PAPULOSQUAMOUS DISORDERS

Papulosquamous eruptions

• Also k/a scaly rash disease

• Clinical lesions characterized by scaly papules and plaques(may be due to proliferation of cells of epidermis or dermis,infiltration with inflammatory cells or deposits in dermis)

• Morphology of papules /plaques varies in different papulosquamous eruption plus there is characteristic scales in each variety.

Causes of sudden scaly rash

Common• Eczema Psoriasis• Lichen planus Secondary

syphilis• Drug eruptions

Less common• Pityriasis rosea Pityriasis versicolor• Tinea corporis• Exfoliative erythroderma • Gianotti-Crosti syndrome

History

• Common presenting problem- Eruptive scaly rash with or without itching

• Differentiation of these diseases are done based upon history and examination

Ask

• Rash• Location- Ask where the rash is• Is it at multiple places?

• Onset, duration and progression• Associated symptoms

Ask if the lesion is:• Itchy– Eczema is extremely itchy• Breathing problems/ chest pain/ joint pain/fever/

red eyes- to R/O other systemic diseases

• Aggravating factors• Temperature- Itching of acute eczema increases with

rise in temperature

• Allievating factors• Ask if anything makes the problem better• Cooler temperature in Acute eczema.

History taking..

• Past Medical History:

Previous H/O similar episodes:• Allergic history:• Medical problems in the past:• Hospitalization:• Family History:• Obstetric and Gynecological history:• Sexual History:• Social History:

Mnemonics for history taking:

• LIQOR AAA

L- Location

I - Intensity

Q- Quality

O- Onset, duration and frequency

R- Radiation

A- Aggravating factors

A- Alleviating factors

A- Associated problems

• PAM HUGS FOSS

P- Previous episodes of C/O

A- Allergic History

M- Medical problems in the past

H- Hospitalization

U- Urinary problems

G- Gastrointestinal problems

S- Sleep

Begin with transition question for FOSS

F- Family History

O- Obstetric and gynecology history

S- Sexual H/O

S- Social H/O

Examination:

• Complete exposure, in bright and uniform light• General examination• Local examination:

• Rash - Symmetrical/ asymmetrical

- Extensor or flexor

- Proximal/ Distal/ Facial

- Localised or widespread• Examine scalp, face, eyes, oral mucosa,

neck, axilla, nails, groin and joints

C/F of common scaly rashesType of rash Distribution Morphology Associated signs

Eczema Face/ flexors Poorly defined erythema and scalingLichenification

Shiny nailsInfraorbital creaseDirty neck

Psoriasis Extensor surfaces Well defined plaque with silvery scale

Nail pittingScalp involvementAxilla and genital areas are often affected

Pityriasis rosea Fir tree pattern on torso

Well defined erythematous papules and plaques

Drug eruption Widespread Maculopapular erythematous scaly areas followed by exfoliation

Pityriasis versicolor Upper torso and upper shoulders

Hypo and hyperpigmented scaly patches

Lichen planus Distal limbsLower back

Shiny flat papules White lacy network in buccal mucosa

Tinea corporis Asymmetrical red scaly lesions

Scaly plaques Nail involvement

Eczema• Eczema literally means ‘to boil out’

• Terms 'eczema' and 'dermatitis' are synonymous.

• They refer to distinctive reaction patterns in the skin, which can be either acute or chronic and are due to a number of causes.

• It has 2 components:• Clinical • histological

Clinical component 0f THE ECZEMA REACTION

Acute • Redness and swelling, usually with ill-defined margins • Papules, vesicles and, more rarely, large blisters • Exudation and cracking • Scaling• Pruritis • Erythema

Chronic

• May show all of the above features, although it is usually less vesicular and exudative

• Lichenification, a dry leathery thickening with increased skin markings, is secondary to rubbing and scratching(trIad of hyperpigmentation ,thickening of skin and increased skin markings)

• Fissures and scratch marks

• Pigmentation changes (hypo- and hyper-)

Histological component

Hallmarks- (depending on clinical appearance)•spongiosis•Hyperkeratosis and acanthosis

In the acute stage, oedema of the epidermis (spongiosis) progresses to the formation of intra-epidermal vesicles, which may enlarge and rupture. In the chronic stage there is less oedema and vesiculation but more thickening of the viable epidermis(acanthosis),thickening of stratum corneum(hyperkeratosis)This is accompanied by a variable degree of vasodilatation and T-cell lymphocytic infiltration in the upper dermis.

