Skin Disorders I

Skin disordersI & II Laurie C. Clark, D.O.

October 15, 2013

Objectives

1)To be able to describe various skin lesions using appropriate terminology

2) To be able to identify various dermatological conditions based on clinical findings and appearance of lesions

3) To be able to discuss basic treatment concepts of various dermatological conditions

Dermatologic macroscopic terms (from first aid)Macule: flat discoloration < 1 cm

Patch: Macule > 1 cm

Papule: Elevated skin lesion < 1 cm

Plaque: Papule > 1 cm

Vesicle: Small fluid-containing blister

Dermatologic macroscopic terms (from first aid)Wheal: Transient vesicle

Bulla: Large fluid-containing blister

Keloid: Irregular, raised lesion resulting from scar tissue hypertrophy

Pustule: Blister containing pus

Crust: Dried exudates from a vesicle, bulla, or pustule

Pigmented LesionsCommon benign pigmented lesions:

1)melanocytic nevi (normal moles)2)freckles and lentigines (flat brown spots that gradually appear in sun-exposed areas)

3)seborrheic keratosis

QuestionA 70 year-old male presents to the office with chief complaint of a large lesion on his face. It has been present for about a year, and his wife has asked him to have it checked out. It does not itch, bleed or ulcerate. It has irregular borders, but no color variation. It has a stuck-on appearance.

This lesion most likely represents which of the following?Malignant melanomaSeborrheic keratosis*Atopic dermatitisPsoriasisActinic keratosis

Seborrheic keratosisBenign plaques

Beige to brown; can be black

Velvety or warty appearance

stuck on appearance

Very common

No treatment necessary

Scaling LesionsCommon scaling lesions:

1)Atopic dermatitis (eczema)2)Lichen simplex chronicus (self perpetuating scratch-itch cycle)3)Psoriasis4)Pityriasis Rosea5)Seborrheic dermatitis and dandruff6) Fungal infectionsTinea corporis (body; ringworm)Tinea cruris (groin; jock itch)Tinea pedis (feet; athletes foot)Tinea versicolor (usually on trunk)

questionA 3 year-old child is brought to the clinic with chief complaint of pruritic, scaling, erythematous rash on bilateral cheeks, popliteal and antecubital folds. It seems to be worse in the winter.

Which of the following is the most likely diagnosis?Atopic dermatitis*PsoriasisSeborrheic dermatitisTinea corporisHerpes zoster

Atopic dermatitisPruritic and exudative

Most common locations are face, neck, upper trunk and antecubital and popliteal folds

Personal or family history of allergies and/or asthma

Onset in childhood

Treatment: Avoidance of drying or irritating skin factors, emollients after bathing, and topical corticosteroids as needed.

Vesicular LesionsCommon vesicular lesions:

1)Herpes simplex (fever blister)

2)Herpes zoster (shingles)

3)Dyshidrosis (or, pompholyx)

questionA 55 year-old male presents to the clinic with severe pain on left side of trunk which was followed 48 hours later by eruption of a rash. Physical exam reveals grouped vesicles distributed on left trunk. Patient denies exposure to poison oak or poison ivy. Which of the following is the most likely diagnosis for this patient?

Which of the following is the most likely diagnosisTinea corporisHerpes simplexImpetigoHerpes zoster*Allergic contact dermatitis

Herpes zoster (shingles)Pain along a dermatome

Unilateral (occassional few vesicles may appear outside of dermatome

Usually on face or trunk

Treatment: oral antiviral medication, systemic corticosteroids, various treatments for postherpetic neuralgia

Recommend vaccination for persons aged 60 and older

Weeping or Crusted LesionsCommon weeping or crusted lesions:

1)Impetigo

2)Allergic contact dermatitis

questionA 3 year-old boy is brought to your office by his mother with chief complaint of a rash on his face which has worsened over the last few days. The lesion consists of honey-colored crusted superficial erosions.

Which of the following is the most likely finding in this pt?Positive viral culturePositive fungal cultureElevated eosinophilsPositive bacterial culture*Microscopic ova

impetigoSuperficial pus filled blisters that rupture easily

Macules, vesicles, pustules, bullae

Honey-colored crusted superficial erosions

Positive gram stain and bacterial culture

Treatment: topical and/or systemic antibiotics

Pustular DisordersCommon pustular disorders:

1)Acne vulgaris

2)Rosacea

3)Folliculitis

4)Milaria (heat rash)

5) Cutaneous candidiasis

questionA 45 year-old female presents to the office with chief complaint of chronic erythema, pustules and papules on her cheeks, nose and chin. She also reports exacerbation of lesions with spicy food, alcohol, sunlight and exercise.

