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Clin Med III: Dermatology > Papulosquamous and Inflammatory Disorders > Flashcards

Papulosquamous and Inflammatory Disorders Flashcards

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Dermatology Board Prep flashcards
1
Q

An acute exanthematous eruption with a distinctive morphology and often with a characteristic self limited course
Single “herald” patch, 1-2 wks later = generalized

A

Pityriasis Rosea

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2
Q

MCC of Pityriasis Rosea

A

Herpes Human Virus 6 and 7

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3
Q

Pityriasis Rosea MC in who and when?

A

Onset: 10-40 years old
MC in Spring and Fall

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4
Q
  1. Oval, slightly raised plaque or patch (2-5 cm)
  2. Salmon red, fine collarette
  3. 1-2 wks after patch develops = Exanthem
    - Fine scaling papules and patches with marginal collarette /dull pink
    - Oval scattered (Christmas Tree pattern)
    - Confined to trunk (rare on face)

dx?
tx?

A
  • Pityriasis Rosea
  • spontaneous remission; oral antihistamines, topical antipruritic lotion (sarna), steroids (TAC or prednisone)
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5
Q

Acute or chronic inflammatory dermatosis involving skin and or mucous membranes

A

Lichen Planus

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6
Q

causes of Lichen Planus

A
  1. Idiopathic MC
    - Cell mediated immunity - CD8+ & CD45Ro+ cells
  2. Drugs
  3. Metals (gold and mercury)
  4. Infection (hep C)
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7
Q
  1. Papules, flat topped - Polygonal or oval ; Annular; Purple; Pruritic
  2. 1-10 mm
  3. Sharply defined, shiny
  4. Violaceous, with white lines (Whickham striae)
  5. Grouped or disseminated - Dark phototype hyperpigmented
A

lichen planus

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8
Q

how to observe Whickham striae under dermatoscope?

A

seen after the use of oil under a dermatoscope

lichen planus

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9
Q

lichen planus is MC found where on the body?

A
  1. Wrists (flexor)
  2. Lumbar region
  3. Shins
  4. Scalp
  5. Glans penis
  6. Mouth
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10
Q

11 variants of lichen planus

A
  1. Hypertrophic: Large thick plaques
  2. Atrophic: White bluish, well-demarcated papules and with central atrophy
  3. Follicular: Follicular papules and plaques –> cicatrical alopecia
  4. Vesicular: Bullous pemphigoid w/ LP
  5. Pigmentosus: Hyperpigmented, dark-brown macules in sun exposed areas and flexural folds
  6. Actinicus: Papules in sun exposed areas
  7. Ulcerative /erosive: Therapy resistant spots = ulcers
  8. MUCOUS MEMBRANES : MC in mouth
  9. Reticular: Lacy white hyperkeratosis on buccal mucosa, lips, tongue, gingiva
  10. Genitalia: Papular, annular, or erosive lesions on penis, scrotum, labia majora, labia minora and vagina
  11. Hair & nails: Scarring alopecia possible; Destruction of nail fold and bed w/ longitudinal splintering
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11
Q

w/u and tx for lichen planus

A
  1. bx
  2. TAC BID x 4wks; ILK
  3. Cyclosporine and tacrolimus solution - for mouth
  4. systemic - cyclosporin, prednisone, retinoids
  5. other: PUVA
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12
Q

Granuloma Annulare MC in who?

A
  • MC Children and young adults
  • Female
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13
Q

Granuloma Annulare cause is unknown, but has been seen in pts with this chronic condition?

A

diabetics

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14
Q
  1. Skin colored or brownish-red
  2. Shiny beaded papules - Annular arrangement
  3. MC hands, feet, elbows and knees - Generalized MC, can be isolated spot
A

granuloma annulare

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15
Q

if GA is diagnosed and ____ hasn’t been diagnosed, the patient should be sent to PCP for work up

A

DM

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16
Q

histologic findings of granuloma annulare on bx?

A
  1. Foci of chronic inflammatory and histiocytic infiltrations in superficial and mid dermis
  2. Necrobiosis of CT surrounded by a wall of palisading histiocytes and multinucleated giant cells
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17
Q

tx for granuloma annulare

A
  1. Not needed (spontaneous remission within 2 yrs)
  2. TAC 0.5% BID x 4 weeks
  3. ILK – 3 mg/mL (very effective)
  4. Cryo - not recommended due to scarring
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18
Q

Common acute inflammatory/immunologic reaction pattern of the subcutaneous fat
MC type of panniculitis

A

Erythema Nodosum

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19
Q

causes of Erythema Nodosum

A
  1. Infection
  2. Drugs
  3. Inflammatory/granulomatous diseases
  4. Sarcoidosis
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20
Q

Erythema Nodosum MC in who?

