Slides Dermatology Inflammatory Skin Diseases

Dermatology
Inflammatory Disorders
With Kartik Rangaraj, MD
Neuer Nutzer, ssemwogererethaddeus@gmail.com

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General Terminology
Macule – lesion < 1.0 cm that is not palpable

Patch – lesion > 1.0 cm that is not palpable
Ulcer Erosion Fissure

Papule – elevation < 1.0 cm in diameter
Plaque – flat-topped elevation > 1.0 cm in diameter
Nodule – rounded elevation > 1.0 cm in diameter

Tumor – elevation > 2.0 cm in diameter
Vesicle – clear fluid-filled blister < 1.0 cm diameter

Pustule – pus-filled blister < 1.0 cm in diameter
Bulla – fluid-filled vesicle > 1.0 cm in diameter
Erosion – loss of part of the epidermis

Ulcer – full-thickness loss of the epidermis
© by Lecturio
Acne Vulgaris
Left: PD, Right: openi, Macroscopic appearance of biopsied lesions from acne patients, http://lectur.io/2l, CC BY 4.0
Acne Vulgaris
Demographics
• 80 % of people seek medical care for
acne.
• Most common in teens and early 80 %

adulthood

Acne Vulgaris
Multifactorial
• Adrenarche increases sebum production.
• Comedones form due to accumulation of lipid and

keratin in follicular unit.
• Bacteria (P. acnes) overgrowth in abundance of oil.
• Bacteria convert sebum into fatty acids that elicit an

inflammatory response.
Etiology

Acne Vulgaris
Open comedones (“blackheads”)

• Oxidized keratin plug
Morphology

Acne Vulgaris
Closed comedones (“whiteheads”)

• Papules without oxidation, potential for follicular rupture and
inflammation
Morphology

Acne Vulgaris
Nodules
• Arise as follicles,
rupture and inflame
dermis
Morphology
Patil UA, Dhami LD, Severe pustular acne, https://openi.nlm.nih.gov/detailedresult.php?img=PMC2825126_IJPS-41-101-

g006&query=acne+vulgaris&it=xg&req=4&npos=177, CC BY 2.0, openi
Acne Vulgaris
Nodulocystic lesions
• Can yield systemic
symptoms (most often in
teen boys)
Morphology
Lindsley, Susan, Public Domain

Acne Vulgaris
Topical antiseptics (e.g., benzoyl peroxide)

• Prevent comedones and decrease bacterial counts
Oral antibiotics (e.g. tetracyclines)

• Also depends on anti-inflammatory properties
• Most commonly doxycycline (may cause photosensitivity)

or minocycline (may cause drug-induced lupus)
• All tetracyclines can cause pseudotumor cerebri.

Treatment

Acne Vulgaris
Topical retinoids (e.g. tretinoin)

• Prevent comedones and may decrease inflammation
Oral retinoids (e.g., isotretinoin)

• Reserved for severe nodulocystic scarring acne
• SE: teratogenicity, pseudotumor cerebri, hyperlipidemia,

↑lipids
Treatment

Acne Vulgaris
Rosacea
• Usually adults of Northern European heritage
• Occurs on the central face with flushing,

background erythema, telangiectasias
Differential diagnosis • Comedones are not a feature.

Acne Vulgaris
Perioral/periocular dermatitis
• Occurs in specific areas, may follow topical steroid use
• Monomorphic in appearance
• Inflammatory papules without comedones

Differential diagnosis

Acne Vulgaris
Folliculitis
• Infection of hair follicles (related to various causes)
• Predominantly on the trunk and extremities
• Occurs at any age, may progress to furuncles, carbuncles,

Differential diagnosis abscesses

Rosacea
A myriad of presentations
Erythema Papulopustules Rhinophyma
left: CDC/James Gathany, http://phil.cdc.gov/phil/details.asp?pid=9875, PD; middle: PubMed,

https://openi.nlm.nih.gov/detailedresult.php?img=PMC2903548_1746-160X-6-7-9&query=papulopustular+rosacea&it=xg&lic=by&req=4&npos=1, CC-BY 2.0;
right:
Neuer M. Sand, https://commons.wikimedia.org/wiki/File:Rhinophyma_01.jpg, CC-BY 2.0
Nutzer, ssemwogererethaddeus@gmail.com
Rosacea
Demographics
• Typically in adulthood
• More often in those of Northern European heritage
• Women > men, but usually men with rhinophyma

Rosacea
Poorly understood
• Abnormal vasoactivity/vasoreactivity
• “Flushers and blushers”
• Demodex (oil mites) implicated by some researchers.

