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

3. HISTORY OF PRESENT ILLNESS 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

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

5. 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

6. 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)

7. DIFFERENTIAL DIAGNOSIS Erythema multiforme Fixed drug reaction Seborrheic dermatitis Cellulitis Urticaria Exfoliative dermatitis Hansen’s Disease

8. Erythema Multiforme an acute, self-limiting, inflammatory skin eruption. Most common cause is Herpes Simplex Occurs in response to medications, infections Medications include: Barbiturates Penicillins Phenytoin Sulfonamides Infections include: Herpes simplex Mycoplasma

9. (brief description of pathology) (epidemiology, incidence, etc.)  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  Erythema Multiforme  Lesion Begin as sharply marginated, erythematous macules, which become raised, edematous papules over 24 to 48 hours “target” or “iris” lesion with 3 zones – central dusky purpura; an elevated, edematous, pale ring; and surrounding macular erythema  Age of Predilection Young adults  Site of predilection dorsal hands, dorsal feet, extensor limbs, elbows and knees, and palms and soles  Lesion Begin as sharply marginated, erythematous macules, which become raised, edematous papules over 24 to 48 hours “target” or “iris” lesion with 3 zones – central dusky purpura; an elevated, edematous, pale ring; and surrounding macular erythema  Age of Predilection Young adults  Site of predilection dorsal hands, dorsal feet, extensor limbs, elbows and knees, and palms and soles

11. There are two types of EM: EM minor and EM major. EM minor comprises nearly 70% of the cases. Most cases of EM minor resolve in one to three weeks EM major might take three to six weeks to resolve. Recurrences are more commonly seen in EM minor, but are rare in EM major. Traditionally, Stevens- Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) were included in the same spectrum as EM.

12. EM MINOR Most patients with EM minor present with new- onset mucocutaneous lesions which are usually symmetrical and rapidly progressing in nature. These lesions may be pruritic or may be associated with a burning sensation.

13. EM MAJOR EM major is usually preceded by prodromal symptoms such as fatigue, fever, headaches, and myalgias. These symptoms can appear up to two weeks prior to the mucocutaneous manifestations. Oral mucosal involvement may lead to difficulty in drinking and eating. Ocular involvement may lead to complaints of redness, discharge and ocular pain.

14. Treatment Prevention is cornerstone of treatment if HSV can be demonstrated as the trigger. Antiherpetic antibiotic

15. Fixed Drug Eruption the development of one or more annular or oval erythematous patches as a result of systemic exposure to a drug. normally resolve with hyperpigmentation and may recur at the same site with reexposure to the drug.

16. Erythema MultiformeFixed Drug Eruption Lesion Begin as sharply marginated, erythematous macules, which become raised, edematous papules over 24 to 48 hours “target” or “iris” lesion with 3 zones – central dusky purpura; an elevated, edematous, pale ring; and surrounding macular erythema Begins as a red patch that soon evolves to an iris or target lesion identical to erythema multiforme, and may eventually blister and erode Nonpigmenting fixed drug eruption: large, tender, often symmetrical eythematous plaques Age of PredilectionYoung adults Site of Predilectiondorsal hands, dorsal feet, extensor limbs, elbows and knees, and palms and soles Oral and genital mucosa

17. Erythema MultiformeFixed Drug Eruption Etiologic FactorsUsually has non-drug causes, most commonly herpes simplex infection Genetic susceptibility with an increased incidence of HLA- B22 Treatment Prevention is cornerstone of treatment if HSV can be demonstrated as the trigger. Sunblock creams Antiherpetic antibiotic Stop taking the offending drug.

18. PatientFixed Drug Eruption Multiple erythematous to skin-colored plaques and nodules (1.5x3.5 to 2.0x4.0 cm) Begins as a red patch that soon evolves to an iris or target lesion identical to erythema multiforme, and may eventually blister and erode Forehead, malar area, left ear, trunk, and extremities Oral and genital mucosa (+) Leonine facies (+) HPN, DM

19. 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.

20. 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

21.  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.

22.  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.

