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Acne and Related Disorders( Chart1of 1)

Acne vulgaris
Presentation Inflammation of the
pilosebacuous(area around hair
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 Acute cutaneous Lupus
Erythematous(SLE)
Chronic acneiform disorder: vassular Inflammatory connective tissue disease
dililation of central face: which is multifaceted with a wide range of
Nose manifestations ranging from chronic skin
Cheek lesions(Discoid LE) to widespread
Eyelids polymorphos lesions(Subacute cutaneous
Forehead LE) to multiple organ involvement(Systemic
Background erythema LE)
Woman are affected more than men(8:1)

More frequent in people in 30-40 age range

Distribution Predominantly on face, back, Central facial area Sun exposed areas(face, arms, chest,
shoulders and chest shoulders, backs or hands etc.)
Lesions Primary Primary Superficial to indurated(becoming hard and
-Open comedomes (Blackheads;lipid -Papules, pustules, nodules, cysts firm)
has oxidized) telangiectasia (later)
Non puritic
-Closed comedomes Secondary
White head -Erythema Erythmatous to violacceaous (red to violet
-Scarring colored) plaques appear
-Papules
-Pustules Special lesions May be scaling on surface
-Nodular cysts -Rhinophyma (hyperplasia of the soft
tissues of the nose. (Nose appears larger) In 10-15% of patients, a butterfly rash
appears over malar and nasal bridge
Secondary
-Erythema
-Scar
-Excoriation(scratching)
Signs/Symptoms Flushing Serious multisystem disease: may be fever,
<heat, alcohol, spicy food, sunlight, hot food arthritis, renal, cardiac, pulmonary and
central nervous system involvement
Dx -Clinical appearance In laboratory
Can screen for underlying antinuclear
-Age Ab(ANA), blood count, urinalysis

-Can do hormonal panel

History May appear with out any history of acne or
seborrhea

Affects individuals 30 years or older; often

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of Celtic origin
Duration -Can wax and wane in adulthood

-May persist to age 35 or older

DDx Folliculitis Contact dermatitis

Acne rosacea Rosacea

Tinea

Erysipelas

Seborrheic dermatitis
Other Aggrivating factors/risk factors Pathology
-Drugs(lithium, adrogens, topical and The dysregulation of T cells causes
systemic corticosteroids and oral activation of B cells which produce a variety
contraceptives of anutoanitbodies directs towards cellular
-Endocrine imbalance(thyroid, insulin, antigens(DNA, RNA, RNA protein
sex hormones) complexes)
-Malabsorption, HCL deficiency, liver
or color problems

Emotional considerations
-Self-rejection, anger, fear, boundaries

Bullous, Vesicular Diseases( Chart 1 of 1)

Pemphigus Bullous Perphigoid Dermatitis Erythema Multiforme(wide variety
vulgaris(pemphix=bubble) herpetiformis(clustering) of lesions)

Presentation A potentially fatal
autoimmune siease
characterized by
destruction of the
desmosomes of stratified
squamous epithelium of
mucus membranes and
skin
Incidence 1/1000,000 and
usually occurs in middle or
older aged individuals
-A chronic blistering Chronic recurrent Pruritic General term for diverse reaction
autoimmune eruption on extensor patterns of blood vassels in
disease(idiopathic) surfaces occurring often in dermis with secondary epidermal
-Attachment of basal cells symmetric groups and changes
to basement membrane is including three types of
selectively damaged lesions “Multiforme” refers to a wide
Commonly affects people -Vesicles variety of lesions
60yoa or older -Papules
-Urticarial wheals
-Occurs twice as often as
pemphigus vulgaris
-Less aggressive than
Pemphigus vulgaris and
is not life threatening
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Widespread blistereing
eruption in a older patient
who is taking multiple
medications
Distribiton Localized Flexural areas Extensor surfaces -Symmetric
-mouth -Groin -Sarcum
-Axillae -Elbows -Predilection for dorsum of hand,
Generalized Oral involvement -Knees tops of feet, soles
-scalp Occurs in 1/3 of cases -Lower back
-face -Shoulders -Also on forearms, feet, face,
-chest penis and vulva
-axillae
-groin
Lesions Pirmary Primary Primary Primary
-Bullae -Bullae Vesicles Papules
-Urticarial(hives) plaques Papultes Plaques
Secondary Uriticarial wheals
-Erosions Secondary Plaques Secondary
-erythema -Erosions Erythema
-Erythema Secondary
Lesions Excoriations Lesions
-Skin colored Erythema - blanch with pressure
-Round or oval
-Randomly scattered Often no intact primary -Vesicles and bullae in center of
lesions are seen because papule
Mucous membranes of the intense pruritis
-Erosions of mouth, nose, and excoriations -Iris or target shaped lesions
pharynx, larynx ad vagina
-Central clearing

