Transcript Dermatology Dave Walsh

Dermatology
Dave Walsh
Topics Reviewed last year
 Common Rashes
 Eczematous Dermatoses
 Contact Dermatitis
 Atopic dermatitis
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Papulosquamous Dermatosis
Psoriasis
Pityriasis Rosea
Seborrheic Dermatitis
 Acneiform Eruptions
 Acne
 Rosacea
 Common skin and Nail Infections
 Superficial Fungal Infections
 Tinea
 Candidiasis
 Viral Skin Infections
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Herpes Simplex Virus
Herpes Zoster
Wart
Molluscum
Topics Reviewed last year
(continued)
 Stings and Bites
 Scabies
 Lice
 Bedbugs
 Common Neoplasm
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Basal Cell Carcinoma
Actinic Keratosis and Squamous cell carcinoma In situ
Squamous Cell carcinoma
Keratoacanthoma
Malignant Melanoma
 Foot and Leg Ulcers
 Venous stasis ulcers
 Arterial Ulcers
 Neuropathic ulcers
Topics for this talk
 Treatment of Dermatologic Conditions in
Pregnancy
 Common Rashes
 Eczematous Dermatoses
 Hand Dermatitis
 Xerotic Eczema
 Nummular Dermatitis
 Stasis Dermatitis
 Papulosquamous Dermatoses
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Lichen Planus
Drug Reactions
Pigmented Purpuric Dermatoses
Miliaria
Acontholytic Dermatosis (Grover Disease)
 Acneiform Eruptions
 Hidraenitis Suppurativa
 Common Skin and Nail Infections
 Bacterial Skin Infections
 Folliculitis
 Abscess/furuncle/carbuncle
 Impetigo
 Cellulitis/Erysipelas
 Erythrasma
 Keratolysis
 Cuts and Scrapes
Topics for this talk (continued)
 Pruritis
 Urticaria
 Autoimmune bullous disease
 Cutaneous Manifestations of Internal Disease
 Derm Urgencies and Emergencies
 Hair Disorders
 Nail Disorders
 Disorders of mucous membranes
 Not covered:
 Derm diseases of skin of color
 Aging skin
Topical steroids General Rules
 Ultrapotent steroids should be avoided on the face, groin, and
axilla, atrophic skin
 Clobetasol
 Exception: ultrapotent steroids used to treat lichen sclerosis of the
vulva
 Creams, ointments, gels, foams, lotions
 Creams – can be used widely
 Ointments – greasy feel, bad for hairy areas
 Lotion, foams, solutions – good for scalp and when large areas of
skin need to be covered
 30 Gm is needed to cover the skin of a 70-Kg man once
 Avoid combo steroid-antifungal products unless diagnosis is
established
A 22-year-old woman is evaluated for acne, which she has had since her
teens. She is 2 months pregnant, and the acne seems to be worsening. She
has been using over-the-counter benzoyl peroxide products, but the acne is not
improving. Medical history is unremarkable, and her only medication is prenatal
vitamins.
On physical examination, scattered inflammatory papules, a few pustules, and
open and closed comedones on the medial cheeks and chin are present
Azelaic acid
Clindamycin
Tazarotene
Tretinoin
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Answer Review
 Azelaic acid – Pregnancy category B
 Clindamycin – Pregnancy category B
 Tazarotene – topical acetylenic retinoid – Category X
 Tretinoin – differentiated retinoid (ATRA) – Category C;
usually avoided in pregnancy
 In general, retinoids have an antineoplastic effect
Treatment of Derm Conditions in
Pregnancy
 Risk/benefit ratio
 Steroids (topical and systemic): category C; although
generally considered safe
 Antihistamines – usually safe in pregancy
 Teteracycline – Category D – should be avoided
 Isotretinoin – X – mandatory pregnancy prevention plan
 Thalidomide – X – mandatory pregnancy prevention plan
 Spironolactone - avoid
Table 4. Selected Pregnancy Category X Drugs to Avoid During Pregnancy and Lactation
Acitretin
Danazol
Estrogens
Finasteride
5-Fluorouracil
Flutamide
Isotretinoin (Accutane)
Methotrexate
Stanozolol
Tazarotene (topical)
Thalidomide
A 40-year-old woman is evaluated for a rash on her hands that has been present for 6 weeks. This rash
comes and goes throughout the year and has been present for many years, but never as severe as it is
now. She also experiences itchy skin on her body. She had eczema as a child and currently has seasonal
allergies. She is otherwise well and is currently taking no medication.
