Papulosquamous and Inflammatory Disorders Flashcards
(77 cards)
1
Q
An acute exanthematous eruption with a distinctive morphology and often with a characteristic self limited course
Single “herald” patch, 1-2 wks later = generalized
A
Pityriasis Rosea
2
Q
MCC of Pityriasis Rosea
A
Herpes Human Virus 6 and 7
3
Q
Pityriasis Rosea MC in who and when?
A
Onset: 10-40 years old
MC in Spring and Fall
4
Q
- Oval, slightly raised plaque or patch (2-5 cm)
- Salmon red, fine collarette
- 1-2 wks after patch develops = Exanthem
- Fine scaling papules and patches with marginal collarette /dull pink
- Oval scattered (Christmas Tree pattern)
- Confined to trunk (rare on face)
dx?
tx?
A
- Pityriasis Rosea
- spontaneous remission; oral antihistamines, topical antipruritic lotion (sarna), steroids (TAC or prednisone)
5
Q
Acute or chronic inflammatory dermatosis involving skin and or mucous membranes
A
Lichen Planus
6
Q
causes of Lichen Planus
A
- Idiopathic MC
- Cell mediated immunity - CD8+ & CD45Ro+ cells - Drugs
- Metals (gold and mercury)
- Infection (hep C)
7
Q
- Papules, flat topped - Polygonal or oval ; Annular; Purple; Pruritic
- 1-10 mm
- Sharply defined, shiny
- Violaceous, with white lines (Whickham striae)
- Grouped or disseminated - Dark phototype hyperpigmented
A
lichen planus
8
Q
how to observe Whickham striae under dermatoscope?
A
seen after the use of oil under a dermatoscope
lichen planus
9
Q
lichen planus is MC found where on the body?
A
- Wrists (flexor)
- Lumbar region
- Shins
- Scalp
- Glans penis
- Mouth
10
Q
11 variants of lichen planus
A
- Hypertrophic: Large thick plaques
- Atrophic: White bluish, well-demarcated papules and with central atrophy
- Follicular: Follicular papules and plaques –> cicatrical alopecia
- Vesicular: Bullous pemphigoid w/ LP
- Pigmentosus: Hyperpigmented, dark-brown macules in sun exposed areas and flexural folds
- Actinicus: Papules in sun exposed areas
- Ulcerative /erosive: Therapy resistant spots = ulcers
- MUCOUS MEMBRANES : MC in mouth
- Reticular: Lacy white hyperkeratosis on buccal mucosa, lips, tongue, gingiva
- Genitalia: Papular, annular, or erosive lesions on penis, scrotum, labia majora, labia minora and vagina
- Hair & nails: Scarring alopecia possible; Destruction of nail fold and bed w/ longitudinal splintering
11
Q
w/u and tx for lichen planus
A
- bx
- TAC BID x 4wks; ILK
- Cyclosporine and tacrolimus solution - for mouth
- systemic - cyclosporin, prednisone, retinoids
- other: PUVA
12
Q
Granuloma Annulare MC in who?
A
- MC Children and young adults
- Female
13
Q
Granuloma Annulare cause is unknown, but has been seen in pts with this chronic condition?
A
diabetics
14
Q
- Skin colored or brownish-red
- Shiny beaded papules - Annular arrangement
- MC hands, feet, elbows and knees - Generalized MC, can be isolated spot
A
granuloma annulare
15
Q
if GA is diagnosed and ____ hasn’t been diagnosed, the patient should be sent to PCP for work up
A
DM
16
Q
histologic findings of granuloma annulare on bx?
A
- Foci of chronic inflammatory and histiocytic infiltrations in superficial and mid dermis
- Necrobiosis of CT surrounded by a wall of palisading histiocytes and multinucleated giant cells
17
Q
tx for granuloma annulare
A
- Not needed (spontaneous remission within 2 yrs)
- TAC 0.5% BID x 4 weeks
- ILK – 3 mg/mL (very effective)
- Cryo - not recommended due to scarring
18
Q
Common acute inflammatory/immunologic reaction pattern of the subcutaneous fat
MC type of panniculitis
A
Erythema Nodosum
19
Q
causes of Erythema Nodosum
A
- Infection
- Drugs
- Inflammatory/granulomatous diseases
- Sarcoidosis
20
Q
Erythema Nodosum MC in who?
