Transcript Dermatology - Wayne State University

Dermatology
Board Review 2005
Julia Akaah M.D.
Case 1
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6 month old infant has a 2 month history
of erythematous erosions around the
mouth, hands, feet, and in the perineum.
There is crusting of the scalp and hair is
sparse. The infant has experienced
diarrhea and poor weight gain for the past
month. The infant was weaned from
breast milk to formula at 2 months of age
Acrodermatitis enteropathica
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AR disorder associated with defective transport
protein in the GI tract, resulting in impaired
absorption of dietary zinc
Human milk contains a protein that facilitates
xinc absorption therefore symptoms appear after
infant is weaned
Zinc deficiency occurs with CF, celiac disease and
patients on TPN w/o zinc
Zinc deficiency  altered keratin synthesis
Diagnosis is confirmed by low serum zinc levels
Tx: zinc sulfate 5mg/kg/d with topical
corticosteroids
Case 2
You are asked to evaluate a boy with dry
skin. He has history of mild atopic
dermatitis. The boy’s father also has scaly
skin and allergic rhinitis. PE reveals
generally dry skin and thin scales that
have a “pasted on” appearance on the
extensor surface of the legs and butttocks
Ichthyosis vulgaris
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Ichthyosis describes group of inherited and
acquired disorders of keratinization which are all
associated with scaling
Ichthyosis vulgaris is most common: AD,
apparent between 3m to 5 years
Thin scales with elevated edges, with pasted on
appearance, extensor surfaces of lower
extremities, trunk and upper extremities (face
antecubital and popliteal fossa are spared)
Improves over time
50% of children also have atopic dermatitis
Treatment: Keratolytics (lactic a., glycolic a, urea
based emolliants) and oral retinoids in severe
cases
Case 3
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You are asked to evaluate a 1 day old
healthy term infant with a rash. Scattered
pustules without surrounding erythema
involving the trunk and forehead and
several small hyperpigmented macules,
some of which possess a collarette of
scale
Transient neonatal pustular
melanosis
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Condition begins in utero
At birth there are pustules and 2-3 mm
hyperpigmented macules
Macules are surrounded by collarette of
scale that represents remnant of a pustule
roof
A gram or Wright stain will reveal PMNs
without organisms
Benign self limited disorder
Diff dx: erythema toxicum, neonatal acne,
milia
Case 4
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Your are asked to evaluate a 1 day old full
term, healthy infant with a rash. There
are erythematous macules and in the
center of each macule is a solitary papule
or occasionally a vesicle
Erythema Toxicum
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Benign, self limited eruption occurs in
50% of term newborns
Develop 2-3 cm erythematous macules
that have a central papule, pustule or
vesicle
Can involve any body surface area except
palms or soles
Eruption begins 24-48 hours of life and
lasts 4-5 days
Wright stain of vesicles reveals eosinophils
DDx: milia, neonatal acne, and transient
pustular melanosis
Case 5
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18 month old boy presents with 2 month
history of recurring pruritic eruption.
Outbreaks last 1-2 weeks. No one else in
the household is similarly affected.
Physical exam reveals clustered
erythematous papules 4-6mm in diameter.
Several papules have a central punctum.
Papular urticaria
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Delayed hypersensitivity reaction to stinging or
biting arthropods (dog or cat fleas, mosquitos,
lice, grass mites etc.)
Affected children are 18 months to 7 years and
only members of household to have symptoms
Each crop of papules last 2-10 days and
recurrences may be observed for 3-9 months
Tx: remove the offending agent, topical
corticosteroid and oral antihistamine if pruritis is
severe, apply insect repellent (with DEET) if
outdoor insects are implicated
Case 6
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14 yo girl with tuberous sclerosis comes
for evaluation of rash on the face. The
only medication she takes is felbamate for
seizures. Examination of face reveals
numerous 1-3 mm pink papules in the
malar areas bilaterally
Adenoma sebaceum
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These lesions are angiofibromas, benign
tumors
Appear during childhood or adolescence
but occasionally observed at birth
These lesions do not involute and may
coalesce to form plaques
Case 7
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8 year old presents with localized loss of
scalp hair of 2 months duration. PE
reveals patch of alopecia within which
hairs are of differing lengths. Remainder
of the scalp is normal with no erythema,
scaling, or “black dot” hairs
Trichotillomania
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Alopecia from repetitive twirling, rubbing,
or plucking of the hair
Scalp, eyebrows and lashes are affected
Often result of habit and stress
Irregularly shaped patch of alopecia
without erythema or scaling containing
hairs of differing lengths
Diff Dx: traction alopecia, alopecia areata
and tinea capitus
Case 8
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Healthy 14 yr old girl is worried about an
area of skin thickening, tightness and
discoloration, that developed 3 months
ago. No trauma and no associated
symptoms. PE shows shiny
hypopigmented patch with a brown
border, skin is immobile and firm and has
bound down feeling
Linear scleroderma
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Scleroderma is a C.T. disorder with
autoimmune etiology
Lesions begin as an area of indurated skin
surrounded by a violaceous halo. Over
time the violaceous halo takes on a waxy,
ivory appearance. As the disease remits it
becomes atrophic with hyper and
hypopigmentation
Linear scleroderma develops in band like
distribution, unilateral, involve extremities,
face and trunk
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Self limited with disease activity lasting 35 yrs
Morbidity when face is involved or joint
function is compromised
Case 9
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7 year old girl develops widespread linear
red papules and vesicles over her arms
and legs. Seven days earlier she had
been riding her bike in the woods with her
dog. The rash began 3 days ago and new
blisters are continuing to develop
Rhus dermatitis (poison ivy)
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Poison ivy is a type IV delayed hypersensitivity
reaction that occurs in patients with contact
dermatitis
Following a period of sensitization of 1-2 wks
predisposed individuals develop a cutaneous
reaction on re-exposure to allergen
Following exposure to poison ivy, the skin rash
can spread for several days
Langerhans cells process the contact allergen
and vary over the skin surface
Reaction subsides over 2-4 weeks if no
treatment given
Tx: cool tap water compresses, topical lotions
and steroids and antihistamines
Case 10
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40 year old female comes in for evaluation
of flushing around the nose and cheeks
associated with dilated veins
Rosacea
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Pustular eruption with
flushing and
telangiectasias of the
butterfly area of the
face
Adults 40-60yrs of
age
Severe longstanding
cases eventuate in
the bulbous, greasy,
hypertrophic nose
characterisitic of
rhinophyma
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Pustules are recurrent and difficult to heal
Disease is influenced by oily skin,
excessive alcohol ingestion, spicy foods
and hot drinks, sun exposure and stress
Tx: avoidance of chocolate, nuts, cheese,
cola, alcohol, spices, seefood
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Metronidazole gel, tetracycline