FAMILY PRACTITIONERS! Beirut Medical Center
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1 LESIONS THAT MAY FOOL FAMILY PRACTITIONERS! Samer Ghosn American University of Beirut Medical Center
2 DERMATOLOGY PATIENTS GP Diagnosis is in doubt Diagnosis and treatment DERMATOLOGIST Failure
3 GPs are often the first physicians to evaluate skin lesions. Their initial assessment is crucial for early diagnosis, timely referral, and proper management.
4 Assessing diagnostic skill in dermatology: a comparison between general practitioners and dermatologists. Australas J Dermatol consecutive general practitioner referrals to a private dermatology practice were assessed. Concordance (GP-D) in 42% of all biopsied cases General practitioners agreed with the histological diagnosis in 24% of cases Dermatologists agreed with the histological diagnosis in 77% of cases. Concordance (GP-D) in 45% of all non-biopsied cases.
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6 THE NON-DISTINCT LESIONS OF THE FACE THAT HAVE REAL THAT HAVE REAL SIGNIFICANCE!!!
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10 Sebaceous gland hyperplasia
11 Imperfect SGH!! SGH Sebaceous adenoma
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13 Muir-Torre syndrome Syndrome that combines: At least one sebaceous neoplasm (other than sebaceous gland hyperplasia) At least one visceral malignancy AD in 59% of cases.
14 Visceral neoplasm in MTS Colorectal l cancer (50%) Genitourinary cancers (25%). Others Breast cancer Lymphoma and rarely leukemia Salivary gland tumors Lower and upper respiratory tract tumors Chondrosarcoma Intestinal polyps >25% of patients Benign tumors: ovarian granulosa cell tumor, hepatic angioma, benign schwannoma of the small bowel, and uterine leiomyomas.
15 May uncover colon CA
16 Verrucoid lesions! Multiple trichilemmoma
17 AD Cowden Syndrome (Multiple hamartoma syndrome) Multiple trichilemmoma Higher incidence of breast carcinoma in women Hamartomas a as of internal organs including cud the thyroid gland, breasts and gastrointestinal tract.
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19 May uncover breast CA
20 Resistant acneiform lesions!! Multiple fibrofolliculomas/trichodiscomas
21 Birt-Hogg-Dube syndrome Skin: fibrofolliculomas, trichodiscomas & acrochordons Kidney: malignant chromophobe h carcinomas L ng c sts or spontaneo s Lung: cysts or spontaneous pneumothoraces
22 Birt-Hogg-Dube syndrome Medullary thyroid carcinomas Parathyroid adenomas Neurothekeoma Meningioma Adenocarcinoma of the colon and colonic polyps
23 AD Birt-Hogg-Dube syndrome Gene encodes folliculin, a protein highly conserved and expressed in the lungs, skin and kidneys Gene locus close to p53 gene locus (17p13.1)? tumor formation
24 CASE A 40-year-old woman with asymptomatic facial papules and history of pneumothoraces - many years
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28 +ve FH of similar lesions in mother, brother and maternal uncle CT of chest: numerous pulmonary cysts System review negative
29 Birt-Hogg-Dube syndrome Timely diagnosis important Renal cancers major cause of morbidity and mortality Renal ultrasound or abdominal/pelvic CT scan Screening of family members & genetic counseling
30 Resistant acneiform lesions! Multiple angiofibromas!
31 Tuberous sclerosis
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33 Angiofibroma
34 NON-DISTINCT LESIONS OF THE FACE SHOULD BE BIOPSIED.
35 ECZEMATOUS LESIONS THAT ARE FAR FROM BEING THAT ARE FAR FROM BEING ECZEMA!
36 Unexplained persistent eczema over hand!
37 Bowen s disease (SCCIS)
38 Unexplained persistent eczema over trunk!
39 Mycosis fungoides
40 Unexplained persistent eczema over breast!
41 Mammary Paget disease
42 Extramammary Paget disease
43 Tinea incognito
44 Tinea penis
45 SEBORRHEIC RASHES BUT NOT SEBORRHEIC BUT NOT SEBORRHEIC DERMATITIS!
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47 Familial foul-smelling seborrheic rash!!
