kin 405: medical aspects of sports
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KIN 405: Medical Aspects of Sports. Dermatology: Recognizing Illnesses and Disorders of the Skin. Skin Lesions. Often overlooked or trivialized Can signify serious disease in well patients Local conditions Systemic conditions Difficult for many health professionals to recognize. - PowerPoint PPT PresentationTRANSCRIPT
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KIN 405: Medical Aspects of Sports
Dermatology: Recognizing Illnesses and Disorders of the
Skin
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Skin Lesions
Often overlooked or trivialized Can signify serious disease in well
patients Local conditions Systemic conditions Difficult for many health professionals to
recognize
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Athletic Trainers’ Goals RRecognize various forms of
skin lesions
RReassure patients that every little blemish is NOT skin cancer
RRefer for definitive diagnosis and treatment
RRestrict competition for athletes with communicable illness
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Presentation Outline
Anatomy of the skin Types of lesions Rashes Infections
– Bacterial– Fungal– Viral
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Presentation Outline (cont)
Skin cancer Assessment techniques Treatment techniques
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Anatomy of the Skin
Stratum corneum Epidermis Dermis Pilosebaceous unit Subcutaneous fat
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Stratum Corneum
Top layer of skin Flakes off
imperceptibly Barrier to noxious
substances Totally replaced
every 27 days
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Epidermis
Protects against UV damage
Provides cutaneous immunity
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Dermis
Connective tissue Provides elasticity &
strength Contains blood
vessels, nerves, & sweat glands
Skin splits when dermis is cut
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Pilosebaceous Unit
Hair shaft Hair follicle Erector muscle Sebaceous gland Common site of
bacterial infections
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Subcutaneous Fat
Insulates Protects
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Kinds of Skin Lesions
Macules Papules Plaques Pustules Vesicles
Nodules Desquamination Bullae Ulcers Wheals
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Macules
Flat Nonpalpable Discolored Less than 1cm
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Causes of Macules
Hypopigmentation Hyperpigmentation Permanent vascular abnormalities of
the skin Transient capillary dilatation (erythema)
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Hypopigmentation Macules
Vitiligo Depigmentation
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Hyperpigmentation Macules
Café-au-lait spots
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Permanent Vascular Abnormalities of the Skin
CAPILLARY HEMANGIOMA OF INFANCY PORT-WINE STAIN
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Transient Capillary Dilatation (Erythema)
Erythema Infectiosum (systemic viral)
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Papules
Latin for “Pimple” Raised lesion Less than .5 cm Solid
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Example of Papules
Rosacea
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Plaques
Large, raised lesion Well-defined Confluence of
multiple papules Chronic rubbing
leads to “lichenification” (thickened skin)
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Example of Plaques
PSORIASIS VULGARIS OF THE ELBOW
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Pustules
Circumscribed Superficial Contains purulent
exudate that may be– white– yellow– greenish yellow– hemorrhagic.
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Example of Pustules
Acne Vulgaris
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Vesicles
Latin for “little bladder”
Fluid filled cavity Less than .5 cm Walls can be
translucent Contains serum,
lymph, blood, or extracellular fluid
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Example of Vesicles
Nongenital herpes simplex virus (HSV) infection
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Bullae
Latin for “bubble” Fluid filled cavity Greater than .5 cm Walls can be
translucent Contains serum,
lymph, blood, or extracellular fluid
Diabetic bullae
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Nodules
Latin for “small knot” Palpable, solid Round or ellipsoid Epidermal, dermal,
or subcutaneous Generally deeper
and larger than papules
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Example of Nodules
Adult T-Cell Leukemia/Lymphoma
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Desquamination
Proliferation of epidermis resulting in abnormally formed stratum corneum
“Scaly” Large
(membranous) or small (dust)
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Example of Desquamination
Solar Keratosis
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Ulcers
Pathologically altered tissue (different from a wound)
Epidermal - heals w/out scar
Dermal - heals w/ scar
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Example of Ulcers
Stage IV Pressure Ulcer on Sacrum
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Wheals Hives Rounded or flat
topped Pale red Transient Can change rapidly in
size, shape, and location due to shifting edema in the dermis
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Example of Wheals
Cutaneous Vasculitis
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Rashes
Acne Dermatitis Intertrigo Urticaria Psoriasis Seborrheic dermatitis Pityriasis rosea
