askaderm.net

2. Case 1

3. Cutaneous leishmaniasis

4. Clinical approach
Uncomplicated Vs. complicated infection
The approach to management of CL begins with establishing
the clinical severity of infection.

5. Features of uncomplicated CL include:
●Infection with species not likely to be associated with mucosal
leishmaniasis
●No mucosal involvement
●Single lesion or a few lesions
●Small lesion size (eg, <1 cm)
●Immunocompetent host

6. Features of complicated CL include:
●Infection with species associated with ML; primarily Viannia subgenus
●More than four lesions of significant size (eg, >1 cm)
●Individual lesions ≥5 cm
●Subcutaneous nodules
●Regional adenopathy >1 cm size (somewhat controversial)
●Size or location of lesions for which local treatment is not feasible
●Lesions on face, fingers, toes, or genitalia
●Immunosuppressed host
●Clinical failure of local therapy after two to three months post-treatment

7. Forms of CL that should be managed as complicated infection
with expert consultation include:
●Leishmaniasis recidivans (due to L.L. tropica)
●Disseminated CL (due to L.V. braziliensis)
●Diffuse CL (due to L.L. mexicana or L.L. amazonensis)
●Infections due to L.L. aethiopica

9. DoseDrug
Local therapy
0.5 to 2 mL of 100 mg/mL
pentavalent antimony IL
every 3 to 7 days until healed
(treat up to 3 weeks)
Sodium stibogluconate
Pentavalent antimonials
0.5 to 2 mL of 81 mg/mL
pentavalent antimony IL
every 3 to 7days until healed
(treat up to 3 weeks)
Meglumine antimoniate
Apply topically to lesions BID
for 10 days, rest for 10 days,
then reapply for 10 days
Paromomycin ointment
paromomycin
Apply topically to lesions OD
for 20 days
WR 279396 cream

10. oral systemic therapy
200 mg orally once daily for
six weeks
Fluconazole
Azoles
600 mg orally once daily for
28 days
Ketoconazole
2.5 mg/kg (maximum 150 mg)
PO in three divided doses for
28 days; if weight is 30 to 44
kg, use 50 mg PO BID
MiltefosineMiltefosine

11. Parentral systemic therapy
20 mg SbV/kg/day IV or IM for
10 to 20 days
Sodium stibogluconate
Pentavalent antimonials 20 mg SbV/kg/day IV or IM for
10 to 20 days
Meglumine antimoniate
0.5 to 1 mg/kg IV dosed daily
or every other day for a
cumulative total dose of 15 to
30 mg/kg
Amphotericin B deoxycholate
Amphotericin
3 mg/kg IVdaily for 5 to 7
doses, such as days 1 to 5, 10
Liposomal amphotericin B
(AmBisome)
3 to 4 mg/kg IV or IM every
other day for 4 to 7 doses or
until healed
Pentamidine isethionatePentamidine

12. Cryotherapy
Cyotherapy may be used for infection of recent onset ( < 3/12)
Disease with relatively few and relatively small lesions (<3 cm)
 Nodular lesions
Individuals who cannot use systemic treatment
The efficacy is ↑ when cryotherapy is used in combination with IL
pentavalent antimonials

13. Thermotherapy
 Dermatotrophic leishmaniasis species (L.L. mexicana, L.L. major, and L.L. tropica)
are thermosensitive; their ability to replicate is limited at higher temperatures
Radiofrequency instrument
ThermoMed, has received FDA approval for this purpose
The radiofrequency instrument is portable, battery operated, and delivers
superficial heat to 50°C via a set of prongs placed directly on the lesion.
 The treatment is painful, and local anesthesia is required

14. Injection of up to five sites per lesion with a 25- to 27-gauge needle, for an
estimated dose of 0.1 mL per cm2

15. Intralesional antimony should be
avoided on fingers, nose, ear, eyelid,
and near lip.

17. Photodynamic therapy
PDT destroys tissue by generating reactive oxygen species, which
interfere with normal cell function.
 Treatment consists of administration of a photosensitizing
compound (5-aminolaevulinic acid) that selectively accumulates in the
target tissue, followed by irradiation.
PDT is a relatively new therapy; thus far, it appears promising,
although data are limited.

