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Dermatology
Laura Gheuc- Solovstru
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Clinical Diagnosis in Dermatology
Clinical Diagnosis
In Dermatology
Edited by
Laura Gheuc Solovstru
Contributors
Laura Gheuc Solovstru
Associate Professor
Dermatology Department
Faculty of Medicine
University of Medicine and Pharmacy Gr. T. Popa
Iasi, Romania
Elena Andrese
PhD student
Dermatology Department
Faculty of Medicine
University of Medicine and Pharmacy Gr. T. Popa
Iasi, Romania
Dan V
Assistant Professor
Dermatology Department
Faculty of Medicine
University of Medicine and Pharmacy Gr. T. Popa
Iasi, Romania
Laura Sttescu
Assistant Professor
Dermatology Department
Faculty of Medicine
University of Medicine and Pharmacy Gr. T. Popa
Iasi, Romania
Alina Stncanu
M.D. dermatology
Dermatology Clinic
Emergency Clinical Hospital Sf. Spiridon
Iasi, Romania
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Clinical Diagnosis in Dermatology
Table of Contents
SKIN STRUCTURE AND FUNCTIONS ....................................................... 7
GENERAL CONSIDERATIONS ................................................................. 37
Dermatological Examination ........................................................................ 37
Fundamentals Of Clinical Diagnosis ............................................................ 40
Lesions As A Result Of Color Alteration ................................................. 41
Raised Lesions .......................................................................................... 43
Fluid Filled Lesions .................................................................................. 46
Depressed Lesions..................................................................................... 47
Surface Change Lesions ............................................................................ 48
General Notions Of Dermatological Therapy ............................................... 50
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Clinical Diagnosis in Dermatology
Our skin is the largest organ of the body (making up 16% of body
weight), with a total area of about 20 square feet. The skin together with its
annexes form the integumentary system performing outer layer of the
organism.
The skin consists of three layers that intertwine, having an irregular
shape:
the epidermis - the outermost layer of skin, provides a waterproof barrier
and creates our skin tone.
the dermis beneath the epidermis, contains tough connective tisssue, hair
follicles and sweat glands.
the hypodermis (subcutis) is a deeper skin layer that contains loose
connective tissue with abundant adipose lobules, which connects with the
subadjacent tissues, being thicker in colder regions of the body. It represents
a source of energy and insulation; it also contains a thin layer of striate
muscle panniculus carnosus.
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Clinical Diagnosis in Dermatology
Horny
layer/Stratum
corneum
Spinous layer
Dermis
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receptors of the basement membrane and the other end to the collagen of
lamina densa. Laminin is a glycoprotein structure that binds the fibrils
to one another and the epithelial cells to the basal lamina; it forms a
cross-like structure (fig. no.3A).
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Clinical Diagnosis in Dermatology
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Clinical Diagnosis in Dermatology
their replication capacity during life at a slower rate than that of keratinocytes in
order to maintain the epidermal-melanin unit.
Melanin protects against tissue damage caused by UV radiation.
Melanin is a polymer composed of indoles and quinones.
Eumelanin is a dark brown pigment produced by melanocytes,
insoluble in all solvents.
Pheomelanin is the pigment of the red hair, cysteine-rich, poorly
soluble in alkaline solutions.
Melanogenesis
Four stages are distinguished during the synthesis, as the melanosomes migrate
from the perinuclear area to cytoplasmic processes:
stage I: spherical vesicles appear, delineated by membranes, called
premelanosomes.
stage II: the vesicle is called early melanosome, it is ovoid, contains
parallel filaments with a periodicity of around 10 nm , with transverse
striae due to tyrosinase molecules; the melanin starts to accumulate on
the protein matrix.
stage III: abundant formation of melanin into melanosomes, along
with the appearance of less conspicuous periodic structures.
stage IV mature melanin granules appear, visible in optical
microscopy - completely melanized melanosomes, the melanin
completely filling the ellipsoidal vesicles m of 1 length and m
diameter; the melanosomes become electronopaque m 0.4 granules,
arranged within the cell and at the bases of the cell processes .
Subsequently, the melanin granules are transferred to keratinocytes, by
pigment donation. This process, which involves the phagocytosis of the tips of
the melanocyte processes by keratinocytes, is a type of cytocrine secretion due
to the fact that a small amount of the surrounding cytoplasm is also
phagocytosed; the granules are deposited above the nucleus, protecting it
against the harmful effects of solar radiation. The extent of melanin transfer to
keratinocytes causes variable skin pigmentation. The melanin granules fuse
with lysosomes within the superficial epidermal layer, along with the
disappearance of melanin. The variety of the melanin-epidermal unit
contributes to the vast diversity in colour on various body areas.
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Clinical Diagnosis in Dermatology
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protofibril
fibril
fibril
cluster
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Clinical Diagnosis in Dermatology
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NERVE SUPPLY
The skin is endowed with sensory receptors of various types, that are
peripheral terminations of sensory nerves. It is also supplied with motor nerve
endings to the blood vessels, arrector pili muscles and sweat glands.
Free nerve endings extend to the granular layer, they lack a connective
tissue or Schwann cell investment. These neuronal endings subserve numerous
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Clinical Diagnosis in Dermatology
sensory modalities, including fine touch, heat and cold, without apparent
morphologic distinction.
Due to the fact that networks of free dermal endings surround most hair
follicles and attach to their outer root sheath, they are particularly sensitive to
hair movement and serve as mechanoreceptors.
Encapsulated nerve endings (enclosed in a connective tissue capsule)
include the following:
Pacinian or Vater-Pacini corpuscles (lamellar corpuscles) are ovoid
structures, measuring more than 1 mm along their long axis, found in
the deeper dermis and hypodermis, in connective tissue in general, and
in association with joints, periosteum and internal organs (Fig. No.5).
They are made up of a myelinated nerve ending surrounded by a
capsule structure.
arterioles
Pacinian
Corpuscle
nerve
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tongue and in the papillary dermis. They detect pressure and function as
sensory cold receptors.
The skin receives a rich blood supply from 2 arterial plexuses and 3
venous plexuses.
The arterial plexuses are:
An arterial plexus located between the superficial and deep dermis
An arterial plexus located between the dermis and hypodermis.
There is also a subcutaneous plexus, consisting of fine branches of
muscular arteries that penetrate the subcutaneous adipose tissue, each artery
being accompanied by two veins.
These plexuses give rise to branches that penetrate the dermal papillae,
forming a loop system that consists of an ascending arterial limb and a
descending venous limb.
The venous plexuses are:
2 venous plexuses that have the same site as the arterial ones
a plexus located in the middle of the dermis.
The dermis also contains an extensive lymphatic system, which is closely
associated with the vascular plexuses. Deep lymphatics are located between the
dermis and the subcutaneous tissue as well as in the septa of the latter.
The dermal microvascular unit consists of:
vessels
mastocytes
CD34 dendritic cells.
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Clinical Diagnosis in Dermatology
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-Myoepithelial cells, scattered below the clear cells; they have stellate
or spindled cell morphology; they are engaged in long, radial processes and are
distributed in a spiral, parallel array along the long axis of the secretory tubule.
The myoepithelial cell are interconnected and connected to epithelial cells
through gap junctions and desmosomes. Contraction of the filaments enable the
rapid expression of sweat from the gland.
The duct is narrow, it takes a spiral course until it reaches the
epidermis, where it continues in a tighter spiral towards the surface. The duct is
made up of a stratified cuboidal epithelium, consisting of a basal cell layer
and a luminal cell layer. The duct has a smaller diameter than the secretory
portion. The cells of the duct are rich in keratin filaments, mitochondria,
ribosomes and a conspicuous nucleus that contains a prominent nucleolus. The
apical cytoplasm of the luminal cells appears hyalinized, as a result of the
aggregated tonofilaments in the apical cytoplasm.
As the secretion products pass along the duct, there is a partial
reabsorption of NaCl by duct cells, resulting in the delivery of a hypotonic fluid
to the skin surface, its pH ranging between 4 and 6.8. Inorganic compounds
include potassium, calcium, magnesium, phosphorus, iodine, carbon, iron,
zinc. The organic substances that are being secreted include: urea, lactate,
ammonia, uric acid, amino acids, glucose, pyruvate, histamine, bradykinin,
immunoglobulins, prostaglandins, vitamin C, B2, B6,K; various drugs can
also be eliminated; the composition is similar to that of an ultrafiltrated
plasmatic component and therefore the glands exhibit an excretory function.
Secretion of sweat provides a mechanism for thermoregulation via
evaporative heat loss.
Usually, the human body loses about 600 ml of water per day through
skin and lungs. If the ambient temperature increases, so does the sweating rate,
by cholinergic control, a process known as thermoregulated sweat. At first,
the process affects the forehead and the scalp, then the face, after that the entire
body and ultimately the palms and soles.
Exercising makes the entire skin surface sweat.
Emotional stress first causes sweating of the palms, soles and armpits -
emotional sweating. This process is under nervous adrenergic control.
Hyperhidrosis can lead to significant loss of elecrolytes: potassium,
magnesium and a great amount of water.
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Clinical Diagnosis in Dermatology
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Clinical Diagnosis in Dermatology
From place to place, there are keratinized cells, arranged in fine bands,
which provide the supportive framework of the gland.
Around the glands, there is a smooth muscle-the arrector pili muscle,
which has the same role as myoepithelial cells. The contraction of this smooth
muscle elevates the hair and is responsible for formation of goose bumps.
The glands become functionally active at puberty, stimulated by
dihydrotestosterone and testosterone in men and ovarian and adrenal
androgens. Exogenous estrogens, fasting, exogenous retinoids are known to
diminish their secretion.
Damage to the epidermis appears to cause the sebaceous glands beneath
the wound to cease producing lipid.
Sebum is known to have bacteriostatic, antifungal, emollient, barrier
and pheromonal roles. At puberty, the amount of sebum increases
significantly in both sexes. Free fatty acids that come into being during the
breakdown of triglycerides by lipases secreted by bacteria, are present in sebum
and are thought to be irritants in the pathogenesis of acne vulgaris.
Histologically, acne is characterized by the retention of sebum in the
isthmus of the hair follicle, accompanied by variable amounts of infiltrating
lymphocytes. In severe cases, swollen hair follicles can cause dermal
abscesses. The sebaceous gland is a holocrine simple saccular
gland extending over the entire skin except for the palms and soles.
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The secretory portion of the sebaceous gland lies in the dermis, and
the excretory duct opens into the neck of the hair follicle. Sebaceous glands
can be independent of the hairs and open directly on the surface of the skin of
the lips, the corner of the mouth, the glans penis, the labia minora, and the
mammary nipple.
The secretory portion of the sebaceous gland consists of groups of
alveoli connected to the excretory duct by a short ductule. Each alveolus is
lined by cells resembling multilocular adipocytes with numerous small lipid
droplets. The excretory duct is lined by stratified squamous epithelium
continuous with the external root sheath of the hair and the epidermis (the
malpighian layer). The oily secretion of the gland (sebum) is released on the
surface of the hair and the epidermis.
Hair follicles are invagination of the epidermis extending deep into
the dermis. The hairs are present almost all over the body surface, except on the
thick skin of the palms and soles, the lips, the sides of the fingers and toes, the
glans penis, the clitoris, labia minor and the nipple
Hair follicles develop as complex structures. Therefore, a cross section
of the hair shaft reveals three zones:
-infundibulum (has the form of a funnel)-the upper segment of the
pilosebaceous canal (where sebum is released); it extends from the upper
opening of the follicle up to the opening of the sebaceous gland
-isthmus extends from the base of the infundibulum up to the insertion
of the arrector pili muscle.
-the lower segment- the lower par, where the hair bulb (the terminal
expanded region of the hair follicle in which the hair is rooted); a vascularized
connective tissue core (dermal papilla) projects into the hair bulb.
The hair shaft is surrounded by (1) the external root sheath, a
downgrowth of the epidermis; and (2) the internal root sheath, generated by
the hair bulb (the hair matrix).The cells arranged in close proximity to the
dermal papilla represented the innermost layer,
The hair shaft is a long, thin filament, made up of three concentric zones
(fig.no. 8):
-the medulla consists of 3-4 layers of large, round cells, separated by air
bubbles; they are moderately keratinized.
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-intermediate scalp hair is short, less than 1cm, fine, hypopigmented and it can
be seen in 11-16 year old individuals.
-vellus is fine, hypopigmented hair that covers most of the body in infants under
6 months (anterior surface of forearms and head) and the forehead of adult
individuals.
-lanugo -the soft, fine hair that covers the fetus.
Hair distribution is influenced by sex hormones. In both sexes, at
puberty, pubic and axillary hair appears as a secondary sex characteristic.
At puberty, males develop pigmented facial hair. In elderly males, the
insertion hair line of the scalp tends to move downwards and the surface
covered with hair diminishes.
In both sexes, with age, the scalp hair becomes thinner due to reduced
secretion of estrogens and similar hormones.
Every day about 100 scalp hairs are lost physiologically. The growth
rate varies from 0.35 mm to 0.37 mm / day.
The color of the hair depends on the amount and distribution of
melanin in the hair shaft.
Nails are located on the distal phalanx of each finger and toe.
They are hard keratinized plates that rest on the nail bed of the
epidermis. They consist of compacted, anucleate, keratin-filled squames in two
or three horizontal layers. Ultrastructurally, the squames contain closely packed
filaments which lie transversely to the direction of proximodistal growth, and
are embedded in a dense protein matrix. Unlike the general epidermis, squames
are not shed from the nail plate surface. The nail apparatus consists of five
structures: the nail plate, proximal and lateral nail folds, nail matrix, nail bed
and hyponychium (cuticle). The nail bed consists only of basal spinous layers
and is adherent to the base of the nail plate.
The proximal end-the root of the nail is covered by a fold of epidermis,
called the cuticle or eponychium (prone to breaking), which corresponds to the
stratum corneum. The cuticle overlies the crescent-shaped whitish lunula.
At the distal (free) edge, each nal is underlain by the hyponychium,
which is also composed of stratum corneum.
Nails grow as the result of mitoses of cells in the matrix of the nail root.
Most of the matrix underlies the proximal nail fold, but on some digits it
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extends under the nail plate. The most proximal portion of the matrix forms the
top of the nail plate; the most distal portion forms the bottom of the nail plate.
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Clinical Diagnosis in Dermatology
HISTOGENESIS
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in the form of parallel crests, protruding in the dermis. These are the future
eccrine sweat glands.The lumens appear within the XXIVth week and the
process of glandular secretion begins. Epidermal and dermal ridges begin to
take shape, later becoming recognizable features of the surface landscape.
Dermis and hypodermis arise in the first 6 weeks from the mesenchyme,
with migrated cells. Starting with the second month, the fibrillar interstitial
substance arises, produced by the differentiated fibroblasts of the mesenchymal
cells. Collagen fibers appear in the third month, whereas elastic fibers appear in
the fourth month.
Later, the mesenchyme divides into a dense peripheral layer with a
compact arrangement of the constituents - the dermis and a deep loose layer,
the future hypodermis. The papillary layer differentiates within the dermis. The
vessels begin to arise from the mesenchyme at the end of the first trimester and
are fully developed by the end of the third trimester of pregnancy. The adipose
hypodermic tissue arises in the second trimester from the mesenchymal cells
that undergo intermediate stages of lipoblasts, when they start to accumulate
intracytoplasmic triglycerides. The nerves appear in the skin in the fifth,
subsequently continuing their further development.
In humans, the hair starts to develop at the end of the second month,
and this process is fully completed in the XVIIIth week Hair first covers the
eyebrows, the chin and the area above the upper lip.
The hairs follows a cephalocaudal gradient over the body, completely covering
the skin with lanugo, with the exception of glabrous skin areas. At first, a
group of prismatic cells arise in the deep layer of the epidermis. These cells
divide in order to increase the subadjacent connective tissue only to form an
epithelial cylinder that will gradually lengthen. This is the primary hair,
rounded and slightly flattened at the ends. At the end there is a deep reservoir of
condensed connective tissue that forms the hair papilla and protrudes into the
epithelial mass of the hair bulb. The epithelial cells on the surface of connective
papillae are known to become the future hair matrix. The connective tissue that
surrounds the bulb will later form the connective structures of the hair follicle.
Hair formation is recognizable for the first time at about the 12th week
of pregnancy as regularly spaced epidermal placodes associated with small
condensations of dermal cells so called dermal papillae. Under a continuing
influence of a dermal papilla, the placode forms an epidermal downgrowth,
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Clinical Diagnosis in Dermatology
which over the next few weeks forms an early hair peg. In succeeding weeks of
intrauterine life, the epidermal peg overgrows the dermal papilla, and this
process results in the shaping of an early hair follicle. At this stage, the hair
follicle still does not protrude beyond the outer surface of the epidermis, but in
the portion of the follicle that penetrates deeply into the dermis, two bulges
presage the formation of sebaceous glands, which secrete an oily skin lubricant
(sebum), and are the attachment site for the tiny arrector pili muscle. The
developing hair follicle induces the adjacent dermal mesoderm to form the
smooth muscle cells of this muscle. As the developing hair matures, a small
bulge below the sebaceous gland marks an aggregation of epidermal stem cells.
At the end of the third month, epidermal thickenings (primary nail
field) on the dorsal surfaces of the digits mark the beginnings of nail
development. Cells from the primary nail field expand proximally to undercut
the adjacent epidermis. Proliferation of cells in the proximal part of the nail
field results in the formation of a proximal matrix, which gives rise to the nail
plate that grows distally to cover the nail bed. The nail plate itself consists of
highly keratinized epidermal cells. A thin epidermal layer, the eponychium,
initially covers the entire nail plate, but it eventually degenerates, except for a
thin persisting rim along the proximal end of the nail. The thickened epidermis
underlying the distalmost part of the nail is called the hyponychium, and it
marks the border between dorsal and ventral skin.
Eccrine sweat gland development is independent of the hair. Early
structural units appear during the fifth month on the palms and soles, the lower
surface of the fingers. Starting with the seventh month, an irregular lumen is
formed in the lower part, which will become the adenomere. Across the future
duct, another lumen will develop and will later join the first one. The
epithelium that surrounds the lumen forms two layers that differentiate into an
external layer of myoepithelial elements and an internal layer of glandular
cells.
CUTANEOUS REPAIR
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activity is highest in the first 24 hours after injury. The lesion is covered with a
crust and a large number of neutrophils are seen at the incision margin. Under
the crust, the basal cells migrate at a rate of 0.5 mm / day, starting with the first
8 to 18 hours after the appearance of the lesion and cover the entire surface.
After that, proliferation and differentiation into stratified epithelium are the next
steps, along with keratinization and shedding. The crust is removed from the
periphery towards the center.
In third degree burns or extensive abrasions, re-epithelization is almost
impossible, requiring skin grafts.
Dermal repair involves the removal of damaged collagen fibers by
macrophages and subsequently fibroblast proliferation, along with the
production of all the components of the extracellular matrix. Skin sutures
reduce the extension of the repair area by bringing in close proximity the edges
of the wound and therefore minimizing scarring. Surgical sections are made
along the cleavage lines, parallel to the collagen fibers and thereby reducing the
extension process for the production of collagen and thus reducing the size of
the scar. In pathological cases, excessive collagen production is known to
produce scars, termed keloids.
The regeneration capacity is influenced by growth factors (EGF,
epidermal growth factor, IGF-I, II - insulin-like growth factors, GH - Growth
hormone, somatomedins) and inhibitors of growth factors (chalone).
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Clinical Diagnosis in Dermatology
GENERAL CONSIDERATIONS
DERMATOLOGICAL EXAMINATION
It is structured by two important elements:
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6. Skin biopsy
It is frequently performed in dermatology for histopathologic
and other analyses (immunofluorescence, electron
microsopy, special stains) to confirm a diagnosis or to
differentiate the clinical diagnosis. There are three main
types of skin biopsies:
shave biopsy- we use a tool similar to a razor to
remove small section of the top layer of skin (in
protruding skin lesions: seborrheic keratosis, warts,
actinic keratosis)
punch biopsy- we use a circular tool to remove a
small section of skin including deeper layers
(superficial inflammatory diseases, papulosquamous
disorders, connective-tissue disorders)
excisional biopsy-we use a small knife (scalpel) to
remove an entire area of abnormal skin, including a
portion of normal skin down to the fatty layer of skin
incisional biopsy we use a scalpel to take away the
entire lesion.
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Clinical Diagnosis in Dermatology
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Macules determined by substances that are not normal constituents of the skin
This type of lesions appears in disorders with systemic involvement:
-metabolic disorders (carotenemia)
-infectious diseases (hepatitis)
-occupational diseases (lead poisoning with purple-blue lines within gingival
tissue)
A separate category is represented by the tattoos. Tattooing is the process by
which a pigment is permanently or temporary introduced into the skin for
cosmetic purpose.