On physical examination, vital signs are normal. She has dry skin on her trunk and extremities. Her hands
are extremely dry with scaling, erythema, and fissuring on the dorsal hand surfaces. Her feet are not
involved.
A. Atopic hand dermatitis
B. Keratoderma
blenorrhagica
C. Scabies
D. Tinea manuum
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Answer Review: Common skin
rashes
 Atopic hand dermatitis – increased prevalence in patients
with atopic eczema; sometimes outgrow childhood eczema
and then develop atopic hand dermatitis later in life
 Keratoderma blenorrhagica – erythematous scaly plaques
palms and soles associated in with spondyloarthropathy
(Reiter syndrome)
 Scabies – vesicular, itchy rash, burrows, interdigital web,
wrist, penis, axillae, nipples, umbilicus, scrotum
 Tinea manuum –dermatophyte infection of the hand; usually
only unilateral upper extremity and bilateral lower extremities
Common Skin Rashes: (Eczematous Rashes)
 Hand Dermatitis – often in people that work that involves
water (food services, hairdressers, health care workers)
 Patch testing can help if atypical/difficult to Rx disease
 Rx: avoidance of exposure, wear gloves
 Rx: mid to high potency steroids until rash clears
 Xerotic eczema – “winter itch”; dry skin, erythematous
patches topped by dry tiles. Rx: moisterizers +/- low or mid
potency steroids
Common Rashes:
 Xerotic eczema
Common rashes continued
 Nummular dermatitis:
 Form of eczema
 coin shaped patches and plaques.
 Affects patients with a history of atopic ezcema.
Check KOH to rule out tinea.
 Rx: steroids, UVB. Slow to respond to Rx
 Stasis Dermatitis:
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Venous problem
Older patients
Erythema, edema, and brown discoloration, :”woody”
DDx: cellulitis (cellulitis more commonly unilateral)
Rx: Goal reduce venous HTN: elevation, weight loss
Common skin rashes:
Papulosquamous Dermatoses
 Lichen Planus:
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Idiopathic
Skin, hair follicles, nails, mucous membrane
4Ps: pruritic, pink-purple, papules, plaques
Lichenoid drug eruption – similar appearance, but associated
with ACEi, TZDs, Lasix, b-blockers, anti-malarials
 Longstanding LP is a risk factor for SCC
 Rx: topical steroids first line, cola tar, calcineurin inhibitors, and
UV therapy are second line.
Drug Reactions:
Fixed, DRESS, AGEP, EM, SJS, TEN
 Drug reactions:
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Can be localized to skin or systemic
First step: stop the offending drug
Similar appearing to vasculitis and viral exanthems
Fixed drug eruptions (antibiotics, NSAIDs, acetaminophen)
DRESS: fever, LAD, skin findings, hepatopathy; anticonvulsants; remove
offending agent +/- steroids
 AGEP (acute generalized exanthematous pustulosis):
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widespread erythema studded by small pustules
fever, leukocytosis
MCC: Antibiotics, antimalarial, diltiazem, terbinafine
Self limiting
Rx: removal of agent +/- steroids
 EM, SJS, TEN – discuss in a bit
A 23-year-old woman is evaluated for a very itchy rash for the last 2 days. She
also reports “puffiness” in her face and fever. Because she has epilepsy, she
was started on a new anticonvulsant 6 weeks ago. She takes no other
medication.
On physical examination, temperature is 38.7 °C (101.6 °F), blood pressure is
130/78 mm Hg, pulse rate is 106/min, and respiration rate is 16/min. She has
facial edema and erythema. She has erythematous pink papules coalescing
into plaques that diffusely involve her trunk and extremities. Her mucous
membranes are hyperemic but not eroded or painful. Lymphadenopathy is
noted in the cervical and axillary regions and inguinal regions.
Laboratory studies show a serum alanine aminotransferase level of 330 units/L
and a serum aspartate aminotransferase level of 355 units/L. Results of a
complete blood count are normal except for 16% eosinophils.
