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Acne and Related Disorders( Chart1of 1)


Acne vulgaris
Inflammation of the pilosebacuous(area around hair
Presentation
follicle) glands or specific surfaces.(Face, back, trunk)
Occurs most frequently in adolescence but may occur in
adulthood(10-17years in Females and 14-19years in
Males)

Acne Rosacea
Chronic acneiform disorder:
vassular dililation of central
face:
Nose
Cheek
Eyelids
Forehead
Background erythema

Acute cutaneous Lupus Erythematous(SLE)


Inflammatory connective tissue disease which is multifaceted with a
wide range of manifestations ranging from chronic skin
lesions(Discoid LE) to widespread polymorphos
lesions(Subacute cutaneous LE) to multiple organ
involvement(Systemic LE)
Woman are affected more than men(8:1)
More frequent in people in 30-40 age range

Distribution

Predominantly on face, back, shoulders and chest

Central facial area

Sun exposed areas(face, arms, chest, shoulders, backs or hands etc.)

Lesions

Primary
-Open comedomes (Blackheads;lipid has oxidized)

Primary
-Papules, pustules, nodules,
cysts telangiectasia (later)

Superficial to indurated(becoming hard and firm)

Secondary
-Erythema
-Scarring

Erythmatous to violacceaous (red to violet colored) plaques appear

Special lesions
-Rhinophyma (hyperplasia of
the soft tissues of the nose.
(Nose appears larger)
Flushing <heat, alcohol, spicy
food, sunlight, hot food

In 10-15% of patients, a butterfly rash appears over


malar and nasal bridge

-Closed comedomes
White head
-Papules
-Pustules
-Nodular cysts
Secondary
-Erythema
-Scar
-Excoriation(scratching)
Signs/Sympto
ms
Dx

-Clinical appearance
-Age
-Can do hormonal panel

Non puritic

May be scaling on surface

Serious multisystem disease: may be fever, arthritis, renal, cardiac,


pulmonary and central nervous system involvement
In laboratory
Can screen for underlying antinuclear Ab(ANA), blood count,
urinalysis

May appear with out any


history of acne or seborrhea

History

Affects individuals 30 years or


older; often of Celtic origin
Duration
DDx
Other

-Can wax and wane in adulthood


-May persist to age 35 or older
Folliculitis
Acne rosacea
Aggrivating factors/risk factors
-Drugs(lithium, adrogens, topical and systemic
corticosteroids and oral contraceptives
-Endocrine imbalance(thyroid, insulin, sex hormones)
-Malabsorption, HCL deficiency, liver or color problems
Emotional considerations
-Self-rejection, anger, fear, boundaries

Contact dermatitis; Rosacea; Tinea; Erysipelas


Seborrheic dermatitis
Pathology
The dysregulation of T cells causes activation of B cells which
produce a variety of anutoanitbodies directs towards cellular
antigens(DNA, RNA, RNA protein complexes)

2
Bullous, Vesicular Diseases( Chart 1 of 1)
Pemphigus vulgaris
Bullous Perphigoid
-A chronic blistering autoimmune
Pres (pemphix=bubble)
disease(idiopathic)
enta A potentially fatal autoimmune
-Attachment of basal cells to basement
disease characterized by
tion
membrane is selectively damaged
destruction of the desmosomes
Commonly affects people 60yoa or older
of stratified squamous epithelium
-Occurs twice as often as
of mucus membranes and skin
pemphigus vulgaris
Incidence 1/1000,000 and
-Less aggressive than Pemphigus vulgaris
usually occurs in middle or older
and is not life threatening
aged individuals
Widespread blistereing eruption in a older

Dermatitis herpetiformis
(clustering)

Chronic recurrent Pruritic


eruption on extensor surfaces
occurring often in symmetric
groups and including three types
of lesions
-Vesicles
-Papules
-Urticarial wheals

Erythema Multiforme( wide variety of lesions)


