Derm Board Review - The University of Chicago Department of ...
Derm Board Review - The University of Chicago Department of ...
Derm Board Review - The University of Chicago Department of ...
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April 2011<br />
<strong>The</strong> Chiefs
A 39-year-old y man is evaluated for a 3-day y history y <strong>of</strong> stinging g g<br />
lesions on his shins. He also notes joint pain and some numbness<br />
and tingling in his feet. He has a history <strong>of</strong> hepatitis C infection<br />
that has not required antiviral treatment.<br />
On physical examination, vital signs are normal. Skin examination<br />
discloses 2- to 3-mm, purple, palpable, nonblanching papules on<br />
the dorsal feet, shins, and buttocks. <strong>The</strong>re is no evidence <strong>of</strong><br />
synovitis. iti Laboratory L b t studies t di reveal l a normal l serum creatinine ti i<br />
level, modestly elevated levels <strong>of</strong> serum alanine and aspartate<br />
aminotransferases, low complement levels, and circulating<br />
cryoglobulins cryoglobulins. Skin biopsy shows leukocytoclastic vasculitis vasculitis.
Which Which <strong>of</strong> the following is the most<br />
appropriate treatment?<br />
A A. Pegylated interferon alfa and ribavirin<br />
B. Plasma exchange<br />
C C. Systemic corticosteroids<br />
D. Topical corticosteroids
Which Which <strong>of</strong> the following is the most<br />
appropriate treatment?<br />
A A. Pegylated interferon alfa and ribavirin<br />
B. Plasma exchange<br />
C C. Systemic corticosteroids<br />
D. Topical corticosteroids
Most Most consistent with mixed<br />
cryoglobulinemia associated with<br />
hepatitis C
Biopsy: leukocytoclastic vasculitis
Mixed Cryoglobulinemia<br />
Present in up to 50% <strong>of</strong> patients infected<br />
with hepatitis p C<br />
Symptomatic in less than 15% <strong>of</strong> infected<br />
patients<br />
All patients with Cryoglobulins should be<br />
checked for hepatitis C<br />
Associated A i t d signs/symptoms: i / t weakness, k<br />
arthralgia, peripheral neuropathy, and<br />
glomerulonephritis
Indications include: progressive systemic<br />
disease affecting small blood vessels<br />
• Organ dysfunction or cutaneous vasculitis<br />
First line therapy is treatment <strong>of</strong> the underlying<br />
Hepatitis C infection with pegylated interferon<br />
and ribavarin<br />
<strong>The</strong>oretical concern that steroids will lead to<br />
iincreased d viral i l replication li ti<br />
Plasma exchange only for very advanced<br />
disease-such disease such as limb threatening or advanced<br />
renal failure
More easily palpated then visualized
Half Half are idiopathic<br />
Associated with<br />
• Infections<br />
• Drugs<br />
• Inflammatory systemic disease
http://www.flickr.com/photos/35230739@N05/3315480015,<br />
http://www.afv.org.hk/uveitis_e.htm
Erythema Erythema nodosum<br />
Hilar lymphadenopathy<br />
Lower Lower extremity arthritis<br />
Anterior uveitis<br />
Acute self resolving subset <strong>of</strong><br />
sarcoidosis
E Nodosum parallels activity <strong>of</strong> GI<br />
E. Nodosum parallels activity <strong>of</strong> GI<br />
disease
A A 62-year-old 62 year old man is evaluated for an<br />
asymptomatic nodule on his shoulder<br />
that has been present for more than 1<br />
year.
