Transcript Dermatology Case 2:

Dermatology Case 2:
alegre. almora. alonzo. amaro.
amolenda. anacta. andal. ang. ang. ang.
 EG 43 y/o F
Chief Complaint:
Plaques and Nodules on the face, trunk, and
extremities
HISTORY OF PRESENT ILLNESS
8 months PTC
• Few erythematous ill-defined
asymptomatic patches over both upper
extremities
-associated tingling sensation and
numbness of the hands and forearms
•No consult was done nor medications
taken
6 month PTC
• Plaques and nodules involving the
forehead, malar area, left ear, trunk and
extremities
CONSULT
FAMILY HISTORY
 (+) HPN, DM
 (-) similar lesion
PHYSICAL EXAMINATION
 Skin:
 multiple erythematous to skin-colored plaques and nodules
1.5x 3.5 to 2.0 x 4.0 cm over the malar area, helix of ears,
upper extremities, thighs
 (+) leonine facies
 (-) madarosis
CLINICAL IMPRESSION
 Salient Features
 erythematous ill-defined
asymptomatic patches
(upper extremities) into
multiple erythematous to
skin-colored plaques and
nodules 1.5x 3.5 to 2.0 x
4.0 cm (malar area, helix
of ears, upper extremities,
thighs)
 (+) leonine facies
 (-) madarosis
 Lepromatous type
of Leprosy
(Hansen’s Disease)
DIFFERENTIAL DIAGNOSIS
 Erythema multiforme
 Fixed drug reaction
 Seborrheic dermatitis
 Cellulitis
 Urticaria
 Exfoliative dermatitis
 Hansen’s Disease
Erythema Multiforme
 an acute, self-limiting, inflammatory skin eruption.
 Most common cause is Herpes Simplex
 Occurs in response to medications, infections
 Medications include:
 Barbiturates
 Penicillins
 Phenytoin
 Sulfonamides
 Infections include:
 Herpes simplex
 Mycoplasma
 Erythema
Multiforme
Data
EG 43 y/o F
Begin as sharply marginated,
 erythematous ill-defined
 (brief
description
of pathology)
erythematous
macules, which
become
asymptomatic patches
raised, edematous papules over 24 to
 (epidemiology,
incidence, etc.) (upper extremities, with
48 hours
tingling sensation,
“target” or “iris” lesion with 3 zones –
numbness of the hands)
central dusky purpura; an elevated,
into multiple
edematous, pale ring; and surrounding
erythematous to skinmacular erythema
colored plaques and
nodules 1.5x 3.5 to 2.0 x
 Age of Predilection
4.0 cm (malar area, helix
Young adults
of ears, upper extremities,
thighs)
 Site of predilection
 (+) leonine facies
dorsal hands, dorsal feet, extensor
limbs, elbows and knees, and
 (-) madarosis

Lesion
 Patient’s
palms and soles

There are two types of EM:
 EM minor and EM major.
 EM minor comprises nearly 70% of the cases.
 Most cases of EM minor resolve in one to three
weeks
 EM major might take three to six weeks to resolve.
 Recurrences are more commonly seen in EM minor,
but are rare in EM major.
 Traditionally, Stevens- Johnson syndrome (SJS) and
toxic epidermal necrolysis (TEN) were included in
the same spectrum as EM.
EM MINOR
 Most patients with EM minor present with new-
onset mucocutaneous lesions which are usually
symmetrical and rapidly progressing in nature.
 These lesions may be pruritic or may be associated
with a burning sensation.
EM MAJOR
 EM major is usually preceded by prodromal
symptoms such as fatigue, fever, headaches, and
myalgias.
 These symptoms can appear up to two weeks prior to
the mucocutaneous manifestations.
 Oral mucosal involvement may lead to difficulty in
drinking and eating.
 Ocular involvement may lead to complaints of
redness, discharge and ocular pain.
Treatment
 Prevention is cornerstone of treatment if HSV can be
demonstrated as the trigger.
 Antiherpetic antibiotic
Fixed Drug Eruption
 the development of one or more annular or oval
erythematous patches as a result of systemic
exposure to a drug.
 normally resolve with hyperpigmentation and may
recur at the same site with reexposure to the drug.
Erythema Multiforme
Lesion
•Begin as sharply marginated,
erythematous macules, which
become raised, edematous
papules over 24 to 48 hours
•“target” or “iris” lesion with
3 zones – central dusky
purpura; an elevated,
edematous, pale ring; and
surrounding macular
erythema
Age of Predilection
Young adults
Site of Predilection
dorsal hands, dorsal feet,
extensor limbs, elbows and
knees, and palms and soles
Fixed Drug Eruption
•Begins as a red patch that
soon evolves to an iris or
target lesion identical to
erythema multiforme, and
may eventually blister and
erode
•Nonpigmenting fixed drug
eruption: large, tender, often
symmetrical eythematous
plaques
Oral and genital mucosa
Etiologic Factors
Treatment
Erythema Multiforme
Fixed Drug Eruption
Usually has non-drug causes,
most commonly herpes
simplex infection
Genetic susceptibility with an
increased incidence of HLAB22
•Prevention is cornerstone of
treatment if HSV can be
demonstrated as the trigger.
•Sunblock creams
•Antiherpetic antibiotic
•Stop taking the offending
drug.
Patient
Fixed Drug Eruption
Multiple erythematous to skin-colored plaques
and nodules (1.5x3.5 to 2.0x4.0 cm)
Begins as a red patch that soon evolves to an
iris or target lesion identical to erythema
multiforme, and may eventually blister and
erode
Forehead, malar area, left ear, trunk, and
extremities
Oral and genital mucosa
(+) Leonine facies
(+) HPN, DM
Seborrheic Dermatitis
 also known as seborrhea
 common non-contagious condition of skin areas rich
in oil glands (the face, scalp, and upper trunk)

