Skin Manifestations of Systemic Disorders Flashcards
Characteristics of Pyoderma Gangrenosum
Rapidly evolving
Idiopathic
Chronic & severely debilitating ulcerative skin disease
Associated Underlying Inflammatory or Malignant Disease Presenting with Pyoderma Gangrenosum
Chronic UC Crohn's disease Chronic active hepatitis Hematologic malignancies Rheumatoid arthritis
Hx of Pyoderma Gangrenosum
Acute onset
Painful hemorrhagic pustule
Painful nodule surrounding by erythematous halo
PE Findings of Pyoderma Gangrenosum
Breakdown with ulcer formation with dusky red or purple borders
Irregular & raised
Boggy with perforations that drain pus
Most Common Sites for Pyoderma Gangrenosum
Lower extremities
Buttocks
Abdomen
Treatment of Pyoderma Gangrenosum
Treat underlying disease
Avoid trauma
High dose systemic corticosteroids
Systemic immunosuppression
Types of Systemic Immunosuppression
Sulfasalazine
Cyclosporine
Infiximab
Diabetic Associations with Skin Issues
Acanthosis nigricans Necrobosis lipoidica diabeticorum (NLD) Granuloma annulare Thrush Intertrigo
Characteristics of Acanthuses Nigricans
Velvety thickening & hyper pigmentation of the skin
Acanthosis Nigricans is Associated with what Issues
Diabetes
Insulin resistant syndromes
Obesity
Internal malignancy (GI most common)
History with Acanthuses Nigricans
Insidious onset
Darkening of pigmentation
PE Findings of Acanthosis Nigricans
Hyperpigmentation
Velvety looking
Skin line accentuated
Surface become wrinkled or creased
Most Common Sites for Acanthosis Nigricans
Axilla
Neck (back & sides)
Groin
AC fossae
Treatment of Acanthosis Nigricans
R/O DM
Treat associated disorder
Usually none required
PE Findings of Necrobiosis Lipoidica Diabeticorum (NLD)
Oval, violaceous patch Advancing border is red Central area turns yellow-brown Telangiectasias Ulceration possible esp. after trauma Usually anterior surface of the legs
Treatment of Necrobiosis Lipoidica Diabeticorum (NLD)
Difficult
Refer to derm
DM control doesn’t determine presence of NLD
Type 1 DM Trifecta
PVD
Neuropathy
Sugar everywhere
Characteristics of Granuloma Annular
Self limiting
Asymptomatic
Chronic dermatosis
Slight association with DM
History of Granuloma Annular
Slowly increases over months
Duration variable
PE Findings of Granuloma Annular
Smooth, shiny firm ring of flesh colored papule & plaques
Annular with central depression
Most Common Sites of Granuloma Annular
Dorm of hands & feet
Extremities
Trunk
Treatment of Granuloma Annular
Not necessary
If needed: potent topical steroids, or intralesional injections of steroids
Characteristics of Intertrigo
Irritation in the skin folds
Worse with heat & moisture
Intertrigo Associated With
DM
HIV
Obesity
Intertrigo Related to
Candida
Fungus irritation
Secondary bacterial infection
Most Common Sites of Intertrigo
Axilla
Groins
Gluteal folds
Overlapping abdominal panniculus
PE Findings of Intertrigo
Erythema
+/- pruritis
Tenderness
Erythematous plaques
Treatment of Intertrigo
Keep cool & dry
Treatment based on cause
What should be avoided in the treatment of intertrigo?
Steroids: fungus will spread rapidly
Describe Thrush
White plaques or red erosive areas in the oral mucosa
Associations with Thrush
DM
HIV
Immunosuppresion
Treatment of Thrush
Antifungal troches
Fluconazole
Itraconazole
Other Systemic Disorders that Manifest Dermatologic Symptoms
Lupus
Dermatomyositis
Scleroderma
Xanthoma
3 Types of Lupus
Chronic cutaneous (discoid)
Subacute cutaneous
Systemic lupus erythematosus (SLE)
Describe Chronic Cutaneous Lupus (Discoid)
Scarring, dispigmented, scaly plaques on primarily the face
Epidemiology of Chronic Cutaneous Lupus
Women > Men
Treatment of Chronic Cutaneous Lupus
Potent topical steroids
+/- anti-malarials
Describe Subacute Cutaneous Lupus
Polycyclic scaly plaques in sun exposed areas
Epidemiology of Subacute Cutaneous Lupus
White women 15-40
50% meet criteria for SLE
Treatment of Subacute Cutaneous Lupus
Anti-malarials
Immunosuppressants
Symptoms of Systemic Lupus
Severe fatigue
Low grade fever that won’t go away
Glomerulonephritis
Joint pain
Describe Systemic Lupus Erythematosus (SLE)
“Butterfly” facial erythema
Photosensitivity
Oral ulcers
Discoid lupus
Treatment for Systemic Lupus Erythematosus (SLE)
Anti-malarials
Immunosuppression
Describe Dermatomyositis
Erythema, photosensitivity, heliotrope eyelid rash
Weakness of proximal muscles
Define Gottron’s Papules
Knuckles
Periungual
Telangiectasia
Poikiloderma (red, white, brown)
Synonym of Scleroderma
CREST Syndrome
What does CREST stand for?
