dermatology look a likes -...

DERMATOLOGY LOOK‐A‐LIKES

PEGGY VERNON, RN, MA, C‐PNP,FAANP

©PVernon2019

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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DISCLOSURESDISCLOSURES

• There are no financial relationships with 

l d lcommercial interests to disclose

• Any unlabeled/unapproved uses of drugs or • Any unlabeled/unapproved uses of drugs or 

products referenced will be disclosed

©PVernon2019

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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RESTRICTIONSRESTRICTIONS

P i i   t d t  th    N ti l N  • Permission granted to the 2019 National Nurse 

Practitioner Symposium and its attendees

• All rights reserved.  No part of this presentation may 

b d d d d fbe reproduced, stored, or transmitted in any form or 

by any means without written permission of the 

author

©PVernon2019

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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ObjectivesObjectives

b d l h fI.  Describe and list two treatment choices   for 

tinea capitus p

II. Identify two clinical differences between  

pityriasis rosea and tinea corporis. 

III   D ib   h  diff  i   l  b  III.  Describe the difference in scale between 

atopic dermatitis and psoriasis©PVernon2019

p p

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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Alopecia Areatap

• Localized area of hair loss in round, oval, or reticulated, diffuse patterns

• Noninfectious, nonscarring

• Scalp is the most Scalp is the most common site

• Can occur at any age, but most common <25 years most common <25 years of age

• 10‐20% have family history of AA

©PVernon2019

history of AA

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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Diagnosis Alopecia Areatag p

l d• Visual diagnosis

• KOH and fungal cultures 

negative

• ANA to rule out SLE• ANA to rule out SLE

• RPR to rule out 

secondary syphilis

• Biopsy

©PVernon2019

p y

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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Treatment Alopecia Areatap

• Systemic  topical  • Systemic, topical, 

intralesional 

corticosteroidscorticosteroids

• Off label: Imiquimod 

(Aldara®), anthralin, 

squaric acid, 

immunomodulators

• Psychological support

©PVernon2019

g

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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Associated Disorders

• Associated autoimmune disorders: thyroiditis, y ,

Down syndrome, autoimmune 

polyendocrinopathy‐candidiasis‐ectodermal 

dysplasia syndromedysplasia syndrome

• Nails:  fine pitting (hammered brass), mottled 

lunula, rough nails, separation of nail from matrix 

©PVernon2019

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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Tinea Capitus• Most common fungal 

infection in children• More common in black 

boys• Noninflammatory scaling Noninflammatory scaling 

and broken‐off hairs• Severe, painful 

inflammation with boggy inflammation with boggy nodules (kerion) can result in scaring 

• Palpable lymph nodes• Palpable lymph nodes• Contagious

©PVernon2019

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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Treatment Tinea Capitusp• Topical antifungal agents 

ineffective• Griseofulvin:  Microsized 

15mg/kg/day for at least 6 weeks to several months; better with high fat mealbetter with high fat meal

• Terbinafine:  250 mg/day (10mg/ml solution) 4‐6 weeks

• Itraconazole:  100mg capsules Itraconazole:  100mg capsules or oral solution (10 mg/ml) 3‐4 weeks

• Fluconazole:  6mg/kg/day 2 k kweeks, repeat at 4 week 

intervals• Ketoconazole: 5mg/kg/day

©PVernon2019

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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Adjunctive Therapyj py

P d i   /k /d  • Prednisone 1mg/kg/day 

for 14 days for painful 

kerion

• Systemic antibiotics for • Systemic antibiotics for 

culture positive for 

s.aureus or GAS

• Surgery to drain kerion©PVernon2019

Surgery to drain kerion

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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Wooly Hair SyndromeWooly Hair Syndrome

• Light colored 

• Sparse distribution

• Coarse  woolly hair• Coarse, woolly hair

• Short, kinky, slow 

growing

©PVernon2019

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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ASSOCIATED ABNORMALITIESASSOCIATED ABNORMALITIES

• Autosomal recessive:  palmoplantar 

h k h l hhyperkeratosis, heart anomalies, right 

ventricular cardiomyopathyventricular cardiomyopathy

• Present at birth

• Autosomal dominant most common

©PVernon2019

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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TREATMENTTREATMENT

l l bl• No treatment currently available

• Screen for heart anomalies• Screen for heart anomalies

• Genetic counselingg

©PVernon2019

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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Pityriasis AmiantaceaPityriasis Amiantacea• Distinct scalp disorderp• Female predilection:  young 

adults, adolescents, and childrenchildren

• Clinical diagnosis:  Adherent thick silver scales which 

d  d bi d d  h i  surround and bind down hair tufts.  Scale attached to hair shaft and scalp

