back to the basics lmcc preparation dermatology
DESCRIPTION
Back to the Basics LMCC Preparation Dermatology. Jim Walker Assoc. Clinical Prof. Medicine Dermatology. Websites. Ottawa U Dermatology Block Slides http://www.med.uottawa.ca/curriculum/dermato.htm UBC Dermatology Undergraduate Problem Based Learning Modules http://www.derm.ubc.ca/teaching - PowerPoint PPT PresentationTRANSCRIPT
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Back to the BasicsLMCC Preparation
Dermatology
Jim WalkerAssoc. Clinical Prof. Medicine
Dermatology
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Websites• Ottawa U Dermatology Block Slides
http://www.med.uottawa.ca/curriculum/dermato.htm• UBC Dermatology Undergraduate Problem Based Learning Modules
http://www.derm.ubc.ca/teaching• Good Quiz site & Resource – Johns Hopkins Univ.
http://dermatlas.med.jhmi.edu/derm/• eMedicine Textbook
http://www.emedicine.com/derm/index.shtml• Medline
http://www.ncbi.nlm.nih.gov/pubmed• University of Iowa Dept of Dermatology
http://tray.dermatololgy/uiowa.edu/home.html• Dermatology Online Atlas
http://dermis.multimedica.de/
• * Please do not use images without attribution or permission!
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Morphology• Living gross pathology of skin, hair nails and visible
mucosae• Review basic lesions, the nouns (papules, ulcers etc.)• Add the adjectives (size, shape, colour, texture, etc.)• Consider distribution, symmetry and pattern• Visual literacy: simple descriptions→complex
interpretations (you see, but do you observe?)• Excellent lighting• Position patient• Look all over (skin, mucosa, hair, nails) • Observe and think
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Pathology – high degree of clinical pathological correlation
Assess depth of lesion in skin
Dermatopathology
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Bacterial Skin Disease
• Barrier – dry, tough, acidic, Ig in sweat, epidermal turnover every 28 days
• Normal Flora: Gm+, yeasts, anaerobes, Gm-
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Bacterial Skin Diseases
• Impetigo– Bullous and non-bullous
• Folliculitis/furuncle• Erysipelas/cellulitis• Necrotizing Fasciitis• Toxin diseases: SSSS, Scarlet fever, toxic shocks• Superantigen: Staph. aureus in atopic derm.• Pseudomonas: warm, moist, alkaline
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Impetigenization (bullous) of pre-existing dermatosis
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Impetigenized Atopic(Non-bullous)Staph. > strep.
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Erysipelas
-Strep. pyogenes-Dermal infection-Asymmetrical, sharp demarcation-Spreading-Septic patient
Treatment Oral – amoxacillin 500 QID x
14 days IV – if severe or recurrent, or co-morbidities
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Cellulitis – haemorrhagic
-usually Strep. pyogenes-deep dermal and sub-cutaneousTreat – as for erysipelas, but cover for Staph.
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Necrotizing Fasciitis
-Pain out of proportion to apparent lesion-Strep or multi-bacterial deep infection-Emergency debridement and multiple IV antibiotics
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Meningococcal septicaemia
PetechiaePurpuraNecrosis
Treatment-blood cultures-immediate IV antibiotics-lumbar puncture-support for gram
negative endotoxic shock
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Meningococcal Disease• Septicemia vs meningitis
- 40-70% vs 10% mortality
• Peaks: infancy to 5 years - Second peak age 15
• Infection and Endotoxin and DIC cause damage
• Rash subtle at first- Erythema→purpura →necrosis- Search for petechiae / purpura
- “any febrile child with a petechial rash should be considered to have meningococcal septicemia, and treatment should be commenced without waiting for further confirmation.”
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SSSSprimary Staph. infection conjunctivitis
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Staph. Scalded Skin SyndromeSSSS – same child, back, sterile blisters-epidermolytic toxin mediated disease
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31 yr. gay male admitted for biopsy of lymph node for expected lymphoma. Rash noted, dermatology consulted.Widespread papular eruption with adenopathy.
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Soles of same patient.
Your diagnosis?
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Secondary syphilis
-a systemic disease-order STS and treponemal tests-LP?