A
- 20-30 years old
- Females
21
Q
- Painful, Tender, Fever, Malaise, Arthralgia (MC ankle joints)
- Indurated, tender nodules 3-20cm - Bright to deep red; Only appreciated on palpation
- Not sharply marinated - Oval, round, and acriform
- Deep seated in fat (MC anterior leg) - brownish, yellowish, green with age
- Bilateral but not symmetrical
A
Erythema Nodosum
22
Q
w/u for Erythema Nodosum
A
Hematology - Elevated ESR and CRP; Leukocytosis
23
Q
tx for erythema nodosum
A
- Spontaneous resolution occurs in 6 weeks w/o scarring
- symptomatic tx - rest, compression, wet dressings
- antiinflammatory tx - NSAIDs, Prednisone
24
Q
Chronic, multifactorial inflammatory skin disorder resulting in hyperproliferation of the keratinocytes in the epidermis
A
psoriasis
25
pathogenesis of psoriasis?
* *not completely understood*
* T-cell proliferate the epidermis = overproduction of epidermal cells
* dysregulated inflammatory process = large production of various cytokines
26
development/steps of psoriatic lesions
1. **psoriatic skin w/o active lesion** - capillary dilation and curvature, more mononuclear cells and mast cells, increased epidermal thickness
2. **developing lesion** - more cap dilatation and tortuosity, mast cells, T-cells, and mast cell degranulation, thickness of epidermis
3. **developed lesion** - 10-fold increase in blood flow, lots of macrophages underlying basement membrane, more T cells, 10-fold increase in epidermis, accumulation of NEUT in stratum corneum (*Munro's microabscesses*)
27
RF for psoriasis
1. _Environmental_ - trauma (*Koebner phenomenon*), stress, cold, infection, alc, medications
- _Acute streptococcal infection_ precipitates guttate psoriasis
1. _Genetic_
2. _Immunologic_
- first lesion typically appears after _URI_
- evidence of autoimmune properties (*T-cell hyperactivity*)
28
3 subtypes of psoriasis
1. Eruptive, inflammatory psoriasis
1. Pustular
1. Chronic stable (plaque) psoriasis (**MC**): classic lesions present for months-years without little change
29
* aka: guttate or nummular psoriasis
* multiple small lesions appearing rapidly
* spontaneous remission
* often follows strep pharyngitis
which types of psoriasis
Eruptive, inflammatory psoriasis
30
1. erythematous papule/patch/plaque with sharp margins
1. overlying silvery-white scales easily removed with scratching
- Auspitz sign: removal of scale leaves small blood droplet
1. pruritus is common historical finding
Psoriasis
31
1. 2-10 mm, salmon pink papules, +/- scales
1. concentrated to the trunk, few scattered lesions to face, scalp, extremities
1. may resolve spontaneously within a few wks
1. most often evolves into chronic stable type
which type of psoriasis
Eruptive, inflammatory psoriasis
32
1. sharply marginated, dull-red plaques with loosely adherent silver-white scales
1. plaques may coalesce
1. Waxing and waning of lesions throughout lifetime
which type of psoriasis
Chronic Stable Psoriasis
33
MC sites of psoriasis
Bilateral, often symmetric
Elbows
Knees
Sacral/gluteal region
Scalp
Palm/soles
34
special sites of psoriasis presentation
1. **Palms/soles**: thick adherent silvery-white or yellow scaling; painful cracking/fissures
1. **Scalp**: sharply marginated plaques with thick adherent scales; intense pruritus; no hair loss
1. **face**: uncommon; seen in refractory cases
2. **Peri-anal/body folds** *(inverse psoriasis)*: macerated d/t warm moist area; sharply marginated, bright red, fissured lesions
3. **Nails**: pitting, subungual hyperkeratosis, onycholysis; yellowish-brown spots (*oil-spots*)
35
1. results from increase in polymorphonuclear (PMN) leukocytes present in the psoriatic epidermis
1. Outbreak is often precipitated by corticosteroid withdrawal
1. Subjective: stinging, burning, pruritus
1. Erythematous patches or thin plaques that rapidly become studded with numerous pinhead-sized sterile pustules
which type of psoriasis
Pustular Psoriasis
36
2 presentations of pustular psoriasis
1. **palmoplantar** - palms/soles: pustules 2-5 mm; erupt into dusky-red erosions and crusts; persists for years with unexplained remissions/exacerbations
1. **generalized “von Zumbusch variant”**: pustules coalesce into “lakes” of pus; (+) Nikolsky sign in generalized presentation; **_life threatening_**; relapses and remissions occur over years; may evolve into chronic stable psoriasis
37
1. joint stiffness & pain worse after inactivity, improves with movement
1. swelling, redness and tenderness of involved joints
1. psoriatic lesions develop over involved joints
which type of psoriasis
Psoriatic Arthritis
38
w/u for psoriasis?
