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Dermatology

By
Katrice L. Herndon, MD
Internal Medicine/Pediatrics
June 2, 2005

What is this?

Acne Vulgaris
Acne is a self-limited disorder primarily of
teenagers & young adults.
Acne is a disease of pilosebaceous follicles.
4 factors are involved:
Retention hyperkeratosis
Increased Sebum production
Propionbacterium acnes within the follicle
Inflammation

Acne Vulgaris
External Factors that contribute to Acne

Oils, greases, dyes in hair products


Detergents, soaps, astringents
Occlusive clothing: turtlenecks, bra straps
Environmental Factors: Humidity & Heavy
exercise.
Psychological stress
Diet is controversial

Acne Vulgaris
Acne vulgaris typically affects those areas of the body that have the
greatest number of sebaceous glands:

the face, neck, chest, upper back, and upper arms.

In addition to the typical lesions of acne vulgaris, scarring and


hyperpigmentation can also occur.

Hyperpigmentation is most common in patients with dark complexions

Acne Vulgaris
Classification of Acne
Type 1 Mainly comedones with an occasional small inflamed
papule or pustule; no scarring present

Type 2 Comedones and more numerous papules and pustules


(mainly facial); mild scarring
Type 3 Numerous comedones, papules, and pustules, spreading to
the back, chest, and shoulders, with an occasional cyst or nodule;
moderate scarring
Type 4 Numerous large cysts on the face, neck, and upper trunk;
severe scarring

Acne Vulgaris

What is this?

Acne Rosacea
Rosacea is an acneiform disorder of middle-aged and
older adults.

Characterized by vascular dilation of the central face,


including the nose, cheek, eyelids, and forehead.

The cause of vascular dilatation in rosacea is unknown.


The disease is chronic.

Acne Rosacea
rosacea is a chronic disorder characterized by periods
of exacerbation and remission.

Increased susceptibility to recurrent flushing

reactions that may be provoked by a variety of


stimuli including hot or spicy foods, drinking alcohol,
temperature extremes, and emotional reactions.

The earliest stage of rosacea is characterized by facial


erythema and telangiectasias.

Acne Rosacea
Patients with rosacea may develop severe

sebaceous gland growth that is accompanied by


papules, pustules, cysts, and nodules.

The diagnosis of rosacea is based upon clinical


findings(1 or more of the following):

Flushing (transient erythema)


Non-transient erythema
Papules and pustules
Telangiectasia

Acne Rosacea
Topical antibiotics or benzoyl peroxide are the
initial treatments of choice.

Tretinoin cream is used in patients with papular or


pustular lesions that are unresponsive to other
treatments.

The chronicity of rosacea requires that medical

therapy be continued long-term, not just for flareups of the condition.

What is This?

Allergic Contact Dermatitis


Contact dermatitis refers to any dermatitis
arising from direct skin exposure to a
substance. It can be allergic or irritantinduced.

An allergen induces an immune response,


while an irritant directly damages the skin.

Allergic Contact Dermatitis


The most common sensitizer in North America is the plant

oleoresin urushiol found in poison ivy, poison oak, and poison


sumac

Other common sensitizers in the US:

nickel (jewelry)
formaldehyde (clothing, nail polish),
fragrances (perfume, cosmetics),
preservatives (topical medications, cosmetics),
rubber
chemicals in shoes (both leather and synthetic)

Allergic Contact Dermatitis


Treatment
Avoidance of exposure to the offending
substance.

Use of corticosteroids topical or oral in the acute


phase of the reaction maybe helpful.

Cooling of the skin by using calamine lotion or


aluminum acetate

What is this?

Psoriasis
Psoriasis is a common chronic skin disorder
typically characterized by erythematous
papules and plaques with a silver scale.

Most of the clinical features of psoriasis


develop as a secondary response triggered
by T-lymphocytes in the skin.

Psoriasis
Several clinical types of psoriasis have been described:
Plaque psoriasis - symmetrically distributed plaques

involving the scalp, extensor elbows, knees, and back.

Guttate psoriasis - abrupt appearance of multiple small


psoriatic lesions.

Pustular psoriasis - most severe form of psoriasis.


Characterized by erythema, scaling, and sheets of
superficial pustules with erosions.

Inverse psoriasis - refers to a presentation involving the


intertriginous areas.

Psoriasis

Nail psoriasis -the typical nail abnormality in


psoriasis is pitting w/ color changes & crumbling of
the nail.

