dermatology maculopapular and plaque dermatitis by stacey singer-leshinsky r-pac
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DermatologyMaculopapular and Plaque Dermatitis
ByStacey Singer-Leshinsky R-
PAC
Maculopapular Description A Maculopapular rash is usually a
large erythematous area with confluent bumps.
Plaque
Allergic and Hypersensitivity Dematoses Inflammatory response Epidermal edema and separation of
epidermal cells. Includes: Atopic dermatitis, Nummular
eczema, Dyshidrotic eczema, Contact dermatitis, stasis dermatitis, Diaper dermatitis, perioral dermatitis, seborrheic dermatitis, lichen simplex chronicus, Psoriasis, lichen planus, seborrheic keratosis, Actinic keratosis
Atopic Dermatitis (Eczema) Type I (IgE) hypersensitivity
inflammatory reaction Risk factors: Family history of
atopy. Exacerbated by scratching, stress
Atopic Dermatitis (Eczema) Epidemiology: Usually begins prior
to 6m of age. (FACE): flexor surfaces get adults,
children extensor)
Atopic DermatitisClinical Manifestations
Acute form Pruritus. Appear
erythematous, edematous with papules/plaques.
Scaling, weeping, and crusting
Atopic DermatitisClinical Manifestations
Chronic form Lichenification painful fissures
Atopic DermatitisClinical Manifestations
Infantile eczema Weeping
inflammatory patches and crusted plaques on:
Atopic DermatitisClinical Manifestations Juvenile/adult
Affects flexural areas
Appear as dry, lichenified pruritic plaques
Atopic DermatitisDiagnosis/ Complications Diagnosis
History Serum IgE Differentiate from viral HSV
Complications:
Atopic DermatitisManagement Avoidance of triggers. Avoid
scratching Lubricants. Oral antihistamines Topical corticosteroids
Atopic DermatitisManagement Topical antibiotics for
staphylococcus aureus infection Non-glucocorticoid anti-
inflammatory agents now available such as pimecrolimus.
Avoid oral steroids
Nummular Eczema Inflammatory response. Etiology: Risk factors: young and old. Fall and
winter. Xerosis. Clinical manifestations
Round coin like sharply demarcated erythematous papulovesicular patches/ plaques
Intense pruritus, Lichenification
Nummular EczemaDiagnosis /Differentials Diagnosis
History and physical exam Rule out secondary infection, allergy
Differential diagnosis to include seborrheic dermatitis, psoriasis, contact dermatitis, tinea
Nummular EczemaManagement Avoid scratching Lubricants Oral antihistamines Topical corticosteroids Intralesional triamcinolone Systemic antibiotics Phototherapy Complications:
Recurrent chronic relapsing form of vesicular hand and foot dermatitis
No evidence of eccrine gland dysfunction dyshidrotic
Intraepidermal vesicles Etiology/risks: Unknown etiology Epidemiology: Prior to age 40.
Dyshidrotic Eczema
Dyshidrotic EczemaClinical Manifestations
Pruritus and burning Begins on lateral fingers
and progress to palms and soles.
Vesicles: 1-2mm with clear fluid resembling tapioca
Later: desquamation and Lichenification
Dyshidrotic EczemaDiagnosis/Differentials Diagnosis
Clinical Rule out secondary infection, allergy
Differential diagnosis to include contact dermatitis, drug reaction
Complications:
Dyshidrotic Eczema Management Burrow wet dressings High potency glucocorticoids and
occlusive dressings Topical antipruritics. Severe need systemic steroids Intralesional Triamcinolone Systemic antibiotics
Contact Dermatitis Cell mediated reaction involving
sensitized T lymphocytes. Etiology
Irritant form: Chemical insult to skin. No previous sensitizing event.
Allergic form is delayed-hypersensitivity reaction. Skin sensitized from initial exposure. During next exposure patient has reaction.
Contact DermatitisClinical manifestations
Develop 24-96h post exposure
Pruritus Acute present as vesicles
with clear fluid on erythematous edematous skin.
Sub-acute is edema and papules
Chronic-
Contact dermatitisDiagnosis/Differential Diagnosis
Diagnosis: Clinical Rule out secondary infection. Patch testing
Differential diagnosis to include seborrheic dermatitis, atopic eczema
Contact DermatitisTreatment Remove etiologic agent Wet dressings with gauze soaked
in Burow’s solution changed every 2-3 hours.
