Dermatology

1. Dermatology By Katrice L. Herndon, MD Internal Medicine/Pediatrics June 2, 2005

2. What is this?

3. 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

4. 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

5. 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

6. Acne Vulgaris • Classification of Acne • Type 1 — Mainly comedones with an occasional small inflamed papule or pustule; no scarring presentType 2 — Comedones and more numerous papules and pustules (mainly facial); mild scarringType 3 — Numerous comedones, papules, and pustules, spreading to the back, chest, and shoulders, with an occasional cyst or nodule; moderate scarringType 4 — Numerous large cysts on the face, neck, and upper trunk; severe scarring

7. Acne Vulgaris

8. What is this?

9. 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.

10. 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.

11. 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

12. 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.

13. What is This?

14. 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.

15. 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)

16. 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

17. What is this?

18. 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.

19. 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.

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

21. Psoriasis

22. 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.

23. 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.

24. What is this?

25. 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.

26. 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

27. Vitiligo • Repigmentation therapies include: • corticosteroids • calcineurin inhibitors • Ultraviolet light • Pseudocatalase cream • Surgery – minigrafting techiniques • Depigmentation therapy w/ hydroquinone

28. What is this?

29. 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.

30. Pityriasis Rosea

31. 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.

32. 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.

33. 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

34. What is this?

35. 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.

36. 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

37. Cellulitis • Cellulitis is a recognizable clinical syndrome with both local & systemic features. • Systemic symptoms include: • Fever and chills • Myalgias • Increased WBC count

38. 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

39. 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.

40. 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

41. What is this?

42. 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

43. 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).

44. 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

45. Erysipelas • Treatment: • Penicillin is the preferred treatment • Erythromycin • Clindamycin • Fluoroquinolones • Erysipelas does have the propensity of recur.

46. What is this?

47. 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.

48. 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.

49. Ecthyma Treatment: • Topical mupirocin ointment • Gentle surgical debridement • Oral/IV antibiotics • Penicillin • Clindamycin • Macrolides • Cefazolin

50. What is this?