![Page 1: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/1.jpg)
4/26/2016
1
Dermatology for the Primary Care Provider
Practical Advances in Internal MedicineApril 14, 2016
Amy Swerdlin Frankel, MDProvidence Medical Group
Overview Common skin conditions and their mimics Atypical presentations of common
dermatologic conditions Treatment pearls
![Page 2: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/2.jpg)
4/26/2016
2
Case #1 65 y/o M with 1 year h/o of a lesion
growing on his left clavicle Reports occasional bleeding and tenderness
![Page 3: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/3.jpg)
4/26/2016
3
BCC
Case #2 40 y/o F with 8 month h/o a new growth
on her temple
![Page 4: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/4.jpg)
4/26/2016
4
Pigmented BCC
Ddx?
Melanoma
![Page 5: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/5.jpg)
4/26/2016
5
Case #3 85 y/o M with growing ulcer on his lip x 2
years
Squamous cell carcinoma
![Page 6: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/6.jpg)
4/26/2016
6
Case #4 50 y/o F with 6 month h/o enlarging
growth on her leg
SCC in situ
![Page 7: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/7.jpg)
4/26/2016
7
Superficial BCC
Case #5 68 y/o F with an enlarging growth on her
back x 8 months
![Page 8: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/8.jpg)
4/26/2016
8
Melanoma
A – AsymmetryB – BorderC – ColorD – DiameterE – Evolution
![Page 9: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/9.jpg)
4/26/2016
9
Blue nevus
Seborrheic keratosis
![Page 10: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/10.jpg)
4/26/2016
10
Seborrheic keratosis
Cherry angioma
![Page 11: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/11.jpg)
4/26/2016
11
Case #6 59 y/o M with new “brown spot” on his
nose which has been slowly enlarging
DX? MIS (aka lentigo maligna)
![Page 12: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/12.jpg)
4/26/2016
12
Solar lentigo
Case #7 56 y/o F with 6 month h/o an enlarging
scaly lesion on her arm
![Page 13: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/13.jpg)
4/26/2016
13
Amelanotic melanoma
![Page 14: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/14.jpg)
4/26/2016
14
Amelanotic melanoma Up to 8% are this variant Often with hypopigmentation – sign of
regression Do not obey ABCDE rules Treat the same as pigmented melanomas,
but often more advanced due to delayed diagnosis
Case #8 76 y/o M avid golfer with the development
of several scaly lesions on his scalp
![Page 15: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/15.jpg)
4/26/2016
15
Actinic keratoses
Pigmented actinic keratosis
![Page 16: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/16.jpg)
4/26/2016
16
Most Common Skin cancers Basal cell carcinoma
~2.8 million cases/year in US Rarely fatal, but disfiguring
Squamous cell carcinoma ~700,000 cases/year in US
~2500 deaths in 2011
Melanoma ~123,590 cases/year in US
~8,790 deaths in 2011 Oregon ranks 5th in nation for new melanoma cases
www.skincancer.org/skincancerfacts
Basal cell
Keratinocyte
Melanocyte
Treatment options Non-melanoma skin cancer
Mohs Excision Curettage and Desiccation Topical chemotherapeutics
Aldara – for superficial BCC, AKs Efudex – AKs, SCCis (off label)
PDT; Cryotherapy – AK’s Radiation therapy
Melanoma 5mm margins for MIS WLE; sentinel node bx if ≥1mm depth OR >0.75mm
with adverse features (high mitotic rate/ulceration)
![Page 17: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/17.jpg)
4/26/2016
17
Nicotinamide (Vitamin B3) Reduces the incidence of BCC & SCC in
people with a h/o NMSC Decreased rate of developing new NMSC by 23% Decreased rate of developing new AK’s by 13%
500mg PO BID Unlike niacin or nicotinic acid, the amide did NOT
cause HA, flushing or low BP Reports of increased blood sugar & sweating
![Page 18: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/18.jpg)
4/26/2016
18
Case #9 66 y/o F with new rash x 3 months. Failed
a course of oral lamisil
![Page 19: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/19.jpg)
4/26/2016
19
Granuloma annulare
![Page 20: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/20.jpg)
4/26/2016
20
