Advanced Practice Education Associates

Dermatological
Disorders
Dermatological Disorders

OVERVIEW

• Skin infections: Bacterial infections, fungal infections

• Systemic things: Herpes zoster, lupus, Lyme disease
• Skin cancer
• Itchy things

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 Dermatological Disorders

SKIN INFECTIONS
Good Terms to Know (these are primary skin lesions):
• Abscess = furuncle = boil: deep infection of hair follicles
• Bulla or blister: fluid-filled or pus-filled >0.5 cm
• Macule: flat change in skin with a color change (brown, blue, red, or hypopigmented)
• Nodule: solid lesion >0.5-2.0 cm (nodule >2.0 cm is a tumor)
• Papule: raised, solid lesion ≤0.5 cm; varies in color
• Plaque: raised, solid lesion >0.5 cm
• Vesicle: ≤0.5 cm elevated lesion that contains fluid
• Wheal (hive): transient rounded or flat-topped plaque

A Day In Clinical Practice Impetigo

Is this most appropriately treated with an oral or topical
agent?____________________________________________________
Why?_____________________________________________________

What is a deep form of impetigo that causes erosions into the dermis?
1. Cellulitis
2. Furunculosis Image Copyright
www.visualdx.com. ©2014 Logical
3. Ecthyma Images, Inc.
4. Folliculitis
Is this most appropriately treated with an oral or topical agent?
_____________________________________________________________________________
Why? ________________________________________________________________________

What is your diagnosis? Image (Rash)Copyright The University

of Auckland.
Answer: ___________________________________ http://www.health.auckland.ac.nz/cours
es/dermatology/2-
__________________________________________ infections/bacteria.html

What clues helped to make the diagnosis?

Answer: ___________________________________
__________________________________________

Cellulitis:
• Cellulitis, a bacterial infection of the skin and subcutaneous tissue, commonly misdiagnosed
 C: cellulitis history
 E: edema
 L: local warmth
 L: lymphangitis
 U: unilateral
 L: leukocytes
 I: injury
 T: tender
 I: instant onset
 S: systemic signs
Dermatol Online J. 2019 Jan 15;25(1). pii: 13030/qt9mt4b2kc

Additional Notes:

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Dermatological Disorders

Purulent cellulitis? Image Copyright Wikispaces.

Answer: ___________________________________ https://skindisorders6.wikispace
s.com/Boils+%26+Carbuncles
__________________________________________
When there is pus about … what is the most likely
pathogen?
Answer: ___________________________________
__________________________________________

What infection? Image Copyright James

Answer: ___________________________________ Heilman, MD. Wikimedia
Commons.
__________________________________________ https://reference.medscape.co
m/slideshow/skin-rashes-
How would you treat this? 6004772#27

Answer: ___________________________________
__________________________________________

Skin Cell

Image Copyright 2017

Spanish Researchers in the
United Kingdom
SRUK/CERU. Anatomy of the
skin. (Source: Wikimedia
Commons)
https://sruk.org.uk/skin-color-
an-example-of-adaptation-to-
the-environment/

Folliculitis
• Inflammation of the superficial or deep portion of the hair follicle
• Classic: follicular pustules or papules on hair-bearing skin
• Staph is most common culprit

How do we treat patients who present with skin infections?

Infection Treatment per IDSA, 2014
Cellulitis without purulence (MSSA) Cephalexin, cefadroxil, clindamycin
Cellulitis with purulence (MRSA) I&D, TMP-SMX, clindamycin, tetracycline,
linezolid (5-10 days)
Carbuncle (deeper furuncle (boil) I&D FIRST! Consider antibiotics if fever, systemic
symptoms, or failed initial treatment
Impetigo Mupirocin (Bactroban) or retapamulin (Altabax)
twice daily (BID) for 5 days
Ecthyma (MSSA (most common), MRSA, Strep) (If MSSA: dicloxacillin, cephalexin
known or suspected MRSA, treatment) MRSA: doxycycline, clindamycin, or SMX-TMP
(MRSA)
Additional Notes:

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 Dermatological Disorders

BITES: CAT, DOG, HUMAN

• Very common injury
• Organisms are from oral flora of biting animal and skin flora of victim
• Pasteurella, Staph, Strep

Management
• Clean and flush bite thoroughly
• Antibiotic prophylaxis (3-5 days) in high-risk patients: immunocompromised; asplenic;
advanced liver disease; preexisting or resultant edema of the affected area; moderate to
severe injuries (especially to the hand or face); injuries that may have penetrated the
periosteum or joint capsule
• Tetanus prophylaxis (within 10 years)
• For hands and feet: examine in anatomic and clenched positions

