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12 Dermatology2008


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12 Dermatology2008

  1. 1. Dermatology
  2. 2. Acne Vulgaris <ul><li>Chronic disease of sebaceous follicle, primarily affecting face, chest, and back </li></ul><ul><li>Occurs at puberty with sebum production triggered by increased androgen levels </li></ul><ul><li>Inflammation is due in part to over-proliferation of Propionibacterium acnes , an anaerobic Gram-positive organism </li></ul>
  3. 3. <ul><li>Topical Retinoids: tretinoin (Retin A), adapalene (Differin), Tazarotene (Tazorac) </li></ul><ul><ul><li>Foundation of treatment </li></ul></ul><ul><ul><li>Only agents that affect follicular epitheliuim </li></ul></ul><ul><li>Benzoyl Peroxide </li></ul><ul><ul><li>Antibacterial and comedolytic effects </li></ul></ul><ul><li>Topical Antibacterials </li></ul><ul><ul><li>Eliminate P. acnes from the sebaceous gland and thereby suppress inflammation in patients with papular and inflammatory acne </li></ul></ul><ul><ul><li>Azelaic Acid (Azelex), clindamycin, erythromycin, metronidazole </li></ul></ul>Acne Treatment
  4. 4. Acne Treatment (Cont’d) <ul><li>Oral Antibiotics </li></ul><ul><ul><li>Inhibit P. acnes </li></ul></ul><ul><ul><li>Tetracyclines have a direct anti-inflammatory effect </li></ul></ul><ul><ul><li>Tetracyclines, Doxycycline, Minocycline, Erythromycin, Trimethoprim-Sulfa, Clindamycin </li></ul></ul><ul><ul><li>Antibiotic resistance increasing problem </li></ul></ul><ul><ul><ul><li>Treatment courses should be short 4-6 months </li></ul></ul></ul><ul><ul><ul><li>Concomitant Benzoyl Peroxide may decrease resistance </li></ul></ul></ul><ul><li>Oral Istotretinoin (Accutane) </li></ul><ul><ul><li>Useful for severe acne – nodulocystic scarring </li></ul></ul><ul><ul><li>Hormonal – OCP in women </li></ul></ul>
  5. 5. Acne Treatment (Cont’d) <ul><li>It takes 8 weeks for a microcomedo to mature. Thus any therapy effectiveness should be assessed after 8 weeks of therapy. </li></ul><ul><li>Water-based cosmetics are less comedogenic than oil based. </li></ul><ul><li>Soaps, detergents, and astringenets have little impact on acne and vigorous “cleansing” can worsen inflammation. </li></ul>
  6. 6. Acne Treatment (Cont’d) <ul><li>Recommendations </li></ul><ul><ul><li>Mainly comedones with occasional inflamed papule or pustule (Type 1) </li></ul></ul><ul><ul><ul><li>Topical Retinoid </li></ul></ul></ul><ul><ul><ul><li>Consider benzoyl peroxide, azelaic acid </li></ul></ul></ul><ul><ul><li>Comedones, papules and pustules (Type 2) </li></ul></ul><ul><ul><ul><li>Topical Retinoids plus benzoyl peroxide, azelaic, or topical antibiotic </li></ul></ul></ul><ul><ul><li>Worsening Type 2 – spread to shoulders, back, chest, occasional cysts/nodules </li></ul></ul><ul><ul><ul><li>Systemic antibiotic plus topical Retinoid, benzoyl peroxide, or azelaic acid </li></ul></ul></ul><ul><ul><ul><li>Add OCP or antiandrogen for women </li></ul></ul></ul>
  7. 7. Acne Treatment (Cont’d) <ul><li>Recommendations (cont’d) </li></ul><ul><ul><li>Numerous cyst, scarring </li></ul></ul><ul><ul><ul><li>Systemic antibiotics plus topical Retinoid plus benzoyl peroxide </li></ul></ul></ul><ul><ul><ul><li>Oral isotretinoin (Accutane) </li></ul></ul></ul>
