Dermatology For The Primary Care Practitioner Michael G. Bryan, M.D. Dermatologist Las Vegas Skin & Cancer Clinics
Disclosures <ul><li>Novartis Speaker’s Bureau </li></ul>
Overview <ul><li>Acne </li></ul><ul><li>Eczema </li></ul><ul><li>Tinea </li></ul><ul><li>Psoriasis </li></ul><ul><li>Skin ...
Acne <ul><li>Disease of youth-adult </li></ul><ul><li>> 85% of individuals affected </li></ul><ul><li>4 main pathophysiolo...
Acne <ul><li>No set recipe for acne treatment--different patients make different kinds of lesions </li></ul><ul><li>Comedo...
Topical Acne Treatments <ul><li>Comedolytics (topical retinoids)—combat clumping of cells and follicular plugging: </li></...
Acne Treatments contin. <ul><li>Oral antibiotics— P. acnes  (resistance),   anti-inflammatory </li></ul><ul><ul><ul><li>Te...
Acne Treatment contin. <ul><li>Oral retinoids (isotretinoin)— decreases sebum, corrects epidermal desquamtion, anti-inflam...
Isotretinoin contin. <ul><li>Many potential side effects—few actually seen </li></ul><ul><li>Very effective and safe if do...
“ Zit” tattoos—the newest craze in the U.K.
Left hip <ul><li>Coumadin Necrosis </li></ul><ul><li>Females > males </li></ul><ul><li>Usually upon start of coumadin, but...
Eczema <ul><li>Umbrella term </li></ul><ul><li>Definition: Red, dry, itchy skin </li></ul><ul><li>Location:  </li></ul><ul...
Eczema
Eczema <ul><li>Family History: allergies, </li></ul><ul><li>asthma, hayfever, eczema </li></ul><ul><li>Clinical findings: ...
Eczema Treatment <ul><li>Emollients:  ointments > creams > lotions </li></ul><ul><li>Topical corticosteroids </li></ul><ul...
Eczema Treatment contin. <ul><li>Systemic corticosteroids </li></ul><ul><ul><ul><li>Intermittent (1-2x/year) IM can help d...
Porphyria cutanea tarda <ul><li>Vesicles, bullae ,  erosions, scars  and  milia (tiny cysts)  in photo-exposed areas </li>...
Tinea
Tinea--clues <ul><li>Central clearing </li></ul><ul><li>Hx of exposure to  pets or infected humans (school, daycare) </li>...
Tinea <ul><li>Quick, easy to diagnose in office </li></ul><ul><li>Do KOH: </li></ul><ul><ul><ul><li>Scrape scale from lead...
Tinea Treatment <ul><li>Topicals: </li></ul><ul><ul><li>-Azoles—fungistatic: </li></ul></ul><ul><ul><ul><li>Ketoconazole <...
Tinea Treatment contin. <ul><li>Systemic for T. capitis or bullous tinea: </li></ul><ul><ul><ul><li>Griseofulvin ultramicr...
<ul><li>Confluent and Reticulated Papillomatosis of Gougerot and Carteaud </li></ul><ul><li>Young, African-American </li><...
Psoriasis
Psoriasis <ul><li>2% of population affected </li></ul><ul><li>Family history in 35-70% of cases </li></ul><ul><li>Common D...
Psoriasis--clues <ul><li>Look elsewhere—nails </li></ul><ul><ul><ul><li>Pits </li></ul></ul></ul><ul><ul><ul><li>Oil spots...
Psoriasis Treatment <ul><li>Topical: </li></ul><ul><ul><ul><li>Calcipotriene (dovonex)—corrects abnormal epidermal prolife...
Psoriasis Treatment contin. <ul><li>** Systemic: </li></ul><ul><ul><ul><li>UV light—NBUVB 3x/week </li></ul></ul></ul><ul>...
<ul><li>Erythema Chronicum Migrans </li></ul><ul><li>(Early localized cutaneous Lyme  Disease) </li></ul><ul><li>Red papul...
Skin Cancer <ul><li>3 common types: </li></ul><ul><ul><ul><li>Basal cell carcinoma—1  million cases/yr in U.S. </li></ul><...
Basal Cell Carcinoma <ul><li>Pearly, translucent papule in sun-exposed area </li></ul><ul><li>Dilated, superficial vessels...
Basal Cell Carcinoma <ul><li>Treatment options include: </li></ul><ul><ul><li>Excision </li></ul></ul><ul><ul><li>Electrod...
