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
3
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
 Hansen’s Disease (other types)
 Erythema multiforme
 Fixed drug reaction
 Seborrheic dermatitis
 Cellulitis
 Urticaria
 Exfoliative dermatitis
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
(Differential Dignosis)
 (brief description of pathology)
 (epidemiology, incidence, etc.)
 (Differential…)

(pertinent data per
differential)
 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
(Differential Dignosis)
 (diagnostic evaluation)
 (therapeutic plans)
(Differential Dignosis)
 (brief description of pathology)
 (epidemiology, incidence, etc.)
 (Differential…)

(pertinent data per
differential)
 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
(Differential Dignosis)
 (diagnostic evaluation)
 (therapeutic plans)
(Differential Dignosis)
 (brief description of pathology)
 (epidemiology, incidence, etc.)
 (Differential…)

(pertinent data per
differential)
 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
(Differential Dignosis)
 (diagnostic evaluation)
 (therapeutic plans)
(Differential Dignosis)
 (brief description of pathology)
 (epidemiology, incidence, etc.)
 (Differential…)

(pertinent data per
differential)
 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
(Differential Dignosis)
 (diagnostic evaluation)
 (therapeutic plans)
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.
Tuberculoid Leprosy
 one large red patch with well-defined raised borders




or a large hypopigmented asymmetrical spot
lesions become dry and hairless
loss of sensation may occur at site of some lesions
tender, thickened nerves with subsequent loss of
function are common
spontaneous resolution may occur in a few years or it
may progress to borderline or rarely lepromatous
types
Tuberculoid Leprosy
• organisms present at low to
undetectable levels
• low infectivity
• granulomas and local inflammation
• peripheral nerve damage
• normal serum immunoglobulin levels
• normal T – cell responsiveness
• specific response to M. leprae antigens

Tuberculoid Leprosy
?????????????????
 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
Borderline Tuberculoid Leprosy
 similar to tuberculoid type except that lesions are
smaller and more numerous
 cutaneous lesions are numerous and less well
defined
 anesthesis is less severe
 disease may stay in this stage or convert back to
tuberculoid form, or progress
Borderline Tuberculoid Leprosy

Borderline Tuberculoid
?????????????????
 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

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 no loss of sensation
over the lesions, there is no nerve
thickening, and there are no changes
in sweating.


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 and symptoms
 Skin patch, tingling sensation, numbness of the hands
 Treatment: Dapsone (cornerstone of therapy)
 Dapsone and rifampin – initial combination therapy