Skin disorders.F Medical

Pruritic, exudative, or lichenified eruption on the face, neck, upper trunk, wrists, hands, antecubital and popliteal folds • Personal or family history of allergies or asthma with a tendency to recur • Onset in childhood in most patients; onset after age 30 years is very uncommon

Also known as eczema. • Looks different at different ages and in people of different races. • Diagnostic criteria include pruritus, onset in childhood, chronicity, and typical morphology and distribution (flexural lichenification; hand, nipple, and eyelid eczema in adults). • Also helpful diagnostically are a personal or family history of atopic disease such as asthma, atopic dermatitis or allergic rhinitis, xerosis-ichthyosis, facial pallor with intraorbital darkening, elevated serum IgE, and repeated skin infections.

Itching may be severe and prolonged. • Rough, red plaques, usually without the thick scale and discrete demarcation of psoriasis, affect the face, neck, and upper trunk. • Flexural surfaces of elbows and knees are often involved. • In chronic cases, the skin is dry, leathery, and lichenified. • In black patients with severe disease, pigmentation may be lost in lichenified areas. • During acute flares, widespread redness with weeping, either diffusely or in discrete plaques, occurs.

Seborrheic dermatitis • Impetigo • Secondary staphylococcal infections • Psoriasis • Lichen simplex chronicus (circumscribed neurodermatitis)

Eosinophilia and increased serum IgE levels may be present.

Medications • On the body (excluding genitalia, axillary or crural folds), begin with triamcinolone 0.1% ointment or a stronger corticosteroid, then taper to hydrocortisone 1% ointment or another slightly stronger mild corticosteroid (alclometasone 0.05% or desonide 0.05% ointment). Apply sparingly to affected areas once or twice daily. Taper off corticosteroids and substitute emollients as the dermatitis clears to avoid the side effects of corticosteroids and to avoid rebound. • Tacrolimus or pimecrolimus is also effective as first-line steroid-sparing agent. • Systemic and adjuvant therapies include corticosteroids such as oral prednisone (which should be tapered to nil within 4 weeks), antihistamines for pruritus, antistaphylococcal antibiotics for superinfections (which should only be used if indicated by bacterial culture), and phototherapy. • Oral cyclosporine, mycophenolate mofetil, methotrexate, interferon gamma, dupilumab, or azathioprine may be used for the most severe and recalcitrant cases. • Bedtime doses of hydroxyzine, diphenhydramine, or doxepin may be helpful via their sedative properties in reducing perceived pruritus. • Acute weeping lesions: use soothing or astringent soaks and dressings (with saline, aluminum subacetate, colloidal oatmeal) as well as high-potency topical corticosteroids. (Staphylococcal or herpetic superinfection should be formally excluded.) • Subacute or scaly lesions (lesions are dry but still red and pruritic): use mid- to high-potency corticosteroid ointments (or creams), sparing the face and body folds, with a taper. • Chronic, dry lichenified lesions (thickened and usually well demarcated): require high- to ultrahigh-potency corticosteroid ointments; occlusion may enhance the initial response. • Maintenance treatment with moisturizers or topical anti-inflammatory agents can be used on weekends only or three times weekly to prevent flares.

Erythema and edema, with pruritus, often followed by vesicles and bullae in an area of contact with a suspected agent • A history of previous reaction to suspected contactant • A positive result for a patch test with the agent • May develop secondary infection

An acute or chronic dermatitis that results from direct skin contact with chemicals or allergens. • Irritant contact dermatitis is red and scaly, but not vesicular, and is usually caused by irritants such as soaps, detergents, or organic solvents. • Allergic contact dermatitis occurs commonly from poison ivy, oak, or sumac; topical medications; hair-care products; preservatives; jewelry (nickel); rubber (latex); essential oils; propolis (from bees); vitamin E; adhesive tape; occupational exposure. • Weeping and crusting lesions and vesicles are typically caused by allergic, rather than irritant, dermatitis.

The acute phase is characterized by tiny vesicles and weepy and crusted lesions. • Resolving or chronic contact dermatitis presents with scaling, erythema, and possibly thickened skin; itching, burning, and stinging may be severe. • The lesions, distributed on exposed parts or in bizarre asymmetric patterns, consist of erythematous macules, papules, and vesicles. • The affected area is often hot and swollen, with exudation and crusting, simulating—and at times complicated by—infection. • The pattern of the eruption may be diagnostic (eg, typical linear streaked vesicles on the extremities in poison oak or ivy dermatitis). • The location of involvement often suggests the offending agent.

• Impetigo. • Cellulitis. • Scabies. • Dermatophytid reaction (allergy or sensitivity to fungi). • Atopic dermatitis. • Pompholyx. • Asymmetric distribution, blotchy erythema around the face, linear lesions, and a history of exposure help distinguish contact dermatitis from other skin lesions. • The most commonly confused diagnosis is impetigo, in which case Gram stain and culture rule out impetigo or secondary infection (impetiginization).

Laboratory Tests • Gram stain and culture rule out impetigo or secondary infection (impetiginization). • After the episode of allergic contact dermatitis has cleared, patch testing may be useful if the triggering allergen is not known. Diagnostic Procedures • If itching is generalized, then consider scraping for scabies.

Medications • Acute weeping dermatitis is usually treated with wet dressings and high-potency topical corticosteroid (fluocinonide, clobetasol, or halobetasol gel or cream), tapering or switching to midpotency corticosteroid (triamcinolone cream). • Oral corticosteroids for a 12- to 21-day course including a taper are used for severe cases. • Soothing lotions such as Calamine or Sarna can also be helpful. • Subsiding or subacute dermatitis is treated with mid- (triamcinolone) to high-potency topical corticosteroids (clobetasol, fluocinonide, desoximetasone). • Chronic dermatitis (dry, lichenified) may require high- to super-potency topical corticosteroids. Therapeutic Procedures • Compresses and wet dressing bandages are often used. • Calamine or zinc oxide paste can be used between wet dressings. • Removal of the offending irritant is important.

