44 adultdermatology

Wright, 2008 1

Adult Dermatology:Name That Rash and Lesion

Wendy L. Wright, MS, RN, ARNP, FNP, FAANPAdult/Family Nurse Practitioner

Owner - Wright & Associates Family HealthcareAmherst, NH

Partner – Partners in Healthcare Education, LLC

Objectives

Upon completion of this lecture, the participant will:1. Identify various dermatology conditions found

in adults2. Discuss those dermatology conditions that

require an immediate referral3. Develop an appropriate plan for evaluation,

treatment, and follow-up of the various lesions

Dermatofibroma

Common, benign asymptomatic lesionsMay be slightly itchy; Retract beneath the skin when you try to elevate them1-10 lesions occurring on the extremities; most1 10 lesions occurring on the extremities; most common location is the anterior surface of the lower legEtiology: fibrous reaction to trauma, virus or an insect bite

Multiple lesions: Systemic lupus

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Dermatofibroma

Size: 3 – 10 mm in sizeColor: pink - brownAppearance: may appear slightly scaly and feel hardTreatment:

Generally – nothing needs to be done about these lesionsNot worrisomeBiopsy occasionally warranted if unsure of lesion etiology

Dermatofibroma

Dermatofibroma

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Dermatofibroma

TreatmentMonitorElli ti l i iElliptical excisionShave excisionCryosurgery

Contact Dermatitis: Rhus Dermatitis

Rhus DermatitisPoison ivy, poison oak and poison sumac produce more cases of contact dermatitis than all other contactants combinedOccurs when contact is made between the leaf or internal parts of the roots and stem and the individual

Can occur when individual touches plant or an animal does and then touches human

Eruption can occur within 8 hours of the contact but may take up to 1 week to occur

Clinical Pearls

Poison ivy is not spread by scratchingNo oleoresin is found in the vesicles and therefore, can not be spread by scratchingscratchingLesions will appear where initial contact with plant occurredResin needed to be washed from skin within 15 minutes of exposure to decrease risk of condition

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Clinical Presentation

Clinical presentationCharacteristic linear appearing vesicles are likely to appear firstOften surrounded by erythemay yIntensely itchyLesions often erupt for a period of 1 week and will last for up to 2 weeksMore extensive and widespread presentation can occur with animal exposures or burning of the plants / smoke exposure

Contact Dermatitis

Contact Dermatitis

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Treatment

Cool compresses 15 – 30 minutes three times dailyTopical calamine or caladryl lotionsZanfel (OTC) wash binds urushiol oil andZanfel (OTC) wash – binds urushiol oil and removes from body/blisters

75% decrease in itching and rash within 24 hours per package

Colloidal oatmeal baths (AVEENO) once daily

TreatmentOral antihistamines

May wish to use sedating antihistamines at bedtime

Topical corticosteroidsA id th fAvoid usage on the face

Oral prednisone vs. injectable Kenalog or similar

20 mg two times daily x 7 daysKenalog 40 mg injection (IM)

Follow-up

Monitor for secondary infectionsImpetigo

Staph vs. strepMRSAMRSA

Education:Lesions will decrease over a 2 week periodMay continue to erupt over 48 hours despite steroid administrationNot spreading lesions with rubbing or scratching

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Hot Tub FolliculitisInflammation of the hair follicleCaused by infection which occurs within 8 hours – 5 days of using contaminated hot tub or whirlpoolUnfortunately showering after exposureUnfortunately, showering after exposure provides no protectionPseudomonas is the most common cause of hot tub folliculitisMay also be caused by Staphylococcus, but unusual

MSSA or MRSA

Clinical Presentation

One or more pustules may first appearFever may or may not be present; usually low grade if it does occurMalaise and fatigue may accompany the outbreakPustules may have wide rims of erythema

Hot Tub Folliculitis

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TreatmentCulture of lesions is likely warrantedWhite vinegar wet compresses – 20 minutes on three x daily may provide significant benefitOral Antibiotics

Ciprofloxacin is preferred agent if hot tub folliculitis is suspected due to pseudomonas coverage

Discuss contagiousnessNo evidence that it is spread person - person

Perioral DermatitisOccurs in young women and closely resembles acnePapules and pustules are frequently presentLesions are confined to chin and nasolabial f ldfoldsCan also occur in childrenCause is unknown but is believed to be exacerbated by benzoyl peroxide, tretinoin, alcohol based products and frequent moisturizing

