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Dermatology > Papulosquamous and Inflammatory Disorders > Flashcards

Papulosquamous and Inflammatory Disorders Flashcards

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Dermatology Board Prep flashcards
1
Q

What is pityriasis rosea?

A

Acute exanthematous eruption
Self limited
Remits in 6 weeks

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2
Q

MCC of pityriasis rosea

A

Herpes Human Virus 6 and 7

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3
Q

Epidemiology of pityriasis rosea

A

10-40 years old
MC in spring and fall

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4
Q

Clinical presentation of pityriasis rosea

A

Herald patch: oval, slightly raised plaque or patch
Salmon red, fine collarette
1-2 weeks later fine scaling papules and patches with marginal collarette/dull pink
Oval scattered (christmas tree pattern)
confined to trunk

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5
Q

Which disorder is in a christmas tree distribution?

A

Pityriasis Rosea

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6
Q

Course of pityriasis rosea

A

Spontaneous remission in 6-12 weeks
Recurrences are uncommon

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7
Q

Management of pityriasis rosea

A

Control itch
Oral antihistamines
Topical antipruritic lotions
Topical steroids: triamcinolone .1% cream/ointment/lotion BID x 4 weeks
Oral steroids: prednisone taper (if really bad)

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8
Q

What is lichen planus?

A

Acute or chronic inflammatory dermatosis involving skin and/or mucous membranes MC idiopathic

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9
Q

What is thought to play a role in lichen planus?

A

Cell mediated immunity (CD8 and CD45Ro+ cells)
Drugs
Metals (gold and mercury)
Infection (hep C)

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10
Q

Presentation of lichen planus

A

Papules that are flat topped, polygonal or oval
Annular
Purple
Pruritic
1-10 mm in size
Sharply defined, shiny
Violaceous with white lines (Whickham striae) seen after use of oil under dermascope
Grouped or disseminated
If darker phototype, hyperpigmented

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11
Q

Locations of lichen planus

A

Wrists
Lumbar
Shins
Scalp
Glans penis
Oral

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12
Q

Variants of lichen planus

A

Hypertrophic
Atrophic
Follicular
Vesicular
Pigmentosus
Actinicus
Ulcerative/erosive
Mucous membranes
Reticular

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13
Q

Characteristics of hypertrophic lichen planus? Atrophic?

A

Hypertrophic: Large thick plaques
Atrophic: White bluish, well demarcated papules and plaques with central atrophy

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14
Q

Characteristics of follicular lichen planus? Vesicular?

A

Follicular: follicular papules and plaques that lead to cicatrical alopecia
Vesicular: bullous pemphigoid with LP

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15
Q

Characteristics of pigmentosus lichen planus? Actinicus?

A

Pigmentosus: hyperpigmented, dark-brown macules in sun exposed areas and flexural folds
Actinicus: papules in sun exposed areas

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16
Q

Characteristics of ulcerative/erosive lichen planus? Reticular?

A

Ulcerative/erosive: ulcers that are therapy resistant
Reticular: lacy, white hyperkeratosis on buccal mucosa, lips, tongue, gingiva

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17
Q

what percent of lichen planus has mouth involvement?

A

40-60%

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18
Q

What is the appearance of lichen planus on genitalia?

A

Papular, annular, or erosive lesions on the penis, scrotum, labia majora, labia minora, and vagina

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19
Q

What is the appearance of lichen planus of the hair and nails?

A

Scarring alopecia possible
Destruction of nail fold and bed with longitudinal splintering

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20
Q

Course of lichen planus

A

Months to years

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21
Q

Diagnosis of lichen planus?

A

Biopsy helpful

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22
Q

Treatment of localized lichen planus

A

Topical steroids: under occlusion for cutaneous lesions, 1st line =triamcinolone BID x 4weeks
ILK injection
Cyclosporine and tacrolimus solution, mouthwash for oral lesions

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23
Q

Treatment of systemic lichen planus

A

Cyclosporin 5 mg/kg per day
Prednisone 70 mg initially then taper by 5 mg
Retinoids 1 mg/kg per day as adjunct
PUVA

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24
Q

What is the use of prednisone in systemic lichen planus?

