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Ward Rounds in Dermatology
Bela J Shah, Santosh Rathod
CHAPTER 1:
Autoimmune Vesiculobullous Disorders
INTRODUCTION
ORIGIN, DURATION AND PROGRESS
TREATMENT HISTORY
LOCAL EXAMINATION
HISTORY TAKING AND CLINICAL EXAMINATION
CLINICAL EXAMINATION
LABORATORY INVESTIGATIONS
Assessment of Severity in Pemphigus Vulgaris
Intraoral Scoring System
Treatment Plan
Adjuvant
Corticosteroids1
MANAGEMENT OF A CASE OF BULLOUS PEMPHIGOID
Laboratory Diagnosis
Biopsy
Therapy
Systemic Steroids
OUR EXPERIENCE
CHAPTER 2:
Drug Reactions
INTRODUCTION
CASE HISTORY
PHYSICAL EXAMINATION
General Examination
Local Examination
Clinical Outline of Severe Cutaneous Drug Reactions
Classification of SJS-TEN
Drug Rash with Eosinophilia and Systemic Symptoms or DHS or DIHS
Acute Generalized Exanthematous Pustulosis
Bullous Fixed Drug Eruption
Erythema Multiforme (EM) Major
Diagnostic Work-up
Varying Degrees of Organ Involvement
Critical Care Management
Fluid Management
Skin Care in TEN
Pain Management
Ophthalmology Assessment
Therapeutics
Systemic Corticosteroids
Usage Remains Controvesial2
Cyclosporine
Intravenous Immunoglobulin (IVIg)
Infection Issues
Pyrexia
Management of DRESS
Management of AGEP
APPROACH
Investigations
TREATMENT OF TOXICITY
CHAPTER 3:
Systemic Lupus Erythematosus
INTRODUCTION
CLINICAL HISTORY (FIGS 3.1 TO 3.4)
ORIGIN, DURATION AND PROGRESS
NEGATIVE HISTORY
Salient Features of General Symptoms in Systemic Lupus Erythematosus
Weight Loss
Fatigue
Fever
QUESTIONING FOR MUCOCUTANEOUS MANIFESTATIONS
Photosensitivity
Raynaud's Phenomenon
Alopecia
Oral Erosions—are Asymptomatic
MUSCULOSKELETAL MANIFESTATIONS
Arthritis/Arthralgia
Abdominal Pain
PHYSICAL EXAMINATION
Cardiovascular System
Respiratory System
Gastrointestinal System
Central Nervous System
Cutaneous Examination
LABORATORY EVALUATION OF PATIENT WITH SYSTEMIC LUPUS ERYTHEMATOSUS
Acute Phase Reactants
Clinical Relevance of Acute Phase Reactants
Comparison of Erythrocyte Sedimentation Rate and C-reactive Protein
HEMATOLOGICAL ABNORMALITIES
Obtain Complete Blood Count with Differential Interpretations
Anemia
Leukopenia
Thrombocytopenia
URINE ANALYSIS
RENAL FUNCTION TESTS
Cockcroft-Gault Formula
Characteristic Features and Clinicopathological Correlations in Lupus Nephritis
Drugs Used in Management of SLE
CHAPTER 4:
Systemic Sclerosis, Dermatomyositis and Other Connective Tissue Diseases
INTRODUCTION
CHIEF COMPLAINTS
HISTORY OF PRESENT ILLNESS
Personal History
Past History
Family History
PHYSICAL EXAMINATION*
Cardiovascular System
Respiratory System
Warning Signs
Gastrointestinal System
MUSCULOSKELETAL SYSTEM
Bone Involvement
Tendon Involvement
Muscle Involvement
CUTANEOUS EXAMINATION
Antinuclear Antibodies
Nail-fold Capillaroscopy
Classification of Systemic Sclerosis (Table 4.4)
MANAGEMENT OF A CASE OF SYSTEMIC SCLEROSIS
Immunomodulator
Therapy for Raynaud's and Digital Ischemia
Potential Antifibrotic Strategies
Organ-based Treatment Strategies
MIXED CONNECTIVE TISSUE DISORDER
Case Report
Introduction
On Examination
Investigations
Diagnosis
Complications
Management
CHAPTER 5:
Erythroderma
INTRODUCTION
HISTORY OF PRESENTING ILLNESS
Past History
Personal History
