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Rashes/Dermatology Jackie Weaver-Agostoni, DO, MPH UPMC Shadyside
Director, Osteopathic Family Medicine Residency 3/5/16
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Pre-Test #1
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Pre-Test #2
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Pre-Test #3
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Pre-Test #4
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Pre-Test #5
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Pre-Test #6
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Pre-Test #7
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History Length of symptoms Initial appearance and location
Changes/Spread Treatments tried and response Associated symptoms Sick contacts History of similar symptoms and treatment New exposures
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History PMHx Medications Family history
Social history- occupation, hobbies
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Lesion Morphology Macule – nonpalpable
Ex: vitiligo, cafe au lait, petechiae
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Lesion Morphology Papule – palpable, </= 5 mm
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Lesion Morphology Plaques - Large >/= 5 mm superficial flat lesions
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Lesion Morphology Pustules – small purulent-filled papules
Vesicles – small < 5 mm papules containing serous material Bullae – large >/=6 mm vesicles
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Lesion Morphology Nodules – palpable, discrete lesions >/= 6 mm
Tumors = large nodules
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Lesion Morphology Cysts – enclosed lined cavities filled with liquid/semisolid material Telangiectasia – dilated superficial blood vessel Wheals - hives
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Diagnostic Techniques
KOH Prep Fungal Tzanck smear HSV VZV Wood’s Lamp Tinea Erythrasma Vitiligo Melasma Porphyria
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Melanoma Risk factors Prognosis Moles: Atypical, total # > 50
Red hair and freckling Severe sunburn, especially in childhood First degree relative Prognosis Breslow’s classification (tumor thickness) and lymph node spread No staging workup needed if lesion < 1 mm thickness as low risk
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Irritant Contact Dermatitis
Xerosis, fissures, erythema, eczematous eruption Change frequently Increase air exposure Protective ointment Petroleum Jelly A and D ointment Desitin
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Diaper Candidiasis Satellite lesions
Antifungal creams, frequent diaper changes Usually lasts about 10 days
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Rhus Dermatitis Lasts 1-2 weeks Linear Lesions
Blister fluid can NOT spread the inflammation Remove source, wet dressings (Burow’s solution), Class I topical glucocorticoid if non-bullous Blisters may require oral Prednisone (1-2 week taper). Do NOT remove the tops.
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Miliaria Crystallina Miliaria- “Heat rash”
Eccrine sweat duct occlusion Vesicles filled with clear fluid Asymptomatic Cool water compress and proper ventilation
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Pityriasis Rosea Benign and self-limiting
Herald patch- trunk or proximal extremities Christmas–tree distribution Reach their maximum number in 1-2 wks. Clears in 1-3 months More papular/vesicular in kids
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Molluscum Contagiosum
Virus Umbilicated, flesh-colored, dome-shaped papules Autoinnoculation, scratching, touching Most self-limited in 6-9 months Curettage, cryosurgery, tretinoin (not very effective), salicylic acid, cantharidin Physical expression of lesion rather than tx with phenol worked just as well with less scarring
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Primary Herpes Simplex
HSV-1 Kids- typically start around or in mouth Respiratory droplets, direct contact with active lesion, virus-containing fluid (saliva) Primary infection with more lesions than recurrence Uniform in size vs. herpes zoster Lasts 2-6 wks Acyclovir (Zovirax)
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Erythema Multiforme Acute, immune-mediated Target-like lesions
Can have mucosal disease (erosions, bullae) Virus typical cause (HSV, mycoplasma pneumonia in kids) Medications, autoimmune dz, malignancy Usually self-limited over couple weeks Young adults Symmetrical, extensor surfaces, centripetal spread
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Stevens-Johnson Syndrome
Commonly triggered by medications Allopurinol, antibiotics, antipsychotics and anti-epileptics, analgesics and NSAIDs Fever and mucocutaneous reaction followed by necrosis and sloughing of epidermis Starts as erythematous or purpuric macules and placques < 10% body surface (vs. Toxic Epidermal Necrolysis)
