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major mAnifestation of skin disease

major mAnifestation of skin disease. By :Dr . Pawana Kayastha. Immunity: alterations in immune surveillance and antigen presentation, and reduced cutaneous vascular supply which lead to decreases in the inflammatory response, absorption and cutaneous clearance of topical medications.

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major mAnifestation of skin disease

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  1. major mAnifestation of skin disease By :Dr .PawanaKayastha

  2. Immunity: alterations in immune surveillance and antigen presentation, and reduced cutaneous vascular supply which lead to decreases in the inflammatory response, absorption and cutaneous clearance of topical medications. • Consequences: these changes make the skin less durable, slower to heal, and more susceptible to damage and disease.

  3. . • inflammatory skin diseases, e.g. asteatotic, gravitational and seborrhoeic eczema, psoriasis • lichen sclerosus et atrophicus • scabies • lymphoedema • pruritus of old age • drug-related rashes

  4. THE CHANGING MOLE • Long standing pigmented spot. • The principal clinical concern is to distinguish correctly between benign pigmented lesions and melanoma. • The situation is complicated by the fact that any one of a number of changes in a pigmented lesion is highly sensitive as a marker of melanoma, specificity is low.

  5. 'is it cancer, doctor?' ABCDE FEATURES OF MALIGNANT MELANOMA • Asymmetry • Border irregular • Colour irregular • Diameter often greater than 0.5 cm • Elevation irregular(+ Loss of skin markings)

  6. History • Determine the precise nature of the change. Is it due to the development of itch, inflammation, bleeding or ulceration, or does it relate to the colour, size, shape or surface of the lesion? • Subtle changes:pluckinghair,shaving,irritants • Is the patient worried about change in one or many moles? • Positive family history of melanoma. Fewer than 10% of melanomas occur in individuals with a strong family history but in some of these families up to 50% of individuals may develop melanoma.

  7. Examination • Examine the pigmented lesion carefully. • Look at the morphology of the melanocyticnaevi at other sites. • magnifying glass or dermatoscope • whether the lesion is a benign melanocyticnaevus or a malignant melanoma • Before trying to answer this, the clinician needs to exclude the possibility that it is another type of pigmented lesion: • Lentigo (a benign proliferation of melanocytes) • Freckle (ephelis, a focal overproduction of melanin,)

  8. Seborrhoeic wart (basal cell papilloma, a benign keratinocytetumour) • Dermatofibroma. This lightly pigmented firm dermal nodule is common on extremities in young adults. It feels larger than it looks. There is dimpling when the skin is squeezed on both sides (positive Fitzpatrick sign). • Pigmented basal cell carcinoma : This lesion is usually found on the face of the elderly and is slow-growing. It has a blue-brown hue with an opalescent look. There may be a rolled edge around an ulcer. • Subungualhaematoma

  9. Management • Any changing lesion which is suspected of being a malignant melanoma should be excised without delay, with a clear margin. • If there is even a low index of suspicion of a malignant melanoma ,then the lesion should be reviewed 1 month and may be 3mths later. Continuing change demands excision. • If benign then reassurance but advised to report back without delay if the change and concern continue • If in doubt cut out and then check the histology

  10. Pruritis An unpleasant localized or generalized sensation on the skin, mucus membranes or conjunctivae which the patient instinctively attempts to relieve by scratching or rubbing

  11. Diversity of Causes and Presentation Many Causes, Many Treatments Trivial to Life threatening (mosquito bite) (malignancy) 10-50% of cases with generalized itching have systemic disease

  12. Diseases & Itching

  13. Skin diseases associated with generalisedpruritus Eczema Scabies Urticaria/dermographism Pruritus of old age and xeroderma Skin diseases associated with localisedpruritus Eczema Lichen planus Dermatitis herpetiformis Pediculosis

  14. CAUSES OF PRURITUS iin IN PREGNANCY IN PREGNANCY

  15. Renal Diseases and Itching • Chronic Renal Failure: 25-86% itching (not in acute renal failure) • Attrib to accumulation of pruritogens: • histamine (mast cells), serotonin • Ca, Phos, Mg, Al, vit A also implicated • 1/3 uremic patients not on dialysis • Maintenance hemodialysis: 70-80%

  16. Hepatic Diseases & Itching • 20-25% janudiced patients with hepatobiliary disease associated with cholestasis • 100% primary biliary cirrhosis • Viral hepatitis • Attrib to bile salts in serum and tissues • Begins palms and soles & spreads inward

  17. Hematologic Disease & Itching • Polycythemiavera(50%) • iron def anemia, • lymphomas • Hodgkins – 30% • T-cell: almost all • leukemias, plasma cell dyscrasias, mastocytosis

