Wow that looks PrettyWow that looks Pretty
Bad!!Bad!!
Jai Gilliam, M.D.Jai Gilliam, M.D.
Internal medicine/PediatricsInter...
45 yo Caucasian male is coming to45 yo Caucasian male is coming to
see you in clinic for a new rashsee you in clinic for a...
Seborrhea (Seborrheic dermatitis)Seborrhea (Seborrheic dermatitis)
 Patient will present with generalized, fine, scalingP...
 Mrs. Jackson is being seen in clinic for a “personalMrs. Jackson is being seen in clinic for a “personal
matter”. She st...
IntertrigoIntertrigo
 Contact irritant dermatitis where candida is aContact irritant dermatitis where candida is a
common...
Mr. Powers is a 43 yo male who is coming to yourMr. Powers is a 43 yo male who is coming to your
clinic because he is conc...
Necrobiosis lipoidicaNecrobiosis lipoidica
Rash is commonly seen in diabeticsRash is commonly seen in diabetics
15% Preced...
Your next patient is a 28 yo male from the middleYour next patient is a 28 yo male from the middle
east who speaks very li...
Pyoderma GangrenosumPyoderma Gangrenosum
 2 types:2 types: Classic PG-Classic PG- involving primarily the legs.involving ...
Mrs.Lenning is a 36 yo female who is bringing herMrs.Lenning is a 36 yo female who is bringing her
4month old infant in fo...
Paget’s disease of the breastPaget’s disease of the breast
1.Eczematous rash is pathoneumonic for the1.Eczematous rash is ...
You have been consulted to see a 67 yo female S/PYou have been consulted to see a 67 yo female S/P
right knee replacement ...
 What questions do you want to know about herWhat questions do you want to know about her
post-op course.post-op course.
...
Coumadin NecrosisCoumadin Necrosis
Typically presentsTypically presents 7-14 days7-14 days after administration ofafter ad...
 Mr.Lewis is a 34 yo male with Hx of HTN is comingMr.Lewis is a 34 yo male with Hx of HTN is coming
to your clinic for th...
Lupus PernioLupus Pernio
No relation to SLENo relation to SLE, term Lupus= Chronic autoantibody, term Lupus= Chronic autoa...

 Anything in the History that you should ask aboutAnything in the History that you should ask about
for this patient?for ...
 Bullous PemphigoidBullous Pemphigoid
 Pemphigus VulgarisPemphigus Vulgaris
 StarwarsStarwars
 Episode IIIEpisode III
 Secrets RevealedSecrets Revealed
Thank YouThank You
SourcesSources
 11 MedstudyMedstudy: Internal medicine core curriculum: Internal medicine core curriculum
section on Derm...
Wow that looks Pretty Bad!
Wow that looks Pretty Bad!
Wow that looks Pretty Bad!
Wow that looks Pretty Bad!
Wow that looks Pretty Bad!
Wow that looks Pretty Bad!
Wow that looks Pretty Bad!
Wow that looks Pretty Bad!
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Wow that looks Pretty Bad!

  1. 1. Wow that looks PrettyWow that looks Pretty Bad!!Bad!! Jai Gilliam, M.D.Jai Gilliam, M.D. Internal medicine/PediatricsInternal medicine/Pediatrics Noon ConferenceNoon Conference
  2. 2. 45 yo Caucasian male is coming to45 yo Caucasian male is coming to see you in clinic for a new rashsee you in clinic for a new rash that has developed over the past 1that has developed over the past 1 month. He says that the rashmonth. He says that the rash itches “a lot” and that he has trieditches “a lot” and that he has tried multiple over the counter creamsmultiple over the counter creams but this has provided no relief. Hebut this has provided no relief. He describes the rash as being verydescribes the rash as being very dry and that it “peels” a lot. It isdry and that it “peels” a lot. It is localized around his nose,localized around his nose, forehead, and involves the lateralforehead, and involves the lateral aspects of his hair lineaspects of his hair line
  3. 3. Seborrhea (Seborrheic dermatitis)Seborrhea (Seborrheic dermatitis)  Patient will present with generalized, fine, scalingPatient will present with generalized, fine, scaling (flaky) rash of the scalp, ear, nose, and occasionally(flaky) rash of the scalp, ear, nose, and occasionally lips.lips.  Rash is puritic in natureRash is puritic in nature  Treatment: Selenium sulfide shampoo, zinc pyrithione,Treatment: Selenium sulfide shampoo, zinc pyrithione, and Tarand Tar  What other crucial questions would you ask thisWhat other crucial questions would you ask this patient?patient?  Have you ever been tested for HIV ?Have you ever been tested for HIV ?
