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Disorders of the Skin and Subcutaneous Tissues Disease Etiology/Patho S&S/PE Labs/Imaging Treatment Seborrheic Dermatitis - Common, chronic, or relapsing -Ye...

Disorders of the Skin and Subcutaneous Tissues Disease Etiology/Patho S&S/PE Labs/Imaging Treatment Seborrheic Dermatitis - Common, chronic, or relapsing -Yellow to white flakes on heads for - Ketoconazole cream, ketoconazole shampoo form of eczema/dermatitis that kids (antifungals) mainly affects the sebaceous gland- - Topical steroids for short term inflammation rich regions of the scalp, face, and Erythematous, yellowish greasy -Solution for scalp if really itchy trunk. scales, crusted lesions. - Dandruff aka Pityriasis capitis-> Scalp: Antifungal shampoos include selenium uninflamed version of SD of scalp Infants - scalp (cradle cap) sulfide 2.5%, ketoconazole 2%, or ciclopirox 1% -Infantile seborrheic dermatitis Adults/adolescents - face, chest, shampoo affects babies under the age of 3 scalp Face: low-potency topical corticosteroid cream, a months and usually resolves by 6- topical antifungal agent, or a combination of the two 12 months of age-> Cradle Cap -Happens when yeast overgrows Dyshidrosis - Itchy, chronic, recurrent, often - Small, deep-seated, 1–2 mm fluid- Diagnosis is clinical Topical steroids, tacrolimus, emollients symmetric eruption on palms of filled vesicles which resolve after Tapioca hands, fingers, and soles of feet several weeks with scaling vesicles on hands and feet following stress Avoid possible causative factors: stress, direct skin - Associated w/ eczema “Tapioca Pearl” rash or hot, humid weather contact with irritants, nickel, occlusive gloves, - Chronic or cyclic household cleaning products, smoking, sweating a 13-year-old with a pruritic Although the exact etiology vesicular eruption comprised remains uncertain, it is considered a of clear, deep-seated First-line treatment includes high-strength topical reaction pattern induced by vesicles without erythema erupting steroids various endogenous on the lateral aspects of fingers, - Two weeks of moderate to high potency conditions (e.g. contact dermatitis the central palm, and plantar corticosteroids. If need to repeat to nickel, balsam, cobalt, sensitivity surfaces. corticosteroids, allow at least a 1-week to ingested metals, dermatophyte break before reusing infections, and bacterial infections) Use moisturizers/emollients for symptomatic relief and exogenous factors (e.g. and to maintain an effective skin barrier (apply 10-20 environmental factors and times daily will the skin is still moist) emotional stress). The disorder is Oral steroids are considered the second line of also frequently associated treatment, especially for acute flares with atopy. Lichen Simplex Chronicus Lichen simplex chronicus a 34-year-old male with a very Diagnosis of lichen simplex chronicus is Topical steroids are 1st-line agents (LSC) is a chronic itchy skin lesion on the front of the by clinical evaluation and history -High-potency steroids alone, such as 0.05% dermatitis resulting from chronic, ankle of his left foot. The itching is betamethasone dipropionate cream or 0.05% repeated rubbing or scratching of paroxysmal and severe. On Microscopy (i.e., KOH prep) and culture clobetasol propionate cream, can be used initially but the skin. Skin becomes thickened examination, there is a well-defined, preparation may be helpful in identifying a not on the face, anogenital region, or intertriginous with accentuated lines thickened and hyperpigmented superimposed bacterial or fungal infection. areas. (“lichenification”). large plaque spreading across the -Efficacy can be increased by using the topical Common triggers are excess front of the left ankle. corticosteroid under occlusion (cover the treated dryness of skin, heat, sweat, and area with plastic wrap and leav it on overnight) psychological stress. The constant scratching -Small areas may be locally injected with a long- Scratching may be secondary to causes thick, leathery, brownish acting corticosteroid habit or a conditioned response to skin anxiety. The formation of an itch- scratch cycle leads to chronic dermatosis. Repeated scratching or rubbing causes inflammation and pruritus → continued scratching. Tinea Versicolor -Common yeast infection of the flaky discolored patches appear on Wood lamp (black light) examination — Topical antifungal (ketoconazole), selenium sulfide skin the chest and back. yellow-green fluorescence may be observed shampoos (easy to use as body wash), oral antifungal - Most frequently affects young in affected areas if widespread (fluconazole) adults and is slightly more common in men than in women. It can also LFTs – want to make sure do not have liver conditions for oral antifungals  affect children, adolescents, and older adults. -”Spaghetti and meatball” appearance - Hot, humid climates - Malassezia furfur Tinea Corporis - Superficial fungal infection of the - Affects any part of body EXCEPT Topical antifungals (-azoles, terbinafine) skin hands and feet, scalp, face and - T rubrum m/c beard, groin, and nails. - Hot humid climates, young adults, - Ring shaped lesions (ringworm) keeping house pets - Solitary circular red patch with a raised scaly leading edge. - Spreads out from center forming ring-shape w/ central hypopigmentation and a peripheral scaly red rim (ringworm). - Papular or pustular - Itch common - Multiple lesions can develop which may coalesce to form a polycyclic pattern. - Asymmetrical -Borders are raised with fungal rashes -Usually one patch but some present with a bunch at one time Tinea Pedis - Foot infection due to a Asymmetrical and maybe - Topical antifungals (-azoles), oral antifungal if not dermatophyte fungus. Unilateral. Could present as: responsive (even if on oral can come back) - M/c dermatophyte infection 1. Itchy erosions and/or scales Powder