PAC 03 DERMATOLOGYVesicular, Bullae, Acneiform Disease

ByStacey Singer-Leshinsky R-

PAC

Terms Vesicle: Bullae: Fluid filled blister

greater than 100cm in diameter

Acneiform:

Vesicular BullaeBullous Pemphigoid Humoral and cellular response

against self-antigens BP 180, 230. These are needed for dermo-epidermal cohesion.

Sub epidermal blister formation from cascade of events

Vesicular BullaeBullous Pemphigoid Lesions usually appear on

extremities first then trunk. Flexor surfaces of extremities.

Exacerbations/remissions.

Bullous PemphigoidHistory and Physical Exam

Non Bullous phase: mild to severe pruritus with excoriated, eczematous, papular, urticarial lesions

Bullous phase: Vesicles and bullae on erythematous skin. Filled with clear or blood tinged fluid. Erode and crust.

Bullous PemphigoidDrug Induced Diuretics, analgetics, antibiotics Drug acts as a trigger in patients

with genetic susceptibility by modifying immune response

Bullous PhemphigoidDiagnosis Clinical confirmed by

histopathology/immunopathology Immunofluorescence studies reveal

IgG and/or C3 at dermal-epidermal junction

IgE in serum Light microscopy of lesions reveals

eosinophils, neutrophils, lymphocytes

Bullous PhemphigoidDifferentials/Complications Differentials include erythema

multiforme, drug eruptions, dermatitis herpetiformis

Complications

Bullous PemphigoidTreatment Systemic or Topical corticosteroids.

Immunosuppressive medications Patients often go into a permanent

remission

Pemphigus Vulgaris IgG auto antibodies against cell

surface of keratinocytes. Results in acantholysis and blister formation.

Found in middle age-elderly Can be due to reaction to

medications 50-70% of patients have mucosal

lesions

Pemphigus VulgarisClinical manifestations

Pain Flaccid blister filled with clear

serous fluid Blisters fragile. Blisters rupture Mucosal lesions can precede

cutaneous lesions.

Pemphigus VulgarisDiagnosis Nikolsky’s sign positive. Asboe-Hansen sign: gentle

pressure on intact bulla forces fluid to spread under the skin away from site of pressure.

Immunofluorescence Tzanck smear: acantholytic cells

Pemphigus VulgarisDifferentials/complications Differentials: Acute herpetic stomatitis,

aphthous stomatitis, erythema multiforme, bullous lichen planus, bullous pemphigoid,

Complications Secondary infection Dehydration Often fatal unless treated with

immunosuppressive agents Recurrent and relapsing

Pemphigus VulgarisTreatment Treat dehydration Glucocorticoids- Immunosuppressive therapy-

Azathioprine, Methotrexate, cyclophosphamide

Pilosebaceous Unit Sebaceous gland

empties into hair follicle.

Pilosebaceous unit opens to surface.

Sebaceous gland produces sebum.

Pilosebaceous Unit Amount of sebum produced

depends on size of gland, rate of sebaceous cell proliferation

Large sebaceous glands Sebum production related

to androgens Sebaceous glands are rich

in staphyloccus epidermidis and Propionibacterium.

Acne Vulgaris Primarily disorder of adolescence.

Affecting 40-50 million in USA. Psychosocial and economic impact Clinically characterized by

comedones and inflammatory lesions

Etiology: unknown.

Acne Vulgaris Androgens cause sebaceous glands to

overproduce sebum. Bacteria secrete lipase which converts

lipids to fatty acids. Hyperkeratinization in lining of follicle

and follicle plugging. Papules, pustules, scarring result from

follicular rupture and inflammatory response

Acne VulgarisClinical manifestations

Non-inflammatory acne: open and closed comedones. , open comedones

Inflammatory acne: above expands to form papules, pustules, nodules and cysts of varying severity. 1-5mm filled with sterile pus.

Found on face, neck, shoulders and upper trunk

Acne VulgarisDiagnosis/Differentials

Hormone studies will rule out other etiologies

Differential diagnosis to include folliculitis, steroid folliculitis

Complications to include abscess formation and severe infection

Scarring

Acne VulgarisManagement Comedolytics- Sebum suppressive medications-

antiandrogens include spironolactone, oral contraceptives

Topical/Systemic antibiotics- emycin, clindamycin

Benzoyl peroxide- Severe Acne- Isotretinion(Accutane)-

inhibits sebaceous gland function and keratinization.

Rosacea Peaks in 30-40’s. Associated with

Parkinson’s, might be associated with Helicobacter pylori or hair follicle mites (Dermodex folliculorum)

Related to vascular hyper-activity-Repeated episodes of dilation lead to release of inflammatory mediators into dermis.

Rosacea Involves nose, cheeks, forehead and

chin Complain of reddening of face with

heat, hot fluids, spicy foods and ETOH

Rhinophyma caused by sebaceous hyperplasia M>F

Blepharophyma Metrophyma

RosaceaTypes

Vascular Rosacea: Flushing and persistent central facial erythema with or without telangiectasia.

Papulopustular rosacea: central facial erythema with transient papules and pustules.

RosaceaTypes

Sebaceous hyperplasia: thickening skin, irregular surface nodularities and enlargement.

Ocular rosacea: Foreign body sensation in eyes. Photosensitivity, periorbital edema, telangiectasia of sclera.

