1. Common Skin problems Family Medicine Specialist CME October 15-17, 2012 Pakse

2. Objectives Identify common skin diseases based on the pattern of the rash Describe strategies to prevent and treat common skin diseases

3. Pre-Test 1 What disease causes this scaly rash on extensor surfaces (such as elbows and knees)? a. Psoriasis b. Eczema c. Fungal infection d. Skin cancer

4. Pre-test 2 What is the diagnosis? a. Chickenpox (varicella) b. Yeast infection c. Superficial bacterial infection (impetigo) d. Scabies

5. Pre-test 3 This very itchy skin condition, which affects flexor surfaces (such as in front of the elbows and behind the knees) can occur in adults but more often occurs young children a. Psoriasis b. Eczema c. Fungal infection d. Bacterial infection

6. Case 1 A 4 year old female presents with a 2 day history of this facial rash: What is the diagnosis? What are the most common bacteria that causes this condition? How would you treat this?

7. Impetigo Contagious superficial bacterial infection Most common in children 2 types ▫Primary: Infection occurs on normal skin ▫Secondary: Infection occurs on areas of skin where there has been mild trauma or a break (such as from scratching, abrasion, insect bite, eczema) Most caused by Staphylococcus aureus

8. Impetigo: Diagnosis Clinical diagnosis: no tests needed! Characteristics of the rash: ▫Start as papules (non fluid filled) ▫Progress to fluid filled vesicles with surrounding erythema ▫These turn into pus filled lesions called pustules ▫Pustules break and the fluid forms a yellow or golden crust ▫The changes occur over 1 week ▫Occurs mostly on face and legs/arms

9. Impetigo: Prevention Prevention ▫Keep any cuts and scratches clean and covered ▫This condition is very contagious through direct contact, especially when there is fluid drainage from the rash! ▫Do not share towels or washcloths with someone with impetigo ▫Wash hands with soap and water each time you touch the infected area

10. Impetigo: Treatment Topical treatment: ▫Mupirocin three times a day is the best choice ▫Other topical treatments: fusidic acid, hydrogen peroxide 1% cream 2-3 times a day Oral antibiotics ▫If a large area is involved, and rash is severe ▫cephalexin 500mg q6h, or ▫cloxacillin 500mg q6h, or ▫clindamycin 300mg q6h for 7 days (these are adult doses)

11. Case 2 A 65 year old man presents with this very painful rash to his back. What is this disease? What characteristics of the rash lead you to this diagnosis? How do you treat it? What are some complications that can occur?

12. Herpes Zoster (shingles) Reactivation of latent varicella zoster virus (same virus that causes chickenpox) Clinical diagnosis:  Rash  Starts off as papules, then progress to a cluster or group of vesicles. Over 3-4 days they become more pustular. The rash crusts by 10 days. Heal in 2-4weeks  Follow 1-2 dermatomes and do not cross midline  Usually on the trunk  Pain  “burning” pain that can start days- weeks before the rash appears

13. Dermatomes

14. Herpes zoster: More examples

15. Herpes zoster: Complications Postherpetic neuralgia (pain even after rash is gone) Bacterial skin infection If trigeminal nerve involved: eye & corneal involvement can lead to vision loss ▫This is called herpes zoster opthalmicus Motor weakness Varicella zoster encephalitis If a patient has HIV, they are more likely to get herpes zoster and its complications

16. Herpes zoster: Treatment Treatment with antiviral drugs can lead to faster healing of the skin lesions if started within 72h from symptom onset ▫Oral Acyclovir 800mg five times/day x 7 days In herpes zoster opthalmicus, use ▫IV Acyclovir 10mg/kg q8h x 7 days ▫Topical steroid drops

17. Case 3 A 10 year old girl presents with itchiness between her fingers, worse at night What does she have? How do you diagnose it? What are the characteristics of the rash? How do you treat it?

