Dermatology

1. Dermatology Dave Walsh

2. Topics Reviewed last year • Common Rashes • Eczematous Dermatoses • Contact Dermatitis • Atopic dermatitis • PapulosquamousDermatosis • Psoriasis • PityriasisRosea • Seborrheic Dermatitis • Acneiform Eruptions • Acne • Rosacea • Common skin and Nail Infections • Superficial Fungal Infections • Tinea • Candidiasis • Viral Skin Infections • Herpes Simplex Virus • Herpes Zoster • Wart • Molluscum

3. Topics Reviewed last year (continued) • Stings and Bites • Scabies • Lice • Bedbugs • Common Neoplasm • Basal Cell Carcinoma • Actinic Keratosis and Squamous cell carcinoma In situ • Squamous Cell carcinoma • Keratoacanthoma • Malignant Melanoma • Foot and Leg Ulcers • Venous stasis ulcers • Arterial Ulcers • Neuropathic ulcers

4. Topics for this talk • Treatment of Dermatologic Conditions in Pregnancy • Common Rashes • Eczematous Dermatoses • Hand Dermatitis • Xerotic Eczema • Nummular Dermatitis • Stasis Dermatitis • PapulosquamousDermatoses • Lichen Planus • Drug Reactions • Pigmented PurpuricDermatoses • Miliaria • AcontholyticDermatosis (Grover Disease) • Acneiform Eruptions • HidraenitisSuppurativa • Common Skin and Nail Infections • Bacterial Skin Infections • Folliculitis • Abscess/furuncle/carbuncle • Impetigo • Cellulitis/Erysipelas • Erythrasma • Keratolysis • Cuts and Scrapes

5. Topics for this talk (continued) • Pruritis • Urticaria • Autoimmune bullous disease • Cutaneous Manifestations of Internal Disease • Derm Urgencies and Emergencies • Hair Disorders • Nail Disorders • Disorders of mucous membranes • Not covered: • Derm diseases of skin of color • Aging skin

6. Topical steroids General Rules • Ultrapotent steroids should be avoided on the face, groin, and axilla, atrophic skin • Clobetasol • Exception: ultrapotent steroids used to treat lichen sclerosis of the vulva • Creams, ointments, gels, foams, lotions • Creams – can be used widely • Ointments – greasy feel, bad for hairy areas • Lotion, foams, solutions – good for scalp and when large areas of skin need to be covered • 30 Gm is needed to cover the skin of a 70-Kg man once • Avoid combo steroid-antifungal products unless diagnosis is established

7. A 22-year-old woman is evaluated for acne, which she has had since her teens. She is 2 months pregnant, and the acne seems to be worsening. She has been using over-the-counter benzoyl peroxide products, but the acne is not improving. Medical history is unremarkable, and her only medication is prenatal vitamins.On physical examination, scattered inflammatory papules, a few pustules, and open and closed comedones on the medial cheeks and chin are present • Azelaic acid • Clindamycin • Tazarotene • Tretinoin

8. Answer Review • Azelaic acid – Pregnancy category B • Clindamycin – Pregnancy category B • Tazarotene – topical acetylenic retinoid – Category X • Tretinoin – differentiated retinoid (ATRA) – Category C; usually avoided in pregnancy • In general, retinoids have an antineoplastic effect

9. Treatment of Derm Conditions in Pregnancy • Risk/benefit ratio • Steroids (topical and systemic): category C; although generally considered safe • Antihistamines – usually safe in pregancy • Teteracycline – Category D – should be avoided • Isotretinoin – X – mandatory pregnancy prevention plan • Thalidomide – X – mandatory pregnancy prevention plan • Spironolactone - avoid

11. A 40-year-old woman is evaluated for a rash on her hands that has been present for 6 weeks. This rash comes and goes throughout the year and has been present for many years, but never as severe as it is now. She also experiences itchy skin on her body. She had eczema as a child and currently has seasonal allergies. She is otherwise well and is currently taking no medication.On physical examination, vital signs are normal. She has dry skin on her trunk and extremities. Her hands are extremely dry with scaling, erythema, and fissuring on the dorsal hand surfaces. Her feet are not involved. • Atopic hand dermatitis • Keratodermablenorrhagica • Scabies • Tineamanuum

