Blotches: Dark rashes

1. Blotches:Dark rashes Medical Student Core Curriculum in Dermatology Last updated April 18, 2011

2. Module Instructions • The following module contains a number of blue, underlined terms which are hyperlinked to the dermatology glossary, an illustrated interactive guide to clinical dermatology and dermatopathology. • We encourage the learner to read all the hyperlinked information.

3. Goals and Objectives • The purpose of this module is to help medical students develop a clinical approach to the evaluation and initial management of patients presenting with hyperpigmented rashes. • After completing this module, the medical student will be able to: • Identify and describe the morphology of common hyperpigmented rashes • Provide an initial treatment plan for selected dark rashes • Determine when to refer a patient with a dark rash to a dermatologist

4. Case One Scott Goff

5. Case One: History • HPI: Scott Goff is a 28-year-old male who presents with “blotches” on his upper back and chest for several years. They do not cause any symptoms other than anxiety because he has these dark spots. • PMH: no major illnesses or hospitalizations • Allergies: none • Medications: protein supplements • Family history: none • Social history: accountant; weightlifter • ROS: negative

6. Case One: Skin Exam

7. Case One: Skin Exam

8. Case One, Question 1 • Mr. Goff’s chest shows hyperpigmented, scaly macules on his upper chest and back. Which is the best test to confirm the diagnosis? • Bacterial culture • Direct fluorescent antibody (DFA) test • Potassium hydroxide (KOH) exam • Wood’s light

9. Case One, Question 1 Answer: c • Mr. Goff’s chest shows hyperpigmented, scaly macules on his upper chest and back. Which is the best test to confirm the diagnosis? • Bacterial culture • Direct fluorescent antibody (DFA) test • Potassium hydroxide (KOH) exam • Wood’s light

10. Case One, KOH exam Spores (yeast forms) Short Hyphae The KOH exam shows short hyphae and small round spores. This is diagnostic of tinea (pityriasis) versicolor.

11. Diagnosis: Tinea versicolor • Based on his skin findings and KOH exam, Mr. Goff has tinea versicolor • It’s called “versicolor” because it can be light, dark, or pink to tan • Let’s look at some examples of the various colors of tinea versicolor

12. Tinea versicolor: lighter

13. Tinea versicolor: darker

14. Tinea versicolor: pink or tan

15. Case One, Question 2 • What is the best treatment for Mr. Goff? • Ketoconazole shampoo • Narrow band UVB phototherapy • Oral griseofulvin • Tacrolimus cream • Triamcinolone cream

16. Case One, Question 2 Answer: a • What is the best treatment for Mr. Goff? • Ketoconazole shampoo • Narrow band UVB phototherapy (may worsen appearance by increasing contrast) • Oral griseofulvin (does not work for Malassezia species) • Tacrolimus cream (does not fight yeast) • Triamcinolone cream (does not fight yeast)

17. Case One, Question 3 • Which of the following statements is true about the treatment of tinea versicolor? • Normal pigmentation should return within a week of treatment • Oral azoles should be used in most cases • When using shampoos as body wash, leave on for ten minutes before rinsing

18. Case One, Question 3 Answer: c • Which of the following statements is true about the treatment of tinea versicolor? • Normal pigmentation should return within a week of treatment (usually takes weeks to months to return to normal) • Oral azoles should be used in most cases (mild cases can be treated with topicals) • When using shampoos as body wash, leave on for ten minutes before rinsing

19. Case Two Melinda Kinsley

20. Case Two: History • HPI: Melinda Kinsley is a 48-year-old Guatemalan woman who presents with ten years of dark spots on her face. She tried a bleaching cream she got from Mexico but her friend told her it could make the spots worse. • PMH: three normal pregnancies; s/p tubal ligation • Allergies: none • Medications: supplements black cohosh, evening primrose • Family history: noncontributory • Social history: lives with husband and children • ROS: negative

21. Case Two: Skin Exam

22. Case Two, Question 1 • Which of the following is most likely associated with this symmetric hyperpigmentation? • Ginseng • Limes • Minocycline • Malassezia furfur • Pregnancy

23. Case Two, Question 1 Answer: e • Which of the following is most likely associated with this symmetric hyperpigmentation? • Ginseng • Limes • Minocycline • Malassezia furfur • Pregnancy

24. Melasma

25. Melasma (aka Chloasma) • Melasma is characterized by patchy light to dark brown hyperpigmentation of the face • Usually affects women, runs in families • Associated with hormonal changes • Called the “mask of pregnancy” • May occur with pregnancy, birth control pills, and hormone replacement therapy

26. Melasma (aka Chloasma) • Worse with exposure to UV radiation • Treatments • Strict sun avoidance, daily sunscreen with broad spectrum coverage and SPF > 30 • Hydroquinone 4% cream BID • If this fails, may refer to dermatology for cosmetic treatments like triple topical therapy, lasers, or chemical peels, but these will usually be at the patient’s expense

27. Case Three Henry Fontana

28. Case Three: History • HPI: Henry Fontana is a 78-year-old man who presents with of darkening of his arms and neck over the past few years. He recently underwent knee replacement surgery, and the orthopedist noticed a greenish pigmentation of his bones. • PMH: hypertension, GERD, osteoarthritis, BPH, basal cell and squamous cell carcinomas, rosacea • Allergies: none • Medications: atenolol, felodipine, celecoxib, oxybutinin, rabeprazole, minocycline • Family history: noncontributory • Social history: widower; lives alone • ROS: negative