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Acne
Affects 75% of the population Can involve inflammation of the
pilosebaceous unit Food choices NOT causative Endocrine and emotional links Not contagious Four stages
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Grade I Acne Comedones
(blackheads) Some whiteheads Topical antibiotics
(clindamycin, erythromycin
Benzoyl peroxide gels (2%,5%,10%)
Tretinoin (Retin-A) creams
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Grade II Acne
Erythematous papules
Oral tetracycline antibiotics added to previous tx regimen
For females, oral estrogens combined with progesterone or antiandrogens
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Grade III Acne Pustules Isotretinoin (Accutane) Contraception (2
forms) is absolutely necessary
Do not combine tetracycline and isotretinoin
Risk of psychiatric side effects
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Grade IV Acne
Cysts Nodules Scars
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Dermatitis
Inflammation of the skin Sometimes called eczema Many causes and forms (allergic vs non-
allergic) Not contagious Contact dermatitis caused by contact with
noxious substances (formaldehyde, plant oils, rubber, etc)
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Dermatitis-Signs and Symptoms
Pruritis (itching) Erythematous
papules Vesicles (or bullae) Crusting Edema
Poison Ivy, 5 days post exposure
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Dermatitis-Treatment
Identify and remove the etiologic agent
Bullae may be drained, but tops should not be removed
Cool compresses Topical
corticosteroids Contact dermatitis from paraben-containing foot cream
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Dermatitis-Treatment (cont)
In severe cases, systemic corticosteroids may be indicated
Prednisone: two-week course, 70 mg initially, tapering by 5 mg daily
Chronic contact dermatitis on the hands of a concrete worker
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Intertrigo
Caused by friction in skin folds Axilla, inframammary area, groin Gradual and progressive skin abrasion
irritated by sweat and heat
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Intertrigo-Treatment
Mild topical hydrocortisone
Zinc oxide ointment Reduce friction Corn starch/baby
powder Expose to air
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Urticaria
Transient hives characterized by wheals Pruritis Caused by sunlight, medication or food
allergy, cold, and exercise
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Urticaria
Wheals with white-to-light-pink color centrally and peripheral erythema in a close-up view.
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Cholinergic Urticaria
Exercise-induced wheals & pruritis
Hot shower may also reproduce symptoms
Urticarial papules on neck w/in 30 minutes of vigorous exercise
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Cold-Induced Urticaria
Caused by cold sensitivity Ten minute application of ice pack
cause a wheal w/in five minutes of the removal of the ice
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Urticaria-Treatment Oral antihistamines
(Benadryl) Avoidance of
causative agent Prednisone May compete as
long as pruritis is not disabling & breathing not compromised
Urticaria as it appeared 5 minutes after stroking the skin with a wooden stick. The patient had experienced generalizedpruritus for several months with no spontaneously occurring urticaria.
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Psoriasis
Genetically inherited disease Erythematous papules and plaques Primarily on extensor surfaces
– elbows– knees– scalp– intergluteal area
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Psoriasis-Trigger Factors
Trauma (Koebner effect)
Drugs Stress Infections
Psoriasis of the elbow
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Psoriasis-Treatment
Limited course of topical corticosteroids (long term application causes skin breakdown)
Triamicinolone acetonide (Aristocort, Kenalog)
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Psoriasis-Treatment (cont)
Anthralin (Anthra-Derm cream -- not for use on face or skin creases)
Vitamin D analogues (e.g., calcipotriol)
UV light therapy No participation
restrictions
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Seborrheic Dermatitis
Common chronic dermatosis Characterized by redness and scaling
occurring in regions where the sebaceous glands are most active, such as the face and scalp, and in the body folds.
Mild scalp SD causes flaking (dandruff)
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Seborrheic Dermatitis-Treatment
Creams or shampoos containing– selenium (Selsun
Blue)– ketocanazole
(Nizoral)
Similar lesions were also present in the retroauricular areas and presternal chest.
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Pityriasis Rosea Distinctive morphology Characteristic course “Herald” plaque lesion develops, usually on the
trunk, and 1 or 2 weeks later a generalized secondary
eruption develops in a typical distribution pattern
Spontaneous remission in 6 weeks without any therapy
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Pityriasis Rosea (cont)
Herald Patch (80 % of patients) oval, slightly raised plaque
2 to 5 cm, bright red, fine scale at periphery
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Pityriasis Rosea (cont) Long axes of the
lesions follow the lines of cleavage in a “Christmas tree” distribution
Lesions usually confined to trunk and proximal arms and legs
Rarely on face
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Pityriasis Rosea-Treatment Pruritus may be controlled by UVB
phototherapy or natural sunlight exposure if begun in the first week of eruption.
