CHAPTER 7: ERYTHEMA AND URTICARIA

Question 1

Is usually
most marked on the hypothenar areas and is associated with
an elevated level of circulating estrogen. Cirrhosis, hepatic
metastases, and pregnancy are common causes.

Answer 1

Erythema palmare

Question 2

Erythema multiforme major is most often caused by

Answer 2

Mycoplasma infection

Question 3

Erythema multiforme minor is usually caused by

Answer 3

HSV infection

Question 4

Recurrent self limited disease Sharply marginated, erythematous macules then evolve to papules Target lesions observed in palms and soles Koebner phenomenon

Answer 4

EM minor

Question 5

Type of EM: Frequently accompanied by a febrile prodrome Lesions on extremities and face, may include trunk Mucous membrane disease prominent

Answer 5

EM major

Question 6

Describe the classic “target” or “iris” lesion of erythema multiforme

Answer 6

This lesion is the classic “target” or “iris”
lesion with three zones:

central dusky purpura;
an elevated,
edematous, pale ring; and surrounding macular erythema
(Figs. 7-2 and 7-3)

Question 7

What diagnostic test is necessary to exclude paraneoplastic pemphigus from mycoplasma-induced EM major?

Answer 7

Direct immunoflorescence

Question 8

is the most common
gyrate erythema.
. . .
It is characterized by asymptomatic annular
or polycyclic lesions that grow slowly (2–3 mm/day), rarely
reaching more than 10 cm in diameter. Characteristically,
there is a trailing scale at the inner border of the annular
erythema (Fig. 7-7). The surface is typically devoid of crusts
or vesicles, although atypical cases with telangiectasia and
purpura have been described. Lesions usually occur on the
trunk and proximal extremities. Mucosal lesions are absent

Answer 8

Erythema annulare centrifugum

Question 9

Histologically, the epidermis will show mild focal spongiosis and parakeratosis. Within the superficial dermis and at
times the deep dermis, lymphocytes are organized tightly
around the blood vessels in a pattern described as a “coat
sleeve” arrangement

Answer 9

Erythema annulare centrifugum

Question 10

a rare disease that is striking and unique in appearance. Lesions consist of undulating
wavy bands of slightly elevated erythema with trailing scale
over the entire body. Lesions migrate rapidly (up to 1 cm/day)
and are characteristically concentric, giving the skin a “wood
grain” appearance (Fig. 7-8)

Answer 10

Erythema gyratum repens

Question 11

Sharply marginated rapidly extending, tender, erythematous or violaceous, painful, elevated plaque, 2-10cm diameter Face, neck, upper trunk and extremities May burn but do not itch Fever

Answer 11

Sweet syndrome Acute febrile neutrophilic dermatosis

Question 12

Majority of cases of Sweet syndrome follow this infection

Answer 12

URTI

Question 13

Pregnancy associated Sweet syndrome usually presents in what trimester

Answer 13

1st or 2nd

Question 14

Treatment for Sweet syndrome

Answer 14

Self limited Oral prednisone 1mg/kg/day

Question 15

Begins as an inflammatory pustule with a surrounding halo that enlarges and begins to ulcerate Lower extremities and trunk

Answer 15

Pyoderma gangrenosum

Question 16

Least aggressive form of pyoderma gangrenosum

Answer 16

Vegetative

Question 17

Disease most often associated with pyoderma gangrenosum

Answer 17

IBD

Question 18

Most common inherited auto inflammatory syndrome

Answer 18

Familial Mediterranean fever

Question 19

Autosomal recessive Recurrent 12-72h of fever and monoarthritis and erysipela like erythema

Answer 19

Familial Mediterranean fever

Question 20

Treatment for familial Mediterranean fever

Answer 20

Colchicine

Question 21

Revised diagnostic criteria for diagnosis of Sweet
syndrome*

Answer 21

Major criteria

1. Abrupt onset of erythematous plaques or nodules,
   occasionally with vesicles, pustules, or bullae
2. Nodular and diffuse neutrophilic infiltration in the dermis with
   karyorrhexis and massive papillary dermal edema

