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Dermatology for the Primary Care Provider Practical Advances in Internal Medicine April 14, 2016 Amy Swerdlin Frankel, MD Providence Medical Group

Overview Common skin conditions and their mimics  Atypical presentations of common dermatologic conditions  Treatment pearls 

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Case #1 

65 y/o M with 1 year h/o of a lesion growing on his left clavicle 

Reports occasional bleeding and tenderness

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BCC

Case #2 

40 y/o F with 8 month h/o a new growth on her temple

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Pigmented BCC Ddx? Melanoma

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Case #3 

85 y/o M with growing ulcer on his lip x 2 years

Squamous cell carcinoma

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Case #4 

50 y/o F with 6 month h/o enlarging growth on her leg

SCC in situ

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Superficial BCC

Case #5 

68 y/o F with an enlarging growth on her back x 8 months

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A – Asymmetry B – Border C – Color D – Diameter E – Evolution Melanoma

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Blue nevus

Seborrheic keratosis

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Seborrheic keratosis

Cherry angioma

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Case #6 

59 y/o M with new “brown spot” on his nose which has been slowly enlarging

DX?

MIS (aka lentigo maligna)

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Solar lentigo

Case #7 

56 y/o F with 6 month h/o an enlarging scaly lesion on her arm

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Amelanotic melanoma

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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

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Actinic keratoses

Pigmented actinic keratosis

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Most Common Skin cancers 

Basal cell carcinoma 

~2.8 million cases/year in US 

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Keratinocyte

Squamous cell carcinoma 

~700,000 cases/year in US 

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Rarely fatal, but disfiguring

~2500 deaths in 2011

Melanoma 

Melanocyte Basal cell

~123,590 cases/year in US  

~8,790 deaths in 2011 Oregon ranks 5th in nation for new melanoma cases

www.skincancer.org/skincancerfacts

Treatment options 

Non-melanoma skin cancer    

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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)

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Nicotinamide (Vitamin B3) 

Reduces the incidence of BCC & SCC in people with a h/o NMSC  

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Decreased rate of developing new NMSC by 23% Decreased rate of developing new AK’s by 13%

500mg PO BID 

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Unlike niacin or nicotinic acid, the amide did NOT cause HA, flushing or low BP Reports of increased blood sugar & sweating

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Case #9 

66 y/o F with new rash x 3 months. Failed a course of oral lamisil

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Granuloma annulare

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Granuloma annulare Benign inflammatory dermatosis  Localized or generalized  Associated with diabetes mellitus 

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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

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Treatment of acne in pregnancy Topical erythromycin or clindamycin  Topical Azelaic acid (Finacea)  Oral erythromycin BASE (Base is safe for Babies) 

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*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

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Atopic dermatitis

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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 

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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

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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

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Eczema herpeticum

Eczema herpeticum Complication of atopic dermatitis  Viral culture important 

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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

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Case #13 

26 y/o F with pruritic/burning eruption around mouth, which recently spread around eyes

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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 

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Taper topical steroids 

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Can bridge with short course of topical tacrolimus

Oral tetracyclines (MCN or doxy for 6-8 wks) Topical erythromycin, clindamycin, azelaic acid or metrocream

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Case #14 

49 y/o F with 4 year history of acne-like lesions and flushing

Rosacea

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Management of Rosacea Daily sunscreen important!  Avoid triggers (hot fluid, spicy food, EtOH)  Screen for ocular rosacea  Treatment 

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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

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Case #15 

76 y/o F with pruritic and painful eruption on her legs 

Has had chronic leg swelling for years

Stasis dermatitis

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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% 

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Compromised barrier allows sensitization to occur more easily Topical antibiotics are a common cause

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Case #16 

36 y/o F with 3 day h/o pruritic eruption

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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 

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Case #17 

57 y/o F with progressive, itchy rash x 5 days  

Started on trunk and spread to extremities Undergoing treatment for cellulitis

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Morbilliform drug eruption

Drug eruptions 

Morbilliform 90%  

Maculopapular Exanthematous

Urticarial (5%)  Papulosquamous  Pustular  Bullous 

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Drug eruptions 

Pruritus is a common feature 

Distinguishes it from a viral exanthem

Occurs within first 2 weeks of treatment  Simple – cutaneous only 

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Resolve within 2 weeks after stopping drug

Complex – systemic findings 

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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 eruption 

Most common type of drug eruption 

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Don’t have to stop the causative drug 

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In contrast, urticarial drug reaction could progress to angioedema & anaphylaxis

Common causes  

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1 to 5% of patients on antibiotics will develop

Antibiotics (aminopenicillins, sulfa) Anticonvulsants

Treatment  

Takes days to weeks for rash to resolve Antihistamines and topical steroids

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Case #18 

25 y/o F presenting with an asymptomatic scaly pink eruption 

She is 12 weeks pregnant

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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 

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Reassurance If pruritic: Topical steroids, Antihistamines If extensive: acyclovir

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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

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Inverse psoriasis

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Plaque psoriasis

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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 

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Consider throat culture to r/o strep infection

Nummular dermatitis

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Tinea corporis

Subacute cutaneous lupus

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Wickham striae

Lichen planus

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Mycosis Fungoides (CTCL)

Thank you! 

Our Office: PMG-Dermatologic Specialties 5330 NE Glisan St., Suite 200 Portland, OR 97213 Phone: 503-215-9080

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Case #12 

26 y/o M with spreading fine scaly rash x 3 months 

Rash is more prominent after tanning

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KOH

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Tinea Versicolor 

Caused by lipophilic yeast – Malassezia     

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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

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Scabies!

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Scabies prep Try to find burrows  Scrape several lesions until pinpoint bleeding 

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Buttocks and acral skin typically high yield

Place scrapings on slide  

Add a few drops of mineral oil Place a cover slide

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Eggs

Feces

Nodular scabies

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Scabies Often takes close family members three months to show symptoms  All close contacts need to be treated 

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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

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Comedonal acne

Inflammatory acne

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Cystic acne

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Hormonal acne

Acne treatment 

Comedonal   

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Inflammatory     

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Tretinoin Adapalene (differin) Tazorac (category X in pregnancy) Tretinoin Topical antibiotics (ie clindamycin) Oral antibiotics (ie doxycycline or minocycyline) OCPs, Spironolactone – if hormonal distribution Benzoyl peroxide lotion and/or wash

Cystic 

Isotretinoin

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Case #21 

18 y/o M present with very itchy blisters on his face and extremities

Dermatitis herpetiformis

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Dermatitis herpetiformis 

Chronic autoimmune blistering disorder associated with celiac disease 

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Often complete remission on gluten-free diet 

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Dapsone also effective

Diagnosis  

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>90% have underlying gluten-sensitive enteropathy even though 20% have GI sx

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

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Wickham striae

Lichen planus

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Lichen planus 

Flat-topped violaceous polygonal papules 

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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