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