dermatology review

Transcription

dermatology review

DERMATOLOGY REVIEW
Sheryl L. Geisler, MS, PA-C
Associate Professor
UMDNJ Physician Assistant Program
UMDNJ PANCE/PANRE Review
Course
Based on my mock practice exam results
this week, when it comes to dermatology:
50%
1. I rock!
2. I do so-so
3 I stink
3.
30%
k
tin
Is
Id
o
Ir
so
-s
o
oc
k!
20%
Course
Course
U.S. Navy public domain image
Taken from Wikimedia Commons
1
Structures of the skin
Public domain image at:
http://commons.wikimedia.org/wiki/File:Skin.jpg
Course
Dermatologic Terminology
MORPHOLOGY describes the type of
individual lesion (flat vs raised, scales,
color, shape, consistency, etc)
 Primary lesions
macule, patch, papule, plaque,
nodule, vesicle, bulla, pustule
 Secondary lesions
 crusts, erosions, ulcers, fissures,
scars, scale
Course
Actinic Keratosis (solar keratosis)
Small, lightly pigmented
Rough to touch
Sun-exposed
p
areas
Considered premalignant
Tx – liquid nitrogen
fluorouracil (Efudex) 2%,5% soln; 5% crm
imiquimod 5% crm (Aldara)
diclofenac sodiuim 3% gel (Solaraze)
Course
2
Course
Photo used with permission of the New Zealand
Dermatological Society Incorporated.
Published online at: http://www.dermnetnz.org
Skin Cancer Risk Factors
Fair complexion
Light hair/eyes
Hx of blistering sunburn
sunburn, especially
as a child
Increased sun exposure
Family history
Course
Squamous Cell Carcinoma
Arises primarily from prior actinic
keratosis
Varied appearance
Can appear on any area of skin, but
face and hands most common
Course varies with grade of malignancy
Cure rates usually high if treated early
Bowen’s disease = SCC in situ
Course
3
Squamous Cell Carcinoma
Public domain image at: http://commons.wikimedia.org/wiki/File:Squamous_Cell_Carcinoma.jpg
Basal Cell Carcinoma
Slowly enlarging nodule with central
depression and pearly border;
surface telangiectasias
g
>90% on head and neck; bleeding
common
Metastasis rare
Tx: Surgical excision
Course
Public domain image at: http://commons.wikimedia.org/wiki/File:Basal_cell_carcinoma.jpg
4
From Wikimedia Commons, author Watplay
http://commons.wikimedia.org/wiki/File:BCC-mini.jpg
ABCs of mole evaluation:
melanoma recognition
Asymmetry
Border irregular
Color mottled
Diameter > 6 mm
Elevation common, irregular
Course
Asymmetry
Border
Color
Diameter
http://commons.wikimedia.org/wiki/File:Melano
ma_vs_normal_mole_ABCD_rule_NCI_Visuals_
Online.jpg;
5
Melanoma
Flat or raised
Recent change in appearance
Varying
– red,
V i colors
l
d white,
hit black,
bl k
and bluish
Borders typically irregular
Prognosis related to thickness
Course
http://commons.wikimedia.org/wiki/File:Melanoma4.jpg
Skin Cancer Appearance
Location
Treatment
Squamous
Cell
Variable,
Sun
eroded papule exposed
or plaque
Excision
Basal Cell
Pearly papule Head &
w/erosion,
upper
telangiectasias chest
Excision;
superficial:
5-FU or
Imiquimod
Melanoma
Mottled color, anywhere
size >6.0 mm,
irregular
Excision
Actinic
Keratosis
(precursor)
Rough, dry,
scale <1 cm
Cryosurgery
5-FU
Imiquimod
Sun
exposed
areas
6
Seborrheic Keratoses
Benign, age-related plaques
Beige to brown to black
3-20 mm diameter
Common
No treatment needed
Geisler personal file photo
Course
Dermatitis
Atopic
Contact
Diaper
Nummular
eczematous
Perioral
Seborrheic
Stasis
Course
Atopic Dermatitis
Called “the itch that rashes”
Pruritic, exudative, or lichenified
eruption on face
face, neck
neck, upper
trunk, wrists and hands
Personal or family hx of allergic
manifestations
Tendency to recur
Course
7
Atopic Dermatitis
Image from Wikimedia Commons at:
http://commons.wikimedia.org/wiki/File:Atopic_dermatitis.png
Management
Therapeutic lifestyle issues
Topical corticosteroids
Tacrolimus ointment (Protopic
0 1% and 0.03%
0.1%
0 03% strengths)
Pimecrolimus (Elidel 0.1%)
Systemic steroids only for
extensive, severe cases
Oral antihistamines can aid pruritus
Course
Topicals: vehicle choice as
important as active ingredient
Ointments – most hydrating, use in
chronic
Creams – more drying, better for
acute/subacute
Gels – best for acute, weeping lesions
Lotions – can be drying, good for moist
intertrigenous areas or scalp
Foams – newer vehicle, likely similar to
lotions
Course
8
Contact Dermatitis
Irritant – result of chemical
exposure
Chronic vs acute
 Affected area clue; severity varies
widely
 History of AD increases risk
 Detergents and industrial cleaners
common

