I WON T MISS THAT ONE NEXT TIME..

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Albert Richard
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1 I WON T MISS THAT ONE NEXT TIME.. JANUARY 29, 2018 RICHARD E JOHNSON, DO, FAAD, FAOCD OBJECTIVES A couple of days away from the office, cell phones off please A little time with friends, family, and colleagues Obtain required CME in a relaxed, no-stress venue Recognize some commonly seen dermatologic entities Getting through winter with minimal use of the snowblower Reinforcing your visual-diagnostic skills with the requisite dermatology pics Win the powerball..but only if it s more than $800 million RISK MANAGEMENT PATIENT SAFETY From POMA website. 12 CME credit hours in the areas of patient safety or risk management (either Category 1 or Category 2). For Florida licensees: medical errors requirement January 25 28,

2 Activities in patient safety and risk management may include the following topics: Patient safety Risk management Improving medical records and record keeping Reducing medical errors Professional conduct and ethics Improving communications Preventative medicine Health-care quality improvements DISCLOSURES. 1. I m old 2. I can be opinionated at times 3. I still use paper charts 4. I don t think we have a health care problem in the United States.. we have a health INSURANCE COMPANY problem in the United States (see #2 above) 5. I attempt, as best as I can, to be a patient advocate: cost effective treatments, prior authorizations fights on the patients behalf, follow-up care ( hey, that s an osteopathic approach.) 6. I attempt to provide useful, relevant, and fun lectures with information that can be used to fulfill #5 above 7. Oh, and I have no drug company affiliations, but I do tend to slip in brand names occasionally (see #1 above) Biopsy Refer IF IN DOUBT January 25 28,

diagnosis, but Cosmetic bx cost tx cost path fees scar results you want?

3 Patient-initiated i.e. pt s reason for visit Physician-initiated i.e. incidental finding I don t like it Changes noted Change size shape color symptoms Obvious diagnosis Not sure of diagnosis, but Cosmetic bx cost tx cost path fees scar results you want? Refer Reassure Pt returns bx bx-tx right then refer bx or tx refer tx refer No this is not an insurance company lecture A BASS-ACKWARDS LECTURE My first attempt May be my last attempt Get your clickers ready..participant input from the get-go January 25 28,

Get the brain cells started before going into the room Each case presented as if medical assistant gave you a brief raison d etre for the next patient Pick from group of possible diagnoses Add more

4 Get the brain cells started before going into the room Each case presented as if medical assistant gave you a brief raison d etre for the next patient Pick from group of possible diagnoses Add more into What s a derm lecture without pictures Whittle down the list of usual suspects and possibles Make the final, and of course, the correct diagnosis Maybe some treatment pearls Repeat with the next patient s saga 7 YEAR OLD MALE WITH MOM AND DAD?? January 25 28,

5 7 YEAR OLD MALE 1. Acne 2. Warts 3. Tinea corporis 4. Psoriasis 5. Granuloma annulare 6. Molluscum 7. Flea bites 8. Scabies 1. Tinea corporis 2. Granuloma annulare 3. Seborrheic dermatitis 4. Psoriasis 5. Flea bites 6. Scabies 7. Impetigo 8. Bed bugs 1. Molluscum 2. Tinea corporis 3. Impetigo 4. Granuloma annulare 5. Warts 6. Pyogenic granuloma 7. Bed bugs 8. Psoriasis USE CLICKERS HERE DF DX #1 1. Acne 2. Warts 3. Tinea corporis 4. Psoriasis 5. Granuloma annulare 6. Molluscum 7. Flea bites 8. Scabies January 25 28,

6 Df Dx #2 1. Tinea corporis 2. Granuloma annulare 3. Seborrheic dermatitis 4. Psoriasis 5. Flea bites 6. Scabies 7. Impetigo 8. Bed bugs Df Dx #3 1. Molluscum 2. Tinea corporis 3. Impetigo 4. Granuloma annulare 5. Warts 6. Pyogenic granuloma 7. Bed bugs 8. Psoriasis All three groups are correct at this point Let s get some info from the patient. (I try to converse directly with the patients; if possible and when applicable) January 25 28,

