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Papulosquamous disorders

• Conditions which present with both papule and scales

Lichen simplex chronicus (not on 2019 blueprint)

A skin disorder characterized by repetitive itching and scratching. This may be secondary to eczema, psoriasis, bug bites, psych disorders etc.

Clinical Presentation & Physical Exam findings

• Itching
• Lichenified (leathery) skin with well defined borders

Labs, Studies and Physical Exam Findings

• Lichenified skin with well defined borders
• Plaques
• Darkened skin
• Scratch marks
• Biopsy may be necessary
  • Hyperplasia and hyperkeratosis

Treatment

• Must reduce scratching
  • Lotions and creams to keep skin moist
  • Psych disorder or stress response may require antidepressants or tranquilizers
• Antihistamine
• Cortisone cream

Drug Eruptions

• Morbilliform (the term means looks like measles) or an erythematous rash make up about 90% of cases
• Type A
  • Pharmatoxicologic events
    • Side effect of drug
    • Predictable
• Type B
  • Hypersensitivity reaction
    • Urticarial
    • Angioedema
    • Anaphylaxis

Examples

• Red man syndrome from vancomycin infusion
• Penicillin may cause a rash
• Percocet may cause itching

Treatment

• Stop the offending agent

Lichen Planus

Inflammation of the skin and or mucosal surfaces

Causes

• Largely unknown
• Some drugs may cause an eruption

Clinical Presentation & Physical Exam findings

• Lesions which are solid and raised with white lines
• Itching

Labs, Studies and Physical Exam Findings

• Violaceous (purple),
• Flat-topped
• Angulated papules
• 1–4 mm in diameter
• The six P’s
  • Pruritic
  • Planar
  • Purple
  • Polygonal
  • Papules
  • Plaques
• Wickham striae – white lines in papules
• Lesions often found on mucosal surfaces including the mouth, esophagus, vaginal or anal tissue.
• Lesions may be in the hair and nails
• Biopsy

Treatment

• Strong topical steroid
• Cyclosporine mouth wash
• Systemic therapy may be necessary
• Phototherapy

Pityriasis rosea

Cause

• The cause is unknown however it is suspected to be viral. More than 60% of patients have a recent history of upper respiratory infection.

Clinical Presentation & Physical Exam findings

• Rash on the upper trunk
• 25% will have pruritus
• Salmon or fawn colored lesions
• Maculopapular lesions

Labs, Studies and Physical Exam Findings

• Herald patch – a single raised pink or red plaque measuring 2 to 10 mm most commonly appearing on the abdomen one to two weeks before the rash breaks out.
• Rash on the upper trunk
• Biopsy to confirm diagnosis
• Salmon or fawn colored lesions
• Maculopapular lesions
• Christmas tree pattern – Lesions tend to follow the natural skin lines creating the look of a Christmas tree.

Treatment

• Self limiting and typically lasts from 3 to 8 weeks
• Lotion
• Antihistamines

Psoriasis

• A chronic condition characterized by thick red flaky, scaling skin
• There is a genetic component and is believed to be an autoimmune disorder.
• In these patients skin cells are are produced at almost thirty times the normal rate.
• Usually affects certain areas of the skin (extensor surfaces), but in more severe cases may affect skin over the entire body as well as mucosal surfaces.

Triggers

• Injury
• Sunburn
• HIV infection
• Beta-hemolytic streptococcal infection
• Drugs
• Emotional stress
• Alcohol consumption
• Tobacco smoking
• Obesity

Clinical Presentation & Physical Exam findings

• Rash
  • Salmon colored
  • Well defined
  • Papules and plaques
  • Dry and itchy
  • Scratching leads to more lesions
  • Raised and thickened
  • Loosely adherent silvery scales
  • Auspitz sign – peeling off scales causes punctate bleeding
  • Usually occurs on elbows knees and trunk but may occur anywhere
• Nail bed findings
  • Onycholysis – separation of the nail plate typically occurs at the distal end, but in severe psoriasis it begins proximally
• Joint pain in the hands and feet.

Labs, Studies and Physical Exam Findings

• Diagnosis is made clinically

Treatment

• Keep skin moist (emollients)
• Topical steroid (systemic steroid should be avoided due to risk of pustular psoriasis)
• Topical vitamin D
• Tazarotene gel is a topical retinoid
• Phototherapy (UV light)
• Methotrexate or cyclosporine

There are several variations of psoriasis you should be aware of

• Psoriatic arthritis develops in 5–30% of patients
• Psoriatic erythroderma – In this variation lesions cover the entire skin surface. This may occur when treatment is abruptly stopped and can be fatal due to severe systemic inflammation and difficulty regulating body temperature.
• Pustular psoriasis – This form involves small white blisters. The vesicles are filled with pus and this very serious condition.

Study tip
Do not trade sleep for study time