General term for diverse reaction patterns of blood vassels
in dermis with secondary epidermal changes
Multiforme refers to a wide variety of lesions

patient who is taking multiple medications

Dist
ribit
on
Lesi
ons

Signs
/

Sx

Localized: -mouth
Generalized: -scalp; -face; -chest;
-axillae; -groin
Pirmary: -Bullae
Secondar; -Erosions; -erythema
Lesions; -Skin colored; -Round or
oval; -Randomly scattered
Mucous membranes
-Erosions of mouth, nose, pharynx,
larynx ad vagina

Painful
Bullae are rarely seen
No pruritis

Flexural areas: -Groin; -Axillae


Oral involvement: Occurs in 1/3
of cases
Primary
-Bullae
-Urticarial(hives) plaques
Secondary
-Erosions
-Erythema
Puritis may be present

Weakness, malaise, weight loss if


prolonged mouth involment

Dx

Based on Positive Nikolskys sign


(+)dislodging of epidermis with the
lateral aspect of the finger in area of
lesions results in an erosion and
pressure on bullae leads to lateral
extension of bullae (blister breaks
when you apply pressure)
-Confirmed by biopsy and
examination for IgG deposits between
epidermal cells

Deep shave or punch biopsy from


intact bulla to reveal subepidermal bullae.

Extensor surfaces
-Sarcum; -Elbows; -Knees; -Lower
back; -Shoulders
Primary
Vesicles; Papultes; Uriticarial
wheals; Plaques
Secondary
Excoriations; Erythema
Often no intact primary lesions are seen
because of the intense pruritis and
excoriations
-Puritis
-Intense episodic burning or
stinging of skin
-Gluten enteropathy in most
patients
-Local symptoms(pruritis and
stinging of skin) precede
appearance of skin lesions by
8-12 hours
-Clinical eruption of sever itching,
burning and stinging
-On extensor surfaces
Biopsy
PMNs
(polymorphonucleocytes) and
subepidermal blister formation

-Symmetric
-Predilection for dorsum of hand, tops of feet, soles
-Also on forearms, feet, face, penis and vulva
Primary
Papules; Plaques
Secondary
Erythema
Lesions
- blanch with pressure; -Vesicles and bullae in center
of papule; -Iris or target shaped lesions
-Central clearing; -Localized to hands or generalized
Severe fever
Sever prostration (complete physical or mental exhaustion)
Mild form
-Little or no mucus membrane involvement
-No bullae or systemic Sx
-Eruptions usually confined to extensor surfaces
Severe form
-Most often occurs as a drug reaction
-Always involves mucous membrane

Positive Nikolskys sign(like Pemphigus Vulgaris)


Stevens-Johnsons syndrome
-Severe erythema multiforme with extensive mucosal
erosions, target-like lesions and skin blisters. Almost total
loss of epidermis known as toxic epidermal necrolysis.
-Often associated fever and malaise. Commonly affects oral
cavity, pharynx, conjunctiva and anogenital regions

History

Often associated with gluten intolerance

Duration

Lesions last days to weeks

Lesions last several days

Scabies
Excoriated eczema
Insect bites

Target lesions are quite typical and Dx is not difficult

DDx

Dermatitis Herpetiformis
Apthae (canker sores)
Erythema multiforme
Tx: -Systemic
corticosteroids(prednisone)
-Immunosuppressant
agents(methotrexate) -Referral

Pemphigus vulgaris(not purities,


mucous membrane is involved and
rarely are bullae intact.

