Derm 1

Dermatology

Derm 2

Acne Vulgaris

Chronic disease of sebaceous follicle, primarily affecting face, chest, and back

Occurs at puberty with sebum production triggered by increased androgen levels

Inflammation is due in part to over-proliferation of Propionibacterium acnes, an anaerobic Gram-positive organism

Derm 3

Topical Retinoids: tretinoin (Retin A), adapalene (Differin), Tazarotene (Tazorac)

Foundation of treatment Only agents that affect follicular epitheliuim

Benzoyl Peroxide Antibacterial and comedolytic effects

Topical Antibacterials Eliminate P. acnes from the sebaceous gland and

thereby suppress inflammation in patients with papular and inflammatory acne

Azelaic Acid (Azelex), clindamycin, erythromycin, metronidazole

Acne Treatment

Derm 4

Acne Treatment (Cont’d) Oral Antibiotics

Inhibit P. acnes Tetracyclines have a direct anti-inflammatory

effect Tetracyclines, Doxycycline, Minocycline,

Erythromycin, Trimethoprim-Sulfa, Clindamycin Antibiotic resistance increasing problem

Treatment courses should be short 4-6 months Concomitant Benzoyl Peroxide may decrease resistance

Oral Istotretinoin (Accutane) Useful for severe acne – nodulocystic scarring Hormonal – OCP in women

Derm 5

Acne Treatment (Cont’d)

It takes 8 weeks for a microcomedo to mature. Thus any therapy effectiveness should be assessed after 8 weeks of therapy.

Water-based cosmetics are less comedogenic than oil based.

Soaps, detergents, and astringenets have little impact on acne and vigorous “cleansing” can worsen inflammation.

Derm 6

Acne Treatment (Cont’d) Recommendations

Mainly comedones with occasional inflamed papule or pustule (Type 1)

Topical Retinoid Consider benzoyl peroxide, azelaic acid

Comedones, papules and pustules (Type 2) Topical Retinoids plus benzoyl peroxide, azelaic, or

topical antibiotic Worsening Type 2 – spread to shoulders, back,

chest, occasional cysts/nodules Systemic antibiotic plus topical Retinoid, benzoyl

peroxide, or azelaic acid Add OCP or antiandrogen for women

Derm 7

Acne Treatment (Cont’d)

Recommendations (cont’d) Numerous cyst, scarring

Systemic antibiotics plus topical Retinoid plus benzoyl peroxide

Oral isotretinoin (Accutane)

Derm 8

Atopic Dermatitis Therapy usually involves

emollients and good skin hydration, antipruritics, and controlling exacerbating factors including temperature, humidity and airborne allergens and dust.

Can use topical steroids to clear skin (low potency)

Pimecrolimus (Elidel) may be tried in unresponsive cases

Derm 9

Atopic Dermatitis (Cont’d)

Eczematous eruption genetically determined

Characterized by lichenification, excoriation and crusting

Classically involves face, neck and flexual surfaces of arms and legs

Picture can vary with age of patient, usually seen in early childhood

Derm 10

Eczema Characterized by scaly,

occasionally fissured patches of dermatitis overlying dry skin

Also called Xerosis Treated with lubricants

and hydration, such as Eucerin, Alpha-Keri, etc.

If severe may use low- potency topical steroids (level V or less)

Derm 11

Psoriasis

Derm 12

Psoriasis (Cont’d) Red, scaling papules which coalesce to round-to-oval

plaques Adherent silvery white thick scale which when

removed bleeds (Auspitz’s sign) Can develop at sites of physical trauma (Koebner’s

phenomenon) Usually extensor surfaces Differential diagnosis may include secondary syphilis,

eczema or seborrhea Associated arthritis can develop Treatment: Steroids, Tar, UV light (PUVA),

Calcipotriene - Vit D3 Derivative (Dovonex), Methotrexate in and other immunomodulatory drugs and other immunomodulating drugs in severe cases

Derm 13

Seborrheic Dermatitis

Derm 14

Seborrheic Dermatitis (Cont’d) Etiology

Unknown Relationships

Hormone levels – infancy (cradle cap) and reappears at puberty Fungal infections (Malassezia furfur) response to antifungal

agents Nutritional (common in AIDS)

