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Dermatology for Internists. Susan Riggs Runge, MD January 2008. Pictures. Pictures of common and less common skin lesions Cover each topic very briefly Realize most of you have vast experience in seeing many of these lesions in your years of practice

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Dermatology for internists

Dermatology for Internists

Susan Riggs Runge, MD

January 2008


Pictures
Pictures

  • Pictures of common and less common skin lesions

  • Cover each topic very briefly

  • Realize most of you have vast experience in seeing many of these lesions in your years of practice

  • This is a very superficial review of topics I hope you may find interesting

  • All slides and photos are available at:

    http://medicine.med.unc.edu/education/dermatology_for_internists.ppt


Lupus erythematosus
Lupus Erythematosus

  • One of the papulosquamous diseases

  • Papules and scaly areas

  • Other papulosquamous diseases include: psoriasis, tinea, seborrheic dermatitis, pityriasis rosea, syphilis, lichen planus and other more rare skin disorders

  • Many of these have differentiating characteristics but lots of overlap clinically makes skin biopsy particularly helpful in many cases



Acute cutaneous lupus1

Dilated capillary loops along nail fold

This can also be seen in dermatomyositis and other connective tissue diseases

Acute Cutaneous Lupus


Acute cutaneous lupus2

Malar erythema, can involve neck, forehead and periorbital area in photodistribution

Erythema and sometimes edema of V of neck, forearms

Look for ulcers on the hard palate

ANA positive

60-80% will have positive dsDNA

Other tests: CBC, ESR, UA, skin biopsy

Treatments: Prednisone, hydroxychloroquine

Referral to rheumatologist

Acute Cutaneous Lupus


Subacute cutaneous lupus
Subacute Cutaneous Lupus area in photodistribution


Scle subacute cutaneous lupus

Annular scaly erythematous patches in sun-exposed areas area in photodistribution

Worse upon sun exposure

Non-scarring

Many patients have arthralgias expecially of hands and wrists

Consider drugs as cause: HCTZ, calcium channel blockers, ACE inhibitors, terbinafine and TNF-antagonists

SCLE (subacute cutaneous lupus)


Hands in subacute cutaneous lupus

Erythematous scaly patches between the knuckles (unlike Gottron’s papules of dermatomyositis which are on the knuckles)

Hands in Subacute Cutaneous Lupus


Subacute cutaneous lupus labs

Most are ANA positive Gottron’s papules of dermatomyositis which are

Most are Anti-Ro (SS-A) positive

1/3 will meet criteria for systemic lupus

Other lab tests: CBC, ESR, UA, Rheumatoid factor, complement levels, skin biopsy

Treatment: Stop suspected drugs, sunscreen, hydroxychloroquine

Refer to rheumatologist if joint involvement, nephrologist if renal involvement, etc

Subacute Cutaneous Lupus Labs


Subacute cutaneous lupus more subtle
Subacute Cutaneous Lupus-more subtle Gottron’s papules of dermatomyositis which are


Discoid lupus
Discoid Lupus Gottron’s papules of dermatomyositis which are


Discoid lupus1

Hyperpigmentation and hypopigmentation Gottron’s papules of dermatomyositis which are

Atrophy of skin

These lesions cause SCARRING

Skin lesions occur in photodistributed areas (wider distribution may correlate with greater likelihood of SLE)

Discoid lesions and follicular prominence in conchae of ears

Discoid lupus


Ear lesions in discoid lupus
Ear Lesions in Discoid Lupus Gottron’s papules of dermatomyositis which are


Discoid lupus labs

ANA positive in 5-20% Gottron’s papules of dermatomyositis which are

Do CBC, ESR, Rheumatoid factor, UA, complement levels, skin biopsy

Discoid Lupus Labs


Discoid lupus2

These patients rarely progress to SLE (5%) Gottron’s papules of dermatomyositis which are

Rarely have systemic disease

Treatment: sunscreen, topical steroids, intralesional steroids, hydroxychloroquine

Referrals as indicated

Discoid Lupus


Other papulosquamous diseases psoriasis
Other Papulosquamous Diseases: Psoriasis Gottron’s papules of dermatomyositis which are


Psoriasis
Psoriasis Gottron’s papules of dermatomyositis which are


Psoriasis1

Well-demarcated erythematous plaques Gottron’s papules of dermatomyositis which are

Thick white or silvery scale

Knees and elbows classically, can be scalp only or diffuse

Also favors gluteal cleft, navel

Psoriasis


Psoriasis2

Not very itchy Gottron’s papules of dermatomyositis which are

Scale is thicker and whiter than with fungal infection

Less scaly in moist areas (in body folds) or if partially treated

Psoriasis


Psoriasis of scalp
Psoriasis of scalp Gottron’s papules of dermatomyositis which are


