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Syringoma
Syringomas are small, firm, skin-colored papules occurring most commonly in women around the eyelids, upper chest and on the vulva.
They are benign tumors of the eccrine sweat glands.
Sebaceous Hyperplasia
Sebaceous Hyperplasia is a common, benign condition consisting of yellow minimally elevated papules usually found on the face.
Usually a papule is derived from the enlargement of sebaceous glands around an central enlarged sebaceous gland.
Pilar or Trichilemmal Cyst
*Pilar or Trichilemmal Cyst is a benign, firm, subcutaneous, keratin-filled cyst originating from the hair follicle.
*Most commonly found on the scalp.
*Therapy
- None
- Incision and drainage
- Excision
Epidermal Cyst
An epidermal cyst is a benign flesh-colored, dome-shaped, firm, but often malleable keratin filled nodule derived from the lining of the hair follicle.

There may be a central pore.

There is semisolid whitish, cheesy, foul-smelling material that is trapped within.

Therapy
- None
- Incision and drainage
- Excision
Chondrodermatitis Nodularis Helicis
Chondrodermatitis nodularis helicis is an inflammatory condition of the helical ear cartilage with a firm, tender, red to pink papule with a central crust or scale.
Nevus Sebaceous
*Starts at birth as a yellowish plaque of hair loss on the scalp then becomes verrucous into adulthood.

*Benign and malignant tumors may develop within it.
Keratoacanthoma
*Keratoacanthoma is a rapidly growing crater-like (volcano-like) nodule with a central keratotic plug or keratinous cavity.

*Although they have spontaneous resolution after several months, they are best regarded as a low-grade squamous cell carcinoma.
Keloids
A keloid represents excessive proliferation of collagen (scar tissue) after trauma to the skin.

A keloid appears as an elevated, firm, protuberant nodule or plaque that extends beyond the area of trauma or injury

Occur most often in African-Americans

Therapy for Keloids
Monthly intralesional steroids: Kenalog-40 mg/ml
Surgery followed by monthly intralesional steroids
Pressure earrings or pressure dressings.
Silicone gel dressings
Dermatofibrosarcoma Protuberans
Low-grade malignant fibrous tumor that resembles a dermatofibroma, grows slowly but persistently and rarely metastasizes.
Dermatofibroma
A Dermatofibroma is a common benign tan, pink or brown firm papule or nodule that is more indurated than elevated due to a focal area of dermal fibrosis.

Pinching the lesion results in the “dimple sign”. It dimples on compression.

Thighs and legs are common locations.

The origin is unknown, but trauma like an insect bite may be an initiating factor.

Sometimes they itch.
No treatment is needed.
Skin Tags (Acrochordons)
A skin tag is a benign soft, flesh colored, tan or dark pedunculated ,fleshy papules that may have a smooth or folded surface.

Predilects skinfolds in overweight persons: axillae, neck,

inframammary area, inquinal region, and eyelids.
No association exists between skin tags and colonic polyps.
Stucco Keratoses
Stucco keratoses describe the small, whitish seborrheic keratoses more commonly found on the lower legs and ankles of older Caucasian people.
Dermatosis Papulosa Nigra
Dermatosis papulosa nigra are the seborrheic keratoses on the face more commonly seen in Africa-American people.

Sign of Leser-Trélat - The sudden explosive onset of numerous seborrheic keratoses in association with internal malignancy.
Seborrheic Keratosis
Definition: a seborrheic keratosis is a common benign growth of epidermal cells that clinically appears as a scaling, “stuck-on” appearing papule or plaque.

Multiple seborrheic keratoses may be inherited.

Usually appear in middle age and increase in number with age.

Physical exam: 2 mm – 2 cm, slightly to markedly elevated, flesh colored to tan, brown, or occasionally black, oval to round, greasy appearing, stuck-on appearing, verrucous or crumbly in appearance.

Lesions occur on the head, neck, trunk, and extremities, sparing the lips, palms and soles.
Solar Lentigines & Lentigo (Plural Lentigines)

The Plural Lentigines (Lentigo) is seen on the mouth pic
Solar lentigines are common in sun-exposed Caucasian people as a response to actinic damage.

Lesions tend to be larger, 2 – 20 mm macules and patches

Therapy
- Cryosurgery
- Laser
- Tretinoin cream
- Mequinol plus tretinoin solution (Solagé)
- Sunscreen
Juvenile Lentigines
Juvenile lentigines appear in childhood.

They are 2 – 10 mm macules that are usually darker than freckles.

They do not increase in number or size or darken in color in response to sunlight, and do not fade in the absence of sunlight.
Freckles
Freckles appear in childhood and occur as an autosomal dominant trait.

They are usually confined to the face, arms, and upper trunk.

They increase in number and darken in color in response to sun exposure.
Idiopathic Guttate Hypomelanosis
Idiopathic guttate hypomelanosis is characterized by 2 – 5 mm white and hypopigmented spots with regular borders.

