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DISCLOSURE OF RELEVANT RELATIONSHIPS WITH INDUSTRY

Nicole Burkemper, MD

Associate Professor of Dermatology and Pathology

Saint Louis University

I HAVE NO RELEVENT RELATIONSHIPS WITH ANY COMPANIES

The most likely diagnosis is:

A. Allergic contact dermatitis

B. Cellulitis

C. Neuropathic diabetic ulcer

D. Pyoderma gangrenosum

E. Sweet syndrome

The most likely diagnosis is:

A. Allergic contact dermatitis

B. Cellulitis

C. Neuropathic diabetic ulcer

D. Pyoderma gangrenosum

E. Sweet syndrome

Cellulitis

• Ill-defined erythema, warmth, edema

• Systemic symptoms of fever, chills and malaise

• Leading edge not raised or sharply demarcated (distinguishes from erysipelas)

• Bullae and petechiae

• Streptococcus pyogenes and Staphylococcus aureus

• Often after wound; on leg, tinea pedis is most common portal of entry

• Predisposing factors: venous and lymphatic damage, congenital vascular malformations

Distractors

Allergic contact dermatitis *—epidermal changes

Neuropathic diabetic ulcer—sole of foot

Distractors

Pyoderma gangrenosum *—sharply marginated wet ulcer with purple undermined border

Sweet’s syndrome *—pink edematous plaques on the face, upper trunk and arms

The most likely diagnosis is:

A. Allergic contact dermatitis

B. Cutaneous candidiasis

C. Lichen sclerosus

D. Tinea corporis

E. Tinea versicolor

The most likely diagnosis is:

A. Allergic contact dermatitis

B. Cutaneous candidiasis

C. Lichen sclerosus

D. Tinea corporis

E. Tinea versicolor

Tinea versicolor

• Presents as hypo- or hyperpigmented coalescing scaly macules

• Trunk, upper arms and neck

• Caused by Malassezia furfur

• KOH—short, thick hyphae and spores (“spaghetti and meatballs”)

• Topical or systemic antifungal treatment

• Recurrence rate very high—ketoconazole shampoo weekly to prevent recurrence

Distractors

Allergic contact dermatitis *—pink patches or plaques, not hypo- or hyperpigmented; patterned

Cutaneous candidiasis *—moist patches in intertriginous areas with satellite pustules

Distractors

Lichen sclerosus *—atrophic “cigarette paper” plaques often in genital and perianal areas

Tinea corporis *—annular, sharply circumscribed, erythematous, scaly patches

The most likely diagnosis is:

A. Contact dermatitis

B. Cellulitis

C. Erythema migrans

D. Erythema dyschromicum perstans

E. Psoriasis

The most likely diagnosis is:

A. Contact dermatitis

B. Cellulitis

C. Erythema migrans

D. Erythema dyschromicum perstans

E. Psoriasis

Contact dermatitis

• Well-demarcated erythematous vesicular to scaly plaque with well-defined margins corresponding to the area of contact

• Because irritant contact dermatitis and allergic contact dermatitis not always discernible clinically, patch testing may be required to identify an allergen and exclude allergy

• Most common allergens are nickel, neomycin, balsam of Peru, fragrance mix, thimerosal (often not relevant), gold, quaternium-15, formaldehyde, bacitracin and cobalt

Distractors

Cellulitis *—more well-defined, erythematous and edematous; leg most common site

Erythema migrans *—annular patches most commonly on legs, groin, axilla and trunk

Distractors

Erythema dyschromicum perstans—ashy-gray oval macules and patches on the face, neck, trunk and proximal extremities in patients with darker skin types

Psoriasis *—more well-demarcated bright red plaques with overlying silvery scale

This patient just returned from a beach vacation in the Caribbean and complains of this itchy rash on the buttock. The most likely

diagnosis is:

A. Allergic contact dermatitis

B. Cutaneous candidiasis

C. Cutaneous larva migrans

D. Perianal strep dermatitis

E. Scabies

This patient just returned from a beach vacation in the Caribbean and complains of this itchy rash on the buttock. The most likely

diagnosis is:

A. Allergic contact dermatitis

B. Cutaneous candidiasis

C. Cutaneous larva migrans

D. Perianal strep dermatitis

E. Scabies

Cutaneous larva migrans

• Most commonly caused by larvae of cat and dog hookworm, Ancylostoma braziliense; SE United States, Caribbean

• From environment contaminated with animal feces, beach

• Human is dead-end host

• Sxs: 1-6 days from exposure; creep several cm per day; die in 2 to 8 weeks without treatment

• Tx: single-dose ivermectin or 3 days albendazole

Distractors

Allergic contact dermatitis *—can be linear, not serpiginous

Cutaneous candidiasis *—Often in the folds; beefy red, moist patches with satellite pustules

Distractors

Perianal strep dermatitis—Perianal well-demarcated rim of erythema

Scabies *—Short burrows that prefer the finger webs, wrists, axillae, areolae, umbilicus and genitals

This patient presents with fatigue and anemia. The most likely diagnosis is:

A. Basal cell nevus syndrome

B. Blue rubber bleb nevus

syndrome

C. Gaucher disease

D. Pachyonychia congenita

E. Peutz Jeghers

This patient presents with fatigue and anemia. The most likely diagnosis is:

A. Basal cell nevus syndrome

B. Blue rubber bleb nevus

syndrome

C. Gaucher disease

D. Pachyonychia congenita

E. Peutz Jeghers

Blue rubber bleb nevus syndrome

• Autosomal dominant

• Dark blue papules and nodules and skin-colored compressible protuberances (“rubber blebs”) and larger venous malformations affecting skin and mucosa

• GI lesions bleed and lead to iron deficiency anemia

Distractors

Basal cell nevus syndrome

*—palmar pits Gaucher disease

• Bronze coloration of skin;

some have congenital

ichthyosis

Distractors

Pachyonychia congenita—”doorstop nails”; steatocystomas when mutations in keratin 17

Peutz-Jeghers *—hyperpigmented

macules on lips and oral mucosa;

polyposis of SI with GI bleeding

The most likely diagnosis is:

A. Cellulitis

B. Ichthyosis vulgaris

C. Mycosis fungoides

D. Necrolytic migratory erythema

E. Psoriasis

The most likely diagnosis is:

A. Cellulitis

B. Ichthyosis vulgaris

C. Mycosis fungoides

D. Necrolytic migratory erythema

E. Psoriasis

Ichthyosis Vulgaris

• Ichthyosis is derived from the Greek word

ichthys, meaning “fish”

• Autosomal dominant; prevalence as high as 1 in 250

• Onset in early childhood

• Extensor LE primarily affected with scales; hyperlinear palms

• Loss-of-function mutations in the filaggrin gene

(FLG)

Distractors

Cellulitis * —well-defined erythema, warmth, edema; no scale

Mycosis fungoides *—fairly well-demarcated patches/plaques typically in sun-protected areas

Distractors

Necrolytic migratory erythema *—pink and eroded plaques classically in intertriginous areas

Psoriasis *—well-demarcated red plaques with silver scale

This patient also has a fever. The most likely diagnosis is:

A. Acne keloidalis

B. Arthropod bites

C. Nummular dermatitis

D. Prurigo nodularis

E. Sweet syndrome

This patient also has a fever. The most likely diagnosis is:

A. Acne keloidalis

B. Arthropod bites

C. Nummular dermatitis

D. Prurigo nodularis

E. Sweet syndrome

Sweet syndrome

• Acute febrile neutrophilic dermatosis

• Adults; F3:M1

• Sharply demarcated, tender, pink-violaceous edematous plaque involving face, neck, upper trunk and extremities

• Fever, arthralgias, myalgias

• Elevated ESR and neutrophilia

• Associated with URI (most common), hematologic malignancy or solid tumors, inflammatory diseases and pregnancy

• Standard treatment is systemic corticosteroids

Distractors

Acne keloidalis *—no fever; papules, pustules and keloidal plaques at back of neck

Arthropod bite *—no fever; edematous papule, plaque or bulla

Distractors

Nummular eczema *—no fever; discrete, coin-shaped vesicular or crusted pruritic plaques

Prurigo nodularis *—no

fever; pruritic dome-shaped

papules

This condition becomes more prominent with cold

exposure. The most likely diagnosis is:

A. Erythema ab igne

B. Livedo reticularis

C. Lymphangioma

D. Necrolytic acral erythema

E. Small vessel vasculitis

Add close up or bigger version of photo

This condition becomes more prominent with cold

exposure. The most likely diagnosis is:

A. Erythema ab igne

B. Livedo reticularis

C. Lymphangioma

D. Necrolytic acral erythema

E. Small vessel vasculitis

Livedo reticularis

• Netlike, mottled or reticulated, pink or reddish-blue discoloration of the skin, mostly on the legs

• Livedo racemosa (fixed LR)—broken circular segments; almost always associated with significant systemic disease such as hypercoagulable states (including myelodysplasias, cancer, and antiphospholipid and Sneddon syndromes), vasculitis (especially medium- and large-vessel), emboli, medications, and neurologic disorders

Livedo racemosa

Distractors

Erythema ab igne—no

variability with temperature;

reticulated erythema or

pigmentation in area of of

persistent heat exposure

Lymphangioma *--no worse with change in temperature; white vesicles that can become hemorrhagic (frog spawn)

Distractors

Necrolytic acral erythema *—no change with temperature; dusky plaques on feet +/- hands

Small vessel vasculitis *—no change with temperature; palpable purpura

The most likely diagnosis is:

A. Darier disease

B. Lichen planus

C. Onychomycosis

D. Psoriasis

E. Yellow nail syndrome

The most likely diagnosis is:

A. Darier disease

B. Lichen planus

C. Onychomycosis

D. Psoriasis

E. Yellow nail syndrome

Onychomycosis

• Yellowing, hypertrophy, and dystrophy of the distal nail plate with subungual hyperkeratosis (distal subungual onychomycosis)

• Trichophyton rubrum most common cause

• Usually multiple nails

• Toenail infection is much more common than fingernail infection

• Nail dystrophy is secondary to onychomycosis in more than 50% of cases (90% dermatophytes)

Distractors

Darier disease *—red and white longitudinal streaks; V-shaped nicking of distal margin

Lichen planus *—dorsal pterigium; trachyonychia (twenty nail dystrophy)

Distractors

Psoriasis *—salmon patches, “oil drop” sign, pitting, onycholysis; can be clinically indistinguishable from onychomycosis

Yellow nail syndrome *—marked thickening and yellow discoloration

The most likely diagnosis is:

A. Cowden syndrome

B. Epidermodysplasia verruciformis

C. Heck disease

D. Traumatic fibromas

E. Tuberous sclerosis

The most likely diagnosis is:

A. Cowden syndrome

B. Epidermodysplasia verruciformis

C. Heck disease

D. Traumatic fibromas

E. Tuberous sclerosis

Cowden syndrome

• Autosomal dominant; PTEN tumor suppressor gene

• Mucocutaneous findings: – Facial papules: flesh-colored, flat-topped, or elongated verrucoid

papules ranging from 1- to 5-mm

• Most are trichilemmomas and have a keratin-plugged center

– Oral lesions: 1- to 3-mm smooth whitish oral papules on gingiva, lips, palate or tongue in 80%

• May coalesce giving “cobblestone” appearance

– Acral keratoses: flesh-colored smooth or verrucoid papules on dorsal hands and feet in 60%

• Neoplasms of the breast and thyroid occur in up to two thirds of patients, can be malignant

Distractors

Heck disease

• Small white to pink papules diffusely in the mouth, not on face; HPV-13

Epidermodysplasia verruciformis—flat, wart-like lesions on dorsal hands, extremities, face and neck; tinea versicolor type patches on trunk; HPV-5 and -8

Distractors

Traumatic fibromas—solitary, smooth, pink nodule at bite line of buccal or labial mucosa or tongue; no skin findings

Tuberous sclerosis *—oral findings are gingival fibromas and dental pits; would also have facial angiofibromas

The most likely diagnosis is:

A. Acne vulgaris

B. Eosinophilic folliculitis

C. Pityriasis lichenoides

D. Prurigo nodularis

E. Steatocystoma multiplex

The most likely diagnosis is:

