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Dermatology
By
Katrice L. Herndon, MD
Internal Medicine/Pediatrics
June 2, 2005
What is this?
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
Acne Vulgaris
• External Factors that contribute to Acne
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Oils, greases, dyes in hair products
Detergents, soaps, astringents
Occlusive clothing: turtlenecks, bra straps
Environmental Factors: Humidity & Heavy
exercise.
• Psychological stress
• Diet is controversial
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
Acne Vulgaris
• Classification of Acne
• Type 1 — Mainly comedones with an occasional small
inflamed papule or pustule; no scarring present
Type 2 — Comedones and more numerous papules and
pustules (mainly facial); mild scarring
Type 3 — Numerous comedones, papules, and pustules,
spreading to the back, chest, and shoulders, with an
occasional cyst or nodule; moderate scarring
Type 4 — Numerous large cysts on the face, neck, and
upper trunk; severe scarring
Acne Vulgaris
What is this?
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.
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.
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):
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Flushing (transient erythema)
Non-transient erythema
Papules and pustules
Telangiectasia
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 flareups of the condition.
What is This?
Allergic Contact Dermatitis
• Contact dermatitis refers to any dermatitis
arising from direct skin exposure to a
substance. It can be allergic or irritantinduced.
• An allergen induces an immune response,
while an irritant directly damages the skin.
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:
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nickel (jewelry)
formaldehyde (clothing, nail polish),
fragrances (perfume, cosmetics),
preservatives (topical medications, cosmetics),
rubber
chemicals in shoes (both leather and synthetic)
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
What is this?
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.
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.
Psoriasis
• Nail psoriasis -the typical nail abnormality in
psoriasis is pitting w/ color changes & crumbling of
the nail.
Psoriasis
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.
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.
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Tazarotene, is a topical retinoid, systemic retinoids
Methotrexate, cyclosporine
Immunmodulator therapy (embrel, remicade)
Ultraviolet light.
What is this?
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.
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
Vitiligo
• Repigmentation therapies include:
• corticosteroids
• calcineurin inhibitors
• Ultraviolet light
• Pseudocatalase cream
• Surgery – minigrafting techiniques
• Depigmentation therapy w/ hydroquinone
What is this?
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.
Pityriasis Rosea
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.
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.
Pityriasis Rosea
• Differential Dx include: Psoriasis, secondary
syphilis, tinea corporis, Lyme disease, & drug
eruptions.
• Treatment is usually reasurrance.
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Topical Steroids
Antipruitic lotions (prax, pramagel)
Phototherapy
Erthyromycin in severe cases
Rash usually persists for 2-3 months
What is this?
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.
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
Cellulitis
• Cellulitis is a recognizable clinical syndrome with
both local & systemic features.
• Systemic symptoms include:
• Fever and chills
• Myalgias
• Increased WBC count
Cellulitis
• Local findings typical of cellulitis:
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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
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.
Cellulitis
• Diagnosis is clinical
• Treatment: Anti-strep/Anti- staph
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Cefazolin
Nafcillin
Clindamycin
Vancomycin
Fluoroquinolones (3rd & 4th generations)
Macrolides (erythromycin, azithromycin)
Duration of treatment is usually 10-14 days
What is this?
Erysipelas
• Erysipelas is a characteristic form of cellulitis that
affects the superficial epidermis, producing
marked swelling.
• Bacterial Organisms:
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Beta-hemolytic streptococci group A
Group C & G less commonly
Staph. Aureus
Streptococcus pneumoniae, enterococci, gram negative
bacilli
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).
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
Erysipelas
• Treatment:
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Penicillin is the preferred treatment
Erythromycin
Clindamycin
Fluoroquinolones
• Erysipelas does have the propensity of
recur.
What is this?
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.
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.
Ecthyma
Treatment:
• Topical mupirocin ointment
• Gentle surgical debridement
• Oral/IV antibiotics
• Penicillin
• Clindamycin
• Macrolides
• Cefazolin
What is this?
Tinea Vesicolor
• Tinea versicolor is a common superficial
infection caused by the organism
Pityrosporum orbiculare.
• Which is a saprophytic yeast that is part of
the normal skin flora.
Tinea Vesicolor
• Lesions can be hypopigmented, light brown, or
salmon colored macules.
• A fine scale is often apparent, especially after
scraping.
• Individual lesions are typically small, but
frequently coalesce.
• Lesions are limited to the outermost layers of the
skin.
Tinea Vesicolor
• Most commonly found on the upper trunk &
extremities, & less often on the face and
intertriginous areas.
• While most patients are asymptomatic, some
complain of mild pruritus
• The diagnosis of tinea versicolor is confirmed by
direct microscopic examination of scale with 10 %
potassium hydroxide (KOH).
Tinea Vesicolor
• The differential diagnosis includes seborrhea,
eczema, pityriasis rosea, and secondary syphilis.
• Treatment includes topical antifungals. Oral
antifungals can be used for more extensive
disease: Ketocanozole 400mg x 1 dose.
Fluconazole and itraconazole are also effective.
What is this?
Cutaneous Warts
• Cutaneous warts AKA verrucae are caused by
HPV which infects the epithelium of skin and
mucus membranes.
• Cutaneous warts occur most commonly in children
and young adults.
• Also more common among certain occupations
such as handlers of meat, poultry, and fish.
• Predisposing conditions include atopic dermatitis
& any condition in which there is decreased cellmediated immunity.
Cutaneous Warts
• Infection with HPV occurs by skin-to-skin contact
• Incubation period following exposure in 2-6
months.