Psoriasis

Psoriasis
Most patients w/ psoriasis tend to have the disease
for life.

There is variability in the severity of the disease


overtime w/ complete remission in 25% of cases.

The diagnosis of psoriasis is made by physical


examination and in some cases skin biopsy.

Psoriasis
Treatment
Treatment modalities are chosen on the basis of
disease severity.
Topical emmollients, topical Steroids, tar
Calcipotriene(Dovonex) affects the growth and

differentiation of keratinocytes via its action at the level of


vitamin D receptors in the epidermis.

Tazarotene, is a topical retinoid, systemic retinoids


Methotrexate, cyclosporine
Immunmodulator therapy (embrel, remicade)
Ultraviolet light.

What is this?

Vitiligo
Vitiligo is an acquired skin depigmentation that affects all races
but is far more disfiguring in blacks.

The precise cause of vitiligo is unknown Genetic factors appear


to play a role.

20-30 percent of patients may have a family history of the


disorder.

The pathogenesis is thought to involve an autoimmune process


directed against melanocytes.

Vitiligo
Peaks in the second and third decades.
The depigmentation has a predilection for acral areas

and around body orifices (eg, mouth, eyes, nose, anus).

The course usually is slowly progressive.


The diagnosis of vitiligo is based upon the clinical
presence of depigmented patches of skin

Vitiligo
Repigmentation therapies include:
corticosteroids
calcineurin inhibitors
Ultraviolet light

Pseudocatalase cream
Surgery minigrafting techiniques
Depigmentation therapy w/ hydroquinone

What is this?

Pityriasis Rosea
Pityriasis rosea is an acute, self-limited, exanthematous
skin disease characterized by the appearance of
slightly inflammatory, oval, papulosquamous lesions
on the trunk & proximal areas of the extremities.

The eruption commonly begins with a "herald" or

"mother" patch, a single round or oval, rather sharply


delimited pink or salmon-colored lesion on the chest,
neck, or back.

2 to 5 cm in diameter.

Pityriasis Rosea

Pityriasis Rosea
A few days later lesions similar in appearance to the herald
patch, appear in crops on the trunk & proximal areas of the
extremities.

The eruption spreads centrifugally or from the top down in


just a few days.

The long axes of these oval lesions tend to be oriented along

the lines of cleavage of the skin, like a christmas tree pattern.

Then the lesions fade without any residual scarring.

Pityriasis Rosea
The presence of a herald patch by history or on
examination.

The characteristic morphology and distribution of


the lesions.

The absence of symptoms other than pruritus

combine to make PR an easy diagnosis in most


instances.

Pityriasis Rosea
Differential Dx include: Psoriasis, secondary syphilis,
tinea corporis, Lyme disease, & drug eruptions.

Treatment is usually reasurrance.

Topical Steroids
Antipruitic lotions (prax, pramagel)
Phototherapy
Erthyromycin in severe cases
Rash usually persists for 2-3 months

What is this?

Cellulitis
Cellulitis is an infection of the skin with
some extension into the subcutaneous
tissues.

An extremity is the most common location


but any area of the body can be involved.

Cellulitis
Five factors were identified as independent
risk factors:
Lymphedema
Site of entry (leg ulcer, toe web intertriginous,
and traumatic wound)

Venous insufficiency
Leg edema
Being overweight

Cellulitis
Cellulitis is a recognizable clinical syndrome with
both local & systemic features.

Systemic symptoms include:


Fever and chills
Myalgias
Increased WBC count

Cellulitis
Local findings typical of cellulitis:

Macular erythema that is largely confluent


Generalized swelling of the involved area
Warmth to the touch of the involved skin
Tenderness in the affected area
Tender regional lymphadenopathy is common
Lymphangitis may be present
Abscess formation also may be present

Cellulitis
Cellulitis in the majority of patients is

caused by beta-hemolytic streptococci


groups A, B, C, G, and Staphylococcus
aureus.

Other less common pathogens include

H.flu, P.aeruginosa, Aermonas hydrophilia,


Pasturella multocida.

Cellulitis
Diagnosis is clinical
Treatment: Anti-strep/Anti- staph

Cefazolin
Nafcillin
Clindamycin
Vancomycin
Fluoroquinolones (3rd & 4th generations)
Macrolides (erythromycin, azithromycin)

Duration of treatment is usually 10-14 days

What is this?

Erysipelas
Erysipelas is a characteristic form of cellulitis that

affects the superficial epidermis, producing marked


swelling.

