Tutorial 28

Topics discussed in this Tutorial

Neuromas

DD of Angiokeratomas

Lipoatrophy DD

Scleroderma of the Hands

Alopecia Mucinosa

Perianal fistulas

Abscesses

Animal contact lesions

DD of an Epidermal nevus

Streptococcal infections

Keratoacanthomas

DD of upper respiratory Obstructions

Cysts with clear fluid

Sarcoidosis of the face

 Neuromas

There is the schwanoma, the neurofibroma which can be both syndromal and non-syndromal, neurofibrosarcoma and cutaneous meningioma. Another name for a swannoma is a neurilemmoma.   

The histiocytoses are described as histiocytosis X types and the non X. The non X include benign cephalic histiocytosis, juvenile xanthogranuloma, self limiting benign histiocytosis, generalised disseminated histiocytosis, xanthoma disseminatum and multicentric reticulo histiocytosis.

The differential diagnosis of angiokeratomas includes angiokeratoma circumscriptum, Fabry’s disease, Mibelli’s disease that is seen in females with acrocyanosis of the feet and hands and angiokeratoma Fordyce

The image below is of benign cephalic histiocytosis. courtesy of Dr Nameer Al Sudany

Lipoatrophy Differential Diagnosis

There is a localised panatrophy, localised fat atrophy, symmetrical partial atrophy and syndromal atrophy.

The image below is of lipodystrophy See source

The differential diagnosis of scleroderma of the legs is stasis, Lipodermatosclerosis, acrodermatitis chronica atrophicans, Eosinophilic fascitis, Scleromyxedema, Nephrogenic systemic fibrosis , Werner’s disease, scurvy, acrogeria and localised graft versus host disease.

Scleroderma of the Hands

The differential diagnosis is scleroatrophic syndrome of Huriez. There is no Raynaud’s and it is a familial condition. Lichen myxedematosus, juvenile diabetes, amyloid and drugs such as Bleomycin, Lavamizole and vinyl chloride disease. There is also acrogeria, shoulder hand syndrome and phenyl ketonuria.  

 Scleroderma of the neck is scleredema, PCT and the carcinoid syndrome.

Alopecia Mucinosa

This can be the localised plaque type, generalised plaque type or mycosis fungoides plaques.

The image below is from the article linked above on the Scleroatrophic syndrome of Huriez See these other examples in GlobalSkinAtlas

Perianal Fistulas

Consider Crohn’s disease and also hidradenitis suppurativa. Fistulas in the neck consider scrofuloderma and branchial fistulas. Fistulas on the face consider nasal, lip, ear and dental.

Perianal Crohn's disease

The image below is of scrofuloderma courtesy of Dr Nameer Al Sudany

Lymphadenopathy

Rapid onset of lymphadenopathy occurs in infectious mononucleosis, syphilis, Hodgkin’s disease and leukaemia.

Abscesses

These are divided into Animal contact such as glanders and necrobacillosis or Travellers such as tularaemia, plague or melioidosis and Surgical or immunosuppressed such as gangrenous cellulitis, protothecosis and Jobs syndrome and then the Rest including bacterial folliculitis or furunculosis, carbuncles, salmonella, mycobacterium fortuitum and botryomycosis.

Animal Contact Lesions

These include conditions such as orf, cat scratch disease, plaque, erysipelothrix, pasturella multocida, listeriosis, anthrax, tularaemia, necrobacillosis and glanders.

The Differential Diagnosis of an Epidermal Nevus   

This includes ILVEN, Conradi’s disease, epidermal hyperkeratosis, epidermodysplasia verruciformis, ichthyosiform erythroderma, incontinentia pigmenti and also the epidermal nevus syndrome.

The image below is an ILVEN

Streptococcal Infections

Watch ecthyma and also streptococcus viridans causing sub-acute bacterial endocarditis. There is also strep millieri associated with hidradenitis suppurativa.

Compare acnitis versus acne necrotica versus a tuberculid.
In Acnitis the active lesions are on the forehead, it scars and there is pigmentation. In Acne necrotica it is umbilicated, there is itch and it goes through many stages quickly but a tuberculid stays a while and is usually seen on the elbows.

The image below is of acne necrotica

Milia

Question

What are the types of milia?