Histological events in eczema

classification

Etiological• Endogenous• Exogenous• combined

Morphological• Discoid• Hyperkeratotic• Lichenified• Seborrheic

Endogenous• Atopic dermatitis• Seborrheic dermatitis• Discoid • Pompholyx• Pityriasis alba• Stasis dermatitis• Lichen simplex

chronicus

Exogenous• Irritant • Allergic• Photo dermatitis• Radiation dermatitis• Infective dermatitisCombined• atopic

Investigations

• Acute to be treated before investigations• Chronic:• Patch test• Prick test• Photopatch test• Serological test RAST

Differential diagnosis

• Psoriasis• Scabies• Any other papulosquamous lesions

complications

Dermatological complications

Infecton

Dissemination

Contact dermatitis

Erythroderma

Psychosocial complication

Anxiety,depression,social comp.

Treatment

• General measuresRemoval of triggerHydration• Acute phase: topical treatment-soln of either

potassium permanganate (0.01%)or aluminium acetate(0.65%)or for large area-

calamine lotion /local steroidssystemic treatment: short course of steroid ,

antibiotics,antihistaminics• Chronic phase: nonsteroid-ichthammol,topical

steroids,plus keratolytic agents like salicylic acid or urea(for lichenified lesion)antibiotics

Atopic eczema/ dermatitis

• Most common form• It is an endogenous eczema triggered by

exogenous agents characterised by extremely pruritic recurrent ,symmetric eczematous lesion

• Epidemiology:

Seen in 3% of all infants ,

increasing worldwide(decr.breast feeding and increasing pollutants)

Etiology and pathogenesis

Genetic predisposition

maternal imprinting-that is, they are inherited more often from the mother than from the father

Immunological changes:IgE levels,abnormal

lymphocytes:Generalized and

prolonged hypersensitivity to

common environmental antigens

Atopic EczemaAtopic Eczema

Associated features:Positive H/O or Family H/O Asthma, Hay fever, Urticaria or food allergies

Associated features:Positive H/O or Family H/O Asthma, Hay fever, Urticaria or food allergies

Clinical features andDistribution of rashInfantile phase

•Begins after age of 3 mths,intensely itchy papules and vesicle which soon become exudative,secondayry infection is commn• Face and trunk• Napkin area is spared

Childhood phase

•Dry ,leathery and extremely itchy plaques• Back of knees, front of elbows, wrists and ankles

Adults phase

•Lesions are very itchy,lichenified plaques• cubital and popliteal fossae and sometimes neck and low grade involvement in rest of the body•Discoid pattern may be seen on hands and feet• Lichenification is common

Course of atopic dermatitis

Infantileeczema in 3%of popln

40% clear by age of 18mths

60%develop childhood eczema

70%clear by the age of 10yrs

Adult eczema

Diagnostic criteria for atopic eczema

Itchy skin and at least three of the following

H/O itch in skin creases or cheeks if <10yrsH/O asthma/ hay fever (or in a first degree relative if < 4yrs)Dry skin (Xeroderma)Visible flexural eczema (cheeks, forehead, outer limbs if <4yrs)Onset in first 2 years of life

COMPLICATIONS OF ATOPIC ECZEMA

•Superinfection, most often with bacteria (Staphylococcus aureus) but also importantly with virusesand fungus Herpes simplex virus causes a widespread severe eruption-eczema herpeticum. Papillomavirus and molluscum contagiosum superinfections are also more common and are encouraged by use of local corticosteroids

•Irritant reactions due to defective barrier function

•Sleep disturbance, loss of schooling and behavioural difficulties

•Children with atopic eczema have an increased incidence of food allergy, particularly to eggs, cow's milk, protein, fish, wheat and soya. These foods cause an immediate urticarial eruption rather than exacerbating the child's eczema

•Systemic absorption of steroid

Investigations

Prick testIgE levels

Differential diagnosis

infantile seborrheic dermatitisscabiesairborne contact dermatitis

Prevention

• EARLY PREVENTION OF ATOPIC ECZEMA 'Restrictions in maternal diet during pregnancy have no effect on the incidence of atopic eczema in an infant at hereditary risk and may adversely affect maternal and/or fetal nutrition. Breastfeeding, however, appears to reduce the prevalence of atopic eczema in early childhood.'

Rx• General measures:

Avoid scratching,and avoid triggers Good hydration

• Topical therapyEmollients Topical steroids:also with combination of antibiotics /emollients,start with lose dose and if fail then increase the dose,In lichenified lesion with keratolytic agents like salicylic acidTopical calcineurin inhibitors:immunomodulators-pimecrolimus(1%),tacrolimus(0.03%and 0.1%)

• systemic therapy in extensive cases:systemic antibioticssystemic steroids antihistaminics

New therapies

UVB or PUVA3 mths course of oral evening primrose oil cyclosporin