It is usually located on sun-exposed upper and lower extremities of middle-age and elderly people.

The condition is asymptomatic.
There is no treatment.
Vitiligo
Vitiligo is an acquired condition in which functional melanocytes disappear from the affected skin resulting in totally white, non-scaling, sharply demarcated macules and patches.

Vitiligo is an acquired condition in which functional melanocytes disappear from the affected skin resulting in totally white, non-scaling, sharply demarcated macules and patches.

Depigmented areas are at an increased risk for sunburn and subsequent skin cancers
Porphyria Cutanea Tarda
Porphyrias represent abnormalities in the pathway for heme synthesis.

Porphyria cutanea tarda is the most common form of porphyria.

It mostly affects middle-aged men and women, and younger women on oral contraceptives.

Alcohol and estrogens are associated with more than 80% of cases

Blisters occur in sun-exposed areas such as the face and neck, the dorsa of the hands, and forearms.

Blisters rupture leaving erosions and ulcers that heal with scarring.

Milia are cysts that form in previously blistered sites on the hands.

Porphyria cutanea tarda can be seen in people with liver disease from ethanol abuse, estrogens, aromatic hydrocarbons; benign, malignant or metastatic tumors; chronic renal failure; sarcoidosis; hepatitis C; hepatitis B, and HIV infection.

Treatment
- Discontinue alcohol
- Wear sunscreen
- Iron removal by phlebotomy is the treatment of choice. It - reduces hepatic iron stores and produces remissions of several years durations.
- Combined treatment with repeated bleeding and chloroquine results in remissions in an average of 3.5 months.
Polymorphous Light Eruption
In polymorphous light eruption, lesions recur usually in the spring with first sun exposure.

Lesions appear 2 hours to 5 days after sun exposure.

Initial symptoms are burning, itching, and erythema on exposed skin such as the upper chest, back of the hands, extensor aspects of the forearms and the lower legs.

Lesions may be
- Papular
- Plaque type
- Papulovesicular

There is a hereditary form that can develop in Native Americans
Ultraviolet A light is the trigger
Sun-Damaged Skin
Actinic-Damaged Skin Photoaging :)
Solar elastosis: Numerous yellowish globules in the dermis can be seen through the thin, atrophic epidermis.

Leathered wrinkling is a sign of severe sun damage.

Reactive hyperplasia of melanocytes causes lentigines on the upper back. Diffuse persistent erythema is most prominent in fair-skinned people. Sun-induced wrinkling on the back of the neck shows a series of crisscrossed lines.

Fragile sun-damaged skin is easily torn and heals with haphazard scars called stellate pseudoscars.

Actinic comedones. Open and closed comedones are present in the periorbital areas. Acne-like inflammation does not occur.
Morphea
Morphea is localized scleroderma confined to the skin.
Morphea appears as a sharply demarcated indurated plaque, which may be flat, slightly elevated, or slightly depressed.

Linear scleroderma is more common on the extremities than the face.
“En coup de sabre” is the term for linear scleroderma affecting the forehead and scalp
Scleroderma
Scleroderma is a connective tissue disease with an increase in the number and activity of fibroblasts producing excessive collagen which results in thickening of the dermis. Parchment-like appearance.

Involvement of the digits produces thickened skin, sausage shaped digits that are tapered toward the fingertips (sclerodactyly)

Serum ANA pos in 70-90% of cases.

Therapy
- Steroids
- Immunosuppressants
- Physical therapy

It may be helpful to apply heat to help skin hardening.
Moisturizer

Can affect multiple organ systems with fibrosis:
Skin, GI tract, resp tract, kidneys
Dermatomyositis
Dermatomyositis is an acquired idiopathic connective tissue disease characterized by proximal muscle weakness and a characteristic, violaceous skin rash prominent on the eyelids, scalp, metacarpophalangeal joints and bony prominences.

Female: male = 2:1
The heliotrope rash is the violaceous erythema of the eyelids.

Pathognomonic Gottron’s papules are the violaceous papules and plaques located over bony prominences, particularly the PIP, DIP, MCP joints, elbows, knees, and medial malleoli.

The shawl sign refers to the violaceous erythema over the back of the neck and posterior shoulders.
Increased risk of malignant neoplasm in 15-20% of the cases particularly lung cancer
Acute Cutaneous Lupus Erythematosus
Acute cutaneous lupus erythematosus is a serious multisystem disease with the possibility of fever, arthritis, renal, cardiac, pulmonary and central nervous system involvement.
Women out-number men 8:1.
Sunlight exacerbates and may induce the condition.