A
  • 20-30 years old
  • Females
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21
Q
  1. Painful, Tender, Fever, Malaise, Arthralgia (MC ankle joints)
  2. Indurated, tender nodules 3-20cm - Bright to deep red; Only appreciated on palpation
  3. Not sharply marinated - Oval, round, and acriform
  4. Deep seated in fat (MC anterior leg) - brownish, yellowish, green with age
  5. Bilateral but not symmetrical
A

Erythema Nodosum

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22
Q

w/u for Erythema Nodosum

A

Hematology - Elevated ESR and CRP; Leukocytosis

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23
Q

tx for erythema nodosum

A
  1. Spontaneous resolution occurs in 6 weeks w/o scarring
  2. symptomatic tx - rest, compression, wet dressings
  3. antiinflammatory tx - NSAIDs, Prednisone
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24
Q

Chronic, multifactorial inflammatory skin disorder resulting in hyperproliferation of the keratinocytes in the epidermis

A

psoriasis

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25
Q

pathogenesis of psoriasis?

A
  • not completely understood
  • T-cell proliferate the epidermis = overproduction of epidermal cells
  • dysregulated inflammatory process = large production of various cytokines
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26
Q

development/steps of psoriatic lesions

A
  1. psoriatic skin w/o active lesion - capillary dilation and curvature, more mononuclear cells and mast cells, increased epidermal thickness
  2. developing lesion - more cap dilatation and tortuosity, mast cells, T-cells, and mast cell degranulation, thickness of epidermis
  3. developed lesion - 10-fold increase in blood flow, lots of macrophages underlying basement membrane, more T cells, 10-fold increase in epidermis, accumulation of NEUT in stratum corneum (Munro’s microabscesses)
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27
Q

RF for psoriasis

A
  1. Environmental - trauma (Koebner phenomenon), stress, cold, infection, alc, medications
    - Acute streptococcal infection precipitates guttate psoriasis
  2. Genetic
  3. Immunologic
    - first lesion typically appears after URI
    - evidence of autoimmune properties (T-cell hyperactivity)
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28
Q

3 subtypes of psoriasis

A
  1. Eruptive, inflammatory psoriasis
  2. Pustular
  3. Chronic stable (plaque) psoriasis (MC): classic lesions present for months-years without little change
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29
Q
  • aka: guttate or nummular psoriasis
  • multiple small lesions appearing rapidly
  • spontaneous remission
  • often follows strep pharyngitis

which types of psoriasis

A

Eruptive, inflammatory psoriasis

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30
Q
  1. erythematous papule/patch/plaque with sharp margins
  2. overlying silvery-white scales easily removed with scratching
    - Auspitz sign: removal of scale leaves small blood droplet
  3. pruritus is common historical finding
A

Psoriasis

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31
Q
  1. 2-10 mm, salmon pink papules, +/- scales
  2. concentrated to the trunk, few scattered lesions to face, scalp, extremities
  3. may resolve spontaneously within a few wks
  4. most often evolves into chronic stable type

which type of psoriasis

A

Eruptive, inflammatory psoriasis

32
Q
  1. sharply marginated, dull-red plaques with loosely adherent silver-white scales
  2. plaques may coalesce
  3. Waxing and waning of lesions throughout lifetime

which type of psoriasis

A

Chronic Stable Psoriasis

33
Q

MC sites of psoriasis

A

Bilateral, often symmetric
Elbows
Knees
Sacral/gluteal region
Scalp
Palm/soles

34
Q

special sites of psoriasis presentation

A
  1. Palms/soles: thick adherent silvery-white or yellow scaling; painful cracking/fissures
  2. Scalp: sharply marginated plaques with thick adherent scales; intense pruritus; no hair loss
  3. face: uncommon; seen in refractory cases
  4. Peri-anal/body folds (inverse psoriasis): macerated d/t warm moist area; sharply marginated, bright red, fissured lesions
  5. Nails: pitting, subungual hyperkeratosis, onycholysis; yellowish-brown spots (oil-spots)
35
Q
  1. results from increase in polymorphonuclear (PMN) leukocytes present in the psoriatic epidermis
  2. Outbreak is often precipitated by corticosteroid withdrawal
  3. Subjective: stinging, burning, pruritus
  4. Erythematous patches or thin plaques that rapidly become studded with numerous pinhead-sized sterile pustules

which type of psoriasis

A

Pustular Psoriasis

36
Q

2 presentations of pustular psoriasis

A
  1. palmoplantar - palms/soles: pustules 2-5 mm; erupt into dusky-red erosions and crusts; persists for years with unexplained remissions/exacerbations
  2. generalized “von Zumbusch variant”: pustules coalesce into “lakes” of pus; (+) Nikolsky sign in generalized presentation; life threatening; relapses and remissions occur over years; may evolve into chronic stable psoriasis
37
Q
  1. joint stiffness & pain worse after inactivity, improves with movement
  2. swelling, redness and tenderness of involved joints
  3. psoriatic lesions develop over involved joints

which type of psoriasis

A

Psoriatic Arthritis

38
Q

w/u for psoriasis?