Presentation Cradle cap

Treatments Topical steroids – low potency Topical calcineurun inhibitors (Protopic, Elidel) Keratolytics (salicyclic and shampoo) Antifungals (Nizoral shampoo 3x/week, Selsun 2-3x/week) and

others

Dandruff Greasy scales

Derm 15

Pityriasis Rosea

Derm 16

Pityriasis Rosea (Cont’d)

Benign, self-limiting eruption Herald patch abruptly appears several days to

weeks before rest of rash Smaller lesions appear in 1-2 weeks, usually on

trunk but can be upper arms and thighs 1-2 cm oval plaques with wrinkled tissue-like ring

of scale (collarette) with long axis oriented along the skin lines (Christmas tree distribution on back)

Treatment directed to symptom relief with antihistamines for itching

Derm 17

Petechiae/Purpura Nonpalpable -superficial,

thrombocytopenia Palpable - deep,

vasculitis Petechiae

< 3mm Purpura > 3mm Causes: Drugs,

vasculitis, infections Treatment: Depends on

etiology, antibiotics, steroids or even plasmapheresis if needed

Derm 18

Urticaria Wheals, hives diffuse

itchy rash 80% of the time etiology

unknown Usually IgE mediated Self limited Treatment with

antihistamine, antipruritics, H2 blockers

ANGIOEDEMA is deeper dermis

Familial - C1 esterase inhibitor deficiency

Derm 19

Eyrsipelas Usually Group A strep Superficial cellulitis and

lymphangitis Often “butterfly rash”

on face Characterized by bright

red, shiny plaques on lower extremities

Well-demarcated border between normal and infected skin

Treatment: PCN, dicloxacillin, erythromycin

Derm 20

Erythema Nodosum Delayed hypersensitivity

reaction caused by infections (Strep, TB and sarcoidosis), medications (OCPs, sulfa) and 50% idiopathic

Bright painful nodules that are violet in color

Most common in women May have arthralgias before

eruptive phase Treatment: Symptomatic relief

with salicylates, NSAIDs and potassium iodide 300mg tid for 3-4 weeks may help

Derm 21

Drug Eruption Asymmetrical eruption Can see urticaria, erythema multiforme, and

serum sickness Common causes: PCN, sulfa, cephalosporins Usually resolves in 1-2 weeks Complication: Stevens-Johnson Syndrome -

mucosal and cutaneous bullous forms with 5-10% mortality

Treatment: D/C offending agent, steroids (topical or oral) and antihistamines

Derm 22

Erythema Multiforme Secondary to hypersensitivity

reaction Severe form is Stevens-Johnson

and Toxic Epidermal Necrolysis (TEN)

Palmar, plantar and extensor surfaces

Target lesions (bull’s eye) Severe form is Stevens-Johnson

with severe bullous form Treatment: Remove offending

agent, oral steroid burst (40-80mg/day of prednisone or equivalent oral steriod)

Derm 23

Drug Eruption

Derm 24

Henoch-Schonlein Purpura Associated with strep and viral

infections, drugs Seen most commonly in 2-10,

with abdominal pain, GI bleeding, hematuria

Palpable purpura usually on lower extremities, buttocks

IgA mediated Complications: arthritis,

glomerulonephritis, hematuria No thrombocytopenia Usually spontaneous resolution,

may need renal consult, and the use of oral steroids

Derm 25

Stevens-Johnson Syndrome

Derm 26

Toxic Epidermal Necrolysis (TEN)

Derm 27

Toxic Epidermal Necrolysis (TEN) (Cont’d) Considered severe form of erythema

multiforme with more than 30% of epidermal detachment

Patient toxic and in the elderly mortality approaches 50%

Nikolsky’s sign: with slight thumb pressure, skin wrinkles, slides laterally and separates from the epidermal-dermis junction

Treatment: Admit, IV fluids, steroids are controversial, antibiotics if infection-related

Derm 28

Pemphigus Vulgaris Rare, often lethal

(10-15%) autoimmune intradermal blistering disease

Use punch bx to help dx using direct immunofluorescence

Circulating IgG autoantibodies destroy the adhesion between epidermal cells

Oral lesions precede the onset of skin blisters; Nikolsky’s sign positive

Treatment: Steroids orally

Derm 29

Bullous Pemphigoid Rare relatively benign

subepidermal blistering disease Usually seen in older adults

(>60) Begins with urticarial lesions

that may progress to tense bullae. May see oral lesions first

Punch bx with direct immunofluorescence shows IgG but also IgA, IgB, IgE

Treatment: Antipruritics, topical steroids, sulfones or immunosuppressive medications

