alegre. almora. alonzo. amaro. amolenda. anacta. andal. ang. ang. ang. Dermatology Case 2:

EG 43 y/o F Chief Complaint: Plaques and Nodules on the face, trunk, and extremities

HISTORY OF PRESENT ILLNESS 3 8 months PTC 6 month PTC Few erythematous ill-defined asymptomatic patches over both upper extremities -associated tingling sensation and numbness of the hands and forearms No consult was done nor medications taken Few erythematous ill-defined asymptomatic patches over both upper extremities -associated tingling sensation and numbness of the hands and forearms No consult was done nor medications taken Plaques and nodules involving the forehead, malar area, left ear, trunk and extremities CONSULT

FAMILY HISTORY (+) HPN, DM (-) similar lesion

PHYSICAL EXAMINATION Skin:  multiple erythematous to skin-colored plaques and nodules 1.5x 3.5 to 2.0 x 4.0 cm over the malar area, helix of ears, upper extremities, thighs (+) leonine facies (-) madarosis

CLINICAL IMPRESSION Salient Features  erythematous ill-defined asymptomatic patches (upper extremities) into multiple erythematous to skin-colored plaques and nodules 1.5x 3.5 to 2.0 x 4.0 cm (malar area, helix of ears, upper extremities, thighs)  (+) leonine facies  (-) madarosis Lepromatous type of Leprosy (Hansen’s Disease)

DIFFERENTIAL DIAGNOSIS Hansen’s Disease (other types) Erythema multiforme Fixed drug reaction Seborrheic dermatitis Cellulitis Urticaria Exfoliative dermatitis

Seborrheic Dermatitis also known as seborrhea common non-contagious condition of skin areas rich in oil glands (the face, scalp, and upper trunk)  marked by flaking (overproduction of skin cells) and sometimes redness and itching (inflammation) of the skin varies in severity from mild dandruff of the scalp to scaly, red patches on the skin.

Seborrheic Dermatitis Epidemiology:  with redness and flaking = 3–5% of the population  affects all races; worse in men, and starts after puberty (although babies have a version called cradle cap) and peaks around the age of 40 and then may improve Cause:  due to a combination of an over production of skin oil and irritation from a yeast, Pityrosporum ovale. Risk:  Stress, fatigue, weather extremes, oily skin, infrequent shampoos or skin cleaning, use of lotions that contain alcohol, skin disorders (such as acne), or obesity  Familial

 Patient’s Data  EG 43 y/o F  erythematous ill-defined asymptomatic patches (upper extremities, with tingling sensation, numbness of the hands) into multiple erythematous to skin- colored plaques and nodules 1.5x 3.5 to 2.0 x 4.0 cm (malar area, helix of ears, upper extremities, thighs)  (+) leonine facies  (-) madarosis  EG 43 y/o F  erythematous ill-defined asymptomatic patches (upper extremities, with tingling sensation, numbness of the hands) into multiple erythematous to skin- colored plaques and nodules 1.5x 3.5 to 2.0 x 4.0 cm (malar area, helix of ears, upper extremities, thighs)  (+) leonine facies  (-) madarosis  Seborrheic Dermatitis  Lesion  Scanty, loose, dry, moist or greasy scales and by crusted pinkish or yellowish patches  Age of Predilection  Starts at puberty and peaks at the age of 40  Signs & Symptoms:  Scalp is itchy and sheds white, oily skin flakes.  In darker skin, some of the affected areas may look lighter in color.  Lesion  Scanty, loose, dry, moist or greasy scales and by crusted pinkish or yellowish patches  Age of Predilection  Starts at puberty and peaks at the age of 40  Signs & Symptoms:  Scalp is itchy and sheds white, oily skin flakes.  In darker skin, some of the affected areas may look lighter in color.