RosaceaDiagnosis/Differentials Diagnosis: Clinical diagnosis,

histopathological features Differential diagnosis:

Acne vulgaris- Perioral dermatitis Seborrheic dermatitis Systemic Lupus Erythematosus

RosaceaManagement Avoid environmental and dietary triggers

such as heat/sun exposure, ETOH. Topical Metronidazole- Azelaic acid cream. Tetracycline- treats inflammation. Retinoids- Isotretinoin- Clonidine NO potent topical fluorinated steroids on

face

Hidradenitis Suppurativa Skin infection that affects apocrine

gland bearing skin sites especially the axillae and anogenital areas.

Characterized by recurrent boils and draining sinus tracts with scarring.

Hidradenitis Suppurativa Risk factors include obesity,

apocrine duct obstruction, family history

Inflammatory condition originating in the hair follicle. Follicle ruptures spilling contents into surrounding dermis.

Hidradenitis Suppurativa Initially inflammatory

nodules and sterile abscesses in axillae, groin, perianal areas. Then sinus tracts and hypertrophic scars develop.

Pain/foul odor Erythematous abscess up to

2cm Chronic and remitting

Hidradenitis SuppurativaDiagnosis/Differentials Diagnosis:

Bacterial cultures for antibiotic therapy

Differentials: Cellulitis, pilonidal cysts, bacterial folliculitis

Complications: Squamous cell carcinoma

Hidradenitis SuppurativaManagement Might need incision and drainage if

large and painful. Antibiotics such as tetracycline,

cephalosporin, clindamycin, ciprofloxacin

Isotretinoin Corticosteroids Reduce friction and moisture.

Hypersensitivity Vasculitis Immune complex mediated

inflammation of small vessels such as arterioles, capillaries, venules.

Occur as an exaggerated immune response to a drug, infection or autoantibodies

This leads to injury to vessel walls, and so decreased function and blood flow.

Hypersensitivity Vasculitis

Patients might report use of a new drug, history of streptococcal infection or collagen/vascular disease such as lupus, Rheumatoid Arthritis

If not isolated then can have systemic vascular involvement of kidneys, muscles, joints, GI tract, peripheral nerves

Hypersensitivity Vasculitis Palpable purpura 1-

3mm in diameter Usually localized to

lower third of legs/ankles

Lesions are scattered, discrete, confluent

Lesions can form papules and ulcers due to lack of blood supply

Diagnosis: confirmed by skin

biopsy (vascular and perivascular infiltration of broken up leukocytes)

Look for evidence of systemic disease

Hypersensitivity VasculitisDiagnosis

Hypersensitivity VasculitisComplications/Differentials

Complications Systemic vascular involvement Necrosis Irreversible damage to kidneys

Differential diagnosis Thrombocytopenia purpura Disseminated intravascular coagulation Rocky Mountain Spotted Fever Steven Johnson Syndrome

Hypersensitivity VasculitisManagement

Antibiotics If skin involvement use colchicine

or Dapsone If visceral involvement then use

steroids such as Prednisone combined with Cytotoxic immunosuppressives

Folliculitis Common disorder with perifollicular

pustules. Etiology: staphylococcus aureus,

pseudomonas aeruginosa chemical irritation, friction, perspiration, shaving, skin injury.

Follicle infiltrate of lymphocytes, neutrophils, macrophages. Can lead to formation of abscess.

Folliculitis Papule or pustule on

erythematous base Asymptomatic, mild

discomfort or pruritic Favors areas with terminal hair

Eye involvement: Healing can lead to

keloids

FolliculitisDiagnosis/Differentials Diagnosis

History and physical exam Cultures, gram stains, KOH

Differentials Insect bites Scabies Rosacea Tinea

FolliculitisManagement Wash area with antibacterial soaps Topical and/or oral antibiotics

(s.aureus-often resistant to pcn so use dicloxacillin or cephalosporin or emycin or clindamycin)

Pseudomonas Antifungals/Antivirals

Xerosis Dry skin Can be a natural occurrence

sometimes associated with aging , second to contact dermatitis. Also exogenous causes such as dry climate, excessive exposure to water

Etiology:

XerosisClinical Manifestations Pruritus Involves back, abdomen,

extremities Dry rough, scaly skin Cracking, fissuring

XerosisDiagnosis Diagnosis: histological findings Differential Diagnosis: Eczema,

contact dermatitis, scabies

XerosisManagement Moisturizing agents humectants

(alpha hydroxy acids- dry water from deeper layers to skin surface), occlusives which reduce water loss by epidermis

Example 1 Prodrome of

erythematous skin prior to bullae eruption

Pruritus weeks to months prior to blister eruption

Extremities first then trunk

What is this? What do immunofluorescence studies reveal?

Treatment

Example 2 Mucosal lesions Flaccid blister on

normal or erythematous skin.

Blisters rupture leading to erosions

What sign is positive?

What happens if not treated?

Treatment options:

Example 3 Follicular

comedones with or without inflammatory papules, pustules and nodules

What is the cause of this condition?

What is the management?

Example 4 Blood vessels dilate

easily and leakage of inflammatory mediators into dermis

Aggravated by what medication

Describe the appearance of the lesion

Describe the management

Example 5 Chronic infection

of apocrine sweat glands

Inflammatory red hard raised nodules in axilla, groin, perineum

What is this? What is the

management?

Example 6 What is this? What bacteria are

involved with this?

What is the treatment of this?