tropical dermatology - wrair.army.mil for ft... · tinea cruris tinea manuum tinea pedis tinea...
TRANSCRIPT
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UNCLASSIFIED Slide 1
Tropical Dermatology COL Mark Kortepeter, MD, MPH
Associate Dean for Research Consultant to the Army Surgeon General for Biodefense
Uniformed Services University, Bethesda, MD September 2014
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UNCLASSIFIED Slide 2
Thanks to:
Boris D. Lushniak, MD, MPH RADM USPHS, Deputy Surgeon General Adjunct
Professor Dermatology, USUHS
Without his expertise, leadership, and instruction, this slide set would not be in existence.
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UNCLASSIFIED Slide 4
Overview
•The Derm Evaluation and Lexicon •Common Conditions in Global Dermatology •Fungus Among Us •That’s Just Nasty •Infestations and Ectoparasites •A Potpourri of Interesting Diseases •Don’t forget the rule of twos:
– STIs, trauma, birth defects
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UNCLASSIFIED Slide 5
Overview
•The Derm Evaluation and Lexicon • Common Conditions in Global Dermatology
• Fungus Among Us
• That’s Just Nasty
• Infestations and Ectoparasites
• A Potpourri of Interesting Diseases
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UNCLASSIFIED Slide 6
Military Perspective
Historically, diseases of the skin have not been accorded the concern they deserve. This fact may result from the low mortality…The high morbidity rates and the non-effectiveness rates, however, demand critical attention to the skin…
Brig Gen (ret) Andre J. Ognibene Medical Corps, US Army 1977
Skin diseases such as infections, infestations, and immersion foot may devastate the fighting strength of a unit by incapacitating its soldiers…It is important to keep in mind that incapacity due to skin disease is usually preventable.
LT GEN Alcide M. LaNoue The Surgeon General, US Army 1994
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UNCLASSIFIED Slide 7
Dermatologic Evaluation
• History • Subjective symptoms • Clinical signs
– Physical examination of the skin
• Laboratory examinations – Scrapings – Culture – Biopsy
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UNCLASSIFIED Slide 8
Examination
• It’s all about observation! • Well lit room or in natural sunlight • Magnification • Palpation (ahem…wear gloves) • Wide angle to close up approach
Issues of undressing (i.e. chaperone)
Teledermatology A derm consult is just a click away if you have a camera 23.4% of teleconsults in FY13 were to dermatology 40.2% of teleconsultations in general have been to derm 46 unneccessary evacuations prevented
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UNCLASSIFIED Slide 9
The Lexicon Dermatological Terms
It’s all about having common ground for
communication
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UNCLASSIFIED Slide 10
Cutaneous Signs
• Primary lesions – original lesions
• Secondary lesions – modified by regression, trauma (scratching), extraneous factors
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UNCLASSIFIED Slide 11
Primary Lesions
• Macules • Papules/Plaques • Nodules • Tumors • Wheals/hives • Vesicles/bullae • Pustules
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UNCLASSIFIED Slide 12
Configuration
• Linear • Annular (complete circle) • Arcuate (portion of circle) • Polycyclic (intersecting circles) • Serpiginous (snaking) • Guttate (small drops) • Nummular (coin-shaped)
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UNCLASSIFIED Slide 13
Cutaneous Symptoms
• Pruritus / pruritic – itching • Burning • Tingling • Pain • Numbness
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Macules / Macular
• Non-palpable changes in skin color
• Circular, oval, irregular • Discrete or confluent. • Patch > 1 cm
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Papules / Plaques
Discrete elevations without visible fluid.
