Disorders of Skin

Fall 2005

Acne Vulgaris

• Demographics- ♂>♀; 12% ♀ & 3% ♂ over 25

• Essentials of Diagnosis

• Occurs at puberty but may be 3^rd or 4^th decade

• Open & closed comedones are hallmark

• Most common of all skin conditions

• Severity varies from comedonal to pustular or cysts

• Face and trunk mostly affected with scarring when picked at

• General Considerations

• Activated by androgens & genetics

• Parallel sebaceous activity

• Resistant case in women consider hyperandrogenism

• Pathogens (propionibacterium acnes) with release and irrituation by fatty acids or foreign body reaction to extrafollicular sebum

Antibiotics for Acne Vulgaris

• Mild

• Cleocin T,

• Moderate

• Severe Cystic acne

Differential Diagnosis for Acne

• Acne rosacea (face)

• Bacterial folliculitis (face or trunk)

• Tinea (face or trunk); also pustules by tinea

• Topical steroid use (face)

• Perioral dermatitis (face)

• Pseudofolliculitis barbae (ingrown beard)

• Miliaria (heat rash- trunk)

• Eosinophilic folliculitis (trunk)

Treatment of Acne Vulgaris

• Comedonal acne

• Topical retinoids: Tretinoin (0.025% cream only 2x/wk then increase to nightly as needed, 20 min after washing); Adapalene gel (0.1%) & reformulated tretinoin (Retin A, Avita, etc) if tretinoin cause irritation; lesions may be worse first 4 weeks and not for pregnancy

• Benzoyl peroxide – 2.5% just as effective

• Papular inflammatory acne

• Antibiotics either topically or orally

Papular inflammatory Acne

• Mild acne

• Topical antibiotic combination of erythromycin or clinidamycin with benzoyl peroxide as gel + tretinoin 0.025% cream at hs

• Moderate acne

• Tetracyclin 500 mg, erythromycin 500 mg, doxycycline 100 mg, or minocycline 50-100 mg bid- taper q 6-8 wks when clear for lowest dose

• May add oral contraceptive or spironolactone as antiandrogen in ♀ isotretinoin therapy

• Severe cystic acne

Severe cystic acne

• Isotretinoin (Accutane) used before scarring occurs

• Get informed consent before use, preg testing before and q month

• 0.5 to 1 mg/kg/day with cumulative of 120 mg/kg usually adequate

• Dry skin, ↑cholesterol and triglycerides and LFTs, myalgias –monitor labs

Procedures & Outcomes for Acne

• Procedures

– Comedones removed with extractor- temp

– Moderate acne- inject with triamcinolone acetonide hasten resolution of deeper cysts

– Dermabrasion of inactive lesions, cosmetic excision and punch grafting

• Outcomes

– Scarring

– Relapse may occur throughout adulthood

– Remission in 60% after isotretinoin

– Relapse after isotretinoin can occur within 3 years- retreat

– Refer if fulminant scarring or failure to respond

– Avoid greases, oils

Actinic Keratosis

• Premalignant 1:1000 lesions progress to squamous cell carcinoma

• 0.2-1 cm patches, flesh-colored, pink or slightly hyperpigmented, feel like sandpaper and tender when finger drawn over them

• Sun exposed areas

• Treat with liquid nitrogen or

• 0.5 (Carac)-5% fluorouracil cream bid 2-3 wks

Squamous Cell Carcinoma

• Essentials- nodule, ulcer or patch on sunexposed site or in genital area

• General Considerations – SCC

– Far skinned who sunburn easily, tan poorly

• Demographics- 20% as common as BCC

• S & S

– Lesions small red, conical, hard nodules may ulcerate- easily misdiagnosed & may metastasize