18. Case 3: Scabies From infestation of the mite Sarcoptes scabiei Typical lesion: ▫Small erythematous papule ▫Usually excoriated ▫Hemorrhagic crust ▫Burrows, when seen, make the diagnosis  Thin gray/ red/ brown line 2-15mm long Typical distribution: Web of fingers, wrist flexor surface, elbow, axilla, knees, buttocks, waist, male genitalia

19. Scabies distribution

20. Scabies: More examples Examples of burrows

21. Scabies: Diagnosis Clinical diagnosis: (1 or more of) ▫Itching, worse at night out of proportion to changes that can be seen on the skin ▫Itchy rash with characteristic lesions and distribution ▫Other people in the house with same symptoms Investigations ▫Skin scraping(can see mite under microscope) ▫Adhesive tape test  Use clear tape to apply directly over skin lesion. Pull it off quickly. Using a microscope, look for eggs and mites

22. Scabies: Treatment Whole body application of 5% permethrin cream or Whole body application of 1% lindane cream or Single dose oral ivermectin 200mg/kg For the itching, can use antihistamine or topical corticosteroid

23. Scabies: Prevention Transmitted by close skin to skin contact Contaminated clothing and linens should be put in a plastic bag for at least 3 days before being washed Treat everyone who lives in the same household for scabies

24. Case 4 A 6 year old boy is complaining of itchiness to his wrists, neck, front part of his elbow, and behind his knees. His parents thought the problem was dry skin, but the rash and itchiness have been present for several years.

25. Case 4 Describe the rash. What is the diagnosis? What treatments (both lifestyle and medication) can you recommend?

26. Eczema (atopic dermatitis) Often first present as children <2 years of age Clinical diagnosis ▫Itchy skin. Evidence of rubbing/scratching ▫Lichenified (thickened) skin from chronic scratching ▫Distribution in the flexor skin creases  In front of elbow, behind knees, neck, around eyes, fronts of ankles  Usually not in axilla, groin, or buttocks  think psoriasis in this distribution ▫Dry skin

27. Case 4: More examples

28. Eczema: Treatment Lifestyle changes ▫Keep skin hydrated  Use thick creams on the skin, and apply right after bathing (while skin still damp) Medications ▫Topical corticosteroids (apply at least once daily)  Mild: Low potency (1% -2.5% hydrocortisone cream)  Severe: Medium potency (triamcinolone 0.1% cream)  Do not use higher potency steroid creams for more than 10 days

29. Case 5 A 25 year old man says he has noticed a scaly, non-itchy rash to his scalp, along with some changes to his nails. Describe this rash. What is the diagnosis? What other non-skin body parts can this disease affect? What is the treatment?

30. Psoriasis Onset peaks at ages 20-30 and again at 50-60 Clinical diagnosis ▫Erythematous raised plaques with a thick silvery scale ▫Better in summer months because of exposure to ultraviolet light ▫No or only mild itchiness ▫Distribution  Scalp, elbows, knees (extensor surfaces), back, buttocks, and at old sites of trauma

31. Psoriasis: Distribution

32. Psoriasis: More examples

33. Associated non-dermatologic findings Inflammation of the eyes: ▫Red, painful eyes, flaking or crusting of eyelashes, swelling of eyelids, visual changes Arthritis ▫Can involve distal joints (see picture), large joints such as hips and knees, or the back Nails ▫Pits, or brown discoloration

34. Psoriasis: Treatment Mild-moderate ▫Keep skin soft and moist with vaseline or creams ▫Topical corticosteroids  Mild potency (hydrocortisone 1%) on the face  Medium potency (betamethasone 0.05%) on thick plaques to elbows or knees ▫Tar creams and shampoos Severe ▫Phototherapy with UV light ▫Oral drugs such as methotrexate

35. Post-Test 1 This girl has a rash and she is very itchy! Which skin disease(s) can cause itchiness? (Can have more than one right answer) a. Eczema b. Herpes zoster c. Scabies d. Impetigo

36. Post-Test 2 What common skin disease does not cross midline and stays within 1-2 dermatomes? a. Eczema b. Psoriasis c. Impetigo d. Herpes Zoster

37. Post-Test 3 What is the most common bacteria that causes impetigo? a. Beta-hemolytic streptococci b. Staphylococcus aureus c. Enterococci d. Pseudomonas aeruginosa