DISCLOSURE OF RELEVANT RELATIONSHIPS WITH INDUSTRYDermExamPrepRefresher/08... · DISCLOSURE OF...
Transcript of DISCLOSURE OF RELEVANT RELATIONSHIPS WITH INDUSTRYDermExamPrepRefresher/08... · DISCLOSURE OF...
DISCLOSURE OF RELEVANT RELATIONSHIPS WITH INDUSTRY
Nicole Burkemper, MD
Associate Professor of Dermatology and Pathology
Saint Louis University
I HAVE NO RELEVENT RELATIONSHIPS WITH ANY COMPANIES
The most likely diagnosis is:
A. Allergic contact dermatitis
B. Cellulitis
C. Neuropathic diabetic ulcer
D. Pyoderma gangrenosum
E. Sweet syndrome
The most likely diagnosis is:
A. Allergic contact dermatitis
B. Cellulitis
C. Neuropathic diabetic ulcer
D. Pyoderma gangrenosum
E. Sweet syndrome
Cellulitis
• Ill-defined erythema, warmth, edema
• Systemic symptoms of fever, chills and malaise
• Leading edge not raised or sharply demarcated (distinguishes from erysipelas)
• Bullae and petechiae
• Streptococcus pyogenes and Staphylococcus aureus
• Often after wound; on leg, tinea pedis is most common portal of entry
• Predisposing factors: venous and lymphatic damage, congenital vascular malformations
Distractors
Allergic contact dermatitis *—epidermal changes
Neuropathic diabetic ulcer—sole of foot
Distractors
Pyoderma gangrenosum *—sharply marginated wet ulcer with purple undermined border
Sweet’s syndrome *—pink edematous plaques on the face, upper trunk and arms
The most likely diagnosis is:
A. Allergic contact dermatitis
B. Cutaneous candidiasis
C. Lichen sclerosus
D. Tinea corporis
E. Tinea versicolor
The most likely diagnosis is:
A. Allergic contact dermatitis
B. Cutaneous candidiasis
C. Lichen sclerosus
D. Tinea corporis
E. Tinea versicolor
Tinea versicolor
• Presents as hypo- or hyperpigmented coalescing scaly macules
• Trunk, upper arms and neck
• Caused by Malassezia furfur
• KOH—short, thick hyphae and spores (“spaghetti and meatballs”)
• Topical or systemic antifungal treatment
• Recurrence rate very high—ketoconazole shampoo weekly to prevent recurrence
Distractors
Allergic contact dermatitis *—pink patches or plaques, not hypo- or hyperpigmented; patterned
Cutaneous candidiasis *—moist patches in intertriginous areas with satellite pustules
Distractors
Lichen sclerosus *—atrophic “cigarette paper” plaques often in genital and perianal areas
Tinea corporis *—annular, sharply circumscribed, erythematous, scaly patches
The most likely diagnosis is:
A. Contact dermatitis
B. Cellulitis
C. Erythema migrans
D. Erythema dyschromicum perstans
E. Psoriasis
The most likely diagnosis is:
A. Contact dermatitis
B. Cellulitis
C. Erythema migrans
D. Erythema dyschromicum perstans
E. Psoriasis
Contact dermatitis
• Well-demarcated erythematous vesicular to scaly plaque with well-defined margins corresponding to the area of contact
• Because irritant contact dermatitis and allergic contact dermatitis not always discernible clinically, patch testing may be required to identify an allergen and exclude allergy
• Most common allergens are nickel, neomycin, balsam of Peru, fragrance mix, thimerosal (often not relevant), gold, quaternium-15, formaldehyde, bacitracin and cobalt
Distractors
Cellulitis *—more well-defined, erythematous and edematous; leg most common site
Erythema migrans *—annular patches most commonly on legs, groin, axilla and trunk
Distractors
Erythema dyschromicum perstans—ashy-gray oval macules and patches on the face, neck, trunk and proximal extremities in patients with darker skin types
Psoriasis *—more well-demarcated bright red plaques with overlying silvery scale
This patient just returned from a beach vacation in the Caribbean and complains of this itchy rash on the buttock. The most likely
diagnosis is:
A. Allergic contact dermatitis
B. Cutaneous candidiasis
C. Cutaneous larva migrans
D. Perianal strep dermatitis
E. Scabies
This patient just returned from a beach vacation in the Caribbean and complains of this itchy rash on the buttock. The most likely
