This document discusses various cutaneous manifestations of internal diseases. It focuses on cutaneous findings in diabetes mellitus, thyroid disease, adrenal disease, and renal disease. Some of the key points discussed include:
1) Skin lesions occur in 30% of patients with diabetes mellitus, including necrobiosis lipoidica, granuloma annulare, diabetic bullae, and acanthosis nigricans. Skin infections are also more common.
2) Hyperthyroidism can cause pretibial myxedema, scleromyxedema, thyroid acropachy, and Graves' dermopathy. Hypothyroidism results in dry skin, hair changes, nail changes, and generalized
history of TB,epidemiology, clinical features, lab diagnosis, treatment, MDR TB, XDR TB, TDR TB, and mechanism of drug resistant, methods of identification of resistant drugs
history of TB,epidemiology, clinical features, lab diagnosis, treatment, MDR TB, XDR TB, TDR TB, and mechanism of drug resistant, methods of identification of resistant drugs
Drug-induced hypersensitivity syndrome (DIHS)/Drug reaction with eosinophilia and systemic symptoms (DRESS)
Presented by Pongsawat Rodsaward, MD.
December 17, 2021
A brief coverage of all IIM, including major junk of #Polymyositis, #Dermatomyositis #InclusionBodyMyositis and other IIM's.
Includes classification, characteristic features of all and specific features of each of them with diagnosing and approach to management.
NB: This presentation is equipped with animations, which might not work on slideshare
Cutaneous involvement is very common in the different types of vasculitis. Skin lesions may be the only manifestation or may occur in the context of systemic disease
Drug-induced hypersensitivity syndrome (DIHS)/Drug reaction with eosinophilia and systemic symptoms (DRESS)
Presented by Pongsawat Rodsaward, MD.
December 17, 2021
A brief coverage of all IIM, including major junk of #Polymyositis, #Dermatomyositis #InclusionBodyMyositis and other IIM's.
Includes classification, characteristic features of all and specific features of each of them with diagnosing and approach to management.
NB: This presentation is equipped with animations, which might not work on slideshare
Cutaneous involvement is very common in the different types of vasculitis. Skin lesions may be the only manifestation or may occur in the context of systemic disease
Skin or Dermatological Manifestations of Endocrine Diseases - diabetes thyroid adrenal cushings pituitary and acquired and cushings and myxedema and graves
An educational presentation that consists of general complaint of skin diseases, history taking and examining various lesions and differentiating it and lastly tools required and investigation to be done to diagnose the skin manifestations
COMPLICATIONS OF DIABETES BY DR BASHIR AHMED DAR ASSOCIATE PROFESSOR MEDICINE...Prof Dr Bashir Ahmed Dar
The complications of diabetes mellitus are far less common and less severe in people who have well-controlled blood sugar levels.Wider health problems accelerate the deleterious effects of diabetes. These include smoking, elevated cholesterol levels, obesity, high blood pressure, and lack of regular exercise.
GESTATIONAL DIABETES BY DR BASHIR AHMED DAR ASSOCIATE PROFESSOR MEDICINE SOPO...Prof Dr Bashir Ahmed Dar
The complications of diabetes mellitus are far less common and less severe in people who have well-controlled blood sugar levels.Wider health problems accelerate the deleterious effects of diabetes. These include smoking, elevated cholesterol levels, obesity, high blood pressure, and lack of regular exercise.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
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- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
CDSCO and Phamacovigilance {Regulatory body in India}NEHA GUPTA
The Central Drugs Standard Control Organization (CDSCO) is India's national regulatory body for pharmaceuticals and medical devices. Operating under the Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, the CDSCO is responsible for approving new drugs, conducting clinical trials, setting standards for drugs, controlling the quality of imported drugs, and coordinating the activities of State Drug Control Organizations by providing expert advice.
Pharmacovigilance, on the other hand, is the science and activities related to the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problems. The primary aim of pharmacovigilance is to ensure the safety and efficacy of medicines, thereby protecting public health.