EXAMINATION
General Examination
Cutaneous Examination
SPARING SIGNS IN ERYTHRODERMA
Specific Sites
ERYTHRODERMA IN NEONATES, INFANTS AND CHILDREN
History
Age of Onset of the Disease
Enquire About
Clinical Signs and Symptoms
Systemic Examination
LYMPHOMA WORK-UP
Imaging
Drug-induced Erythroderma
Treatment of Erythroderma
Alefacept
Itolizumab
Infliximab
Etanercept
Adalimumab
Golimumab
Ustekinumab
ABT-874
CHAPTER 6:
Lepra Reactions
CLINICAL HISTORY–1
Origin, Duration and Progress
CLINICAL HISTORY–2
Lepra Reactions
Causes
Types
Eliciting History in Leprosy Affected Person
Case History
Details of Skin Lesions
Presence of any Deformity
Any Other Associated Illness
Treatment History
General Physical Examination
Cutaneous Examination
Precautions for Examination of Skin Lesion
Details of Skin Lesions
Eliciting Sensory Loss in Skin Patches
Interpretation of Test for Loss of Sensation
Examination of Nerves
Components of Nerve Examination
Assessment of Sensory Function of Nerves
Assessment of the Motor Function of Nerve (VMT)
For Hand Muscles
Test for Lower Limb
Examination of Individual Important Nerves of Face and Neck
Examination of Nerves of Limbs (Table 6.2)
Nerves of Lower Extremity (Table 6.3)
Look for Autonomic Function of the Nerve, Deformities and Check for Disabilities
How to Examine a Previously Treated Person Affected by Leprosy?
Treatment of Lepra Reactions
Type 1 Lepra Reactions
Type 2 Lepra Reactions
TERMINOLOGIES
Impairments
Disabilities
Handicaps
Prevention of Impairments and Disabilities (POID)
Prevention of Worsening of Disabilities (POWD)
WHO Disability Grading
Hands and Feet
Eyes
Types of Deformities
CHAPTER 7:
Cutaneous T-cell Lymphomas
INTRODUCTION
HISTORY
PHYSICAL EXAMINATION
SKIN BIOPSY (FIGS 7.2 TO 7.4)
BLOOD TEST
RADIOLOGICAL TEST1
LYMPH NODE BIOPSY
Site of Biopsy
DIFFERENTIAL DIAGNOSIS2
TREATMENT (TABLE 7.1)
SYSTEMIC THERAPIES
SYSTEMIC CHEMOTHERAPY
ALLOGENEIC HEMATOPOIETIC STEM CELL TRANSPLANTATION
CLINICAL VARIANTS OF MYCOSIS FUNGOIDES
Pagetoid Reticulosis (Woringer–Kolopp Disease/Unilesional MF)9
Granulomatous Slack Skin Disorder (Fig. 7.5)
Lymphomatoid Papulosis (LyP)
Subcutaneous Panniculitis-like T-cell Lymphoma (SPTCL)10
CHAPTER 8:
Immunosuppressants in Dermatology
AZATHIOPRINE
Mechanism of Action
Licensed Indications
Autoimmune Bullous Disorders
Lupus Erythematosus
Dermatomyositis and Polymyositis
Recommendations: Off-label Indications for Azathioprine
Inflammatory Skin Diseases
Atopic Dermatitis
Psoriasis
Checklist for Use Prior to Prescribing Azathioprine
Adverse Effects
Short-term Toxicity
Nausea
Hypersensitivity
Medium-term Toxicity
Myelotoxicity
Susceptibility to Infection
Hepatotoxicity
Long-term Toxicity
Carcinogenesis
Ultraviolet Radiation and Skin Cancer
Lymphoma Risk
Drug Interactions
Drug Risks/Interactions
Toxicity Monitoring
Frequency
Monitoring for Myelosuppression
Methotrexate
Pharmacology
Mechanism of Action (Flow chart 8.1)
Anti-inflammatory Properties
Immunosuppressant Action
Clinical Uses
Indications of Methotrexate Therapy in Psoriasis
Two Types of Intermittent Weekly Regimens
Single Dose Weekly Regimen (Oral; i/m, i/v or S/C)
How Long can or should a Patient be Maintained on Methotrexate?
