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Back to the Basics LMCC Preparation Dermatology. Jim Walker Assoc. Clinical Prof. Medicine Dermatology. Websites. Ottawa U Dermatology Block Slides http://www.med.uottawa.ca/curriculum/dermato.htm UBC Dermatology Undergraduate Problem Based Learning Modules http://www.derm.ubc.ca/teaching

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Back to the basics lmcc preparation dermatology

Back to the BasicsLMCC PreparationDermatology

Jim Walker

Assoc. Clinical Prof. Medicine

Dermatology


Websites
Websites

  • Ottawa U Dermatology Block Slideshttp://www.med.uottawa.ca/curriculum/dermato.htm

  • UBC Dermatology Undergraduate Problem Based Learning Moduleshttp://www.derm.ubc.ca/teaching

  • Good Quiz site & Resource – Johns Hopkins Univ.http://dermatlas.med.jhmi.edu/derm/

  • eMedicine Textbookhttp://www.emedicine.com/derm/index.shtml

  • Medlinehttp://www.ncbi.nlm.nih.gov/pubmed

  • University of Iowa Dept of Dermatologyhttp://tray.dermatololgy/uiowa.edu/home.html

  • Dermatology Online Atlashttp://dermis.multimedica.de/

  • * Please do not use images without attribution or permission!


Morphology
Morphology

  • Living gross pathology of skin, hair nails and visible mucosae

  • Review basic lesions, the nouns (papules, ulcers etc.)

  • Add the adjectives (size, shape, colour, texture, etc.)

  • Consider distribution, symmetry and pattern

  • Visual literacy: simple descriptions→complex interpretations (you see, but do you observe?)

  • Excellent lighting

  • Position patient

  • Look all over (skin, mucosa, hair, nails)

  • Observe and think


Dermatopathology

Pathology – high degree of clinical pathological correlation

Assess depth of lesion in skin


Bacterial skin disease
Bacterial Skin Disease

  • Barrier – dry, tough, acidic, Ig in sweat, epidermal turnover every 28 days

  • Normal Flora: Gm+, yeasts, anaerobes, Gm-


Bacterial skin diseases
Bacterial Skin Diseases

  • Impetigo

    • Bullous and non-bullous

  • Folliculitis/furuncle

  • Erysipelas/cellulitis

  • Necrotizing Fasciitis

  • Toxin diseases: SSSS, Scarlet fever, toxic shocks

  • Superantigen: Staph. aureus in atopic derm.

  • Pseudomonas: warm, moist, alkaline




Impetigenized Atopic

(Non-bullous)

Staph. > strep.


Erysipelas

-Strep. pyogenes

-Dermal infection

-Asymmetrical, sharp demarcation

-Spreading

-Septic patient

Treatment

Oral – amoxacillin 500 QID x 14 days

IV – if severe or recurrent, or co-morbidities


Cellulitis – haemorrhagic

-usually Strep. pyogenes

-deep dermal and sub- cutaneous

Treat – as for erysipelas, but cover for Staph.


Necrotizing Fasciitis

-Pain out of proportion to apparent lesion

-Strep or multi-bacterial deep infection

-Emergency debridement and multiple IV antibiotics


Previously healthy 10 mos. child, 12 hour history of fever, decreased LOC, petechial rash progressing to current picture


Meningococcal septicaemia decreased LOC, petechial rash progressing to current picture

Petechiae

Purpura

Necrosis

Treatment

-blood cultures

-immediate IV antibiotics

-lumbar puncture

-support for gram negative endotoxic shock


Meningococcal disease
Meningococcal Disease decreased LOC, petechial rash progressing to current picture

  • Septicemia vs meningitis

    - 40-70% vs 10% mortality

  • Peaks: infancy to 5 years - Second peak age 15

  • Infection and Endotoxin and DIC cause damage

  • Rash subtle at first

    - Erythema→purpura →necrosis

    - Search for petechiae / purpura

    - “any febrile child with a petechial rash should be considered to have meningococcal septicemia, and treatment should be commenced without waiting for further confirmation.”