Treatment -Benzathine penicillin 2.4 million
units IM -Herxheimer reaction -follow STS -report disease -contact tracing -check for other venereal diseases
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Secondary syphilis
Condylomata lata
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Viral Skin Disease
• DNA – tend to proliferate on skin• RNA – tend to be erythemas/exanthems• Exanthem – epidermal/skin• Enanthem - mucosal
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Definitions
• Exanthem(s) = Exanthema(ta), (Greek)– A bursting out (ex) in flowers (anthema)– Any dermatosis that erupts or “flowers” quickly– Only the erythemas are numbered– Includes papular, vesicular, pustular eruptions
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Classic ExanthemsErythemas of Childhood
1 Rubeola - Measles2 Scarlet Fever3 Rubella – German Measles4 Kawasaki disease5 Erythema Infectiosum6 Roseola Infantum - Exanthem Subitum
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Human Herpes Virus
1 HSV-12 HSV-23 VZV4 EBV5 CMV6 Roseola7 ?8 Kaposi’s Sarcoma
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Measles – morbilliform erythemaRed measles = rubeolaKoplick’s spots in oral mucosa, early
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Rubella with post auricular nodes(German measles)
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Erythema infectiosum = Parvo virus B19 = slapped cheek syndrome
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Erythema infectiosumReticulate erythema on arms
Treatment – supportive
Systemic-arthritis in adults-hydrops fetalis-anaemia
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Toxic erythema
-viral-scarlet fever-drug- acute collagen vascular
disease
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Herpes simplex, recurrent, post pneumococcal pneumonia
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HSV 2, genital
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Herpes virus – Tzanck smear – multinucleated giant cells
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Eczema herpeticum
HSV in atopic dermatitis
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Herpes zoster = recurrence of Varicella Zoster virus
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Herpes virus, treatment
• Acyclovir, famciclovir, valacyclovir• Must treat early (72 hours)• Front end load dose• Shortens course and reduces severity• Does not eliminate virus
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MC in Atopic
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Post herpetic Erythema Multiforme
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Herald plaque - pityriasis rosea
annular, NOT fungus
Cause unclear, probably infectious (HHV7)
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Pityriasis rosea
Diagnosis-symmetrical discrete oval salmon-coloured papules and plaques, collarette scales
Treatment-UVL-erythromycin 250 QID, early-hydrocortisone cream if itchy-lasts 6-12 weeks, no scars
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Common (vulgar) warts
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Plantar Wart
-demarcation
-dermatoglyphics
-micro-haemorrhage
-lateral tenderness
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Mosaic plantar warts
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(Plantar) Wart, Treatment Summary
• Respect natural history• First do no harm• Cryotherapy• Caustics: salicylic acid, lactic acid, cantharadine• Other chemicals: imiquimod, fluorouracil• Immunotherapy: DPCP• Surgery: curette only, no desiccation, no excision• No radiation
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HIV – primary exanthem
This rash not a problem.
It’s the permissive effect of immune suppression that allows other infections and tumors to kill
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Primary HIV Infection• Lapins et al BJD 1996, 22 consecutive men• HIV Exposure
– Acute illness 11–28 days, Seroconvert in 2–3wks– Fever 22, pharyngitis21, adenopathy21,– Exanthem day 1-5 of illness– Upper trunk and neck, discrete non-confluent red
macules and maculopapules in 17 / 22– Enanthem of palatal erosions in 8 / 22
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Fungal Skin Infections
• Superficial and Deep• Superficial
– Tinea plus location– Tinea = dermatophyte– Lives on keratin (non-viable)– Tinea versicolour is misnomer = dimorphic yeast
– Hair and nail infections must be treated systemically (terbinafine, griseofulvin)
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Tinea capitis – Trichophyton tonsurans
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Id reaction from Tinea capitis
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Lymphadenopathy with tinea capitis
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Kerion – tinea capitis, not bacterial infection
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Tinea pedis - interdigital
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Tinea pedis – moccasin pattern
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Tinea manuum – 1 hand, 2 feet
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Tinea incognito – topical steroids
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Tinea incognito from topical steroids
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Tinea faciei
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Onychomycosis = tinea unguium
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Tinea – source of recurrent infection
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Yeast infection
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Tinea - Management
Diagnosis• Scrape• KOH• Fungal culture – 3 weeks
Treatment• Topical – azoles: clotrimazole, ketoconazole cream
BID x 2-3 weeks, terbinafine cream similar• Oral – must use for hair and nails. Terbinafine 250
mg. OD for 4-12 weeks for adult
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N.A. Blastomycosis
Deep fungal infections – invade viable tissue
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Blastomycosis
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Blastomycosis
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Deep Fungal InfectionsManagement
Diagnosis• Tissue culture• Skin biopsy with special stainsTreatment• Amphotericin B, IV -if multi-organ infection• Itraconazole, po -if minimal disease in healthy
patient
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Break Time
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Eczema• A morphological diagnosis based on observations
of the inflammatory pattern in the skin• Eczema is not an etiologic diagnosis• Eczema is a subgroup of dermatitis• Etiology: exogenous vs endogenous• Acute signs: erythema, edema, edematous papules,
vesicles, erosions, crusting, secondary pyoderma• Chronic signs: lichenification, scales, fissures,
dyspigmentation• Borders usually ill-defined
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Atopic Dermatitisendogenous
• To make a diagnosis of atopic dermatitis (Hanifin) - must have 3 or more major features:1) pruritus2) typical morphology and distribution
• flexural lichenification• facial and extensor involvement in infants and children
3) chronic or relapsing dermatitis4) personal family history of atopy
• Plus 3 or more minor features:
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Endogenous - Pompholyx of Palms, sago vesicles, acute phase
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Chronic palmar eczema, fissures and scale
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Atopic dermatitis
Anti-cubital lichenificationBlack skin
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Atopic dermatitis – anticubital lichenification with impetigenization
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Severe lichenification – ankles, chronic phase
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Exogenous - allergic contact dermatitis, poison ivy, acute signs
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Rhus radicans
The rashThe plant
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Patch testing, to diagnose cause of allergic contact dermatitis
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Impetigenized eczema – what is the cause?