  4. 4.  Mrs. Jackson is being seen in clinic for a “personalMrs. Jackson is being seen in clinic for a “personal matter”. She states that she is reallymatter”. She states that she is really embarrassed about her weight and wants to tryembarrassed about her weight and wants to try to loss some weight. She also would like to talkto loss some weight. She also would like to talk about a rash that she has had for a long time.about a rash that she has had for a long time. She says that it occurs along her skin folds andShe says that it occurs along her skin folds and that it “itches like crazy”. Patient tried somethat it “itches like crazy”. Patient tried some Hydrocortisone cream on the rash but the rashHydrocortisone cream on the rash but the rash got worse.got worse.  On her physical exam you see this.On her physical exam you see this.
  5. 5. IntertrigoIntertrigo  Contact irritant dermatitis where candida is aContact irritant dermatitis where candida is a common fungus that causes this rash.common fungus that causes this rash.  Occurs along the folds where there is a lot ofOccurs along the folds where there is a lot of moisture making it an ideal location for fungus tomoisture making it an ideal location for fungus to grow.grow.  Commonly seen in obese patients.Commonly seen in obese patients. Treatment: Make sure that the area is driedTreatment: Make sure that the area is dried especially after showering/bathing.especially after showering/bathing. Topical antifunguls and antifungal powder toTopical antifunguls and antifungal powder to prevent moisture.prevent moisture.
  6. 6. Mr. Powers is a 43 yo male who is coming to yourMr. Powers is a 43 yo male who is coming to your clinic because he is concerned about theseclinic because he is concerned about these “Weird” circular rashes on his arm and legs. He“Weird” circular rashes on his arm and legs. He describes the lesion as “shiny” and almost like adescribes the lesion as “shiny” and almost like a “irregular circular” pattern. He says that he has“irregular circular” pattern. He says that he has had it for the past 6 months but he came inhad it for the past 6 months but he came in because it just keeps getting worse. He deniesbecause it just keeps getting worse. He denies any itching and no trauma. You review hisany itching and no trauma. You review his medication and he is taking Lipitor, allegra-D,medication and he is taking Lipitor, allegra-D, accupril, Glucophage, and glipizide.accupril, Glucophage, and glipizide. When you do your physical exam you see thisWhen you do your physical exam you see this
  7. 7. Necrobiosis lipoidicaNecrobiosis lipoidica Rash is commonly seen in diabeticsRash is commonly seen in diabetics 15% Precedes the onset of diabetes15% Precedes the onset of diabetes 25 % occur at the onset of diabetes25 % occur at the onset of diabetes 60% will occur in patients already diagnosed60% will occur in patients already diagnosed Etiology- 3 theoriesEtiology- 3 theories 1.1. Diabetic microangiopathyDiabetic microangiopathy secondary to glycoprotiensecondary to glycoprotien deposition.deposition. 2.2.VasculitisVasculitis- secondary to immunoglobulin deposition along- secondary to immunoglobulin deposition along with complement/fibrinogen depositswith complement/fibrinogen deposits 3.3. Abnormal Collagen-Abnormal Collagen- defective collagen has been seen indefective collagen has been seen in other diabetic end organ damageother diabetic end organ damage TreatmenTreatment: Topical & intralesional steroids. ( atrophy of skin),t: Topical & intralesional steroids. ( atrophy of skin), Aspirin & Dipyridamole (Anti-platelet therapy, platelet inducedAspirin & Dipyridamole (Anti-platelet therapy, platelet induced vasocclusion disease.vasocclusion disease.
  8. 8. Your next patient is a 28 yo male from the middleYour next patient is a 28 yo male from the middle east who speaks very little English. He’s at thiseast who speaks very little English. He’s at this office visit with his wife who is able to translate.office visit with his wife who is able to translate. She says that they are being referred to you fromShe says that they are being referred to you from another physician. Her concern is that heranother physician. Her concern is that her husband has developed a medium size ulcer onhusband has developed a medium size ulcer on his ankle. It has been there for about 4 months,his ankle. It has been there for about 4 months, but it has gotten worse. The wound is nowbut it has gotten worse. The wound is now draining purulent discharge.draining purulent discharge. The only other medical issue is that he hasThe only other medical issue is that he has been having problems with his “bowels” for whichbeen having problems with his “bowels” for which his wife says that he is taking a specialhis wife says that he is taking a special medication for his bowel problem.medication for his bowel problem.