7 Present for 6 months No symptoms, just there Prior treatments = no help Topical antifungal Triple antibiotic OTC hydrocortisone HISTORY No other family members with it No family history of same 7 YEAR OLD MALE 1. Acne 2. Warts 3. Tinea corporis 4. Psoriasis 5. Granuloma annulare 6. Molluscum 7. Flea bites 8. Scabies 1. Tinea corporis 2. Granuloma annulare 3. Seborrheic dermatitis 4. Psoriasis 5. Flea bites 6. Scabies 7. Impetigo 8. Bed bugs 1. Molluscum 2. Tinea corporis 3. Impetigo 4. Granuloma annulare 5. Warts 6. Pyogenic granuloma 7. Bed bugs 8. Psoriasis 7 YEAR OLD MALE 1. Tinea corporis 2. Psoriasis 3. Granuloma annulare 4. Molluscum 1. Tinea corporis 2. Granuloma annulare 3. Seborrheic dermatitis 4. Psoriasis 5. Impetigo 1. Molluscum 2. Tinea corporis 3. Impetigo 4. Granuloma annulare 5. Pyogenic granuloma 6. Psoriasis January 25 28,

8 USE CLICKERS HERE PHYSICAL EXAM Several round/ovoid lesions Raised rubbery/firm rim with essentially clear center No scale Flesh colored No inflammation 7 YEAR OLD MALE 1. Tinea corporis 2. Psoriasis 3. Granuloma annulare 4. Molluscum 1. Tinea corporis 2. Granuloma annulare 3. Seborrheic dermatitis 4. Psoriasis 5. Impetigo 1. Molluscum 2. Tinea corporis 3. Impetigo 4. Granuloma annulare 5. Pyogenic granuloma 6. Psoriasis January 25 28,

9 7 YEAR OLD MALE 1. Granuloma annulare 2. Molluscum 1. Granuloma annulare 1. Molluscum 2. Granuloma annulare 3. Pyogenic granuloma WHAT S A DERM LECTURE WITHOUT PICTURES January 25 28,

10 January 25 28,

insect bites, viral induced,? medications (allopurinal), sun exposure.

11 GRANULOMA ANNULARE Generally children and young adults but, diseases don t read the textbooks Generally self-limiting but, diseases don t read the textbooks Etiology: trauma, insect bites, viral induced,? medications (allopurinal), sun exposure. TYPES OF GRANULOMA ANNULARE Localized lesions Generalized Subcutaneous Perforating Patch Actinic January 25 28,

LOCALIZED Most commonly seen type Raised rubbery edge Centrally, surface normal color/texture, may be slightly depress/hyperpigmented More than half of

More in <10yo and >50yo Generally truncal in distribution Generally rings are <5cm?

12 LOCALIZED Most commonly seen type Raised rubbery edge Centrally, surface normal color/texture, may be slightly depress/hyperpigmented More than half of the patients have single lesion but diseases don t read the textbooks GENERALIZED GRANULOMA ANNULARE About 10-15% of patients have more than 10 lesions More in <10yo and >50yo Generally truncal in distribution Generally rings are <5cm???may be a marker for diabetes SUBCUTANEOUS GRANULOMA ANNULARE BB sized to large painless papules/nodules Elbows, knees, and ankles most common sites??may be a marker for diabetes or abnormal glucose tolerance January 25 28,

PERFORATING GRANULOMA ANNULARE Superficial small papules Hands

? MC s) Ulceration rarely occurs, but is possible 1/3 +/-

patches without induration or scale Women > men Proximal

variants have been described ACTINIC GRANULOMA Large annular

13 PERFORATING GRANULOMA ANNULARE Superficial small papules Hands and fingers May develop umbilication (?? MC s) Ulceration rarely occurs, but is possible 1/3 +/- patients have diabetes PATCH GRANULOMA ANNULARE Subtle pink patches without induration or scale Women > men Proximal extremities most common sites Localized and generalized variants have been described ACTINIC GRANULOMA Large annular plaques develop on face or other actinically damaged skin May be quite large and elevated January 25 28,

