Skin problems in rheumatology

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Skin problems in rheumatology

• Beverley Harrison
• Consultant Rheumatologist
• North Manchester General Hospital

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Terminology
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• Macule
• Flat lesion
• Papule
• Raised lesion lt 1cm diam
• Nodule
• Raised lesion gt 1cm diam
• Vesicle
• Fluid-filled lesion lt 0.5 cm diam
• Bulla
• Fluid-filled lesion gt 0.5cm diam

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Petechia / purpura

• Due to platelet disorders with leakage of RBC
  from blood vessels where platelet plugs are the
  major source of coagulation
• Eg. Thrombocytopenia
• Petechia
• Intra-dermal haemorrhage lt 0.3cm diam
• Purpura
• Intra-dermal haemorrhage gt 0.3cm diam ( vascular
  inflammation with increased blood vessel
  permeability)

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Seronegative spondylarthropathies (SpA)
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• Seronegative RF neg
• Spondyl. spinal inflammation
• Often HLA-B27 positive
• Ankylosing spondylitis

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Psoriatic arthritis (PsA)
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PsA

• Psoriasis affects 1-3 UK population
• Up to 1/3 develop arthritis
• Sacro-iliitis
• Asymmetrical large joint arthritis
• DIPJ arthritis

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Plaque psoriasis

• Type I age lt 40 yrs 85 HLA-Cw6
• Type II age gt 40 yrs
• Extensor surfaces
• Inverse psoriasis scalp, axillae, umbilicus,
  perineum
• Triggers
• Infection
• Skin trauma (Koebner)
• Drugs
• stress

Sharply demarcated Silvery scale
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Guttate psoriasis

• Triggered by streptococcal infection

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Nail changes

• In 30 pts with psoriasis 70 pts with PsA
• Pitting
• Ridging
• Onycholysis
• hyperkeratosis

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DIPJ arthritis
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Dactylitis
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Reactive arthritis
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• Incidence 3-4 / 10 000 / year
• Young adults
• M gt F
• Triggered by infection
• STD (chlamydia)
• Enteritis (salmonella, shigella)

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Asymmetrical large joint oligoarthritis
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Keratoderma blenorrhagica
Identical to pustular psoriasis
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Circinate balanitis
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Connective tissue diseases
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Raynauds phenomenon
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• White / blue / red
• Primary
• 15 popn.
• Onset in teenage years
• Secondary
• Esp. limited cutaneous systemic sclerosis
• 95 pts have positive ANA or abnormal nail fold
  capillaries

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Nail fold capillaries
Opthalmoscope 20 d
Nail fold hyperaemia
Dilated, tortuous loops
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Nail fold microscopy
normal
Drop-out
Dilated loops
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Digital pitting
Usually systemic sclerosis
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SLE
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SLE

• Auto-immune disease with immune complex formation
  tissue destruction
• Prevalence 0.2 / 1 000
• 9F M
• ANA positive in 20 normals (95 SLE)
• ds-DNA specific for SLE

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Acute cutaneous lupus

• Malar (butterfly) rash
• 50 patients
• Itchy / painful
• Lasts hours weeks
• May reflect disease activity

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Photosensitivity

• 50 patients
• Sunlight also exacerbates systemic disease
• Need total sun block

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Lupus band test (skin biopsy)
Deposition of Ig and complement at
dermo-epidermal junction
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Discoid lupus

• Can occur alone or with systemic lupus
• Papules / plaques with scaling on cheeks other
  photosensitive areas

• Central hypopigmentation
• Follicular plugging
• Atrophy scarring
• Permanent alopecia

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Alopecia

• Patchy or diffuse
• May reflect disease activity
• Non-scarring
• lupus hairs on forehead

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Non-specific features of SLE
vasculitis
Mouth ulcers
Livedo reticularis
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Systemic sclerosis
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SSc

• Auto-immune disease characterised by vascular
  fibrosis collagen deposition in skin and organs
• Prevalence 0.2 / 1 000
• 4F M
• Anti-centromere antibodies and anti-scl 70

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• Limited cutaneous SSc
• Commonest form
• Skin involvement on face and distal to elbows and
  knees
• Includes CREST (calcinosis, raynauds, esophageal,
  sclerodactyly, telangiectasia)
• Diffuse cutaneous systemic sclerosis
• High risk of internal organ involvement (heart,
  kidneys, lungs)

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Hand involvement
Puffy hands
Pitting / ulcer
Digital loss
scerodactyly
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Facial involvement
Pinched (beak) nose
mauskopf
Pseudo-rhagades
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telangiectasiae
Esp. CREST
Mat telangiectasiae flat, up to 7mm diam.
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Diffuse SSc
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Dermatomyositis
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• Rare inflammatory disorders of skeletal muscle
• Proximal muscle weakness and high CPK
• Polymyositis and dermatomyositis

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Heliotrope rash
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Rash on extensor surfaces
Gottrons papules
shawl sign
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Mechanics hands
calcinosis
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Vasculitis
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(No Transcript)
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venulitis

• Legs, buttocks (increased orthostatic pressure)
• Triggers
• Chronic bacterial infection
• Hep B
• Drugs
• RA / CTD
• HSP
• Good prognosis

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Necrotising arteritis
Irregular purpura
livedo
nodules
infarction
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Erythema nodosum

• Panniculitis
• Red/violet tender sc nodules up to 5cm diam
• Esp. in pre-tibial area
• Often assoc. with arthritis or arthralgia
• Self-limiting (6 weeks)

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Causes of EN

• Infection
• Streptococcal
• TB
• Drugs
• OCP
• Sulphonamides
• Pregnancy
• IBD

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Acute sarcoidosis

• EN
• Arthritis
• Iritis
• Bilateral hilar lymphadenopathy

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The end