Squamous Cell Carcinoma <ul><li>Keratotic, crusted nodule in sun-exposed area </li></ul><ul><li>Most frequent risk factor ...
Mohs Surgery <ul><li>In-office surgery under local anesthesia  </li></ul><ul><li>Thin-margin surgical specimen evaluated b...
Melanoma <ul><li>4% of skin cancer, 77% of skin cancer deaths </li></ul><ul><li>1/37 Americans </li></ul><ul><li>Risk and ...
Melanoma <ul><li>ABCDE Rule </li></ul><ul><li>A symmetry— ½ of lesion is visually different than other ½ </li></ul><ul><li...
Melanoma Treatment <ul><li>Surgery is mainstay of treatment </li></ul><ul><ul><ul><li>5 mm margin for  in-situ  lesions </...
Red/bluish, tender subcutaneous nodules on lower extremities Erythema Nodosum (erythema contusiformis) <ul><li>Young women...
Skin Biopsies For a pigmented lesion, should I do a punch, a shave, excision, etc? <ul><li>Shave biopsy most commonly done...
Skin Biopsies <ul><li>Excision is probably best to sample entire lesion </li></ul><ul><li>Most time-consuming, expensive <...
Summary <ul><li>Acne </li></ul><ul><li>Eczema </li></ul><ul><li>Tinea </li></ul><ul><li>Psoriasis </li></ul><ul><li>Skin C...
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Eczema and Atopic Dermatitis

  1. 1. Dermatology For The Primary Care Practitioner Michael G. Bryan, M.D. Dermatologist Las Vegas Skin & Cancer Clinics
  2. 2. Disclosures <ul><li>Novartis Speaker’s Bureau </li></ul>
  3. 3. Overview <ul><li>Acne </li></ul><ul><li>Eczema </li></ul><ul><li>Tinea </li></ul><ul><li>Psoriasis </li></ul><ul><li>Skin Cancer </li></ul><ul><li>Biopsies </li></ul>
  4. 4. Acne <ul><li>Disease of youth-adult </li></ul><ul><li>> 85% of individuals affected </li></ul><ul><li>4 main pathophysiologic factors: </li></ul><ul><ul><ul><li>1—follicular plugging </li></ul></ul></ul><ul><ul><ul><li>2—excess sebum (oil) </li></ul></ul></ul><ul><ul><ul><li>3—presence/activity of P. acnes </li></ul></ul></ul><ul><ul><ul><li>4 — inflammation </li></ul></ul></ul>
  5. 5. Acne <ul><li>No set recipe for acne treatment--different patients make different kinds of lesions </li></ul><ul><li>Comedones—clogged pores (noninflammatory) </li></ul><ul><ul><ul><li>Open—”blackheads” </li></ul></ul></ul><ul><ul><ul><li>Closed—”whiteheads” </li></ul></ul></ul><ul><ul><ul><li>(not pustules) </li></ul></ul></ul><ul><li>Inflammatory lesions: </li></ul><ul><ul><ul><li>Red papules </li></ul></ul></ul><ul><ul><ul><li>Pustules </li></ul></ul></ul><ul><ul><ul><li>Nodules/cysts </li></ul></ul></ul><ul><li>Treatments should target patient’s type of acne </li></ul>
  6. 6. Topical Acne Treatments <ul><li>Comedolytics (topical retinoids)—combat clumping of cells and follicular plugging: </li></ul><ul><ul><ul><li>Retin-A (tretinoin) </li></ul></ul></ul><ul><ul><ul><li>Differin (adapalene) </li></ul></ul></ul><ul><ul><ul><li>Tazorac (tazarotene) </li></ul></ul></ul><ul><li>Benzoyl peroxide—anti-inflammatory, </li></ul><ul><li>antimicrobial to P. acnes (no resistance) </li></ul><ul><li>Topical antibiotics— P. acnes </li></ul><ul><ul><ul><li>Clindamycin </li></ul></ul></ul><ul><ul><ul><li>Erythromycin </li></ul></ul></ul>
  7. 7. Acne Treatments contin. <ul><li>Oral antibiotics— P. acnes (resistance), anti-inflammatory </li></ul><ul><ul><ul><li>Tetracycline, doxycycline, minocycline </li></ul></ul></ul><ul><ul><ul><li>Trimethoprim/sulfamethoxazole </li></ul></ul></ul><ul><ul><ul><li>Erythromycin </li></ul></ul></ul><ul><li>Hormonal Therapies—reduce circulating androgens </li></ul><ul><ul><ul><li>Ortho-tri-cylcen (labeled) </li></ul></ul></ul><ul><ul><ul><li>Yasmin, Yaz (off-label) </li></ul></ul></ul><ul><ul><ul><li>Spironolactone </li></ul></ul></ul>