Silvery scales on bright red, well-demarcated plaques, usually on the knees, elbows, and scalp. • Nail findings include pitting and onycholysis (separation of the nail plate from the bed). • Mild itching (usually). • May be associated with psoriatic arthritis. • Patients with psoriasis are at increased risk for metabolic syndrome and lymphoma. • Histopathology is not often useful and can be confusing.

A common benign, chronic inflammatory skin disease with both a genetic basis and known environmental triggers. • Injury or irritation of normal skin tends to induce lesions of psoriasis at the site (Koebner phenomenon). • Obesity worsens psoriasis, and significant weight loss in persons with high body mass index may lead to substantial improvement. • Psoriasis has several variants; the most common is the plaque type.

There are often no symptoms, but itching may occur. • Although psoriasis may occur anywhere, examine the scalp, elbows, knees, palms and soles, umbilicus, intergluteal fold, and nails. • The lesions are red, sharply defined plaques covered with silvery scales; the glans penis and vulva may be affected; occasionally, only the flexures (axillae, inguinal areas including genitalia) are involved (“inverse psoriasis”). • Fine stippling (“pitting”) in the nails is highly suggestive; onycholysis may occur. • Patients with psoriasis often have a pink or red intergluteal fold. • There may be associated seronegative arthritis, often involving the distal interphalangeal joints. • Eruptive (guttate) psoriasis consisting of myriad lesions 3 to 10 mm in diameter occurs occasionally after streptococcal pharyngitis. • Plaque-type or extensive erythrodermic psoriasis with an abrupt onset may accompany HIV infection.

Atopic dermatitis (eczema) • Contact dermatitis • Nummular eczema (discoid eczema, nummular dermatitis) • Tinea, candidiasis, or intertrigo • Seborrheic dermatitis • Pityriasis rosea • Secondary syphilis • Pityriasis rubra pilaris • Onychomycosis (nail findings) • Cutaneous features of reactive arthritis • Cutaneous features of lupus • Cutaneous T-cell lymphoma (mycosis fungoides)

Diagnostic Procedures • The combination of red plaques with silvery scales on the elbows and knees with scaliness in the scalp or nail pitting or onycholysis is diagnostic. • Psoriasis lesions are well demarcated and affect extensor surfaces in contrast to atopic dermatitis, which has poorly demarcated plaques in a flexural distribution. • In body folds and groin, scraping and culture for Candida spp and examination of the scalp and nails will distinguish inverse psoriasis from intertrigo and candidiasis.

Medications • Never use systemic corticosteroids; they may lead to severe rebound flares. • β-blockers, antimalarial agents, statins, and lithium may flare or worsen psoriasis.

Topical corticosteroid creams or ointments or vitamin D analogs such as calcipotriene ointment or calcitriol ointment may be used. • Occlusion alone clears isolated plaques in 30% to 40% of patients. • For the scalp, tar shampoo, salicylic acid, and corticosteroid preparations are available. • Topical tacrolimus ointment or pimecrolimus cream may be effective in penile, groin, and facial psoriasis.

Oral methotrexate is very effective, and oral cyclosporine dramatically improves severe cases. • Oral acitretin, a synthetic retinoid, is most effective for pustular psoriasis. Acitretin is a teratogen and persists for 2 to 3 years in fat tissue. • Tumor necrosis factor (TNF) inhibitors (etanercept subcutaneously, infliximab intravenously, adalimumab subcutaneously); and IL-12/23 monoclonal antibodies (ustekinumab subcutaneously) may be considered however, TNF inhibitors can also induce or worsen psoriasis.

Ultraviolet (UV) or narrow-band UVB phototherapy can be used with or without crude coal tar (Goeckerman regimen). • PUVA (psoralen plus ultraviolet A) may be effective even if standard UVB treatment has failed. Long-term use of PUVA (more than 250 doses) is associated with an increased risk of skin cancer. • Patients (especially those over age 40 years) should be monitored for the metabolic syndrome.

basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and melanoma.

A-Asymetry, B-Borders irregular, C-Color changes or multiple colors presented. D-Diameter >6mm. E-Evolution of the mole

Comedones: Open (blackheads) and closed (whiteheads) Inflammatory Lesions: Papules, pustules, nodules, cysts Distribution: Typically on the face, neck, chest, upper back, and shoulders

Rosacea: Absence of comedones, presence of telangiectasias, typically affects middle-aged adults Folliculitis: Inflammatory papules and pustules around hair follicles Keratosis Pilaris: Small, rough bumps typically on the upper arms, thighs, cheeks, or buttocks

Painful Nodules: Often inflamed and deep-seated Abscesses: Recurrent, may rupture and drain purulent material Sinus Tracts: Chronic, interconnected tunnels under the skin that can become secondarily infected

Common Sites: Axillae, groin, perianal, perineal, inframammary regions Less Common Sites: Buttocks, inner thighs, waistline, and other areas with apocrine glands

Positive Nikolsky Sign: Gentle pressure on unaffected skin causes the epidermis to shear off, indicating fragile skin in Pemphigus Vulgaris

Positive Asboe-Hansen Sign: Lateral pressure on the edge of a blister causes it to spread under the skin

Bullous Pemphigoid: Typically has tense bullae and subepidermal blisters, less mucosal involvement Mucous Membrane Pemphigoid: Primarily affects mucous membranes with subepidermal blistering Dermatitis Herpetiformis: Intensely pruritic, grouped vesicles, often associated with celiac disease Erythema Multiforme: Target lesions, often following infections or medications