Download - Welcome. Patient itch/ Itchy Rash-2 Prof. DOULAT RAI BAJAJ Professor & Chairman Dept. of Dermatology
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Patient itch/Itchy Rash-2
Prof. DOULAT RAI BAJAJ Professor & Chairman
Dept. of Dermatology
Goals of Presentation
At the end of presentation you would be able to:
1. Clinically evaluate a patient with itch or itchy rash
2. Make a working diagnosis
3. Manage it at the best
Review Last Presentations
Evaluation of a patient presenting with itchy rash
Aopic Derm, Sebh. Derm. Irritant Contact Dermatitis (ICD) allergic CD, Discoid, LSC, Prurigo, Pompholyx, P.rosea, P. alba, xerotic eczema
General Principles of treatmentPreventive measures
Tasks of Today
PsoriasisLichen PlanusScabiesPediculosisUrticariaDermatitis herpetiformis
PSORIASIS
Psoriasis
An autoimmune disease characterized by: Well defined, erythematous, plaques Bilateral Symmetrical distribution Silvery scales, varying thickness Predilection for Extensor aspects May be associated Joint involvement Runs a very chronic course with
remissions and relapses Auspitz Sign
Psoriasis contd….
May occur from infancy to very old age. Mostly b/w ages of 15 & 35 yrs
M: F affected equally. Same phenotype in both sexes
Koebner Phenomena: Psoriasis may develop @ sites of trauma, e,g, Scratch mark, Injury, Surgical incision, Friction from tight-fitting clothing/obesity Sun burn
Kobner Phenomena
Predisposing Factors:
Actual etiology unknown.
Genetic Factors Environmental Factors
Etiology:
Genetic factors
HLA Cw6Familial occurrence: 14% if one parent affected 41% if both parents affected 06% if one sibling affected 02% when no parent/sibling affected
Environmental:Trauma: Physical, Chemical, Electrical, SurgicalDry skinInfections: Streptococcal, HIVSunlight : may relieve or exacerbateHypocalcemia: Drugs: Lithium, Antimalarials, β-blockers,
NSAIDs, ACEIs, Terbinafine, Ca Chanel Block Withdrawal of corticosteroids Psychogenic factorsSmoking, Alcoholism
Clinical Types
Psoriasis vulgaris Guttate psoriasis Rupoid, Elephantine & ostraceous Unstable psoriasis
• Erythrodermic psoriasis • Pustular psoriasis
Psoriasis Vulgaris
Guttate Psoriasis
Generalized shower of small “rain drop” like deep red papules ē fine scaling.
Most common form in children.
Acute onset: Usually follow 3/4 wks off strept. pharyngitis.
Recurrent, b/c of pharyngeal carriage of streptococci.
Mainly trunk, sparing face, palms & soles.
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Management It includesIt includes
General measures
Local therapy
Intralesional therapy
UV phototherapy
Systemic therapy
Lasers
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GENERAL MEASURES
Attention should be paid to general, physical & psychological health.
Rest & mild sedation
Stress alleviation
Stop smoking, alcohol, drugs
Spa therapy
DIET
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Local Therapy
Keratolytics: salicylic acid
Tar: 2-10%
Dithranol: 0.05-4%
Corticosteroid
Vitamin D analogue: calcipotriol, calcitriol, tacalcitol
Vitamin A analogue: Tazarotene
Topical tacrolimus
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Photo chemotherapy
Combination of psoralens & UVA.
Moderate to severe psoriasis.
It is one of the standard treatment b/c: Effective, long term effect. ORAL 8-MOP = 0.6 mg /kg or 5-MOP UV radiation/laser light 2 hours later UVA dosage depends upon skin type.
frequency: 2-4 times weekly (for 15-25 min.).
Systemic therapy
MethotrexateHydroxyureaOral retinoids: Etretinate
IsotretinoinAcetretin
Cyclosporin Systemic steroids. Biological Therapies
Methotrexate
MOA: Inhibits DNA synthesis by inhibiting DHFR
Start ē 7.5-15 mg/wk in single/divided × 3, given 12 hrly over 36 hrs. Inc 2.5 mg every 2-4 wk, Max: 30mg/wk
Folic acid supplement 5mg daily (on days without Mtx)
Monitor ing Monitor ing : : Hepatic, renal & marrow function. Routine liver biopsy.
