PAC 03 DERMATOLOGY Vesicular, Bullae, Acneiform Disease

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PAC 03 DERMATOLOGYVesicular, Bullae, Acneiform
Disease

• By
• Stacey Singer-Leshinsky R-PAC

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Terms

• Vesicle
• Bullae Fluid filled blister greater than 100cm
  in diameter
• Acneiform

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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

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Vesicular BullaeBullous Pemphigoid

• Lesions usually appear on extremities first then
  trunk. Flexor surfaces of extremities.
• Exacerbations/remissions.

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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.

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Bullous PemphigoidDrug Induced

• Diuretics, analgetics, antibiotics
• Drug acts as a trigger in patients with genetic
  susceptibility by modifying immune response

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Bullous PhemphigoidDiagnosis

• Clinical confirmed by histopathology/immunopatholo
  gy
• Immunofluorescence studies reveal IgG and/or C3
  at dermal-epidermal junction
• IgE in serum
• Light microscopy of lesions reveals eosinophils,
  neutrophils, lymphocytes

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Bullous PhemphigoidDifferentials/Complications

• Differentials include erythema multiforme, drug
  eruptions, dermatitis herpetiformis
• Complications

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Bullous PemphigoidTreatment

• Systemic or Topical corticosteroids.
• Immunosuppressive medications
• Patients often go into a permanent remission

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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

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Pemphigus VulgarisClinical manifestations

• Pain
• Flaccid blister filled with clear serous fluid
• Blisters fragile.
• Blisters rupture
• Mucosal lesions can precede cutaneous lesions.

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Pemphigus VulgarisDiagnosis

• Nikolskys 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

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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

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Pemphigus VulgarisTreatment

• Treat dehydration
• Glucocorticoids-
• Immunosuppressive therapy- Azathioprine,
  Methotrexate, cyclophosphamide

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Pilosebaceous Unit

• Sebaceous gland empties into hair follicle.
• Pilosebaceous unit opens to surface.
• Sebaceous gland produces sebum.

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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.

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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.

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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

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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

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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

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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.

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Rosacea

• Peaks in 30-40s. Associated with Parkinsons,
  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.

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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 MgtF
• Blepharophyma
• Metrophyma

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RosaceaTypes

• Vascular Rosacea Flushing and persistent central
  facial erythema with or without telangiectasia.
• Papulopustular rosacea central facial erythema
  with transient papules and pustules.

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RosaceaTypes

• Sebaceous hyperplasia thickening skin, irregular
  surface nodularities and enlargement.
• Ocular rosacea Foreign body sensation in eyes.
  Photosensitivity, periorbital edema,
  telangiectasia of sclera.

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RosaceaDiagnosis/Differentials

• Diagnosis Clinical diagnosis, histopathological
  features
• Differential diagnosis
• Acne vulgaris-
• Perioral dermatitis
• Seborrheic dermatitis
• Systemic Lupus Erythematosus

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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

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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.

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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.

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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

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Hidradenitis SuppurativaDiagnosis/Differentials

• Diagnosis
• Bacterial cultures for antibiotic therapy
• Differentials Cellulitis, pilonidal cysts,
  bacterial folliculitis
• Complications
• Squamous cell carcinoma

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Hidradenitis SuppurativaManagement

• Might need incision and drainage if large and
  painful.
• Antibiotics such as tetracycline, cephalosporin,
  clindamycin, ciprofloxacin
• Isotretinoin
• Corticosteroids
• Reduce friction and moisture.

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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.

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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

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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

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Hypersensitivity Vasculitis Diagnosis

• Diagnosis confirmed by skin biopsy (vascular and
  perivascular infiltration of broken up
  leukocytes)
• Look for evidence of systemic disease

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Hypersensitivity VasculitisComplications/Differe
ntials

• Complications
• Systemic vascular involvement
• Necrosis
• Irreversible damage to kidneys
• Differential diagnosis
• Thrombocytopenia purpura
• Disseminated intravascular coagulation
• Rocky Mountain Spotted Fever
• Steven Johnson Syndrome

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Hypersensitivity VasculitisManagement

• Antibiotics
• If skin involvement use colchicine or Dapsone
• If visceral involvement then use steroids such as
  Prednisone combined with Cytotoxic
  immunosuppressives

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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.

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Folliculitis

• Papule or pustule on erythematous base
• Asymptomatic, mild discomfort or pruritic Favors
  areas with terminal hair
• Eye involvement
• Healing can lead to keloids

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FolliculitisDiagnosis/Differentials

• Diagnosis
• History and physical exam
• Cultures, gram stains, KOH
• Differentials
• Insect bites
• Scabies
• Rosacea
• Tinea

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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

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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

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XerosisClinical Manifestations

• Pruritus
• Involves back, abdomen, extremities
• Dry rough, scaly skin
• Cracking, fissuring

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XerosisDiagnosis

• Diagnosis histological findings
• Differential Diagnosis Eczema, contact
  dermatitis, scabies

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XerosisManagement

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

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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

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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

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Example 3

• Follicular comedones with or without inflammatory
  papules, pustules and nodules
• What is the cause of this condition?
• What is the management?

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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

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Example 5

• Chronic infection of apocrine sweat glands
• Inflammatory red hard raised nodules in axilla,
  groin, perineum
• What is this?
• What is the management?

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Example 6

• What is this?
• What bacteria are involved with this?
• What is the treatment of this?