A Beginners Guide to Red Scaly Spots (Papulosquamous Disorders)

A Beginners Guide to Red Scaly Spots (Papulosquamous Disorders) Ian D.R. Landells, MD, FRCPC Clinical Associate Professor Memorial University of Newfoundland Medical Director Dermatology Nexus Clinical Research St. John s, NL Canada

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Learning Objectives Identify various types of skin lesions Assess red, scaly plaques and determine key factors for accurate diagnosis Make a differential diagnosis of plaque skin lesions commonly seen in clinical practice

Disclosure I have two daughters They have both had red, scaly spots at some point in their lives No other conflicts

Non-Palpable vs. Palpable Skin Lesions Non-palpable Macule <1 cm Patch >1 cm Palpable Papule <1cm Plaque >1cm Photo top left: DermAtlas; www.dermatlas.org

Depressed Lesions Ulcer Excoriation Erosion Atrophy

Other Skin Terminology Scale Lichenification Depigmentation Hyper- / Hypopigmentation

Initial Observations of Red, Scaly Plaques: Eczema or Plaque Psoriasis? Are the edges of the lesions well demarcated? Is the scale broken? Are there cracks in the surface of the lesions with any oozing or weeping? When the plaques are scratched, are scales silvery? Photo on left: Danderm; www.danderm-pdv.is.kkh.dk; photo on right: DermAtlas; www.dermatlas.org

Initial Observations of Red, Scaly Plaques: Eczema or Plaque Psoriasis? Are the edges of the lesions well demarcated? Yes No Are there cracks in the surface with any oozing or weeping? Eczematous What lesions is your or one of provisional other several diagnosis? lesion types Yes No What is your Eczematous lesions provisional diagnosis? When the plaques are scratched, are scales silvery? Yes No What is your Plaque psoriasis provisional diagnosis? Take scrapings What is your for fungal provisional culture before diagnosis? treating Adapted from: Spektor M, et al. In: Harwood-Nuss Clinical Practice of Emergency Medicine. 2010:831; dermadvocate, 2010; ddderm.blogspot.com, 2010.

Eczematous or Plaque Psoriasis Lesions? A B Plaque psoriasis Asteatotic eczema Photo on left: Danderm; www.danderm-pdv.is.kkh.dk; photo on right: DermAtlas; www.dermatlas.org

Differential Dx Eczema/Nummular Dermatitis Psoriasis Lichen Planus Pityriasis Rosea Tinea Corporis Secondary Syphilis Mycosis Fungoides/Cutaneous T-Cell Lymphoma Neurodermatitis/Lichen Simplex Chronicus

Cutaneous Lichen Planus

Cutaneous Lichen Planus Cutaneous lichen planus is an inflammatory disease Also affects mucosae and genitals (mouth, vulva, penis) It has an unknown etiology May be associated with drug exposure (where it appears as a generalized eruption) May be associated with chronic hepatitis C infection Consider verifying the patient s hepatitis C serology It can occur at any age, although it has a mean onset in the 40s Rare in children younger than 5 years Habif TP. Clinical Dermatology. 2010. Dorland s Online Dictionary; www.dorlands.com. Lazar AJF, et al. In: Robbins and Cotran Pathologic Basis of Disease, Professional Edition. 2009.

Clinical Signs/Symptoms of Cutaneous Lichen Planus Characterized by the six Ps : Pruritic Purple Polygonal Planar Papules Plaques Numerous patterns and sites; common on wrists, forearms, legs, ankles, and lumbar region Check for lesions in mucosae and genitals: mouth, penis, vulva DermAtlas; www.dermatlas.org Acute and localized or chronic and widespread Habif TP. Clinical Dermatology. 2010. Dorland s Online Dictionary; www.dorlands.com. Lazar AJF, et al. In: Robbins and Cotran Pathologic Basis of Disease, Professional Edition. 2009.

Clinical Signs/Symptoms of Cutaneous Lichen Planus New lesions are pinkwhite, but over time develop a distinct purple color with a waxy luster Lesions may coalesce to form plaques Close examination can reveal Wickham s striae: Lacy, crisscrossed, whitish lines on the surface of lichen planus papules, which can be accentuated by applying a drop of immersion oil DermAtlas; www.dermatlas.org Habif TP. Clinical Dermatology. 2010. Lazar AJF, et al. In: Robbins and Cotran Pathologic Basis of Disease, Professional Edition. 2009.

