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Dermatology for Internists

Dermatology for Internists. Susan Riggs Runge, MD January 2008. Pictures. Pictures of common and less common skin lesions Cover each topic very briefly Realize most of you have vast experience in seeing many of these lesions in your years of practice

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Dermatology for Internists

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  1. Dermatology for Internists Susan Riggs Runge, MD January 2008

  2. Pictures • Pictures of common and less common skin lesions • Cover each topic very briefly • Realize most of you have vast experience in seeing many of these lesions in your years of practice • This is a very superficial review of topics I hope you may find interesting • All slides and photos are available at: http://medicine.med.unc.edu/education/dermatology_for_internists.ppt

  3. Lupus Erythematosus • One of the papulosquamous diseases • Papules and scaly areas • Other papulosquamous diseases include: psoriasis, tinea, seborrheic dermatitis, pityriasis rosea, syphilis, lichen planus and other more rare skin disorders • Many of these have differentiating characteristics but lots of overlap clinically makes skin biopsy particularly helpful in many cases

  4. Acute Cutaneous Lupus

  5. Dilated capillary loops along nail fold This can also be seen in dermatomyositis and other connective tissue diseases Acute Cutaneous Lupus

  6. Malar erythema, can involve neck, forehead and periorbital area in photodistribution Erythema and sometimes edema of V of neck, forearms Look for ulcers on the hard palate ANA positive 60-80% will have positive dsDNA Other tests: CBC, ESR, UA, skin biopsy Treatments: Prednisone, hydroxychloroquine Referral to rheumatologist Acute Cutaneous Lupus

  7. Subacute Cutaneous Lupus

  8. Annular scaly erythematous patches in sun-exposed areas Worse upon sun exposure Non-scarring Many patients have arthralgias expecially of hands and wrists Consider drugs as cause: HCTZ, calcium channel blockers, ACE inhibitors, terbinafine and TNF-antagonists SCLE (subacute cutaneous lupus)

  9. Erythematous scaly patches between the knuckles (unlike Gottron’s papules of dermatomyositis which are on the knuckles) Hands in Subacute Cutaneous Lupus

  10. Most are ANA positive Most are Anti-Ro (SS-A) positive 1/3 will meet criteria for systemic lupus Other lab tests: CBC, ESR, UA, Rheumatoid factor, complement levels, skin biopsy Treatment: Stop suspected drugs, sunscreen, hydroxychloroquine Refer to rheumatologist if joint involvement, nephrologist if renal involvement, etc Subacute Cutaneous Lupus Labs

  11. Subacute Cutaneous Lupus-more subtle

  12. Discoid Lupus

  13. Hyperpigmentation and hypopigmentation Atrophy of skin These lesions cause SCARRING Skin lesions occur in photodistributed areas (wider distribution may correlate with greater likelihood of SLE) Discoid lesions and follicular prominence in conchae of ears Discoid lupus

  14. Ear Lesions in Discoid Lupus

  15. ANA positive in 5-20% Do CBC, ESR, Rheumatoid factor, UA, complement levels, skin biopsy Discoid Lupus Labs

  16. These patients rarely progress to SLE (5%) Rarely have systemic disease Treatment: sunscreen, topical steroids, intralesional steroids, hydroxychloroquine Referrals as indicated Discoid Lupus

  17. Other Papulosquamous Diseases: Psoriasis

  18. Psoriasis

  19. Well-demarcated erythematous plaques Thick white or silvery scale Knees and elbows classically, can be scalp only or diffuse Also favors gluteal cleft, navel Psoriasis

  20. Not very itchy Scale is thicker and whiter than with fungal infection Less scaly in moist areas (in body folds) or if partially treated Psoriasis

  21. Psoriasis of scalp

  22. Psoriasis

  23. NOT psoriasis-cutaneous T cell lymphoma

  24. Cutaneous T-cell lymphoma Could mimic psoriasis Atypical locations Biopsy should differentiate Refer skin problems that are atypical or do not resolve as expected Not psoriasis - CTCL: does not have thick scale

  25. Allergic Contact Dermatitis

  26. Localized to area of contact Scaly erythematous plaques Can be blistering On eyelids, can be due to nail polish Allergic Contact Dermatitis

  27. Allergic Contact Dermatitis

  28. Allergic Contact Dermatitis-fragrance

  29. Allergic Contact Dermatitis-diethylthiourea in scuba diving gear

  30. Cinnamon often used as flavoring agent in gum or toothpaste Allergic Contact-cinnamon

  31. Identify and avoid allergen if possible Increase moisturization of skin Topical steroid as needed Rarely oral steroid if severe Allergic Contact Dermatitis

  32. Linear blisters are classic for allergic contact dermatitis due to poison ivy Allergic Contact-Poison Oak

  33. Allergic Contact Dermatitis-more subtle

  34. Erythematous patches on skin Thick, yellow greasy scale Seborrheic distribution: eyebrows, sides of nose, nasolabial folds, ear canals, chest More severe in patients with HIV or Parkinson’s disease Seborrheic Dermatitis

  35. Nasolabial fold Chin area Ear canal Seborrheic Dermatitis

  36. Dermatophyte

  37. Superficial fungal infection of skin Tinea

  38. Tinea named by location: tinea capitis, tinea corporis, tinea manum, tinea pedis, tinea barbae (beard), tinea cruris (body fold especially groin and pubic area), tinea unguium of nails (onychomycosis) Tinea corporis

  39. Erythematous annular plaques Not as well-demarcated as psoriasis Scaly, itchy Involved areas tend to fade centrally Treat with topical antifungal if limited area or oral agent if extensive Tinea faceii

  40. Tinea Corporis

  41. Causes itching and scaling of scalp More common in children Hair may break just beyond follicle Often more than one family member affected Can be severe and cause hair loss which can be scarring (loss of follicles) Tinea Capitis

  42. Tinea Capitis

  43. Tinea pedis

  44. Tinea-more subtle

  45. Atopic Dermatitis

  46. Atopic Dermatitis (Eczema)

  47. Nummular Eczema

  48. Severe Atopic Dermatitis

  49. Our Recommendations: Bathe in tepid water with mild soap Moisturize skin frequently with vaseline or other thick cream Topical steroids as needed for control Rarely treated with oral immunosuppressive Atopic Dermatitis

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