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Cutaneous CareCutaneous Care
Paul W. Baumert, Jr., M.D., FAAFPPaul W. Baumert, Jr., M.D., FAAFP
Sports Medicine RoundsSports Medicine Rounds
November 15, 2007November 15, 2007
OutlineOutline
““Dermatology 101”Dermatology 101” Clinical pearlsClinical pearls Common conditionsCommon conditions
PapulosquamousPapulosquamous AcneiformAcneiform MorbilliformMorbilliform UrticariaUrticaria
Skin cancersSkin cancers CA-MRSACA-MRSA Diagnostic toolsDiagnostic tools
““Dermatology 101”Dermatology 101”
If it’s dry: WET itIf it’s dry: WET it
If it’s wet: DRY itIf it’s wet: DRY it
If it’s red and itchy: Use steroidsIf it’s red and itchy: Use steroids
MORE COMPLEXMORE COMPLEX!!!!
Medicine is a calling, not a business.You are in this profession as a calling, not as a business; as a calling which exacts from
you at every turn self-sacrifice, devotion, love and tenderness to your fellow-men. Once you get down to a purely business level, your influence is gone and the true light of your
life is dimmed. You must work in the missionary spirit, with a breadth of charity that raises you far above the petty jealousies of life.
Sir William Osler
Clinical pearlsClinical pearls
Dry skinDry skin
Topical corticosteroidsTopical corticosteroids
Dry SkinDry Skin
Worsens almost Worsens almost anyany skin condition skin condition SeasonalSeasonal MoisturizersMoisturizers
TipsTips Avoid long, hot showersAvoid long, hot showers Towel dry (get big drops off)Towel dry (get big drops off) Apply to damp skinApply to damp skin
TypesTypes Ointment > cream > lotionOintment > cream > lotion Aquaphilic ointmentAquaphilic ointment
Winter Dry Skin handout (UIHC derm)Winter Dry Skin handout (UIHC derm)
Topical CorticosteroidsTopical Corticosteroids
Treat the erythema, Treat the erythema, notnot the itch the itch Side effectsSide effects
Atrophy/striaeAtrophy/striae TelangiectasiaTelangiectasia PurpuraPurpura
Absorption depends on Absorption depends on Skin thicknessSkin thickness OcclusionOcclusion
FormsForms
Common ConditionsCommon Conditions
Papulosquamous (“raised and scaly”)Papulosquamous (“raised and scaly”) Eczematous or contact dermatitisEczematous or contact dermatitis Tinea corporisTinea corporis ScabiesScabies Pityriasis roseaPityriasis rosea
PrinciplesPrinciples Proper diagnosisProper diagnosis Initial choice of treatmentInitial choice of treatment
Common ConditionsCommon Conditions
AcneiformAcneiform AcneAcne Molluscum contagiosumMolluscum contagiosum FolliculitisFolliculitis
Common ConditionsCommon Conditions
MorbilliformMorbilliform Viral exanthemsViral exanthems
Measles, rubella, roseola, enteroviruses, etc.Measles, rubella, roseola, enteroviruses, etc. Scarlet feverScarlet fever ScarlatinoformScarlatinoform Drug exanthemsDrug exanthems
Usually pruriticUsually pruritic Usually within 2 weeks of beginning a medicationUsually within 2 weeks of beginning a medication
Common ConditionsCommon Conditions
Urticaria (Hives)Urticaria (Hives) IngestionIngestion
FoodFood MedicationMedication
PhysicalPhysical 50% have no identifiable cause50% have no identifiable cause Treatment pearlsTreatment pearls
Potent antihistamine(s), adequate durationPotent antihistamine(s), adequate duration
Skin CancersSkin Cancers
MelanomaMelanoma
Basal cell carcinomaBasal cell carcinoma
Squamous cell carcinomaSquamous cell carcinoma
MelanomaMelanoma
IncidenceIncidence 1930: 1 in 15001930: 1 in 1500 1960: 1 in 6001960: 1 in 600 2001: 1 in 712001: 1 in 71
Lifetime risk (2006)Lifetime risk (2006) Caucasians: 1 in 60 (slightly higher in males)Caucasians: 1 in 60 (slightly higher in males) Non-caucasians: 1 in 1176Non-caucasians: 1 in 1176
75% of skin cancer deaths75% of skin cancer deaths
MelanomaMelanoma
4 main types of malignant melanoma4 main types of malignant melanoma
Clinical prediction rulesClinical prediction rules ABCDE criteria (ACS)ABCDE criteria (ACS) 7 point checklist (UK)7 point checklist (UK)
Types of melanomasTypes of melanomas
Superficial spreadingSuperficial spreading 50% of cases50% of cases More frequent in More frequent in
younger adultsyounger adults
Types of melanomasTypes of melanomas
NodularNodular 20 to 25% of cases20 to 25% of cases Also in younger adultsAlso in younger adults
Types of melanomasTypes of melanomas
Lentigo malignaLentigo maligna 15% of cases15% of cases Older adultsOlder adults
Types of melanomasTypes of melanomas