marked by flaking (overproduction of skin cells) and
sometimes redness and itching (inflammation) of the skin
 varies in severity from mild dandruff of the scalp to
scaly, red patches on the skin.
Seborrheic Dermatitis
 Epidemiology:
 with redness and flaking = 3–5% of the population
 affects all races; worse in men, and starts after puberty
(although babies have a version called cradle cap) and peaks
around the age of 40 and then may improve
 Cause:
 due to a combination of an over production of skin oil and
irritation from a yeast, Pityrosporum ovale.
 Risk:
 Stress, fatigue, weather extremes, oily skin, infrequent
shampoos or skin cleaning, use of lotions that contain alcohol,
skin disorders (such as acne), or obesity
 Familial
 Seborrheic

Dermatitis
Lesion

Scanty, loose, dry, moist or
greasy scales and by crusted
pinkish or yellowish patches

Age of Predilection
 Starts at puberty and peaks
at the age of 40

Signs & Symptoms:


Scalp is itchy and sheds white,
oily skin flakes.
In darker skin, some of the
affected areas may look lighter
in color.
 Patient’s




Data
EG 43 y/o F
erythematous ill-defined
asymptomatic patches
(upper extremities, with
tingling sensation,
numbness of the hands)
into multiple
erythematous to skincolored plaques and
nodules 1.5x 3.5 to 2.0 x
4.0 cm (malar area, helix
of ears, upper extremities,
thighs)
(+) leonine facies
(-) madarosis
 Seborrheic

 Patient’s
Site of Predilection

Areas has patches of red, scaly
skin:


Dermatitis


the scalp, hairline, forehead,
eyebrows, eyelids, creases of the
nose and ears, ear canals, beard
areas, breastbone, midback,
groin, or armpit; Flexors of
elbow and knee
Classifications



Mild – only some flaking and
redness in a few small areas.
Moderate – several areas affected 
with bothersome redness and itch. 
Severe – large areas of redness,
severe itch and unresponsive to
self-care measures.
Data
EG 43 y/o F
erythematous ill-defined
asymptomatic patches
(upper extremities) into
multiple erythematous to
skin-colored plaques and
nodules 1.5x 3.5 to 2.0 x
4.0 cm (malar area, helix
of ears, upper
extremities, thighs)
(+) leonine facies
(-) madarosis
Seborrheic Dermatitis
Seborrheic Dermatitis
 The diagnosis is based on the appearance and
location of the skin lesions

In rare cases - skin biopsy to r/o other diseases
 Therapeutic Plans
 Shampoo several times a week


