Papulosquamous and Inflammatory Disorders Flashcards
An acute exanthematous eruption with a distinctive morphology and often with a characteristic self limited course
Single “herald” patch, 1-2 wks later = generalized
Pityriasis Rosea
MCC of Pityriasis Rosea
Herpes Human Virus 6 and 7
Pityriasis Rosea MC in who and when?
Onset: 10-40 years old
MC in Spring and Fall
- Oval, slightly raised plaque or patch (2-5 cm)
- Salmon red, fine collarette
- 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?
- Pityriasis Rosea
- spontaneous remission; oral antihistamines, topical antipruritic lotion (sarna), steroids (TAC or prednisone)
Acute or chronic inflammatory dermatosis involving skin and or mucous membranes
Lichen Planus
causes of Lichen Planus
- Idiopathic MC
- Cell mediated immunity - CD8+ & CD45Ro+ cells - Drugs
- Metals (gold and mercury)
- Infection (hep C)
- Papules, flat topped - Polygonal or oval ; Annular; Purple; Pruritic
- 1-10 mm
- Sharply defined, shiny
- Violaceous, with white lines (Whickham striae)
- Grouped or disseminated - Dark phototype hyperpigmented
lichen planus
how to observe Whickham striae under dermatoscope?
seen after the use of oil under a dermatoscope
lichen planus
lichen planus is MC found where on the body?
- Wrists (flexor)
- Lumbar region
- Shins
- Scalp
- Glans penis
- Mouth
11 variants of lichen planus
- Hypertrophic: Large thick plaques
- Atrophic: White bluish, well-demarcated papules and with central atrophy
- Follicular: Follicular papules and plaques –> cicatrical alopecia
- Vesicular: Bullous pemphigoid w/ LP
- Pigmentosus: Hyperpigmented, dark-brown macules in sun exposed areas and flexural folds
- Actinicus: Papules in sun exposed areas
- Ulcerative /erosive: Therapy resistant spots = ulcers
- MUCOUS MEMBRANES : MC in mouth
- Reticular: Lacy white hyperkeratosis on buccal mucosa, lips, tongue, gingiva
- Genitalia: Papular, annular, or erosive lesions on penis, scrotum, labia majora, labia minora and vagina
- Hair & nails: Scarring alopecia possible; Destruction of nail fold and bed w/ longitudinal splintering
w/u and tx for lichen planus
- bx
- TAC BID x 4wks; ILK
- Cyclosporine and tacrolimus solution - for mouth
- systemic - cyclosporin, prednisone, retinoids
- other: PUVA
Granuloma Annulare MC in who?
- MC Children and young adults
- Female
Granuloma Annulare cause is unknown, but has been seen in pts with this chronic condition?
diabetics
- Skin colored or brownish-red
- Shiny beaded papules - Annular arrangement
- MC hands, feet, elbows and knees - Generalized MC, can be isolated spot
granuloma annulare
if GA is diagnosed and ____ hasn’t been diagnosed, the patient should be sent to PCP for work up
DM
histologic findings of granuloma annulare on bx?
- Foci of chronic inflammatory and histiocytic infiltrations in superficial and mid dermis
- Necrobiosis of CT surrounded by a wall of palisading histiocytes and multinucleated giant cells
tx for granuloma annulare
- Not needed (spontaneous remission within 2 yrs)
- TAC 0.5% BID x 4 weeks
- ILK – 3 mg/mL (very effective)
- Cryo - not recommended due to scarring
Common acute inflammatory/immunologic reaction pattern of the subcutaneous fat
MC type of panniculitis
Erythema Nodosum
causes of Erythema Nodosum
- Infection
- Drugs
- Inflammatory/granulomatous diseases
- Sarcoidosis
Erythema Nodosum MC in who?
- 20-30 years old
- Females
- Painful, Tender, Fever, Malaise, Arthralgia (MC ankle joints)
- Indurated, tender nodules 3-20cm - Bright to deep red; Only appreciated on palpation
- Not sharply marinated - Oval, round, and acriform
- Deep seated in fat (MC anterior leg) - brownish, yellowish, green with age
- Bilateral but not symmetrical
Erythema Nodosum
w/u for Erythema Nodosum
Hematology - Elevated ESR and CRP; Leukocytosis
tx for erythema nodosum
- Spontaneous resolution occurs in 6 weeks w/o scarring
- symptomatic tx - rest, compression, wet dressings
- antiinflammatory tx - NSAIDs, Prednisone
Chronic, multifactorial inflammatory skin disorder resulting in hyperproliferation of the keratinocytes in the epidermis
psoriasis
pathogenesis of psoriasis?