Acral-lentiginousAcral-lentiginous 10% of cases10% of cases Palms, soles, around first Palms, soles, around first
toenailtoenail
Risk factors for malignant Risk factors for malignant melanomamelanoma
Atypical nevus syndrome with personal Atypical nevus syndrome with personal andand family hx of melanoma (500)family hx of melanoma (500)
Changing mole (>400)Changing mole (>400) Atypical nevus syndrome with family hx of Atypical nevus syndrome with family hx of
melanoma (148)melanoma (148) Age Age >> 15 15 Dysplastic moles (7-70)Dysplastic moles (7-70)
Risk factors con’tRisk factors con’t
Large congenital nevus (Large congenital nevus (>> 15 cm) (17) 15 cm) (17) Caucasian race (12)Caucasian race (12) Atypical nevi (7-27)Atypical nevi (7-27) Regular tanning bed use before age 30 (7.7)Regular tanning bed use before age 30 (7.7) Multiple nevi (5-12)Multiple nevi (5-12) Personal hx of melanoma (5-9)Personal hx of melanoma (5-9) Family hx (first degree) of melanoma (3-8)Family hx (first degree) of melanoma (3-8) Sun sensitivity/tendency to burn (2-3)Sun sensitivity/tendency to burn (2-3)
Clinical prediction rulesClinical prediction rules
ABCDE Criteria (American Cancer Society)ABCDE Criteria (American Cancer Society)
7 point checklist (United Kingdom)7 point checklist (United Kingdom)
ABCDE CriteriaABCDE Criteria
AAsymmetrysymmetry BBorderorder CColorolor DDiameteriameter EEvolving (Elevation or Enlargement)volving (Elevation or Enlargement)
AAsymmetrysymmetry
BBorderorder
CColorolor
DDiameteriameter
EEvolving (elevation/enlargement)volving (elevation/enlargement)
7 point checklist (Glasgow)7 point checklist (Glasgow)
Major signs (1 or more):Major signs (1 or more):
Change in sizeChange in size
Change in shapeChange in shape
Change in colorChange in color
Minor signs:Minor signs:
InflammationInflammation
Crusting or bleedingCrusting or bleeding
Sensory changeSensory change
Diameter Diameter >> 7 mm 7 mm
A2BCD3EFG’s of MelanomaA2BCD3EFG’s of Melanoma
2005 Additions:2005 Additions: AngularityAngularity DysplasticDysplastic Different (from patient’s other nevi)Different (from patient’s other nevi) EVOLVINGEVOLVING Family historyFamily history Great numbers of neviGreat numbers of nevi
Clinical AssessmentClinical Assessment
Apply the ABCD+ criteria Apply the ABCD+ criteria Excisional (full thickness) biopsy if either test Excisional (full thickness) biopsy if either test
has positive criteria has positive criteria oror if you or your patient if you or your patient has any doubthas any doubt
Guidelines are developed from large studies Guidelines are developed from large studies and tell you nothing about the patient in front and tell you nothing about the patient in front of youof you
The Bottom Line Re: MelanomasThe Bottom Line Re: Melanomas
When educating patients, if one were to stress When educating patients, if one were to stress only only oneone characteristic of melanoma, it would characteristic of melanoma, it would be CHANGE.be CHANGE.
However, only 25% of melanomas arise from However, only 25% of melanomas arise from a preexisting lesion. 75% of the time they a preexisting lesion. 75% of the time they arise de novo!arise de novo!
CA-MRSACA-MRSA
AcquisitionAcquisition Contact, skin breakdown, hygieneContact, skin breakdown, hygiene
TreatmentTreatment Physician-directed medication, drainage, carePhysician-directed medication, drainage, care
PreventionPrevention Wash hands often, use alcohol-based hand rubsWash hands often, use alcohol-based hand rubs Keep cuts/scrapes clean and coveredKeep cuts/scrapes clean and covered Do Do notnot touch other people’s cuts or bandages touch other people’s cuts or bandages Do Do notnot share personal items, such as towels or razors share personal items, such as towels or razors
Diagnostic ToolsDiagnostic Tools
Experienced clinician/proper environmentExperienced clinician/proper environment KOHKOH CultureCulture
Bacterial (+/- sensitivity)Bacterial (+/- sensitivity) ViralViral FungalFungal
BiopsyBiopsy PunchPunch
Specialty referral is Specialty referral is notnot needed in most cases needed in most cases
Live neither in the past nor in the future, Live neither in the past nor in the future, but let each day’s work absorb your but let each day’s work absorb your
entire energies, and satisfy your widest entire energies, and satisfy your widest ambitionambition
Sir William OslerSir William Osler