papulosquamous lesion


Case Discussion 

Patient with ESRD, comes with the complaint of pruritic lesion of 3-4 months duration. Below are the findings. 

 

 

What is the DDx? Diagnostic skin biopsy should be performed for reaching a diagnosis. 

  1. Inflammatory Disorder
    1. Lichen Planus
    2. Lichenoid Drug eruption
    3. Sarcoidiosis
    4. Psoriasis (BB like labetelol can cause it, usually is diffuse in such case)
    5. Dyshidrotic Eczema
  2. Infectious Disease
    1. Secondary Syphilis
    2. Eythema nodosum Leprosum
  3. Malignancy
    1. Kaposi Sarcoma
    2. Mast Cell Disease
    3. Primary Cutaneous T-cell lymphoma
    4. HTLV-associated adult T-cell lymphoma/leukemia
    5. Primary B cell cutaneous lymphoma
    6. Acute Myeloid or lymphoid leukemia with skin involvement (leukemia cutis)

Detailed Description
  1. Inflammatory Disorder
    1. Lichen Planus: exaggerated skin markings and scales; polygonal, purple, pruritic, flat topped papules and plaques; Koebner’s phenomenon (i.e., the appearance of lesions at sites of trauma) ; Flexor surfaces and mucous membranes are commonly involved, but the lesions can also be eruptive 
    2. Lichenoid Drug eruption: similar in appearance to those of lichen planus but are usually seen in photo distributed areas; Labetelol etc can cause it; two entities can be distinguished histologically; lichen planus, there is a bandlike lymphohistiocytic infiltrate at the dermoepidermal junction, whereas in patients with a lichenoid drug eruption, there are eosinophils and plasma cells in the infiltrate 
    3. Sarcoidiosis: may occur in many different morphologic forms, including scaly papules or plaques ; The lesions may be generalized (as they were in this patient), but cutaneous sarcoidosis most commonly occurs along the nares or lips or in scars ; Lymph node involvement is common
    4. Psoriasis (BB like labetelol can cause it, usually is diffuse in such case): pink scaly plaques that are usually well demarcated and keratotic; Psoriasis is most commonly seen on extensor surfaces or in areas of friction, but it can be widespread in severe cases or when it is induced by drugs,2 including beta-blockers such as labetalol 
    5. Dyshidrotic Eczema: pruritic and can be accompanied by wide- spread nummular eczema or atopic dermatitis 
  2. Infectious Disease
    1. Secondary Syphilis
    2. Eythema nodosum Leprosum: immune-complex reaction that occurs during treatment of borderline and lepromatous leprosy, can be manifested by eruptive erythematous plaques and nodules, along with systemic symp- toms, including painful lymphadenopathy. 
  3. Malignancy
    1. Kaposi Sarcoma: purple erythematous plaques and nodules; limited to one arm or leg but can be widespread; usually accompanied by lymphedema; skin-biopsy specimen would reveal spindle cells with slitlike vascular spaces that would be positive for human herpesvirus 8 on immunohistochemical staining 
    2. Mast Cell Disease: Widespread pruritic papules and plaques can be associated with cutaneous mastocytosis; Although urticaria pigmentosa lesions can easily urticate (Darier’s sign) in children, this feature is less common in adults ;Urticaria pigmentosa is more likely to be associated with systemic disease and hematologic cancer or mast-cell leukemia in adults than it is in children; rarely scaly;  
    3. Primary Cutaneous T-cell lymphoma: can be manifested by pruritic scaly plaques and papules that usually occur on the buttocks and other nonphotodistributed areas and appear gradually; There are several types of primary cutaneous T-cell lymphoma, including 
      1. mycosis fungoides (which is the most common): patch, plaque, or tumor and may also progress to involve the lymph nodes and viscera 
      2. primary cutaneous ana- plastic large-cell lymphoma (CD30+), 
      3. primary cutaneous gamma–delta T-cell lymphoma, and 
      4. primary cutaneous aggressive epidermotropic CD8+ T-cell lymphoma 
    4. HTLV-associated adult T-cell lymphoma/leukemia: The clinical variants of adult T-cell leukemia– lymphoma are acute, lymphomatous, chronic, and smoldering. Patients with the acute variant typically present with generalized lymphadenopathy, hepatosplenomegaly, skin lesions, peripheral- blood involvement, and hypercalcemia 
    5. Primary B cell cutaneous lymphoma
    6. Acute Myeloid or lymphoid leukemia with skin involvement (leukemia cutis)



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