Question
Which antibiotic is preferred prophylaxis for a cat bite?
1. Cephalexin
2. Doxycycline
3. Amoxicillin-clavulanate
4. Moxifloxacin
How many days? _______________________________________________________________
Suppose patient is allergic to first choice? ____________________________________________

A Day In Clinical Practice

A patient was bitten on the face by a dog and has a 4.5 cm gaping facial wound. How might this
be managed? Select all that apply.
1. Copious irrigation
2. Cautious debridement
3. Preemptive antibiotics
4. Wound closure
5. Leave wound open
6. Tetanus prophylaxis if needed
7. Rabies prophylaxis if needed

FUNGAL INFECTIONS
Fungal Infection (where is it?) Effective Treatment: Oral or Topical?
Tinea capitis
Tinea corporis
Tinea cruris
Tinea pedis
Tinea unguium

Question
Which clinical features are common to tinea corporis? Select all that apply.
1. Central clearing
2. Circular plaque
3. Oval patch
4. Annular ring
5. Moist circular plaque
6. Pain
7. Erythematous scales

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Dermatological Disorders

What 2 characteristics identify this as fungal?

Answer: ___________________________________________
__________________________________________________

Tinea cruris

Image Copyright, 11-21-2011 Arif Image Copyright, James Heilman, MD.

Siregar. Health Teller. http://health- Wikimedia Commons.
teller.blogspot.com/2011/02/tinea- https://reference.medscape.com/slidesh
kruris-eczema-marginatum.html ow/skin-rashes-6004772#5

Question
Fungal infections are expected to be more common in patients who:
1. are asplenic.
2. have hepatitis C.
3. are immunocompetent.
4. have poorly managed DM.

Question
What are these images?
Image # 1 Image # 2
Image Copyright James Image Copyright Beauty
Heilman, MD. Wikimedia Health Plus.
Commons. https://www.beautyhealthpl
https://reference.medscap us.org/christmas-tree-rash-
e.com/slideshow/skin- causes-treatment-home-
rashes-6004772#16 remedies-pictures-
homeopathic-remedies/

__________________ _________________
How is this treated? _____________________________________________________________

LYME DISEASE
Question Image Copyright © 2018
Tri-Lakes Family Care. All
What is this? rights reserved.
http://www.trilakesfamilyc
are.com/blog/lyme-
1. Allergic reaction disease-can-you-get-it-in-
missouri/
2. Sting
3. Id reaction
4. Erythema migrans

Erythema migrans?
History of likely tick exposure
• Early localized Lyme disease is characterized by the appearance of the characteristic skin
lesion, erythema migrans (EM), with or without constitutional symptoms.

Question
An antibiotic used first line to treat early Lyme disease and other tickborne infections is:
1. levofloxacin.
2. clindamycin.
3. doxycycline.
4. azithromycin.

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 Dermatological Disorders

HERPES ZOSTER
• A reactivation of the varicella zoster (chickenpox) virus that
Shingles
has lain dormant in nerve cells. This involves the skin of a Front Back
single dermatome or, less commonly, several dermatomes.

Painful vesicular eruption

Image Copyright CDC.

http://health.hawaii.gov/docd/disease
_listing/shingles-herpes-zoster/

Image Copyright Satri Si Suriyothai Image Copyright Max Healthcare.

School. https://www.maxhealthcare.in/blogs/pain-
http://www.suriyothai.ac.th/th/node/756 management/what-do-you-need-know-
about-neuralgias

Pharmacologic Management
• NSAIDs (mild to moderate pain) or narcotic analgesics for severe pain
• Antiviral agents if patient presents ≤72 hours of symptoms (acyclovir, famciclovir, valacyclovir
for 7 days)
• Antiviral agents ≥72 hours if new lesions are appearing
• Antiviral agents to all immunocompromised patients

A Day In Clinical Practice

A 76-year-old patient has vesicles and pain on his right forehead and eyebrow. His right eye is
red, and he feels more comfortable with his lid closed. In addition to treating with an oral antiviral
agent, how should this be managed?
1. Cool compresses to lid, oral steroids.
2. Treat with steroid injection, oral steroids.
3. Check vision, if abnormal, refer to ophthalmology.
4. Refer to ophthalmology.

