It wasn’t until #dermatology residency I learned about all the subtypes of cutaneous lupus (CLE)! I thought it was all just one disease: SLE. But in reality there are many forms of CLE, each with its own implications on systemic involvement and effect on the patient. 2/
Let’s start with the 3 subtypes:
Acute, Subacute, and Chronic Cutaneous Lupus Erythematosus (ACLE, SCLE, CCLE). CCLE is aka Discoid.
Each subtype "overlaps" with SLE in a different way.
ACLE is the typical “malar rash” we all learn in #medschool. Patients with ACLE theoretically all have SLE!
Main items on the ddx for ACLE are things like rosacea, seborrheic dermatitis, and other facial rashes. To differentiate, ACLE spares which of the following areas?
4/
The nasolabial fold (NLF) is classically spared in ACLE, whereas seborrheic dermatitis and rosacea can involve this area! Patients with ACLE, given their high likelihood of having SLE, should probably be seeing our #rheumatology colleagues as well! 5/
SCLE looks like a scaly eruption that is photodistributed. The overlap with SLE is smaller than ACLE, so some patients can get SCLE only (without systemic involvement).
There is a form of drug-induced SCLE that is Ro-positive (different from drug induced SLE). 6/
CCLE (discoid lupus) is a scarring process that usually is on the head and neck. This is ideally found early so as to prevent the scarring process. An alopecia is common, and on exam, it classically involves the conchal bowls. Overlap with SLE is low, but still possible. 7/
Brief interlude for a midway recap:
-ACLE is the malar rash. This spares the NLF.
-SCLE is scaly and photo distributed, can be drug induced.
-CCLE is on head and neck, look at conchal bowls and for alopecia.
-Each subtype has a different risk of having SLE. 8/
Bullous lupus is Ab-mediated and usually starts on dorsal hands. The bullae are tense (because the split happens at the BMZ). The ddx for this includes porphyria cutanea tarda and epidermolysis bullosa acquisita. This responds well to dapsone!
(Pic is EBA, but similar look!) 9/
Lupus panniculitis, since deep, usually doesn’t have surface change, but patients will have deep inflammatory processes that can be painful, that then become atrophic over time. Main differential includes all other panniculitic processes like erythema nodosum! 10/
And one for our #pediatric crowd. Neonatal LE presents with annular scaly plaques. These babies need EKGs to rule out heart block (+/- cardiomyopathy). Their mothers are the ones that have SLE that passed along an auto-antibody through the placenta. Which Ab was it?
11/
Anti-Ro is the reason for neonatal LE, which also comes with risk of anemia, thrombocytopenia and hepatobiliary disease. Usually, the NLE resolves with time, but the sequelae (eg: heart block) can be permanent. Check out the photo of the characteristic rash! 12/
And one note to say that SLE can also involve the skin in other ways. These include oral ulcers, rash on the dorsal hands (especially around nailfolds, and not limited to knuckles like in dermatomyositis), and dilated nailfold capillary loops. 13/
The work up of CLE types can include a biopsy, but often the physical exam is enough to make a clinical diagnosis. A good history is all you need with some select auto-antibody testing. I try to avoid a huge laundry list of labs to send, but will keep SLICC in mind. 14/
One last tiny point. #Dermatologists like to confuse people, so these two things are NOT lupus:
As opposed to (pic3) "pernio," which can be associated w/lupus, despite not having the name. 15/
Summary:
-Many different forms of CLE, each with their own implications.
-Early diagnosis can help prevent permanent effects.
-Good history and select lab testing can help with diagnosis. Biopsy helps in some cases.
-Collaboration between #derm and #rheum are crucial! 16/
Thanks all for joining me. I didn’t comment on #dermpath if a biopsy is taken, since we have such an active #dermpathtwitter group here, I’ll let them fill in the details. Also, hope this helps some of you out in #medstudenttwitter too! Until next time!
17/17
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Hi #medtwitter and #dermtwitter! Since I'm giving a talk at the upcoming @SocietyHospMed Converge meeting, I thought I'd put together a brief #tweetorial on:
DIFFERENTIATING PEMPHIGUS AND PEMPHIGOID!
Follow along for a reminder on how to tell them apart! 1/
Reminder that Pemphigus is from an antibody targeting the Desmosome - which holds skin cells (keratinocytes) together.
Pemphigoid is from an antibody targeting the Hemidesmosome, which holds keratinocytes to the basement membrane.
pc: 2/ bookdown.org/jcog196013/BS2…
So to remember:
pemphiguS (S for Superficial/higher up)
pemphigoiD (D for Deep/lower down)
This also means the clinical exam is different. Since Pemphigoid is deeper, these bullae stand tall and proud and don't droop over (see pic)! We call these TENSE bullae. 3/
If everyone could just humor me for a little, here's a #dermtwitter/#medtwitter/#pharmtwitter #tweetorial on...
AZATHIOPRINE
Did you know that dermatologists use this medication too? Read on to see all the ins and outs of safety and dosing, from a #dermatology point of view! 1/
Did you notice those two rings above? That's how it works.
Azathioprine is a purine (see figure) analogue, so it gets in the way of RNA/DNA synthesis (making transcription and replication and all that downstream goodness more difficult). 2/
And as you might imagine, cells that are rapidly dividing (like your immune cells) would be affected more by this purine disruption.
But it's not azathioprine itself that does all the work. It has to be broken down into active metabolites and that's where it gets interesting. 3/
The spirochete Borrelia burgdorferi is the most common cause. It is transmitted via tick bite, and so, certain areas of the country have higher rates based on endemicity of the organism.
What tick classically transmits lyme?
2/
Ixodes tick is the classic vector for B burgdorferi. But remember:
The tick usually has to be attached to the patient for >36 hours to transmit and cause Lyme disease.
Can you identify all these types of ticks and pick out which one is Ixodes?
We're seeing more consult questions for this, and it's also garnering national attention, so let's take a brief moment in #tweetorial format to talk about:
What is Xylazine? It was created in the 70s as a veterinary anesthetic. As an analog of clonidine, it has similar effects as an alpha-2 agonist, leading to sedation, anesthesia, and euphoria in the CNS. 2/
Recently, Xylazine has entered the drug supply, moreso in certain cities, but increasingly everywhere. It is often mixed with fentanyl as a cutting agent, and can also be used on its own. It may be called Tranq, Zombie Drug, or anestesia de caballo (horse anesthetic).
3/
Let's go back to the basics. Syphilis is from an infection by the bacterium Treponema pallidum. Usually spread by sexual means, syphilis has three main stages of disease.
Primary infection usually presents as a papule that turns into a painless ulcer called a chancre. 2/
Time from inoculation to chancre usually is 10-90 days (21 days is most typical).
There is a rare variant where the patient can get many smaller ulcerations, which is called Follman balanitis. 3/
Let’s spend some time in this #tweetorial on the dermatologic manifestations of this potentially paraneoplastic disease!
First, a question: What is necessary to make a diagnosis of DM?
1/
None of the above! DM is a clinical diagnosis, which is why getting the exam right is super important! That said a biopsy CAN help with getting to a diagnosis, but it’s not necessary.
So let’s start! Heliotrope rash! This poikilodermatous erythema occurs around the eyes. 2/
Remember though that exams are different across skin tone. Heliotrope can look a lot more subtle in someone with more melanated skin. That rash can also include the rest of the face! 3/