Primary Care DermPrimary Care Derm

Seborrheic KeratosesSeborrheic Keratoses

• Stuck on, white, tan, Stuck on, white, tan, brown, black papulesbrown, black papules

• Smooth with pearlsSmooth with pearls• Rough, crackedRough, cracked• Mimic melanomaMimic melanoma• In darker skin on the In darker skin on the

face called dermatosis face called dermatosis papulosis nigricanspapulosis nigricans

• Can treat with LN2, Can treat with LN2, currette or active currette or active noninterventionnonintervention

Seb KerSeb Ker

Cherry AngiomasCherry Angiomas

Pyogenic GranulomaPyogenic Granuloma

• Lobular Capillary Lobular Capillary HemangiomaHemangioma

• Band-aid signBand-aid sign

Venous LakesVenous Lakes

LentigoLentigo

Poikiloderma of CivattePoikiloderma of Civatte

Cutis Rhomboidalis NuchaeCutis Rhomboidalis Nuchae

DermatofibromaDermatofibroma

• Seen more Seen more commonly females commonly females on the legon the leg

• Dimple sign- Dimple sign- retraction with retraction with palpation (feels like palpation (feels like pea under skin) pea under skin) benignbenign

Epidermal Inclusion CystEpidermal Inclusion Cyst

• Soft mobile Soft mobile masses, sometimes masses, sometimes with punctumwith punctum

• Excision (need to Excision (need to remove cyst wall) remove cyst wall) is the only way to is the only way to get rid of themget rid of them

• If inflamed, can If inflamed, can inject with steroidinject with steroid

Basal Cell CarcinomaBasal Cell Carcinoma

• Risk Factor for BCC: Risk Factor for BCC: inability to taninability to tan

• Different types of BCC: Different types of BCC: nodular, superficial, nodular, superficial, micronodular, infiltr, micronodular, infiltr, morpheaformmorpheaform

• Head- most common Head- most common site for BCCsite for BCC

• Needs surgical Needs surgical excision with about 3 excision with about 3 mm margins, send to mm margins, send to derm or MOHsderm or MOHs

BCCBCC

Actinic KeratosesActinic Keratoses

• PremalignantPremalignant

• Can process to SCC Can process to SCC (3-8% if left (3-8% if left untreated)untreated)

• Distinguish two by Distinguish two by biopsybiopsy

• Treat with LN2Treat with LN2

Actinic KeratosesActinic Keratoses

• Scaly Scaly erythematous erythematous maculesmacules

Squamous Cell CarcinomaSquamous Cell Carcinoma

• Cumulative sun Cumulative sun exposureexposure

• Found on scalp, Found on scalp, hands, ears, lips hands, ears, lips

• Need to biopsyNeed to biopsy• Treat with surgical Treat with surgical

excision 5 mm excision 5 mm margins, Send to margins, Send to derm or MOHsderm or MOHs

Squamous Cell CarcinomaSquamous Cell Carcinoma

• Keratoacanthoma- Keratoacanthoma- subtype that subtype that evolves rapidlyevolves rapidly

NeviNevi

• Junctional nevi- Junctional nevi- melanocytes in the melanocytes in the epidermis only, flat epidermis only, flat pigmented or flesh pigmented or flesh colored maculescolored macules

• Congenital nevi are Congenital nevi are nevi present at nevi present at birth, they tend to birth, they tend to be larger and be larger and darkerdarker

NeviNevi

• Compound Nevus- Compound Nevus- melanocytes in the melanocytes in the epidermis&dermisepidermis&dermis

• Intradermal Nevus- Intradermal Nevus- melanocytes in melanocytes in dermis onlydermis only

Dysplastic NeviDysplastic Nevi

• Diagnosis made by Diagnosis made by pathologypathology

• Melanocystes look Melanocystes look atypicalatypical

MelanomaMelanoma

• Superfical Superfical spreading- most spreading- most common typecommon type

• Greatest relative Greatest relative risk: personal h/o risk: personal h/o atypical moles, atypical moles, family h/o family h/o melanoma, >75-melanoma, >75-100 moles100 moles

MelanomaMelanoma

• If thinking If thinking melanoma, do melanoma, do excisional bxexcisional bx

• Treatment for Treatment for melanoma is melanoma is excision (margins excision (margins depend of depth of depend of depth of melanoma)melanoma)

Paget’s DiseasePaget’s Disease

• On breast, On breast, associated with associated with adenocarcinomaadenocarcinoma