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Acute generalized exanthematous pustolosis
Drug reaction with eosinophilia and systemic
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Erythema multiforme
Livedo reticularis
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Common rashes:
Pigmented Purpuric Dermatoses
Miliaria
 PPD:
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Group of eruptions that share similarities
Red-brown patches and plaques with superimposed petechiae
New lesions form over old ones
MC of lower extremities; bx shows small vessel disease
Bx to rule out T-cell lymphoma, MF
Rx: mid to high potency steroids over 6 weeks
 Miliaria – heat rash; sweat gland rupturing
A 66-year-old man is evaluated for a persistent rash for 6 years' duration. The
rash waxes and wanes in severity, and it becomes pruritic only after he
becomes hot and sweating, such as when he mows the lawn or exercises. It
has always been limited to his back and lower chest. He has never treated it.
The patient is otherwise well, has no other medical problems, and takes no
medication.
On physical examination, vital signs are normal. There are small 2- to 3-mm
red papules, some with slight scale, on his back and across the lower part of
his chest. There are no lesions on his arms, legs, face, soles, or palms. The
remainder of the examination is unremarkable
Bacterial folliculitis
Grover disease
Miliairia
Pityriasis Rosea
Tinea Versicolor
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Answer Review: Grover Disease
 Bacterial folliculitis – acute; not 6 years duration
 Grover – red papules on chest, flanks, and back that become
pruritic with heat;
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50 years and older
bx shows acantholysis (loss of intercellular connections)
Rx: reassurance, cooling, low to mid potency topical steroids
Tends to recur regardless of rx
 Miliaria – should not persist for 6 years
 Pityriasis rosea – Herald patch, followed by diffuse eruption on
torso, usually lasts no more than months
 Tinea versicolor – scaly hyyper/hypopigmented macules on the
trunk and upper arms. Caused by Malassezia furfur, non-itchy,
clinically manifests when in hot and humid conditions.
A 44-year-old man is evaluated for tender, extremely painful nodules in the axillae and groin area.
These lesions drain chronically. The patient is self-conscious about the occasional malodorous
discharge. Topical and oral antibiotics have only been minimally helpful. He is a heavy smoker
and has a family member with a similar condition that improved with age.
On physical examination, vital signs are normal. He has inflammatory nodules with some double
comedones in axilla and groin folds, some with drainage and sinus tracts. Skin findings are
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Acne
Hidradenitis suppurativa
Pyogenic granuloma
Sweet syndrome
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Answer Review: Acneiform
Eruption: Hidradenitis suppurativa
 Acne – no sinus tracts, atypical for axilla
 Hidradenitis (acne inversa) – follicular occlusion
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Tender, subcutaneous nodules; may rupture or lead to sinus tract
Chronic, sterile abscess
Axilla
Associated with smoking and obesity
Rx: no FDA Rx: tetracycline, surgical removal down to subcutaneous
tissues
 Pyogenic granuloma – bright red/friable papules resulting from
capillary proliferation
 Sweet syndrome – neutrophilic dermatitis; often associated with
hematologic malignancies and females after an upper URI.
(fevers, arthralgia), myalgia, and cutaneous lesions
An 18-year-old man is evaluated for a 3-month history of asymptomatic lesions on the soles of
his feet. His discomfort is worsened after wearing running shoes for long periods of time. He also
notices odor and attributes it to excessively sweaty feet from his physical activities. He was
previously diagnosed with palmar-plantar hyperhidrosis.
On physical examination, vital signs are normal. Skin findings are shown
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Ecthyma
Keratoderma blennorhagica
Pitted keratolysis
Tinea pedis
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Answer Review: Pitted keratolysis
 Ecythma: saucer shaped, superficial ulcers with overlying crust
caused by strep.
 Associated with IVDU and AIDS
 Ecythma gangrenosum – similar but caused by pseudomonas
 Keratoderma blennorrhagica
 Hyperkeratotic skin lesions on the soles and palms – associated with
reactive arthritis
 Pitted keratolysis:
 crateriform pitted lesions on pressure areas of the feet associated
with hyperhydrosis
 Typical asymptomatic but odorous.
