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Fernando Vega, M.D. 1
Common Dermatological Common Dermatological DilemmasDilemmas
Fernando Vega, M.D.Seattle Healing Arts
Itchy WhealsItchy Wheals
Itchy WhealsItchy Wheals
• When is it Urticaria?• When is it angioedema?• When is it allergic?• When is it non-allergic?
UrticariaUrticaria
• Wheals, superficial• Pruritic• Transient• Pale center• Different initiators
Angioedema
• Deeper swelling• Poorly defined• May affect mucosa• Not Transient
Dermatographism
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Urticaria - Excercise Urticaria - Pressure
Urticaria - cold Urticaria - vasculitis
• Lasts longer• May bruise
Urticaria – Allergic contact Urticaria – non allergic
• Non immunological contact from Nettle stingNettle sting
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UrticariaUrticaria
• Idiopathic• Immunologic
– Autoimmune (auto antibodies against Fc RI or IGEIgE dependent (allergic)
Etiologies and Pathomechanisms
– IgE dependent (allergic)– Immune complex (vasculitic)– Complement and kinin dependent (C1 esterase deficiency)
• Non-immunologic– Direct mast cell-releasing agents (eg. Opiates)– Vasoactive stimuli (nettle stings)– Aspirin, NSAIDS, – Angiotensin converting enzyme inhibitors
UrticariaUrticaria
• Ordinary urticaria• Physical Urticaria
Clinical classification of urticaria and angioedema
• Urticarial Vasculitis• Contact Urticaria• Angioedema without wheals• Distinctive Urticarial Syndrome
UrticariaUrticaria
• Urticaria due to mechanical stimuli– Dermographism
• Immediate– Simple– Symptomatic
• Delayed– Delayed pressure urticaria– Vibratory angioedema
I h it d
Classification of Physical Urticarias
• Inherrited• Acquired
• Urticaria due to temperature changes– Heat and stress
• Cholinergic urticaria• Localized heat-contact urticaria
– Stress– Cold contact urticaria
• Primary• Secndary (cryoglobulin, cold agglutinins)
– Exercise induced• Solar Urticaria• Aquagenic urticaria
Itchy RashesItchy Rashes
Atopic Dermatitis
• Chronic, relapsing, pruritic• Three stages:infantile, childhood, adulthood• Xerosis component with susceptibility to irritants
Synonym: Eczema
Xerosis component with susceptibility to irritants• Family history of atopy• Majority have occurences before 5 years of age• Disposition influenced by environment• Immunoabeerration: IgE, eosinophillia• Responsive to corticosteroids and macrolide
immuomodulators
Atopic DermatitisAtopic Dermatitis
• In infancy occurs more on face, extensor surfacessurfaces
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Atopic DermatitisAtopic Dermatitis
• On extensor surfaces of arms
Atopic DermatitisAtopic Dermatitis
• Severe chronic hand dermatitis in an adult
Atopic DermatitisAtopic Dermatitis
• Exaggerated palmar creases in icthyosis
Atopic DermatitisAtopic Dermatitis
• Keratosis pilaris
Atopic DermatitisAtopic Dermatitis
• Infected hand dermatitis
Complications
Atopic DermatitisAtopic DermatitisDiagnostic Features by AAD consensus
Essential features: must be present, and if complete are sufficient for diagnosis•Pruritus•Eczematous Changes
•Typical and age-specific patters•Face, neck and extensor involvement in infants and children•Current or piror flexural lesions at current or any agep y g•Sparing of groin and axiallry regions
•Chronic or relapsing courseImportant features: seen in most cases for support of the diagnosis
•Early age of onset•Atypical vascular responses•Xerosis
Associated features: help in suggesting the diagnosis•Perifollicular accentuation / lichenification / prurgo•Keratosis pilaris / ichthyosis vulgaris / palmar hyperlinearity•Ocular / Periorbital changes•Perioral / periauricular lesions
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Atopic DermatitisAtopic DermatitisDiagnostic Features
Major features (3 of 4 present)•Pruritius•Typical morphology and distribution•Chornic or chronically relapsing dermatitis•Personal or family history of atopy
Minor features (3 of 23 present)Minor features (3 of 23 present)•Xerosis•Ichthyosis/palmar hyperlinearity/keratosis pilaris•Type 1 skin reactivity•Elevated serrum IgE•Early age of onset•Tendency toward cutaneous infection/impaired cell-mediated immunity•Tendency towrds non-specific hand or foot dermatitis•Nipple eczema•Cheilitis•Recurrent conjuntivitis•Denne-Morgan intraorbital fold
Atopic DermatitisAtopic DermatitisDiagnostic Features
More Minor features (3 of 23 present)•Keratoconus•Anterior subcapsular cataract•Orbital darkening•Facial pallor/erythema•Pityriasis alba•Anterior neck folds•Pruritus when sweating•Intolerance to wool and lipid solvents•Perifollicular accentuation•Food intolerance•Course influenced by environmental or emotional factors•White dermatographism / delayed blanch
