GRANULOCYTIC DERMATITIS

COMMONLY BIOPSIED LESIONS IN MALAYSIA

1. Subcorneal Pustular Dermatosis
2. Sweet's Syndrome
3. Eosinophilic Cellulitis
4. Pyoderma Gnagrenosum
5. Pustular Folliculitis
6. Hidradenitis Suppurativa
7. Arthropod Reaction

VASCULITIS

COMMONLY BIOPSIED LESIONS IN MALAYSIA

1. Leukocytoclastic Vasculitis
2. Lymphocytic Vasculitis
3. Perniosis
4. Atrophie Blanche
5. PAN
6. Nodular Vasculitis (+lobular panniculitis)
7. Angiolymphoid Hyperplasia with Eosinophilia

GRANULOMATOUS DERMATITIS

COMMONLY BIOPSIED LESIONS IN MALAYSIA

1. Foreign Body Granuloma
2. Sarcoidosis
3. Granuloma Annulare
4. Rheumatoid Nodule
5. Necrobiosis Lipoidica Diabeticorum
6. Leprosy
7. Rosacea
8. Atypical Mycobacterial Infection

VESICULOBULLOUS DERMATITIS

COMMONLY BIOPSIED LESIONS IN MALAYSIA

1. Pemphigus
2. Bullous Pemphigoid
3. Epidermolysis Bullosa (Weber-Cockayne)
4. Epidermolysis Bullosa Simplex
5. Epidermolysis Bullosa Acquisita
6. Darier's Disease
7. Dermatitis Herpetiformis
8. Grover's Disease
9. Hailey Hailey Disease

SPONGIOTIC DERMATITIS

COMMONLY BIOPSIED LESIONS IN MALAYSIA

1. Spongiotic Dermatitis / Eczema
2. Allergic Contact Dermatitis
3. Pityriasis Rosea
4. Miliaria
5. Spongiosis associated with other pattern like erythema multiforme

PSORIASIFORM DERMATITIS

COMMONLY BIOPSIED LESIONS IN MALAYSIA

1. Psoriasis
2. Picker's Nodule
3. Lichen Simplex Chronicus
4. Prurigo Nodularis
5. Pityriasis Rubra Pillaris
6. Pityriasis Rosea
7. Mycosis Fungoides

LICHENOID DERMATITIS

COMMONLY BIOPSIED LESION IN MALAYSIA

1. Erythema Multiforme
2. Pityriasis Lichenoides Chronicum
3. PLEVA
4. Lupus Erythematosus
5. Lichen Planus
6. Lichen Nitidus
7. Lichenoid Drug Eruption
8. Lichen Planopilaris

MAJOR TISSUE REACTIONS

1. Lichenoid Dermatitis
2. Psoriasiform Dermatitis
3. Spongiotic Dermatitis
4. Vesicobullous Dermatitis
5. Granulomatous Dermatitis
6. Vasculitis
7. Panniculitis
8. Granulocytic Dermatitis (Neutrophilic / eosinophilic)

DRUG INDUCED LE

PASCHA ALI

Penicillamine, Procainamide
Antihypertensives (ACE-I., Atenolol)
Sulfonamides
Chlorpromazine
Hydralazine
Antibiotics (Griseofulvin, Sulfa)
Anticonvulsants (Phenytoin, Phenobarbital)
Lithium
Isoniazid

CAUSES OF PERIPHERAL EOSINOPHILIA

CHINA

Connective tissue disease (SLE, DM, Sjogren's, CSS)
Helminths (All worms, parasites, Giardia)
Idiopathic hypereosinophilic syndrome
Neoplasms (Leukaemia)
Allergies, Asthma

SCARRING ALOPECIA

ALOPECIAS

Autoimmune (DLE, Morphea, Cicatricial pemphigoid)
Lichen Planus (Lichen planopilaris)
pseudOpelada de Brocq
Physical damage (chemicals, trauma, radiation)
Epidermal Nevus and Neoplasms (BCC, SCC, metastases)
Congenital (Aplasia cutis)
Infectious (Bacterial, Fungal, Viral - Herpes zoster)
Alopecia mucinosa (Sometimes associated with mycosis fungoides)
Sarcoidosis

DRUG INDUCED PEMPHIGUS

CRAP

Captopril
Rifampicin
ACE Inhibitor
Piroxicam; Penicillamine

CAUSES OF BLUE SCLERA

A POEM

Anaemia
Pseudoxanthoma elasticum
Osteogenesis imperfect
Ehlers Danlos syndrome
Marfan syndrome