Which of the following would be the best treatment for rosacea?1. Topical antibiotic medication **

2. Oral antifungal medication

3. Topical antiviral medication

4. Oral antiviral medication

5. Topical steroid medication

ErythemasCommon erythemas:

1)Reactive erythemas

Urticaria and angioedema

Erythema multiforme (acute inflammatory skin disease; symmetric erythematous lesions; history of recurrence; target lesions with central clearing and concentric rings)

Erythema migrans (unique cutaneous eruption from early stage of Lyme disease; gradual expansion of redness around papule at site of bite; advancing border is red, raised and free of scale)

Erythemas (contd)

2) Infectious erythemas

Erysipelas St anthonys fireGroup A StrepFaceRed, hot, painfulF chills

Cellulitis bacterial infection of the dermis

Question - ErysipelasA 60 year-old female presents to the emergency department with a painful, circmscribed, hot, erythematous area on her face. She also complains of fever, chills and feeling generally ill.

Which of the following is the best treatment for this?1. Incision and drainage of lesion

2. Tapered dose of oral steroids

3. Topical antibiotic ointment

I.V. antibiotics **

I.V. antifungal

erysipelasSuperficial form of cellulitis; usually on face

Caused by beta-hemolytic strep Group A Strep =GAS

Pain, chills, fever, and systemic toxicity

Treatment: bed rest; I.V. antibiotics for first 48 hours followed by 7 day course of oral antibiotics

Blistering DiseasesCommon blistering diseases:

Pemphigus

Bullous pemphigoid

Dermatitis herpetiformis

Question - PemphigusA 35 year old male presents to the clinic with recurring outbreaks of bullae. Ulcerations of the mucous membranes often precede the skin lesions.

Which of the following is the most likely diagnosis?1. Herpes Zoster

2. Pemphigus **

3. Folliculitis

4. Erythema nodosum

5. Photodermatitis

pemphigusRelapsing crops of bullae which are tender and painful when rupture

Often preceded by mucous membrane lesions

Autoimmune disorder

Treatment: systemic corticosteroids, and antibiotics if indicated

PapulesCommon papule disorders:Warts (verrucous papules)

Callousities and corns of feet or toes

Molluscum contagiosum

Example of papule

Question Molluscum contagiosum A 6 year-old boy is brought to the clinic by his mother with chief complaint of multiple dome-shaped waxy umbilicated papules. The child is otherwise healthy and asymptomatic.

Which of the following is the most likely diagnosis?1. Common warts

2. Scabies

3. Varicella

4. Milaria

5. Molluscum contagiosum **

Violaceous to Purple Papules and NodulesCommon violaceous to purple papules and nodules:

Lichen planus (inflammatory pruritic disease of skin and mucous membranes;pruritic, violaceous, flat-topped papules with fine white streaks and symmetric distribution; lacey mucosal lesions)

Kaposi Sarcoma

Question - Kaposi sarcoma **

A 35 year-old HIV positive male who is taking immunosuppressive medications presents to the clinic with purple plaques and nodules noted on his upper extremities. He also has mild swelling and pain associated with lesions.

Which of the following is the most likely diagnosis?1. Erythema nodosum

2. Scabies

3. Kaposi sarcoma **

4. Squamous cell carcinoma

5. Dermatitis medicamentosa

Kaposi sarcomaMalignant skin lesion

Primarily seen with HIV infection

Is an AIDS-defining illness

Stopping immunosuppressive therapy may result in improvement of skin lesion

Can also be present in lungs and GI tract

PruritisCommon causes of pruritis:

1) Dry skin2) Psychiatric disorders Atopic dermatitis4) Anogenital pruritis Scabies Pediculosis7)Skin lesions due to other arthropods

questionA 22 year-old woman presents to the clinic with chief complaint of intensely pruritic generalized rash. She is having difficulty sleeping due to the itching. Physical exam reveals vesicles and pustules in the web spaces of the hands, around the wrists and elbows, axillae and breasts. She states that her 2 year-old son has similar symptoms.

Which one of the following is correct?1. Treatment should include both topical steroids and oral antibiotics

2. Treatment should focus on relieving pruritis while condition clears on its own without specific treatment

3. Treatment should consist of both topical and oral antibiotics

4. Treatment should include topical antifungal medication

5. Treatment should focus on killing mites and controlling dermatitis **

Inflammatory NodulesCommon causes of inflammatory nodules:

1)Erythema nodosum

2)Furunculosis (boils)

3)Carbuncles (several coalescing furuncles)

Question - EN18 year-old female presents to the clinic with chief complaint of recent onset of painful red nodules on the front of both legs. Her past medical history is negative. Her only medication is oral contraceptives. Prior to the onset of lesions she had a fever and malaise.