 Caused by Kytococcus congolensis
 Rx: topical macrolide
 Tinea pedis – interdigital scaling and maceration. Does not
present with pitting.
Common Skin and Nail Infections
Erythrasma
Keratolysis
 Folliculitis: infection of the hair follicle
 Can be caused by bacteria, fungi, HSV (S. aereus)
 Dx: clinical; culture if concerned for resistant organism (MRSA)
 Rx: Topical abx +/- oral anti-staph
 Abscess/furuncles/carbuncles:
Abscess – soft tissue infection
Furuncle – abscess that involves a hair follicle
Carbuncles – collection of furnucles/folliculitis
S. aereus – MCC
Dx: clinical
Rx: warm compresses, I&D, abx if associated cellulitis, systemic sx,
imuunosuppresion, prosthetic joints, abnormal heart valves
 Should ctx to help tailor abx if needed
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Common skin and nail infections
(continued)
 Impetigo:
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S. aureus, strep pyogenes
Usually healthy patients
Not ill appearing
Dx: clinical
Rx: topical mupirocin or oral anti-staph
Very contagious so hygiene is important
 Cellulitis:
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Infection of the deeper layers of skin (lower dermis, subcutaneous fat)
staph and strep
Nidus of infection include skin breaks, tinea, trauma
Dx: usually clinical; bx: only to rule out other etiologies of erythema
Rx: B-lactam (cephalexin and/or dicloxacillin) – cover b-hemolytic strep and staph
aureus. If no improvement, cover MRSA (clinda, bactrim, tetracycline). Consider
broad spectrum up front if immunocompromised.
 Erysipelas
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Infection of the superficial lymphatics and upper dermis
Usually group A strep
Acute onset erythematous plaques that are indurated
Dx: clinical
Rx: PCN
Common skin and nail Infections
(continued)
 Erythrasma
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Superficial infection caused by Corynebacterium minutissimum
Pink brown pathces with fine scales
Groin, axilla, intertrigious region
Rx: topical macrolide antibiotics (clinda/erythro)
Cuts, Scrapes, Burns
 Tetanus immunization indicated for 2nd degree burns or
worse if not updated or unknown immunization.
 Wounds heal faster when they are kept moist and occluded
 Don’t give topical abx unless concern for secondary infection
 Neomycin, bacitracin – frequently cause allergic contact
dermatitis
Common Neoplasms
A 78-year-old man reports a several-year history of developing an increasing number of
irregularly pigmented “moles” on the back. The lesions are mostly asymptomatic, although some
itch at times, and some may be getting larger. He is concerned they could be melanoma and
wonders if they can all be removed. Family history is significant for a sister with melanoma at 55
years of age.
Atypical nevi
Melanomas
Seborrheic keratoses
Solar lentigines
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Answer Review: Seborrheic
keratosis
 Atypical nevi – usually flat, can appear otherwise like
seborrheic keratosis
 Melanomas – another discussion
 Seborrheic keratosis – benign, waxy, verrucous papules that
can be flesh colored to tan. Increase with age. No malignant
potential.
 Lesser-Trelat: rapid growth of multiple seborrheic keratosis
assoicated with underlying malignancies
 Solar lentigines – completely flat; “liver spots”; brown, welldemarcated macules and patches
Common Neoplasms
 Melanocytic nevi (moles)
 Benign pigmented lesions
 Birth to first three decades of life
 Congenital – at birth
 Compound – raised papules with possible irregular pigmentation
 Dermal – soft, flesh colored to light brown papules.
 Dysplastic nevi
 Melanocytic lesions
 Biology between benign nevi and melanomas
 Marker for increased risk for melanoma (although the nevi
themselves are not considered precancerous)
 Need regular physical exams and very careful monitoring
Common neoplasms
 Halo Nevi:
 Benign
 Results in a white macule
 Sebaceous hyperplasia:
 enlarge oil glands
 small umbilicated pink or yellowish papules on the face; harmless.
 Can be mistaken for BCC (telangiectasias should distinguish the two)
 Neurofibromas
 Soft, flesh colored asymptomatic papules
 Isolated NF very common and not associated with genetic conditions
 Multiple can be a sign of NF (axillary freckles, café au lait, Lisch
nodules)
Common neoplasms (continued)
 Skin tags:
 benign soft, fleshy papules that arise in areas of friction.