12. Answer Review: Common skin rashes • Atopic hand dermatitis – increased prevalence in patients with atopic eczema; sometimes outgrow childhood eczema and then develop atopic hand dermatitis later in life • Keratodermablenorrhagica – erythematous scaly plaques palms and soles associated in with spondyloarthropathy (Reiter syndrome) • Scabies – vesicular, itchy rash, burrows, interdigital web, wrist, penis, axillae, nipples, umbilicus, scrotum • Tineamanuum –dermatophyte infection of the hand; usually only unilateral upper extremity and bilateral lower extremities

13. Common Skin Rashes: (Eczematous Rashes) • Hand Dermatitis – often in people that work that involves water (food services, hairdressers, health care workers) • Patch testing can help if atypical/difficult to Rx disease • Rx: avoidance of exposure, wear gloves • Rx: mid to high potency steroids until rash clears • Xerotic eczema – “winter itch”; dry skin, erythematous patches topped by dry tiles. Rx: moisterizers +/- low or mid potency steroids

14. Common Rashes: • Xerotic eczema

15. Common rashes continued • Nummular dermatitis: • Form of eczema • coin shaped patches and plaques. • Affects patients with a history of atopic ezcema. Check KOH to rule out tinea. • Rx: steroids, UVB. Slow to respond to Rx • Stasis Dermatitis: • Venous problem • Older patients • Erythema, edema, and brown discoloration, :”woody” • DDx: cellulitis (cellulitis more commonly unilateral) • Rx: Goal reduce venous HTN: elevation, weight loss

16. Common skin rashes:PapulosquamousDermatoses • Lichen Planus: • Idiopathic • Skin, hair follicles, nails, mucous membrane • 4Ps: pruritic, pink-purple, papules, plaques • Lichenoid drug eruption – similar appearance, but associated with ACEi, TZDs, Lasix, b-blockers, anti-malarials • Longstanding LP is a risk factor for SCC • Rx: topical steroids first line, cola tar, calcineurin inhibitors, and UV therapy are second line.

17. Drug Reactions:Fixed, DRESS, AGEP, EM, SJS, TEN • Drug reactions: • Can be localized to skin or systemic • First step: stop the offending drug • Similar appearing to vasculitis and viral exanthems • Fixed drug eruptions (antibiotics, NSAIDs, acetaminophen) • DRESS: fever, LAD, skin findings, hepatopathy; anticonvulsants; remove offending agent +/- steroids • AGEP (acute generalized exanthematouspustulosis): • widespread erythema studded by small pustules • fever, leukocytosis • MCC: Antibiotics, antimalarial, diltiazem, terbinafine • Self limiting • Rx: removal of agent +/- steroids • EM, SJS, TEN – discuss in a bit

18. A 23-year-old woman is evaluated for a very itchy rash for the last 2 days. She also reports “puffiness” in her face and fever. Because she has epilepsy, she was started on a new anticonvulsant 6 weeks ago. She takes no other medication.On physical examination, temperature is 38.7 °C (101.6 °F), blood pressure is 130/78 mm Hg, pulse rate is 106/min, and respiration rate is 16/min. She has facial edema and erythema. She has erythematous pink papules coalescing into plaques that diffusely involve her trunk and extremities. Her mucous membranes are hyperemic but not eroded or painful. Lymphadenopathy is noted in the cervical and axillary regions and inguinal regions.Laboratory studies show a serum alanine aminotransferase level of 330 units/L and a serum aspartate aminotransferase level of 355 units/L. Results of a complete blood count are normal except for 16% eosinophils. • Acute generalized exanthematouspustolosis • Drug reaction with eosinophilia and systemic symptoms • Erythema multiforme • Livedoreticularis

19. Common rashes:Pigmented PurpuricDermatosesMiliaria • PPD: • Group of eruptions that share similarities • Red-brown patches and plaques with superimposed petechiae • New lesions form over old ones • MC of lower extremities; bx shows small vessel disease • Bxto rule out T-cell lymphoma, MF • Rx: mid to high potency steroids over 6 weeks • Miliaria – heat rash; sweat gland rupturing