Five consecutive exposures, starting with 80 % of the minimum erythema dose and increasing 20 % each exposure.
Usually goes away by itself.
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Infectious Disorders
Bacterial Infections Fungal Infections Viral Infections
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Bacterial Infections
Impetigo & ecthyma Abscess, furuncle, & carbuncle Scarlet fever
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Impetigo & Ecthyma
Caused by Staphylococcus aureus and Streptococcus pyogenes
Impetigo-epidermis Ecthyma-dermis Superficial breaks in
the skin
Scattered, discrete, thin-walled vesicles and bullae that easily rupture and form erosions.
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Impetigo
Transient superficial small vesicles or pustules, rupture resulting in erosions, which in turn become surmounted by a crust
Crusted (golden-yellow, stuck-on) erosionsbecoming confluent on the nose, cheek, lips, and chin.
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Ecthyma
Ulceration with a thick adherent crust
A large, circumscribed ulcer with a necrotic base andsurrounding erythema in the pretibial region.
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Impetigo & Ecthyma-Treatment
Mupirocin (Bactroban) applied three times daily to involved skin and to nares for 7 to 10 days.
Oral antibiotics (10 day course is typical)
Highly infectious -- disqualify from contact athletics until infection is cleared by physician
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Abscess, Furuncle, & Carbuncle
Abscess - a circumscribed collection of pus appearing as an acute or chronic localized infection with tissue destruction.
Furuncle - an acute,deep-seated, red, hot, tender nodule or abscess that evolves from a staphylococcal folliculitis.
Carbuncle - a deeper infection composed of interconnecting abscesses usually arising in several contiguous hair follicles.
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Abscess
Usually caused by Staphylococcus aureus.
Very tender Warm Will develop a
pustulent headA very tender abscess with surrounding erythemaon the heel.
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Furuncle (boil)
Firm tender nodule 1 to 2 cm
Central necrotic plug. staphylococcal
folliculitis in beard area or neck.
Nodule becomes fluctuant with abscess formation
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Furuncle (boil)
Necrotic plug often topped by a central pustule.
Following drainage a nodule.
A zone of cellulitis may surround the furuncle.
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Carbuncle Evolution similar to that of
furuncle. Comprised of multiple,
adjacent, coalescing furuncles
Characterized by multiple dermal and subcutaneous abscesses,pustules, necrotic plugs, and sieve-like openings draining pus
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Treatment
Incision and drainage
Systemic antibiotics (10 day course)
Local heat Disqualification from
contact sport until resolved
Highly contagious
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Scarlet Fever
Acute infection of the tonsils, skin, or other sites by Streptococcus
Associated with a characteristic toxigenic rash
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Scarlet Fever Erythema on the upper
trunk Face flushed with a
perioral pallor. Linear petechiae
(Pastia’s sign) occur in body folds.
Rash fades w/in 5 followed sheetlike exfoliation on the palms and soles.
Pastia’s Sign
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Scarlet Fever-Treatment Aspirin or
acetaminophen for fever and/or pain
The goal of therapy is to eradicate Streptococcus throat carriage to prevent rheumatic fever.
Drug of choice is penicillin because of its efficacy in prevention of rheumatic fever.
Desquamation of the volar fingertips 10 days after onset of streptococcal pharyngitis in an adult female.
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Fungal Infections
Varieties of Tinea infections Onychomycosis Candidiasis Pityriasis versicolor
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Tinea Pedis (Athlete’s Foot)
Dermatophytic infection of the feet
Erythema,desquamation, and/or bulla formation
Hot, humid weather, occlusive footwear, excessive sweating
Scaling, maceration, erythema, and erosion in the 4-5 webspace. 4th toenail also infected.
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Tinea Pedis (Athlete's Foot)
Walking barefoot on contaminated floors
Arthrospores can survive in human skin scales 12 months.
