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
Dana Romalis, MD
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.
Quick definition review
superficial, elevated, palpable lesion ≤0.5 cm; >0.5 cm.
circumscribed colour change without elevation or depression.
like A), but containing fluid.
palpable, solid, deeper than A).
pale red, palpable, superficial lesion, evanescent, disappearing
in 1-2 days. From edema in the papillary layer of the dermis.
like C), only with purulent exudate as the fluid.
7 yo with itchy rash & fever x1d,
feels unwell. Blisters on red
base. New lesions are still
- Varicella (chicken pox)
Etiology: VZV, airborne
When is it infectious?
- from 1-2 days before rash
develops, until after last lesion
When will I know if I have it?
- 1.5-2.5 wks after exposure
64 yo M w/burning pain for 3
days, now with rash on back
“in a stripe”
Etiology: VZV reactivation
Acyclovir <72 hr, +/- oral
Treat for 7-10 days
reduce pain/duration of lesions
Is this contagious? How?
When do you need to refer? to
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
27 yo M, no pmhx,
w/itchy rash “all over”
body for 3 days. It
started with this patch
here 1 wk ago…
-“Christmas tree” pattern
- Herald patch 1-2wks
before rash appears
Lesions on “Langer’s lines”
28 yo F says “I’ve always had
itchy arms, but it’s been awful this
winter”. History of asthma,
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”
Nickel (belt buckle, button)
Treatment for all types:
Emollients (Eucerin, Aquaphor, …
glycerin content is key)
Immune modulators: tacrolimus/
Protopic, pimecrolimus/Elidel, …?
safe in kids (not under 2)
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
Papular rashes: Treatment
What else should you
be concerned about?
- topical antifungal
- continue for 1-2 wks
after lesions resolve.
Can he go to school?
Anyone else at risk?
What makes these rashes so
A- symmetric, complete
depigmentation. Clear edges.
B- decreased pigmentation,
edges flake when scratched
1) Vitiligo; any age.
- Fewer melanocytes
2) Pityriasis versicolor; young
- etiology: P. ovale (yeast)
- associated with
thyroid dz & diabetes
- commonly affects:
- topical steroid, PUVA
- support group
P. Versicolor: Treatment
- selenium sulfide shampoo
- alt: ketoconazole shampoo
x3d (or oral azole -1
- may take months to
repigment after summer
- prevent recurrence with
repeat Rx qmonth x3m
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.
Oral griseofulvin until 2 wks
beyond clinical resolution
Mother brings in 4 yo w/lg. red
exudative swelling on head.
Tinea capitis w/kerion
What do you have to tell mom?
Scarring alopecia will result.
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
14 yo M w/ red papulopustular rash for 6m.
Getting worse. “is it because I eat fast
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
Etiology: unknown, strong genetic link
6 yo M brought in with “rash that’s
spreading all over his face!”
Is this an STD?
How is picture B different?
Treatment? If desired- virtually the
Topicals: Salicyclic acid, tretinoin,
duct tape, podofilox
Nodules: spot diagnoses
Very soft, mobile, slow-
growing in 50 yo M
Slips under fingers
central dark spot
Keratin plug helpful for
Usually not necessary
May become painful or
Must remove capsule
or lesion will recur
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
Most conditions are common and easily treated
or self-resolve…but for those that are not…
Biopsies may be needed for definitive diagnosis.