20. A 66-year-old man is evaluated for a persistent rash for 6 years' duration. The rash waxes and wanes in severity, and it becomes pruritic only after he becomes hot and sweating, such as when he mows the lawn or exercises. It has always been limited to his back and lower chest. He has never treated it. The patient is otherwise well, has no other medical problems, and takes no medication.On physical examination, vital signs are normal. There are small 2- to 3-mm red papules, some with slight scale, on his back and across the lower part of his chest. There are no lesions on his arms, legs, face, soles, or palms. The remainder of the examination is unremarkable • Bacterial folliculitis • Grover disease • Miliairia • PityriasisRosea • Tinea Versicolor

21. Answer Review: Grover Disease • Bacterial folliculitis – acute; not 6 years duration • Grover – red papules on chest, flanks, and back that become pruritic with heat; • 50 years and older • bx shows acantholysis (loss of intercellular connections) • Rx: reassurance, cooling, low to mid potency topical steroids • Tends to recur regardless of rx • Miliaria – should not persist for 6 years • Pityriasisrosea – Herald patch, followed by diffuse eruption on torso, usually lasts no more than months • Tineaversicolor – scaly hyyper/hypopigmented macules on the trunk and upper arms. Caused by Malassezia furfur, non-itchy, clinically manifests when in hot and humid conditions.

22. A 44-year-old man is evaluated for tender, extremely painful nodules in the axillae and groin area. These lesions drain chronically. The patient is self-conscious about the occasional malodorous discharge. Topical and oral antibiotics have only been minimally helpful. He is a heavy smoker and has a family member with a similar condition that improved with age.On physical examination, vital signs are normal. He has inflammatory nodules with some double comedones in axilla and groin folds, some with drainage and sinus tracts. Skin findings are • Acne • Hidradenitissuppurativa • Pyogenic granuloma • Sweet syndrome

23. Answer Review: AcneiformEruption: Hidradenitissuppurativa • Acne – no sinus tracts, atypical for axilla • Hidradenitis (acne inversa) – follicular occlusion • Tender, subcutaneous nodules; may rupture or lead to sinus tract • Chronic, sterile abscess • Axilla • Associated with smoking and obesity • Rx: no FDA Rx: tetracycline, surgical removal down to subcutaneous tissues • Pyogenic granuloma – bright red/friable papules resulting from capillary proliferation • Sweet syndrome – neutrophilic dermatitis; often associated with hematologic malignancies and females after an upper URI. (fevers, arthralgia), myalgia, and cutaneous lesions

24. An 18-year-old man is evaluated for a 3-month history of asymptomatic lesions on the soles of his feet. His discomfort is worsened after wearing running shoes for long periods of time. He also notices odor and attributes it to excessively sweaty feet from his physical activities. He was previously diagnosed with palmar-plantar hyperhidrosis.On physical examination, vital signs are normal. Skin findings are shown • Ecthyma • Keratodermablennorhagica • Pitted keratolysis • Tineapedis

25. Answer Review: Pitted keratolysis • Ecythma: saucer shaped, superficial ulcers with overlying crust caused by strep. • Associated with IVDU and AIDS • Ecythmagangrenosum – similar but caused by pseudomonas • Keratodermablennorrhagica • Hyperkeratotic skin lesions on the soles and palms – associated with reactive arthritis • Pitted keratolysis: • crateriformpitted lesions on pressure areas of the feet associated with hyperhydrosis • Typical asymptomatic but odorous. • Caused by Kytococcuscongolensis • Rx: topical macrolide • Tineapedis – interdigital scaling and maceration. Does not present with pitting.

26. Common Skin and Nail InfectionsErythrasmaKeratolysis • Folliculitis: infection of the hair follicle • Can be caused by bacteria, fungi, HSV (S. aereus) • Dx: clinical; culture if concerned for resistant organism (MRSA) • Rx: Topical abx +/- oral anti-staph • Abscess/furuncles/carbuncles: • Abscess – soft tissue infection • Furuncle – abscess that involves a hair follicle • Carbuncles – collection of furnucles/folliculitis • S. aereus – MCC • Dx: clinical • Rx: warm compresses, I&D, abx if associated cellulitis, systemic sx, imuunosuppresion, prosthetic joints, abnormal heart valves • Should ctx to help tailor abx if needed

