DERMATOLOGYDERMATOLOGY

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DermatologyDermatology• Pityriasis versicolorPityriasis versicolor• ScabiesScabies• PsoriasisPsoriasis• Rosacea ( Rhinopyoma)Rosacea ( Rhinopyoma)• Acne and treatmentAcne and treatment• Secondary syphilis – skin rashSecondary syphilis – skin rash• Pemphigus vulgaris & Bullous pemphigoidPemphigus vulgaris & Bullous pemphigoid• ImpetigoImpetigo• Lichen PlanusLichen Planus• Warafarin / hepain skin necrosisWarafarin / hepain skin necrosis• Malignant MelanomaMalignant Melanoma• Squamous cell caSquamous cell ca• Basal cell CaBasal cell Ca• Contact DermatitisContact Dermatitis

This adolescent boy complained of chronic and recurrent scaly white spots on his trunk for years. The scaling cleared with topical selenium sulfide lotion but the pigment took 4 months to recover.

Pityriasis VersicolorPityriasis Versicolor• Also called Tinea Versicolor Also called Tinea Versicolor not a true dermatophyte not a true dermatophyte

infection.Etiology includes Pityrosporum orbiculare , infection.Etiology includes Pityrosporum orbiculare , Pityrosporum ovale Pityrosporum ovale

and Malassezia furfur (prior name for organisms above)and Malassezia furfur (prior name for organisms above)

• Charecterized by scaly macules with fine scale. They can be Charecterized by scaly macules with fine scale. They can be hyper/ hypo pigmented hyper/ hypo pigmented “ “do not tan in summerdo not tan in summer” ” involves involves trunks and proximal extremitiestrunks and proximal extremities

• Diagnosis : is by KOH mount. Diagnosis : is by KOH mount. Spaghetti (hyphae) and Spaghetti (hyphae) and meatball (yeast) appearance meatball (yeast) appearance

Wood's Lamp may show irregular pale yellow fluorescence.Wood's Lamp may show irregular pale yellow fluorescence.

Differential Diagnosis : Vitiligo , Seborrheacdermatitis , Tinea Differential Diagnosis : Vitiligo , Seborrheacdermatitis , Tinea Corporis & Pityriasis Rosea Corporis & Pityriasis Rosea

Rx: Hypopigmentation resolves Rx: Hypopigmentation resolves slowlyslowly after Treatment!! after Treatment!!First choice rx : Topical selenium sulfide 2.5% lotion daily for 7 First choice rx : Topical selenium sulfide 2.5% lotion daily for 7

days. Alternatively, can use ketoconozole 2% cream daily x 14 days. Alternatively, can use ketoconozole 2% cream daily x 14 daysdays

Second choice : systemic antifungal – ketoconozole, itraconozole, Second choice : systemic antifungal – ketoconozole, itraconozole, fluconozolefluconozole

Recurrence rate is very high Recurrence rate is very high consider repeat Rx prior to consider repeat Rx prior to summer / discard or boil suspected clothing that might be summer / discard or boil suspected clothing that might be harboring the fungusharboring the fungus

What do u do about What do u do about Acne?Acne?

Advise to pts, medical Advise to pts, medical management, exacerbating management, exacerbating

factors etcfactors etc

Acne - Ask Pts to avoid Acne - Ask Pts to avoid These!These!

Exacerbating factors to avoidExacerbating factors to avoid • Medications that exacerbate acne Medications that exacerbate acne

– Androgenic steroids (e.g. Danazol Testosterone )Androgenic steroids (e.g. Danazol Testosterone )– Corticosteroids Corticosteroids – LithiumLithium– Oral Contraceptives Oral Contraceptives If Acne, Change Oral Contraceptive If Acne, Change Oral Contraceptive Increase Increase

Estrogen (50ug Ethinyl Estradiol minimum) and Decrease androgenic Estrogen (50ug Ethinyl Estradiol minimum) and Decrease androgenic effects of Progestin ( switch to 3effects of Progestin ( switch to 3rdrd generation) generation)

– Isoniazid Isoniazid – Phenytoin (Dilantin) – choose carbamazepine for seizure control in Phenytoin (Dilantin) – choose carbamazepine for seizure control in

teenagers. teenagers. • Oil based Cosmetics Oil based Cosmetics Cosmetics with Lanolin or petroleum Cosmetics with Lanolin or petroleum

jelly / Oil based shampoos or Sunscreen jelly / Oil based shampoos or Sunscreen Change cosmetics to Change cosmetics to water based productswater based products

• Emotional Stress Emotional Stress • Physical Pressure (acne mechanica) Physical Pressure (acne mechanica) Tight chinstrap , Helmet Tight chinstrap , Helmet Clear the Myths Clear the Myths • Foods Foods DO NOTDO NOT worsen acne worsen acne Pizza , Nuts , Sweets , Chocolate Pizza , Nuts , Sweets , Chocolate

nope, they don’t have anything to do with acne nope, they don’t have anything to do with acne• Acne is not a result of poor hygiene Acne is not a result of poor hygiene

– Constant washing does not improve acne Constant washing does not improve acne Limit washing face to 2-3 Limit washing face to 2-3 times per day times per day

– Scrubbing dries and irritates skin further Scrubbing dries and irritates skin further

Moderate Acne Vulgaris Moderate Acne Vulgaris Management Management

Indications Indications moderate Acne vulgaris, moderate Acne vulgaris, Comedonal Acne vulgarisComedonal Acne vulgaris

1: OTC topical medications for 6 weeks eg: 1: OTC topical medications for 6 weeks eg: Topical Benzoyl Peroxide gelTopical Benzoyl Peroxide gel

If fails, If fails, 2: Comedolytics and Topical Antibiotics for 2: Comedolytics and Topical Antibiotics for

6 weeks6 weeks • When there is comedonal acne, always Start When there is comedonal acne, always Start

Comedolytic (discontinue Benzoyl Peroxide) Comedolytic (discontinue Benzoyl Peroxide) – First-line options First-line options Topical Tretinoin Topical Tretinoin Warn Warn

regarding redness and irritation/ contraception regarding redness and irritation/ contraception

