Cutaneous CareCutaneous Care

Paul W. Baumert, Jr., M.D., FAAFPPaul W. Baumert, Jr., M.D., FAAFP

Sports Medicine RoundsSports Medicine Rounds

November 15, 2007November 15, 2007

OutlineOutline

““Dermatology 101”Dermatology 101” Clinical pearlsClinical pearls Common conditionsCommon conditions

PapulosquamousPapulosquamous AcneiformAcneiform MorbilliformMorbilliform UrticariaUrticaria

Skin cancersSkin cancers CA-MRSACA-MRSA Diagnostic toolsDiagnostic tools

““Dermatology 101”Dermatology 101”

If it’s dry: WET itIf it’s dry: WET it

If it’s wet: DRY itIf it’s wet: DRY it

If it’s red and itchy: Use steroidsIf it’s red and itchy: Use steroids

MORE COMPLEXMORE COMPLEX!!!!

Medicine is a calling, not a business.You are in this profession as a calling, not as a business; as a calling which exacts from

you at every turn self-sacrifice, devotion, love and tenderness to your fellow-men.  Once you get down to a purely business level, your influence is gone and the true light of your

life is dimmed.  You must work in the missionary spirit, with a breadth of charity that raises you far above the petty jealousies of life.

Sir William Osler

Clinical pearlsClinical pearls

Dry skinDry skin

Topical corticosteroidsTopical corticosteroids

Dry SkinDry Skin

Worsens almost Worsens almost anyany skin condition skin condition SeasonalSeasonal MoisturizersMoisturizers

TipsTips Avoid long, hot showersAvoid long, hot showers Towel dry (get big drops off)Towel dry (get big drops off) Apply to damp skinApply to damp skin

TypesTypes Ointment > cream > lotionOintment > cream > lotion Aquaphilic ointmentAquaphilic ointment

Winter Dry Skin handout (UIHC derm)Winter Dry Skin handout (UIHC derm)

Topical CorticosteroidsTopical Corticosteroids

Treat the erythema, Treat the erythema, notnot the itch the itch Side effectsSide effects

Atrophy/striaeAtrophy/striae TelangiectasiaTelangiectasia PurpuraPurpura

Absorption depends on Absorption depends on Skin thicknessSkin thickness OcclusionOcclusion

FormsForms

Common ConditionsCommon Conditions

Papulosquamous (“raised and scaly”)Papulosquamous (“raised and scaly”) Eczematous or contact dermatitisEczematous or contact dermatitis Tinea corporisTinea corporis ScabiesScabies Pityriasis roseaPityriasis rosea

PrinciplesPrinciples Proper diagnosisProper diagnosis Initial choice of treatmentInitial choice of treatment

Common ConditionsCommon Conditions

AcneiformAcneiform AcneAcne Molluscum contagiosumMolluscum contagiosum FolliculitisFolliculitis

Common ConditionsCommon Conditions

MorbilliformMorbilliform Viral exanthemsViral exanthems

Measles, rubella, roseola, enteroviruses, etc.Measles, rubella, roseola, enteroviruses, etc. Scarlet feverScarlet fever ScarlatinoformScarlatinoform Drug exanthemsDrug exanthems

Usually pruriticUsually pruritic Usually within 2 weeks of beginning a medicationUsually within 2 weeks of beginning a medication

Common ConditionsCommon Conditions

Urticaria (Hives)Urticaria (Hives) IngestionIngestion

FoodFood MedicationMedication

PhysicalPhysical 50% have no identifiable cause50% have no identifiable cause Treatment pearlsTreatment pearls

Potent antihistamine(s), adequate durationPotent antihistamine(s), adequate duration

Skin CancersSkin Cancers

MelanomaMelanoma

Basal cell carcinomaBasal cell carcinoma

Squamous cell carcinomaSquamous cell carcinoma

MelanomaMelanoma

IncidenceIncidence 1930: 1 in 15001930: 1 in 1500 1960: 1 in 6001960: 1 in 600 2001: 1 in 712001: 1 in 71

Lifetime risk (2006)Lifetime risk (2006) Caucasians: 1 in 60 (slightly higher in males)Caucasians: 1 in 60 (slightly higher in males) Non-caucasians: 1 in 1176Non-caucasians: 1 in 1176

75% of skin cancer deaths75% of skin cancer deaths

MelanomaMelanoma

4 main types of malignant melanoma4 main types of malignant melanoma

Clinical prediction rulesClinical prediction rules ABCDE criteria (ACS)ABCDE criteria (ACS) 7 point checklist (UK)7 point checklist (UK)

Types of melanomasTypes of melanomas

Superficial spreadingSuperficial spreading 50% of cases50% of cases More frequent in More frequent in

younger adultsyounger adults

Types of melanomasTypes of melanomas

NodularNodular 20 to 25% of cases20 to 25% of cases Also in younger adultsAlso in younger adults