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Varicella Chicken Pox Contagious 2 days before rash, and until all lesions crust Trunk face and extremities All phases present “Dew drop on a rose petal” March-May Complications: secondary infection, encephalitis, Reye’s syndrome, pneumonia Symptomatic tx, antivirals (Acyclovir approved)- within 24 hrs Immunization- 80% effective
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Measles Rubeola Droplets Cough, coryza, conjunctivitis
Koplik’s spots- blue-white spots with red halo on buccal mucosa Downward spread Morbilliform (confluent elevated maculopapules)
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Hand-Foot-and-Mouth Disease
Coxsakievirus A16 Oral-oral and fecal-oral routes Warmer months “Linear” vesicles on palms and soles Self-limited 7-10 days Symptomatic treatment 1st trimester may cause spontaneous abortion
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Scarlet Fever Strep pyogenes Downward spread
Circumoral pallor, pinpoint papules, sandpaper Pastia’s sign- linear petechiae in skin folds Desquamation of palms and soles Beau’s lines- transverse grooves on all nails several wks after rash gone PO abx- PCN, e-mycin
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Rubella German measles, 3-day measles Respiratory spread
1st trimester congenital rubella synd. Cataracts, deafness, heart defects, bone damage, neurologic issues including mental retardation Immunization- do not get pregnant for at least 1 month following Downward spread Pinkish or rosy-red macules or maculopapules No treatment required- rash fades in 1-2 days
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Erythema Infectiosum Parvovirus B19 Fifth disease “Slapped cheek”
Lacy eruption on trunk and extremities 2-day prodrome Respiratory spread Symptomatic treatment Rash lasts approx 10 days Risk to pregnant women- fetal death
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Roseola Infantum Exanthem subitum, sixth disease HHV-6 6 mo.- 4y/o
High fever ( degrees) rash Pale-pink, almond shaped, macules Symptomatic tx.
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Kawasaki Syndrome Mucocutaneous lymph node syndrome
Multisystem vasculitis Fever plus at least 4: bilateral conjunctivitis, red lips/pharynx/”strawberry tongue”, erythema palms or soles, edema of hands or feet, desquamation, rash (erythematous exanthem), cervical lymphadenopathy Cardiovascular sequelae Tx: ASA, Gamma globulin
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Rocky Mountain Spotted Fever
Palms and Soles Tick-borne disease Rickettsia rickettsii Southeastern and south central states Spring and early summer Rash typically between 3rd and 5th day Early treatment
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Meningococcemia Petechial Rash- discrete 1-2 mm lesions can coalesce into larger purpuric/ecchymotic lesions Trunk and lower body Mucus membranes- hemorrhage
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Scabies Direct contact
Nocturnal itching Burrows, vesicles or pustules on palms/soles- highly characteristic in infants More widespread in kids- face and scalp involvement (vs adults) Permethrin, Lindane (?safety re: neurotoxicity, Ivermectin, sulfur (?safe), Crotamiton (60% cure vs 89% with permethrin) Launder contaminated items
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Lupus Butterfly Rash- spares nasolabial fold
After sun exposure Can precede systemic symptoms Discoid lesions more inflammatory- scar If DLE alone, rarely anti-Ro ab and normal or low titer ANA Tx: Topical glucocorticoids, antimalatial drugs
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Psoriasis Etiology- genetic, other (smoking, obesity, etc)
Arthritis, nail involvement Tx: Topical, Phototherapy, Systemic
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Henoch-Schonlein Purpura
2-10 y/o Palpable purpura of legs and buttocks, abdominal pain, GI bleed, arthralgia, hematuria Widespread vasculitis Prognosis based on renal involvement Usually benign and self-limited IgA deposition on biopsy Corticosteroids/dapsone
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Tinea
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Erythema migrans
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Secondary Syphilis
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References Habif, Thomas P. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. Mosby. Dermatology (Chapter 8) in Zitelli, Basil J. and Holly W. Davis. Atlas of Pediatric Physical Diagnosis, 4th edition, Philadelphia: Mosby Inc., Pp ONLINE Sites Ely JW, Stone MS. The Generalized Rash: Part I and Part II. Differential Diagnosis. AFP, March 2010. Free dermatology photo atlas for your PDA
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