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									    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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