Differential Diagnosis: Cutaneous Lichen Planus vs. Other Red, Scaly Lesions Lichen planus Plaque psoriasis Photos DermAtlas; www.dermatlas.org

Treatment of Cutaneous Lichen Planus Usually resolves spontaneously 1 to 2 years after onset, often leaving a persistent brown stain Low to moderate potency topical steroids (cream or ointment applied twice daily) are used for initial treatment of localized disease Steroid injections may reduce lesions on wrists and lower legs Antihistamines may provide relief from itching PUVA and UVB therapy are effective for generalized disease PUVA = UVA with psoralen Habif TP. Clinical Dermatology. 2010. Lazar AJF, et al. In: Robbins and Cotran Pathologic Basis of Disease, Professional Edition. 2009.

Take-Home Pearls Cutaneous lichen planus is an inflammatory skin reaction, either acute and localized or chronic and widespread May be drug-induced or associated with chronic hepatitis C infection Its clinical appearance is characterized by the six Ps Pruritic, purple, polygonal, planar, papules, and plaques Wickham s striae are lacy, crisscrossed, whitish lines on the surface of lichen planus papules The disease commonly resolves spontaneously in 1 to 2 years after onset, often leaving a persistent brown stain Initial treatment is topical steroids Phototherapy may be useful

Differential Diagnosis: Cutaneous Lichen Planus vs. Other Red, Scaly Lesions Pityriasis rosea Lichen planus Photo at left: DermAtlas; www.dermatlas.org. Photo at right: Danderm; www.danderm-pdv.is.kkh.dk.

Pityriasis Rosea

Pityriasis Rosea Common, acute, distinctive, self-limiting skin eruption of unknown origin Possibly linked to human herpesvirus 6 Typically affects children and young adults, with a peak incidence among people in their twenties Outbreaks may occur in clusters (e.g., in fraternity houses, military bases) Up to 69% of patients have a viral upper respiratory tract infection prior to the skin lesion Habif TP. Clinical Dermatology. 2010. Stulberg DL, et al. Am Fam Physician. 2004;69:87-92,94.

Clinical Signs/Symptoms of Pityriasis Rosea Typically, a single herald plaque appears following a viral infection Most commonly appears on the trunk or nearby extremities Lesion is a slightly raised, erythematous, oval plaque, 2 to 10 cm in diameter Tissue-like scale (collarette of scale) at the margins Often mistaken for eczema or acute guttate psoriasis Danderm; www.danderm-pdv.is.kkh.dk Habif TP. Clinical Dermatology. 2010. Stulberg DL, et al. Am Fam Physician. 2004;69:87-92,94.

Clinical Signs/Symptoms of Pityriasis Rosea 7 to 14 days after the herald plaque appears, crops of 1- to 2-cm oval, raised plaques appear Salmon-coloured in people with light skin and hyper- or hypo-pigmented in people with dark skin Plaques are aligned along Langer s lines Christmas tree pattern on the back V-shape pattern on the upper chest Transverse pattern across the lower abdomen DermAtlas; www.dermatlas.org 26 Habif TP. Clinical Dermatology. 2010. Stulberg DL, et al. Am Fam Physician. 2004;69:87-92,94.

Clinical Signs/Symptoms of Pityriasis Rosea Secondary lesions are typically limited to the trunk, but may involve the arms, legs, and face Inverse distribution is rare The number of lesions ranges from a few to hundreds Pruritus is rarely prominent Compared to Caucasians, dark-skinned patients are more likely to have: Lesions on the face and scalp Extensive and papular lesions Faster resolution of the disease Residual pigmentation changes In more than 80% of patients, the rash lasts about 5 weeks and resolves by 8 weeks Habif TP. Clinical Dermatology. 2010. Stulberg DL, et al. Am Fam Physician. 2004;69:87-92,94. Amer A, et al. Arch Pediatr Adolesc Med. 2009;161:503-506.