 Rx: remove (cryotherapy or scissor excision)
 Cherry hemangiomas
 Benign vascular lesion
 Bright red smooth papules, usually on trunk
 Benign, no Rx required
A 25-year-old woman is evaluated for a firm “bump” on the leg. It has been
present for approximately 3 years and has not changed in size or shape. The
lesion is frequently traumatized by shaving. Skin findings are shown
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Dermatofibroma
Epidermal inclusion cyst
Melanoma
Pigmented basal cell
carcinoma
E. Seborrheic keratosis
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Answer Review: Dermatofibroma
 Dermatofibroma – firm pink brown papules, usually found on
legs, When squeezed, they exhibit a “dimple sign”. Benign
 Epidermal inclusion cyst – benign, non-tender, smooth, firm
well demarcated subcutaneous nodules. Central punctum,
“sebaceous cysts”, white, cheesy, malodorous material when
incised
 Melanoma – reviewed last year
 Pigmented basal cell carcinoma – reviewed last year
 Seborrheic keratosis – reviewed earlier
Common Neoplasms (continued)
 Hypertrophic scars and keloids
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Occur at the site of injury or surgery
Genetic predisposition, MC in darker skin tomes
HS – don’t extend beyond site of injury
Keloids – extend beyond site of injury; can occur spontaneously
Rx: intralesional steroids
 Pyogenic granuloma
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Friable red, vascular papules, arise spontaneously and grow fast
Collection of capillaries
Common in pregnant wome
Rx: shave technique or electrodessication
 Lipomas
 Benign, collections of fat commonly occur on the trunk and
extremities. Asymptomatic, smooth
Pruritis
 Evaluation – determine if related to underlying skin disorder
 “The rash that itches, or the itch that rashes”
 MCC – dry skin; Rx: bath every 2-3 days, use moisturizers
 Skin disorders
 Dry skin
 Dermatitis (atopic and allergic)
 Med reaction, scabies, psoriasis, lichen planus, dermatographism
 Non-skin disorder related (think systemic conditions)
 Malignancy (heme), cholestatic liver disease, renal disease, IDA,
thyroid dysfunction, meds, HIV
 Work up: CBC, iron studies, TFTs, BMP, LFTs, CXR, age appropriate
maligancy work up
 Neuropathic itch:
 Localized itch without skin lesion (damage to sensory nerves)
 General Rx measures:
 Rx underlying conditions
 General skin care, and reuglar emollient use
 Hot water – worsens histamine mediated itch
A 43-year-old woman is evaluated in the emergency department for widespread pruritic wheals. The individual
lesions seem to migrate, with each wheal lasting 30 to 60 minutes. The patient says this has been going on for 2
days. There is no accompanying wheezing and no lip or eyelid swelling. The patient is breathing comfortably, has
no difficulty swallowing or clearing secretions, and no skin pain. She took diphenhydramine twice yesterday without
relief. She has no known drug allergies and just finished a 3-day course of levofloxacin for her third urinary tract
infection in the past 6 months.
On physical examination, temperature is normal, blood pressure is 110/78 mm Hg, pulse rate is 90/min, respiration
rate is 18/min. BMI is 22. There are scattered edematous indurated erythematous plaques consistent with wheals
over the scalp, face, neck, chest, upper back, flanks, and arms. The patient has marked dermatographism. There is
no wheezing or stridor, no mucosal lesions, and no bullae.