  8. 8. Atopic Dermatitis <ul><li>Therapy usually involves emollients and good skin hydration, antipruritics, and controlling exacerbating factors including temperature, humidity and airborne allergens and dust. </li></ul><ul><li>Can use topical steroids to clear skin (low potency) </li></ul><ul><li>Pimecrolimus (Elidel) may be tried in unresponsive cases </li></ul>
  9. 9. Atopic Dermatitis (Cont’d) <ul><li>Eczematous eruption genetically determined </li></ul><ul><li>Characterized by lichenification, excoriation and crusting </li></ul><ul><li>Classically involves face, neck and flexual surfaces of arms and legs </li></ul><ul><li>Picture can vary with age of patient, usually seen in early childhood </li></ul>
  10. 10. Eczema <ul><li>Characterized by scaly, occasionally fissured patches of dermatitis overlying dry skin </li></ul><ul><li>Also called Xerosis </li></ul><ul><li>Treated with lubricants and hydration, such as Eucerin, Alpha-Keri, etc. </li></ul><ul><li>If severe may use low- potency topical steroids (level V or less) </li></ul>
  11. 11. Psoriasis
  12. 12. Psoriasis (Cont’d) <ul><li>Red, scaling papules which coalesce to round-to-oval plaques </li></ul><ul><li>Adherent silvery white thick scale which when removed bleeds (Auspitz’s sign) </li></ul><ul><li>Can develop at sites of physical trauma (Koebner’s phenomenon) </li></ul><ul><li>Usually extensor surfaces </li></ul><ul><li>Differential diagnosis may include secondary syphilis, eczema or seborrhea </li></ul><ul><li>Associated arthritis can develop </li></ul><ul><li>Treatment: Steroids, Tar, UV light (PUVA), Calcipotriene - Vit D 3 Derivative (Dovonex), Methotrexate in and other immunomodulatory drugs and other immunomodulating drugs in severe cases </li></ul>
  13. 13. Seborrheic Dermatitis
  14. 14. Seborrheic Dermatitis (Cont’d) <ul><li>Etiology </li></ul><ul><ul><li>Unknown </li></ul></ul><ul><ul><li>Relationships </li></ul></ul><ul><ul><ul><li>Hormone levels – infancy (cradle cap) and reappears at puberty </li></ul></ul></ul><ul><ul><ul><li>Fungal infections (Malassezia furfur) response to antifungal agents </li></ul></ul></ul><ul><ul><ul><li>Nutritional (common in AIDS) </li></ul></ul></ul><ul><ul><li>Presentation </li></ul></ul><ul><ul><ul><li>Cradle cap </li></ul></ul></ul><ul><ul><li>Treatments </li></ul></ul><ul><ul><ul><li>Topical steroids – low potency </li></ul></ul></ul><ul><ul><ul><li>Topical calcineurun inhibitors (Protopic, Elidel) </li></ul></ul></ul><ul><ul><ul><li>Keratolytics (salicyclic and shampoo) </li></ul></ul></ul><ul><ul><ul><li>Antifungals (Nizoral shampoo 3x/week, Selsun 2-3x/week) and others </li></ul></ul></ul><ul><ul><li>Dandruff </li></ul></ul><ul><li>Greasy scales </li></ul>
  15. 15. Pityriasis Rosea
  16. 16. Pityriasis Rosea (Cont’d) <ul><li>Benign, self-limiting eruption </li></ul><ul><li>Herald patch abruptly appears several days to weeks before rest of rash </li></ul><ul><li>Smaller lesions appear in 1-2 weeks, usually on trunk but can be upper arms and thighs </li></ul><ul><li>1-2 cm oval plaques with wrinkled tissue-like ring of scale (collarette) with long axis oriented along the skin lines (Christmas tree distribution on back) </li></ul><ul><li>Treatment directed to symptom relief with antihistamines for itching </li></ul>