RAISED LESIONS
These are circumscribed, well defined lesions which cause changes on the
surface and consistency of the skin. This group includes:
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Tubercle
is a deep lesion located in the dermis , circumscribed, that protrudes
slightly from the skin (becomes clearly visible at diascopy)
the tubercle can run a chronic course, may ulcerate leaving a
characteristic scar (tuberculosis luposa)
the morphological substrate of tubercle is represented by a deep dermal
cellular infiltrate
Nodule
is a solid mass located deep in the dermis and hypodermis, is less
prominent and well identified by palpation
it may run an acute (erythema nodosum), subacute (erythema
induratum/ Bazins disease) or chronic (sarcoidosis) course
A particular form of nodule is gumma whose evolution comprises several
stages:
-rawness( in which the nodule is firm, covered with large, shiny skin)
-weakening (as a result of a necrotic process)
-ulceration (elimination of necrotic tissue)
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Clinical Diagnosis in Dermatology
Vegetation
is an outgrowth papillary excrescence with irregular surface,
cauliflower-like growths or cockscomb
has a hard consistency, can be found isolated (papilloma) or has the
tendency to form globular masses with pseudotumor -like
appearance (condyloma acuminatum)
Lichenification
It presents as a plaque with pseudopapules; it appears in pruritic
dermatoses as a result of prolonged scratching
Tumor
is a prominent and persistent lesion with a tendency towards expansion
, without inflammatory character
in terms of clinical and evolutionary features tumors are classified as:
- benign tumors (nevus, lipoma), are well defined, non-invasive,
do not metastasize
- malignant tumors (malignant melanoma, squamous- cell
carcinoma, basal-cell carcinoma, sarcoma) are invasive masses
with negative prediction , which lead to metastases
Comedo
Scar
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Vesicle
a vesicle is a fluid filled cavity or elevation equal or smaller than 0,5
cm, commonly located within the epidermis
the vesicle usually breaks open and forms erosions
in case of bacterial infection the content fluid becomes festering,
constituting itself a pustule
vesicles arise from the cleavage at various levels of the epidermis
(intraepidermal) or of the dermal-epidermal interface (sub-epidermal)
by the mechanism of organization, vesicles can be
- interstitial (due to the accumulation of fluid or acantholysis/ loss
of cohesion between keratinocytes)- vesicles from eczema
- parenchymal (is formed as a result of alteration in cellular
parenchyma of keratinocytes under the action of intracellular
pathogens such as viruses)- vesicles from shingles or herpes
simplex infection.
Bulla (blister)
is a fluid filled lesion, larger than 0,5 cm
it arises due to loss of cohesion at the intraepidermal level or at the
dermal-epidermal level
the original content is translucent, serous, hemorrhagic or pus filled
by the degree of filling, it can be flaccid (pemphigus vulgaris) or under
pressure (bullous pemphigoid)
after breaking open, only an erosion or white thin plaque may be noted
depending on the site involved, they are classified into:
- superficial bullae, below the corneous stratum (bullous impetigo)
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Clinical Diagnosis in Dermatology
Pustule
a circumscribed raised cavity containing pus
depending on the mechanism of evolution there are described:
- primitive pustules (the liquid is a purulent exudate from the
beginning)
- secondary pustules (the phenomenon occurs due to
superinfection of a vesicle)
- in relation to hair follicle, pustules can be follicular (superficial
folliculitis) or non-follicular (pustular psoriasis)
depending on the presence of microbial factor, the pustules can be
- pus-filled pustules (staphylococcal folliculitis)
- sterile pustules (pustular psoriasis)
DEPRESSED LESIONS
Erosion
An erosion is a loss of a portion of the viable epidermal epithelium. It does not
exceed the basement membrane and does not leave scar.
It may result from local trauma, rupture of vesicle or bullae.
Excoriation
An excoriation is a surface excavation of epidermis that is produced by
scratching.
Ulcer
An ulcer of the skin is a defect in which dermis and epidermis have been
removed, often with loss of the underlying tissue. The defect heals with
scarring. The base may be clean or necrotic. It appears as a chronic ulcer
(venous ulcers) or as an acute lesion (pyoderma gangrenosum).
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Informative features for a right diagnosis are: the base, the borders and the
surrounding skin.
Atrophy
Is a loss of tissue involving epidermis, dermis or subcutaneous tissues. The skin
is atrophic, almost transparent and may not retain normal skin lines. If there is a
dermal atrophy, the area is normal in color with a circumscribed depression.
Atrophy may be physiological (older people) or pathological (scleroderma).
Scale
A scale is a group of coherent cornified cells, packed with filamentous proteins.
It is the result of a process of hyperkeratosis with accumulation of corneous
cells that descuamate in scales.
Their appearance is often diagnostically revelant.
In description it is useful to make the following clarifications:
size of scale- furfuraceous or pityriasiform are small, fine and loose
scales (pityriasis versicolor)
-lamellar scales have average size (psoriasis, lamellar ichthyosis)
-ichthyosiform scales, diameter of a few centimeters (ichthyosis
vulgaris)
color
adherence of scales
- adherent scales as in lupus erythematosus
- less adherent scales - easily removed by the slightest
friction as in pityriasis simplex/ pityriasis alba.
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Clinical Diagnosis in Dermatology
Crust
A crust is a dry purulent exudate, serum or blood. The appearance of crust
depends on the nature of secretion: golden- yellow as in impetigo contagiosa
(meliceric/honey colored crust), reddish-black when formed from hemorrhagic
secretion (profound ulceration).
Lichenification
is presented as a plaque of thickening of the epidermis in response to
prolonged rubbing, with accentuated marking of the skin and
pseudopapules
it appears in pruritic dermatoses as a result of repeated rubbing
Eschar
an eschar is a tissue necrosis produced by ischemia
is a circumscribed, adherent black crust on the surface of the skin.
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4. Varnishes
- Liquids which dry in direct contact with air to form a glossy
film
- they have protective or therapeutic effects.
5. Gels
- hydrogels use methylcellulose or carboxymethylcellulose as
a base
- have the ability to easily release the active substance and are
well tolerated
6. Pastes
- are equal mixtures of fat substances and powders
- have protective, soothing and siccative effects
- are recommended in dry acute dermatitis (such as subacute
eczema, intertrigo)
7. Creams
- these are are mixtures of fats and aqueous solutions, grease,
oils
- they act superficially, having emollient, soothing, refreshing
effects
8. Ointments
- a mixture of hydrophobic fats (grease) and inert powders
- can be combined with active substances such as antibiotics,
antifungals, keratolytics
- they have powerful occlusive effects and are recommended
in chronic lichenified dermatosis
9. Sprays
- mixtures containing solutions, emulsions and powders only
in the form of aerosols , which are applied by using a
pressurized inert gas (freon)
- give good results in wet acute inflammatory dermatitis
Topical treatment using physical agents
The topical treatment of various dermatoses uses therapeutic techniques
such as:
1. Radiotherapy (direct or indirect) - uses therapeutic radiation on
skin cancers or persistent inflammatory processes
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Clinical Diagnosis in Dermatology
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A. Antibiotic therapy
it is recommended in dermatoses such as:
- primary skin infections (pyoderma)
- secondary skin infections (pyodermization of a pre-existing
lesion)
- sexually transmitted diseases
frequently involved pathogens are Staphylococcus aureus, beta
hemolytic streptococcus, gram-negative bacilli.
An appropriate antibiotic treatment must obey the following rules:
1. the antibiotic is chosen according to the antibiogram
2. the dosage is determined by taking into consideration the
characteristics of the antibiotic, clinical manifestations, body
weight, associated pathology
3. Keeping an effective plasma level that would control general
manifestations (fever, chills, pain).
The main antibiotics used include:
beta-lactams
- have bactericidal effect
- act on specific receptors on the cellular wall of bacteria
- the most used are: biosynthetic penicillins
anti-staphylococcal penicillins (oxacillin, cloxacillin,
dicloxacillin)
aminopenicillins (ampicillin, amoxicillin)
beta-lactamase inhibitors (clavulanic acid, sulbactam,
tazobactam)
cephalosporins (generation I: cephalothin, cefalozina, or
generation II: cefuroxime cefamadol; generation III: cefotaxime,
ceftriaxone, cefixime; generation IV: cefpiramide, cefepime)
aminoglycosides (streptomycin, gentamicin, tobramycin,
amikacin)
macrolides
- Natural (erythromycin, spiramycin, josamycin)
- Synthetic (azithromycin, clarithromycin)
synergistins- pristinamycin
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Clinical Diagnosis in Dermatology
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Once introduced into the body, the vaccines cause the appearance of
specific antibodies (which contain inactive germs).
Sera are preparations which contain specific antibodies.
2. Immunostimulant therapy
acts to stimulate transiently the bodys nonspecific immune
capacity and consists in the administration of biological or
medicinal preparations
commonly used immunostimulatory substances include:
- Corynebacterium parvum
- BCG
- interferons
- levamisole
- isoprinosine.
E. Hyposensitization therapy
comprises the gradual administration of a small amount of
sensitization allergen,
up to an optimal concentration
the major role is to improve symptoms (eg hypo-sensitization to
molds, pollen , microbial antigens)
F. Anticancer drugs and immunosuppressants
Anticancer drugs inhibit selectively the cell cycle or trigger metabolic
changes. Among these, the most important ones include:
- alkylating agents (cyclophosphamide, chlorambucil,
fotemustine)
- methyl agents (procarbazine)
- antibiotics (bleomycin)
- inhibitors of topoisomerases (amsacrine, etoposide)
- antimetabolites in combination with:
- antipurines(azathioprine, allopurinol)
- antipyrimidine (5-fluorouracil)
- antifolate (methotrexate)
- cyclosporine ( has immunosuppressive cell properties).
Immunosuppressive drugs act on the immune system, reducing the
ability to undergo multiplication, proliferation and blast transformation.
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Clinical Diagnosis in Dermatology
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INFECTIOUS DERMATOSES
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Clinical Diagnosis in Dermatology
Cutaneous Staphylococci
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Clinical Diagnosis in Dermatology
Etiology:
the lesions are due to the action of the epidermolytic toxin produced
by type II Staphylococcus, 71 phage type;
the disorder occurs in children with immune deficient status;
the lesions are produced by shallow cleavage (granular stratum).
Clinically:
the skin is covered with large flaccid bubbles, located on an
erythematous base that breaks open quickly, the skin exfoliates into
flaps, leaving large bare areas. The appearance resembles that of a
scalded skin (Staphylococcal scalded Skin Syndrome). The general
condition is profoundly altered (fever, pain and skin burns).
Prognosis - reserved due to major hydro-electrolytic changes of the bare
surfaces.
Differential diagnosis:
Stevens Johnson Syndrome
bullous toxidermatosis as a reaction to drugs/ drug-induced bullous
toxidermatosis
2. Erythemato-squamous Staphylococci
Ritter von Rittersheim Exfoliative erythroderma
Etiology: the condition occurs in infants in the first month of life and is
determined by the specific exfoliative toxin, produced by Staphylococcus
aureus hemolytic 71 phage type.
Clinical features:
peribuccal initial erythema, accompanied by blisters and crusts on
the lips;
the erythema is expanding rapidly, with a tendency to generalize and
is accompanied by skin exfoliation;
a marked skin fragility (Nicolski positive sign).
Evolution and prognosis: the lesions usually epithelize withim 5-7 days, but
the process of exfoliation could last between 7 and 17 days.
Differential Diagnosis with
bullous impetigo,
Lyell syndrome.
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3. Exophytic Staphylococci
The Botryomycosis (pyogenic granuloma)
It is an inflammatory pseudotumoral mass, of unclear infectious origin .
Histologically, the appearance is of a vascular benign proliferation and a
granulomatous type reaction.
Clinical features:
it appears as a round red pseudotumoral mass, friable, with an
irregular scouring surface and covered with hematic crusts;
the base of the mass is delimited by an epidermal collar;
it normally develops on a partial loss of a portion of healthy tissue
occurring after a trauma;
Location: the mass can be located anywhere on the skin, with a predilection for
extremities (fingers), scalp and lips.
The differential diagnosis is made with other tumorous masses:
hemangiomas;
papilloma;
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Clinical Diagnosis in Dermatology
malignant melanoma;
Kaposi's sarcoma.
Pyoderma vegetans
Etiology: there were many antimicrobial agents involved in the etiology of this
disease: Staphylococcus aureus, group A Streptococcus. The disease develops
on a body with a poor immune status and was described in association with
immunodeficiency states or ulcerative colitis.
Clinical features:
it is characterized by an epithelial hyperplasia associated with
dermal granulomatous inflammatory changes;
the lesions are arranged in plaques or patches that evolve
eccentrically, exhibiting a raised, firm, papillomatous surface,
whereas the periphery is marked by small pustules.
Location: the localized forms are arranged around some infected wounds while
the generalized forms predominantly affect the inguinocrural folds, buttocks,
abdomen or thorax.
Differential diagnosis is made with tuberculosis vegetans, pemphigus vegetans.
4. Necrotic Staphylococci
Acute necrotizing cutaneous staphylococci
Epidemiology: it occurs in immunodepressed children in their first days of life.
Clinical features:
the teguments are intensely erythematous and infiltrative;
the lesions are evolving rapidly to intense necrosis of deep tissues ;
the general condition is profoundly damaged;
Sites: abdomen, lumbar-sacral region, thorax.
The prognosis is reserved.
Differential diagnosis includes other dermatitis caused by staphylococcus.
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Clinical Diagnosis in Dermatology
Sites: the cutaneous lesions are located in the same areas as the apocrine glands:
armpits, perineal region, buttocks, breast region.
Prognosis: the healing process is achieved with unsightly vicious scars and,
depending on the site, they may sometimes determine functional disabilities.
The differential diagnosis is made with:
furuncle
scrofuloderma
nail granuloma.
Pilosebaceous Staphylococci
1. Folliculitis (follicular staphylococci)
This is a disorder of the hair follicles, caused by a staphylococcus.
According to the depth and evolution of the inflammatory process folliculitises
are classified into:
Superficial Folliculitis
a) Superficial Pustular Folliculitis (Bockards impetigo)
b) chronic folliculitis of the legs
Deep Folliculitis
a) acute
- nasal folliculitis
- folliculitis of the eyelash (stye or hordeolum)
b) subacute
- staphylococcal sycosis
c) chronic
- lupoid sycosis
- folliculitis decalvans (Quinquad)
- keloidal folliculitis
Impetigo of Bockard
Etiopathogenesis: the causative agent is Staphylococcus aureus which enters
through the follicular ostium (the weakest point of the skin).
Clinical features: it develops through the appearance of small pustules
surrounded by an inflammatory halo, around the hair structure.
Location: it is located especially on the face after shaving, on the scalp,
buttocks or around some partial loss of a portion of healthy tissues (wounds,
ulcers).
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Staphylococcal Sycosis
Etiopathogenesis:
subacute folliculitis is caused by staphylococcus;
the infection goes beyond the follicular ostium and enters the depth
of the hair follicle, building up a follicular abscess as a "shirt
button".
Clinical features: the lesions are papular-nodular, pustular, surrounding the hair
and they are grouped into suppurative patches. A typical bilocular abscess is
formed in depth.
Sites: the beard and the mustache of adult males and rarely other areas (armpits,
pubic region).
Prognosis and evolution: subacute slightly inflammatory evolution. The hair is
shaved with difficulty.
The differential diagnosis is made with trichophytic sycosis.
The lupoid sycosis has got a chronic relapsing evolution.
Clinical features: the lesions have a tendency to a centrifugal active-evolving
extension, with papular pustules and they exhibit an atrophic cicatricial center.
The inflammatory changes are granulomatous, causing the destruction of the
hair follicles and leading to scarring.
Folliculitis decalvans is a deep form of disease with a chronic
development, affecting the hairy skin of the head, leading to cicatricial alopecia.
The inflammatory process consists in plaques that have a centrifugal evolution,
active at the periphery and covered with follicular pustules.
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Clinical Diagnosis in Dermatology
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2. Perifolliculitises
The boil (furuncle) is a deep acute staphylococcal infection which
affects the hair follicle, the sebaceous gland, the perifollicular connective tissue
and sometimes even the subcutaneous adipose tissue.
Etiopathogenesis:
Staphylococcus aureus is the etiologic agent, which spreads towards
the skin;
the predisposing factors are diabetes, malnutrition, immuno-
suppressive states, prolonged corticosteroid therapy.
Clinical features:
the initial lesion is a painful inflammatory hard lump, centered on a
follicular pustule;
the lesion develops within two to three days forming central
abscesses, enclosing a necrotic core (bourbillon);
the residual ulceration heals with scarring and local pigmentation.
The clinical symptoms are accompanied by changes of the overall
condition
fever
live pulsatile pain (when the location is in the vestibule of the nose
or upper lip)
significant edema (if the boils occur inside the nostrils, on the
eyelashes or between the eyebrows).
The recurrent prolonged evolution in different areas of the skin is called
furunculosis. This is explained by the increased virulence of Staphylococcus or
the existence of a significant immunosuppression.
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Clinical Diagnosis in Dermatology
2. Staphylococcal Onyxis
Clinical features
it is characterized by the appearance of small yellow abscesses under
the body of the nail. The lesions are painful and the nail becomes
brittle with an uneven surface;
the lesion may occur alone or secondary to a perionyxis.
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Streptococcal cellulitis
Etiology: The condition is caused by pyogenic cocci, and especially by group A
Streptococcus and less rarely by group B and C, to which other germs are
sometimes added . It has the appearance of an erythematous and oedematous
crust developed around the partial loss of a portion of healthy tissue and / or
due to a chronic venous insufficiency.
From an evolutionary perspective two clinical forms are described:
nonsuppurative cellulitis
cellulitis suppurativa (the crust is covered with bubbles which
open while the lesions lead to necrosis).
b) erythematous-squamous Streptococci
Pityriasis alba
Clinical features:
this condition is considered by some authors a form of atopy, with
atypical manifestations;
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Clinical Diagnosis in Dermatology
another by skin lesions and may take the form of an epidemic disease in
isolated communities.
Clinical features: the initial elementary lesions are bullous subcorneal
vesicules, of variable diameter (from a few millimeters to 3 cm), with a clear
content, located on an erythematous base. Their content is rapidly becoming
purulent, the lesions break open, leaving scourings and then they cover with
crusts. Clinical manifestation often includes a polymorphism due to lesions of
different types of coexisting elements (vesicles, bullae, pustulae, scourings and
crusts).
Sites: the lesions most commonly occur on the face, natural orifices (nose,
mouth), but they may appear on the extremities, scalp and trunk.
The presence of pruritus explains the extension of lesions through
autoinoculation.
Immunoblastic adenopathy is likely to occur. The overall condition is
generally unchanged.
Evolution and prognosis: if adequately treated, the evolution is favorable, the
lesions epithelialize within days without scarring. The lesions may rarely
relapse or become chronic due to an insufficient treatment, or due to the
existence of a favorable dermatosis.
The complications are rare:
locoregional infections (pyoderma vegetans, lymphangitis);
general infection (fever, septicemia);
acute poststreptococcal glomerulonephritis;
toxic syndrome (SSSS) - exceptional.
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covers the submucosa of the lower lip, which appears rupturing and
erythemato-scaling.
Intertrigo
The condition affects mostly the body folds, its appearance being
favoured by heat, humidity, poor hygiene and other pre-existing conditions
(eczema, mycosis).
Clinical features: the erythematous and erosive plaque that occupies the folds
(retroauricular, groin), covered with melicerous scabs and accompanied by
cracks at the bottom of the fold. The affection is accompanied by dermatopathic
lymphadenopathy.
Ecthyma
This is a pyogenic infection that develops on a weak site, caused by
multiple factors such as:
chronic venous insufficiency;
superficial wounds;
metabolic deficiencies;
poor hygiene.
In etiology, germs such as Pseudomonas aeruginoasa, Escherichia coli
are sometimes involved along with Staphylococci and Streptococci.
Clinical features: it begins as a deep bullae located on an erythematous base,
which breaks open and is covered with haematic crusts, while maintaining a
perilesional inflammatory erythematous halo. Healing leaves pigmentation and
scarring.
A particular clinical form is gangrenous ecthyma that occurs on a
immune suppressed ground. The lesions are covered with brown, adherent
scabs, covering gangrenous ulcers and the necrotic tissue.
Sites: usually on the legs, but the lesions may extend on the thighs, buttocks,
and rarely on the arms.
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Clinical Diagnosis in Dermatology
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Clinical Diagnosis in Dermatology
Erythrasma
Etiopathogenesis:
it is a bacterial intertrigo, caused by a gram positive bacteria -
Corynebacterium minutissimum and it mostly affects males;
the etiological agent is located in the corneum stratum and its
adhesion is favored by heat, humidity, poor hygiene
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Clinical Diagnosis in Dermatology
Trichomycosis axillaris
Etiopathogenesis:
the disease is caused by C. tenuis, in combination with other
aerobic corynebacterias in axillary and pubic hair;
the bacterium has affinity for the hair shaft and causes changes
regarding the stregth of its filament.