Course
Irritant Dermatitis Secondary
to Chronic Kerosene Exposure
Public domain image from Wikimedia Commons
Available at: http://en.wikipedia.org/wiki/File:Hands_damaged_by_kerosene.jpg
Hand Dermatitis
Wikimedia Commons image
Available at: http://en.wikipedia.org/wiki/File:Dermititis10.JPG
9
Contact Dermatitis
Allergic contact dermatitis - develops
after exposure to chemicals to which
the individual has become sensitized
 Initially confined to area of contact,
later can spread beyond
 Progression: erythema-papulesvesicles-erosions-crusts-scaling
(acute)
Course
Blistering poison ivy rash
CDC image from the Hardin MD public domain:
library:http://www.lib.uiowa.edu/hardin/md/cdc/4483.html
Treatment
Avoidance of irritants
Topical steroids
Burow’ss solution compresses
Burow
Oral antihistamines
Emollients
Severe – systemic steroids if >20%
BSA
Course
10
Diaper dermatitis
Irritant dermatitis from prolonged
exposure to urine/feces
C. albicans infection common
(satellite pustules)
Clinical diagnosis typical
Treatment – topical antifungals
 Nystatin (Rx- Mycostatin)
 Clotrimazole (OTC)
 Miconazole (OTC)
Course
Nummular eczema
Characterized by “coin-shaped” plaques of
papules/vesicles on erythematous base
Mild to severe pruritus
M
More
common on lower
l
legs
l
off older
ld men
Treatment



