Dermatologic Board Review

Dermatologic Board Dermatologic Board ReviewReview

Lane Bower, MHSc, PA-CLane Bower, MHSc, PA-C

Which is the SK?Which is the SK?

Seborreic KeratosisSeborreic Keratosis

Most common benign cutaneous neoplasmMost common benign cutaneous neoplasm Origin unknownOrigin unknown No malignant potentialNo malignant potential Easily and quickly removedEasily and quickly removed Vary in size shape, most ovalVary in size shape, most oval Most common on torso, lesser degree on faceMost common on torso, lesser degree on face Increasing numbers with ageIncreasing numbers with age Leser Tre’lat SignLeser Tre’lat Sign

NevusNevus

A benign, pigmented lesion that is not caused A benign, pigmented lesion that is not caused by any outside catalyst. by any outside catalyst.

There are many types of nevi; junctional, There are many types of nevi; junctional, compound, dermal. Refer to textcompound, dermal. Refer to text

Main job is differentiating from dysplastic Main job is differentiating from dysplastic nevi which have malignant potentialnevi which have malignant potential

What to do?What to do?

When in doubt, remove it and send it to When in doubt, remove it and send it to pathology. pathology.

Do a conservative full excisionDo a conservative full excision If it just doesn’t look right, remove itIf it just doesn’t look right, remove it That’s the thing with dysplastic nevi, if you That’s the thing with dysplastic nevi, if you

can’t make up your mind as to whether it is can’t make up your mind as to whether it is benign or a possible melanoma, it is probably benign or a possible melanoma, it is probably the middle ground of dyplasticthe middle ground of dyplastic

Actinic KeratosisActinic Keratosis

Common, sun induced, pre-malignant, changes Common, sun induced, pre-malignant, changes that increase with agethat increase with age

Most common sites are forehead, shoulders, Most common sites are forehead, shoulders, back, and dorsum of armsback, and dorsum of arms

Start as an erythematous, rough, area, that Start as an erythematous, rough, area, that forms a yellow crust.forms a yellow crust.

They are usually very symmetrical in They are usually very symmetrical in distribution. distribution.

…………actinic keratosisactinic keratosis

Basal cell and other skin Basal cell and other skin cancers can develop in cancers can develop in these transitional type these transitional type

lesions.lesions.

Treatment of AKTreatment of AK

5-FU get incorporated in to rapidly 5-FU get incorporated in to rapidly reproducing cells and causes cell deathreproducing cells and causes cell death

Retin-A has been helpfulRetin-A has been helpful Cryotherapy for early lesions is effectiveCryotherapy for early lesions is effective Laser is excellent!Laser is excellent! Avoidance of further sun damage is paramountAvoidance of further sun damage is paramount Explain the Course using 5-FUExplain the Course using 5-FU

Who’s the Mole?Who’s the Mole?

ZosteriformZosteriform

Lesions arranged along the cutaneous Lesions arranged along the cutaneous distribution of a spinal dermatomedistribution of a spinal dermatome

They are unilateral and denoteThey are unilateral and denote herpes zoster herpes zoster metastatic carcinoma of the breast metastatic carcinoma of the breast dermatomal hemangiomatous growths of Sturge-dermatomal hemangiomatous growths of Sturge-

Weber syndromeWeber syndrome

ImpetigoImpetigo Level of InfectionLevel of Infection

Epidermal superficial infectionEpidermal superficial infection Port of EntryPort of Entry

Cuts, abrasions, bug biteCuts, abrasions, bug bite Likes moist areas (mouth, nose) and hot Likes moist areas (mouth, nose) and hot

moist climatesmoist climates SusceptibilitySusceptibility

Common in infants & childrenCommon in infants & children VERY Contagious!VERY Contagious!