is also good – want to absorb as much - Hot, tropical, urban environments. between the toes, especially between moisture as possible - Trichophyton Rubrum 4th and 5th toes -This recurs 2. Scale covering the sole and sides of the feet (hyperkeratotic/moccasin type, usually caused by T. rubrum) 3. Small to medium-sized blisters, usually affecting the inner aspect of the foot (vesiculobullous type). -Peeling, blisters -Can sometimes smell if very bad Lichen Planus - Chronic inflammatory condition **6 Ps: Planar, purple, polygonal, Skin Biopsy Antihistamines, topical steroids, 1-3 month of affecting the skin and mucosal pruritic, papules, plaques systemic steroids surfaces Diagnosis can be confirmed with a - May have a chronic remitting and relapsing course - T-cell mediated autoimmune - Purple Papules and polygonal biopsy that shows a “saw-tooth” shaped Switch to triamcinolone disorder: inflammatory cells attack plaques are shiny, flat-topped, firm dermo-epidermal junction, and a thickened an unknown protein within the skin on palpation stratum granulosum or hypergranulosis Topical steroid ointments and sometimes systemic and mucosal keratinocytes - Wickham striae: Plaques crossed steroids - 30-60 yrs by fine white lines in the buccal -Although LP can resolve spontaneously, treatment is - RF: genetic predisposition, stress, mucosa usually requested by patients who may be severely skin injury, systemic viral infection symptomatic or troubled by its cosmetic appearance. (hepatitis C), contact allergy, drugs, Irregular borders -Topical steroid ointments, antihistamines graft-versus-host disease flexor surfaces of extremities, (hydroxyzine 25 mg PO Q6 hours) mucous membranes on skin, mouth, -Second line treatment is systemic steroids scalp, genitals, and nails a 40-year-old female with an acute eruption of violaceous, pruritic, polygonal, shiny, flat-topped  papules involving the flexor surfaces. Lichen means tree moss, and planus refers to flat - lichen planus is a flat-topped skin rash that looks a bit like tree moss Pityriasis Rosea - Self-limiting rash, which resolves -Little bit of itchiness – one huge Pityriasis rosea is usually diagnosed based on Self-limiting, control pruritus – topical steroid, oral in about 6–10 weeks spot on stomach and now all over a physical examination of the rash antihistamine, emollients, acyclovir - Teens/young adults back and chest The characteristic rash of pityriasis rosea is - Herpesvirus 6 and 7 a herald patch, which is a single, Asymptomatic lesions do not require treatment - Large circular or oval "herald oval or round, pink or red patch with Topical or systemic steroids and patch", usually found on the chest, a scaly border antihistamines are often used to relieve itching, if abdomen, or back. The herald patch is usually followed by necessary. - Herald patch followed usually 2 a generalized rash of smaller, pink or red Emollients may be used to soften scales. weeks later by development of patches that are often arranged in However, pityriasis rosea is typically self-limiting smaller scaly oval patches a "Christmas tree" pattern without intervention resembling christmas tree mainly on chest/back. sometimes an upper respiratory prodrome before the rash. Psoriasis - Chronic inflammatory clearly - Itch-> scratching-> nichification Skin biopsy - Topical steroids, vitamin D analogue, calcineurin defined, red and scaly plaques. - Koebner phenomenon: inhibitors, coal tar, phototherapy (low doses of UV Classified into several types generation of new lesions on the Diagnosis is based on the help psoriasis heal – once to twice a week), - Any age-> childhood w/ onset skin that has been damaged or appearance and distribution of lesions methotrexate(uncommon, very high risk – unless bad peaks at 15-25 and 50-60 irritated -KOH will be negative, and Doppler studies insurance), biologics - Lifelong, fluctuating in severity - Post inflammatory hyper or of lower extremities will show an intact - Immune factors and inflammatory hypopigmentation vascular system ** Evaluate comorbidities (higher risk for CV cytokines (messenger proteins) such - Auspitz sign: pinpoint bleeding -Biopsy is confirmatory and will disease) as IL1β and TNFα, IL-23, and IL- upon removal of the scaly layer be consistent with Plaque psoriasis Biologics and oral meds can cause adverse cardiac 17 – targets for biological drugs and - +/- Nail and +/- Joint involvement -ESR may be elevated along with serum uric events have led to success in drug - Symmetrically distributed, red, acid levels management scaly plaques with well-defined -Disease Activity in Psoriatic Arthritis Common triggers include edges (DAPSA) - measure disease activity in trauma, infection, and certain - Silvery white, except in skin folds psoriatic arthritis based on joint symptoms, drugs. Symptoms are usually where the plaques often appear CRP and pain evaluation minimal, but mild to severe itching shiny with a moist peeling surface. may occur. Cosmetic implications - M/C sites include SCALP, elbows, may be major. knees but any part can be involved. Plaques are usually very persistent Guttate Psoriasis: without treatment - Post streptococcal acute guttate -Can have isolated scalp psoriasis psoriasis -Opposite of eczema locations - Widespread small plaques - Resolves after several months a 75-year-old female with patches of Just had strep a week ago chronic, inflammatory, well- demarcated, erythematous, silvery, scaly plaques that involve the scalp and extensor surfaces. Psoriatic arthritis is a seronegative spondyloarthropathy and chronic inflammatory arthritis that occurs in people with psoriasis of the skin or nails. The arthritis is  often asymmetric, and some forms involve the distal interphalangeal joints. Diagnosis is clinical. Treatment involves disease- modifying antirheumatic drugs (DMARDs) and biological agents -Inflammation of the flexor tendons of fingers, toes, or