Dermatology 2 PDF

DERMATOLOGY 2 Danelle Jacobus, MSBS, PA-C South College Where Dreams Find Direction INSTRUCTIONAL OBJECTIVES Identify and describe the etiology, epidemiology, clinical features, differential diagnosis, and management of selected skin disorders. TOPICS...

DERMATOLOGY 2 Danelle Jacobus, MSBS, PA-C South College Where Dreams Find Direction INSTRUCTIONAL OBJECTIVES Identify and describe the etiology, epidemiology, clinical features, differential diagnosis, and management of selected skin disorders. TOPICS Benign skin lesions Precancerous lesions Insects & parasites Envenomations & arthropod bite reactions alopecia Diseases/disorders of the nails Viral/fungal skin diseases Verrucous lesions Fitzpatrick Skin Types TOPICS Benign skin lesions Precancerous lesions Insects & parasites Envenomations & arthropod bite reactions alopecia Diseases/disorders of the nails Viral/fungal skin diseases Verrucous lesions BENIGN LESIONS Seborrheic keratosis SEBORRHEIC KERATOSIS Most common benign epithelial tumor Hereditary, rare before 30 y/o, M>F Skin-colored, tan, brown, black Small papules to larger plaques with warty surface (“stuck-on” appearance) Stippling on surface Face, trunk, upper extremities Exclude SCC & melanoma No treatment necessary, can use cryo if bothersome ACANTHOSIS NIGRICANS Velvet, thickened, hyperpigmentation on neck, axilla, groin, other body folds Related to obesity, endocrine disorders, diabetes, drugs (insulin, OCP and other hormone therapies, corticosteroids,) and malignancy Can be common at the onset of puberty Treatment: ?retinoids, address underlying disorders, difficult to completely eradicate ACANTHOSIS NIGRICANS  Cherry angioma aka hemangioma Very common erythematous papule. Typically F, Skin Type I-III Usually < 1cm, round or oval-ish Rough, like coarse sandpaper  ACTINIC KERATOSIS Cont. Possibly tender, painful if excoriated Precancerous (m/c precursor lesion of Squamous cell carcinoma) Treatment: Cryo- and laser surgery, 5- fluorouracil cream, imiquimod cream CRYOSURGERY TOPICS Benign skin lesions Precancerous lesions Insects & parasites Envenomations & arthropod bite reactions alopecia Diseases/disorders of the nails Viral/fungal skin diseases Verrucous lesions INSECTS / PARASITES Lice Scabies PEDICULOSIS (LICE) Infestations: Pediculus Humanus Capitis (head lice) Phthirus pubis (pubic louse, “crabs”) Nits (eggs) on hair shafts (even eyelashes) Transmission: hats, caps, brushes, combs, pillows, theater seats (crowding, poverty, low personal hygiene,) SELFIES Pruritis of scalp and back of neck Visible lice and nits Excoriations on scalp (r/o secondary infection) Possible posterior occipital lymphadenopathy DDx: seborrheic dermatitis, scabies, bed bugs, hair spray or gel, impetigo, LSC, delusions of parasitosis Diagnosis: clinical detection of lice (louse comb), nits within 4 mm of scalp PEDICULOSIS Treatment (capitus & pubis): Over-the-counter treatment: Permethrin cream rinse (5% Elimite, 1% Nix) (resistance common) Prescription treatments: Topical ivermectin lotion (most effective,) benzyl alcohol Lindane (Kwell): not 1st line (neurotoxicity, seizures), do not use in children. Not used in US Malathion (Ovide): > 6 y/o (volatile, flammable) Remove nits using a special comb (wet combing) Sanitize clothing and bedding (hot water) Examine/treat close contacts at same time, especially children SCABIES Sarcoptes scabiei Intense, generalized, intractable pruritis “Itching so bad I can't sleep” Burrows, vesicles, nodules, excoriations Skin-colored, linear or serpiginous ridges Interdigital web spaces, axilla, wrists, flexor areas waist, groin, waistband, genitals (usually spares head & neck in adults) Can look like urticaria, drug reactions, eczema Diagnosis: Clinical, skin scraping