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
• Lichen planus
• Drug eruptions
Psoriasis
Secondary syphilis
Less common
• Pityriasis rosea
Pityriasis versicolor
• Tinea corporis
• Exfoliative erythroderma
• Gianotti-Crosti syndrome
History
• Common presenting problemEruptive 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 rashes
Type of rash
Distribution
Morphology
Associated signs
Eczema
Face/ flexors
Poorly defined erythema
and scaling
Lichenification
Shiny nails
Infraorbital crease
Dirty neck
Psoriasis
Extensor surfaces
Well defined plaque with
silvery scale
Nail pitting
Scalp involvement
Axilla 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 limbs
Lower 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 dermatitis
Combined
• 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.
• General measures
Removal of trigger
Hydration
• Acute phase:
Treatment
topical treatment-soln of either
potassium permanganate
(0.01%)or aluminium
acetate(0.65%)or for large areacalamine lotion /local steroids
systemic 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 Eczema
Associated features:Positive
H/O or Family H/O Asthma,
Hay fever, Urticaria or food
allergies
Clinical features andDistribution of rash
Infantile 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 <10yrs
H/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 test
IgE levels
Differential diagnosis
infantile seborrheic dermatitis
scabies
airborne 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 therapy
Emollients
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 acid
Topical calcineurin inhibitors:
immunomodulatorspimecrolimus(1%),tacrolimus(0.03%and 0.1%)
•
systemic therapy in extensive cases:
systemic antibiotics
systemic steroids
antihistaminics
New therapies
UVB or PUVA
3 mths course of oral evening primrose oil
cyclosporin