I WON’T MISS THAT ONE NEXT TIME…..€¦ · Scabies DF DX 2 1. Tinea corporis 2. Granuloma annulare 3. Seborrheic dermatitis 4. Psoriasis 5. Flea bites 6. Scabies 7. Impetigo 8

“I Won’t Miss That One Next Time…”Richard E. Johnson, DO

POMA District VIII 31st Annual Educational Winter SeminarJanuary 25‐28, 2018 1

I WON’T MISS THAT ONE NEXT TIME…..

JANUARY 29, 2018

RICHARD E JOHNSON, DO, FAAD, FAOCD

OBJECTIVES

• A couple of days away from the office, cell phones off please

• A little time with friends, family, and colleagues

• Obtain required CME in a relaxed, no-stress venue

• Recognize some commonly seen dermatologic entities

• Getting through winter with minimal use of the snowblower

• Reinforcing your visual-diagnostic skills with the requisite

dermatology pics

• Win the powerball…..but only if it’s more than $800 million

RISK MANAGEMENT—PATIENT SAFETY

From POMA website….“12 CME credit hours in the areas of patient safety or risk management (either Category 1 or Category 2).”

For Florida licensees: “medical errors” requirement



Activities in patient safety and risk management may include the following topics:

Patient safety Risk management Improving medical records and record keeping Reducing medical errors Professional conduct and ethics Improving communications Preventative medicine Health-care quality improvements

DISCLOSURES………….1. I’m old

2. I can be opinionated at times

3. I still use paper charts

4. I don’t think “we” have a health care problem in the United States

……..”we” have a health INSURANCE COMPANY problem in the United States (see #2 above)

5. I attempt, as best as I can, to be a patient advocate: cost effective treatments, prior

authorizations fights on the patients’ behalf, follow-up care

(……hey, that’s an osteopathic approach.)

6. I attempt to provide useful, relevant, and fun lectures with information that can be used to fulfill

#5 above

7. Oh, and I have no drug company affiliations, but I do tend to slip in brand names occasionally

(see #1 above)

IF IN DOUBT

• Biopsy

• Refer



Patient-initiatedi.e. pt’s reason for

visit

Physician-initiatedi.e. incidental finding

I don’t like it

Changes noted…

Cosmetic•bx cost•tx cost•path fees•scar•results you want?

Refer Reassure

Pt returns

referbxor tx

Change•size•shape•color•symptoms

Obvious diagnosis

Not sure of

diagnosis, but…

bx-txright then referbx

tx refer

No this is not an insurance company lecture

A BASS-ACKWARDS LECTURE

• My first attempt

• May be my last attempt

• Get your clickers ready…..participant input from the get-go



• Get the brain cells started before going into the room

• Each case presented as if medical assistant gave you a brief raison d’etre for the next patient

• Pick from group of possible diagnoses

• Add more into

• What’s a derm lecture without pictures

• Whittle down the list of usual suspects and “possibles”

• Make the final, and of course, the correct diagnosis

• Maybe some treatment pearls

• Repeat with the next patient’s saga

7 YEAR OLD MALE WITH MOM AND DAD

??



7 YEAR OLD MALE

DF DX 11. Acne

2. Warts

3. Tinea corporis

4. Psoriasis

5. Granuloma annulare

6. Molluscum

7. Flea bites

8. Scabies

DF DX 21. Tinea corporis


3. Seborrheic dermatitis

4. Psoriasis

5. Flea bites

6. Scabies

7. Impetigo

8. Bed bugs

DF DX 31. Molluscum

2. Tinea corporis

3. Impetigo


5. Warts

6. Pyogenic granuloma

7. Bed bugs

8. Psoriasis

USE CLICKERS HERE

1. Acne2. Warts3. Tinea corporis4. Psoriasis5. Granuloma annulare6. Molluscum7. Flea bites8. Scabies

DF DX #1



1. Tinea corporis2. Granuloma annulare3. Seborrheic dermatitis4. Psoriasis5. Flea bites6. Scabies7. Impetigo8. Bed bugs

Df Dx #2

1. Molluscum2. Tinea corporis3. Impetigo4. Granuloma annulare5. Warts 6. Pyogenic granuloma7. Bed bugs8. Psoriasis

Df Dx #3

All three groups are correct at this point………

Let’s get some info from the patient…….