23. Seborrheic Dermatitis

24. 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

25. PatientErysipelas Multiple erythematous to skin-colored plaques and nodules (1.5x3.5 to 2.0x4.0 cm) Fiery-red swelling with characteristic raised, indurated border; distinctive features is the advancing edge of the patch Newborn, postpartum women, elderly and immunocompromised Forehead, malar area, left ear, trunk, and extremities Face and legs (+) Leonine facies Beta hemoytic Group A streptococcus Any inflammation of the skin, especially if fissured or ulcerative, may provide an entrance for the causative streptococcus Bacterial cultures Systemic penicillin Erythromycin Locally, ice bags and cold compresses (+) HPN, DM

26. PatientCellulitis Multiple erythematous to skin-colored plaques and nodules (1.5x3.5 to 2.0x4.0 cm) Warm tender painful swelling with ill- defined borders (pits on pressure) Children and immunocompromised No predilection for either sex is usually reported Forehead, malar area, left ear, trunk, and extremities (+) Leonine facies Streptococcus pyogenes or S. aureus Usually follows some discernible wound Laboratory Studies Intravenous penicillinase-resistant penicillins or a first-generation cephalosporin (+) HPN, DMMalaise, chilly sensation, sudden chill and fever may be present at the onset

28.  Patient’s Data  Age & Sex Predilection  43 y/o, female  Lesion  multiple erythema-tous to skin-colored plaques and nodules  Area of Predilection  malar area, upper extremities, thighs  Predisposing Factors  none  Age & Sex Predilection  43 y/o, female  Lesion  multiple erythema-tous to skin-colored plaques and nodules  Area of Predilection  malar area, upper extremities, thighs  Predisposing Factors  none  Exfoliative Dermatitis  Age & Sex Predilection  >40 y/o, females  Lesion  Erythematous plaques  Area of Predilection  Face and extremities  Predisposing Factors  Drug allergy, underlying cutaneous or systemic disease (ex. Lymphoma)  Age & Sex Predilection  >40 y/o, females  Lesion  Erythematous plaques  Area of Predilection  Face and extremities  Predisposing Factors  Drug allergy, underlying cutaneous or systemic disease (ex. Lymphoma)

29.  Patient’s Data  Exfoliative Dermatitis  Course of Illness  Multiple remissions and exacerbations  Other associated s/sx Swelling or lymphadenopathy Recurrent infections Low-grade fever, chills, malaise Gynecomastia Hepatomegaly, splenomegaly Steatyorrhea Hyper/hypopigmentation Alopecia Dystrophic nails  Course of Illness  Multiple remissions and exacerbations  Other associated s/sx Swelling or lymphadenopathy Recurrent infections Low-grade fever, chills, malaise Gynecomastia Hepatomegaly, splenomegaly Steatyorrhea Hyper/hypopigmentation Alopecia Dystrophic nails  Course of Illness  (-) remissions and exacerbations  Other associated s/sx Leonine facies Tingling sensation Numbness of hand and forearm  Course of Illness  (-) remissions and exacerbations  Other associated s/sx Leonine facies Tingling sensation Numbness of hand and forearm

30.  Patient’s Data  Exfoliative Dermatitis  Etiology  Drugs, food, infections, emotional stress, neoplasm  Course of Illness IgE-mediated  transient (<24 hours)  Migratory  no residual skin abnormalities Vasculitis  >24 hours  painful and pruritic  leave purpuric and hyperpigmented lesions  Etiology  Drugs, food, infections, emotional stress, neoplasm  Course of Illness IgE-mediated  transient (<24 hours)  Migratory  no residual skin abnormalities Vasculitis  >24 hours  painful and pruritic  leave purpuric and hyperpigmented lesions  Etiology  Not present  Course of Illness  8 months  Etiology  Not present  Course of Illness  8 months

