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.
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.
Definition – Exfoliation 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.
History – Named 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
Firkin BG and Whitwirth JA. Dictionary of Medical Eponyms. 2nd ed. New York, NY; Parthenon Publishing Group. 1996.
Bartolucci S, Forbis P. Stedman’s Medical Eponyms. 2nd ed. Baltimore, MD; LWW. 2005.
Yee AJ, Pfiffner P. (2012). Medical Eponyms (Version 1.4.2) [Mobile Application Software]. Retrieved http://itunes.apple.com.
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]
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.
What is the clinically distinguishing feature between Steven-Johnson Syndrome and Toxic Epidermal Necrolysis?
Other known aliases – Langer’s lines of skin tension, cleavage lines
Definition – topographical 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 Significance – Incisions 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.
History – Named 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
Firkin BG and Whitwirth JA. Dictionary of Medical Eponyms. 2nd ed. New York, NY; Parthenon Publishing Group. 1996.
Bartolucci S, Forbis P. Stedman’s Medical Eponyms. 2nd ed. Baltimore, MD; LWW. 2005.
Yee AJ, Pfiffner P. (2012). Medical Eponyms (Version 1.4.2) [Mobile Application Software]. Retrieved http://itunes.apple.com.
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.
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]