Topical Antifungals


Selenium sulfide, zinc pyrithionate, tar and resorcin shampoos
Ketoconazole 2% cream
Corticosteroid creams
Patient
Erysipelas
Multiple erythematous to skin-colored
plaques and nodules (1.5x3.5 to 2.0x4.0
cm)
Fiery-red swelling with characteristic
raised, indurated border; distinctive
features is the advancing edge of the patch
Newborn, postpartum women, elderly and
immunocompromised
Forehead, malar area, left ear, trunk, and
extremities
Face and legs
(+) Leonine facies
Beta hemoytic Group A streptococcus
Any inflammation of the skin, especially if
fissured or ulcerative, may provide an
entrance for the causative streptococcus
Bacterial cultures
Systemic penicillin
Erythromycin
Locally, ice bags and cold compresses
(+) HPN, DM
Patient
Cellulitis
Multiple erythematous to skin-colored
plaques and nodules (1.5x3.5 to 2.0x4.0
cm)
Warm tender painful swelling with illdefined borders (pits on pressure)
Children and immunocompromised
No predilection for either sex is usually
reported
Forehead, malar area, left ear, trunk, and
extremities
(+) Leonine facies
Streptococcus pyogenes or S. aureus
Usually follows some discernible wound
Laboratory Studies
Intravenous penicillinase-resistant
penicillins or a first-generation
cephalosporin
 Exfoliative
Dermatitis
 Patient’s
Data

Age & Sex Predilection
 >40 y/o, females

Age & Sex Predilection
 43 y/o, female

Lesion
 Erythematous plaques

Lesion
 multiple erythema-tous
to skin-colored plaques
and nodules

Area of Predilection
 Face and extremities

Area of Predilection
 malar area, upper
extremities, thighs


Predisposing Factors
Drug allergy, underlying
cutaneous or systemic disease
(ex. Lymphoma)


Predisposing Factors
none
 Exfoliative
Dermatitis
 Patient’s
Data

Course of Illness
 Multiple remissions and
exacerbations

Course of Illness
 (-) remissions and
exacerbations

Other associated s/sx

Other associated s/sx
Swelling or lymphadenopathy
Recurrent infections
Low-grade fever, chills, malaise
Gynecomastia
Hepatomegaly, splenomegaly
Steatyorrhea
Hyper/hypopigmentation
Alopecia
Dystrophic nails
Leonine facies
Tingling sensation
Numbness of hand and forearm
 Exfoliative


Dermatitis
Etiology
 Drugs, food, infections,
emotional stress,
neoplasm
Course of Illness
IgE-mediated
 transient (<24 hours)
 Migratory
 no residual skin
abnormalities
Vasculitis
 >24 hours
 painful and pruritic
 leave purpuric and
hyperpigmented lesions
 Patient’s
Data

Etiology
 Not present

Course of Illness
 8 months
 Urticaria
 Patient’s
Data

Age & Sex Predilection
 Any age, Male=Female
 Chronic = 40 y/o, Female

Age & Sex Predilection
 43 y/o, female

Lesion
 white or red evanescent
plaques
 Blanching , raised, palpable
wheals
 linear, circular or serpiginous
 dermographism

Lesion
 multiple erythematous to skin-colored
plaques and nodules
1.5x 3.5 to 2.0 x 4.0
cm

Area of Predilection
 Any skin area

Area of Predilection
 malar area, helix of
ears, UE, thighs
Indeterminate Leprosy
 earliest and mildest form of the disease
 few numbers of hypopigmented macules (cutaneous
lesions)
 loss of sensation is rare.
 most cases progress into a later form, although
patients with strong immunity may either clear the
infection on their own or persist in this form without
progressing.






Indeterminate Leprosy
 Patient’s
Earliest and mildest form
One to a few of
hypopigmented or
erythematous macules
Loss of sensation is rare
75% of affected persons have
lesions that heal
spontaneously
Most cases progress into a
later form, although patients
with strong immunity may
either clear the infection on
their own or persist in this
form without progressing.



Data
erythematous ill-defined
asymptomatic patches
(upper extremities, with
tingling sensation,
numbness of the hands) into
multiple erythematous to
skin-colored plaques and
nodules 1.5x 3.5 to 2.0 x 4.0
cm (malar area, helix of
ears, upper extremities,
thighs)
(+) leonine facies
(-) madarosis
 Tuberculoid





Leprosy
One erythematous large plaque
with well-defined borders that
are elevated and that slope
down into an atrophic center
Lesions can become arciform
or annular
Can be found on the face,
limbs, or elsewhere, but they
spare intertriginous areas and
the scalp
Lesions can be dry and scaly,
hypohidrotic, and hairless
Involves a large, asymmetric
hypopigmented macule
 Patient’s



