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wahib

Дата: Пятница, 07.11.2008, 02:05 | Сообщение # 1

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What's Your Assessment?

Helen M. Petros, FNP, PA-C

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History

This 32-year-old Asian female presented to the dermatology office complaining of "blisters" on her hands and feet. She stated she had something similar but milder last winter on her feet, which was noted after a week of skiing. The condition seemed to worsen after wearing tightly fitted ski boots. The condition seemed to clear up "on its own" but this fall reoccurred, only much more severely, after a change in jobs. The patient stated that it "felt very uncomfortable and pressure or rubbing made it worse." She tried various over-the-counter modalities, including Bag Balm®, moisturizers, and 1% hydrocortisone cream. She said over the last week the skin has become thickened with painful cracks. She is concerned that the level of discomfort would prevent her from skiing this year. The patient is otherwise healthy, takes no prescription medication, but does smoke one pack of cigarettes daily and has done so for the last 10 years. She believes her mother had a similar condition several years ago. She is also disturbed by the cosmetic appearance, especially on her hands.

Description of Lesions

Crops of sterile pustules appear in groups on the palmoplantar surfaces. The surrounding skin is thickened, scaly, and erythematous. The right, dominant hand is more affected than the left. There are several cracks and fissures noted on both palms and soles as well as several brown-yellow macules. The skin on the scalp, face, torso, and remainder of the extremities is not affected (see Figures 1-4).

Figure 1.Crops of sterile pustules appear in groups on the palmoplantar surfaces.

Figure 2.The surrounding skin is thickened, scaly, and erythematous.

Figure 3.There are several cracks and fissures noted on both palms and soles as well as several brown-yellow macules.

Figure 4.The right, dominant hand is more affected than the left.

Differential Diagnosis

1. Dyshidrotic eczema
2. Impetigo herpetiformis
3. Pustular miliaria
4. Tinea manum and pedis
5. Infected contact dermatitis
6. Palmoplantar pustulosis

Dyshidrotic eczema, also known as pomphylox, presents with extremely pruritic vesicles. These vesicles are clear, tapioca-like, and deep seated and occur in crops often on the palms and sides of the fingers, as well as on the soles of the feet, to a much lesser degree. Pomphylox comes from the Greek word "bubble" while dyshidrotic eczema was derived from the unproven association with sweat gland activity (Fitzpatrick & Aeling, 2001). Erythema is often absent, although patients may complain of a "stinging, prickly" sensation prior to eruption. Patients do not usually experience pain (although fissures may be present) nor are the lesions pustular. Eruptions are often triggered by stress.

Impetigo herpetiformis is a form of generalized pustular psoriasis. It occurs acutely, and is usually severe with accompanying fever. The condition occurs with pregnancy and terminates with delivery although recurring outbreaks can occur with subsequent pregnancies. Lesions present as grouped pustules on an erythematous base occurring in the neck, axilla, and groin.

Pustular miliaria, also known as miliaria pustulosa, presents with superficial and distinct pruritic pustules that are sterile bacteriologically. This condition is seen after dermatoses that block, injure, or destroy sweat ducts. The pustules are independent of the hair follicle and are seen most frequently on flexural surfaces of the extremities, intertriginous areas, and scrotum.

Tinea manum and pedis are fungal infections or dermatophytoses caused primarily by T. rubrum. Lesions appear as small, clear vesicles which are usually intensely pruritic. Most often, lesions are seen symmetrically on the hands, but eruption may be unilateral. Dermatophytid of the hands may be associated with tinea of the feet, usually involving dorsa and sides. There is erythema, scaling, fissuring, and often interdigital maceration present.

Infected contact dermatitis can occur with either irritant or allergic contact dermatitis. These dermatoses cause cutaneous inflammation after exposure of an external agent to the skin. Secondary infections are most often seen with Staphylococcus aureus or group A streptococcus.

Palmoplantar pustulosis (PPP) is the correct answer. This condition is also known as localized pustular psoriasis or pustular psoriasis of the extremities. This chronic condition is seen on the central portion of the palms and soles or thenar or hypothenar eminences. Lesions begin as areas of erythema and progress to pinhead-sized creamy yellow deep-seated pustules. These then coalesce and enlarge to form small lakes of pus. These eventually form dusky red crusts and scaly macules. The surrounding skin is smooth, pink, and tender. Although limited to palms and soles, lesions can be seen on an isolated palm or sole or both hands and feet. This relapsing course of exacerbations and periods of quiescence is seen more often in women and can persist for years. A recent study of 216 patients with PPP revealed that 80% were smokers at disease onset and had 7.2 times the risk of developing PPP compared to non-smokers (Behnam, Behnam, & Koo, 2005). Difficult to treat, patients often need a combination of therapies, including topical corticosteroids under occlusion, topical retinoids, topical calcipotriene, acetretin, low-dose cyclo sporine, dapsone, colchicines, tetracycline, or psoralens and ultraviolet radiation (PUVA). Topical treatments are generally less effective.

Measures

It is important to rule out dermatophytosis when diagnosing this condition. A KOH preparation should be performed along with bacterial and viral cultures to rule out Staphylococcus aureus infection and HSV infection, especially if lesions are localized to one site.
As with any chronic disease, with relapses and cosmetic disfigurement, be aware of any psychological or emotional changes in patients that may herald the onset of depression. Reassure patients that more times than not a series of treatments (trial and error) may be needed to find a treatment that will work for them. Prolonged walking can trigger exacerbations and manual injuries to hands can do likewise. In some cases, patients may need to be referred for career counseling if their occupations are inadvisable with prolonged involvement refractory to treatments.

Patient Education

Because comfort is often affected, proper protection to the extremities is warranted. Counsel patients in using footwear, for example, that does not cause pressure, friction, or rubbing. These can worsen the condition. Comfortable footwear made of natural fibers is preferable. Deep fissures can be covered with waterproof dressings, while thick emollients can help soften skin to prevent fissures.
When patients use topical corticosteroids under occlusion, it is important to stress that although long-term occlusion may often bring beneficial results, steroid rebound flaring and/or steroid atrophy can occur. Similarly, in those patients being treated with PUVA, with or without oxsoralens, the risk of blistering burns also exists.
All oral medications (acetretin, methotrexate, etc.) must be monitored carefully with blood work to assess potential serious side effects.
Finally, although the connection between smoking and the pathogenesis of PPP remains unclear, the connection does exist. This would be an appropriate and opportunistic time to educate patients regarding the dangers of smoking for this and other illnesses and diseases.

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Дата: Пятница, 07.11.2008, 02:09 | Сообщение # 2