• Consider adding a topical antibiotic Consider adding a topical antibiotic – Topical Erythromycin or ClindamycinTopical Erythromycin or Clindamycin

Severe Acne VulgarisSevere Acne Vulgaris• Includes Moderate to severe Acne Vulgaris & Includes Moderate to severe Acne Vulgaris &

Nodular, pustular, or cystic Acne VulgarisNodular, pustular, or cystic Acne Vulgaris• RX: Start Comedolytic ( Retin A) & topical RX: Start Comedolytic ( Retin A) & topical

antibiotic as above. antibiotic as above. Also start oral antibioticAlso start oral antibiotic first line tetracycline/ erythromycin. first line tetracycline/ erythromycin. Second line are doxycycline, bactrimSecond line are doxycycline, bactrim

• In very severe cases ( nodulocystic acne) In very severe cases ( nodulocystic acne) maximal medical therapy ( here side effects maximal medical therapy ( here side effects are high )are high )

• Antiandrogens : spironolactoneAntiandrogens : spironolactone• Isotretinoin 1mg/kg/d for 20 weeks Isotretinoin 1mg/kg/d for 20 weeks

extremely teratogenic. extremely teratogenic. Be aware to monitor Be aware to monitor liver function tests and triglyceridesliver function tests and triglycerides

Isotretinoin ( Accutane)Isotretinoin ( Accutane)Indicated in Refractory acne vulgaris/ Nodulo Indicated in Refractory acne vulgaris/ Nodulo

cystic Acnecystic AcneAdverse EffectsAdverse Effects • Very Teratogenic (even 1 pill) Very Teratogenic (even 1 pill) Needs two Needs two

forms Contraception while taking , forms Contraception while taking , Counsel Counsel extensively before useextensively before use

• CheilitisCheilitis, Dry or chapped skin ,Dry nose , Dry or chapped skin ,Dry nose and eyes and eyes

• Elevated serum Triglycerides (25%) Elevated serum Triglycerides (25%) • Arthralgias and MyalgiasArthralgias and Myalgias• Elevated liver transaminasesElevated liver transaminases• Peeling of palms and soles (5%) Peeling of palms and soles (5%) • Intracranial HypertensionIntracranial Hypertension• Night blindness Night blindness

IsotretinoinIsotretinoinMonitoringMonitoring • Check Liver transaminases & Triglycerides at Check Liver transaminases & Triglycerides at

baseline and every 2-4 weeks baseline and every 2-4 weeks • System Manage Accutane Related System Manage Accutane Related

Teratogenicity (SMART) -Teratogenicity (SMART) -AccutaneAccutane– Only SMART registered members may prescribe Only SMART registered members may prescribe

Accutane Accutane – Prescription limited to 30 days Prescription limited to 30 days – Mandates 2 forms of Birth Control Mandates 2 forms of Birth Control

• Both forms started >1 month before Accutane and continue Both forms started >1 month before Accutane and continue Contraception for 1 month after stopping Contraception for 1 month after stopping

• One form must be primary ContraceptionOne form must be primary Contraception– Tubal Ligation or partner's VasectomyTubal Ligation or partner's Vasectomy– Intrauterine Device Intrauterine Device – Oral Contraceptive Oral Contraceptive – Depo Provera, Norplant or similar Depo Provera, Norplant or similar

– Mandatory urine pregnancy timing Mandatory urine pregnancy timing • Initial urine Pregnancy Test and Urine Pregnancy Test Initial urine Pregnancy Test and Urine Pregnancy Test

immediately before Accutane and Urine Pregnancy Test immediately before Accutane and Urine Pregnancy Test monthly at time of refill monthly at time of refill

– Prescriptions must carry qualification sticker Prescriptions must carry qualification sticker Yellow Yellow Accutane Qualification Sticker ( to obtain the sticker the Accutane Qualification Sticker ( to obtain the sticker the provider has to complete the best practices booklet)provider has to complete the best practices booklet)

This 45-year-old woman developed erythema, papules, pustules, and telangiectasias on the cheeks and forehead. The eruptions worsened with by high ambient temperature, hot drink, alcohol, spicy foods.

What is this ?A. Nodulo cystic acneB. Acne RosaceaC. Folliculitis

Acne rosaceaAcne rosacea• Most common in 30 to 5o yrs of ageMost common in 30 to 5o yrs of age• Precipitated by Sun Exposure, hot weather, and hot baths, Emotional stressors , Precipitated by Sun Exposure, hot weather, and hot baths, Emotional stressors ,

Alcohol ,Hot drinks & ExerciseAlcohol ,Hot drinks & Exercise• Symptoms : stinging pain with facial flushingSymptoms : stinging pain with facial flushing• Signs : Affects middle third of face (forehead to chin) Signs : Affects middle third of face (forehead to chin)

– Stage 1: Initial presentation Stage 1: Initial presentation Intermittent facial Flushing Intermittent facial Flushing – Stage 2: Early vascular changes Stage 2: Early vascular changes Facial erythema , Telangiectasis , Eye changes Facial erythema , Telangiectasis , Eye changes

( conjunctivitis, dry eyes, keratitis)( conjunctivitis, dry eyes, keratitis)– Stage 3: Inflammatory changes Stage 3: Inflammatory changes Papules, Sterile Pustules Papules, Sterile Pustules Comedones are typically Comedones are typically

absent absent – Stage 4: Rhinophyma (Red bulbous nose) Stage 4: Rhinophyma (Red bulbous nose) More common in men , Thickening of facial More common in men , Thickening of facial

skin (especially nose due to connective tissue hypertrophy & Sebaceous Gland skin (especially nose due to connective tissue hypertrophy & Sebaceous Gland hypertrophy )hypertrophy )

