Wow that looks Pretty Wow that looks Pretty Bad!!Bad!!

Jai Gilliam, M.D.Jai Gilliam, M.D.

Internal medicine/PediatricsInternal medicine/Pediatrics

Noon ConferenceNoon Conference

45 yo Caucasian male is coming to 45 yo Caucasian male is coming to see you in clinic for a new rash that see you in clinic for a new rash that has developed over the past 1 has developed over the past 1 month. He says that the rash itches month. He says that the rash itches “a lot” and that he has tried “a lot” and that he has tried multiple over the counter creams multiple over the counter creams but this has provided no relief. He but this has provided no relief. He describes the rash as being very describes the rash as being very dry and that it “peels” a lot. It is dry and that it “peels” a lot. It is localized around his nose, localized around his nose, forehead, and involves the lateral forehead, and involves the lateral aspects of his hair lineaspects of his hair line

Seborrhea (Seborrheic dermatitis)Seborrhea (Seborrheic dermatitis) Patient will present with generalized, fine, scaling Patient will present with generalized, fine, scaling

(flaky) rash of the scalp, ear, nose, and occasionally (flaky) rash of the scalp, ear, nose, and occasionally lips.lips.

Rash is puritic in natureRash is puritic in nature

Treatment: Selenium sulfide shampoo, zinc pyrithione, Treatment: Selenium sulfide shampoo, zinc pyrithione, and Tarand Tar

What other crucial questions would you ask this What other crucial questions would you ask this patient?patient?

Have you ever been tested for HIV ?Have you ever been tested for HIV ?

Mrs. Jackson is being seen in clinic for a “personal Mrs. Jackson is being seen in clinic for a “personal matter”. She states that she is really matter”. She states that she is really embarrassed about her weight and wants to try embarrassed about her weight and wants to try to loss some weight. She also would like to talk to loss some weight. She also would like to talk about a rash that she has had for a long time. She about a rash that she has had for a long time. She says that it occurs along her skin folds and that it says that it occurs along her skin folds and that it “itches like crazy”. Patient tried some “itches like crazy”. Patient tried some Hydrocortisone cream on the rash but the rash Hydrocortisone cream on the rash but the rash got worse.got worse.

On her physical exam you see this. On her physical exam you see this.

IntertrigoIntertrigo Contact irritant dermatitis where candida is a Contact irritant dermatitis where candida is a

common fungus that causes this rash. common fungus that causes this rash. Occurs along the folds where there is a lot of Occurs along the folds where there is a lot of

moisture making it an ideal location for fungus to moisture making it an ideal location for fungus to grow. grow.

Commonly seen in obese patients.Commonly seen in obese patients.

Treatment: Make sure that the area is dried Treatment: Make sure that the area is dried especially after showering/bathing. especially after showering/bathing.

Topical antifunguls and antifungal powder to Topical antifunguls and antifungal powder to prevent moisture. prevent moisture.

Mr. Powers is a 43 yo male who is coming to your Mr. Powers is a 43 yo male who is coming to your clinic because he is concerned about these clinic because he is concerned about these “Weird” circular rashes on his arm and legs. He “Weird” circular rashes on his arm and legs. He describes the lesion as “shiny” and almost like a describes the lesion as “shiny” and almost like a “irregular circular” pattern. He says that he has “irregular circular” pattern. He says that he has had it for the past 6 months but he came in had it for the past 6 months but he came in because it just keeps getting worse. He denies because it just keeps getting worse. He denies any itching and no trauma. You review his any itching and no trauma. You review his medication and he is taking Lipitor, allegra-D, medication and he is taking Lipitor, allegra-D, accupril, Glucophage, and glipizide. accupril, Glucophage, and glipizide.

When you do your physical exam you see thisWhen you do your physical exam you see this

Necrobiosis lipoidicaNecrobiosis lipoidica

Rash is commonly seen in diabeticsRash is commonly seen in diabetics

15% Precedes the onset of diabetes 15% Precedes the onset of diabetes

25 % occur at the onset of diabetes25 % occur at the onset of diabetes

60% will occur in patients already diagnosed60% will occur in patients already diagnosed

Etiology- 3 theoriesEtiology- 3 theories

1. 1. Diabetic microangiopathyDiabetic microangiopathy secondary to glycoprotien secondary to glycoprotien deposition. deposition.

