Papulosquamous and Inflammatory Disorders - Exam 2 Flashcards
_____ An acute exanthematous eruption with a distinctive morphology and often with a characteristic self limited course. A single _____ patch
pityriasis rosea
Single “herald” patch
Where do single “herald” patches usually develop? What happens 1-2 weeks later? When does it go away?
Plaque that develops usually on the trunk
1-2 weeks later = generalized
remits in 6 weeks
What are the MC cause of Pityriasis Rosea? What age range? What time of the year?
herpes human virus (HHV) 6 and 7
10-40
spring and fall
What am I? How does it usually start for >80% of the population?
pityriasis rosea
> 80% of patients = starts as Herald Patch
Describe a herald patch. What happens 1-2 weeks later?
Oval, slightly raised plaque or patch (2-5 cm)
usually Salmon red, fine collarette
1-2 weeks after herald patch develops Exanthem
**Describe the pattern of a pityriasis rosea once it has fully erupted. Where do you typically NOT see it?
**Oval scattered (Christmas Tree pattern)= Pityriasis Rosea
NOT usually on the face
How long does it take for Pityriasis Rosea
to run its course? What is the tx?
Spontaneous remission in 6-12 weeks and recurrences are NOT common
will go away on their own
_____ Acute or chronic inflammatory dermatosis involving skin and or mucous membranes. What is the MC etiology?
lichen planus
Idiopathic most commonly: CD8+ & CD45Ro+ cells
What are some additional causes of lichen planus?
drugs
metals (gold and mercury)
infection (hep C)
What am I?
lichen planus
Papules, flat topped
Polygonal or oval
Annular
Purple
Pruritic
usually 1-10mm in size
sharply defined, shiny
Violaceous, with white lines
What am I?
Where are 2 common locations?
lichen planus
wrist and ankles
______ are the violaceous with white lines commonly seen in lichen planus
Whickham striae
What are some additional locations of lichen planus?
wrists
lumbar region
shins
scalp
glans penis
mouth
What are some different variants of lichen planus? **What is the highlighted one?
hypertrophic
atrophic
follicular
vesicular
pigmentosus
actinicus
ulcerative/erosive
mucous membranes 40-60% have mouth involvement
reticular
genitalia
hair/nails
_____: Large thick plaques
hypertrophic lichen planus
______ White bluish, well demarcated papules and plaques with central atrophy
atrophic lichen planus
_____ Follicular papules and plaques that lead to cicatrical alopecia
follicular lichen planus
______ Hyperpigmented, dark-brown macules in sun exposed areas and flexural folds
pigmentous lichen planus
_____ Papules in sun exposed areas
actinicus lichen planus
_____ Lacy white hyperkeratosis on buccal mucosa, lips, tongue, gingiva
reticular lichen planus
How will lichen planus of the hair/nails present?
Destruction of the nail fold and bed w/ longitudinal splintering
What is the typical course of lichen planus? ____ is extremely helpful in diagnosis
course is months to years
bx!! is extremely helpful
What is the tx for cutaneous lichen planus?
triamcinolone BID 4 weeks under occlusion for cutaneous lesions
intralesion kenalog injections
What is the tx for oral lichen planus
Cyclosporine and Tacrolimus Solution as a
mouthwash for oral lesion
What is the treatment for systemic lichen planus? ____ can be used as adjunct
Cyclosporin
oral prednisone 70mg then taper
Retinoids 1mg/kg per day
What am I? Who is the MC pt population?
granuloma annulare
MC in female children and young adults
commonly seen in DM pts
Do you always need to tx granuloma annulare? How does it compare to ringworm?
NO! it is a common self limiting condition of the dermis
also has a raised border but NO SCALE present
Skin colored or brownish-red
Shiny beaded papules
Annular arrangement
MC on hands and feet, elbows and knees
can also just be one spot
What am I?
Should consider working the pt up for _____
Granuloma Annulare
DM! need to rule out
What am I?
How do you dx?
granuloma annulare
bx is dx
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. This is the path reports of what dx?
granuloma annulare
What is the management of granuloma annulare?
no tx neccessary!
but can give topical triamcinolone 0.5% BID x 4 weeks
or ILK injections
______ are common acute inflammatory/immunologic reaction pattern of the subcutaneous fat. These are the MC type of ______
erythema nodosum
panniculitis
What are the 4 etiology factors of Erythema Nodosum?
Infection
Drugs
Inflammatory/granulomatous diseases
Sarcoidosis
What is the MC pt population for erythema nodosum?
female 20-30 years old typically in the lower extremities
Painful and tender nodules
Fever
Malaise
Arthralgia (MC ankle joints)
Indurated, tender nodules 3-20cm
bright to deep red
NOT sharply marinated
bilateral but not symmetrical
What am I?