both may lead to sausage-shaped deformities (dactylitis), which are not present in patients with rheumatoid arthritis Steven-Johnson - Rare, acute, serious and - Prodromal illness prior to rash Clinical evaluation and skin biopsy - shows - Cessation of causative agent Syndrome/Toxic Epidermal potentially fatal skin condition appearance that is flu like necrotic epithelium - Hospital admission – ICU and/or burn unit Necrolysis - Sheet-like skin and mucosal loss - Abrupt onset of painful skin rash -If the test is available, elevated levels - Pain relief, nutritional and IV fluid replacement - Develops within first week of abx starting on trunk and spreading of serum granulysin taken in the first few - Topical antiseptics and dressings therapy or within 2 months of rapidly to face and limbs days of a drug eruption may be predictive of anticonvulsant - Targetoid macules with diffuse SJS/TEN. -Prompt ophthalmology and dermatology erythema and flaccid bullae -Diagnosis is often obvious from the consultation Rare complication of medication (blisters) appearance of lesions and rapid progression -Intravenous immunoglobulin (IVIG) use: *** - Nikolsky sign+ : new lesions of symptoms. Histologic examination of -Steroids used to be the treatment of choice are - Sulfonamides: cotrimoxazole appear where the skin is rubbed sloughed skin shows necrotic epithelium, a now thought to be an increased risk for sepsis - Beta-lactam: penicillins, gently; top layer of skin rubbed distinguishing feature. cephalosporins away from bottom layer -Differential diagnosis in SJS and - Anticonvulsants: lamotrigine, - Mucosal involvement is prominent early TEN include erythema carbamazepine, phenytoin, and severe multiforme, viral exanthems, and phenobarbitone -Mouth, full body, patient is in pain, other drug rashes; SJS/TEN can usually be - Allopurinol starts with blister lesions and then differentiated clinically as the disorder -Paracetamol/acetaminophen systemic symptoms evolves and is characterized by significant - Nevirapine pain and skin sloughing. -NSAIDs a 60-year-old woman with a severe drug-induced reaction on both SCORTEN is an illness severity score that - SJS: 30% BSA elsewhere in addition to mucosal SJS and TEN cases. One point is scored for - Mortality for SJS 10%, TEN is involvement of the mouth of two each of the seven criteria present at the time 30% d/t: Dehydration and acute days duration. The insulting drug of admission. The SCORTEN criteria are: malnutrition, Infection (open was sulfonamide, and the onset of -Age > 40 years wounds for bacteria to get inside), the rash was within 48 hours of -Presence of malignancy (cancer) ARDS, GI ulceration, perforation taking the drug. The rash is -Heart rate > 120 and intussusception, Shock, comprised of bilateral symmetrical -Initial percentage of epidermal detachment > Thromboembolism bullae on a background of 10% erythematous macules and patches -Serum urea level > 10 mmol/L ***Rule of 9’s in addition to erosions and peeling. -Serum glucose level > 14 mmol/L -Serum bicarbonate level < 20 mmol/L The risk of dying from SJS/TEN depends on the score. -SCORTEN 0-1 > 3.2% -SCORTEN 2 > 12.1% -SCORTEN 3 > 35.3% -SCORTEN 4 > 58.3% -SCORTEN 5 or more > 90% ABCD 10 Mortality prediction model score A: Age over 50 years (one point) B: Bicarbonate level < 20 mmol/L (one point) C: Cancer present and active (two points) D: Dialysis prior to admission (3 points) 10:  Epidermal detachment ≥ 10% of body surface area on admission (one point) -0 → 2.3 -1 → 5.4 -2 → 12.3 -3 → 25.5 -4 → 45.7 -5 →67.4 -6 → 83.6 Epithelial Inclusion Cysts - Benign cyst derived from the - Occluded pilosebaceous unit Diagnosis of an epidermoid cyst is Oral antibiotics if inflamed, surgical excision infundibulum or upper portion of a - Firm, flesh colored nodules fixed usually clinical hair follicle to the skin with a central punctum -Ultrasound can be used in the initial Can be infected – looks red – incision and drainage, - Common in adults - Foul smelling cheesy debris can be evaluation of a soft tissue mass but is not culture, antibiotics -Dead skin cells or keratin under expressed usually required the skin - Rupture can result in swelling, -Rapidly growing lesions should be biopsied Most small uncomplicated epidermoid cysts will not redness, tenderness, bacterial require treatment the most common cutaneous cysts infection (abscess) -> drainage -The most effective treatment for an epidermoid cyst Anywhere except palms and soles is complete surgical excision with an intact cyst capsule a 39-year-old female with a lesion -Removal of the entire cyst lining decreases rates of on her neck. Examination reveals a recurrence. This can be difficult to achieve following firm, round, yellow/flesh-colored, cyst rupture. movable, nontender lesion on the -Injection of triamcinolone acetonide into the nape of the patient's neck. The inflamed lesion can hasten the resolution of remainder of his scalp, face, and inflammation and may prevent infection and the need neck are unremarkable. for incision and drainage -Histological examination of the surgical specimen is recommended due to the small risk of malignant transformation and misdiagnosis Erythema Multiforme - Immune-mediated, self-limiting, - “target/bull’s eye lesions” - CBC, LFTs, ESR, testing for HSV - Self resolves within 4 weeks from onset (up to 6 mucocutaneous condition developing symmetrically in an weeks) Major: causes widespread skin acral distribution Diagnosis is based on absent or mild - Tx: Oral antihistamine, topical steroids, antiseptic lesions and affects 2 + mucosal - Cutaneous lesions develop at prodromal symptoms, preceding HSV oral wash or local anesthetic (so they can eat). sites peripheries and spread centrally infection (up to 50% of cases) 10–15 days Prednisone, antiviral therapy for recurrent disease Minor: affects a limited region of - Symmetrical with preference