May 24, 2011

You just attended the delivery of the infant shown. The parents want to know what is wrong with his skin. What condition is most commonly associated with this finding at birth? A. Ichthyosis B. Psoriasis C. Atopic Dermatitis D. Epidermolysis Bullosa E. Incontinentia Pigmenti

Red, well-demarcated plaques Covered with dry, thick, silvery scales Extensor surfaces Also scalp and bullocks

Other Pressure points Thickening of palms Guttate Lesions Drop-like lesions All over body After GAS

Infants Persistent diaper dermatitis Indistinguishable from seborrheic diaper dermatitis Moistness prevents thick scale Confirm with biopsy

Koebner phenomenon Lesions induced at sites of injury Nail changes Reddish-brown psoriatic plaques in the nail bed Oil drop changes Surface pitting Distal hyperkeratosis

Auspitz sign Hallmark of psoriasis Small bleeding points when scale removed Due to thin skin between the epidermal ridges where the scale is close to the subepidermal vessels

Cause Rapid turnover of epidermal cells Inherited predisposition Precipitated by URI Strep infections Course Guttate – self-limited Chronic and unpredictable

AD 0.5% of population Fishlike scales by 3 months on extensor surfaces Not present at birth Trunk may be involved Flexural areas spared Worsens Winter – dry air Improves Summer With age Biopsy Retention hyperkeratosis, thinned granular layer Treatment Liberal use of emollients

1/6000 males Occasionally hemizygous females Newborn findings Collodion membrane Typical presentation 3-12 months “Dirty” brown scales Abdomen, back, anterior legs and feet Central face and flexor areas spared Biopsy Increased granular layer and stratum corneum Decreased or absent steroid sulfatase in the serum and skin

Rare <1/250,000 AD Newborns Collodion membrane 1 st month of life Thick, brownish gray, sheet-like scales with raised edges Face, trunk, extremities, flexor Other findings Eversion and fissuring of the eyelids and lips Treatment Topical keratolytics Lactic acid Salicylic acid Oral retinoids Some improve with age

Most common in lamellar ichthyosis Can be seen in X-linked At birth Thick, parchment-like scale 7-14d Membrane dries and sheds Problems Fluid Electrolytes Heat losses

Rare AD Form of Ichthyosis Features Generalized, thick, warty scales Intermittent blistering May be severe in newborns Confused with HSV or EB Severe involvement of flexures Biopsy Massive hyperkeratosis, ballooning of squamous cells, formation of vesicles Treatment Keratolytics Lubricants Antibiotics Secondary infection Oral retinoids

What is the most appropriate treatment for this skin condition? A Topical antibiotics B Oral antibiotics C Topical immunomodulators D Frequent moisturizers Abdomen Near Elbow

3 Phases Infantile (up to age 3) Red, itchy papules and plaques that ooze and crust Extensor surfaces Cheeks, forehead, scalp, trunk Diaper spared

Childhood phase (Age 4-10) Dry, papular, intensely pruritic Circumscribed scaly patches Wrists, ankles, antecubital and popliteal fossae Palms/Soles cracking, dryness, scaling 75% improve between ages 10-14y/o

Adult Phase Begins age 12 Flexural areas of arms, neck, legs Dorsal surface of hands/feet Possible marked lichenification

Other findings: Xerosis (dryness) Ichthyosis vulgaris Hyperkeratosis pilaris Ichthyosis vulgaris Pityriasis alba

Part of atopic derm picture Keratin plugging of hair follicles Perifollicular scales Upper ext, trunk

Co-infections Staph aureus (90%) Warts Molluscum Eczema herpeticum

IgE mediated Familial tendency Asthma, allergic rhinitis, food allergies Precipitating factors (Itch-Scratch Cycle) Food allergens, soaps, wool fabrics, infections, environmental antigens Spares intertriginous areas

Avoidance of triggers Hydration and lubrication Antipruritic agents Topical steroids (inflammation and itching)

Severly pruritic, chronic, recurrent, vesicular eruption Vescicles symmetrical, multilocular, 1-3mm Rupture leaving scales/crust on erythematous base Palms, soles, lateral aspect of fingers/toes

Triggers Wet shoes Chemicals Hyperhidrosis Treatment Similar to atopic derm

Location Extensor thighs or abdomen Description Acute papulovesicular eruption Coin shaped configuration Intensely pruritic, well-circumscribed, round to oval, red, scaly patches Studded with 1-3mm vesicles Treatment: similar