Answer

There is the congenital type as seen in epidermolysis bullosa and Marie una hypotrichosis. It is familial when it is an autosomal dominant. There are milia after trauma particularly dermabrasion, there are milia after bullae heal particularly epidermolysis bullosa dystrophica and porphyria cutanea tarda and there are milia associated with congenital ectodermal defects.

Milia in EBA after blisters heal

Types of Keratoacanthomas   

There is the solitary type but there are the atypical forms for example keratoacanthoma centrifugum or coral reef keratoacanthomas or giant keratoacanthomas. There is the multiple Ferguson Smith self healing epithelioma and there are the eruptive keratoacanthomas which are generally very small sparing the palms and soles and associated with severe pruritus. Multiple small eruptive KAs have also been reported in red tattoos.

Keratoacanthoma centrifugum Image of Dr John Rowlands

Differential Diagnosis of Obstruction of the Upper Respiratory Tract

Rhinoscleroma presents as an atrophic rhinitis followed by an infiltrative stage and later the larynx can be involved and patients can die from respiratory asphyxia. There is Wegener’s granulomatosis, there is lethal midline granuloma, there is mucocutaneous leishmaniasis, South American blastomycosis which generally affects the lung with dissemination but there is a mucocutaneous type with perioral abscesses and lymphadenopathy. North American blastomycosis has a granular appearance and there is a sporotrichoid type, chromomycosis type and a bromoderma type. It often has central clearing with white peripheral scars.

Rhinosporidiosis

This gives rise to cauliflower like masses in the nose or the mouth and should be differentiated from tertiary syphilis, nasal TB, lymphoma or neoplasms, yaws and leprosy.

The image below is of North American Blastomycosis

Cysts that Present with Clear Fluid

They are either due to impetigo or hidrocystomas. Fox Fordyce disease can affect the axillae but often there is itch only at first and it may be seen around the nipples provoked by emotion and has a prolonged course.

Lymphocytoma Cutis

It is usually circumscribed, it can be solitary but may be grouped. Rarely it has a hyperkeratotic surface like lupus and it may also cause a temporary alopecia in males. Jessners lymphocytic infiltrate in contrast is usually pink, red to brown in colour, can be annular and it is not circumscribed

View the image below at source

Sarcoidosis affecting the face

The types that you see are the plaque type which is rare, the angiolupoid type, lupus pernio particularly in the nose or the ears, a papular type and an annular on the forehead and also a scar sarcoid.

View the image below at source

Tutorial 32

 Topics covered in this Tutorial

Animal Contact lesions, Blisters with red papules, Parapsoriasis, Keratoderma, Raynaud's , Nail and keratoderma syndromes, Purpura, Acnitis, Leptospirosis, 

View the video of this tutorial Press the arrow to start and then click on the cogwheel and change the resolution to HD 1080 and click the right hand box at the base to make full screen. Use ESC on your computer to return to normal size.

Animal Scabies 

 Generally the infection is acquired from dogs and the face is involved as well. However there are no burrows in this condition and it is self limiting. Cheyletiella is derived from cats and dogs. It is a mite that is found particularly around the neck area in these animals. Generally the rash comes up in areas of contact with the animal. Starling mites or bird mites are usually seen on the upper part of the body or in an occupation that involves someone accessing a loft area where the lesions are usually found at the sites of pressure.

The image below is of a scabies mite

Blisters with Erythematous Papules

If symmetrical consider dermatitis herpetiformis, vasculitis and dermatitis autoeczematous lesions. If asymmetrical consider pemphigoid, insect bites and scabies.

Atypical Types of Erythema Multiforme

1        Recurrent erythema multiforme
2        A variant with one extending or static lesion

The image below is of dermatitis herpetiformis

Parapsoriasis

This is a term we do not use as much nowadays but the small plaque type of parapsoriasis goes under the name of digitate dermatosis. It is not indurated. It is usually on the trunk. Generally lesions are less than 5cm in diameter and is very well demarcated. With the large plaque parapsoriasis there is some slight induration. There are indistinct irregular borders. It may be scaly and may have so called cigarette paper atrophy. It is particularly seen on the buttocks and the proximal extremities. It is thought that 10% will go on to develop into a frank lymphoma though many people believe that all parapsoriasis represents a lymphoma of sorts.    With retiform parapsoriasis or the reticulate variant almost 100% will develop full T cell lymphoma of the skin. In lymphomatoid papulosis about 15% will go on to develop what we know as a frank lymphoma of the skin.

