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 | 
  
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‡ Fibromatous hyperplasia of the palmar

aponeurosis, nodular thickening of fascia with
associated flexion contractures of 1 or more
digits.
‡ Familial,alcoholism, cirrhosis, epilepsy and
diabetes mellitus,TB.
‡ Polyfibromatosis syndrome
‡ Periarthritis of shoulder,chronic lung
disease,gout,trauma and ulnar nerve damage
  
| 

 
|  

‡ Shins, forearms, thighs, bony prominences
‡ Initial lesion oval dull red papule evolves
slowly producing superficial scale, leaving
an atrophic brownish scar.

 
|



‡ The cutaneous lesion is a plantar ulcer,
often accompanied by soft tissue and
bone infections which can require
amputation.
‡ TRIGGERS include poorly fitting shoes,
poor foot care, or overlooked foreign
bodies, coupled with a structural foot
deformity.
 
 
 
|




 
|

‡ The most important is optimal control of

the diabetes mellitus
‡ Relieving pressure points and
‡ Avoiding or reducing callus formation
Association- 0.3 % of
diabetic patients.
Relatively
asymptomatic lesions,
F:M=3:1
Characteristically
found on the anterior
and lateral
surfaces of the lower
legs.
- Bullae appear spontaneously, usually on
the extremities, especially the feet.
- Heal in several weeks without significant scarring,
although they may recur.
  
|| 
 


‡  !" #$$ "%

&'"#"%( #&)&%
‡ Most apparent at acral sites, and may be
associated with limited joint mobility (also known
as cheirarthropathy) due to the abnormal
collagen.
‡ The proposed mechanism is an increased cross-
linking of collagen, known as non-enzymatic
glycosylation (NEG), which produces stiffer
collagen.
 |
   |

‡ Cutaneous marker, most commonly of insulin

resistance and less frequently of a malignancy.
‡ Hyperpigmented, hyperkeratotic, verrucous plaques that
bestow a velvety texture on involved skin.
‡ Typically symmetric in distribution
‡ Involves intertriginous areas, including the neck, axillae,
groin, antecubital and popliteal fossae, and umbilicus
‡ Occasionally involves the oral, esophageal, pharyngeal,
laryngeal, conjunctival, and anogenital mucosae
    
|*





|  
 + acromegaly, cushing¶s, hypo and

hyperthyroidism, Polycystic ovarian disease (Stein-Leventhal
syndrome)
 |,

‡ Adenocarcinoma: gastric
‡ Endocrine: phaeochromocytoma,testicular, thyroid,carcinoid
‡ Melanoma, Sarcoma
‡ Lung
‡ Lymphomas
‡ Other: cervical, urinary bladder
 ,  |+Testosterone, nicotinic acid, diethylstilbestrol, oral
contraceptives, triazinate, glucocorticoids, and with topical application
of fusidic acid.

  
 |
‡ Familial
‡ Nonfamilial
  
|
 

‡ An exaggeration of the skin markings over

the knuckles and on the dorsal aspect of
the terminal phalanges.
‡ They are more cobblestoned than knuckle
pads.
|
- 


| 
 |
Areas of induration
frequently after
infection, spontaneously
clear in months or
years.
 |
 

| 

.
 


‡ Infections
‡ Peripheral vascular and small-vessel disease
‡ Neuropathy
‡ Pruritus
‡ Necrobiosis lipoidica
‡ Granuloma annulare variants
‡ Perforating disorders
‡ Xanthomas
‡ Scleredema
‡ Drug-related
‡ Features of associated autoimmune disease
  
 

The combination of acropachy with

exophthalmos and pretibial myxedema.
 
 /

‡ Localized oedematous and thickened

pretibial plaques
‡ 1-10% hyperthyroidism
‡ Erythema and slight edema are the early
signs, with subsequent peau d'orange
appearance as the degree of infiltration
increases.

 | |

‡ Clubbing of fingers and toes in Grave¶s

disease associated with soft tissue
swelling of hands and feet with periosteal
new bone formation.
‡ A number of other causes, including
bronchial neoplasia.
 |
 







 
-

/ | 
0 
‡ Soft, smooth, velvety, warm, Palmar erythema, facial
flushing
‡ Pruritus
‡ Hyperpigmentation
‡ Pretibial myxedema
‡ May also be features of associated autoimmune
diseases, e.g. vitiligo, urticaria
.
+ Increased
 + Fast growth, Soft nails, koilonychia, distal
onycholysis,Thyroid acropachy
 + Fine thin hair, diffuse alopecia,Loss of pubic, axillary,
and facial hair,Loss of lateral eyebrows
+Large tongue, gingival swelling, oral candidosis.


 
 |
 







 
- 
  
0 
‡ Pale, cold, scaly, wrinkled
‡ Puffy edema of hands, face, and eyelids
‡ Purpura and ecchymoses
‡ Pruritus (due to xerosis or asteatotic eczema)
‡ Ivory-yellow color (in part due to carotenemia)
‡ Xanthomatosis (secondary to hyperlipidemia)
.
+ Decreased
 +Slow nail growth, brittle and striated nails
 + Coarse hair, diffuse alopecia

 
   




 

‡ PALPATE PURPURA
‡ CHECK TEMPERATURE and assess if
patient is unwell
‡ Complete blood examination (CBC)
platelets
‡ SKIN biopsy for HP&direct IF
 1
    
2 
2 | 
  

-

|

A. Actinic (senile) purpura
A. Hemophilia
B. Glucocorticoid therapy,
B. Anticoagulant use topical or systemic
C. Disseminated C. Vitamin C deficiency
intravascular coagulation (scurvy)
D. Vitamin K deficiency
E. Hepatic insufficiency with D. Systemic amyloidosis
poor procoagulant (light chain±related, some
synthesis familial types)

E. Ehlers-Danlos
syndrome (some types)

F. Pseudoxanthoma
elasticum
 


| 

‡ pANCA
‡ Streptococcal serology or throat swab
(especially in children)
‡ Erythrocyte sedimentation rate (ESR), urea and
electrolytes (U&E), liver function tests (LFTs)
OTHER INVESTIGATIONS
‡ Findings on history including hepatitis serology,
rheumatoid factor, cryoglobulins,
immunoglobulins, antinuclear factor (ANF), total
complement levels and serum protein
electrophoresis.
 
/




-| 

Further investigations should be directed toward
investigating relevant systems:
‡ RENAL ± urinalysis looking for proteinuria and
haematuria
‡ GASTROINTESTINAL ± abdominal pain,
gastrointestinal bleeding
‡ MUSCULOSKELETAL ± nonerosive polyarthritis
‡ PULMONARY ± pleural effusion
‡ CARDIAC ± pericardial effusion.
 

‡ General principles of management for

vasculitis:
Rest, elevation of the legs and
compression hosiery.
‡ Systemic therapy indicated if the vasculitis
is extensive, painful, ulcerating, or if there
is renal involvement.
‡ The cause of the vasculitis should be
managed as appropriate.