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A. Admit to hospital
B. Treat with cetirizine, ranitidine, and
diphenhydramine
C. Treat with high potency topical
steroids
D. Treat with indomethacin
Answer Review: Urticaria
 Inflammatory reaction that results from mast cell degranulation
 Triggers:
 Infections (viral, bacterial, parasitic) and meds (PCN, beta lactams, vanc, ASA,
NSAIDs, opiates, contrast dye), food, stings allergies, chemical exposures
(latex), and physical agents (heat, cold, pressure, exercise)
 Clinically: red, edematous, wheals; acute v. chronic; look for
warning/atypical features
 All acute needs to be evaluated for anaphylaxis
 Chronic: difficult to assess; 50% idiopathic
 Atypical features (last > 24 hours, burning sensation, resolve with
bruising, fail to respond to anti-histamines) – should be evaluated for
underlying vasculitis
 Food allergies – refer for RAST testing
 Rx:
 Acute – H1 and H2 blockade, followed by po steroids on people that don’t
resolve; management changes if signs of impending airway obstruction
 Chronic – colchicine, dapsone, plaquenil, mycophenolate mofetil, MTX
 If patient has angioedema, they need an epi-PEN
A 79-year-old woman is evaluated for pruritic blisters on the chest, abdomen, and lower
extremities of 3 to 4 weeks' duration. The blisters arise in crops, drain clear yellow fluid,
and crust over before healing. She reports no recent illness and, other than significant
itching, feels well. She cannot identify any precipitating causes of the blisters; she reports
taking no new medications, using no new topical products, and having no new exposures
to plants. She has not been around anyone who is ill or who has had similar skin lesions.
Medical history is remarkable only for hypothyroidism secondary to Hashimoto thyroiditis;
her only medication is levothyroxine.
On physical examination, the patient is afebrile. Typical skin findings are shown :shown .
Sk
in
bx
0%
ck
ct
pr
e
im
pa
m
ra
t
un
...
io
n
0%
Tz
an
PC
R
an
d
di
re
fro
m
bl
ist
e
rf
lu
re
ul
tu
lc
ia
0%
id
0%
ct
er
D.
Bacterial culture
PCR from blister fluid
Skin bx and direct
immunoflourescence microscopy
Tzanck preparation
Ba
A.
B.
C.
Answer Review: Autoimmune
Bullous Disease
 Rare, heterogeneous group of unrelated skin disorders
 Bullous pemphigoid, dermatitis herpetiformis, IgA bullous
dermotosis, pemphigous vulgaris
 Blisters and erosions
 Cause significant M&M, so recognition and dx are important
 Dx should be considered when unexplained blisters or
erosions are seen
 Skin bx +/- blood testing (circulating auto-antibodies)
 Rx: Most diseases have systemic steroids or other
immunosuppressants (azathioprine, MTX,
cyclophosphamide, Cellcept) as part of Rx.
 Often require multiple drugs
Cutaneous Manifestations of
Internal Disease
 Rheum

Covered in Rheum lecture
 Nephrology
 Pruritis: discussed earlier
 Calciphylaxis: necrotic tissue caused by vascular calcifications

Rx: Sodium thiosulfate, wound care
 Nephrogenic systemic fibrosis



Distal extremity thickening, fibrosis, limited mobility
Dx: clinical, bx can confirm
Suspected to be related to gadolinium based MRI
 Post – Tx:

Think about non-melanoma skin cancers (especially SCC)
 Pulmonary
 Sarcoidosis:




Violaceous papules and infiltrative plaques
Granulomas at the site of trauma (surgical scars or tattoos)
Lupus pernio
Erythema Nodosum in Lofgren syndrome (can also be seen as the result of abx, ocp, HRT)
 Gastroenterology
 IBD:

Erythema Nodosum and pyoderma gagrenosum
 ESLD

Covered in liver
 Heme/Onc
 Sweet Syndrome

Covered previously
 Endocrine
 Covered in endocrine
 ID
 HIV

Covered previously
A 22-year-old man is evaluated for lip erosions and a new rash on the
palms. A representative example of the skin findings is shown
0%
0%
lla
ic e
Va
r
Gr
o
up
A
o
st
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p
r
0%
B1
9
0%
Pa
rv
HSV
Parvo B19
Group A strep
Varicella zoster
HS
V
A.
B.
C.
D.
A 37-year-old woman is evaluated in the emergency department for a 24-hour history of
peeling skin. She was recently treated for a urinary tract infection with trimethoprimsulfamethoxazole. Several days into treatment, she developed fever followed by fine, red,
itchy papules on her torso and extremities. She continued the antibiotics, the rash
worsened, and her skin became painful during the next few days. This morning, she awoke
with sores in her mouth, and when she touched her skin it peeled off. She takes no other
medications and has no documented allergies.
