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Dermatologic Board Review Lane Bower, MHSc, PA-C.

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Presentation on theme: "Dermatologic Board Review Lane Bower, MHSc, PA-C."— Presentation transcript:

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2 Dermatologic Board Review Lane Bower, MHSc, PA-C

3 Which is the SK?

4 Seborreic Keratosis Most common benign cutaneous neoplasm Most common benign cutaneous neoplasm Origin unknown Origin unknown No malignant potential No malignant potential Easily and quickly removed Easily and quickly removed Vary in size shape, most oval Vary in size shape, most oval Most common on torso, lesser degree on face Most common on torso, lesser degree on face Increasing numbers with age Increasing numbers with age Leser Tre’lat Sign Leser Tre’lat Sign

5 Nevus A benign, pigmented lesion that is not caused by any outside catalyst. A benign, pigmented lesion that is not caused by any outside catalyst. There are many types of nevi; junctional, compound, dermal. Refer to text There are many types of nevi; junctional, compound, dermal. Refer to text Main job is differentiating from dysplastic nevi which have malignant potential Main job is differentiating from dysplastic nevi which have malignant potential

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7 What to do? When in doubt, remove it and send it to pathology. When in doubt, remove it and send it to pathology. Do a conservative full excision Do a conservative full excision If it just doesn’t look right, remove it If it just doesn’t look right, remove it That’s the thing with dysplastic nevi, if you can’t make up your mind as to whether it is benign or a possible melanoma, it is probably the middle ground of dyplastic That’s the thing with dysplastic nevi, if you can’t make up your mind as to whether it is benign or a possible melanoma, it is probably the middle ground of dyplastic

8 Actinic Keratosis Common, sun induced, pre-malignant, changes that increase with age Common, sun induced, pre-malignant, changes that increase with age Most common sites are forehead, shoulders, back, and dorsum of arms Most common sites are forehead, shoulders, back, and dorsum of arms Start as an erythematous, rough, area, that forms a yellow crust. Start as an erythematous, rough, area, that forms a yellow crust. They are usually very symmetrical in distribution. They are usually very symmetrical in distribution.

9 ……actinic keratosis Basal cell and other skin cancers can develop in these transitional type lesions.

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11 Treatment of AK 5-FU get incorporated in to rapidly reproducing cells and causes cell death 5-FU get incorporated in to rapidly reproducing cells and causes cell death Retin-A has been helpful Retin-A has been helpful Cryotherapy for early lesions is effective Cryotherapy for early lesions is effective Laser is excellent! Laser is excellent! Avoidance of further sun damage is paramount Avoidance of further sun damage is paramount Explain the Course using 5-FU Explain the Course using 5-FU

12 Who’s the Mole?

13 Zosteriform Lesions arranged along the cutaneous distribution of a spinal dermatome Lesions arranged along the cutaneous distribution of a spinal dermatome They are unilateral and denote They are unilateral and denote herpes zoster herpes zoster metastatic carcinoma of the breast metastatic carcinoma of the breast dermatomal hemangiomatous growths of Sturge- Weber syndrome dermatomal hemangiomatous growths of Sturge- Weber syndrome

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15 Impetigo Level of Infection Level of Infection Epidermal superficial infection Epidermal superficial infection Port of Entry Port of Entry Cuts, abrasions, bug bite Cuts, abrasions, bug bite Likes moist areas (mouth, nose) and hot moist climates Likes moist areas (mouth, nose) and hot moist climates Susceptibility Susceptibility Common in infants & children Common in infants & children VERY Contagious! VERY Contagious!

16 Impetigo Symptoms Symptoms Itch Itch Signs (Appearance) Signs (Appearance) Vesicular Vesicular Toxins cause epidermal cleavaging of stratum corneum Toxins cause epidermal cleavaging of stratum corneum Some strains Strep. aureus cause thin-roofed bulla Some 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)

17 Impetigo Causative Agents Causative Agents Staphylococcus aureus (most usual) Staphylococcus aureus (most usual) ? 2wk incubation ? 2wk incubation Streptococcus pyrogenes (occ. alone OR together) Streptococcus pyrogenes (occ. alone OR together)

