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Disorders of Pigmentation. Postinflammatory Pigmentary Changes. Occurs Following Dermatitis Acne Infection Injury Description Hyperpigmentation Hypopigmentation Course Resolution over a few months. Pigmentary Mosaicism. Genetic mosaicism Born with 2 genetically different cell lines

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postinflammatory pigmentary changes
PostinflammatoryPigmentary Changes
  • Occurs Following
    • Dermatitis
    • Acne
    • Infection
    • Injury
  • Description
    • Hyperpigmentation
    • Hypopigmentation
  • Course
    • Resolution over a few months
pigmentary mosaicism
PigmentaryMosaicism
  • Genetic mosaicism
    • Born with 2 genetically different cell lines
  • Timing
    • May be seen at birth
    • May appear in infancy or early childhood
  • Description
    • Whorled, fountain-like pattern of alternating hypo- and hyperpigmentation
    • Blaschkoid distribution
    • Macules without vesicular or verrucous lesions
  • Other problems
    • CNS, MSK, eye
    • More likely if skin findings are prominent
vitiligo
Vitiligo
  • Acquired partial to complete loss of pigmentation
  • Description
    • Well-demarcated hypopigmented and depigmentedmacules and patches
    • Enhance under Wood’s lamp
    • Absence of melanocytes
  • Location
    • Eyes, mouth, genitals, elbows, hands and feet
    • Can appear anywhere
  • Cause
    • Autoimmune
ash leaf spots
Ash-Leaf Spots
  • Timing
    • Congenital
  • Description
    • Well demarcated, hypopigmentedmacules
    • Lancinate shape
    • May enhance with Wood’s light
  • Location
    • Truncal
  • Associated with
    • Tuberous Sclerosis
    • Normal
      • 0.5% newborns
      • Nevus depigmentosus
        • Localized form of pigmentarymosaicism
albinism
Albinism
  • Timing
    • Congenital
  • Description
    • Hypopigmentation of the skin, eyes and hair
  • X-linked ocular
    • Skin is normal
  • AR
    • Oculocutaneous
    • Many variants
  • Complications
    • At risk of skin cancer
    • Must avoid excessive sun and use sunscreen
albinism7
Albinism
  • Variants
    • Tyrosinase-negative OCA
      • No trace of pigment
      • Snow-white hair, pinkish-white skin, translucent or blue irises
      • Also may have nystagmus, moderate to severe strabismus and poor visual acuity
    • Tyrosinase-positive OCA
      • Look similar at birth
      • Develop variable amounts of pigment with increasing age
        • Eye color – gray to light brown
        • Hair color – blonde or light brown
piebaldism
Piebaldism
  • Partial albinism
  • AD – rare
  • Description
    • White forelock
      • Triangular patch of depigmentation and white hair on the frontal scalp
    • Circumscribed congenital leukoderma
      • Hypopigmented or depigmentedmacules on the face, neck, ventral trunk, flanks or extremities
      • May have scattered patches of normal pigmentation within
piebaldism9
Piebaldism
  • Variants
    • Waardenburg syndrome
      • Lateral displacement of the inner canthi and inferior lacrimal ducts
      • Flattened nasal bridge
      • Sensorineural deafness
    • Wolf syndrome
      • AR
      • Neurologic deficits
caf au lait spots
Café-au-lait spots
  • Description
    • Tan macules
  • May be a marker for
    • Neurofibromatosis type 1
      • Small and smooth borders
    • McCune-Albright
      • Large and segmental with jagged borders
    • Large or >4
question 10
Question 10

An 8-year-old boy presents with a 2-week history of an enlarging, tender lump on the scalp. The only notable finding on physical examination are alopecia overlying a boggy mass on the scalp and posterior cervical lymphadenopathy. Of the following, the MOST appropriate treatment is