Clinical features:
it is characterized by the presence of small corpuscles adherent
to the hair shaft, of different colours: yellow, red or black;
oversweating with odor that stains linen;
the disease is asymptomatic.
Differential diagnosis: pediculosis pubis, thinning of hair.
Treatment: local usage of antiperspirant or aqueous formaldehyde solution 1%.
Cutaneous diphtheria
Etiology: Corynebacterium diphtheriae
Clinically, there are two forms:
1. primitive cutaneous diphtheria characterized by pustular lesions,
that ulcerate and become covered by a gray membrane;
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Gram-negative folliculitis
Etiology: Bacillus Proteus is the microbial agent isolated from cutaneous
lesions.
Clinical features: small, multiple pustules, placed on a erythematous base,
accompanied by discrete itching; the lesions can sometimes take nodular or
cystic appearance.
Sites: the lesions are clustered on seborrheic facial areas, but they may also
appear on anterior and posterior thorax.
Differential diagnosis: is done with papulopustular acne, superficial and deep
staphylococcal folliculitis.
Treatment: lLocal antibiotic therapy.
Recurrent folliculitis associated with Pseudomonas aeruginosa
The disease occurs in young children, causing small outbreaks. The
lesions occur after a pool bath or a steam bath. Excessive humidity is a high risk
factor for the occurrence of lesions.
Clinical features: cutaneous rash is of papulopustular type, with follicular
arrangement, surrounded by an erythematous halo.
Sites: the lesions are commonly located on the trunk and buttocks, and rarely on
legs or face.
Differential diagnosis is done with: Staphylococcal folliculitis, Pytirosporum
folliculitis
Treatment:
- mild forms do not require treatment;
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Clinical Diagnosis in Dermatology
Cutaneous meningococcal
Cutaneous contact is not rare in N. meningitides sepsis. Cutaneous
lesions may vary without special characteristics; erythematous rash; urticarial
lesions; papular or purpuric lesions located on the trunk, shoulders, arms.
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Cutaneous tuberculoses
They are skin conditions caused by Mycobacterium tuberculosis.
Koch bacillus (Mycobacterium tuberculosis) is an acid-alcohol resistant
bacillus, revealed through Ziehl -Nielsen staining and produced in Jensen and
Dubois selective environments (Lwenstein).
Inoculated on the skin level, the Koch bacillus produces a
granulomatous specific reaction, and the clinical manifestation is determined by
the amount of bacilli, its virulence and immunity of the body.
A variety of factors such as: malnutrition, lack of hygiene, infectious
diseases (HIV infection) creates optimal conditions for Koch bacillus
inoculation.
Mycobacterium tuberculosis reaches the skin either by exogenous
(tuberculous chancre, tuberculosis verrucosa), or endogenous inoculation
(lymphatic or hematogenous) from a severe tuberculosis epidemics.
The primary infection of tuberculosis is commonly inconspicuous, but
the penetration of Koch bacillus produces good overall immunization that can
be evidenced through skin tests (intrauctaneous reaction to tuberculin).
The diagnosis of cutaneous tuberculosis infection is made upon the
following criterias:
1. major criterias:
presence of Koch bacillus in the cutaneous lesions;
isolation of Koch bacillus from cutaneous lesions on
appropriate cultures;
reproduction of the tuberculous lesion in guinea pigs after
the inoculation of the pathological product.
2. minor criterias:
personal history of tuberculosis;
positive intraucutaneous tuberculin test;
histological structure of the tuberculid ;
Classification of cutaneous tuberculosis:
I. Typical cutaneous tuberculosis:
a) Primary inoculation tuberculosis
1) tuberculous chancre
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Lupus vulgaris
is the most common form of cutaneous tuberculosis and it occurs :
- through exogenous inoculation;
- through endogenous inoculation (lymphatic or hematogenous);
- contiguously (from a serious tuberculosis outbreak).
the disorder occurs in people with good overall resistance.
Clinical features:
the defining elementary lesion is lupus tubercle, located deep in the
dermis, of soft consistency, with a diameter of 3-4 mm, visible on
vitropressure;
the tubers coalesce to form well defined plaques, covered with fine
scales and having a slow rate of progress .
Sites: normally located on the face, the contamination occuring most frequently
on the endonasal mucosa.
Clinical forms:
a) plaque form:
is clinically characterized by small tubers, grouped in slightly
raised plaques, with infiltrated edges covered with scales;
vitropressure identifies the isolated tuber on the periphery of
plaques, that changes color to yellow-brownish , similar to an
apple marmalade;
the plaquess center evolves into cicatricial atrophy (through an
interstitial sclerosis process) and is marked by the appearence of
new relapsing tubers.
Differential diagnosis is done with:
- chronic lupus erythematosus;
- pearl - shaped basal scar epitheliom.
b) lupus vulgaris profundus:
Differential diagnosis:
lupus myxomatous
lupus tumidus
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Clinical Diagnosis in Dermatology
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Lichen scrofulosorum
Etiopathogenesis:
it is a rare condition affecting young BCG vaccinated or people with
deep tuberculosis outbreak (ganglionic or pulmonary) ;
lesions are produced by a reaction of sensitivity of the skin to
bacillary antigens ;
the structure of the lesions is tuberculous;
the condition manisfest itself after intercurrent febrile infection
(influenza, measles, scarlet fever).
Clinical features:
the lesions are small, yellowish or reddish papules, chronic,
acuminated, covered with scales or crust ;
the lesions prefer a perifollicular site, but they may be separated
from the pilosebaceous follicle;
the lesions may be isolated or they may coalesce into ill-defined
plaques;
they are not accompanied by subjective symptoms.
Sites: the lesions are commonly located on the trunk, rarely on the face and
extremities.
Progress: after a few weeks or months, the lesions heal spontaneously, however
relapses are also possible.
The differential diagnosis is done with:
lichenoid syphilids;
follicular keratosis;
follicular microbial eczematides;
lichen planus;
pityriasis rubra pilaris.
Papulonecrotic Tuberculids
Etiopathogenesis:
skin lesions occur as a result of hematogenous dissemination of deep
tuberculous outbreaks;
an immunological hypersensitivity reaction to the tuberculous
bacillus occurs on a cutaneous level, causing a necrosis process;
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Clinical features:
dusky- red small nodules of just a few millimeters in diameter, of
callous consistency
the lesions rarely ulcerate and the healing is done without scarring.
Sites: usually on the face.
Rosacea-like tuberculids
They represent a distinctive form of miliary tuberculids.
Clinical features: papulo-nodular lesions located on erythematous skin and
rosacea.
The differential diagnosis is done with rosacea and lupus vulgaris.
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Clinical Diagnosis in Dermatology
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Clinical Diagnosis in Dermatology
Leprosy
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It has a particular affinity for the nervous tissue, the target cell being the
Schwann cell.
Clinical manifestations
After contamination, the type of clinical expression (otherwise varied)
depends on the individual resistance, especially on the cell mediated immunity.
The main clinical forms, grouped according to histopathological,
bacteriological and immunological criteria, are the following:
1. stable clinical forms (polar typical)
- lepromatous leprosy (LL)
- tuberculoid leprosy (LT)
2. unstable clinical forms (atypical)
- indeterminate leprosy (IL)
- borderline leprosy (BL)
Lepromatous leprosy
It is the most severe form of leprosy which can occur with:
symmetric skin lesions, bilateral, affecting the face, arms, legs, buttocks
(cutaneous areas with lower temperatures): small, relatively well delimited
erythematous or copper-colored macules; papules and nodules of regular
skin color or erythematous / copper-colored, stiff, in the thickness of the
skin, of varying sizes; facial skin and ears become thickened (infiltrated)
with deep folds, the nose becomes swollen and enlarged, eyebrows and
eyelashes are lost, becoming "leonine facies". A firm chronic swelling of
the legs, emphasized during the evening, is also present. A late cutaneous
sign is ichthyosis.
mucosal lesions: nasal obstruction and rhinorrhea, sometimes with blood,
can be the clinical sign of an onset. The nasal mucosa is infiltrated, folded
and subsequently ulcerated. In late evolutionary stages septum perforations,
destruction of the nasal cartilage or the collapse of the nasal pyramid may
occur. The condition can occur on other mucosas such as: oral mucosa
(papules, nodules on the labial mucosa, tongue, palate, evolving towards
ulceration), laryngeal mucosa (fibrous changes of the vocal cords with
hoarseness or painful ulcers and dysphonia), lining of the eye (iritis and
iridocyclitis, punctate keratitis).
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Clinical Diagnosis in Dermatology
nerve symptoms: abnormal sensitivity (sensory loss " in gloves and socks ,
involving limb extremities), which lead, due to the absence of pain and
thermal sensitivity, after repeated trauma, to trophic disorders : ulcers,
neuropathic ulcerations, distal digital amputations.
other systemic involvement:
- bones (hands, feet, skull): resorption, concentric bone atrophy as
a result of repeated trauma, abnormal vascularity and
innervation, osteoporosis, osteomyelitis secondary to chronic
mucositis;
- testicular (atrophy after repeated orchi-epididymitis), evolving to
impotence and gynecomastia;
- nefritic (amyloidosis, glomerulonephritis, interstitial nephritis,
pyelonephritis), reasons for an increased mortality.
the general condition is affected, patients suffer from fever and
fatigue, lose weight, develop poliadenomegaly.
Tuberculoid leprosy
It is a less severe clinical form, less contagious, which manifests itself
by:
various skin symptoms: macules or papules in single or multiple
plaques anywhere on the skin of cold regions (regions in the
proximity of hairy scalps, armpits, groin, perineum), erythematous /
copper-colored or hypopigmented, irregular, scaly, with raised
distinctive borders, alopecia and without tactile, thermal or pain
sensitivity;
nerve symptoms may be the only manifestations and consist in
sensory loss, muscle weakness or peripheral paralyses; they are
accompanied by thickening of a nerve that becomes palpable, in the
proximity of possible skin lesions.
Indeterminate Leprosy
It usually appears in childhood and it manifests as macular skin lesions,
usually single or multiple, with asymmetrical distribution, erythematous or
hyperpigmented, relatively well-defined on the face or limbs, accompanied by
slight sensory loss.
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Clinical Diagnosis in Dermatology
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Actinomycosis
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Clinical Diagnosis in Dermatology
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changes during this clinical form are secondary to the thoracic wall
involved.
3. Abdominal actinomycosis - it has appendicular and cecal
involvement, the source of infection being the oral cavity or the
tonsils.
4. Primary cutaneous actinomycosis - is a rare clinical form, which
occurs through inoculation (exogenous infection) resembling
mycetoma.
5. Pelvic actinomycosis - is associated with intrauterine contraception
devices and doesnt cause skin lesions.
The evolution of actinomycosis without treatment is serious, leaving marks;
cervico- facial and primary cutaneous actinomycosis remain localized
conditions for a long time.
The positive diagnosis is based on the appearance of the lesions, the presence of
sulphur granules (1-2 mm diameter, adherent to gauze dressings) which
histologically consist of narrow bacillary forms and elongate hyphae with
branching.
Histopathological examination is the one that confirms the clinical
diagnosis. The inoculators require enriched media and incubation at 37 C in
anaerobiosis. It develops in white shiny colonies, with irregular edges.
The differential diagnosis
For cutaneous lesions, the following are taken into consideration:
- scrofuloderma;
- accumulated syphilitic gummas;
- mycetoma;
- botryomycosis.
Treatment
The inflammatory cycle that follows the granulomatous reaction inhibits
the penetration of antibiotics. Therefore, the disease requires long periods of
treatment. Sulphonamide, streptomycin, penicillin in large doses i.v.,
chloramphenicol, tetracycline and imipenem are used.
The antibiotic treatment is sometimes associated with a surgical
treatment.
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Clinical Diagnosis in Dermatology
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Herpesviruses
They are conditions produced by herpes viruses. This category includes:
1. Epidermal- neuro viral infections
herpes simplex
varicella zoster virus
2. Other types of herpes infections
infection with the Epstein-Barr virus (EBV)
cytomegalovirus Infection
human Herpesvirus 6
Epidermal-herpetic viruses
They are diseases caused by DNA viruses, which are part of the herpes
virus family, with intranuclear replication and persistence, remaining silent over
the years.
These viruses are reactivated in conditions of immune suppression and
prefer tissues of ectodermal origin (skin, nervous tissue).
The characteristic lesions are of erythematous vesicular type.
Herpes simplex
Etiology:
Herpes virus hominis (HSV) types 1 and 2 is the etiologic agent of
herpes simplex. HSV-1 is responsible for herpes infections located in the upper
half of the body while HSV-2 is associated with genital herpes infection, or the
lower half of the body.
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Eczema herpeticum
It is a severe form of primary herpes infection. It occurs in children with
atopic eczema and it is a manifestation of Kaposi Juliusberg varicelliform
pustulosis.
Clinical features: it manifests as an erythematous, generalized vesiculobullous
pustular rash, evolving towards erosions, ulcers and crusts. The lesions may
affect the buccal and conjunctival mucosa and are accompanied by fever and
general malaise. Mild forms resolve within 8 - 14 days, while severe forms
occur in immunocompromised children and may take a dramatic turn, with
visceral complications and even death.
Neonatal herpes
Primary infection with neonatal herpes is rare and can be produced by
HSV1 as well as by HVS2. The HVS1 infection may occur in the first day of
life, by direct contact with family members or medical staff.
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Ecthyma contagiosum
(Contagious pustular dermatitis or Orf disease)
Etiology:
This is an exudative type of viral skin infection produced by a
parapoxvirus. The source of infection is represented by the goats and sheep
infected with pustular stomatitis. It can be transmitted by direct contact or
through fodder. The incubation period is 3-10 days.
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Clinical features: the lesions are firm purplish papules, which can turn
into vesiculo-bullous pustules or hemorrhagic bullae. After they break open, a
central crust is formed and it is surrounded by a distinctive purple or white
gray ring. The lesions are located on the fingers, hands and forearms, and may
be accompanied by lymphangitis and regional adenopathy.
Positive diagnosis is supported by their clinical appearance and the
epidemiological background.
Differential diagnosis is done with of milkers nodules, verruca
vulgaris.
Treatment
The condition heals spontaneously within 5-6 weeks and confers
sustainable immunity. To avoid a pyococcus superinfection, topical medication
with antibiotics and dermocorticoids may be applied.
Milkers nodules
This is an exudative occupational dermatitis.
Etiology:
The disease is caused by a parapoxvirus (paravaccinia poxvirus). The
source of infection is represented by sick animals and human disease is
contracted through direct contact with cattle affected by paravaccinia.
The incubation period is approximately 5-7 days.
Clinical features: they are firm nodules, brown-purple with an
erythematous margin and a slightly depressed center covered with a crust. The
lesions occur on the fingers, the dorsal part of hands and are accompanied by
lymphangitis and lymphadenopathy.
A positive diagnosis is supported by the distinctive clinical appearance
of the disease, anamnestic and epidemiological data and through microscopic
examination that outlines distinctive inclusion corpuscles within malpighian
cells.
The differential diagnosis is done with pyogenic granulomas, ecthyma
contagiosum, verruca vulgaris.
Treatment
The condition heals spontaneously within 4-6 weeks. Local applications
of dyes and antiseptic solutions such as gentian violet 1% or methylene blue are
recommended.
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Vaccinia
Etiology: poxvirus officinalis
It has the same antigenicity as Poxvirus variolae and it was used in
smallpox vaccination. The infection occured after vaccination and its possible
complications (generalized vaccinia) have disappeared with the eradication of
smallpox.
Other mucocutaneous manifestations caused by viruses
1. Herpangina
2. Hand, foot and mouth disease
3. Epidemic Erythema Infectiosum
Herpangina
Etiology: group A Coxsackie virus.
It usually manifests as short seasonal epidemics, affecting mainly
children up to the age of 3.
Clinical features: characterized by erosive vesiculobullous and
ulcerative lesions on an erythematous enanthema, developed on the palatal
mucosa, the pillars of the tonsils and pharynx. The lesions are accompanied by
fever, headache, vomiting and abdominal pain.
The evolution is favorable, the recovery occurs spontaneously within 5-
6 days, with healing of the lesions and remission of fever.
The positive diagnosis is suggested by the epidemiological features of
the disease, its clinical appearance and benign evolution.
Differential diagnosis
Herpangina must be differentiated from aphthous stomatitis, herpetic
stomatitis and hand, foot and mouth disease.
The treatment consists of anti-pyretic drug administration and adequate
oral hygiene.
Hand-foot-and-mouth disease
Etiology Coxsackie A16, ECHO or enteroviruses.
The disease affects mostly children, it is contagious and the outbreaks
usually occur in the summer.
Clinical features: the eruption is characterized by painful lesions of
vesiculo-erosive stomatitis, affecting the oral mucosa, the palate, gums and
tongue, which hinders the nourishment.
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- rest;
- adequate hygiene to prevent further bacterial complications.
Cutaneous mycoses
The etiology of mycoses:
Mycoses are conditions caused by the fungi. Fungi are eukaryotic
organisms that thrive in an aerobic, moist and neutral pH environment, which
feed themselves by absorption and reproduce by spores.
They have sufficient characteristics that place them apart from plants
and animals, and it is considered that they deserve their own world, called
regnum fungorum. Fungi can be unicellular (yeasts) or multicellular
(dermatophytes).
The talus (fungal head) consists of two structures: a vegetative apparatus
and a reproductive apparatus.
The vegetative apparatus is represented by hyphae, which are tubular
filaments that extract from the external environment the substances needed in
order to develop the talus and reproductive system. The reproduction apparatus
consists of a vegetative apparatus and its reproduction takes place either
asexually (by spores that come directly from the talus) or sexually (through the
development of sexual stages and fertilization).
Basically, from a medical point of view, we distinguish between the
following types of fungi with implications in the mucocutaneous pathology:
1. dermatophytes;
2. yeasts;
3. dimorphic fungi;
4. non-pathogenic fungi (but able to become pathogenic in certain
circumstances) - molds.
Classification of cutaneous mycoses
I. superficial cutaneous mycoses:
a) dermatophytes;
b) candidiasis;
c) pityriasis versicolor
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Regarding hair mycoses, the sampling of the hairs is done with a pair of
tweezers, choosing only hairs that have lost their colour, are torn or embedded
in scales. In suppurative forms, sampling is performed at the periphery of the
lesion.
Regarding onychomycoses, the sampling of the material is done with a
lancet in the distal part, from the subungual deposit.
Laboratory examination:
Direct microscopic examination - this examination is done methodically
and in most of the cases it is sufficient to diagnose a mycosis. The examination
is performed between the blade and the slide, on achromic items.
In order to see the filaments or spores of the pathological material
sampled, they are hydrolyzed into dissociated substances. In practice, in order
to see the dissociated material that will be later be examined, 40 % potassium
hydroxide is used to obtain clear images.
On direct microscopic examination of scales, fungal agents in the form
of myceloid filaments of different shapes and lengths can be seen.
On microscopic examination of the hairs, the hyphae are visualized as
arthrospores, while their parasitism could be endothrix, ectohtrix or mixed,
depending on the etiologic agent.
Over the years, various methods of dyeing the extemporaneous
preparations have been suggested, but none of the methods provided the same
clarity as achromous chemicals.
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Parts of the skin are collected and stabilized in 15% formalin while the
sections performed on paraffin are stained by the usual methods (PAS).
Without neglecting the utility of direct examination, the stabilization
and staining of the biopsies support the positive diagnosis in many superficial
mycoses and allow the isolation of some opportunistic fungi.
Ultramicroscopic examination
Using transmission electron microscopy (TEM), and scanning (SEM)
makes it possible to study the structural characteristics of a fungal agent,
elements that are different from one species to another.
Molecular tests
Given the large number of fungal species with a pathogenic potential,
the molecular tests are focusing on a single parameter, namely the detection of a
specific nucleotide sequence known as unique for certain species. Molecular
testing will become even more useful if they could identify the mutations that
turn normal fungal genes into antifungal-resistant genes.
Unfollicular epidermal mycoses (dermatophyte infections of the
glabrous skin)
These are superficial mycoses caused by dermatophytes pertaining to
the following genera: Microsporum, Trichophyton, Epidermophyton.
Depending on their usual habitat, a distinction has to be made between
anthropophilic, zoophilic and geophilic dermatophytes.
They are predominantly confined to the superficial keratin of the
corneum stratum and may present various clinical pictures.
All dermatophytes are generically known as tinea with the additional
Latin term for body sites.