Where is the MC location?
Erythema Nodosum
MC: deep seated in fat in the anterior leg
What will labs show of a pt with erythema nodosum? What is the course progression?
Elevated ESR and C-reactive protein
Leukocytosis
Spontaneous resolution occurs in 6 weeks
Heal without scarring
What is the management of erythema nodosum? How do you bx them?
tx symptoms: bed rest, compressive bandages, wet dressings, NSAIDs, steroids
need 2 punch bx, wider punch bx then take a 2nd punch bx out of the fat underneatht the hole from the first
aka need to bx the subq fat
______ Chronic, multifactorial inflammatory skin disorder resulting in hyperproliferation of the keratinocytes in the epidermis
psoriasis
What is the pathogenesis of psoriasis?
not super well understood:
T-cell proliferate the epidermis resulting in an over production of epidermal cells
dysregulated inflammatory process results in large production of various cytokines
What are the 2 peaks of age onset for psoriasis?
20-30 y/o and 50-60 y/o but can occur at any age
What is happening in psoriatic skin without an active lesion?
Psoriatic skin without active lesion:
slight capillary dilatation and curvature
slight increase dermal mononuclear cells and mast cells
increase in epidermal thickness
What are the 3 steps that lead to a lesion developing in psoriasis?
progressive capillary dilatation and tortuosity
increase in mast cells, macrophages, and T cells, and mast cell degranulation (small arrows)
increasing thickness of the epidermis
What is the 5 step process that leads to a fully developed psoriatic lesion?
10 - fold increase in blood flow
numerous macrophages underlying the basement membrane
increased numbers of T cells
10-fold increase in epidermis
accumulation of neutrophils in the stratum corneum
What are Munro’s microabscesses? What dx are they associated with?
accumulation of neutrophils in the stratum corneum
psoriasis
What are environmental etiological factors that contribute towards psoriasis? What specific one?
trauma, stress, cold, infection, alcohol, medications
Acute streptococcal infection precipitates guttate psoriasis
What is Koebner phenomenon?
trauma that leads to psoriasis around the trauma
think psoriasis around surgical sites
____% psoriasis patients have a first degree relative that also has psoriasis. When does the first psoriasis lesion typically appear?
30%
first lesion typically appears after URI -> evidence of autoimmune properties ( T-cell hyperactivity)
What are the 3 different subtypes of psoriasis?
eruptive, inflammatory
pustular
chronic stable (plaque) psoriasis
type of psoriasis: _____ multiple small lesions appearing rapidly, spontaneous remission. What does it often follow?
Eruptive, inflammatory psoriasis
often follow strep pharyngitis
type of psoriasis: _____ presence of _____ instead of papules, patches and plaques
pustules psoriasis
pustules
type of psoriasis: ______ MC presentation, classic lesions present for months-years without little change
Chronic stable (plaque) psoriasis
What am I?
**What is the Auspitz sign?
What will the pt complain of?
psoriasis
**removal of scale leaves small blood droplet
pruritis
erythematous papule/patch/plaque with sharp margins
overlying silvery-white scales easily removed with scratching
pruritic
What am I?
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
What am I?
What can it evolve into?
Eruptive, inflammatory psoriasis
chronic stable psoriasis
sharply marginated, dull-red _____ with loosely adherent silver-white scales
_____ may coalesce
Waxing and waning of lesions throughout lifetime
What am I?
chronic stable plaque psoriasis
plaque and plaque
What is the typical lesion spread of psoriasis? What are some common places?
bilateral and symmetric!
Elbows
Knees
Sacral/gluteal region
Scalp
Palm/soles
What will psoriasis look like on the palms/soles? scalp?
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
Is it common to see psoriasis on the face?
uncommon but can be seen with refractory cases
What is inverse psoriasis?
Peri-anal/body folds psoriasis
macerated due to warm moist environment
sharply marginated, bright red, fissured lesions
What will nail psoriasis present like? How common is it?
pitting, subungual hyperkeratosis, onycholysis
yellowish-brown spots (oil-spots)
involved 25% of the time
What am I? What does this result from? ____ is often found in the history
pustular psoriasis
results from increase in polymorphonuclear (PMN) leukocytes present in the psoriatic epidermis
Outbreak is often precipitated by corticosteroid withdrawal
Describe pustular psoriasis in words. What are the 2 presentations?
