Common FP Office Dermatology

Dana Romalis, MD

August 2006

Objectives

Recognize 17 common dermatologic conditions seen in the office setting

Identify other diseases that appear similarly and may confuse diagnosis

Learn basic treatment of these conditions, (as well as what doesn’t require treatment)

Recognize the psychosocial implications of these conditions.

Quick definition review

A) Papule/Plaque: superficial, elevated, palpable lesion ≤0.5 cm; >0.5 cm.

B) Macule/Patch: circumscribed colour change without elevation or depression.

C) Vesicle/Bulla: like A), but containing fluid.

D) Nodule: palpable, solid, deeper than A).

E) Wheal: pale red, palpable, superficial lesion, evanescent, disappearing

in 1-2 days. From edema in the papillary layer of the dermis. F) Pustule:

like C), only with purulent exudate as the fluid.

Vesicular7 yo with itchy rash & fever x1d,

feels unwell. Blisters on red base. New lesions are still appearing.

Diagnosis: - Varicella (chicken pox)

Etiology: VZV, airborneWhen is it infectious?

- from 1-2 days before rash develops, until after last lesion scabs over.

When will I know if I have it?- 1.5-2.5 wks after exposure

Vesicular

64 yo M w/burning pain for 3 days, now with rash on back “in a stripe”

Diagnosis: Herpes Zoster

Etiology: VZV reactivationTreatment:

Acyclovir <72 hr, +/- oral prednisoneTreat for 7-10 days

Why treat?reduce pain/duration of lesions

Is this contagious? How?When do you need to refer? to

whom?

Zoster treatment

Medication Dose Cost (generic for 7d)

Acyclovir 800 mg po 5x/day for 7 days $174-248

Famciclovir 500 mg po TID for 7 days $140

Valacyclovir 1000 mg po TID for 7 days $84

Prednisone 30 mg po BID on days 1-7; $1-2 then 15 mg BID on days 8-14; then 7.5 mg BID on days 15-21

Papular

27 yo M, no pmhx, w/itchy rash “all over” body for 3 days. It started with this patch here 1 wk ago…

Diagnosis:Pityriasis rosea-“Christmas tree” pattern

- Herald patch 1-2wks before rash appears

Pityriasis RoseaEtiology unknownLesions on “Langer’s lines”Differential diagnosis:

drug eruptionsecondary syphilistinea corporisviral exanthemguttate psoriasis

Treatment??anti-pruriticscontroversial:

erythromycinUVB

Papulosquamous

38 yo M w/symmetric, vivid pink, raised, scaly lesions.

Diagnosis: Psoriasis vulgaris

Pathophysiology: Immune activation of

keratinocyte cell cycle Epidemiology: bimodal Appearance:

localized vs. generalized Extensor surfaces

(macarena) Treatment:

Topicals –> phototherapy –> systemics

Psoriasis

Associated with: Arthritis (small joints) Nail dystrophy

- Oil spot (pathognomonic)

- Pitting

- Onycholysis

Other issues/forms: Koebbnerization Guttate (Gp A Strep) psychosocial

Papulosquamous 28 yo F says “I’ve always had

itchy arms, but it’s been awful this winter”. History of asthma, seasonal allergies

Diagnosis: Atopic dermatitis/ Eczema cheeks/extensor surfaces (infant) Flexure surfaces (older)

How is this rash different? 14 yo F “This rash has been

spreading for 3 months” Diagnosis:

Contact dermatitis To what?

Nickel (belt buckle, button)

Dermatitis/Eczema Treatment for all types:

Avoid triggers Allergens Excessive bathing

Emollients (Eucerin, Aquaphor, …glycerin content is key)

Topical steroids Immune modulators: tacrolimus/

Protopic, pimecrolimus/Elidel, …?safe in kids (not under 2)

STOP SCRATCHING! Lichenification Infection-impetigo

Papular rashes

Rash A: just started 1 hour ago, very itchy

Rash B: present for 2-3 months, not responding to OTC steroid cream.

A) Urticaria/wheals- allergic reaction AKA “hives”

B) Tinea corporis- well demarcated patches with central clearing “ringworm”

Papular rashes: Treatment

Urticaria: - H1-blockers

What else should you be concerned about?