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Diagnosis = Scabies infant
Eczema caused by infestation
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Scabies Burrows, sole
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Scabies Burrows - finger
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Scabetic nodules in infant
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Scabetic nodules, adult scrotum
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Eczema - Treatment
• Remove or treat the cause• General measures
– Optimise the environment for healing– Compress if moist, hydrate if dry
• Topical – Corticosteroids: hydrocortisone, betamethasone, clobetasol– BID max. frequency– Ointments, creams, gels, lotions
• Systemic– Prednisone: define endpoint, always warn of osteonecrosis
• Phototherapy
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Scabies - treatment
• Permethrin 5% cream or lotion neck to toes overnight
• Treat all close contacts whether itchy or not• Wash clothes and bed-sheets• Set aside gloves for 10 days• Nodules may persist few months• May use topical steroid after mites dead
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Psoriasis
• T-cell disease, Th1 inflammatory pattern• Morphology• Symmetry (endogenous)
• Plaque: sharply demarcated plaque with coarse scale across whole lesion.
• Guttate: drop-like or papular variant of plaque psoriasis
• Pustular (sterile) and erythrodermic forms are more inflammatory and unstable
• Erythrodermic – involves > 90% skin
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Erythemato-squamous Diseasesdifferential diagnosis
• Psoriasis• Seborrheic dermatitis• Pityriasis versicolour• Pityriasis rosea• Dermatophyte
• Parapsoriasis and Mycosis fungoides
• Pityriasis rubra pilaris• Secondary Syphilis • Chronic Dermatitis
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Psoriasis plaques – symmetry, sharp demarcation, coarse scale across lesion
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normal skin
psoriasis
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Psoriasis – trunk
partially treated
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Psoriasis – annular
not ringworm
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Psoriasis – guttate
(drop-like or papular)
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Guttate Psoriasis
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Psoriasis on black skin
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Psoriasis - flexural
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Psoriasis - scalp
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Psoriasis – toes and nails, NOT fungus, culture if in doubt
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Psoriasis – palms – pustular (sterile)
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Pustular Psoriasis – widespread, unstable patient and disease
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Pustular psoriasis
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Psoriasis -Treatment• Consider exacerbating factors: stress, drugs, infection• Consider stability of disease (pustular and erythrodermic)• Koebner = isomorphic phenomenon• Three Pillars of therapy
– Topical – creams, ointments, lotions, baths– Scalp, extensors, flexures
• Steroids• Calcipotriene• Salicylic acid• Tar
– Systemic –Pills and Injections• Methotrexate, Acitretin, Cyclosporin, Biologicals
– Ultraviolet Radiation• UVB –broad and narrow band, UVA, PUVA
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Acne
• Etiology: heredity, hormones, drugs, ?diet• Sebum – encourages growth of P. acnes• Propionibacterium acnes – inflammation,
initiates comedones• Morphology
– “Noninflammatory” – comedones, open and closed
– Inflammatory – papule, pustule, nodule, abscess (“cyst”), scars...ulcers
– Microcomedo is probably the primary lesion
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• Androgens• Sebum• Comedogenesis• Proprionibacterium acnes• Diet• Psychological• Topicals• Antibiotics• Anti-androgens• Isotretinoin• Physical• Exacerbating factors• Rosacea• Perioral dermatitis •
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Acne – lesion morphology
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Acne – scarring
Isotretinoin use-teratogen, not mutagen-depression real but rare-1 mg/kg/day x 4-5
months-beta-HCG, lipids, ALT-double contraception-record discussion
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Acne abscess vs. cyst
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Acne scars – pits and box-cars
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Acne – severe
Treatment-erythromycin-prednisone-isotretinoin – low dose and increase slowly
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Ulcerative acne
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Acne - Treatment• Psychological impact• General measures: avoid picking, not due to poor hygeine
– Mechanical –rubbing clothes and equipment– Chemical – oils, chlorinated hydrocarbons– Diet - glycemic index?, milk?