GENERALIZED SKIN HYPERPIGMENTATION

"Generalized mean none of the skin is SPARED"

Sunlight
Pregnancy
Addison's Disease
Renal failure
Excess iron (haemochromatosis)
Drugs (e.g. amiodarone, minocycline)

HENOCH-SCHONLEIN PURPURA

NAPA

Nephritis
Arthritis, arthralgias
Purpura, palpable (especially on lower extremities)
Abdominal pain (intussusception to be ruled out)

INCONTINENTIA PIGMENTI (BLOCH-SULZBERGER'S DISEASE)

BLOCH

Bony abnormalities; Bullae/vesicles (I)
Loss or dystrophy of hair, nails or teeth
Ocular (blindness, strabismus, cataracts)
Central Nervous System (seizures, mental retardation)
Heart malformations (uncommon);

Stages:

Bullae/vesicles (I),
Hyperkeratotic plaques (II),
Hyperpigmentation (III),
Hypopigmentation- (IV)

LEUKOCYTOCLASTIC VASCULITIS

VASCULITIS

Viral hepatitis B, C
Anaphylactoid purpura, Autoimmune (SLE, PSS, DM)
Systemic lupus & other autoimmune Disease, Staph/Strep Sepsis
Cryoglobulins
Urticarial Vasculitis, ulcerative colitis
Lymphoproliferative Disease (Hairy Cell leukemia)
Idiopathic
Thiazides, PhenoThiazines, Lasix
Immune Sera, & Iodides
Sulfa (& other antibiotics)

Hair shaft abnormalities

1) Increased fragility - monilethrix, pili torti,trichorrhexis invaginata, trichorrhexis nodosa, trichoschisis
2) Without fragility - pili annulati, uncombable hair, loose anagen hair



Pili torti - twisting of hair, flattened hair with rotation of 180 degree around long axis at irregular interval
eg. Menkes' syndrome, Bjornstard syndrome
Trichorrhexis nodosa is the fraying of hair ends so that the resemble a "broom-stick" or "paint brush".
eg. argininosuccinic aciduria

Trichoschisis or clean fracture of the hair shaft.
eg. Tay's syndrome is also known as trichothiodystrophy

Trichorrhexis invaginata or bamboo hair.
eg. Netherton's syndrome

Monilethrix means beading of hairs, it is an Autosomal Dominant condition.
Abnormality is in gene coding for human hair keratins hHb1 and hHb6.
Pili Annulati is the alternating light and dark bands secondary to air-spaces seen in normal light and has been associated with alopecia areata.

CLASSIFICATION OF HYPERSENSITIVITY REACTION

ACID

A = Type 1 Anaphylactic
C = Type 2 Cytotoxic
I = Type 3 Immune complex
D = Type 4 Delayed

Modified sebaceous glands

Fordyce spots = lips
Montgomery's tubecles = nipples
Meibomian glands = eyelids
Tyson glands = genitalia

KOEBNER'S PHENOMENON

Very Low Density Lipo-ProteinS

V = Vitiligo; Viral wart
L = Lichen planus / Lichen striatus
D = DLE
L = Molluscum contagiosum
P = Psoriasis
S = Sarcoidosis

LICHEN PLANUS

"7P"

Pruritic, Papules, Plaques, Purple, Polygonal, Plain top, Peripheral

LYMPHOGRANULOMA VENEREUM

ABCDEFG

A = Asymptomatic in early stage
B = Bilateral buboes
C = Causative organism Chlamydia trachomatis
D = Drug of choice doxycycline
E = Estheomine
F = Frei's test
G = Groove's sign

Important HPV types

Plantar warts 1,2
Common warts 1,2
Flat warts 3,10
Butcher's warts 7
Epidermodysplasia verruciformis 5,8,9
Condyloma acuminatum (CA) 6,11
Bushke Lowenstein tumour (Giant CA) 6,11
Focal epithelial hyperplasia of Heck 13,32
Bowenoid papulosis 16
Intraepithelial neoplasias 11,16,31,33

Classification of cutaneous TB

1.Exogenous
- Primary inoculation TB (nonsensitized)
- TB verrucosa cutis (sensitized)

2.Endogenous
- Lupus vulgaris
- Scrofuloderma
- Metastatic TB abscess
- Acute miliary TB
- Orificial TB

3.Tuberculid
- Erythema induratum
- Papulonecrotic tuberculid
- Lichen scrofulosorum

Blueberry Muffin spots

Causes:
Prenatal infections (e.g. TORCH)
Severe anemia (e.g. Hemolytic Disease of the newborn, Hereditary spherocytosis)
Neoplastic diseases (e.g. rhabdomyosarcoma, Neuroblastoma)

Indicate extramedullary erythropoiesis

AGEP

Acute generalized Examthematous Pustulosis

Drugs: Ampicilin, cephalosporins, macrolides, Ca channel blockers, hydrochloroquine, paracetamol
Infections: Enterococcus, Parvo virus 19, CMV, Chlamydia, spider bites

MHC molecules

MHC Class I molecules are on ALL nucleated cells
MHC Class II molecules are on B cells, monocytes, dendritic cells, and are inducible on keratinocytes and endothelial cells.