Granuloma annulare Benign inflammatory dermatosis Localized or generalized Associated with diabetes mellitus
Primarily Type I DM 21% of pts with generalized GA compared to
9.7% with localized GA Rarely pre-dates the onset of DM Pearl – check a fasting blood glucose if no
previous h/o DM
Case #10 30 y/o F with worsening acne in pregnancy
![Page 21: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/21.jpg)
4/26/2016
21
Treatment of acne in pregnancy Topical erythromycin or clindamycin Topical Azelaic acid (Finacea) Oral erythromycin BASE (Base is safe for
Babies)
*Even benzoyl peroxide and salicyclic acid are category C in pregnancy
Case #11 20 y/o F with h/o dry skin who presents
with a diffuse itchy eruption Reports having asthma as a child and currently
has hayfever
![Page 22: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/22.jpg)
4/26/2016
22
Atopic dermatitis
![Page 23: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/23.jpg)
4/26/2016
23
Treatment for atopic dermatitis OINTMENTS are better than creams Triamcinolone 0.1% ointment (a favorite) Protopic ointment if on genital skin or face Moisturizing is VERY important
Cetaphil, Cerave or Vanicream (emphasize the jar cream); Vaseline ointment
Gentle moisturizing cleanser Recurrent infections
Always culture pustules! Bleach baths can be helpful Often require oral antibiotics
Allergic contact dermatitis to nickel
![Page 24: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/24.jpg)
4/26/2016
24
Asteatotic dermatitis/Eczema craquele
Case #12 24 y/o F with h/o atopic dermatitis and a
progressive, painful & pruritic eruption on her face x 2 weeks
![Page 25: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/25.jpg)
4/26/2016
25
Eczema herpeticum
Eczema herpeticum Complication of atopic dermatitis Viral culture important
Also consider bacterial culture since lesions frequently superinfected with staphylococcus
Treatment Oral acyclovir or Valtrex Ophthalmology consult if near the eye or on
the tip of the nose
![Page 26: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/26.jpg)
4/26/2016
26
Case #13 26 y/o F with pruritic/burning eruption
around mouth, which recently spread around eyes
![Page 27: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/27.jpg)
4/26/2016
27
Periorificial dermatitis
Periorificial dermatitis Cross between rosacea, acne & dermatitis Usually there is a history of steroid use Sometimes caused by prolonged topical
tacrolimus use Treatment
Taper topical steroids Can bridge with short course of topical tacrolimus
Oral tetracyclines (MCN or doxy for 6-8 wks) Topical erythromycin, clindamycin, azelaic acid
or metrocream
![Page 28: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/28.jpg)
4/26/2016
28
Case #14 49 y/o F with 4 year history of acne-like
lesions and flushing
Rosacea
![Page 29: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/29.jpg)
4/26/2016
29
Management of Rosacea Daily sunscreen important! Avoid triggers (hot fluid, spicy food, EtOH) Screen for ocular rosacea Treatment
Topical: Azelaic acid (Finacea), Metronidazole, Sodium sulfacetamide/sulfur lotion, Ivermectin
Oral: Doxycycline/Oracea, minocycline Flushing & telangiectasias
Laser Mirvaso - Brimonidine 0.33% topical gel (аlpha2
agonist)
Pyoderma faciale / Roscea fulminans
![Page 30: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/30.jpg)
4/26/2016
30
Case #15 76 y/o F with pruritic and painful eruption
on her legs Has had chronic leg swelling for years
Stasis dermatitis
![Page 31: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/31.jpg)
4/26/2016
31
Lipodermatosclerosis
Stasis dermatitis Prevention techniques
Leg elevation Support stockings Application of emollient (eg cetaphil cream or
vaseline ointment) Topical steroid if pruritic Associated allergic contact dermatitis in 60%
Compromised barrier allows sensitization to occur more easily
Topical antibiotics are a common cause
![Page 32: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/32.jpg)
4/26/2016
32
Case #16 36 y/o F with 3 day h/o pruritic eruption
![Page 33: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/33.jpg)
4/26/2016
33
Pseudomonas hot tub folliculitis Occurs 1 to 4 days after being in hot tub
