Morning Report Brought to you By Tom Rishling And the D In PODeS Meet the Patient • 24 yo latino male • presents to the dermatology clinic with nasal erythema, pruritis, pain, and occasional bleeding. Off and on for 3 years. Uses some type cream that helps sometimes. • Left nare – Erythematous firm plaque with microfissures, serosangunious crusts • Other Complaints: – Dry scaling, tender pustules on face forearms, and face especially in the beard region. – Findings On Physical Exam: • Pinpoint sanginous Other Skin findings Past Medical History • Crohns Disease • Colectomy x 3 • H/o abdominal fistulas • Palpitations • Medications Azathioprine Prevacid Metoprolol Social/ Family History • No tobacco/drug/or alcohol use • Family History – No skin ca – No psoriasis – No eczema + Sister with acne Clinical Impression/Plan • 1. Seborrheic Dermatitis – Hydrocortisone cream 2.5 lotion bid – Selenium sulfide 2.5% tiw shampoo. • 2. Folliculitis. duricef • 3. Nasal errythema: Impetigo vs crohns – Given Duricef (Cefadroxil) 500 bid x 10d – Bactroban oint bid – Biopsy nose!!! Follow up • Biopsy results of nasal lesion biopsy showed noncaseating granulomatous changes. Consistent with “Malignant Crohns. – Patient following with GI – On Humira – Short doses of steroids can also be beneficial. Cutaneous Manifestations of IBD • Acrochordons (skin tags) – Perianal skin tags are common in Crohns Cutaneous Manifestations of IBD • Erythema nodosum – Most frequently seen cutaneous manifestation of UC & Crohn’s. (15% of patients) Cutaneous Manifestations of IBD • Erythema nodosum – Raised, tender, red- violet subcutaneous nodules 1-5cm – Usually extensor surfaces – Biopsy shows panniculitis – Onset and severity usually parallels intestinal disease activity. • Erythema nodosum – Likely a delayed hypersensitivity reaction – Associated with infections, immmunopathies, sarcoidosis, Behcet’s malignancy and drug therapy esp. halides, sulfonamides, oral contraceptives, omeprazole. • Lofgren’s syndrome: hilar lymphadenopathy, EN, and acute polyarthritis. • Infections: streptococcal, coccidiomycosis (San Joaquin Valley Fever in the SW), histoplasmosis, blasto, lymphgranuloma v. • Erythema Nodosum – Lymphoma: esp Hodgkin’s disease (EN may proceed diagnosis by months) • Diagnosis – Usually clinical – Deep incisional biopsy will show panniculitis with no evidence of vasculitis – CBC, ASO titer, Urinalysis, throat culture, PPD, CXR should be obtained for further eval. EN – Treatment • Usually self limited. NSAIDS are helpful. Potassium iodide in orange juice may be helpful. • Steroids can be used but not usually needed. • In case of Crohn’s treat underlying disease and rule out treatable infections or drug causes. • Pyoderma Gangrenosum – 5% of UC, 2% of Crohns – Initially may look like a papule or pustule, often preceded by trauma to skin – Can develop anywhere but most commonly on legs – Can develop in scars after surgery. Sterile necrosis and abscess. – Usually after 5-10 years of being diagnosed with IBD Pyoderma Gangrenosum • Noninfectious neutrophilic ulcerating skin disease • Lesions parallel IBD only 50% of the time • Several weeks of high dose steroids may be needed • Azathioprine, dapsone, hyperbaric oxygen, or even IVIG may be used PG • Also seen in: – Chronic Hepatitis – Rheumatoid arthritis – IgA monoclonal gammopathy – Malignancy – 40-50% no assoc. disease is found • Biopsy usually nonspecific Sweet’s Syndrome (SS) • A form of neutrophilic dermatosis • Cutaneous marker of systemic disease • Sudden onset of fever, leukocytosis, and tender, erythematous well-demarcated papules and plaques • Papillary dermal infiltrates of neutrophils on pathology • Most often idiopathic (up to 50%), may be preceded by upper respiratory or GI infection • Associations: Inflammatory Bowel Disease, Strep Infection Leukemia (esp. AML) in 20% other immunological diseases (RA) SS Risk Factors • Female • Between 30 and 50 years of age • Having associated health problems (discussed in previous slide) • Pregnancy (1st and 2nd trimester) • Previous history of SS (1/3 have recurrence) Case: 29 year old Female who developed Sweet’s Syndrome during 20th week of pregnancy Sweet’s Syndrome (continued) • SS may precede systemic disease by months to years • Granulocyte colony stimulating factors and Granuocyte-macrophage colony stimulating factor (treatments for leukemia) can also cause SS. • Diagnostic Studies – Moderate neutrophilia (<50%) – Elevated ESR (>30) – Slight increase in Alk- phos – Biopsy Sweet’s Syndrome Treatment • Systemic Corticosteroids 0.5 to 1.5 mg/kg is gold standard tapered over 2 to 6 weeks • Skin eruption typically resolves within a week. • Other options: Indomethacin 150 mg/day for 3 weeks: 17/18 patients in one study cleared cutaneous lesions within 2 weeks. • Others: oral Potassium Iodide or colchicine Psoriasis • More common in in patients with Crohn’s than general population • Patients with psoriasis w/ psoriatic arthritis commonly have microscopic colon inflammation even if they do not have bowel symptoms • Anti-TNF drugs has been assoc. w/ development of eczema and psoriasis New Case • 55 yo female with uncomfortable red eye. • Episcleritis – 2 to 5 % of people with IBD – Also seen in other inflammatory conditions. – In This Case, Rheumatoid arthritis! • Ocular therapy – often requires no treatment. – Artificial tears – severe or prolonged episodes may require topical corticosteroids. • Topical ophthalmic 0.5% prednisolone, 0.1% dexamethasone, or 0.1% betamethasone daily may be used.
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