- not completely understood
- T-cell proliferate the epidermis = overproduction of epidermal cells
- dysregulated inflammatory process = large production of various cytokines
development/steps of psoriatic lesions
- psoriatic skin w/o active lesion - capillary dilation and curvature, more mononuclear cells and mast cells, increased epidermal thickness
- developing lesion - more cap dilatation and tortuosity, mast cells, T-cells, and mast cell degranulation, thickness of epidermis
- 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)
RF for psoriasis
-
Environmental - trauma (Koebner phenomenon), stress, cold, infection, alc, medications
- Acute streptococcal infection precipitates guttate psoriasis - Genetic
-
Immunologic
- first lesion typically appears after URI
- evidence of autoimmune properties (T-cell hyperactivity)
3 subtypes of psoriasis
- Eruptive, inflammatory psoriasis
- Pustular
- Chronic stable (plaque) psoriasis (MC): classic lesions present for months-years without little change
- aka: guttate or nummular psoriasis
- multiple small lesions appearing rapidly
- spontaneous remission
- often follows strep pharyngitis
which types of psoriasis
Eruptive, inflammatory psoriasis
- erythematous papule/patch/plaque with sharp margins
- overlying silvery-white scales easily removed with scratching
- Auspitz sign: removal of scale leaves small blood droplet - pruritus is common historical finding
Psoriasis
- 2-10 mm, salmon pink papules, +/- scales
- concentrated to the trunk, few scattered lesions to face, scalp, extremities
- may resolve spontaneously within a few wks
- most often evolves into chronic stable type
which type of psoriasis
Eruptive, inflammatory psoriasis
- sharply marginated, dull-red plaques with loosely adherent silver-white scales
- plaques may coalesce
- Waxing and waning of lesions throughout lifetime
which type of psoriasis
Chronic Stable Psoriasis
MC sites of psoriasis
Bilateral, often symmetric
Elbows
Knees
Sacral/gluteal region
Scalp
Palm/soles
special sites of psoriasis presentation
- Palms/soles: thick adherent silvery-white or yellow scaling; painful cracking/fissures
- Scalp: sharply marginated plaques with thick adherent scales; intense pruritus; no hair loss
- face: uncommon; seen in refractory cases
- Peri-anal/body folds (inverse psoriasis): macerated d/t warm moist area; sharply marginated, bright red, fissured lesions
- Nails: pitting, subungual hyperkeratosis, onycholysis; yellowish-brown spots (oil-spots)
- results from increase in polymorphonuclear (PMN) leukocytes present in the psoriatic epidermis
- Outbreak is often precipitated by corticosteroid withdrawal
- Subjective: stinging, burning, pruritus
- Erythematous patches or thin plaques that rapidly become studded with numerous pinhead-sized sterile pustules
which type of psoriasis
Pustular Psoriasis
2 presentations of pustular psoriasis
- palmoplantar - palms/soles: pustules 2-5 mm; erupt into dusky-red erosions and crusts; persists for years with unexplained remissions/exacerbations
- 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
- joint stiffness & pain worse after inactivity, improves with movement
- swelling, redness and tenderness of involved joints
- psoriatic lesions develop over involved joints
which type of psoriasis
Psoriatic Arthritis
w/u for psoriasis?
- clinical
- labs to r/o ddx - throat cx, KOH, bacterial/viral cx, CBC (leukocytosis w/ left shift in generalized pustular psoriasis)
referrals for psoriasis
- refer to derm
- localized psoriasis- can be managed by PCP once therapy is initiated
- generalized psoriasis- managed by dermatology provider
- psoriatic arthritis- refer to rheumatology
tx for Localized Psoriasis - trunk/extremities
-
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 - Vitamin D analog - calcipotriol, calcitriol
- tazarotene - for thick plaques, best with mid-high potent CS or UVB phototherapy
- Coal Tar + SA
- Emollients
MOA of Topical Vitamin D Analogs
binds to Vit D receptor and regulates cell growth
inhibits proliferation of keratinocytes
inhibits proinflammatory cytokines
SE of calcipotriene 0.005%
burning, itching, skin irritation, photosensitivity, hypercalcemia
CI: hypersensitivity
SE of calcitriol 0.0003% oint
hypercalcemia, photosensitivity
CI: none
tx for localized scalp psoriasis
tar shampoo followed by medium-high potency lotion
tx for localized pals/soles psoriasis
- high-potency topical steroids oint with occlusive dressing
-
PUVA ‘soaks’
- immerse affected area in photosensitizer liquid 15 minutes
- expose hands/feet to UVA phototherapy units - Oral retinoids: if unresponsive thick hyperkeratotic lesions
tx for palmoplantar pustulosis
- PUVA ‘soaks’
- MTX or Cyclosporine CS unresponsive cases
tx for Inverse(body folds)/genital
localized psoriasis
- start with short term (2-4 wks) of topical steroids
- then one of the following: Vitamin D analog; topical retinoid (tazarotene); topical calcineurin inhibitors (tacrolimus/pimecrolimus)
tx for localized nail psoriasis
- PUVA phototherapy in hand/foot lighting units
- Oral retinoids
- Immunosuppressant: MTX or CS for unresponsive cases
which topical psoriasis tx can be used for all types of psoriasis?
SE?
- topical steroids
- Skin atrophy, hypopigmentation, striae
which topical psoriasis tx is used in combination or rotation with topical steroids for added benefit?
SE?
