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| == Differential Diagnosis == | | == Differential Diagnosis == |
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| The size or validity of the differential diagnosis presented with a child or adult with blistering of the skin is most certainly a reflection of the level of training and expertise of the physician. In almost all situations the diagnosis of EB should be apparent to a dermatologist, with only a marginal number of cases needing more of wide-ranging differential diagnoses before tissue confirmation<ref name="5" />. | | |
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| <br><u>Pemphigus vulgaris</u><br> Pemphigus vulgaris (PV) is a rare autoimmune, intraepithelial, blistering disease that is associated with a very encumbering quality of life. PV is characterized by autoantibodies against desmoglein 3 and desmoglein 1 of keratinocytes. It clinically, however, is characterized by extensive blisters that affect the skin and mucous membranes<ref name="6">Zhao C, Murrell D. Pemphigus Vulgaris: An Evidence-Based Treatment Update. Drugs [serial on the Internet]. (2015, Feb 15), [cited April 5, 2016]; 75(3): 271-284 14p. Available from: CINAHL with Full Text.</ref>. This is found in the mucous membrane in 95% of cases (oral, pharyngeal, esophageal, nasal, and genital), followed by skin lesions, crusting, and purple stains on the anterior chest, back, and abdomen, with oral lesions being common as well. Characteristics of these blisters include a diameter consisting of millimeters to centimeters that is isolated or in groups that appear to be fragile and flaccid, breaking in eroded areas, becoming bloody and wet, and covered with bloody crusting. Areas such as the face, scalp, neck, sternum, armpit, groin and periumbicals may experience a burning sensation<ref name="7">Pena S, Guimarães H, Bassoli S, Casarin S, Herdman T, Barros A. Nursing Diagnoses in Pemphigus Vulgaris: A Case Study. International Journal Of Nursing Knowledge [serial on the Internet]. (2013, Oct), [cited April 5, 2016]; 24(3): 176-179 4p. Available from: CINAHL with Full Text</ref>. <br> The treatment goal of PV is to prevent new blister formation, heal old wounds, and eventually complete the tapering of treatment. As of now, there has been been no treatment strategy for PV according to the international consensus. The best treatment strategy for PV remains unclear as higher quality RCTs are needed in the future to explore other unstudied interventions<ref name="6" />.
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| <u>Bullous systemic lupus erythematosus</u><br> Bullous systemic lupus erythematosus (BSLE) is a rare and distinct subtype of SLE, occurring mostly in the third decade. This subepidermal blistering disease occurs in patients that have been diagnosed with systemic lupus erythematosus (SLE), with a low occurrence of only 1%. Clinically, patients diagnosed with BSLE present with a rapid, widespread small vesicles or large tense blisters that are filled with fluid<ref name="8">Duan L, Chen L, Zhong S, Wang Y, Huang Y, Shi G, et al. Treatment of Bullous Systemic Lupus Erythematosus. Journal Of Immunology Research [serial on the Internet]. (2015, May 18), [cited April 5, 2016]; 20151-6. Available from: Academic Search Complete.</ref>. These lesions may affect the trunk and limbs, or even face and mucous membranes, involving any area of the body. Diagnosis of BSLE includes the following: a past diagnosis of SLE based on American College Criteria (ACR), presence of vesicles and bullae most commonly located in sun-exposed sites, histopathology findings, and deposition of immunoglobulins at the basement membrane zone. Patient evaluation is critical, as a prompt diagnosis may prevent further SLE complications and change the prognosis and method to treatment<ref name="9">Lourenço D, Cunha Gomes R, Aikawa N, Campos L, Romiti R, Silva C. Childhood-onset bullous systemic lupus erythematosus. Lupus [serial on the Internet]. (2014, Nov), [cited April 5, 2016]; 23(13): 1422-1425. Available from: Academic Search Complete.</ref>. <br> In regards to treatment for BSLE, dapsone, corticosteroids, and/or immunosuppressant’s are the first treatment options to consider. If symptoms do not go away rituximab might be appropriate to consider<ref name="8" />.
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| <u>Bullous Pemphigoid</u><br> Bullous pemphigoid (BP), idiopathic in origin, is the most common autoimmune subdermal blistering disease of the skin and mucous membranes, occurring from antibodies directed against the proteins BPAG1 and BPAG2<ref name="10">KIBSGAARD L, BAY B, DELEURAN M, VESTERGAARD C. A Retrospective Consecutive Case-series Study on the Effect of Systemic Treatment, Length of Admission Time, and Co-morbidities in 98 Bullous Pemphigoid Patients Admitted to a Tertiary Centre. Acta Dermato-Venereologica [serial on the Internet]. (2015, Mar), [cited April 5, 2016]; 95(3): 307-311. Available from: Academic Search Complete.</ref>. This disease is most commonly seen in elderly individuals and is characterized with blistering of the skin as well as intense pruritus<ref name="11">Feliciani C, Joly P, Jonkman M, Zambruno G, Zillikens D, Borradori L, et al. Management of bullous pemphigoid: the European Dermatology Forum consensus in collaboration with the European Academy of Dermatology and Venereology. British Journal Of Dermatology [serial on the Internet]. (2015, Apr), [cited April 5, 2016]; 172(4): 867-877. Available from: Academic Search Complete.</ref>. Systemic corticosteroids, prednisone, in doses of 1 mg/kg/day, with dose tapering according to the therapeutic control of disease was shown to be the treatment of choice with the highest level of evidence for BP<ref name="12">ROTARU M, OPRIŞ A. UPDATE AND LITERATURE REVIEW OF TREATMENT AND PROGNOSIS FACTORS IN BULLOUS PEMPHIGOID. Acta Medica Transilvanica [serial on the Internet]. (2015, June), [cited April 5, 2016]; 20(2): 52-54. Available from: Academic Search Complete.</ref>.
