KIN 405: Medical Aspects of Sports

KIN 405: Medical Aspects of Sports
Dermatology: Recognizing Illnesses and Disorders of the Skin

Skin Lesions Often overlooked or trivialized
Can signify serious disease in well patients Local conditions Systemic conditions Difficult for many health professionals to recognize

Athletic Trainers’ Goals
Recognize various forms of skin lesions Reassure patients that every little blemish is NOT skin cancer Refer for definitive diagnosis and treatment Restrict competition for athletes with communicable illness

Presentation Outline Anatomy of the skin Types of lesions Rashes
Infections Bacterial Fungal Viral

Presentation Outline (cont)
Skin cancer Assessment techniques Treatment techniques

Anatomy of the Skin Stratum corneum Epidermis Dermis
Pilosebaceous unit Subcutaneous fat

Stratum Corneum Top layer of skin Flakes off imperceptibly
Barrier to noxious substances Totally replaced every 27 days

Epidermis Protects against UV damage Provides cutaneous immunity

Dermis Connective tissue Provides elasticity & strength
Contains blood vessels, nerves, & sweat glands Skin splits when dermis is cut

Pilosebaceous Unit Hair shaft Hair follicle Erector muscle
Sebaceous gland Common site of bacterial infections

Subcutaneous Fat Insulates Protects

Kinds of Skin Lesions Macules Papules Plaques Pustules Vesicles
Nodules Desquamination Bullae Ulcers Wheals

Macules Flat Nonpalpable Discolored Less than 1cm

Causes of Macules Hypopigmentation Hyperpigmentation
Permanent vascular abnormalities of the skin Transient capillary dilatation (erythema)

Hypopigmentation Macules
Vitiligo Depigmentation

Hyperpigmentation Macules
Café-au-lait spots

Permanent Vascular Abnormalities of the Skin
CAPILLARY HEMANGIOMA OF INFANCY PORT-WINE STAIN

Transient Capillary Dilatation (Erythema)
Erythema Infectiosum (systemic viral)

Papules Latin for “Pimple” Raised lesion Less than .5 cm Solid

Example of Papules Rosacea

Plaques Large, raised lesion Well-defined
Confluence of multiple papules Chronic rubbing leads to “lichenification” (thickened skin)

Example of Plaques PSORIASIS VULGARIS OF THE ELBOW

Pustules Circumscribed Superficial
Contains purulent exudate that may be white yellow greenish yellow hemorrhagic.

Example of Pustules Acne Vulgaris

Vesicles Latin for “little bladder” Fluid filled cavity
Less than .5 cm Walls can be translucent Contains serum, lymph, blood, or extracellular fluid

Example of Vesicles Nongenital herpes simplex virus (HSV) infection

Bullae Latin for “bubble” Fluid filled cavity Greater than .5 cm
Walls can be translucent Contains serum, lymph, blood, or extracellular fluid Diabetic bullae

Nodules Latin for “small knot” Palpable, solid Round or ellipsoid
Epidermal, dermal, or subcutaneous Generally deeper and larger than papules

Example of Nodules Adult T-Cell Leukemia/Lymphoma

Desquamination Proliferation of epidermis resulting in abnormally formed stratum corneum “Scaly” Large (membranous) or small (dust)

Example of Desquamination
Solar Keratosis

Ulcers Pathologically altered tissue (different from a wound)
Epidermal - heals w/out scar Dermal - heals w/ scar

Example of Ulcers Stage IV Pressure Ulcer on Sacrum

Wheals Hives Rounded or flat topped Pale red Transient
Can change rapidly in size, shape, and location due to shifting edema in the dermis

Example of Wheals Cutaneous Vasculitis

Rashes Acne Dermatitis Intertrigo Urticaria Psoriasis
Seborrheic dermatitis Pityriasis rosea

Acne Affects 75% of the population
Can involve inflammation of the pilosebaceous unit Food choices NOT causative Endocrine and emotional links Not contagious Four stages

Grade I Acne Comedones (blackheads) Some whiteheads
Topical antibiotics (clindamycin, erythromycin Benzoyl peroxide gels (2%,5%,10%) Tretinoin (Retin-A) creams