• Scale resembles asbestos• Fungal cultures usually negative• Staph most common

©PVernon2019

• Staph most common

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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Pityriasis Amiantacea TreatmentPityriasis Amiantacea Treatment

• Mineral oil soaks prior to • Mineral oil soaks prior to 

shampoo

• Keratolytic shampoo:  

Salicylic acid, Clobetasol, 

Silver sulfadiazine, 

ketoconazole

• Topical corticosteroids

• Oral Antibiotics©PVernon2019

Oral Antibiotics

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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Papulosquamous Disorders

©PVernon2019

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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Tinea Versicolor

• Latin:  “Tinea of various • Latin:   Tinea of various colors”

• Yeast Malassezia furfurYeast Malassezia furfur• Multiple oval macules• Fine scale• Fine scale• Neck, shoulders, chest, 

upper back  armsupper back, arms• Color dependent on 

season and pigmentation©PVernon2019

season and pigmentation

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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Diagnosis and Treatment• KOH:  multiple short, curved 

hyphae and circular spores‐‐‐spaghetti and meatballs

• Wood’s light:  orange fluorescence

• Topical antifungal creams:  costly

• Ketoconazole or selenium • Ketoconazole or selenium sulfide shampoo   30 minutes daily for one week then monthly for  3 monthsmonthly for  3 months

• Oral ketoconazole, fluconazole, or itraconazole daily for 2 

f ff©PVernon2019

weeks for difficult cases 

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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Pityriasis Roseay

• Herald patch:  oval, Herald patch:  oval, salmon colored patch with fine collarette of scale; develops over 1‐2 ; pweeks

• Smaller oval plaques follow lines of Blashko in follow lines of Blashko in “christmas tree”configuration

• Usually confined to trunk  • Usually confined to trunk, proximal arms and legs, rarely on face; never on palms and soles

©PVernon2019

palms and soles

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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Diagnosis and Treatmentg

• Biopsy if unclear• Biopsy if unclear

• Spontaneous remission in 

6‐12 weeks

• Treat symptomatically:Treat symptomatically:

– Antihistamines for itching

– Topical glucocorticoids

– UVB

©PVernon2019

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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Nummular Dermatitis• Latin: nummularis “like 

”a coin”

• Plaques and papulesaques a d papu es

• Erythema, scale, often 

crusted 

• Pruritus often intense• Pruritus often intense

©PVernon2019

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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Diagnosis and Treatmentg

• Bacterial culture of crusts

• Topical steroids• Antihistamines for 

itching• Moisturizers• Systemic antibiotics if 

S.aureus is present

©PVernon2019

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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Tinea Corporisp

O     l • One or several circular 

th t  erythematous patches

• Central clearing, occasionally follicular pustules

• Usually unilateral©PVernon2019

y

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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Diagnosis and Treatment• Visual diagnosis• KOH:  scrapings of the border 

of the lesion• Fungal culture• Misdiagnosed cases treated g

with topical steroids will not display scaling; annular border may be obscured (tinea incognito)

• Treat with topical antifungal agents BID for 2‐3 weeks to 

l lensure complete resolution• Occasionally oral antifungal 

agents for severe or l

©PVernon2019

recalcitrant cases

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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Psoriasis

• Erythematous/violaceous plaques and papules with thick silvery‐white scale, sharply marginated

• Scalp, ears, elbows, knees, gluteal crease

• Guttate: Latin guttata “dew drop”• Guttate: Latin guttata dew drop

– Discrete papules mostly on trunktrunk

– Follows URI, Strep

©PVernon2019

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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Diagnosis and Treatmentg• Visual Diagnosis• Culture for oral and rectal strep; 

ASOASO• Treat with oral antibiotics for 

guttate • Moderate to high potency 

steroidssteroids• Topical calcipotriene (Vitamin D3 

analog)• Topical tazoratene (Vitamin A)

UVA UVB• UVA;UVB• Systemic steroids 

contraindicated• Educate: chronic nature of 

didisease• Guttate:  likely to develop plaque 

psoriasis within 5 years

©PVernon2019

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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F  D i iFoot Dermatitis

©PVernon2019

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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PsoriasisPsoriasis

• Thick scale• Fissures and Bleeding• Only on the soles of 

feet• Previously treated with 

topical anti‐fungal creams

• Long‐standing history

©PVernon2019

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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PSORIASIS DIFFERENTIALPSORIASIS DIFFERENTIAL

• Tinea Pedis

• Atopic Dermatitis

• Contact Dermatitis

• Psoriasis

©PVernon2019

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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PSORIASIS