Which Which <strong>of</strong> the following is the most likely<br />
diagnosis?<br />
A A. Basal cell carcinoma<br />
B. Pyogenic granuloma<br />
C C. Seborrheic keratosis<br />
D. Squamous cell carcinoma
Which Which <strong>of</strong> the following is the most likely<br />
diagnosis?<br />
A A. Basal cell carcinoma<br />
B. Pyogenic granuloma<br />
C C. Seborrheic keratosis<br />
D. Squamous cell carcinoma
Basal Basal cell carcinoma (BCC) typically<br />
presents as a pearly, pink papule or<br />
nodule with telangiectatic vessels<br />
As BCC grow, central area <strong>of</strong>ten ulcerates<br />
giving a rolled edge appearance<br />
Pyogenic granuloma: bright red, friable.<br />
Crusted develop over days to weeks
http://courses.washington.edu/hubio567/melanoma/dx1.htm
Most commonly: Scalp, neck, pinna, or lip
Sudden appearance<br />
or inflammation <strong>of</strong><br />
multiple p seborrheic<br />
keratoses<br />
Associated with<br />
acanthosis nigricans<br />
What cancer<br />
associations?<br />
GI or GU. Most<br />
common: stomach
Velvety or verrucous<br />
hyperpigmentation <strong>of</strong><br />
intertiginous areas<br />
g<br />
Endocrinopathy<br />
Also GI/GU<br />
malignancy,<br />
especially stomach
AKA acrokeratosis<br />
neoplastica<br />
Disease associations?<br />
Squamous cell<br />
carcinoma <strong>of</strong> the<br />
upper respiratory<br />
tract or upper GI tract<br />
Goes away when you<br />
treat the malignancy
A 64-year-old y man is evaluated in the emergency g y department p for<br />
a rash that first developed 3 days ago and has rapidly spread to<br />
cover most <strong>of</strong> his body. His skin is painful and does not itch. He<br />
feels feverish and ill. He has a history <strong>of</strong> mild psoriasis,<br />
hypertension, asthma, and prostate cancer. His psoriasis has been<br />
well controlled with topical corticosteroids as needed. His prostate<br />
cancer was treated with radiation therapy 6 years ago and is in<br />
remission. i i His Hi medications di ti include i l d lisinopril li i il (started ( t t d 3 weeks k<br />
ago), an inhaled corticosteroid and salmeterol daily, and inhaled<br />
albuterol as needed. One week ago, he completed a 10-day<br />
tapering dose <strong>of</strong> oral corticosteroids for an acute exacerbation <strong>of</strong><br />
asthma. He reports no known medication allergies.
On pphysical y examination, , he appears pp ill. Temperature p is 38.9 °C<br />
(102.0 °F), blood pressure is 118/78 mm Hg, and pulse rate is<br />
112/min. Greater than 90% <strong>of</strong> his body surface area is<br />
erythematous. <strong>The</strong>re are widespread coalescing erythematous<br />
patches and plaques, many with pinpoint pustules coalescing into<br />
lakes <strong>of</strong> pus and many with fine desquamation. Erythematous<br />
plaques with overlying silvery scale are present on his occipital<br />
scalp. l His Hi conjunctival, j ti l oral, l and d urethral th l mucous membranes b are<br />
normal. <strong>The</strong>re is no palpable lymphadenopathy. A complete blood<br />
count reveals leukocytosis with a predominance <strong>of</strong><br />
polymorphonuclear cells cells. A complete metabolic pr<strong>of</strong>ile and<br />
serum aminotransferase levels are normal.
Which Which <strong>of</strong> the following is the most likely<br />
diagnosis?<br />
A A. Drug hypersensitivity syndrome<br />
B. Paraneoplastic erythroderma<br />
C C. Pustular psoriasis<br />
D. Sézary syndrome (cutaneous T-cell<br />
lymphoma)<br />
E. Staphylococcal scalded skin syndrome
Which Which <strong>of</strong> the following is the most likely<br />
diagnosis?<br />
A A. Drug hypersensitivity syndrome<br />
B. Paraneoplastic erythroderma<br />
C C. Pustular psoriasis<br />
D. Sézary syndrome (cutaneous T-cell<br />
lymphoma)<br />
E. Staphylococcal scalded skin syndrome
An erythematous eruption that involves greater<br />
than 90% <strong>of</strong> the body surface area is indicative<br />
<strong>of</strong> erythroderma.<br />
y<br />
Causes <strong>of</strong> erythroderma are drug eruptions,<br />
psoriasis, atopic dermatitis, and cutaneous Tcell<br />
lymphoma<br />
Patients with history <strong>of</strong> psoriasis treated with<br />
systemic corticosteroids corticosteroids, are particularly prone<br />
to developing an acute pustular erythrodermic<br />
flare days to weeks after discontinuation <strong>of</strong> the<br />
corticosteroids.