Differentials & Treatment of SCC

• Differentials

– Actinic keratosis, BCC, Seborrheic keratosis, warts, Keratocanthomas

• Treatment- bx for diagnosis

– Excision

– X-ray radiation for some

• Follow up

– Q 3 mo and examine lymph nodes

– ? Frequency of metastasis

Basal Cell Carcinoma

• Essentials

• Slow growing

• Pearly or translucent appearance

• Telangiectatic vessels

• General Considerations

• most common form of cancer

• HCP examine skin, esp fair skinned, scabbed area

• S & S

• Papule or nodule with scab or erosion

• Brown-gray color or stippled pigment

• 1-2 cm in diameter after years of growth

• Waxy, pearly appearance with telangiectatic vessels

• Can be hypopigmented, thickened plaques

• Back and chest, reddish, shiny, scaly

• Look at eyelids, lips, behind ears

• BCC of medial canthi particularly dangerous

Diagnosis, Treatment and Follow up of BCC

• Diagnosis- biopsy

• Treatment

• Medications- Imiquimod cream 5%, 3x/wk for 10

• Surgery- 3 cycles of curettage not on face/head or Mohs surgery to revise after frozen bx

• Rediotherapy- for older individuals

• Outcome

• Follow up for 1-2 years for recurrence

• Neglected may ulcerate

• Metastases almost never occurs

Insect Bites

• Essentials-localized rash, furuncle-like lesions with live arthropods

• General Considerations

• Arthropods (mosquitoes/flies)-delayed reaction

• Body lice, fleas, bedbugs

• Spiders rarely attach – but brown spider (Lososceles reclusa) cause necrotic areas and even death, also black widow

• Most common venomous stings (bees, etc)

• Ticks- Rocky Mt spotted fever, Lyme dx, relapsing fever, ehrlichiosis

Insect Bites

• Diagnosis- clinical features, labs ?

• Differentials

• Scabies or Lice

• FleasTiccks

• Bird or rodent mites

• Treatment

• Corticosteroid lotions

• Calamine lotion with cool wet dsg

• Stings tx immediately with Adlphi’s Meat Tenderizer

• If concern of Rocky Mt spotted fever, lyme treat appropriately

Rocky Mt Spotted Fever

• Key Features- Rickettsia fickettsii

• Most occur late spring and summer, mid/Southern Atlantic and Miss River valley

• Incubation after tick bite is 2-14 days (mean 7)

• Findings- 3-5% fatal

• Initially, fever, chills, HA, N&V

• Cough & pneumonia early in disease

• Rash (not always) faint macule -> maculopupules & peechiae

• Dx- thrombocytopenia, hyponatremia,hepatitis, CSF low glucose, skin bx and serological test

• Treatment-Doxycycline or chloramphenicol

Lyme Disease

• Essentials- most in spring & summer

• Erythema migrants- flat or slightly raised red lesion that expands with center clearing

• HA or stiff neck

• Arthralgias, arthritis, myalgias

• 95% of cases in mid-Atlantic , northeast, and north central US with some in Pacific area

• General Consideration

• Spirochete- Borrelia burgdorferi by ticks that must feed > 24 hrs to transmit infection and ↑ with 72 hr

S & S of Lyme

• 3 stages: 1-flu like and rash; 2- weeks/months Bell’s palsy or meningitis; 3- months to years is arthritis

• Can invole skin, CNS and Musculoskeletal

• CNS is peripheral neuropathy (sensory & motor) transverse myelitis

• Migratory pain in joints, muscles,tendons

• Can resemble localized scleroderma

Diagnosis of Lyme

• Labs

• ↑ sed rate >20 in 50%, mild ↑LFTs, mild anemia, leukocytosis and hermaturia (10%)

• Antibodies in serum by IFA or ELISA (? + & -)

• IgM & IgG by Western blot confirms-2 tests

• 38% spinal fluid +, 85% synovial if arthritis

• Procedures

• Dx based on clinical and labs

• Could get + bx if early in disease

• EMG for peripheral neuropathy

Treatment and Outcome

• Treatment

• Medications

– Erythema migrants (doxycycline 100 bid x 3-4 wks or amoxicillin 500 tid); Bell’s palsy (same); CNS need IV ceftiaxone or pen G 2-4 wks; 1^st AVB doxycycline; AVB ceftriaxone or pen G