A

Ease discomfort and pruritis

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25
Q

What is granuloma annulare?

A

Chronic condition of the dermis
Self limited

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26
Q

Epidemiology of granuloma annulare

A

Females: males 2:1
MC children and young adults

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27
Q

Etiology of granuloma annulare

A

Unknown see in diabetes

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28
Q

Presentation of granuloma annulare

A

Skin colored or brownish-red
Shiny beaded papules in annular arrangement
MC on hands and feet, elbows and knees (commonly misdiagnosed as tinea)
Generalized but can be isolated spot

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29
Q

If GA is diagnosed, what should be worked up?

A

Work up for diabetes

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29
Q

Diagnosis of granuloma annulare

A

Clinical but biopsy diagnostic
See foci of chronic inflammatory and histiocytic infiltrations in superficial and mid dermis
Necrobiosis of connective tissue surrounded by a wall of palisading histiocytes and multinucleated giant cells

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30
Q

management of granuloma annulare

A

no treatment necessary
topical triamcinolone
ILK
Cryo may resolve (but not recommended due to scarring)

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31
Q

What is erythema nodosum?

A

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

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32
Q

Etiology of erythema nodosum

A

Infection
Drugs
Inflammatory/granulomatous disease
Sarcoidosis

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33
Q

What is the age of onset/gender of erythema nodosum

A

20-30 yo
Female >Male (6:1)

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34
Q

Symptoms of erythema nodosum

A

Painful
Tender
Fever
Malaise
Arthralgia (MC ankle)

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35
Q

Lesion presentation in erythema nodosum

A

Indurated, tender nodules 3-20 cm
Bright to deep red
Only appreciated on palpation
Not sharply marginated: oval, round, and acriform
Deep seated in fat (MC anterior leg)
As they age: brownish, yellowish, green
Bilateral but not symmetrical

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36
Q

Diagnosis of erythema nodosum

A

Elevated ESR and CRP
Leukocytosis
2 punch biopsy of nodule

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37
Q

Course of erythema nodosum

A

Spontaneous resolution in 6 weeks
Heal without scarring

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38
Q

Management of erythema nodosum

A

Symptomatic
Bed rest
Compressive bandages
Wet dressings

Antiinflammatory treatment: NSAIDs and prednisone

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39
Q

What is psoriasis

A

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

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40
Q

Pathogenesis of psoriasis

A

Theory that T cell proliferate the epidermis resulting in over production of epidermal cells
Dysregulated inflammatory process results in large production of various cytokines

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41
Q

Epidemiology of psoriasis

A

2 peaks
20-30 yo and 50-60 yo

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42
Q

Histology of psoriatic skin without active lesion

A

Slight capillary dilatation
Slight increase in dermal mononuclear cells and dermal cells
Increase in epidermal thickness

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43
Q

Histology of developing lesion

A

Progressive capillary dilatation
Increase in mast cells, macrophages, and T cells, and mast cell degranulation
Increasing thickness of the epidermis

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44
Q

What is histology of fully developed psoriatic lesion

A

10 fold increase in blood flow
Numerous macrophages underlying basement membrane
Increase number of T cells
Increase in epidermis
Accumulation of neutrophils in stratum corneum

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45
Q

Etiology of psoriasis

A

Environmental: trauma (Koebner phenomenon), stress, cold, infection, alcohol, medications
Acute streptococcal infection precipitates guttate psoriasis
Genetic: 30% have first degree relative with psoriasis
Immunologic: first lesion typically after URI, evidence of autoimmune properties

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46
Q

Subtypes of psoriasis

A

Eruptive/inflammatory
Pustular
Chronic stable psoriasis

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47
Q

What is eruptive inflammatory psoriasis

A

aka guttate or nummular
multiple small lesions appearing rapidly
spontaneous remission
often follows strep pharyngitis

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48
Q

Pustular psoriasis

A

presence of pustules instead of papules, patches, and plaques

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49
Q

What is chronic stable psoriasis

A

MC presentation
Classic lesions present for months - years with little change

50
Q

Classic lesion presentation

A

Erythematous papule/patch/plaque with sharp margins
OVerlying silvery white scales easily removed with scratching
Auspitz sign
Pruritis

51
Q

What is Auspitz sign?