SSSS decreased LOC, petechial rash progressing to current picture

primary Staph. infection conjunctivitis


Staph. Scalded Skin Syndrome decreased LOC, petechial rash progressing to current picture

SSSS – same child, back, sterile blisters

-epidermolytic toxin mediated disease


31 yr. decreased LOC, petechial rash progressing to current picturemale admitted for biopsy of lymph node for expected lymphoma. Rash noted, dermatology consulted.Widespread papular eruption with adenopathy.


Soles of same patient. decreased LOC, petechial rash progressing to current picture

Your diagnosis?


Secondary syphilis decreased LOC, petechial rash progressing to current picture

-a systemic disease

-order STS and treponemal tests

-LP?

Treatment

-Benzathine penicillin 2.4 million units IM

-Herxheimer reaction

-follow STS

-report disease

-contact tracing

-check for other venereal diseases


Secondary syphilis decreased LOC, petechial rash progressing to current picture

Condylomata lata


Viral skin disease
Viral Skin Disease decreased LOC, petechial rash progressing to current picture

  • DNA – tend to proliferate on skin

  • RNA – tend to be erythemas/exanthems

  • Exanthem – epidermal/skin

  • Enanthem - mucosal


Definitions
Definitions decreased LOC, petechial rash progressing to current picture

  • Exanthem(s) = Exanthema(ta), (Greek)

    • A bursting out (ex) in flowers (anthema)

    • Any dermatosis that erupts or “flowers” quickly

    • Only the erythemas are numbered

    • Includes papular, vesicular, pustular eruptions


Classic exanthems erythemas of childhood
Classic Exanthems decreased LOC, petechial rash progressing to current pictureErythemas of Childhood

1 Rubeola - Measles

2 Scarlet Fever

3 Rubella – German Measles

4 Kawasaki disease

5 Erythema Infectiosum

6 Roseola Infantum - Exanthem Subitum


Human herpes virus
Human Herpes Virus decreased LOC, petechial rash progressing to current picture

1 HSV-1

2 HSV-2

3 VZV

4 EBV

5 CMV

6 Roseola

7 ?

8 Kaposi’s Sarcoma


Measles – morbilliform erythema decreased LOC, petechial rash progressing to current picture

Red measles = rubeola

Koplick’s spots in oral mucosa, early


Rubella with post auricular nodes decreased LOC, petechial rash progressing to current picture

(German measles)



Erythema infectiosum syndrome

Reticulate erythema on arms

Treatment – supportive

Systemic

-arthritis in adults

-hydrops fetalis

-anaemia


  • Toxic erythema syndrome

  • -viral

  • -scarlet fever

  • drug

  • acute collagen vascular disease


Herpes simplex, recurrent, syndrome

post pneumococcal pneumonia


HSV 2, genital syndrome



Eczema herpeticum syndrome

HSV in atopic dermatitis



Herpes virus treatment
Herpes virus, treatment syndrome

  • Acyclovir, famciclovir, valacyclovir

  • Must treat early (72 hours)

  • Front end load dose

  • Shortens course and reduces severity

  • Does not eliminate virus


Mollusca syndromeContageosain Atopic



Herald plaque - pityriasis rosea syndrome

annular, NOT fungus

Cause unclear, probably infectious (HHV7)


Pityriasis rosea syndrome

Diagnosis

-symmetrical discrete oval salmon-coloured papules and plaques, collarette scales

Treatment

-UVL

-erythromycin 250 QID, early

-hydrocortisone cream if itchy

-lasts 6-12 weeks, no scars



Plantar Wart syndrome

-demarcation

-dermatoglyphics

-micro-haemorrhage

-lateral tenderness



Plantar wart treatment summary
(Plantar) Wart, Treatment Summary syndrome

  • Respect natural history

  • First do no harm

  • Cryotherapy

  • Caustics: salicylic acid, lactic acid, cantharadine

  • Other chemicals: imiquimod, fluorouracil

  • Immunotherapy: DPCP

  • Surgery: curette only, no desiccation, no excision

  • No radiation


HIV – primary exanthem syndrome

This rash not a problem.