Hydration and systemic antihistamines
Topical steroids
Phototherapy if resistant
Course
Course
11
Perioral dermatitis
(aka “Muzzle Rash”)
Mainly adult females, 20-45 years
Often assoc. w/topical steroid use
Tender,small red papules,vesicopustules
Tingling & burning; itching rare
Topical metronidazole, erythromycin,
benzoyl peroxide, pimecrolimus
Severe – oral tetracycline, doxycycline,
minocycline, or erythromycin
Course
Course
Seborrheic Dermatitis
Red, scaly, itchy rash (M>F)
Nasal folds, eyebrows, eyelids,
postauricular and scalp common
Often seen with oily skin or hair
Fungal involvement implicated
Common; worse in cold weather
Course
12
Course
CDC Public Health Image Library
Available at: http://phil.cdc.gov/phil/home.asp
Treatment
Frequent cleansing of area
Shampoos with selenium sulfide,
ketoconazole, zinc pyrithione
Ketoconazole cream bid x 4 wks
Topical steroids
Refractory – isotretinoin (Accutane)
Maintenance treatment required
Course
Stasis Dermatitis
Vascular etiology; inflammatory papules
and scaly, crusted erosions
Lower legs & ankles
Treatment geared to improving blood
return (compression stockings, wraps)
Weeping lesions – Burow’s compresses,
petroleum jelly, topical hydrocortisone,
antibiotic meds if infected
Course
13
Course
Dyshidrosis
(pompholyx)
Disorder of hands and/or feet
Pruritus w/sudden onset of “tapioca-like”
blisters; later scaling and fissures
Chronic intermittent course; onset third
decade
Treatment
 Topical corticosteroids mainstay
 Burow’s wet dressings, drain large bullae
 Oral prednisone if severe
Course
Dyshidrotic eczema
of the hands
Public domain image available at:
http://commons.wikimedia.org/wiki/File:DyshidroticDermatitisOnHandsLateStage.jpg
14
A 38 y.o. male presents w/slightly
pruritic, erythematous, scaling areas
between his eyebrows, eyelids and nasal
folds. The most likely diagnosis is:
1.
2
2.
3.
4.
atopic dermatitis
contact dermatitis
dyshidrotic dermatitis
seborrheic dermatitis
89%
2%
at
iti
s
bo
rr
he
ic
de
rm
m
at
iti
s
de
rm
at
i ti
s
de
r
co
at
op
i
nt
ac
t
c
Course
1%
hi
dr
ot
ic
de
rm
at
iti
s
8%
Which of the following would be an
appropriate treatment for actinic
keratosis?
antihistamines
emollients
liquid nitrogen
steroids
91%
4%
er
oi
ds
st
en
tro
g
ni
ol
li
em
tih
is
ta
m
in
es
Course
3%
en
ts
1%
ui
d
1.
2.
3.
4.
Lichen Simplex Chronicus
(Circumscribed Neurodermatitis)
Intense itching causes reflexive, selfperpetuating scratch-itch cycle
Circumscribed, lichenified lesions
w/exaggerated skin lines
Tx: cessation of itch-scratch cycle
imperative
 Topical steroids
(alternate intralesional triamcinolone)
Occlusion to prevent further trauma
 Patient education

Course
15
Course
Lichen Planus
Lesions are plentiful, pruritic, purple,
polygonal, papular and planar
Wickham’s striae on surface
Oral and nail manifestations
Koebner’s phenomenon
Treatment – often resistant



Topical steroids w/occlusion
Oral steroids in severe cases; recurrence
common after taper
Cyclosporine or PUVA if generalized &
resistant
Course
Copyright free image from Wikimedia Commons
Available at: http://commons.wikimedia.org/wiki/File:Lichen_planus_lip.jpg
16
Lichen Planus



common after taper
resistant
Course
Lichen Planus
Wickham’s striae
Course
Lichen Planus



common after taper
resistant
Course
17
Pityriasis Rosea
Benign, transient
Oval erythematous to fawn-colored
discrete lesions
Herald patch days-2
days 2 weeks prior
Mainly chest/trunk along cleavage lines
(Christmas tree pattern)
Primarily young adults (F>M), increased
in spring/fall
Self-limiting; resolves w/in 6 weeks –
symptomatic treatment only UMDNJ PANCE/PANRE Review
Course
Pityriasis rosea with herald patch on the abdomen
CDC image from the Hardin MD public domain library:
http://www.lib.uiowa.edu/hardin/md/cdc/4812.html
Pityriasis Rosea
Benign, transient
Oval erythematous to fawn-colored
discrete lesions
Herald patch days-2
days 2 weeks prior
Mainly chest/trunk along cleavage lines
(Christmas tree pattern)
Primarily young adults (F>M), increased
in spring/fall
Self-limiting; resolves w/in 6 weeks –
symptomatic treatment only UMDNJ PANCE/PANRE Review
Course
18
Drug Eruptions
Widely varying presentations
Immune compromised increased risk
Occurs days to weeks into treatment
Penicillin and sulfa drugs most common
Generally self-limited, occasionally
severe
Treatment


Discontinue offending drug
Supportive UMDNJ PANCE/PANRE Review
Course
Fixed Drug
Eruption
Course
Drug Eruptions
Widely varying presentations
Immune compromised increased risk
Occurs days to weeks into treatment
Penicillin and sulfa drugs most common
Generally self-limited, occasionally
severe
Treatment


