Lecture 2 Sept 15th

Pg 13: Section II: Bullous, Vesicular diseases • You want to identify whether lesions are primary or secondary when looking at skin. If raised/blistered: primary lesion. If fluid is gone: secondary lesion. • These conditions are worse if they occur in the mouth: can lead to death. II-1 …destruction of the desmosomes (cellular cement) of stratified squamous epithelim… Pg. 14: Bullae are rarely seen because they are so fragile. Pyuretic. DDX: Apthae: • Only mouth is involved • Reappearance Erythema multiforme • Lesions vary from plaques, blisters to target lesions • Pus-filled, but not always. • Symmetric: predilection for dorsum of hands, palms and soles of feet Treatment: Systemic corticosteroid (prednisone): can lead to Stevens-Johnsons syndrome Pg 15: Bullous pemphigoid • Attachment of basal cells to basement membrane is selectively damaged. Characterized by: …junction of dermis and epidermis… DDX of Bullous Pemphigoid 1. Pemphigus vulgaris • More tensile strength • Not itchy, pruritic • Rarely intact bullae Pg 16: II-3 Dermatitis herpetiformis … three types of lesions: vesicles, papules, urticarial wheals. Epidemiology: More common in males. Other:

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Pruritis, intense episodic burning or stinging of skin A gluten enteropathy usually occurs (a GI pathology) Local symptoms __________ appearance of skin lesions…

Dx: • Local symptoms precede appearance of eruption. Itches first before lesions present. DDX: Scabies: • Wrists, webs of fingers and feet • Family members have symptoms too Excoriated eczema: Flexural surfaces Insect bites: • May be a puncture • They come and go • Distribution? Not just on extensor surfaces. Pg 17: II-4: Erythema multiforme: REFER! Setenvs-Johnsons syndrome: Can erode oral cavity down to gums. Will heal. Distribution: Symmetric (bilateral) with predilection for dorsum of hands, top and soles of feet. Lesions: Central clearing: clearer in the centre than the edges. Other: Positive Nikolsky’s sign (like pemphigus vulgaris) Pg 18: Mild form: Eruptions usually confined to extensor surfaces. Severe forms: Most often occurs as a drug reaction: always with mucous membrane involvement… SECTION III Urticaria • …pruritic, transient (comes and goes, moves from place to place) as a result…

Angioedema: Involvement of deeper tissues with predilection for mucous membranes May see dermatographia. Pg 19: DDX of urticaria 1. Erythema multiforme: • target lesions •

lesions last longer than 24 hours

2.  Insect bites: • also lasts more than 24 hours Naturopathic approach: Reduce histamines Take vitamin C (strengthens mast cells) IV­1a  Atopic Dermatitis:  (atopy = out of place) • Pruritic skin disorder involving cutaneous hypersensitivity “The itch that rashes” constant scratching leads to cycle of itch ­­>scratch­­>itch which  leads to lichenification (rash) of skin (skin becomes very rough) In chronic eczema, see thickened skin and pigmentation. Common to occur with allegies and asthma. Pg. 20: Distribution: (esp. in infantile dermatitis) Predilection for the flexural surfaces, … Primary lesions (acute phase): Fluid is being retained, erosions look very wet. Secondary lesions: erythema, scale, excoriation etc, from scratching. Other: Periorbital pigmentation: will see this in people of colour as well. Hypopigmentation also possible. Can be confused with tenia versicolour, vitiligo. DDX: Seborrheic dermatitis:

Not usually at margins of hair. Psoriasis: Much thicker plaques, discrete area. Thick, silvery scales Usually extensor involvement, not flexure. Scaling might be covered up with moisturizer use. Pg 21: Allergic/contact dermatitis: secondary to poison ivy. Did they come in contact with anything? What did they touch? Were they camping? Did they change soap? When an allergen or related compound causes a delayed hypersensitivity… Appears as an acute vesicular dermatitis DDX of allergic contact dermatitis Nummular eczema: circular eczema Discrete, coin-shaped erythematous scaling plaques… Scabies: • Usually begins in webs of fingers and wrists and spreads to axillae… Pg 22: IV 1c:  Nummular Eczema = Discoid Eczema •  chronic, pruritic inflammatory dermatitis occurring in the form of coin­shaped  plaques •  worse in fall and winter: dryness, hotter showers Physical Examination: Primary: •  closely grouped, small vesicles and papules that coalesce into plaques • often 4­5 cm in diameter, with an erythematous base and distinct borders Secondary:   • excoriation (scratch marks) and lichenifcation have to know how it presented  before they started scratching. Distribution: •  regional clusters of lesions (ex legs) or generalized  •  predilection; lower legs and trunk

