Dermatology 3 CAM I Notes PDF

DERMATOLOGY 3 CAM I Professor 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 s...

DERMATOLOGY 3 CAM I Professor 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 Neoplasms Bacterial infections Others TOPICS Neoplasms-Malignant Bacterial infections Others MALIGNANT NEOPLASMS Basal Cell Carcinoma (BCC) Squamous Cell Carcinoma (SCC) Melanoma Kaposi Sarcoma BASAL CELL CARCINOMA (BCC) Most common cancer Onset >40 y/o, M>F Etiology: ultraviolet light (UVB) Occur mostly in fair-skin (I-III) rare in brown & black skin (V-VI,) 70% on face/chest, “Danger sites”: medial/lateral canthi, nasolabial fold, post-auricular RISK FACTORS: fair skin (I-III), albinos, light-colored eyes, red hair, prolonged sun exposure, northern European ancestry, older age, heavy sun exposure in youth, tanning beds Clinical & histologic sub-types Clinical: superficial, nodular, pigmented, morpheaform Histologic: superficial, nodular, micronodular, infiltrative Slow growing, usually asymptomatic, but can bleed/scab or feel sensitive if on a nerve BASAL CELL CARCINOMA (BCC) DDx: all smooth papules, melanoma, all non-painful ulcers (SCC, syphilis) Diagnosis: clinical, confirmed microscopically with biopsy Treatment Excision with primary closure Cryosurgery & electrosurgery (limited) Mohs is best for morpheaform & lesions in danger or cosmetically sensitive sites and scalp Topical (5-fluorouracil ointment & imiquimod) for superficial lesions below neck Treatment depends on location, size and type NODULAR BCC Most common subtype ~80% Skin-colored or reddish, translucent (“pearly”), well-defined, firm, smooth papule or nodule with telangiectasia Erosions & melanin stipples Ulceration with crust & rolled border Nodular BCC PIGMENTED BCC Brown, blue, or black Hard, firm Round, oval, can be ulcerated DDx: superficial spreading melanoma, nodular melanoma MORPHEAFORM BCC aka sclerosing BCC 5-10% of BCC cases Smooth, flesh-colored or light erythematous papules or plaques, atrophic. ill-defined borders. Scar-like appearance in some areas SQUAMOUS CELL CARCINOMA (SCC) >55 y/o, M>F Risk factors: sun exposure, light-colored skin, easily burns/poor tanning, outdoor occupations-pilots/truckers/farmers, immunosuppression (organ transplant, HIV,) chronic inflammation, industrial carcinogens Solitary or multiple macules, papules, plaques, ulcers Hyperkeratotic or scaling **May arise from AK** can rapidly evolve Diagnosis: biopsy (shave, punch, or excisional) SQUAMOUS CELL CARCINOMA (SCC) Treatment In Situ: imiquimod or 5- fluorouracil, curettage & electrodessication Invasive: excision or Mohs surgery SUPERFICIAL SCC Most common site = trunk Presentation = slightly scaly, macules, patches, or thin plaques light red to pink in color. Telangectasias may be seen. Differential diagnosis: actinic keratosis (AK) SQUAMOUS CELL CARCINOMA (SCC) BCC vs SCC MOHS MICROGRAPHIC SURGERY (MMS) MMS offers superior histologic analysis of tumor margins while permitting maximal conservation of tissue compared with standard surgical excision Recurrence rates tend to be lower with MMS compared to other modalities, including standard electro-desiccation and curettage, radiation, and cryotherapy Indications include: Lesions on nose, ears, eyes, lips, scalp, hands, and cosmetically sensitive areas Aggressive histologic subtypes: infiltrative, sclerosing, morpheaform, or micronodular Large tumors or tumors with indistinct clinical borders Recurrent tumors MELANOMA Most common malignant tumor of the skin Leading cause of death due to skin disease Least common skin cancer 1 in 4 cases before age 40 Lifetime risk 2% Caucasians, 0.1- 0.5% non- Caucasian Etiology & pathogenesis unknown (likely due to exposure to solar radiation) MELANOMA Tumor thickness single most important prognostic factor 10-year survival related to thickness in mm 6 mm E: Evolution (changing in shape, size, color, or is new) “ABCDE” CRITERIA DDx: melanocytic lesions, non-melanocytic