diagnosis is:
A. Allergic contact dermatitis
B. Cutaneous candidiasis
C. Cutaneous larva migrans
D. Perianal strep dermatitis
E. Scabies
Cutaneous larva migrans
• Most commonly caused by larvae of cat and dog hookworm, Ancylostoma braziliense; SE United States, Caribbean
• From environment contaminated with animal feces, beach
• Human is dead-end host
• Sxs: 1-6 days from exposure; creep several cm per day; die in 2 to 8 weeks without treatment
• Tx: single-dose ivermectin or 3 days albendazole
Distractors
Allergic contact dermatitis *—can be linear, not serpiginous
Cutaneous candidiasis *—Often in the folds; beefy red, moist patches with satellite pustules
Distractors
Perianal strep dermatitis—Perianal well-demarcated rim of erythema
Scabies *—Short burrows that prefer the finger webs, wrists, axillae, areolae, umbilicus and genitals
This patient presents with fatigue and anemia. The most likely diagnosis is:
A. Basal cell nevus syndrome
B. Blue rubber bleb nevus
syndrome
C. Gaucher disease
D. Pachyonychia congenita
E. Peutz Jeghers
This patient presents with fatigue and anemia. The most likely diagnosis is:
A. Basal cell nevus syndrome
B. Blue rubber bleb nevus
syndrome
C. Gaucher disease
D. Pachyonychia congenita
E. Peutz Jeghers
Blue rubber bleb nevus syndrome
• Autosomal dominant
• Dark blue papules and nodules and skin-colored compressible protuberances (“rubber blebs”) and larger venous malformations affecting skin and mucosa
• GI lesions bleed and lead to iron deficiency anemia
Distractors
Basal cell nevus syndrome
*—palmar pits Gaucher disease
• Bronze coloration of skin;
some have congenital
ichthyosis
Distractors
Pachyonychia congenita—”doorstop nails”; steatocystomas when mutations in keratin 17
Peutz-Jeghers *—hyperpigmented
macules on lips and oral mucosa;
polyposis of SI with GI bleeding
The most likely diagnosis is:
A. Cellulitis
B. Ichthyosis vulgaris
C. Mycosis fungoides
D. Necrolytic migratory erythema
E. Psoriasis
The most likely diagnosis is:
A. Cellulitis
B. Ichthyosis vulgaris
C. Mycosis fungoides
D. Necrolytic migratory erythema
E. Psoriasis
Ichthyosis Vulgaris
• Ichthyosis is derived from the Greek word
ichthys, meaning “fish”
• Autosomal dominant; prevalence as high as 1 in 250
• Onset in early childhood
• Extensor LE primarily affected with scales; hyperlinear palms
• Loss-of-function mutations in the filaggrin gene
(FLG)
Distractors
Cellulitis * —well-defined erythema, warmth, edema; no scale
Mycosis fungoides *—fairly well-demarcated patches/plaques typically in sun-protected areas
Distractors
Necrolytic migratory erythema *—pink and eroded plaques classically in intertriginous areas
Psoriasis *—well-demarcated red plaques with silver scale
This patient also has a fever. The most likely diagnosis is:
A. Acne keloidalis
B. Arthropod bites
C. Nummular dermatitis
D. Prurigo nodularis
E. Sweet syndrome
This patient also has a fever. The most likely diagnosis is:
A. Acne keloidalis
B. Arthropod bites
C. Nummular dermatitis
D. Prurigo nodularis
E. Sweet syndrome
Sweet syndrome
• Acute febrile neutrophilic dermatosis
• Adults; F3:M1
• Sharply demarcated, tender, pink-violaceous edematous plaque involving face, neck, upper trunk and extremities
• Fever, arthralgias, myalgias
• Elevated ESR and neutrophilia
• Associated with URI (most common), hematologic malignancy or solid tumors, inflammatory diseases and pregnancy
• Standard treatment is systemic corticosteroids
Distractors
Acne keloidalis *—no fever; papules, pustules and keloidal plaques at back of neck
Arthropod bite *—no fever; edematous papule, plaque or bulla
Distractors
Nummular eczema *—no fever; discrete, coin-shaped vesicular or crusted pruritic plaques
Prurigo nodularis *—no
fever; pruritic dome-shaped
papules
This condition becomes more prominent with cold