  • Cefazolin orally
  • Griseofulvin orally
  • Incision and drainage
  • Ketoconazole topically
  • Mupirocin topically
alopecias
Alopecias
  • Alopecia Telogen Effluvium
    • Partial, temporary
    • 3 months after an emotional or physical stress
    • <50% loss
  • Alopecia Anagen Effluvium
    • Sudden loss of growing hairs
    • 80%
    • Tapering of the hair shaft and loss of adhesion to the follicle
    • Chemotherapy
alopecias14
Alopecias
  • Alopecia Areata
    • Description
      • Round or oval patches of hair loss
      • Absence of inflammation and scaling
      • Short (3-6mm) easily removable hairs at the margins
    • Location
      • Scalp, eyebrows, lashes or body
    • Severity
      • May be diffuse or generalized
    • Cause
      • Autoimmune
    • Other findings
      • Scotch-plaid pitting of the nails
    • Course
      • Difficult to predict
      • Treat any comorbid conditions
alopecias15
Alopecias
  • TrichorrhexisNodosa
    • Timing
      • At any age
    • Description
      • Hair shaft breakage
      • Brittle, short hairs
      • Frayed edges by microscopy
    • Cause
      • Damage to the outer cortex of the hair shaft
      • Trauma, chemicals
    • Course
      • Resolution with removal of insult
alopecias16
Alopecias
  • Friction alopecia
    • Infants
    • Self-limited
    • Prevented/treated with tummy-time
    • If severe or long standing consider neglect
  • Traction alopecia
    • Maintaining a tight pull on the hair shafts
      • Ponytails, pigtails, braids, cornrows
    • Course
      • Shaft fractures and follicular damage
      • Can lead to permanent scarring
alopecias17
Alopecias
  • Trichotillosis
    • AKA trichotillomania
    • Timing
      • School-age children and adolescents
    • Description
      • Bizarre patterns of hair loss
        • Usually broad linear bands on vertex or sides of scalp
        • Side opposite of dominant hand
      • Short, broken-off hairs with stubs of different lengths
      • Never completely bald
    • Associations
      • Situational stress
      • Sometimes psychiatric
aplasia cutis congenita
Aplasia Cutis Congenita
  • AR
  • Timing
    • Congenital
  • Etiology
    • Absence of or failure of formation of a localized area of scalp or skin
      • Dermis and epidermis
      • Some involve subq tissue and rarely calvarial defects
  • Location
    • Single lesion on vertex of scalp
    • Rarely multiple or involving trunk or extremities
aplasia cutis congenita19
Aplasia Cutis Congenita
  • Description
    • Birth
      • Sharply circumscribed open and weeping ulceration that may be covered by a thin membrane or crust
    • Healed in several weeks to months
      • Usually smooth atrophic scar
      • Look for hair collar sign
        • Neural tube defects
  • Associations
    • Limb defects, genetic anomalies
  • Treatment
    • Saline compresses
    • Topical antibiotics
    • Sterile dressings
tinea capitis
TineaCapitis
  • Most common organism
    • Trichophytontonsurans
      • Does not fluoresce
      • >95%
    • Microsporumcanis
      • Fluoresces bluish-green
      • 5%
  • Description is variable
    • Mild erythema and scaling with partial alopecia
    • Widespread breakage of the scalp
      • “salt-and-pepper”
    • More erythema, edema and pustules
      • Crusting
    • Heaped up scale with small pustules
tinea capitis21
TineaCapitis
  • Description is variable
    • Kerion
      • Intense inflammation with raised, tender, boggy plaques or masses studded with pustules
    • KOH mount shows infected hairs
    • Associated occipital, postauricular and posterior cervical adenopathy
  • Treatment
    • Oral antifungal agents
      • 6 weeks to 4 months
    • Selenium sulfide shampoo
    • Steroids
      • Severe inflammation
  • Course
    • May lead to scarring and permanent hair loss if untreated
  • Prevention
    • Do not share!
congenital and genetic disorders
Congenital and Genetic Disorders
  • Monilethrix
    • AD
    • Developmental hair defect
    • Timing
      • 2-3 month of age
    • Description
      • Brittle, beaded hair
      • Periodic narrowing of the hair shaft
    • Location
      • Scalp most severely affected
    • Course
      • Permanent
      • Appearance may improve with age
congenital and genetic disorders23
Congenital and Genetic Disorders
  • Pili torti
    • Hair shaft is twisted on its own axis
    • Timing
      • Appears with first terminal hair growth of infancy
    • Location
      • Localized or generalized
    • Associations
      • Menkes kinky hair syndrome
        • Defect of copper absorption
        • CNS, CV, Skeletal systems
disorders affecting nails
Disorders Affecting Nails
  • Paronychia
    • Acute
      • Red, swollen, tender nail fold
      • Bacterial invasion
        • Staph or strep
    • Chronic
      • One or several nails
      • Chronic dermatitis or frequent exposure to water
      • Nail dystrophy
      • Candida species
      • Treat with topical antimycotics
disorders affecting nails25
Disorders Affecting Nails
  • Onychomycosis
    • Fungal infection
    • Uncommon before puberty
  • Dystrophic nails
    • More commonly a result of trauma
      • Or underlying dermatosis
disorders affecting nails26
Disorders Affecting Nails
  • Subungual hemorrhage
    • Trauma
      • Crush injuries
      • Turf toe
        • Jamming toe into the end of a shoe suddenly
    • Description
      • Purplish-brown pigment
    • Treatment
      • Evacuation if painful