Herpes zoster vaccine

• ACIP recommends for all patients ≥50 years
• 32% of adults will have shingles
• Shingrix: (recombinant) vaccine (higher efficacy); (preferred vs Zostavax live)
• Contraindicated in pregnancy, severe immunocompromising conditions (including HIV inf with
CD4 count <200 cells/uL)

LUPUS
Systemic Lupus Erythematosus (SLE)
• Multisystem autoimmune disease
• Inflammatory disease that affects the skin, joints, kidneys, lungs, other organs
• More common in black, Asian and Hispanic women of childbearing age
• Fatigue most common complaint
• Fever (manifestation of active disease)
• Arthritis, arthralgias, myalgias
• Mucocutaneous lesions: butterfly rash most common
• Oral and nasal ulcers: painless
• Renal involvement: 50%
• Gastritis, peptic ulcers
• Others

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Dermatological Disorders

SLE Butterfly Rash Malar Rash

Image Copyright Cedars-Sinai. Image Copyright cure4lupus.
https://www.cedars- https://www.hxbenefit.com/malar-
sinai.edu/Patients/Health- rash-butterfly-rash-pictures-
Conditions/Lupus.aspx?_ga=2 causes-and-treatment.html
.131344710.872941202.15109
55228-
957700693.1510955228

Question
What is a criterion for diagnosis of lupus?
1. Presence of fatigue
2. Involvement of multiple joints
3. Elevated CRP or sed rate
4. Presence of antinuclear antibodies

SKIN CANCER
• Malignant tumors of the skin arising from various skin layers
• Dermoscope (light and magnification) used for eval of skin lesions (visualize subsurface skin
structures in epidermis, dermis not visible to naked eye)

Decision tree:
• Biopsy
• Refer
• Reassure

Skin Cancer
Image Copyright 2019
Mayo Clinic.
https://newsnetwork.mayo
clinic.org/discussion/living-
with-cancer-squamous-
cell-carcinoma-of-the-skin/

Skin Cancer Pearl!

• Asymmetric distribution of colors and structures within a lesion is considered best predictor of
malignancy! (need dermoscopy)
Additional Notes:

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 Dermatological Disorders

Assessment Findings: Squamous Cell Carcinoma (SCC)

• Common on sun exposed areas of the skin
 Head and neck: 55%
 Dorsum of the hands/forearms: 18%
 Legs: 13%
 Lower lip is common location in smokers
• Presents as papules, plaques, nodules, smooth, hyperkeratotic or ulcerative lesions
• May bleed easily
• Definitive diagnosis always with biopsy or excision of specimen

Papular-appearing tumor Wart-like tumor

Image Copyright Squamous Cell Image Copyright Patient Info Squamous Cell Carcinoma of Skin Authored
Carcinoma Symptoms. by Dr Colin Tidy, Reviewed by Dr John Cox on 18 August 2015 | Certified
https://www.youtube.com/watch?v=o by The Information Standard
TnoUjcPyQ4 https://patient.info/doctor/squamous-cell-carcinoma-of-skin

Assessment Findings: Basal Cell Carcinoma

• Common in 50- and 60-year-olds Image Copyright
SkinCancer.net © 2017–18
• Most common sites are head and neck Health Union, LLC. All rights
reserved.
• Usual appearance is pearly domed nodule with https://skincancer.net/images/

overlying telangiectatic vessels; later, central

ulceration and crusting
• 40x more common than squamous cell
• Particularly common in white people
• Uncommon in dark-skinned populations
• Most important risk factor is sun exposure
• Definitive diagnosis always with biopsy or
excision of specimen
• 70% occur on face
• Nodular: Typically present on face as a pink or flesh-colored papule

Malignant Melanoma: Patient Education: ABCDE mnemonic

• Usual age is 40s Image Copyright Arthur C.
• ABCDE characteristics of any lesion Huntley, MD, 1994.

 A = asymmetry
 B = border is irregular
 C = color variation (multiple colors
within the lesion-black or blue gray
most suggestive)
 D = diameter >6 mm (pencil eraser)
(in white patients, primarily on lower
legs and back; in black patients, on
hands, feet and nails)
 E = elevation above level of skin
 F= feeling (sensation)

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Dermatological Disorders

A Day In Clinical Practice

A patient has had atopic dermatitis since childhood. What other disease is he likely to have?
1. Asthma
2. Psoriatic arthritis
3. Seborrheic dermatitis
4. Ulcerative colitis

ITCHY THINGS
Atopic Dermatitis (eczema) Image Copyright 2001-2008
• Clinical diagnosis: pruritis is predominant Images courtesy of
DermAtlas.
symptom http://www.dermatologistsnyc.
com/atopicdermatitis.html
• Clues: chronic and recurring
• Family history of allergic disease

A Day In Clinical Practice

A 36-year-old man presents with a silvery, scaly,
pruritic rash. Which statement is NOT true?
1. This may be associated with inflammatory bowel disease.
2. He is at high risk for cataracts.
3. Monoclonal antibodies may be used to treat this.
4. He may have an associated arthritis.

