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Back to the Basics LMCC Preparation Dermatology

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1 Back to the Basics LMCC Preparation Dermatology
Jim Walker Assoc. Clinical Prof. Medicine Dermatology

2 Websites Ottawa U Dermatology Block Slides UBC Dermatology Undergraduate Problem Based Learning Modules Good Quiz site & Resource – Johns Hopkins Univ. eMedicine Textbook Medline University of Iowa Dept of Dermatology Dermatology Online Atlas * Please do not use images without attribution or permission!

3 Morphology Living gross pathology of skin, hair nails and visible mucosae Review basic lesions, the nouns (papules, ulcers etc.) Add the adjectives (size, shape, colour, texture, etc.) Consider distribution, symmetry and pattern Visual literacy: simple descriptions→complex interpretations (you see, but do you observe?) Excellent lighting Position patient Look all over (skin, mucosa, hair, nails) Observe and think

4 Dermatopathology Pathology – high degree of clinical pathological correlation Assess depth of lesion in skin



7 Bacterial Skin Disease
Barrier – dry, tough, acidic, Ig in sweat, epidermal turnover every 28 days Normal Flora: Gm+, yeasts, anaerobes, Gm-

8 Bacterial Skin Diseases
Impetigo Bullous and non-bullous Folliculitis/furuncle Erysipelas/cellulitis Necrotizing Fasciitis Toxin diseases: SSSS, Scarlet fever, toxic shocks Superantigen: Staph. aureus in atopic derm. Pseudomonas: warm, moist, alkaline

9 Impetigenization (bullous) of pre-existing dermatosis

10 Impetigenized Atopic (Non-bullous) Staph. > strep.

11 Erysipelas -Strep. pyogenes -Dermal infection
-Asymmetrical, sharp demarcation -Spreading -Septic patient Treatment Oral – amoxacillin 500 QID x days IV – if severe or recurrent, or co-morbidities

12 Cellulitis – haemorrhagic
-usually Strep. pyogenes -deep dermal and sub- cutaneous Treat – as for erysipelas, but cover for Staph.

13 Necrotizing Fasciitis
-Pain out of proportion to apparent lesion -Strep or multi-bacterial deep infection -Emergency debridement and multiple IV antibiotics

14 Meningococcal septicaemia
Petechiae Purpura Necrosis Treatment -blood cultures -immediate IV antibiotics -lumbar puncture -support for gram negative endotoxic shock

15 Meningococcal Disease
Septicemia vs meningitis % vs 10% mortality Peaks: infancy to 5 years - Second peak age 15 Infection and Endotoxin and DIC cause damage Rash subtle at first - Erythema→purpura →necrosis - Search for petechiae / purpura - “any febrile child with a petechial rash should be considered to have meningococcal septicemia, and treatment should be commenced without waiting for further confirmation.”

16 SSSS primary Staph. infection conjunctivitis

17 Staph. Scalded Skin Syndrome
SSSS – same child, back, sterile blisters -epidermolytic toxin mediated disease

18 31 yr. gay male admitted for biopsy of lymph node for expected lymphoma. Rash noted, dermatology consulted. Widespread papular eruption with adenopathy.

19 Soles of same patient. Your diagnosis?

20 Secondary syphilis -a systemic disease -order STS and treponemal tests
-LP? Treatment -Benzathine penicillin 2.4 million units IM -Herxheimer reaction -follow STS -report disease -contact tracing -check for other venereal diseases

21 Secondary syphilis Condylomata lata

22 Viral Skin Disease DNA – tend to proliferate on skin
RNA – tend to be erythemas/exanthems Exanthem – epidermal/skin Enanthem - mucosal

23 Definitions Exanthem(s) = Exanthema(ta), (Greek)
A bursting out (ex) in flowers (anthema) Any dermatosis that erupts or “flowers” quickly Only the erythemas are numbered Includes papular, vesicular, pustular eruptions

24 Classic Exanthems Erythemas of Childhood
1 Rubeola - Measles 2 Scarlet Fever 3 Rubella – German Measles 4 Kawasaki disease 5 Erythema Infectiosum 6 Roseola Infantum - Exanthem Subitum

