SKIN MANIFESTATIONS OF SYSTEMIC DISEASES

Question 1

PYODERMA GANGRENOSUM ASSOCIATIONS

Answer 1

• idiopathic
• chronic & severely debilitating ulcerative skin disease

***ASSOCIATED WITH CHRONIC UNDERLYING INFLAMMATORY OR MALIGNANT DISEASES**
Chronic Ulcerative colitis
Chronic active hepatitis
RA
Crohn's 
Hematologic malignancies

HLA B27 diseases

Question 2

associated with UC & crohns

Answer 2

Pyoderma Gangrenosum

Question 3

Acute onset with painful hemorrhagic pustule or painful nodule surrounded by erythematous halo.

Answer 3

pyoderma gangrenosum

Question 4

most common sites of pyoderma gangrenosum

Answer 4

lower extremities (shins), buttocks, abdomen

Question 5

pyoderma gangrenosum

Answer 5

History:
Acute onset with painful hemorrhagic pustule or painful nodule surrounded by erythematous halo.

PE:
Breakdown with ulcer formation with dusky red or purple borders, irregular and raised, boggy with perforations that drain pus.

Most common sites:
Lower extremities (shins), buttocks, abdomen

Question 6

Skin conditions associated with Diabetes

Answer 6

Acanthosis nigricans
Necrobosis lipoidica diabeticorum
Granuloma annulare
Thrush
Intertrigo

Question 7

acanthosis nigricans is associated with

Answer 7

endocrine disorders (diabetes, insulin resistant syndromes)

obesity

internal malignancy (most commonly GI)

Question 8

velvety thickening & hyperpigmentation of skin

Answer 8

acanthosis nigricans

Question 9

first visible change of acanthosis nigricans

Answer 9

darkening of skin

Question 10

acanthosis nigricans

hx

PE

most common sites

Answer 10

HX = insidious onset; first visible change = darkening of pigmentation

PE = hyperpigmentation, velvety looking, skin line accentuation, surface becomes wrinkled or creased

MOST COMMON SITES = axilla, neck (back & sides), groin, antecubital fossa

if < 40 = usually diabetes or endocrinopathy
if > 40 = should rule out adenocarcinomas of the colon
if dark thickening in the mouth = think malignancy

Question 11

treatment of acanthosis nigricans

Answer 11

• 1) rule out diabetes
• 2) treat associated disorder
• 3) usually no tx required

Question 12

NECROBIOSIS LIPOIDICA DIABETICORUM

Answer 12

• origin unknown
• 50% of pts with NLD = are insulin dependent diabetics

PE = oval, violaceous patch that expands slowly. the advancing border is red and the central area turns yellow-brown. Telangiectasias = prominent. Ulceration is possible, especially after trauma

sharply circumscribed, multi-colored, anterior & lateral surfaces of lower shins
shins =most common areas
0.3% of diabetic population will develop this, but cause unknown

TREATMENT = DIFFICULT, REFER TO DERM!
really good diabetes control doesn’t seem to manage this manifestation

• advacing border that turns different colors, telangiectasias that become more prominent

Question 13

granuloma annulare

Answer 13

• self-limiting asymptomatic chronic dermatosis
• slight association with DM (20% of patients with DM)
• more common in older women

HX = slowly increases over months; duration = variable
PE = smoothy shiny firm rings of flesh colored papules and plaques; annular with central depression
MOST COMMON SITE = dorsum of hands & feet, extremities, and trunk

Question 14

treatment for granuloma annulare

Answer 14

not necessary, as it disappears in 75% of pts in 2 years

• if needed - potent topical steroids or can do ILK

Question 15

intertrigo is associated with

Answer 15

⦁ Diabetes
⦁ HIV
⦁ Obesity

Question 16

INTERTRIGO

Answer 16

• irritation in skin folds; worse with heat & moisture
• associated with
  ⦁ Diabetes
  ⦁ HIV
  ⦁ Obesity
• related to Candida, fungus irritation, and secondary bacterial infection (group A / B strep, pseudomonas)

Most common sites = axilla, groin, gluteal folds, and overlapping abdominal panniculus (folds)

Question 17

intertrigo treatment

Answer 17

• keep cool & dry (hair dryer)
• AVOID TOPICAL STEROIDS***
• antifungal / antibacterial powders (nystatin)
• zinc oxide ointment reduces friction

Question 18

intertrigo symptoms

Answer 18

have erythema, may or may not have pruritus, tenderness, erythematous plaques

Question 19

satellite lesions are pretty classic for

Answer 19

candida

Question 20

thrush treatment

Answer 20

• antifungal troches
• fluconazole (diflucan)
• itraconazole (sporanox)