ImpetigoImpetigo SymptomsSymptoms

ItchItch Signs (Appearance)Signs (Appearance)

VesicularVesicular Toxins cause epidermal cleavaging of stratum corneumToxins cause epidermal cleavaging of stratum corneum Some strains Strep. aureus cause thin-roofed bullaSome strains Strep. aureus cause thin-roofed bulla

Evolves to pustules and become “honey-crusted”Evolves to pustules and become “honey-crusted” Satellite lesions on periphery (asymptomatic)Satellite lesions on periphery (asymptomatic)

ImpetigoImpetigo Causative AgentsCausative Agents

Staphylococcus aureus (most usual)Staphylococcus aureus (most usual) ? 2wk incubation? 2wk incubation

Streptococcus pyrogenes (occ. alone OR Streptococcus pyrogenes (occ. alone OR together)together)

ImpetigoImpetigo Course of DiseaseCourse of Disease

Self-limiting !!Self-limiting !! But…But…

may last weeks or monthsmay last weeks or months Post streptococcal glomerulonephritis may Post streptococcal glomerulonephritis may

follow! Esp. 2 - 4 yo. Hematuria/proteinuria.follow! Esp. 2 - 4 yo. Hematuria/proteinuria. Osteomyelitis, septic arthritis & pneumonia from Osteomyelitis, septic arthritis & pneumonia from

otherwise seemingly innocuous impetigootherwise seemingly innocuous impetigo

ImpetigoImpetigo TreatmentTreatment (cover both Staph & Strep) (cover both Staph & Strep)

AllAll Wash with anti-bacterial soap 1-2/d to remove crusts.Wash with anti-bacterial soap 1-2/d to remove crusts. Wash entire body to prevent spread 1- 2/dayWash entire body to prevent spread 1- 2/day

Non BullousNon Bullous DicloxicillinDicloxicillin 250-500 mg Qid 250-500 mg Qid X5-10 daysX5-10 days

CloxicillinCloxicillin 500-1000 mg 500-1000 mg

Q6h X 5-10 daysQ6h X 5-10 days

BactrobanBactroban apply TID X 5-10 apply TID X 5-10 daysdays

AzithromycinAzithromycin 500mg QD for 500mg QD for 1 day then 250 mg X 4days1 day then 250 mg X 4days

ErythromycinErythromycin 250-500 mg 250-500 mg TID X 5-10 daysTID X 5-10 days

22ndnd Generation Generation CephalosporinCephalosporin

BactrobanBactroban

BullousBullous DicloxicillinDicloxicillin 250-500 mg Qid 250-500 mg Qid X5-10 daysX5-10 days

Keflex Keflex 250-500 mg QID X 10 250-500 mg QID X 10 daysdays

AzithromycinAzithromycin 500mg QD for 500mg QD for 1 day then 250 mg X 4days1 day then 250 mg X 4days

Augmentin Augmentin 875/125 mg BID 875/125 mg BID x 10 days or 500/125 mg TID x 10 days or 500/125 mg TID X 10 daysX 10 days

Erysipelas & CellulitisErysipelas & Cellulitis

Level of InfectionLevel of Infection Erysipelas Erysipelas epidermis & dermis (defined border). epidermis & dermis (defined border).

Acute inflammatory version of Cellulitis with streaking.Acute inflammatory version of Cellulitis with streaking. Cellulitis Cellulitis dermis & subcutaneous tissue (diffuse) dermis & subcutaneous tissue (diffuse)

SymptomsSymptoms Area is red, hot, swollen, tender, edema, ?malaiseArea is red, hot, swollen, tender, edema, ?malaise perhaps vesicles, bullae, petechiae/purpuraperhaps vesicles, bullae, petechiae/purpura Perhaps spread to lymphatics, “red streaks”Perhaps spread to lymphatics, “red streaks”

lymph nodes may be swollen and tenderlymph nodes may be swollen and tender chills and fever may be presentchills and fever may be present


A portals of entryA portals of entry Open lesion, trauma, surgical wound, Open lesion, trauma, surgical wound,

athletes foot, IV drug use, insect bite, fissureathletes foot, IV drug use, insect bite, fissure Radiation therapyRadiation therapy Arms usually in young adultsArms usually in young adults