  17. 17. Petechiae/Purpura <ul><li>Nonpalpable -superficial, thrombocytopenia </li></ul><ul><li>Palpable - deep, vasculitis </li></ul><ul><li>Petechiae < 3mm </li></ul><ul><li>Purpura > 3mm </li></ul><ul><li>Causes: Drugs, vasculitis, infections </li></ul><ul><li>Treatment: Depends on etiology, antibiotics, steroids or even plasmapheresis if needed </li></ul>
  18. 18. Urticaria <ul><li>Wheals, hives diffuse itchy rash </li></ul><ul><li>80% of the time etiology unknown </li></ul><ul><li>Usually IgE mediated </li></ul><ul><li>Self limited </li></ul><ul><li>Treatment with antihistamine, antipruritics, H2 blockers </li></ul><ul><li>ANGIOEDEMA is deeper dermis </li></ul><ul><li>Familial - C1 esterase inhibitor deficiency </li></ul>
  19. 19. Eyrsipelas <ul><li>Usually Group A strep </li></ul><ul><li>Superficial cellulitis and lymphangitis </li></ul><ul><li>Often “butterfly rash” on face </li></ul><ul><li>Characterized by bright red, shiny plaques on lower extremities </li></ul><ul><li>Well-demarcated border between normal and infected skin </li></ul><ul><li>Treatment: PCN, dicloxacillin, erythromycin </li></ul>
  20. 20. Erythema Nodosum <ul><li>Delayed hypersensitivity reaction caused by infections (Strep, TB and sarcoidosis), medications (OCPs, sulfa) and 50% idiopathic </li></ul><ul><li>Bright painful nodules that are violet in color </li></ul><ul><li>Most common in women </li></ul><ul><li>May have arthralgias before eruptive phase </li></ul><ul><li>Treatment: Symptomatic relief with salicylates, NSAIDs and potassium iodide 300mg tid for 3-4 weeks may help </li></ul>
  21. 21. Drug Eruption <ul><li>Asymmetrical eruption </li></ul><ul><li>Can see urticaria, erythema multiforme, and serum sickness </li></ul><ul><li>Common causes: PCN, sulfa, cephalosporins </li></ul><ul><li>Usually resolves in 1-2 weeks </li></ul><ul><li>Complication: Stevens-Johnson Syndrome - mucosal and cutaneous bullous forms with 5-10% mortality </li></ul><ul><li>Treatment: D/C offending agent, steroids (topical or oral) and antihistamines </li></ul>
  22. 22. Erythema Multiforme <ul><li>Secondary to hypersensitivity reaction </li></ul><ul><li>Severe form is Stevens-Johnson and Toxic Epidermal Necrolysis (TEN) </li></ul><ul><li>Palmar, plantar and extensor surfaces </li></ul><ul><li>Target lesions (bull’s eye) </li></ul><ul><li>Severe form is Stevens-Johnson with severe bullous form </li></ul><ul><li>Treatment: Remove offending agent, oral steroid burst (40-80mg/day of prednisone or equivalent oral steriod) </li></ul>
  23. 23. Drug Eruption
  24. 24. Henoch-Schonlein Purpura <ul><li>Associated with strep and viral infections, drugs </li></ul><ul><li>Seen most commonly in 2-10, with abdominal pain, GI bleeding, hematuria </li></ul><ul><li>Palpable purpura usually on lower extremities, buttocks </li></ul><ul><li>IgA mediated </li></ul><ul><li>Complications: arthritis, glomerulonephritis, hematuria </li></ul><ul><li>No thrombocytopenia </li></ul><ul><li>Usually spontaneous resolution, may need renal consult, and the use of oral steroids </li></ul>
  25. 25. Stevens-Johnson Syndrome
  26. 26. Toxic Epidermal Necrolysis (TEN)
  27. 27. Toxic Epidermal Necrolysis (TEN) (Cont’d) <ul><li>Considered severe form of erythema multiforme with more than 30% of epidermal detachment </li></ul><ul><li>Patient toxic and in the elderly mortality approaches 50% </li></ul><ul><li>Nikolsky’s sign: with slight thumb pressure, skin wrinkles, slides laterally and separates from the epidermal-dermis junction </li></ul><ul><li>Treatment: Admit, IV fluids, steroids are controversial, antibiotics if infection-related </li></ul>