A. Acne vulgaris

B. Eosinophilic folliculitis

C. Pityriasis lichenoides

D. Prurigo nodularis

E. Steatocystoma multiplex

Acne vulgaris

• Comedones, papules, pustules, cysts, scarring

• Patients have a variety of lesions in various states of formation and resolution

• Follicular hyperkeratosis, ↑ sebum production, Propionibacterium acnes bacteria, inflammation

• Retinoids = 1st line for all forms of acne vulgaris due to their comedolytic and anti-inflammatory effects as well as their ability to help penetration of other topicals

Distractors

Eosinophilic folliculitis—papulopustules and plaques studded with pustules and central clearing; no comedones; pruritic

Pityriasis lichenoides *—eroded or scaly papules that heal with hypopigmentation; no comedones

Distractors

Prurigo nodularis *—dome-shaped nodules with central crust in accessible areas

Steatocystoma multiplex—Yellowish cysts without puncta; no pustules

This patient presents with fever and rash. The most

likely diagnosis is:

A. Acute generalized

exanthematous pustulosis

B. Bacterial folliculitis

C. Disseminated zoster

D. Measles

E. Toxic epidermal necrolysis

This patient presents with fever and rash. The most

likely diagnosis is:

A. Acute generalized

exanthematous pustulosis

B. Bacterial folliculitis

C. Disseminated zoster

D. Measles

E. Toxic epidermal necrolysis

Acute generalized exanthematous pustulosis (AGEP)

• Fever and countless nonfollicular, sterile, 1- to 2-mm pustules on background of erythema

• Typically ≤4 days of new drug

• β-lactam antibiotics, macrolides, Ca++ channel blockers, antimalarials…

• Treatment: Drug cessation, topical steroids, antipyretics

• Acuity and drug history help distinguish from pustular psoriasis

Distractors Bacterial folliculitis *—follicular pustules without background erythema

Disseminated zoster *—vesicles (not pustules) on an erythematous base; immunocompromised

Distractors

Measles—morbilliform eruption; spreads cephalocaudad; no pustules

Toxic epidermal necrolysis *—painful, pink to dusky-red patches with vesicles, bullae and erosions; mucosal erosions

This patient also complains of loss of the eyebrows. Of the following, the most likely diagnosis is:

A. Androgenetic alopecia

B. Central centrifugal cicatricial alopecia

C. Lichen planopilaris

D. Telogen effluvium

E. Trichotillomania

This patient also complains of loss of the eyebrows. Of the following, the most likely diagnosis is:

A. Androgenetic alopecia

B. Central centrifugal cicatricial alopecia

C. Lichen planopilaris

D. Telogen effluvium

E. Trichotillomania

Lichen planopilaris

• Keratotic plugs surrounded by violaceous rim on the scalp resulting in scarring alopecia

• Peri-infundibular lymphocytic inflammation with vacuolar interface dermatitis

• Women affected more frequently than men • Frontal fibrosing alopecia is a variant of LPP that presents in

older women with bandlike frontotemporal scarring alopecia with loss of eyebrows

• Treatment often difficult—hydroxychloroquine; topical, IL and po steroids, pioglitazone (PPAR-gamma agonist) and immunosuppressive agents

Distractors

Central centrifugal cicatricial

alopecia--almost exclusively

black women; scarring alopecia

at the vertex or crown

Androgenetic alopecia *—thinning of

crown with wider part anteriorly and

preservation of frontal hairline

Distractors Telogen effluvium—thinning of hair of entire scalp, not just crown

Trichotillomania *—patches of alopecia with hairs of varying lengths interspersed with uninvolved areas of the scalp

The most likely diagnosis is:

A. Allergic contact dermatitis

B. Amyloidosis

C. Dermatomyositis

D. Necrobiotic xanthogranuloma

E. Xanthelasma

The most likely diagnosis is:

A. Allergic contact dermatitis

B. Amyloidosis

C. Dermatomyositis

D. Necrobiotic xanthogranuloma

E. Xanthelasma

Amyloidosis

• Primary systemic amyloidosis (AL amyloid)

– Multiorgan disease with underlying plasma cell dyscrasia

– Cutaneous manifestations in 25%: • Purpura/ecchymoses (most common)

