How to Approach a Patient With a Rash or Concerning Skin Lesion
Grand Strand Advanced Practice Nurse Association September 19, 2015 M. Holly B. Glover, M.D. Grand Strand Dermatology Myrtle Beach, SC Disclosures I have no financial disclosures nor any conflicts of interest. Learning Objectives Introduction to skin anatomy
Introduction to dermatology terminology Common skin rashes Recognition and treatment Additional pediatric dermatology Common skin lesions Epidermis Epidermis: Major physical barrier of the skin
Made up of 4 distinct cell layers, each with different cell structure and function 1 2 3 The epidermis, the outermost or most superficial layer is the major physical barrier of the skin.It is made up of 4 distinct cell layers, each with a different cell structure and function. The 4 layers of the epidermis are known as the stratum corneum, which is the outermost layer, the stratum granulosum, the stratum spinosum, and the stratum basale or basal layer. 4 Epidermis Epidermis: Made up of several different cell types
Keratinocyte: major cell that keratinizes to form hard, outer layer Melanocyte: pigment-producing cell Langerhans cell: immune cell of skin The epidermis is also made up of several different cell types.The keratinocyte is the major cell in the epidermis, and this is the cell that keratinizes or dies while losing its nucleus. The dead cells merge together and form the outer layer of the epidermis, the stratum corneum, which serves as a hard, protective barrier. The melanocyte is the pigment producing cell, which protects our skin from ultraviolet light. Interestingly, every person has the same amount of melanocytes. Its the amount of melanin produced by the melanocytes that determines our skin, hair, and eye color. And lastly, Langerhans cells are the immune cells of our skin, which travel to our lymph nodes when they are exposed to bacteria or viruses that come in contact with our skin. Dermis and Hypodermis Dermis: tough, support structure
Hypodermis or subcutaneous fat: insulates the body and cushions deep tissues Both contain nerves, blood vessels, hair follicles and sweat glands Below the epidermis is the dermis and hypodermis.The dermis is a tough, support structure, and the hypodermis or layer of subcutaneous fat insulates the body and cushions deep tissues. Both contain nerves, blood vessels, hair follicles, and sweat glands. Common Rashes In Dermatology
Recognition Diagnosis Treatment When to Refer Eczema Numerous different types: Atopic dermatitis Dyshidrotic eczema
Xerotic eczema Nummular eczema Allergic contact dermatitis Irritant contact dermatitis Stasis dermatitis There are several different types of eczema, and this category of skin rashes is probably one of the most common things we see as dermatologists.Atopic dermatitis is more common in children, but you may see it in adults who did not grow out of it as a child or who developed it later in life. Dyshidrotic eczema or hand eczema is the form of eczema that is usually characterized by small blisters and erosions on the hands. Xerotic eczema is common the elderly due to loss of moisture in our skin secondary to skin thinning, which occurs as we age.Nummular eczema is a form of eczema that occurs in round patches and plaques. Allergic and irritant contact dermatitis are due to substances in our environment causing skin breakdown, and these types of dermatitis are also common on the hands. Stasis dermatitis is usually found on the lower legs and is caused by swelling and venous stasis. Eczema Treatment Continued
Macrolide immunosuppresants (nonsteroidal topicals that dont have the side effects of topical steroids) Tacrolimus (Protopic) Pimecrolimus (Elidel) For itchiness, antihistamines can be recommended or prescribed OTC Diphenhydramine (Benadryl) mg QID PRN Rx Hydroxyzine mg QID PRN Stasis dermatitis: leg elevation and compression stockings Mild soaps and moisturizers Macrolide immunosuppresants which include Protopic and Elidel are nonsteroidal topicals that dont have the side effects of topical steroids. -side effects of topical steroids include skin atrophy, skin dyspigmentation, and stretch marks. Therefore, topical steroids should not be used for daily for a long period of time. But the macrolide immunosuppresants such as Protopic and Elidel can be used safely for a long period of time, but they are more expensive than the topical steroids. -For the symptom of itchiness, you can recommended OTC Benadryl or prescribe hydroxyzine, which are antihistamines, but you should warm your patients about the drowsiness they may cause. If you are treating stasis dermatitis, the mainstay for treatment is leg elevation and compression stockings. -and finally, the most basic treatment that all eczema patients have to be counseled on is mild soaps and moisturizers. I tend to recommend Dove and Oil of Olay fragrance free soaps. Mild fragrance free moisturizers such as Aveeno, Curel, Cetaphil, CeraVe should be used twice a day. I Also recommend clothing detergents that are free of dyes and fragrances such as Tide Free or All Free. Psoriasis Incidence rising:
Around 2% of population More common in Caucasians Onset at the average age of 35 but may be any age Disease usually starts gradually but may have an explosive onset as in the guttate variety (often preceded by streptococcal throat infection) Aggravating factors include trauma, stress, infections (HIV, strep), obesity, medications, positive family history Associations: Nail involvement Psoriatic arthritis The incidence of psoriasis is rising and includes around 2% of the population. It is more common in caucasians, and the average age of onset is usually around 35 but it may occur at any age, even in children. The disease usually starts gradually but may have an explosive onset as in the guttate variety, which is often preceded by a streptococcal throat infection. Aggravating factors include. Patients may also have significant nail involvement or associated arthritis, which is most commonly in the hands. Psoriasis Treatment Topical steroids (medium and high strength)
Triamcinolone 0.1% cream or ointment Clobetasol 0.05% cream or ointment Topical tars OTC or compounded Cutar cream OTC Tarsum shampoo Topical vitamin D derivatives Calcipotriene cream or ointment Calcitriol Topical vitamin A derivative Tazarotene (Tazorac) Here is a list of the topical treatments available.Medium and high strength topical steroids are usually required, including triamcinolone or clobetasol. Topical tars were commonly used in the past, but are still available over the counter at specialty pharmacies. I sometimes recommend Cutar cream and Tarsum shampoo.Topical vitamin D derivatives work well with topical steroids, and they include calcipotriene and calcitriol. Topical vitamin A is also effective with Tazarotene or Tazorac being the most potent and effective. Psoriasis Treatment Continued
Phototherapy NBUVB (Narrow band ultraviolet B) PUVA (Psoralen combined with ultraviolet A) Systemic immunosuppresants Methotrexate Acitretin (Soriatane) Cyclosporine Biologics Etanercept (Enbrel) Adalimumab (Humira) Infliximab (Remicade) Ustekinumab (Stelara) If a significant body surface area is involved, more complicated treatment regimens are usually required.Narrow band ultraviolent B phototherapy is commonly used in dermatology clinics that have a light box. PUVA or psoralen combined with ultraviolent A is less commonly used because psoralen is a pill patients take before phototherapy which makes patients more light sensitive, but it has lots of side effects.Systemic immunosuppressants are sometimes required including methotrexate, acitretin, and cyoclosporine.Within the last 10 years, biologics have become very popular, and these include Enbrel, Humira, Remicade, and Stelara. These injections are quite effective, but pretty expensive. When to Refer Psoriasis is a chronic condition with intermittent flares Above therapies can control disease but not cure it A few plaques involving little body surface area can be controlled with topical medications However, if more than 5-10% body surface area is involved, a systemic medication may be warranted along with a referral to a specialist Psoriasis is a chronic condition with intermittent flares.The above therapies can control the disease but there is no cure unfortunately.If a patient has a few plaques involving little body surface area, they can usually be controlled with topical medications.However, if more than 5-10% body surface area is involved, a systemic medication is usually required along with a referral to a specialist.All of these systemic medications have side effects and require lab monitoring. For example, methotrexate can lead to liver inflammation so liver enzymes have to be monitored. Cyclosporine can cause renal failure so creatinine has to be monitored. In all the biologics and immunosupprsants, annual TB skin tests or quantiferon gold is necessary since these medication have been known to reactive tuberculosis. Fungal Infections Tinea corporis Tinea pedis Tinea manuum Tinea cruris