IV 2  Lichen Simplex Chronicus •  localized form of lichenification usually occurring in circumscribed plaques •  result of chronic scratching Physical Examination: •  scaling is limited •  excoriations are often present •  palpably thickened skin •  skin markings are accentuated­lines in the skin

DDX of Lichen Simplex Chronicus 1.  Psoriasis •  look for silvery scales that are thick and rough •  nail involvement possibly 2.  Contact dermatitis •   resolves within 21 days •  associated with specific substance; history of exposure Pg 23: IV 3  Lichen Planus commonly lower leg, writsts.  Looks like textbook picture. •  characterized by polygonal violaceous papules and plaques •  unknown cause Physical Examination: •  papules and plaques •  post­inflammatory hyperpigmentation •  Wickham’s striae: white lacelike patterns on surface of papules and plaques.  Might be easier to see in mouth.  Feels very HARD upon palpation. Occurs in  genitals too, and won’t let tissue expand… Occurs on top of lesions. Distribution: • mouth, genitals, volar wrists (looks like a bracelet), ankles • may be generalized, symmetrical • nails may be involved ­­> varies from minor dystrophy to total nail loss

Diagnosis: •  based on lesions appearance in characteristic location •  with buccal involvement look for Wickham’s striae in individual lesions to  confirm diagnosis •  deep shave of punch biopsy may be necessary DDX of Lichen Planus 1.  Psoriasis •  scales are usually thicker and silvery:  Positve Auspitz take scale off psoriasis  lesion, get pinpoint bleeding.  sign •  no buccal involvement •  distribution: rarely symmetrical 2.  Lichenoid drug eruptions • historical correlation: most commonly: gold, antimalarials, thiazide, methyldopa,  penicillamine

IV 4   Seborrheic (“sebum”) Dermatitis: • • • •

  Common, chronic, erythematous scaling eruption of unknown cause that affects  all age groups but usually affects adults 20 years and older  occurs in regions where the sebaceous glands are most active. ie face and scalp  and body folds  scalp involvement is commonly known as dandruff in adults and cradle cap in  infants homeopathic: calc carb, sulfur.  Pityrosporum ovale:  a normal yeast flora is thought to play a role

Skin lesions: • yellowish red often greasy scaling macules and papules varying from  5­20 mm • sticky crusts are common when scalp, external ear, axillae and groin are involved • shape:  nummular, annular on trunk •  arrangement:  scattered, discrete on face and trunk; diffuse on scalp  • flakes can be adherent to scalp.  Scaling around nose is common. Pg. 24 DDX of Seborrheic dermatitis

a.  Psoriasis on the scalp: almost indistinguishable.  Could use Auspitz sign, but not much  bleeding on the scalp. • Thick, silvery scale •   usually no facial involvement •   scalp: can be indistinguishable b.  Candidiasis: • beefy red plaques are present along with satellite lesions that are KOH positive c.  Acne rosacea: • flushing •

talangectasia (sp?) ­> vasodilation

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  can exist simultaneously

d.  Butterfly rash of SLE (Systemic Lupus Erythematosus *  erythema *  no scale IV 5  Psoriasis • • • • • •

 means an itching condition Very uncomfortable  chronic, hyperproliferative inflammatory disorder of unknown cause  result of rapid cell turnover in epidermis.  Not correlated with higher cancer rate.  Rate of mitosis is 1000 times higher.  normally epidermal cells live about one month, in psoriasis its life is shortened to  about 3 days  family history common  initially appears in people under 20 years of age but can occur at any age

Physical Examination: Distribution:   •  can be single lesion(s) localized to one area ie penis, nails or regional ie scalp.   •  unilateral or bilateral  • often spares exposed areas • favours; elbows, knees, intertriginous areas and scalp

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 nail involvement: look for pitting of nails, oil spot (yellow discolouration on nail  bed) and for distal separation of the nail plate from the bed (onycholysis) ­ scale  forms beneath the nail plate.  Can move nail in nail bed. Sunlight: good results with psoriasis.  Increases Vitamin D.  Mechanism for  improving psoriasis not well understood. Healing properties of salt baths…