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Google automatically generates html versions of documents as we crawl the web. Dermatology Review Cecilia Dowsing-Adams, MD Department of Family Medicine University of Tennessee, Memphis Objectives

1. Recognize and treat common skin conditions. 2. Diagnose and treat common bacterial skin infections. 3. Identify and treat mycotic and viral infections. 4. Identify aging skin and precancerous lesions. 5. Discuss other dermatologic disorders.

Type of lesions 1. Primary lesions

Initial orientation of the lesion

2. Secondary lesions

Evolutionary process Created by scratching or infection

3. Special skin lesions

Unique structures and changes

Macule

Flat, circumscribed alteration in skin color Less than 10 mm

Papule

A small solid elevation Less than 10 mm in diameter

Nodule

Small, circumscribed solid elevation 10-20 mm in diameter

Extends in deeper tissue

Wheal

A relative transient round or flat lesion Usually colorless or pale

Pustule

Elevation that contains a purulent exudate

Vesicle

A circumscribed lesion that contains a clear liquid

Bullae

A vesicle larger than 10 mm

Scale

Accumulation of loose fragments on surface of skin Flaking of skin

Crust

A dried exudate on the surface Color depends on exudate

Erosion

Loss of part of the epidermis Depressed, moist Follows rupture of a vesicle or bulla

Ulcer

A deep loss of skin surface Varies in size

Fissure

Linear crack or break from the epidermis to the dermis Moist or dry

Atrophy

Thinning and loss of elasticity Shiny appearance Loss of hair

Scar

Fibrous tissue that replaces damaged skin Thick or thin

Cyst

Elevated, circumscribed, encapsulated lesion Filled with liquid or semisolid material

Lichenification

A thickened and roughening of the skin Appears as exaggeration of skin markings Usually cased by rubbing

Telangiectasias

Fine, irregular red lines Permanent enlargement in capillaries (dilatation)

Excoriation

Superficial removal of epidermis Usually caused by scratching and rubbing

Keloid

A fibrous hyperplasia usually at the site of a scar Grows beyond the boundaries of the wound Excessive collagen formation during healing

Patch

A macule larger than 10 mm

Tumor

A mass larger than 20 mm in diameter

Primary lesions

Macule: flat, circumscribed alteration in skin Papule: small, solid circumscribed elevation Plaque: large, flat lesion greater then 10mm Nodule: small, circumscribed solid elevation 10-20mm in diameter extends in deeper tissue

color

Primary lesions

Wheal: relative transient round or flat lesion usually colorless or pale should not last over 72 hours

Vesicle: circumscribed elevated lesion containing a clear liquid

Pustule: circumscribed elevated lesion that Bullae: vesicle larger than 10mm

contains a purulent exudate

Secondary lesions

Scale: Accumulation of loose fragments on Flaking of skin

surface of skin

Crust: A dried exudate on the surface Color depends on exudate

Erosion: Loss of part of the epidermis Depressed, moist Follow rupture of a vesicle or bulla

Ulcer: Deep loss of skin surface

Secondary lesions

Fissure: Linear crack or break from the epidermis to the dermis Moist or dry

Atrophy: Thinning and loss of elasticity Shiny appearance Loss of hair

Scar: Fibrous tissue that replaces damage skin Thick or thin

Special skin lesions

Cyst: Elevated, circumscribed, encapsulated Filled with liquid or semisolid material

lesion

Lichenification: A thickened and roughening of skin Exaggeration of skin markings Usually caused by rubbing

Telangiectasias: Fine, irregular red lines Permanent enlargement in capillary

Special skin lesions

Keloid: Fibrous hyperplasia usually at the site of a scar Grows beyond boundaries of the wound Excessive collagen formation in healing

Excoriation: Superficial removal of epidermis Usually caused by scratching and rubbing

