DISCLOSURE OF RELEVANT RELATIONSHIPS WITH INDUSTRY. Daniel A. West, MD I HAVE NO RELEVENT RELATIONSHIPS WITH ANY COMPANIES

DISCLOSURE OF RELEVANT RELATIONSHIPS WITH INDUSTRY Daniel A. West, MD I HAVE NO RELEVENT RELATIONSHIPS WITH ANY COMPANIES

The most likely diagnosis is: A. Allergic contact dermatitis B. Pemphigus vulgaris C. Psoriasis D. Tinea corporis E. Tinea versicolor

Epidemiology All races Male = female Peak age of onset 25-40 years 90% cases before 40 years

Arthritis Variable, but up to 20-40% Types: Asymmetric oligoarticular Symmetric polyarticular DIP Ankylosing spondylitis Arthritis mutilans

Type 1 and 2 psoriasis? Henseler and Christophers Type 1 psoriasis (onset age <40 y), and type 2 psoriasis (onset age >40 y) Type 1: increased in first-degree relatives, increased HLA linkage, more severe disease Type 2: sporadic, less familial, less HLA linkage, less severe

Infection HIV Triggers Trauma (physical, chemical, electrical, etc) Pregnancy Drugs (b-blockers, lithium, steroid withdrawal, NSAIDS, antimalarials) Smoking

Distractors Pemphigus vulgaris* Allergic contact dermatitis*

Tinea corporis* Incorrect Choices Tinea versicolor*

The most likely diagnosis is: A. Arterial ulcer B. Lipodermatosclerosis C. Livedoid vasculopathy D. Pyoderma gangrenosum E. Venous stasis ulcer

Pathergy Pyoderma gangrenosum Satellite purple papules will appear just distal to the edge of the ulcer and eventually ulcerate Painful with violaceous overhanging border Bullous forms 50% patients with underlying disease Inflammatory bowel disease is most common Therapy often difficult

Arterial ulcer Distractors Lipodermatosclerosis*

Distractors Livedoid vasculopathy* Venous stasis*

The most likely diagnosis is: A. Contact dermatitis B. Psoriasis C. Minocycline hyperpigmentation D. Phytophotodermatitis E. Photodrug eruption

The most likely diagnosis is:

The most likely diagnosis is: A. Contact dermatitis B. Psoriasis C. Minocycline hyperpigmentation D. Phytophotodermatitis E. Photodrug eruption

Photodrug eruption Broad types of photodrug eruptions Phototoxic Photoallergic

Phototoxic Photodrug eruption Does not require sensitization Resembles exaggerated sunburn Pain > itch Can develop quickly, i.e. within hours Photoallergic Requires sensitization Resembles contact dermatitis Itch > pain Potentially more delayed

Phototoxic Oral > topical Photodrug eruption Amiodarone, tetracyclines, quinolones, sulfonamides, NSAIDs, thiazides, psoralens, voriconazole, phenothiazines, hypericin Photoallergic Topical > oral Sunscreens, fragrances, chlorhexidine NSAIDs, phenothiazines, griseofulvin

Unique phototoxic reactions Psuedoporphyria Photo-onycholysis Slate-gray hyperpigmentation Phytophotodermatitis

Contact dermatitis* Distractors Psoriasis*

Minocycline hyperpigmentation Distractors Phytophotodermatitis

The most likely diagnosis is: A. Calciphylaxis B. Erythema induratum C. Erythema nodosum D. Leukocytoclastic vasculitis E. Toxic epidermal necrolysis

Calciphylaxis Rare disorder with high mortality rate Cutaneous ischemia and necrosis secondary to calcification, intimal fibroplasia and thrombosis of pannicular arterioles Commonly affects individuals with end-stage renal failure High levels of serum calcium and phosphate Risk factors include hyperparathyroidism, elevated calcium-phosphate product, diabetes mellitus, female gender, obesity, warfarin use and protein C or S deficiency, liver disease, systemic corticosteroid use Typical clinical presentation: painful ischemic purpura and necrotic ulceration

Distractors Erythema induratum Erythema nodosum*

Distractors Leukocytoclastic vasculitis Toxic epidermal necrolysis*

The most likely diagnosis is: A. Plasma cell balanitis B. Lichen planus C. Lichen sclerosus D. Herpes simplex infection E. Aphthosis

Lichen sclerosus Sclerotic and atrophic white patches and plaques with associated erosion or ulceration Occurs in all ages Genitalia most commonly affected Complications: scarring, phimosis, squamous cell carcinoma Pruritus common complaint

Plasma cell balanitis Distractors Lichen planus*

Distractors Herpes simplex infection*

A 48 year old woman presents with several months of a progressive itchy rash that started on the upper torso and spread to the lower torso and extremities including the palms and soles. The most likely diagnosis is: A. Ichthyosis vulgaris B. Lichen planus C. Pityriasis lichenoides D. Pityriasis rosea E. Pityriasis rubra pilaris