Atopic DermatitisAtopic DermatitisDifferential Diagnosis
Seborrheic DermatitisContact dermatitis (allergic or irritant)Psoriasis (especially Palmoplantar)Asteatotic eczemaLichen simplex chronicusScabiesDermatophytosisImpetigo (mimickng AD)
Seborrheic DermatitisSeborrheic DermatitisDifferentiated from Atopic Eczema
Infantile and adult forms existLesions favor the scalp, ears face, central chest and
intertriginous areasEtiological links with seborrhea, abnormal sebum
composition and commensal yeast M. furfurLymphocytic infiltrate, not IgE or eosinophillic in nature
Seborrheic DermatitisSeborrheic DermatitisDifferentiated from Atopic Eczema
Greasy scalesIn infants, starts at scalp and can genralizeIn adults:
scalp – dandruffMilder form on faceLess often over central chest and intertriginous areas
M. furfur always foundSebaceous glands
Seborrheic DermatitisSeborrheic DermatitisDifferentiated from Atopic Eczema
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Seborrheic DermatitisSeborrheic DermatitisDifferentiated from Atopic Eczema
Lichen Simplex ChronicusLichen Simplex ChronicusDifferentiated from Atopic Dermatitis
Neruodermatitis from rubbingMost frequently seen in adults > 60 yearsOften seen on posterior neck, extensor
surfaces of the forearm and lower legs, and the genital region
Lichen Simplex ChronicusLichen Simplex ChronicusDifferentiated Differentiated from Atopic Dermatitis
Stasis DermatitisStasis DermatitisDifferentiated from Atopic Dermatitis
Id reactionId reactionDifferentiated from Atopic Dermatitis
Di i t d
Synonyms
Disseminated eczemaAutosensitization Dermatitis
Disseminated Eczema Disseminated Eczema –– Id reactionId reactionDifferentiated from Atopic Dermatitis
Secondary lesions of eczema
Key Features
ydistant form the primary site of involvementSymmetric distribution patternOften associated with
Allergic contact dermatitisStasis dermatitisOnychomycosis
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Disseminated Eczema Disseminated Eczema –– Id reactionId reactionDifferentiated from Atopic Dermatitis
Poorly demarcated patches of eczema usu over extremitiesS t i
Clinicial Features
SymmetricKeratinocyte proinflamatory mediators: IL-, IL-6, TNF-α
Cutaneous Fungal Cutaneous Fungal InfectionsInfections
Cutaneous Fungal InfectionsCutaneous Fungal Infections
• Limited to – Stratum Corneum– Hair
Nails– Nails– Dermis– Subcutaneous Tissures
Cutaneous Fungal Infections
Disorder Pathogen
Minimal Inflamation Pityriasis(tinea)versicolor Mlassezia furfur
Superficial Mycoses of the Skin
y ( )Tinea nigra Exophial werneckii
Inflammatory response common
Tinea capitis barbae, faciei, corpris, cruris, manuum, pedis
Cutaneous candidiasis
Trichophyton, microsporumEpidermophyton
Candida albicans
Cutaneous Fungal Infections
• T. versicolor– Not inflamatory– Non pruritic
Oil requirements– Oil requirements
Cutaneous Fungal Infections
• KOH prep of – Pityriasis versicolor– Tinea
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Cutaneous Fungal Infections
• Tinea corporis– Active border– Scaloped interior
borderborder– Pustules not
vescilces
Cutaneous Fungal Infections
• Tinea cruris– Archiform
erhythematous border
Cutaneous Fungal Infections
• Tinea manum– No vesicles
Cutaneous Fungal Infections
• Tinea barbae
Cutaneous Fungal Infections
• Tinea capitis
Cutaneous Fungal Infections
• Tinea pedis
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Cutaneous Fungal Infections
• Tinea Unguium
Cutaneous Fungal Infections• Cutaneous candidais
Cutaneous Fungal Infections
• Sporotrichosis
Bites and stings
Bites and Stings• Papular urticaria• Excoriated papules may progress to prurigo
nodularis• Pseudolymphomatous nodes are common• Anaphylaxis is mainly related to• Anaphylaxis is mainly related to
hymernopterids• Secondary infections are usually
staphyloccocal• Nocardiosis and sporotrichosis can also be
innoculated by insects
Bites and Stings
• Flea bites, bedbug bites come in threes:– Breakfast, Lunch and Dinner
Ticks• Ticks• Spiders
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Bites and Stings• Bullous bug bites
Bites and Stings
• Tick granuloma
Bites and Stings
• Lone star ticks
Bites and Stings• Brown recluse spider
Bites and Stings
• Central dusky necrosis of brown recluse bite
Oral Disease
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Oral Diseases
• Geographic tounge
Oral Diseases
• Hairy Tongue
Oral Diseases
• Fissured tounge
Oral Diseases
• Apthous Ulcer
Oral Diseases
• Herpes Stomatitis
Oral Disease• Leukoplakia• Most common
premalignant condition• Biopsy mandatory
(ventral surface tongue)
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Oral Disease• Squamous cell CA
exophytic masstypical
presentation and site
Oral Disease• Nicotine stomatitis
– Umbilicated papules– Infl mucous glands