Grade II Acne Erythematous papules
Oral tetracycline antibiotics added to previous tx regimen For females, oral estrogens combined with progesterone or antiandrogens

Grade III Acne Pustules Isotretinoin (Accutane)
Contraception (2 forms) is absolutely necessary Do not combine tetracycline and isotretinoin Risk of psychiatric side effects

Grade IV Acne Cysts Nodules Scars

Dermatitis Inflammation of the skin Sometimes called eczema
Many causes and forms (allergic vs non-allergic) Not contagious Contact dermatitis caused by contact with noxious substances (formaldehyde, plant oils, rubber, etc)

Dermatitis-Signs and Symptoms
Pruritis (itching) Erythematous papules Vesicles (or bullae) Crusting Edema Poison Ivy, 5 days post exposure

Dermatitis-Treatment
Identify and remove the etiologic agent Bullae may be drained, but tops should not be removed Cool compresses Topical corticosteroids Contact dermatitis from paraben-containing foot cream

Dermatitis-Treatment (cont)
In severe cases, systemic corticosteroids may be indicated Prednisone: two-week course, 70 mg initially, tapering by 5 mg daily Chronic contact dermatitis on the hands of a concrete worker

Intertrigo Caused by friction in skin folds
Axilla, inframammary area, groin Gradual and progressive skin abrasion irritated by sweat and heat

Intertrigo-Treatment
Mild topical hydrocortisone Zinc oxide ointment Reduce friction Corn starch/baby powder Expose to air

Urticaria Transient hives characterized by wheals Pruritis
Caused by sunlight, medication or food allergy, cold, and exercise

Urticaria Wheals with white-to-light-pink color centrally and peripheral erythema in a close-up view.

Cholinergic Urticaria
Exercise-induced wheals & pruritis Hot shower may also reproduce symptoms Urticarial papules on neck w/in 30 minutes of vigorous exercise

Cold-Induced Urticaria
Caused by cold sensitivity Ten minute application of ice pack cause a wheal w/in five minutes of the removal of the ice

Urticaria-Treatment Oral antihistamines (Benadryl)
Avoidance of causative agent Prednisone May compete as long as pruritis is not disabling & breathing not compromised Urticaria as it appeared 5 minutes after stroking the skin with a wooden stick. The patient had experienced generalized pruritus for several months with no spontaneously occurring urticaria.

Psoriasis Genetically inherited disease
Erythematous papules and plaques Primarily on extensor surfaces elbows knees scalp intergluteal area

Psoriasis-Trigger Factors
Trauma (Koebner effect) Drugs Stress Infections Psoriasis of the elbow

Psoriasis-Treatment Limited course of topical corticosteroids (long term application causes skin breakdown) Triamicinolone acetonide (Aristocort, Kenalog)

Psoriasis-Treatment (cont)
Anthralin (Anthra-Derm cream -- not for use on face or skin creases) Vitamin D analogues (e.g., calcipotriol) UV light therapy No participation restrictions

Seborrheic Dermatitis
Common chronic dermatosis Characterized by redness and scaling occurring in regions where the sebaceous glands are most active, such as the face and scalp, and in the body folds. Mild scalp SD causes flaking (dandruff)

Seborrheic Dermatitis-Treatment
Creams or shampoos containing selenium (Selsun Blue) ketocanazole (Nizoral) Similar lesions were also present in the retroauricular areas and presternal chest.

Pityriasis Rosea Distinctive morphology Characteristic course
“Herald” plaque lesion develops, usually on the trunk, and 1 or 2 weeks later a generalized secondary eruption develops in a typical distribution pattern Spontaneous remission in 6 weeks without any therapy

Pityriasis Rosea (cont)
Herald Patch (80 % of patients) oval, slightly raised plaque 2 to 5 cm, bright red, fine scale at periphery

Pityriasis Rosea (cont)
Long axes of the lesions follow the lines of cleavage in a “Christmas tree” distribution Lesions usually confined to trunk and proximal arms and legs Rarely on face

Pityriasis Rosea-Treatment
Pruritus may be controlled by UVB phototherapy or natural sunlight exposure if begun in the first week of eruption. Five consecutive exposures, starting with 80 % of the minimum erythema dose and increasing 20 % each exposure. Usually goes away by itself.

