(BQ) Part 1 book Illustrated synopsis of dermatology and sexually transmitted diseases presents the following contents: Introduction, diagnosis of skin diseases, genodermatology and genodermatoses, papulosquamous disorders, bullous disorders, eczematous dermatitis,...
Illustrated Synopsis of Dermatology and Sexually Transmitted Diseases Prelims.indd 7/28/2011 6:40:26 PM “This page intentionally left blank" Illustrated Synopsis of Dermatology and Sexually Transmitted Diseases Fourth Edition Neena Khanna, MD Professor Department of Dermatology and Venereology All India Institute of Medical Sciences New Delhi, India ELSEVIER A division of Reed Elsevier India Private Limited Prelims.indd 7/28/2011 6:40:27 PM Illustrated Synopsis of Dermatology and Sexually Transmitted Diseases, 4/e Neena Khanna ELSEVIER A division of Reed Elsevier India Private Limited Mosby, Saunders, Churchill Livingstone, Butterworth-Heinemann and Hanley & Belfus are the Health Science imprints of Elsevier © 2011 Elsevier First Edition 2005 Second Edition 2008 Third Edition 2009 Fourth Edition 2011 All rights are reserved No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise without the prior permission of the publisher ISBN: 978-81-312-2802-9 Medical knowledge is constantly changing As new information becomes available, changes in treatment, procedures, equipment and the use of drugs become necessary The author, editors, contributors and the publisher have, as far as it is possible, taken care to ensure that the information given in this text is accurate and up-to-date However, readers are strongly advised to confirm that the information, especially with regard to drug dose/usage, complies with current legislation and standards of practice Please consult full prescribing information before issuing prescriptions for any product mentioned in this publication Published by Elsevier, a division of Reed Elsevier India Private Limited Registered Office: 622, Indraprakash Building, 21 Barakhamba Road, New Delhi–110 001 Corporate Office: 14th Floor, Building No 10B, DLF Cyber City, Phase II, Gurgaon–122 002, Haryana, India Managing Editor (Development): Shabina Nasim Development Editor: Shravan Kumar Copy Editor: Shrayosee Dutta Manager Publishing Operations: Sunil Kumar Manager Production: NC Pant Production Executive: Arvind Booni Typeset by Chitra Computers, Delhi Printed and bound at Thomson Press, Delhi Prelims.indd 7/28/2011 6:40:27 PM Dedicated to the three people I miss immensely My Dad, who had the tenacity to survive all handicaps, My Teacher, Prof LK Bhutani who academically honed many of us and My Sister, Sunita who was an epitome of life and verve Prelims.indd 7/28/2011 6:40:27 PM “This page intentionally left blank" Preface to the Fourth Edition About the book … The importance of Dermatology cannot ever be overemphasized A quarter of a general practitioner’s patients are ‘dermatological’, and it is necessary for the physician to be well-versed with the presentations of common skin diseases It is equally important to remember that the skin manifestation may be a clue to the patient’s internal disease The book is nothing but a simplified and brief journey through skin diseases, peppered with numerous clinical pictures, illustrations, and tables—the basic aim being to familiarize medical students and general practitioners with the plethora of common skin conditions they are likely to encounter and to help them in handling these correctly and not to succumb to the morbid temptation of prescribing steroids— often thought to be ‘panacea of all skin ills’ About this edition … “A picture is worth a thousand words” is an apt description for Dermatology, because it is a visual specialty So it is necessary for any dermatology textbook to be more of an atlas rather than just full of text And that is the reason that about 100 new pictures have been added in this new edition Neena Khanna Prelims.indd 7/28/2011 6:40:27 PM “This page intentionally left blank" Acknowledgements There are some people whom I cannot thank enough My Teachers Professor (Late) LK Bhutani, who honed our clinical skills during our training and in his charming way admonished us to ‘click’ the lesion Professor RK Pandhi, who was a friend and mentor during our training and afterwards too! Professor JS Pasricha, who insisted we write what we see This book, in a sense, is a tribute to them all I owe so-so much to them! My Family My father, who overcame several handicaps with his discipline and perfection and who was to a large measure responsible