Types of melanomasTypes of melanomas

Lentigo malignaLentigo maligna 15% of cases15% of cases Older adultsOlder adults

Types of melanomasTypes of melanomas

Acral-lentiginousAcral-lentiginous 10% of cases10% of cases Palms, soles, around first Palms, soles, around first

toenailtoenail

Risk factors for malignant Risk factors for malignant melanomamelanoma

Atypical nevus syndrome with personal Atypical nevus syndrome with personal andand family hx of melanoma (500)family hx of melanoma (500)

Changing mole (>400)Changing mole (>400) Atypical nevus syndrome with family hx of Atypical nevus syndrome with family hx of

melanoma (148)melanoma (148) Age Age >> 15 15 Dysplastic moles (7-70)Dysplastic moles (7-70)

Risk factors con’tRisk factors con’t

Large congenital nevus (Large congenital nevus (>> 15 cm) (17) 15 cm) (17) Caucasian race (12)Caucasian race (12) Atypical nevi (7-27)Atypical nevi (7-27) Regular tanning bed use before age 30 (7.7)Regular tanning bed use before age 30 (7.7) Multiple nevi (5-12)Multiple nevi (5-12) Personal hx of melanoma (5-9)Personal hx of melanoma (5-9) Family hx (first degree) of melanoma (3-8)Family hx (first degree) of melanoma (3-8) Sun sensitivity/tendency to burn (2-3)Sun sensitivity/tendency to burn (2-3)

Clinical prediction rulesClinical prediction rules

ABCDE Criteria (American Cancer Society)ABCDE Criteria (American Cancer Society)

7 point checklist (United Kingdom)7 point checklist (United Kingdom)

ABCDE CriteriaABCDE Criteria

AAsymmetrysymmetry BBorderorder CColorolor DDiameteriameter EEvolving (Elevation or Enlargement)volving (Elevation or Enlargement)

AAsymmetrysymmetry

BBorderorder

CColorolor

DDiameteriameter

EEvolving (elevation/enlargement)volving (elevation/enlargement)

7 point checklist (Glasgow)7 point checklist (Glasgow)

Major signs (1 or more):Major signs (1 or more):

Change in sizeChange in size

Change in shapeChange in shape

Change in colorChange in color

Minor signs:Minor signs:

InflammationInflammation

Crusting or bleedingCrusting or bleeding

Sensory changeSensory change

Diameter Diameter >> 7 mm 7 mm

A2BCD3EFG’s of MelanomaA2BCD3EFG’s of Melanoma

2005 Additions:2005 Additions: AngularityAngularity DysplasticDysplastic Different (from patient’s other nevi)Different (from patient’s other nevi) EVOLVINGEVOLVING Family historyFamily history Great numbers of neviGreat numbers of nevi

Clinical AssessmentClinical Assessment

Apply the ABCD+ criteria Apply the ABCD+ criteria Excisional (full thickness) biopsy if either test Excisional (full thickness) biopsy if either test

has positive criteria has positive criteria oror if you or your patient if you or your patient has any doubthas any doubt

Guidelines are developed from large studies Guidelines are developed from large studies and tell you nothing about the patient in front and tell you nothing about the patient in front of youof you

The Bottom Line Re: MelanomasThe Bottom Line Re: Melanomas

When educating patients, if one were to stress When educating patients, if one were to stress only only oneone characteristic of melanoma, it would characteristic of melanoma, it would be CHANGE.be CHANGE.

However, only 25% of melanomas arise from However, only 25% of melanomas arise from a preexisting lesion. 75% of the time they a preexisting lesion. 75% of the time they arise de novo!arise de novo!

CA-MRSACA-MRSA

AcquisitionAcquisition Contact, skin breakdown, hygieneContact, skin breakdown, hygiene

TreatmentTreatment Physician-directed medication, drainage, carePhysician-directed medication, drainage, care

PreventionPrevention Wash hands often, use alcohol-based hand rubsWash hands often, use alcohol-based hand rubs Keep cuts/scrapes clean and coveredKeep cuts/scrapes clean and covered Do Do notnot touch other people’s cuts or bandages touch other people’s cuts or bandages Do Do notnot share personal items, such as towels or razors share personal items, such as towels or razors

Diagnostic ToolsDiagnostic Tools

Experienced clinician/proper environmentExperienced clinician/proper environment KOHKOH CultureCulture

Bacterial (+/- sensitivity)Bacterial (+/- sensitivity) ViralViral FungalFungal

BiopsyBiopsy PunchPunch

Specialty referral is Specialty referral is notnot needed in most cases needed in most cases

Live neither in the past nor in the future, Live neither in the past nor in the future, but let each day’s work absorb your but let each day’s work absorb your

entire energies, and satisfy your widest entire energies, and satisfy your widest ambitionambition

Sir William OslerSir William Osler