Infectious Disorders Bacterial Infections Fungal Infections
Viral Infections

Bacterial Infections Impetigo & ecthyma Abscess, furuncle, & carbuncle
Scarlet fever

Impetigo & Ecthyma Caused by Staphylococcus aureus and Streptococcus pyogenes Impetigo-epidermis Ecthyma-dermis Superficial breaks in the skin Scattered, discrete, thin-walled vesicles and bullae that easily rupture and form erosions.

Impetigo Transient superficial small vesicles or pustules, rupture resulting in erosions, which in turn become surmounted by a crust Crusted (golden-yellow, stuck-on) erosions becoming confluent on the nose, cheek, lips, and chin.

Ecthyma Ulceration with a thick adherent crust
A large, circumscribed ulcer with a necrotic base and surrounding erythema in the pretibial region.

Impetigo & Ecthyma-Treatment
Mupirocin (Bactroban) applied three times daily to involved skin and to nares for 7 to 10 days. Oral antibiotics (10 day course is typical) Highly infectious -- disqualify from contact athletics until infection is cleared by physician

Abscess, Furuncle, & Carbuncle
Abscess - a circumscribed collection of pus appearing as an acute or chronic localized infection with tissue destruction. Furuncle - an acute,deep-seated, red, hot, tender nodule or abscess that evolves from a staphylococcal folliculitis. Carbuncle - a deeper infection composed of interconnecting abscesses usually arising in several contiguous hair follicles.

Abscess Usually caused by Staphylococcus aureus. Very tender Warm
Will develop a pustulent head A very tender abscess with surrounding erythema on the heel.

Furuncle (boil) Firm tender nodule 1 to 2 cm Central necrotic plug.
staphylococcal folliculitis in beard area or neck. Nodule becomes fluctuant with abscess formation

Furuncle (boil) Necrotic plug often topped by a central pustule.
Following drainage a nodule. A zone of cellulitis may surround the furuncle.

Carbuncle Evolution similar to that of furuncle.
Comprised of multiple, adjacent, coalescing furuncles Characterized by multiple dermal and subcutaneous abscesses,pustules, necrotic plugs, and sieve-like openings draining pus

Treatment Incision and drainage Systemic antibiotics (10 day course)
Local heat Disqualification from contact sport until resolved Highly contagious

Scarlet Fever Acute infection of the tonsils, skin, or other sites by Streptococcus Associated with a characteristic toxigenic rash

Scarlet Fever Erythema on the upper trunk
Face flushed with a perioral pallor. Linear petechiae (Pastia’s sign) occur in body folds. Rash fades w/in 5 followed sheetlike exfoliation on the palms and soles. Pastia’s Sign

Scarlet Fever-Treatment
Aspirin or acetaminophen for fever and/or pain The goal of therapy is to eradicate Streptococcus throat carriage to prevent rheumatic fever. Drug of choice is penicillin because of its efficacy in prevention of rheumatic fever. Desquamation of the volar fingertips 10 days after onset of streptococcal pharyngitis in an adult female.

Fungal Infections Varieties of Tinea infections Onychomycosis
Candidiasis Pityriasis versicolor

Tinea Pedis (Athlete’s Foot)
Dermatophytic infection of the feet Erythema,desquamation, and/or bulla formation Hot, humid weather, occlusive footwear, excessive sweating Scaling, maceration, erythema, and erosion in the 4-5 webspace. 4th toenail also infected.

Tinea Pedis (Athlete's Foot)
Walking barefoot on contaminated floors Arthrospores can survive in human skin scales 12 months. Pruritus Pain with secondary bacterial infection Moccasin type tinea pedis. Erythema, fine white scaling of the plantar and lateral foot, and kerato-derma(thickening of the keratin layer)

Tinea Pedis-Treatment
Keep feet clean, dry, exposed to air Dry shoes thoroughly Terbinafine (Lamisil) cream

Tinea Manuum Fungal infection of the hands
Diffuse hyperkeratosis of the palms (especially the creases) Patchy scaling on the dorsa and sides of fingers 50% of patients have unilateral involvement Erythema and scaling of the right hand, associated with bilateral tinea pedis; the “one hand, two feet” distribution is typical of epidermal dermatophytosis of the hands and feet.