C: calcinosis R: reynaud's phenomenon E: esophageal dysmotility S: sclerodactyly T: telangiectasia
What internal organs involved in scleroderma?
Heart
Lungs
GI
Kidney
Treatment with Scleroderma
Systemic immunosuppression
Define Xanthomas
Lipid deposits in skin & tendons
Describe Xanthomas
Yellow-brown, pinkish or orange merciless, papule, plaques, nodules
Xanthomas Associated With
Hyperlipidemia Biliary cirrhosis DM CRF Hyperthyroid
Common Sites of Xanthomas
Upper & lower eyelids
Inner canthus
Xanthelasma
Most common of all xanthomas
Unrelated to hyperlipidemia
Individuals >50 y/o
Treatment of Xanthomas
Laser
Excision
Electrodesiccation or topical application of trichloroacetic acid
Types of Desquamation Disorders
Erythema Multiforme
Stevens-Johnson Syndrome (SJS)
Toxic Epidermal Syndrome
Erythema Multiforme Presentation
Erythematous "targetoid" macules/patches Papules/plaques Vesicles/bullae Wheals (urticaria) Erosions
En Minor Erythema Multiforme
Little/no mucous membrane involvement Few systemic systems Often due to HSV Can be due to medications Extensor surfaces
En Major Erythema Multiforme
Always mucous membrane involvement Skin involvement more widespread Systemic symptoms Hepatitis, nephritis Often due to medications Nikolasky Sign
Frequent Offenders for Erythema Multiforme
Sulfa containing drugs
Anti-epileptic drugs
Antibiotics
Allopurinol
Sulfa Containing Drugs that Cause Erythema Multiforme
Bactrim
Dapsone
Anti-epileptic Drugs that Cause Erythema Multiforme
Phenytoin
Cabemazepine
Pehnobarbital
Antibiotics that Cause Erythema Multiforme
Penicillin
Cephalosporins
Treatment of Erythema Multiforme
Systemic steroids
Define Stevens-Johnson Syndrome
Mucocutaneous drug-induced or idiopathic reaction patterns characterized by skin tenderness & erythema of skin & mucosa, followed by extensive cutaneous & mucosal epidermal necrosis & sloughing
Characteristics of Stevens-Johnson Syndrome
Onset at any age Associated with drugs Systemic lupus HIV HLS-B12
Prodromes of Stevens-Johnson Syndrome
Rash: morbilliform, diffuse erythema
Fever
Mouth lesions
Flu-like symptoms prior to mucocutaneous lesions
Mucocutaneous lesion, skin pain, burning & itching
Progression of Stevens-Johnson Syndrome
Necrotic epidermis, macular areas
Sheet-like loss of epidermis
Flaccid blisters that spread with lateral pressure on erythematous areas
With trauma: full thickness epidermal detachment yielding expose, red, oozing dermis resembling a 2nd degree burn
Define Nickolsky Sign
Flaccid blisters that spread with lateral pressure on erythematous areas
Other Organs that may be Involved in Stevens-Johnson Syndrome
Hepatitis
Nephrititis
Pneumonitis
Drugs Associated with SJS & TEN
Sulfa drugs Barbituates Allopurinal Diclofenac Sulindac Ketoprofen Ibuprofen Naproxen Cephalosporins Fluroquinolones Vancomycin Aminopenicillins Rifampin Ethambutol
Treatment of EM Minor/Major
Antiviral prophylaxis to control HSV
Early diagnosis & cessation of suspected causative drug
Treatment of SJS/TEN
Early diagnosis & cessation of suspected causative drug
Supportive care: ICU, fluids
Systemic steroids controversial
Growing evidence for the use of IVIG
Treat eye lesions with erythromycin ointment
Transfer to burn unit if widespread sloughing
Treatment of Drug Reactions
Benadryl
IV/IM steroids
Steroid dose pack
Don’t use covers
Characteristics of Bacterial Endocarditis
Staph aureas, strep viridans
Proliferation of microorganisms on the endocardium
Incidence increasing in the elderly, IVDU, & prosthetic valves
History of Bacterial Endocarditis
Fever Chills Sweats Anorexia Weight loss Malaise
PE Findings of Bacterial Endocarditis
Heart murmur
Arterial emboli
Splenomegaly
Skin Lesions Associated with Bacterial Endocarditis
January lesions
Osler’s nodes
Subungual splinter hemorrhage
Petechial lesion
Define Janeway Lesions
Nontender, hemorrhagic maculopapular lesions on palms & soles
Define Osler’s Nodes
Painful, red nodules on fingertips
Define Petechial Lesions
Small, non-blanching, reddish-brown merciless on extremities, upper chest, mucus membranes
Occur in crops
Work Up for Bacterial Endocarditis
Identify patients at risk & prophylaxis Blood cultures CBC Chem panel Coags Echo
Treatment of Bacterial Endocarditis
PCN-G Nafcillin Gentamycin Vanco in MRSA Zyvox in MRSA
What is the most common cause of bacterial endocarditis in IVDU?