• 1‐3% of the population

• 25‐45 & after age ten

• one third of adults with psoriasis developed before • one‐third of adults with psoriasis developed before 

age 16

• Both sexes affected equally in adults

• Familial tendency

• Up to 42% have psoriatic arthritis©PVernon2019

Up to 42% have psoriatic arthritis

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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PSORIASIS PATHOPHYSIOLOGYPSORIASIS PATHOPHYSIOLOGY

Ch i  i fl t   t i  di• Chronic, inflammatory, systemic disease

• Epidermis thickened, silver‐white scaleEpidermis thickened, silver white scale

• Transit time from basal cell layer to surface of 

skin in 3‐4 days, compared to normal cell 

t it ti   f  8 dtransit time of 20‐28 days

• Itching variable©PVernon2019

Itching variable

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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PSORIASIS TREATMENT• Ultraviolet B (UVB)

• Ultraviolet A (UVA) • Systemic DrugsA it ti  (S i t ®)• PUVA (psoralens with UVA)

• Home UVB

– Acitretin (Soriatane®)– Methotrexate (MTX)– Cyclosporine (CsA)– Apremilast (Otezla®)– Adjunct Therapies

– Topical Steroids

Vit i  A  d D d i ti

– Apremilast (Otezla®)• Biologic Therapy

– Alefacept (Amevive®)– Etanercept (Enbrel®)– Vitamin A and D derivatives

– Topical calcineurin inhibitors

Intralesional steroid 

ta e cept ( b e )– Adalimumab (Humira®)– Infliximab (Remicade®)– Ustekinumab (Stelara®)– Intralesional steroid 

injections

– Coal Tar (Scytera®)

– Ixekizumab (Taltz®)– Secukinumab (Cosentyx®)– Tildrakizumab (Ilumya®)

©PVernon2019

Coal Tar (Scytera )

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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PITTED KERATOLYSIS• Superficial bacterial infection 

of the soles of the foot, lateral toes, occasionally , ypalms

• Asymptomatic erythematous plaques and circular shallow p qpits on weight‐bearing areas; occasionally painful

• Often misdiagnosed as tineag• Hyperhidrosis, moist socks, 

humid environment, occlusive shoes and 

l dprolonged immersion in water are predisposing factors

©PVernon2019

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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TreatmentTreatment• Remove environment, promote drynessRemove environment, promote dryness

• 20% aluminum chloride (Drysol®) BID

• Alcohol‐based benzoyl peroxide

• Topical erythromycin or clindamycin

©PVernon2019

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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Warts• HPV induced benign 

epidermal tumorsS li     l i l   ki• Solitary or multiple, skin‐colored to light tan

• Grouped  appear within • Grouped, appear within sites of trauma

• Variable history, incubation y,unknown, transmission to others well‐documented

• Spontaneous remission within 24 months

©PVernon2019

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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TreatmentHIn‐office

• Cryotherapy

Home

• Cantharidin

• Injection therapy

• OTC products

• Injection therapy

– Candida• Squaric Acid

• Immiquiod – Bleomycin

• Laser therapy

q

• Retinoids py

• Surgical excision• Cimetidine 

• Watchful Waiting©PVernon2019

Watchful Waiting

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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Tinea Pedis

• Most common in post‐Most common in postpubertal

• Vesicles and erosions on instep

• Occasional fissuring between toes with erythema and scale f d kof surrounding skin

• Dorsum of toes and feet sparedspared

• Often unilateral

©PVernon2019

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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Diagnosis and Treatment

• Visual diagnosis

• KOH

• Fungal culture

• Treat:  topical Treat:  topical 

antifungal creams BID 

for  2‐4 weeks

• Rarely oral medications©PVernon2019

Rarely oral medications

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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Dyshidrotic Eczemay

• Recurrent eruption of palms  soles  lateral palms, soles, lateral aspects of digits

• Inflammatory vesicles, Inflammatory vesicles, pruritic, burn

• Symmetricaly• Hyperhidrosis

©PVernon2019

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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TreatmentTreatment• Dry environment

• Aluminum chloride 12% (Certain Dry®) or 

20% (Drysol®)

• Topical steroids• Topical steroids

• Tacrolimus (Protopic)  ointment; p

Pimecrolimus (Elidel)

©PVernon2019

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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Juvenile Plantar Dermatosis

• Cracked, shiny, dry on , y, y

weight‐bearing surface

• Painful fissures

• Common in children • Common in children 

and preadolescents

• Symmetrical

©PVernon2019

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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Treatment• Ointments (Aquaphor, 

Vaseline) immediately Vaseline) immediately 

after removing shoes 

d  kand socks

• Cotton socks

• Topical steroids for 

inflammationinflammation

• Immunomodulators

©PVernon2019

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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Nail DisordersNail Disorders