for mites, eggs, & feces Treatment: Elimite (5% Permethrin 60 gm) - apply from neck down after bath (< 2 yo treat head also) leave on 8-10 hrs then rinse. Repeat in 1 wk. Do not use in children < 2 months old Ivermectin 0.2 mg/kg/dose PO q2wk x 2 doses give w food if crusted or severe give more often Pruritis can continue up to 2-3 weeks (Post Scabietic Dermatitis) Topical steroids, Antihistamines (Atarax, Benadryl) Clothes, sheets, etc. wash normally the next morning; bedspread, stuffed animals, pillows, coats→ put in plastic bag for 7 days Treat all family members on the same nights as patient TOPICS Benign skin lesions Precancerous lesions Insects & parasites Envenomations & arthropod bite reactions alopecia Diseases/disorders of the nails Viral/fungal skin diseases Verrucous lesions SPIDER BITES Latrodectism: Latrodectus (widow spiders) Outdoor activities ~75% on extremities Initially asymptomatic or mild pain Systemic symptoms 30-120 min Muscle pain (extremities, abdomen, back), rigidity Pain self-limited, resolves in 24-72 hours Possibly tremor, diaphoresis, weakness, shaking, local paresthesia, nausea, vomiting, HA Treatment: depends on severity Wound care, PO analgesics IV analgesics & benzos, consider Antivenom Monitor vitals and breathing closely SPIDER BITES Loxoscelism: Loxosceles (recluse spiders) Upper arm, thorax, inner thigh, LE Red plaque or papule, vesicles possible Usually asymptomatic, may have pain or burning Most self-resolve in 1 week May (not everyone reacts to them) develop dark, depressed center (24-48 hrs), then dry eschar & ulcer (~10% necrosis) red, white, blue lesions Systemic (rare): malaise, n/v, fever, myalgias, dark urine, pallor, jaundice, icterus Treatment: wound care, analgesics, tetanus prophylaxis, surgical debridement, consider admission (severe cases) TOPICS Benign skin lesions Precancerous lesions Insects & parasites Envenomations & arthropod bite reactions alopecia Diseases/disorders of the nails Viral/fungal skin diseases Verrucous lesions ALOPECIA ALOPECIA Scarring: inflammatory, permanent loss Non-scarring: mild/non- inflammatory, non-permanent loss SLE, secondary syphilis, hyper/ hypothyroidism, Fe defic anemia, Vit D deficiency, pituitary insufficiency Androgenic (non-scarring): most common form (genetic) Minoxidil 5% (OTC), finasteride (Propecia) ALOPECIA AREATA! Etiology: unknown, possibly autoimmune Possible associations: Hashimoto thyroiditis, pernicious anemia, Addison disease, vitiligo Localized round oval patches, non-scarring May also involve beard, brows, or lashes “Exclamation point hairs” (2-3 mm long) Entire scalp (alopecia totalis), entire body (alopecia universalis) Self-limiting: 80% complete re-growth (focal) Treatment: PO steroids (severe), IL steroids Alopecia Areata!  Telogen Effluvium Non-scarring, temporary hair loss after recent stress (up to 3 months prior) Most common in middle-aged females Dx: history: major life event, illness, major weight loss Hair pull test: Gently pull on small tuft of hair from different places on scalp. If > 4-6 hairs fall out with white bulbs at the root, then TE likely Labs: thyroid panel, vitamin deficiencies Tx: supportive care, reassurance, self-care. Hair grows back over months when stress resolves TOPICS Benign skin lesions Precancerous lesions Insects & parasites Envenomations & arthropod bite reactions alopecia Diseases/disorders of the nails Viral/fungal skin diseases Verrucous lesions  Disorders of the nails Onychomycosis – toenail fungus paronychia ONYCHOMYCOSIS  ONYCHOMYCOSIS Tinea Unguium Trichophyton (T. rubrum) infection of fingernails or toenails Brittle, hypertrophic, yellowing & friable nails with**subungual debris** Confirm diagnosis: KOH prep (hyphae), fungal culture Difficult to treat: long