Chronic Inflammatory Dermatoses Flashcards
To recognize and descrbie psoriasis To recognize and describe lichen planus To recognize and describe Systemic Lupus Erythematosus (SLE) no histopathology (24 cards)
PSORIASIS
Population: ~4% with geographic and ethnic variance
Peaks: third and sixth decades
Genetics: presumed autosomal dominance with modifying features but also environmental triggers
Clinical Features: sharply demarcated erythema usually with thick micaceous scale, Auspitz Sign and Koebner phenomenon; Nail disease up to 50%; Rarely pustular
psoriasis pathogenesis
T Cell Mediated Autoimmune Disorder
Environmental factor-T cell produce cytokines – Stimulate keratinocyte proliferation and production of antigenic adhesion molecules in the dermal blood vessels-adhesion molecules further stimulate T cells to produce cytokines…
psoriasis risk factors
Genetic: 30% of patients have first degree relative with psoriasis Psychological Stress Medications Infection Chronic HIV
psoriasis PRECIPITATING AGENTS
Infection Trauma Stress ETOH Systemic steroids-especially upon withdrawal Beta blockers Lithium Antimalarials Indomethacin
psoriasis diagnosis
Differential Diagnosis: lichen simplex chronicus, nummular eczema, seborrheic dermatitis and tinea corporis
Punch Biopsy
PSORIASIS: Chronic Plaque Type
Scalp
Extensor Surfaces: elbows, knees, presacral, nails
Palms and Soles: thick scale of the arch of the foot and the thenar and hypothenar palms
PSORIASIS: Inverse Type
Intertriginous areas (Fold Areas): Gluteal fold, axillae, glans of the penis Scale may not appear in these areas
PSORIASIS: Guttate Type
Post streptococcal Infection
Usually Childhood, Young Adults
Eruptive Trunkal Dermatosis
Sudden onset of tear drip shaped 2 to 5 mm scaled spots of the trunk and proximal extremities
<2% of all psoriasis
Greater tendency toward spontaneous resolution
PSORIASIS: Pustular Type
Generalized: Potentially life threating; Small pustules becoming generalized with fever
Localized: Hand and foot form involves the palms and soles. May be termed Pustular Psoriasis of Barber
psoriasis treatment
topicals: Steroid Anthralin Tar Calciptriol Retinoids Tacrolimus
systemic: Retinoids Cyclosporin PUVA/UVB/Narrow Band UVB Methotrexate Etanercept, Efalizumab, Alefacept
psoriasis complications
Depression, anxiety, sexual dysfunction, poor, self-esteem, and suicidal thoughts may coexist from the cosmetic effects of the disease
Increased risk of non-melanoma skin cancers and lymphoma
Psoriatic Arthritis
PSORIATIC ARTHRITIS
Inflammatory, seronegative arthritis with a variable course
Asymmetric and involves the fingers and toes
Prevalence: ~1/3 of patients with psoriasis
LICHEN PLANUS
Chronic, inflammatory, autoimmune disease
Population: 0.1 to 4% general population
Gender: Females > Males; Perimenopausal women most often
Age: 30-60 years
Association with Hepatitis C (HCV)
Location: wrists, shins, mucous membranes, Wickham’s stria (lacy, reticular, white lines)
Diagnosed by Punch Biopsy
Lichen Planus Histopathology
“Interface Dermatitis”: Dermatitis occurs at the junction of the epidermis with the dermis
Band of infiltration of dermis and perivascular areas with lymphocytes and histiocytes
Vascular degeneration at the D-E junction
Necrosis of keratinocytes
Saw Tooth Acanthosis
Immunofluorescence: shaggy deposits of IgM along the basement membrane zone (unlike lupus which would have IgG)
LICHEN PLANUS (6 Ps)
Planar (flat topped) Purple Polygonal Pruritic Papules Plaques
LICHEN PLANUS: Linear (Classical)
Erythematous to violaceous polygonal papules especially on the flexor areas such as wrists and ankles
Genitalia frequently involved
Hallmark is development of Wickham’s Striae
LICHEN PLANUS: Forms
Hypertrophic: very thick plaques of scale over the lichen planus especially over the extremities and extensor surfaces
Bullous: blisters that occur under the lichen planus due to the severe interface dermatitis
Scalp: Lichen Planopilaris-scarring alopecia of scalp due to lichenoid infiltrate
Oral: Can occur by itself or with classical LP but not common with drug induced; tender red patches especially buccal mucosa with a with surface (Wickham’s Striae) that does not wipe off like thrush
SYSTEMIC LUPUS ERYTHEMATOSUS risk factors
More common in women
Most often diagnosed between ages 14-40
More common in African-Americans, Hispanics and Asians
labs: CBC Sed Rate Kidney/Liver tests UA ANA*
SYSTEMIC LUPUS ERYTHEMATOSUS histopathology
Long term autoimmune disorder that may affect skin, joints, kidney, brain
Immunofluorencence: IgG at the basement membrane
Acute: Pauci-inflammatory interface dermatitis; prominent dermal edema and dermal mucin
Subacute: Prominent suprabasilar exocytosis of lymphocytes, prominent epidermal atrophy; lymphocytic infiltrate
Discoid: Very thick basement membrane, follicular plugging; Dense perivascular and peri-adenxal infiltrate
ACUTE LUPUS ERYTHEMATOSUS
Photosensitive pattern of erythema
Butterfly rash across the nose and the cheeks
Red rash of the sun exposed upper chest and the extensor areas
May become bullous in these areas
May have non-specific features like digital infarcts, Raynaud’s Syndrome
SUBACUTE CUTANEOUS LUPUS
Erythematous and usually scaling rash of upper trunk and extensor surfaces that is psoriasis plaque like form or annular polycyclic form
Due to SSA or SSB antibody
CHRONIC CUTANEOUS LUPUS
Discoid Lupus: scarring lesions of skin (especially pinna)
Tumid Lupus: erythematous indurated plaques in sun exposed areas
Lupus Panniculitis: infiltration and destruction of adipose tissue, especially upper extremities, unlike erythema nodusum which is usually lower extremities
Verrucous Lupus: very thick hyperkeratotic discoid lupus like lesions that usually occur on the extensor sun exposed surfaces
SLE
treatment: NSAIDs Antimalarials (Plaquenil) Corticosteroids Immunosuppressants-cyclophosphamide (Cytoxan), Azathaprine (Imuran)
triggers:
Sunlight
Medications (anti-seizure, antibiotics, BP Rx)
NON-SPECIFIC SKIN LESIONS OF LUPUS
Vascular 50-70%: Telangiectasia, Vasculitis, Thrombophlebitis, Raynaud’s phenomenon, Livedo reticularis, ulcers, gangrene
Alopecia 40-60%: Frontal, Diffuse
Other: Urticaria, Mucous membrane, pigment changes