18. Case 2

21. Lepromatous Leprosy

22. WHO and Ridley-Jopling classification

23. Leprosy should be suspected in the setting of the following symptoms:
●Hypopigmented or reddish patch(es) on the skin
●Diminished sensation or loss of sensation within skin patch(es)
●Paresthesias (tingling or numbness in the hands or feet)
●Painless wounds or burns on the hands or feet
●Lumps or swelling on the earlobes or face
●Tender, enlarged peripheral nerves

24. Immunological reactions
 Immunologic reactions are systemic inflammatory complications
that may occur before treatment ,during treatment, or months to
years after treatment has been completed.
These reactions may affect 30 to 50 percent of all leprosy patients

25. Type 1 reaction
Occurs in patients with BT, BB, or BL disease
A red, swollen patch in preexisting skin lesion on the face or overlying a major nerve
trunk
Erythema and induration of preexisting skin lesions
The inflammation associated with reactions can lead to severe nerve injury with
subsequent paralysis and deformity
Significant edema of the hands or feet, sometimes associated with small joint pain
Ulcerated skin lesions
Loss of nerve function with muscle weakness or loss of sensation

27. Type 2 reaction
occurs in patients with BL and LL disease.
It is characterized by sudden eruption of numerous painful nodules
which may be superficial or deep in the dermis.
These can form pustules and may ulcerate
 Discharging yellow pus that contains polymorphs and degenerating acid-
fast bacilli
sterile on culture.

29. The Lucio phenomenon is a very rare complication presenting
as sudden necrotizing vasculopathy in patients with
longstanding, untreated LL

30. Treatment of leprosy
Multiple drug treatment.
Dapsone (100 mg daily), rifampicin (600 mg daily), and, for LL
clofazimine (50 mg daily) .
 Treatment of TL consists of 12 months of therapy with dapsone and
rifampin
Treatment of LL consists of 24 months of therapy with all three drugs.
BCG as a protection vaccine

31. Case 3
53 years old
male
k/c/o Colon CA
On xeloda

33. Acral erythema
*Capecitabine is an oral fluoropyrimidine that is converted in vivo
to 5-FU, providing prolonged tissue exposure

34. Acral erythema
Hand foot syndrome
Palmar-plantar erythrodysesthesia
Toxic erythema of the palms and soles
Burgdorf's reaction
Acral erythema has been described most often in patients receiving
cytarabine, pegylated liposomal doxorubicin, capecitabine, or 5-FU

35.  Patients initially complain of a tingling sensation in the palms and/or
soles.
 Followed by edema and tender, symmetrical erythema, which is most
pronounced over the fat pads of the distal phalanges.
 Skip areas may occur, as can extension to the dorsal surfaces of the
extremities.
Although rare, acral erythema involving the penis and scrotum has been
reported
Fingerprint loss

36. Bleomycin
Capecitabine
Cisplatin
Cyclophosphamide
Cytarabine*
Daunorubicin
Docetaxel
Doxifluridine
Doxorubicin (particularly the liposomal
preparation)
Etoposide
Fludarabine
Fluorouracil (infusional regimens)
Gemcitabine
Hydroxyurea
Idarubicin
Ixabepilone
Methotrexate
Mitotane
Paclitaxel
Tegafur
Thiotepa
Vinorelbine

37. Treatment
The main ttt for acral erythema is drug cessation and symptomatic ttt to
provide analgesia, lessen edema, and prevent superinfection.
Acral erythema usually resolves within 2-4/52 after D/C of the causative
agent, but healing frequently involves superficial desquamation of
involved areas.
Palmoplantar keratoderma may develop as a result of long-standing
acral erythema

38. Case 4

40. Pustular psoriasis

41. Approach to treatment consists of the following key steps:
Determine need for hospitalization and supportive care
Identify and discontinue the causative drug (in drug-induced cases)
Initiate treatment to control skin disease
Medical treatment options for GPP consist of systemic
therapies, topical therapies, and phototherapy
Manage extracutaneous complications

42. First-line therapy
Acitretin
 Methotrexate
 Infliximab
Cyclosporine
The faster acting drugs infliximab and cyclosporine are
preferred initial agents
Once control of acute disease is achieved, patients may be
transitioned to acitretin, methotrexate, or other therapies

43. Patients with relatively stable disease:
 Acitretin is treatment of choice for the initial management of adults
with relatively stable GPP.
Usual starting dose for acitretin is 0.75 to 1 mg/kg per day.
Improvement in GPP is usually noted within 7 to 10 days of oral retinoid
therapy.
After disease control is achieved, the dose of acitretin can be tapered
slowly to the lowest dose necessary to maintain the response

44. Patients with relatively stable disease:
MTX an alternative first-line treatment.
A typical dose of MTX for adults with GPP is 15 mg per
week, with a maximum dose of 25 mg per week.