TREATMENT TREATMENT • Avoid alcohol , prolonged heat exposure, hot liquids (coffee, tea), heavy cosmetics Avoid alcohol , prolonged heat exposure, hot liquids (coffee, tea), heavy cosmetics

and Use sun screen regularly and Use sun screen regularly • Avoid provocative medications Avoid provocative medications Benzoyl Peroxide and Topical Benzoyl Peroxide and Topical

CorticosteroidCorticosteroid• For Papular & Pustular Rosacea For Papular & Pustular Rosacea

– First choice First choice topical agents Metronidazole gel or Azelaic acid gel. topical agents Metronidazole gel or Azelaic acid gel. Alternatively u can use clindamyicin gel or permethrin 5% creamAlternatively u can use clindamyicin gel or permethrin 5% cream

– Oral antibiotics for 1 month and then taper dose Oral antibiotics for 1 month and then taper dose useful in rxng severe useful in rxng severe rosacea or ocular rosacea with blepharitis, keratitis rosacea or ocular rosacea with blepharitis, keratitis doxycycline 100 bid or doxycycline 100 bid or erythromycin 250 bid. Because of the higher risk of adverse reactions erythromycin 250 bid. Because of the higher risk of adverse reactions associated with long-term use of oral antibiotics, topical therapy is usually associated with long-term use of oral antibiotics, topical therapy is usually preferred long-termpreferred long-term

– In refractory cases consider topical retinoic acidIn refractory cases consider topical retinoic acid• For Rhinopyoma For Rhinopyoma Early cases treat with antibiotics, Advanced cases – Early cases treat with antibiotics, Advanced cases –

surgerysurgery• For Ocular Rosacea For Ocular Rosacea Artificial tears and oral antibiotics are first choice Artificial tears and oral antibiotics are first choice• For vasomotor symptoms like facial flushing and erythema For vasomotor symptoms like facial flushing and erythema u still use u still use

first choice antibiotics as above. For symptomatic relief you may add first choice antibiotics as above. For symptomatic relief you may add clonidine or propranololclonidine or propranolol

Acne Rosacea – D/DAcne Rosacea – D/DDifferential DiagnosisDifferential Diagnosis • Late-onset Acne Vulgaris Late-onset Acne Vulgaris ComedonesComedones present, present,

No telangiectasis & No eye symptoms or signs No telangiectasis & No eye symptoms or signs • Steroid-induced Acne - Results from Corticosteroid Steroid-induced Acne - Results from Corticosteroid

use on face use on face Charecterized by occurrence after Charecterized by occurrence after steroid use, lack of comedones and presence of steroid use, lack of comedones and presence of Perioral dermatitis Perioral dermatitis

• Perioral Dermatitis Perioral Dermatitis • Systemic Lupus Erythematosu Systemic Lupus Erythematosu • Allergic ConjunctivitisAllergic Conjunctivitis• Seborrheic Dermatitis ( can affect the same areas Seborrheic Dermatitis ( can affect the same areas

does not have pustules, but has a scale, does not does not have pustules, but has a scale, does not have flushing)have flushing)

• Carcinoid Syndrome (severe facial Flushing)Carcinoid Syndrome (severe facial Flushing)

•

Rosacea may be associated with enlargement of the nose from excess tissue, a condition known as rhinophyma includes thickening of the skin and irregular surface nodulesRx Early cases antibioticsLate cases surgery

Alopecia AreataAlopecia AreataNon-scarring autoimmune Alopecia - Non-scarring autoimmune Alopecia -

Most common under age 30 Most common under age 30 TypesTypes • Alopecia areata: Patches of Hair Alopecia areata: Patches of Hair

Loss Loss • Alopeca totalis: Hair Loss over totalis: Hair Loss over

entire scalp entire scalp • Alopecia universalis: Hair Loss over Alopecia universalis: Hair Loss over

entire body entire body SignsSigns Well-demarcatedWell-demarcated oval patches oval patches

of Hair Loss of Hair Loss • Exclamation point hairs at edges of Exclamation point hairs at edges of

Hair Loss, Club shaped Hair Root, Hair Loss, Club shaped Hair Root, Thin proximal Hair Shafft, Normal Thin proximal Hair Shafft, Normal caliber distal Hair Shaftcaliber distal Hair Shaft

Lab Evaluation (Consider)Lab Evaluation (Consider) • KOH Scraping of patch KOH Scraping of patch • Thyroid Stimulating Hormone (TSH) Thyroid Stimulating Hormone (TSH) • Rapid Plasma Reagin (RPR) Rapid Plasma Reagin (RPR) • CBC, ESR CBC, ESR • Antinuclear Antibody (ANA) and Antinuclear Antibody (ANA) and

Rheumatoid Factr (RF) Rheumatoid Factr (RF) Differential DiagnosisDifferential Diagnosis Other non- Other non-

scarring Alopecia , Tinea Capitis scarring Alopecia , Tinea Capitis Associated ConditionsAssociated Conditions • Atopic Dermatitis , Vitiligo , Thyroid Atopic Dermatitis , Vitiligo , Thyroid

disease and Pernicious Anemia disease and Pernicious Anemia

Alopecia areata - RxAlopecia areata - Rx Moderate Involvement (<50% of scalp involved)Moderate Involvement (<50% of scalp involved)

DOC is DOC is Intralesional ( not topical)Intralesional ( not topical) Triamcinolone. Triamcinolone. Spontaneous resolution occurs in most cases.Spontaneous resolution occurs in most cases.