• Warts can have several different forms based upon
location & morphology (flat, mosaic, and filiform
warts)
• Lesions may occur singly, in groups, or as
coalescing lesions forming plaques.
Cutaneous Warts
• The diagnosis of verrucae is based upon clinical
appearance.
• Scrape off any hyperkeratotic debris & reveal
thrombosed capillaries (seeds).
• The wart also will obscure normal skin markings
Cutaneous Warts
Differential Diagnosis:
• Lichen Planus
• Seborrheic Keratosis
• Acrochordon or skin tag
• Clavus or corn
Treatment
• Spontaneous regression in 2/3 over 2yrs
• Salicylic acid, liquid nitrogen, cantharidin
• Cyrotherapy, curettage, laser therapy
• Immunotherapy, intralesional injections
What is this?
Secondary Syphilis
• Syphilis is a chronic infection caused by the
bacterium Treponema pallidum which is
sexually transmitted.
• Syphilis occurs in 3 stages:
• 1st stage is characterized by the classic chancre,
which is a 1-2cm ulcer with raised indurated
borders, usually painless and occurs at site of
innoculation. Heals spontaneously.
Secondary Syphilis
Secondary Syphilis
• Secondary or systemic syphilis is characterized by a rash.
• The rash is classically a symmetric papular eruption
involving the entire trunk & extremities including the
palms and soles.
• Systemic symptoms include fever, headache, malaise,
anorexia, sore throat, myalgias, & weight loss.
• Lymphadenopathy (inquinal, axillary)
• So-called "moth-eaten" alopecia
• Condyloma lata, grayish white lesions involving the
mucus membranes
Secondary Syphilis
Secondary Syphilis
• Diagnosis at this stage is usually by serologic
testing but darkfield microscopy can also be done
for direct visualization of spirochete.
• Non-treponemal testing:
• Veneral disease research laboratory (VDRL)
• Rapid plasma reagent (RPR)
• Treponemal testing:
• Fluorescent treponemal antibody absorption test
• Microhemagglutination test for antibodies
Seconday Syphilis
Treatment
• T.Pallidum remains very sensitive to PCN.
• Long-acting benzathine penicillin G should be used.
• If documented chancre or a NR serologic testing was done
in the past 1 yr, one IM dose is appropriate.
• If neither of the above applies this needs to treated as latent
syphilis and 3 q week doses must be given.
• Doxycycline, erythromycin or zithromycin in pen allergic
patients x 14 days.
What is this?
Herpes Zoster
• Reactivation of endogenous latent VZV infection
within the sensory ganglia results in herpes zoster
or "shingles", a syndrome characterized by a
painful, unilateral vesicular eruption in a restricted
dermatomal distribution.
• How the virus emerges from latency is not clearly
understood.
• Patients frequently experience a prodrome of
fever, pain, malaise and headache which precedes
the vesicular dermatomal eruption by several days.
Herpes Zoster
• The rash initially appears along the dermatome as
grouped vesicles or bullae which evolve into
pustular or occasionally hemorrhagic lesions
within three to four days.
• The thoracic and lumbar dermatomes are the most
commonly involved sites of herpes zoster.
• The complications of herpes zoster include ocular,
neurologic, bacterial superinfection of the skin and
postherpetic neuralgia
Herpes Zoster
Treatment
• Antivirals:
• Acyclovir
• Famciclovir
• Valacyclovir
• Antivirals w/ corticosteroids
• Analgesics: opioids/acetominophen
What is this?
Actinic Keratosis
• Actinic keratoses (AKs) are premalignant
lesions that develop only on sun-damaged
skin.
• AKs appear as patches of hyperkeratosis
with some surrounding erythema on sunexposed areas of the head and neck,
forearms and hands, and upper back.
Actinic Keratosis
Actinic Keratosis
• The differential diagnosis of AKs includes
seborrheic keratoses, verruca vulgaris, SCC, and
superficial BCC.
• The treatment of AKs begins with prevention.
• Avoiding sun exposure
• sunscreens reduce the development of AKs,
• Active treatment of AKs depends upon the size of the
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lesion and the number of lesions present.
Liquid Nitrogen
Surgical curettage
Chemotherapy (5-FU, diclofenac, imiquimod)
Dermabrasion
Photodynamic therapy
Which one is which?
• Basal Cell Carcinomas begins as small
shiny nodules and grows slowly. It is the
most common form of skin cancer.
• Frequently, the central portion breaks down
to form an ulcer with a reddish-purple scab.
These tumors usually remain fairly
localized and rarely spread elsewhere.
• Squamous Cell Carcinoma is another common form of
skin cancer. When these tumors first appear they are firm
to the touch. They appear most often on sun-exposed areas
of your body.
• Squamous cell carcinoma evolves very slowly through a
premalignant stage known as a solar or actinic keratosis.
• Untreated, significant numbers of these lesions can
metastasize to distant sites. Tumors on the lower lip and
ears are at higher risk to spread.
• Malignant Melanoma is the most dangerous form of skin
cancer.
• They arise from either pre-existing moles or normal skin.
• Malignant melanoma, like basal and squamous
carcinomas, is linked to overexposure to the sun.
• But it can appear any place on your body.
• When detected early & with proper treatment, the recovery
rate from this form of skin cancer can be very high.
References
• Harrison’s 15th Edition. Principles of Internal
Medicine
• Up to Date
• Emedicine
• Dermatology Pearls Adult and Pediatric
Thank You