exposure. The most likely diagnosis is:
A. Erythema ab igne
B. Livedo reticularis
C. Lymphangioma
D. Necrolytic acral erythema
E. Small vessel vasculitis
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This condition becomes more prominent with cold
exposure. The most likely diagnosis is:
A. Erythema ab igne
B. Livedo reticularis
C. Lymphangioma
D. Necrolytic acral erythema
E. Small vessel vasculitis
Livedo reticularis
• Netlike, mottled or reticulated, pink or reddish-blue discoloration of the skin, mostly on the legs
• Livedo racemosa (fixed LR)—broken circular segments; almost always associated with significant systemic disease such as hypercoagulable states (including myelodysplasias, cancer, and antiphospholipid and Sneddon syndromes), vasculitis (especially medium- and large-vessel), emboli, medications, and neurologic disorders
Livedo racemosa
Distractors
Erythema ab igne—no
variability with temperature;
reticulated erythema or
pigmentation in area of of
persistent heat exposure
Lymphangioma *--no worse with change in temperature; white vesicles that can become hemorrhagic (frog spawn)
Distractors
Necrolytic acral erythema *—no change with temperature; dusky plaques on feet +/- hands
Small vessel vasculitis *—no change with temperature; palpable purpura
The most likely diagnosis is:
A. Darier disease
B. Lichen planus
C. Onychomycosis
D. Psoriasis
E. Yellow nail syndrome
The most likely diagnosis is:
A. Darier disease
B. Lichen planus
C. Onychomycosis
D. Psoriasis
E. Yellow nail syndrome
Onychomycosis
• Yellowing, hypertrophy, and dystrophy of the distal nail plate with subungual hyperkeratosis (distal subungual onychomycosis)
• Trichophyton rubrum most common cause
• Usually multiple nails
• Toenail infection is much more common than fingernail infection
• Nail dystrophy is secondary to onychomycosis in more than 50% of cases (90% dermatophytes)
Distractors
Darier disease *—red and white longitudinal streaks; V-shaped nicking of distal margin
Lichen planus *—dorsal pterigium; trachyonychia (twenty nail dystrophy)
Distractors
Psoriasis *—salmon patches, “oil drop” sign, pitting, onycholysis; can be clinically indistinguishable from onychomycosis
Yellow nail syndrome *—marked thickening and yellow discoloration
The most likely diagnosis is:
A. Cowden syndrome
B. Epidermodysplasia verruciformis
C. Heck disease
D. Traumatic fibromas
E. Tuberous sclerosis
The most likely diagnosis is:
A. Cowden syndrome
B. Epidermodysplasia verruciformis
C. Heck disease
D. Traumatic fibromas
E. Tuberous sclerosis
Cowden syndrome
• Autosomal dominant; PTEN tumor suppressor gene
• Mucocutaneous findings: – Facial papules: flesh-colored, flat-topped, or elongated verrucoid
papules ranging from 1- to 5-mm
• Most are trichilemmomas and have a keratin-plugged center
– Oral lesions: 1- to 3-mm smooth whitish oral papules on gingiva, lips, palate or tongue in 80%
• May coalesce giving “cobblestone” appearance
– Acral keratoses: flesh-colored smooth or verrucoid papules on dorsal hands and feet in 60%
• Neoplasms of the breast and thyroid occur in up to two thirds of patients, can be malignant
Distractors
Heck disease
• Small white to pink papules diffusely in the mouth, not on face; HPV-13
Epidermodysplasia verruciformis—flat, wart-like lesions on dorsal hands, extremities, face and neck; tinea versicolor type patches on trunk; HPV-5 and -8
Distractors
Traumatic fibromas—solitary, smooth, pink nodule at bite line of buccal or labial mucosa or tongue; no skin findings
Tuberous sclerosis *—oral findings are gingival fibromas and dental pits; would also have facial angiofibromas
The most likely diagnosis is:
A. Acne vulgaris
B. Eosinophilic folliculitis
C. Pityriasis lichenoides
D. Prurigo nodularis
E. Steatocystoma multiplex
The most likely diagnosis is:
A. Acne vulgaris
B. Eosinophilic folliculitis
C. Pityriasis lichenoides
D. Prurigo nodularis
