Clinical Pearls in Dermatology Lisa H Scatena, M.D. F.A.A.D. Rocky Mountain Dermatology, Boulder Assistant Clinical Professor Dermatology & Internal Medicine University of Colorado, Denver 6 February 2009. What Can We Glean from the Largest Organ in the Body?.
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Clinical Pearls in DermatologyLisa H Scatena, M.D. F.A.A.D.Rocky Mountain Dermatology, BoulderAssistant Clinical ProfessorDermatology & Internal Medicine University of Colorado, Denver6 February 2009
Earlier detection, diagnosis and treatment of systemic diseases.
Case 1: A 54 year old man with diabetes mellitus and chronic renal failure complains of swelling, tightness and darkening of the skin on his arms and legs. His symptoms have developed over the past 2-3 weeks following a failed kidney transplant and imaging. Upon further questioning, this patient is most likely to also complain of:
Cowper et al. Lancet 2000; 356:1000
Curr Opin Rheumatol 2003, 15: 785
CDC NFD associated with exposure to gadolinium-containing contrast agents-St Louis, Missouri, 2002-2006. MMWR 2007 Feb 23;56;137-41
Todd et all. Cutaneous changes of NSF. Predictor of early mortality and associated with gadolinium exposure. Arth Rheum 2007 Sept 28;56:3433.
BJD 2005; 152: 531
PEARL #1Consider alternate imaging processes when possible in patients with renal failure. If a patient must have an MRI, prompt dialysis after MRI is suggested.
This 63 year old man has been on this medication for years. Not only has he experienced the skin changes below, he has developed arthralgias and a (+) ANCA.
10 Not only has he experienced the skin changes below, he has developed arthralgias and a (+) ANCA.Causative agents for his skin changes include:
Well known agent to result in hyperpigmentation as a result of both melanin and iron deposition
Blue gray legs & forearms
Muddy brown on sun exposed areas
Reported to cause a lupus-like syndrome
(+) ANA, (+) pANCA
Occurs at a greater rate in those patients on minocycline for longer duration of time
Resolves when minocyline is discontinuedMinocycline
Case 3: A 56 year old woman with arthralgias, malaise, scaling scalp, and intractable itching develops this bizarre eruption. What other findings would you expect on examination?
Arch Dermatol 2000; 136: 665
J Rheumatol 1999; 26: 692
Arch Dermatol 2000; 136: 665 J Rheum 1999;26:692
Arch Dermatol 1999; 135: 1370
10 Point…What finding is most predictive of an underlying malignancy in DM?
Arch Dermatol 2003; 139: 539
Lancet 2001; 357:85-86
Br J Cancer 2001; 85:41-45
Curr Opin Rheumatol 2000; 12:498-500
Dermatol Clin 2002; 20:387-408
Dermatol Clin 2002; 20:387-408
PEARL #3 Point…In the case of a new diagnosis of dermatomyositis in an adult, at a bare minimum, age appropriate screening for malignancy should be performed. Strongly consider imaging if clinically indicated.
10 Started with 1 red patch and spread after application of a prescription medication.What prescription medication did he put on his skin with this resultant rash?
9 white-flesh colored bumps all over his face since his 30’s.Our patient and his family members are at risk for:
JAAD 2000; 43:1120
JAAD 2003; 48:111
J Am Acad Dermatol 2003;49:698,717
PEARL #5 white-flesh colored bumps all over his face since his 30’s.If you see a patient with numerous monomorphic firm small papules on his face, ASK about family members. If others in the family have similar bumps, this warrants further evaluation including skin biopsy and renal imaging.
9 white-flesh colored bumps all over his face since his 30’s.Associated disease?
PEARL #6 white-flesh colored bumps all over his face since his 30’s.If you see a patient with a waxy yellow atrophic plaque on the anterior tibia, without a diagnosis of diabetes, check for it. If you see a patient with known diabetes and NLD, aggressive management to minimize the risk of microvascular complications is a must.
10 feet and hands.Which of his pre-existing conditions has likely contributed to his dermatoses?
Arch Dermatol 2005; 141: 85
55yo man presents with an indolent onset of thick skin on the back of his neck and shoulders. He also complains of “chipmunk cheeks” which he did not have 6 months ago.
10 the back of his neck and shoulders. He also complains of “chipmunk cheeks” which he did not have 6 months ago.Far and away, the most common association with his finding is:
58 year old man presents with painful genital sores and “thrush” in his mouth. The thrush has not improved with nystatin swish and spit regimen. He recently got new glasses, but he still finds his vision has changed and feels as if something is in his eyes.He wonders if it could be from a lack of Vitamin D because his dermatologist has beaten into him the need for daily sunscreen.
10 “thrush” in his mouth. The thrush has not improved with nystatin swish and spit regimen. He recently got new glasses, but he still finds his vision has changed and feels as if something is in his eyes.Your Leading Clinical Diagnosis is:
Arch Dermatol 1994, 130:1521
Vodegel RM, et al JAAD 2003;48:542.
Retrospective study of 35 patients, median age 65 “thrush” in his mouth. The thrush has not improved with nystatin swish and spit regimen. He recently got new glasses, but he still finds his vision has changed and feels as if something is in his eyes.
10 had solitary solid tumors
lung, stomach, colon, endometrial
Overall relative risk= 6.8; RR 1y after diagnosis = 15.4
8 of 10 developed cancer AFTER blisters
7 of 8, within 14 months of onset
8 of 8diedwithin 21 months of diagnosisAnti-Laminin 5 Cicatricial Pemphigoid
Lancet 2001; 357: 1850