DERM MIDTERM REVIEW

Acute allergic reaction (penicillin) = macule/plaque = URTICARIAL WHEEL TUBEROUS SCLEROSIS (46) o Genetic (autosomal dominant) o Aka: Adenoma Sebaceum (face lesions)- looks like acne but they never go away (pustules) o Pt inherits a number of other abnormalities (mental retardation) o Other manifestations: PERIUNGUAL FIBROMAS (Koenens tumors) SHAGREEN PATCH collection of collagen accumulating under skin which gives it this bump on the skin. Present close to birth ASH-LEAF HYPOMELANOTIC MACULES Also present close to birth Looks like a patch of vitiligo (pigment loss in the shape of a leaf) PSEUDOXANTHOMA ELASTICUM (314) o Elastic tissue calcification (of the internal elastic lamina arteries) o Prematurely aged skin (looks like xanthoma) o Complications: Intermittent claudication GI bleeding HTN Angina Acute loss of vision o Eye findings ANGIOD STREAKS of the retina (cracks in bruchs membrane) SLE (criteria required to establish the diagnosis) Antinuclear Antibodies Neurogenic seizures/ psychosis Thrombocytopenia/Lymphopenia/leucopenia/ hemolytic anemia Immunologic disorder Nasopharyngeal or other ulcers Urinary abnormalities (proteinuria/casts) Cutaneous discoid rash Light sensitivity Effusions (pleural/ pericardial) Arthritis (2 or more joints) Rash- malar

PRETIBIAL MYXEDEMA (132, 306) o Nodules or diffuse plaques usually on the anterior lower leg o Dermal mucin deposits o Specific for GRAVES DZ (see exopthalmos) Treatment of hyperthyroidism has no effect on the myxedema

PYODERMA GANGRENOSUM (313) o o o o o o o Severe ulcerative condition most often affecting the lower legs Associated with abdominal pain and bleeding of IBD Start as tender pustule that breaks down to form an expanding ulcer Sites of minor trauma PATHERGY Heals with thin, atrophic scar Assoctiated with Chrons disease and ulcerative colitis

LEUKOCYTOCLASTIC VASCULITIS (123) o Symmetrical palpable purpura of the lower extremities o Usually affects superficial (post capillary venules) vessels Nevertheless, punch biopsy strongly recommended to rule out large vessel involvement o Vessel walls = fibrinoid changes/ necrosis o Aka = allergic/ hypersensitivity vasculitis o Nuclear dust (histo) o One of the most common causes = Meds (Pen like drugs) and Strep infxs

DDX: Vasculitis (Mt Sinai Hospital Center) Meds Strep- other infx Henoch- Schonlein Purpura Connective Tissue Dz Malignancies Serum Sickness Hep C Cryoglobulinemia

REITERS SYNDROME (94)

Arthritis Balanitis circinata Urethritis = pain on urination Iritis = conjunctivitis Conjunctivitis Keratoderma Blenorrhagicum = pinpoint erythmatous papules that progress to pustules and hyperkeratosis papules and plaques (classic triad = nongonococcal urethritis, conjunctivitis, arthritis) Histologically, the findings are identical to the pustules seen in pustular psoriasis

NEUROFIBROMATOSIS (44-46) o Inheritance = autosomal dominant o Clinical features Caf- au- lait macules = sharply defined, light brown patches. Usually appear within 1st year of life Crowes sign = diffuse pigmentation of the axillae or other body folds Peripheral Neurofibromas = Start at puberty. Soft, pink, or flesh colored papules, nodules, or tumors distributed mainly over trunk and limbs Plexiform Neurofibromas = diffuse elongated neurofibroma occurring along the course of a nerve (trigeminal, upper cervical). Often disfiguring, associated with overlying skin hypertrophy, hyperpigmentation, and increase hair. Lisch nodules = Melanocytic hamartoma of the iris (90% in second decade of life) Most common CNS tumor = Optic glioma Most common skeletal abnormalities Macrocephaly Short stature Kyphoscoliosis Pseudoarthroses of tibia or fibula

KAPOSI SARCOMA

A) Classic o Risk group Elderly, male Eastern European or Mediterranean descent (Ashkenazi Jews/ Italians/ Greeks) o Course Slowly progressive- indolent, localized to skin and subcutaneous tissue

Starts in lower extremities with multiple red to purple plaques or nodules Spreads to more proximal sites May be locally aggressive Visceral organ involvement rare Lesions often respond to radiation therapy

