3

: DERMATOLOGY ROTATION 2015-2016

Common, chronic and recurrent inflammatory disease

of the skin
Characterized by circumscribed, erythematous, dry,
scaling plaques of various sizes
Lesion is covered by silvery white lamellar scales
Predilection: scalp, nails, extension surfaces of limbs,
umbilical region, sacrum
Symmetrical (usually)
Develops slowly or exanthematous with sudden guttate
(droplike) lesions
Subjective symptoms: itching or burning

Early psoriatic lesions

Small erythematous macules covered with dry, silvery
scales
Increases in size by peripheral extension and
coalescence
Scales:
o Micaceous (peels in layers)
o Loose at periphery, adherent centrally
o Bleeds points appear when removed
*Auspitz sign punctate bleeding spots when
scales are removed due to dilated and tortuous
vessels on dermal papillae

2.

Inverse psoriasis
Selectively and exclusively in folds, recesses and
flexor surfaces (ears, axillae, groins, inframammary
folds, navel, intergluteal crease, penis, lips, and
web spaces) *INTERTRIGINOUS AREA

3.

Napkin psoriasis
psoriasis in diaper area infants between 2 8
months of age.
Bright erythematous, sharply demarcated patches
of skin involving the diaper area
Clears with topical therapy
Reappears in adulthood

4.

Psoriatic arthritis
+ HLA B27
Five clinical patterns of arthritis:
a. Asymmetrical distal interphalangeal joint
involvement with nail damage (16%)
b. Arthritis mutilans with ostelysis of
phalanges and meta-carpals (5%0
c. Symmetrical polyarthritis-like rheumatoid
arthritis with claw hands (15%)
d. Oligoarthritis with swelling and
tenosynovitis of one or a few hand joints
e. Ankylosing spondylitis alone or with
peripheral arthritis (5%)
Radiographic findings:
o resemble rheumatoid arthritis
o Acrosteolysis - erosion of terminal
phalangeal tufts
o Pencil in a cup deformity tapering or
whittling of phalanges or metacarpal
with cupping of proximal ends of
phalanges
o Bony ankyloses
o Osteolysis of metatarsals
o Predilection for DIP and PIP joints, with
sparing of metacarpal phalangeal and
metatarsal phalangeal joints
o Bamboo spine - paravertebral
ossification, asymmetrical sacroiliitis
Symptomatic relief: rest, splinting, passive motion
and NSAIDS
Disease-modifying drugs that prevent deformity:
Methotrexate, cyclosporine, tacrolimus and
biologic agents

5.

Guttate psoriasis
Lesions are the size of water drops 1-5mm in diameter

Old psoriatic lesions

PSORIASIS OSTRACEA old patches that are thick and
covered with tough lamellar scales (like oyster shells)
Variants:

psoriaris guttata droplet sized lesions

psoriasis follicularis scaly lesions at hair follicle orifices
psoriasis figurate
curved linear patterns produced
psoriasis annulata
by central involution
psoriasis gyrate
psoriasis discoidea no central involution, solid patches
perists
psoriasis rupioides crusted lesions like syphilitic rupia

TYPES
1. Seborrheic-like psoriasis (sebopsoriasis, sebborrhiasis)
Overlap
Predominate on the face, under the breasts, scalp,
flexures and axillae
Breast lesions are moist and erythematous with
yellow, greasy, soft scales (rather than dry
micaceous scales)

6.

7.

8.