Perioral Dermatitis

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Treatment

Tetracycline creamsTwo times daily x 4 weeks

Erythromycin creamsTwo times daily x 4 weeks

MetrogelTwo times daily x 4 weeksMay not be as effective as above agents

Avoid topical steroidsStop moisturizing

Seborrheic Keratoses

Most common benign skin lesionUnknown originNo potential for malignancyUsually asymptomaticRarely familialMost individuals develop 1 or more of these lesions throughout lifetime


CharacteristicsSmooth surface with tiny round, embedded pearlsM b h d d k dMay be rough, dry and crackedSharply demarcatedAppear stuck on the surfaceVary in size from 2 mm to 3 cmLesions are completely epidermal with no deep tissue penetration

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Seborrheic Keratosis

Can Mimic a Malignant Melanoma

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TreatmentReassuranceLesions are only removed for cosmetic

f bi if th l ipurposes or for a biopsy if pathology is unknownIf removed, shave excisionCryosurgeryMonitor for any increase in size, change in appearance

Acne Vulgaris

EtiologyDisease involving the pilosebaceous unitMost frequent and intense where sebaceous glands are the largestAcne begins when sebum production increasesPropionibacterium acnes proliferates in the sebumP. acnes is a normal skin resident but can cause significant inflammatory lesions when trapped in skin

Acne Vulgaris

Noninflammatory lesionsOpen and closed comedones

Inflammatory lesionsInflammatory lesionsPapules, pustules and nodules (cysts)

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Acne Vulgaris

SymptomsPapular lesions on the face, chest and backWhi h dWhite headsBlack heads

SignsPapular lesionsClosed and open comedones

Closed Comedones

Closed Comedones

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Open Comedones

Cystic Acne

Acne Vulgaris

DiagnosisHistory and physical examination

PlanDiagnostic: None

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Acne VulgarisTherapeutic

Benzoyl Peroxide (2.5%, 5% and 10%)Effective as initial medicationBegin early on in the disease process

TretinoinVery effective agentStart with 0.05% - 0.1% creamReduces and minimizes scarring

Topical AntibioticsInitial medication or can be combined with benzoyl peroxideErygel, clindamycin are most commonly utilized

Acne VulgarisTherapeutic

Oral AntibioticsTetracyclineMinocyclineErythromyciny yCephalosporinsShould only be used when topicals are ineffective or when patient has moderate disease at presentation

OCP’sWomen desiring contraception who also have acne

AccutaneCystic acne or mod-severe disease

Acne VulgarisPlan

Educational6 weeks for improvement to be seenAvoid antibacterial soapsDove soap or similar is recommendedDove soap or similar is recommendedAvoid hatsFoods have not been implicated as a causeCaramel products may worsen situationAvoid picking at the lesionsReview side effects of the medications

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PsoriasisEtiology

1-3% of the population worldwideTransmitted geneticallyDisease is lifelong; often beginning in childhoodCharacterized by chronic, recurrent exacerbations and remissionsStress can precipitate an episodeStrep pharyngitis has been known to precipitate the onset

PsoriasisEtiology

Physically and emotionally disablingErodes self esteem and often forces the patient into a life of concealmentpatient into a life of concealmentMedications can precipitate (Beta blockers, lithium)

PsoriasisSymptoms

Red, scaling papules that coalesce to form round-oval plaquesScale is silvery white and is adherentWhen removed, bleeding occurs (Auspitz’s sign)May begin at a site of a sunburn or surgery

This is called Koebner’s phenomenonElbows, knees, scalp, gluteal cleft, toenails, fingernails

Extensor surfaces

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Psoriasis

SignsErythematous papulesPlaquesNail involvementMay be associated with arthritis

Psoriasis

Guttate Psoriasis

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PsoriasisDiagnosis

History and physical examinationBiopsy if uncertain

PlanPlanDiagnostic: None

PsoriasisTherapeutic

Topical corticosteroidsPulse therapyTwo weeks on/ two weeks offCaution: side effects

DovonexDovonexVitamin D3 analogueWorks by inhibiting epidermal cell proliferationCan be used long-term and is very safeDovonex ointment two times daily x 8 weeksMay see about a 70% improvement

