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					     Dermatology
             By
  Katrice L. Herndon, MD
Internal Medicine/Pediatrics
        June 2, 2005
What is this?
             Acne Vulgaris
• Acne is a self-limited disorder primarily of
  teenagers & young adults.
• Acne is a disease of pilosebaceous follicles.
• 4 factors are involved:
   • Retention hyperkeratosis
   • Increased Sebum production
   • Propionbacterium acnes within the follicle
   • Inflammation
               Acne Vulgaris
• External Factors that contribute to Acne
  • Oils, greases, dyes in hair products
  • Detergents, soaps, astringents
  • Occlusive clothing: turtlenecks, bra straps
  • Environmental Factors: Humidity & Heavy
    exercise.
  • Psychological stress
  • Diet is controversial
                 Acne Vulgaris
• Acne vulgaris typically affects those areas of the
  body that have the greatest number of sebaceous
  glands:
   • the face, neck, chest, upper back, and upper arms.


• In addition to the typical lesions of acne vulgaris,
  scarring and hyperpigmentation can also occur.

• Hyperpigmentation is most common in patients
  with dark complexions
                Acne Vulgaris
• Classification of Acne
   • Type 1 — Mainly comedones with an occasional small
     inflamed papule or pustule; no scarring present

     Type 2 — Comedones and more numerous papules and
     pustules (mainly facial); mild scarring

     Type 3 — Numerous comedones, papules, and
     pustules, spreading to the back, chest, and shoulders,
     with an occasional cyst or nodule; moderate scarring

     Type 4 — Numerous large cysts on the face, neck, and
     upper trunk; severe scarring
Acne Vulgaris
What is this?
               Acne Rosacea
• Rosacea is an acneiform disorder of middle-aged
  and older adults.

• Characterized by vascular dilation of the central
  face, including the nose, cheek, eyelids, and
  forehead.

• The cause of vascular dilatation in rosacea is
  unknown.

• The disease is chronic.
                Acne Rosacea
• rosacea is a chronic disorder characterized by
  periods of exacerbation and remission.

• Increased susceptibility to recurrent flushing
  reactions that may be provoked by a variety of
  stimuli including hot or spicy foods, drinking
  alcohol, temperature extremes, and emotional
  reactions.

• The earliest stage of rosacea is characterized by
  facial erythema and telangiectasias.
                  Acne Rosacea
• Patients with rosacea may develop severe
  sebaceous gland growth that is accompanied by
  papules, pustules, cysts, and nodules.

• The diagnosis of rosacea is based upon clinical
  findings(1 or more of the following):
   •   Flushing (transient erythema)
   •   Non-transient erythema
   •   Papules and pustules
   •   Telangiectasia
               Acne Rosacea
• Topical antibiotics or benzoyl peroxide are the
  initial treatments of choice.

• Tretinoin cream is used in patients with papular or
  pustular lesions that are unresponsive to other
  treatments.

• The chronicity of rosacea requires that medical
  therapy be continued long-term, not just for flare-
  ups of the condition.
What is This?
    Allergic Contact Dermatitis
• Contact dermatitis refers to any dermatitis
  arising from direct skin exposure to a
  substance. It can be allergic or irritant-
  induced.


• An allergen induces an immune response,
  while an irritant directly damages the skin.
       Allergic Contact Dermatitis
• The most common sensitizer in North America is
  the plant oleoresin urushiol found in poison ivy,
  poison oak, and poison sumac

• Other common sensitizers in the US:
   •   nickel (jewelry)
   •   formaldehyde (clothing, nail polish),
   •   fragrances (perfume, cosmetics),
   •   preservatives (topical medications, cosmetics),
   •   rubber
   •   chemicals in shoes (both leather and synthetic)
   Allergic Contact Dermatitis
• Treatment
  • Avoidance of exposure to the offending
    substance.

  • Use of corticosteroids topical or oral in the
    acute phase of the reaction maybe helpful.