(I try to converse directly with the patients; if possible and when applicable)



HISTORY

• Present for 6 months

• No symptoms, just there

• Prior treatments = no help

• Topical antifungal

• Triple antibiotic

• OTC hydrocortisone

• No other family members with it

• No family history of same

7 YEAR OLD MALE

DF DX 1

1. Acne

2. Warts

3. Tinea corporis

4. Psoriasis


6. Molluscum

7. Flea bites

8. Scabies

DF DX 2

1. Tinea corporis



4. Psoriasis

5. Flea bites

6. Scabies

7. Impetigo

8. Bed bugs

DF DX 3

1. Molluscum

2. Tinea corporis

3. Impetigo


5. Warts


7. Bed bugs

8. Psoriasis

7 YEAR OLD MALE


2. Psoriasis


4. Molluscum




4. Psoriasis

5. Impetigo

DF DX 31. Molluscum

2. Tinea corporis

3. Impetigo



6. Psoriasis



USE CLICKERS HERE

PHYSICAL EXAM

• Several round/ovoid lesions

• Raised rubbery/firm rim with essentially clear center

• No scale

• Flesh colored

• No inflammation

7 YEAR OLD MALE


2. Psoriasis


4. Molluscum




4. Psoriasis

5. Impetigo

DF DX 31. Molluscum

2. Tinea corporis

3. Impetigo



6. Psoriasis



7 YEAR OLD MALE

DF DX 11. Granuloma annulare

2. Molluscum

DF DX 21. Granuloma annulare

DF DX 31. Molluscum



WHAT’S A DERM LECTURE WITHOUT PICTURES





GRANULOMA ANNULARE

• Generally children and young adults—but, diseases don’t read the textbooks

• Generally self-limiting—but, diseases don’t read the textbooks

• Etiology: trauma, insect bites, viral induced,

? medications (allopurinal), sun exposure…….

TYPES OF GRANULOMA ANNULARE

• Localized lesions

• Generalized

• Subcutaneous

• Perforating

• Patch

• Actinic



LOCALIZED

• Most commonly seen type

• Raised rubbery edge

• Centrally, surface normal color/texture, may be slightly depress/hyperpigmented

• More than half of the patients have single lesion

……but diseases don’t read the textbooks

GENERALIZED GRANULOMA ANNULARE

• About 10-15% of patients have more than 10 lesions

• More in <10yo and >50yo

• Generally truncal in distribution

• Generally rings are <5cm

• ???may be a marker for diabetes

SUBCUTANEOUS GRANULOMA ANNULARE

• BB sized to “large” painless papules/nodules

• Elbows, knees, and ankles most

common sites

• ??may be a marker for diabetes or abnormal glucose tolerance



PERFORATING GRANULOMA ANNULARE

• Superficial small papules

• Hands and fingers

• May develop umbilication (?? MC’s)

• Ulceration rarely occurs, but is possible

• 1/3 +/- patients have diabetes

PATCH GRANULOMA ANNULARE

• Subtle pink patches without induration or scale

• Women > men

• Proximal extremities most common sites

• Localized and generalized variants have been

described

ACTINIC GRANULOMA

• Large annular plaques develop on face or

other actinically damaged skin

• May be quite large and elevated



TREATMENT

• Rarely needs biopsy• Perhaps with less common variants, but with classic GA, no biopsy needed

• Benign neglect

• Topical steroids—with or without occlusion• Atrophy potential

• Intralesional steroids

• Cryotherapy

• Oral retinoids—isotretinoin with iPledge “hassles” vs acitretin• Seems to be effective, but relapses expected when d/c med

CAVEATS

• Not all round rashes are ringworm

• Firm-edged asymptomatic annulare lesion dorsum of foot/hand

think GA

• Biopsy rarely needed for classic GA, but if done for confirmation,

sometimes lesions resolves with biopsy—”therapeutic biopsy”

• Generalized, “sudden onset” GA, consider any new meds started

…..?allopurinol



75 YEAR OLD MALE

75 YEAR OLD MALE

DF DX 11. BCC/SCC

2. Seborrheic keratosis

3. Tinea

4. Psoriasis

5. Eczema

6. Stasis dermatitis

7. Bateman’s purpura

DF DX 21. Tinea

2. Seborrhea


4. Rosacea


6. Actinic keratosis

7. Eczema

DF DX 31. BCC/SCC

2. Tinea

3. Eczema

4. Onychomycosis

5. Psoriasis



CLICKER RESPONSE PAGE



ONCE AGAIN, ALL CORRECT

HISTORY AND PHYSICAL WILL HELP

HISTORY

• Present for “awhile”• “Patient-speak”: anywhere from this morning to “I was born with it.

