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Diagnostic Criteria
MAJOR (3+) MINOR (3+)
• xerosis Dry skin
• pruritus •
•
ichthyosis/hyperlinear palms/keratosis pilaris formation
IgE reactivity (RAST test
of dry, f
• typical morphology, •
•
serum IgE
early age of onset
• cutaneous infxn tendency
distribution • tendency to non-specific hand/foot dermatitis
• nipple eczema
– adults: flexural lichenification • cheilitis
• recurrent conjunctivitis
– infants: facial, extensor • Dennie Morgan folds
• keratoconus
• chronically relapsing • anterior subcapsular cataracts
• orbital darkening
• personal, family h/o atopy •
•
facial pallor / erythema
pityriasis alba
– asthma, hay fever, AD •
•
itch when sweating
intolerance to wool and lipid solvents
• perifollicular accentuation
• food hypersensitivity
• environmental &/or emotional factors infl course
• white dermatographism
Recent Literature
• maternal dietary restrictions during pregnancy or lactation does not prevent
atopic disease
• exclusive breastfeeding for at least 4 mo.s prevents or delays the
occurrence of atopic dermatitis, cow’ s milk allergy, and wheezing in early
childhood in at risk infants
• no clear evidence
– supporting the use of soy-based infant formulas for the purpose of
allergy prevention
– after 4-6 mo.s, delaying solid food introduction, including highly
allergenic foods, has a significant protective effect
Childhood Atopic Dermatitis
• less exudative
• atecubital / popliteal fossae, flexor wrists, eyelids, face common sites
• lichenified, indurated plaques
• growth retardation
– > 50% BSA involvement
– rebound growth with treatment
Childhood Atopic Dermatitis
• prognosis
– 40% resolve by age 5
– 40% carry to adulthood
• unfavorable prognostic factors
– widespread dermatitis in childhood
– family h/o AD
– associated bronchial asthma
– early age of onset
– female sex
– persistent dry / itchy skin in adult life
Adult / Adolescent AD
• erythematous, scaly, papular, exudative or lichenified plaques
• classic sites = antecubital / popliteal fossae, flexor wrists,
around neck, eyelids
• lichenification, prurigo-like nodules
• darker skinned individuals
– hyper- and hypopigmentations
– papular variants
Adult / Adolescent AD
• pruritus occurs in crises or paroxysms
• flares triggered by heat or stress
– decreased itch perception
– difficulty delivering sweat to surface and in
transepidermal water loss (TEWL)
• improvement occurs with time, uncommon after middle life
• new onset HIV may serve as trigger r/o if high risk
Associated clinical findings and
complications
• Pruritus
• Xerosis
• Keratosis pilaris protein in the skin called keratin forms hard plugs within hair follicles.
•
Ichthyosis vulgaris
• Dennie–Morgan lines
• Palmoplantar hyperlinearity
• Pityriasis alba Round or oval, colorless patches of skin appear on the face, upper arms, neck, and upper
middle of the body. scales.
• Lichenification
• Infection
• Edema
• Complications of treatment
Associated clinical findings
• pityriasis alba
– poorly marginated, hypopigmented slightly scaly patches
on cheeks
– typically in young children
• keratosis pilaris
grouped together
– horny, agminated, follicular erythematous lesions
– outer aspects of upper arms legs, cheeks, buttocks
• hyperkeratosis, hyperpigmentation dirty neck
keratosis pilaris
pityriasis alba
Ophthalmologic
Atopic Dermatitis
Abnormalities
• 10% develop cataracts
– anterior most common
– posterior subcapsular well-established complication of
systemic steroids
– more common in severe atopic dermatitis
• 1% develop keratoconus
– elongation and protrusion of the corneal surface
secondary to
– considered to be 2/2 continuous rubbing of eye or as a
degenerative change
– onset usually p/ adolescence
Staphylococcus Colonization
• staph colonization nearly universal
– lesion superinfection common
– antibiotic of benefit during flares
• recovered in
– 90+% lesions vs 76% uninvolved skin
– 79% anterior nares in atopics vs 10% nonatopics
• staph exacerbates atopic derm
– organism superantigen production T-cell activation
– organism superantigen production alternative
glucocorticoid receptor expression topical steroid
resistance
Superinfection
Atopic dermatitis
Irritant Contact
• localized to contact site (hands, face)
• direct cytotoxic effect inflammatory response, not
immunologic
• Pathogenesis
– Penetration through permeability barrier
– Mild damage to keratinocytes
– Release of mediators of inflammation
• TNF-a, IL-6 and IL-1B
Irritant Contact dermatitis
ICD Subtypes
Acute ICD
• Developes 2/2 potent irritant
exposure, often an
occupational accident
• Must be a potent irritant,
most commonly acids and
alkaline solutions resulting in
chemical burns
• Symptoms include burning,
stinging and soreness
• Physical signs: erythema,
edema, bullae and necrosis
ICD Subtypes
• acute delayed ICD
– retarded inflammatory response
– anthralin, benzalkonium chloride, ethylene oxide
– rxn not seen until 8-24h after exposure
– mimics ACD, however burning > pruritus
• irritant reaction ICD
– wet chemical environments
– hairdressers, caterers, metal workers
– scaling, redness, vesicles, pustules, erosions
– begins under occlusive jewelry
ICD Subtypes
• cumulative ICD
– multiple subthreshold insults, without sufficient time for
barrier restoration
– lichenification/hyperkeratosis
– pruritus, pain
– Examples include soaps, water, household products...
• asteatotic dermatitis / eczema craquele
– dry winter months
– elderly, frequently bathe without remoisturization
– dry icthyosiform scale, superficially cracked
– intense pruritus
ICD Subtypes
• pustular acneiform ICD
– metals, croton oil, mineral oil,
tars, greases, cutting and metal
fluids, naphthalenes
– Chloracne
– Consider when folliculitis or
acneiform lesions develop in
setting outside of typical acne
• airborne ICD
– Developes in irritant exposed
sensitive skin
– Distinguish from photoallergic
reactions by looking for
involvement of upper eyelids,
philtrum and submental regions
• frictional ICD hyperpigmented, velvety plaques
– lichenification, acanthosis,
hyperkeratosis
thickening of the stratum corneum
Irritants
• acids • solvents
– inorganic > organic – benzene petechial eruption
(aplastic anemia)
• alkalis
– turpentine
– more painful/destructive (with
exception of HF) • alcohols
– wet cement (+/- concurrent • detergents/cleansers
chromate ACD)
• metal salts • disinfectants
– ethylene oxide
– cobalt
– aldehydes, iodines
– mercury bluish linear
pigmentation tongue, gums – quaternium ammonium salts
– thimerosal • plastics
Irritants
• food
• water = universal solvent
– maceration intertrigo (+/- candida)
• bodily fluids
– urine, feces diaper rash, incontinent pts
– drool angular cheilitis (+/- candida)
• plants
– spurges (poinsetta) milky sap
– oxalate crystals (tulips, daffodils) bulb sorter’s disease
• caterpillars = puss (wooly), Io (green, red stripe)
ACD Pathogenesis
Allergic contact dermatitis
toilet seat
PRESERVATIVES FRAGRANCES
• formaldehyde • balsam of Peru
• quaternium-15 • fragrance mix
• thimerosal
Nickel
Nickel
• most common allergen
• role of ear piercing sensitization
• classic locale
– periumbilical dermatitis
• replace buttons or sew fabric over divot
• avoid nickel belt-buckles
– earring dermatitis
• bilateral pseudotumor of the earlobe
– eyelid dermatitis (eyelash curlers)
• In children may lead to widespread lichenoid papular eruption
• Dimethylglyoxime test can identify objects that release nickel
Neomycin
Neomycin
• 2nd most common allergen
• Neosporin aka “triple antibiotic ointment”
polymyxin B, bacitracin and neomycin
• Neomycin is also found in:
– Hemorrhoid creams, otic and ophthalmic
preparations and in topical steroid preparations
• co-reactivity with bacitracin
• cross-reactivity with aminoglycosides
Poison Ivy
microvesicular
Poison Ivy/Oak/Sumac
• plant ACD
• structure
– poison oak/ivy contain 3-5 leaflets per stalk
– “leaves of 3, let it be”
– poison sumac contains 7-13 leaflets per stalk
– poison ivy has pointed tips, poison oak has round tip
• family Anacardiaceae,
spp. Toxicodendron
• distinct genus from Rhus
Treatment
• Wash body should be thoroughly washed with copious amounts of
water. Soap may be used afterwards, but early use of soap may
expand the area of resin on the body.
• potent topical corticosteroids only help if applied during the earliest
stages of the outbreak-no vesicles or blisters
• Systemic corticosteroids-very effective dose of 1–2 mg/kg/day,
slowly tapered over 2-3 weeks
• Antihistamine doesn't
- take care of pruritus, but alows pt to sleep.
SEBORRHEIC DERMATITIS
• confined to skin regions with high
sebum production &large body
folds
• link to sebum overproduction
and the commensal yeast
Malassezia
SEBORRHEIC DERMATITIS
• Epidemiology
– Infantile-self-limited and confined to the first 3 months of life
– Adult-chronic with a peak in the fourth to sixth decades
– no indication of a genetic predisposition
• Associated with?
CVI
Chronic venous insufficiency
STASIS DERMATITIS
• DDX- • Tx-
– straightforward diagnosis – management of venous
hypertension adequate
– asteatotic eczema
compression bandages or
– irritant or allergic contact stockings(if ulcer present must
dermatitis r/o arterial)
– psoriasis – lifestyle changes
– mycosis fungoides – exercise calf muscles
– removal of insufficient
saphenous veins
– topical corticosteroids and
emollients
Diaper Dermatitis
• most common cutaneous disorder of infancy & early childhood
• being prolonged contact with urine and feces, skin maceration, and,
in many cases, secondary infection with bacteria or Candida
albicans
• three most common types of diaper dermatitis are chafing
dermatitis, irritant contact dermatitis, and diaper candidiasis
Diaper Dermatitis
• Chafing Dermatitis
– most prevalent form
– friction is the most pronounced (the inner surfaces of the thighs,
the genitalia, buttocks, and the abdomen)
– presents as mild redness and scaling and tends to wax and
wane quickly, frequent diaper changes and good diaper
hygiene.
Diaper Dermatitis
• Irritant Contact Dermatitis
• Diaper Candidiasis
– buttocks, the vulva, perineal
area, lower abdomen, and – suspected whenever a
proximal thighs, with sparing diaper rash fails to respond
of the intertriginous creases to usual therapy.
– etiology-potential roles for – Candidiasis possible 2/2
ammonia, bacteria, and systemic antibiotic therapy
bacterial products and urine and should be considered
pH
in any diaper dermatitis
– petrolatum-based formulations
as a barrier
Diaper Dermatitis
• widespread, beefy red
erythema on the buttocks,
lower abdomen, and inner
aspects of the thighs
• raised edge, sharp
marginization w/ white scales
at border,pinpoint
pustulovesicular satellite
lesions (diagnostic hallmark)
Diaper Dermatitis
• DDX- • DDX-
– Seb derm – Atopic dermatitis
– Psoriasis – Granuloma gluteale infantum
– Intertrigo – Langerhans cell histiocytosis
– Jacquet's dermatitis – Burns Child abuse
– Perianal pseudoverrucous – Epidermolysis bullosa
papules and nodules – Congenital syphilis
– Miliaria – Varicella/herpes
– Folliculitis – Tinea cruris
– Impetigo – Chronic bullous dermatosis of
– Scabies childhood
– acrodermatitis enteropathica, – Bullous mastocytosis
cystic fibrosis, biotin deficiency
– Allergic contact dermatitis,
– Atopic dermatitis
Diaper Dermatitis
• Tx
– appropriate etiology
– Educating
– keeping the skin dry, protected, and infection-free
– Zinc oxide and petrolatum-based formulation
– low-potency, nonfluorinated topical corticosteroid (i.e., 1% H.C.)
