Eczema and Dermatitis, Are they the same?

Both these conditions are the same, but doctors usually don’t use the word dermatitis in most of the time, because for patients it means an industrial cause. This can lead to many unnecessary litigation and compensation.

Scaly skin lesion? Psoriasis?

Eczema and Dermatitis, Are they the same?

Both these conditions are the same, but doctors usually don’t use the word dermatitis in most of the time, because for patients it means an industrial cause. This can lead to many unnecessary litigation and compensation.

Is Psoriasis Infective

Psoriasis is a skin disease which produces unsightly lesions. Due to that it’s anybody’s nature to stay as far as from a person with psoriasis, because they look infectious.  But it is not infective! People with psoriasis find it very uncomfortable to go into the society due to embarrassment.  But this should not happen because they are not infective.

On the other hand medical staff should touch these lesions and inspect them without hesitancy. It helps develop a rapport with the patient and lead to good doctor patient relationship.

How to identify Psoriasis

Scally Skin Lesion?Psoriasis

Definition – A chronic non-inflammatory dermatosis characterized by well demarcated erythematous plaques topped with silvery scales. 

Do any of your parents have Psoriasis? Then can you get it too?

There is a well known genetic predisposition to psoriasis. So, if you have psoriasis, yes, you can get it too. If your mother or father has psoriasis, then there is a 25% chance for you to get it too. Studies have been done all over the world and they have found that there is 73% concordance of the disease among identical twins. It means that there is a strong genetic predisposition. 

What happens in Psoriasis?

In psoriasis, there is abnormal proliferation of the cells of the skin. Not only that, the keratinization is also defective. These results in abnormal skin lesions.

How to identify psoriasis

Psoriasis can be identified by the characteristics of the lesions and their distribution. The lesions can range from chronic plaques on the elbows to the acute generalized pustular form. But still it can be confused with several other diseases because they show the same lesion pattern.

·         Psoriasiform drug eruptions

·         Hyperkeratotic eczema

·         Reiter’s disease

·         Seborrhoeic dermatitis (scalp)

·         Pityriasis rosea

·         Candidiasis of flexures (on flexures)

·         Fungal infections of the nails (nails)

The usual presentation patterns of Psoriasis

·         Plaque –red plaques (ranging up to several centimeters) covered by waxy whitish scales on knees and elbows. If you remove these scales, it can bleed. These lesions sometimes can be pruritic.

·         Guttate – In this form there are symmetrical, drops like lesions over the trunk and the limbs. These lesions usually occur in adolescents and young adults following streptococcal throat infections.

·         Flexural – These lesions are found in axillae, submamary areas and natal clefts of elderly people.

·         Localized forms – yellow to brown colour sterile pustules on the palms or soles. Commonly seen in middle aged females. Or it could present in nails, scalp or nappy areas. Psoriasis in the scalp can be confused with dandruff, but can be differentiated by its well demarked and more thickly scaled nature.

·         Generalized pustular – small sterile yellowish pustules are seen all over the body. This is very rare but can be life threatening. The disease starts rapidly and the patient will have fever and malaise. This form requires hospital admission.

·         Nail involvement – thimble pitting, onycholysis (separation of the distal edge of the nail from the nail bed), oily or salmon pink discoloration of the nail and building up of keratin under the distal nail edge..

·         erythroderma

The Psoriatic condition may be complicated by arthropathy, erythroderma and Koebner phenomenon.

Treatment

Psoriasis is a condition which needs long term treatment. Treatment of psoriasis includes tropical therapy, systemic therapy..

·         Tropical therapy

o   Vitamin D analogues – These inhibit cell proliferation and stimulate keratinocyte differentiation.These preparations are well tolerated by patients as they do not have any bad smell or stain. In comparision to steroids, they do not cause skin atrophy, but they may cause some skin irritation.  E.g:  Dovonex, Curatoderm

o   Topical corticosteroids – These are non irritative compared to vitamin D analogues.

o   Coal tar preparations

o   Dithranol

o   Retinoids

o   Keratolytics and scalp preparations

·         Systemic Therapy

o   Methotrexate

o   Retinoids

o   Ciclosporins

Standard Amount of ointment you should apply on your skin

·         Whole body – 20-30g

·         Adult face or neck – 1g

·         Trunk – 3g each side

·         Arm – 1.5g

·         Hangd– 0.5g

·         Leg – 3g

·         Foot- 1g

 So, you know the amounts, but how are you going to measure them. Measuring 0.5 g is not easy, is it?

