dermatology lecture 2
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DERMATOLOGY LECTURE 2
PsoriasisInfective Skin Disorders
CASE STUDIES Me-atopic and contact and autoimmune
Patient x with eczema on foot and eyelids
Patient y with history of chronic appendicitis
PSORIASIS A hyperprolifitive inflammatory scaling
or plaquing skin disease affecting 2-3% of pop.
Lesions are usually well circumscibed red patches with silver or whitish scaling
No known cause but predisposing factors include stress, trauma, infection or as a drug rxn. May be genetically predisposed
Lesions vary in degree of itchiness Diagnosis is by appearance or scrapings I have seen overconsumption of alcohol
and/or sugar to be a predisposing factor
PSORIASIS Considered by some sources to be
autoimmune condition. Basically what is happening is that
a lot of immune cells (activated t-lymphocytes) migrate to an area, sometimes in response to a trauma or infection of the skin, often with no obvious trigger.
Inflammation ensues, disrupting the boundaries between the epidermal layers, and the ability to cement the immature cells in place with lipids.
and immature keratinocytes migrate up to the surface and form a flaky plaque over the erythematous, inflamed underlying tissue
DIFFERENT TYPES OF PSORIASIS
Nail Psoriasis-pitting, discoloration of nails ddx fungal infxn, often indistinguishable, but if fungal, will get worse with conventional psoriasis treatment. Tx usually sytemic and unsuccessful. Occasional injection into nail.
Pustular psoriasis of palms and soles-Develops gradually with deep sterile pustules. Can crack and become painful, may become infected. Tx is systemic
Guttate psoriasis-Sudden onset of small lesions (0.5-1.5 cm) often on trunk of kids or teens after a strep throat or suddenly dcing systemic meds. Tx’d with systemic antibiotics, if strep related. Generally resolves completely, but may progress into plaque psoriasis.
Guttate psoriasis-Referral may be necessary
Guttate psoriasis-Referral may be necessary
TYPES OF PSORIAIS Psoriatic arthritis- 5-30% of those with psoriasis
develop arthritis in the joint associated with psoriaisis
Inverse psoriasis=Psoriasis on the flexor rather than the characteristic extensor surfaces
Erythrodermic psoriasis-Usually seen in patients who already have plaque psoriasis. Diffuse erythema without plaque, often a response to irritating meds or suddenly dcing systemic steroids. Treated with higher level, immunosuppressive drugs.
Generalized pustular or exfoliative psoriasis-Can be fatal. Sudden widespread erythema with sterile pustules. Tx’d with systemic retinoids.
PSORIATIC ARTHRITIS Develops in 5-30% of those with psoriasis Increasing incidence, but may be due to
increasing recognition and diagnosis Mostly (60-80% of the time) lesions appear
before joint pain and deformity Most often in folks with more severe psoriasis,
but also often, sometimes just nails affected Characteristically the distal interphalangeal
(“dips”) joints are affected-helps to differentiate from rheumatoid arthritis.
Also large joints may be involved, esp knee, rarely spine.
DifferentiatingRheumatoidArthritis fromPsoriaticArthritis
ERYTHRODERMIC PSORIASIS
REFER
EXFOLIATIVE PSORIASIS
Refer
GENERAL COURSE AND TREATMENT OF PSORIASIS Waxes and wanes with stresses, especially
emotional, hormonal, or climate changes Considered incurable, but manageable Topical corticosteroids used for flare-ups “Systemic corticosteroids are generally
ineffective, and they can significantly exacerbate the disease upon withdrawal. Combination therapy with a vitamin D analog (calcipotriol and calcipotriene) or a retinoid such as tazarotene and a topical corticosteroid is more effective than therapy with either agent alone.”(Medscape)
CONVENTIONAL TREATMENT
“The simplest treatment of psoriasis is daily sun exposure, sea bathing, topical moisturizers, and relaxation. Moisturizers, such as petrolatum jelly, are helpful. Daily application of moisturizing cream to the affected area is inexpensive and successful adjunct to psoriasis treatment. Application immediately after a bath or shower helps to minimize itching and tenderness.” (Medscape)
“Nonprescription tar preparations are available and have therapeutic success, especially when used in conjunction with topical corticosteroids; the newer foams are less messy preparations than some of the older ones. Anthralin, topical corticosteroids, salicylic acid, phenolic compounds, and calcipotriene (a vitamin D analog) also may be effective.” (Medscape)
CONVENTIONAL TREATMENTS
PUVA therapy involves an orally ingested psoralen medication activated by UltraViolet A.
