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Dermatology for the Primary Care Provider

Practical Advances in Internal MedicineApril 14, 2016

Amy Swerdlin Frankel, MDProvidence Medical Group

Overview Common skin conditions and their mimics Atypical presentations of common

dermatologic conditions Treatment pearls

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Case #1 65 y/o M with 1 year h/o of a lesion

growing on his left clavicle Reports occasional bleeding and tenderness

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BCC

Case #2 40 y/o F with 8 month h/o a new growth

on her temple

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Pigmented BCC

Ddx?

Melanoma

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Case #3 85 y/o M with growing ulcer on his lip x 2

years

Squamous cell carcinoma

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Case #4 50 y/o F with 6 month h/o enlarging

growth on her leg

SCC in situ

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Superficial BCC

Case #5 68 y/o F with an enlarging growth on her

back x 8 months

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Melanoma

A – AsymmetryB – BorderC – ColorD – DiameterE – Evolution

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Blue nevus

Seborrheic keratosis

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Seborrheic keratosis

Cherry angioma

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Case #6 59 y/o M with new “brown spot” on his

nose which has been slowly enlarging

DX? MIS (aka lentigo maligna)

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Solar lentigo

Case #7 56 y/o F with 6 month h/o an enlarging

scaly lesion on her arm

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Amelanotic melanoma

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Amelanotic melanoma Up to 8% are this variant Often with hypopigmentation – sign of

regression Do not obey ABCDE rules Treat the same as pigmented melanomas,

but often more advanced due to delayed diagnosis

Case #8 76 y/o M avid golfer with the development

of several scaly lesions on his scalp

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Actinic keratoses

Pigmented actinic keratosis

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Most Common Skin cancers Basal cell carcinoma

~2.8 million cases/year in US Rarely fatal, but disfiguring

Squamous cell carcinoma ~700,000 cases/year in US

~2500 deaths in 2011

Melanoma ~123,590 cases/year in US

~8,790 deaths in 2011 Oregon ranks 5th in nation for new melanoma cases

www.skincancer.org/skincancerfacts

Basal cell

Keratinocyte

Melanocyte

Treatment options Non-melanoma skin cancer

Mohs Excision Curettage and Desiccation Topical chemotherapeutics

Aldara – for superficial BCC, AKs Efudex – AKs, SCCis (off label)

PDT; Cryotherapy – AK’s Radiation therapy

Melanoma 5mm margins for MIS WLE; sentinel node bx if ≥1mm depth OR >0.75mm

with adverse features (high mitotic rate/ulceration)

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Nicotinamide (Vitamin B3) Reduces the incidence of BCC & SCC in

people with a h/o NMSC Decreased rate of developing new NMSC by 23% Decreased rate of developing new AK’s by 13%

500mg PO BID Unlike niacin or nicotinic acid, the amide did NOT

cause HA, flushing or low BP Reports of increased blood sugar & sweating

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Case #9 66 y/o F with new rash x 3 months. Failed

a course of oral lamisil

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Granuloma annulare

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Granuloma annulare Benign inflammatory dermatosis Localized or generalized Associated with diabetes mellitus

Primarily Type I DM 21% of pts with generalized GA compared to

9.7% with localized GA Rarely pre-dates the onset of DM Pearl – check a fasting blood glucose if no

previous h/o DM

Case #10 30 y/o F with worsening acne in pregnancy

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Treatment of acne in pregnancy Topical erythromycin or clindamycin Topical Azelaic acid (Finacea) Oral erythromycin BASE (Base is safe for

Babies)

*Even benzoyl peroxide and salicyclic acid are category C in pregnancy

Case #11 20 y/o F with h/o dry skin who presents

with a diffuse itchy eruption Reports having asthma as a child and currently

has hayfever

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Atopic dermatitis

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Treatment for atopic dermatitis OINTMENTS are better than creams Triamcinolone 0.1% ointment (a favorite) Protopic ointment if on genital skin or face Moisturizing is VERY important

Cetaphil, Cerave or Vanicream (emphasize the jar cream); Vaseline ointment

Gentle moisturizing cleanser Recurrent infections

Always culture pustules! Bleach baths can be helpful Often require oral antibiotics

Allergic contact dermatitis to nickel

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Asteatotic dermatitis/Eczema craquele

