Rash Decisions Approach to the patient with a skin condition

Transcription

1 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 University School of Medicine and Frances Payne Bolton School of Nursing University Hospitals Case Medical Center Department of Dermatology, Faculty and Director of NP Residency Margaret.bobonich@uhhospitals.org Disclosure none Objectives 1. Identify the key physiologic characteristics in assessing any rash and accurate documentation. 2. Develop an systematic approach for the diagnosis of rashes. 3. Discuss at least three papulosquamous dermatoses and physical findings important for differential diagnoses. 1

2 Clinical Dermatology: A Manual of Differential Diagnosis, 3 rd Ed. by Stanferd L. Kusch, M.D. Free download: Diagnosing a rash DermAtlas; 2

3 Approach to a Rash History Examination Distribution Body site Morphology (primary) Fluid filled Red or colored Scale Diagnostics Past Medical History Allergies Immunization Previous infections Major diseases or illness Recent illnesses (colds, flu, etc) Stressful events Exposure Medications RX and OTC Family Social Travel History Present Illness Age/time of onset Previous treatment Chronology of illness When & where did it start How has it change (better, worse, same) Change in eating, sleep, elimination, behavior/activity pattern Has it ever happened before What treatment (OTC and Rx) Patient s (or caregivers) perception 3

4 Approach to a Rash History Examination Distribution Symmetrical/asymmetrical Diffuse or localized Arrangement Site Morphology Fluid filled/blisters Color (especially RED) Scale Diagnostics Symmetry Distribution Diffuse vs localized Bilateral Symmetrical Others: Dermatomal, blaschkoid, photodistributed, keobnerized, etc. Arrangement Reticular Linear Herpetiform Confluent Annular Targetoid Blaschko lines.more 4

5 Body Site Trunk Extremities (extensors/flexors) Acral (palms, soles, nose, ears) Mucosa Head/neck/scalp Eyelids and ENT Interdigital Intertriginous Hair and nails Morphology & Characteristics Identify primary lesions for accurate diagnosis Documentation Important for collaborating with others EXAMPLE* (Symmetrically/Asymmetrically) involving the (body parts) of this patient are (number of lesions), (size of lesions), (color), (morphologic description), (arrangement), and (scale/without scale). *does not have to be exact order Approach to a Rash History Examination Distribution Symmetrical/asymmetrical Diffuse or localized Arrangement Site Morphology Primary Lesions Fluid filled/blisters Color (especially RED) Scale Diagnostics 5

6 Morphology Primary (1cm/ >1cm) Macule/Patch flat Papule/Plaque raised Nodule solid Vesicle/Bulla clear fluid Pustule yellow fluid Wheal (hive).and many more Secondary Scale Crust Erosion Ulcer Fissure Atrophy Lichenification Associated Characteristics Mobility of skin Nails Hair Pruritus Morphology of Lesions for Differential Diagnosis Focus of 3 characteristics: Fluid filled/solid Color (especially RED) Scale 6

7 Macule < 1cm Patch 1cm Flat or Raised Papule < 1cm Plaque 1cm Vesicle Fluid filled lesions Pustule Scale Scale Crust 7

8 Color 1 Diagnostic Algorithm Adapted from Lynch PJ. (1994). Dermatology for the hous officer, Adapted 3rd ed. from Baltimore: Lynch PJ. Williams (1994). & Dermatology Wilkins. for the ho officer, 3rd ed. Baltimore: Williams & Wilkins. 2 3 Hint: Save this for practice! Fluid Filled Vesiculobullous Diseases Vesicular disease Herpes simplex Varicella zoster Vesicular tinea pedis Dyshidrosis Dermatitis herpetiformis Misc (arthropod, pityriasis lichenoides, contact dermatitis, etc) Bullous disease Autoimmune Blistering Disease Stevens Johnson syndrome Bullous erythema multiforme Contact dermatitis Infection (i.e. bullous impetigo) Traumatic 8

9 True (Soft) Pustules Acne vulgaris Rosacea Bacterial folliculitis Fungal folliculitis Candidiasis Pseudopustules See white papules Fluid Filled Pustular Diseases Clinical Dermatology: A Manual of Differential Diagnosis, 3 rd Ed. by Stanferd L. Kusch, M.D. Free download: 9

10 Diagnostic Algorithm Color Skin Colored Papules/Nodules Keratotic (rough surface) Verruca (warts) Actinic keratoses Corns and calluses Non keratosis (smooth surface) Verruca Basal cell carcinoma Squamous cell carcinoma Epidermoid sebaceous cysts Lipomas Molluscum contagiosum Solid, non-red White lesions Patches & plaques Pityriasis alba Pityriasis (tinea) versicolor Vitiligo Papules Milia Keratosis pilaris (can also be red) Molluscum contagiosum Brown Black lesions Macules, papules, & nodules Freckles & lentigines Nevi Melanoma Seborrheic keratoses Dermatofibromas Patches & plaques Cafe au lait patches Giant congenital nevus Yellow lesions Smooth Xanthelasma Necrobiosis lipoidica Rough Actinic keratosis**** Crusted lesions (see Vesiculobullous and eczematous) 10

11 Diagnostic Algorithm Solid, red, non scaling Dome shaped, red papule and nodule, usually solitary Papules Insect bites Cherry angiomas Pyogenic granulomas Granuloma annulare Nodules Furuncles Inflamed epidermoid cysts Hidradenitis Solid, red, non scaling Flat topped, vascular reactions, usually multiple Transient erythemas Urticaria & angioedema Persistent erythemas Erythema multiforme Erythema nodosum Purpuric erythemas Leukocytoclastic vasculitis 11

12 Diagnostic Algorithm Papulosquamous no epithelial disruption Sharply marginated around lesion Sometimes secondary eczematous Eczematous epithelial disruption Erosions, weeping, crusts, fissures Poorly marginated (+/- partial areas) Lichenification (pathognomonic) Papulosquamous (No epithelial disruption) Solid, red, scaling Eczematous (Epithelial disruption) Prominent plaque formation Psoriasis Tinea Lupus erythematosus, incl. discoid type Mycosis fungoides (CTCL) Nonconfluent papules Pityriasis rosea Lichen planus Secondary syphilis ( the great imitator ) Excoriations prominent Atopic dermatitis Dyshidrotic eczema Stasis dermatitis Scabies (and post scabies) Little or no excoriation Seborrheic dermatitis Irritant contact dermatitis Allergic contact dermatitis Xerotic eczema Lynch PJ. (1994). Dermatology for the house officer, 3rd ed. Baltimore: Williams & Wilkins. 12

13 Making the Diagnosis DDX list Eczematous Little/no excoriation Seborrheic dermatitis Irritant contact dermatitis Allergic contact dermatitis Xerotic eczema Drug eruption Location Distribution History Body site Distribution Arrangement Hair/follicles Nails Comorbidities History Diagnostic tests Dx Dx Case Studies Lesion Identification and Diagnosis Margaret Margaret Bobonich Bobonich Free download: 13

14 ISBN-10: ISBN-13: January