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Dermatology Board Review

Dermatology Board Review. May 24, 2011. Question 1. You just attended the delivery of the infant shown. The parents want to know what is wrong with his skin. What condition is most commonly associated with this finding at birth? Ichthyosis Psoriasis Atopic Dermatitis Epidermolysis Bullosa

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Dermatology Board Review

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  1. Dermatology Board Review May 24, 2011

  2. Question 1 You just attended the delivery of the infant shown. The parents want to know what is wrong with his skin. What condition is most commonly associated with this finding at birth? • Ichthyosis • Psoriasis • Atopic Dermatitis • EpidermolysisBullosa • IncontinentiaPigmenti

  3. Papulosquamous Disorders

  4. Psoriasis • Red, well-demarcated plaques • Covered with dry, thick, silvery scales • Extensor surfaces • Also scalp and bullocks

  5. Psoriasis • Other • Pressure points • Thickening of palms • Guttate Lesions • Drop-like lesions • All over body • After GAS

  6. Psoriasis • Infants • Persistent diaper dermatitis • Indistinguishable from seborrheic diaper dermatitis • Moistness prevents thick scale • Confirm with biopsy

  7. Psoriasis • Koebner phenomenon • Lesions induced at sites of injury • Nail changes • Reddish-brown psoriatic plaques in the nail bed • Oil drop changes • Surface pitting • Distal hyperkeratosis

  8. Psoriasis • Auspitz sign • Hallmark of psoriasis • Small bleeding points when scale removed • Due to thin skin between the epidermal ridges where the scale is close to the subepidermal vessels

  9. Psoriasis • Cause • Rapid turnover of epidermal cells • Inherited predisposition • Precipitated by • URI • Strep infections • Course • Guttate – self-limited • Chronic and unpredictable

  10. IchthyosisVulgaris • AD • 0.5% of population • Fishlike scales by 3 months on extensor surfaces • Not present at birth • Trunk may be involved • Flexural areas spared • Worsens • Winter – dry air • Improves • Summer • With age • Biopsy • Retention hyperkeratosis, thinned granular layer • Treatment • Liberal use of emollients

  11. X-Linked Ichthyosis • 1/6000 males • Occasionally hemizygous females • Newborn findings • Collodion membrane • Typical presentation • 3-12 months • “Dirty” brown scales • Abdomen, back, anterior legs and feet • Central face and flexor areas spared • Biopsy • Increased granular layer and stratum corneum • Decreased or absent steroid sulfatase in the serum and skin

  12. Lamellar Ichthyosis • Rare • <1/250,000 • AD • Newborns • Collodion membrane • 1st month of life • Thick, brownish gray, sheet-like scales with raised edges • Face, trunk, extremities, flexor • Other findings • Eversion and fissuring of the eyelids and lips • Treatment • Topical keratolytics • Lactic acid • Salicylic acid • Oral retinoids • Some improve with age

  13. Collodion Baby • Most common in lamellar ichthyosis • Can be seen in X-linked • At birth • Thick, parchment-like scale • 7-14d • Membrane dries and sheds • Problems • Fluid • Electrolytes • Heat losses

  14. Epidermolytic Hyperkeratosis • Rare AD • Form of Ichthyosis • Features • Generalized, thick, warty scales • Intermittent blistering • May be severe in newborns • Confused with HSV or EB • Severe involvement of flexures • Biopsy • Massive hyperkeratosis, ballooning of squamous cells, formation of vesicles • Treatment • Keratolytics • Lubricants • Antibiotics • Secondary infection • Oral retinoids

  15. Question 2 • What is the most appropriate treatment for this skin condition? • A Topical antibiotics • B Oral antibiotics • C Topical immunomodulators • D Frequent moisturizers Abdomen Near Elbow

  16. Atopic Dermatitis

  17. Atopic Derm • 3 Phases • Infantile (up to age 3) • Red, itchy papules and plaques that ooze and crust • Extensor surfaces • Cheeks, forehead, scalp, trunk • Diaper spared

  18. Atopic Derm • Childhood phase (Age 4-10) • Dry, papular, intensely pruritic • Circumscribed scaly patches • Wrists, ankles, antecubital and poplitealfossae • Palms/Soles cracking, dryness, scaling • 75% improve between ages 10-14y/o

  19. Atopic Derm • Adult Phase • Begins age 12 • Flexural areas of arms, neck, legs • Dorsal surface of hands/feet • Possible marked lichenification

  20. Atopic Derm • Other findings: • Xerosis (dryness) • Ichthyosisvulgaris • Hyperkeratosis pilaris Ichthyosisvulgaris Pityriasis alba

  21. (Hyper)keratosispilaris • Part of atopic derm picture • Keratin plugging of hair follicles • Perifollicular scales • Upper ext, trunk

  22. Atopic Derm • Co-infections • Staph aureus (90%) • Warts • Molluscum • Eczema herpeticum

  23. Atopic Derm • IgE mediated • Familial tendency • Asthma, allergic rhinitis, food allergies • Precipitating factors (Itch-Scratch Cycle) • Food allergens, soaps, wool fabrics, infections, environmental antigens • Spares intertriginous areas

  24. Atopic Derm: Treatment • Avoidance of triggers • Hydration and lubrication • Antipruritic agents • Topical steroids (inflammation and itching)

  25. Dyshidrotic Eczema • Severlypruritic, chronic, recurrent, vesicular eruption • Vescicles symmetrical, multilocular, 1-3mm • Rupture leaving scales/crust on erythematous base • Palms, soles, lateral aspect of fingers/toes

  26. Dyshidrotic Eczema • Triggers • Wet shoes • Chemicals • Hyperhidrosis • Treatment • Similar to atopic derm

  27. Nummular Eczema • Location • Extensor thighs or abdomen • Description • Acute papulovesicular eruption • Coin shaped configuration • Intensely pruritic, well-circumscribed, round to oval, red, scaly patches • Studded with 1-3mm vesicles • Treatment: similar

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