

A
  • abrupt and evanescent swelling of the skin, mucous membranes, resp/GI tracts
  • deeper rxn: more diffuse swelling than hives; deeper form of urticaria that involves deep dermis and subQ tissue
  • caused by increased vascular permeability
60
Q

ANGIOEDEMA

Predisposing conditions

A
  • sex: F >M

- may be with or w/o family history, urticaria, systemic symptoms

61
Q

ANGIOEDEMA

Clinical appearance

A
  • subQ tissue: face including lips, hands, arms, legs, genitals
  • GI organs: stomach, intestines, bladder; nausea, vomiting, diarrhea
  • upper airway: dyspnea and dysphagia
  • non-pitting swelling
  • may have pain or burning
  • pruritus typically absent
  • marked periorbital/perioral swelling
62
Q

ANGIOEDEMA

Diagnosis

A
  • detailed H&P
  • possible biopsy
  • immunologic studies deferred to allergy or derm
  • some recommend CBC/diff, basic metabolic panel, thyroid
63
Q

ANGIOEDEMA

Differential dx

A
  • anaphylaxis
  • urticaria
  • cellulitis
  • erysipelas
  • contact dermatitis
64
Q

ANGIOEDEMA

Treatment

A
  • acute severe attacks: epinephrine and antihistamines
  • refer to derm/allergist
  • ID bracelets w/ Dx
  • Epi Pen
  • hereditary angioedema: replacement with C1 inhibitor concentrate; fresh frozen plasma
  • intense support may be necessary depending on Sxs
65
Q

ERYTHEMA MULTIFORME

A
  • common, acute, might be recurrent, inflammatory, hypersensitivity disease
  • EM minor: localized skin eruption with no mucosal involvement
  • EM major: more severe mucosal and skin (eg SJS or TEN - potentially life threatening disorders, derm emergencies)
66
Q

ERYTHEMA MULTIFORME

Predisposing conditions

A
  • M>F slightly

- 20-40 y.o; 20% in adolescents

67
Q

ERYTHEMA MULTIFORME

Causes

A
  • most common is herpes simplex virus, Mycoplasma pneumoniae, acute URI
  • medications
  • other infection (bacterial/viral/fungal)
  • contact allergens
  • flavoring, preservative, food
  • immunologic disorders; connective tissue diseases
  • mechanical (tattoos)
68
Q

ERYTHEMA MULTIFORME

Clinical features

A
  • prodrome: malaise, fever, itching, burning, couch
  • numerous lesions: target lesions, erythematous macules and papules, urticarial-like, vesicles, bullae
  • primary lesion: small dull red macule with central papule/vesicle that may flatten and clear
  • symmetrical on palms, soles, extensor surfaces of forearms/legs
  • with or w/o burning, Koebner phenomenon
  • mucosal lesions
  • heal w/o scarring
69
Q

ERYTHEMA MULTIFORME

Diagnosis

A
  • detailed H&P
  • biopsy - helpful if dx uncertain
  • HSV PCR if lesions suggestive
  • more systemic work-up in severe cases
70
Q

ERYTHEMA MULTIFORME

Differential Dx

A
  • urticaria
  • Stevens Johnson syndrome
  • toxic epidermal necrolysis
  • drug eruption
  • bullous pemphigoid
71
Q

ERYTHEMA MULTIFORME

Treatment

A
  • most mild cases don’t require Tx
  • antiviral therapy
  • antihistamines for pruritus
  • systemic steroids for widespread disease
  • soothing mouthwashes
  • symptomatic for wounds - topical antibiotics
  • supportive care: IV fluids w/ electrolytes if severe
  • refer to derm
72
Q

ERYTHEMA NODOSUM

A
  • hypersensitivity reaction to various triggers
  • inflammatory reaction in the panniculus
  • self limiting
  • 55% cases are idiopathic
73
Q

ERYTHEMA NODOSUM

Predisposing conditions

A
  • age 18-34 years
  • 5F:M in adults; kids affected equally
  • bacterial: strep infections, TV, yersinia, salmonella, shigella
  • fungal: coccidiomyosis
  • viruses: hep B, HSV, Epstein Barr
  • parasitic: giardiasis, ascariasis
  • drugs: sulfonamids, oral contraceptives, penicillin
  • inflammatory conditions
  • malignancy: lymphoma, leukemia, renal cell carcinoma
  • pregnancy
74
Q

ERYTHEMA NODOSUM

Clinical features

A
  • lesions start as poorly defined, red, firm, tender subQ nodules, 2-6cm that fade over 1-3 weeks, do not scar
  • extensor surfaces, bilateral but not symmetric, most common on pretibial surfaces
  • new lesions appear for 3-6 weeks
  • ankle edema and leg pain are common
  • may have prodrome of flu-like Sxs, fever, myalgias a few weeks before or with onset of lesions
  • arthralgia > 50%
75
Q

ERYTHEMA NODOSUM

Diagnosis

A
  • detailed H&P
  • biopsy if atypical and include fat
  • throat culture/rapid strep
  • complete CBC
  • CXR
  • PPD
  • ESR
  • stool culture with GI sxs
76
Q

ERYTHEMA NODOSUM

Differential Dx

A
  • erysipelas
  • cellulitis/thrombophlebitis
  • acute urticaria
  • physical abuse
  • Henoch Schonlein purpura
77
Q

ERYTHEMA NODOSUM

Treatment

A
  • treat underlying condition and stop offending medication
  • NSAIDs
  • rest
  • cool wet compresses
  • potassium iodide or corticosteroids (only if severe or recurrent)

Fall 2014 - CM Dermatology (11 decks)

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