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Dermatology for Out-Patient Internal Medicine

Dermatology for Out-Patient Internal Medicine. Crystal Wiley Cen é, MD,MPH. Objectives. Recognize some common dermatologic conditions seen in the office setting. Identify other diseases that appear similarly and may confuse diagnosis

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Dermatology for Out-Patient Internal Medicine

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  1. Dermatology for Out-Patient Internal Medicine Crystal Wiley Cené, MD,MPH

  2. Objectives • Recognize some common dermatologic conditions seen in the office setting. • Identify other diseases that appear similarly and may confuse diagnosis • Learn basic treatment of these conditions, (as well as what doesn’t require treatment). • Recognize the psychosocial implications of these conditions.

  3. Quick definition review • A) Papule/Plaque: • superficial, elevated, palpable lesion ≤0.5 cm; >0.5 cm. • B) Macule/Patch: • circumscribed colour change without elevation or depression. • C) Vesicle/Bulla: • like A), but containing fluid. • D) Nodule: • palpable, solid, deeper than A). • E) Wheal: • pale red, palpable, superficial lesion, evanescent, disappearing in 1-2 days. From edema in the papillary layer of the dermis. • F) Pustule: • like C), only with purulent exudate as the fluid.

  4. Histology: layers of skin • Epidermis: outer, waterproof, protective layer. Contains melanocytes and keratinocytes. • Dermis: collagen and elastin for toughness and elasticity • Hypodermis: subcutaneous tissue, mainly fat. Padding, blood supply.

  5. Papulopustular • 14 yo M w/ red papulopustular rash for 6m. Getting worse. “is it because I eat fast food?” • Diagnosis: • Acne Vulgaris • Etiology: • Excess sebum production, hair follicle hyperkeratinization blocks sebum release, causing buildup of sebum, lipids, cellular debris  ideal for bacterial growth. • 38 yo F “I keep getting acne on my cheeks and chin. I thought I was done with this years ago!” • Diagnosis: • Rosacea • Etiology: unknown, strong genetic link

  6. Acne vulgaris • desquamation of keratinocytes within the pilosebaceous unit • increased sebum production, • proliferation of Propionibacterium acnes • and inflammation

  7. Treatment of Acne

  8. Treatment: Rosacea • Early: • avoidance of triggers • sunscreens • topical antibiotics • systemic antibiotics • oral isotretinoin • Metronidazole/Flagyl • Late: • Laser treatments • Other: • Associated blepharitis • rhinophyma

  9. Vesicular 7 yo with itchy rash & fever x1d, feels unwell. Blisters on red base. New lesions are still appearing. Diagnosis: - Varicella (chicken pox) When is it infectious? - from 1-2 days before rash develops, until after last lesion scabs over. When will I know if I have it? - 1.5-2.5 wks after exposure

  10. Vesicular 64 yo M w/burning pain for 3 days, now with rash on back “in a stripe” Diagnosis: Herpes Zoster Etiology: VZV reactivation Treatment: - Acyclovir <72 hr, +/- oral prednisone - Treat for 7-10 days Why treat? - reduce pain/duration of lesions Is this contagious? How? When do you need to refer? to whom?

  11. Papular 27 yo M, no pmhx, w/itchy rash “all over” body for 3 days. It started with this patch here 1 wk ago… Diagnosis: Pityriasis rosea -“Christmas tree” pattern - Herald patch 1-2wks before rash appears

  12. Etiology unknown Lesions on “Langer’s lines” Differential diagnosis: drug eruption secondary syphilis tinea corporis viral exanthem guttate psoriasis Treatment?? anti-pruritics Pityriasis Rosea

  13. Papulosquamous • 28 yo F says “I’ve always had itchy arms, but it’s been awful this winter”. History of asthma, seasonal allergies • Diagnosis: • Atopic dermatitis/ Eczema • cheeks/extensor surfaces (infant) • Flexure surfaces (older) How is this rash different? • 14 yo F “This rash has been spreading for 3 months” • Diagnosis: • Contact dermatitis • To what? • Nickel (belt buckle, button)

  14. Dermatitis/Eczema • Treatment for all types: • Avoid triggers • Allergens • Excessive bathing • Emollients (Eucerin, Aquaphor, …glycerin content is key) • Topical steroids • Immune modulators: tacrolimus/ Protopic, pimecrolimus/Elidel, …?safe in kids (not under 2) • STOP SCRATCHING! • Lichenification • Infection-impetigo

  15. Papular rashes A Rash A: started 1 hour ago, very itchy, first episode Rash B: present for 2-3 months, not responding to OTC steroid cream. A) Urticaria/wheals- allergic reaction AKA “hives” B) Tinea corporis- well demarcated patches with central clearing “ringworm” B

  16. Papular rashes: Treatment Urticaria: - H1-blockers What else should you be concerned about? Tinea Corporis: - topical antifungal - continue for 1-2 wks after lesions resolve. Can he go to school?

  17. Hypopigmented A What makes these rashes so different? A- symmetric, complete depigmentation. Clear edges. B- decreased pigmentation, edges flake when scratched A) Vitiligo; can occur at any age. - autoimmune disease B) Pityriasis versicolor; young adults. - colonization by Malassezia furfur (yeast) B

  18. Pathophysiology A- Vitiligo A- autoimmune destruction of melanocytes. B- depletion of melanosomes in keratinocytes B- Pityriasis versicolor

  19. Vitiligo: Treatment Autoimmune disease: - associated with thyroid dz & diabetes - commonly affects: perioral, hands, shins, genitals Rx: - topical steroid, PUVA - support group - cosmetics

  20. P. Versicolor: Treatment - selenium sulfide 2.5% shampoo x1wk - alt: ketoconazole shampoo x3-5d (or oral azole -1 dose) - may take months to repigment after summer - prevent recurrence with repeat Rx qmonth x3m

  21. Scalp lesions • 9 yo boy sent home from school, removes hat to show you this red, scaly lesion. You see tiny black dots in an area of alopecia, with a fine scale. • Diagnosis? • Tinea capitis • Differential? • Treatment? • Oral griseofulvin until 2 wks beyond clinical resolution

  22. T. Capitis • Mother brings in 4 yo w/lg. red exudative swelling on head. Diagnosis? • Tinea capitis w/kerion • What do you have to tell mom? • Scarring alopecia will result. • Treatment? • As above, but with po steroids • 2 weeks after treatment begins, a widespread pruritic eczematous rash erupts… What is this? • Id reaction to the fungus • Rx with lubricants and topical steroids and continue on griseofulvin for a complete course

  23. Nodules: spot diagnoses • Very soft, mobile, slow-growing in 50 yo M • Slips under fingers • Diagnosis: • Lipoma • Firm, slow-growing, central dark spot • Diagnosis: • Epidermoid cyst • Keratin plug helpful for diagnosis

  24. Nodules: treatment • Usually not necessary • However… • May become painful or inflamed. • Poor cosmesis… • Surgical removal • Must remove capsule or lesion will recur

  25. Conclusion • Generalists physicians encounter a wide variety of dermatologic lesions in a wide variety of stages. • History and clinical picture are often enough to make the diagnosis • Attempts at self-treatment present additional diagnostic challenges. • Most conditions are common and easily treated or self-resolve…but for those that are not… • Biopsies may be needed for definitive diagnosis.

  26. Questions?

  27. Acknowledgements and Bibliography • Adapted from lecture by Nicole Tan Kirchen, MD, MPH • Up-to-date • Google images • American Family Practice • Pediatrics • Fitzpatrick Atlas of Clinical Dermatology • www.dermatlas.com

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