A

Removal of scale leaves small blood droplet

52
Q

Clinical presentation of eruptive inflammatory psoriasis

A

2-10 mm salmon pink papules +/- scales
concentrated to trunk, few scattered lesions to face, scalp, extremities
may resolve spontaneously within few weeks
most often evolves into chronic stable type

53
Q

clinical presentation of chronic stable psoriasis

A

sharply marginated dull-red plaques with loosely adherent silver-white scales
plaques may coalesce
waxing and waning of lesions throughout lifetime

54
Q

sites of predilections to psoriasis

A

bilateral, often symmetric
elbows
knees
sacral/gluteal region
scalp
palm/soles

55
Q

Clinical presentation of palms/sole psoriasis

A

thick adherent silvery-white or yellow scaling
painful cracking/fissures

56
Q

clinical presentation of face psoriasis

A

uncommon
seen with refractory cases

57
Q

clinical presentation of scalp psoriasis

A

sharply marginated plaques with thick adherent scales
intense pruritis
no hair loss

58
Q

clinical presentation of psoriasis of peri-anal/body folds

A

macerated due to warm moist environment
sharply marginated, bright red, fissured lesions

59
Q

clinical presentation of nail psoriasis

A

pitting, subungual hyperkeratosis, onycholysis
yellowish-brown spots
involved 25% of the time

60
Q

clinical presentation of pustular psoriasis

A

results from increase in PMN leukocytes in psoriatic epidermis
often precipitated by corticosteroid withdrawal
stinging
burning
pruritis
erythematous patches or thin plaques that rapidly become studded with nummerous pinhead-sized sterile pustules

61
Q

2 presentations of pustular psoriasis

A

palmoplantar (pams/soles)
generalized “Von Zumbusch variant”

62
Q

Presentation of palmoplantar pustular psoriasis

A

pustules 2-5 mm
erupt into dusky-red erosions and crusts
persists for years with unexplained remissions/exacerbations

63
Q

presentation of generalized pustular psoriasis

A

pustules coalesce into lakes of pus
+ Nikosky sign in generalized presentation
life threatening
relapses and remissions occur over years
may evolve into chronic stable psoriasis

64
Q

subjective findings of psoriatic arthritis

A

joint stiffness and pain worse after inactivity, improves with movement

65
Q

objective findings of psoriatic arthritis

A

swelling
redness
tenderness of involved joints
psoriatic lesions over involved joints

66
Q

diagnosis of psoriasis

A

clinical
labs to r/o other disorders: throat culture to r/o strep for acute inflammatory psoraisis, KOH prep, bacterial/viral culture for pustular psoriasis
leukocytosis with left shift seen in generalized pustular psoriasis

67
Q

management of psoriasis

A

refer to dermatology to confirm diagnosis and initiate management
localized psoriasis - can be managed by PCP once therapy initiated
generalized: managed by dermatology provider
psoriatic arthritis: refer to rheumatology

68
Q

management of localized psoriasis on trunk/extremities

A

topical steroids mid to high potency
Consider ointment for night and cream for day

Vitamin D analog: calcipotriol, calcitriol

Topical retinoid (tazarotene) reserved for thick plaques, best in combo with topical mid-high potency glucocorticoid or UVB phototherapy

Coal tar with salicylic acid

Emollients liberally in between treatments and always after bathing/showering

69
Q

What are the vitamin D analogs used for psoriasis

A

calcipotriene, calcitriol

70
Q

what vehicle is often used for vitamin D for scalp psoriasis

A

solution

71
Q

MOA of vitamin D analog

A

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

72
Q

directions for vitamin D analog

A

apply thin layer to affected area BID, avoid application to >40% body area and 100 g/week maximum

