Papulosquamous and Inflammatory Disorders Flashcards
(124 cards)
1
Q
What is pityriasis rosea?
A
Acute exanthematous eruption
Self limited
Remits in 6 weeks
2
Q
MCC of pityriasis rosea
A
Herpes Human Virus 6 and 7
3
Q
Epidemiology of pityriasis rosea
A
10-40 years old
MC in spring and fall
4
Q
Clinical presentation of pityriasis rosea
A
Herald patch: oval, slightly raised plaque or patch
Salmon red, fine collarette
1-2 weeks later fine scaling papules and patches with marginal collarette/dull pink
Oval scattered (christmas tree pattern)
confined to trunk
5
Q
Which disorder is in a christmas tree distribution?
A
Pityriasis Rosea
6
Q
Course of pityriasis rosea
A
Spontaneous remission in 6-12 weeks
Recurrences are uncommon
7
Q
Management of pityriasis rosea
A
Control itch
Oral antihistamines
Topical antipruritic lotions
Topical steroids: triamcinolone .1% cream/ointment/lotion BID x 4 weeks
Oral steroids: prednisone taper (if really bad)
8
Q
What is lichen planus?
A
Acute or chronic inflammatory dermatosis involving skin and/or mucous membranes MC idiopathic
9
Q
What is thought to play a role in lichen planus?
A
Cell mediated immunity (CD8 and CD45Ro+ cells)
Drugs
Metals (gold and mercury)
Infection (hep C)
10
Q
Presentation of lichen planus
A
Papules that are flat topped, polygonal or oval
Annular
Purple
Pruritic
1-10 mm in size
Sharply defined, shiny
Violaceous with white lines (Whickham striae) seen after use of oil under dermascope
Grouped or disseminated
If darker phototype, hyperpigmented
11
Q
Locations of lichen planus
A
Wrists
Lumbar
Shins
Scalp
Glans penis
Oral
12
Q
Variants of lichen planus
A
Hypertrophic
Atrophic
Follicular
Vesicular
Pigmentosus
Actinicus
Ulcerative/erosive
Mucous membranes
Reticular
13
Q
Characteristics of hypertrophic lichen planus? Atrophic?
A
Hypertrophic: Large thick plaques
Atrophic: White bluish, well demarcated papules and plaques with central atrophy
14
Q
Characteristics of follicular lichen planus? Vesicular?
A
Follicular: follicular papules and plaques that lead to cicatrical alopecia
Vesicular: bullous pemphigoid with LP
15
Q
Characteristics of pigmentosus lichen planus? Actinicus?
A
Pigmentosus: hyperpigmented, dark-brown macules in sun exposed areas and flexural folds
Actinicus: papules in sun exposed areas
16
Q
Characteristics of ulcerative/erosive lichen planus? Reticular?
A
Ulcerative/erosive: ulcers that are therapy resistant
Reticular: lacy, white hyperkeratosis on buccal mucosa, lips, tongue, gingiva
17
Q
what percent of lichen planus has mouth involvement?
A
40-60%
18
Q
What is the appearance of lichen planus on genitalia?
A
Papular, annular, or erosive lesions on the penis, scrotum, labia majora, labia minora, and vagina
19
Q
What is the appearance of lichen planus of the hair and nails?
A
Scarring alopecia possible
Destruction of nail fold and bed with longitudinal splintering
20
Q
Course of lichen planus
A
Months to years
21
Q
Diagnosis of lichen planus?
A
Biopsy helpful
22
Q
Treatment of localized lichen planus
A
Topical steroids: under occlusion for cutaneous lesions, 1st line =triamcinolone BID x 4weeks
ILK injection
Cyclosporine and tacrolimus solution, mouthwash for oral lesions
23
Q
Treatment of systemic lichen planus
A
Cyclosporin 5 mg/kg per day
Prednisone 70 mg initially then taper by 5 mg
Retinoids 1 mg/kg per day as adjunct
PUVA
24
Q
What is the use of prednisone in systemic lichen planus?
A
Ease discomfort and pruritis
25
What is granuloma annulare?
Chronic condition of the dermis
Self limited
26
Epidemiology of granuloma annulare
Females: males 2:1
MC children and young adults
27
Etiology of granuloma annulare
Unknown see in diabetes
28
Presentation of granuloma annulare
Skin colored or brownish-red
Shiny beaded papules in annular arrangement
MC on hands and feet, elbows and knees (commonly misdiagnosed as tinea)
Generalized but can be isolated spot
29
If GA is diagnosed, what should be worked up?