PSORIASIS

Plaque psoriasis- most Classic psoriasis Psoriasis Psoriasis

common variant Image Copyright Semedic. Image Copyright HealthTap. Image Copyright Natural Herbal
Image Copyright StudyBlue. http://semedic.ru/en/how-to- https://www.healthtap.com/to Medicine.
https://www.studyblue.com/notes/n treat-psoriasis-at-home- pics/white-crusty-dry-patch- http://www.naturalherbalmedizine.
ote/n/papulosquamous-disease- proven-folk-remedies-for- on-my-knee com/cure-psoriasis-from-the-
psoriasis-seb-derm-rosacea- head-psoriasis.html inside/
lichen-planus/deck/4597789

Pharmacologic Management
• Emollients to hydrate skin
• Topical steroids (lowest strength that eradicates symptoms)
• Methotrexate
• Systemic agents prescribed by derm

Itchy Things: Systemic

• Renal, liver disease
• Connective tissue disorders
• Postherpetic neuralgia
• Multiple sclerosis
• Psychogenic itch
• Burns/scars

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 Dermatological Disorders

TOPICAL STEROIDS
• Potency based on ability to vasoconstrict skin
• Ranked on a scale from I-VII
 Class I = highest potency
 Class II = very high potency
 Class III, IV, and V = medium potency
 Class VI and VII = low potency

Question
Which vehicle is least appropriate to use to treat a steroid-responsive condition on thickened skin
of the elbows and knees of an adult?
1. Gel
2. Cream
3. Ointment
4. Lotion

Pharmacologic Management
• Vehicle strength determines ability of drug to enter skin
 Lotions < Creams < Gels < Ointments

Steroid Selection
• Steroid selection based on:
1. site of involvement
2. steroid potency
3. severity of condition

Question
All of the organisms listed below can produce pruritus. Which one is treated with oral agent?
1. Pinworms
2. Bed bugs
3. Pubic louse
4. Scabies
How are the others treated?
_____________________________________________________________________________

SCABIES
• Infection of human skin by mites; usually Image Copyright 2004 Renee
Cannon
Sarcoptes scabiei

What is this?
____________________________________
____________________________________
Where is the mite?
Image Copyright WebMD.
____________________________________ https://www.webmd.com/ski
____________________________________ n-problems-and-
treatments/ss/slideshow-
scabies-overview

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Dermatological Disorders

Assessment Findings
• Itching (more noticeable at nighttime)
• Small itching blisters in a thin line
• Mite burrows between finger webbing, feet, wrists, axilla, scrotum, penis, waist, and/or
buttocks

A Day In Clinical Practice

A patient has scabies. Which asymptomatic contact listed below does not need to be treated for
scabies?
1. Household contacts
2. Sexual contacts
3. Office mates
4. Close personal contacts

Exam Checklist:
• Antibiotics ✓ Know clinical presentation (subj, obj
• Diseases/conditions that present with: findings)
vesicles/bulla ✓ Know how to diagnose
• Papules/macules ✓ What’s in diff dx?
• Pustules/purulence ✓ Pharm, nonpharm management
• Nodules ✓ Follow-up care
• Plaques ✓ Recognize normal course
• Hives ✓ When to refer
• Systemic derm conditions

Resources for Dermatologic Disorders

• CareOnPoint, a mobile clinical reference tool available by subscription; developed by NPs;

provides contact hours: http://www.apea.com/careonpoint/about-careonpoint
• Hollier, A. (2018). Clinical Guidelines in Primary Care. Lafayette, LA: APEA.
• Topical Steroid Dispensing Cards; APEA
• Dermatology DDx Deck; Elsevier
• Pediatric Dermatology DDx Deck; Elsevier
• To view this lecture again, visit the APEA CE Library and purchase the Fundamentals of
Dermatology on video: https://www.apea.com/ce-library
Additional Notes:

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