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CUTANEOUS
MANIFESTATIONS OF
INTERNAL DISEASE
PEGGY VERNON, RN, MA, DCNP, FAANP
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DISCLOSURES
There are no financial relationships with commercial interests to disclose
Ay unlabeled/unapproved uses of drugs or products referenced will be disclosed
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RESTRICTIONS
Permission granted to Skin, Bones, Hearts, and Private Parts 2017 and its attendees
All rights reserved. No part of this presentation may be reproduced, stored, or transmitted in any form or by any means without written permission of the author
Contact Peggy Vernon at creeksideskincare@icloud
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Objectives
• Identify three common cutaneous
disorders with possible internal
manifestations
• List two common cutaneous
presentations of diabetes
• Describe two systemic symptoms of
Wegeners Granulomatosis
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Psoriasis
• Papulosquamous eruption
• Well-circumscribed erythematous
macular and papular lesions with loosely
adherent silvery white scale
• Remissions and spontaneous recurrences
• Both genetic and environmental factors
predispose development
• Unpredictable course
• Great social, psychological, & economic
stress
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Pathophysiology
• Epidermis thickened; silver-white scale
• Transit time from basal cell layer to surface of skin is 3-4 days, compared to normal cell transit time of 20-28 days
• Dermis highly vascular
• Pinpoint sites of bleeding when scale removed (Auspitz sign)
• Cutaneous trauma causes isomorphic response (Koebnerphenomenon)
• Itching is variable
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Pathophysiology
• T-cell mediated disorder
• Over-active inflammatory response
• Tumor necrosis factor-α (TNF-α): pro-
inflammatory cytokine
• TNF α levels elevated in the skin and
synovium of patients with psoriasis
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Epidemiology
• 1-3% of the population
• 25-45% after age ten
• 2:1 ratio of females to males in children
• Both sexes affected equally in adults
• Familial tendency
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Psoriasis Comorbidities
Psoriatic Arthritis
Crohn’s Disease, Ulcerative colitis
Depression
Cardiovascular disease
Obesity
Diabetes
Hypertension
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PsoriasisTreatment Options
• Light therapy
• Ultraviolet B (UVB)
• Ultraviolet A (UVA)
• PUVA (psoralens with UVA)
• Home UVB
• Adjunct therapies
• Topical Steroids
• Vitamin A and D derivatives
• Topical calcineurin inhibitors
• Intralesional steroid injections
• Coal Tar (Scytera®)
• Systemic drugs
• Acitretin (Soriatane®)
• Methotrexate (MTX)
• Cyclosporine (CsA)
• Otezla ( Apremilast)
• Biologic therapy
• Alefacept (Amevive®)
• Etanercept (Enbrel®)
• Adalimumab (Humira®)
• Infliximab (Remicade®)
• Ustekinumab (Stelara®)
• Cizia (certolizumab pegol)
• Cosentyx ( Secukinumab)
• Taltz (lxekizumab)
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Malignant Skin Tumors
Cutaneous T-cell Lymphomas (CTCL)
Primary site of malignant T-lymphocyte
proliferation
Type of non-Hodgkin lymphoma
Malignant CD4+ T cells (lymphocytes) invade
lymphatic nodes, blood, and visceral organs
Mycosis Fungoides (MF)
Sèzary Syndrome (SS)
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CTCL Epidemiology
Incidence tripled from 1973-2002
32% more common in blacks
Male-female ratio 2:1
Increased incidence with age
Confirmed but uncommon in children
3.9% of all non-Hodgkin lymphomas
MF 72% of CTCL cases; SS 2.5%
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CTCL Incidence
Increased incidence in areas
with
High provider density
High family income
Higher education
High home property values
??access to medical care
??earlier and better
diagnosis
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CTCL Pathophysiology
Cause unknown
Infectious agents
proposed: bacteria &
viruses
Cytomegalovirus
Epstein-Barr
Data not strong
enough to conclude
causal relation
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CTCL Pathophysiology
Multiple abnormalities in cytokine expression,
chemokine expression and antigen presentation
Malignant CD4+ T cells release cytokines,
causing proliferation of keratinocytes
Causes scaling, thickening of epidermis, and
pruritus
Cytokines, including IL4, contribute to
immunosuppression
