Skin tutorial

Alopecia areata:
– Alopecia areata (AA) is a recurrent non-scarring type of hair loss that can affect any hair-bearing area
– The most widely accepted hypothesis is that AA is a T-cell mediated autoimmune condition that is most likely to occur in genetically predisposed individuals.

– Alopecia totalis refers to the total absence of scalp and hair.
– Alopecia universalis refers to total loss of body and scalp hair.

. particularly at the periphery of areas of hair loss.– The scalp appears normal in alopecia areata. – The near pathognomic “exclamation point” hairs may be present.

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but some patients (14%) experience a burning sensation or pruritus in the affected area. .– AA most often is asymptomatic. except in the uncommon presentations. – A scalp biopsy is generally unnecessary to establish the diagnosis of alopecia areata.

• Thyroid disease: Clinically evident thyroid disease was found in 0.85% of 1700 patients with AA.3% in control subjects. • Vitiligo is seen with an incidence varying from 1. • Atopic dermatitis is seen in 9-26% of patients with AA.– Associated conditions. .83% compared to 0.

and Candida endocrinopathy syndrome . ulcerative colitis. lichen planus.• Diabetes mellitus: The incidence of type I diabetes mellitus was significantly higher • Others associations: Pernicious anemia. MG.

.– Precipitating factors. • • • • • Major life events Febrile illnesses Drugs Pregnancy Trauma – Despite these findings. most patients with AA fail to report a triggering factor preceding episodes of hair loss.

• Positive pull test at the periphery of a plaque usually indicates that the disease is active. and further hair loss can be expected. . • Presence of exclamation point hairs is pathognomonic sign.– Physical findings: • Presence of smooth slightly erythematous (peach color) or normal-colored alopecic patches is characteristic.

no inflammation or epidermal change occurs.– DDx. scaling. – A scalp biopsy can be helpful if the diagnosis is difficult clinically. Non-scarring alopecia • Trichotillomania: – Alopecic patches have unusual shapes and sizes and show broken hairs. and crusting locally on the scalp. • Tinea capitis: – The diagnosis is suggested by erythema. .

– ไข้ สูง หลังคลอดบุตร การผ่าตัด การเสียเลือด การอดอาหารอย่ างเฉียบพลัน ความเครียด – Differentiating TE from diffuse AA is difficult in absence of an obvious precipitating factor that can result in TE.• Telogen effluvium (TE) – Exclude these when hair loss is diffuse. • Secondary Sy : moth eaten alopecia .

hypopituitarism – Hypo/hyperparathyroidism .• Drug : – Thallium. chemotherapy – Chronic vitamin A intoxication • Endocrine – Hypo/hyperthyroid. heparin.

• Systemic disease – Dermatomyositis – SLE – Cachexia – malignancy .

– Adverse effects mostly include pain during injection and minimal transient atrophy (10%).• Intralesional steroids: – Intralesional steroids are the first-line treatment in localized conditions. • Topical steroids . – Triamcinolone acetonide (Kenalog) is used most commonly. – Injections are administered every 4-6 weeks.

• Prednisone: – Systemic prednisone is not an agent of choice for AA because of the adverse effects associated with both short-term and long-term treatment. alopecia universalis • Dinitrochlorobenzene (DNCB) . – Alopecia totalis.

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.10 Describe lesions………………………………..40 • Hyperkeratotic papules of palms and soles ………20 • Hyperpigmentation and mottling depigmented macules………20 .Key points – – – – Check palms and soles…………………….10 Check oral cavity………………………………5 Check lymph node status……………….

5 Internal malignancy………………5 ..20 – Associated diseases……………………….15 Bowen’s disease…………………5 Squamous cell CA……………….Key points – Dx ……Chronic arsenic poisoning….

It is also found in certain water supplies and seafood.Chronic arsenic poisoning: – Arsenic has been used as a medicinal agent. a pesticide. – Arsenic is primarily used in the production of glass and semiconductors. and an agent of criminal intent. a pigment. .

.– Arsenic is listed as a presumed carcinogenic substance based on the increased prevalence of lung and skin cancer observed in human populations with multiple exposures (primarily through industrial inhalation).

and hypovolemic shock. • Acute exposures – Generally manifest with the choleralike GI symptoms of vomiting and severe diarrhea. dehydration (often).– Physical findings. . – These patients will experience acute distress.

