Dermatology for internists
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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

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

  • 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

  • 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 Lupus


Dilated capillary loops along nail fold

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

Acute Cutaneous Lupus


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


Annular scaly erythematous patches in sun-exposed areas

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)


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

Hands in Subacute Cutaneous Lupus


Most are ANA positive

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


Discoid Lupus


Hyperpigmentation and hypopigmentation

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


ANA positive in 5-20%

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

Discoid Lupus Labs


These patients rarely progress to SLE (5%)

Rarely have systemic disease

Treatment: sunscreen, topical steroids, intralesional steroids, hydroxychloroquine

Referrals as indicated

Discoid Lupus


Other Papulosquamous Diseases: Psoriasis


Psoriasis


Well-demarcated erythematous plaques

Thick white or silvery scale

Knees and elbows classically, can be scalp only or diffuse

Also favors gluteal cleft, navel

Psoriasis


Not very itchy

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


NOT psoriasis-cutaneous T cell lymphoma


Cutaneous T-cell lymphoma

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


Localized to area of contact

Scaly erythematous plaques

Can be blistering

On eyelids, can be due to nail polish

Allergic Contact Dermatitis


Allergic Contact Dermatitis


Allergic Contact Dermatitis-fragrance


Allergic Contact Dermatitis-diethylthiourea in scuba diving gear


Cinnamon often used as flavoring agent in gum or toothpaste

Allergic Contact-cinnamon


Identify and avoid allergen if possible

Increase moisturization of skin

Topical steroid as needed

Rarely oral steroid if severe

Allergic Contact Dermatitis


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

Allergic Contact-Poison Oak


Allergic Contact Dermatitis-more subtle


Erythematous patches on skin

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


Nasolabial fold

Chin area

Ear canal

Seborrheic Dermatitis


Dermatophyte


Superficial fungal infection of skin

Tinea


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


Erythematous annular plaques

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 Corporis


Causes itching and scaling of scalp

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 Capitis


Tinea pedis


Tinea-more subtle


Atopic Dermatitis


Atopic Dermatitis (Eczema)


Nummular Eczema


Severe Atopic Dermatitis


Our Recommendations:

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

  • 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 Keratoses


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


Moles and Melanoma


Normal Moles (nevi)


Symmetrical

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 nevus


Dysplastic Nevus


Irregular borders

May have more than one color

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

Dysplastic Nevus


Multiple dysplastic nevi

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


Most common type is superficial spreading

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


Melanoma


Lentigo maligna melanoma

Occurs most often on head and neck

Usually evolves slowly in older patients with significant sun damage


Melanoma


ABCDEs

Asymmetry

Irregular BORDERS

Colors (more than one)

Diameter (more than 6 mm)

Evolving-very important

Melanoma


Melanoma-more subtle


Melanoma


Melanoma


Grows rapidly (6-8 weeks)

Deeper

Prognosis related to depth so worse prognosis than superficial melanoma

Nodular Melanoma


Lacks pigment so may not be recognized as melanoma

Amelanotic Melanoma


Actinic keratoses


Precancerous

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 Carcinoma


Pearly papule with rolled borders

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


Basal Cell Carcinoma


Pigmented Basal Cell Carcinoma


Basal Cell Carcinoma-more subtle (morpheaform: looks like a scar)


Squamous Cell Carcinoma


Enlarging scaly, crusty plaques

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


Outlier Topic


Pyoderma Gangrenosum


Not all ulcers are infectious

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

  • 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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