Non-pruritic, erythematous to violaceous plaques appear on the sun-exposed chest, shoulders, extensor arms, and backs of the hands.
10 – 50% of the patients have a butterfly rash appearing over the malar and nasal bridge.
Subacute Cutaneous Lupus Erythematosus
Subacute lupus erythematosus is a form of cutaneous lupus erythematosus typically characterized by lesions on the upper trunk, nape of the neck, upper back and shoulders, extensor arms, face and dorsal hands.
Two patterns:
Papulosquamous lesions that have scale similar to psoriasis
Annular, polycyclic lesions with minimal scale.

Lesions lack the follicular plugging, hyperkeratosis, scarring and dermal atrophy of chronic cutaneous (discoid) lupus.
Chronic Cutaneous Lupus
Chronic cutaneous lupus is the most common form of cutaneous lupus erythematosus.
Lesions may be localized or widespread papules and plaques often with central atrophy and scarring.
An older term is discoid lupus erythematosus

Lesions are well-defined, elevated, red to violaceous, 1 – 2 cm, flat-topped plaques with firmly adherent scaling.
Follicular plugs are prominent. Peeling the scale reveals an under-surface that looks like a carpet penetrated by several carpet tacks.
Epidermal atrophy gives the surface either a smooth white or wrinkled appearance.

Chronic lupus erythematosus is more common in women and African-Americans.
Trauma and ultraviolet light may initiate and exacerbate lesions.
Lesions may occur on any body surface, but the scalp, face, and ears are the most common areas.
Scarring alopecia is permanent hair loss.
Chronic Cutaneous Lupus
Chronic cutaneous lupus is the most common form of cutaneous lupus erythematosus.
Lesions may be localized or widespread papules and plaques often with central atrophy and scarring.
An older term is discoid lupus erythematosus

Lesions are well-defined, elevated, red to violaceous, 1 – 2 cm, flat-topped plaques with firmly adherent scaling.
Follicular plugs are prominent. Peeling the scale reveals an under-surface that looks like a carpet penetrated by several carpet tacks.
Epidermal atrophy gives the surface either a smooth white or wrinkled appearance.

Chronic lupus erythematosus is more common in women and African-Americans.
Trauma and ultraviolet light may initiate and exacerbate lesions.
Lesions may occur on any body surface, but the scalp, face, and ears are the most common areas.
Scarring alopecia is permanent hair loss.
Lupus Erythematosus
Cutaneous lupus erythematosus is a disease with a wide spectrum of skin and/or internal manifestations caused by autoantibodies directed against cell components.
SLE - Systemic lupus erythematosus is an autoimmune disorder in which virtually any kind of skin lesion can occur, including macules, papules, plaques, bullae, purpura, subcutaneous nodules, and ulcers.

Women (especially those of childbearing age) outnumber men 6:1
There are 3 Types of Chronic Cutaneous Lupus Erythematosus
Bullous Pemphigoid
Bullous pemphigoid is a blistering disease primarily in elderly people.
Lesions begin with erythema, then pruritic urticarial papules coalescing into plaques with a predilection for skinfolds and flexural areas and dependent areas.

Firm pressure on the blister will not result in extension into normal skin as occurs in pemphigus.
Bullae rupture within 1 week. Leaving an eroded base which does not spread and which heals rapidly.

The goal of treatment is to arrest blistering (with steroids and immunosuppressive drugs), decrease itching, protect the skin and limit secondary infection.
Pemphigus Foliaceus
There is an increased incidence of thymoma, myasthenia gravis, and other autoimmune disease.
Early localized disease may be managed with prescription strength topical steroids.
Active widespread disease is treated aggressively like pemphigus vulgaris.

Lesions appear in a “seborrheic distribution” on the face or first appear on the scalp, chest, or upper back.
The vesicle roof is so thin that it ruptures and serum leaks out and desiccates, forming areas of crust.

There is an increased incidence of thymoma, myasthenia gravis, and other autoimmune disease.
Early localized disease may be managed with prescription strength topical steroids.
Active widespread disease is treated aggressively like pemphigus vulgaris.
Pemphigus Vulgaris
Pemphigus Vulgaris is a potentially life-threatening autoimmune blistering disease involving the skin and mucous membranes.
Bullae rupture easily because the blister roof is very fragile.

Traction pressure on intact skin causes bullae formation (Nikolsky’s sign).
Painful oral erosions occur in 50 -70% of patients and typically precede the skin blisters by weeks or months.

The goal of treatment is to arrest blister formation with steroids and immunosuppressive drugs.
In the past, death occurred often and was usually from infection. Nowadays, death occurs in 5 – 15% of cases and is usually a complication of steroid therapy.
Dermatitis Herpetiformis
Dermatitis herpetiformis is a chronic, intensely pruritic blistering disease associated with a gluten-sensitive enteropathy.
Symmetrically distributed blisters or excoriations are symmetrically distributed on the elbows, knees, sacrum and base of the scalp, but may be generalized.