In India, pharmacovigilance activities are monitored by the Pharmacovigilance Programme of India (PvPI), which works closely with CDSCO to collect, analyze, and act upon data regarding adverse drug reactions (ADRs). Together, they play a critical role in ensuring that the benefits of drugs outweigh their risks, maintaining high standards of patient safety, and promoting the rational use of medicines.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
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This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
4. DIABETES MELLITUS
• approximately 30% of patients with DM develop
skin lesions at some point
• Overall prevalence of cutaneous disorders does
not differ between type I and type II diabetics
● Type I patients get more
autoimmune-type lesions
● Type II patients get more cutaneous
infections
5. DIABETES MELLITUS
• Cutaneous lesions usually appear after the
development of DM, but may be the first
presenting sign
• Four major groups of skin findings
1. Skin diseases associated with DM
2. Cutaneous infections
3. Cutaneous manifestions of diabetic complications
4. Skin reactions to diabetic treatment
6. NECROBIOSIS LIPOIDICA (NL)
• NL is 3x more common in
women.
• NL appears earlier (mean age
22) in Type I diabetics than
Type II (mean age 49.)
• Appearance
● Begins as an oval, violaceous patch
and expands slowly.
● Advancing border is red.
● Central area turns yellowish brown.
● Central area atrophies and
telangiectasia become evident.
● 13% of cases progress to ulceration
7. NECROBIOSIS LIPOIDICA (NL)
• Classically, NL occurs
bilaterally on the
pretibial or medial
malleolar areas.
• Not painful.
• Spontaneous resolution
occurs in 13-19% with
residual scarring.
8. GRANULOMA ANNULARE (GA)
• Appearance
● Ring of small, firm,
flesh-colored or red
papules
● If localized, most
frequently found on
lateral and dorsal
surfaces of hands and
feet
● Can spontaneously
regress without
scarring
9. DIABETIC BULLAE
• Approximately 0.5% of diabetics
• Two types have been described
● More frequent, non-scarring lesions with
a histologic intraepidermal split without
acantholysis
● Less common, occasionally hemorrhagic
bullae that heal with scarring, slight
atrophy, and have a histologic
subepidermal split
o Trauma and microvascular disease may
play a role
• Appearance
● Painless bullae on non-inflamed base
that appear suddenly
● Most common on the dorsa and sides of
lower legs and feet, sometimes with
similar lesions on the hands and forearms
● Bullae contain clear, sterile fluid
10. DIABETIC BULLAE
• Bullae tend to heal spontaneously in 2-5
weeks
• diagnosis of exclusion
● DDx: bullous pemphigoid, epidermolysis
bullosa acquisita, porphyria cutanea
tarda, bullous impetigo, erythema
multiforme
● May recur in the same or new locations
11. ACANTHOSIS NIGRICANS
• Seen in situations of insulin
resistance
• Besides in DM, also seen in the
following:
● Carcinomas, especially of the stomach
● Secondary to drugs (nicotinic acid,
estrogen, or corticosteroids)
● Pineal tumors
● Other endocrine syndromes (PCOS,
acromegaly, Cushing’s disease,
hypothyroidism)
● Obesity
• Pathogenesis
● it may be related to insulin binding
insulin-like growth factor receptors on
keratinocytes and dermal fibroblasts,
thus stimulating growth.