• Can look like nipple Can look like nipple ezcemaezcema

InflammatoryInflammatory

AcneAcne

• Mild, noninflamm acne Mild, noninflamm acne (open and closed (open and closed comedones)comedones)

• Treat with benzoyl Treat with benzoyl peroxide wash qam, peroxide wash qam, clindamycin qam, and clindamycin qam, and retina qpmretina qpm

• Advise pt acne will get Advise pt acne will get worse 4-6 wks, may worse 4-6 wks, may take up to 3 mos for take up to 3 mos for improvement (do not improvement (do not back earlier than 3mos)back earlier than 3mos)

Acne (moderate to severe)Acne (moderate to severe)

• Typically requires Typically requires oral antibiotic (doxy oral antibiotic (doxy 100mg BID or tcn 100mg BID or tcn 500 mg bid, then 500 mg bid, then minocin 100 mg bid) minocin 100 mg bid) or accutaneor accutane

• In addition to topical In addition to topical clindamycin, retina, clindamycin, retina, benzoy peroxide benzoy peroxide washwash

Cystic AcneCystic Acne

RosaceaRosacea

• Treat with Treat with metrocream bid, metrocream bid, azelaic acid bid, or azelaic acid bid, or PO tetracyclinePO tetracycline

• No good treatment No good treatment to get out redness, to get out redness, can use laser can use laser therapytherapy

• Avoid triggersAvoid triggers

RosaceaRosacea

Seborrheic DermatitisSeborrheic Dermatitis

• Treat with nizoral Treat with nizoral cream bid, nizoral cream bid, nizoral shampoo as face shampoo as face wash, sometimes wash, sometimes low dose top low dose top steroid (desonide)steroid (desonide)

• Typically seen in Typically seen in adult menadult men

Seb DermSeb Derm

EzcemaEzcema

• Atopic dermatitis- Atopic dermatitis- typically occurs in typically occurs in children, improves as children, improves as adultsadults

• Treat with moisturizers Treat with moisturizers (and lots of them eucerin, (and lots of them eucerin, aquaphor, cetaphil), aquaphor, cetaphil), cetaphil soap in shower, cetaphil soap in shower, top steroids (tac top steroids (tac ointment bid for 3 wks ointment bid for 3 wks then off for 1 wk), oral then off for 1 wk), oral antihistamines (zyrtec antihistamines (zyrtec qam and atarax qpm)qam and atarax qpm)

EzcemaEzcema

Dyshidrotic EzcemaDyshidrotic Ezcema

• PomphyloxPomphylox• Ezcema on the hands/feet Ezcema on the hands/feet

in adultsin adults• Develop little Develop little

blisters/peeling/erythemablisters/peeling/erythema• Confused with tinea or Confused with tinea or

pustular psoriasis (also pustular psoriasis (also check KOH)check KOH)

• Treat with moisturizer Treat with moisturizer eucerin and strong topical eucerin and strong topical steroid (lidex or steroid (lidex or clobetasol), limit hand clobetasol), limit hand washing (use cetaphil washing (use cetaphil soap)soap)

Hand EzcemaHand Ezcema

NickelNickel

• Most common allergenMost common allergen• Commonly seen in kids w Commonly seen in kids w

atopic dermatopic derm• Belt buckles, pants Belt buckles, pants

buttons, watches, buttons, watches, jewelry jewelry

• Pt needs to stop wearing Pt needs to stop wearing product, can sew patch product, can sew patch over pants button or over pants button or paint clear nailpolishpaint clear nailpolish

• Treat with topical steroid Treat with topical steroid (tac or lidex bid for (tac or lidex bid for several weeks)several weeks)

PsoriasisPsoriasis

• Seen in males/females, all agesSeen in males/females, all ages

• Auspitz sign- pinpoint bleeding when Auspitz sign- pinpoint bleeding when removing scaleremoving scale

• Typically have papule and plaques Typically have papule and plaques with silvery scalewith silvery scale

• Subtypes include guttate, Subtypes include guttate, palmoplantar, pustular, inverse palmoplantar, pustular, inverse

PsoriasisPsoriasis

PsoriasisPsoriasis

Inverse PsoriasisInverse Psoriasis

PsoriasisPsoriasis

• Treatment: if guttate psoriasis- check Treatment: if guttate psoriasis- check for strep and if positive treatfor strep and if positive treat

• Moisturizer to areas, topical steroid Moisturizer to areas, topical steroid (lidex) alternating with dovonex, light (lidex) alternating with dovonex, light therapytherapy

