9-25-06 Derm – Petronic-Rosic

Medical Dermatology
Vesna Petronic-Rosic, MD
Assistant Professor and PDP Director
University of Chicago
Section of Dermatology

Infections and Infestations

• Form of cellulitis with prominent
lymphatic involvement
• Etio:
– Adults: Group A streptococcus
and S. Aureus
– Children: Haemophilus
influenzae type B
• More superficial with margins more
clearly demarcated from normal
skin than conventional cellulitis
• Lower legs, face, and ears
• Suspect H influenzae if TOXIC
appearance
Erysipelas

Recurrent episodes of
infection result in lymphatic
obstruction with permanent
thickening of the skin
Erysipelas
Rx:
• Cephalosporins or PNC
• Rifampin prophylaxis
– where the household includes
a child in the susceptible age
group (less than 4 years old)
– in a day-care classroom where
a case of systemic H.
influenzae type B disease has
occurred

• Etiol: group A betahemolytic
streptococci or
Staphylococcus aureus
• RF: injury, stasis,
lymphoedema, tinea pedis
• PE: tender, deep red, and
swollen
• Dx: clinical, biopsy, tissue
culture
• Rx: cephalosporin
Cellulitis

• Etiology: S. aureus - injury,
abrasion, near surgical
wounds or draining abscesses,
may be a complication of
occlusive topical steroid
therapy
• PE: follicular pustules with
erythematous halo
• Rx:
– tepid, wet Burrow's compress
– oral antibiotics
Folliculitis

• Etiology : Pseudomonas
from poorly maintained hot
tubs / whirlpools
Hot Tub Folliculitis
• Clinical: small follicular,
vesicular, pustular, or papular
lesions occur a few hours to 5
days after exposure, resolving
in 7 to 10 days
• Rx: needed only in severe
cases - fluoroquinolones

Impetigo (Bullous/Nonbullous)
• Etiology: Staph >Strep
• Complications
– Poststreptococcal
glomerulonephritis may
follow impetigo (10 days
later): hematuria, edema
• Will heal without Rx
– Rheumatic Fever not a
complication of impetigo
• Rx: Bactroban ointment tid or
Cephalosporin

Staphylococcal Scalded Skin Syndrome
• Etio: S. aureus epidermolytic toxin
in children < 5 y and in adults with
renal insufficiency
• 75% of children > 10y have the
toxin AB
• Renal function impaired: cannot
clear toxin
• Starts in flexures; + Nikolskiy sign
• Dx: culture - nares, perianal,
flexures
• DDx: bullous impetigo
• Rx: NO STEROIDS
– Anti staph antibiotics

• Etio: Treponema pallidum
• Transmission: sexual contact, in
utero, and via blood transfusion
Syphilis
• Incubation 10-90 days: initial lesion of
primary syphilis develops at the site of
transmission, heals in 3-7 weeks
• Chancre: single, painless papule that
rapidly becomes eroded and indurated,
ulcer has a cartilaginous consistency
at the edge and base
• High-risk groups include men having
sex with men, inmates in correctional
facilities, high-risk sexual activity

Secondary Syphilis
• 4-10 weeks after primary lesion
• Dermatitis-arthritis syndrome:
malaise, fever, myalgias, and
arthralgias + generalized body
rash + lymphadenopathy
• Immune reaction is at its peak
and antibody titers are high
• Rx for primary, secondary and
early latent syphilis: benzathine
penicillin 2.4 million U IM
• Alternative treatments (14 d):
doxycycline 100 mg PO bid,
tetracycline 500 mg PO qid, or
erythromycin 500 mg PO qid.
• Penicillin-allergic patients should
be desensitized in order to
receive standard drug therapy

Late Syphilis
• Chronic, progressive
inflammatory process that
produces clinical symptoms years
to decades after initial infection
– Gummatous
– Neurosyphillis
– Cardiovascular
• Rx for late latent and tertiary:
benzathine penicillin G 2.4 million
U IM once weekly for 3
consecutive weeks
• Alternative treatments (4w):
Doxycycline 100 mg PO bid or
tetracycline 500 mg PO qid

Cutaneous Larva Migrans
• Etiology: Ancylostoma braziliense
• Random wandering of the hookworm
larvae through the skin
• Elevated tracks that change position
and shape as the larvae migrate
through the epidermis
• Rx:
– Topical application of thiabendazole
is the treatment of choice
– Albendazole #2
– Do not freeze – may miss worm

• Etio: herpes simplex virus
• Phases
Herpes Simplex
– primary phase, after which the
virus becomes established in a
nerve ganglion.
– secondary phase,
characterized by recurrent
disease at the same site
• Rx: acyclovir, famcyclovir,
valacyclovir

Eczema Herpeticum
(Kaposi Varicelliform Eruption)
Atopic dermatitis, Darier’s disease, pemphigus, immunosuppressed

