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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