therapy & frequent recurrence Indications for treatment: discomfort, inability to exercise, DM, immunocompromised  Microscopic tinea Capitis, corporis, unguium, pedis Pears/ovals and septated sticks (hyphae)  ONYCHOMYCOSIS Tinea Unguium Con’t Treatment: Fingernails: topical antifungals (limited); PO griseofulvin 500mg 1 PO BID w/high fat meal x 4mo, terbinafine 250 mg PO QD x 6 wk must monitor ANC and d/c if ANC< 1000 or itraconazole 200mg cap PO BID w food x 1 wk Toenails: PO terbinafine 250 mg PO QD x 12 wk must monitor ANC and d/c if ANC< 1000 (if no response to griseofulvin) itraconazole 200mg cap PO QD w food x 12 wks Must confirm dx prior to tx **Hepatic function test & CBC q4-6 weeks for PO antifungals Ketoconazole not recommended for either form due to higher risk for hepatotoxicity lasers now available PARONYCHIA Infection of lateral & proximal nail folds, painful Acute or chronic Risk factors: hangnail, thumb sucking, nail biting, DM, manicures, dishwashing Treatment: skin care (warm water soaks,) PO antibiotics, triple antibiotic cream, *I&D abscess (acute) PARONYCHIA TOPICS Benign skin lesions Precancerous lesions Insects & parasites Envenomations & arthropod bite reactions alopecia Diseases/disorders of the nails Viral/fungal skin diseases Verrucous lesions VIRAL DISEASES Dermatophytes/tinea Condyloma acuminatum Molluscum contagiosum Herpes simplex Varicella-zoster virus infections Verrucae  DERMATOPHYTOSIS Tinea pedis (foot) Tinea manum (hand) Tinea cruris (crural fold, groin “jock itch”) Tinea corporis, aka “ringworm” (body, extremities) Tinea facialis (facial) Tinea capitis (scalp hair) Tinea barbae (beard hair) Moist environment Treatment: PO terbinafine, itraconazole, fluconazole Topical clotrimazole, miconazole, ketoconazole ** remember to monitor LFTs and CBC/ANC  Tinea Corporis Circular lesion on the body with erythematous border and scales, may have excoriation or vesicles. Pruritic. Diagnosis – skin scraping, KOH prep Treatment – topical antifungal (clotrimazole cream OTC = Lotrimin. PO antifungal if widespread or resistant to topical treatment. Tinea Corporis ringworm” Cont’d Tinea versicolor  Tinea Versicolor Cont’d Hypo/hyper-pigmented, scaly, sharp margins, scattered, usually on trunk; waxes and wanes x years, hypopigmented areas can remain after effectively treated Overgrowth of cutaneous flora – Malassezia Skin scraping –> round yeast and elongated hyphae = “spaghetti and meatballs” on microscopic exam prepared with KOH **Scale may fluoresce blue/green with woods lamp. Vitiligo remains white without scale  Malassezia – spaghetti and meatballs Microscopic spores and hyphae Treatment – topical Selenium sulfide 2.5% shampoo, azole creams, terbinafine 1%soln CONDYLOMA ACUMINATA aka anogenital warts HPV 6 and/or 11 most common Soft flesh -colored papules “cauliflower -like”: external genitalia, perianal skin, perineum, or groin Transmission: direct contact with skin or mucosa (STI) Risk factors: sex, immunosuppression; screen for other STIs Treatment: cryotherapy, Imiquimod 5% cream, surgery Prevention: HPV vax, condoms MOLLUSCUM CONTAGIOSUM Poxvirus Single or multiple dome-shaped, waxy papules 2-5 mm diam, umbilicated m/c on face, lower abdomen, genitals Autoinoculable (wet skin-skin contact,) shared towels STI: penis, pubis, inner thighs Self limiting Common in AIDS Remission ~13 months Best treatment: curettage or liquid nitrogen (cryotherapy) Other treatment: imiquimod cream, retinoid cream HERPES SIMPLEX HSV-1 (oral): primary infection, then possible recurrent attacks due to sun exposure, orofacial surgery/lasers, fever, viral infections, stress HSV-2 (genital): sexual contact, asymptomatic shedding Genital herpes may also be due to HSV-1 Burning, stinging, grouped vesicles on erythematous