Derm E1: Inflammatory, Sebaceous, and Cystic Skin Disease

Important section!! Especially Psoriasis

What is Psoriasis?

chronic inflammatory skin disease that involves hyper-proliferation of keratinocytes in the epidermis

What is the pathophysiology of Psoriasis?

complex immune mediated using T lymph, dendritic cells, cytokines: cell cycle shortened → dec turnover time → inc cells undergoing DNA synthesis → inc number of epidermal stem cells

What are the risk factors for Psoriasis?

age, genetics (HLA-B17: more severe), environmental, smoking, stress, medications

What would you see on a skin biopsy of Psoriasis?

parakeratosis, epidermal hyperplasia, neutrophils, absence of granular layer, leukocytes, and lymphocytes

What are the clinical features of Chronic Plaque Psoriasis?

erythematous plaques w/ silvery scale, sharply defined, well-demarcated margins, ± pruritus

What is Type 1 plaque psoriasis?

strong FMHx, sx before age 40, associated w/ HLA-cw6

What is Type 2 plaque psoriasis?

no FMHx, sx after age 40, not associated w/ HLA-cw6; associated w/ + Auspitz sign and Koebner phenomenon

Where does Chronic Plaque Psoriasis typically occur?

extensor surfaces, scalp, gluteal cleft, intertriginous areas, ear canal, umbilicus, nails, palms/sole → painful fissures

What is the tx for limited Chronic Plaque Psoriasis?

• TCS: class 1-3 & emollients ± phototherapy

  • clobetasol

• Vitamin D analogs

• Topical Retinoids

  • Tazarotene

What is the tx for moderate/severe Chronic Plaque Psoriasis?

• Phototherapy

• Retinoids

• DMARDS

  • methotrexate, cyclosporine

• Anti-TNF (biologics)

  • Infliximab (Remicade), Adalimumab (Humira)

What are the clinical features of Guttate Psoriasis?

abrupt appearance of multiple small psoriatic papules and scales w/ raindrop appearance, < 1cm, may spontaneously remit

Where does Guttate Psoriasis typically occur?

trunk, back, proximal extremeties

What are the risk factors of Guttate Psoriasis?

age (children/young adult), associated w/ recent Streptococcal infxn

What would you see in a skin biopsy of Guttate Psoriasis?

early lesions: non-dx; mature lesions: hyperkeratosis, epidermal acanthosis, neutrophils in epidermis

What is the tx for Guttate Psoriasis?

• 1st line: UV phototherapy

• alternative: TCS & Vit D analogs

  • not ideal due to disease being widespread

What is the cause of Pustular Psoriasis?

pregnancy, stress, infection, withdrawal of oral glucocorticoids

What are the clinical features of Pustular Psoriasis?

acute onset, erythematous pustules, local/general, associated w/ malaise, fever, diarrhea, leukocytosis, hypocalcemia, can be life-threatening

What are the variants of Pustular Psoriasis?

• Von Zumbusch: most severe

• Acrodermatitis continue of Hallopeau: localized to distal digits

• Palmoplantar pustulosis: localized to palms/soles

What labs would see in pts w/ Pustular Psoriasis?

elevated WBC, inc ESR, hypocalcemia, hypoalbuminemia

What would you see in a skin biopsy of Pustular Psoriasis?

parakeratosis, elongation of rete ridges, spongiform pustules of Kogoj

What is the tx for Pusutlar Psoriasis?

• Mild

  • 1st line: Acitretin and Methotrexate

• Severe/acute

  • Cyclosporine, Infliximab

What are complications that can arise due to Pustular Psoriasis?

Renal: AKI, Hepatic: abn LFTs, jaundice, Resp: ARDS; hair loss

What are the clinical features of Erythrodermic Psoriasis?

generalized erythema & exfoliation of most of the BSA, painful and pruritic scales, associated w/ fevers, chills, malaise, arthralgia, LAD; appears similar to SJS

What causes Erythrodermic Psoriasis?

results from exacerbation of unstable plaque psoriasis; most commonly pts stopped taking their meds

What labs findings would you see in pts w/ Erythrodermic Psoriasis?

leukocytosis w/ eosinophilia, anemia

What are the risk factors of Erythrodermic Psoriasis?

age, hx of psoriasis, infections -HIV, medications: systemic glucocorticoids, bactrum, bupropion, withdrawal of antipsoriatic meds

What are complications that can arise from Erythrodermic Psoriasis?

infections, sepsis, electrolyte imbalances

What would you see in a skin biopsy of Erythrodermic Psoriasis?

epidermal hyperplasia, marked dilation and coiling of vessels w/in the papillary dermis

What is the tx for Erythrodermic Psoriasis?

• Stable = outpt/supportive

  • topical steroids

  • systemic psoriatic tx: Cyclosporine, Infliximab

• Unstable = admit to ICU or inpt

  • fluid/electrolyte replacement

  • nutritional support

  • tx infections

  • topical steroids or systemic immunomodulators

What are the clinical features of Inverse (intertriginous) Psoriasis?

well-demarcated, smooth, shiny plaques w/ absent or minimal scale; often mis-dx as fungal/bacterial

Where does Inverse (intertriginous) Psoriasis typically occur?

intertriginous area, inguinal, perineal, genital, intergluteal axillary, infra-mammary

What is the tx for Inverse (intertriginous) Psoriasis?