Psoriasis3
Psoriasis Gottron’s papules of dermatomyositis which are


Not psoriasis cutaneous t cell lymphoma
NOT psoriasis-cutaneous T cell lymphoma Gottron’s papules of dermatomyositis which are


Not psoriasis ctcl does not have thick scale

Cutaneous T-cell lymphoma Gottron’s papules of dermatomyositis which are

Could mimic psoriasis

Atypical locations

Biopsy should differentiate

Refer skin problems that are atypical or do not resolve as expected

Not psoriasis - CTCL: does not have thick scale


Allergic contact dermatitis
Allergic Contact Dermatitis Gottron’s papules of dermatomyositis which are


Allergic contact dermatitis1

Localized to area of contact Gottron’s papules of dermatomyositis which are

Scaly erythematous plaques

Can be blistering

On eyelids, can be due to nail polish

Allergic Contact Dermatitis


Allergic contact dermatitis2
Allergic Contact Dermatitis Gottron’s papules of dermatomyositis which are


Allergic contact dermatitis fragrance
Allergic Contact Dermatitis-fragrance Gottron’s papules of dermatomyositis which are




Allergic contact dermatitis3

Identify and avoid allergen if possible gear

Increase moisturization of skin

Topical steroid as needed

Rarely oral steroid if severe

Allergic Contact Dermatitis


Allergic contact poison oak

Linear blisters are classic for allergic contact dermatitis due to poison ivy

Allergic Contact-Poison Oak



Seborrheic dermatitis

Erythematous patches on skin due to poison ivy

Thick, yellow greasy scale

Seborrheic distribution: eyebrows, sides of nose, nasolabial folds, ear canals, chest

More severe in patients with HIV or Parkinson’s disease

Seborrheic Dermatitis


Seborrheic dermatitis1

Nasolabial fold due to poison ivy

Chin area

Ear canal

Seborrheic Dermatitis


Dermatophyte
Dermatophyte due to poison ivy


Tinea

Superficial fungal infection of skin due to poison ivy

Tinea


Tinea corporis

Tinea named by location: tinea capitis, tinea corporis, tinea manum, tinea pedis, tinea barbae (beard), tinea cruris (body fold especially groin and pubic area), tinea unguium of nails (onychomycosis)

Tinea corporis


Tinea faceii

Erythematous annular plaques tinea manum, tinea pedis, tinea barbae (beard), tinea cruris (body fold especially groin and pubic area), tinea unguium of nails (onychomycosis)

Not as well-demarcated as psoriasis

Scaly, itchy

Involved areas tend to fade centrally

Treat with topical antifungal if limited area or oral agent if extensive

Tinea faceii


Tinea corporis1
Tinea Corporis tinea manum, tinea pedis, tinea barbae (beard), tinea cruris (body fold especially groin and pubic area), tinea unguium of nails (onychomycosis)


Tinea capitis

Causes itching and scaling of scalp tinea manum, tinea pedis, tinea barbae (beard), tinea cruris (body fold especially groin and pubic area), tinea unguium of nails (onychomycosis)

More common in children

Hair may break just beyond follicle

Often more than one family member affected

Can be severe and cause hair loss which can be scarring (loss of follicles)

Tinea Capitis


Tinea capitis1
Tinea Capitis tinea manum, tinea pedis, tinea barbae (beard), tinea cruris (body fold especially groin and pubic area), tinea unguium of nails (onychomycosis)


Tinea pedis
Tinea pedis tinea manum, tinea pedis, tinea barbae (beard), tinea cruris (body fold especially groin and pubic area), tinea unguium of nails (onychomycosis)


Tinea more subtle
Tinea-more subtle tinea manum, tinea pedis, tinea barbae (beard), tinea cruris (body fold especially groin and pubic area), tinea unguium of nails (onychomycosis)


Atopic dermatitis
Atopic Dermatitis tinea manum, tinea pedis, tinea barbae (beard), tinea cruris (body fold especially groin and pubic area), tinea unguium of nails (onychomycosis)


Atopic dermatitis eczema
Atopic Dermatitis (Eczema) tinea manum, tinea pedis, tinea barbae (beard), tinea cruris (body fold especially groin and pubic area), tinea unguium of nails (onychomycosis)


Nummular eczema
Nummular Eczema tinea manum, tinea pedis, tinea barbae (beard), tinea cruris (body fold especially groin and pubic area), tinea unguium of nails (onychomycosis)


Severe atopic dermatitis
Severe Atopic Dermatitis tinea manum, tinea pedis, tinea barbae (beard), tinea cruris (body fold especially groin and pubic area), tinea unguium of nails (onychomycosis)


Atopic dermatitis1

Our Recommendations: tinea manum, tinea pedis, tinea barbae (beard), tinea cruris (body fold especially groin and pubic area), tinea unguium of nails (onychomycosis)