It’s the permissive effect of immune suppression that allows other infections and tumors to kill


Primary hiv infection
Primary HIV Infection syndrome

  • Lapins et al BJD 1996, 22 consecutive men

  • HIV Exposure

    • Acute illness 11–28 days, Seroconvert in 2–3wks

    • Fever 22, pharyngitis21, adenopathy21,

    • Exanthem day 1-5 of illness

    • Upper trunk and neck, discrete non-confluent red macules and maculopapules in 17 / 22

    • Enanthem of palatal erosions in 8 / 22


Fungal skin infections
Fungal Skin Infections syndrome

  • Superficial and Deep

  • Superficial

    • Tinea plus location

    • Tinea = dermatophyte

    • Lives on keratin (non-viable)

    • Tinea versicolour is misnomer = dimorphic yeast

    • Hair and nail infections must be treated systemically (terbinafine, griseofulvin)




Kerion – tinea capitis, syndromenot bacterial infection







Tinea faciei syndrome




Yeast infection
Yeast infection syndrome


Tinea management
Tinea - Management syndrome

Diagnosis

  • Scrape

  • KOH

  • Fungal culture – 3 weeks

    Treatment

  • Topical – azoles: clotrimazole, ketoconazole cream BID x 2-3 weeks, terbinafine cream similar

  • Oral – must use for hair and nails. Terbinafine 250 mg. OD for 4-12 weeks for adult


N.A. Blastomycosis


Blastomycosis syndrome


Blastomycosis syndrome


Deep fungal infections management
Deep Fungal Infections syndromeManagement

Diagnosis

  • Tissue culture

  • Skin biopsy with special stains

    Treatment

  • Amphotericin B, IV -if multi-organ infection

  • Itraconazole, po -if minimal disease in healthy patient


Break time
Break Time syndrome


Eczema
Eczema syndrome

  • A morphological diagnosis based on observations of the inflammatory pattern in the skin

  • Eczema is not an etiologic diagnosis

  • Eczema is a subgroup of dermatitis

  • Etiology: exogenous vs endogenous

  • Acute signs: erythema, edema, edematous papules, vesicles, erosions, crusting, secondary pyoderma

  • Chronic signs: lichenification, scales, fissures, dyspigmentation

  • Borders usually ill-defined


Atopic dermatitis endogenous
Atopic Dermatitis syndromeendogenous

  • To make a diagnosis of atopic dermatitis (Hanifin) - must have 3 or more major features:

    1) pruritus

    2) typical morphology and distribution

    • flexural lichenification

    • facial and extensor involvement in infants and children

      3) chronic or relapsing dermatitis

      4) personal family history of atopy

  • Plus 3 or more minor features:




  • Atopic dermatitis syndrome

    Anti-cubital lichenification

    Black skin




    Exogenous impetigenization- allergic contact dermatitis, poison ivy, acute signs


    Rhus radicans impetigenization

    The rash

    The plant


    Patch testing impetigenization, to diagnose cause of allergic contact dermatitis



    Diagnosis = Scabies infant impetigenization

    Eczema caused by infestation


    Scabies Burrows, sole impetigenization


    Scabies Burrows - finger impetigenization


    Scabetic nodules in infant impetigenization



    Eczema treatment
    Eczema - Treatment impetigenization

    • Remove or treat the cause

    • General measures

      • Optimise the environment for healing

      • Compress if moist, hydrate if dry

    • Topical

      • Corticosteroids: hydrocortisone, betamethasone, clobetasol

      • BID max. frequency

      • Ointments, creams, gels, lotions

    • Systemic

      • Prednisone: define endpoint, always warn of osteonecrosis

    • Phototherapy


    Scabies treatment
    Scabies - treatment impetigenization

    • Permethrin 5% cream or lotion neck to toes overnight

    • Treat all close contacts whether itchy or not

    • Wash clothes and bed-sheets

    • Set aside gloves for 10 days

    • Nodules may persist few months

    • May use topical steroid after mites dead


    Psoriasis
    Psoriasis impetigenization

    • T-cell disease, Th1 inflammatory pattern

    • Morphology

    • Symmetry (endogenous)

      • Plaque: sharply demarcated plaque with coarse scale across whole lesion.

