Transcript SKIN DISORDERS

SKIN DISORDERS
Part 2
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Contact dermatitis
 The most
important
irritants are:
1. water and
other fluids
2. abrasives
i.e. frictional
irritancy
3. chemicals,
e.g. acids
and alkalis
4. solvents
 The sources of common allergens:
1. Chromate:
Cement,
tanned
leather,
primer
paint,
anticorrosives
2. Cobalt:
Pigment, paint, ink, metal
alloys
3.
Colophony: Glue, plasticizer,
adhesive tape, varnish, (Rosin)
polish
4. Epoxy resins:
Adhesive, plastics,
mouldings
5. Fragrance: Cosmetics, creams,
soaps, detergents
6. Nickel:
Jewellery, zips, fasteners,
scissors,
instruments2
7. Paraphenylenediamine: Dye
Seborrhoeic dermatitis
Chronic, scaly inflammatory
eruption
usually affecting the scalp and
face.
Occurs in the sebaceous gland
areas
of the scalp, face and chest.
Genetics and overgrowth of the
commensal yeast Pityrosporum
ovale
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Lichen Planus (LP)
 Acute or chronic inflammatory disorder affecting the
skin,
mucous membranes, and nails (5%—10%).
 Etiology: Likely an immunologically mediated
reaction;
oral erosive lichen planus associated with
hepatitis C.
 History: Pruritus common; oral lesions may or may
not be symptomatic.
Ask about Hep C risk factors (e.g., transfusions, IV
drug use) for
oral-erosive LP.
 Course: May resolve spontaneously or have chronic
course (esp. oral LP);
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increased risk of oral SCC in oral LP.
 DDx: Drug reaction, pityriasis rosea, psoriasis
Lupus Erythematosus
 Etiology:

Heterogeneous 1.
autoimmune
2.
disease resulting 3.
4.
from the interplay 5.
of genetic,
6.
environmental,
7.
and hormonal
8.
factors.
9.
 F> M.
 History & Physical:
Spectrum of
Need four or more over any span of time
for diagnosis:
Malar rash
Discoid rash
Photosensitivity
Oral ulcers (oral or nasopharyngeal)
Arthritis (nonerosive, involving 2 or more
joints)
Serositis (pleuritis: + pleuritic pain or rub,
OR pleural effusion, OR pericarditis, OR
pericardial effusion)
Renal disorder (persistent proteinuria > 0.5
grams per day OR cellular CASTS)
Neurologic disorder (seizures OR
psychosis)
Hematologic disorder (hemolytic anemia
w/ reticulocytosis OR Leukopenia < 4,000
on two or more checks OR Lymphopenia <
1,500 on two or more checks OR
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thrombocytopenia <100,000)
10. Positive anti-nuclear antibody (in absence
SLE Management
Clinical
Comment
Acute
cutaneous
Classic “butterfly”
malar rash.
Often association with
anti-dsDNA Ab and
lupus nephritis.
Evaluate for evidence of
systemic disease.
Hydroxychloroquine.
steroid-sparing agents
(azathioprine, methotrexate,
mycophenolate mophetil).
LE
Two subtypes:
Annular or
papulosquamous
presentation. Often
associated with anti-Ro
Ab.
Sun protection.
Corticosteroids (topical,
intralesional) and
hydroxychloroquine.
Most often in
5%–10% will get systemic
Subacute
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BURNS: cause between 3000 and 4000
deaths/yr in the US and about 2 million
physician visits.
Burns: thermal, radiation, chemical, or electrical
contact.
Classified by depth1st -degree- affect only the epidermis,
causing reddening of the
skin, pain,
and edema.
2nd -degree- affect not only the epidermis but also
some of the dermis, causing reddening of the
skin, acute pain, and the formation of blisters
and edema. Heals by scarring
3rd -degree- destroy the full thickness of the skin
(epidermis, dermis, subcutaneous fat, muscle,
and bones. Requires skin grafting
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Rule of nines for BSA
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Partial-thickness (2nd-degree) burn
Most of the third finger has a
full-thickness burn, where the
skin is dark and leathery. The
base of the finger has blisters
and redness, indicating that this
part of the finger has a partialthickness burn.
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BURN Categories:
Thermal burns –Any external heat
source (flame, hot liquids, hot solid
objects, or, occasionally, steam
Radiation burns –Prolonged exposure
to solar ultraviolet radiation (sunburn)/
other sources of ultraviolet radiation (eg,
tanning beds) or from exposure to
sources of x-ray or other non solar
radiation.