Legs usually in children and older adultsLegs usually in children and older adults Puerperal sepsis common form before Puerperal sepsis common form before

antibioticsantibiotics Peripheral vascular disease is a common Peripheral vascular disease is a common

underlying factorunderlying factor

Erysipelas & CellulitisErysipelas & Cellulitis DiagnosisDiagnosis

Largely Clinical:Largely Clinical: typical presentation and appearancetypical presentation and appearance

LabsLabs CBCCBC gram stain and culture wounds poor yieldgram stain and culture wounds poor yield needle aspiration (5% yield), biopsy (20% yield), needle aspiration (5% yield), biopsy (20% yield),

blood cultures (5% yield)blood cultures (5% yield) Films (?)Films (?)

Plain / CT / MRI: underlying fasciitis or Plain / CT / MRI: underlying fasciitis or osteomyelitis osteomyelitis

Referrals: (?) Ortho if over jointReferrals: (?) Ortho if over joint

Erysipelas & CellulitisErysipelas & Cellulitis Differential DiagnosisDifferential Diagnosis

Necrotizing Fasciitis: deeper and much more virulent. Necrotizing Fasciitis: deeper and much more virulent. Consider if patient doesn’t respond to antibiotics Consider if patient doesn’t respond to antibiotics within 48 hours.within 48 hours.

Deep vein thrombosisDeep vein thrombosis CourseCourse

AntibioticsAntibiotics possible abscess (I&D), sepsis, fasciitis (rare)possible abscess (I&D), sepsis, fasciitis (rare) Erysipelas Erysipelas Endocarditis Endocarditis Recurrent cellulitis Recurrent cellulitis persistent lymphedema persistent lymphedema


InpatientInpatient IV methacillinase-resistant penicillin (nafcillin) or cephazolinIV methacillinase-resistant penicillin (nafcillin) or cephazolin Consider pseudomonas in immunocompromised patients--Consider pseudomonas in immunocompromised patients--

ticarcillin, piperacillinticarcillin, piperacillin

Others:Others: Elevate limbs, treat sources Elevate limbs, treat sourcesWarning: May get worse first day or two of tx. Draw on pt.Warning: May get worse first day or two of tx. Draw on pt.

Cellulitis PitfallsCellulitis Pitfalls

NecrosisNecrosis Devitalized tissue (tense, cyanotic, necrotic, Devitalized tissue (tense, cyanotic, necrotic,

bronzing of the skin, blanched) will not be perfused, bronzing of the skin, blanched) will not be perfused, so antibiotics will not get to the site.so antibiotics will not get to the site.

If not improvement on ABX, consider devitalized If not improvement on ABX, consider devitalized

tissue & tissue & surgical debridementsurgical debridement

Cellulitis Pitfalls Cellulitis Pitfalls (cont.)(cont.)

Facial Cellulitis in adultsFacial Cellulitis in adults H. Flu in adult is rare and may be toxic with H. Flu in adult is rare and may be toxic with

airway compromise. (usually >50yo) Admit & airway compromise. (usually >50yo) Admit & tx (cefuroxime IV)tx (cefuroxime IV)

Facial Cellulitis in childrenFacial Cellulitis in children Potentially serious !!!!Potentially serious !!!! If no obvious entry for, probably H. FluIf no obvious entry for, probably H. Flu

? Meningitis (8% infants) ?tap.? Meningitis (8% infants) ?tap.


Cellulitis around the eyeCellulitis around the eye Dangerous !!!Dangerous !!! Orbital vs. Peri-orbital cellulitisOrbital vs. Peri-orbital cellulitis

Periorbital (more common)Periorbital (more common) Limited to eyelids in the preseptal regionLimited to eyelids in the preseptal region Treat aggressively with IV abxTreat aggressively with IV abx

Orbital is Orbital is EMERGENCYEMERGENCY Infection spreads both by extension and retrogradeInfection spreads both by extension and retrograde H. Flu usualH. Flu usual IV abx, admit, ? CT (globe displacement)IV abx, admit, ? CT (globe displacement)


Necrotizing FasciitisNecrotizing Fasciitis Dangerous !!!Dangerous !!! S. pyrogenes or othersS. pyrogenes or others Sx: painful, edema, necrosis, Sx: painful, edema, necrosis,

widespreadwidespread Occlusion of small blood Occlusion of small blood

vessels to gangrene (growth vessels to gangrene (growth of anaerobes - eg of anaerobes - eg Bacteroides).Bacteroides).