Differential Diagnosis: Pityriasis Rosea vs. Other Red, Scaly Lesions Pityriasis rosea Lichen planus Photos DermAtlas; www.dermatlas.org

Differential Diagnosis: Pityriasis Rosea vs. Other Red, Scaly Lesions Pityriasis rosea Plaque psoriasis Photos DermAtlas; www.dermatlas.org

Differential Diagnosis: Pityriasis Rosea vs. Other Red, Scaly Lesions Pityriasis rosea Nummular eczema Photos DermAtlas; www.dermatlas.org

Treating and Managing Pityriasis Rosea Disease is self-limiting, but patients may need treatment for pruritus Reassure patients that lesions should clear on their own in 1 to 3 months but to return if they last longer than 3 months For pruritus, if any, treat with zinc oxide, calamine lotion, topical steroids, and oral antihistamines For severe pruritus (very rare), oral steroids can be considered but should be used with caution The value of treatment with erythromycin remains to be determined UVB radiation may help to achieve earlier lesion improvement in patients with extensive disease Some experts do not recommend this use, since it can lead to hyperpigmentation Habif TP. Clinical Dermatology. 2010. Stulberg DL, et al. Am Fam Physician. 2004;69:87-92,94. Drago F, et al. Skin Therapy Lett. 2009;14(3):6-7.

Take-Home Pearls Pityriasis rosea is a common, acute, self-limiting skin eruption of unknown origin, found mainly in children and young adults in their 20s The initial herald lesion is an erythematous, slightly raised, oval plaque with a collarette of scale at the margins ~ 7 to 14 days later, a few to hundreds of 1- to 2-cm oval, raised plaques appear, often in a Christmas tree pattern on the back The rash typically lasts about 5 weeks and resolves by 8 weeks Treat pruritus as necessary with zinc oxide, calamine lotion, topical steroids, or oral antihistamines Phototherapy may be useful

Differential Diagnosis: Pityriasis Rosea vs. Other Red, Scaly Lesions Pityriasis rosea Tinea corporis Photo at left: Danderm; www.danderm-pdv.is.kkh.dk; Photo at right: DermAtlas; www.dermatlas.

Tinea Corporis

Clinical Signs/Symptoms of Tinea Corporis Annular erythematous plaques with a raised leading edge and scaling Central clearing may be visible in plaques Other possible manifestations: Erythematous papules or series of vesicles Large pustular lesions ± frank bullae DermAtlas; www.dermatlas.org. Gupta AK, et al. Dermatol Clin. 2003;21(3):395-400.

Clinical Signs/Symptoms of Tinea Corporis Lesions appear on glabrous skin (skin normally devoid of hair) of the torso, legs, and arms Tinea of the scalp, face, groin, hands, and feet are classified separately Pruritus is common Lesions may be painful if macerated DermAtlas; www.dermatlas.org Gupta AK, et al. Dermatol Clin. 2003;21(3):395-400.

Differential Diagnosis: Tinea Corporis vs. Other Red, Scaly Lesions Tinea corporis 37 Plaque psoriasis Photos DermAtlas; www.dermatlas.

Differential Diagnosis: Tinea Corporis vs. Other Red, Scaly Lesions Lichen planus Tinea corporis Photo at left: Danderm; www.danderm-pdv.is.kkh.dk. Photo at right: DermAtlas; www.dermatlas.org.

Non-Pharmacological Management of Tinea Corporis Wash affected area with antibacterial soap and dry area thoroughly before dressing Advise patient to wear loose-fitting clothing and to avoid sharing towels or clothing Collect skin scraping and send for fungal culture BEFORE any treatment

Pharmacological Management of Tinea Corporis Twice-daily application of a topical antifungal cream (e.g., ciclopirox, clotrimazole, ketoconazole, miconazole, naftifine, terbinafine) 1-3 Treatment response is typically seen within 2 weeks 3 Continue treatment for at least 1 week after infection is resolved 3 Topical corticosteroid use may be useful to reduce inflammation in combination with antifungal creams Warning: If used alone, can suppress signs of fungal disease, which may be mistaken for clearance of infection 2 Systemic treatment with an antifungal is necessary for chronic or recurrent disease or when large areas of the body are involved 1,2 Terbinafine: 250 mg/day for 2 to 4 weeks Fluconazole: 150 300 mg once weekly for 2 to 4 weeks Itraconazole: 200 mg/day for 1 week Ketoconazole: 200 400 mg/day for 4 to 8 weeks 1. Gupta AK, et al. Dermatol Clin. 2003;21(3):395-400. 2. Gupta AK, et al. Mycopathologia. 2008;166(5-6):353-367. 3. Habif TP. Clinical Dermatology. 2010.