Depending on the location and appearance of the lesions, the following
clinical forms can be distinguished:
1. tinea corporis (herpes circinatus);
2. tinea faciei;
3. tinea cruris (eczema marginatum of Hebra);
4. tinea pedis;
5. tinea manuum.
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seborrheic dermatitis;
pityriasis rosea.
Treatment:
Topical treatment with antifungal medication is often enough to achieve
healing of the lesions. As therapeutic alternatives the following may be used:
- local sprinkling with iodine alcohol, Castellani solution,
clotrimazole solution;
- application of creams, ointments with Miconazole, Bifonazole,
Tolnaftat, Ketoconazole or Naftifine - Hydrocloride with
complex antifungal, anti-inflammatory and antibacterial effects.
When the lesions are chronic and do not respond to topical treatment, an
oral treatment can be administered, with antifungals such as Ketoconazole or
Fluconazole, Itraconazole or Terbinafine.
Tinea faciei
It is a fungal infection that affects the glabrous skin of the face,
including the eyelids.
Etiology: any of the genera and species of dermatophytes can be
involved.
Clinical features: is a circinate herpes lesion that affects the face.
A certainty diagnosis is given by mycological examination and
anamnesis which often reveal the fact that it was acquired due to animal contact
Differential diagnosis:
- polymorphic light eruption;
- lupus erythematosus, discoid;
- rosacea.
Treatment:
- Imidazole derivatives can be used (clotrimazole, bifonazole,
miconazole, ketoconazole) in topical applications as solutions,
ointments or creams. Healing can take place within 3-6 weeks.
Tinea cruris (ringworm of the groin or eczema marginatum Hebra)
It is the mycosis of inguinal creases.
Etiology: anthropophilic and zoophilic dermatophytes such as T.rubrum,
E. floccosum and T. verrucosum are involved.
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Tinea pedis
It is the dermatomycosis of modern life.
Etiology: it is caused by Tr. rubrum, Tr. Mentographytes interdigitalis,
E. floccosum.
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- contact dermatitis;
- vesiculo-bullous erythrasma.
Scaly or hyperkeratotic tinea differs from:
- plantar psoriasis;
- plantar keratoderma;
- hyperkeratotic eczema.
The positive diagnosis is supported by:
- the clinical examination;
- the mycological examination (which highlights the presence of
filaments and spores in the scales and crusts sampled from the
lesions).
Treatment:
1. the topical treatment consists in the application of keratolytics in
combination with antifungal substances (Dubreuilh pomade) or
creams / ointments with antifungal action.
2. oral treatment may be associated with topical treatment in resistant
forms of tinea pedis. Ketoconozole, Itraconazole, Griseofulvin can
be used.
3. a prophylactic treatment is vital to a successful therapy and consists
in:
- Disinfection of the stockings, shoes, toilet articles;
- Removal of predisposing factors (hyperhidrosis,
endocrinological imbalances, associated diseases).
Tinea manuum
It is the superficial mycosis of the hand.
Etiology: Tr. rubrum, E. floccosum, Tri. mentagrophytes interdigitalis.
Pathogenesis: the adhesion and germination of arthroconidia is favored
by partial loss of a portion of healthy tissues, skin maceration and deficient
peripheral circulation.
Clinical features- there are several forms:
a) dried form - with diffuse scaling;
b) exudative form-vesicular;
c) hyperkeratotic form - characterized by cracks and accentuating
flexural creases.
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Pityriasis versicolor
It is a superficial keratomycosis that occurs in the corneum layer of
epidermis.
Etiology: the condition is caused by a lipophilic yeast - Malassezia
furfur.
Pathogenesis: fungi invade stratum corneum and they are found among
keratinocytes as well as inside them. The process of adherence is favored by
maceration and high humidity. Factors such as hypersecretion of the sweat
glands or hyperhidrosis determine the occurrence of lesions, by turning the
fungal agent from a skin saprophyte into a parasite. A hereditary predisposition
to this condition is also taken into consideration.
Clinically there are two forms:
- colored Pityriasis versicolor;
- achromatic Pityriasis versicolor.
On physical examination the following were noticed:
the presence of macules or plaques of varying sizes, well
marginated which tend to coalesce into shaped patches of
pigmentary alteration;
the lesions have different colours ranging from yellow, brown,
fawn or white, they present fine furfuraceous scales, visible after
methodical scratching (fingernail or shaving marks);
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the lesions are located on the trunk, along the cleavage line,
around the genitals but they can extend to the neck, face, upper
or lower limbs.
Laboratory diagnosis: several laboratory tests can be used in order to
establish a diagnosis:
a) Wood's lamp examination - which make the lesions visible due
to yellow-green fluorescence and allows the assessment of their
size;
b) direct mycological examination of the scales - showing many
thin elements, grouped in oval-to-round macules, fragmented,
distributed among round spores, clustered.
Differential diagnosis includes:
- eczematids;
- seborrheic dermatitis;
- herpes circinatus;
- pityriasis rosea.
Treatment: topical treatment is known to work well. Creams, ointments,
antifungal shampoos (Ketoconazole, Travocort, Clotrimazole) may be used. For
patients with extensive involvement or for those with recurrent infections, oral
drugs such as Itraconazole 200mg/day for 5-7 days, Fluconazole 50mg/day for
10 days may be indicated etc.
Follicular mycoses (follicular dermatophytosis)
They are dermatoses that mainly affect the hair. Depending on their
location, the major types include Tinea capitis which usually affects children
and Tinea barbae, seen in adults.
Dermatophyte infections of the scalp (tinea capitis)
Tinea capitis occurs in two different forms:
1. aplastic pilomycoses
microsporosis
trichophytosis
2. inflammatory pilomycoses
inflammatory trichophytosis
favus.
Microsporosis
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Inflammatory Trichophytosis
It is defined as an inflammatory mycosis limited to the scalp in children
and to the beard and mustache in adults.
Etiology: Zoophilic species are involved (Tr. verrucosum, Tr
mentagrophytes), while the source of infection is represented by horses, cattle,
dogs and cats.
Epidemiology:
This condition occurs more frequently in rural areas. It is estimated that
the condition is more contagoius in the family, when sharing toiletries (however
without becoming as epidemic as microsporosis).
Clinical features:
From a clinical point of view, it is characterized by inflammatory
plaques of a pseudotumorous appearance, painful, round, well- delimited,
known as Kerion celsi.
Their surface is covered with multiple follicular pustules. The hairs on
the plaque could be easily shaved or they find themselves in an agglutinated
squamous crusty mass. When it manifests, drops of pus from the deep-seated
collection can be seen.
The lesions are often accompanied by painful lymphadenopathy.
In the course of evolution, hypersensitivity lesions may appear after a
while- tricophitydes - with different clinical aspects (lichen trichophytic,
erythema nodosum, etc).
In the beard and mustache, the lesions may have the same appearance as
the ones on the scalp of the children (kerion Celsi) or they may be scattered and
isolated (trichophytic sycosis). The disease tends to heal spontaneously.
Healing of the lesions is achieved with permanent cicatricial alopecia.
Laboratory diagnosis:
Direct examination of the hairs shows an endoectothrix infestation.
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1. favus scutularis;
2. favus psoriasiformis (squamous);
3. favus impetigoides (crust-like).
Favus scutularis
It is characterized by inflammatory lesions with centrifugal evolution. It
is characterized by cup-shaped depressions developed on the thick horny layer,
consisting of dermatophytic colonies and yellow debris (similar to sulphur).
The lesions smell as unpleasantly as a mouses urine.
Although fragile, the hairs can keep their normal length, but they are
lacking luster (gray mat shade) and are compared with pig bristles (coarse
hairs).
The infection may affect the entire skin of the scalp, except the
peripheral hairy region. This area is not affected probably because it remains
uncovered or because of a natural immunity.
Favus psoriasiformis
It is characterized by scaly plaques on the scalp, which covers an
erythematous skin. The hairs are dull (without brightness) and fragile - typical
favic hair.
Favus impetigoides
It is characterized by yellowish brown squamous plaques, which are
sticky and dry, mimicking a ringworm. The hairs have a typical appearance.
Favus has no tendency to clear spontaneously at puberty and the three
clinical forms may lead to permanent cicatricial alopecia - some authors
described a fourth form of cicatricial favus.
Laboratory diagnosis:
direct microscopic examination of hairs shows a distinctive
endothrix infection, with mycelial tubes of different sizes,
unevenly segmented, forming rectangular arthrospores similar to
tarsus bones " favic tarsus "
Sabouraud culture medium helps visualize the fungal elements.
Differential diagnosis includes:
- other diseases that cause alopecia, associated with inflammatory
phenomena;
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- impetigo;
- discoid lupus erythematosus;
- lichen planus.
General treatment is essential. It is recommended the use of oral
antifungals such as Ketoconazole, Itraconazole, Terbinafine for 4 weeks.
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Otomycoses
Etiology:
Infections of the external auditory canal, caused by dermatophytes, in
combination with molds and opportunistic fungi (Aspergillus Penicilium
migratum).
Clinical features:
They are characterized by scaling erythema, cracks and intense pruritus,
having an eczema-like appearance.
Positive diagnosis is supported by mycological examination that
highlights causative fungal agents.
Differential diagnosis includes external otitis, contact dermatites,
exogenous eczemas.
The treatment an antifungal local treatment is generally preferred, in
combination with antibacterial medication (naftifine, ciclopirox olamine).
Mucocutaneous candidiases
Etiology:
they are infections caused by yeasts of the genus Candida, albicans
species
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in the mouth it has the form of separate grains which can coalesce
and form pseudomembrane ;
it is associated with symptoms such as burning and pain.
b. acute atrophic (erythematous) candidiasis is characterized by:
depapillated area, leaving a smooth area on the tongue;
it occurs after antibiotic therapy;
clinical features: acute erythema on the mucosa, atrophic
appearance, areas of edema and secondary papilloma;
c. chronic atrophic candidiasis (denture-related stomatitis)
encountered mostly in denture wearers;
lesions are located on the palate;
little or no subjective symptoms.
d. chronic hyperplastic candidiasis (candidal leukoplakia)
white, slightly infiltrated patches on the mouth ;
differential diagnosis includes other leukoplakia (leukoplakia caused
by tobacco).
e. median rhomboid glossitis (candida is not the causative agent all the
time)
it is characterized clinically by a depapillated area on the dorsal side
of the tongue, having a rhomboid shape, located just anterior of the
circumvallate papillae, having a smooth or slightly raised surface;
the lesion is asymptomatic and has a self-limiting character.
f. black hairy tongue (candida is not the causative agent all the time)
it is characterized by hypertrophy of the lingual papillae which
become elongated as the hairs
keratinization on the tip of filiform papillae and oxidation by direct
contact with air causes mouth pigmentation
g. angular Stomatitis (perlche) lesions affect the angles of the mouth
Clinical features:
maceration of commissural submucosa
on the bottom of the fold there is fissure covered with crusts
the disease could be confused with streptococcal and
secondary syphilis lesions
h. angular cheilitis - inflammation of the lip caused by Candida
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Clinical features:
erythema, swelling and erosion in the mucosal and submucosal areas
of the lips and sometimes white creamy deposits
Differential diagnosis of oral candidiasis includes:
a. for oral and lingual sites:
oral leukoplakia
mucous plaques of syphilis
leukoplakia caused by Epstein - Barr virus
oral lichen planus
b. for labial and commissural sites:
systemic lupus erythematosus
streptococcal perlche
leukoplakia cheilitis
papular erosive syphilide
actinic cheilitis
II. Candidiasis of the genital mucosa
a. vulvovaginal candidiasis this disease occurs frequently in sexually
active or pregnant women
Clinical features:
the vaginal mucosa is congested, edematous, with erosions and
creamy white deposits
thick, white, curdlike vaginal discharge
pruritus
there is also a special appearance with reduced secretion,
mucosal atrophy and reduced deposits
the lesions may extend to the vulva, resulting in erythema,
edema, erosion and deposits; they may extend to the fold
between the buttocks
chronic, relapsing development
Differential diagnosis of vulvovaginal candidiasis
bacterial vulvovaginatis
physiological leucorrhea
trichomoniasis
vulvar contact dermatitis
b. Candidal Balanitis or balanoposthitis
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Clinical features:
erythematous, edematous mucosas, accompanied by small
pustules on the glans or foreskin, with erosion and creamy white
deposits
lesions extending to the folds erythemato-squamous
appearance
differential diagnosis:
- balanitis
- herpes simplex
- lichen planus
- erythroplasia
c. Inflammation of anal mucosa - perianal candidiasis
III. Cutaneous candidiasis
a. Candidal intertrigo is an inflammation of the folds caused by
Candida
clinical features: erythema, edema, having plaques with pustules
at the periphery, that either open and form erosions or they dry
and detach themselves, leaving a desquamation collar
skin is macerated at the bottom of the fold
it often occurs in the interdigital folds of the hand,
inframammary fold in women and rarely in the inguinal fold
Differential Diagnosis
epidermophytosis involving the folds
eczema involving the folds
erythrisma
Streptococcal intertrigo
b. Candidal perionyxis (paronychia)- inflammation of the tissue in the
periungual caused by Candida
Clinical features: edema and erythema, scaling cuticle. When
pressed, a small amount of creamy yellowish-white pus appears
from beneath the nail.
Differential diagnosis includes:
staphylococcal perionyxis
periungual psoriasis
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c. Candidal Onyxis- the nail is attached to the base or to the side and
follows a perionyxis; nail slide shows changes in colour, striations, it
is friable, undergoing an onycholysis process
Differential diagnosis:
staphylococcal onyxis
dermatophytic onychomycosis
onychomycosis trigerred by general disorders
d. Candida folliculitis is characterized by pustules in the follicular
ostium, surrounded by discreet erythema
e. Otitis externa - inflammation of the outer ear canal
Clinical features:
Erythema and edema
desquamation, pruritus
IV. Chronic mucocutaneous candidiasis
it usually manifests in the first years of life
it is resistant to treatment
it affects the mucous membranes, skin and nails
Congenital chronic mucocutaneous candidiasis
it begins in the first days of life
it associates oral, ungual and severe skin lesions (autosomal
recessive form)
Diffuse chronic mucocutaneous candidiasis (granulomatous
candidiasis)
it is a chronic form of disease
it occurs in children
it affects the skin (face, scalp, glabrous skin)
the lesions are granulomatous-hyperkeratotic and papillomatous
it associates with severe immunosuppression
Mucocutaneous candidiasis with endocrinopathy
it begins in childhood
it is associated with hyperparathyroidism, ovarian insufficiency,
thymoma
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Laboratory diagnosis
direct microscopic examination of pathological products
(secretions or nail fragments) highlights Candida filaments and
estimates the amount of fungal elements on the mucosas
Sabouraud agar culture identifies the species: Candida albicans
frequently present
serology tests are recommended for disseminated candidiasis
and they determine Ac specific, by highlighting flowing Ag
Treatment
Therapeutic principles:
in order to get good results in chronic forms, the treatment should be
aimed at:
- changing the favorable conditions (pH change, oral and
cutaneous hygiene and improvement of the immunosuppressed
factors)
- administration of effective antifungal medication
Treatment of oral candidiasis:
As a general treatment the following are recommended:
- antibiotics (polyenes, nystatin, natamycin)
- imidazoles (ketoconazole)
- triazoles (fluconazole, itraconazole)
Topical treatment: the administration of oral suspensions or gels
containing nystatin and amphotericin B.
Treatment of genital candidiasis: vaginal suppositories or tablets in
combination with antifungal medication administered orally (eg, fluconazole
150mg / in a single dose or itraconazole 600 mg / in a single dose).
Treatment of candidal balanitis consists in the administration of local
antifungals (nystatin, natamycin) in combination, or not necessarily, with oral
antifungal in a single dose.
Treatment of cutaneous candidiasis:
- azoles or polyenes in creams or ointments
- elimination of favorable conditions by applying compresses or
baths with antiseptic solutions
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Laboratory Diagnosis
direct microscopic examination reveals mycelial filaments
Sabouraud culture
histological examination
The treatment: is difficult, the chronic lesions are resistant to
antifungals.
The following are recommended:
systemic treatment
1. antibiotics (when the etiology is bacterial)
- penicillins
- sulfonamides
- tetracycline
- erythromycin
antifungals (when the etiology is fungal)
- itraconazole
- ketoconazole
surgery
- excision of lesion
- leg amputation when there is severe bone damage
Sporotrichosis - is a rare form of deep chronic mycosis.
Etiology The disease is caused by a dimorphic fungus (Sporothricum
schenckii) and is commonly found in temperate and tropical zones. The natural
habitat is represented by soil and plant debris.
Pathogenesis Fungus reaches the skin through a micro traumatism and
forms subcutaneous nodules that could progress along lymphatic channels.
Clinical features
The infection acquired through cutaneous inoculation is clinically
characterized by:
pustules or nodules that slowly progress to ulceration, becoming
chronic
a nodular formation that wears out appears at the site of inoculation ,
known as sporotrichotic canker
the surrounding lymph channels and ganglia are enlarged and
swollen
subsequently, similar nodules appear along the lymphatic channel
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lesions occur on the limbs (foot and leg), they are accompanied by
pain and functional impotence
a particular clinical form is verrucous sporotrichosis, affecting the
dorsal side of hands
Systemic form:
frequently the access path is pulmonary, following an inhalation of
spores, after which it can disseminate through blood ;
the disorder occurs in immunocompromised hosts
Clinical features:
The clinical manifestations are dominated by respiratory symptoms, but
articular or meningeal manifestations are also possible.
Mucocutaneous lesions are characteristic: nodules and ulcerations with a
chronic course.
Laboratory diagnosis:
1. direct examination of purulent secretion reveals mycelial filaments
2. culture on agar media shows colonies with folded surface, that
change their color from white to brown
3. histopathology - PAS staining reveals a mycotic granuloma (the
fungal element surrounded by an asteroid eosinophilic star-shaped
body).
Differential diagnosis includes:
mycetoma
tuberculosis
Kaposis angiosarcoma
Treatment
systemic - the following are indicated:
- systemic antifungals: itraconazole 200 mg / day, for 30 days;
Ketoconazole 200 mg / day for 1-2 months; amphotericin B,
terbinafine
- potassium iodide 30 droplets / day up to 1 ml / day,
depending on the patients tolerance
surgery: it is a rare alternative, that consists in the excision of the
nodules and in extreme situations - leg amputation.
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PARASITICAL DERMATOSES
SCABIES
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PEDICULOSIS
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Clinical features:
intense itching is the major clinical sign of disease in louse infested
areas.
Pruritus leads to prolonged scratching that results in excoriations
(ringworm crust) with tangling of the hair;
in old forms of the disease or when the lesions are intensely infested,
retromastoidian or laterocervical adenopathy may set in.
the nits are on the hairs, located a few mm from the emergence of the
hair (gray-white elongated formations), highly adherent.
Sites: the occipital region is the most common site for Pediculus capitis, but the
lesions may extend and the scalp is fully affected.
Treatment:
1. local hygiene (washing with soap and water and application of a 15-
20% acetic acid solution);
2. Application of substances against parasites:
- 1% lindane (smearing);
- pyrethrins;
- crotamiton;
- malathion 0.5-1 %
- topical antibiotics (for intense impetiginized forms).
The treatment is repeated after 8 10 days.
Differential diagnosis includes:
squamous streptococcal infection of the scalp;
neurodermatitis;
scalp eczema;
seborrheic dermatitis.
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Clinical features:
papular - vesicular lesions that occur from bites, accompanied by
intense itching.
other less characteristic lesions are hives, haemorrhagic lesions,
hematic crusts, linearly distributed scars, along the interscapular -
vertebral region ;
at the same time, a brown pigmentation of the skin also appears, due
to toxins found in the parasites saliva.
Treatment
- Lindane 2-3% of talc, topical sprinklings for 2-3 days.
- Crotamiton lotion 10%;
- Malathion lotion 0.5 %;
- Pipevonyl butoxide 3% in inert carriers;
- Disinfection of linen by sprinkling insecticides, washing, boiling and
ironing.
Differential diagnosis: scabies, chronic prurigo.
Phthiriasis pubic, Phthirus pubis(pubic lice, crab lice)
is produced by Phthiriasis pubis or crab and it affects
predominantly the genital area;
it is 1.5 mm long and has three pairs of feet, provided with strong
claws, with which it clings on the hairs;
they lay their eggs at the root of the hairs, after 7-8 days the nymphs
appear and every other week the adult crabs;
contamination takes place through direct contact (sexually
transmitted) or indirectly, through underwear.
Clinical features:
the specific lesions are small blue spots known as macules cerulea,
secondary to bites;
other possible lesions: papulovesicular lesions, hematic crusts,
excoriations, lichenification;
intense pruritus accompanies the lesions constantly;
the nits can be identified on the hairs as yellowish-gray grains.
Sites: lice can mostly be found in the genital region, but their involvement may
spread to the hair around the anus, thighs, armpits, beard, mustache, eyelashes
and eyebrows.