Patch: A macule larger than 10 mm Tumor: A mass larger than 20 mm in diameter

Common Skin Disorders Acne Acne Vulgaris

Sebaceous glands are everywhere except: palms, soles, dorsa of the feet, and lower lip Primarily affects face, chest, back and upper outer arms It usually occurs at puberty with sebum production triggered by increased androgen levels; TestosteroneDHT DHT increases the size and metabolic rate of the sebaceous gland Estrogen sebaceous gland output

Acne Vulgaris

Chronic inflammation and obstruction of the pilosebacaceous units

Increase production of sebum leads to colonization with propionibacterium acnes and inflammation ensues. Follicular epithelial lining becomes altered and forms plugs called comedones Glucocorticoids, anabolic steroids, lithium, some OCPs, and iodides may exacerbate disease

Acne Vulgaris

Symptoms/exam

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Presents with noninflammatory comedones (blackhead and whiteheads) Presents with inflammatory papules, pustules, and cysts

Acne Vulgaris Treatment

Non-pharmacologic o Face washing, oil-free moisturizers Mild acne o Topical benzyl peroxide (2.5%) gel o Add topical tretinoin or adapalene o Add topical clindamycin or erythromycin o Add systemic tetracycline

Acne Vulgaris Treatment

Moderate to Severe pustular acne o Systemic antibiotics (4 months): tetracycline, doxycycline, clindamycin, erythromycin, minocycline, TMP-SMX o Isotretinoin (Accutane) 13-cis-retinoic acid Beta HCG must be done prior to initiation of therapy 2 forms of birth control

Acne Rosacea Acne Rosacea

Recurring, chronic disorder of the pilosebaceous units, Acne of the aged patient (40-60) Characterized by erythema and pustules Aggravating factors include exercise, stress, hot liquids, spicy foods, and ETOH

Acne Rosacea

Symptoms/Exam

- Initially presents with flushing - Erythema and telangiestaias on the central face - Papules, pustules and occasionally lymphedema - Distribution is important (cheeks, nose, forehead and chin) - No comedones are seen

Acne Rosacea Treatment

Non-pharmacologic o Avoid precipitating factors Pharmacologic o Topical metronidazole gel or cream (0.75%) o Topical sodium sulfacetamide lotion o Tetracycline, doxycycline, or erythromycin for 2-3 months o Use isotretinoin for severe disease

Acne Rosacea

Rhinophyma (large nose) is a complication affecting primarily middle-aged men Irreversible (electrodessication may improve cosmesis)

Atopic Dermatitis Atopic Dermatitis

A chronic, pruritic eczematous skin disease o Itch-scratch cycle, worsening rash Onset is usually before age 7 o 3 Stages: Infant Childhood Adulthood (least common)

Atopic Dermatitis

Multifactorial Thought to be immune mediated,

roughly 85% of patients have IgE

Environmental stress triggers reactions on genetically compromised skin (not allergen related)

Atopic Dermatitis

Major Diagnostic Criteria (3 or more) o Pruritus o Typical morphology and distribution o Flexural lichenfication in adults o Facial and extensor involvement in children o Dermatitis chronically relapsing o Personal or family history of atopy asthma, allergic rhinitis, atopic dermatitis

Atopic Dermatitis

Symptoms/exam o Acute lesion include vesicles and serous exudates o Lichenification, excoriation and fibrotic plaques are characteristic of chronic disease o Other findings include xerosis (dry skin), infraorbital skin folds (Dennie-Morgan lines), periorbital darkening, hyperlinear palms, and keratosis pilaris

Atopic Dermatitis

Triggers: o Temperature change and sweating o Decreased humidity o Excessive washing o Foods (eggs, milk, peanuts, wheat)

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Aeroallergens Dry skin

Atopic Dermatitis Treatment

Non-pharmacologic

- Eliminate exacerbating factors - Skin hydration with lotions and emollients

Pharmacologic

- Anti-inflammatory

Topical corticosteroids Topical calcineurin inhibitors (elidel)