  28. 28. Pemphigus Vulgaris <ul><li>Rare, often lethal (10-15%) autoimmune intradermal blistering disease </li></ul><ul><li>Use punch bx to help dx using direct immunofluorescence </li></ul><ul><li>Circulating IgG autoantibodies destroy the adhesion between epidermal cells </li></ul><ul><li>Oral lesions precede the onset of skin blisters; Nikolsky’s sign positive </li></ul><ul><li>Treatment: Steroids orally </li></ul>
  29. 29. Bullous Pemphigoid <ul><li>Rare relatively benign subepidermal blistering disease </li></ul><ul><li>Usually seen in older adults (>60) </li></ul><ul><li>Begins with urticarial lesions that may progress to tense bullae. May see oral lesions first </li></ul><ul><li>Punch bx with direct immunofluorescence shows IgG but also IgA, IgB, IgE </li></ul><ul><li>Treatment: Antipruritics, topical steroids, sulfones or immunosuppressive medications </li></ul>
  30. 30. Varicella <ul><li>Highly infectious viral illness </li></ul><ul><li>Incubation average of 14 days after exposure by airborne droplets or vesicular fluid, followed by prodrome of low fever, headache and malaise </li></ul><ul><li>Concurrent macules/papules to vesicles to crusted lesions </li></ul><ul><li>Complications include encephalitis, pneumonia and secondary bacterial infections </li></ul>
  31. 31. Varicella (Cont’d) <ul><li>Varicella vaccine available and recommended </li></ul><ul><li>Avoid salicylates (Reye’s syndrome) </li></ul><ul><li>Use Acyclovir and immune globulin for immunocompromised patients </li></ul><ul><li>Can be associated with increased risk in pregnant women </li></ul><ul><li>Antivirals such as Acyclovir are clinically effective in shortening rash if started within 72 hours of its onset </li></ul>
  32. 32. Herpes Zoster - Shingles <ul><li>AKA shingles, usually dermatomal in distribution </li></ul><ul><li>Pre-eruptive itching or burning </li></ul><ul><li>Eruptive phase has typical appearance of varicella </li></ul><ul><li>Complications: Postherpetic neuralgia, scarring and dissemination </li></ul><ul><li>Therapy: Consider antivirals, oral steroids, pain medications and topical burrows solution </li></ul><ul><li>May also consider tegretol or neurontin as adjunctive Rx </li></ul>
  33. 33. Herpes Simplex <ul><li>HSV 1: Stomatitis with fever, decreased oral intake </li></ul><ul><li>HSV 2: painful vesicles of anus, genitalia </li></ul><ul><li>Complications include infection (secondary), congenital transfer (TORCH) or neonatal infections </li></ul><ul><li>Treatment: Topical antivirals such as acyclovir and analogs </li></ul>
  34. 34. Hand-Foot-Mouth Disease <ul><li>Coxsackie Virus A16 most common </li></ul><ul><li>Seen in outbreaks </li></ul><ul><li>Oval vesicles on the hands and feet, especially on the plantar and palmar surfaces common </li></ul><ul><li>Fecal-oral transmission </li></ul><ul><li>Oral lesions are aphthous-like in character </li></ul><ul><li>Treatment is symptomatic relief of itching and painful mouth symptoms </li></ul>
  35. 35. Hand-Foot-Mouth Disease (Cont’d)
  36. 36. Herpangina <ul><li>Coxsackie virus </li></ul><ul><li>Symptoms include: fever, dysphagia, drooling, vomiting and headaches </li></ul><ul><li>Ulcerative lesions on the pharynx with no generalized rash </li></ul><ul><li>Treatment is symptomatic but recommend avoidance of viscous lidocaine in children to avoid overdose and seizures </li></ul>