• Outcome

• Complete recovery 4-6 wks after therapy if early

• Fatigue, etc last weeks/months

• Rarely Bell’s palsy or AVB last

• Admit if severe complications

• No prophylactic antibiotics following tick bites

Parovirus or other viruses

Scleroderma (Systemic Sclerosis)

• Essentials- 3^rd to 4^th decades with ♀ 4x >♂

• Diffuse thickening of skin, telangiectasia and ↑ pigmentation and depigmentation

• Raynaud’s in 90%

• Systemic: dysphagia, GI hypo, pulmonary fibrosis, CV and renal involvement

• + test for antinuclear antibodies

• General Consideration

• Chronic disorder of skin and internal organs

• 2 forms: limited (80%) & diffuse (20%)

• Ask about tryptophan use (FDA banned) when pts present

• Alternative is Eosinophilic fascilitis with fascia inflammation only with peripheral eosinophilia, no Raynaud’s, respond to steroids

Scleroderma S & S

• Skin involvement precedes visceral

• Polyarthralgia & Raynaud’s (90%) early

• With time, skin thickened, loss of folds

• Telangiectasia, pigmentation/depigmentation

• Ulceration about fingertips, calcification

• Dysphagia (motility/fibrosis),malabsorption

• Pulmonary fibrosis

• CV includes HB, pericarditis, RHF 2^nd to PulHTN

• Systemic may be renal crisis with obstruction of renal blood vessels

Diagnosis & Treatment

• Diagnosis

• ANA almost always +

• Scleroderma antibody (SCL-70)1/3

• Not increase in sed rate

• Mild anemia may be present

• Proteinuria indicates renal involvement

• Treatment- manage in consultation with rheumatologist

• Raynaud’s: CCB nifedipine 30-120/d or losartan 50

• For healing ulcers, IV iloprost (prostacyclin analog leads to vasodilation and inhibits platelets

• IV prostaglandins

• Reflux with antacids, H₂ blockers, PPIs

• Malabsorption d/t bacterial overgrowth, tetracycline 500 qid

• No prednisone

• Cyclophosphamide, may improve interstitial lung dx

Calluses & Corns

• Key features

• Caused by pressure and friction

• Findings

• Tenderness on pressure and “after-apin”

• Hyperkeratotic at pressure areas

• Fingerprint lines preserved (not in warts)

• When paring, glassy core don’t bleed

• Soft corn on 4^th toe from Joint pressure 5^th toe

• Treatment

• Correct friction- pumice stone

• Paring

• On heals, tx with 20% urea or combination therapy

Dermatatis

• Atopic- no smallpox vaccine

• Pruritic etc on face, neck wrists, hands

• Peripheral eosinophilia, ↑ IgE, chronic pruritis

• S & S: on face, neck upper trunk (monk’s cowl”), dry scaly skin,pustules staph, blacks on cheeks and extremities

• Treatment: Steroids, Doxepin cream, phototherapy

• Contact- erythema & edema, + patch test

• Acute or chronic

• Exfoliating-scaling and erythema over body

• Seborrheic- dry scaling and erythema of face, scalp, folds, interscapular, & umbilicus

Contact Dermatitis

• General Considerations

• Acute or chronic from direct skin contact

• 80% d/t excessive exposure/additive to primary irritants (soaps, solvents, etc)

• Actual contact (poison ivy or oak)

• Topicals causing are antimicrobials (neo), antihistamines, anesthetics (benzocaine), hair dye, preservatives (parabens), latex, adhesive tape

• Irritant (dry & scaly); allergic (weeping and crusting)

• S & S

• Acute tiny vesicles, weepy and crusted with chronic scaling, erythema and thickened skin

• Pattern my be diagnostic (linear streaked vesicles poison ivy)