 Patient’s Data  EG 43 y/o F  erythematous ill-defined asymptomatic patches (upper extremities) into multiple erythematous to skin-colored plaques and nodules 1.5x 3.5 to 2.0 x 4.0 cm (malar area, helix of ears, upper extremities, thighs)  (+) leonine facies  (-) madarosis  EG 43 y/o F  erythematous ill-defined asymptomatic patches (upper extremities) into multiple erythematous to skin-colored plaques and nodules 1.5x 3.5 to 2.0 x 4.0 cm (malar area, helix of ears, upper extremities, thighs)  (+) leonine facies  (-) madarosis  Seborrheic Dermatitis  Site of Predilection  Areas has patches of red, scaly skin:  the scalp, hairline, forehead, eyebrows, eyelids, creases of the nose and ears, ear canals, beard areas, breastbone, midback, groin, or armpit; Flexors of elbow and knee  Classifications  Mild – only some flaking and redness in a few small areas.  Moderate – several areas affected with bothersome redness and itch.  Severe – large areas of redness, severe itch and unresponsive to self-care measures.  Site of Predilection  Areas has patches of red, scaly skin:  the scalp, hairline, forehead, eyebrows, eyelids, creases of the nose and ears, ear canals, beard areas, breastbone, midback, groin, or armpit; Flexors of elbow and knee  Classifications  Mild – only some flaking and redness in a few small areas.  Moderate – several areas affected with bothersome redness and itch.  Severe – large areas of redness, severe itch and unresponsive to self-care measures.

Seborrheic Dermatitis

The diagnosis is based on the appearance and location of the skin lesions  In rare cases - skin biopsy to r/o other diseases Therapeutic Plans  Shampoo several times a week  Selenium sulfide, zinc pyrithionate, tar and resorcin shampoos  Topical Antifungals  Ketoconazole 2% cream  Corticosteroid creams

(Differential Dignosis) (brief description of pathology) (epidemiology, incidence, etc.)

 Patient’s Data  erythematous ill-defined asymptomatic patches (upper extremities, with tingling sensation, numbness of the hands) into multiple erythematous to skin-colored plaques and nodules 1.5x 3.5 to 2.0 x 4.0 cm (malar area, helix of ears, upper extremities, thighs)  (+) leonine facies  (-) madarosis  erythematous ill-defined asymptomatic patches (upper extremities, with tingling sensation, numbness of the hands) into multiple erythematous to skin-colored plaques and nodules 1.5x 3.5 to 2.0 x 4.0 cm (malar area, helix of ears, upper extremities, thighs)  (+) leonine facies  (-) madarosis  (Differential…)  (pertinent data per differential)

(Differential Dignosis) (diagnostic evaluation) (therapeutic plans)

(Differential Dignosis) (brief description of pathology) (epidemiology, incidence, etc.)

 Patient’s Data  erythematous ill-defined asymptomatic patches (upper extremities, with tingling sensation, numbness of the hands) into multiple erythematous to skin-colored plaques and nodules 1.5x 3.5 to 2.0 x 4.0 cm (malar area, helix of ears, upper extremities, thighs)  (+) leonine facies  (-) madarosis  erythematous ill-defined asymptomatic patches (upper extremities, with tingling sensation, numbness of the hands) into multiple erythematous to skin-colored plaques and nodules 1.5x 3.5 to 2.0 x 4.0 cm (malar area, helix of ears, upper extremities, thighs)  (+) leonine facies  (-) madarosis  (Differential…)  (pertinent data per differential)

(Differential Dignosis) (diagnostic evaluation) (therapeutic plans)

(Differential Dignosis) (brief description of pathology) (epidemiology, incidence, etc.)