Derm 30

Varicella Highly infectious viral illness

Incubation average of 14 days after exposure by airborne droplets or vesicular fluid, followed by prodrome of low fever, headache and malaise

Concurrent macules/papules to vesicles to crusted lesions

Complications include encephalitis, pneumonia and secondary bacterial infections

Derm 31

Varicella (Cont’d)

Varicella vaccine available and recommended

Avoid salicylates (Reye’s syndrome)

Use Acyclovir and immune globulin for immunocompromised patients

Can be associated with increased risk in pregnant women

Antivirals such as Acyclovir are clinically effective in shortening rash if started within 72 hours of its onset

Derm 32

Herpes Zoster - Shingles

AKA shingles, usually dermatomal in distribution

Pre-eruptive itching or burning Eruptive phase has typical

appearance of varicella Complications: Postherpetic

neuralgia, scarring and dissemination

Therapy: Consider antivirals, oral steroids, pain medications and topical burrows solution

May also consider tegretol or neurontin as adjunctive Rx

Derm 33

Herpes Simplex HSV 1: Stomatitis with

fever, decreased oral intake

HSV 2: painful vesicles of anus, genitalia

Complications include infection (secondary), congenital transfer (TORCH) or neonatal infections

Treatment: Topical antivirals such as acyclovir and analogs

Derm 34

Hand-Foot-Mouth Disease Coxsackie Virus A16 most common Seen in outbreaks Oval vesicles on the hands and feet,

especially on the plantar and palmar surfaces common

Fecal-oral transmission Oral lesions are aphthous-like in character Treatment is symptomatic relief of itching and

painful mouth symptoms

Derm 35

Hand-Foot-Mouth Disease (Cont’d)

Derm 36

Herpangina Coxsackie virus Symptoms include: fever,

dysphagia, drooling, vomiting and headaches

Ulcerative lesions on the pharynx with no generalized rash

Treatment is symptomatic but recommend avoidance of viscous lidocaine in children to avoid overdose and seizures

Derm 37

Actinic Keratosis (AK) Premalignant Often more felt than seen

Rough, scaly and erythematous patches, poorly defined borders

Increased incidence in fair skinned patients

5-20% of AKs will transform to SCC within 10 years

Derm 38

Actinic Keratosis (AK) (Cont’d)

Risk factors are fair skin and cumulative sun exposure

Diagnosis: Red, scaling papule that is rough to feel. Can be red to yellowish or even keratinized to form a horn

Prevention by use of sun blocks

Derm 39

Actinic Keratosis (AK) Treatment Treatment: Cyrosurgery with Liquid N2 for

limited number of lesions - some pain and risk of scarring

Curettage: Scrap away lesion with curette and follow with electro or radio frequency to “feather” and stop bleeding, but need to use local anesthetic and best for limited numbers of lesions

Derm 40

Actinic Keratosis (AK) Treatment (Cont’d) Topical 5-Fluorouricil (5-FU): Is a cytostatic

agent which inhibits enzymes in tumor cells Apply locally and repeat daily until the lesion

erodes and reddens (usually 2-3 weeks) Advantage is ability to treat larger areas and

numbers of lesions Disadvantage is the pain and redness associated

with treatment

Derm 41

Sunscreens Most do good job filtering UVB-Rays

that cause sunburn; don’t defend as well against UVA that causes skin cancer and wrinkles.

Best protection against UVA includes zinc oxide, titanium dioxide or avobenzone.

SPF (Sun Protection Factor) refers to UVB protection.