How to measure

Don’t worry, it is easy. The amount can be measured by the unit called finger tip unit(FTU). In this measurement, we take the amount of cream or ointment that can be taken to the terminal phalanx of the index finger as one unit. So, 1 FTU equals 0.5g. So if you want to apply 1g, all you have to do is take to FTUs.

Purple Discoloration around the Eyes? Is it Dermatomyositis?

Dermatomyositis is a rare condition in which there is purple discoloration and edema around the eyes. They also have purple raised vasculitic patches on the fingers. They may also have Raynaud phenomenon.

 But, these are not the only main symptoms in dermatomyositis. People who have dermatomyositis also have fatigue, weight loss, fever and malaise and the cardinal feature, progressive, symmetrical proximal muscle weakness. Their pelvic and shoulder muscles become wasted and movements like squatting and climbing stairs become difficult. Usually the face muscles and distal limb muscles are not affected. 

This is a disease common among females. These patients are in a higher risk of developing pulmonary interstitial fibrosis, Raynaud phenomenon, arthritis and hardening and fissuring of skin over the purple surface of the fingers. 

This can be a part of paraneoplastic syndrome, so the patient should be checked for breast, lung ovarian and stomach cancers.  

The disease is treated with physiotherapy, steroids and immunosuppressive therapy.

Related Topics:

Causes of 'Black Eye' 

More in:

The Official Patient's Sourcebook on Dermatomyositis: A Revised and Updated Directory for the Internet Age

Myositis and You: A Guide to Juvenile Dermatomyositis for Patients, Families, and Healthcare Providers

Systemic Lupus Erythematosus

SLE is a multi-organ, multi-systemic autoimmune disease predominant among females. There is high prevalence among black Americans, but its prevalence is low among black Africans.

As it is a multi systemic disease condition, its manifestation can be seen in many organ systems of the body. The symptoms can be categorized as follows.

Mucocutaneous lesions

The characteristic skin rashes are the commonest manifestation of the disease.  They will have the typical malar rash over the butterfly distribution of the face. Apart from that they will presents with,

•  discoid rash
•  urticarial and purpuric rashes
• levido reticularis
• Alopecia (loss of hair) - they may have reversible loss of hair or scaring alopecia in which the hair does not regrow.
• They may have nasal, oral, pharyngeal and laryngeal ulcers
• Raynaud phenomenon and shincter haemorrages are seen on the hands.

 Musculoskeletal diseases

The joints are usually affected and they present with migratory assymmetrical arthralgia. They may have reducible non erosiv ejoint difformity, avascular necrosis and myalgia.

Neuropsychiatric Disease

They may develop headache, fits, psychosis, strokes, aseptic meningitis, peripheral or cranial neuropathies or movement disorders. 

Renal Disease 


The disease can affect the interstitiam, glomeruli or the tubules. It can vary from mild (mild hematuria and proteinuria)  to severe disease (nephrotic syndrome). 

Cardiovascular Disease

Pericardium, myocardium or the endocardium can get affected giving rise to,

1. pericarditis, cardiac tamponade
2. myocardial ischemia (rare)
3. endocarditis
4. congenital heart block in neonatal lupus
5. hypertension

Hematological Disorders 

Alterations of most of the blood consituents occurs giving rise to,

1. neutripenia
2. lymphopenia
3. thrombocytopenia
4. hemolytic anemia
5. thrombotic tendencies
6. bleeding tendencies
7. non tender lymphadenopathy
8. splenomegally

Pulmonary Disease

The pleura, interstitium or the  vasculature can get affected, giving rise to, 

1. pleuricy
2. acute pneumonitis
3. chronic pneumonitis
4. shrinking lung

Gastrointestinal Disorders

 Involvement of the gastrointestinal tract is uncommon, but they may get affected leading to,

1. dyspepsia
2. peptic ulcer disease
3. pancreatitis
4. chronic active hepatitis
5. peritonitis
6. mesenteric vasculitis 

Investigations

• The WBC/DC could be normal or low. 
• High ESR and low C reactive protein ca be used to differentiate SLE from other disorders, but this is also hard as SLE patients are immunosupprsed and more prone to infections, which causes elevated CRP levels.
• High immunoglobulin levels and low complement C4 levels are also seen.
• There could be also Antinucleic antibodies and anti double strant DNA antibodies

Treatment

• Mild SLE is usually traeted with tropical steroids and hydroxychloroquine. They should be also advised to avoid exposure to sunlight.
• Moderate SLE is traeted with systemic steroids - prednisilone or methyl prednisilone or steroidsparing other cytotoxic drugs.
• Cyclophosphamide pulse therapy, azathioprine, methyl prednisilone are given for other organ involvemint.