In absence of skin lesions


Mucus membrane lesions must be DDx with
-Bullous diseases
-Fixed drug erruption

3
Urticaria(Chart 1 of 1)
Urticaria (burning)
Presentation

From Latin to burn and the nettle species Urtica which produces a stinging sensation of the skin when contacted.
Common condition characterized by Pruritic, transient hives or wheals as a result of vasodilation and subsequent fluid leakage into the dermis

Distribution
Lesions

Lesions change in size and shape


Can be oval, arciform, annular, and as coalesce; serpiginos
Individual lesions last less than 24hrs
Wheals
Erythema
Edema

Signs/Sx

Angiodema(Allergic skin disease characterized by patches of circumscribed swelling)


-involvment of deeper tissues with predilection for mucus membrane

Dx

When taking history, include onset, medications, environmental changes, foods, illness
Acute Urticaria: Lesions are present for less than 6 weeks
Chronic Urticaria: Lesions last longer than 6 weeks
Generalized Urticaria: May be life-threatening and involve major organ systems

History

Underlying cause is identifiable in less than 25-50% of cases


-Circulating Ag(drugs, inhalants, stress)
-Physical or environmental exposure(i.e. cold urticaria which occurs during re-warming, pressure urticaria)

Duration

Individual lesions last less than 24hrs

DDx

Erythema multiforme
Insect bites

Other

Dermatographism (Hives appear after scraping skin)


ND Approach
Identify food sensitivities
Adrenal support
Immune support

4
Papilloquammous Diseases( Chart 1 of 2)
Allergic/Contact
Dermatitis

Nummular
eczema(Discoid eczema)

Lichen Simplex
Chronicus

Atopic Dermatitis

Localized form of
lichenification usually
occurring in circumscribed
plaques

Atopy (out of place)


Pruritic skin disorder involving cutaneous
hypersensitivity

Presentation

Acute vesicular dermatitis with in


a few hours to 72 hours after
contact.

Chronic, puritic inflammatory


dermatitis occurring in the form
of coin shaped plaques

Distribution

Site of contact

Regional clusters of lesions or


generalized.

Lesions

Primary
Vesicles, bullae, papules and
wheals
Secondary
Erythema, edema, exudate,
excoriation, fissures,
lichenification and
hypopigmentation

Sign

Only in area of exposure, history


important

Symptom

Puritis

Predilection; lower legs and


trunk
Primary
Closely grouped, small vesicles
and papules that coalesce into
plaques
4-5cm in diameter
Erythematosus base
Distinct borders
Secondary
Excoriation and lichenification
Worse in fall or winter

Puritis

Predilection for the flexural surfaces, front and side of


the neck, eyelids, forehead, wrists and dorsa of feet and
hands
Scaling is limited
Excoriations are often
present
Palpably thicker skin

Primary/acute phase
Plaques, papules Skin appears puffy and
edematous(swollen)
Secondary
Erythema, scale excoriation, fissures, crusts and
lichenification in chronic lesions

Skin markings are


accentuated and more
visible

Chronic scratching

Dx

The itch that rashes.


Constant scratching leads to a cycle of itchscratcitch
which leads to lichenification(rough skin) rash of the
skin
Can have periorbital pigmentation from compulsicely
rubbing the eyelids
Atopic individuals may also have allergies, allergic
rhinitis, asthma, elevated levels of IgE
Puritis
Dry skin

History

History of exposure to allergen


or related compound

Personal history of allergic rhinitis


Family history of atopic dermatitis
Early age of onset(</= 2 yrs)
Usually begins in early childhood

Ask person how it initially


presents before they scratch.

Variable disease course


Duration
DDx
Image

Resolves with in 21 days


Nummular eczema
Atopic eczema
Scabies

Psoriasis
Contact dermatitis

Lesions persist for months and/or years


Seborrheic dermatitis
Psoriasis
Scabes

5
Papillosquammous Diseases( Chart 2 of 2)
Lichen Planus
Seborrheic Dermatitis
Characterized by a polygonal
Common, chronic
Present violaceous(violet) papules and
erythematosus scaling eruption
ation
plaques
of unknown cause that affects
all age groups but usually
affects adults 20 years or older
Distrib
ution

