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Concise review of common adult and pediatric derm complaints seen in a clinical setting.
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Derm Study Guide • How to describe a lesion:
o Flat= MACULAR o Raised= PAPULAR o If the lesion is small and
flat, it’s a MACULE o If the lesion is large and flat,
it’s a PATCH o Small and raised= PAPULE o Large and raised= PLAQUE o Small and fluid filled=
VESICLE o Large and fluid filled=
BULLAE o Small and filled with pus=
PUSTULE
Anything under the skin and round= NODULE
• Descriptive terms of derm: o Border (smooth, not well demarcated) o Size o Color o Shape o Distribution
What is this??????
ACNE!
Lesion Description
FLAT RAISED
<1cm
macule papule
>1cm
patch plaque
Wednesday, November 6, 13
Lesion Description
pustule
nodule
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Lesion Description
pustule
nodule
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MODERATE ACNE
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Why is acne a horrible disease? o HUGE psychological impact. Strongly associated with anxiety and
depression o You are more likely to have depression and anxiety with acne than
with cancer!!!
Pathophysiology of Acne
1. During ADRENARCHE (a few years before puberty), get DESQUAMATION of cells in the hair follicle (aka they grow and block) AND too much sebum production (because of androgens)
2. PLUG forms! This is called a MICROCOMEDONE
3. In PUBERTY, P. acnes decides to grow. This causes inflammation and immune sensitivity (but NOT an actual infection
-‐The Lesions of Acne:
• Comedones o Open= black head (filled with dirt and gunk) o Closed= white head
• Inflammation
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Psychologic Impact: Anxiety and Depression
02
468
1012
1416
Anxiety Depression
Mea
n H
AD
Sco
re
Psychiatric—depressed
Psychiatric—anxious
Acne
Psoriasis
General dermatology population
Cancer
HAD = Hospital Anxiety and Depression Scale. Kellett SC et al. Br J Dermatol. 1999;140:273-82.
Wednesday, November 6, 13
Acne Pathophysiology
HairSkinsurfaceSebumFollicle
Sebaceousgland
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General Treatment of Acne • Topical agents
o Retinoids o Benzyl peroxide (OTC) o Abx o Salicylic acid o Combos
• Oral o Abx o Hormones….aka BCP o Isotretinoin (Accutane) o Corticosteroids
• Other o Laser and light therapy
Mild Acne: -‐ see both open and closed comedones -‐ NO inflammation -‐ Acne begins with mild
Treatment of Mild acne
o Topical retinoids § Different kinds..: tretintoin, adapalene, tazarotene
Moderate Acne: -‐Open and closed comedones
INFLAMMATION
-‐Treatment of moderate acne -‐Topical retinoids -‐PLUS benzyl peroxide (reduces inflammation) -‐Plus ABX (oral or topical)
MILD ACNE
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TREATMENT TARGETSCOMEDONES
Treatment: Topical Retinoids (tretinoin, adapalene, tazarotene)
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TREATMENT TARGETSCOMEDONES and INFLAMMATORY LESIONS
Treatment: Topical Retinoids,
Benzoyl Peroxide,
Antibiotics (topical or oral)
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Severe Acne: -‐open and closed comedones -‐more inflammation -‐inflammation forms “sinus tracts” -‐cysts and nodules -‐scarring potential
-‐Treatment of severe acne -‐topid retinoids+ benzyl peroxide + ORAL abx or BCP -‐really start to think about isotretinoin (works very well for these cases) What is this?????????