      • Guttate: drop-like or papular variant of plaque psoriasis

      • Pustular (sterile) and erythrodermic forms are more inflammatory and unstable

      • Erythrodermic – involves > 90% skin


    Erythemato squamous diseases differential diagnosis

    Psoriasis impetigenization

    Seborrheic dermatitis

    Pityriasis versicolour

    Pityriasis rosea

    Dermatophyte

    Parapsoriasis and Mycosis fungoides

    Pityriasis rubra pilaris

    Secondary Syphilis

    Chronic Dermatitis

    Erythemato-squamous Diseasesdifferential diagnosis


    Psoriasis plaques impetigenization– symmetry, sharp demarcation, coarse scale across lesion


    psoriasis impetigenization

    normal skin


    Psoriasis – trunk impetigenization

    partially treated


    Psoriasis – annular impetigenization

    not ringworm


    Psoriasis – guttate impetigenization

    (drop-like or papular)


    Guttate Psoriasis impetigenization


    Psoriasis on black skin impetigenization


    Psoriasis - flexural impetigenization


    Psoriasis - scalp impetigenization


    Psoriasis impetigenization – toes and nails, NOT fungus, culture if in doubt





    Psoriasis treatment
    Psoriasis -Treatment disease

    • Consider exacerbating factors: stress, drugs, infection

    • Consider stability of disease (pustular and erythrodermic)

    • Koebner = isomorphic phenomenon

    • Three Pillars of therapy

      • Topical – creams, ointments, lotions, baths

      • Scalp, extensors, flexures

        • Steroids

        • Calcipotriene

        • Salicylic acid

        • Tar

      • Systemic –Pills and Injections

        • Methotrexate, Acitretin, Cyclosporin, Biologicals

      • UltravioletRadiation

        • UVB –broad and narrow band, UVA, PUVA


    Acne disease

    • Etiology: heredity, hormones, drugs, ?diet

    • Sebum – encourages growth of P. acnes

    • Propionibacterium acnes – inflammation, initiates comedones

    • Morphology

      • “Noninflammatory” – comedones, open and closed

      • Inflammatory – papule, pustule, nodule, abscess (“cyst”), scars...ulcers

      • Microcomedo is probably the primary lesion


    • Androgens disease

    • Sebum

    • Comedogenesis

    • Proprionibacterium acnes

    • Diet

    • Psychological

    • Topicals

    • Antibiotics

    • Anti-androgens

    • Isotretinoin

    • Physical

    • Exacerbating factors

    • Rosacea

    • Perioral dermatitis



    Acne – scarring disease

    Isotretinoin use

    -teratogen, not mutagen

    -depression real but rare

    -1 mg/kg/day x 4-5 months

    -beta-HCG, lipids, ALT

    -double contraception

    -record discussion




    Acne – severe disease

    Treatment

    -erythromycin

    -prednisone

    -isotretinoin – low dose and increase slowly


    Acne treatment
    Acne - Treatment disease

    • Psychological impact

    • General measures: avoid picking, not due to poor hygeine

      • Mechanical –rubbing clothes and equipment

      • Chemical – oils, chlorinated hydrocarbons

      • Diet - glycemic index?, milk?

    • Drugs that flare acne

      • Lithium, anabolic steroids, catabolic steroids, dilantin, halogens, EGFRI’s

    • Topicals

      • Benzoyl peroxide 5% aq. gel, once daily, (bleach)

      • Retinoids – comedonal acne, tretinoin cream or gel nightly,

        adapalene, tazarotene are 2nd generation retinoids

      • Antibiotics – consider issue of resistance

    • Oral

      • Antibiotics: Tetra 500 BID, minocycline, erythromycin, clindamycin, trimethoprim – X 3 months

      • Hormones in females

      • Isotretinoin – (Accutane, Clarus) – only disease remitting agent




    Perioral dermatitis treatment
    Perioral Dermatitis diseaseTreatment

    • Don’t be fooled by name, it’s acne not eczema

    • Stop topical steroids

    • Metronidazole 1% topical cream or gel, or topical antibiotic (erythro, clinda)

