Common FP Office Dermatology Dana Romalis, MD


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  • With new VZV vaccine, fewer cases and fewer complications
  • Grandparents to babies (only cutaneous, not airborne like regular varicella)
  • 1) Within 72 hours, reduces duration and pain of rash itself. Unlikely to be useful once lesions crusted. Controversial as to whether they reduce post-herpetic neuralgia incidence…acyclovir has the most evidence for such effect.
    2) Oral steroids have been shown to reduce pain associated with herpes zoster rash
    3) If involves eye or tip of nose-nasociliary branch of (ophthalmic division of Facial nerve (CN V1), urgent ophtho consult as may have complications such as mucopurulent conjunctivitis, episcleritis, keratitis and anterior uveitis.
  • Vulgaris: early (22.5 years) vs. Late: 55 years. Localized vs. generalized, Effects on psychosocial health.
  • Also see from metal jewellery (neck, earlobe, wrist, finger)
  • Kerion ddx: scalp abscess, impetigo, cellulitis
  • Kerion ddx: scalp abscess, impetigo, cellulitis
    2) Id reaction to the fungal infection. Easily confused with t. corporis
  • Common FP Office Dermatology Dana Romalis, MD

    1. 1. Common FP Office Dermatology Dana Romalis, MD August 2006
    2. 2. Objectives Recognize 17 common dermatologic conditions seen in the office setting Identify other diseases that appear similarly and may confuse diagnosis Learn basic treatment of these conditions, (as well as what doesn’t require treatment) Recognize the psychosocial implications of these conditions.
    3. 3. Quick definition review  A) Papule/Plaque:  superficial, elevated, palpable lesion ≤0.5 cm; >0.5 cm.  B) Macule/Patch:  circumscribed colour change without elevation or depression.  C) Vesicle/Bulla:  like A), but containing fluid.  D) Nodule:  palpable, solid, deeper than A).  E) Wheal:  pale red, palpable, superficial lesion, evanescent, disappearing in 1-2 days. From edema in the papillary layer of the dermis.  F) Pustule:  like C), only with purulent exudate as the fluid.
    4. 4. Vesicular 7 yo with itchy rash & fever x1d, feels unwell. Blisters on red base. New lesions are still appearing. Diagnosis: - Varicella (chicken pox) Etiology: VZV, airborne When is it infectious? - from 1-2 days before rash develops, until after last lesion scabs over. When will I know if I have it? - 1.5-2.5 wks after exposure
    5. 5. Vesicular 64 yo M w/burning pain for 3 days, now with rash on back “in a stripe” Diagnosis: Herpes Zoster Etiology: VZV reactivation Treatment: Acyclovir <72 hr, +/- oral prednisone Treat for 7-10 days Why treat? reduce pain/duration of lesions Is this contagious? How? When do you need to refer? to whom?
    6. 6. Zoster treatment Medication Dose Cost (generic for 7d) Acyclovir 800 mg po 5x/day for 7 days $174-248 Famciclovir 500 mg po TID for 7 days $140 Valacyclovir 1000 mg po TID for 7 days $84 Prednisone 30 mg po BID on days 1-7; $1-2  then 15 mg BID on days 8-14;  then 7.5 mg BID on days 15-21
    7. 7. Papular 27 yo M, no pmhx, w/itchy rash “all over” body for 3 days. It started with this patch here 1 wk ago… Diagnosis: Pityriasis rosea -“Christmas tree” pattern - Herald patch 1-2wks before rash appears
    8. 8. Pityriasis Rosea Etiology unknown Lesions on “Langer’s lines” Differential diagnosis: drug eruption secondary syphilis tinea corporis viral exanthem guttate psoriasis Treatment?? anti-pruritics controversial: erythromycin UVB
    9. 9. Papulosquamous  38 yo M w/symmetric, vivid pink, raised, scaly lesions.  Diagnosis:  Psoriasis vulgaris  Pathophysiology:  Immune activation of keratinocyte cell cycle  Epidemiology: bimodal  Appearance:  localized vs. generalized  Extensor surfaces  (macarena)  Treatment:  Topicals –> phototherapy –> systemics
    10. 10. Psoriasis  Associated with:  Arthritis (small joints)  Nail dystrophy - Oil spot (pathognomonic) - Pitting - Onycholysis  Other issues/forms:  Koebbnerization  Guttate (Gp A Strep)  psychosocial
    11. 11. Papulosquamous  28 yo F says “I’ve always had itchy arms, but it’s been awful this winter”. History of asthma, seasonal allergies  Diagnosis:  Atopic dermatitis/ Eczema  cheeks/extensor surfaces (infant)  Flexure surfaces (older) How is this rash different?  14 yo F “This rash has been spreading for 3 months”  Diagnosis:  Contact dermatitis  To what?  Nickel (belt buckle, button)
    12. 12. Dermatitis/Eczema  Treatment for all types:  Avoid triggers  Allergens  Excessive bathing  Emollients (Eucerin, Aquaphor, … glycerin content is key)  Topical steroids  Immune modulators: tacrolimus/ Protopic, pimecrolimus/Elidel, …? safe in kids (not under 2)  STOP SCRATCHING!  Lichenification  Infection-impetigo
    13. 13. Papular rashes Rash A: just started 1 hour ago, very itchy Rash B: present for 2-3 months, not responding to OTC steroid cream. A) Urticaria/wheals- allergic reaction AKA “hives” B) Tinea corporis- well demarcated patches with central clearing “ringworm”
    14. 14. Papular rashes: Treatment Urticaria: - H1-blockers What else should you be concerned about? Tinea Corporis: - topical antifungal - continue for 1-2 wks after lesions resolve. Can he go to school? Anyone else at risk?