base (“dew drops on a rose petal”) Any location, most common on vermillion border, penile shaft, labia, perianal skin, or buttocks Possible tender regional lymphadenopathy HERPES SIMPLEX DDx: chancroid, syphilis, trauma, other vesicular skin eruptions Diagnosis: clinical, viral culture or PCR, Western blot, ELISA Treatment 1st episode: acyclovir 400 mg PO TID x 7-10 d (or BID for suppression,) valacyclovir, or famciclovir Mild recurrences: no therapy for most, may use 3-5 days of antivirals (above) Frequent or severe recurrences: suppressive antiviral therapy reduces outbreaks & viral shedding (labialis – valacyclovir 500 mg PO QD, genital 1000mg PO QD) VARICELLA ZOSTER VIRUS (VZV) INFECTIONS VZV/HHV-3 chickenpox (varicella) Mostly presents during childhood, highly contagious Fever & malaise (mild in children, marked in adults) Pruritic rash: face, scalp, trunk & later extremities Maculopapular > vesicles > crusts/excoriated More severe disease in older & immunocompromised Treatment: uncomplicated in children require no antivirals; consider 5-7 days of acyclovir for patients > 12 y/o Vaccination > 98% effective (single or quad MMRV) VARICELLA ZOSTER VIRUS (VZV) INFECTIONS VZV/HHV-3 herpes zoster ( shingles); primarily affects adults Risk factors: immunosuppressed, biologic agents, older age, stress VZV dormant in cranial nerve sensory ganglia & spinal dorsal root ganglia after primary infection Lesions resemble chickenpox but follow unilateral dermatomal pattern (thoracic & lumbar roots most common) Pain often severe & usually precedes rash Complications: HZ opthalmicus, Ramsay Hunt syndrome (VII) Postherpetic neuralgia (60-70% pts with HZ & > 60 y/o) Treatment: valacyclovir or famciclovir within 72 hrs (uncomplicated), tapering course steroids; IV acyclovir for extradermatomal complications Vaccine: for pts > 50 y/o (2 doses, 2 months apart) VARICELLA ZOSTER VIRUS (VZV) INFECTIONS FUNGAL INFECTIONS Candidiasis oral cutaneous genital  Oral Candidiasis Symptoms: can cause pain or changes in taste Treatment: nystatin susp: swish and spit QID x 1w CUTANEOUS CANDIDIASIS Fungal infection: Candida species (albicans) Warm, humid environments Very Pruritic , sometimes painful papules and patches, can become macerated – often mirror images in intrigenous areas with satellite lesions Risk factors: Obesity, DM, steroids Oral, Interdigital, groin, perineal, intergluteal cleft, inframammary, axillae, intertrigo (satellite lesions) Treatment: keep area dry, nystatin cream, PO antifungals if severe GENITAL CANDIDIASIS Very common in females Risk factors: HIV, DM, Pregnancy, uncircumcised, recent antibiotic use Clinical diagnosis PO Diflucan, can use topicals, but not as effective here Can have cottage cheese like discharge TOPICS Benign skin lesions Precancerous lesions Insects & parasites Envenomations & arthropod bite reactions alopecia Diseases/disorders of the hair & nails Viral/fungal skin diseases Verrucous lesions VERRUCAE aka warts (HPV) Common, plantar, genital Usually asymptomatic; tenderness (plantar), itching (anogenital) Vaccination for anogenital HPV types (prevent infection & reduce cancer) Can have spontaneous resolution Treatment: ocular ; oculoplastic surgery Non-genital: Salicylic/lactic acid, imiquimod cream, cryotherapy (liquid nitrogen), laser, surgery Genital: cryotherapy, imiquimod, surgery Plantar: paplex ultra (salicylic and lactic acid) INSTRUCTIONAL OBJECTIVES Identify and describe the etiology, epidemiology, clinical features, differential diagnosis, and management of selected skin disorders. TOPICS Benign skin lesions Precancerous lesions Insects & parasites Envenomations & arthropod bite reactions alopecia Diseases/disorders of the nails Viral/fungal skin diseases Verrucous lesions QUESTIONS??