Rashes/Dermatology. Jackie Weaver-Agostoni, DO, MPH UPMC Shadyside. Director, Osteopathic Family Medicine Residency 1/28/17
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1 Rashes/Dermatology Jackie Weaver-Agostoni, DO, MPH UPMC Shadyside Director, Osteopathic Family Medicine Residency 1/28/17
2 Pre-Test #1
3 Pre-Test #2
4 Pre-Test #3
5 Pre-Test #4
6 Pre-Test #5
7 Pre-Test #6
8 Pre-Test #7
9 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
10 History PMHx Medications Family history Social history- occupation, hobbies
11 Lesion Morphology Macule nonpalpable Ex: vitiligo, cafe au lait, petechiae
12 Lesion Morphology Papule palpable, </= 5 mm
13 Lesion Morphology Plaques - Large >/= 5 mm superficial flat lesions
14 Lesion Morphology Pustules small purulent-filled papules Vesicles small < 5 mm papules containing serous material Bullae large >/=6 mm vesicles
15 Lesion Morphology Nodules palpable, discrete lesions >/= 6 mm Tumors = large nodules
16 Lesion Morphology Cysts enclosed lined cavities filled with liquid/semisolid material Telangiectasia dilated superficial blood vessel Wheals - hives
17 Diagnostic Techniques KOH Prep!! Fungal Tzanck smear!! HSV!! VZV Wood s Lamp!! Tinea!! Erythrasma!! Vitiligo!! Melasma!! Porphyria
18 Melanoma Risk factors!!!!!!!! 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
19
20 Irritant Contact Dermatitis Xerosis, fissures, erythema, eczematous eruption Change frequently Increase air exposure Protective ointment!! Petroleum Jelly!! A and D ointment!! Desitin
21
22 Diaper Candidiasis Satellite lesions Antifungal creams, frequent diaper changes Usually lasts about 10 days
23
24
25 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.
26
27 Miliaria Crystallina Miliaria- Heat rash Eccrine sweat duct occlusion Vesicles filled with clear fluid Asymptomatic Cool water compress and proper ventilation
28
29 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
30
31 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
32
33 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)
34
35 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
36
37 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)
38
39
40 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
41
42 Measles Rubeola Droplets Cough, coryza, conjunctivitis Koplik s spots- blue-white spots with red halo on buccal mucosa Downward spread Morbilliform (confluent elevated maculopapules)
43
44 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
45
46 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
47
48 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
49
50 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
51
52 Roseola Infantum Exanthem subitum, sixth disease HHV-6 6 mo.- 4y/o High fever ( degrees) " rash Pale-pink, almond shaped, macules Symptomatic tx.
53
54 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
55 Rocky Mountain Spotted Fever!! Palms and Soles!! Tick-borne disease Rickettsia rickettsii!! Southeastern and south central states!! Spring and early summer!! Rash typically between 3 rd and 5 th day!! Early treatment
56 Meningococcemia Petechial Rash- discrete 1-2 mm lesions can coalesce into larger purpuric/ecchymotic lesions Trunk and lower body Mucus membranes- hemorrhage
57
58
59 Scabies Direct contact Nocturnal itching Burrows, vesicles or pustules on palms/soleshighly 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
60 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
61 Psoriasis Etiology- genetic, other (smoking, obesity, etc) Arthritis, nail involvement Tx: Topical, Phototherapy, Systemic
62
63 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
64 Tinea
65 Erythema migrans
66 Secondary Syphilis
67 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 Free dermatology photo atlas for your PDA
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