Tinea Corporis:- topical antifungal - continue for 1-2 wks after lesions resolve.

Can he go to school?Anyone else at risk?

Hypopigmented

What makes these rashes so different?

A- symmetric, complete depigmentation. Clear edges.

B- decreased pigmentation, edges flake when scratched

1) Vitiligo; any age. - Fewer melanocytes (autoimmune)

2) Pityriasis versicolor; young adults. - etiology: P. ovale (yeast) most common

Vitiligo: Treatment

Autoimmune disease: - associated with thyroid dz & diabetes- commonly affects: perioral, hands, shins, genitals

Rx: - topical steroid, PUVA- support group- cosmetics

P. Versicolor: Treatment

- selenium sulfide shampoo x1wk

- alt: ketoconazole shampoo x3d (or oral azole -1 dose)

- may take months to repigment after summer

- prevent recurrence with repeat Rx qmonth x3m

Scalp lesions

9 yo boy sent home from school, removes hat to show you this red, scaly lesion. You see tiny black dots in an area of alopecia, with a fine scale.

Diagnosis? Tinea capitis

Differential? Treatment?

Oral griseofulvin until 2 wks beyond clinical resolution

T. Capitis Mother brings in 4 yo w/lg. red

exudative swelling on head. Diagnosis? Tinea capitis w/kerion

What do you have to tell mom? Scarring alopecia will result.

Treatment? As above, but with po steroids

• 2 weeks after treatment begins, a widespread pruritic eczematous rash erupts… What is this?

• Id reaction to the fungus• Rx with lubricants and topical steroids and

continue on griseofulvin for a complete course

Papulopustular 14 yo M w/ red papulopustular rash for 6m.

Getting worse. “is it because I eat fast food?”

Diagnosis: Acne Vulgaris

Etiology: Excess sebum production, hair follicle

hyperkeratinization blocks sebum release, causing buildup of sebum, lipids, cellular debris ideal for bacterial growth.

28 yo F “I keep getting acne on my cheeks and chin. I thought I was done with this years ago!”

Diagnosis: Rosacea

Etiology: unknown, strong genetic link

Treatment: Acne Mild: comedonal, with few papules &

pustules. No nodules Benzoyl peroxide (not w/retinoid) adapalene/Differin, azelaic acid/Azelex (improves

postinflammatory hyperpigmentation) retinoid OCPs

Mod: papulopustular, rare nodules. topical antibiotic (clinda, erythro) oral antibiotic (tetracycline, erythro)

Severe: nodulocystic, painful Isotretinoin/Accutane

Treatment: Rosacea Early:

avoidance of triggers sunscreens topical antibiotics systemic antibiotics oral isotretinoin

Metronidazole/Flagyl

Late: Laser treatments

Other: Associated blepharitis rhinophyma

Papules

6 yo M brought in with “rash that’s spreading all over his face!”

Dx: Molluscum contagiosum

Is this an STD?

How is picture B different? Common warts

Treatment? If desired- virtually the same Liquid nitrogen Electrocautery/scraping Topicals: Salicyclic acid, tretinoin,

duct tape, podofilox

Nodules: spot diagnoses

Very soft, mobile, slow-growing in 50 yo M

Slips under fingers Diagnosis:

Lipoma

Firm, slow-growing, central dark spot

Diagnosis: Epidermoid cyst

Keratin plug helpful for diagnosis

Nodules: treatment

Usually not necessary However…

May become painful or inflamed.

Poor cosmesis…

Surgical removal Must remove capsule

or lesion will recur

Conclusion

Family physicians encounter a wide variety of dermatologic lesions in a wide variety of stages.

History and clinical picture are often enough to make the diagnosis

Attempts at self-treatment present additional diagnostic challenges.

Most conditions are common and easily treated or self-resolve…but for those that are not…

Biopsies may be needed for definitive diagnosis.

Questions?

Bibliography

UptodateGoogle imagesAmerican Family PracticeFitzpatrick Atlas of Clinical Dermatologywww.dermatlas.com