Cases in Dermatology

Annual Primary Care Conference

June 5, 2015
Chong Foo, M.D.
PeaceHealth Medical Group, Dermatology
 I have no conflicts of interest to declare for this presentation
News of the day!
12 Cases

 Clinical diagnosis of common rashes

 Topical corticosteroids
 Skin biopsy for rash
 Drug reactions
 Pruritus
 Psychocutaneous disease
Monday 7.30am
Case #1
 “I’ve got a rash”

 “I’ve had it for years, but I

decided to come in today”

 “Make it go away”

 “Now..”
Differentials

 Drug eruption
 Tinea corporis
 Eczema
 Psoriasis
Diagnosis?

 Drug eruption
 Tinea corporis
 Eczema
 Psoriasis
 Well-demarcated erythematous scaly
plaques
Chronic Plaque Psoriasis
Guttate psoriasis
 Common in children and young
adults

 >50% have preceding Strep

infection

 May regress in children in

months
Koebner phenomenon
 More likely to become chronic in
adults

 Responsive to phototherapy
Psoriasis Take Home Point

 Check for recent Streptococcal infection if one sees guttate psoriasis

 Empiric antibiotics for Streptococcal related guttate psoriasis

 Baughman RD. Search for Streptococcus. Arch Dermatol. Jan
1992;128(1):103.
Treatment options

 Topicals
 Corticosteroids
 Vitamin D analogues (calcipotriene)
 hypercalcemia

 Phototherapy (PT)
 Narrowband UVB
 Potential risk of skin cancer
 Inform patients on PT about medications
that cause photosensitivity
Treatment options

 Systemic
 Biologics
 TNF-alfa inhibitors (etanercept, adalimumab, infliximab)
 IL-17 (ustekinumab, secukinumab)

 Methotrexate, apremilast, cyclosporine

 Potential risks related to immunosuppression

 Infection
 Malignancy
Monday 7.45am
Case #2
 “I’ve got a rash”

 “Make it stop itching”

Differentials

 Drug eruption
 Tinea corporis
 Eczema
 Psoriasis
Diagnosis?

 Drug eruption
 Tinea corporis
 Eczema
 Psoriasis

 Nummular dermatitis / nummular eczema

Treatment

 Topical corticosteroids

 Emollients
 Ointments > creams > lotions

 Use fragrance free products

 Vitamin P (Prednisone) is only for rescue treatment

Topical corticosteroids

 7 classes – Superpotent (class 1)  Low potency (class 7)

 Superpotent (class 1):
 Clobetasol, betamethasone diproprionate ointment
 High potency (class 2-3):
 Betamethasone diproprionate cream, fluocinonide, triamcinolone 0.1% ointment
 Medium potency (class 4-5):
 Triamcinolone 0.1% cream, betamethasone valerate, hydrocortisone butyrate and
valerate
 Low potency (class 6-7) – face, skin fold, young children:
 Desonide, triamcinolone 0.025%, hydrocortisone 1% or 2.5% cream
Complications of topical corticosteroids

Cutaneous atrophy
Complications of topical corticosteroids

Steroid induced acne

Corticosteroids Take Home Point

 Avoid potent topical corticosteroid use on face,

eyelids and skin fold areas

 Avoid potent topical corticosteroid use in infants

and young children
Atopic Dermatitis
Keratosis Pilaris Pityriasis alba
Treatment for atopic dermatitis

 Topical corticosteroids

 Emollients
 Ointments > creams > lotions

 Use fragrance free products

 Vitamin P (Prednisone) is only for rescue treatment

Topical calcineurin inhibitors

 Tacrolimus
 For moderate to severe atopic dermatitis

 Pimecrolimus
 For mild to moderate atopic dermatitis

 FDA warning: Cancer risk

 Do not use in children younger than 2 years
Complications of atopic dermatitis

Impetigo Eczema herperticum

Stasis Dermatitis
Treatment

 Topical corticosteroids
 Medium to Super Potent topical steroids

 Emollients

 External compression / Leg elevation

 Diuretics

 Vitamin P (Prednisone) for rescue

Monday 8.00am
Case #3
 “ I’ve got a rash”

 “I’m not sure what happened”

 “I got my shingles vaccine last

week, and I bet that’s the reason”