27. Common skin and nail infections (continued) • Impetigo: • S. aureus, strep pyogenes • Usually healthy patients • Not ill appearing • Dx: clinical • Rx: topical mupirocin or oral anti-staph • Very contagious so hygiene is important • Cellulitis: • Infection of the deeper layers of skin (lower dermis, subcutaneous fat) • staph and strep • Nidus of infection include skin breaks, tinea, trauma • Dx: usually clinical; bx: only to rule out other etiologies of erythema • Rx: B-lactam (cephalexin and/or dicloxacillin) – cover b-hemolytic strep and staph aureus. If no improvement, cover MRSA (clinda, bactrim, tetracycline). Consider broad spectrum up front if immunocompromised. • Erysipelas • Infection of the superficial lymphatics and upper dermis • Usually group A strep • Acute onset erythematous plaques that are indurated • Dx: clinical • Rx: PCN

28. Common skin and nail Infections (continued) • Erythrasma • Superficial infection caused by Corynebacteriumminutissimum • Pink brown pathces with fine scales • Groin, axilla, intertrigious region • Rx: topical macrolide antibiotics (clinda/erythro)

29. Cuts, Scrapes, Burns • Tetanus immunization indicated for 2nd degree burns or worse if not updated or unknown immunization. • Wounds heal faster when they are kept moist and occluded • Don’t give topical abx unless concern for secondary infection • Neomycin, bacitracin – frequently cause allergic contact dermatitis

30. Common Neoplasms

31. A 78-year-old man reports a several-year history of developing an increasing number of irregularly pigmented “moles” on the back. The lesions are mostly asymptomatic, although some itch at times, and some may be getting larger. He is concerned they could be melanoma and wonders if they can all be removed. Family history is significant for a sister with melanoma at 55 years of age. • Atypical nevi • Melanomas • Seborrheickeratoses • Solar lentigines

32. Answer Review: Seborrheic keratosis • Atypical nevi – usually flat, can appear otherwise like seborrheic keratosis • Melanomas – another discussion • Seborrheic keratosis– benign, waxy, verrucous papules that can be flesh colored to tan. Increase with age. No malignant potential. • Lesser-Trelat: rapid growth of multiple seborrheic keratosis assoicated with underlying malignancies • Solar lentigines – completely flat; “liver spots”; brown, well-demarcated macules and patches

33. Common Neoplasms • Melanocytic nevi (moles) • Benign pigmented lesions • Birth to first three decades of life • Congenital – at birth • Compound – raised papules with possible irregular pigmentation • Dermal – soft, flesh colored to light brown papules. • Dysplastic nevi • Melanocytic lesions • Biology between benign nevi and melanomas • Marker for increased risk for melanoma (although the nevi themselves are not considered precancerous) • Need regular physical examsand very careful monitoring

34. Common neoplasms • Halo Nevi: • Benign • Results in a white macule • Sebaceous hyperplasia: • enlarge oil glands • small umbilicated pink or yellowish papules on the face; harmless. • Can be mistaken for BCC (telangiectasias should distinguish the two) • Neurofibromas • Soft, flesh colored asymptomatic papules • Isolated NF very common and not associated with genetic conditions • Multiple can be a sign of NF (axillary freckles, café au lait, Lisch nodules)

35. Common neoplasms (continued) • Skin tags: • benign soft, fleshy papules that arise in areas of friction. • Rx: remove (cryotherapy or scissor excision) • Cherry hemangiomas • Benign vascular lesion • Bright red smooth papules, usually on trunk • Benign, no Rx required

36. A 25-year-old woman is evaluated for a firm “bump” on the leg. It has been present for approximately 3 years and has not changed in size or shape. The lesion is frequently traumatized by shaving. Skin findings are shown • Dermatofibroma • Epidermal inclusion cyst • Melanoma • Pigmented basal cell carcinoma • Seborrheic keratosis

37. Answer Review: Dermatofibroma • Dermatofibroma – firm pink brown papules, usually found on legs, When squeezed, they exhibit a “dimple sign”. Benign • Epidermal inclusion cyst – benign, non-tender, smooth, firm well demarcated subcutaneous nodules. Central punctum, “sebaceous cysts”, white, cheesy, malodorous material when incised • Melanoma – reviewed last year • Pigmented basal cell carcinoma – reviewed last year • Seborrheic keratosis – reviewed earlier