  • Cooling of the skin by using calamine lotion or
    aluminum acetate
What is this?
                 Psoriasis
• Psoriasis is a common chronic skin disorder
  typically characterized by erythematous
  papules and plaques with a silver scale.


• Most of the clinical features of psoriasis
  develop as a secondary response triggered
  by T-lymphocytes in the skin.
                           Psoriasis
• Several clinical types of psoriasis have been described:
   • Plaque psoriasis - symmetrically distributed plaques
      involving the scalp, extensor elbows, knees, and back.

   • Guttate psoriasis - abrupt appearance of multiple small
      psoriatic lesions.

   • Pustular psoriasis - most severe form of psoriasis.
      Characterized by erythema, scaling, and sheets of
      superficial pustules with erosions.

   • Inverse psoriasis - refers to a presentation involving the
      intertriginous areas.
                   Psoriasis



• Nail psoriasis -the typical nail abnormality in
  psoriasis is pitting w/ color changes & crumbling of
  the nail.
Psoriasis
                    Psoriasis

• Most patients w/ psoriasis tend to have the disease
  for life.

• There is variability in the severity of the disease
  overtime w/ complete remission in 25% of cases.

• The diagnosis of psoriasis is made by physical
  examination and in some cases skin biopsy.
                         Psoriasis
Treatment
• Treatment modalities are chosen on the basis of
  disease severity.
   • Topical emmollients, topical Steroids, tar

   • Calcipotriene(Dovonex) affects the growth and
       differentiation of keratinocytes via its action at the level of
       vitamin D receptors in the epidermis.

   •   Tazarotene, is a topical retinoid, systemic retinoids
   •   Methotrexate, cyclosporine
   •   Immunmodulator therapy (embrel, remicade)
   •   Ultraviolet light.
What is this?
                     Vitiligo
• Vitiligo is an acquired skin depigmentation that
  affects all races but is far more disfiguring in
  blacks.

• The precise cause of vitiligo is unknown Genetic
  factors appear to play a role.

• 20-30 percent of patients may have a family
  history of the disorder.

• The pathogenesis is thought to involve an
  autoimmune process directed against melanocytes.
                     Vitiligo
• Peaks in the second and third decades.

• The depigmentation has a predilection for acral
  areas and around body orifices (eg, mouth, eyes,
  nose, anus).

• The course usually is slowly progressive.

• The diagnosis of vitiligo is based upon the clinical
  presence of depigmented patches of skin
                 Vitiligo
• Repigmentation therapies include:
   • corticosteroids
   • calcineurin inhibitors
   • Ultraviolet light
• Pseudocatalase cream
• Surgery – minigrafting techiniques
• Depigmentation therapy w/ hydroquinone
What is this?
               Pityriasis Rosea
• Pityriasis rosea is an acute, self-limited,
  exanthematous skin disease characterized by the
  appearance of slightly inflammatory, oval,
  papulosquamous lesions on the trunk & proximal
  areas of the extremities.

• The eruption commonly begins with a "herald" or
  "mother" patch, a single round or oval, rather
  sharply delimited pink or salmon-colored lesion
  on the chest, neck, or back.

• 2 to 5 cm in diameter.
Pityriasis Rosea
              Pityriasis Rosea
• A few days later lesions similar in appearance to
  the herald patch, appear in crops on the trunk &
  proximal areas of the extremities.

• The eruption spreads centrifugally or from the top
  down in just a few days.

• The long axes of these oval lesions tend to be
  oriented along the lines of cleavage of the skin,
  like a christmas tree pattern.

• Then the lesions fade without any residual
  scarring.
                 Pityriasis Rosea
• The presence of a herald patch by history or on
  examination.

• The characteristic morphology and distribution of
  the lesions.

• The absence of symptoms other than pruritus
  combine to make PR an easy diagnosis in most
  instances.
                 Pityriasis Rosea
• Differential Dx include: Psoriasis, secondary
  syphilis, tinea corporis, Lyme disease, & drug
  eruptions.