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Mycosis Fungoides (MF)
Months to years diagnosed with
psoriasis, nummular eczema,
parapsoriasis
Stages:
Patch: Varying shades of red,
scaling and non -scaling
Plaque: Round, oval or bizarre
shapes, randomly distributed,
often non-exposed
Tumor: Nodules, tumors, with
& without ulceration; palmar
hyperkeratosis, hair loss
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MF Work-up
Repeated and multiple
biopsies
CBC with smear
Chest X-ray
Lymph node biopsy
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Symptomatic, extent of disease
Topical corticosteroids
Nitrogen Mustard
Carmustine
Phototherapy
Radiation
MF Treatment
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Sèzary Syndrome (SS)
Leukemic from of MF
Universal erythroderma
Lymphadenopathy
Cellular infiltrates of atypical
lymphocytes (Sèzary cells) in
skin and blood
Pts. appear sick, shivering,
scared, generalized scaling
erythroderma and thickening of
skin; diffuse hair loss,
generalized lymphadenopathy
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SS Management
Same as MF
Supportive measures for erythroderma
Without treatment, disease is progressive
Patients die from opportunistic
infections
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Sweet Syndrome
• Acute febrile neutrophilic
dermatosis
• Associated with inflammatory
bowel diseases
• Ulcerative colitis
• Crohn disease
• Autoimmune syndromes
• Hashimoto thyroiditis
• Sjörgren syndrome
• Intestinal bypass surgery
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Pathophysiology
• Hypersensitivity reaction
• Infection
• Tumor antigen, drug
• Lesions in upper dermis
• Vesicular or bullous
appearance
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Subtypes
• Idiopathic
• Women 30-60 years of age
• URI, IBD (Crohn,
ulcerative colitis), or
pregnancy
• Patients ill, fever, physical
distress
• Malignancy-associated
• Males:females equal
• Solid tumor of breast, GU,
GI systems
• Leukemia, lymphoma
• Drug induced
• Isotretinoin
• OCP
• Trimethoprim/sulfamethox
azole
• Furosemide
• Minocycline, doxycycline
• Lesions appear 1 week-1 month
after administration and
resolve after drug stopped
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Clinical Presentation
• Painful, erythematous papules
• May be vesicles or bullae
• Dorsum of hands, face, neck, trunk
• Sudden onset fever, abdominal pain,
malaise, joint pain, headache,
conjunctivitis, pregnancy
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Differential
• Pyoderma gangrenosum
• Bullous disease
• Erythema multiforme
• Bowel-associated dermatosis
• Bechet disease
• Erythema nodosum
• Drug eruption
• Urticaria
• Cellulitis
• Paraneoplastic syndrome
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Diagnostics
• Biopsy
• Labs:
• CBC/Diff: WBC’s, neutrophilia
ESR, alkaline phosphatase
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Management
• Systemic steroids
• Anti-inflammatory antibiotics
(Tetracycline class)
• Off-label dapsone
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Dermatomyositis
Violaceous inflammatory
changes of eyelids and
periorbital areas (heliotrope)
Variable edema
Violaceous flat-topped papules
over knuckles (Gottron papule)
Erythema of face, neck, upper
trunk
Myositis, muscle weakness,
dysphagia, burning and
pruritus of entire scalp
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Dermatomyositis Etiology
Cutaneous involvement: 30-40% of adults;
95% of children
Male=Female
Over 50 years higher risk for collagen
vascular disease and malignancy: ovarian,
breast, bronchopulmonary, GI
Juvenile: associated with vasculitis and
calcinosis
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Dermatomyositis Diagnosis
Serum muscle enzymes, AST, ALT, ANA, urinary
creatine
MRI of muscles: focal lesions
ECG myocarditis, atrial ventricular irritability,
atrioventricular block
X-ray: Chest ± interstitial fibrosis. Esophagus:
reduced peristalsis
Muscle biopsy: muscle fiber and capillary damage
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Dermatomyositis Management
Prednisone. Taper when muscle enzyme
levels approach normal. Best combined
with azathioprine
Alternatives: MTX, cyclophosphamide,
cyclosporine, TNF agents
Physical therapy, rest
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Neurofibromatosis
Autosomal dominant
NF1: von Recklinghausen
Diagnostic sign: Lisch
nodules
NF2: bilateral acoustic
neuroma
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Differential Diagnosis
Brown Cafe′Au Lait lesions
(CAL)
