Conflict of Interest I have no relevant conflicts to disclose. 2 - - PDF document
7/1/2013 2013 Internal Medicine Board Review Dermatology Lindy Fox, MD Department of Dermatology University of California, San Francisco 1 Conflict of Interest I have no relevant conflicts to disclose. 2 Case 1 A 45 year old man
Lindy Fox, MD Department of Dermatology University of California, San Francisco
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– Erosions (fragility) – Hypertrichosis – Hyperpigmentation – Milia
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– HCV 85% – Hemochromatosis – Alcoholism – Genetic predisposition
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diarrhea, weight loss
shortening of intestinal villa
vesicles on extensor surfaces and buttocks
involvement
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– Elbows, knees, forearms, buttocks, scalp, neck
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– hypothyroidism #1 – acute autoimmune thyroiditis – hyperthyroidism
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Test Mode Result in DH Notes Skin biopsy H&E DIF Collections of neutrophils at dermal-epidermal junction DIF(+) granular IgA upper dermis IgA tissue transglutaminase ELISA, blood Sensitivity 90% Specificity 95% Higher false (+), confirm with anti- endomysial Ab IgA anti- endomysial Ab IF, blood (+) 70-90% Antigen is tissue transglutaminase
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– Heliotrope: peri-orbital edema, violaceous rash @ eyelids – Gottron’s papules: flat, violaceous @ MCP, PIP, DIP joints – Photosensitive rash, shawl sign – Skin biopsy: similar to lupus (vacuolar interface + mucin)
– Elevated CK or aldolase – Muscle biopsy, electromyography – ANA positive in 60-80% – Anti-Jo antibody associated with interstitial lung disease
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earlier, larger plaque
plaques with a central scale
(Christmas tree pattern)
secondary syphilis
– CHECK RPR
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– Neonatal heart block is risk
– Ro correlates with photosensitivity
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diffuse erythema (erythroderma)
– ACE inhibitor x 3 months – 1 week of pulsed prednisone with rapid taper for COPD flare
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– High cardiac output state – Electrolyte imbalance – Respiratory distress – Temperature dysregulation
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– Arthritis – Cardiovascular disease (including MI) – Hypertension – Obesity – Diabetes – Metabolic syndrome – Malignancies
– Higher mortality – Poor quality of life
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– Up to 6% of patients with AIDS develop psoriasis
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– Steroid ointment (start mid-potency) – Calcipotriene ointment – Tar
– PUVA: psoralens + UVA
– Acitretin (oral retinoid) – Methotrexate, cyclosporine – Biologics
**Systemic steroids are NOT on this list!**
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Potentially life threatening Morbilliform drug eruption Drug hypersensitivity reaction Stevens-Johnson (SJS) Toxic epidermal necrolysis (TEN) Minimal systemic symptoms Systemic involvement
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diphenhydramine, topical steroids
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– Aromatic anticonvulsants THESE CROSS-REACT
ALSO – Allopurinol – Dapsone – NSAIDs – Sulfonamides – Anti-retrovirals
– Must stop medication (cannot treat through) – Prednisone (1-2mg/kg/day)
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Facial edema is key to the diagnosis of drug hypersensitivity reactions
Clinical morphology: – Target lesions – Two or more mucous membranes (eyes, mouth, genitalia) involved – Can progress to resemble toxic epidermal necrolysis (TEN)
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denuded dermis
dermatology immediately
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– The major predictor of survival and severity of disease
– Systemic
patients
– SJS: high dose corticosteroids – TEN: IVIG 0.5-1g/kg/d x 4 days – Refer to burn unit or ICU early
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– Inflammatory bowel disease (1.5%-5% of IBD patients get PG) – Rheumatoid arthritis – Seronegative arthritis – Hematologic abnormalities
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– Superpotent steroids – Topical tacrolimus
– Systemic steroids – Cyclosporine – Tacrolimus – Mycophenolate mofetil – Thalidomide – TNF-inhibitors (infliximab)
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Evolution
cellulitis with recent 10 day course of cephalexin
pain and loose stool
bowel disease
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– Idiopathic (35-55%) – Infection: STREP
– Drugs
PCN, halides – Sarcoidosis – IBD (Crohns > UC)
– Yersinia – Behçet's – Sweet’s syndrome – Pregnancy – Malignancy
– Brucellosis – Meninigococcus/gonococcus – E. coli – Pertussis – Syphilis – Leprosy – Cat Scratch – Chlamydia – Blastomycosis – Histoplasmosis – HIV
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asthma
antihistamines prn
triamcinolone ointment but recurs
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– Vesicles on the nasal tip or side suggest nasociliary nerve branch involvement – prompt ophthalmology referral
– Vesicles in distribution of the nervus intermedius (external auditory canal, pinna, soft palate, anterior 2/3 of tongue) – Associated with vertigo, ipsilateral hearing loss, tinnitus, facial paresis
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– Faster resolution, shorter duration of pain – May help prevent and shorten duration of PHN
– Improves QOL score in patients with acute pain – Does not prevent PHN – Don’t use in immunosuppressed patients (increased risk of dissemination)
– Capsaicin, amitriptyline, gabapentin
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– Post strep GN – Hepatitis B – SBE
– Henoch-Schönlein purpura – Serum sickness – Medication
– RA – Sjögren’s syndrome
(HCV)
– CLL – Multiple myeloma – Lymphoma – Hodgkin’s disease
vasculitis
– Wegeners granulomatosis – Microscopic polyangiitis – Churg Strauss
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– Chronic sun exposure – Organ transplant recipients
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– SCC: 70x increased risk – BCC: 10-20x increased risk – Melanoma: 2x increased risk
Traywick and O’Rielly. Derm Therapy. 2005; 18: 12-18
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– Reduce total immunosuppressive dose to minimum required – Absolute sun protection – Oral acitretin (25 mg daily) may reduce rate of SCC development