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Treatment:
- shaving of the hairs;
- lindane 1% spraying;
- yellow mercury precipitate 2% (for eyebrows and eyelashes);
- applications of fluorescein 20 % (instillations on the eyelid);
- linen disinfection.
Treatment should be repeated after 7-10 days. All sexual partners should
be treated.
Differential diagnosis:
- vulvar pruritus of other etiologies;
- contact dermatitis;
- inguinal Epidermophytosis
Etiology:
parasites are nematodes that commonly infest animals: Ankylostoma
caninum, Strongyloides stercoides, A. duodenale;
the parasite normally lives in the intestine of animals, where eggs
pass into the feces;
filiform larvae develop from eggs and penetrate the skin;
the larva migrates along the skin, describing a cutaneous linear
lesion, advancing 1-2cm/day.
Clinical features:
initially a pruritic linear urticarial lesion appears on the skin, located
near the penetration site;
lesions subsequently migrate, creating linear paths and involving
large skin areas;
because of the scratching, secondary bacterial infection and
impetiginisation are common
Differential diagnosis:
linear dermographism;
acute urticaria;
centrifugal annular erythema.
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Treatment:
- general: administration of anti-helmintic drugs (thiobendazol 25 mg
/ day for 5 days)
- local - cryotherapy for the active extremity of the linear lesion
(where the larva is).
ALLERGIC DERMATOSES
URTICARIA (HIVES)
Definition
Urticaria refers to a group of allergic or nonallergic manifestations,
clinically characterized by a monomorphic cutaneous rash, erythematous-
edematous, migratory, transient and intensely pruriginous.
Classification
According to their evolution, urticarias may be categorized as acute,
when the eruption resolves within hours or days and occur in less than six
weeks, or chronic, when the eruption persists intermittently for several months /
years.
Regarding their occurrence, urticarias may be allergic - mediated by
immune reactions, especially type I (anaphylactic) and type II (with circulating
immune complexes and activation of the serum complement system) or non-
allergic, in which the mast cell activation is mediated directly by neuropeptides,
drugs, food.
Etiopathogenesis
The triggering or causative factors of allergic rashes are:
food and food additives: eggs (white), cocoa, milk and dairy
products, salami, fish, dyes, preservatives, sweeteners,
antioxidants;
medicines: antibiotics (penicillins, cephalosporins, tetracyclines,
sulfas), salicylates, non-steroidal anti-inflammatory drugs,
angiotensin-converting enzyme inhibitors;
allergens: pollens, molds, house dust, cigar smoke;
insect venom;
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Clinical features
Urticaria has got very suggestive features: circumscribed lesions that
have a monomorphic appearance, being edematous, erythematous or white
(depending on the importance of superficial dermal edema), migratory (from
one skin area to another), transient (resolving within minutes / hours), intensely
pruriginous (by stimulation of histamine H1 receptors), having different sizes
(either millimetric or forming plaques and patches) and shapes (round, oval,
figurate, ring-shaped).
Skin lesions are sometimes associated with digestive disorders
(vomiting, diarrhea, abdominal pain), arthralgia, dizziness, episodes of
faintness. Anaphylaxis can occur in severe forms, which could be lethal, IgE-
mediated, which associates urticarial eruption with: angioedema, hypotension,
cardiac arrhythmias, lacrimation, nasal obstruction, bronchospasm.
Positive diagnosis
The positive diagnosis is based on the appearance and progressive
features of the lesions. The etiologic diagnosis requires a detailed history of the
data that reveal the onset, duration of individual lesions and rash, associated
systemic signs, possible precipitating factors: heat, cold, pressure, friction, solar
radiation, recent infection, ingestion of food or medication, a family history of
atopy or angioedema and investigations such as:
the titre of specific IgE serum (RAST test) - in patients with
severe clinical forms;
prick - tests with the suspected allergen;
challenge tests involving food additives: during the periods of
remission of chronic food urticaria (eg sodium benzoate);
immunoelectrophoresis, measuring the serum complement.
Differential diagnosis
Urticarial lesions should be differentiated from:
erythematous - edematous erythema multiforme;
dermatitis herpetiformis on its onset;
figurate rash (annular centrifugal erythema).
Treatment
The etiologic treatment aims at avoiding or removing the triggering
etiologic factors (food, medicines).
The pathogenic treatment refers to the administrations of:
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Differential diagnosis
Angioedema must be differentiated from:
- dermatomyositis;
- erysipelas;
- cellulite;
- acute contact dermatitis.
Treatment
It is similar to the treatment indicated for anaphylaxis:
- oxygen therapy;
- epinephrine (adrenaline) 0.1-1.5 ml sol. 1/1000 should be
administered i.m. / s.c. or inhaled;
- i.v. hydrocortisone hemisuccinate;
- antihistaminic i.m.
ECZEMA
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Clinical manifestations
The cutaneous lesions are marked by age but they are constantly
accompanied by an incessant pruritus which enables their perpetuation. Thus,
their clinical manifestations are the following:
atopic dermatitis that starts in early infancy, characterized by
inflammatory erosive-exudative or dry lesions, fissuring of the
cheeks, with onset after the third month of life;
juvenile atopic dermatitis, manifested clinically by subacute eczema
affecting the flexural folds (elbows, popliteal, axillary folds), latero -
cervical regions, the back sides of hands and feet;
adult atopic dermatitis characterized by lichenified eczema
especially on the folds, around the orbit of the eye and mouth, the
dorsal side of hands.
The clinical cutaneous manifestations may be accompanied by relapsing
courses of asthma, seasonal rhinitis, kerato - conjunctivitis, kerato - conus,
subcapsular cataract.
Other suggestive signs of atopic skin include:
dry skin;
Derrnie - Morgan sign (extra fold of the lower eyelid);
Hertzoce sign (thinning of the hair on the lateral side of the
eyebrows) ;
follicular hyperkeratosis;
white dermographism (through predisposition to
vasoconstriction due to mechanical factors).
Positive Diagnosis:
According to the British Study Group regarding atopic dermatitis, the
major criterion in establishing a positive diagnosis is itching and the minor
criteria include a history of flexural, latero-cervical, perimalleolar lesions, a
history of one year of xerosis , present eczematous lesions on the folds or on the
cheek of children under 4 years, onset of cutaneous symptoms before the age of
two years.
Atypical cutaneous manifestations of atopic dermatitis include:
forefoot eczema in children between 3 and 14 years;
prurigo with small papular lesions distributed mainly on the
lower parts of the limbs;
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Eczema vulgaris
It is characterized by lesions arranged in plaques and patches, vaguely
delineated, located symmetrically on the dorsal side of hands and feet, calves,
forearms, arms, scalp, face, neck, groins, folds and rarely on the trunk. The
appearance of these lesions may be predominantly erythemato-edematous
(especially the facial and genital locations), keratosic and fissural (in palmar-
plantar location) or lichenified if the development is chronic.
Seborrheic dermatitis
It is a dermatitis of unknown etiology linked on the one hand to
Malassezia ovale and sometimes to increased sebaceous secretion and a range
of anomalies and system diseases (myocardial ischemia, malabsorption,
obesity, alcohol abuse, ethanolic pancreatitis, Parkinson disease). On the other
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ECZEMATIDS
Etiopathogenesis
Eczematids are allergic dermatoses characterized by itchy erythemato-
squamous lesions, induced by reactions of sensitivity to internal allergens
(microbial food parasites) or from bacterial or fungal skin outbreaks. The
histological features are similar to eczema, but from a clinical point of view, the
lesions do not have a vesicular or an exudative stage.
Clinical features
Depending on lesion morphology, eczematids may have the following
appearances:
pityriasiform : round - oval plaques with ill-defined limits and
covered with branny powdery scales, located on the scalp
(simple pityriasis), on children 's faces, on the extensor sides of
the limbs, the sides of the thorax;
psoriasiform: scaly erythematous plaques covered with thick
scales that desquamate;
acromial: white round plaques with smooth scales (pityriasis
alba) that occur in children with ENT disorders or on atopic
place on the limbs.
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NEURODERMATITIS
It is a cutaneous manifestation dominated by marked pruritus and
characterized by a primary lichenification of the skin.
Etiopathogenesis
The disorder occurs in adulthood, especially in females. It affects
persons prone to scratching as a result of any pruritic stimulus. Emotional stress
causes paroxysmal episodes of scratching.
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Clinical manifestations
The lesions are represented by solitary or multiple plaques that occur
more frequently on the nape of neck, the upper inner region of thighs, perineal
region, cubital edge of forearms, the dorsal and lateral side of feet. Initially,
these lesions are erythematous edematous plaques with raised borders and
subsequently their center is covered with scales, with infiltrated and pigmented
skin, whereas lichenoid papules, surrounded by an area of slightly pigmented
skin are formed at the periphery.
Positive diagnosis:
It is more obviously suggested by the clinical features of the lesions than
by the histopathological changes dominated by epidermal hyperplasia. Argentic
impregnation identifies the proliferation of Schwann cells.
Differential diagnosis
The following should be excluded:
- secondary lichenification occurring in atopic dermatitis,
irritant contact dermatitis with chronic progression;
- lichen planus;
- psoriasis.
Treatment
Sedatives, anxiolytics and topical corticosteroids in occlusive dressing
and tars; 5% doxepin cream; solitary lesions should be treated with 10mg/ml
triamcinolone infiltrations.
PRURIGO
Prurigo refers to allergic manifestations clinically characterized by
papular and papular-vesicular lesions caused by scratching, that may develop
acutely or chronically.
Acute Prurigo
a) prurigo simplex acuta infantum or prurigo strophulus
It presents as an eruption of erythemato-edematous lesions surmounted
by intensely itchy vesicles, localized on the limbs and trunk. The lesions
occur in tandem and sometimes they are related to dental eruption,
consumption of a certain type of food and they may resolve
spontaneously, however they have the tendency to relapse. The
condition resolves around the age of 7.
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Chronic prurigo
a) Besnier prurigo
It coincides with the chronic manifestations of juvenile atopic dermatitis
with polymorphic lesions: lichenified hyperpigmented patches,
sometimes papular - vesicular and erosive and crusty. It affects the face,
the neck and the large folds. It attenuates after puberty or in adulthood;
b) chronic prurigo of adults
It is a condition characterized by sudden itching, followed by a papular
and papulo-vesicular eruption usually affecting the limbs.
Lichenification may occur as a result of intense itching. The evolution
can be long (it may take years).
Except predisposing biologic factors (digestive, endocrinical, metabolic,
neuropsychic), there are other ethiopatogenic circumstances such as
malignant neoplasms (eg Hodgkin's disease) that have a role in the
occurrence of chronic prurigo.
c) Hyde prurigo nodularis
It is characterized clinically by an eruption consisting in pruritic
nodules, with chronic progression and possibly areas of lichenification.
It is a condition of unknown etiology but 65-80 % of the patients are
atopic. It can occur at all ages but usually between 20-60 years in
equally both sexes.
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The lesions are globular, firm, raised nodules, with keratotic or eroded
surface, covered with hematic crusts and surrounded by a
hyperpigmentated ring. The most common sites are the extensor
surfaces of the limbs. They are accompanied by itching with
exacerbations and may resolve spontaneously leaving scars.
Positive diagnosis:
It is based on the appearance, site of lesions and lesion development. It
requires laboratory investigations and interdisciplinary consultations
regarding the biological factors.
Differential diagnosis
Prurigo must be distinguished from:
- hives,
- papular - vesicular eczema;
- scabies;
- erythema multiforme;
- lichen planus;
- dermatitis herpetiformis;
- chickenpox.
Treatment:
It is adapted according to age, clinical context and severity of rash.
Besides the etiologic treatment antihistamines, sedatives, anxiolytics and topical
antipruritic medication (mixtures or lotions), dermocorticosteroids are also
administered.
Severe cases of chronic prurigo of adults, prurigo nodularis, benefit
from systemic corticosteroids, sulphonotherapy, nonspecific desensitization.
ERYTHEMA MULTIFORME
Erythema multiforme is a dermatosis of plurietiological determinism,
commonly relapsing, with mucocutaneous involvement, usually affecting
young adults.
Etiopathogenesis
Erythema multiforme is linked to:
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Clinical diagnosis
The "target" or cockade appearance as well as the herpes iris are
evocative for erythema multiforme.
Differential diagnosis
Erythemato - papular clinical form must be differentiated from:
- papular syphilides;
- urticarial lesions;
- Gougerot - Ruiter vasculitis.
Vesiculobullous lesions of erythema multiforme must be differentiated
from:
- porphyria cutanea tarda;
- dermatitis herpetiformis;
- bullous pemphigoid.
Stevens-Johnson syndrome should be differentiated from autoimmune
bullous dermatitis and Lyell syndrome of adults (drug-induced toxic epidermal
necrolysis).
In adults, Lyell syndrome (toxic epidermal necrolysis) - life-threatening
condition in approximately 30 % of the cases, is considered to be the
consequence of a hypersensitivity reactions to drugs.
Clinically features: erythematous skin lesions with a tendency towards
spreading, followed by an epidermal flare up as a result of the flaccid bullae
that break open and may involve the entire skin surface. The mucosal lesions
are severe and affect the lips, oral cavity, pharynx, genital and connective
mucosa.
Malaise and high fever (38-39 C) occur whereas hyperacute or severe
forms are characterized by hydroelectrolytic imbalances along with visceral
lesions: renal (glomerulonephritis which may progress to acute renal failure),
hepatic, pulmonary, pancreatic.
Treatment
Minor and moderate clinical forms of erythemato-edematous and
vesiculobullous erythema multiforme can be self-limiting, requiring only the
suppressing of the cause and a symptomatic treatment: antihistamines, vitamin
C.
Extensive and severe clinical forms of vesiculobullous and Stevens-
Johnson syndrome of erythema multiforme require systemic corticosteroid
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CUTANEOUS VASCULITIDES
Cutaneous vasculitis is thought to have many etiologic causes and
manifests as pleomorphic skin lesions (urticarial, purpuric, necrotic) resulting
or not in systemic involvement. Histopathologically it is characterized by
inflammation of the small and medium vessels in the dermis and hypodermis,
mediated immunologically.
Etiopathogenesis
It may affect both sexes and all age groups.
The triggering factors include:
bacterial infections (hemolitic streptococcus, sinus, dental,
urinary infections), viral infections (hepatitis B, C, herpes
simplex), parasitic infections ;
drugs (antibiotics, NSAIDs, aspirin, sulfonamides, purgatives);
food and food additives (colour additives);
environmental factors (cold, excessive heat);
anxiety,
pregnancy;
chronic conditions: diabetes mellitus, hematology (including
lymphomas), rheumatoid arthritis, liver disease, lupus
erythematosus;
gravitational eczemas.
The pathogenic mechanism is usually based on a hypersensitivity
reaction mediated by immune complexes that activate C ' and rarely on a cell
mediated immune reaction.
Histopathology
The typical morphological features include:
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ERYTHEMA NODOSUM
Erythema nodosum is a deep cutaneous vasculitis cuased by deposits of
immune complexes on the walls of the vessels in the deep dermis and
hypodermis.
Antigenic sources consist of bacteria (streptococcus, Mycobacterium
tuberculosis, Treponema pallidum, Salmonella), viruses (infectious
mononucleosis), fungi (dermatophytes, Histoplasma), chlamydia, drugs
(analgesics, antipyretics, gold salts, contraceptives). Erythema nodosum can
occur in hematologic, sarcoidosis, leukemia, lymphomas.
Clinical features include:
a febrile prodrome of malaise and possibly arthralgia;
a characteristic rash consisting in dermo- hypodermic lumps on
the anterior surface of the shins (rarely on the thighs or
forearms) having an inflammatory and fluctuant character (red,
warm, painful, discreetly raised);
during their evolutionary stages, the lumps become purple,
brown, yellow-green and may reabsorb without sequelae, within
approximately 2-3 weeks ; but they may recur.
Laboratory findings confirm an increased sedimentation rate,
leukocytosis, high levels of fibrinogen and 2 - globulins.
POLYARTERITIS NODOSA
It is a necrotizing vasculitis that can take two aspects:
1. benign periarteritis nodosa characterized clinically by cutaneous
lesions of livedo racemosa or nodular type, along the vascular
tracts of the limbs, face, posterior cervical region, evolving
towards ulceration or resorption, and histologically by a
leukocytoclastic vasculitis of the muscular arteries;
2. cutaneous-visceral polyarteritis nodosa, more frequent in males,
having clinical manifestations that may include skin lesions
(palpable purpura, ulcers, digital gangrenes) and visceral
involvement.
cardiovascular- myocardial arrhythmias, coronary artery
disease, myocardial infarction, hypertension;
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GRANULOMATOUS VASCULITIS
Wegener's granulomatosis
It is a rare systemic vasculitis caused by anti-neutrophil cytoplasmic
autoantibodies (ANCAs) that may be triggered by chronic infections such as
tuberculosis, syphilis. The presence of these autoantibodies causes damage to
tissues by blocking proteinase inhibitors.
Clinical manifestations include nodules on the face which ulcerate
unsteadily, papular and papulonecrotic lesions on the limbs, mouth ulcers.
Destructive granulomatous lesions affect the pharynx, larynx and
trachea.
Renal glomerulitis involvement may lead to uremia.
Churg-Strauss allergic granulomatosis
It is a systemic vasculitis that occurs in asthmatic patients, the clinical
manifestations include:
nodular skin lesions, palpable purpura, chronic ulcers located on
the limbs, trunk, scalp;
pulmonary infiltrates, carditis, arthralgia, neurological signs,
hematuria, bloody diarrhea.
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ERYTHEMATO-SQUAMOUS DERMATOSES
PSORIASIS
It is a dermatosis characterized by erythemato-squamous lesions, with
chronic evolution, genetically determined.
As the disorder progresses with flares, it has a negative impact on the
quality of life.
The treatment regimens target the lesions, maintaining its reactive
potential due to the fact that the disease is genetically determined.
Pathophysiology
Psoriasis is characterized by two types of anomalies:
1. abnormal epidermal hyperproliferation;
2. an immune disorder marked by an inflammatory dermal infiltrate
accompanied by exocytosis.
Etiopathogenesis
The main anomaly remains the disruption of keratinization, that
involves hyperproliferation of the keratinocytes in the superficial layer
(parakeratosis), thus shortening the epidermal cell turnover rate.
Keratinization disorders include:
inhibition of filagrin synthesis (protein involved in the final
process of keratinization);
early expression of involucrin and transglutaminase by
keratinocytes;
persistence of basal keratin (K5 and K14) on the superficial
layers of epidermis (granular and corneal);
presence of K6 and K16 abnormal keratins;
Absence of K1 and K10 keratins.
The keratinocytes pertaing to plaque lesions have revealed the following
changes responsible for cell division acceleration:
the ratio of cyclic nucleotides (cAMP /CGMP) changes in favor
of GMPC -factor favoring cell division;
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Clinical aspects
Psoriasis vulgaris
Psoriasis vulgaris is the most common type of psoriasis. Psoriasis is
typically characterized by plaques and patches of skin, which usually have very
well defined edges:
The lesions are represented by erythematous papules or plaques
covered with scales. The erythema is red violaceous and is largely
covered with thick, silvery, shiny, stratified and less adherent scales.
Brocq 's methodical scratching detaches the scales progressively,
highlighting typical signs of psoriasis :
- spermaceti droplets(fragmentation of the scale in small particles
and its bleaching when touched with a scoop)
- Auspitzs sign (punctate bleeding spots when the scales are fully
scraped off)
the lesions are not usually itchy
the sites of the lesions:
- are very suggestive for diagnosis
- preferentially affect the extensor surfaces, elbows and knee,
lumbar- sacral region, scalp
- other typical locations include : the palmar- plantar and genital
region and the flexural creases where the squamous appearance
is less visible but it is dominated by well-defined plaque
erythema
Classic lesions are frequently accompanied by ungual involvement
which becomes difficult to diagnose when it is isolated. Nail injuries
can be characterized by:
- small depressed dots, cupuliform depressions located on the nail
plate
- subungual hyperkeratosis and fragility
- distal onycholysis
Inverse psoriasis (flexural/ intertriginous psoriasis)
it occurs in the skin folds, having both a discreet squamous
appearance and an erythematous one, due to the nature of the area
(heat, moist)
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PARAPSORIASIS
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PRP - Classic Juvenile PRP (Type III): this form accounts for 10 %
of all cases of PRP. The clinical picture is similar to type I and the
remissions occur more rapidly.
circumscribed juvenile PRP (Type IV) : this form accounts for 25 %
of all cases of PRP. It manifested clinically as corneous papules,
hyperkeratosis and erythema on elbows and knees. This form rarely
progresses.
atypical Juvenile PRP (Type V)-clinically manifested by follicular
hyperkeratosis, scleroderma -like lesions and erythematous lesions.