Discontinue offending drug
Supportive UMDNJ PANCE/PANRE Review
Course
19
Desquamation Disorders
Erythema multiforme (EM)
Stevens-Johnson syndrome
(SJS)
Toxic epidermal necrolysis
(TEN)
Course
Erythema Multiforme
B/L target lesions ≤ 2.0 cm.
Related to H. simplex, but majority
idiopathic
p
Mainly children, young adults (~ 50%)
Commonly spares trunk
Mucous membrane lesions possible
Recurrences common
Tx supportive
Course
Erythema Multiforme
Image from Wikimedia Commons at: http://commons.wikimedia.org/wiki/File:EMminor09.JPG
20
SJS and TEN
Fever, HA, cough, aches, EM-like rash
Confluent, asymmetric areas of dusky
erythema with truncal involvement
SJS < 10% BSA vs. TEN > 30% BSA
Drugs (antibiotics, anticonvulsants,
NSAIDs) most commonly implicated
Life-threatening, require specialized
management
Course
Stevens-Johnson Syndrome
(Erythema Multiforme Major)
Secondary To
Smallpox Vaccination
6 month old with
toxic epidermal necrolysis
secondary to small pox
vaccination
Course
21
Bullous pemphigoid
Autoimmune disorder; mostly > 60 yrs
Pruritic tense blisters on normal or
erythematous skin, rupture & crust
Constitutional symptoms rare
Treatment – months to years
 Topical potent steroids if limited
 Oral corticosteroids if widespread
 Dapsone for oral lesions
Course
Photo courtesy of
International Pemphigus & Pemphigoid Foundation
Psoriasis
Chronically recurring, papulosquamous
disease; genetic predisposition
Silvery scales on bright red, welldemarcated
d
t d plaques
l
+ Auspitz’s sign, Koebner’s phenomenon
Scalp, elbows, and knees most common
Fine nail pitting seen
Worse in winter
Course
22
Courtesy of the National Psoriasis Foundation
Courtesy of the National Psoriasis Foundation
Treatment – localized disease
Topical corticosteroids
Calcipotrien (Dovonex)
Tar p
preparations
p
(various)
(
)
Hydrocolloid occlusion (i.e.DuoDerm)
Anthralin (Antra-Derm, Lasan,
Drithrocreme, Miconal)
Tazarotene (Tazorac)
Avoidance of stress & ETOH
Course
23
Generalized Disease
Outpatient UVB light exposure
PUVA (psoralen plus UVA)
Methotrexate
Oral retinoids – acitretin (Soriatane) &
isotretinoin (Accutane)
Cyclosporine, TNF blockers
Avoid parenteral corticosteroids
Course
What associated sign or
symptom would you expect to
find with these lesions?
1.
2.
3.
4.
50%
Auspitz’s
p
sign
g
Herald patch
Nail pitting
Wickham’s striae
28%
17%
am
’s
st
ria
e
itt
in
g
ai
lp
pa
tc
h
W
ic
kh
N
er
al
d
H
A
us
pi
tz
’s
si
gn
6%
Tinea corporis
Dermatophyte infection
Round, oval or semicircular scaly
patches with slightly raised border
Sh l marginated
Sharply
i t d
Autoinoculation, contact w/animals
Treatment - antifungals
 Topical: “azoles”, terbinafine
 Systemic: itraconazole, terbinafine
Course
24
Tinea Pedis
Most common young, adult men
Various types: interdigital, “moccasin”
tinea, and inflammatory
Asymptomatic scaling most common
Hyphae on KOH exam
Management
 Prevention – use shower shoes
 Dry, scaly – same as T. Corporis
 Macerated – Burow’s wet dressings
(aluminum acetate)
Course
Tinea Pedis
25
Tinea Versicolor (Pityriasis Versicolor)
Mainly adolescents & young adults, summer
Nontanning pale macules w/fine scales
or hyperpigmented macules
Upper trunk, shoulders most frequent site
Blunt hyphe and budding spores w/KOH
Treatment (recurrence common)