Tar: newer preparations are more pleasantIntralesional steroids

Psoriasis

TherapeuticUltraviolet light BRetinoidsRetinoidsSystemic Treatments

MethotrexatePlaquenilEnbrel

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Psoriasis

PlanEducational

MoisturizeConsider psychological therapyReview the nature of this chronic disease

Skin Tags (Achrochordons)

Very commonly encountered benign lesionsSeen in approximately 25% of men and womenMost common locations: axilla, neck, inguinal regionUsually begin in 2nd decade and peak by the 5th decade of life


AppearanceBegins as a tiny flesh-toned or brown lesionM i t 1 i iMay increase to 1 cm in sizeHallmark: polypoid mass on a long narrow stalkBleeds very easily; particularly because they often get caught on a necklace or clothing

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Diagnosis?Linked with____________?

Skin Tags


TreatmentShave excisionCCryosurgeryElectrocautery

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Case StudyS:TM is a 64-year-old Caucasian male who presents with a painful rash located on his right buttock.

Describes the rash as red and blisteredHas been present x 96 hours and is in for an evaluation because the pain is severe. Pain is “9” on 0 – 10 scale. Has tried oral OTC medications without significant improvement Pain is described as a burning sensation;significant improvement. Pain is described as a burning sensation; deep in his buttock. Denies precipitating factors. Pain began approx 2 days before the rash appeared. Denies fever, chills, new soaps, lotions, changes in medications.

Medications: atorvastatin 40 mg 1 po qhs; amlodipine 5 mg 1 po qhs; loratidine 10mg 1 po qd; aspirin 81 mg 1 po qam; various vitamins

Case StudyAllergies: NKDAPMH: dyslipidemia; hypertension; obesity, allergic rhinitisSocial history: 30 pack year history of i tt ki 10 M hi i tcigarette smoking; none x 10 years; Machinist;

happily married x 40+ years

Case StudyO: T:97.8; P: 94; R:18; BP: 148/90

Skin: p/w/d; approximately 15-20 vesicles located on right buttock overlying an erythematous base; vesicles are clustered but without obvious pattern; no streaking, petecchiae. Few scattered vesicles on posterior aspect of right thigh; no lesions on left buttock or legHips: FROM: no tenderness, erythema, masses

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Case StudyO: PE continued

Back: From: no tenderness, erythema, massesAbdomen: Soft, large; + BS; no masses, tenderness, hsmNeuro: intact including light touch pain vibratory toNeuro: intact including light touch, pain, vibratory to right lower extremity; heel, toe walking intact

+ AllodyniaClothing, light touch, cool object

+ HyperalgesiaPainful stimuli elicited significant pain

Examples of Herpes Zoster

Herpes Zoster

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Acute Herpes Zoster

©© Dr P. Dr P. MarazziMarazzi, Science Photo Library. Image used with permission., Science Photo Library. Image used with permission.

Herpes Zoster

Highly contagious DNA virus which during the varicella infection (primary infection) gains access into the dorsal root gangliaVirus remains dormant for decades and is reactivated when an insult occurs to the individual’s immune system

Examples: HIV, chemotherapy, illness, stress, corticosteroid usage

Incidence and Prevalence

3 million cases of chickenpox yearlyDisease of childhood

600,000 - 1 million cases of herpes zoster each year in the United Statesy

Tends to be more of a disease of agingBy age 80, 20% of us will have zoster at some point in our lifetimeMen = Women

www.niaid.nih.gov/shingles/cq.htm

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Risk Factors Increasing age (50-60 years and beyond)Varicella infection when < 2 years of ageImmunosuppressionStress (controversial)Stress (controversial)TraumaMalignancies

25% of patients with Hodgkin’s will develop zoster1

1Stankus, S. et. Al. Management of Herpes Zoster and Postherpetic Neuralgia. Am Fam Physician 2000;61:2437-44, 2447-8)

Goals of Treatment

Treat acute viral infectionShorten courseReduce lesionsReduce lesions

Treat acute painPrevent complications

Postherpetic neuralgia

Acute Treatment OptionsAntiviral

Goal: Reduce viral reproductionCorticosteroids

Initially postulated that these reduce viral replication; recent studies have not found this to be truebe trueHowever, they do decrease pain

Pain ManagementTopical agentsAnti-inflammatory agentsNarcotics

Postherpetic neuralgia preventionwww.aad.org/pamphlets/herpesZoster.html

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Antiviral Treatment Options

Ideally, want to begin within the first 72 hours of the eruption as benefits may be reduced if started after thatThese medications decrease duration ofThese medications decrease duration of the rash and severity of the pain