References:

Kumar and Clark’s Clinical Medicine 7^th Edition

What is Raynaud Phenomenon?

Normally when our body is exposed to called weather, vasoconstriction of the peripheral blood vessels occurs. So the heat loss from the body is minimized. When this reaction is exaggerated, it leads to Raynaud phenomenon. It is classified clinically into primary or secondary forms. Primary disease occurs without any association with other disease or pathology where as secondary disease always has another underlying disease.

Diseases which have Raynaud phenomenon as one of their symptoms

• Scleroderma
• Systemic Lupus Erythematosus
• Other connective tissue disorders
• Hematologic disorders (eg: cryoglobulinaemia)
• Vibration injury
• Endocrine disorders (e.g.: hypothyroidism)
• Some drugs (e.g.: sympathomemetics)

Symptoms and Signs

 Mostly the fingers are affected (mainly middle, index and  ring fingers), but it can also occur in toes and face. Each attack has a characteristic sequence of events.

• Sudden onset of coldness or pallor of digits (white attack)
• Cyanosis (Blue attack)
• Redness from reperfusion

Diagnosis Criteria for Primary Raynaud Phenomenon

• Symmetrical intermittent attacks
• No evidence of peripheral vascular disease can be found
• No tissue gangrene or digital pitting
• Nail fold capillary microscopy is normal
• ANA antibody test is negative and ESR is normal

Treatment

• Preventive strategies
• Vasodilator Therapy
• Nitrates and Other Topical Therapy
• Prostaglandins/Endothelin-Receptor Inhibitors
• Calcium Channel Blockers
• Angiotensin-Converting Enzyme Inhibitors
• Phosphodiesterase Inhibitors
• Sympatholytic Agents
• Sympathectomy
• Selective Serotonin Reuptake Inhibitors
• Anticoagulation

References: Rheumatology Current Diagnosis and Treatment

Hard Skin Lesion? Is it Scleroderma?

Don’t get panic if you also have a similar lesion, because it is a very rare disease with an incidence of 30 cases per 100,000.  It is 4 times commoner in females than in males, so if you are a female, you have a higher chance of getting the disease. People at the age of 30-50 years are affected by this disease.

It can manifest either as localized scleroderma or systemic scleroderma. 

The localized scleroderma can be either linear or morphea, and it only affect the skin.

The systemic disease can be,

1.      Limited
2.      Diffuse
3.     Sine

And it can affect the skin, underlying tissues, and internal organs (heart, lungs, and kidneys).

What are the symptoms?

Initially you may have,

•   musculoskeletal discomfort
•  fatigue
• weight loss 
•   heartburn

The more specific symptoms are referred to as CREST syndrome.

·         Calcinosis

·         Raynaud phenomenon

·         Esophageal reflux

·         Sclerodactily (tightly bound waxy skin on the fingers)

·         Talangiectasias

How to identify a scleroderma skin lesion? 

Thickening or hardening of the skin is the characteristic feature in scleroderma. The area of the body, in which the lesions develop, varies depending on the kind of the disease you have. Those common areas are listed below.

1.      Morphea – face, chest, back, arms, legs

2.      Linear scleroderma – arm, leg, forearm

3.      Limited scleroderma – face, lower arms and legs, hands, fingers

4.      Diffuse scleroderma – face, upper arms, upper legs, hands

·         Course of skin changes in diffuse scleroderma

o   Inflamed fingers – presence of edema and erythema,

o   pigmentory changes are also seen – alternating hyperpigmented and vitiligo like areas slat and pepper appearance)

o   pruritus (itching) in the early phase of the disease

These symptoms may last from weeks to months.

