Papulosquamous and Inflammatory dermatoses Flashcards

Question

What type

Answer 1

Plaque type psoriasis

Answer 2

Erythodermic psoriasis Entire skin surface is involved Generalized erythema and scaling Can be very severe

Answer 3

Chronic plaque: Seborrheic dermatitis Nummular eczema Tinea corporis Drug eruption Guttate: Pityriasis rosea Secondary syphilis Drug eruption Inverse : Candida Contact dermatitis Bacterial infection

Answer 4

Topical Topical steroids/intralesional Tar preparations Salicylic acid (scalp) Vitamin D analogues -Calcipotriene (Dovonex) -Calcipotriol (Vectical) Retinoid creams -Tazarotene (Tazorac) Anthralin (Drithocreme, Micanol cream, Psoriatec) Phototherapy - UVB Systemic (refer to dermatology) Methotrexate Cyclosporine Acitretin (Soriatane) PUVA (psoralen + UVA) Biologics \*\*Patient Education/treatment monitoring

Answer 5

Pityriasis Rosea Acute, self-limiting skin eruption Etiology unclear -Several theories – Thought to be viral in origin Age: \> 75% between 10-35 years old -Rare in very young or very old Sex: M = F (slightly MC in females) Seasonal predisposition: -More common in cooler months; Spring/Fall Clustered in families/close contacts Higher incidence in immunocompromised

Answer 6

Pityriasis Rosea Distinct course Initial primary plaque (Herald patch) Generalized secondary rash 1-2 weeks later Spontaneous resolution 6-8 wk May be preceded by upper respiratory infections (URI) – 68% +/- Lymphadenopathy Mild pruritus in some; and can possibly be severe Can return to school Resolves spontaneously; Recurrence 2-3% Symmetrical eruption Trunk, extremities Typically spares palms & soles Atypical presentations exist; small papules more common in very young, pregnancy

Answer 7

Herald patch * Solitary lesion; usually annular * 2-6 cm, round-to-oval lesion * MC on the trunk, neck, but can occur anywhere

Answer 8

(1-2 weeks after primary) Generalized eruption, often trunk and prox. limbs Salmon-pink, 0.5cm- 1.5cm macules or patches; annular “Christmas Tree Distribution” = long axis of each lesion follows skin lines Collarette scale = inward facing, cigarette paper- like in appearance

Answer 9

Diagnosis: Clinical Dx (H&P) Biopsy Histology is not pathognomonic Not typically required Labs Not usually necessary VRDL to R/O syphilis KOH to R/O tinea

Answer 10

Guttate psoriasis Viral exanthems Tinea corporis Nummular eczema Lichen planus Drug eruptions Seborrheic dermatitis Secondary syphilis

Answer 11

No treatment (self-limiting) Emollients for scale Topical corticosteroids (Class V) for itching Anti-histamines (po), & anti-pruritic lotions Sarna lotion NO topical lidocaines or topical benadryls UVB phototherapy / direct sun Most helpful if started during 1st week of eruption

Answer 12

Lichen Planus Inflammatory cutaneous & mucous membrane reaction pattern Sex: F \> M Age: may occur any age; Adults (MC 30-60 y.o.) Rare in kids \< 5 y.o. FHx: 10% +FHx Unknown etiology

Answer 13

may be associated with chronic active hepatitis C -Hep C antibodies in about 16% with cutaneous lichen planus and approx. 30% with mucosal lesions Lichen planus – like eruptions (lichenoid) due to: \*medications –thiazide diuretics, gold, chloroquine, methyldopa, penicillamine \*chemical exposure – film processing \*post-bone marrow transplant (graft vs host reaction)

Answer 14

Location: Skin, mucous membranes, the genitalia, the nails, scalp, Most common sites: flexor surfaces of the wrists and forearms, legs just above ankles, lumbar region The 5 P’s: Pruritic (20% none) Planar (flat-topped) Polyangular Purple (violaceous) Papules Size: 1mm - \>1cm Grouping: random clusters, discrete, linear, annular, or diffusely papular (guttate) Koebner phenomenon – lesion in response to injury/scratch Wickham striae: White, lacy reticular pattern of criss-crossed lines Immersion oil on skin New lesions appear pink/white and then become purple hue with waxy luster. If persist for months may become thicker and dark red (hypertrophic lichen planus) Heals with post-inflammatory hyperpigmentation

