urgent care dermatology

Urgent Care DermatologyDermatology Differential Diagnosis in Images

James S. Studdiford, MDKathryn P. Trayes, MDJune 23, 2021

2019 Eastern Shore Symposium Presentation

• Annals of Internal Medicine, February 4, 2020• Prolongation of the PR interval >200 ms occurs in 90% of

patients with disseminated Lyme disease.

Case 1• 57 yo M from Vermont: fever, fatigue, SOB, CP• EKG: first degree AV block with PR interval 220 ms• Lyme test ordered, came back + 2 days later, not treated• 8 days later, pt presented to ED, worsening symptoms, ID

consulted, F/U appt scheduled, no Tx• 12 days later: pt found unresponsive

Cautionary Tale: Fatal Lyme Carditis in New England: Two Case Reports

Ann Intern Med, Feb 4, 2020; 172(3): 222-24

• Case 2• 49 yo F presented to ED with HA, nausea, vomiting• Normal CT head and EKG• IV fluids, antiemetics, analgesics, D/C home• 2 weeks later, saw PCP with c/p 2 episodes of syncope with

bowel and bladder incontinence, persistent fatigue, nausea and SOB

• EKG: AV dissociation• Cardiology ordered cardiac event monitor and lab tests

including Lyme• 2 days later, + Lyme result, Doxy started, but before she

took the first dose, she went into V tach and died

Cautionary Tale:

Ann Intern Med, Feb 4, 2020; 172(3): 222-24

Cautionary Tale:

Ann Intern Med, Feb 4, 2020; 172(3): 222-24

• Carditis can be an early manifestation of Lyme disease

• Lyme carditis should be considered when younger patients present with severe conduction abnormalities

• EKG is essential

• AV block in Lyme carditis can progress rapidly and be fatal

• Treat with antibiotics empirically

Take Home Points

Ann Intern Med, Feb 4, 2020; 172(3): 222-24

Correctly diagnosing dermatologic disease can save lives!

Dermatology is more than just identifying and treating

rashes!

Objectives

● Outline and practice the approach to dermatologic diagnoses

● The role of the history and physical examination

● Common entities

● Diagnostic challenges

Our GOAL: - Master the diagnosis and treatment of skin conditions- Appreciate that this expertise falls within the purview of Family Med/EM/IM/peds/etc..

Treatment

Natural history

Visual diagnosis

Workup

Morphology

Location

Border

Pattern

Differential

Diagnosis

Welcome to DERM think – defining moments

Primary lesion

History

Nodular lesions: pyogenic granuloma, MRSA

6/20/2021

Erythema nodosum

Annular and Targetoid Lesions

American Family Physician, Sept 2018; 98(5): 283-91

69 yo F with “itchy/burning rash” which developed one week after initiating Bactrim

American Family Physician, Sept 2018; 98(5): 283-91

Fixed Drug Eruption

American Family Physician, Sept 2018; 98(5): 283-91

Erythema Multiforme

18 yo male with a rash that developed shortly after receiving Menactra

vaccination Pharmacotherapy, Nov 2006; 26(11): 1658-61,

Treatment:self-limited, ; steroids,

Anti-virals for associated recurrent

HSV-1

Workup:Visual Dx

(plus pertinent History)

“Multiple raised, annular, targetoid lesions”

Lesions appeared suddenly after

vaccination

Differential: urticaria, LD, pityriasis R,

contact dermatitis Diagnosis: Erythema

multiforme

Etiology:Infections (~90% ),

Medications (~10%)

vaccinations

18-y-o male developed a red rash following a menactra vaccination

Pharmacotherapy, Nov 6, 2006; 26(11): 1658-61

Erythema multiforme

IgA vasculitis, Henoch-Schonlein Purpura

21 yo with a sore throat. One week later developed small red spots on ankles which grew to larger lesions over the

next two days. + ankle swelling.American Family Physician, Sept 2018; 98(5): 283-91

IgA vasculitis Work up

16 yo with a history of eczema presents with fever, malaise and a one-week history of a

“bumpy”, painful skin rash. Emerg Med, Feb 2011; 40(2): 167-9

Herpes Zoster

Nails

Quote attributed to Abraham Herzberg, DPM

American Family Physician, April 15, 2012; 85(8): 779-87

Beau’s lines, vertical nail bands

American Family Physician, April 15, 2012; 85(8): 779-87

Splinter hemorrhages, koilonychia

Psoriasis

Studdiford JS,et al. Images from the Wards: Diagnosis and Treatment. Saunders Elsevier, 2010.

Queen Anne’s sign, trichotillomania,alopecia areata

Daycare specials

5 yo with fever and decreased appetite. Three days later she developed erythematous macules on cheeks and then a lacey

reticular rash on her upper extremities and trunk

6/20/2021

29

Erythema infectiosum

3 yo low-grade fever, malaise and decreased appetite. One day later, she developed a rash that started on her hands

30

Coxsackie

31

17 mos with three days of fever to 102-103°F, decreased appetite. On day three, he developed a rash on trunk and

proximal extremities

Roseola

In Summary….

• Urgent Care Dermatology

• Higher acuity

• Think like dermatologists

• Lyme carditis

• nodular, annular, violaceous

• A difficult diagnosis: Eczema herpeticum

• Update on nails and hair

• Childhood infectious diseases

Entities Discussed Today:

• Disseminate Lyme Disease• Pyogenic granuloma• MRSA cellulitis with

furuncle• Erythema nodosum• IgA vasculitis• Eczema herpeticum• Staphylococcus aureas• Varicella Zoster• Beau’s lines• Splinter hemorrhages

• Koilyonychia• Plaque psoriasis• Onycholysis• Alopecia universalis• Trichotillomania• Alopecia areata• Erythema infectiosum• Coxsackie• Roseola

References:• Fitzpatrick JE, High WA, Kyle WL. Urgent Care Dermatology Symptom-Based Diagnosis.

Philadelphia, Elseiver, 2018.

• Marx GE, Leikauskas J, Lindstrom K, etc. al. Ann Intern Med. Feb 4, 2020; 172(3): 222-24.

• Studdiford JS, Altshuler M, Salzman B, Tully A. Images from the Wards: Diagnosis and Treatment. Philadelphia, Saunders Elsevier, 2010.

• Studdiford JS, Altshuler M et al, "Erythema multiforme after meningitis vaccine: patient safety concerns with repeat immunization.” Pharmacotherapy. Nov 6, 2006; 26(11):1658-61.

• Studdiford JS, Valko G, Stonehouse AS. “Eczema herpeticum: Making the Diagnosis in the Emergency Department.” Emerg Med. Feb 2011; 40(2): 167-9.

• Trayes KP, Savage K, Studdiford JS. “Annular Lesions: Diagnosis and Treatment.” American Family Physician. Sept 1 2018; 98(5): 283-91.

• Tully AS, Trayes KP, Studdiford JS. “Evaluation of Nail Abnormalities.” American Family Physician. April 15, 2012; 85(8): 779-87.

Thank you for your time and attention!

Contact information

Kathryn.Trayes@jefferson.edu

James.Studdiford@gmail.com