Risk factor: DMRisk factor: DM Dx: x-rays show gasDx: x-rays show gas Mortality 30% ! Surgical Mortality 30% ! Surgical

treatmenttreatment

Upper lid avulsionUpper lid avulsion

Animal BitesAnimal Bites

Cats- Pasteurella multocida, S. aureusCats- Pasteurella multocida, S. aureus Primary Antibiotic Augmentin 875mg BID x Primary Antibiotic Augmentin 875mg BID x

10 days10 days Alternative- Cefuroxime 500 mg TID x 7dyasAlternative- Cefuroxime 500 mg TID x 7dyas 80% of all cat bites become infected! 80% of all cat bites become infected!

DO NOT USE KEFLEX!!!!!!DO NOT USE KEFLEX!!!!!!

Animal BitesAnimal Bites

Dogs- Pasteurella mutlicoda,S. aureusDogs- Pasteurella mutlicoda,S. aureus Primary- Augmentin 875 mg BIDPrimary- Augmentin 875 mg BID Alternative- Clindamycin 300 mg QID plus a Alternative- Clindamycin 300 mg QID plus a

flouroquinoloneflouroquinolone

ONLY 5% become infected.ONLY 5% become infected.

Tinea of the FootTinea of the Foot

Uncommon in women! Uncommon in women! Uncommon in prepubertal childrenUncommon in prepubertal children Inevitable in immunocompromised patientsInevitable in immunocompromised patients Acquired from locker-room floors and Acquired from locker-room floors and

communal bathscommunal baths Once infected, patient becomes a carrier and is Once infected, patient becomes a carrier and is

at risk for recurrenceat risk for recurrence Tight fitting shoes and work-bootsTight fitting shoes and work-boots

Tinea PedisTinea Pedis

TreatmentTreatment

Promote drynessPromote dryness Drysol 20% (aluminum chloride) H.S.Drysol 20% (aluminum chloride) H.S. Topical antifungal (Loprox, Lotrimin, Spectazole)Topical antifungal (Loprox, Lotrimin, Spectazole) Sometimes oral if refractory (Lamisil tablets)Sometimes oral if refractory (Lamisil tablets) Shoes that “breathe” and socks that wick away Shoes that “breathe” and socks that wick away

moisturemoisture Lamb’s wool between the toesLamb’s wool between the toes Treat secondary infection!!!!! (staph & Treat secondary infection!!!!! (staph &

pseudomonas)pseudomonas)

Special Treatment ConsiderationsSpecial Treatment Considerations

Tinea Capitis is not responsive to topical Tinea Capitis is not responsive to topical agents. You must use an oral drug such as agents. You must use an oral drug such as Giseofulvin 500 mg. po qd.Giseofulvin 500 mg. po qd.

Pediatric dosing: 10-20 mg/kg po qd X 4 – 6 Pediatric dosing: 10-20 mg/kg po qd X 4 – 6 weeks. Max 1 g/d. Absorption is better with a weeks. Max 1 g/d. Absorption is better with a fatty meal. fatty meal.

Tinea CrurisTinea Cruris

Warm, moist, dark, environment most Warm, moist, dark, environment most conducive to growthconducive to growth

If any dermatitis is treated withtopical steroids, it will initially look better and lead to what iscalled, “tinea incognito”

How Do We Know?How Do We Know?

MelanomaMelanoma

A.A. One-half of the mole does not match the One-half of the mole does not match the other half (i.e. it is asymmetricother half (i.e. it is asymmetric))

B.B. The edge (border) of the mole is jagged or The edge (border) of the mole is jagged or irregularirregular

CC. More than one color is present in a mole. More than one color is present in a mole D.D. It is larger than 5mm in diameter (the size It is larger than 5mm in diameter (the size

of a pencil eraserof a pencil eraser

How Can I Determine MyHow Can I Determine MyPersonal Risk?Personal Risk?

