DERMATOLOGY LOOK A LIKES - npsymposium.comnpsymposium.com/wp-content/uploads/2019/07/Pre-2-Dermatology-Look-a... · • Tinea Pedis • Atopic Dermatitis • Contact Dermatitis •

DERMATOLOGY LOOK‐A‐LIKES

PEGGY VERNON, RN, MA, C‐PNP,FAANP

©PVernon2019

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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DISCLOSURESDISCLOSURES

• There are no financial relationships with

l d lcommercial interests to disclose

• Any unlabeled/unapproved uses of drugs or • Any unlabeled/unapproved uses of drugs or

products referenced will be disclosed

©PVernon2019


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RESTRICTIONSRESTRICTIONS

P i i t d t th N ti l N • Permission granted to the 2019 National Nurse

Practitioner Symposium and its attendees

• All rights reserved. No part of this presentation may

b d d d d fbe reproduced, stored, or transmitted in any form or

by any means without written permission of the

author

©PVernon2019


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ObjectivesObjectives

b d l h fI. Describe and list two treatment choices for

tinea capitus p

II. Identify two clinical differences between

pityriasis rosea and tinea corporis.

III D ib h diff i l b III. Describe the difference in scale between

atopic dermatitis and psoriasis©PVernon2019

p p


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Alopecia Areatap

• Localized area of hair loss in round, oval, or reticulated, diffuse patterns

• Noninfectious, nonscarring

• Scalp is the most Scalp is the most common site

• Can occur at any age, but most common <25 years most common <25 years of age

• 10‐20% have family history of AA

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history of AA


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Diagnosis Alopecia Areatag p

l d• Visual diagnosis

• KOH and fungal cultures

negative

• ANA to rule out SLE• ANA to rule out SLE

• RPR to rule out

secondary syphilis

• Biopsy

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p y


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Treatment Alopecia Areatap

• Systemic topical • Systemic, topical,

intralesional

corticosteroidscorticosteroids

• Off label: Imiquimod

(Aldara®), anthralin,

squaric acid,

immunomodulators

• Psychological support

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g


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Associated Disorders

• Associated autoimmune disorders: thyroiditis, y ,

Down syndrome, autoimmune

polyendocrinopathy‐candidiasis‐ectodermal

dysplasia syndromedysplasia syndrome

• Nails: fine pitting (hammered brass), mottled

lunula, rough nails, separation of nail from matrix

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Tinea Capitus• Most common fungal

infection in children• More common in black

boys• Noninflammatory scaling Noninflammatory scaling

and broken‐off hairs• Severe, painful

inflammation with boggy inflammation with boggy nodules (kerion) can result in scaring

• Palpable lymph nodes• Palpable lymph nodes• Contagious

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Treatment Tinea Capitusp• Topical antifungal agents

ineffective• Griseofulvin: Microsized

15mg/kg/day for at least 6 weeks to several months; better with high fat mealbetter with high fat meal

• Terbinafine: 250 mg/day (10mg/ml solution) 4‐6 weeks

• Itraconazole: 100mg capsules Itraconazole: 100mg capsules or oral solution (10 mg/ml) 3‐4 weeks

• Fluconazole: 6mg/kg/day 2 k kweeks, repeat at 4 week

intervals• Ketoconazole: 5mg/kg/day

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Adjunctive Therapyj py

P d i /k /d • Prednisone 1mg/kg/day

for 14 days for painful

kerion

• Systemic antibiotics for • Systemic antibiotics for

culture positive for

s.aureus or GAS

• Surgery to drain kerion©PVernon2019

Surgery to drain kerion


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Wooly Hair SyndromeWooly Hair Syndrome

• Light colored

• Sparse distribution

• Coarse woolly hair• Coarse, woolly hair

• Short, kinky, slow

growing

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ASSOCIATED ABNORMALITIESASSOCIATED ABNORMALITIES

• Autosomal recessive: palmoplantar

h k h l hhyperkeratosis, heart anomalies, right

ventricular cardiomyopathyventricular cardiomyopathy

• Present at birth

• Autosomal dominant most common

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TREATMENTTREATMENT

l l bl• No treatment currently available

• Screen for heart anomalies• Screen for heart anomalies

• Genetic counselingg

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Pityriasis AmiantaceaPityriasis Amiantacea• Distinct scalp disorderp• Female predilection: young

adults, adolescents, and childrenchildren

• Clinical diagnosis: Adherent thick silver scales which

d d bi d d h i surround and bind down hair tufts. Scale attached to hair shaft and scalp