for what I am doing today My mother, who believed that education is the only true wealth and one is never too old to learn Anil, my better half (!) who has always been a mountain (literally!) of support My mother-in-law, who believes (wrongly though!) that I am a perfectionist My sister Sunita, for always believing in my ability My bacchas, Chandni and Abhishek who have accepted the book as another sib, and are now showing signs of intense sibling rivalry!! And my pug Cuddles, for quietly sitting at my ‘charan’ like an obedient son and giving me constant company while I worked on the manuscript (and thankfully not showing any sibling rivalry!) For this edition Several people helped with this edition: My Colleagues Dr Seema, Divya, Ishita and Neetu for nit picking the lous(e)y initial manuscript and giving suggestions that culminated in the present shape of the book The feedback of undergraduate students has always helped in more ways than one Office Staff Meenu who has worked endlessly on all editions Tanu who worked on this edition Munni for keeping the papers sorted My Publisher Several people from Elsevier helped the new edition see the light of day— Rohit and Vidhu for their constructive optimism Shabina, Shukti, Shrayosee and Shravan for their editorial expertise (and gentle pressurising!!) and ability to put up with an intrusive author! Swaroop and Thakur saab for typesetting Sunil and Arvind for overseeing the production Neena Khanna Prelims.indd 7/28/2011 6:40:28 PM Illustrated Synopsis of Dermatology and Sexually Transmitted Diseases 176 A Fig 10.5 SJS–TEN complex: extensive erythema and erosions in buccal mucosa and hemorrhagic crusting on lips B Fig 10.3 A and B: SJS–TEN complex: appears as diffuse erythematous lesions, with a typically crinkled surface Initial lesions may or may not be targetoid but they rapidly coalesce into large sheets of dusky erythema Some form flaccid, sometimes hemorrhagic blisters Oral lesions Hemorrhagic crusting of lips SJS-TEN complex Erythema multiforme to form erosions (Fig 10.5) covered with grayish white slough Eye: Purulent conjunctivitis, corneal erosions with possible sequelae like corneal opacities, synechiae, and even blindness Genital mucosa: Erosions which may be complicated by urinary retention Nasal mucosa: Erosions Course Erythema multiforme: Self-limiting May recur SJS–TEN complex: In absence of complications, healing of denuded skin begins within a couple of days and is complete within weeks, except on pressure points and periorificial areas Skin, which has not denuded, is shed in sheets (especially on palms and soles) Complications Complications are frequent in SJS–TEN complex, especially in extensive disease: Secondary infection: Of skin And septicemia Complications of skin failure: Electrolyte imbalance, temperature dysregulation, protein loss, and cardiac complications Tracheobronchial involvement: May lead to asphyxia Eyes: Corneal opacities, synechiae, and even blindness Investigations Fig 10.4 Sites of predilection of erythema multiforme and SJS–Ten complex Biopsy Histopathology is distinctive: Chapter 10 • Abnormal Vascular Responses 177 Epidermal cell necrosis Papillary dermal edema Endothelial swelling Lymphohistiocytic perivascular infiltrate To Identify the triggers Careful history with regard to drug intake History, examination, and investigations like chest X-ray to rule out infections (HSV and Mycoplasma) Differential diagnosis SJS–TEN complex needs to be differentiated from: b Bullous pemphigoid (BP) BP SJS–TEN complex Chronic eruption Acute eruption Patient toxic Tense, large, and hemorrhagic Bullae surrounded by rim of erybullae Often not rupture thema; bullae usually rupture, but roof settles down sometimes in sheets Oral lesions uncommon Diagnosis Erosions in buccal mucosa; hemorrhagic crusts on lips Erythema multiforme Points for diagnosis Diagnosis of erythema multiforme is based on: An antecedent history of HSV (oral/genital) infection Only minimal prodrome Appearance of target lesions (center dusky + bulla with erythematous halo) in crops Predominant acral (symmetrical) and facial distribution Treatment Differential diagnosis EM needs to be differentiated from: EM Symptomatic treatment with antihistamines and calamine lotion a Urticaria Urticaria EM Morphology: wheals If annular have a pale center Initial urticarial plaque Develops a dark center Bullae: absent Common Lasts: 12–24 h Much longer Distribution: any part of body Acral parts SJS–TEN complex Points for diagnosis The diagnosis of SJS–TEN complex