The image below is of a digitate dermatosis

Keratoderma

There obviously are a large number of causes of keratoderma, some are congenital and some are acquired but always look between the toes to exclude a fungus. Remember that you may get crusting rather than keratin with a fungus and also consider crusted scabies where the "keratoderma" is made up of crusts rather than layered keratin. With Darier’s disease you can get pustules and sometimes when you remove the scale in Darier’s disease a little pit is left. With histiocytosis X you get no pustules but sometimes  slight skin purpura.

Cicatricial Pemphigoid

We typically think of it attacking mucosal surfaces but sometimes the process will attack the scalp and present as a scarring alopecia.

The image below is of synechiae in cicatricial pemphigoid

Raynaud’s Phenomenon

It is usually seen in women under the age of 40. Often all the fingers are involved but gangrene does not happen in Raynaud’s disease. The paroxysmal nature of the process is important. Cold agglutinins, cold haemolysins and cryo precipitins can all cause Raynaud’s but cold fibrinolysins do not. If you have Raynaud’s plus livedo then it is usually due to a cryoprotein. A mnemonic for causes of Raynaud’s disease using the letters of Raynaud’s are –

R for Raynaud’s disease
A for autoimmune such as lupus, scleroderma, dermatomyositis or mixed
    connective tissue disease
Y for ‘bloody’ Y – cryos and cold agglutinins
N for neurovascular compression
N for neoplasms
A for arterials such as Buergers disease and arthrosclerosis and arteritis
U for ‘you done it’ – typewriter, piano, vibration, vinyl chloride
D for drugs such as ergot, methysergide, beta blockers, bromocriptine

Acrocyanosis rather than Raynaud's. True Raynauds has a white blanching stage.

The Differentiation of Still’s Disease and Erythema Marginatum

In Still’s disease the rash can come on before the rheumatoid symptoms and it is macular. In erythema marginatum the rash is larger and often annular. Still’s disease starts worse and then gets better.

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Ichthyosis and Palmoplantar Keratoderma

 Syndromes to consider  along with others are tyrosinemia 2 and erythrokeratoderma variabilis.

An AI answer is more informative !

Nails and Palmoplantar Keratoderma Syndromes

Consider hidrotic ectodermal dysplasia, dyskeratosis congenita, pachyonychia congenita and Darier’s disease.

The image below is erythema marginatum seen in Rheumatic fever

Purpura

We usually think of it as either palpable or non-palpable but from an etiological point of view you can think of it as being due to platelet abnormalities or vascular abnormalities. If platelet abnormalities there will be associated ecchymoses and often it is on the upper limbs. If vascular abnormalities it can be physical, toxic, infectious or immune. The physical causes are pressure with a lack of support particularly senile purpura or scurvy, amyloidosis or Ehler’s Danlos syndrome. It can be toxic due to chemicals, drugs and other diseases. It can be due to infection from meningococci or septicaemia. It can be immune with vasculitis, dysproteinemia and lupus and often this causes a painful bruising. In the pigmented purpuric dermatoses, note the Hess test. It is done for five minutes. If you examine an area of 5cm there should be more than five purpuric lesions at 80mm of mercury pressure if positive.

The image below is a pigmented purpuric dermatosis

Acnitis

This is a scar like lesion particularly on the forehead with brownish pigmentation and sometimes some yellow in the middle of it.

Compare granuloma annulare and sarcoidosis.   Granuloma annulare is made up of indurated papules. Sarcoid again is papules but they are a different colour. There is fusion of the papules. Both these lesions though will give a crust on the surface when they perforate. Disseminated granuloma annulare can last three to four years. The differential diagnosis is sarcoid, lichen planus and lymphoma. Sometimes it can be annular in other areas such as the back of the hands and it can also be reticulate, but usually disseminated granuloma annulare is papular.

Disseminated Granuloma annulare

Compare lichen scrofulosorum and lichen nitidus. Lichen scrofulosorum usually is quite rough because it has keratosis spinulosa on the surface and feels nutmeg like whereas lichen nitidus is more monomorphic and smooth. Lichen nitidus is acral and genital while lichen scrofulosorum is trunk  and buttocks.

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Lichen scrofulosorum

Leptospirosis

This condition due to a spirochete will give jaundice and necrotic lesions in the skin.

The image below is acnitis