    15. 15. Hypopigmented What makes these rashes so different? A- symmetric, complete depigmentation. Clear edges. B- decreased pigmentation, edges flake when scratched 1) Vitiligo; any age. - Fewer melanocytes (autoimmune) 2) Pityriasis versicolor; young adults. - etiology: P. ovale (yeast) most common
    16. 16. Vitiligo: Treatment Autoimmune disease: - associated with thyroid dz & diabetes - commonly affects: perioral, hands, shins, genitals Rx: - topical steroid, PUVA - support group - cosmetics
    17. 17. P. Versicolor: Treatment - selenium sulfide shampoo x1wk - alt: ketoconazole shampoo x3d (or oral azole -1 dose) - may take months to repigment after summer - prevent recurrence with repeat Rx qmonth x3m
    18. 18. Scalp lesions  9 yo boy sent home from school, removes hat to show you this red, scaly lesion. You see tiny black dots in an area of alopecia, with a fine scale.  Diagnosis?  Tinea capitis  Differential?  Treatment?  Oral griseofulvin until 2 wks beyond clinical resolution
    19. 19. T. Capitis  Mother brings in 4 yo w/lg. red exudative swelling on head. Diagnosis?  Tinea capitis w/kerion  What do you have to tell mom?  Scarring alopecia will result.  Treatment?  As above, but with po steroids • 2 weeks after treatment begins, a widespread pruritic eczematous rash erupts… What is this? • Id reaction to the fungus • Rx with lubricants and topical steroids and continue on griseofulvin for a complete course
    20. 20. Papulopustular  14 yo M w/ red papulopustular rash for 6m. Getting worse. “is it because I eat fast food?”  Diagnosis:  Acne Vulgaris  Etiology:  Excess sebum production, hair follicle hyperkeratinization blocks sebum release, causing buildup of sebum, lipids, cellular debris  ideal for bacterial growth.  28 yo F “I keep getting acne on my cheeks and chin. I thought I was done with this years ago!”  Diagnosis:  Rosacea  Etiology: unknown, strong genetic link
    21. 21. Treatment: Acne  Mild: comedonal, with few papules & pustules. No nodules  Benzoyl peroxide (not w/retinoid)  adapalene/Differin,  azelaic acid/Azelex (improves postinflammatory hyperpigmentation)  retinoid  OCPs  Mod: papulopustular, rare nodules.  topical antibiotic (clinda, erythro)  oral antibiotic (tetracycline, erythro)  Severe: nodulocystic, painful  Isotretinoin/Accutane
    22. 22. Treatment: Rosacea  Early:  avoidance of triggers  sunscreens  topical antibiotics  systemic antibiotics  oral isotretinoin  Metronidazole/Flagyl  Late:  Laser treatments  Other:  Associated blepharitis  rhinophyma
    23. 23. Papules  6 yo M brought in with “rash that’s spreading all over his face!”  Dx:  Molluscum contagiosum  Is this an STD?  How is picture B different?  Common warts  Treatment? If desired- virtually the same  Liquid nitrogen  Electrocautery/scraping  Topicals: Salicyclic acid, tretinoin, duct tape, podofilox
    24. 24. Nodules: spot diagnoses  Very soft, mobile, slow- growing in 50 yo M  Slips under fingers  Diagnosis:  Lipoma  Firm, slow-growing, central dark spot  Diagnosis:  Epidermoid cyst  Keratin plug helpful for diagnosis
    25. 25. Nodules: treatment  Usually not necessary  However…  May become painful or inflamed.  Poor cosmesis…  Surgical removal  Must remove capsule or lesion will recur
    26. 26. Conclusion  Family physicians encounter a wide variety of dermatologic lesions in a wide variety of stages.  History and clinical picture are often enough to make the diagnosis  Attempts at self-treatment present additional diagnostic challenges.  Most conditions are common and easily treated or self-resolve…but for those that are not…  Biopsies may be needed for definitive diagnosis.
    27. 27. Questions?
    28. 28. Bibliography Uptodate Google images American Family Practice Fitzpatrick Atlas of Clinical Dermatology 