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David, Hannah; David, Hazel; De Guzman, Jan; De Guzman, Raquel; De Leon, Gemma ; De Mesa, Monique & De Vera, Jestha. Dermatology Case 2: Non-Scaly Plaques. 27 y/o call center agent. NON- SCALY PLAQUES. Erysipelas Cellulitis Urticaria Erythema Multiforme Exfoliative Dermatitis - PowerPoint PPT Presentation
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DERMATOLOGYCASE 2: NON-SCALY PLAQUESDavid, Hannah; David, Hazel; De Guzman, Jan; De Guzman, Raquel; De Leon, Gemma; De Mesa, Monique & De Vera, Jestha
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27 y/o call center agent
pricked a pustule on her left cheek
2 days later• t
ender, warm, red to violaceous edematous plaque with ill-defined borders on the left cheek
• Self-medicated with trimethoprim- sulfamethoxazole
A few hours after• g
eneralized eruption of red papules with dusky centers
• Ulcers on palms & lip mucosa
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NON- SCALY PLAQUES Erysipelas Cellulitis Urticaria Erythema Multiforme Exfoliative Dermatitis Hansen’s Disease
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Differential DiagnosisPatient’s Features Erysipelas Cellulitis
Etiologytrimethoprim- sulfamethoxazole medication
beta hemolytic group A Streptococcal (Occ. GBS)
Streptococcus pyogenes, Staphylococcus aureus
Epidemiology Age: 27 yoSex: F
NewbornPostpartum womenPatients with
breaks in the skin
High risk in immunocompromi-sed patients and in children
CourseAcute; few hours after intake of drugs
Acute Acute
Prodromes
Malaise for several hours, chills, high fever, headache, vomiting, and joint pains
Malaise, chills, fever
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Differential DiagnosisPatient’s Features Erysipelas Cellulitis
Eruption Generalized Palms and lip
mucosa
Face and legs Begins in the
cheeck near the nose or in front of the lobe of the ear and spreads upward to the scalp
Local erythema Tinea pedis-
most common portal of entry
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Differential DiagnosisPatient’s Features Acute Urticaria Erythema
MultiformeTypical Lesions red papules with
dusky centers.Ulcers in the lip mucosa
May vary from transient hyperemia followed by slight desquamation to intense inflam.
Erythematous patch with peripheral extension
Scarlet, hot to touch, brawny,swollen
Raised and sharply demarcated.
Erythema rapidly becomes intense and spreads
Area becomes infiltrated
Pits on pressure Central part
becomes nodular and surmounted by a vesicle that ruptures and discharges pus and necrotic material
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Complications Septicemia Deep cellulitits
Lymphangitis Gangrene Metastatic abscess Sepsis
Patient’s Features Acute Urticaria Erythema Multiforme
Differential Diagnosis
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Erysipelas
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Cellulitis
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Differential DiagnosisPatient’s Features
Acute Urticaria
Erythema Multiforme
Etiologytrimethoprim- sulfamethoxazole medication
Drugs, food, infections
Usually non-drug causes, most commonly Herpes Simplex infection
Epidemiology Age: 27 yoSex: F
In young adults
Recurrent episodes more prevalent in females
Young adlults
CourseAcute; few hours after intake of drugs
Acute; may recur; evolves over days to weeks
Acute, self-limited recurrent
Prodromes Absent to moderate
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Differential DiagnosisPatient’s Features Acute Urticaria Erythema
Multiforme
Eruption Generalized Palms and lip
mucosa
May be localized or generalized (more common); usually favors covered areas e.g. trunk, buttocks or chest
Disseminated; symmetrically and acrally on extremities, face
dorsal hands (initially); dorsal feet, extensor limbs, elbows and knees, palms and soles
Typical Lesionsred papules with dusky centers.Ulcers in the lip mucosa
Wheals, white or red evanescent plaques, generally surrounded by a red halo or flare.
Erythematous macules raised edematous papules over 24-28 hrs.
Classic “target” or “iris” lesions
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Differential DiagnosisPatient’s Features Acute Urticaria Erythema
Multiforme
Other Clinical Features
Subcutaneous swellings (angioedema), especially of eyelids or lips.
Angiodema of GI and respi tracts
- abdominal pan, coryza, asthma and respi problems.
Involvement of oral mucosa (frequent, mild)
No internal organ involvement
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Erythema Multiforme
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Urticaria
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Kelly’s part
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Differential DiagnosisPatient’s Features Fixed Drug Eruption
Etiologytrimethoprim-
sulfamethoxazole medication
DrugsMost common cause:
Trimethoprim-sulfamethoxazole
Epidemiology Age: 27 yoSex: F
Age: (1.5-81 y/o)F: 31 y/oM: 30 y/o
M:F = 1:1.1
Course Acute; few hours after intake of drugs
Develops over a period of hours, may persist from days to weeks and then fade slowly to residual oval hyperpigmented patches
Prodromes
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Differential DiagnosisPatient’s Features Fixed Drug Eruption
Eruption Generalized Palms and lip
mucosa
• mostly </6 lesions • >/1 cm in diameter• frequently located on the lip or genitalia
Typical Lesionsred papules with dusky centers.Ulcers in the lip mucosa
• Begins as a red patch• evolves into an iris or target lesion (dusky center) and may eventually blister and erode
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Differential DiagnosisPatient’s Features Fixed Drug Eruption
Other Clinical Features
normally resolve w/ hyperpigmentation and may recur at the same site with reexposure to the drug
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Fixed Drug Eruption
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DIAGNOSIS: Fixed Drug Eruption
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Pathophysiology exact mechanism is unknown cell-mediated process that initiates both
the active and quiescent lesions. may involve an antibody-dependent,
cell-mediated cytotoxic response. CD8+ effector/memory T cells play an
important role in reactivation of lesions with re-exposure to the offending drug.
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WORK- UPS
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Patch Test•relies on the principle of a type IV (delayed) hypersenstitivity reaction
•must be performed on a previously involved site
•comprises a series of small, aluminium wells containing various concentrations of the offending medication mounted on hypoallergenic tape
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Patch Test• standard occlusion time : 48 h• first reading: day 2 generally 15-30 min after patch removal • second reading: day 3 or 4
• Results are recorded using a standardized scoring system
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Oral Provocationcheck for cross-sensitivities to medications
*A refractory period has been reported in fixed drug eruption; therefore, a delay before and between patch testing and oral provocation is recommended
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Skin Biopsy
Acute interface dermatitis with prominent vacuolar change and individual necrotic keratinocytes within the epidermis (X10).
Interface dermatitis, vacuolar change, necrotic keratinocytes, and incontinent pigment in the dermis (X40).
Diagnostic procedure of choiceGenerally performed during the acute stage of recurrence