Atopic Dermatitis Treatment

Pharmacologic

- Anti-pruritic agents

Atarax (hydroxyzine) Benadryl (diphenhydramine) Claritin/allegra to avoid sedation Seraquel (doxepin)

Phototherapy

- UVA & UVB light

Seborrheic Dermatitis Seborrheic Dermatitis

Common, chronic inflammatory disease Malassezia furfur yeast probable cause Once established, it may persist Older patients (especially those bedridden and those with Parkinsons) have chronic and extensive disease

Seborrheic Dermatitis

Distribution of scaling and inflammation: head and trunk where sebaceous glands are most prominent

- Scalp and scalp margins (dandruff/cradle cap) - Eyebrows - Base of eyelashes - Nasolabial folds - External ear canals - Posterior auricular fold Seborrheic Dermatitis

Symptoms/exam o Dry or greasy, yellow, sharply demarcated scales on an erythematous base o Crust and fissures can develop and can become superinfected

Seborrheic Dermatitis Treatment

Scalp

- Frequent washings with an anti- seborrheic shampoo

Zinc soaps Selenium lotions Tar (Tarsum, T-Gel) 2% ketoconazole (Nizoral)

Seborrheic Dermatitis Treatment

Intertriginous areas

- Low potency steroids - +/- 2% ketoconazole cream

Treat infants with emollients and 1%hydrocortisone ointment or a miconazolehydrocortisone combo

Seborrheic Dermatitis Treatment

Face

- Topical steroids not to be used as maintenance therapy - +/- 2% ketoconazole cream Pityriasis Rosea Pityriasis Rosea

Benign, self-limited eruption Generally affects adolescents and young adults as a response to a viral infection Affects females more often than males

Pityriasis Rosea

Symptoms/exam o Herald patch appears several days before the rest of the rash o Days later small plaques appear on the trunk, arms and thighs o Delicate peripheral collarette of scale distributed parallel to the lines of the ribs, creating Christmas tree distribution

Pityriasis Rosea

Symptoms/exam

- Mild to moderate pruritus Pityriasis Rosea Treatment

Directed to symptom relief with antihistamines for itching Moderate-potency steroids may be used for itching if necessary Spontaneous resolution usually occurs within 1-2 months.

Psoriasis Psoraisis

Chronic, noninfectious disease Immune-mediated inflammatory response Lifelong disease affecting ~1-3% of the population Bimodal distribution (peaks at 22 and 55 years of age)

Psoraisis

Triggered by environmental factors:

- Infection (strep)

- Stress - Trauma (Koebners phenomenon) - Drugs (beta-blockers, lithium) Psoraisis

Symptoms/exam o Red, scaling papules which coalesce to oval plaques with sharp margins o Covered by silvery, white thick scales which bleed when removed (Auspitzs sign) o Epidermal hyperpigmentation with bilateral involvement of extensor surfaces, scalp, palms, and soles

Psoraisis

Symptoms/exam o Nail involvement: nail pitting oil spots Onycholysis (lifting of the nail plate)

Psoraisis

Symptoms/exam o Guttate psoriasis generally follows a streptococcal infection and presents with an acute symmetrical eruption o Associated arthritis can develop

Psoraisis Treatment

Pharmacologic o Potent topical steriods o Calcipotriol (vit D der.) donovex o Intralesional steriod injections (kenalog 5-10mg) o Topical retinoids

Psoraisis Treatment

Pharmacologic (systemic) o Phototherapy - UVB o Photochemotherapy PUVA o Oral retinoids o Methotrexate and other immunomodulatory drugs in severe cases

Acute Allergic Contact Dermatitis

Contact Dermatitis Allergic

Delayed (type IV hypersensitivity Previous sensitization must have occurred Upon reexposure to an allergen, dermatitis occurs to 2 days later Common agents: nickel, chromium, neomycin, and oleoresin (poison ivy, poison oak, poison sumac)

Contact Dermatitis Allergic

Symptoms/exam o Intensely pruritic, erythematous papular rash with indistinct margins o Distribution depends on allergen and pattern of exposure to the allergen