Topical corticosteroids Systemic corticosteroids
Stasis Dermatitis Inflammatory skin disease that
occurs on lower extremities Extravasation of plasma proteins
and RBC into subcutaneous tissues. Becomes brown in color due to hemosiderin deposits
Results in interstitial fluid accumulation . Leads to reduced capillary blood flow
Stasis Dermatitis Can progress to venous stasis
ulcers and fibrosis Found in 6-7% of elderly
population
Stasis Dermatitis Acute form:
Initially medial aspect of ankle.
Inflammation Weeping lesions Plaques/ Erythema Crusting/ Exudate
Stasis Dermatitis Chronic form
Thin, shiny bluish brown irregularly pigmented scaling skin.
Stasis DermatitisDiagnosis/Differentials Diagnosis:
Clinical Doppler
Differential diagnosis to include contact dermatitis, Atopic dermatitis, cellulitis
Stasis DermatitisManagement
Mid potency topical corticosteroids. Control chronic edema For ulcers:
Unna venous boot changed every week.
Wound care Advise patient to elevate legs and
wear compression stockings Avoid standing or sitting for long
time
Diaper Dermatitis Irritant dermatitis Cutaneous Candidiasis infection (C.
Albicans ) Risks: areas where warmth and
moisture lead to maceration of skin or mucous membranes
Diaper DermatitisHistory and Physical Exam
Pruritus, pain Erythematous
papules/vesicles, edema
Satellite lesions to Peri-genital, peri-anal, inner thigh, buttocks
Diaper DermatitisDiagnosis/Differentials Diagnosis- KOH examination Differential diagnosis to include
contact dermatitis, child abuse
Diaper DermatitisManagement Topical antifungal agents such as
Nystatin, miconazole, or clotrimatzole
Topical corticosteroids Complications Educate care givers
Perioral Dermatitis Facial dermatosis with confluent
papulopustular lesions. Lead to inflammatory plaques.
Unknown etiology. Risks: young women, prolonged
use of topical steroids or steroid sprays
Perioral DermatitisHistory and Physical Exam
Lesions resemble rosacea
Burning Follicular papules,
vesicles and pustules on an erythematous base
Grouped
Perioral DermatitisDiagnosis/ Differentials Diagnosis:
Clinical. Rule out secondary causes.
Differentials Acne Vulgaris Contact dermatitis Rosacea seborrheic dermatitis
Perioral DermatitisManagement AVOID topical corticosteroids. Antibiotics
Metronidazole, erythromycin topical Systemic antibiotics: Monocycline,
Doxycycline, or tetracycline Wash with mild soap, use
nonfluorinated toothpaste. Avoid oral contraceptives
Seborrheic DermatitisSeborrhea Skin rash that occurs in areas of
high sebaceous gland concentration
Cutaneous inflammation to dermis Etiology: Immune response to
endogenous yeast Pityrosporum Triggered by seasonal changes,
scratching, emotional stress, medications.
Seborrheic Dermatitis Infants
Affects scalp, flexural area and perioral
Erythematous plaques
Fine white scales Thick yellow
brown greasy scaling
Seborrheic Dermatitis Adults
Pruritus Burning Erythematous plaques
with scaling
Seborrheic DermatitisDiagnosis/Differentials Diagnosis
History/Physical Differential diagnosis to include
atopic dermatitis, candidiasis, lupus
Seborrheic DermatitisManagement Selenium sulfide shampoos, 2%
ketoconazole shampoo, ketoconazole cream.
Salicylic acid Corticosteroids Cradle cap- Treat for secondary infection
Lichen Simplex Chronicus End stage of pruritic and
eczematous disorders. Skin responds to physical trauma
by epidermal hyperplasia. Common areas Risk factors:
Lichen Simplex ChronicusHistory and Physical Exam
Well circumscribed plaques with lichenified or thickened skin
Pruritus- Hyperpigmentation Excoriation
Lichen Simplex ChronicusDiagnosis/Differentials Differential diagnosis to include
psoriasis Vulgaris, contact dermatitis, fungal infection
Diagnosis Clinical Biopsy shows hyperplasia acanthosis,
hyperkeratosis KOH examination
Lichen Simplex ChronicusManagement High potency topical
glucocorticoids Oral antihistamines- Hydration Complications:
Psoriasis Increased epidermal cell proliferation due to
a shortened epithelial cell cycle. Leads to hyperkeratosis.
This results in keratinization defects, forming thick adherent scales .
