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METHODOLOGICAL INSTRUCTIONS
TO PRACTICAL LESSONS FOR 4-nd COURSE STUDENTS OF
DENTISTRY FACULTY
LESSON №4 (6 HOURS)
Themes: 1. Lichen simplex chronic (Neurodermitis limited).
2. Diagnostic criteria and dermatological symptoms of collagen vascular
diseases. Systemic lupus erythematosus. Discoid lupus erythematosus.
3. Systemic sclerosis (dermatosclerosis): progressive systemic sclerosis.
Morphea
localized.
Scleroderma
striata.
Sclerodactylia.
Dermatopolymiositis.
Aim: To develop skills in methods of skin assessment, identification of skin
lesions, working out plan of general examination, treatment and prophylaxis of
lichen simplex chronic, systemic lupus erythematosus (SLE), discoid lupus
erythematosus (DLE), systemic sclerosis.
Professional orientation of students:
Connective tissue disorders include a family of more than 200 different
disorders that affect connective tissues. Connective tissue disorders are caused
primarily by gene mutations affecting the production of tissue and by a number of
different specific and overlapping autoimmune diseases. In autoimmune
connective tissue disorders, specific organs (organ-specific diseases) or multiple
organs (systemic diseases) may be affected. Up until the late 70’s, most systemic
or rheumatological autoimmune diseases were referred to as connective tissue
diseases or collagen diseases. Today, connective tissue diseases are classified as
either 1) autoimmune connective tissue disorders such as lupus disorders,
rheumatoid arthritis, and dermatomyositis or 2) heritable connective tissue
disorders (HCTDs) such as Ehlers-Danlos syndrome, epidermolysis bullosa, and
Marfan syndrome caused by gene mutations. In the HCTDs, alterations in affected
genes may change the structure and development of connective tissue in specific
organs.
Inflammatory
myopathies.
Inflammatory
myopathies,
including
dermatomyositis and polymyositis, are a heterogeneous group of acquired diseases
of skeletal muscle characterized by weakness and inflammation. They are rare,
involving 5-10 per million adults. Dermatomyositis, which includes skin
involvement, is seen most often. It can involve internal organs like the heart and
lungs. Polymyositis mainly affects only the muscles. Although these disorders can
be life threatening, with modern treatment most patients achieve good long-term
outcomes1. Inflammatory myositis impacts on many aspects of life including
employment, social activities and family relationships. Mainly this is due to muscle
weakness. But fatigue and general ill health associated with persistent
inflammation and the involvement of internal organs such as the lungs also have
debilitating effects2. Patients with myositis are seen by several specialists
including rheumatologists, neurologists and dermatologists and this creates
particular challenges in delivering high-quality care for people with a rare
condition.
Scleroderma.Scleroderma (systemic sclerosis) is an uncommon connective
tissue disease affecting around 1 in 10,000 of the population but has a major
impact on those who develop the disease. It is a multi-system connective tissue
disease that affects the musculoskeletal system and skin but also can involve
internal organs such as the heart, lung and kidneys. It can be life-threatening and
has the highest mortality per case of any of the connective tissue diseases.
Scleroderma impacts on almost all aspects of the life of someone with the
condition, including employment, social interactions and family relationships by
restricting function, causing fatigue and by affecting vital organs such as the heart,
lungs, kidneys and gastrointestinal tract. The diversity of scleroderma presents a
real challenge to developing recommendations for management but without these,
care will be fragmented and inadequate, and there is a real possibility that
important treatable aspects of the condition will be neglected.
Sjogren's syndrome. Sjogren's syndrome causes severe dryness of the eyes
and mouth with an accompanying arthritis. It usually starts over the age of 50 and
prevalence figures between 0.5% and 3% of the population have been claimed.
Swelling of the lymph glands in the head and neck and of the parotid gland are
well recognized complications, as are poor circulation, fatigue and 1neurological
complications. It is not usually a fatal disease but is associated with a greatly
increased risk (up to 40 times) of a non-Hodgkin's B cell lymphoma. The treatment
of Sjogren's syndrome is principally symptomatic using replacement eye drops and
saliva solutions to keep the eyes and mouth as moist as possible. Our increased
understanding of the causes of this disease is also leading to the development of
some newer therapies for it.