Pityriasis rubra pilaris Coalescence of orange-red plaques with islands of sparing Cephalocaudad spread Orange-red waxy keratoderma of palms and soles Follicular papules on an erythematous base on dorsal fingers Varying degrees of exfoliation Thickened nail plate with subungual hyperkeratosis

Ichthyosis vulgaris* Distractors Lichen planus* Pityriasis lichenoides*

Distractors Pityriasis rosea*

The most likely diagnosis is: A. Eruptive xanthomas B. Erythema elevatum diutinum C. Lichen amyloidosis D. Lichen planus E. Necrobiosis lipoidica

Eruptive xanthomas Erythematous to yellow papules Extensor extremities, buttocks and hands May be accompanied by pruritus or tenderness Occur in setting of primary or secondary hypertriglyceridemia (>3000 to 4000mg/dL) Type I, IV and V hypertriglyceridemias

Distractors Erythema elevatum diutinum Lichen amyloidosis

Lichen planus* Distractors Necrobiosis lipoidica*

The most likely diagnosis is: A. Arsenical keratoses B. Keratoderma climactericum C. Erythema multiforme D. Punctate keratoderma E. Syphilis

Syphilis Chronic infection caused by Treponema pallidum Intermittent disease with primary, secondary and tertiary stages Variety of clinical presentations Secondary syphillis is associated with systemic signs including fever, malaise and adenopathy

Syphilis

Distractors Arsenical keratoses Keratoderma climactericum

Erythema multiforme* Distractors Punctate keratoderma

A 65 year-old man presented with this condition. He said it gets worse in the sun. The most likely diagnosis is: A. Allergic contact dermatitis B. Erysipelas C. Lupus erythematosus D. Rosacea E. Seborrheic dermatitis

Rosacea Inflammatory condition of the pilosebaceous unit Exact cause unknown Known triggers UV light Alcohol Spicy food Extremes in temperature Stress

Clinical features Rosacea Erythematotelangiectatic (vascular): flushing, erythema, telangiectasia Papulopustular Phymatous: especially rhinophyma Ocular: dry or gritty sensation, blepharitis, conjuntivitis Rosacea fulminans (pyoderma faciale): very severe form

Treatement Avoid triggers Metronidazole Azeleic acid Sulfacetamide +/- sulfur Brimonidine Cyclosporine drops (ocular) Tetracyclines Azithromycin Isotretinoin Lasers Rosacea

Distractors Erysipelas Allergic contact dermatitis*

Distractors Lupus erythematosus* Seborrheic dermatitis*

A. Sarcoidosis B. Leprosy C. Erysipelas D. Tinea E. Urticaria The most likely diagnosis is:

Leprosy Chronic, slowly progressive infectious disease caused by Mycobacterium leprae Predilection for peripheral nerves and skin Organism spread via nasal and oral droplets or breaks in skin barrier Affects all races and ages Peak incidences: 10-15 yrs and 30-60 yrs Three requirements for spread of disease Contagious person, susceptible person and close intimate contact

Leprosy Most common classification scheme used is by Ridley and Joplin (1966) LL: lepromatous leprosy TT: tuberculoid leprosy BB: borderline leprosy (BL, BB, BT) WHO classification (1997) Paucibacillary (single lesion) Paucibacillary (2-5 skin lesions) Multibacillary (more than 5 skin lesions)

Cutaneous manifestations: Leprosy Lepromatous leprosy: widespread, symmetric poorly defined erythematous macules, papules and plaques on face, buttocks, lower extremities Leonine facies, saddle nose deformities, bilateral earlobe infiltration, acquired icthyosis Borderline leprosy: asymmetric discrete erythematous plaques with alopecia Tuberculoid leprosy: few well-demarcated erythematous plaques

Distractors Sarcoidosis* Erysipelas

Distractors Tinea* Urticaria*

A 37 year-old woman presents with a 3 year history of painful erosions in the skin folds that heal leaving scars. The most likely diagnosis is: A. Hailey-Hailey disease B. Candidiasis C. Irritant dermatitis D. Lichen simplex chronicus E. Herpes simplex virus infection

A 37 year-old woman presents with a 3 year history painful erosions in the skin folds that heal leaving scars. The most likely diagnosis is: A. Hailey-Hailey disease B. Candidiasis C. Irritant dermatitis D. Lichen simplex chronicus E. Herpes simplex virus infection