  9. 9. Pyoderma GangrenosumPyoderma Gangrenosum  2 types:2 types: Classic PG-Classic PG- involving primarily the legs.involving primarily the legs. Atypical PG-Atypical PG- involves superficial skin, effecting theinvolves superficial skin, effecting the handshands  Diagnosis is based on exclusion by history/biopsy- DDxDiagnosis is based on exclusion by history/biopsy- DDx is infection, connective tissue dz, vasculitis, traumais infection, connective tissue dz, vasculitis, trauma  Cause: speculated to be related immune dysregulationCause: speculated to be related immune dysregulation  Prognosis is goodPrognosis is good, associated with other systemic dz:, associated with other systemic dz: IBDIBD, rheumatoid arthritis, chronic hepatitis, Wagener's, rheumatoid arthritis, chronic hepatitis, Wagener's  Treatment:Treatment: MildMild- topical steroid.- topical steroid. Moderate-SevereModerate-Severe:: Oral steroid, cyclosporin, methotrexate, and tacrolimusOral steroid, cyclosporin, methotrexate, and tacrolimus
  10. 10. Mrs.Lenning is a 36 yo female who is bringing herMrs.Lenning is a 36 yo female who is bringing her 4month old infant in for well child check. The only4month old infant in for well child check. The only concern on this visit is about breast feeding. Sheconcern on this visit is about breast feeding. She claims that she has been having some difficultyclaims that she has been having some difficulty with breast feeding. She has noticed that there iswith breast feeding. She has noticed that there is a dry rash around her areola on her right breast.a dry rash around her areola on her right breast. She has tried some Hydrocortisone cream on itShe has tried some Hydrocortisone cream on it because she thought it was eczema but the rashbecause she thought it was eczema but the rash did not improvedid not improve When you do her physical exam you see thisWhen you do her physical exam you see this
  11. 11. Paget’s disease of the breastPaget’s disease of the breast 1.Eczematous rash is pathoneumonic for the1.Eczematous rash is pathoneumonic for the presence of intraepithelial breast adenocarcinomapresence of intraepithelial breast adenocarcinoma 2.2.DiagnosisDiagnosis-confirmed by punch biopsy,showing-confirmed by punch biopsy,showing Paget cells-(adenocarcinoma cells).Paget cells-(adenocarcinoma cells). 3.3. Prognosis:Prognosis: depends on the stage of disease (+)depends on the stage of disease (+) lymph nodes vs localized disease.lymph nodes vs localized disease. 4.4.TreatmentTreatment option:masectomy (rarely), breastoption:masectomy (rarely), breast conserving surgery(nipple-areoloa resection),conserving surgery(nipple-areoloa resection), Conserving surgery + whole breast irradiationConserving surgery + whole breast irradiation provided the lowest % with recurrenceprovided the lowest % with recurrence
  12. 12. You have been consulted to see a 67 yo female S/PYou have been consulted to see a 67 yo female S/P right knee replacement for a possible woundright knee replacement for a possible wound infection of the right knee.She is complaining ofinfection of the right knee.She is complaining of right knee swelling, tenderness, and skinright knee swelling, tenderness, and skin hyperpigmentation. Her surgery was approx 1 weekhyperpigmentation. Her surgery was approx 1 week ago and she is being seen today in Post-op clinic.ago and she is being seen today in Post-op clinic. Her entire post-op course was unremarkable and sheHer entire post-op course was unremarkable and she has never had this before. Patient denies anyhas never had this before. Patient denies any trauma to this leg, no fever, no chills, no othertrauma to this leg, no fever, no chills, no other systemic symptomssystemic symptoms When you do your physical exam you see theWhen you do your physical exam you see the following?following?
  13. 13.  What questions do you want to know about herWhat questions do you want to know about her post-op course.post-op course.  Where you taking any Coumadin during herWhere you taking any Coumadin during her recent hospitalization?recent hospitalization?