  37. 37. Actinic Keratosis (AK) <ul><li>Premalignant </li></ul><ul><li>Often more felt than seen </li></ul><ul><ul><li>Rough, scaly and erythematous patches, poorly defined borders </li></ul></ul><ul><li>Increased incidence in fair skinned patients </li></ul><ul><li>5-20% of AKs will transform to SCC within 10 years </li></ul>
  38. 38. Actinic Keratosis (AK) (Cont’d) <ul><li>Risk factors are fair skin and cumulative sun exposure </li></ul><ul><li>Diagnosis: Red, scaling papule that is rough to feel. Can be red to yellowish or even keratinized to form a horn </li></ul><ul><li>Prevention by use of sun blocks </li></ul>
  39. 39. Actinic Keratosis (AK) Treatment <ul><li>Treatment: Cyrosurgery with Liquid N 2 for limited number of lesions - some pain and risk of scarring </li></ul><ul><li>Curettage: Scrap away lesion with curette and follow with electro or radio frequency to “feather” and stop bleeding, but need to use local anesthetic and best for limited numbers of lesions </li></ul>
  40. 40. Actinic Keratosis (AK) Treatment (Cont’d) <ul><li>Topical 5-Fluorouricil (5-FU): Is a cytostatic agent which inhibits enzymes in tumor cells </li></ul><ul><ul><li>Apply locally and repeat daily until the lesion erodes and reddens (usually 2-3 weeks) </li></ul></ul><ul><ul><li>Advantage is ability to treat larger areas and numbers of lesions </li></ul></ul><ul><ul><li>Disadvantage is the pain and redness associated with treatment </li></ul></ul>
  41. 41. Sunscreens <ul><li>Most do good job filtering UVB-Rays that cause sunburn; don’t defend as well against UVA that causes skin cancer and wrinkles. </li></ul><ul><li>Best protection against UVA includes zinc oxide, titanium dioxide or avobenzone. </li></ul><ul><li>SPF (Sun Protection Factor) refers to UVB protection. </li></ul>
  42. 42. Sunscreens (Cont’d) <ul><li>Use of sunscreen recommendations </li></ul><ul><ul><li>SPF of 30 or better (SPF 15 blocks 93% and SPF 50 blocks 98% of UVB Rays) </li></ul></ul><ul><ul><li>Water resistant </li></ul></ul><ul><ul><li>Apply every 2 hours and after swimming or sweating </li></ul></ul><ul><ul><li>30-35ml per body application – usually “too little” for an average adult </li></ul></ul>
  43. 43. Squamous Cell Carcinoma <ul><li>Common in middle-aged and elderly </li></ul><ul><li>2 types depending on site of origin </li></ul><ul><ul><li>Arising in areas of prior irradiation or thermal injury </li></ul></ul><ul><ul><li>Arising from prior actinic damaged skin </li></ul></ul><ul><li>Seen in sun exposed areas but also common on scalp, backs of hands, and superior surface of pinna, with BCC not usually seen here </li></ul>
  44. 44. <ul><li>Rapid growth with central ulcerations and raised indurated borders </li></ul><ul><li>Metastasis occurs and depends on size, location, tumor differentiation and depth of invasion (greater than 6mm thick at higher risk) </li></ul><ul><li>Treatment: excisional surgery, radiation and chemotherapy </li></ul><ul><li>Small (< 2cm dia) tumors need a 4mm margin and larger tumors a 6mm margin or Moh’s may be needed </li></ul>Squamous Cell Carcinoma (Cont’d)