Fungus
What is the most common cause of bacterial endocarditis in tooth extractions?
Strep viridans
Characteristics of Rocky Mountain Spotted Fever
Rickettsia rickettsii spirochete
Common May-September
Fatal if not treated
History of Rocky Mountain Spotted Fever
Hx of tick bite
Ask about outdoor activity
Prodrome: anorexia, irritability, malaise
PE Findings of Rocky Mountain Spotted Fever
Fever >102 Chills Weakness Headache Photophobia Pronounced joint pain
Skin Lesions of Rocky Mountain Spotted Fever
2-6 mm, pink blanching merciless begin on extremities & spread centrally
Evolve to papules & petechiae
Begins on wrists, forearms, ankles
Treatment of Rocky Mountain Spotted Fever
Doxycycline (except for PG)
Chloramphenical (for PG)
Lyme Disease can Cause What Kind of Problems
Skin
Joint
Heart
Nervous system
How is Lyme disease transmitted?
Bite of an infected tick or flea
Ticks that cause Lyme Disease
Deer tick
Lone star tick
Rocky Mountain tick
Signs/Symptoms of Stage 1 Lyme Disease
Flu-like symptoms Fatigue Headache Fever/chills Muscle/join pain N/V Dizziness Non-productive cough Small, red circular rash skin lesions
Signs/Symptoms of Stage 2 Lyme Disease
Severe headache Neck pain or stiffness Arthritis Neurological symptoms Psychiatric problems
Preventing Lyme Disease
Take protective measures when outdoors
Keep pets free of ticks
Protective Measures when Preventing Lyme Disease
Wear light-colored clothing Tuck pants into boots or socks Use repellant containing DEET Walk in the center of trails Avoid contact with high grass & brush at trail edges
Characteristics of Meningococcemia
Mid-winter to early spring
Most rapidly lethal form of septic shock
PE Findings in Meningococcemia
High fever Tachycardia Mild hypotension Signs of meningeal irritation Patient appears acutely ill
Early Exanthema in Meningococcemia
Soon after onset
Pink 2-10 mm macules/papules
Sparsely distributed on trunk/lower extremities, face, palate, conjunctivae
Later Lesions in Meningococcemia
Petechiae in center of merciless
Lesions become hemorrhagic
Purpura fulminans
Hemorrhagic bullae
Work Up of Meningococcemia
Blood cultures
Pus from nodular lesions
D-dimers
LP
What will LP show?
Increased pressure Cloudy Decreased sugar Increased protein Gram negative diplo-cocci
Treatment of Meningococcemia
Cefotaxine (Claforin)
Ceftriaxone (Rocephin)
PCN-G
Hemodynamic stabilization
Characteristics of Gonococcemia
Bacteremic phase: tenosynovitis, arthralgias, & dermatitis
Males age 20-24
Females aged 15-19
Acral hemorrhagic pustules lesions
Most Common Joints Affected in Gonococcemia
Wrists Fingers Elbows Knees Ankles Migratory polyarthralgia
Labs to Determine Gonococcemia
CBC
ESR
Culture
Treatment of Gonococcemia
Hospitalization with IV antibiotics
IV Antibiotics Use to Treat Gonococcemia
Empiric with Rocephin
PCN-G
Augmentin
Doxycycline & Azithromycin