It is estimated that 1 out of 7 people in the It is estimated that 1 out of 7 people in the United States will develop some form of this United States will develop some form of this cancer during their lifetime. One serious cancer during their lifetime. One serious sunburn can increase the risk by as much as sunburn can increase the risk by as much as 50%. 50%.

These early studies are coming into These early studies are coming into question. Risk determination is complexquestion. Risk determination is complex

Pathologic StagingPathologic Staging

Depth of invasion offers the greatest Depth of invasion offers the greatest prognostic value in determining survivalprognostic value in determining survival

Depth of invasion determines need for therapy Depth of invasion determines need for therapy up and above surgical excisionup and above surgical excision

TreatmentTreatment

Wide excisionWide excision Regional lymph node dissection for higher Regional lymph node dissection for higher

stage diseasestage disease Chemotherapy for higher stage diseaseChemotherapy for higher stage disease

PsoriasisPsoriasis

Extensor surfaces most commonExtensor surfaces most common Palms and soles not commonly involved but Palms and soles not commonly involved but

can be. R/O Reiter Syndromecan be. R/O Reiter Syndrome Localized plaques may be confused with Localized plaques may be confused with

eczema or seborrheic dermatitiseczema or seborrheic dermatitis Guttate form may be confused with secondary Guttate form may be confused with secondary

syphilis or pityriasis roseasyphilis or pityriasis rosea

Principles of TreatmentPrinciples of Treatment

Control stressControl stress Stress reduction techniques are effective in Stress reduction techniques are effective in

controlling flares in certain patientscontrolling flares in certain patients Determine end of treatmentDetermine end of treatment

Patients perceive discoloration after clearing Patients perceive discoloration after clearing plaques as continued diseaseplaques as continued disease


Calcipotriol (Dovonex)Calcipotriol (Dovonex) Discovered in 1985 by chance-Women taking Vitamin Discovered in 1985 by chance-Women taking Vitamin

D for osteoporosis noted marked improvement in D for osteoporosis noted marked improvement in psoriasispsoriasis Vitamin D3 analogueVitamin D3 analogue Inhibits cell proliferation and induces terminal differentiationInhibits cell proliferation and induces terminal differentiation Inhibits epidermal cell proliferationInhibits epidermal cell proliferation Safe and effectiveSafe and effective Applied BID in amounts up to 100 grams per weekApplied BID in amounts up to 100 grams per week Rx for 6-8 weeks gives 60% improvementRx for 6-8 weeks gives 60% improvement Does not effect ca++ or bone metabolismDoes not effect ca++ or bone metabolism


Topical steroidsTopical steroids Control itchingControl itching Results very gratifying earlyResults very gratifying early Tachyphylaxis occursTachyphylaxis occurs Skin atrophy and tangelectasias limit extensive useSkin atrophy and tangelectasias limit extensive use Useful for treating intertriginous plaques and inflamed Useful for treating intertriginous plaques and inflamed

areasareas Plastic occlusion potentiatesPlastic occlusion potentiates Diprolene, TemovateDiprolene, Temovate


Intralesional steroidsIntralesional steroids Kenalog 5-10 mg.Ml (atrophy with 10 mg Kenalog 5-10 mg.Ml (atrophy with 10 mg

strength)strength) Anthralin (Anthra-Derm)Anthralin (Anthra-Derm)

Used only for chronic plaquesUsed only for chronic plaques Messy stains long treatment timesMessy stains long treatment times Best used in combination with UVBBest used in combination with UVB


PUVAPUVA Psoralens and UVA radiation in combinationPsoralens and UVA radiation in combination

