Lecture 9: Papulosquamous & Inflammatory Disorders Flashcards
(96 cards)
1
Q
What is the most distinctive feature of pityriasis Rosea?
A
Herald patch on the trunk
or Christmas Tree Rash
2
Q
What is the MCC of Pityriasis Rosea?
A
HHV6 & 7
3
Q
Who is Pityriasis Rosea MC in?
A
- 10-40
- Spring/fall
4
Q
After the herald patch, what is the usual pattern used to describe Pityriasis Rosea?
A
Christmas Tree Pattern
Almost always on the trunk!
Occurs 1-2 weeks after the herald patch
5
Q
Describe the exanthem associated with Pityriasis Rosea
A
- Fine scaling papules and patches
- Dull pink, salmon red
6
Q
What is used in the tx of Pityrasis Rosea? (4)
A
- Oral antihistamines
- Topical antipruritic lotions (Sarna)
- Topical Triamcinolone BID x 4 weeks
- Oral steroids
7
Q
What is the MCC of Lichen Planus?
A
Idiopathic
8
Q
What metals and infection are associated with Lichen Planus?
A
- Gold & Mercury
- Hep C
9
Q
What kind of condition is Lichen Planus?
A
Inflammatory Dermatosis of the skin +/- mucuos membranes
Acute or chronic
10
Q
What does Lichen Planus look like?
A
- Flat topped papules
- Annular, purple pruritic
11
Q
Dermoscopy with oil of these small, flat-topped papule has white lines around it. What are these white lines and what condition is it?
A
Whickham striae seen in Lichen Planus
12
Q
Where does Lichen Planus tend to occur?
A
- Wrists (flexor)
- Lumbar
- Shins
- Scalp
- Penis
- Mouth
13
Q
Which Lichen Planus type involves cicatricial/scarring alopecia?
A
Follicular
14
Q
Which Lichen Planus variant is associated with Bullous Pemphigoid?
A
Vesicular
15
Q
Involvement of this area with Lichen Planus is concerning?
A
Mouth
16
Q
If Lichen Planus occurs in the hair and nails, what may happen?
A
- Scarring alopecia
- Nail Bed destruction + longitudinal splintering
17
Q
What is the most concerning variant type of Lichen Planus that we need to consider DDx for?
A
Papular
18
Q
For cutaneous lesions of Lichen Planus, the preferred tx is…
A
Triamcinolone under occlusion BID x 4 weeks
Can also use ILK
19
Q
For Lichen Planus in the mouth, the preferred tx is…
A
Cyclosporine and Tacrolimus MOUTHWASH
20
Q
Systemic tx of Lichen Planus can use 3 drugs and 1 therapy, which are…
A
- Cyclosporine
- Prednisone
- Retinoids (adjunctive)
- PUVA therapy
21
Q
Who is Granuloma Annulare MC in?
A
Female children/young adults
22
Q
What condition can Granuloma Annulare mimic?
A
Tinea Corporis
But it has NO SCALING.
23
Q
MC Etiology for Granuloma Annulare
A
Idiopathic
But seen in diabetics
24
Q
How does Granuloma Annulare present?
A
- Shiny beaded papules
- ANNULAR arrangement
- Skin colored/brownish red
25
Where does Granuloma Annulare MC appear?
* Hands and feets
* Elbows and Knees
26
A patient has been recently diagnosed with granuloma annulare. They have no other medical hx. You should refer them to...
PCP for a DM workup
27
How is granuloma annulare diagnosed?
Biopsy showing **histiocytic** infiltration or **necrobiosis of CT**.
28
If you do want to treat granuloma annulare, what can you give?
Topical Triamcinolone BID x 4 weeks
| ILK if ^ under occlusion doesnt work.
29
What is the issue with using cryotherapy on granuloma annulare?
Hypopigmentation
| Esp on darker skin
30
What layer is erythema nodosum inflammation of?
SQ **fat**
31
What is Erythema Nodosum the MC type of?
Panniculitis
32
A patient presents with **indurated, tender red nodules** up to 20cm in diameter on **both their anterior legs** that are only appreciable on palpation. The nodules are **bilateral but not symmetrical**. What condition should you be suspicious of that they may have?
Sarcoidosis, because this is erythema nodosum
33
MC area for arthralgia 2/2 Erythema Nodosum?
Ankle Joints
34
What labs would you consider ordering in someone presenting with Erythema Nodosum?
* ESR/CRP (HIGH)
* CBC (leukocytosis)
| Sarcoidosis!