• Adjunctive therapy Adjunctive therapy Apply Minoxidil 5% solution Apply Minoxidil 5% solution twice daily or Mid-potency Topical Corticosteroid twice daily or Mid-potency Topical Corticosteroid (eg. Kenalog 0.1%) (eg. Kenalog 0.1%)

Severe Involvement (>50% of scalp involved)Severe Involvement (>50% of scalp involved) refer to dermatology, use combination therapy with refer to dermatology, use combination therapy with intralesional kenalog + topical contact sensitizer. intralesional kenalog + topical contact sensitizer. Contact sensitizers Contact sensitizers minoxidil 5% with topical minoxidil 5% with topical steroids or Anthralinsteroids or Anthralin

Prognosis: the following indicates poor Prognosis: the following indicates poor prognosis prognosis

• Disease duration > one year Disease duration > one year • Onset of Alopecia prior to PubertyOnset of Alopecia prior to Puberty• Family History of Alopecia areata Family History of Alopecia areata • Atopic PatientsAtopic Patients• Down Syndrome Down Syndrome

Topical Topical CorticosteroidsCorticosteroids

Topical SteroidsTopical SteroidsCorticosteroid Potency Corticosteroid Potency

SelectionSelection • Low potency topical Low potency topical

Corticosteroids Corticosteroids – Face , Groin , Intertriginous Face , Groin , Intertriginous

areas areas • Mid-potency topical Mid-potency topical

Corticosteroids Corticosteroids – Thin skin trunk areas Thin skin trunk areas – Extremity lesions Extremity lesions

• High potency topical High potency topical Corticosteroids ( clobetasol Corticosteroids ( clobetasol 0.05%)0.05%)– Thick skin trunk areas Thick skin trunk areas – Extremity lesions Extremity lesions

• Very high or super-potent Very high or super-potent Corticosteroids Corticosteroids – Very thick-skinned areas Very thick-skinned areas – Palms and soles Palms and soles

Adverse Effects of Adverse Effects of Topical SteroidsTopical Steroids

• Percutaneous Percutaneous absorption absorption

• Skin atrophy Skin atrophy • Steroid AcneSteroid Acne• Rebound papular Rebound papular

dermatitis after dermatitis after medium-high potency medium-high potency – Avoid high potency Avoid high potency

steroid on genital or face steroid on genital or face • Striae formation Striae formation

Fluorinated CS are more Fluorinated CS are more effective but have high effective but have high risk of side effectsrisk of side effects

VitiligoVitiligo

Koebner Phenomenon - Koebner Phenomenon - vitilgovitilgo

Treatment - VitiligoTreatment - VitiligoA. Localized Vitiligo (involving <20% of total A. Localized Vitiligo (involving <20% of total

body surface area )body surface area )– Topical corticosteroids - first-line treatment in Topical corticosteroids - first-line treatment in

localized vitiligo localized vitiligo Start with medium potency CS Start with medium potency CS ( betamethasone 0.1)( betamethasone 0.1)

– Calcipotriol can be used as adjunctive therapy Calcipotriol can be used as adjunctive therapy but never as monotherapy. but never as monotherapy.

– Use tacrolimus, a topical T-cell immunomodulator Use tacrolimus, a topical T-cell immunomodulator (calcineurin inhibitor), as an alternative to topical (calcineurin inhibitor), as an alternative to topical steroids in the treatment of localized vitiligo. steroids in the treatment of localized vitiligo.

B. Wide spread vitiligo ( > 50% B. Wide spread vitiligo ( > 50% depigmentation)depigmentation)

- Consider complete depigmentation using - Consider complete depigmentation using monobenzone rather than repigmentation, monobenzone rather than repigmentation, especially if repigmentation therapies have especially if repigmentation therapies have failed. If monobenzone fails failed. If monobenzone fails laser laser repigmentationrepigmentation

ScabiesScabies

ScabiesScabies

Scabies - CluesScabies - Clues• Itching, particularly at night Itching, particularly at night • Family members, friends, or relatives with unexplained pruritus Family members, friends, or relatives with unexplained pruritus

or scabies or scabies • Recent visits to a nursing home, hospital, or day care center Recent visits to a nursing home, hospital, or day care center

and the time interval between onset of pruritus and the visit and the time interval between onset of pruritus and the visit Look for: Look for: • Burrows Burrows

– Wavy, threadlike, grayish-white, skin elevations measuring 1 to 10 Wavy, threadlike, grayish-white, skin elevations measuring 1 to 10 mm mm

• Excoriations , Vesicles , Indurated nodules , Eczematous Excoriations , Vesicles , Indurated nodules , Eczematous dermatitis dermatitis

• Common sites : the interdigital webbing of the hands , Axillae , Common sites : the interdigital webbing of the hands , Axillae , Waist Waist

Feet , Buttocks , areola in women, scrotal area in menFeet , Buttocks , areola in women, scrotal area in men

Examine Skin scrapings from suspicious lesions Examine Skin scrapings from suspicious lesions put KOH in put KOH in burrowburrow, scrape it and examine under microscope for mites or , scrape it and examine under microscope for mites or obtain skin biopsy from burrows for diagnosisobtain skin biopsy from burrows for diagnosis

In a patient with generalized pruritis In a patient with generalized pruritis If the diagnosis is If the diagnosis is uncertain, obtain a skin biopsy uncertain, obtain a skin biopsy to look for mites and eggsto look for mites and eggs within within the stratum corneum of the epidermis along with a dermal the stratum corneum of the epidermis along with a dermal inflammatory infiltrate. inflammatory infiltrate.

Mineral Oil Scraping Under Mineral Oil Scraping Under Light MicroscopeLight Microscope

• Shows fecal pellets (scybala) and eggs. Shows fecal pellets (scybala) and eggs. These are diagnostic even without a live These are diagnostic even without a live mite mite

Scabies in Nursing Home Scabies in Nursing Home ptspts

• As commonly happens, this patient's scabies As commonly happens, this patient's scabies was misdiagnosed for many months as was misdiagnosed for many months as psoriasis psoriasis

Scabies Drug therapyScabies Drug therapy• Choose one of the following agents: Choose one of the following agents:

Permethrin, Lindane, Topical malathion , Permethrin, Lindane, Topical malathion , Benzyl benzoate or Topical ivermectin Benzyl benzoate or Topical ivermectin

• Oral therapy – alternative to topical Rx - Oral therapy – alternative to topical Rx - IvermectinIvermectin

• Apply the preparation overnight to the entire Apply the preparation overnight to the entire body surface, regardless of the location of the body surface, regardless of the location of the lesions. lesions.

