Cutaneous manifestation of sarcoid?
Sarcoid granulomas
- 1a hydroxylase activated by M0
- conversion of inactive to active vitamin D
- increased calcium absorption / decreased calcium secretion. PTH suppressed
Lupus Pernio
small black raised papules that may coalesce
Indication of active sarcoid and associated with more severe disease
- responds poorly to topical agents
- increase dose of systemic steroid
ERYTHEMA NODOSUM
Painful erythematous or pigmented lesions which are poorly defined
-LOFGRENS SYNDROME = SARCOID with Erythema Nodosum / Hilar involvement / Arthropathy
Pemphigus - describe
Flaccid blisters
(raised = pemphigoid)
Ig deposition throughout epidermis
(basement membrane = pemphigus)
Treat with high dose steroids
look for mucosal ulceration
long term low dose steroids to maintain remission - 2 years
mortality on treatment 5-15%
Pemphigoid - describe
Cutaenous tense blisters
Ig deposition in basement membrane only and not in epidermis itself
treated with high dose steroids to stimulate remission
Tapering and long term low dose steroids for up to 2 years
Lichen planus
Eczematous outbreak with white lines streaking throughout and ITCHY
See white striae especially in mouth
causes pruritis - steroids if so
self limiting.
Flexor surfaces (esp wrists) (Eczema is on extensor surfaces then moves to flexors)
white lines = WICKHAM’S STRIAE
Koebner phenomen
- follows excoriation lines and scars
(as psoriasis)
Associated: B blockers TZD or indapamide methyl dopa anti-malarials
What are Wickham’s Striae
White lines seen via hand lens pathogenic for lichen planus
What is Koebner’s phenomenon
Rash follows scars or excoriations
- lichen planus
- psoriasis
Scabies
SARCOPTES SCABIEI
Human scabies mite
burrows into epidermis
NOCTURNAL PRURITIS
Pruritis onset 4-6 weeks after infection - hypersensitivity to mite or waste products deposited in skin.
RESULTS IN SECONDARY ECZEMA
See burrows between finger webs and toes
Itchy
penile papules
Widespread itchy macular rash
Residential homes
Hostels
TREATMENT: PERMETHRIN
BOIL WASH / THROW OUT ALL LINEN
Dermatofibroma
White pearly papule
dimples when pinched
benign
occurs post trauma
Excision
- diagnostic to R/O BCC
- cosmetic
Describe a typical syphillitic chancre and its management
- shallow ulceration
- typically painless but not always
typically 6 weeks post infection
management:
Benzylpenicillin single dose IM
Describe a benign epidermal naevus
Typically over shoulder region
pigmented due to melanocyte melanin deposition
may have a white demarcation as well
may have hair
Describe a mangolian blue spot
blue naevus typically on lumbar spine but may also be seen on sclera
Describe naevus flaevum
Port wine stain
When on the face should be investigated for leptomeningeal AVM
Describe the associations of acanthosis nigricans
- Colonic carcinoma
- Addisons
- Cushings
- Hypothyroidism
Deeper pigmentation in creases
Describe the lesions in erythema nodosum
Poorly demarcated tender nodular epidermal lesions
Due to neutrophillic inflammation of adipocytes
Sarcoid
mycoplasma pneumonia
Erythema multiforme
Target lesions
multiple differentials
Roth spots
retinal microhaemorrhages with white centre
multiple pathologies Ig deposition in vasculitis HIV bacterial endocarditis microembolism mycoplasma pneumonia
Janeway Lesions
Bacterial Endocarditis
Palmer SC lesions
Poor demarcated
erythematous
painless
Represent dermal microabscesses secondary to septic embolisation in bacterial endocarditis
Osler nodes
Bacterial Endocarditis
Vasculitic manifestation therefore purpuric in appearance
Painful / tender nodules
Ig deposition throughout
Describe a shingles rash
Vesicular outbreak that then crusts and heals
specific to a dermatome in distribution corresponding to the infected anterior horn
Treat with oral aciclovir n the acute instance
If already crusting treat post herpetic neuralgia with gabapentin 300mg daily and increase to 900mg daily (therapeutic dose)
target dose 3.6g/day
What is impetigo
Superficial infection of the skin by staph aureu / A haemolytic strep
highly contagious
causes maculo-papular vesicular rush with crusting and discharge
topical abx - FUSIDIC ACID
IF WIDESPREAD - FLUCLOX OR ERYTHROMYCIN
What is Pyoderma Gangrenosum
Auto immune necrotising skin condition cuasing blisterin and ulceration over wound sites and sites of trauma
NON HEALING STERILE PAINFUL ULCER
i.e. no response to fluclox
AssociatIons
Inflammatory bowel disease:
Ulcerative colitis
Crohn’s disease
Arthritides:
Rheumatoid arthritis
Seronegative arthritis
Hematological disease: Myelocytic leukemia Hairy cell leukemia Myelofibrosis Myeloid metaplasia Monoclonal gammopathy
Autoinflammatory disease:
Pyogenic sterile arthritis, pyoderma gangrenosum, and acne syndrome (PAPA syndrome)
Treatment:
Prednisolone 60mg od
How is Atopic Eczema treated?