Answer 15

Pruritic (20% none) Planar (flat-topped) Polyangular Purple (violaceous) Papules

Answer 16

**Papular** (localized) – most common form found on forearms, wrist, ankles and low back typically Often chronic – average 4 years **Hypertrophic** – 2nd most common - Can be anywhere, but most common on the shins and ankles - Become confluent, rough red-brown thick - may have severe itching and last for average 8 yr and develop vesicles/bullae **Follicular** (lichen planopilaris) – localized to hair - follicles and may occur with papular form - causes hair loss – can be permanent from scarring

Answer 17

Mucosal Lichen Planus Mucosal membrane (oral, vulva, glans penis) Oral – can occur w/out cutaneous lesions - F\>M; mean age onset 60 yo - seen in greater than 50% with cutaneous lesions - most common form is non-erosive with white lacy pattern on buccal mucosa - erosive form more severe and painful; 0.8-3% develop into SCC

Answer 18

Lichen Planus Nail Disease Nail changes: Longitudinal grooving, ridging, splitting, thinning and red streaks/ dots, pterygium “Tenting” or “pup-tent” = elevation of nail plate +/- longitudinal splitting. Changes are proximal to distal 25% of pts with nail LP have LP at other sites before or after the nail disease is noted Most common: 50s &60s

Answer 19

Lichen Planus Clinical (H&P) Biopsy for confirmation if needed. AST, ALT, & Alk phos HIV Hepatitis C

Answer 20

Cutaneous * Syphilis * Lichen simplex chronicus * Guttate vs plaque psoriasis Mucosal * Candida * SCC * Leukoplakia

Answer 21

Lichen Planus Refer to Dermatology: Generalized or mucosal disease, scarring alopecia, and refractory cases. Unsure of dx. Topical corticosteroids (Class I – II) initial treatment of localized disease Intralesional corticosteroids - sometimes used for hypertrophic lesions Anti-histamines for pruritus Topical corticosteroids in an orabase for oral lesions (watch for candidiasis with treatment) Systemic therapies: Generalized or painful disease

Answer 22

Granuloma Annulare Benign inflammatory/reactive dermatosis; self-limited Pathophysiology : unknown Several clinical variants Localized GA is the most common Sex: 2F : M Age: Localized GA: MC in kids & adults \< 30 y.o. (70%) Generalized GA: bimodal \< 10 y.o; 30-60 y.o. (rare) Seasonal: worse in summer; better in winter

Answer 23

Granuloma Annulare Primary Lesion: firm, 1-2mm, skin-colored to erythematous papules Slowly progressing; Grouped lesion expand to arcuate or annular plaques (1-5cm) Central depression, slightly hypo- or hyperpigmented Smooth, non-scaling Location: Dorsal surface of hands, fingers, & feet, Extensor aspects of arms and legs, Rare on face, scalp, or penis Symptoms: asymptomatic ; mild pruritus Duration: variable; Weeks to decades Spontaneous involution within 2 years in 50%

Answer 24

Diabetes Tuberculosis Insect bites/ trauma Sun exposure Thyroid disease Viral infections: HIV, Epstein-Barr virus, and herpes zoster virus

Answer 25

Granuloma Annulare Clinical (H&P) Biopsy +/- KOH (-) Consider if indicated: TSH Fasting Glucose

Answer 26

Granuloma Annulare Tinea Annular lichen planus Basal cell carcinoma Erythema migrans (Lyme disease) Sarcoidosis Nummular eczema

Answer 27

Granuloma Annulare Asymptomatic localized lesion can be left untreated Topical corticosteroids - not very effective Class I or II or lower potency under occlusion (\*) Use in intervals Intralesional Kenalog only at the elevated border (\*) Cryotherapy Other generalized variants may need systemic treatment. Ü ## Footnote \* Caution: increased risk for atrophy

Answer 28

Uticaria Reactive immunologic/inflammatory process Also referred to as hives or wheals Prevalence: May occur at any age – up to 20% of the population will have at least one episode. May be more common in atopic patients. Cause undetermined in most cases Classification: Acute or chronic

Answer 29

Uticaria Major effector cell: Mast cell Releases histamine – most important mediator of urticaria – in response to immunologic, non-immunologic , physical and chemical stimuli H1 Receptors: Triple response of Lewis: Vasodilation (erythema), Axon reflex (pruritus) and wheal Vasodilation, respiratory and GI smooth muscle contraction, pruritus & sneezing H2 Receptors: Vasodilation, increased gastric secretion

Answer 30

Acute: lasts \< 6 weeks majority of cases, lasts from hours to a few weeks. More common in children and young adults. Cause is undetermined in many cases Chronic: lasts \> 6 weeks more common in young adults and middle-aged women. Cause determined in only 5-20% of cases.