The severity of the skin disease does not correlate with the degree of intestinal involvement.
There is an increased risk of lymphoma which is reduced with gluten-free diet.
Seabather's Eruption
Seabather's eruption. A common problem in the Caribbean. Nematocyst-bearing larvae may be trapped under the bathing suit and produce an intensely itching and painful papular eruption.

It is advisable to bring a bottle of vinegar to the beach, because rubbing the affected area or washing with fresh water can cause nematocysts to discharge. Saturating the area with vinegar immobilizes unspent nematocysts.
Swimmer's Itch (Schistosomiasis)
Swimmer’s itch is a pruritic inflammatory response to the larvae released from a snail that accidentally penetrate human skin.
The parasites are obtained while swimming in fresh-water lakes.
As the water evaporates from the swimmer’s skin, the larvae penetrate causing highly pruritic, red, edematous, bite-like papules and occasionally pustules
Lesions are in areas not covered by the swimming suit.
The eruption is self-limited
Fire Ant Stings
Fireants have prominent inward-curving jaws and stingers on their tails.
The bite causes a painful pustular lesion.
The classic lesion is two pinpoint red dots (the bite) surrounded by a ring of pustules (the stings)
Cutaneous Larva Migrans (Creeping Eruptions)
Cutaneous larva migrans is caused by the aimless wandering of the hookworm larvae within the skin.
The lesions typically begin about 3 weeks after a beach vacation in the Caribbean, Africa, South America, southeast Asia, or even the southeastern USA.
The larvae can penetrate the skin when humans walk on moist feces-contaminated sand.
A serpiginous red to purple lesion with a 3 mm wide tract is characteristic
Rocky Mountain Spotted Fever
Rocky Mountain spotted fever is a potentially lethal disease caused by Rickettsia rickettsii, a short Gram-negative bacteria.
The infection is characterized by an acute onset of fever, a severe headache, myalgia, vomiting and a petechial rash that starts on the wrists and ankles, involves the palms and soles, then becomes generalized.
The rash does not occur at all in about 15% of cases.
Flea Bites
The typical eruption for flea bites is papules on the legs.
Initially, tiny red dots or bite puncta may be seen, often grouped around the ankles.
Lyme Disease
Lyme disease is a tick-borne disease caused by the spirochete Borrelia burgdorferi.
The cutaneous eruption of Lyme disease is called erythema migrans which is a slowly enlarging ring of erythema that may last 2 – 3 weeks.

The typical eruption for flea bites is papules on the legs.
Initially, tiny red dots or bite puncta may be seen, often grouped around the ankles.
Brown Recluse Spider Bite
The bite of the brown recluse spider (Loxosceles reclusa) may cause necrotic skin lesions

The spider is yellow, tan or brown in color and can be identified by a dark brown, violin-shaped marking on its cephalothorax (hence the name the fiddle-back spider).
The body length is 10-15 mm and the leg and is about 25 mm

The bite site may show localized hive-like reaction with minimal redness and swelling early in the course. A cyanotic color, followed by expanding necrosis of the skin develops within days.
Black Widow Spider Bite
The adult female black widow spider (Latrodectus mactans) is about 3 – 4 cm in length and has a shiny, fat abdomen resembling a large grape.
The black widow spider has a characteristic red hourglass-shaped marking on the ventral surface of the abdomen
The clinical appearance is variable; typically erythema or swelling occurs at the bite site.
Cramping abdominal pain is common and is the classic presenting complaint.
Chiggers
Chiggers or "red bugs" are the larvae of mites belonging to the family Trombiculidae.
In humans, chiggers can cause intense itching and small reddish welts on the skin.
The intense irritation and subsequent scratching may result in secondary infection.

Chiggers attach themselves to the skin, hair follicles or pores by inserting their piercing mouthparts.
When chiggers attach to humans, they are not usually noticed for some time.
During feeding, they inject a fluid into the skin which dissolves tissue.

Chiggers feed by sucking up the liquefied tissues.
The human immune reaction to a bite prevents the chigger from obtaining adequate nourishment resulting in their survival rate to be less than a full meal.

Chiggers favor the legs and areas of tight fitting clothes
BedBug
Bed bugs are small, oval, non-flying insects that belong to the insect family Cimicidae.
Bed bugs are most active at night and bite any exposed areas of skin while an individual is sleeping. The face, neck, hands, and arms are common sites for bed bug bites.

The bite itself is painless and is not noticed. Small, flat, or raised bumps on the skin are the most common sign; redness, swelling, and itching commonly occur.
If scratched the area may become infected.