TREATMENT Rarely needs biopsy Perhaps with less common variants, but with classic GA, no biopsy needed Benign neglect Topical steroids with or without occlusion

d/c med CAVEATS Not all round rashes are ringworm Firm-edged asymptomatic annulare lesion dorsum of foot/hand think GA Biopsy rarely needed for classic GA, but if

14 TREATMENT Rarely needs biopsy Perhaps with less common variants, but with classic GA, no biopsy needed Benign neglect Topical steroids with or without occlusion Atrophy potential Intralesional steroids Cryotherapy Oral retinoids isotretinoin with ipledge hassles vs acitretin Seems to be effective, but relapses expected when d/c med CAVEATS Not all round rashes are ringworm Firm-edged asymptomatic annulare lesion dorsum of foot/hand think GA Biopsy rarely needed for classic GA, but if done for confirmation, sometimes lesions resolves with biopsy therapeutic biopsy Generalized, sudden onset GA, consider any new meds started..?allopurinol January 25 28,

75 YEAR OLD MALE 75 YEAR OLD MALE 1. BCC/SCC 2. Seborrheic keratosis 3. Tinea 4. Psoriasis 5. Eczema 6. Stasis dermatitis 7. Bateman s purpura 1. Tinea 2. Seborrhea 3. Seborrheic dermatitis 4.

15 75 YEAR OLD MALE 75 YEAR OLD MALE 1. BCC/SCC 2. Seborrheic keratosis 3. Tinea 4. Psoriasis 5. Eczema 6. Stasis dermatitis 7. Bateman s purpura 1. Tinea 2. Seborrhea 3. Seborrheic dermatitis 4. Rosacea 5. Stasis dermatitis 6. Actinic keratosis 7. Eczema 1. BCC/SCC 2. Tinea 3. Eczema 4. Onychomycosis 5. Psoriasis 6. Bateman s purpura 7. Seborrheic keratosis CLICKER RESPONSE PAGE January 25 28,

16 ONCE AGAIN, ALL CORRECT HISTORY AND PHYSICAL WILL HELP Present for awhile HISTORY Patient-speak : anywhere from this morning to I was born with it. After conversing with the patient: about 8 months Itchy at first, now, not at all Prior treatments OTC: Benadryl cream and hydrocortisone 1% Rx: betamethasone for 3 months and since then, about 4 months fluocinolone Was size of quarter, now whole back of hand 1. BCC/SCC 2. Seborrheic keratosis 3. Tinea 4. Psoriasis 5. Eczema 6. Stasis dermatitis 7. Bateman s purpura January 25 28,

17 1. SCC 2. Seborrheic keratosis 3. Tinea 4. Psoriasis 5. Eczema 6. Stasis dermatitis 7. Bateman s purpura 1. SCC 2. Tinea 3. Psoriasis 4. Eczema 1. Tinea 2. Seborrhea 3. Seborrheic dermatitis 4. Rosacea 5. Stasis dermatitis 6. Actinic keratosis 7. Eczema January 25 28,

18 1. Tinea 2. Eczema 1. BCC/SCC 2. Tinea 3. Eczema 4. Onychomycosis 5. Psoriasis 6. Bateman s purpura 7. Seborrheic keratosis 1. SCC 2. Tinea 3. Eczema 4. Onychomycosis 5. Psoriasis 6. Bateman s purpura 7. Seborrheic keratosis January 25 28,

19 1. SCC 2. Tinea 3. Eczema 4. Psoriasis 75 YEAR OLD MALE 1. SCC 2. Tinea 3. Psoriasis 4. Eczema 1. Tinea 2. Eczema 1. SCC 2. Tinea 3. Eczema 4. Psoriasis ALL THREE PRETTY MUCH THE SAME LET S SEE WHAT THE PATIENT HAS January 25 28,