Tinea Manuum-Treatment
Must eradicate all other sources of tinea infection Topicals don’t work (stratum corneum too thick) Terbinafine (Lamisil) Itraconazole (Sporanox) Griseofulvin (Grisactin)

Tinea Cruris (Jock Itch)
Subacute or chronic dermatophytosis of the groin, pubic regions,and thighs. Warm, humid environment, tight clothing worn by men, obesity. Pruritis Erythematous, scaling plaques on the medial thighs,inguinal folds, and pubic area. The margins are raised and sharply marginated.

Tinea Cruris Most individuals with tinea cruris have tinea pedis.
Dermatophyte is transferred from feet to crural region by hands. Affects groins and thighs. May extend to buttocks. Scrotum and penis are rarely involved.

TOPICAL ANTIFUNGALS CATEGORIES AGENTS TRADE NAMES
Imidazoles Clotrimazole Lotrimin, Mycelex Miconazole Micatin Ketoconazole Nizoral Econazole Spectazole Oxiconizole Oxistat Sulconizole Exelderm Allylamines Naftifine Naftin Terbinafine Lamisil Naphthiomates Tolnaftate Tinactin Substituted pyridone Ciclopiroxalamine Loprox

Tinea Cruris-Treatment
Eradicate other sources of tinea infection Differentiate from intertrigo Avoid tight clothing Keep dry, cool

Tinea Corporis (Ringworm)
Dermatophyte infections of the trunk, legs, and arms, excluding the feet, hands, and groin. More common in animal workers in tropical climates. Sharply marginated, hyperpigmented plaques of chronic duration. Associated tinea cruris and tinea pedis are usually present.

Tinea Corporis Often asymptomatic Mild pruritus
Scaling, sharply marginated plaques Peripheral enlargement and central clearing Annular configuration with concentric rings Tinea corporis contracted from a pet guinea pig.

Tinea Corporis-Treatment
CATEGORIES AGENTS TRADE NAMES Imidazoles Clotrimazole Lotrimin, Mycelex Miconazole Micatin Ketoconazole Nizoral Econazole Spectazole Oxiconizole Oxistat Sulconizole Exelderm Allylamines Naftifine Naftin Terbinafine Lamisil Naphthiomates Tolnaftate Tinactin Substituted pyridone Ciclopiroxalamine Loprox

Tinea Facialis (Face Ringworm)
Dermatophytosis of the glabrous facial skin Well-circumscribed erythematous patch More commonly misdiagnosed than any other dermatophytosis. Sharply marginated, erythematous plaque with some central clearing and peripheral scaling on the lower eyelid and cheek

Tinea Facialis Pruritus and photosensitivity Pink to red
In black patients, hyperpigmentation Scaling often is minimal but can be pronounced Sharply marginated, erythematous, scaling, and crusted plaques on the face of a child. Note asymmetry.

Tinea Facialis-Treatment
Topical antifungal preparations Eradicate dermatophyte infection at other sites such as feet and hands. Tinea Facialis is more common in children.

Tinea Capitis Fungal infection of the scalp
Follicular inflammation with painful, boggy nodules that drain pus Scarring alopecia Scaling patches Large, round, hyperkeratotic plaque of alopecia due to breaking off of hair shafts close to the surface, giving the appearance of a mowed wheat field on the scalp of a child.

Tinea Capitis Blacks>whites Children>adults Three types
“Black dot” Kerion Favus

Tinea Capitis-”Black Dot” Type
Broken-off hairs near surface give appearance of “dots” in dark-haired patients Tends to be diffuse and poorly circumscribed Resembles seborrheic dermatitis. A subtle, asymptomatic patch of alopecia due to breaking off of hairs on the frontal scalp in a 4-year-old black child.

Tinea Capitis-Kerion Type
Boggy, purulent, inflamed nodules and plaques Usually extremely painful Drains pus from multiple openings Hairs do not break off but fall out and can be pulled without pain Heals with scarring alopecia. Large, very painful, inflammatory tumor with hair loss, studded with multiple pustules on the scalp of a young child.