A peculiarity of bed bug bites is the tendency to find several bites lined up in a row which is a sign signifying the sequential feeding that occurs from site to site.
Bed bugs also have glands whose secretions may leave odors, and they also may leave dark fecal spots on bed sheets and around their hiding places
Bee Stings
Honey bees are the most common source of insect stings and can cause severe allergic reactions
The stinger of the honey bee separates from the bees abdomen while stinging and remains embedded in the vertebrate’s tissue
The stingers of other bees and wasps do not detach
The stinger should be removed as fast as possible. A delay of just a few seconds in removing the stinger leads to greater venom delivery

A hive or raised pink wheal with a central pinpoint red punctum appears minutes after the sting and lasts for about 20 minutes.
Angioedema may occur, which is a localized reaction that appears thick, hard and edematous over an area as large as 10 – 50 cm
Tungiasis
Another less common type of myiasis is caused by a red-brown sand flea called Tunga penetrans
Tungiasis is seen on the soles, toe webs, and ankles of travelers returning from Africa or Central or South America
Botfly Myiasis
Myiasis is an infestation of the body tissues of animals or humans by the larval stage of non-biting flies.
Dermatobia hominis causes human botfly infestation.
Botfly life cycle:
The female botfly glues her eggs to the abdomen of a mosquito or tick which deposits the larvae while biting or feeding
At maturation, the larva exits the body and drops to the ground and matures into an adult fly.

Skin findings
The tender red nodule is about 2 – 5 mm in diameter
Lesions are typically found on the scalp, face or upper arms or chest
The larval breathing tube is mobile and can be seen opening and closing within the skin about once every minute
An enlarged cyst-like structure enlarges over days to weeks and is known as a “warble”
Head Lice
Treatment
Permethrin rinse 1% (Nix creme rinse)
Lice (Pediculosis)
Lice are flattened, wingless insects with 3 pairs of legs that infest hair of the scalp, body and pubic region.


Lice attach to the skin and feed on human blood.
Nits are lice eggs attached to the hairs.

Lice feeds on human blood every 3 to 6 hours.
Females lay eggs (nits) that hatch every 10 days
Moderate to severe itching in the affected area worse at night causing crusted excoriations most commonly in the scalp, body and pubic areas but can migrate to the armpits and eyebrows.
Secondary bacterial infections are possible.
Scabies
The itching and inflammation are thought to results from a hypersensitivity reaction to the foreign material (mite, eggs, and feces).
Itching may persist after adequate treatment due to allergic response to dead mites, eggs, and feces.

Physical exam:
The diagnostic finding is a burrow which appears as a 1-2 mm wide delicate, white, linear, curved or S-shaped superficial, thread-like line especially between fingers
small vesicles, papules and excoriations
favors finger webs, wrists, sides of the hands and feet, the penis, buttocks and scrotum.

In infants, vesicles may also be present particularly on the palms and soles.
Nodules may be present in the axillae and on the penis

Norwegian scabies is the crusted variant that occurs in immunocompromised and institutionalized patients and in those with an altered mental status.
The lesions in Norwegian scabies contain numerous mites.

Scabies Prep
Scrape a burrow with a #15 blade, apply scraping to a slide with mineral oil, view the mites, eggs, or scabelum (feces) under microscopy
Panniculitis
Panniculitis refers to a group of disorders that cause inflammation of the subcutaneous fat.
Erythema nodosum is a form of panniculitis
Can affect the fat cells themselves – lobular
Can affect the septa between the cells – septal.

Panniculitis manifests as discrete pink to deep red, tender nodules and firm plaques.
Skin feels thick and woody to touch and may exhibit reddish nodules or lumps under the skin.
Following resolution of the inflammation, the skin may exhibit a depression due to lipodystrophy.
Sweet's Syndrome
Sweet’s syndrome is an acute inflammatory eruption characterized by multiple pink to red tender plaques, associated with fever, malaise, and leukocytosis
Sweet’s syndrome is paraneoplastic (hematological malignancy or solid tumors) in 15 – 20% of patients and may precede the malignancy by up to 6 years.

Sweet’s syndrome lesions erupt acutely and can be painful. They are plum-colored and “Juicy” (pseudovesicular) in appearance.
They can occur on any surface, but tend to occur on the head, neck, legs, arms, dorsal hands, and fingers
Schamberg's Disease (Schamberg's Purpura)
Schamberg’s disease is characterized by petechiae and brown purpuric (rusty colored) patches, occurring most commonly on the lower extremities
It is a lymphocytic capillaritis suggesting a cell-mediated hypersensitivity reaction
It is also known as pigmented purpura.

Patient’s develop multiple distinct orange-brown, pinhead-sized “cayenne pepper” macules with numerous petechiae.
Lesions occur symmetrically on the lower extremities and sometimes on the upper body.
The condition is confined to the skin (no internal disease) and the vast majority of patients improve with time.
Henoch-Schonlein Purpura

(a leukocytoclastic small vessel vasculitis
Henoch-Schonlein purpura is a leukocytoclastic small vessel vasculitis
Characterized by palpable purpura mostly on the buttocks and lower extremities (but they may appear on the upper body)
Other findings include joint pain, abdominal pain and glomerulonephritis.