  45. 45. Basal Cell Carcinoma <ul><li>Telangiectatic vessels </li></ul><ul><li>Rolled edges with pearly gray borders </li></ul><ul><li>Can have central ulcerations </li></ul><ul><li>Also called rodent cell ulcers </li></ul><ul><li>5 types: Listed from most common </li></ul><ul><ul><li>Nodular </li></ul></ul><ul><ul><li>Superficial </li></ul></ul><ul><ul><li>Micronodular </li></ul></ul><ul><ul><li>Infiltrative </li></ul></ul><ul><ul><li>Morpheaform </li></ul></ul>
  46. 46. <ul><li>Treatment includes surgical excision </li></ul><ul><ul><li>Most successful if < 2cm in diameter </li></ul></ul><ul><ul><li>Advocate Moh’s surgery if large, recurrent morpheaform, aggressive tumors, or cosmetically or functionally critical areas (nose, lips, ears) </li></ul></ul><ul><ul><li>Margins of 4mm of normal appearing skin give a 98% complete excision </li></ul></ul><ul><li>Smaller tumors can be treated with desiccation and curettage </li></ul>Basal Cell Carcinoma (Cont’d)
  47. 47. Pyogenic Granuloma
  48. 48. Pyogenic Granuloma (Cont’d) <ul><li>Benign, acquired vascular lesion </li></ul><ul><li>Small, but rapidly growing, yellow to red, dome shaped fragile protrusions </li></ul><ul><li>Seen most often on head, neck and extremities (fingers) </li></ul><ul><li>Minimal trauma causes brisk bleeding </li></ul><ul><li>Treatment: Firm, thorough curettage to completely eradicate </li></ul><ul><li>If any abnormal tissue remains, will recur </li></ul>
  49. 49. Impetigo <ul><li>Staph/Strep </li></ul><ul><li>Superficial but highly contagious </li></ul><ul><li>See in infants, children or with poorer hygiene </li></ul><ul><li>Red, with vesicles most often seen on face </li></ul><ul><li>“ Honey crusted” lesions </li></ul><ul><li>Can become bullous </li></ul><ul><li>Treatment: </li></ul><ul><ul><li>Minimal - topical mupirocin ointment </li></ul></ul><ul><ul><li>Extensive - Dicloxacillin, cephalosporins, erythromycin </li></ul></ul>
  50. 50. Fifth’s Disease <ul><li>Erythema infectiosum </li></ul><ul><li>Human parvovirus B19 </li></ul><ul><li>Prodrome of low-grade fever, malaise, sore throat precede the rash </li></ul><ul><li>“ Slapped cheeks” and “lace-like” erythematous rash on trunk and limbs </li></ul><ul><li>Complications: anemia, arthritis/arthralgia </li></ul><ul><li>Associated with fetal abnormalities if acquired in pregnancy </li></ul><ul><li>Treatment: Symptomatic </li></ul>
  51. 51. Rubeola (Measles) <ul><li>Paramyxovirus </li></ul><ul><li>Fever, cough, conjunctivitis, coryza (3 “C”s) </li></ul><ul><li>Koplik spots located on the buccal mucosa precede the rash </li></ul><ul><li>Maculopapular rash, red-brown (morbilliform) </li></ul><ul><li>Starts on trunk and spreads head to feet </li></ul><ul><li>Complications: pneumonia, encephalitis, OM, conjunctivitis </li></ul><ul><li>Usually atypical in adults with fever and vesicular rash </li></ul><ul><li>Prevention by live attenuated vaccine (MMR) </li></ul>
  52. 52. Rubeola (Measles) (Cont’d)
  53. 53. Rubella <ul><li>Togavirus </li></ul><ul><li>Cervical and posterior auricular adenopathy with URI symptoms, H/A and N/V </li></ul><ul><li>Rash is described as palpable petechiae </li></ul><ul><li>Starts as pink maculopapular rash on face and spreads to limbs </li></ul><ul><li>Causes fetal congenital defects, especially 1st trimester </li></ul><ul><li>Complications: TORCH, encephalitis, arthritis </li></ul>