Combination Therapy in Psoriasis
Methotrexate and Phototherapy
Methotrexate and Retinoids (Acitretin)
Methotrexate and Cyclosporine
Methotrexate and Biological Agents
Rotational Therapy
Other Proliferative Disorders Responding to Methotrexate
Other Indications of Methotrexate and its Efficacy
Dermatomyositis (DM)
Childhood DM
Systemic Lupus Erythematosus
Atopic Dermatitis
Systemic Sclerosis and Morphea
Cutaneous Sarcoidosis
Bullous Pemphigoid
Other Dermatoses
Individual Case Reports or Small Series
Methotrexate in HIV Infected Patients
Methotrexate in Children
Adverse Effects
Gastrointestinal
Hematopoietic
Risk Factors for Methotrexate-induced Pancytopenia
Acute Toxicity and Overdose
Hepatic Toxicity
Risk Factors for Methotrexate-induced Hepatic Fibrosis
Other Noninvasive Tests
Limitations of p3NP
Pulmonary Toxicity
Methotrexate Osteopathy
Teratogenicity
Mucocutaneous Side Effects
Renal Effects
Secondary Malignancy
Potential Drug Interactions with Methotrexate
Folate Supplementation
Contraindications to Methotrexate Therapy
Absolute Contraindications
Relative
Monitoring
Baseline (Premethotrexate Evaluation)
Laboratory
Follow-up
Electroporation
CYCLOPHOSPHAMIDE
PHARMACOLOGY
MECHANISM OF ACTION
FDA-APPROVED INDICATIONS IN DERMATOLOGY
Mycosis Fungoides
OFF-LABEL DERMATOLOGIC USES
Vasculitis
Mucous Membrane Pemphigoid (Cicatricial Pemphigoid)
Pemphigus
Neutrophilic Dermatoses
Autoimmune Connective Tissue Diseases
Other
CONTRAINDICATIONS
Absolute
Relative
ADVERSE EFFECTS
Hemorrhagic Cystitis and Bladder Cancer57
Carcinogenesis
Gastrointestinal
Hematologic
Reproductive
Dermatologic60,61
DRUG INTERACTIONS
Drugs that may Reduce Cyclophosphamide Levels
Drugs that may Increase Cyclophosphamide Levels
Immunosuppressive Agents
Cytotoxic Agents
THERAPEUTIC GUIDELINES
PHARMACOLOGY
Structure
Metabolism and Excretion
Mechanism of Action
Clinical Use
FDA-approved Indications
Off-label Dermatologic Uses
Contraindications
Absolute
Relative
Adverse Effects
Renal Effects
Hypertension
Malignancy Risk
Hyperlipidemia
Neurologic
Mucocutaneous
Gastrointestinal
Musculoskeletal
Laboratory Abnormalities
Drug Interactions
CHAPTER 9:
Glucocorticosteroids
MODE OF ACTION
VARIOUS EFFECTS OF CORTICOSTEROIDS5–7
DERMATOLOGIC INDICATIONS OF SYSTEMIC CORTICOSTEROIDS4
Bullous Dermatoses
Autoimmune Connective Tissue Diseases
Vasculitis
Neutrophilic Dermatoses
Dermatitis/Papulosquamous Dermatoses
Other Dermatoses
Intramuscular Corticosteroids Pulse Intravenous Methylprednisolone
CONTRAINDICATIONS4
Absolute
Relative
RELATIVE POTENCIES OF COMMONLY USED CORTICOSTEROIDS2,4
