Presentation on theme: "Blotches: Light rashes"— Presentation transcript:
1Blotches: Light rashes Medical Student Core Curriculumin DermatologyLast updated April 18, 2011
2Module InstructionsThe following module contains a number of blue, underlined terms which are hyperlinked to the dermatology glossary, an illustrated interactive guide to clinical dermatology and dermatopathology.We encourage the learner to read all the hyperlinked information.
3Goals and ObjectivesThe purpose of this module is to help medical students develop a clinical approach to the evaluation and initial management of patients presenting with light rashes.After completing this module, the medical student will be able to:Identify and describe the morphology of common light rashesDescribe the use of Wood’s lamp and KOH exam to evaluate light spotsRecommend an initial treatment plan for selected light rashesDetermine when to refer to a patient with a light rash to a dermatologist
5Case One: HistoryHPI: Heather Doyle is a 10-year-old girl who presents with several lightly colored spots on her knees and hands over the past 8 months. They do not itch. Her mother reports they have not improved with over-the-counter hydrocortisone cream.PMH: no chronic illnesses or prior hospitalizationsAllergies: penicillin (rash)Medications: noneFamily history: grandmother with diabetesSocial history: lives at home with parents; attends elementary school; takes karate lessonsROS: negative
7Case One, Question 1Heather has some light colored, non-scaly, flat spots on her knees. Which of the following will likely aid in the diagnosis?DermatoscopePotassium hydroxide (KOH) examSwab for bacterial cultureWood’s light
8Case One, Question 1 Answer: d Heather has some light colored, non-scaly, flat spots on her knees. Which of the following will likely aid in the diagnosis?DermatoscopePotassium hydroxide (KOH) examSwab for bacterial cultureWood’s light
10Case One, Question 2 How would you describe Heather’s exam? well-circumscribed hypopigmented macules and patcheswell-circumscribed depigmented macules and patchespoorly circumscribed hypopigmented macules and patchespoorly circumscribed hypopigmented papules and plaques
11Case One, Question 2 Answer: b How would you describe Heather’s exam? well-circumscribed hypopigmented macules and patcheswell-circumscribed depigmented macules and patchespoorly circumscribed hypopigmented macules and patchespoorly circumscribed hypopigmented papules and plaques
12VitiligoLesions of vitiligo are well- circumscribed depigmented macules and patches.The Wood’s light exam distinguishes hypopigmented and depigmented lesions.Very few rashes other than vitiligo are completely depigmented.
13More Examples of Vitiligo Demonstration of bright white (depigmented) area with Wood’s light illumination
14Vitiligo: The BasicsVitiligo is caused by an autoimmune attack on melanocytes, the cells that produce skin pigmentIt favors areas of trauma (knees, elbows, fingers, mouth, eyes, genitalia)There is an association with other autoimmune disordersHeather’s vitiligo may be autoimmune, given her family history
15Vitiligo: The Basics Treatment options include Potent topical steroids or tacrolimus ointmentPhototherapy (Narrow band UVB, UVA)Cosmetic cover-upsRefer vitiligo patients to dermatology for initial evaluation
16Is this hypopigmented or depigmented? Use the Wood’s light.
17Wood’s light examLighter areas without complete loss of pigment are “hypopigmented”
18Steroid hypopigmentation Skin lightening can result from potent topical or intralesional corticosteroidsThe risk is higher in darker skin types. Counsel patients and parents on this risk.Avoid this side effect by using appropriate strength topical steroidsUse high-potency steroids for short durationsThen back off to mid-potency or low-potency steroids for maintenance
20Case Two: HistoryHPI: Tony Maddox is a 32-year-old man who presents with “blotches” on his upper back and chest for several years. They are more noticeable in the summertime.PMH: back pain, hyperlipidemia, birthmark (Nevus of Ito) on his left chestAllergies: noneMedications: NSAID as neededFamily history: noneSocial history: aircraft mechanicROS: negative
22Case Two, Question 1Mr. Maddox’s skin exam shows hypopigmented, slightly scaly macules on his upper chest. Which is the best test to confirm the diagnosis?Bacterial cultureDirect fluorescent antibody (DFA) testPotassium hydroxide (KOH) examWood’s light
23Case Two, Question 1 Answer: c Mr. Maddox’s chest shows hypopigmented, slightly scaly macules on his upper chest. Which is the best test to confirm the diagnosis?Bacterial cultureDirect fluorescent antibody (DFA) testPotassium hydroxide (KOH) examWood’s light
24Case Two: KOH exam Spores (yeast forms) Short Hyphae The KOH exam shows short hyphae and small round spores. This is diagnostic of tinea (pityriasis) versicolor.
