Tutorial

Tutorial

Dermatology
د. احمد طه

عدد الاوراق (7)

28/2/2013

Dermatological Manifestations Of Medical Disorders

Introduction
The skin is the mirror of the human body.
It is also the window through which we can look inside the body.
There is virtually no disease of the body that does not give itself away on the skin.
In some cases, one needs to determine if the Dermatologic complaints may be a manifestation of a more serious underlying systemic disease. some of which are due to treatment of these conditions.

Objective

It is beyond the scope of tutorial to cover all potential skin manifestations of systemic disease.
aims to highlights:
dermatologic presentations require further assessment to exclude underlying systemic disease
systemic diseases that have classic cutaneous findings
cutaneous paraneoplastic disorders


Pruritus
Excoriations and prurigo nodules may be seen in a patient with pruritus in the absence of primary skin pathology

Causes of pruritus

Haematologic disorders
Iron deficiency anaemia
Myeloproliferative disorders including polycythaemia, leukaemia
Monoclonal gammopathy and multiple myeloma
Lymphoma
Renal disorders
Uraemia due to any cause
Liver disorder
Cholestasis due to any cause
Endocrine disorders
Either hyperthyroidism or hypothyroidism

Patient has not improved

Systems review and pruritus screen
full blood count
urea and creatinine
liver function tests
thyroid function tests
iron studies
serum protein electrophoresis
consider fasting blood sugar level


Erythema nodosum
Erythema nodosum is an acute, reactive inflammation of the subcutis, or panniculitis. This most commonly affects young women, presenting as symmetric tender, hot erythematous nodules over the extensor legs
Patients may also complain of fever, arthralgias and malaise.
Most cases follow a self limiting course.
When a patient presents with erythema nodosum, there are a number of investigations which should be performed to look for an associated cause

Causes of EN

Infections
Bacterial- Streptococcal infections; tuberculosis
Fungal- systemic fungal infections
Viral-Infectious mononucleosis, hepatitis B, herpes simplex
GI parasites
Drugs- Sulfonamides, Oral contraceptives
Malignancies
Others: Sarcoidosis, Inflammatory bowel disease
Idiopathic About 20% of cases

Cutaneous vasculitis

Vasculitis refers to an inflammation of the blood vessels, which can affect small, medium or large vessels.
Both small and medium vessel vasculitis may present with cutaneous findings.
In any patient who presents with a cutaneous vasculitis, it is important to look for any evidence of systemic vasculitis, which has more serious implications.


Small vessel vasculitis affects the arterioles, capillaries and venules and classically presents as palpable purpuric papules and plaques
This is the most common form of cutaneous vasculitis, typically affecting the lower legs and dependent areas.
Medium vessel vasculitis is much less common and often associated with a systemic vasculitis and connective tissue disorder including systemic lupus erythematosus (SLE)
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Henoch Schonlein Purpura

Palpable purpura, urticaria, necrotic ulcers on buttocks, distal legs
Vasculitis with arthritis, abdominal pain, and hematuria
IgA vasculitis
GI symptoms + arthritis, long term concern for hypertension and renal involvement
mainly affects children
often follows streptococcal infection URI

HSP


medium vessel vasculitis

Certain Systemic Diseases Have Classic Cutaneous Findings
Chronic liver disease
Chronic liver disease is associated with a number of cutaneous manifestations.
Some of these occur in any patient, while others are more specific to the nature or cause of the liver disease.
Any patient with chronic liver impairment may have multiple spider naevi, palmar erythema, an acquired ichthyosis or macular purpura in association with a coagulopathy.
Cholestasis may be associated with jaundice and generalised pruritus, which can result in secondary changes such as excoriations and prurigo nodules
Hepatitis C infection


Pruritis

Lichen planus violaceous flat topped papules have beenreported in hepatitis C infection

Diabetes Mellitus
Acanthosis Nigricans
Diabetic Dermopathy
Bullosis Diabeticorum
Necrobiosis Lipoidica
Diabetic Foot Ulcers
Skin Infections

Acanthosis Nigricans

Hyperpigmented velvety plaques of the flexures
Genetic sensitivity of the skin to hyperinsulinemia
endocrine disorders (acromegaly)
Inherited
Associated with obesity, insulin resistance

Diabetic Dermopathy

shin spots or pigmented pretibial papules
Most common cutaneous manifestation of diabetes
Benign asymptomatic red brown macules on shins
No treatment needed