• Treatment is usually reasurrance.
   •   Topical Steroids
   •   Antipruitic lotions (prax, pramagel)
   •   Phototherapy
   •   Erthyromycin in severe cases
   •   Rash usually persists for 2-3 months
What is this?
                  Cellulitis
• Cellulitis is an infection of the skin with
  some extension into the subcutaneous
  tissues.


• An extremity is the most common location
  but any area of the body can be involved.
                    Cellulitis
• Five factors were identified as independent
  risk factors:
   • Lymphedema
   • Site of entry (leg ulcer, toe web intertriginous,
    and traumatic wound)
  • Venous insufficiency
  • Leg edema
  • Being overweight
                   Cellulitis
• Cellulitis is a recognizable clinical syndrome with
  both local & systemic features.


• Systemic symptoms include:
   • Fever and chills
   • Myalgias
   • Increased WBC count
                      Cellulitis
• Local findings typical of cellulitis:

   •   Macular erythema that is largely confluent
   •   Generalized swelling of the involved area
   •   Warmth to the touch of the involved skin
   •   Tenderness in the affected area
   •   Tender regional lymphadenopathy is common
   •   Lymphangitis may be present
   •   Abscess formation also may be present
                  Cellulitis
• Cellulitis in the majority of patients is
  caused by beta-hemolytic streptococci
  groups A, B, C, G, and Staphylococcus
  aureus.

• Other less common pathogens include
  H.flu, P.aeruginosa, Aermonas hydrophilia,
  Pasturella multocida.
                       Cellulitis
• Diagnosis is clinical
• Treatment: Anti-strep/Anti- staph
   •   Cefazolin
   •   Nafcillin
   •   Clindamycin
   •   Vancomycin
   •   Fluoroquinolones (3rd & 4th generations)
   •   Macrolides (erythromycin, azithromycin)

   Duration of treatment is usually 10-14 days
What is this?
                     Erysipelas
• Erysipelas is a characteristic form of cellulitis that
  affects the superficial epidermis, producing
  marked swelling.

• Bacterial Organisms:
   •   Beta-hemolytic streptococci group A
   •   Group C & G less commonly
   •   Staph. Aureus
   •   Streptococcus pneumoniae, enterococci, gram negative
       bacilli
                  Erysipelas
• The erysipelas skin lesion has a raised border
  which is sharply demarcated from normal skin.

• This is its most unique feature and allows it to be
  distinguished from other types of cellulitis.

• The demarcation is sometimes seen at bony
  prominences.

• The affected skin is painful, edematous, intensely
  erythematous, and indurated (peau d'orange
  appearance).
                     Erysipelas
• The face historically was the most common area
  of involvement.


• Erysipelas is diagnosed clinically

• It can mimic other skin conditions:
   • Herpes zoster (5th cranial nerve)
   • Contact Dermatitis
   • Urticaria
                   Erysipelas
• Treatment:
  •   Penicillin is the preferred treatment
  •   Erythromycin
  •   Clindamycin
  •   Fluoroquinolones

• Erysipelas does have the propensity of
  recur.
What is this?
                   Ecthyma
• Ecthyma is an ulcerative pyoderma of the skin
  caused by group A beta-hemolytic streptococci.

• Because ecthyma extends into the dermis, it is
  often referred to as a deeper form of impetigo.

• Preexisting tissue damage (excoriations, insect
  bites, dermatitis) & immunocompromised states (
  diabetes, neutropenia) predispose patients to the
  development of ecthyma.
                      Ecthyma
• Ecthyma begins as a vesicle or pustule overlying an
  inflamed area of skin that deepens into a dermal ulceration
  with overlying crust.
   • A shallow, punched-out ulceration is apparent when
      adherent crust is removed.

   • The deep dermal ulcer has a raised and indurated
     surrounding margin.