Herpes Zoster
• Varicella zoster virus latent in dorsal
root ganglion � single dermatome
• 20% lifetime incidence, rarely recurs
• Factors: age, immunosuppression,
lymphoma, fatigue, stress, Rtg tx
• May be the earliest clinical sign of HIV
• Dx: Tzanck smear, biopsy,
complement-fixation titer, DFA, culture
• Rx: Acyclovir oral/Iv within 72 hrs
• Postherpetic neuralgia: capsaicin,
antidepressants, topical lidocaine,
rhizotomy, emotional support

• Common, benign, usually
asymptomatic, self-limited skin
eruption
• Etio: HHV-6 and -7
• Phases
Pityriasis Rosea
I: 2-10 cm oval lesion (herald
patch)
II: The fully evolved eruption 2
weeks after onset

• Ring of scale (collarette scale)
• Christmas tree pattern on back
• No systemic symptoms
• Dx: clinical, biopsy
• DDx: tinea, secondary syphilis,
psoriasis and nummular
dermatitis
• Rx: topical & PO steroids,
Benadryl, sun exposure, UVB
Pityriasis Rosea

Molluscum Contagiosum
• DNA poxvirus infection in
children and adults
• Transmission by direct skin
contact and autoinoculation
• Incubation: 14-50 days
• Firm, smooth, umbilicated 2-6 mm
papules in groups or widely
disseminated on the skin and
mucosal surfaces; > 15 mm in HIV
• Self-limited but can persist for
several years
• Rx: cantharidin, tretinoin,
podophyllin, TCA, AgNo3 , LN2

• Etio: Trichophyton (T. rubrum),
Microsporum, Epidermophyton
Tinea Corporis
• Clinical: annular,erythematous,
papulosquamous lesion that may
grow rapidly, with vesicular edge
• Dx: KOH and culture
• Rx:
– topical: azoles, allylamines
– systemic: griseofulvin,
itraconazole, terbinafine

• Etio: Malassezia furfur
• Clinical: hypopigmented or
hyperpigmented macules and
patches on chest and back
• Chronically recurrent
• Dx: clinical, Woods light, KOH
• Rx:
– topical: antifungals, selenium
sulfide,
– systemic: ketoconazole,
itraconazole, fluconazole
Tinea Versicolor

• Etio: Borrelia burgdorferi
• Vector: deer tick
• Stages
1. EM + flu like Sx
2. Cardiac/Neuro Disease
Lyme Disease
3. Arthritis and chronic neurological
symptoms
• Dx: PCR most sensitive
• Rx: doxycycline or amoxicillin
• DEET repellant for prophylaxis

• Etio: Sarcoptes scabiei
• Clinical
– burrow in the web space
– inflammatory papules
– nocturnal pruritis
• Dx: clinical, scabies prep, bx
• Rx
– permethrin (92%)
– lindane (86%) ?neurotoxic
– sulfur
– ivermectin
Scabies

Scabies
Pustules on the palm and
papular lesions on the wrist
are typical in infants
Eroded papules on the glans are a
highly characteristic sign of scabies;
large papules may remain after
appropriate therapy and sometimes
require treatment with intralesional
steroids (noduli scabiei)

Treat the entire family!

Lice
• Pediculus humanus
• Transmission: close contact, fomites, overcrowding encourages spread
• The body louse is the vector of typhus, trench fever, and relapsing fever.
• Clinical: itching � scratching � inflammation and sec bacterial infection
• Dx: clinical, Wood’s light
• Rx: permethrin, lindane, combing with vinegar solution; treat family

Immunologically Mediated Diseases

Bullous Pemphigoid
• Etiol: autoimmune blistering disease
• IgG autoantibodies: circulating and bound in the lamina lucida region of BMZ
• Complement is activated � chemotaxis and degranulation of leukocytes,
release of proteolytic enzymes � basement membrane destruction resulting in
dermal-epidermal separation: subepidermal blister

Bullous Pemphigoid
• No race/sex preference
• Usually > 60 y
• Bullae good structural integrity, in
contrast to the large, flaccid, easily
ruptured bullae of pemphigus
• Nikolskiy's sign is negative
• Generally heal without problems
• Rx:
– itching: hydroxyzine
– antibiotics (tetracycline)
– systemic steroids
– immunosuppressive agents:
azathioprine, cyclophosphamide,
methotrexate, or chlorambucil

Pemphigus Vulgaris
• Autoimmune intraepidermal blistering
disease of skin and mucous
membranes
• Circulating IgG autoantibodies directed
against desmosomal proteins
• Oral erosions commonly occur and may
precede the onset of skin blisters by
weeks or months
• Flaccid blisters, + Nikolskiy sign
• Exposed erosions last for weeks before
healing with hyperpigmentation
• Death used to be 10% from
complications of steroid therapy

