DermatologyDermatology

Board Review 2005Board Review 2005Julia Akaah M.D.Julia Akaah M.D.

Case 1Case 1

6 month old infant has a 2 month history of 6 month old infant has a 2 month history of erythematous erosions around the mouth, erythematous erosions around the mouth, hands, feet, and in the perineum. There is hands, feet, and in the perineum. There is crusting of the scalp and hair is sparse. crusting of the scalp and hair is sparse. The infant has experienced diarrhea and The infant has experienced diarrhea and poor weight gain for the past month. The poor weight gain for the past month. The infant was weaned from breast milk to infant was weaned from breast milk to formula at 2 months of ageformula at 2 months of age

Acrodermatitis enteropathicaAcrodermatitis enteropathica

AR disorder associated with defective transport AR disorder associated with defective transport protein in the GI tract, resulting in impaired protein in the GI tract, resulting in impaired absorption of dietary zincabsorption of dietary zinc

Human milk contains a protein that facilitates Human milk contains a protein that facilitates xinc absorption therefore symptoms appear after xinc absorption therefore symptoms appear after infant is weanedinfant is weaned

Zinc deficiency occurs with CF, celiac disease Zinc deficiency occurs with CF, celiac disease and patients on TPN w/o zincand patients on TPN w/o zinc

Zinc deficiency Zinc deficiency altered keratin synthesis altered keratin synthesis Diagnosis is confirmed by low serum zinc levelsDiagnosis is confirmed by low serum zinc levels Tx: zinc sulfate 5mg/kg/d with topical Tx: zinc sulfate 5mg/kg/d with topical

corticosteroidscorticosteroids

Case 2Case 2

You are asked to evaluate a boy with dry You are asked to evaluate a boy with dry skin. He has history of mild atopic skin. He has history of mild atopic dermatitis. The boy’s father also has scaly dermatitis. The boy’s father also has scaly skin and allergic rhinitis. PE reveals skin and allergic rhinitis. PE reveals generally dry skin and thin scales that generally dry skin and thin scales that have a “pasted on” appearance on the have a “pasted on” appearance on the extensor surface of the legs and butttocksextensor surface of the legs and butttocks

Ichthyosis vulgarisIchthyosis vulgaris

Ichthyosis describes group of inherited and Ichthyosis describes group of inherited and acquired disorders of keratinization which are all acquired disorders of keratinization which are all associated with scalingassociated with scaling

Ichthyosis vulgaris is most common: AD, Ichthyosis vulgaris is most common: AD, apparent between 3m to 5 yearsapparent between 3m to 5 years

Thin scales with elevated edges, with pasted on Thin scales with elevated edges, with pasted on appearance, extensor surfaces of lower appearance, extensor surfaces of lower extremities, trunk and upper extremities (face extremities, trunk and upper extremities (face antecubital and popliteal fossa are spared)antecubital and popliteal fossa are spared)

Improves over timeImproves over time 50% of children also have atopic dermatitis50% of children also have atopic dermatitis Treatment: Keratolytics (lactic a., glycolic a, urea Treatment: Keratolytics (lactic a., glycolic a, urea

based emolliants) and oral retinoids in severe based emolliants) and oral retinoids in severe casescases

Case 3Case 3

You are asked to evaluate a 1 day old You are asked to evaluate a 1 day old healthy term infant with a rash. Scattered healthy term infant with a rash. Scattered pustules without surrounding erythema pustules without surrounding erythema involving the trunk and forehead and involving the trunk and forehead and several small hyperpigmented macules, several small hyperpigmented macules, some of which possess a collarette of some of which possess a collarette of scalescale

Transient neonatal pustular Transient neonatal pustular melanosismelanosis

Condition begins in uteroCondition begins in utero At birth there are pustules and 2-3 mm At birth there are pustules and 2-3 mm

hyperpigmented maculeshyperpigmented macules Macules are surrounded by collarette of Macules are surrounded by collarette of

scale that represents remnant of a pustule scale that represents remnant of a pustule roofroof

A gram or Wright stain will reveal PMNs A gram or Wright stain will reveal PMNs without organismswithout organisms