Newer Corticosteroids—Deflazacort
MECHANISMS RESPONSIBLE FOR VARIOUS ADVERSE EFFECTS OF CORTICOSTEROIDS5,6,8–12
TOPICAL CORTICOSTEROIDS
Relative Potencies of Various Topical Steroids13
Class 1 (Superpotent)
Class 2 (High Potency)
Class 3 (High Potency)
Class 4 (Medium Potency)
Class 5 (Medium Potency)
Class 6 (Low Potency)
Class 7 (Low Potency)
Newer Topical Corticosteroids
Halometasone
Clobetasone
CONTRAINDICATIONS OF TOPICAL CORTICOSTEROIDS4
Absolute
Relative
Use in Pregnancy
Use in Lactation
FTU GUIDELINES FOR ADULTS4
ADVERSE EFFECTS OF TOPICAL CORTICOSTEROIDS4
Systemic
Local (Figs 9.1A to D)
RISK FACTORS FOR SYSTEMIC EFFECTS AND LOCAL ATROPHY4
Systemic Effects
Local Atrophy
Vehicle of Topical Corticosteroids4
CHAPTER 10:
Antihistamines
H1 ANTIHISTAMINES
Mechanism of Action
Indications
Contraindications
Special Points
Second-generation Antihistamines
Fexofenadine
Loratadine
Cetirizine
Desloratadine
Levocetrizine
Mizolastine
Olopatadine
H2 ANTIHISTAMINES
MAST-CELL STABILIZERS
Ketotifen
Mechanism of Action
Indications
CHAPTER 11:
Use of Antibiotics in a Patient Admitted in Dermatology Ward
INTRODUCTION
CULTURE AND SENSITIVITY PATTERN7
Methicillin-resistant Staphylococcus aureus (MRSA)
TREATMENT
Oral Antibiotics
Intravenous Antibiotics
VANCOMYCIN-RESISTANT STAPHYLOCOCCUS AUREUS
Topical Antibiotics
NOSOCOMIAL INFECTIONS IN DERMATOLOGY
Welsh Regimen and Modifications
CHAPTER 12:
Signs in Dermatology
PSORIASIS
Auspitz Sign
CONNECTIVE TISSUE DISEASES
Lupus Erythematosus
Carpet Tack Sign (Tin-tack Sign, Cat Tongue Sign)
Shuster's Sign
Heugh-Gottron Sign
Raccoon Sign
Systemic Sclerosis
Ingram's Sign
Mizutani's Sign (Round Finger Pad Sign)
Stafne's Sign
Barnett's Sign (Scleroderma Neck Sign)
Dermatomyositis
Samitz's Sign
Holster Sign of Dermatomyositis
Gottron's Sign
Shawl Sign
V-sign
AUTOIMMUNE BULLOUS DISORDERS
Asboe-Hansen Sign (Blister Spread Sign)
Nikolsky's Sign
Hypopyon Sign
ERYTHRODERMA
Deck-chair Sign
Pavithran Nose Sign
CHAPTER 13:
Frequently Asked Questions in Dermatology
CHAPTER 14:
Miscellaneous
CHIEF COMPLAINTS
HISTORY OF PRESENT ILLNESS
Treatment History
PHYSICAL EXAMINATION
PHYSICAL EXAMINATION
CUTANEOUS EXAMINATION
Laboratory Investigations
CHIEF COMPLAINTS
HISTORY OF PRESENT ILLNESS
GENERAL PHYSICAL EXAMINATION
CUTANEOUS EXAMINATION
LABORATORY INVESTIGATIONS
PULMONARY
Physical Examination
Pulmonary/Respiratory System
Cutaneous Examination
CHIEF COMPLAINTS
HISTORY OF PRESENT ILLNESS
PHYSICAL EXAMINATION
INDEX
TOC
Index
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