  18. Neurologic Disorders & Itching • Central: CNS abscess, spinal and cerebral tumors (17%), CVAs • Attrib to effects on descending pathways which  itching • Neurogenic • Shingles (10-15% in US) • Notalgiaparesthetica: sensory entrapment syndrome causing neuropathy of T2-6 dorsal spinal nerves

  19. Endocrine D/O & Itching • Diabetes • Thyrotoxicosis,Hypothyroidism • Generalised due to dry skinLocalised may be due to Candida • Myxodema • Postmenopausal syndrome • Most common trigger: mucocutaniouscandidiasis

  20. HIV infection Infection, infestationEosinophilicfolliculitisUnknown • Malignancy Unknown • Psychogenic Unknown

  21. Chemically induced itching:Neuroaxial • opioids commonly • Direct action on medullary dorsal horn and trigeminal nucleus of medulla – not t/histamine release • Spinal anesthesia with lidocaine: 30-100% pruritis

  22. Fentanyl: • Intrathecal 67-100% • Epidural 67% • Morphine • Intrathecal 62-82% • Epidural 65-70%

  23. Chemically induced itching:Antibiotics • Penicillin: immediate type I hypersensitivity reaction • Vancomycin: massive nonimmunologic release of histamine “Red Man Syndrome” • (flushing CP, pruritis, muscle spasms, hypotension) • Related to rate of infusion • Potentiated by muscle relaxants and opioids • Attenuated by H1 blockers • Rifampin

  24. Chemically induced itching:Other drugs • Fentanyl: itching decreased when mixed with bupivicane, increased when mixed with procaine • Drug induced cholestasis • esp phenothiazenes, estrogens, tolbutamide, anabolic steroids

  25. HISTORY & examination

  26. LOOK for skin changes • If no skin disease identified then search for systemic diseases by systemic examination • Investigation –as per systemic illness

  27. Pruritogenic Stimuli • Pressure • Low-intensity electrical • Histamine: acts directly on free nerve endings in skin

  28. Histamine Prostaglandins Leukotrienes Serotonin Acetylcholine Substance P Proteases Peptides Enzymes Cytokines Itch Mediators

  29. Itch Pathways • Cutaneous (pruritoceptive) • Neurogenic • Neuropathic • Mixed Psychogenic

  30. Itch pathways • C-Fibers originate @ dermal/epidermal jxn • Thin unmyelinated axons, lots of branching  • Ipsilateral dorsal horn of spinal cord  • Synapse with itch-specific secondary neurons • Cross to opposite anterolateralspinothalamic tract to thalamus  • Somatosensory cortex of postcentralgyrus • SLOW transmission and BROAD receptor field

  31. Lateral Inhibition: “Gate Theory” • Scratching stimulates large fast-conducting A-fibers adjacent to slow unmyelinated C fibers • A-fibers synapse with inhibitory interneurons and inhibit C-fibers • Scratching may either–stimulating ascending sensory pathway-inhibit itch at the spinal cord Or,may damage itch fibers directly

  32. Pain & Itch • Painful stimuli (thermal, mechanical, chemical) can inhibit itching • Inhibition of pain (opioids) may enhance itching

  33. How to Treat an Itch(Understand the Cause!) • Inhibit mediators of itch: histamine, prostaglandins, substance P, serotonin, cytokines • Block chemicals that induce pruritis: opioids, antimicrobials • Treat effects of diseases which induce itching: eczema, CRF, LF, heme, neuro, endo

  34. Eczema & Itching: Treatment • cool compresses • emollients • topical steroids • antidepressants • anxiolytics • antibiotics

  35. Renal Diseases and Itching • Tx for uremic itching: renal transplant • Effective even when transplant is failing as long as immunosuppresants are given • Antihistamines not effective • Also effective: moisturizers, UV-B tx (vit A in skin), oral activated charcoal, cholstyramine, naltrexone, ondansterone, topical capsaicin, azelastin, thalidomide, IV lidocaine, erythropoetin, electric needle stim

  36. Hepatic Diseases & Itching • Tx: reverse cholestatis, liver transplant • Also helpful: oral guar gum (dietary fiber) binds bile acids; cholestyramine; rifampin! (inhibits bile uptake), opioid antagonists, codeine, propofol, ondansetron,NaltrexoneUVB • Not helpful: scratching

  37. others • Thyrotoxicosis Emollients • LymphomaCimetidine • Iron defn Iron supplement • HIV • Treatment of opportunistic infectionLocal corticosteroids, UVBUVB • Pshychogenic PsychotherapyAnxiolyticsAntidepressives

  38. opioid related pruritis : • Diphenhydramine– for systemic opioids • For NeuraxialOpioids: • Ondansteron • Naloxone (1-2mcg/kg/hr) • Nalbuphine (10-20 mcg/kg/hr) • Propofol (.5-1mg/kg/hr) • Lidocaine (2mg/kg/hr) • NSAIDs (diclofenac, tenoxicam) • Droperidol • Penicillin Reaction Diphenhydramine

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