Etiology

Rosacea
Papules and pustules, usually on central face
Telangiectasias (minute dilated blood vessels)
Often triggered by:

• Sunlight/wind
• Spicy foods
• Hot (temperature) foods and beverages
• Caffeine and EtOH

Morphology

Rosacea
Topical antibiotics (e.g. metronidazole)

• Mechanism of action poorly understood
Other topical agents (e.g. azelaic acid)
Oral antibiotics (e.g. tetracycline derivatives)

• Only those with anti-inflammatory properties
Cosmetic procedures
• Rhinophymectomy and laser treatment for telangiectasias
Treatment

Rosacea
Acne
• Usually in adolescents or younger
adults
• Comedones are a feature
Park KY et al., representative patient with acne, https://openi.nlm.nih.gov/detailedresult.php?img=PMC4628978_BMRI2015-

596161.001&query=acne+vulgaris&it=xg&req=4&npos=180, CC BY 3.0, openi
Rosacea
Perioral/periocular dermatitis
• Occurs in specific areas
• Monomorphic in appearance
• Inflammatory papules without comedones

Rosacea
Malar rash of sytemic lupus

• Abrupt onset with greater
confluence
• Spares the nasolabial folds

(photodistribution)
Shrestha D et al., patient with a butterfly rash, https://cnx.org/contents/5CvTdmJL@4.4:csuzHZ8A@3/Autoimmune-Disorders, CC 4.0, openstax

Rosacea
Seborrheic dermatitis
• Often intensely pruritic with greasy, yellow scale
• Prominent involvement of the nasolabial folds, glabella, hairline

Seborrheic Dermatitis
• Greasy, yellow scale
• May involve nasolabial area, eyebrows,

scalp, chest
• Infants = “cradle cap”
• Tx: antifungal creams or washes, mild topical

steroids
Thomas P. Habif, Clinical Dermatology, 6th Edition, 2016, p. 305, Saunders (Elsevier)
• Aberrant reaction to pityrosporum yeast upon skin
• Ranges from simple “dandruff” to severe disease
Etiology

10–15 %
Demographics
• Affects up to 10–15 % of population
• Increases with age

Psoriasis
• Generally with more scale and less
waxy or weeping appearance
• Psoriasis often involves skin outside

of the seborrheic areas
Kavala M. et al., Severe plaque type psoriasis involving the face, scalp, trunk, and limps
https://openi.nlm.nih.gov/detailedresult.php?img=PMC3615587_CRIM.DM2013-601412.001&query=Psoriasis&it=xg&lic=by&req=4&npos=82, CC 3.0, openi
Tinea capitis
• Not usually so diffuse in
involvement
• Tinea often with boggy

swelling or significant scalp
inflammation
Sentamilselvi G et al., Kerion, https://openi.nlm.nih.gov/detailedresult.php?img=PMC2938571_IJT-1-100-

g005&query=Inflammatory+tinea+capitis&it=xg&lic=by&req=4&npos=3, CC 2.0, openi
Acute systemic lupus

• Tends to involve the maxillary
skin
• Spares the actual nasolabial

fold (opposite of seborrheic
dermatitis)
Shrestha D et al., patient with a butterfly rash, https://cnx.org/contents/5CvTdmJL@4.4:csuzHZ8A@3/Autoimmune-Disorders, CC 4.0, openstax

Rosacea
• Primarily consists more of
erythematous papules and
pustules
• Usually limited to the central

face with a background of
telangiectasias
M. Sand et al., https://openi.nlm.nih.gov/detailedresult.php?img=PMC2903548_1746-160X-6-7-9&query=papulopustular+rosacea&it=xg&lic=by&req=4&npos=1, CC-BY

