Skin Involvement Skin Involvement in Internal in Internal MedicineMedicine

''ד"ר גורשטיין אלכס, פנ. הד"ר גורשטיין אלכס, פנ. ה

ביה"ח מאירביה"ח מאיר

Primary skin lesionsPrimary skin lesions

MaculeMacule- a flat, coloured, not raised - a flat, coloured, not raised lesion <2 cmlesion <2 cm

Intussusception due to intestinal polyp Intussusception due to intestinal polyp and lentigines in a patient with Peutz-and lentigines in a patient with Peutz-

Jeghers syndromeJeghers syndrome

NEJM , Dec. 6, 2007

PatchPatch

A flat, coloured, not raised lesion >2 A flat, coloured, not raised lesion >2 cmcm

Café-au-lait spot VitiligoCafé-au-lait spot Vitiligo

PapulePapule

A raised, palpable lesion < 0.5 cmA raised, palpable lesion < 0.5 cm

Maculopapular rashMaculopapular rash

Rubelliform Rubelliform MorbilliformMorbilliform

NoduleNodule

A raised, palpable lesion 0.5-5 cmA raised, palpable lesion 0.5-5 cm

TumorTumor

A raised, palpable lesion >5 cmA raised, palpable lesion >5 cm

PlaquePlaque

A raised, palpable flat-topped lesion A raised, palpable flat-topped lesion >1 cm>1 cm

VesicleVesicle

A fluid-filled raised lesion <0.5 cmA fluid-filled raised lesion <0.5 cm

PustulePustule

A vesicle filled with leukocytes.A vesicle filled with leukocytes.

BullaBulla

A fluid-filled raised lesion >0.5 cmA fluid-filled raised lesion >0.5 cm

Secondary skin lesionsSecondary skin lesions

Crust-Crust- dried exudate of body fluids dried exudate of body fluids Erosion-Erosion- loss of epidermis without loss of epidermis without

dermisdermis Ulcer-Ulcer- loss of epidermis and at least loss of epidermis and at least

partial loss of dermispartial loss of dermis Excoriations-Excoriations- linear erosions caused by linear erosions caused by

scratching.scratching. Lichenification-Lichenification- thickening of the skin thickening of the skin

with resulting accentuation of skin lines.with resulting accentuation of skin lines.

Excoriations and Excoriations and lichenificationlichenification

Approach to a patient with Approach to a patient with purpurapurpura

Non-blanching rash caused by Non-blanching rash caused by extravasation of bloodextravasation of blood

Depending on size called:Depending on size called:

- petechiae <3 mm- petechiae <3 mm

- purpura >3 mm- purpura >3 mm

- ecchymosis >2 cm- ecchymosis >2 cm

11stst step- rule out step- rule out “pseudopurpura“pseudopurpura””

Kaposi’s sarcomaKaposi’s sarcoma

Hereditary hemorrhagic Hereditary hemorrhagic telangiectasia (HHT) = telangiectasia (HHT) =

Osler-Weber-Rendu Osler-Weber-Rendu syndromesyndrome

Erythema nodosumErythema nodosum Acute nodular erythematous Acute nodular erythematous

eruptioneruption Represents a delayed Represents a delayed

hypersensitivity reaction to hypersensitivity reaction to aa

variety of antigens.variety of antigens. Common causes:Common causes: - Infections- Strep., Tb., other- Infections- Strep., Tb., other - Drugs- sulfa, contraceptives- Drugs- sulfa, contraceptives - IBD- IBD - Sarcoidosis- Sarcoidosis - Idiopathic- Idiopathic

22ndnd step – palpable or not step – palpable or not

Non-palpableNon-palpable1. 1. Primary cutaneousPrimary cutaneous - trauma- trauma - solar = actinic- solar = actinic - steroid- steroid2. 2. SystemicSystemic - -

thrombocytopeniathrombocytopenia - -

thrombocytopathythrombocytopathy - scurvy- scurvy

3. 3. With intravascular With intravascular thrombithrombi

- DIC - DIC - TTP- TTP - Janeway - Janeway

lesionslesions4. 4. Caused by Caused by

embolismembolism - Cholesterol - Cholesterol

emboliemboli - Fat embolism- Fat embolism

Steroid purpuraSteroid purpura

Purpura due to ITPPurpura due to ITP

Purpura in DICPurpura in DIC

Janeway lesionsJaneway lesions

Vascular phenomenon of Vascular phenomenon of endocarditis related to embolism endocarditis related to embolism and skin necrosisand skin necrosis

Non-palpable, non-tenderNon-palpable, non-tender

Cholesterol embolismCholesterol embolism

Palpable purpuraPalpable purpura

1. 1. VasculiticVasculitic - Small vessel vasculitis - Small vessel vasculitis

(leukocytoclastic vasculitis)(leukocytoclastic vasculitis) - Henoch-Sch- Henoch-Schöönlein purpuranlein purpura - Polyarteritis nodosa- Polyarteritis nodosa - Osler’s nodes- Osler’s nodes2. 2. InfectiousInfectious - Disseminated gonococcal infection- Disseminated gonococcal infection - Rickettsial spotted fever- Rickettsial spotted fever

Henoch-SchHenoch-Schöönlein nlein purpurapurpura

Osler’s nodesOsler’s nodes

Immune phenomenon of Immune phenomenon of endocarditis related to deposition of endocarditis related to deposition of immune complexes.immune complexes.