Chemical burns - From strong acids,
strong alkalis (eg, lye, cement), phenols,
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BURN Categories:
 Electrical Injuries
 Skin burns, damage to internal
organs and other soft tissues,
cardiac arrhythmias, and
respiratory arrest. Higher the
voltage (V) and amperage, the
greater the ensuing electrical
injury
 Treatment
Shut off current
Resuscitation
Analgesia
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Moxa and Cancer
http://www.cancer.org/Treatment/TreatmentsandSideEffects/Compleme
ntaryandAlternativeMedicine/HerbsVitaminsandMinerals/moxibustion
 Direct moxibustion can burn the skin.
 Oils from mugwort and wormwood can cause
toxic reactions if taken internally, although
their toxicity is much lower when applied
externally.
 Mugwort is on the Commission E (Germany’s
regulatory agency for herbs) list of
unapproved herbs. This means that it is not
recommended for internal use because it has
not been proven to be safe or effective, due to
the possibility that it may cause miscarriage in
pregnant women.
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Acanthosis Nigricans (AN)
Heredity/ Endocrine disorder—most commonly
associated with- insulin resistance/
hyperandrogenic state/ hypothyroidism/
obesity
Drugs—e.g., nicotinic acid, niacinamide, oral
contraceptives, steroids
Malignancy: usually adenocarcinoma—e.g.,
gastrointestinal (60% stomach), lung, breast
Physical: Hyperpigmented velvety, typically
symmetrical plaques
predominantly
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Acne Vulgaris:
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Acne Vulgaris:
Acne Vulgaris:
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Hyperhidrosis
Etiology: generalized or
focal- palmar,
palmoplantar, axillae and
affecting 2%—3% of
population;
most common in
adolescence and young
adults.
Generalized - infectious (e.g.,
TB), endocrine, or
neurologic;
Focal hyperhidrosis- cause
unknown.
Diagnostic criteria for primary
focal idiopathic
hyperhidrosis:
■ Focal, visible, excessive
sweating of at least 6 mo
Investigations: Starch iodine
test can be used to
outline the area of
excessive sweating.
DDx:Thyrotoxicosis,
medication-induced
hyperhydrosis,
pheochromocytoma.
Management:
rule out— infections,
malignancy (ask about
night sweats).
Topical: Aluminum chloride
hexahydrate solution in
ethanol (e.g., Drysol®),
glycopyrrolate
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iontophoresis.
Molluscum
Contagiosum
Etiology: Self-limited
viral infection of
skin caused by
poxvirus affecting
mainly children.
History:
Asymptomatic;
occasional
perilesional
pruritus.
Physical: 2- to 6-mm
flesh colored, domeshaped, umbilicated
pearly papules;
most common
Management
■ Observation.
■ Liquid nitrogen
cryotherapy.
■ Curettage; may be
uncomfortable.
■ Papule incision with a
scalpel blade or at home
sharp fingernail and
expression of contents.
■ Topical cantharidin:
Blistering (intentional)
will occur; apply with
wooden end of cotton
swab and cover with
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tape for 30 min, then
wash off with soap and
Pediculosis (Lice)
Etiology: Infestation by
wingless, 6-legged insects
 Management
Spread by direct contact or
through fomites (e.g., clothing, ■ Head lice: Wash hair, rinse, and
towel dry; then apply
bedding).
permethrin cream (Nix®,
History: Symptoms none to
Elimite®) rinse for 10 min and
extreme pruritus.
rinse out; repeat in 7 d.
Pediculosis capitis (head
■ Pyrethrin, malathion,
louse)
crotamiton, petrolatum.
■ For pediculosis pubis—affecting
Gray-white nits/eggs or lice
eyelashes, apply petrolatum to
firmly adhere to hair shaft;
eyelashes bid—tid x 10 d.
postauricular and occipital
■ Nits may be removed with
regions commonly affected;
vinegar soaks (vinegar:water
children adults.
1:1) and a fine-toothed comb.
Pediculosis pubis (crab louse)
■ Soak combs and brushes in
Eyelashes and pubic hair
permethrin shampoo for 10 min
may be affected; usually
or boil.
transmitted by sexual
■ Bedding, clothing, and head 18
contact; nits seen on
gear should be washed and
hair, red excoriated skin.
heatdried; environment should
Rosacea
Common chronic inflammatory
Management
disorder of the face.
■ Based on severity and
Role of Demodex mite controversial.
subtype.
Easy and recurrent flushing,
■ Lifestyle modification: Avoid
exacerbated by heat \
triggers; sun protection &
avoidance; facial massage for
(shower, hot drinks), spicy foods,
lymphedema.
sunlight, cold, alcohol, stress.
Sensitive skin. May complain of dry ■ Topical antibiotics
and gritty eyes.
■ Metronidazole 0.75% gel or 1%
Peak incidence 30—50 yr;
cream bid.