System lupus erythematosus. Systemic lupus erythematosus (SLE or
sometimes known just as lupus) is a connective tissue disease which is mostly
found in women during the childbearing years. It affects between 40 and 200
people per 100,000, being commonest in the black population. Although the skin
and joints are the most commonly affected organs, lupus is a disease which can
affect any organ or system. Though the mortality and morbidity rates for lupus
have improved significantly, it retains a life threatening capacity and has major
effects on the quality of life of people living with the condition. It causes a huge
range of problems from severe fatigue to renal failure requiring renal dialysis
and/or transplantation. It is a great mimic of other conditions and one of the
ongoing challenges is to recognize the condition as soon as possible and thus to
treat it appropriately. Important advances in our understanding of the cause of this
disease are leading to some exciting new developments in its treatment.
Methodology of Practical Class (9.00-12.00)
Methodic of Student s Practical Activity:
1. To prepare to communication with a patient and examination (clean warm
hands, cut off nails, if necessary - gloves, spatula, needed instruments).
2. Greeting and identification (name, level of competence), get the agreement
of patient.
3. At the receiving of agreement of patient to set confidential mutual relations
(a friendly face, respect and concern, soft talk during conversation).
4. To collect complaints, anamnesis of illness to explain to the patient the
reason of finding out of separate questions.
5. To explain the results of questioning.
6. To explain to the patient, what examination will be done and its
reasonability, to get an agreement.
7. To notify about the possibility of the occurrence of unpleasant feelings
during examination.
8. To conduct the examination of patient (to estimate the general state,
consciousness status, position of patient in the bed, detail history of the disease,
inspection of unigured skin areas (color – pale, icteric, cyanotic etc.);
dermatological status (inspection; palpation; scraping; diascopy), skin lesions
(type, shape, and arrangement). It is necessary to reveal features of clinical motion
of lichen simplex chronic, systemic lupus erythematosus (SLE), discoid lupus
erythematosus (DLE), systemic sclerosis.
9. To explain the results of examination understandably for patient.
10. To finish a conversation, thank for communication, wish favorable flow of
illness and rapid convalescence.
Practical work 1. To diagnose sites of predilection of Discoid lupus
erythematosus
Practical work 2. To diagnose sites of predilection of Systemic sclerosis.
Break (12. 00-12.30)
Students’ independent Study Program:
1.
Anatomy, histology, and physiology of the skin – layers of skin, epidermal
layers, cell of the epidermis, dermis layers, and cells of the dermis, hypodermis,
functions of the skin, glands of the skin, hair and nails.
2.
Skin lesions and methods of examination of patients with skin diseases –
terms used to describe skin lesions (type, shape, and arrangement), investigations.
3.
Features of clinical motion of lichen simplex chronic, systemic lupus
erythematosus (SLE), discoid lupus erythematosus (DLE), systemic sclerosis. Principles
of their differential diagnosis, prophylaxis, and treatment.
Seminar discussion of theoretical questions and practical work (12.30-14.00)
Break (14. 00-14.15)
Individual students work (14.15-15.00)
Test evaluation and situational tasks.
Tests:
1) The localized form of Morphoea may present as all, except:
A.
Guttate.
B.
Plaque.
C.
Linear.
D.
Burrow.
E.
Both are wrong.
2) Scleroderma is a disease characterized by all, except:
A.
Sclerosis of the skin.
B.
Sclerosis of the visceral organs.
C.
Vasculapathy (Raynaud’s phenomenon).
D.
Presence of autoantibodies.
E.
Discoid lupus erythematosus.
3) Coetaneous manifestations of progressive systemic sclerosis (PSS) can be divided into
such stages:
A.
Edematous.
B.
Atrophic.
C.
Indurative or sclerotic.
D.
Both are correct.
E.
Both are wrong.
4) Lupus erythematosus (LE) means:
A.
Discoid lupus erythematosus (DLE).
B.
Subacute cutaneous lupus erythematosus (SCLE).
C.
Systemic lupus erythematosus (SLE).
D.
Both are correct.
E.
Both are wrong.
5) Discoid lupus erythematosus (DLE) mens all, except:
A.
Localized discoid lupus erythematosus .
B.
Lupus profundus ( lupus panniculitis ).
C.
Hypertrophic DLE.
D.
Morphoea.
E.
Both are correct.
6) When the scale is removed (Benye-Meschersky sign), according to great pain,
patient throw back it’s:
A.
Head.
B.
Hand.
C.
Leg.
D.
Hand and leg.
E.
Head and leg.