Pruritus Pain with secondary
bacterial infection
Moccasin type tinea pedis. Erythema, fine white scaling of the plantar and lateral foot, and kerato-derma(thickening of the keratin layer)
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Tinea Pedis-Treatment
Keep feet clean, dry, exposed to air
Dry shoes thoroughly
Terbinafine (Lamisil) cream
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Tinea Manuum Fungal infection of the
hands Diffuse hyperkeratosis
of the palms (especially the creases)
Patchy scaling on the dorsa and sides of fingers
50% of patients have unilateral involvement
Erythema and scaling of theright hand, associated with bilateral tinea pedis; the “one hand, two feet” distribution is typical of epidermal dermatophytosis of the hands and feet.
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Tinea Manuum-Treatment Must eradicate all other
sources of tinea infection
Topicals don’t work (stratum corneum too thick)
Terbinafine (Lamisil) Itraconazole
(Sporanox) Griseofulvin (Grisactin)
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Tinea Cruris (Jock Itch)
Subacute or chronic dermatophytosis of the groin, pubic regions,and thighs.
Warm, humid environment, tight clothing worn by men, obesity.
Pruritis
Erythematous, scaling plaques on the medial thighs,inguinal folds, and pubic area. The margins are raised and sharply marginated.
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Tinea Cruris Most individuals with
tinea cruris have tinea pedis.
Dermatophyte is transferred from feet to crural region by hands.
Affects groins and thighs. May extend to buttocks. Scrotum and penis are rarely involved.
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TOPICAL ANTIFUNGALS
CATEGORIES AGENTS TRADE NAMESImidazoles Clotrimazole Lotrimin, Mycelex
Miconazole MicatinKetoconazole NizoralEconazole SpectazoleOxiconizole OxistatSulconizole Exelderm
Allylamines Naftifine NaftinTerbinafine Lamisil
Naphthiomates Tolnaftate TinactinSubstituted pyridone Ciclopiroxalamine Loprox
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Tinea Cruris-Treatment
Eradicate other sources of tinea infection
Differentiate from intertrigo
Avoid tight clothing Keep dry, cool
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Tinea Corporis (Ringworm)
Dermatophyte infections of the trunk, legs, and arms, excluding the feet, hands, and groin.
More common in animal workers in tropical climates.
Sharply marginated, hyperpigmented plaques of chronic duration. Associated tinea cruris and tinea pedis are usually present.
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Tinea Corporis Often asymptomatic Mild pruritus Scaling, sharply
marginated plaques Peripheral
enlargement and central clearing
Annular configuration with concentric rings Tinea corporis contracted
from a pet guinea pig.
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Tinea Corporis-Treatment
CATEGORIES AGENTS TRADE NAMESImidazoles Clotrimazole Lotrimin, Mycelex
Miconazole MicatinKetoconazole NizoralEconazole SpectazoleOxiconizole OxistatSulconizole Exelderm
Allylamines Naftifine NaftinTerbinafine Lamisil
Naphthiomates Tolnaftate TinactinSubstituted pyridone Ciclopiroxalamine Loprox
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Tinea Facialis (Face Ringworm)
Dermatophytosis of the glabrous facial skin
Well-circumscribed erythematous patch
More commonly misdiagnosed than any other dermatophytosis.
Sharply marginated, erythematous plaque with some central clearing and peripheral scaling on the lower eyelid and cheek
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Tinea Facialis
Pruritus and photosensitivity
Pink to red In black patients,
hyperpigmentation Scaling often is
minimal but can be pronounced
Sharply marginated, erythematous, scaling, and crusted plaques on the face of a child. Note asymmetry.
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Tinea Facialis-Treatment
Topical antifungal preparations
Eradicate dermatophyte infection at other sites such as feet and hands. Tinea Facialis is more
common in children.
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Tinea Capitis
Fungal infection of the scalp
Follicular inflammation with painful, boggy nodules that drain pus
Scarring alopecia Scaling patches
Large, round, hyperkeratoticplaque of alopecia due to breaking off of hair shafts close to the surface, giving the appearance of a mowed wheat field on the scalp of a child.
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Tinea Capitis
Blacks>whites Children>adults Three types
– “Black dot”– Kerion– Favus
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Tinea Capitis-”Black Dot” Type Broken-off hairs near
surface give appearance of “dots” in dark-haired patients
Tends to be diffuse and poorly circumscribed
Resembles seborrheic dermatitis.
A subtle, asymptomatic patch of alopecia due to breaking off of hairs on the frontal scalp in a 4-year-old black child.