45. Patients with severe acute disease
Cyclosporine and infliximab are ttt of choice for the initial
management of severe acute GPP
Cyclosporine doses ranged from 2.5 to 5 mg/kg per day
severe acute GPP with 4 to 5 mg/kg (ideal body weight) per day.
 Because side effects of ttt with cyclosporine are a concern, once
disease control is achieved, taper the dose over the course of 2-3/12.

46. Patients with severe acute disease
Standard dosing for infliximab for psoriasis is 5 mg/kg at weeks
zero, two, and six, and every six to eight weeks thereafter
A case report documenting dramatic improvement in acute GPP
within 24 hours following a single dose of infliximab followed by the
initiation of MTX

47. Second-line therapy
Inhibitors of the Th17 pathway
 Photochemotherapy
 (TNF)-alpha inhibitors
Combination therapy.

48. Several case reports document the successful use of:
Granulocyte and monocyte apheresis for the treatment of refractory GPP
Anakinra ( IL 1 receptor antagonist)
Ustekinumab
 Canakinumab (IL-1 )
 Mycophenolate mofetil
 Oral zinc
 Dapsone

49. Children
Childhood GPP is rare
First-line therapy
Acitretin (<1 mg/kg per day)
Cyclosporine (1 to 3 mg/kg per day)
Methotrexate (0.2 to 0.4 mg/kg per week)
Etanercept (0.4 mg/kg per day)

50. Pregnancy
Evidence for the treatment of PPP is limited
Systemic corticosteroids as initial therapy (prednisolone up to
60 to 80 mg per day)
Low-dose cyclosporine (2 to 3 mg/kg per day)

53. Case 5

55. Bullous erythema multiforme

56. A variety of factors have been implicated in the pathogenesis of EM.
Most commonly induced by infection, with (HSV)
The clinical course of EM is usually self-limited, resolving within weeks
without significant sequelae.
 However, in a minority of cases, the disease recurs frequently over the
course of years

57. Mild disease
 Symptomatic relief
Topical corticosteroids
 Oral antihistamines
Painful oral erosions can be treated with a high potency topical
corticosteroid gel and mouthwashes that contain a mixture of
lidocaine, diphenhydramine, and antacids

58. Severe oral mucosal involvement
Systemic glucocorticoids are often used in an attempt to decrease the
severity of symptoms and to shorten the course of the disease
Oral prednisone (40 to 60 mg/day initially and subsequently tapered
over two to three weeks)

59. Preventation of recurrent EM
Systemic antiviral medication is the first-line treatment for HSV-induced
recurrent EM and recurrent EM without an identifiable cause.
Immunosuppressive or immunomodulatory therapies are used for patients
who do not improve with antiviral drugs.

60. Antiviral therapy
Three approaches to antiviral prophylaxis have been evaluated in patients
with recurrent EM:
continuous antiviral therapy, which is the preferred approach
intermittent antiviral prophylaxis
and topical acyclovir

61. A six-month trial of one of the following regimens:
•Acyclovir – 400 mg BID
•Valacyclovir – 500 mg BID
•Famciclovir– 500 mg BID
For patients who fail initial treatment with an antiviral agent, the above doses
can be doubled.
If this is not effective, a trial of an alternative antiviral should be considered
If EM recurs after treatment is stopped, we restart the antiviral drug at the
lowest effective dose and reattempt cessation of therapy every 6 to 12 months
thereafter.

62. Second-line systemic therapies
For patients who have recurrent EM despite a course of continuous
antiviral therapy, other systemic agents should be considered.
Azathioprine (100 to 150 mg/day or 2 mg/kg/day in patients with normal
thiopurine methyltransferase activity)
Mycophenolate mofetil (1000 to 1500 mg BID)
Dapsone (100 to 200 mg/day) although data on efficacy are limited