http://www.meddean.luc.edu/lumen/MedEd/medicine/dermatology/melton/erthderm1.htm
Treatment<br />
• Treat underlying<br />
disease<br />
• Treat complications<br />
such as temperature<br />
dysregulation dysregulation, fluid<br />
and electrolyte<br />
abnormalities, and<br />
superinfection<br />
i f ti
A 45 45-year-old year old man with poorly controlled type 2<br />
diabetes mellitus is evaluated for the sudden onset 2<br />
weeks ago <strong>of</strong> bumps on the elbows and knees. His<br />
medications edicatio iinclude cl de pioglitazone, io lita o e glipizide, li i ide aand d<br />
metformin.<br />
On physical examination, vital signs are normal; BMI is<br />
32. Skin examination discloses more than 100<br />
monomorphic, yellow-orange, 2- to 4-mm papules on<br />
the buttocks, elbows, and knees. Skin biopsy<br />
demonstrates collections <strong>of</strong> lipid-laden macrophages<br />
with extracellular lipid.
Which Which <strong>of</strong> the following is the most likely<br />
diagnosis?<br />
A A. Eruptive xanthomas<br />
B. Plane xanthomas<br />
C C. Tendon xanthomas<br />
D. Xanthelasmas
Which Which <strong>of</strong> the following is the most likely<br />
diagnosis?<br />
A A. Eruptive xanthomas<br />
B. Plane xanthomas<br />
C C. Tendon xanthomas<br />
D. Xanthelasmas
Disease Disease association?<br />
Primary or secondary hyperlipidemias<br />
Color: Color: yellow yellow, orange, orange reddish, reddish or yellow-<br />
brown<br />
Can Can be papules, papules plaques, plaques or nodules
Xanthelasma<br />
Asymptomatic<br />
y p<br />
Flat, yellow/orange papules near eyelids<br />
Elevated LDL cholesterol; 50% have normal lipids<br />
Associated with familial hypercholesterolemia
Tendon xanthomas<br />
Lipid p deposition p within tendons, , ligaments, g , and fasciae<br />
smooth, firm, lobulated nodules over extensor tendons <strong>of</strong> hands,<br />
elbows, knees, and Achilles tendon<br />
Elevated LDL cholesterol<br />
Associated with Familial hypercholesterolemia
Tuberous xanthomas<br />
S<strong>of</strong>t, ,y yellow, , orange, g , or red papules p p or nodules over extensor<br />
surfaces, (elbows, knees, and buttocks)<br />
coalesce to form large, lobular masses<br />
Elevated LDL cholesterol or triglycerides<br />
Associated with Familial hypercholesterolemia
Eruptive xanthomas<br />
Yellow or yellow-orange y g ppapules p<br />
Appear suddenly in crops over buttocks, thighs, arms, forearms,<br />
back, or chest<br />
May be pruritic<br />
Elevated Triglycerides<br />
Associated with Familial lipoprotein deficiency; apoprotein CII<br />
deficiency; familial hypertriglyceridemia<br />
http://dermatology.cdlib.org/DOJvol7num2/nyu2/1/1.html
Well demarcated tender nonpruritic bright red<br />
Well demarcated , tender, nonpruritic, bright red<br />
Develop in areas <strong>of</strong> minor trauma<br />
Neutrophilic
Disease associations?<br />
Most common: middle<br />
aged women after URI<br />
UUnderlying de l i malignancy ali a c<br />
• Hematologic (AML)<br />
• Solid So d organ o ga (breast, (b east, G GI, ,<br />
GU)<br />
IBD<br />
Medications<br />
• ATRA, GCSF, vaccines,<br />
minocycline)
A 22-year-old man is evaluated for a 1-day<br />
history <strong>of</strong> a painful rash in the beard area. He<br />
has not used any y ointments, creams, or other<br />
occlusive coverings on his face, and he has not<br />
had hot-tub, whirlpool, or swimming-pool<br />
exposure. He does have a history <strong>of</strong> herpes<br />
labialis and had a recurrence 3 days ago. He is<br />
otherwise healthy and takes no medications<br />
medications.<br />
Skin examination findings are shown .