Treatment:
Aqueous creams
topical steroids
Calcineurin inhibitor - Tacrolimus in severe or resistant atopic eczema
What is oral hairy leukoplakia?
White painless plaques over the lateral aspects of the tongue.
Cause:
REACTIVATION OF EBV
SIGN OF ?HIV in context of EBV reactivation
mx:
HIV testing
Describe what erythema gyratum ripens looks like and what its associations are
Erythematous rash which appears as concentric rings like wood grains
Associated with Squamous cell carcinoma of the bronchus
What are the prognostic markers in malignant melanoma?
Form of skin cancer arising from pigmented melanocytes
risk factors:
- Family history
- sun exposure
prognosis:
depth at excision MOST IMPORTANT-BRESLOW THICKNESS
8 year survival <0.76MM 93% <1.69MM 85% <3.6MM 60% >3.6MM 33%
signs: asymmetric poor defined elevated increasing sie change in colour
What is lupus vulgaris?
Tuberculoid focal and limited infection
Typically deforming due to granulomatous process
Treat as pulmonary TB RIPE rifampicin isoniazide pyridoxine (side effects of ethambutol and isoniazid to prevent neuropathy via supplement Vit B6) ethambutol
What is Pityriasis Versicolor?
Caused by a fungal skin infection:
MALASSEZIA FURFUR
HYPO OR HYPERPIGMENTED macules <1cm
ring of scar tissue surrounds
fine scaling ring
widespread
treatment:
ketoconazole shampoo
itraconazole 200mg OD
Similar to Vitiligo
VITILIGO = DEPIGMENTATIONS >1CM + NO SCALING + HANDS FACE GENITALIA DOMINATE
Cutaneous manifestation of gastric adenocarcinoma
Acanthosis nigrans
- dark pigmentation in skin folds / face
LOOK FOR VIRCHOWS NODE
Cutaneous manifestation of coeliac disasee
Dermatitis Herpetiformis
chronic blistering skin condition, characterised by blisters filled with a watery fluid.
Cutaneous manifestation of Crohns disease
Erythema nodosum - painful Ig complex deposition + infl
Pyoderma gangrenosum - superficial flaccid ulcers with granulomatous borders
Management of keloid scars?
Intradermal corticosteroid - helps with resolution and itching.
What are the symptoms of ZINC deficiency
dermatitis
alopecia
diarrhoea
SEE BEAUS LINES nails
ACRODERMATITS ENTEROPATHICA
What are the symptoms of Pellagra?
Vit b3 deficiency
Dermatitis
Diarrhoea
dementia
What are features of superficial spreading melanoma?
Name 3 differentials
malignant melanoma = cancer of melanocytes irregular increased pigmentation nodular 66% arise from normal skin 33% arise from existing naevus
Superifical = good prognosis as no deep penetration depth = prognosis
diffs
lentigo maligna
- benign and superficial but not as well contrasted with skin
BCC
-classically heavy pigmented with pearly rolled border whcih is regular - alignant melanoma classically is irregular
How is solar keratosis treated?
What can it progress to?
Topical 5 FU
Cryotherapy
Can progress to SCC
How is mild / mod acne treated?
Whats the major risk in using it?
Isotretinoin topical
TERATOGENIC
How is solar keratosis managed?
5 fluoro uracil first line
Diclofenac gelt
cryotherapy
What is granuloma annulare
coalesced dermal papules that form a ring
typically backs of hands / extensor surfaces
degenerative collagen surrounded by granulomas
entirely benign of unclear aetiology
prednisolone = effective remission
What does mycobacterium marinum cause?
localised mycobacertial infections typically over hands due to mycobacterium marinum
fish tanks / aquariums
How does pityriasis versicolor present?
fungal infection causing hypopigmented rings
- yeast infection
Superficial cotrimazole
Stevens johnson syndrome causes..?
toxic epidermal necrolysis (TEN)
drug reactions are associated:
SLE
HLA-DRw4
Han Chinese
HLA-B1502
Japanese and Europe
HLA-1301
How is alopecia areata managed?
Topical steroids
Intralesional SC steroids - hydrocortisone / triamcinolone
-steroid sparing effects
wigs
counselling - stress
tattooing
topical minoxidil for androgen sensitive alopecia