35
What is the expected course of erythema nodosum?
Self-resolving in 6 weeks.
| No scarring either.
36
What can you treat erythema nodosum with if the patient really wanted you to?
* NSAIDs
* Steroids
| Inflammatory condition
37
Say you decided to biopsy erythema nodosum because you were really curious. How would you do it?
Lots of punches to get into the FAT
38
What is the pathophysiology of psoriasis?
Hyperproliferation of keratinocytes in the EPIdermis
39
What are the bimodal peaks for psoriasis?
* 20-30
* 50-60
40
What characterizes psoriatic skin WITHOUT active lesion?
* Minor capillary dilation
* Minor epidermal thickness
41
What happens as psoriasis progresses on a pathophys level?
* Increased capillary dilation + tortuosity
* Increased mast cell degranulation
* Increased epidermal thickness
42
How much thicker is a fully developed psoriatic lesion?
* 10x thicker
* 10x blood flow
| Also has neutrophils now in stratum corneum (Munro's microabscesses)
43
What is Koebnerization?
Stressor induces something like psoriasis at that location
| Trauma, stress, infection
44
Guttate/nummular/eruptive, inflammatory psoriasis is often precipitated by...
Streptococcal infection
| Strep pharyngitis
45
What is the MC subtype of psoriasis?
Chronic, stable plaque psoriasis
| Little change.
46
What is an auspitz sign?
Removal of scale leaves a small blood droplet
| **This screams PSORIASIS**
47
What does the classic lesion of psoriasis look like?
* Erythematous papule/patch/plaque with sharp margins
* Silvery-white scales that fall with scratching
* Itchy
48
Where does eruptive inflammatory psoriasis tend to occur?
Trunk
| Usually will become chronic stable afterwards.
49
How does chronic stable psoriasis tend to look?
* Sharp margins
* Dull-red
* Loose silver-white scales
* **Waxes and wanes**
50
If you had one place to check a person's body for psoriasis, you should choose...
sacral/gluteal region
51
When is psoriasis seen on the face?
Refractory cases
| Very rare
52
Is Psoriasis on the hair scarring?
Nope, causes no hair loss
| But v itchy
53
How does psoriasis in the intertrignous areas differ from the regular sites?
* Macerated due to warm moist
* Fissured
54
How does psoriasis on the nails present?
* Yellow-brown oil spots
* Subungal hyperkeratosis or onycholysis
| 25% of the time
55
What often precipiates a pustular psoriasis breakout?
CS withdrawal
56
Describe pustular psoriasis
Lots of sterile pustules
| It looks so GROSS
57
What are the two ways pustular psoriasis present?
* Palmoplantar (turns dusky-red and persists)
* Generalized **von Zumbusch**, which turns into lakes of pus.
58
What is the concern with generalized/von zumbusch pustular psoriasis?
* **LIFE THREATENING**
* **(+) nikolsky sign**
| but can also just evolve into regular stable
59
When would you expect to see leukocytosis with a left shift in psoriasis?
Generalized pustular psoriasis
| Von Zumbusch
60
How do you manage localized psoriasis?
* PCP with **high-potency topical CS** under occlusion overnight and Vit D.
* Topical retinioids + CS/UVB phototherapy (**THICK**)
* Coal Tar + SA (**THICK**)
* Emollients in between
61
How do you manage generalized psoriasis?
Send to derm.
62
What vehicle for carrying Vit D analogs is best for scalp psoriasis?
Solution
63
What are the topical Vit D analog options for psoriasis?
* Calcipotriene (solution for scalp)
* Calcitriol (good for allergic to above^^)
64
A patient has localized psoriasis on their scalp and on their palms/soles. You would recommend BLAH for their scalp and BLAH for their palms and soles.
* Scalp: Tar shampoo + lotion
* Palms/Soles: High-potency CS with occlusive dressing or PUVA soaks.
* **Last resort**: Oral retinoids for thick, hyperkeratotic lesions that are unresponsive.
65
A patient presents with palmoplantar PUSTULOSIS psoriasis. You recommend...
* PUVA soaks
* MTX or Cyclosporine for unresponsive
66
A patient is having psoriasis under in their groin areas. You recommend treatment with...
* Short-term topical steroids for 2 weeks
* Vit D analog, topical retinoid, or topical calcineurin inhibitors
67
A patient is having localized psoriasis in their nails, you recommend...
