Skin problems in rheumatology

Beverley Harrison
Consultant Rheumatologist
North Manchester General Hospital
Terminology
• Macule
– Flat lesion
• Papule
– Raised lesion < 1cm diam
• Nodule
– Raised lesion > 1cm diam
• Vesicle
– Fluid-filled lesion < 0.5 cm diam
• Bulla
– Fluid-filled lesion > 0.5cm diam
 Petechia / purpura
• Due to platelet disorders with
leakage of RBC from blood
vessels where platelet plugs are
the major source of coagulation
• Eg. Thrombocytopenia
• Petechia
– Intra-dermal haemorrhage
< 0.3cm diam
• Purpura
– Intra-dermal haemorrhage
> 0.3cm diam ( vascular
inflammation with
increased blood vessel
permeability)
 Seronegative
spondylarthropathies (SpA)
• Seronegative = RF
neg
• Spondyl…. = spinal
inflammation
• Often HLA-B27
positive
• Ankylosing
spondylitis
Psoriatic arthritis (PsA)
 PsA

• Psoriasis affects 1-3 % UK population

• Up to 1/3 develop arthritis
– Sacro-iliitis
– Asymmetrical large joint arthritis
– DIPJ arthritis
 Plaque psoriasis
Type I: age < 40 yrs: 85%
HLA-Cw6
Type II: age > 40 yrs
Extensor surfaces Sharply demarcated
Inverse psoriasis : scalp, Silvery scale
axillae, umbilicus,
perineum
Triggers
– Infection
– Skin trauma (Koebner)
– Drugs
– stress
 Guttate psoriasis
• Triggered by
streptococcal
infection
 Nail changes
• In 30% pts with
psoriasis & 70% pts
with PsA

• Pitting
• Ridging
• Onycholysis
• hyperkeratosis
DIPJ arthritis
Dactylitis
Reactive arthritis
• Incidence 3-4 / 10 000 / year
• Young adults
• M>F
• Triggered by infection
– STD (chlamydia)
– Enteritis (salmonella, shigella)
Asymmetrical large joint
oligoarthritis
Keratoderma blenorrhagica

Identical to pustular psoriasis

Circinate balanitis
Connective tissue diseases
Raynauds phenomenon
• White / blue / red
• Primary
– 15% popn.
– Onset in teenage years
• Secondary
– Esp. limited cutaneous
systemic sclerosis
– 95% pts have positive
ANA or abnormal nail fold
capillaries
 Nail fold capillaries

Opthalmoscope + 20 d

Nail fold hyperaemia

Dilated, tortuous loops

 Nail fold microscopy

normal

Drop-out
Dilated loops
Digital pitting

Usually systemic sclerosis

SLE
 SLE

• Auto-immune disease with immune

complex formation & tissue destruction
• Prevalence 0.2 / 1 000
• 9F: M
• ANA positive in 20% normals (95%
SLE)
• ds-DNA specific for SLE
 Acute cutaneous lupus
• Malar (butterfly)
rash
• 50% patients
• Itchy / painful
• Lasts hours – weeks
• May reflect disease
activity
 Photosensitivity
• 50% patients
• Sunlight also
exacerbates
systemic disease
• Need total sun block
Lupus band test (skin biopsy)

Deposition of Ig and complement at dermo-epidermal junction

 Discoid lupus
• Can occur alone or
with systemic lupus
• Papules / plaques
with scaling on
cheeks & other
photosensitive areas

–Central hypopigmentation
–Follicular plugging
–Atrophy & scarring
–Permanent alopecia
 Alopecia
• Patchy or diffuse
• May reflect disease
activity
• Non-scarring
• ‘lupus hairs’ on
forehead
Non-specific features of SLE
vasculitis

Mouth ulcers

Livedo reticularis
Systemic sclerosis
 SSc

• Auto-immune disease characterised by

vascular fibrosis & collagen deposition
in skin and organs
• Prevalence 0.2 / 1 000
• 4F : M
• Anti-centromere antibodies and anti-scl
70
• Limited cutaneous SSc
– Commonest form
– Skin involvement on face and distal to
elbows and knees
– Includes CREST (calcinosis, raynauds,
esophageal, sclerodactyly, telangiectasia)
• Diffuse cutaneous systemic sclerosis
– High risk of internal organ involvement
(heart, kidneys, lungs)
 Hand involvement

Puffy hands Pitting / ulcer

scerodactyly Digital loss

 Facial involvement

Pinched (beak) nose

‘mauskopf’

Pseudo-rhagades
 telangiectasiae

Esp. CREST
Mat telangiectasiae
flat, up to 7mm diam.
Diffuse SSc
Dermatomyositis
• Rare inflammatory disorders of skeletal
muscle
• Proximal muscle weakness and high
CPK
• Polymyositis and dermatomyositis
Heliotrope rash
Rash on extensor surfaces

Gottron’s papules

‘shawl’ sign
Mechanics hands

calcinosis
Vasculitis
 venulitis
• Legs, buttocks
(increased orthostatic
pressure)
• Triggers
– Chronic bacterial
infection
– Hep B
– Drugs
– RA / CTD
– HSP
• Good prognosis
 Necrotising arteritis

Irregular purpura
livedo

nodules
infarction
 Erythema nodosum
• Panniculitis
• Red/violet tender sc
nodules up to 5cm diam
• Esp. in pre-tibial area
• Often assoc. with
arthritis or arthralgia
• Self-limiting (6 weeks)
 Causes of EN
• Infection
– Streptococcal
– TB
• Drugs
– OCP
– Sulphonamides
• Pregnancy
• IBD
 Acute sarcoidosis
• EN
• Arthritis
• Iritis
• Bilateral hilar
lymphadenopathy
The end