<strong>The</strong> <strong>The</strong> eruption is tender and is present on<br />
both sides <strong>of</strong> the face.<br />
Which Which <strong>of</strong> the following is the most likely<br />
diagnosis?<br />
A A. Acne vulgaris<br />
B. Eosinophilic folliculitis<br />
C C. Herpetic folliculitis<br />
D. Pseudomonas folliculitis<br />
E E. Staphylococcal folliculitis
Which Which <strong>of</strong> the following is the most likely<br />
diagnosis?<br />
A A. Acne vulgaris<br />
B. Eosinophilic folliculitis<br />
C C. Herpetic folliculitis<br />
D. Pseudomonas folliculitis<br />
E E. Staphylococcal folliculitis
Herpes may cause foliculitis in the beard area that<br />
appears vesicular<br />
Treatment includes acyclovir, valacyclovir, and<br />
fa famciclovir ciclo i<br />
Acne is not usually tender and does not usually appear<br />
so suddenly<br />
Pseudomonas foliculitis usually associated with<br />
hottubs, whirlpools, or swimming pools, and primarily<br />
affects the trunk<br />
Staph foliculitis would be pustular, not vesicular<br />
Eosinophilic foliculitis is intensely pruritic and is<br />
virtually only found in individuals with advanced HIV<br />
infection
A 24-year-old woman is evaluated for a rapidly<br />
progressive ulcer on her leg that began 3 days<br />
after she bumped p her leg gon<br />
a chair. <strong>The</strong> lesion<br />
began as multiple small, painful pustules that<br />
eroded and rapidly progressed over several<br />
days to form a large ulcer. She has a 6-year<br />
history <strong>of</strong> distal ulcerative colitis that is<br />
currently well controlled on mesalamine<br />
mesalamine.<br />
On physical examination, she is afebrile, and<br />
vital signs are normal. Skin findings are shown .
Prurulent base, violaceous ragged borders<br />
Neutrophilic<br />
Pathergy
A A complete blood count is normal. normal<br />
Which <strong>of</strong> the following is the most<br />
appropriate treatment?<br />
A. Intravenous antibiotics<br />
B B. Proctocolectomy<br />
C. Surgical debridement<br />
D D. Systemic corticosteroids<br />
E. Wet-to-dry dressings
A A complete blood count is normal. normal<br />
Which <strong>of</strong> the following is the most<br />
appropriate treatment?<br />
A. Intravenous antibiotics<br />
B B. Proctocolectomy<br />
C. Surgical debridement<br />
D D. Systemic corticosteroids<br />
E. Wet-to-dry dressings
Associated with<br />
systemic disease in<br />
50-78% <strong>of</strong> patients<br />
p<br />
Disease associations?<br />
IBD<br />
RA<br />
Seronegative<br />
spondyloarthropathy<br />
Hematologic<br />
diseases<br />
• Most common-AML
Must Must rule out infection as mimicer <strong>of</strong> PG<br />
(suggested by normal wbc, lack <strong>of</strong> fever)<br />
Treat Treat with Immunosupression Immunosupression-<strong>of</strong>ten <strong>of</strong>ten with<br />
systemic corticosteroids<br />
Proctocolectomy Proctocolectomy suggested for severe<br />
refractory PG<br />
Contraindicated: Contraindicated: wet wet-to-dry to dry or surgical<br />
debridement. Pathergy-trauma makes it<br />
worse
Heliotrope rash<br />
Gottron papules
Nail fold telangectasias, cuticular overgrowth<br />
Shawl sign
Skin Skin findings + proximal inflammatory<br />
myopathy<br />
Disease Disease associations?<br />
Six fold increase in risk <strong>of</strong> malignancy<br />
Types Types <strong>of</strong> malignancies correlate with age<br />