* PUVA phototherapy
* Oral retinoids
* Immunosuppressants if unresponsive.
| Must tailor depending on nail growth.
68
Which psoriasis drug is ABSOLUTELY CONTRAINDICATED IN PREGNANCY
Tazarotene
| Topical retinoid, but still a NONO
69
What two psoriasis treatments are specifically for plaque psoriasis?
* Tazarotene (topical ret)
* Coal tar (scalp)
70
For a generalized, acute inflammatory psoriasis, the recommended management is...
**Refer to derm** for UVB irradiation or oral PUVA chemo.
71
For generalized PUSTULAR psoriasis, you should...
* Admit
* Refer to derm
* Give IVF and IV ABX and Oral rets
72
For generalized chronic plaque psoriasis, you would...
Refer to derm for UVB, PUVA chemo, Oral rets, or immunosuppressants.
73
Overall, if you have generalized psoriasis, you should...
refer to derm
74
What is the MOST IMPORTANT piece of historical information regarding adverse cutaneous drug reactions?
TIMING
75
What are the unique RFs for adverse cutaneous drug reactions?
* Female
* EBV and CMV with PCN
* HIV with sulfonamides
76
How quickly does an immediate adverse cutaneous drug reaction have to occur within to be considered immediate?
**Less than ONE HOUR** prior to last dose.
| Urticaria, angioedema, anaphylaxis
77
How quickly do delayed adverse cutaneous drug reactions tend to occur within?
1-6 hours
| Occasionally weeks-months after.
## Footnote
Exanthematous eruptions
Fixed drug rxns
Systemic rxns
78
What is the MC type of adverse cutaneous drug rxn?
Exanthematous drug reactions
79
Classic viruses that produce exanthematous drug reactions when given this drug class...
EBV and CMV with PCNs
80
Exanthematous drug reactions can be immediate or delayed. When does an immediate one occur? Delayed?
* Immediate: 2-3 days after starting the drug (**but you were previously sensitized**)
* Delayed: 7-10 days after, due to sensitization requirement.
81
Top 4 drug classes for exanthematous reaction probability
* PCNs
* Carbamazepine
* Allopurinol
* Gold salts
82
Mainstays of treating exanthematous drug reactions (2)
* DC drug
* Topical steroids/antihistamines for symptoms
83
What characterizes a fixed drug eruption?
Location is always fixed!
| Solitary erythematous patch/plaque
84
T/F Hyperpigmentation can occur after a fixed drug reaction resolves
True :(
85
How does a fixed drug eruption present early on color wise? Later?
* Early: Erythematous
* Later: Dusky red-violaceous
86
MC sites of fixed drug eruptions
* Genitals
* Pubic/crural region
* Perioral
* Periorbital
* Conjunctiva
* Oropharynx
87
Tx of a non-eroded lesion 2/2 fixed drug eruption
Topical steroid ointment
88
Tx of an eroded lesion in a fixed drug eruption
Topical antimicrobial ointment
89
2 MC drug classes that can cause drug-induced hypersensitivity syndrome
* Antiepileptics (phenytoin, carbamazepine, phenobarbital)
* Sulfonamides (antimicrobials, dapsone, sulfasalazine)
90
A patient presents with widespread maculopapular rash that first began on their face and trunk. They have a fever, feel tired, and look like their face is swollen. Their physical exam is positive for LAN and hepatosplenomegaly. They recently started on phenytoin for seizure tx about 3 weeks ago. What is most likely occurring?
Drug-induced hypersensitivity syndrome
| Check the rest of the organs.
91
What would CBC show for a drug-induced hypersensitivity syndrome?
* Leukocytosis
* Eosinophilia
92
What is the Diagnostic criteria for a drug-induced hypersensitivity syndrome?
| 3 must be present
* Cutaneous drug eruption
* Hematologic abnormalities
* Systemic involvement (LAN > 2 cm, elevated LFTs, and elevated BUN/Cr)
93
For a mild-moderate drug-induced hypersensitivity syndrome, the first-line tx is...
Topical steroids
| Also stop any suspected meds
94
For just symptom relief of drug-induced hypersensitivity syndrome, we would recommend
Oral antihistamines
95
A patient started taking a new medication and developed a fever shortly after. They also have associated leukocytosis and lots of wide specks on their forehead. It began about 1 week ago. This is most likely a ????? drug eruption
Pustular drug eruption.
| 2-3 days if they were already sensitized to the drug.
96
Where do pustular drug eruptions typically begin?
* Intertriginous folds
* Face