McCune-Albright syndrome
2of 3: polyostotic fibrous
dysplasia, cafe′au lait
pigmentation, autonomous
endocrine hyperfunction
10-20% of normal
population have few CAL
macules (<3)
pvernon2012
pvernon2012
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Two of the following criteria:
Multiple CAL macules: >6 w/1.5cm diameter
adults; >5 macules w/0.5cm diameter children
<5 years
Multiple freckles in axillary and inguinal areas
2/more neurofibromas of any type or 1
plexiform neurofibroma
Sphenoid wing dysplasia; congenital bowing or
thinning of long bone cortex w/wo
pseudoarthrosis
Bilateral optic nerve gliomas
2/more Lisch nodules on slit lamp
First degree relative with NF1pvernon2012
pvernon2012
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Epidemiology
NF1: 1:4000
NF2: 1:50,000
All races
Males slightly more
than females
Autosomal dominant
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Co-Management
Orthopedics: kyphoscoliosis and tibial bowing
Plastics: reconstructive surgery on facial asymmetry
Psychology: language disorders and learning
disabilities
Opthalmology: Lisch nodules
Neurology: Optic glioma, acoustic neuromoma,
neurofibrosarcoma
Genetic counseling
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Diabetes Mellitus
Acanthosis Nigricans
Necrobiosis Lipoidica
Peripheral Neuropathy
Peripheral Vascular Disease
Scleredema Diabeticorum
Diabetic Dermopathy
Diabetic Bullae
Eruptive Xanthoma
Infection: Furuncles,
paronychia, cellulitis,
dermatophytoses
Candidiasis
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Diabetic Bullae
Large intact bullae
Arise spontaneously on
legs, feet, dorsa of hands
and fingers
Rupture→oozing bright
red erosions,heal after
several weeks
Trauma or immunologic
mechanism has been
indicated
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Acanthosis Nigricans
Associated with insulin resistance in
DM
Brown→Black velvety
hyperpigmentation
Usually in body folds: posterior and
lateral folds of the neck, axillae,
groin, umbilicus
Prominent feature of obesity,
polycystic ovary syndrome, Donohue
syndrome, Rabson-Mendenhall
syndrome
Medications: glucocorticoids, niacin,
insulin, OCP, protease inhibitors
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Necrobiosis Lipoidica
Erythematous papules
over pretibial areas
Well-demarcated atrophic
yellow→red brown
Female:Male 3:1
Severity not related to
severity of diabetes
Control of diabetes has no
effect on course of NLD
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NLD Differential Diagnosis
Granuloma Annulare
Morphea
Stasis dermatitis
Cellulitis
Sarcoidosis, lichen sclerosis
tertiary syphilis
Hansen’s disease
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NLD Treatment
Intralesional steroid injections
Tretinoin
Topical steroids
Laser
Topical PUVA
Less common: cyclosporin, excision, skin
grafting
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Scleredema Diabeticorum
Onset correlates with
duration of diabetes and
presence of microangiopathy
Poorly demarcated
scleroderma-like induration
of skin and subcutaneous
tissue of upper back, neck,
proximal extremities
2.5-14% of patients with
diabetes
Rapid onset and progression
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Treatment
PUVA
UVA
UVB
Corticosteroids
Chemotherapy, radiation
Physiotherapy
Tight glycemic control
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Diabetic Dermopathy
Circumscribed atrophic
depressed lesions on lower legs
Arise in crops, gradually resolve
4/more lesions almost always
limited to patients with diabetes
Accompanied by
microangiopathy
Asymptomatic
No treatment necessary
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Eruptive Xanthoma
Discrete inflammatory
papules
Erupt suddenly in showers
Buttocks, elbows, lower
arms, knees
Dome-shaped, red→yellow
center with red halo
Resolve with low-calorie
low-fat diet
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Pyoderma Gangrenosum
• Rapidly evolving, idiopathic,
chronic
• Most commonly associated
with chronic ulcerative colitis
• Less common: arthritis,
hematologic dyscrasias,
malignancy; rarely
occurs alone
• Irregular, boggy ulcers with
undermined borders
surrounding purulent
necrotic bases
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Epidemiology
• Rare, unknown prevalence
• All age groups, peak between 40-60
years
• Slight preponderance in females
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Pathogenesis
• No microbiological etiology
• Neutrophilic dermatosis: massive
