Topics discussed in this Tutorial
Compare Alopecia areata, trichotillomania and traction alopecia
Cutaneous calcification
Pachyonychia congenita
Skin lesions in Hogkin's lymphoma
Eyelid papules
Genitocrural candidiasis
Clinical features of Lipoid proteinosis
Ichthyosis with mental retardation
Punctate keratodermas
Ichthyosis on the face
Compare alopecia areata, trichotillomania and traction alopecia.
Alopecia areata can occur in all age groups. There is a bald area with complete loss of hair follicles but preservation of the follicular openings.
In trichotillomania in adults it is usually occipital, in children it is temporal opposite to the handedness. Also adults tend to close crop the hair whereas in children it is left with very irregular lengths, which point irregularly in all directions.
In traction alopecia it usually is due to the hair being pulled up into a bun and it gives an ophiasis like pattern. If mainly affecting the frontal scalp it can look like frontal fibrosing alopecia. Other types of traction alopecia include marginal which is usually the forehead. Hot comb which involves the crown then spreads centrifugally (now called central centrifugal cicatricial alopecia) and the massage type alopecia.
Pressure alopecia occurs after surgery or in the neonatal period particularly on the occipital scalp.
The image below is of Trichotillomania
Cutaneous Calcification
This is usually considered under the headings of dystrophic, metabolic, idiopathic and normocalcemic. Dystrophic is just localised injury due to trauma or inflammation. It can occur in degenerative processes such as pseudoxanthoma elasticum and also in benign and malignant neoplasms.
Metabolic calcification is found with hyperparathyroidism and sarcoidosis, vitamin D intoxication, the milk alkali syndrome or in destructive bone disease seen in myeloma and Paget’s disease of bone.
Idiopathic calcification can be due to calcinosis universalis, which is a primary disorder seen in girls and young children where sinuses may develop. Other forms are cutaneous calculus, pinnal calcification and tumoral calcinosis. Universal calcification can be a secondary feature of dermatomyositis, scleroderma, lupus and acrodermatitis chronica atrophicans.
Normocalcemic cutaneous calcification is seen in chronic renal failure and pseudo hyperparathyroidism.
Pineal calcification occurs in Addison’s disease, ochronosis, acromegaly, dermatomyositis, hyperthyroidism, systemic chondromalacia and familial cold hypersensitivity.
Hypocalcemic calcification causes dry skin, alopecia, brittle nails that are grooved. You may have chronic mucocutaneous candidiasis.
Intravenous Bleomycin and calcium gluconate injections can give localised calcification.
The image below is of Calcification in Scleroderma
This can look like large corns on weight bearing areas with the plantar keratoderma.
Adolescent striae obviously presents in adolescents. The site of choice is usually the lumbo sacral area in boys whereas in girls it is the breasts and hips.
Question
What are the skin lesions of Hodgkin’s disease?
Answer
They are often non-specific in 30% to 50% of cases and include pruritus, prurigo, herpes zoster, addisonian pigmentation particularly in the axillae, groins and nipples.
The image below is of Pachyonychia Congenita
Causes of Eyelid Papules
They include acnitis, syringomas, molluscum, amyloid, lipoid proteinosis, sarcoidosis, rosacea, Fabry’s disease and trichoepitheliomas. Most trichoepitheliomas are skin coloured or yellow or pink. They can occasionally be bluish because of pigment. The inheritance is probably autosomal dominant but there are more females than males.
The image below is of Syringomas
What are the types of genitocrural candidiasis?
Answer
Firstly there is the intertrigo like, then there is a pustular type, and also an erosive type on the scrotum. There is an ulcerating type and there is a balanitis type on the penis. Around the perianal and natal cleft candida looks like psoriasis and there is the rare granulomatous type of candidiasis seen in neonates.
The image below is of groin candidiasis.
What are the clinical features of lipoid proteinosis?
Answer
Hoarseness with thickening and stiffening of the tongue, eyelid papules and papules on the hands. The nodular lesions on the elbows look like xanthomata.
The image below is of eyelid papules in lipoid proteinosis.
Adolescent striae obviously presents in adolescents. The site of choice is usually the lumbo sacral area in boys whereas in girls it is the breasts and hips. What are the other causes of striae? Answer Pregnancy, drugs, collagen diseases and Cushing’s disease. Note that there are no striae with Ehler’s Danlos patients when they are pregnant. You can get a rare horizontal striae on the nose in children under 10 with a defined ridge on the bridge of the nose, which is related to the growth of underlying structures. It just disappears.
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What are the causes of ichthyosis with mental retardation? Answer X-linked ichthyosis sometimes, Sjogren Larsen, Rudd’s syndrome, Richner Hanhart syndrome and Downs syndrome. The image below is X linked ichthyosis  What are the causes of punctate keratoderma? Answer In an infant it is the Richner Hanhart syndrome. In an adolescent it is disseminated punctate keratoderma and Darier’s disease is usually seen in adults though it is variable.  Ichthyosis on the Face In ichthyosis vulgaris the face involvement includes the forehead, cheeks and scalp. In X-linked ichthyosis it tends to involve the periphery of the face.
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