Rounded, conical, flat-topped, umbilicated, capped by scales (squamous papules)
Plaque = Broad papule or confluence > 1 cm
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Wheals / Hives
• Evanescent, edematous, plateau-like elevations
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Nodules
• Morphologically similar to papule > 1 cm, deep
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Tumors
• Soft or firm, freely movable or fixed masses of various sizes and shapes (usually > 2 cm)
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Vesicles / Bullae
• Circumscribed, fluid-containing epidermal elevations
• Bullae > 1 cm
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Pustules
• Small elevations containing purulent material
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UNCLASSIFIED Slide 21
Secondary Lesions Look for patient-caused changes
• Scales (exfoliation) • Crusts (scabs) • Excoriations and abrasions (scratch marks) • Fissures (cracks, clefts) • Erosions (loss of epidermis) • Scars • Ulcers (excavations)
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UNCLASSIFIED Slide 22
Ulcers
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UNCLASSIFIED Slide 23
Overview
• The Derm Evaluation and Lexicon
•Common Conditions in Global Dermatology • Fungus Among Us
• That’s Just Nasty
• Infestations and Ectoparasites
• A Potpourri of Interesting Diseases
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UNCLASSIFIED Slide 24
Some Common Conditions in Global Dermatology
• Dermatitis and eczema
• Pyoderma (bacterial infections)
• Pigmentary disorders
• Other common disorders (psoriasis, warts, miliaria, insect bites)
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UNCLASSIFIED Slide 25
Dermatitis
• Inflammation of the skin • Contact is most common type
•Poison ivy is most common
Vesicles usually indicate an acute process
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Photosensitivity and Photodermatoses
• Phototoxic --furocoumarins (limes), coal tars, drugs (antimicrobials, anitmalarials)
• Photoallergic -- fragrances, sunscreens, plants
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UNCLASSIFIED Slide 27
Eczema (atopic dermatitis) 9yo Afghan girl with itchy red skin
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Pyoderma
• Most common -- impetigo, furunculosis
• Staph aureus and Group A (Beta-hemolytic) strep
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UNCLASSIFIED Slide 29
Staphylococcal SSTI
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UNCLASSIFIED Slide 30
Uptodate.com
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UNCLASSIFIED Slide 31
Uptodate.com
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UNCLASSIFIED Slide 32
Staphylococcal SSTI
• Treatment – Warm compresses – Incision and Drainage (send culture if you can) – Antibiotics if:
• Large abscess • Surrounding cellulitis • Immunocompromised • Systemic signs or symptoms
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UNCLASSIFIED Slide 33
Staphylococcal SSTI
• Antibiotics – Need to consider MRSA
• Oral options – Trimethoprim-sulfamethoxazole1-2 DS tabs
BID – Clindamycin 300-450 mg TID – Linezolid 600 mg BID – Doxycycline 100 mg BID – Minocycline 200 mg X1, then 100 mg BID – Tedizolid 200 mg once daily
– 5 to 7 days of therapy is generally sufficient
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UNCLASSIFIED Slide 34
Staphylococcal SSTI
• Antibiotics – IV options for severe disease
• Vancomycin 15 – 20 mg/kg/dose every 8-12 hours • Daptomycin 4 mg/kg once daily • Linezolid 600 mg BID • Telavancin 10 mg/kg once daily • Dalbavancin 1g on day 1, then 500 mg on day 8 • Ceftaroline 600 mg every 12 hours • Tedizolid 200 mg BID
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UNCLASSIFIED Slide 35
Ecthyma gangrenosum (p. aeruginosa)
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Folliculitis
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UNCLASSIFIED Slide 37
Pigmentary Disorders -- Vitiligo
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UNCLASSIFIED Slide 38
Psoriasis
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UNCLASSIFIED Slide 39
Verruca (Warts)
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Miliaria (prickly heat, heat rash)
• Blockage of sweat ducts • Hot, humid environments
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UNCLASSIFIED Slide 41
Insect bites
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UNCLASSIFIED Slide 42
Bedbugs
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UNCLASSIFIED Slide 43
Overview
• The Derm Evaluation and Lexicon
• Common Conditions in Global Dermatology
•Fungus Among Us • That’s Just Nasty
• Infestations and Ectoparasites
• A Potpourri of Interesting Diseases
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UNCLASSIFIED Slide 44
Superficial mycoses (surface to surface) Tinea (Pityriasis) versicolor
Candidiasis
Dermatophytosis (true tinea/ringworm)
Subcutaneous mycoses (penetration) Sporotrichosis, Phaeohyphomycosis, Chromoblastomycosis
Systemic mycoses (inhalation) Histoplasmosis, coccidioidomycosis, and others
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UNCLASSIFIED Slide 45
Tinea versicolor
• Chest, neck, back
• Malassezia furfur
(or Pityrosporum ovale) is not truly “tinea”
• Asymptomatic hypo- or hyperpigmented slightly scaley patches
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UNCLASSIFIED Slide 46
Can you appreciate the scale?