-Localized to hands or
generalized
Signs/Sx Painful Puritis may be present -Puritis Severe fever
Bullae are rarely seen
No pruritis -Intense episodic burning Sever prostration(complete
or stinging of skin physical or mental exhaustion)
Weakness, malaise, weight
loss if prolonged mouth -Gluten enteropathy in Mild form
involment most patients -Little or no mucus membrane
involvement
-Local symptoms(pruritis -No bullae or systemic Sx
and stinging of skin) -Eruptions usually confined to
precede appearance of extensor surfaces
skin lesions by 8-12
hours Severe form

Dx Based on Positive
Nikolsky’s 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
History
Duration
DDx Dermatitis Herpetiformis
Apthae (canker sores)
Erythema multiforme
Other Tx
-Systemic
corticosteroids(prednisone)
-Immunosuppressant
agents(methotrexate)
-Referral
Deep shave or punch
biopsy from intact bulla to
reveal subepidermal bullae
Pemphigus vulgaris(not
purities, mucous
membrane is involved and
rarely are bullae intact.
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-Most often occurs as a drug
reaction
-Always involves mucous
membrane
Clinical eruption of sever Positive Nikolsky’s sign(like
itching, burning and Pemphigus Vulgaris)
stinging
On extensor surfaces
Biopsy
PMNs
(polymorphonucleocytes)
and subepidermal blister
formation
Often associated with
gluten intolerance /
sensitivity
Lesions last days to weeks Lesions last several days
Scabies Target lesions are quite typical
Excoriated eczema and Dx is not difficult
Insect bites
In absence of skin lesions
Mucus membrane lesions must
be DDx with
-Bullous diseases
-Fixed drug erruption
Stevens-Johnson’s syndrome
-Severe erythema multiforme with
extensive mucosal erosions,
target-like lesions and skin
blisters. Almost total loss of
epidermis known as toxic
epidermal necrolysis.
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-Often associated fever and
malaise. Commonly affects oral
cavity, pharynx, conjunctiva and
anogenital regions

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
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Immune support

Papilloquammous Diseases( Chart 1 of 2)

Allergic/Contact Dermatitis Nummular eczema(Discoid Lichen Simplex Chronicus Atopic Dermatitis
eczema)

Presentation Acute vesicular dermatitis with in Chronic, puritic inflammatory Localized form of Atopy (out of place)
a few hours to 72 hours after dermatitis occurring in the lichenification usually Pruritic skin disorder involving
contact. form of coin shaped plaques occurring in circumscribed cutaneous hypersensitivity
plaques
Distribution Site of contact Regional clusters of lesions Predilection for the flexural
or generalized. surfaces, front and side of the
neck, eyelids, forehead, wrists
Predilection; lower legs and and dorsa of feet and hands
trunk
Lesions Primary Primary Scaling is limited Primary/acute phase
Vesicles, bullae, papules and Closely grouped, small Excoriations are often Plaques, papules –Skin appears
wheals vesicles and papules that present puffy and edematous(swollen)
coalesce into plaques Palpably thicker skin
Secondary 4-5cm in diameter Secondary
Erythema, edema, exudate, Erythematosus base Erythema, scale excoriation,
excoriation, fissures, Distinct borders fissures, crusts and lichenification
lichenification and in chronic lesions
hypopigmentation Secondary
Excoriation and lichenification
Sign Only in area of exposure, history Worse in fall or winter Skin markings are The itch that rashes.
important accentuated and more Constant scratching leads to a
visible cycle of itch→scratc→itch which
leads to lichenification(rough skin)
rash of the skin
Can have periorbital pigmentation
from compulsicely rubbing the
eyelids
Symptom Puritis Puritis Chronic scratching Atopic individuals may also have
allergies, allergic rhinitis, asthma,
elevated levels of IgE
Dx Puritis

