Skin and systemic disease Flashcards by Nader Raafat

Presentation of dermatomyositis - hands

Gottron’s papules - flat-topped, red, lichenoid, over MCPs and IPs

Nails - telangiectasia, ragged edges, inflammation, highly suggestive

Rash may be itchy or asymptomatic

Hx of Raynaud’s common

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Presentation of dermatomyositis - non-hand

Heliotrope (purple) rash in periorbital distribution, often w/ oedema

Photosensitive rash around upper arms, chest, back (‘shawl sign’)

Symmetrical proximal myopathy

Possible scalp involvement - alopecia

Calcinosis of skin

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Aetiology of dermatomyositis

Drugs - esp statins

Idiopathic

Malignancy - may precede or follow malignancy

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Differential for proximal myopathy

Thyrotoxicosis

Polymyalgia rheumatica

Cushing’s

Alcohol excess

Also consider SLE or overlap w/ e.g. systemic sclerosis

Polymyositis/dermatomyositis

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Investigation of dermatomyositis

ESR, CRP

FBC

ANA, anti-Jo, anti-Mi

Skin/Muscle biopsy, EMG, muscle MRI

Malignancy screen?

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Management of dermatomyositis

Photoprotection, rest

Systemic steroids - 0.5-1mg/kg of prednisolone

Second-line: steroid sparing e.g. HCQ, AZA, MTX

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Dermatological manifestation of SLE

Malar rash, erythema, photosensitive

Raised or non-raised

Sparing nasolabial folds

Non-scarring (c.f. discoid), no pustules (c.f. rosacea)

Fine scale

Doesn’t necessarily indicate systemic involvement

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Dermatological appearance of discoid lupus

Discoid rash over face, ears, scalp, chest

Progresses to hyperkeratotic, pigmented, papules appearance –> atrophic, hypopigmented scarring

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Dermatological appearance of subacute lupus

Annular, polycyclic lesions

Non-scarring

May have non-indurated psoriasiform appearance

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Management of SLE

Sun protection

Stop smoking

Topical steroids for localised skin disease

HCQ for systemic disease

Oral steroids for acute flare-ups

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Presentation of dermatitis herpetiformis

Intensely pruritic vesicles

Extensor distribution - buttocks, knees, elbows, forehead/scalp

?coeliac

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Investigation of dermatitis herpetiformis

Skin biopsy of early blister

Anti-TTG or anti-endomysial Abs

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Management of dermatitis herpetiformis

PO dapsone 50-200mg - need FBC (haemolysis, agranulocytosis) and LFT (hepatitis) monitoring

GF diet

Gastro referral - increased risk of small bowel lymphoma so surveillance

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Presentation of cutaneous vasculitis

Palpable, nonblanching purpura

Usually lower legs

May become necrotic/ulcerate

?symptoms of systemic vasculitis

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Causes of cutaneous vasculitis

Idiopathic - not necessarily systemic

Drugs - esp abx

ANCA-assoc vasculitides

CTD e.g. SLE, RA

Infx - e.g. strep, Hep B/C, TB, leprosy

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Management of cutaneous vasculitis

May take 6w to resolve

Compression stockings, elevation, dressing

Topical/oral steroid dep on severity

Remove ppt cause

Investigation of cutaneous vasculitis

Vasculitic screen - FBC, CRP/ESR, ANCA, U&Es, LFTs, complement

Urine dip and BP - exclude renal involvement

?CXR if pulmonary involvement

Presentation of meningococcal septicaemia

Viral-like prodrome

Meningism, nausea, vomiting, photophobia, neck stiffness

Petechial rash with grey centre > nonblanching purpura w/ necrotic centre

Management of meningococcal septicaemia

Sepsis-6 + supportive care

IV ceftriaxone

Notify PHE, contact tracing (ciproflox)

Presentation of acanthosis nigricans

Hyperpigmented

Hyperkeratotic - rough, velvety texture

Symmetrical

Warty/skin tag lesions

Flexural - neck, groin, axillae, antecubittal/popliteal

Associations of acanthosis nigricans

Endocrine - polycystic ovarian disease, diabetes mellitus, obesity

Neoplastic - gastric adenocarcinoma

Iatrogenic - OCP, steroids

Presentation of erythema nodosum

Red-blue, raised, indurated nodules

Thighs, shins, upper arms

Painful, non-scarring

Last 2-3w

Systemically unwell - fever, malaise

Aetiology of erythema nodosum

Infection - TB, HBV, Yersinia, chlamydia, GrpA strep

Iatrogenic - OCP, dapsone, sulphonamides (e.g. trimethoprim)

Neoplastic - haem malignancy, pregnancy

Inflammatory - IBD, sarcoidosis

Management of erythema nodosum

Treat underlying cause

NSAIDs

Bed rest, leg elevation, compression stockings

Presentation of necrobiosis lipoidica

Red plaque \> yellow-brown w/ telangiectasia \> ulceration Often shins, possible bilateral Usually assoc w/ diabetes mellitus smaller + not rapidly enlarging + purple edges c.f. pyoderma gangrenosum

Management of necrobiosis lipoidica

Avoid trauma Topical, intralesional and oral steroids

Presentation of pretibial myxoedema

Waxy - peau d'orange Nontender and normal temp (c.f. cellulitis) Erythematous, nonpitting oedema around legs and feet

Management of pretibial myxoedema

Very potent topical and intralesional steroids Ix thyroid - usually Grave's or hashimotos, treat

Presentation of erythema multiforme

Symmetrical, 'target lesions' with central blister Widespread (c.f. migrans tick bite) Mucosal -- worry about SJS

Associations of erythema multiforme

Drugs - abx, NSAIDs, allopurinol, anticonvulsants Collagen disorders Infx - mycoplasma, herpes

Presentation of vitiligo

Macular hypopigmentation +/- inflamer, hyperpigmented borders Usually symmetrical Sunlight makes them itch

Management of vitiligo

Assoc w/ autoimmune disorders and premature ovarian failure Treat w/ cosmesis, sunscreen, ?topical steroids/tacrolimus

Types of xanthomata

**Xanthalesema:** Over eyelid **Tuberous:** Pressure points e.g. knees, elbows **Tendinous:** Commonly Achilles **Eruptive:** Usually buttocks, shoulders, extensor surfaces Yellow or yellow-pink nodules, lipid accumulation

Presentation of lichen planus

Violaceous papules \> coalesce to polygonal plaques White streaks overlying - Wickham's striae Intensely pruritic (but not oral) Esp volar wrist/ankle May cause ulceration in genital or mouth mucosa Hyperpigmentaion after resolution Trachyonychia - sandpaper-like nails

Features of tuberous sclerosis

Ash-leaf hypopigmented macules Suede-like shagreen patches on lower back Multiple angiofibromata, firm skin overgrowths Cafe-au-lait macules Most suffer from epilepsy and developmental delay

Features of Sturge-Weber syndrome

Port-wine stain in ophthalmic distribution of trigeminal nerve - may thicken/hypertrophy Conjunctival haemangiooma Increased risk of glaucoma ipsilaterally Focal neurology, developmental delay

Features of Peutz-Jeghers syndrome

Pigmented macules commonly around mouth Can occur aroun umbilicus, genitalia, anus Prolapsed rectal polyp Increased risk of malignancy

Management of lichen planus

Topical corticosteroid Screen for HCV if concern

Melasma

Facial skin pigmentation Assoc w/ hypothyroid, pregnancy, OCP, sun damage