Dermatology Review

Jay Vary, MD PhD

Assistant Professor

Division of Dermatology

VAPSHCS and UWMC

jvary@uw.edu

I have no financial conflicts

Please do not use or reproduce any of these clinical photographs

WAPA 28th Annual Spring Conference 4/22/2017

Objectives

By the end of the session, you will be able to:

• Describe the basic structure of the skin

• Use the correct dermatology terminology

• Distinguish common Dermatology mimics

• Describe when to worry with a drug rash

Skin and its Appendages

Skin and its Appendages

Eccrine Sweat Gland

Sebaceous Gland

Arrector Pili Muscle

Apocrine (Sweat) Gland

Hair Follicle

The Nail

Indiana University http://anatomy.iupui.edu/courses/histo_D502/D502f04/lecture.f04/integument.f04/integumentf04.html

matrix

matrix

Proximal Nail Fold

Lateral Nail Fold

Proximal Nail Fold

Nail matrix

plate

plate

Cuticle

Language of Dermatology

• Macule, patch

• Papule, plaque

• Vesicle, bulla, pustule

• Erosion, ulceration

• Nodule

“There is a big lesion on his face”

Macule (<1cm) Patch (>1cm)

Papule/plaque Vitiligo

Macule or Patch

Papule (<1cm) Plaque (>1cm)

Psoriasis

Papule<1cm Plaque>1cm

Vesicle (<1cm) Bullae (>1cm)

Vesicle<1cm Bullae>1cm

Bullous Pemphigoid

Vesicle<1cm Bullae>1cm

Pustular Psoriasis

Erosion Ulcer

Erosion Ulcer

Epidermolysis Bullosa

Erosion Ulcer

Diabetic Foot Ulcer

What is the best description for the primary lesions shown?

• A) White papules

• B) White flat papules

• C) White macules

• D) White flat macules

• E) Maculopapular rash

What is the best description for the primary lesions shown?

• A) Red crusted plaques

• B) Red scaly plaques

• C) Red crusted patches

• D) Red scaly patches

• E) Maculopapular rash

https://nyti.ms/2jSOE0u

Which is it?

a)Tinea corporis b)Atopic dermatitis c) Psoriasis d)Impetigo e)Scabies

Atopic Dermatitis vs Psoriasis Atopic Dermatitis:

POORLY defined scaly plaques, often with EXUDATE and CRUST

Psoriasis:

WELL define erythematous plaques with MICACEOUS SCALE

Atopic Dermatitis vs Psoriasis Atopic Dermatitis:

Flexural surfaces-antecubital fossa

Psoriasis:

Extensor surfaces-elbows

Atopic Dermatitis vs Psoriasis Atopic Dermatitis:

Flexural areas-popliteal fossa

Psoriasis:

Extensor surfaces-knees

Atopic Dermatitis vs Psoriasis

Atopic Dermatitis

Flexural areas

Psoriasis

Extensor surfaces

Cohen, BA; Davis, HW; Gehris, RP. Dermatology Atlas of Pediatric Physical Diagnosis. Published January 2, 2012. Pages 299-368.

Which is it?

a) Cutaneous Larva Migrans b) Tinea Pedis c) Granuloma Annulare d) Psoriasis

Tinea Corporis vs Granuloma Annulare

Tinea Corporis

Advancing red edge with SCALE

Granuloma Annulare

Red raised border WITHOUT scale

James, WD; Berger, TG; Elston, DM. Diseases Resulting from Fungi and Yeasts. Andrews' Diseases of the Skin. Published January 1, 2016. Pages 285-318.e1.

Cohen, BA; Davis, HW; Gehris, RP. Dermatology Atlas of Pediatric Physical Diagnosis. Published January 2, 2012. Pages 299-368.

Case from: American Academy of Dermatology Medical Student Core Curriculum: aad.org/education

Which is it?

a) Bilateral Lower Extremity Cellulitis

b) Allergic Contact Dermatitis

c) Tinea Corporis d) Stasis Dermatitis

Stasis Dermatitis vs Cellulitis Stasis Dermatitis

Subacute (weeks)

Scaly

Pruritic

Often bilateral shins only

Spares the ankle

Cellulitis

Acute (days)

Not scaly

Painful

Always unilateral

No anatomic boundaries

Case from: American Academy of Dermatology Medical Student Core Curriculum: aad.org/education

Hirschmann, JV; Raugi, GJ. Lower limb cellulitis and its mimics JAAD. Published August 1, 2012. Volume 67, Issue 2. Pages 163.e1-163.e12.

Cellulitis????

Cellulitis is misdiagnosed in 30% of hospitalized patients 2/3 of the time it was the reason for admission Estimated costs in US alone are over $1,000,000,000 dollars/year due to unnecessary admissions, antibiotics, and complications Mimics: Stasis Dermatitis DVT Edema Gout

Weng QY et al. Costs and consequences associated with misdiagnosed lower extremity cellulitis. JAMA Dermatol 2016 Nov 2 Consuelo, D., et al. Diagnostic accuracy in patients admitted to hospitals with cellulitis. Dermatology Online Journal 17 (3): 1, 2011.

Bilateral Lower Extremity Cellulitis

Habif, TP. Superficial fungal infections. Clinical Dermatology. Published January 1, 2016. Pages 487-533

Which is it?

a) Candida b) Tinea Cruris c) Intertrigo d) Psoriasis e) Erythrasma

Intertrigo vs Candida vs Tinea Intertrigo

Erythema

Candida

Erythema with satellites

Pustules

Tinea cruris

Erythema with scaly border

Does NOT involve scrotum

Habif, TP. Superficial fungal infections. Clinical Dermatology. Published January 1, 2016. Pages 487-533

Which is it?

a) Drug Exanthem b) Pityriasis Rosea c) Tinea corporis d) Guttate psoriasis e) Scabies

Habif, TP, Principles of diagnosis and anatomy. Clinical

Dermatology. Published January 1, 2016. Pages 1-74.