Dry skin

Personal history of allergic rhinitis

Family history of atopic dermatitis
Early age of onset(</= 2 yrs)
History History of exposure to allergen or Ask person how it initially Usually begins in early childhood
related compound presents before they scratch.
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Variable disease course

Duration Resolves with in 21 days Lesions persist for months and/or

years
DDx Nummular eczema Psoriasis Seborrheic dermatitis
Atopic eczema Contact dermatitis Psoriasis
Scabies Scabes
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Papillosquammous Diseases( Chart 2 of 2)

Lichen Planus Seborrheic Dermatitis Psoriasis Pityriasis Rosea

Characterized by a polygonal Common, chronic
Presentation violaceous(violet) papules and erythematosus scaling
plaques eruption of unknown cause
that affects all age groups but
usually affects adults 20
years or older
Distribution Mouth Occurs in regions where the
sebaceous glands are most
Genitals active
-Face
Volar wrists(bracelet) -Scalp
-Body folds
Ankles
Scalp involvement is
May be generalized commonly known as dandruff
in adults and cradle cap in
Symmetrical infants
Nails may be involved(varies
from minor dystrophy to total
nail loss)
Lesions Papules and plaques Yellowish red often greasy
Post inflammatory scaling macules and
hypopigmentation(similar to a papules(5-20mm)
scar)
Sticky crusts are common
when scalp, external ear,
axillae and groin are involved
Nummular, annular or trunk
shape
An itching condition
Common hyperproliferative
inflammatory disorder of
unknown cause
Results in rapid cell turnover in
the epidermis(1000x than
normal)
Can be single lesion or lesions
localized to one area(i.e penis,
nails) or it can be regional(i.e.
scalp)
Unilateral or bilateral
Often spares exposed
areas(palms)
Favors elbows, knees,
intertriginous (where 2 surfaces
rub together) areas and scalp
Nail involvement
-Pitting of nails, oil spot(yellow-
brown)
-Distal separation of the nail
plate from the bed (onycholysis)
-Scale forms underneath nail
plate
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
Trunk
Upper extremities
Rarely on face
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

Scattered, discrete
arrangement on face and
trunk
Diffuse arrangement on scalp
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(Auspitz’s sign)
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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

Signs Whickham’s striae (white lace
like patterns on surface of
papules and plaques). Not
always present
Feels very hard and can often
affect genitals
Symptoms
Dx Based on lesions appearance a
characteristic location
With buccal involvement look for
Wickham’s striae
Deep shave or punch biopsy
may be necessary
Pityrosporum ovale (a normal
yeast flora is thought to play a
role)
Initially appears in people under
20 yoa but can occur at any
age
Thick silvery scale
Auspitz’s sign
Clinical appearance of typical
erythematous papules and
plaques with a thick silvery
scale
and plaques with typical marginal
collarette(scaling around edge)
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)

History Family history common Often history of URTI

Duration Self-limited
DDx Psoriasis Psoriasis Guttate psoriasis
Lichenoid drug eruptions Candidiasis Eczema(discoid)
Acne rosacea Tinea corporis
Butterfly rash of Drug eruption
SLE(Systemic lupus
Erythematosus)

Other Forms
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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)

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