2017 All right reserved Bellomo Consulting, Inc RECOGNIZING COMMON SKIN CONDITIONS
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1 RECOGNIZING COMMON SKIN CONDITIONS
2 Perioral Dermatitis
3 Perioral Dermatitis Predominately seen in females ranging in age from 16 to 45 years old. Also seen in infants and toddlers due to excess moisture from drooling or pacifier use; make sure to rule out bacterial and fungal component. Can also be seen periocular but much less common and more difficult to treat. Fitzpatrick,T. etal. Fitzpatrick's Color Atlas 2017 & Synopsis All of right Clinical reserved Dermatology. Bellomo Fifth Edition Consulting, p. 12. Inc
4 Potential Causes Unknown etiology. Potentially aggravated by: Potent topical (fluorinated) glucocorticoids; nasal steroids; ocular steroids, and steroids used in airway diseases. Fluoride toothpaste; cinnamon and peppermint; over moisturizing. Fitzpatrick,T. etal. Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology. Fifth Edition p. 12.
5 Signs and Symptoms 1-2 mm erythematous confluent papules and satellite papules; less common pustules, no comedones. May appear eczematous with fine scale. Typically starts unilateral and spreads symmetrically periorally, at the nasal creases and nasolabial folds sparing the vermillion border of the upper and lower lip. Fitzpatrick,T. etal. Fitzpatrick's Color Atlas 2017 & Synopsis All of right Clinical reserved Dermatology. Bellomo Fifth Edition Consulting, p. 12. Inc
6 Perioral Dermatitis
7 Perioral Dermatitis
8 Perioral Dermatitis Accessed February 2010
9 Periorbital Dermatitis Accessed February 2010
10 Therapeutic Options for Perioral Dermatitis AVOID TOPICAL STEROIDS Oral doxycycline or minocycline 100mg qd to bid Topical metronidazole 1% qd Azaleic acid (Finacea qd to bid in combo with metrogel) Topical Sodium Sulfacetamides (cleansers/lotions) Erythromycin 2% qd bid Ketoconazole Gel (Xologel)
11 DERMATITIS
12 Contact Dermatitis
13 Contact Dermatitis Irritant Contact Dermatitis Caused by a chemical irritant. Can be acute or chronic. Confined to the area of exposure. Allergic Contact Dermatitis Caused by an allergen that elicits a Type IV (cellmediated or delayed) hypersensitivity reaction. Dependent on sensitization of the individual. May spread beyond affected sites. Fitzpatrick,T. etal. Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology. Fifth Edition pp
14 Irritant Contact Dermatitis
15 Irritant Dermatitis Most common form of occupational skin disease accounting for up to 80%. Ask your patients what kind of work they do? Housekeeping, hairdressing, medical, construction, electrical, mechanical, floral/landscaping, food industry, bartending, printing/exposure to paper products or ink, fishing, painting, metal work Fitzpatrick,T. etal. Fitzpatrick's Color Atlas 2017 & Synopsis All of Clinical right Dermatology. reserved Bellomo Fifth Edition Consulting, pp Inc
16 Agents and Factors that cause ICD Abrasives, cleaning agents, hand sanitizers, solvents, oxidizing agents, plants, animal secretions, powders, dust, soils, excessive exposure to water. Patients with a history of atopy; lighter skin types; temperature and humidity; mechanical irritation. Fitzpatrick,T. etal. Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology. Fifth Edition pp
17 Signs and Symptoms of ICD Burning, stinging, itching, pain. Erythema, painful fissures, vesicles and bulla, dryness, hyperkeratosis, papules and pustules, erosions, lichenification. Fitzpatrick,T. etal. Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology. Fifth Edition pp
18 Acute ICD Erythema, edema, acute bullous, burning and pain. Due to acute exposure of chemicals, oils, and solvents. Fitzpatrick,T. etal. Fitzpatrick's Color Atlas 2017 & Synopsis All of right Clinical reserved Dermatology. Bellomo Fifth Edition Consulting, pp Inc
19 ICD from Garlic
20 ICD from Cement Accessed February 2010
21 Bullous ICD Accessed February 2010
22 Chronic ICD Hand Dermatitis most common chronic ICD, which occurs in combination with ACD due to sensitization. Airborne ICD found on face, neck, anterior chest, and arms. Caused by dust and volatile chemicals. Distinguish from photoallergic contact dermatitis. Pustular and Acneiform ICD May target follicles and be papulopustular. May result from metals, mineral oils, greases and solvents. Fitzpatrick,T. etal. Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology. Fifth Edition pp
23 Airborne Dermatitis Accessed February 2010
24 Chronic Hand Eczema Accessed February 2010
25 Management of ICD Removal of noxious substance or irritant. Wear protective clothing and eyewear. Wash with water or neutralizing solution right after contact. Barrier creams (cerave, hylatopic plus foam or cream). Change of job may be necessary.
