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PAPULOSQUAMOUS DISORDERS

Disorders exhibiting papules and scale.

PSORIASIS

A chronic, recurrent disorder. Classic lesion is a well-marginated, erythematous plaque with silvery-white surface scale. Distribution includes extensor surfaces (i.e., knees, elbows, and buttocks); may also involve palms and scalp (particularly anterior scalp margin). Associated findings include psoriatic arthritis (Chap. 161) and nail changes (onycholysis, pitting or thickening of nail plate with accumulation of subungual debris).

TREATMENT: PSORIASIS

Maintain cutaneous hydration; topical glucocorticoids; topical vitamin D analogue (calcipotriol) and retinoid (tazarotene); UV light (PUVA, when UV used in combination with psoralens); for severe disease methotrexate or cyclosporine; acitretin can also be used but is teratogenic. Ustekinumab (human monoclonal antibody that blocks IL-12 and IL-23) or apremilast (phosphodiesterase 4 inhibitor) can be considered for chronic, moderate to severe plaque psoriasis. Etanercept (dimeric fusion protein: TNF receptor/Fc human IgG1), infliximab, and adalimumab (monoclonal antibodies directed against TNF) are approved for psoriasis and psoriatic arthritis.

PITYRIASIS ROSEA

A self-limited condition lasting 3–8 weeks. Initially, there is a single 2- to 6-cm annular salmon-colored patch (herald patch) with a peripheral rim of scale, followed in days to weeks by a generalized eruption involving the trunk and proximal extremities. Individual lesions are similar to but smaller than the herald patch and are arranged in symmetric fashion with long axis of each individual lesion along skin lines of cleavage. Appearance may be similar to that of secondary syphilis.

TREATMENT: PITYRIASIS ROSEA

Disorder is self-limited, so treatment is directed at symptoms; oral antihistamines for pruritus; topical glucocorticoids; UV-B phototherapy in some cases.

LICHEN PLANUS

Disorder of unknown cause; can follow administration of certain drugs, chronic graft-versus-host disease, hepatitis C; lesions are pruritic, polygonal, flat-topped, and violaceous. Course is variable, but most pts have spontaneous remissions 6–24 months after onset of disease.

TREATMENT: LICHEN PLANUS

Topical glucocorticoids.

ECZEMATOUS DISORDERS

ECZEMA

Eczema, or dermatitis, is a reaction pattern that presents with variable clinical and histologic findings; it is the final common expression for a number of disorders.

ATOPIC DERMATITIS

One aspect of atopic triad of hayfever, asthma, and eczema. Usually an intermittent, chronic, severely pruritic, eczematous dermatitis with scaly erythematous patches, vesiculation, crusting, and fissuring. Lesions are most commonly on flexures, with prominent involvement of antecubital and popliteal fossae; generalized erythroderma in severe cases.

TREATMENT: ECZEMA AND ATOPIC DERMATITIS

Avoidance of irritants; cutaneous hydration; topical glucocorticoids; treatment of infected lesions [often with Staphylococcus aureus (SA)—consider community-acquired methicillin-resistant strains (CA-MRSA)]. Systemic glucocorticoids only for severe exacerbations unresponsive to topical conservative therapy. Topical calcineurin inhibitors have been used for severe disease but may carry toxicity.

ALLERGIC CONTACT DERMATITIS

A delayed hypersensitivity reaction that occurs after cutaneous ...

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