TH relation of skin diseases

TH1: psoriasis, contact dermatitis, tuberculoid leprosy
TH2: atopic dermatitis, lepromatous leprosy, SLE

TH1:IL1, IL2, IL12, IL15, IL18, IL23, IFN alpha, IFN gamma, TNF alpha, TNF beta
TH2:IL4, IL5, IL6, IL9, IL10, IL13

Sutures

Absorbable: Catgut, Vicryl, Maxon, Monocryl, PDS, Dexon

Non-absorbable: Polypropylene, Nylon, Navafil, Silk

Waardenburg's syndrome gene

"pack your mittens and pack your socks"

PAX-3
MITF
SOX10

POEMS syndrome

Polyneuropathy
Organomegaly
Endocrinopathy
Monoclonal gammopathy
Skin lesions - gromeruloid hemangioma

DFSP VS Dermatofibroma

Immunohistochemistry staining

Dermatofibrosarcoma protuberans : CD34+++ Factor XIIIa +
Dermatofibroma : CD34+ Factor XIIIa+++

Acute sarcoidosis

LöfgreN syndrome
Hilar Lympadenopathy, erythema Nodosum, fever, migrating polyarthritis, acute iritis

Heerfordt syndrome
Parotid gland enlargement, fever, uveitis, and cranial (usually facial) nerve palsies

IBD and Skin

Ulcerative colitis: Erythema nodosum, pyoderma gangrenosum and pyoderma vegetans (more common than CD)

Crohn's disease: PAN (but not with UC), oral cobblestone, perineal fissures and fistula

Hepatitis C skin manifestation

Vasculitis - mixed cryoglobulinemia
Porphyris cutaneous tarda
Lichen planus - erosive mucous LP
Cutaneous polyarteritis nodosa
Pyoderma gangrenosum
Pruritus
Others: Sjogren syndrome, urticaria, erythema multiforme, erythema nodosum, prurigo nodularis, disseminated superficial actinic porokeratosis, generalized GA, necrolytic acral erythema

Source: Rook's Dermatology 7th

Paraneoplastic pemphigus

Tumors associated with paraneoplastic pemphigus

Target antigens include desmoplakin (250kD), envoplakin (210kD), periplakin (190kD), bullous pemphigoid antigen-1 (230kD) and desmogleins 1 and 3.

Tay syndrome

Tay syndrome=Trichothiodystrophy

Photosensitivity
Icthyosis
Brittle hair
Intellectual impairment
Decreased fertility
Short stature

Elastosis Perforans Serpiginosa

Associated with PROMEDA

Pseudoexanthoma elasticum
Rothmund-Thomson
Osteogenesis imperfecta
Marfan's syndrome
Enles-Danlos syndrome
Down's syndrome (1/3 of the cases)
Acrogeria

Painful cutaneous nodules

BENGAL CO

Blue rubber bleb nevus
Eccrine spiradenoma
Neurilemmoma/ Neuroma
Glomus tumor
Angiolipoma/ Angioleiomyoma/ Angiosarcoma
Leiomyoma
Cutaneous endometriosis/ Calcinosis cutis
Osteoma cutis

Black dot ringworm

"Ringo Gave Yoko Two Squeaky Violins"

T. rubrum
T. gourvilli
T. yaounde
T. tonsurans
T. schoeleinii
T. soudanense
T. violaceum

Fluorescent ectothrix dermatophyte

"Cats And Dogs Fight and Growl Sometimes"

M. canis
M. audouinii
M. distortum
M. ferrugineum
M. gypseum
T. schoenleinii

Local anesthetics

Local anesthetics come in one of two types, esters and amides.

Esters have one “i”, and amides have two “I’s” in their name.

eg Esters = cocaine, procaine, tetracaine

Amides= lidocaine

These two classes differ in their metabolism, and potential for sensitization.

• Esters are metabolized by plasma pseudocholinesterase, so individuals with dysfunctional pseudocholinesterase may be susceptible to toxic effects. In addition, PABA is a metabolite of ester anesthetics, and may result in allergic sensitivity.
  