Contact Dermatitis Treatment

Non-pharmacologic o Avoid allergen Pharmacologic o Medium- to high-potency topical steriods o Cool compresses Burrows solution=Aluminum acetate 1:20 o Antihistamines o Severe cases: short course of oral corticosteriods

Contact Dermatitis Irritant

Breakdown of the normal epidermal barrier Reaction may be initiated by a common irritant or a one-time exposure to an allergen Patients with compromised skin barriers are at higher risk

Contact Dermatitis Irritant

Symptoms/exam o Erythema, fissures, and pruritus o Bullae may develop in severe cases o Often affects the hands (web spaces) o May affect the face and eyelids Diagnosis: patch test to distinguish from allergic contact dermatitis

Contact Dermatitis Treatment

Non-pharmacologic

Avoid triggers Restore normal epidermal barrier Use emollients Pharmacologic o Topical corticosteriods o Oral corticosteriods are of little benefit if irritant is not removed

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Dyshidrotic eczema Dyshidrotic Eczema

An intensely pruritic, chronic recurrent dermatitis Typically involves the palms and soles

Dyshidrotic Eczema

Symptoms/exam o Starts as an episode of intense itching o Formation of small vesicles o Desquamation occurs over 1-2 weeks o Leaves fissures and erosions

Dyshidrotic Eczema Treatment

Non-pharmacologic o Avoid triggers o Restore normal epidermal barrier o Use emollients

Dyshidrotic Eczema Treatment

Pharmacologic o Medium to high-potency topical corticosteriods o Systemic steroids in severe cases o Recalcitrant cases may respond to PUVA or UVA

Bacterial Infections Carbuncle: S. aureus Folliculitis

A superficial, pustular infection of the hair follicles Causative agent is usually Stap. aureus

Folliculitis

Symptoms/exam o Clusters of small, pruritic erythematous lesions o Pustules may be centrally located o Lesions are generally found in hair-bearing areas

Folliculitis Treatment

Non-pharmacologic o Hygeine is key Pharmacologic o Systemic and topical antibiotics in acute infections o Carrier sites (nose) must be treated with mupirocin (bactroban) in chronic infections along with systemic antibiotics

Streptococcal Cellulitis Cellulitis

Bacterial infection that results from breach of skin barrier Most frequently among middle-aged and elderly individual Risk factors: leg ulcers, trauma, venous insufficiency, obesity

Cellulitis

Symptoms/exam o Fever, chills and myalgias o Rubor, calor, tumor, and dolor o Most commonly affects the extremities o Regional lymphadenopathy is common o Lymphangitis may be present o +/- abscess

Cellulitis

Pathogens o Furuncles, carbuncles or abscesses S. aureus (MRSA?) o Diffuse with no defined portal - Strep o Facial cellulitis in children H. influenza o Regional lymphadenopathy is common o Post-puncture wound - Pseudomonas o +/- abscess

Cellulitis Treatment

Infectious Disease Society of America guidelines: Penicillinase-resistant semisynthetic penicillin or a first generation cephalosporin unless Strep or Stap resistant is common in the community Clindamycin or vancomycin for PCN-allergic patients

Also treat any predisposing conditions

Erysipelas Erysipelas

Acute inflammation of the dermis Causative agent: Strep. pyogenes Elderly and immunocompromised patients at higher risk

Erysipelas

Symptoms/exam o Well-demarcated erythema, edema, and tenderness o Typically affecting the face and lower legs o Systemically ill, fever, chills and malaise o Lesions can rapidly advance

Erysipelas Treatment

IV antibiotics against Strep

Bullous Impetigo Impetigo

Superficial skin infection Children > adults Contagious and autoinocuable Causative agents Staph and Strep Usually involves face, neck and extremities

Impetigo

Symptoms/exam o Primary lesions are vesicles/pustules that easily rupture o Spread rapidly and become crusted (honey-crusted)