• After conversing with the patient: about 8 months

• Itchy at first, now, not at all

• Prior treatments

• OTC: Benadryl cream and hydrocortisone 1%

• Rx: betamethasone for 3 months and since then, about 4 months fluocinolone

• Was size of quarter, now whole back of hand

1. BCC/SCC


3. Tinea

4. Psoriasis

5. Eczema



DF DX 1



1. SCC


3. Tinea

4. Psoriasis

5. Eczema



DF DX 1

1. SCC

2. Tinea

3. Psoriasis

4. Eczema

DF DX 1

1. Tinea

2. Seborrhea


4. Rosacea


6. Actinic keratosis

7. Eczema

DF DX 2



1. Tinea

2. Eczema

DF DX 2

1. BCC/SCC

2. Tinea

3. Eczema

4. Onychomycosis

5. Psoriasis



DF DX 3

1. SCC

2. Tinea

3. Eczema

4. Onychomycosis

5. Psoriasis



DF DX 3



1. SCC

2. Tinea

3. Eczema

4. Psoriasis

DF DX 3

75 YEAR OLD MALE

DF DX 1

1. SCC

2. Tinea

3. Psoriasis

4. Eczema

DF DX 2

1. Tinea

2. Eczema

DF DX 3

1. SCC

2. Tinea

3. Eczema

4. Psoriasis

ALL THREE PRETTY MUCH THE SAME

LET’S SEE WHAT THE PATIENT HAS







75 YEAR OLD MALE

DF DX 1

1. SCC

2. Tinea

3. Psoriasis

4. Eczema

DF DX 2

1. Tinea

2. Eczema

DF DX 3

1. SCC

2. Tinea

3. Eczema

4. Psoriasis

TINEA INCOGNITO

• Remember, diseases don’t read the textbook…..

• Generally:

scaly edged, clear center…..tinea

scaly throughout…..eczema

• One hand only…..probably not eczema

• Any onychomycotic nails?

• Check the feet………….

two foot, one hand syndrome

• Biopsy, if in doubt.

TREATMENT

• Topical may do it, but not

wrong adding short-term oral

• Majocchi’s granuloma-type

needs oral and topical

• Wrestlers………shampoo?



PATIENT IN ROOM #3

• Was here an hour before his appointment time

…… “to beat the crowd”

• Has another appointment across town scheduled for 30

minutes after his scheduled appointment was to start here.

68 YEAR OLD MALE

?

68 YEAR OLD MALE

DF DX 11. BCC/SCC


3. Tinea

4. Psoriasis

5. Warts

6. Lichen simplex

chronicus

7. Tags

DF DX 21. Changing mole

2. Seborrhea


4. Rosacea

5. Lichen simplex

chronicus

6. Scabies

7. Lyme disease

DF DX 31. BCC/SCC

2. Tinea

3. Scabies

4. Hair loss

5. Psoriasis

6. Lichen simplex

chronicus




CLICKERS

No fooling you…… all acceptable.

Let’s get some history

68 YEAR OLD MALE

• Itchy rash in groin for last 6 months

• Scrubbing with antibacterial soap

• No Rx treatments

• OTC hydrocortisone 1% and clotrimazole creams,

…..on and off use

• “I think it started this summer with “crotch-rot”