29. Case Three: Skin Exam

30. Case Three, Question 1 • Which of the following medications is most likely associated with this pigmentation? • Atenolol • Celecoxib • Minocycline • Oxybutinin • Rabeprazole

31. Case Three, Question 1 Answer: c • Which of the following medications is most likely associated with this pigmentation? • Atenolol • Celecoxib • Minocycline • Oxybutinin • Rabeprazole

32. Minocycline pigmentation

33. Minocycline pigmentation • Deposition appears after months to years in a small percentage of patients • First noticeable on the alveolar ridge, palate, sclera • May involve bones, thyroid, but this is harmless • Skin deposition can be brown or blue-grey • Blue-grey pigmentation may occur in scars • Skin pigmentation may not fade after discontinuation • Patients on long-term minocycline should be screened; if seen on gums or sclerae, discontinue

34. Other causes of medication-related hyperpigmentation • Amiodarone • Antimalarials • Hydroxychloroquine • Chloraquine • Calcium channel blockers • Verapamil • Diltiazem • Zidovudine • Imipramine • Some antipsychotics • Some chemotherapy agents

35. Case Four Elaine Gosnel

36. Case Four: History • HPI: Elaine Gosnel is a 66-year-old woman with a two-year history of an itchy rash on her legs that has resulted in dark spots. • PMH: hypertension, diabetes, hyperlipidemia • Allergies: none • Medications: metoprolol, simvastatin, metformin • Family history: noncontributory • Social history: widowed; lives in a retirement community • ROS: edematous legs

37. Case Four: Skin Exam

38. Case Four, Question 1 • The patient’s legs show scaly brown plaques on her lower legs bilaterally. Pedal pulses are normal. What is the most likely diagnosis for Mrs. Gosnel’s rash? • Atopic dermatitis • Erysipelas • Irritant contact dermatitis • Stasis dermatitis • Tinea corporis

39. Case Four, Question 1 Answer: d • The patient’s legs show scaly brown plaques on her lower legs bilaterally. Pedal pulses are normal. What is the most likely diagnosis for Mrs. Gosnel’s rash? • Atopic dermatitis(wrong location, no history) • Erysipelas(usually unilateral, acute not chronic) • Irritant contact dermatitis (not good location, no history) • Stasis dermatitis • Tinea corporis(more superficial)

40. Stasis dermatitis

41. Case Four, Question 2 • You correctly diagnose Mrs. Gosnel with stasis dermatitis. What do you recommend? • Bacitracin ointment twice daily • Daily oral trimethoprim-sulfamethoxazole • Debridement of superficial erosions • Elevation and compression stockings • Immediate referral to vascular surgery

42. Case Four, Question 2 Answer:d • You correctly diagnose Mrs. Gosnel with stasis dermatitis. What do you recommend? • Bacitracin ointment twice daily (likely to cause allergic contact dermatitis) • Daily oral trimethoprim-sulfamethoxazole (no active infection) • Debridement of superficial erosions (may worsen) • Elevation and compression stockings • Immediate referral to vascular surgery (not indicated for most stasis dermatitis)

43. Stasis dermatitis • Venous stasis dermatitis is an eczematous eruption that occurs in venous insufficiency and leg edema • Acute eczematous dermatitis (itchy red scaly plaques) leads to chronic eczematous dermatitis; may be weepy • Extravasation leads to brown pigmentation and petechiae • Venous ulcers may result, especially on medial malleolus Refer to the module on Stasis Dermatitis and Leg Ulcers for more information

44. Stasis dermatitis: Treatment • Reduce edema with elevation and compression stockings • Wet compresses may aid in healing erosions or ulcers • Mid-potency topical steroids control inflammation • Avoid topical antibiotics because up to half develop allergic contact dermatitis, especially to neomycin and bacitracin

45. Quick Case: Dark spot on the leg • This 32-year-old man who had a small laceration two years ago and presents with a dark spot • He’s worried it might be something bad

46. Quick Case: Diagnosis? • What is the most likely diagnosis? • Drug-induced pigmentation • Melanoma • Postinflammatory hyperpigmentation • Post-traumatic fungal infection

47. Quick Case: Diagnosis? Answer: c • What is the most likely diagnosis? • Drug-induced pigmentation • Melanoma • Postinflammatory hyperpigmentation • Post-traumatic fungal infection

48. Postinflammatory hyperpigmentation • Postinflammatory hyperpigmentation describes a common phenomenon of darkening of the skin at or around sites of injury or inflammation • Individuals with olive or slightly darker complexion are at particular risk • The pigmentation takes months to years to fade but usually improves gradually over time

49. Postinflammatory hyperpigmentation • Reassure patients this is normal • This is not a scar; it’s just increased pigment • Use sunscreen after injuries or surgical procedures • For significant or problematic hyperpigmentation, refer to a dermatologist

50. Postinflammatory hypopigmentation • Some patients heal with light spots instead • Stigma may be caused by fear of infectious diseases • Social impact can be more severe than original rash • Pigmentation may return slowly • It is important to treat rashes aggressively to avoid this if possible