– Stronger steroids and combination antifungal-corticosteroid
preparations should be avoided
– appropriate systemic antibiotic
– Candidal infection requires the use of a topical antifungal agent
(i.e., nystatin, azoles)
Dyshidrosis
• Dyshidrotic eczema • DDX
• not a disorder of the sweat gland – inflammatory tinea
• most common in adults, can occur pedis/manuum
in children
– photoinduced pompholyx-
• Emotional stress and hot weather like hand dermatitis
may exacerbate the condition
– dyshidrosiform pemphigoid
cutaneous
– T-cell lymphoma
– scabies(children)
– infantile acropustulosis
Dyshidrosis
• extremely pruritic vesicles
(filled with clear fluid)
• „tapioca pudding‟-like
appearance
• lateral and medial aspects of
the fingers, palms and soles
and parts of palmar and
plantar surfaces
Dyshidrosis
• Tx • Tx
– identification and treatment – Severe recalicitrant-
of underlying causes azathioprine, methotrexate
– High-potency topical and mycophenolate mofetil
corticosteroids (although mycophenolate
– Topical calcineurin mofetil-induced dyshidrosis
inhibitors and phototherapy has been described)
(e.g. broadband or – Botulinum toxin injection
narrowband UVB, UVA1, – Psychotherapy
PUVA)
– Short courses-systemic
corticosteroids severe
outbreaks
Lichen Simplex Chronicus
• excessive scratching
• Predisposing factors include
xerosis and atopy
• characterized as hyperpigmented,
lichenified, leathery plaques
• well circumscribed -occipital and
nuchal areas in women QuickTime™ and a
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• wrists and extensor surfaces of
the forearms and lower legs
Lichen Simplex Chronicus
• Tx
– breaking the itch-scratch cycle
– Antipruritics
– Moisturizers
– Topical corticosteroids under occlusion
– Intralesional corticosteroids
– situational stressors-psychological
Tinea Corporis
• Fungi that invade keratinized tissue via keratinases
– Hair, Nails, S.cornuem
• Dermatophytes
– Trichophyton, Microsporum, Epidermophyton
– Trichophyton rubrum-most common dermatophyte
worldwide
– occur most frequently in postpubertal, except tinea
capitis
Tinea Corporis
• Transmission of dermatophytes to humans occurs via three sources
– Geophilic-soil-human
– Zoophilic-animal-human
– Anthropophilic-human-fomite-human
– Inhibited by sebum
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Tinea Corporis
• Incubation-1 to 3 weeks
• Spreads centrifugally w/ central clearing annular lesions
of varying sizes
• Scaly, although scale may be lessened or absent if
topical corticosteroids have been used (tinea incognito)
• Pustules within the active border, can be vesicular,
granulomatous or verrucous in appearance.
• Symptoms include pruritus and burning
• Dx made via KOH, occasional fungal cx & PAS stain via
bx
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Tinea Corporis
• DDX- • Tx
– Nummular eczema, Atopic, – Topical antifungals-first line
Stasis, Contact, Seborrheic,
– Systemic antifungal
Pityriasis versicolor, Pityriasis
rosea, Parapsoriasis,
therapy-higher incidence
Erythema annulare and increased severity of
centrifugum, Annular side effects-Fluconazole,
psoriasis, Subacute lupus, Griseofulvin, Itraconazole,
Granuloma annulare,Impetigo Terbinafine
Tinea Pedis
• Epidemiology and pathogensis similar to corporis
• soles of feet interdigital web spaces
• most common location for dermatophyte infections
• more common in adults and is found around the world, affecting
both sexes
• most believe acquried going barefoot (locker rooms, gyms, public
facilities), no specific susceptibility has been determined
• T. rubrum, T. mentagrophytes, E. floccosum and T. tonsurans (in
children)-typical dermatophytes
• Four types-Moccasin, Interdigital, Inflammatory (vesicular),
Ulcerative
Moccasin
Inflammatroy
Tinea Pedis
• Dx, DDX and Tx-similar to tinea corporis
• Erythrasma can be diagnosed with Wood's light examination
because of its coral-red fluorescence; empiric treatment with topical
erythromycin
• oral antifungals should be considered in diabetics,
immunocompromised patients, and those with moccasin type
• other dermatophyte infections often associated with tinea pedis-
tinea cruris, onychomycosis and tinea manus
Erythrasma
chronic superficial infection of the intertriginous areas of the skin
Tinea Versicolor
• Caused by Malassezia furfur
• occurs in tropical climates w/ high ambient temperatures & high
humidity, also in temperate climates
• Malassezia has an oil requirement for growth, increased incidence
in adolescents and sebum-rich areas of the skin, has been
implicated in seborrheic dermatitis and atopic dermatitis
• potassium hydroxide (KOH) examination-‟ziti and meatballs‟
• Other factors have been implicated-oily skin, excessive sweating,
immunodeficiency, poor nutrition, pregnancy and corticosteroid use
Tinea Versicolor
• multiple oval to round patches or thin plaques with mild scale
• upper trunk and shoulders, are the favored sites of involvement.,
less frequently, lesions are seen on the face (more so in children),
scalp, antecubital fossae, submammary region and groin
• most common colors are brown (hyperpigmented) and
tan(hypopigmented) occasionally there is mild inflammation leading
to a pink color
• asymptomatic and the major concern is its appearance.
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Tinea Versicolor
• DDX • Tx
– vitiligo, pityriasis alba, – Ketoconazole (1% or 2%)
postinflammatory or 2.5% selenium sulfide
hypopigmentation, seborrheic
shampoo is quite effective
dermatitis, pityriasis rosea,
tinea corporis and secondary – azole/allylamine creams
syphilis may mimic the and lotions
disease – nystatin, salicylic acid and
a variety of over-the-
counter dandruff shampoos
– Systemic tx-ketoconazole,
fluconazole or itraconazole
may provide simple and
effective
Drug Eruptions
• Exanthematous or morbilliform eruptions are the most common
• Urticaria, Angioedema and Anaphylaxis
• Photosensitivity
• Vasculitis
• Neutrophilic Drug Eruptions
• Drug Reaction with Eosinophilia and Systemic Symptoms:
Hypersensitivity Syndrome
• Bullous Eruptions
• Drug-induced bullous pemphigoid
Drug Eruptions
• skin is one of the most common targets for adverse drug reactions
• women are more susceptible than men
• increases with the age of the patient, as well as the number of drugs
taken by the patient
• In a retrospective cohort study from the Netherlands of 13 679
patients from general practices, the most frequently reported skin
reactions to antimicrobials were due to
trimethoprim/sulfamethoxazole (2.1% of users), fluoroquinolones
(1.6%) and penicillins (1.1%).
• Common eruptive cutaneous drug eruptions are hypersensitivity
reactions with an underlying immunologic mechanism
Drug Eruptions
• Immunologically Mediated Drug Reactions
– IgE-dependent drug reactions (formerly type I, Gell-Coombs
classification): urticaria, angioedema and anaphylaxis.
– Cytotoxic drug-induced reactions (antibody against a fixed
antigen; formerly type II): petechiae secondary to drug-induced
thrombocytopenia
– Immune complex-dependent drug reactions (formerly type III):
vasculitis, serum sickness and certain types of urticaria
– Possible delayed-type, cell-mediated drug reactions (formerly
type IV) versus undefined: exanthematous, fixed and lichenoid
drug eruptions, as well as Stevens-Johnson syndrome (SJS) and
TEN.
Drug Eruptions
• Non-immunologic Mechanisms
– Overdose, Pharmacologic side effects, Cumulative toxicity,
Delayed toxicity, Drug-drug interactions, Alterations in
metabolism, Exacerbation of disease
• complete list of current (as well as past) medications, including
prescription, non-prescription/over-the-counter, and complementary
or alternative treatments
• time between initiation of drug & onset of eruption is a key element
in identifying offending drug-most immunologically mediated drug
reactions occur within 8 to 21 days after initiation of a new
medication
• usual practice is to discontinue all drugs that are non-essential
Drug Eruptions
• Exanthematous Drug Eruptions
– most common adverse drug reactions affecting the skin
– maculopapular drug eruptions
– erythematous macules that sometimes become slightly palpable;
the distribution is usually symmetric, begins on the trunk and
upper extremities and progressively becomes confluent
– polymorphous with morbilliform or sometimes urticarial lesions
on the limbs, confluent areas on the thorax and purpuric lesions
on the ankles and feet
– possibility of a more severe drug-induced eruption-edema of
face or a marked peripheral blood hypereosinophilia(
hypersensitivity syndrome/DRESS) and mucous membrane
lesions or painful or dusky skin, which may announce TEN or
SJS.
– A biopsy of morbilliform-not particularly helpful
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Drug Eruptions
• DDX-viral exanthems (e.g. • Tx-largely supportive, Topical
Epstein-Barr virus, corticosteroids may help to
enteroviruses, adenovirus, alleviate pruritus,discontinuing
early HIV, human herpesvirus the offending agent is the first
type 6 [HHV-6], parvovirus therapeutic measure
B19), which are often • drugs have a significantly
indistinguishable higher incidence (>3% of
• drug etiology is favored in patients): aminopenicillins,
adults, whereas a viral cause sulfonamides, cephalosporins
is favored in the pediatric and anticonvulsants
population • ACEI, NASIDS
Lichen Planus
• idiopathic inflammatory • Variants- Bullous, atrophic,
disease of the skin and hypertrophic,
mucous membranes Ulcerative/Erosive, Inverse,
• pruritic, violaceous papules Linear, Annular, Lichen
that favor the extremities planopilaris
• has been associated with • Assoc w/hep c more with oral
multiple disease processes
and agents, including viral LP
infections, autoimmune • VirusesHSV,Varicella,
diseases, medications, HHV6, Hep C
vaccinations and dental • VaccineHep B
restorative materials • Drugs
• fifth or sixth decade, with 2/3 • Contact allergensnickel(ID),
patients developing the amalgem
disease between the ages of • Neoplasms
30 and 60 years
Lichen Planus
• Flexor surfaces
• Wickham striae
• small, polygonal-shaped,
violaceous, flat-topped papule;
some papules are umbilicated
• slightly shiny
• Pruritic
• Koebner phenomenon
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Lichen Planus
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Lichen Planus
• Dx made via clinical features and bx
• DDX
– lupus erythematosus (LE), lichen nitidus, lichen striatus, lichen
sclerosus, pityriasis rosea, erythema dyschromicum perstans
(ashy dermatosis), psoriasis, annular lichenoid eruption,
lichenoid GVHD and secondary syphilis
• Tx
– TSC(superpotent), Topical calcineurin inhibitors, Intralesional
corticosteroids, Intramuscular triamcinolone acetonide [0.5-1
mg/kg/month X 3-6 months], Phototherapy, Oral metronidazole,
Antimalarials, Systemic retinoids
PITYRIASIS ROSEA
• healthy adolescents and young
adults
• absence of significant systemic
manifestations & spontaneous
resolution provides great
consolation to the patient
• ages of 10 and 35 years
• no racial predilection
• eruption lasts 6 to 8 weeks
• cause of pityriasis rosea remains
elusive-(HHV-7)
• herald patch is a skin- to pink- to
salmon-colored patch or plaque
with a slightly raised advancing
margin
PITYRIASIS ROSEA
• Couple days after herald patch
increase number of smaller
usually round to oval in shape
long axis following Langer's lines
of cleavage.
• On the posterior trunk-„fir tree‟ or
„Christmas tree‟ pattern
• approximately 25% of patients,
pruritus is noted that is mild to
severe
• darkly pigmented skin, the lesions
tend to be more papular and
hyperpigmented
PITYRIASIS ROSEA
PITYRIASIS ROSEA
• clinical picture is quite characteristic and the histopathology
relatively non-specific.
• DDX-secondary syphilis, drug eruptions, tinea corporis, nummular
eczema, guttate psoriasis
• Tx- patient education and reassurance, low- to medium-strength
topical corticosteroids, UVB light treatments or natural sunlight
exposure and oral antihistamines 73% of patients had complete
resolution after receiving 14 days of erythromycin
Psoriasis
• The impact of psoriasis on quality of life is significant given its
chronicity and prevalence (up to 2% worlds population)
• US and Canada, prevalences as high as 4.6%
• Africans, African-Americans, Norwegian Lapps, and Asians of
between 0.4% and 0.7%
• Psoriatic arthritis probably occurs in 5-30% of the patients
• skin lesions appear well before the psoriatic arthritis
• peaks in age of onset-one at 20-30 years of age and at 50-60 years.
In approximately 75% of patients-before the age of 40 years
• positive family history has been reported by 35% to 90%
• Obesity, increased alcohol consumption, and an increased
incidence of smoking have all been associated with psoriasis
Psoriasis
• associated with several: HLA-B13, • Triggers
HLA-B17, HLA-B37 and HLA- – Drugs
Bw16
– steroid withdrawal
• Triggers
– -blockers
– cutaneous injury-Koebner
– Lithium
phenomenon, sunburn, viral
exanthems, 2-6wk lag – IFN
– psychogenic stress – Terbinafine
– HIV (greater dz severity) – ACE-I
– strep pharyngitis guttate – Antimalarials
(1-2wk lag) – NSAIDs
– hypocalcemia pustular – GCSF
psoriasis – Rapid tapers of corticosteroid
Psoriasis
• symmetric distribution of
sharply defined erythematous
scaly plaques
• scalp, elbows, knees and
presacrum predilection, as are
the hands and feet, genitalia
are involved in up to 30%.