26 Treatment of ICD Topical steroids (Class I most effective), oral (2- week course) or IM steroids depending on severity Tacrolimus or pimecrolimus for chronic ICD maintenance therapy Lubricants/barrier creams Keratolytic creams PUVA therapy (chronic conditions)
27 Allergic Contact Dermatitis
28 Allergic Contact Dermatitis Delayed, cell-mediated hypersensitivity reaction. Symptoms begin from 48h to days after contact; it may even takes months of exposure for symptoms to appear. The first symptoms is typically severe itching; sometimes burning and stinging can occur too. Fitzpatrick,T. etal. Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology. Fifth Edition pp
29 Characteristic Skin Findings Acute edema, erythema, vesicles, papules, erosions, or crusts. Subacute plaques with mild erythema, dry scales, small round pointed firm papules. Chronic plaques of lichenification, scaling, excoriations, firm papules and pigmentary changes. May be isolated to the area of exposure or spread to other areas. Fitzpatrick,T. etal. Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology. Fifth Edition pp
30 Testing for Allergens Patch Testing (Tru Test) Wait until dermatitis has subsided for at least 2 weeks. Should be performed on a uninvolved site. Stop oral antihistamines, oral steroids and topical steroids to the area patch test will be applied. Positive response should elicit erythema, papules and possibly vesicles. Fitzpatrick,T. etal. Fitzpatrick's Color Atlas 2017 & Synopsis All right of Clinical reserved Dermatology. Bellomo Fifth Edition Consulting, pp. Inc
31 Top 10 Most common allergens Nickel sulfate (metals of clothing, jewelry) (#1) Neomycin sulfate (contained in cream/ointment) Balsam of Peru (topical medications) Fragrance Mix (fragrances and cosmetics) Thimerosal (antiseptics) Sodium gold thiosulfate (medication) Formaldehyde (disinfectants, curing agent, plastic) Quaternium-15 ( disinfectant) Cobalt chloride (Cement, oils, eyeshades) Bacitracin (ointments and powders) Fitzpatrick,T. etal. Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology. Fifth Edition pp
32 Patch Testing Accessed February 2010
33 Hypersensitivity Reactions from Patch Test Accessed February All right reserved Bellomo Consulting, Inc
34 Nickel Allergy Accessed February 2010
35 Nickel Allergy Accessed February 2010
36 Shoe allergy Accessed February All right reserved Bellomo Consulting, Inc
37 ACD Accessed February All right reserved Bellomo Consulting, Inc
38 Allergic Reaction to Poison Ivy
39 Lichen Simplex Chronicus and Prurigo Nodularis
40 Lichen Simplex Chronicus (LSC) and Prurigo Nodularis (PG) Localized areas of hyperkeratosis and hyperpigmentation. Causes from chronic itching, rubbing or picking due to chronic pruritis, inflammation or a habit. Associated with Atopic Dermatitis and atopy. PN can also be associated with neurosis. Fitzpatrick,T. etal. Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology. Fifth Edition pp
41 Lichen Simplex Chronicus
42 Prurigo Nodularis
43 Acanthosis Nigricans
44 Acanthosis Nigricans A velvety thickening and hyperpigmentation of the skin. Commonly seen around the neck, axillae and other body folds. Etiology Hereditary Endocrine disorders (such as diabetes, PCOS, Addison s) Obesity Drug administration Malignancy (paraneoplastic, adenocarcinoma of gastrointestinal or genitourinary tract) Fitzpatrick,T. etal. Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology. Fifth Edition pp
45 Acanthosis Nigricans
46 Acanthosis Nigricans
47 Acanthosis Nigricans Course and Prognosis Seen in puberty, may regress as patient gets older. Look for underlying endocrine disorder. Diet and exercise; loss of weight. Discontinue causative drug. Look for underlying malignancy.