Benign self limited disorderBenign self limited disorder Diff dx: erythema toxicum, neonatal acne, Diff dx: erythema toxicum, neonatal acne,

miliamilia

Case 4Case 4

Your are asked to evaluate a 1 day old full Your are asked to evaluate a 1 day old full term, healthy infant with a rash. There are term, healthy infant with a rash. There are erythematous macules and in the center of erythematous macules and in the center of each macule is a solitary papule or each macule is a solitary papule or occasionally a vesicleoccasionally a vesicle

Erythema ToxicumErythema Toxicum

Benign, self limited eruption occurs in 50% Benign, self limited eruption occurs in 50% of term newbornsof term newborns

Develop 2-3 cm erythematous macules Develop 2-3 cm erythematous macules that have a central papule, pustule or that have a central papule, pustule or vesiclevesicle

Can involve any body surface area except Can involve any body surface area except palms or solespalms or soles

Eruption begins 24-48 hours of life and Eruption begins 24-48 hours of life and lasts 4-5 dayslasts 4-5 days

Wright stain of vesicles reveals Wright stain of vesicles reveals eosinophilseosinophils

DDx: milia, neonatal acne, and transient DDx: milia, neonatal acne, and transient pustular melanosispustular melanosis

Case 5Case 5

18 month old boy presents with 2 month 18 month old boy presents with 2 month history of recurring pruritic eruption. history of recurring pruritic eruption. Outbreaks last 1-2 weeks. No one else in Outbreaks last 1-2 weeks. No one else in the household is similarly affected. the household is similarly affected. Physical exam reveals clustered Physical exam reveals clustered erythematous papules 4-6mm in diameter. erythematous papules 4-6mm in diameter. Several papules have a central punctum. Several papules have a central punctum.

Papular urticariaPapular urticaria

Delayed hypersensitivity reaction to stinging or Delayed hypersensitivity reaction to stinging or biting arthropods (dog or cat fleas, mosquitos, biting arthropods (dog or cat fleas, mosquitos, lice, grass mites etc.)lice, grass mites etc.)

Affected children are 18 months to 7 years and Affected children are 18 months to 7 years and only members of household to have symptomsonly members of household to have symptoms

Each crop of papules last 2-10 days and Each crop of papules last 2-10 days and recurrences may be observed for 3-9 monthsrecurrences may be observed for 3-9 months

Tx: remove the offending agent, topical Tx: remove the offending agent, topical corticosteroid and oral antihistamine if pruritis is corticosteroid and oral antihistamine if pruritis is severe, apply insect repellent (with DEET) if severe, apply insect repellent (with DEET) if outdoor insects are implicatedoutdoor insects are implicated

Case 6Case 6

14 yo girl with tuberous sclerosis comes 14 yo girl with tuberous sclerosis comes for evaluation of rash on the face. The for evaluation of rash on the face. The only medication she takes is felbamate for only medication she takes is felbamate for seizures. Examination of face reveals seizures. Examination of face reveals numerous 1-3 mm pink papules in the numerous 1-3 mm pink papules in the malar areas bilaterallymalar areas bilaterally

Adenoma sebaceumAdenoma sebaceum

These lesions are angiofibromas, benign These lesions are angiofibromas, benign tumorstumors

Appear during childhood or adolescence Appear during childhood or adolescence but occasionally observed at birthbut occasionally observed at birth

These lesions do not involute and may These lesions do not involute and may coalesce to form plaquescoalesce to form plaques

Case 7Case 7

8 year old presents with localized loss of 8 year old presents with localized loss of scalp hair of 2 months duration. PE scalp hair of 2 months duration. PE reveals patch of alopecia within which reveals patch of alopecia within which hairs are of differing lengths. Remainder hairs are of differing lengths. Remainder of the scalp is normal with no erythema, of the scalp is normal with no erythema, scaling, or “black dot” hairsscaling, or “black dot” hairs

TrichotillomaniaTrichotillomania

Alopecia from repetitive twirling, rubbing, Alopecia from repetitive twirling, rubbing, or plucking of the hairor plucking of the hair

Scalp, eyebrows and lashes are affectedScalp, eyebrows and lashes are affected Often result of habit and stressOften result of habit and stress Irregularly shaped patch of alopecia Irregularly shaped patch of alopecia

without erythema or scaling containing without erythema or scaling containing hairs of differing lengthshairs of differing lengths