Avoid concurrent therapy ē NSAIDS, sulpha, ASA & Septran b/c they displace MTX from plasma albumin
Ciclosporin Antilymphocytic, inhibition of T-lymphos. Start with 2.5 mg/kg BID, for 2 wks. No response
to 5mg/kg/day. Use for short courses of 3-4 months.
S. ES. E. . Renal toxicity. HTN Malignancies: CIN (females), PIN (males), cut.lymphoma Hypertrichosis Gum hyperplasia Biochemical: serum K+, serum uric acid. serum Mg+
Retinoids: Etretinate & Acetretin Synthetic analogues of Vit. A.
Acitretin is active metabolite of etretinate, ē ½ life of just 50 hrs VS ≥ 80 days for etretinate.
Best results when combined ē UVA (PUVA) Dose: 0.7-1mg/kg/d
Protocol: Protocol: Contraception during & up to 2 yr after stopping Rx. Lipid profile & LFT, CBC ē platelets, Renal profile
Lichen planus
LICHEN PLANUS A chronic papulosquamous disorder
characterized: plane toppedPolygonalPurple papuleswhich are highly pruritic Surface may show white lines: Wickham’s Stria
Etiology: Exact etiology unknown. Genetic, immunological
Plane topped polygonal purple color papules
Papules appear in group
Size ranges from pinpoint to centimeter
SITESMost common sites: wrists, lumbar
region & around ankle. May occur any where on body
Ankles & shins are the most common sites for hypertrophic LP
Hypertrophic lesions around ankle
Hypertrophic lesions present on shin
MUCOSAL INVOLVEMENTMucosal lesions very common, mostly
seen on buccal mucosa & tongue. White lacy streaks on inner surface of the cheeks, gum margins and lips: a very common finding
Mucosal Lesions includeWhite streaksFixed white patchesUlcerative lesionsStreaks of pigmentation
LP involving buccal mucosa
Lesion present on inner surface of cheeks
White streaks present on lips
White streaks on tongue
Drug Induced LP:
COMMON INDUCERS
Gold saltsβ-blockersAntimalarialsThiazide diureticsFrusemideSpironolactonepenicillamine
LESS COMMON INDUCERS
ACEIs
Calcium channel
blocks
Ketoconazole
Tetracyclines
Phenothiazine
CLINICAL & H/P Difference b/w IDIOPATHIC & DRUG induced LP
PRESENTATIONS IDIOPATHIC LP Drug Induced
lesions Smaller Larger and scally
Wickhams striae Usually present Usually absent
Alopecia Uncommon Common
Residual hyperpigmentation
Possible common
MM involvement Very common Less common
Parakeratosis Not seen common
Cystoid in granular layer
Very common common
TREATMENT
TOPICAL STERIODS:Flucinonide 0.05%Clobetasol propionate 0.05%
FOR PRURITIS:Promethazine HCLTrimeperazine tartrateBrom-pheneramine maleate
TREATMENT
SYSTEMIC STEROIDS: Oral prednisolon 15-20mg/d for about 6
wks for severe cases.
For cutaneous and erosive LP Acetretin Itraconazole Metronidazole PUVA
TREATMENT
FOR ORAL LESIONS: Lidocain gel triamcinolone in orabase Corticosteroids lozenges Betamethasone mouth washes Fluticasone propionate spray
Oral or systemic CYCLOSPORIN used to treat
ulcerative form of LP
Scabies
Scabies
Caused by Sarcoptes scabiei var humanis
Acquired through close personal contact (not
casual), but may be transmitted through clothing,
linen, furniture or towels.