E. Steatocystoma multiplex
Acne vulgaris
• Comedones, papules, pustules, cysts, scarring
• Patients have a variety of lesions in various states of formation and resolution
• Follicular hyperkeratosis, ↑ sebum production, Propionibacterium acnes bacteria, inflammation
• Retinoids = 1st line for all forms of acne vulgaris due to their comedolytic and anti-inflammatory effects as well as their ability to help penetration of other topicals
Distractors
Eosinophilic folliculitis—papulopustules and plaques studded with pustules and central clearing; no comedones; pruritic
Pityriasis lichenoides *—eroded or scaly papules that heal with hypopigmentation; no comedones
Distractors
Prurigo nodularis *—dome-shaped nodules with central crust in accessible areas
Steatocystoma multiplex—Yellowish cysts without puncta; no pustules
This patient presents with fever and rash. The most
likely diagnosis is:
A. Acute generalized
exanthematous pustulosis
B. Bacterial folliculitis
C. Disseminated zoster
D. Measles
E. Toxic epidermal necrolysis
This patient presents with fever and rash. The most
likely diagnosis is:
A. Acute generalized
exanthematous pustulosis
B. Bacterial folliculitis
C. Disseminated zoster
D. Measles
E. Toxic epidermal necrolysis
Acute generalized exanthematous pustulosis (AGEP)
• Fever and countless nonfollicular, sterile, 1- to 2-mm pustules on background of erythema
• Typically ≤4 days of new drug
• β-lactam antibiotics, macrolides, Ca++ channel blockers, antimalarials…
• Treatment: Drug cessation, topical steroids, antipyretics
• Acuity and drug history help distinguish from pustular psoriasis
Distractors Bacterial folliculitis *—follicular pustules without background erythema
Disseminated zoster *—vesicles (not pustules) on an erythematous base; immunocompromised
Distractors
Measles—morbilliform eruption; spreads cephalocaudad; no pustules
Toxic epidermal necrolysis *—painful, pink to dusky-red patches with vesicles, bullae and erosions; mucosal erosions
This patient also complains of loss of the eyebrows. Of the following, the most likely diagnosis is:
A. Androgenetic alopecia
B. Central centrifugal cicatricial alopecia
C. Lichen planopilaris
D. Telogen effluvium
E. Trichotillomania
This patient also complains of loss of the eyebrows. Of the following, the most likely diagnosis is:
A. Androgenetic alopecia
B. Central centrifugal cicatricial alopecia
C. Lichen planopilaris
D. Telogen effluvium
E. Trichotillomania
Lichen planopilaris
• Keratotic plugs surrounded by violaceous rim on the scalp resulting in scarring alopecia
• Peri-infundibular lymphocytic inflammation with vacuolar interface dermatitis
• Women affected more frequently than men • Frontal fibrosing alopecia is a variant of LPP that presents in
older women with bandlike frontotemporal scarring alopecia with loss of eyebrows
• Treatment often difficult—hydroxychloroquine; topical, IL and po steroids, pioglitazone (PPAR-gamma agonist) and immunosuppressive agents
Distractors
Central centrifugal cicatricial
alopecia--almost exclusively
black women; scarring alopecia
at the vertex or crown
Androgenetic alopecia *—thinning of
crown with wider part anteriorly and
preservation of frontal hairline
Distractors Telogen effluvium—thinning of hair of entire scalp, not just crown
Trichotillomania *—patches of alopecia with hairs of varying lengths interspersed with uninvolved areas of the scalp
The most likely diagnosis is:
A. Allergic contact dermatitis
B. Amyloidosis
C. Dermatomyositis
D. Necrobiotic xanthogranuloma
E. Xanthelasma
The most likely diagnosis is:
A. Allergic contact dermatitis
B. Amyloidosis
C. Dermatomyositis
D. Necrobiotic xanthogranuloma
E. Xanthelasma
Amyloidosis
• Primary systemic amyloidosis (AL amyloid)
– Multiorgan disease with underlying plasma cell dyscrasia
– Cutaneous manifestations in 25%: • Purpura/ecchymoses (most common)