Tinea faciale Tinea barbae Tinea capitis Tinea unguium or onychomychosis Fungal infection of the skin include this list, which is named depending on the location of the fungal infections.Tinea corporis or ringowrm can be on any locations, tinea pedis is on the feet and AKA athletes food.Tinea manuum is on the hand, tinea cruris in the groin and AKA jock itch. Tinea faciale is on the face, tinea barbae in the beard, tinea capitis in the scalp, and tinea unguium in the nails. Fungal Infections Fungal infections of the skin are caused by organisms collectively referred to as dermatophytes Feed on the keratin in our epidermis. Prefer warm, moist environments Ringworm is used by the general population but is a misnomer Diagnosis: KOH (potassium hydroxide) preparation Fungal infections. Diagnosis can be made by KOH or potassium hydroxide preparation. This is done by scraping the skin of the fungal infection onto a glass slide. KOH is then applied to the slide.This causes the skin cells to break down, making it easier to visualize fungal elements underneath the microscope. Treatment of Tinea Topical antifungals (for limited disease)
OTC clotrimazole 1% cream (Lotrimin) OTC miconazole 2% cream (Micatin) OTC miconazole powder (Zeasorb AF) OTC terbinafine 1% cream (Lamisil) Rx ketoconazole 2% cream Systemic antifungals (for tinea capitis, tinea unguium, or extensive involvement) Griseofulvin (most effective in children with tinea capitis) Terbinafine 250 mg Qdaily for adults Ketoconazole Fluconazole Itraconazole Topical efinaconazole 10% solution (Jublia) and tavaborole 5% solution (Kerydin) now available for tinea unguium Topical antifungals can treat most forms of tinea since most are found in limited areas of the body.These include. Terbinafine is bolded because it is in the class of antifungals that is usually the most effective at treated fungal skin infections. Systemic antifungals are required for tinea capitis, tinea unguium, or extensive involvment of tinea corporis.Griseofulvin is prescribed to children with tinea capitis, but resistance has started to develop.In adults and in children with resistant tinea capitis, terbinafine is the most effective.Terbinifine can lead to inflammation of the liver, but if used for less than a month, this side effect is very rare, so terbinafine can usually be prescribed safely for a short period of time.Ketoconazole, fluconazole, and itraconazole are still sometimes prescribed orally, but they have numerous side effects and require lab monitoring. Tinea Versicolor Anti-yeast/anti-dandruff shampoos used as a face/body wash. Leave on for 5 minutes then wash off. Use daily for a week, then weekly until resolution, then monthly to prevent recurrence Zinc pyrinthione 1% (Head and Shoulders) Selenium sulfide 1% (Selsun Blue) or 2.5% (Rx only) Ketoconazole 1% (Nizoral) or 2% (Rx only) If only a few spots, OTC miconazole cream or Rx ketoconazole cream Oral: fluconazole (Diflucan) one 200 mg tablet repeated two weeks apart Treatment includes anti-yeast/anti-dandruff shampoos used as a face and body wash. Instruct the patient to leave on for 5 minutes then wash off. My favorite regimen is daily for a week, then weekly until complete resolution,then monthly to prevent recurrence.These shampoos can dry the skin out.If extensive involvement, the prescription strength ketoconazole 2% is the most effective. If only a few spots, over the counter miconazole cream or prescription ketoconazole cream daily will work. Some patients will request for a pill, at which at that point, one dose of fluconazole 200 mg can be prescribed with a couple of refills. This can be repeated every 2 weeks until resolution. When you are only taking one dose of fluconazole 2 weeks apart, you dont have to worry about the serious side effects that can be associated with this medication. Seborrheic Dermatitis
Common: Found in around 5% of the healthy population Treatment: Anti-yeast/anti-dandruff shampoos a few times a week, can use as face or body wash. Leave on for 5 minutes then wash off Zinc pyrinthione 1% (Head and Shoulders) Selenium sulfide 1% (Selsun Blue) or 2.5% (Rx only) Ketoconazole 1% (Nizoral) or 2%(Rx only) Ketoconazole 2% cream BID PRN for face Hydrocortisone cream 1% or 2.5% BID PRN for face Clobetasol solution 0.05% BID PRN for severe inflammation of scalp Seborrheic dermatitis is common.. Since this yeast causes significant inflammation in our skin, a topical steroid is sometimes required. For the face, OTC hydrocortisone 1% cream can be recommended or hydrocortisone 2.5% cream can be prescribed. If there is significant inflammation of the scalp, clobetasol 0.05% topical solution can be prescribed Herpes Simplex Grouped vesicles that recur in the same location