• Scale resembles asbestos• Fungal cultures usually negative• Staph most common

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• Staph most common


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Pityriasis Amiantacea TreatmentPityriasis Amiantacea Treatment

• Mineral oil soaks prior to • Mineral oil soaks prior to

shampoo

• Keratolytic shampoo:

Salicylic acid, Clobetasol,

Silver sulfadiazine,

ketoconazole

• Topical corticosteroids

• Oral Antibiotics©PVernon2019

Oral Antibiotics


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Papulosquamous Disorders

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Tinea Versicolor

• Latin: “Tinea of various • Latin: Tinea of various colors”

• Yeast Malassezia furfurYeast Malassezia furfur• Multiple oval macules• Fine scale• Fine scale• Neck, shoulders, chest,

upper back armsupper back, arms• Color dependent on

season and pigmentation©PVernon2019

season and pigmentation


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Diagnosis and Treatment• KOH: multiple short, curved

hyphae and circular spores‐‐‐spaghetti and meatballs

• Wood’s light: orange fluorescence

• Topical antifungal creams: costly

• Ketoconazole or selenium • Ketoconazole or selenium sulfide shampoo 30 minutes daily for one week then monthly for 3 monthsmonthly for 3 months

• Oral ketoconazole, fluconazole, or itraconazole daily for 2

f ff©PVernon2019

weeks for difficult cases


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Pityriasis Roseay

• Herald patch: oval, Herald patch: oval, salmon colored patch with fine collarette of scale; develops over 1‐2 ; pweeks

• Smaller oval plaques follow lines of Blashko in follow lines of Blashko in “christmas tree”configuration

• Usually confined to trunk • Usually confined to trunk, proximal arms and legs, rarely on face; never on palms and soles

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palms and soles


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Diagnosis and Treatmentg

• Biopsy if unclear• Biopsy if unclear

• Spontaneous remission in

6‐12 weeks

• Treat symptomatically:Treat symptomatically:

– Antihistamines for itching

– Topical glucocorticoids

– UVB

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Nummular Dermatitis• Latin: nummularis “like

”a coin”

• Plaques and papulesaques a d papu es

• Erythema, scale, often

crusted

• Pruritus often intense• Pruritus often intense

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Diagnosis and Treatmentg

• Bacterial culture of crusts

• Topical steroids• Antihistamines for

itching• Moisturizers• Systemic antibiotics if

S.aureus is present

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Tinea Corporisp

O l • One or several circular

th t erythematous patches

• Central clearing, occasionally follicular pustules

• Usually unilateral©PVernon2019

y


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Diagnosis and Treatment• Visual diagnosis• KOH: scrapings of the border

of the lesion• Fungal culture• Misdiagnosed cases treated g

with topical steroids will not display scaling; annular border may be obscured (tinea incognito)

• Treat with topical antifungal agents BID for 2‐3 weeks to

l lensure complete resolution• Occasionally oral antifungal

agents for severe or l

©PVernon2019

recalcitrant cases


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Psoriasis

• Erythematous/violaceous plaques and papules with thick silvery‐white scale, sharply marginated

• Scalp, ears, elbows, knees, gluteal crease

• Guttate: Latin guttata “dew drop”• Guttate: Latin guttata dew drop

– Discrete papules mostly on trunktrunk

– Follows URI, Strep

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Diagnosis and Treatmentg• Visual Diagnosis• Culture for oral and rectal strep;

ASOASO• Treat with oral antibiotics for

guttate • Moderate to high potency

steroidssteroids• Topical calcipotriene (Vitamin D3

analog)• Topical tazoratene (Vitamin A)

UVA UVB• UVA;UVB• Systemic steroids

contraindicated• Educate: chronic nature of

didisease• Guttate: likely to develop plaque

psoriasis within 5 years

©PVernon2019


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F D i iFoot Dermatitis

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PsoriasisPsoriasis

• Thick scale• Fissures and Bleeding• Only on the soles of

feet• Previously treated with

topical anti‐fungal creams

• Long‐standing history

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PSORIASIS DIFFERENTIALPSORIASIS DIFFERENTIAL

• Tinea Pedis

• Atopic Dermatitis

• Contact Dermatitis

• Psoriasis

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PSORIASIS

• 1‐3% of the population

• 25‐45 & after age ten

• one third of adults with psoriasis developed before • one‐third of adults with psoriasis developed before

age 16

• Both sexes affected equally in adults

• Familial tendency

• Up to 42% have psoriatic arthritis©PVernon2019

Up to 42% have psoriatic arthritis


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PSORIASIS PATHOPHYSIOLOGYPSORIASIS PATHOPHYSIOLOGY

Ch i i fl t t i di• Chronic, inflammatory, systemic disease

• Epidermis thickened, silver‐white scaleEpidermis thickened, silver white scale

• Transit time from basal cell layer to surface of

skin in 3‐4 days, compared to normal cell

t it ti f 8 dtransit time of 20‐28 days

• Itching variable©PVernon2019

Itching variable


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PSORIASIS TREATMENT• Ultraviolet B (UVB)