12. ACANTHOSIS NIGRICANS
• Appearance
● Hyperpigmented,
velvety plaques in
body folds, mostly
axillae and neck
● Can also present
on groin,
umbilicus, areolae,
submammary
areas, and on the
hands
13. SKIN INFECTIONS IN DM
• Occur in 20-50% of poorly controlled diabetics
• More common in Type II
• May be related to
➢ Abnormal microcirculation
➢ Hypohidrosis
➢ PVD
➢ Neuropathy
➢ Decreased phagocytosis and killing activity
➢ Impaired leukocyte adherence
➢ delayed chemotaxis
14. CANDIDIASIS IN DIABETICS
• Fungal infections- most
common
• Candida
● Candidial paronychia
● Inframammary candida
● Genital candida
• Oral candidiasis
• White, curdlike material
adherent to
erythematous, fissured
oral commisure;
• angular stomatitis
17. SKIN INFECTIONS IN DM
• Bacterial Infections- can
be more severe and
widespread in diabetics
• Malignant otitis externa
● Pseudomonas aeruginosa
● Fatal in over 50% patients
● Can progress to chondritis,
osteomyelitis, and
bacterial meningitis
18. SKIN INFECTIONS IN DM
• Bacterial infections in DM
• Erythrasma
● Sharply demarcated
erythematous patches
● upper inner thighs,
axillae, toe web spaces,
and inframammary
creases
● Gram positive
Corynebacterium
minutissimum
● Identified with Wood’s
light coral fluorescence
19. DIABETIC ERUPTIVE XANTHOMAS
• Seen in
uncontrolled
diabetes,
hypertriglyceride
mia
• Sudden crops on
firm, non-tender
yellow papules
with a red rim on
extensors
• Control of glucose
and lipid reduction
reduce the lesions
20. DIABETIC DERMOPATHY
➢ AKA “shin spots” or
pigmented pretibial
papules
➢ Most common
cutaneous
manifestation of
diabetes
➢ Benign asymptomatic
red brown macules on
shins
➢ No treatment needed
21. CUTANEOUS MANIFESTATIONS OF DIABETIC
COMPLICATIONS: FOOT ULCERS
• Peripheral neuropathy leads to unnoticed trauma
• Vascular complications may lead to ulcers and
complicate ulcer healing
• Risk of amputation goes up 8x once these develop
22. CUTANEOUS REACTIONS TO DIABETIC
TREATMENT
Insulin
● Allergy may be local or systemic and usually
occurs within the first month of therapy
• Erythematous or urticarial pruritic nodules
at the site of injection
● Lipoatrophy can also occur
• Circumscribed depressed areas of skin at the
insulin injection site 6-24 months after
starting insulin
• More common in women and children
● Lipohypertrophy can also occur
• Soft dermal nodules that resemble lipomas
at sites of frequent injection
• May be a response to the lipogenic action of
insulin
• Treat and prevent by rotating sites of
injection
23. CUTANEOUS REACTIONS TO DIABETIC TREATMENT-ORAL
HYPOGLYCEMICS
• Most rxns are associated with the first-generation
sulfonylureas (chlorpropamide and tolbutamide)
• 1-5% of patients on these drugs will develop skin rxns
during the first 2 months of treatment
• Most commonly, they present with maculopapular
eruptions that resolve despite continuation of the
drug.
25. THYROID HORMONE AND THE SKIN
• Thyroid hormone plays a pivotal role in the
growth and formation of hair and sebum
production.
• Thyroid hormone stimulates epidermal oxygen
consumption, protein synthesis, mitosis, and
determination of epidermal thickness.
• There is increased cutaneous blood flow and
peripheral vasodilation.
26. HYPERTHYROIDISM AND THE SKIN
• Skin is usually warm, moist, and smooth
(best assessed on the inner aspect of arm and over
the chest)
• Facial flushing
• Palmar erythema
• Hyperpigmentation, esp. creases of palms and soles
(buccal pigementation doesn’t occur)
• hair is fine and friable, hair loss may be excessive
• History of early graying
• Hyperhydrosis, particularly of palms and soles
27. PLUMMER’S NAIL IN HYPERTHYROIDISM
“Plummer’s nail”: concave contour and distal
onycholysis, esp. the ring finger (not specific- also seen
in hypothyroidism, psoriasis, after trauma, or in allergic
contact dermatitis)
28. SCLEROMYXEDEMA IN HYPERTHYROIDISM
• Numerous firm white, yellow, or
pink papules on face, trunk, axillae,
and extremities
● Lesions result from accumulation of
hyaluronic acid in the dermis,
accompanied by large fibrocytes
31. GRAVES’ DERMOPATHY
• Pretibial myxedema (0.5-4% of
patients)
• Late manifestation, accompanied by
ophthalmopathy in 99%.