May be preceded by a prodrome of symptoms including itching, burning, tingling, painful sensations Treatment is suppressive, not curative HSV1 usually causes herpes labialis (cold sores), and HSV2 usually causes genital herpes Primary infection ranges from going unnoticed to being severe with fever, myalgias, lymphadenopathy, necrotic ulcers, etc. Herpes simplex is characterized by grouped vesicles that recur in the same location. It may be preceded by a prodrome of symptoms including itching, burning, tingling, or painful sensations. Treatment is supressive, not curative, as the virus chronically lies in our nerves, most of the time dormant. HSV1 usually causes herpes labialis or cold sores, and HSV2 usually causes genital herpes, but certain sexual behaviors can reverse the two. Primary infection with the virus ranges from going unnoticed to being severe with fever, myalgias, lymphadenopathy, necrotic ulcers, etc. Recurrent Herpes Simplex Treatment
Valacyclovir: 2000 mg BID for 1 day for herpes labialis, 500 mg BID for 3 days for genital herpes Acyclovir: 400 mg TID for 5 days Famciclovir: 125 mg BID for 5 days Acyclovir 5% ointment: 6 times daily for 7 days Chronic suppressive: Valacyclovir mg Qdaily Acyclovir 400 mg BID Famcicloir 250 mg BID I most commonly prescribe valacyclovir or Valtrex for recurrent cold sores mg taken at the first sign of an outbreak, then again 12 hours later, is the recommended dosing regiment. Some providers prefer acyclovir or famciclovir for HSV1 and 2. For chronic suppressive therapy for patients who get numerous outbreaks per year, the dosing is a little different and may require long term treatment. This is more common in patients who are immunosupressed. Herpes Zoster Caused by a reactivation of the latent varicella-zoster virus (in the herpes family) in patients who have had varicella (chicken pox) May have a prodrome of itching, pain, headache, myalgias After the several week disease course, postherpetic neuralgia may present, which is characterized by months of skin pain and burning Zoster is caused by a reactivation of the latent varicella-zoster virus, which lies dormant in patients who have had varicella or chicken pox.There may be a prodrome of itching, pain, headache, and myalgias.After the several week disease course, postherpetic neuralgia may present, which can be extremely difficult for some patients. This is characterized by months of skin pain and burning. Herpes Zoster Treatment
Antivirals Valacyclovir 1000 mg TID for 7 days Acyclovir 800 mg 5 times a day for 7 days Famciclovir 500 mg TID for 7 days Pain/nerve medication Gabapentin 300 mg BID or TID Pregabalin 100 mg BID or TID Amitriptyline mg QHS Analgesics and NSAIDs OTC capsaicin cream BID or TID For zoster, my go to is again valacyclovir or Valtrex 1000 mg TID for 7 days. Again, acyclovir and famciclovir can also be used.It may be a good idea to prescribe a pain or nerve medication, especially if patients have symptoms of postherpetic neuralgia. Gabapentin, pregabalin, amitriptyline can be used. NSAIDs and OTC Capsaicin cream can also be recommended Folliculitis Treatment
Antibacterial soaps daily OTC Dial OTC Lever 2000 Hospital strength antiseptic cleansers 1-2 times per week OTC Hibaclens (chlorohexadine) Bleach baths or bleach spritzers 1-2 times per week cup of bleach in a tub of bath water 1 tablespoon of bleach in spray bottle Topical antibiotics Mupirocin 2% ointment (can be used on affected areas and in staph colonized areas: nose, axilla, umbilicus, groin. Use BID for 5 days and repeat monthly) Clindamycin 1% lotion, solution, or gel Oral antibiotics Doxycycline 100 mg BID (may require several month course) Clindamycin 300 mg QID Bactrim DS BID Folliculitis treatment includes Urticaria Treatment Discontinue suspected drugs