  14. 14. Coumadin NecrosisCoumadin Necrosis Typically presentsTypically presents 7-14 days7-14 days after administration ofafter administration of coumadin.coumadin. Caused by Protein C deficiency: Bx will show fibrin thrombi within cutaneousCaused by Protein C deficiency: Bx will show fibrin thrombi within cutaneous vessels leading to interstitial hemorrhage.vessels leading to interstitial hemorrhage. Clinically: Rash will develop over the trunk, arms, breast, and penisClinically: Rash will develop over the trunk, arms, breast, and penis (common symptom).(common symptom). Treatment: Stop Coumadin, Protein C need to be replaced.(concentrated orTreatment: Stop Coumadin, Protein C need to be replaced.(concentrated or FFP), surgical debridement if rapidly progressing necrosis.FFP), surgical debridement if rapidly progressing necrosis. Once a patient has experienced this drug induced necrosis, Is it safe to tryOnce a patient has experienced this drug induced necrosis, Is it safe to try the patient back on Warfarin?the patient back on Warfarin? Yes,Yes, Patient can be placed back on Warfarin but these patient need to bePatient can be placed back on Warfarin but these patient need to be closely monitor. If a patient has previously had a skin reaction toclosely monitor. If a patient has previously had a skin reaction to coumadin there is no contraindication for subsequent dosescoumadin there is no contraindication for subsequent doses
  15. 15.  Mr.Lewis is a 34 yo male with Hx of HTN is comingMr.Lewis is a 34 yo male with Hx of HTN is coming to your clinic for the first time.He is concerned of ato your clinic for the first time.He is concerned of a small “bump” on his face. He says that it has beensmall “bump” on his face. He says that it has been there for the past 1 year, but the bump hasthere for the past 1 year, but the bump has progressivley gotten worse. He denies any bleedingprogressivley gotten worse. He denies any bleeding from the lesion or trauma.from the lesion or trauma. Overall, he says he has been healthy but saysOverall, he says he has been healthy but says that for the past 2 month he has really felt very tiredthat for the past 2 month he has really felt very tired and that his “smokers” cough has gotten worseand that his “smokers” cough has gotten worse over the same duration. He denies any fever, chills,over the same duration. He denies any fever, chills, or wt loss.or wt loss. When you do your physical exam you notice this on hisWhen you do your physical exam you notice this on his face?face?
  16. 16. Lupus PernioLupus Pernio No relation to SLENo relation to SLE, term Lupus= Chronic autoantibody, term Lupus= Chronic autoantibody inflammatory disease and Pernio associated withinflammatory disease and Pernio associated with SARCOIDOSIS.SARCOIDOSIS. 25% of patients with Sarcoidosis will develop some form25% of patients with Sarcoidosis will develop some form of skin rash.of skin rash. Biopsy of skin lesion in Sarcoid reveal the classic findingBiopsy of skin lesion in Sarcoid reveal the classic finding ofof non-necrotizing granulomasnon-necrotizing granulomas Mimics other disease, systemic involvement: eyes, heart,Mimics other disease, systemic involvement: eyes, heart, skin, muscle, CNS, kidney, spleenskin, muscle, CNS, kidney, spleen TreatmentTreatment: Prednisone and other immunosupresive: Prednisone and other immunosupresive
  17. 17.
  18. 18.  Anything in the History that you should ask aboutAnything in the History that you should ask about for this patient?for this patient?  Have You Ever been tested for HIV?Have You Ever been tested for HIV?
  19. 19.  Bullous PemphigoidBullous Pemphigoid
  20. 20.  Pemphigus VulgarisPemphigus Vulgaris
  21. 21.  StarwarsStarwars  Episode IIIEpisode III  Secrets RevealedSecrets Revealed
  22. 22. Thank YouThank You
  23. 23. SourcesSources  11 MedstudyMedstudy: Internal medicine core curriculum: Internal medicine core curriculum section on Dermatology, 11section on Dermatology, 11thth edition 2005/2006edition 2005/2006  2.Uptodate2.Uptodate  3.Lawrence, Cox Physical signs in Dermatology 23.Lawrence, Cox Physical signs in Dermatology 2ndnd edition chapter on hair/scalp disease. Pg 334-edition chapter on hair/scalp disease. Pg 334- 350. copyright 2002350. copyright 2002
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