B) AIDS o Most common neoplasm in pts with AIDS o Cutaneous lesions can occur anywhere: trunk, head, neck, feet o Often multifocal o Disseminate early in widely o Skin, mucous membranes, GI, lymph nodes, lungs o Often develop second malignancies (lymphoma, leukemia, myeloma o Tumors respond to chemo and alpha interferon therapy CONTACT DERMATITIS (76-81) Well known dermatosis Type IV reaction to topically applied Ag Most allergens are small Lipophilic molecules easily diffuse through epidermis and serve as hapten Most common cause = nickel Others: p- Phenylenediamine (hair dyes) Ethylenediamine (topical meds, asthma meds Amynophylline) o Cross reacts with PABA (in sunscreens) o Name of the Ag in poison ivy Rhus (poison ivy family = urushiol) Also found in cashews, mangos, Japanese lacquer, India ink Only Americans get poison ivy (Europeans dont) Lines of vesicles FELON = Infection of soft tissue space ONYCHOLYSIS o o o o o o Causes Tetracycline as a result of photosensitivity Hyperthyroidism Eczema, irritants ONYCHOSCHIZIA o o o o Fragmentation of edge of fingernail (splitting of ends of nail plate into layers) Characteristic of brittle nails Causes disputed Rx- Biotin 2.5, urea, moisturizers, avoid acetone containing nail enamel remover

CLUBBING (532-533)

o Ungual- Phalangeal angle (Lovibonds angle) increased o Tissue proximal to cuticle has spongy feel o Causes Respiratory ailments- 80% (Sarcoidosis, Emphysema) Congenital heart dz, Cirrhosis Pretibial Myxedema Congenital/ genetic factors May occur in association wit hypertrophic osteoarthropathy GLOMUS TUMOR o Benign vascular cutaneous tumor on or near the nail o Arises from the arterial segment of the cutaneous glomus, the Sucquet-Hoyer canal o Lesions = skin colored/dusky blue, firm nodules o Subungual tumor shows a bluish tinge through the translucent nail plate o Characteristically subungual but may occur elsewhere o Usually but not always painful. When multiple, usually not painful o Pain with cold temps o Squeezing tip helps with Dx >> bigger and brighter o Usually much larger than they appear PYOGENIC GRANULOMA (351) o Soft red papules that bleed easily with minor trauma o Most common on skin but can occur on mucosal surfaces HYDROSYSTOMA o Sweat gland tumor (apocrine gland so doesnt happen on the finger) PERIUNGUAL TELANGICTASIA (189) o Little capillaries proximal/ around cuticle o Happen in CT dzs (lupus, dermatomiositis) as well as in normal pts HYPERTROPHIC OSTEOARTHROPATHY (533) o Consists of hypertrophy of the upper and lower extremities, peripheral neurovascular dz, acute burning bone pain, joint problems, muscle weakness, 90% of time with malignant tumors of the chest o Beaus lines Transverse indented furrow from growth arrest of nail matrix o Pitting o Clubbing HABIT TIC (536) o Common self induced nail condition of the thumb characterized by horizontal parallel ridges in the nail plate induced by constant manipulation of the cuticle and proximal nail fold.

PSEUDOSYNDACTLY o Dystrophic Epidermolysis Bullosa o Pseudofusion of the digits (hands look like mittens)

PICTURES ON MIDTERM Neurotropic ulcer Patient has a large ulcer on the heel not aware- Diabetes. You call this ulcer when there is no sensation Diabetic dermopathy Slightly depressed atropic hyperpigmented macules. People call them shin spots; Diabetics heal differently than other people. Necrobiosis lipoidica diabeticorum Looks yellow like lipid because dermis gone and looking at subcutaneous fat. - It turns out that like 98% of this occurs in diabetics. - Almost always occur on the feet or legs. - It is caused by poor circulation in the diabetics, can turn into an ulcer Erythema nodosum: - Complained of chronic diahrea, cough, recent sore throat, can feel tender nodules in her leg - Can actually palpate these deep tender nodules acute in onset in the legs is an inflammation of the fat called Erythema nodosum.-- under the microscope this shows septal poniculitis. - Fat comes in lobules separated by septae which is an inflammation of those septae. - Usually people get and then it just gets away. The causes of erythema nodosum. BEDREST: 1. Bechets- inflammation of many tissue and get a true septal poniculits, 2. Estrogen- also during pregnancy and birth control pills, 3. Drugs- virtually any drugs, 4. Regional ileitis- chrons disease or ulcerative colitis, 5. Erythema nodosum leprosum 6. Sarcoid- if a patient with sarcoidosis develops this its actually a good sign because burns out in about 2 yrs, 7. Tuberculosis- one of the first things we order is a test for Tb, also strep is commonly associated with it; ppd test done for TB; Chest x-ray- cavity caused by tuberculosis Erythema chronic migrans- the rash of limes disease. - Have been bitten by a tick, described a papule which grew into a round ring. - The organism is Borrelia burgdofera which is a spirochete. - Its similar to the chancre in syphilis. - You need to treat or else it spreads hematogenously; rashes all over the back which is just multiple lesions where the spirochete landed.

With one day of doxycylin treatment the rashes went away. This is not contagious by touch but syphilis is. The tick is pretty small which is called X.scapularis. If you get the tick off within 18 hrs the risk of transmission of the lyme disease is very low, so important to detect early.