• Itching could persist for 2 weeks after Itching could persist for 2 weeks after successful treatment because the dead mite successful treatment because the dead mite and its antigens gradually slough off with the and its antigens gradually slough off with the dead skin layers dead skin layers Reassure patients about Reassure patients about this! this!

• TTreat all family members and close contacts, reat all family members and close contacts, even if they are unaffected or asymptomatic, even if they are unaffected or asymptomatic, simultaneously simultaneously A Asymptomatic mite carriers symptomatic mite carriers in the household are very common and are the in the household are very common and are the reason for recurrence reason for recurrence

Lichen PlanusLichen Planus

White lacy WICKHAM White lacy WICKHAM STRIAE are your clue STRIAE are your clue for diagnosis.for diagnosis.

May have pruritic May have pruritic cutaneous Papules on cutaneous Papules on body body

No RX required as most No RX required as most forms are forms are asymptomatic. asymptomatic.

Erosive form of lichen Erosive form of lichen planus can cause pain planus can cause pain Erosive form is treated Erosive form is treated with topical steroids.with topical steroids.

DiagnosisDiagnosis• Biopsy lichenoid lesions! Biopsy lichenoid lesions!

Advise Pts – Lichen Advise Pts – Lichen PlanusPlanus

• Advise patients to avoid scratching Advise patients to avoid scratching cutaneous lesions and eating Irritant cutaneous lesions and eating Irritant food ( sharp-edged, spicy, or acidic food ( sharp-edged, spicy, or acidic food ) as trauma can lead to spread food ) as trauma can lead to spread of lesions ( Kobner phenomenon)of lesions ( Kobner phenomenon)

• If pruritic papules are present, use If pruritic papules are present, use oral antihistamines to reduce oral antihistamines to reduce pruritus. pruritus.

This patient has joint pains and scaly patch This patient has joint pains and scaly patch behind his ear. What is the most likely cause behind his ear. What is the most likely cause

of his findings?of his findings?

PsoriasisPsoriasis• Plaques characterized by Scaling, erythema and Plaques characterized by Scaling, erythema and

induration. induration. • Chronic plaque psoriasis : erythematous, thick plaques with Chronic plaque psoriasis : erythematous, thick plaques with

silvery scale, can be found anywhere on the body.silvery scale, can be found anywhere on the body.• Guttate Psoriasis : mostly seen on the trunk, multiple , small drop-Guttate Psoriasis : mostly seen on the trunk, multiple , small drop-

like papules and plaqueslike papules and plaques• Erythrodermic Psoriasis Erythrodermic Psoriasis severe erythema, scaling involving severe erythema, scaling involving

most of the body surface / exfoliation of skin can occur leading to most of the body surface / exfoliation of skin can occur leading to fluid loss and infectionsfluid loss and infections

• Common areas affected Common areas affected scalps, ears, nails, scalps, ears, nails, intertriginous folds and flexural surfaces.intertriginous folds and flexural surfaces.

• Nail changes Nail changes pitting, thickening or yellowing pitting, thickening or yellowing• Joints Joints arthritis, tendonitis, dactylitis ( DIP joint arthritis, tendonitis, dactylitis ( DIP joint

inflammation, sausage shaped finger), “pencil-in inflammation, sausage shaped finger), “pencil-in cup” deformity on the x-ray ( occurs when the distal cup” deformity on the x-ray ( occurs when the distal end of the bone becomes pointed appearing as if it end of the bone becomes pointed appearing as if it had been sharpened and the surrounding articular had been sharpened and the surrounding articular surfaces become “saucerized” due to “Erosions”. surfaces become “saucerized” due to “Erosions”. Also, seen in RA )Also, seen in RA )

Psoriasis - RxPsoriasis - Rx• Localized plaques Localized plaques topical topical

corticosteroids. Can be alternated with corticosteroids. Can be alternated with anthralin, tar preperations, retinoids or anthralin, tar preperations, retinoids or topical vitamin D analogs. Never use topical vitamin D analogs. Never use systemic corticosteroidssystemic corticosteroids

• Plaque or Guttate psoriasis involving Plaque or Guttate psoriasis involving more than more than 5% body area5% body area or in case of or in case of poor response to topical agents poor response to topical agents use use phototherapy.phototherapy.

• Erythrodermic Psoriasis Erythrodermic Psoriasis refer to refer to dermatologist STAT – it’s a dermatologist STAT – it’s a dermatological emergency!dermatological emergency!

Atopic dermatitis Atopic dermatitis

• Picture – on forearmPicture – on forearm• RxRx

Tinea cruris + pictureTinea cruris + picture

• Test to diagnose ? – koh preperationTest to diagnose ? – koh preperation

A 25 y/o man presents with the lesion shown A 25 y/o man presents with the lesion shown

on his lower lip. What is the treatment?on his lower lip. What is the treatment?

Herpes Labialis Herpes Labialis • Caused by Herpes simplex Virus Type Caused by Herpes simplex Virus Type

I. I. • Most people are asymptomatic but Most people are asymptomatic but

only few people have recurrent only few people have recurrent outbreaks. outbreaks.

• Triggers for outbreak are cold Triggers for outbreak are cold weather, stress, trauma. weather, stress, trauma.

• Rx Rx • Topical Penciclovir as your first choice.Topical Penciclovir as your first choice.• Recurrent severe cases can be treated with Recurrent severe cases can be treated with

oral Acyclovir. oral Acyclovir.