Take-Home Pearls Tinea corporis can be identified by annular erythematous plaques with scaling and a raised leading edge May also manifest as erythematous papules, a series of vesicles or large pustular lesions ± frank bullae Lesions appear on glabrous skin, excluding scalp, face, beard, hands, feet, and groin Pruritus is common Collect skin scraping and send for fungal culture BEFORE any treatment Mainstay of pharmacological therapy is topical antifungal Systemic therapy with an antifungal is necessary for chronic disease or when a large area of the body is affected Patients should be advised to wear loose-fitting clothing and ensure area is thoroughly dry before dressing

Differential Diagnosis: Tinea Corporis vs. Other Red, Scaly Lesions Secondary syphilis Tinea corporis Photos DermAtlas; www.dermatlas.org

Secondary Syphilis

Clinical Signs/Symptoms of Secondary Syphilis Nonpruritic, pink or dusky red rash on the trunk, palms, and soles, in a symmetric pattern Lesions often occur along with superficial scale, or they may be smooth or follicular Lesions in the perineum may coalesce to form condyloma lata DermAtlas; www.dermatlas.org Baughn RE, et al. Clin Microbiol Rev. 2005;18(1):205-216. Domantay-Apostol GP, et al. Dermatol Clin. 2008;26:191-202. Dylewski J, et al. CMAJ. 2007;176(1):33-35.

Clinical Signs/Symptoms of Secondary Syphilis Additional possible clinical manifestations of secondary syphilis include: Adenopathy Arthralgia/arthritis Fever Malaise/anorexia Headache Meningitis Anterior uveitis Retinitis Cranial neuropathies Glomerulonephritis Hepatitis Osteitis/periostitis Alopecia The great imitator, secondary syphilis lesions can mimic eczema, psoriasis, drug eruptions, lichen planus, and pityriasis rosea Lesions appear 2 to 8 weeks after the primary chancre, which may not be noticed by the patient Baughn REMicro, et al. Clin Biol Rev. 2005;18(1):205-216. Domantay-Apostol GP, et al. Dermatol Clin. 2008;26:191-202. Dylewski J, et al. CMAJ. 2007;176(1):33-35. Dorland s Online Dictionary; www.dorlands.com.

Differential Diagnosis: Secondary Syphilis vs. Other Red, Scaly Lesions Secondary syphilis Eczema Photo at left: Danderm; www.danderm-pdv.is.kkh.dk. Photo at right: DermAtlas; www.dermatlas.org.

Differential Diagnosis: Secondary Syphilis vs. Other Red, Scaly Lesions Secondary syphilis Psoriasis Photos DermAtlas; www.dermatlas.org.

Differential Diagnosis: Secondary Syphilis vs. Other Red, Scaly Lesions Secondary syphilis Pityriasis rosea Photos DermAtlas; www.dermatlas.org.

Pharmacological Management of Secondary Syphilis Preferred treatment: Benzathine penicillin G 2.4 million units IM in a single dose Some experts recommend 3 weekly doses (total of 7.2 million units) of benzathine penicillin G in HIV-infected individuals Treatment for penicillin-allergic patients: Doxycycline 100 mg PO bid for 14 days Alternative, only in exceptional circumstances: Ceftriaxone 1 g IV or IM daily for 10 days Public Health Agency of Canada. 2010.

Other Patient Management Attempt to obtain material from secondary lesions for dark-field microscopy and/or direct/indirect fluorescent antibody for T. pallidum except for oral and anal lesions Perform serologic testing: Non-treponemal tests (NTT) such as rapid plasma reagin (RPR) or venereal disease research laboratory (VDRL), followed by confirmatory treponemal tests if the NTT is reactive Treponemal tests include T. pallidum particle agglutination (TP-PA), microhemagglutination-t. pallidum (MHA-TP), fluorescent treponemal antibody absorbed (FTA-ABS), EIA to detect IgG and/or IgM antibodies and the syphilis Inno Lia TM Syphilis testing algorithms vary across Canada; check with your lab regarding local testing protocols Public Health Agency of Canada. 2010.

