Facial Rash. Facial Rash 10/14/2013. Ten Look Alike Rashes Michelle DiBaise, MPAS, PA-C, DFAAPA Associate Clinical Professor NAU PA Program

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1 Ten Look Alike Rashes Michelle DiBaise, MPAS, PA-C, DFAAPA Associate Clinical Professor NAU PA Program Facial Rash Facial Rash Case 1 28 year female Progressive development of erythematous facial lesions x 6 months Scaling, atrophy, and follicular plugging noted Case 2 44 year old male Rash and fine flaking on face, in the ears, scalp, and chest x 1 year No pruritis 1

2 Facial Rash 2

3 Facial Rash Discoid Lupus Seborrheic Dermatitis Facial Rash Case 1 ANA (NAP) Punch biopsy for H&E and DIF Treatment: Sun protection Hydroxychloroquine Corticosteroids and other immunomodulators Case 2 Topical shampoos and creams: Ketoconazole Selenium sulfide Ciclopirox Zinc pyrithione Salicylic acid Extensor Surface Rash 3

4 Extensor Surface Rash 52 year old male Small tear drop plaques with silvery white scale Elbows, knees, buttocks/sacral area Minimally pruritic 23 year old male Multiple excoriations with occasional vesicle Elbows, knees, buttocks/sacral area Very pruritic 4

5 Extensor Surface Rash Extensor Surface Rash Guttate Psoriasis Dermatitis Herpetiformis Extensor Surface Rash Can be precipitated by strep infection Treat strep infection Topical corticosteroids Vitamin D analogues Phototherapy Manifestation of Gluten enteropathy (Celiac disease) Biopsy for IgA Serum antibodies for Celiac Gluten free diet Dapsone 5

6 New Lesion New Lesion 52 year old female Lesion developed rapidly over 4 months Otherwise asymptomatic 63 year old male Lesion developed slowly over the past 18 months Occasionally bleeds when traumatized 6

7 New Lesion New Lesion Amelanotic Melanoma Basal Cell Carcinoma 7

8 New Lesion Biopsy if uncertain of diagnosis Follow up with excision Referral to: Moh s surgeon Oncology Follow up every 3 months for the first year Biopsy or excision initially depending on size of lesion Follow up every 6 12 months for skin exam Itchy Rash Itchy Rash 49 year old male Indurated, pruritic plaques with cigarette paper appearance Developed over the course of the past 2 years Unresponsive to topical steroids 68 year old male Non-indurated, pruritic plaques KOH negative Comes and goes Worse in humid weather 8

9 Itchy Rash 9

10 Itchy Rash CTCL (Mycosis Fungoides) Nummular Eczema Itchy Rash Biopsy with T cell typing Sezary cell count once CTCL confirmed on biopsy Referral to oncology Check feet and groin for underlying fungal infection (Id reaction) Treat underlying infection Topical steroids to nummular dermatitis Emollients Tar preparations Topical immunomodulators Phototherapy Drug Reaction? 10

11 Drug Reaction? 78 year old female Lesions present for 15 months, never migrate nor disappear Stop all medications and re-introduction one at a time No change in rash History of CML 28 year old female Lesions present, migrate and disappear within 24 hours Mild pruritis 11

12 Drug Reaction? Drug Reaction? Leukemia Cutis Acute Urticaria Drug Reaction? Biopsy Referral to oncology Attempt to identify allergen Remove offending agent H1 blockers Epinephrine IM steroids 12

13 Eyelid Rash Eyelid Rash 23 year old female Dry, flaky, itchy rash on eyelids x 2 months Occasionally burns or stings History of allergic rhinitis 52 year old male Discoloration in periorbital area x 6 months Noted difficulty walking up stairs and carrying groceries 13

