pemphigous patient treatment

1. Integrated
seminar
pemphigus foliaceus
DEPARTMENT OF DERMATOLOGY

2.  Male patient
 32 years
 Resident of Giddarbaha
 Patient was admitted in pulmonary medicine ward ,AIMSR, Bathinda
with complaints of cough, chest pain and shortness of breath for 2
days.
 Then a referral was sent to our department for skin complaints.

3.  Patient presented with chief complaints of erythematous,
itchy erosive skin lesions on scalp, face, behind ears, trunk
and palms since 5 years.
 Scaling and crusting of skin – scalp,face and trunk.
 Ulcerative Skin lesions - axillae and groins since 1 year.
 Dystrophy of nails of both hands since 1.5year.

4.  5 years back, patient noticed a skin lesion -started on scalp
- single, on lateral side of scalp.
 Within 1 year - lesions progressed to involve the entire
scalp, forehead, retro auricular areas, nose, cheeks, chest,
axillae and groins.
 The patient took treatment from multiple local practitioners
of which no documentation is present right now.

5.  Took treatment on lines of Pityriasis rubra pilaris in last year which
include oral retinoids for few months.
 He had three episodes of pneumothorax in last 6 months because of
which there was interruption in regular medication for skin lesions.
 There used to be temporary relief but he was never completely free of
skin lesions in last 5 years.

6. Past history:
 Patient is non- hypertensive, non-diabetic.
 No history of asthma, tuberculosis and epilepsy.
Personal history:
 Vegetarian , unmarried.
 Occasional drinker and non-smoker.
 M.A. B.Ed. - English teacher.
Family history:
 No significant history of similar skin complaints,hypertension, diabetes mellitus , tuberculosis ,
asthma in other members of family.

7. General physical examination: He was calm, conscious,
cooperative, well oriented to time, place and person.
Weight= 52 kg, Height- 172 cm, BMI= 17.6 kg/m2
Thin built and poorly nourished.
Icterus: present in sclera of both eyes.
No Pallor
No Cyanosis
No Clubbing
No Lymphadenopathy

8. VITALS:
Afebrile
Pulse rate:96 bpm
Respiratory rate: 15/min
BP:110/70 mm Hg
Systemic examination:
CVS: S1, S2 heard. No murmurs.
Respiratory system: Decreased breath sounds on left side, normal vesicular
sounds on right side.
Per abdomen: Soft, non-tender,no scar mark visible. Hepatomegaly was
present.Normal bowel sounds.

9. MUCOCUTANEOUS EXAMINATION

10.  Multiple scaly papules
associated with crusting.

11.  Ulceration -both axillae.
 Movements -restricted
RIGHT AXILLA
LEFT AXILLA

12. RIGHT GROIN LEFT GROIN

13. Onycholysis
Elkonyxis
Periungal erythema

14. Scaly plaques
Yellowish discoloration

15.  Yellow discoloration was
present in the buccal mucosa.

16. MANAGEMENT
INVESTIGATIONS
 Complete blood count
 Renal function test
 Liver function test
 Tzanck smear:-upper right side of chest
 Skin biopsy:-left side of abdomen

17. Complete blood count-
 TLC- 15200/cumm
 Hb- 14.3 gm/dl
 Platelet count- 5.32 lakhs/cumm
RBS- 94 mg/dl
Liver function test-
 SGOT- 113 IU/L
 SGPT- 89 IU/L
 Total bilirubin-7.1 mg/dl
 ALP- 786 U/L
Renal function test-
 Blood urea- 23 mg/dl
 S. creatinine- 1.0 mg/dl
CRP-85.2 mg/L
INR-2.64

18. Tzanck smear
 SITE:- Upper right side of chest
 Microscopic examination:-smears studied shows
dense acute inflammatory infiltrate along with
many acantholytic cells.
 IMPRESSION:-Cytomorphological features are
suggestive of vesiculobullous lesions.

19. Skin biopsy finding
 Site- left side of abdomen
 Microscopic examination- sections studied show keratinized,
stratified, squamous epidermal lining exhibiting focal subcorneal
split. There is seen infiltration by acute inflammatory infiltrate along
with occasional acantholytic keratinocyte. The dermis show
collagenization and unremarkable skin appendages.
 Impression- histomorphological features are supportive of
Pemphigus Foliaceus.

20. TREATMENT
 Oral steroids-Tab. Prednisolone 30 mg/day
 Mid potent topical steroids for scalp,face ,trunk and hand
lesions.
 Emollients.
 Aseptic dressing with topical antibiotics on axillae and
groins ulcers.
 Vitamin C supplementation.

21.  The lesions on scalp , face and trunk are resolved.
 Ulcers in the axillae and groins are healing.
 Patient is still under our follow up.