Take-Home Pearls Secondary syphilis, the great imitator, can mimic many dermatologic diseases, including eczema, psoriasis, drug eruption, lichen planus, and pityriasis rosea RPR or VDRL serological testing Standard treatment is benzathine penicillin G, and for penicillin-allergic patients, doxycycline

Mycosis Fungoides/Cutaneous T- Cell Lymphoma

Clinical Signs/Symptoms of Cutaneous T-Cell Lymphoma Mycosis fungoides (MF), the most common type of cutaneous T-cell lymphoma (CTCL), appears as pink or red plaques Lesions commonly first appear on buttocks, sun-protected areas Typically, patients are diagnosed at age 55 to 60, and CTCL is about twice as common in men DermAtlas; www.dermatlas.org Mayo Foundation for Medical Education and Research; www.mayoclinic.org. The Leukemia & Lymphoma Society. www.leukemia-lymphoma.org. Whittaker SJ, et al. Br J Dermatol. 2003;149(6):1095-1107. Willemze R, et al. Ann Oncol. 2010;21(Supplement 5):v177-v180. Willemze R, et al. Blood. 2005;105:3768-3785.

Differential Diagnosis: Cutaneous T-Cell Lymphoma vs. Other Red, Scaly Lesions Cutaneous T-cell lymphoma Plaque psoriasis Photos DermAtlas; www.dermatlas.org

Differential Diagnosis: Cutaneous T-Cell Lymphoma vs. Other Red, Scaly Lesions Cutaneous T-cell lymphoma Contact dermatitis Photos DermAtlas; www.dermatlas.org

Differential Diagnosis: Cutaneous T-Cell Lymphoma vs. Other Red, Scaly Lesions Cutaneous T-cell lymphoma Eczema Photos DermAtlas; www.dermatlas.org

Patient Management Diagnosis Cutaneous T-cell lymphoma is diagnosed with a biopsy of the affected skin Treatment Depends on the type and stage of the disease Skin-directed therapies for localized, early stage disease Topical ointment (steroid or nitrogen mustard) Photochemotherapy (e.g., PUVA [psoralen + ultraviolet A light], Photophoresis) Radiotherapy (e.g., electron beam radiation) Whittaker SJ, et al. Br J Dermatol 2003;149(6):1095-1107. Willemze R et al. Blood 2005;105:3768-3785. Willemze R et al. Ann Oncol. 2010;21(Supplement 5):v177-v180. Cutaneous T-Cell Lymphoma. The Leukemia & Lymphoma Society. T-cell Lymphoma Diagnosis and Treatment Options at Mayo Clinic.

Patient Management Therapies for more advanced disease (i.e., involving lymph nodes): Chemotherapy Extracorporeal photophoresis Systemic therapy (e.g., interferon alpha, acitretin) Supportive therapies: Antihistamines, skin softeners, or steroid ointments may relieve itch Antibiotics for infected lesions Treatment for depression or insomnia, if needed Whittaker SJ, et al. Br J Dermatol 2003;149(6):1095-1107. Willemze R et al. Blood 2005;105:3768-3785. Willemze R et al. Ann Oncol. 2010;21(Supplement 5):v177-v180. Cutaneous T-Cell Lymphoma. The Leukemia & Lymphoma Society. T-cell Lymphoma Diagnosis and Treatment Options at Mayo Clinic.

Take-Home Pearls Mycosis fungoides, the most common type of CTCL, appears as pink or red plaques Sézary syndrome, a more aggressive form of CTCL, appears as erythroderma, sometimes with marked exfoliation, edema, and pruritic lichenification Treatment and management is related to disease severity Skin-directed therapies for localized, early stage disease include topical ointment, photochemotherapy (PUVA) and radiotherapy Supportive therapies may include anti-itch therapies, antibiotics, and treatment for depression or insomnia

Neurodermatitis/Lichen Simplex Chronicus

Neurodermatitis / Lichen Simplex Chronicus Neurodermatitis is eczema created by prolonged, self-inflicted scratching or rubbing to relieve pruritus 2 types of neurodermatitis: Disseminated neurodermatitis Circumscribed neurodermatitis (also known as lichen simplex chronicus), which is today s focus Lichen simplex chronicus commonly occurs in adults aged 30 to 50 years, although it may be seen in children Higher incidence in women and in Asians Habif TP. Clinical Dermatology. 2010. Prajapati V, et al. Can Fam Physician. 2008;54(10):1391-1393. Wine SJ, et al. Can Fam Physician. 1972;18(4):65-66. Dorland s Online Dictionary; www.dorlands.com.