90% of affected patients are younger than 10 years old.
The peak incidence is during the winter months.
Commonly follows an acute respiratory illness by 1 – 2 weeks, suggesting that infection is an important factor.
Caused by circulating IgA antibody deposited in small venules.
Vasculitis - Cutaneous Vasculitis
Cutaneous vasculitis is a group of small blood vessel diseases of the skin caused by circulating immunoglobulin's (IgA, IgM, IgG, IgE) that deposit in the small blood vessels.
In some instances the immune complexes deposit in the eyes, joints, kidneys, lungs, heart and nervous system resulting in end stage organ failure

Causes of cutaneous vasculitis include
Infections and Sepsis
Chemicals
Food allergens
Connective tissue disease
Malignancies
Drugs
Idiopathic

Treatment consists of
removal of precipitating agents
appropriate treatment of coexistent disease
Cutaneous Small Vessel Vasculitis
(Hypersensitivity Vasculitis)
When the skin is affected by vasculitis, lesions are elevated (palpable) because of inflammation and edema and purpuric because of extravasation of blood from damaged blood vessels.
The result is purpuric papules (palpable purpura)
Lesions are mostly located on the legs
Erythema Nodosum
Erythema nodosum is a panniculitis (inflammation of the fat cells) characterized by symmetrical pink to dusky red tender nodules on the extensor surface of the lower legs.
Frequently accompanied with fever and arthralgia.

Women out-number men 6:1
Thought to be due to a hypersensitivity reaction to a variety of antigenic stimuli like streptococcal infections and sarcoidosis.
Toxic Epidermal Necrolysis
Toxic epidermal necrolysis is a rare life-threatening mucocutaneous disease characterized by widespread blistering and sloughing of the skin and mucous membranes.
The cause is unknown, but drugs and infection can precipitate toxic epidermal necrolysis.

Most patients develop diffusely red “sunburn-like” tender skin with scattered target lesions and bullae. Bullae quickly coalesce, resulting in widespread skin sloughing.
Gentle lateral pressure easily produces epidermal detachment (Nikolsky’s sign)
Stevens-Johnson Syndrome
A form of toxic epidermal necrolysis that can be life threatening that involves cell death and separation of the dermis from the epidermis.
Blindness and visual impairment is common.

Stevens-Johnson syndrome is a severe blistering syndrome involving the skin and at least 2 mucous membranes. It is similar to erythema multiforme and is usually caused by drugs or infection.

Mortality may be predicted with the use of the SCORTEN scale which includes:
age
associated malignancies
heart rate
serum BUN
area of skin involved
serum bicarbonate and glucose

Erythema Multiforme
Erythema multiforme is a relatively common, acute – often recurrent - inflammatory disease characterized by target-shaped skin lesions.
It is characterized clinically by a variety of lesions, including erythematous plaques, blisters and “target” lesions.

The cause is unknown although it is thought to be caused by immune complexes being deposited in the microvasculature of the skin or mucus membranes.
Recurrent disease is caused most often by herpes simplex infection.
Mycoplasma pneumoniae infection and upper respiratory tract infections are precipitating events in some patients.

Target or “iris” lesions have
a central dark red purpuric or blistered area surrounded by
a pale edematous zone surrounded by
a sharp discrete ring of erythema.

This disorder most often affects older children and young adults. The lesions are pruritic and may have a burning sensation. Characteristically, the distribution of lesions favors the extremities, particularly the palms and soles, and is strikingly symmetric. Target lesions are often present and diagnostic.
This condition is self limiting and usually resolves within 7 to 10 days.
Therapy for Erythema Multiforme, Stevens-Johnson Syndrome & Toxic Epidermal Necrolysis
Treat infection, if present
Discontinue responsible drug, if any
If significant areas of skin are denuded, hospitalize the patient in a burn unit, give supportive care, intravenous immunoglobulin is beneficial and sometimes systemic steroids are used briefly
Uticaria (Hives), 2 pics on the left.

Uticarial Drug Reactions (Hives), upper right pic

Exfoliative Erythroderma (lower right picture) - potentially life threatening
Cutaneous Drug Reactions
The two most common appearances of drug eruptions are hives and morbilliform rashes.
A morbilliform drug rash appears as a generalized eruption of erythematous macules and papules, often confluent in large areas.
There are no laboratory tests available to identify the responsible drug, thus reliance is placed on the history.