Palpable, tender lesionsPalpable, tender lesions

Disseminated gonococcal Disseminated gonococcal infectioninfection

Rickettsial spotted feverRickettsial spotted fever

Approach to a patient with Approach to a patient with leg ulcersleg ulcers

Venous= ulcus crurisVenous= ulcus cruris Ischemic in peripheral arterial disease Ischemic in peripheral arterial disease

(PAD)(PAD) NeuropathicNeuropathic Other:Other: - Decubitus ulcers=pressure sores- Decubitus ulcers=pressure sores - Skin cancer- Skin cancer - Infections- Infections - Antiphospholipid syndrome- Antiphospholipid syndrome - Vasculitis- Vasculitis - Pyoderma gangrenosum- Pyoderma gangrenosum

PAD and leg ulcersPAD and leg ulcers

Symptoms and signs of PAD:Symptoms and signs of PAD:

- Intermittent claudication, ulcers, - Intermittent claudication, ulcers, gangrenegangrene

- Pallor/ cyanosis- Pallor/ cyanosis

- Decreased pulses- Decreased pulses

- Atrophic shiny skin- Atrophic shiny skin

- Loss of skin appendages- Loss of skin appendages

- Thickened nails- Thickened nails

Ischemic skin ulcersIschemic skin ulcers

Usually occur over pressure pointsUsually occur over pressure points

Chronic venous Chronic venous insufficiencyinsufficiency

Results from damage to venous Results from damage to venous valves due to DVT or valvular valves due to DVT or valvular incompetenceincompetence

Leads to increased leg Leads to increased leg circumference, edema, stasis circumference, edema, stasis dermatitis.dermatitis.

Predisposes to skin infections.Predisposes to skin infections.

Stasis dermatitisStasis dermatitis

Severe stasis dermatitis, Severe stasis dermatitis, recurrent cutaneous recurrent cutaneous

infections and leg edemainfections and leg edema

Venous ulcersVenous ulcers Usually appear near the malleoliUsually appear near the malleoli

Neuropathic ulcersNeuropathic ulcers

Usually seen in diabetic patientsUsually seen in diabetic patients The most common form of diabetic The most common form of diabetic

neuropathy is distal symmetric neuropathy is distal symmetric polyneuropathy.polyneuropathy.

Pain classically worsens at night.Pain classically worsens at night. Physical examination reveals sensory Physical examination reveals sensory

loss, loss of ankle reflexes, and loss, loss of ankle reflexes, and abnormal position sense. abnormal position sense.

Neuropathic ulcersNeuropathic ulcers

Plantar ulcers are the result of Plantar ulcers are the result of moderate repetitive trauma moderate repetitive trauma underneath a metatarsal headunderneath a metatarsal head. .

Diabetic footDiabetic foot

Up to 15% of diabetic patients develop Up to 15% of diabetic patients develop foot ulcers = diabetic foot.foot ulcers = diabetic foot.

Foot ulcers in diabetic patients appear Foot ulcers in diabetic patients appear due to:due to:

- Neuropathy- Neuropathy - PAD- PAD - Abnormal foot biomechanics and - Abnormal foot biomechanics and

structurestructure - Poor wound healing.- Poor wound healing. 10-20% of patients with leg ulcer 10-20% of patients with leg ulcer

undergo amputation of leg.undergo amputation of leg.

Squamous cell carcinoma Squamous cell carcinoma and leg ulcerand leg ulcer

Marjolin's ulcerMarjolin's ulcer refers to ulcerating refers to ulcerating SqCCSqCC presenting in an presenting in an area of previouslyarea of previously traumatisedtraumatised, , chronically inflamed or chronically inflamed or scarred skinscarred skin

Pressure sores/ Pressure sores/ Decubitus ulcerDecubitus ulcer

Pyoderma gangrenosumPyoderma gangrenosum

Represents an overreactive inflammatory Represents an overreactive inflammatory response to traumatic, inflammatory, or response to traumatic, inflammatory, or neoplastic processes.neoplastic processes.

Extraintestinal cutaneous manifestation of Extraintestinal cutaneous manifestation of IBD- UC> Crohn’s disease.IBD- UC> Crohn’s disease.

In IBD-usually associated with severe In IBD-usually associated with severe disease, but not related to the course of the disease, but not related to the course of the disease, does not improve after colectomy.disease, does not improve after colectomy.

Begins as a pustule, usually on dorsal Begins as a pustule, usually on dorsal surface of feet and legs, spreads to involve surface of feet and legs, spreads to involve healthy skins, ulcerate. healthy skins, ulcerate.