Impetigo Treatment

Non-pharmacologic o Remove crust with saline soaks Pharmacologic o Topical mupirocin (Bactroban) o Systemic antibiotics for severe cases (empiric treatment for Stap/Strep)

Hidradenitis Suppurativa

Hidradenitis suppurativa

Chronic, suppurative process Results from occlusion of follicles and secondary inflammation of apocrine glands More common in females (especially hirsute females)

Hidradenitis suppurativa

Symptoms/exam o Recurring, deep boils for > six months in flexural areas o Commonly affects the axillary, groin, vulva, perineal or perianal areas

Hidradenitis suppurativa Treatment

There is no cure Goal is to reduce the extent and progression of disease; and to allow regression of scars and sinuses in more extensive disease

Hidradenitis suppurativa Treatment

Topical clindamycin Antiandrogens and retinoids have yielded mixed results Severe disease requires surgical treatment

Hidradenitis suppurativa Treatment, Hurleys criteria

Stage I - abscess formation, without sinus tracts; drug therapy Stage II recurrent abscess with tract formation, single or multiple widely separated lesions; drug therapy and limited excision of recalcitrant lesions Stage III diffuse involvement, or multiple interconnected tracts and abscesses across the entire area; unlikely to benefit from medical therapy; wide surgical excision.

Mycotic Infections Tinea Pedis Tinea

Most common type of fungal infections of skin and nails Usually it is localized, erythematous, scaly lesion that form as vesicles/pustules with satellite lesions

Tinea

Differentiation is site dependent

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T. capitus: occurs primarily in children Treat with griseofulvin, terbinafine and intraconazole T. pedis: athletes foot, interdigital maceration Treat with topical antifungal cream Resistant cases may require oral antifungals

Tinea

Differentiation is site dependent o T. corporis: ringworm, sharply demarcated margins with scaling Treat with antifungal cream o T. cruris: jock itch, male predispostion, risk factors are obesity and sweaty physical activity Treat with topical antifungals Talc or desiccant powders may prevent recurrence

Tinea Vesicolor

Chronic fungal skin infection Resulting with pigmentary changes of the skin Causative agent Pityrosporum orbiculare Typically affects young adults

Tinea Vesicolor

Symptoms/exam o If fair-skinned, brown or pink, superficially scaly macules o If darker-skinned, hypopigmented superficially scaly, macules

Tinea Vesicolor Treatment

Pharmacologic o Topical antifungal Clotrimazole Miconazole o Selenium sulfide lotions o Ketoconazole shampoo

Tinea Vesicolor Treatment

Pharmacologic o Ketoconazole 400 mg single dose (short-term cure 90% of the time) o Systemic antifungal, itraconazole for 7 days for resistant cases

Candidiasis Candidiasis/Intertrigo

Fungal infection with predilection of moist areas Intertriginous area most common sites involved Risk factors: o DM, obesity, sweating, heat, maceration o Systemic and topical steriod use o OCPs and antibiotics may be contributory

Candidiasis/Intertrigo

Symptoms/exam o Vesiculopustular enlargement with rupture o Erosion and confluency ensues o Sharply, demarcated plaques with scaly borders and surrounding erythema o Satellite lesions

Candidiasis/Intertrigo Treatment

Non-pharmacologic o Keep area clean and dry Pharmacologic o Topical antifungal

Viral Infections Molluscum Contagiosum Molluscum Contagiosum

Discrete umbilicated papules Involves the trunk, face and neck Causative agent DNA pox virus Usually in children or young adults Spread is by direct contact (towels)

Molluscum Contagiosum

Symptoms/exam o Lesions usually occur is groups o Dome shaped lesion with central umbilication

Molluscum Contagiosum Treatment

Non-pharmacologic o Lesions can be removed via expression with forceps o Lesions can be removed with curetage under local anesthesia o Lesions can be removed with cryosurgery

Viral Exanthems

Rash associated with a viral illness Exanthems are usually generalized Etiology: o Enterovirus o Echovirus o Coxsackie virus