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Tinea Capitis-Kerion Type Boggy, purulent, inflamed
nodules and plaques Usually extremely painful Drains pus from multiple
openings Hairs do not break off but
fall out and can be pulled without pain
Heals with scarring alopecia. Large, very painful,
inflammatory tumor with hair loss, studded with multiple pustules on the scalp of a young child.
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Tinea Capitus-Favus Type
Thick yellow adherent crusts (scutula)
Fetid odor Untreated results in
cutaneous atrophy, scar formation, and scarring alopecia.
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Tinea Capitis-Treatment Topical antifungal agents are ineffective in
management of tinea capitis Systemic antifungals should be used until
symptoms have resolved and fungal cultures negative
Terbinafine and itraconazole superior to ketoconazole and all three to griseofulvin. Side effects in increasing order: terbinafine < itraconazole < ketoconazole < griseofulvin
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Tinea Barbae- Ringworm of the Beard
Fungal infection of the beard and moustache areas
Adult males only More common in
farmers Pruritus,tenderness,
pain
Scattered, discrete follicular pustules and papules in themoustache area, easily mistaken for S. aureus folliculitis.
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Tinea Barbae-Treatment
Similar to tinea capitis
Topical antifungals ineffective
Systemic antifungals should be used until symptoms have resolved and fungal cultures negative
Confluent, painful papules, nodules, and pustules on the upper lip. Tinea facialis present on the cheeks, eyelids, eyebrows,and forehead.
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Onychomycosis Toenail becomes
opaque, thickened, cracked, friable, raised by underlying hyperkeratotic debris in the nail bed
Toenails more common than fingernails
When fingernails are involved, pattern is usually two feet and one hand
Distal subungual hyperkeratosis and onycholysis involving most of the nail bed of the great toenails; these findings are usually associated with tinea pedis.
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Onychomycosis-Treatment Does not resolve
spontaneously;invol-vement of multiple toenails is the rule.
Relapse occurs in the majority of persons treated with griseofulvin.
Relapse rate with itraconazole or terbinafine is less than with griseofulvin The proximal nail plate is a chalky white
color due to invasion from the undersurface of the nail matrix. The patient had advanced HIV disease.
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Cutaneous Candidiasis Superficial infection
occurring on moist cutaneous sites
Many patients have predisposing factors that alter local immunity such as increased moisture at the site of infection, diabetes, or alteration in systemic immunity
Erosions on the medial thighs,inguinal folds, and scrotum with “satellite” pustules and papules of an obese male.
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Cutaneous Candidiasis
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Cutaneous Candidiasis
Penis/scrotum Vulva Fingernails Interdigital Treatment is
primarily topical Erythematous eroded area with surrounding maceration in a webspace of the hand occurring in a health care worker is a type of intertrigo.
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Pityriasis Versicolor Also known as tinea
versicolor Yeast infection Usually on the trunk Depigmentation of
the skin Should not disqualify
am athletes from participation
Hypopigmented, sharply marginated, scaling macules on the shoulder area of an individual with brown skin. Gentle abrasion of the surface accentuates the scaling.
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Pityriasis Versicolor-Treatment Selenium sulfide (2.5%)
lotion or shampoo: Apply daily for 10 to 15 minutes, followed by shower, for 1 week.
Azole creams (ketoconazole, econazole, micronazole, clotrimazole): Apply b.i.d. for 2 weeks.
Follicular, hypopigmented macules on the upper chest of an individual with black skin.
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Viral Infections
Molluscum Contagiosum Herpes Warts
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Molluscum Contagiosum
Epidermal viral infection
Skin-colored papules
Children and sexually active adults
Transmission by skin-to-skin contact
Discrete, solid, skin-colored papules, 1 to 2mm in diameter with central umbilication on the chest of an adolescent female. The lesion with an erythematous halo is undergoing spontaneous regression.
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Molluscum Contagiosum In healthy individuals
resolves spontaneously. In HIV-infected
individuals often progresses despite treatment.
Painful aggressive therapy is best avoided.
Avoid skin-to-skin contact
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Herpes Simplex Virus
Three types– Nongenital – Genital – Herpes Gladiatorum
Multiple painful erosions on the lower labial mucosa with erythema and edema of the gingiva; plaque has formed on the teeth because of pain within the lesions that restricts brushing. Fever and tender submandibular lymphadenopathy were also present.
