Lupus Erythematosus

Etiology: Heterogeneous autoimmune disease resulting from the interplay of genetic, environmental, and hormonal factors. F > M.

History & Physical: Spectrum of disease varies from limited cutaneous involvement to severe systemic disease.

Systemic Lupus Erythematosus (SLE): 1997 Update of the 1982 ACR Revised Criteria

Management

LE-specific skin manifestations are divided into 3 categories (other less common forms exist as well).

Clinical

Comment

Acute cutaneous LE

Classic "butterfly" malar rash.

Often association with anti-dsDNA Ab and lupus nephritis.

Evaluate for evidence of systemic disease.

Hydroxychloroquine.

Systemic steroids (0.5 mg-1 mg/kg/d) + steroid-sparing agents (azathioprine, methotrexate, mycophe-nolate mophetil).

Subacute cutaneous LE

Two subtypes: Annular or papu-losquamous presentation.

Often associated with anti-Ro Ab.

Sun protection. Corticosteroids (topical, intralesional) and hydroxychloroquine.

Chronic cutaneous/discoid LE

Most often in head/neck area: Atrophic inflammatory plaques.

Can lead to scarring alopecia.

5%-10% will get systemic disease Tx: Photoprotection, topical or intralesional steroids, hydroxychloro-quine

Other important variants of lupus: Drug-induced lupus, lupus profundus, neonatal lupus.

Investigations: Diagnosis requires clinicopathologic correlation;

often multiple skin biopsies needed before diagnosis made. DDx: Eczema, neurodermatitis, parapsoriasis.

Mycosis fungoides (MF)

The most common clinicopathologic subtype of primary cutaneous T-cell lymphoma (CTCL).

Management

Choice of therapy and management setting depends on stage of disease: "stage-directed therapy"

Overview of Mycosis Fungoides Therapies

Skin-directed Therapies

Systemic Therapies

Topical therapies Steroids (mid to strong potency) Topical chemotherapy

■ Nitrogen mustard

■ Carmustine (BCNU) Bexarotene 1% gel Imiquimod 5% cream Phototherapy: PUVA,

BB/NB-UVB, UVA-1 Radiation therapy Local x-ray therapy Electron Beam Therapy

Biological/immune therapies Bexarotene, Acitretin Denileukin

Diftitox Interferon

Extracorporeal photopheresis (ECP) Monoclonal antibodies Cytokine therapy Chemotherapy Methotrexate, gemcitabine

Pentostatin and purine analogues Combination chemotherapy Bone marrow/stem cell transplantation

Melanoma

Images Lupus Profundus

Etiology: Melanocyte-derived skin cancer. May arise within a previously existing nevus or dysplastic nevus, but ~70% arise de novo.

History:

Risk factors

■ Fair complexion: Red/blonde hair, blue/green eyes, tendency to freckle and burn.

■ Sun exposure, particularly blistering sunburns during childhood.

■ Personal or family history of melanoma; Genes involved in some cases: CDKN2A, BRAF.

■ Giant congenital melanocytic nevi or multiple dysplastic nevi.

Physical: Pigmented macule or plaque with some or all of the following features (ABCDE of melanoma): Asymmetry, Borders (irregular), Color variegation, Diameter (>6 mm), Evolution (lesion change by history).

Classically divided into subtypes based on clinical and histopathologic features:

1. Superficial spreading malignant melanoma—60%—70% of melanomas.

2. Nodular melanoma.

3. Acral-lentiginous melanoma — Most common form in blacks, Asians, and Hispanics, mostly on volar skin of the palms or soles and the nailbeds.

4. Lentigo maligna melanoma — Develops from a lentigo maligna, usually on the face of elderly, slow-growing.

5. Amelanotic melanoma — Pink-red.

6. Rare variants.

Most common sites of local and/or regional metastases— Draining lymph node basins and the skin between the primary site and the lymph nodes; most common sites of systemic metastases—Lung, liver, brain (#1 cause of death), bone, and gastrointestinal tract.

Investigations: Dermoscopy (ABCD rule or 7-point checklist; requires expertise); excisional biopsy if melanoma is suspected.

■ Most important prognostic indicator is maximal thickness of tumor invasion on biopsy (Breslow depth in mm).

DDx: BCC, blue or dysplastic nevus, SK.

How To Deal With Rosacea and Eczema

How To Deal With Rosacea and Eczema

Rosacea and Eczema are two skin conditions that are fairly commonly found throughout the world. Each of them is characterized by different features, and can be both discomfiting as well as result in undesirable appearance features. In a nutshell, theyre problems that many would want to deal with.

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