• Dx: biopsy for H&E and DIF
• Rx:
Pemphigus Vulgaris
– steroids
– adjuvant (steroid-sparing) therapy:
mycophenolate mofetil, cyclophosphamide,
chlorambucil, azathioprine, dapsone, Cs,
gold, plasma exchange, ECP, IvIg
• Associations: myasthenia gravis and
thymoma
– most patients develop myasthenia gravis,
followed by the detection of thymus
disease, and finally by pemphigus
– malignancy (lymphoid or RES) more
frequently than in healthy controls

Erythema Nodosum
• Hypersensitivity reaction to a
variety of antigenic stimuli
• Associations
– diseases: strep, sarcoidosis,
Hodgkin’s disease
– drugs: halides, sulfonamides, OCP
– pregnancy
• 50% of cases are idiopathic
• F>M
• Nonspecific systemic illness with
low-grade fever, malaise,
arthralgias, and arthritis
• Self-limited: symptomatic relief,
SSKI, steroids, NSAIDs

Lupus erythematosus - Discoid
• Autoimmune disease
• F > M
• RF: UV exposure, trauma
• Clinical signs
– alopecia
– atrophy
– telangectasies
– urticaria
– Raynaud’s syndrome
– vasculitis

Lupus Erythematosus
Clinical Workup
– biopsy for histology and DIF
– system review
– ANA, anti-dsDNA, anti- Ro/La
– urinalysis
– ESR, CBC
– C3, C4, CH50
Therapy
– sunscreens
– topical/intralesional/systemic steroids
– anti-malarial drugs
– dapsone
– other
• azathioprine
• thalidomide
• acitretin is effective for severe,
chloroquine-resistant DLE

• Idiopathic inflammatory myopathy with
characteristic cutaneous findings
• Frequently affects joints, esophagus,
lungs, and, less commonly, heart
• Females 50-60 yo, W>B
• Clin: Heliotrope rash + Gottron papules +
proximal symmetrical muscle weakness
• Malar erythema, poikiloderma, violaceous
erythema on extensor surfaces,
periungual changes
• Dx: CK, ANA, anti-Mi-2, anti-Jo-1, anti-Ku
• Tx:
– steroids
– immunosupressive/cytotoxic drugs
– IvIg
– antimalarial drugs
– phototprotection
Dermatomyositis

• Systemic connective tissue disease
– Essential vasomotor disturbances
– Fibrosis
– Subsequent atrophy of the skin, subcutaneous
tissue, muscles, and internal organs
– Immunologic disturbances
• Females 30-40 yo
• Clin: pruritus, Raynaud, difficulty swallowing,
SOB, palpitations, cough, arthralgia, weakness
• Dx: 1 major + 2 minor
Systemic Sclerosis
– Major features: centrally located skin sclerosis that
affects the arms, face, and/or neck
– Minor features: sclerodactyly, erosions, atrophy of
the fingertips, and bilateral lung fibrosis
– ANAs: anti-topoisomerase I DNA (Scl 70),
anticentromere
• Tx: organ specific +
– D-penicillamine
– Interferon alfa and interferon gamma
– Immunomodulatory agents

Drug Induced Dermatoses

Fixed Drug Eruption
• Lesions recur in the same area
when the offending drug is given
• PE: circular, violaceous,
edematous plaques that resolve
with macular hyperpigmentation
• Lesions occur 30 m to 8 hrs after
drug administration
• Hands, feet, and genitalia
• Acetaminophen, ampicillin,
anticonvulsants, aspirin/NSAIDs,
phenacetin, phenolphthalein,
sulfonamides, tetracyclines

Urticaria
• PE: Small wheals that may coalesce or
have cyclical or gyrate forms
• Lesions appear shortly after start of
drug therapy and resolve rapidly when
drug is withdrawn
• Dx: clinical
• DDX: giant urticaria may resemble EM
• Etio: ACE-inhibitors, aspirin/NSAIDs,
blood products, cephalosporins,
infliximab, opiates, penicillin, radiologic
contrast material, tetracycline,
vaccines, and zidovudine

Henoch-Schoenlein Purpura
• Acute IgA–mediated
leukocytoclastic vasculitis that
affects primarily children
• Etiology
– allergens
– infections: mono, strep
– vaccines
– drugs: ampicillin, erythromycin,
penicillin, quinidine, quinine
• Purpura, arthritis, abdominal pain, GI
bleeding, orchitis, and nephritis
• Dx: biopsy and DIF
• Rx: admit for monitoring of abdominal
and renal complications, steroids prn

Erythema Multiforme
Etiol: unknown in 50% cases
Associations :
Herpes simplex (HSAEM),
Mycoplasma infection, primary
atypical pneumonia
Clinical: target lesions on acral
sites
Rx
• steroids
• acyclovir may prevent herpes
recurrence
– no help once herpes occurs or to
prevent EM from occurring

