Papulosquamous diseases Pityriasis rosea Acute and self limiting
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Papulosquamous diseases
Pityriasis rosea • Acute and self limiting disorder of unknown etiology. • Characterised by oval scaly paules and plaques mainly over the trunk.
Manifestation • Firstly, a single lesion about 2 -5 cm also known as “herald patch”appears. • Somedays later many smaller plaques appear on the trunk , arms and thighs. • Plaques are oval , pink and have delicate peripheral collarette of scale. • They are distributed parallel to the ribs, radiating away from the spine. • Itching is present, may be mild. • The eruption fades spontaneously in 4 -8 weeks. • Common in teenagers and young adults.
Herald patch
Collarette scale
• In atypical PR (20% of patients), the herald patch may be missing or confluent with • • other lesions. The distribution of the rash may be peripheral, and facial involvement may be seen in children. Involvement of the axilla and groin (inverse variant) can also be seen. • TYPES of lesion: – PR gigantea – PR urticata – Vesicular – Pustular – Purpuric – Erythema multiforme–like. • Oral lesions of various types have been reported with PR, including erythematous plaques, hemorrhagic puncta, and ulcers.
Extensive pityriasis rosea showing a ‘fir tree’ distribution on the back.
Differential diagnosis Pityriasis rosea Psoriasis (Guttate) Lichen planus Secondary syphilis Tinea corporis Mycosis fungoides (cutaneous T- cell lymphoma) Discoid lupus erythematosus Pityriasis lichenoides Pityriasis versicolor Nummular eczema Seborrhoeic dermatitis Drug eruptions
Treatment • • • Self limiting disease. Treatment doesn’t hasten the clearance. Antihistamines, calamine lotion Mild topical steroid can help. PUV A UVB BANDS
Lichenoid eruption
Lichen planus (LP)
Lichen planus (LP) • Lichen planus (LP) is a rash characterised by intensely itchy polygonal papules with violaceous hue involving the skin and less commonly the oral or genital mucosa, hair and nails and/or the scalp. • The most frequent oral presentation is asymptomatic reticular LP, but painful erosive or ulcerative areas may appear.
ETIOLOGY • Cause unknown • but immune pathogenesis has been suggested because of finding of IGM at the dermo epidermal junction and • it’s association with some autoimmune diseases like myesthenia gravis, thymoma and graft-versus-host disease
Shiny flat-topped papules of lichen planus.
Pathology • Hyperkeratosis • Prominent granular layer • Basal cell degeneration forming apoptotic bodies • Heavy T lymphocytesawtooth dermo-epidermal junction.
Presentation Two third of cases occurs in 30 -60 years age group. Male=female Tend to start at limbs. It may spread rapidly to become genelarized within 4 weeks. Localized forms are more common and progress much more slowly. • Lesion are very itchy, flat topped polygonal papules , few mm in size , and the surface shows white line known as wickham’s striae. • Initially the papules are red but later become voilaceous. • Are also found in the mouth, particularly inside the cheeks, in about 50% of patients, and oral lesions may be the sole manifestation of the disease. • • •
Presentation
• May rapidly become generalised • Lesions may last for months to years • Although the skin plaques are usually itchy, patients rub rather than scratch, so that excoriations are uncommon.
• The lesion are symmetrical and involves: Forearm and wrist Lower legs and thighs Genitalia Palmas and soles In two third of cases buccal mucosa is involved. In most cases papules flattens to leave a pigmentation, but some may become hypertrophied.
The thickened lesions characteristic of hypertrophic lichen planus on the shins.
LP
Lichen planus: classic white lacy network lying on the buccal mucosa .
LP as seen in tongue
• As in psoriasis, the Koebner phenomenon may occur • The nails are usually normal, but in about 10% of patients changes ranging from fine longitudinal grooves to destruction of the entire nail fold and bed is seen • Scalp lesions can cause a patchy scarring alopecia.
Lichen planus: striking Koebner effect on the forearm.
Nail changes in LP
Drugs causing lichen planus like eruption • • • Antibiotic: tetracycline, streptomycin Antimalairial: quinine, choloquinine Anti-tb: isoniazid, ethambutol Diuretics: furesemide, thiazide Antiarthritic: gold, penicillamine.
Variants of lichen planus. • • • Annular Atrophic Bullous Follicular Hypertrophic Ulcerative
Course • Individual lesions may last for many months and the eruption as a whole tends to last about 1 year. • In the hypertrophic variant of the disease, thick warty lesions usually around the ankles, often last for many years. • As lesions resolve, they become darker, flatter and leave discrete brown or grey macules. • About one in six patients will have a recurrence
Complications • Nail and hair loss can be permanent. • The ulcerative form of lichen planus in the mouth may lead to squamous cell carcinoma. • Ulceration, usually over bony prominences, may be disabling, especially if it is on the soles.
Differential diagnosis • • Psoriasis Pityriasis rosea Discoid lupus erythematosus Tinea Nummular eczema Seborrhoeic dermatitis Secondary syphilis Drug eruptions
Investigations • The diagnosis is usually obvious clinically. • The histology is characteristic, so a biopsy will confirm the diagnosis if necessary.
Treatment • Treatment can be difficult. • If drugs are suspected as the cause, they should be stopped and substituted. • Potent topical steroids will sometimes relieve symptoms and flatten the plaques. • Systemic steroids work too, but are recommended only in special situations (e. g. unusually extensive involvement, nail destruction or painful and erosive oral lichen planus). • Treatment with photochemotherapy with psoralen and ultraviolet A (PUVA) or with narrow-band UVB may reduce pruritus and help to clear up the skin lesions. • Acitretin has also helped some patients with stubborn lichen planus. • Antihistamines may blunt the itch. • Mucous membrane lesions are usually asymptomatic and do not require treatment; if they do, then applications of a corticosteroid or tacrolimus in a gel base may be helpful.
Lichen sclerosis • Uncommon condition. • It is a chronic disese. • White lichenified atrophic lesion are seen over the genitalia. • Cause unknown but associated with autoimmune diseases.
Pathology • Epidermis may be thickenes, thinned or hyperkeratotic. • Upper dermis is oedematous, hyalinsed, and acellular. • Lower dermis there is lymphocyte infiltration.
Clinical presentation. • More common in female about 10 times. • Common in middle age although can occur during childhood. • More common in genital area but may involve trunk or arms. • Individual lesion are few mm in size white and atrophic. These atrophic lesion may aggregate into wrinkled plaques.
• Hyperkeratosis, telangectasia, purpura and even blistering can occur. • Perineal and vulval lesion causes itching and soreness. • In male due to recurrent balanitis and ulceration of glans there is chance of urethral stricture and phimosis to develop.
Complication • Dysuria • Recurrent balanitis • Scc on long standing cases infrequently.
Management • Non genital lesion (those over the mouth or trunk) requires no treatment –sponateously regresses. • In female genital lesion mild to moderate steroid. • Sometimes steroid along with antibacterial cream can be used. • Long term follow up is necessary and biopsy of the suspected lesion has to be done.
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