Case #12 24 y/o F with h/o atopic dermatitis and a

progressive, painful & pruritic eruption on her face x 2 weeks

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Eczema herpeticum

Eczema herpeticum Complication of atopic dermatitis Viral culture important

Also consider bacterial culture since lesions frequently superinfected with staphylococcus

Treatment Oral acyclovir or Valtrex Ophthalmology consult if near the eye or on

the tip of the nose

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Case #13 26 y/o F with pruritic/burning eruption

around mouth, which recently spread around eyes

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Periorificial dermatitis

Periorificial dermatitis Cross between rosacea, acne & dermatitis Usually there is a history of steroid use Sometimes caused by prolonged topical

tacrolimus use Treatment

Taper topical steroids Can bridge with short course of topical tacrolimus

Oral tetracyclines (MCN or doxy for 6-8 wks) Topical erythromycin, clindamycin, azelaic acid

or metrocream

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Case #14 49 y/o F with 4 year history of acne-like

lesions and flushing

Rosacea

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Management of Rosacea Daily sunscreen important! Avoid triggers (hot fluid, spicy food, EtOH) Screen for ocular rosacea Treatment

Topical: Azelaic acid (Finacea), Metronidazole, Sodium sulfacetamide/sulfur lotion, Ivermectin

Oral: Doxycycline/Oracea, minocycline Flushing & telangiectasias

Laser Mirvaso - Brimonidine 0.33% topical gel (аlpha2

agonist)

Pyoderma faciale / Roscea fulminans

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Case #15 76 y/o F with pruritic and painful eruption

on her legs Has had chronic leg swelling for years

Stasis dermatitis

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Lipodermatosclerosis

Stasis dermatitis Prevention techniques

Leg elevation Support stockings Application of emollient (eg cetaphil cream or

vaseline ointment) Topical steroid if pruritic Associated allergic contact dermatitis in 60%

Compromised barrier allows sensitization to occur more easily

Topical antibiotics are a common cause

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Case #16 36 y/o F with 3 day h/o pruritic eruption

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Pseudomonas hot tub folliculitis Occurs 1 to 4 days after being in hot tub

Warm temps cause free chlorine levels to fall Self resolves in 1 to 2 weeks Can treat with cephalosporin or

fluoroquinolone if systemic symptoms or prolonged disease

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Case #17 57 y/o F with progressive, itchy rash x 5

days Started on trunk and spread to extremities Undergoing treatment for cellulitis

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Morbilliform drug eruption

Drug eruptions Morbilliform 90%

Maculopapular Exanthematous

Urticarial (5%) Papulosquamous Pustular Bullous

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Drug eruptions Pruritus is a common feature

Distinguishes it from a viral exanthem Occurs within first 2 weeks of treatment Simple – cutaneous only

Resolve within 2 weeks after stopping drug Complex – systemic findings

Stevens-Johnson Syndrome, Toxic epidermal necrolysis, DRESS (drug reaction w/ eosinophilia & systemic sx)

If in question, get vitals, CBC, CMP Check for bullae

Morbilliform drug eruptionMost common type of drug eruption

1 to 5% of patients on antibiotics will develop

Don’t have to stop the causative drug In contrast, urticarial drug reaction could

progress to angioedema & anaphylaxis

Common causes Antibiotics (aminopenicillins, sulfa) Anticonvulsants

Treatment Takes days to weeks for rash to resolve Antihistamines and topical steroids

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Case #18 25 y/o F presenting with an asymptomatic

scaly pink eruption She is 12 weeks pregnant

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Pityriasis rosea Affects young adults (10-35 yrs) Peaks in spring and fall Lasts 6-8 wks Rare variant (inverse) is localized to the

axillae and groin Asymptomatic or mildly pruritic Treatment

Reassurance If pruritic: Topical steroids, Antihistamines If extensive: acyclovir

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Special consideration Reactivation of HHV-6 or HHV-7 Associated with miscarriage if develops in

the first 15 weeks of pregnancy

Case #19 61 y/o F with 8 month h/o itchy rash in

her groin

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Inverse psoriasis

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Plaque psoriasis

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Psoriasis Always ask about arthritis

Can be debilitating if left untreated Affects up to 30% of psoriatic patients

Increased risk for cardiovascular disease If guttate morphology

Consider throat culture to r/o strep infection

Nummular dermatitis

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Tinea corporis

Subacute cutaneous lupus

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Lichen planus

Wickham striae

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Mycosis Fungoides (CTCL)