A
  1. clinical
  2. labs to r/o ddx - throat cx, KOH, bacterial/viral cx, CBC (leukocytosis w/ left shift in generalized pustular psoriasis)
39
Q

referrals for psoriasis

A
  1. refer to derm
  2. localized psoriasis- can be managed by PCP once therapy is initiated
  3. generalized psoriasis- managed by dermatology provider
  4. psoriatic arthritis- refer to rheumatology
40
Q

tx for Localized Psoriasis - trunk/extremities

A
  1. high-potency topical steroids
    - after soaking lesions in water and removing scales
    - apply oint onto wet skin, cover with plastic wrap and leave overnight
    - re-apply in AM and leave uncovered during the day
    - ointment for PM and cream for AM
  2. Vitamin D analog - calcipotriol, calcitriol
  3. tazarotene - for thick plaques, best with mid-high potent CS or UVB phototherapy
  4. Coal Tar + SA
  5. Emollients
41
Q

MOA of Topical Vitamin D Analogs

A

binds to Vit D receptor and regulates cell growth
inhibits proliferation of keratinocytes
inhibits proinflammatory cytokines

42
Q

SE of calcipotriene 0.005%

A

burning, itching, skin irritation, photosensitivity, hypercalcemia
CI: hypersensitivity

43
Q

SE of calcitriol 0.0003% oint

A

hypercalcemia, photosensitivity
CI: none

44
Q

tx for localized scalp psoriasis

A

tar shampoo followed by medium-high potency lotion

45
Q

tx for localized pals/soles psoriasis

A
  1. high-potency topical steroids oint with occlusive dressing
  2. PUVA ‘soaks’
    - immerse affected area in photosensitizer liquid 15 minutes
    - expose hands/feet to UVA phototherapy units
  3. Oral retinoids: if unresponsive thick hyperkeratotic lesions
46
Q

tx for palmoplantar pustulosis

A
  1. PUVA ‘soaks’
  2. MTX or Cyclosporine CS unresponsive cases
47
Q

tx for Inverse(body folds)/genital
localized psoriasis

A
  1. start with short term (2-4 wks) of topical steroids
  2. then one of the following: Vitamin D analog; topical retinoid (tazarotene); topical calcineurin inhibitors (tacrolimus/pimecrolimus)
48
Q

tx for localized nail psoriasis

A
  1. PUVA phototherapy in hand/foot lighting units
  2. Oral retinoids
  3. Immunosuppressant: MTX or CS for unresponsive cases
49
Q

which topical psoriasis tx can be used for all types of psoriasis?
SE?

A
  • topical steroids
  • Skin atrophy, hypopigmentation, striae
50
Q

which topical psoriasis tx is used in combination or rotation with topical steroids for added benefit?
SE?

A
  • Calcipotriene (Vitamin D derivative)
  • Skin irritation, photosensitivity (but no contraindication with UVB phototherapy)
51
Q

which topical psoriasis tx is reserved for Plaque-type psoriasis?
Best when used with topical corticosteroids.

SE?

A

Tazarotene (Topical retinoid)
Skin irritation, photosensitivity

52
Q

which topical psoriasis tx is reserved for Plaque-type psoriasis?
SE?

A
  • Coal tar
  • Skin irritation, odor, staining of clothes, carcinogenic
53
Q

which topical psoriasis tx has Off-label use for facial and intertriginous psoriasis?
SE?

A
  • Calcineurin inhibitors
  • Skin burning and itching
54
Q

mgmt for Generalized Acute, inflammatory Psoriasis

A
  1. tx underlying strep if applicable
  2. Refer to Dermatology
    - narrow band UVB irradiation
    - oral PUVA photochemotherapy (if UVB therapy fails)
55
Q

mgmt for Generalized Pustular Psoriasis

A
  1. hospitalization with IV fluids
  2. in hospital consult with dermatology
  3. prophylactic IV antibiotics
  4. oral retinoids
56
Q

mgmt for Generalized Chronic Plaque Psoriasis

A
  1. Refer to dermatology
  2. narrow band UVB irradiation
  3. oral PUVA photochemotherapy
  4. oral retinoids
  5. immunosuppressants/biologic agents
57
Q

what is the most important of hx for Adverse Cutaneous Drug Reactions

A

TIMING
start with onset of rash and work backwards and forwards considering all possible causes and pharmacologic agents

58
Q

RF for Adverse Cutaneous Drug Reactions

A
  1. female
  2. prior hx of drug reaction
  3. recurrent drug exposure
  4. EBV & CMV infection with PCN drugs
  5. HIV with sulfonamides
59
Q

difference between Immediate vs Delayed adverse cutaneous drug Reactions

A
  1. Immediate: < 1 hr of last dose; urticaria, angioedema, anaphylaxis
  2. Delayed: 1- 6 h, weeks-months after drug use; exanthematous eruptions, fixed drug eruptions, systemic reactions
60
Q
  • MC of all drug reactions
  • Mechanism not fully known - likely a delayed hypersensitivity reaction
  • EBV and CMV produce eruptions with administration of PCN drug class (not believed to be allergy related)
A

Exanthematous Drug Reactions

61
Q

Exanthematous Drug Reactions are classified how?