    • Tetracycline 500 bid x 6-8 weeks

    • Sun protection

    • Reduce flare factors – fluoride in toothpaste


    Rosacea rhinophyma papules and pustule
    Rosacea disease – rhinophyma, papules and pustule


    Rosacea
    Rosacea disease

    Diagnosis

    • Erythema and telangectasias

    • Papulopustular

    • Sebaceous hyperplastic

    • Symmetrical – usually

    • Central facial

    • Ill-defined

    • No significant scale

    Treatment

    -sun protect

    -reduce flare factors

    -stop topical steroids

    -Metronidazole cr. 1% nightly

    -Tetracycline 500 BID

    -surgery for rhinophyma

    -laser or IPL for telangectasia


    Pruritus itchy dermatoses
    Pruritus diseaseItchy dermatoses

    • eczematous dermatitis

    • scabies and insect bites

    • urticaria

    • dermatitis herpetiformis

    • lichen planus

    • bullous pemphigoid

    • psoriasis – sometimes


    Systemic causes of pruritus itch without rash
    Systemic causes of Pruritus disease“itch without rash”

    • chronic renal failure

    • cholestasis

    • Polycythemia

    • pregnancy

    • thyroid dysfunction

    • malignancy - Hodgkins

    • H.I.V.

    • ovarian hormones

      separate itch nerves. ,unmyelinated slow C fibres


    Mediators of pruritus
    Mediators of Pruritus disease

    • Histamine (H)-(from mast cell via various receptors)- itch mediated at H1 receptor

    • substance P, tryptase

    • opioid peptides-central or peripheral

    • cytokines-IL-2,IF….

    • Prostaglandin E, serotonin


    Drug reactions
    Drug reactions disease

    • Acute onset

    • Cephalo-caudal spread

    • Antibiotics, anticonvulsants, NSAID’s

    • Accurate history critical – graph drugs vs date

    • Treatment

      • stop offending drugs

      • supportive care



    Skin cancer
    Skin Cancer disease

    • BCCa, SCCa, Melanoma include over 98% of skin cancers you will see

    • Sunlight, UVB>UVA is major carcinogen





    Superficial Multicentric BCCa disease

    Red plaque, sharp demarcation, irregular border



    Atypical Mole disease

    Rule out melanoma

    Biopsy

    -shave

    -excise, conservative

    -incise

    -punch


    Melanoma-Canada 2008 (estimated) disease

    -4600 cases

    -910 deaths

    Asymmetry

    Border

    Colour

    Diameter

    Evolution

    Melanoma – back, superficial spreading


    Melanoma prognosis
    Melanoma - Prognosis disease

    • Depth of invasion = Breslow thickness

      • Most important for stage 1-2 melanoma

      • Measured from granular layer of epidermis to deepest malignant cell, with ocular micrometer

        Also assess ulceration and mitotic rate of primary tumor

    • Regional Lymph-node Mets – stage 3

      • Sentinel node biopsy – high prognostic value

    • Distant Mets – stage 4

      • 10-20% 5 yr survival





    Skin cancer risk factors
    Skin Cancer – Risk Factors disease

    • Ultraviolet radiation

      • UVB – 290 - 320 nm

      • UVA – 320 – 400 nm

    • Other Controllable

      • Ionizing radiation

      • Arsenic

      • Tobacco

      • Tar

      • HPV

      • Immune-suppression (permissive)

        HIV, Drugs


    Skin cancer treatment
    Skin Cancer - Treatment disease

    • Biopsy if in doubt

      • match method to depth of lesion (shave, punch, incision, excision)

    • Curettage (BCCa, SCCa small, not Melanoma)

      • may precede with shave excision

      • electrodesiccation

    • Surgical Excision

      • Closure: fusiform, flap, graft

    • Margin Control

      • Ill-defined, critical real-estate, recurrent, aggressive

      • Mohs’, frozen section

    • Radiotherapy

    • Other: chemotherapy (imiquimod), PDT



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