Erythematous patches or thin plaques that rapidly become studded with numerous pinhead-sized sterile pustules
palmoplantar - palms/soles
generalized “von Zumbusch variant”
pustules 2-5 mm
erupt into dusky-red erosions and crusts
persists for years with unexplained remissions/exacerbations
What am I?
palmoplantar pustular psoriasis
pustules coalesce into “lakes” of pus
(+) Nikolsky sign in generalized presentation
relapses and remissions occur over years
may evolve into chronic stable psoriasis
What am I?
generalized “von Zumbusch variant” pustular psoriasis
What is the tx for generalized “von Zumbusch variant” pustular psoriasis?
life threatening!! needs to be hospitalized for treatment
What is the presentation of psoriatic arthritis? Affected ____ of psoriasis patients
joint stiffness & pain worse after inactivity, improves with movement
swelling, redness and tenderness of involved joints
psoriatic lesions develop over involved joints
30% of psoriasis patients are affected
What am I?
psoriatic arthritis
How do you dx psoriasis? What labs do you need to order?
clinical based on detailed H&P
throat culture: r/o strep
KOH: r/o fungal
bacterial/viral culture: pustular psoriasis
Who should manage localized psoriasis? generalized? psoriatic arthritis?
localized psoriasis- can be managed by PCP once therapy is initiated
generalized psoriasis- managed by dermatology provider
psoriatic arthritis- refer to rheumatology
What is the treatment for localized psoriasis on the trunk/extremeties?
high-potency topical steroids:
apply steroids after soaking lesions in water and removing scales
apply oint onto wet skin, cover with plastic wrap and leave overnight
re-apply steroid to lesion in AM and leave uncovered during the day
consider ointment for night application and cream for daytime application
vitamin D analog: calcipotriol, calcitriol
______ can be used in thick localized psoriasis on the trunk/extremities and works better in combo with ____ or _____
Topical retinoid (tazarotene
combo with topical steroid or UVB phototherapy
______ has keratolytic action is beneficial in thick plaques in localized psoriasis
Coal Tar combined with salicylic acid
______ MOA binds to Vit D receptor and regulates cell growth and inhibits proliferation of keratinocytes and proinflammatory cytokines
Topical Vitamin D Analogs:
calcitriol 0.0003% oint
calcipotriene 0.005% (Dovonex, Calcitrene)
can use calcipotriene 0.005% (Dovonex, Calcitrene) up to ____% of total body surface area with a 100g/week max
40% but do not apply to body surface area greater than 40%
What is the max gram dose for calcipotriene 0.005% and calcitriol 0.0003%?
calcipotriene 0.005% -> 100g/week max
calcitriol 0.0003% -> 20g/week max
What is the treatment for localized psoriasis on the scalp?
tar shampoo followed by medium-high potency lotion
What is the tx for localized psoriasis on the palms/soles?
high-potency topical steroids ointment with occlusive dressing
OR
PUVA ‘soaks’
OR
Oral retinoids
What is a PUVA soak? When is it used?
immerse affected area in photosensitizer liquid 15 minutes
expose hands/feet to UVA phototherapy units
localized psoriasis on the palms/soles
When is oral retinoids used in localized psoriasis?
reserved for unresponsive thick hyperkeratotic lesions
What is the tx for palmoplantar pustulosis localized psoriasis?
PUVA ‘soaks’
methotrexate or cyclosporine in unresponsive cases
What is the management of inverse/genital psoriasis?
initiate with short term (2-4 wks) of topical steroids
then ONE of the following options
1. Vitamin D analog
OR
2. topical retinoid (tazarotene)
OR
3. topical calcineurin inhibitors (tacrolimus/pimecrolimus)
What are the tx options for nail psoriasis? What if unresponsive?
PUVA phototherapy in hand/foot lighting units
Oral retinoids
Immunosuppressant: MTX or CS for unresponsive cases
What are the uses in psoriasis for the following medication classes:
topical steroids
vit d derivatives
topical retinoids
coal tar
calcineurin inhibitors
What is the tx for GENERALIZED acute inflammatory psoriasis?
tx underlying strep if applicable
Refer to Dermatology
narrow band UVB irradiation
oral PUVA photochemotherapy (if UVB therapy fails)
What is the tx for GENERALIZED pustular psoriasis?
hospitalization with IV fluids!!!
in hospital consult with dermatology
prophylactic IV antibiotics
oral retinoids
What is the tx for GENERALIZED chronic plaque psoriais?
refer to derm
narrow band UVB irradiation
oral PUVA photochemotherapy
oral retinoids
immunosuppressants/biologic agents
____ is the MOST important piece of historical information obtained when working a pt up for a possible adverse cutaneous drug reaction. What should you do next?