Work up for diabetes
29
Diagnosis of granuloma annulare
Clinical but biopsy diagnostic
See foci of chronic inflammatory and histiocytic infiltrations in superficial and mid dermis
Necrobiosis of connective tissue surrounded by a wall of palisading histiocytes and multinucleated giant cells
30
management of granuloma annulare
no treatment necessary
topical triamcinolone
ILK
Cryo may resolve (but not recommended due to scarring)
31
What is erythema nodosum?
Common acute inflammatory/immunologic reaction pattern of the subcutaneous fat
MC type of panniculitis
32
Etiology of erythema nodosum
Infection
Drugs
Inflammatory/granulomatous disease
Sarcoidosis
33
What is the age of onset/gender of erythema nodosum
20-30 yo
Female >Male (6:1)
34
Symptoms of erythema nodosum
Painful
Tender
Fever
Malaise
Arthralgia (MC ankle)
35
Lesion presentation in erythema nodosum
Indurated, tender nodules 3-20 cm
Bright to deep red
Only appreciated on palpation
Not sharply marginated: oval, round, and acriform
Deep seated in fat (MC anterior leg)
As they age: brownish, yellowish, green
Bilateral but not symmetrical
36
Diagnosis of erythema nodosum
Elevated ESR and CRP
Leukocytosis
2 punch biopsy of nodule
37
Course of erythema nodosum
Spontaneous resolution in 6 weeks
Heal without scarring
38
Management of erythema nodosum
Symptomatic
Bed rest
Compressive bandages
Wet dressings
Antiinflammatory treatment: NSAIDs and prednisone
39
What is psoriasis
Chronic, multifactorial inflammatory skin disorder resulting in hyperproliferation of the keratinocytes in the epidermis
40
Pathogenesis of psoriasis
Theory that T cell proliferate the epidermis resulting in over production of epidermal cells
Dysregulated inflammatory process results in large production of various cytokines
41
Epidemiology of psoriasis
2 peaks
20-30 yo and 50-60 yo
42
Histology of psoriatic skin without active lesion
Slight capillary dilatation
Slight increase in dermal mononuclear cells and dermal cells
Increase in epidermal thickness
43
Histology of developing lesion
Progressive capillary dilatation
Increase in mast cells, macrophages, and T cells, and mast cell degranulation
Increasing thickness of the epidermis
44
What is histology of fully developed psoriatic lesion
10 fold increase in blood flow
Numerous macrophages underlying basement membrane
Increase number of T cells
Increase in epidermis
Accumulation of neutrophils in stratum corneum
45
Etiology of psoriasis
Environmental: trauma (Koebner phenomenon), stress, cold, infection, alcohol, medications
Acute streptococcal infection precipitates guttate psoriasis
Genetic: 30% have first degree relative with psoriasis
Immunologic: first lesion typically after URI, evidence of autoimmune properties
46
Subtypes of psoriasis
Eruptive/inflammatory
Pustular
Chronic stable psoriasis
47
What is eruptive inflammatory psoriasis
aka guttate or nummular
multiple small lesions appearing rapidly
spontaneous remission
often follows strep pharyngitis
48
Pustular psoriasis
presence of pustules instead of papules, patches, and plaques
49
What is chronic stable psoriasis
MC presentation
Classic lesions present for months - years with little change
50
Classic lesion presentation
Erythematous papule/patch/plaque with sharp margins
OVerlying silvery white scales easily removed with scratching
Auspitz sign
Pruritis
51
What is Auspitz sign?
Removal of scale leaves small blood droplet
52
Clinical presentation of eruptive inflammatory psoriasis
2-10 mm salmon pink papules +/- scales
concentrated to trunk, few scattered lesions to face, scalp, extremities
may resolve spontaneously within few weeks
most often evolves into chronic stable type
53
clinical presentation of chronic stable psoriasis
sharply marginated dull-red plaques with loosely adherent silver-white scales
plaques may coalesce
waxing and waning of lesions throughout lifetime
54
sites of predilections to psoriasis
bilateral, often symmetric
elbows
knees
sacral/gluteal region
scalp
palm/soles
55
Clinical presentation of palms/sole psoriasis
thick adherent silvery-white or yellow scaling
painful cracking/fissures
56
clinical presentation of face psoriasis
uncommon
seen with refractory cases
57
clinical presentation of scalp psoriasis
sharply marginated plaques with thick adherent scales
intense pruritis
no hair loss
58
clinical presentation of psoriasis of peri-anal/body folds
macerated due to warm moist environment
sharply marginated, bright red, fissured lesions
59
clinical presentation of nail psoriasis
pitting, subungual hyperkeratosis, onycholysis
yellowish-brown spots
involved 25% of the time
60
clinical presentation of pustular psoriasis
results from increase in PMN leukocytes in psoriatic epidermis
often precipitated by corticosteroid withdrawal
stinging
burning
pruritis
erythematous patches or thin plaques that rapidly become studded with nummerous pinhead-sized sterile pustules
61
2 presentations of pustular psoriasis
palmoplantar (pams/soles)
generalized "Von Zumbusch variant"
62
Presentation of palmoplantar pustular psoriasis
pustules 2-5 mm
erupt into dusky-red erosions and crusts