73
Q

SE of topical vitamin D analogs

A

burning
itching
skin irritation
photosensitivity
hypercalcemia

74
Q

CI for vitamin D analogs

A

hypersensitivity

75
Q

MOA of calcitriol

A

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

76
Q

directions for calcitriol

A

apply thin layer to affected area BID 20 g/wk maximum

77
Q

SE/CI of calcitriol analog

A

hypercalcemia, photosensitivity
no CI

78
Q

management of scalp psoriasis

A

tar shampoo followed by medium- high potency lotion

79
Q

management of palm/sole psoriasis

A

high potency topical steroids ointment with occlusive dressing
PUVA soaks (immerse in photosensitizer liquid 15 mins and expose to UVA phototherapy units)
oral retinoids: reserved for unresponsive thick hyperkeratotic lesions

80
Q

management of palmoplantar pustulosis

A

PUVA soaks
immunosuppressant: methotrexate or cyclosporine in unresponsive cases

81
Q

management of inverse/genital psoriasis

A

initiate with short term (2-4 weeks) of topical steroids
followed by one of the following:
vitamin D analog, topical retinoid (tazarotene), topical calcineurin inhibitors (tacrolimus/pimecrolimus)

82
Q

management of nail psoriasis

A

goal: normal regrowth, consider length of therapy based on rate of nail growth
Options: PUVA phototherapy in hand/foot lighting units, oral retinoids, immunosuppressant MTX or CS for unresponsive types

83
Q

Which psoriasis treatment is pregnancy category X?

A

Tazarotene

84
Q

Topical steroids side effects

A

skin atrophy
hypopigmentation
striae

85
Q

calcipotriene side effects

A

skin irritation
photosensitivity

86
Q

tazarotene side effects

A

skin irritation
photosensitivity

87
Q

coal tar side effects

A

skin irritation
odor
staining of clothes
carcinogenic

88
Q

calcineurin inhibitors side effects

A

skin burning and itching

89
Q

when are calcineurin inhibitors used?

A

off-label for facial and intertriginous psoriasis

90
Q

generalized acute, inflammatory psoriasis management

A

treat underlying strep infection if applicable
refer to dermatology for PUVA or UVB irradiation

91
Q

generalized pustular psoriasis management

A

hospitalization with IV fluids
in hospital consult with derm
prophylactic IV antibiotics
oral retinoids

92
Q

generalized chronic plaque psoriasis management

A

refer to dermatology for narrow band UVB irradiation, oral PUVA photochemotherapy, oral retinoids, immunosuppressants/biologic agents

93
Q

What is the most important piece of historical information for adverse cutaneous drug reactions

A

Timing
Start with onset of rash and work backwards and forwards considering all possible causes

94
Q

Risk factors for adverse cutaneous reactions

A

female
prior hx of drug reactions
recurrent drug exposure
EBV and CMV infection with PCN
HIV with sulfonamides

95
Q

Immediate reactions occur within —— of last dose and symptoms include:

A

1 hour
urticaria, angioedema, anaphylaxis

96
Q

delayed reactions usually occur after ——, usually before —–, and occasionally ——- after initiation of drug use

A

1 hour, 6 hours, weeks-months

97
Q

skin presentation of delayed adverse cutaneous drug reactions

A

exanthematous eruptions
fixed drug eruptions
systemic reactions

98
Q

What are exanthematous drug reactions?

A

MC of all drug reactions
mechanism not fully known, likely delayed hypersensitivity

99
Q

What is one example of exanthematous drug reactions not thhought to be allergey relatedp

A

EBV and CMV and PCN

100
Q

What are classifications of exanthematous drug reactions

A

immediate reactions
delayed reactions

101
Q

what is immediate exanthematous drug reaction

A

previously sensitized
2-3 days after initiation of drug

102
Q

what are delayed exanthematous drug reactions?

