dermatology review
TRANSCRIPT
Dermatology Review
Jay Vary, MD PhD
Assistant Professor
Division of Dermatology
VAPSHCS and UWMC
I have no financial conflicts
Please do not use or reproduce any of these clinical photographs
WAPA 28th Annual Spring Conference 4/22/2017
Objectives
By the end of the session, you will be able to:
• Describe the basic structure of the skin
• Use the correct dermatology terminology
• Distinguish common Dermatology mimics
• Describe when to worry with a drug rash
Skin and its Appendages
Skin and its Appendages
Eccrine Sweat Gland
Sebaceous Gland
Arrector Pili Muscle
Apocrine (Sweat) Gland
Hair Follicle
The Nail
Indiana University http://anatomy.iupui.edu/courses/histo_D502/D502f04/lecture.f04/integument.f04/integumentf04.html
matrix
matrix
Proximal Nail Fold
Lateral Nail Fold
Proximal Nail Fold
Nail matrix
plate
plate
Cuticle
Language of Dermatology
• Macule, patch
• Papule, plaque
• Vesicle, bulla, pustule
• Erosion, ulceration
• Nodule
“There is a big lesion on his face”
Macule (<1cm) Patch (>1cm)
Papule/plaque Vitiligo
Macule or Patch
Papule (<1cm) Plaque (>1cm)
Psoriasis
Papule<1cm Plaque>1cm
Vesicle (<1cm) Bullae (>1cm)
Vesicle<1cm Bullae>1cm
Bullous Pemphigoid
Vesicle<1cm Bullae>1cm
Pustular Psoriasis
Erosion Ulcer
Erosion Ulcer
Epidermolysis Bullosa
Erosion Ulcer
Diabetic Foot Ulcer
What is the best description for the primary lesions shown?
• A) White papules
• B) White flat papules
• C) White macules
• D) White flat macules
• E) Maculopapular rash
What is the best description for the primary lesions shown?
• A) Red crusted plaques
• B) Red scaly plaques
• C) Red crusted patches
• D) Red scaly patches
• E) Maculopapular rash
https://nyti.ms/2jSOE0u
Which is it?
a)Tinea corporis b)Atopic dermatitis c) Psoriasis d)Impetigo e)Scabies
Atopic Dermatitis vs Psoriasis Atopic Dermatitis:
POORLY defined scaly plaques, often with EXUDATE and CRUST
Psoriasis:
WELL define erythematous plaques with MICACEOUS SCALE
Atopic Dermatitis vs Psoriasis Atopic Dermatitis:
Flexural surfaces-antecubital fossa
Psoriasis:
Extensor surfaces-elbows
Atopic Dermatitis vs Psoriasis Atopic Dermatitis:
Flexural areas-popliteal fossa
Psoriasis:
Extensor surfaces-knees
Atopic Dermatitis vs Psoriasis
Atopic Dermatitis
Flexural areas
Psoriasis
Extensor surfaces
Cohen, BA; Davis, HW; Gehris, RP. Dermatology Atlas of Pediatric Physical Diagnosis. Published January 2, 2012. Pages 299-368.
Which is it?
a) Cutaneous Larva Migrans b) Tinea Pedis c) Granuloma Annulare d) Psoriasis
Tinea Corporis vs Granuloma Annulare
Tinea Corporis
Advancing red edge with SCALE
Granuloma Annulare
Red raised border WITHOUT scale
James, WD; Berger, TG; Elston, DM. Diseases Resulting from Fungi and Yeasts. Andrews' Diseases of the Skin. Published January 1, 2016. Pages 285-318.e1.
Cohen, BA; Davis, HW; Gehris, RP. Dermatology Atlas of Pediatric Physical Diagnosis. Published January 2, 2012. Pages 299-368.
Case from: American Academy of Dermatology Medical Student Core Curriculum: aad.org/education
Which is it?
a) Bilateral Lower Extremity Cellulitis
b) Allergic Contact Dermatitis
c) Tinea Corporis d) Stasis Dermatitis
Stasis Dermatitis vs Cellulitis Stasis Dermatitis
Subacute (weeks)
Scaly
Pruritic
Often bilateral shins only
Spares the ankle
Cellulitis
Acute (days)
Not scaly
Painful
Always unilateral
No anatomic boundaries
Case from: American Academy of Dermatology Medical Student Core Curriculum: aad.org/education
Hirschmann, JV; Raugi, GJ. Lower limb cellulitis and its mimics JAAD. Published August 1, 2012. Volume 67, Issue 2. Pages 163.e1-163.e12.
Cellulitis????
Cellulitis is misdiagnosed in 30% of hospitalized patients 2/3 of the time it was the reason for admission Estimated costs in US alone are over $1,000,000,000 dollars/year due to unnecessary admissions, antibiotics, and complications Mimics: Stasis Dermatitis DVT Edema Gout
Weng QY et al. Costs and consequences associated with misdiagnosed lower extremity cellulitis. JAMA Dermatol 2016 Nov 2 Consuelo, D., et al. Diagnostic accuracy in patients admitted to hospitals with cellulitis. Dermatology Online Journal 17 (3): 1, 2011.
Bilateral Lower Extremity Cellulitis
Habif, TP. Superficial fungal infections. Clinical Dermatology. Published January 1, 2016. Pages 487-533
Which is it?
a) Candida b) Tinea Cruris c) Intertrigo d) Psoriasis e) Erythrasma
Intertrigo vs Candida vs Tinea Intertrigo
Erythema
Candida
Erythema with satellites
Pustules
Tinea cruris
Erythema with scaly border
Does NOT involve scrotum
Habif, TP. Superficial fungal infections. Clinical Dermatology. Published January 1, 2016. Pages 487-533
Which is it?
a) Drug Exanthem b) Pityriasis Rosea c) Tinea corporis d) Guttate psoriasis e) Scabies
Habif, TP, Principles of diagnosis and anatomy. Clinical
Dermatology. Published January 1, 2016. Pages 1-74.