Pityriasis Rosea

James, WD; Berger, TG; Elston, DM. Pityriasis Rosea, Pityriasis Rubra Pilaris, and Other Papulosquamous and Hyperkeratotic Diseases. Andrews' Diseases of the Skin. Published January 1, 2016. Pages 199-208.e1.

Fassihi H; White, I. Diseases of the skin Medicine & Surgery: An Integrated

Textbook. Published January 2, 2007. Pages 847-934.

Calonie, E; Brenn, T; Lazar, A. Spongiotic, psoriasiform and pustular dermatoses McKee's Pathology of the Skin. Published January 1, 2012. Pages 180-218.

Herald Patch Central ring of scale (like a popped bubble) NOT a Christmas tree

It’s a drug rash. Is he gonna die?

a) Yes b) No c) Maybe so

What to check History PE PE-Nikolsky’s sign PE PE PE PE Labs--LFTs, Creatinine/UA. H&P for pleuritis/carditis/cerebritis Labs--CBC with differential

___ ___ ___ ___ ___ ___ ___ ___ ___

Signs of a serious drug rash:

Painful skin Fever

Loss of skin integrity/blistering Facial edema

Mucosal involvement Palm/sole involvement

Lymphadenopathy Systemic involvement

Marked peripheral eosinophilia

Typical Benign Drug Exanthem

• Aka maculopapular or “morbilliform”

• ~90% of cutaneous drug reactions.

• Type IV (T-cell mediated) hypersensitivity reaction.

• Starts 7-14d after start of drug – Stops up to 7d after stopping drug

What to check History PE PE-Nikolsky’s sign PE PE PE PE Labs--LFTs, Creatinine/UA. H&P for pleuritis/carditis/cerebritis Labs--CBC with differential

___ ___ ___ ___ ___ ___ ___ ___ ___

Signs of a serious drug rash:

Painful skin Fever

Loss of skin integrity/blistering Facial edema

Mucosal involvement Palm/sole involvement

Lymphadenopathy Systemic involvement

Marked peripheral eosinophilia

Benign Drug Exanthem

Fever

Benign Drug Exanthem Treatment

• STOP the offending agent

• Oral SEDATING antihistamines (benadryl, hydroxyzine) (histamine is not the problem)

• Topical steroids help a little

Day 1

WBC 16K +reactive lymphocytes AST/ALT 110/134 INR 2.1 BUN/Cr 20/0.8

Day 3

DRESS

• Drug reaction with eosinophilia and systemic symptoms—aka “drug/dilantin hypersensitivity syndrome”

• Type IV delayed hypersensitivity reaction

• Onset 2-8 weeks after first exposure

• Can be fatal (10%) if untreated

What to check History PE PE-Nikolsky’s sign PE PE PE PE Labs--LFTs, Creatinine/UA. H&P for pleuritis/carditis/cerebritis Labs--CBC with differential

___ ___ ___ ___ ___ ___ ___ ___ ___

Signs of a serious drug rash:

Painful skin Fever

Loss of skin integrity/blistering Facial edema

Mucosal involvement Palm/sole involvement

Lymphadenopathy Systemic involvement

Marked peripheral eosinophilia

DRESS

Fever

Facial edema

Lymphadenopathy Systemic involvement

Marked peripheral eosinophilia

DRESS Treatment

• STOP the offending agent

• PO or IV steroids

• Monitor TSH for 6 months

Day 1

Day 2

Day 4

What is it, and is their skin going to fall off?

Stevens- Johnson

Syndrome

SJS/TEN overlap

TEN

Skin rash + 2 or more mucosal sites

<10% 10-30% >30% BSA:

Mortality: 30-50% 5-10%

Stevens-Johnson Syndrome (SJS) &

Toxic Epidermal Necrolysis (TEN)

• Rare; 1-2 cases per million person years

• Occurs 1-3 weeks after starting drug; sooner if rechallenged

• URI-prodrome 1-2 weeks before rash

• fever (universal), conjunctivitis, pharyngitis, pruritis and PAINFUL SKIN!!

What to check History PE PE-Nikolsky’s sign PE PE PE PE Labs--LFTs, Creatinine/UA. H&P for pleuritis/carditis/cerebritis Labs--CBC with differential

___ ___ ___ ___ ___ ___ ___ ___ ___

Signs of a serious drug rash:

Painful skin Fever

Loss of skin integrity/blistering Facial edema

Mucosal involvement Palm/sole involvement

Lymphadenopathy Systemic involvement

Marked peripheral eosinophilia

SJS/TEN

Painful skin Fever

Loss of skin integrity/blistering Facial edema

Mucosal involvement Palm/sole involvement

Lymphadenopathy Systemic involvement

SJS/TEN Treatment

• STOP the offending agent

• Admit-Refer to burn ICU if TEN

• Ophtho & Gyn consultation to prevent irreversible scarring

• Consider PO or IV steroids or IVIG, but benefits are unclear.

• rule out serious drug rash and systemic involvement

• discontinue all unnecessary medications

• change all necessary medications to different chemical class

• consider Dermatology consultation

New Suspected Drug Rash

Excellent resource for Dermatology www.aad.org