Warm temps cause free chlorine levels to fall Self resolves in 1 to 2 weeks Can treat with cephalosporin or
fluoroquinolone if systemic symptoms or prolonged disease
![Page 34: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/34.jpg)
4/26/2016
34
Case #17 57 y/o F with progressive, itchy rash x 5
days Started on trunk and spread to extremities Undergoing treatment for cellulitis
![Page 35: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/35.jpg)
4/26/2016
35
Morbilliform drug eruption
Drug eruptions Morbilliform 90%
Maculopapular Exanthematous
Urticarial (5%) Papulosquamous Pustular Bullous
![Page 36: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/36.jpg)
4/26/2016
36
Drug eruptions Pruritus is a common feature
Distinguishes it from a viral exanthem Occurs within first 2 weeks of treatment Simple – cutaneous only
Resolve within 2 weeks after stopping drug Complex – systemic findings
Stevens-Johnson Syndrome, Toxic epidermal necrolysis, DRESS (drug reaction w/ eosinophilia & systemic sx)
If in question, get vitals, CBC, CMP Check for bullae
Morbilliform drug eruptionMost common type of drug eruption
1 to 5% of patients on antibiotics will develop
Don’t have to stop the causative drug In contrast, urticarial drug reaction could
progress to angioedema & anaphylaxis
Common causes Antibiotics (aminopenicillins, sulfa) Anticonvulsants
Treatment Takes days to weeks for rash to resolve Antihistamines and topical steroids
![Page 37: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/37.jpg)
4/26/2016
37
Case #18 25 y/o F presenting with an asymptomatic
scaly pink eruption She is 12 weeks pregnant
![Page 38: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/38.jpg)
4/26/2016
38
Pityriasis rosea Affects young adults (10-35 yrs) Peaks in spring and fall Lasts 6-8 wks Rare variant (inverse) is localized to the
axillae and groin Asymptomatic or mildly pruritic Treatment
Reassurance If pruritic: Topical steroids, Antihistamines If extensive: acyclovir
![Page 39: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/39.jpg)
4/26/2016
39
Special consideration Reactivation of HHV-6 or HHV-7 Associated with miscarriage if develops in
the first 15 weeks of pregnancy
Case #19 61 y/o F with 8 month h/o itchy rash in
her groin
![Page 40: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/40.jpg)
4/26/2016
40
Inverse psoriasis
![Page 41: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/41.jpg)
4/26/2016
41
Plaque psoriasis
![Page 42: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/42.jpg)
4/26/2016
42
Psoriasis Always ask about arthritis
Can be debilitating if left untreated Affects up to 30% of psoriatic patients
Increased risk for cardiovascular disease If guttate morphology
Consider throat culture to r/o strep infection
Nummular dermatitis
![Page 43: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/43.jpg)
4/26/2016
43
Tinea corporis
Subacute cutaneous lupus
![Page 44: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/44.jpg)
4/26/2016
44
Lichen planus
Wickham striae
![Page 45: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/45.jpg)
4/26/2016
45
Mycosis Fungoides (CTCL)
Thank you! Our Office:
PMG-Dermatologic Specialties5330 NE Glisan St., Suite 200Portland, OR 97213
Phone: 503-215-9080
![Page 46: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/46.jpg)
4/26/2016
46
Case #12 26 y/o M with spreading fine scaly rash x
3 months Rash is more prominent after tanning
![Page 47: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/47.jpg)
4/26/2016
47
KOH
![Page 48: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/48.jpg)
4/26/2016
48
Tinea Versicolor Caused by lipophilic yeast – Malassezia
Malassezia is naturally found on human skin Enzyme tyrosinase causes hypopigmentation Not contagious Recurrence is common Pigmentation change generally improves 2
months s/p treatment Treatment
Selenium sulfide 2.5% shampoo Ketoconazole shampoo Oral fluconazole
Case #15 32 y/o M with 3 month h/o pruritic
generalized eruption Temporary relief with topical steroids and oral
antibiotics
![Page 49: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/49.jpg)
4/26/2016
49
![Page 50: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/50.jpg)
4/26/2016
50
Scabies!