Pyoderma gangrenosumPyoderma gangrenosum Lesions have violaceous borders surrounded by Lesions have violaceous borders surrounded by

erythemaerythema Biopsy of an early lesion of pyoderma Biopsy of an early lesion of pyoderma

gangrenosum often demonstrates a dermal gangrenosum often demonstrates a dermal

neutrophilic abscessneutrophilic abscess

DD of pyoderma DD of pyoderma gangrenosumgangrenosum Lesions resembling pyoderma Lesions resembling pyoderma

gangrenosum may appear in other gangrenosum may appear in other conditions, including vasculitis, conditions, including vasculitis, cancer, vascular diseases, infections, cancer, vascular diseases, infections, trauma, or antiphospholipid trauma, or antiphospholipid syndrome, as in this case.syndrome, as in this case.

Skin Ulcers Misdiagnosed as Pyoderma Gangrenosum. NEJM Oct 31, 2002. Weeing RH, et al .

Ecthyma gangrenosumEcthyma gangrenosum EGEG is a cutaneous infection most is a cutaneous infection most

commonly associated with a commonly associated with a Pseudomonas aeruginosaPseudomonas aeruginosa bacteremia, bacteremia, but also other bacteria and fungi. but also other bacteria and fungi.

EG usually occurs in patients who are EG usually occurs in patients who are critically ill and immunocompromised.critically ill and immunocompromised.

Appears as painless round red macules Appears as painless round red macules that become pustular with surrounding that become pustular with surrounding erythema -> bullous -> gangrenous erythema -> bullous -> gangrenous ulcer with blackulcer with black//gray eschar. gray eschar.

Ecthyma gangrenosumEcthyma gangrenosum

Approach to a patient with Approach to a patient with palmar/ plantar rash palmar/ plantar rash

Rickettsial spotted feverRickettsial spotted fever MeningococcemiaMeningococcemia Infective endocarditisInfective endocarditis Secondary syphilis Secondary syphilis Hand-foot-and-mouth diseaseHand-foot-and-mouth disease Erythema multiformeErythema multiforme

Secondary syphilisSecondary syphilis Scaly papular eruption, diffuse but Scaly papular eruption, diffuse but

prominent on palms and soles, never prominent on palms and soles, never vesicular.vesicular.

Condyloma latum, mucous patches Condyloma latum, mucous patches and alopecia in some cases.and alopecia in some cases.

Hand-foot-and-mouth Hand-foot-and-mouth diseasedisease

Most frequently caused by Most frequently caused by coxsackievirus A16.coxsackievirus A16.

Usually appears in summer and fall.Usually appears in summer and fall. Highly contagious.Highly contagious. Papules evolving into tender vesicles Papules evolving into tender vesicles

appear on hands and feet. Patients appear on hands and feet. Patients complain on sore throat caused by complain on sore throat caused by mouth erosions. mouth erosions.

Hand-foot-and-mouth Hand-foot-and-mouth diseasedisease

Erythema multiformeErythema multiforme Target lesions up to 2 cm.Target lesions up to 2 cm. May involve mucosal surfaces and >10% May involve mucosal surfaces and >10%

body surface= EM major body surface= EM major Causes: - Infections- HSV, Causes: - Infections- HSV, M. M.

pneumoniaepneumoniae - Drugs- sulfa, penicillin, - Drugs- sulfa, penicillin,

phenytoinphenytoin - Rheumatic diseases- Rheumatic diseases - Leukemias, NHL, MM- Leukemias, NHL, MM - Idiopathic- Idiopathic

Erythema multiformeErythema multiforme

Cutaneous Cutaneous manifestations of manifestations of

internal internal malignancymalignancy

Sister Mary Joseph’s nodule Sister Mary Joseph’s nodule (sign)(sign)

Firm periumbilical lesion associated Firm periumbilical lesion associated with cancers of the GI tract and with cancers of the GI tract and

ovary ovary

Virchow’s nodeVirchow’s nodeEnlarged and firm left supraclavicular Enlarged and firm left supraclavicular

lymph node near the junction of the lymph node near the junction of the thoracic duct and the left subclavian thoracic duct and the left subclavian

vein- a sign of abdominal vein- a sign of abdominal malignancy malignancy

Sign of Leser-TrSign of Leser-Tréélatlat

Sudden appearance Sudden appearance of multiple of multiple seborrheic seborrheic

keratoses- a sign of keratoses- a sign of internal malignancy, internal malignancy,

usually of GI tractusually of GI tract

Acanthosis nigricansAcanthosis nigricans

Hyperpigmentation, primary in the Hyperpigmentation, primary in the flexural areas. Usually a sign of flexural areas. Usually a sign of insulin resistance, but may reflect insulin resistance, but may reflect internal malignancy, usually of GI internal malignancy, usually of GI tract.tract.

DermatomyositisDermatomyositis

Inflammatory myopathy Inflammatory myopathy characterized by muscle weakness characterized by muscle weakness and characteristic skin findings. and characteristic skin findings.

Associated with breast, NHL, Associated with breast, NHL, ovarian, melanoma and GI cancers ovarian, melanoma and GI cancers in up to 50% of affected adults. in up to 50% of affected adults.

DermatomyositisDermatomyositis

Heliotrope rashHeliotrope rash Gottron rashGottron rash