18 Impetigo Course of Disease Course of Disease Self-limiting !! Self-limiting !! But… But… may last weeks or months may last weeks or months Post streptococcal glomerulonephritis may follow! Esp yo. Hematuria/proteinuria. Post streptococcal glomerulonephritis may follow! Esp yo. Hematuria/proteinuria. Osteomyelitis, septic arthritis & pneumonia from otherwise seemingly innocuous impetigo Osteomyelitis, septic arthritis & pneumonia from otherwise seemingly innocuous impetigo

19 Impetigo Treatment (cover both Staph & Strep) Treatment (cover both Staph & Strep) All All 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/day Wash entire body to prevent spread 1- 2/day Non Bullous Dicloxicillin mg Qid X5-10 days Cloxicillin mg Q6h X 5-10 days Bactroban apply TID X 5-10 days Azithromycin 500mg QD for 1 day then 250 mg X 4days Erythromycin mg TID X 5-10 days 2 nd Generation Cephalosporin BactrobanBullous Dicloxicillin mg Qid X5-10 days Keflex mg QID X 10 days Azithromycin 500mg QD for 1 day then 250 mg X 4days Augmentin 875/125 mg BID x 10 days or 500/125 mg TID X 10 days

20 Erysipelas & Cellulitis Level of Infection Level of Infection Erysipelas  epidermis & dermis (defined border). Erysipelas  epidermis & dermis (defined border). Acute inflammatory version of Cellulitis with streaking. Acute inflammatory version of Cellulitis with streaking. Cellulitis  dermis & subcutaneous tissue (diffuse) Cellulitis  dermis & subcutaneous tissue (diffuse) Symptoms Symptoms Area is red, hot, swollen, tender, edema, ?malaise Area is red, hot, swollen, tender, edema, ?malaise perhaps vesicles, bullae, petechiae/purpura perhaps vesicles, bullae, petechiae/purpura Perhaps spread to lymphatics, “red streaks” Perhaps spread to lymphatics, “red streaks” lymph nodes may be swollen and tender lymph nodes may be swollen and tender chills and fever may be present chills and fever may be present

21 Erysipelas & Cellulitis A portals of entry A portals of entry Open lesion, trauma, surgical wound, athletes foot, IV drug use, insect bite, fissure Open lesion, trauma, surgical wound, athletes foot, IV drug use, insect bite, fissure Radiation therapy Radiation therapy Arms usually in young adults Legs usually in children and older adults Arms usually in young adults Legs usually in children and older adults Puerperal sepsis common form before antibiotics Puerperal sepsis common form before antibiotics Peripheral vascular disease is a common underlying factor Peripheral vascular disease is a common underlying factor

22 Erysipelas & Cellulitis Diagnosis Diagnosis Largely Clinical: Largely Clinical: typical presentation and appearance typical presentation and appearance Labs Labs CBC CBC gram stain and culture wounds poor yield gram stain and culture wounds poor yield needle aspiration (5% yield), biopsy (20% yield), blood cultures (5% yield) needle aspiration (5% yield), biopsy (20% yield), blood cultures (5% yield) Films (?) Films (?) Plain / CT / MRI: underlying fasciitis or osteomyelitis Plain / CT / MRI: underlying fasciitis or osteomyelitis Referrals: (?) Ortho if over joint Referrals: (?) Ortho if over joint

23 Erysipelas & Cellulitis Differential Diagnosis Differential Diagnosis Necrotizing Fasciitis: deeper and much more virulent. Consider if patient doesn’t respond to antibiotics within 48 hours. Necrotizing Fasciitis: deeper and much more virulent. Consider if patient doesn’t respond to antibiotics within 48 hours. Deep vein thrombosis Deep vein thrombosis Course Course Antibiotics Antibiotics possible abscess (I&D), sepsis, fasciitis (rare) possible abscess (I&D), sepsis, fasciitis (rare) Erysipelas  Endocarditis Erysipelas  Endocarditis Recurrent cellulitis  persistent lymphedema Recurrent cellulitis  persistent lymphedema

24 Erysipelas & Cellulitis Differential Diagnosis Differential Diagnosis Necrotizing Fasciitis: deeper and much more virulent. Consider if patient doesn’t respond to antibiotics within 48 hours. Necrotizing Fasciitis: deeper and much more virulent. Consider if patient doesn’t respond to antibiotics within 48 hours. Deep vein thrombosis Deep vein thrombosis Course Course Antibiotics Antibiotics possible abscess (I&D), sepsis, fasciitis (rare) possible abscess (I&D), sepsis, fasciitis (rare) Erysipelas  Endocarditis Erysipelas  Endocarditis Recurrent cellulitis  persistent lymphedema Recurrent cellulitis  persistent lymphedema