• Rubbery swelling and infiltration of tongue/oral mucosa
• Waxy infiltration of palms/fingertips
• Waxy or purpuric periorificial papules
• Diffuse sclerodermoid infiltration
• Bullae
• Onychodystrophy
Cutaneous amyloidosis
• Macular amyloidosis: brown rippled macules, often on back
• Lichen amyloidosis: persistent, brown, pruritic papules/rippled plaques on the shins
• Nodular amyloidosis: waxy nodule(s) often at acral sites, AL amyloid but rare progression to systemic amyloidosis
Distractors
Allergic contact dermatitis *—scaly pink patches
Dermatomyositis *—violaceous erythema (heliotrope)
Distractors
Necrobiotic xanthogranuloma--indurated yellowish plaques that can ulcerate
Xanthelasma--yellow papules and plaques
The most likely diagnosis is:
A. Grave disease
B. HAART-associated
lipodystrophy
C. Lupus panniculitis
D. Rosacea
E. Scleromyxedema
The most likely diagnosis is:
A. Grave disease
B. HAART-associated
lipodystrophy
C. Lupus panniculitis
D. Rosacea
E. Scleromyxedema
HAART-associated lipodystrophy
• Lipodystrophy occurs in up to 80% of HIV-infected patients, most of whom are on anti-retroviral therapy
• Fat of the face, buttocks and limbs is lost with increased fat at the upper back and abdomen
• Related to non-nucleoside reverse transcriptase inhibitors which also lead to adipocyte apoptosis
• May also have hypertriglyceridemia, hypercholesterolemia and insulin resistance, especially if also on a protease inhibitor
• Treatment with rosiglitazone, metformin, growth hormone and fillers
Distractors
Grave disease—
exophthalmos
Lupus panniculitis *—
proximal extremities;
nodules or indurated
plaquesatrophy
Distractors Rosacea *—conjunctivitis, styes; centrofacial erythema, papules and micropustules
Scleromyxedema--waxy firm papules that coalesce into infiltrated plaques
The most likely diagnosis is:
A. Brown recluse spider bites
B. Bed bug bites
C. Erythema migrans
D. Scabies
E. Sporotrichosis
The most likely diagnosis is:
A. Brown recluse spider bites
B. Bed bug bites
C. Erythema migrans
D. Scabies
E. Sporotrichosis
Bites, stings, infestations
• Excoriated, pruritic papules, often grouped
• Central puncta
• Exaggerated responses: bullous lesions or papular urticaria more common in children
• Bedbug bites (Cimex lectularius) often linear
Distractors
Erythema migrans *—erythematous expanding annular plaque; usually solitary
Brown recluse spider bite—Painful edematous reaction progressing to bulla with surrounding erythema and ischemia
Distractors
Scabies *—burrows in finger webs, umbilicus, nipples, male genitalia
Sporotrichosis *—ulcerated papule at site of inoculation (hand) and nodules along path of lymphatic drainage
The most likely diagnosis is:
A. Confluent and reticulated papillomatosis
B. Hailey-Hailey disease
C. Recurrent and disseminated infundibulofolliculitis
D. Tinea versicolor
E. Transient acantholytic dermatosis
The most likely diagnosis is:
A. Confluent and reticulated papillomatosis
B. Hailey-Hailey disease
C. Recurrent and disseminated infundibulofolliculitis
D. Tinea versicolor
E. Transient acantholytic dermatosis
Confluent and reticulated papillomatosis
• Onset: puberty-young adulthood, more common in black patients
• Multiple brown verrucous papules/patches, central chest/abdomen/upper back; confluent centrally and reticulated peripherally
• May mimic tinea versicolor (KOH will be negative) or acanthosis nigricans
• Treatment: Minocycline, azithromycin, topical and oral retinoids
Distractors Hailey-Hailey disease *—macerated plaques in intertriginous areas
Recurrent and disseminated infundibulofolliculitis--numerous, pruritic, 1-2 mm skin-colored papules on trunk, neck and upper extremities; darker pigmented patients
Distractors Tinea versicolor *—brown, tan or hypopigmented scaly round to oval patches on trunk
Transient acantholytic dermatosis *—crusted pink papules on upper trunk of older adults