A

timing - immediate vs delayed

62
Q

s/s of exanthematous drug reactions

A
  • bright red, maculopapular rash
  • symmetric: starts on trunk and spreads to extremities
  • scaling/desquamation with healing
  • mild pruritus
63
Q

drugs that have a High probability to cause Exanthematous Reaction

A
  1. PCN drug class
  2. carbamazepine
  3. allopurinol
  4. gold salts
64
Q

drugs that have a medium probability to cause Exanthematous Reaction

A
  1. sulfonamides
  2. NSAIDs
  3. isoniazid
  4. erythromycin
  5. streptomycin
65
Q

drugs that have a low probability to cause Exanthematous Reaction

A
  1. barbiturates
  2. BZD’s
  3. phenothiazines
  4. tetracyclines
66
Q

tx and pt ed for exanthematous drug reactions

A
  1. identify and DC offending agent - oral/IV steroids if they must continue agent
  2. topical steroids and antihistamines
  3. ensure pt is aware of offending agent and drug class
67
Q

a drug reaction characterized by a solitary erythematous patch/plaque that will recur at same site if re-exposure of offending agent occurs - occasionally multiple fixed lesion will occur
Unknown pathogenesis

A

Fixed Drug Eruption

68
Q

s/s of Fixed Drug Eruption

A
  1. Onset: 30 min-8 hours after ingestion
  2. Pruritus, burning pain
  3. Skin Lesion
    - sharply marginated macule
    - erythema (early), dusky red-violaceous (later)
    - may become edematous and bullous followed by erosion
    - PIH after resolution
69
Q

Fixed Drug Eruption - Sites of Predilection

A
  1. genital
  2. pubic/crural region
  3. perioral
  4. periorbital
  5. conjunctiva
  6. oropharynx
70
Q

mgmt for fixed drug eruption

A
  • remove offending agent - Lesion resolves days-weeks after discontinuation
  • non-eroded lesions: topical steroid ointment
  • eroded lesion: topical antimicrobial ointment
  • antihistamines for pruritus; throat
  • widespread presentation - refer to dermatologist
71
Q

skin eruptions with systemic symptoms and internal organ involvement

A

Drug-Induced Hypersensitivity Syndrome

72
Q

causes of Drug-Induced Hypersensitivity Syndrome

A
  1. Antiepileptics: phenytoin, carbamazepine, phenobarbital
  2. Sulfonamides : antimicrobial agents, dapsone, sulfasalazine
73
Q

s/s of Drug-Induced Hypersensitivity Syndrome

A
  1. onset 2-6 wks after drug initiation or increased dose
  2. F, malaise, facial edema, LAD, hepatosplenomegaly
  3. maculopapular eruption - starts on face, upper trunk and UE; scaling/desquamation occur with healing
  4. oropharyngeal mucosal lesions - cheilitis, erosions, pharyngitis, tonsillitis

Assess: liver, kidneys, lymph nodes, heart, lungs, joints, muscles, thyroid, and brain for systemic involvement

74
Q

w/u and criteria for Drug-Induced Hypersensitivity Syndrome

A
  1. CBC: leukocytosis, eosinophilia; LFT; BUN/Cr
  2. Diagnostic Criteria (3 must be present):
    - cutaneous drug eruption
    - hematologic abnormalities
    - systemic involvement: LAD >2 cm; elevated LFT (hepatitis); elevated BUN/Cr (interstitial nephritis)
75
Q

tx for Drug-Induced Hypersensitivity Syndrome

A
  1. stop/substitute ALL suspected medications
  2. consult dermatology
  3. mild-moderate: topical steroids
  4. Mod-severe reaction/organ failure: oral steroids with long gradual taper
  5. symptomatic: oral antihistamines
76
Q

an acute febrile eruption that is often associated with leukocytosis after drug administration

A

Pustular Drug Eruptions

77
Q

s/s of Pustular Drug Eruptions?
w/u?

A
  • sterile pustules on an erythematous base, often starting in the intertriginous folds and/or the face
  • fever
  • CBC: leukocytosis

Clin Med III: Dermatology (13 decks)

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