Plaques may persist for
months to years at the same
locations
Psoriasis
Psoriasis
• Guttate psoriasis-2% of the
patients, common form of the
disease in children, preceding
severe upper respiratory
infection,
Psoriasis
• Erythrodermic Psoriasis-
generalized erythema and scaling,
diagnosis of psoriatic
erythroderma include previous
plaques in classic locations,
characteristic nail changes, and
facial sparing.
Psoriasis
• pustular psoriasis-erythema and
the appearance of sterile pustules
dominate clinical picture,
• triggering factors-pregnancy, rapid
tapering of corticosteroids (or
other systemic therapies),
hypocalcemia, infections, in case
of localized disease, topical
irritants
Psoriasis
• Pustulosis of the palms and soles-
sterile‟ pustules of the
palmoplantar surfaces admixed
with yellow–brown macules scaly
erythematous plaques may also
be seen
• commonly associated with sterile
inflammatory bone lesions
Psoriasis
• Acrodermatitis continua of
Hallopeau- rare manifestation,
pustules are seen on the distal
portions of the fingers, nail bed
shedding of nail plates
Psoriasis
Psoriasis
• DDX-mycosis fungoides variant of • Tx-
cutaneous T-cell lymphoma (CTCL)
keratotic eczema of the palms and – Vitamin D3 Analogues-
soles pityriasis rubra pilaris drug inhibits epidermal
reactions intertrigo seborrheic proliferation, (Dovonex,
dermatitis, cutaneous candidiasis, Vectical), max app
tinea incognito
100g/week, CI-Abnormality
• Clinical picture and bx to confirm dx
in bone or calcium
metabolism, Renal
insufficiency, Allergy
Pregnancy, lactation
Psoriasis
• TCS- first-line therapy in mild to moderate psoriasis
• Indications-
– Mild to moderate psoriasis: first-line treatment as monotherapy or in
combination
– Severe psoriasis: often in combination with a vitamin D3 analogue,
topical retinoid, anthralin or tar
– Monotherapy for flexural and facial psoriasis (usually mild strength
– Recalcitrant plaques often require occlusion (plastic, hydrocolloid
• CI-
– Bacterial, viral and mycotic infection
– Atrophy of the skin
– Allergic contact dermatitis due to corticosteroids or constituents of the
formulation
– Pregnancy or lactation
• 80% of patients treated with high-potency topical corticosteroids experience
clearance
• Combination topical therapy
Psoriasis
• Anthralin • Topical Retinoids: tazarotene
– inhibits mitogen-induced T- (Tazorac)
lymphocyte proliferation – second-line treatment as
and neutrophil chemotaxis monotherapy
– treatment in an inpatient – Selectively binds RAR-beta
setting or day-care center and RAR-gamma
– Indications-second-line – epidermal proliferation,
treatment as monotherapy inhibits transglutaminase and
or in combination K16 expression
– CI-Unstable plaque – max BSA = 10-20%
psoriasis in a phase of – CI-Unstable plaque psoriasis,
progression, pustular and Erythrodermic psoriasis,
erythrodermic psr Allergic contact dermatitis,
Pregnancy and lactation
Psoriasis
• Photo(chemo)therapy
– BB or NB UVB(311nm), UVA oral or topical psoralen
– Mod-Severe: first line
– CI-Insufficient efficacy of UVB and PUVA
• Pustular psoriasis (UVB and PUVA)
• Erythrodermic psoriasis (UVB and PUVA)
• Light-sensitive dermatoses (UVB and PUVA)
• Photodermatoses (UVB and PUVA)
• Phototoxic systemic or topical medications (UVB and PUVA)
• Vitiligo (UVB and PUVA)
• Previous history of arsenic exposure, excessive irradiation or excessive
photo(chemo)therapy (UVB and PUVA)
• Excessive exposure to UV light
• Previous cumulative PUVA therapy >2000 J/cm2
• Immunosuppressive medication
• Previous history of skin cancer (UVB and PUVA)
• Men and women in reproductive years without contraception (PUVA)
• Pregnancy and lactation (PUVA)
• Liver and kidney impairment (PUVA)
• Cataracts (PUVA)
I-
Psoriasis
SYSTEMICS • Cyclosporine
• Methotrexate – Severe, failed conv tx
– Severe chronic(>20 BSA), – rapid clearance
pustular, erythrodermic, – blocks IL2 upregulation
psoriatic arthritis, Severe nail – CI-Impaired renal function,
psr Uncontrolled hypertension,Past or
present malignancy, Concomitant
– lymphocyte effect immunosuppressive therapy,
– max effect = 8-12wk drugs affecting cyclosporine
– CI-kidney function (creat cl pharmacokinetics, history of
arsenic exposure, history of
<60 ml/min), Concomitant excessive photo(chemo)therapy,
medications, pregnancy and Concurrent photo(chemo)therapy,
lactation, planning to have Active infections, Pregnancy or
children liver function lactation, immunodeficiency,
abnormalities, hepatitis, Severe chronic organ dysfunction
severe anemia, leukopenia, Non-compliance, Alcohol and drug
thrombocytopenia, active abuse
infections Peptic ulcer (active) – AE: HTN, renal tox
unreliable patient
– AE: liver tox, pancytopenia
Psoriasis
• Acitretin
– Severe monotherapy
– pustular, erythrodermic
– CI-liver/kidney dysfxn, Pregnancy and lactation Women of
childbearing potential who cannot guarantee adequate
contraception during and up to 3 years following discontinuation
of acitretin, hyperlipidemia, especially hypertriglyceridemia,
concomitant medications and hepatotoxic meds,diabetes
mellitus, alcohol abuse
– AE: hyperlipidemia, liver tox
Psoriasis
BIOLOGICS
• T-cell activation inhibitors(Alefacept)
• TNF- inhibitors(Etanercept, Infliximab, Adalimumab)
• CI-Significant viral, bacterial or fungal infections,
Increased risk for developing sepsis, Active tuberculosis
Immunocompromised or immunosuppressed, Pregnancy* (anti-TNF
agents are category B, efalizumab is category C, alefacept is
category B), Allergic reaction to the biologic agent, Excessive
chronic exposure to UVR or photo(chemo)therapy
• AE: immunosuppresion
– Etanercept AE: demyelinating dz, lupus-like syndrome
– Adalimumab AE: thrombocytopenia
– Infiximab CI in CHF
EM/SJS/TEN
• Erythema Multiforme (rarely caused by drugs) is a
distinct disease from Stevens-Johnsons Syndrome /
Toxic Epidermal Necrolysis (caused by drug)
• EM does not commonly progress to SJS/TEN
• SJS and TEN same fatal disease spectrum
• Skin is major target organ for many drug reactions
• Drug reactions usually 7-21 days after drug exposure,
not next day typically
• It is often very difficult to identify the exact drug causing
the reaction
Erythema Multiforme
• acute, self-limited, • Pathogensis
• abrupt onset of symmetrical fixed red – Infection(90%)
papules, • HSV 1,2
• typical and/or occasionally „atypical‟ • Mycoplasma Pneumoniae
papular target lesions • Histoplasma Capsulatum
• precipitated by an infection, particularly • Drugs <10%
HSV
• Exposures (poison ivy)
• Minor-ext, face, mild to no mucosal, no
systemic sx • Systemic disease (rare)(IBD,
LE/Rowell‟s
• Major-ext, face, severe mucosal, syndrome,Bechets)
systemic sx
– fever and asthenia(weakness) of
varying degrees, arthralgias w/
joint swelling, pulmonary. Renal,
hepatic and hematologic
abnormalities-rare
Erythema Multiforme
• Painful mucosal erosions – usually
absent in EM minor
• Natural History
– Abrupt 24-72 hours
– 50% preceded by herpes
labalis 3-14 days
– Last up to 2 weeks
• Recurrences quite common
when?
– Each spring
Erythema Multiforme
Erythema Multiforme
Erythema Multiforme
• DDX-Urticaria, fixed drug – HSV-associated EM- acyclovir (10
eruptions subacute cutaneous LE, mg/kg/day in divided doses)
erythema annulare centrifugum, valacyclovir (500-1000 mg/day)
famciclovir (250 mg twice daily)
and several forms of vasculitis
systemic corticosteroids (e.g.
• Dx-skin bx, good H&P, prednisone [0.5–1 mg/kg/day]) or
• Tx-topical antiseptics for eroded pulse methylprednisolone [1
skin lesions and mg/kg/day for 3 days]) should be
considered, despite the absence
antiseptic/antihistamine rinses and
of controlled studies
local anesthetic solutions for oral
– azathioprine (100 mg/day for
lesions
several months), prednisone (0.5
– Tx underlying cause-bacterial mg/kg/day for several months),
vs viral thalidomide, dapsone,
cyclosporine, mycophenolate
mofetil and PUVA(no controlled
trials
Stevens-Johnson Syndrome (SJS)
Toxic epidermal necrolysis (TEN)
• Rare, acute and life-threatening mucocutaneous diseases that are
almost always drug-related
• unpredictable course
• annual incidence of 1.2-6 and 0.4-1.2 per million persons
• TEN affects women more frequently than men, with a ratio of 1.5:1,
and the incidence increases with age
• Patient groups particularly at risk
– AIDS (1000x greater risk!)
– Slow acetylator genotypes
– Immunocompromised (HIV, lymphoma)
– Brain tumor patients undergoing radiotherapy and concomitantly
receiving antiepileptics
Stevens-Johnson Syndrome (SJS)
Toxic epidermal necrolysis (TEN)
• mortality rates • Drugs associated
– 25% to 50%-TEN – Allopurinol
– 5% for patients-SJS – Aminopenicillins
• Pathogensis – Amithiozone (thioacetazone)
– Massive Keratinocyte Apoptosis – Antiretroviral drugs
– Overwhelms phagocytes‟ ability to – Barbiturates
eliminate apoptotic cells – Carbamazepine
– Chlormezanone
– Phenytoin antiepileptics
– Lamotrigine
– Phenylbutazone
– Piroxicam
– Sulfadiazine
– Sulfadoxine
– Sulfasalazine
– Trimethoprim–sulfamethoxazole
Stevens-Johnson Syndrome (SJS)
Toxic epidermal necrolysis (TEN)
• SJS <10%
• TEN >30%
• Typical interval between the onset
of drug therapy and SJS/TEN is
between 1 and 3 weeks (2 months
for aromatic anticonvulsants)
• Epidermal detachment
• Initial sx-fever, stinging eyes, and
pain upon swallowing can precede
cutaneous 1-3 days
• Erythema and erosions of the
buccal, ocular and genital
mucosae are present in more than
90% of patients
Stevens-Johnson Syndrome (SJS)
Toxic epidermal necrolysis (TEN)
• respiratory tract is involved in 25% of
patients with TEN
• lesions are usually tender, and
mucosal erosions are very painful
• Additional systemic manifestations
include fever, LAD, hepatitis and
cytopenias
• First, lesions appear as erythematous,
dusky red or purpuric macules of
irregular size and shape, and have a
tendency to coalesce
• Nikolsky sign-Tangential pressure on
erythematous lesion to induce
cleavage
Stevens-Johnson Syndrome (SJS)
Toxic epidermal necrolysis (TEN)
Stevens-Johnson Syndrome (SJS)
Toxic epidermal necrolysis (TEN)
• epidermal involvement progresses
toward full-thickness necrosis, the
dusky red macular lesions-hours to
days
• epidermis then detaches -fluid fills the
space between the dermis
• (flaccid) and can be extended
sideways by slight pressure of the
thumb as more necrotic epidermis is
displaced laterally (Asboe-Hansen
sign)
Stevens-Johnson Syndrome (SJS)
Toxic epidermal necrolysis (TEN)
• SCORTEN • Mortality rate
• 1 point for ? – 0-1 - 3.2%
– Age >40 – 2 - 12.1%
– Heart rate >120 – 3 - 35.8%
– Malignancy – 4 - 58.3%
– BSA above 10% – >5 - 90%
– Serum Urea >10 mmol/l
– Serum Bicarbonate <20
mmol/l
– Serum glucose > 14mmol/l
Stevens-Johnson Syndrome (SJS)
Toxic epidermal necrolysis (TEN)
• DDX-EM. SSSS, AGEP and • Tx
generalized fixed drug eruption, – early diagnosis,
Paraneoplastic pemphigus, drug- – Discontinue all meds
induced linear IgA bullous dermatosis
(LABD), Kawasaki disease, LE, and – Protect against hypovolemia,
severe acute GVHD electrolyte imbalance, renal
insufficiency and sepsis
– Burn care/ ICU
– Careful manipulation
– Vaseline gauze on denuded areas
– Regular eye exam by optho
– Periodic cultures of eyes, sputum,
drainage
– Steroid efficacy controversial
– IVIg 1g/kg/day x 3 - 4 days
Stevens-Johnson Syndrome (SJS)
Toxic epidermal necrolysis (TEN)
BULLOUS PEMPHIGOID
• most common autoimmune subepidermal blistering disease, and it
predominantly affects the elderly
• after 60 years of age
• patients over 90 years of age appears to be about 300-fold higher
• higher predominance in men
• immune-mediated disease-self-antigens: the BP antigen 180
(BP180, BPAG2 or type XVII collagen) and the BP antigen 230
(BP230 or BPAG1)
• Manifestations extremely polymorphic(bullous vs nonbullous)
BULLOUS PEMPHIGOID
• Nonbullous-non-specific mild to severe pruritus w/o excoriated,
eczematous, papular and/or urticarial lesions that may persist for
several weeks or months
• Bullous-vesicles and bullae on apparently normal or erythematous,
annular or figurate pattern blisters are tense, up to 1–4 cm leaving
eroded and crusted areas,
• Symmetrical distribution pattern, and they predominate on the
flexural aspects of the limbs and the lower trunk, including the
abdomen. Within intertriginous zones, vegetating plaques can be
observed.