Tinea Capitus-Favus Type
Thick yellow adherent crusts (scutula) Fetid odor Untreated results in cutaneous atrophy, scar formation, and scarring alopecia.

Tinea Capitis-Treatment
Topical antifungal agents are ineffective in management of tinea capitis Systemic antifungals should be used until symptoms have resolved and fungal cultures negative Terbinafine and itraconazole superior to ketoconazole and all three to griseofulvin. Side effects in increasing order: terbinafine < itraconazole < ketoconazole < griseofulvin

Tinea Barbae- Ringworm of the Beard
Fungal infection of the beard and moustache areas Adult males only More common in farmers Pruritus,tenderness, pain Scattered, discrete follicular pustules and papules in the moustache area, easily mistaken for S. aureus folliculitis.

Tinea Barbae-Treatment
Similar to tinea capitis Topical antifungals ineffective Systemic antifungals should be used until symptoms have resolved and fungal cultures negative Confluent, painful papules, nodules, and pustules on the upper lip. Tinea facialis present on the cheeks, eyelids, eyebrows,and forehead.

Onychomycosis Toenail becomes opaque, thickened, cracked, friable, raised by underlying hyperkeratotic debris in the nail bed Toenails more common than fingernails When fingernails are involved, pattern is usually two feet and one hand Distal subungual hyperkeratosis and onycholysis involving most of the nail bed of the great toenails; these findings are usually associated with tinea pedis.

Onychomycosis-Treatment
Does not resolve spontaneously;invol-vement of multiple toenails is the rule. Relapse occurs in the majority of persons treated with griseofulvin. Relapse rate with itraconazole or terbinafine is less than with griseofulvin The proximal nail plate is a chalky white color due to invasion from the undersurface of the nail matrix. The patient had advanced HIV disease.

Cutaneous Candidiasis
Superficial infection occurring on moist cutaneous sites Many patients have predisposing factors that alter local immunity such as increased moisture at the site of infection, diabetes, or alteration in systemic immunity Erosions on the medial thighs, inguinal folds, and scrotum with “satellite” pustules and papules of an obese male.

Penis/scrotum Vulva Fingernails Interdigital Treatment is primarily topical Erythematous eroded area with surrounding maceration in a webspace of the hand occurring in a health care worker is a type of intertrigo.

Pityriasis Versicolor
Also known as tinea versicolor Yeast infection Usually on the trunk Depigmentation of the skin Should not disqualify am athletes from participation Hypopigmented, sharply marginated, scaling macules on the shoulder area of an individual with brown skin. Gentle abrasion of the surface accentuates the scaling.

Pityriasis Versicolor-Treatment
Selenium sulfide (2.5%) lotion or shampoo: Apply daily for 10 to 15 minutes, followed by shower, for 1 week. Azole creams (ketoconazole, econazole, micronazole, clotrimazole): Apply b.i.d. for 2 weeks. Follicular, hypopigmented macules on the upper chest of an individual with black skin.

Viral Infections Molluscum Contagiosum Herpes Warts

Molluscum Contagiosum
Discrete, solid, skin-colored papules, 1 to 2mm in diameter with central umbilication on the chest of an adolescent female. The lesion with an erythematous halo is undergoing spontaneous regression. Epidermal viral infection Skin-colored papules Children and sexually active adults Transmission by skin-to-skin contact

Molluscum Contagiosum
In healthy individuals resolves spontaneously. In HIV-infected individuals often progresses despite treatment. Painful aggressive therapy is best avoided. Avoid skin-to-skin contact

Herpes Simplex Virus Three types Nongenital Genital Herpes Gladiatorum
Multiple painful erosions on the lower labial mucosa with erythema and edema of the gingiva; plaque has formed on the teeth because of pain within the lesions that restricts brushing. Fever and tender submandibular lymphadenopathy were also present.