Atopic Dermatitis! Description of dermatitis (aka eczema)
-‐ POORLY demarcated lesions (hallmark!) -‐ Lots of excoriation and inflammation
SEVERE ACNE
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ATOPIC DERMATITIS
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-‐ More common in kids -‐ Family history
-‐ Face and extensors common in young ;
-‐ Flexors in adults
Nummular dermatitis:
o Coin-‐like round lesions o Adults only
Treatment of Dermatitis: -‐ Avoid irritants -‐ Frequent BATHING! MUST be followed by moisturizing
o Most effective treatment is to trap water in deeper layers of skin with lotion
o Have severe cases bathe more than 1x/day -‐ Topical corticosteroids and immunomodulators -‐ Oral antihistamines…..Only really work by sedating the kids so they don’t
scratch -‐ AVOID ORAL STEROIDS!
o Causes rebound -‐ AVOID oral abx
o Increases resistance of Staph which is HIGHLY colonized on dermatitis patients
o Only use when a crusty, infected lesion present
ATOPIC DERMATITIS
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ATOPIC DERMATITIS
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What is this?????
Psoriasis!!!
-‐ Hallmark of psoriasis: SCALY, WELL DEMARCATED, SILVER-‐WHITE PLAQUES
-‐no excoriation -‐no inflammation -‐thick, white scale
Pathophysiology of psoriasis -‐ very thick layers of keratin from overactive keratinocytes -‐keratinocytes move up to superficial layers of skin from deep layers in a few days, when it should take almost a month. As a result, they can’t be shed quickly enough, so get plaques!
Most common areas affected: -‐Joints: elbows and knees -‐Eyes common in kids
PSORIASIS
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PSORIASIS
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PSORIASIS
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Diaper region can also be affected…..misdiagnosed as diaper rash
Scalp also super common! But difficult to treat
Which one is psoriasis?
(Answer: trick question. They are both psoriasis) What is the diagnosis?
(good job, its dermatitis)
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PSORIASIS
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PSORIASIS
DERMATITIS
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PSORIASIS
Wednesday, November 6, 13
PSORIASIS
DERMATITIS
Wednesday, November 6, 13
Inverse Psorasis -‐ Develops in FOLDS instead of
joint -‐ Often misdiagnosed as tinnea -‐ How to tell if its tinnea: tinnea
will have a region of clearance in the middle
Guttate psoriasis
-‐ Tons of little psoriasis plaques all over chest
-‐ Commonly seen in kids after a Strep infection
Nail psoriasis
Strongly associated with arthritis…so better ask patients about it.
Psoriasis treatment!
-‐ Topicals o Steroids o Intralesional steroids o Tazorac
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INVERSE PSORIASIS
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GUTTATE PSORIASIS
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NAIL PSORIASIS
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o Salicylic acid o Tar o Calcipotriene (vit D analogue) o Protopic (for inverse psoriasis)
-‐ Others o UV light (special medical tanning bed)…works really well, but
requires 3x/week o Methotrexate….oldie but goodie. Try topicals first o Most patients are successfully treated with topicals, but if not, try UV,
then methotrexate What is this???
Herpes! Fun Facts about The Herp.
-‐ Loves Labial areas -‐ Groups in vesicles with
erythematous base -‐ LOTS of vesicles -‐ Can live other places besides
the lip….like the cheek -‐ Herpes ≠ impetigo (seriously
she loved this concept)
What’s the problem here?
-‐ LOOKS LIKE IMPETIGO -‐ Impetigo= bacterial infection that is NEVER recurrent
o Some bad docs don’t understand this and refer their patients to dermatologists for “recurrent impetigo”…but its really herpes
Treatment of Herpes Simplex:
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HERPES SIMPLEX
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HERPES SIMPLEX
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-‐if you are immunocompetent -‐ Nothing or a round or two of
antivirals -‐ Acyclovir -‐ Valtrex -‐ Famvir
if you are Immunocompromised (or get >6 HSV outbreaks/year):
-‐ Suppressive antiviral therapy!
-‐If you are a neonate born with herpes from your mom -‐This is really BAD! -‐treat ASAP w/IV antivirals
What’s this?
Correct answer: It’s NOT herpes! It’s Impetigo caused by Staph! NO vesicles present! At one time there were blisters, but they have since crusted over. What’s this?
HSV! See how it’s very different from impetigo???