25Diagnosis: Tinea versicolor Based on his skin findings and KOH exam, Mr. Maddox has tinea versicolorIt’s called “versicolor” because it can be light, dark, or pink to tanLet’s look at some examples of the various colors of tinea versicolor
29Case Two, Question 2 What is the best treatment for Mr. Maddox? Ketoconazole shampooNarrow band UVB phototherapyOral griseofulvinTacrolimus creamTriamcinolone cream
30Case Two, Question 2 Answer: a What is the best treatment for Mr. Maddox?Ketoconazole shampooNarrow band UVB phototherapy (may worsen appearance by increasing contrast)Oral griseofulvin (does not work for Malassezia species)Tacrolimus cream (does not fight yeast)Triamcinolone cream (does not fight yeast)
31Case Two, Question 3What is true about the treatment of tinea versicolor?Normal pigmentation should return within a week of treatmentOral azoles should be used in most casesWhen using shampoos as body wash, leave on for ten minutes before rinsing
32Case Two, Question 3 Answer: c What is true about the treatment of tinea versicolor?Normal pigmentation should return within a week of treatment (usually takes weeks to months to return to normal)Oral azoles should be used in most cases (mild cases can be treated with topicals)When using shampoos as body wash, leave on for ten minutes before rinsing
34Case Three: HistoryHPI: Shaun Lee is a 20-year-old male seen in the hospital with a worsening light colored scaling rash on his face. It has been getting worse since he stopped taking HAART for HIV. He also has painful erosions and ulcers in his mouth for 2 months and was admitted for pneumonia.PMH: HIV, extensive molluscum contagiosum, pneumoniaAllergies: penicillin (rash)Medications: levofloxacinFamily history: noncontributorySocial history: lives at home with parents; father does not believe he should take HIV medicationsROS: fatigue, dyspnea, fevers
36Case Three, Question 1Shaun’s exam shows hypopigmented scaling patches on his central face, eyebrows, and hairline. KOH is negative. What is the most likely diagnosis?Pityriasis albaSeborrheic dermatitisSteroid hypopigmentationTinea versicolor
37Case Three, Question 1 Answer: b Shaun’s exam shows hypopigmented scaling patches on his central face, eyebrows, and hairline. KOH is negative. What is the most likely diagnosis?Pityriasis alba (no history of atopy)Seborrheic dermatitisSteroid hypopigmentation (not using steroids)Tinea versicolor (wrong location)
38Seborrheic dermatitis Seborrheic dermatitis is a very common inflammatory reaction to the Malassezia (Pityrosporum ovale) yeast that thrives on seborrheic (oil-producing) skinIt presents as erythematous scaling macules on the scalp, hairline, eyebrows, eyelids, central face and nasolabial folds, external auditory canals, or central chestIt can be hypopigmented, especially in darker skin typesSeborrheic dermatitis is often worse in HIV-positive individuals
39Seborrheic dermatitis Often hypopigmented in darker skin types
40Seborrheic dermatitis Favors central chest. May be hypopigmented or erythematous.