Bullosis Diabeticorum
Rapid onset painless, tense blisters on hands and feet
Trauma and microvascular disease may play a role
Spontaneous healing in 2-5 weeks

Necrobiosis Lipoidica

20-35% of patients with NLD have diabetes, only about 1-3% of diabetics have NLD
Start as red-brown papules and progress to well defined yellow-brown atrophic plaques with irregular violaceous borders and telangiectasias. Shins.
Ulceration in 35%.
Glucose control will not clear NLD

Diabetic Eruptive Xanthomas

Seen in uncontrolled diabetes, high TG
Sudden crops on firm, non-tender yellow papules with a red rim on extensors
Control glucose and lipid reduction will reduce lesions

Diabetic Neurotropic Ulcers

Peripheral neuropathy leads to unnoticed trauma
Vascular complications may lead to ulcers and complicate ulcer healing
Risk of amputation goes up 8x once these develop


Skin Infections in DM
Occur in 20-50% of poorly controlled diabetics
Fungal infections- most common
Candida
Dermatophytosis
Bacterial Infections- can be more severe and widespread in diabetics like Malignant otitis externa
Erythrasma

Candidiasis in Diabetics
White material adherent to erythematous, fissured oral commisure; angular stomatitis


Malignant Otitis Externa in Diabetics

Malignant otitis externa
Pseudomonas aeruginosa
Can progress to chondritis, osteomyelitis, and bacterial meningitis

Erythrasma

Reddish tan scaling patches of the upper inner thighs, axillae, toe web spaces

Woods Lamp

Connective tissue disorders
Connective tissue disorders often have classic cutaneous findings, some of which are disease specific.
Recognising these signs will help to differentiate between the different diseases, although overlap between them can be seen.
Lupus erythematosus
Dermatomyositis
Systemic sclerosis
Other connective tissue diseases

Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is an autoimmune disease in which organs, tissues, and cells undergo damage mediated by tissue-binding autoantibodies and immune complexes.
+ANA
dsDNA
Systemic Lupus Erythematosus (SLE)
Discoid Lupus (DLE)
SLE
Butterfly Rash
photosensitivity
Photodistrubited erythematous, papular scaling eruption
discoid plaques or psoriasiform erythema
Poikiloderma, alopecia, and mucosal ulcers


Scarring,hypopigmented and hyperpigmented erythematous well demarcated plaques in sun exposed areas of discoid lupuserythematosus

Discoid Lupus: Cutaneous manifestations
Scar upon healing

Dermatomyositis

Periocular (Heliotrope rash) with periorbital edema
Nailfold telangiectasias
Gottrons papules
Poikiloderma favoring scalp and extensor skin sites



Gottrons papules in Dermatomyositis

Flat-topped, violaceous or erythematous papules on extensor surfaces

Systemic Sclerosis

Systemic sclerosis (SSc) is a chronic multisystem disorder of unknown etiology characterized clinically by thickening of the skin caused by accumulation of connective tissue and by structural and functional abnormalities of visceral organs, including the gastrointestinal tract, lungs, heart, and kidneys.
1. Systemic
2. Localized scleroderma
CREST syndrome (Calcinosis cutis, Raynaud phenomenon, Esophageal motility, Sclerodactyly, and Telangectasia
Morphea
Linear scleroderma (en coup de sabre)


Raynaud phenomenon

Sclerodactyly

bird-like facies
Periungual erythema

Paraneoplastic Disorders

Acanthosis Nigricans
Acquired Ichthyosis
Dermatomyositis
Cushings Disease
Sign of Lesser-Trelat
Paraneoplastic Pemphigus
Hypertrichosis Lanuginosa
Pyoderma gangrenosum
Erythroderma

Acanthosis Nigricans/ gastric adenocarcinoma

Dermatomyositis

Women=ovarian and berast ca,
Men= gastric and lymphoma




Cushings syndrome/ oat cell lung ca

Sign of Lesser-Trelat/ Gastric or colon ca


Paraneoplastic Pemphigus/ Non-Hodgkins lymphoma, CLL, thymoma

Acquired hypertrichosis lanuginosa

Abrupt onset of soft hair on face > trunk, extremitites
Lung cancer most common
May have associated glossitis

Pyoderma gangrenosum

typically as a painful nodule or pustule that evolves to an enlarging necrotic ulcer with undermined violaceous borders.
Acute myeloid leukemia,multiple myeloma

Acquired Ichthyosis/ Hodgkins disease



Erythroderma/ Lymphoma and leukaemias












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