Dermatology For Boards (And Real Life) Rita Khodosh, MD, PhD Department of Dermatology UC San Francisco

Transcription

1 Dermatology For Boards (And Real Life) Rita Khodosh, MD, PhD Department of Dermatology UC San Francisco

2 A 32-year-old farmer comes to your office because of an upper respiratory infection. While he is there he points out a lesion on his forearm that he first noted approximately 1 year ago. It is a 1-cm asymmetric nodule with an irregular border and variations in color from black to blue. The patient says that it itches and has been enlarging for the past 2 months. He says he is so busy that he is not sure when he can return to have it taken care of.

3 Suspicious Pigmented Lesion

4 In such cases the best approach would be to A) perform a punch biopsy and have the patient return if the biopsy indicates pathology B) perform a shave biopsy, with a recheck in 2 months for signs of recurrence C) use electrocautery to destroy the lesion and the surrounding tissue D) perform an elliptical excision as soon as possible E) freeze the site with liquid nitrogen

5 In such cases the best approach would be to A) perform a punch biopsy and have the patient return if the biopsy indicates pathology B) perform a shave biopsy, with a recheck in 2 months for signs of recurrence C) use electrocautery to destroy the lesion and the surrounding tissue D) perform an elliptical excision as soon as possible E) freeze the site with liquid nitrogen

6 Melanoma Destruction (cryotherapy, electrodessication, currettage) is NEVER appropriate If you are not comfortable performing a biopsy, get the patient to someone who is Best way to biopsy a suspicious pigmented lesion is an EXCISIONAL BIOPSY (elliptical, punch, or saucerization) To properly stage and treatment a melanoma one needs to know it s greatest DEPTH

7 Melanoma Margins

8 Melanoma Sentinel Lymph Node Biopsy Sentinel Lymph Node Biopsy is offered for melanomas : >1mm Breslow Depth <1mm with ulceration, increased mitotic rate and certain adverse features

9 A 72-year-old white farmer presents to your office with an enlarging raised lesion on the dorsum of his hand. It appears to be arising from an area of actinic keratosis.

10 Due to its location you suspect which one of the following? A) Basal cell carcinoma B) Keratoacanthoma C) Malignant melanoma D) Psoriatic plaque E) Squamous cell carcinoma

11 Due to its location you suspect which one of the following? A) Basal cell carcinoma B) Keratoacanthoma C) Malignant melanoma D) Psoriatic plaque E) Squamous cell carcinoma

12 Cutaneous Squamous Cell Carcinoma Most associated with chronic sun exposure (cumulative effect) Scalp, face, dorsal hands, neck Other risk factors for development of SCC: - burn - chronic ulcer - radiation - HPV (anogenital) - immunosuppression

13 Keratoacanthoma A type of SCC? Rapid growth Nodule with keratinous core Can involute on its own Usually treated Excision is best

14 You note a skin lesion on the nose of a 70- year-old male painter during a visit for a routine upper respiratory infection. He tells you that the lesion "sometimes bleeds a little." It is a raised, smooth, pale, pearly, shiny papule with prominent telangiectasia evident across its surface.

15 This lesion is most likely A) a spider angioma B) a basal cell carcinoma C) an atypical melanoma D) actinic keratosis E) sebaceous hyperplasia

16 This lesion is most likely A) a spider angioma B) a basal cell carcinoma C) an atypical melanoma D) actinic keratosis E) sebaceous hyperplasia

17 Basal Cell Carcinoma Most common type of skin cancer Sun-exposed areas (face, neck) Fair skin, sunburn history Rarely metastasize, some can be locally invasive and aggressive Diagnosed with shave or punch biopsy (punch if you are worried about more infiltrative BCC)

18 BCC Treatment Face (especially mid face) Mohs procedure Excision Electrodessication and Curettage (not on face or neck, not for infiltrative BCC) Imiquimod or 5FU (Superficial BCC) Radiation if cannot tolerate surgery (usually elderly patients) Vismodegib--hedgehog pathway inhibitor (metastatic or inoperable BCC)

19 Which one of the following statements is consistent with current U.S. Preventive Services Task Force recommendations for skin cancer screening for the adult general population with no history of premalignant or malignant lesions?