- Calcipotriene (Vitamin D derivative)
- Skin irritation, photosensitivity (but no contraindication with UVB phototherapy)
which topical psoriasis tx is reserved for Plaque-type psoriasis?
Best when used with topical corticosteroids.
SE?
Tazarotene (Topical retinoid)
Skin irritation, photosensitivity
which topical psoriasis tx is reserved for Plaque-type psoriasis?
SE?
- Coal tar
- Skin irritation, odor, staining of clothes, carcinogenic
which topical psoriasis tx has Off-label use for facial and intertriginous psoriasis?
SE?
- Calcineurin inhibitors
- Skin burning and itching
mgmt for Generalized Acute, inflammatory Psoriasis
- tx underlying strep if applicable
- Refer to Dermatology
- narrow band UVB irradiation
- oral PUVA photochemotherapy (if UVB therapy fails)
mgmt for Generalized Pustular Psoriasis
- hospitalization with IV fluids
- in hospital consult with dermatology
- prophylactic IV antibiotics
- oral retinoids
mgmt for Generalized Chronic Plaque Psoriasis
- Refer to dermatology
- narrow band UVB irradiation
- oral PUVA photochemotherapy
- oral retinoids
- immunosuppressants/biologic agents
what is the most important of hx for Adverse Cutaneous Drug Reactions
TIMING
start with onset of rash and work backwards and forwards considering all possible causes and pharmacologic agents
RF for Adverse Cutaneous Drug Reactions
- female
- prior hx of drug reaction
- recurrent drug exposure
- EBV & CMV infection with PCN drugs
- HIV with sulfonamides
difference between Immediate vs Delayed adverse cutaneous drug Reactions
- Immediate: < 1 hr of last dose; urticaria, angioedema, anaphylaxis
- Delayed: 1- 6 h, weeks-months after drug use; exanthematous eruptions, fixed drug eruptions, systemic reactions
- 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)
Exanthematous Drug Reactions
Exanthematous Drug Reactions are classified how?
timing - immediate vs delayed
s/s of exanthematous drug reactions
- bright red, maculopapular rash
- symmetric: starts on trunk and spreads to extremities
- scaling/desquamation with healing
- mild pruritus
drugs that have a High probability to cause Exanthematous Reaction
- PCN drug class
- carbamazepine
- allopurinol
- gold salts
drugs that have a medium probability to cause Exanthematous Reaction
- sulfonamides
- NSAIDs
- isoniazid
- erythromycin
- streptomycin
drugs that have a low probability to cause Exanthematous Reaction
- barbiturates
- BZD’s
- phenothiazines
- tetracyclines
tx and pt ed for exanthematous drug reactions
- identify and DC offending agent - oral/IV steroids if they must continue agent
- topical steroids and antihistamines
- ensure pt is aware of offending agent and drug class
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
Fixed Drug Eruption
s/s of Fixed Drug Eruption
- Onset: 30 min-8 hours after ingestion
- Pruritus, burning pain
- Skin Lesion
- sharply marginated macule
- erythema (early), dusky red-violaceous (later)
- may become edematous and bullous followed by erosion
- PIH after resolution
Fixed Drug Eruption - Sites of Predilection
- genital
- pubic/crural region
- perioral
- periorbital
- conjunctiva
- oropharynx
mgmt for fixed drug eruption
- 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
skin eruptions with systemic symptoms and internal organ involvement
Drug-Induced Hypersensitivity Syndrome
causes of Drug-Induced Hypersensitivity Syndrome
- Antiepileptics: phenytoin, carbamazepine, phenobarbital
- Sulfonamides : antimicrobial agents, dapsone, sulfasalazine
s/s of Drug-Induced Hypersensitivity Syndrome
- onset 2-6 wks after drug initiation or increased dose
- F, malaise, facial edema, LAD, hepatosplenomegaly
- maculopapular eruption - starts on face, upper trunk and UE; scaling/desquamation occur with healing
- oropharyngeal mucosal lesions - cheilitis, erosions, pharyngitis, tonsillitis
Assess: liver, kidneys, lymph nodes, heart, lungs, joints, muscles, thyroid, and brain for systemic involvement
w/u and criteria for Drug-Induced Hypersensitivity Syndrome
- CBC: leukocytosis, eosinophilia; LFT; BUN/Cr
- Diagnostic Criteria (3 must be present):
- cutaneous drug eruption
- hematologic abnormalities
- systemic involvement: LAD >2 cm; elevated LFT (hepatitis); elevated BUN/Cr (interstitial nephritis)
tx for Drug-Induced Hypersensitivity Syndrome
- stop/substitute ALL suspected medications
- consult dermatology
- mild-moderate: topical steroids
- Mod-severe reaction/organ failure: oral steroids with long gradual taper
- symptomatic: oral antihistamines
an acute febrile eruption that is often associated with leukocytosis after drug administration
Pustular Drug Eruptions
s/s of Pustular Drug Eruptions?
w/u?
- sterile pustules on an erythematous base, often starting in the intertriginous folds and/or the face
- fever
- CBC: leukocytosis
