Recognizing common Dermatologic conditions Tanya Nino, MD St. Joseph Heritage Medical Group Case presentations 65 year old female referred for rule out melanoma a lesion on back 30 year old female has an unusual growth on lower leg 50 year old male complaining of multiple new flesh colored bumps on face 42 year old male with a facial rash 75 year old female with CHF admitted for lower extremity cellulitis, BMI 32 And more 65 year old female referred for rule out melanoma a lesion on back Lesion present for at least 1 year Appeared suddenly out of the blue Rough texture Occasionally itchy 1
Differential Diagnosis: Nevus Seborrheic Keratosis Pigmented AK Melanoma Lentigo Seborrheic Keratoses 30 year old female with unusual growth on lower leg 2
Common benign fibrous skin lesion Arms and legs most common Persist for years Cause unknown: insect bite, shaving, thorn prick, reactive process Dermatofibroma Dermatofibroma: pinch test Skin is tethered to underlying fibrous tissue 50 year old male with multiple new flesh colored bumps on face 3
Sebaceous hyperplasia Enlarged sebaceous glands Middle aged-elderly Central hair follicle surrounded by yellowish lobules Often prominent blood vessels 42 year old male with facial rash Seborrheic Dermatitis Associated with proliferation of Malassezia in its yeast form Inflammatory Differences in skin barrier function account for individual presentation 4
Differential Diagnosis Erythematous Facial Rash Seborrheic dermatitis Rosacea Other dermatitis (Contact, atopic, perioral) Lupus erythematosus Many others Rosacea - Papulopustular Rosacea - Erythematotelangiectatic 5
Phymatous Rosacea / Rhinophyma Ocular Rosacea Redness Burning Itching Dry eyes Foreign body sensation Photophobia Erythematous swollen eyelids Tearing Rosacea treatment options Topical metronidazole Topical azelaic acid Oral doxycycline Subantimicrobial dose Brimonidine gel a-adrenergic receptor agonist More effective for erythematotelangiectatic rosacea Topical permethrin/ivermectin Demodex folliculorum may contribute to rosacea by stimulating toll like receptor 2 Other treatments for refractory rosacea isotretinoin, topical retinoids, laser treatments, and more 6
75 year old female with CHF admitted for lower extremity cellulitis, BMI 32 Stasis Dermatitis Common inflammatory skin disease that occurs on the lower extremities It is usually the earliest cutaneous sequela of chronic venous insufficiency with venous hypertension May be a precursor to more problematic conditions, such as venous leg ulceration and lipodermatosclerosis Accurate diagnosis is critical Etiology of Stasis Dermatitis Leaky valves in the deep venous plexus of legs Backflow of blood from deep venous system into superficial venous system Increase venous hydrostatic pressure Permeability of dermal capillaries Fibrinogen leaks into tissue and polymerizes into fibrin and forms fibrin cuffs around capillaries Barrier to oxygen diffusion = tissue hypoxia and cell damage Leukocytes get trapped in fibrin cuffs and release inflammatory mediators inflammation and fibrosis 7
Complications of Stasis Dermatitis Cellulitis Nonhealing venous ulcers Lipodermatosclerosis Contact dermatitis/contact sensitization Neomycin, Bacitracin, rubber products found in wraps and stockings Consider contact in any patient with stasis who becomes clinically worse despite appropriate topical treatment Id reaction (autoeczematization) Lipodermatosclerosis Stasis Dermatitis - Treatment Compression therapy Compliance is an issue Difficulty in stocking application Concerns about appearance Discomfort Topical steroids Atrophy is an issue Possible susceptibility to infection Topical Tacrolimus and Pimecrolimus Prevent/manage infection Topical or oral antibioitcs as needed Culture with sensitivity 8
Follow up for Stasis Dermatitis Stasis dermatitis is a chronic condition Acute exacerbations should be closely monitored with weekly office visits Careful observation for signs of infection Patients with long-standing stasis can manage on their own Compression stockings Elevation Proper skin care Short courses of topical steroids for inflammatory exacerbations Vigilance in treating any sings of cutaneous ulceration A 28 year old woman with a diffuse rash, had a Strep URI 2 weeks ago Psoriasis 2% world s population Psoriatic arthritis occurs in up to 30% of psoriasis patients 85-90% have cutaneous lesions first 10-15% present with arthritis de novo Most frequent form in children? Guttate What is guttate psoriasis associated with? Streptococcal infection Most common? Strep URI 9