• Topical glucocorticoids (class 6-7)

• Topical Vit D analog: Calcitriol

• Topical Calcineurin inhibitor: Tacrolimus, Pimecorlimus

What are the clinical features of Nail Psoriasis?

common w/ psoriatic arthritis (80-90%), pitting, nail dystrophy, splinter hemorrhages, subungal hyperkeratosis, “oil drop sign”

What can you do to r/o onychomycosis when dx Nail Psoriasis?

KOH prep

What is the tx for Nail Psoriasis?

• prevent nail trauma

• TCS and topical Vit D analog

  • Calcipotriol

  • high potency (group 1) -Betamethasone

What are the clinical features of Palmoplantar Psoriasis?

hyperkeratotic plaques that may have associated fissures

Where is Palmoplantar Psoriasis typically located?

palms and soles

What is the tx for Palmoplantar Psoriasis?

• based on severity: topical vs oral tx similar to plaque psoriasis

• Topical steroids: high potency due to location

What is Psoriatic Arthritis?

oligoarthritis found in pts w/ psoriasis, caused by immunologic, environmental, hereditary factors

What are the clinical features of Psoriatic Arthritis?

associated nail involvement (80-90%), joint pain, joint stiffness in a.m., asymmetric, dactylitis “sausage digits”, “pencil in cup” deformity; similar to gout

Where is Psoriatic Arthritis typically located?

asymmetric peripheral joint involvement of UE, smaller joints

What are the risk factors for Psoriatic Arthritis?

psoriasis, gout

What labs can you get to exclude other conditions when dx Psoriatic Arthritis?

RF, ANA, ESR, CRP HLA-B27

What criteria is used to dx Psoriatic Arthritis?

CASPAR

What is the tx for Psoriatic Arthritis?

• Mild axial disease

  • NSAIDS: naproxen, celecoxib

• Moderate/severe axial disease

  • TNF inhibitors: Humira (1st), Enbrel, Infliximab

• Dactylitis

  • DMARDS: Methotrexate

What non-pharm tx can help manage Psoriatic Arthritis?

exercise, wt loss, avoid alc & smoking

What is important to educate women taking biologics on?

must use contraceptive measures

When prescribing Methotrexate, what is important to also give pts?

MUST supplement folic acid

What is Acne Vulgaris?

inflammatory disorder of the pilosebaceous unit characterized by chronic/recurrent development of comedones, papules, pustules, and nodules

What are the main pathogenic factors of Acne vulgaris?

follicular hyperkeratinization, inc sebum production, cutibacterium acne, inflammation

Where is Acne vulgaris typically located?

face and trunk

What is the pathophysiology behind Acne vulgaris?

adrogen stimulate inc sebum → microcomedomes form from accumulation of sebum and bacteria → comedone or pustule → bacteria activates inflammatory response → follicular rupture

What are the types of Acne vulgaris?

acne mechanica, papulopustular acne, comedonal acne, nodulocystic acne

What are variants of Acne vulgaris?

infantile acne, acne conglobata (severe nodular), acne fulminans (rare)

What causes infantile acne?

elevated levels of androgens produced by immature adrenal glands or left over from the mother’s hormones

What is required to dx Acne vulgaris?

comedones

When prescribing Accutane what must you do?

LFTs, lipid panel, Beta-Hcg pregnancy test;

What is mild Acne vulgaris?

few scattered comedones or small inflammatory papules w/o scarring

What is the tx for Acne vulgaris?

• Monotherapy

  • Benzoyl Peroxide, Topical Tretinoin, Salicyclic acid, or Azelaic acid

• Combotherapy

  • Benzyol peroxide + Topical Tretinoin

• Resistant

  • Topical dapsone

What can you not apply Topical dapsone (Aczone) with?

topical benzoyl peroxide

What is moderate Acne vulgaris?

prominent comedones, large inflammatory pustules and papules

What is the tx for moderate Acne vulgaris?

• Topical combo therapy

  • benzoyl peroxide + topical tretinoin + topical abx

• topical + oral combo therapy:

  • benzoyl peroxide + topical tretinoin + oral abx

• topical Abx: erythro or clindamycin

• oral Abx: doxy or minocycline

• Alternative: intralesional triamcinolone

What is severe Acne vulgaris?

prominent comedones, large inflammatory pustules and papules, nodules, scarring, can affect many body parts

What is the tx for severe Acne vulgaris?

• oral abx + topical retinoid + benzoyl peroxide ± topical abx

• Refractory: Accutane

What are complications of Acne vulgaris?

psychological morbidity, scarring, G- folliculitis

What is Rosacea?

inflammatory acneiform disorder of the facial pilosebaceous units

What are the clinical features of Rosacea?

facial flushing, papules, pustules, telangiectasias, NO comedones, ± burning sensation, phymatous changes, ocular manifestations

What is Rosacea typically located?

face

What are the risk factors for Rosacea?