• Amides are metabolized in the liver, and patients with impaired liver function may be at risk of toxic effects from high levels of amide anesthetics.

Gardner syndrome

An autosomal dominant inherited disorder associated with colon cancers.

• Triad of signs

1. Intestinal polyposis
2. Bony tumors eg osteoma
3. Soft-tissue lesions eg epidermoid cyst

• Displays an autosomal dominant inheritance pattern with complete penetrance and variable expressivity.
• Intestinal polyps become malignant in virtually 100% of patients if not treated.
• Polyps also develop in the upper gastrointestinal tract.
• Malignancies may occur in the brain and in the thyroid gland.
• The APC gene located at 5q21 is mutated.
• Extracolonic features precede intestinal polyposis.

Exacerbating causes of plaque psoriasis

TEA IS DRUG

Trauma/ Sunburn
Endocrine: postpartum
Alcohol

Infection: Steptococcus, HIV
S: Stress, Smoking, Sunburn

Drugs: Steroids, lithium, antimalarials, beta-blockers

Behcet's syndrome: Diagnostic Criteria

PROSE
Oral ulceration is central criterion, plus any 2 others

• Pathergy test
• Recurrent genital ulcer
• Oral ulcer (recurrent)
• Skin lesions (erythema nodosum, subcutaneous thrombophlebitis, cutaneous hypersensitivity)
• Eye lesions (iridocyclitis, chorioretinitis)

SLE Diagnosis

SOAP BRAIN MD
4 out of 11 criteria needed for diagnosis

• Serositis
• Oral ulcer
• Arthritis
• Photosensitivity
• Blood (cytopenia)
• Renal
• ANA
• Immune (dsDNA, anti-Sm)
• Neurological (seizures, stroke)
• Malar rash
• Discoid rash

Rash

Really Sick Children Must Take No Exercise
Number of days after fever onset that a rash will appear

1. Day: Rubella
2. Days: Scarlet fever/ Smallpox
3. Days: Chickenpox
4. Days: Measles (and see the Koplik spots one day prior to rash)
5. Days: Typhus & rickettsia (this is variable)
6. Days: Nothing
7. Days: Enteric fever (salmonella)

Leukocytoclastic vasculitis

VASCULITIS

Viral hepatis B/C
Autoimmune (SLE, RA, Sjogren)
Streptococcus, staphylococcus
Cryoglobulins
Ulcerative colitis, urticarial vasculitis
Lymphoproloferative ds esp hairy cell leukemia
Idiopathic
Thiazides, phenothiazine
Iodides, immune serum (from blood transfusions)
Sulfa-based drugs, penicillin

Erythroderma causes

SCALP ID

• Seborrheic dermatitis, Sezary syndrome
• Contact dermatitis
• Atopy/Allergy
• Lymphoma/leukemia
• Psoriasis/PRP
• Idiopathic
• Drug eruption

Painful Cutaneous Nodules

BENGAL CO.

• Blue rubber bleb nevus
• Eccrine spiradenoma
• Neurilemmoma / Neuroma
• Glomus tumor
• Angiolipoma/Angioleiomyoma/Angiosarcoma
• Leiomyoma
• Cutaneous endometriosis/Calcinosis cutis
• Osteoma Cutis

High Risk for Adverse Cutaneous DR

I AM MAD

• Infections (HIV, TB, EBV)
• Age (very young, very old)
• Malignancy esp hematological
• Multiorgan failure
• Autoimmune ds (Sjogren ds, SLE, RA)
• Drugs (polypharmacy)

Phototoxic drugs

FAT BIG

• F luoroquinolones
• A miodarone
• T etracyclines
• B enoxaprofen (most of the NSAIDS)
• I buprofen (least)
• G riseofulvin

Eczema precipitating factors

FASCIE

• Food
• Allergy
• Stress
• Cold (weather change)
• Infection (staphylococcus, scabies, herpes)
• Estrogen (pregnancy)

Incontinentia Pigmenti stages

V.V.H.H.

1. Vesicular
2. Verrucous
3. Hyperpigmentation
4. Hypopigmentation

X-Linked Recessive syndromes

CHAD's KINKY WIFE:

• Chronic Granulomatous Disease, Chondrodysplasia puncata
• Hunter's Disease
• Anhidrotic ectodermal dysplasia
• Dyskeratosis congenita
• SCID
• Menke's Kinky Hair disease
• Wisckott-Aldrich
• Ichtyosis, X-linked
• Fabry's disease
• Ehler's Danlos V and IX