  8. 8. Acne Treatment contin. <ul><li>Oral retinoids (isotretinoin)— decreases sebum, corrects epidermal desquamtion, anti-inflammatory, antimicrobial </li></ul><ul><li>Usually 16 to 20-week therapy </li></ul><ul><li>Most insurance plans require at least 90-day trial of more conservative therapy </li></ul><ul><li>New FDA-mandated, internet-based “ Ipledge ” program very restrictive--to reduce accutane-associated pregnancies (220/yr) from careless prescribing, incorrect usage </li></ul>
  9. 9. Isotretinoin contin. <ul><li>Many potential side effects—few actually seen </li></ul><ul><li>Very effective and safe if done carefully: </li></ul><ul><ul><ul><li>Baseline labs (incl. 2 HCGs, if female) </li></ul></ul></ul><ul><ul><ul><li>2 forms birth control (abstinence is one ) </li></ul></ul></ul><ul><ul><ul><li>Labs each month: lft, lipids, hcg </li></ul></ul></ul><ul><ul><ul><li>30 days of pills, no refills </li></ul></ul></ul><ul><ul><ul><li>Office visit each month </li></ul></ul></ul>
  10. 10. “ Zit” tattoos—the newest craze in the U.K.
  11. 11. Left hip <ul><li>Coumadin Necrosis </li></ul><ul><li>Females > males </li></ul><ul><li>Usually upon start of coumadin, but reported during chronic therapy </li></ul><ul><li>Fatty areas: buttocks, breast, thigh, abdomen </li></ul><ul><li>Common underlying protein C or S deficiency </li></ul>
  12. 12. Eczema <ul><li>Umbrella term </li></ul><ul><li>Definition: Red, dry, itchy skin </li></ul><ul><li>Location: </li></ul><ul><ul><ul><li>Lower extremities </li></ul></ul></ul><ul><ul><ul><li>Upper extremities </li></ul></ul></ul><ul><ul><ul><li>Hands/feet </li></ul></ul></ul><ul><ul><ul><li>Trunk </li></ul></ul></ul>
  13. 13. Eczema
  14. 14. Eczema <ul><li>Family History: allergies, </li></ul><ul><li>asthma, hayfever, eczema </li></ul><ul><li>Clinical findings: </li></ul><ul><ul><ul><li>Erythematous patches, plaques </li></ul></ul></ul><ul><ul><ul><li>Lichenification (thickened skin/accentuated skin lines) </li></ul></ul></ul><ul><ul><ul><li>Excoriations (scratches) </li></ul></ul></ul>
  15. 15. Eczema Treatment <ul><li>Emollients: ointments > creams > lotions </li></ul><ul><li>Topical corticosteroids </li></ul><ul><ul><ul><li>Short-term (2-4 weeks) is OK depending on site </li></ul></ul></ul><ul><ul><ul><li>Class I-IV intermittent use OK for flares </li></ul></ul></ul><ul><ul><ul><li>Not on face—nothing >class V on face </li></ul></ul></ul><ul><ul><ul><li>Cannot be used continuously long-term </li></ul></ul></ul><ul><ul><ul><li>Risks: steroid-induced atrophy, acne, hypopigmentation, striae </li></ul></ul></ul><ul><li>Topical Immunomodulators (TIMs): safe for short-term or intermittent long-term </li></ul><ul><ul><ul><li>Pimecrolimus (elidel) </li></ul></ul></ul><ul><ul><ul><li>Tacrolimus (protopic) </li></ul></ul></ul>
  16. 16. Eczema Treatment contin. <ul><li>Systemic corticosteroids </li></ul><ul><ul><ul><li>Intermittent (1-2x/year) IM can help during flare </li></ul></ul></ul><ul><ul><ul><li>More commonly used is oral </li></ul></ul></ul><ul><ul><ul><li>Typical ER “dose-pak” course (4-6 days) is insufficient, often requires 2-3 weeks </li></ul></ul></ul><ul><ul><ul><li>Taper 60mg/40mg/20mg over 15-21 days </li></ul></ul></ul><ul><ul><ul><li>Usually dosed qd in am @ 8:00 </li></ul></ul></ul><ul><ul><ul><li>Side effects/complications inherent to systemic steroids—for both IM, po </li></ul></ul></ul><ul><li>Oral Antihistamines </li></ul><ul><ul><ul><li>Sedating--HS: Benadryl, Atarax, Doxepin </li></ul></ul></ul><ul><ul><ul><li>Non-sedating--AM: Allegra, Zyrtec, Claritin </li></ul></ul></ul><ul><li>Oral Leukotriene receptor antagonists </li></ul><ul><ul><ul><li>Monteleukast (Singulair) </li></ul></ul></ul>