20 January 25 28,

21 January 25 28,

22 75 YEAR OLD MALE 1. SCC 2. Tinea 3. Psoriasis 4. Eczema 1. Tinea 2. Eczema 1. SCC 2. Tinea 3. Eczema 4. Psoriasis TINEA INCOGNITO Remember, diseases don t read the textbook.. Generally: scaly edged, clear center..tinea scaly throughout..eczema One hand only..probably not eczema Any onychomycotic nails? Check the feet. two foot, one hand syndrome Biopsy, if in doubt. TREATMENT Topical may do it, but not wrong adding short-term oral Majocchi s granuloma-type needs oral and topical Wrestlers shampoo? January 25 28,

23 PATIENT IN ROOM #3 Was here an hour before his appointment time to beat the crowd Has another appointment across town scheduled for 30 minutes after his scheduled appointment was to start here. 68 YEAR OLD MALE? 68 YEAR OLD MALE 1. BCC/SCC 2. Seborrheic keratosis 3. Tinea 4. Psoriasis 5. Warts 6. Lichen simplex 7. Tags 1. Changing mole 2. Seborrhea 3. Seborrheic dermatitis 4. Rosacea 5. Lichen simplex 6. Scabies 7. Lyme disease 1. BCC/SCC 2. Tinea 3. Scabies 4. Hair loss 5. Psoriasis 6. Lichen simplex 7. Seborrheic keratosis January 25 28,

24 CLICKERS No fooling you all acceptable. Let s get some history 68 YEAR OLD MALE Itchy rash in groin for last 6 months Scrubbing with antibacterial soap No Rx treatments OTC hydrocortisone 1% and clotrimazole creams,..on and off use I think it started this summer with crotch-rot January 25 28,

25 68 YEAR OLD MALE 1. BCC/SCC 2. Seborrheic keratosis 3. Tinea 4. Psoriasis 5. Warts 6. Lichen simplex 7. Tags 1. Changing mole 2. Seborrhea 3. Seborrheic dermatitis 4. Rosacea 5. Lichen simplex 6. Scabies 7. Lyme disease 1. BCC/SCC 2. Tinea 3. Scabies 4. Hair loss 5. Psoriasis 6. Lichen simplex 7. Seborrheic keratosis 68 YEAR OLD MALE 1. Tinea 2. Psoriasis 3. Lichen simplex 1. Changing mole 2. Seborrhea 3. Seborrheic dermatitis 4. Rosacea 5. Lichen simplex 6. Scabies 7. Lyme disease 1. BCC/SCC 2. Tinea 3. Scabies 4. Hair loss 5. Psoriasis 6. Lichen simplex 7. Seborrheic keratosis 68 YEAR OLD MALE 1. Tinea 2. Psoriasis 3. Lichen simplex 1. Seborrheic dermatitis 2. Lichen simplex 3. Scabies 1. BCC/SCC 2. Tinea 3. Scabies 4. Hair loss 5. Psoriasis 6. Lichen simplex 7. Seborrheic keratosis January 25 28,

26 68 YEAR OLD MALE 1. Tinea 2. Psoriasis 3. Lichen simplex 1. Seborrheic dermatitis 2. Lichen simplex 3. Scabies 1. Tinea 2. Scabies 3. Psoriasis 4. Lichen simplex EXAM TIME Red inflamed lichenified scrotum with minimal crease or thigh involvement Some excoriations noted No nodules noted No other body areas January 25 28,

27 68 YEAR OLD MALE 1. Tinea 2. Psoriasis 3. Lichen simplex 1. Seborrheic dermatitis 2. Lichen simplex 3. Scabies 1. Tinea 2. Scabies 3. Psoriasis 4. Lichen simplex CLICKERS January 25 28,