Hailey-Hailey disease Familial benign chronic pemphigus AD, mutation in ATP2C1 gene, dysfunctional Ca2+ ATPase and intracellular Ca2+ signalling Second and third decade of life Flaccid blisters and erosions of neck and intertriginous areas axillae, groin, inframammary Easily ruptured blisters, macerated crusted erosions, chronic moist vegetative plaques with painful fissures common

Distractors Irritant dermatitis* Candidiasis*

Distractors Lichen simplex chronicus* Herpes simplex virus Infection*

The most likely diagnosis is: A. Tinea versicolor B. Psoriasis C. Parapsoriasis D. Tinea corporis E. Granuloma annulare

Controversial entity Parapsoriasis Clonal dermatitis transition point between chronic polyclonal dermatitis and mycosis fungoides? 2 types: small plaque, large plaque

Small plaque parapsoriasis Parapsoriasis Considered minimal to no chance of evolving to MF Less than 5 cm diameter Round to oval variably pinkish to hyperpigmented patches, thin plaques Digitate variant Large plaque parapsoriasis Considered to have potential for evolution to MF vs just early stage MF Larger than 5 cm diameter Often more irregular Retiform variant

Tinea versicolor* Distractors Psoriasis*

Distractors Tinea corporis* Granuloma annulare*

The most likely diagnosis is: A. Cutaneous anthrax B. Gonococcemia C. Reactive arthritis D. Sweet syndrome E. Syphilis

Gonococcemia Characteristic cutaneous lesions: Scattered papules or pustules (often hemorrhagic) with necrotic centers on distal acral sites Embolic septic vasculitis Acute arthritis-dermatosis syndrome Most common clinical manifestation of gonoccocal bacteremia Fever, joint pain, rash

Distractors Reactive arthritis (Reiter s)* Sweet s syndrome*

Distractors Syphilis*

The most likely diagnosis is: A. Aphthous stomatitis B. Contact dermatitis C. Erythema multiforme D. Paraneoplastic pemphigus E. Squamous cell carcinoma

Aphthous stomatitis Oval, shallow, discrete painful ulcers with yellowish base and erythematous halo Commonly involves labial or buccal mucosa Most often heal within 7-10 days Peak prevalence occurs during second decade

Distractors Erythema multiforme* Paraneoplastic pemphigus

Distractors Squamous cell carcinoma*

The most likely diagnosis is: A. Chronic radiation dermatitis B. Coumadin necrosis C. Leukocytoclastic vasculitis D. Squamous cell carcinoma E. Toxic epidermal necrolysis

Coumadin necrosis Develops within 2-5 days of starting warfarin in the absence of heparin especially with loading doses of coumadin Early drop in protein C levels Incidence is higher in women; peak incidence in 6 th and 7 th decades of life

Coumadin necrosis Begins as intense pain, with subsequent development of sharply demarcated erythema with overlying hemorrhage and necrosis. Retiform branching purpura seen at periphery of cutaneous lesions Peak incidence in women >50 years of age. Typical in sites with abundant subcutaneous tissue, such as the breasts, hips, buttocks or thighs.

Chronic radiation dermatitis* Distractors Leukocytoclastic vasculitis

Distractors Squamous cell carcinoma* Toxic epidermal necrolysis*

A 60 year old man presents with severely itchy blisters on the elbows, knees and upper back. The most likely diagnosis is: A. Neurotic excoriations B. Erythema elevatum diutinum C. Pemphigoid D. Scabies infestation E. Dermatitis herpetiformis

The most likely diagnosis is: A. Neurotic excoriations B. Erythema elevatum diutinum C. Bullous pemphigoid D. Scabies infestation E. Dermatitis herpetiformis

Dermatitis Herpetiformis Cutaneous manifestation of celiac disease and is associated with gluten sensitivity in most cases IgA antiendomysial antibodies are directed against tissue transglutaminase Mean age of onset: 4 th decade of life M>F:2:1

Dermatitis Herpetiformis Symmetric distribution: extensor elbows, forearms, nape of neck, back, buttocks and extensor knees Pleomorphic primary lesions: urticarial papules, plaques and vesicles Classic presentation: grouped excoriated papulovesicles on an erythematous base

Distractors Neurotic excoriations Erythema elevatum diutinum

Distractors Pemphigoid* Scabies infestation*

A 31 year-old female got this eruption shortly after using a topical steroid for a rash. The most likely diagnosis is: A. Perioral dermatitis B. Perleche C. Actinic cheilitis D. Contact dermatitis E. Herpes simplex virus

Perioral dermatitis (AKA periorificial dermatitis) Common in young adult women Cause unknown, but can be triggered by topical steroids Papules, pustules, erythema, scale; primary lesions often monomorphic Commonly spares vermillion border Can be periocular Can have burning, itching Treat similar to rosacea

Perleche (angular cheilitis) Distractors Actinic cheilitis

Distractors Contact dermatitis* Herpes simplex*

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