View
548
Download
0
Category
Tags:
Preview:
Citation preview
Common FP Office Dermatology
Dana Romalis, MD
August 2006
Objectives
Recognize 17 common dermatologic conditions seen in the office setting
Identify other diseases that appear similarly and may confuse diagnosis
Learn basic treatment of these conditions, (as well as what doesn’t require treatment)
Recognize the psychosocial implications of these conditions.
Quick definition review
A) Papule/Plaque: superficial, elevated, palpable lesion ≤0.5 cm; >0.5 cm.
B) Macule/Patch: circumscribed colour change without elevation or depression.
C) Vesicle/Bulla: like A), but containing fluid.
D) Nodule: palpable, solid, deeper than A).
E) Wheal: pale red, palpable, superficial lesion, evanescent, disappearing
in 1-2 days. From edema in the papillary layer of the dermis. F) Pustule:
like C), only with purulent exudate as the fluid.
Vesicular7 yo with itchy rash & fever x1d,
feels unwell. Blisters on red base. New lesions are still appearing.
Diagnosis: - Varicella (chicken pox)
Etiology: VZV, airborneWhen is it infectious?
- from 1-2 days before rash develops, until after last lesion scabs over.
When will I know if I have it?- 1.5-2.5 wks after exposure
Vesicular
64 yo M w/burning pain for 3 days, now with rash on back “in a stripe”
Diagnosis: Herpes Zoster
Etiology: VZV reactivationTreatment:
Acyclovir <72 hr, +/- oral prednisoneTreat for 7-10 days
Why treat?reduce pain/duration of lesions
Is this contagious? How?When do you need to refer? to
whom?
Zoster treatment
Medication Dose Cost (generic for 7d)
Acyclovir 800 mg po 5x/day for 7 days $174-248
Famciclovir 500 mg po TID for 7 days $140
Valacyclovir 1000 mg po TID for 7 days $84
Prednisone 30 mg po BID on days 1-7; $1-2 then 15 mg BID on days 8-14; then 7.5 mg BID on days 15-21
Papular
27 yo M, no pmhx, w/itchy rash “all over” body for 3 days. It started with this patch here 1 wk ago…
Diagnosis:Pityriasis rosea-“Christmas tree” pattern
- Herald patch 1-2wks before rash appears
Pityriasis RoseaEtiology unknownLesions on “Langer’s lines”Differential diagnosis:
drug eruptionsecondary syphilistinea corporisviral exanthemguttate psoriasis
Treatment??anti-pruriticscontroversial:
erythromycinUVB
Papulosquamous
38 yo M w/symmetric, vivid pink, raised, scaly lesions.
Diagnosis: Psoriasis vulgaris
Pathophysiology: Immune activation of
keratinocyte cell cycle Epidemiology: bimodal Appearance:
localized vs. generalized Extensor surfaces
(macarena) Treatment:
Topicals –> phototherapy –> systemics
Psoriasis
Associated with: Arthritis (small joints) Nail dystrophy
- Oil spot (pathognomonic)
- Pitting
- Onycholysis
Other issues/forms: Koebbnerization Guttate (Gp A Strep) psychosocial
Papulosquamous 28 yo F says “I’ve always had
itchy arms, but it’s been awful this winter”. History of asthma, seasonal allergies
Diagnosis: Atopic dermatitis/ Eczema cheeks/extensor surfaces (infant) Flexure surfaces (older)
How is this rash different? 14 yo F “This rash has been
spreading for 3 months” Diagnosis:
Contact dermatitis To what?
Nickel (belt buckle, button)
Dermatitis/Eczema Treatment for all types:
Avoid triggers Allergens Excessive bathing
Emollients (Eucerin, Aquaphor, …glycerin content is key)
Topical steroids Immune modulators: tacrolimus/
Protopic, pimecrolimus/Elidel, …?safe in kids (not under 2)
STOP SCRATCHING! Lichenification Infection-impetigo
Papular rashes
Rash A: just started 1 hour ago, very itchy
Rash B: present for 2-3 months, not responding to OTC steroid cream.