persists for years with unexplained remissions/exacerbations
63
presentation of generalized pustular psoriasis
pustules coalesce into lakes of pus
+ Nikosky sign in generalized presentation
life threatening
relapses and remissions occur over years
may evolve into chronic stable psoriasis
64
subjective findings of psoriatic arthritis
joint stiffness and pain worse after inactivity, improves with movement
65
objective findings of psoriatic arthritis
swelling
redness
tenderness of involved joints
psoriatic lesions over involved joints
66
diagnosis of psoriasis
clinical
labs to r/o other disorders: throat culture to r/o strep for acute inflammatory psoraisis, KOH prep, bacterial/viral culture for pustular psoriasis
leukocytosis with left shift seen in generalized pustular psoriasis
67
management of psoriasis
refer to dermatology to confirm diagnosis and initiate management
localized psoriasis - can be managed by PCP once therapy initiated
generalized: managed by dermatology provider
psoriatic arthritis: refer to rheumatology
68
management of localized psoriasis on trunk/extremities
topical steroids mid to high potency
Consider ointment for night and cream for day
Vitamin D analog: calcipotriol, calcitriol
Topical retinoid (tazarotene) reserved for thick plaques, best in combo with topical mid-high potency glucocorticoid or UVB phototherapy
Coal tar with salicylic acid
Emollients liberally in between treatments and always after bathing/showering
69
What are the vitamin D analogs used for psoriasis
calcipotriene, calcitriol
70
what vehicle is often used for vitamin D for scalp psoriasis
solution
71
MOA of vitamin D analog
binds to vitamin D receptor and regulates cell growth
inhibits proliferation of keratinocytes
inhibits proinflammatory cytokines
72
directions for vitamin D analog
apply thin layer to affected area BID, avoid application to >40% body area and 100 g/week maximum
73
SE of topical vitamin D analogs
burning
itching
skin irritation
photosensitivity
hypercalcemia
74
CI for vitamin D analogs
hypersensitivity
75
MOA of calcitriol
binds to vitamin D receptor and regulates cell growth
inhibits proliferation of keratinocytes
inhibits proinflammatory cytokines
76
directions for calcitriol
apply thin layer to affected area BID 20 g/wk maximum
77
SE/CI of calcitriol analog
hypercalcemia, photosensitivity
no CI
78
management of scalp psoriasis
tar shampoo followed by medium- high potency lotion
79
management of palm/sole psoriasis
high potency topical steroids ointment with occlusive dressing
PUVA soaks (immerse in photosensitizer liquid 15 mins and expose to UVA phototherapy units)
oral retinoids: reserved for unresponsive thick hyperkeratotic lesions
80
management of palmoplantar pustulosis
PUVA soaks
immunosuppressant: methotrexate or cyclosporine in unresponsive cases
81
management of inverse/genital psoriasis
initiate with short term (2-4 weeks) of topical steroids
followed by one of the following:
vitamin D analog, topical retinoid (tazarotene), topical calcineurin inhibitors (tacrolimus/pimecrolimus)
82
management of nail psoriasis
goal: normal regrowth, consider length of therapy based on rate of nail growth
Options: PUVA phototherapy in hand/foot lighting units, oral retinoids, immunosuppressant MTX or CS for unresponsive types
83
Which psoriasis treatment is pregnancy category X?
Tazarotene
84
Topical steroids side effects
skin atrophy
hypopigmentation
striae
85
calcipotriene side effects
skin irritation
photosensitivity
86
tazarotene side effects
skin irritation
photosensitivity
87
coal tar side effects
skin irritation
odor
staining of clothes
carcinogenic
88
calcineurin inhibitors side effects
skin burning and itching
89
when are calcineurin inhibitors used?
off-label for facial and intertriginous psoriasis
90
generalized acute, inflammatory psoriasis management
treat underlying strep infection if applicable
refer to dermatology for PUVA or UVB irradiation
91
generalized pustular psoriasis management
hospitalization with IV fluids
in hospital consult with derm
prophylactic IV antibiotics
oral retinoids
92
generalized chronic plaque psoriasis management
refer to dermatology for narrow band UVB irradiation, oral PUVA photochemotherapy, oral retinoids, immunosuppressants/biologic agents
93
What is the most important piece of historical information for adverse cutaneous drug reactions
Timing
Start with onset of rash and work backwards and forwards considering all possible causes
94
Risk factors for adverse cutaneous reactions
female
prior hx of drug reactions
recurrent drug exposure
EBV and CMV infection with PCN
HIV with sulfonamides
95
Immediate reactions occur within ------ of last dose and symptoms include:
1 hour
urticaria, angioedema, anaphylaxis
96
delayed reactions usually occur after ------, usually before -----, and occasionally ------- after initiation of drug use
1 hour, 6 hours, weeks-months
97
skin presentation of delayed adverse cutaneous drug reactions
exanthematous eruptions
fixed drug eruptions
systemic reactions
98
What are exanthematous drug reactions?