  17. 17. Porphyria cutanea tarda <ul><li>Vesicles, bullae , erosions, scars and milia (tiny cysts) in photo-exposed areas </li></ul><ul><li>Enzyme defect in heme production: </li></ul><ul><ul><li>80% sporadic </li></ul></ul><ul><ul><li>20% AD </li></ul></ul><ul><li>Most common porphyria </li></ul><ul><li>Precipitated by: </li></ul><ul><ul><li>ETOH-assoc. liver disease </li></ul></ul><ul><ul><li>Hep C </li></ul></ul><ul><ul><li>Meds: </li></ul></ul><ul><ul><ul><li>OCPs </li></ul></ul></ul><ul><li>Treatment: </li></ul><ul><ul><li>avoidance of precipitants </li></ul></ul><ul><ul><li>phlebotomy </li></ul></ul>
  18. 18. Tinea
  19. 19. Tinea--clues <ul><li>Central clearing </li></ul><ul><li>Hx of exposure to pets or infected humans (school, daycare) </li></ul><ul><li>1/10 vs 9/10 rule : * if presented with a red, scaly rash, tinea will likely occur < 1/10 times and eczema will be greater than 9/10 times. </li></ul><ul><li>Try steroid first, hold off on antifungal </li></ul>
  20. 20. Tinea <ul><li>Quick, easy to diagnose in office </li></ul><ul><li>Do KOH: </li></ul><ul><ul><ul><li>Scrape scale from leading edge onto glass slide </li></ul></ul></ul><ul><ul><ul><li>Add 2-3 drops KOH ($12.50/ 1 oz bottle), add cover slip </li></ul></ul></ul><ul><ul><ul><li>Look under 10x </li></ul></ul></ul>KOH—branching hyphae
  21. 21. Tinea Treatment <ul><li>Topicals: </li></ul><ul><ul><li>-Azoles—fungistatic: </li></ul></ul><ul><ul><ul><li>Ketoconazole </li></ul></ul></ul><ul><ul><ul><li>Clotrimazole </li></ul></ul></ul><ul><ul><ul><li>Miconazole </li></ul></ul></ul><ul><ul><ul><li>Oxiconazole </li></ul></ul></ul><ul><ul><ul><li>Sertraconazole </li></ul></ul></ul><ul><ul><li>Naftifine (naftin) </li></ul></ul><ul><ul><li>Terbinafine (lamisil) fungicidal </li></ul></ul><ul><ul><li>Ciclopirox (loprox) </li></ul></ul>
  22. 22. Tinea Treatment contin. <ul><li>Systemic for T. capitis or bullous tinea: </li></ul><ul><ul><ul><li>Griseofulvin ultramicronized15-20 mg/kg/day </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Safe, effective, cheap </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Needs fat for absorption </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Usually treat for 2-4 months </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Terbinafine (lamisil) </li></ul></ul></ul><ul><ul><ul><ul><ul><li>> 40 kg—250 mg/day </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>20-40 kg—125 mg/day (1/2 tab) </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>< 20 kg—62.5 mg/day (1/4 tab) </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Treat 2-4 weeks </li></ul></ul></ul></ul></ul>
  23. 23. <ul><li>Confluent and Reticulated Papillomatosis of Gougerot and Carteaud </li></ul><ul><li>Young, African-American </li></ul><ul><li>Midline back or chest </li></ul><ul><li>Wavy, net-like pattern </li></ul><ul><li>Clears with one month of minocycline 100 mg bid </li></ul>
  24. 24. Psoriasis
  25. 25. Psoriasis <ul><li>2% of population affected </li></ul><ul><li>Family history in 35-70% of cases </li></ul><ul><li>Common Distribution </li></ul><ul><ul><ul><li>Elbows, knees </li></ul></ul></ul><ul><ul><ul><li>Scalp </li></ul></ul></ul><ul><ul><ul><li>Hands, feet </li></ul></ul></ul><ul><ul><ul><li>Extremities, trunk </li></ul></ul></ul>