2.0;
Neuer wikipedia
Atopic Dermatitis
• Unknown, familial
• Associated with asthma and allergic rhinitis (atopic triad)
• Immunology: Th2 disease

Etiology

Atopic Dermatitis
Demographics
• Increasing incidence in the industrialized world
• Most common in childhood with many “growing out of it”
Highly pruritic, eczematous plaques
Location of plaques changes with advancing age

• Face and extensor surfaces in infants
• Flexural areas in older children and some adults

Morphology

Atopic Dermatitis
Associations
• Ichthyosis, keratosis pilaris, Dennie-Morgan lines
Morphology
PubMed, https://openi.nlm.nih.gov/detailedresult.php?img=PMC4405870_13601_2014_1066_Fig2_HTML&query=atopic+dermatitis&it=xg&lic=by&req=4&npos=1,
https://openi.nlm.nih.gov/detailedresult.php?img=PMC4470205_jcm-04-00884-g016&query=atopic+dermatitis&it=xg&lic=by&req=4&npos=97 CC-BY 4.0
Atopic Dermatitis
Morphology
PubMed, https://openi.nlm.nih.gov/detailedresult.php?img=PMC4470205_jcm-04-00884-g016&query=atopic+dermatitis&it=xg&lic=by&req=4&npos=97,
CC-BY 4.0;
Atopic Dermatitis
• Education, gentle bathing, generous emollients
• Topical steroids and antihistamines (for itch)
Treatment

Atopic Dermatitis
Contact dermatitis
• Usually revealed by history
• Often forms unusual patterns with sharp demarcation
Seborrheic dermatitis
• Often occurs in infants as “cradle cap”, but is transient
• Seb derm is more likely to involve the diaper area

Atopic Dermatitis
Diaper dermatitis
• Limited to the groin area (where
atopic dermatitis is unusual)
• Often spares body folds where

feces/urine does not contact
skin
Siegfried EC, Hebert AA, Candida culture-positive diaper dermatitis,

https://openi.nlm.nih.gov/detailedresult.php?img=PMC4470205_jcm-04-00884-g019&query=Diaper+candidiasis&it=xg&lic=by&req=4&npos=4, CC 4.0, openi
Atopic Dermatitis
Mycosis fungoides
• Uncommon in children
• Often involves “double

protected” sites beneath
undergarments
Kneitz H. et al., Bullous lesions on the left thigh, https://openi.nlm.nih.gov/detailedresult.php?img=PMC2838916_1752-1947-4-78-

1&query=Mycosis+fungoides&it=xg&lic=by&req=4&npos=3, CC 2.0, openi
Ichthyosis Vulgaris
Dry skin that forms fish-like scales, esp. on

lower legs
More common in patients with atopic dermatitis

• Both associated with mutation in
filaggrin gene
Ichthyosis Vulgaris
Moisturizers and keratolytic topical agents
Treatment

Allergic Contact Dermatitis
• Type IV immune reaction that appears 24–48 hours

after contact
• Poison ivy is the classic example of allergic contact dermatitis.
• Common sources traced to workplace and hobbies

Etiology

• Fairly well-demarcated erythematous and weeping plaques
• Intensely pruritic
• May assume a linear distribution when due to contact

with plants
Morphology

Common allergens
• Nickel (cheap jewelry)
• Chromates (leather and cement)
• Neomycin (topical antibiotic)
• Paraphenylenediamine (hair dye)

Poison Ivy
• Withdrawal of the offending allergen

• Topical steroids for local reactions
• Systemic steroids for widespread disease
Treatment

Lichen Simplex Chronicus
• A neurodermatitis (self-induced)
• Perpetuated by an itch-scratch cycle
Etiology

• Plaques of thickened skin
• Due to constant manipulation
• Only occurs in “reachable areas”