 She starts crying because the rash

is so bad
Differentials

 Atopic dermatitis
 Contact dermatitis
 Dermatomyositis
 Reaction to zoster vaccination
 Too much crying
Contact dermatitis

 Tedious history
 Her grand-daughter started doing her nails
about 1-2 months ago

 Delayed type IV hypersensitivity reaction

 Weeks to months to years of exposure

Diagnosis of contact dermatitis

 History for potential contact allergen

 Patch testing (not skin prick tests)

 Avoidance of allergen
Dermatomyositis
Dermatomyositis associations

 Interstitial lung disease

 Cardiac conduction defects

 Malignancy, especially genitourinary and colon cancer

 Overlap with rheumatoid arthritis, systemic lupus and scleroderma

Dermatomyositis Take Home Point

 Eyelid and hand rashes are common, and dermatomyositis is uncommon

 Cutaneous signs of dermatomyositis are subtle

 One would only see cutaneous signs of dermatomyositis if one thinks of or

looks for it
Monday 8.15am
Case #4
 College student

 Very healthy

 “I’ve got a new rash”

 “I’ve got a new girlfriend

and I think I got it from
her”
Differentials

 Scabies!
 Scabies!
 Scabies!
Diagnosis?

 Pityriasis rosea

 Self-limited (usually 6 to 8 weeks)

 Seen primarily in adolescents and young adults,

favoring the trunk and proximal extremities

 Needs follow up if persists beyond 3 to 4 months

Tinea versicolor
Spaghetti and meatballs
Oral ketoconazole Take Home Point

 FDA warning issued in 2013 regarding potentially fatal liver injury requiring
transplantation
 Adrenal insufficiency and drug interactions

 Limit use to patients who do not have option of taking alternative antifungals
Scabies
Scabies treatment

 Permethrin 5% cream
 Applied overnight to entire body surface
 Head to toe for infants and elderly
 Can be used during pregnancy (2 hours)
 Repeat in a week

 Wash all clothes, linens and towels used in the past week with hot water and dried in high
heat
 Store in bag for 10 days

 Asymptomatic mite carriers

 Household and close contacts should be treated even if asymptomatic
 Pets do not have to be treated
Scabies treatment

 Ivermectin (200 to 400mcg/kg) 2 doses, 2 weeks apart (off label use)

 Blocks glutamate and GABA neurotransmission causing paralysis in ectoparasites
 Affects peripheral motor function in insects

 Blood brain barrier in humans protects against neurotoxicity in CNS

 Inadequate blood brain barrier in fetuses and early infancy
 Avoid in early infancy (<15kg), pregnant women and breastfeeding mothers
Scabies Take Home Point

 Remind patients that rash and pruritus from can last for 2 to 4 weeks after
successful treatment
Skin biopsy for rash

 Case 1: Psoriasis – psoriasiform or spongiotic dermatitis

 Case 2: Nummular dermatitis / Atopic dermatitis / Stasis dermatitis –

psoriasifrom or spongiotic dermatitis

 Case 3: Contact dermatitis – spongiotic dermatitis

 Case 4: Pityriasis rosea / scabies – spongiotic dermatitis

 A skin biopsy, in the last 4 cases, would have shown the similar pathologic
findings under the microscope.
Skin biopsy for rash

 A dermatopathologist will report the pattern of inflammation seen

 Spongiotic, psoriasiform, interface, granulomatous, lichenoid etc

 The clinician decides whether the pathologic findings support the clinical
diagnosis

 The location, type and chronicity of a lesion where a skin biopsy is taken
from, will greatly affect and determine the pattern of inflammation
Skin biopsy take home point

 “If you send me a piece of skin, I’ll tell you it’s skin”
 “If you send me a piece of a rash, I’ll tell you it’s a rash”
 “If you tell me what you’re looking for, I’ll tell you what if it fits”
 “If you don’t know what the rash is (when you can seen all of a person’s skin),
please don’t expect me to give you an answer from a tiny piece of skin”

 Do not depend on a skin biopsy to provide a diagnosis for your patient’s rash

 A skin biopsy should be performed only if one can correlate the pathologic
findings with clinical findings to reach a diagnosis
Skin biopsy take home point