Derm 42

Sunscreens (Cont’d)

Use of sunscreen recommendations SPF of 30 or better (SPF 15 blocks 93%

and SPF 50 blocks 98% of UVB Rays) Water resistant Apply every 2 hours and after swimming or

sweating 30-35ml per body application – usually “too

little” for an average adult

Derm 43

Squamous Cell Carcinoma Common in middle-aged and

elderly 2 types depending on site of

origin Arising in areas of prior

irradiation or thermal injury Arising from prior actinic

damaged skin Seen in sun exposed areas but

also common on scalp, backs of hands, and superior surface of pinna, with BCC not usually seen here

Derm 44

Rapid growth with central ulcerations and raised indurated borders

Metastasis occurs and depends on size, location, tumor differentiation and depth of invasion (greater than 6mm thick at higher risk)

Treatment: excisional surgery, radiation and chemotherapy

Small (< 2cm dia) tumors need a 4mm margin and larger tumors a 6mm margin or Moh’s may be needed

Squamous Cell Carcinoma (Cont’d)

Derm 45

Basal Cell Carcinoma Telangiectatic vessels Rolled edges with pearly gray

borders Can have central ulcerations Also called rodent cell ulcers 5 types: Listed from most

common Nodular Superficial Micronodular Infiltrative Morpheaform

Derm 46

Treatment includes surgical excision Most successful if < 2cm in diameter Advocate Moh’s surgery if large, recurrent

morpheaform, aggressive tumors, or cosmetically or functionally critical areas (nose, lips, ears)

Margins of 4mm of normal appearing skin give a 98% complete excision

Smaller tumors can be treated with desiccation and curettage

Basal Cell Carcinoma (Cont’d)

Derm 47

Pyogenic Granuloma

Derm 48

Pyogenic Granuloma (Cont’d)

Benign, acquired vascular lesion Small, but rapidly growing, yellow to red,

dome shaped fragile protrusions Seen most often on head, neck and

extremities (fingers) Minimal trauma causes brisk bleeding Treatment: Firm, thorough curettage to

completely eradicate If any abnormal tissue remains, will recur

Derm 49

Impetigo Staph/Strep Superficial but highly contagious See in infants, children or with

poorer hygiene Red, with vesicles most often seen

on face “Honey crusted” lesions Can become bullous Treatment:

Minimal - topical mupirocin ointment Extensive - Dicloxacillin,

cephalosporins, erythromycin

Derm 50

Fifth’s Disease Erythema infectiosum Human parvovirus B19 Prodrome of low-grade fever,

malaise, sore throat precede the rash

“Slapped cheeks” and “lace-like” erythematous rash on trunk and limbs

Complications: anemia, arthritis/arthralgia

Associated with fetal abnormalities if acquired in pregnancy

Treatment: Symptomatic

Derm 51

Rubeola (Measles) Paramyxovirus Fever, cough, conjunctivitis, coryza (3 “C”s) Koplik spots located on the buccal mucosa precede

the rash Maculopapular rash, red-brown (morbilliform) Starts on trunk and spreads head to feet Complications: pneumonia, encephalitis, OM,

conjunctivitis Usually atypical in adults with fever and vesicular rash Prevention by live attenuated vaccine (MMR)

Derm 52

Rubeola (Measles) (Cont’d)

Derm 53

Rubella Togavirus Cervical and posterior auricular

adenopathy with URI symptoms, H/A and N/V

Rash is described as palpable petechiae

Starts as pink maculopapular rash on face and spreads to limbs

Causes fetal congenital defects, especially 1st trimester

Complications: TORCH, encephalitis, arthritis

Derm 54

Roseola Infantum Herpes Human Virus type 6 Common ages 6-18 months High fever for 3-5 days then

rash develops after fever resolves

Maculopapular rash on arms, trunk and neck

Associated with febrile seizures

Symptomatic treatment (tincture of time)

Derm 55

Scarlet Fever Group A strep. Rash caused by toxin Rapid onset, with sore throat, fever, H/A and

sometimes vomiting Rash is a “sandpaper” type – starts on trunk

and moves to limbs, with circumoral sparing Strawberry tongue Pastia’s lines on groin, limbs and antecubital

areas May see post-strep skin peeling on

palms/soles Dx: Rapid strep test or culture Treatment: PCN, erythromycin

Derm 56

Scarlet Fever (Cont’d)

Derm 57

Staphylcoccal Scalded Skin Syndrome (SSSS)

Derm 58

Staphylcoccal Scalded Skin Syndrome (SSSS) (Cont’d)

Usually under age 5 Staph toxin, with

scarlatiniform rash after onset of fever, irritability and then exfoliation

Positive Nikolsky’s sign Treated with antibiotics

(beta-lactamase resistant) but this does not change the skin effects

Better prognosis than toxic epidermal necrolysis (TEN)

