PAINE #PANCE Pearl – Dermatology



Question

A 29yo patient is seen for a severe drug reaction after starting lamotrigine (Lamictal) for new-onset epilepsy. She has significant desquamation of her mucous membranes as well as large patches of denuded epidermis with multiple bullae present.

  1. What is the clinically distinguishing feature between Steven-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN)?

Answer

The main clinical difference between SJS and TEN is the severity and degree of involvement. SJS classically is < 10% TBSA involvement, where as TEN is > 30% TBSA.

Ep-PAINE-nym



Nikolsky’s Sign

Other Known Aliasesnone

DefinitionExfoliation of the outermost layer and elicitation of blistering as a result of gentle mechanical pressure on the skin

Clinical Significance This sign is classically associated with pemphigus vulgaris and is used to differentiate vulgaris (where it is present) and bullous (where it is absent). It is also present in Stevens-Johnson Syndrome, Toxic Epidermal Necrolysis, and scalded skin syndrome.

HistoryNamed after Pyotr Vaseilyevich Nikolsky (1858-1940), who was a Russian dermatologist and received his medical doctorate from the Saint Vladimir Imperial University of Kiev in 1884. His doctoral dissertation and thesis was on pemphigus foliaceus, where he described his now famous eponym. He went on to have a career in academic medicine becoming professor at the Imperial University of Warsaw and establishing the Department of Dermatology and Venerology at the future Southern Federal University.


References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. Grando SA, Grando AA, Glukhenky BT, Doguzov V, Nguyen VT, Holubar K. History and clinical significance of mechanical symptoms in blistering dermatoses: a reappraisal. Journal of the American Academy of Dermatology. 2003; 48(1):86-92. [pubmed]

PAINE #PANCE Pearl – Dermatology



Question

A 29yo patient is seen for a severe drug reaction after starting lamotrigine (Lamictal) for new-onset epilepsy. She has significant desquamation of her mucous membranes as well as large patches of denuded epidermis with multiple bullae present.

  1. What is the clinically distinguishing feature between Steven-Johnson Syndrome and Toxic Epidermal Necrolysis?

PAINE #PANCE Pearl – Dermatology



Question

Vitiligo and tinea versicolor are both hypomelanocytic dermatologic afflications. What are some ways to differentiate these two conditions?



Answer

  • Location
    • Tinea versicolor – trunk and proximal extremities
    • Vitiligo – can occur anywhere, but most common on hands and face
  • Color
    • Tinea versicolor – hypopigmented, more prominent with sun exposure
    • Vitiligo – milk or chalk-white, no change with sun exposure
  • Wood’s lamp
    • Tinea versicolor – fluoresce yellow/green
    • Vitiligo – fluoresce blue/white

Ep-PAINE-nym



Langer’s Lines

Other known aliasesLanger’s lines of skin tension, cleavage lines

Definitiontopographical lines on the human body that correspond to the natural orientation of the collagen fibers of the dermis and are parallel to the orientation of the underlying muscle fibers

Clinical SignificanceIncisions made on the skin that run parallel with these lines produce much less tension on the wound, heal better with less scarring, and have a much better cosmetic appearance.  This is important in cosmetic surgery applications, as well as elective surgical procedures when you can select where to make your incision.

HistoryNamed after Karl Langer (1819-1887), an Austrian anatomist, who received his medical doctorate from the Universities of Vienna and Prague.  He worked under Joseph Hyrtl as a prosector for the University of Vienna and later becoming the director in 1874.  In his famous procedure discovering these tension lines, he punctured circular holes on the skin of cadavers and noticed that they would result in ellipisoidal wounds.  By following the direction of these ellipses, he was able to topographically map these lines on the entire body.  He did give credit to Baron Dupuytren as being the first to observe this phenomenon and published his findings in 1861 entitled “Zur Anatomie und Physiologie der Haut. Über die Spaltbarkeit der Cutis”

Karl Langer

References

PAINE #PANCE Pearl – Dermatology



Question

 

What are the 5 things to assess in a suspicious lesion/mole to evaluate for melanoma?

 



Answer

 

The ABCDEs of melanoma will help you identify suspicious lesions that will need dermatologic follow-up

 

Asymmetry

  • Draw a line through the lesion and the two halves do not look similar, it is concerning

Border Irregularity

  • If the borders of the lesion are not uniform and smooth, it is concerning

Color

  • Different colors within the same lesion are concerning

Diameter

  • ≥ 6 mm is concerning

Evolution

  • Any lesion that changes in size, shape, color is concerning

 

The is also another set of criteria that was developed in the UK by the United Kingdom National Institute for Clinical Excellence (NICE) and by the Scottish Intercollegiate Guidelines Network called the Glasgow Seven-point Checklist.  These guidelines incorporate 3 major and 4 minor criteria and any major or 3 minor criteria is an indication for referral.

Major

  • Change in size or new lesion
  • Change in shape
  • Change in color

Minor

  • Diameter ≥ 7mm
  • Inflammation
  • Crusting or bleeding
  • Sensory change


Once a patient has been referred to a dermatologist, they use a similar seven point system on dermoscopy to diagnose melanoma.

Major (2 points each)

  • Atypical pigment network
  • Blue-whitish veil
  • Atypical vascular pattern

Minor (1 point each)

  • Irregular streaks
  • Irregular pigmentation
  • Irregular dots/globules
  • Regression structures

 

A melonoma score of ≥ 3 is required for diagnosis

 



References

  1. National Collaborating Centre for Cancer (UK). Melanoma: Assessment and Management. London: National Institute for Health and Care Excellence (UK); 2015
  2. Scottish Intercollegiate Guidelines Network. Cutaneous Melanoma. A national clinical guideline. January 2017.
  3. Argenziano G, Fabbrocini G, Carli P, De Giorgi V, Sammarco E, Delfino M. Epiluminescence microscopy for the diagnosis of doubtful melanocytic skin lesions. Comparison of the ABCD rule of dermatoscopy and a new 7-point checklist based on pattern analysis. Archives of dermatology. 1998; 134(12):1563-70. [pubmed]
  4. http://www.dermoscopy.org/consensus/2d.asp