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Dermatology Lecture 5-21-09

by Ma. Socorro W. Toledo, MD,FPDS

To the third year medical student:


• After the 2nd year PD lecture, this session aims to
bridge that discussion of skin lesions with
diagnosis of specific diseases.
• Review the PD concepts.
• Familiarize yourself with the diseases mentioned
in this handout.
• We will view and discuss actual clinical cases.
• We start promptly at 8 a.m.
Primary Skin Lesions and
Differential Diagnoses
(Ma. Socorro W. Toledo, MD, FPDS)

• Outline of Discussion According to Skin Lesion:


• I. Macules,Patches/ Papules,Plaques
• II. Wheals
• III. Nodules
• IV. Ulcers
• V. Blisters = Vesicles/ Bullae
I. Macules/Patches;
Papules/ Plaques
• A. SLE
• B. Exfoliative Dermatitis
• C. Hyperpigmented Lesions
• D. Hypopigmented Lesions
• E. Alopecia
• F. Purpura
• G. Leprosy
• H. Cutaneous Lymphoma (MF)
I. Macules/patches or
papules/plaques
A. Systemic Lupus
Erythematosus (SLE)
• 4/11 criteria: Malar rash, discoid rash,
photosensitivity, oral ulcers
• 11 criteria involve cutaneous(4),
musculoskeletal, hematologic, renal,
pulmonary, cardiac, immunologic,
nervous system abnormalities
Gilliam Classification of
LE skin lesions
1. LE-specific skin disease (cutaneous LE):
LE-specific on histopathology
• a. acute CLE– localized (malar or butterfly rash),
generalized erythema
• b. subacute CLE– annular, papulosquamous
• c. chronic CLE
i..classic discoid
ii. hypertrophic/verrucous
iii. lupus profundus or
lupus panniculitis
iv. Lupus tumidus (urticarial)
v. Mucosal dle – oral, conjunctival
Gilliam Classification of LE skin
lesions
2. LE-nonspecific skin disease:
Not LE-specific on histology
• Vasculitis
• Alopecia
• Bullae
• Leg ulcers
• Urticaria
• Nodules
• Acanthosis nigricans
Pathogenesis
• Triggers:
UV radiation, infection, drug and chemical
exposure, cigarette smoking

• Example of a mechanism:
UV light induces expression of “neoantigens” (i.e
intracellular antigens like Ro/SS-A,
La/ SS-B and calreticulin displaced to
keratinocyte cell surface)  target of a
dysregulated immune attack.
B. Exfoliative dermatitis
(Erythroderma)
• Characterized by erythema and extensive scaling of skin (70% or
more)
• Scaling may be thick or thin, of large sheets or small flakes of
skin, exudative or thickly crusted
• Constitutional signs and symptoms are present
• Chilliness  (+)inability of cutaneous blood vessels to constrict
• Hospitalization : For laboratory work-ups, proper therapeutics and
nutrition, patient convenience
• Varied etiologic factors: Inflammatory dses, Infectious dses,
Malignancies
• Skin biopsy by a dermatologist is IMPERATIVE
• Prognosis: Very good to grave depending on etiology
• Therapy : Months or years
C. Hyperpigmented Lesions
a. Post-inflammatory hyperpigmentation
b. Acanthosis nigricans
c. Amyloidosis –cutaneous/ systemic
d. Reaction to drugs (eg minocycline) heavy
metals, exogenous agents
e. Congenital d/o: Mongolian spot
f. Idiopathic: Ashy dermatosis
D. Hypopigmented Lesions
• VITILIGO
• - Loss of melanocytes
• - Etiology(?): autoimmunity,
autocytotoxicity, neurohumoral factors
• – most often associated with diseases of
the thyroid gland (hypo/hyperthyroidism)
• - localized (focal, segmental, acrofacial) or
generalized
E. ALOPECIA
-Definition: Loss of hair
- Most common area: Scalp
- SLE – scarring or nonscarring alopecia
- Syphilis – “moth-eaten” appearance
- Other causes: anemia, thyroid disorders,
infections
- Idiopathic
F. PURPURA
- Extravasation of blood
- Nonblanching (as opposed to
telangiectasia)
Example:
Hypersensitivity Vasculitis
Etiologies: Infections, Drug Reactions
II. Wheals = Urticaria

A. Primary or idiopathic
B. Secondary Varied etiology:
1. contact urticaria
2. food
3. drugs
4. physical urticaria
5. infectious etiology - UTI, PTB, Hepatitis, HIV
6. systemic disease - SLE, hyperthyroidism
7. genetic origin - hereditary angioedema

8. malignancy
Physical urticaria

a. Pressure urticaria - e.g.dermographism


b. Solar urticaria
c. Heat urticaria
d. Cold urticaria
e. Exercise-induced urticaria
f. Vibration-induced urticaria
III. Nodules
a. Hereditary/ metabolic disorders
- Neurofibroma
- Xanthoma
- Myxedema (in hyperthyroidism)
b. Infection: Leprosy
c. Malignancy : leukemia/lymphoma cutis
d. Autoimmune disorders: SLE
e. Congenital malformations: hemangioma
f. Inflammatory d/o: Panniculitis
IV. Ulcers
a. Infection
b. Malignancy

c. Disorders of the circulatory system


1. Stasis ulcers 2* to venous insufficiency
2. Ulcers 2* to thromboembolism/ infarction

d. Metabolic diseases –
e.g.Necrobiosis lipoidica diabeticorum
e. Idiopathic – e.g. pyoderma gangrenosum
V. Blistering disorders
a. Burns
b. Infection – viral, bacterial, fungal
c. Contact dermatitis

d. Autoimmune diseases –
Pemphigus, Bullous pemphigoid,
Epidermolysis bullosa, SLE

e. Endocrine diseases – diabetic bulla


f. Nutritional disorders - zinc deficiency