● Presentation varies from “peau
d’orange” appearance to extensive
infiltration.
● Most often, bilateral, asymmetric,
raised, firm plaques or nodules
varying from pink to brown,
sometimes with woody induration
● Can appear anywhere (arms,
shoulders, head).
● Histologically, the process involves
dermal accumalation of hyaluronic
acid.
Pathogenesis :pretibial fibroblasts are
the target for antithyroid antibodies
T cells may be interacting with a
dermal antigen similar to a thyroid
autoantigen, with cytokines
subsequently activating fibroblasts to
secrete hyalouronic acid.
❖Can treat with topical steroids,
intralesional steroids, IV pulse
steroids, or IVIG
32. THYROID ACROPACHY IN GRAVES’
DISEASE
•Thyroid acropachy (1% of Graves’ patients).
•Triad of digital clubbing, soft tissue swelling of hands and feet, and periosteal
new bone formation
•Usually accomapanied by exophthalmos and dermopathy (diamond triad)
•May occur in hashimioto’s thyroiditis and hurtle cell adenocarcinoma.
33. HYPOTHYROIDISM AND THE SKIN
• Skin is cool, dry, and pale.
● Pallor results from cutaneous
vasoconstriction and increased
deposition of water and
mucopolysaccharides in the dermis,
which alter the refraction of light
• Hypohydrosis may lead to
palmoplantar keratoderma (possibly
along with reduced epidermal steroid
synthesis)
• Carotenemia (from decreased hepatic
conversion of beta carotene to Vit A)
gives skin yellowish hue (palms, soles,
+nasolabial folds)
• Hair: dry, brittle, coarse; partial
alopecia
• Loss of hair from lateral 1/3 of eyebrows
(lateral superciliary madarosis)
Hertog’s sign
• Hair growth slows down, the
proportion of telogen hair is increased.
• These changes normalise with
normalization of thyroid hormone
levels.
34. HYPOTHYROIDISM AND THE SKIN
• Nails are brittle, grow slowly, purpura
• Easy bruising
• Wound healing is impaired.
• Diminished levels of clotting factors may manifest as
purpura.
35. HYPOTHYROIDISM FACIES WITH GENERALIZED
MYXEDEMA
• Generalized myxedema
• Characteristic skin sign
● Occurs as a result of
deposition of PAS-positive
dermal acid
mucopolysaccharides (esp.
hyaluronic acid and
chondroitin sulfate) in the
skin
● Skin is non-pitting, with a
firm waxy appearance
● Characteristic facies: swollen
lips, broad nose, macroglossia,
and puffy eyelids
● Also apparent on the dorsa of
hands and feet and in the
supraclavicular fossa
● Carpal tunnel syndrome and
facila nerve palsy may occur
owing to nerve entrapment
36. CONGENITAL HYPOTHYROIDISM (CRETINISM)
• Myxodema
• Yellowing (carotenemia or prolonged jaundice)
• Pronounced clavicular fat pad
• Coarse, dry, brittle hair with patchy alopecia
• Persistent, long, lanugo hair on the upper back,
shoulders, and extremities
• Hypothermia
• Reflex peripheral vasoconstriction may
accentuate cutis marmorata
• Poor nail growth
• Delayed eruption of deciduous teeth
• Retardation of mental and physical development
• Delayed milestones
37. • Thyroid replacement therapy rapidly reverses
many of the cutaneous features of
hypothyroidism, with gradual disappeaarance of
excessive dermal mucopolysaccharides.