Psoriasis Vulgaris Pathophysiology of psoriasis Complex, multifactorial disease that appears to be influenced by genetic and immune-mediated components. The epidermis is infiltrated with large numbers of T cells, which induce keratinocyte proliferation. a patient with 20% body surface area affectedwith psoriasis lesions has around 8 billion blood circulating T cells compared with approximately 20 billion T cells located in the dermis and epidermis of psoriasis plaques. Epidermal hyperplasia leads to accelerated cell turnover rate (from 23 days to 3-5 days). Cell turnover is so rapid that keratinocytes retain their nuclei (parakeratosis) Keratinocytes fail to release lipids, decreasing the cement normally formed in the stratum corneum. This causes poorly adherent scale leading to the flaking in psoriasis lesions. Immunology of Psoriasis This is a very complex topic, and is being researched extensively. New therapies are being formulated to target key processes in the psoriasis pathway with less side effects 10
Psoriasis comorbidities Patients with psoriasis are more likely to suffer other medical conditions including heart and blood vessel disease, chronic lung disease, diabetes, kidney disease, joint problems, and other health conditions. Diabetes Moderate psoriasis 22% increase in prevalence Severe psoriasis 32% increase in prevalence Moderate and severe psoriasis increase the risk of cardiovascular disease by 39% and 81% respectively TNF alpha blockers and MTX may decrease cardiovascular issues in patients with psoriasis. Psoriasis impacts patients quality of life. In some studies the impact is as much as having cancer, and other serious medical disease. Triggers cutaneous injury Koebner phenomenon sunburn, viral exanthems 2-6 week lag psychogenic stress HIV (greater disease severity) strep pharyngitis guttate (1-2 week lag) hypocalcemia pustular psoriasis drugs steroid withdrawal β-blockers lithium IFN terbinafine ACE-I antimalarials NSAIDs GCSF Psoriasis Vulgaris 11
Body Surface Area patient s palm = 1% Inverse Psoriasis Guttate Psoriasis 12
Guttate Psoriasis lesion size ~ drops of water common in children preceding strep pharyngitis ASO, anti-dnase B, streptozyme titer dicloxacillin 250mg qid + rifampin 600mg q d x 10d children: spontaneously resolves adults: chronic rapidly responds to UVB Pustular Psoriasis Pustular Psoriasis lakes of pus, sterile pustules systemic symptoms patterns von Zumbusch = diffuse annular exanthemic = overlap with AGEP localized = within pre-existing plaques 13
Psoriatic Arthritis asymmetric oligoarthritis RA-like DIP predominant ~ arthritis mutilans ~ spondylitis EROSIONS are a hallmark Psoriatic Arthritis Sausage digits Involvement of both DIP and PIP joints Involvement of DIP almost always associated with nail changes Enthesis (swelling of tendons where they insert onto bone) Dactylitis (swelling of the fingers) Nails 14
Nail Pathology pits = parakeratosis of proximal nail matrix oil spots = nail bed exocytosis of leukocytes beneath nail plate. subungual hyperkeratosis = parakeratosis of distal nail bed onycholysis = parakeratosis of distal nail bed splinter hemorrhages = increased capillary fragility Topical Treatment vitamin D3 calcipotriene (Dovonex), calcitriol (Vectical) inhibits epidermal proliferation max application = 100g q wk topical corticosteroids Topical Retinoids: tazarotene (Tazorac) Selectively binds RAR-beta and RAR-gamma epidermal proliferation, inhibits transglutaminase and K16 expression max BSA = 10-20% 45 15
Psoriasis Treatment PHOTOTHERAPY NB-UVB (311 nm) PUVA excimer laser (308 nm) *contraindicated in erythrodermic psoriasis BIOLOGICS TNF-α inhibitors IL12, 23, and 17 inhibitors AE: immunosuppression, CHF, demyelinating disease, druginduced lupus, lymphoma, and more SYSTEMIC TREATMENT methotrexate Max effect at 8-12 weeks AE: liver toxicity, pancytopenia Increased risk of pulmonary toxicity w/ decreased creatinine clearance and hypoalbuminemia cyclosporine rapid clearance blocks IL-2 upregulation AE: HTN, renal toxicity acitretin pustular, erythrodermic AE: hyperlipidemia, liver toxicity A 16 year old girl comes in with a rash preceded by fever and sore throat Pityriasis Rosea 16
Children and adolescents Self-limited Christmas tree distribution along lines of cleavage Viral association HSV 6, 7 Treatment: Supportive care Disease resolves in 6-12 weeks Topical steroids for pruritus Oral antihistamines as needed Acyclovir or Erythromycin Pityriasis Rosea Herald Patch 17
Scabies Scabies 18
Scabies Scabies Scabies 19
Tinea Tinea 20
Erythema Multiforme Erythema Multiforme 21
Erythema Multiforme Erythema Multiforme Granuloma Annulare 22
Granuloma Annulare 23