Question 21

• yeast infection in the mouth = usually candida

- get white plaques or red erosive areas in oral mucosa

Answer 21

thrush

Question 22

associations with thrush

Answer 22

diabetes
HIV
immunosuppression

Question 23

3 different types of lupus

Answer 23

⦁ Chronic cutaneous lupus (discoid lupus)
⦁ Subacute cutaneous lupus
⦁ Systemic Lupus Erythematosus (SLE)

Question 24

chronic cutaneous (discoid) lupus

Answer 24

• scarring, depigmented, scaly plaques on face primarily (butterly rash)
• more common in women 2:1
• progression to systemic lupus is uncommon
• TX = potent topical steroids +/- antimalarials (hydroxychloroquine)

Question 25

subacute cutaneous lupus

Answer 25

- or cutaneous lupus erythematosis - white women; age 15-40 - polycyclic scaly plaques in sun exposed areas - 50% meet criteria for systemic lupus - can be drug induced - TX = with antimalarials or other immunosuppressants the prognosis for subacute cutaneous lupus = much better than for systemic lupus - sun exposed areas, not a lot of scarring. Lot of plaques, but they go away

Question 26

systemic lupus erythematosis

Answer 26

- "butterfly" erythema - nonscarring - photosensitivity - oral ulcers - discoid lupus + systemic involvement - skin involvement in 80% of SLE TX = antimalarials + immunosuppression affects multiple organ systems: kidneys, eyes, heart, complement goes down ANA, anti-smith, anti-double-stranded DNA, anti-RO/LA - have antigen antibody complexes depositing in organs / vasculature / etc.

Question 27

DERMATOMYOSITIS

Answer 27

- erythema - photosensitivity - heliotrope eyelid rash - Gottron's Papules = raised scaly eruptions on knuckles - Calcinosis Cutis - "Shawl's sign" - MYOSITIS - weakness of proximal muscles, elevation in muscle enzymes (aldolase & creatinine kinase) increased ESR - poikiloderma

Question 28

SCLERODERMA

Answer 28

``` - CREST ⦁ Calcinosis ⦁ Raynaud's phenomenon ⦁ Esophageal Dysmotility ⦁ Sclerodactyly ⦁ Telangiectasia ``` - Progressive systemic sclerosis - progresses to internal organ involvement (heart, lungs, GI, kidneys) - tightening of the skin - usually die from pulmonary HTN (lungs become fibrotic --> cor pulmonale) TX = systemic immunosuppression

Question 29

associations with xanthomas

Answer 29

⦁ Hyperlipidemia ⦁ Biliary cirrhosis ⦁ Diabetes ⦁ CRF

Question 30

XANTHOMAS

Answer 30

- lipid deposits in skin & tendons - yellow-brown, pinkish or orange macules/papules/plaques/nodules ``` - Associations ⦁ Hyperlipidemia ⦁ Biliary cirrhosis ⦁ Diabetes ⦁ CRF ``` COMMON SITES = upper & lower eyelids, inner canthus

Question 31

lipid deposits in skin & tendons

Answer 31

xanthomas

Question 32

where xanthomas are most common

Answer 32

tendons

Question 33

different types/locations of xanthomas

Answer 33

⦁ eruptive xanthomas = can be anywhere on skin ⦁ tuberous xanthomas = usually over joints ⦁ tendinous xanthomas = around tendons = where xanthomas are most common

Question 34

most common of all xanthomas

Answer 34

xanthelasma

Question 35

XANTHELASMA

Answer 35

- most common of all xanthomas - most cases = unrelated to hyperlipidemia (if lipids are normal = don't need further workup) - occurs in ppl > 50 - when seen in children or young adults = associated with familial hypercholesterolemia

Question 36

EM minor = often due to EM major = often due to

Answer 36

HSV Medications

Question 37

meds that can cause erythema multiforme

Answer 37

⦁ Sulfa containing drugs (bactrim, dapsone)***** ⦁ anti epileptics (phenytoin, carbemazepine, phenobarbital) ⦁ ABX (PCN, cephalosporins) ⦁ Allopurinol

Question 38

leading cause of SJS / TEN

Answer 38

drugs

Question 39

other organs may be involved in SJS / TEN other than skin

Answer 39

⦁ Hepatitis, Nephrititis, Pneumonitis kidneys liver lungs

Question 40

tx for drug rash

Answer 40

- benadryl - IV / IM steroids - steroid dose pack - try not to sweat at night, don't use covers