Nongenital Herpes Simplex
Grouped vesicles arising on an erythematous base on keratinized skin or mucous membrane Lips most common Incubation 3-12 days Chronic and recurrent A. Grouped and confluent vesicles with an erythematous rim on the lips. B. Edema with crusting of the lips which followed sun exposure; vesiculation is present but difficult to detect because of confluence of lesions. In some cases, crusting is the only finding.

Nongenital Herpes Simplex
Restrict from athletics until lesions crusted and dry Acyclovir (Zovirax) 800 mg b.i.d. for 5 days Valacyclovir (Valtrex) 500 to 1000 mg b.i.d. Famciclovir (Famvir) Herpetic Whitlow-Painful, grouped, confluent vesicles on the volar finger on an erythematous edematous base.

Genital Herpes Simplex
Grouped vesicles at the site of inoculation and inguinal lymphadenopathy Flu-like symptoms (myalgia, headache) Chronic and recurrent Oral antiviral meds May participate unless they feel too crummy Group of vesicles with early central crusting on a red base arising on the shaft of the penis. Multiple, extremely painful, punched-out, confluent, shallow ulcers on the vulva and perineum.

Herpes Gladiatorum Spread of herpes to abraded of injured skin
Associated with widespread dermatitis Looks like impetigo Oral antivirals Common in wrestlers No participation until cleared

Herpes Zoster (Shingles)
Chicken pox virus Distribution along dermatomes Painful Headache, malaise, fever Spontaneous resolution 2-3 weeks Analgesics, antivirals (acyclovir) Dermatomal, grouped and confluent vesicles and pustules arising in the third sacral dermatome; note extension of lesions 1–2 cm across the midline.

Warts Caused by human papillomavirus (HPV) Three types
Common warts (verruca vulgaris-70%) Plantar warts (verruca plantaris-30%) Flat warts (verruca plana-4%) The thrombosed capillaries (brown dots) differentiate the lesion from a corn or callus.

Common Warts (Verruca Vulgaris)
Palmar lesions disrupt the normal line of fingerprints. Return of finger-prints a sign of resolution of the wart. Hands, fingers, knees. Hyperkeratotic papules becoming confluent around the periungual tissue of four fingers; the brown dots represent thrombosed capillaries.

Plantar Warts (Verruca Plantaris)
Plantar surface of feet Often solitary but may be three to six or more Pressure points, heads of metatarsal, heels, toes The warts are surrounded by nonwarty callus. Tinea pedis is also present in the webspaces and instep with sites of excoriation.

Flat Warts (Verruca Plana)
Always numerous discrete lesions, closely set Face, beard area, dorsa of hands, shins Flat-topped, pink papules with sharp margination and minimal hyperkeratosis on the dorsum on the hands and fingers.

Wart Treatments Usually resolve sponatneously
Painful plantar warts warrant more aggressive treatment 40% salicylic acid plaster for 1 week Cryosurgery Electrosurgery CO2 laser surgery

Infestations Scabies Pediculosis

Scabies Mites burrow beneath stratum corneum Undiagnosed pruritis
Palms, wrists, ankles, nipples, ubilicus, genitals Acquired sexually or through crowded living conditions Papules and burrows in typical location on the finger webs. Burrows are tan or skin-colored ridges with linear configuration with a minute vesicle or papule at the end of the burrow and are often difficult to locate.

Scabies No contact sports until cleared (1 wk) Examine sexual partners
Wash bedding Lindane (Kwell, Scabene lotion or shampoo). Do not use after bathing, with pregnancy or lactation Permethrin (Nix lotion) A mite at the end of a burrow with 8 eggs and smaller fecal particles obtained from a papule on the webspace of the hand.

Pediculosis (Lice) Pediculosis capitis Pediculosis pubis
Pediculosis corporis Highly infectious Pruritis Regional lymphadenopathy Eggs (nits) adhere to hair A crab louse (see arrow) on the skin in the pubic region.

Pediculosis (Lice) No contact sports until all nits removed
Examine sexual partners Wash bedding Lindane (Kwell) Pyrethins (RID, R&C, A-200 gel, liquid, shampoo) Crab lice (see arrow) and nits on the upper eyelashes of a child; this was the only site of infestation.

Skin Cancer Three major types Basal cell carcinoma
Squamous cell carcinoma Melanoma Oral Leukoplakia - The lesion, in a heavy pipe smoker, progressed to a verrucous carcinoma.