• Rubbery swelling and infiltration of tongue/oral mucosa

• Waxy infiltration of palms/fingertips

• Waxy or purpuric periorificial papules

• Diffuse sclerodermoid infiltration

• Bullae

• Onychodystrophy

Cutaneous amyloidosis

• Macular amyloidosis: brown rippled macules, often on back

• Lichen amyloidosis: persistent, brown, pruritic papules/rippled plaques on the shins

• Nodular amyloidosis: waxy nodule(s) often at acral sites, AL amyloid but rare progression to systemic amyloidosis

Distractors

Allergic contact dermatitis *—scaly pink patches

Dermatomyositis *—violaceous erythema (heliotrope)

Distractors

Necrobiotic xanthogranuloma--indurated yellowish plaques that can ulcerate

Xanthelasma--yellow papules and plaques

The most likely diagnosis is:

A. Grave disease

B. HAART-associated

lipodystrophy

C. Lupus panniculitis

D. Rosacea

E. Scleromyxedema

The most likely diagnosis is:

A. Grave disease

B. HAART-associated

lipodystrophy

C. Lupus panniculitis

D. Rosacea

E. Scleromyxedema

HAART-associated lipodystrophy

• Lipodystrophy occurs in up to 80% of HIV-infected patients, most of whom are on anti-retroviral therapy

• Fat of the face, buttocks and limbs is lost with increased fat at the upper back and abdomen

• Related to non-nucleoside reverse transcriptase inhibitors which also lead to adipocyte apoptosis

• May also have hypertriglyceridemia, hypercholesterolemia and insulin resistance, especially if also on a protease inhibitor

• Treatment with rosiglitazone, metformin, growth hormone and fillers

Distractors

Grave disease—

exophthalmos

Lupus panniculitis *—

proximal extremities;

nodules or indurated

plaquesatrophy

Distractors Rosacea *—conjunctivitis, styes; centrofacial erythema, papules and micropustules

Scleromyxedema--waxy firm papules that coalesce into infiltrated plaques

The most likely diagnosis is:

A. Brown recluse spider bites

B. Bed bug bites

C. Erythema migrans

D. Scabies

E. Sporotrichosis

The most likely diagnosis is:

A. Brown recluse spider bites

B. Bed bug bites

C. Erythema migrans

D. Scabies

E. Sporotrichosis

Bites, stings, infestations

• Excoriated, pruritic papules, often grouped

• Central puncta

• Exaggerated responses: bullous lesions or papular urticaria more common in children

• Bedbug bites (Cimex lectularius) often linear

Distractors

Erythema migrans *—erythematous expanding annular plaque; usually solitary

Brown recluse spider bite—Painful edematous reaction progressing to bulla with surrounding erythema and ischemia

Distractors

Scabies *—burrows in finger webs, umbilicus, nipples, male genitalia

Sporotrichosis *—ulcerated papule at site of inoculation (hand) and nodules along path of lymphatic drainage

The most likely diagnosis is:

A. Confluent and reticulated papillomatosis

B. Hailey-Hailey disease

C. Recurrent and disseminated infundibulofolliculitis

D. Tinea versicolor

E. Transient acantholytic dermatosis

The most likely diagnosis is:

A. Confluent and reticulated papillomatosis

B. Hailey-Hailey disease

C. Recurrent and disseminated infundibulofolliculitis

D. Tinea versicolor

E. Transient acantholytic dermatosis

Confluent and reticulated papillomatosis

• Onset: puberty-young adulthood, more common in black patients

• Multiple brown verrucous papules/patches, central chest/abdomen/upper back; confluent centrally and reticulated peripherally

• May mimic tinea versicolor (KOH will be negative) or acanthosis nigricans

• Treatment: Minocycline, azithromycin, topical and oral retinoids

Distractors Hailey-Hailey disease *—macerated plaques in intertriginous areas

Recurrent and disseminated infundibulofolliculitis--numerous, pruritic, 1-2 mm skin-colored papules on trunk, neck and upper extremities; darker pigmented patients

Distractors Tinea versicolor *—brown, tan or hypopigmented scaly round to oval patches on trunk

Transient acantholytic dermatosis *—crusted pink papules on upper trunk of older adults