Bathe in tepid water with mild soap

Moisturize skin frequently with vaseline or other thick cream

Topical steroids as needed for control

Rarely treated with oral immunosuppressive

Atopic Dermatitis


Benign growths of the skin
Benign Growths of the Skin tinea manum, tinea pedis, tinea barbae (beard), tinea cruris (body fold especially groin and pubic area), tinea unguium of nails (onychomycosis)

  • There are many: skin tags, cysts, lipomas, dermatofibromas, warts, keloidsand many others

  • One of the most common in adults in seborrheic keratosis


Seborrheic keratosis
Seborrheic Keratosis tinea manum, tinea pedis, tinea barbae (beard), tinea cruris (body fold especially groin and pubic area), tinea unguium of nails (onychomycosis)


Seborrheic keratoses
Seborrheic Keratoses tinea manum, tinea pedis, tinea barbae (beard), tinea cruris (body fold especially groin and pubic area), tinea unguium of nails (onychomycosis)


Seborrheic keratosis1

Verrucous (warty looking) tan to black stuck-on appearing growth

Common on back, chest, abdomen, but may be anywhere

May be multiple or single

Not necessary to remove; treat with cryotherapy or electrodessication if symptomatic or as cosmetic procedure

Treatment can cause a hypopigmented spot or scarring

Seborrheic Keratosis




Normal nevi

Symmetrical growth

Regular Borders

One color or shades of brown

Smaller size , less than 6 mm, although can be larger

Do not grow or change

Develop new nevi up to age 30’s

Normal Nevi




Dysplastic nevus2

Irregular borders growth

May have more than one color

If it meets two or more of the criteria for melanoma, we may remove it

Dysplastic Nevus


Dysplastic nevus syndrome

Multiple dysplastic nevi growth

Familial (also known as Familial Atypical Mole and Melanoma Syndrome FAMM)

Melanoma common in one or more first or second degree relatives

Histologic criteria

Many cases linked to mutations in the CDKN2A gene, which codes for p16 (a regulator of cell division)

Difficult to evaluate visually because have 50 or more moles

Annual examinations by dermatologist plus frequent self-monitoring for change in moles

“Mole mapping” (digital imaging at UNC) if prior melanoma or if available

Dysplastic Nevus Syndrome


Melanoma
Melanoma growth


Melanoma1
Melanoma growth


Melanoma2

Most common type is superficial spreading growth

Tends to grow wide before it grows deep

Look for the “ugly duckling” mole-one that is different than the patient’s other moles

Melanoma


Melanoma3
Melanoma growth


Lentigo maligna melanoma growth

Occurs most often on head and neck

Usually evolves slowly in older patients with significant sun damage


Melanoma4
Melanoma growth


Melanoma5

ABCDEs growth

Asymmetry

Irregular BORDERS

Colors (more than one)

Diameter (more than 6 mm)

Evolving-very important

Melanoma



Melanoma6
Melanoma growth


Melanoma7
Melanoma growth


Nodular melanoma

Grows rapidly (6-8 weeks) growth

Deeper

Prognosis related to depth so worse prognosis than superficial melanoma

Nodular Melanoma




Actinic keratoses1

Precancerous growth

Scaly erythematous macules in sun-damaged skin

Persistent scaly areas-patient scratches them off and they recur

Treated with liquid nitrogen or topical 5-fluorouracil or imiquimod

Actinic keratoses



Basal cell carcinoma1

Pearly papule with rolled borders growth

Has central dell (indentation)-will erode with time and form ulcer

Telangectasia

Slow growing

Extremely rare to metastasize but can erode bony structures

Can be pigmented

Basal Cell Carcinoma






Squamous cell carcinoma1

Enlarging scaly, crusty plaques scar)

Not the thick white scale of psoriasis

Not symmetrical on the body (unlike psoriasis)

Squamous cell or basal cell carcinomas may present as a non-healing spot (allow 4 weeks to heal: if it doesn’t , then biopsy)

Squamous Cell Carcinoma




Pyoderma gangrenosum1

Not all ulcers are infectious scar)

Diagnosis of exclusion: rule out infection and tumor

Starts as a small red papule, then spreads into ulcer

Occurs in healthy-looking people (abdomen and legs), can occur anywhere including in the mouth

Tendency to occur in patients with inflammatory bowel disease but idiopathic in 50%

Spreads to surrounding tissues if debrided or excised

Responds to topical or oral steroids

Pyoderma Gangrenosum


Referrals to dermatology
Referrals to Dermatology scar)

  • Any new growth that you are suspicious about

  • Refer blistering processes early

  • A rash (an eruption) in a body fold might be fungus or yeast, so an antifungal cream might be worth a trial

  • Consider a trial of over the counter cortisone or topical triamcinolone for body lesions that you believe may be a transient dermatitis or eczema (we prefer ointments over creams)

  • Refer when a skin lesion is growing or does not resolve with usual treatment

  • Refer suspected melanoma promptly


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