20 Skin Cancer Screening A) Whole-body examination should be conducted by a primary care provider every 3 years B) Whole-body patient self-examination should be performed every 6 months C) Benefits from screening have been established only for high-risk patients D) The evidence is currently insufficient to determine whether early detection reduces mortality and morbidity from skin cancer E) The harms of detection and early treatment outweigh the benefits

21 Skin Cancer Screening A) Whole-body examination should be conducted by a primary care provider every 3 years B) Whole-body patient self-examination should be performed every 6 months C) Benefits from screening have been established only for high-risk patients D) The evidence is currently insufficient to determine whether early detection reduces mortality and morbidity from skin cancer E) The harms of detection and early treatment outweigh the benefits

22 I screen: Skin Cancer Screening patients with history of skin cancer patients with fair skin over 50 (especially men) who have evidence of significant sun damage (Actinic Keratoses) patients with other risk factors for NMSC (genetic risk, immunosuppression) patients with increased melanoma risk

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24 What about indoor tanning?

25 UV radiation causes melanoma

26 A 55 year old white female presents with redness at the scar from a lumpectomy performed for stage I cancer of her right breast 4 months ago. The patient has completed radiation treatments to the breast. She is afebrile and there is no axillary adenopathy. There is no wound drainage, crepitance, or bullous lesions.

27 Which one of the following organisms would be the most likely cause of cellulitis in this patient? A) Non group A Streptococcus B) Pneumococcus (Strep pneumoniae) C) Clostridium perfringens D) Escherichia coli E) Pasteurella multocida

28 Which one of the following organisms would be the most likely cause of cellulitis in this patient? A) Non group A Streptococcus B) Pneumococcus (Strep pneumoniae) C) Clostridium perfringens D) Escherichia coli E) Pasteurella multocida

29 Causes of Cellulitis Beta-hemolytic Streptococci (most often Group A) Staph Aureus Non-purulent cellulitis cover for Strep and MSSA (Cephalexin) Purulent cellulitis cover for MRSA (Bactrim DS, Doxycycline, Clindamycin) and culture Abscess INCISION AND DRAINAGE Unless complicated (cellulitis, immunocompromised, fever, etc)

30 Other Staph and Strep infections Impetigo S. aureus more common Beta-hemolytic Strep less Localized cases can be treated with mupriocin More generalized with oral antibiotics (Cephalexin or Dicloxacillin) for 7 days Culture (if MRSA, tx with doxycycline, clinda or trimethoprim-sulfamethoxazole)

31 Other Staph Infections Acute Paronychia No abscess warm soaks and topical mupirocin Abscess drainage, soaks and mupirocin Culture Oral anti-staph antibiotics for 7 days for more severe cases

32 Not to be confused with Herpetic Whitlow Grouped vesicles on an erythematous base HSV 1 or 2 infection of finger from oral inoculation (most often in children, healthcare workers) Painful, can have fever and regional lymphadenopathy DFA or viral culture No need to treat Self-limited

33 Herpes Zoster Reactivation of latent VZV

34 Treatment of Herpes Zoster Antiviral therapy with acyclovir, valacyclovir, famciclovir Best when given within first 72 hours Treat after 72 hrs if still getting new lesions, immunosuppressed, pregnant Treat pain! Warn about contact with pregnant women, unvaccinated babies, immunocompromised Treat with antivirals AND call ophthalmology if Herpes Zoster Ophthalmicus

35 Imiquimod (Aldara) is approved by the FDA for treatment of which one of the following conditions? A) External anogenital warts B) Plantar warts C) Flat warts D) Periungual warts E) Molluscum contagiosum

36 Imiquimod (Aldara) is approved by the FDA for treatment of which one of the following conditions? A) External anogenital warts B) Plantar warts C) Flat warts D) Periungual warts E) Molluscum

37 Imiquimod A toll-like receptor-7 agonist Enhances both the innate and acquired immune response FDA approved for treatment of external anogenital warts

38 An otherwise healthy 37-year-old male presents to your office with a 2-week history of redness and slight irritation in his groin. On examination a tender erythematous plaque with mild scaling is seen in his right crural fold. The area fluoresces coral-red under a Wood s light.