©PVernon2019

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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LICHEN PLANUS

• Unique inflammatory cutaneous and mucocutaneous eruption

• Unknown etiology• Unknown etiology• Purple, flat‐topped 

polygonal papules• Oral lesions on buccal 

mucosa (wickham’s striae)N i   f th   il   ith • Narrowing of the nails with overgrowth of fibrous tissue proximally to distally

©PVernon2019

©Pvernon 2015

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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LICHEN PLANUS: TREATMENT

• Topical corticosteroids p

• Antihistamines for 

pruritus

• Immunomodulators• Immunomodulators

• Permanent damage g

rare

©PVernon2019

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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Twenty Nail Dystrophy(T h h )(Trachyonychya)

• Longitudinal ridgingg g g

• Pitting

• Loss of Lustre

R h i   f  il • Roughening of nail 

surface

• Change in color:  

dd h©PVernon2019

muddy, grey‐white

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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PSORIASIS NAILS

• Pittingg

• Yellowing of distal 

tiportion

• Separation of nail plate 

(onycholysis)

• Thickening of entire Thickening of entire 

nail (hyperkeratosis)

©PVernon2019

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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Psoriasis Nails Treatment• Corticosteroids

• Tazorac gel .05‐.1%

C l i i  • Calcipotriene 

• Moisturizers

• Treat underlying 

disease

• Keep nails trimmed©PVernon2019

• Keep nails trimmed

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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Onychomycosis (Tinea unguium)

• Fungal infection of the nail

• Hyperkeratotic brittle nails with Hyperkeratotic brittle nails with 

thick sub‐ungual debris

• Caused by dermatophytes, Caused by dermatophytes, 

Candida, or molds

• Risk Factors:  poor circulation, p ,

diabetes, perspiration, humid 

environment, damp public 

places (gyms, swimming pools, 

shower rooms), presence of 

h f l f©PVernon2019

other fungal infections

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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Onychomycosis Diagnosis and T t tTreatment

• Diagnosis:  clinical, KOH smear, l b h dculture, biopsy with PAS (periodic 

acid‐Schiff stain)• Treatment: 

– Topical:  Ciclopirox (Penlac, Loprox TS) daily, amorolfine weekly  efinaconazole (Jublia®) weekly, efinaconazole (Jublia ) daily

– Oral:  Terbinafine (Sporonox®) 6%  ff ti  It l  76% effective, Itraconazole (Lamisil®) 60% effective, Fluconazole 48% effective

©PVernon2019

– Laser therapy:  low quality

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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Alopecia Areata Nailsp

• Disorder of 

keratinkeratin

• Treat underlying • Treat underlying 

disorderd so de

• Moisturizers©PVernon2019

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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Nail Tic

• Repeated trauma to 

il  t inail matrix

• Transverse ridgesTransverse ridges

• Central depressionp

• Cuticle hypertrophy

©PVernon2019

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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Nail Tic

• Repeated trauma to Repeated trauma to 

nail matrix

• Transverse ridges

• Central depression

• Cuticle hypertrophy

©PVernon2019

Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2

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OnychomadesisOnychomadesis

• Painless Painless 

spontaneous 

separation of 

i l  il  lproximal nail plate

©PVernon2019

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Onychomadesisy

• Trauma (e g  subungual • Trauma (e.g. subungual haematoma)

• Inflammation or infection (fever, HFM disease)

• Peripheral vascular diseaseR d’• Raynaud’s

• Familial trait

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MelanomaMelanoma

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ReferencesBobonich, M, Nolen, M. Dermatology for Advanced Practice Clinicians. Wolters Kluwer, 2015. First Edition.

• Bolognia, Jean L., et al. Dermatology.  Mosby, 2003.• Habif, Thomas.  Clinical Dermatology. Fourth Edition, Mosby, 

2004.4• Schachner, Lawrence A. & Hansen, Ronald C. Pediatric 

Dermatology, Third Edition, Mosby, 2003. • Wolff  Klaus & Hohnson  Richard A  Fitzpatrick’s Color Atlas & Wolff, Klaus & Hohnson, Richard A. Fitzpatrick s Color Atlas & 

Synopsis of Clinical Dermatology, Sixth Edition, McGraw Hill, 2009

• Pediatric Annals, Vol. 36, No 12, Dec. 2007; Persistent Facial Pediatric Annals, Vol. 36, No 12, Dec. 2007; Persistent Facial Dermatitis: Pediatric Perioral Dermatitis.

• Consultant for Pediatricians, Vol. 8, No. 3, March 2009; Dermclinic.

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