Bacterial Organisms:

Beta-hemolytic streptococci group A


Group C & G less commonly
Staph. Aureus
Streptococcus pneumoniae, enterococci, gram negative
bacilli

Erysipelas
The erysipelas skin lesion has a raised border which is
sharply demarcated from normal skin.

This is its most unique feature and allows it to be


distinguished from other types of cellulitis.

The demarcation is sometimes seen at bony


prominences.

The affected skin is painful, edematous, intensely

erythematous, and indurated (peau d'orange appearance).

Erysipelas
The face historically was the most common area
of involvement.

Erysipelas is diagnosed clinically


It can mimic other skin conditions:
Herpes zoster (5th cranial nerve)
Contact Dermatitis
Urticaria

Erysipelas
Treatment:

Penicillin is the preferred treatment


Erythromycin
Clindamycin
Fluoroquinolones

Erysipelas does have the propensity of


recur.

What is this?

Ecthyma
Ecthyma is an ulcerative pyoderma of the skin caused
by group A beta-hemolytic streptococci.

Because ecthyma extends into the dermis, it is often


referred to as a deeper form of impetigo.

Preexisting tissue damage (excoriations, insect bites,

dermatitis) & immunocompromised states ( diabetes,


neutropenia) predispose patients to the development
of ecthyma.

Ecthyma
Ecthyma begins as a vesicle or pustule overlying an inflamed area
of skin that deepens into a dermal ulceration with overlying crust.
A shallow, punched-out ulceration is apparent when adherent
crust is removed.

The deep dermal ulcer has a raised and indurated surrounding


margin.

Ecthyma lesions can remain fixed in size or can progressively


enlarge to 0.5-3 cm in diameter.

Ecthyma heals slowly and commonly produces a scar.


Regional lymphadenopathy is common.

Ecthyma
Treatment:
Topical mupirocin ointment
Gentle surgical debridement
Oral/IV antibiotics
Penicillin
Clindamycin
Macrolides
Cefazolin

What is this?

Tinea Vesicolor
Tinea versicolor is a common superficial
infection caused by the organism
Pityrosporum orbiculare.

Which is a saprophytic yeast that is part of


the normal skin flora.

Tinea Vesicolor
Lesions can be hypopigmented, light brown, or salmon
colored macules.

A fine scale is often apparent, especially after


scraping.

Individual lesions are typically small, but frequently


coalesce.

Lesions are limited to the outermost layers of the skin.

Tinea Vesicolor
Most commonly found on the upper trunk &
extremities, & less often on the face and
intertriginous areas.

While most patients are asymptomatic, some


complain of mild pruritus

The diagnosis of tinea versicolor is confirmed by

direct microscopic examination of scale with 10 %


potassium hydroxide (KOH).

Tinea Vesicolor
The differential diagnosis includes seborrhea,
eczema, pityriasis rosea, and secondary syphilis.

Treatment includes topical antifungals. Oral


antifungals can be used for more extensive
disease: Ketocanozole 400mg x 1 dose.
Fluconazole and itraconazole are also effective.

What is this?

Cutaneous Warts
Cutaneous warts AKA verrucae are caused by HPV
which infects the epithelium of skin and mucus
membranes.

Cutaneous warts occur most commonly in children and


young adults.

Also more common among certain occupations such as


handlers of meat, poultry, and fish.

Predisposing conditions include atopic dermatitis & any


condition in which there is decreased cell-mediated
immunity.

Cutaneous Warts
Infection with HPV occurs by skin-to-skin contact
Incubation period following exposure in 2-6 months.
Warts can have several different forms based upon
location & morphology (flat, mosaic, and filiform
warts)

Lesions may occur singly, in groups, or as coalescing


lesions forming plaques.

Cutaneous Warts
The diagnosis of verrucae is based upon clinical
appearance.

Scrape off any hyperkeratotic debris & reveal


thrombosed capillaries (seeds).

The wart also will obscure normal skin markings

Cutaneous Warts
Differential Diagnosis:
Lichen Planus
Seborrheic Keratosis
Acrochordon or skin tag
Clavus or corn
Treatment
Spontaneous regression in 2/3 over 2yrs
Salicylic acid, liquid nitrogen, cantharidin
Cyrotherapy, curettage, laser therapy
Immunotherapy, intralesional injections

What is this?

Secondary Syphilis
Syphilis is a chronic infection caused by the
bacterium Treponema pallidum which is
sexually transmitted.