25 Erysipelas & Cellulitis Inpatient Inpatient IV methacillinase-resistant penicillin (nafcillin) or cephazolin IV methacillinase-resistant penicillin (nafcillin) or cephazolin Consider pseudomonas in immunocompromised patients--ticarcillin, piperacillin Consider pseudomonas in immunocompromised patients--ticarcillin, piperacillin Others: Elevate limbs, treat sources Warning: May get worse first day or two of tx. Draw on pt.

26 Cellulitis Pitfalls Necrosis Necrosis Devitalized tissue (tense, cyanotic, necrotic, bronzing of the skin, blanched) will not be perfused, so antibiotics will not get to the site. Devitalized tissue (tense, cyanotic, necrotic, bronzing of the skin, blanched) will not be perfused, so antibiotics will not get to the site. If not improvement on ABX, consider devitalized tissue & surgical debridement If not improvement on ABX, consider devitalized tissue & surgical debridement

27 Cellulitis Pitfalls (cont.) Facial Cellulitis in adults Facial Cellulitis in adults H. Flu in adult is rare and may be toxic with airway compromise. (usually >50yo) Admit & tx (cefuroxime IV) H. Flu in adult is rare and may be toxic with airway compromise. (usually >50yo) Admit & tx (cefuroxime IV) Facial Cellulitis in children Facial Cellulitis in children Potentially serious !!!! Potentially serious !!!! If no obvious entry for, probably H. Flu If no obvious entry for, probably H. Flu ? Meningitis (8% infants) ?tap. ? Meningitis (8% infants) ?tap.

28 Cellulitis Pitfalls (cont.) Cellulitis around the eye Cellulitis around the eye Dangerous !!! Dangerous !!! Orbital vs. Peri-orbital cellulitis Orbital vs. Peri-orbital cellulitis Periorbital (more common) Periorbital (more common) Limited to eyelids in the preseptal region Limited to eyelids in the preseptal region Treat aggressively with IV abx Treat aggressively with IV abx Orbital is EMERGENCY Orbital is EMERGENCY Infection spreads both by extension and retrograde Infection spreads both by extension and retrograde H. Flu usual H. Flu usual IV abx, admit, ? CT (globe displacement) IV abx, admit, ? CT (globe displacement)

29 Cellulitis Pitfalls (cont.) Necrotizing Fasciitis Necrotizing Fasciitis Dangerous !!! Dangerous !!! S. pyrogenes or others S. pyrogenes or others Sx: painful, edema, necrosis, widespread Sx: painful, edema, necrosis, widespread Occlusion of small blood vessels to gangrene (growth of anaerobes - eg Bacteroides). Occlusion of small blood vessels to gangrene (growth of anaerobes - eg Bacteroides). Risk factor: DM Risk factor: DM Dx: x-rays show gas Dx: x-rays show gas Mortality 30% ! Surgical treatment Mortality 30% ! Surgical treatment

30 Upper lid avulsion

31 Animal Bites Cats- Pasteurella multocida, S. aureus Cats- Pasteurella multocida, S. aureus Primary Antibiotic Augmentin 875mg BID x 10 days Primary Antibiotic Augmentin 875mg BID x 10 days Alternative- Cefuroxime 500 mg TID x 7dyas Alternative- 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!!!!!!

32 Animal Bites Dogs- Pasteurella mutlicoda,S. aureus Dogs- Pasteurella mutlicoda,S. aureus Primary- Augmentin 875 mg BID Primary- Augmentin 875 mg BID Alternative- Clindamycin 300 mg QID plus a flouroquinolone Alternative- Clindamycin 300 mg QID plus a flouroquinolone ONLY 5% become infected.