1. clinical
2. labs to r/o ddx - throat cx, KOH, bacterial/viral cx, CBC (leukocytosis w/ left shift in generalized pustular psoriasis)
39
referrals for psoriasis
1. refer to derm
1. localized psoriasis- can be managed by PCP once therapy is initiated
1. generalized psoriasis- managed by dermatology provider
1. psoriatic arthritis- refer to rheumatology
40
tx for Localized Psoriasis - trunk/extremities
1. **high-potency topical steroids**
- after soaking lesions in water and removing scales
- apply oint onto wet skin, cover with plastic wrap and leave overnight
- re-apply in AM and leave uncovered during the day
- ointment for PM and cream for AM
2. **Vitamin D analog** - calcipotriol, calcitriol
3. **tazarotene** - for thick plaques, best with mid-high potent CS or UVB phototherapy
4. **Coal Tar + SA**
5. **Emollients**
41
MOA of Topical Vitamin D Analogs
binds to Vit D receptor and regulates cell growth
inhibits proliferation of keratinocytes
inhibits proinflammatory cytokines
42
SE of calcipotriene 0.005%
burning, itching, skin irritation, photosensitivity, hypercalcemia
CI: hypersensitivity
43
SE of calcitriol 0.0003% oint
hypercalcemia, photosensitivity
CI: none
44
tx for localized scalp psoriasis
tar shampoo followed by medium-high potency lotion
45
tx for localized pals/soles psoriasis
1. **high-potency topical steroids oint with occlusive dressing**
1. **PUVA ‘soaks’**
- immerse affected area in photosensitizer liquid 15 minutes
- expose hands/feet to UVA phototherapy units
1. **Oral retinoids**: if unresponsive thick hyperkeratotic lesions
46
tx for palmoplantar pustulosis
1. PUVA ‘soaks’
1. MTX or Cyclosporine CS unresponsive cases
47
tx for Inverse(body folds)/genital
localized psoriasis
1. start with short term (2-4 wks) of topical steroids
1. then one of the following: Vitamin D analog; topical retinoid (tazarotene); topical calcineurin inhibitors (tacrolimus/pimecrolimus)
48
tx for localized nail psoriasis
1. PUVA phototherapy in hand/foot lighting units
1. Oral retinoids
1. Immunosuppressant: MTX or CS for unresponsive cases
49
which topical psoriasis tx can be used for all types of psoriasis?
SE?
* topical steroids
* Skin atrophy, hypopigmentation, striae
50
which topical psoriasis tx is used in combination or rotation with topical steroids for added benefit?
SE?
* Calcipotriene (Vitamin D derivative)
* Skin irritation, photosensitivity (but no contraindication with UVB phototherapy)
51
which topical psoriasis tx is reserved for Plaque-type psoriasis?
Best when used with topical corticosteroids.
SE?
Tazarotene (Topical retinoid)
Skin irritation, photosensitivity
52
which topical psoriasis tx is reserved for Plaque-type psoriasis?
SE?
* Coal tar
* Skin irritation, odor, staining of clothes, carcinogenic
53
which topical psoriasis tx has Off-label use for facial and intertriginous psoriasis?
SE?
* Calcineurin inhibitors
* Skin burning and itching
54
mgmt for Generalized Acute, inflammatory Psoriasis
1. tx underlying strep if applicable
1. Refer to Dermatology
- narrow band UVB irradiation
- oral PUVA photochemotherapy (if UVB therapy fails)
55
mgmt for Generalized Pustular Psoriasis
1. hospitalization with IV fluids
1. in hospital consult with dermatology
1. prophylactic IV antibiotics
1. oral retinoids
56
mgmt for Generalized Chronic Plaque Psoriasis
1. Refer to dermatology
1. narrow band UVB irradiation
1. oral PUVA photochemotherapy
1. oral retinoids
1. immunosuppressants/biologic agents
57
what is the most important of hx for Adverse Cutaneous Drug Reactions
**TIMING**
start with onset of rash and work backwards and forwards considering all possible causes and pharmacologic agents
58
RF for Adverse Cutaneous Drug Reactions
1. female
1. prior hx of drug reaction
1. recurrent drug exposure
1. EBV & CMV infection with PCN drugs
1. HIV with sulfonamides
59
difference between Immediate vs Delayed adverse cutaneous drug Reactions
1. Immediate: < 1 hr of last dose; urticaria, angioedema, anaphylaxis
1. Delayed: 1- 6 h, weeks-months after drug use; exanthematous eruptions, fixed drug eruptions, systemic reactions
60
* MC of all drug reactions
* Mechanism not fully known - likely a delayed hypersensitivity reaction
* EBV and CMV produce eruptions with administration of PCN drug class (not believed to be allergy related)
Exanthematous Drug Reactions
61
Exanthematous Drug Reactions are classified how?