39 Which one of the following would be the most appropriate treatment at this time? A) Amoxicillin B) Erythromycin C) Ketoconazole D) Nystatin (Mycostatin) E) Triamcinolone (Kenalog)

40 Which one of the following would be the most appropriate treatment at this time? A) Amoxicillin B) Erythromycin C) Ketoconazole D) Nystatin (Mycostatin) E) Triamcinolone (Kenalog)

41 Erythrasma Erythrasma is caused by C. minutissimum, a component of the normal skin flora Overgrowth in stratum corneum occurs under conditions of occlusion and moisture Topical erythromycin and clindamycin are first line Oral clarithromycin or erythromycin for extensive disease Topical imidazole antifungals (econazole) also work

42 Other Groin Rashes Candida Moist beefy red Satellite pustules Keep area dry Nystatin Imidazole antifungals

43 Other Groin Rashes Tinea Cruris Scaly plaque Serpiginous scaly border - Topical Tx: Imidazoles or Allylamines (Terbinafine) - Oral Terbinafine for extensive tinea infections

44 A 69-year-old female sees you for an annual examination. She asks you to look at her toes, and you note a fungal infection in five toenails. She says the condition is painful and limits her ability to complete her morning walks. She asks for treatment that will allow her to resume her daily walks as soon as possible. Her only other medical problem is allergic rhinitis, which is well controlled.

45 Which one of the following would be the most appropriate treatment for this patient? A) Oral griseofulvin ultramicrosize (Gris-PEG) daily for 12 weeks B) Oral terbinafine (Lamisil) daily for 12 weeks C) Topical terbinafine (Lamisil AT) daily for 12 weeks D) Topical ciclopirox (Penlac Nail Lacquer) daily for 12 weeks E) Toe nail removal

46 Which one of the following would be the most appropriate treatment for this patient? A) Oral griseofulvin ultramicrosize (Gris-PEG) daily for 12 weeks B) Oral terbinafine (Lamisil) daily for 12 weeks C) Topical terbinafine (Lamisil AT) daily for 12 weeks D) Topical ciclopirox (Penlac Nail Lacquer) daily for 12 weeks E) Toe nail removal

47 Onychomycosis Dermatophyte infection most common Candida and non-dermatophyte mold (Fusariam, Aspergillus, others) Diagnosis: PAS most sensitive, Culture--only about 50% sensitivity Treatment not necessary if asymptomatic Treat if recurrent cellulitis (diabetics), pain, immunosuppression, patient preference

48 Onychomycosis Treatment Treat for presumed dermatophyte infection while waiting for culture results Oral Terbinafine 250mg daily for 12 weeks Cure rate about 70%, half relapse by 5 years Itraconazole, same cure rate, more side effects and interactions Topicals: Efinaconazole, Ciclopirox (cure rates 16%, 8% respectively) Cost: $31,000 for a course of Jublia/$184,000 to cure 10 toenails

49 Which one of the following would be considered first-line therapy for mild to moderately severe psoriasis confined to the elbows and knees? A) Phototherapy using ultraviolet B light B) Methotrexate C) Etretinate (Tegison) D) Betamethasone dipropionate (Diprolene)

50 Which one of the following would be considered first-line therapy for mild to moderately severe psoriasis confined to the elbows and knees? A) Phototherapy using ultraviolet B light B) Methotrexate C) Etretinate (Tegison) D) Betamethasone dipropionate (Diprolene)

51 Psoriasis Treatment LOCALIZED DISEASE TOPICAL TREATMENT Topical steroids (Clobetasol) Topical retinoids (Tazorac) Topical Vitamin D derivatives (Calcipotriene) Tar Combinations of topical treatments are more effective Intralesional Steroids NB UVB (more generalized disease)