The frequency of this clinical form is about 5 %.
HIV -associated PRP (Type VI): In this form, the lesions are less
characteristic, aside from follicular papules, acneiform lesions may
also be encountered (pustules, papules, pustules and cystic nodules)
Clinical features
Cutaneous lesions
The basic typical lesion is the corneous follicular papule, element that
distinguishes PRP from other erythemato -squamous dematoses.
Other lesions include:
follicular hyperkeratosis
erythematous lesions
palmoplantar hyperkeratosis
pityriasis capitis lesions
subungual hyperkeratosis
the papular erythematous -squamous lesions are arranged in plaques
and large patches with sharp borders, with an orange hue, located on
the trunk, abdomen, limbs and feet
follicular keratotic papular lesions are commonly seen on forearms,
arms, thighs and buttocks.
erythematous lesions can be seen on the face, neck and ears
subjectively: pruritus
The emergence of the clinical signs generally follows a chronological
order.
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LICHEN PLANUS
Lichen planus is a dermatosis which affects the skin and / or mucosa
with chronic self-limiting evolution.
The condition is relatively common in both sexes and all races. The
prevalence is estimated at 1%.
The onset is usually in the 5th or 6th decade of life, it may be a familial
trait and it has a high incidence in patients with HLA A3, A5, B7 and DR1
antigens.
Lichen planus belongs to the group of lichenoid dermatoses and it is
characterized clinically by papular cutaneous lesions and histologically by
mononuclear cell infiltrate with linear distribution in the superficial dermis.
Etiopathogenesis
The etiopathogenetic mechanisms are not fully understood.
Many factors are incriminated:
1. viral infections (keratinocytes have revealed virus -like inclusions).
2. stress (the lesions are exacerbated by psychological trauma).
3. drugs (gold salts, antimalarials give rise to lichenoid eruptions.)
4. neurological diseases (lichen planus is associated with severe
neurological conditions, peripheral neuritis, syringomyelia).
Cutaneous lesions:
clinically, lichen planus is characterized by erythematous violaceous
papules. The lesions have 1-3 mm, they are shiny, polygonal, very
itchy and sometimes centrally depressed;
characteristic fine, white lines are often found on the papules
(Wickham stria);
the papules may be found separately or they may coalesce to form
plaques and patches;
the linear distribution of the papular lesions is typical for lichen
planus and it is known as the Kbner phenomenon or isomorphic
response;
healing leaves small persistent hyperpigmented spots.
Sites- the most affected areas are:
the anterior surface of the forearm and wrist;
the lumbar-sacral region;
the anterior surface of the feet;
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Clinical Diagnosis in Dermatology
the lesions are found on the flexor areas, upper chest, neck,
sacral region ;
on the scalp the lesions are characterized by follicular papules
associated with moderately adhesional scales which can lead to
atrophic cicatricial alopecia.
3. Annular lichen planus
clinical features: small round plaques with a depressed center
and lichenoid papules at the periphery;
the lesions can be found on the male genitalia.
4. Erosive oral lichen planus:
clinical features: erosive, ulcerative and persistent patches in the
mouth, sometimes associated with atrophic pigmented lesions
and desquamative gingivitis.
5. Vesicular and bullous lichen planus:
it associates lichenoid papular lesions with bullous lesions.
Positive diagnosis depends on:
1. clinical appearance;
2. subjective symptoms (pruritus);
3. histopathological examination.
Pathological diagnosis
Histopathological changes in lichen planus include:
hyperkeratosis accompanied by ortokeratosis
focal hypergranulosis
irregular acanthosis (" saw teeth " appearance)
hydropic degeneration of the basal layer
the upper dermis has a band-like infiltrate of lymphocytic and
histiocytic cells
presence of colloid bodies in the epidermis and upper dermis
4. direct immunofluorescence (DIF) reveals deposits of IgM, G, Aand
complement, in a band-like distribution along the basal membrane.
5. indirect immunofluorescence reveals antibodies of a specific lichen
planus antigen.
Differential diagnosis:
1. lichenoid eruptions;
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2. papular-scaly syphilides;
3. chronic prurigo;
4. lichen amyloid;
5. verruca plana;
6. guttate psoriasis;
7. lichenified chronic prurigo;
8. papular - vesicular eczema.
Complications of lichen planus
- are rare and include:
1. candidal superinfections (for lesions in the mucosas);
2. lichenification;
3. persistent residual pigmentations;
4. atropho-cicatricial lesions;
5. synechiae in the genital region;
6. carcinomatous degenerations(in oral lesions).
Evolution and prognosis:
This is a self-limited disease, it has a benign evolution, without any
signs of malaise. Skin lesions heal with persistent residual pigmentations.
The prognosis is usually good, the impact of the condition on the overall
state is controlled by the intensity of the subjective manifestations. Recurrences
are possible in about 20 % of patients.
Treatment
The effectiveness of the treatment is difficult to assess for this chronic
and benign condition. If the lesions are extensive and the pruritus is intense, the
following therapeutic options are available:
1. Abstinence therapy if:
the lesions are few in number and on limited areas;
the itching is intense;
the patient accepts.
2. Topical treatment:
topical corticosteroids applications with or without occlusive
dressing;
cyclosporine for oral mucosal lesions (topical applications) or
corticosteroids
retinoids (isotretinoin gel 0.1 %).
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Clinical Diagnosis in Dermatology
General treatment:
It is appropriate for acute extensive forms, involving a wide range of
areas, or for severe erosive forms.
Depending on the particularity of the case the following can be
administered:
corticosteroid therapy (prednisone 15-20 mg / day, 6-8 weeks)
systemic retinoids (etetrinate 75mg/day)
griseofulvin (500 mg / day)
cyclosporine (5 mg / kg c / d)
PUVA therapy
Other treatment methods
1. surgical excision of oral lesions of lichen planus;
2. cryosurgery;
3. laser therapy;
4. radiculomedullary radiotherapy.
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PEMPHIGUS VULGARIS
It is a severe autoimmune disorder, usually seen in the adults with
genetic and ethnic predisposition. Groups HLA - B38, HLA - DR4, HLA - B55,
HLA - DPW4 are more commonly affected.
Etiopathogenesis
The pathogenic mechanism of the pemphigus is based on the process of
autoimmune acantholysis.
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Clinical Diagnosis in Dermatology
When pressed, the skin that covers a prominent bony surface exfoliates
and gives rise to erosions.
Bullous skin lesions exhibit a predilection for the scalp, face, inguinal
and axillary folds, chest, and for anatomical areas prone to pressure and trauma.
The onset of cutaneous lesions usually affects the oral mucosa, may appear
secondary to the skin rash or they may even be absent after the first flares.
The disease runs a chronic course, of increased severity, and as the
disease progresses, the general condition is deteriorating. Fever, electrolytic
disorders, severe superinfections of bare skin areas are major life-threatening
factors.
Positive diagnosis of pemphigus vulgaris rests upon its characteristic
clinical appearance and it is confirmed by laboratory tests.
Laboratory diagnosis
1. Tzanck cytodiagnosis reveals the process of acantholysis.
- the base of a blister is scraped, and a May- Grunwald Giemsa
staining is being performed
- the examination detects the presence of malpighian cells, either
scattered or clustered, with a distinctive morphology, known as
acantholytic cells (large nucleus, basophilic cytoplasm and a
reversed nucleo- cytoplasmic ratio)
2. Histopathological examination
Shows the presence of a blister located in the deeper malpighian
layer.
The base of the blister is made up of basal keratinocytes, whereas
acantholytic cells are found inside the blister
3. Direct immunofluorescence
- Shows a specific fluorescence of reticulated appearance caused
by deposition of IgG, M and fraction C3 of the complement
within the intercellular malpighian gaps (this method uses anti-
IgG antibodies, highlighted by fluorescein).
4. Indirect immunofluorescence
- reveals the presence and titer of circulating autoantibodies in the
patients serum
- demonstrates the presence of anti-intercellular cement substance
autoantibodies, pertaing to IgG class
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Clinical Diagnosis in Dermatology
PEMPHIGUS VEGETANS
Pemphigus vegetans is a particular form of pemphigus, characterized by
papillomatous hypertrophic vegetating lesions, frequently involving large body
folds.
Etiopathogenesis:
The antigen of pemphigus vegetans is a 130KD molecule.
Clinical manifestations:
Two forms of pemphigus vegetans are described
1. Pemphigus vegetans of Neumann: this form is initially characterized
by flaccid bullae, with a clear fluid, that rupture, whereas the
erosions are covered with hypertrophic granulation tissue that
subsequently develops into plaques. Sometimes these vegetative
masses are covered with fetid secretions due to maceration and local
superinfection.
Sites: it usually appears on the axillary, inguinal, nasolabial folds, on
the corner of the lips, vulvar and anal region. Oral lesions may have
a vegetative appearance as well.
2. Pemphigus vegetans of Hallopeau: the onset lesions are pustules that
may develop into erosions that are quickly covered with
papillomatous proliferations forming plaques, with active edges and
a tendency to extend peripherally. The lesions are painful, have a
fetid smell, and have a predilection for intertriginous areas (groins,
axillary and perianal regions).
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PEMPHIGUS FOLIACEUS
Pemphigus foliaceus is a rare form of pemphigus and two varieties are
described, an endemic one and a sporadic one.
Etiopathogenesis:
This form of pemphigus is also characterized by antibodies which react
against intercellular adhesion molecules, belonging to the cadherin family. The
antibodies belong to IgG4 class and are directed against desmoglein 1, whereas
circulating antibodies are directed against desmoglein 1and 2.
The endemic variant (fogo selvagem) can be seen in Brazil and it is
caused by an insect bite (Simulium preunosum).
Clinical manifestations:
The onset lesions are flaccid vesiculo-bullae that rupture quickly and are
cover with multilayered squamous crusts. The characteristic appearance is of an
exfoliative erythematous - squamous crusty erythroderma. Nikolsky 's sign is
positive. The disease starts in the cephalic and thoracal extremities and from
here it may extend.
Mucous membranes are rarely affected, and the overall condition is
good.
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Clinical Diagnosis in Dermatology
Laboratory diagnosis:
histopathological examination shows that acantholysis affects
superficial layers of the epidermis (spinosum and granular strata)
direct and indirect immunofluorescence show closely resemblances
to pemphigus vulgaris in all respects.
immunoelectron microscopy shows that the autoantibodies of
endemic pemphigus foliaceus bind diffusely not only to the
desmosomal region, but to the surface of keratinocytes as well.
Differential diagnosis include:
- seborrheic dermatitis
- impetigo
- Lyell Syndrome
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PARANEOPLASTIC PEMPHIGUS
It is a particular form of pemphigus found in patients with malignancies
(lymphoma, thymoma).
Etiopathogenesis:
Four target antigens are responsible for the initiation of the autoimmune
process, desmoplakina1 (250KD) desmoplakina2 (210KD), the major antigen
of pemphigoid B (230KD) and one molecule of 190KD. IgG antibodies are
anti-surface pemphigus -like cells that bind to the transitional epithelia.
Clinical manifestations:
The lesions are atypical, polymorphic and affect the mucous membranes
and the skin. Mucosal lesions are painful erosions and ulcerations, with necrotic
appearance. Oral mucosa and conjunctiva are often affected.
The skin rash is characterized by polymorphic bullae, erosions and
cockade lesions similar to those of erythema multiforme and subacute -like
lupus erythematosus.
Laboratory Studies
histopathological examination: shows suprabasal acantholysis,
keratinocyte necrosis and vacuolar degeneration of the basal layer.
direct Immunofluorescence testing (DIF) detects depositions of
immunoreactants IgG and C3 within the epidermal intercellular
spaces, or granular and linear depositions of C3 in the epidermal
basement membrane
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Clinical Diagnosis in Dermatology
PEMPHIGUS HERPETIFORMIS
Pemphigus herpetiformis is a clinical variant of pemphigus, with distinct
clinical features.
Clinical manifestations:
The lesions are similar to those found in dermatitis herpetiformis: the
vesicles demonstrate aherpetiform pattern, being clustered on an
erythematous base and scattered along the trunk and limbs.
Histopathology shows characteristic changes: spongiosis accompanied
by eosinophils and acantholysis, intraepidermal edema and exocytosis of PMN.
DIF shows depositions of IgG, IgA and C3 on the surface of
keratinocytes without involving the desmosomes.
IIF highlights IgG circulating antibodies that recognize desmoglein 1
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- osteoporosis
- gastrointestinal bleeding
- blood clotting
- iatrogenic Cushing syndrome
- resistance to corticoids.
Immunosuppressive drugs
Immunosuppressive drugs are recommended during the consolidation
and maintenance phase, either by means of a single drug (in cases of resistance
to corticosteroids or when there is contraindication to glucocorticosteroids) or
in combination with corticosteroids.
1. Azathioprine
is a nitroimidazole derivative of mercaptopurine, acting as an
intense and prolonged immunosuppressant;
it is recommended in serious forms of disease and in cases of
resistance to corticosteroids;
azathioprine is a safe drug when carefully administered;
its toxic effect can not be neglected (bone marrow and liver
involvement), nor its decreased resistance to infections and its
carcinogenic effect on the blood. Dermatologic doses (1.5 -
3mg/kg / day) are generally low and provide some protection in
this sense.
2. Cyclophosphamide
is a nitrogen mustard alkylating agent acting that interferes with
DNA structure and hinders its replication, transcription and
translation functions.
it has an important immunosuppressive effect, thus it is indicated
in autoimmune diseases.
is useful in the maintenance phase of treatment of severe forms
of pemphigus, single or in combination with corticosteroids.
The average dose is 1-3mg/kg/day, in 2-3 divided doses.
The side effects are common to all cytostatics and include acute (nausea,
vomiting, visual disturbances) or late reactions (myeloid toxicity, sterile
hemorrhagic cystitis, alopecia) and are determined by the frequency and
duration of administration.
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Methotrexate
Methotrexate is an analogue of folic acid, that inhibits the formation
folic acid, by blocking the enzyme dihydrofolate reductase, necessary for DNA
and RNA synthesis. Its effect is cytostatic, antiproliferative, and strong
immunosuppressant.
Methotrexate is used in mild forms of disease, or as maintenance
treatment in severe forms, in combination with corticosteroids.
It is administered in doses ranging from 25-50mg/week in the control
stage of the treatment and 7.5 mg / week during the maintenance phase. The
dose is divided into 3-4 doses every 12 hours.
The side effects include:
high risk of liver toxicity and possibly cirrhosis
marked immunosuppression, increasing the risk of infections
worsening of oral lesions
Cyclosporine
Cyclosporine acts as an immunomodulatory drug. T-helper lymphocytes
are selectively inhibited. It is recommended in severe forms of pemphigus
vulgaris, but used alone, it has proved less effective. It is used in small doses of
3-5 mg / kg / day, in oral administration. Oral lesions of pemphigus vulgaris
respond well to topical therapy with cyclosporin (5 minutes gargle 3 times /
week, for 8 weeks), using 5 ml of the 100mg/ml Sandimmun solution. The
results are inconsistent with pemphigus foliaceous.
The side effects are numerous. Nephrotoxicity and hepatotoxicity
dependent on the dose, but they are present in 25-75 % of patients treated with
cyclosporine. Other frequent manifestations include gingival hyperplasia,
hypertension, hirsutism, neurological disorders.
Mycophenolate mofetil
This immunosuppressant has recently been used in the treatment of
pemphigus vulgaris, suppressing T and B lymphocyte proliferation by
inhibiting inosine monophosphate dehydrogenase, an enzyme essential for the
synthesis of guanine nucleotides. The inhibition of proliferation of B cells
suppresses the production of antibodies in pemphigus vulgaris. Mycophenolate
mofetil is recommended in cases of pemphigus vulgaris resistant to therapy.
The usual dose is 2g/day administered alone or in combination with
cyclosporine and prednisone.
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Clinical Diagnosis in Dermatology
foliaceous, bullous pemphigoid. Although the exact Ig mechanisms are still not
fully understood, the main immunomodulatory mechanisms are described:
blocking of Fc receptor function
purification of circulating immune complexes
suppression of antibody production
reduction of complement-mediated damage
modulatory effects on the production and release of cytokines
regulation of cell-mediated immune response
The side effects of this therapy include:
anaphylactic reactions
renal failure
hemolysis
cardiovascular complications
Adjuvant therapy associates:
anabolic drugs
vitamins
sedatives
Topical treatment:
It is essential and consists of applying antiseptic, inflammatory
solutions, with a healing effect. The blisters must be cleaned up, then topical
antiseptics and siccatives must be applied. After drying of the lesions, topical
corticosteroids may be applied.
Epithelializing, antiseptic and anticandidal suspensions, are
recommended in mucosal lesions. Orabase corticoid preparations are known to
have beneficial effects.
Notably, lipo-soluble bases should be avoided in pemphigus vegetans
because they enhance the formation of vegetations.
Hygienic-dietary treatment
a diet rich in proteins, vitamins and minerals
a low sodium, hypoglucidic and hypolipidaemic diet
avoiding mucocutaneous trauma
an easy-going lifestyle
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Clinical Diagnosis in Dermatology
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Clinical Diagnosis in Dermatology
Associated diseases:
Bullous pemphigoid has often been associated with malignancy, being
considered a paraneoplastic disorder.
Differential diagnosis includes
pemphigus vulgaris
Duhring - Brocq dermatitis
erythema multiforme
Evolution and prognosis:
bullous pemphigoid has a favorable evolution and a self-limited, but
prolonged course.
Treatment:
The following are recommended:
1. general corticosteroid therapy, alone or in combination with
cytostatic drugs such as (azathioprine, cyclophosphamide,
methotrexate);
2. sulfones (dapsone) in combination or not with systemic
corticosteroid therapy
3. antibiotic therapy (erythromycin);
4. the topical treatment includes corticosteroids.
Cicatricial pemphigoid
Cicatricial pemphigoid is a rare, chronic bullous dermatosis
characterized by blistering lesions on the mucous membranes, leading to the
residual scars.
Areas commonly involved are the ocular, nasal, buccal, genital mucosa
and occasionally the skin.
Etiopathogenesis
Cicatricial pemphigoid antigens are:
180 kDa and 230 kDa bullous pemphigoid antigens
160kda, 120kDa antigens and laminin 5
The clinical manifestations are dominated by mucosal involvement. Early
bullous eruptions become erosive, whereas healing leaves vicious scars.
Ocular mucosa
the initial sign is unilateral conjunctivitis, then the lesions
become bilateral.
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clinically they are vesicles that turn into erosions that heal with
scarring
with persistent disease activity, a mucosal symblepharon affects
the conjunctiva, the eyelids become atrophic, and in the final
stages, the cornea becomes dry and opaque.
Oral mucosa
mucosal erosions affect the jugal (cheek) mucosa, the hard or
soft palate, having a persistent nature
desquamative gingivitis may be the only manifestation of the
disease (gum swelling and bleeding erosions)
healing takes place with adhesion between the oral mucosa and
alveolar processes.
Genital mucosa
vesicles and erosions on the labia heal with scarring or changes
of the vaginal opening or labia.
Pharyngeal and oesophageal mucosa
the lesions are responsible for dysphagia, dysphonia and
strictures.
Cutaneous lesions
are erythematous plaques covered with recurrent blisters, leaving
pigmented scars;
the rash can be generalized as in bullous pemphigoid or located
in the vicinity of the affected mucous membranes.
Laboratory findings
Histopathological examination- reveals the presence of an infiltrate in
the dermis made up of lymphocytes, plasmocytes, eosinophils and fibroblasts as
well as a deep subepidermal blister.
Direct immunofluorescence (DIF)
DIF studies demonstrate the presence of IgG or C3, rarely IgA or IgE
arranged linearly on the basement membrane zone.
Indirect immunofluorescence (IIF)
The presence of circulating anti-basement membrane autoantibodies is
very rarely seen.
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Clinical Diagnosis in Dermatology
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Clinical Diagnosis in Dermatology
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Clinical Diagnosis in Dermatology
MAJOR COLLAGENOSES
LUPUS ERYTHEMATOSUS (LE)
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Environmental factors
A variety of environmental factors trigger the onset of the disease. The
most important ones include: natural ultraviolet radiations, viral infections,
microbial infections, drugs (penicillin, contraceptives, streptomycin), trauma.
Classification of lupus erythematosus
Based on clinical, immunological, histological and evolutionary
considerations, LE can be divided into:
1. Chronic cutaneous LE;
2. Subacute LE;
3. Acute LE.
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Clinical Diagnosis in Dermatology
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Clinical Diagnosis in Dermatology
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Treatment
The local treatment is often able to control the course of the disease and
is recommended for superficial forms of lupus, with just a few lesions. The
following preparations can be used:
- moderate topical corticosteroids (in the form of creams,
ointments or intralesional injections);
- cryotherapy or laser therapy for resistant forms of lupus;
- the use of sunscreens is recommended for highly
photosensitive people.