Physical:
■ Sodium sulfacetamide lotion
Erythema, telangiectases, papules, and 10% bid.
pustules of central face; no
■ Oral antibiotics (moderate to
comedones in contrast to acne.
severe cases with inflammatory
papulopustular component):
Sebaceous hyperplasia, seborrheic
dermatitis & facial lymphedema
■ Tetracycline 500 mg po bid
more common.
■ Minocycline 100 mg po od—
4 Major Subtypes
bid.
Erythematotelangiectatic,
■ Doxycycline 20 mg po bid
papulopustular, ocular, phymatous. (subantimicrobial dose therapy)19
or 100 mg po qd–bid.
Chronic inflammation may progress to
rhinophyma (enlarged nose; in
■ Isotretinoin (low dose); less
Leg Ulcers
 Etiology: Most common lower extremity ulcers
are: venous,
arterial or neuropathic; can be mixed.
Other causes: Trauma, vasculitis, pyoderma
gangrenosum, bacterial infections,
malignancy, sickle cell anemia).
 History: Ask about—onset & course,
symptoms, PMHx, social history, & meds.
 Physical: Inspect & document—location, size,
shape, odor, ulcer edge & base features,
surrounding skin (cellulitis, dermatitis),
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Ulcers, Leg
Ulcer Type Clinical
Management
Venous
(most
common;
70%)
Compression
wraps and, once
healed, support
stockings for life.
Arterial
Occur in malleolar region;
irregular borders; stasis
changes, edema,
varicose veins,
hemosiderosis, painful.
Occur in pressure sites &
toes; necrotic base,
punched out with shiny
atrophic surrounding skin;
history of claudication,
decreased/ absent pulses
& prolonged capillary
refill.
If possible,
surgery to
restore arterial
blood flow.
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Ulcers, Leg- Management
Principles of Wound Care
Treat any underlying cause:
■ Venous insufficiency—
compression.
■ Arterial insufficiency—
surgery.
■ Neuropathic or decubitus
ulcer—pressure relief.
■ Infection—antibiotics.
■ Neoplasm—surgery,
radiation.
■ Promote wound healing.
■ Débride: Enzymes,surgery/
Allergic contact
dermatitis common
with long-term topical
antibiotic use (esp.
bacitracin, neomycin);
use petroleum jelly—
low allergenicity, safe,
& cheap.
Compression stockings
required if evidence of
pitting/stasis
dermatitis; obtain
ankle-brachial index
prior to
initiatingtreatment;
medical grade better
curette.Dressings:
than over-the-counter.
Promote moisture, but not
Topical metronidazole 22
oozing/ weeping; know your
eliminates odor. Short-
Vitiligo
Acquired skin disorder characterized by
well defined areas of complete
epidermal depigmentation; various
pathogenesis theories; likely a large
autoimmune component.
History:
Asymptomatic; 50% present before age
20;
1%—2% affected; rare in infancy & old
age.
Associated with immune disorders;
therefore work-up for thyroid disease
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Management of Vittiligo
Note that facial and
DDx: Leprosy, pityriasis
alba, tinea versicolor,
more proximal
tuberous sclerosis,
lesions respond
Management
better than acral
Mainly for
lesions.
cosmetic/psychological
■ Surgical
burden; consider
transplants can be
assessment for
considered in stable
Diabetes, Thyroid &
Addison disease.
vittiligo—
uncommon
Topical steroids and new
topical immuno
■ If extensive, rarely
modulator (tacrolimus
can consider
& pimecrolimus), PUVA,
bleaching of non
NB-UVB phototherapy,
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NAIL images
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Beau’s Lines
Deep grooved
lines that run from
side to side
Look like
indentations
Temporary
cessation of cell
division in the nail
matrix
Infections,
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Muehrcke lines
 Paired, white, transverse lines that signify an
abnormality in the vascular bed of the nail seen
in
√chronic hypoalbuminemia
√ chemotherapy-induced nail changes
√ pellagra
√ Hodgkin disease
√ renal failure
√ sickle cell anemia
√ nail damage from paraquat
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Mee’s Lines
Poisoning
with arsenic,
thallium or
other heavy
metals, and
can also
appear if the
subject is
suffering from
renal failure
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Clubbing
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‘Half and Half’ nails
Typical in chronic renal failur
and uremia
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Leukonychia (White nails)
√ hypoalbuminaemia
√ nephrotic syndrome
√ liver failure,
√ protein malabsorption
ad
√ protein-losing
enteropathies
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Nail beds in SLE/ Dermatomyositis
√ Nail bed vasculitis
√ Copper colored
rash
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Onycholysisspontaneous separation of the nail
√ seen in women
with long
fingernails
√ common cause:
trauma
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Splinter hemorrhages
√ Trauma to the nail
√ Subacute or acute
bacterial
endocarditis
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