• increased risk of malignancy in patients with BP appeared to be
marginal-ca screening correlate w/ sx
• Triggers-trauma, burns, radiotherapy or UV irradiation
• Assoc w/ psr & LP
BULLOUS PEMPHIGOID
BULLOUS PEMPHIGOID
BULLOUS PEMPHIGOID
BULLOUS PEMPHIGOID
• Drug Induced BP • Dx & DDx
– Diuretics (e.g. furosemide, – Clinical
bumetanide) – Histo, IIF, DIF
– Analgesics (e.g. – DIF-fine, linear, continuous
phenacetin) deposits of IgG and/or C3
– D-penicillamine along the epidermal
– Antibiotics (e.g. amoxicillin, basement membrane
ciprofloxacin) – EBA, LABD, CP,drug
– Potassium iodide reactions, contact
– Gold dermatitis, prurigo
nodularis, urticarial
– Captopril dermatitis, vasculitis,
arthropod, scabies
BULLOUS PEMPHIGOID
• Tx-Mild and/or localized • Tx-extensive/persistent
disease disease
– Superpotent TCS – Superpotent TCS
– Nicotinamide in association – Oral corticosteroids
w/ minocycline or – Azathioprine
tetracycline – Mycophenolate mofetil
– Erythromycin, penicillins – MTX
– Dapsone, sulfonamides – Chlorambucil
– Topical immunomodulators – Cyclophosphamide
(e.g. tacrolimus)
– IVIg
– Plasma exchange
– Rituximab
Acne Vulgaris
• disorder of the pilosebaceous unit
• primarily a disorder of adolescence(85% btw between 12 & 24 y/o)
• sebaceous gland is controlled primarily by hormonal stimulation
– High in 1st 6 mos
– Decreases at 1yr + stabilizes
– Dramatically increases at adrenarche, correlating w/androgen
production and acne
– Stable in adulthood
– Decreases in women at menopause and men in 6th and 7th
decade
• Propionibacterium acnes contributes significantly to the production
of acne- Gram-positive, non-motile rods
Acne Vulgaris
• Sticky corneocytes proliferate in infrainfundibulum
• Comedone expands, sebaceous lobule regresses
• Pressure increases, comedo ruptures, keratin and sebum are
extruded
• Inflammation ensues
Acne Vulgaris
Comedonal acne
Acne Vulgaris
Closed comedones
Acne Vulgaris
Vascular type
Rosacea
Inflammatory rosacea
Rosacea
Occular
Rosacea
• Dx-clinical, bx only severe • Tx-topical
persistent cases – Metronidazole-topical therapy
daily to BID
• DDX-perioral derm, – Azelaic acid cream
granulomatous rosacea, – BPO if not too irritating, topical
pyoderma faciale, steroid anitbiotics not very effictive,
rosacea, Seb derm, Acne, – topical tretinoin
Erythromelanosis Faciei and – Sulfa based face washes
Keratosis Pilaris Rubra, Lupus • Tx-oral
Erythematosus, Lupus Miliaris – Tetracyclines-anti-inflammatory
Disseminatus Faciei, Demodex – Isotretionoin-severe cases
• Tx-surgical
– IPL or PDL
– electrosurgery
– CO2 laser
Folliculitis
• very common disorder
• Culture contents often fails to
identify a bacterial pathogen
• Staphylococcus aureus is the
most common
• Perifollicular pustules, arising
on an erythematous base
• pierced by a hair
• Tender,painful, pruritic
• Neck,scalp, beard area, upper
trunk, buttocks and
thighs,axillae and groin
• Areas of terminal hair
Folliculitis always culture
biopsy it
Actinic Keratosis
• AKs are most often found in fair-skinned individuals
• accounted for 3 million annual visits to dermatologists in the US
during the early 1990s
• 80% of AKs occur on the head, neck and upper extremities (dorsal
hands and forearms),more often in individuals w/ prior history,
increasing age, men. AKs are also markers for an increased risk for
developing invasive NMSC(SCC)/(BCC)
• resistance to UV-induced keratinocyte apoptosis-contributes to
pathogenisis(much more extensive…carcinogensis, cell cy es,
oncogenes, tumor suppersor genes) p53 protein is a key factor for
integrating pathways regulating DNA synthesis, DNA repair and
apoptosis.
• Prolonged UV exposure/intense UV expousre holiday
Actinic Keratosis
• number of mutations in a cell increases with time and partially
explains the increasing risk for acquiring cancer as we age
• inactivation of p53 facilitates angiogenesis-essential for tumor mass
expansion
• „precancerous‟ or „premalignant‟ because the atyypical keratinocy
within these lesions are confined to the epidermis
• Environmental risk factors- Cumulative/occupational sun exposure,
Intermittent/recreational sun exposure, PUVA, tanning beds,Ionizing
radiation,chemicals (arsenic), human papillomavirus, cigarette
smoking
Actinic Keratosis
• Risk factors-
– Fair skin, always burn, never tan, freckling, red hair, light eye
color
– Genetic syndromes-rare Lupus on skin only
– Chronic non-healing wounds, longstanding DLE, LP, nevus
sebaceous
– Organ TPLT, chronic lymphocytic leukemia treated with
fludarabine, AIDS patients with HPV infection
Actinic Keratosis
• likelihood of an invasive SCC evolving from a given AK has been
estimated to occur at a rate of 0.075-0.096% per lesion per year
• sun-damaged skin of the head, neck, upper trunk and extremities
may report tenderness
• rough erythematous papule with white to yellow scale
• Advanced lesions thicker and well defined w/hyperkeratosis and
erythema,in areas of highest sun exposure(ears,forehead, nasal
bridge, malar eminences, dorsal hands, extensor forearms,scalp in
bald individuals)
pale, papule
Actinic Keratosis
flaky
Actinic Keratosis
Actinic Keratosis
ear, lip, nose so take biopsy tell about scars
biopsy
superficial squamos cells
Keratoacanthoma
Volcanic in appearance
SCC
• Dx-clinical and histo • Tx-Standard exc
• DDX-BCC, atypical – 6mm margins for SCC(high
fibroxanthoma, risk lesions)
neuroendocrine carcinoma, – 10% recurrence rate
curette
amelanotic melanoma, • ED&C electrodissecation &
adnexal tumors, prurigo – Cure rate 97-98% (smaller the
nodularis, verruca and irritated better)
seborrheic keratosis. • Curettage alone
– 96% cure rate (avoids
hypertrophic scar)
SCC
• Mohs Micrographic Surgery
– 1% recurrence rate over 5 years
– 5.6% recurrence in prior recurrent BCCs
– Preferred treatment in:
• Recurrent type
• Poorly delineated
• High-risk
• Incompletely removed BCC
• Sites of tissue conservation
• Need for reliable clear margins
SCC
• Radiation
– Use if surgery is contraindicated
– Disadvantages:
• Lack of margin control
• Poor cosmesis in some patients (scars worsen with time,
unlike surgery)
• Prolonged course of therapy
• Increased risk for future skin cancers
• High recurrence rates
BCC
• Sun exposure and anatomic site appear to be of etiologic
importance
• development of BCCs is restricted to skin containing pilosebaceous
units
• commonly develop on the face, and in particular on the nose,
suggests that anatomic site
• BCC appears to have a capacity for infinite growth and spontaneous
regression is not a feature
• virtually never develop metastases
• no known precursors (with the possible exception of p53 clones)
• BCC is the most common skin cancer in humans
• Men generally have higher rates of BCC than do women
BCC
• Women have a greater frequency of BCC on the lower extremities
while men have more ear lesions
• incidence of BCC is increasing
• increase with age and the median age at diagnosis is 68 years
• Mortality from BCC is quite rare and can occur in
immunocompromised patients
• metastatic BCC are more likely from tumors with aggressive
histologic patterns (morpheaform, infiltrating, metatypical,
basosquamous)
• Perineural space invasion an indicator of aggressive disease
• Metastases often involve regional lymph nodes, lungs, bone and
skin
• Risk factors similar to AK, SCC
BCC pink
pairly papule
Superficial bcc
BCC
morpheaform
BCC
• Dx-clinical and histo
• DDX-AK, SCC(is), AMM, inflammed SK, hidrocystoma
• TX- Standard excision
– 4mm margins for BCC radiation
– ED&C, Curettge alone, Mohs for high risk types and sites, XRT,
medical management, photodynamic
aldera
Melanoma
• Melanoma is a malignancy arising from melanocytes-incidence and
overall mortality rates have been rising in recent decades
• most common forms of cancer in young adults,up to one-fifth of
patients develop metastatic disease, which usually is associated
with death
• Germline genetic mutations and polymorphisms can predispose
individuals to melanoma
• CDKN2A(gene locus)
• Immunogenic tumor(provokes immune response)- Halo nevi,Vitiligo-
like depigmentation,Higher rate of melanoma in immunosuppressed
pts
• melanoma incidence rate in Australia is the highest world-wide
Melanoma
Melanoma
Melanoma
• Risk factors
– Genetic(Family history of atypical (dysplastic) nevi or melanoma,
lightly pigmented skin, tendency to burn, inability to tan, red hair
color, dNA repair defects (e.g. xeroderma pigmentosum))
– Environmental factors(Intense intermittent sun exposure,
sunburn, residence in equatorial latitudes)
– Phenotypic expressions of gene/environment
interactions(Melanocytic nevi: – Increased total number,
Multiple atypical (dysplastic), congenital (particularly large axial
lesions with multiple satellites), ephelides, personal history of
melanoma
Melanoma
Melanoma
men in their back
• Types
– Superficial spreading – 70%-Any site, preference for lower
extremities (women), trunk (men and women)-radial growth-More
pagetoid spread, less solar elastosis
– Nodular – 15-30%-Any site, preference for trunk, head, neck-no
radial growth-Nodule with more rapid vertical growth
– Lentigo maligna melanoma-5-15%-Face, especially nose and
cheeks-radial growth-Slower growth over years within sun-
damaged skin
– Acral lentiginous melanoma-5-10%-Palms, soles, nail unit-radial
growth-Most common melanoma type in patients with darker
skin types
Melanoma
Nodular melanoma
Melanoma
• Management
– Bring pt back for a total body skin
exam
– Studies – usually a CBC, CMP,
LDH & CXR
• Limited value for melanomas
<4mm -surgery is going to
want most of these anyway
for pre-op
– New marker not routinely used -
S100beta and MIA
– StageIII/IV – MRI head, CT
chest/abd/pelvis, PET scan or
PET-CT
Melanoma
Sentinel lymph node biopsy
• SLNB • SLNB- Exceptions
– Primary melanomas – For those patients with a lesion <
>1.0mm 1mm a selective SLN biopsy will
be performed. Those patients
• Provides info on who we would consider
subclinical nodes with (Controversial, no nationwide
guidelines)
minimal morbidity
– 1. Those with a depth between
• Identifies metastatic 0.75-0.99 mm
nodes for early – 2. Clark level IV or higher
therapeutic dissection – 3. Ulceration
• Identifies candidates for – 4. Those with some “soft” poor
IFN alpha prognostic criteria: head and
neck or trunk melanomas, male
sex, evidence of regression,
vascular or neural invasion
NOT theraputic however
• We have had 2 young women with
positive lymph nodes with thin
melanomas
SCABIES
• Worldwide problem and all ages, races and socioeconomic groups
are susceptible
• Environmental factors-overcrowding, delayed treatment of primary
cases, and lack of public awareness of the condition
• Transmitted directly by close personal contact, sexual or otherwise,
or indirectly via fomite transmission
• Prevalence is higher in children and in people who are sexually
active
• Spread of the infestation between family members and close
contacts is common
• Crusted scabies-compromised immune systems (e.g. the elderly,
people infected with HIV, and transplant patients) as well as those
with decreased sensory functions (e.g. patients with leprosy or
paraplegia)
SCABIES
• Sarcoptes scabiei var. hominis
causes human scabies
• entire 30-day life cycle of mites is
completed within the epidermis
• female mite will lay 60-90 eggs,
which require 10 days to mature
• incubation period before
symptoms-days to months
• first-time infestations- 2-6 weeks
before the host's immune system
becomes sensitized to the mite or
its byproducts, resulting in pruritus
and cutaneous lesions
• Asymptomatic scabies-infested
individuals are not uncommon,
and these individuals can be
considered „carriers
•
SCABIES
• history distribution,types of lesions, and pruritus form the
basis of the clinical diagnosis
• intense pruritus at night exacerbated by a hot bath or
shower
• Symmetrical-interdigital/web spaces, flexural aspect of
the wrists, axillae, behind the ears, waist, ankles, feet,
buttocks and belt area
• men-penile and scrotal lesions are common
• women-areolae, nipples and genital area are often
affected
• infants, elderly and immunocompromised-all skin
surfaces are susceptible, including the scalp and face
SCABIES
• small erythematous papules are
present, excoriations
• vesicles, indurated nodules,
eczematous dermatitis and
secondary bacterial infection are
common
• pathognomonic sign is the burrow-
wavy, thread-like, grayish-white
and 1-10 mm in length
SCABIES
SCABIES
• Dx-mineral oil examination in which skin scrapings from infested
areas are inspected under light microscopy for adult mites, eggs
and/or fecal pellets
• DDx- atopic, contact or nummular dermatitis, autosensitization („id‟
reaction), pyoderma, dermatitis herpetiformis, bullous pemphigoid,
and other insect bites should be considered
• Tx-Topical
– Permethrin cream (5%)Originally a single, overnight treatment;
current recommendation is to repeat on day 8; RF-Allergy to
formaldehyde; Good, but some signs of tolerance developing.