 If referring a patient for a rash, please allow the dermatologist to decide if a

biopsy is helpful, and which lesion to take a sample of

 Taking a skin biopsy prior to a referral often leads to confusion, inaccurate

diagnosis, unrealistic patient expectations, a difficult and unhappy
consultation, and a repeat skin biopsy
Monday 8.30am
Case #5
 “I’ve got a rash”

 40 year old man

 Had a fever 5 days ago, that has resolved

 The rash showed up 3 days ago

 Otherwise healthy and well

 Same rash occurred perhaps twice in the past,

same spot, also after a fever
Differentials

 Burn
 Bite
 Self-inflicted
 Infectious?
More history

 He really feels fine

 He took ibuprofen over-the-counter for his fever

 He would take ibuprofen only when he had fevers in the past, and the fever
always went away within 1-2 days, and he loves ibuprofen

 “Ibuprofen is a wonderful medication”

Diagnosis?

 Fixed drug eruption

 Adverse drug reaction characterized by the formation

of a solitary erythematous patch or plaque that will
recur at the same site with re-exposure to the drug
 Onset within 1-2 days of drug exposure
 Commonly involved drugs include:
 phenolphthalein (laxatives), tetracyclines, sulfonamides,
NSAIDs, salicylates
Fixed Drug Eruption

To acetaminophen To doxycycline

62
Exanthematous or morbilliform drug
eruptions (“maculopapular rash”)

63
Morbilliform drug eruption
 Onset within a week to 10 days

 Resolves in a few days to 2 weeks after the

medication is stopped

 Resolves without sequelae (though extensive

dryness, scaling and desquamation can occur)

 Treatment consists of topical steroids, oral

antihistamines, and reassurance
64
 Drug-Induced Hypersensitivity
Syndrome
 AKA Drug Reaction with Eosinophilia and
Systemic Symptoms (DRESS)

 Morbilliform eruption
 Facial swelling, fever, malaise, lymphadenopathy,
and other organs (liver, kidneys) involved,
eosinophilia

 Onset 3 weeks or more after medication

 10% mortality rate 65

Medications commonly implicated

 Allopurinol
 Sulfonamide
 Anti-convulsants
 Dapsone
 Isoniazid
 NSAIDs
 Anti-HIV drugs

66
Acute Generalized Exanthematous
Pustulosis
 Beta-lactam antibiotics, calcium channel blockers
Stevens-Johnson Syndrome / Toxic
epidermal necrolysis
Stevens-Johnson syndrome / Toxic
epidermal necrolysis
 Acute life-threatening mucocutaneous reaction

 Characterized by extensive necrosis and detachment of the

epidermis and mucosal surfaces

 SJS can rapidly progress to TEN

 Early treatment with intravenous immunoglobulin

 Best managed in tertiary center with burns unit for specialized

care
Monday 8.45am
Case #6
 “What’s happening to my
face?”
Differentials

 Seborrheic dermatitis
 Atopic dermatitis
 Lupus
 Allergic contact dermatitis
 Rosacea
 Self-inflicted
Diagnosis

 Seborrheic dermatitis
 Atopic dermatitis
 Lupus
 Allergic contact dermatitis
 Rosacea
 Self-inflicted
Malar rash of systemic lupus
erythematosus
Discoid lupus
Violaceous atrophic plaques
Discoid Lupus scars if untreated
Subacute Cutaneous Lupus

 Resemble psoriasis, dermatitis, or tinea corporis

 Sun-exposed skin
Tumid lupus erythematosus

 Resemble granuloma
annulare, sarcoidosis or
urticaria
Lupus panniculitis
More cutaneous lupus

 Neonatal lupus
 Mom anti-Ro positive
 50% 3rd degree heart block

 Lupus chilblains
 Resemble pernio, but ANA positive
Cutaneous Lupus Take Home Point

 There are different types of cutaneous lupus, which often have no systemic
involvement

 Subacute cutaneous lupus is often ANA negative

 Subacute cutaneous lupus is more often associated with elevated anti-SSA or

anti-SSB antibodies

 Subacute cutaneous lupus can be drug induced (terbinafine, ACE-inhibitors,

calcium channel blockers, thiazide diuretics).
Seborrheic dermatitis
Treatment

 Low potency topical corticosteroid

 Topical ketoconazole

 OTC zinc pyrithione, selenium sulfide

 Topical sodium sulfacetamide

Rosacea

 Erythema and telangiectasia

 Erythematous papules and
pustules
 Rhinophyma
Treatment

 Topical metronidazole

 Oral tetracycline (doxycycline, minocycline)

 Topical Azelaic acid

 Topical ivermectin

 Vascular laser
Contact dermatitis

 Eyelids and lips tend to be

involved first

 With progression, diffuse

erythema over the face, extending
down to the anterior neck
Monday 9.00am
Case #7
 Painful sores on the legs
Diagnosis?