On physical examination, she appears acutely ill and is in pain. Temperature is 39.4 °C
(102.9 °F), blood pressure is 100/60 mm Hg, pulse rate is 106/min, and respiration rate is
20/min. The skin shears when lateral pressure is applied to areas of erythema. Erythema
and crusting are present around the eyes and on the lips, and open erosions are present in
the mouth. The vulva has superficial erosions. Skin findings are shown :shown .
The patient is admitted to the intensive care unit, and aggressive intravenous fluid
replacement is begun.
0%
bx
kin
Va
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as
n
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Be
Begin iv corticosteroids
Begin topical corticosteroids
Begin Vanc
Obtain a skin bx
Be
A.
B.
C.
D.
Derm Urgencies and Emergencies:
Erythema multiforme, SJS, TEN
EM
SJS
TEN
SJS/TEN –
Morphology
Typical three-zoned target
Atypical targets and
confluent erythema with
sloughing
Distribution
Favors extremities
Trunk, extremities
Up to 10% BSA
involvementa
Trunk, extremities
At least 30% BSA
involvementa
Mucosal disease (oral, eye,
genitourinary)
One or two sites
Two or more sites
Two or more sites
Constitutional symptoms
+
++/+++
+++
Extensive, confluent
erythema with sloughing
antiseizure
medications,
NSAIDs, abx,
PPI, sertraline,
tramadol,
allopurinol
Dx: clinical; bx
Caused by infection (%)
(herpes simplex or
Mycoplasma pneumoniae)
30-80
22
6
confirms
Rx:
Caused by drugs implicated
in (%)
Up to 50
74
94
Mortality (%)
0
5-13
25-39
1. Supportive (fluid,
electrolytes,
wound care)
2. dc offending agent
A 58-year-old man is evaluated for a 3-year history of an itchy, scaly rash. It began as
patches and plaques but over the past several months has progressed to a generalized,
red skin rash. The pruritus is intense and interferes with his life. His only other medical
problem is hypertension for which he has taken lisinopril for the past 5 years.
On physical examination, vital signs are normal. He has erythema with scales affecting
more than 90% of the body surface area. Skin findings are shown :shown .
He also has alopecia, thickening of the nails, palms, and soles, and nail dystrophy.
Generalized lymphadenopathy is also present.
St
ap
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sc
a
in
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ed
sk
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sit
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sis
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ps
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m
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Cutaneous T-cell lymphoma
Drug hypersensitivity reaction
Pustular psoriasis
Staph scalded skin syndrome
Cu
t
A.
B.
C.
D.
0%
a
0%
Answer Review: Erythroderma
 Erythroderma: erythema (inflammation) of at least 80% skin
surface
 Erosions from severe pruritis, peripheral edema, scaling,
LAD
 Difficult to find underlying cause
 Acute caused by uncontrolled dermatosis, meds, idiopathic
 Alopecia, nail dystrophy, thickening of the palms and soles of
the feet indicate long term erythroderma
 T-cell lymphoma, GVHD, psoriasis
 Dx: largerly clinical; bx has high rate of being non-specific
 Rx: stop the medication if involved, referral to dermatologist,
supportive care
A 21-year-old man is evaluated for a 1-month history of hair loss in a small, oval patch on the
scalp. He indicates that a similar process occurred several years ago in a different location on the
frontal scalp, but the hair re-grew spontaneously. He has no hair loss elsewhere. He is in
excellent health and takes no medications. His family history is significant for Hashimoto
thyroiditis in his mother.
On physical examination, the scalp appears normal, without inflammation or scale. Scalp findings
are shown :shown .
s
0%
Ti
ne
a
Ca
p
iti
um
ef
ge
n
lo
Te
ne
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flu
vi
op
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ic
c ia
al
ar
0%
Lu
pu
s
0%
ia
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ta
0%
op
e
Alopecia areata
Androgenetic alopecia
Lupus
Telogen effluvium
Tinea Capitis
Al
A.
B.
C.
D.
E.
Hair Disorders
 Alopecia (hair loss)
 Scarring v. non-scarring (bx can distinguish)
 Non-scarring:
 PCOS, thyroid dysfunction, IDA, meds (beta blockers, anti-siezure, coumadin,
oral retinoids)
 alopecia areata
 telogen effluvium (diffuse hair loss triggered by stress)
 Androgenetic (male/female pattern baldness)
 Scarring Alopeica:




Traction
CCCA (central centrifugal cicatricial alopecia) “hot comb alopecia”
Lichen planopilaris (associated with lichen planus elsewhere)
discoid SLE
A 30-year-old man presents with concern about nail changes. He underwent induction
chemotherapy for acute myeloid leukemia approximately 1 month ago and has done well in
the interim.