25 Human Herpes Virus 1 HSV-1 2 HSV-2 3 VZV 4 EBV 5 CMV 6 Roseola 7 ?
7 ? 8 Kaposi’s Sarcoma

26 Measles – morbilliform erythema
Red measles = rubeola Koplick’s spots in oral mucosa, early

27 Rubella with post auricular nodes
(German measles)

28 Erythema infectiosum = Parvo virus B19 = slapped cheek syndrome

29 Erythema infectiosum Reticulate erythema on arms Treatment – supportive Systemic -arthritis in adults -hydrops fetalis -anaemia

30 Toxic erythema -viral -scarlet fever drug
acute collagen vascular disease

31 Herpes simplex, recurrent,
post pneumococcal pneumonia

32 HSV 2, genital

33 Herpes virus – Tzanck smear – multinucleated giant cells

34 Eczema herpeticum HSV in atopic dermatitis

35 Herpes zoster = recurrence of Varicella Zoster virus

36 Herpes virus, treatment
Acyclovir, famciclovir, valacyclovir Must treat early (72 hours) Front end load dose Shortens course and reduces severity Does not eliminate virus

37 MC in Atopic

38 Post herpetic Erythema Multiforme

39 Herald plaque - pityriasis rosea
annular, NOT fungus Cause unclear, probably infectious (HHV7)

40 Pityriasis rosea Diagnosis
-symmetrical discrete oval salmon-coloured papules and plaques, collarette scales Treatment -UVL -erythromycin 250 QID, early -hydrocortisone cream if itchy -lasts 6-12 weeks, no scars

41 Common (vulgar) warts

42 Plantar Wart -dermatoglyphics -micro-haemorrhage -lateral tenderness
-demarcation -dermatoglyphics -micro-haemorrhage -lateral tenderness

43 Mosaic plantar warts

44 (Plantar) Wart, Treatment Summary
Respect natural history First do no harm Cryotherapy Caustics: salicylic acid, lactic acid, cantharadine Other chemicals: imiquimod, fluorouracil Immunotherapy: DPCP Surgery: curette only, no desiccation, no excision No radiation


46 HIV – primary exanthem This rash not a problem. It’s the permissive effect of immune suppression that allows other infections and tumors to kill

47 Primary HIV Infection Lapins et al BJD 1996, 22 consecutive men
HIV Exposure Acute illness 11–28 days, Seroconvert in 2–3wks Fever 22, pharyngitis21, adenopathy21, Exanthem day 1-5 of illness Upper trunk and neck, discrete non-confluent red macules and maculopapules in 17 / 22 Enanthem of palatal erosions in 8 / 22

48 Fungal Skin Infections
Superficial and Deep Superficial Tinea plus location Tinea = dermatophyte Lives on keratin (non-viable) Tinea versicolour is misnomer = dimorphic yeast Hair and nail infections must be treated systemically (terbinafine, griseofulvin)

49 Tinea capitis – Trichophyton tonsurans

50 Id reaction from Tinea capitis

51 Lymphadenopathy with tinea capitis

52 Kerion – tinea capitis, not bacterial infection

53 Tinea pedis - interdigital

54 Tinea pedis – moccasin pattern

55 Tinea manuum – 1 hand, 2 feet

56 Tinea incognito – topical steroids

57 Tinea incognito from topical steroids

58 Tinea faciei

59 Onychomycosis = tinea unguium

60 Tinea – source of recurrent infection

61 Yeast infection

62 Tinea - Management Diagnosis Treatment Scrape KOH
Fungal culture – 3 weeks Treatment Topical – azoles: clotrimazole, ketoconazole cream BID x 2-3 weeks, terbinafine cream similar Oral – must use for hair and nails. Terbinafine 250 mg. OD for 4-12 weeks for adult

63 Deep fungal infections – invade viable tissue
N.A. Blastomycosis

64 Blastomycosis

65 Blastomycosis

66 Deep Fungal Infections Management
Diagnosis Tissue culture Skin biopsy with special stains Treatment Amphotericin B, IV -if multi-organ infection Itraconazole, po -if minimal disease in healthy patient

67 Break Time

68 Eczema A morphological diagnosis based on observations of the inflammatory pattern in the skin Eczema is not an etiologic diagnosis Eczema is a subgroup of dermatitis Etiology: exogenous vs endogenous Acute signs: erythema, edema, edematous papules, vesicles, erosions, crusting, secondary pyoderma Chronic signs: lichenification, scales, fissures, dyspigmentation Borders usually ill-defined