The general treatment consists of the administration of:
- synthetic antimalarials (chloroquine, hydroxychloroquine);
- low doses of systemic corticosteroids are recommended for
forms that respond to treatment with antimalarials;
- retinoids are recommended for hypertrophic forms or for
those that do not respond to conventional and local therapy;
- dapsone, clofamizine, beta - carotene, thalidomide are
considered backup variants.
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Clinical Diagnosis in Dermatology
Histopathological findings:
Particular histopathological findings of subacute forms of lupus include:
- moderate hyperkeratosis;
- basal hydropic degeneration (without colloid bodies);
- inflammatory infiltrate superficially distributed.
Immunohistopathological tests
IFD tests highlight the lupus band at the dermo- epidermal junction.
Evolution and prognosis subacute cutaneous lupus erythematosus runs a
chronic course, but the prognosis is generally favorable.
Differential diagnosis
- LE chronic
- psoriasiform eczematids
- tinea capitis
- psoriasis.
Treatment the following are recommended:
- synthetic antimalarials (hydroxychloroquine 200-400 mg / day)
- corticosteroids per os
- sulfonate or retinoids
- sunscreens.
Systemic lupus erythematosus (SLE)
SLE is a multisystemic autoimmune disease that commonly affects
females.
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Clinical Diagnosis in Dermatology
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Clinical Diagnosis in Dermatology
SCLERODERMAS
Sclerodermas are connective tissue disorders, of unknown etiology, as a
result of some autoimmune mechanisms.
Clinicaly they are characterized by fibrosis of the dermis and atrophy of
the epidermis, with or without visceral involvement.
According to clinical, immunological and histopathological criteria,
sclerodermas are classified as follows:
1. Systemic scleroderma (generalized or progressive);
2. Circumscribed localized scleroderma (morphea).
Systemic scleroderma (generalized systemic scleroderma)
Systemic scleroderma is a multisystem disorder that results in sclerosis
and atrophy of the connective tissue, muscular abnormalities and
immunological alterations.
Etiopathogenesis: the etiology of this condition is obscure. However,
the fact is that the development of this condition is linked to a genetic factor.
Scleroderma associates with HLA-B8 and HLA9 groups frequently, and the
genotype susceptible to the disease is characterized by a dominant allele,
located on chromosome X.
On this highly "sclerodermiform" background, the lesions may develop
as a result of a microangiopathy, an immunological disorder or an imbalance
between the synthesis and degradation of collagen.
The primary lesions occur in the small blood vessels of skin, triggering
a chain of reactions targeting the endothelial cell.
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Clinical Diagnosis in Dermatology
Cutaneous manifestations:
the onset is insidious in the upper extremities, with vasospastic
and skin colour changes, known as Raynaud's syndrome;
these vascular phenomena are accompanied by interphalangeal
and joint numbness and swelling of the fingers;
during the course of the disease, the fingers become thinner at
the distal extremity, the skin becomes shiny and tightly bound to
the underlying structures, the interphalangeal joints become
semiflexible and the nails undergo dystrophic changes
(sclerodactyly-like appearance);
at the base of the fingers there are necrotic ulcerative lesions that
heal leaving stellate scars;
other possible changes include:
- whitlow and paronychia which are resistant to treatment, due
to vascular disorders;
- thenar and hypothenar erythema;
- calcification of the fingers.
the lesions on the hand may advance to forearm and arm;
the lower extremities of the feet may also be affected, but the
lesions are less severe;
some changes in the cephalic extremity, especially on the face,
may occur at the same time with the lesions on the hands;
the typical appearance is that of a "Byzantine icon";
sclerosis and atrophy of the skin make the skin appear rough,
shiny, smooth and tightly bound to the underlying structures;
the wrinkles are erased, the nose becomes thinner, the lips retract
partially revealing the dental arch, microstomia with radial
furrowing, reduced facial expression;
the lower eyelids retract, enabling erosion and ulceration of the
cornea, whereas tear secretion is highly diminished.
Sometimes sclerosis extends to the entire skin, taking an armor-like
appearance, characterized by thickened dry skin, cardboad-like, because of the
sweat glands atrophy.
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- anti-collagen Ab;
- anti- endothelial cell Ab;
- anti-histone Ab (found in scleroderma associated with
cardiovascular lesions);
Other useful investigations include:
- periungual capillaroscopy (shows a decreasing number of
capillary or megacapillary loops);
- digital plethysmography (absence of pulse waves);
- radiological studies in order to detect visceral involvement.
Histopathological findings
Skin biopsy reveals different aspects depending on the stage of the
lesions.
In the initial stages, the lesions are represented by:
edema and dermal and hypodermic perivascular infiltrates;
moderate collagen proliferation.
Older lesions are characterized by:
clusters of thick collagen bundles, oriented in different
directions;
a notably reduction of vascularity within the dermis;
the disappearance of the hair follicles, sebaceous and sweat
glands;
epidermal atrophy.
The positive diagnosis is confirmed by the following changes required
by ARA criteria:
1. cutaneous sclerosis involving the extremities (limbs, face, or throat)
and the trunk;
2. combination of two of the following changes
- sclerodactyly;
- stellate scars on the pulp of the fingers;
- bilateral basal pulmonary fibrosis.
Differential Diagnosis is done with other collagen or scleroderma -like
conditions as follows:
- morphea;
- dermatomyositis;
- scleromyxedema.
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Clinical Diagnosis in Dermatology
B. Generalized morphea
Retractile scars and facial hemiatrophy develop during the course of the
disease.
Guttate morphea (guttate / drop-shaped scleroderma)
The clinical features include a large number of lesions, which are small
(3-5 mm) round - oval, depressed, white, located on the torso.
The lesions tend to coalesce and become atrophic.
Laboratory findings
laboratory changes are less specific and inconsistent
can reveal antinuclear antibodies (anti - single-stranded DNA
Ab), anti - histone Ab and increased levels of procollagen type I
The antinuclear antibodies and eosinophils are markers of the disease
activity, whereas anti KV antibodies are markers of its progression.
The differential diagnosis is done with:
1. polyarteritis nodosa;
2. panniculitis nodosa;
3. sclerodermiform hypodermitis;
4. plaque parapsoriasis;
5. keloidal scars.
Treatment:
a) general treatment promotes the administration of vasodilators,
anti-fibrotic drugs and corticosteroids
b) the following are recommended in the topical treatment:
- local vasoactive massages;
- physical therapy (ionization, ultrasound);
- infiltrations with cortisone preparations.
Generalized morphea
It is a rare disease, with an insidious onset, frequently affecting adult
females.
Clinical manifestations
the lesions are represented by indurated ivory plaques and
patches, with a large purple halo, commonly affecting the
abdomen and the trunk ;
the plaques and patches coalesce, new lesions occur and the
entire skin may be affected;
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extensive injuries can affect the face, neck, the scalp and the
extremities of the limbs;
may be associated with arthralgia, muscle contractures of the
limbs, or intercostal muscles, which impairs the movement of
thorax.
Evolution and prognosis
the evolution is chronic, it may last for years, sometimes
following a partially remitting course ;
in advanced stages the prognosis can be serious, leading to death
by respiratory failure.
Differential diagnosis
Generalized morphea should be distinguished from:
1. Systemic scleroderma;
2. Sclerodermiform states;
3. eosinophilic fasciitis.
Treatment
There is no specific treatment, however for cutaneous symptom relief
the following can be administered:
- vasodilators;
- anti-fibrotic drugs;
- corticosteroids.
DERMATOMYOSITIS
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Clinical Diagnosis in Dermatology
Classification
Two main clinical forms are described:
Wagner- Unvericht acute dermatomyositis
Petges - Clejat chronic dermatomyositis
Acute dermatomyositis
Clinical manifestations
acute onset with fever, chills, muscle weakness, weight loss,
joint pain;
two major events dominate the course of the disease:
- muscle syndrome
- cutaneous Syndrome
The muscular syndrome is characterized by:
myalgia: affects the muscles of the shoulder girdle, of the pelvis
and calves ;
muscle weakness - marked fatigue;
muscle atrophy - occurs in the late stages of the disease, in
chronic forms and it manifests as myofibrosis and tendon
retraction. Other groups of muscles involved: the muscles of the
pharynx, of the diaphragm, the flexors of the neck and the
vertebral groove (their involvement triggers an unfavorable
prognosis)
Cutaneous Syndrome:
may be the first manifestation of the disease in 25 % of cases;
characteristic cutaneous lesions include:
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Laboratory findings
Three elements have to be taken into consideration when performing
laboratory studies on dermatomyositis:
1. levels of certain muscle enzymes;
2. electromyography;
3. histopathological examination of the muscles involved.
The level of certain muscle enzymes shows a cytolysis of the muscles,
manifested through:
high levels of CK, LDH enzymes;
elevated levels of aldolases and TGO, TGP;
creatinuria over 1g/day;
myoglobinuria.
Electromyography (EMG) showed an inflammatory myopathy resulting
from a reduction of the amplitude waves, a diminished duration of the motor
unit potential and spontaneous fibrillations.
Histopathological examination
Skin biopsy shows the following changes:
a) in the acute phase
- atrophic epidermis ;
- focal basal hydropic degeneration;
- edema and inflammatory infiltrate in the superficial dermis.
b) in the late phase:
- fibrosis, sclerosis and calcium deposits in the subcutaneous
tissue ;
- degenerative lesions resulting in the disappearance of the cross
striations of the muscle fibers;
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Clinical Diagnosis in Dermatology
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ACNE VULGARIS
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ACNE ROSACEA
Rosacea is a chronic dermatitis affecting predominantly females aged
35-50 years and it is rarely seen in adolescents or the elderly people. The
lesions predominantly affect the skin of the nose, surrounding the cheek area
and they are represented by papules and pustules, occurring on a background of
couperosis and evolve in successive stages. Despite its benign characters,
rosacea can be the source of an important aesthetic damage.
Etiopathogenesis
Many but unconfirmed factors have been involved in the etiology of this
disease, however the pathophysiological mechanism of rosacea remains
obscure. The role of digestive endocrinic, infectious, psycho- emotional and
vasomotor factors is frequently mentioned. The association of vascular lesions
with inflammatory lesions and the development in stages are universally
accepted.
Evolutionary stages of rosacea (Wilkin JK, Arch. Dermatol.)
I. pre - rosacea (flushing)
II. vascular rosacea (redness, telangiectasia)
III. inflammatory rosacea (papulopustular rosacea)
IV. hyperplasia of connective tissue (Rhinophyma)
Subjects who develop rosacea are believed to have a constitutional
predisposition. Primary vascular cephalic abnormalities, disturbed venous
drainage, physiological vascular reverse flow from the facial vein to its
collaterals, especially when cerebrovascular hyperthermia is involved, they all
lead to stasis accompanied by vascular dilatation. These vascular dilatations
have a paroxysmal nature"flushing" and are exacerbated by alcohol ingestion,
hot liquids, stress or sun exposure. Enkephalins, endorphins, bradikinins are
also responsible for flushing, due to the fact that their release is stimulated by
adrenaline.
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Treatment
The treatment needs to be adapted according to the disease progression.
Treatment of vascular hyperreactivity (flushing)
At this stage the therapeutic goal is to reduce the discomfort caused by
paroxysmal flushing, by reducing its intensity and duration. Patients must be
advised to have a proper lifestyle and diet and they must understand that this is
the key to a successful long-term treatment. Avoidance of alcohol, spicy foods,
highly emotional states, changes of temperature and exposure to sunlight are
some of the ordinary rules that must be followed by the patient with rosacea.
The control of the vascular component can be done by using topical
vasoconstrictors or by systemic administration of substances that could control
the circulatory anomaly. Clonidine 1-2mg/day has satisfactory vasoconstrictor
effects, but its use is limited by its general secondary effects (vertigo,
constipation).
Treatment of rosacea
The therapeutic alternatives for erythematotelangiectatic rosacea
include:
cryotherapy
linear scarification
dermabrasion
electrocautery
micro-injections with sclerosing substances
laser therapy
Treatment of papulopustular rosacea
The use of general and local antibiotic therapy represents the first choice
of treatment for this stage.
General treatment
Second-generation cyclines (minocycline, doxycycline) are well
tolerated when administered for several weeks as they prevent eye involvement.
In case of intolerance or ineffectiveness, medium dose macrolides may be
prescribed (erythromycin, clarithromycin), in repeated courses.
Metronidazole is effective but poorly tolerated on a long-term basis,
therefore, its topical administration is preferred. For subjects diagnosed with
Helicobacter pylori, the use of metronidazole is beneficial in doses of 250 mg
twice a day, for a month, and then 250mg/day in the second month, followed by
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cutaneous horn
botryomycome.
Treatment:
surgical excision
electrocautery
curettage
radiotherapy.
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Clinical Diagnosis in Dermatology
7. blue naevi.
Naevus planus it presents as a round - oval pigmented spot, slightly
raised.
Papillomatous naevus dark brown protruding structure, irregularly
shaped, of blackberry-like appearance.
Hairy congenital naevi - brown protruding structures, of irregular
surface and covered with hairs.
Dome-shaped naevi - firm pigmentary lesion, dome-shaped, of smooth
surface.
Giant pigmented naevus denotes a very large infiltrated pigmented
patch , of irregular surface, covered with hairs. It is a dystrophy, usually
systematic, visible even from birth.
Suttons naevus - small prominent pigmented structure, surrounded by
an achromatic halo.
Blue naevi - small dark blue growth, which does not degenerate.
Treatment:
usually pigmentary naevi need close supervision
their number, size, and color are being monitored;
any sign of activity (increase in size or surface, color variations,
ulceration, bleeding) is considered a dermatological emergency
and requires immediate excision.
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Clinical Diagnosis in Dermatology
Genetic factors
Recent studies have highlighted the role of three major types of genes
involved in the process of carcinogenesis: oncogenes (Bcl -2- Beel leukalmia
lymphoma), antioncogenes (RB gene, located on chromosome 13q14) and
metastogenes (NM23 gene - metastasis suppressor gene). All these genetic
mutations damage the cell division rate and increase the ability of invasion and
metastasis of neoplastic cells.
Immunological factors
Immunosuppression is a condition that enables the development of
cutaneous malignancies (HIV infections, metabolic disorders, viral diseases -
HPV which is highly oncogenic).
Extrinsic factors along with individual phenotypical predisposition, play
a major role in the appearance of skin cancers.
Ultraviolet radiation (photocarcinogenesis)
has a carcinogenic action, having a cumulative effect, due to
excessive exposure to sun or artificial light;
Phenotype I people and those who live in sunny geographical
areas are prone to develop skin tumors.
Depending on their histogenesis, malignant skin tumors are classified
into:
cutaneous carcinomas (of epithelial origin);
malignant melanomas (malignancies of the pigmentary system);
cutaneous sarcomas (malignant tumours of mesenchymal
origin).
SKIN CARCINOMAS
Skin carcinomas account for 90 % of all skin cancers. Histologically
they are classified into:
1. basal cell carcinomas
2. squamous cell carcinomas
Basal cell carcinomas
General features
1. they are tumorous masses which develop slowly on unharmed skin
or other pre-existing lesions;
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2. the fact that the tumour affects two thirds of the upper face (or
other sun-exposed areas);
3. slow rate of progression;
4. it does not metastasize;
5. it develops on a pre-epitheliomatous lesion (solar keratosis);
6. absence of subjective symptoms.
Evolution and prognosis
Basal cell carcinoma runs a chronic course, slowly increases in size, and
evolves spontaneously to ulceration.
Treatment
The choice of the therapeutic method depends on:
clinical form;
tumor size;
site;
age of the patient.
Therapeutic alternatives include:
1. surgical excision;
2. electrosurgery;
3. curettage (recommended for superficial forms);
4. cryosurgery;
5. CO2 Laser Therapy.
6. radiotherapy (for severe extended forms, which can not be
addressed surgically);
7. topical cytotoxics (5- fluouracil, podophyllin);
8. interferon gamma - administered systemically or intralesionally.
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General features
these are invasive tumours, with a high potential of becoming
malignant;
they metastasize lymphatically;
clinical polymorphism is lower than that of basal cell
carcinomas;
they occur frequently on precancerous lesions ;
they are evolving faster (compared to basal cell carcinomas).
Clinical aspects regarding the onset of spindle cell carcinoma SCC
Spindle cell carcinoma SCC may begin as following:
a) persistent fissure without being prone to epithelialization;
b) papillomatous or verrucous tumour;
c) small keratotic plaque progressing to cutaneous horn;
d) ulcerated and indurated base.
During its development, spindle cell carcinoma may present the
following clinical forms:
Spindle cell carcinoma SCC of the skin
1. vegetative squamous cell carcinoma is the typical clinical form
of squamous cell carcinoma and it presents as a vegetative and
ulcerated mass, covered with fetid discharge, of indurated base
and infiltrating adjacent structures;
2. nodular squamous cell carcinoma presents as a nodular mass of
hematic crusts;
3. keratotic squamous cell carcinoma: clinically, it appears as a
small node (1-2 cm in diameter) with gray verrucous
hyperkeratotic surface. It frequently affects the lips;
4. gigant cauliflower-like vegetative squamous cell carcinoma:
clinically, it is an irregularly shaped vegetative tumorous mass,
mammillated surface, covered with fetid discharge;
5. ulcerous-endophytic squamous cell carcinoma, is an irregularly
shaped ulceration, of hardened infiltrated base, usually affecting
the mucosas.
6. superficially infiltrating/ invasive squamous cell carcinoma:
- it presents as a red -violet infiltrated plaque, ill delimited and
extensive; it may ulcerate during its course of development;
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- it affects the naso - genian fold, the sides of the nose, the
subnarinar region.
7. actinomycotic squamous cell carcinoma - this is a rare clinical
form and is characterized by ulcerative lesions, necrotic
tumorous masses and polymorphic microbial flora, affecting the
face.
Spindle cell carcinoma of the mucosas
Clinical features: it presents as a persistent ulceration which bleeds
easily, having an infiltrated base and a surface covered by hematic crusts.
Sites: it affects semi-mucosas and mucosas (oral or genital).
Anatomical and clinical distinctive features of spindle cell carcinoma in
relation to location of Squamous cell carcinoma of the lip:
is the most common clinical form of squamous cell carcinoma;
it occurs frequently in males, smokers, those with poor hygiene
of the mouth, and those who are chronically exposed to solar
radiation;
it develops on preexisting lesions such as: chronic or actinic
cheilitis, leukoplakia, trauma;
it occurs with predilection for the lower lip mucosa and semi
mucosa;
the clinical form is ulcerous vegetative
rapid rate of progression;
it metastasizes lymphatically in regional lymph nodes.
Squamous cell carcinoma of the genitalia:
the usual clinical form is ulcerous -vegetative or keratotic;
it develops on a scleroatrophic balanitis in males or on a
leukoplasic plaque in females; it arises from
Squamous cell carcinoma of the oral cavity:
common clinical forms are vegetative or ulcerous -vegetative;
it commonly affects the tongue, the gums, the palate, the floor of
the mouth;
predisposing factors include : smoking, microtraumas produced
by the accumulation of miscellaneous particles at the root of the
teeth, poor oral hygiene.
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Treatment:
usually, the surgical excision is the first line of treatment, within
oncological limits, followed by contact radiation therapy or
transcutaneous penetrating radiation;
intralesional chemotherapy using bleomycin or methotrexate is
recommended in extensive form of disease.
CUTANEOUS SARCOMAS
Sarcomas are malignant skin tumors of the connective tissue.
Clinical forms:
Fibrosarcoma
Clinical features:
it presents as an erythematous -violet nodular mass, unique,
indurated, ranging in size from 5 to 10 cm.
it most commonly affects the knee, the thighs and upper
extremities of the arms and is rarely seen on the trunk
the development of fibrosarcoma is infiltrating, destructive, the
prognosis is poor due to its increased ability to metastasize
Histological findings:
it is characterized by proliferation of atypical spindle cells
arranged in bundles
the tumorous cells have an ill-developed cytoplasm and nuclei of
uniform appearance
a large number of mitoses takes place.
Treatment: wide surgical excision, followed by radiation therapy, or
chemotherapy.
Recurrent dermatofibrosarcoma (Darier - Ferand)
Clinical features: at first, it appears as a patch made up of firm, dermal
nodules, flesh-coloured, which have coalesced. During its course, the tumorous
mass has a plurinodular appearance and the superjacent skin is subjected to
pressure.
Sites: it especially affects the young and the male adults and it occurs on
the scalp, anterior thorax or abdomen.
Histopathological findings:
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Clinical Diagnosis in Dermatology
the tumorous cells resemble the fibroblasts and they are arranged
in short bundles like arranged in a particular pattern (storiform or
"wagon wheel")
nuclear pleomorphism is discreet and the mitotic activity is
moderate
tumorous stroma has a myxoid appearance.