TIMING
start with onset of rash and work backwards and forwards considering all possible causes and pharmacologic agents
What are the risk factors for an adverse cutaneous drug reaction?
female
prior hx of drug reaction
recurrent drug exposure
EBV & CMV infection with PCN drugs
HIV with sulfonamides
What is considered an immediate drug reaction?
occur < 1 hour of last dose
urticaria, angioedema, anaphylaxis
What is considered a delayed drug reaction?
occurring after 1 hour, usually before 6 hours, occasionally weeks-months after initiation of drug use
_____ is the MC of all drug reaction. Why do they think it happens?
Exanthematous Drug Reactions
likely a delayed hypersensitivity reaction but MOA is not fully known
**____ and _____ produce eruptions with administration of ____ drug class that is NOT allergy related
EBV and CMV
PCN
What am I?
Adverse Cutaneous Drug Reactions
What is the timing for an Exanthematous Drug Reactions?
Immediate reactions:
previously sensitized
2-3 days after initiation of drug
Delayed reactions:delay due to sensitization requirement, most often 7-10 days after initiation of drug but may take up to 3 weeks
Describe exanthematous drug reaction in words. Where does it start?
bright red, maculopapular rash
symmetric: starts on trunk and spreads to extremities
scaling/desquamation with healing
mild pruritus
What drugs/drug classes have a high probability of exanthematous drug reaction?
PCN drug class, carbamazepine, allopurinol, gold salts
What drugs/drug classes have a medium probability of exanthematous drug reaction?
sulfonamides, NSAIDs, isoniazid, erythromycin, streptomycin
What drugs/drug classes have a low probability of exanthematous drug reaction?
barbiturates, BZD’s, phenothiazines, tetracyclines
What is the tx for Exanthematous Drug Reaction?
identify and discontinue offending agent
topical steroids and antihistamines for symptomatic relief
educate pt of offending agent and drug class
_____ is a drug reaction characterized by a solitary erythematous patch/plaque that will recur at same site if re-exposure of offending agent occurs
fixed drug eruption
What am I?
What is the typical onset?
fixed drug eruption
30 min-8 hours after ingestion
sharply marginated macule
erythema (early)
dusky red-violaceous (later)
may become edematous and bullous followed by erosion
postinflammatory hyperpigmentation after resolution may occur
What am I?
Where are 6 common sites?
fixed drug eruption
genital (penis is very common!)
pubic/crural region
perioral
periorbital
conjunctiva
oropharynx
What is the tx for a fixed drug eruption with an non-eroded lesion?
remove offending agent
topical steroid ointment
antihistamines for pruritus
What is the tx for a fixed drug eruption with an eroded lesion?
remove offending agent
topical antimicrobial ointment
antihistamines for pruritus
______ is skin eruptions with systemic symptoms and internal organ involvement. What are 2 common drug classes?
Drug-Induced Hypersensitivity Syndrome
Antiepileptic drugs: phenytoin, carbamazepine, phenobarbital
Sulfonamides: antimicrobial agents, dapsone, sulfasalazine
What is the timing associated with Drug-Induced Hypersensitivity Syndrome? What are some s/s?
onset 2-6 wks after drug initiation or increased dose
fever, malaise, facial edema, lymphadenopathy, hepatosplenomegaly
Where does the maculopapular eruption start in Drug-Induced Hypersensitivity Syndrome?
starts on face, upper trunk and UE
scaling/desquamation occur with healing
can also have lesions in the mouth
What organ systems need to be addressed in Drug-Induced Hypersensitivity Syndrome?
liver, kidneys, lymph nodes, heart, lungs, joints, muscles, thyroid, and brain for systemic involvement
What is the diagnostic criteria for Drug-Induced Hypersensitivity Syndrome? __ must be present
cutaneous drug eruption
hematologic abnormalities
lymphadenopathy >2 cm
elevated LFT (hepatitis)
elevated BUN/Cr (interstitial nephritis)
need 3 to dx
What is the tx for Drug-Induced Hypersensitivity Syndrome? give both mild/moderate and moderate/severe reaction
What am I? What are the 2 different options for onset?
Pustular Drug Eruptions
1-3 wks after initiation (no previous sensitization)
2-3 days after initiation (previously sensitized)
______ an acute febrile eruption that is often associated with leukocytosis after drug administration. Will have sterile pustules on an erythematous base, often starting in the intertriginous folds and/or the face. These patients will have a _____
Pustular Drug Eruptions
will have a fever!
What is the prognosis for a pustular drug eruption? will have ____ on labs
pustules resolve over 2 wks followed by desquamation (skin peeling) 2 wks later
leukocytosis