![Page 51: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/51.jpg)
4/26/2016
51
Scabies prep Try to find burrows Scrape several lesions until pinpoint bleeding
Buttocks and acral skin typically high yield Place scrapings on slide
Add a few drops of mineral oil Place a cover slide
![Page 52: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/52.jpg)
4/26/2016
52
Eggs
Feces
Nodular scabies
![Page 53: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/53.jpg)
4/26/2016
53
Scabies Often takes close family members three
months to show symptoms All close contacts need to be treated
Topical 5% permethrin – repeat in 1 wk Oral ivermectin
Post-scabetic itch is common Can last for a few months s/p treatment Treatment with topical steroids
Case #11 16 y/o M with long h/o acne
![Page 54: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/54.jpg)
4/26/2016
54
Comedonal acne
Inflammatory acne
![Page 55: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/55.jpg)
4/26/2016
55
Cystic acne
![Page 56: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/56.jpg)
4/26/2016
56
Hormonal acne
Acne treatment Comedonal
Tretinoin Adapalene (differin) Tazorac (category X in pregnancy)
Inflammatory Tretinoin Topical antibiotics (ie clindamycin) Oral antibiotics (ie doxycycline or minocycyline) OCPs, Spironolactone – if hormonal distribution Benzoyl peroxide lotion and/or wash
Cystic Isotretinoin
![Page 57: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/57.jpg)
4/26/2016
57
Case #21 18 y/o M present with very itchy blisters
on his face and extremities
Dermatitis herpetiformis
![Page 58: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/58.jpg)
4/26/2016
58
Dermatitis herpetiformis Chronic autoimmune blistering disorder
associated with celiac disease >90% have underlying gluten-sensitive
enteropathy even though 20% have GI sx Often complete remission on gluten-free diet
Dapsone also effective Diagnosis
Biopsy for H&E and DIF Celiac panel (anti-endomysial, anti-tissue
transglutaminase, anti-gliadin antibodies) DH + positive celiac blood tests = Celiac dz
Case #25 46 y/o F with new onset pruritic eruption x
2 months Temporary relief with oral prednisone, but it
recurred
![Page 59: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/59.jpg)
4/26/2016
59
Lichen planus
Wickham striae
![Page 60: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/60.jpg)
4/26/2016
60
Lichen planus Flat-topped violaceous polygonal papules
Look for surface white streaks (Wickham striae) Many clinical variants
Ulcerative mucosal LP – increased risk of SCC Predilection for flexor surfaces, but can also
have genital, oral, and nail involvement Pruritus a prominent feature 2/3 resolve spontaneously in <1 year Can be related to hepatitis C
Case #24 59 y/o F presented with new skin lesions
in addition to weight loss
![Page 61: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/61.jpg)
4/26/2016
61
MetastaticSignet cell carcinoma
![Page 62: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/62.jpg)
4/26/2016
62
Case #25 78 y/o F hospitalized with failure to thrive,
diarrhea and a painful erosive eruption Refractory to oral fluconazole and antibiotics
Acquired acrodermatitis enteropathica
![Page 63: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/63.jpg)
4/26/2016
63
Case #16 27 y/o F presenting with skin darkening
on the legs for 1 year
![Page 64: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/64.jpg)
4/26/2016
64
Erythema ab igne Reticulated (net-like) hyperpigmentation
due to chronic thermal injury Common causes
Space heater Heating pad Laptop computer
Pigmentation changes may be permanent Very low risk of developing SCC
![Page 65: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/65.jpg)
4/26/2016
65
How to biopsy Reinforce to the patient: the biopsy itself
is for diagnosis and is NOT the definitive treatment
Take enough tissue for the pathologist to make a diagnosis, but try to minimize scarring in cosmetically sensitive areas
Biopsy technique pearls Rash
4mm punch biopsy x 2 Neoplasm
Shave biopsy
![Page 66: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/66.jpg)
4/26/2016
66
Biopsying melanocytic lesions The more raised the nevus, the deeper it
penetrates into the dermis Do a deep shave biopsy to superficial SubQ
if concerned about melanoma Can do a punch biopsy if the nevus is small
and fits completely within the punch Make sure that the diameter of the punch is
larger than the neoplasm
SHAVE BIOPSY EXAMPLE
![Page 67: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/67.jpg)
4/26/2016
67
Clean skin with alcohol swab
Anesthetize w/ lidocaine (1%) with epinephrine (1:100,000)
![Page 68: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/68.jpg)
4/26/2016
68
PUNCH BIOPSY EXAMPLE
![Page 69: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/69.jpg)
4/26/2016
69
![Page 70: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/70.jpg)
4/26/2016
70
Pull skin taut perpendicular to skin tension lines
![Page 71: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/71.jpg)
4/26/2016
71
Hold & cut from base of specimen; try not to damage epidermis
![Page 72: Dermatology for the Primary Care Provider - …cmetracker.net/PPMC/Files/EventMaterials/29-Dermatology.pdfDermatology for the Primary Care Provider ... Seborrheic keratosis Cherry](https://reader031.vdocuments.site/reader031/viewer/2022021817/5a9fe4f97f8b9a8e178d5360/html5/thumbnails/72.jpg)
4/26/2016
72