– Lindane lotion (1%)Topically overnight, on days 1 and 8,RF-for
CNS toxicity, age <2 years, pregnancy, breastfeeding, areas of
eroded skin; Poor, resistance very common(not used anymore)
SCABIES
• Tx-topical
– Crotamiton (10%)Topically overnight, on days 1, 2, 3 and 8; RF-
for irritant contact dermatitis, denuded skin; Very poor; has
antipruritic properties and may be used for post-scabetic pruritus
• Tx-oral
– Ivermectin (200–400 mg/kg); commercially available as 3 and 6
mg tablets; Orally on day 1 and 14; RF-for potential CNS toxicity,
<15 kg, pregnancy, breastfeeding; Excellent
• Pruritus and lesions can persist for 2-4 weeks after successful
treatment
Lice(head)
• Lice are bloodsucking,
wingless insects belonging to
the order Anoplura
• worldwide with no strict
limitations based upon age,
sex, race or socioeconomic
class
• children 3-11 years of age
have the highest incidence
• more frequently observed in
girls
• head louse, Pediculus capitis
Lice(head)
• Transmission occurs via direct head-to-head contact or by fomites
such as combs, brushes, blow-dryers, hair accessories, bedding,
helmets and other head gear
• head lice do transmit coagulase-positive Staphylococcus aureus
and group A Streptococcus pyogenes by carrying these organisms
on their external surfaces.
• scalp, behind the ears and the nape of the neck-pruritus,
excoriations, erythema, pyoderma, and scaliness of the scalp and
posterior neck are common
• diagnosis is made by id of nits and/or adult lice on the scalp hair,
viable eggs are tan to brown in color
• occ pt will present with a low-grade fever, irritability,
lymphadenopathy and a secondary bacterial infection
•
Lice(head)
Lice(head)
• DDX-seb derm, psoriasis
• Tx-similar to that of scabies,
– With all topical preparations (regardless of package instructions),
two applications, 1 week apart, are advisable in order to:
• (1) kill any nits that survived treatment
• (2) better defend against the seemingly growing resistance to
most pediculicides
• (3) reduce the risk of reinfestation by means of fomites
Crab lice(pubic)
• Pthirus pubis, the crab louse
• may coexist with other sexually
transmitted
• slightly higher in men
• highest prevalence in msm.
Infestation is most frequently
observed in those 15 to 40 years
of age
• infestation in pubic hair, in scalp,
eyebrows, eyelashes, moustache,
beard, axillae and perianal area.
Indeed, 60% of patients with pubic
lice are infested in two different
hair-bearing sites.
Crab lice(pubic)
• skin-colored or simply appear as hemorrhagic crusts, may be
erythema around the hair follicles, excoriations, secondary bacterial
infection, and lymphadenopathy
• DDX-ID diagnostic, all infestation and bites, other other ds w/pruritus
• Tx-all tx should be given 1 week apart, tx similar to scabies
Body Lice
• associated with overcrowding, poor hygiene, poverty, wars and
natural disasters
• primary vectors for several diseases caused by Rickettsia, Borrelia
and Bartonella species
• Pediculosis corporis is caused by an infestation of humans and their
clothing by Pediculus humanus var. corporis, infestation requires an
inability to wash and change clothes
• transmitted by the body louse-epidemic typhus (caused by
Rickettsia prowazekii), relapsing fever (caused by a spirochete,
Borrelia recurrentis), and trench fever and bacillary angiomatosis or
endocarditis (caused by Bartonella quintana)
• Transmission not by louse bites but contaminated fecal pellets being
scratched into excoriated skin or inhalation of dry, powdery louse
feces from infected bedding or clothing.
Body Lice
• nits and lice are rarely found
on the patients' skin they
reside primarily on the clothing
of their host
• back, neck, shoulders and
waist areas are commonly
involved. Clinical findings
include small pinpoint red
macules, papules, crusts and
excoriations, occasionally
complicated by impetigo and
lymphadenopathy
Body Lice
• DDX-any condition causing pruritus
• Preferably, the clothing and bedding of infested individuals are
discarded in tightly sealed, plastic biohazard bags and incinerated
• involves fumigating the clothing and heating it to a temperature of
65°C for 15-30 minutes
Spider Bites
• Black widows are large, shiny black
spiders with a large round abdomen
• Found in woodpiles, in shoes and
under outhouse seats
• In Latrodectus mactans, an hourglass
design is seen on the abdomen most
common in North America
• Lactrodectus mactans; alpha-
lactrotoxin; bites are painful; releases
Neurotoxin: Ach is irreversibly
releasedsevere pain in local
muscles crampy abd pain, chills,
vomiting, paralysis, mimicks acute
abdomen, rhabdomyolysis
• Benzodiazepines and intravenous
calcium gluconate can be helpful for
the associated tetany
Spider Bites
• Loxosceles spiders are found throughout the world. In the US, L.
reclusa, L. laeta, L. rufescens, L. deserta and L. arizonica cause
skin necrosis
• Brown recluse spiders are commonly found in south central US,
from Tennessee and Missouri to Oklahoma and Texas, often found
in woodpiles, attics and under radiators.
• Brown spiders are non-aggressive
• diagnosis can now be confirmed either by an enzyme immunoassay
to detect Loxosceles venom in a skin biopsy
• Sphingomyelinase D interacts with serum amyloid protein gravity
dependent state
• majority of bites do not cause serious reactions
• Dermonecrotic reactions can present as dry, necrotic eschars or
ulceration; sys rxn-DIC, Coombs'-positive hemolytic anemia
Spider Bites
• Most bites can be treated with
rest, ice and elevation
• more widely available agents
such as dapsone, colchicine,
triamcinolone and prednisone
have been inconsistent and
often disappointing
• Antivenin
• Avoid heat and immediate
surgery as they can spread
venom
• Augmentin 2/2 infection
Spider Bites
• Tegenaria agrestis- Large, hairy,
aggressive spiders found in dark,
moist areas, especially basements
• found in the northwest US,
Canada and Europe
• Hobo spider toxins may cause
local necrosis and directly affect
the CNS
• Systemic symptoms include
headache, nausea and weakness;
hemolysis and thrombocytopenia
• Funnel shapped web
Spider Bites
• Tarantulas are large hairy spiders
common in the southwestern US
• tarantulas possess urticating hairs
on the dorsal abdomen
• Itching at the site of urticating hair
penetration may persist for several
weeks after exposure-Hairs that
penetrate the cornea can result in
ophthalmia nodosa, a chronic
granulomatous reaction that can
result in loss of vision
• do not produce severe systemic
toxicity
Androgenetic Alopecia
• 80% of Caucasian men by age 70
• Genes and hormones are
implicated, inheritance is
polygenic
• Hormones in AGA
– Testosterone-Increased
muscle mass
– Growth of the phallus &
scrotrum
– Voice change
– Sex drive
– Terminal pubic and axillary
hair fibers
AGA
• Hormones in AGA
– Testosterone
• Increased muscle mass
• Growth of the phallus & scrotrum
• Voice change
• Sex drive
• Terminal pubic and axillary hair fibers
– Testosterone is converted to DHT by 5 alpha reductase which
leads to temporal scalp hair recession, acne, growth of the
prostate, growth of terminal hairs in the beard region, external
ears, nostrils & limbs
AGA
• The genetic absence
of type II 5a-
reductace prevents
male androgenetic
alpecia
• 5a-reductase activity
and DHT levels are
increased in affected
skin
AGA
• Classification systems – Hamilton Norwood
– Ludwig
AGA
• DDX-other non scarring alopecias,
• Dx-clinical in men bx to confirm, hair loss in women
should suggest the possibility of pathologic
hyperandrogenism, and appropriate screening laboratory
tests (total and free testosterone,
dehydroepiandrosterone sulfate, and 17-hydroxy-
progesterone) should be performed
AGA
• Tx
– Hair transplant
– Minoxidil 2% and 5%, 1ml applied to scalp bid
– Finasteride 1mg po daily
• Stops hair loss in 90% of men for at least 5 years
• Can regrow hair in 65% of men
– hyperandrogenemia in women-Oral contraceptives,
spironolactone or even finasteride(off-label use, birth defects)
Alopecia Areata
localized hair loss
• 0.1% to 0.2% of the population
• Normal follicle keratinocytes lack MHC class I and II giving them
immunologic privilege
• In AA human leukocyte antigens become expressed by the hair
follicle
• T lymphocytes then interact with hair matrix cells causing
destruction
• presents as round or oval patches of non-scarring hair loss
• Short „exclamation mark‟ hairs (i.e. distal end broader than the
proximal end) can often be seen, particularly at the margins of areas
of alopecia
• Other presentations include alopecia totalis (loss of all scalp hair),
alopecia universalis (loss of all scalp and body hair and an ophiasis
pattern (band-like pattern of hair loss along the periphery of the
temporal and occipital scalp)
AA
AA
• Assoc Disease
– Atopy (allergic rhinitis, atopic dermatitis, asthma); >40% in some
studies
– Autoimmune thyroid disease (e.g. Hashimoto's thyroiditis),
vitiligo, inflammatory bowel disease
– Autoimmune polyendocrinopathy syndrome type 1 (autosomal
recessive; due to mutations in the autoimmune regulator gene
[AIRE]; up to 30% of patients have alopecia areata)
– Type 1 diabetes increased in relatives of patients with alopecia
areata
AA
scaring or no scaring
• DDx
– Tinea capitis, trichotillomania, temporal triangular
alopecia, traction alopecia, secondary syphilis and
loose anagen syndrome, pressure-related alopecia,
aplasia cutis and „burnt-out‟ cicatricial alopecia. The
diffuse variant may initially be confused with telogen
effluvium and androgenetic alopecia
• DX-history and clinical examination is sufficient to
distinguish between these conditions, but a scalp biopsy
may be needed.