for before the skin eruptions and - Persistent Dz: consider Hep C, Leukemia, the skin and 1 type of extensor surfaces a rash involving the skin and sometimes the Lymphoma, solid organ cancer malignancy mucosa (usually oral) - Painful, pruritic, swollen mucous membrane, most commonly the - Triggers: infection, medication, -Raised, blanching mouth. Symptomatic treatment with oral antihistamines vaccination - Mucosal lesions develop as blisters and topical corticosteroids for mild cases; - Infection: HSV, Mycoplasma and turn to erosions with a white mouthwashes or topical steroid gels for oral disease. pneumonia, URI overlying pseudo membrane EM major (involvement of mucous membranes and - Medications: Antibiotics (beta systemic signs) lactam), anti-epileptics (phenytoin), Three concentric zones of color ▪ Corticosteroids NSAIDs, sulfa drugs from center to outer ring ▪ Ophthalmology consult if ocular - Young patients (20-40 year old), - Central dusky/dark area involvement predominantly males that can be crust or EM minor (no mucous membrane involvement and - HLA-DQB1 allele genetic vesicle no systemic signs) is usually self-limited predisposition - paler pink or edematous zone ▪ Supportive care Early treatment with acyclovir may lessen the type IV hypersensitivity reaction - peripheral red/dark ring number and duration of cutaneous lesions for Fixed lesions (as opposed to patients with coexisting or recent HSV infection. urticaria, in which lesions typically resolve within 24 hours) ▪ Acyclovir for adults: 200 mg, 5× Negative Nikolsky sign (as opposed a day for 7–10 days in the onset to SJS/TEN of EM ▪ For pediatric patients: 10 mg/kg/dose TID for 7–10 days  a 15-year-old complaining of several red lesions on her palms, the back of her hands, and on her lips for one-week duration. On examination, you note a symmetrical red papular rash with many target lesions. The rash appeared just a few days after herpes facialis. Bullous Pemphigoid - M/C Autoimmune subepidermal - Causes severe itch skin biopsy – direct immunofluorescence Topical steroids, systemic steroids, tetracycline blistering dz - Large, tense bullae (fluid-filled antibiotics, pain relief caused by linear deposition of blisters) shows deposition of IgG and C3 basement autoantibodies against the epithelial which rupture forming crusted membrane. **Tx needed for several yrs. Usually clears after tx basal membrane zone: IgG erosions – risk of infection is high but should resume tx if blister recur. produced against the basement as bullae rupture – pemphigus are membrane. flaccid High-potency topical corticosteroids (eg, clobetasol - >80 years of age (ages 30-60 years - FLEXOR aspects of limbs (may be 0.05% cream) should be used for localized disease for pemphigus vulgaris) - probably localized to one area or spread on and may reduce the required dose of systemic drugs. the only autoimmune disease that trunk/prox limbs) Patients with generalized disease often require increases in likelihood with age. - Affects skin around folds prednisone 60 to 80 mg po once/day, which can be -association w/ (HLA)-> genetic - Blisters inside mouth/genital are tapered to a maintenance level of ≤ 10 to 20 mg/day predisposition to the disease uncommon – common in Pemphigus after several weeks. - May be an association with Vulgaris Most patients achieve remission after 2 to 10 mo. internal malignancy NEGATIVE Nikolsky sign (vs. If long-term therapy is necessary, a new blister every - Attack on the basement membrane Pemphigus vulgaris which is few weeks does not require increasing the prednisone of the epidermis by IgG +/- IgE POSITIVE) dose. immunoglobulins (antibodies) and - Tetracycline and nicotinamide may be activated T lymphocytes (white beneficial in disease control and longer blood cells) a 75-year-old female who presents remission period -Geriatric patients to the clinic with a large number of - Immunosuppressive agents in severe cases pruritic, tense, subepidermal bullae across her upper thighs. There was no mucosal involvement, a negative Nikolsky sign, and a skin biopsy showed subepidermal bullae filled with eosinophils and neutrophils Acne Vulgaris - Chronic disorder affecting the hair - Open comedones: Blackheads Grade 1: mild acne (comedones) - The Mild: 125 lesions cosmetics, humidity, dairy and high he also has atrophic scars on the retinoid + benzoyl peroxide - Higher dose oral antibiotics glycemic foods – PCOS – cystic lateral forehead, consistent with - If unsatisfactory response ⇒ - Isotretinoin (accutane) for suitable patients hormonal acne – cheek and jawline permanent scarring from previous consider topical -3-6 months for severe – usually topicals do not work acne lesions. He is started on topical clascoterone or topical  because affecting deep down in the retinoids and topical benzoyl minocycline + retinoid + benzoyl Acne in Pregnancy skin peroxide. You suggest that he also peroxide - Azelaic acid*** - Familial tendency consider a systemic retinoid if this Grade 3: severe acne - Blemishes occur in Acne Scarring: topical therapy does not work. larger numbers, and inflammation is more - Tretinoin, tazarotene, chemical peels, micro pronounced. When it reaches this point, the needling, laser treatments, other cosmetic treatments skin’s structure is compromised, and the risk (first two are the only topicals that stimulate collagen of acne scarring is very high which can help scarring over time) - Add a systemic antibiotic (doxycycline, minocycline, sarecycline) to the grade 2 regimen Grade 4: cystic acne (severe scarring) - Characterized by large, angry- looking blemishes on the face and jawline, which can also affect the upper body, neck, arms, shoulders and back - isotretinoin Rosacea - Chronic inflammatory skin - Persistent facial redness +/- Diagnosis is based on the characteristic - Inflammatory Rosacea: Pulsed Light therapy, condition predominantly affecting acneiform