• Ultraviolet A (UVA) • Systemic DrugsA it ti (S i t ®)• PUVA (psoralens with UVA)

• Home UVB

– Acitretin (Soriatane®)– Methotrexate (MTX)– Cyclosporine (CsA)– Apremilast (Otezla®)– Adjunct Therapies

– Topical Steroids

Vit i A d D d i ti

– Apremilast (Otezla®)• Biologic Therapy

– Alefacept (Amevive®)– Etanercept (Enbrel®)– Vitamin A and D derivatives

– Topical calcineurin inhibitors

Intralesional steroid

ta e cept ( b e )– Adalimumab (Humira®)– Infliximab (Remicade®)– Ustekinumab (Stelara®)– Intralesional steroid

injections

– Coal Tar (Scytera®)

– Ixekizumab (Taltz®)– Secukinumab (Cosentyx®)– Tildrakizumab (Ilumya®)

©PVernon2019

Coal Tar (Scytera )


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PITTED KERATOLYSIS• Superficial bacterial infection

of the soles of the foot, lateral toes, occasionally , ypalms

• Asymptomatic erythematous plaques and circular shallow p qpits on weight‐bearing areas; occasionally painful

• Often misdiagnosed as tineag• Hyperhidrosis, moist socks,

humid environment, occlusive shoes and

l dprolonged immersion in water are predisposing factors

©PVernon2019


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TreatmentTreatment• Remove environment, promote drynessRemove environment, promote dryness

• 20% aluminum chloride (Drysol®) BID

• Alcohol‐based benzoyl peroxide

• Topical erythromycin or clindamycin

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Warts• HPV induced benign

epidermal tumorsS li l i l ki• Solitary or multiple, skin‐colored to light tan

• Grouped appear within • Grouped, appear within sites of trauma

• Variable history, incubation y,unknown, transmission to others well‐documented

• Spontaneous remission within 24 months

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TreatmentHIn‐office

• Cryotherapy

Home

• Cantharidin

• Injection therapy

• OTC products

• Injection therapy

– Candida• Squaric Acid

• Immiquiod – Bleomycin

• Laser therapy

q

• Retinoids py

• Surgical excision• Cimetidine

• Watchful Waiting©PVernon2019

Watchful Waiting


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Tinea Pedis

• Most common in post‐Most common in postpubertal

• Vesicles and erosions on instep

• Occasional fissuring between toes with erythema and scale f d kof surrounding skin

• Dorsum of toes and feet sparedspared

• Often unilateral

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Diagnosis and Treatment

• Visual diagnosis

• KOH

• Fungal culture

• Treat: topical Treat: topical

antifungal creams BID

for 2‐4 weeks

• Rarely oral medications©PVernon2019

Rarely oral medications


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Dyshidrotic Eczemay

• Recurrent eruption of palms soles lateral palms, soles, lateral aspects of digits

• Inflammatory vesicles, Inflammatory vesicles, pruritic, burn

• Symmetricaly• Hyperhidrosis

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TreatmentTreatment• Dry environment

• Aluminum chloride 12% (Certain Dry®) or

20% (Drysol®)

• Topical steroids• Topical steroids

• Tacrolimus (Protopic) ointment; p

Pimecrolimus (Elidel)

©PVernon2019


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Juvenile Plantar Dermatosis

• Cracked, shiny, dry on , y, y

weight‐bearing surface

• Painful fissures

• Common in children • Common in children

and preadolescents

• Symmetrical

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Treatment• Ointments (Aquaphor,

Vaseline) immediately Vaseline) immediately

after removing shoes

d kand socks

• Cotton socks

• Topical steroids for

inflammationinflammation

• Immunomodulators

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Nail DisordersNail Disorders

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LICHEN PLANUS

• Unique inflammatory cutaneous and mucocutaneous eruption

• Unknown etiology• Unknown etiology• Purple, flat‐topped

polygonal papules• Oral lesions on buccal

mucosa (wickham’s striae)N i f th il ith • Narrowing of the nails with overgrowth of fibrous tissue proximally to distally