Which of the following is the most likely diagnosis?

1. Dermatitis medicamentosa

2. Erythema multiforme

3. Furunculosis

4. Erythema nodosum **

5. Erythema migrans

Erythema nodosumTender, erythematous subcutaenous nodules on anterior legs

May be preceded by fever, malaise and arthralgia

Slow regression over several weeks

Women: men ratio of 10:1

May be associated with infection or medications

May be associated with pregnancy or oral contraceptives

Erythema nodosumTreatment:

Identify and treat underlying disorder, if presentNSAIDsCorticosteroids

photodermatitismanifested as a: phototoxicity ~ a tendency to sunburn more easily than expected occur w/in 24hrs of sun exposureOR photoallergy, a true immunologic reaction that often presents with dermatitis-Often drug induced: TMP-SMX, tetracyclines, hydrochlorothiazidePhotoallergic reactions, however, do not occur until one to three days after the substance has come into contact with the body, since they require activation of the immune system to mount the response

question

A 65 year old man presents with painful erythema and edema of face, neck and bilateral hands. He was mowing his lawn yesterday and did not use sunscreen. He states, however, that he does this every weekend and has never had a skin reaction like this before. Past medical history is positive only for a new diagnosis of Stage I hypertension for which he was recently startedon hydrochlorothiazide.

Which of the following is true?1. Antibiotics such as tetracyclines and trimethoprim-sulfamethoxazole are rarely implicated in photodermatitis.

2. Contact dermatitis would not be included in the differential for the above patient.

3. Lupus erythematosis would be included in the differential for the above patient. **

4. Application of sunscreen will always prevent photodermatitis.

5. If a patient has used a certain medication for over a month, it should not be considered as a suspected cause for photosensitivity.

Drug eruptionsMultiple types of drug eruptions:

Toxic erythema (most common; usually on trunk; maculopapular)

2)Erythema multiforme major (target-like lesions)

3) Erythema nodosum (inflammatory cutaneous nodules usually on extensor surfaces of legs)

4)Exfoliative dermatitis (red and scaly; entire skin surface)

Drug eruptions (contd)

5) Photosensitivity (sunburn, vescicles and papules in photodistributed pattern; exaggerated response to UV light)

6)Urticaria (red, itchy wheals)

7)Pityriasis rosea-like eruptions (oval, red, slightly raised patches with central scale mainly on trunk)

questionA 20 year-old male presents to the clinic with chief complaint of abrupt onset of generalized, bilateral erythematous skin rash. Three days previously he had started a course of amoxicillin for a sinus infection. Past medical history is essentially negative.

Which of the following is most appropriate first step?1. Topical steroid application

2. Discontinuation of antibiotic **

3. Skin biopsy

4. Complete blood count

5. Liver enzyme tests

LOOK AT THE FOLLOWING SLIDES

DESCRIBE LESIONS

LOCATIONCOLORTYPE OF LESIONSIZE OF LESION(S)DISTRIBUTION

PROVIDE 3 POSSIBLE DIFFERENTIAL DIAGNOSES

26 y/o female with pruritic rash; no meds or allergies

PITYRIASIS ROSEA

Common, mild acute inflammatory disease

Oval, fawn colored, scaly eruption

Christmas tree pattern; lesions follow cleavage lines of trunk

Herald patch precedes eruption by 1 2 weeks

Should usually get a serologic test for syphilis if any question about diagnosis

Usually self-limiting and disappears within 6 weeks

6 month-old infant

Cutaneous candidiasis

Diaper dermatitis with superimposed candidiasis. The skin folds are involved and satellite lesions are typically present at the periphery of the involved area.

20 year-old male with sudden onset; no meds or allergies

urticaria

Wheals (or hives) of urticaria

Itching is usually intense

Most are acute and self-limiting over 1 2 weeks

Chronic urticaria (> 6 weeks) may have autoimmune basis

40 year old male with chronic rash; also behind ears

Seborrheic dermatitis

Orange to salmon-colored erythematous plaques covered with yellowish, greasy scale involve the malar areas. Nasolabial folds may be included.

Seborrheic dermatitis affects the scalp, central face, and anterior chest. In adolescents and adults, it often presents as scalp scaling (dandruff). Seborrheic dermatitis also may cause mild to marked erythema of the nasolabial fold, often with scaling. Stress can cause flare-ups. The scales are greasy, not dry, as commonly thought

BIOPSY

Thank you!