Dermatology Case Epetia Mar, Erestain Noel, Esguerra Peter Hans, Esmael Krista, Eugenio Clarisse Marie, Evangelista Emman, Evangelista Kristy Elleza, Facton Rosabelle

Patient Profile 57 year old Male Veterinarian

History 4 days PTC  complained of pain on his left cheek. A day after, he noted numerous vesicles on this left cheek affecting the left periorbital area and nasal region. He then consulted the emergency room due to the pain & difficulty of opening his left eye.

Salient features 57 years old Male Veterinarian Numerous vesicles on left cheek affecting left periorbital area and nasal region Pain and difficulty opening his left eye

Differential Diagnosis Miliaria Crystalline (Sudamina) Impetigo Contagiosa Steven Johnson Syndrome Herples Simplex Herpes Zoster

Miliaria The retention of sweat as a result of occlusion of eccrine sweat ducts Produces an eruption that is common in hot, humid climates(tropics and hot summer months in temperate climates) Staphylococcus epidermidis (Mowad et al) – Produces an extracellular polysaccharide that obstructs the delivery of sweat to the skin surface – occlusion prevents normal secretion from the sweat glands, and eventually the backed up pressure causes rupture of the sweat glands

Miliaria Crystalline/ Sudamina Small, clear, and very superficial vesicles with no inflammatory reaction Lesions are asymptomatic, short lived and self limited Appears in bedridden patients – in whom fever produces increased perspiration Bundled children – clothing prevents dissipation of heat and moisture

Miliaria crystallina in an infant. Note that the lesions are confluent. Courtesy of K.E. Greer, MD. Miliaria crystallina in an infant. Note that the lesions are confluent. Courtesy of K.E. Greer, MD.

Miliaria crystallina. Note the water-drop appearance of the lesions. Courtesy of K.E. Greer, MD.

Impetigo Contagiosa PatientImpetigo Contagiosa LesionNumerous vesicles Superficial weepy lesions covered by thick golden- yellow crusts with loose edges AgeAdult: 57 years oldEarly childhood AreaLeft cheek, Left periorbital area, and nasal region Face, hands neck and extremeties SequelaeSensory deficit: Pain and diffculty of opening left eye Renal Pathology: Acute glumerulonephritis

Impetigo Contagiosa

Steven Johnson Syndrome affecting the skin in which cell death causes the epidermis to separate from the dermis. Involves less than 10% body surface Initial lesion: macular followed by desquamation, or may form atypical targets with purpuric centers that coalesce, form bullae, then slough. Areas of predilection: oral mucosa and conjunctiva being most frequently affected.

Steven Johnson Syndrome Signs and Symptoms Fever and influenza-like symptoms precede eruption Photophobia Difficulty with swallowing Cough Painful on urination Rectal erosions

Steven Johnson Syndrome Skin biopsy: lymphocytic infiltrate at dermoepidermal junction with necrosis of keratinocytes. Etiology: Infections ( following HSV, Influenza, EBV, etc.) Adverse effects of drugs (allopurinol, diclofenac, isotretinoin, fluconazole, valdecoxib, oseltamivir, penicillins, brabiturates, sulfonamides, phenytoin, azithromycin, lamotrigine, pyrimethamine, ibuprofen, ethosuximide, carbamazepine and gout medications) Most common sequelae: ocular scarring, vision loss & sicca-like syndrome

Differential Diagnoses Herpes Simplex Lesion – Vesicles are intraepidermal – Dermis and epidermis containing infiltrates of leukocytes and serous exudates Area of Predilection – Oral herpes: Face and mouth (cold sores)

Herpes Simplex Signs and Symptoms Common infection of the skin or mucosa may affect the face and mouth (orofacial herpes), genitalia (genital herpes), or hands (herpes whitlow). More serious disorders occur when the virus infects and damages the eye (herpes keratitis), or invades the central nervous system, damaging the brain (herpes encephalitis).

Herpes Simplex Hallmark – Tzanck Smear: multinucleate epidermal giant cell. Etiology – HSV-1 Tzanck Smear showing multinucleated giant cell

Herpes zoster (Shingles) classically occurs unilaterally within the distribution of a cranial or spinal sensory nerve, often with some overflow into the dermatomes above and below. Most frequently affected: thoracic (55%) cranial (20%, with the trigeminal nerve being the most common single nerve involved) lumbar (15%) sacral (5%)

Herpes zoster (Shingles) Prodromal pain typically confined to the same dermatomal distribution occurs days before development of cutaneous lesions. The rashes, which are initially vesicular, gradually become pustular and then crust over during a period of 7-10 days.

Herpes zoster ophthalmicus The ophthalmic division of the CN V is involved. If the external division of the nasociliary branch is affected, with vesicles on the side and tip of the nose (Hutchinson's sign), and the eye is involved 76% of the time. Etiology: Varicella-zoster virus (reactivation)