Viral Exanthems

Symptoms/exam o Erythematous, maculopapules o Palms and soles may be involved o Rash typically fades without pigmentation o Systemic Fever, nausea, vomiting Photophobia, LAD, sore throat, encelphalitis

Viral Exanthems Treatment

Non-pharmacologic o Emollients or cooling agents o Relieve symptoms

Herpes Simplex Herpes Simplex

Vesicles on an erythematous base HSV enters the host through abraded skin or intact mucous membranes HSV I, 90% oral lesions HSV II, 90% genital lesions

Herpes Simplex

Symptoms/exam o Painful, recurring vesicular eruptions o Primary eruptions is longer and more severe that recurrences o Primary infection: fever, LAD, and malaise o Recurrence is limited to mucocutaneous area of involved nerve o Prodromal tingling, burning, or pain

Herpes Simplex Treatmemt

Six or more recurrences of genital herpes per year, treat daily for life Denavir (penciclovir) 1% cream for labial sores Suppress 70 to 80 percent of symptomatic recurrences:

o o o

Acyclovir 400 mg BID (Zovirax) Valacyclovir 1 gm q daily (Valtrex) Famciclovir 250 mg BID (Famvir)

Varicella Chicken Pox Varicella

Highly infectious viral illness Incubation average of 14 days after exposure by airborne droplets or vesicular fluids Can be associated with increase risk of infection in pregnant women

Varicella

Symptoms/exam o Prodrome of low grade fever, headache and malaise o Concurrent macules/papules to vesicles to crusted lesions

Varicella Treatment

Varicella vaccine is recommended Avoid salicylates (Reyes syndrome) Acyclovir and immune globulin for immunocompromised host Antivirals, acyclovir are clinically effective in shortening rash if started within 72 hours of its onset

Varicella

Complications o Bacterial skin infections o Congenital varicella Fetal varicella when acquired early in pregnancy (first 20 weeks) Low birth weight, mental retardation, seizures, GI/GU/skeletal problems, dermatomal hypoplasia o Encephalitis o Pneumonia

Varicella

Complications o Congenital varicella Neonatal varicella when acquired late in pregnancy Newborns affected with chickenpox which may disseminate to multiple organs-prompt antiviral therapy

Varicella Herpes Zoster

Shingles, rash in a single, unilateral dermatonal distribution Pre-eruptive itching or burning Eruptive phase has typical varicella appearance

Varicella Herpes Zoster

Symptoms/exam o Preherptic neuralgia usually 4-5 days before the eruptions (up to 100 days) o Fever, headache, and malaise o Regional LAD o Thoracic region involved in 2/3 of cases varicella is centripetal

Varicella Herpes Zoster Treatment

Antivirals: reduces pain, inflammation, vesicle formation and viral shedding o Valtrex 1 gm po TID x 7 days Pain meds o Xylocaine 0.5% SQ o Epidural injections

Varicella Herpes Zoster Treatment

Prevention and treatment of postherpetic neuralgia o Amitriptyline 25 mg q d x 90 days o Lyrica (Pregabalin) o Zotrix (Caspaicin) cream o Merck vaccine reduces the incidence Valtrex 1 gm po TID x 7 days of zoster but does not eliminate it

Measles Rubeola (Measles)

Paramyxovirus Maculopapular rash, red-brown (morbilliform) Spread by respiratory droplets

Rubeola (Measles)

Symptoms/exam th o Morbilliform rash on 4 day begins around ears and head and then spreads caudally o Fever, cough, conjunctivitis, coryza (3 Cs)

Rubeola (Measles)

Symptoms/exam

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Koplik spots located on the buccal mucosa precede the rash Usually atypical in adults with fever and vesicular rash

Rubeola (Measles) Treatment

Supportive Therapy o Acetaminophen o Increase fluid intake Prevention by live attenuated vaccine (MMR)

Rubeola (Measles)

Complications: o Pneumonia o Otitis media o Myocarditis o Subacute sclerosing panencephalitis