lesions, flushing, appearance and history, and there are no Vascular laser the central face papulopustular rash, rhinophyma, specific diagnostic tests. The age of onset - Acne Rosacea: Topical Antibiotics - Ages 30-60, women m/c hyperplasia of skin and absence of comedones help distinguish (metronidazole), Oral Antibiotics, Azeleic Acid, - Genetic susceptibility, altered - Relapsing and remitting course rosacea from acne. oral isotretinoin, topical ivermectin – topical microbiome, bacteria/gut (lifelong, no cure, there are triggers antibiotics for more mild and oral antibiotics for more microbiome dysregulation and it gets better) severe patients with cystic component (doxy) - Worsens with sun exposure/heat, - Lifestyle modifications: physical sunscreens (zinc Most common on the forehead, spicy foods, caffeine, stress, alcohol, oxide), moisturizers, gentle cleansers, cosmetics with cheeks, and nose exercise, smoking green tint to hide redness Associated with telangiectasia, Can be painful - Rhinophyma: Surgical and laser treatment options flushing, papules, and pustules for severe cases a 46-year-old white woman who presents with facial flushing that Topical metronidazole, azelaic acid, and topical she notes is worse when she has ivermectin are considered first-line therapies in mild her morning coffee and when she to moderate disease is stressed at work. Physical - Oral antibiotic examination reveals the presence therapy with tetracycline, of localized facial doxycycline, and minocycline in those erythema, telangiectasia, as well as who fail topical therapy several scattered papules and - Oral isotretinoin in patients who fail to pustules on her cheeks. The patient respond to topical and oral therapy is treated with topical - Clonidine may be used for flushing metronidazole. - Laser ablation has been used for the treatment of rhinophymatous skin Lack of comedones changes Folliculitis - inflamed hair follicle due to Small, white-headed The diagnosis is usually clinical - culture for - Topical/oral abx/antifungals/antivirals (antifungal infection, occlusion, or irritation pimples appear around the hair bacteria, viruses, and fungi in diseases and antivirals are less common) - superficial or deep follicles. They may itch or burn refractory to standard therapy or if unusually - Benzoyl peroxide/ Chlorhexidine wash for prevention - Affects the chest, back, buttocks, severe -Treated the same way as acne so resembles it arms, legs - The lesions are erythematous - Bacterial: Staph aureus or Fungal: Itchy upper trunk of young papules or pustules. They are Gentle cleansing with antibacterial soap and pseudomonas aeurginosa (spa adult usually not painful but may burn mild compresses help pool) - Sycosis is severe, deep-seated, - Mupirocin ointment and topical benzoyl - Fungal: Pityrosporum a 35-year-old woman comes to your recalcitrant folliculitis with peroxide 5% cream are first-line ovale/Malassezia (Tx: office complaining of "pimples in surrounding eczema and crusting - Topical application Ketoconazole) my armpit." She said that it first - Abscesses may form at the site of of clindamycin or erythromycin works - Viral: HSV appeared five days ago and they more severe folliculitis well on mild cases of infectious folliculitis are itchy and mildly painful. She denies fever, nausea, vomiting, and  Noninfectious folliculitis is recent travel - she has never had any - Correction of the underlying cause is common among people working in prior lesions like this in the past. critical to resolving noninfectious hot, oily environments, such as She admits to going to a party where folliculitis engine workers on ships, she used a hot tub two weeks ago. - In more extensive cases, machinists, or anyone working in a Temperature is 98.1°F (36.7°C), oral antibiotics may be necessary hot, dirty environment blood pressure is 132/75 mm-Hg, - dicloxacillin and cephalexin. - Caused by occlusion, pulse is 76/min, and respirations are If methicillin-resistant S. aureus is perspiration, and skin 14/min. Both axillae have short, 2- suspected, patients should be treated rubbing against tight mm hairs, and lack with trimethoprim/sulfamethoxazole, clothes lymphadenopathy. You note clindamycin, or doxycycline Pseudofolliculitis barbae (razor multiple papules and pustules in Hot tub folliculitis usually resolves without bumps), another form of the right axillae. The lesions treatment; severe or recalcitrant cases may be noninfectious folliculitis, is caused are mildly tender to palpation. treated with an oral fluoroquinolone by ingrown hairs in the beard area from shaving in the direction against the grain of hair growth Scabies - Transmissible skin disease with - Rash w/ intense itching - Diagnosed by dermoscopy - Topical 5% permethrin cream - apply to the entire the mite Sarcoptes scabiei hominis - Spread through close bodily skin - Skin Scrapings via a blade and microscopy body for 8-10 hours and repeat in one week (m/c) contact and via fomites (clothing, More of a clinical diagnosis - Oral ivermectin - Infests humans only – cannot towels) -Change sheets and wash with high temp, make survive off the human body for >4 - Symmetrical rash affecting mainly family aware/treat family days the hands, axillae, thighs, buttocks, - High contagious infestation of the waist, soles of feet and vulva in Pruritus may persist for 2-4 weeks after treatment epidermis females/scrotum in males (above the - Risk factors: crowded conditions, neck usually spared) poor hygiene, poverty, malnutrition, - Generalized itch worse at night homelessness, immunodeficiency time - Excoriations, linear scratch marks, nodules, crusting, erythematous papules - Burrows: serpiginous thread like tracks measuring 5-10mm *web spaces, palms, soles, fingers, toes, inner wrists, elbows, umbilicus and beltline an 11-year-old male complaining of intensely itchy, painful, red streaks between his fingers