Psoralens are plant derived furanocoumarins most commonly from Queen Anne’s Lace or Heracleum candicans ( bai liang du huo)
There is also therapy using UltraViolet B spectrum light using coal tar ointments
UVA and UVB therapies work best on plaque and guttate psoriasis
It is important not to become sunburn, as this can traumatize and exacerbate the psoriasis.
Higher force medications: Methotrexate, a folic acid inhibitor; cyclosprine, an immunosuppressant; systemic retinoids.
MORE RESOURCES 2013 Medscape Overviews of psoriasis:
http://emedicine.medscape.com/article/1943419-overview#aw2aab6b2b1aa
http://www.rxlist.com/psoriasis_slideshow/article.htm
INFECTIOUS SKIN DISEASES
Derm Lecture 2 part 2
INFECTIOUS SKIN ISSUES Very common Usually have an age range Can range in severity from self-limiting to
life threatening Conventional treatment is generally aimed
at using a medication that kills off infectious organism. For viral issues often suppression is the goal
Complementary and alternative treatments are based around soothing skin, and increasing immune function, and using natural products to inhibit or kill organism
BACTERIAL SKIN ISSUE Impetigo
Usually seen in very young children or occasionally in the elderly
Very contagious-keep child home Defined by it’s appearance “honey-colored crust” Most commonly appears around mouth, nose, knees
and elbows Can be a secondary infection from diaper rash, bug
bite or scratch Usually a coag-positive Staph. aureus or group A
betahemolytic Strep Starts out as a small red macular lesion, which
develops into a pustule, which breaks up and spreads.
Impetigo
DIAGNOSIS AND TREATMENT
Diagnosis by appearance, a swab for culture and sensitivity may be done, WBC’s might be elevated
Conventional treatment includes topical antibiotics, lots of washing with soap and water. Systemic antibiotics (commonly cephalosporins) may be used for extensive cases.
Alternative complementary therapies usually include a wash from a tea of goldenseal, calendula, echinacea, tea tree, or lavender
Red flag issues may include spreading infection, MRSA or rarely streptococcal glomerulonephritis
FOLLICULITIS An infection of a hair follicle usually by
Staph aureus Extremely common When a group of follicles is involved they
will be called a “boil” or “carbuncle”. Furunculosis occurs when the more
superficial folliculitis develops into hard, nodular, painful lesions
Treatment is usually hot compresses and soap and water. Deeper lesions may need to be drained
Red flag issues are MRSA, septicemia
Folliculitis-notitchy but sore
MRSA Methicillin Resistant Staph Aureus A not uncommon antibiotic reistant
bacterial infection that can progress quickly to a systemic life threatening or disfiguring infection.
Often, first misdiagnosed as a “boil” or “spider bite”
Refer for a culture/sensitivity, CBC and treatment-Vancomycin, Clindamycin
Alternative treatments of essential oils, Four (or sometimes “Seven”) Thieves vinegar may be effective, but things can go bad quickly, so do not attempt this lightly
MRSARefer
SCALDED SKIN SYNDROME
Named for the appearance of the disorder Staph aureus is the causative organism and the
disorder is sometimes called “SSSS” Certain strains of the bacteria release toxins
which cause an exfoliation of the epidermal layer of the skin, resulting in the scalded appearance.
It is usually seen in children. 62% are less than 2, and 98% younger than 6. Often cases will start out as an impetigo or other infected lesion.
There are only 50 adult cases documented. Immune deficiency, renal insufficiency or other chronic disease were underlying factors
Mortality in children is 1-5%. In adults 50-60%. Refer.