69 Atopic Dermatitis endogenous
To make a diagnosis of atopic dermatitis (Hanifin) - must have 3 or more major features: 1) pruritus 2) typical morphology and distribution flexural lichenification facial and extensor involvement in infants and children 3) chronic or relapsing dermatitis 4) personal family history of atopy Plus 3 or more minor features:

70 Endogenous - Pompholyx of Palms, sago vesicles, acute phase

71 Chronic palmar eczema, fissures and scale

72 Atopic dermatitis Anti-cubital lichenification Black skin

73 Atopic dermatitis – anticubital lichenification with impetigenization

74 Severe lichenification – ankles, chronic phase

75 Exogenous - allergic contact dermatitis, poison ivy, acute signs

76 Rhus radicans The rash The plant

77 Patch testing, to diagnose cause of allergic contact dermatitis

78 Impetigenized eczema – what is the cause?

79 Diagnosis = Scabies infant
Eczema caused by infestation

80 Scabies Burrows, sole

81 Scabies Burrows - finger

82 Scabetic nodules in infant

83 Scabetic nodules, adult scrotum

84 Eczema - Treatment Remove or treat the cause General measures Topical
Optimise the environment for healing Compress if moist, hydrate if dry Topical Corticosteroids: hydrocortisone, betamethasone, clobetasol BID max. frequency Ointments, creams, gels, lotions Systemic Prednisone: define endpoint, always warn of osteonecrosis Phototherapy

85 Scabies - treatment Permethrin 5% cream or lotion neck to toes overnight Treat all close contacts whether itchy or not Wash clothes and bed-sheets Set aside gloves for 10 days Nodules may persist few months May use topical steroid after mites dead

86 Psoriasis T-cell disease, Th1 inflammatory pattern Morphology
Symmetry (endogenous) Plaque: sharply demarcated plaque with coarse scale across whole lesion. Guttate: drop-like or papular variant of plaque psoriasis Pustular (sterile) and erythrodermic forms are more inflammatory and unstable Erythrodermic – involves > 90% skin

87 Erythemato-squamous Diseases differential diagnosis
Psoriasis Seborrheic dermatitis Pityriasis versicolour Pityriasis rosea Dermatophyte Parapsoriasis and Mycosis fungoides Pityriasis rubra pilaris Secondary Syphilis Chronic Dermatitis

88 Psoriasis plaques – symmetry, sharp demarcation, coarse scale across lesion

89 psoriasis normal skin

90 Psoriasis – trunk partially treated

91 Psoriasis – annular not ringworm

92 Psoriasis – guttate (drop-like or papular)

93 Guttate Psoriasis

94 Psoriasis on black skin

95 Psoriasis - flexural

96 Psoriasis - scalp

97 Psoriasis – toes and nails, NOT fungus, culture if in doubt

98 Psoriasis – palms – pustular (sterile)

99 Pustular Psoriasis – widespread, unstable patient and disease

100 Pustular psoriasis

101 Psoriasis -Treatment Consider exacerbating factors: stress, drugs, infection Consider stability of disease (pustular and erythrodermic) Koebner = isomorphic phenomenon Three Pillars of therapy Topical – creams, ointments, lotions, baths Scalp, extensors, flexures Steroids Calcipotriene Salicylic acid Tar Systemic –Pills and Injections Methotrexate, Acitretin, Cyclosporin, Biologicals Ultraviolet Radiation UVB –broad and narrow band, UVA, PUVA

102 Acne Etiology: heredity, hormones, drugs, ?diet
Sebum – encourages growth of P. acnes Propionibacterium acnes – inflammation, initiates comedones Morphology “Noninflammatory” – comedones, open and closed Inflammatory – papule, pustule, nodule, abscess (“cyst”), scars...ulcers Microcomedo is probably the primary lesion

103 Androgens Sebum Comedogenesis Proprionibacterium acnes Diet Psychological Topicals Antibiotics Anti-androgens Isotretinoin Physical Exacerbating factors Rosacea Perioral dermatitis

104 Acne – lesion morphology

105 Acne – scarring Isotretinoin use -teratogen, not mutagen
-depression real but rare -1 mg/kg/day x months -beta-HCG, lipids, ALT -double contraception -record discussion