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UNCLASSIFIED Slide 47
Tinea (Pityriasis) versicolor
hyphae spores
“spaghetti & meatballs”
• Treatment- – Topical azole – Oral ketoconazole (take 1 pill, sweat, then wait to
shower)
• Most recur
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UNCLASSIFIED Slide 48
Candidiasis
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UNCLASSIFIED Slide 49
Dermatophytes • Three closely related genera
subsist on keratin in stratum corneum
– Microsporum – Trichophyton – Epidermophyton
Tinea “X” Tinea corporis Tinea capitis Tinea cruris Tinea manuum Tinea pedis Tinea unguium Tinea faciei Tinea barbae
Source Anthropophilic
Geophilic
Zoophilic
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UNCLASSIFIED Slide 50
Tinea (dermatophyte) infections Clinically:
Central clearing Elevated borders Any part of body Round, red, scaling Central clearing Can be polycyclic
Treat with topical antifungals
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UNCLASSIFIED Slide 51
- Annular scaly itchy plaques
- Varying degrees of redness
- Scale at margin
Trichophyton rubrum Microsporum canis
Tinea corporis (Common ringworm)
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Tinea Cruris: Clues to diagnosis Symmetric half-rings on medial inner
thighs Spares scrotum (less keratin) Scale at margin
KOH and culture cinch the diagnosis Prevention: “Hang loose” Treatment: topical antifungal
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UNCLASSIFIED Slide 53
Inflammatory in the web-spaces
Burning, itching
Sometimes polymicrobial
Exacerbated in humid tropics
Uncommon in barefoot populations
Tinea pedis (Inflammatory)
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UNCLASSIFIED Slide 54
Tinea pedis
-Scaling +/- erythema -Occasionally blisters -Treat with Lamisil (Terbinafine) or Clotrimazole
for 4-6 weeks -Antifungal powders (Zeasorb AF or Tolnaftate)
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UNCLASSIFIED Slide 55
Diagnosis: KOH, culture
Examined with lactophenol cotton blue
Skin scraping with potassium hydroxde (KOH) shows fungal hyphae
Culture with Sabauraud’s agar
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UNCLASSIFIED Slide 56
Diagnosis: DTM, fluorescence
Dermatophytes will turn DTM (Dermatophyte Test Medium) from orange to red
Several fungi will fluoresce under ultraviolet light (Wood’s lamp)
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UNCLASSIFIED Slide 57
Allylamines
Terbinafine, naftifine, etc.
Fungicidal (inhibit fungal cell wall formation)
Best coverage for dermatophytes Marginal coverage for yeast (i.e. Candida)
Come in cream, spray, and powder
Usually cream BID continued until one week after clinical
clearance
Powder can be excellent prevention measure for patients with recurrent tinea pedis or cruris (usually related to underlying hyperhidrosis)
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UNCLASSIFIED Slide 58
Azoles
• Clotrimazole, miconazole, etc.