©PVernon2019

©Pvernon 2015


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LICHEN PLANUS: TREATMENT

• Topical corticosteroids p

• Antihistamines for

pruritus

• Immunomodulators• Immunomodulators

• Permanent damage g

rare

©PVernon2019


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Twenty Nail Dystrophy(T h h )(Trachyonychya)

• Longitudinal ridgingg g g

• Pitting

• Loss of Lustre

R h i f il • Roughening of nail

surface

• Change in color:

dd h©PVernon2019

muddy, grey‐white


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PSORIASIS NAILS

• Pittingg

• Yellowing of distal

tiportion

• Separation of nail plate

(onycholysis)

• Thickening of entire Thickening of entire

nail (hyperkeratosis)

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Psoriasis Nails Treatment• Corticosteroids

• Tazorac gel .05‐.1%

C l i i • Calcipotriene

• Moisturizers

• Treat underlying

disease

• Keep nails trimmed©PVernon2019

• Keep nails trimmed


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Onychomycosis (Tinea unguium)

• Fungal infection of the nail

• Hyperkeratotic brittle nails with Hyperkeratotic brittle nails with

thick sub‐ungual debris

• Caused by dermatophytes, Caused by dermatophytes,

Candida, or molds

• Risk Factors: poor circulation, p ,

diabetes, perspiration, humid

environment, damp public

places (gyms, swimming pools,

shower rooms), presence of

h f l f©PVernon2019

other fungal infections


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Onychomycosis Diagnosis and T t tTreatment

• Diagnosis: clinical, KOH smear, l b h dculture, biopsy with PAS (periodic

acid‐Schiff stain)• Treatment:

– Topical: Ciclopirox (Penlac, Loprox TS) daily, amorolfine weekly efinaconazole (Jublia®) weekly, efinaconazole (Jublia ) daily

– Oral: Terbinafine (Sporonox®) 6% ff ti It l 76% effective, Itraconazole (Lamisil®) 60% effective, Fluconazole 48% effective

©PVernon2019

– Laser therapy: low quality


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Alopecia Areata Nailsp

• Disorder of

keratinkeratin

• Treat underlying • Treat underlying

disorderd so de

• Moisturizers©PVernon2019


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Nail Tic

• Repeated trauma to

il t inail matrix

• Transverse ridgesTransverse ridges

• Central depressionp

• Cuticle hypertrophy

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Nail Tic

• Repeated trauma to Repeated trauma to

nail matrix

• Transverse ridges

• Central depression

• Cuticle hypertrophy

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OnychomadesisOnychomadesis

• Painless Painless

spontaneous

separation of

i l il lproximal nail plate

©PVernon2019


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Onychomadesisy

• Trauma (e g subungual • Trauma (e.g. subungual haematoma)

• Inflammation or infection (fever, HFM disease)

• Peripheral vascular diseaseR d’• Raynaud’s

• Familial trait

©PVernon2019

©Pvernon 2015


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MelanomaMelanoma

©PVernon2019

©Pvernon 2015


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ReferencesBobonich, M, Nolen, M. Dermatology for Advanced Practice Clinicians. Wolters Kluwer, 2015. First Edition.

• Bolognia, Jean L., et al. Dermatology. Mosby, 2003.• Habif, Thomas. Clinical Dermatology. Fourth Edition, Mosby,

2004.4• Schachner, Lawrence A. & Hansen, Ronald C. Pediatric

Dermatology, Third Edition, Mosby, 2003. • Wolff Klaus & Hohnson Richard A Fitzpatrick’s Color Atlas & Wolff, Klaus & Hohnson, Richard A. Fitzpatrick s Color Atlas &

Synopsis of Clinical Dermatology, Sixth Edition, McGraw Hill, 2009

• Pediatric Annals, Vol. 36, No 12, Dec. 2007; Persistent Facial Pediatric Annals, Vol. 36, No 12, Dec. 2007; Persistent Facial Dermatitis: Pediatric Perioral Dermatitis.

• Consultant for Pediatricians, Vol. 8, No. 3, March 2009; Dermclinic.

©PVernon2019

Dermclinic.


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Documents

DERMATOLOGY LOOK A LIKES - npsymposium.comnpsymposium.com/wp-content/uploads/2019/07/Pre-2-Dermatology-Look-a... · • Tinea Pedis • Atopic Dermatitis • Contact Dermatitis •