• Location suggest cause (soaps, dyes, jewelry, shaving, cosmetics)

Differentials, Diagnosis of Contact Dermatitis

• Differentials

• Impetigo- most common confused dx, do gram stain and culture to rule out impetigo or secondary infection (impetiginization)

• Scabies

• Dermatophytid reaction (allergy or sensitive to fungi)

• Atopic dermatitis

• Diagnosis

• Can’t do patch testing during acute

• If itching generalized and impetiginized, scabies and scrape for mites

Treatment & Outcomes from Contact Dermatitis

• Treatment

– Medications

• Vesicular & weepy systemic steroid therapy (prednisone 12-21 days) 60 mg 4-7 days and then taper slowly to avoid rebound not Medrol dosepak

• Localized managed with topicals

• Irritant treated with avoidance

– Local Measures

• Acute weeping: compresses, calamine or starch shake lotions, topical steroids (-.5% fluocinonide 2-3 x/d but not on face or folds), not ointments if weeping bad, triamcinolone 0.1% is soothing

• Subacute: mid-potency (triamcinolone 0.1%) to high-potency (amcinonide, fluocinonide, etc)

• Chronic: high to highest potency steroids in ointment form

• Outcomes- self limiting, prevention by exposure, barrier creams

Exfoliating Dermatitis

• General Considerations

• Preexisting dermatoisis (65%) cause including psoriastis, atopic, seborrheic or contact dermatitis

• Reactions to topical or systemic drugs (sulfa) and cancer (cutaneous T cell lymphoma or Sezary syndrome), pityriasis rubra pilaris or ? Reason

• S & S

• Itching, malaise, fever, chills (prominent) and weight loss

• Redness and scaling generalized sometimes hair loss

• Generalized lymphadenopathy

• Diagnosis

• Skin bx to show inflammatory dermatitis or cutaneous T cell lymphoma or leukemia

Treatment and Outcome of Exfoliating Dermatitis

• Treatment

• Stop drugs

• Systemic steroids for acute with immediate results but no long term therapy

• Acitretin or methotrexate if psoriatic erythroderma or pityriasis rubra pilaris

• Evidence of bacterial infection cover for Staph

• Outcome

• Careful follow up as cause may not be determined

• If generalized, sepsis, protein loss or dehydration may occur

• Chronic therapy as most do not improve greatly

• Refer early

Scabies

• Essentials

• Severe itching

• Pruritic vesicles and pustules in runs or galleries (finger webs, heels or palms or wrist creases)

• Mites, ova and brown dots of feces visible microscopically

• Red papules or nodules on scrotum or penis

• General Consideration

• Caused by Sarcoptes scabiei

• Spares head and neck except in elderly and if AIDS

• Acquired through bedding of infested person or close contact

• Differentials

• Pediculosis (Lice), dermatitis, arthropod bites

Scabies Diagnosis and Treatment

• Diagnosis

• Microscopic , use immersion oil and scape or apply ink and shave the burrow

• Treatment- failures d/t incorrect use

• Treat mites and control dermatitis

• Permethrin 5% cream for 8i-12 hr, repeat in 1 wk

• Crotamiton cream or lotion used nightly for 4 nights

• Benzyl benzoate 20-30% from collarbone down overnight x2, 1 week apart

• Most disinfect all clothing and bed clothes- then leave in plastic bag for 14 days

• Treat all persons in contact– really bad for nursing homes

Impetigo

• Essentials- skin infected with staph aureus as eiither vesiculopustular or bullous

• General Considerations- most staph

• Contagious and autoinoculable infection of skin from staph &/or strep

• Vesiculopustular (thich golden-crusted lesions) or bullous associated with group II S aureus

• S & S

• Itching is only symptom

• Macules, vesicles, bullae, pustules, and honey-colored gummy crusts when removed leave denuded red area

• Face and exposed areas most involved

• Ecthyma is deeper form of impetigo with ulceration and scarring on legs and other covered areas