Rubella Rubella

AKA German measles 3-day measles Togavirus Spread transplacentally or through respiratory droplets

Rubella

Symptoms/exam o Cervical and posterior auricular adenopathy with URI symptoms, H/A and N/V o Rash is described as palpable petechiae o Prodrome of malaise, low grade fever, and conjunctivitis

Rubella

Symptoms/exam

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Exanthem consisting of discrete rose pink macules that begin on the face and spread downward over 1-3 days +/- Forcheimers sign-petechia on palate

Rubella Treatment

Supportive Therapy o Rest o Increase fluid intake Prevention by live attenuated vaccine (MMR)

Rubella

Complications: o Usually self limiting o Spontaneous abortion o Congenital rubella-cataracts, heart disease, deafness, microcephaly

Erythema Infectiosum Erythema Infectiosum

AKA Fifth Disease Caused by Parvovirus B19 Transmitted by respiratory secretions Ususally affects children 4 10 years of age

Erythema Infectiosum

Symptoms/exam o Slapped cheek appearance o +/- prodome of fever, malaise, headache, myalgias o Erythemous, edematous, confluent plaque on the malar face lasts 1-4 days

Erythema Infectiosum

Symptoms/exam o Eruptions of erythematous macules and papules o the extensor surfaces of extremities, trunk, and neck o Exanthem becomes confluent-lacy and reticulated

Erythema Infectiosum Treatment

Supportive therapy Usally self limited disease

Eruption generally lasts 5-9 days May recur for months with sunlight, exercise, heat, or stress

Erythema Infectiosum

Primary infection in pregnant women is associated with nonimmune fetal hydrops and fetal demise

Parasitic Infection Scabies Scabies

Infection where the female mite burrows into skin and lays eggs Causative agent Sarcoptes scabiei Highly contagious Spreads through prolonged contact with infected host

Scabies

Symptoms/exam o Pruritic papules, pustules, and burrows o Usually located in the web-spaces of hands o Symptoms are worse at night o Involves axilla, antecubital fossa, gluteal crease, genitalia, nipples and waistband

Scabies

Symptoms/exam o Itching and rash are due to type IV hypersensitivity reaction to mite eggs and feces o Two to four week delay between infection and onset of symptoms

Scabies Treatment

Non-pharmacologic o Wash clothes and linens in hot water o Consider treating family members who share the same room Pharmacologic o Apply permethrin 5% below the neck and leave for 8 hours o May be repeated in 1 week

Scabies Treatment

Non-pharmacologic

Wash clothes and linens in hot water Consider treating family members who share the same room Pharmacologic o Apply permethrin 5% below the neck and leave for 8 hours o May be repeated in 1 week

o o

Aging Skin and Cutaneous Oncology Basal Cell Epithelioma Basal Cell Carcinoma

Most common skin cancer Occurs in sun exposed area, especially the face and ears 5 Types: o Nodular o Superficial o Micronodular o Infiltrative o Morpheaform

Basal Cell Carcinoma

Symptoms/exam o Shiny, pearly-gray papule with an umbilicated center and telangiectasias o Rodent cell ulcers

Basal Cell Carcinoma Treatment

Non-pharmacologic o Sun avoidance is key to further prevention o Excision or destruction of small lesions (electrodesiccation and curettage) o Advocate for Mohs surgery if larger than 2 cm, recurrent morpheaform, aggressively tumors, critically located o Margins of 4 mm normal skin gives a 98% complete excision

Actinic Keratosis Actinic Keratosis (AK)

Premalignant lesion to squamous cell carcinoma Superficial keratotic lesion Increased incidence in fair-skinned patients More often felt than seen

Actinic Keratosis (AK)

Symptoms/exam o Red, keratotic papule that feels rough o Can be red to yellow or keratonize to form a horn (must biopsy base to R/O SCC)