A) Urticaria/wheals- allergic reaction AKA “hives”
B) Tinea corporis- well demarcated patches with central clearing “ringworm”
Papular rashes: Treatment
Urticaria: - H1-blockers
What else should you be concerned about?
Tinea Corporis:- topical antifungal - continue for 1-2 wks after lesions resolve.
Can he go to school?Anyone else at risk?
Hypopigmented
What makes these rashes so different?
A- symmetric, complete depigmentation. Clear edges.
B- decreased pigmentation, edges flake when scratched
1) Vitiligo; any age. - Fewer melanocytes (autoimmune)
2) Pityriasis versicolor; young adults. - etiology: P. ovale (yeast) most common
Vitiligo: Treatment
Autoimmune disease: - associated with thyroid dz & diabetes- commonly affects: perioral, hands, shins, genitals
Rx: - topical steroid, PUVA- support group- cosmetics
P. Versicolor: Treatment
- selenium sulfide shampoo x1wk
- alt: ketoconazole shampoo x3d (or oral azole -1 dose)
- may take months to repigment after summer
- prevent recurrence with repeat Rx qmonth x3m
Scalp lesions
9 yo boy sent home from school, removes hat to show you this red, scaly lesion. You see tiny black dots in an area of alopecia, with a fine scale.
Diagnosis? Tinea capitis
Differential? Treatment?
Oral griseofulvin until 2 wks beyond clinical resolution
T. Capitis Mother brings in 4 yo w/lg. red
exudative swelling on head. Diagnosis? Tinea capitis w/kerion
What do you have to tell mom? Scarring alopecia will result.
Treatment? As above, but with po steroids
• 2 weeks after treatment begins, a widespread pruritic eczematous rash erupts… What is this?
• Id reaction to the fungus• Rx with lubricants and topical steroids and
continue on griseofulvin for a complete course
Papulopustular 14 yo M w/ red papulopustular rash for 6m.
Getting worse. “is it because I eat fast food?”
Diagnosis: Acne Vulgaris
Etiology: Excess sebum production, hair follicle
hyperkeratinization blocks sebum release, causing buildup of sebum, lipids, cellular debris ideal for bacterial growth.
28 yo F “I keep getting acne on my cheeks and chin. I thought I was done with this years ago!”
Diagnosis: Rosacea
Etiology: unknown, strong genetic link
Treatment: Acne Mild: comedonal, with few papules &
pustules. No nodules Benzoyl peroxide (not w/retinoid) adapalene/Differin, azelaic acid/Azelex (improves
postinflammatory hyperpigmentation) retinoid OCPs
Mod: papulopustular, rare nodules. topical antibiotic (clinda, erythro) oral antibiotic (tetracycline, erythro)
Severe: nodulocystic, painful Isotretinoin/Accutane
Treatment: Rosacea Early:
avoidance of triggers sunscreens topical antibiotics systemic antibiotics oral isotretinoin
Metronidazole/Flagyl
Late: Laser treatments
Other: Associated blepharitis rhinophyma
Papules
6 yo M brought in with “rash that’s spreading all over his face!”
Dx: Molluscum contagiosum
Is this an STD?
How is picture B different? Common warts
Treatment? If desired- virtually the same Liquid nitrogen Electrocautery/scraping Topicals: Salicyclic acid, tretinoin,
duct tape, podofilox
Nodules: spot diagnoses
Very soft, mobile, slow-growing in 50 yo M
Slips under fingers Diagnosis:
Lipoma
Firm, slow-growing, central dark spot
Diagnosis: Epidermoid cyst
Keratin plug helpful for diagnosis
Nodules: treatment
Usually not necessary However…
May become painful or inflamed.
Poor cosmesis…
Surgical removal Must remove capsule
or lesion will recur
Conclusion
Family physicians encounter a wide variety of dermatologic lesions in a wide variety of stages.
History and clinical picture are often enough to make the diagnosis
Attempts at self-treatment present additional diagnostic challenges.
Most conditions are common and easily treated or self-resolve…but for those that are not…
Biopsies may be needed for definitive diagnosis.
Questions?
Bibliography
UptodateGoogle imagesAmerican Family PracticeFitzpatrick Atlas of Clinical Dermatologywww.dermatlas.com
Recommended