  54. 54. Roseola Infantum <ul><li>Herpes Human Virus type 6 </li></ul><ul><li>Common ages 6-18 months </li></ul><ul><li>High fever for 3-5 days then rash develops after fever resolves </li></ul><ul><li>Maculopapular rash on arms, trunk and neck </li></ul><ul><li>Associated with febrile seizures </li></ul><ul><li>Symptomatic treatment (tincture of time) </li></ul>
  55. 55. Scarlet Fever <ul><li>Group A strep. Rash caused by toxin </li></ul><ul><li>Rapid onset, with sore throat, fever, H/A and sometimes vomiting </li></ul><ul><li>Rash is a “sandpaper” type – starts on trunk and moves to limbs, with circumoral sparing </li></ul><ul><li>Strawberry tongue </li></ul><ul><li>Pastia’s lines on groin, limbs and antecubital areas </li></ul><ul><li>May see post-strep skin peeling on palms/soles </li></ul><ul><li>Dx: Rapid strep test or culture </li></ul><ul><li>Treatment: PCN, erythromycin </li></ul>
  56. 56. Scarlet Fever (Cont’d)
  57. 57. Staphylcoccal Scalded Skin Syndrome (SSSS)
  58. 58. Staphylcoccal Scalded Skin Syndrome (SSSS) (Cont’d) <ul><li>Usually under age 5 </li></ul><ul><li>Staph toxin, with scarlatiniform rash after onset of fever, irritability and then exfoliation </li></ul><ul><li>Positive Nikolsky’s sign </li></ul><ul><li>Treated with antibiotics (beta-lactamase resistant) but this does not change the skin effects </li></ul><ul><li>Better prognosis than toxic epidermal necrolysis (TEN) </li></ul>
  59. 59. Kawasaki’s Disease
  60. 60. Kawasaki’s Disease (Cont’d) <ul><li>Inflammatory vasculitis </li></ul><ul><li>Need fever for > 5 days PLUS 4/5 of the following </li></ul><ul><ul><li>Conjunctivitis (bilateral) </li></ul></ul><ul><ul><li>Strawberry tongue, fissures </li></ul></ul><ul><ul><li>Erythematous rash - starts palms/soles </li></ul></ul><ul><ul><li>Enlarged lymph nodes </li></ul></ul><ul><ul><li>Desquamation of fingers/toes with swelling </li></ul></ul><ul><li>Increased WBC, ESR; may be anemic </li></ul><ul><li>Associated with increased risk for coronary artery aneurysms </li></ul><ul><li>Treat with high-dose ASA (100mg/kg/day through the 14th day or until afebrile, then 3-5mg/kg/day for 6-8 weeks), IV gamma-globulin (2gm/kg given over 10 hours or 400mg/kg/day for 4 consecutive days) </li></ul>
  61. 61. Seborrheic Keratosis (SK) <ul><li>Most common of benign skin tumors </li></ul><ul><li>Widely variable presentation from flat, brown macules to raised blackened verrucous lesions - need to be familiar with variations to prevent unnecessary destructive procedures </li></ul><ul><li>Sign of Leser-Trelat (eruptive SK as sign of internal malignancy) </li></ul><ul><li>Treatment: Cryo, Curettage, Shave bx technique </li></ul>
  62. 62. Tinea Corporis <ul><li>Classical ring appearance with red raised borders associated with central clearing </li></ul><ul><li>KOH skin scraping may help in confirmation of diagnosis </li></ul><ul><li>Treatment: </li></ul><ul><ul><li>Superficial - topical antifungal </li></ul></ul><ul><ul><li>Deep - 1-3 months of oral therapy such as griseofulvin </li></ul></ul>
  63. 63. Tinea Cruris <ul><li>Lesions occur in warm moist areas often in summer months </li></ul><ul><li>Often bilateral disease with a half-moon plaque </li></ul><ul><li>Treatment: Topical antifungal creams for 10-14 days </li></ul>
  64. 64. Kerion <ul><li>Severe inflammatory reaction to tinea of the scalp </li></ul><ul><li>Indurated and exudes pus (sterile) </li></ul><ul><li>Must use ORAL therapy as topical does NOT work </li></ul>