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| <u>Dyshidrotic eczema</u><br> Dyshidrotic eczema is a chronic, recurrent skin disease that effects the palms and soles symmetrically. It often is a very intense and painful condition that can have a very devastating impact on quality of life. Although the etiology is unclear, dyshidrotic eczema is often triggered by emotional stress, smoking, seasonal changes, fungal infections, atopy, nickel allergy, hyperhidrosis, and intravenous immunoglobulin therapy<ref name="13">Markantoni V, Kouris A, Armyra K, Vavouli C, Kontochristopoulos G. Remarkable improvement of relapsing dyshidrotic eczema after treatment of coexistant hyperhidrosis with oxybutynin. Dermatologic Therapy [serial on the Internet]. (2014, Nov), [cited April 5, 2016]; 27(6): 365-368. Available from: MEDLINE.</ref>. Much like many other types of eczema, this is a benign chronic inflammatory disease that may occur at intervals of 3 to 4 weeks for months or years, or even progress to longer irregular intervals. Dyshidrotic eczema has no impact on survival as well as very few effective treatment options<ref name="14">Velez A, Pinto Jr. F, Howard M. Dyshidrotic eczema: relevance to the immune response in situ. North American Journal Of Medical Sciences [serial on the Internet]. (2009, Aug), [cited April 5, 2016]; 1(3): 117-120. Available from: Academic Search Complete.</ref>.
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| <u>Linear IgA Bullous Dermatosis </u><br> Linear IgA Bullous Dermatosis (LAD) is an autoimmune, chronic bullous disease affecting mainly young children and adults. Sub-epithelial blister formation with neutrophils along the basement membrane zone are typically histological characteristic features in LAD.<br>Childhood onset LAD is characterized by vesicles and bulla mainly around the mouth, eyes, lower abdomen, thighs, buttocks, genitals, wrists, and ankles. Subjective symptoms range mild pruritus to severe burning. The adult onset form presents with lesions on the trunk and occasionally head and limbs. The most often used treatment modalities in both children and adults are corticosteroids, dapsone, and sulpapyridine<ref name="15">Lings K, Bygum A. Linear IgA bullous dermatosis: a retrospective study of 23 patients in Denmark. Acta Dermato-Venereologica [serial on the Internet]. (2015, Apr), [cited April 5, 2016]; 95(4): 466-471. Available from: MEDLINE.</ref>. <br><br>
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| == Case Reports/ Case Studies == | | == Case Reports/ Case Studies == |
Welcome to
PT 635 Pathophysiology of Complex Patient Problems This is a wiki created by and for the students in the School of Physical Therapy at Bellarmine University in Louisville KY. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!
Epidermolysis bullosa (EB) consists of a rare group of genetically determined skin fragility disorders, categorized by blistering skin and mucosa in response to little or no apparent trauma, with some forms leading to substantial morbidity and increased mortalityCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title. The fragility of skin and mucosa within this disease is due to defects in structural proteins within the epidermis, specifically at the epidermal-dermal junction, that cause a deficiency of cellular structures that normally stabilize the adhesion of the epidermis. These, in turn, result from abnormalities in the genes encoding various proteins that define EB into specific categoriesCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title. Accordingly, EB has been classified into three major different subtypes based on mode of inheritance, location of lesions, and clinical features which include the following three major forms: EB simplex (EBS), junctional EB (JEB), and dystrophic EB (DEB)Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title. These three different subtypes are based on the level of blistering of the skin, although the classification of EB continues to evolve with recognition of up to 30 clinical subtypesCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.
All types and subtypes of EB are rare. Estimates of prevalence and incidence of EB have been endeavored by many different sampling techniques in numerous populations worldwide, but the most accurate and up to date epidemiological data is derived from the National EB registry (NEBR) from the USA. This registry is a cross-sectional and longitudinal epidemiological study of patients diagnosed with EB across the entire U.S. Over 16 years (1986-2002), 3,300 patients were identified, enrolled, classified, characterized, and followed for outcomesCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title. Among this study, the overall incidence and prevalence of inherited EB, within the United States, is approximately 19.60 per one million live births and 8.22 per one million population, respectively. When analyzing the different classifcations of EB, the incidence and prevalence rates for EB simplex are 10.75 and 4.65, for junctional EB are 2.04 and 0.44, for dystrophic EB recessive type are 2.04 and 0.92, and dystrophic EB dominant type are 2.86 and 0.99Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.
Characteristics/Clinical Presentation[edit | edit source]
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Currently no drugs are known to correct the primary molecular effects in EB. Recently, the use of topical opiates for pain management has been proven to reduce the need for powerful systemic analgesia. Amitriptyline, as well, has also been found to be useful in both children and adults in reducing pain. As far as systemic treatment, no agents thus so far have proven to be effective in controlling blisters in patients diagnosed with EB. Along with this, prolonged use of corticosteroids is contraindicated because of the high risk of complications associated with this drug. No other medication, including phenytoin and tetracycline, have improved the blistering or epithelial disadhesion in EB. Thus, there is no current reliable clinical trial evidence for any type of treatment with medicationCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.
Diagnostic Tests/Lab Tests/Lab Values[edit | edit source]
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Medical Management (current best evidence)[edit | edit source]
Physical Therapy Management (current best evidence)[edit | edit source]
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Case Reports/ Case Studies[edit | edit source]
add links to case studies here (case studies should be added on new pages using the case study template)
add appropriate resources here
see tutorial on Adding PubMed Feed
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see adding references tutorial.