Data
erythematous ill-defined
asymptomatic patches
(upper extremities, with
tingling sensation,
numbness of the hands) into
multiple erythematous to
skin-colored plaques and
nodules 1.5x 3.5 to 2.0 x 4.0
cm (malar area, helix of
ears, upper extremities,
thighs)
(+) leonine facies
(-) madarosis
 Tuberculoid





Leprosy
Spontaneous resolution can
occur in a few years, leaving
pigmentary disturbances or scars
Progression can also occur,
leading to borderline-type
leprosy
Neural involvement is common leads to tender, thickened nerves
with subsequent loss of function
Great auricular nerve, common
peroneal, ulnar, and radial
cutaneous and posterior tibial
nerves are often prominent
Nerve damage can happen early,
resulting in wrist drop or foot
drop
 Patient’s



Data
erythematous ill-defined
asymptomatic patches
(upper extremities, with
tingling sensation,
numbness of the hands) into
multiple erythematous to
skin-colored plaques and
nodules 1.5x 3.5 to 2.0 x 4.0
cm (malar area, helix of
ears, upper extremities,
thighs)
(+) leonine facies
(-) madarosis
Tuberculoid Leprosy

Borderline Tuberculoid
 Patient’s

Similar to tuberculoid
type except that lesions
are smaller and more
numerous
Alopecia is less
Anesthesis is less severe
Disease may stay in this
stage or convert back to
tuberculoid form, or
progress to lepromatous
leprosy






Data
erythematous ill-defined
asymptomatic patches
(upper extremities, with
tingling sensation,
numbness of the hands) into
multiple erythematous to
skin-colored plaques and
nodules 1.5x 3.5 to 2.0 x 4.0
cm (malar area, helix of
ears, upper extremities,
thighs)
(+) leonine facies
(-) madarosis
Borderline Tuberculoid Leprosy

Borderline Lepromatous Leprosy
Lesions: symmetrical, numerous
(too many to count) and may
include macules, papules,
plaques, and nodules
 Patient’s

Age of predilection: 2 peaks of
presentation; in children aged 1020 years, and in adults 30-60 y/o
Site of predilection: face, limbs
Nerve involvement appears later.
The involvement is symmetrical.
Sensation and sweating over
individual lesions is normal.


Data
erythematous ill-defined
asymptomatic patches
(upper extremities, with
tingling sensation,
numbness of the hands) into
multiple erythematous to
skin-colored plaques and
nodules 1.5x 3.5 to 2.0 x 4.0
cm (malar area, helix of
ears, upper extremities,
thighs)
(+) leonine facies
(-) madarosis

Lepromatous Leprosy
Lesions: Mainly pale lepromatous
macules or lepromatous infiltrations,
with numerous bacilli in the lesions;
leonine facies positive
 Patient’s

Age of predilection: 2 peaks of
presentation; in children aged 1020 years, and in adults 30-60 y/o
Site of predilection: face, limbs
There is little or loss of sensation
over the lesions, there is no nerve
thickening; numbness of hands


Data
erythematous ill-defined
asymptomatic patches
(upper extremities, with
tingling sensation,
numbness of the hands) into
multiple erythematous to
skin-colored plaques and
nodules 1.5x 3.5 to 2.0 x 4.0
cm (malar area, helix of
ears, upper extremities,
thighs)
(+) leonine facies
(-) madarosis
Leonine Facies

Histoid Leprosy
Lesions: Yellow-red, shiny, large
papules and nodules in the dermis or
subcutaneous tissue
 Patient’s

Age of predilection: 2 peaks of
presentation; in children aged 1020 years, and in adults 30-60 y/o
Site of predilection: buttocks, lower
back, face, and bony prominences
may appear de novo or in patients
with dapsone resistance


Data
erythematous ill-defined
asymptomatic patches into
multiple (upper extremities,
with tingling sensation,
numbness of the hands)
erythematous to skincolored plaques and nodules
1.5x 3.5 to 2.0 x 4.0 cm
(malar area, helix of ears,
upper extremities, thighs)
(+) leonine facies
(-) madarosis
Leprosy
 Diagnosis: based on clinical signs/symptoms and the
presence of infectious organism (M. leprae) from
skin biopsy

Skin lesions, tingling sensation, numbness of the hands
 Treatment: Dapsone (cornerstone of therapy)
 Dapsone, rifampin, clofazimine – initial combination therapy