  26. 26. Psoriasis--clues <ul><li>Look elsewhere—nails </li></ul><ul><ul><ul><li>Pits </li></ul></ul></ul><ul><ul><ul><li>Oil spots </li></ul></ul></ul><ul><ul><ul><li>Onycholysis </li></ul></ul></ul><ul><li>Look at scale— </li></ul><ul><li> silvery, “micaceous” </li></ul>
  27. 27. Psoriasis Treatment <ul><li>Topical: </li></ul><ul><ul><ul><li>Calcipotriene (dovonex)—corrects abnormal epidermal proliferation, not topical steroid </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Avoid face, intertriginous areas (irritation) </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Topical steroids—Class1-2 bid for 2-4 weeks; not good option long-term—tolerance, atrophy </li></ul></ul></ul><ul><ul><ul><li>** “Pulse” therapy: dovonex bid Mon-Fri, clobetasol (class I) bid Sat/Sun ** </li></ul></ul></ul><ul><ul><ul><li>Taclonex—new topical combination of dovonex + betamethasone—dosed qd </li></ul></ul></ul>
  28. 28. Psoriasis Treatment contin. <ul><li>** Systemic: </li></ul><ul><ul><ul><li>UV light—NBUVB 3x/week </li></ul></ul></ul><ul><ul><ul><li>Acitretin (soriatane)—retinoid, decrease abnormal epidermal proliferation </li></ul></ul></ul><ul><ul><ul><li>“ Biologics” (enbrel, remicade, raptiva, humira)—block cytokines (pro-inflammatory signals) </li></ul></ul></ul><ul><ul><ul><li>Methotrexate—inhibits DNA synth. in rapidly prolif. Cells </li></ul></ul></ul><ul><ul><ul><li>Others… </li></ul></ul></ul><ul><li>** Psoriasis requiring systemic therapy should be referred to Derm </li></ul>
  29. 29. <ul><li>Erythema Chronicum Migrans </li></ul><ul><li>(Early localized cutaneous Lyme Disease) </li></ul><ul><li>Red papule @ site of tick bite </li></ul><ul><li>Expands outward over days-weeks— avg. = 16 cm. </li></ul><ul><li>Geographical distrib of ixodes tick: 95% of cases from NE U.S. </li></ul><ul><li>3 wks of oral antibiotic clears most cases: </li></ul><ul><li>Adults: Doxy 100 mg bid </li></ul><ul><li>Peds: Amoxil 250-500 mg tid (20-50 mg/kg/day) </li></ul>
  30. 30. Skin Cancer <ul><li>3 common types: </li></ul><ul><ul><ul><li>Basal cell carcinoma—1 million cases/yr in U.S. </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Most common skin cancer </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Negligible risk of metastasis </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Squamous cell carcinoma- - >100 cases/100,000 per year in U.S. </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Risk of metastasis 2-6%; higher for lip, ear lesions </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Melanoma —least common, most deadly cancer </li></ul></ul></ul><ul><ul><ul><ul><ul><li>Prognosis depends on depth of tumor at time of biopsy </li></ul></ul></ul></ul></ul>
  31. 31. Basal Cell Carcinoma <ul><li>Pearly, translucent papule in sun-exposed area </li></ul><ul><li>Dilated, superficial vessels--(telangiectasia) </li></ul><ul><li>Bleeds easily </li></ul><ul><li>“ Sore that won’t heal” </li></ul><ul><li>Due to cumulative sun damage </li></ul>
  32. 32. Basal Cell Carcinoma <ul><li>Treatment options include: </li></ul><ul><ul><li>Excision </li></ul></ul><ul><ul><li>Electrodessication and curettage </li></ul></ul><ul><ul><li>Imiquimod (aldara) cream </li></ul></ul><ul><ul><li>Mohs micrographic surgery </li></ul></ul><ul><li>*Most appropriate therapy depends on size, location, histologic subtype of tumor </li></ul>
  33. 33. Squamous Cell Carcinoma <ul><li>Keratotic, crusted nodule in sun-exposed area </li></ul><ul><li>Most frequent risk factor is chronic UV damage </li></ul><ul><li>Most common skin cancer in immunosuppressed patients </li></ul><ul><li>Uncommon cases of HPV-related SCC in genital areas and periungual </li></ul><ul><li>Treatment similar to BCC </li></ul>