A healthy 20 year old female come with history of paroxysmal lip A healthy 20 year old female come with history of paroxysmal lip swelling.  In the past , her doctor tried solumedrol and benasdryl but they swelling.  In the past , her doctor tried solumedrol and benasdryl but they

never seem to make it better.  She says the swelling comes and goes never seem to make it better.  She says the swelling comes and goes spontaneously.  She has had negative skin prick testing spontaneously.  She has had negative skin prick testing

Angioedema Angioedema • Angioedema is a skin reaction similar to hives or urticaria. Angioedema is a skin reaction similar to hives or urticaria.

characterized by an abrupt and short-lived swelling of the skin characterized by an abrupt and short-lived swelling of the skin and mucous membranes and mucous membranes Any body part may be affected but Any body part may be affected but swelling most often occurs around the eyes and lips, In severe swelling most often occurs around the eyes and lips, In severe cases the upper respiratory tract and intestinal mucosa may cases the upper respiratory tract and intestinal mucosa may also be affected. also be affected. Can be hereditary or acquired Can be hereditary or acquired

• Know about ACEI induced angioedema – no more ACEI or ARBsKnow about ACEI induced angioedema – no more ACEI or ARBs• Know thE\e main differences b/w urticaria and Angioedema Know thE\e main differences b/w urticaria and Angioedema

1.Tissues involved: Angioedema Subcutaneous and submucosal 1.Tissues involved: Angioedema Subcutaneous and submucosal surfaces(beneath the dermis). Urticaria involves only the surfaces(beneath the dermis). Urticaria involves only the epidermis (outer layer of skin) and dermis (inner layer of skin) epidermis (outer layer of skin) and dermis (inner layer of skin) 2.Organs affected: Angioedema involve skin and mucosa, 2.Organs affected: Angioedema involve skin and mucosa, particularly the eyelids and lips . Urticaria involves skin only particularly the eyelids and lips . Urticaria involves skin only 2.Duration: Angioedema is Transitory (usually lasts between 24-2.Duration: Angioedema is Transitory (usually lasts between 24-48 hours). Urticaria is transitory (usually lasts < 24 hours) 48 hours). Urticaria is transitory (usually lasts < 24 hours) 3. Physical signs: Angioedema involves red or skin coloured 3. Physical signs: Angioedema involves red or skin coloured swellings occurring below the surface of the skin. Urticaria has swellings occurring below the surface of the skin. Urticaria has Red patches and weals on the surface of skin Red patches and weals on the surface of skin 4. Symptoms: Angioedema may or may not be itchy. Often 4. Symptoms: Angioedema may or may not be itchy. Often accompanied by pain and tenderness. Urticaria is usually accompanied by pain and tenderness. Urticaria is usually associated with an itch -Pain and tenderness uncommon. associated with an itch -Pain and tenderness uncommon.

Hereditary AngioedemaHereditary Angioedema

• Hereditary Angioedema Hereditary Angioedema occurs due occurs due to deficiency of c1 esterase inhibitor to deficiency of c1 esterase inhibitor

• Diagnosis of HAE Diagnosis of HAE C1 inhibitor level C1 inhibitor level is low, C4 level is low (C1-INH is low, C4 level is low (C1-INH deficiency allows auto-activation of deficiency allows auto-activation of C1, with consumption of C4 and C2 )C1, with consumption of C4 and C2 )

• Rx depends on the type. Rx depends on the type. • If it is hereditary you need to give C1 If it is hereditary you need to give C1

inhibitor concentrate. If C1 concentrate is not inhibitor concentrate. If C1 concentrate is not available, give FFP. Alternatively, you can use available, give FFP. Alternatively, you can use high dose steroids like Danazol. high dose steroids like Danazol.

• If laryngeal edema/ stridor If laryngeal edema/ stridor intubate! intubate!

Genital WartsGenital Warts

Only PicsOnly Pics

Therapy – refer I.D SlidesTherapy – refer I.D Slides

Genital warts - The real Genital warts - The real HPV - Differentiate from HPV - Differentiate from

Benign Lesions Benign Lesions

Pearly Penile Papules - A benign Lesion at Pearly Penile Papules - A benign Lesion at corona - do not confuse with Warts! – corona - do not confuse with Warts! –

Reassure patients!Reassure patients!

Fordyce Spots - vulva – These are Fordyce Spots - vulva – These are Sebaceous glands - do not confuse with Sebaceous glands - do not confuse with

warts!warts!

Scabies can occur in Scabies can occur in Genital Areas - Do not Genital Areas - Do not confuse with warts! confuse with warts!

• Questions like this are Questions like this are common on Step 3. A genital common on Step 3. A genital scabies should not be scabies should not be confused with other confused with other conditions like warts, syphilis conditions like warts, syphilis etc. Look for clues in the etc. Look for clues in the history carefully - such as history carefully - such as itching especially itching especially in the in the nightsnights, family members with , family members with similar problems. Also, look at similar problems. Also, look at other sites on body - finger other sites on body - finger webs etc for burrows which is webs etc for burrows which is typical of scabies. typical of scabies.

• Look at finger webs! Common Look at finger webs! Common site of involvement - scabies site of involvement - scabies

Q. Q. • A 46-year-old fisherman and Vietnam veteran presented with a A 46-year-old fisherman and Vietnam veteran presented with a

recurrent rash on his arms and legs and a painful, swollen recurrent rash on his arms and legs and a painful, swollen area on his left leg of several days' duration. The rash had area on his left leg of several days' duration. The rash had been a problem for about two years and was treated with been a problem for about two years and was treated with several courses of antibiotics for cellulitis. The patient several courses of antibiotics for cellulitis. The patient reported that for the past two years his skin had been prone to reported that for the past two years his skin had been prone to blister and tear with minor trauma and that at times his urine blister and tear with minor trauma and that at times his urine appeared to be dark reddish in color. On examination, he had appeared to be dark reddish in color. On examination, he had a slight fever and an area of cellulitis on his left leg. His face a slight fever and an area of cellulitis on his left leg. His face was erythematous. On his hands, arms, and legs were vesicles was erythematous. On his hands, arms, and legs were vesicles and small bullae, some crusted lesions, and hypopigmented and small bullae, some crusted lesions, and hypopigmented and hyperpigmented macules. What is the most important and hyperpigmented macules. What is the most important next step in diagnosis?next step in diagnosis?