Morphology
PubMed, https://openi.nlm.nih.gov/detailedresult.php?img=PMC4470211_jcm-04-00979-g005&query=lichen+simplex+chronicus&it=xg&lic=by&req=4&npos=1,
CC-BY 4.0
• Potent topical steroids
• Interruption of the itch-scratch cycle
Treatment

Contact dermatitis
• Usually revealed by history
• Contact dermatitis may complicate or

perpetuate lichen simplex chronicus
Kim HK et al., (A) Erythematous patches with scales on the left wrist. (B) Marked improvement of the lesion without post-inflammatory pigmentation after 1 week of
green
Neuer tea extract treatments, https://openi.nlm.nih.gov/detailedresult.php?img=PMC3834413_toxicr-28-113-g001&query=contact+dermatitis&it=xg&req=4&npos=24,
Psoriasis
• Thicker, silver scale
• Histopathology of psoriasis
demonstrates neutrophilic
microabscesses within and
loss of the granular layer
Kavala M. et al., Severe plaque type psoriasis, https://openi.nlm.nih.gov/detailedresult.php?img=PMC3615587_CRIM.DM2013-
601412.001&query=Psoriasis&it=xg&lic=by&req=4&npos=82, CC 3.0, openi
Tinea
• Active peripheral
scale with central
clearing
Siegfried EC, Hebert AA, Tinea corporis, https://openi.nlm.nih.gov/detailedresult.php?img=PMC4470205_jcm-04-00884-
g016&query=Tinea+corporis&it=xg&lic=by&req=4&npos=3, CC 4.0, openi
Lichen Planus
• Thought to be an autoimmune phenomenon
• Associated with Hep C in areas of high prevalence
Etiology

Lichen Planus
Disease of the p’s

• Pruritic purple polygonal papules
• Coalescing into plaques
• Common on wrists and ankles
• Can also occur on oral and genital mucosa

Morphology

Lichen Planus
Morphology
PubMed, https://openi.nlm.nih.gov/detailedresult.php?img=PMC2737762_1752-1947-0003-0000007421-1&query=lichen+planus&it=xg&lic=by&req=4&npos=4,
CC-BY 3.0
Lichen Planus
Band-like inflammation and destruction of keratinocytes

at the dermoepidermal junction
Pathology

Lichen Planus
• Limited disease is treated with potent topical steroids.
• Antihistamines may be used for pruritus.
• Extensive skin/mucosal disease may require oral steroids.
• Mucosal involvement is a sign of a more recalcitrant and

longer-lasting disease.
• Consultation with a dermatologist or dentist is often

recommended.
Treatment

Urticaria (Hives)
• IgE-mediated release of histamine from mast cells

(Type I)
• Caused by food/medication, exercise, temp, vibration,

stress, etc.
Etiology • 2–3 episodes/wk for 6 weeks is chronic urticaria

Urticaria (Hives)
• Rapid development of edematous, erythematous wheal and

flare lesion
• Lesions evolve and dissipate rapidly (< 24 hours)

Morphology

Urticaria (Hives)
• Rapidity of evolution is clinically

distinctive
• Biopsy rarely performed
• If swelling is deeper, consider

angioedema
Diagnosis
PubMed, https://openi.nlm.nih.gov/detailedresult.php?img=PMC4223736_40413_2014_70_Fig1_HTML&query=Urticaria&it=xg&lic=by&req=4&npos=9, CC-

BY 4.0
Urticaria (Hives)
Identification and avoidance of stimulus
Antihistamines
• Sedating (diphenhydramine, hydroxyzine)
• Moderately sedating (cetirizine)

Treatment • Non-sedating (loratidine)

Angioedema
Swelling of lips/airway and/or eyes
Openi, Diffuse swelling of the upper lip, http://lectur.io/2m, cropped, and scaled, CC BY 2.0
Angioedema
Hereditary: C1 esterase inhibitor deficiency (no urticaria)

• Patients will have low C4 level.
Acquired:
• Most common = ACE inhibitors
• Due to increase in bradykinins
• not assoc. with urticaria
• Allergic = IgE-mediated
• Often in response to drugs
Causes • Often associated with urticaria