106 Acne abscess vs. cyst

107 Acne scars – pits and box-cars

108 Acne – severe Treatment -erythromycin -prednisone
-isotretinoin – low dose and increase slowly

109 Ulcerative acne

110 Acne - Treatment Psychological impact
General measures: avoid picking, not due to poor hygeine Mechanical –rubbing clothes and equipment Chemical – oils, chlorinated hydrocarbons Diet - glycemic index?, milk? Drugs that flare acne Lithium, anabolic steroids, catabolic steroids, dilantin, halogens, EGFRI’s Topicals Benzoyl peroxide 5% aq. gel, once daily, (bleach) Retinoids – comedonal acne, tretinoin cream or gel nightly, adapalene, tazarotene are 2nd generation retinoids Antibiotics – consider issue of resistance Oral Antibiotics: Tetra 500 BID, minocycline, erythromycin, clindamycin, trimethoprim – X 3 months Hormones in females Isotretinoin – (Accutane, Clarus) – only disease remitting agent

111 Hidradenitis suppurativa - axilla

112 Perioral dermatitis

113 Perioral Dermatitis Treatment
Don’t be fooled by name, it’s acne not eczema Stop topical steroids Metronidazole 1% topical cream or gel, or topical antibiotic (erythro, clinda) Tetracycline 500 bid x 6-8 weeks Sun protection Reduce flare factors – fluoride in toothpaste

114 Rosacea – rhinophyma, papules and pustule

115 Rosacea Diagnosis Erythema and telangectasias Papulopustular
Sebaceous hyperplastic Symmetrical – usually Central facial Ill-defined No significant scale Treatment -sun protect -reduce flare factors -stop topical steroids -Metronidazole cr. 1% nightly -Tetracycline 500 BID -surgery for rhinophyma -laser or IPL for telangectasia

116 Pruritus Itchy dermatoses
eczematous dermatitis scabies and insect bites urticaria dermatitis herpetiformis lichen planus bullous pemphigoid psoriasis – sometimes

117 Systemic causes of Pruritus “itch without rash”
chronic renal failure cholestasis Polycythemia pregnancy thyroid dysfunction malignancy - Hodgkins H.I.V. ovarian hormones separate itch nerves. ,unmyelinated slow C fibres

118 Mediators of Pruritus Histamine (H)-(from mast cell via various receptors)- itch mediated at H1 receptor substance P, tryptase opioid peptides-central or peripheral cytokines-IL-2,IF…. Prostaglandin E, serotonin

119 Drug reactions Acute onset Cephalo-caudal spread
Antibiotics, anticonvulsants, NSAID’s Accurate history critical – graph drugs vs date Treatment stop offending drugs supportive care

120 Toxic Epidermal Necrolysis – Chinese herbal medication


122 Skin Cancer BCCa, SCCa, Melanoma include over 98% of skin cancers you will see Sunlight, UVB>UVA is major carcinogen

123 Cystic BCCa - Forehead

124 Basal Cell Carcinoma - Eyelid

125 Neglected BCCa - forehead


127 Superficial Multicentric BCCa
Red plaque, sharp demarcation, irregular border

128 Keratoacanthoma pattern SCCa – sun damaged neck


130 Atypical Mole Rule out melanoma Biopsy -excise, conservative -incise
-shave -excise, conservative -incise -punch

131 Melanoma – back, superficial spreading
Melanoma-Canada 2008 (estimated) -4600 cases -910 deaths Asymmetry Border Colour Diameter Evolution Melanoma – back, superficial spreading

132 Melanoma - Prognosis Depth of invasion = Breslow thickness
Most important for stage 1-2 melanoma Measured from granular layer of epidermis to deepest malignant cell, with ocular micrometer Regional Lymph-node Mets – stage 3 Distant Mets – stage 4

133 Melanoma – sole, amelanotic

134 Melanoma – Thumb, acral lentigenous

135 Cutaneous T-Cell Lymphoma = Mycosis Fungoides

136 Skin Cancer – Risk Factors
Ultraviolet radiation UVB – nm UVA – 320 – 400 nm Other Controllable Ionizing radiation Arsenic Tobacco Tar HPV Immune-suppression (permissive) HIV, Drugs


138 Skin Cancer - Treatment
Biopsy if in doubt match method to depth (shave, punch, incision, excision) Curettage (BCCa, SCCa small, not Melanoma) may precede with shave excision electrodesiccation Surgical Excision Closure: fusiform, flap, graft Margin Control Ill-defined, critical real-estate, recurrent, aggressive Mohs’, frozen section Radiotherapy Other: chemotherapy (imiquimod), PDT

139 Mohs’ micrographic surgery


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