Studies vary as to how much these products actually reduce the incidence of post-herpetic neuralgia1Stankus, S. et. Al. Management of Herpes Zoster and Postherpetic Neuralgia. Am Fam Physician 2000;61:2437-44, 2447-8)

Controlled Trials of Antiviral Agents in Herpes Zoster

% of patients with PHN at:

3 months 6 months

Acyclovir vs. Placebo

25% vs. 54% 15% vs. 35%

Valacyclovir vs. Acyclovir

31% vs. 38% 19.9% vs. 25.7%

Famciclovir vs. Placebo

34.9% vs. 49.2% 19.5% vs. 40.3%

Adapted from Johnson RW. J Antimicrob Chemother. 2001;47:1-8.

CorticosteroidsOften utilized despite mixed results in clinical trialsPrednisone, when used with acyclovir, in one study reduced pain associated with herpes

tzosterCorticosteroids are currently recommended for individuals over 50 years of age with HZDosage:

30 mg bid x 7 days; 15 mg bid x 7 days; 7.5 mg bid x 7 days1


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Pain

Pain associated with herpes zoster can range from mild – severeClinician must tailor pain medication options based upon individual presentationbased upon individual presentation

Pain ManagementTopical Agents

Calamine lotion to lesions 2 – 3x/dayBetadine to lesions qdCapsaicin cream once lesions crusted 3 – 5x/dayT i l lid i 5% t h f 12 h t tiTopical lidocaine 5% patch for 12 hours at a time once lesions are crusted


Acute Pain Management

Oral AgentsAcetaminophen

Has not been shown to be effective in trials)Ibuprofen or similar

Not likely to be effective with neuropathic painy p p

Nerve BlocksHave been shown to be effective for many individuals with severe pain in some trials; other trials -ineffective

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And…the use of medications such as TCA’s, gabapentin, pregabalin,

oxycodone and tramadol during the acute phase of HZ decrease painacute phase of HZ decrease pain

but also may also reduce the risk of PHN

Follow-up

Monitor for secondary infectionsMonitor for evidence of postherpetic neuralgiagMonitor for adverse impact on quality of life

Bullous PemphigoidBullous pemphigoid is a rare, benign subepidermal rash characterized by bullae formationOrigin is unknownDisease of the elderlyMost cases occur after 60 years of ageNo evidence to support any association with other conditions or diseasesMay be an association with concomitant medication usage

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Bullous Pemphigoid

Clinical ManifestationsBegins with a localized area of erythema which looks similar to hives/urticariaIt hi i d tItching is moderate – severeOver the course of 1 – 3 weeks – area becomes darker red or cyanotic in appearanceResembles – erythema multiformeVesicles and bullae rapidly appear

Bullous Pemphigoid

Clinical ManifestationsMost common locations are:

AbdomenGroinFlexor surfaces of the arms and legsPalms and soles are also affected

Nikolsky’s sign is negative

Bullous Pemphigoid

Clinical ManifestationsMay last 9 weeks – 17 yearsAverage – 2 yearsPeriods of remission will follow exacerbationsAfebrileNo systemic illness

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Bullous Pemphigoid

Diagnosis

History and physical examinationCBC with differential

Eosinophilia will be present in 70%Eosinophilia will be present in 70% or greater of individuals

Biopsy of lesions/skin

TreatmentAtarax or similar for itchingTopical steroids

May be helpful in someOral antibiotics

S f l l ti i ith th f ll i tSuccessful resolution in some with the following agents:TCN or MinocyclineErythromycin

Systemic steroidsImmunosuppressive agents

MTXAzathioprine

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Actinic Keratoses

Common, sun-induced, premalignant lesionsIncidence: Increases with age, light complexioncomplexionCaused by years of sun exposureLesions frequently appear after the summer suggesting that sun exposure may cause lesions to become more active

Actinic KeratosesClinical presentation:

Slightly roughened area that often bleeds when excoriatedBest recognized by palpation than observation when first beginsfirst beginsProgresses to an adherent yellow crustSize: 3-6 mmCommon location: scalp, temples, forehead, handsLesion with drainage suggests degeneration into a malignancy