-Mouth
-Genitals
-Volar wrist s(bracelet)
-Ankles
-May be generalized
-Symmetrical
-Nails may be involved(varies
from minor dystrophy to total nail loss)
Lesions Papules and plaques
Post inflammatory
hypopigmentation (similar to a
scar)

Signs

Whickhams striae (white lace like


patterns on surface of papules and
plaques). Not always present
Feels very hard and can often affect genitals

Psoriasis
An itching condition
Common hyperproliferative inflammatory
disorder of unknown cause
Results in rapid cell turnover in the
epidermis(1000x than normal)

Pityriasis Rosea
-Eruptive dermatitis that primarily affects people age
10-35
Suspected to be of viral origin
-Characteristic eruption usually begins with a
herald patch on the trunk 1 to 2 weeks prior to the
onset of the truncal eruption
Occurs in regions where the -Can be single lesion or lesions localized Trunk
to one area(i.e penis, nails) or it can be
sebaceous glands are
regional(i.e. scalp)
Upper extremities
most active
-Face -Scalp
-Unilateral or bilateral
-Often spares exposed areas(palms)
Rarely on face
-Body folds
Scalp involvement is commonly Favors elbows, knees, intertriginous (where 2
known as dandruff in adults and
surfaces rub together) areas and scalp
cradle cap in infants

-Yellowish red often


greasy scaling macules and
papules(5-20mm)
-Sticky crusts are common
when scalp, external ear,
axillae and groin are involved
-Nummular, annular or
trunk shape
-Scattered, discrete
arrangement on face and
trunk
-Diffuse arrangement on scalp
Pityrosporum ovale (a normal
yeast flora is thought to play a
role)

Nail involvement
-Pitting of nails, oil spot(yellow-brown)
-Distal separation of the nail plate
from the bed (onycholysis)
-Scale forms underneath nail plate
Skin lesions
-Sharply demarcated papules and
plaques
-well developed lesions have a
thick silvery scale
-Peeling off the scale will reveal
pinpoint bleeding from capillaries close
to the top layer of skin (Auspitzs sign)

-Initially appears in people under 20


yoa but can occur at any age
-Thick silvery scale
-Auspitzs sign

Sx

Dx

Clinical appearance of typical


erythematous papules and plaques
with a thick silvery scale

Based on lesions appearance a


characteristic location
With buccal involvement look for
Wickhams striae

Deep shave or punch biopsy may


be necessary

Family history common

Hx
prognosis

DDx

Psoriasis
Lichenoid drug eruptions

Psoriasis
Candidiasis
Acne rosacea
Butterfly rash of SLE(Systemic
lupus Erythematosus)

Herald Patch
-Several cm in diameter and can mimic tinea
corporis
-Oval, slightly raised dull red plaque, bright red with a
fine collarette/centripical scale at periphery
- Herald patch occurs in 80% if patients
-Herald patch is followed by generalized secondary
eruption
Generalized eruption
-Plaques, papules, erythematous scale,
hyperpigmentation in dark skinned patients
-Scales tend to be centrally located
Exanthum: Fine scaling papules and plaques with
typical marginal collarette(scaling around edge)

Trigger factors
-Kobners phenomenon(physical
trama will lead to the development of
a plaque)
-Infections; -Stress; -Drugs
-Diet high is arachidonic acid,
cGMP cycle

May or may not have mild to severe puritis


-Based on clinical history, the presence of Herald
Patch(not always present)
-Characteristic distribution; trunk and upper
extremities
-Appearance of central scale(exanthemous lesions)
Often history of URTI
Self-limited
Psoriasis Forms:
Guttate -Sudden onset of small scattered tear drop
schaped papules and plaques after a streptococcal
infection as a child or young adult(URTI)
Ask Px, Where you sick prior to the skin irruption?
Pustular: Occurs on the hands and feet including the
nails(toenails and fingernails)
-Eczema(discoid); -Tinea corporis; -Drug eruption