Basal Cell Carcinoma Most common type of skin cancer.
Locally invasive, aggressive, and destructive Limited capacity to metastasize Exposure to UV light Large, shiny, red nodule with a cobblestoned surface and an ulcerated nodule.

Basal Cell Carcinoma Excision with primary closure, skin flaps, or grafts. Cryosurgery and electrosurgery Danger sites - nasolabial area, around the eyes, ear canal, posterior auricular sulcus, scalp - microsurgery required

Squamous Cell Carcinoma
Less common than basal cell carcinoma Exposure to UV light and x-rays, arsenic Slowly evolving Cheeks, nose, lips, tips of ears, preauricular areas, scalp, dorsa of the hands, forearms, trunk, and shins (females) A large notch on the superior aspect of the helix, a nodule of SCC with hyperkeratosis and ulceration.

Any isolated keratotic or eroded papule or plaque in a suspect patient that persists for over a month is considered a carcinoma until proved other-wise.

Surgery Microscopically controlled surgery in difficult sites Radiotherapy should be performed only if surgery is not feasible

Melanoma Most deadly kind of skin cancer Increasing rapidly
Sun exposure? Thinning ozone layer? Assymetric,pigmented, irregular, large lesions Suspicious nevi: Two large, variegated, brown oval macules.

Melanoma Radial growth phase Vertical growth phase
Critical to identify & treat early during radial growth phase The lighter macular portion of this lesion is a suspicious nevus on the upper back; the blue-black plaque is a superficial spreading melanoma (1.2 mm thickness). The patient was a 34-year-old internist who died 36 months following detection and excision of this lesion.

Melanoma Surgery is treatment Suspicious nevi (moles):
changing (increase in size, change in pigmentation pattern, changes in shape and/or border) location that cannot be closely followed by the patient by self-examination (on the scalp, genitalia, upper back) Melanoma-The left image (1990) shows variegation of pigmentation and irregular borders. Five years later, the lesion (right) shows darkening of melanin pigmentation, more irregularity in shape, and elevation in the most darkly pigmented region.

Six Warning Signs for Melanoma
A ASYMMETRY in shape—one-half unlike the other half B BORDER is irregular—edges irregularly scalloped C COLOR is mottled—haphazard display of colors; shades of brown, black, gray, red, and white D DIAMETER is usually large—greater than the tip of a pencil eraser (6.0 mm) E ELEVATION is almost always present—surface distortion is assessed by side-lighting. ENLARGEMENT—a history of an increase in the size of lesion is perhaps one of the most important signs of melanoma

Dermatology Assessment
General Approach to Patients With Skin Signs and Symptoms

Epidemiology and Etiology
Age Race Sex Occupation

History Duration of onset
Relationship of skin lesions to season, travel history, heat, cold, previous treatment, drug ingestion, occupation, hobbies, effects of menses, pregnancy Skin symptoms: pruritus, pain, paresthesia

History (cont) Constitutional symptoms Systems review
“Acute illness’’ syndrome: headaches, chills, feverishness, weakness “Chronic illness’’ syndrome: fatigue, weakness, anorexia, weight loss, malaise Systems review

Physical Examination Appearance of patient: uncomfortable, “toxic,’’ well Vital signs: pulse, respiration, temperature Skin—four major skin signs: (1) type, (2) shape, (3) arrangement, (4) distribution of lesions

Types of Skin Lesions Macules Papules Plaques Pustules Vesicles
Nodules Desquamination Bullae Ulcers Wheals

Color and Palpation White Brown Purple Violet Red “Flesh” Consistency
Temperature Mobility Tenderness Depth of lesion (i.e., dermal or subcutaneous)

Shape Round Oval Annular (ring-shaped) Serpiginous (snakelike)
Umbilicated Margination well-defined (can be traced with the tip of a pencil) ill-defined

Arrangement Grouped Disseminated

Distribution Extent Pattern isolated (single lesions), localized
regional generalized universal Pattern symmetrical exposed areas sites of pressure intertriginous area follicular localization random

KIN 405: Medical Aspects of Sports

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