• Ecthyma lesions can remain fixed in size or can
  progressively enlarge to 0.5-3 cm in diameter.

• Ecthyma heals slowly and commonly produces a scar.

• Regional lymphadenopathy is common.
                Ecthyma
Treatment:
• Topical mupirocin ointment
• Gentle surgical debridement
• Oral/IV antibiotics
  • Penicillin
  • Clindamycin
  • Macrolides
  • Cefazolin
What is this?
            Tinea Vesicolor
• Tinea versicolor is a common superficial
  infection caused by the organism
  Pityrosporum orbiculare.


• Which is a saprophytic yeast that is part of
  the normal skin flora.
              Tinea Vesicolor
• Lesions can be hypopigmented, light brown, or
  salmon colored macules.

• A fine scale is often apparent, especially after
  scraping.

• Individual lesions are typically small, but
  frequently coalesce.

• Lesions are limited to the outermost layers of the
  skin.
             Tinea Vesicolor
• Most commonly found on the upper trunk &
  extremities, & less often on the face and
  intertriginous areas.

• While most patients are asymptomatic, some
  complain of mild pruritus

• The diagnosis of tinea versicolor is confirmed by
  direct microscopic examination of scale with 10 %
  potassium hydroxide (KOH).
              Tinea Vesicolor

• The differential diagnosis includes seborrhea,
  eczema, pityriasis rosea, and secondary syphilis.


• Treatment includes topical antifungals. Oral
  antifungals can be used for more extensive
  disease: Ketocanozole 400mg x 1 dose.
  Fluconazole and itraconazole are also effective.
What is this?
             Cutaneous Warts
• Cutaneous warts AKA verrucae are caused by
  HPV which infects the epithelium of skin and
  mucus membranes.

• Cutaneous warts occur most commonly in children
  and young adults.

• Also more common among certain occupations
  such as handlers of meat, poultry, and fish.

• Predisposing conditions include atopic dermatitis
  & any condition in which there is decreased cell-
  mediated immunity.
            Cutaneous Warts
• Infection with HPV occurs by skin-to-skin contact
• Incubation period following exposure in 2-6
  months.

• Warts can have several different forms based upon
  location & morphology (flat, mosaic, and filiform
  warts)

• Lesions may occur singly, in groups, or as
  coalescing lesions forming plaques.
             Cutaneous Warts
• The diagnosis of verrucae is based upon clinical
  appearance.


• Scrape off any hyperkeratotic debris & reveal
  thrombosed capillaries (seeds).


• The wart also will obscure normal skin markings
             Cutaneous Warts
Differential Diagnosis:
  • Lichen Planus
  • Seborrheic Keratosis
  • Acrochordon or skin tag
  • Clavus or corn
Treatment
  • Spontaneous regression in 2/3 over 2yrs
  • Salicylic acid, liquid nitrogen, cantharidin
  • Cyrotherapy, curettage, laser therapy
  • Immunotherapy, intralesional injections
What is this?
          Secondary Syphilis
• Syphilis is a chronic infection caused by the
  bacterium Treponema pallidum which is
  sexually transmitted.
• Syphilis occurs in 3 stages:
  • 1st stage is characterized by the classic chancre,
    which is a 1-2cm ulcer with raised indurated
    borders, usually painless and occurs at site of
    innoculation. Heals spontaneously.
Secondary Syphilis
             Secondary Syphilis
• Secondary or systemic syphilis is characterized by a rash.

• The rash is classically a symmetric papular eruption
  involving the entire trunk & extremities including the
  palms and soles.

• Systemic symptoms include fever, headache, malaise,
  anorexia, sore throat, myalgias, & weight loss.

• Lymphadenopathy (inquinal, axillary)

• So-called "moth-eaten" alopecia

• Condyloma lata, grayish white lesions involving the
  mucus membranes
Secondary Syphilis
            Secondary Syphilis
• Diagnosis at this stage is usually by serologic
  testing but darkfield microscopy can also be done
  for direct visualization of spirochete.

