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