Derm for the Nurse Practitioner

1. Derm for the Nurse Practitioner Tim Berger, MD Professor of Clinical Dermatology

2. Case • Painless penile ulcer for 2 weeks • Moderate, non-tender inguinal adenopathy

4. Diagnosis?

5. Syphilis Epidemiology • San Francisco has a very high syphilis rate • 60% of syphilis cases are occurring in HIV infected gay men

6. Primary Syphilis • Clean-based, moist ulceration • Painless, non-tender • Rubbery texture on palpation • Whole lesion moves as an unit • Single or multiple • Non-tender adenopathy 1 week later • Heals spontaneously in 1-4 months with NO scarring

10. Secondary Syphilis • 80% of patients with secondary syphilis have skin lesions • Early secondary syphilis is more exanthematous, transient, and macular • Later secondary syphilis eruptions are firmer, fixed, papular, pustular, or nodular

17. Secondary Syphilis (2) • Alopecia (5%): Moth eaten, diffuse • Adenopathy: Generalized, non-tender • Mucous patches (33%): Denuded (tongue), or white/stuck on plaques (other oral areas) • Glomerulonephritis, gastritis/gastric ulcer, rectal ulcers, hepatitis, hearing loss (acute, unilateral), uveitis, neuritis, pulmonary infiltrates, etc.

20. Secondary Syphilis (3) • Think of syphilis whenever you see a skin rash--It is the great imitator

21. Fixed Drug Eruption • Reappears at same site with each rechallenge • Individual lesion-iris or target, which blisters, then erodes leaving a shalllow, unilocular, wide ulcer • Oral Mucosa, genitalia (2% of GUD) • Causes: NSAIDs, laxatives, SMZ/TMP

24. Case • 34 year old gay man with a 2 week history of lethargy, sore throat, fever, pain when swallowing, and rash • VS: Temp 38.6 • Ill appearing

25. Case • Physical Exam: Pharyngeal erythema without exudate; 3 small ulcerations on the tongue, pharynx; generalized lymphadenopathy (cervical, axillary, groin > 1cm) • Oval plaques with petichiae on the upper chest

28. Case • Lab: CBC-atypical lymphocytosis • What is the differential diagnosis?

29. Case • Anticonvulsant hypersensitivity • Streptococcal Pharyngitis • Primary EBV • Primary CMV • Secondary syphilis • Primary HIV infection

30. Case • Lab: RPR- nonreactive, prozone checked • EBV serology: Negative • HIV Serology: ELISA: Negative • What is your diagnosis?

31. Case • CD4= 180 • HV Viral load=500,000 • Diagnosis: Primary HIV infection

32. Primary HIV Infection • Multi-system disease at the time of initial virus replication in the recently infected host (in the first few weeks of infection) • Resembles mononucleosis: rash, oral and genital ulcerations, adenopathy • Skin eruption may precede other findings

37. Primary HIV Infection • Diagnosis: HIV Viral Load, Helper T cell count; ELISA negative initially

38. Case • 34 year old healthy male • 2 weeks of recurring blisters on the legs • Mildly itchy

40. Bullous Impetigo

41. Bacterial Infections • Pyoderma • Impetigo • Folliculitis • Abscess • Ecthyma • Cellulitis/Necrotizing Fasciitis • Toxic Shock Syndromes

42. Impetigo

43. Folliculitis

44. Ecthyma

45. Abscess

46. Cellulitis

47. Cellulitis with Purpura and Bullae

48. Erysipelas

49. Necrotizing Fasciitis

50. Quiz • The Correct treatment for an abscess is?