The treatment consists of surgical excision and radiotherapy.
Kaposi's sarcoma - is a tumor developed as a result of a conjunctive-
vascular proliferation.
Etiology:
Viral infections account for one of the most important etiological factors
that cause Kaposi's sarcoma.
Possible viruses involved include: cytomegalovirus (CMV), hepatitis B
virus, herpes - virus, papilloma virus type (HPV), HIV.
Besides viral factors, Kaposi's sarcoma is thought to be derived from
genetic lineage or from immunological factors.
Investigation of HLA antigens in Kaposi's sarcoma has revealed a
significant link between HLA - DK5 and this sarcoma.
Clinical forms
Four clinical etiological forms of Kaposi's sarcoma are described:
1. Classic Kaposi's sarcoma (European)
2. Endemic (African)
3. Epidemic Kaposi's sarcoma (HIV -related)
4. Drug-induced (Immunocompromised) Kaposi's sarcoma (due to
immunosuppression ; posttransplant).
The four types differ in terms of etiology. They have similar clinical
aspects, but their clinical course is different.
Classic Kaposi's sarcoma
Clinically characterized by specific skin lesions: infiltrated plaques and
nodulo -tumorous lesions.
The infiltrated plaques are protruding purplish- red masses, well
enclosed by the surrounding tissues, oval or irregularly shaped. The surface of
the plaques is usually flat, but it can also be scaly or keretotic.
Nodulo -tumorous lesions are deep dermal nodules or large
angiomatous tumours, progressing to central ulceration.
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Sites: initially the lesions are grouped on the extremities of the lower
and upper limbs and on the cephalic extremity.
Other clinical cutaneous manifestations include: telangiectasia, purpura,
bruising, hematomas (inconsistent elements without any influence on
diagnosis).
Extracutaneous sites:
isolated nodules may occur on the internal organs, having a slow
evolution, without subjective symptoms
the lesions usually affects the skeletal system, the digestive tract,
the respiratory apparatus, the heart and the pericardium
Although the clinical expression of these systemic lesions is
secondary, in 20 % of cases they are causing death.
Endemic Kaposi syndrome
It is characterized clinically by marked polymorphism, the lesions have
a gradual progression, from the nodes to ulcerative lesions located at the end of
the limbs.
A distinctive form of endemic sarcoma, namely lymphadenopathy, is
seen in young people and it is characterized by general impairement of mucosas
and nodes, with reduced or absent skin involvement. Visceral involments are
multiple, while the progression is unpredictable and often fatal.
Epidemic Kaposi sarcoma
This form occurs in individuals infected with HIV.
Clinically, the lesions are similar to those of Kaposi's classic sarcoma,
but they can occur anywhere in the body and and have a rapid rate of
progression. They are accompanied by general symptoms (fever, fatigue,
weight loss).
Iatrogenic Kaposi's Syndrome
It occurs in subjects with liver lung and heart transplants, approximately
16 months after having started the immunosuppressive therapy.
Clinically, the lesions are similar to those described in the classic form
disease, whereas their progression is linked to the degree of immune deficiency.
Reducing the immunosuppressive therapy and improving the immune status
have as effect the regression up to the disappearance of the lesions.
Histopathological examination:
The structure of Kaposi's sarcoma is made up of three types of cells:
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1. endothelial cells
2. Spindle cells
3. cells of the inflammatory infiltrate (plasma cells or
macrophages).
In general, there is a balance between vascular proliferation and cell
proliferation within the lesions of Kaposi's sarcoma.
In some cases there is a predominance of vascular proliferation, known
as angiomatous or fibroblastic (sarcomatous) aspect, when cell proliferation
prevails.
Treatment
Treatment of Kaposi's sarcoma is varied.
Therapeutic alternatives include:
radiotherapy
cytostatics
interferon
retinoids
antibiotic therapy.
The topical treatment is reserved for forms of single or less damaged
lesions, small in size, for which general therapy is not indicated due to its side
effects.
The most important methods of topical therapy include:
surgical excision
laser therapy
cryotherapy
sclerotherapy.
MALIGNANT MELANOMA
Malignant melanoma is a tumour arising primarily from melanocytes, or
secondarily due to naevi.
It is one of the most aggressive malignancies. It has a rapid rate of
progression and metastasizes lymphatically and hematogenously. Among the
risk factors in the occurrence of melanoma, we can mention genetic factors, sun
exposure, pigmentary damage.
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Histopathological findings
the histological structure is dominated by atypical melanocytes
arranged singly or in clusters;
the atypical cells are arranged at the dermo - epidermal junction
and around the adnexal areas;
the dermis is abundant in inflammatory infiltrate;
the tumorous cells are spindly and a variable amount of melanin
is found in the cytoplasm.
Nodular malignant melanoma
Clinical features: round nodular mass, polylobulated, with a narrow
implantation base, unevenly colored (red, tan or brown).
The evolution of the tumour is towards ulceration, whereas satellite
lesions appear around the primary tumor (small blue nodules or patches with
intense pigmentation); elements that are considered micrometastases. They
commonly appear on the scalp, neck or trunk.
Clinical forms and particular sites of malignant melanoma:
1. primary malignant melanoma of the mucosas- is a rare form and
may affect the buccal, conjunctival mucosa, the nasal cavities,
the vaginal and anorectal mucosa. The clinical picture varies
from pigmented plaque to sessile pedunculated nodule.
2. subungual malignant melanoma -the clinical aspect is of a higly
pigmented macule, brown, evenly coloured, or it may occur in
longitudinal striations. It affects the matrix region of the nail and
has a slow rate of progression.
3. achromic malignant melanoma - clinical features: nodular, pink
or flesh-like mass, that develops on healthy-looking skin. The
palms and the genitals are possible sites for this form of
melanoma.
4. multiple malignant melanoma - this form is frequently common
in people who have dysplastic naevi and consists of: successive
appearance of two or more primary melanomas.
The classification of malignant melanoma clinically and evolutionarily:
stage I - localized malignant melanoma, without metastases
(primary tumor);
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Primary syphilis
the average incubation period is 21-25 days and may vary depending
on the number and aggressiveness of treponeme inoculation, but also
on the way the body reacts to this aggression;
the lesions are always located on the skin breach and they are
represented by: a syphilitic chancre and regional lymphadenopathy.
The syphilitic chancre appears on average after 3 weeks of exposure to
infection.
Clinical features
it begins as a small erythematous spot, which erodes and
gradually extends (micro chancre);
it reaches maturation within 8-10 days and achieves its classic
appearance
the classic chancre is a round erosion, measuring 0.5-2 cm in
diameter, well defined, red-copper in colour, of smooth surface,
covered by a clear serosity which gives it a shiny appearance;
the erosion edges are slightly blurred and they easily get lost into
the healthy-looking skin;
the base of the chancre is rough, cardboard-like, painless,
persistent even if the chancre has healed, thereby enabling a
retrospective diagnosis of the disease;
the chancre heals spontaneously (without treatment) in 30-40
days and leaves a pigmented mark.
Sites
It usually affects the genital region. Depending on their sites, the
chancres are classified into:
1. genital chancres (on the glans penis, near the frenum or on the
underside of the prepuce, labia, cervix)
2. perigenital chancres (perianal, rectal, anal)
3. genital chancres (lip, tonsillar, lingual, gingival chancre )
Clinically, a distinction has to be made between:
small chancre it is small and has nodular appearance, affecting
the perianal and vulvovaginal folds;
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B. gumma
it is a firm, round-oval nodule, of various sizes, non-
inflammatory, painless and slides on the underlying
structures
This stage corresponds to the stage of rawness
In its progression, the nodule adheres to the superficial surface of the
skin, it wears out centrally (decrepit state), it breaks open and ulcerates, oozing
a slimy fluid and the core of the gumma (ulcerative stage). Healing leaves deep
depigmented scarring (scarring stage). Lesions are found mainly on the scalp,
forehead, presternal, pretibial regions.
B. mucous membrane lesions
they frequently affect the palate, the tongue, the nasal
cavities
ulcerative lesions lead to the perforation of the hard palate, or
to significant deformations regarding the cartilages and
bones of the nose ("saddle" nose)
Visceral tertiary syphilis
it predominantly affects the cardiovascular system and the
liver (myocarditis, syphilitic aortitis and syphilitic hepatitis)
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Neurosyphilis
the lesions affect the brain and spinal masses, namely the
meninges and the brain matter
Clinical manifestations include: headache, vertigo,
paresthesia, paralysis, sensory disturbance
Osteo-myo-articular tertiary syphilis
the lesions of the osteoarticular system are the result of a
highly hyperplastic or destructive process
the following are described: plastic osteoperiostitis,
gummatous osteomyelitis, sclerosing osteitis
The most commonly affected are the tibia, the clavicle, the
humerus
articular manifestations include: arthritis, synovitis and pain
Congenital syphilis
Congenital syphilis is an infectious disease that is transmitted from a
mother with syphilis to her fetus. The evolution and clinical manifestations of
congenital syphilis are caused by:
the elapsed time of the disease (prior to or during pregnancy)
the treatment given.
Maternal syphilis (recently untreated pregnant women with syphilis) can
cause: premature births, stillbirths or death of the neonates. Mothers with late
untreated syphilis can bore apparently healthy children, children with positive
serology and rarely children with florid syphilis.
Clinically and evolutionally, congenital syphilis is classified into early
congenital syphilis and late congenital syphilis.
Early congenital syphilis
syphilis becomes symptomatic at birth or within the first two
years of life
clinical manifestations overlap with those of secondary florid
syphilis, with the difference that the fragility of the skin and
mucous membranes of the toddler are the ones that determine the
special features of this disease.
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Cutaneous manifestations
The cutaneous manifestations are represented by bullous (palmar-
plantar), infiltrative (perioral), papular, psoriasiform, papulo- hypertrophic and
ulcerative syphilides.
Mucous manifestations
These can clinically be expressed by:
syphilitic laryngitis of early onset, characteristic to the child with
congenital syphilis
syphilitic coryza, occurring in the first weeks of life and
manifested as a purulent or bloody nasal discharge, which
obstructs the newborns nostrils.
Osteo-articular manifestations
they are typical and suggestive, affecting both the long and the
wide bones of the skull
the most important lesions are:
- diaphyseal-epiphyseal osteochondritis which leads to Parots
pseudoparalysis (painful and unable to function limbs)
- syphilitic osteochondritis which affects the tibia, visible on
X-ray, which leads to a typical anterior curving resembling a
"scimitar blade"
- syphilitic osteomyelitis, confirmed on X-ray by geodes and
bone condensation.
Late congenital syphilis
Late congenital syphilis includes the events occurring after the first two
years of life, and clinically they are categorized into:
- active lesions
- stigmata
- dystrophies.
Active lesions - are similar to those of tertiary syphilis and affect:
the skin and mucous membranes (tubercular syphilides and
gummas)
the osteo-articular system (arthritis, osteomyelitis,
osteoperiostitis)
the nervous system (meningitis, encephalitis, tabes)
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2. Locoregional complications:
- prostatitis
- epididymitis
- orchitis.
Gonococcal infection in women
it presents as an acute urethro-cervicitis characterized by
urinary frequency, dysuria, yellow-green purulent vaginal
discharge
complications include salpingitis, metritis, bartholinitis,
skenitis, which may increase the risk of infertility.
Gonococcal infection in girls
Infant gonorrhea occurs due to contact with contaminated toiletries
(linen, towels).
It manifests as an acute, purulent vulvovaginitis accompanied by
significant inflammatory phenomena.
Extragenital Gonococcal infections
1. rectal gonococcal infection (rectitis)
- manifested by pus, tenesmus and bleeding
- it is common in gay people.
2. Gonococcal oropharyngitis
- clinical manifestations include erythema, swelling, erosion,
purulent deposits and dysphagia
- it occurs as a result of oral-genital sexual practices
3. Gonococcal conjunctivitis
- clinical manifestations include erythema and eyelid edema,
accompanied by purulent secretion
- it occurs in infants who are infected by their mothers during
childbirth, or in adults by self-inoculation of a primary
gonorrheal infection
A hematogenous dissemination can enable remote events such as
gonococcal arthritis, gonococcal carditis or gonococcal septicemia.
Laboratory findings
1. microscopic examination of heavy secretions evidences intracellular
paired gonococci
2. culture on selective media (useful in chronic forms of the disease)
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Clinical Diagnosis in Dermatology
Treatment
targets both the source of infection and the sexual partner
uncomplicated forms of disease may require instant treatment
antibiotics belonging to the group of cephalosporins, quinolones
or aminoglycosides are also recommended
chronic , complicated forms of disease require higher doses and
longer courses of antibiotics (7-15 days).
The regimens proposed in the treatment of gonococcal infections must
comply with the following requirements:
they have to be administered in low doses
to achieve up to 100% rate of curing
the side effects should be minimal
that the treatment would not conceal a syphilitic infection
they should not favor the development of other pathogens
they should have a broad spectrum in order to be effective in
cases of miscellaneous infections.
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Cutaneous lesions
the lesion of chancroid begins as an erythematous-papular lesion
that ulcerates rapidly
as the disease progresses, the typical lesion presents as a rounded
or oval ulcer, of 0.5-2 cm diameter embedded in the dermis and
surrounded by a double collarette (Petges double collarette)
the base of the ulcer is soft and the bottom is covered with pus
and cellular debris
the edges of the ulcer are straight
the lesion is spontaneously painful or if it is pressed.
Sites
Typically, the ulcers are located in the genital area (fourchette,
balanopreputial fold, prepuce, the sheath of the penis, labia, clitoris, cervix,
perineal region) and rarely extra- genitally. The presence of multiple ulcers is
usually the result of autoinoculation with Ducrey bacillus of the surrounding
areas. Cutaneous lesions are accompanied by lymphangitis and
lymphadenopathy.
Adenopathy
it occurs after approximately 2 weeks after initial infection
iniatially a single lymph node is affected but as the disease
progresses, many more are affected
this adenopathy is inflammatory, painful, leading to a localized
collection of fistulas of oozing pus.
Distinctive clinical forms
a) follicular canker affecting the pilosebaceous follicles
b) phagedenic canker - characterized by significant ulcer, resulting
in erosion of the surrounding tissues
c) papular canker its clinical appearance is of a papule with
slightly protruding edges, resembling papulo-hypertrophic
syphilides.
Evolution - soft chancre heals spontaneously within a few weeks.
Laboratory investigations of diagnostic value include:
1. direct bacteriological examination:
- it uses secretion or pus extracted from the ulcer lymph nodes
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Etiology
LGV is caused by serovars L1, L2, L3 of Chlamydia trachomatis.
Clinical features
the incubation period is 10-12 days
the initial lesion may be a small shallow ulcer, that heals
spontaneously within a few days, known as
lymphogranulomatous canker (stage I of the disease)
it commonly affects the glans, the foreskin, large and small
labia, the rectal region (in homosexuals)
after a period of 2-4 weeks after the onset, an inguinal
lymphadenopathy occurs, which is unilateral, inflammatory,
forming enlarged lymph nodes (stage II)
during the course of the disease, adenitis fistulizes in many
places, having a typical appearance (of a sprinkler)
usually, the crural and inguinal lymph nodes are affected
untreated, the course of the diesease is higly ulcerative and
destructive, causing ano-rectal strictures, vulvar elephantiasis or
important external genital ulcers (stage III). These lesions may
be accompanied by systemic manifestations: fever, generalized
lymphadenopathy, myalgias.
Positive diagnosis
Chlamydia trachomatis is identified in purulent secretions, which
confirms the diagnosis
detection of chlamydial antigens
the detection of antibodies in the serum and local secretions.
Treatment
general: consists of taking one of the following antibiotics:
- doxycycline 200mg/day, for 21 days
- erythromycin 2g/day, for 21 days
local: it is directed only against important destructive
processes or against long-lasting recto-vaginal fistulas.
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VIRAL INFECTIONS
Oral hairy leukoplakia
It was described in 1984 in homosexuals, and it accounts for 25% of the
HIV + patients. This manifestation was considered a pathognomonic marker of
HIV infection, but later it has also been reported in other immunocompromised
individuals.
Nowadays it is common knowledge that these lesions are manifestations
of Epstein Barr virus. The presence of oral hairy leukoplakia in HIV + patients
marks the progression of AIDS. Oral hairy leukoplakia manifests as ill
delimited white striae, mucosal adherent, of verrucous surface, commonly
affecting the two posterior thirds and the sides of the tongue. The following
changes are relevant for the diagnosis:
the whiteness of the lesions
the fact that the lesions are present on the sides of the tongue
the stiffness of the lesions
the hairy tongue appearance
the fluctuant nature of the lesions
the fact they do not respond to antifungals.
In most cases the lesions are asymptomatic and the clinical diagnosis
can be confirmed by skin biopsy and by evidencing the Epstein Barr virus in
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Moluscum contagiosum
as AIDS runs its course, moluscum lesions are large and
numerous, affecting especially the genital and perigenital
regions, as well as the face.
these are typical papulo-nodular lesions with a tendency to
cluster together
they have got a recurrent nature and they barely respond to
treatment.
HPV infections
clinically manifested as common warts (verruca vulgaris), flat
warts (verruca plana) condylomata acuminata or
epidermodysplasia verruciformis.
the lesions are large, numerous, recurrent and present a high risk
of malignancy
they affect the face, the oral or genital mucosa
infections resulted.
BACTERIAL INFECTIONS
Cutaneous manifestations of Staphylococci
Staphylococcus aureus is the pathogen frequently singled out in
patients with AIDS
it is responsible for different clinical forms of the disease:
staphylococcal impetigo, recurrent and treatment-resistant
folliculitis.
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FUNGAL INFECTIONS
Oral candidiases are common problems encountered during HIV
infection. Different sequencing or coexisting clinical forms have been described
during the development of the disease.
Muguet is considered a marker of evolutivity and it manifests as
white deposits that rub off easily, located on the back side of the
tongue or in the mouth. This clinical form is usually
asymptomatic but it sometimes may be accompanied by a
stinging sensation that occurs spontaneously or when in contact
with food.
Erythematous candidiasis can take the appearance of
erythematous plaque-like stomatitis commonly affecting the
tongue.Oral candidiasis may rarely take a hyperplastic aspect,
but when this happens, biopsy and pathological examination are
mandatory in order to rule out epidermoid carcinoma.
Perleche or angular cheilitis usually accompany other forms of
candidiasis. Candida species are usually singularised, include
Candida albicans, krusei and tropicalis. Oral candidiasis may
complicate other manifestations in the oral mucosa, and HIV +
patients are subjected to a new evolutionary spurt.
Dermatophytoses
clinical manifestations include: tinea faciei, corporis, cruris,
capitis, pedis and onychomycoses.
the species of fungi involved are: Trichopyton rubrum,
Trichopyton interdigitale and Epidermophyton floccosum
the lesions are extensive, atypical and require prolonged
treatment
Systemic/ Deep mycoses
Cryptococcosis
it is caused by Cryptococcus neoformans
it manifests as chronic ulcerations of the oral mucosa, exhibiting
infiltrated edges, nodules or pseudo-carcinomatous vegetative
structures.
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PARASITICAL DERMATOSES
Scabies
widespread parasitic dermatosis, with normal benign
development
in HIV - infected individuals, the lesions are extensive, covered
with scales and crusts filled with parasites (Norwegian scabies).
Rosacea-like eruptions
they are caused by Demodex Folliculorum, a mite that colonizes
the pilosebaceous follicle
these are common lesions in patients with AIDS.
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LYMPHOMAS
Lymphomas occur as a result of a severe immune deficiency. The most
common histological type is large cell immunoblastic lymphoma, accompanied
by lesions in the mouth that include swelling of of the palate, exhibiting an
ecchymotic appearance. Lymphomas usually mark the beginning of the disease
and have a poor prognosis.
IATROGENIC LESIONS
Many mouth ulcers can be caused by toxic or immuno-allergic
neutropenia due to sulfonamides, antibiotics or betalactams administration.
Ulcerative lesions may be accompanied by petechial or haemorrhagic bullae, as
a result of an idiopathic thrombocytopenia, frequent and early manifestation of
HIV infection.
Other nonspecific skin manifestations, relevant to HIV infection
include:
Pytirosporum infections (cause an increased prevalence of seborrheic
dermatitis, pityriasis versicolor or pytirosporum folliculitis), prurigo
(manifested as a pruritic erythematous-vesicular eruption, that affects the
extensor surfaces of the limbs), psoriasis vulgaris (during HIV infection, the
lesions are extensive, and their evolution is to erythroderma), lymphomatoid
granulomatosis (characterized by aphtous lesions that affect the oral or
esophageal mucosa), skin xerosis, bullous eruptions (toxic dermal type),
changes in the hair follicle (alopecia) and so on.
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