28 68 YEAR OLD MALE 1. Tinea 2. Psoriasis 3. Lichen simplex 1. Seborrheic dermatitis 2. Lichen simplex 3. Scabies 1. Tinea 2. Scabies 3. Psoriasis 4. Lichen simplex 68 YEAR OLD MALE 1. Lichen simplex 1. Lichen simplex 1. Lichen simplex RASS Red Angry Scrotum Syndrome Much more common in males females get it too, but LSC only name they get Lichen Simplex Chronicus Also seen ankles, elbows; anywhere chronic friction/scratching January 25 28,

not wash to wash rash Patient education key to treatment success

29 TREATMENT Long term care Often recurrent Castle moat analogy rebuilding barrier function Sprained thumb analogy wash to wash, not wash to wash rash Patient education key to treatment success 2/2/2 dosing of topical steroids 32 YEAR OLD FEMALE January 25 28,

30 32 YEAR OLD FEMALE 1. Acne 2. Annoying mole 3. Eczema 4. Psoriasis 5. Warts 6. Rosacea 7. Shingles 1. Tags 2. Onychomycosis 3. Hair loss 4. Warts 5. BCC 6. Scabies 7. Tinea 1. Rosacea 2. Tinea 3. Shingles 4. Hair loss 5. Annoying mole 6. Eczema 7. Tags CLICKER PAGE HISTORY Present for about 3 years Regularly/occasionally shaves to bleed No symptoms Was flatter, now more raised Other similar lesions on legs and arms, but not in the way Tried wart medicine for a couple of days, but never bothered me, so I stopped using it. January 25 28,

31 32 YEAR OLD FEMALE 1. Acne 2. Annoying mole 3. Eczema 4. Psoriasis 5. Warts 6. Rosacea 7. Shingles 1. Tags 2. Onychomycosis 3. Hair loss 4. Warts 5. BCC 6. Scabies 7. Tinea 1. Rosacea 2. Tinea 3. Shingles 4. Hair loss 5. Annoying mole 6. Eczema 7. Tags 32 YEAR OLD FEMALE 1. Annoying mole 2. Warts 1. Tags 2. Onychomycosis 3. Hair loss 4. Warts 5. BCC 6. Scabies 7. Tinea 1. Rosacea 2. Tinea 3. Shingles 4. Hair loss 5. Annoying mole 6. Eczema 7. Tags 32 YEAR OLD FEMALE 1. Annoying mole 2. Warts 1. Warts 2. BCC 1. Rosacea 2. Tinea 3. Shingles 4. Hair loss 5. Annoying mole 6. Eczema 7. Tags January 25 28,

32 32 YEAR OLD FEMALE 1. Annoying mole 2. Warts 1. Warts 2. BCC 1. Annoying mole PHYSICAL EXAM Firm pink/red nodule Small surface scab January 25 28,

33 32 YEAR OLD FEMALE 1. Annoying mole 2. Warts 1. Warts 2. BCC 1. Annoying mole 32 YEAR OLD FEMALE 1. Annoying mole 1. BCC 1. Annoying mole If in doubt, biopsy ANNOYING MOLE Dermatofibroma Trauma induced?? Firm Flat or domed Dimples Not easily traumatized, as opposed to BCC...remember, diseases don t read the textbook. January 25 28,

34 TREATMENT Benign neglect Surgery Cryosurgery IL injections Lightening Round January 25 28,

35 3 SECOND VISUAL Pick your diagnosis Review picture Discuss PICK YOUR POISON 1. Vasculitis 2. Zoster 3. Contact dermatitis 4. Erythema ab igne 5. Urticaria 6. Leprosy January 25 28,

36 CLICKERS Erythema ab igne..also known as hot water bottle rash, fire stains, laptop thigh, granny's tartan and toasted skin syndrome..caused by long-term exposure to heat (infrared radiation) January 25 28,

37 READY? HERE S THE PITCH..STRIKE 2 HHHMMMMMMMMM? 1. Melanoma 2. Eclipse mole 3. Tinea capitis 4. Bug bite site 5. I don t know, but I m going to biopsy it 6. I don t know, but I m going to refer January 25 28,