2.2.VasculitisVasculitis- secondary to immunoglobulin deposition along - secondary to immunoglobulin deposition along with complement/fibrinogen depositswith complement/fibrinogen deposits

3. 3. Abnormal Collagen-Abnormal Collagen- defective collagen has been seen in defective collagen has been seen in

other diabetic end organ damage other diabetic end organ damage

TreatmenTreatment: Topical & intralesional steroids. ( atrophy of skin),t: Topical & intralesional steroids. ( atrophy of skin),

Aspirin & Dipyridamole (Anti-platelet therapy, platelet induced Aspirin & Dipyridamole (Anti-platelet therapy, platelet induced vasocclusion disease. vasocclusion disease.

Your next patient is a 28 yo male from the middle Your next patient is a 28 yo male from the middle east who speaks very little English. He’s at this east who speaks very little English. He’s at this office visit with his wife who is able to translate. office visit with his wife who is able to translate. She says that they are being referred to you from She says that they are being referred to you from another physician. Her concern is that her another physician. Her concern is that her husband has developed a medium size ulcer on husband has developed a medium size ulcer on his ankle. It has been there for about 4 months, his ankle. It has been there for about 4 months, but it has gotten worse. The wound is now but it has gotten worse. The wound is now draining purulent discharge. draining purulent discharge.

The only other medical issue is that he has The only other medical issue is that he has been having problems with his “bowels” for which been having problems with his “bowels” for which his wife says that he is taking a special his wife says that he is taking a special medication for his bowel problem. medication for his bowel problem.

Pyoderma GangrenosumPyoderma Gangrenosum 2 types: 2 types: Classic PG-Classic PG- involving primarily the legs. involving primarily the legs.

Atypical PG-Atypical PG- involves superficial skin, effecting the involves superficial skin, effecting the handshands

Diagnosis is based on exclusion by history/biopsy- DDx Diagnosis is based on exclusion by history/biopsy- DDx is infection, connective tissue dz, vasculitis, traumais infection, connective tissue dz, vasculitis, trauma

Cause: speculated to be related immune dysregulationCause: speculated to be related immune dysregulation

Prognosis is goodPrognosis is good, associated with other systemic dz: , associated with other systemic dz: IBDIBD, rheumatoid arthritis, chronic hepatitis, Wagener's, rheumatoid arthritis, chronic hepatitis, Wagener's

Treatment: Treatment: MildMild- topical steroid. - topical steroid. Moderate-SevereModerate-Severe: Oral : Oral steroid, cyclosporin, methotrexate, and tacrolimussteroid, cyclosporin, methotrexate, and tacrolimus

Mrs.Lenning is a 36 yo female who is bringing her Mrs.Lenning is a 36 yo female who is bringing her 4month old infant in for well child check. The only 4month old infant in for well child check. The only concern on this visit is about breast feeding. She concern on this visit is about breast feeding. She claims that she has been having some difficulty claims that she has been having some difficulty with breast feeding. She has noticed that there is with breast feeding. She has noticed that there is a dry rash around her areola on her right breast. a dry rash around her areola on her right breast. She has tried some Hydrocortisone cream on it She has tried some Hydrocortisone cream on it because she thought it was eczema but the rash because she thought it was eczema but the rash did not improvedid not improve

When you do her physical exam you see thisWhen you do her physical exam you see this

Paget’s disease of the breastPaget’s disease of the breast1.Eczematous rash is pathoneumonic for the 1.Eczematous rash is pathoneumonic for the

presence of intraepithelial breast adenocarcinomapresence of intraepithelial breast adenocarcinoma

2.2.DiagnosisDiagnosis-confirmed by punch biopsy,showing -confirmed by punch biopsy,showing Paget cells-(adenocarcinoma cells).Paget cells-(adenocarcinoma cells).

3. 3. Prognosis:Prognosis: depends on the stage of disease (+) depends on the stage of disease (+) lymph nodes vs localized disease.lymph nodes vs localized disease.

4.4.TreatmentTreatment option:masectomy (rarely), breast option:masectomy (rarely), breast conserving surgery(nipple-areoloa resection), conserving surgery(nipple-areoloa resection), Conserving surgery + whole breast irradiation Conserving surgery + whole breast irradiation provided the lowest % with recurrenceprovided the lowest % with recurrence

You have been consulted to see a 67 yo female S/P You have been consulted to see a 67 yo female S/P right knee replacement for a possible wound right knee replacement for a possible wound infection of the right knee.She is complaining of right infection of the right knee.She is complaining of right knee swelling, tenderness, and skin knee swelling, tenderness, and skin hyperpigmentation. Her surgery was approx 1 week hyperpigmentation. Her surgery was approx 1 week ago and she is being seen today in Post-op clinic. ago and she is being seen today in Post-op clinic. Her entire post-op course was unremarkable and she Her entire post-op course was unremarkable and she has never had this before. Patient denies any trauma has never had this before. Patient denies any trauma to this leg, no fever, no chills, no other systemic to this leg, no fever, no chills, no other systemic symptomssymptoms

When you do your physical exam you see the When you do your physical exam you see the following?following?