neutrophilic infiltrates within the skin
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Clinical Manifestation
• Acute: Painful hemorrhagic pustule or
nodule de novo or after minimal trauma
• Chronic: Slow progression, less painful,
with granulation and hyperkeratosis
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Skin Lesions
• Acute
• Superficial hemorrhagic pustule
surrounded by erythematous
halo
• Very painful
• Ulcer borders dusky-red,
purple, irregular, boggy
• Base is purulent, necrotic
• Pustules at advancing border
and base of lesion
• Halo of erythema spreads
centrifugally
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Skin Lesions
• Chronic
• Lesions slowly progress
• Large areas of the body
• Massive granulation within
ulcer
• Lesions usually solitary
• Lower extremities, buttocks,
abdomen
• Healing ulcers results in thin
atrophic cribriform scars
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Associated Systemic Disease
• Up to 50% occur without associated
disease
• Large and small bowel disease: Crohn
disease, ulcerative colitis, diverticulosis,
arthritis, leukemia, chronic hepatitis,
Behcet syndrome
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Treatment
• Treat underlying disease
oral/IV glucocorticoid steroids
Sulfasalazine
Sulfones
Cyclosporine
Biologics: infliximab, etanercept, adalimumab
Topical: tacrolimus ointment, intralesional
triamcinalone
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Vasculitis
Giant Cell Arteritis
Hypersensitivity Vasculitis
Nodular Vasculitis
Polyarteritis Nodosa
Urticarial Vasculitis
Wegener Granulomatosis
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Hypersensitivity Vasculitis
Hypersensitivity to antigens from
infectious agents, drugs,
exogenous/endogenous
Palpable Purpura primarily
lower legs
Lesions do not blanch
Systemic: kidney, muscles, joints,
GI tract, peripheral nerves
All ages
Male:Female equal
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Etiology
Infecitons
Hep B Hep C
Group A Strep
Staph Aureus
Mycobacterium leprae
Neoplasms
CA Kidney
SLE
RA
Sjögren
Drugs
Sulfonamides
Penicillin
Dysprotenemias
Cryoglobulinemia
Paraproteinemia
Hypergammaglobulinemia
congenital deficiencies of complement
°Idiopathic
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Hypersensitivity Vasculitis Management
Antibiotics for bacterial infection
Prednisone for moderate/severe disease
Immunosuppressives:
Cyclophosphamide, azathioprine in
combination with prednisone,
Cyclosporine, IV immunoglobulin
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Polyarteritis Nodsosa
Multisystem necrotizing
vasculitis
Small and Medium muscular
arteries
Involvement of renal and
visceral arteries
Mean age 45 years
Male:Female 2.5:1
Etiology unknown
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Polyarteritis Nodosa
Chronic:
Cardio: CHF, MI, hypertension, pericarditis
Neuro: CVA, mixed motor/sensory involvement
Muscles: diffuse myalgias
GI: n/v, abd. pain, hemorrhage, infarction
Eyes: ocular vasculitis, retinal artery aneurysm, optic
disc edema/atrophy
Kidneys: renal failure, edema
Testes: pain, tenderness
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Polyarteritis Nodosa
Skin:
15% of all cases
Bright red→bluish nodules
follow course of involved
arteries
bilateral lower legs, thighs
duration: days to months
resolve with residual violaceous
PIH
lesions in systemic and
cutaneous: identical
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Polyarteritis Nodosa
Course and Prognosis:
Untreated: high morbidity and mortality
Cutaneous: chronic, relapsing, benign course
Management:
Systemic
Prednisone 1 mg/kg/day
Cyclophosphamide 2 mg/kg/day
Cutaneous
Nonsteroidal anti-inflammatory agents
Prednisone
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Henoch-Schonlein Purpura
Hypersensitivity vasculitis: mainly in
children
History: URI, 75% group A Strep
Palpable purpura
Bowel angina: abdominal pain worse after
meals
Bowel ischemia, bloody diarrhea
Kidney: hematuria
Artiritis
5% long-term morbidity, renal disease
pvernon2012
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Henoch-Schonlein Treatment
Bed rest, supportive care
Appropriate antibiotics
Serial UA
Corticosteroids
debatable: helpful for
short periods with GI
complications or chronic
glomerulonephritis ©pvernon2012
©
pvernon2012
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Kawasaki Disease
85% < 10 years
50% < 2 1/2 years
Triphasic
Acute period
Subacute period
Convalescent period
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Kawasaki Disease