Fitzpatrick phototype 1 &2; genetics

What are aggravating factors for Rosacea?

alcohol, UV light, smoking, spicy foods, hot beverages, temperature extremes, psychological stress

What are phymatous skin changes characterized by?

tissue hypertrophy, dilated follicles, irregular nodular overgrowths caused by sebaceous gland hyperplasia/fibrosis

What make up the “Phyma” family?

• Rhinophyma → Cauliflower-like nose

• Metophyma → enlarged cushion-like swelling of forehead

• Blepharophyma → swelling of the eyelids

• Otophyma → cauliflower-like swelling of the earlobes

• Gnathophyma → swelling of the chin

What is the tx for Rosacea?

• mild/moderate

  • topic abx: Metronidazole

  • Alternative: azelaic acid gel

  • Oral abx: tetracyclines

• Refractory: oral tretinoin (Accutane)

• Non-pharm: pulse dye laser

What can Accutane not be taken with?

vit A, Tetracyclines

What is Perioral Dermatitis?

skin condition that presents w/ multiple small, inflammatory papules around the mouth, nose, or eyes

What are the clinical features of Perioral Dermatitis?

discrete erythematous micropapules and microvesicles, no comedoens, associated w/ atopy

What is Perioral Dermatitis typically located?

perioral or periorbital skin; spares narrow area around the vermillion border

What are the risk factors for Perioral Dermatitis?

age, F > M, Topical steroid use

What is the tx for Perioral Dermatitis?

• non-pharm

  • STOP corticosteroid usage using taper

• Topical erythromycin or clindamycin gel

• Topical metronidazole gel

• Topical Calcineurin inhibitors

• moderate/severe

  • oral Tetracyclines

What is Hidradenitis Suppurativa?

chronic inflammatory disorder characterized by follicular occlusion, relapsing inflammation, mucopurulent discharge, progressive scarring

What are the clinical features of Hidradenitis Suppurativa?

recurrent inflamed, painful nodules and abscess, malodorous drainage, bands of severe scar formation, open comedones

Where is Hidradenitis Suppurativa typically located?

intertriginous regions: axilla, inframammary folds, inner thigh, groin, buttocks, gluteal cleft

What is the pathophysiology behind Hidradenitis Suppurativa?

follicular occlusion + mechanical stress → inflammation & leakage of antigens = perifolliculitis → rupture → sinus tracts → bacterial infections → scarring and extension of lesion

What are the most common bacteria in Hidradenitis Suppurativa?

Coagulase negative Staph and anaerobic bacteria

How is Hidradenitis Suppurativa staged?

• Hurley stages: 3 stages

  • 1: abscess w/o tracts or scars

  • 2: recurrent abscess w/ tract and scar

  • 3: diffuse multiple interconnected tracts and abscesses

What are complications of Hidradenitis Suppurativa?

squamous cell carcinoma (rare), psychosocial stress, strictures/contractures, scarred tissue, lymphatic obstruction, lymphedema

How do you tx Hurly stage 1 (mild) Hidradenitis Suppurativa?

• Abx

  • 1st line: topical clindamycine

  • refractory: oral tetra + antiandrogenic drugs (spirono) + metformin

• Intralesional triamcinolone

How do you tx Hurly stage 2 (moderate) Hidradenitis Suppurativa?

• oral tetracycline

• combo: clinda + rifampin

• oral retinoids

• dapsone

• humira (preferred)

• infliximab

What is the tx for Hurly stage 3 (severe) Hidradenitis Suppurativa?

wide excision

What is Epidermoid Cysts?

most common type of cutaneous cyst; may be a result from trauma of the follicular epithelium or comedones

What is another name for Epidermoid Cysts?

Epidermal Inclusion Cyst

What are common sites of Epidermoid Cysts?

face, neck, upper trunk, scrotum

What is the pathophysiology behind Epidermoid Cysts?

derived from the follicular infundibulum; trauma or occlusion of pilosebaceous unit → proliferation and implantation of epidermal cells in the dermis

What are the clinical features of Epidermoid Cysts?

skin-colored benign dermal nodules, visible central punctum, non-tender, freely moveable, filled w/ thick malodorous keratin material

What is the tx for Epidermoid Cysts?

• Asx: no tx necessary

• Surgical excision -definitive tx

What are the clinical features of Milia (Milium)?

1-2 mm, white papules, filled w/ keratin/sebaceous material; cannot squeeze out

What are Milia (Milium)?

painless, tiny subepidermal keratin cysts

What is Milia en plaque?

rare, inflammatory condition characterized by a cluster of milia on an erythematous and edematous bed in the periauricular region

What are common sites of Milia (Milium)?

eyelids, cheeks, forehead

What is the tx for Milia (Milium)?

• Asx: no tx necessary

• Neonatal: spontaneously resolve

• Definitive: incision and expression of contents