Avoid aspirin and NSAIDs Antihistamines OTC diphenhydramine 25 mg QID Rx hydroxyzine mg QID OTC cetirizine (Zyrtec) 10 mg BID OTC fexofenadine (Allegra) 180 mg BID Tricyclic drugs Doxepin mg QHS Immunosuppresants Prednisone 0.5 mg/kg daily Treatment includes discontinuing the suspected drugs and avoiding aspirin and NSAIDs as this can worsen urticaria.Antihistamines taken often should be recommended or prescribed.Zyrtec and Allegra can be increased to twice daily.Doxepin is a tricyclic antidepressant that has great antihistamine properties and is safe to use with little side effects at a low dose of mg QHS.Immunosuppresants such as prednisone may be required, usually with a several week taper. Other Common Skin Eruptions
Scabies Acne vulgaris Rosacea Lichen planus Other common skin eruptions include scabies which is caused by a mite that lives in our epidermis.Is is relatively common, especially during outbreaks in nursing homes, group homes, or hospitals. I could go on all day about the treatments of acne and rosacea, which overlap.Then theres lichen planus, a rash with unknown cause that is hard to treat and can last for years. Additional Pediatric Dermatology
Hemangioma Verruca vulgaris Molluscum contagiosum Impetigo Viral exanthems Hemangioma Benign proliferation of blood vessels in the dermis and subcutis Occur in about 10% of infants, more frequently in females, premature, and Caucasian infants Arise in the first few weeks of infancy as a red macule or patch then rapidly enlarge Most are asymptomatic and require no treatment, unless they are large, ulcerate, or cause local obstruction If treatment required, topical or systemic beta blockers are the mainstay of treatment. Other treatments include systemic steroids, interferon, laser surgery, or excision Hemangioma Most of superficial and have a bright red color, whereas deeper and mixed varieties may be skin colored or have a blue or purple hue Hemangiomas increase in size over the first year of life then subside spontaneously. 10% resolve by age 1 50% by age 5 100% by age 10 May resolve with scarring, atrophy, and telangiectasias Verruca Vulgaris Wart = verruca vulgaris
Common in healthy children and some adults Caused by multiple types of human papilloma virus (HPV) Genital warts = condyloma acuminatum Treatment: Cryosurgery with liquid nitrogen Acids: OTC salicylic Trichloroacetic (TCA) in office Cantharidin in office Podophyllin in office Rx imiquimod 5% cream Surgical excision Laser surgery Candida intralesionally in office 5-fluorouracil intralesionally in office Bleomycin intralesionally in office Again, the medical term for wart is verruca vulgaris. They are very common in healthy children and adults.They are caused by multiple types of the HPV or human papillomavirus. HPV is associated with some carcinomas, particularly cervical carcinoma. However, that is usually caused by specific, high risk, aggressive types of the virus. Warts are caused by low risk forms of the virus. Genital warts are also caused by a specific type of HPV, and the medical term is known as condyloma acuminatum. Warts do not have to be treated because in several cases, especially in children, the immune system will finally start fight off the virus and get rid of the wart.However, since warts do spread and are contagious, many people choose to treat them. Treatment options include Molluscum Contagiosum
Becoming more and more common in healthy children Caused by a poxvirus Spontaneous remission usually occurs in 6-18 months Treatment: Cryotherapy with liquid nitrogen OTC salicyclic acid Cantharidin in office Curettage .. Again, treatment can be observation since the childs immune system will finally rid them of the molluscum. However, molluscum is also contagious so some parents choose to get their kids treated with . Impetigo Superficial skin infection caused by gram-positive bacteria, usually Staphylococcus aureus (including MRSA) or Streptococcus pyogenes Most common bacterial infection in children, and tends to affect skin that has been disrupted with cuts, abrasions, insect bites, etc. Can occur anywhere but is found most frequently on the face Highly contagious and more common in warm, moist environments Impetigo Even without treatment, impetigo will resolve within 2-3 weeks. However, treatment is recommended to prevent the spread of infection and to speed up recovery Mupirocin (Bactroban) ointment TID for a week for isolated lesions Cephalexin is the treatment of choice in children with complicated or extensive cases Erythromycin in penicillin allergic patients If MRSA suspected, clindamycin and doxycycline are options (>8 years old) Viral exanthems Major viruses producing exanthems:
Measles (rubeola) German measles (rubella) Herpes virus type 6 (roseola) Parvovirus B19 (erythema infectiosum) Enteroviruses (ECHO and coxsackievirus) Most viral exanthems are preceded by a prodrome of fever and constitutional symptoms Common Lesions In Dermatology
Recognition Diagnosis Treatment When to Refer Seborrheic Keratosis Extremely common in adults
First begin to appear around the age 30 Everyone will develop this type of lesion; genetics determine how many we get Treatment: None Cryosurgery with liquid nitrogen if symptomatic Curettage Shave biopsy to confirm diagnosis Shave removal Every elderly person will have at least one or two Actinic Keratosis AKA precancers
Fair skin, aging skin, and abundant sun exposure can lead to development of AKs Variable course: Spontaneous resolution Remaining unchanged Intermittent in presentation Development into squamous cell carcinoma (about 15-20% of the time) Actinic Keratosis Treatment
Sunscreen, broad-brimmed hat, sun protective clothing, sun avoidance (especially midday sun from 10:00 AM-4:00 PM) Cryosurgery with liquid nitrogen Imiquimod 5% (Aldara) cream 5-Flurouracil 5% (Efudex) cream Diclofenac 3% (Solaraze) gel Squamous Cell Carcinoma
Malignancy of keratinocytes in the epidermis Caused by carcinogens: ultraviolent light, X-irradiation, coal tar, arsenic, viruses (HPV) Second most common skin cancer Potential to metastasize, especially in immunosuppressed individuals or transplant patients Most common on the head and neck, but can occur anywhere Diagnosis: skin biopsy Chronic ulcers should undergo biopsy to exclude malignancy Squamous Cell Carcinoma Treatment
Excision with 0.5 cm margins Curettage and electrodessication Mohs micrographic surgery Radiation Treat includes excision with 4-5 mm margins. Some can be treated less aggressively with curettage and electrdessication, which some people call ED and C or the scrape and burn method. SCCs on the face are usually treated with Mohs micrographic surgery, which is a specialized type of skin cancer surgery which has the highest cure rate. Radiation is usually reserved for large, extensive cases that cannot be surgically removed. Basal Cell Carcinoma Malignancy of the basal keratinocytes of the epidermis Caused by ultraviolet radiation; more common in fair skinned individuals Most common skin cancer Very rarely metastasizes. Locally grows Several different types with different appearances Most common on the head and neck followed by the trunk then the extremities Diagnosis: skin biopsy Nonhealing scars should undergo biopsy to exclude carcinoma Basal Cell Carcinoma Treatment
Excision with 0.5 cm margins Curettage and electrodessication Mohs micrographic surgery Radiation Cryosurgery 5-Flurouracil or imiquimod cream for superficial basal cell carcinomas Since bCCs are usually less aggressive than SCCs, superficial ones can be treated with cryosurgery or topical immunotherapy creams such as 5-fluorouracil or imiquimod, but this usually has a lower cure rate than would an excision. Malignant Melanoma Malignancy of the pigment-forming cells or melanocytes within the epidermis Exact cause is unknown but sunlight, heredity, and a large number of moles are risk factors Incidence of melanoma is increasing faster than any other cancer in the USA Melanomas tend to metastasize to lymph nodes, lungs, and brain Several different types depending on location, growth pattern, metastatic potential, but overall, most common location is back for men and lower legs for women Diagnosis: excisional biopsy Malignant Melanoma Course and Treatment
Thin melanoma is curable with wide excision Margin recommendations: 0.5 cm for melanoma-in-situ 1 cm for tumors 2 mm in thickness Prognosis is best predicted by depth of invasion into the skin If invades >1 mm, sentinal lymph node biopsy is recommended If have a deep tumor, positive lymph nodes, or metastasis is noted on PET scan, chemotherapy, immunotherapy, and radiation can be discussed References Bolognia JL, Jorizzo JL, Schaffer JV. Dermatology. 3rd edition. Saunders Elsevier, PA; 2012. James WD, Berger TG, Elston DM. Andrews Diseases of the Skin: Clinical Dermatology. 11th edition. Saunders Elsevier, PA; 2011. Lebwohl MG, Heymann WR, Berth-Jones J. Treatment of Skin Disease: Comprehensive Therapeutic Strategies. 4th edition. Saunders Elsevier, PA; 2014. Marks JG, Miller JJ. Lookingbill and Marks Principles of Dermatology. 4th edition. Saunders Elsevier, PA; 2006.