68 YEAR OLD MALE

DF DX 11. BCC/SCC


3. Tinea

4. Psoriasis

5. Warts

6. Lichen simplex

chronicus

7. Tags


2. Seborrhea


4. Rosacea

5. Lichen simplex

chronicus

6. Scabies

7. Lyme disease

DF DX 31. BCC/SCC

2. Tinea

3. Scabies

4. Hair loss

5. Psoriasis

6. Lichen simplex

chronicus


68 YEAR OLD MALE

DF DX 11. Tinea

2. Psoriasis

3. Lichen simplex

chronicus


2. Seborrhea


4. Rosacea

5. Lichen simplex

chronicus

6. Scabies

7. Lyme disease

DF DX 31. BCC/SCC

2. Tinea

3. Scabies

4. Hair loss

5. Psoriasis

6. Lichen simplex

chronicus


68 YEAR OLD MALE

DF DX 11. Tinea

2. Psoriasis

3. Lichen simplex

chronicus

DF DX 21. Seborrheic dermatitis

2. Lichen simplex

chronicus

3. Scabies

DF DX 31. BCC/SCC

2. Tinea

3. Scabies

4. Hair loss

5. Psoriasis

6. Lichen simplex

chronicus




68 YEAR OLD MALE

DF DX 11. Tinea

2. Psoriasis

3. Lichen simplex

chronicus


2. Lichen simplex

chronicus

3. Scabies

DF DX 31. Tinea

2. Scabies

3. Psoriasis

4. Lichen simplex

chronicus

EXAM TIME

• Red inflamed lichenified scrotum with minimal crease or

thigh involvement

• Some excoriations noted

• No nodules noted

• No other body areas



68 YEAR OLD MALE

DF DX 11. Tinea

2. Psoriasis

3. Lichen simplex

chronicus


2. Lichen simplex

chronicus

3. Scabies

DF DX 31. Tinea

2. Scabies

3. Psoriasis

4. Lichen simplex

chronicus

CLICKERS



68 YEAR OLD MALE

DF DX 11. Tinea

2. Psoriasis

3. Lichen simplex

chronicus


2. Lichen simplex

chronicus

3. Scabies

DF DX 31. Tinea

2. Scabies

3. Psoriasis

4. Lichen simplex

chronicus

68 YEAR OLD MALE

DF DX 11. Lichen simplex

chronicus


chronicus


chronicus

RASS

• Red Angry Scrotum Syndrome

• Much more common in males…………

females get it too, but LSC only name they get

• Lichen Simplex Chronicus

• Also seen ankles, elbows; anywhere chronic friction/scratching



TREATMENT

• Long term care

• Often recurrent

• Castle moat analogy—rebuilding barrier function

• Sprained thumb analogy—wash to wash, not wash to wash rash

• Patient education key to treatment success

• 2/2/2 dosing of topical steroids

32 YEAR OLD FEMALE



32 YEAR OLD FEMALE

DF DX 11. Acne

2. Annoying mole

3. Eczema

4. Psoriasis

5. Warts

6. Rosacea

7. Shingles

DF DX 21. Tags

2. Onychomycosis

3. Hair loss

4. Warts

5. BCC

6. Scabies

7. Tinea

DF DX 31. Rosacea

2. Tinea

3. Shingles

4. Hair loss

5. Annoying mole

6. Eczema

7. Tags

CLICKER PAGE

HISTORY

• Present for about 3 years

• Regularly/occasionally shaves to bleed

• No symptoms

• Was flatter, now more raised

• Other similar lesions on legs and arms, but not in the way

• Tried wart medicine for a couple of days, but “never

bothered me, so I stopped using it.”



32 YEAR OLD FEMALE

DF DX 11. Acne

2. Annoying mole

3. Eczema

4. Psoriasis

5. Warts

6. Rosacea

7. Shingles

DF DX 21. Tags

2. Onychomycosis

3. Hair loss

4. Warts

5. BCC

6. Scabies

7. Tinea

DF DX 31. Rosacea

2. Tinea

3. Shingles

4. Hair loss

5. Annoying mole

6. Eczema

7. Tags

32 YEAR OLD FEMALE

DF DX 11. Annoying mole

2. Warts

DF DX 21. Tags

2. Onychomycosis

3. Hair loss

4. Warts

5. BCC

6. Scabies

7. Tinea

DF DX 31. Rosacea

2. Tinea

3. Shingles

4. Hair loss

5. Annoying mole

6. Eczema

7. Tags

32 YEAR OLD FEMALE


2. Warts

DF DX 21. Warts

2. BCC

DF DX 31. Rosacea

2. Tinea

3. Shingles

4. Hair loss

5. Annoying mole

6. Eczema

7. Tags



32 YEAR OLD FEMALE


2. Warts

DF DX 21. Warts

2. BCC


PHYSICAL EXAM

• Firm pink/red nodule

• Small surface scab



32 YEAR OLD FEMALE


2. Warts

DF DX 21. Warts

2. BCC


32 YEAR OLD FEMALE


DF DX 21. BCC


If in doubt, biopsy

ANNOYING MOLE

• Dermatofibroma• Trauma induced ??

• Firm

• Flat or domed

• Dimples

• Not easily traumatized, as opposed to BCC

.…..remember, diseases don’t read the textbook.