MC of all drug reactions
mechanism not fully known, likely delayed hypersensitivity
99
What is one example of exanthematous drug reactions not thhought to be allergey relatedp
EBV and CMV and PCN
100
What are classifications of exanthematous drug reactions
immediate reactions
delayed reactions
101
what is immediate exanthematous drug reaction
previously sensitized
2-3 days after initiation of drug
102
what are delayed exanthematous drug reactions?
delay due to sensitiization requirement
most often 7-10 days after initiation of drug
may take up to 3 weeks
103
clinical findings of exanthematous drug reactions
bright red, maculopapular rash
symmetric: starts on trunk and spreads to extremities
scaling/desquamation with healing
mild pruritis
104
high probability agents for exanthematous reaction
PCN
carbamazepine
allopurinol
gold salts
105
medium probability exanthematous reaction
sulfonamides
NSAIDs
isoniazid
erythromycin
streptomycin
106
low probability of exanthematous reaction drugs
barbiturates
BZDs
phenothiazines
tetracyclines
107
management of exanthematous drug reaction
identify and discontinue offending agent
if benefit outweighs risk (rare), oral/IV steroids
topical steroids and antihistamines for symptomatic relief
ensure patient is aware of offending agent and drug class
108
what is fixed drug eruption
drug reaction characterized by solitary erythematous patch/plaque that recurs at same site if re-exposure of offending agent occurs
Occasionally multiple fixed lesions occur
Unknown pathogenesis
109
clinical presentation of fixed drug eruption
onset 30 mins-8 hrs after ingestion
pruritis, burning pain
skin lesion
sharply marginated macule
erythema
dusky-red violaceous
edematous and bullous followed by erosion (may occur)
postinflammatory hyperpigmentation may occur
110
sites of predilection to fixed drug eruption
genital
pubic/crural
periorbital
conjunctiva
oropharynx
111
management of fixed drug eruption
remove offending agent
non-eroded lesions: topical steroid ointment
eroded lesion: topical antimicrobial ointment
symptomatic: antihistamines for pruritis, oral liquid compound for painful oral lesions
widespread presentation: refer to dermatologist
112
what is drug-induced hypersensitivity syndrome?
Skin eruptions with systemic symptoms and internal organ involvement
113
etiology of drug induced hypersensitivity syndrome
antiepileptic drugs: phenytoin, carbamazepine, phenobarbital
sulfonamides: antimicrobial agents, dapsone, sulfasalazine
114
clinical findings of drug induced hypersensitivity syndrome
onset 2-6 wks after drug initiation or increased dose
fever, malaise, facial edema
lymphadenopathy, hepatosplenomegaly
maculopapular eruption: starts on face, upper trunk, and UE, scaling and desquamation with healing
oropharyngeal mucosal lesions: cheilitis, erostions, pharyngitis, tonsillitis
115
dont forget to do this on exam of drug-induced hypersensitivity syndrome
full work up for systemic involvement
116
labs for drug-induced hypersensitivity syndrome
CBC: leukocytosis, eosinophilia
LFT
BUN/Cr
117
Diagnostic criteria for drug-induced hypersensitivity syndrome
3 must be present
Cutaneous drug eruption
hematologic abnormalities
systemic involvement: lymphadenopathy >2 cm, elevated LFTs, elevated BUN/Cr (interstitial nephritis)
118
treatment of drug-induced hypersensitivity syndrome
stop/substitute all suspected medications
consult dermatology
mild-moderate reaction: topical steroids
moderate-severe reaction/organ failure: oral steroids with long gradual taper
systemic: oral antihistamines
119
what is pustular drug eruption
acute febrile eruption often associated with leukocytosis after drug administration
120
onset of pustular drug eruption
1-3 weeks after initiation (if no previous sensitization)
2-3 days after initiation (if previously sensitized)
121
clinical findings of pustular drug eruptions
sterile pustules on an erythematous base, often starting in the intertriginous folds and/or face
fever
122
labs/diagnostics for adverse cutaneous drug reactions
leukocytosis
123
course/prognosis of adverse cutaneous drug reactions
pustules resolve over 2 wks followed by desquamation 2 weeks later