Answer 31

Uticaria raised, red, transitory, area of edema Various sizes and shapes - Papules, plaques, annular, arcuate, polycyclic Newest lesions = reddest No scale Pruritus – varies in severity \Sudden onset; each lesion lasts\< 24 hours Occur on any skin surface

Answer 32

Uticaria ÜRecent infection: viral ( hepatitis, mono, coxsackie), bacteria(URI, UTI, gallbladder, dental) ÜMedications: ÜACE inhibitors, aspirin, NSAIDs, sulfa-based drugs, penicillins, diuretics, opioids, polymyxin B ÜFood and food additives: Ünuts, fish, shellfish, eggs, chocolate, strawberries,tomatoes, cheese, cow’s milk, salicylate, benzoates,dyes ÜChemical/contact: latex, ammonium persulfate (in hair chemicals),perfumes, plants, cosmetics, textiles, bacitracin ÜOther misc: parasites, arthropod bites, IV contrast, physical, Sick serum, malignancy, hormones, autoimmune, inhalants (pollens, house dust)

Answer 33

"skin writing” Minor trauma/scratch = hive Lasts \< 30 minutes

Answer 34

Uticaria Detailed H&P Evaluate for the 5 “I”s * Infections (bacterial, viral, fungal, parasitic) * Ingestants (meds, foods, additives) * Inhalants (dust, pollen) * Injectants (drugs, stings, bites) * Internal disease (SLE, hyperthyroid, cancer, JRA) Contact/Chemical **LABS** No routine labs for mild acute or pressure urticaria Chronic: Based on HX CBC, ESR, BMP, LFTs, UA Allergen testing Stool cultures/sinus xray/dental exam Autoimmune/CT work-up Malignancy work-up Thyroid disease (TSH) \*\*Biopsy if indicated

Answer 35

Infection Ingestants Inhalants Injectants Internal Disease

Answer 36

Acute: drug eruption, viral exanthem, insect bites, angioedema, urticaria vasculitis, pityriasis rosea Chronic: Erythema multiforme, Bullous pemphigoid, Lyme disease, Mastocytosis, urticarial vasculitis

Answer 37

Uticaria Refer to Dermatology; if recurrent or chronic Treat underlying condition ## Footnote Antihistamines preferred initial treatment (will control the majority of acute and chronic urticaria) ``` 1st generation (sedating): hydroxyzine (Atarax) ``` diphenhydramine (Benadryl) ``` 2nd generation(low sedating): fexofenadine (Allegra) ``` cetirizine (Zyrtec) loratadine (claritin) Topicals: Tepid baths, oatmeal baths Avoid: Aspirin, NSAIDS, tight clothing, alcohol, wool **For difficult cases:** **H2-receptor antagonists** (added to H1 antagonists): Ranitidine (zantac) , Famotidine (pepcid), cimetidine (Tagamet) **Corticosteroids** Oral (for refractory cases): Various tapering doses possible. Prednisone or methylprednisolone tricyclic; H1 and H2: Doxepin

Answer 38

Angioedema Definition: abrupt and evanescent swelling of the skin, mucous membranes, Resp/GI tracts Deeper rxn – more diffuse swelling than hives Histologically deeper form of urticaria - deep dermis & subcutaneous tissue Caused by increased vascular permeability Potentially life-threatening Sex: F \> M +/- FHx +/- Urticaria +/- systemic symptoms

Answer 39

Angioedema 3 Prominent sites: * Subcutaneous tissue: Face including lips, hands, arms, legs, genitals * GI Organs: (MC in inherited types) Stomach, intestines, bladder Nausea, vomiting, colicky pain, diarrhea * Upper airway/larynx: Dyspnea, dysphagia Non-pitting swelling +/- pain & burning Pruritus typically absent Marked periorbital/ perioral swelling * +/- throat, tongue, hands, feet and/or genitals

Answer 40

Angioedema Detailed H&P +/- Biopsy **Labs** Immunologic studies to be deferred to Allergy or Dermatology Some recommend CBC/diff; basic metabolic panel, LFTs, thyroid If HAE is suspected: C1 esterase inhibitor and C4

Answer 41

Angioedema Anaphylaxis Urticaria Cellulitis Erysipelas Contact dermatitis

Answer 42

Angioedema Acute severe attacks: epinephrine and antihistamines +/- steriods IV vs po antihistamines IV vs po corticosteriods Refer to Dermatology/Allergist ID bracelets with Dx Epi-pen; Epi-pen Jr. HAE – replacement with C1 inhibitor concentrate; fresh frozen plasma Intense support may be necessary, depending on symptoms intravenous fluids, hospitalization.

