Bullous Pemphigoid BP
Bullous Pemphigoid (BP) (Continued)
Etiology: IgG produced against antigens in the dermal-epidermal basement membrane leads to subepidermal tense bullae.
History: Autoimmune bullous skin disease observed predominantly in patients > 60 yr; usually self-limited over 5—6-yr period. It may be accompanied by pruritus, especially in urticarial (early) form of BP.
Physical: Large tense bullae and denuded areas on erythematous or normal skin; 20% have oral lesions.
Investigations: Lesional biopsy for histology and perilesional for immunofluorescence.
DDx: Bullous impetigo/tinea, pemphigus (or many other autoimmune blistering conditions), drug-induced bullous disorders.
Management
■ Topical strong steroids, e.g., clobetasol cream/ungt bid (for localized disease).
■ Can use oral prednisone (0.75 mg — 1 mg/kg/d) +/- steroid sparing agents (e.g., azathioprine, mycophenolate mophetil).
■ Methotrexate (lower doses than psoriasis; often 7.5 mg—15 mg sufficient).
■ Tetracycline (1g—2 g/d) and nicotinamide (1.5 g—2 g/d) effective in some cases.
Courtesy of Dr. William Gerstein
Etiology: Cutaneous or mucous membrane infection caused by Candida albicans yeast. More prevalent in immunosuppres-sed patients, diabetics, patients who've had prolonged use of antibiotics, corticosteroids, or immunosuppressive agents; heat, humidity, and shear friction promote infection. History: Skin surfaces in close proximity that provide a warm and moist environment. Pruritic red rash. Paronychia and onychomycosis present as painful and red areas around the nail and can be associated with immersion of hands in water and with diabetes mellitus. Investigations: KOH microscopy of scrapings from lesions reveals mycelium & spores; confirmatory fungal culture. DDx: Eczema, psoriasis, seborrheic dermatitis. Candidal intertrigo is a common cutaneous pattern: E.g., groin and gluteal folds, the inframammary region, axilla and the interdigital spaces of the hands and feet affected. Physical: Initially vesicles, pustules, or erythematous plaques, progressing to maceration and fissuring. Central erythematous plaque often bordered by discrete pustules in a "satellite pattern."
Oral candidiasis = thrush: Chronic mucocutaneous candidiasis may be associated with autoimmune diseases and endocrino-pathies.
Physical: White plaques occur on the mucosal surfaces of the mouth (thrush); lesions may be removed by scraping, yielding an erythematous base.
Candida paronychia (nail infection) is often a result of chronic water exposure and trauma: Painful red swelling of periungual skin.
Management
Prevention: Avoid heat, humidity, and tight-fitting clothing. Tx
■ Identify and control underlying diseases, e.g., diabetes.
■ Topical antifungals: E.g., nystatin, ketoconazole, clotrimazole, bid x 2 wk
■ Oral antifungals in extensive mucocutaneous infections: E.g., ketoconazole 200 mg po qd x 10 d.
■ Vaginal candidiasis: Single dose oral fluconazole 150 mg effective; topical & suppositories can be tried.
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