• Drugs that flare acne– Lithium, anabolic steroids, catabolic steroids, dilantin, halogens, EGFRI’s
• Topicals– Benzoyl peroxide 5% aq. gel, once daily, (bleach)– Retinoids – comedonal acne, tretinoin cream or gel nightly, adapalene, tazarotene are 2nd generation retinoids– Antibiotics – consider issue of resistance
• Oral– Antibiotics: Tetra 500 BID, minocycline, erythromycin, clindamycin,
trimethoprim – X 3 months– Hormones in females– Isotretinoin – (Accutane, Clarus) – only disease remitting agent
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Hidradenitis suppurativa - axilla
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Perioral dermatitis
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Perioral DermatitisTreatment
• Don’t be fooled by name, it’s acne not eczema• Stop topical steroids• Metronidazole 1% topical cream or gel, or
topical antibiotic (erythro, clinda)• Tetracycline 500 bid x 6-8 weeks• Sun protection• Reduce flare factors – fluoride in toothpaste
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Rosacea – rhinophyma, papules and pustule
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Rosacea
Diagnosis• Erythema and
telangectasias• Papulopustular• Sebaceous hyperplastic
• Symmetrical – usually• Central facial• Ill-defined• No significant scale
Treatment-sun protect-reduce flare factors-stop topical steroids-Metronidazole cr. 1% nightly-Tetracycline 500 BID-surgery for rhinophyma-laser or IPL for telangectasia
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PruritusItchy dermatoses
• eczematous dermatitis• scabies and insect bites• urticaria• dermatitis herpetiformis• lichen planus• bullous pemphigoid• psoriasis – sometimes
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Systemic causes of Pruritus“itch without rash”
• chronic renal failure• cholestasis• Polycythemia• pregnancy• thyroid dysfunction• malignancy - Hodgkins• H.I.V.• ovarian hormones
separate itch nerves. ,unmyelinated slow C fibres
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Mediators of Pruritus
• Histamine (H)-(from mast cell via various receptors)- itch mediated at H1 receptor
• substance P, tryptase• opioid peptides-central or peripheral• cytokines-IL-2,IF….• Prostaglandin E, serotonin
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Drug reactions
• Acute onset• Cephalo-caudal spread• Antibiotics, anticonvulsants, NSAID’s• Accurate history critical – graph drugs vs date• Treatment
– stop offending drugs– supportive care
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Toxic Epidermal Necrolysis – Chinese herbal medication
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Skin Cancer
• BCCa, SCCa, Melanoma include over 98% of skin cancers you will see
• Sunlight, UVB>UVA is major carcinogen
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Cystic BCCa - Forehead
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Basal Cell Carcinoma - Eyelid
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Neglected BCCa - forehead
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Superficial Multicentric BCCa
Red plaque, sharp demarcation, irregular border
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Keratoacanthoma pattern SCCa – sun damaged neck
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Atypical Mole
Rule out melanoma
Biopsy-shave-excise, conservative-incise-punch
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Melanoma – back, superficial spreading
AsymmetryBorderColourDiameter
Evolution
Melanoma-Canada 2008 (estimated)-4600 cases-910 deaths
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Melanoma - Prognosis• Depth of invasion = Breslow thickness
– Most important for stage 1-2 melanoma– Measured from granular layer of epidermis to
deepest malignant cell, with ocular micrometer
• Regional Lymph-node Mets – stage 3• Distant Mets – stage 4
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Melanoma – sole, amelanotic
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Melanoma – Thumb, acral lentigenous
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Cutaneous T-Cell Lymphoma = Mycosis Fungoides
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Skin Cancer – Risk Factors• Ultraviolet radiation
– UVB – 290 - 320 nm– UVA – 320 – 400 nm
• Other Controllable– Ionizing radiation– Arsenic– Tobacco– Tar– HPV– Immune-suppression (permissive) HIV, Drugs
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Skin Cancer - Treatment• Biopsy if in doubt
– match method to depth (shave, punch, incision, excision)
• Curettage (BCCa, SCCa small, not Melanoma)– may precede with shave excision– electrodesiccation
• Surgical Excision– Closure: fusiform, flap, graft
• Margin Control– Ill-defined, critical real-estate, recurrent, aggressive– Mohs’, frozen section
• Radiotherapy• Other: chemotherapy (imiquimod), PDT
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Mohs’ micrographic surgery
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