38. ASSOCIATION BETWEEN CUTANEOUS AND
THYROID DISEASE
• Vitiligo (higher levels of antithyroid
peroxidase, antithyroid microsome, anti-TSH)
• Connective tissue diseases
● Dermatomyositis, SLE, scleroderma,
polymyositis, sjogren’s syndrome.
● Generalised granuloma annulare,
● reticular erythematous mucinosis
● Chronic urticaria
● Melasma
● Chronic mucocutaneous candidiasis
● MEN syndromes
❖Patients with idiopathic chronic urticaria and/or angiodema should therefore
be screened for thyroid autoimmunity
39. ASSOCIATION BETWEEN CUTANEOUS AND
THYROID DISEASE CONTD.
➢ ALOPECIA
AREATA
● Rapid onset of
total hair loss in
a sharply
defined, usually
round, area
● Regrowth begins
in 1 to 3 months
and may be
followed by loss
in the same or
other areas
40. ASSOCIATION BETWEEN CUTANEOUS AND
THYROID DISEASE CONTD.
• Pemphigus foliaceus
Herpes gestationis
Bullous pemphigoid
Dermatitis herpetiformis
• Pemphigus vulgaris
42. ADRENAL INSUFFICIENCY
• Increased
stimulation of
melanocortin-2
receptor by ACTH
itself
• Pigmentation is
maximal over
photoexposed
areas, mucuos
membranes,
palmar creases,
areas subject to
friction, genitalia,
areola, axillae,
perineum as well as
in scars.
• Nails-longitudinal
melanonychia
43. HYPERCORTISM
• Truncal obesity
• Buffalo hump
• Moon facies
• Slender limbs
• Cutaneous atrophy and
telangiectasias
• Fragility with purpura
• Poor wound healing
• Acneform eruptions
• Hirsuitism
• Cigarette paper like
wrinkling of skin on
dorsum of hands(liddle’s
sign)
• Livid, purplish straie on
abdomen, breasts,
proximal part of limbs
44. RENAL DISEASES
➢ Signs of ESRD
➢ Signs associated with dialysis
➢ Signs in renal transplant patients
46. XEROSIS
• Most common cutaneous abnormality
• Is predominantly seen over the extensor surfaces of the forearms, legs and
thighs.
• The abdomen and chest may show fine scaling
• Hypervitaminosis A, reduction in size of eccrine sweat glands, high dose
diuretic regimens are some of the causes of xerosis
47. UREMIC PRURITUS
• Incidence is 50-90%
• Usually on forarms, back
• Cutaneous manifestations of pruritus
include excoriations, prurigo nodularis
and lichen simplex chronicus
● Decreased transepidermal
elimination of pruritogenic factors
● Hyperparathyroidism
● Hypercalcemia
● Hyperphosphatemia
● Elevated histamine levels
● Topical
➢ Moisturizing creams
➢ Capsaicin
o Physical treatments
➢ UVB light
➢ parathyroidectomy
o Systemic medications
➢ Sedating Antihistamines
➢ Cholestyramine
● Alternative strategies
➢ Acupuncture
➢ homeopathy
48. PIGMENTARY CHANGES PURPURA/ECHHYMOSIS
• Pallor – Anemia
• Yellow hue – Carotenoids and
nitrogenous pigments (urochromes) in
the skin.
• Brown-black Hyperpigmentation -
➢ Sunexposed areas
➢ can be attributed to retention of
chromogens and deposition of melanin in
the basal layer and superficial dermis due to
failure of kidney to excrete
beta-melanocyte stimulating
hormone
➢ Sunscreens, sun avoidance
measures and clothing are advised
for these pigmentary changes.
• Defects in primary
hemostasis like increased
vascular fragility
• Abnormal platelet function
• Use of heparin during
dialysis are the main causes
of abnormal bleeding in these
patients
• Dialysis treatment partially
corrects these changes
49. CALCIFIC UREMIC ARTERIOLOPATHY (CALCIPHYLAXIS)
• Metastatic skin calcification
• abnormally elevated level of
parathyroid hormone (PTH)
which may trigger the deposition of
crystalline calcium pyrophosphate
in the dermis, subcutaneous fat, or
arterial walls.