38 CLICKERS Nevus en cocarde Benign ECLIPSE MOLE biopsy/refer certainly an option January 25 28,

39 HERE S THE WINDUP..STRIKE 3 AND. 1. Onychomycosis 2. Psoriasis 3. Onychomadesis 4. Oops, be more careful with closing the car door 5. Paronychia January 25 28,

40 CLICKERS ONYCHOMADESIS Proximal, complete separation of the nail plate from nail bed Results from full, but temporary, arrest of nail growth Stressful events, commonly seen after Hand-Foot-Mouth Disease Beau s lines transverse grooves cause be partial arrest of nail growth January 25 28,

41 BOTTOM OF THE NINTH TWO OUTS, 3-2 COUNT January 25 28,

42 WELL..? 1. Melanoma 2. Halo nevus 3. Lyme disease 4. Bateman s purpura CLICKERS January 25 28,

patient s age?? Periodic evaluation of lesion and patient recommended 2.

43 HALO NEVUS Central lesion characteristics and symmetry of halo may determine decision tree 1. If benign appearing and centrally placed nevus with symmetrical depigmentation is noted, need not be removed.patient s age?? Periodic evaluation of lesion and patient recommended 2. Biopsy/refer: Atypical appearing central nevus asymmetrical halo eccentric placement of nevus in halo personal or family hx of atypical nevi and/or melanoma OOPS, LOOKS LIKE EXTRA INNINGS January 25 28,

44 WHAT S IT GONNA BE? 1. Psoriasis 2. Tinea versicolor 3. Pityriasis alba 4. Vitiligo 5. Tinea faciale and corporis CLICKERS January 25 28,

hypopigmented -- caused by transient and mild dermal inflammation TREATMENT emollient moisturizers -- mild

45 PITYRIASIS ALBA -- more common in children than adults -- often seen in atopic patients -- most common sites are face and upper lateral arms -- usually begins with non-specific erythema and gradually becomes scaly and hypopigmented -- caused by transient and mild dermal inflammation TREATMENT emollient moisturizers -- mild inflammation treated with anti-inflammatory Protopic and Elidil probably work better than topical steroids January 25 28,

46 POST-LECTURE QUESTIONS 1. This reverse lecture format was a bust 2. This reverse lecture format was okay 3. Some of the lecturer s objectives were met 4. Enough with winter already! 5. Yea!! The end. (sorry, no powerball winning today) CLICKERS January 25 28,

47 1. I m old 2. I can be opinionated at times 3. I still use paper charts DISCLOSURES. 4. I don t think we have a health care problem in the United States.. we have a health INSURANCE COMPANY problem in the United States (see #2 above) 5. I attempt, as best as I can, to be a patient advocate: cost effective treatments, prior authorizations fights on the patients behalf, follow-up care ( hey, that s an osteopathic approach.) 6. I attempt to provide useful, relevant, and fun lectures with information that can be used to fulfill #5 above 5. Oh, and I have no drug company affiliations, but I do tend to slip in brand names occasionally (see #1 above).just SAYIN PAPER CHART Diagnosis made in about 5 seconds Chart note: same Patient education: 2 minutes Chit-chat time: 2 minutes Visit complete: 4+ minutes EMR Meaningful use entries: 5 minutes Entry of history: 3 minutes Look at patient/diagnosis: 5 seconds Entry of PE: 3 minutes Patient education: 2 minutes Entry documenting same: 3 minutes Chit-chat time: not allowed, no time Visit complete: minutes How many visits per day/week/month/year are like this for EVERY specialty. Where are our national organizations? See # 2 under DISCLAIMERS January 25 28,

Rash Decisions Approach to the patient with a skin condition

National Conference for Nurse Practitioners April 25, 2014 Rash Decisions Approach to the patient with a skin condition Margaret A. Bobonich, DNP, FNP C, DCNP, FAANP Assistant Professor, Case Western Reserve