Angioedema
All: epinephrine if airway is compromised
Allergic
• Antihistamines
• IV steroids
Hereditary
• FFP (or directly replace C1 esterase inhibitor)
ACE-Inhibitor associated
Treatment • Stop ACEI

Alopecia Areata
• Unknown, likely autoimmune
• Associated with thyroid disease and Down’s syndrome
Etiology

Alopecia Areata
Non-scarring alopecia
Patches of loss on the scalp/beard
Sometimes causes loss of:

• All hair on scalp (alopecia totalis)
• All hair on body (alopecia

universalis)
Morphology
PubMed, https://openi.nlm.nih.gov/detailedresult.php?img=PMC3968982_ijem-11-04-9860-g001&query=alopecia+areata&it=xg&lic=by&req=4&npos=37,
CC-BY 3.0
Alopecia Areata
• Topical steroids
• Intralesional steroids
• Oral steroids
Treatment • Light therapy

Alopecia Areata
Hair bulb attacked by lymphocytes
Pathology

Alopecia Areata
Tinea capitis
• Usually more inflammatory than alopecia areata
• Causes erythema, scaling, and bogginess
• Purulence of positive occipital lymphadenopathy noted

Differential
• KOH examination or biopsy demonstrates fungal organisms.
diagnosis

Alopecia Areata
Cutaneous lupus erythematosus

• More inflammatory with distinctive pigmentary changes
• Cutaneous lupus creates a scarring and permanent alopecia.

Differential
diagnosis

Alopecia Areata
Trichotillomania
• Non-scarring loss due to
tearing or plucking of hair
• Most common in young girls

with co-existing psychiatric
disturbances
Differential • Characterized by wide
diagnosis variations in the lengths of
remaining hair
De Puysseleyr A et al., Lateral view of a patient’s scalp, https://openi.nlm.nih.gov/detailedresult.php?img=PMC4118657_1748-717X-9-170-

4&query=alopecia+areata&it=xg&lic=by&req=4&npos=16, CC 4.0, openi
Psoriasis
Demographics
Affects 1–3 % of Americans; 1/3 report a positive family history
Unknown, likely genetic inheritance with environmental trigger
Etiology

Psoriasis
• Salmon-colored erythematous plaques with thick silver scale
• Involvement of elbows, knees, scalp, and the gluteal

cleft is typical.
• Pruritus is a chief complaint in only 1/3 of cases.
• Nail changes include pits and oil spots and nail loss.
Morphology

Psoriasis
Other
• Lithium and beta blockers can exacerbate psoriasis.
• Strep respiratory infection can trigger guttate lesions.
• Psoriatic arthritis can be debilitating.

Psoriasis
Morphology/Clinical presentation
PubMed, https://openi.nlm.nih.gov/detailedresult.php?img=PMC2834624_1757-1626-3-69-1&query=psoriasis&it=xg&lic=by&req=4&npos=75,
https://openi.nlm.nih.gov/detailedresult.php?img=PMC4332333_PAMJ-19-84-g002&query=psoriases+&it=xg&lic=by&req=4&npos=19,
https://openi.nlm.nih.gov/detailedresult.php?img=PMC2965905_IJD-55-225-g002&query=psoriases&it=xg&lic=by&req=4&npos=57, CC-BY 2.0
Psoriasis
• Acanthosis (thickened epidermis) with elongated rete ridges
• Thinned or absent granular layer
• Parakeratosis with neutrophil microabscesses

Pathology

Psoriasis
Pathology
PubMed, https://openi.nlm.nih.gov/detailedresult.php?img=PMC4047554_1746-1596-9-102-2&query=psoriasis&it=xg&lic=by&req=4&npos=47, CC-BY 2.0

Psoriasis
• Topical corticosteroids
• Topical calcipotriene (vitamin D derivative)
• Oral retinoids
• Methotrexate
• Cyclosporine
• Biologics (inhibit TNF-alpha)
Treatment • Light therapy, if available