Syphilis occurs in 3 stages:


1st stage is characterized by the classic chancre,
which is a 1-2cm ulcer with raised indurated
borders, usually painless and occurs at site of
innoculation. Heals spontaneously.

Secondary Syphilis

Secondary Syphilis
Secondary or systemic syphilis is characterized by a rash.
The rash is classically a symmetric papular eruption involving
the entire trunk & extremities including the palms and soles.

Systemic symptoms include fever, headache, malaise, anorexia,


sore throat, myalgias, & weight loss.

Lymphadenopathy (inquinal, axillary)


So-called "moth-eaten" alopecia
Condyloma lata, grayish white lesions involving the mucus
membranes

Secondary Syphilis

Secondary Syphilis
Diagnosis at this stage is usually by serologic testing
but darkfield microscopy can also be done for direct
visualization of spirochete.

Non-treponemal testing:
Veneral disease research laboratory (VDRL)
Rapid plasma reagent (RPR)

Treponemal testing:
Fluorescent treponemal antibody absorption test
Microhemagglutination test for antibodies

Seconday Syphilis
Treatment
T.Pallidum remains very sensitive to PCN.

Long-acting benzathine penicillin G should be used.


If documented chancre or a NR serologic testing was done in
the past 1 yr, one IM dose is appropriate.

If neither of the above applies this needs to treated as latent


syphilis and 3 q week doses must be given.

Doxycycline, erythromycin or zithromycin in pen allergic


patients x 14 days.

What is this?

Herpes Zoster
Reactivation of endogenous latent VZV infection within

the sensory ganglia results in herpes zoster or "shingles",


a syndrome characterized by a painful, unilateral vesicular
eruption in a restricted dermatomal distribution.

How the virus emerges from latency is not clearly


understood.

Patients frequently experience a prodrome of fever, pain,


malaise and headache which precedes the vesicular
dermatomal eruption by several days.

Herpes Zoster
The rash initially appears along the dermatome as grouped

vesicles or bullae which evolve into pustular or


occasionally hemorrhagic lesions within three to four days.

The thoracic and lumbar dermatomes are the most


commonly involved sites of herpes zoster.

The complications of herpes zoster include ocular,

neurologic, bacterial superinfection of the skin and


postherpetic neuralgia

Herpes Zoster
Treatment
Antivirals:
Acyclovir
Famciclovir
Valacyclovir

Antivirals w/ corticosteroids
Analgesics: opioids/acetominophen

What is this?

Actinic Keratosis
Actinic keratoses (AKs) are premalignant

lesions that develop only on sun-damaged


skin.

AKs appear as patches of hyperkeratosis

with some surrounding erythema on sunexposed areas of the head and neck,
forearms and hands, and upper back.

Actinic Keratosis

Actinic Keratosis
The differential diagnosis of AKs includes

seborrheic keratoses, verruca vulgaris, SCC, and


superficial BCC.
The treatment of AKs begins with prevention.
Avoiding sun exposure
sunscreens reduce the development of AKs,
Active treatment of AKs depends upon the size of the
lesion and the number of lesions present.
Liquid Nitrogen

Surgical curettage
Chemotherapy (5-FU, diclofenac, imiquimod)
Dermabrasion
Photodynamic therapy

Which one is which?

Basal Cell Carcinomas begins as small

shiny nodules and grows slowly. It is the


most common form of skin cancer.

Frequently, the central portion breaks down

to form an ulcer with a reddish-purple scab.


These tumors usually remain fairly
localized and rarely spread elsewhere.

Squamous Cell Carcinoma is another common form of

skin cancer. When these tumors first appear they are firm
to the touch. They appear most often on sun-exposed areas
of your body.

Squamous cell carcinoma evolves very slowly through a


premalignant stage known as a solar or actinic keratosis.

Untreated, significant numbers of these lesions can

metastasize to distant sites. Tumors on the lower lip and


ears are at higher risk to spread.

Malignant Melanoma is the most dangerous form of skin cancer.


They arise from either pre-existing moles or normal skin.
Malignant melanoma, like basal and squamous carcinomas, is
linked to overexposure to the sun.

But it can appear any place on your body.


When detected early & with proper treatment, the recovery rate
from this form of skin cancer can be very high.

References
Harrisons 15th Edition. Principles of Internal
Medicine

Up to Date
Emedicine
Dermatology Pearls Adult and Pediatric

Thank You