Two variables to consider in the history:
the temporal relationship between the initiation of the drug and the onset of the rash
the likelihood that a given drug is likely to cause a drug eruption.
Remember to ask about over-the-counter medications.
Treatment:
Discontinue the offending drug
Antihistamines to control the itch
Oral and topical steroids to decrease the inflammation
Kawasaki Disease

aka

mucocutaneous lymph node syndrome
Kawasaki disease, also known as mucocutaneous lymph node syndrome, is an acute multisystem vasculitis of unknown origin that occurs in infants and young children.
Cardiovascular involvement is the major cause of morbidity.
Most common in Japan
No diagnostic test exists

The rash is polymorphous – has many forms...macules, papules, urticarial-like lesions, and erythema multiforme-like lesions

Treatment:
Intravenous immune globulin
Aspirin
methylprenisolone
Dx is based on having 5 of 6 signs:

-Fever of unknown origin for more than 5 days
-Bilateral conjunctival injection
-Changes of the lips and oral cavity
-Cervical lymphadenopathy
-Polymorphous exanthem with vesicles or crusts
-Changes of the peripheral extremities
Erythema Infectiosum (Fifth Disease)
Erythema infectiosum, also known as “fifth disease” or “slapped cheek syndrome” is a common viral exanthem that causes bright red cheeks and lacy erythema of the arms.
Erythema infectiosum occurs in the winter and spring and is associated with community outbreaks.
It is caused by parvovirus B19 and is transmitted via respiratory secretions, blood, or vertically from mother to fetus.

There is facial erythema – the slapped-cheek appearance. The slapped-cheek appearance fades in 4 days.
Approximately 2 days after the slapped-cheek rash, lacy erythema in a “fish-net” pattern begins on the proximal extremities and extends to the trunk and buttocks, fading in 6 – 14 days.
Palms and soles are spared.
Most infections are self-limited without adverse sequelae.
Roseola Infantum
Roseola infantum is a viral exanthem characterized by high fever followed by the abrupt appearance of a diffuse rash as the fever resolves.
Roseola infantum occurs in infants from the ages of 6 months to 3 years with a peak incidence at 6 months.
Within 2 days of the fever breaking, small pink almond-shaped macules occur on the neck, the trunk, the proximal extremities and face.
Non-Specific Viral Rash

A Viral Exanthem (a rash that arises due to a viral infection)
An exanthem is a rash that occurs as a sign of a systemic disease.
A viral exanthem is a rash that arises due to a viral infection.
Viral exanthems may have different presentations and frequently are a generalized eruption composed of erythematous macules and papules usually preceded by a prodrome of fever and constitutional symptoms.
Give 6 examples of viruses capable of causing non-specific viral exanthems:
non-polio enteroviruses(enterovirus, coxsackievirus, echovirus)
Epstein-Barr virus
human herpes virus-6
human herpes virus-7
parvovirus B-19
respiratory viruses (rhinovirus, adenovirus, parainfluenza virus, respiratory syncytial virus, influenza virus)
Fixed Drug Eruptions
Single or multiple, round, sharply demarcated, dusky red plaques appear soon after drug exposure and reappear in exactly the same site each time the drug is taken.
from L to R, Top to Bottom
Tinea Capitus (scalp), Pedis (interdigital), Manuum (hand)

Pedis (vesiculopustular), Cruris (groing), Barbae

Corporis (body), Faciei (face)
Angular Cheilitis (Perleche)
Angular cheilitis is a chronic recurring inflammation at the angles of the mouth.
Saliva macerates and irritates this small intertriginous area leading to eczema, fissuring and secondary bacterial and yeast infections.
from Top Left, clockwise;
Distal Subungual Onychomycosis
Proximal Subungual Onychomycosis
Candida Onychomycosis
White Superficial Onychomycosis
Pityrosporum (Malassezia) Folliculitis
An infection of the hair follicle caused by the yeast Pityrosporum orbiculare (Malassezia furfur), the same organism that causes tinea versicolor.
Follicular occlusion may be a primary event, with yeast overgrowth as a secondary occurrence.
Diabetes mellitus, broad-spectrum antibiotics or corticosteroids are predisposing factors.
Tinea Versicolor
Tinea versicolor is a superficial infection caused by the lipophilic yeast Pityrosporum orbiculare (Malassezia furfur) that results in altered pigment in the epidermis.
The lesions appear as finely scaling patches that can be pink, tan, brown or white mostly on the neck, trunk, and upper arms.

The organism cannot grow on routine fungal culture; therefore, the diagnosis is made by KOH examination.
The KOH resembles spaghetti and meatballs.
Treatment: Selsun Shampoo, Nizoral Shampoo, prescription antifungal creams and pills
from top L, Clockwise:
1, 4 - Thrush (Oral Candidiasis)
2, 3, 5 - Candidiasis of Large Skinfolds (Candida Intertrigo)
6. Candidiasis (Diaper Dermatitis)
Hand, Foot and Mouth Disease

(Coxsackievirus A-16)
Hand, foot and mouth disease is a highly contagious viral infection that causes aphthae-like oral erosions and a vesicular eruption on the hands and feet.
The classic benign, self-limited form of this disease is associated with coxsackie A16 virus.
It is usually mild, self-limited and resolves without treatment in about 10 days. Keep the child hydrated and give acetaminophen to control pain and fever.
Herpes Zoster