Thank you! Our Office:

PMG-Dermatologic Specialties5330 NE Glisan St., Suite 200Portland, OR 97213

Phone: 503-215-9080

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Case #12 26 y/o M with spreading fine scaly rash x

3 months Rash is more prominent after tanning

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KOH

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Tinea Versicolor Caused by lipophilic yeast – Malassezia

Malassezia is naturally found on human skin Enzyme tyrosinase causes hypopigmentation Not contagious Recurrence is common Pigmentation change generally improves 2

months s/p treatment Treatment

Selenium sulfide 2.5% shampoo Ketoconazole shampoo Oral fluconazole

Case #15 32 y/o M with 3 month h/o pruritic

generalized eruption Temporary relief with topical steroids and oral

antibiotics

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Scabies!

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Scabies prep Try to find burrows Scrape several lesions until pinpoint bleeding

Buttocks and acral skin typically high yield Place scrapings on slide

Add a few drops of mineral oil Place a cover slide

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Eggs

Feces

Nodular scabies

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Scabies Often takes close family members three

months to show symptoms All close contacts need to be treated

Topical 5% permethrin – repeat in 1 wk Oral ivermectin

Post-scabetic itch is common Can last for a few months s/p treatment Treatment with topical steroids

Case #11 16 y/o M with long h/o acne

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Comedonal acne

Inflammatory acne

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Cystic acne

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Hormonal acne

Acne treatment Comedonal

Tretinoin Adapalene (differin) Tazorac (category X in pregnancy)

Inflammatory Tretinoin Topical antibiotics (ie clindamycin) Oral antibiotics (ie doxycycline or minocycyline) OCPs, Spironolactone – if hormonal distribution Benzoyl peroxide lotion and/or wash

Cystic Isotretinoin

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Case #21 18 y/o M present with very itchy blisters

on his face and extremities

Dermatitis herpetiformis

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Dermatitis herpetiformis Chronic autoimmune blistering disorder

associated with celiac disease >90% have underlying gluten-sensitive

enteropathy even though 20% have GI sx Often complete remission on gluten-free diet

Dapsone also effective Diagnosis

Biopsy for H&E and DIF Celiac panel (anti-endomysial, anti-tissue

transglutaminase, anti-gliadin antibodies) DH + positive celiac blood tests = Celiac dz

Case #25 46 y/o F with new onset pruritic eruption x

2 months Temporary relief with oral prednisone, but it

recurred

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Lichen planus

Wickham striae

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Lichen planus Flat-topped violaceous polygonal papules

Look for surface white streaks (Wickham striae) Many clinical variants

Ulcerative mucosal LP – increased risk of SCC Predilection for flexor surfaces, but can also

have genital, oral, and nail involvement Pruritus a prominent feature 2/3 resolve spontaneously in <1 year Can be related to hepatitis C

Case #24 59 y/o F presented with new skin lesions

in addition to weight loss

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MetastaticSignet cell carcinoma

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Case #25 78 y/o F hospitalized with failure to thrive,

diarrhea and a painful erosive eruption Refractory to oral fluconazole and antibiotics

Acquired acrodermatitis enteropathica

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Case #16 27 y/o F presenting with skin darkening

on the legs for 1 year

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Erythema ab igne Reticulated (net-like) hyperpigmentation

due to chronic thermal injury Common causes

Space heater Heating pad Laptop computer

Pigmentation changes may be permanent Very low risk of developing SCC

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How to biopsy Reinforce to the patient: the biopsy itself

is for diagnosis and is NOT the definitive treatment

Take enough tissue for the pathologist to make a diagnosis, but try to minimize scarring in cosmetically sensitive areas

Biopsy technique pearls Rash

4mm punch biopsy x 2 Neoplasm

Shave biopsy

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Biopsying melanocytic lesions The more raised the nevus, the deeper it

penetrates into the dermis Do a deep shave biopsy to superficial SubQ

if concerned about melanoma Can do a punch biopsy if the nevus is small

and fits completely within the punch Make sure that the diameter of the punch is

larger than the neoplasm

SHAVE BIOPSY EXAMPLE

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Clean skin with alcohol swab

Anesthetize w/ lidocaine (1%) with epinephrine (1:100,000)

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PUNCH BIOPSY EXAMPLE

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Pull skin taut perpendicular to skin tension lines

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Hold & cut from base of specimen; try not to damage epidermis

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