 Patient’s Data  erythematous ill-defined asymptomatic patches (upper extremities, with tingling sensation, numbness of the hands) into multiple erythematous to skin-colored plaques and nodules 1.5x 3.5 to 2.0 x 4.0 cm (malar area, helix of ears, upper extremities, thighs)  (+) leonine facies  (-) madarosis  erythematous ill-defined asymptomatic patches (upper extremities, with tingling sensation, numbness of the hands) into multiple erythematous to skin-colored plaques and nodules 1.5x 3.5 to 2.0 x 4.0 cm (malar area, helix of ears, upper extremities, thighs)  (+) leonine facies  (-) madarosis  (Differential…)  (pertinent data per differential)

(Differential Dignosis) (diagnostic evaluation) (therapeutic plans)

(Differential Dignosis) (brief description of pathology) (epidemiology, incidence, etc.)

 Patient’s Data  erythematous ill-defined asymptomatic patches (upper extremities, with tingling sensation, numbness of the hands) into multiple erythematous to skin-colored plaques and nodules 1.5x 3.5 to 2.0 x 4.0 cm (malar area, helix of ears, upper extremities, thighs)  (+) leonine facies  (-) madarosis  erythematous ill-defined asymptomatic patches (upper extremities, with tingling sensation, numbness of the hands) into multiple erythematous to skin-colored plaques and nodules 1.5x 3.5 to 2.0 x 4.0 cm (malar area, helix of ears, upper extremities, thighs)  (+) leonine facies  (-) madarosis  (Differential…)  (pertinent data per differential)

(Differential Dignosis) (diagnostic evaluation) (therapeutic plans)

Indeterminate Leprosy earliest and mildest form of the disease few numbers of hypopigmented macules (cutaneous lesions) loss of sensation is rare. most cases progress into a later form, although patients with strong immunity may either clear the infection on their own or persist in this form without progressing.

Tuberculoid Leprosy one large red patch with well-defined raised borders or a large hypopigmented asymmetrical spot lesions become dry and hairless loss of sensation may occur at site of some lesions tender, thickened nerves with subsequent loss of function are common spontaneous resolution may occur in a few years or it may progress to borderline or rarely lepromatous types

Tuberculoid Leprosy organisms present at low to undetectable levels low infectivity granulomas and local inflammation peripheral nerve damage normal serum immunoglobulin levels normal T – cell responsiveness specific response to M. leprae antigens

 Patient’s Data  erythematous ill-defined asymptomatic patches (upper extremities, with tingling sensation, numbness of the hands) into multiple erythematous to skin-colored plaques and nodules 1.5x 3.5 to 2.0 x 4.0 cm (malar area, helix of ears, upper extremities, thighs)  (+) leonine facies  (-) madarosis  erythematous ill-defined asymptomatic patches (upper extremities, with tingling sensation, numbness of the hands) into multiple erythematous to skin-colored plaques and nodules 1.5x 3.5 to 2.0 x 4.0 cm (malar area, helix of ears, upper extremities, thighs)  (+) leonine facies  (-) madarosis  Tuberculoid Leprosy ?????????????????

Borderline Tuberculoid Leprosy similar to tuberculoid type except that lesions are smaller and more numerous cutaneous lesions are numerous and less well defined anesthesis is less severe disease may stay in this stage or convert back to tuberculoid form, or progress

Borderline Tuberculoid Leprosy

 Patient’s Data  erythematous ill-defined asymptomatic patches (upper extremities, with tingling sensation, numbness of the hands) into multiple erythematous to skin-colored plaques and nodules 1.5x 3.5 to 2.0 x 4.0 cm (malar area, helix of ears, upper extremities, thighs)  (+) leonine facies  (-) madarosis  erythematous ill-defined asymptomatic patches (upper extremities, with tingling sensation, numbness of the hands) into multiple erythematous to skin-colored plaques and nodules 1.5x 3.5 to 2.0 x 4.0 cm (malar area, helix of ears, upper extremities, thighs)  (+) leonine facies  (-) madarosis  Borderline Tuberculoid ?????????????????

