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4/23/10 Justin Endo, M.D. Dermatology for the podiatrist. Disclosure. No financial disclosures Primary reference and images unless otherwise specified from Bolognia et al. Objectives. Diagnose dermatologic conditions affecting the lower leg Discuss management options
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4/23/10 Justin Endo, M.D. Dermatology for the podiatrist
Disclosure • No financial disclosures • Primary reference and images unless otherwise specified from Bolognia et al.
Objectives • Diagnose dermatologic conditions affecting the lower leg • Discuss management options • Understand the limitations of biopsies, especially shave biopsies, using standard breadloaf histologic grossing methods • Describe a lesion and consult dermatology appropriately
Vasculitis • Immune-mediated destruction of vessels • Often classified by vessel size involved • Small: • Sometimes renal involvement • Palpable purpura • Medium/large: • +/- systemic symptoms • Ulcers • Livedoreticularis • Nodules
Vasculitis • Dermatology and/or rheumatology consult to help rule out systemic involvement • If systemic involvement (or severely symptomatic small vessel disease without renal involvement) • Steroids or other immunosuppressants • Compression stockings for small vessel vasculitis
Pigmented purpuricdermatosis • Capillaritis • Various morphologies • Annular telangiectasias (Majocchi) • Cayenne pepper petechiae and macules (Schaumberg) • Eczematoid patches (Ducas and Kapetanakis) • Lichenoid patches (Gougerot and Blum) • Treatment • Observation • Topical steroids rarely helpful
Pyodermagangrenosum (PG) • Clinical features • Pathergy (sterile pustule at sites of trauma) • Wound or ulcer that keeps getting “infected” despite debridement • Undermining and rolled borders • Cribiform healing • Erythematous margins • Bullous and granulomatous variants
PG • Associated conditions • Inflammatory bowel disease • Hematologic malignancy (bullous variants) • Paraproteinemia • Up to 50% idiopathic • Diagnosis of exclusion • Infectious etiology workup needed • Biopsy will not RULE IN diagnosis but RULES OUT other causes of chronic ulcer
PG • Treatment • NO DEBRIDEMENT!!! • NO DEBRIDEMENT!!! • NO DEBRIDEMENT!!! • Dermatology consult • Steroids (often systemic) • Immunosuppressives
Premalignant & malignant • Kaposi’s sarcoma • Squamous cell carcinoma • Melanoma • Basal cell carcinoma • Cutaneous lymphoma
Kaposi’s sarcoma • Abnormal endothelial neoplasm caused by human herpes virus 8 (HHV-8) • Pink, black-violet nodules, plaques, or polyps • 4 variants • Chronic/classic (Mediterranean) • African endemic • Iatrogenically immunocompromised (CyA) • AIDS related
Kaposi’s sarcoma • Childhood lymphadenopathic variant is fulminant and fatal • Chemotherapy +/- XRT usually before surgery due to multifocality
Squamous cell carcinoma • Malignant infiltration of keratinocytes • Risk factors: • Immunosuppression (transplant) • Sun damage • Can follow nerves, invade into bone, and metastasize • Refer to dermatology to discuss treatment options, regardless of biopsy “margins”
Melanoma, acrallentiginous • Rarer type of melanoma • Significant proportion of melanoma type in Asian and African skin • Brown to black macule with irregular borders, color variegation, longitudinal melanonychia • Consider biopsy • Fair-skinned individuals • Width >=3mm • Changing lesion
Melanoma, acrallentiginous • Staging / prognosis depends upon • HistologicBreslow depth • Lymph node involvement • Mitotic rate • Ulceration • Treatment • Wide local excision • Sentinel lymph node biopsy for melanomas > 1 mm • Adjuvant treatments and clinical trials
Basal cell carcinoma • Most common skin cancer • Least likely to metastasize • Recommend referral to dermatology, regardless of biopsy “margins” • Surgical management depends upon histologic appearance
Primary cutaneous lymphoma • Abnormal, clonal T or B cell proliferation • Violaceous nodules (B cell) or widespread eczematous-like plaques (T cell) • Differential includes “pseudolymphoma” benign lymphocytic hyperplasia • Referral to dermatology and hematology/oncology for treatment options
Benign neoplasms • Dermatofibroma • Disseminated superficial actinic porokeratosis • Kyrle’s disease • Poroma
Dermatofibroma • Pink to brown dome shaped papules (sometimes flatter) that dimples when squeezed • Thought to be reactive to trauma • Management options • Expectant (watchful neglect) • Punch / excise • Triamcinolone injection • Cordran tape
Disseminated superficial actinic porokeratosis (DSAP) • Multiple flesh colored, scaly papules or plaques with double edge rim of scale • Malignant transformation risk is low • Treatment is generally unsatisfactory • Expectant (watchful neglect) • Cryotherapy • Topical 5-FU or imiquimod • Topical retinoids • Curettage
Kyrle’s disease • Keratin perforates through skin • ? form of prurigo nodularis associated with renal disease • Treatment (difficult) • Topical steroids • Antipruritic lotions • UV light • Laser
Poroma • Benign tumor of eccrine > apocrine duct origin • Palmo-plantar vascular papules, nodules, plaques • No treatment indicated (or excise if symptomatic)
Scaly eruptions • Lichen planus • Psoriasis
Lichen planus • Purple polygonal papules and plaques, sometimes with lacy netlike Wicham’sstriae • Affects wrists, arms, genitals, buttocks, oral mucosa • Association with hepatitis C, metal contact allergies, hepatitis B vaccine, medications • Can be difficult to treat • Topical steroids • Light • Antimalarials (hydroxychloroquine)
Photos AAFP.org Psoriasis • Polygenetic disorder • Itchy, red, well-demarcated plaques with silvery scale involving the scalp, torso, umbilicus, gluteal fold, extensor extremities • Often nail pitting and oil spots • Sometimes involving genitals, axillae • Rarely palmar or plantar distribution • Uncommonly pustular or erythrodermic Oil spot Nail pit
Psoriasis • Triggers • Trauma • Infection (streptococcal, HIV) • Hypocalcemia • Drugs (lithium, interferon, beta blocker, systemic steroid, antimalarials) • Major comorbidity: metabolic syndrome!
Psoriatic arthritis • Enthesitis • Morning stiffness lasting at least 1 hour • 5-30% of all psoriasis patients • 15% of cases arthritis precedes skin lesions
Psoriatic arthritis • Categories • Classic (DIP) • Mono/asymmetric arthritis • RA-like (small and medium joints) • Arthritis mutilans • Spondyloarthritis
Psoriasis: Treatment • Depends upon extent/sites of skin disease, arthritis, comorbidities, lifestyle • Topical steroids and vitamin D analogs • Light • Methotrexate • Biologics (e.g., etanercept, infliximab, adalimumab, ustekinumab)
Metabolic • Necrobiosis lipoidica (diabeticorum) • Erythema nodosum • Pretibial myxedema
Necrobiosislipoidica • Yellow-red-brown plaques +/- atrophy or ulceration on shins • NOT strictly associated with diabetes or glucose control • Treatment • Potent topical or intralesional steroid into active borders • Niacinamide • Light • Surgery as last line
Necrolyticacralerythema • Associated with hepatitis C • Obtain hepatitis C antibody study and refer to hepatology
Erythemanodosum (EN) • Tender, red, poorly demarcated, subcutaneous deep-seated nodules on anterior shins resolving like a bruise • +/- arthralgias and fevers • Typically young adults • RARELY (if ever) ulcerates • Usually acute and self-limited eMedicine.com