Occurs as an abrupt eruption following acute infections

(e.g. streptococcal pharyngitits)
Mostly patients under age of 30
Treatment
o Broad-band UVB at erythemogenic doses
o Minimal erythemogenic dose (MED) testing
recommended
o For recurrent episodes due to streptococcal
pharyngeal carriers

Semisyntheitic penicillin
(dicloxacillin, 250mg QID for 10
days) with Rifampicin (600 mg/day
for an adult)

Generalized pustular psoriasis (von Zumbusch)

Typical lesions: plaque psoriasis with hx of psoriatic
arthritis
Sudden onset with formation of pus lakes periungually,
on palms, and at edge of plaques
Erythema in flexures generalized
eruptiongeneralized erythema and more pustules
(+) pruritus and intense burning
Mucous membrane lesions are common
o Lips are red and scaly with superficial
ulcerations of the tongue and mouth
o (+) Geographic or fissured tongue
Patient is usually ill with fever, erythroderma,
hypocalcemia and cachexia
Systemic complications: pneumonia, CHF and hepatitis
Episodes provoked by withdrawal of systemic
corticosteroids
o Other involved drugs: iodides, coal tar,
terbinafine, minocycline, hydroxychloroquine,
acetazolamide and salicylates
o No implicated drugs if it occurs in infants and
children
TX:
o Acitretin (DOC)
o Isotretinoin
o Dapsone in 50-100 mg/day
o Alternatives: Cyclosporine, methotrexate and
biologicals
Acrodermatitis continua of Hallopeau
Acral erythematous plaques studded with pustules
Nailbeds involved, fingernails float away on lakes of pus
anonychiahyperkeratosis, fingertips become
increasingly painful tapering to long keratotic points
May develop generalized pustular flares
Impetigo herpetiformis
Generalized pustular psoriasis of pregnancy
Flexure erythema studded with pustules initially
generalized pustular flare and increasing toxicity
NO TREATMENT WITH SYSTEMIC RETINOIDS due to
pregnancy

9.

Management:
o only responds to delivery
o responds to prednisone at 1mg/kg/day also
contributes to neonatal lung maturity

Keratoderma blennorragicum (Reiter syndrome)

Resembles psoriasis both histologically and clinically
BUT with thicker keratotic lesions
(+) HLA B27
Develops reactive arthritis and skin disease after a bout
of urethritis or enteritis

10. Erythrodermic psoriasis

Generalized
Under exfolative dermatitis

Course

Unpredictable
Begins at the scalp or elbows. (remains localized in the
original region for years)
CHRONIC DISEASE - may be limited to fingernails
Onset : sudden and widespread
2 chief complains
o Recurrence
o Persistence
Koebner phenomenon (isomorphic response)
appearance of lesions on sites of injury
Woronoffs ring concentric blanching of the
erythematous skin at/or near the periphery of a healing
psoriatic plaques
o First sign of response to phototherapy
Psoriasis of palms and soles chronic and resistant to
treatment

Inheritance
PSORS1 On chromosome 6 and within the MHC
PSORS2 on chromosome 17q
PSORS9 susceptible for psoriasis
Early onset (type 1 psoriasis) Cw6, B57 and DR7
Late onset (type II psoriasis) Cw2
HLA associated genes:
o B13 or B17 increased risk for guttate and
erythrodermic psoriasis
o HLA-B8, Bw35, Cw7, DR3 associated with
palmoplantar pustulosis
Epidemiology
M=F, less frequent in troopics
Onset: Mean age of 27 but wide range from neonatal to
70s
Aggravated by severe emotional stress
Improvement during pregnancy but aggravation upon
childbirth