Psoriasis
Eczema/dermatitis
• Usually involves flexural rather
than extensor areas
• Eczema has a more exudative

and weeping appearance.
Differential • Lacks the distinctive dry silver

diagnosis scale of psoriasis
Salava A, Lauerma A, Typical lichenified atopic dermatitis in the kneefolds,

https://openi.nlm.nih.gov/detailedresult.php?img=PMC4405870_13601_2014_1066_Fig1_HTML&query=Atopic+dermatitis&it=xg&lic=by&req=4&npos=22, CC 4.0,
openi | This document is protected by copyright.
© www.lecturio.com
Psoriasis
Secondary syphilis
• Positive serology by RPR
• Generally smaller plaque
Differential • Plasma cells and possibly even spirochetes by biopsy

diagnosis

Psoriasis
Tinea corporis
• Not usually in such
characteristic locations
(elbows, knees, posterior
scalp, gluteal cleft)
• Tinea demonstrates an
Differential active scaling border with
diagnosis central clearing.
Siegfried EC, Hebert AA, Tinea corporis, https://openi.nlm.nih.gov/detailedresult.php?img=PMC4470205_jcm-04-00884-

g016&query=Tinea+corporis&it=xg&lic=by&req=4&npos=3, CC 4.0, openi
Pityriasis Rosea
• Unknown
• Self-limited eruption in young people
• Possibly caused by human herpes virus 7

Etiology

Pityriasis Rosea
• Follows viral prodrome
• Erythematous papules/plaques in “T-shirt” distribution
• First lesion (“Herald patch”) is often the largest.
Morphology • Often occurs in a “Christmas-tree” pattern on the back

Pityriasis Rosea
• Self-limited
• Requires no treatment
Treatment
PubMed, https://openi.nlm.nih.gov/detailedresult.php?img=PMC3107956_IJT-2-113-g003&query=Pityriasis+Rosea&it=xg&lic=by&req=4&npos=6, CC-BY 2.0

Morphea
• Unknown disease of the dermis
• Affects both children and adults
Etiology

Morphea
• Classic shiny and atrophic plaque
• Often with lilac-colored erythema at the periphery
• Over time, it becomes more “burned-out”.
• Skin becomes thickened and bound down.
• Involvement across joint lines may yield contractures.

Morphology

Morphea
Other
• Morphea can occur in linear line on the forehead.
• Referred to as coup de sabre (“sword stroke”)

Morphea
Morphology
PubMed, https://openi.nlm.nih.gov/detailedresult.php?img=PMC2390574_1752-1947-2-136-1&query=Morphea&it=xg&lic=by&req=4&npos=18,, CC-BY 2.0

Morphea
• Characteristic change
• Square biopsy edges
• A thickened scar-like dermis
• Entrapment of sweat glands and other

appendages by thick collagen bundles
Pathology
PubMed, https://openi.nlm.nih.gov/detailedresult.php?img=PMC3532086_1756-0500-5-689-2&query=Morphea&it=xg&lic=by&req=4&npos=6, CC-BY 2.0

Morphea
• No ideal treatment
• Topical corticosteroids
• Topical vitamin D derivatives (calcipotriene)
• Severe cases → oral hydroxychloroquine
• Joint contracture requires physical therapy.
Treatment

Erythema Nodosum
• Most common form of panniculitis
• Involves the septa between fat lobules
• Usually idiopathic
• May be secondary to any inflammation, e.g. infection,

autoimmune disease, reaction to medication, hormonal
Etiology (esp. OCP), etc.

Erythema Nodosum
Tender subcutaneous nodules on the anterior shin
Morphology

Erythema Nodosum
Raised, erythematous, painful nodules,

on the anterior shins
Morphology
PubMed, https://openi.nlm.nih.gov/detailedresult.php?img=PMC3520703_1752-1947-6-398-2&query=Erythema+Nodosum&it=xg&lic=by&req=4&npos=5,
CC-BY 2.0
Erythema Nodosum
Inflammation involving the subcutaneous fat
Pathology