TREATMENT

• Benign neglect

• Surgery

• Cryosurgery

• IL injections

Lightening Round



3 SECOND VISUAL

• Pick your diagnosis

• Review picture

• Discuss

PICK YOUR POISON

1. Vasculitis

2. Zoster

3. Contact dermatitis

4. Erythema ab igne

5. Urticaria

6. Leprosy



CLICKERS

Erythema ab igne

…..also known as hot water bottle rash, fire stains, laptop thigh, granny's tartan and toasted skin syndrome

…..caused by long-term exposure to heat (infrared radiation)



READY?

HERE’S THE PITCH…..STRIKE 2

HHHMMMMMMMMM?

1. Melanoma

2. Eclipse mole

3. Tinea capitis

4. Bug bite site

5. I don’t know, but I’m going to biopsy it

6. I don’t know, but I’m going to refer



CLICKERS

ECLIPSE MOLE

• Nevus en cocarde

• Benign

• biopsy/refer certainly an option



HERE’S THE WINDUP

…..STRIKE 3

AND………….

1. Onychomycosis

2. Psoriasis

3. Onychomadesis

4. Oops, be more careful with closing the car door

5. Paronychia



CLICKERS

ONYCHOMADESIS

• Proximal, complete separation of the nail plate from nail bed

• Results from full, but temporary, arrest of nail growth

• Stressful events, commonly seen after Hand-Foot-Mouth Disease

• Beau’s lines—transverse grooves cause be partial arrest of nail

growth



BOTTOM OF THE NINTH

TWO OUTS,3-2 COUNT



WELL……………..?

1. Melanoma

2. Halo nevus

3. Lyme disease


CLICKERS



HALO NEVUS

Central lesion characteristics and symmetry of halo may determine decision tree

1. If benign appearing and centrally placed nevus with symmetrical depigmentation is noted, need not be removed….patient’s age??

Periodic evaluation of lesion and patient recommended

2. Biopsy/refer:

Atypical appearing central nevus

asymmetrical halo

eccentric placement of nevus in halo

personal or family hx of atypical nevi and/or melanoma

OOPS, LOOKS LIKE EXTRA INNINGS



WHAT’S IT GONNA BE?

1. Psoriasis

2. Tinea versicolor

3. Pityriasis alba

4. Vitiligo

5. Tinea faciale and corporis

CLICKERS



PITYRIASIS ALBA

-- more common in children than adults

-- often seen in atopic patients

-- most common sites are face and upper lateral arms

-- usually begins with non-specific erythema and gradually

becomes scaly and hypopigmented

-- caused by transient and mild dermal inflammation

TREATMENT

emollient moisturizers

-- mild inflammation treated with anti-inflammatory

Protopic® and Elidil® probably work better than topical steroids



POST-LECTURE QUESTIONS

1. This “reverse” lecture format was a bust

2. This “reverse” lecture format was okay

3. Some of the lecturer’s objectives were met

(sorry, no powerball winning today)

4. Enough with winter already!

5. Yea!! The end.

CLICKERS



DISCLOSURES………….1. I’m old

2. I can be opinionated at times

3. I still use paper charts

4. I don’t think “we” have a health care problem in the United States

……..”we” have a health INSURANCE COMPANY problem in the United States (see #2 above)

5. I attempt, as best as I can, to be a patient advocate: cost effective treatments, prior authorizations fights on the patients’ behalf, follow-up care

(……hey, that’s an osteopathic approach.)

6. I attempt to provide useful, relevant, and fun lectures with information that can

be used to fulfill #5 above5. Oh, and I have no drug company affiliations, but I do tend to slip in brand names occasionally

(see #1 above)

…….JUST SAYIN’

PAPER CHART

• Diagnosis made in about 5 seconds

• Chart note: same

• Patient education: 2 minutes

• Chit-chat time: 2 minutes

• Visit complete: 4+ minutes

EMR

• Meaningful use entries: 5 minutes

• Entry of history: 3 minutes

• Look at patient/diagnosis: 5 seconds

• Entry of PE: 3 minutes

• Patient education: 2 minutes

• Entry documenting same: 3 minutes

• Chit-chat time: not allowed, no time

• Visit complete: 16+++ minutes

How many visits per day/week/month/year are like this for EVERY specialty…….Where are our national organizations?

See # 2 under “DISCLAIMERS”

Documents

I WON’T MISS THAT ONE NEXT TIME…..€¦ · Scabies DF DX 2 1. Tinea corporis 2. Granuloma annulare 3. Seborrheic dermatitis 4. Psoriasis 5. Flea bites 6. Scabies 7. Impetigo 8