Patients have exacerbations and remissions. Can be triggered by stress, class I topical
corticosteroids, or Koebner reaction. Etiology: Genetic abnormalities in the
immune system
PsoriasisHistory and Physical Exam Plaque lesions most
common Erythematous or
salmon colored plaques with distinct borders covered with silvery white scales
Extensor >flexor. Nails
PsoriasisHistory and Physical Exam Pustular psoriasis:
Painful Deep sterile
yellow pustules Pustules evolve
into red macules
PsoriasisHistory and Physical Exam Guttate Psoriasis
Could be immune Slight pruritus Small
erythematous papules with fine scale
Can be discrete or confluent
PsoriasisDiagnosis/Differentials Skin biopsy shows increased
mitosis in keratinocytes Auspitz phenomenon Differential diagnosis to include
lichen planus, eczema
PsoriasisManagement Supportive care Hydrating creams Mid-potency topical glucocorticoids Retinoids such as tazarotene UV light combined with coal tar,
salicylic acid, and anthralin Systemic immunosuppressive –
Moderate, severe or disabling psoriasis
Lichen Planus Cell mediated immunologic
reaction targeting keratinocytes. Etiology: Unknown, possibly
genetic, liver disease. Involves skin and/or mucous
membranes. Risks: age, HLA associated gene
Lichen PlanusHistory and Physical Exam
Pruritic, polygonal, purple, flat topped papules covered with fine scales
Lesions Found on flexor areas,
shins, and mucous membranes.
Lesions resolve with post inflammatory hyperpigmentation.
Oral Lichen Planus Oral lesions involve
the tongue and buccal mucosa
Present with wickham’s striae
Can then erode
Lichen PlanusDiagnosis/Differentials Diagnosis:
Clinical inspection Skin biopsy Look for associated disorders
Differential diagnosis to include chemical exposure, psoriasis, candidiasis, scabies
Complications to include squamous cell carcinoma, alopecia
Lichen PlanusManagement Antihistamines Topical corticosteroids Systemic corticosteroids Topical and systemic retinoids
Retinoids normalize epidermal differentiation and are anti inflammatory
Immunosuppressant -Cyclosporine.
Seborrheic Keratosis Due to proliferation of
Keratinocytes and melanocytes Etiology: Genetics Usually asymptomatic Benign, however must rule out
malignant melanoma Spontaneous resolution rare
Seborrheic Keratosis Begin as sharply define
light brown flat macules Then develop velvety to a
warty surface with multiple plugged follicles
Pasted on plaque Color from brown to black Size up to several
centimeters.
Seborrheic KeratosisDiagnosis/Differentials Diagnosis:
Skin Biopsy Differentials
Actinic Keratosis Carcinoma Warts
Seborrheic KeratosisManagement Keratolytic agents-leads to
desquamation of hornified epithelium- Ammonium Lactate lotion
Trichloroacetic acid- cauterizes skin, keratin and tissues.
Actinic Keratosis Found in those with fair skin Sun exposure leads to damage to
keratinocytes by UV radiation Hyperkeratotic form more
prominent and palpable.
Actinic Keratosis Multiple,
discrete flat or elevated
Skin colored, yellow-brown or brown.
Dry, rough, adherent scaly lesion
3-10mm
Actinic KeratosisDiagnosis/Differentials Diagnosis:Biopsy will show
epidermal changes Differentials
Squamous cell carcinoma Lupus Seborrheic keratosis
Actinic KeratosisManagement Topical 5-fluorouracil: Surgical curettage or cryosurgery Retinoids Dermabrasion Avoid sun exposure.
Urticaria IgE or complement mediated
edema of dermis or subcutaneous tissue
Etiology: antigens Pathology: Mast cell stimulated to
degranulate by IgE.
Urticaria Clinical: Pink Edematous Papules or plaques Vary in appearance Resolve within 24 hours Angioedema: Painless, deeper
urticaria
Diagnostics: Management: Eliminate cause Oral antihistamines
Urticaria
Review 1 In infants this lesion
is found on extensor surfaces while in adults it is found on flexor surfaces.
Pt presents with pruritic lesions that are erythematous
What is this?
Review #2 Pruritus and
burning prior to eruption
Vesicles resemble tapioca
No erythema What is this? Where is it found? How is it treated?
Review #3 This is the
result of chronic venous insufficiency
What is it? How is it
managed?
Review #4 This rash occurs
in areas with high sebaceous gland concentration.
What is it? Describe this
lesion What is the
management?
Review #5 T-cell mediated
autoimmune disease Abnormal growth of
keratinocytes Erythematous plaques
with distinct borders and silvery white scales
What is this? Where is it found? How is it treated?
Review #6 What is the
pathophysiology behind this?
Describe this What are
management options?
Review #7 What is this? What is the
management of this?
Review #8
What is this? What causes this? What is the treatment for this?
Review #9 What is this? What is the
cause of this? How is this
treated?
Review #10 What is this? What is the
cause of this? How is this
managed?