Title: GZ / The Grenz Zone Season 1 / Episode 11
Tags: GZ DermnetNZ Waikato

Q: Fungi can be classified as [filamentous fungi that weave together and form mycelium], [round, unicellular organisms that reproduce by budding], or [i.e. blastomycosis] fungi
A: molds; yeasts; dimorphic
Back Extra: Molds - Dermatophytes, opportunistic aspergillus
Yeasts - Cryptococcus, Candida, Malassezia furfur
Dimorphic - Mold in the cold, yeast in the beast: Coccidiomycosis, Paracoccidiomycosis, Histoplasmosis, Blastomycosis

Q: Dermatophytes fall into which type of fungus?
[molds, yeasts, or dimorphic]
A: Molds
Back Extra: Molds - Dermatophytes, opportunistic aspergillus
Filamentous fungi that weave together and form mycelium
Acquired via direct contact with animals, other infected humans, fomites
Example of another mold (aspergillus) shown

Q: What are the 3 main types of molds that make up tinea infections?
[...], [...], and [...]
A: Microsporum; epidermophyton; trichophyton

Q: Most common cause of tinea capitis in the U.S?
[...]
Worldwide?
[...]
A: Trichophyton tonsurans; Microsporum canis
Back Extra: Trichophyton - Causes an endothrix, within the hair shaft
Canis - Causes an ectothrix, outside the hair shaft

Q: Tinea capitis
Trichophyton tonsurans causes an [...]-thrix, while microsporum canis causes an [...]-thrix
A: endo; ecto
Back Extra: Meaning the infection is within (endo) or outside of (ecto) the hair shaft

Naming tinea infections by location
Scalp, eyebrows, or eyelashes: Tinea Capitis
Beard: Tinea Barbae
Face: Tinea Faciei
Torso: Tinea Corporis
Arms & Legs: Tinea Corporis
Groin: Tinea Cruris
Feet: Tinea Pedis
Nails: Tinea unguium or onychomycosis
Hair Follicles outside scalp: Majocchi granuloma
Back Extra: Remember if scrotum affected think candida, not tinea
Capitis
Barbae
Facei
Corporis
Pedis
Cruris
Onychomycosis
Majocchi granuloma

Q: What is the difference between hyphae and pseudohyphae?
Pseudohyphae are chains or budding cells that can look similar to hyphae but [...]
A: have constrictions between the cells that makes them look like sausage link
Back Extra: Hyphae are long branching filaments that are partitioned by septa w/out constrictions between the cells
Pseudohyphae of candida shown

Q: Histology of tinea would show hyphae in the stratum [...]
A: corneum
Back Extra: Highlighted by PAS stains

Topical antifungals (terbinafine (lamisil), ketoconazole, clotrimazole, ciclopirox, tolnaftate, naftine) are often used to treat superficial tinea infections that do not involve the face or hair follicle
Back Extra: Econazole used as well
Naftine ie naftifine works for tinea infections, whereas nystatin does not work for
Oral antifungals for extensive lesions and hair follicle involvement (terbinafine, fluconazole)

Q: Why do tinea capitis, tinea faciei, and Majocchi granulomas require oral therapy?
[...]
A: Topical tx cannot penetrate to the hair follicle in the deep dermis
Back Extra: Terbinafine andfluconazole often used

Q: [Acute/Chronic] cutaneous lupus has a stronger association with systemic SLE
A: Acute
Back Extra: Chronic - discoid lupus, hypertrophic lupus, lupus panniculitis,
tumid lupus, mucosal lupus

Q: Subacute cutaneous lupus comes in two forms: [...] and [...]
A: papulosquamous; annular
Back Extra: Papulosquamous may appear like psoriasis, but a nice clue is that it papulosquamous SCLE occurs in photodistributed areas

Q: Annular SCLE presents as [arrangement] annular plaques occurring on the [...]
A: polycyclic; sun-exposed areas of the face, neck and upper back

Q: Which labs are most likely to be positive in a patient with subacute lupus erythematous
[...] & [...]
A: Anti-Ro (anti-SSA); Anti-La (anti-SSB)
Back Extra: Also positive in Sjogren syndrome and neonatal Lupus
Subacute cutaneous lupus erythematosus (SCLE) Rule of 50s
o Rule of 50s: ~ 1⁄2 have + ANA, ~ 1⁄2 meet criteria for SLE, ~ are 1⁄2 photosensitive,
~ 1⁄2 show positive findings on Direct immunofluorescence