and in the groin area. The patient reports that the itchiness seems to be worse at night. His best friend whom he had a sleepover this past weekend, is also having similar symptoms. Basal Cell Carcinoma - Common, locally invasive, - Slow growing pink or pigmented All lesions suspicious for basal cell Excision which should include a 3-5mm margin of keratinocyte cancer (non-melanoma to skin colored papule or nodule - carcinoma should undergo either a shave or normal skin, ED&C, Imiquimod/5-FU, Radiotherapy, cancer) Spontaneously bleeds and ulcerates punch biopsy prior to initiating curative or Mohs Surgery dependent on type and location – M/C skin cancer – 90% of skin - Very rarely a threat to life treatment cancers in US → “pearly telangiectatic lesion” Mohs Surgery: - RF: age, males, sun damage, hx of - Examining excise tissue under microscope to ensure repeated sunburn, fair skin, blue a 45-year-old fair-skinned woman complete excision eyes and blonde or red hair who is concerned about a “pink - Very high cure rates - Rarely life threatening mole” on her cheek. On physical - Suitable for ill-defined, morphoeic, infiltrative and Types of BCC: examination, you note a recurrent subtypes. - Nodular 7 mm pearly papular lesion on the - Large defects are repaired by flap or skin graft. - Superficial right cheek with -Treatment for skin cancer - Morphoeic surface telangiectasias, rolled -Taking least amount of skin as possible - Basosquamous border, and a central erosion  - Advanced - Metastatic (very rare) Melanoma - Uncontrolled growth of - Can occur anywhere on the body, Biopsy or adhesive patch genomic analysis Wide focal excision with margins (margin is melanocytes (pigment cells) including on mucus membranes and dependent on thickness), +/- systemic therapy +/- - Normal melanocytes are found in nails Glasgow 7 pt checklist: radiation therapy the basal layer of the epidermis - Itchy, tender mole that is tan, dark Major features (2 for each) -Melanocytes produce a protein brown, red, blue, grey, or may lack - Change in size The prognosis of melanoma is most strongly called melanin, which protects skin pigment - Irregular shape associated with the depth of the lesion cells by absorbing UV radiation - Irregular color A melanoma entirely within the epidermis carries a - In situ (confined to epidermis), a 67-year-old man of Irish Minor features (1 for each) very good prognosis. As the thickness progresses invasive (dermis) or metastatic descent who presents to your - Diameter >7 mm beyond the epidermis, the prognosis diminishes. The (spread to other tissue) dermatology clinic for the first time. - Inflammation likelihood of survival is further diminished if the -Men: 65 yrs, Women: 63 yrs, one When asked why he was referred to - Oozing melanoma is on the upper back, upper arm, neck, or of m/c CA in 15-29 yrs the clinic, the patient reports that his - Change in sensation scalp. -Uncontrollable proliferation of wife has been nagging him to have **Score 3+ = Sus/biopsy it Treat with excision and wide margins melanin producing cells that have his skin checked for years. On - For stages I–III, surgical excision is undergone genetic transformation exam, you notice an asymmetric, Biopsy should be excisional for most lesions curative in most cases; in patients with -Can have vaginally and mouth elevated, blue-tinged lesion with except those on anatomically sensitive or stage IV disease, systemic treatment with (sometimes basal and squamous in irregular, scalloped borders on his cosmetically important areas; in these cases, chemotherapy is recommended. mouth too) shoulder. When discussing the risk a broad shave biopsy can be done. By doing Prevention: - RF: many melanocytic nevi, factors for skin malignancy, the step sections, the pathologist can determine - Avoidance of sunburns, especially in multiple atypical nevi (dysplastic patient proudly asserts that he was a the maximal thickness of the melanoma. childhood moles), strong family history, lifeguard in Australia for 15 years Definitive radical surgery should not precede - Use of sunscreen with at least SPF 30 to white/fair skin, increasing age, UV from his late teens to his early 30s. histologic diagnosis. all skin exposed to sunlight, reapplying exposure, weakened immune regularly and after toweling or swimming system - Avoid tanning beds; class 1 carcinogen by A symmetry, B order is Microstaging is an integral part of the staging - Majority arise de novo (complete the World Health Organization irregular, C olor variability (blue, and clinical management of melanoma. Two new spot) red, white), D iameter (increasing or methods have been used. The Breslow > 6 mm), E volving (changing in microstaging method measures the thickness Most common sites: Back for men size, shape, or color) of the lesion in millimeters using an ocular and calves for women micrometer. The total vertical height of the Melanoma likes to metastasis and melanoma is measured from the granular can spread to any site in the body. layer to the area of deepest penetration. The Clark method assesses the level of Lifetime risk: men: 1/37; female: penetration into the various skin layers. 