52 Psoriasis Treatment Generalized disease, arthritis systemic treatment Methotrexate Biologics: - TNF alpha inhibitors (Adalimumab-Humira) - IL 12/23 inhibitor (Ustekinumab-Stelara) - IL 17 inhibitors (Secukinumab-Cosentyx) Acitretin, Cyclosporin (less often) Apremilast Otezla (oral PDE4 inhibitor)

53 Psoriasis - Real Life Psoriasis patients have systemic inflammation Co-morbidities: obesity, diabetes, cardiovascular disease More severe psoriasis--higher risk of comorbidities Counsel patients about diet, exercise Address co-morbidities

54 While vacationing, a 27-year-old white male was exposed to poison ivy. Between 48 and 72 hours after exposure he developed a pruritic, erythematous, papulovesicular eruption on his arms and neck. He was given oral methylprednisolone (Medrol Dosepak), starting with 24 mg/day and tapered by 4 mg/day over 6 days. His condition began to improve, but on day 6 he noted a dramatic exacerbation of the eruption with intense pruritus, erythema, and vesiculation, involving extensive areas of his arms, neck, and face.

55 The most appropriate management at this time would be to A) prescribe a superpotent topical corticosteroid B) repeat the oral methylprednisolone treatment C) begin diphenhydramine (Benadryl), 4 times a day D) begin high-dose oral prednisone and taper over 2 weeks E) discontinue all medications and recommend cool compresses

56 The most appropriate management at this time would be to A) prescribe a superpotent topical corticosteroid B) repeat the oral methylprednisolone treatment C) begin diphenhydramine (Benadryl), 4 times a day D) begin high-dose oral prednisone and taper over 2 weeks E) discontinue all medications and recommend cool compresses

57 Allergic Contact Dermatitis to Urushiol in Poison Oak (Ivy or Sumac) Type IV hypersensitivity reaction Localized eruptions can be treated with superpotent topical steroids (clobetasol) Oral prednisone is given for more extensive eruptions Needs to be started at a high dose (40-60mg) and tapered slowly over 2-3 weeks If tapered too quickly, patient will flare Antibiotics if secondarily infected (Staph)

58 Eczema/Atopic dermatitis Itchy erythematous scaly papules and plaques Patients with atopy (allergic rhinitis, asthma, FH) Problem with epidermal barrier and immune dysregulation Treatment MUST address both!

59 Eczema Treatment Emollients, gentle skin care, avoidance of irritants and topical allergens Topical steroids 1 st line Topical calcineurin inhibitors (tacrolimus) Do not use antibiotics unless impetiginized Treat pruritus Phototherapy Immunosuppressive agents for severe cases Dupilumab, modulates IL-4 and IL-13 signaling

60 Patients presenting with erythema multiforme often have a prodromal history of A) egg allergy B) recent immunization C) herpes simplex infection D) thennal trauma E) streptococcal infection

61 Patients presenting with erythema multiforme often have a prodromal history of A) egg allergy B) recent immunization C) herpes simplex infection D) thennal trauma E) streptococcal infection

62 Erythema Multiforme Target lesions (three zones: dark dusky center, pale ring of edema, erythematous halo) Can be atypical, with just 2 or 1 zone Hypersensitivity reaction to: - Infections (most commonly HSV, Mycoplasma pneumoniae, many others) Drugs are a less common cause (NSAIDs, Antibiotics, Anticonvulsants, others) If recurrent, treat with suppressive HSV therapy

63 Stevens Johnson Syndrome (SJS) & Toxic Epidermal Necrolysis (TEN) Severe mucocutaneous reaction usually caused by a medication Starts with fever, flu-like symptoms, mucosal pain Mortality up to 30%, higher in adults Allopurinol Phenobarbetal Bactrim Lamotrigine STOP the MEDICATION