• Chronic toxicity – is more insidious and may manifest as a classical dermatitis – hyperkeratosis papules of palms and soles – Hyperpigmentation and mottling depigmented macules ("dew drops on a dusty road" appearance). .

axillae. .• Affect the nipples. groin and other pressure points. Mee’s line • Peripheral neuropathy (usually a painful paresthesia that is symmetrical and stockingglove in distribution). spare the oral mucosa • Transverse whitish narrow fingernail bands.

anemia.• Diffuse alopecia of scalp hair and acrodermatitis and thromboangiitis-like changes of the legs or gangrene • Their inhalation may result of nasal septum perforation • Other systemic intoxication such as neuropathy. leukopenia.high arsenic in hair and nail . thrombocytopenia • Diagnosis of the arsenic exposure may be difficult.

punctate. .– Arsenical keratoses develop at sites of friction and trauma. yellowish. cornlike papules usually 2 to 10 mm in diameter. – Most arsenical keratoses persist for years without evolving into invasive SCC. as multiple. hard. especially on the palms and soles (heels and toes). often symmetric.

• Internal malignancy. • Bowen’s disease. – Bowen disease is a squamous cell carcinoma (SCC) in situ with the potential for significant lateral spread. • Squamous cell carcinoma. – Associated conditions. .– Chronic hepatic and renal damage is common with chronic exposure.

there are likely to be no traces of arsenic left to remove. but by the time cutaneous and other neoplasms have developed. – Excision.– Arsenic can be chelated with dimercaprol. cryosurgery – Retinoids .

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.10 – Check oral cavity………………………………….• Key points.10 – Check axilla. inframammary……. • วิธีตรวจ – Check nail and surrounding tissues……10 – Check interdigital web…………………………...1 . groin.

....…..... onycholysis...10 – Dx : candida paronychia……………………10 .........10 – Other site of candida infection………………....– ผลการตรวจ – Periungual swelling…………………………………………..........10 – Nail dystrophy.

– Associated conditions.…(2/4)………………20 • • • • Too many hand washing. Steroid usage and immunosuppressive agents. . Chronic cutaneous candidiasis. DM.

but bacteria also may act as copathogens. – The yeast is believed to play an etiologic role in this condition. .Candida paronychia: – Candida organisms occasionally cause infection in the periungual area and underneath the nailbed.

. Cushing syndrome and Raynaud disease. – Disease is more common in people who frequently submerge their hands in water.– Progression to total nail dystrophy has been associated specifically with C albicans and usually has been limited to women with 2 important predisposing conditions. ie.

with an occasional discharge. and tender. infection. • The nailfold becomes erythematous. • Loss of the cuticle occurs. swollen. • A greenish color with hyponychial fluid accumulation may occur that results entirely from Candida.– Physical findings. along with nail dystrophy and onycholysis with discoloration around the lateral nailfold. . and not Pseudomonas.

and polyendocrinopathy are associated with increased susceptibility to infection. – Host factors that predispose patients to infections are numerous. hypoparathyroidism. hypothyroidism. . Cushing syndrome. – Endocrine diseases such as DM.• A potassium hydroxide (KOH) preparation is helpful and is likely to show yeast organisms.

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Candida perlèche with erythema and fissuring at the corners of the mouth. Hyperplastic candidiasis of the tongue. • D.• A. Note the characteristic white patches on the palate. • E. Atrophic candidiasis under dentures. • B. Black hairy tongue is characterized by pigmented hypertrophied filiform papillae of the dorsum of the tongue and is usually associated with oral antibiotic therapy . • C. Pseudomembranous candidiasis or thrush.

•FIGURE 206-3 Candidal intertrigo. .

• B.• A. eroded areas with pustular and erosive satellite lesions • C. . Confluent and discrete erythematous. Outside the main lesions are a few satellite lesions • D. The infant shows red macular plaques on the vulva surrounded by a delicate collar. Erosio interdigitalis blastomycetica. Erythematous eroded areas between the fingers occurring in a waitress. Erythematous. eroded plaques involving the scrotum and inguinal area with satellite lesions.

– Keep hands as dry as possible – Use glove for all wet works – Nystatin or imidazoles cream – Topical steroid kenacomb .– Treatment with topical agents usually is not effective but should be tried for chronic candidal paronychia.

Skin and oral mucosa treatement • Nystatin oral tablets 100.000 unit qid • Oral suspension 1-2 teaspoon held in mouth for 5 min and then swallowed • Fluconazole 200 mg po once followed by 100mg/ day 2-3 wks • Itraconazole 100 mg od or bid 2 wks .

Nail treatment • Griseofulvin 1-2 gm/day 6 mo for fingernail 12 mo for toe nail • Itraconazole 400 mg / day [200 mg bid ] * 7 day every 1 mo 2 mo [ finger nail] 3 mo [ toe nail ] • Terbinafine 250 mg/d 6 wk for fingernail 12 wk for toe nail .

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