A

delay due to sensitiization requirement
most often 7-10 days after initiation of drug
may take up to 3 weeks

103
Q

clinical findings of exanthematous drug reactions

A

bright red, maculopapular rash
symmetric: starts on trunk and spreads to extremities
scaling/desquamation with healing
mild pruritis

104
Q

high probability agents for exanthematous reaction

A

PCN
carbamazepine
allopurinol
gold salts

105
Q

medium probability exanthematous reaction

A

sulfonamides
NSAIDs
isoniazid
erythromycin
streptomycin

106
Q

low probability of exanthematous reaction drugs

A

barbiturates
BZDs
phenothiazines
tetracyclines

107
Q

management of exanthematous drug reaction

A

identify and discontinue offending agent
if benefit outweighs risk (rare), oral/IV steroids
topical steroids and antihistamines for symptomatic relief
ensure patient is aware of offending agent and drug class

108
Q

what is fixed drug eruption

A

drug reaction characterized by solitary erythematous patch/plaque that recurs at same site if re-exposure of offending agent occurs
Occasionally multiple fixed lesions occur
Unknown pathogenesis

109
Q

clinical presentation of fixed drug eruption

A

onset 30 mins-8 hrs after ingestion
pruritis, burning pain

skin lesion
sharply marginated macule
erythema
dusky-red violaceous
edematous and bullous followed by erosion (may occur)
postinflammatory hyperpigmentation may occur

110
Q

sites of predilection to fixed drug eruption

A

genital
pubic/crural
periorbital
conjunctiva
oropharynx

111
Q

management of fixed drug eruption

A

remove offending agent
non-eroded lesions: topical steroid ointment
eroded lesion: topical antimicrobial ointment
symptomatic: antihistamines for pruritis, oral liquid compound for painful oral lesions
widespread presentation: refer to dermatologist

112
Q

what is drug-induced hypersensitivity syndrome?

A

Skin eruptions with systemic symptoms and internal organ involvement

113
Q

etiology of drug induced hypersensitivity syndrome

A

antiepileptic drugs: phenytoin, carbamazepine, phenobarbital
sulfonamides: antimicrobial agents, dapsone, sulfasalazine

114
Q

clinical findings of drug induced hypersensitivity syndrome

A

onset 2-6 wks after drug initiation or increased dose
fever, malaise, facial edema
lymphadenopathy, hepatosplenomegaly
maculopapular eruption: starts on face, upper trunk, and UE, scaling and desquamation with healing
oropharyngeal mucosal lesions: cheilitis, erostions, pharyngitis, tonsillitis

115
Q

dont forget to do this on exam of drug-induced hypersensitivity syndrome

A

full work up for systemic involvement

116
Q

labs for drug-induced hypersensitivity syndrome

A

CBC: leukocytosis, eosinophilia
LFT
BUN/Cr

117
Q

Diagnostic criteria for drug-induced hypersensitivity syndrome

A

3 must be present

Cutaneous drug eruption
hematologic abnormalities
systemic involvement: lymphadenopathy >2 cm, elevated LFTs, elevated BUN/Cr (interstitial nephritis)

118
Q

treatment of drug-induced hypersensitivity syndrome

A

stop/substitute all suspected medications
consult dermatology
mild-moderate reaction: topical steroids
moderate-severe reaction/organ failure: oral steroids with long gradual taper
systemic: oral antihistamines

119
Q

what is pustular drug eruption

A

acute febrile eruption often associated with leukocytosis after drug administration

120
Q

onset of pustular drug eruption

A

1-3 weeks after initiation (if no previous sensitization)
2-3 days after initiation (if previously sensitized)

121
Q

clinical findings of pustular drug eruptions

A

sterile pustules on an erythematous base, often starting in the intertriginous folds and/or face
fever

122
Q

labs/diagnostics for adverse cutaneous drug reactions

A

leukocytosis

123
Q

course/prognosis of adverse cutaneous drug reactions

A

pustules resolve over 2 wks followed by desquamation 2 weeks later

Dermatology (12 decks)

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