(Shingles)
Herpes Zoster (shingles) is a cutaneous viral infection generally involving the skin of a single or adjacent dermatomes.
It results from a reactivation of varicella-zoster virus that entered the cutaneous nerves during an earlier episode of chicken pox.
10% to 20% of individuals develop herpes zoster during their lifetime.
A prodrome of radicular pain and itching precedes the eruption.
The pain can mimic a migraine, pleurisy, myocardial infarction, or appendicitis.
Post-herpetic neuralgia: pain can persist long after the skin heals.
Differential diagnosis: herpes simplex occurring in a dermatomal fashion.
Physical exam reveals eruptions characterized by groups of vesicles on an erythematous base situated unilaterally along the distribution of a cranial or spinal nerve.
The diagnosis is made clinically, but a Tzanck preparation can confirm the diagnosis.
Chiropractic therapy
Lauric acid 3 caps/ 3 times a day for two
bottles.
Ultrasound to the vesicles.
Plain Ban roll-on applied to the vesicles 4 to 5 times a day.
Adjust
Varicella (Chicken Pox)
Chicken pox is an acute highly contagious, intraepidermal vesicular eruption caused by the varicella zoster virus.
Transmission is via airborne droplets or vesicular fluid.
Most cases occur in children.
Adolescents, adults, and immunocompromised persons have more severe disease and are at risk for complications.


Therapy is mainly symptomatic with the use of antihistamines for itching and Aveeno baths.
There is a varicella vaccine (Varivax) that is given to children prior to exposure.
There is varicella zoster immunoglobulin (passive immunization) that can be given as post-exposure prophylaxis to someone in a high risk group.
Complications can include superinfection with Strep and Staph, pneumonia, encephalitis, and hepatitis.
from top L clockwise
1, 2, Herpes Simplex (cold sores, fever blisters)
3. Herpetic whitlow
4. Eczema herpeticum (Kaposi's varicelliform eruption)
5. Could be Herpes gladiatorum
Physical exam reveals indurated erythema followed by grouped vesicles on an erythematous base.
Vesicles quickly become pustules which erupt, weep, and crust.

A viral culture confirms the diagnosis
A Tzanck smear quickly confirms the diagnosis by swabbing the base of the blister, smearing the material on a glass slide and detecting multinucleated giant cells under the microscope
Allopathic therapy consists of:
Acyclovir (Zovirax)
Valacyclovir (Valtrex)
Famciclovir (Famvir)
Molluscum Contagiosum
Caused by a DNA pox virus that is contagious and spread by skin to skin contact and autoinoculation
Lesions begin as smooth, 1-2 mm shiny. White to flesh-colored, firm papules that often are umbilicated
Common childhood disease
Can be sexually transmitted in adults
Therapy,

Curettage
Cryosurgery with liquid nitrogen
Salicylic acid
Cantharidin
Imiquimod 5% cream
Retin-A
Cimetidine orally
Corn aka clavus and heloma
A corn is a localized thickening of epidermis secondary to chronic pressure, friction, ill-fitting shoes.
Also called clavus and heloma
Occurs at pressure points

On exam, corns are white-gray or yellow-brown, well circumscribed, hyperkeratotic papules or nodules
Paring the surface with a scalpel reveals a translucent core with preservation of skin lines

Paring down with a scalpel
Softening with salicylic acid plaster (Mediplast)
Reduction of trauma – change of shoes, shield the sites with protective pads, rings, and orthotic devices
Surgical correction of the deformity
Warts, from Top L, clockwise
1. Cryosurgery
2. Ring around the Wart (annular configuration at periphery of a blister induced by treatment)
3,4,5 - Retin A, Podofilox, Catharone
Plantar Wart
Located on the sole of the foot
Infection frequently occurs at points of maximal pressure, such as over the heads of the metatarsal bones, the heels or the toes
Round, single or multiple coalescing flesh-colored rough keratotic papules
A “mosaic wart” is cluster of many warts
Black dots are due to thrombosed capillaries
Flat Wart
Has a subtle appearance
These pink, light brown or light yellow papules are slightly elevated, flat-topped, and 1 – 3 mm.
Can spread in a local region through trauma such as shaving or in a line from scratching
Filiform Wart
Is a variant of the common wart
Often occurs on the face.
Has finger-like projections on exam
Common Wart aka Verruca Vulgaris
Definition – benign epidermal proliferation caused by human papilloma virus
On physical exam warts vary in appearance
Common wart (verruca vulgaris)
Filiform wart
Flat wart
Plantar wart
Condyloma acuminatum

Physical Exam:
Flesh-colored firm papule or nodule that has a hyperkeratotic surface
Interrupts the skin lines
Black dots are due to thrombosed capillaries
Common sites are the hands, periungual skin, elbows, knees, and plantar surfaces
Can occur in a linear fashion from autoinoculation