Sexual transmission as common as non-sexual
Suspect scabies when several members of a
family complain of itching
Clinical Features: The IP <1 month (max: 2 months)
Severe itching: prominent symptom Nocturnal Pruritus first noticed 3-4 wks after primary infection,
but occurs sooner after subsequent attacks. May be localized initially to burrow, but later
becomes generalized. Burrow is the diagnostic lesion: Multiple straight or S-
shaped ridges or dotted lines resembling thread, 5-20 mm long
Sites:
interdigital webs of hands
wrists, anticubital fossae, points of elbow
nipples
Around the umbilicus, lower abdomen
Genitilia
Gluetal cleft
Lesions on glans penis→ Characteristic in males
Infants & small children: lesions on palms, soles, head & neck.Generalized urticarial papules, excoriations
& eczematous changes common in childrenIndurated erythematous nodules, most
noticeable on male genitalia → more common.
Sec: bacterial infection: Impetiginization, furunculosis
DIAGNOSIS H/O of pruritis with nocturnal exacerbations.Positive family history.Distribution of lesions In doubtful cases confirm by microscopyPolymerase chain reaction has been
employed in difficult diagnostic and atypical cases.
Treatment
General Measures: Improve general hygiene frequent bathing Trim down nails avoid close contact with active caseObserve caution when caring/nursing
patient keep personal utensils and towels separateTreat all family members at a time
Drugs
Topical Treatment is the gold standard & very effectiveTopical Permethrin 5%: lotions, creamsGamma benzene hexa chloride: Benzyl benzoateSulphur 10%Malathione: NAOral Ivermectin: efficacy???
URTICARIA
Urticaria characterized by weals: transient, well-demarcated, superficial erythematous or pale swellings of the dermis, usually associated with itching
While angioedema is a transient swelling in deep dermis, subcutaneous & submucosal tissue.
•Usually painful •Poorly defined •pale or skin colour
Definition
Urticaria and Angioedema
Urticaria Angioedema
Urticaria not a single disease: A REACTION PATTERN mediated by HISTAMINE
Mast Cells/Basophils play cardinal role. Their activation by various factors/agents/stimuli with subsequent release of MEDIATORS leads to clinical symptoms/signs.
Acute urticaria & chronic urticaria are not single entity. Clinically it is useful to d/b the two to make proper clinical decisions.
PATHOGENESIS
CLASSIFICATION
classificationclassification
According to According to duration of diseaseduration of disease
According to According to clinical featuresclinical features
DURATION OF DISEASE Acute urticaria
≤ 06 weeks Cause can be found in in approx. 50%; by history Good prognosis
Chronic urticaria ≥ 06 weeks workup indicated often persistent
Chronic idiopathic urticaria - subset of chronic urticaria in which workup fails to pinpoint cause; diagnosis by exclusion; not homogeneous.
Start as itchy erythematous macules Wheal Pale to pink with surrounding red flare. Duration: few hrs to several days, no sequelae Very itchy but pts. tend to rub rather than scratch Size: few mm to many cms Shape: round ,annular, bizarre. Angio oedema associated ē 50% of cases Sites: face, eye lids lips, ears, neck, hands, feet,
genitalia, buccal, tongue, pharynx & larynx
ORDINARY URTICARIA
Acute ordinary urticaria: ≤ 6 weeks.
TypesAllergic
Non-allergic
A reaction B/W an allergen with specific IgE antibody bound to mast cell
Common in atopic persons with raised IgE levels
ALLERGIC URTICARIA (IgE mediated)
Penicillin Cephalosporin Insulin vaccines Blood products Bee and wasp strings
Substances causing urticaria
Foods causing AU
Lobsters, shrimp, crab Milk nuts Fish Beans Potato Carrots Spices Rice Banana Apple Orange
Non allergic Acute urticaria from ingested substances
may be non-allergic.
They are referred to as intolerance reaction.