Linked to metabolic syndrome, CVD and lymphoma

Pathogenesis
Hyperproliferative disorder driven by a complex cascade
of inflammatory mediators
Represents a mixed Th1 and Th17 inflammatory disease
Overexpression of type 1 cytokines (IL-2,6,8,12, IFN-
and TNF-
o IL8 - accumulation of neutrophils
o IL 12 - IFN- production
o IL4 induces Th2 response and improves
psoriasis
o IL17, IFN- and TNF- - upregulates psoriatic
lesions
anti inflammatory cytokines (IL-1RA and IL-10) and
NK cells
a. STREPTOCOCCI
Beta hemolytic streptococci of Lancefield groyps A,
C and G causes exacerbation
b. Stress
c. Drug-induced psoriasis
Beta blcokers, lithium, antimalarials, terbinafine,
calcium channels blockers, captopril, glyburide,
granulocytic CSF, interleukins, interferons, lipid
lowering agents
Systemic steroids causes rebound of pustular flares
Pathology
HISTOLOGICALLY, all are pustular
o Microscopic pustules include spongiform
intraepidermal pustules
o Munro micro abscesses with the stratum
corneum
In early guttate focal parakeratosis in s. corneum, with
neutrophils above the focus of parakeratosis
In plaque psoriasis numerous neutrophilic foci
o microabscesses are generally present at
stratum corneum; alternate with areas of
orthokeratotic stratum corneum rhythmic
fashion production of underlying spongiform
pustules
o The granular layer is absent
In well-developed plaques
o
regular epidermal acanthosis with long,
bulbous rete ridges, thinning over the dermal
papillae
o dilated capillaries within the dermal papillae.
Differential Diagnosis
dermatomyositis same distribution (extensors and
scalp)
o with heliotrope rash, atrophy, poikiloderma
and nailfold changes
SLE lacks extensor surface involvement
o Follicular hyperkeratosis (Carpet track sign)
Seborrheic dermatitis

Predilection : eyebrows, nasolabial angle, ears,

sternal angle, flexor surfaces
o Greasy and yellowish rather than dry white
and silvery such as in psoriasis
o No Auspitz sign
Pityriasis rosea
o Upper arms, trunk and thighs
o Lesions FOLLOW SKIN TENSION LINES with fine
scaling (COLLARETTE SCALING)
o +herald patch
o Violaceous color
o No pitted nails
o Duration : weeks
Eczema
Psoriasiform syphilid
o Copper colored papules arranged in a
figurate pattern

Treatment
Topical therapy is generally suitable
Systemic agent TOC: Methotrexate
1. Topical treatment
a. Corticosteroids
- Class 1 steroids for 2 weeks.
Continued as pulse applications on
weekends
- Scalp: in propylene glycol, gel, foam
or spray forms
- Intertriginous low to mild strength
- IL triamcinolone for psoriatic nails
b. Tars
c. Anthralin wash off after 15-30 minutes
- Exerts direct effect on keratinocytes
and leukocytes by suppressing
neutrophil superoxide generation
and inhibiting monocyte-derived
mediators
d. Tazarotene
- Modulates keratinocyte
differentiation and
hyperproliferation. Suppresses
inflam.
e. Calcipotriene (Dovonex)
- Vitamin D3 keratinocyte
differentiation through regulation of
epidermal responsiveness to calcium
f. Macrolactams (Calceneurin inhibitors)
- For thin lesions in areas prone to
atrophy
g. Salicylic acid
- Promote absorption of other topical
agents
- Toxicity: tinnitus, acute confusion
and refractory hypoglycemia
h. Goeckerman technique
- 2-5% tar applied to skin + tar bath
at least once a day

i.

j.

2.
3.
4.
5.

6.

7.

- Lesions clear in an average of 18

days
Ingram technique
- Daily coal tar bath in 120 ml solution
LCD to 80 ml of warm water + daily
UV exposure + anthralin paste on
each plaque
PUVA therapy
- High intensity longwave UV
radiation (UVA) for 2 hours after
ingestion of 8-methoxypsoralen
twice a week

Surgical treatment
Hyperthermia with rapid relapse
Occlusive treatment
Systemic treatment
a. Corticosteroids
b. Methotrexate
- Standard treatment
- 3 divided oral doses (12h apart)
weekly OR oral single dose weekly
OR subcutaneous single dose weekly
- With oral folic acid supplement
c. Cyclosporine
- Down modulation of
proinflammatory epidermal
cytokines
d. Diet
- Fish oils n-3/n-6 PUFA
e. Oral antimicrobial therapy
- If associated with Strep pharyngitis
with guttate psoriasis
f. Retinoids
g. Dapsone - limited to palmoplantar pustulosis
variant of pustular psoriasis
Biologic agents
a. Infliximab, Etanercept, Adalimumab,
Alefacept, Efaliizumab, Utekinumab
Combination therapy
a. Methotrexate wit acitretin