• papular or nodular cutaneous
lesions around large joints or
flexural sites
• acute thrombosis of calcified
vessels.
• This produces violaceous mottling
of the skin that are acutely painful
due to ischemia.Surrounding tissue
may be inflamed with cellulitis.
• Lesions often progress to necrosis
and gangrene.
• The condition is associated with a
high mortality, particularly when
the skin of the trunk is involved.
• Infectious complications – non
healing ulcers
50. ACQUIRED PERFORATING DERMATOSIS ( APD )
• Hyperpigmented papules, up
to 1 cm in diameter, with a
central keratinous plug in
patients of CRF.
• The exclusive feature of the
perforating disorders is the
trans-epidermal
elimination of altered
dermal substances.
• The changes are significantly
more prevalent in diabetic
patients
• Excessive scratching +
diabetic vasculopathy - dermal
necrosis- eliminated through
the epidermis
• The extensor surfaces of the
limbs are more commonly
affected but the trunk and face
may be involved.
oDistinct from primary perforating disorders
➢Kyrle’s disease
➢Elastosis Perforans serpiginosa
➢Perforating folliculitis
➢Reactive perforating collagenosis
51. BULLOUS DISEASE OF DIALYSIS
• Syndrome of cutaneous
fragility and blistering
• Sun-exposed skin, most
often on the dorsal
hands
• Resembles Porphyria
• Plasma porphyrin levels
are normal or only
minimally elevated
52. NEPHROGENIC FIBROSING DERMOPATHY (NFD)
• Scleroderma like fibrosing
skin condition
• Typically, symmetrical skin
plaques with a peau d’orange
surface and advancing
ameboid edges develop on
limbs and trunk sparing the
head and neck.
• Nodules and contractures
can be seen in patients with
disease of long duration.
• Skin biopsy-marked fibrosis
53. UREMIC FROST
➢ Was a frequent in the
pre-dialysis era
➢ blood urea nitrogen level of
more than 250-300 mg/dl.
➢ The concentration of urea in
sweat is increased and, after
evaporation, there is a
deposition of urea crystals on
the skin surface.
➢ The frost consists of a white or
yellowish coating of urea
crystals on the beard area and
other parts of the face, neck and
on the trunk.
54. NAIL CHANGES
• Lindsay's nails (half and half nails, prevalence 30-50 %)
• Others
● Koilonychia
● Subungual hyperkeratosis
● Onycholysis
● Mees’ lines
● Muehrcke’s lines
● Splinter hemorrhages
● Beaus lines
Proximal
half opaque
white
Normal to red
brown distal half
55.
56. Yellow nail syndrome (YNS) is triad of yellow nails,
lymphedema, and respiratory tract involvement
57. HAIR ABNORMALITIES
• Sparse body hair and diffuse alopecia with dry,
lusterless hair
• Decreased secretion of sebum
• Chronic telogen effluvium
• Drugs – Heparin / Statins / Antihypertensives
58. CUTANEOUS MANIFESTATIONS IN PTS
ON DIALYSIS
• Diffuse
hyperpigmentation
• Accelerated cutaneous
aging
➢ Actinic elastosis
➢ Excessive wrinkling of neck(
cutis rhomboidalis nuchae)
➢ Telangiectasias
o Skin infections common
59. DERMATOLOGIC DISORDERS ASSOCIATED WITH
RENAL TRANSPLANTATION.