48 Treatment Treat underlying disorder Weight loss and diet Topical medications that can help; mainly cosmetic options Azaleic acid 4% Hydroquinone AHAs Low dose tretinoin With all the above topical treatment options, warn against possible irritation Explain all therapies are considered off-label
49 Pityriasis Rosea
50 Pityriasis Rosea An acute exanthematous eruption. Self-limiting (6 to 12 weeks duration). Commonly confused as Tinea Corporis, especially in the beginning of eruption when only the primary patch appears called a Herald s Patch. Herald patch precedes full eruption by 1 to 2 weeks; herald patch is seen in 80% of patients. Fitzpatrick,T. etal. Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology. Fifth Edition p. 118.
51 Pityriasis Rosea Distribution: truncal in a Christmas Tree pattern and proximal aspects of arms and legs. Appearance: oval, salmon to dull pink fine scaly patches and plaques. Pruritis: none; mild to severe. May follow and upper respiratory infection. Not contagious. Fitzpatrick,T. etal. Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology. Fifth Edition p. 118.
52 Pityriasis Rosea Accessed February 2010
53 Herald Patch Accessed February 2010
54 Pityriasis Rosea Accessed February 2010
55 Management and Treatment Reassurance Oral antihistamines Antipruritic lotions Topical steroids
56 Lichen Planus
57 Lichen Planus Acute or chronic inflammatory dermatosis involving skin, nails and/or mucous membranes. Flat-topped, pink to violaceous, shiny pruritic polygonal papules and plaques. Wickham s striae: milky white reticulated lines. The Four P s Pruritic Polygonal Purple Papule Fitzpatrick,T. etal. Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology. Fifth Edition pp
58 Causes of Lichen Planus Idiopathic Cell-mediated Immunity Drugs, metals, infection (Hepatitis C) Fitzpatrick,T. etal. Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology. Fifth Edition pp
59 Lichen Planus Wickham s striae seen with a magnifying glass and application of mineral oil. Common areas of distribution: flexor wrists, lumbar region, shins, scalp, glans penis, mouth. Examine inside the mouth at the mucous membranes (40% 60% occurrence). Can also effect scalp showing atrophy and nails with destruction of nail fold and bed with longitudinal splintering, atrophy, and ptergyium formation. Fitzpatrick,T. etal. Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology. Fifth Edition pp
60 Lichen Planus
61 Wickham s Striae
62 Lichen Planus of the Nails
63 Lichen Planus of the Scalp showing atrophy
64 Management and Treatment Topical steroids (sometimes under occlusion on thicker and harder to manage lesions) Intralesional kenalog injections (4mg/cc to 10mg/cc) Topical oral triamcinolone (ie. oralone) Systemic therapy Cyclosporine Oral Prednisone Systemic Retinoids (soriatane) Phototherapy Fitzpatrick,T. etal. Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology. Fifth Edition pp
65 Granuloma Annulare
66 Granuloma Annulare Potential self-limited (may last several years and in some cases may last a lifetime); asymptomatis to having mild symptoms of itching and/or burning, chronic dermatosis of the dermis. Annular and semicircular plaques with central regression or depression. May be skin-colored, pearly white, pink, reddish to brown in color. Feels firm, smooth and rubbery with no scale. May be localized or disseminated. Fitzpatrick,T. etal. Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology. Fifth Edition p. 128.
67 Granuloma Annulare Seen most commonly on distal extremities, near joints, palms and soles, and buttocks. The disease will disappear in 70% of patients in 2 years, but recurrences are common. Not a marker for internal disease. Fitzpatrick,T. etal. Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology. Fifth Edition p. 128.