Diff Dx: traction alopecia, alopecia areata Diff Dx: traction alopecia, alopecia areata and tinea capitusand tinea capitus

Case 8Case 8

Healthy 14 yr old girl is worried about an Healthy 14 yr old girl is worried about an area of skin thickening, tightness and area of skin thickening, tightness and discoloration, that developed 3 months discoloration, that developed 3 months ago. No trauma and no associated ago. No trauma and no associated symptoms. PE shows shiny symptoms. PE shows shiny hypopigmented patch with a brown border, hypopigmented patch with a brown border, skin is immobile and firm and has bound skin is immobile and firm and has bound down feelingdown feeling

Linear sclerodermaLinear scleroderma

Scleroderma is a C.T. disorder with Scleroderma is a C.T. disorder with autoimmune etiologyautoimmune etiology

Lesions begin as an area of indurated skin Lesions begin as an area of indurated skin surrounded by a violaceous halo. Over surrounded by a violaceous halo. Over time the violaceous halo takes on a waxy, time the violaceous halo takes on a waxy, ivory appearance. As the disease remits it ivory appearance. As the disease remits it becomes atrophic with hyper and becomes atrophic with hyper and hypopigmentationhypopigmentation

Linear scleroderma develops in band like Linear scleroderma develops in band like distribution, unilateral, involve extremities, distribution, unilateral, involve extremities, face and trunkface and trunk

Self limited with disease activity lasting 3-5 Self limited with disease activity lasting 3-5 yrsyrs

Morbidity when face is involved or joint Morbidity when face is involved or joint function is compromisedfunction is compromised

Case 9Case 9

7 year old girl develops widespread linear 7 year old girl develops widespread linear red papules and vesicles over her arms red papules and vesicles over her arms and legs. Seven days earlier she had and legs. Seven days earlier she had been riding her bike in the woods with her been riding her bike in the woods with her dog. The rash began 3 days ago and new dog. The rash began 3 days ago and new blisters are continuing to developblisters are continuing to develop

Rhus dermatitis (poison ivy)Rhus dermatitis (poison ivy)

Poison ivy is a type IV delayed hypersensitivity Poison ivy is a type IV delayed hypersensitivity reaction that occurs in patients with contact reaction that occurs in patients with contact dermatitisdermatitis

Following a period of sensitization of 1-2 wks Following a period of sensitization of 1-2 wks predisposed individuals develop a cutaneous predisposed individuals develop a cutaneous reaction on re-exposure to allergenreaction on re-exposure to allergen

Following exposure to poison ivy, the skin rash Following exposure to poison ivy, the skin rash can spread for several dayscan spread for several days

Langerhans cells process the contact allergen Langerhans cells process the contact allergen and vary over the skin surfaceand vary over the skin surface

Reaction subsides over 2-4 weeks if no Reaction subsides over 2-4 weeks if no treatment giventreatment given

Tx: cool tap water compresses, topical lotions Tx: cool tap water compresses, topical lotions and steroids and antihistaminesand steroids and antihistamines

Case 10Case 10

40 year old female comes in for evaluation 40 year old female comes in for evaluation of flushing around the nose and cheeks of flushing around the nose and cheeks associated with dilated veinsassociated with dilated veins

RosaceaRosacea

Pustular eruption with Pustular eruption with flushing and flushing and telangiectasias of the telangiectasias of the butterfly area of the butterfly area of the faceface

Adults 40-60yrs of Adults 40-60yrs of ageage

Severe longstanding Severe longstanding cases eventuate in cases eventuate in the bulbous, greasy, the bulbous, greasy, hypertrophic nose hypertrophic nose characterisitic of characterisitic of rhinophymarhinophyma

Pustules are recurrent and difficult to healPustules are recurrent and difficult to heal Disease is influenced by oily skin, Disease is influenced by oily skin,

excessive alcohol ingestion, spicy foods excessive alcohol ingestion, spicy foods and hot drinks, sun exposure and stressand hot drinks, sun exposure and stress

Tx: avoidance of chocolate, nuts, cheese, Tx: avoidance of chocolate, nuts, cheese, cola, alcohol, spices, seefoodcola, alcohol, spices, seefood Metronidazole gel, tetracyclineMetronidazole gel, tetracycline