❖ Drugs – Steroids, Immunosuppresants
❖ Infections
➢ Severe herpes zoster
➢ Viral warts and condylomata accuminata are more common later
➢ Pityriasis versicolor commonest fungal infection
➢ Candidal infections
❖ Malignancies
➢ Kaposi sarcoma- oral cavity, limbs, trunk; associated with edema
➢ SCC> BCC
✓ Younger age, multiple, extracephalic, HP features of HPV infection, spindle cell
morphology is more common
Transplant patients should be counselled on minimizing UV light
exposure, regular sunscreen use, self screening for skin lesions
61. CHRONIC LIVER DISEASES
• Jaundice
• Because of raised
levels of bilirubin
more than
2.5-3.0mg/dl
• Diffuse
hyperpigmentation
62. SPIDER ANGIOMAS/ SPIDER NEVUS/NEVUS ARANEUS
• Pinhead to upto 2mm
• Mostly on skin drained by
superior vena cava
• Central arteriole visible as a red,
flat or slightly elevated point
surrounded by multiple, small
and tortuous radiating capillaries
• Commoner in alcoholic cirrhosis
• Presence may indicate an
increased risk of bleeding from
oesophageal varices
• Abundant cutaneous spider
angiomata –clinical marker of
hepatopulmonary syndrome,
where circulatory and
gas-exchange abnormalities in
lungs occur secondary to
advanced CLD.
63. CHRONIC LIVER DISEASES
• Palmar erythema
• Exaggerated mottling or a well
defined hypothenar erythema
that later spreads to fingers
and rest of the palm
• gynaecomastia
(Because of hyperestrogenemia)
64. CHRONIC LIVER DISEASES
• Pruritus
• Recurrent purpura
• Xanthoma straitum
palmare
(Multiple xanthomas may
appear as yellowish plaques
covering large areas of skin
in palmar creases)
66. CHRONIC LIVER DISEASES
• Clubbing
• Longitudinal ridging
• Thickening
• Brittleness
• Total leuconychia
• terry’s nails
• (whitening of the
entire nail plate
except for a narrow
pink band distally)
• Muehrcke’s nails
(multiple parallel
transverse white
bands Terry’s nails
Muehrcke’s nails
clubbing
68. PORPHYRIA CUTANEA TARDA
• Vesicles and bullae
on sun-exposed
areas, scarring
with milia
• Hypertrichosis
• Fragile skin with
sclerodermoid
changes
• Anti HCV
antibodies found in
upto 2/3rd
of cases
of these patients
• HCV serology
should be a part
of routine
investigative
work up in
patients with
PCT
69. LICHEN PLANUS
• Variable association of
0.1% to 35%
• Associated with LP ,
especially in mucosal,
generalised or long
standing LP
• Purple, pruritic, polygonal
papules
70. NECROLYTIC ACRAL ERYTHEMA
• Starts as
erythematous papules
and sometimes
blisters that coalesce
into
well-circumscribed
dusky areas with
scaling and erosions.
• Hyperkeratotic
surface develops in
older lesions
• Mc site- drsal surface
of feet-great toes
• Spares periorificial
areas-d/f with other
necrolytic erythemas
such as necrolytic
migratory erythemas
and zinc deficiency
71. HEPATITIS B
• About 30% may
have Urticaria or
present a serum
sickness like picture
(because of
circulating immune
complexes)
• Associated with
5-7% cases of
Polyarteritis nodosa
➢ Classical PAN
➢ Renal vasculitis present
➢ ANCA negative
86. Major criteria:
Proximal Scleroderma :
Symmetrical thickening, tightening, induration of skin of digits
and
dorsal hands; may affect entire extremity and involve face and
torso
Minor criteria:
1. Sclerodactyly: skin changes (above) limited to
digits
2. Digital pitted scars or loss of finger pad soft
tissue
3. bibasilar pulmonary
fibrosis
Diagnosis requires 1 major or 2 minor
CRITERIA FOR DIAGNOSIS: SYSTEMIC
SCLEROSIS
92. HENOCH-SCHÖNLEIN PURPURA
•vasculitis with arthritis, abdominal pain, and
hematuria
• mainly affects children
• often follows streptococcal infection
• In the skin, the disease causes palpable purpura (small
hemorrhages)
• chronic kidney disease- loss of small amounts of blood
and protein in the urine
98. CYANOSIS
• Capillary concentration of
reduced Hb is more than
4g/Dl.