Topical selenium sulfide lotion/shampoo
Topical or systemic ketoconazole
Course
Tinea Versicolor (Pityriasis Versicolor)
http://commons.wikimedia.org/wiki/File:Tinea.jpg
Author Klaus D. Peter
Folliculitis
Multiple causes, obesity risk
 Infection
 Physical or chemical irritation
Itching and burning in hairy areas
Pustules in the hair follicles
Pseudofolliculitis – beard area from
ingrowing hairs
Treatment varies depending on etiology
(gram stain/culture needed)
Course
26
Folliculitis
Course
Image from Wikimedia Commons
Available at:http://commons.wikimedia.org/wiki/File:Folliculitis-1.jpg
Cellulitis
Infection of dermis, subcutaneous tissues
Pain, erythema, edema, warmth; fever &
lymphadenopathy possible
GAS & S. aureus most common
Treatment
 Mild - oral antibiotics
 Severe - hospitalization for I.V.
antibiotics
Course
http://www.lib.uiowa.edu/hardin/md/cdc/staph/cellulitis2.html
27
Erysipelas
Involves dermis and lymphatics, mostly
in adult population
Prodromal sxs, then fiery red rash
Typically caused by Group A Strep
Generally benign; can be fatal
Diagnosis clinical; labs of little value
Tx: IV antibiotics first 48 hrs (oral after)
and supportive therapy
Course
Erysipelas
Course
Erysipelas
Involves dermis and lymphatics, mostly
in adult population
Prodromal sxs, then fiery red rash
Typically caused by Group A Strep
Generally benign; can be fatal
Diagnosis clinical; labs of little value
Tx: IV antibiotics first 48 hrs (oral after)
and supportive therapy
Course
28
Impetigo
S. aureus & S. pyogenes likely; more common in
children
Multiple presentations
p g transient small
 Nonbullous impetigo:
vesicle/pustule, honey-colored crusts
 Bullous impetigo: superficial, fragile bullae on
normal skin
Treatment
 Mupirocin (Bactroban), bacitracin for small area
 Oral antibiotics for larger area and bullous
Course
Lower extremity impetigo
CDC image from the Hardin MD
public domain library:
http://www.lib.uiowa.edu/hardin/md/
cdc/staph/impetigo1.html
Impetigo
S. aureus & S. pyogenes likely; more common in
children
Multiple presentations
 Nonbullous impetigo:
p g transient small
vesicle/pustule, honey-colored crusts
 Bullous impetigo: superficial, fragile bullae on
normal skin
Treatment
 Mupirocin (Bactroban), bacitracin for small area
 Oral antibiotics for larger area and bullous
Course
29
Viral - Verrucae (warts)
Caused by HPV
Most frequent presentations:



Common warts
Plantar warts
Flat warts
Treatment




OTC salicylic acid
Cryotherapy
CO2 Laser surgery
Surgical excision
Course
Verruca
http://commons.wikimedia.org/wiki/File:Verruca.jpg
Author: Klaus D. Peter
Viral-Condylomata acuminata
Soft lesions in genital area (HPV types 6
& 11 most common)
Depending on location can be painful,
friable and/or pruritic
Highly infectious, but partner screening
not recommended
Goal of treatment removal of
symptomatic warts, cannot eradicate
infection
 Podofilox (Condylox), imiquimod
(Aldara), cryotherapy
Course
30
CDC. STD Curriculum – HPV. Available at:
http://www2a.cdc.gov/stdtraining/ready-to-use/hpv.asp
Viral-Condylomata acuminata
Soft lesions in genital area (HPV types 6
& 11 most common)
Depending on location can be painful,
friable and/or pruritic
Highly infectious, but partner screening
not recommended
Goal of treatment removal of
symptomatic warts, cannot eradicate
infection
 Podofilox (Condylox), imiquimod
(Aldara), cryotherapy
Course
Viral - Herpes Simplex
HSV 1 vs HSV 2
Herpes simplex labialis (cold sores)
Genital herpes-STD
Prodrome then painful, vesicular lesions on
erythematous base
Multinucleated giant cells on Tzanck
Treatment: consider prophylaxis if frequent