Derm 59

Kawasaki’s Disease

Derm 60

Kawasaki’s Disease (Cont’d) Inflammatory vasculitis Need fever for > 5 days PLUS 4/5 of the following

Conjunctivitis (bilateral) Strawberry tongue, fissures Erythematous rash - starts palms/soles Enlarged lymph nodes Desquamation of fingers/toes with swelling

Increased WBC, ESR; may be anemic Associated with increased risk for coronary artery aneurysms 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)

Derm 61

Seborrheic Keratosis (SK) Most common of benign skin

tumors Widely variable presentation

from flat, brown macules to raised blackened verrucous lesions - need to be familiar with variations to prevent unnecessary destructive procedures

Sign of Leser-Trelat (eruptive SK as sign of internal malignancy)

Treatment: Cryo, Curettage, Shave bx technique

Derm 62

Tinea Corporis Classical ring appearance

with red raised borders associated with central clearing

KOH skin scraping may help in confirmation of diagnosis

Treatment: Superficial - topical

antifungal Deep - 1-3 months of oral

therapy such as griseofulvin

Derm 63

Tinea Cruris Lesions occur in

warm moist areas often in summer months

Often bilateral disease with a half-moon plaque

Treatment: Topical antifungal creams for 10-14 days

Derm 64

Kerion Severe inflammatory

reaction to tinea of the scalp

Indurated and exudes pus (sterile)

Must use ORAL therapy as topical does NOT work

Derm 65

Kerion (Cont’d)

Treatment: Griseofulvin - 15mg/kg for 6-12 weeks Terbinafine - 3-6 mg/kg/day for 6 weeks Itraconazole - 2-5 mg/kg/day for 6 weeks

Derm 66

Erythema Migrans (Lyme) Begins as small red papule at site

of tick bite with expanding ring of rash with central clearing

Associated flu-like symptoms of H/A, stiff neck, fever, chills

Borrelia burgdorferi transmitted by the Ixodes tick

Can have early and late manifestations including arthritis and meningitis

Treatment: doxycycline, azithromycin

Best treatment: tick prevention using products containing DEET

Derm 67

Syphilis

Derm 68

Syphilis (Cont’d)

Treponema pallidum (spirochete) Primary = painless chancre Secondary = rash (palm/sole),

lymphadenopathy, condyloma lata Tertiary = CNS or cardiovascular effects Diagnosis: RPR followed by FTA-ABS Treatment: PCN, ceftriaxone, erythromycin Jarisch-Herxheimer Rxn: limited reaction due

to release of antigens following antibiotics - chills, fever, H/A, myalgias

Derm 69

Smallpox

Derm 70

Smallpox (Cont’d)

Orthopox virus - Variola Was officially eradicated by WHO 1980 Still stockpiled in US and Russia Theoretically produced by genetic

manipulation of cowpox and monkeypox One of most contagious diseases

known

Derm 71

Smallpox (Cont’d)

3-17 day incubation ACUTE onset of fever, malaise,

vomiting, headache, backache, delirium and erythematous rash

2-3 days after onset, a varicella-like rash begins on face (forehead), upper arms, forearms, hands and legs and spreads centrally

Derm 72

Smallpox (Cont’d)

Medical Management: There is NO treatment, although Cidofovir may have some utility

Need to provide airborne droplet precautions for at least 17 days after exposure, quarantine recommended

Immediate post-exposure vaccination Supportive care

Derm 73

References Evidence Based Medicine

Practice Points

Derm 74

SLIDE 10Low-potency corticosteroids are recommended for maintenance therapy, whereas

intermediate-and high-potency corticosteroids should be used for the treatment of clinical exacerbation and applied to affected areas of skin over short periods of time.

Name of AAFP-approved source of systematic evidence review: National Guideline Clearinghouse

Specific web site of supporting evidence from the approved source identified immediately above: http://www.guideline.gov/summary/summary.aspx?doc_id=6872&nbr=004210&string=atopic+AND+dermatitis

Strength of evidence (description and/or grade as provided by the approved source): Strength of recommendation A – Directly based on category I evidenceCategory of evidenceIa Evidence from meta-analysis of randomized controlled trialsIb Evidence from at least 1 randomized controlled trial