*Psoriatic Nail Changes

Common (10-78% of patients with psoriasis)
Predominates in:
o Older patients
o Active psoriatic exacerbations
o Psoriatic arthritis
Nail plate:
o Nail pits
o Furrows
o Beauss lines transverse depression
o Leukonychia crumbling nail plate
o Reddish discoloration
Nailbed:
o Splinter hemorrhages

o Horny masses
Hyponychium:
o Subungal keratosis
o Oil spots
o Yellowish-green discoloration (area of
onycholysis)
Correlates with severity of skin and joint disease
Pustular psoriasis
o may produce onycholyis with pus lakes in
nailbed or perionychial areas
Nail changes that mimics psoriatic nails EXCEPT NAIL
PITTING:
o Reiters disease
o Pityriasis rubra pilaris
o Sezary syndrome
o Acrokeratosis paraneoplastica
*ALL PRODUCES HYPERTROPHIC NAILS WITH SUBUNGAL
HYPERKERATOSIS

Treatment
*depends on degree of involvement
a. Systematic treatment of psoriasis clears nail
changes
Methotrexate, PUVA, Cyclosporine,
Biologics, Acitretin
b. Local therapies limited
1. IL triamcinolone acetonide suspension
injection 3-5mg/ml
(2-10mg/ml in alopecia areata)
Digital nerve block needed
2. Topical 5-FU at proximal nailfold
Avoid free edge of nail it causes
distal onycholysis
3. Topical cyclosporine
4. Topical tazarotene 0.1% gel
5. Topical calcipotriol for localized pustular
psoriasis of nails
Maintenance after systemic
retinoids
Source:
Andrews Diseases of the Skin: Clinical Dermatology 11 th Ed
Page 190 Psoriasis
Page 771 Psoriatic Nails

BY:

mild inflammatory exanthem

salmon colored papular and macular lesion that may
become confluent
individual patches:

oval or circinate covered with finely crinkled,

dry epidermis, which often desquamates,
leaving a collarette of scaling
scales tend to fold across the lines of stretch: hanging
curtain sign
disease begins often with a single herald or mother patch
incidence highest between ages 15 and 40
women>men
most prevalent in spring and autumn
Fully developed eruption has a striking appearance
because of the distribution and definite characteristics

Arranged so that the long axis of macules runs

parallel to the lines of cleavage

Generalized eruption (affects the trunks chiefly

and sparing of sun exposed area)

Localized at times to certain areas:

Neck

Thighs

Groins

Axillae
rarely, the eyelids, palms and soles, scalp or penis may
be involved
oral lesions are uncommon: they are asymptomatic,
erythematous macules with raised borders and clearing
centers or apthous ulcer like lesions
Moderate pruritus maybe present (particualry during
outbreaks)
Variations in the mode of onset, course and clinical
manifestations are common
Papular pityriasis (unusual form)

Common in children <5yo (esp. black children)

Occurring in the typical sites and running s

course similar to the common form ot
pityriasis rosea
Pruritic pityriasis rosea

Manifests with petechiae, and ecchymosis

along Langer lines of the neck, trunk, and
proximal extremities

Etiology
-

active replication of human herpes virus (HHV 6&7) in

mononuclear cells of lesional skin, and identifying the
viruses in serum samples of patients
these viruses are nearly universally acquired in early
childhood and remain in a latent phase as mononuclear
cells, the eruption is secondary to reactivation leading to
viremia
a pityriasis rosea like reaction may occur as a reaction to:

captopril, arsenicals, imatinib

mesylate, interferon, gold, ketotifen,
bismuth, clonidine,
methoxypromazine, tripelennamine
hcl, ergotramine, lisinopril or
barbiturates