acyclovir, famciclovir, valacyclovir
patient education issues
Course
31
Herpes simplex lesion of the lower lip on the 2nd day after onset
Viral-Herpes Zoster (Shingles)
Groups of vesicles in a unilateral dermatomal
pattern
New crops of vesicles appear for 3-5 days
Vesicles rupture and crust over. Average of 3
weeks
k tto clear
l
Tzanck prep + for multinucleated giant cells
Post-herpetic pain can persist for months or
even years (especially elderly)
Treatment- acyclovir, valacyclovir,
famciclovir; supportive, oral steroids in
immunocompetent help reduce acute pain
Course
Herpes Zoster
http://commons.wikimedia.org/wiki/File:Herpes_zoster_back.png
Author: Fisle
32
Viral-Molluscum contagiosum
DNA pox virus, transmit via direct contact
Pearly, dome-shaped papules with central
umbilication
Generally self limited
 Children – face, trunk & extremities
 Adults – lower abdomen, inner thighs,
genitalia
Treatment (will resolve spontaneously)

Curettage or cryosurgery best tx
Course
Molluscum Contagiosum
Centers for Disease Control and Prevention
Available at: http://www.cdc.gov/ncidod/dvrd/molluscum/clinical_overview.htm
Which of the following disorders is
often triggered by H. simplex
infection?
79%
10%
5%
l..
.
...
in
ea
ve
cz
e
rs
ic o
m
nu
s
r e
ul
a
en
p
la
N
um
m
Er
Course
Li
ch
yt
he
m
a m
ul
ti.
..
7%
T
1. Erythema multiforme
2. Lichen planus
3. Nummular eczema
4. Tinea versicolor
33
A 20 y.o. male c/o of numerous round to oval,
hypopigmented, lightly scaling macules across
his upper trunk and shoulders. Microscopic
examination of scrapings will likely reveal:
1. clue cells
2. diplococci
3 multinucleated giant
3.
94%
cells
4. “spaghetti &
meatballs”
...
m
&
t ti
co
cc
i
pl
o
cl
ea
te
d.
ce
lls
e
lu
4%
..
2%
1%
Acne Vulgaris
Common adolescents and young
adults
Primaryy comedones,, papules,
p p
,
pustules, cysts
Secondary pits and scars if severe
Face, neck & chest most affected
Improves in summer
Course
Acne Vulgaris
Public domain image at; Wikhttp://commons.wikimedia.org/wiki/File:Teenager-with-acne.jpg
34
Treatment Options
Mild – Topical (comedonal)
 Retinoids (tretinoin)
 Benzoyl peroxide
 Clindamycin, erythromycin
Moderate inflammatory
 Topical antibx + benzoyl peroxide + oral
tetracycline, minocycline or doxycycline
Severe inflammatory
 Severe – systemic isotretinoin
(Accutane), intralesional injection
Course
Rosacea
Typically seen in middle-aged patients
Papules, papulopustules, erythema,
telangiectasias on nose,cheeks, chin, forehead
Exacerbated by vasodilating triggers
Treatment
 Avoidance of flushing triggers; sunscreen
 Oral tetracycline, minocycline, doxycycline
 Topical metronidazole, azelaic acid
 Severe, resistant - isotretinoin
Course
Rosacea
Image compliments of
Robert Paull, MD
Course
35
Course
Image compliments of Robert Paull, MD
Vitiligo
Benign
Autoimmune etiology (?)
Face,, hands,, arms,, legs,
g , genital
g
areas
Hypopigmented, nonscaling patches
Pigment rarely returns unaided
Treatment depends on extent and
degree of disfiguration
Course
Vitiligo
Image from Wikimedia Commons at: http://commons.wikimedia.org/wiki/File:Vitiligo2.JPG
36
Acanthosis nigricans
Benign vs internal malignancy
Associated w/obesity, insulin-resistance,
some meds; definitive cause unknown
Symmetrical, hyperpigmented, velvety
plaques in any location (axillae, groin,
posterior neck common)
Management