In addition to these, you may have Talangiectasias (dilated capillaries). They occur on the face and palmer surface of the hands. Subcutaneous Calcinosis is also seen along the extensor surface of the forearm and on the fingers.

How the heart is affected

Heart is involved in the late stages of the disease. The disease causes contraction band necrosis and tissue fibrosis, which result in arrhythmias, cardiomiopathy and heart failure. These may manifest as chest pain, palpitation or as dyspnoea on exertion.

How the lungs are affected

The lung involvement may manifest either as interstitial fibrosis or as pulmonary artery hypertension or both. The patient may have dyspnoea on exertion, but this is seen in later stages of the disease. 

How the kidneys are affected

Kidney involvement manifest as sudden onset of malignant hypertension. Earlier, before the drug, angiotensin converting enzyme inhibitors were discovered, renal failure was the cause of death for many scleroderma patients.  Therefore scleroderma patients must have regular blood pressure check ups. These patients may have other symptoms of hypertension such as headache, visual changes or seizures.  

How to diagnose

To diagnose there should be

·         Thickened skin changes proximal to the metacarpophalangial joint

                                   Or two of the following

·         Sclerodactily

·         Digital pitting

·         Bibasilar pulmonary fibrosis

Another way of diagnosing scleroderma is by the presence of 3 of the five features of the crest syndrome.

Presence of Rhaynaud’s phenomenon for longer period indicates limited scleroderma and rapidly progressed Rhaynaud’s phenomenon and other symptoms indicate diffuse scleroderma.

Treatment

Although there is no cure for scleroderma, there are treatment for some of the symptoms of the disease.

•    NSAIDS
•   Immunosuppressant drugs
•   Prostacyclin infusion for digital ulcerations

Urinary Problems: Normal Anatomy and Physiology of Urinary System

There are a lot people all around the world suffering from various kinds of urinary problems. To get an clear idea about how these problems occur, one should have a basic picture of the normal anatomy and physiology of the urinary system.

Urine Culture Positive, But no Urinary Symptom?

This is common finding during elderly, when a urine culture is performed. The report may say that there are bacterial growths in the urine, but the patient may not have any urinary symptom.

In such instances, the best thing to do is DO NOTHING!

UNLESS

·         The patient is pregnant

·         The organism is proteus

·         The patient have severe diabetic mellitus

·         The patient is awaiting any urological procedure  

Symptoms of Urinary Tract Diseases 

Complications of Urinary tract obstruction 

Complications of Urinary tract obstruction

Urinary tract obstruction leads to retention of urine, which leads to following complications.

1. 1.       Acute retention of urine

1. 2.       Chronic retention of urine

1. 3.       Urinary tract infections

1. 4.       Stone Formation

1. 5.       Chronic renal failure.

Symptoms of Urinary Tract Diseases 

Urine culture positive, but no urinary symptoms? 

Symptoms of Urinary Tract Diseases

Do you have the following symptoms? May be you are having a urinary tract disease.

There are many diseases that can affect the urinary tract, but many of them can be identified by the urinary symptoms you have. The disease can be guessed by checking the kind of symptoms you have. I will briefly explain what are those symptoms are.

We divide urinary tract symptoms in to two categories. They are,

1. 1.      Obstructive features

1. 2.      Storage/ irritative features

This categorization is very helpful because some diseases cause obstruction, and thereby lead to urinary retention and some reduce the ability of the bladder to store urine.

The obstructive features are,

1.      

• Poor stream

This means that the projectile nature of the urine flow is low.

• 2.      Intermittent stream

This means that the urine is voided little by little intermittently.  You cannot maintain a steady continues flow of urine.

• 3.      Terminal dribbling

In terminal dribbling you may find some drops of urine flowing drop by drop even after you have finished urination.

• 4.      Hesitancy

In hesitancy you find it difficult to start urination. You really want to pass urine, but find it difficult to initiate urination.

The storage/ irritative features are,

• 1.      Precipitancy

Passing urine without knowing.

• 2.      Recent onset nocturnal enuresis

• 3.      Urgency

The patient cannot hold urination when he feels like wanting to pass urine.

• 4.      Nocturia

Passing urine several times in the night.

• 5.      Frequency

Increased number of times you pass urine.

You may have symptoms from either one of the above two categories or symptoms from both.

Urinary tract obstruction?  What are the Complications? 

Urine culture positive, but no urinary symptoms?