Derma Wet Clinic Notes

Derma Wet Clinic Notes by 하니 제인 델라 그루스 (Ha-ni Je-in del-la Keu-ru-seu) // Oy 죠셒 (Dyo-sep) at 말세르 (Mar-se-leu), eto na po. Pagpasensiyahan niyo na. May trans naman ata dapat. :D Case 1: Leprosy    

CC: 4 years PTC, noted presence of erythematous, annular plaque with hyposthesia  dumami, lumaki Hx: Sister previously diagnosed with leprosy, currently undergoing multi-drug theraphy PE: generalized patches of hyperpigmentation, loss of hair, decreased sweating, loss of eyebrows on lateral side Discussion:  Hyperpigmentation due to the medication (clofazemine)  Spectrum of leprosy (I, TT, BT, BB, BL, LL vs paucibacillary and multibacillary)

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Paucibacillary

Multibacillary

Lesion

I: hypopigmented patches (usually on the face) TT: Few, erythematous, punched-out plaques with well defined borders

Numerous erythematous plaques with illdefined borders Generalized thickening of the skin Leonine facies

Histology

Few or no acid fast bacilli visible Multinucleated giant cells Fragmented nerves

Foamy histiocytes Numerous bacilli No granuloma formation

Nerve

Early hyposthesia

+/-

Diagnostics: clinical presentation, Skin biopsy (bacillary index, morphology index)

Case 2: Tinea versicolor  CC: multiple pruritic hypopigmented macules and patches with scaling on the upper arms, anterior chest, upper back  Hx: 8 mos prior to PTC, Px noted multiple pruritic hypopigmented macules on the upper arm. Sweat aggravates itchiness. Treated with salicylate and Trosyd but kept on recurring.  Discussion: o Etiology: Malazessia furfur (a yeast, not a dermatophyte!) o To assess severity (for appropriate treatment) estimate percentage of body surface area affected  Palm = 1%.. So hers is approx. 12%  Tx: if BSA >10% or duration > 1 month, give combination of oral and topical antifungals o Predisposing factors: family history o Ask for Hx of immunosupressive disease e.g. DM

Case 3: Acne Vulgaris OSCE sample  CC: ?  HX o o o o

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Kailan pa po yan nagsimula? Nung 13 y.o., nung niregla ko Paano po nagsimula? May mapula, tapos yung iba may nana Meron po bang parang may nakabara na itim? O kaya may puti sa ibabaw? Meron po kayong ginagawa na nakakapagpalala? Pag may exam ako, o pag kumakain ng chocolates at mani o Meron po ba kayong ibang sakit? Mga ibang gamot na iniinom?  To check for drug-induced acne (ex. SLE treated with steroids) o Sa pamilya niyo po meron di bang may ganyan? o Personal/Social Hx PE: Look first for comedones! Multiple open and closed comedones distributed on the forehead, cheeks, nose. There are also multiple erythematous papules and pustules distributed on the forehead, cheeks, nose. Upon examination of the chest and the back, there are also similar lesions.There are also atrophic scars.

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DDx and reasons to rule out: o Acneiform eruptions: monomorphic, no comedones, generalized (esp if drug-induced) o Rosacea: no comedone, telangiectasia, flushing, rhynophyma o Perioral dermatitis: history of topical steroid use Acne vulgaris because from history: o Onset at adrenarche (puberty) o Imbalance of hormones during menstruation o Exacerbated by stress (inc. levels of cathecolamines stimulate androgens, hence seborrhea), and high glycemic index Treatment o For impaired keratinizations: keratolytics (isotretinoin) o For P. acnes proliferation: oral and topical antibiotics (clindamycin, doxycycline) o For seborrhea: oral contraceptives o For inflammation: intralesional steroids (esp for deeply-seated nodules)

Case 4: Psoriasis  CC: Skin lesions in the legs, arms and back  Hx: Started as multiple erythematous plaques on the scalp that were very pruritic. Eventually spread to the extremities and back. Has been taking medication for 3 years (but on/off). Sister was previously diagnosed of psoriasis (did not tell family members initially).  PE: Multiple eythematous plaques with white scales distributed on the extremities and back. Multiple hypopigmented macules and patches distributed on the arms, extremities and back. Pitting of the nails. Woronoff's ring: sign of remission; white ring around the patch.  DDx: o Tinea corporis: also erythematous, with central clearing and advancing borders o Nummular eczema: no scaling o Seborrheic dermatitis: predilection in the centrals areas of scalp, face (nose, nasolabial folds), chest, and pre and post auricular areas; once it is beyond the scalp line, consider psoriasis o Tinea alba: thin scales o Intertrigo for inverse psoriasis  Pwedeng intertrigo lang, or candidal if may satellite lesions

Case 5: Tinea Cruris  CC, Hx, PE: Erythematous, pruritic papules and plaques with raised defined borders, fine scaling, crusting and excoriations started on the medial thigh and spread to the labia, inguinal area and butt cheeks. Px is a messenger.  Characteristic of tinea cruris: Erythematous, pruritic plaques with raised borders and central clearing and fine scaling  DDx o Candidal intertrigo: satellite lesions o Allergic contact dermatitis: Hx of contactant o Eczema: accentuated skin lines o Psoriasis: thick white scales, most likely on intergluteal folds o Erythrasma: caused by Corynebacterium, red flourescence on Wood's lamp (as compared to neon yellow of Tinea)  Caused by dermatophytes (not part of normal flora.. Infection!) o Feeds off keratin, affects stratum corneum, hence the scaling o Risk factors: occluded, moist areas, with frequent movement (macerated skin where fungi can enter) Case 6: Scabies  CC: pruritic papules on the interdigital areas of the hands and feet, wrists  Hx: other family members have same symptoms; live in a crowded area; itching more severe at night, aggravated by heat and sweat. Ask for presence of lesions in the axilla, inguinal area and buttocks.  DDx o Dyshydrotic eczema: only in hands and feet, vesicles o Atopic dermatitis: Hx of irritant o Insect bite o Pediculosis corporis  Tx: permethrin cream (leave for 6-8 hours), repeat for a week; prophylactic treatment for the family members; wash clothes in warm water or expose to the sun

Case 7: Pediculosis capitis  CC: itchy scalp  Hx: elicit Hx of contact with people having the same symptoms; Sister also had it, experiencing it for 5 years  PE: Check entire scalp, look for nits, palpate cervical lymph nodes (possible secondary bacterial infection)  DDx: o Seborrheic dermatitis o Tinea capitis o Artifacts

Case 8: Carbuncle  CC and PE: Solitary erythematous, nodule with pus draining from multiple drainage sinuses, with crusting  Hx: 4 days ago, the lesion was as small as a pimple, painful. Applied hot compress, and Coyo (pampahinog?) Sibling also had a similar lesion. Previously had the lesion during childhood  DDx: nbnn o Furuncle: Single drainage sinus o Insect bite: no pus discharge o Ruptured cyst: no pus discharge  Tx: o Cloxacillin (oral), mupiricin (topical) o Prophylactic for family members: apply to the nares, body folds (flexural areas), and other carrier sites