Histology
-

acanthosis, focal parakeratosis, and extravastion of

erythrocytes into the epidermis
mild perivascular infiltrate of lymphocytes is found in
dermis
Differential diagnosis
-

seborrheic dermatitis- scalp and eyebrows are scaly with

predilection for the sternal, interscapular regions, and
flexor surfaces covered with greasy scales
tinea corporis
tinea versicolor
macular syphilid- uniform size and assume a brownish
tint
drug errruption
psoriasis
other viral exanthema

Treatment
-

Most patients require no therapy (they are

asymptomatic)
UVB- expedite the involution of the lesions
Corticosteroid lotions or creams give immediate relief
Antihistamines by mouth are also beneficial
Simple emollients- for dryness and irritation
BY: NicDavs

Contagious, sexually-transmitted disease caused by

spirochete Treponema pallidum subspecies pallidum.
TREPONEMA PALLIDUM
o Delicate spiral spirochete that is actively
motile
o Number of spirals varies from 4-14 and the
entire length is 5-20 um
o Enters through the skin or mucous
membranes, on which primary manifestations
are seen.
o In congenital syphilis the treponeme crosses
the placenta and infects the fetus.
o It can be demonstrated in preparations from
fresh primary or secondary lesions by
DARKFIELD MICROSCOPY or by FLUORESCENT
ANTIBODY TECHNIQUES.
o Motility is characteristic, consisting of three
movements

A projection in the direction of long

axis

A rotation on its long axis and

Bending or twisting from side to side

o Direct fluorescent antibody testing can be
used for confirming the presence of the
organism
Syphilis screening is advisable among:
o Military personnel
o Professional sex workers
o Men who have sex with men
o Patients with other sexually-transmitted
infections and
o Pregnant women
Syphilis and other genital ulcer disease enhance the risk
of transmission and acquisition of HIV.
o This may due to the fact that early lesions of
syphilis contain mononuclear cells with
enhanced expression of CCR5, the coreceptor
for HIV
CUTANEOUS SYPHILIS (PRIMARY STAGE)
o Chancre is usually the first cutaneous lesion
appearing 18-21 days after infection
o Typical incipient chancre is a small red papule
or a crusted superficial erosion
o In a few days to weeks it becomes round or
oval, indurated, slightly elevated papule with
an eroded BUT NOT ulcerated surface that
exudes serous fluid
o on palpation: it has a cartilage-like
consistency; lesion is invariably PAINLESS-->
this is the uncomplicated or classic
HUNTERIAN CHANCRE
o regional lymph nodes on one or both sides are
usually enlarged, firm, and nontender and do
not suppurate
o Adenopathy begins 1-2 weeks after
appearance of the chancre.
o HUNTERIAN CHANCRE--> leaves NO SCAR
o Chancers occur singly, although they may be
multiple; they vary in diameter from a few
mm to several cm
o In women, genital chancre is less often
observed due to its location within the vagina
or on the cervix
o Extensive edema of the labia or cervix may
also occur
o In men, the chancre is common in the coronal
sulcus or on either side of the frenum.
o A chancre in the prepuce, being hard to bend,
will flip over all at once when the prepuce is
drawn back, a phenomenon called dory flop

Extra genital chancres may be larger than

those on the genitalia.

They affect the lips, tongue, tonsil,

female breast, index finger and,
especially in men who have sex with
men, the Anus. (presenting
symptoms of anal chancre include
anal sore or fissure and irritation or
bleeding on defecation)
o Anal chancre must be RULED OUT in any anal
fissure not at the 6 or 12-o'clock positions
o Atypical chancres are also common.
Simultaneous infection by a spirochete and
another microbial agent may produce atypical
chancre.
o The mixed chancre caused by infection with
Haemophilus ducreyi and T. pallidum will
produce a lesion that runs a course different
from either chancroid or primary syphilis
alone.
o In patient with an acute genital ulceration, a
DARKFIELD EXAMINATION should be
performed.
o Finding of typical T. pallidum in a sore on the
cutaneous surface establishes the diagnosis of
syphilis
o An alternative to darkfield microscopy is the
DIRECT FLUORESCENT ANTIBODY TEST (DFATTP) for the identification of T. pallidum
o Results of serologic test for syphilis are
positive in 50% (non treponemal test) to 90%
(treponemal test) of patients with primary
syphilis.
SYPHILIC CHANCRE
o This must be differentiated from chancroid
o CHANCRE has an:

Incubation period of 3 weeks

Usually a painless erosion not an

ulcer

Has no surrounding inflammatory

zone

They are round or oval

Edge is undermined and the surface

is smooth and at the level of the skin

It has a Dark, velvety red, lacquered

appearance, without an overlying
membrane and is cartilage-hard on
palpation

Lymphadenopathy maybe bilateral

and is nontender and
nonsuppurative
o CHANCROID on the other hand

Has a shorter incubation period of 47 days

The ulcer is acutely inflamed

Extremely painful

Has a surrounding inflammatory

zone

Ulcer edge is undermined and

extends into the dermis

Covered by a membrane and is soft

to the touch

Lymphadenopathy is usually
unilateral, tender and may
suppurate

Chancroid lesions are multiple and

extends into each other
SECONDARY SYPHILIS
o CUTANEOUS LESIONS

Skin manifestations of secondary

syphilis have been called syphilids
and occur in 80% or more of cases of
secondary syphilis

Early eruptios are symmetrical,

more or less generalized, superficial,
non destructive, exanthematic,
transient, and macular

Later they are maculopapular or

papular erupations which are usually
polymorphous and less often scaly,
pustular or pigmented

MANIFESTATIONS are apt to be

distributed over the face, shoulders,
flanks, palms, soles and anla or
genital regions
o MACULAR ERUPTIONS- earliest form of
macular secondary syphilis begins with the
appearance of an exanthematic erythema 6-8
weeks after the devp of chancre
o PAPULAR ERUPTIONS- papular types of
eruption usually arise a little later than the
macular. The fully developed lesions are rawham or coppery shade, round and from 2-5
mm or more in diameter. THey are often
raised, but a deep, firm infiltration is palpable
LATENT SYPHILIS
o After the lesions of secondary syphilis have
involuted, a latent period occurs.
o This may last for a few months or continue for
the remainder of the infected person's life
o EARLY LATENCY: less than 1 year duration
o LATE LATENCY: of >1 year or unknown
duration
LATE SYPHILIS

Infection of greater than 1 year in duration

(CDC), or greater than 2 years in duration
(WHO)

BY:

WHC 2016

Generally occurs in young adults; women>men (2:1)

Begin as dull red macules or indurated plaques that
develop an adherent scale, and evolve with atrophy,
scarring, and pigment changes
Darker skinned: hyper- and de-pigmentation
Lighter skinned: gray or have little pigment alteration
Carpet tacks or langue au chat (cats tongue)
o Hyperkeratosis extends into patulous follicles,
producing carpet tack-like spines on the
undersurface of scales
Mistaken for:
o Actinic keratosis: very small lesions
o Mild seborrheic dermatitis: very superficial
o Noninflammatory alopecia: minimal erythema

Biopsydeep
nodular
and
perifollicular kymphoid infiltrates

LOCALIZED DISCOID LUPUS ERYTHEMATOSUS

Usually localized above the neck

Favored sites: scalp, bridge of nose, malar area, lower lip,
and ears; frequently concha of ear and external canal
Some present with periorbital edema and erythema
On the scalp
o begin as erythematous patches or plaques that
evolve into white, often depressed, hairless
patches
o perifollicular erythema and presence of easily
extractable anagen hairs (sign of active
disease)

helful in monitoring response to

therapy
o scarred areas: completely smooth, or may
demonstrate dilated follicular openings in few
remaining follicles
o itchiness and tenderness are common; rarely
severe
On the lips
o Gray or red and hyperkeratotic
o May be eroded
o Usually surrounded by a narrow, red
inflammatory zone