 Palpable purpura = vasculitis

Diagnosis?

 Palpable purpura = vasculitis

 Confirm on skin biopsy = leucocytoclastic vasculitis

 Biopsy an early lesion

 Etiology?
 Primary cutaneous
 Secondary (drug reaction, endocarditis, viral hepatitis etc)
 Autoimmune (SLE, RA, ANCA vasculitidis, Henoch Schonlein, cryoglobulin, etc)
 Paraneoplastic
Henoch Schonlein Purpura

 Most commonly seen in children

 Adult onset HSP associated with increased risk

of developing chronic kidney disease

 Skin biopsy for direct immunofluorescence

 IgA, C3 and fibrin deposition
Monday 9.15am
Case #8
 “I am itching all over and it is
getting worse”

 Excoriations
Generalized Pruritus

 No underlying rash

 Work up for underlying systemic disease

 CBC, BUN/creatinine, liver function, LDH, TSH, serum protein electrophoresis with
immunofixation
 Viral hepatitis, HIV, stool ova cyst parasite

 Consider urticarial
 Individual lesions last for minutes to hours
 May demonstrate dermatographism
Skin changes caused
by pruritus

Lichen simplex chronicus

Prurigo nodularis
Treatment

 Treat underlying systemic disease

 Topical anesthetics, capsaicin (localized)

 Topical emollients to reduce dry skin

 Phototherapy

 Systemic options include antihistamines, naltrexone, gabapentin

Monday 9, 9,30am
Case #9
 “I’ve got something
to show you”
Delusion of parasitosis

 Primary psychiatric disorder

 Experience formication
 Something biting, stinging, crawling
 See or are able to remove fibers in your presence

 Close contacts come to believe in the delusion as well

 “What do you think is causing the problem?”

Delusion of parasitosis

 These patients think they need a dermatologist

 They often have seen several dermatologists

 They need a behavioral health specialist

 Treatment of choice is / was pimozide

 Atypical antipsychotic medications are more commonly used

Neurotic excoriation
Unexplained scars
Cigarette burns
Acne excoriee
Take Home Point

 For psychocutaneous diseases

 Treat underlying depression, anxiety or obsessive-compulsive disorder

Monday, 9.45am
Case 10
 “I have blisters all over my body”
Diagnosis

 Bullous Pemphigoid

 Refer to dermatology (phone call)

 Immunobullous disease

 Diagnosis made on skin biopsy for H&E

and direct immunofluorescence

 Immunosuppression

 Association with malignancy is marginal

Monday, 10.00am
Case 11
 “I’ve got acne”
Comedones

 Topical retinoids
 Tretinoin
 Adapalene
 Tazarotene
Inflammatory

 Topical anti-inflammatory Rx
 Clindamycin, benzoyl peroxide,
dapsone, azelaic acid

 Oral Tetracyclines (avoid in <8 years)

 Oral contraceptives / Spironolactone

for women with menstrual flares
 FDA approved for acne: Estrostep, Yaz,
Ortho-tricyclen
Take home point

 Hyperandrogenism should be suspected in women with acne, hirsutism and

irregular menstrual periods

 Lab work up: DHEA-S, free or total testosterone and 17-hydroxyprogesterone

 DHEA-S 4,000-8,000ng/ml or raised 17-OHprogesterone may indicate congenital
adrenal hyperplasia
 DHEA-S >8,000ng/ml, suspect adrenal tumor
 Elevated testosterone may indicate polycystic ovarian syndrome or ovarian tumor
Nodulocystic

 Isotretinoin
Monday, 10.15a,
Case 12
 “I’ve got something growing on my skin”
Melanoma Take Home Point

 Always look at the skin during annual exams

 Especially back and legs

 Phone call for urgent consults

Monday 10.30am

That’s all, folks!