Clinical Signs/Symptoms of Lichen Simplex Chronicus Pruritus, the predominant symptom, is often worse at night Triggers include clothing irritation, sweating, stress, and anxiety Patients scratch the itchy area, leading to erythema and skin thickening With time, the skin becomes thickened and leathery (lichenified) Habif TP. Clinical Dermatology. 2010. Prajapati V, et al. Can Fam Physician. 2008;54(10):1391-1393. Wine SJ, et al. Can Fam Physician. 1972;18(4):65-66. Danderm; www.danderm-pdv.is.kkh.dk

Clinical Signs/Symptoms of Lichen Simplex Chronicus Predominant sites include the nape and sides of the neck, extensor surfaces of the forearms and elbows, inner thighs, lower legs, ankle flexures, vulva, scrotum, and anus Patients with atopic dermatitis, psoriasis, or tinea corporis may develop secondary lichen simplex chronicus Combination of clinical and histological features of both diseases Patients usually present with a single lesion but may present with multiple lesions A typical plaque stays localized and shows little tendency to enlarge with time Habif TP. Clinical Dermatology. 2010. Prajapati V, et al. Can Fam Physician. 2008;54(10):1391-1393. Wine SJ, et al. Can Fam Physician. 1972;18(4):65-66.

Differential Diagnosis: Lichen Simplex Chronicus vs. Other Red, Scaly Lesions Lichen simplex Psoriasis Photos Danderm; www.danderm-pdv.is.kkh.dk

Differential Diagnosis: Lichen Simplex Chronicus vs. Other Red, Scaly Lesions Lichen simplex Contact dermatitis Photo at left: DermAtlas; www.dermatlas.org. Photo at right: Danderm; www.danderm-pdv.is.kkh.dk.

Differential Diagnosis: Lichen Simplex Chronicus vs. Other Red, Scaly Lesions Lichen simplex Tinea corporis Photo at left: Danderm; www.danderm-pdv.is.kkh.dk. Photo at right: DermAtlas; www.dermatlas.org.

Treatment and Management of Lichen Simplex Chronicus Advise patients to stop rubbing and scratching the lesions Pharmacologic therapy: High-potency topical steroid creams (betamethasone dipropionate and clobetasol propionate) are very effective for initial therapy Low-to-medium potency topical steroids, possibly compounded with menthol, camphor, or tar are also options Use of plastic film occlusion over steroid cream improves drug penetration and prevents patients from scratching lesions Tacrolimus ointment, topical capsaicin cream are used less often Intralesional corticosteroid injections may be used with caution for persistent lesions Sedating antihistamines may help severe nocturnal pruritus Habif TP. Clinical Dermatology. 2010. Prajapati V, et al. Can Fam Physician. 2008;54(10):1391-1393. Wine SJ, et al. Can Fam Physician. 1972;18(4):65-66.

Treatment and Management of Lichen Simplex Chronicus Non-pharmacologic therapy: Apply ice to the itchy area until the itch subsides Cover the affected skin area to prevent scratching during sleep Make lifestyle changes to lower stress Recalcitrant patients with severe lichen simplex chronicus may need to be referred to a psychologist or psychiatrist Treatment is difficult and recurrence is frequent Habif TP. Clinical Dermatology. 2010. Prajapati V, et al. Can Fam Physician. 2008;54(10):1391-1393. Wine SJ, et al. Can Fam Physician. 1972;18(4):65-66.

Take-Home Pearls Lichen simplex (localized neurodermatitis) is created by prolonged self-inflicted scratching or rubbing in response to pruritus of unknown origin Circumscribed neurodermatitis, also called lichen simplex chronicus, can be triggered by stress and anxiety Patients scratch the itchy skin area, leading to erythema and lichenification Treatments include topical steroids, plastic film occlusion, and possibly referral to a psychologist or psychiatrist Advise patients to stop scratching and rubbing the lesions

Summary Eczema most common, then psoriasis Lichen Planus Pruritic Purple Polygonal Papules Don t Forget Syphilis and Cutaneous T Cell Lymphoma Look for clues of self-induced or secondary lesions When in doubt Biopsy!

Thank You Any Questions?