Minor criteria

1. Preceded by a respiratory infection, gastrointestinal tract
   infection or vaccination, or associated with:
   * Inflammatory disease or infection
   * Myeloproliferative disorders or other malignancy
   * Pregnancy
2. Malaise and fever (>38°C [100.4°F])
3. Abnormal laboratory findings ≥3 of the following:
   * Erythrocyte sedimentation rate >20 mm/hr
   * C-reactive protein elevated
   * Leukocytosis >8000/mm3
   * Left shift with >70% neutrophils
4. Excellent response to treatment with systemic corticosteroids

*Both major criteria and two minor criteria are needed for diagnosis

Question 22

Vascular reaction of the skin characterized by appearance of wheals surrounded by red halo or flare with severe itching Caused by localized edema

Answer 22

Urticaria

Question 23

Acute and chronic urticaria timeline

Answer 23

Acute: 12 hrs to 6 wks
Chronic: more than 6 wks

Question 24

Sharply localized edema or wheal with a surrounding erythematous flare after the skin has been stroked 2-5% of population

Answer 24

Dermatographism

Question 25

Cholinergic urticaria is produced by the action of acetylcholine on what cell

Answer 25

Mast cells

Question 26

Adrenergic urticaria is mediated by this hormone

Answer 26

Norepinephrine

Question 27

Management of cholinergic and adrenergic urticaria

Answer 27

1. H2- antihistamine 2. Monteleukast 3. Propanolol 4. Danazol

Question 28

Angioedema in the absence of urticaria can be due to

Answer 28

hereditary angioedema or an ACE inhibitor. . . . C1 esterase deficiency does not cause hives, only angioedema, and measurement of C4 is indicated. If C4 is low, an evaluation of C1 esterase inhibitor is appropriate

Question 29

Intense flushing may be associated with

Answer 29

Rosacea . . . In patients with rosacea, exercise, ambient heat or cold, spicy foods, alcohol, and hot beverages are common triggers for flushing.

Question 30

drugs associated with flushing include

Answer 30

niacin, calcium channel blockers, cyclosporine, chemotherapeutic agents, vancomycin, bromocriptine, intravenous contrast material, sildenafil and related drugs for erectile dysfunction, and high-dose methylprednisolon

Question 31

Define erythema

Answer 31

means blanchable redness (hyperemia) of the skin. A number of reactive skin conditions are referred to as erythema. These include toxic erythemas related to viral and bacterial infections, erythema multiforme, erythema nodosum, and the gyrate (figurate) erythemas

Question 32

As treatment and prognosis are related in part to the inciting agent, it is useful to classify erythema multiforme (EM) as follows:

Answer 32

Herpes simplex–associated EM (HAEM) * Erythema multiforme major (most often caused by Mycoplasma) * Chronic oral EM * Contact dermatitis–induced EM (see Chapter 6) * Radiation-induced EM (see Chapter 6) * Idiopathic

Question 33

is a recurrent selflimited disease, usually of young adults, occurring seasonally in the spring and fall, with each episode lasting 1–4 weeks. The individual clinical lesions begin as sharply marginated, erythematous macules, which become raised, edematous papules over 24–48 h. The lesions may reach several centimeters in diameter. Typically, a ring of erythema forms around the periphery, and centrally the lesions become flatter, more purpuric, and dusky. This lesion is the classic “target” or “iris” lesion with three zones: central dusky purpura; an elevated, edematous, pale ring; and surrounding macular erythema (Figs. 7-2 and 7-3)

Answer 33

Herpes simplex–associated EM (HAEM) (erythema multiforme minor)

Question 34

How is SJS distinguised from EM?

Answer 34

Erythema multiforme major is frequently accompanied by a febrile prodrome and sometimes arthralgias. It occurs in all ages, is centered on the extremities and face, but more often than EM minor may include truncal lesions, which are papular and erythematous to dusky in color. Mucous membrane disease is prominent and often involves not only the oral mucosa and lips, but the genital and ocular mucosa as well (Fig. 7-5). SJS is distinguished morphologically by the presence of purpura or bullae in macular lesions of the trunk (Fig. 7-6).