33 Tinea of the Foot Uncommon in women! Uncommon in women! Uncommon in prepubertal children Uncommon in prepubertal children Inevitable in immunocompromised patients Inevitable in immunocompromised patients Acquired from locker-room floors and communal baths Acquired from locker-room floors and communal baths Once infected, patient becomes a carrier and is at risk for recurrence Once infected, patient becomes a carrier and is at risk for recurrence Tight fitting shoes and work-boots Tight fitting shoes and work-boots

34 Tinea Pedis

35 Treatment Promote dryness Promote 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 moisture Shoes that “breathe” and socks that wick away moisture Lamb’s wool between the toes Lamb’s wool between the toes Treat secondary infection!!!!! (staph & pseudomonas) Treat secondary infection!!!!! (staph & pseudomonas)

36 Special Treatment Considerations Tinea Capitis is not responsive to topical agents. You must use an oral drug such as Giseofulvin 500 mg. po qd. Tinea Capitis is not responsive to topical agents. You must use an oral drug such as Giseofulvin 500 mg. po qd. Pediatric dosing: mg/kg po qd X 4 – 6 weeks. Max 1 g/d. Absorption is better with a fatty meal. Pediatric dosing: mg/kg po qd X 4 – 6 weeks. Max 1 g/d. Absorption is better with a fatty meal.

37 Tinea Cruris Warm, moist, dark, environment most conducive to growth Warm, moist, dark, environment most conducive to growth If any dermatitis is treated with topical steroids, it will initially look better and lead to what is called, “tinea incognito”

38 How Do We Know?

39 Melanoma A. One-half of the mole does not match the other half (i.e. it is asymmetric) A. One-half of the mole does not match the other half (i.e. it is asymmetric) B. The edge (border) of the mole is jagged or irregular B. The edge (border) of the mole is jagged or irregular C. More than one color is present in a mole C. More than one color is present in a mole D. It is larger than 5mm in diameter (the size of a pencil eraser D. It is larger than 5mm in diameter (the size of a pencil eraser

40 How Can I Determine My Personal Risk? It is estimated that 1 out of 7 people in the United States will develop some form of this cancer during their lifetime. One serious sunburn can increase the risk by as much as 50%. It is estimated that 1 out of 7 people in the United States will develop some form of this cancer during their lifetime. One serious sunburn can increase the risk by as much as 50%. These early studies are coming into question. Risk determination is complex These early studies are coming into question. Risk determination is complex

41 Pathologic Staging Depth of invasion offers the greatest prognostic value in determining survival Depth of invasion offers the greatest prognostic value in determining survival Depth of invasion determines need for therapy up and above surgical excision Depth of invasion determines need for therapy up and above surgical excision

42 Treatment Wide excision Wide excision Regional lymph node dissection for higher stage disease Regional lymph node dissection for higher stage disease Chemotherapy for higher stage disease Chemotherapy for higher stage disease

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44 Psoriasis Extensor surfaces most common Extensor surfaces most common Palms and soles not commonly involved but can be. R/O Reiter Syndrome Palms and soles not commonly involved but can be. R/O Reiter Syndrome Localized plaques may be confused with eczema or seborrheic dermatitis Localized plaques may be confused with eczema or seborrheic dermatitis Guttate form may be confused with secondary syphilis or pityriasis rosea Guttate form may be confused with secondary syphilis or pityriasis rosea

45 Principles of Treatment Control stress Control stress Stress reduction techniques are effective in controlling flares in certain patients Stress reduction techniques are effective in controlling flares in certain patients Determine end of treatment Determine end of treatment Patients perceive discoloration after clearing plaques as continued disease Patients perceive discoloration after clearing plaques as continued disease

46 Principles of Treatment Calcipotriol (Dovonex) Calcipotriol (Dovonex) Discovered in 1985 by chance-Women taking Vitamin D for osteoporosis noted marked improvement in psoriasis Discovered in 1985 by chance-Women taking Vitamin D for osteoporosis noted marked improvement in psoriasis Vitamin D3 analogue Vitamin D3 analogue Inhibits cell proliferation and induces terminal differentiation Inhibits cell proliferation and induces terminal differentiation Inhibits epidermal cell proliferation Inhibits epidermal cell proliferation Safe and effective Safe and effective Applied BID in amounts up to 100 grams per week Applied BID in amounts up to 100 grams per week Rx for 6-8 weeks gives 60% improvement Rx for 6-8 weeks gives 60% improvement Does not effect ca++ or bone metabolism Does not effect ca++ or bone metabolism