lesions, benign nevi Diagnosis: Clinical, ABCDE criteria, “ugly duckling” sign Excisional biopsy-must take wide margin (1 cm margin for every 1mm of lesion depth.) vs punch biopsy + Treatment: Excision & histology, followed by re-excision with borders based on thickness of tumor (pathology report) Referral to centers with expertise in melanomas for intermediate-to- high risk patients Sentinal lymph node biopsy All lesions >1 mm thickness High-risk histologic features (ulcers) KAPOSI SARCOMA Systemic endothelial cell tumor Linked with HSV-8 infection Purple, brown, black patches, plaques, & nodules 4 clinical variants (seen in those with immunodeficiencies/ HIV/AIDS) Treatment: radiation, chemotherapy, antivirals- typically responds to treatment CONGENITAL NEVUS Nevus (single), nevi (plural) Small congenital nevi can be dome- shaped, especially when on the face. Sometimes they are mamillated (with small protuberances) and have hypertrichosis (increase in density and coarseness of hairs). Benign moles CONGENITAL NEVUS Large or Giant: > 20 cm (in an adult) For large/giant congenital nevi, the risk of developing melanoma is ~ 5-10% Monitor yearly with photos SKIN EXAM “Signature nevi” SKIN EXAM “Ugly duckling” sign ATYPICAL NEVI aka dysplastic nevi Benign acquired melanocytic nevi Share clinical features of melanoma: asymmetry, irregular borders, color variegation, diameter > 5mm Increased risk of melanoma: Pts with >50 nevi with >1 atypical nevi & 1 nevus >8 mm Children & adults, M=F 5% of Caucasian population, rare in Japanese Occur in almost all patients with familial cutaneous melanoma ATYPICAL NEVI Any location, most common on trunk & extremities Rarely on chronically sun-exposed skin (face, hands) Variegated color with tan, brown, black and pink macules May have “fried egg” appearance Diagnosis: clinical, dermoscopy, biopsy if suspect melanoma BIOPSY OF SUSPICIOUS LESIONS A basic rule: never do a superficial shave biopsy of a pigmented lesion that is a possible melanoma. The reason is that the most important determinant of survival in melanoma is the Breslow depth, or tumor thickness, of the initial tumor. If a shallow shave biopsy does not contain the entire depth of the lesion, that information is unknown. BIOPSY VS EXCISION Why not initially excise the entire lesion? It is best to biopsy the lesion in order to obtain histologic confirmation prior to surgical removal, as biopsy may have revealed: A benign growth, in which case excision would have been unnecessary A tumor different from suspected lesion that may have required a different management approach Melanomas require large margins SKIN BIOPSY contraindication: infection Caution if patient on blood thinners TOPICS Neoplasms Bacterial infections Others BACTERIAL INFECTIONS Abscess Folliculitis Furuncle/carbuncle Cellulitis Erysipelas Impetigo ABSCESS Collection of pus in dermis or subcutaneous space Risk factors: skin disruption or inflammation, edema, obesity, immunosuppression, pre-existing skin infection, skin breaks (toe web spaces) S. aureus (MSSA, MRSA) Skin erythema, edema, warmth and fluctuance, very painful ABSCESS The patient needs to stop mashing it-may further damage surrounding tissue. Damaged tissue does not heal. Must perform incision and drainage (I&D) irrigation Have patient apply heat/warm compress afterwards Do not typically need PO antibiotics Typically, will heal up after drainage without further antibiotics or treatment INCISION & DRAINAGE (I&D) CELLULITIS Diffuse, spreading infection of dermis & subcutaneous tissue Usually on lower leg; unilateral Group A Beta-hemolytic streptococci or S. aureus Edema, erythema, pain, warmth May progress to chills, fever, malaise (possible septicemia, hypotension, shock) DDx: DVT, necrotizing fasciitis Treatment: antibiotics (IV vs PO) ex/ PO Cephalexin 500mg PO BID IV/IM Cefazolin 0.5- 1 gm q6-8 hr Mark borders to monitor progress Admit: severe local symptoms, WBC > 10K, failure to respond to PO