Screen for internal malignancy, DM, insulin
resistance
Weight loss
Review
Cosmetic treatment: keratolytics UMDNJ PANCE/PANRE
Course
Acanthosis
Nigricans
Course
Photo used with permission of the New Zealand Dermatological Society Incorporated.
Burns
ABC’s
Rule of 9’s; transfer criteria
First-degree: redness w/o change in
texture and intact sensation
(superficial)
Second-degree: blister formation and
pink to mildly pale tissue w/intact
sensation (partial thickness)
Third-degree: area is white, leathery,
w/o sensation (full thickness)
Course
37
Hidradenitis suppurativa
Chronic disease affecting apocrine gland
follicles
Postpubertal females most common
Tender, inflammatoryy nodules, abscess
formation, scarring, and sinus tracts
Treatment
 Reduce friction & moisture
 Oral antibiotics for acute exacerbations;
I&D abscesses
 Intralesional steroids for nodules
Course
Course
Urticaria
Acute vs chronic
More common children & young adults
Pruritic pink or red wheals of varying size
with surrounding erythema (F>M)
Allergic vs nonallergic: thorough history
important
Treatment
 Antihistamines mainstay of tx
 Short course of steroids if needed
 Avoidance of identified triggers
Course
38
Course
Image compliments of Robert Paull, MD
Melasma
Hypermelanosis of sun-exposed areas
Mainly reproductive-age females
Hormones, meds, thyroid, cosmetics
implicated
Difficult to treat - sun avoidance key




Hydroquinone cream (depigmenting agent)
Tretinoin
Azelaic acid
Slow to resolve
Course
Course
39
Lipomas
Benign tumor of mature fat cells
Discrete, rubbery, mobile subcutaneous
nodule, 2-10 cm.
Can be lobulated
Slow growing, nonpainful
Removal via excision or liposuction
Fine-needle aspiration will R/O
liposarcoma
Course
Epidermal Inclusion Cyst
From implantation of epidermal elements in
dermis
Slow growing firm, round, mobile mass
May express foul-smelling cheeselike material
th central
thru
t l punctum
t
Can become inflamed, infected
Rare malignancies develop (fast growth/bleeding)
Require no treatment
 Intralesional triamcinolone if inflamed
 I&D, oral antibiotics if infected
 Excision most definitive
Course
Course
Image compliments of
Robert Paull, MD
40
Which of the following topical treatments is
recommended in the management of rosacea?
benzoyl peroxide
clindamycin
erythromycin
metronidazole
75%
id
az
ol
e
ro
m
yc
in
8%
et
ro
n
cl
in
d
am
yc
in
6%
m
be
nz
oy
lp
er
ox
id
e
12%
er
yt
h
1.
2.
3
3.
4.
Decubitus ulcers
Ischemia resulting from immobility-related
pressure; wetness, poor nutrition increase risk
National Pressure Ulcer Advisory Panel
 Stage I – intact skin w/impending ulceration
 Stage
St
II – partial-thickness
ti l thi k
loss
l
involving
i
l i
epidermis, possibly dermis
 Stage III – full-thickness loss w/extension into
subcutaneous tissue
 Stage IV - full-thickness loss w/extension into
muscle, bone, tendon, or joint capsule
Treatment depends on severity
Four stages of pressure sores
http://commons.wikimedia.org/wiki/File:Schema_stades_escarres.svg
41
Pediculosis (lice)
Three clinical entities: hair, body, genital
Oval 1 to 2-mm nits (eggs) seen on hairs
Pruritus with excoriation
S
Spread
d by
b contact
t t
Treatment – all intimate contacts