Answer 43

Erythema Multiforme Common, acute, +/- recurrent, inflammatory, hypersensitivity disease EM minor: localized skin eruption with no mucosal involvement EM major: more severe mucosal and skin Steven-Johnson Syndrome, Toxic Epidermal Necrolysis potentially life-threatening disorders Dermatologic Emergencies Sex: M\>F, slightly Age: 20-40 y.o.; 20% in adolescents

Answer 44

Erythema Multiforme MC = HSV, Mycoplasma pneumoniae, acute upper respiratory infection Medications Other Infection: Bacterial, viral, fungal, parasitic Contact allergens Flavoring, preservative, food Immunologic disorders; connective tissue diseases Mechanical (tattoos) Other – cancers, pregnancy, xray therapy

Answer 45

Erythema Multiforme (Prodromal sxs, morphology, intensity varies) Prodrome: malaise, fever, itching, burning, cough Numerous lesions: target lesions, erythematous macules & papules, urticarial-like, vesicles, bullae Primary lesion: small dull red macule or urticarial papule with central papule/vesicle that may flatten and clear Hallmark = Targetoid lesion – spreads Centripetally up to 1-3 cm in size Symmetrical on palms, soles, hands, feet, extensor surfaces of forearms and legs +/- itch, burn; asymptomatic +/- Koebner phenomenon - Nikolsky sign Mucosal lesions: ( up to 70%) Lips, the palate, and gingiva Painful Ocular involvement mild ÜHeal without scarring Ü+/- post-inflammatory hyper/hypo-pigmentation

Answer 46

Erythema Multiforme Detailed H&P Biopsy – helpful if dx uncertain **Labs** HSV PCR if lesions suggestive More systemic work-up in severe cases

Answer 47

Erythema Multiforme: Urticaria Steven-Johnson Syndrome Toxic Epidermal Necrolysis Drug eruption Bullous pemphigoid

Answer 48

Erythema Multiforme Most mild cases don’t require tx Antiviral therapy If associated with reactivated HSV – used for prevention of Recurrent episodes Antihistamines for pruritis Systemic steroids for more wide-spread disease Soothing mouthwashes Symptomatic for wounds – topical antibiotics Supportive care IV fluids with electrolytes if severe Refer to Dermatology

Answer 49

Erythema Nodosum Hypersensitivity reaction to various triggers Inflammatory reaction in the panniculus Self-limiting 55% cases = idiopathic Age: mean 18-34 y.o. Sex: 5 F:1 M adults: children affected equally

Answer 50

Erythema Nodosum Bacterial * Streptococcal infections (MC), TB, Yersinia, Mycoplasma pnemoniae, Salmonella, Campylobacter, Shigella Fungal * Coccidiomycosis (San Joaquin Valley fever); Histoplasmosis Viruses * Hepatitis B, Herpes simplex, Epstein-Barr Parasitic * Amebiasis, Giardiasis, Ascariasis Drugs * Sulfonamides, OCPs, Minocycline, PCN, Salicylates Inflammatory conditions Sarcoidosis, Inflammatory bowel disease Malignancy Lymphoma, leukemia, renal cell CA, post-radiation therapy Pregnancy Idiopathic

Answer 51

Erythema Nodosum Lesions start as poorly defined, red, firm, tender subcutaneous nodules, 2-6cm in size that fade over 1-3 weeks similar to a bruise and do not scar Extensor surfaces; bilateral but not symmetrical, most common on pretibial surfaces. Can see on head, neck, torso , arms and thighs. New lesions appear for 3-6 weeks Ankle edema and leg pain are common. May have prodrome of flulike symptoms, fever, myaligias, and polyarthralgias a few weeks prior or with onset of lesionsÜArthralgias \> 50% Erythema, swelling, tenderness, +/- effusion, morning stiffness MC in knees, ankles, wrists Synovial fluid is acellular May last for 6 months Resolves without adverse reactions

Answer 52

Erythema Nodosum Detailed H&P Biopsy, if atypical, include fat ## Footnote Labs Throat culture/rapid strep/Antistreptolysin titer Complete CBC CXR PPD ESR Stool culture with GI sxs Rheumatoid Factor (-)

Answer 53

Erythema Nodosum: Erysipelas Cellulitis/Thrombophelbitis Infected Insect Bites Acute urticaria Physical abuse Henoch-Schonlein purpura

Answer 54

Erythema Nodosum Treat underlying conditions; stop offending medication NSAIDs Rest Cool wet compresses Potassium iodide (only if severe or recurrent) Corticosteroids (only if severe or recurrent)

Papulosquamous and Inflammatory dermatoses Flashcards

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