  65. 65. Kerion (Cont’d) <ul><li>Treatment: </li></ul><ul><ul><li>Griseofulvin - 15mg/kg for 6-12 weeks </li></ul></ul><ul><ul><li>Terbinafine - 3-6 mg/kg/day for 6 weeks </li></ul></ul><ul><ul><li>Itraconazole - 2-5 mg/kg/day for 6 weeks </li></ul></ul>
  66. 66. Erythema Migrans (Lyme) <ul><li>Begins as small red papule at site of tick bite with expanding ring of rash with central clearing </li></ul><ul><li>Associated flu-like symptoms of H/A, stiff neck, fever, chills </li></ul><ul><li>Borrelia burgdorferi transmitted by the Ixodes tick </li></ul><ul><li>Can have early and late manifestations including arthritis and meningitis </li></ul><ul><li>Treatment: doxycycline, azithromycin </li></ul><ul><li>Best treatment: tick prevention using products containing DEET </li></ul>
  67. 67. Syphilis
  68. 68. Syphilis (Cont’d) <ul><li>Treponema pallidum (spirochete) </li></ul><ul><li>Primary = painless chancre </li></ul><ul><li>Secondary = rash (palm/sole), lymphadenopathy, condyloma lata </li></ul><ul><li>Tertiary = CNS or cardiovascular effects </li></ul><ul><li>Diagnosis: RPR followed by FTA-ABS </li></ul><ul><li>Treatment: PCN, ceftriaxone, erythromycin </li></ul><ul><li>Jarisch-Herxheimer Rxn: limited reaction due to release of antigens following antibiotics - chills, fever, H/A, myalgias </li></ul>
  69. 69. Smallpox
  70. 70. Smallpox (Cont’d) <ul><li>Orthopox virus - Variola </li></ul><ul><li>Was officially eradicated by WHO 1980 </li></ul><ul><li>Still stockpiled in US and Russia </li></ul><ul><li>Theoretically produced by genetic manipulation of cowpox and monkeypox </li></ul><ul><li>One of most contagious diseases known </li></ul>
  71. 71. Smallpox (Cont’d) <ul><li>3-17 day incubation </li></ul><ul><li>ACUTE onset of fever, malaise, vomiting, headache, backache, delirium and erythematous rash </li></ul><ul><li>2-3 days after onset, a varicella-like rash begins on face (forehead), upper arms, forearms, hands and legs and spreads centrally </li></ul>
  72. 72. Smallpox (Cont’d) <ul><li>Medical Management: There is NO treatment, although Cidofovir may have some utility </li></ul><ul><li>Need to provide airborne droplet precautions for at least 17 days after exposure, quarantine recommended </li></ul><ul><li>Immediate post-exposure vaccination </li></ul><ul><li>Supportive care </li></ul>
  73. 73. References Evidence Based Medicine Practice Points
  74. 74. <ul><li>SLIDE 10 </li></ul><ul><li>Low-potency corticosteroids are recommended for maintenance therapy, whereas intermediate-and high-potency corticosteroids should be used for the treatment of clinical exacerbation and applied to affected areas of skin over short periods of time. </li></ul><ul><li>Name of AAFP-approved source of systematic evidence review: National Guideline Clearinghouse </li></ul><ul><li>Specific web site of supporting evidence from the approved source identified immediately above: </li></ul><ul><li>Strength of evidence (description and/or grade as provided by the approved source): </li></ul><ul><li>Strength of recommendation A – Directly based on category I evidence </li></ul><ul><li>Category of evidence </li></ul><ul><li>Ia Evidence from meta-analysis of randomized controlled trials </li></ul><ul><li>Ib Evidence from at least 1 randomized controlled trial </li></ul>