7) When the scale is removed (“Carpet tack” sign), its undersurface shoes keratotic
spikes which have occupied the dilated:
A.
Pilosebaceous canals.
B.
Sebaseous glands.
C.
Sweat glands.
D.
Sebaseous glands and sweat glands.
E.
Both are correct.
Students should know:
1. Classification of connective tissue diseases.
2. Pathogenesis of connective tissue diseases.
3. Types of lupus erythematosus (LE).
4. Types of discoid lupus erythematosus (DLE).
5. Types of subacute cutaneous lupus erythematosus (SCLE).
6. Types of systemic lupus erythematosus (SLE).
7. Etiology of discoid lupus erythematosus (DLE).
8. Complications of discoid lupus erythematosus (DLE).
9. Diagnosis of subacute cutaneous lupus erythematosus (SCLE).
10.Complications of subacute cutaneous lupus erythematosus (SCLE).
11.Etiology of systemic lupus erythematosus (SLE).
12.Named clinical features of systemic lupus erythematosus (SLE).
13.ARA criteria for classification of systemic lupus erythematosus (SLE).
14.Diagnosis of systemic lupus erythematosus (SLE).
15.Treatment of systemic lupus erythematosus (SLE).
16.Etiology of dermatomyositis.
17.Clinical features of dermatomyositis.
18.Skin biopsy in dermatomyositis.
19.Diagnosis of dermatomyositis .
20.Forms of scleroderma.
21.Named forms of localized Scleroderma (Morphea).
22.Named stages of coetaneous manifestations of progressive systemic sclerosis.
23.Raynaud’s phenomenon.
24.Diagnosis of scleroderma.
25.Symptomatic treatment of scleroderma.
26.Immunosuppressive treatment of scleroderma.
Students should be able to:
1. To describe skin lesions.
2. To assess nails, hair, and mucosal surfaces, even if these are recorded as
unaffected.
3. To perform diascopy, to investigate dermographism.
4. To work out plan of review; appropriate treatment and preventive of lichen
simplex chronic, systemic lupus erythematosus (SLE), discoid lupus erythematosus
(DLE), systemic sclerosis.
5. Write out of prescription of drugs for topical and systemic treatment of lichen
simplex chronic, systemic lupus erythematosus (SLE), discoid lupus erythematosus
(DLE), systemic sclerosis.
Answers to the Self-assessment:
Test evaluations:
1) Burrow.
2) Discoid lupus erythematosus.
3) Both are correct.
4) Both are correct.
5) Morphoea.
6) Head.
7) Pilosebaceous canals.
Reference:
Basic:
1. Savchak V., Kovalchuk M. Skin diseases in the family doctor practice. –
Ternopil, Ukrmedknyha, 2005.-397p.
2. M. Kovalchuk. Skin diseases. Color atlas. – Ternopil, Ukrmedknyha, 2007.210 p.
3. Savchak V., Halnykina S. Sexually transmitted diseases. – Ternopil,
Ukrmedknyha, 2001.-506 p.
4. Patient’s photo, phototests №204-205, 210-213.
5. Materials for practical class 4
Additional:
1. Color atlas of and Synopsis of clinical dermatology (Thomas B. Fitzpatrick at al,
1988, p. 1-5.
2. Thomas P.Habif. Clinical Dermatology. Mosby, 2004. – 1004 p.
3. P.N. Behl, A. Aggarwal. Practice of dermatology (tenth edition). Bangalore,
2005. – 500 p.
4. Alan B. Fleischer Dermatology. Common problems. New York, 2000. – 303 p.
5. Virendra N Sehgal. Clinical Dermatology. New Delhi, 2004. – 305 p.
Internet links:
1.
Systemic lupus erythematosus, SLE, how to diagnosis, Etiology and
Pathogenesis.Video.
http://www.youtube.com/watch?feature=player_detailpage&v=sQCsZef2BUk
2. Oral mucosal ulceration in systemic lupus erythematosus.
http://www.ncbi.nlm.nih.gov/pubmed/623694
3.Oral Manifestations of Systemic Disease.
http://www.aafp.org/afp/2010/1201/p1381.html
4. Management of Erythematous Oral Lesions .
http://emedicine.medscape.com/article/2066299-overview#aw2aab6b5
The methodical instruction has been done: by ass. Shkilna M.I.
Methodical instruction was discussed
at the Department sitting 14/06/2013 Minute N 10.