Lichen PlanusLichen Planus

• Pruritic, Planar, Pruritic, Planar, Polygonal, Purple Polygonal, Purple Papules Papules

Lichen PlanusLichen Planus

• Typically around Typically around joints (wrists, ankles)joints (wrists, ankles)

• No great treatment, No great treatment, topical steroids topical steroids provide some relief, provide some relief, if severe may need if severe may need oral oral immunosuppresantsimmunosuppresants

Acne Keloidalis NuchaAcne Keloidalis Nucha

• Occurs more Occurs more commonly in darker commonly in darker skinned ptsskinned pts

• Bumps on the back of Bumps on the back of the neck, can the neck, can develop into keloidsdevelop into keloids

• Treat with doxy for Treat with doxy for sev mos, top sev mos, top clindamycin, and clindamycin, and clobetasol solnclobetasol soln

Pseudofolliculitis BarbaePseudofolliculitis Barbae

• Treat with retina, Treat with retina, top antibiotics, top antibiotics, hydroquinone, stop hydroquinone, stop shaving, laser (laser shaving, laser (laser works the best)works the best)

• Can develop Can develop scarrring and scarrring and keloids from keloids from inflammationinflammation

Acanthosis NigricansAcanthosis Nigricans

• Seen in obesity, Seen in obesity, diabetes, pineal diabetes, pineal tumors, idiopathic ( tumors, idiopathic ( overweight overweight teenage girls)teenage girls)

• No treatmentNo treatment

Hidradenitis SuppurativaHidradenitis Suppurativa

• Double Double comedones, cysts, comedones, cysts, sinus tractssinus tracts

• Treat with oral and Treat with oral and topical antibiotics, topical antibiotics, hibiclens/benzoyl hibiclens/benzoyl peroxide to wash, peroxide to wash, sometimes sometimes accutane, surgeryaccutane, surgery

CapillaritisCapillaritis

• Schamberg’s DzSchamberg’s Dz

• Pigmented purpuraPigmented purpura

• Cayenne pepperCayenne pepper

Stasis DermatitisStasis Dermatitis

• Older individualsOlder individuals

• Blood supply is Blood supply is compromisedcompromised

• Treat with exercise, Treat with exercise, compressive compressive stockings, emollientsstockings, emollients

• Many times Many times misdiagnosed as misdiagnosed as cellulitis refractory to cellulitis refractory to antibioticsantibiotics

Stasis DermatitisStasis Dermatitis

LipodermatosclerosisLipodermatosclerosis

• Women, lower 1/3 Women, lower 1/3 of lower legs c high of lower legs c high BMIBMI

• Mimic cellulitis-Mimic cellulitis-warm and redwarm and red

• Woody induration Woody induration from fibrosis of from fibrosis of subq fatsubq fat

• Venous InsuffVenous Insuff

MiliariaMiliaria

• Retention of sweat Retention of sweat as a result of as a result of occlusion of occlusion of eccrine ductseccrine ducts

• Hot, humid Hot, humid climatesclimates

• Bundled children, Bundled children, bedridden patientsbedridden patients

Erythema Ab IgneErythema Ab Igne

SarcoidSarcoid

• Diagnosis by Diagnosis by biopsy- will have biopsy- will have granulomasgranulomas

• Erythema nodosum Erythema nodosum is a nonspecific is a nonspecific finding seen in finding seen in sarcoidsarcoid

• Can have lung Can have lung involvementinvolvement

Erythema NodosumErythema Nodosum

• Looks like bruising on Looks like bruising on lower legslower legs

• More commonly seen More commonly seen in womenin women

• Seen with URI, Sulfa Seen with URI, Sulfa drugs, sarcoid, drugs, sarcoid, pregnancy, infection, pregnancy, infection, estrogen estrogen

• Treat with rest, NSAIDTreat with rest, NSAID

Alopecia AreataAlopecia Areata

• Typically treat with Typically treat with intralesional steroid intralesional steroid injections (start at injections (start at 10 mg/cc ILK, inject 10 mg/cc ILK, inject 1-3 cc every 4-6 1-3 cc every 4-6 wks)wks)

• Can resolve without Can resolve without treatmenttreatment

• Can be seen with Can be seen with autoimmune thyroid autoimmune thyroid dz or vitiligodz or vitiligo

Pityriasis RoseaPityriasis Rosea

• Viral infectionViral infection

• Herald patch- first Herald patch- first lesion typically largerlesion typically larger

• Can have in Can have in christmas tree distr christmas tree distr on backon back