31.  Patient’s Data  Age & Sex Predilection  43 y/o, female  Lesion  multiple erythema- tous to skin-colored plaques and nodules 1.5x 3.5 to 2.0 x 4.0 cm  Area of Predilection  malar area, helix of ears, UE, thighs  Age & Sex Predilection  43 y/o, female  Lesion  multiple erythema- tous to skin-colored plaques and nodules 1.5x 3.5 to 2.0 x 4.0 cm  Area of Predilection  malar area, helix of ears, UE, thighs  Urticaria  Age & Sex Predilection  Any age, Male=Female  Chronic = 40 y/o, Female  Lesion  white or red evanescent plaques  Blanching, raised, palpable wheals  linear, circular or serpiginous  dermographism  Area of Predilection  Any skin area  Age & Sex Predilection  Any age, Male=Female  Chronic = 40 y/o, Female  Lesion  white or red evanescent plaques  Blanching, raised, palpable wheals  linear, circular or serpiginous  dermographism  Area of Predilection  Any skin area

33. 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.

34.  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  Indeterminate Leprosy  Earliest and mildest form  One to a few of hypopigmented or erythematous macules  Loss of sensation is rare  75% of affected persons have lesions that heal spontaneously  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.  Earliest and mildest form  One to a few of hypopigmented or erythematous macules  Loss of sensation is rare  75% of affected persons have lesions that heal spontaneously  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.

36.  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  One erythematous large plaque with well-defined borders that are elevated and that slope down into an atrophic center  Lesions can become arciform or annular  Can be found on the face, limbs, or elsewhere, but they spare intertriginous areas and the scalp  Lesions can be dry and scaly, hypohidrotic, and hairless  Involves a large, asymmetric hypopigmented macule  One erythematous large plaque with well-defined borders that are elevated and that slope down into an atrophic center  Lesions can become arciform or annular  Can be found on the face, limbs, or elsewhere, but they spare intertriginous areas and the scalp  Lesions can be dry and scaly, hypohidrotic, and hairless  Involves a large, asymmetric hypopigmented macule

37.  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  Spontaneous resolution can occur in a few years, leaving pigmentary disturbances or scars  Progression can also occur, leading to borderline-type leprosy  Neural involvement is common - leads to tender, thickened nerves with subsequent loss of function  Great auricular nerve, common peroneal, ulnar, and radial cutaneous and posterior tibial nerves are often prominent  Nerve damage can happen early, resulting in wrist drop or foot drop  Spontaneous resolution can occur in a few years, leaving pigmentary disturbances or scars  Progression can also occur, leading to borderline-type leprosy  Neural involvement is common - leads to tender, thickened nerves with subsequent loss of function  Great auricular nerve, common peroneal, ulnar, and radial cutaneous and posterior tibial nerves are often prominent  Nerve damage can happen early, resulting in wrist drop or foot drop

38. Tuberculoid Leprosy

39.  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  Similar to tuberculoid type except that lesions are smaller and more numerous  Alopecia is less  Anesthesis is less severe  Disease may stay in this stage or convert back to tuberculoid form, or progress to lepromatous leprosy  Similar to tuberculoid type except that lesions are smaller and more numerous  Alopecia is less  Anesthesis is less severe  Disease may stay in this stage or convert back to tuberculoid form, or progress to lepromatous leprosy

40. Borderline Tuberculoid Leprosy

41.  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 10- 20 years, and in adults 30-60 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 10- 20 years, and in adults 30-60 y/o Site of predilection: face, limbs Nerve involvement appears later. The involvement is symmetrical. Sensation and sweating over individual lesions is normal.

42.  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 10- 20 years, and in adults 30-60 y/o Site of predilection: face, limbs There is little or loss of sensation over the lesions, there is no nerve thickening; numbness of hands 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 10- 20 years, and in adults 30-60 y/o Site of predilection: face, limbs There is little or loss of sensation over the lesions, there is no nerve thickening; numbness of hands

43. Leonine Facies

44.  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 10- 20 years, and in adults 30-60 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 10- 20 years, and in adults 30-60 y/o Site of predilection: buttocks, lower back, face, and bony prominences may appear de novo or in patients with dapsone resistance

45. Leprosy Diagnosis: based on clinical signs/symptoms and the presence of infectious organism (M. leprae) from skin biopsy  Skin lesions, tingling sensation, numbness of the hands Treatment: Dapsone (cornerstone of therapy)  Dapsone, rifampin, clofazimine – initial combination therapy