is based on: History of drug intake 1–3 weeks prior to onset of rash Prodrome common and often severe Sudden appearance of large areas of diffuse erythema with typically crinkled surface; ± target lesions Rapidly coalesce, form blisters (flaccid), and denude Positive Nikolsky sign Face, neck, and central trunk initially; generalized later Mucosal involvement universal: oral, eye, genital, and nasal Systemic manifestations common and severe Remove the cause Infections should be treated appropriately In case of HSV associated EM, acyclovir may be given All drugs should be withdrawn If that is not possible, substitute with chemically unrelated drugs Symptomatic treatment Recurrent EM HSV infection is often the cause of recurrent EM Suppressive long-term therapy with acyclovir (400 mg, twice daily × 6–12 months) may help Suppressive acyclovir also helps in recurrent EM, even in the absence of clinically overt HSV infection SJS–TEN complex Nursing care: Extremely important and includes: Maintenance of a patent airway Good nutrition Proper fluid and electrolyte balance Suspension beds for patients with extensive lesions Prevention of secondary infection, by intensive barrier nursing, use of prophylactic antibiotics (but only if necessary) Thermoregulation Care of mouth and eyes Systemic steroids Role is debatable Illustrated Synopsis of Dermatology and Sexually Transmitted Diseases 178 Many dermatologists use a short course of steroids (about 80 mg prednisolone equivalent daily) during the acute phase Even given as bolus pulse therapy Usually relieve constitutional symptoms Newer modalities: Cyclosporine and intravenous IgG are promising Urticaria and Angioedema Synopsis Terminology: Two main subtypes: Urticaria: Due to edema of dermis Angioedema: Due to edema of dermis and subcutis Etiology: Edema of dermis and subcutis due to mediators released from mast cells Degranulation of mast cells mediated by IgE, complement, directly by drugs or idiopathic Triggers: Physical stimuli (scratching, cold, sunlight, pressure, etc.), dietary and inhaled allergens, and drugs Often no cause Clinical features: Itchy evanescent wheals in urticaria Less evanescent, not itchy in angioedema Linear in dermographism; small wheals in cholinergic urticaria Complications: Laryngeal edema, anaphylaxis Treatment: Remove triggers Antihistamines (often combination) mainstay of treatment Oral steroids in anaphylaxis and recalcitrant urticaria Immunosuppressives (methotrexate, azathioprine, and cyclosporine) in resistant disease Urticaria is a heterogeneous group of disorders characterized by itchy wheals, which develop due to evanescent edema of dermis (and sometimes of subcutis) Classification of Urticaria Urticaria is classified either based on chronicity or on pathogenesis Depending on Duration Based on its chronicity, urticaria is classified into: Acute urticaria: Urticaria of 72 h 1 cm/day) painful, necrolytic ulcer with an irregular, undermined, violaceous border (Fig 10.18), and pain out of proportion to size of ulcer Heals with cribriform scarring Rapid response to oral steroids Sweet’s Syndrome Is a neutrophilic dermatosis May be classical (triggered by upper respiratory and other infections, IBD, and pregnancy), malignancy associated, or drug associated Skin lesions consist of multiple, erythematous to violaceous tender papules or nodules that Fig 10.19 Sweet’s syndrome: erythematous to violaceous tender papules or nodules that coalesce to form irregular plaques Note pseudovesiculation due to prominent dermal edema and tiny pustules coalesce to form irregular plaques (Fig 10.19) Later lesions may appear pseudovesicular because of prominent dermal edema and may be studded with tiny pustules Arms, face, and neck Herpetiform aphthae in oral mucosa and conjunctivitis in eyes Fever and neutrophilic leukocytosis invariable Systemic steroids, standard therapy Other agents used include colchicine and potassium iodide .. .Illustrated Synopsis of Dermatology and Sexually Transmitted Diseases Prelims.indd 7/28/2 011 6:40:26 PM “This page intentionally left blank" Illustrated Synopsis of Dermatology and Sexually Transmitted. .. pink12 11 PAS: periodic acid schiff 12 Amyloid: gives orange pink color with congo red with apple green birefringence Illustrated Synopsis of Dermatology and Sexually Transmitted Diseases 18 ... discussion on diseases into: Etiology: Usually illustrated with tables Illustrated Synopsis of Dermatology and Sexually Transmitted Diseases Epidemiology Clinical features: Morphology, illustrated