Erythema Multiforme
Erythema multiforme (EM) can be a reaction to an infection

or a medication
EM minor is highly associated with HSV infection
• It usually involves the hands and feet with targetoid and dusky
plaques.
EM major (Stevens-Johnson) is more severe
• It involves at least one mucosal surface.
Toxic epidermal necrolysis Drugs
• Correct term if > 30% body surface area
Etiology is involved

Erythema Multiforme
Morphology
Vasudevan B, Bahal A, Raghav V, Herpes labialis with oral erosions, https://openi.nlm.nih.gov/detailedresult.php?img=PMC2840948_JGID-01-48-

g003&query=Erythema+multiforme&it=xg&lic=by&req=4&npos=14,
Vierucci F et al., Changes in child’s skin manifestations, https://openi.nlm.nih.gov/detailedresult.php?img=PMC3632492_1824-7288-39-11-
2&query=Erythema+multiforme&it=xg&lic=by&req=4&npos=11,
CC-BY 2.0
Erythema Multiforme
• EM minor – self-resolving
• SJS/TEN – supportive care, possibly IVIG
Treatment

Drugs That Cause SJS/TEN
Bactrim (Trimethoprim/SMX)
Seizure medications
• Phenobarbital
• Phenytoin
Other antibiotics
Allopurinol

Pemphigus Vulgaris
Autoimmune antibody-mediated attack on desmosomes

that join keratinocytes in the epidermis
Etiology

Pemphigus Vulgaris
Demographics
Often seen in middle-aged men and women
• Usually presents first in oral mucosa
• Loss of keratinocyte adhesion yields superficial

blisters that rupture easily.
Morphology

Pemphigus Vulgaris
Superficial blisters on scalp, face, trunk, and groin
Morphology/clinical
presentation

Pemphigus Vulgaris
Morphology
F.l.t.r.: Fox, George Henry, PD

Yang Y et al., Pustules in epidermis, https://openi.nlm.nih.gov/detailedresult.php?img=PMC2965924_IJD-55-293-
g003&query=pemphigus+vulgaris&it=xg&lic=by&req=4&npos=31,
Neuer Nutzer, ssemwogererethaddeus@gmail.com CC BY 2.0, openi
Pemphigus Vulgaris
Immunosuppressive agents (steroids, others)
Treatment

Bullous Pemphigoid
Autoimmune attack on hemi-desmosomes joining

keratinocytes to the basement membrane zone
Etiology

Bullous Pemphigoid
Demographics
• Often seen in elderly and debilitated patients
• Usually presents first on the lower extremities.
• Loss of keratinocyte adhesion to the basement

membrane leads to large and tense blisters.
Morphology

Bullous Pemphigoid
Clinical presentation
• Bullae on thighs, flexors,
axilla, lower abdomen
Morphology
PubMed, https://openi.nlm.nih.gov/detailedresult.php?img=PMC2763740_IJD-53-157-g002&query=Bullous+Pemphigoid&it=xg&lic=by&req=4&npos=11,
CC-BY 2.0
Bullous Pemphigoid
Immunosuppressive agents (steroids, others)
Treatment

Vesiculobullous Dermatitis Immunofluorescence
• Diagnostic technique that reveals the location of deposited immunoreactants
• Which is pemphigus vulgaris and which is bullous pemphigoid?
Linear band at DEJ Net-like band in epidermis
Bullous pemphigoid Pemphigus vulgaris
Vinay Kumar & Abul K. Abbas & Jon C. Aster, Robbins & Cotran Pathologic Basis of Disease, 9th Edition, 2015, p. 1171 (left), p. 1170 (right), (Elsevier)
Nikolsky’s Sign
Pressure is placed on blister or perilesional skin
If blister spreads laterally (skin sloughs), the Nikolsky’s sign is positive; if not, it is negative.
• + Nikolsky = pemphigus vulgaris
• - Nikolsky = bullous pemphigoid

Lupus Erythematosus
Three categories of cutaneous lupus:
1. Acute SLE
• Often with a malar “butterfly” rash
2. Subacute LE
• Annular/psoriasiform, erythematous plaques on sun-exposed skin
• Often involves the arms and neck
• Associated with anti-Ro (SSA) antibodies
• May be caused by thiazides or other meds