antibiotics, systemic symptoms ERYSIPELAS Superficial form of cellulitis due to beta- hemolytic strep “St. Anthony’s Fire” rash Young & old Risk Factors: prior episode, skin break, nephrotic syndrome, prior injury, HIV, alcoholism, obesity, pregnancy Pain, malaise, fever, chills Lower limbs & butterfly distribution on *face, borders better defined than cellulitis, skin is shiny Treatment: IV vs PO antibiotics Cephalexin 500mg PO q12hr, Cefazolin 0.5 – 1 gm q6-8 hr IMPETIGO Contagious superficial bacterial infection Most frequent in children 2-5 y/o S. aureus, Group A strep Papules progress to vesicles, surrounding erythema, then pustules, then honey-colored crust Treatment: topical antibiotics (mupirocin) especially in nares BID x 5d, PO antibiotics as indicated for underlying infection -cephalexin 250-500 mg PO q 6-12 h x 5-7 d – will treat group A strep and S. aureus ( for 20% TBSA: severe Airway, Breathing, Circulation, Disability, Exposure Parkland formula: adults: 4ml/kg x % TBSA, ½ given first 8 hrs = MLs of fluid needed in first 24 hrs Tetanus/pain meds Hyperglycemia: predictor of worse outcomes LIPOMA Benign subcutaneous fatty tumor Soft round, lobulated, mobile Most common on neck, trunk, & extremities Reassurance or surgical removal EPIDERMAL INCLUSION CYST (EIC) Benign growth of upper hair follicle, very common on scalp Firm, dermal papule or nodule; overlying black comedone (punctum) on face, base of ears, or trunk Expressible foul-smelling cheesy material May become red & drain (mimics abscess) 0.3 cm – several cm Treatment: None if asymptomatic-tell patients not to manipulate I&D Surgical excision if symptomatic PRESSURE ULCER Body weight over bony prominence creates friction and pressure Elderly/bedridden Risk factors: poor nursing care, lack of sensation, hypotension Stage I-Non blanching erythema, skin intact Stage II-Epidermis/dermis layer Stage III-full thickness (to sub Q) Stage IV-muscle and bone Treatment-repositioning / reduce pressure Antibiotics/Surgery Consider osteomyelitis PRESSURE ULCER VITILIGO White macules, complete absence/destruction of melanocytes 1% population, all races May enlarge to affect entire skin, often starts on knuckles or around mouth Psychological problem Tx: Oral PUVA psoralen (drug) and ultra-violet radiation Can use tinted creams/makeup to cover lesions in cosmetically sensitive areas  melasma Very common females>>>males 9:1 Hyperpigmented sharply demarcated macules in sun exposed areas, usually face malar/frontal; benign Results from exposure to sunlight Can be idiopathic, but usually hormone related Pregnancy, OCP Some meds = anti-seizure, photosensitive meds (ATBs, anti-HTN) Tx: hydroquinone 3% soln, 4% crm azelaic acid 20% crm Can be compounded or in combo with tretinoin or glycolic acid PREVENT with sun blocks, hats, UV protectant on car windows *Lasers can worsen* Melasma cont’d  Photosensitivity reactions Abnormal response to sunlight exposure Only sun exposed areas Types: sunburn type- photoreaction to drugs (mimics sunburn) Rash : macules, papules or plaques → photoallergic Urticarial – solar urticaria Chr sun exposure = photoaging Prevention: sun block, UV blocking clothes, hats TX: time, cool bath, avoid sunlight, NSAIDs as needed, topical steroids for sunburn if indicated Photoaging – laser and prevention, hydroquinone Syphilis Treponema pallidum (spirochete) “The Great Imitator/Masquerader” 10 million cases annually STI Painless chancre Secondary: Maculopapular rash on trunk, extremities (palms and soles) Treatment -2.4 million units penicillin G IM/IV QD x7d DERMATOLOGY- topical treatments INSTRUCTIONAL OBJECTIVES Identify and describe the etiology, epidemiology, clinical features, differential diagnosis, and management of selected skin disorders. Neoplasms-Malignant Bacterial infections Others  Dermatology Steroids Danelle Jacobus, MSBS, PA-C South College Where Dreams Find Direction Steroid Potencies Steroid Dosing Steroid Dosing Steroid Side Effects QUESTIONS