timing - immediate vs delayed
62
s/s of exanthematous drug reactions
* bright red, maculopapular rash
* symmetric: starts on trunk and spreads to extremities
* scaling/desquamation with healing
* mild pruritus
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drugs that have a High probability to cause Exanthematous Reaction
1. PCN drug class
1. carbamazepine
1. allopurinol
1. gold salts
64
drugs that have a medium probability to cause Exanthematous Reaction
1. sulfonamides
1. NSAIDs
1. isoniazid
1. erythromycin
1. streptomycin
65
drugs that have a low probability to cause Exanthematous Reaction
1. barbiturates
1. BZD’s
1. phenothiazines
1. tetracyclines
66
tx and pt ed for exanthematous drug reactions
1. identify and DC offending agent - oral/IV steroids if they must continue agent
1. topical steroids and antihistamines
1. ensure pt is aware of offending agent and drug class
67
a drug reaction characterized by a solitary erythematous patch/plaque that will recur at same site if re-exposure of offending agent occurs - occasionally multiple fixed lesion will occur
Unknown pathogenesis
Fixed Drug Eruption
68
s/s of Fixed Drug Eruption
1. Onset: 30 min-8 hours after ingestion
1. Pruritus, burning pain
1. Skin Lesion
- sharply marginated macule
- erythema (early), dusky red-violaceous (later)
- may become edematous and bullous followed by erosion
- PIH after resolution
69
Fixed Drug Eruption - Sites of Predilection
1. genital
1. pubic/crural region
1. perioral
1. periorbital
1. conjunctiva
1. oropharynx
70
mgmt for fixed drug eruption
* remove offending agent - Lesion resolves days-weeks after discontinuation
* non-eroded lesions: topical steroid ointment
* eroded lesion: topical antimicrobial ointment
* antihistamines for pruritus; throat
* widespread presentation - refer to dermatologist
71
skin eruptions with systemic symptoms and internal organ involvement
Drug-Induced Hypersensitivity Syndrome
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causes of Drug-Induced Hypersensitivity Syndrome
1. **Antiepileptics**: phenytoin, carbamazepine, phenobarbital
1. **Sulfonamides** : antimicrobial agents, dapsone, sulfasalazine
73
s/s of Drug-Induced Hypersensitivity Syndrome
1. onset 2-6 wks after drug initiation or increased dose
1. F, malaise, facial edema, LAD, hepatosplenomegaly
1. maculopapular eruption - starts on face, upper trunk and UE; scaling/desquamation occur with healing
1. oropharyngeal mucosal lesions - cheilitis, erosions, pharyngitis, tonsillitis
Assess: liver, kidneys, lymph nodes, heart, lungs, joints, muscles, thyroid, and brain for systemic involvement
74
w/u and criteria for Drug-Induced Hypersensitivity Syndrome
1. CBC: leukocytosis, eosinophilia; LFT; BUN/Cr
1. Diagnostic Criteria (3 must be present):
- cutaneous drug eruption
- hematologic abnormalities
- systemic involvement: LAD >2 cm; elevated LFT (hepatitis); elevated BUN/Cr (interstitial nephritis)
75
tx for Drug-Induced Hypersensitivity Syndrome
1. stop/substitute ALL suspected medications
1. consult dermatology
1. mild-moderate: topical steroids
1. Mod-severe reaction/organ failure: oral steroids with long gradual taper
1. symptomatic: oral antihistamines
76
an acute febrile eruption that is often associated with leukocytosis after drug administration
Pustular Drug Eruptions
77
s/s of Pustular Drug Eruptions?
w/u?
* sterile pustules on an erythematous base, often starting in the intertriginous folds and/or the face
* fever
* CBC: leukocytosis