Lupus Erythematosus
Three categories of cutaneous lupus:
3. Chronic cutaneous LE
• Depigmented, indurated and scarred plaques
• Surrounding hyperpigmentation and erythema
• Most often affects the face, scalp, and ear
• African-American women most often affected

Lupus Erythematosus
Morphology
Acute SLE SCLE CCLE/DLE
left: E. Goljan, Rapid Review Pathology E-Book, 4th Edition, 2013, p. 77, Mosby (Elsevier), middle: PubMed,
https://openi.nlm.nih.gov/detailedresult.php?img=PMC3277486_1755-7682-5-1-1&query=lupus+erythematosus+systemic&it=xg&lic=by&req=4&npos=27, right:
PubMed, https://openi.nlm.nih.gov/detailedresult.php?img=PMC2807152_IJD-54-132-g003&query=lupus+erythematosus+systemic&it=xg&lic=by&req=4&npos=120,
CC-BY 2.0
Lupus Erythematosus
Other:
• Malar rash is a presentation of SLE.
• SCLE has systemic complications in 15–30 %.
• CCLE(DLE) has systemic complications in 5–15 %.

Lupus Erythematosus
• Evaluation for systemic disease
• Referral to a dermatologist or rheumatologist
• Topical/intralesional steroids
• Antimalarials
• Sun protection
Treatment

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Dermatology

With Kartik Rangaraj, MD

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Macule – lesion < 1.0 cm that is not palpable

Ulcer Erosion Fissure

Nodule – rounded elevation > 1.0 cm in diameter

Vesicle – clear fluid-filled blister < 1.0 cm diameter

Erosion – loss of part of the epidermis

• Most common in teens and early 80 %

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• Comedones form due to accumulation of lipid and

• Bacteria (P. acnes) overgrowth in abundance of oil.

• Bacteria convert sebum into fatty acids that elicit an

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Open comedones (“blackheads”)

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Closed comedones (“whiteheads”)

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Patil UA, Dhami LD, Severe pustular acne, https://openi.nlm.nih.gov/detailedresult.php?img=PMC2825126_IJPS-41-101-

Lindsley, Susan, Public Domain

Topical antiseptics (e.g., benzoyl peroxide)

Oral antibiotics (e.g. tetracyclines)

• Most commonly doxycycline (may cause photosensitivity)

• All tetracyclines can cause pseudotumor cerebri.

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Topical retinoids (e.g. tretinoin)

Oral retinoids (e.g., isotretinoin)

• SE: teratogenicity, pseudotumor cerebri, hyperlipidemia,

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• Occurs on the central face with flushing,

Differential diagnosis • Comedones are not a feature.

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• Inflammatory papules without comedones

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• Predominantly on the trunk and extremities

• Occurs at any age, may progress to furuncles, carbuncles,

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Erythema Papulopustules Rhinophyma

left: CDC/James Gathany, http://phil.cdc.gov/phil/details.asp?pid=9875, PD; middle: PubMed,

• More often in those of Northern European heritage

• Women > men, but usually men with rhinophyma

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• “Flushers and blushers”

• Demodex (oil mites) implicated by some researchers.

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Papules and pustules, usually on central face

Telangiectasias (minute dilated blood vessels)

Often triggered by:

• Hot (temperature) foods and beverages

• Caffeine and EtOH

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Topical antibiotics (e.g. metronidazole)

Other topical agents (e.g. azelaic acid)

Oral antibiotics (e.g. tetracycline derivatives)

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• Comedones are a feature

Park KY et al., representative patient with acne, https://openi.nlm.nih.gov/detailedresult.php?img=PMC4628978_BMRI2015-

• Inflammatory papules without comedones

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Malar rash of sytemic lupus

• Spares the nasolabial folds

Shrestha D et al., patient with a butterfly rash, https://cnx.org/contents/5CvTdmJL@4.4:csuzHZ8A@3/Autoimmune-Disorders, CC 4.0, openstax

• Prominent involvement of the nasolabial folds, glabella, hairline

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