He is currently afebrile, has no systemic complaints, and his vital signs are normal. His
kidney and liver chemistry studies are normal. Nail findings are shown :shown .
sis
0%
Ps
or
ia
ld
ys
tro
an
us
L ic
he
n
pl
lin
0%
ph
y
0%
es
0%
ai
Beau lines
Lichen planus
Median nail dystrophy
Psoriasis
Be
au
A.
B.
C.
D.
Answer Review:
Nail Disorders
 Psoriatic nail changes: pitting, onycholysis, “oil drop sign”, multiple nails, no
correlation with disease severity
 Lichen Planus – pitting, pterygium formation, and onycholyis
 Melanonychia (picture) and subungal melanoma
 Single nail affected is suggestive of an underlying melanocytic lesion (melanoma)
 Subungal melanoma: rare in Caucasians, but MC type of melanoma in Asian and
black patients
 Beau lines – transverse linear depressions that occur during severe
illness/stress
 Median nail dystrophy – logitudinal depression ususally involving 1-2 nails
usually the result of trauma. Most commonly occurs in the thumb
 Onychogryphosis – thickening/yellowing of nail plate see in elderly patients
 “Ram horn” deformity
 Rx: Trimming the nails +/- ablation of the nail matrix
A 35-year-old man presents with a 6-month history of small polygonal violaceous papules on the
wrists bilaterally and a white, lacy, discoloration on the buccal mucosa of the cheeks bilaterally.
The white lacy areas do not come off when scraped with a tongue depressor. The affected areas
in the mouth occasionally ulcerate and become tender. The patient is in excellent health, takes no
medications, and has no history of chronic disease or immunosuppression. Oral mucosal findings
are shown
0%
0%
lak
ia
an
us
uk
op
pl
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le
air
y
al
h
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Ca
n
di
d
ia
rs
lce
us
u
0%
sis
0%
L ic
he
Aphthous ulcers
Candidiasis
Lichen planus
Oral hairy leukoplakia
Ap
ht
ho
A.
B.
C.
D.
Answer Reviewed: Disorders of
Mucous Membranes
 Aphthous ulcers:
 Small tender ulcers that occur on tongue and buccal mucosa
 Candidiasis:
 Discussed previously
 Lichen planus:
 Idiopathic autoimmune disease of skin and mucous membranes
 mucous membrane findings: white, reticulated network on the buccal mucosa;
desquamative gingivitis; chronic erosions of the oral or vulvar mucosa
 Oral hairy leukoplakia:
 Wrinkled, white adherant plaques that generally occur on lateral aspects of the
tongue; no ulceration; HIV; Etiology – EBV
 Oral Melanotic macule:
 Brown, macules on lower lip, singular, benign
 Need to remove if atypical to r/o melanoma
 Erythroplakia:
 Erythematous, velvety plaques on tongue, need to bx
 Actinic cheilitis:
 Erythema, scaling, and fissuring of the lower lip
 Rx: with cryotherapy, imiquimod, laser therapy (high rate of carcinoma)
 Black Hairy Tongue
 Hypertrophy and filiform papillae on dorsum of the tongue
 Caused by abx, coffee, tea, poor hygiene, and tobacco
 SCC:
 Reviewed previously; MCC of intraoral malignancy
A 26-year-old man is evaluated for a firm, smooth nodule. This appeared
several weeks after trauma to the area and enlarged steadily until reaching its
current size. The nodule is occasionally tender, but is otherwise asymptomatic.
Skin findings are shown
In
tra
on
e
c in
ol
la
pi
ca
m
ra
i
lt
pi
ca
al
p
Or
To
To
le
sio
na
l
tri
a
m
c in
ol
o.
.
re
dn
is o
ne
A. Intralesional triamcinolone
injections
B. Oral prednisone
C. Topical abx
D. Topical traimcinolone
bx
25% 25% 25% 25%