SSS WEEK 5

Give me 4 resp causes of nail clubbing

• TB

• lung cancer

• interstitial lung disease

• sarcoidosis

Give 4 cardio causes of nail clubbing

• CHD

• tetralogy of fallot

• subacute bacterial endocarditis

• AA

Characteristics of nail clubbing

• loss of small diamond window when index fingers are brought together

• thickening of fingers

• softening of nail beds

• increased nail convexity

4 GI causes of nail clubbing

• Crohns and UC

• hepatocellular

• Celiac disease

• Liver cirrhosis

Treatment of nail clubbing

Treat underlying disease

Alopecia areata

• Discrete annular areas of hair loss anywhere on body

• sudden onset of hair loss, increasing area will have a smooth surface, completely devoid of hair or with scattered ‘exclamation mark’ hairs

Trichotillomania (+ddx)

condition where patients compulsively pull out their hair

can be a sign of stress relief habit, impulse control disorder, depression

DDx

• alopecia areata 

• tinea capitis 

NORMAL HAIR GROWTH IN THE BALDING AREAS

Telogen effluvium

when anagen stops prematurely and hair then enters telogen phase. anagen then recommences and telogen hairs are released from follicles after the shock

THIS OcCURS DUE TO A SHOCK OF THE SYSTEM

like acute telogen effluvium occurs folllowing childbirth or stopping OCP, any acute illness or major surgery and severe dieting

chronic may be primary and idiopathic or secondary to hypo/hyperthyroidism, malnutrition, cancer, TB, or iron deficiency anemia

CONFIRM by examining lost hair which is mostly in telogen stage (white bulb or club-shaped tip)

Anagen effluvium

drugs, toxins or inflammation cause interruption of active or anagen hair growth

Hypertrichosis vs hirsutism

widespread overgrowth of non–androgen-dependent hair, occasionally

seen with drugs such as cyclosporin and phenytoin.

• In hypertrichosis, areas like the forehead and forearms have increased hair growth— rather than the lower face and midline of the trunk that are preferentially affected by androgens

Acute vs chronic clinical features of DIC

Acute

• Ecchymoses (bruises)

• Mucous membrane involvement

• Internal hemorrhage

• Malaise and high fever purpuric rash affecting the extremities

• Petechiae and purpura

Chronic

• Thromboembolism

• Deep vein thrombosis

Acute vs chronic causes of DIC

General signs

• peripheral and central cyanosis

• finger clubbing

• swelling of ankle

• elevated JVP

Skin manifestations of sarcoidosis and clinical features

Sarcoidosis - non-caseating granulomas

multisystem granulomatous disorder

presents with one or more of the following abnormalities

• bilateral hilar adenopathy (hilar - lungs)

• pulmonary reticular opacities (a net-like pattern of fine lines seen on a chest X-ray or CT scan, indicating a problem in the lung's interstitium)

• skin joint and/or eye lesions

1. lupus pernio

violaceous or erythematous indurated papules, plaques or nodules

distributed on nose, cheeks, chin and ears

2. erythema nodosum

• a type of panniculitis

• painful nodules that are most common on anterior surface of lower extremities

Skin manifestations of diabetes

1. necrobiosis lipoidica

starts as violaceous but atrophy and become brown-red or slightly yellow

blood vessels VISIBLE

apear on front of shins (like erythema nodosum)

2. diabetic dermopathy

brownish scars on skin, mostly on shins too!

3. granuloma annulare

skin coloured or slightly pink annular lesions over knuckles composed of dermal nodules fused into a rough circle

4. candida infections

5. staph infections

6. eruptive xanthomas - crops of yellow papules with erythematous base

7. neuropathic foot ulcers

8. acrochordons (skin tags)

9. acanthosis nigricans - hyperpigmented, velvety thickening of skin folds

Signs of hyperthyroidism (graves) + specific manifestations

• skin: hyperhidrosis, facial flushing, hyperpigmentation

• hair: alopecia

• nails: yellow nail syndrome

Specific manifestations

• ophthalmopathy

• pretibial myxedema

• acropachy (triad - digital clubbing, soft tissue swelling of hands and feet, periosteal reaction in long bones)

• pretibial myxoedema 

Hypothyroidism signs

• loss of outer third of eyebrows

• cold insensitivity

• bruising and purpura

• weight gain

• puffiness of eyes, face and hands

General descriptions of adrena hyperfunction vs insufficiency

Skin signs of cushings

• acne

• telangiectasia

• facial roundness

• buffalo hump

• central adiposity

• bruising

• excess facial and body hair

• striae

Adrenal insufficiency skin signs

• hyperpigmentation of skin, buccal surfaces and knees, elbows and genitals

• loss of body hair

• vitiligo

Skin manifestations of hepatic disease

1. pruritis (most common) - worse at night, hands and feet

2. jaundice

3. palmer and facial erythema

4. spider naevi

5. nails - half and half nails

6. bruising

7. feminisation

8. photosensitivity, skin erosions and mucosal changes due to deficiencies in zinc, vitamin B leading to classic rashes of pellagra

GIT disease skin manifestations

1. Dermatitis herpetiformis

• associated w gluten intolerance

• pruritis vesicles, papules and bullae on elbows, knees and lumbosacral areas

• need biopsy to confirm IgA

2. erythema nodosum (also seen in sarcoidosis resp disease)

• panniculitis

3. pyoderma gangrenosum

• painful ulcerative disease

associated with

• IBD

• RA

• lupus

• begins as papule and breaks down to form rapidly enlarging ulcer

• investigate biopsy to differentiate infective and malignant

Clin presentation of chronic cutaneous discoid LE (+ treatment)

• chronic rash

• well defined red scaly plaques (like plaque psoriasis lol)

• secondary changes: hyper/hypopigmentation and atrophic scarring

treatment

• sun protection

• topical corticosteroids

• systemic agents eg. methotrexate (like psoriasis), hydroxychloroquine

Autoimmune - Scleroderma

Autoimmune - bullous pemphigoid

• may present as non-specific dermatitis or urticarial rash

investigations

• skin autoantibodies

• skin biopsy and direct immunofluorescence

treatment

• potent topical steroids or oral steroids

• long term alternatives

• antibiotics: doxy as a steroid sparing

nicotinamide as steroid sparing agent

List 5 causes of pruritis

• liver disease

• intrahepatic cholestasis of pregnancy

• lymphoma and leukemia

• multiple myeloma

• iron deficinecy anemia

Presentation of dermatomyositis

• periorbital macular violaceous erythema (heliotrope rash)

• scaly, reddish papules over dorsum of IPJs of hands (Gottons papules)

so if u get a case saying heliotrope rash, gottons papules immediately think dermatomyositis and immediately think internal malignancy

Skin manifestations of internal malignancy

1. acanthosis nigricans GI malignancy adenocarcinoma

2. pyoderma gangrenosum

3. dermatomyositis

4. generalised pruritis

5. superficial thrombophllebitis

6. erythroderma

7. sweets syndrome

Aetiology of chronic leg ulcers

Treatment of chronic leg ulcers