Acute febrile period
∼ 12 days
Abrupt onset of fever
Subacute period
∼ 30 days
Resolution of fever, thrombosytosis,
desquamation
Highst risk of sudden death
Convalescent period
8-10 weeks after illness
Signs of illness disappeared, ends when SED rate
normal
Small number of deaths in this period
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Kawasaki Disease Management
Most important: diagnosis,
prevention of coronary
aneurysm and MI
Repeated echocardiogram,
EKG, Lab evaluation
IV gamma globulin
ASA
Corticosteroids
contraindicated: increase risk
of coronary artery aneurysm
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Kawasaki Disease Diagnosis
Five of Six Criteria:
Fever lasting at least 5 days
Four of following features:
Changes in peripheral extremities: acute
erythema and edema of hands and feet,
convalescent desquamation of fingertips
Polymorphous exanthem
Bilateral painless bulbar conjunctival
injection without exudate
Changes in lips and oral cavity
(erythema, cracking lips, strawberry
tongue, diffuse injection or oral and
pharyngeal mucosa
Acute nonpurulent cervical adenopathy,
usually unilateral
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Wegener GranulomatosisGranulomatosis with Polyangitis
Ulcers resemble pyoderma
gangrenosum
Papules, vesicles, palpable
purpura
Most common on lower
extremities
Oral ulcers, gingival
hyperplasia
Nasal mucosal ulcers,crusting,
nasal septal perforation,
saddle-nose deformity
pvernon2012
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Systemic Symptoms
Fever, paranasal sinus pain, purulent or bloody
nasal discharge
Cough, hemoptysis, dyspnea, discomfort
External auditory canal pain, OM, mild
conjunctivitis, scleritis, granulomatous
sclerouveitis, ciliary vessel vasculitis
Cranial neuritis, cerebral vasculitis
Renal failure in advanced disease 85%
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Differential Diagnosis
Other vasculitides
Goodpasture syndrome
Tumors of the upper airway and lung
Infectious/noninfectious granulomatous
disease (blastomycosis)
Lymphoma
Allergic granulomatosis
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Etiology
Any age, mean age 40
Equal male:female
ratio
Rare in blacks
Unknown etiology
©pvernon2012
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Laboratory
Mild anemia, Leukocytosis,± thrombocytosis
ESR markedly elevated
Impaired renal function
Proteinuria, hematuria, RC casts
Antineutrophil cytosplasmic autoantibodies (ANCA) are
seromarkers
Cytoplasmic pattern (c-ANCA)
Perinuclear pattern (p-ANCA)
Titers correlate with disease activity
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Pathology
Necrotizing vasculitis of small
arteries/veins, granuloma formation
Kidneys: glomerulonephritis
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Imaging
Paranasal sinuses: opacification with or
without sclerosis
Chest: pulmonary infiltrates, nodules;
consolidation upper lobes
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Management
Cyclophosphamide: 2mg/kg/day. Dose adjusted for
leukocyte 5000/µL (neutrophil count 1500/µL). Therapy 1
year after complete remission
Alternative: azathioprine if cyclophosphamide not
tolerated
Presnisone: 1 mg/kg/day x 1 month, tapered to alternate
day doses x 6 months
Rituximab: refractory patients
Trimethoprim-Sulfamethoxazole: prevent upper airway
bacterial infections; adjunctive therapy
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Prognosis
Untreated fatal due to renal failure
Cyclophosphamide and prednisone
therapy gives long-term remission in
95%
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References
Bobonich, M. Nolen, M. Dermatology for Advanced Practice Cliicians. Wolters Kluwer, 2015. First Edition
Bolognia, Jean L., et al. Dermatology. Mosby, 2003.
Booher, Susan, et al. Cutaneous T-Cell Lymphoma: Mycosis Fungoides/Sèzary Syndrome. Journal of the Dermatology Nurses’ Association: 3 (18-32) 2011.
Goodhearts, Herbert P. Goodheart’s Photoguide to Common Skin Disorders, Third Edition,Lippincott Williams & Wilkins 2009.
Habif, Thomas. Clinical Dermatology. Fourth Edition, Mosby, 2004.
Schachner, Lawrence A. & Hansen, Ronald C. Pediatric Dermatology, Third Edition, Mosby, 2003
Wolff, Klaus et al. Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology, Sixth Edition, McGraw-Hill, 200
Jordan, G, Ryan, G., Wegener’s Granulomatosis. Advance for NP’s & PA’s. December, 2011.
Vernon, P. ,Neurofibromatosis: An Elephant by Another Name. Journal of Pediatric Healthcare. 4( 244-246), 2000.