GENERALIZED DISCOID LUPUS ERYTHEMATOSUS

-

Less common than localized DLE

All degrees of severity are encountered

Thorax, upper extremities, head and neck
On the scalp
o Quite bald with striking patterns of hyper- and
de-pigmentation.
On the face and lower extremities
o Diffuse scarring
LABORATORY ABNORMALITIES
o More common than in localized DLE
sedimentation rate
antinuclear antibodies and ssDNA antibodies
Leukopenia
COURSE: variable
o But 95% of cases confined to skin will remain so
o Purely cutaneous DLE to SLE: UNCOMMON
(but SLE patients frequently have discoid
lesions)

Systemic involvement early

ANAs,
dsDNA
antibodies, C1q antibodies

Leukopenia

Hematuria, proteinuria

Fever and arthralgia common

CHILDHOOD DISCOID LUPUS ERYTHEMATOSUS

-

Lack of female predominance

Low frequency of photosensitivity
Higher progression to SLE
Clinical presentation and course are similar to adults

HISTOLOGY
-

Epidermis usually thin with effacement of the rete ridge

pattern
CHARACTERISTIC compact hyperkeratosis without
parakeratosis
Prominent follicular plugging
Hydropic degeneration of basal layer of the epidermis
and follicular epithelium results in pigmentary
incontinence
Patchy perivascular and periadnexal lymphoid
inflammatory infiltrate occurs in superficial and deep
dermis
o Characteristically surround vessels, follicles,
and eccrine coil
Increased mucin: often present; deposition of a blue to
amphophilic substance between collagen bundles
Prominent thickening of basement zones
STAGES OF THE LESION
o ACUTE
Patchy lymphoid inflammation and
vacuolar interface dermatitis
o CHRONIC
Hyperkeratosis, basement membrane
thickening, and dermal mucin
o CHRONIC, INACTIVE
Atrophy with postinflammatory
pigmentation and scarring throughout
the dermis
Inflammatory infiltrate is sparse to
absent

Pilosebaceous units, except orphaned

arrector muscles, are destroyed
Dermis appears fibrotic, but an elastic
tissue stain can still distinguish the
diffuse dermal scar of lupus from the
focal wedge shaped superficial scars of
lichen planopilaris or folliculitis decalvans
DIRECT IMMUNOFLUORESCENCE (DIF) is positive (active
lesions for several months)
o EARLY LESIONS: negative or nonspecific
o ESTABLISHED LESIONS: strng continuous
granular deposition of immunoglobulin and
complement located at epidermal junction
o UNINVOLVED SKIN: negative
BOPSY: from LESIONAL skin of a well ESTABLISHED
inflammatory lesion
TRANSPORTATION OF SPECIMEN
o normal saline > Michels transport medium
(<24hrs)

DIFFERENTIAL DIAGNOSES
-

Immunoglobulin deposits
o Distinguish DLE from latter conditions
LYMPHOCYTIC INFILTRATION/Jessners
o CD4+ lymphocytes (LE) vs. CD8+
lymphocytes (Jessners)
SEBBORHEIC DERMATITIS
o Does not show atrophy, alopecia, dilated
follicles
o Has greasy, yellowish scale w/o follicular
plugs
CHRONIC CUTANEOUS LE
o Lichenoid dermatitis histologically
o Continuous granular immunoglobulin +
cytoid bodies
ROSACEA
o (x) atrophy
o Pustules are found
LUPUS VULGARIS
o Apple jelly nodules (granulomas) with
diascopy
SARCOIDOSIS AND TERTIARY SYPHILIS
o Biopsy and serologic testing
POLYMORPHOUS LIGHT ERUPTION
o absence of scarring
o presence of intensely edematous plaques
and papules
o DIF is negative and nonspecific
DRUG ERUPTIONS
ACTINIC KERATOSIS
BOWENS DISEASE
LICHEN PLANUS
By:

Etiology:

Malassezia furfur
o The yeast phase Pityrosporum orbiculare
o The genus includes 12 lipid-dependent species
and a single non lipid-dependent species
(Malassezia pachydermatis)

colonizes the skin and mucosal sites

of healthy cats and dogs
o part of the normal follicular flora
o produce skin lesions when they grow in the
hyphal phase

Clinical Presentation:

Microscopically short, thick fungal hyphae + many

variously sized spores

Confirmed by KOH: Spaghetti and meatballs

combination of strands of mycelium and numerous
spores

Identification by culture requires lipid enrichment of the

media, and is rarely done to establish the diagnosis

Woods Light yellow-green pigment changes

Biopsy :
o thick basket-weave stratum corneum with
hyphae and spores.
o atrophic variant epidermal colonization with
hyphae and spores is accompanied by
effacement of the rete ridges, subepidermal
fibroplasia, pigment incontinence, and
elastolysis
Differential diagnosis:

hypo- or hyperpigmented coalescing scaly macules on

the trunk and upper arms
Pink, atrophic, and trichrome variants exist
eruption is more common during the summer months
favors oily areas of skin

Sites of predilection:

sternal region and the sides of the chest, abdomen, back,

pubis, neck, and intertriginous areas.
The face and scalp may be affected.
o Facial lesions - in infants and
immunocompromised patients.
scalp, palms, and soles.
Penile lesions may occur as well, and the organism is
commonly isolated from patients with balanoposthitis.

Associated symptoms:

Mild itching aninflammation about the patches may be

present.
In some instances many follicular papules are present.
In hypopigmented tinea versicolor,
o abnormally small and poorly melanized
melanosomes are produced, and are not
transferred to keratinocytes properly.
o most conspicuous (very noticeable) in
dark-skinned people
o hypopigmentation may persist for weeks or
months after the fungal disease is cured

In the atrophic variant, the lesions may suggest parapsoriasis,

mycosis fungoides, anetoderma, lupus erythematosus, or steroid
atrophy.
Treatment:
Topical:

Diagnosis
The diagnosis in all forms of tinea versicolor is generally easily
established by KOH examination.

based on clinical presentation!

Easily demonstrated in scrapings of profuse scales that
cover the lesions
Tape stripping

seborrheic dermatitis
o seborrheic dermatitis patches have an
erythematous yellowish tint and the scales are
soft and greasy
o tinea versicolor scales are furfuraceous
(fluffy)
pityriasis rosea
pityriasis rubra pilaris
pityriasis alba
Hansens disease
vitiligo
syphilis
o Macular syphilid consists of faint pink lesions,
less than 1 cm in diameter, irregularly round or
oval, which are distributed principally on the
nape, sides of the trunk, and flexor aspects of
the extremities.
o They are slightly indurated with a peripheral
scale, and may be copper- colored.
o There may be general adenopathy.
o Serologic tests positive in this phase of
syphilis, but prozone reactions may occur, and
the serum may have to be diluted.

Oral:

selenium sulfide, zinc pyrithione, imidazoles, triazoles,

ciclopirox olamine, sulfur preparations, salicylic acid
prep, propylene glycol, benzoyl peroxide, terbinafine
terbinafine has been shown to be ineffective via the oral
route
Selenium sulfide lotion
Selenium sulfide shampoo
Zinc pyrithione soap


Ketoconazole 400mg, monthly intervals

Itraconazole 200mg od for 7 days

Ff by prophylactic 200mg bid once a month

Fluconazole 400mg once

**5-aminolevulinic acid photodynamic therapy has been reported
as effective.
Prognosis:

Patients should be informed that the hypo- and

hyperpigmentation will take time to resolve and is not a
sign of treatment failure.
Relapse is likely if prophylactic doses are not given
occasionally, but many options are available for
prophylactic treatment.
After initial therapy, patients may prefer weekly washing
with a topical zinc pyrithione bar, single overnight
applications of selenium sulfide, ketoconazole, econazole
or bifonazole shampoo every 3060 days, or monthly
oral therapy.

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TITLE: Postino Std (Size 11)

BODY: Calibri (Size 9)