• A. ANAA. ANA• B. Rheumatoid factorB. Rheumatoid factor• C. Skin biopsyC. Skin biopsy• D. Hepatitis C serologyD. Hepatitis C serology• E. Hepatitis B serologyE. Hepatitis B serology

Porphyria Cutanea TardaPorphyria Cutanea Tarda

• PCT is due to a defective enzyme (uroporphyrinogen PCT is due to a defective enzyme (uroporphyrinogen decarboxylase) in liver . ( the enzyme is involved in decarboxylase) in liver . ( the enzyme is involved in hem synthesis)hem synthesis)

• Genetic predisposition presentGenetic predisposition present• PCT begins in mid-adult life especially after PCT begins in mid-adult life especially after

exposure to substances that increase the production exposure to substances that increase the production of porphyrins (precursors of haem) in the liver.of porphyrins (precursors of haem) in the liver.

• alcohol alcohol • oestrogen e.g. oral contraceptive, hormone replacement or oestrogen e.g. oral contraceptive, hormone replacement or

liver disease liver disease • polychlorinated aromatic hydrocarbons (e.g. dioxins)polychlorinated aromatic hydrocarbons (e.g. dioxins)• iron overload, due to excessive intake (orally or by blood iron overload, due to excessive intake (orally or by blood

transfusion), viral infections (hepatitis) or chronic blood transfusion), viral infections (hepatitis) or chronic blood disorders such as thalassaemia (acquired haemochromatosis), disorders such as thalassaemia (acquired haemochromatosis), or hereditary haemochromatosisor hereditary haemochromatosis

C/F and RxC/F and Rx• Sores (erosions) following relatively minor injuries Sores (erosions) following relatively minor injuries • Fluid filled blisters (vesicles and bullae) Fluid filled blisters (vesicles and bullae) • Tiny cysts (milia) arising as the blisters heal Tiny cysts (milia) arising as the blisters heal • Increased sensitivity to the sun Increased sensitivity to the sun • Characteristically, the urine is darker than usual, Characteristically, the urine is darker than usual,

with a reddish or tea-coloured huewith a reddish or tea-coloured hue• If asked on the exam, consider the diagnosis of If asked on the exam, consider the diagnosis of

Hepatitis C infection ( imp association)Hepatitis C infection ( imp association)• DX – Elevated urinary porphyrins, wood’s light on DX – Elevated urinary porphyrins, wood’s light on

urine gives marked fluorescence urine gives marked fluorescence • RX RX

• Avoid alcoholAvoid alcohol• Use tanning creams in sun and avoid sun in acute flare.Use tanning creams in sun and avoid sun in acute flare.• Discontinue estrogensDiscontinue estrogens• Therapeutic phlebotomy to reduce iron stores (this improves Therapeutic phlebotomy to reduce iron stores (this improves

heme synthesis disturbed by ferroinhibition of UROD. ) heme synthesis disturbed by ferroinhibition of UROD. ) • In patients in whom phlebotomy is not convenient or is In patients in whom phlebotomy is not convenient or is

contraindicated and in those who have relatively mild iron contraindicated and in those who have relatively mild iron overload overload use oral chloroquine phosphate (or ) use oral chloroquine phosphate (or ) hydroxychloroquine sulfatehydroxychloroquine sulfate

Erythema MultiformeErythema Multiforme

• Target lesionsTarget lesions• Etiology : drugs ( penicillamine, Etiology : drugs ( penicillamine,

sulfa) , HSV sulfa) , HSV • Rx the etiology – corticosteroids are Rx the etiology – corticosteroids are

not effective.not effective.

Erythema NodosumErythema Nodosum

• Rx – NSAIDSRx – NSAIDS• Good prognosis in sarcoidosisGood prognosis in sarcoidosis• Bad prognosis in ulcerative colitis Bad prognosis in ulcerative colitis

Actinic KeratosesActinic Keratoses• Pre Malignant lesions for squamous cell carcinomaPre Malignant lesions for squamous cell carcinoma• Found more on sun exposed areas.Found more on sun exposed areas.• Flesh colored, red papules with whitish scale Flesh colored, red papules with whitish scale • Get biopsy Get biopsy

• If lesion > 5mm If lesion > 5mm • Rapidly growing lesionsRapidly growing lesions• Thick, indurated papulesThick, indurated papules• Lesions that grow rapidly in sizeLesions that grow rapidly in size

• Rx – If lesion looks suspicious for malignancy Rx – If lesion looks suspicious for malignancy excision is the choice. For all others, Rx with excision is the choice. For all others, Rx with cryotherapy or curettagecryotherapy or curettage

• If Actinic keratoses are numerous If Actinic keratoses are numerous use topical 5- use topical 5-FluorouracilFluorouracil

Seborrheic KeratosesSeborrheic Keratoses

• Stuck on appearacnceStuck on appearacnce• Yellowish, waxy plaquesYellowish, waxy plaques• Benign lesionsBenign lesions

Basal cell carcinomaBasal cell carcinoma

– Pink pearly papule with central Pink pearly papule with central ulceration – usually on faceulceration – usually on face

– Get biopsyGet biopsy– Rx – MOHs micrographic surgery for Rx – MOHs micrographic surgery for

BCC on faceBCC on face

Contact DermatitisContact Dermatitis• Inflammatory skin reaction resulting from Inflammatory skin reaction resulting from DIRECTDIRECT contact with an contact with an

offending agent. Two principal types:offending agent. Two principal types:• Irritant Contact Dermatitis ( ICD)Irritant Contact Dermatitis ( ICD)• Allergic Contact Deramatitis (ACD)Allergic Contact Deramatitis (ACD)

• ICD : Occurs from direct injury to the skin by a specific irritant. ICD : Occurs from direct injury to the skin by a specific irritant. • Acute ICD occurs Acute ICD occurs immediatelyimmediately after exposure to the irritant after exposure to the irritant

( acid, alkali) and is associated with burning sensation, bright ( acid, alkali) and is associated with burning sensation, bright red edematous skin and bullae/ vesicle formation. red edematous skin and bullae/ vesicle formation.