AA
• Tx
– May improve on its own
– Topical steroids – clobetasol (1)
intralesional
– IL steroids - 3-5mg/ml - into the mid dermis, q 4-8 wks (1)
– Minoxidil (2)
– Immunotherapy: Squaric Acid, anthralin,
diphenylcyclopropenone (2)
– Systemic steroids (2)
– PUVA (2)
– Excimer laser (3)
– Photodynamic therapy (3)
– Systemic cyclosporine (3)
Onychomycosis
• affects men more than
• challenging to manage due to difficulty in diagnosis, long treatment
periods, potential side effects of systemic medications, and the
frequent recurrence
• dermatophytes as well as non-dermatophytes-3 main pattern types
– distal/lateral subungual with invasion via the hyponychium (most
common)
– white superficial with direct invasion into the superficial nail plate
(often due to T. mentagrophytes)
– proximal subungual with direct invasion under the proximal nail
fold (immunocompromised hosts)
• discomfort and pain associated with trimming the nails, running
Onychomycosis
• frequently associated with chronic tinea pedis
• most common causative pathogens are T. rubrum, T.
mentagrophytes and E. floccosum
• Toenail more common than fingernail, 80% reoccur
• Clinical and Histologic examination of formalin-fixed, PAS-stained
nail plates is a quick and reliable method for diagnosing
onychomycosis
• Tx-preferred terbinafine 250mg daily x3months, check LFT‟s prior to
tx and mid-way, lower reoccurrence rates than iatraconazole, other
antifungals avalible many med interactions
– Topical cicloprox 8% nail lacquer-expensive
Onychomycosis
Paronychia
• affected digit becomes swollen, red and painful
• Compression of the nail fold may produce pus drainage
• most commonly due to bacteria, in particular Staphylococcus aureus
or Streptococcus pyogenes, and follows minor trauma to the nail
• Recurrent episodes of acute paronychia should raise the suspicion
of an HSV infection. Viral cultures, direct fluorescent antibody assay,
and/or PCR should be obtained to identify the responsible agent.
• Tx-drainage of the abscess, systemic antibiotics according to culture
results, systemic antivirals when due to HSV
Paronychia
Condyloma Acuminatum
• Caused by human Paillomavirus
• transmission
– direct skin : skin
– indirect contaminated surfaces (swimming pool, gym)
– aerosolized
• laser, ED&C
• absence of viral envelope resistance to dessication
– recurrent respiratory papillomatosis = HPV -6, -11
• childhood vertical trans., adult genital : oral
– cellular target = basal keratinocytes
– maceration promotes
• Genital warts are uncommon in prepubertal children and are of special concern to
healthcare providers- may have been caused by sexual abuse should always be
carefully considered
• one of the most common sexually transmitted infections (STI) among adolescents
and adults
Condyloma Acuminatum
• Most genital papillomavirus infections resolve spontaneously
• median duration of high-risk HPV infections in women is reported to
be 8 months and persistence is observed in 30% after 1 year and in
9% after 2 years of observation
• HPV-16, -18, -31 and -45 are found in approximately 80% of cervical
cancers worldwide
• Immune suppression in HIV-infected patients or organ transplant-
infections are more frequent, tend to persist, and more often
progress to intraepithelial neoplasias
• Recurrent respiratory papillomatosis (RRP)-exophytic lesions of
airways and not seen by dermatologists. It occurs in a juvenile- or
adult-onset form and is caused by HPV-6 and -11, low incidence
RRP is the most common benign tumor of the larynx and the second
most common cause of hoarseness in children
Condyloma Acuminatum
• non-enveloped dsDNA virus
• cellular target = basal keratinocytes(enter through break in skin)
• oncogenicity
– HPV-16, -18, - 31, -33, -45
– cervical cancer, bowenoid papulosis, upper aerodigestive
malignancies, SCC
– HPV -5, -8 SCCs in EDV
• Most will resolve w/in 2 years
• external genitalia and the perineum, perianally, or in adjacent areas
such as the inguinal fold and the mons pubis
Condyloma Acuminatum
• Condylomata-one to several
millimeters in diameter
• discrete, sessile, smooth-surfaced
exophytic papillomas
• skin-colored, brown or whitish
(especially when macerated in
moist areas)
• pedunculated or broad-based
papillomas up to several
centimeters in diameter
• large confluent plaques and may
extend into the vagina, the
urethra, or the anal canal, but
rarely beyond the dentate line
Condyloma Acuminatum
• DDX-diagnosis of skin and genital warts is uncomplicated if typical clinical features
are present
• Dx-hx, clinical, histo
• Tx
– Cryotherapy, TCA, excision, curettage, laser
– Salicylic acid
– Cantharadin (occlusion)
– Imiquimod
• 3x per wk x 16wks
– 5-fluorouracil
– Podofilox (Condylox) – cytotoxic
• BID x 3 days in weekly cycles
– Cimetidine – activates Th1 cells to make IL-2 and interferon
– Cidofovir (topical, systemic)
– Intralesional candida, trychophyton, mumps antigens, bleomycin
Verruca Vulgaris
• person-to-person transmission
• Cutaneous warts are caused by a small group of specific HPV types
• prevalence of 20% in schoolchildren and a decline
• One of the three most common dermatoses in children and occur
with equal frequency in both sexes. Patients living in larger
households often report an infected cohabitant
• The majority of warts will regress spontaneously within 1-2 years
• Reinfection with the same HPV type appears uncommon after
clearance, suggesting that protective type-specific immunity may
develop
• Pathogensis similar for all HPV
• hyperkeratotic, exophytic and dome-shaped papules or nodules
associated typically with HPV-1, -2 or – 4
Verruca Vulgaris
• commonly located on fingers,
the dorsal surfaces of hands,
and other sites prone to
trauma such as knees or
elbows, but may occur at any
anatomic location
• Palmar and plantar appear as
thick, endophytic papules on
palms, soles, and lateral
aspects of the hands and feet,
with gently sloping sides and a
central depression
• painful to pressure when
walking
Verruca Vulgaris
• DDX-Seborrheic keratoses, actinic • Cryotherapy, TCA, excision,
keratoses, cornu cutaneum, curettage, laser
keratoacanthoma, lesions of • Salicylic acid
acrokeratosis verruciformis, • Cantharadin (occlusion)
angiokeratoma and amelanotic • Imiquimod
melanoma may resemble common – 3x per wk x 16wks
warts, LP • 5-fluorouracil
• Dx-clinical and histo • Podofilox (Condylox) – cytotoxic
– BID x 3 days in weekly cycles
• Cimetidine – activates Th1 cells to
make IL-2 and interferon
• Cidofovir (topical, systemic)
• Intralesional candida,
trychophyton, mumps antigens,
bleomycin
Viral Exanthems
• Varicella-Zoster Virus (HHV-3)
– Etiologic agent of chicken pox
and herpes zoster (shingles)
– High morbidity and mortality in
immunocompromised hosts
– Transmission via airborne
droplets or direct contact with
vesicle fluid
– Incubation 11-20 days
– Extremely contagious(80-
90%)
– Zoster = reactivation of latent
VZV
Viral Exanthems
• Primary Varicella (Chickenpox)
– Fever, malaise, myalgia
– Erythematous, pruritic macules
and papules
– Start on scalp and facetrunk
and extremities
– Dew drops on a rose petal
– Hallmark: Lesions in all stages of
development
Viral Exanthems
• Herpes Zoster (Shingles)
• Complication: Ramsay-Hunt Syndrome
– VZV infection of the geniculate ganglion of the facial nerve
– Zoster involves external ear
– Facial paralysis – ipsilateral
– Tinnitus or other auditory symptoms
Viral Exanthems
• Varicella in Pregnancy
• First 20 weeks of gestation:
– Congenial varicella syndrome:
– hypoplastic limbs, ocular and CNS abnormalities
• 5 days before and 2 days after delivery
– Neonatal varicella
– Neonate develops at 5-10 days of age
– Treat with VZIG + IV Acyclovir
Viral Exanthems
• DDX-HSV, vesicular viral exanthems (Coxsackie, ECHO), pityriasis
lichenoides et varioliformis acuta (PLEVA), rickettsialpox, a drug
eruption, contact dermatitis, and, occasionally, insect bites or even
scabies
• Dx-clinical diagnosis, based upon both the history (e.g. initial
episode versus multiple recurrences; previous history of varicella or
receipt of the varicella vaccine) & the physical examination, is very
important because a decision regarding instituting antiviral therapy
is critical
• Tzanck smear(cannot differentiate HSV types) and/or a DFA(allows
distinction) are initially performed
• Histo not too helpful b/w VZV and HSV(need staining)
• PCR is a highly sensitive molecular technique and its use as a
diagnostic test of choice is increasing
Viral Exanthems
• Varicella in children-symptomatically with antipyretics, antihistamines,
calamine lotion and tepid baths
• acyclovir has been shown to decrease the duration and severity of varicella
infection(24 to 72 hours from start)
• Acyclovir is clearly recommended for varicella in the adult population
• Varicella zoster immunoglobulin (VIG)-prophylaxis for all susceptible
immunocompromised individuals
• VZV vaccine (Oka strain; Varivax®)-ages 12 months and 4-6 years
• herpes zoster-early tx within 72 hours of the onset of the first vesicle, is
optimal, but initiation of antiviral therapy after 72 hours but within 7 days
also appears to be beneficial
• Acyclovir, famciclovir and valacyclovir are all FDA-approved for the
treatment of zoster in immunocompetent individuals and result in decreased
disease duration and pain.
• Intravenous acyclovir is indicated for the treatment of zoster in
immunocompromised patients as well as those with serious complications
Viral Exanthems
• Epstein-Barr Virus (HHV-4)-causes
– Infectious mononucleosis
– Endemic Burkitt‟s lymphoma
– Oral hairy leukoplakia
– Nasopharyngeal carcinoma
– Post-transplant lymphoproliferative disorders
– Gianotti-Crosti Syndrome
Viral Exanthems
• EPSTEIN–BARR VIRUS (HHV-4)
– seropositivity approaches 60-80% in children of developing countries;
similar rates are reached during adolescence in the US
– Most children with primary EBV infection will have either no symptoms
or a mild, non-specific, febrile illness.
– adolescents and young adults, primary infection with EBV results in the
infectious mononucleosis syndrome in 50% of individuals. In the US, the
annual incidence of infectious mononucleosis is 45.2 cases per 100 000
– EBV is transmitted primarily through infectious saliva, although its
presence in genital secretions and breast milk has been reported
– Cell-mediated immunity to EBV infection is persistent and protects
against developing infectious mononucleosis syndrome with virus
superinfection later in life.
Viral Exanthems
• Infectious mononucleosis
– Fever, pharyngitis,
lymphadenopathy
– Malaise, headache, myalgias
– Hepatosplenomegaly
– Commonly morbilliform
eruption 7-10 days after
treatment with ampicillin
• Cross-reaction between
anti-EBV antibodies and
penicillin-like drug
• Desquamation 1 week
later
– Affects teens and young
adults
Viral Exanthems
• Oral Hairy Leukoplakia
– Slightly raised white plaque on lateral tongue
– Corrugated appearance
– HIV and immunocompromised
Viral Exanthems
• DDx-group A streptococcal infection, acute viral hepatitis, drug
reaction with eosinophilia and systemic symptoms (DRESS),
toxoplasmosis, lymphoma, and primary CMV, HHV-6 and HIV
• Dx-mild to moderately elevated hepatic transaminase levels, mild
thrombocytopenia and an absolute and relative lymphocytosis
• Diagnosis is usually made by a positive monospot test (a simple
slide test that detects IgM heterophile antibodies) or increased titers
of heterophile antibodies; the latter are >1:40 in approximately 90%
of young adults infected with EBV
– Post-inflammatory hyperpigmentation
Vasculitis
Vasculitis(scvv)
• Henoch-Schonlein Purpura (HSP)
– Most common in children < 10 yo,
associated with a preceding respiratory
infection
Cryoglobulinemia
Vasculitis(med)
• Polyarteritis Nodosa
– Multisystem segmental
necrotizing vasculitis affecting
medium- and small-sized
arteries
– 50% have skin findings:
livedo reticularis and punched-
out ulcers, painful
subcutaneous nodules, digital
infarcts
– p-ANCA positive
– Associated with:
• Hepatitis B
• Hepatitis C
• HIV
• Strep
• IBD
BASIC LABORATORY EVALUATION FOR PATIENTS WITH CONFIRMED CUTANEOUS VASCULITIS.
Second degree
Burns(thermal)
3rd degree
Burns(thermal)
• definitive diagnosis of wound
depth may not be possible for the
first 24 to 72 hours because of
vascular occlusive changes
• severity of burn injuries is based
upon depth and BSA involvement.
BSA is estimated in adults by the
„rule of nines‟
Burns(thermal)
• Necrosis of the epidermis occurs in about 45 minutes at 47°C
(117°F), but only 1 second at 70°C (158°F)
• Denaturation and coagulation of cellular proteins occur in thermal
injury.