• Non-treponemal testing:
   • Veneral disease research laboratory (VDRL)
   • Rapid plasma reagent (RPR)

• Treponemal testing:
   • Fluorescent treponemal antibody absorption test
   • Microhemagglutination test for antibodies
              Seconday Syphilis
Treatment
• T.Pallidum remains very sensitive to PCN.

• Long-acting benzathine penicillin G should be used.

• If documented chancre or a NR serologic testing was done
  in the past 1 yr, one IM dose is appropriate.

• If neither of the above applies this needs to treated as latent
  syphilis and 3 q week doses must be given.

• Doxycycline, erythromycin or zithromycin in pen allergic
  patients x 14 days.
What is this?
                Herpes Zoster
• Reactivation of endogenous latent VZV infection
  within the sensory ganglia results in herpes zoster
  or "shingles", a syndrome characterized by a
  painful, unilateral vesicular eruption in a restricted
  dermatomal distribution.

• How the virus emerges from latency is not clearly
  understood.

• Patients frequently experience a prodrome of
  fever, pain, malaise and headache which precedes
  the vesicular dermatomal eruption by several days.
               Herpes Zoster
• The rash initially appears along the dermatome as
  grouped vesicles or bullae which evolve into
  pustular or occasionally hemorrhagic lesions
  within three to four days.

• The thoracic and lumbar dermatomes are the most
  commonly involved sites of herpes zoster.

• The complications of herpes zoster include ocular,
  neurologic, bacterial superinfection of the skin and
  postherpetic neuralgia
                Herpes Zoster
Treatment
• Antivirals:
   • Acyclovir
   • Famciclovir
   • Valacyclovir

• Antivirals w/ corticosteroids

• Analgesics: opioids/acetominophen
What is this?
          Actinic Keratosis
• Actinic keratoses (AKs) are premalignant
  lesions that develop only on sun-damaged
  skin.

• AKs appear as patches of hyperkeratosis
  with some surrounding erythema on sun-
  exposed areas of the head and neck,
  forearms and hands, and upper back.
Actinic Keratosis
              Actinic Keratosis
• The differential diagnosis of AKs includes
  seborrheic keratoses, verruca vulgaris, SCC, and
  superficial BCC.
• The treatment of AKs begins with prevention.
   • Avoiding sun exposure
   • sunscreens reduce the development of AKs,
   • Active treatment of AKs depends upon the size of the
       lesion and the number of lesions present.
   •   Liquid Nitrogen
   •   Surgical curettage
   •   Chemotherapy (5-FU, diclofenac, imiquimod)
   •   Dermabrasion
   •   Photodynamic therapy
Which one is which?
• Basal Cell Carcinomas begins as small
  shiny nodules and grows slowly. It is the
  most common form of skin cancer.

• Frequently, the central portion breaks down
  to form an ulcer with a reddish-purple scab.
  These tumors usually remain fairly
  localized and rarely spread elsewhere.
• Squamous Cell Carcinoma is another common form of
  skin cancer. When these tumors first appear they are firm
  to the touch. They appear most often on sun-exposed areas
  of your body.

• Squamous cell carcinoma evolves very slowly through a
  premalignant stage known as a solar or actinic keratosis.

• Untreated, significant numbers of these lesions can
  metastasize to distant sites. Tumors on the lower lip and
  ears are at higher risk to spread.
• Malignant Melanoma is the most dangerous form of skin
  cancer.

• They arise from either pre-existing moles or normal skin.

• Malignant melanoma, like basal and squamous
  carcinomas, is linked to overexposure to the sun.

• But it can appear any place on your body.

• When detected early & with proper treatment, the recovery
  rate from this form of skin cancer can be very high.
                  References
• Harrison’s 15th Edition. Principles of Internal
  Medicine

• Up to Date

• Emedicine

• Dermatology Pearls Adult and Pediatric
Thank You