64 A 20-year-old female college tennis player presents with painful anterior lower leg lesions. You note several 2- to 3- cm deep, tender, warm lesions over both shins. The patient denies specific trauma or increased exercise. The most significant etiology to be considered in this case is A) papular urticaria B) early rheumatoid arthritis C) shin splints D) superficial thrombophlebitis E) oral contraceptive use

65 A 20-year-old female college tennis player presents with painful anterior lower leg lesions. You note several 2- to 3- cm deep, tender, warm lesions over both shins. The patient denies specific trauma or increased exercise. The most significant etiology to be considered in this case is A) papular urticaria B) early rheumatoid arthritis C) shin splints D) superficial thrombophlebitis E) oral contraceptive use

66 Erythema Nodosum Panniculitis Delayed-type hypersensitivity reaction to: - Infection (Streptococcal most common) - Drugs (OCPs, antibiotics) - IBD - Pregnancy

67 Erythema Nodosum Treatment Self-resolving, but takes several weeks Treat underlying condition or stop medicatin Supportive treatment - Leg elevation - Rest - NSAIDs - If severe, can consider short course of lowdose prednisone (20mg 7-10 days)

68 A 5-year-old African-American child has been experiencing scalp pruritus for several months, along with hair loss in a motheaten pattern. Small block dots can be seen within the larger alopecic patches. A potassium hydroxide (KOH) reparation shows occasional branching hyphae and multiple spores.

69 Which one of the following is the preferred treatment? A) Topical ketoconazole (Nizoral) B) Topical minoxidil (Rogaine) C) Oral griseofulvin (Fulvicin) D) Oral hydroxyzine (Atarax) E) Psoralen-ultraviolet A (PUVA) therapy

70 Which one of the following is the preferred treatment? A) Topical ketoconazole (Nizoral) B) Topical minoxidil (Rogaine) C) Oral griseofulvin (Fulvicin) D) Oral hydroxyzine (Atarax) E) Psoralen-ultraviolet A (PUVA) therapy

71 Tinea Capitis - Treatment Long Course (4-6 weeks or more) Griseofulvin mg/kg divided bid x 6-12 weeks (give with ice cream of other fatty food) Works best against Microsporum Species Lamisil (Terbinafine) 5mg/kg/d x 4 wks Works best against Trichophyton Species Itraconazole has a worse side effect profile, do not use first line for skin/nail infections

72 Kerion Inflammatory reaction to tinea infection Can lead to scarring Not a bacterial infection does not require antiobiotics We often add low-dose prednisone to treat inflammation and minimize scarring

73 A 30-year-old white male presents with a polymorphous skin rash consisting of grouped vesicles,urticarial wheals, and papular lesions distributed symmetrically over the elbows, knees, and buttocks. A skin biopsy shows IgA deposition and a diagnosis of dermatitis herpetiformis is made. The mainstay of therapy is A) dapsone B) prednisone C) cephalosporins D) methotrexate E) tetracycline

74 A 30-year-old white male presents with a polymorphous skin rash consisting of grouped vesicles,urticarial wheals, and papular lesions distributed symmetrically over the elbows, knees, and buttocks. A skin biopsy shows IgA deposition and a diagnosis of dermatitis herpetiformis is made. The mainstay of therapy is A) dapsone B) prednisone C) cephalosporins D) methotrexate E) tetracycline

75 Dermatitis Herpetiformis Associated with gluten sensitivity celiac disease Treatment Strict gluten-free diet works slowly Dapsone works quickly, can later be discontinued

76 A 62-year-old female presents with painful lesions at both corners of her mouth characterized by redness, scaling, and deep cracks. The cracks sometimes bleed when she opens her mouth. She has treated them with bacitracin/neomycin/polymyxin B ointment (Neosporin) but says it has not helped. Which one of the following would be most appropriate at this point? A) A biopsy of the lesions B) An anticandidal medication C) Bacitracin D) Vitamin B12

77 A 62-year-old female presents with painful lesions at both corners of her mouth characterized by redness, scaling, and deep cracks. The cracks sometimes bleed when she opens her mouth. She has treated them with bacitracin/neomycin/polymyxin B ointment (Neosporin) but says it has not helped. Which one of the following would be most appropriate at this point? A) A biopsy of the lesions B) An anticandidal medication C) Bacitracin D) Vitamin B12