38. Common Neoplasms (continued) • Hypertrophic scars and keloids • Occur at the site of injury or surgery • Genetic predisposition, MC in darker skin tomes • HS – don’t extend beyond site of injury • Keloids – extend beyond site of injury; can occur spontaneously • Rx: intralesional steroids • Pyogenic granuloma • Friable red, vascular papules, arise spontaneously and grow fast • Collection of capillaries • Common in pregnant wome • Rx: shave technique or electrodessication • Lipomas • Benign, collections of fat commonly occur on the trunk and extremities. Asymptomatic, smooth

39. Pruritis • Evaluation – determine if related to underlying skin disorder • “The rash that itches, or the itch that rashes” • MCC – dry skin; Rx: bath every 2-3 days, use moisturizers • Skin disorders • Dry skin • Dermatitis (atopic and allergic) • Med reaction, scabies, psoriasis, lichen planus, dermatographism • Non-skin disorder related (think systemic conditions) • Malignancy (heme), cholestatic liver disease, renal disease, IDA, thyroid dysfunction, meds, HIV • Work up: CBC, iron studies, TFTs, BMP, LFTs, CXR, age appropriate maligancy work up • Neuropathic itch: • Localized itch without skin lesion (damage to sensory nerves) • General Rx measures: • Rx underlying conditions • General skin care, and reuglar emollient use • Hot water – worsens histamine mediated itch

41. A 43-year-old woman is evaluated in the emergency department for widespread pruritic wheals. The individual lesions seem to migrate, with each wheal lasting 30 to 60 minutes. The patient says this has been going on for 2 days. There is no accompanying wheezing and no lip or eyelid swelling. The patient is breathing comfortably, has no difficulty swallowing or clearing secretions, and no skin pain. She took diphenhydramine twice yesterday without relief. She has no known drug allergies and just finished a 3-day course of levofloxacin for her third urinary tract infection in the past 6 months.On physical examination, temperature is normal, blood pressure is 110/78 mm Hg, pulse rate is 90/min, respiration rate is 18/min. BMI is 22. There are scattered edematous indurated erythematous plaques consistent with wheals over the scalp, face, neck, chest, upper back, flanks, and arms. The patient has marked dermatographism. There is no wheezing or stridor, no mucosal lesions, and no bullae. • Admit to hospital • Treat with cetirizine, ranitidine, and diphenhydramine • Treat with high potency topical steroids • Treat with indomethacin

42. Answer Review: Urticaria • Inflammatory reaction that results from mast cell degranulation • Triggers: • Infections (viral, bacterial, parasitic) and meds (PCN, beta lactams, vanc, ASA, NSAIDs, opiates, contrast dye), food, stings allergies, chemical exposures (latex), and physical agents (heat, cold, pressure, exercise) • Clinically: red, edematous, wheals; acute v. chronic; look for warning/atypical features • All acute needs to be evaluated for anaphylaxis • Chronic: difficult to assess; 50% idiopathic • Atypical features (last > 24 hours, burning sensation, resolve with bruising, fail to respond to anti-histamines) – should be evaluated for underlying vasculitis • Food allergies – refer for RAST testing • Rx: • Acute – H1 and H2 blockade, followed by po steroids on people that don’t resolve; management changes if signs of impending airway obstruction • Chronic – colchicine, dapsone, plaquenil, mycophenolatemofetil, MTX • If patient has angioedema, they need an epi-PEN

43. A 79-year-old woman is evaluated for pruritic blisters on the chest, abdomen, and lower extremities of 3 to 4 weeks' duration. The blisters arise in crops, drain clear yellow fluid, and crust over before healing. She reports no recent illness and, other than significant itching, feels well. She cannot identify any precipitating causes of the blisters; she reports taking no new medications, using no new topical products, and having no new exposures to plants. She has not been around anyone who is ill or who has had similar skin lesions. Medical history is remarkable only for hypothyroidism secondary to Hashimoto thyroiditis; her only medication is levothyroxine.On physical examination, the patient is afebrile. Typical skin findings are shown :shown . • Bacterial culture • PCR from blister fluid • Skin bx and direct immunoflourescence microscopy • Tzanck preparation