What questions do you want to know about her What questions do you want to know about her post-op course.post-op course.

Where you taking any Coumadin during her Where you taking any Coumadin during her recent hospitalization?recent hospitalization?

Coumadin NecrosisCoumadin Necrosis

Typically presents Typically presents 7-14 days7-14 days after administration of after administration ofcoumadin.coumadin.

Caused by Protein C deficiency: Bx will show fibrin thrombi within cutaneous Caused by Protein C deficiency: Bx will show fibrin thrombi within cutaneous vessels leading to interstitial hemorrhage.vessels leading to interstitial hemorrhage.

Clinically: Rash will develop over the trunk, arms, breast, and penis (common Clinically: Rash will develop over the trunk, arms, breast, and penis (common symptom).symptom).

Treatment: Stop Coumadin, Protein C need to be replaced.(concentrated or Treatment: Stop Coumadin, Protein C need to be replaced.(concentrated or FFP), surgical debridement if rapidly progressing necrosis.FFP), surgical debridement if rapidly progressing necrosis.

Once a patient has experienced this drug induced necrosis, Is it safe to try Once a patient has experienced this drug induced necrosis, Is it safe to try the patient back on Warfarin?the patient back on Warfarin?

Yes,Yes, Patient can be placed back on Warfarin but these patient need to be Patient can be placed back on Warfarin but these patient need to be closely monitor. If a patient has previously had a skin reaction to closely monitor. If a patient has previously had a skin reaction to coumadin there is no contraindication for subsequent doses coumadin there is no contraindication for subsequent doses

Mr.Lewis is a 34 yo male with Hx of HTN is coming to Mr.Lewis is a 34 yo male with Hx of HTN is coming to your clinic for the first time.He is concerned of a your clinic for the first time.He is concerned of a small “bump” on his face. He says that it has been small “bump” on his face. He says that it has been there for the past 1 year, but the bump has there for the past 1 year, but the bump has progressivley gotten worse. He denies any bleeding progressivley gotten worse. He denies any bleeding from the lesion or trauma. from the lesion or trauma.

Overall, he says he has been healthy but says Overall, he says he has been healthy but says that for the past 2 month he has really felt very tired that for the past 2 month he has really felt very tired and that his “smokers” cough has gotten worse and that his “smokers” cough has gotten worse over the same duration. He denies any fever, chills, over the same duration. He denies any fever, chills, or wt loss.or wt loss.

When you do your physical exam you notice this on his When you do your physical exam you notice this on his face? face?

Lupus PernioLupus PernioNo relation to SLENo relation to SLE, term Lupus= Chronic autoantibody , term Lupus= Chronic autoantibody

inflammatory disease and Pernio associated with inflammatory disease and Pernio associated with SARCOIDOSIS.SARCOIDOSIS.

25% of patients with Sarcoidosis will develop some form 25% of patients with Sarcoidosis will develop some form

of skin rash.of skin rash.

Biopsy of skin lesion in Sarcoid reveal the classic finding Biopsy of skin lesion in Sarcoid reveal the classic finding of of non-necrotizing granulomasnon-necrotizing granulomas

Mimics other disease, systemic involvement: eyes, heart, Mimics other disease, systemic involvement: eyes, heart,

skin, muscle, CNS, kidney, spleenskin, muscle, CNS, kidney, spleen

TreatmentTreatment: Prednisone and other immunosupresive : Prednisone and other immunosupresive

Anything in the History that you should ask about for Anything in the History that you should ask about for this patient?this patient?

Have You Ever been tested for HIV?Have You Ever been tested for HIV?

Bullous PemphigoidBullous Pemphigoid

Pemphigus VulgarisPemphigus Vulgaris

Starwars Starwars Episode IIIEpisode III

Secrets RevealedSecrets Revealed

Thank YouThank You

SourcesSources

1 1 MedstudyMedstudy: Internal medicine core curriculum : Internal medicine core curriculum section on Dermatology, 11section on Dermatology, 11thth edition 2005/2006 edition 2005/2006

2.Uptodate2.Uptodate

3.Lawrence, Cox Physical signs in Dermatology 3.Lawrence, Cox Physical signs in Dermatology 22ndnd edition chapter on hair/scalp disease. Pg 334- edition chapter on hair/scalp disease. Pg 334-350. copyright 2002350. copyright 2002