Due to direct histamine release from mast cell
Substances causing non allergic urticariaDrugs Aspirin, Other NSAIDs Polymyxin, ciproxin, rifampsin ,vancomycin. Radio contrast media Plasma expanders General anaesthetic agentsInfections Epstein bar virus, Hepatitis B virus Strept. sore throat in children
Etiology: D/B Acute VS Chronic
Acute UrticariaDrugs
Foods
Food additives
Viral: Hep: A, B, C, EBV
Insect bites and stings
Animal dander and latex
Chronic Urticaria Physical factors
–Cold, heat, solar, pressure
Ch. Viral, bacterial, fungal infect
chronic yeast infection
autoimmune: SLE, DLE, DM, SS
Complement deficiency
Malignancies: Lymphoma, leukemia
Idiopathic
Initial Workup of Urticaria
Patient history URTIs: Sore throat, Sinusitis,
pharyngitis Arthritis Thyroid disease Cutaneous fungal infections UTI symptoms Travel history (parasitic infection) EBV infectious mononucleosis Insect stings Foods Recent transfusions Recent intake of drugs
Physical examSkinEyesEarsThroatLymph nodesFeetLungsJointsAbdomen
Lab: Assessment for Chronic Urticaria
Tests for selected patients Stool exam. for ova, parasites, giardia Blood chemistry profile Antinuclear antibody titer (ANA) Hepatitis B and C Skin prick tests (IgE-reactions) RAST for specific IgE
Initial testsCBC with differentialESRUrinalysis
Complement studies: CH50
CryoproteinsT3, T4, TSH, Thyroid
antibodies
Treatment: Pharmacologic Options
Antihistamines, othersFirst-generation H1
Second-generation H1
Antihistamine/decongestant combinations
Tricyclic antidepressants (eg, doxepin)
Combined H1 and H2 agents
Beta agonists Epinephrine 1:10,000; 0.5-1ml
S/C: angioedema, sever acute urticaria
Terbutaline
CorticosteroidsSevere acute urticaria
–avoid long-term use–use alternate-day regimen
when possibleAvoid in chronic urticaria
(lowest dose plus antihistamines might be necessary)
MiscellaneousPUVAHydroxychloroquineThyroxine
H1-Receptor Antagonists: Pros and Cons for Urticaria and Angioedema
First-generation antihistamines (diphenhydramine, hydroxyzine) Advantages: Rapid onset of action, relatively inexpensive
Disadvantages: Sedating, anticholinergic effects
Second-generation antihistamines (astemazole, cetirizine, fexofenadine, loratadine) Advantages: No sedation (except cetirizine); no adverse
anticholinergic effects
Disadvantages: Prolongation of QT interval; ventricular tachycardia (astemizole only) in a patient subgroup
Dermatitis Herpetiformis
Very pruritic condition Characterized by: crusted, excoriated papules and vesicles. Vesicles very seldom seen
Widespread on back of trunk, head, elbows Occur in all age 22 – 55 years Sites : Elbow, knee, shin, scapulae & buttocks Patient may have gastrointestinal symptoms OR systemic signs of gluten sensitivity/CD.
Dermatitis herpatiformisDermatitis herpatiformis
Pruritus with Systemic Diseases
Systemic Diseases
Thyroid: hypothyroidism, hyperthyroidism, Hashimoto’s thyroiditis
Ch. Liver Diseases: cirrhosis, CAH, PBC Renal : CRF especially with dialysisis Blood: Anemia, Polycythemia Metabolic: Diabetes, HIV, AIDS Malignancies: lymphoma, leukemia, internal
malignancies
Characteristic Features There are minimal cutaneous lesions If present; these are non-specific, no predilection
for site Mostly there are dry papules broken in centre OR
dispersed excoriations S/S of systemic diseases are Dominant in whole
clinical picture Some specific features may be seen (next slide) Prognosis depends upon the prognosis of
underlying disease
Specific features of Systemic Ds Liver Ds: xerosis, diffuse melanosis, red palms, spiders,
gynaecomastia(males), edema, icteric Diabetes: xerosis, loose wrinkled skin, acanthosis, skin
tags, pyodermas, carbuncles, candida Renal: xerosis, uremic frost, perforating lesions, calcinosis,
vasculitic lesions Thyroid: xerosis, alopecia, madarosis, wrinkling in Hypo;
general flush, sweaty palms, angiomas, fine atrophic skin in Hyperthyroidism
AIDS: prurigo, urticaria, SD, cutaneous & mucosal candida Blood: general pale, lethargic look in anemia,
suffused, congested bronze skin in polycythemia
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