Stevens Johnson Syndrome
• Vesiculobullous disease of the
skin, mouth, eyes, and genitals
• Drugs most common cause:
phenytoin, phenobarbital,
sulfonamides, penicillins
• Dx: clinical, biopsy
• Rx:
– steroids
– antihistamines
– IvIg

Toxic Epidermal Necrolysis (TEN)
• Full-thickness loss of the epidermis
results in a mortality of 25% to 100%
• Death is usually caused by
overwhelming sepsis
• Etiol: drugs (not related to dose)
• Seen in HIV pts due to sulfa
• Dx: clinical, frozen sections, bx
Drugs most commonly involved:
• Phenytoin
• Phenobarbital
• Carbamazepine
• Sulfonamides
• Ampicillin
• Allopurinol
• Antituberculous drugs
• Thiacetazone
• Isoniazid
• NSAIDs

Symptoms
TEN
– Mucosal involvement: inflammation,
blistering, and erosion, especially
oropharynx, are early and
characteristic
– Pneumonia: 40% pts
– Eye findings common
Rx: conservative
conjunctival erosions with
subsequent revascularization,
fibrous adhesions, and corneal
ulceration
– burn unit
– keep clean, dry
– no steroids
– IvIg

Neoplasms

• Risk Factors
Basal Cell Carcinoma
– fair skin + sun exposure (UVA & B)
• Location: Head/neck
• Locally invasive, rarely metastasize
• Rx: surgical excision, radiation

Squamous Cell Carcinoma
• AGGRESSIVE
– Prior radiation
– Thermal injury
– Chronic draining sinuses
– Chronic ulcers
– Immunosuppression
• Renal Transplant pts
• NON AGGRESSIVE
– Sun exposure
• Rx: surgical excision

Keratoacanthomas vs. SCC
Keratoacanthoma
– Grow rapidly, then regress
– Smooth surface (compared to
SCC)
– Red papule that develops
keratotic plug
– Not associated with internal
malignancy
Rx: electrodesiccation and curettage, surgical excision
– Intralesional: 5-FU , MTX

Malignant Melanoma
• Etiol: environmental, genetic
• RF
– excessive sun exposure (esp
UVA)
– alterations of the upper
atmosphere by pollutants
resulting in increased radiation
– white > black
• Prevention
– stay out of sun
– sunscreen
– frequent skin exams

Physical Exam
• Asymmetry
Malignant Melanoma
• Border irregularity
• Color variegation
• Diameter enlargement
Poor Prognostic Factors
– vertical growth phase (mm)
– ulceration
– high mitotic index
– marked cytologic atypia
– minimal tumor inflammatory ly
– presence of regression
– presence of plasma cells
– male sex
– age > 45 years
– axial anatomic location

Miscellaneous

Insect Bite Reaction
• Intensely pruritic commonly excoriated
papules grouped where the bites occur
– linear arrangement of 3 bites in a row is
often a sign of bedbug (Cimex) bites;
head and neck
– flea bites usually occur on the legs
• Vesicular and bullous reactions and
pseudolymphomatous nodules may
occur
• Dx: clinical, biopsy
• Rx: topical steroids, anesthetics,
antipruritics
• Repellent!
• Vectors for disease

Miliaria
• Disorder of the eccrine sweat
glands
• Heat and humidity � blockage of
sweat ducts� leakage of sweat
into the epidermis/dermis:
– crystallina
– profunda
– rubra: tropics; heat exhaustion
• Dx: clinical
• Rx: cooling, showers, anhydrous
lanolin for miliaria profunda, limit
activity

Seborrheic Dermatitis
PE: fine, dry, white or yellow scale with
minor itching
Associations: Parkinson’s, HIV, CNS
disorders
TREATMENT
• Frequent washing of all affected
areas with an antidandruff shampoo
• Group V topical steroid creams
• Ketoconazole
• Zinc soaps or selenium lotions
suppress activity, maintain remission

Psoriasis
Clinical: red plaques with silvery
scale on extensor surfaces, nail
pitting, arthritis
Etiology: genetic, drugs, infection
(strep)
Dx: clinical, biopsy
DRUGS causing/worsening psoriasis
– lithium
– antimalarials
– beta blockers
– steroids

Psoriasis – Therapy
• Localized lesions
– injections in the plaque with steroids
• Generalized lesions
– topical steroids
– calcipotriol (Dovonex) - vitamin D3 analogue inhibits
epidermal cell proliferation and enhances cell differentiation
– anthralin: chronic plaques (and in combination with UVB)
– UVB (+ tar), PUVA, methotrexate, etretinate, and cyclosporine
• Guttate psoriasis
– antibiotics and UVB

Thank you!