• Interstitial edema develops from altered osmotic pressure and
capillary permeability
• chemical mediators with vasoactive and tissue-destructive
properties are released, including prostaglandins, bradykinin,
serotonin, histamine, lipid peroxides and oxygen radicals
• Heat-related illness accounted for more than 8000 deaths in the US
between 1979 and 1999, and is responsible for 7% of wilderness
deaths
Burns(thermal)
• DDx-Heat cramps, heat • Tx
syncope, heat edema, heat – removal from the hot
exhausation, heat stroke environment, rest, rehydration,
restoration of electrolyte
• most important diagnostic
balance, and evaluation of
issue with thermal burns is the involved systems
depth of the injury
– assessment of
• important distinction is the cardiopulmonary status as
degree of neurologic well as the extent and depth
compromise – cool compresses, cleaned
gently to remove any foreign
material, infection prevention,
– proper healing environment
Burns(thermal)
• Con‟t Tx
– Topical antimicrobial effective in burn wound care include silver
sulfadiazine, mafenide acetate and silver nitrate. Silver
sulfadiazine has gained wide acceptance for both pediatric and
adult burn tx-absorption can lead to leukopenia.
– silver sulfadiazine produces a pseudoeschar that may interfere
with burn depth assessment. Superficial wounds may require
little additional therapy
– Deeper burn wounds need more aggressive therapy, the most
popular approach being serial excision
– 3rd degree excised early
– Newer skin substitutes such as acellular dermal matrix
(AlloDerm®), bilaminar collagen-chondroitin sulfate and silicone
(Integra®) and cultured epithelial autografts are gaining
popularity
Decubitus Ulcers
• An ulcer is a wound with loss of PATHOGENESIS
epidermal and dermal layers
• INFLAMMATION • pressure
platelets, damaged parenchymal – > 32mmHg at risk
cells growth factors, cytokines – > 70mmHg rapid ulcer
activate inflammatory cells, fibroblasts formation
vasodilation, permeability, PMNs – 150mmHg lying on hospital
____________________________ mattress
PROLIFERATION
within hrs – bone : muscle interface
cells detach from BM migrate • shearing forces
MØs phagocytize, release VEGF – HOB > 30 shearing forces
granulation tissue formation in sacral/coccygeal area
____________________________ • friction
REMODELING
fibrobalsts remold collagen matirx
– dragging across bed sheets
strength, thickness – damage to stratum corneum
• moisture
Decubitus Ulcers
Decubitus Ulcers
STAGE I
• erythema
• induration
• warmth
STAGE II
• shallow ulcer
• loss of epi +/- dermis
STAGE III
• deep ulceration
• necrotic base
STAGE IV
• deep ulceration to bone
Decubitus Ulcers
• The US Department of Health and Human Services
reports that approximately 10% of all hospitalized
patients and 25% of nursing home patients have
pressure ulcers, most of which develop during the first
few weeks of hospitalization
• approximately 20%-at home
• 70% occur in patients over 70 years of age
• 95% on lower body, pelvic, legs
• Risk factors that predispose to the development of
pressure ulcers include prolonged immobility, sensory
deficit, circulatory disturbance, and poor nutrition
Decubitus Ulcers
• labs
– anemia/polycythemia, infection
• CBC
• ESR, CRP
– nutritional satus
• albumin/pre-albumin, transferrin/ferritin, vit A/C, zinc
– throbogenic state, vasculitis
• protein C/S, antithrombin III, lupus anticoagulant, anticardiolipin,
factor V Leiden
• cryoglobulins/cryofibrinogens, RF, ANA, hep B/C
• biopsy
– r/o malignancy (Marjolin ulcer), vasculitis, panniculitis
– r/o unusual ulcer causes
– tissue culture (bacterial, mycobacterial, fungal)
• patch testing
Decubitus Ulcers
• Tx-
• nutrition
– sound nutrition essential to wound healing
– carbohydrates, fats cellular energy
– protein anabolic repair
– vitamins A, C, E
– selenium, thiamine, zinc, copper, manganese, pathotenic acid
– bariatric surgery risk
• infection
– polymicrobial
– staph, anaerobes (Pseudomonas, enterobacter)
– mycobacterial, fungal lack signs of intense inflammation
Decubitus Ulcers
• rotation q 2h
• appropirate mattress, pillows, foam wedges, booties
• stage IV surgical debridement
• debridement
– enzymatic
• controversial
• collagenase (Santyl)
• papain (Panafil, Accuzyme)
– mechanical
• wet-moist saline
• surgical
• antiseptics
– chlorhexidine, acetic acid, providone-iodine cytotoxic to open wounds
• growth factors
– topical becaplermin (Regranex) 0.01% gel
• diabetic ulcers
• black box = risk of cancer mortality with 3+ tubes
Decubitus Ulcers
• Fonder M. A. , et al. Treating the chronic wound. J Am Acad Dermatol
2008;58:185-206.
• moist environment
– wounds heal best in moist environment
– dry wounds further tissue death
– occlussive dressings infection rate
– caution in wounds with heavy exudate, macerated tissue
• semi-occlusive dressings
– semipermeable to gass, moisture
– Impermeable to liquids
– hydrogels, alginates, foams, films
Decubitus Ulcers
Pressure / Decubitus
Stage I- Film ( friction), thin Hydrocolloid
Stage II, III- Hydrocolloid, Foam, Hydrogel, Debriding agent
Stage IV- Alginate, Hydrofiber, Debriding agent
DDX- Buerger‟s Disease, Cryofibrinogenemia
Leg Ulcers
• Venous Ulcer
– Prevalence increases with age, as demonstrated by one study
which found that >85% of those affected were over 64 years of
age
– Risk factors for the development of leg ulcers include obesity
and a history of significant leg injury, deep venous thrombosis
and/or phlebitisIn addition, the factor V Leiden mutation is more
prevalent in patients with venous ulcers than in the general
population
– incidence of venous ulcers is equal in men and women
– recurrence rate can be over 70%
Leg Ulcers
• ulcer subtypes • venous insufficiency risk factors
– venous – obesity
– phlebitis
– arterial – DVT, factor V Leiden
– neuropathic (diabetic) – neuromuscular dyfunction
– pressure/decubitus • pathogenesis
– vasculitic – tissue ischemia theories
• distension of capillary bed
– other: infectious, fibrinogen leakage
malignancy, PG, NLD, capillary fibrin cuffs O2
vasculitic, vaso-occlusive, depriv
panniculitis, drug induced • fibrin traps growth factors
(hydroxyurea), genetic inavailablity
(Klinfelter) • white cell trapping release
collagenase, free radicals,
TNF
– inappropriate wound healing
Leg Ulcers
Leg Ulcers
• Venous Stasis
• edema
– limb heaviness, aching
• stasis changes
– hemosiderin in macs, extravasated RBCs
• red-brown dusky disoloration
• petechiae
– stasis dermatitis = eczematous
• lipodermatosclerosis
– aka sclerosing panniculitis
membranous lipodystrophy
– woody induration
– inverted champagne bottle
– fibrosed sub q, arabesque bodies
Leg Ulcers
• DDx-cellulitis(acute, unilateral, erythema, induration, warmth, systemic sx)
• Venous Ulcer
– medial
– large
– along sup saphenous v.
– may involve entire
circumference
– irregularly shaped
– superficial
– yellow fibrinous base w.
beefy red tissue beneath
Leg Ulcers
Venus Ulcer
ATROPHIE BLANCHE
• aka livedoid vasculopathy
• smooth ivory white atrophic sclerotic plaques
• peripheral trelengectasias
• ulcerations of various sizes
Leg Ulcers
• DDx
• elephantiasis nostra
– chronic lymphedema
– hyperkeratotic, verrucous
– massive enlargement
• infestation
aka lymphatic filariasis
parasitic filarial worms
Wuchereria bancrofti
Brugia malayi
Africa
Leg Ulcers
• Venous
• labs
– anemia/polycythemia, infection
• CBC
• ESR, CRP
– nutritional satus
• albumin/pre-albumin, transferrin/ferritin, vit A/C, zinc
– throbogenic state, vasculitis
• protein C/S, antithrombin III, lupus anticoagulant, anticardiolipin,
factor V Leiden
• cryoglobulins/cryofibrinogens, RF, ANA, hep B/C
• biopsy
– r/o malignancy (Marjolin ulcer), vasculitis, panniculitis
– r/o unusual ulcer causes
– tissue culture (bacterial, mycobacterial, fungal)
• patch testing
Leg Ulcers
• venous
– compression ~40mmHg (cautionn in PAD), leg elevation
– debridement of necrotic fibrinous debris
• All other tx methods similar to that of decubitus-nutrition, infection
control, wound care and dressing
• Tx underlying cause
Leg Ulcers
• Arterial
– PAD 10% in the general population over the age of 45
years
– risk factors are age >40 years, cigarette smoking and
diabetes mellitus, hyperlipidemia, hypertension,
hyperhomocysteinemia, male gender, and sedentary
lifestyle.
– Peripheral arterial disease increases the risk of death
from cardiovascular causes even in the absence of a
history of a myocardial infarction or ischemic stroke
Leg Ulcers
• pathogenesis
– progressive luminal narrowing
• PVD
– embolic
• thromboembolic/cholesterol emboli
• infectious
– vasospastic
• Raynaud‟s
Leg Ulcers
• atherosclerosis >
cholesterol emboli, AVM
• clinical clues
– claudication
– poor pulses
– acute palor rubor
– severe pain
• ulcer
– over bony prominence
– round
– sharply demarcated borders
– little granulation tissue
– exposure of deep tendons, bone
– surrounding skin often normal, may be shiny/atrophic
Leg Ulcers
• labs
– anemia/polycythemia, infection
• CBC
• ESR, CRP
– nutritional satus
• albumin/pre-albumin, transferrin/ferritin, vit A/C, zinc
– throbogenic state, vasculitis
• protein C/S, antithrombin III, lupus anticoagulant, anticardiolipin,
factor V Leiden
• cryoglobulins/cryofibrinogens, RF, ANA, hep B/C
• biopsy
– r/o malignancy (Marjolin ulcer), vasculitis, panniculitis
– r/o unusual ulcer causes
– tissue culture (bacterial, mycobacterial, fungal)
• patch testing
Leg Ulcers
• Tx-
• arterial
– angioplasty +/- bypass
• Wound care , dressings, nutrition issues similar to prev wounds
Leg Ulcers
• Neuropathic and Diabetic Ulcers
– The most common cause of neuropathic foot ulcers in the US is
diabetes mellitus, 20% of the 16 million people in the US known
to have diabetes will develop an ulcerated foot at some time
during their lifetime
– Of these, 15-25% will require an amputation
– major cause of non-traumatic lower-extremity amputations in the
US is in fact non-healing diabetic foot ulcers, which are
responsible for 85% of all amputations
– Risk factors include male gender, diabetes for >10 years, poor
glucose control, and associated cardiovascular, retinal or renal
complications.
– Other causes of peripheral neuropathy that are associated with
neuropathic ulcers include spinal cord lesions, spina bifida,
alcohol abuse, medications and leprosy.
Leg Ulcers
Leg Ulcers
• combination
– peripheral neuropathy
• sensation loss trauma
• motor dysfxn foot deformities
• autonomic dysfxn dry, brittle skin
– macrovascular dz
• calcification of arteries pulse exam less reliable
• pallor on limb elevation, rubor with dependency
• shiny, atrophic skin, hair loss, onychodystrophy
– impaired wound healing
• HbA1C
– > 9% risk
– > 12% WBC fxn altered
• chemotaxis, adherence
• phagocytosis, intracellular bacterocidal activity
Leg Ulcers
Leg Ulcers
• labs
– anemia/polycythemia, infection
• CBC
• ESR, CRP
– nutritional satus
• albumin/pre-albumin, transferrin/ferritin, vit A/C, zinc
– throbogenic state, vasculitis
• protein C/S, antithrombin III, lupus anticoagulant,
anticardiolipin, factor V Leiden
• cryoglobulins/cryofibrinogens, RF, ANA, hep B/C
• biopsy
– r/o malignancy (Marjolin ulcer), vasculitis, panniculitis
– r/o unusual ulcer causes
– tissue culture (bacterial, mycobacterial, fungal)
• patch testing
Leg Ulcers
• DDx-arterial, venous, other causes of peripheral neuropathy, ACD
• Tx-nutirtion, infection control
– aggressive debridement (surgical, enzymatc)
– pressure off loading
– address vascular dz
– Wound care , dressings similar to prev
EIC
• present to clinicians because of medical or cosmetic concerns, or
due to discomfort from mechanical irritation or inflammation of the
cyst
• histologic features determine the definitive diagnosis
• Can occur any where on body
• most common cutaneous cysts
• most common on the face and upper trunk
• range from a few millimeters to several centimeters in diameter
• derive from the follicular infundibulum
• multiple epidermoid cysts may occur in individuals with a history of
significant acne vulgaris
EIC
• Multiple cysts may also occur in
the setting of Gardner syndrome
(familial adenomatous polyposis)
and in nevoid basal cell carcinoma
syndrome
• Non-inflamed epidermoid cysts
are usually asymptomatic, but,
with pressure, cysts contents may
be expressed that may have an
objectionable odor
• Rupture of the cyst wall can result
in an intensely painful
inflammatory reaction, and this is
a common reason for presentation
to a physician's office
EIC
• Tx-excision is curative
• incision and expression of the cyst contents and wall
through the surgical defect
• If the entire cyst wall is not removed, the cyst may recur.
