Transcript Dermatology Case 2: Non

David, Hannah; David, Hazel; De Guzman, Jan;
De Guzman, Raquel; De Leon, Gemma;
De Mesa, Monique & De Vera, Jestha
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
27 y/o call center agent
pricked a pustule on her left cheek
2 days later
• tender, warm, red to violaceous edematous
plaque with ill-defined borders on the left cheek
• Self-medicated with trimethoprimsulfamethoxazole
A few hours after
• generalized eruption of red
papules with dusky centers
• Ulcers on palms & lip mucosa
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Differential Diagnosis
Patient’s
Features
Etiology
Epidemiology
Course
Prodromes
Erysipelas
Cellulitis
trimethoprimsulfamethoxazole
medication
beta hemolytic
group A
Streptococcal
(Occ. GBS)
Streptococcus
pyogenes,
Staphylococcus
aureus
Age: 27 yo
Sex: F
Newborn
Postpartum women
Patients with breaks
in the skin
High risk in
immunocompromised patients and in
children
Acute; few hours
after intake of
drugs
Acute
Acute
Malaise for several
hours, chills, high
Malaise, chills,
fever, headache,
fever
vomiting, and joint
pains
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Differential Diagnosis
Patient’s Features
Eruption


Generalized
Palms and lip
mucosa
Erysipelas


Face and legs
Begins in the
cheeck near
the nose or in
front of the
lobe of the ear
and spreads
upward to the
scalp
Cellulitis


Local erythema
Tinea pedismost common
portal of entry
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Differential Diagnosis
Patient’s Features
Typical Lesions
red papules with
dusky centers.
Ulcers in the lip
mucosa
Acute Urticaria




May vary from
transient
hyperemia
followed by slight
desquamation to
intense inflam.
Erythematous
patch with
peripheral
extension
Scarlet, hot to
touch,
brawny,swollen
Raised and
sharply
demarcated.




Erythema
Multiforme
Erythema rapidly
becomes intense
and spreads
Area becomes
infiltrated
Pits on pressure
Central part
becomes nodular
and surmounted
by a vesicle that
ruptures and
discharges pus
and necrotic
material
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Differential Diagnosis
Patient’s Features
Complications
Acute Urticaria


Septicemia
Deep cellulitits
Erythema Multiforme




Lymphangitis
Gangrene
Metastatic abscess
Sepsis
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Erysipelas
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Cellulitis
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Differential Diagnosis
Patient’s Features
Etiology
Epidemiology
Course
Prodromes
trimethoprimsulfamethoxazole
medication
Age: 27 yo
Sex: F
Acute; few hours
after intake of
drugs
Acute Urticaria
Drugs, food,
infections
Erythema
Multiforme
Usually non-drug
causes, most
commonly Herpes
Simplex infection
In young adults
Recurrent
episodes more Young adlults
prevalent in
females
Acute; may recur;
Acute, self-limited
evolves over days
recurrent
to weeks


Absent to
moderate
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Differential Diagnosis
Patient’s Features
Acute Urticaria


Eruption


Generalized
Palms and lip
mucosa

Typical Lesions
red papules with
dusky centers.
Ulcers in the lip
mucosa
May be localized
or generalized
(more common);

usually favors
covered areas
e.g. trunk,
buttocks or chest

Wheals, white or
red evanescent
plaques,
generally
surrounded by a
red halo or flare.

Erythema
Multiforme
Disseminated;
symmetrically
and acrally on
extremities, face
dorsal hands
(initially); dorsal
feet, extensor
limbs, elbows
and knees,
palms and soles
Erythematous
macules 
raised
edematous
papules over 2428 hrs.
Classic “target”
or “iris” lesions
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Differential Diagnosis
Patient’s Features
Acute Urticaria
Erythema
Multiforme

Other Clinical
Features
Subcutaneous
swellings
(angioedema),
especially of

eyelids or lips.
 Angiodema of GI
and respi tracts 
- abdominal pan,
coryza, asthma
and respi
problems.
Involvement of
oral mucosa
(frequent, mild)
No internal organ
involvement
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Erythema Multiforme
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Urticaria
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Kelly’s part
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Differential Diagnosis
Etiology
Epidemiology
Course
Patient’s Features
Fixed Drug Eruption
trimethoprimsulfamethoxazole
medication
Drugs
Most common cause:
Trimethoprimsulfamethoxazole
Age: 27 yo
Sex: F
Age: (1.5-81 y/o)
F: 31 y/o
M: 30 y/o
M:F = 1:1.1
Acute; few hours after
intake of drugs
Develops over a period
of hours, may persist
from days to weeks and
then fade slowly to
residual oval
hyperpigmented patches
Prodromes
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Differential Diagnosis
Patient’s Features
Eruption
Typical Lesions


Generalized
Palms and lip
mucosa
red papules with dusky
centers.
Ulcers in the lip mucosa
Fixed Drug Eruption
• mostly </6 lesions
• >/1 cm in diameter
• frequently located on
the lip or genitalia
• Begins as a red patch
• evolves into an iris or
target lesion (dusky
center) and may
eventually blister and
erode
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Differential Diagnosis
Patient’s Features
Other Clinical Features
Fixed Drug Eruption
 normally resolve w/
hyperpigmentation
and may recur at the
same site with
reexposure to the
drug
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Fixed Drug Eruption
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Pathophysiology
exact mechanism is unknown
 cell-mediated process that initiates both
the active and quiescent lesions.
 may involve an antibody-dependent,
cell-mediated cytotoxic response.
 CD8+ effector/memory T cells play an
important role in reactivation of lesions
with re-exposure to the offending drug.
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Drug binds to basal keratinocytes leading to inflammatory response
liberation of cytokines (tumor necrosis factor-alpha) that up-regulate
expression of the ICAM1
up-regulated ICAM1 has been shown to help T cells (CD4 and CD8)
migrate to the site of an insult
CD8 cells likely perpetuate tissue damage by their production of the
inflammatory cytokines interferon-gamma and tumor necrosis factoralpha
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Changes in cell surface markers allow vascular endothelium to select
CD4 cells for migration into active lesions
Suppress immune function, resulting in a resting lesion
As the inflammatory response dissipates, interleukin 15 expression
from keratinocytes is thought to help ensure the survival of CD8 cells,
helping them fulfill their effector memory phenotypes
when reexposure to the drug occurs, a more rapid response develops
in the exact location of any prior lesions.
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•relies on the principle of a
type IV (delayed)
hypersenstitivity reaction
•must be performed on a
previously involved site
•comprises a series of small,
aluminium wells containing
various concentrations of the
offending medication
mounted on hypoallergenic
tape
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•
•
•
standard occlusion time : 48 h
first reading: day 2 generally 15-30 min after patch removal
second reading: day 3 or 4
•
Results are recorded using a standardized scoring system
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check for cross-sensitivities to medications
*A refractory period has been reported in fixed drug
eruption; therefore, a delay before and between patch
testing and oral provocation is recommended
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Diagnostic procedure of choice
Generally performed during the acute stage of recurrence
Acute interface dermatitis with prominent vacuolar
change and individual necrotic keratinocytes within the
epidermis (X10).
Interface dermatitis, vacuolar change, necrotic
keratinocytes, and incontinent pigment in the
dermis (X40).
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