1/56. Melanoma is responsible for 2% of all cancer deaths and is Clark Classification System of the most common cancer affecting Microstaging women age 25–29 years of age and 1. Level I: Confined to the epidermis second only to breast cancer in (in situ) women 30–34 years of age 2. Level II: Invasion into the papillary dermis The HARMM acronym identifies 3. Level III: Penetration to the the five most important papillary-reticular interface independent factors for the 4. Level IV: Invasion into the increased likelihood of reticular dermis melanoma. A score of 5 represents 5. Level V: Penetration into high-risk patients versus 0–1 subcutaneous fat confers a low risk of melanoma. - History of prior melanoma - Age older than 50 years - Absence of a regular dermatologist - A changing Mole - Male gender Squamous Cell Carcinoma - Common type of keratinocyte Present as enlarging scaly or crusted Skin biopsy Excision, ED&C (electrodesiccation and curettage), cancer (non-melanoma) lumps that grow over weeks to Mohs, Radiotherapy - Derived from cells within the months, often painful epidermis that make keratin — the Crusty, yellow, cutaneous horn from Prognosis is good with immediate treatment – horny protein that makes up skin, build up of keratin negative margins, and small lesions – 10% hair and nails. metastasize. - Mutations in the p53 tumor a 63-year-old male who comes to suppressor gene are caused by your office for a lesion on his lip of exposure to ultraviolet radiation 8-10 months duration. His past (UV), especially UVB medical history is significant for - Precursor: Actinic keratosis multiple actinic keratoses treated Types of SCC: with cryotherapy. On physical 1. Cutaneous horn exam, you note a scaly, crusted, 2. Keratoacanthoma keratotic nodule about one cm in 3. Cacinoma cuniculatum diameter on the lateral part of the 4. Marjoin ulcer lower lip. Metastatic SCC is found in regional lymph nodes (80%), lungs, liver, brain, bones and skin Androgenetic Alopecia Typical male pattern baldness Examination of the scalp should note the distribution of hair loss, the presence Topical minoxidil and oral finasteride are the and characteristics of any skin lesions, and whether there is scarring. therapeutic agents that have been most extensively ▪ Part widths should be measured. Abnormalities of the hair shafts studied for the treatment of androgenetic alopecia in should be noted. men. Both drugs have demonstrated efficacy and high ▪ A full skin examination should be done to evaluate hair loss tolerability in placebo-controlled randomized trials. elsewhere on the body (e.g., eyebrows, eyelashes, arms, legs), rashes that may be associated with certain types of alopecia (e.g., discoid lupus lesions, signs of secondary syphilis or of other bacterial or fungal infections), and signs of virilization in women (e.g., hirsutism, acne, deepening voice, clitoromegaly) ▪ Signs of potential underlying systemic disorders should be sought, and a thyroid examination should be done. Onychomycosis - Fungal nail infection a 29-year-old field worker with a - Nail clipping-> Microscopic examination - Topical antifungal agents (ciclopirox lacquer), - - Affects toenails, fingernails, or rash on his nails. The patient has a using potassium hydroxide cilopirox is like nail polish 7-9 months to go away both - more common for toenails to history of tinea pedis and tinea -Oral antifungal options (terbinafine, fluconazole) – be affected (decreased blood supply manuum and thought that this might LFT monitoring is necessary for most oral if really bothering patients and will not go away – and slower growth compared to be related. On physical exam, mild antifungal regimens. Psoriasis and chronic preferred due to higher rates of cure but have fingernails along with dark, moist paronychia, loss of the cuticle of nail trauma are commonly mistaken for systemic adverse effects and many drug-drug environment) some nails, dirt-like yellowish- fungal infection. interactions - Common in older aged adults, green nail Terbinafine: 250 mg/day PO × 6 weeks for diabetics, immunocompromised, pigmentation, subungual debris, Diagnosis is by appearance, wet mount, fingernails and 12 weeks for toenails; most effective athletes and dystrophy of some nails is seen. culture, PCR, or a combination in cure and prevention of relapse compared with - Pathogens: Dermatophytes (T. Symptoms may include white or - A typical workup includes other antifungals and with itraconazole pulse in a rubrum most common), Non- yellow nail discoloration, thickening a fungal culture plus a test that meta-analysis for toenail onychomycosis Dermatophytes including yeast, of the nail, and separation of the nail yields faster results, such as Itraconazole pulse: 200 mg PO BID × 1 week, then molds from the nail bed. a (KOH) preparation or periodic 3 weeks off, repeat for 2 cycles for fingernails and 3– acid-Schiff (PAS) stain 4 cycles for toenails more effective than terbinafine for Candida and molds; does not need to monitor liver function tests (LFTs) with pulse dosing Itraconazole continuous: 200 mg/day PO × 6 weeks for fingernails and 12 weeks for toenails (less effective than itraconazole pulse for dermatophytes, more effective than terbinafine for Candida and molds) Formation of a new fingernail takes 4–6 months, and a new toenail takes 12–18 months Paronychia - Superficial inflammation of the a 32-year-old female with a painful Inspection - Soak in warm water several times daily skin around a finger or toenail index finger. She obtains regular - Topical antibiotic for mild (mupirocin – covers - Bacterial infection: Staph aureus manicures, changing colors every 2 MRSA), localized infection Caused by candida if chronic and weeks. She recently had one a week - Oral antibiotics may be necessary for severe or staph aureus if acute ago and started feeling pain near the prolonged infection nail on her left index finger. - Herpetic whitlow (vesicles caused by HSV) treat Physical exam reveals redness, with acyclovir warmth, and pain along the nail - Incision and drainage margin of the index finger. When applying pressure to the nail plate, Acute paronychia: warm compresses, elevation, some pus drains from the nail. She splint protection if pain severe. is prescribed frequent warm soaks - Antibiotic cream applied TID–QID with chlorhexidine and oral after warm soak (e.g., mupirocin or antibiotics gentamicin/neomycin/polymyxin B) for 5–10 days. Acute: characterized by pain, - If eczematous: low potent topical steroid erythema, and swelling; usually a applied BID (e.g., betamethasone 0.05% bacterial infection, appears after cream) for 7–14 days. trauma. It