68 Granuloma Annulare
69 Granuloma Annulare Accessed February 2010
70 Granuloma Annulare Accessed February 2010
71 Treatment Options Reassurance Topical steroids Intralesional Kenalog injections (4mg/cc) Tacrolimus PUVA therapy for disseminated disease TNF-inhibitors (such as Enbrel and Humira have shown improvement in some cases)
72 Vitiligo
73 Vitiligo Affects 1% of the population. 50% of cases begin between the ages of 10 to 30. Genetic. Pathogenesis (Three Theories) Autoimmune: destroyed by certain lymphocytes. Neurogenic: interaction between melanocytes and neurons. Self-destruct hypothesis: melanocytes are destroyed by toxic substances formed as part of normal melanin synthesis. Fitzpatrick,T. etal. Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology. Fifth Edition pp
74 Vitiligo Potential Precipitating factors Trauma Koebner phenomenon Illness Emotional stress Sunburn Thyroid Disease Addison s Disease Fitzpatrick,T. etal. Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology. Fifth Edition pp
75 Vitiligo Wood s Lamp Examination can be helpful in lighter skin types and in sun-protected areas of darker skin types to evaluate macules. Vitiligo affected areas will emit a blue-white light with sharp margins. Clinical diagnosis. Fitzpatrick,T. etal. Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology. Fifth Edition pp
76 Wood s Lamp To use a Wood s Lamp Must be in a completely dark room Examiner must adapt to dark room; may take up to twenty minutes Warm up wood s lamp for at least one minute and hold light cm from the skin All ointments, creams and medicines must be wiped from the skin prior to uses Fitzpatrick,T. etal. Fitzpatrick's Color Atlas 2017 & Synopsis All of right Clinical reserved Dermatology. Bellomo Fifth Edition Consulting, pp Inc
77 Vitiligo
78 Management/Treatment Sunscreen SPF >30 with both UVA/UVB protection Cosmetic Coverup Repigmentation Topical steroids (short-term use) Immunomodulators (Tacrolimus) PUVA in combination with topical or oral methoxypsoralen Narrow UVB (Excimer laser) Fitzpatrick,T. etal. Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology. Fifth Edition pp
79 Management/Treatment Minigrafting Depigmentation Bleaching normally pigmented skin n Monobenylether of hydroquinone 20% (MEH) Fitzpatrick,T. etal. Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology. Fifth Edition pp
80 Vitiligo Before Excimer Laser treatment During Excimer Laser Treatment
81 Vitiligo
82 Vitiligo Sunburn appearance during excimer laser treatment Brown speckling
83 Alopecia Areata
84 Alopecia Areata Localized loss of hair in an annular pattern without any visible inflammation (completely smooth); most common area affected is scalp. Alopecia Totalis Total absence of terminal scalp hair. Alopecia Universalis Total loss of terminal body and scalp hair. Fitzpatrick,T. etal. Fitzpatrick's Color Atlas 2017 & Synopsis All of right Clinical reserved Dermatology. Bellomo Fifth Edition Consulting, pp Inc
85 Alopecia Areata Autoimmune disease. Can be associated with other autoimmune disorders and endocrine disorders. May show gradual loss over weeks to months. Patches may be stable and spontaneously resolve. Asymptomatic. Fitzpatrick,T. etal. Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology. Fifth Edition pp
86 Alopecia Areata Nail Involvement Fine pitting (hammer brass) of dorsal nail plate Trachyonychia (rough nails) Onychomadesis (separation of nail from matrix) Accessed February 2010 Fitzpatrick,T. etal. Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology. Fifth Edition pp
87 Localized Alopecia Areata Accessed February 2010
88 Alopecia Totalis Accessed February 2010
89 Alopecia Areata Accessed February 2010
90 Management/Treatment Topical Steroids (superpotent agents may be effective) Intralesional injections with 4mg/cc IL Kenalog or 3mg/ml IL triamcinolone acetonide Systemic glucocorticoids Tacrolimus Potential new therapeutics in the near future Fitzpatrick,T. etal. Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology. Fifth Edition pp
91 QUESTIONS???
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