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Skin problems in rheumatology Differential diagnoses: these reflect the LE subtype. The facial
Many autoimmune systemic conditions, for example lupus rash in SLE can be mistaken for acne rosacea, seborrhoeic
erythematosus (LE), dermatomyositis (DM) and scleroderma, dermatitis, erysipelas or DM. Psoriasis and eczema should be
have skin manifestations. Other rheumatological conditions, considered with SCL, and granuloma faciale, sarcoidosis and
such as rheumatoid arthritis (nodules), cutaneous vasculitis, cutaneous infections including tuberculosis with DLE.
panniculitis and pyoderma gangrenosum (PG), also demon-
strate skin changes. Treatment: management of SLE can require systemic immuno-
suppression. Photoprotection is the mainstay of management for
Lupus erythematosus skin manifestations of all LE subtypes. Topical corticosteroids or
LE is a group of chronic inflammatory conditions with skin calcineurin inhibitors can be useful.
involvement. Systemic LE (SLE) affects several systems including
renal, neuropsychiatric, haematological and musculoskeletal. It
usually occurs in female patients aged 15e45, with an incidence Dermatomyositis
of around 6.5 per 100,000 per year in the UK depending on the DM is an idiopathic inflammatory myopathy characterized by
sex and racial group studied. The disease is characterized by skin changes and proximal muscle weakness. Its incidence is
remissions and relapses. Diagnostic criteria help diagnosis.1 The estimated at 2 per 100,000 annually, and it is twice as common in
aetiology is not fully understood, but clinical features may result female patients. Cutaneous changes can precede muscle changes
from antibody production and resulting immune complexes. but are seen in around 60% of patients presenting with muscle
symptoms. The pathogenesis is incompletely understood, but it
is known that myofibres and capillaries are injured by an un-
Ruth C Lamb MBCHB BMedSci (Hons) MRCP UK (Dermatology) is a
known mechanism.
Consultant Dermatologist at St Georges NHS University Hospital
Trust, London, UK. She has a special interest in medical
dermatology. Competing interests: she has undertaken sponsored Skin clinical manifestations: patients are often photosensitive.
lectures and previously sat on an advisory board for Abbvie. Characteristic findings include Gottrons papules (violaceous
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DERMATOLOGY AND GENERAL HEALTH
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DERMATOLOGY AND GENERAL HEALTH
Clinical features: raised painful inflammatory nodules can transplant and rarely in patients without ESRD. A cross-sectional
occur, classically on the anterior shins. study of 242 outpatient haemodialysis patients showed a preva-
lence of 4%.3 The pathogenesis is unclear but it may result from
Investigations: the diagnosis is usually clinical, but biopsy may vascular and soft tissue calcification that produces reduced
demonstrate septal panniculitis. Other investigations, for arteriolar blood flow.
example antistreptolysin O titres, are directed at ruling out un-
derlying causes. Clinical features: these depend on the stage of evolution of the
lesion and range from painful purple nodules to necrotic ulcer-
Treatment: management of the underlying cause, rest, ation with a central black eschar in keeping with thrombosis and
compression hosiery and anti-inflammatory medications can be ischaemia.
required.
Investigations: skin biopsy shows arteriolar calcification and
Pyoderma gangrenosum thrombosis. A blood profile, for example parathyroid hormone
PG associated with IBD is thought to be the second most common concentrations and phosphate, should be performed to examine
skin manifestation of IBD, although it remains rare. It can also be calcium haemostasis.
associated with other medical conditions including haemato-
logical malignancy. PG is a neutrophilic dermatosis, and patho- Differential diagnosis: this includes warfarin necrosis, athero-
genesis can relate to neutrophil dysfunction and systemic sclerosis and cholesterol emboli.
inflammation.
Treatment: management includes wound care, maintenance of
Clinical features: lesions begin as painful pustules or nodules calcium homeostasis and sodium thiosulphate (unlicensed indi-
that ulcerate with a characteristic purple undermined edge cation), although evidence for the latter is scanty. The prognosis
(Figure 2), most commonly on the legs but also around stoma is poor.
sites.
Acquired perforating disorders
Investigations: clinical appearances are characteristic, but swabs These encompass a group of conditions seen in up to 11% of
may reveal coexistent infection. Biopsy is often non-specific or ESRD patients on renal replacement therapy,4 or with diabetes
shows a neutrophilic infiltrate.
Calciphylaxis
This presents with necrosis and ischaemia of the skin in patients
with ESRD on dialysis, in those who have recently had a renal
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DERMATOLOGY AND GENERAL HEALTH
Leser-Tr
elat disorder Multiple rapidly appearing seborrhoeic Gastrointestinal adenocarcinoma
keratoses
Necrolytic migratory erythema Erosions affecting flexural sites Glucagon-secreting tumour of the pancreas
Acanthosis palmaris and acquired Velvety appearance to the palms with ridging Gastric or lung cancer
pachydermatoglyphia (tripe palms)
Erythema gyratum repens Concentric erythematous migrating rings in Bronchial carcinoma
plaques
Acrokeratosis paraneoplastica (Bazex Psoriasiform plaques affecting acral sites Squamous cell carcinoma of the upper
syndrome) including the nose and ears aerodigestive tract, e.g. oesophagus, pharynx
Ectopic Cushings syndrome Generalized hyperpigmentation of skin and Small cell lung carcinoma
mucous membranes, often in addition to other
features of Cushings syndrome
Acanthosis nigricans Velvety, hyperpigmented, thickened flexural Gastric cancer
surfaces
Hypertrichosis lanuginosa Widespread fine hair growth commonly Adenocarcinoma of lung, bowel, breast or
affecting the head and neck kidney
Table 2
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DERMATOLOGY AND GENERAL HEALTH
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DERMATOLOGY AND GENERAL HEALTH
2 Barnes BE, Mawr B. Dermatomyositis and malignancy. A review of 4 Zelger B, Hintner H, Aubock J, et al. Acquired perforating derma-
the literature. Ann Intern Med 1976; 84: 68e76. tosis. Transepidermal elimination of DNA material and possible role
3 Angelis M, Wong LL, Myers SA, et al. Calciphylaxis in patients on of leucocyte in pathogenesis. Arch Dermatol 1991; 127: 695e700.
haemodialysis: a prevalence study. Surgery 1997; 122: 1083e9.
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Descargado para Anonymous User (n/a) en Universidad Nacional Autonoma de Mexico de ClinicalKey.es por Elsevier en octubre 07, 2017.
Para uso personal exclusivamente. No se permiten otros usos sin autorizacin. Copyright 2017. Elsevier Inc. Todos los derechos reservados.