HERPES SIMPLEX
IMPETIGO
Wednesday, November 6, 13
HERPES SIMPLEX
IMPETIGO
Wednesday, November 6, 13
What’s this?
Impetigo…..remember: CRUSTY BLISTERS
Herpes or Impetigo?
HSV!
Bullae Impetigo
Common Benign Cutaneous Growths Common theme: all seen in adults Seborrheic Keratoses
-‐thick, rough, raised -‐completely harmless -‐can be waxy and dry -‐have a “stuck on appearance”
IMPETIGO
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IMPETIGO
Wednesday, November 6, 13
Seborrheic Keratoses
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Impetigo
Herpes Simplex
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-‐Common in AAs
Cherry Angiomas
-‐very common -‐more numerous in 40’s and 50’s -‐usually small papule
Epidermoid Cysts
-‐form when your normal oils are secreted into a closed area
-‐completely harmless until they become inflamed…..then super painful -‐often have a little pore on top Inflamed Epidermoid Cyst
Treatment of Epidermoid cysts: Inflammed: -‐Incision and drainage -‐inject with corticosteroids -‐Excision
Non-‐inflammed: -‐no treatment -‐remove entire sac if repeatedly becoming inflamed (excision)
Seborrheic Keratoses
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Seborrheic Keratoses
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Cherry Angiomas
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Epidermoid Cysts(Epidermal Inclusion Cysts)
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Epidermoid Cysts
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Epidermoid Cysts - inflamed
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Here’s a step-‐by-‐step guide if you want to learn to do this: http://ispub.com/IJPS/7/1/4654
Pigmented Lesions Ephelides -‐freckles, liver spots, age spots -‐NOT cute! They mean you have skin damage Solar Lentigines -‐another form of sun-‐related skin damage -‐more liver and age spots
Melnocytic Nevi -‐the common mole -‐develop as kids, young adults
Inflamed Cyst: Incision and Drainage (I&D)
Intralesional Corticosteroids Excision
Non-inflamed Cyst: No treatment Excision
Epidermoid Cysts - Treatment
Wednesday, November 6, 13 Solar Lentigines
Wednesday, November 6, 13
KidsYoung adultsOlder adultsCongenital
Melanocytic Nevi (“moles”)
epidermis
dermis
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-‐Junctional Nevi…..what they begin as during childhood -‐flat -‐no nests of cells to cause them to be raised
-‐Compound nevi….when junctional nevi become raised -‐teens, adults
-‐Dermal nevi…..when you are old, your moles become even more raised and lose their color
-‐these might eventually go away. Congenital GIANT melanocytic nevi
-‐Develop near the hair follicle, which is why they are hairy -‐want to try to remove these because very prone to becoming cancer
Melanocytic Nevi -kids
JunctionalOr Compound
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Melanocytic Nevi -kids
JunctionalOr Compound
Wednesday, November 6, 13
Melanocytic Nevi - adults
Dermal
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Melanocytic Nevi – congenital
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Melanoma A – asymmetric B-‐ Border uneven C-‐ multiple colors D-‐ Diameter >1/4 inch E-‐ evolving. Any change at all…such as bleeding or itching
Risk Factors: -‐ Family history (1st degree
relative) -‐ Numerous nevi -‐ Multiple dysplastic nevi -‐ Hx of BLISTERING sunburn
as a kid -‐ Fair skin -‐ Tanning Beds -‐ Immunosuppression -‐ Giant congenital nevi
Melanoma Prognosis -‐ Best= Breslow thickness. How
deep the cancer goes in biopsy o Determines how large
margins for removal need to be
o And if you need to check lymph nodes
o Might want to also do a CXR and blood chem
Melanoma Treatment
-‐ Excision w/wide margins -‐ Sentinal lymph node biopsy -‐ Interferon -‐ Chemo
Melanoma
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Melanoma
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85
Melanoma
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Melanoma
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Melanoma
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