• Fungistatic (inhibit fungal cell membrane formation)
• Cover both dermatophyte and yeast decently
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UNCLASSIFIED Slide 59
Polyenes
Nystatin Fungicidal (binds candida cell membranes)
Excellent coverage for candida, does not kill
dermatophytes Cream for drier, irritated skin such as diaper dermatitis
Powder for macerated skin such as intertrigo between
skin folds
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UNCLASSIFIED Slide 60
Gentian Violet
• Very messy; stains
• Traditional “anti-infective” treatment, rarely used in USA
• Gentian violet can be painted onto bacterial or fungal infections and left to dry
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UNCLASSIFIED Slide 61
Onychomycosis • Several different clinical
presentations based on fungal entry point into the nail unit
• Proximal subungual pattern should prompt HIV test
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UNCLASSIFIED Slide 62
Treatment of Onychomycosis Terbinafine (Lamisil): 250mg po qd x 90 days
Itraconzaole (Sporonox) 200mg bid for 1 week q month x 4 months
Treatment is largely cosmetic and optional
Non-dermatophyte
Scytalidium, Scopulariopsis, Fusarium
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UNCLASSIFIED Slide 63
Posterior cervical adenopathy
Scaly scalp
Patchy hair loss
Tinea capitis: dandruff-like
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UNCLASSIFIED Slide 64
Hairs broken off at surface produce black dots.
No erythema
Non-inflammatory. Hairs break off at skin surface.
Commonly due to Trichophyton tonsurans
Sometimes fluorescing Microsporum audouinii
Tinea capitis: black-dot ringworm
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UNCLASSIFIED Slide 65
Intensely inflamed boggy nodule A robust immunologic response, often to few organisms. May resemble bacterial abscess and be colonized. Kerions often cause scarring (irreversible) alopecia.
Tinea capitis: Kerion
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UNCLASSIFIED Slide 66
. Kerion • Microsporum canis • Oral antifungals and systemic steroids
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UNCLASSIFIED Slide 67
T. capitis Treatment
• Oral antifungal agents - griseofulvin - newer azoles (eg, fluconazole) - terbinafine (Lamisil) • Topicals alone are ineffective - Nystatin has no effect - Selsun or Nizoral shampoo may help
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UNCLASSIFIED Slide 68
Many deep fungal infections can present as leg ulcers
• Sporotrichosis • Blastomycosis • Coccidioidomycosis • Cryptococcosis • Histoplasmosis • Protothecosis • Chromoblastomycosis
Protothecosis
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UNCLASSIFIED Slide 69
Chromoblastomycosis Usually one lower extremity Male Farmers Fonsecaea pedrosoi
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UNCLASSIFIED Slide 70
Chromoblastomycosis
• Treatment is difficult • Small lesions: surgical excision or LN2 • Itraconazole or Terbinafine
Below: fungal elements found in smear taken from ulcer
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UNCLASSIFIED Slide 71
Lobomycosis (Lacazia loboi) • Acquired from soil, water, vegetation in forested areas
• Recurrence common
• Amazonian wetlands
• Small lesions- surgical excision
• Itraconazole & Clofazimine
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Sporotrichosis
• Nodules with lymphatic spread and ulceration
• Sporothrix schenkii
• Worldwide
• Itraconazole
• Potassium Iodide
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UNCLASSIFIED Slide 73
Differential for sporotrichoid spread aka Lymphocutaneous syndrome • Sporotrichosis • Nocardiosis • Leishmaniasis • Tularemia • Atypical mycobacteria (esp M. marinum)
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UNCLASSIFIED Slide 74
Rhinosporidiosis • Rhinosporidium seeberi
• India, East Asia, Latin America
• Mucosal polypoid lesions
• Bleed easily
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UNCLASSIFIED Slide 75
Rhinosporidiosis Treatment
• Destruction of involved area by excision or electrosurgery
• Antifungals are of little value
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UNCLASSIFIED Slide 76
Humanitarian mission in Darfur
• Several men have similar appearing painless, swollen feet
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UNCLASSIFIED Slide 77
Mycetoma (“fungal tumor”) Madura foot (maduramycosis)
Sites of minor trauma and exposure to decaying wood Foot/leg (75%), upper back Clinical triad of :
Tumefaction Draining sinuses Extruded grains
Etiology and treatment (True fungal vs bacterial)
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UNCLASSIFIED Slide 78
Mycetoma Actinomycetoma: antibiotics targeting causative
organism Eumycetoma: Combo surgery and Antifungal
therapy