Q: Positive Antii-Ro (anti-SSA) & Anti-La (anti-SSB) antibodies are  in what 3 conditions?
[...], [...], [...]
A: SCLE; Sjogren syndrome; neonatal Lupus

Q: Drug-induced subacute cutaneous lupus presents with what antibody?
[...]
A: Anti-Ro (80% of cases)
Back Extra: Different from the anti-histone antibody seen in drug-induced SLE, in which there is more systemic involvement (arthralgias) and less cutaneous involvement than is seen in SCLE

Q: What drugs are known to cause subacute cutaneous lupus erythematous (SCLE)?
[...]
A: Terbinafine, Hydrochlorothiazide, ACE-I, NSAIDs, Griseofulvin
Back Extra: “THANG”
vs “My HIPP” for drug-induced SLE – Minocycline (+p-ANCA), Hydralazine, Isoniazid, Procainamide, Penicillamine

Biopsy for subacute cutaneous lupus erythematous (SCLE)
Vacuolar interface with prominent lymphocytic infiltrate, thickening of the basement membrane, mucin deposition, perivascular and peri-adnexal lymphoid aggregates
Back Extra: Vacuolar interface = degenerative changes at DEJ looking like bubbles (example shown below)

Treatment options/considerations for subacute cutaneous lupus erythematous
Hydroxychloroquine (plaquinil)
Sun Protection
Topical steroids
Stop/switch possible causative medications

Treatment options/considerations for subacute cutaneous lupus erythematous
Antimalarials: hydroxychloroquine
Sun Protection
Topical steroids
Stop/switch possible causative medications

Q: Erythema annulare centrifigum has a long list of possible triggers, including infections, particularly [...] infections
A: tinea
Back Extra: Make sure to inspect for tinea infections elsewhere
Other causes include
Medications: penicillin, plaquenil, cimetidine, HCTZ, amitriptyline
Foods: blue cheese, tomatoes
Autoimmune: SLE, hashimotos thyroiditis, pemphigus vulgaris
Cancer: leukemia, lymphoma, breast, lung, GI, and prostate cancer

Q: Erythema annulare centrifigum has a long list of possible triggers, including infections, [...], foods, [...], and [...]
A: medications; autoimmune associations; cancers
Back Extra: Drugs: penicillin, hydroxychloroquine (plaquenil), cimetidine, HCTZ, amitriptyline
Autoimmune: SLE, hashimotos thyroiditis, pemphigus vulgaris
Cancer: leukemia, lymphoma, breast, lung, GI, and prostate cancer

Q: Erythema annulare centrifigum has a long list of possible triggers, including foods, such as [...] and [...]
A: blue cheese; tomatoes
Back Extra: Watch out for that chopped salad!
Other causes include
Infections: Particularly tinea
Medications: penicillin, plaquenil, cimetidine, HCTZ, amitriptyline
Autoimmune: SLE, hashimotos thyroiditis, pemphigus vulgaris
Cancer: leukemia, lymphoma, breast, lung, GI, and prostate cancer

Q: Erythema annulare centrifugum is subdivided into [...] and [...] variants
A: superficial; deep
Back Extra: Superficial: Single or multiple annular, erythematous scaling plaques that are slow growing and occasionally pruritic w/ trailing
scale
Deep: Dermal process, so no scale on lesions
Superficial shown

Q: Diagnosis of erythema annulare centrifugum involves first performing a KOH prep, which will be [...]
A: negative
Back Extra: May address triggers and/or perform biopsy after that

Q: Biopsy of erythema annulare centrifugum classically displays a “[...]” infiltrate with a diagonal cut
A: coat-sleeve
Back Extra: “Coat-sleeve” infiltrate = densely packed lymphocytes around the blood vessels

Q: The most important treatment for erythema annulare centrifugum involves [...]
A: addressing triggers
Back Extra: Treatments that may work (but haven't shown to be completely effective) include topical steroids, calcineurin inhibitors, and UV treatments

In subacute cutaneous lupus erythematosus (SCLE), ~ 1 ⁄ 2 of patients have a positive ANA, ~ 1 ⁄ 2 meet criteria for SLE, ~1 ⁄ 2 are photosensitive, and ~ 1 ⁄ 2 show positive findings on direct immunofluorescence
Back Extra: Rule of 50s (~50%)