Body – topical permethrin
Pubic – permethrin cream rinse 1%
Head – permethrin cream rinse 1%
All - clean/dispose of infested clothing, linen
Course
Eggs (nits) of head and body lice
CDC image. http://www.dpd.cdc.gov/dpdx/HTML/ImageLibrary/HeadLice_il.htm
Scabies
Generalized severe itching
Pruritic vesicles & pustules in “runs”
Mites & ova visible microscopically
Spread
S
d by
b physical
h i l contact
t t
KOH prep helpful in diagnosis
Treatment
 Clean clothing & bedding; tx contacts
 Permethrin 5% cream – resistance
rare; use 2X one week apart
Course
42
Sarcoptes scabiei mites in a skin scraping, stained
with lactophenol cotton-blue.
CDC image. http://www.dpd.cdc.gov/dpdx/HTML/Scabies.htm
Sarcoptes scabei infestation
CDC image from the Hardin MD
public domain library:
http://www.lib.uiowa.edu/hardin/md/
cdc/6538.html
Spider Bites
Black widow – generalized muscle
pain, spasms, and rigidity
 Parenteral narcotics, muscle relaxants
 Calcium g
gluconate 10% I.V.
Brown recluse – progressive local necrosis
possible, fever,chills,N/V
 Excision of bite site
 Oral corticosteroids (?)
 Dapsone (?)
 Colchicine (?)
43
Alopecia Areata
Rapid nonscarring hair loss, usually in
round patches
Benign, cause unknown
Exclamation point hairs pathognomonic
Treatment




Intralesional triamcinolone acetonide
Topical and systemic steroids of
questionable value
PUVA photo therapy
Minoxidil UMDNJ PANCE/PANRE Review
Course
Alopecia Areata
Public domain image from: http://commons.wikimedia.org/wiki/File:Allopecia_areata.JPG
Androgenetic alopecia
Common, affects both men and women
Typical patterns of hair loss
 Males- receding hairline at temples and
h i loss
hair
l
att vertex
t
 Females - loss of hair over central scalp;
no frontal loss
Only 2 FDA approved treatments


Minoxidil (Rogaine) topical
Finasteride (Propecia) – men only
Course
44
Course
Courtesy of HEAL database. Available at:
http://www.healcentral.org/healapp/showMetadata?metadataId=649
Course
Onychomycosis
Dystrophic nail growth from fungal
infection
Risk factors: age, family hx, warm
climate, occlusive footwear, poor health
Microscopy and culture helpful
Treatment


Topical generally ineffective
Newer oral antifungals - terbinafine,
itraconazole
Regrowth slow
Course
45
Onychomycosis
Public domain image available at:
http://commons.wikimedia.org/wiki/File:Onychomycosis_due_to_Trychophyton_rubrum,_right_and
_left_great_toe_PHIL_579_lores.jpg
Paronychia
Breakdown of protective barrier between
nail & nail fold
Acute



History of trauma (S.
(S Aureus #1 organism)
Erythema, pain, swelling
I&D if abscessed; oral antibiotics & warm soaks
Chronic



Worsens w/water exposure (Candida #1)
Intermittent X weeks
Review
Keep dry, topical antifungals UMDNJ PANCE/PANRE
Course
Acute Paronychia
Public domain image available at: http://commons.wikimedia.org/wiki/File:Paronychia.jpg
46
Dermatologic Manifestations of
Systemic Disease
Viral exanthems
Infectious diseases
Sexually transmitted diseases
Nutritional disorders
Cutaneous markers of internal
malignacy
Course
Reference Sources
American Academy of Dermatology:
http://www.aad.org
Arend WP, Armitage JO, Clemmons DR, Drazen
gg RC,, LaRusso N.,, eds. Cecil Texbook of
JM,, Griggs
Medicine, 22nd ed. Saunders;Philadelphia:2008.
McPhee SJ, Papadakis MA, Rabow MW, eds.
Current Medical Diagnosis & Treatment 2011.
McGraw-Hill;New York:2011.
Wolff K, Johnson RA. Fitzpatrick’s Color Atlas &
Synopsis of Clinical Dermatology 6th ed. McGrawHill. New York:2009.
Course
Best of Luck!!!
Sheryl L. Geisler, MS, PA-C
Associate Professor
UMDNJ Physician Assistant Program
Course
47

dermatology review

Transcription

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