41Case Three, Question 2 What is the best treatment for Shaun? Caspofungin IV infusionClobetasol proprionate cream (high potency steroid)Desonide cream (low potency steroid)Imiquimod creamNarrow band UVB phototherapy
42Case Three, Question 2 Answer: c What is the best treatment for Shaun? Caspofungin IV infusion (this is a systemic antifungal for severe infections)Clobetasol proprionate cream (would work, but too potent for use on the face)Desonide cream (low potency steroid)Imiquimod cream (irritating; for warts, actinic keratoses)Narrow band UVB phototherapy (doesn’t work)
43Seborrheic dermatitis treatment Antidandruff shampooKetoconazole (Nizoral), selenium sulfide, zinc pyrithione (Head & Shoulders) shampoosLather, leave on 10 minutes, rinse3-5 times weekly until under controlLow-potency topical steroid (e.g. desonide) for flaresUse BID for 1-2 weeks for flaresCan also use topical ketoconazole or ciclopirox, or topical pimecrolimus
44Seborrheic dermatitis (scalp) Severe scalp seborrheic dermatitis may need topical steroids; adjust to severity, patient ethnicityTriamcinolone spray BID for flaresFluocinolone in peanut oil (DermaSmooth™)Wet scalp; leave on 8 hours then wash outIf wash hair daily, apply at night with shower capIf not, use a little oil each morningClobetasol foam daily after shower if severeTowel dry and apply directly to damp scalp
45A note on postinflammatory hypopigmentation Some patients heal with light spots from any rashStigma may be caused by fear of infectious diseasesSocial impact can be more severe than original rashPigmentation may return slowlyIt is important to treat rashes aggressively to avoid this if possible
47Case Four: HistoryHPI: Damien Gonsalves is a 8-year-old boy who presents with light spots on his face.PMH: had “eczema” as infant and young childAllergies: noneMedications: noneFamily history: brother with asthma, mother has seasonal allergic rhinitisSocial history: lives at home with parents; student in second gradeROS: negative
49Case Four: QuestionDamien has hypopigmented patches on his cheeks bilaterally. The most likely diagnosis is:Pityriasis albaSeborrheic dermatitisTinea versicolorVitiligo
50Case Four: Question Answer: a Damien has hypopigmented patches on his cheeks bilaterally. The most likely diagnosis is:Pityriasis alba (atopic history supports this)Seborrheic dermatitis (usually more central)Tinea versicolor (rarely occurs on the face)Vitiligo (would be depigmented, not hypopigmented)
51Pityriasis albaPityriasis alba is a mild form of atopic dermatitis of the face in childrenAs in all atopic dermatitis, the first goal is moisturizationUse of sunscreens minimizes tanning, thereby limiting the contrast between involved and normal skinIf moisturization and sunscreen do not improve the hypopigmentation, consider low strength topical steroid
52Common light rashes Vitiligo Tinea versicolor Seborrheic dermatitis Pityriasis alba
53Comparing common light rashes FaceTrunkArms, LegsNotesSeborrheic dermatitisXCentral faceGreasy scaleTinea versicolor+KOH positiveVitiligoDepigmented (“bone white”) on Woods light examPityriasis albaHistory of atopy
54Take Home Points: Light Rashes Vitiligo is totally depigmented (“bone white”) on Wood’s light examinationHypopigmented macules on the upper back and chest should be scraped for KOH exam to rule out tinea versicolorHypopigmented patches on the central face with greasy scale are usually seborrheic dermatitisHypopigmented patches on the face of atopic children are usually pityriasis alba; reassure parents and encourage use of sunscreen and moisturizersPotent corticosteroids can cause hypopigmentation, so be aware of that when prescribing or injecting, and warn patients of this possible side effect when appropriate
55AcknowledgementsThis module was developed by the American Academy of Dermatology Medical Student Core Curriculum Workgroup fromPrimary author: Patrick McCleskey, MD, FAAD.Peer reviewers: Timothy G. Berger, MD, FAAD; Peter A. Lio, MD, FAAD; Jennifer Swearingen, MD; Sarah D. Cipriano, MD, MPH.Revisions: Patrick McCleskey, MD, FAAD.Last revised April 2011.
56ReferencesBerger T, Hong J, Saeed S, Colaco S, Tsang M, Kasper R. The Web- Based Illustrated Clinical Dermatology Glossary. MedEdPORTAL; Available from:Habif TP. Clinical Dermatology: a color guide to diagnosis and therapy, 4th ed. New York, NY: Mosby; 2004.Layton AM, Cunliffe WJ. Minocycline induced skin pigmentation in the treatment of acne—a review and personal observations. J Dermatol Treatment 1989;1:9-12.Lio PA. Little white spots: an approach to hypopigmented macules. Arch Dis Child Pract Ed 2008;93:Marks Jr JG, Miller JJ. Chapter 13. White Spots (chapter). Lookingbill and Marks’ Principles of Dermatology, 4th ed. Elsevier; 2006:Wolverton SE. Systemic drugs for infectious diseases (Chapter 5) and Topical Antifungal Agents (Chapter 29). Comprehensive Dermatologic Drug Therapy, 2nd ed. Elsevier; 2007: 80-99,