  34. 34. Mohs Surgery <ul><li>In-office surgery under local anesthesia </li></ul><ul><li>Thin-margin surgical specimen evaluated by frozen section </li></ul><ul><li>Highest cure rates of cutaneous cancer surgery </li></ul><ul><li>Tissue sparing due to micrographic, mapping nature of procedure </li></ul>
  35. 35. Melanoma <ul><li>4% of skin cancer, 77% of skin cancer deaths </li></ul><ul><li>1/37 Americans </li></ul><ul><li>Risk and behavior not fully understood </li></ul><ul><li>½ risk appears to be genetic </li></ul><ul><li>½ risk appears to be sun-related </li></ul><ul><li>Growth is initially usually superficial (radial), invades at some point—reasons, signals unknown </li></ul>
  36. 36. Melanoma <ul><li>ABCDE Rule </li></ul><ul><li>A symmetry— ½ of lesion is visually different than other ½ </li></ul><ul><li>B order is irregular, jagged, scalloped </li></ul><ul><li>C olor is varied—black, tan, brown, pink, white </li></ul><ul><li>D iameter-- > than 6mm (pencil eraser size) </li></ul><ul><li>E volving—lesion is changing (possibly most important criteria) </li></ul>
  37. 37. Melanoma Treatment <ul><li>Surgery is mainstay of treatment </li></ul><ul><ul><ul><li>5 mm margin for in-situ lesions </li></ul></ul></ul><ul><ul><ul><li>1.0 cm margins for tumors up to 1.0 mm in depth </li></ul></ul></ul><ul><ul><ul><li>2.0 cm margin for 1-4 mm tumors </li></ul></ul></ul><ul><ul><ul><li>Sentinel lymph node biopsy offered for tumors </li></ul></ul></ul><ul><ul><ul><li>1.0 mm and greater (no survival benefit yet) </li></ul></ul></ul><ul><li>Adjuvant medical treatment </li></ul><ul><ul><ul><li>High-dose Interferon only FDA-approved therapy </li></ul></ul></ul><ul><ul><ul><li>Some prolongation of relapse-free survival, unclear if overall survival is improved </li></ul></ul></ul><ul><ul><ul><li>No other treatment—chemotherapy, radiation, vaccines—proven yet to improve survival </li></ul></ul></ul>
  38. 38. Red/bluish, tender subcutaneous nodules on lower extremities Erythema Nodosum (erythema contusiformis) <ul><li>Young women 18-34 yrs. </li></ul><ul><li>Lower extremities </li></ul><ul><li>Hypersensitivity reaction to: </li></ul><ul><ul><li>Infections— </li></ul></ul><ul><ul><ul><li>Bacterial *(strep) </li></ul></ul></ul><ul><ul><ul><li>Fungal (systemic) </li></ul></ul></ul><ul><ul><li>Drugs— </li></ul></ul><ul><ul><ul><li>OCPs </li></ul></ul></ul><ul><ul><ul><li>Sulfa </li></ul></ul></ul><ul><ul><li>Inflam. Bowel Disease </li></ul></ul><ul><ul><ul><li>UC </li></ul></ul></ul><ul><ul><ul><li>Crohns </li></ul></ul></ul><ul><ul><li>Pregnancy </li></ul></ul><ul><ul><li>Sarcoidosis </li></ul></ul><ul><li>Key is to find and treat underlying cause </li></ul><ul><li>NSAIDS for pain/inflammation </li></ul>
  39. 39. Skin Biopsies For a pigmented lesion, should I do a punch, a shave, excision, etc? <ul><li>Shave biopsy most commonly done for elevated lesions. </li></ul><ul><li>Punch biopsy done for flat, depressed or inflammatory lesions. </li></ul>
  40. 40. Skin Biopsies <ul><li>Excision is probably best to sample entire lesion </li></ul><ul><li>Most time-consuming, expensive </li></ul><ul><li>Punch biopsy, unless entire lesion is removed, will produce sampling error </li></ul><ul><li>Shave is quick, inexpensive </li></ul><ul><li>Must be deep enough to remove all pigment—easily done </li></ul>
  41. 41. Summary <ul><li>Acne </li></ul><ul><li>Eczema </li></ul><ul><li>Tinea </li></ul><ul><li>Psoriasis </li></ul><ul><li>Skin Cancer </li></ul><ul><li>Biopsies </li></ul>
  42. 42. Questions?
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