MethotrexateMethotrexate CyclosporineCyclosporine RetinoidsRetinoids

Etretinate (Tegison)Etretinate (Tegison) HydreaHydrea

Psoralin UVA TreatmentPsoralin UVA Treatment

UVB Treatment – Before and After

Contact DermatitisContact Dermatitis

contact dermatitis, contact dermatitis, Skin Skin rash resulting from rash resulting from exposure to either an exposure to either an irritating or allergic irritating or allergic substance. In the first substance. In the first type, an irritant, as type, an irritant, as detergent or acid, causes detergent or acid, causes a sore much like a burn. a sore much like a burn. In the allergic type, the In the allergic type, the reaction is delayed. reaction is delayed. Symptoms are swelling, Symptoms are swelling, blisters, and large blisters, and large amounts of fluid in the amounts of fluid in the body tissues. Poison ivy body tissues. Poison ivy is a common example of is a common example of this type.this type.

Contact DermatitisContact Dermatitis Rhus dermatitis – (allergic)Rhus dermatitis – (allergic)

poison ivy, poison oak and poison ivy, poison oak and poison sumac account for poison sumac account for more cases of allergic more cases of allergic contact dermatitis than all contact dermatitis than all other contactants combinedother contactants combined

Occurs from contact with Occurs from contact with the leaf,or internal parts of the leaf,or internal parts of the stem or rootsthe stem or roots

Occurs from direct contact Occurs from direct contact with the oleo resinwith the oleo resin

Can not be spread via the Can not be spread via the blister fluid of current blister fluid of current lesionslesions


Metal dermatitisMetal dermatitis Nickel is the most common contact allergenNickel is the most common contact allergen Women >menWomen >men Jewelry most often the sourceJewelry most often the source

Contact DermatitisContact Dermatitis Diagnosis – Diagnosis –

History – persistent questioning may eventually History – persistent questioning may eventually uncover the offending antigenuncover the offending antigen

Date of onsetDate of onset Relationship to workRelationship to work Skin care productsSkin care products JewelryJewelry

Physical examPhysical exam DistributionDistribution Types of lesionsTypes of lesions DistributionDistribution DistributionDistribution

Patch testing – indicated in cases in which Patch testing – indicated in cases in which inflammation persists despite avoidance and inflammation persists despite avoidance and appropriate topical therapyappropriate topical therapy


Fundamental principals of dermatological Fundamental principals of dermatological therapytherapy : :Avoid the offending agentAvoid the offending agentWet lesions driedWet lesions driedDry lesions hydratedDry lesions hydratedInflammation treated with corticosteroidsInflammation treated with corticosteroids

Contact DermatitisContact Dermatitis Treatment –Treatment –

the aim of treatment is to decrease erythema, pruritis and the aim of treatment is to decrease erythema, pruritis and edemaedema

Prevent secondary infection – keep cleanPrevent secondary infection – keep clean Remove/avoid causative agentsRemove/avoid causative agents Topical steroidsTopical steroids Oozing lesions should be dried with Burrow’s solution Oozing lesions should be dried with Burrow’s solution

compresses 3 to 4 times dailycompresses 3 to 4 times daily Oral prednisone may be necessary for severe cases (tapering Oral prednisone may be necessary for severe cases (tapering

dose)dose)

Contact Contact DermatitisDermatitis

Topical corticosteroid precautionsTopical corticosteroid precautions

Wide variation in potencyWide variation in potency Vehicle affects potencyVehicle affects potency

Ointments more potent than creamsOintments more potent than creams

Occlusive dressing Occlusive dressing increases potency (do not increases potency (do not use ointments – folliculitis)use ointments – folliculitis)

Adverse effects –Adverse effects – AtrophyAtrophy Telangiectasia Telangiectasia /tlan'je-ekta'zh/, /tlan'je-ekta'zh/,

permanent widening of groups of permanent widening of groups of superficial capillaries and small vessels superficial capillaries and small vessels (venules). Common causes are damage (venules). Common causes are damage due to excess sunlight, some skin diseases, due to excess sunlight, some skin diseases, as rosacea, too-high levels of female as rosacea, too-high levels of female hormone, and collagen blood vessel hormone, and collagen blood vessel diseases.diseases.

THE ENDTHE END

Dermatologic Board Review

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