• Treat with emycin for Treat with emycin for 14 days, if itchy- 14 days, if itchy- treat itchtreat itch

ScabiesScabies

• Need to do scabies Need to do scabies prep (seeing burrows in prep (seeing burrows in skin is not definitive)skin is not definitive)

• Found on finger Found on finger webspaces, wrist, webspaces, wrist, waist, peniswaist, penis

• Treat with elimite, Treat with elimite, kwell (lindane- can kwell (lindane- can cause neurotoxic), (do cause neurotoxic), (do not treat with Nix), not treat with Nix), ivermectinivermectin

                                    

MolluscumMolluscum

• Treatment includes Treatment includes currettage, aldara, currettage, aldara, cryosurgerycryosurgery

• Umbilicated papulesUmbilicated papules• Virus- if left Virus- if left

untreated with untreated with resolve in about 1 yrresolve in about 1 yr

• In adults seen in In adults seen in pubic area as STDpubic area as STD

Herpes (HSV)Herpes (HSV)

• Virus, it diagnosed Virus, it diagnosed early can be treated early can be treated with acyclovirwith acyclovir

• Causes lip and Causes lip and genital lesionsgenital lesions

• In pts with ezcema, In pts with ezcema, can be generalizedcan be generalized

• Associated with Associated with erythema erythema multiformemultiforme

Erythema MultiformeErythema Multiforme

• Targetoid lesions on Targetoid lesions on bodybody

• Can occur after HSV, Can occur after HSV, mycoplasma mycoplasma pneumoniapneumonia

• Treat is symptomatic, Treat is symptomatic, top steroids, if itchy top steroids, if itchy antihistaminesantihistamines

• Treat HSV with Treat HSV with acycloviracyclovir

Herpes ZosterHerpes Zoster

• Grouped vesicles on Grouped vesicles on an erythematous an erythematous basebase

• To treat herpes To treat herpes zoster: acyclovir zoster: acyclovir (decreases (decreases neuralgia if given in neuralgia if given in first 48 hrs), first 48 hrs), narcotics, topical for narcotics, topical for itchingitching

VerrucaVerruca

• Virus- will go away in Virus- will go away in 3-7 yrs if left 3-7 yrs if left untreateduntreated

• Use destructive Use destructive methods to treat methods to treat warts: paring down, warts: paring down, LN2, aldara, LN2, aldara, podocon, cantharonepodocon, cantharone

• Flat warts more Flat warts more typically on facetypically on face

Genital WartsGenital Warts

Staph AureusStaph Aureus

• Most common offender of Most common offender of skin infectionsskin infections

• Causes carbuncles, treat Causes carbuncles, treat with warm compresses, with warm compresses, I&D with iodoform gauze, I&D with iodoform gauze, bactroban, sometimes oral bactroban, sometimes oral antibiotics antibiotics

• Causes bullous impetigo Causes bullous impetigo (get honey colored crust)(get honey colored crust)

• Community acquired Staph Community acquired Staph common in Iraq, treat c common in Iraq, treat c clinda or bactrim, clinda or bactrim, bactroban to bactroban to nares/fingernails, hibiclensnares/fingernails, hibiclens

ImpetigoImpetigo

CellulitisCellulitis

• Area is erythematous, Area is erythematous, tender to palpation, tender to palpation, warm to touchwarm to touch

• Diff: DVT, Erythema Diff: DVT, Erythema Nodosum, Fixed Drug, Nodosum, Fixed Drug, and Stasis Dermatitisand Stasis Dermatitis

• Treat with oral Treat with oral antibiotics (staph/strep antibiotics (staph/strep coverage)coverage)

Tinea VersicolorTinea Versicolor

• Caused by Caused by Pityrosporon Pityrosporon orbiculare, ovale, orbiculare, ovale, and globalisand globalis

• Treat with oral and Treat with oral and topical ketoconazoletopical ketoconazole

• Fluorescence pale Fluorescence pale white/yellow with white/yellow with wood’s lampwood’s lamp

Tinea Tinea

• Tinea pedis can look like Tinea pedis can look like dyshidrotic ezcema, look dyshidrotic ezcema, look for maceration btwn toesfor maceration btwn toes

• Most commonly caused Most commonly caused by T. rubrum (which is by T. rubrum (which is cause of many cause of many cutaneous tinea cutaneous tinea infections)infections)

• If extensive, may need If extensive, may need to treat with oral lamisil to treat with oral lamisil (terbinafine)(terbinafine)