• Inflamed epidermoid cysts may require incision and
drainage,occasionally, antibiotic therapy
• Intralesional triamcinolone may be helpful in speeding
the resolution of the inflammation.
Hidradenitis Suppurativa
• targets apocrine gland-bearing skin sites
• axillae and anogenital region
• starts at or soon after puberty
• women are affected three times as often as men
• thought to represent an inflammatory disorder originating from the
hair follicle
• Rupture of the follicle allows introduction of its contents, including
keratin and bacteria, into the surrounding dermis This excites a
vigorous chemotactic response and abscess formation. Epithelial
strands are generated, possibly from ruptured follicular epithelia,
and form sinus tracts
Hidradenitis Suppurativa
• inflammatory nodules and sterile abscesses develop in the axillae,
groin, perianal and/or inframammary areas
• tender and extremely painful
• sinus tracts and hypertrophic scars form
• chronic drainage, leading to a marked degree of frustration,
embarrassment, self-consciousness and depression, especially
when the discharge is malodorous
• discharged fluid is often a mixture of serous exudate, blood and pus,
in varying proportions
• Complications include- anemia, secondary amyloidosis,
lymphedema, and fistulae to the urethra, bladder, peritoneum and
rectum
• Other complications include hypoproteinemia, nephrotic syndrome
and arthropathy.
• Squamous cell carcinoma, sometimes with metastasis, may be an
occasional complication of chronic scarring disease.
Hidradenitis Suppurativa
Hidradenitis Suppurativa
• DDx-staphylococcal furunculosis, Crohn's disease, granuloma
inguinale, mycetoma and tuberculosis
• Dx- clinical, histo, infection control
• Tx-Many are successful some of the time, but none are successful
all of the time
– weight reduction
– measures to reduce friction and moisture
– ILK 5mg
– topical clindamycin-Staphylococcus aureus
– 5-day courses of intranasal mupirocin are used in nasal carriers
of S. aureus.
– Incision and drainage should be minimized because it may result
in scarring and chronic sinus tract formation.
Hidradenitis Suppurativa
• Systemic corticosteroids (prednisone 60-80 mg/day)-improves
initially then flare once d/c‟d
• Isotretinoin has not been particularly effective
• Specific systemic antibiotics are chosen on the basis of the results
of bacterial cultures
• cyclosporine and TNF-α inhibitors
• Surg/exc-often not helpful
Lipomas
• benign tumors composed of mature lipocytes
• among the most common neoplasms in humans
• often solitary
• most commonly-beyond the fourth decade of life
• incidence in men to be higher than in women
• incidence of lipomas is increased in overweight individuals,
diabetics, and patients with elevated serum cholesterol
• predilection are the neck, trunk, arms, proximal lower extremities,
and buttocks
• round to oval, soft, mobile subcutaneous nodules with a normal
overlying epidermis
• asymptomatic, unless they encroach upon and compress nerves, in
which case they may be painful
Lipomas
• DDx-epidermoid cysts
• Dx-clinial and histo
• Tx-easily excised
Melasma
• common, acquired disorder, characterized by symmetric,
hyperpigmented patches with an irregular outline that occur most
commonly on the face. It is most prevalent among young to middle-
aged women who are Hispanic, Asian or of African or Middle
Eastern descent
• Exacerbating factors include pregnancy, oral contraceptives and, of
course, sun exposure
• following exposure to UV irradiation (or another inducer),
hyperfunctional melanocytes within involved skin produce increased
amounts of melanin as compared to uninvolved skin
• Potential aggravating factors include other medications (e.g.
phenytoin-related anticonvulsants, phototoxic drugs) and
autoimmune thyroid disease
Melasma
• Light to dark brown or brown–gray patches with irregular
borders appear primarily on the face
• three classic patterns–centrofacial, malar and
mandibular
• Additional sites of involvement include the extensor
forearms and the mid upper chest
• fade during the winter months and they frequently either
first appear or are accentuated following exposure to UV
irradiation or during pregnancy
Melasma
Melasma
• DDx-Drug-induced • Tx-sun protection, broad-spectrum
hyperpigmentation or sunscreens w/o all tx will fail
discoloration, Postinflammatory • While epidermal pigmentation is
hyperpigmentation, Actinic lichen somewhat amenable to topical
planus, Lichen planus therapies and chemical peels, dermal
pigmentosus, Lichen planus pigmentation is notoriously difficult to
treat.
pigmentosus, Pigmented contact
dermatitis, Exogenous ochronosis, • hydroquinone (2-4%), tretinoin (0.05-
0.1%) and a corticosteroid (class V–
Acquired bilateral nevus of Ota- VII)
like macules (Hori's nevus), • topical lightening include glycolic acid,
Erythema dyschromicum perstans kojic acid (a tyrosinase inhibitor), and
• Dx-hx, clinical, possible bx azelaic acid (15-20%; also an inhibitor
of tyrosinase)
• Salicylic acid and glycolic acid peels
can be used as adjunctive therapy
• Deeper chemical peels, laser therapy
(e.g. Q-switched ruby)
Vitiligo
• acquired, idiopathic disorder characterized by circumscribed
depigmented macules and patches
• 0.5-2% of the general population worldwide
• age of onset is approximately 20 years
• absence of functional melanocytes
• autoimmune theory proposes that alterations in humoral or cellular
immunity result in the destruction of melanocytes
• most common form of vitiligo is a totally amelanotic macule (or
patch) surrounded by normal skin
• fairly discrete margins, and they are round, oval or linear in shape
• Lesions enlarge centrifugally over time, but the rate may be slow or
rapid
Vitiligo
• face, dorsal aspect of the hands,
nipples, axillae, umbilicus,
sacrum, and inguinal and
anogenital regions.
• Typically, facial vitiligo occurs
around the eyes and mouth (i.e.
periorificial), and on the
extremities it favors the elbows,
knees, digits, flexor wrists, dorsal
ankles and shins
Vitiligo
• Localized
– Focal: one or more macules in one area, but not clearly in a
segmental distribution
– Unilateral (segmental): one or more macules involving a
unilateral segment of the body lesions stop abruptly at the
midline
– Mucosal: mucous membranes alone
• Generalized
– Vulgaris: scattered patches that are widely distributed
– Acrofacial: distal extremities and faceMixed: various
combinations of segmental, acrofacial and/or vulgaris
• Universal
– Complete or nearly complete depigmentation
Vitiligo
Vitiligo
• case-by-case basis is unpredictable
• Associations:
– IDDM
– Pernicious Anemia
– Grave‟s Disease
– Hashimoto‟s Thyroiditis
– Addison‟s Disease
– Alopecia areata
• DDx-chemical leukoderma, the leukodermas associated with
melanoma or scleroderma, postinflammatory depigmentation, and
the late stages of treponematosis or onchocerciasis,
postinflammatory hypopigmentation, pityriasis (tinea) versicolor, or
other cutaneous infections (e.g. leprosy). Prior treatment with potent
topical corticosteroids can also lead to hypomelanosis.
Vitiligo
• Tx
– NB-UVB, PUVA, TCS-for small localized, 0.1% tacrolimus ointment,
Minigrafting is the simplest method, 20% monobenzyl ether of
hydroquinone (MBEH), applied once to twice daily to the affected areas
for 9-12 months or longer
– MBEH is a potent irritant and/or allergen, and an open use test should
be performed before more widespread application(only for small area of
normal pigment)
Urticaria
• recurrent whealing of the skin
• pruritic, pink or pale swellings of the superficial dermis that may
have an initial flare around them
• Lesions may be a few millimeters in diameter or as large as a hand,
and numerous or single.
• Hallmark-individual lesions come and go w/in 24 hours
• as high as 30% in the general population
• Urticaria is a worldwide disease and may present at any age.
• The peak incidence depends on etiology
• female:male ratio of approximately 2:1 for chronic urticaria
• mast cell is the primary effector cell of urticaria
• Mast cell granules contain preformed mediators of inflammation, the
most important of which is histamine
Urticaria
• Immunologic
– Autoimmune (autoantibodies against FceRI or IgE)
– IgE-dependent (allergic)
– Immune complex (vasculitic)
– Complement- and kinin-dependent (C1 esterase inhibitor def)
• Non-immunologic
– Direct mast cell-releasing agents (e.g. opiates)
– Vasoactive stimuli (e.g. nettle stings)
– Aspirin, other non-steroidal anti-inflammatory drugs, dietary
pseudoallergens
– Angiotensin-converting enzyme inhibitors
Urticaria
• important to distinguish urticaria from urticarial dermatoses, such as
urticarial drug eruptions, eosinophilic cellulitis and bullous
pemphigoid
• „here today and gone tomorrow‟ (i.e. they last less than 24 hours)
• Wheals may be small or large, single or multiple
• Classification
– Ordinary urticaria (all urticaria not classified below)
– Physical urticarias
– Urticarial vasculitis (defined by vasculitis on skin biopsy)
– Contact urticaria (induced by percutaneous or mucosal
penetration)
– Angioedema without wheals
– Distinctive urticarial syndromes
Urticaria
Urticaria
Urticaria
• Acute urticaria is common in
young children with atopic
dermatitis, but chronic urticaria
peaks in the fourth decade
Urticaria
• Chronic
– Autoimmune
• Thyroid ds
• Vitiligo
• Insulin-dependent diabetes
• RA
• Pernicious anemia
– Infectious
• H. Pylori
• Parasitic infection
• Gastric anisakiasis simplex
• Dental infection
• G.I. Candidasis
Urticaria
Cold urticaira
Urticaria
dermatographism
Urticaria
Pressure urticaria
Urticaria
• Urticarial vasculitis
– >24 hours
– Histo will show LCV
– Choose newest lesion when performing bx
– Causes-hep b,c, SLE, sjorgrens, lyme ds, infectious
mononucleosis, Drugs(cimetidine, diltiazem)
Urticaria
• DDx
– insect bite reactions (papular urticaria), acute febrile neutrophilic
dermatosis (Sweet's syndrome), pre-bullous pemphigoid (i.e.
urticarial bullous pemphigoid), acute facial contact dermatitis,
urticarial drug reactions (e.g. antibiotics)
• Dx
– comprehensive history and phys exam is essential
– CBC, ESR, ANA, bx,
Urticaria
• IgE-mediated reactions to
environmental allergens as a
cause of acute urticaria and
contact urticaria can be confirmed
by skin prick testing and
radioallergosorbent tests (RAST)
of blood. Results of both have to
be interpreted in the clinical
context.
Urticaria
• Tx-1st line antihistamine
• Classic (sedating)
– Chlorpheniramine -4 mg tid (up to 12 mg at night)
– Hydroxyzine-10–25 mg tid (up to 75 mg at night)
– Diphenhydramine-10-25 mg at night)
– Doxepin-10-mg at night
• 2nd gen
– Acrivastine-8 mg tid
– Cetirizine-10 mg once daily
– Loratadine-10 mg once daily
– Mizolastine-10 mg once daily
Urticaria
• Newer 2nd gen
– Desloratadine-5 mg once daily
– Fexofenadine-180 mg once daily
– Levocetirizine- 5 mg once daily
• H2 antagonist
– Cimetidine-400 mg bid
– Ranitidine-150 mg bid
Topical Corticosteroids
• Superpotent(1)
– dermatoses resistent to intermediate or high potency TCS,
– avoid extensive app(>50g weekly),
– for short term use only(2-3 weeks at a time),
– Do not use on the face, axillae, submammary area or groin,
– avoid use in infants and children under 12,
– best for thick lichenified or hypertrophic skin
• High(2&3)
– Severe
– Avoid ext use(>50g weekly)
– Short term use(2-3 weeks at a time)
– Do not use on the face axillae, submammary are or groin
– Avoid use in infants and children under 12
– Best for thick, lichenified or hypertrophic skin
Topical Corticosteroids
• Intermediate(4&5)
– Moderate
– Best for short term tx of extensive dermatoses
– Avoid extended use(>1-2 weeks in infants and children
– Best on trunk and ext
– Safer for short term use on thin skin
• Low(6&7)
– Steroid sensitive
– Preferred for large areas
– Best if long term tx required
– Best choic for face, axilla, groin, and other occluded
– Infants and children
– Best for thin skin
Topical Corticosteroids