matched controls except:<br />
• More ovarian cancer than age matched controls
A 24 24-year-old year old woman is evaluated in the emergency<br />
department for skin blistering. Her symptoms began 3<br />
days ago when she noted a gritty sensation in her eyes;<br />
the following follo i day da her he skin ki all oover e he her body bod beca became e<br />
red and painful. When she awoke today, her skin was<br />
blistered and there were moist, open erosions where<br />
the skin had sloughed <strong>of</strong>f. Approximately 1 week ago,<br />
she received a 3-day course <strong>of</strong> trimethoprim-<br />
sulfamethoxazole for an uncomplicated urinary tract<br />
infection. She has a history <strong>of</strong> gastroesophageal reflux<br />
disease, which is treated with omeprazole that was<br />
started 1 year ago. ago She also takes ibupr<strong>of</strong>en<br />
intermittently for pain.
On pphysical y examination, , temperature p is 39.1 °C ( (102.4 °F), ), blood<br />
pressure is 110/75 mm Hg, pulse rate is 105/min, and respiration<br />
rate is 20/min. <strong>The</strong>re is confluent erythema <strong>of</strong> the entire trunk and<br />
all extremities, with blistering and erosions affecting greater than<br />
30% <strong>of</strong> the body surface area. Lateral pressure on erythematous,<br />
nonblistered skin causes the skin to slough. Erosions are present<br />
on the eyelids, and there is conjunctival hyperemia. <strong>The</strong> lips are<br />
crusted t d and d bloody, bl d and d there th are ragged d ulcers l on th the buccal b l<br />
mucosa. <strong>The</strong>re are painful ulcers on the labia minora. Laboratory<br />
studies show a slight elevation in the leukocyte count with<br />
increased polymorphonuclear cells and eosinophils, eosinophils normal renal<br />
function, and a slight elevation in liver aminotransferase levels.
Which Which <strong>of</strong> the following is the most<br />
appropriate first step in management?<br />
A A. Empiric acyclovir<br />
B. Empiric ceftazidime and vancomycin<br />
C C. Systemic corticosteroids<br />
D. Stop all medications
Which Which <strong>of</strong> the following is the most<br />
appropriate first step in management?<br />
A A. Empiric acyclovir<br />
B. Empiric ceftazidime and vancomycin<br />
C C. Systemic corticosteroids<br />
D. Stop all medications
This This patient has toxic epidermal<br />
necrolysis (TEN), which is characterized<br />
by mucous membrane involvement (eyes (eyes,<br />
oral mucosa, and genitalia in this patient),<br />
epidermal detachment affecting greater<br />
than 30% <strong>of</strong> the body surface area, and a<br />
positive Nikolsky sign (lateral pressure<br />
on nonblistered skin leads to<br />
denudation)
<strong>The</strong> most important step in management is<br />
stopping all medications that may have caused it
Treating Treating with acyclovir would add<br />
another medicine and there is no<br />
evidence TEN is caused by viral infection<br />
Emperic antibiotics are also not<br />
indicated and would add to unnecessary<br />
medications<br />
Steroids Steroids may be useful in severe allergic<br />
drug reactions, however not in TEN.<br />
Steroids may also predispose these<br />
patients to superinfection
Systemic Systemic disease associations with skin<br />
disorders<br />
Xanthomas<br />
Xanthomas<br />
Skin cancers
MKSAP MKSAP 15
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