SCALDED SKIN SYNDROME
Fluid and electrolyte balance and overwhelming sepsis are usually the cause of death.
Differential diagnosis is another disorder: toxic epidermal necrosis (TEN), a similar disorder but which involves both the skin and the mucous membranes and has a higher mortality rate, also affect adults much more than children and is usually seen in HIV.
Treatment is with systemic antibiotics, either oral or I.V.-Vancomycin, Nafcillin, Clindamycin and rehydration
Often treated in burn centers
TINEA VERSICOLOR “Tinea versicolor is a common, benign, superficial
cutaneous fungal infection usually characterized by hypopigmented or hyperpigmented macules and patches on the chest and the back.” Medscape
Caused by the fungal organisms in the genus Malassezia, formerly known as Pityrosporum, which are considered normal, but opportunistic, skin flora.
Lesions are scaly macular or papular patches that can be white, red or brown (“versicolor”). The fungus messes with pigment production by the melanocytes
Sometimes the hypopigmented patches won’t tan with the rest of the skin, but can burn more easily. Eventually the pigment will return to normal
TineaVersicolor
TINEA VERSICOLOR Highest prevalance in people 15-24. Rare before
puberty or after 64. The organism is lipophilic, so it is thought that it is most active when the sebaceous glands are most active
Best diagnosed microscopically with skin scrapings mixed in a KOH preparation
Differential dx includes vitiligo, tinea corporis, and seborrheic derm.
Treatment is with topical selenium sulfide lotion or if preferred by patient with oral antifungal drugs, typically ketoconazole, fluconazole, and itraconazole.
Alternative therapies include increasing immune function and decreasing sugar in the diet.
DERMATOPHYTOSIS Commonly known as a group as tinea. Further
designation indicates location of infection These infections include the commonly known
athlete’s foot (tinea pedis), jock itch (tinea cruris), but also occur on the scalp (tinea capitis), the nails (tinea ungum), the trunk (tinea corporis), the bearded face (tinea barbae).
The cause are fungi in the Trichophyton, Microsporum, or Epidermophyton genera
These dermatophytes live normally on the hair, skin and nails and actually require keratin for nutrition
Often called “ringworm”
TINEA DIAGNOSIS AND TREATMENT
Appearance-it is circular with scaling on the borders, and sewer shinier skin towards the center of the lesion.
Microscopic study of skin scraping with KOH is preferred method of dx.
Treatment is often with topical antifungals, usually of the –azole class. Occasionally oral antifungals are used, or terbinafine (aka Lamisil)
Alternative therapies, Diet low in simple carbs, probiotics, sometimes applied topically, or herbal vinegar solutions
CANDIDIASIS (AKA MONOLIASIS)
Common fungal infection of the skin and mucus membranes by Candida albicans or any of the other of the 150 Candida species, which are normal but opportunistic flora.
Infections commonly occur in skin folds where it is moist and warm, also common on the penis, around fingernails and between the fingers. A common cause of diaper rash, vaginitis, and infection of nipple in nursing mom.
Very itchy, often beefy red, can be pustular with crusting or plaquing making it hard to distinguish from psoriasis.
Oral candidiasis (thrush) causes a thick whitish coating on the tongue or mucus membrane that bleeds when scraped off.
Candida
DIAGNOSIS AND TREATMENT
Diagnosis by appearance and a KOH prep of skin scraping
Gentian violet, antifungal topical powders, occasional oral antifungal drugs including nystatin are conventional treatments
Volumes written about the alternative txLimiting carbs esp simple or low fiber carbsDetox or elimination diet commonSome diet also restrict any fungal or fermented
foodLots of antifungal agents: Goldenseal or Oregon
Grape, grapefruit seed extract, tea tree or lavender essential oil
OTHER RESOURCES CDC MRSA Info:
http://www.cdc.gov/mrsa/ Outpatient management of MRSA. CDC
PDF: http://www.cdc.gov/mrsa/pdf/Flowchart_pstr.pdf
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