• Chronic ICD occurs from Chronic ICD occurs from prolonged exposure to a mild irritant prolonged exposure to a mild irritant (soaps and prolonged exposure to water)(soaps and prolonged exposure to water). This presents initially . This presents initially as dryness which is followed by erythema and eventually, as dryness which is followed by erythema and eventually, progress to lichenification, cracking and formation of painful progress to lichenification, cracking and formation of painful fissures. Edema is minimal fissures. Edema is minimal

• ACD : Is strikingly different from ICD in the time of onset after ACD : Is strikingly different from ICD in the time of onset after exposure. ACD occurs only in those people that were previously exposure. ACD occurs only in those people that were previously sensitized to the substance. It is a delayed (cell-mediated, type IV) sensitized to the substance. It is a delayed (cell-mediated, type IV) hypersensitivity reaction ( and presents within 24 to 72 hours after hypersensitivity reaction ( and presents within 24 to 72 hours after exposure to the allergenexposure to the allergen) ( poison ivy, nickel , potassium dichromate). ) ( poison ivy, nickel , potassium dichromate). Associated with erythema, bullae formation and pruritis. Lasts for 3 to 4 Associated with erythema, bullae formation and pruritis. Lasts for 3 to 4 weeks. weeks.

Contact DermatitisContact Dermatitis• Management : Management :

• First step is to identify and avoid the irritant.First step is to identify and avoid the irritant. – – MOST IMPORTANT STEP!MOST IMPORTANT STEP!

• Symptomatic treatment :Symptomatic treatment :• Emollients ( petrolatum jelly) for chronic casesEmollients ( petrolatum jelly) for chronic cases• Wet compresses with an astringent such as Aluminium Wet compresses with an astringent such as Aluminium

acetate acetate gives soothing effect and helps pruritis gives soothing effect and helps pruritis• H1 blockers (benadry) for erythema and itchingH1 blockers (benadry) for erythema and itching

• Drug of choice Drug of choice for treating contact dermatitis are for treating contact dermatitis are Topical steroids Topical steroids eg: Triamcinolone acetateeg: Triamcinolone acetate

• For For severesevere cases ( cases ( contact dermatitis involving contact dermatitis involving more than 10% of total body surface area or more than 10% of total body surface area or associated with extensive bullaeassociated with extensive bullae) eg: Prednisone ) eg: Prednisone orally orally use at least for 2 to 3 weeks with slow use at least for 2 to 3 weeks with slow tapering. Very short course can lead to recurrence tapering. Very short course can lead to recurrence of the problem. of the problem.

Subacute Contact Dermatitis from a mild irritant – like eg: Subacute Contact Dermatitis from a mild irritant – like eg: Bacitracin in the first picture and wool clothing in fig.2 – Note Bacitracin in the first picture and wool clothing in fig.2 – Note the prolonged exposure must have led to dryness followed by the prolonged exposure must have led to dryness followed by

erythema and lichenificationerythema and lichenification

Fig # 1Fig # 1 Fig# 2Fig# 2

Nickel Contact DermatitisNickel Contact Dermatitis

This boy presented with Itchy rash around the naval. This boy presented with Itchy rash around the naval. Note the Note the sharply defined borderssharply defined borders of the lesion of the lesion consistent with the contact area of the metal ( in this consistent with the contact area of the metal ( in this case, blue jeans button made of Nickel). Treatment is case, blue jeans button made of Nickel). Treatment is Topical steroid and avoidance of nickel . Topical steroid and avoidance of nickel .

QuestionQuestion• A 10 y/o boy is brought by his mother for extensive rash on A 10 y/o boy is brought by his mother for extensive rash on

his lower extremities that started one day ago and has been his lower extremities that started one day ago and has been worsening. There is no history of fever . The family just worsening. There is no history of fever . The family just returned four days ago from a camping trip and the mother returned four days ago from a camping trip and the mother does not recall any exposure to ticks except that the boy does not recall any exposure to ticks except that the boy stepped in to a bush while walking downhill. On examination, stepped in to a bush while walking downhill. On examination, there is extensive erythema along with vesicles and bullae on there is extensive erythema along with vesicles and bullae on the front and the back of bilateral lower extremities up until the front and the back of bilateral lower extremities up until the level of the knees. The upper portion of the lower the level of the knees. The upper portion of the lower extremities is unaffected. The rest of the physical extremities is unaffected. The rest of the physical examination is normal. The best treatment for the examination is normal. The best treatment for the management of this child’s condition is :management of this child’s condition is :

• A. Topical triamcinoloneA. Topical triamcinolone• B. Prednisone orallyB. Prednisone orally• C. Ceftriaxone intra-muscularC. Ceftriaxone intra-muscular• D. DiphenhydramineD. Diphenhydramine• E. Observation E. Observation

Ans. BAns. B

• Oral prednisone is the treatment of Oral prednisone is the treatment of choice here since the boy has greater choice here since the boy has greater than 10% involvement of total body than 10% involvement of total body surface area and also, extensive bullae. surface area and also, extensive bullae.

• The lesions are too extensive for The lesions are too extensive for Topical steroid use. Topical steroid use.

• Diphenhydramine may provide Diphenhydramine may provide symptomatic relief but will not address symptomatic relief but will not address the underlying pathologythe underlying pathology

Malignant MelanomaMalignant Melanoma

• A 69-year-old woman A 69-year-old woman was evaluated for an was evaluated for an enlarging pigmented enlarging pigmented lesion of her right cheek. lesion of her right cheek. A malignant lentigo A malignant lentigo melanoma was clinically melanoma was clinically suspected. Two biopsies suspected. Two biopsies were performed with the were performed with the help of dermoscopy to help of dermoscopy to outline the borders of outline the borders of the lesion. Pathology the lesion. Pathology revealed a lentigo revealed a lentigo maligna melanoma maligna melanoma

RASHESRASHES

• All rashes – infectiousAll rashes – infectious• Maculopapular etcMaculopapular etc

IMAGESIMAGES

• OPHTHALMIC - FundusOPHTHALMIC - Fundus• DERMDERM• Some CT/ MRISome CT/ MRI