Actinic Keratosis

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Actinic Keratosis

Keratin may accumulate and transform lesion into a cutaneous horna cutaneous hornFrequently seen on the pinna of the ear

Actinic Keratoses

PrognosisCan spontaneously regress if sun exposure is eliminatedG d i if d d lGood prognosis if treated adequatelySmall percentage transform into a squamous cell carcinoma which can metastasize

60% of all squamous cell carcinomas began as an actinic keratosis

Actinic Keratoses

TreatmentCryosurgery

Preferred methodS i l R lSurgical RemovalTretinoin

0.05% - 0.1% cream applied once daily at bedtimeIf no improvement in 3 – 4 months, treat with cryosurgery

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Actinic Keratoses

Treatment5-fluorouracilTopical chemotherapeutic agents

Example – ActinexExample – ActinexImiquimod (Aldara)

2x weekly x 16 weeksAcid peels

Glycolic acid chemical peelsSunscreen

Follow-up

Continuous monitoring of skin for changes in lesionsMonitor for new lesionsSunscreen is essentialSunscreen is essentialMinimize sun exposure

Basal Cell Carcinoma

Most common cutaneous malignancy found in humansPresenting complaint: bleeding or scabbing sore that heals and recurssore that heals and recursRisk factors: fair skin, sun exposure, tanning salon, previous injuryIncidence: Men > women: Incidence increases after age 40

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Location: 85% appear on the head and neck; 25-30% on the nose alonePrognosis: Excellent because basal cell carcinomas rarely metastasize but willcarcinomas rarely metastasize but will grow and spread to adjacent locationsVery common for a 2nd or 3rd basal cell to appear

Basal Cell CarcinomaSix Clinical Types:

Nodular (21%): rounded massMost common formPearly white or pinkT l i t ti l tTelangiectatic vessels are presentUlcerating center is commonMay present as a nonhealing lesion

Superficial (17%): Least aggressive lesionPigmented: May resemble a melanoma

Basal Cell CarcinomaSix Clinical Types:

Cystic: Similar to nodular lesionSclerosing: Borders indistinct

May grow for years before recognizedMay grow for years before recognizedMay resemble a scar – depressed lesion

Nevoid: very rare; inherited as an autosomal dominant trait; Multiple BCC’s appear at birth

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TreatmentElectrodessicationExcisionCryosurgeryMohs’ micrographic surgeryRadiationImiquimod (superficial basal cells)

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Squamous Cell Carcinoma

Arises in the epithelium and is common in middle-aged to elderly population2 types

Areas of prior radiation or thermal injury and in chronic ulcers: most likely to metastasizeActinically damaged skin: Least likely to metastasize


Risk factorsSun exposureRenal transplant recipients (253 fold increase secondary to immunosuppression)increase secondary to immunosuppression)Areas of chronic inflammation or thermal burns

LocationSun exposed regions: scalp, back of the hands, and superior aspect of the pinna


Clinical PresentationMay arise from previous actinic keratosisThick, adherent scale with a red, inflamed baseFirm, movable, elevated lesion with a sharply defined borderCan spread locally and metastasize

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TreatmentReferral to dermatology or plastics depending upon location / availabilityp g p yElectrodessicationExcision with margins

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Malignant Melanoma

Very dangerous cancer that arises from the cells of the melanocytic systemCan metastasize to any organ including the brainEpidemic proportions - Lifetime risk: 1:90Risk factors

Sun exposureFamily history of melanomaImmunosuppression

Malignant Melanoma

ABCDE’s of Malignant MelanomaAsymmetryBordersColorDiameter enlargementEnlarging or evolving

Malignant Melanoma

CharacteristicsCan be black, brown, red, white or blue

TypesypSuperficial spreadingLentigo malignaNodular melanomaAcrallentiginous melanoma

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Malignant Melanoma

Malignant Melanoma

Malignant Melanoma

TreatmentBiopsy with elliptical excision onlyShave excision and punch biopsy are NOT recommendedReferral to dermatology/general surgeon/plastics depending upon accessSurgical excision with margin clearing

1-2 cm marginRecent evidence that a 3 cm margin may improve survival rates

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Thank You!

I Would Be Happy To Entertain Any

Questions

Wendy L. Wright, MS, RN, ARNP, FNP, FAANP

Partners in Healthcare Education, LLCwww.4healtheducation.com

Health & Medicine

44 adultdermatology