Actinic Keratosis (AK) Treatment

Non-pharmacologic o Use sun blocks and avoid excessive sun exposure Pharmacologic o Topical 5-fluorouricil (5-FU) cyctostatic agent which inhibits enzymes in tumor cells o Topical imiquimod

Actinic Keratosis (AK) Treatment

Cryotherapy with liquid nitrogen (limited lesions) Curettage followed by electro or radio frequency to stop bleeding

Squamous cell carcinoma Squamous Cell Carcinoma

Common in middle-aged and elderly May arise with base of AK, within HPV-induced lesions, and within burn and radiation scars Present in sun exposed area

Squamous Cell Carcinoma

Symptoms/exam o Rapid growth with central ulceration and raised indurated borders, hyperkeratotic o Metasis occurs and depends on size, location, tumor differentiation and depth of invasion (>6 mm at risk)

Squamous Cell Carcinoma Treatment

Surgical excision with clear margins

Melanoma Melanoma

Malignancy of melanocytes occurs on any skin 7th most common cancer in the USA

Superficial spreading has better prognosis than nodular melanoma (grows downward)

Melanoma

Malignant melanoma risk (MMRISK) o Moles, atypical o Moles, total number > 50 o Red hair and freckling o Inability to tan o Severe sunburn st o Kindred, 1 degree relative

Melanoma

Symptoms/exam o Changing moles ABCDEs Asymmetry Borders Color Diameter Evolution Grows suddenly, begins to bleed, itch, or becomes painful

Melanoma Treatment

Excision with appropriate borders Sentinel lymph node dissection for melanoma > 1 mm thick to determine need for adjuvant therapy Close follow-up

Other Dermatologic Disorders Condylomata Acuminata Human Papillomavirus

Most common sexually transmitted disease Benign clinical lesions on mucous membranes HPV induces hyperplasia and hyperkeratosis

Human Papillomavirus

Symptoms/exam o Small papular, cauliflower-floret o Keratotic warts o Flat-topped papules/plaques (most common on cervix) o Lesions are skinned colored, pink, red, tan, brown

Human Papillomavirus Treatment

Immunologic response o Spontaneous regression involves cell mediated immunity and interferons o AIDs patients tend to have more Often several attempts: o Topical salicylic acid (keratolytic therapy) o Liquid nitrogen (cryosurgery) o Duct tape o Electrocautery

Kawasakis disease Kawasakis Disease

Inflammatory vasculitis Need fever for >5 days PLUS 4/5 of the following o Conjunctivitis (bilateral) o Strawberry tongue, fissures o Erythematous rash starts palms/soles o Enlarged lymph nodes o Desquamation of fingers/toes with swelling

Kawasakis Disease

Increased WBC, ESR; may be anemic +/- plts Associated with increased risk for coronary artery Treat with high-dose ASA (100mg/kg/day through the 14th day or until afebrile, then 3-5mg/kg/day for 6-8 weeks), IV gamma-globulin (2gm/kg given over 10 hours or 400mg/kg/day for 4 consecutive days.

Seborrheic Keratosis Seborrheic Keratosis (SK)

Most common of benign skin tumors Widely variable presentation from flat, brown macules to raised blackened verruccous lessions need to be familiar with variations to prevent unnecessary destructive procedures.

Seborrheic Keratosis (SK)

Sign of Leser-Trelat (eruptive SK as sign of internal malignancy) Treatment: Cryo, Curettage, Shave bx technique

Erythema nodosum Toxic Epidermal Necrolysis (TEN)

Purpuric Drug Reaction Meningococcemia Diabetic, neuropathic ulcers on the soles. Alopecia Areata Cushings syndrome Acute systemic lupus erythematosus Bibliography

Color Atlas & Synopsis of Clinical Dermatology, Fitzpatrick et al, 4th ed. 2001 First Aid for the Family Medicine Boards, Tao Le et al, 2007 Dermatlas.org.http://dermatlas.med.jhml.edu/derm http://www.aafp.org http://www.UpToDate.com http://www.merk.com