Diagnosis and Treatment of Impetigo

• Diagnosis- clinical picture and gram stain and culture to confirm

• Treatment

• Systemic antibiotics as topical don’t work as well

• If limited dx the 2% mupirocin ointment (Bactroban) tid x 10 days

• Dicloxacillin or cephalexin 250 mg 4x/d or erythromycin 250 4x/d (may not be sensitive)

• Compresses for crusts and weepy areas

• Outcome

• Recurrent treat with rifampin 600 mg daily or intranasal mupirocin ointment bid x 5 days

Herpes Zoster

• Essentials- HIV pts 20X more likely

• Pain (about 48 hr before) along nerve then vesicular lesions and even worse after lesions disappear

• Unilateral with few lesions outside dermatone

• Face or trunk

• Tzanck smear is positive with vesicular lesions

• General Consideration

• d/t varicella-zoster virus usually adults only

• If generalized dx, consider Hodgkins or HIV

• Early (72 hr after onset) treat aggressively with antiviral to decrease severity and duration of postherpetic neuralgia

• Pain can mimic angina, peptic ulcer, appendicitis, or biliary/renal colic

Diagnosis, Treatment and Outcome of Herpes Zoster

• Diagnosis- clinical presentation

• Treatment

• > 55 treat with antiviral therapy, younger maybe

• Oral famciclovir (500 tid), valacyclovir (1 g tid), acyclovir (800 5 x/d) all for 7 days- renal function

• Systemic steroids for pain (60 mg taper over 3 wk) (not for immunocompromised person)

• Postherpetic: capsaicin ointment (.25-.75%), lidoderm patches, regional blocks, amitriptyline (25-75 mg hs) or gabapentin up to 3600 mg (start slowly)

• Outcome

• Sacral zoster associated with bladder or bowel dysfunction

• If ophthalmic, can lead to visual impairment—treat early- send to ophthalmologist if 5^th cranial nerve involved

Oncychomycosis

• Essential

• Trichophyton infection of nails

• Yellowish discoloration with heaping of keratin

• General Consideration

• Candidal infection of nail folds and subungual area, nail hardeners and drug photosensitivity may cause onycholysis as well as hyper/hypothyroidism and psoriasis

• S & S- brittle, lusterless, hypertrophic nails

Diagnosis, Treatment and Outcome of Onychomycosis

• Diagnosis- Hyphae after cleaning nail with 10 K hydroxide then microscope

• Treatment- 35 % cure in 1 year

– Topical

• Low efficacy (10% or <) better if minimal thick nails using naftifine gel 1% or ciclopirox 8% bid 4-6 months fingernails and 12-18 months toenails

– Systemic- generally required- itraconazole interacts with numerous drugs

• Fingernails (uamicrozie griseofulvin (750 qd x 6 months) or itraconazole, itraconazole and terbinafine (better than itraconazole 250 qd x 3 mo)

• Toenails no grisofulvin or ketoconazole use itraconazole 200 x 3 mo or 400 x 7 days of each month x 3 months (not FDA approved for toenails)

• Outcomes

• May need treatment for life

• May need to pare thickened nail plate

• Alternative is removal of nail ( some do excellent work for this others don’t) and get deformities of nail

Pityriasis Rosea

• Essentials- oval fawn-colored scaly eruption in cleavage lines of trunk with herald patch 1-2 weeks before

• General consideration

• Common, mild acute inflammatory 50% females

• Lasts 4-6 weeks without scarring in spring/fall

• S & S

• One or more classic lesions with centers crinkled or cigarette paper appearance, scale bound at periphery and free in center

• Christmas tree pattern

• May/may not have pruritus

Diagnosis and Treatment of Pityriasis Rosea

• Diagnosis

• Based on appearance

• Do syphilis test if not perfectly typical

• Treatment

• Daily UVB treatments for 1 week or prednisone as contact dermatitis

• 73% cleared with erythromycin in 14 days

• May not need treatment