can progress to abscess - Acute (exposure to oral flora) formation. o Amoxicillin-clavulanate Chronic: characterized by swelling, potassium: 875 mg/125 mg tenderness, cuticle elevation, and BID or 500 mg/125 mg TID nail dystrophy and separation. May for 7 days; pediatric, 45 mg/kg be considered work-related among q12h (for 10 cm Lipomas are usually soft, homogeneous, oval, and nontender, with a rubbery or doughy consistency; if hard, suspect another diagnosis Not erythematous a 30-year-old male being seen for a non-painful mass on the upper back which has grown slowly over the past year. He denies previous trauma, drainage from the area, or a history of dermatologic diseases. Examination reveals a four- centimeter firm, but highly mobile subcutaneous mass with no overlying skin discoloration or punctum with drainage. Vitiligo - Acquired, chronic, depigmenting The lesions appear as Thyroid function (send them for TSH, T3, Sun protection, cosmetic camouflage, topical disorder of the skin in which hypopigmented chalk-white lesions and T4 just in case), ANA, B12 steroids, tacrolimus (calcineurin inhibitor), vitamin D pigment producing cells and are more obvious on people derivatives, Ruxolitinib cream (opzelura), (melanocytes) that determine the who have dark complexions. The Wood’s lamp (lights up really bright, phototherapy, depigmentation therapy color of skin, hair, and eyes are condition is bilateral and symmetric indication there are no melanocytes there), progressively lost in appearance and typically forms dermoscopy, skin biopsy No cure - The result of autoimmune around orifices (i.e., mouth, eyes, destruction of melanocytes nose, and anus). Wood’s light examination reveals a “milk- white” fluorescence over the lesion  - M/C in India, strong inheritance Similar to tinea versicolor – vitiligo pattern, thyroid dz is very white whereas tinea is more - 20-24 yrs pigmented -Body is destroying melanocytes Vitiligo is often cyclical. Some may a 7-year-old female with large experience partial repigmentation. patches of depigmentation affecting the neck, upper back, and chest of three years Associated with three other duration. The whitish patches autoimmune diseases: are sharply demarcated with some residual brownish areas - Addison's disease within. Some hairs in the involved - Hyperthyroidism areas have become white as - Pernicious anemia well. Wood’s light examination reveals a “milk-white” fluorescence over the lesion. The patient is started on topical corticosteroids, and a referral is provided to the dermatologist. Gastrointestinal and Nutritional Disorders Disease Etiology/Patho S&S/PE Labs/Imaging Treatment Esophagitis **Inflammation of the esophagus Clinical Presentation Esophagogastroduodenoscopy (EGD)- aka **Treat underlying cause Occurs secondary to: 1. Odynophagia “upper endoscopy” with biopsy 1. Reflux* - Reflux - Painful swallowing 1. “Gold standard” - *To be discussed in GERD section* 1. Most common 2. Dysphagia Barium swallow may aid in diagnosis 2. Infectious - Infection - Difficulty swallowing - Antimicrobials 1. More often in the immunosuppressed 3. Retrosternal discomfort, 3. Medication-induced a. Candida, CMV, HSV “heartburn” Diagnosis is by endoscopy, biopsy, double - Discontinue offending agent - Certain medications - May not be responsive to contrast esophagram, and culture 4. Auto-immune 1. Common culprits include antibiotics (in typical GERD treatment Eosinophilic esophagitis - barium swallow - Steroids such as fluticasone, particular tetracyclines), NSAIDs, a 54-year-old female with a history of will show a ribbed esophagus and multiple budesonide bisphosphonates (glass of water to avoid GERD presents with 1 week corrugated rings 5. Supportive care this) of progressive - Acid suppression, swallowed a. Causing irritation, mucosal dysphagia and retrosternal burning viscous lido injury chest pain worsening to inability to - See GERD lecture b. Increased risk dependent on swallow liquids. On EGD, she is found medication size, route of to have LA grade D erosive Management: treat the underlying condition administration (patient esophagitis in the distal esophagus. - Candida: treat position, quantity of fluid Biopsies reveal reflux esophagitis with fluconazole 100 mg PO daily ingested), underlying without eosinophilia. She is diagnosed - HSV: treat with acyclovir esophageal anatomic or with erosive reflux esophagitis, likely - CMV: treat with ganciclovir motility disorder from uncontrolled GERD, and started on - Corrosive: treat with steroid - Auto-immune high-dose PPI, leading to improvement - Eosinophilic: treat by removing 1. Eosinophilic esophagitis in her symptoms over the next week. foods that incite allergic response, a. Chronic, immune-mediated topical steroids via inhaler (Eosinophil-predominant - Medication-induced: to prevent inflammation) bisphosphonate-related esophagitis treat by drinking pills with at least 4 Esophagitis is simply inflammation that may ounces of water, avoid laying down damage tissues of the esophagus. Patints present for at least 30-60 minutes after with odynophagia (painful swallowing), ingestion dysphagia, and retrosternal chest pain It can be divided into two types: 1. ⇒ Non-infectious  - Reflux esophagitis: mechanical or functional abnormality of the LES - Medication-induced: think NSAIDS or bisphosphonates - Eosinophilic: Pt with asthma symptoms and GERD not responsive to antacids. Allergic, eosinophilic infiltration of the esophageal epithelium. ▪ Diagnosed with a biopsy ▪ A barium swallow will show a ribbed esophagus and multiple corrugated rings -Radiation: radiosensitizing drugs include doxorubicin, bleomycin, cyclophosphamide, cisplatin ▪ Dysphagia lasting weeks-months after therapy ▪ Radiation exposure of 5000 cGy associated with increased risk for stricture -Corrosive: Ingestion of alkali or acid from attempted suicide 2. ⇒ Infectious - odynophagia (pain while