Pityriasis Rosea
James, WD; Berger, TG; Elston, DM. Pityriasis Rosea, Pityriasis Rubra Pilaris, and Other Papulosquamous and Hyperkeratotic Diseases. Andrews' Diseases of the Skin. Published January 1, 2016. Pages 199-208.e1.
Fassihi H; White, I. Diseases of the skin Medicine & Surgery: An Integrated
Textbook. Published January 2, 2007. Pages 847-934.
Calonie, E; Brenn, T; Lazar, A. Spongiotic, psoriasiform and pustular dermatoses McKee's Pathology of the Skin. Published January 1, 2012. Pages 180-218.
Herald Patch Central ring of scale (like a popped bubble) NOT a Christmas tree
It’s a drug rash. Is he gonna die?
a) Yes b) No c) Maybe so
What to check History PE PE-Nikolsky’s sign PE PE PE PE Labs--LFTs, Creatinine/UA. H&P for pleuritis/carditis/cerebritis Labs--CBC with differential
___ ___ ___ ___ ___ ___ ___ ___ ___
Signs of a serious drug rash:
Painful skin Fever
Loss of skin integrity/blistering Facial edema
Mucosal involvement Palm/sole involvement
Lymphadenopathy Systemic involvement
Marked peripheral eosinophilia
Typical Benign Drug Exanthem
• Aka maculopapular or “morbilliform”
• ~90% of cutaneous drug reactions.
• Type IV (T-cell mediated) hypersensitivity reaction.
• Starts 7-14d after start of drug – Stops up to 7d after stopping drug
What to check History PE PE-Nikolsky’s sign PE PE PE PE Labs--LFTs, Creatinine/UA. H&P for pleuritis/carditis/cerebritis Labs--CBC with differential
___ ___ ___ ___ ___ ___ ___ ___ ___
Signs of a serious drug rash:
Painful skin Fever
Loss of skin integrity/blistering Facial edema
Mucosal involvement Palm/sole involvement
Lymphadenopathy Systemic involvement
Marked peripheral eosinophilia
Benign Drug Exanthem
Fever
Benign Drug Exanthem Treatment
• STOP the offending agent
• Oral SEDATING antihistamines (benadryl, hydroxyzine) (histamine is not the problem)
• Topical steroids help a little
Day 1
WBC 16K +reactive lymphocytes AST/ALT 110/134 INR 2.1 BUN/Cr 20/0.8
Day 3
DRESS
• Drug reaction with eosinophilia and systemic symptoms—aka “drug/dilantin hypersensitivity syndrome”
• Type IV delayed hypersensitivity reaction
• Onset 2-8 weeks after first exposure
• Can be fatal (10%) if untreated
What to check History PE PE-Nikolsky’s sign PE PE PE PE Labs--LFTs, Creatinine/UA. H&P for pleuritis/carditis/cerebritis Labs--CBC with differential
___ ___ ___ ___ ___ ___ ___ ___ ___
Signs of a serious drug rash:
Painful skin Fever
Loss of skin integrity/blistering Facial edema
Mucosal involvement Palm/sole involvement
Lymphadenopathy Systemic involvement
Marked peripheral eosinophilia
DRESS
Fever
Facial edema
Lymphadenopathy Systemic involvement
Marked peripheral eosinophilia
DRESS Treatment
• STOP the offending agent
• PO or IV steroids
• Monitor TSH for 6 months
Day 1
Day 2
Day 4
What is it, and is their skin going to fall off?
Stevens- Johnson
Syndrome
SJS/TEN overlap
TEN
Skin rash + 2 or more mucosal sites
<10% 10-30% >30% BSA:
Mortality: 30-50% 5-10%
Stevens-Johnson Syndrome (SJS) &
Toxic Epidermal Necrolysis (TEN)
• Rare; 1-2 cases per million person years
• Occurs 1-3 weeks after starting drug; sooner if rechallenged
• URI-prodrome 1-2 weeks before rash
• fever (universal), conjunctivitis, pharyngitis, pruritis and PAINFUL SKIN!!
What to check History PE PE-Nikolsky’s sign PE PE PE PE Labs--LFTs, Creatinine/UA. H&P for pleuritis/carditis/cerebritis Labs--CBC with differential
___ ___ ___ ___ ___ ___ ___ ___ ___
Signs of a serious drug rash:
Painful skin Fever
Loss of skin integrity/blistering Facial edema
Mucosal involvement Palm/sole involvement
Lymphadenopathy Systemic involvement
Marked peripheral eosinophilia
SJS/TEN
Painful skin Fever
Loss of skin integrity/blistering Facial edema
Mucosal involvement Palm/sole involvement
Lymphadenopathy Systemic involvement
SJS/TEN Treatment
• STOP the offending agent
• Admit-Refer to burn ICU if TEN
• Ophtho & Gyn consultation to prevent irreversible scarring
• Consider PO or IV steroids or IVIG, but benefits are unclear.
• rule out serious drug rash and systemic involvement
• discontinue all unnecessary medications
• change all necessary medications to different chemical class
• consider Dermatology consultation
New Suspected Drug Rash
Excellent resource for Dermatology www.aad.org