47 Principles of Treatment Topical steroids Topical steroids Control itching Control itching Results very gratifying early Results very gratifying early Tachyphylaxis occurs Tachyphylaxis occurs Skin atrophy and tangelectasias limit extensive use Skin atrophy and tangelectasias limit extensive use Useful for treating intertriginous plaques and inflamed areas Useful for treating intertriginous plaques and inflamed areas Plastic occlusion potentiates Plastic occlusion potentiates Diprolene, Temovate Diprolene, Temovate

48 Principles of Treatment Intralesional steroids Intralesional steroids Kenalog 5-10 mg.Ml (atrophy with 10 mg strength) Kenalog 5-10 mg.Ml (atrophy with 10 mg strength) Anthralin (Anthra-Derm) Anthralin (Anthra-Derm) Used only for chronic plaques Used only for chronic plaques Messy stains long treatment times Messy stains long treatment times Best used in combination with UVB Best used in combination with UVB

49 Principles of Treatment PUVA PUVA Psoralens and UVA radiation in combination Psoralens and UVA radiation in combination Methotrexate Methotrexate Cyclosporine Cyclosporine Retinoids Retinoids Etretinate (Tegison) Etretinate (Tegison) Hydrea Hydrea

50 Psoralin UVA Treatment

51 UVB Treatment – Before and After

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

53 Contact Dermatitis Rhus dermatitis – (allergic) Rhus dermatitis – (allergic) poison ivy, poison oak and poison sumac account for more cases of allergic contact dermatitis than all other contactants combined poison ivy, poison oak and poison sumac account for more cases of allergic contact dermatitis than all other contactants combined Occurs from contact with the leaf,or internal parts of the stem or roots Occurs from contact with the leaf,or internal parts of the stem or roots Occurs from direct contact with the oleo resin Occurs from direct contact with the oleo resin Can not be spread via the blister fluid of current lesions Can not be spread via the blister fluid of current lesions

54 Contact Dermatitis Metal dermatitis Metal dermatitis Nickel is the most common contact allergen Nickel is the most common contact allergen Women >men Women >men Jewelry most often the source Jewelry most often the source

55 Contact Dermatitis Diagnosis – Diagnosis – History – persistent questioning may eventually uncover the offending antigen History – persistent questioning may eventually uncover the offending antigen Date of onset Date of onset Relationship to work Relationship to work Skin care products Skin care products Jewelry Jewelry Physical exam Physical exam Distribution Distribution Types of lesions Types of lesions Distribution Distribution Patch testing – indicated in cases in which inflammation persists despite avoidance and appropriate topical therapy Patch testing – indicated in cases in which inflammation persists despite avoidance and appropriate topical therapy

56 Contact Dermatitis Fundamental principals of dermatological therapy : Avoid the offending agent Wet lesions dried Dry lesions hydrated Inflammation treated with corticosteroids

57 Contact Dermatitis Contact Dermatitis Treatment – Treatment – the aim of treatment is to decrease erythema, pruritis and edema the aim of treatment is to decrease erythema, pruritis and edema Prevent secondary infection – keep clean Prevent secondary infection – keep clean Remove/avoid causative agents Remove/avoid causative agents Topical steroids Topical steroids Oozing lesions should be dried with Burrow’s solution compresses 3 to 4 times daily Oozing lesions should be dried with Burrow’s solution compresses 3 to 4 times daily Oral prednisone may be necessary for severe cases (tapering dose) Oral prednisone may be necessary for severe cases (tapering dose)

58 Contact Dermatitis Topical corticosteroid precautions Topical corticosteroid precautions Wide variation in potency Wide variation in potency Vehicle affects potency Vehicle affects potency Ointments more potent than creams Ointments more potent than creams Occlusive dressing increases potency (do not use ointments – folliculitis) Occlusive dressing increases potency (do not use ointments – folliculitis) Adverse effects – Adverse effects – Atrophy Atrophy Telangiectasia /tlan'je-ekta'zh/, permanent widening of groups of superficial capillaries and small vessels (venules). Common causes are damage due to excess sunlight, some skin diseases, as rosacea, too-high levels of female hormone, and collagen blood vessel diseases. Telangiectasia /tlan'je-ekta'zh/, permanent widening of groups of superficial capillaries and small vessels (venules). Common causes are damage due to excess sunlight, some skin diseases, as rosacea, too-high levels of female hormone, and collagen blood vessel diseases.

59 THE END


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