44. Answer Review: Autoimmune Bullous Disease • Rare, heterogeneous group of unrelated skin disorders • Bullous pemphigoid, dermatitis herpetiformis, IgA bullous dermotosis, pemphigousvulgaris • Blisters and erosions • Cause significant M&M, so recognition and dx are important • Dx should be considered when unexplained blisters or erosions are seen • Skin bx +/- blood testing (circulating auto-antibodies) • Rx: Most diseases have systemic steroids or other immunosuppressants (azathioprine, MTX, cyclophosphamide, Cellcept) as part of Rx. • Often require multiple drugs

45. Cutaneous Manifestations of Internal Disease • Rheum • Covered in Rheum lecture • Nephrology • Pruritis: discussed earlier • Calciphylaxis: necrotic tissue caused by vascular calcifications • Rx: Sodium thiosulfate, wound care • Nephrogenic systemic fibrosis • Distal extremity thickening, fibrosis, limited mobility • Dx: clinical, bx can confirm • Suspected to be related to gadolinium based MRI • Post – Tx: • Think about non-melanoma skin cancers (especially SCC) • Pulmonary • Sarcoidosis: • Violaceous papules and infiltrative plaques • Granulomas at the site of trauma (surgical scars or tattoos) • Lupus pernio • Erythema Nodosum in Lofgren syndrome (can also be seen as the result of abx, ocp, HRT) • Gastroenterology • IBD: • Erythema Nodosum and pyodermagagrenosum • ESLD • Covered in liver • Heme/Onc • Sweet Syndrome • Covered previously • Endocrine • Covered in endocrine • ID • HIV • Covered previously

46. A 22-year-old man is evaluated for lip erosions and a new rash on the palms. A representative example of the skin findings is shown • HSV • Parvo B19 • Group A strep • Varicella zoster

47. A 37-year-old woman is evaluated in the emergency department for a 24-hour history of peeling skin. She was recently treated for a urinary tract infection with trimethoprim-sulfamethoxazole. Several days into treatment, she developed fever followed by fine, red, itchy papules on her torso and extremities. She continued the antibiotics, the rash worsened, and her skin became painful during the next few days. This morning, she awoke with sores in her mouth, and when she touched her skin it peeled off. She takes no other medications and has no documented allergies.On physical examination, she appears acutely ill and is in pain. Temperature is 39.4 °C (102.9 °F), blood pressure is 100/60 mm Hg, pulse rate is 106/min, and respiration rate is 20/min. The skin shears when lateral pressure is applied to areas of erythema. Erythema and crusting are present around the eyes and on the lips, and open erosions are present in the mouth. The vulva has superficial erosions. Skin findings are shown :shown .The patient is admitted to the intensive care unit, and aggressive intravenous fluid replacement is begun. • Begin iv corticosteroids • Begin topical corticosteroids • Begin Vanc • Obtain a skin bx

48. Derm Urgencies and Emergencies:Erythema multiforme, SJS, TEN SJS/TEN – antiseizure medications, NSAIDs, abx, PPI, sertraline, tramadol, allopurinol EM SJS TEN Dx: clinical; bx confirms Rx: Supportive (fluid, electrolytes, wound care) dc offending agent

49. A 58-year-old man is evaluated for a 3-year history of an itchy, scaly rash. It began as patches and plaques but over the past several months has progressed to a generalized, red skin rash. The pruritus is intense and interferes with his life. His only other medical problem is hypertension for which he has taken lisinopril for the past 5 years.On physical examination, vital signs are normal. He has erythema with scales affecting more than 90% of the body surface area. Skin findings are shown :shown .He also has alopecia, thickening of the nails, palms, and soles, and nail dystrophy. Generalized lymphadenopathy is also present. • Cutaneous T-cell lymphoma • Drug hypersensitivity reaction • Pustular psoriasis • Staph scalded skin syndrome

50. Answer Review: Erythroderma • Erythroderma: erythema (inflammation) of at least 80% skin surface • Erosions from severe pruritis, peripheral edema, scaling, LAD • Difficult to find underlying cause • Acute caused by uncontrolled dermatosis, meds, idiopathic • Alopecia, nail dystrophy, thickening of the palms and soles of the feet indicate long term erythroderma • T-cell lymphoma, GVHD, psoriasis • Dx: largerly clinical; bx has high rate of being non-specific • Rx: stop the medication if involved, referral to dermatologist, supportive care