• Best observed in
fulorescent lightening
• Most prominent in areas
with thin vascular surfaces
➢ Oral mucosa
➢ Lips
➢ Earlobes
➢ Nail beds
➢ Palms and soles in children
99. CYANOSIS
• May be
• Central (decreased arterial oxygen saturation)
➢ Congenital heart disease
➢ Impaired pulmonary function
❖ Tongue is the most reliable site for detecting cyanosis.
• Peripheral (owing to poor blood flow)
➢ Cold exposure
➢ Peripheral vascular disease
➢ Congestive heart failure
➢ Polycytemia
❖ Oral mucosa is often spared in peripheral cyanosis
o Mixed
➢ Pulmonary odema
➢ Cardiogenic shock
100. CLUBBING
• Increase in the
angle between the
proximal nail fold
and the nail plate
(Lovibond’s angle)
• Due to connective
tissue proliferation
between the nail
matrix and the
underlying distal
phalanx
102. CUTANEOUS ASSOCIATIONS OF CORONARY
ARTERY DISEASE
• Xanthomas:
localized lipid
infiltrates in
the dermis or
tendons.
• Indicative of
abnormal
lipid profile
and risk of
coronary
artery disease
103. INFECTIVE ENDOCARDITIS
• Subungual splinter
hemorrhages
➢ 1-2mm brown streaks
under the finger/toe nails
➢ Proximal appearance has
more diagnostic value
➢ Petechiae
➢ Osler’s nodes
➢ tender purpuric nodules on
the finger pads and toes)
➢ Janeway lesions
➢ nontender purpuric macules
of the palms and soles
104. RHEUMATIC FEVER
• Subcutaneous
nodules:
➢ Extensor aspect of elbows and
knees
➢ Exclusively seen in pts of
rheumatic carditis
• Erythema marginatum
➢ Seen in 10% pts of
rheumatic fever
➢ Dull red ,flat or palpable,
discrete or confluent,
annular lesions on the
trunk, esp the abdomen
and proximal parts of the
extremities
105. CUTANEOUS SIGNS INDICATIVE OF
INTERNAL DISEASES
oErythema nodosum
oAcanthosis nigricans
oPyoderma gangrenosum
oAcquired ichthyosis
oGeneralised pruritus without an eruption
106. Erythema Nodosum
Due to panniculitis
(inflammation of the
subcutaneous fat)
deep, firm, and tender
reddish-blue nodules, 1-5 cm
diameter
Most commonly at calves
and shins
108. Acanthosis nigricans
Asymptomatic brown velvety plaques of coalescent papules
Affects flexures - neck, axillae, groin
Potential causes
obesity
endocrine disorders
(acromegaly, insulin-
resistant diabetes)
Inherited
GI malignancy
109.
110. Pyoderma Gangrenosum
rapidly expanding ulcer with purple
undermined border, start as pustules
Often affects legs
Causes
■
■
50% idiopathic;
10% associated with ulcerative colitis;
■ Other associations: Crohn’s, chronic
active hepatitis, rheumatoid arthritis,
HIV, leukemia, myeloma
111. ACQUIRED ICHTHYOSIS
➢ If develops in adulthood,
consider:
• underlying malignancy
(e.g. Hodgkin’s disease),
• essential fatty acid
deficiency (e.g. due to
malabsorption from
intestinal by-pass or from
lipid lowering drugs)
112. Generalized pruritus
without an eruption
Causes:
Idiopathic (‘senile’)
Iron deficiency
Liver disease
Malignancy (e.g. Hodgkin’s lymphoma)
Neurological disorders
Polycythemia
Renal failure
Thyroid dysfunction