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NongenitalHerpes Simplex
– Grouped vesicles arising on an erythematous base on keratinized skin or mucous membrane
– Lips most common– Incubation 3-12 days– Chronic and
recurrent
A. Grouped and confluent vesicles with an erythematous rim on the lips. B. Edema with crusting of the lips which followed sun exposure; vesiculation is present but difficult to detect because of confluence of lesions. In some cases, crusting is the only finding.
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Nongenital Herpes Simplex Restrict from
athletics until lesions crusted and dry
Acyclovir (Zovirax) 800 mg b.i.d. for 5 days
Valacyclovir (Valtrex) 500 to 1000 mg b.i.d.
Famciclovir (Famvir) Herpetic Whitlow-Painful, grouped, confluent vesicles on the volar finger on an erythematous edematous base.
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Genital Herpes Simplex
– Grouped vesicles at the site of inoculation and inguinal lymphadenopathy
– Flu-like symptoms (myalgia, headache)
– Chronic and recurrent– Oral antiviral meds– May participate
unless they feel too crummy
Group of vesicles with early central crusting on a red base arising on the shaft of the penis.
Multiple, extremely painful,punched-out, confluent, shallow ulcers on the vulva and perineum.
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Herpes Gladiatorum Spread of herpes to
abraded of injured skin Associated with
widespread dermatitis Looks like impetigo Oral antivirals Common in wrestlers No participation until
cleared
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Herpes Zoster (Shingles) Chicken pox virus Distribution along
dermatomes Painful Headache, malaise,
fever Spontaneous resolution
2-3 weeks Analgesics, antivirals
(acyclovir)
Dermatomal, grouped andconfluent vesicles and pustules arising in the third sacral dermatome; note extension of lesions 1–2 cm across themidline.
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Warts Caused by human
papillomavirus (HPV) Three types
– Common warts (verruca vulgaris-70%)
– Plantar warts (verruca plantaris-30%)
– Flat warts (verruca plana-4%)
The thrombosed capillaries (brown dots) differentiate the lesion from a corn or callus.
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Common Warts (Verruca Vulgaris) Palmar lesions
disrupt the normal line of fingerprints. Return of finger-prints a sign of resolution of the wart.
Hands, fingers, knees.
Hyperkeratotic papules becoming confluent around the periungual tissue of four fingers; the brown dots represent thrombosed capillaries.
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Plantar Warts (Verruca Plantaris)
Plantar surface of feet
Often solitary but may be three to six or more
Pressure points, heads of metatarsal, heels, toes
The warts are surrounded by nonwarty callus. Tinea pedis is also present in the webspaces and instep with sites of excoriation.
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Flat Warts (Verruca Plana)
Always numerous discrete lesions, closely set
Face, beard area, dorsa of hands, shins
Flat-topped, pink papules with sharp margination and minimal hyperkeratosis on the dorsum on the hands and fingers.
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Wart Treatments Usually resolve
sponatneously Painful plantar warts
warrant more aggressive treatment
40% salicylic acid plaster for 1 week
Cryosurgery Electrosurgery CO2 laser surgery
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Infestations
Scabies Pediculosis
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Scabies
Mites burrow beneath stratum corneum
Undiagnosed pruritis Palms, wrists,
ankles, nipples, ubilicus, genitals
Acquired sexually or through crowded living conditions
Papules and burrows in typical location on the finger webs.Burrows are tan or skin-colored ridges with linear configuration with a minute vesicle or papule at the end of the burrow and are often difficult to locate.
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Scabies No contact sports until
cleared (1 wk) Examine sexual partners Wash bedding Lindane (Kwell,
Scabene lotion or shampoo). Do not use after bathing, with pregnancy or lactation
Permethrin (Nix lotion)A mite at the end of a burrow with 8 eggs and smaller fecal particles obtained from a papule on the webspace of the hand.
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Pediculosis (Lice)
Pediculosis capitis Pediculosis pubis Pediculosis corporis Highly infectious Pruritis Regional
lymphadenopathy Eggs (nits) adhere to
hair
A crab louse (see arrow) on the skin in the pubic region.
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Pediculosis (Lice)
No contact sports until all nits removed
Examine sexual partners
Wash bedding Lindane (Kwell) Pyrethins (RID, R&C,
A-200 gel, liquid, shampoo)
Crab lice (see arrow) and nits on the upper eyelashes of a child; this was the only site of infestation.
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Skin Cancer
Three major types– Basal cell carcinoma– Squamous cell
carcinoma– Melanoma
Oral Leukoplakia - The lesion, in a heavy pipe smoker, progressed to a verrucous carcinoma.