14 Eyelid Rash Eyelid Rash Eczema Dermatomyositis 14

15 Eyelid Rash Consider patch testing for allergic contact dermatitis Apply emollients Immunomodulator agents Avoid irritants Laboratory: ANA (NAP) CK and aldolase CXR Muscle biopsy EMG MRI Acneiform Eruption Acneiform Eruption 54 year old male Pruritic papules on the chest and upper back x 3 weeks Mineral oil scraping negative for mites or scybala 16 year old male Papules and pustules on chest and upper back x 1 year Some lesions are tender 15

16 Acneiform Eruption 16

17 Acneiform Eruption Grover s Disease (Transient Acantholytic Dermatosis) Acne Vulgaris Acneiform Eruption Usually self-limited Avoid activities that trigger flares High potency topical corticosteroids Moisturizers and emollients Antihistamines Vitamin D analogues Antibacterial soap Topical retinoid Topical antibiotic Benzoyl peroxide If no improvement consider oral antibiotics Depigmentation 17

18 Depigmentation 18 year old female Oval circumscribed area of induration with a waxy, ivory color surrounded by a violaceous halo over the lateral malleolus Initially the lesion was erythematous before the current appearance The center is atrophic Lesion has been present for 6 months 12 year old male Macular depigmentation on left side of neck No induration or atrophy noted Appears to have follicular repigmentation at the periphery 18

19 Depigmentation Depigmentation Morphea Vitiligo Depigmentation Biopsy to confirm if there is a doubt in the diagnosis ANA (NAP) Emollients, topical corticosteroids, vitamin D analogues Possible physiotherapy if contractures across the joint line Association with other autoimmune disorders: Thyroid disease, pernicious anemia, SLE, Type I DM, and Addison s disease TSH, FBG Topical corticosteroids Topical calcineurin inhibitors UV therapy Skin grafting Depigmentation 19

20 Pustular Rash Pustular Rash 36 year old female Multiple, firm, white lesions x 9 months Periorbital area Otherwise asymptomatic 53 year old male Blisters that easily rupture, scarring and firm white lesions on the dorsum of the hands especially after sun exposure Hirsutism on the cheeks and forearms Patient has a history of heavy alcohol use 20

21 Pustular Rash Pustular Rash Milia Porphyria Cutanea Tarda 21

22 Pustular Rash Extraction with needle or 11-blade and comedone extractor Topical retinoid Associated with excess alcohol consumption, estrogen use, hepatic siderosis, hepatitis C, HIV, and smoking Test urine and/or plasma porphyrins Repeated phlebotomy Hydroxychloroquine if phlebotomy not tolerated Hyperpigmented rash Hyperpigmented rash 18 year old male Grayish-blue, hyperkeratotic papules, located on the chest x 8 months Lesions coalesce to form plaques centrally and a net-like pattern peripherally KOH negative Otherwise asymptomatic 18 year old male Hyperpigmented, velvety plaques on the chest and back Worse when weather is hot and humid Has re-occurred over the past three summers 22

23 Hyperpigmented rash 23

24 Hyperpigmented rash Confluent and Reticulated Papillomatosis of Gougerot and Carteaud Hyperpigmented Tinea Versicolor Hyperpigmented rash Minocycline Keratolytic agents Oral, and topical forms of vitamin A Oral and topical retinoids Topical mupirocin 70% alcohol swabbing KOH shows hyphae and spores (spaghetti and meatballs) Malassezia species Topical antifungals: Ketoconazole Topical terbinafine Topical ciclopirox Selenium sulfide Systemic therapy: Itraconazole Fluconazole Reserved for patients with recalcitrant tinea versicolor or widespread disease References DelRosso, J.Q. (2011). Adult seborrheic dermatitis: a status report on practical topical management. Journal of Aesthetic Dermatology,4(5), Emedicine: emedicine.medscape.com Habif, T.P. (2010). Clinical Dermatology, 5 th Ed., Mosby, elsevier, Inc. Wolff, K., Johnson, R.A., & Saavedra, A. (2013). Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology, 7 th Ed., McGraw-Hill Professional. UpToDate: uptodate.com 24