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49 Darier s disease
50 PEMPHIGUS FOLIACEUS
51 ATYPICAL ECZEMATOUS RASHES SHOULD BE BIOPSIED!
52 GENITAL LESIONS THAT ARE NOT SEXUALLY THAT ARE NOT SEXUALLY TRANSMITTED!
53 FIXED DRUG ERUPTION
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57 Pearly penile papule
58 Angiokeratomas of Fordyce
59 Tyson s s spots
60 Fordyce spots Montgomery spots
61 Ectopic sebaceous glands
62 ACNE OR FOLLICULITIS? OR NEITHER?!!
63 Pityrosporum folliculitis
64 Rosacea
65 Steroid-induced induced rosacea
66 Acquired perforating disorder of diabetes and renal failure
67 Miliaria i
68 PIGMENTED LESIONS THAT ARE NOT MELANOCYTIC!
69 Polythelia
70 Dermatofibroma
71 IF MULTIPLE LESIONS
72 Seborrheic keratoses
73 Pigmented basal cell carcinoma
74 Pigmented actinic keratoses
75 LESIONS THAT ARE TOO WEIRD TO BE NEVI!!
76 Spitz nevus
77 Blue nevus
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79 HALO NEVUS: risk of vitiligo!
80 Which lesion would you like to have on your skin?
81 URTICARIAL RASHES THAT ARE NOT URTICARIA!
82 Urticaria Evanescent Itchy No marks!
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86 Non-evanescent evanescent, painful, and purpuric urticaria!!!
87 Urticarial vasculitis
88 Resistant urticaria in an elderly man! Later on bullae!!
89 Bullous pemphigoid
90 VERY BENIGN LESIONS THAT MIMIC CARCINOMA!
91 Chondrodermatitis nodularis helicis: look for vascular problems!
92 WHEN COMMON TONGUE CHANGES ARE IMPORTANT TO ARE IMPORTANT TO RECOGNIZE!
93 Scrotal tongue (fissured, lingua plicata)
94 Melkerson-Rosenthal syndrome Scrotal tongue Episodes of facial nerve palsy Recurrent episodes of lip swelling that becomes persistent t over time Crohn s disease?
95 Geographic tongue (benign migratory glossitis)
96 BLACK HAIRY TONGUE
97 Peutz-Jeghers syndrome
98 LESIONS THAT MAY MIMIC PITYRIASIS ROSEA AND MANY OTHER THINGS!
99 Secondary syphillis
100 LOTS OF VERRUCAE SO WHAT?
101 -EDV -BIOPSY!
102 WHEN TINEA DOES NOT RESPOND TO DOES NOT RESPOND TO ANTIFUNGUALS!
103 Inverse psoriasis
104 Familial benign pemphigus (Hailey- Hailey disease)
105 Beware of axillary lipomas! Because they may not be Because they may not be lipomas
106 A 31 year old Indian woman with stable bilateral y axillary lipomas since the age of thirteen
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108 Aberrant breast tissue Class I (Polymastia) Class II (Supernumerary breast without areola) Complete breast(s) with nipple, areola, and glandular tissue Nipple and glandular tissue but no areola Class III (Supernumerary breast without nipple) Areola and glandular tissue but no nipple Class IV (ABT or Mamma aberrata) Glandular tissue only Class V (Pseudomamma) Nipple and areola but without t glandular l tissue (replaced by fat) Class VI (Polythelia) Class VII (Polythelia areolaris) Class VIII (Polythelia pilosis) Nipple only Areola only Patch of hair only Kajava classification of ectopic mammary tissue
109 Aberrant breast tissue Often misdiagnosed as lipoma, hidradenitis, follicular cysts, and lymphadenopathy inappropriate Rx. The lack of associated nipple complex The late onset of diagnosis
110 ABT & Breast cancer Increased incidence of cancer in ABT but not in polymastia/ supernumerary breast Stagnation in the lumina of ABT, a promoting factor? Most reported cases of malignant degeneration: ductal carcinoma (79%). Cancers arising in axillary ABT have a worse prognosis.
111 Aberrant breast tissue Therapy Prophylactic surgical excision associated with significant morbidity The current approach is conservative e Periodical examination
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113 DERMATOLOGY The importance of The importance of clinicopathologic correlation!
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116 Surgeon gets result : SCCIS And he does act accordingly
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119 Bowenoid papulosis Bowen s disease
120 Clinicopathologic correlation is very important! It might save the patient a It might save the patient a vulvectomy!
121 A 21 year-old woman with a 3-year-history of recurrent vesicular eruption
122 Case 3
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124 D = Bullous EM
125 No history of herpetic lesions o sto y o e pet c es o s No improvement on valtrex 500mg BID for 3months!!!
126 GP noted: Patient was having monthly eruptions!
127 AUTO-IMMUNE PROGESTERONE DERMATITIS Premenstrual lesions Premenstrual lesions 24 hours after test t injection Premenstrual lesions Progesterone challenge(50mg/cc)
128 GP
129 Why GPs get fooled by these lesions? Because of fthe lesions themselves! Because of GP s Not interested? Not trained enough? They don t refer when they don t know!? Because of dermatologists They don t like to teach GPs! They don t give them feedback about patients! Because of the system!
130 Thank you!
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132 PURPURIC LESIONS BUT NOT VASCULITIC!
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134
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