 Patient’s Data  erythematous ill-defined asymptomatic patches (upper extremities, with tingling sensation, numbness of the hands) into multiple erythematous to skin-colored plaques and nodules 1.5x 3.5 to 2.0 x 4.0 cm (malar area, helix of ears, upper extremities, thighs)  (+) leonine facies  (-) madarosis  erythematous ill-defined asymptomatic patches (upper extremities, with tingling sensation, numbness of the hands) into multiple erythematous to skin-colored plaques and nodules 1.5x 3.5 to 2.0 x 4.0 cm (malar area, helix of ears, upper extremities, thighs)  (+) leonine facies  (-) madarosis  Borderline Lepromatous Leprosy Lesions: symmetrical, numerous (too many to count) and may include macules, papules, plaques, and nodules Age of predilection: 2 peaks of presentation; in children aged years, and in adults y/o Site of predilection: face, limbs Nerve involvement appears later. The involvement is symmetrical. Sensation and sweating over individual lesions is normal. Lesions: symmetrical, numerous (too many to count) and may include macules, papules, plaques, and nodules Age of predilection: 2 peaks of presentation; in children aged years, and in adults y/o Site of predilection: face, limbs Nerve involvement appears later. The involvement is symmetrical. Sensation and sweating over individual lesions is normal.

 Patient’s Data  erythematous ill-defined asymptomatic patches (upper extremities, with tingling sensation, numbness of the hands) into multiple erythematous to skin-colored plaques and nodules 1.5x 3.5 to 2.0 x 4.0 cm (malar area, helix of ears, upper extremities, thighs)  (+) leonine facies  (-) madarosis  erythematous ill-defined asymptomatic patches (upper extremities, with tingling sensation, numbness of the hands) into multiple erythematous to skin-colored plaques and nodules 1.5x 3.5 to 2.0 x 4.0 cm (malar area, helix of ears, upper extremities, thighs)  (+) leonine facies  (-) madarosis  Lepromatous Leprosy Lesions: Mainly pale lepromatous macules or lepromatous infiltrations, with numerous bacilli in the lesions; leonine facies positive Age of predilection: 2 peaks of presentation; in children aged years, and in adults y/o Site of predilection: face, limbs There is little or no loss of sensation over the lesions, there is no nerve thickening, and there are no changes in sweating. Lesions: Mainly pale lepromatous macules or lepromatous infiltrations, with numerous bacilli in the lesions; leonine facies positive Age of predilection: 2 peaks of presentation; in children aged years, and in adults y/o Site of predilection: face, limbs There is little or no loss of sensation over the lesions, there is no nerve thickening, and there are no changes in sweating.

Leonine Facies

 Patient’s Data  erythematous ill-defined asymptomatic patches into multiple (upper extremities, with tingling sensation, numbness of the hands) erythematous to skin- colored plaques and nodules 1.5x 3.5 to 2.0 x 4.0 cm (malar area, helix of ears, upper extremities, thighs)  (+) leonine facies  (-) madarosis  erythematous ill-defined asymptomatic patches into multiple (upper extremities, with tingling sensation, numbness of the hands) erythematous to skin- colored plaques and nodules 1.5x 3.5 to 2.0 x 4.0 cm (malar area, helix of ears, upper extremities, thighs)  (+) leonine facies  (-) madarosis  Histoid Leprosy Lesions: Yellow-red, shiny, large papules and nodules in the dermis or subcutaneous tissue Age of predilection: 2 peaks of presentation; in children aged years, and in adults y/o Site of predilection: buttocks, lower back, face, and bony prominences may appear de novo or in patients with dapsone resistance Lesions: Yellow-red, shiny, large papules and nodules in the dermis or subcutaneous tissue Age of predilection: 2 peaks of presentation; in children aged years, and in adults y/o Site of predilection: buttocks, lower back, face, and bony prominences may appear de novo or in patients with dapsone resistance

Leprosy Diagnosis: based on clinical signs and symptoms  Skin patch, tingling sensation, numbness of the hands Treatment: Dapsone (cornerstone of therapy)  Dapsone and rifampin – initial combination therapy