Bells palsy - Put on doxyclyine and went away. - In New York one of the causes of idiopathic Bell s palsy is untreated lyme disease. - First thing within days you get erythema chronic migrans due to the tick bite. - Then there is an acute or chronic arthritis develops. - Then there is heart block that develops; also nervous system- which common one is Bell s palsy Pyoderma gangrenosum - Had an ulcer involving almost the entire leg. - You distinguish this from venous stasis ulcer and bilateral squamous cell carcinomas; clean ulcer caused by Clorox. - It is an entity associated with ulcerative colitis and chrons disease which is about 50% of all cases. Patients develop these crater like holes which you can take out pus. As a result you develop these cribiform scarring. - Starts as postules (if doesnt have postules then not this) break down to ulcers and become large eventually. - The postules form intra locking fistule and squeeze the pus out of it. - One of the treatments is injection of cortisones steroids. There is a tract that goes along with the pus track. - The location of pyoderma gangrenosum is almost always found on the legs or in peristomal sites (dont have normal bowels, its the opening for the intestine). - The patients who have it in other sites also have it on the legs. A finding which is very but specific is called pathergy which is gets ulcer every time you try to get blood from them. - Kebbners phenomenon is that they develop psoriasis every time they get trauma, the difference is that in pyoderma gangrenosum get a huge ulcer, where as in psoriasis its pretty small FUNGI Tinea mannum; Ring worm on the hand; a dermatophyte infection on the hand almost always on the foot as well. - Tinea pedis, tinea ungunum or onchomycosis, tinea cruris, tinea corporis, tinea capitis, tinea versicolor- not the same kind of fungus o Have hypo or hyperpigmentation. - The most common appearance of T. mannum; white marks on the creases. o Looks like manual laborers hands. o This is called a mockensen distribution which affects both hand and feet versus toe web distribution which affects the interspaces. - Maceration between 1st and 2nd; not tinea pedis, unless have it also between the 4th and 5th toe, which is most common.

Microsporum canis used to be the common cause of tinea capitis which floureced with woods lamp. Trichophyton tonsurans has been recently the more common cause of tinea capitis - Doesnt fluoresce under wood lamp. - How do we diagnose this is through scraping. Or use a curette, put KOH which leaves the fungus and then look under microscope and see hyphea which is the causative organism of most fungus which is trichophyton rubrum; most common cause of tinea pedis - MOST OF THE TIME THE ANSWER WILL BE T. RUBRUM o Called rubrum because after few weeks you see this white cotton stuff and red around it. o The importance of this appearance is indicative of T. Rubrum. o The little wet white dots characteristics of yeasts. A person with tinea pedis walking around and found that it is not contagious unless there is a break in your feet or pre existing tinea pedis. o There is also an autosomal dominant inheritance for them not to fight off this fungus. o Its actually a challenge to treat them because it comes back.

The patient here has bullae which are large blisters and underneath foot, it is caused by trichophyton mentagrophytes which causes a very inflamed form of athletes foot. maceration between web spaces is pseudomonas and looks like athletes foot because 2/3 of the time it is not the fungus. Athletes foot, shaved her legs and has these bumps and this is called majocchi granuloma which is caused by fungus. Most common cause is T. Rubrum. Fungul infection around the hair follicles of the leg and need to do biopsy to see it. tinea capitis- mostly happens in children, they grow t. tonsurans especially can get in movie theaters. Sebum is fungus static which prevents fungus from growing when you hit puberty so common in children. kerion- plaque, if treat with antifungal the scalp will scar, combine treatment with steroid; inflammation response, you can spare the hair with combined treatment. Favus- very inflammatory tinea capitis- mount an a huge immune response to it tinea likes moist areas- axilla and groin Can be very extensive and involve huge areas usually in immunosuppressed individual. annular, treated with oral antifungal and did nothing- his buttocks which looks just like tinea Mycosis fungoites- nice round ring worm like border. Or its called cutaneous T cell lymphoma which is a malignancy. tinea cruris- the scrotum and penis is spared, so doesnt go to genital just in the thigh 26. satellite lesions- shiny, macerated, beefy red, and does involve the genitals which is a yeast infection which is called Mornellia or candida albicans. Very wet looking versus the tinea. 27. candida can involve the mouth and get thrush when put on oral antibiotics. 28. eryrasma- fairly common in diabetics, corynebacterium minitissumum which Is a bacteria

29. onocholysis- nail is separated, caused by trauma 30. green black nail- onocholysis, yeast and bacteria present, patients with hyperthyroidism can be associated with it also, as well as psoriasis (know the nail manifestation of it) This is actually pseudomonas onocholysis 31. The cuticle is gone, water sinks it and yeast grows there, chronic paronychia where it swells and the caused by chronic candida. And u see beaus lines going longitudinally caused by compressing the nail matrix. 1. This rash is an acute allergic reaction. This skin lesion is elevated papule called an urticaria wheal or papule. 2. Tuberosclerosis (adenoma sebaceous)- a genetic inherited disease, face lesions, inherit other things like mental retardation. Lesion looks like acne but never goes away. 3. Podiatric manifestation- periungual fibromas or Koenens tumors 4. Ash leef macule- looks like a little patch of vitiligo 5. Shugreen patch- a collection of collagen under skin which causes a bump, which is present close to birth These are the manifestations of tubero sclerosis we must know about