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Basal Cell Carcinoma
Most common type of skin cancer.
Locally invasive, aggressive, and destructive
Limited capacity to metastasize
Exposure to UV light Large, shiny, red nodule with a cobblestoned surface and an ulcerated nodule.
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Basal Cell Carcinoma Excision with primary
closure, skin flaps, or grafts.
Cryosurgery and electrosurgery
Danger sites - nasolabial area, around the eyes, ear canal, posterior auricular sulcus, scalp - microsurgery required
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Squamous Cell Carcinoma Less common than basal
cell carcinoma Exposure to UV light and
x-rays, arsenic Slowly evolving Cheeks, nose, lips, tips
of ears, preauricular areas, scalp, dorsa of the hands, forearms, trunk, and shins (females) A large notch on the superior
aspect of the helix, a nodule of SCC with hyperkeratosisand ulceration.
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Squamous Cell Carcinoma
Any isolated keratotic or eroded papule or plaque in a suspectpatient that persists for over a month is considered a carcinoma until proved other-wise.
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Squamous Cell Carcinoma
Surgery Microscopically
controlled surgery in difficult sites
Radiotherapy should be performed only if surgery is not feasible
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Melanoma
Most deadly kind of skin cancer
Increasing rapidly Sun exposure? Thinning ozone
layer? Assymetric,pigmente
d, irregular, large lesions
Suspicious nevi: Two large, variegated, brown oval macules.
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Melanoma
Radial growth phase Vertical growth
phase Critical to identify &
treat early during radial growth phase
The lighter macular portion of this lesion is a suspicious nevus on the upper back; theblue-black plaque is a superficial spreading melanoma (1.2 mm thickness). The patient was a 34-year-old internist who died 36 months following detection and excision of this lesion.
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Melanoma Surgery is treatment Suspicious nevi (moles):
– changing (increase in size, change in pigmentation pattern, changes in shape and/or border)
– location that cannot be closely followed by the patient by self-examination (on the scalp, genitalia, upper back)
Melanoma-The left image (1990) shows variegation of pigmentation and irregular borders. Five years later, the lesion (right) shows darkening of melanin pigmentation, more irregularity in shape, and elevation in the most darkly pigmented region.
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Six Warning Signs for Melanoma
A A ASYMMETRY in shape—one-half unlike the other half
B B BORDER is irregular—edges irregularly scalloped
CC COLOR is mottled—haphazard display of colors; shades of brown, black, gray, red, and white
DD DIAMETER is usually large—greater than the tip of a pencil eraser (6.0 mm)
EE ELEVATION is almost always present—surface distortion is assessed by side-lighting.
ENLARGEMENT—a history of an increase in the size of lesion is perhaps one of the most important signs of melanoma
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Dermatology Assessment
General Approach to Patients With Skin Signs and Symptoms
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Epidemiology and Etiology
Age Race Sex Occupation
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History
Duration of onset Relationship of skin lesions to season,
travel history, heat, cold, previous treatment, drug ingestion, occupation, hobbies, effects of menses, pregnancy
Skin symptoms: pruritus, pain, paresthesia
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History (cont)
Constitutional symptoms– “Acute illness’’ syndrome: headaches,
chills, feverishness, weakness– “Chronic illness’’ syndrome: fatigue,
weakness, anorexia, weight loss,malaise
Systems review
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Physical Examination
Appearance of patient: uncomfortable, “toxic,’’ well
Vital signs: pulse, respiration, temperature
Skin—four major skin signs: (1) type, (2) shape, (3) arrangement, (4) distribution of lesions
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Types of Skin Lesions
Macules Papules Plaques Pustules Vesicles
Nodules Desquamination Bullae Ulcers Wheals
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Color and Palpation
White Brown Purple Violet Red “Flesh”
Consistency Temperature Mobility Tenderness Depth of lesion (i.e.,
dermal or subcutaneous)
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Shape Round Oval Annular (ring-shaped) Serpiginous (snakelike) Umbilicated Margination
– well-defined (can be traced with the tip of a pencil)– ill-defined
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Arrangement
Grouped Disseminated
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Distribution
Extent– isolated (single
lesions),– localized– regional– generalized– universal
Pattern– symmetrical– exposed areas– sites of pressure– intertriginous area– follicular localization– random