78 Angular Cheilitis More common in elderly people Ill-fitting dentures Dry mouth Poor oral hygiene Complicated by candidal or staph infection Barrier creams (zinc or vaseline) Treat infection Minimize exacerbating factors Can check for B12 or iron deficiency

79 A 25-year-old female has an annular rash on the dorsal surface of both hands. The rash does not respond to initial treatment with an antifungal medication, and a biopsy reveals granuloma annulare. Which one of the following would be the most appropriate advice for this patient? A) Allow the rash to resolve without further treatment B) Cover the rash because it is contagious C) Treat the rash with systemic corticosteroids D) Treat the rash with a stronger antifungal medication

80 A 25-year-old female has an annular rash on the dorsal surface of both hands. The rash does not respond to initial treatment with an antifungal medication, and a biopsy reveals granuloma annulare. Which one of the following would be the most appropriate advice for this patient? A) Allow the rash to resolve without further treatment B) Cover the rash because it is contagious C) Treat the rash with systemic corticosteroids D) Treat the rash with a stronger antifungal medication

81 Granuloma Annulare Non-scaly erythematous annular papules and plaques on dorsal hands, elbows, feet, knees A benign, reactive condition, can self resolve Treatments included superpotent topical steroids and intralesional steroids

82 A 50-year-old female presents with a 3-week history of a moderately pruritic rash, characterized by flat- topped violaceous papules 3 4 mm in size. The lesions are located primarily on the volar wrists and forearms, lower legs, and dorsa of both feet. Ten days after the rash first appeared she went to the emergency department and was treated for possible scabies, but the treatment has made little or no difference.

83 Which one of the following treatments is indicated at this time? A) Clobetasol (Cormax, Temovate) 0.05% ointment B) Permethrin 5% cream C) Tacrolimus (Protopic) 0.1% ointment D) Triamcinolone 0.1% cream

84 Which one of the following treatments is indicated at this time? A) Clobetasol (Cormax, Temovate) 0.05% ointment B) Permethrin 5% cream C) Tacrolimus (Protopic) 0.1% ointment D) Triamcinolone 0.1% cream

85 Lichen Planus 5 P s: pruritic, purple, planar (flat-topped), polygonal papules Wickham striae Wrists/ankles classic Oral/genital involvement Can be erosive Etiology unknown?associated with Hep C? Potent or superpotent topicals steroids are first line tx Other tx: topical tacrolimus, prednisone taper, plaquenil, acitretin, methotrexate

86 Scabies

87 Scabies Erythematous papules, pustules, burrows Likes hands, skin folds, groin, less on head Very itchy SCRAPE IT Treat all family members Permethrin cream x 2 Ivermectin PO if crusted

88 Erythema Migrans 7-14 days after tick bite

89 Lyme Disease - Caused by Borrelia spirochete transmitted by bite of Ixodes deer tick - In early Lyme disease serologic testing is likely to be negative - Diagnosis should be made based on the clinical picture (EM lesion or lesions, nonspecific viral symptoms, and history of living in or travel to an endemic area Treatment: - Doxycycline 100mg BID for days or - Amoxicillin 500mg po BID for days

90 Secondary Syphilis Treponemal test (FTA-ABS) to screen and non-treponemal test (RPR) to confirm Treat with Penicillin G

91 Acne Assess severity Mild to moderate topical therapy (retinoids, Benzoyl Peroxide, clindamycin) Moderate course of antibiotics (Doxy, limit to 6 months) Hormonal treatments for women (OCP, spironolactone) Severe nodulocustic/scarring: Isotretinoin teratogen, otherwise quite safe)

92 Urticaria Acute urticaria < 6 weeks Chronic urticaria > 6 week Triggers - Foods acute - Medications and Infections - Over 50% of chronic urticaria is idiopathic Treat with anti-histamines (non-sedating up to 4 times the daily dose) Do not use prednisone, especially for chronic