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• Food allergies are an uncommon cause of flares in atopic dermatitis.

Contact Dermatitis: Discretely grouped red vesicles and bullae in a linear distri-

bution are characteristic of contact dermatitis due to poison ivy. Atopic Dermatitis: The rash involves the antecubital fossae, with lichenification and surrounding excoriations.

Therapy

For irritant hand dermatitis, treat by washing less, moisturizing more, and wearing cotton gloves inside of rubber gloves when around chemicals or during activities such as dishwashing. Contact dermatitis, atopic dermatitis, and dyshidrotic eczema may benefit from a short course of topical glucocorticoids for symptom relief.

• 1% topical hydrocortisone for the face and intertriginous

areas (low-potency glucocorticoid)

• 0.1% triamcinolone for other body sites (medium-potency

glucocorticoid)

• nighttime sedating antihistamines to reduce scratching • topical tacrolimus for recalcitrant atopic eczema • potent glucocorticoids for the palms, soles, and

extremely thick eruptions (atopic eczema)

Treatment of xerotic eczema consists of regular emollient use. Mid- to low-potency topical glucocorticoids may minimize itch- ing and facilitate healing.

Always select emollients as part of eczema treatment. Emollients work through various mechanisms, including trapping water in the skin (petrolatum), introducing water into the skin (aqueous cream), or increasing the water-holding capacity of the skin (urea).

◆

◆Don’t Be trickeD

• Do not select potent glucocorticoids for the face because of the risk of steroid-induced acne and cutaneous atrophy.

◆

❖test Yourself

A healthy 40-year-old female nurse has a 1-month history of vesicular eruptions on the dorsum and distal areas of her hands.

ANSWER: The diagnosis is acute eczema. Select a topical glucocorticoid.

Xerotic Dermatitis: Asteatotic dermatitis is characterized by the location on the

anterior shin of red, dry, and cracked skin with multiple fine fissures.

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Dermatology

Psoriasis

Diagnosis

Typical findings of chronic plaque psoriasis are erythema, scaling, and induration on the extensor surfaces, scalp, ears, inter- triginous folds, and genitalia. The nails may be pitted, thickened, loose, or yellow and may be the only manifestation of psoriasis. Psoriatic arthritis and spondylitis may coexist in 25% of patients.

Psoriasis is exacerbated by systemic glucocorticoids, lithium, antimalarial drugs, tetracyclines, β-blockers, NSAIDs, and ACE inhibitors.

StUDY tABLe: Clinical Appearance of Common Psoriasis Subtypes

Subtype Description

Chronic plaque psoriasis Thick, erythematous lesions with silvery, adherent scale anywhere on the body

Guttate psoriasis Many small drop-like papules and plaques on the trunk often developing after infection with β-hemolytic Streptococcus

Erythrodermic psoriasis Generalized erythema and scaling involving most of the body, often occurring after abrupt discontinuation of systemic glucocorticoids; potentially life-threatening

Inverse psoriasis Red, thin plaques with variable amount of scale in the axillae, under the breasts or pannus, intergluteal cleft, and perineum

Nail psoriasis Indentations, pits, and oil spots often involving multiple nails

Therapy

Select topical glucocorticoids for limited, localized plaques. Next, rotate therapy with topical vitamin D analogues (calci- potriene, tacalcitol), retinoids, anthralin, or tar preparations. Patients with >10% body surface area or those with psoriatic arthritis, recalcitrant palmoplantar psoriasis, pustular psoria- sis, or psoriasis in challenging anatomic areas (groin, scalp) are considered for systemic therapy including:

• phototherapy

• systemic agents (retinoids, methotrexate, cyclosporine) • TNF inhibitors and interleukin-inhibitors

Patients receiving systemic glucocorticoids or cyclosporine are at risk for acute erythrodermic or pustular flares with sudden cessation of medication. Erythrodermic psoriasis is a derma- tologic emergency, because patients are at high risk for infec- tion and electrolyte abnormalities secondary to fluid loss.

Guttate Psoriasis: Guttate psoriasis is characterized by small, drop-like, scaly

papules and plaques.

Dermatology

◆

◆Don’t Be trickeD

• Never select systemic glucocorticoids for the treatment of psoriasis.

◆

❖test Yourself

A 28-year-old woman has a chronic extensive skin rash consisting of multiple small and large plaques with an adherent, thick, silvery scale covering 25% of her body surface area.

ANSWER: The diagnosis is psoriasis.

StUDY tABLe: Other Papulosquamous Disorders

Condition Presentation Therapy

Lichen planus Acute eruption of purple, pruritic, polygonal papules that most commonly presents on the wrists and ankles. Lichen planus can also present in the mouth, vaginal vault, penis, and in the nails (leading to thickening and distortion of the nail plate).

Topical glucocorticoids

Pityriasis rosea Presents with one scaling patch that is a few centimeters wide (herald patch), followed by many 0.5- to 2.0-cm red scaling pruritic patches along the skin cleavage lines in a “Christmas tree” distribution on the back, and lasting 1 to 3 months.

Topical glucocorticoids and antihistamines for pruritus

Seborrheic dermatitis An inflammatory scaling, itchy dermatosis that most commonly affects the scalp but can also affect the eyebrows, nasolabial folds, chin, central chest, and perineum. Explosive onset with wide distribution may be a sign of HIV infection.

Selenium sulfide or zinc pyrithione shampoos, ketoconazole shampoo

◆

◆Don’t Be trickeD

• Pityriasis rosea can resemble secondary syphilis but does not involve the palms and soles; obtain rapid plasma reagin (RPR) in high-risk individuals.

• Extensive seborrheic dermatitis may be a clue to underlying HIV infection.

◆

❖test Yourself

A 28-year-old man is evaluated for severe seborrheic der- matitis of acute onset.

ANSWER: Test for HIV infection.

Nail Findings in Psoriasis: Psoriatic nails with characteristic discoloration,

crumbling, subungual debris, and separation of the nail plate from the nail bed. Chronic Plaque Psoriasis: Typical plaque psoriasis consists of a polymorphic red plaque covered with a thick, silvery scale.

Seborrheic Dermatitis: Seborrheic dermatitis, with fine, oily scale around the

medial eyebrows.

Dermatology